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Background: Treating an anterior cruciate ligament (ACL) injury in pediatric patients is challenging. The GNRB® is a diagnostic tool for laximetry and can provide valuable information for clinical decision. As few data exist on this subject, the first objective is to provide physiological laxity values of anterior tibial translation in healthy and pathological knees in pediatric population by age and gender groups. A second objective is to establish injury thresholds with the GNRB®., Methods: This prospective study included 141 pediatric patients with a complete ACL tear. They all underwent GNRB® measurements before the surgery. Age and gender groups were created: child/adolescent girls and child/adolescent boys. Thresholds were established using ROC curves and 2-factors ANOVA tests were used for comparisons., Results: A significant age effect was found for laxities measured on healthy knees. Significant age and gender effects were found for laxities measured on pathological knees and for side-to-side differences of laxity (SSD) between healthy and pathological knees. The optimal threshold to detect a complete ACL rupture with GNRB® is 1.5 mm at 134N with a sensitivity of 83.7% and a specificity of 92.7%., Conclusion: GNRB® brought new information about ACL laxities for healthy and pathological knees in pediatric population. Children have a greater anterior tibial translation which decreases gradually with age, and girls have grater laxities than boys. Thresholds for complete ACL tears, presenting good predictive values, were established and can help surgeons in their decisions to improve clinical practice., Level of Evidence: Prospective cohort study, level of evidence III., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Quantifying proprioception deficit in patients with osteoarthritis (OA) may be important in evaluating treatment effectiveness. This study investigated the concurrent and known-groups validity as well as test-retest reliability of a smartphone application in assessing joint position sense (JPS) in asymptomatic individuals and patients with knee OA., Methods: Sixty-four knees, from 16 asymptomatic controls and 16 patients with bilateral OA, were assessed twice with a 1-week interval in between. The smartphone Goniometer Pro application and isokinetic dynamometer simultaneously quantified JPS, in terms of absolute repositioning error (RE) angle, during active and passive limb movements at selected angles., Results: Both devices showed moderate to almost perfect correlations in measuring JPS; whether active (intra-class correlation coefficient (ICC) >0.87) or passive (ICC >0.97). The mean RE angle differences between the two devices were <0.77° (passive JPS) and <2.76° (active JPS). Both devices were capable of distinguishing patients and asymptomatic controls at 55° and 80°. The smartphone showed moderate test-retest reliability of active JPS measurement (ICC = 0.51) in the two groups, similar to that of the isokinetic dynamometer (ICC = 0.62), but with a high measurement error., Conclusions: Smartphone application is a valid alternative to the isokinetic dynamometer in assessing JPS in patients with knee OA and asymptomatic controls. The two devices could distinguish patients and asymptomatic volunteers during passive JPS measured at 55° and 80°. Both devices have moderate reliability in quantifying active JPS, but reliability results should be considered with caution., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purpose: Information is limited regarding the validity and reliability of measurements made during remote assessment of wrist range of motion (ROM) motion. We sought to determine intra- and inter-observer agreement among visual estimation, direct goniometric measurement, and patients' self-taken digital photographs and line tracings by comparing the degree differences among measurements. We hypothesized that inter- and intra-observer differences would be less than 10° at least 90% of the time for all measurement modalities., Methods: Thirty-seven patients were enrolled in this prospective cohort study. Visual estimation immediately followed by direct goniometry of maximal active wrist ROM (extension [E], flexion [F], radial deviation, and ulnar deviation) were independently and blindly assessed by 3 different providers: a hand surgeon, a hand therapist, and an orthopedic resident. Self-taken photographs and line tracings were blindly evaluated 3 weeks later. Intra- and inter-observer agreement was described using the Bland-Altman method., Results: The surgeon and hand therapist observed intra-observer agreement within 10° for visual estimation of all 4 directions of motions greater than 90% of the time, but inter-observer agreement for E/F was lower (76% to 86%). Intra-observer agreement by the resident was within 10° 78% of the time for E/F. Intra-observer agreement for photographs and tracings were lower than visual estimation for all observers. Inter-observer agreement for photographs and tracings was higher than intra-observer agreement. The surgeon and hand therapist agreed within 10° at least 76% of the time, the surgeon and resident agreed within 10° at least 62% of the time, and the hand therapist and resident agreed within 10° at least 54% of the time., Conclusions: Visual estimation may be a valid method of remote assessment, but compared with goniometry, measurements may be susceptible to observer bias. Self-taken photographs and line tracings are unreliable, perhaps falsely lower owing to submaximal effort from task distraction, and we question their current use for remote assessment of wrist ROM., Clinical Relevance: These results represent an initial step in evaluating potential methods of remote assessment of wrist ROM., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Patients with severe osteoarthritis (OA) of the knee have changes in bone mineral density (BMD) of the distal femur and proximal tibia. Correlations between the medial-to-lateral BMD (M/L-BMD) ratio (which normalizes the potentially confounding effects of body size and sex on BMD) and radiographic parameters that indicate OA progression have not been adequately studied. The purpose of this study was to evaluate correlations between radiographic indicators of OA progression and femoral and tibial M/L-BMD ratios., Methods: A consecutive series of 182 knees in 156 patients with advanced medial knee OA who underwent total knee arthroplasty were included. We evaluated correlations between the femoral and tibial M/L-BMD ratios and various radiographic parameters, including tibiofemoral angle (TFA), mechanical axis angle (MAA), tibial coronal angle, tibiofemoral subluxation (%), load-bearing axis deviation at the tibial plateau (%), and medial and lateral laxity., Results: Univariate analyses using Spearman's correlation coefficient revealed significant positive correlations between femoral and tibial M/L-BMD ratios and both TFA and MAA and negative correlations with tibial coronal angle and load-bearing axis deviation. Multivariate analyses showed significant associations between TFA and the femoral M/L-BMD ratio (β = 0.434, p < 0.001) and between MAA and the tibial M/L-BMD ratio (β = 0.384, p < 0.001)., Conclusion: BMD distribution around the knee might be predictable with radiographic parameters such as the TFA for the femur and MAA for the tibia. The findings of this study provide in vivo data on the evaluation of preoperative femoral and tibial M/L-BMD ratios without dual-energy X-ray absorptiometry., (Copyright © 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Purpose: To explore the efficacy of injectable collagenase Clostridium histolyticum (CCH) in distal interphalangeal (DIP) joint contractures in Dupuytren disease., Methods: A retrospective review was conducted for patients with DIP joint contractures treated with CCH. Baseline contracture and posttreatment residual contracture were recorded. The primary end point was achievement of 0° to 5° of residual contracture 30 days postmanipulation. Recurrence and adverse events are also reported., Results: Twenty-one patients were treated with collagenase for DIP joint contractures and had a mean follow-up of 2.6 months. Seventeen of 21 patients reached the primary end point of less than 5° residual flexion contracture. Eleven of 21 patients experienced an adverse event, most commonly bruising and edema. No serious complications such as neurovascular injuries or tendon ruptures were recorded. Two patients had recurrence of disease., Conclusions: Injection with CCH is an option for the treatment of DIP joint contractures in Dupuytren disease., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to systematically review the literature and identify factors which would contribute to the intraoperative correction of FFD to frame a potential surgical algorithm or predictive model to guide intraoperative decision-making., Methods: Electronic searches of six databases were undertaken in April 2016 according to the PRISMA guidelines, and the reference lists of studies searched. Quality of studies was assessed using the STROBE checklist, and the Downs and Black Scores., Results: Twenty-five studies investigating 10, 679 knees were found to satisfy the inclusion and exclusion criteria. These studies described a variety of pre-operative and intra-operative factors which contribute to the development or correction of post-operative FFD. The only patient predictor of post-operative FFD was pre-operative FFD. The intra-operative steps described to correct FFD were: distal femoral resection, soft-tissue balancing (in the posterior and medial compartments), sagittal component flexion and posterior condylar offset. However, no studies investigated these in an integrated model., Conclusion: This review has identified various pre-, intra- and post-operative factors predictive of post-operative FFD. In practice, these factors are likely to interact, and therefore further investigation in an integrated model is crucial to developing a statistically sound and reliable intraoperative algorithm for surgeons to follow when correcting fixed flexion deformity., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The functional range of motion (fROM) of the metacarpophalangeal (MCP) joints during the performance of activities of daily living (ADL) has not yet been established. This study aimed to determine the fROM of all five digits and verify the accuracy and reproducibility of dynamic angle measurement using a single-axis electric goniometer (EG) during ADL movements of the hand., Methods: This was a cross-sectional study. In EG suitability testing, we first confirmed the angles of a three-dimensional calibration device 10 times, and then compared EG readings with those determined by tomosynthesis images. Next, we determined the fROM of the MCP joints by evaluating all five digits of the dominant hands of 10 healthy adults performing 16 ADL. Intra-rater reproducibility of MCP joint data during task performance was assessed in two healthy adults., Results: Static measurements of the triangular object showed variance to be within one degree in 39 of 40 trials. Differences between angles measured by the EG and those depicted by radiograph were a range of plus or minus five degrees in 88 of 96 digits. The fROM values for the thumb and index, middle, ring, and little fingers were -7.5 to 35.3, 10.6 to 67.8, 4.0 to 79.9, 3.0 to 83.9, and 2.9-91.4 degrees of flexion, respectively. Flexion angle in the fROM of the index finger was significantly smaller than those of the ring and little fingers. The flexion and extension angles of the thumb were significantly smaller than those of the four ulnar fingers. The intra-rater correlation coefficients of two participants were high at 0.94 and 0.93, respectively., Conclusions: The method adopted in this study exhibited excellent accuracy and reproducibility and was therefore considered suitable for the real-time establishment of fROM flexion-extension angles of the MCP joints for all five digits. Our data are useful as a target arc of motion in the treatment of MCP joint disease or injury., (Copyright © 2018. Published by Elsevier B.V.)

