Clinical relevance of 3D gait analysis in patients with haemophilia.

Haemophilia is characterized by a congenital deficiency of clotting factor VIII or IX. One of the consequences of haemophilia is joint bleedings. Repetitive haemathroses induce cartilage damage and chronic synovitis leading to joint deterioration, and to definitive haemophilic arthropathy which is source of walking disability. Three-dimension gait analysis (3DGA) appears particularly relevant in the case of haemophilia because it allows an evaluation of several joints in weight-bearing situations. The purpose of this study was to review the interest and the contribution of 3DGA in the management of patients with haemophilia. The greatest interest of gait analysis would be to detect early walking changes with a non-invasive and well-tolerated examination, especially in paediatric population. In adulthood, this technic may be also useful to help detect walking worsening in patients known to have already arthropathy. However, it takes time to realize and needs expensive equipment, which limits its possibility of routine use. Although generalizations of these results remain difficult, especially to compare patients with haemophilia to normal population. Indeed, in the studies, patient groups are small and usually heterogeneous in terms of age and target joints. It certainly results of the rarity of the disease. So, it could be interesting to perform a study with a larger cohort in order to allow subgroup analysis, helping to define clearly the place of 3DGA in the strategy of haemophilia evaluation.

Cutoffs of isokinetic strength ratio and hamstring strain prediction in professional soccer players.

Hamstring strain injuries frequently occur during professional soccer practice. Low hamstring strength represents an intrinsic modifiable risk factor but cutoffs of isokinetic knee strength ratios are controversial to predict hamstring strain in professional soccer players. We aimed to predict hamstring strain in accordance with cutoffs of isokinetic knee strength ratios. Bilateral, conventional, and functional isokinetic strength ratios were calculated in 194 professional soccer players at the beginning of 15 consecutive seasons. 36 soccer players presented a moderate hamstring strain and 158 were not injured. The different calculated isokinetic ratios were compared with the right and left limb of the uninjured population. Different usual cutoffs were tested: at 0.85 and 0.90 for the bilateral concentric and eccentric hamstring-to-hamstring ratio, at 0.60 and 0.47 for the conventional hamstring-to-quadriceps ratio and at 0.80 and 1 for the mixed hamstring-to-quadriceps ratio. The specific ratios for the studied population were also determined by the 10th percentile and then tested. Hamstring strain prediction was established in terms of odds ratios. No cutoff with bilateral, conventional, or functional isokinetic strength ratio was predictive of hamstring strain after univariate analysis. Specific cutoffs determined from the studied population were not more predictive. Very few injured soccer players presented values under the cutoffs at 0.47 for the conventional ratio and at 0.80 for the mixed ratio. Regardless of their values, cutoffs of isokinetic strength ratios were not predictive of hamstring injuries. The use of isokinetic cutoffs is not recommended to predict hamstring muscle strain in professional soccer players.

Muscular isokinetic strength recovery after knee anterior cruciate ligament reconstruction revision: preliminary study.

METHOD: Thirty-nine revision of ACL reconstructions were evaluated: 23 primary ACL reconstructions with bone-patellar tendon-bone graft (BPTB) revised with hamstring tendon (HT) grafts, 10 primary ACL reconstructions with HT grafts revised with ipsilateral BPTB graft (iBPTB) and finally 6 primary ACL reconstructions with BPTB grafts revised with contralateral BPTB (cBPTB) grafts were compared with 78 primary ACL reconstructions (46 HT grafts and 32 BPTB grafts). Recovery of isokinetic muscle strength was evaluated at 4, 6 and 12 months post-revision surgery. RESULTS: Deficits in muscle strength at 12 months post-revision ACL surgery were comparable to the one observed for primary ACL reconstruction with the same technique. At 4 and 6 months post-surgery, strength deficits for the knee extensors were less pronounced after revision ACL reconstruction with HT grafts (25%±16 vs. 37%±16; P<0.001) and iBPTB grafts (41%±11 vs. 17%±17; P<0.001). DISCUSSION: Lower strength deficits for the knee extensors after revision ACL reconstruction with HT grafts can be explained by a less intensive rehabilitation program due to lower stakes in resuming sport activities. With cBPTB, donor-site morbidity could explain the decreased strength deficits for knee extensors. CONCLUSION: Deficits in isokinetic muscle strength after ACL revision seem similar to the ones observed after primary ACL reconstruction with the same surgical technique.

