Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability. METHODS: We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score-4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367. FINDINGS: Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5-13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications. INTERPRETATION: Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management. FUNDING: The UK National Institute for Health Research Health Technology Assessment Programme.

Cartilage Injury in the Knee: Assessment and Treatment Options.

Cartilage injuries in the knee are common and can occur in isolation or in combination with limb malalignment, meniscus, ligament, and bone deficiencies. Each of these problems must be addressed to achieve a successful outcome for any cartilage restoration procedure. If nonsurgical management fails, surgical treatment is largely based on the size and location of the cartilage defect. Preservation of the patient's native cartilage is preferred if an osteochondral fragment can be salvaged. Chondroplasty and osteochondral autograft transfer are typically used to treat small (<2 cm) cartilage defects. Microfracture has not been shown to be superior to chondroplasty alone and has potential adverse effects, including cyst and intralesional osteophyte formation. Osteochondral allograft transfer and matrix-induced autologous chondrocyte implantation are often used for larger cartilage defects. Particulated juvenile allograft cartilage is another treatment option for cartilage lesions that has good to excellent short-term results but long-term outcomes are lacking.

Usefulness of a job-exposure matrix 'MADE' as a decision tool for compensation of work-related musculoskeletal disorders.

We aimed to assess the predictivity of the biomechanical job-exposure matrix 'MADE' using compensation data from the National Health Insurance for work-related disorders. Data were obtained from 2013 to 2015, area under curves (AUC), sensitivity, specificity and predictive values were calculated using compensation results as reference. We collected 163 128 cases data. AUC ranged from 0.64 for shoulders disorder to 0.82 for knee disorders. If two thresholds were considered, 28.7% of the sample fit under or over those. The matrix showed a fair predictivity. Such matrix cannot replace expertise but might be a tool used for improving compensation process.

Synthetic Graft Compared With Allograft Reconstruction for Extensor Mechanism Disruption in Total Knee Arthroplasty: A Multicenter Cohort Study.

BACKGROUND: Extensor mechanism disruption after total knee arthroplasty is a serious complication leading to notable patient morbidity. The purpose of this study is to compare the outcomes of extensor mechanism allograft with synthetic graft reconstruction. METHODS: We retrospectively identified all patients who underwent extensor mechanism reconstruction using either allograft or synthetic graft from two high-volume academic arthroplasty institutions between 2006 and 2017. We collected extensor lag, need for ambulatory aids, and patient-reported outcome measures, as well as the incidence of postoperative complications and revision surgeries. We evaluated cost differences, considering both material cost and the need for revision surgery. RESULTS: We identified 27 cases. A significantly greater postoperative extensor lag was found in the allograft group (P = 0.05). Graft failure after synthetic reconstruction was zero, with an overall revision surgery rate of 15%. Graft failure was 21%, and the revision surgery rate was 43% after allograft reconstruction. The allograft cost was significantly higher compared with the synthetic graft cost (P = 0.001). The mean total cost was 4,733.08 CAD for the synthetic group and 24,050.40 CAD for the allograft group (P = 0.17). DISCUSSION: Synthetic reconstruction for extensor mechanism disruption shows benefit in postoperative extensor lag, graft failure, revision surgery, and cost when compared with allograft. LEVEL OF EVIDENCE: Level III.

Assessment of Compensated Turnout Characteristics and their Relationship to Injuries in University Level Modern Dancers.

Dancers may compensate alignment at the spine, hip, knees, ankles, and feet to achieve a greater turnout than is available at the hip alone. Such compensations are believed to lead to many of the musculoskeletal injuries experienced by dancers, especially overuse injuries. The aim of this study was to explore the relationship between compensated turnout and injury of the lower extremities and low back. Twenty-two university level modern dancers age 19 to 23 participated. Measurements were taken of active hip external rotation (AHER) prone and functional turnout (FTO) in first position. The difference between FTO and AHER was designated as compensated turnout (CTO). A questionnaire was conducted to gather information about dancers' injuries within the past 2 years. A total of 17 participants (77%) reported experiencing at least one injury in the 24 month period. All dancers compensated turnout. Results revealed a large variability in CTO among participants, ranging from 3° to 72°. Statistical analysis showed a significant relationship (r = 0.45, N = 22, p = 0.04) between CTO and the number of injuries experienced, especially as related to low back pain (r = 0.50, N = 22, p = 0.02). Students with no injury had a CTO mean of 26°, while those with two or more injuries had a CTO mean of 43°. Results contribute to previous studies that have examined the effects of CTO in ballet dancers and further indicate that compensatory patterns of turnout may increase the risk of experiencing more than one injury in university level modern dancers.