Objectives: Comparison of range of motion measurements by 3 types of investigators with different levels and types of training using three different measurement techniques. The study hypothesis was that the accuracy and precision of range of motion measurements would vary based on (1) the level and type of experience of the investigator and (2) the measurement technique used., Design/setting: Descriptive laboratory study., Participants: Ten fresh frozen cadavers (20 upper and 20 lower extremities)., Interventions: Shoulder, elbow, hip, and knee motion were measured using 3 different measurement techniques (digital photography, goniometry, and visual estimation) by 3 groups of investigators (attending orthopedic surgeons, physical therapists, and residents). Accuracy was defined by the difference from the reference standard (motion capture analysis), whereas precision was defined by the proportion of measurements within either 5° or 10° of the reference standard. Analysis of variance, t-tests, and chi-squared tests were used., Results: Statistically significant (p < 0.05) differences in accuracy were found for hip flexion, abduction, internal rotation, external rotation, and knee flexion. However, none of these differences met the authors' defined clinical significance (maximum difference 3°). Precision was significantly (p < 0.05) different for elbow extension, hip flexion, abduction, internal rotation, external rotation, and knee flexion., Conclusion: This study found that clinically accurate measurements of shoulder, elbow, hip, and knee motion are obtained regardless of technique used or the investigators' level and type of experience. Precision was equivalent for all shoulder motions, elbow flexion, and knee extension, but varied by as much as 7% to 28% between groups for all other motions., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There are few large-scale, long-term studies comparing medial meniscal repairs with or without concurrent anterior cruciate ligament (ACL) reconstruction., Methods: A total of 140 patients who underwent arthroscopic medial meniscal repair were divided into two groups: Group A, meniscus repair only and Group B, meniscus repair with concurrent ACL reconstruction. Clinical assessments in- cluded physical examination findings, Lysholm score, and the International Knee Documentation Committee (IKDC) form. Barret criteria were used for the clinical assessment of healing status. Magnetic resonance imaging (MRI)was obtained to confirmhealing and failure. Subgroups of participants were compared in terms of suture technique, type of tear, and location of tear. KT-2000 arthrometer testing was used for objective evaluation of anterior-posterior knee movement., Results: Mean follow-up duration was 61 (34-85) months. Clinical outcomes in both groups were significantly improved compared to baseline (P=0.001 vs. P=0.001); however, there was no significant between-group difference in postoperative Lysholm and IKDC scores (P=0.830). The outcomes of three participants (seven percent) in Group A and 11 (11.3%) in Group B were considered as treatment failures (P=0.55). Red-red zone tears had higher scores. Mean postoperative KT2000 arthrometer values of failed participants in Groups A and B were 4.66mm (range, four to six) and 5.2mm (range, two to seven), respectively., Conclusion: Concurrentmedialmeniscus repair and ACL reconstruction did not have clinical superiority over meniscus repair alone. Repairs in the red-red zone appeared to be associated with better outcomes., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: In current practice, anterior cruciate ligament (ACL) tears can be diagnosed using several devices to measure anterior tibial translation and rotational knee laxity, but these measures are never collected together. The Rotab®, which yields simultaneous measurements of anterior tibial translation and passive lower limb rotation under stress, would therefore be advantageous in current practice, but its reliability has never been tested., Aim of Study: To evaluate the accuracy and reliability of the Rotab® compared to the reference system, radiostereometric analysis (RSA)., Methods: This anatomical study was conducted on 14 lower limbs collected from fresh cadavers. Simultaneous measurements of anterior tibial translation and rotation were obtained with both systems, with antero-posterior (AP) forces of 134N and 250N using the Rotab®. Measurements were made on intact ACL and then repeated after ACL section. Variables were analyzed in univariate analysis by ANOVA, and the intraclass correlation coefficient (ICC) between the systems was determined by the Bland and Altman method., Results: The difference between the two methods for evaluating anterior tibial translation was 0.05±0.98mm at 134N and 0.29±1.04mm at 250N. The correlation between the tests was high (r 134 =r 250 =0.97, p=0.8). The difference between the two methods for rotational laxity was 0.69±2.7° at 134N and 0.5±0.6° at 250N. The Rotab® showed a significant difference only at 250N for rotational laxity after the ACL tear., Conclusion: The Rotab® is a reliable device to measure rotational laxity coupled with anterior translation of the knee., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Conduct a prospective randomized study to compare clinical outcomes of anterior cruciate ligament (ACL) reconstruction using quadrupled hamstring tendon (HT) allograft or doubled tibialis anterior (TA) allograft. Limited level 1 data exist comparing outcomes of different soft tissue allograft constructs for ACL reconstruction. We hypothesized no difference would exist in the patient reported outcomes (PRO), arthrometric testing, or rate of re-rupture between the two constructs., Methods: Ninety eight subjects undergoing primary ACL reconstruction were randomized to HT (n=47) or TA (n=51) allograft. Subjects completed validated (PRO) measures pre-operatively, and six months and two years post-operatively. Arthrometric testing was performed at six months to assess integrity of the reconstruction., Results: Fifty-eight percent of subjects (57/98) completed a two-year follow up. Allograft re-tear rates were similar between groups (6.2% HT vs. 4.0% TA, respectively, p=1.0). The relative risk of re-tear in the HT group was 1.5 compared to the TA group (p=0.7). The TA group improved significantly more on the physical portion of the VR-12 (p=0.046) and Lysholm score (p=0.014) compared to the HT group. There was no difference in the change from baseline for the other PRO scores at two years., Conclusions: Our data indicate no difference in graft failure rate and similar improvement from baseline in most PRO scores between treatment groups after two years. Based on these findings, TA allograft appears to provide a reliable and satisfactory option for patients who elect to undergo allograft ACL reconstruction., (Copyright © 2016. Published by Elsevier B.V.)