Care pathways in physical and rehabilitation medicine (PRM): the patient after shoulder stabilization surgery.

This document is part of the "Care pathways in physical and rehabilitation medicine" series developed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Physical and Rehabilitation Medicine Federation (FEDMER). For a given patient profile, each concise document describes the patient's needs, the care objectives in physical and rehabilitation medicine, the required human and material resources, the time course and the expected outcomes. The document is intended to enable physicians, decision-makers, administrators and legal and financial specialists to rapidly understand patient needs and the available care facilities, with a view to organizing and pricing these activities appropriately. Here, patients with shoulder instability requiring surgical stabilization are classified into five care sequences and two clinical categories, each of which are treated according to the same six parameters and by taking account of personal and environmental factors (according to the WHO's International Classification of Functioning, Disability and Health) that may influence patient needs.

Using the Risk Assessment and Predictor Tool (RAPT) for patients after total knee replacement surgery.

OBJECTIVES: The aim of this study was to use the Risk Assessment and Predictor Tool (RAPT) to evaluate the risk of complications in patients hospitalized after total knee replacement (TKR) surgery. METHOD: The medical charts of 272 patients who had TKR surgery for knee osteoarthritis (OA) were included in the study. The presurgical RAPT score and Lequesne functional pain index score were determined based on a thorough analysis of the medical charts. Complications that had an impact on the vital prognosis or knee prosthesis outcomes were reported. Patients were compared according to the RAPT and a relative risk of complications was established. RESULTS: Only 12.2% of patients hospitalized in a Physical Medicine and Rehabilitation (PM&R) center after their surgery could have been discharged home directly after their initial hospital stay for TKR surgery (score RAPT more than 9). These patients were mostly men and significantly younger. Their Lequesne score was significantly lower by an average of at least two points. Their relative risk of complications was 0.45 vs. 2.16 for patients who had a RAPT score less than 6. CONCLUSION: Patients with a RAPT score more than 9 have a low risk of complications. They should not systematically be admitted to a PM&R unit after surgery. On the other hand, for patients with a RAPT score less than 6 a hospital stay in a PM&R care center is justified after TKR surgery.

Incidence of injuries in French professional soccer players.

In this prevalence cohort study, injuries sustained during 15 seasons in a professional soccer team were investigated according to the different soccer seasons, number of matches per season, month the injury occurred, location, severity, playing position and the team's rank at the end of the French professional championship. Altogether, 903 injuries in 173 professional soccer players were reported. Injury incidence per 1 000 h of exposure during matches and training was 4.7±5. This incidence did not vary significantly between seasons. However, injury incidence increased after the year 2003 and constantly exceeded 4.2. In the same way, after 2002 muscle injury incidence always exceeded 2 per 1 000 h of exposure. Injury incidence peaked during the month of January. Hamstring muscle injury represented the most frequent injury. No difference in injury incidence was found according to the playing position or to the season whether the team participated or not in the European cup. No correlation was found with the team's rank at the end of the French championship. This study highlighted no significant variation on injury incidence over a 15-season period except for the muscle injury rate in high level soccer players.

Effects of running retraining after knee anterior cruciate ligament reconstruction.

OBJECTIVE: The aim of this study was to analyze the effect of running retraining on the recovery of the knee's functional and muscular properties after anterior cruciate ligament (ACL) reconstruction. METHODS: Eighty-five athletes who had undergone ACL reconstruction surgery were selected randomly to receive, or not to receive, controlled running training based on interval training and speed exercises. The effect of retraining was measured by the evolution of the knee's isokinetic strength deficit and progress (at angular speeds of 60 and 180 degrees /s), the knee laxity parameters and the score on the Lysholm Knee Scale from the 4th to the 6th month after the surgery. Forty subjects were retrained and compared with 40 control-group subjects. The effect of the retraining program was studied in terms of the type of ACL reconstruction and the effect of time. RESULTS: After retraining, no difference was found for isokinetic knee strength deficit and progress, knee laxity and Lysholm Knee Score. The isokinetic strength deficit was influenced mainly by the type of ACL reconstruction. CONCLUSION: It would seem that running retraining has an insufficient effect on the muscular and functional recovery after ACL reconstruction, despite the fact that this type of training is well-tolerated.

