Passive Mobilization With Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial.

PURPOSE: Mobilization after flexor tendon repair in fingers has been a subject of debate for several years. Many hand surgery clinics have turned to early active mobilization. However, there is no strong scientific evidence suggesting that early active mobilization produces a better range of motion (ROM) than the Kleinert regimen when place and hold is added. Therefore, the purpose of this prospective randomized trial was to investigate whether active mobilization is superior to passive mobilization with place and hold after flexor tendon repair in the fingers. Our hypothesis was that patients who follow the active mobilization protocol have a better ROM than those who follow the passive protocol with place and hold. METHODS: Sixty-four patients with a flexor tendon injury in zone I or II were included. After surgery, randomization to undergo either active mobilization or passive mobilization with place and hold was performed. The patients were followed-up for 12 months using outcome measurements, including ROM, strength, rupture frequency, Disabilities of the Arm, Shoulder and Hand score, ABILHAND questionnaire, and performance on the Purdue Pegboard test. RESULTS: We were unable to find any significant difference between the 2 groups for any of the outcome measurements, ROM, grip strength, key pinch, rupture frequency, Disabilities of the Arm, Shoulder and Hand score, ABILHAND questionnaire, and performance on the Purdue Pegboard test. CONCLUSIONS: The outcomes were equivalent for both the mobilization groups. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Open versus arthroscopic repair of the triangular fibrocartilage complex: a systematic review.

BACKGROUND AND PURPOSE: To investigate the outcome of open versus arthroscopic repair of injuries of the triangular fibrocartilage complex (TFCC). METHODS: An electronic literature search of articles published between January 1, 1985, and May 26, 2016, in PubMed, Embase, and the Cochrane Library was carried out in May 2016 and updated in March and December 2017. Studies comparing open and arthroscopic repair of TFCC injury with a mean follow up of more than 1 year were eligible for inclusion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the extraction and reporting of data. The methodological quality of the included articles was assessed with the Cochrane Collaboration's tool for assessing risk of bias. The primary outcome measure was the rate of postoperative distal radioulnar joint (DRUJ) re-instability. Secondary outcome measures were range of motion (ROM), grip strength, residual pain, functional wrist scores and the rates of complications and re-operations. RESULTS: A total of 868 articles were identified by the electronic search. After duplicate removal and subsequent study selection, a total of two studies were included in this systematic review. The methodological quality of the included articles displayed risks of bias. There was no difference in DRUJ re-instability between open and arthroscopic repair of the TFCC. There were no differences in obtained postoperative ROM, grip strength or values in functional outcome scores, between open and arthroscopic TFCC repair in the two included studies, except for the Disability of the Arm Shoulder and Hand (DASH) questionnaire - in favor of arthroscopic surgery - in one of the included studies. CONCLUSIONS: This systematic review shows comparable results between open and arthroscopic repair of the TFCC, in terms of DRUJ re-instability and functional outcome scores. There is insufficient evidence to recommend one technique over the other in clinical practice. There is an immense lack of comparison studies with high level of evidence in the area of wrist ligament repair and reconstruction, including TFCC-injuries and DRUJ-instability.

The Long-Term Outcome After Early and Late Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare long-term clinical and radiographic outcomes in patients undergoing either early (group A) or late (group B) surgery after anterior cruciate ligament (ACL) injury. METHODS: ACL reconstruction using hamstring tendon autografts was performed in 30 patients in group A (median age, 23 years; range, 17-49 years) and 31 patients in group B (median age, 27 years; range, 17-38 years). The patients in group A were operated on within 5 months (median, 3 months; range, 2-5 months) of injury, whereas those in group B were operated on more than 24 months (median, 30 months; range, 24-48 months) after injury. The follow-up period was 10 years (median, 117 months [range, 77-222 months] in group A and 129 months [range, 77-206 months] in group B; P = .44). Multiple objective clinical evaluation tests and patient-reported outcome measures were obtained preoperatively and at follow-up. At follow-up, radiographic assessments of knee osteoarthritis (OA) bilaterally were performed. RESULTS: The frequency of meniscectomy at the index operation was significantly lower in group A (20%) than in group B (52%) (P = .01). There were no significant differences between the groups in terms of Tegner and Lysholm scores and laxity tests both preoperatively and at follow-up. Both groups improved over time in terms of Tegner and Lysholm scores (P < .05). At follow-up, significantly more medial-compartment OA in the index knee was found in group B than in group A (P = .037) according to the Ahlbäck classification system. The index knee showed significantly more OA than the contralateral knee in both groups (P < .01). CONCLUSIONS: Patients who underwent early ACL reconstruction required significantly fewer meniscectomies at the index operation than patients who underwent late reconstruction and showed significantly less OA on the medial side of the knee 10 years after reconstruction. However, no significant differences were found between the groups in terms of clinical assessments. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Inflammatory cytokines and biomarkers of cartilage metabolism 8 years after anterior cruciate ligament reconstruction: results from operated and contralateral knees.