Background: The main option to perform an anatomic anterior cruciate ligament (ACL) reconstruction is the anteromedial portal (AMP) technique. It has several reported complications (iatrogenic chondral injury, posterior-wall blowout, short sockets, increased risk of injury to common peroneal nerve). In an attempt to avoid these complications the outside-in (OI) technique was revived with the addition of a retrodrill. The aim of this study is to evaluate the clinical and arthrometric outcomes of a series of anatomical OI single bundle ACL reconstruction using a retrodrill., Methods: Prospective case series. KT-1000 and Pivot Shift Test were done at 24 months follow-up. International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores preoperatively and at final follow-up. Complications were reported. Statistical analysis was done with t-test., Results: 275 knees of 200 (73%) males and 75 (27%) females were enrolled in the study. Mean age 29.1 years (15-54). Mean follow-up 34.5 months (24-49). Mean preoperatively Lysholm Score 62 (25-95) versus 95 (76-100) at final follow-up (p<0.001) Mean preoperatively IKDC score 60 (26.4-90.8) versus 92 (59.8-100) at final follow-up (p<0.001) Mean Tegner activity Score pre injury 5 versus 5 at final follow-up. (p=0.59) Mean KT-1000 side-to-side difference 2mm (1-6). Pivot Shift test negative in 243 patients (90%); positive in 32 (10%) patients. 13 (5%) ACL re-ruptures. 2 (0.7%) infections. No other complications were reported., Conclusion: OI single bundle anatomic ACL reconstruction using a retrodrill is a valid and safe option that avoids the complications reported with the AMP technique., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Purpose: The purpose of this study was to investigate and describe buckling of the patellar tendon., Methods: Healthy young adults (28±4years, 10F/10M) underwent passive knee flexion/extension during the simultaneous measurement of knee angle and collection of cine ultrasound from the patellar tendon. Patellar tendon buckling was observed visually in ultrasound images, and the corresponding knee angle at which evidence of buckling disappeared was identified., Results: All subjects showed evidence of distal buckling which occurred on average at 23±8° flexion. Proximal buckling was only observed in fourteen subjects (10F/4M) at an average of 15±8°. Buckling patterns varied between subjects, but with high within-subject consistency. Buckling magnitude increased with age (p=0.03) and decreased with more weekly exercise (p=0.02)., Discussion: The patellar tendon exhibited significant buckling in knee extension suggesting that buckling is a component of healthy knee function. Like tendon crimp, buckling may serve as a protective mechanism, allowing the tissue to unwrinkle prior to undergoing pure strain. The links between increased buckling magnitude and both age and reduced activity suggest that excessive buckling may be maladaptive, though future work is necessary to elucidate this relationship. Buckling is relevant to consider when estimating tendon length, as buckling can lead to significant underestimation of resting length and thus overestimation of strain., Conclusion: This study demonstrates the complexity of tendon behavior even in healthy adults undergoing passive motion, suggesting that buckling may be relevant to an improved understanding of tendon health and pathology., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Purpose: A high incidence of nonunion and relatively poor outcomes with prior fixation techniques has precluded scapholunate (SL) arthrodesis as a standard treatment for SL instability. Our purpose was to determine the impact on range of motion (ROM) of simulated SL arthrodesis via headless screw fixation., Methods: We performed baseline wrist ROM for 10 cadaveric wrists using a standardized mounting-and-weights system. Extension, flexion, radial deviation, ulnar deviation, dart-thrower's extension, and dart-thrower's flexion were assessed. Two 3.0-mm headless compression screws were inserted across the SL joint to simulate SL arthrodesis. Goniometric measurements and fluoroscopic imaging were repeated to assess ROM differences after simulated SL arthrodesis. We assessed SL angle and gap during testing to ensure there was no significant motion between the scaphoid and lunate, thus confirming stable simulated fusion. Differences in ROM were compared between baseline and simulated SL arthrodesis using paired t tests., Results: Mean SL angle remained constant between pre- and post-arthrodesis imaging (47° ± 6° vs 46° ± 4°) and did not change during post-arthrodesis ROM testing, indicating a stable simulated fusion. Compared with baseline, SL arthrodesis had a statistically significant reduction in maximum flexion of 6° and 9° based on fluoroscopy and goniometry, respectively, in dart-thrower's extension of 5° and 9° based on fluoroscopy and goniometry, respectively, and in dart-thrower's flexion of 6° for both fluoroscopy and goniometry. No other ROMs after simulated SL arthrodesis were significantly different compared with baseline., Conclusions: The effects of simulated SL arthrodesis on radiocarpal and midcarpal motion compare favorably with motion after SL soft tissue repair and other reconstructive techniques that have been previously reported. The statistically significant decreases in wrist flexion and dart-thrower's extension-flexion after simulated SL arthrodesis are of questionable clinical importance., Clinical Relevance: These results may support reconsidering SL arthrodesis as a viable treatment option for acute or chronic SL instability with regard to apparent minimal adverse effects on functional wrist ROM., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to validate elbow flexion and extension measured from smartphone photography obtained by participants and compared them with photographs obtained by surgeons and goniometric measurements., Methods: We enrolled 32 participants with a total of 64 elbows, aged 25 to 68 years. Participants obtained smartphone photographs of full elbow flexion and extension. Then surgeons obtained the same photographs and goniometric measurement of elbow range of motion (ROM). We measured ROM from the photographs using Adobe Photoshop and calculated average ROM. Comparisons of manual goniometer versus digital measurements, participant versus surgeon photograph measurements, and interobserver measurements were statistically analyzed., Results: Average ROM measured by manual goniometer and digital photographs was 0° to 129° (range, 0° to 140°) and 0° to 129° (range, 0° to 145°), respectively. The goniometer versus digital measurements interclass correlation was 0.828 (L) and 0.740 (R). Pearson coefficient was 0.845 (L) and 0.757 (R). Bland-Altman plots demonstrated that 30 of 32 digital measurements (L) and 31 of 32 measurements (R) were within the 95% confidence interval. Participant-obtained photographs compared with researcher's photographs interclass correlation was 0.955 (L) and 0.941 (R), with a Pearson coefficient of 0.962 (L) and 0.957 (R), respectively. Reviewing interobserver reliability, concordance coefficients were 0.793 (L) and 0.767 (R) and Pearson coefficients were 0.811 (L) and 0.780 (R). Bland-Altman plots demonstrated that 28 of 32 digital measurements (L) and 26 of 32 measurements (R) were within the 95% confidence interval., Conclusions: Measuring elbow ROM using smartphone digital photography is valid and reliable. Participants were able to obtain accurate photographs and the measurements based on these photographs show no statistical difference from those taken by surgeons or goniometric measurement., Clinical Relevance: This study validates using smartphone photography for measuring elbow ROM by laymen in a remote setting., Type of Study/level of Evidence: Diagnostic II., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare goniometric and visual assessments of angular hand joint and wrist joint positions measured by board-certified hand surgeons and certified hand therapists. We hypothesized that visual estimation would be similar to the goniometric measurement accuracy of digital and wrist joint positions., Methods: The wrist, index finger metacarpophalangeal (MCP) joint, and index finger proximal interphalangeal (PIP) joint were evaluated in different positions by 40 observers: 20 board-certified hand surgeons and 20 certified hand therapists. Each observer estimated the position of the wrist, index MCP joint, and index PIP joint of the same volunteer, who was positioned in low-profile orthoses to reproduce predetermined positions. Following visual estimation, the participants measured the same joint positions using a goniometer. The control measurement was digitally determined by a radiologist who obtained radiographs of the hand and wrist positions in each orthosis. Observers were blinded to the results of control measurements., Results: When considering all joints at all positions, neither visual assessments nor goniometer assessments were consistently within ± 5° of the measurements obtained on control radiographs. When considering individual joints, goniometer measurements were significantly closer to control radiograph measurements than the visual assessments for all 3 PIP joint positions. There was no difference for the measurements at the wrist or for 2 of the 3 MCP joint positions. Significant differences between surgeon and therapist joint angle measurements were not observed when comparing visual and goniometer assessments to radiograph controls., Conclusions: Compared with radiograph measurements, neither visual nor goniometer assessment displayed high levels of accuracy. On average, visual assessment of the angular positions of the index MCP and wrist joint were as accurate as the goniometer assessment, whereas goniometer assessment of the angular position of the PIP joint was more accurate than visual assessment. There was a relatively high degree of between-observer variability in measurements, and therefore, no one person's measurements could be consistently relied upon to be accurate., Type of Study/level of Evidence: Diagnostic II., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Fast-track TKA has significantly shortened the time available for physiotherapists to optimize knee ROM before discharge. Safety aspects concerning knee stiffness and the need for manipulation in a fast-track setting need to be illuminated. The study aims were to analyze if fast-track TKA can be considered safe considering rates of knee manipulation and if there is an association between knee ROM at time of discharge and the need for later manipulation., Methods: Primary TKAs operated in 2011 at our institution were eligible for inclusion. The study group consisted of 359 TKAs., Results: Manipulation of the knee was performed in 21 of 359 TKAs (5.8%). Seventy-one percent were discharged with a flexion ≥70° combined with an extension deficit of ≤10°. The occurrence of MUA for these patients was 4.3%. The prevalence of knee manipulation showed a statistically significant association with the achieved knee flexion at discharge (p=0.02). Median length of stay was two days., Conclusion: Compared with literature findings fast-track TKA surgery may be considered safe based on the acceptable rate of knee manipulations after TKA (5.8%). We suggest ROM of ≥70° flexion combined with an extension deficit of ≤10° as an "optimal-zone" for ROM at discharge. The reason for this is the low occurrence of MUA (4.3%) in relation to the large amount of TKAs it represents (71%). The indication for MUA is multifactorial and ROM at discharge serves only as an indicator of later MUA risk., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Alterations in scapular muscle activity have been theorized to contribute to abnormal scapular motion and shoulder pain, but pose challenges to quantify in the clinic. Rehabilitative Ultrasound Imaging (RUSI) has proved useful identifying dysfunction of lumbar regional stabilizing muscle activity, specifically contractile behavior. Although, recent examinations of scapular stabilizing trapezius muscle function using RUSI did not detect alterations individuals with shoulder pain or differences in muscle thickness between varying external loads in asymptomatic individuals, a potential confounder to prior results, scapular dyskinesis has not been controlled. It is unknown if dyskinesis alters scapular muscle thickness during activation measured with RUSI. Thus, the purpose of this study was to compare change in scapular muscle thickness between individuals with and without scapular dyskinesis. Thirty-nine asymptomatic adults with (n = 19) and without (n = 20) scapular dyskinesis, defined with a reliable and validated method, participated. Two separate ultrasound images of the serratus anterior (SA) and lower trapezius (LT) were captured under two randomized conditions, rest and isometric contraction against gravity, and saved for blinded measurement. Change in thickness with contraction was calculated and expressed as a percentage. The dyskinesis group demonstrated a greater increase (p = 0.005) in LT thickness with the isometric contraction than the group without (mean difference = 31.6%; 95%CI = 10.3, 53.0). No differences in SA or resting thickness of either muscle were found between groups. The presence of scapular dyskinesis alters thickness changes of the lower trapezius during activation. Furthermore, potential underlying reasons beyond muscle contractile behavior must be considered., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: This paper will review three-dimensional (3D) motion analysis studies done in my laboratory to present an overview of what we have found., Materials and Methods: We have looked at parameters such as roll-back, rotation, the pivot center of rotation etc. using a 2D-3D registration technique by evaluating knees before and after implantation of a total knee arthroplasty., Conclusion: This technique allows comparison of preoperative motion to that after total knee surgery. We have found the phenomenon of "reverse screw-home" to be a common motion pattern in osteoarthritis and it is often present after implantation of a total knee prosthesis.

The objective of this study was to investigate the relative contributions of superficial and deep ankle plantarflexors during repetitive submaximal isometric contractions using surface electromyography (SEMG) and positron emission tomography (PET). Myoelectric signals were obtained from twelve healthy volunteers (27.3±4.2yrs). A tracer ([(18)F]-FDG) was injected during the exercise and PET scanning was done immediately afterwards. The examined muscles included soleus (Sol), medial gastrocnemius (MG), lateral gastrocnemius (LG), and flexor hallucis longus (FHL). It was found that isometric maximal voluntary contraction (MVC) force, muscle glucose uptake (GU) rate, and SEMG of various plantarflexors were comparable bilaterally. In terms of %EMG MVC, FHL and MG displayed the highest activity (∼34%), while LG (∼21%) had the lowest activity. Cumulative SEMG from all parts of the triceps surae (TS) muscle accounted for ∼70% of the combined EMG signal of all four plantarflexors. As for GU, the highest quantity was observed in MG (2.4±0.8μmol*100g(-1)*min(-1)), whereas FHL (1.8±0.6μmol*100g(-1)*min(-1)) had the lowest uptake. Cumulative GU of TS constituted nearly 80% of the combined GU. The findings of this study provide valuable reference for studies where individual muscle contributions are estimated using models and simulations., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to evaluate the results obtained from posterior cruciate ligament (PCL) reconstruction with the double femoral tunnel technique, using quadriceps tendon and semitendinous autograft, in patients with isolated PCL tears or PCL tears associated with other ligament lesions, 2 years after surgery., Methods: The study included 14 patients with isolated PCL lesions and 20 with combined ligament lesions, who underwent PCL reconstruction using the double femoral tunnel technique and were evaluated 24 months after surgery using the International Knee Documentation Committee (IKDC) and Lysholm scores, a KT-1000 arthrometer, and the graduation of the posterior drawer test., Results: Knees were considered normal ("A") or nearly normal ("B") in 92.9% of patients with isolated lesions and in 95.0% of patients with combined tears, according to the IKDC score. Good or excellent results were obtained in 100% of patients in both groups according to the Lysholm score. Absence or outstanding reduction of posterior tibial translation was seen in 92.9% of patients with isolated lesions and in 100% of patients with combined ligament tears, in the posterior drawer evaluation., Conclusion: The PCL double femoral tunnel reconstruction technique using autografts was effective in restoring posterior knee stability, in isolated and/or combined PCL tears, showing remarkable clinical improvement in all patients., Level of Evidence: 2C., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Purpose: To compare ranges of active forearm pronation and supination with subjects wearing short arm casts of different lengths., Materials and Methods: Forty right-handed healthy volunteers (20 men and 20 women) with an average age of 39 years (range, 26-58 y) were recruited. A goniometer with a circular plate and a handle connected to the scale indicator was used to measure forearm pronation and supination without a cast and with 3 different lengths of short arm cast. All casts extended from just proximal to the volar and dorsal aspects of metacarpophalangeal joints, and continued to either 2.5 cm distal to elbow flexion crease or 5 cm distal to the elbow flexion crease, or to the proximal one-third position between the wrist flexion crease and the elbow flexion crease., Results: Compared with no immobilization, the longest of the 3 constructs reduced active forearm rotation by 62%, whereas the cast to 5 cm from the elbow flexion crease reduced rotation to 50%, and the cast to the proximal one third of the way between the wrist and elbow flexion crease reduced rotation by 32%. Active forearm rotation was significantly dependent on cast length, and reductions in active forearm rotation were positively correlated with cast length., Conclusions: Limitation of active forearm rotation by a short arm cast is positively correlated with cast length., Clinical Relevance: When a short arm cast is used to limit wrist motion and forearm rotation, it is better to extend it proximally but not to impinge on the antecubital fossa, where skin breakdown may occur., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Knee laxity measurements have been shown to be associated with some medical conditions such as chronic joint pain and collagen tissue diseases. The aim of this study was to determine the effects of demographic factors and anthropometric measures on knee laxity., Materials and Methods: Data were collected from 521 visitors, staffs and students from the University Malaya Medical Centre and University of Malaya between December 2009 and May 2010. Knee laxity was measured using a KT-1000 arthrometer. Multiple regression analysis was used to find the association of knee laxity with age and anthropometric measures., Results: Using ANOVA, knee laxity did not show significant differences among ethnic groups for both genders. The average knee laxity in men was 3.47 mm (right) and 3.49 mm (left); while in women were 3.90 mm (right) and 3.67 mm (left). Knee laxity in women was significantly higher (right knee p<0.01 and left knee p<0.05) than men. Right knee laxity of men was negatively associated with height (p<0.05) and BMI (p<0.05); also a negative association was observed between left knee laxity and BMI (p<0.05). Overweight and obese men had less knee laxity than normal weight and underweight individuals. Elderly men and women (age 55 and above) had lower knee laxity (p<0.01) than young adults (ages 21-39)., Conclusion: These results suggest that age and body size are important factors in predicting knee laxity., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Purpose: To compare the clinical outcomes of anterior cruciate ligament (ACL) reconstruction with double-bundle and single-bundle techniques., Study Design: Meta-analysis, Methods: We searched electronic databases including PubMed, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar from 1966 to Jan 2012 to identify randomized controlled trials (RCTs) comparing clinical outcomes of anterior cruciate ligament (ACL) reconstruction with double-bundle and single-bundle techniques. Two reviewers independently extracted data and assessed trial quality. Meta-analysis was performed to pool results., Results: Nineteen RCTs were included with a total of 1686 patients. The pooled analysis across all studies showed that the double-bundle ACL reconstruction technique could have significantly better outcomes in rotational laxity, as assessed by the pivot-shift test, KT grading and IKDC grading than the single-bundle techniques. We found no evidence of a difference in function measured by IKDC scores, KT arthrometer, Lysholm knee, or Tegner activity scores and complications after operations between single and double-bundle ACL reconstruction groups., Conclusion: Our meta-analysis demonstrated the superiority of double-bundle over single-bundle anterior cruciate ligament reconstruction. The double-bundle ACL reconstruction technique has better outcomes in rotational laxity (pivot-shift test, KT grading and IKDC grading). However, for functional recovery, there was no significant difference between single-bundle and double-bundle reconstruction techniques., (Crown Copyright © 2012. Published by Elsevier B.V. All rights reserved.)