Which factors affect the duration of inpatient rehabilitation after total knee arthroplasty in the absence of complications?

OBJECTIVE: The aim of this study was to determine which preoperative factors might predict the duration of inpatient rehabilitation for total knee arthroplasty (TKA) patients in the absence of complications. METHODS: We included 282 patients who had undergone primary TKA for osteoarthritis. The aim of the rehabilitation program was to recover 90 degrees of active knee flexion and good enough functional status to allow direct discharge to the patient;s home. Patients presenting complications were excluded. The following preoperative parameters were recorded: demographic factors, comorbidity, previous lower limb arthroplasty, the presence of a home help, the pain level (on a visual analogue scale, VAS) and functional scores. The length of stay in the orthopaedic surgery unit was also taken into consideration. Predictive factors for the duration of inpatient rehabilitation were analyzed using univariate and then multivariate linear regression. RESULTS: In a univariate analysis, the length of stay (24.1 +/- 8.1 days) depended on female gender, living alone, the presence of a home help and previous arthroplasty ( p < 0.25). However, when these factors were introduced into a multivariate predictive model, only 2% of the variation in the length of stay was accounted for. CONCLUSION: The duration of inpatient rehabilitation for TKA patients in the absence of complications cannot be statistically modelled from the preoperative parameters studied here.

[Return to pivot-contact sports after anterior cruciate ligament reconstruction: patellar tendon or hamstring autografts]. / Reprise du sport pivot-contact après reconstruction du ligament croisé antérieur : technique au tendon patellaire ou aux ischiojambiers.

PURPOSE OF THE STUDY: The purpose of this study was to compare outcome at 12 months and return of pivot-contact sports in male subjects having undergone anterior cruciate ligament reconstruction using a patellar tendon or four-strand hamstring autografts. MATERIAL AND METHODS: Sixty male athletes underwent arthroscopic ligament reconstruction using either a patellar graft or a hamstring graft. The two groups were comparable for age (25+/-6 years), height (177+/-5cm), weight (74+/-8kg), pivot-contact sports, and level of sports activity. The two groups were reviewed at four, six and 12 months. The Lysholm and Tegner scores were noted and isokinetic tests were performed (60 and 180 degrees /s). The comparison was completed at twelve months with the single-legged hop test, instrumental laximetry (KT-1000) and the Arpege and IKDC 2000 scores. Return to pivot-contact sports at the same level was assessed at last follow-up after having been encouraged at the nine-month check-up. RESULTS: At twelve months, the function scores (IKDC 2000, Lysholm: 99.4+/-5 versus 98+/-5, Tegner: 6.8+/-1 versus 6.5+/-1) and single-legged hop test (94+/-5% versus 95+/-7%) were comparable. Instrumental laxity measurements however demonstrated greater laxity with the hamstring graft (2.7+/-0.4mm versus 1.8+/-0.3mm, p=0.02). A knee extension deficit was observed for the patellar technique (10+/-8%, p<0.01). A knee flexion deficit was observed for the hamstring technique (11+/-14%, p<0.01). Return to pivot-contact sports at the same level was comparable and concerned 53% [95%CI 41-66] of the knees after hamstring ligament reconstruction and 56.6% [44-68] of the knees after patellar ligamentoplasty. CONCLUSION: The two techniques of anterior cruciate ligament reconstruction were found to be equivalent in terms of return to pivot-contact sports at the same level. It was noted however that this resumed sports activity was possible for only one out of two subjects despite the systematic medical and surgical surveillance and selection of subjects free of any complication.

[Sports participation after joint arthroplasty]. / Recommandations du sport et prothèses articulaires: l'avis des chirurgiens orthopédistes, le désir des patients récemment opérés et la revue de la littérature.

