Femoral internal torsion greater than twenty-five degrees and/or external tibial torsion greater than thirty degrees as measured by computed tomography are threshold values for axial alignment correction in patellofemoral instability.

OBJECTIVES: Patellofemoral instability (PFI) has multiple predisposing anatomic factors, including ligamentous hyperlaxity, coronal and axial malalignment, patella alta, trochlea dysplasia, excessive lateral patellar tilt, and excessive lateral Q vector. Yet, few studies have analyzed surgical thresholds for performing axial alignment corrective osteotomies in the treatment of PFI and patella maltracking. The objective of this systematic literature review was to determine if there is a threshold for axial plane alignment that triggers surgical correction for the treatment of patellar instability in the published literature. METHODS: Using a predetermined search strategy, a systematic literature search of 10 major databases and gray literature resources was completed. Only studies reporting on patellar instability and outcomes were included. Radiologic indications, additional procedures, outcomes, and complications were reported. Titles and abstracts were screened, and full-text manuscripts were then selected and extracted. Variables related to radiographic and clinical parameters, patient demographics, surgery performed, surgical correction, complications, and reoperations were recorded preoperatively and postoperatively. RESULTS: A total of 1132 abstracts and titles were screened by two reviewers, yielding 15 eligible studies. The reported threshold identified in our study for axial plane alignment that triggers surgical correction in most of the published literature when discussing PFI was either tibial torsion greater than 30° and/or femoral anteversion greater than 25°. Following rotational osteotomy of one or both long bones, one study (7%) reported improvements in tubercle-sulcus angle, two studies (13%) reported improvements in femoral-tibial angle, and four studies (27%) reported decreases in tibial torsion. For patient-reported outcomes, seven studies (47%) reported improvement in the Kujala score, five studies (33%) reported postoperative improvement in Lysholm, and four studies (27%) reported improvement in the International Knee Documentation Committee (IKDC) score. Nine studies (60%) reported preoperative femoral anteversion; however, only two studies compared pre- and post-operative values (one study reported a decrease in anteversion and another study reported an increase in anteversion). CONCLUSION: When treating PFI, the reported threshold for axial plane alignment that triggers surgical correction in most of the published literature was tibial torsion greater than 30° and/or femoral anteversion greater than 25° as measured by CT. However, there is no consensus on the axial alignment measurement technique. LEVEL OF EVIDENCE: III.

Major complications after total hip arthroplasty with the direct anterior approach at a high-volume Ontario tertiary care centre.

BACKGROUND: The rate of major surgical complications for high-volume orthopedic surgeons using the direct anterior approach (DAA) in Ontario, Canada, is not known. The purpose of this study was to investigate the rate of major surgical complications after total hip arthroplasty (THA) using DAA performed by experienced orthopedic surgeons at a high-volume tertiary care centre in Ontario. METHODS: We conducted a retrospective cohort review of primary THA through DAA performed by 2 experienced fellowship-trained surgeons at an academic hospital in London, Ontario, between Jan. 1, 2012, and May 1, 2019. We excluded the first 100 cases to allow for surgeon learning curves. We recorded major surgical complications (intraoperative events, postoperative periprosthetic fractures, dislocation requiring closed or open reduction, implant failure [aseptic loosening or subsidence], early (< 6 wk) deep wound infection requiring irrigation and débridement, late (≥ 6 wk) deep wound infection requiring irrigation and débridement, and wound complications [wound dehiscence, stitch abscess, erythema, hematoma or seroma]) within 1 year of THA. RESULTS: A total of 875 primary DAA THA procedures were included. The rates of surgical complications were 0.9% for intraoperative events, 1.5% for postoperative periprosthetic fractures, 0.8% for implant failure, 0.7% for early deep wound infection, 0.1% for late deep wound infection and 3.2% for wound complications; there were no cases of dislocation. The rate of revision for implant failure within 1 year was 0.1%. Male sex was associated with a greater risk of implant failure (p = 0.01), and having a higher body mass index was associated with both increased rates of infection (p < 0.01) and having a wound complication (p < 0.01). CONCLUSION: Intraoperative events, postoperative periprosthetic fractures, implant failure, deep wound infection and wound complications accounted for the major surgical complications within 1 year of THA through DAA. The low revision rate suggests that DAA is a safe approach for THA.

