Effect of concurrent training in unilateral transtibial amputees using Paralympic athletes as a control group

Abstract Context: Transtibial Amputation (TA) predisposes to a sedentary lifestyle. Objectives: To evaluate the efficiency of a short-term (8-week) Concurrent Training (CT) program in Unilateral Transtibial Amputees (UTA) and to compare it with the physical condition of a group of Paralympic athletes in preparation for the Rio de Janeiro Paralympics. Design: This was a longitudinal, prospective and controlled trial study. Methods: Thirty-four male subjects with UTA and using prostheses for six months or more were selected for this study. They were divided into two groups: Group 1 (G1) - 17 non-athlete and untrained UTA and Group 2 (G2) - 17 paralympic athletes with active UTA in the training phase. G1 was evaluated before and after eight weeks of CT and G2 made a single evaluation for control. All were submitted to anamnesis, clinical evaluation (blood pressure, electrocardiogram, and heart rate) and cardiopulmonary exercise testing on a lower limb cycle ergometer, and isokinetic knee dynamometry. The CT of G1 included resistance exercise and aerobic interval training on a stationary bicycle and G2 followed the training of the Paralympic teams. Results: Patients were retested by the same methods after CT. The two most important central dependent variables (maximal oxygen uptake and muscular strength) increased by 22% and knee extensor and flexor strength by 106% and 97%, respectively. Conclusion: After eight weeks of CT, there was an improvement in general functional condition, muscle strength, and cardiorespiratory performance improving protection against chronic diseases and quality of life.

A comparative study of transtibial approach and assisted medial approach for femoral tunnel near-isometric reconstruction of anterior cruciate ligament / 中华创伤骨科杂志

Objective:To compare the location and efficacy of femoral tunnel near-isometric reconstruction of anterior cruciate ligament (ACL) between the transtibial and assisted medial approaches.Methods:The clinical data of 47 patients were retrospectively analyzed who had been admitted by Department of Orthopaedics, The 904 Hospital of PLA for ACL rupture from January 2018 to December 2019. They were divided into 2 groups according to different surgical approaches. In groups A of 21 cases, there were 15 males and 6 females with an age of (29.5 ± 4.8) years and their ACL was reconstructed through the transtibial approach with adjustable Endobutton plate; in group B of 26 cases, there were 18 males and 8 females with an age of (31.2 ± 9.6) years and their ACL was reconstructed through the assisted medial approach with adjustable Endobutton plate. The 2 groups were compared in terms of location of femoral tunnel, Lysholm score and International Knee Documentation Committee (IKDC) score at the last follow-up, and anterior-posterior and rotational stability of the knee joint.Results:There was no significant difference in the preoperative general data between the 2 groups, showing comparability ( P>0.05). The 47 patients were followed up for 18 to 27 months (average, 22.3 months). As for the center of the inner opening of the femoral tunnel located by the four grid table method, the X-axis loci was 25.6% ± 2.5% and 26.7% ± 1.8% respectively in groups A and B, showing no statistically significant difference ( P>0.05) while the Y-axis loci 19.8% ± 2.0% and 30.6% ± 1.5% respectively in groups A and B, showing a statistically significant difference ( P<0.05). At the last follow-up, the lyholm scores were 90.9 ± 3.4 and 92.4 ± 3.9 and the IKDC scores 89.9 ± 3.5 and 90.2 ± 3.8 respectively in groups A and B, showing no significant difference between the 2 groups ( P>0.05). There was no significant difference either in the results of front drawer test, Lachman test or axial displacement test between the 2 groups ( P>0.05). Conclusion:In femoral tunnel near-isometric reconstruction of ACL, the transtibial approach can result in a tunnel location which is closer to the top of the condyle than the assisted medial approach, but both approaches can lead to satisfactory curative efficacy in the short postoperative period.

Effects of Tactile Vibration Feedback System on Balance Function and Walking Ability of Unilateral Transtibial Amputees with Prostheses / 中国康复理论与实践

Objective:To observe the effect of the tactile vibration feedback system on the balance and walking function of the unilateral transitional amputees with prostheses. Methods:From October, 2019 to November 2020, eleven unilateral transtibial amputees with prostheses were selected from our hospital. They performed daily activities for three hours wearing tactile vibration feedback system designed by our department. The patients were evaluated by Performance Oriented Mobility Assessment (POMA), gait analysis and outdoor 1000 meters complex road walking test before and after treatment. Results:The balance score of the POMA improved (Z = -2.264, P < 0.05), the gait score and total score of the POMA increased significantly (|t| > 6.249, P < 0.001) after treatment. Gait analysis showed that the step length of the affected side improved, the bilateral step time and double support phase shortened, and the walking speed increased (|t| > 2.250, |Z| > 2.756, P < 0.05) after installation. The outdoor 1000 meters complex road walking test showed that the total steps, energy consumption and time decreased (|t| > 2.412, |Z| > 2.045, P < 0.05). All the patients finished the trail, and no discomfort appeared. Conclusion:The tactile vibration feedback system could safely and effectively improve the balance and walking function of the unilateral transtibial amputees with prostheses.

