The primary purpose of this longitudinal study was to examine the impact of physical and mental well-being on a successful return to work after cartilage or ligament knee injury. A secondary purpose was to examine the effectiveness of our program regarding ordering imaging (plain X-rays, US, MRI, CT scan), and the impact that costly investigations made in clinical management. Workers who had sustained a work-related knee injury and were assessed at the lower extremity specialty clinic of our hospital program were followed up until they were discharged. All patients completed the numeric pain rating scale (NPRS), the Lower Extremity Functional Scale (LEFS), and the Hospital Anxiety and Depression Scale (HADS) on the initial assessment and at final follow-up. We included 30 patients, mean age, 50(9), 11(37%) females, 19(63%) males. The most common mechanisms of injury were twisting (13, 45%) and falls (12, 41%). The knee injuries included 10 anterior collateral ligament (ACL), 3 posterior collateral ligament (PCL), 19 medical and lateral ligament injuries, and 22 meniscus injuries with some injuries overlapping. Ten patients (30%) underwent surgery (8 meniscectomy, two ligamentous repairs). Patients showed improvement in pain scores (p<0.0001) and the LEFS scores (p=0.004). Seventeen patients (57%) returned to full-time work and 11 (37%) were not working at the time of discharge with one patient performing part-time work, and one on re-training. Higher levels of pre (p=0.02) and post-treatment (p=0.03) depression and post-treatment anxiety (p=0.02) had a negative impact on a successful return to work. Most clients had proper investigations ordered by their family physicians in the community (24 plain x-rays, 11 US, and 21 MRI). Our team ordered only 6 plain x-rays and 6 new MRI. We found significant improvement in pain and disability in injured workers who received an expedited multidisciplinary care. Anxiety and depression were the most important predictors of poorer recovery and a less successful work status. The judicious use of costly imaging is expected to reduce the overall health care cost of an injury, while providing new important information such as adding a new diagnosis or changing the management

To investigate changes in quadriceps and hamstrings muscle groups during sustained isokinetic knee flexion and extension. 125 paediatric participants (45 males and 80 females, mean age 14.2 years) were divided into two groups: participants with a confirmed ACL tear (ACLi, n = 64), and puberty- and activity-level matched control participants with no prior history of knee injuries (CON, n = 61). Participants completed a series of 44 repetitions of isokinetic knee flexion and extension at 90 deg/ sec using a Biodex dynamometer (Biodex Medical Systems Inc, Shirley, New York). Surface EMG sensors (Delsys Incorporated, Natick, MA) simultaneously recorded the quadriceps and hamstring activations. Muscle function was assessed as the change in quadriceps activation and extension torque were calculated using the percent difference between the mean of the first five trials, and the mean of the last five trials. ACLi participants had significantly higher percent change in quadriceps activation for both healthy and injured legs, in comparison to CON dominant leg. As such, the healthy leg of the ACLi participants is activating significantly more than their health matched controls, while also demonstrating reduced muscular endurance (less torque in later repetitions). Therefore, we conclude that the non-injured limb of the ACLi participant is not performing as a healthy limb. Since return to activity clearance following ACLi implies return to sport against age- and activity matched opponents, clearing young athletes based on the non-injured contralateral limb may put them at greater risk of reinjury

