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operatively, no significant differences were found between the study groups in terms of anterior side-to-side knee laxity, manual Lachman test, Tegner activity level, Lysholm knee score, range of motion or donor-site morbidity. Both study groups improved significantly in most clinical assessments and functional scores compared with their preoperative values. Two years after ACL reconstruction using ST/G autografts, there were no significant differences between male and female patients in terms of clinical outcome or functional scores.

Recently, a new generation of prostheses for total knee arthroplasty (TKA) were introduced by different companies in order to improve the range of motion, clinical outcome and finally patient satisfaction. However, the basic principles in designing implants for total knee arthroplasty have not changed much over the last two decades. We still need to resect the anterior cruciate ligament (cruciate retaining, CR TKA) or remove both the anterior and posterior cruciate ligaments (posterior stabilised, PS TKA). The femoral component is designed to optimise patella tracking and to unload the patello-femoral compartment. Single and multiple radius designs are being used for the femoral condyles, both showing good reasons for preference. The multi-radius design of the femoral component respects the anatomical shape of the femoral condyles and the physiological change of flexion/extension axis during knee motion. However, CR mobile bearing TKA influence the flexion/extension axis as shown by Iacono et al. [10] in a study published in the current issue. The single-radius design presumes a fixed axis of flexion/ extension, which lies slightly posterior to the natural one. A slight posterior placed axis increases the quadriceps moment arm and improves the efficiency of quadriceps muscle function [16]. In clinical practise, better range of motion and less pain, in particular, when rising from a sitting position has been observed with the single-radius design [14]. These findings are in harmony with a biomechanical study by Ostermeier and Stukenborg-Colsman. However, other studies did not show any differences in range of motion or clinical outcome between the singleand multiple radius designs [7]. Both concepts raise the questions whether one should restore anatomy as exactly as possible or as the osteoarthritic knee’s anatomy is altered by the disease process anyway and hence one should aim for the best knee function and modify the components accordingly? What about CR or PS designs in TKA? A Cochrane analysis showed a slightly better range of motion of 8 using the PS design in comparison to the CR design (105 vs. 113 ) [11]. This finding is supported by a number of studies, but the clinical relevance of the differences in maximal degree of flexion of 8 remains questionable [5]. The prevalence of knee flexion of more than 90 was studied during a period of 35.7 h in 21 patients [9]. The patients flexed their knee more than 90 on average 10 min during this period only and eight oft them more than 120 for 2.2 min only. Range of motion during daily activity depends on patient’s activity, but it shows that small improvement in the degree of motion will not affect patients’ outcome, but may instead increase the risk of aseptic loosening. Innovations in terms of the tibial component have been very limited. Increasing the number of component sizes and the re-introduction of asymmetric tibial component are considered to improve the knee function. Posterolateral impingement of the popliteus tendon is rather unlikely when using the asymmetric plateau due to the smaller R. Becker (&) Department of Orthopedics and Trauma Surgery, City Hospital Brandenburg, Hochstrasse 26, 14770 Brandenburg, Germany e-mail: roland_becker@yahoo.de

Even if mires have proven to be relatively reliable archives over the temporal trends in atmospheric mercury deposition, there are large discrepancies between sites regarding the magnitude of the a ...

The aim of the present study was to assess the function of the isolated muscle component in retracted rotator cuff tears. Muscle biopsies were harvested from the supraspinatus and the ipsilateral deltoid in seven patients undergoing surgery for a large, retracted rotator cuff tear. Single fibres and fibre bundles were subjected to passive stretching in vitro with subsequent recordings of tension and sarcomere lengths using the laser diffraction technique. Stress–strain curves were plotted, and the elastic modulus was calculated for all preparations. Morphology was evaluated with regard to collagen fraction, ratio between fast and slow fibres, fibre size and fibre size variability using standard staining techniques. Intra-individual comparisons of the stress–strain curves showed a high degree of conformity in terms of both shape and tangent values, and there were no statistically significant differences in the elastic modulus for single fibres and bundles in the deltoid and supraspinatus muscles, respectively, supported by the analysis of the observed confidence interval of the differences between the paired values of the elastic modulus. There were no differences in collagen content, fibre size and ratio between fast and slow fibres in the deltoid and supraspinatus muscles, respectively. We conclude that muscle biopsies from the supraspinatus in retracted rotator cuff tears respond normally to mechanical testing in vitro.

Background There is no consensus regarding the optimal treatment for patients with acute Achilles tendon rupture. Few randomized controlled studies have compared outcomes after surgical or nonsurgical treatment with both groups receiving early mobilization. Purpose This study was undertaken to compare outcomes of patients with acute Achilles tendon rupture treated with or without surgery using early mobilization and identical rehabilitation protocols. Study Design Randomized, controlled trial; Level of evidence, 1. Methods Ninety-seven patients (79 men, 18 women; mean age, 41 years) with acute Achilles tendon rupture were treated and followed for 1 year. The primary end point was rerupturing. Patients were evaluated using the Achilles tendon Total Rupture Score (ATRS), functional tests, and clinical examination at 6 and 12 months after injury. Results There were 6 (12%) reruptures in the nonsurgical group and 2 (4%) in the surgical group (P = .377). The mean 6- and 12-month ATRS were 72 and 88 points in the surgical group and 71 and 86 points in the nonsurgical group, respectively. Improvements in ATRS between 6 and 12 months were significant for both groups, with no significant between-group differences. At the 6-month evaluation, the surgical group had better results compared with the nonsurgically treated group in some of the muscle function tests; however, at the 12-month evaluation there were no differences between the 2 groups except for the heel-rise work test in favor of the surgical group. At the 12-month follow-up, the level of function of the injured leg remained significantly lower than that of the uninjured leg in both groups. Conclusion The results of this study did not demonstrate any statistically significant difference between surgical and nonsurgical treatment. Furthermore, the study suggests that early mobilization is beneficial for patients with acute Achilles tendon rupture whether they are treated surgically or nonsurgically. The preferred treatment strategy for patients with acute Achilles tendon rupture remains a subject of debate. Although the study met the sample size dictated by the authors’ a priori power calculation, the difference in the rerupture rate might be considered clinically important by some.

Internal impingement syndrome is a painful shoulder condition related to the impingement of the soft tissue, including the rotator cuff, joint capsule and the long head of the biceps tendon and glenoid labrum. Two types of internal impingement syndrome can be differentiated: posterior-superior impingement and anterior-superior impingement (ASI). The aetiology of ASI in particular is not clear. The purpose of this paper is to discuss the different aetiological theories relating to ASI, try to clarify the clinical, radiological and arthroscopic findings and, finally, suggesting treatment for this complex shoulder syndrome.The article is based on own research and clinical experience, as well as a non-systematic search in the PubMed database.The aetiology of ASI appears to be related to the pulley lesion and instability of the long head of the biceps tendon. It can be caused by trauma or degenerative factors, which produces anterior shoulder pain in middle-aged patients, particularly when performing overhead activities.The ASI is probably more frequent than previously reported. There is no evidence to prove the efficacy of a specific rehabilitative protocol, and the gold standard of surgical management has to be ascertained. However, in patients with a pulley lesion, there is some evidence that early surgical management, when minor soft injury lesions are present, produces better clinical outcomes.

