A Technique of Improved Medial Meniscus Visualization by Anterior Cruciate Ligament Graft Placement in Chronic Anterior Cruciate Deficient Knees

It is customary to perform medial meniscus repair before anterior cruciate ligament (ACL) graft placement when undertaken as a combined procedure. However, in chronic ACL-deficient knees, intraoperative anterior tibiofemoral translation can cause the medial meniscus repair to be more technically challenging. Intraoperative anterior tibiofemoral translation can both reduce the visualization of the medial meniscus and make its reduction unstable. An operative sequence alteration of ACL graft placement and tensioning before medial meniscal repair improves medial meniscus visualization in chronically ACL-deficient knees by using the ACL graft’s ability to prevent anterior tibiofemoral translation. The technique sequence is as follows: (a) the medial meniscus is reduced, (b) ACL reconstruction is undertaken using a hamstring graft without final tibia fixation, (c) distal graft tension is manually applied to distal graft sutures by the surgeon to prevent tibiofemoral subluxation, (d) the medial meniscus is repaired while graft tension is applied, and (e) the graft is then fixed to the tibia using an interference screw or another device

Is home-based, high-intensity interval training cycling feasible and safe for patients with knee osteoarthritis? Study protocol for a randomized pilot study

Background: Osteoarthritis (OA) is a degenerative joint disease affecting the knee joint of many middle-aged and older adults. As OA symptoms typically involve knee pain and stiffness, individuals with knee OA are often insufficiently physically active, have low levels of physical function, and are at increased risk of other comorbidities and reduced quality of life. While moderate-intensity continuous training (MICT) cycling is often recommended, little is known about the feasibility, safety, and benefits of high-intensity interval training (HIIT) cycling for this population, even though the feasibility, safety, and benefits of HIIT have been demonstrated in other chronic disease groups. Purpose: The primary objective of this pilot study was to examine the feasibility and safety of home-based HIIT and MICT cycling in middle-aged and older adults with knee OA. A secondary objective was to gain some insight into the relative efficacy of HIIT and MICT for improving health status (pain, stiffness, and disability), muscle function, and body composition in this population. This study protocol is being published separately to allow a detailed description of the research methods, explain the rationale for choosing the methodological details, and to stimulate consideration of the best means to simulate a research protocol that is relevant to a real-life treatment environment. Study Design: Randomized pilot study protocol. Methods: This trial sought to recruit 40 middle-aged and older adults with knee OA. Participants were randomly allocated to either continuous (MICT) or HIIT home-based cycle training programs, with both programs requiring the performance of 4 cycling sessions (approximately 25 minutes per session) each week. Participants were measured at baseline and postintervention (8 weeks). Feasibility and safety were assessed by adherence rate, dropout rate, and number of adverse events. The relative efficacy of the cycling programs was investigated by 2 knee OA health status questionnaires (Western Ontario and McMaster Universities Osteoarthritis Index scale[WOMAC] and the Lequesne Index) as well as the timed up and go, sit to stand, preferred gait speed, and body composition. Discussion: This pilot study appears to be the first study assessing the feasibility and safety of a home-based HIIT training program for middle-aged and older adults with knee OA. As HIIT has been demonstrated to be more effective than MICT for improving aspects of health status, body composition, and/or muscular function in other chronic disease groups, the current study has the potential to improve patient outcomes and inform the design of future randomized controlled trials

A Technique of Improved Medial Meniscus Visualization by Anterior Cruciate Ligament Graft Placement in Chronic Anterior Cruciate Deficient Knees

It is customary to perform medial meniscus repair before anterior cruciate ligament (ACL) graft placement when undertaken as a combined procedure. However, in chronic ACL-deficient knees, intraoperative anterior tibiofemoral translation can cause the medial meniscus repair to be more technically challenging. Intraoperative anterior tibiofemoral translation can both reduce the visualization of the medial meniscus and make its reduction unstable. An operative sequence alteration of ACL graft placement and tensioning before medial meniscal repair improves medial meniscus visualization in chronically ACL-deficient knees by using the ACL graft's ability to prevent anterior tibiofemoral translation. The technique sequence is as follows: (a) the medial meniscus is reduced, (b) ACL reconstruction is undertaken using a hamstring graft without final tibia fixation, (c) distal graft tension is manually applied to distal graft sutures by the surgeon to prevent tibiofemoral subluxation, (d) the medial meniscus is repaired while graft tension is applied, and (e) the graft is then fixed to the tibia using an interference screw or another device.Griffith Health, School of Allied Health SciencesFull Tex

Is high-intensity interval cycling feasible and more beneficial than continuous cycling for knee osteoarthritic patients? Results of a randomised control feasibility trial