Introduction. The ACTIVE(Advanced Cartilage Treatment with Injectable-hydrogel Validation of the Effect) study investigates safety and performance of a novel dextran-tyramine hydrogel implant for treatment of small cartilage defects in the knee (0.5-2.0cm2). The hydrogel is composed of a mixture of natural polymer conjugates that are mixed intra-operatively and which cross-link in situ through a mild enzymatic reaction, providing a cell-free scaffold for cartilage repair. Method. The ACTIVE study is split into a safety (n=10) and a performance cohort (n=36). The Knee Injury and Osteoarthritis Outcome Score (KOOS), pain (numeric rating scale, NRS), Short-Form Health Survey (SF-36) were compared at baseline and 3, 6, and 12 months after surgery. The primary performance hypothesis is an average change in the KOOS from baseline to 12 months (ΔKOOS) greater than a minimal clinically important change (MIC) of 10. No statistical tests were performed as these are preliminary data on a smaller portion of the total study. Result. All patients of the safety cohort (n=10, mean age±SD, 30±9 years) were treated with the hydrogel for a symptomatic (NRS≥4) cartilage defect on the femoral condyle or trochlear groove (mean size±SD, 1.2±0.4cm2). No signs of an adverse foreign tissue reaction or serious adverse events were recorded within the safety cohort. At final follow-up mean KOOS±SD was 66.9±23.5, mean NRS resting±SD was 1.3±1.9, NRS activity±SD was 3.8±2.9 and mean SF-36±SD was 72.0±10.9. ΔKOOS was 21. One patient sustained new knee trauma prior to final follow-up, affecting final scores considerably. When excluded, ΔKOOS was 24(n=9). Conclusion. These promising initial findings provide a solid basis for continuation and expansion of this unique cartilage treatment. The MIC of 10 was surpassed. Though, results should be interpreted cautiously as they are based solely on preliminary data of the first 10 patients. Acknowledgements. Study is sponsored by Hy2Care, producer of the CartRevive®(dextran-tyramine) Hydrogel implant

Introduction. Numerous risk factors have been identified for patellar tendinopathy (PT), often in small population studies. The aim was to use an online questionnaire internationally to generate a large database and identify significant risk factors. Materials and Methods. Subjects were recruited from England, Spain and Italy with the questionnaire available in all three languages, with the questionnaire previously having been validated by Morton et al. (2014) as to be suitable for self-administration. The questionnaire can be viewed at: . http://patellartendinopathyquestionnaire.blogspot.co.uk/. (English), . http://tendinopatiarotuliana.blogspot.co.uk/. (Spanish) and . http://tendinopatiarotulea.blogspot.co.uk/. (Italian). All data was anonymised and password protected. 825 data sets were collected with 23.4% having clinically diagnosed PT. Results. Eight risk factors were included in the analysis based on a purposeful selection procedure: gender, hours of training, hamstring flexibility, previous patellar tendon rupture, previous knee injury, current/previous back pain, family history and age. To be female was found to be positively associated with PT, suggesting being female is protective (odds ratio (OR) = 0.70, 95% CI: 0.49–1.00, p=0.05). As hours of training increased the association with PT became stronger so that training >20 hours a week had a very significant OR of 8.94 (95%CI: 4.68–17.08, p<0.05), the most significant OR calculated. There was an association between a previous knee injury and PT (OR=2.10, 95% CI: 1.45–3.04, p<0.05) and having self-reported flexible hamstrings suggested some protection from PT (OR=0.61, 95% CI0.38–0.97, p=0.04). There was a trend towards association for back pain (OR=1.45, 95% CI: 0.99–2.14, p=0.06) and a family history of tendon problems (OR=1.51, 95% CI: 0.96–2.37, p=0.08). Discussion. Risk factors have been identified that are potentially modifiable in order to inform prevention and rehabilitation programmes; future research is required to establish causal relationships. Certain risk factors require investigation as they are not currently recognised in the literature

We present a simple seated dial test that can be used by a single examiner in the acute or chronic situation to diagnose posterolateral corner knee injury. In the acute setting a traditional prone dial test can be cumbersome and painful for patients. Therefore a supine technique can be utilised, however this requires an assistant in order to hold the knees together with the tibia in a reduced position. We therefore utilise a seated technique in which the patient sits with their knees flexed over the edge of the examination couch. The patient is then able to hold their knees together, negating the need for an assistant. The sensitivity of a dial test is improved if the knee is reduced and so with this technique the tibia will be held in the anatomical position by the examination couch. The patients' feet are grasped with both medial malleoli together and then an external rotation moment is exerted at 30 and 90 degrees of flexion measuring the thigh-foot angle or visualising the tibial tuberosities. A positive test being 10 degrees or more of increased external rotation in the affected knee. This test is similar to the Spin test however it relies on the tactile sensation of posterolateral tibial rotation. This can be difficult to elicit in the acute situation due to haemarthrosis. Simultaneous side-to-side comparison is also not possible. A further disadvantage of the Spin test is that it can only be performed at 90 degrees of flexion and so only applies in combined PCL and posterolateral corner repair. In conclusion we believe that this modification of the standard dial test is a simple to perform accurate method for assessing posterolateral corner knee injury in the acute and chronic setting