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Anterior cruciate ligament graft fixation has become one of the most investigated topics in the sports traumatology literature. With over 400 publications within the past decade, a plausible explanation for the popularity of the topic would be that anterior cruciate ligament graft fixation represents an obvious clinical problem. Yet this does not seem to be the case. We set out to analyze the veracity of the notion that the fixation site is the weak link in a reconstructed knee in the early postoperative period. A mere temporal association is found between the first clinical reports on increased anterior tibial translation relative to the femur with soft-tissue grafts and the first pullout studies reporting lower ultimate failure loads with such grafts. This association was sufficient to convince the orthopaedic community at large that actual causality exists between soft-tissue graft fixation failure and increased knee laxity during healing. Thus the concept of "graft slippage" was born. Even with the imminent risk of being misconstrued as contentious, we submit that the entire concept of graft slippage is a myth, founded on poor scientific practice and affected by commercial bias. As a way forward, clinically important phenomena should be demonstrated through experiments with clear and sound clinical endpoints. As for preclinical studies, although they are indisputably helpful in the elaboration of such phenomena, serious hazards lie in declaring them a sufficient scientific basis for new research or, worse, for clinical standards of care. More importantly, no matter how sophisticated or fascinating their methodology, preclinical studies do not relieve us from the necessity and duty of proving our theories, whenever possible, with randomized controlled trials.

Purpose Patients undergoing surgery for thumb carpometacarpal (CMC1) osteoarthritis often require sick leave owing to postoperative immobilization, pain, and decreased function. Our goal was to evaluate the amount of sick leave after surgery for 2 common CMC1 arthroplasty procedures. Methods Using registry data from the Skane region of southern Sweden, cross-linked with employment data showing person-specific sick leave, 2 cohorts of CMC1 surgical patients, between ages 40 and 59 years, were examined. These comprised all persons undergoing soft tissue arthroplasty and prosthetic implant arthroplasty from 2004 to 2012 identified using International Classification of Diseases, 10th Revision, and surgical codes. These subjects were analyzed against an age- and sex-matched reference population cohort. Results Surgical cohorts of 326 and 169 subjects undergoing soft tissue and prosthetic CMC1 arthroplasty, respectively, were compared with reference populations of 1,110 and 574 persons. Surgical subjects had a pronounced increase in sick leave in the first 2 months after surgery, followed by diminishing days of leave over time. Mean sick leave time after soft tissue arthroplasty was 202 days in women and 170 days in men. Following prosthetic arthroplasty, mean sick leave was 177 days in women and 188 in men. When we excluded those with documented sick leave in the month before surgery (owing to preoperative CMC1 disability or other medical issues), the mean postoperative sick leave decreased to 137 days in women and 125 days in men after soft tissue arthroplasty compared with 109 and 94 days in women and men after prosthetic implant arthroplasty, and this difference was significant. There were no differences in the length of sick leave between sexes and no correlation with age. Conclusions Soft tissue arthroplasty and implant arthroplasty for patients with CMC1 osteoarthritis are both associated with substantial sick leave time, indicating the impact of surgery on return to work. There were no differences in sick leave by sex or age. Type of study/level of evidence Prognostic II.

Studies evaluating treatment effects on muscle function after an Achilles tendon rupture often use various tests for evaluating calf muscle strength. However, these tests rarely demonstrate the difference between treatment groups; therefore, new tests with a higher ability to detect possible differences in outcome are needed. The purpose of this study was to evaluate the validity and ability to detect differences in outcome of a heel-rise work test that would measure both the height of each heel-rise and the number of repetitions. Seventy-eight patients (65 men and 13 women) at a mean (standard deviation) age of 42 (9) years with Achilles tendon ruptures were included. The patients were evaluated with the new heel-rise test at 6 and 12 months after injury. The limb symmetry index (LSI = involved/uninvolved × 100) was calculated to determine the size of the difference in function between the injured and the uninjured side. The heel-rise height differed significantly between the injured and uninjured sides at the 6- and 12-month evaluations (P < 0.001). At the 6-month evaluation, the patients had achieved a mean LSI of 84% on the number of repetitions parameter but only a mean LSI of 61% on the work parameter. At the 12-month evaluation the mean, LSI of the heel-rise repetition parameter was 95%, indicating that the patients had fully recovered function, but on the work parameter the mean LSI was only 76%. The heel-rise work test in the present study has good validity and greater ability to detect differences between the injured and the uninjured sides than a test that measures only the number of heel-rise repetitions in patients with Achilles tendon rupture.

The aims of the study were to analyse the change in knee laxity over time after anterior cruciate ligament (ACL) reconstruction, using either bone-patellar-tendon-bone (BPTB) or hamstring (HS) tendon autografts, and to compare the knee laxity measurements between the study groups both pre-operatively and on multiple follow-up occasions. Another aim was to compare the radiographic findings in terms of degenerative changes between the study groups. A randomised series of 71 patients, who underwent ACL reconstruction using BPTB or HS tendon autografts and interference screw fixation, were included in the study. Of these patients, 47/71 (66%) attended a clinical examination, including laxity measurements using the KT-1000 arthrometer, pre-operatively and on four post-operative occasions; 6 months, 1 year, 2 years and 7 years after the reconstruction. The BPTB group consisted of 22 patients, while there were 25 patients in the HS group. There were no significant differences in the mean side-to-side knee laxity between the BPTB and the HS group pre-operatively or at the follow-up examinations. There was a tendency towards a reduction in side-to-side knee laxity over time in both groups, measured with the KT-1000 arthrometer. The decrease was significant when analysing the injured and uninjured knee separately (injured side p < 0.001 (BPTB) and p = 0.005 (HS), uninjured side p = 0.008 and p = 0.042, respectively). Forty-four patients (BPTB 21, ST 23) underwent a radiographic assessment at the 7-year follow-up, which revealed no significant differences between the study groups in terms of osteoarthritic findings classified according to the Fairbank and Ahlback rating systems. In overall terms, osteoarthritis was identified in 16% (BPTB 19%; ST 13%; n.s.) according to the Ahlback rating system and 68% (BPTB 67%; ST 70%; n.s.) according to the Fairbank rating system. There were no significant differences in knee laxity measurements between the two study groups pre-operatively or at 7 years. A decrease in knee laxity over time was seen in both groups. There were no significant differences between the BPTB and ST groups in terms of osteoarthritic findings at 7 years.

Purpose The primary aim was to investigate and assess the current evidence of randomized controlled trials (RCTs) on anterior cruciate ligament (ACL) injuries, with special reference to the choice of surgical techniques and aspects of rehabilitation. A secondary aim was to clarify relative strengths and weaknesses of the selected studies, resolve literature conflicts, and finally, evaluate the need for further studies. Methods A PubMed database search using the key words "anterior cruciate ligament" was performed. The search was limited to only RCTs published in English during the period of January 1995 to March 2009. Articles concerning surgical technique and rehabilitation were obtained. After initial screening and subsequent quality appraisal based on the CONSORT (Consolidated Standards of Reporting Trials) Statement, a total of 70 articles were included in this review. Results Initial graft tension and the use of a ligament augmentation device do not affect clinical outcome. Bioabsorbable screws and titanium screws produced equal clinical outcome, regardless of graft type. Radiographic signs of osteoarthritis develop in 50% of ACL-injured patients, regardless of treatment. Meniscectomy further increases the risk. Furthermore, the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction. Closed kinetic chain exercises produced less pain and laxity while promoting better subjective outcome than open kinetic chain exercises after patellar tendon reconstruction. Conclusions In terms of quality assessment, several weaknesses pertaining to study design were discovered among the included RCTs, which intelligibly stress the need for further high-quality studies. Level of Evidence Level II, systematic review of RCTs.