OBJECTIVE: To recommand sports activities after joint arthroplasty from the literature analysis, the French surgeon's opinion and wish patients. METHOD: From the Medline data base interrogation according to keywords: Sports, Arthroplasty, Athletics, Physical training, two different readers, an orthopedic surgeon and a Physical Medicine and Rehabilitation physician selected articles in French or English language according to the level of proofs of the french classification of the Accreditation and Health Evaluation National Agency (Anaes). Professional practices were estimated by the interrogation of 30 orthopedic surgeons members of the french West Orthopaedics Society (SOO). The demand of sports practice was studied with patients recently operated for a primary total knee arthroplasty (TKA) after gonarthrosis. RESULT: Twenty-two articles were selected from 305 articles obtained by the search according to keywords. Ten literature reviews are limited by the absence of prospective randomized study. A level II study and eleven level IV articles are reported. DISCUSSION: According to the subjective orthropedic surgeon's opinion, the objective results based on the joint load studied and the percentage of arthroplasty revision, sport is beneficial for the individual health but perhaps not for the arthroplasty survey. However, aerobic and leisure activities are recommended (walking, swimming, cycling) in agreement with the demand of the patients recently operated with a TKA. TKA differs from Total Hip Arthroplasty for jogging because of knee joint constraints during the knee flexion. A single study reports sports possibilities after shoulder arthroplasty and ankle arthroplasty and no study reports results after elbow arthroplasty.

Physical training in rehabilitation programs before and after total hip and knee arthroplasty.

OBJECTIVE: A review of the literature to investigate physical training in rehabilitation programs before and after hip and knee arthroplasty. METHODS: We performed a literature search of the MedLINE and Cochrane databases since 1966 to 2006 using 8 keywords for articles of literature reviews or randomized controlled trials investigating physical training before and after hip and knee arthroplasty. RESULTS AND DISCUSSION: The search resulted in 14 articles: 2 reviews of the literature and 7 articles of studies concerning total hip arthroplasty and 5 knee arthroplasty. Results were difficult to analyze because of the low number of patients included, a high number of dropouts, no matched control populations, different physical training protocols, and the use of functional scores or inadequate parameters. We found no randomized controlled trial concerning physical training after knee arthroplasty. CONCLUSION: Physical training does not seem benefit patients before hip or knee arthroplasty. However, the training may have benefit immediately after, and particularly well after, total hip arthroplasty.

[Evolution of the isokinetic torque of shoulder rotators before and after 3 months of shoulder stabilization by the Latarjet technique]. / Evolution de la force isocinétique des rotateurs d'épaule avant et à trois mois d'une stabilisation de l'épaule par technique chirurgicale de Latarjet.

OBJECTIVE: To compare prospectively isokinetic shoulder strength before and 3 months after shoulder stabilization by the Latarjet procedure indicated for the treatment of recurrent dislocation. METHOD: Twenty-five subjects, 23+/-6 years old, with anterior unidirectional recurrent shoulder dislocation, underwent isokinetic concentric (con) and eccentric (ecc) measurement of lateral rotators (LR) and medial rotators (MR) of both shoulders at the angular speed of 60 and 120 degrees par second. Evaluation was carried out in the scapular plane with the patient in a sitting position one month before and 3 months after shoulder stabilization by the Latarjet technique. We calculated the concentric ratio LR/MR and mixed ratios LR(ecc)/MR(con) and LR(con)/MR(ecc). RESULTS: Before surgery, the rotator peak torque for the operated shoulder side was similar to that of the healthy shoulder side. The concentric ratio for the healthy shoulder side was higher because the lateral rotators were slightly weaker on the recurrent-dislocated shoulder side. Three months after shoulder stabilization by the Latarjet technique, for the operated shoulder side, the isokinetic concentric torque of rotators was similar to that before surgery. For the operated shoulder side, only the eccentric torque of medial rotators was significantly lower after surgery than before surgery and lower than that for the healthy shoulder side (9 to 15%). Ratios did not differ before and after surgery. CONCLUSION: Three months after surgery with Latarjet technique for recurrent dislocated shoulder, operated shoulders showed a slight strength deficit as compared with healthy shoulders. The concentric deficit after surgery was not significantly different from that before surgery. This result could be explained by strengthening exercises performed during the shoulder rehabilitation program. However, the eccentric strength deficit of medial rotators of the operated shoulder is certainly associated with the opening and stitching of the sub-scapular muscle necessary for the shoulder stabilization.