Contrasting patterns of care for musculoskeletal disorders and injuries of the upper extremity and knee through workers' compensation and private health care insurance among union carpenters in Washington State, 1989 to 2008.

BACKGROUND: Musculoskeletal symptoms and disorders (MSDIs) are common reasons for visits to medical providers in the general population and they are common work-related complaints. Prior reports raise concerns as to whether declines in workers' compensation (WC) rates represent true improvement in occupational health and safety or shifting of care to other payment systems. METHODS: By linking administrative records, we compared patterns of WC claims and private health care utilization for disorders of the upper extremity (UE) and knee among a large cohort of union carpenters over a 20-year period. RESULTS: As WC claim rates declined, private health care utilization increased. The increase was muted somewhat but sustained when adjusting for other patterns of health care utilization. CONCLUSIONS: Findings suggest the decline of WC claim rates do not solely represent improved occupational safety in this population, but also a considerable shifting of care to their private insurance coverage over time.

Assessment of neuromuscular risk factors for anterior cruciate ligament injury through tensiomyography in male soccer players.

PURPOSE: To investigate the role of mechanical and contractile properties of skeletal muscles of the thigh, assessed through tensiomyography (TMG), as risk factors for anterior cruciate ligament (ACL) injury in male soccer players. METHODS: Male soccer players with confirmed ACL tear included in this study underwent resting TMG assessment of thigh muscles of the uninjured side. The same values were obtained from a sex-, sports level-matched control group in both sides. The maximal displacement (Dm), delay time (Td), contraction time (Tc), sustained time (Ts), and half-relaxation time (Tr) were obtained for the following muscles in all subjects: vastus medialis (VM), vastus laterals (VL), rectus femoris (RF), semitendinosus (ST), and biceps femoris (BF). TMG values of the uninjured side in ACL-injured group were compared to mean values between both sides in the control subjects. RESULTS: There were 40 ACL-injured and 38 control individuals. The vast majority of TMG parameters were higher in the uninjured side of ACL-injured individuals compared to the control group. The VL-Tr, RF-Tc, RF-Ts, RF-Tr, and BF-Dm values were significantly higher in the uninjured side compared to the control group. Quadriceps muscles demonstrated more significant between-group differences than hamstring muscles. Specifically, RF was the muscle where most significant between-group differences were found. CONCLUSIONS: Resistance to fatigue and muscle stiffness in the hamstring muscles may be risk factors for ACL injury in male soccer players. In addition, a predominant impairment in TMG characteristics of the quadriceps over hamstrings may indicate an altered muscular co-contraction (imbalance) between both muscle groups, which might be another risk factor for ACL injury in this population. These findings should be taken into account when screening athletes at high risk of ACL injury and also to design adequate prevention programs for ACL injury in male soccer players.

Occupational kneeling and squatting: development and validation of an assessment method combining measurements and diaries.

OBJECTIVES: As knee-straining postures such as kneeling and squatting are known to be risk factors for knee disorders, there is a need for effective exposure assessment at the workplace. Therefore, the aim of this study was to develop a method to capture knee-straining postures for entire work shifts by combining measurement techniques with the information obtained from diaries, and thus avoiding measuring entire work shifts. This approach was applied to various occupational tasks to obtain an overview of typical exposure values in current specific occupations. METHODS: The analyses were carried out in the field using an ambulatory measuring system (CUELA) to assess posture combined with one-day self-reported occupational diaries describing the durations of various work tasks. In total, 242 work shifts were measured, representing 81 typical tasks from 16 professions. Knee-straining postures were analysed as daily time intervals for five different postures. The accuracy of the method was examined by comparing the results to measurements of entire work shifts. RESULTS: Unsupported kneeling was the most widely used knee posture in our sample (median 11.4 % per work shift), followed by supported kneeling (3.0 %), sitting on heels (1.1 %), squatting (0.7 %), and crawling (0.0 %). The daily time spent in knee-straining postures varied considerably, both between the individual occupations, within an occupation (e.g. parquet layers: 0.0-88.9 %), and to some extent even within a single task (e.g. preparation work of floor layers (22.0 ± 23.0 %). The applied measuring method for obtaining daily exposure to the knee has been proven valid and efficient randomly compared with whole-shift measurements (p = 0.27). CONCLUSIONS: The daily degree of postural exposure to the knee showed a huge variation within the analysed job categories and seemed to be dependent on the particular tasks performed. The results of this study may help to develop an exposure matrix with respect to occupational knee-straining postures. The tested combination of task-based measurement and diary information may be a promising option for providing a cost-effective assessment tool.