Objective: To describe the clinical changes following two different physiotherapy treatment protocols after rotator cuff repair.Design: A prospective, randomized pilot study with a two-year follow-up.Subjects: Five women and nine men, 55 (40—64) years old, were included.Intervention: The progressive group (n = 7) started with dynamic, specific muscle activation of the rotator cuff the day after surgery as well as passive range of motion. After four weeks of immobilization the loading to the rotator cuff increased and in a progressive manner throughout the rehabilitation. In the traditional group (n = 7) the rotator cuff was protected from loading. Patients were immobilized for six weeks and started with passive range of motion the day after surgery. No specific exercises to the rotator cuff were introduced during this period.Main measures: A clinical evaluation was made preoperatively, 3, 6, 12 and 24 months after surgery. Pain rating during activity and at rest, patient satisfaction, active range of motion and muscle strength, Constant score, hand in neck, hand in back and pour out of a pot, as well as Functional Index of the Shoulder were used.Results: At two years follow-up, the progressive group and traditional group scored pain during activity visual analogue scale (VAS) 2/0 mm and pain at rest 0/0 mm, respectively. The groups attained 170/175° in active abduction in standing and 70/90° in passive external rotation while lying in supine. Using Constant score, the groups attained 82/77 points respectively.Conclusion: The present study showed that the progressive protocol produced no adverse effects compared with the traditional protocol.

Objective.Naproxcinod, a cyclooxygenase-inhibiting nitric oxide donator antiinflammatory drug, was evaluated in this phase 2, double-blind, randomized, parallel group study to determine its optimal dose in patients with osteoarthritis (OA).Methods.In total 543 patients with OA of the hip or knee were randomized to receive naproxcinod 750 mg once daily (qd), 750 mg twice daily (bid), 1125 mg bid, rofecoxib 25 mg qd, or placebo for 6 weeks. The primary efficacy variable was the within-patient change from baseline to the average of Weeks 4 and 6 in WOMAC™ pain subscale score. Treatment-group differences were compared using ANCOVA with factors for treatment and country, and baseline pain subscale score as a covariate. Safety endpoints included vital signs and adverse events. Treatment-group differences in mean change from baseline to Week 6 in systolic blood pressure (SBP) were compared using an ANCOVA with treatment and country as fixed factors and baseline SBP as covariate.Results.All active treatments showed statistically significant reductions in WOMAC pain score compared to placebo (p ≤ 0.02). Naproxcinod was well tolerated. The 750 mg bid dose appeared to have the best balance of benefit versus safety. All 3 naproxcinod doses showed a reduction in SBP, while an increase was shown for rofecoxib. The changes for the naproxcinod groups were statistically significantly better compared to rofecoxib (p ≤ 0.02).Conclusion.This dose-finding study identified naproxcinod 750 mg bid as the upper dose for further therapeutic confirmatory clinical trials. Naproxcinod at all doses decreased mean SBP compared to an increase with rofecoxib.

The 21-item Three-Factor Eating Questionnaire (TFEQ-R21) is a scale that measures three domains of eating behavior: cognitive restraint (CR), uncontrolled eating (UE) and emotional eating (EE).To assess the factor structure and reliability of TFEQ-R21 (and if necessary, refine the structure) in diverse populations of obese and non-obese individuals.Data were obtained from obese adults in a United States/Canadian clinical trial (n=1741), and overweight, obese and normal weight adults in a US web-based survey (n=1275). Confirmatory factor analyses were employed to investigate the structure of TFEQ-R21 using baseline data from the clinical trial. The model was refined to obtain adequate fit and internal consistency. The refined model was then tested using the web-based data. Relationships between TFEQ domains and body mass index (BMI) were examined in both populations.Clinical data indicated that TFEQ-R21 needed refinement. Three items were removed from the CR domain, producing the revised version TFEQ-R18V2 (Comparative Fit Index (CFI)=0.91). Testing TFEQ-R18V2 in the web-based sample supported the revised structure (CFI=0.96; Cronbach's coefficient alpha of 0.78-0.94). Associations with BMI were small. In the clinical study, the CR domain showed a significant and negative association with BMI. On the basis of the web-based survey, it was shown that the relationship between BMI and CR is population-dependent (obese versus non-obese, healthy versus diabetics).In two independent datasets, the TFEQ-R18V2 showed robust factor structure and good reliability. It may provide a useful tool for characterizing UE, CR and EE.

Deep venous thrombosis (DVT) is common after lower limb injury, but the effect of prophylactic treatment has not been documented in large randomised trials or meta-analyses. As a result, evidence-based recommendations have not been established. The purpose of this study was to evaluate the incidence of venous thromboembolism in patients with Achilles tendon rupture. A total of 100 consecutive patients with an acute Achilles tendon rupture were included in a prospective study and randomised to either surgical or non-surgical treatment. At 8 weeks after the initiation of treatment, 95/100 patients were screened for DVT using colour duplex sonography (CDS) with blinded interpretation by two experienced examiners and adjudication in cases of disagreement by a third person. A total of 95 patients (79 male and 16 female) with a median (range) age of 41 (24-63) years were screened for CDS at 8 weeks. Of the 95 patients, 32 had a CDS-verified thrombosis, 5 proximal and 27 distal, whereas 3 had non-fatal pulmonary embolism. Surgical treatment was performed in 49 patients, non-surgical in 46. There were no significant differences in DVT frequency between the two treatment groups. The incidence of asymptomatic and symptomatic deep venous thrombosis is high after Achilles tendon rupture and there is a need to define the possible benefit of thromboprophylaxis.

The knee self-efficacy scale (K-SES) has been shown to have good reliability, validity and responsiveness during rehabilitation for patients' perceived self-efficacy of knee function. Determinants of self-efficacy of knee function 1 year after ACL reconstruction have been found to be the patients' internal locus of control and knee symptoms in sports and recreation. The predictive ability of perceived self-efficacy of knee function measured by the K-SES has not been studied in terms of patient outcome after an ACL reconstruction. The purpose of this study was to explore the potential for pre-operative self-efficacy of knee function measured by the K-SES to predict patient outcome in terms of physical activity, knee symptoms and muscle function 1 year after an ACL reconstruction. Thirty-eight patients were evaluated for outcome in terms of physical activity with the Tegner activity scale and the physical activity scale (PAS), knee symptoms with the Lysholm knee scoring scale and the knee injury and osteoarthritis outcome score (KOOS) and knee function with ability tests for muscle function 1 year after ACL reconstruction. Multiple regression and logistic multiple regression analysis were used to evaluate the K-SES as a possible predictor of outcome. The patients' present perceived self-efficacy of knee function (K-SES(Present)) pre-operatively was a significant predictor (P = 0.016) of the patients returning to their intensity and frequency of physical activity (PAS) 1 year after ACL reconstruction, when adjusted for age, gender and pre-injury physical activity level (Tegner(Pre-injury)) (odds ratio = 2.1). The patients' perceived future self-efficacy of knee function (K-SES(Future)) pre-operatively was a significant predictor (P = 0.045) of their self-rated knee function in sports/recreational activities (KOOS(Sports/recreation)) at the 1-year follow-up, when adjusted for age, gender and Tegner(Pre-injury )(R (2 )=0.25). The pre-operative K-SES(Future) was also a significant predictor (P = 0.023) of the patients' knee-related quality of life (KOOS(Qol)), at the 1-year follow-up, when adjusted for age, gender and Tegner(Pre-injury) (R (2 )=0.23). The pre-operative K-SES(Future) was furthermore a significant predictor of an acceptable outcome 1 year after surgery, on the Lysholm knee scoring scale (P = 0.003, odds ratio = 1.7), as well as on KOOS(Sports/recreation) (P = 0.002, odds ratio = 1.6) and knee-related quality of life (KOOS(Qol)) (P = 0.037, odds ratio = 1.4), when adjusted for age, gender and Tegner(Pre-injury). The pre-operative K-SES(Future) was also a significant predictor (P = 0.04) of an acceptable outcome 1 year after surgery, on the one-leg hop for distance (odds ratio = 2.2), when adjusted for age, gender and Tegner(Pre-injury). In conclusion, this study indicates that patients' perceived self-efficacy of knee function pre-operatively is of predictive value for their return to acceptable levels of physical activity, symptoms and muscle function 1 year after ACL reconstruction.

