Background:. Total knee replacement (TKR) is a frequent and effective surgery for knee osteoarthritis. Postoperative pain is under concern and can be relieved by different methods, including femoral nerve block (FNB). The efficacy of FNB on pain relief was associated with the absence of clinical impact when measured with the range of motion (ROM). Recent studies suggest that the quadriceps strength is the best indicator of functional recovery after TKR. The goal of this study is to compare the quadriceps strength recovery after TKR according to the kind of analgesia (patient control analgesia (PCA) with or without FNB) Hypothesis: the FNB delays the QSR at short and mid-term follow-up. Methods:. Prospective randomized trial with single-blind assessment involving 135 patients admitted for TKR in an academic center. Randomization into one of the three following groups: A) Continuous FNB 48h + PCA B) Single-shot FNB and PCA C) PCA alone. Groups were comparable for demographic and surgical data. The FNB was realised and controlled (electric stimulation) by an expert anesthesiologist before the surgery. Follow-up standardised in all groups with blinded assessors. Quadriceps strength measured with a validated dynamometer at 6 weeks, 6 and 12 months. Secondary outcomes included clinical evaluation (ROM, pain, stability) and functional scores (SF-36 v2, WOMAC). Multivariate analysis (Kruskal-Wallis, Mann-Whitney) for main outcomes and Spearman factor for correlation. Sample size calculated for alpha 5% and study power 80%. Results:. 111 patients available for 6 weeks follow-up (A-B-C:40-38-33) and 104 (36-36-32) at 6 and 12 months. Two patients in group B excluded for direct fall in the first postoperative week with extensor mechanism rupture and peri-prosthetic femoral fracture. QSR is significantly decreased in patients with FNB at all times (mean, 95% IC): 6 weeks (A 51.3%, 44.1–58.5; B 62.2%, 55.2–69.2; C 77.4%, 70.7–84.1; p < 0,05), 6 months (A 65.4%, 57.9–72.9; B 82.1%, 74.2–90; C 95.7%, 88.5–102.9; p < 0,05) and 12 months (A 87.8%, 82.1–93.5; B 97.8%, 89–106.6; C 104.8%, 96.1–113.5; p < 0,05). No significant difference between continuous or single-shot FNB. Higher ROM in group C at all times (p 6 weeks = 0,046; p 6 months = 0,159; p 12 months = 0,026). No correlation between ROM and QSR (rho = 0,07; p = 0,23). Better functional results in the group C at all times (p < 0,05), with good correlation to QSR (rho = 0,177; p = 0,032). Slight difference in analgesic effect of FNB (p = 0,14). Conclusion:. Femoral nerve block has a negative influence on QSR at short and mid-term follow-up and delays the rehabilitation after TKR. QSR is actually the most sensitive indicator of functional recovery after TKR and is better related to functional tests than ROM. This can explain the harmlessness of FNB in previous studies. FNB should not yet be recommended for analgesia after TKR

Our study is still in progress. The results mentioned in the abstract are preliminary results. The final results will be provided at the time of presentation.

Over the past decade, the widespread availability of high-resolution ultrasonography coupled with advances in regional anaesthesia have popularised peripheral nerve blocks for anterior cruciate ligament reconstructions (ACLRs). The aim of this study is to investigate whether the femoral nerve block (FNB) administered at the time of ACLR has any long-term impact on the quadriceps strength as compared to patients who did not receive a FNB.

This is a retrospective study. Four hundred charts of patients who underwent ACLR at our institution and had subsequent Biodex testing (an isokinetic rehabilitation test that provides objective information about muscle strength deficits and imbalances of the operated leg compared to the non-operated leg) from 2004 to 2015 were reviewed. Patients who had prior ipsilateral knee surgery, multi-ligament knee injury or at extreme ages were excluded from the study. The following baseline patient characteristics was recorded for each reviewed chart: age, sex, medical comorbidities, the date of the injury, date of the surgery, surgery technical notes and associated procedures, the surgeon, the hospital were the patient was operated, the Biodex test date and the Biodex test results. Data extraction assessed any association between the ACLR patients' who received FNB with the results of the Biodex test after completing the rehabilitation protocol. Descriptive statistics were used to compare the type of anaesthesia, mode of pain control and the results of the Biodex tests between patients grouped by the mode of anaesthesia used at the time of surgery (FNB versus no FNB). A multivariate regression model then compared quadriceps strength (inferred by Biodex test results) between groups while controlling for baseline differences between groups.