Assessment of gastrocnemius tensiomyographic neuromuscular characteristics as risk factors for anterior cruciate ligament injury in male soccer players.

PURPOSE: There is a large number of publications evaluating neuromuscular risk factors for anterior cruciate ligament (ACL) injury in athletes. However, most of them have involved the female athlete and, in addition, the gastrocnemius muscles have been less investigated by far compared with the quadriceps and hamstring. The purpose of this study was to investigate the role of the gastrocnemius muscles as neuromuscular risk factors for ACL injury in male soccer players, through tensiomyography (TMG). METHODS: All competitive male soccer players with confirmed ACL tear included in this study underwent resting TMG assessment of gastrocnemius medialis (GM) and gastrocnemius lateralis muscles of the uninjured side. The same values were obtained from a sex-, and sports level-matched control group in both sides. The maximal displacement (D m), delay time (T d), contraction time (T c), sustained time (T s), and half-relaxation time (T r) were obtained for both muscles. TMG values of the uninjured side in ACL-injured group were compared with the mean values between both sides in the control subjects. RESULTS: There were no significant between-group differences in demographic characteristics. Most TMG parameters of the gastrocnemius muscles were not significantly different between the two groups. Only the GM-T r (p = 0.02) and GM-D m (p = 0.006) were significantly higher in the ACL-injured group compared with control group. CONCLUSIONS: Neuromuscular characteristics in terms of mechanical and contractile properties of the gastrocnemius muscles may not be significant risk factors for ACL injury in male soccer players.

Safety assessment characteristics of pedestrian legform impactors in vehicle-front impact tests.

This study investigated the characteristics of safety assessment results of front-area vehicle impact tests carried out using the Transport Research Laboratory (TRL) legform impactor and a flexible legform impactor (FLEX legform impactor). Different types of vehicles (sedan, sport utility vehicle, high-roof K-car, and light cargo van) were examined. The impact locations in the study were the center of the bumper and an extremely stiff structure of the bumper (i.e., in front of the side member) of each tested vehicle. The measured injury criteria were normalized by injury assessment reference values of each legform impactor. The test results for center and side-member impacts indicated that there were no significant differences in ligament injury assessments derived from the normalized knee ligament injury measures between the TRL legform impactor and the FLEX legform impactor. Evaluations made using the TRL legform impactor and the FLEX legform impactor are thus similar in the vehicle safety investigation for knee ligament injury. Vehicle-center impact test results revealed that the tibia fracture assessments derived from the normalized tibia fracture measures did not significantly differ between the TRL legform impactor and the FLEX legform impactor. However, for an impact against an extremely stiff structure, there was a difference in the tibia fracture assessment between the FLEX legform impactor and the TRL legform impactor owing to their different sensor types.

The role of computed tomography in the assessment of open periarticular fractures associated with deep knee wounds.

