No long-term tunnel enlargement following anterior cruciate ligament reconstruction using autograft hamstring tendon with dual suspensory fixation.

PURPOSE: Bone tunnel widening following anterior cruciate ligament reconstruction (ACLR) is well documented, although the aetiology and clinical significance of this phenomenon remain unclear. At mid-term follow-up, a greater prevalence of tunnel enlargement has been reported with the use of hamstring (HS) grafts. However, there are paucity of data on what happens in the longer term. The aim of this study was to assess the change in femoral and tibial tunnel dimensions 15 years after four-strand HS ACLR. METHODS: This is a retrospective review of 15 patients who underwent arthroscopic ACLR using HS autograft tendon and were followed up radiographically at 4 months, 2 years and 15 years. Suspensory fixation was used for both ends of the graft. The diameters of the bone tunnels on posteroanterior (PA) and lateral radiographs were measured using digital callipers. Repeated measures analysis of variance (ANOVA) was used to examine change in tunnel width over time. RESULTS: Radiographic tunnel width did not significantly change between 4 months and 2 years. However, a significant decrease in width was found for both the femoral and tibial tunnels between the 2- and 15-year follow-up (P < 0.01): the femoral tunnel decreased by 50% and 51% in the PA and lateral views, respectively; the tibial tunnel decreased by 77% and 91% in the PA and lateral views respectively. There was no significant correlation between femoral or tibial tunnel width and flexion and extension deficits or with side to side differences in anterior tibial laxity at 15 years. CONCLUSIONS: This radiographic follow-up study of bone tunnel widening following HS ACLR with suspensory fixation demonstrated that tunnel width did not increase beyond 4 months and in fact had decreased significantly at long-term (15 years) follow-up. There was no correlation between tunnel width changes and clinical assessment of flexion and extension deficits or with side-to-side anterior knee laxity at 15-years. LEVEL OF EVIDENCE: IV.

The management of menopause in women with a history of endometriosis: a systematic review.

BACKGROUND: Endometriosis is typically regarded as a premenopausal disease, resolving after natural or iatrogenic menopause due to declining oestrogen levels. Nonetheless, case reports over the years have highlighted the incidence of recurrent postmenopausal endometriosis. It is now clear that both recurrence and malignant transformation of endometriotic foci can occur in the postmenopausal period. Postmenopausal women are commonly treated with hormone replacement therapy (HRT) to treat climacteric symptoms and prevent bone loss; however, HRT may reactivate endometriosis and stimulate malignant transformation in women with a history of endometriosis. Given the uncertain risks of initiating HRT, it is difficult to determine the best menopausal management for this group of women. OBJECTIVE AND RATIONAL: The aim of this study was to systematically review the existing literature on management of menopausal symptoms in women with a history of endometriosis. We also aimed to evaluate the published literature on the risks associated with HRT in these women, and details regarding optimal formulations and timing (i.e. initiation and duration) of HRT. SEARCH METHODS: Four electronic databases (MEDLINE via OVID, Embase via OVID, PsycINFO via OVID and CINAHL via EbscoHost) were searched from database inception until June 2016, using a combination of relevant controlled vocabulary terms and free-text terms related to 'menopause' and 'endometriosis'. Inclusion criteria were: menopausal women with a history of endometriosis and menopausal treatment including HRT or other preparations. Case reports/series, observational studies and clinical trials were included. Narrative review articles, organizational guidelines and conference abstracts were excluded, as were studies that did not report on any form of menopausal management. Articles were assessed for risk of bias and quality using GRADE criteria. OUTCOMES: We present a synthesis of the existing case reports of endometriosis recurrence or malignant transformation in women undergoing treatment for menopausal symptoms. We highlight common presenting symptoms, potential risk factors and outcomes amongst the studies. Sparse high-quality evidence was identified, with few observational studies and only two randomized controlled trials. Given this paucity of data, no definitive conclusions can be drawn concerning risk. WIDER IMPLICATIONS: Due to the lack of high-quality studies, it remains unclear how to advise women with a history of endometriosis regarding the management of menopausal symptoms. The absolute risk of disease recurrence and malignant transformation cannot be quantified, and the impact of HRT use on these outcomes is not known. Multicentre randomized trials or large observational studies are urgently needed to inform clinicians and patients alike.

