Twelve Weeks of a Staged Balance and Strength Training Program Improves Muscle Strength, Proprioception, and Clinical Function in Patients with Isolated Posterior Cruciate Ligament Injuries

Ligament reconstruction is indicated in patients with an isolated posterior cruciate ligament (PCL) injury who fail conservative treatment. To eliminate the need for PCL reconstruction, an ideal rehabilitation program is important for patients with an isolated PCL injury. The purpose of this study was to investigate the improvement in functional outcome, proprioception, and muscle strength after a Both Sides Up (BOSU) ball was used in a balance combined with strength training program in patients with an isolated PCL injury. Ten patients with isolated PCL injuries were recruited to receive a 12 week training program as a study group. In the control group (post-PCL reconstruction group), ten subjects who had undergone isolated PCL reconstruction for more than 2 years were enrolled without current rehabilitation. The Lysholm score, IKDC score, proprioception (active and passive), and isokinetic muscle strength tests at 60°/s, 120°/s, and 240°/s, were used before and after training on the injured and normal knees in the study group, and in the post-PCL reconstruction group. The results were analyzed with a paired t-test to compare the change between pre-training, post-training, and the normal leg in the study group, and with an independent t-test for comparisons between the study and post-PCL reconstruction groups. Both the Lysholm and IKDC scores were significantly improved (p < 0.01) after training, and no difference was observed compared to the post-PCL reconstruction group. The active and passive proprioception was improved post-training compared to pre-training, with no difference to that in the post-PCL reconstruction group. Isokinetic knee quadriceps muscle strength was significantly greater post-training than pre-training in PCL injured knees at 60°/s, 120°/s, and 240°/s, and in hamstring muscle strength at 60°/s and 120°/s. Muscle strength in the post-training injured knee group showed no significant difference compared to that in the post-training normal leg and the post-PCL reconstruction group. The post-training improvement of muscle strength was higher in the PCL injured leg compared to the normal leg and there was no difference between the dominant and non-dominant injured leg in the study group. After 12 weeks of BOSU balance with strength training in patients with an isolated PCL injury, the functional outcome, proprioception, and isokinetic muscle strength were significantly improved, and comparable to the contralateral normal leg and the post-PCL reconstruction group. We suggest that programs combining BOSU balance and strength training should be introduced in patients with a PCL injury to promote positive clinical results.

More Conservative Rehabilitation Strategy within Postoperative 6 Month for All-Inside Reconstruction Compared with Anatomical Reconstruction of Anterior Cruciate Ligament may be able to Achieve Better Stability: Based on the Study of Graft Maturity

Background: Individualized rehabilitation based on graft maturity is necessary to optimize patient function and prevent graft re-injury. But there is a lack of studies on graft maturity in the all-inside single-bundle anterior cruciate ligament reconstruction.Hypothesis/Purpose: Compared to the difference in graft maturity, functional scores, and stability between all-inside and anatomical single-bundle anterior cruciate ligament reconstruction, it was assumed that the stability of all-inside reconstruction is relatively insufficient, and its graft maturity is worse than the anatomical reconstruction.Study Design: Randomized controlled clinical trial.Methods: Fifty-four patients were recruited in this study and randomly assigned to the all-inside reconstruction group (n = 27) and the anatomical reconstruction group (n = 27) using the same rehabilitation strategy. The Tegner, International Knee Documentation Committee, and Lysholm score were recorded at postoperative 3rd, 6th, and 12th month to assess functional recovery. Magnetic resonance imaging was conducted to measure the Signal/Noise quotient (SNQ) of the intra-articular graft to observe the maturity. Stability was assessed using GNRB relaxation measuring instrument at the postoperative 12th month.Results: The graft SNQ of the all-inside group was significantly higher than that in the anatomical group during the postoperative 6th month (p < 0.05). There was no statistical difference in graft SNQ between the two groups at postoperative 3rd and 12th month (p > 0.05). Both groups exhibited the graft’s highest SNQ in the middle region, followed by the proximal region, and the lowest was the distal region. Functional scores improved significantly in both groups and had no statistical difference (p > 0.05). The stability recovered well in both groups during the postoperative 12th month, but the GNRB relaxation was higher in the all-inside group (p < 0.05). There was no correlation between functional scores and graft maturity in the two groups (p > 0.05).Conclusions: All-inside reconstruction graft maturity is inferior to the anatomical reconstruction during postoperative 6th month, which may cause relatively insufficient stability of all-inside reconstruction compared with anatomical reconstruction under the same rehabilitation strategy. A more conservative rehabilitation strategy for all-inside reconstruction around the postoperative 6th month may achieve better stability.

