Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes. Cite this article:
The October 2023 Research Roundup. 360. looks at: Gut microbiota in high-risk individuals for rheumatoid arthritis associated with disturbed metabolome and initiates arthritis by triggering mucosal immunity imbalance; International Consensus on Anaemia Management in Surgical Patients (ICCAMS); Sleep disturbance trends in the short-term postoperative period for patients undergoing total joint replacement; Achilles tendon tissue turnover before and immediately after an acute rupture;
Introduction.
Most previous studies investigating autograft options (quadriceps, hamstring, bone-patella-tendon-bone) in primary anterior cruciate ligament (ACL) reconstruction are confounded by concomitant knee injuries. This study aims to investigate the differences in patient reported outcome measures and revision rates for quadriceps tendon in comparison with hamstring tendon and bone-patella-tendon-bone autografts. We use a cohort of patients who have had primary ACL reconstruction without concomitant knee injuries. All patients from the New Zealand ACL Registry who underwent a primary arthroscopic ACL reconstruction with minimum 2 year follow-up were considered for the study. Patients who had associated ipsilateral knee injuries, previous knee surgery, or open procedures were excluded. The primary outcome was Knee Injury and Osteoarthritis Outcome Score (KOOS) and MARX scores at 2 years post-surgery. Secondary outcomes were all-cause revision and time to revision with a total follow-up period of 8 years (time since inception of the registry). 2581 patients were included in the study; 1917 hamstring tendon, 557 bone-patella-tendon-bone, and 107 quadriceps tendon. At 2 years, no significant difference in MARX scores were found between the three groups (2y mean score; 7.36 hamstring, 7.85 bone-patella-tendon-bone, 8.05 quadriceps, P = 0.195). Further, no significant difference in KOOS scores were found between the three groups; with the exception of hamstring performing better than bone-patella-tendon-bone in the KOOS sports and recreation sub-score (2y mean score; 79.2 hamstring, 73.9 bone-patella-tendon-bone, P < 0.001). Similar revision rates were reported between all autograft groups (mean revision rate per 100 component years; 1.05 hamstring, 0.80 bone-patella-tendon-bone, 1.68 quadriceps, P = 0.083). Autograft revision rates were independent of age and gender variables.
Bone-patellar tendon-bone autografts, hamstring autografts or allografts are widely used grafts for ACL revision surgeries. Also use of quadriceps autograft for both primary and revision ACL surgeries is in an increasing popularity due to its biomechanical superior properties and less donor site morbidity. However, although several fixation techniques and devices for quadriceps tendon graft fixation on femoral side have been reported, literature lacks about biomechanical studies comparing properties of these different fixation techniques and devices. We aimed to investigate whether there is a difference between the fixation techniques of quadriceps tendon graft by using different fixation techniques and devices on the femoral side in terms of stiffness and amount of slippage in the tunnel. Full-thickness central parts of quadriceps tendons from paired knees of twenty five calf knees were fixed through a 10mm x 25mm tunnel in twenty five paired sheep femurs.