A walking program for people with severe knee osteoarthritis did not reduce pain but may have benefits for cardiovascular health: a phase II randomised controlled trial.

OBJECTIVE: The primary aim was to evaluate the effect of a dosed walking program on knee pain for patients with severe knee osteoarthritis (OA). Secondary aims evaluated the effects on cardiovascular health, function and quality of life. DESIGN: Participants with severe knee OA and increased cardiovascular risk were randomly assigned to a 12-week walking program of 70 min/week of at least moderate intensity, or to usual care. The primary outcome was knee pain (0-10). Secondary outcomes were of cardiovascular risk including physical activity, blood pressure, blood lipid and glucose levels, body mass index and waist circumference; WOMAC Index scores; physical function; and quality of life. RESULTS: Forty-six participants (23 each group) were recruited. Sixteen participants (70%) adhered to the walking program. Intention to treat analysis showed no between-group difference in knee pain. The walking group had increased odds of achieving a healthy systolic blood pressure (OR = 5.7, 95% CI 1.2-26.9), and a faster walking speed (Mean Difference (MD) = 0.12 m/s, 95% CI 0.02-0.23). Per protocol analysis based on participant adherence showed the walking group had more daily steps (MD = 1345 steps, 95% CI 365-2325); more time walking (MD = 18 min/day, 95% CI 5-31); reduced waist circumference (MD = -5.3 cm, 95% CI -10.5 to -0.03); and increased knee stiffness (MD = 0.9 units, 95% CI 0.07-1.8). CONCLUSIONS: Patients with severe knee OA prescribed a 12-week walking program of 70 min/week may have had cardiovascular benefits without decreasing knee pain. Australian New Zealand Clinical Trials Registry ACTRN12615000015549.

The maximum tolerated dose of walking for people with severe osteoarthritis of the knee: a phase I trial.

OBJECTIVE: To determine how much physical activity, in the form of walking, can be safely and feasibly tolerated for people with severe knee osteoarthritis (OA). DESIGN: Phase I dose response trial with escalating walking doses of 10, 20, 35, 50, 70, and 95 min over 1 week, were prescribed non-randomly to people with severe knee OA. The primary stopping rule was a substantial increase in knee pain. The primary outcomes were an estimation of the maximum tolerated dose of walking; and the proportion of people who did not complete the dose for feasibility reasons. The secondary outcomes were pain, stiffness and activity limitation Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: Twenty-four participants (13 women) aged 53-83 years, and average body mass index (BMI) of 34 kg/m(2) (SD 9) were recruited. Three participants were assigned to each dose between 10 and 70 min, and nine participants assigned to the 95-min dose. The trial was stopped at 95 min due to the maximum number of adverse events occurring at this dose. Therefore, the maximum tolerated dose was 70 min. No participant stopped due to reasons related to feasibility. There was a moderate association between dose and increased activity (linear R(2) = 0.31, cubic R(2) = 0.69) and reduced stiffness (linear R(2) = 0.20, cubic R(2) = 0.52), with increased benefits at moderate to higher doses. CONCLUSIONS: There is preliminary evidence that 70 min per week of moderate intensity supervised walking was safe and feasible for people with severe OA of the knee; for higher doses there was a risk of exacerbating knee pain levels.

IL-17-producing NKT cells depend exclusively on IL-7 for homeostasis and survival.

Natural killer T (NKT) cells are innate-like T cells that rapidly recognize pathogens and produce cytokines that shape the ensuing immune response. IL-17-producing NKT cells are enriched in barrier tissues, such as the lung, skin, and peripheral lymph nodes, and the factors that maintain this population in the periphery have not been elucidated. Here we show that NKT17 cells deviate from other NKT cells in their survival requirements. In contrast to conventional NKT cells that are maintained by IL-15, RORγt(+) NKT cells are IL-15 independent and instead rely completely on IL-7. IL-7 initiates a T-cell receptor-independent (TCR-independent) expansion of NKT17 cells, thus supporting their homeostasis. Without IL-7, survival is dramatically impaired, yet residual cells remain lineage committed with no downregulation of RORγt evident. Their preferential response to IL-7 does not reflect enhanced signaling through STAT proteins, but instead is modulated via the PI3K/AKT/mTOR signaling pathway. The ability to compete for IL-7 is dependent on high-density IL-7 receptor expression, which would promote uptake of low levels of IL-7 produced in the non-lymphoid sites of lung and skin. This dependence on IL-7 is also reported for RORγt(+) innate lymphoid cells and CD4(+) Th17 cells, and suggests common survival requirements for functionally similar cells.