Patient-Specific Design of Passive Prosthetic Leg for Transtibial Amputee: Analysis Between Two Different Designs

@#Introduction: Amputee patients are usually utilized prosthetic leg for daily activities such as walking, climbing, and running. However, the current prosthetic leg that available from the market often associated with poor comfortability due to its conventional way of socket manufacturing. Therefore, this research aims to build custom-made passive transtibial prosthetic legs and to evaluate the aspects of biomechanical analysis. Methods: The residual leg of a subject was scanned using the Sense three-dimensional scanner. By referring to scanned residual leg model, two design of prosthetic legs which are the low-cost solid ankle cushion heel (SACH) foot (D1), and the high-cost flex foot (D2), were developed by using computer aided software (CAD), SolidWorks and Meshmixer. Each of the components were then meshed with triangle edge length of 5 mm in 3-Matic software. Marc.Mentat software was used to simulate the midstance phase of a gait cycle where an axial load of 350 N was applied. Results: The overall maximum stress of the D1 (190.2 MPa) was higher than D2 (38.47 MPa). In addition, socket and pylon in D1 showed tendency to yield because the maximum stress is higher than yield stress of respective materials. In displacement analysis, D2 showed higher overall displacement than D1 because the flex foot has higher flexibility. Conclusion: From overall result, prosthetic leg of D2 is better in biomechanical strength as compared with the D1 because it can withstand the loading from subject’s weight without showing any sign of yield.

What is the Quality of Life of Transtibial Amputees in Brunei Darussalam?

@#Introduction: Lower limb amputations have a profound impact on the quality of life (QoL) of the patients. This study was done to assess the QoL of patients with transtibial (below-the-knee) amputations (TTA) and transtibial amputees fitted with prosthesis. Materials and Methods: A case-control study of patients who had undergone TTA from 2015 to 2018 was conducted in Raja Isteri Pengiran Anak Saleha Hospital (RIPAS). Complete data was available for 30 subjects and it was compared with 30 diabetic, non-amputee patients matched for age and gender. QoL was assessed using the RAND 36Item Health Survey (SF-36) and the functional outcome of prosthesis-fitted transtibial amputees was assessed using the Houghton Scale. Results:Almost all cases of TTA were a result of vascular problems related to diabetes and chronic renal disease (n=29; 97%). Eighteen (60%) participants were fitted with prosthesis and 15 (50%) reported having phantom pain. QoL of participants was found to be significantly lower than that of age and sex-matched diabetic non-amputees with regards to physical functioning, role limitation due to physical health, emotional well-being, social functioning, and bodily pain. The mean Houghton Score for participants fitted with prosthesis was 4.89 (SD= 2.83) suggesting low functional outcome. Conclusion: TTA has a negative impact on the QoL of patients, especially in terms of functionality. The availability of prosthesis does not significantly improve the quality of life except in the physical functioning domain. Emotional well-being should be emphasised more in the rehabilitation process as this study found poor emotional well-being among participants.

Reconstrucción del ligamento cruzado anterior con túnel femoral por portal medial vs transtibial / Anterior cruciate ligament reconstruction with femoral tunnel via medial portal vs trans-tibial

Resumen: La lesión del ligamento cruzado anterior (LCA) de la rodilla es una lesión traumática severa que disminuye enormemente la función y en ocasiones deja secuelas muy importantes para el paciente joven, por lo que la cirugía para la reconstrucción del ligamento es el tratamiento idóneo. Existen varias técnicas para la elaboración de túneles con diferencia en los portales, los métodos de fijación y los diferentes injertos que se usan; cada uno de los autores defiende sus técnicas señalando sus ventajas y desventajas y posibles complicaciones. El objetivo de este estudio fue valorar las ventajas de dos métodos de abordaje a nivel femoral para el paso del injerto o implantes. Material y métodos: Estudio de dos grupos similares, observacional, transversal, retrospectivo y analítico en pacientes operados por el mismo grupo quirúrgico. Durante tres años se operaron 80 pacientes, 42 de ellos por portal medial y 38 por vía transtibial. Resultados: El sexo masculino predominó en ambos grupos, se valoraron los parámetros de facilidad para observar el paso del tendón o injerto, el paso del implante femoral, la facilidad del agarre del implante, la tensión del mismo y el tiempo quirúrgico en ambos grupos. El resultado fue concluyente siendo un > p 0.06 contemplando el mejor resultado en los pacientes operados por portal medial.