Introduction: The goals of TKR are restoration of the mechanical axis, joint line and Q –angle. Reproduction of the offset of the extensor mechanism during arthroplasty is less well understood. The lever arm of the extensor mechanism is primarily affected by femoral component position, patella tracking and overall patellar thickness. Changing this lever arm alters quadriceps muscle and patellofemoral joint reaction force. Some TKR designs purposefully aim to increase this offset in order to reduce PFJ contact pressures. Overstuffing the PFJ will however adversely affect outcome. The aims of this study were to measure and compare the pre and postoperative quadriceps lever arm and its effect on function in a consecutive series of patients undergoing TKR. Methods: Fifty consecutive patients who had an LCS TKR without patellar resurfacing by a single surgeon were reviewed. Patient demographics were recorded. We measured the pre and post-operative quadriceps lever arm using comparable lateral radiographs and digital imaging software. Functional outcome in these patients was determined using the American Knee Society Score pre and 6-months post-operatively. Patients were specifically questioned regarding the presence or absence of anterior knee pain. Results:
Objective: The objective of this study is to evaluate the role of quadriceps tightness in patients with patellar symptoms. Material and methods: We evaluated 64 patients (12 men and 52 women) diagnosed of patellar malalignment, chondromalacia, patellar pain, patellar subluxation... in 100 knees. We defined 2 groups according the presence or not of imaging disorders: Group A (48 knees) with normal x-ray and CT-scan; group B (52 knees) with malalignment in x-ray or CT-scan. In both groups we evaluated quadriceps tightness by placing the patient prone and passively bringing the heels toward buttock. Average distance between heels/buttock (HBD) was 9.1 cm. in both groups before treatment and none presented HBD = 0 cm. Treatment consisted in passive quadriceps stretches after warm-up. Results: After 11 rehabilitation sessions (range: 9–12), average HBD was 2.5 cm. in group A and 3.6 cm. in group B. HBD = 0 cm. was present in 32/48 knees in group A and 12/52 knees in group B. With a follow-up of 36–48 months, patients with HBD = 0 and values of HBD similar to values after treatment were present in both groups. After follow-up, pain was reported in 4/36 patients in group A and 20/28 in group B. Conclusions:
Patients with advanced osteoarthritis tend to have limited range of motion; the purpose of this in vivo anatomical study is to identify the anatomical structures responsible for limited knee movement in patients with osteoarthritis. Forty-two quadriceps releases were performed in patients who had TKA. The releases were carried out utilising subvastus approach and just before proceeding with the knee replacement surgery. The ranges of motion were documented before and after the release using digital photography and lateral portable X-ray. No bony resection was done, and no ligament release was performed.
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.
Intro:
Introduction &
aims:
Anterior cruciate ligament (ACL) injuries represent a significant burden of disease to the orthopaedic surgeon and often necessitate surgical reconstruction in the presence of instability. The hamstring graft has traditionally been used to reconstruct the ACL but the quadriceps tendon (QT) graft has gained popularity due to its relatively low donor site morbidity. This is a single centre comparative retrospective analysis of prospectively collected data of patients who had an ACL reconstruction (either with single tendon quadrupled hamstring graft or soft tissue quadriceps tendon graft). All surgeries were performed by a single surgeon using the All-inside technique. For this study, there were 20 patients in each group. All patients received the same post-operative rehabilitation protocol and were added to the National Ligament Registry to monitor their patient related outcome scores (PROM).Introduction
Methods
Background:
Patellofemoral instability is one of the most common presentations to a children's orthopaedic clinic. Recurrent patellar dislocations and instability episodes are painful, disabling and increase the risk of irreversible chondral damage. The medial patellofemoral ligament is the primary static stabiliser to prevent lateral dislocation of the patella and is almost always torn or attenuated in these cases. Reconstruction of this ligament is commonly performed using autologous hamstring tendon however there has been some interest recently in use of quadriceps tendon as a graft. Children with patellar instability also present unique challenges due to the small size of the patella and the presence of open growth plates which may require adaptations to the common techniques. Patients undergoing medial patellofemoral ligament reconstruction using quadriceps tendon autograft were identified using electronic theatre records. Prospectively collected clinical records and imaging findings were reviewed and underlying pathology, additional procedures at time of MPFL reconstruction, current function and need for further revision surgery determined.Introduction
Methods
The aim of this study was to compare the results in patients having a quadriceps sparing total knee replacement (TKR) with those undergoing a standard TKR at a minimum follow-up of two years. All patients who had a TKR with a high-flex posterior-stabilised prosthesis prior to December 2002 were reviewed retrospectively. There were 57 patients available for follow-up. Those with a quadriceps sparing TKR had less pain peri-operatively with a greater degree of flexion at all the post-operative visits and at the final follow-up, but their operations took longer, with less accurate radiological alignment. There was no difference in the complications and in the Knee Society scores between the two groups at the final follow-up. Total knee replacement through a quadriceps sparing approach has some peri-operative advantages over the standard incision. At a minimum follow-up of two years the clinical results were similar to those with a standard incision, but the radiological outcomes of the quadriceps sparing group were inferior.