Multi-scaled drivers of ecosystem state: quantifying the importance of the regional spatial scale.

The regional spatial scale is a vital linkage for the informed extrapolation of results from local to continental scales to address broad-scale environmental problems. Among-region variation in ecosystem state is commonly accounted for by using a regionalization framework, such as an ecoregion classification. Rarely have alternative regionalization frameworks been tested for variables measuring ecosystem state, nor have the underlying relationships with the variables that are used to define them been assessed. In this study, we asked two questions: (1) How much among-region variation is there for ecosystems and does it differ by regionalization framework? (2) What are the likely causes of this among-region variation? We present a case study using a large data set of lake water chemistry, uni- and multi-scaled hydrogeomorphic and anthropogenic driver variables that likely influence lake chemistry at the subcontinental scale, and seven existing regionalization frameworks. We used multilevel models to quantify and explain within- and among-region variation in lake water chemistry. Our models account for local driver variables of ecosystem variation within regions, differences in regional mean ecosystem state (i.e., random intercepts in multilevel models), and differences in relationships between local drivers and ecosystem state by region (i.e., random slopes in multilevel models). Using one of the best performing regionalization frameworks (Ecological Drainage Units), we found that for lake phosphorus and alkalinity: (1) a majority of all the variation in water chemistry among the studied lakes occurred among regions, (2) very few regional-scale landscape driver variables were required to explain among-region variation in lake water chemistry, (3) a much higher proportion of the total variation among lakes was explained at the regional scale than at the local scale, and (4) some relationships between local-scale driver variables and lake water chemistry varied by region. Our results demonstrate the importance of considering the regional spatial scale for broad-scale research and ecosystem management and conservation. Our quantitative approach can be easily applied to other response variables, ecosystem types, geographic areas, and spatial extents to inform ecosystem responses to global environmental stressors.

Return of normal gait as an outcome measurement in acl reconstructed patients. A systematic review.

BACKGROUND: Current clinical outcome measurements may overestimate the long term success of anterior cruciate ligament reconstruction (ACLR). There is a need to understand biomechanics of the knee joint during daily activities. This systematic review provides a comprehensive overview of the literature related to gait in patients following ACLR. The purpose of this systematic review was to investigate the available literature and provide a comprehensive overview of kinematic and kinetic variables that present during gait in patients after ACLR. METHODS: A literature search was performed in AMED, CINAHL, EMBASE, Medline and Scopus between January 2000 and October 2012. Inclusion criteria included articles written in English, German or Dutch, and those reporting on gait analysis in patients after ACLR. Kinematic and/or kinetic data of the uninjured and ACLR knee and healthy controls (CTRL) were outcome measurements of interest. Each study's methodological quality was assessed using the Critical Appraisal Skills Programme critical appraisal tool. RESULTS: Twenty two studies fulfilled the inclusion criteria. A total of 479 patients with a mean age of 27.3 were examined. Time between the injury and surgery and ranged from 3 weeks to 5.7 years. Gait analysis was done at a mean of 29.3 months after surgery. Gait was found to be altered in the sagittal, frontal and transverse planes after ACLR and may take months or years to normalize, if normalization occurs at all. CONCLUSION: Patients after ACLR have altered gait patterns that can persist for up to five years after surgery. It is imperative that rehabilitation techniques are examined in order to minimize changes in knee biomechanics during gait, as they have the potential to impact on the development of osteoarthritis. LEVEL OF EVIDENCE: 3a.

What proportion of people with hip and knee osteoarthritis meet physical activity guidelines? A systematic review and meta-analysis.