[Consequences of pain on isokinetic performance after anterior cruciate ligament reconstruction using a semitendinosus and gracilis autograft]. / Conséquences des douleurs à l'effort sur les performances isocinétiques après ligamentoplastie du genou aux tendons ischio-jambiers: étude longitudinale.

PURPOSE OF THE STUDY: The purpose of this study was to investigate isokinetic performance of the knee twelve months after ligamentoplasty of the anterior cruciate ligament using four-strand hamstring autografts. We wanted to ascertain the effect of exercise-induced postoperative pain. MATERIAL AND METHODS: Between January 2001 and January 2003, at total of 75 patients underwent arthroscopic hamstring ligamentoplasty performed by the same surgeon. Isokinetic measurements were obtained at 4, 6, and 12 months postoperatively. At four months, four subpopulations were identified depending on the presence or not of exercise-induced pain. RESULTS: Fifty-two patients were pain free, seven presented exercise-induced posterior pain, nine exercise-induced anterior pain and seven diffuse pain with more than 5 degrees limitation of extension and 10 degrees for flexion. Isokinetic measurements at an angular speed of 60 degrees /s performed at the fourth postoperative month were compared with the pain-free population and demonstrated a significant flexion deficit in patients with exercise induced posterior pain (32% vs 18%, p = 0.04), significant extension deficit in patients with exercise-induced anterior pain (45% vs 30%, p = 0.02), and significant deficit in extension (58% vs 30%, p = 0.001) and flexion (39% vs 18%, p = 0.01) in patients with diffuse pain and limited joint motion. Certain deficits persisted one year after surgery. Patients did not achieve their prior level in contact pivot sports if they presented exercise-induced anterior pain. The population with diffuse pain and limited joint motion only resumed line sports. DISCUSSION: It is not easy to ascertain the origin of knee pain after ligamentoplasty. Posterior pain at the harvesting site occurs after hamstring reconstruction (defective regeneration or incomplete disinsertion with muscle retraction). The hamstring technique can also lead to anterior pain involving all the structures of the extension system. Diffuse pain with limited joint motion is related to "minor" reflex dystrophy. CONCLUSION: A mean 10% extensor and flexor isokinetic deficit can be expected one year after four-strand hamstring ligamentoplasty. Isokinetic tests performed four months postoperatively in patients with exercise-induced pain can provide objective evidence of difficult recovery. Posterior exercise-induced pain is associated with a flexion deficit of more than 30%. Anterior pain with exercise is associated with 45% deficit in extension. Diffuse pain with limited joint motion is associated with more than 40% in flexion and more than 55% in extension. These quantitative results enable the surgeon to inform the patient concerning potential sports level after repair since recovery will be longer with greater deficit.

[Retraining between months 4 and 6 after anterior cruciate ligament reconstruction with hamstring graft: comparison between cycling and running with an untrained operated subject group]. / Réentraînement à l'effort entre le quatrième et le sixième mois après ligamentoplastie de genou au DIDT: comparaison de la pratique de la bicyclette et de la pratique du footing avec un groupe témoin non réentraîné.

OBJECTIVE: To study the effect of cycling or running retraining between 4 and 6 months after patients underwent anterior cruciate ligament reconstruction with hamstring grafting (Semitendinosus-Gracilis) compared with that in patients who had the same surgery but were untrained. METHOD: Patients who had undergone surgery for an anterior cruciate ligament reconstruction by the same surgeon who used hamstring grafting were included if they were free of knee pain 4 months after the surgery. After giving consent, patients were randomized to receive controlled retraining (cycling or running 3 times a week) or not. The effect of retraining was measured by the evolution of the knee isokinetic peak torque at 60 degrees/s and 180 degrees/s 6 months after surgery. RESULTS: Fifteen patients were retrained with cycling (GI), 17 with running (GII) and 15 patients did not retrain (GIII). Before retraining, the 3 groups had the same peak torque deficit, measured at an angular speed of 60 degrees/s and 180 degrees/s, for knee extensors (GI: 33+/-11% and 27+/-8%; GII: 30+/-13% and 24+/-10%; GIII: 31+/-15% and 24+/-13%, respectively) and knee flexors (GI: 26+/-11% and 20+/-13%; GII: 20+/-14% and 17+/-13%; GIII: 19+/-15% and 14+/-15%, respectively). After retraining, progress measured at 60 degrees /s of knee extensors and flexors on the operated knees was 18+/-9% and 16+/-10% for GI, 16+/-9% and 11+/-11% for GII and 12+/-15% and 8+/-12 for GIII, respectively. Progress measured at 180 degrees /s followed the same evolution. After comparison of the 3 groups, any significant difference was put in relief according to the type of retraining. CONCLUSION: Retraining after anterior cruciate ligament reconstruction is necessary for patients to practice their previous sport. In our study, aerobic cycling or running between 4 and 6 months after surgery did not improve peak torque in the operated knee extensors and flexors. However, these 2 types of retraining are well-tolerated.

