The effect of the KNEE program for Netball players on the modified Star Excursion Balance Test - a randomized controlled trial.

BACKGROUND: The aim was to investigate the effect of the KNEE program on postural control as measured by the modified Star Excursion Balance test (mSEBT) in Australian club level netball players. METHODS: Two netball teams from Netball NSW Premier-League were recruited and randomized to complete either the KNEE program or a traditional warm-up. Cumulative, anterior, posteromedial, and posterolateral directions of the mSEBT were measured for both limbs at baseline, 8-weeks, and 5-months. Linear mixed models were used to assess the effect of the intervention on mSEBT outcomes. RESULTS: When compared to a traditional warm-up, the KNEE program led to improvements in postural control in the PM direction of the mSEBT at 8 weeks (R: p = 0.005; L = 0.016) and 5 months (R: p = 0.006 and L: p = 0.026). For the cumulative score, there was a main effect of time with significant improvements between baseline and subsequent time points (p < 0.03), but there was no effect of group or interaction. No significant changes were found in ANT and PL directions. CONCLUSION: The KNEE program when implemented as a warm-up prior to training and match-play can improve postural control in the PM direction which is integral to Netball.

Delivering Load-Modifying Gait Retraining Interventions via Telehealth in People With Medial Knee Osteoarthritis: A Pilot Randomized Placebo-Controlled Clinical Trial.

We aimed to investigate the effects of delivering 3 gait retraining interventions (toe-in, toe-out, and placebo gait) on proxy measures of medial knee load (early- and late-stance peak knee adduction moment [KAM], KAM impulse, and varus thrust) in people with knee osteoarthritis, using a hybrid model of face-to-face and telehealth-delivered sessions over 5 months. This was an originally planned 3-arm randomized placebo-controlled clinical trial. However, during the 2021 COVID-19 outbreak and lockdown in Sydney, Australia, the study became a pilot randomized controlled trial with the remainder of interventions delivered via telehealth. Nine individuals with symptomatic medial knee osteoarthritis were allocated to receive either a toe-in, toe-out, or posture re-education (placebo) gait retraining intervention. Primary outcomes of early- and late-stance peak KAM, KAM impulse, and varus thrust were assessed at baseline and follow-up. Eight participants returned for their follow-up gait assessment. Participants in both active intervention groups (toe-in and toe-out) achieved foot progression angle changes at follow-up. Overall, knee biomechanics in the placebo group did not change at follow-up. It is possible to achieve biomechanical changes in individuals with medial knee osteoarthritis when delivering gait retraining interventions via a hybrid model of face-to-face and telehealth.

In Vitro Evaluation of Vancomycin-Induced Toxicity in Human Primary Knee Chondrocytes.

Septic arthritis as a complication of orthopaedic joint surgery can have catastrophic outcomes for patients. To minimise infection risk associated with elective orthopaedics, topical vancomycin during surgery has become increasingly common. Evidence suggests that high concentrations of vancomycin, following direct application of the drug to the joint, are toxic towards various local cell types in the joint, including chondrocytes. However, the mechanism of this vancomycin tissue toxicity is yet to be determined. The aim of this study was to evaluate the toxicity of vancomycin on chondrocytes and the mechanisms of cell death involved. Human primary knee chondrocytes were exposed to vancomycin (1.25-10 mg/mL) for 24 h and their viability assessed using the resazurin reduction assay in vitro. Specific cell death mechanisms and their contributors, including reactive oxygen species (ROS) production and apoptosis, were measured. This study showed that high concentrations of vancomycin (5 and 10 mg/mL) were toxic towards human primary knee chondrocyte cells, while lower concentrations (1.25 and 2.5 mg/mL) were not. Cell death studies found that this occurred through an apoptotic pathway. This study provides additional support that vancomycin in high doses is toxic towards chondrocytes and preliminary evidence that this toxicity occurs via apoptotic cell death mechanisms.

Toe-in and toe-out gait retraining interventions to reduce proxy measures of medial knee joint load in people with medial knee osteoarthritis: Protocol for a randomised placebo-controlled trial.

OBJECTIVE: Our primary aim is to determine the effect of a six-week toe-in, toe-out and active placebo gait retraining program on proxy measures of medial knee joint load and varus thrust in people with medial knee osteoarthritis. Our secondary aim is to determine the intervention effects on patient reported outcomes and physical function and determine if changes are maintained at three-months follow-up. METHODS: We will conduct a three-arm randomised placebo-controlled trial. Ninety participants with medial knee osteoarthritis will be randomised and stratified via varus thrust status (presence/absence) to: toe-in, toe-out or placebo gait retraining (an intervention that does not change proxy measures of medial knee joint load). The intervention involves weekly clinician-supervised sessions with biofeedback, knee osteoarthritis education, motor learning and behaviour change principles, and daily gait retraining practice. Primary outcomes are proxy measures of medial knee joint load: knee adduction moment (early- and late-stance peaks and impulse), and varus thrust (presence/absence). Secondary outcomes include pain, physical function, medication and health care utilisation, quality of life, work ability, treatment blinding, intervention credibility and other biomechanical outcomes. Assessment timepoints are at baseline, six weeks (post intensive training), and three-months following the six-week intervention. CONCLUSION: Our trial will determine whether toe-in or toe-out gait retraining is most effective at reducing proxy measures of medial knee joint load and varus thrust in people with medial knee osteoarthritis. This study will also evaluate if toe-in or toe-out gait retraining interventions are superior at improving pain, physical function and quality of life compared to placebo. CLINICAL TRIAL REGISTRATION: This clinical trial protocol is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12621000414819).

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries.

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

Relationship Between Knee Biomechanics and Pain in People With Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

OBJECTIVE: Our primary aim was to determine the cross-sectional relationship between knee biomechanics during gait and pain in people with medial knee osteoarthritis. Our secondary aim was to evaluate differences in knee biomechanics between symptomatic and asymptomatic participants with medial knee osteoarthritis. METHODS: Four online databases were searched from inception to July 2021. Eligible studies included people with medial/nonspecific knee osteoarthritis and a reported relationship between knee biomechanics during gait and pain or biomechanics of symptomatic and asymptomatic participants. Two reviewers independently extracted data and evaluated risk of bias. Random-effects meta-analyses were performed when three or more studies reported the same biomechanical variable for pooling (knee adduction moment [KAM], KAM impulse, varus thrust, and peak knee flexion moment [KFM]). RESULTS: Forty studies were included. Methodological quality ranged from 4 to 9/10. Forty-seven unique biomechanical variables were reported. For the KAM, there was no correlation with pain for peak values pooled (early stance and overall) (r = 0.00, 95% confidence interval [95% CI]: -0.12, 0.11, k = 16), a small negative correlation for early stance peak alone (r = -0.09, 95% CI -0.18, -0.002, k = 12), and a medium positive correlation for the overall peak during stance (r = 0.30, 95% CI 0.17, 0.42, k = 4). Metaregression identified that body mass index moderated the peak KAM-pain relationship (P < 0.001). KAM impulse had a small positive correlation with pain (r = 0.23, 95% CI 0.04, 0.40, k = 5), and people with varus thrust had 3.84 greater odds of reporting pain compared with people without (95% CI 1.72, 8.53, k = 3). Meta-analyses for the peak KFM and pain correlation and secondary aim were nonsignificant. CONCLUSION: Some knee gait biomechanics were associated with pain in this cohort. Longitudinal studies are required to determine causality.

Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000-2015.

OBJECTIVES: To investigate the incidence and demographic features of anterior cruciate ligament (ACL) reconstructions in Australia by age and sex, and to determine whether the incidence has changed during the past 15 years. DESIGN AND SETTING: Descriptive epidemiological analysis of longitudinal data on ACL reconstructions (July 2000 - June 2015) in the National Hospital Morbidity Database. MAIN OUTCOME MEASURES: Population ACL reconstruction rates, by age group and sex. RESULTS: 197 557 primary ACL reconstructions were performed during the study period; the annual incidence increased by 43% (from 54.0 to 77.4 per 100 000 population), and by 74% among those under 25 years of age (from 52.6 to 91.4 per 100 000 population). In males, the peak incidence in 2014-15 was for 20-24-year-olds (283 per 100 000 population); for females, it was for 15-19-year-olds (164 per 100 000 population). Annual growth in incidence was greatest in the 5-14-year-old age group (boys, 7.7%; girls, 8.8%). Direct hospital costs of ACL reconstruction surgery in 2014-15 were estimated to be $142 million. The annual incidence of revision ACL reconstructions increased from 2.49 (2000-01) to 5.65 per 100 000 population (2014-15), or by 5.6% per year; revisions as a proportion of all ACL reconstruction increased from 4.4% to 6.8%. CONCLUSIONS: The increasing incidence of ACL reconstructions in young Australians over 15 years is worrying. The individuals at greatest risk are men aged 20-24 years and women aged 15-19 years; the rate of reconstruction is increasing most rapidly among those aged 5-14 years. Revision rates are increasing more rapidly than those of primary reconstructions.

A Technique of Improved Medial Meniscus Visualization by Anterior Cruciate Ligament Graft Placement in Chronic Anterior Cruciate Deficient Knees.

It is customary to perform medial meniscus repair before anterior cruciate ligament (ACL) graft placement when undertaken as a combined procedure. However, in chronic ACL-deficient knees, intraoperative anterior tibiofemoral translation can cause the medial meniscus repair to be more technically challenging. Intraoperative anterior tibiofemoral translation can both reduce the visualization of the medial meniscus and make its reduction unstable. An operative sequence alteration of ACL graft placement and tensioning before medial meniscal repair improves medial meniscus visualization in chronically ACL-deficient knees by using the ACL graft's ability to prevent anterior tibiofemoral translation. The technique sequence is as follows: (a) the medial meniscus is reduced, (b) ACL reconstruction is undertaken using a hamstring graft without final tibia fixation,

No infections in 1300 anterior cruciate ligament reconstructions with vancomycin pre-soaking of hamstring grafts.

PURPOSE: To investigate the pre-soaking of hamstring grafts in topical vancomycin, in addition to IV prophylaxis, during anterior cruciate ligament (ACL) reconstruction to reduce the incidence of post-operative infection, and to describe an evidence-based diagnostic and treatment algorithm to facilitate early diagnosis and appropriate management of possible knee sepsis post-operatively after ACL reconstruction. METHODS: This study is a controlled observational series comprising of 1585 individuals who underwent ACL reconstruction over a 13-year period. All surgeries were performed by a single surgeon at the same hospital. Group 1 consisted of 285 patients who received pre-operative IV antibiotics without topical graft pre-soaking. Group 2 consisted of 1300 individuals who received IV antibiotics and graft pre-soaking in a vancomycin solution of 5 mg/mL. RESULTS: In group 1, a total of four patients suffered a post-operative joint infection (1.4 %). Three out of the four were culture positive for Staphylococcus species. The fourth was culture negative but was managed as an acute infection. Group 2 suffered no post-operative infections (0 %). Statistical analysis of the vancomycin pre-soak with IV antibiotics group, compared with IV antibiotics-alone group, revealed a significantly reduced post-operative infection rate using a Fisher's exact test (P = 0.0011) and Chi-square test with Yates' correction (P = 0.0003). CONCLUSIONS: Pre-soaking of hamstrings grafts with topical vancomycin reduced the rate of post-operative infection when compared to IV antibiotics alone. This technique should be utilised by surgeons to reduce the overall incidence of knee sepsis post-ACL reconstruction. LEVEL OF EVIDENCE: III.

Spinal manual therapy produces rapid onset analgesia in a rodent model.

A rapid hypoalgesic effect following spinal manual therapy (SMT) has been demonstrated in humans. Although the characteristics of the pain relief are well described, the mechanisms have remained speculative. The purpose of this suite of studies was to investigate the effects of SMT on pain measures using animal models. This study employed a randomized, controlled design. Study 1: Rats without inflammation were allocated to either a treatment group (n = 6) that received three applications of joint mobilization centrally over L5 or a sham-treated group (n = 6) who received non-specific handling. Pressure pain threshold (PPT) and thermal pain threshold (TPT) were measured before and immediately after each intervention. Results demonstrated significantly increased mechanical nociceptive thresholds in the SMT group (p = 0.01) compared to that of the sham-treated group but no difference for thermal nociceptive thresholds. Study 2: The time course effect of an inflammatory and mechanical response following i.pl injection of inflammatory mediators was investigated to determine the appropriate time period for a treatment intervention. Study 3: The effects of SMT on mechanical nociception were investigated following interplanar injection of inflammatory mediators into the right hind paw of rats as a pain model (n = 6 for both SMT and sham-treated groups). Injection of endogenous metabolites produced significant swelling and flaring as well as increased PPT values following SMT (p < 0.02) compared with controls. These results demonstrate a rapid analgesic response following application of SMT, which has similar characteristics as that seen in both symptomatic and asymptomatic human populations.