Background Achilles tendinopathy is a common overuse injury, especially among athletes involved in activities that include running and jumping. Often an initial period of rest from the pain-provoking activity is recommended. Purpose To prospectively evaluate if continued running and jumping during treatment with an Achilles tendon-loading strengthening program has an effect on the outcome. Study Design Randomized clinical control trial; Level of evidence, 1. Methods Thirty-eight patients with Achilles tendinopathy were randomly allocated to 2 different treatment groups. The exercise training group (n = 19) was allowed, with the use of a pain-monitoring model, to continue Achilles tendon-loading activity, such as running and jumping, whereas the active rest group (n = 19) had to stop such activities during the first 6 weeks. All patients were rehabilitated according to an identical rehabilitation program. The primary outcome measures were the Swedish version of the Victorian Institute of Sports Assessment—Achilles questionnaire (VISA-A-S) and the pain level during tendon-loading activity. Results No significant differences in the rate of improvements were found between the groups. Both groups showed, however, significant (P < .01) improvements, compared with baseline, on the primary outcome measure at all the evaluations. The exercise training group had a mean (standard deviation) VISA-A-S score of 57 (15.8) at baseline and 85 (12.7) at the 12-month follow-up (P < .01). The active rest group had a mean (standard deviation) VISA-A-S score of 57 (15.7) at baseline and 91 (8.2) at the 12-month follow-up (P < .01). Conclusions No negative effects could be demonstrated from continuing Achilles tendon-loading activity, such as running and jumping, with the use of a pain-monitoring model, during treatment. Our treatment protocol for patients with Achilles tendinopathy, which gradually increases the load on the Achilles tendon and calf muscle, demonstrated significant improvements. A training regimen of continued, pain-monitored, tendon-loading physical activity might therefore represent a valuable option for patients with Achilles tendinopathy.

Title. Effects of nursing interventions within an integrated care pathway for patients with hip fracture Aim. This paper reports a study to evaluate the contribution of nursing care within an integrated care pathway for patients with hip fracture. Background. There is growing interest in quality assurance in health care. Integrated care pathways are a method to achieve this goal, and are a multi-professional team approach where the requirement for nurses to work effectively within the team is important. However, the nurses’ role and contribution within the team have not been well described. Method. A quasi-experimental, prospective study comparing an intervention group with a comparison group was carried out. One hundred and twelve independently living patients, aged 65 years or older and admitted to a Swedish hospital with a hip fracture, were consecutively selected. Pathological fracture and severe intellectual impairment (Pfeiffer's test

To examine trends and effects of weight loss treatment on health-related quality of life (HRQL) in the severely obese over 10 years. Swedish obese subjects (SOS) intervention study is a controlled, longitudinal trial of the health effects of weight loss in the severely obese. A total of 655 of 851 surgically treated and 621 of 852 conventionally treated obese men (body mass index, BMI⩾34) and women (BMI⩾38) who completed 10 years of the study. HRQL was assessed before treatment and after 0.5, 1, 2, 3, 4, 6, 8 and 10 years. HRQL change during the 10-year observation period largely followed phases of weight loss, weight regain and weight stability. Improvements and deteriorations in HRQL were associated with the magnitude of weight loss or regain, except regarding anxiety. Peak improvements in the surgical group were observed during the first year of weight loss, whereas the weight regain phase (mainly between 1- and 6-year follow-up) was accompanied by a gradual decline in HRQL. The period from 6- to 10-year follow-up was characterized by relatively stable observations in both weight and HRQL. At 10 years, net gains were noted in all HRQL domains compared to baseline. Comparisons of treatment effects on HRQL in the surgical vs conventional group after 10 years showed significantly better outcome in the surgical group on current health perceptions, social interaction, psychosocial functioning and depression, whereas no significant differences were found for overall mood and anxiety. Long-term results of the study suggest that a maintained weight loss of about 10% is sufficient for positive long-term effects on HRQL, a limit that was reached in about two-thirds of the surgically treated patients who completed 10 years of the study. Long-lasting weight reduction in the severely obese has a general long-standing positive outcome on HRQL. Bariatric surgery is a favorable option for the treatment of severe obesity, resulting in long-term weight loss and HRQL improvements in a majority of patients. However, difficulties among some surgical patients to control and maintain weight loss over time should not be ignored. Future research should study if the long-term efficacy of bariatric surgery may be further enhanced by implementing lifestyle modification techniques in the postoperative management of patients.

The wide spectrum of shoulder instability is difficult to include in 1 classification. The distinction between traumatic, unidirectional, and atraumatic multidirectional instability is still widely used, even though this classification is not sufficiently precise to include all the different pathological findings of shoulder instability. We present "minor instability," which is a pathological condition causing a dysfunction of the glenohumeral articulation, especially in combination with microtrauma, repetitive or not, or after a period of immobilization or inactivity. When "minor shoulder instability" is suspected, the patient's history and detailed clinical examination represent the most important factors when establishing the diagnosis. In particular, the apprehension test stressing the middle glenohumeral ligament (MGHL)/labral complex in the position of midabduction and external rotation may be painful and may even reveal anterior instability or subluxation. Conventional radiographs are negative in most cases, as is magnetic resonance imaging arthrography. It is only after an accurate arthroscopic assessment that the pathological lesion can be found. The major pathological process can be identified at the level of the anterior superior labrum, in particular the MGHL complex, and appears as hyperemia, fraying, stretching, loosening, thinning, hypoplasia, or even absence. It may, however, be difficult to distinguish between a normal variant and a pathological lesion. Clinical symptoms and examination should always be correlated with arthroscopic findings. Recommended treatment is to restore shoulder stability and thereby prevent shoulder pain secondary to the increase in laxity. A reduction in range of motion should be expected during the postoperative phase, at least up to six to nine months. External rotation is usually permanently reduced by a few degrees.

Muscle function was evaluated in 40 patients with patellofemoral pain syndrome (PFPS) and 20 healthy controls. Patients with PFPS had a significantly lower knee extensor strength in the most symptomatic knee compared to the least symptomatic knee. Further, the patients had less vertical jumping ability and were weaker in the most symptomatic knee compared to the controls, with the largest differences in eccentric knee extension. There were lower strength and EMG activity, in the patients compared to the controls, in the range closer to full extension and significant differences in muscle activity between the vastus medialis and the rectus femoris muscle. The results can be explained by inhibition selective to knee angles and to the vastus medialis muscle.