Aerobic and Resistance Training Attenuate Differently Knee Joint Damage Caused by a High-Fat-High-Sucrose Diet in a Rat Model.

OBJECTIVE: Obesity and associated low-level local systemic inflammation have been linked to an increased rate of developing knee osteoarthritis (OA). Aerobic exercise has been shown to protect the knee from obesity-induced joint damage. The aims of this study were to determine (1) if resistance training provides beneficial metabolic effects similar to those previously observed with aerobic training in rats consuming a high-fat/high-sucrose (HFS) diet and (2) if these metabolic effects mitigate knee OA in a diet-induced obesity model in rats. DESIGN: Twelve-week-old Sprague-Dawley rats were randomized into 4 groups: (1) a group fed an HFS diet subjected to aerobic exercise (HFS+Aer), (2) a group fed an HFS diet subjected to resistance exercise (HFS+Res), (3) a group fed an HFS diet with no exercise (HFS+Sed), and (4) a chow-fed sedentary control group (Chow+Sed). HFS+Sed animals were heavier and had greater body fat, higher levels of triglycerides and total cholesterol, and more joint damage than Chow+Sed animals. RESULTS: The HFS+Res group had higher body mass and body fat than Chow+Sed animals and higher OA scores than animals from the HFS+Aer group. Severe bone lesions were observed in the HFS+Sed and Chow+Sed animals at age 24 weeks, but not in the HFS+Res and HFS+Aer group animals. CONCLOSION: In summary, aerobic training provided better protection against knee joint OA than resistance training in this rat model of HFS-diet-induced obesity. Exposing rats to exercise, either aerobic or resistance training, had a protective effect against the severe bone lesions observed in the nonexercised rats.

Characterizing residual and passive force enhancements in cardiac myofibrils.

Residual force enhancement (RFE), an increase in isometric force after active stretching of a muscle compared with the purely isometric force at the corresponding length, has been consistently observed throughout the structural hierarchy of skeletal muscle. Similar to RFE, passive force enhancement (PFE) is also observable in skeletal muscle and is defined as an increase in passive force when a muscle is deactivated after it has been actively stretched compared with the passive force following deactivation of a purely isometric contraction. These history-dependent properties have been investigated abundantly in skeletal muscle, but their presence in cardiac muscle remains unresolved and controversial. The purpose of this study was to investigate whether RFE and PFE exist in cardiac myofibrils and whether the magnitudes of RFE and PFE increase with increasing stretch magnitudes. Cardiac myofibrils were prepared from the left ventricles of New Zealand White rabbits, and the history-dependent properties were tested at three different final average sarcomere lengths (n = 8 for each), 1.8, 2, and 2.2 µm, while the stretch magnitude was kept at 0.2 µm/sarcomere. The same experiment was repeated with a final average sarcomere length of 2.2 µm and a stretching magnitude of 0.4 µm/sarcomere (n = 8). All 32 cardiac myofibrils exhibited increased forces after active stretching compared with the corresponding purely isometric reference conditions (p < 0.05). Furthermore, the magnitude of RFE was greater when myofibrils were stretched by 0.4 compared with 0.2 µm/sarcomere (p < 0.05). We conclude that, like in skeletal muscle, RFE and PFE are properties of cardiac myofibrils and are dependent on stretch magnitude.

A high-whey-protein diet does not enhance mechanical and structural remodeling of cardiac muscle in response to aerobic exercise in rats.