Abstract: Anterior cruciate ligament injury (ACL) of the knee is a severe traumatic injury that greatly decreases the function and sometimes leaves very important sequelae for the young patient so surgery for ligament reconstruction is the suitable treatment, there are several techniques for the elaboration of tunnels with difference in the portals, the methods of fixation and the different grafts used and each one of the authors defend their techniques giving their advantages and disadvantages and possible complications associated. The objective of this study was to assess the advantages or not of two approaches to the femoral side for the passage of the graft or implants. Material and methods: Two similar groups in this observational, transversal, retrospective and analytical study in patients operated by the same surgeon and assistants. In a period of time of three year, 80 patients were operated, 42 of them by medial portal and 38 of them via trans tibial. Results: The male sex in both groups was the predominant one, the parameters of ease were assessed to observe the passage of the tendon or graft, the passage of the femoral implant, the ease of the implant grip, the tension of the same and the operative time in both groups. The result was conclusive being an > p 0.06 contemplating the best result in patients operated by medial portal.

Short term clinical results of single bundle ACL reconstruction, with a quadruple autologous hamstring graft, modified transtibial versus anteriomedial portal approach for femoral tunnel

Anteriior cruciate ligament injuries are known to be the most common spots injuries, and ACL reconstruction is widely used because of the low success rate of convservative treatment. This study was aimed to compare the short-terma functional results of modifying transtibial and transportal technique for femoral tunnel drilling. This Retrospective comparative case control study included 76 patients with an isolated ACL tear, operated with ST tendon autograft ACL reconstruction by the same surgical tea. 36 patients operated with a modified transtibial approach and 40 patients with an antreomedial approach for femoral drilling. The results of the current study revealed that the mean age in the series was 26 years; the majority of patients were male, only 6 patient's asses again after two years of surgery, by instability tests and lysholm scores reveal no significant differences between two group regarding anterioposterior and rotatory instability, also comparable lysholm score results. The Study concluded that modified transtibial femoral drilling of the femoral tunnel in ACL reconstruction surgery is still useful and give comparable results as tranportal drilling (AU)

A comparative study of arthroscopic anterior cruciate ligament reconstruction via transtibial and transportal techniques / 中国修复重建外科杂志

Objective: To investigate the effectiveness of arthroscopic anterior cruciate ligament (ACL) reconstruction via transtibial (TT) and transportal (TP) techniques after 10 years follow-up. Methods: A clinical data of 103 patients who underwent arthroscopic ACL reconstruction with a single bundle of autologous hamstring tendon between March 2006 and March 2009 was retrospectively analyzed, among which 57 patients were reconstructed with TT technique (TT group) and 46 patients were reconstructed with TP technique (TP group). There was no significant difference in gender, age, cause of injury, interval between injury and operation, preoperative pivot shift test, preoperative International Knee Documentation Committee (IKDC) score, Lysholm score, and KT-2000 side-to-side difference (SSD) between the two groups ( P>0.05). At 10 years after operation, Lachman test was used to evaluate the forward joint stability and pivot shift test to evaluate the rotational stability of the knee; KT-2000 SSD was used to measure tibial anterior displacement; IKDC score and Lysholm score were used to evaluate knee function; MRI examination was performed to observe graft healing and measure coronal inclination angles of the tibia and femoral tunnels. The rate of return to sports was also calculated. Results: The incisions healed by first intention in the two groups, and no early complication occurred after operation. All patients were followed up 10-13 years, with an average of 11.5 years. During the follow-up period, there was no limitation of knee extension and flexion, no discomfort of donor site or graft failure in either group. MRI examination showed that the graft healed well. The IKDC score, Lysholm score, and KT-2000 SSD in the two groups were significantly improved after 10 years ( P0.05). There were significant differences in coronal inclination angles of femoral tunnel and tibial tunnel between the two groups ( P0.05). The rate of return to sports of patients was 61.40% (35/57) in TT group and 63.04% (29/46) in TP group, showing no significant difference between the two groups ( χ2=0.29, P=0.87). Conclusion: TT and TP techniques can both achieve good effectiveness in ACL reconstruction.

