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Background: The plantarflexor muscles are important during walking. However, walking is not the only task that is used during daily life, and not much is known about the role of the plantarflexor muscles during other dynamic tasks. Insight into the demand of the plantarflexor muscles during different dynamic tasks might help to establish training or functional assessment for patients who experience plantarflexor weakness., Research Question: This study aimed to examine the role of the plantarflexor functioning during dynamic tasks in children of 5-9 years old, by identifying differences in ankle kinetics and plantarflexor muscle forces during dynamic tasks., Methods: In this observational cross-sectional study, 28 typically developing children from 5 to 9 years old were included. Three-dimensional movement analysis was performed to extract the peak ankle moment, power and plantarflexor muscle forces during the stance phase of walking, heel walking, toe walking, running and one-leg-hopping. To examine differences in peak ankle moment, ankle power and muscle forces, Friedman tests were used in combination with Wilcoxon signed-rank tests to determine differences in peak ankle moment, power and muscle forces of the various dynamic tasks compared to walking., Results: Based on the differences in peak ankle moment, power and muscle forces compared to walking, heel walking was the least demanding dynamic task. Running and one-leg-hopping were the most demanding tasks., Significance: Dynamic tasks with a high demand on the plantarflexor muscles, such as running and one-leg-hopping could be used to quantify deficits in patient populations with plantarflexor weakness that are not visible during walking. Furthermore, these tasks could be used during functional evaluation or training in these patient populations., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024. Published by Elsevier B.V.)

Purpose: Knee laxity can be experienced as knee instability which may lead to a limitation in the activity of patients. Current methods to determine knee instability are performed in a static setting, which does not always correlate with dynamic knee laxity during activities. Wearables might be able to measure knee laxity in a dynamic setting and could be of added value in the diagnosis and treatment of excessive knee laxity. Therefore, the aim of this systematic review is to provide an overview of the wearables that have been developed and their ability to measure knee laxity during dynamic activities., Methods: The PRISMA guidelines for systematic reviews were followed. A literature search was conducted in EMBASE, PubMed and Cochrane databases. Included studies assessed patients with knee instability using a non-invasive wearable sensor system during dynamic activity, with comparison to a reference system or healthy knees. Data extraction was performed by two authors via a predefined format. The risk of bias was assessed by The Dutch checklist for diagnostic tests., Results: A total of 4734 articles were identified. Thirteen studies were included in the review. The studies showed a great variety of patients, sensor systems, reference tests, outcome measures and performed activities. Nine of the included studies were able to measure differences in patients with knee instability, all including a tri-axial accelerometer. Differences were not measurable in all parameters and activities in these studies., Conclusions: Wearables, including at least a tri-axial accelerometer, seem promising for measuring dynamic knee laxity in the anterior-posterior and mediolateral direction. At this stage, it remains unclear if the measured outcomes completely reflect the knee instability that patients experience in daily life., Level of Evidence: Level III., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s). Journal of Experimental Orthopaedics published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: Risk factors for the development of symptomatic cyclops lesion after anterior cruciate ligament reconstruction (ACLR) surgery are not entirely identified yet. This study aimed to investigate whether the choice of hamstring graft (semitendinosus-gracilis; STG vs. semitendinosus; ST) affects the risk of developing a symptomatic cyclops lesion after ACLR., Methods: This retrospective cohort study included 1416 patients receiving either an ST graft (n = 1209) or an STG graft (n = 207) ACLR with a follow-up of at least 2 years. A persisting extension limitation was clinically determined, and cyclops lesions were confirmed by magnetic resonance imaging (MRI) and second-look arthroscopy. Graft-specific incidence of cyclops lesions was examined with χ 2 test and combined with the factors number of graft bundles, graft diameter and sex evaluated with a binominal logistic regression model., Results: In total, 46 patients developed symptomatic cyclops lesions (3.2%), with 36 having ACLR with an ST graft (3.0%) and 10 with an STG graft (4.8%) (n.s). The mean time from ACLR to the second-look arthroscopy for cyclops removal was 1.1 ± 0.6 years. Female patients were 2.5 times more likely to develop a cyclops lesion than male patients. Patients with an STG graft and larger graft diameters did not have a higher risk of developing cyclops lesions. Patients who received an STG graft with both tendons folded four times (double-quadruple) had significantly higher risk of developing a cyclops compared with all other numbers of graft bundles combined (8.3%, respectively 3.0%; p = 0.014)., Conclusion: This study could not prove an increased risk of developing a symptomatic cyclops lesion for patients with an STG graft compared with an ST graft used for ACLR. However, patients with a double-quadruple ACLR had a higher percentage of cyclops lesions compared with all other numbers of graft bundles. Female sex was associated with an increased risk of developing cyclops lesions., Level of Evidence: Level III., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: Graft failure rates after anterior cruciate ligament reconstruction (ACLR) in children and adolescents are higher compared to adults. Anterolateral augmentation procedures have recently generated increased focus regarding