Background Knee osteoarthritis (OA) patients often suffer joint pain and stiffness, which contributes to negative changes in body composition, strength, physical performance (function), physical activity and health-related quality of life. To reduce these symptoms and side effects of knee OA, moderate-intensity continuous training (MICT) cycling is often recommended. While resistance training is considered the optimal form of training to improve sarcopenic outcomes, it imposes higher joint loads and requires supervision, either initially or continuously by trained exercise professionals. Therefore, this pilot study sought to gain some insight into the feasibility and potential benefits of high-intensity interval training (HIIT) cycling as an alternative exercise option to MICT cycling for individuals with knee OA. Methods Twenty-seven middle-aged and older adults with knee OA were randomly allocated to either MICT or HIIT, with both programs involving four unsupervised home-based cycling sessions (∼25 min per session) each week for eight weeks. Feasibility was assessed by enrolment rate, withdrawal rate, exercise adherence and number of adverse effects. Efficacy was assessed by health-related quality of life (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Lequesne index), physical function (Timed Up and Go (TUG), Sit to Stand (STS) and preferred gait speed) and body composition (body mass, BMI, body fat percentage and muscle mass). Results Twenty-seven of the interested 50 potential participants (54%) enrolled in the study, with 17 of the 27 participants completing the trial (withdrawal rate of 37%); with the primary withdrawal reasons being unrelated injuries or illness or family related issues. Of the 17 participants who completed the trial, exercise adherence was very high (HIIT 94%; MICT 88%). While only three individuals (one in the MICT and two in the HIIT group) reported adverse events, a total of 28 adverse events were reported, with 24 of these attributed to one HIIT participant. Pre–post-test analyses indicated both groups significantly improved their WOMAC scores, with the HIIT group also significantly improving in the TUG and STS. The only significant between-group difference was observed in the TUG, whereby the HIIT group improved significantly more than the MICT group. No significant changes were observed in the Lequesne index, gait speed or body composition for either group. Discussion An unsupervised home-based HIIT cycle program appears somewhat feasible for middle-aged and older adults with knee OA and may produce similar improvements in health-related quality of life but greater improvements in physical function than MICT. These results need to be confirmed in larger randomised controlled trials to better elucidate the potential for HIIT to improve outcomes for those with knee OA. Additional research needs to identify and modify the potential barriers affecting the initiation and adherence to home-based HIIT cycling exercise programs by individuals with knee OA

Can tape–screw fixation of a quadrupled semitendinosus graft in a full-length tibial tunnel provide superior fixation compared with a doubled semitendinosus–gracilis held with an interference screw? A matched-pair cadaveric biomechanical comparison

Abstract Background In anterior cruciate ligament reconstruction, quadrupled semitendinosus (Quad ST) grafts have potential advantages over doubled semitendinosus–gracilis (ST/G) including larger diameter and gracilis preservation, however the ideal tibial fixation method of the resultant shorter Quad ST graft remains elusive if a fixed-loop suspensory fixation device is used on the femur. We investigated whether the tibial fixation biomechanical properties of a Quad ST fixed indirectly with polyethylene terephthalate tape tied over a screw in a full outside-in created tunnel was superior to a ST/G graft fixed with an interference screw. Materials and methods In a controlled laboratory study, six cadaveric matched pairs of each construct were subjected to cyclic loading to mimic physiologic loading during rehabilitation. This included preconditioning cycling, cyclic loading to 220 N for 500 cycles, then cyclic loading to 500 N for 500 cycles. Results High standard deviations across the measured parameters occurred with no significant difference between measured parameters of elongation for the different constructs. Elongation of the Quad-ST construct was greater at 10 and 100 cycles, but not statistically different. Four of the six Quad-ST constructs failed below 100 cycles, compared with two failures below 100 cycles in the ST/G construct. There was a strong correlation between cycles to failure and bone mineral density for the Quad ST-tape constructs. Conclusions Tibial fixation of Quad ST with a tied tape–screw construct in a full-length tunnel was not biomechanically superior to ST/G graft fixed with an interference screw, exhibited greater nonsignificant construct elongation with earlier failure, and was more reliant on bone mineral density. Level of evidence In vitro laboratory study

The effect of surgeon’s preference for hybrid or cemented fixation on the long-term survivorship of total knee replacement: An analysis of 39,623 prostheses from the Australian Orthopaedic Association National Joint Replacement Registry

Background and purpose — Recent direct comparative reports suggest that hybrid fixation may have a similar or superior outcome to cemented fixation in total knee replacement (TKR); however, a paucity of long-term data exists. To minimize the confounders of a direct comparison, we performed an instrumental variable analysis examining the revision rate of 2 cohorts of patients based on their surgeon’s preference for cemented or hybrid fixation. Methods — Registry data were obtained from 1999 until 2015 for 2 cohorts of patients who received minimally stabilized TKR, defined as those treated by high-volume hybrid fixation preferring surgeons, designated routinely hybrid (RH), and those treated by high-volume cemented fixation preferring surgeons, designated routinely cemented (RC). Results — At 13 years, the cumulative percentage revision of the RC cohort was 4.8% (CI 4.1–5.7) compared with 5.5% (CI 3.5–8.7) for the RH cohort. The revision risk for each cohort was the same for all causes (HR =1.0 (CI (0.84–1.20)), non-infective causes, and for infection. This finding was irrespective of patient age or sex, patella resurfacing, and with non-cross-linked polyethylene (NXLPE). The RH cohort who received cross-linked polyethylene (XLPE) had a lower revision risk than the RC cohort with XLPE (HR =0.57 (0.37–0.88), p = 0.01). Interpretation — The risk of revision for the patients of surgeons who prefer cemented fixation in minimally stabilized TKR is the same as for the patients of surgeons who prefer hybrid fixation, except when used with XLPE, where hybrid fixation has a lower revision risk