OBJECTIVE: To determine the proportion of people with hip and knee osteoarthritis that meet physical activity guidelines recommended for adults and older adults. METHOD: Systematic review with meta-analysis of studies measuring physical activity of participants with hip and knee osteoarthritis using an activity monitor. Physical activity levels were calculated using the mean average [95% confidence interval (CI)] weighted according to sample size. Meta-analyses determined the proportion of people meeting physical activity guidelines and recommendations of (1) ≥150 min per week of moderate to vigorous physical activity (MVPA) in bouts of ≥10 min; (2) ≥150 min per week of MVPA in absence of bouts; (3) ≥10,000 steps per day and ≥7000 steps per day. The Grades of Research, Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of the evidence. RESULTS: For knee osteoarthritis, 21 studies involving 3266 participants averaged 50 min per week (95% CI = 46, 55) of MVPA when measured in bouts of ≥10 min, 131 min per week (95% CI = 125, 137) of MVPA, and 7753 daily steps (95% CI = 7582, 7924). Proportion meta-analyses provided high quality evidence that 13% (95% CI = 7, 20) completed ≥150 min per week of MVPA in bouts of ≥10 min, low quality evidence that 41% (95% CI = 23, 61) completed ≥150 min per week of MVPA in absence of bouts, moderate quality evidence that 19% (95% CI = 8, 33) completed ≥10,000 steps per day, and low quality evidence that 48% (95% CI = 31, 65) completed ≥7000 steps per day. For hip osteoarthritis, 11 studies involving 325 participants averaged 160 min per week (95% CI = 114, 216) of MVPA when measured in bouts of ≥10 min, 189 min per week (95% CI = 166, 212) of MVPA, and 8174 daily steps (95% CI = 7670, 8678). Proportion meta-analyses provided low quality evidence that 58% (95% CI = 18, 92) completed ≥150 min per week of MVPA in absence of bouts, low quality evidence that 30% (95% CI = 13, 50) completed ≥10,000 steps per day, and low quality evidence that 60% (95% CI = 47, 73) completed ≥7000 steps per day. CONCLUSION: A small to moderate proportion of people with knee and hip osteoarthritis met physical activity guidelines and recommended daily steps. Future research should establish the effects of increasing physical activity in this population to meet the current physical activity guidelines.

Levels of circulating angiogenic cells are not altered in women with endometriosis.

STUDY QUESTION: Are levels of circulating angiogenic cells (CACs) affected by the presence of endometriosis? SUMMARY ANSWER: Levels of CACs are equivalent in women with and without endometriosis. WHAT IS KNOWN ALREADY: Murine models have suggested a role for CACs in the development of endometriosis, but their levels in humans have not yet been studied. STUDY DESIGN, SIZE, DURATION: Eighty-seven women participated in this study. Recruitment took place from July 2010 to May 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: All women underwent laparoscopy for investigation of symptoms suggestive of endometriosis. Thirty women had no evidence of endometriosis, and 47 women were found to have endometriosis at laparoscopy. CAC levels were determined in peripheral blood by flow cytometry in 64 women. Colony forming unit (CFU) analysis was conducted in 30 women. A separate group of 10 healthy, asymptomatic women donated blood at four time points to assess the effect of the menstrual cycle on CAC levels. MAIN RESULTS AND THE ROLE OF CHANCE: For the whole sample, CAC levels (0.0797 ± 0.0052%) and CFU number (10.68 ± 1.98) were equivalent in women with and without endometriosis. CAC levels and CFU number were also unaffected by the stage of disease. No changes in CACs were detected during the menstrual cycle. LIMITATIONS, REASONS FOR CAUTION: A difference of at least one standard deviation between the groups would be required to detect a difference with this sample size. Therefore, while CAC levels are not a useful biomarker of disease it is still possible that they are modestly altered by the presence of endometriosis. We did not describe specific types of lesion and it is possible that CAC elevation only occurs when vessel development is at its most prolific. Furthermore, although signals from endometriotic lesions may recruit CACs from blood, this may be insufficient to alter peripheral levels. WIDER IMPLICATIONS OF THE FINDINGS: These data show that CACs are not a useful biomarker of endometriosis and indicate that they may be unaffected by the presence of this disease. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by grants from the MRC (New Investigator Award, G0601458 to C.M.B.), the Oxford Partnership Comprehensive Biomedical Research Centre with funding from the Department of Health's NIHR Biomedical Research Centres Scheme and the Oxfordshire Health Services Research Committee (OHSRC). There are no conflicts of interest to be declared.