Bridging Allograft Reconstruction Is Superior to Maximal Repair for the Treatment of Chronic, Massive Rotator Cuff Tears: Results of a Prospective, Randomized Controlled Trial

Background: Despite advances in surgical techniques, the use of maximal repair to treat large or massive rotator cuff tears results in a high retear rate postoperatively. Currently, no randomized controlled trials have compared the outcomes of maximal repair with interposition dermal allograft bridging reconstruction. Hypothesis: We hypothesized that large or massive rotator cuff tendon tears reconstructed using bridging dermal allograft would have better clinical outcomes 2 years postoperatively, as measured using the Western Ontario Rotator Cuff (WORC) index, than would those receiving the current gold standard treatment of debridement and maximal repair alone. We also expected that patients treated via bridging reconstruction using dermal allograft would have fewer postoperative failures as assessed using postoperative magnetic resonance imaging scans. Study Design: Randomized controlled trial; Level of evidence 1. Methods: A sample size of 30 patients (determined using a priori sample size calculation) with massive, retracted rotator cuff tears were randomly allocated to 1 of 2 groups: maximal repair or bridging reconstruction using dermal allograft. All patients completed questionnaires (WORC and Disabilities of the Arm, Shoulder and Hand [DASH]) preoperatively and postoperatively at 3 months, 6 months, 1 year, and 2 years. The primary outcome of this study was the WORC index at 2 years. Secondary outcomes included healing rate, progression of rotator cuff arthropathy, and postoperative acromiohumeral distance in both groups. Results: Patients treated via bridging reconstruction using dermal allograft had better postoperative WORC and DASH scores (23.93 ± 24.55 and 15.77 ± 19.27, respectively) compared with patients who received maximal repair alone (53.36 ± 31.93 and 34.32 ± 23.31, respectively). We also noted increased progression to rotator cuff arthropathy in the maximal repair group with an increased retear rate when compared with the reconstruction group (87% and 21%, respectively; P < .001). The acromiohumeral distance was maintained in the reconstruction group but significantly decreased in the maximal repair group. Conclusion: Rotator cuff bridging reconstruction using a dermal allograft demonstrated improved patient-reported outcomes as measured using the WORC index 2 years postoperatively. This technique also showed favorable structural healing rates and decreased progression to arthropathy compared with maximal repair. Trial Registration: ClinicalTrials.gov (NCT01987973)

Reconstructive surgery in the complex treatment of breast cancer (10 years of experience)

The aim of the study is to improve the quality of life of women with breast cancer (BC) and a high risk of its development by performing one-stage or delayed reconstruction of the lost breast.The objectives of the study were: to clarify the criteria for selecting patients for prophylactic mastectomy; development of surgical tactics in the treatment of breast cancer and a high risk of its development; assessment of oncological safety of LME; clarification of the methods of reconstruction of the breast; analysis of postoperative complications, including the effect of neoadjuvant PCT during simultaneous breast reconstruction on their frequency, and determination of possible ways to prevent them.Material and methods. The prospective controlled study included 258 patients who underwent surgical treatment in our department between 2007 and 2016. The criteria for the inclusion of patients in the study were: carrying out radical surgical treatment for breast cancer, both in isolation and in combination with the reconstruction of the lost breast; carriage of germline mutations in the tumor suppressor genes BRCA1 and BRCA2, the presence of first-degree relatives suffering from breast cancer, previous BRCA-associated breast cancer; the desire of patients with multiple recurrent proliferative benign breast diseases that are not amenable to conservative and surgical treatment to use the surgical method of breast cancer prophylaxis with immediate restoration of the breast.Results. According to the Beck Depression Questionnaire, 72 % of patients in the first group of patients had a critical and high level of depression, while patients who underwent CME with one-stage reconstruction did not have such levels of depression. At the same time, a relatively favorable psychological state of patients with a low level of depression was observed in 17 of 21 patients in the RME + delayed reconstruction group (which amounted to 81% of the group), in 21 of 22 patients in the RME + simultaneous reconstruction group (95% of the group), and only in 5 of 43 patients in the RME group (12% of the group) (χ2 = 51.6; critical value 9.2 at p ≤ 0.01).Conclusions. When analyzing the results obtained, we once again became convinced of the oncological safety of LME with a one-stage reconstruction of the breast, subject to certain requirements. In the presence of appropriate conditions, it is possible to preserve the SAC during the LME. Preventive LME with simultaneous breast reconstruction is the method of choice in patients with a high risk of developing breast cancer, subject to the appropriate selection criteria and the patient's desire.

Transversus Abdominis Release (TAR) Procedure: Experience of An Abdominal Wall Reconstruction Group.