Background: Restoration of anterior tibial stability while avoiding knee extension deficit are a common goal of anterior cruciate ligament (ACL) reconstruction. However, achieving this goal can be challenging. The purpose of this study was to determine whether side-to-side differences in anterior tibial neutral position and laxity are correlated with knee extension deficit in subjects 2 years after ACL reconstruction., Methods: In the reconstructed and contralateral knees of 29 subjects with transtibial reconstruction, anterior tibiofemoral neutral position was measured with MRI and three-dimensional modeling techniques; terminal knee extension at heel strike of walking and during a seated knee extension were measured via gait analysis; and anterior laxity was measured using the KT-1000., Results: Knees that approached normal anterior stability and anterior tibial position had increased extension deficit relative to the contralateral knee. On average the reconstructed knee had significantly less (2.1±4.4°) extension during active extension and during heel strike of walking (3.0±4.3º), with increased anterior neutral tibial position (2.5±1.7 mm) and anterior laxity (1.8±1.0 mm). There was a significant correlation between side-to-side difference in anterior neutral tibial position with both measures of knee extension (walking, r=-0.711, p<0.001); active knee extension, r=-0.544, p=0.002)., Conclusion: The results indicate a relationship between the loss of active knee extension and a change in anterior neutral tibial position following non-anatomic transtibial ACL reconstruction. Given the increasing evidence of a link between altered kinematics and premature osteoarthritis, these findings provide important information to improve our understanding of in vivo knee function after ACL reconstruction., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Background: This study firstly aimed to determine whether proprioception deficits, as measured by joint position sense (JPS), occur in people following recurrent patellar dislocations. Secondly, to determine whether JPS changes following medial patellofemoral ligament reconstruction (MPFL) reconstruction for patellar instability., Methods: Thirty people following recurrent patellar dislocation were recruited. Pre-operative JPS was assessed using the passive angle reproduction test. Through this, an assessor moved a participant's limb to a target position. This was returned to neutral, before finally moving the limb again, whilst requiring the participant to indicate when they thought the target angle was reached. The actual angular error (AAE) was calculated as the difference between the perceived angle and target angle. Clinical outcomes included the Kujala Patellofemoral Disorder Score, the International Knee Documentation Committee (IKDC) form, pain, knee motion, extensor muscle strength and frequency of patellar dislocation. Outcomes were assessed pre-operative, 6 weeks, 3 and 12 months., Results: Mean AAE was 2.2° (inner range) to 3.9° (mid-range); this was not clinically significant. There was no statistically significant difference between the baseline-and-6 week, 6 week-and-3 month or baseline-and-12 month AAE measures (p=0.38 to 1.00). There was a statistically significant improvement in functional outcomes as measured by the Kujala score, IKDC form, reduced pain and increased extension strength from baseline to 12 months (p<0.01)., Conclusions: Following recurrent patellar dislocation, patients exhibit minimal deficits in JPS. Whilst MPFL reconstruction significantly improved clinical and functional outcomes for this population, this operation did not significantly alter JPS during the first post-operative year., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: There is a lack of standardized objective criteria to accurately assess the ability of a patient to progress through the end stages of rehabilitation and safely return to their previous level of athletic activity after anterior cruciate ligament (ACL) reconstruction., Purpose: To determine objective factors involved in returning to sports following ACL reconstruction., Methods: Based on our inclusion criteria of a minimum 2-year follow-up, pre-injury sports activity level of Tegner 5 or greater, we retrospectively evaluated 67 patients who underwent ACL reconstruction. The patients were divided into "return-to-sports" (n=51) and "non-return" groups (n=16) by surveying participants using a questionnaire. Comparisons between the two groups were made using pre-operative and post-operative International Knee Documentation Committee questionnaires (IKDC), Lysholm score, and KT-2000 arthrometer. Flexor and extensor muscle strength, and functional performance tests (one-leg-hop test, co-contraction, shuttle run, and carioca tests) were used for assessment., Results: Overall clinical results, including IKDC score, Lysholm score, and KT-2000 arthrometer, improved in all patients post-operatively and no significant difference was seen between the two groups (P>0.05). Although there was no significant difference in flexor or extensor deficits, one-leg-hop test, or shuttle run test, "return-to-sports" group obtained significantly better scores in the co-contraction and carioca tests (P<0.05)., Conclusions: Tests that assess rotational stability showed statistically significant differences between the two groups. Further prospective studies with larger cohort are needed to determine the factors associated with returning to sports after ACL reconstruction., Level of Evidence: Retrospective comparative study, Level III., (© 2013.)

Background: Insufficient hip flexibility, a limiting factor for lower extremity rotation, can cause great rotational stress and consequent injury to the knees and ankles. A limited range of motion (ROM) of the hip might be associated with increased risk of non-contact anterior cruciate ligament (ACL) injury. We investigated the association between the risk of non-contact ACL injured student athletes and limitations of hip ROM., Methods: A case-control study was conducted at an orthopaedic clinic in Japan. Cases included all patients with non-contact ACL injury and without known marked alignment abnormalities who visited the orthopaedic clinic during 2000-2008. Controls included all patients with non-ACL sports-related injuries who visited the same clinic in 2000. The adjusted odds ratio of ROM of the hip was evaluated for non-contact ACL injury risk., Results: These cases were 44 ACL cases and 123 controls aged 13-17 years. The odds ratios (ORs) of internal and external rotations of hip ROMs were adjusted for age, sex, BMI, type of sports and hip ROM (flexion, extension, adduction, abduction). The adjusted ORs for a 10° increase of the sum of the right and left internal hip rotations were 0.18 (95% confidence interval [CI], 0.10-0.34, p<0.0001), and 0.23 (95% CI, 0.14-0.39, p<0.0001) for external rotations, and the observed ORs were small., Conclusions: Data obtained from this small sample indicate that limited hip rotation ROMs in young athletes have the possibility of association with increased risk of non-contact ACL injury., Level of Evidence: III - case-control study., (© 2013.)