Regulatory T cells expressing granzyme B play a critical role in controlling lung inflammation during acute viral infection.

The inflammatory response to lung infections must be tightly regulated, enabling pathogen elimination while maintaining crucial gas exchange. Using recently described "depletion of regulatory T cell" (DEREG) mice, we found that selective depletion of regulatory T cells (Tregs) during acute respiratory syncytial virus (RSV) infection enhanced viral clearance but increased weight loss, local cytokine and chemokine release, and T-cell activation and cellular influx into the lungs. Conversely, inflammation was decreased when Treg numbers and activity were boosted using interleukin-2 immune complexes. Unexpectedly, lung (but not draining lymph node) Tregs from RSV-infected mice expressed granzyme B (GzmB), and bone marrow chimeric mice with selective loss of GzmB in the Treg compartment displayed markedly enhanced cellular infiltration into the lung after infection. A crucial role for GzmB-expressing Tregs has not hitherto been described in the lung or during acute infections, but may explain the inability of children with perforin/GzmB defects to regulate immune responses to infection. The effects of RSV infection in mice with defective immune regulation closely parallel the observed effects of RSV in children with bronchiolitis, suggesting that the pathogenesis of bronchiolitis may involve an inability to regulate virus-induced inflammation.

Greater peak rearfoot eversion predicts foot orthoses efficacy in individuals with patellofemoral pain syndrome.

OBJECTIVE: There is growing evidence for the provision of foot orthoses when treating individuals with patellofemoral pain syndrome (PFPS), and prescription is frequently based on the assessment of foot posture/function. However, evaluation of the link between abnormal foot posture/function and foot orthoses outcomes has previously been limited to static alignment measures and has produced inconsistent findings. In this study, the ability of baseline foot kinematics associated with pronation to predict marked improvement 12 weeks following foot orthoses prescription in individuals with PFPS was evaluated. METHODS: 26 individuals with PFPS were issued with prefabricated foot orthoses, and patient-reported level of improvement was documented at 12 weeks. Potential predictors of marked improvement at 12 weeks were measured during walking at baseline and included forefoot dorsiflexion and abduction, and rearfoot eversion. RESULTS: Of the 25 participants who completed the study, seven (28%) reported marked improvement with the foot orthoses after 12 weeks. Discriminant function analysis revealed a greater peak rearfoot eversion to be the only significant independent predictor of marked improvement. CONCLUSION: These findings provide preliminary evidence that greater peak rearfoot eversion is predictive of marked improvement 12 weeks following prefabricated foot orthoses prescription in individuals with PFPS. Therefore, foot orthoses may be most effective in the subgroup of people with PFPS and increased dynamic foot pronation.

Outcome of surgery for recurrent patellar dislocation based on the distance of the tibial tuberosity to the trochlear groove.

We evaluated the outcome in a series of patients with recurrent patellar dislocation who had either medial transfer of the tibial tuberosity and lateral release or an isolated lateral release as the primary treatment. The decision to use one or other procedure was based on a pre-operative distance between the tibial tuberosity to the trochlear groove (TTTG) of less than 10 mm to include the tibial tuberosity transfer in addition to the lateral release. Between April 2002 and December 2006, 49 patients (63 knees) underwent one of these procedures. A total of 35 patients (46 knees) was evaluated at a mean of 38 months (13 to 71) post-operatively. Medial transfer of the tibial tuberosity was performed in 33 knees and isolated lateral release in the remaining 13. Evaluation included the International Knee Documentation Committee (IKDC), the Kujala and the Short-form 36 scores. From the tibial tuberosity group 23 knees also underwent radiological examination at follow-up. There were further episodes of patellar dislocation in six of the 46 knees available for review. Further dislocation was noted in five of 33 knees (15.2%) in the tibial tuberosity transfer group and in one of 13 knees (7.7%) in the lateral release group. The mean subjective IKDC score was 80.4 (sd 11.6), the mean Kujala score 88 (sd 8.2) and the mean objective IKDC score was 79% normal and 21% nearly normal. The mean post-operative TTTG distance in the tibial tuberosity transfer group was 8.9 mm (3.2 to 15.7) compared with the mean pre-operative value of 16.8 mm (12.2 to 24.4).