BACKGROUND: Patients who sustain an acute anterior cruciate ligament (ACL) rupture are at increased risk to develop posttraumatic arthritis (PTA) in the injured knee whether the ACL is reconstructed or treated nonoperatively. Inflammatory cytokines and cartilage degradation biomarkers are elevated at the time of acute injury and postoperatively. This suggests that one mechanism for PTA may be an inflammatory degradative process initiated on the acute injury and sustained for some length of time independent of whether adequate joint stability is restored. HYPOTHESIS: Inflammatory cytokines and biomarkers of cartilage degradation are elevated in the synovial fluid several years after reconstruction of the ACL, indicating an ongoing imbalance between extracellular matrix destruction and repair. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: In 11 patients who had undergone ACL reconstruction 8 years earlier, knee synovial fluid was aspirated from the operated knee and the contralateral nonoperated knee. The synovial fluid was analyzed for interleukin (IL)-1ß, IL-6, tumor necrosis factor (TNF)-α, sulfated glycosaminoglycans (sGAG), aggrecan neoepitope fragment (ARGS-aggrecan), and cartilage oligomeric matrix protein (COMP). At follow-up, the patients underwent bilateral weightbearing radiographs and bilateral MRIs of their knees. RESULTS: No significant differences between the operated and the contralateral knee were found for the synovial fluid concentrations of IL-1ß, IL-6, TNF-α, sGAG, ARGS-aggrecan, or COMP. There were significantly more radiographically visible osteoarthritic changes in the operated knees compared with the contralateral knees. MRIs revealed that all grafts and all contralateral ACLs were intact and, furthermore, that there was significantly more meniscal and cartilage damage in the index knees than the contralateral knees. CONCLUSION: Eight years after ACL reconstruction, there were no significant differences in inflammatory cytokines and biomarkers for cartilage degeneration between the nonoperated and the ACL-reconstructed knee, even though there were more osteoarthritic changes and meniscal and cartilage damage in the operated knee, as seen on weightbearing radiographs and MRI.

Histological Evaluation of Regenerated Semitendinosus Tendon a Minimum of 6 Years After Harvest for Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Semitendinosus (ST) and/or gracilis (G) autografts are the most used grafts for anterior cruciate ligament (ACL) surgery. The tendons have been shown to be able to regenerate but with focal areas of scar tissue in the short term. There are no long-term histological studies of the regenerated tendons. HYPOTHESIS: In the long term, the regenerated ST tendon normalizes and has a similar histology as the contralateral nonharvested tendon. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Eighteen patients (8 female, 10 male) who underwent ACL surgery using ipsilateral ST/G tendon autografts were included in this study. Percutaneous specimens were obtained from the regenerated ST tendon and the contralateral nonharvested ST tendon under ultrasonographic guidance at a median of 8.4 years (100.5 months; range, 77-129 months) after the harvest procedure. Specimens from the nonoperated side served as controls. The histology and presence of glycosaminoglycans (GAGs) were assessed using a light microscope and a semiquantitative grading system. RESULTS: Thirty-six biopsies were obtained (2 biopsies from each patient). In 5 biopsies, the amount of tissue was too small to analyze in the light microscope, and 1 patient had been operated on bilaterally and was therefore excluded. In total, 24 biopsies were included in the histological analysis. In overall terms, there were no significant differences between the regenerated and nonharvested ST tendon in terms of fiber structure, cellularity, vascularity, and level of GAGs a minimum 6 years after harvest of the ST tendon. However, 3 of the regenerated tendons displayed a loss of fiber structure. CONCLUSION: The ST tendon regenerates and may regain a histological appearance similar to that of the nonharvested contralateral tendon, as seen in this study a median of 8.4 years after harvesting. However, in some tendons, loss of fiber structure was found.

Bilateral magnetic resonance imaging and functional assessment of the semitendinosus and gracilis tendons a minimum of 6 years after ipsilateral harvest for anterior cruciate ligament reconstruction.

BACKGROUND: Previous studies are contradictory in terms of the function, regeneration potential, insertion point, and cross-sectional area of the semitendinosus and gracilis tendons after harvest for anterior cruciate ligament (ACL) reconstruction. HYPOTHESES: In the long term, the tendons will regenerate in most patients with a more proximal point of insertion, the cross-sectional area of the tendons will be smaller compared with the nonoperated contralateral side, and the patients will be weaker in terms of the internal rotation and deep flexion of the knee. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Nineteen patients (9 women and 10 men) who had undergone ACL reconstruction a minimum of 6 years earlier, median 8.5 years (range, 6-11 years), with ipsilateral semitendinosus and gracilis autografts, underwent bilateral magnetic resonance imaging (MRI) of their knees. An experienced, independent musculoskeletal radiologist evaluated all MRI examinations. To evaluate the function, strength measurements in deep knee flexion and internal rotation were performed using an isokinetic strength-testing machine. RESULTS: The semitendinosus tendon had regenerated in 17 of 19 (89%) patients and the gracilis tendon in 18 of 19 (95%) patients, as seen on MRI. There were no significant differences between the point of insertion for the tendons on the operated and nonoperated sides. The cross-sectional areas of the regenerated tendons revealed no significant differences compared with the normal tendons on the contralateral side, as measured 4 cm above the joint line. The patients were significantly weaker in terms of deep knee flexion at 60 and 180 deg/sec, but they were stronger in terms of internal rotation of the tibia at 60 deg/sec in the operated leg compared with the nonoperated leg. CONCLUSION: The semitendinosus and gracilis tendons regenerated in the majority of patients and regained an almost normal point of insertion on the pes anserinus a minimum of 6 years after harvest. The regenerated tendons had a cross-sectional area similar to that on the nonoperated contralateral side. The patients revealed a strength deficit in deep knee flexion but not in internal rotation.

A comparison of the clinical outcome after anterior cruciate ligament reconstruction using a hamstring tendon autograft with special emphasis on the timing of the reconstruction.

PURPOSE: The aim of the study was to compare the results 2 years after anterior cruciate ligament (ACL) reconstruction using a hamstring tendon (HT) autograft in patients operated within 5 months after the injury (Group A) and patients operated more than 24 months after the injury (Group B). METHODS: Sixty-one patients (27 women, 34 men), with a unilateral ACL rupture, underwent reconstructive surgery using semitendinosus (ST) or semitendinosus and gracilis (ST/G) autografts. Thirty patients (Group A) were operated on within 5 months median 3 (2-5) after the injury, and 31 patients (Group B) were operated on more than 24 months median 30 (24-48) after the injury. The follow-up examination was performed after a median of 25 months (18-43) after the reconstruction. RESULTS: A significantly higher Lysholm score was registered in Group A 90 (58-100) than in Group B 81 (38-100), P = 0.01, as well as a higher Tegner activity level 6 (2-9) versus 5 (0-9), P = 0.01. The clinical assessments revealed no significant differences between the groups in terms of the one-leg-hop test, KT-1000 arthrometer laxity measurements, manual Lachman test and range of motion (ROM). Furthermore, there was no significant difference between the groups in terms of meniscal and cartilage damage at the index operation. CONCLUSION: At 2 years post-operatively, patients who underwent subacute reconstruction had a significantly better outcome in terms of the Lysholm score and Tegner activity level than patients who underwent delayed reconstruction. The clinical relevance of the present study is that if the patient wishes to continue doing sports on a higher level, subacute reconstruction appears beneficial.