BackgroundComplex abdominal wall defects are important conditions with a high morbidity, leading to impairment of patients physical condition and quality of life. In the last decade, the abdominal wall reconstruction paradigm has changed due to formation of experienced and excellence groups, improving clinical outcomes after surgery. Therefore, our study shows the perspective and outcomes of an abdominal wall reconstruction group (AWRG) in Colombia, focused on transverse abdominis release (TAR) procedure.MethodsA retrospective review of a prospectively collected database was conducted. All the patients older than 18 years old that underwent TAR procedure between January 2014 – December 2020 were included. Analysis and description of postoperative outcomes (recurrence, surgical site infection (SSI), seroma, hematoma, and re-intervention) was performed.Results50 patients underwent TAR procedure. 62% of patients were male. Mean age was 55 ± 13.4 years. Mean BMI was 27.8 ± 4.5 Kg/m2. Abdominal wall defects were classified with EHS ventral Hernia classification having a W3 hernia in 72% of all defects (Mean gap size of 11.49 cm ± 4.03 cm). Mean CeDAR preoperative risk score was 20.5 % ± 14.5%. Protective association was established for SSI if the procedure was performed by the AWRG OR 0.7 (IC 95% 0.05-0.93 ). Higher risk of SSI was found in cases not performed by the abdominal wall reconstruction group OR 13.6 (CI 95% 9.12 - 15.5 ). ConclusionsTAR procedure for complex abdominal wall defects under specific clinical conditions including emergency scenarios is viable. Specialized and experienced groups lessen surgical site infection.

Type lll internal hemipelvectomy for primary bone tumours with and without allograft reconstruction

Aim There is insufficient evidence to support bony reconstruction of the pubis after a type III internal hemipelvectomy (resection of all or part of the pubis). In this study, we compared surgical complications, postoperative pain, and functional outcome in a series of patients who had undergone a type III internal hemipelvectomy with or without bony reconstruction. Methods In a retrospective cohort study, 32 patients who had undergone a type III hemipelvectomy with or without allograft reconstruction (n = 15 and n = 17, respectively) were reviewed. The mean follow-up was 6.7 years (SD 3.8) for patients in the reconstruction group and 6.1 years (SD 4.0) for patients in the non-reconstruction group. Functional outcome was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system and the level of postoperative pain with a visual analogue scale (VAS). Results The mean MSTS score of the patients was significantly better in patients after reconstruction (26 (SD 1.7) vs 22.7 (SD 2.0); p < 0.001). The mean visual analogue scale score for pain was significantly less in the reconstruction group (2.1 (SD 2) vs 4.2 (SD 2.2); p = 0.016). One infection occurred in each group. Bladder herniation occurred in three patients (17.6%) in the non-reconstruction group but none in the reconstruction group. Five patients (29.4%) in the non-reconstruction group and one (7%) in the reconstruction group had a limp. Graft displacement occurred in two patients in the reconstruction group. Conclusion We recommend reconstruction of the bony defect after a type III hemipelvectomy: it gives a better functional result, less postoperative pain, and fewer late surgical complications. Cite this article: Bone Joint J 2021;103-B(6):1155–1159.

Comparison of hamstring and quadriceps strength after anatomical versus non-anatomical anterior cruciate ligament reconstruction: a retrospective cohort study

Background Strength recovery of injured knee is an important parameter for patients who want to return to sport after anterior cruciate ligament reconstruction (ACLR). Comparison of muscle strength between anatomical and non-anatomical ACLR has not been reported. Purpose To evaluate the difference between anatomical and non-anatomical single-bundle ACLR in hamstring and quadriceps strength and clinical outcomes. Methods Patients received unilateral primary single-bundle hamstring ACLR between January 2017 to January 2018 were recruited in this study. Patients were divided into anatomical reconstruction group (AR group) and non-anatomical reconstruction group (NAR group) according to femoral tunnel aperture position. The hamstring and quadriceps isokinetic strength including peak extension torque, peak flexion torque and H/Q ratio were measured at an angular velocity of 180°/s and 60°/s using an isokinetic dynamometer. The isometric extension and flexion torques were also measured. Hamstring and quadriceps strength were measured preoperatively and at 3, 6, and 12 months after surgery. Knee stability including Lachman test, pivot-shift test, and KT-1000 measurement and subjective knee function including International Knee Documentation Committee (IKDC) and Lysholm scores were evaluated during the follow-up. Results Seventy-two patients with an average follow-up of 30.4 months (range, 24–35 months) were included in this study. Thirty-three were in AR group and 39 in NAR group. The peak knee flexion torque was significant higher in AR group at 180°/s and 60°/s (P < 0.05 for both velocity) at 6 months postoperatively and showed no difference between the two groups at 12 months postoperatively. The isometric knee extension torque was significant higher in AR group at 6 months postoperatively (P < 0.05) and showed no difference between the two groups at 12 months postoperatively. No significant differences between AR group and NAR group were found regarding knee stability and subjective knee function evaluations at follow-up. Conclusions Compared with non-anatomical ACLR, anatomical ACLR showed a better recovery of hamstring and quadriceps strength at 6 months postoperatively. However, the discrepancy on hamstring and quadriceps strength between the two groups vanished at 1 year postoperatively.