A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery.

OBJECTIVE: To determine whether the psychological characteristics of athletes who have undergone an anterior cruciate ligament (ACL) reconstruction change during rehabilitation are related to returning to competitive sport. DESIGN: Prospective longitudinal study. METHOD: 87 athletes completed the Emotional Response of Athletes to Injury Questionnaire (ERAIQ) and the ACL Return to Sport after Injury scale (ACL-RSI) at 3, 6 and 12 months following ACL reconstruction surgery. Physical outcome measures were also taken at each time point. RESULTS: At 12 months 44 (51%) participants had returned to competitive sport and 43 (49%) participants had not returned. There were no differences in physical recovery or scores on the ERAIQ between the two groups. Participants who had returned to competitive sport at 12 months, however, scored significantly higher on the ACL-RSI scale (reflecting a more positive psychological response about sport participation) at both 6 and 12 months than participants who had not returned to competitive sport. CONCLUSIONS: During rehabilitation there are significant psychological differences regarding sport resumption between athletes who do, and do not, resume competitive sport 12 months following ACL reconstruction. These differences occur as early as 6 months postoperatively and highlight the importance of addressing all aspects of an athlete's recovery in order to help facilitate the athlete returning to sport.

Expression of autoimmune regulator gene (AIRE) and T regulatory cells in human thymomas.

Expression of the autoimmune regulator gene (AIRE) and the presence of CD25(+)/forkhead box p3 (FoxP3)(+) T regulatory (T(reg)) cells were investigated in histologically normal adult thymi and in thymomas using immunohistochemistry and quantitative real-time polymerase chain reaction (PCR). In the normal thymus staining for AIRE was detected in the nucleus of some epithelial-like cells located in the medulla; in thymomas AIRE-positive cells were extremely rare and could be detected only in the areas of medullary differentiation of two B1 type, organoid thymomas. RNA was extracted from 36 cases of thymoma and 21 non-neoplastic thymi obtained from 11 myasthenic (MG(+)) and 10 non-myasthenic (MG(-)) patients. It was found that AIRE is 8.5-fold more expressed in non-neoplastic thymi than in thymomas (P = 0.01), and that the amount of AIRE transcripts present in the thymoma tissue are not influenced by the association with MG, nor by the histological type. A possible involvement of AIRE in the development of MG was suggested by the observation that medullary thymic epithelial cells isolated from AIRE-deficient mice contain low levels of RNA transcripts for CHRNA 1, a gene coding for acetylcholine receptor. Expression of human CHRNA 1 RNA was investigated in 34 human thymomas obtained from 20 MG(-) patients and 14 MG(+) patients. No significant difference was found in the two groups (thymoma MG(+), CHRNA1 = 0.013 +/- 0.03; thymoma MG-, CHRNA1 = 0.01 +/- 0.03). In normal and hyperplastic thymi CD25(+)/Foxp3(+) cells were located mainly in the medulla, and their number was not influenced by the presence of MG. Foxp3(+) and CD25(+) cells were significantly less numerous in thymomas. A quantitative estimate of T(reg) cells revealed that the levels of Foxp3 RNA detected in non-neoplastic thymi were significantly higher (P = 0.02) than those observed in 31 cases of thymomas. Our findings indicate that the tissue microenvironment of thymomas is defective in the expression of relevant functions that exert a crucial role in the negative selection of autoreactive lymphocytes.

Kinematic patterns associated with accuracy of the drop punt kick in Australian Football.

Research into the kinematics of movement associated with the accuracy of the drop punt kick in Australian Football has been limited. The aim of this study was to examine pelvic and lower limb kinematics during the performance of a drop punt kick, in order to identify factors associated with accurate kicking performance. Ten professional Australian Football League (AFL) players performed 20 drop punt kicks towards a target situated 15m away, using their preferred leg. A three-dimensional motion analysis system was used to record the kicking motion from heel contact of the support limb through to ball contact. The subjects were divided into an accurate group (> or =50% accuracy; n=5) and an inaccurate group (<50% accuracy; n=5) based on target hit rate. Kinematic profiles for both kicking and support limbs were compared between the two groups. Results showed that the accurate group had significantly greater hip flexion in both limbs and greater knee flexion in the support limb throughout the kicking movement. The accurate group also had significantly greater anterior pelvic tilt at heel contact (accurate 20.8 degrees ; inaccurate 12.7 degrees ). These data show that kinematic differences in lower limb joint angles may be related to kicking accuracy.