How to Avoid Graft-Tunnel Length Mismatch in Modified Transtibial Technique for Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft

BACKGROUND: We conducted this study to determine the optimal length of patellar and tibial bone blocks for the modified transtibial (TT) technique in anterior cruciate ligament (ACL) reconstruction using the bone-patellar tendon-bone (BPTB) graft. METHODS: The current single-center, retrospective study was conducted in a total of 64 patients with an ACL tear who underwent surgery at our medical institution between March 2015 and February 2016. After harvesting the BPTB graft, we measured its length and that of the patellar tendon, patellar bone block, and tibial bone block using the arthroscopic ruler and double-checked measurements using a length gauge. Outcome measures included the length of tibial and femoral tunnels, inter-tunnel distance, length of the BPTB graft, patellar tendon, patellar bone block, and tibial bone block and graft-tunnel length mismatch. The total length of tunnels was defined as the sum of the length of the tibial tunnel, inter-tunnel distance and length of the femoral tunnel. Furthermore, the optimal length of the bone block was calculated as (the total length of tunnels − the length of the patellar tendon) / 2. We analyzed correlations of outcome measures with the height and body mass index of the patients. RESULTS: There were 44 males (68.7%) and 20 females (31.3%) with a mean age of 31.8 years (range, 17 to 65 years). ACL reconstruction was performed on the left knee in 34 patients (53%) and on the right knee in 30 patients (47%). The optimal length of bone block was 21.7 mm (range, 19.5 to 23.5 mm). When the length of femoral tunnel was assumed as 25 mm and 30 mm, the optimal length of bone block was calculated as 19.6 mm (range, 17 to 21.5 mm) and 22.1 mm (range, 19.5 to 24 mm), respectively. On linear regression analysis, patients' height had a significant correlation with the length of tibial tunnel (p = 0.003), inter-tunnel distance (p = 0.014), and length of patellar tendon (p < 0.001). CONCLUSIONS: Our results indicate that it would be mandatory to determine the optimal length of tibial tunnel in the modified TT technique for ACL reconstruction using the BPTB graft. Further large-scale, multi-center studies are warranted to establish our results.

Tomographic Study of Femoral Positioning in Anterior Cruciate Ligament Reconstruction Using the Transtibial Technique

PURPOSE: To analyze the location of the femoral tunnel by three-dimensional computed tomography (3D CT) of the lateral condyle in patients who underwent arthroscopic single-bundle anterior cruciate ligament (ACL) reconstruction, performed using a modified transtibial technique, and to compare the results with data from the literature. MATERIALS AND METHODS: Seventeen patients with ACL lesions underwent modified transtibial ACL reconstruction. Postoperatively, 3D CT examinations were performed and the images were analyzed by the quadrant system described by Bernard and Hertel to define the femoral tunnel coordinates. RESULTS: The mean value of femoral tunnel location coordinates was 37.1±5.9 in the horizontal plane and 23.9±7.5 in the vertical plane. Compared with other studies using the transtibial or transportal technique, femoral positioning was improved in the vertical plane. The outside-in technique provided the best results both in the vertical and horizontal planes. CONCLUSIONS: The modified transtibial technique was not effective for systematically anatomic femoral tunnel positioning; however, it was relatively better than the conventional transtibial technique.

Walking Ability of Unilateral Transtibial Amputees with Prostheses / 中国康复理论与实践

Objective To investigate walking ability of amputees with unilateral transtibial prosthesis. Methods From April to Decem-ber, 2016, 20 unilateral transtibial amputees (patients) and 20 healthy adults (controls) were tested with L test, balance test, 6-minute walk test (6MWT) and 1000 m walking outdoor on various terrain. Results There was no significant difference in time of L test between the am-putees wearing Solid Ankle Cushion Heel (SACH) and Storage Foot (t=0.675, P>0.05). In balance tests, there was no significant difference in the total track length, confidence ellipse area, maximum horizontal deviation and maximum vertical deviation between the patients and the controls (t0.05). Each parameter was significantly different in 6MWT between them (t>2.774, P4.130, P<0.001). Conclusion The walking ability of the unilateral transtibial ampu-tees wearing prostheses is different from normal people. The transtibial prosthetic feet that the amputees wear may impact their walking abil-ity.