Symptomatic articular cartilage defects are one of the most common knee injuries, arising from acute trauma, overuse, ligamentous instability, malalignment, meniscectomy, osteochondritis dissecans. Surgical treatment options include bone marrow–stimulating techniques such as abrasion arthroplasty and microfracture, osteochondral mosaicplasty, corrective osteotomy, cartilage resurfacing techniques and tissue engineering techniques using combinations of autologous cells (chondrocytes and mesenchymal stem cells), bioscaffolds, and growth factors. Matrix induced autologous chondrocyte implantation (MACI) is considered the most surgically simple form of autologous chondrocyte implantation. Our group has involved in the development of MACI since 2000 and has led to the FDA approval of MACI as the first tissue engineering product for cartilage repair in 2016. In this article, we have documented the characterisation of autologous chondrocytes, the surgical procedure of MACI and the long term clinical assessment (15 years) of patients with treatment of MACI. We have also reported the retrospective survey in patients with MACI in Australia. Our results suggest that MACI has gained good to excellent long term clinical outcome and probably can delay total knee replacement. However, restoration of hyaline-like cartilage by MACI may be interrupted by the osteoarthritic condition of the joint in patients with progressed osteoarthritis. In addition, because articular cartilage and subchondral bone are considered a single functional unit that is essential for joint function, many cartilage repair technologies including MACI and microfractures have failed short to address the functional barrier structure of osteochondral unit. Further studies are required to develop tissue engineering osteochondral construct that is able to fulfil the function of articular cartilage-subchondral bone units

Acute multiligament knee injuries (MLKI) are rare, high energy traumatic injuries associated with an increased risk of lower limb complications. The objectives of this study were to investigate the adequacy of clinical assessment for neurovascular status, compartment syndrome, and deep vein thrombosis in the emergency department (ED) following acute MLKI. The authors conducted a retrospective case note review of 19 patients with MLKI presenting at the ED of a Major Trauma Centre during a 7.5-year period between June 2009 and December 2016. MLKIs were diagnosed by MRI or examination under anaesthesia and confirmed intraoperatively. Arterial assessment consisted of documented capillary refill time, dorsalis pedis and posterior tibial pulse assessment (through palpation or Doppler ultrasound), and ankle-brachial pressure index (ABPI) calculation. Neural assessment was adequate if there was documented assessment of both sensory and motor function of the superficial peroneal, deep peroneal and tibial nerves individually. Data was collected for 19 patients (17 male, 2 female). The mean age was 34 (range: 14–61). The most common injury mechanism was road traffic accident. Neurovascular assessment was suboptimal in all categories: only one patient received a satisfactory lower limb neurological assessment and no patients received complete vascular assessments. Neurovascular assessment of multiligament knee injuries was suboptimal. Reasons for this included poor documentation and lack of certain specific clinical assessments, such as ABPI calculation. We propose the introduction of an acute knee injury pro forma highlighting the components of a full lower limb neurovascular examination to rectify this problem

Aim. The knee radiograph is a commonly requested investigation as the knee joint is commonly injured. Each radiograph exposes 0.01mSv of radiation to the patient that is equivalent to 1.5 days of natural background radiation. Also, each knee radiograph costs approximately £37.16 to produce. The aim of the clinical audit was to use the Pittsburgh knee rules to attempt to reduce the number of knee radiographs taken in patients with acute knee injuries and hence reduce the dose of ionising radiation the patient receives. Method. A retrospective audit was undertaken. 149 knee requests and radiographs taken during October 2016 were evaluated. Each knee radiograph request including patient history and clinical examination was graded against the Pittsburgh knee rules to give a qualifying score. The Pittsburgh knee rules assigns 1 point for each of the following; blunt trauma or a fall, age less than 12 years or over 50 years, and unable to take 4 limping weight bearing steps in the emergency department. A Pittsburgh knee rule qualifying score warranting a knee radiograph is 2 or more points, where the patient must have had blunt trauma or a fall. A Pittsburgh knee rule score less than 2 points predicts a non-fractured knee and hence no radiograph warranted. Each radiograph was reviewed if a fracture was present or not. Results. The clinical audit identified 85 true negative patients where their Pittsburgh knee rule score was less than 2 points and they did not have a fracture of the knee joint. The Pittsburgh knee rule score of less than 2 points did not warrant obtaining knee radiographs. Therefore, a total of 85 knee radiographs were unnecessary which is equivalent to 127.5 days of background radiation. The financial burden of these unnecessary radiographs is £2648.60. The negative predictive value of the Pittsburgh knee rules in this audit was 93.4%. Discussion. The clinical audit shows that the use of the Pittsburgh knee rules scoring system can reduce the number of knee radiographs obtained by 57.4% and hence the doses of ionising radiation patients are exposed to. The audit also showed this clinical scoring system has a high negative predictive value that when utilised can discern patients with a normal knee joint who do not require a knee radiograph. In conclusion employing the Pittsburgh knee rule scoring system can improve patient safety by reducing ionising radiation exposure and can reduce financial costs of patient encounters