their ability to reduce graft failure rates. Concerns in skeletally immatures are potential growth disturbances and overconstraint after anterolateral augmentation. The aim of this scoping review is to provide an overview of all current anterolateral augmentation procedures in skeletally immature patients and to discuss surgical techniques, clinical and biomechanical outcomes., Methods: This scoping review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement extension for scoping reviews. On 22 December 2022, an information specialist performed a systematic literature search in Cochrane, PubMed (Medline) and EMBASE databases. Inclusion criteria were anterolateral augmentation procedures, including lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in combination with ACLR in skeletally immatures., Results: Twenty studies were included after screening 1.485 abstracts. Seventeen studies describe LET techniques, four studies ALLR techniques and one study both techniques. Biomechanical data is scarce and shows conflicting results. Two studies compared ACLR with LET to ACLR in skeletally immatures with promising results in favour of the combined procedure. There were no differences in outcomes between LET and ALLR., Conclusions: Several LET and ALLR techniques have been described for skeletally immature patients and the first clinical data on LET and ALLR is available, which showed promising results. Further research is necessary to evaluate the risk of growth disturbances and overconstraint in skeletally immatures., Level of Evidence: Level IV., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s). Journal of Experimental Orthopaedics published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background: Clubfoot patients show good-to-excellent foot correction after the Ponseti method. Nevertheless, underlying functional problems that limit motor abilities such as one-leg-standing and one-leg-hopping still persist. These restrictions have been proposed to arise due to problems with maintaining balance and the limited force-generating capacity of clubfoot patients. More insight is needed to understand the underlying limiting factors to improve overall motor ability in clubfoot patients., Research Question: The aim of this study was to determine the differences between clubfoot patients and typically developing children (TDC) in force and balance parameters during walking, one-leg-standing and hopping., Methods: Three-dimensional motion analysis was performed in 19 TDC and 16 idiopathic Ponseti-treated clubfoot patients between 5-9 years old. Kinematic and kinetic parameters were calculated during walking and one-leg-hopping. To describe the balance parameters, center of pressure (CoP) data was assessed during walking, one-leg-hopping and one-leg-standing. Mean group values were calculated and compared using nonparametric statistical tests. A general linear model with repeated measures was used to determine which activity showed the largest group differences., Results: Clubfoot patients showed lower peak plantarflexor moment and peak ankle power absorption and generation during one-leg-hopping compared to TDC. Furthermore, clubfoot patients showed a lower hop length and velocity than TDC. The difference in peak plantarflexor moment and ankle power between the study groups was larger during one-leg-hopping than during walking. Finally, clubfoot patients showed a higher anterior-posterior CoP range during one-leg-standing., Significance: Deviations in force parameters seemed to limit one-leg-hopping in clubfoot patients, and impaired anterior-posterior static balance was thought to be the underlying cause of problems with one-leg-standing. Furthermore, one-leg-hopping was more sensitive to distinguish between clubfoot patients and TDC than walking. Individualized physiotherapy targeting static balance and force parameters, with extra emphasis on including eccentric contractions, might improve the overall motor abilities of clubfoot patients., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Aims: The aim of this study was to identify the information topics that should be addressed according to the parents of children with developmental dysplasia of the hip (DDH) in the diagnostic and treatment phase during the first year of life. Second, we explored parental recommendations to further optimize the information provision in DDH care., Methods: A qualitative study with semi-structured interviews was conducted between September and December 2020. A purposive sample of parents of children aged younger than one year, who were treated for DDH with a Pavlik harness, were interviewed until data saturation was achieved. A total of 20 interviews with 22 parents were conducted. Interviews were audio recorded, transcribed verbatim, independently reviewed, and coded into categories and themes., Results: Interviews revealed four fundamental information topics that should be addressed in the different phases of the DDH healthcare trajectory: general information (screening phase), patient-specific information (diagnostic and treatment phase), practical information (treatment phase), and future perspectives (treatment and follow-up phase). To further optimize the information provision in DDH care, parents wished for more accessible and trustworthy general information prior to the first hospital visit to be better prepared for the diagnosis. Furthermore, parents wanted more personalized and visually supported information for a better understanding of the nature of the disease and the reason for treatment., Conclusion: This study offers novel insights to optimize the information provision in DDH care. The main finding is the shift in information need from general information in the screening phase to patient-specific information in the diagnostic and treatment phase of DDH. Parents prefer visually-supported information, provided in a timely fashion, and tailored to their child's situation. These recommendations potentially decrease parental anxiety, insecurity, confusion, and increase parental empowerment and treatment adherence throughout the diagnostic and treatment phase of DDH., Competing Interests: The authors have no conflicts of interest to disclose., (© 2023 Author(s) et al.)