OBJECTIVE: To (1) determine the incidence and injury profile of open periarticular fractures about the knee joint in a cohort of patients presenting to the emergency department with a deep periarticular knee wound and to (2) determine the effectiveness of computed tomography (CT) scan to detect and guide management of these open fractures compared with plain radiographs (XRs). DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Seventy-eight patients (79 knees) with deep periarticular knee wounds of which 62 patients (63 knees) received both a XR and a CT scan of the knee. INTERVENTION: XR and CT scan of the injured knee. MAIN OUTCOME MEASUREMENTS: Comparison of OTA fracture classification and surgeon produced management plan as determined by XRs versus CT scans. CT scan was considered the gold standard test to detect a fracture. RESULTS: Twenty-one (27%, 21/79) knees had an open periarticular fracture of the knee, and 95% (20/21) of these knees had intra-articular air indicative of an associated traumatic arthrotomy. Of 41 (52%, 41/79) knees with a traumatic arthrotomy, 51% (21/41) had an associated open periarticular fracture of the knee. XRs detected 18 fractures in 17 knees (of which 1 fracture was later determined to not be a true fracture), whereas CT scans detected 26 fractures in 21 knees. Overall, CT scans detected 9 additional fractures in 6 knees. The specificity, sensitivity, and positive and negative predictive values of XRs to detect and rule out a fracture were 98%/65% and 94%/82%, respectively. Compared with XRs, CT scan altered the fracture classification in 48% of patients and altered the management plan in 43% of patients, respectively. Gunshot wounds to the knee had a 48% (12/25) incidence of an associated open periarticular fracture compared with a 17% (9/54) incidence for all other injury mechanisms combined (P < 0.01). CONCLUSIONS: Patients with a periarticular knee wound have a high incidence of open periarticular fractures, and the incidence is even higher if the mechanism of injury is a gunshot wound or there is associated traumatic arthrotomy. CT scan improves detection and management of open fractures of the knee compared with XRs. Consideration should be given to routinely using CT scan to evaluate knees with deep periarticular wounds that present to the emergency department, especially if secondary to gunshot injuries, given the high incidence of open periarticular fractures of the knee. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: a systematic review and meta-analysis.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common, result in significant morbidity, and are expensive to repair surgically and to rehabilitate. Several randomized and observational studies have tested neuromuscular interventions as preventive measures for these injuries. PURPOSE: To conduct a systematic review and meta-analysis of all known comparative studies for estimating and testing the effect of neuromuscular and educational interventions on the incidence of ACL injuries in adolescents and adults, both male and female. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Several databases were used to identify eligible studies through July 4, 2011: MEDLINE, EMBASE, SPORTDiscus, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials, and Health Technology Assessment. Eligible studies were assessed for risk of bias, and meta-analyses were performed on the estimated intervention effect (log incidence rate ratio) using inverse-variance weighting, subgroup analysis, and random-effects meta-regression to estimate the overall (pooled) effect and explore heterogeneity of effect across studies (measured by I2 and tested with the Q statistic). RESULTS: Eight cohort (observational) studies and 6 randomized trials were included, involving a total of approximately 27,000 participants. The random-effects meta-analysis yielded a pooled rate-ratio estimate of 0.485 (95% confidence interval [CI], 0.299-0.788; P = .003), indicating a lower ACL rate in the intervention groups, but there was appreciable heterogeneity of the estimated effect across studies (I2 = 64%; P = .001). In the meta-regressions, the estimated effect was stronger for studies that were not randomized, performed in the United States, conducted in soccer players, had a longer duration of follow-up (more than 1 season), and had more hours of training per week in the intervention group, better compliance, and no dropouts. Nevertheless, residual heterogeneity was still observed within subgroups of those variables (I2 > 50%; P < .10). CONCLUSION: The authors found that various types of neuromuscular and educational interventions appear to reduce the incidence rate of ACL injuries by approximately 50%, but the estimated effect varied appreciably among studies and was not able to explain most of that variability. CLINICAL RELEVANCE: Neuromuscular and educational interventions appear to reduce the incidence rate of ACL injuries by approximately 50%.

Assessment of the responsibility between a road traffic accident and medical defects after the traffic accident injury of knee joint.

A 48-year-old Chinese woman was hit by a car in a road traffic accident. Local county hospital considered that her right knee was injured, but didn't find any sign of fracture from X-ray imaging. Then the hospital gave diagnosis of soft tissue contusion and the patient started to exercise with burden 21 days after her right lower limb was fixed by plaster slab. Four months later, she had to go back to the county hospital for recheck due to persistent pain on her right knee. Then, the right tibia outer plateau fracture was found. The patient rejected the advice of open reduction and internal fixation of right tibia plateau fracture. Instead, she accepted the unicompartmental knee arthroplasty in a hospital affiliated to a medical college. The patient felt the knee pain alleviated after surgery However, the joint dysfunction was aggravated even more. The patient used the legal procedure for personal compensation. Both driver and the insurance company disputed that the final consequence of the injured knee was due to not only the traffic accident, but also poor medical practice involved. Therefore the court consigned us to make judicial judgment of expertise. After investigation, we found the earliest X-ray graph after the accident had shown the fracture of right tibia outer plateau and right knee valgum, with articular surface involvement, and the traffic accident was considered as the primary cause of sequelae. At the same time, the county hospital missed the diagnosis of fracture, and led to insufficient fixation of right lower limb, which was not good for rehabilitation from fracture and joint injury. This was the secondary cause of sequelae. Additionally, instead of the standard therapy, the affiliated hospital of medical college made the unicompartmental knee arthroplasty four months later, which also had a little defect. It was the minor reason for the result.

Incidence of bilateral discoid lateral meniscus in an Asian population: an arthroscopic assessment of contralateral knees.