Objective: To explore physical and psychological measures believed to determine patients’ perceived self-efficacy in the rehabilitation of patients with anterior cruciate ligament injury. Design: An explorative descriptive study. Patients: A total of 116 patients with an anterior cruciate ligament deficient or reconstructed knee. Method: At one visit; 12 months post-injury/reconstruction, patients reported their perceived self-efficacy on the Knee Self-Efficacy Scale. Thirty-nine other measures related to self-efficacy were also documented. A linear regression mod el was applied to identify determinants of perceived selfefficacy. Results: 40% of the variance in the complete Knee SelfEfficacy Scale was explained by the Lysholm score, Knee Injury and Osteoarthritis Outcome Score Sport/Recreation , Internal Locus of Control and Locus of Control by Chance. The variance in patients’ present perceived self-efficacy was ex plained to 41% by the same measures. Perceived self-effica cy of future capability was explained to 38% by the variance in the Lysholm score, Knee Injury and Osteoarthritis Outcome Score Sport/Recreation , Tegner Present level and Internal Locus of Control. Conclusion: Self-reported symptoms/functions and Internal Locus of Control were the most important determinants of self-efficacy in patients with an anterior cruciate ligament injury. In order to strengthen self-efficacy, these determi nants should be considered by the clinicians involved in the rehabilitation.

Background The purpose of the present study is to compare the radiological parameters of the spino-pelvic sagittal alignment in young elite skiers and non-athletes of a similar age. Methods The sample group (n = 102) consisted of elite Alpine and Mogul skiers (n = 75) and a non-athletic population (n = 27), mean age for both groups was 17.7 (±1.4) years (skiers mean age 18.3 SD 1.1 and controls 16.4 SD 0.6). Radiological measurements of the spino-pelvic sagittal alignment were examined from plain radiographs taken in the long-standing position. Results There were no significant differences reported in the pelvic parameters between both groups. A difference was reported in the sagittal vertebral axis between skiers (8.0 cm SD 46.0) and the control group (−2.0 cm SD 39.0), which may be of clinical significance, in spite of being statistically non-significant. Type I spinal curves according to Roussouly were shown to be more prevalent in the skiers (18.2 %) compared with the control group (0.0 %) and were statistically significant (p = 0.03). Conclusion Elite young skiers are shown to have a more prevalent type I spine and a different spino-pelvic sagittal alignment compared to a healthy non-sporting population of a similar age.

Health care facilities produce significant waste (2200 kg/bed/year) creating 2% of greenhouse gas emissions and 1% total solid waste nationwide, with 20–70% of waste coming from operating rooms. We performed a waste audit of hip arthroscopy for femoroacetabular impingement (FAI) to understand its environmental impact and identify areas for greening practices. A waste audit of five hip arthroscopy procedures for FAI was performed. All waste was collected and separated into six waste streams in real time: (i) normal/landfill waste; (ii) recyclable cardboards and plastics; (iii) biohazard waste; (iv) sharp items; (v) linens and (vi) sterile wrapping. The surgical waste (except laundered linens) from five FAI surgeries totaled 47.4 kg, including 21.7 kg (45.7%) of biohazard waste, 11.7 kg (24.6%) of sterile wrap, 6.4 kg (13.5%) of normal/landfill waste, 6.4 kg (13.5%) of recyclable plastics and 1.2 kg (2.6%) of sharp items. An average of 9.4 kg (excluding laundered linens) of waste was produced per procedure. Given the considerable biohazard waste produced by FAI procedures, additional recycling programs, continued adherence to proper waste segregation and an emphasis on ‘green outcomes’ is encouraged to demonstrate environmental responsibility and effectively manage and allocate finite resources.

A total of 20 patients scheduled for wrist arthroscopy, all with clinical signs of rupture to the triangular fibrocartilage complex and distal radioulnar joint instability, were tested pre-operatively by an independent observer for strength of forearm rotation. During surgery, the intra-articular pathology was documented by photography and also subsequently individually analysed by another independent hand surgeon. Arthroscopy revealed a type 1-B injury to the triangular fibrocartilage complex in 18 of 20 patients. Inter-rater reliability between the operating surgeon and the independent reviewer showed absolute agreement in all but one patient (95%) in terms of the injury to the triangular fibrocartilage complex and its classification. The average pre-operative torque strength was 71% of the strength of the non-injured contralateral side in pronation and supination. Distal radioulnar joint instability with an arthroscopically verified injury to the triangular fibrocartilage complex is associated with a significant loss of both pronation and supination torque. Level of evidence: Case series, Level IV.

Objective : Foot deformities, neuropathy, and dysfunction in the lower extremities are known risk factors that increase plantar peak pressure (PP) and, as a result, the risk of developing foot ulcers in patients with diabetes. However, knowledge about the prevalence of these factors is still limited. The aim of the present study was to describe the prevalence of risk factors observed in patients with diabetes without foot ulcers and to explore possible connections between the risk factors and high plantar pressure. Patients and methods : Patients diagnosed with type 1 ( n= 27) or type 2 ( n= 47) diabetes (mean age 60.0±15.0 years) were included in this cross-sectional study. Assessments included the registration of foot deformities; test of gross function at the hip, knee, and ankle joints; a stratification of the risk of developing foot ulcers according to the Swedish National Diabetes Register; a walking test; and self-reported questionnaires including the SF-36 health survey. In-shoe PP was measured in seven regions of interests on the sole of the foot using F-Scan ® . An exploratory analysis of the association of risk factors with PP was performed. Results : Neuropathy was present in 28 (38%), and 39 (53%) had callosities in the heel region. Low forefoot arch was present in 57 (77%). Gait-related parameters, such as the ability to walk on the forefoot or heel, were normal in all patients. Eighty percent had normal function at the hip and ankle joints. Gait velocity was 1.2±0.2 m/s. All patients were stratified to risk group 3. Hallux valgus and hallux rigidus were associated with an increase in the PP in the medial forefoot. A higher body mass index (BMI) was found to increase the PP at metatarsal heads 4 and 5. Pes planus was associated with a decrease in PP at metatarsal head 1. Neuropathy did not have a high association with PP. Conclusions : This study identified several potential risk factors for the onset of diabetic foot ulcers (DFU). Hallux valgus and hallux rigidus appeared to increase the PP under the medial forefoot and a high BMI appeared to increase the PP under the lateral forefoot. There is a need to construct a simple, valid, and reliable assessment routine to detect potential risk factors for the onset of DFU. Keywords : diabetic foot; foot deformities; neuropathy; prevention; foot anthropometrics; plantar pressure; risk factors (Published: 17 June 2015) Citation: Diabetic Foot & Ankle 2015, 6: 27593 - http://dx.doi.org/10.3402/dfa.v6.27593

Introduction The Swedish Fracture Register (SFR) was started in 2011 and registers fractures of all types, treated either surgically or non-surgically. Twenty-six orthopaedic departments in Sweden are affiliated and a total of 84,000 fractures have been registered. The physician who establishes the diagnosis of the fracture registers and classifies it according to the AO/OTA classification. The accuracy of the classification of fractures is important for the reliability of the data in the SFR. This study aimed to evaluate how accurate the classification of tibia fractures in the register is. Methods Three experienced trauma surgeons (raters) were presented with the radiographs of 114 patients with tibia fractures randomly allocated from the SFR. The raters classified the fractures independently and blinded to clinical patient information in two classification sessions with a time interval of one month. The AO/OTA classification coded by the three expert raters (our predefined gold standard) was compared with the classifications in the SFR. Inter- and intra-observer agreement was evaluated. The degree of agreement was reported using the approach of Landis and Koch. Results The accuracy of the SFR, defined as agreement between the SFR and the gold standard classification, was kappa = 0.75 for the AO/OTA type and 0.56 for the AO/OTA group, corresponding to substantial and moderate agreement, respectively. Inter-observer agreement across the three expert raters was kappa = 0.74 for the AO/OTA type and 0.53 for the AO/OTA group. Intra-observer agreement was kappa = 0.74–0.79 for the AO/OTA type and 0.62–0.64 for the AO/OTA group. Conclusion This study shows that the accuracy of classification of tibia fractures in the SFR was substantial for the AO/OTA type (kappa = 0.75) and moderate for the AO/OTA group (kappa = 0.56) as defined by Landis and Koch. This degree of accuracy is similar to that in previous studies. We interpret this as meaning that the results of this study demonstrate the high reliability of the data in the SFR and enable the SFR to be used for further scientific analysis.