Avaliação da força muscular, da atividade muscular e das alterações metabólicas de amputados transtibiais / Assessment of muscle strength, muscle activity and metabolic changes of patients with transtibial amputation

Objetivo: Reunir os achados na literatura sobre eletromiografia, força muscular e alterações metabólicas em amputados transtibiais. Métodos: Revisão da literatura, realizada no período de janeiro a março de 2014, com pesquisa nas bases de dados eletrônicas: Pubmed, Scielo, Lilacs, BVS, Dedalus e BCE; utilizando-se as palavras-chave: amputado transtibial, EMG, abaixo do joelho, amputados, força muscular, gasto energético e frequência cardíaca, além de seus correspondentes na língua inglesa. Resultados: Foram identificados 144 artigos. Após análise e avaliação, 33 artigos foram selecionados. A demanda metabólica apresenta-se maior durante a marcha de indivíduos amputados em comparação a não amputados. Para o estudo eletromiográfico nessa população são utilizados, principalmente, os músculos bíceps femoral e reto femoral. O torque foi a variável mais descrita por sua relação direta com a força muscular. Conclusão: Os sinais EMG estão fortemente relacionados ao modo como o amputado. (AU)

Objective: To assemble findings in the literature regarding electromyography, muscle strength and metabolic alterations in patients with transtibial amputations. Methods: Literature review from January to March 2014 in Pubmed, Scielo, Lilacs, BVS, Dedalus and BCE databases; the following key words were used: transtibial amputee, sEMG, below the knee, amputees, muscle strength, energy expenditure and its Portuguese equivalents. Results: 144 articles were identified. After subsequent analysis and evaluation, 33 were selected. Metabolic demand appears to be increased during amputees gait in comparison to non-amputees subjects. Concerning EMG studies, the main muscles used in this population are both biceps femoris and rectus femoris. Torque was the most described variable for its directly relation with muscle strength. Conclusion: EMG signals are strongly related to the transtibial amputee locomotion. The proper prosthesis selection may reduce metabolic demand. (AU)

Anatomical Single-bundle Anterior Cruciate Ligament Reconstruction Using a Freehand Transtibial Technique

PURPOSE: In anatomical single-bundle (SB) anterior cruciate ligament (ACL) reconstruction, the traditional transtibial approach can limit anatomical placement of the femoral tunnel. SURGICAL TECHNIQUE: We present a novel three-point freehand technique that allows for anatomic SB ACL reconstruction with the transtibial technique. MATERIALS AND METHODS: Between January 2012 and December 2012, 55 ACL reconstructions were performed using the three-point freehand technique. All the patients were followed for a minimum of 12 months post-operatively. Clinical evaluation was done using the Lysholm score and International Knee Documentation Committee (IKDC) grade. All patients were analyzed by 3-dimensional computed tomography (3D CT) at 1 week after surgery. RESULTS: The mean Lysholm score improved from 68.2+/-12.7 points preoperatively to 89.2+/-8.2 points at final follow-up. At final follow-up, the IKDC grade was normal in 42 patients and nearly normal in 13 patients. None of the patients had a positive pivot shift test, anterior drawer test and Lachman test at final follow-up. The anatomical position of the femoral tunnel was confirmed on 3D CT scans. CONCLUSIONS: The three-point freehand technique for SB transtibial ACL reconstruction is a simple, anatomic technique showing good clinical results.

Thorax, pelvis and hip pattern in the frontal plane during walking in unilateral transtibial amputees: biomechanical analysis

Background: Lower limb amputees exhibit postural control deficits during standing which can affect their walking ability. Objectives: The primary purpose of the present study was to analyze the thorax, pelvis, and hip kinematics and the hip internal moment in the frontal plane during gait in subjects with Unilateral Transtibial Amputation (UTA). Method: The participants included 25 people with UTA and 25 non-amputees as control subjects. Gait analysis was performed using the Vicon(r) Motion System. We analyzed the motion of the thorax, pelvis, and hip (kinematics) as well as the hip internal moment in the frontal plane. Results: The second peak of the hip abductor moment was significantly lower on the prosthetic side than on the sound side (p=.01) and the control side (right: p=.01; left: p=.01). During middle stance, the opposite side of the pelvis was higher on the prosthetic side compared to the control side (right: p=.01: left: p=.01). Conclusions: The joint internal moment at the hip in the frontal plane was lower on the prosthetic side than on the sound side or the control side. Thorax and pelvis kinematics were altered during the stance phase on the prosthetic side, presumably because there are mechanisms which affect postural control during walking. .