All-tissue quadriceps tendon (QT) is becoming an increasingly popular alternative to hamstrings tendon (HT) and bone-tendon-bone (BTB) autograft for anterior cruciate ligament (ACL) reconstruction. The relatively short graft length however dictates that one, or both, ends rely on suture fixation. The strength of this construct is therefore extremely important. This study evaluates whether the use of a novel fixation technique can improve the tensile properties of the construct compared to a Krackow suture, and a looped tendon (suture free) gold standard. Eighteen porcine flexor tendons were tested, across three groups; suture-tape Krackow, looped tendon, and the novel ‘strain suture’. Biomechanical testing simulated the different stages of ACL graft preparation and loading (60N preload for 10 minutes, 10 cycles from 10N to 75N, and 1000 cycles from 100N to 400N). Elongation and load to failure were recorded, and stiffness calculated for each construct.Abstract
Introduction
Methods
Chronic ruptures of the quadriceps tendon after total knee arthroplasty (TKA) are rare but are a devastating complication. The objective of this study was to validate the use of fresh frozen total fresh quadriceps tendon allografts for quadriceps tendon reconstruction. The hypothesis of this work was that the graft was functional in more than 67% of cases, a higher percentage than the results of conventional treatments. We designed a continuous monocentric retrospective study of all patients operated on between 2009 and 2017 for a chronic rupture of the quadriceps tendon after TKA by quadriceps allograft reconstruction. The usual demographic and perioperative data and the rehabilitation protocols followed were collected. Initial and final radiographs were analyzed to measure patellar height variation. The main criterion was the possibility of achieving an active extension of the knee with a quadriceps contraction force greater than or equal to 3/5 or the possibility of lifting the heel off the ground in a sitting position.Introduction
Material – methods
To evaluate mechanical properties of three suture-tendon constructs, the Krackow stitch (KS), the modified Prusik knot (PK) and the Locking SpeedWhip (LSW), using human cadaveric quadriceps grafts (QT). Thirty QT grafts were obtained from human cadaver specimens and an equal number of tendon-suture constructs were prepared for three stitches: KS, PK and LSW. The constructs were mounted in a materials testing machine (ElectroPuls E10000, Instron, Norwood, MA) and subject to tensile loading based on an established protocol. Load and displacement data for each tendon-suture construct were recorded.Abstract
Objectives
Methods
Initial performance of sutured quadriceps tendon (QT) ACL graft constructs is not well studied in human tissue and the results of animal tissue testing may not extend to the human model. Two common methods of preserving human tissue are to freeze the specimens immediately after death or embalm with formalin solution. The purpose of this study is to compare elongations and loads in biomechanical testing of fresh-frozen to that of embalmed quadriceps tendon-suture constructs. Twenty QT grafts were harvested from human cadaver specimens, 10 fresh-frozen and 10 embalmed. The grafts were prepared with the modified Prusik knot using a No.2 FiberWire (Arthrex, Naples, FL), mounted in a materials testing machine (ElectroPuls E10000, Instron, Norwood, MA) and subjected to tensile loading based on an established protocol. Each tendon was preconditioned with 3 cycles of 0–100N at 1Hz followed by a constant load of 50N for 1 minute and 200 cycles from 50–200N at 1Hz and then loaded to failure at a displacement rate of 20mm/min. Load and displacement data for each tendon-suture construct was recorded.Abstract
Objectives
Methods
ACL graft-suture fixation can be constructed with needle or needleless techniques. Needleless techniques have advantages of decreased injury, preparation time and cost. The Nice Knot (NK) is common among upper extremity procedures; however, its efficacy in ACL reconstruction relative to other needleless methods is not well known. The purpose of this study was to biomechanically compare quadriceps tendon (QT) grafts prepared with the NK versus the modified Prusik Knot (PK). Twenty QT grafts were harvested from 10 embalmed human cadaver specimens. 10 were prepared with the PK and 10 with the NK using a No.2 FiberWire (Arthrex, Naples, FL). The prepared grafts were then mounted in a materials testing machine (ElectroPuls E10000, Instron, Norwood, MA) and subjected to tensile loading based on an established protocol. Each tendon-suture specimen was preconditioned with 3 cycles of 0–100N at 1Hz followed by a constant load of 50N for 1 minute and cyclic loading of 200 cycles from 50–200N at 1Hz and then loaded to failure at a displacement rate of 20mm/min. Load and displacement data for each tendon-suture construct was recorded by the testing machine.Abstract
Objectives
Methods
1. Previous reports of the role of the quadriceps in producing limitation of movement or dislocation of the patella have tended to implicate one particular part of the complex. Experience gained in thirty-five quadricepsplasties in children has shown that all parts of the quadriceps (except vastus medialis) and the ilio-tibial band also may play a part and that each of these must be attended to if a satisfactory result is to be obtained. 2. A simple technique of operation is described and illustrated. 3. Since this paper was prepared, a patient showing features of particular interest has been seen and treated.