Isokinetic and anterior cruciate ligament reconstruction with hamstrings or patella tendon graft: analysis of literature.

We report isokinetic results of anterior cruciate ligament reconstruction with patellar tendon or hamstring graft from the literature analysis. The literature was defined from two search "textwords": Isokinetic and Anterior cruciate ligament reconstruction, and from three databases: Medline, Pascal, and Herasmus. Two independent physicians (Physical Medicine and Rehabilitation) carried out an analysis according to the French National Accreditation and Health Evaluation Agency recommendations. Fifty-three studies were selected: 29 reported isokinetic results after anterior cruciate ligament reconstruction with patellar tendon graft, 15 reported isokinetic results after anterior cruciate ligament reconstruction with hamstring graft, and 9 studies compared the two surgical procedures. After discussing different bias and in reference to prospective randomised and comparative studies, the anterior cruciate ligament reconstruction with patellar tendon graft involves a knee extensors deficit during several months. The hamstring surgical procedure involves a less important knee extensor deficit (from 6 to 19 % against 8 to 21 %). Knee sprain and intra-articular surgery involve a long-lasting knee extensors deficit. Anterior cruciate ligament reconstruction with hamstrings graft involves a knee flexors deficit over several months. The patellar tendon surgical procedure involves a less important knee flexors deficit (from 1 to 15 % against 5 to 17 %). In reference to isokinetic parameters, no difference between the two surgical procedures (patellar tendon graft or hamstring graft) is shown after more than twenty-four post-surgical months.

[Detraining and retraining after injury in a high-level cyclist]. / Désentraînement et réentraînement du cycliste de haut niveau immobilisé par blessure.

OBJECTIVE: To define retraining after injury in a high-level cyclist by taking into account the consequences of detraining. METHOD: From three clinical cases and from the analysis of the consequences of detraining, three principles of retraining were determined. RESULTS: 1. The high-level cyclist is not protected and loses cycling capacity after four weeks of inactivity. The delay in recovery is longer the higher the adaptations. 2. Recovery of cycling capacity is based on bicycle exercises that are greater in intensity than quantity, taking into account delays in injury consolidation. 3. Retraining requires appreciating the individual physiological level by evaluating force and endurance before envisaging the resumption of training and competition. CONCLUSION: The injury of a high-level cyclist is at the origin of detraining, which has been evaluated so that sports rehabilitation may enable the cyclist to find a previous state without relapse, complication or overtraining.

[Stress fracture in athletes and prevalence of extensive rehabilitation]. / Fracture de fatigue chez le sportif et prise en charge intensive de rééducation.

OBJECTIVE: The aim of this work was to review the literature for the place of extensive rehabilitation for athletes with stress fractures. METHOD: We searched the Medline and Embase databases using the keywords stress fracture, sports, rehabilitation, management and treatment. Only French and English articles were included, and articles about bone physiology, animal models, and spine and chest localisations were excluded. From 468 scientific articles, 62 were chosen because they corresponded to literary reviews or to therapeutic evaluations. RESULTS: Treatment of stress fracture is justified according to risk factors, stress-fracture complications, the precocity of diagnosis, the therapeutic method and when the athlete needs to return to the sport. The most common treatment is discontinuing the sport, followed by rest. The progressive resumption of sport is rarely described but must take into account mechanical constraints that can be controlled by the use of shoes adapted to a supple ground. Some treatments such as immobilization by pneumatic splint surgery or use of electric fields are controversial. CONCLUSION: Extensive treatment of stress fractures is mainly dedicated to high-level athletes who need to regain previous physical capacities as soon as possible.