Ligamento cruzado anterior. Reconstrucción transtibial vs. transportal. Evaluación radiológica de la posición del tunel femoral y tibial / Anterior cruciate ligament reconstruction. Transtibial vs. transportal technique. Radiological evaluation

Introducción: La tendencia actual en la cirugía de reconstrucción del LCA es intentar reproducir con la plástica, la huella anatómica original femoral y tibial. La realización de túneles independientes permitiría optimizar el punto de entrada en la huella femoral, que junto con la oblicuidad y el diámetro de la fresa, reproducirían con mayor certeza la anatomía. Objetivo: comparar con parámetros radiográficos objetivos la posición de los túneles femorales y tibiales, en dos grupos de pacientes operados con técnica transtibial y transportal anatómicas. Material y métodos: de diciembre del 2012 a diciembre del 2013, se evaluaron radiológicamente en forma prospectiva 59 pacientes con plástica primaria del LCA divididos en dos grupos, uno con técnica transtibial (TT), 19 pacientes y 40 pacientes con técnica transportal (TP). En el fémur, determinamos, el ángulo de inclinaciónn del túnel, el sitio de inserción con respecto a la línea de Blumensaat y la distancia transósea; en la tibia, la ubicación en porcentaje de la localización con respecto al platillo tibial en el frente y perfil y el ángulo del túnel tibial en el frente y en el perfil. Resultados: en el fémur: el ángulo de inclinación del túnel en el grupo (TP) fue de 45,92º, y en el (TT) de 24,53º, P 0,002; el porcentaje en la línea de Blumensaat en el (TP), fue de 20,95 y en (TT) de 20,74 con una p 0,681, y la distancia transósea en el (TP) fue de 3,43 cm y para el (TT) de 4,79 cm con una p< 0,000. En la tibia la distancia porcentual en el frente fue de 44,35 para (TP) y de 40,80 para TT con p de 0.076, y en el perfil fue de 28,70 para (TP) y de 34,53 para TT con una p 0,367. Finalmente, el ángulo del túnel tibial en el frente fue de 73,48 para el (TP) y de 62,81 para el (TT) con p 0,002, y para el perfil fue de 114,69 para (TP) y de 112,79 para (TT) con p de 0.427. Conclusión: con ambas técnicas es posible realizar un túnel tibial y femoral en posición óptima pero no iguales. La realización de túneles independientes permitiría colocar un túnel tibial más anterior y vertical mejorando la cobertura de la huella anatómica normal, y el túnel femoral por vía transportal nos permitiría obtener un mayor ángulo de inclinación y una menor distancia transósea, detalles técnicos que optimizarían la cobertura anatómica de esta huella. Nivel de evidencia: II. Tipo de estudio: prospectivo comparativo.

Introduction: The most recent advances in ACL reconstruction try to reproduce the anatomic femoral and tibial footprints as close as possible. Creating independent tunnels would allow the optimizacion of the entry point and the femoral tunnel obliquity, and together with an adequate reamer diameter, they would allreproduce with greater certainty the anatomy. Objective: to compare the radiographic parameters of the femoral and tibial tunnel positions in two groups of patients, one operated with a transtibial and other with transportal anatomic techniques. To compare radiographic parameters of a group of patients operates with a transtibial technique versus a group operated with a transportal one and define the the tunnel positions. Materials and methods: from December 2012 to December 2013, 59 patients with a primary ACL reconstruction divided in two groups, a trans tibial technique (TT), 19 patients, and an transportal one (TP) with 40 patients were prospectively evaluated with AP and lateral X-rays. The femoral tunnel angle, the insertion site with respect of the Blumensaat line, the trans osseous distance, the tibial tunnel position as a percentage of the tibial plateau in the AP and lateral views. Finally the tibial tunnel angle in the AP and Lateral views. Results: the femoral tunnel angle was in the TP group of 45,92º and in the TT one 24,53º, p 0,002. The insertion site percentage of the Blumensaat line was of 20,96 in TP and 20,74 in the TT, p 0,681.Trans osseous distance was in the TP of 3,43 cm and in the TT of 4,79 cm, p <0,000. The tibial tunnel position as a percentage in the AP tibial plateau was of 44,35 in TP and of 40,80 TT with a p of 0,076. The tibial tunnel position as a percentage of the lateral tibial plateau was of 28,70 in TP and 34,53 in TT with a p 0,367. Tibial tunnel angle in the AP was of 73,48º in TP and 62,81 in TT with a p of 0,002, and in the lateral plateau of 114,69º in TP and 112,79º in TT with a p of 0,427. Conclusion: it is possible to create tibial and femoral tunnel in optimal positions but not equal between both groups. Creating independent tunnels allow a more anterior and vertical tibial tunnel allowing a better coverage of the tibial footprint. A transportal femoral tunnel would allow a better inclination angle and a lesser trans-osseous distance, technical details that would allow a better coverage of the femoral footprint. Level of Evidence: II. Type of study: prospective comparative study.