Background: Knee pain is highly prevalent worldwide, and this number is expected to rise in the future. The COVID-19 outbreak, in combination with the aging population, rising health care costs, and the need to make health care more accessible worldwide, has led to an increasing demand for digital health care applications to deliver care for patients with musculoskeletal conditions. Digital health and other forms of telemedicine can add value in optimizing health care for patients and health care providers. This might reduce health care costs and make health care more accessible while maintaining a high level of quality. Although expectations are high, there is currently no overview comparing digital health applications with face-to-face contact in clinical trials to establish a primary knee diagnosis in orthopedic surgery., Objective: This study aimed to investigate the currently available digital health and telemedicine applications to establish a primary knee diagnosis in orthopedic surgery in the general population in comparison with imaging or face-to-face contact between patients and physicians., Methods: A scoping review was conducted using the PubMed and Embase databases according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) statement. The inclusion criteria were studies reporting methods to determine a primary knee diagnosis in orthopedic surgery using digital health or telemedicine. On April 28 and 29, 2021, searches were conducted in PubMed (MEDLINE) and Embase. Data charting was conducted using a predefined form and included details on general study information, study population, type of application, comparator, analyses, and key findings. A risk-of-bias analysis was not deemed relevant considering the scoping review design of the study., Results: After screening 5639 articles, 7 (0.12%) were included. In total, 2 categories to determine a primary diagnosis were identified: screening studies (4/7, 57%) and decision support studies (3/7, 43%). There was great heterogeneity in the included studies in algorithms used, disorders, input parameters, and outcome measurements. No more than 25 knee disorders were included in the studies. The included studies showed a relatively high sensitivity (67%-91%). The accuracy of the different studies was generally lower, with a specificity of 27% to 48% for decision support studies and 73% to 96% for screening studies., Conclusions: This scoping review shows that there are a limited number of available applications to establish a remote diagnosis of knee disorders in orthopedic surgery. To date, there is limited evidence that digital health applications can assist patients or orthopedic surgeons in establishing the primary diagnosis of knee disorders. Future research should aim to integrate multiple sources of information and a standardized study design with close collaboration among clinicians, data scientists, data managers, lawyers, and service users to create reliable and secure databases., (©Sander C van Eijck, Daan M Janssen, Maria C van der Steen, Eugenie J L G Delvaux, Johannes G E Hendriks, Rob P A Janssen. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 09.02.2023.)

Background: Functioning in children consists of different aspects, including their ability to execute activities and participate in life situations. Several studies on children with clubfeet showed limited motor abilities and walking capacity compared with healthy control children, while other studies showed comparable athletic abilities and gross motor development. Although participation in activities of daily life plays an important role in the development of children, this has not yet been investigated in children with clubfeet. The study aims to determine the level of parents' perceived motor ability and participation in Ponseti-treated children with clubfeet compared with age-matched healthy controls., Methods: Parents of children aged 5 to 9 years with and without idiopathic Ponseti-treated clubfeet were asked to complete an online questionnaire about their child's motor abilities and participation level using the Dutch version of the Assessment of Life Habits for Children (LIFE-H) version 3 to assess participation and the Dutch Movement Assessment Battery for Children-2 Checklist (MABC-2 Checklist) to assess motor abilities. Statistical analysis focused on differences between groups and the relationship between motor abilities and level of participation., Results: Questionnaires of 86 children with clubfeet (mean age 7.1, 73% boys) and 62 controls (age 6.7, 53% boys) were analyzed. Despite a large variation, results showed no significant differences between groups on the total scores of the LIFE-H and the MABC-2 Checklist. Children with clubfeet, however, scored lower on Mobility and better on the categories Communication and Responsibility of the LIFE-H. Furthermore, children with clubfeet showed lower scores on the MABC-2 Checklist subscale "movement in a static and/or predictable environment." High levels of the parents' perceived participation correlate with good results, as perceived by the parents, in motor ability., Conclusions: Although differences on some aspects of motor ability and participation existed, children with clubfeet in general showed high levels of parents' perceived motor ability and participation. High levels of participation correlated with good results in motor ability., Level of Evidence: Level II., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Altered