1. Contracture of parts of the quadriceps muscle is not uncommon and is often accompanied by tightness of the ilio-tibial tract. It is suggested that this may follow intramuscular injections. 2. Recurrent dislocation of the patella can be a consequence of this muscle contracture. 3. Division of the ilio-tibial tract and lengthening of the fibrotic elements of the quadriceps can prevent further dislocation and restore good function.
To explain the knee kinematics, the vector of the quadriceps muscle, the primary extensor, is important and the relationship of the quadriceps vector (QV) to other kinematic and anatomic axes will help in understanding the knee. Knee kinematics is important for understanding knee diseases and is critical for positioning total knee arthroplasty components. The relationship of the quadriceps to knee has not been fully elucidated. Three-dimensional imaging now makes it possible to construct a computer based solid model of the quadriceps and to calculate the vector of the muscle as individual parts and as a whole. Two studies are presented, one American and one Japanese subjects. Using CT data from subjects who had CT for reasons other than lower extremity pathology (American) or specifically for the study (Japanese), 3-D models of each quadriceps component (vastus medialis, intermedius, lateralis and rectus femoris) were generated. Using principal component analysis for direction and volume for length, a vector for each muscle was constructed and addition of the vectors gave the QV. Three anatomic axes were defined: Anatomic Axis (AA) – long axis of the shaft of the femur; Mechanical Axis (MA) center of the femoral head to the center of the trochlear and the Spherical Axis (SA) – a line from the geometric center of the head of the femur to the geometric center of the medial condyle of the femur at the knee. Fourteen American cases (mean age 39.1, 9 male 5 female) and 40 Japanese subjects (mean age 29.1, 21 male, 19 female) were evaluated. In all subjects the quadriceps vector at the level of the center of the femoral head was anterolateral to the center of the femoral head. The position of the QV was more lateral in Japanese compared to Americans; and, in Japanese, the vector was more lateral and posterior for women than for men. In both study populations, the QV was most closely aligned with the SA as compared to the AA or the MA. The vector representing the quadriceps pull, originating at the top of the patella, progresses proximally toward the We conclude that the QV as calculated progresses from the top of the patella to the mid-femoral neck and the SA is most closely parallel to this vector.
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.
The acetabular labrum serves many integral functions within the hip joint. As a result, novel surgical techniques that aim to preserve or reconstruct the labrum have entered the spotlight. We have successfully performed a labral reconstruction using the quadriceps tendon as an autograft for a patient with a moderate labral defect. The purpose of this report is to propose this novel donor site as a viable alternative for labral reconstruction using an autograft; the potential benefits over currently popular methods will be discussed.
The current indications for functional restoration
of extension of the knee following quadriceps resection or loss require
reappraisal. The contribution of pedicled and free functional muscle
transfer is likely to be over-emphasised in many studies, with good
functional outcomes predominantly reported only in the context of
cases with residual quadriceps function. In cases with total quadriceps
resection or loss, all forms of reconstruction perform poorly. Furthermore,
in smaller resections with loss of two or fewer components of the
quadriceps, minimal impairment of function occurs in the absence
of functional reconstruction, suggesting that functional restoration
may not be warranted. Thus there is a paradox in the current approach
to quadriceps reconstruction, in that small resections are likely
to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and
rationale for reconstructing functional extension of the knee after
quadriceps resection or loss. A classification based on current
evidence is suggested that emphasises more clearly the indications
and rationale for functional transfers.