Anthropometry, physical performance, and ultrasound patellar tendon abnormality in elite junior basketball players: a cross-sectional study.

OBJECTIVE: Patellar tendinopathy has been reported to be associated with many intrinsic risk factors. Few have been fully investigated. This cross-sectional study examined the anthropometric and physical performance results of elite junior basketball players with normal or abnormal patellar tendons to see if any measures were associated with changes in tendon morphology. METHODS: Agility, leg strength, endurance, and flexibility were measured in 71 male and 64 female players. A blinded radiologist ultrasonographically examined their patellar tendons and athletes were grouped as having normal or abnormal tendons. One-way ANOVA was used to test for differences in anthropometric and physical performance data for athletes whose tendons were normal or abnormal (unilateral or bilateral tendinopathy) on ultrasound. RESULTS: Results show that females with abnormalities in their tendons had a significantly better vertical jump (50.9+/-6.8 cm) than those with normal tendons (46.1+/-5.4 cm) (p = 0.02). This was not found in males. In males, the mean sit and reach in those with normal tendons (13.2+/-6.7 cm) was greater (p<0.03) than in unilateral tendinopathy (10.3+/-6.2 cm) or in bilateral tendinopathy (7.8+/-8.3 cm). In females, those with normal tendons (13.3+/-4.8 cm) and bilateral tendinopathy (15.8+/-6.2 cm) were distinctly different from those with unilateral tendinopathy (7.9+/-6.6 cm). CONCLUSION: Flexibility and vertical jump ability are associated with patellar tendinopathy and the findings warrant consideration when managing young, jumping athletes.

Effect of physiotherapy attendance on outcome after anterior cruciate ligament reconstruction: a pilot study.

BACKGROUND: In many centres patients are routinely referred for physiotherapy after anterior cruciate ligament (ACL) reconstruction. However, to date the role and amount of supervised physiotherapy required has not been clearly established. OBJECTIVE: To establish whether there was any difference in outcome between a group of patients who attended physiotherapy regularly after ACL reconstruction and a group who attended only infrequently. METHODS: Ten patients who had attended physiotherapy infrequently (mean 1.9 visits) during the first six months after ACL reconstructive surgery were matched for age, sex, graft type, and activity level and occupation before injury with 10 patients who had attended physiotherapy regularly (mean 26.5 visits). Outcome was assessed at 12 months using the Cincinnati knee rating system and the IKDC form. RESULTS: Compared with the regular physiotherapy group, patients in the minimal physiotherapy group had fewer symptoms (mean Cincinnati symptom score 46.2 v 43.4, p = 0.045). There was also a trend towards higher overall Cincinnati knee scores in the minimal physiotherapy group (mean 93.7 v 87.3, p = 0.06) but no difference in IKDC ratings. CONCLUSION: These preliminary results indicate that some patients who choose to attend physiotherapy on a very limited basis after ACL reconstruction can achieve satisfactory, if not better, outcomes than patients who attend physiotherapy regularly.

Early post-operative morbidity following anterior cruciate ligament reconstruction: patellar tendon versus hamstring graft.

This study documented postoperative morbidity during the first 4 months following anterior cruciate ligament (ACL) reconstruction using either patellar tendon or hamstring tendon autograft. Sixty-five patients undergoing primary arthroscopically assisted single-incision ACL reconstruction were randomized to have a central third bone patellar tendon bone autograft (PT) or a doubled semitendinosus/doubled gracilis autograft (HS). Postoperatively patients undertook a standard 'accelerated' rehabilitation protocol. Patients were reviewed after 2 weeks, 8 weeks, and 4 months. At each review the location and severity of general knee pain and the presence and severity of anterior knee pain (AKP) were recorded as were the presence and size of an effusion as well as the active and passive flexion and passive extension deficits compared to the contralateral limb. Pain on kneeling, KT-1000 measured side to side difference in anterior tibial displacement, isokinetic assessment of quadriceps and hamstring peak torque deficits, IKDC score and Cincinnati sports activity level were also recorded after 4 months. After 2 weeks more patients in the PT group complained of AKP and reported that the pain was more severe. After 8 weeks there was no significant difference between the groups for any variable. After 4 months the severity of general pain experienced and the incidence of pain on kneeling were greater in the PT group. The PT group also demonstrated a significantly greater quadriceps peak torque deficit at 240 degrees /s. IKDC scores were higher in the HS group, but Cincinnati sports activity scores were higher in the PT group. Although we observed a lower morbidity in the HS group, primarily related to pain, the severity of pain in both groups was relatively low and, in light of the higher mean sports activity level observed in the PT group at 4 months the clinical impact of the difference may not be significant.