Background. Meniscal tears are among the most common knee injuries. To preserve as much as possible the joint, partial and total meniscal replacements are necessary. To combine the biocompatibility and mechanical resistance of meniscus allograft with the disponibility of synthetic substitutes, an acellular, viroinactivated and sterile scaffold with well-preserved structure has been developed based on PHOENIX process. Methods. Human menisci were collected from living donors undergoing total knee arthroplasty. They underwent chemical treatments, freeze-drying and gamma irradiation. Decellularisation of menisci and preservation of the matrix structure were explored by histological studies. Meniscal scaffold ultrastructure was analysed by scanning electron microscopy. Biomechanical studies were also conducted. Scaffold viroinactivation was investigated by viral clearance studies. Finally, the allografts were cultured for 4 weeks with Mesenchymal Stem Cells (CSM); cells viability and proliferation were assessed histologically and by confocal microscopy following stainings. Results. Histological data evidenced that the process led to complete decellularisation of the menisci, high porosity within the tissue and to the removal of glycosaminoglycans, present in the center of native menisci. The meniscal surface as well as collagen fibers were preserved as assessed by electron scanning microscopy. Ultimate tensile strengths of native and processed menisci were similar. Viral clearance studies showed that each viral inactivation step induced a viral load reduction compliant with the reduction factor specified in the European guidelines. CSM exhibited great viability and proliferation at the surface of the allograft and partial penetration inside. Conclusions. Scaffold safety is conferred by decellularisation and viroinactivation of the meniscus while preserving structure and mechanical resistance of the tissue, enabling cells to proliferate around and inside the allograft. Freeze-drying and gamma irradiation make it a ready-to-use product, with different sizes for partial and total meniscal replacement

Background. The anatomy of the human body has been studied for centuries. Despite this, recent articles have announced the presence of a new knee ligament- the anterolateral ligament. It has been the subject of much discussion and media commentary. Previous anatomical studies indicate its presence, and describe its location, origin, course and insertion. Magnetic resonance imaging (MRI) is the best and most commonly used investigation to assess the ligamentous structure of the knee. To date, most MRI knee reports make no mention of the anterolateral ligament. The aim of this study was to assess for the presence of the anterolateral ligament using MRI, and to describe the structure if visualised. Methods. All right knee MRIs performed on a Siemens Magnetom Espree 1.5 Tesla scanner in Merlin Park Hospital over a 4 year period were retrospectively analysed. Patients born before 1970, or with reported abnormalities were excluded. The normal MRIs were then analysed by a consultant radiologist specialising in musculoskeletal imaging. Measurements on origin, insertion, course and length were noted. Results. 942 right knee MRIs were performed in the time period. 62 were classed as normal, and within the specified age range. 10 were randomly sampled. Of these the ligament was visible on all 10 MRIs, best viewed in the coronal plane. The average length (visible in 8/10) was 28.88mm +/− 5.14mm. The origin (visible in all 10) was 2.25mm +/− 0.39mm. The insertion (visible in 9/10) was 1.93mm +/− 0.424. The mid thickness was 1.87mm +/− 0.2mm. Conclusions. This study indicates that the ALL is a discrete, visible structure on MRI. This furthers the evidence of the presence of the ALL and also provides information that may be beneficial in future studies, and assessment of knee injuries. Level of evidence. 4