muscle-tendon properties in clubfoot patients could play a role in the occurrence of a relapse and negatively affect physical functioning. However, there is a lack of literature about muscle-tendon properties of clubfoot relapse patients., Research Question: The aim of this study was to determine whether the muscle architecture of the medial gastrocnemius and the morphology of the Achilles tendon differ between typically developing children (TDC) and clubfoot patients with and without a relapse clubfoot and to determine the relationships between morphological and functional gait outcomes., Methods: A cross-sectional study was carried out in clubfoot patients treated according to the Ponseti method and TDC aged 4-8 years. A division between clubfoot patients with and without a relapse was made. Fifteen clubfoot patients, 10 clubfoot relapse patients and 19 TDC were included in the study. Morphologic properties of the medial head of the Gastrocnemius muscle and Achilles tendon were assessed by ultrasonography. Functional gait outcomes were assessed using three-dimensional gait analysis. Mean group differences were analysed with ANOVA and non-parametric alternatives. Relationships between functional and morphologic parameters were determined for all clubfoot patients together and for TDC with Spearman's rank correlation., Results: Morphological and functional gait parameters did not differ between clubfoot patients with and without a relapse, with exception of lower maximal dorsiflexor moment in clubfoot relapse patients. Compared to TDC, clubfoot and relapse patients did show lower functional gait outcomes, as well as shorter and more pennate muscles with a longer Achilles tendon. In all clubfoot patients, this longer relative tendon was related to higher ankle power and plantarflexor moment., Significance: In clubfoot and relapse patients, abnormalities in morphology did not always relate to worse functional gait outcomes. Understanding these relationships in all clubfoot patients may improve the knowledge about clubfoot and aid future treatment planning., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

A ruptured anterior cruciate ligament (ACL) is often reconstructed with a multiple-strand autograft of a semitendinosus tendon alone or combined with a gracilis tendon. Up to 10% of patients experience graft rupture. This potentially results from excessive local tissue strains under physiological loading which could either result in direct mechanical failure of the graft or induce mechanobiological weakening. Since the original location in the hamstring tendon cannot be traced back from an autograft rupture site, this study explored whether clinical outcome could be further improved by avoiding specific locations or regions of human semitendinosus and/or gracilis tendons in ACL grafts due to potential mechanical or biochemical inferiority. Additionally, it examined numerically which clinically relevant graft configurations experience the lowest strains - and therefore the lowest rupture risk - when loaded with equal force. Remnant full-length gracilis tendons from human ACL reconstructions and full-length semitendinosus- and ipsilateral gracilis tendons of human cadaveric specimens were subjected to a stress-relaxation test. Locations at high risk of mechanical failure were identified using particle tracking to calculate local axial strains. As biochemical properties, the water-, collagen-, glycosaminoglycan- and DNA content per tissue region (representing graft strands) were determined. A viscoelastic lumped parameter model per tendon region was calculated. These models were applied in clinically relevant virtual graft configurations, which were exposed to physiological loading. Configurations that provided lower stiffness - i.e., experiencing higher strains under equal force - were assumed to be at higher risk of failure. Suitability of the gracilis tendon proper to replace semitendinosus muscle-tendon junction strands was examined. Deviations in local axial strains from the globally applied strain were of similar magnitude as the applied strain. Locations of maximum strains were uniformly distributed over tendon lengths. Biochemical compositions varied between tissue regions, but no trends were detected. Viscoelastic parameters were not significantly different between regions within a tendon, although semitendinosus tendons were stiffer than gracilis tendons. Virtual grafts with a full-length semitendinosus tendon alone or combined with a gracilis tendon displayed the lowest strains, whereas strains increased when gracilis tendon strands were tested for their suitability to replace semitendinosus muscle-tendon junction strands. Locations experiencing high local axial strains - which could increase risk of rupture - were present, but no specific region within any of the investigated graft configurations was found to be mechanically or biochemically deviant. Consequently, no specific tendon region could be indicated to provide a higher risk of rupture for mechanical or biochemical reasons. The semitendinosus tendon provided superior stiffness to a graft compared to the gracilis tendon. Therefore, based on our results it would be recommended to use the semitendinosus tendon, and use the gracilis tendon in cases where further reinforcement of the graft is needed to attain the desired length and cross-sectional area. All these data support current clinical standards., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)