Clinical value of magnetic resonance imaging of the knee.

BACKGROUND: Magnetic resonance (MR) imaging is an accurate imaging modality of the knee. The role of MR in clinical practice has not been precisely defined, largely due to the relative expense of the technique. METHODS: For each new patient with a knee problem who was referred for MR, a provisional diagnosis was made together with a level of certainty regarding the diagnosis. The waiting time for the scan was recorded. To assess clinical usefulness the MR diagnosis was compared with the provisional diagnosis and classified according to the following descending order of value: unexpected negative (no intra-articular pathology), confirmatory negative, unexpected positive or confirmatory positive. To assess accuracy of the MR diagnosis, the operative diagnosis was compared to the MR diagnosis in those patients who underwent arthroscopy. RESULTS: Fifty-two per cent of scans were assessed as being very useful and a further 20% were assessed as being moderately useful. Magnetic resonance had a 95% accuracy for medial meniscal tears, 91% accuracy for lateral meniscal tears, and 98% accuracy for anterior cruciate ligament tears, similar to previously reported studies. The diagnostic arthroscopy rate in the patients who underwent MR scanning was similar to that in patients for whom the surgeon was more confident about the diagnosis and who therefore did not undergo MR scanning. The diagnostic arthroscopy rate could have been reduced if surgery had not been performed in 14 patients who had a negative MR scan. CONCLUSIONS: There is a role for selective use of MR in the assessment of knee conditions. In particular, MR can be used to reduce the diagnostic arthroscopy rate.

Bone tunnel enlargement following anterior cruciate ligament reconstruction: a randomised comparison of hamstring and patellar tendon grafts with 2-year follow-up.

Radiographic tibial and femoral bone tunnel enlargement has been demonstrated following anterior cruciate ligament (ACL) reconstruction. This study investigated whether bone tunnel enlargement differs between four-strand hamstring (HS) and patellar tendon (PT) ACL reconstructions over the course of a 2-year follow-up. Patients undergoing primary ACL reconstruction (n = 65) were randomised to receive either a PT or HS autograft. Femoral fixation in both groups was by means of an Endobutton. On the tibial side the PT grafts were fixed using a metallic interference screw, and the HS tendons by sutures tied to a fixation post. The PT grafts were inserted such that the proximal end of the distal bone block was within 10 mm of the tibial articular surface, resulting in a portion of free patellar tendon in the femoral tunnel immediately proximal to the articular surface. Patients were reviewed after 4 months and 1 and 2 years. Tunnel enlargement was determined by measuring the widths of the femoral and tibial tunnels with a digital caliper in both lateral and anteroposterior radiographs. Because of the presence of the interference screw and the proximity of the bone block to the tibial articular surface, the tibial tunnel could not be reliably measured in the PT group. Measurements were corrected for magnification, and changes in tunnel width were recorded relative to the diameters drilled at surgery. Standard clinical measures were also noted. In 32% of patients in the PT group there was femoral tunnel obliteration from 4 months onwards. For the other patients there was a significantly greater increase in femoral tunnel width in the HS group than in the PT group at each follow-up, but no significant change with time. There was also a marked increase in tibial tunnel width in the HS group at 4 months but not thereafter. There was no relationship between tunnel enlargement and clinical measurements. Although tunnel enlargement is more common and greater with HS grafts, it does not appear to affect the clinical outcome in the first 2 postoperative years. Femoral suspensory fixation does not in itself appear to be the principal cause of femoral tunnel enlargement, at least for PT grafts.