Walking Ability of Bilateral Transtibial Amputees Assisted with Prostheses / 中国康复理论与实践

@#Objective To compare the walking ability between bilateral transtibial amputees and normal controls, and develope reference indexes of bilateral transtibial amptees' walking ability while wearing prostheses. Methods 11 bilateral transtibial amputees served as amputation group, 12 normal subjects served as controls. The indoor gait characteristics, outdoor time cost and energy consumption, and static balance of both groups were evaluated. Results After the indoor gait analysis, the average self-selected-speed of the amputees was 1.07 m/s, while the self-selected-speed of the normal people was 1.29 m/s. When the subjects walked with their self-selected-speed, there were significant differences in some of the gait spatial and temporal parameters between 2 groups (P<0.05). When the subjects walked on a specially designed 1 km outdoor trail, differences of energy consumption and time cost were also observed (P<0.05). Static balance presented no significant difference between 2 groups (P>0.05). Conclusion The walking ability of the bilateral transtibial amputees wearing prostheses is different from normal people. Quantitative evaluation of walking ability can provide more accurate reference for the rehabilitation of amputees.

Efficacy of removable rigid dressing after transtibial amputation in diabetes mellitus patients.

Background: The aim of this study was to evaluate the RRD’s efficacy in decreasing stump edema and pain compared to elastic bandage for diabetic mellitus patients after transtibial amputation. Methods: Interventional research was using consecutive sampling. Subjects were randomized into two groups: RRD and elastic bandage. Twenty-three subjects were analyzed. Stump edema volume was measured by the amount of water spilled out from volume glass. Elastic bandage was reapplied every 4 hours and RRD was refitted every 7 days during evaluation time. Stump edema volume was evaluated every 7 days during the 8 week observation. Results: There was a significant decrease of stump volume in RRD group during the first and second week (p = 0.03, p = 0.01) and the edema decreasing time was also significant (p = 0.03). The average decrease of edema volume in RRD was 63.85% of second week and in the elastic bandage group was 34.35%. There were a tendency of pain reduction time in RRD group (4.83 ± 1.95 weeks) compared to elastic bandage group (5.18 ± 2.31weeks). Cox regression result of decreasing edema volume time was 3.088 (CI 95%: 1.128 – 4.916). Conclusion: This study found that there was stump edema volume acceleration in RRD group, it was three times faster for stump to become not edematous compared to elastic bandage group. There was a tendency of faster decreasing stump pain in RRD group than elastic bandage group, eventhough this result was not statistically significant.

Clinical Results Comparing Transtibial Technique and Outside in Technique in Single Bundle Anterior Cruciate Ligament Reconstruction

PURPOSE: To compare the clinical results of single-bundle anterior cruciate ligament (ACL) reconstruction using the conventional transtibial technique and the anatomical outside-in technique for femoral tunneling. MATERIALS AND METHODS: From 2007 to 2011, 89 patients who received ACL reconstruction were followed for > or =1 year were enrolled in the study. The conventional transtibial technique was used in 41 patients and the outside-in technique, in 48 patients. Femoral tunnel angle measurement and three-dimensional computed tomography (3D CT) were used for radiologic assessment of the location of femoral tunnel and Lysholm score and other tests were used for clinical assessment. RESULTS: Both techniques did not reveal statistical differences in the clinical assessment. However, in International Knee Documentation Committee subjective knee evaluation, the sum of two questionnaire items regarding instability showed a statistically significant difference (p=0.01). In the pivot shift test, the anatomical outside-in technique showed outstanding rotational stability over the transtibial technique (p=0.04). The mean femoral tunnel inclination in coronal plane were 69.2degrees and 30.3degrees, respectively, for both techniques, and 21.6degrees and 50.8degrees, respectively in sagittal plane, showing statistically significant differences on simple radiography (p=0.04, 0.05). A 3D CT was performed in 17 patients with the conventional transtibial technique and 25 patients with the outside-in technique. Coefficients of variation were 0.33 and 0.13, respectively, from dorsal border of the condyle and 0.67 and 0.24, respectively, from the roof of intercondylar notch. CONCLUSIONS: Femoral tunnels created with the outside-in technique have superior knee joint rotational stability compare to the transtibial technique. Therefore, the outside-in technique could be considered as a valuable technique in single-bundle ACL reconstruction.

Evaluation of Femoral Tunnel Positioning Using 3-Dimensional Computed Tomography and Radiographs after Single Bundle Anterior Cruciate Ligament Reconstruction with Modified Transtibial Technique

BACKGROUND: The purpose of this study is to report a modified transtibial technique to approach the center of anatomical femoral footprint in anterior cruciate ligament (ACL) reconstruction and to investigate the accurate femoral tunnel position with 3-dimensional computed tomography (3D-CT) and radiography after reconstruction. METHODS: From December 2010 to October 2011, we evaluated 98 patients who underwent primary ACL reconstruction using a modified transtibial technique to approach the center of anatomical femoral footprint in single bundle ACL reconstruction with hamstring autograft. Their femoral tunnel positions were investigated with 3D-CT and radiography postoperatively. Femoral tunnel angle was measured on the postoperative anteroposterior (AP) radiograph and the center of the femoral tunnel aperture on the lateral femoral condyle was assessed with 3D-CT according to the quadrant method by two orthopedic surgeons. RESULTS: According to the quadrant method with 3D-CT, the femoral tunnel was measured at a mean of 32.94% +/- 5.16% from the proximal condylar surface (parallel to the Blumensaat line) and 41.89% +/- 5.58% from the notch roof (perpendicular to the Blumensaat line) with good interobserver (intraclass correlation coefficients [ICC], 0.766 and 0.793, respectively) and intraobserver reliability (ICC, 0.875 and 0.893, respectively). According to the radiographic measurement on the AP view, the femoral tunnel angles averaged 50.43degrees +/- 7.04degrees (ICC, 0.783 and 0.911, respectively). CONCLUSIONS: Our modified transtibial technique is anticipated to provide more anatomical placement of the femoral tunnel during ACL reconstruction than the former traditional transtibial techniques.

Three-Dimensional Reconstruction Computed Tomography Evaluation of Tunnel Location during Single-Bundle Anterior Cruciate Ligament Reconstruction: A Comparison of Transtibial and 2-Incision Tibial Tunnel-Independent Techniques

BACKGROUND: Anatomic tunnel positioning is important in anterior cruciate ligament (ACL) reconstructive surgery. Recent studies have suggested the limitations of a traditional transtibial technique to place the ACL graft within the anatomic tunnel position of the ACL on the femur. The purpose of this study is to determine if the 2-incision tibial tunnel-independent technique can place femoral tunnel to native ACL center when compared with the transtibial technique, as the placement with the tibial tunnel-independent technique is unconstrained by tibial tunnel. METHODS: In sixty-nine patients, single-bundle ACL reconstruction with preservation of remnant bundle using hamstring tendon autograft was performed. Femoral tunnel locations were measured with quadrant methods on the medial to lateral view of the lateral femoral condyle. Tibial tunnel locations were measured in the anatomical coordinates axis on the top view of the proximal tibia. These measurements were compared with reference data on anatomical tunnel position. RESULTS: With the quadrant method, the femoral tunnel centers of the transtibial technique and tibial tunnel-independent technique were located. The mean (+/- standard deviation) was 36.49% +/- 7.65% and 24.71% +/- 4.90%, respectively, from the over-the-top, along the notch roof (parallel to the Blumensaat line); and at 7.71% +/- 7.25% and 27.08% +/- 7.05%, from the notch roof (perpendicular to the Blumensaat line). The tibial tunnel centers of the transtibial technique and tibial tunnel-independent technique were located at 39.83% +/- 8.20% and 36.32% +/- 8.10%, respectively, of the anterior to posterior tibial plateau depth; and at 49.13% +/- 4.02% and 47.75% +/- 4.04%, of the medial to lateral tibial plateau width. There was no statistical difference between the two techniques in tibial tunnel position. The tibial tunnel-independent technique used in this study placed femoral tunnel closer to the anatomical ACL anteromedial bundle center. In contrast, the transtibial technique placed the femoral tunnel more shallow and higher from the anatomical position, resulting in more vertical grafts. CONCLUSIONS: After single-bundle ACL reconstruction, three-dimensional computed tomography showed that the tibial tunnel-independent technique allows for the placement of the graft closer to the anatomical femoral tunnel position when compared with the traditional transtibial technique.