A surgical technique using presoaked vancomycin hamstring grafts to decrease the risk of infection after anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to investigate whether presoaking hamstring graft with a dilute antibiotic solution provides a potential new tool to improve measures to prevent joint infection. METHODS: This is a retrospective analysis of data that were prospectively collected for 1,135 consecutive patients who underwent anterior cruciate ligament reconstruction (ACLR) during a 7-year period. In the initial 3-year period, 285 patients (group 1) underwent ACLR with a hamstring autograft with preoperative intravenous (IV) antibiotics. In the subsequent 4-year period, 870 patients underwent ACLR with a vancomycin-presoaked hamstring autograft (group 2) with preoperative IV antibiotics. Presoaking involved wrapping hamstring tendon autografts in a sterile gauze swab, which had been previously saturated with 5-mg/mL vancomycin solution. RESULTS: In group 1 a total of 4 postoperative joint infections were documented (1.4%). Each case showed increasing pain and effusion, as well as a high intra-articular white blood cell count and increased C-reactive protein level. Of the 4 infected cases, 3 cultured coagulase-negative Staphylococcus (Staphylococcus epidermidis). The fourth case was treated as a postoperative infection despite a negative culture and responded to arthroscopic washout and IV antibiotics. In group 2 no infections (0%) were recorded, and no investigatory washouts occurred. The difference was statistically significant. Known failures were similar in each group. CONCLUSIONS: Prophylactic vancomycin presoaking of hamstring autografts statistically reduced the infection rate in this series compared with IV antibiotics alone. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The in vitro elution characteristics of vancomycin from tendons.

BACKGROUND: Infection after ACL reconstruction is uncommon but catastrophic. Prophylactic graft saturation in vancomycin reportedly reduces infection rates. QUESTIONS/PURPOSES: We characterized vancomycin elution from soaked tendons. Specifically, the effect of rinsing was studied. We also determined how vancomycin concentration in the soak solution and tendon dimension influenced this elution rate, and examined whether the vancomycin amount released was lower than osteoblast and chondroblast toxic concentrations. METHODS: Bovine tendons were wrapped in sterile gauze swabs presoaked with 5-, 2.5-, or 1.25-mg/mL vancomycin solutions. After 10 minutes, rinsed and unrinsed tendons were placed in 100 mL agitated 37 °C phosphate-buffered saline (PBS). One-milliliter samples taken at 10 minutes and 1, 6, 12, 24, and 72 hours were analyzed by high-performance liquid chromatography. RESULTS: The maximum elution rate occurred between 10 minutes and 1 hour, with no lag between experiment initiation and drug appearance in the solution. Rinsing affected the initial amount in solution but had little influence on drug release after 10 minutes. Vancomycin diffusion rates were dependent on soak solution concentration at all sampling intervals. The vancomycin amount released or eluted did not increase after the 1-hour interval. At 24 hours, concentrations were 45 ± 12, 16 ± 1, and 9 ± 3 µg/mL for the 5-, 2.5-, and 1.25-mg/mL solutions, respectively. Higher elution rates were observed in larger-volume tendons. CONCLUSIONS: Soaked tendon grafts can act as reservoirs for vancomycin, with the amount released and elution profile dependent on rinsing, tendon volume, and soak solution concentration. Vancomycin elution was lower than previously reported osteoblast and chondroblast toxicity concentrations and above the minimum inhibitory concentration for Staphylococcus. CLINICAL RELEVANCE: Presoaking ACL reconstruction autografts with vancomycin may reduce the risk of ACL reconstruction infection without the risk of local or general toxicity.