Recent emphasis in total knee arthroplasty has been on accelerated rehabilitation and recovery. Minimally invasive and quadriceps sparing techniques have been developed to expediate return to normal function. The aim of this study was to evaluate the effect of the tourniquet on post-operative pain and quadriceps function in total knee arthroplasty. This study involved a randomised, blinded, prospective trial of 20 patients undergoing total knee arthroplasty by a single surgeon. All patients received a general anaesthetic, identical prosthesis and post-operative protocol. Patients were randomly allocated to one of two group: (a) tourniquet group or (b) no tourniquet group. A standard surgical tourniquet was applied to all patients but only inflated in the tourniquet group. Outcomes included Oxford knee scores, post-operative pain scores, post-operative drainage and transfusion requirements, thigh and knee circumference measurements, range of motion, and surface EMG measurements at intervals of two weeks, six weeks, six months and twelve months. The study included 16 male and four female patients with 11 right and nine left knees. There was no significant difference pre-operatively between groups in age, degree of deformity or range of motion. There was no significant difference detected between Oxford knee scores up to twelve months, days to discharge, post-operative drainage and range of motion. However, the pain scores were significantly higher in the tourniquet group. Surface EMG as a measurement of quadriceps activation showed a significant difference between the groups and between time points. The no tourniquet group can support more energy in their quads muscle than the tourniquet group The use of a tourniquet in total knee arthroplasty has no effect on overall knee function at twelve months as measured by the Oxford knee score and range of motion; however tourniquet use results in higher initial pain scores and reduction in quadriceps function as measured by surface EMG.
For 42 of the 54 (78%) subjects, during isometric and walking exercises we observed that activation of the VMO, rectus femoris (RF) and vastus lateralis (VL) muscles of the symptomatic leg was not significantly different from those of the asymptomatic leg (p<
0.01). However, for 31 patients (57%) during the eccentric phase of the squat exercises, the symptomatic leg presented with high activation of VL compared to VMO and RF (p<
0.01). During the concentric phase, 45 patients (83%) presented with higher activation of the VL compared to the VMO.
1. Six cases of quadriceps contracture in children are described. All were either premature or suffered severe illnesses soon after birth. 2. Some additional information is given about cases of the same condition previously published by other authors. 3. It is suggested that injections and infusions given to newborn babies are sometimes the cause of the condition. 4. Some of the therapeutic substances and measures which may be responsible are discussed. These include antibiotics, vitamin K preparations and "subcutaneous" fluid therapy.
ACL reconstruction using a quadriceps tendon autograft was quantitatively evaluated using a robotic testing system. Biomechanical results on joint stability and graft function support its use as an alternative to the hamstrings. Recently, a number of surgeons have chosen the quadriceps tendon (QT) autograft as an alternative autograft over the hamstrings tendon for ACL reconstruction because its bone-to-bone healing on one side, large size, and preservation of lateral and rotatory knee function could lead to fewer post-operative complications. However, there have been little or no biomechanical studies that quantitatively evaluate knee function after reconstruction using a QT autograft. Therefore, the objective of this study was to assess the function of a reconstructed knee with a QT autograft and compare the results with a quadrupled semitendinosus and gracilis (QSTG) tendon autograft on the same knee.Summary Statement
Introduction
For the post-operative evaluation and for the critical comparison of the two groups we’ve considered the following parameters:length of operation,blood loss,ROM(at discharge,at 1 month,at 3 months,at 6 months),functional scores(using the Knee Society Assessment&
Function Score),implants position and postoperative pain.In order to evaluate the differences among the two groups over time,we adopted a general linear model for repeated measures with calculation of Huber White robust standard errors to account for intra-patients correlation over time: a 2 sided p-value<
0.0125 was considered significant and Bonferroni correction was applied for post-hoc test.