Fifty five percent of the ACLR patients received FNB compared to 45% that did not receive FNB over the last 11 years of performing ACLRs (2004–2015) at our institute. Fifty percent of the patients that received FNB failed to achieve more than or equal to 80% quadriceps strength (compared to the contralateral non-operated leg) at 6 months on Biodex test. On the other hand, only 20% of the non-FNB group failed to achieve more than or equal to 80% quadriceps strength.

This study lead us to think that ACLR patients that received FNB are significantly weaker in quadriceps strength at 6 months post ACLR in comparison to non-FNB ACLR patients. This finding subsequently might affect the time needed to return to sports and might indicate a considerable clinical consequence of the FNB on ACL-reconstruction patients.

Background

Most of contemporary total knee systems address on improving of range of motion and bearing materials. Although new total knee designs in most systems accommodated the knee morphology according to gender differences, reestablishing of the same anterior offset of the distal femur during total knee arthroplasty (TKA) has not been well addressed. Furthermore, in most total knee systems, the anterior offset of the femoral component is constant regardless of the increment of the femoral size. We hypothesized that change of the anterior offset of the distal femur during TKA might affect the quadriceps strength and immediate clinical outcomes which may result in improved design of the future femoral component.

Long term quadriceps strength defictis have been reported after a TKA performed with a quadriceps splitting approach. Will an MIS-TKA performed with a mini midvastus approach significantly improve long term quadriceps strength retention?

147 subjects were chosen in a retrospective manner for this study. 52 MIS-TKA, 48 quadriceps splitting TKA, and 47 controls with normal knees and no prior surgery. All groups were age and gender matched. All knees were tested more than 1 year after the index operation on a Cybex isokinetic dynamometer. All surgeries were performed by the author.

The average Knee Society knee score for the MIS-TKA group was 94.3 and the average age was 71. The quadriceps splitting group had an average knee score of 95.7 and an average age of 72. The control group had an average age of 70. All groups averaged 38% male and 62% female. At 30 degrees from full extension the MIS-TKA group retained 96.6% of the control group strength and the quadriceps splitting group 94.5%. At 15 degrees from full extension the MIS-TKA group improved to 99.7% while the quadriceps splitting group fell to 85% of the control group strength.

MIS TKA with a mini midvastus approach preserves terminal quadriceps strength better than a standard quadriceps splitting approach.

Introduction and Aim. Quadriceps strength is crucial for physical function in patients with knee osteoarthritis (KOA). This study aimed to investigate the effect of combining blood flow restriction (BFR) with low-intensity training (LIT) on quadricep strength in patients with advanced KOA. Methods. Patients with advanced KOA were block randomized by gender into the control or BFR group. The control group received LIT with leg press (LP) and knee extension (KE) at 30% of 1-repetition maximum (1-RM), while the BFR group underwent the same training with 70% limb occlusion. Physical function and patient-reported outcomes were assessed up to 16 weeks. Results. A total of 42 patients were analyzed: 22 in the BFR group (9 males, 13 females) and 20 in the control group (8 males, 12 females). In the BFR group, males exhibited increased KE power from the 4th to the 16th week (p<0.05) and LP power from the 4th to the 12th week (p<0.05). Females in the BFR group showed increased KE power in the 4th and 12th weeks (p<0.05), and LP power increased from the 4th to the 16th week (p<0.05). Males also had improved TSS at the 12th week, while females had improved TSS from the 8th to the 16th week. In the control group, males did not experience an increase in quadricep power. Females, however, had increased KE power in the 4th, 12th, and 16th weeks (p<0.05), and LP power from the 4th to the 12th week (p<0.05). Females in the control group also had improved TSS at the 4th week. Patient-reported outcomes did not differ, and all patients tolerated the training without any dropouts or adverse events. Conclusion. Combining BFR with LIT significantly improved quadricep power and physical function in both genders of KOA patients without exacerbating symptoms