PURPOSE: To investigate the incidence of bilateral discoid lateral meniscus (DLM) and to evaluate the arthroscopic features of lateral meniscus in asymptomatic contralateral knees in an Asian population who presented with symptomatic DLMs. METHODS: This study prospectively enrolled 52 consecutive patients who underwent arthroscopic procedures for symptomatic DLMs (31 complete and 21 incomplete) and who consented to the examination of the contralateral knee at the time of arthroscopy. Types of DLMs and of meniscus tears were assessed by use of arthroscopic findings. Preoperative and postoperative functional outcomes were evaluated with Lysholm and Tegner activity scores. RESULTS: Arthroscopic examinations showed 21 complete DLMs, 19 incomplete DLMs, 11 normal lateral menisci, and 1 ring-shaped lateral meniscus in contralateral knees. The incidence of bilateral DLM in our study population was 79% (41 of 52 contralateral knees). Furthermore, 65% of patients (34 pairs of knees) had the same DLM types. In addition, 3 pairs of knees with complete DLMs had menisci of different thicknesses. DLM tears were observed in 2 contralateral knees (1 radial and 1 longitudinal) and were treated by partial central meniscectomy. CONCLUSIONS: This study provides evidence of the high prevalence of bilateral DLM in an Asian population.

Sports knee injuries - assessment and management.

BACKGROUND: Sports knee injuries present commonly in the general practice setting. A good understanding of the anatomy and biomechanics of the knee assists accurate diagnosis of acute knee injuries. OBJECTIVE: This article describes the assessment and management of sports knee injuries in the general practice setting. DISCUSSION: When a patient presents with a sporting knee injury, a detailed history can help narrow down the nature of the injury. Examination can be difficult in the acute setting and may need to be repeated 3 or more days after the injury. Fractures can usually be excluded with plain X-rays; where indicated MRI or CT scan will usually confirm the diagnosis. Management aims are to manage pain, minimise knee swelling, maintain range of movement and quadriceps activation, and arrange appropriate referral. Medial collateral ligament, posterior cruciate ligament and some small meniscal injuries can usually be managed conservatively. Most meniscal injuries, anterior cruciate ligament and lateral collateral ligament injuries require surgical management. Physiotherapy is an integral part of the management of knee injuries in both the conservative and surgical settings.

Ergonomics in industrialized dairy operations.

This paper presents a summary of a panel presentation by agriculture health and safety scientists on ergonomics of industrialized dairy parlor operations in the United States. Dairy industry trends in the United States were discussed in the panel presentation, which took place during the New Paths: Health and Safety in Western Agriculture conference, November 11-13, 2008. Dairy production is steadily moving to large-herd operations because of associated economies of scale and other economic and social conditions. Large-herd operations utilize a parlor milking system, as compared to a stanchion system used primarily in smaller operations. Each milking system presents different risks for worker injury. Low back, knee, and shoulder musculoskeletal symptoms were most frequently reported among workers in smaller dairy operations. Another study analyzing workers' compensation (WC) data from large-herd milking operations found nearly 50% of livestock-handling injury claims involved parlor milking activities. Nearly 27% of injuries were to the wrist, hand, and fingers, nearly 13% to the head or face, and 11% to the chest. Results indicated the vulnerability of these body parts to injury due to the worker-livestock interface during milking. More focused research should investigate milking practices and parlor designs as they relate to worker safety and health. Additional dairy-related injury research is vital given the trend towards large industrial milking operations.

Derivation and theoretical assessment of a set of biomechanics-based, AIS2+ risk equations for the knee-thigh-hip complex.

A set of risk equations was derived to estimate the probability of sustaining a moderate-to-serious injury to the knee-thigh-hip complex (KTH) in a frontal crash. The study consisted of four parts. First, data pertaining to knee-loaded, whole-body, post-mortem human subjects (PMHS) were collected from the literature, and the attendant response data (e.g., axial compressive load applied to the knee) were normalized to those of a mid-sized male. Second, numerous statistical analyses and mathematical constructs were used to derive the set of risk equations for adults of various ages and genders. Third, field data from the National Automotive Sampling System (NASS) were analyzed for subsequent comparison purposes. Fourth, the fidelity of the resulting set of risk equations was assessed by using the risk equations to transform the axial compressive femur loads from simulated, full-engagement, frontal crashes into event risks, and the resulting model-based injury rates were compared with the field-based injury rates. The results were promising: For unbelted drivers in towaway frontal crashes involving 1985-1997 model year passenger cars whose speed changes were less that 58 km/h, the model-based average injury rate was 1.10%; the field-based rate was 1.30%. Moreover, some of the trends in the field were confirmed with the model (e.g., there were more KTH-injured males than KTH-injured females). The risk equations demonstrated better fidelity for lower-speed crashes than high-speed crashes.