PURPOSE: Aerobic exercise training results in distinct structural and mechanical myocardial adaptations. In skeletal muscle, whey protein supplementation is effective in enhancing muscle adaptation following resistance exercise. However, it is unclear whether cardiac adaptation to aerobic exercise can be enhanced by systematic protein supplementation. METHODS: Twelve-week-old rats were assigned to 12 weeks of either sedentary or aerobic exercise with either a standard (Sed+Standard, Ex+Standard) or high-protein (Sed+Pro, Ex+Pro) diet. Echocardiography was used to measure cardiac structural remodeling and performance. Skinned cardiac fiber bundles were used to determine the active and passive stress properties, maximum shortening velocity, and calcium sensitivity. RESULTS: Aerobic training was characterized structurally by increases in ventricle volume (Ex+Standard, 19%; Ex+Pro, 29%) and myocardial thickness (Ex+Standard, 26%; Ex+- Pro, 12%) compared to that of baseline. Skinned trabecula r fiber bundles also had a greater unloaded shortening velocity (Sed+Standard, 1.04±0.05; Sed+Pro, 1.07±0.03; Ex- +Standard, 1.16±0.04; Ex+Pro, 1.18±0.05 FL/s) and calcium sensitivity (pCa50: Sed+Standard, 6.04±0.17; Sed+Pro, 6.08±0.19; Ex+Standard, 6.30±0.09; Ex+Pro, 6.36±0.12) in trained hearts compared to that of hearts from sedentary animals. However, the addition of a high-protein diet did not provide additional benefits to either the structural or mechanical adaptations of the myocardium. CONCLUSION: Therefore, it seems that a high-whey-protein diet does not significantly enhance adaptations of the heart to aerobic exercise in comparison to that of a standard diet.

Botox Injections in Paraspinal Muscles Result in Low Maximal Specific Force and Shortening Velocity in Fast but Not Slow Skinned Muscle Fibers.

STUDY DESIGN: Basic science, experimental animal study. OBJECTIVE: To determine the effects of Botulinum toxin type A (BTX-A) injections on the mechanical properties of skinned muscle fibers (cells) of rabbit paraspinal muscles. SUMMARY OF BACKGROUND DATA: BTX-A has been widely used in the treatment of disorders of muscle hyperactivity, such as spasticity, dystonia, and back pain. However, BTX-A injection has been shown to cause muscle atrophy, fat infiltration, and decreased force output in target muscles, but its potential effects on the contractile machinery and force production on the cellular level remain unknown. METHODS: Nineteen-month-old, male New Zealand White Rabbits received either saline or BTX-A injections into the paraspinal muscles, equally distributed along the left and right sides of the spine at T12, L1, and L2 at 0, 8, 12, 16, 20, and 24 weeks. Magnetic resonance imaging was used to quantify muscle crosssectional area and structural changes before and at 28 weeks following the initial injection. Skinned fibers isolated from the paraspinal muscles were tested for their active and passive force-length relationships, unloaded shortening velocity, and myosin heavy chain isoforms. RESULTS: BTX-A injections led to significant fat infiltration within the injected muscles and a greater proportion of IIa to IIx fibers. Isolated fast fibers from BTX-A injected animals had lower active force and unloaded shortening velocity compared with fibers from saline-injected control animals. Force and velocity properties were not different between groups for the slow fibers. CONCLUSION: Injection of BTX-A into the paraspinal rabbit muscles leads to significant alterations in the contractile properties of fast, but not slow, fibers.Level of Evidence: N/A.

Consumption of a high-fat-high-sucrose diet partly diminishes mechanical and structural adaptations of cardiac muscle following resistance training.

PURPOSE: The purpose of this study was to investigate the effects of a high-fat high-sucrose (HFHS) diet on previously reported adaptations of cardiac morphological and contractile properties to resistance training. METHODS: Twelve-week-old rats participated in 12-weeks of resistance exercise training and consumed an HFHS diet. Echocardiography and skinned cardiac muscle fiber bundle testing were performed to determine the structural and mechanical adaptations. RESULTS: Compared to chow-fed sedentary animals, both HFHS- and chow-fed resistance-trained animals had thicker left ventricular walls. Isolated trabecular fiber bundles from chow-fed resistance-trained animals had greater force output, shortening velocities, and calcium sensitivities than those of chow-fed sedentary controls. However, trabeculae from the HFHS resistance-trained animals had greater force output but no change in unloaded shortening velocity or calcium sensitivity than those of the chow-fed sedentary group animals. CONCLUSION: Resistance exercise training led to positive structural and mechanical adaptations of the heart, which were partly offset by the HFHS diet.

Mechanical and Structural Remodeling of Cardiac Muscle after Aerobic and Resistance Exercise Training in Rats.