Summary Statement. Increased Dkk-1 signaling is associated with OA occurrence and joint microenvironment damage. Interruption of Dkk1 action is beneficial to improve OA knees. Introduction. Osteoarthritis (OA) is a leading cause of disability and healthcare financial burden for total knee arthroplasty, rehabilitation, and disability. Inappropriate mechanical stress, immunological, or biochemical regulation reportedly disturbs homeostasis among cartilage, synovium and subchondral bone microstructure that contributes to OA pathogenesis. Control of joint-deleterious factor action is an emerging strategy to ameliorate OA-induced joint deterioration. Dickkopf-1 (Dkk-1) is a potent inhibitor for Wnt/β-catenin signaling regulation of tissue development and remodeling in physiological or pathological contexts. Dkk-1 also acts as a master deleterious factor that represses osteoblast differentiation capacity and bone repair. Associations among Dkk-1 expression, chondrocyte fate, synovial fibroblast behavior or OA incidence are merit of characterization. Patients & Methods. Cartilage, synovial tissue and fluid were harvested from informed consent OA patients underwent arthroplasty and patient with knee injuries without OA changes as controls. Primary chondrocyte cultures and synovial fibroblasts were treated with inflammatory cytokines or Dkk-1 antisense oligonucleotide or monoclonal antibodies. Knees in experimental animals were subjected to anterior cruciate ligament transection- or intra-articular collagenase injection to induce OA. Joint inflammation, integrity and subchondral bone microstructure in knees as well gait profiles were quantified using 2-deoxyglucose-probed near-infrared in vivo image, µCT, catwalk and histomorphometric analyses. Results. In clinical vignettes, patients with end-stage OA knee had higher abundances of Dkk-1 in cartilage, synovial tissue, and synovial fluid compared to control patients. Disruption of DKk-1 signaling ameliorated the promoting effects of inflammatory cytokines on the survival and cartilage matrix synthesis in primary cartilage chondrocyte cultures. Of interest, Dkk-1 neutralization attenuated the excessive angiogenic activities and matrix metalloproteinase secretion in primary synovial fibroblasts of OA knees. Dkk-1 modulation of survival or metabolic activities in chondrocytes and synovial fibroblasts were through β-catenin-dependent and -independent signaling pathways. Moreover, increased Dkk-1 expression in lesion sites and sera was associated with the incidence of femoral head osteonecrosis. Loss of Dkk-1 action alleviated bone cell apoptosis in osteonecrotic bone microenvironments. In experimental OA knee models, knockdown of Dkk-1 alleviated articular cartilage damage as evidenced by improved Mankin score in OA knees. Dkk-1 disruption also alleviated the adverse effects of OA on subchondral bone exposure and loss of trabecular bone volume and mineral acquisition in injured joints. Loss of Dkk-1 function reduced joint inflammation, vessel number, leukocyte infiltration in synovium compartment of OA joint and improved gait profiles of affected limbs. Conclusion. Dkk-1 signaling is associated with the OA knee occurrence and accelerates apoptosis, matrix degradation and angiogenic activities in chondrocytes and synovial fibroblasts of OA joint. Dkk-1 interference alleviates the promoting effects of OA on cartilage, synovial and subchondral bone remodeling. Blocking the deleterious actions of Dkk-1 in joint microenvironment will be a prospective molecular regime beneficial for retarding excessive joint deterioration in OA knees