Recurrent patellar dislocation is a relatively common disorder in young patients. Historically, treatment options have been based on the underlying disorder predisposing the patient to the dislocation. This has resulted in various soft tissue reefing procedures, patella tendon realignment procedures and boney realignment procedures. Further research has shown that the medial patello-femoral ligament (MPFL) is the primary restraint to lateral patella subluxation and dislocation. Many authors have published their successful treatment of recurrent patella dislocation by reconstruction of the medial patellofemoral ligament. The most widely used is autologous semitendinosis tendon grafts, as well as synthetic materials, and MPFL reconstructions may be combined with boney procedures. Varieties of fixation techniques have been described involving both the patella and femoral sides. We present a technique of MPFL reconstruction using the autologous ipsilateral quadriceps tendon. Our technique avoids the morbidity associated with semitendinosis graft harvesting and the drill holes in, and potential resulting fracture of, the patella. The technique is also simple and is associated with decreased procedure costs. We present the technique and a series of six patients (seven knees) with follow up ranging from eight months to nine years. The average age of patients at the time of surgery 16 to 28 years (mean = 20 years). There have been no redislocations. The median Kujala patellofemoral knee score at follow up was 97 out of 100 (Range 69–100). The results compare very favorably to published results using other techniques. Our technique of reconstructing the MPFL is reliable, produces good results using an objective knee score, and is cost effective. Seventy staff members participated from a potential pool of approximately one hundred staff on duty at the time. Of the seventy staff who participated in this research project a total of three staff members were within 50 mls of the correct amount for each of the three samples. Overall staff were very poor at estimating blood loss. Staff working in the operating theatre, no matter what their affiliation or years of experience, are not accurate when estimating blood loss spilt into a patients bed. A tool that aids in blood loss estimation is a valuable addition to the theatre resource manual.
We measured patellar height, VMO length on the axial views of the scans. The VMO insertion was calculated from the data and we divided the patients into proximal and distal groups in relation to the VMO termination on the patella. The proximal group included patients with VMO termination proximal to the mid-point of the patella and distal group included patients with VMO termination at or distal to the mid-point of the patella.
To calculate the patellar height the apex of the patella was considered as ‘Reference Slice 1’. The consecutive slices were followed distally to the last slice in which the patella was visible. From ‘Reference Slice 1’ VMO muscle was followed distally to the slice in which the muscle was last visible. We calculated the patella height and VMO muscle length as the product of the number of MRI slices and MRI slice thickness.
A statistically significant inverse relationship was noted between the level of insertion of VMO and the age of the patient.
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. To evaluate the peak quadriceps strength and immediate clinical outcomes related to the change of anterior offset of the distal femur during TKA.Background
Purpose
A prospective study was done to assess the outcome of MPFL reconstruction for patellar instability using quadriceps graft. MPFL reconstruction was done using superficial strip of quadriceps by an anteromedial incision and attached close to medial epicondyle of femur. There were 15 knees in thirteen patients with a mean age of 23.4 years. All patients had MPFL reconstruction and 5 had tibial tuberosity transfers. With a mean follow-up of 39.4 (12–57) months, the mean pre-op Kujala scores improved from 47.8 to 87.2. The mean Lysholm scores improved from 54.2 to 86.8. None of the patients had patella re-dislocations. MPFL reconstruction with quadriceps graft appears to be effective producing good results in patients with patellar instability.
1. A case of bilateral spontaneous and simultaneous rupture of the quadriceps tendons is described. 2. The underlying cause was found to be gouty affection of the tendons. 3. So far as is known, a similar case has not previously been recorded.
We hypothesize that tethering adhesions of the quadriceps muscle are the major pathological structures responsible for a limited range of motion in the stiff arthritic knee. Forty-two modified quadriceps muscle releases were performed on 24 patients with advanced osteoarthritis scheduled for total knee arthroplasty. The ranges of motion were documented intraoperatively both before and immediately after the release. Passive flexion improved significantly in all patients (mean, 32.4 degrees of improvement, P < .001) following a modified quadriceps release, despite any presence of osteophytes or severe deformities. These results strongly implicate adhesions of the quadriceps muscle to the underlying femur, which prevent the distal excursion of the quadriceps tendon, as the restrictive pathology preventing deep flexion in patients with osteoarthritis.