The purposes of this study were to establish the reliability for measuring scapular muscle thickness, and to examine how scapular muscle thickness changes with respect to external loads. Participants were asymptomatic subjects recruited from a sample of convenience. Thickness Measures were taken using rehabilitative ultrasound imaging (RUSI) under 11 conditions, rest and 10 progressive loads, for the Lower Trapezius (LT) and Serratus Anterior (SA). The procedures were repeated 1 week later to determine reliability. Bland and Altman limits of agreement and Interclass correlation coefficients (ICC) were used to determine reliability. Separate repeated measure ANOVAs were performed to determine differences in muscle thickness for both muscles across 3 conditions; rest and the 2 loaded conditions that represented the lowest and highest torque values. Results demonstrate good within and between day reliability for the LT (ICC = .86 to .99) and SA (ICC = .88 to .99). For the LT and SA, there were significant differences between the resting thickness and 2 lifting conditions (p ≤ .01) but not between the two lifting conditions. It was concluded that RUSI is reliable in measuring scapular muscle thickness. RUSI is sensitive enough to detect absolute changes in thickness from resting to a contracted state but unable to detect differences between loads imposed on the shoulder., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Previous research suggests that Mulligan's Mobilisation-with-Movement (MWM) technique for the shoulder produces an immediate improvement in movement and pain. The aims of this study were to investigate the time course of the effects of a single MWM technique and to ascertain the effects of adding tape following MWM in people with shoulder pain. Twenty-five participants (15 males, 10 females), who responded positively to an initial application of MWM, were randomly assigned to MWM or MWM-with-Tape. Range of movement (ROM), pressure pain threshold (PPT) and current pain severity (PVAS) were measured pre- and post-intervention, 30-min, 24-h and one week follow-up. Following a one-week washout period, participants were crossed over to receive a single session of the opposite intervention with follow-up measures repeated. ROM significantly improved with MWM-with-Tape and was sustained over one week follow-up (p < 0.001; 18.8°, 95% confidence intervals (CI) 7.3-30.4), and in PVAS up to 30-min follow-up (38.4 mm, 95% CI 20.6-56.1 mm). MWM demonstrated an improvement in ROM (11.8°, 95% CI 1.9-21.7) and PVAS (40.4 mm, 95% CI 27.8-53.0 mm), but only up to 30-min follow-up. There was no significant improvement in PPT for either intervention at any time point. MWM-with-Tape significantly improved ROM over the one-week follow-up compared to MWM alone (15.9°, 95% CI 7.4-24.4). Both MWM and MWM-with-Tape provide a short-lasting improvement in pain and ROM, and MWM-with-Tape also provides a sustained improvement in ROM to one-week follow-up, which is superior to MWM alone., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Our objective was to assess the effectiveness of Diacutaneous Fibrolysis on pain intensity, range of motion and functional status in patients suffering from Subacromial Impingement Syndrome. A randomised controlled trial was conducted in two Spanish National Health Service Primary Health Care Centres. Participants (n = 120) were randomly assigned to one of three groups (intervention, placebo or control groups). All three groups received a protocolised treatment based on therapeutic exercises, analgesic electrotherapy and cryotherapy. Additionally, the intervention group received six sessions of Diacutaneous Fibrolysis treatment; the placebo group received six sessions of sham Diacutaneous Fibrolysis treatment, while the control group received only the protocolised treatment. Pain intensity, available active range of motion and function were measured pre-treatment, post-treatment, and at a three-month follow-up. At the post-treatment assessment, differences between intervention and control groups were statistically significant or clinically relevant in function, flexion, extension and external rotation movements. Differences between placebo and control groups were significant only in extension movement. No significant differences were found in pain intensity. At the 3 month follow-up assessment, between-groups differences were not statistically significant and clinical relevance was achieved only for external rotation movement between intervention and control groups. At the post-treatment assessment 89% of the participants in the intervention group, 76% of the participants in the placebo group and 67% of the participants in the control group reported subjective improvement (p < 0.01). In conclusion, adding Diacutaneous Fibrolysis to the conservative treatment of Subacromial Impingement Syndrome improves function and external rotation movements and also gives significantly higher patient satisfaction., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Alterations in scapular muscle activity, including excess activation of the upper trapezius (UT) and onset latencies of the lower trapezius (LT) and serratus anterior (SA) muscles, are associated with abnormal scapular motion and shoulder impingement. Limited information exists on the reliability of neuromuscular activity to demonstrate the efficacy of interventions. The purpose of this study was to characterize the reproducibility of scapular muscle activity (mean activity, relative onset timing) over time and establish the minimal detectable change (MDC). Surface electromyography (sEMG) of the UT, LT, SA and anterior deltoid (AD) muscles in 16 adults were captured during an overhead lifting task in two sessions, one-week apart. sEMG data were also normalized to maximum isometric contraction and the relative onset and mean muscle activity during concentric and eccentric phases of the scapular muscles were calculated. Additionally, reliability of the absolute sEMG data during the lifting task and MVIC was evaluated. Both intrasession and intersession reliability of normalized and absolute mean scapular muscle activity, assessed with intraclass correlation coefficients (ICC), ranged from 0.62 to 0.99; MDC values were between 1.3% and 11.7% MVIC and 24 to 135 mV absolute sEMG. Reliability of sEMG during MVIC was ICC = 0.82-0.99, with the exception of intersession upper trapezius reliability (ICC = 0.36). Within session reliability of muscle onset times was ICC = 0.88-0.97, but between session reliability was lower with ICC = 0.43-0.73; MDC were between 39 and 237 ms. Small changes in scapular neuromuscular mean activity (>11.7% MVIC) can be interpreted as meaningful change, while change in muscle onset timing in light of specific processing parameters used in this study is more variable., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Purpose: To quantify the range, velocity, and smoothness of wrist circumduction, to explore the oblique functional plane of wrist circumduction, and to establish the reproducibility and reliability of these measures., Methods: Forty healthy subjects with a mean age of 43 years and without a history of wrist pathology or pain participated in this study. We used a flexible electrogoniometer with a twin-axis sensor to measure the relative angles between the 2 end blocks while the subject performed maximum excursion of flexion-extension, radioulnar deviation, and circumduction of the wrist held in a standardized, fully pronated position. A software package was used to further analyze the characteristics of the circumduction curve or oval such as the mean area (designated as degree-degree or oo) shape, size, rate, smoothness, and orientation., Results: The mean area of circumduction (4729 [degree-degree]) and circumference (265°) of the circumduction curve indicated the total range of circumduction. The velocity of circumduction (mean 179°/s) and the time (1.6 second) taken to complete 1 cycle of circumduction were similar in both hands. The 4 quadrants for the velocity of circumduction showed that the velocity was faster in the radioulnar deviation quadrants compared with flexion and extension. Quadrant analysis showed the smoothness was greater in the radioulnar deviation quadrants than in the flexion and extension quadrants. The oblique planes of the circumduction curves of all the normal wrists lie in ulnopalmar and radiodorsal direction with a mean angle of 28° to the vertical flexion and extension plane., Conclusions: This technique was accurate and reliable in measuring the velocity, range, and smoothness of wrist circumduction., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Clinicians frequently assess frontal plane knee alignment of patients suspected of having knee osteoarthritis. However, there is little data to indicate whether simple to obtain clinical measures frontal plane alignment indicate the actual bony alignment of the knee or the extent and type of knee osteoarthritis. The purpose of this study was to assess the validity of goniometric measures of frontal plan knee position as a simple clinical tool to assess lower limb alignment and tibiofemoral OA status. Data from the Osteoarthritis Initiative were used to assess concurrent and diagnostic validity of goniometric measures. Data from 142 persons with symptomatic knee OA were used to examine concurrent validity, based on comparison to whole limb radiographs. Diagnostic validity was examined using data from 1390 persons with symptomatic knee OA, based on comparison to tibiofemoral joint space narrowing obtained from standardized radiographs. Associations between goniometric measures and whole limb radiographs were moderate (r = 0.43 for right knee and r = 0.46 for left knee). Goniometric measurements explained approximately 20% of the variation in lower limb alignment as measured by whole limb radiography suggesting that simple clinical measures of lower limb alignment contain too much error for inferring actual lower limb alignment. Diagnostic validity indicated positive likelihood ratios of 3.3 or less for detecting isolated severe medial or lateral joint space narrowing and a high rate of misclassification. Simple clinical assessments of frontal plane lower limb alignment or tibiofemoral OA status, in isolation, contain substantial error and likely do not inform clinical practice., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