Surgical hip dislocation (SHD) and hip arthroscopy are surgical methods used to correct deformity associated with femoroacetabular impingement (FAI). Though both of these approaches appear to benefit patients, no studies exist comparing healthcare resource utilization of the two surgical approaches. This systematic review examines the literature and the records of two surgeons to evaluate the resource utilization associated with treating symptomatic FAI via these two methods. EMBASE, MEDLINE and PubMed were searched for relevant articles. The articles were systematically screened, and data was abstracted in duplicate. To further supplement resource utilization data, a retrospective chart review of two surgeon’s patient data (one using SHD and another using an arthroscopic approach) was completed. Experts in pharmacy, physiotherapy, radiology, anaesthesia, physiatry and the local hospital finance department were also consulted. There were 52 studies included with a total of 460 patients (535 hips) and 3886 patients (4147 hips) who underwent SHD and arthroscopic surgery for FAI, respectively. Regardless of approach, most patients treated for symptomatic FAI improved across various outcomes measures with low complication rates. Surgical time across all approaches was similar, averaging 118 ± 2 min. On a per patient basis, hip arthroscopy ($10,976) uses approximately 41 % of the resources of SHD ($24,379). There were no significant differences in outcomes for FAI treated with SHD or arthroscopy. However, with regard to healthcare resource utilization based on the OHIP healthcare system, hip arthroscopy uses substantially less resources than SHD within the first post-operative year. Systematic Review of Level IV Studies, Level IV.

a time-related return to sports has been most common, for instance 6 months after ACL reconstruction? But, during the last years, physicians understand better and better that time-related decisions are not correct and moreover that we must think individually. So, are there any new and better ways to decide on return to sports. What about the objective tests, e.g. strength testing? Approximately 10 years ago, a research group forwarded the idea to use not only one objective test, but a test battery. The reason for this is increased accuracy and less risk of incorrect judgement [1, 4, 5]. The test battery was concentrated around hop performance and strength testing. Myer et al. [4] described criteria-based algorithm that can be used through the entire rehabilitation phase after an ACL reconstruction. They included in their protocol assessment of baseline limb strength, patient-reported outcomes, functional knee stability bilateral limb symmetry with functional tasks, postural control, power, endurance and sports-specific tasks. They concluded that if criteria-based guidelines were not used, this might lead to deficits in proprioception, strength and reaction forces. They also concluded that such deficits might follow the athlete into competitive play and increase the risk of reinjury. A few years later (in 2011), a group of physiotherapists performed a thorough systematic analysis on the factors that are most relevant in terms of decision-making for safe return to sports [6]. They concentrated mainly on muscle strength recovery after the ACL reconstruction. In this issue of the journal, Herbst et al. and Hildebrandt et al. have taken this even further [2, 3]. In two studies, they describe the development of a new test battery for functional assessment for decision-making with regard to return to sports following ACL reconstruction [2]. And in the second study, they describe the clinical application of the new test battery [3]. The following tests were included: When, how and if ACL-injured athletes can return to sports is a very controversial topic [1–6]. ACL injuries are still a major problem for the insured athlete and the society, in spite of the great number of research studies published. In fact, even though the number of studies appears to be increasing and our knowledge rapidly increasing as well, new research questions are more and more obvious and relevant. Today, probably the majority of ACL reconstructions are performed using anatomical techniques. And, there is no doubt that during the last decade, the scientific knowledge about injury mechanisms, biomechanics and relevant knee anatomy has substantially increased. We have also studies and accepted prevention as a natural part of the big picture. Today, we have also learned to better understand the term “individualised treatment”. This means that physicians better understand not only the injury mechanism and the knee anatomy, but also the patient who is injured, the requirements and the demands and what the individual athlete wishes to use her/his knee for. Does she/he want to return to sports, in spite of the inherent risk of a reinjury? Or are patients well enough educated about the long-term risks of developing osteoarthritis? And how relevant is it to take the long-term consequences into consideration? Most people like to live for today. Do athletes really care about what happens after 15–30 years? The main problem in terms of safe return to sports is that until now we really do not know how to evaluate and how to decide on safe return to sports, e.g. football. Previously

Background The recent discovery of residing tendon stem/progenitor cells has triggered a growing interest in stem cells as a useful tool in tendon repair. Our knowledge of their involvement in naturally healing tendons is, however, sparse. The aim of this study was to identify and determine stem/progenitor cells in relation to different healing phases and regions in a rat model of Achilles tendon rupture. Methods Surgery was performed to create a mid-tendon rupture on the right Achilles tendon of 24 rats, whereas the left tendon was used as a control. Tendons were harvested at one, two, eight and 17 weeks post-rupture and stained with antibodies specific to stem/progenitor cells (Octamer-binding transcription factor 3/4 (Oct 3/4) and nucleostemin), migrating cells (Dynamin 2 (Dyn 2)) and leukocytes (CD45). A histological examination was performed on sections stained with Alcian blue. Results At one and two weeks post-rupture, a large number of stem/progenitor cells were discovered throughout the tendon. Most of these cells were nucleostemin positive, whereas only a few Oct 3/4-positive cells were found, mainly situated inside the injury region (I region). At eight and 17 weeks, the increment in stem/progenitor cells had diminished to equal that in the control tendons. At all time points, Oct 3/4-positive cells were also found in the connective tissue surrounding the tendon and at the muscle-tendon junction in both ruptured and control tendons and were often seen at the same location as the migration marker, Dyn 2. Conclusions The whole length of the Achilles tendon is infiltrated by stem/progenitor cells at early time points after a mid-tendon rupture. However, different stem/progenitor cell populations exhibit varying anatomical and temporal expressions during Achilles tendon healing, suggesting distinct reparative implications. Oct 3/4 may thus act as a more local, migrating stem/progenitor cell involved in injury-site-specific regenerative effects, as compared to the more general proliferative role of nucleostemin-positive stem/progenitor cells.

Team members in ORs have frequent hand contact with many surfaces and sites during high workload, thus increasing the risk for microorganism cross-transmission. This study aimed at identifying risks for hand contamination and microorganism cross-transmission during invasive procedures in ORs. We carried out observations during 22 daytime sessions and analyzed data using qualitative content analysis. The results revealed that clinicians' hands may be contaminated by self-contamination, via objects, or by touching the patient. Contamination may occur before, during, or directly after performing an invasive procedure requiring the use of aseptic technique, which risks cross-transmitting microorganisms. The results of the study contribute detailed knowledge about risk-associated activities and behaviors in relation to performing invasive procedures in the OR. This knowledge provides clinicians, managers, and educators with specific information that can be used in nursing and medical education and in quality improvement projects aimed at improving hand hygiene routines and enhancing aseptic technique.