Optimal Management of the Unilateral Recurrent Laryngeal Nerve Involvement in Patients with Thyroid Cancer

We aimed to determine the optimal management of recurrent laryngeal nerve (RLN) involvement in thyroid cancer. We enrolled 80 patients with unilateral RLN involvement in thyroid cancer between 2000 and 2016. Eleven patients with preoperatively functional vocal folds (VFs) underwent sharp tumor resection to preserve the RLN (shaving group). Thirty-three patients underwent RLN reconstruction with RLN resection (reconstruction group). We divided the reconstruction group into two subgroups based on preoperative VF mobility (normal-reconstruction and paralyzed-reconstruction subgroups). In the cases where RLN reconstruction was difficult, phonosurgeries including arytenoid adduction (AA), with or without thyroplasty type I, or nerve muscle pedicle implantation with AA were performed later (phonosurgery group). We evaluated and compared vocal function among the evaluated periods and different groups. Postoperative vocal function in the shaving and normal-reconstruction subgroups was favorable. There were no significant differences between the two groups. In the paralyzed-reconstruction and phonosurgery groups, postoperative vocal function was significantly improved, and vocal function in the paralyzed-reconstruction subgroup was significantly better than that in the phonosurgery group. For optimal management of unilateral RLN involvement in thyroid cancer, first, sharp dissection should be performed, and if this is impossible, a simultaneous RLN reconstruction procedure should be adopted whenever possible.

Early surgical reconstruction versus rehabilitation with elective delayed reconstruction for patients with anterior cruciate ligament rupture: COMPARE randomised controlled trial

Objective To assess whether a clinically relevant difference exists in patients’ perceptions of symptoms, knee function, and ability to participate in sports over a period of two years after rupture of the anterior cruciate ligament (ACL) between two commonly used treatment regimens. Design Open labelled, multicentre, parallel randomised controlled trial (COMPARE). Setting Six hospitals in the Netherlands, between May 2011 and April 2016. Participants Patients aged 18 to 65 with an acute rupture of the ACL, recruited from six hospitals. Patients were evaluated at three, six, nine, 12, and 24 months. Interventions 85 patients were randomised to early ACL reconstruction and 82 to rehabilitation followed by optional delayed ACL reconstruction after a three month period (primary non-operative treatment). Main outcomes Patients’ perceptions of symptoms, knee function, and ability to participate in sporting activities were assessed with the International Knee Documentation Committee score (optimum score 100) at each time point over 24 months. Results Between May 2011 and April 2016, 167 patients were enrolled in the study and randomised to one of two treatments (mean age 31.3; 67 (40.%) women), and 163 (98%) completed the trial. In the rehabilitation and optional delayed ACL reconstruction group, 41 (50%) patients underwent reconstruction during follow-up. After 24 months, the early ACL reconstruction group had a significantly better (P=0.026) but not clinically relevant International Knee Documentation Committee score (84.7 v 79.4 (difference between groups 5.3, 95% confidence interval 0.6 to 9.9). After three months of follow-up, the International Knee Documentation Committee score was significantly better (P=0.002) for the rehabilitation and optional delayed ACL reconstruction group (difference between groups −9.3, −14.6 to −4.0). After nine months of follow-up, the difference in the International Knee Documentation Committee score changed in favour of the early ACL reconstruction group. After 12 months, differences between the groups were smaller. In the early ACL reconstruction group, four re-ruptures and three ruptures of the contralateral ACL occurred during follow-up versus two re-ruptures and one rupture of the contralateral ACL in the rehabilitation and optional delayed ACL reconstruction group. Conclusions In patients with acute rupture of the ACL, those who underwent early surgical reconstruction, compared with rehabilitation followed by elective surgical reconstruction, had improved perceptions of symptoms, knee function, and ability to participate in sports at the two year follow-up. This finding was significant (P=0.026) but the clinical importance is unclear. Interpretation of the results of the study should consider that 50% of the patients randomised to the rehabilitation group did not need surgical reconstruction. Trial registration Netherlands Trial Register NL 2618.