INTRODUCTION: Aerobic and resistance exercise training results in distinct structural changes of the heart. The mechanics of how cardiac cells adapt to resistance training and the benefits to cells when combining aerobic and resistance exercise remains largely unknown. The purpose of this study was to compare mechanical adaptations of skinned cardiac fiber bundles after chronic resistance, aerobic and combined exercise training in rats. We hypothesized that differences in mechanical function on the fiber bundle level coincide with differences previously reported in the structure of the heart. METHOD: Twelve-week-old rats were assigned to (i) an aerobic running group (n = 6), (ii) a ladder climbing resistance group (n = 6), (iii) a combination group subjected to aerobic and resistance training (n = 6), or (iv) a sedentary (control) group (n = 5). Echocardiography was used to measure cardiac structural remodeling. Skinned cardiac fiber bundles were used to determine active and passive force properties, maximal shortening velocity, and calcium sensitivity. RESULTS: Aerobically trained animals had 43%-49% greater ventricular volume and myocardial thickness, and a 4%-17% greater shortening velocity and calcium sensitivity compared with control group rats. Resistance-trained rats had 37%-71% thicker ventricular walls, a 56% greater isometric force production, a 9% greater shortening velocity, and a 4% greater calcium sensitivity compared with control group rats. The combination exercise-trained rats had 25%-43% greater ventricular volume and myocardial wall thickness, a 55% greater active force production, a 7% greater shortening velocity, and a 60% greater cross-bridge cooperativity compared with control group rats. CONCLUSIONS: The heart adapts differently to each exercise modality, and a combination of aerobic and resistance training may have the greatest benefit for cardiac health and performance.

Mechanical function of cardiac fibre bundles is partly protected by exercise in response to diet-induced obesity in rats.

Decrements in contractile function resulting from obesity are thought to be major reasons for the link between obesity and cardiovascular disease, while exercise has been shown to improve cardiac muscle contractile function. The purpose of this study was to evaluate cardiac contractile properties following obesity induction and the potential protective effect of exercise. Twelve-week-old rats (n = 30) were organized into either a chow diet or a high-fat, high-sucrose (HFHS) diet group. Following 12 weeks of obesity induction the HFHS group animals were stratified and grouped into sedentary (HFHS+Sed) and exercise (HFHS+Ex) groups for an additional 12 weeks. Following 24 weeks of diet intervention, with 12 weeks of aerobic exercise (25 m/min, 30 min/day, 5 days/week) for the HFHS+Ex group, skinned cardiac fibre bundle testing was used to evaluate cardiac contractile properties. Body fat and mass were significantly greater in the HFHS-fed animals compared with the chow controls (p < 0.043). Hearts from rats in the HFHS+Sed group had significantly greater mass (p < 0.03), significantly slower maximum shortening velocity (p = 0.001), and tended to have lower calcium sensitivity (p = 0.077) and a lower proportion of α-myosin heavy chain composition (p = 0.074) than the sedentary chow animals. However, 12 weeks of moderate aerobic exercise partially prevented these decrements in contractile properties. Novelty Cardiac muscle from animals exposed to an obesogenic diet for 24 weeks had impaired contractile properties compared with controls. Obesity-induced impairment of contractile properties of the heart were partially prevented by a 12-week aerobic exercise regime.

Cardiac ventricular muscle mechanical properties through the first year of life in Sprague-Dawley rats.

Advanced age has been shown to result in decreased compliance, shortening velocity, and calcium sensitivity of the heart muscle. Even though cardiac health has been studied extensively in elderly populations, relatively little is known about cardiac health and age for the first part of adulthood. The purpose of this study was to compare cardiac contractile properties across the first year of life in rats (between 17-53 weeks), corresponding to early to mid-adulthood. Hearts were harvested from rats aged 17-, 24-, 36-, and 53-weeks. Skinned cardiac trabecular fibre bundle testing was used to evaluate active and passive force properties, maximum shortening velocity, calcium sensitivity, and myosin heavy chain isoforms. Maximum active stress production was not different between age groups. Calcium sensitivity increased progressively, while shortening velocity remained unchanged after an increase from 17-and 24-weeks. Passive stiffness decreased between 17- and 24-weeks, but then increased progressively through to 53-weeks. Thus, many of the observed detrimental changes in systolic function (reduced shortening velocity and calcium sensitivity) associated with aging, do not seem to occur in early to mid-adulthood, while early signs of increased diastolic stiffness manifest within 53 weeks of age and may represent a first sign of decreasing heart function and health.

Residual and passive force enhancement in skinned cardiac fibre bundles.

In skeletal muscle, steady-state force is consistently greater following active stretch than during a purely isometric contraction at the same length (residual force enhancement; RFE). Similarly, when deactivated, the force remains higher following active stretch than following an isometric condition (passive force enhancement; PFE). RFE and PFE have been associated with the sarcomere protein titin, but skeletal and cardiac titin have different structures, and results regarding RFE in cardiac muscle have been inconsistent and contradictory. Therefore, the purpose of this study was to determine if cardiac muscle exhibits RFE and PFE. Skinned fibre bundles (n = 10) were activated isometrically at a sarcomere length of 2.2 µm and actively stretched by 15% of their length. The resultant active and passive forces were compared to the corresponding forces obtained for purely isometric contractions at the long length. RFE was observed in all fibre bundles, averaging 5.5 ± 2.5% (ranging from 2.3 to 9.4%). PFE was observed in nine of the ten bundles, averaging 11.1 ± 6.5% (ranging from -2.1 to 18.7%). Stiffness was not different between the active isometric and the force enhanced conditions, but was higher following deactivation from the force-enhanced compared to the isometric reference state. We conclude that there is RFE and PFE in cardiac muscle. We speculate that cardiac muscle has the same RFE capability as skeletal muscle, and that the most likely mechanism for the RFE and PFE is the engagement of a passive structural element during active stretching.

Mechanical adaptations of skinned cardiac muscle in response to dietary-induced obesity during adolescence in rats.

Childhood obesity is a major risk factor for heart disease during adulthood, independent of adulthood behaviours. Therefore, it seems that childhood obesity leads to partly irreversible decrements in cardiac function. Little is known about how obesity during maturation affects the mechanical properties of the heart. The purpose of this study was to evaluate contractile properties in developing hearts from animals with dietary-induced obesity (high-fat high-sucrose diet). We hypothesized that obesity induced during adolescence results in decrements in cardiac contractile function. Three-week-old rats (n = 16) were randomized into control (chow) or dietary-induced obesity (high-fat high-sucrose diet) groups. Following 14 weeks on the diet, skinned cardiac trabeculae fibre bundle testing was performed to evaluate active and passive force, maximum shortening velocity, and calcium sensitivity. Rats in the high-fat high-sucrose diet group had significantly larger body mass and total body fat percentage. There were no differences in maximal active or passive properties of hearts between groups. Hearts from the high-fat high-sucrose diet rats had significantly slower maximum shortening velocities and lower calcium sensitivity than controls. Decreased shortening velocity and calcium sensitivity in hearts of obese animals may constitute increased risk of cardiac disease in adulthood. Novelty Cardiac muscle from animals exposed to an obesogenic diet during development had lower shortening velocity and calcium sensitivity than those from animals fed a chow diet. These alterations in mechanical function may be a mechanism for the increased risk of cardiac disease observed in adulthood.

Force properties of skinned cardiac muscle following increasing volumes of aerobic exercise in rats.

The positive effects of chronic endurance exercise training on health and performance have been well documented. These positive effects have been evaluated primarily at the structural level, and work has begun to evaluate mechanical adaptations of the myocardium. However, it remains poorly understood how the volume of exercise training affects cardiac adaptation. To gain some understanding, we subjected 3-mo-old Sprague-Dawley rats ( n = 23) to treadmill running for 11 wk at one of three exercise volumes (moderate, high, and extra high). Following training, hearts were excised and mechanical testing was completed on skinned trabecular fiber bundles. Performance on a maximal fitness test was dose dependent on training volume, where greater levels of training led to greater performance. No differences were observed between animals from any group for maximal active stress and passive stress at a sarcomere length of 2.2 µm. Heart mass and passive stress at sarcomere lengths beyond 2.4 µm increased in a dose-dependent manner for animals in the control and moderate- and high-duration groups. However, hearts from animals in the extra high-duration group presented with inhibited responses for heart mass and passive stress, despite performing greatest on a graded treadmill fitness test. These results suggest that heart mass and passive stress adapt in a dose-dependent manner, until exercise becomes excessive and adaptation is inhibited. Our findings are in agreement with the beneficial role exercise has in cardiac adaptation. However, excessive exercise comes with risks of maladaptation, which must be weighed against the desire to increase performance. NEW & NOTEWORTHY For the first time, we present findings on cardiac trabecular muscle passive stiffness and show the effect of excessive exercise on the heart. We demonstrated that heart mass increases with exercise until a maximum, after which greater exercise volume results in inhibited adaptation. At paraphysiological lengths, passive stiffness increases with exercise but to a lesser degree with excessive training. Despite greater performance on graded exercise tests, animals in the highest trained group exhibited possible maladaptation.

Quantifying the Effects of Different Treadmill Training Speeds and Durations on the Health of Rat Knee Joints.

BACKGROUND: Walking and running provide cyclical loading to the knee which is thought essential for joint health within a physiological window. However, exercising outside the physiological window, e.g. excessive cyclical loading, may produce loading conditions that could be detrimental to joint health and lead to injury and, ultimately, osteoarthritis. The purpose of this study was to assess the effects of a stepwise increase in speed and duration of treadmill training on knee joint integrity and to identify the potential threshold for joint damage. METHODS: Twenty-four Sprague-Dawley rats were randomized into four groups: no exercise, moderate duration, high duration, and extra high duration treadmill exercise. The treadmill training consisted of a 12-week progressive program. Following the intervention period, histologic serial sections of the left knee were graded using a modified Mankin Histology Scoring System. Mechanical testing of the tibial plateau cartilage and RT-qPCR analysis of mRNA from the fat pad, patellar tendon, and synovium were performed for the right knee. Kruskal-Wallis testing was used to assess differences between groups for all variables. RESULTS: There were no differences in cartilage integrity or mechanical properties between groups and no differences in mRNA from the fat pad and patellar tendon. However, COX-2 mRNA levels in the synovium were lower for all animals in the exercise intervention groups compared to those in the no exercise group. CONCLUSIONS: Therefore, these exercise protocols did not exceed the joint physiological window and can likely be used safely in aerobic exercise intervention studies without affecting knee joint health.

Quadrupedal Locomotion-Respiration Entrainment and Metabolic Economy in Cross-Country Skiers.

A 1:1 locomotion-respiration entrainment is observed in galloping quadrupeds, and is thought to improve running economy. However, this has not been tested directly in animals, as animals cannot voluntarily disrupt this entrainment. The purpose of this study was to evaluate metabolic economy in a human gait involving all four limbs, cross-country skiing, in natural entrainment and forced nonentrainment. Nine elite cross-country skiers roller skied at constant speed using the 2-skate technique. In the first and last conditions, athletes used the natural entrained breathing pattern: inhaling with arm recovery and exhaling with arm propulsion, and in the second condition, the athletes disentrained their breathing pattern. The rate of oxygen uptake (VO2) and metabolic rate (MR) were measured via expired gas analysis. Propulsive forces were measured with instrumented skis and poles. VO2 and MR increased by 4% and 5% respectively when skiers used the disentrained compared with the entrained breathing pattern. There were no differences in ski or pole forces or in timing of the gait cycle between conditions. We conclude that breathing entrainment reduces metabolic cost of cross-country skiing by approximately 4%. Further, this reduction is likely a result of the entrainment rather than alterations in gait mechanics.

A clinic-supported group exercise program for head and neck cancer survivors: managing cancer and treatment side effects to improve quality of life.

PURPOSE: The purpose of the evaluation of this clinic-supported 12-week progressive strength-training program was to assess the feasibility and impact of an exercise intervention for head and neck cancer (HNC) survivors. METHODS: Recruitment and adherence feasibility, as well as health-related fitness measures and patient-reported symptom management were assessed on the 21 HNC survivors in the exercise program. RESULTS: Overall, this program was feasible, as indicated by recruitment, adherence, and safety outcomes. Survivors experienced improved acute symptom management over the period of one exercise class for tiredness, depression, anxiety, drowsiness, and overall wellbeing. Over the course of the program, survivors experienced significant improvements in physical functioning outcomes and improved management of tiredness and fatigue. CONCLUSIONS: A progressive strength-training program is feasible for HNC survivors on and following treatment and is associated with improved acute and chronic fitness outcomes and symptom management.