The purpose of this study was to evaluate any differences in quadriceps activation during functional activity between patients with patellofemoral problems and normal subjects. 24 patients and 11 controls were assessed. Surface EMG amplitudes were recorded from three parts of the quadriceps, vastus medialis obliquus (VMO), lower fibres of vastus lateralis (VLO) and rectus femoris (RF), whilst subjects stepped on and off a stool. These amplitudes were normalised to those from a maximal isometric voluntary contraction at 90° of knee flexion. The patients activated their VMO significantly less effectively than controls (mean + SEM normalised peak amplitude was 1.06 + 0.09 in patients, compared to 1.41 + 0.12 in the control subjects). In the controls, most of the activity was seen with the knee in flexion, with very little activity with the knee in extension. In comparison, patients recorded less activity with the knee in flexion and more when the knee approached extension. EMG amplitudes in isometric contractions at 60° of knee flexion were compared with those at 90°. VMO and VLO showed less activation at 60° in both groups of subjects, but in RF there was no difference in the EMG, between these two angles. This suggests that the motor control of VMO/VLO may be different from the bulk of the quadriceps. We have shown that high activity in the VMO and VLO parts of the quadriceps appears to be important in an exercise that involved taking the body weight on one knee at around 90° of flexion. This high activity is likely to have two effects: it is important for the stability of the knee itself, and by increasing the area of contact, it reduces contact pressures. Patients with patellofemoral problems were unable to produce this needed activity in VMO. The VMO and VLO may have a different motor control from the bulk of the quadriceps, and in normal function, work synchronously. The loss of this synchronicity in patients with patellofemoral problems, could well help to explain the retropatellar pain that these patients experience.
Patient demand for a less invasive surgical approach reducing the trauma induced to the joint has resulted in the development of Minimally Invasive Surgery (MIS). Although the length of the surgical incision is appealing to patients, the changes are not purely cosmetic. The surgery should not violate the extensor mechanism in any way. Incisions into the quadriceps tendon or into the vastus medialis muscle make the approach less difficult but this violation will slow the recovery and affect the ROM of the knee. In Asian knees, authors found the variation of VMO, which is essential in early functional recovery in TKA patient, is so much, so new clinical test for MIS QS should be needed to show location relationship between the upper pole of the patella and the insertion of VMO itself to avoid unnecessary injury of VMO during TKA. The purpose of this comparison study was to verify whether MIS QS TKA can be a more functional and better method in treatment of advanced degenerative arthritis comparing with mini MIS TKA.Introduction
Purpose
Neglected rupture of quadriceps tendon is an infrequently occurring lesion resulting from sport, but it is very interesting as regards the physiological and functional repercussions. The lesion is common in football players. The pathogenesis is a flexion trauma of knee. Many authors point out the importance of a pre-existent degeneration due to exogenous and endogenous factors. Pain, inextensible knee, ecchymosis, axe hit are a common presentation in acute events, difficult knee extension and pain in chronic. X-ray study shows calcification at the tendon-bone junction. The treatment of neglected rupture of quadriceps tendon is surgical. If a defect of 5 cm or more is present between the ends of tendon the fascia lata can be used to correct the gap. When the ends can be apposed an end-to-end repair is possible. We treated a neglected rupture of quadriceps femoris muscle tendon in a bodybuilder with a particular technique: we stripped and harvested the semitendinosus and gracilis tendon and sutured them together. Then we made a transverse hole in the mid-portion of the patella; the tendons were passed through the transverse hole in the patella and sutured with the lateral, medial and intermendial vastus, and with the rectum femoral. At 6-month follow-up the patient has no pain and stability is improved, a practical range of knee motion regained. Full forceful extension is not completely restored.