Purpose To investigate the diagnostic performance of magnetic resonance imaging (MRI) and clinical provocative tests on injuries to the triangular fibrocartilage complex (TFCC), the scapholunate (SL) ligament, and the lunotriquetral (LT) ligament. Methods An electronic literature search of articles published between January 1, 2000, and February 28, 2014, in PubMed, Embase, and the Cochrane Library was carried out in April 2014. Only studies of the diagnostic performance of MRI and clinical provocation tests using wrist arthroscopy as the gold standard were eligible for inclusion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the extraction and reporting of data. The methodologic quality of the included articles was assessed with the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The primary outcome measure was the negative predictive value (NPV) of wrist MRI and provocative wrist tests, which was defined as the probability of an intact wrist ligament given a negative investigation. The question was whether negative results of MRI or provocative tests were enough to safely discontinue further investigation with arthroscopy. A minimum NPV of 95% was considered a clinically relevant cutoff value. The secondary outcome measures were the positive predictive value (PPV), sensitivity, and specificity. Results A total of 7 articles (327 patients with MRI and 105 patients with clinical tests) were included in this systematic review. The included articles displayed heterogeneity regarding participants, diagnostic methods, and study design. Seven articles investigated the diagnostic performance of MRI, whereas 1 article investigated clinical testing. The NPVs of MRI were as follows: TFCC, 37% to 90%; SL ligament, 72% to 94%; and LT ligament, 74% to 95%. The NPVs of clinical tests were 55%, 74%, and 94% for the TFCC, SL ligament, and LT ligament, respectively. Only 1 study reached the predetermined cutoff value for the primary outcome measure (NPV ≥95%) but only for MRI of the LT ligament; this study also reached a borderline-cutoff NPV of 94% for MRI of the SL ligament. Another study reached borderline-cutoff NPVs of 94% both for MRI and for clinical tests of the LT ligament. Conclusions A negative result from MRI is unable to rule out the possibility of a clinically relevant injury to the TFCC, SL ligament, or LT ligament of the wrist. Clinical provocation wrist tests were of limited diagnostic value. The current gold standard—wrist arthroscopy—remains the preferred diagnostic technique with sufficient conclusive properties when it comes to wrist ligament injuries. Level of Evidence Level II, systematic review of Level II diagnostic studies.

Achilles tendon ruptures are increasingly common, especially in males. The rupture commonly occurs in sports-active persons with a peak age around 40 years. Achilles tendon rupture should be diagnosed clinically, using the well-known Thompson’s and Matles tests. Ultrasonography and Magnetic Resonance Imaging are seldom needed to establish the diagnosis. The treatment is either non-surgical or surgical. Surgical treatment is related to lower risk of rerupture and is generally recommended in active athletes. A strong core suture, with local augmentation is a safe method with very low risk of rerupture. Early range of motion is recommended after surgical treatment. The rerupture rate is higher after non-surgical treatment, over 10 %. Interestingly, only 50–65 % of all patients who have sustained an Achilles tendon rupture return to the pre-injury activity level.

Validation of the Debrunner Kyphometer as a clinical non-radiological method for investigating spinal sagittal alignment was compared with standing lateral radiographs. The sample group (n=102) consisted of elite Alpine skiers (n=75) and a non-athletic population (n=27), mean age 17.7 (±1.4) years. Non-radiological and radiological measurements of the spinal sagittal kyphosis and lordosis range of motion were carried out in the erect standing position. Thoracic kyphosis measurements comparing the Debrunner Kyphometer with a radiological standard, showed a good level of agreement and a statistical significance (ICC 0.67, 95% CI: 0.26 to 0.83, p

Objectives: The rotational laxity, or the pivot shift test, is a key to understanding the anterior cruciate ligament (ACL) function after the ACL injury and reconstruction. Various measurement methods have been developed to quantify the pivot shift test, but the clinical implications of the measurement results have not been established mainly because of a wide variability of the pivot shift test between examiners. The purpose of this study was to determine the relationship between quantitative measurement and clinical grade of the pivot shift test at four international centers. Methods: Seventy-three unilateral ACL injured patients at four different sites were included in this study. While performing the standardized pivot shift test under anesthesia, two quantitative technologies were utilized; an accelerometer and image analysis system using iPad. Accelerometer wireless sensor (KiRA, Orthokey, Italy) was attached on the lateral side of the tibial tubercle using a strap (Figure1A). The tibial acceleration was recorded through a Bluetooth connection to the tablet PC. Image analysis of lateral compartment translation was simultaneously performed using software implemented on iPad (Apple Inc, USA) which tracked the movement of three markers on the lateral side of the knee joint (two on the lateral tibial plateau and one on the lateral femoral epicondyle) to measure the anterior-posterior shift between the lateral tibia and femur (Figure 1B). Tibial acceleration and the lateral compartment translation were compared to the clinical pivot shift grade (grade 0, 1, 2 and 3). Spearman correlations were use to determine the relationship between the quantitative measurements and clinical pivot shift grade. Considering limited number of individuals with a grade 0 and 3 pivot shift test, we used independent t-tests to compare the quantitative measurements between those with a grade 0 or 1 (low grade) pivot shift versus grade 2 or 3 (high grade) pivot shift. The alpha level was set at pResults: There were weak correlations between the quantitative measurements and clinical pivot shift grade (acceleration: 0.32, translation: 0.31, pConclusion: This study confirms that clinical grading of the pivot shift is subjective and inconsistent. The tools to perform non-invasive, quantitative pivot shift measurements (tibial translation and acceleration) are simple to learn as shown across 4 centers in this study. However, there were only weak correlations between clinical grading and quantitative measurements. From the data of this study, it is suggested to use a simple positive/negative grading and add a quantitative value to it. Future research is needed to determine the correlation of quantitative pivot shift measurements and additional soft tissue injury in patients with ACL injury.

BackgroundThe use of biodegradable screws in anterior cruciate ligament reconstruction has grown in popularity.PurposeTo compare the clinical and radiographic results in arthroscopically assisted anterior cruciate ligament reconstruction using 4-strand hamstring tendon grafts and either metallic (metal group) or biodegradable (PLLA group) interference screw fixation.Study DesignRandomized controlled trial; Level of evidence, 1.MethodsA randomized series of 77 patients, all with a unilateral anterior cruciate ligament rupture, was included in the study. The preoperative assessments in both groups were similar in gender, Tegner activity level, Lysholm score, KT-1000 arthrometer measurements, and single-legged hop test results. In both groups, interference screw fixation of the graft was used at both ends, and 68 of 77 (88%) patients returned for a radiographic examination at 6 and 24 months, respectively.ResultsAt follow-up, no significant differences were found between the 2 groups in KT-1000 arthrometer laxity measurements, Tegner activity level, or Lysholm score. The PLLA group had a significantly better outcome in the single-legged hop test and the final International Knee Documentation Committee classification (P=. 007 and P=. 03,respectively). At 6 and 24 months after the index operation, the PLLA group displayed significantly larger drill holes on the radiographs than did the metal group on both the tibial (8.1 vs 6.6 mm at 6 months [P=.0007]; 6.0 vs 3.2 mm at 24 months [.0001]) and femoral sides (7.8 vs 5.6 mm at 6 months [P ConclusionThere were significantly larger radiographically visible drill holes on both the tibial and femoral sides in the PLLA group compared with the metal group at 6 and 24 months. Clinical examination at 2 years revealed no major differences between the groups. The larger drill holes in the PLLA group did not correlate with inferior clinical results.

The choice of the optimal graft for anterior cruciate ligament (ACL) revision surgery is still controversial. Reharvesting the patellar tendon has been suggested as one graft alternative. Our hypothesis was that in the long-term, ACL revision surgery using reharvested patellar tendon autografts would render a good clinical outcome and a normal patellar tendon at the donor site as seen on magnetic resonance imaging (MRI). Fourteen consecutive patients (five women, nine men), who underwent ACL revision surgery using reharvested ipsilateral patellar tendon grafts, were included in the study. They underwent bilateral MRI evaluations of the patellar tendon and were tested for clinical outcome 26 (20-35) and 115 months (102-127) after the revision procedure. On the second occasion, they also underwent standard weight-bearing X-ray examinations. The serial MRI evaluations revealed that the thickness of the patellar tendon at the donor site was significantly increased compared with the non-harvested, normal contralateral side and that the donor-site gap was still visible after 10 years. No significant differences were seen between the 2- and 10-year MRI evaluations. Standard weight-bearing X-ray examinations revealed signs of mild degenerative changes in all patients. Clinical results in terms of the Lysholm score, IKDC evaluation system, one-leg-hop test, KT-1000 laxity test and the knee-walking test revealed no significant differences between the 2- and 10-year assessments. In overall terms, the clinical results were considered to be poor on both occasions. The patellar tendon at the donor site had not normalised 10 years after the reharvesting procedure, as seen on MRI. Furthermore, the clinical results were poor after ACL revision surgery using reharvested patellar tendon autograft.

Achilles tendinopathy is considered to be one of the most common overuse injuries in elite and recreational athletes. However, the effect that the Achilles tendinopathy has on patients' physical performance is still unclear. The purpose of this study was to evaluate if Achilles tendinopathy caused functional deficits on the injured side compared with the non-injured side in patients. A test battery comprised of tests for different aspects of muscle-tendon function of the gastrocnemius, soleus and Achilles tendon complex was developed to evaluate lower leg function. The test battery's test-retest reliability and sensitivity (the percent probability that the tests would demonstrate abnormal lower limb symmetry index in patients) were also evaluated. The test battery consisted of three jump tests, a counter movements jump (CMJ), a drop counter movement jump (drop CMJ) and hopping, and two strength tests, concentric toe-raises, eccentric-concentric toe-raises and toe-raises for endurance. The reliability was evaluated through a test-retest design on 15 healthy subjects. The test battery's sensitivity and possible functional deficits in patients with Achilles tendinopathy were evaluated on 42 patients (19 women and 23 men). An excellent reliability was found between test days 1-2 and 2-3 for all tests (ICC = 0.76-0.94) except for concentric toe-raise, test 2-3, which had fair reliability (ICC = 0.73). The methodological error ranged from 8 to 17%. There were significant differences (P = 0.001-0.049) between the non-injured (or least symptomatic) side and injured (most symptomatic) side for hopping, drop CMJ, concentric and eccentric-concentric toe-raises, and significant differences (P = 0.000-0.012) in the level of pain during CMJ, hopping, and drop CMJ. The sensitivity of the test battery at a 90% capacity was 88. Achilles tendinopathy causes not only pain and symptoms in patients but also apparent impairments in various aspects of lower leg muscle-tendon function as measured with the test battery. This test battery is reliable and able to detect differences in lower leg function between the injured or "most symptomatic" and non-injured or "least symptomatic" side in patients with Achilles tendinopathy. The test battery has higher demand on patients' function compared with each individual test.

It has been suggested that self-efficacy belief is of major importance for rehabilitation outcome after sports-related injuries. No instruments are, however, available to evaluate perceived self-efficacy for prognostic and outcome expectations in patients with an anterior cruciate ligament (ACL) injury. Perceived self-efficacy is defined as a judgment of one's potential ability to carry out a task, rather than a measure of whether or not one actually can or does perform the task. The purpose of this study was to develop a reliable and valid instrument for measuring perceived self-efficacy in patients with an ACL injury. A total of 210 male and female patients with an ACL injury were included in this study. The items were generated by health professionals with long clinical experience of patients with an ACL injury and by discussions with patients. After item analysis and item reduction, based on the results from 88 patients, the final 22-item version of the Knee Self-Efficacy Scale (K-SES) was evaluated in 18 patients for test-retest reliability and in 104 patients for internal consistency and validity. The K-SES was compared with the Multidimensional Health Locus of Control (MHLC), Coping Strategies Questionnaire (CSQ), SF-36 and Knee Injury and Osteoarthritis Outcome Score (KOOS) instruments. A factor analysis was also performed on the K-SES. The test-retest revealed a correlation of r(s)=0.73 between test-days and an intraclass correlation coefficient of 0.75. No significant difference between test-days was found. The internal consistency was 0.94, as calculated with Cronbach's alpha. There were low correlations between the K-SES and MHLC and the K-SES and CSQ, respectively. A strong correlation was found between the K-SES and physical functioning, as measured by the SF-36 (r(s)=0.8). All the sub-scales in the KOOS correlated moderately to strongly (r(s)=0.4-0.7) to the K-SES. The factor analysis produced two factors of importance. Factor one was related to how patients perceived their present physical performance/function, while factor two was related to how patients perceived the future physical performance/prognosis of their knee. Good reliability and good face, content, construct and convergent validity were demonstrated for this new instrument (K-SES) for measuring perceived self-efficacy in patients with an ACL injury. The K-SES is recommended for studies designed to evaluate prognostic and outcome expectations of perceived self-efficacy in patients with an ACL-insufficient knee.

A fatiguing exercise protocol was combined with single-leg hop testing to improve the possibilities of evaluating the effects of training or rehabilitation interventions. In the first test-retest experiment, 11 healthy male subjects performed two trials of single-leg hops under three different test conditions: non-fatigued and following fatiguing exercise, which consisted of unilateral weight machine knee extensions at 80% and 50%, respectively, of 1 repetition maximum (1 RM) strength. Intraclass correlation coefficients ranged from 0.75 to 0.98 for different hop test conditions, indicating that all tests were reliable. For the second experiment, eight healthy male subjects performed the fatiguing exercise protocol to investigate how fatigue influences lower-extremity joint kinematics and kinetics during single-leg hops. Hip, knee and ankle joint angles, moments and powers, as well as ground-reaction forces were recorded with a six-camera, motion-capture system and a force platform. Recovery of hop performance following the fatiguing exercise was also measured. During the take-off for the single-leg hops, hip and knee flexion angles, generated powers for the knee and ankle joints, and ground-reaction forces decreased for the fatigued hop conditions compared with the non-fatigued condition (P

A more sports-specific and detailed strength assessment has been advocated for patients after anterior cruciate ligament (ACL) injury and reconstruction. The purpose of this study was to develop a test battery of lower extremity strength tests with high ability to discriminate between leg power development on the injured and uninjured sides in patients after ACL injury and in patients who have undergone ACL reconstruction. Twenty-three patients were tested 6 months after ACL injury and 44 patients were tested 6 months after ACL reconstruction. Twenty-four of the 44 patients were operated on using a hamstrings graft and 20 patients were operated on using a patellar tendon graft. All the patients performed a test battery of three strength tests for each leg in a randomised order. The three strength tests were chosen to reflect quadriceps and hamstring muscular power in a knee-extension and a knee-flexion test (open kinetic chain) and lower-extremity muscular power in a leg-press test (closed kinetic chain). There was a higher sensitivity for the test battery to discriminate abnormal leg power compared with any of the three strength tests individually. Nine out of ten patients after ACL reconstruction and six out of ten of the patients after ACL injury exhibited abnormal leg power symmetry using the test battery. Thus, this test battery had high ability in terms of discriminating between the leg power performance on the injured and uninjured side, both in patients with an ACL injury and in patients who have undergone ACL reconstruction. It is concluded that a test battery consisting of a knee-extension, knee-flexion and leg-press muscle power test had high ability to determine deficits in leg power 6 months after ACL injury and reconstruction. Only a minority of the patients had restored leg muscle power. The clinical relevance is that the test battery may contribute to the decision-making process when deciding whether and when patients can safely return to strenuous physical activities after an ACL injury or reconstruction.