In clinical practice, it is increasingly important to assess patients' daily functionality routinely and objectively. Acceleration-based gait analysis (AGA) has shown to be reliable and technically suitable for routine clinical use outside the laboratory. This study investigated the suitability of AGA for measuring function in orthopaedic patients with symptomatic gonarthrosis listed for total knee arthroplasty (TKA) by investigating (a) the ability of AGA to distinguish patients from healthy subjects, (b) the sensitivity to gait changes of AGA in assessing recovery following total knee arthroplasty in a subpopulation, and (c) correlations between AGA parameters and clinical scales. Gait was assessed using AGA in 24 patients with symptomatic gonarthrosis listed for TKA, and in 24 healthy subjects. AGA parameters (e.g. speed, asymmetry) and clinical scales (e.g. KSS) were used to monitor progress in 12 patients 3 months after TKA. The Mann-Whitney-U test, Receiver Operating Characteristic (ROC) curves, repeated measurement ANOVA and Pearson correlations were performed. AGA differentiated pathological from healthy gait. The area under the ROC curve, sensitivity and specificity values were high for speed, step frequency and step length. Different recovery profiles were found, with clinical scales showing faster recovery rates. None or only weak correlations were found between AGA and clinical scores. AGA was found to be of clinical relevance in identifying and monitoring patients with symptomatic gonarthrosis in orthopaedic practice, providing objective and additional information about function beyond clinical scales. This, together with the fact that AGA can be applied routinely, suggests the suitability of AGA for use in rehabilitation programs., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Implant positioning and knee alignment are two primary goals of successful unicompartmental knee arthroplasty. This prospective study outlines the radiographic results following 32 patient-specific unicompartmental medial resurfacing knee arthroplasties. By means of standardized pre- and postoperative radiographs of the knee in strictly AP and lateral view, AP weight bearing long leg images as well as preoperative CT-based planning drawings an analysis of implant positioning and leg axis correction was performed.The mean preoperative coronal femoro-tibial angle was corrected from 7° to 1° (p<0.001). The preoperative medial proximal tibial angle of 87° was corrected to 89° (p<0.001). The preoperative tibial slope of 5° could be maintained. The extent of the dorsal femoral cut was equivalent to the desired value of 5mm given by the CT-based planning guide. The mean accuracy of the tibial component fit was 0mm in antero-posterior and +1mm in medio-lateral projection. Patient-specific fixed bearing unicompartmental knee arthroplasty can restore leg axis reliably, obtain a medial proximal tibial angle of 90°, avoid an implant mal-positioning and ensure maximal tibial coverage., (Copyright © 2010 Elsevier B.V. All rights reserved.)

There is limited research on peak activity of the separate triceps surae muscles in select knee flexion (KF) positions during a maximum voluntary isometric contraction (MVIC) used to normalize EMG signals. The aim of this study was to determine how frequent peak activity occurred during an MVIC for soleus (SOL), gastrocnemius medialis (GM), and gastrocnemius lateralis (GL) in select KF positions, and if these peaks were recorded in similar KF positions. Forty-eight healthy individuals performed unilateral plantar-flexion MVIC in standing with 0°KF and 45°KF, and in sitting with 90°KF. Surface EMG of SOL, GM, and GL were collected and processed in 250 ms epochs to determine peak root-mean-square amplitude. Peak activity was most frequently captured in standing and rarely in sitting, with no position selective to SOL, GM or GL activity. Peak GM and GL activity was more frequent in 0°KF than 45°KF, and more often in similar KF positions than not. Peak SOL activity was just as likely in 45°KF as 0°KF, and more in positions similar to GM, but not GL. The EMG amplitudes were at least 20% greater in positions that captured peak activity over those that did not. The overall findings support performing an MVIC in more than one KF position to normalize triceps surae EMG. It is emphasized that no KF position is selective to SOL, GM, or GL alone., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The objective of this study was to evaluate the effectiveness of hamstring (HT) autografts versus bone-patellar tendon-bone (BPTB) autografts for reconstruction of the anterior cruciate ligament (ACL). We searched the Cochrane Library, MEDLINE, EMBASE and the Chinese Biomedicine Database (CBM) for published randomised clinical trials (RCTs) relevant to ACL reconstruction comparing HT and BPTB autografts. Data analyses were performed with Cochrane Collaboration's RevMan 5.0. A total of 23 reports of 19 randomised controlled trials (RCTs) (1643 patients) met the inclusion criteria. Outcomes favouring BPTB autografts were found in terms of KT-1000 arithmometer values, negative rates of Lachman tests and negative rates of Pivot tests. Outcome measures that favoured HT autografts included anterior knee pain, kneeling pain and extension loss. There was no statistical difference of postoperative graft failure. Overall, postoperative complications of the knee joint were lower for HT autografts than for BPTB autografts, and BPTB autografts were superior to HT autografts in resuming stability of the knee joint, but four-strand HT combined with application of the modern endobutton HT graft-fixation technique could increase knee-joint stability., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Upper Limb Neurodynamic Test 1 (ULNT1) is commonly used within clinical practice. However, the existing evidence regarding its reliability is conflicting and raises methodological questions. Therefore, the aim of this study was to investigate how reliable and precise physiotherapists are at recording both intra and inter-rater measurements of ULNT1 on an asymptomatic population. Forty asymptomatic subjects, 29 females and 11 males (18-42 years, mean 23.35), were recruited into this intra (stability) and inter-rater (equivalence) reliability and precision study. ULNT1 was recorded twice using an electrogoniometer by two experienced physiotherapists using a standardised operational description in conditions replicating clinical practice. Reliability was analysed using the Intraclass Correlation Coefficient (ICC₂,₁), and precision using Standard Error of Measurement (SEM) and Smallest Detectable Difference (SDD). The findings demonstrated excellent intra-rater (ICC₂,₁ 0.98 Rater 1; ICC₂,₁) 0.96 Rater 2) and good inter-rater (ICC₂,₁ 0.80) reliability. Precision was acceptable for both intra-rater (SEM 2.59° Rater 1; SEM 0.97° Rater 2; SDD 7.16° Rater 1; SDD 2.68° Rater 2), and inter-rater (SEM 3.83°; SDD 10.58°) measurements. These findings demonstrate that physiotherapists can use ULNT1 reliably and with precision for intra and inter-rater measurements of asymptomatic subjects in conditions that replicate clinical practice. The reproduction of this study on a population of symptomatic subjects is now warranted., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Diminished range of motion (ROM) of the knee joint after total knee arthroplasty (TKA) is thought to be related to reduced patellar mobility. This has not been confirmed clinically due to a lack of quantitative methods adequate for measuring patellar mobility. We investigated the relationship between patellar mobility by a reported quantitative method and knee joint ROM after TKA. Forty-nine patients [osteoarthritis--OA: 29 knees; rheumatoid arthritis--RA: 20 knees] were examined after TKA. Respective medial and lateral patellar mobility was measured 1 and 6 months postoperatively using a patellofemoral arthrometer (PFA). Knee joint ROM was also measured in each of those 2 sessions. Although the flexion and extension of the knee joints improved significantly from 1 to 6 months after TKA, the medial and lateral patellar displacements (LPDs) failed to improve during that same period. Moreover, only the changes in knee flexion and medial patellar displacement (MPD) between the two sessions were positively correlated (r = 0.31, p < 0.05). However, our findings demonstrated that medial and lateral patellar mobility had no sufficient longitudinal relationship with knee ROM after TKA., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Malalignment may contribute to early prosthesis failure through point loading and premature polyethylene wear. Femoral resection requires for distal planar resection contingent upon correct rotation and coronal alignment. Using a standard model, we have examined the influence of differing femoral entry points and rotations upon final femoral component positioning. A graphical method and navigation system independently quantified the individual and combined impact of these variables, in 3 planes. Nine permutations were assessed with reference to neutral rotation and a central entry point. The graphical results were corroborated by the navigation analyses. We found that external rotation and a superolateral entry point introduced the greatest error in final component positioning. We have identified a safe envelope for femoral rod positioning and recommend that the rotational alignment is determined before distal bone resection., (Copyright 2009 Elsevier B.V. All rights reserved.)