Anterior cruciate ligament reconstruction has become a standard procedure with a documented good and excellent outcome of 70–90%. It has been demonstrated by previous research that all patients following surgery demonstrate a strength deficit of almost 20%. However it is not known whether these strength deficits have an influence on postoperative functionality. 52 consecutive patients (38 males and 14 females) were selected (mean age 27.9 years). All subjects were tested prior and 12 month following anterior cruciate ligament reconstruction. Muscle strength was assessed using a Biodex dynamometer. Isometric strength was examined at 30 and 60 degrees of flexion. Isokinetic testing was performed at 180 degrees/sec and peak torque and symmetry indices were analysed. No correlations were found between the Cinncinnati Score and isokinetic peak torque for extension. A moderate significant (p=0.001–0.007) correlation (r=0.200.45) was found for peak flexion torque in ACL reconstructed patients. In ACL deficient patients symmetry indices (r=0.36–0.43, p=0.001–0.004) were moderately related to functionality for both flexion and extension. Quadriceps muscle strength does not seem to be an important predictor of knee function after ACL reconstruction. Flexors seem to be important to protect the graft from overload. In ACLD knees functionality is related to high symmetry indices suggesting similar strength is necessary to perceive knee function as near normal. This is possibly a normal neuromuscular adaptation caused by contralateral quadriceps avoidance

Introduction. A total knee replacement is a proven cost-effective treatment for end-stage osteoarthritis, with a positive effect on pain and function. However, only 80% of the patients are satisfied after surgery. It is known that high preoperative expectations and residual postoperative pain are important determinants of satisfaction, but also malalignment, poor function and disturbed kinematics can be a cause. The purpose of this study was to investigate the correlation between the preoperative function and the postoperative patient reported outcomes PROMs) as well as the influence of the postoperative functional rehabilitation on the PROMs. Methods. 57 patients (mean 62,9j ± 10,6j), who suffer from knee osteoarthritis and who were scheduled for a total knee replacement at our centre, participated in this study. The range of motion of the knee, the muscle strength of the M. Quadriceps and the M. Hamstrings and the functional parameters (‘stair climbing test’ (SCT), ‘Sit to stand’ (STS) and ‘6 minutes walking test’ (6MWT)) were measured the night before surgery, ±6 months and ±1 year after surgery. This happened respectively with the use of a goniometer, HHD 2, stopwatch and the ‘DynaPort Hybrid’. Correlations between pre- and postoperative values were investigated. Secondly, a prediction was made about the influence of the preoperative parameters on on the subjective questionnaires (KOOS, OXFORD and KSS) as well as a linear and logistic regression. Results. 6 Months after surgery, an improvement of all parameters for ROM, muscle strength and functional status was found. With a significant difference for the active and passive ROM toward knee flexion (p=0.007;p=0.008), asymmetry in active and passive ROM toward flexion between the healthy leg and the leg with the TKA (p=0.001;p=0.001), Quadriceps- and Hamstrings strength (p=0.001;p<0.001), time of the STS test (p=0.012), time sit-stand (p=0.002), time stand-sit (p=0.001;p<0.001), all parameters for the 6MWT and the time of the SCT (p=0.001). Regarding the prediction model, the 6month PROMs can be predicted by some parameters for the 6MWT (distance (p=0.001), gait steps (p=0.002) and step time TKA (p=0.007)). These parameters are predictors for the score on the subscales ‘symptoms’ and ‘pain’ of the KOOS questionnaire. 1 Year after surgery, there is an improvement of all parameters, except for the active and passive ROM toward knee extension. However, these differences are not significant. The 1 year PROMs can only be predicted by the muscle strength (Quadriceps- and Hamstrings strength (p=0.026; p=0.039) and the asymmetry in Quadriceps strength between the healthy leg and the leg with the TKA (p=0.031)). The score on the subscale ‘pain’ can be predicted based on the parameters mentioned above. Conclusion. Patient satisfaction after TKA is a multivariate model. Regarding the functional outcome, we could find that there is a correlation between the muscle force, walking distance and the PROMs. More research is currently being done to create a better prediction model and investigate the correlations more thoroughly