The subvastus approach to the knee has been described as early as 1929. This approach for primary total knee arthroplasty (TKA) maintains the integrity of the quadriceps mechanism and maintains the vascularity of the patella. We have conducted a prospective, double blind, randomised trial to evaluate the quadriceps function in TKA after the paramedian and the subvatus approaches in 40 patients with osteoarthitis. Patients were randomised to the two groups and were evaluated by an independent observer blinded to the approach used. The two groups were compared as regards function (range of motion, quadriceps lag, quadriceps power); functional outcomes (Hospital for Special Surgery scores); patellofemoral alignment (Patellar tilt); and operative time, blood loss and hospital stay. There was a statistically significance difference between the two groups as regards quadriceps power and lag in the first post-operative week. The subvastus group performed better than the paramedian group. The range of motion was also better in the subvastus group, though this difference was not statistically significant. The subvastus approach avoids the painful inhibitory arc of the quadriceps and allows for better and rapid rehabilitation in the early post-opertaive phase. There were fewer lateral retinacular releases in the subvastus group. The presence of an intact extensor mechanism allows for more accurate assesment of the patellofemoral alignment intraoperatively. The patello-femoral alignment readings were better in the subvastus group. The subvastus approach does not interfere with the vascular supply of the patella. The patients operated by the subvatus group were discarged from hospitals early.
Continuous epidural anesthesia or femoral nerve block has decreased postoperative pain after total knee arthroplasty to some extent. Although the established efficacy of these pain relief method, some adverse events such as hematoma or muscle weakness are still problematic. Intraoperative local infiltration of analgesia (LIA) has accepted as a promising pain control method after total knee arthroplasty. The safety and efficacy of LIA has been reported, although there are still limited evidence about the effect of LIA on quadriceps function and recovery of range of motion in early post-operative phase. The purpose of this study is to compare the quadriceps function and range of motion after TKA between the LIA with continuous epidural anesthesia and continuous epidural anesthesia alone. Thirty patients with knee osteoarthritis who underwent primary TKA were included in this study. Patients who took anticoagulants were treated continuous epidural anesthesia alone (n=11) and the other patients were treated with LIA with continuous epidural anesthesia (n=19). A single surgeon at our department performed all surgeries. Surgical procedure and rehabilitation process was identical between two groups. Before the implantation, analgesic drugs consisting of 20 ml of 0.75 % ropivacaine and 6.6 mg of dexamethasone were injected into the peri-articular tissues. In each group, fentanyl continuous epidural patient-controlled analgesia (PCA) was also used during 48-h post-operative period. Knee flexion and extension angle were evaluated before surgery, post-op day 3, 7, 10 and 14. The quadriceps function was evaluated by quadriceps peak torque at 30° and 60° flexion using VIODEX. The peak torque was recorded preoperatively, day 14 and 3 month after surgery. The difference between two groups was analyzed by Mann Whitney U-test using Prism 6, a statistical software.Background
Methods
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.
The drive in contemporary medicine is improved utilisation of scarce resources and a faster turn around of patients, with patients seeking faster recovery from surgery. Delaying factors in discharge from hospital following total knee replacement surgery include the time taken to get active extension and a straight leg raise following surgery. A retrospective case matched study of 20 patients shows that reducing the length of incision into the quadriceps tendon, therefore sparing the quadriceps mechanism speeds the post operative recovery significantly. Reducing the average time to discharge from 9.6 days in the control group to 3.2 days in the quadriceps-sparing group. All but one patient had an ASA grade of 2 with no significant co-morbidity in either group. No patient in either group suffered a post-operative medical event precipitating a delayed discharge. The criteria for discharge were the same in both groups.
Electromyography (EMG) is the best known method in obtaining in vivo muscle activation signals during dynamic activities, and this study focuses on comparing the EMG signals of the quadriceps muscles for different TKA designs and normal knees during maximum weight bearing flexion. It is hypothesized that the activation levels will be higher for the TKA groups than the normal group. Twenty-five subjects were involved in the study with 11 having a normal knee, five a rotating platform (RP) posterior stabilized (PS) TKA, and nine subjects with a PFC TC3 revision TKA. EMG signals were obtained from the rectus femoris, vastus medialis, and vastus lateralis as the patients performed a deep knee bend from full extension to maximum flexion. The data was synchronized with the activity so that the EMG data could be set in flexion-space and compared across the groups. EMG signals were pre-processed by converting the raw signals into neural excitations and normalizing this data with the maximum voluntary contraction (MVC) performed by the subject. The signals were then processed to find the muscle activations which, normalized by MVC, range from 0 to 1.Introduction
Methods