Comparison of four alternative national universal anterior cruciate ligament injury prevention programme implementation strategies to reduce secondary future medical costs

Background/aim Anterior cruciate ligament (ACL) injury is a common and devastating sporting injury. With or without ACL reconstruction, the risk of knee osteoarthritis (OA) and permanent disability later in life is markedly increased. While neuromuscular training programmes can prevent 50-80% of ACL injuries, no national implementation strategies exist in Australia. The aim of this study was to compare the ability of four alternative national universal ACL injury prevention programme implementation strategies to reduce future medical costs secondary to ACL injury. Methods A Markov economic decision model was constructed to estimate the value in lifetime future medical costs prevented by implementing a national ACL prevention programme among four hypothetical cohorts: high-risk sport participants (HR) aged 12-25 years; HR 18-25 years; HR 12-17 years; all youths (ALL) 12-17 years. Results Of the four programmes examined, the HR 12-25 programme provided the greatest value, averting US$693 of direct healthcare costs per person per lifetime or US$221 870 880 in total. Without training, 9.4% of this cohort will rupture their ACL and 16.8% will develop knee OA. Training prevents 3764 lifetime ACL ruptures per 100 000 individuals, a 40% reduction in ACL injuries. 842 lifetime cases of OA per 100 000 individuals and 584 TKRs per 100 000 are subsequently averted. Numbers needed to treat ranged from 27 for the HR 12-25 to 190 for the ALL 12-17. Conclusions The HR 12-25 programme was the most effective implementation strategy. Estimation of the break-even cost of health expenditure savings will enable optimal future programme design, implementation and expenditure

A Technique of Improved Medial Meniscus Visualization by Anterior Cruciate Ligament Graft Placement in Chronic Anterior Cruciate Deficient Knees

It is customary to perform medial meniscus repair before anterior cruciate ligament (ACL) graft placement when undertaken as a combined procedure. However, in chronic ACL-deficient knees, intraoperative anterior tibiofemoral translation can cause the medial meniscus repair to be more technically challenging. Intraoperative anterior tibiofemoral translation can both reduce the visualization of the medial meniscus and make its reduction unstable. An operative sequence alteration of ACL graft placement and tensioning before medial meniscal repair improves medial meniscus visualization in chronically ACL-deficient knees by using the ACL graft's ability to prevent anterior tibiofemoral translation. The technique sequence is as follows: (a) the medial meniscus is reduced, (b) ACL reconstruction is undertaken using a hamstring graft without final tibia fixation, (c) distal graft tension is manually applied to distal graft sutures by the surgeon to prevent tibiofemoral subluxation, (d) the medial meniscus is repaired while graft tension is applied, and (e) the graft is then fixed to the tibia using an interference screw or another device

The effect of surgeon’s preference for hybrid or cemented fixation on the long-term survivorship of total knee replacement

<p><b>Background and purpose — Recent direct comparative reports suggest that hybrid fixation may have a similar or superior outcome to cemented fixation in total knee replacement (TKR); however, a paucity of long-term data exists. To minimize the confounders of a direct comparison, we performed an instrumental variable analysis examining the revision rate of 2 cohorts of patients based on their surgeon’s preference for cemented or hybrid fixation.</b></p> <p><b>Methods — Registry data were obtained from 1999 until 2015 for 2 cohorts of patients who received minimally stabilized TKR, defined as those treated by high-volume hybrid fixation preferring surgeons, designated routinely hybrid (RH), and those treated by high-volume cemented fixation preferring surgeons, designated routinely cemented (RC).</b></p> <p><b>Results — At 13 years, the cumulative percentage revision of the RC cohort was 4.8% (CI 4.1–5.7) compared with 5.5% (CI 3.5–8.7) for the RH cohort. The revision risk for each cohort was the same for all causes (HR =1.0 (CI (0.84–1.20)), non-infective causes, and for infection. This finding was irrespective of patient age or sex, patella resurfacing, and with non-cross-linked polyethylene (NXLPE). The RH cohort who received cross-linked polyethylene (XLPE) had a lower revision risk than the RC cohort with XLPE (HR =0.57 (0.37–0.88), p = 0.01).</b></p> <p><b>Interpretation — The risk of revision for the patients of surgeons who prefer cemented fixation in minimally stabilized TKR is the same as for the patients of surgeons who prefer hybrid fixation, except when used with XLPE, where hybrid fixation has a lower revision risk.</b></p