This multicenter study compared computer-navigated TKA using either MIS or conventional surgical technique, using a CR fixed bearing knee, Stryker Navigation system and dedicated MIS instrumentation. It was hypothesized that patients would benefit from the MIS technique by shorter recovery periods, less blood loss, faster wound healing and improved mobility during early rehabilitation. A prospective multicentre double-blind controlled trial included 69 patients matched for age, gender, BMI (MIS n=36, CONV n=33). Assessments at pre-op, 1 week, 3 and 6 months post-op included surgery time, bloodloss, range of motion, Knee Society Score (KSS) and WOMAC, Chair rise test and quadriceps strength. Radiographic analysis included radiographs for lucencies and CAT scans for alignment,. Four patients were lost to follow-up. The MIS group had significantly more prolonged surgery time and blood loss at 24 hours p<0.05. At 6 months mean flexion values for MIS (106,7°±12,91) and CONV 105,92 ±11,58) with no significant differences in flexion ROM between both groups at any time point. KSS scores showed a significant improvement (p<0,01) over time in both groups but no statistical significance between groups. WOMAC score also improved significantly (p<0,01) over time in both groups without reaching statistical significance. A significant decrease of anterior knee pain score was observed over time with no significant difference between both groups. Quadriceps strength recovery was not significant between groups but trended toward faster recovery in the MIS group. X-rays showed stable implants with no progressive radiolucent lines in all patients. The hypothesis that patients benefit from the MIS technique in the short term was not confirmed by the results of this study. The MIS surgery technique resulted in more blood loss intra-op and in the first 24hours post op as well as an elongated surgery time. The MIS surgery technique also failed to generate clear advantages in clinical or functional outcome that persisted over time

ACL injured patients show variability in the ability to perform functional activities (Button et al., 2006). It is unknown whether this is due to differences in physical capability or whether fear of re-injury plays a role. Fear of re-injury is not commonly addressed in rehabilitation. This study aimed to investigate whether fear of re-injury impacts rehabilitation of ACL injured patients. An initial group of five ACL reconstructed participants (ACLR, age: 30±11 years, weight: 815±115 N, height: 1.74±0.07 m, all male), five ACL deficient participants (ACLD, age: 31±12 years, weight: 833±227 N, height: 1.80±0.11 m, four male and one female), and five healthy controls (age: 30±3 years, weight: 704±126 N, height: 1.70±0.09 m, three male and two female) were compared. Fear of re-injury was assessed using the Tampa Scale for Kinesiophobia (Kvist, 2004). Quadriceps strength was measured on a Biodex dynamometer. Functional activity was assessed by a single legged maximum distance hop (on the injured leg for ACL patients). Motion analysis was performed with a VICON system, and a Kistler force plate. Hop distance was calculated using the ankle position. The peak knee extension moment during landing, and the knee angle at this peak moment were calculated in VICON Nexus. The ACLD group scored worse on the Tampa scale for Kinesiophobia than the ACLR group (32±4 and 26±4). The ACLD patients did not hop as far as the ACLR and control groups (1.0±0.3, 1.3±0.1 and 1.4±0.3 m). The peak knee extension moments during landing were lowest in the ACLD group (263±159 Nm), slightly higher in the control group (354±122 Nm) and highest in the ACLR group (490±222 Nm), while knee flexion angles at these moments were similar (ACLD: 28±11, ACLR: 33±7 and control: 36±13 degrees). The ACLD group had weaker quadriceps than the control group, while the ACLR group was stronger (143±44 Nm, 152±42, and 167±50 Nm respectively). Fear of re-injury and decreased quadriceps strength potentially both impact on the functional performance of ACL injured patients. Rehabilitation of ACL injured patients could therefore be improved by addressing strength and fear of re-injury. Future research with more participants will further clarify this