In unicondylar knee prostheses, the relative angle and congruency of the femoral against the tibial component is not mechanically constrained and may vary with the surgical implantation technique. The contact area between both components was measured with increasing varus (0-20 degrees) and flexion angles (-20 degrees to 90 degrees) in five prosthesis models in the laboratory. The contact area varied with the relative position of the components and was critically reduced up to 70% at a varus range between >5 degrees and <25 degrees. The importance of relative malpositioning of the femoral and tibial components may be underestimated and reduces the contact area of unicondylar prostheses decisively, independent from the limb axis. This increases local pressure and may thus importantly contribute to increased wear and early loosening., (Copyright 2009 Elsevier B.V. All rights reserved.)

It is assumed that strain in a nerve segment at the end of a neurodynamic test will be greatest if the joint nearest that nerve segment is moved first in the neurodynamic test sequence. To test this assumption, the main movements of the median nerve biased neurodynamic test were applied in three different sequences to seven fresh-frozen human cadavers. Strain and longitudinal excursion were measured in the median nerve at the distal forearm. Strain and relative position of the nerve at the end of a test did not differ between sequences. The nerve was subjected to higher levels of strain for a longer duration during the sequence where wrist extension occurred first. The pattern of excursion was different for each sequence. The results highlight that order of movement does not affect strain or relative position of the nerve at the end of a test when joints are moved through comparable ranges of motion. When used clinically, different neurodynamic sequences may still change the mechanical load applied to a nerve segment. Changes in load may occur because certain sequences apply increased levels of strain to the nerve for a longer time period, or because sequences differ in ranges of joint motions., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Purpose: The second dorsal metacarpal artery flap from the middle finger is a reconstructive technique that can be used to repair extensive volar defects in a normal-length thumb. However, few reports advocate using it for coverage of volar thumb defects. In this article, an anatomic study of 9 flaps used for resurfacing thumb defects is presented along with the clinical experience of the authors., Methods: From 2004 to 2006, 9 patients (6 men and 3 women; mean age, 33 years; range, 18-51 years) with extensive volar defects of their normal-length thumbs had reconstruction using the described technique. In all cases, the first dorsal metacarpal artery flap technique was unable to be used because of injury. Donor sites were covered using full-thickness skin grafts. After surgery, the thumb was immobilized with a splint, followed by rehabilitation. During the follow-up period, which lasted 24 to 30 months, flap-site skin quality, scar contractures, and finger mobility were assessed. The range of motion of the hand was measured by a goniometer. Sensibility was evaluated by the 2-point discrimination test and the Semmes-Weinstein monofilament test. Cold intolerance was also assessed., Results: Patient postoperative courses were uneventful, and all flaps survived completely without complication. Good coverage was obtained in all cases. Full active range of motion was observed in all patients in both the donor finger and the thumb. The mean Semmes-Weinstein sensitivity and 2-point discrimination scores of the flap were 4.02 g and 8.4 mm, respectively. Mild cold intolerance was observed in all of the thumbs., Conclusions: The second dorsal metacarpal artery flap from the middle finger is a single-stage flap that produces good results. Although its pedicle length is limited, it is reliable and can be used as an alternative for reconstruction of extensive thumb-pulp defects, especially when the first dorsal metacarpal artery flap cannot be used., Type of Study/level of Evidence: Therapeutic IV.

Stress radiographs have been recommended in order to obtain a better objective quantification of abnormal compartment knee motion. This tool has showed to be superior in quantifying a posterior cruciate ligament (PCL) lesion compared to clinical or arthrometer evaluation. Different radiographic techniques have been described in literature to quantify posterior pathological laxity. In this study we evaluated the total amount of posterior displacement (PTD) and side to side difference (SSD), before and after surgical reconstruction of PCL or PCL and posterolateral complex (PLC), using two different stress radiography techniques (Telos stress and kneeling view). Twenty patients were included in this study. We found a statistical significant difference about both total PTD and SSD among the two techniques preoperatively and at follow-up, with greatest values occurring using the kneeling view. Although stress radiographies has been introduced to allow an objective quantification of laxity in ligamentous injured knee, we believe that further studies on a large numbers of subjects are required to define the relationship between PTD values, measured with stress knee radiography, particularly using kneeling view, and ligamentous knee injury, in order to obtain a real useful tool in the decision making process, as well as to evaluate the outcome after ligamentous surgery.

Purpose: To report a series of clinodactyly patients to report clinical and radiographic outcomes after closing wedge osteotomy and K-wire fixation of abnormal middle phalanges., Methods: Twenty-five fingers from 17 patients were included in the study. All patients had more than 25 degrees of angulation and were treated with closing wedge osteotomy. Subjective and objective data with radiographic assessment were compared preoperatively and postoperatively., Results: Male gender was predominant in our series (14 of the total 17 patients). Family history was positive for clinodactyly in 4 patients. The appearance of all fingers improved after surgery. Angular deformity was corrected on average from 33 degrees preoperatively to 9 degrees postoperatively. Analysis of radiographs showed deformity correction from 29 degrees preoperatively to 5 degrees postoperatively. Preoperative and postoperative arc of motion measurements were available for 10 patients. Distal interphalangeal joint arc of motion decreased from 84 degrees prior to surgery to 81 degrees after surgery, whereas proximal interphalangeal joint arc of motion was unchanged., Conclusions: Closing wedge osteotomy of the abnormal middle phalanx for clinodactyly has provided our patients with adequate correction of the deformity, improved hand function, and has provided high satisfaction for parents. This treatment is recommended for moderate (15 degrees to 30 degrees ) and severe (>30 degrees ) deformities.

Background: The aim of this study was to quantify the compensatory movements of the shoulder and elbow in patients with congenital radioulnar synostosis during 10 activities of daily living (ADL)., Methods: Maximum and minimum joint angles and range of motion were measured by use of a motion capture system in seven patients and seven matched controls. The forearm was fixed in 0 degrees of rotation in four patients and in 20 degrees of pronation in three patients., Results: The main compensatory movements were shoulder internal/external rotation during five ADL tasks, shoulder abduction/adduction and elbow flexion/extension during three tasks, and shoulder flexion/extension during two tasks. These compensatory movements were observed mainly when turning a key and drawing., Conclusions: Patients with congenital radioulnar synostosis in nearly neutral rotation could perform all ADL tasks with the aid of compensatory movements of the shoulder and elbow.

Purpose: The aim of the current study was to assess reliability of 6 palmar thumb abduction measurement methods: conventional goniometry, the Inter Metacarpal Distance, the method described by the American Medical Association, the method described by the American Society of Hand Therapists, and 2 new methods: the Pollexograph-thumb and the Pollexograph-metacarpal., Methods: An experienced hand therapist and a less-experienced examiner (trainee in plastic surgery) measured the right hands of 25 healthy subjects. Palmar abduction was measured both passively and actively. Means and ranges for palmar abduction were calculated, and intrarater and interrater reliability was expressed in intraclass correlation coefficients, standard errors of measurement, and smallest detectable differences., Results: Mean active and passive angles measured with goniometry resembled values measured with the Pollexograph-thumb method (approximately 60 degrees). Mean angles found with the Pollexograph-metacarpal method were approximately 48 degrees. Mean active and passive distances for the Inter Metacarpal Distance were 64 mm. Mean active and passive distances found with the American Society of Hand Therapists method were 97 to 101 mm, and mean distances found with the American Medical Association method were 67 to 70 mm for active and passive measurements. Intraclass correlation coefficients for the Pollexograph-thumb, Pollexograph-metacarpal, and the Inter Metacarpal Distance indicated good and significantly higher intrarater agreement for active and passive measurements than intraclass correlation coefficients of conventional goniometry, the American Society of Hand Therapists method, and the American Medical Association method, which showed only moderate agreement. For interrater reliability, the same measurement methods were found to be most reliable: the Pollexograph-thumb, Pollexograph-metacarpal, and the Inter Metacarpal Distance., Conclusions: We found that the Pollexograph-thumb, Pollexograph-metacarpal, and the Inter Metacarpal Distance are the most reliable measurement methods for palmar abduction.