Knee injuries in cyclists are often thought to result from an imbalance of load during the cycling motion as a consequence of inappropriate bike set-up. Recently, it has been postulated that incorrect foot positioning may be a significant factor in lower limb injury and poor cycling performance. The purpose of this study is to assess the effect of changing the foot position at the shoe-pedal interface on Vastus Medialis (VM) and Vastus Lateralis (VL) activity (mean and mean peak), knee angle and knee displacement. Maximum power tests were completed on a first visit, with data collection on a second visit recorded at 60% of the subjects maximum. Video footage and surface electromyography (SEMG) from VM and VL muscles was obtained. Data was recorded over 10 crank cycles in 3 experimental conditions; neutral, 10 degrees inversion and 10 degrees eversion using Ethylene Vinyl Acetate (EVA) wedges fitted between the cyclists shoe and the shoe cleat. Raw data (mean SEMG, mean peak SEMG) was obtained using Noraxon and SiliconCOACH measured knee angle and knee displacement. Data was analyzed using Friedmans test with appropriate post hoc tests. 12 male subjects (range 26-45, mean 35.9 years) completed the study. Mean and mean peak SEMG data showed no significant differences between the 3 experimental conditions for VM and VL. VM:VL ratios from raw mean SEMG data demonstrated a decrease in synchronicity in inversion and eversion compared to neutral. Pronators demonstrated most synchronicity in inversion and least synchronicity in eversion. There were statistically significant differences in knee angle and knee displacement between neutral, inversion and eversion (p<0.05). Inversion promoted smaller knee valgus angles and greater knee displacement from the bike. Eversion promoted larger knee valgus angles and a smaller displacement from the bike. By altering the foot position to either 10 degrees inversion or 10 degrees eversion, knee angle and knee displacement can be significantly influenced. Clinically, subjects who foot type is classified as pronating may benefit from some degree of forefoot inversion posting. Further research on subjects with knee pain needs to be undertaken

Objectives

In this study, we compared the pain behaviour and osteoarthritis (OA) progression between anterior cruciate ligament transection (ACLT) and osteochondral injury in surgically-induced OA rat models.

Objectives

Given the function of adiponectin (ADIPOQ) on the inflammatory condition of obesity and osteoarthritis (OA), we hypothesized that the ADIPOQ gene might be a candidate gene for a marker of susceptibility to OA.

Objectives

The objectives of this study were: 1) to examine osteophyte formation, subchondral bone advance, and bone marrow lesions (BMLs) in osteoarthritis (OA)-prone Hartley guinea pigs; and 2) to assess the disease-modifying activity of an orally administered phosphocitrate ‘analogue’, Carolinas Molecule-01 (CM-01).

Objectives

This study looked to analyse the expression levels of microRNA-140-3p and microRNA-140-5p in synovial fluid, and their correlations to the severity of disease regarding knee osteoarthritis (OA).

Objectives

Whilst gait speed is variable between healthy and injured adults, the extent to which speed alone alters the 3D in vivo knee kinematics has not been fully described. The purpose of this prospective study was to understand better the spatiotemporal and 3D knee kinematic changes induced by slow compared with normal self-selected walking speeds within young healthy adults.

Objectives

Sustained intra-articular delivery of pharmacological agents is an attractive modality but requires use of a safe carrier that would not induce cartilage damage or fibrosis. Collagen scaffolds are widely available and could be used intra-articularly, but no investigation has looked at the safety of collagen scaffolds within synovial joints. The aim of this study was to determine the safety of collagen scaffold implantation in a validated in vivo animal model of knee arthrofibrosis.

Osteoarthritis (OA) is an important cause of pain, disability and economic loss in humans, and is similarly important in the horse. Recent knowledge on post-traumatic OA has suggested opportunities for early intervention, but it is difficult to identify the appropriate time of these interventions. The horse provides two useful mechanisms to answer these questions: 1) extensive experience with clinical OA in horses; and 2) use of a consistently predictable model of OA that can help study early pathobiological events, define targets for therapeutic intervention and then test these putative therapies. This paper summarises the syndromes of clinical OA in horses including pathogenesis, diagnosis and treatment, and details controlled studies of various treatment options using an equine model of clinical OA.

We evaluated two reconstruction techniques for a simulated posterolateral corner injury on ten pairs of cadaver knees. Specimens were mounted at 30° and 90° of knee flexion to record external rotation and varus movement. Instability was created by transversely sectioning the lateral collateral ligament at its midpoint and the popliteus tendon was released at the lateral femoral condyle. The left knee was randomly assigned for reconstruction using either a combined or fibula-based treatment with the right knee receiving the other. After sectioning, laxity increased in all the specimens. Each technique restored external rotatory and varus stability at both flexion angles to levels similar to the intact condition. For the fibula-based reconstruction method, varus laxity at 30° of knee flexion did not differ from the intact state, but was significantly less than after the combined method.

Both the fibula-based and combined posterolateral reconstruction techniques are equally effective in restoring stability following the simulated injury.