Purpose: To present our clinical and quality of life outcomes after one year treatment with our protocol including graft retention. Method: Seventeen of 1, 847 patients who underwent ACL reconstruction surgery were identified as infected following retrospective chart review in our institution (University of Ottawa) from 1995 to 2005. Mean age was 37 years old (range 18–56). Gender ratio was 14 male/ three female. Laterality 13 left/ four right knees. The diagnosis was achieved by clinical suspicion and serum markers (ESR, CPR, WBC) followed with aspiration and culture of intraarticular liquid. After that, our treatment protocol included IV antibiotics (empiric and culture guided) and knee arthroscopy performing debridement and lavage with 12L of saline irrigation as well as graft retention when possible. Clinical and Radiographic data were collected at a minimum of one year follow-up (IKDC, KT-1000, Lysholm, SF-12, Tegner, Cybex Strength testing). Results: The Incidence of septic arthritis following ACL reconstruction was 0, 92%. Bacteriology results were as follows: seven staphylococcus aureus, four Propionibac-terium acnes, one Klebsiella oxytoca, five no growth. The time from ACL reconstruction to first symptoms of infection was 37 days (range 4–63). The time from symptoms to arthroscopic debridement was 5, 5 days (range 0–33). Serology markers were as follows: ESR mean 69 (range 23–128), CPR 136 (50–387), WBC 10.3 (6–15). The average follow up was 41 months (range 12–85). Sixteen of 17 grafts were retained after 1.53 procedures per patient. Antibiotic treatment lasted 5.2 weeks on average. The average clinical outcomes were: Lysholm 77 (44–98), IKDC 74 (46–95), Quadriceps strength 71 % of non operative side, and Hamstrings strength 70 % of non operative side, KT -1000 side to side difference 1 mm (−3 to 4). Degenerative radiological changes were noted in three patients. Two later repeat reconstructions occurred due to instability (11,1%). No delayed recurrence of infection was noted. Conclusion: ACL reconstruction is a safe procedure being the incidence of septic arthritis in our series of 0, 92%. Our protocol of treatment is clinically effective and allows for a stable knee in 88, 9% of the patients avoiding the appearance of a delayed infection

Introduction Following any intraarticular fracture, joint range of movement and muscle strength recovery are vital factors in patient’s return to activities. Quadriceps weakness is a known complication of any injury affecting the knee. The purpose of this study was to investigate the recovery of knee ROM and quadriceps and hamstrings muscle strength in the first year after tibial plateau fracture and to assess factors that affect the recovery. Method 63 patients were recruited over a 5-year period. Data regarding the age and sex of the patient, the mechanism of injury, the grade of the fracture according to Shatzker’s classification and the treatment received were recorded. All patients underwent a standard rehabilitation regime. At 3, 6 and 12 months after injury the patients were seen by a research physiotherapist. The range of movement was recorded. Thigh muscle peak torque was measured using isokinetic dynanmometry. The uninjured limb was used as the control – the peak torque in the injured limb was expressed as a percentage of the value in the uninjured limb to give the percentage recovery in the injured limb. Results There was an initial extension deficit of 7° at 3 months, which improved to 3° at 12 months. Quadriceps strength recovery lagged behind that in the hamstrings at all times and only achieved only 77% at 12 months, compared to 90% in the hamstrings (p< 0.001). Patients under 40 outperformed those over 40 at each time point. At 12 months under 40s had achieved 85% recovery in their quadriceps, while over 40s only reached 74% (p< 0.01). Patient sex, mechanism of injury and grade of fracture had no effect on the level of recovery in this study. Conclusion Patients who sustain a tibial plateau fracture have a residual small extension deficit and objective quadriceps weakness at 1 year post injury. Patient age has a significant effect on the level of quadriceps recovery. This information is useful when counselling patients who sustain these injuries

Aims

The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid.