Lisa M. Kruse

Rehabilitation After Anterior Cruciate Ligament Reconstruction: A Systematic Review

BACKGROUND Rigorous rehabilitation after anterior cruciate ligament (ACL) reconstruction is necessary for a successful surgical outcome. A large number of clinical trials continue to assess aspects of this rehabilitation process. Prior systematic reviews evaluated fifty-four Level-I and II clinical trials published through 2005. METHODS Eighty-five articles from 2006 to 2010 were identified utilizing multiple search engines. Twenty-nine Level-I or II studies met inclusion criteria and were evaluated with use of the CONSORT (Consolidated Standards of Reporting Trials) criteria. Topics included in this review are postoperative bracing, accelerated strengthening, home-based rehabilitation, proprioception and neuromuscular training, and six miscellaneous topics investigated in single trials. RESULTS Bracing following ACL reconstruction remains neither necessary nor beneficial and adds to the cost of the procedure. Early return to sports needs further research. Home-based rehabilitation can be successful. Although neuromuscular interventions are not likely to be harmful to patients, they are also not likely to yield large improvements in outcomes or help patients return to sports faster. Thus, they should not be performed to the exclusion of strengthening and range-of-motion exercises. Vibration training may lead to faster and more complete proprioceptive recovery but further evidence is needed. CONCLUSIONS Several new modalities for rehabilitation after ACL reconstruction may be helpful but should not be performed to the exclusion of range-of-motion, strengthening, and functional exercises. Accelerated rehabilitation does not appear to be harmful but further investigation of rehabilitation timing is warranted. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Asymmetric Lower-Limb Malformations in Individuals with Homeobox PITX1 Gene Mutation

Clubfoot is one of the most common severe musculoskeletal birth defects, with a worldwide incidence of 1 in 1000 live births. In the present study, we describe a five-generation family with asymmetric right-sided predominant idiopathic clubfoot segregating as an autosomal-dominant condition with incomplete penetrance. Other lower-limb malformations, including patellar hypoplasia, oblique talus, tibial hemimelia, developmental hip dysplasia, and preaxial polydactyly, were also present in some family members. Genome-wide linkage analysis with Affymetrix GeneChip Mapping 10K mapping data from 13 members of this family revealed a multipoint LOD(max) of 3.31 on chromosome 5q31. A single missense mutation (c.388G-->A) was identified in PITX1, a bicoid-related homeodomain transcription factor critical for hindlimb development, and segregated with disease in this family. The PITX1 E130K mutation is located in the highly conserved homeodomain and reduces the ability of PITX1 to transactivate a luciferase reporter. The PITX1 E130K mutation also suppresses wild-type PITX1 activity in a dose-dependent manner, suggesting dominant-negative effects on transcription. The propensity for right-sided involvement in tibial hemimelia and clubfoot suggests that PITX1, or pathways involving PITX1, may be involved in their etiology. Implication of a gene involved in early limb development in clubfoot pathogenesis also suggests additional pathways for future investigations of idiopathic clubfoot etiology in humans.

Genetic linkage localizes an adolescent idiopathic scoliosis and pectus excavatum gene to chromosome 18 q.

Study Design. A single large family, in which adolescent idiopathic scoliosis (AIS) and pectus excavatum (PE) segregate as an autosomal dominant condition, was evaluated. Genome-wide linkage analysis and candidate gene sequencing were performed. Objective. To map the disease-causing locus in a large white family in which AIS and PE cosegregate. Summary of Background Data. AIS and PE are common musculoskeletal conditions known to have a genetic component, though few genes have been identified for either. Genetic studies have been confounded by a lack of large families in which the disorders segregate. Methods. Clinical examinations were performed on the proband, who underwent posterior spinal fusion, and 12 additional affected family members. To map a gene causing AIS and PE, a genome-wide linkage analysis was performed with the Affymetrix Mapping 10 K XbaI array on 13 affected and 10 unaffected family members. Candidate genes were sequenced. Results. AIS was present in 13 female family members and PE was present in 3 males and 1 female. Genome-wide linkage analysis resulted in a linkage peak on chromosome 18 q with a maximum parametric multipoint logarithm of the odds score of 3.86. Recombinants delineated the critical genetic region to an interval of 6.4 cM between SNP_A-1519369 and SNP_A-1507702, corresponding to a 7.06-Mb region (hg18: chr18:26342508–34395660). The chromosome 18 q linkage region contains more than 30 genes. Resequencing of the coding regions of 21 candidate genes in the region did not reveal any causative mutation. Conclusion. Linkage analysis in this large family demonstrated a novel locus for AIS and PE on chromosome 18 q. Because of the increased frequency of PE in familymembers of AIS patients, consideration of family members with PE as affected may increase the power of AIS genetic linkage studies.

Polygenic Threshold Model with Sex Dimorphism in Clubfoot Inheritance: The Carter Effect

BACKGROUND Idiopathic clubfoot is approximately twice as common in males than in females. The reason for this discrepancy is unclear but may represent an inherent difference in the susceptibility to the deformity. If this difference is due to genetic factors it is predicted that in order to inherit clubfoot, females need to have a greater number of susceptibility genes than males. Females would also be more likely to transmit the disease to their children and have siblings with clubfoot. This phenomenon is known as the Carter effect, and the presence of such an effect supports a multifactorial threshold model of inheritance. METHODS Ninety-seven multiplex families with more than one individual with idiopathic clubfoot were studied. The study included 1093 individuals: 291 with clubfoot and 802 unaffected relatives. Rates of transmission by the thirty-seven affected fathers and twenty-six affected mothers were calculated, and the prevalence among siblings was determined in the nuclear families of affected persons. RESULTS Within these multiplex families, the prevalence of clubfoot was lowest in daughters of affected fathers (eight of twenty-four) and highest in sons of affected mothers (eleven of thirteen). Affected mothers transmitted clubfoot to 59% of their children (nineteen of thirty-two children), whereas affected fathers transmitted idiopathic clubfoot to 37% of their children (twenty-six of seventy children) (p = 0.04). Siblings of an affected female also had a significantly higher prevalence of clubfoot than siblings of an affected male (46% [fifty-four of 117] compared with 34% [sixty-seven of 197]; p = 0.03). CONCLUSIONS This study demonstrates the presence of the Carter effect in idiopathic clubfoot. This effect can be explained by a polygenic inheritance of clubfoot, with females requiring a greater genetic load to be affected.

Outcome of all-inside second-generation meniscal repair: Minimum five-year follow-up

Background:Meniscal repair and preservation are the goal, when possible, of the treatment of meniscal injury. Current research on second-generation all-inside repair systems has been limited to a maximum of three years of follow-up. The purpose of this study was to evaluate the mid-term clinical suc

Magnetic Resonance Angiography in Clubfoot and Vertical Talus: A Feasibility Study

AbstractCongenital vascular alterations of the normal adult arterial pattern have been associated with multiple congenital limb deformities including clubfoot and vertical talus. Investigators have observed absence of the anterior tibial artery and dorsalis pedis artery in most patients with clubfoot, and absence of the posterior tibial artery in all patients with vertical talus. We used magnetic resonance angiography to define the lower extremity vascular anatomy of two patients with left-sided vertical talus and right-sided clubfoot and one patient with bilateral vertical talus and cartilage-derived morphogenetic protein-1 (CDMP-1) gene mutation. Of the three patients, one had bilateral posterior tibial artery deficiencies while the other had bilateral anterior tibial artery deficiencies. The third patient with bilateral vertical talus and CDMP-1 mutation had normal arterial structure bilaterally. Though clubfoot and vertical talus have distinctly different clinical phenotypes, the association of each with arterial abnormalities suggests a common etiology during development. The presence of normal arterial structure in our patient with vertical talus and CDMP-1 mutation suggests that other nonvascular etiologies may be responsible for some cases of foot deformities. Level of Evidence: Level IV, prognostic case series. See the Guidelines for Authors for a complete description of levels of evidence.

Polygenic Threshold Model with Sex Dimorphism in Adolescent Idiopathic Scoliosis: The Carter Effect

BACKGROUND Adolescent idiopathic scoliosis occurs between two and ten times more frequently in females than in males. The exact cause of this sex discrepancy is unknown, but it may represent a difference in susceptibility to the deformity. If this difference is attributable to genetic factors, then males with adolescent idiopathic scoliosis would need to inherit a greater number of susceptibility genes compared with females to develop the deformity. Males would also be more likely to transmit the disease to their children and to have siblings with adolescent idiopathic scoliosis. Such a phenomenon is known as the Carter effect, and the presence of such an effect would support a multifactorial threshold model of inheritance. METHODS One hundred and forty multiplex families in which more than one individual was affected with adolescent idiopathic scoliosis were studied. These families contained 1616 individuals, including 474 individuals with adolescent idiopathic scoliosis and 1142 unaffected relatives. The rates of transmission from the 122 affected mothers and from the twenty-eight affected fathers were calculated, and the prevalence among siblings was determined in the nuclear families of affected individuals. RESULTS The prevalence of adolescent idiopathic scoliosis in these multiplex families was lowest in sons of affected mothers (36%, thirty-eight of 105) and highest in daughters of affected fathers (85%, twenty-two of twenty-six). Affected fathers transmitted adolescent idiopathic scoliosis to 80% (thirty-seven) of forty-six children, whereas affected mothers transmitted it to 56% (133) of 239 children (p < 0.001). Siblings of affected males also had a significantly higher prevalence of adolescent idiopathic scoliosis (55%, sixty-one of 110) compared with siblings of affected females (45%, 206 of 462) (p = 0.04). CONCLUSIONS This study demonstrates the presence of the Carter effect in adolescent idiopathic scoliosis. This pattern can be explained by polygenic inheritance of adolescent idiopathic scoliosis, with a greater genetic load required for males to be affected.

Contamination of the Surgical Field with Propionibacterium acnes in Primary Shoulder Arthroplasty.

BACKGROUND Propionibacterium acnes is a common pathogen identified in postoperative shoulder infection. It has been shown to be present in culture specimens during primary shoulder arthroplasty; however, recent work has suggested that it is most likely to be a contaminant. Our aim was to identify the potential sources of contamination in shoulder arthroplasty. METHODS Tissue swabs were obtained for microbiological analysis from consecutive patients undergoing primary shoulder arthroplasty. Routine surgical technique was maintained, and 5 specimens were taken from different sites: (1) the subdermal layer, (2) the tip of the surgeons glove, (3) the inside scalpel blade (used for deeper incision), (4) the forceps, and (5) the outside scalpel blade (used for the skin incision). RESULTS Forty patients (25 female patients and 15 male patients) were included. Thirteen (33%) of the 40 patients had at least 1 culture specimen positive for P. acnes. Two (8%) of the 25 female patients and 11 (73%) of the 15 male patients had ≥1 culture specimen positive for P. acnes. The most common site of growth of P. acnes was the subdermal layer (12 positive samples), followed by the forceps (7 positive samples), the tip of the surgeons glove (7 positive samples), the outside scalpel blade (4 positive samples), and the inside scalpel blade (1 positive sample). There were 27 of 75 swabs that were positive on culture for P. acnes in male patients compared with 4 of 125 swabs in female patients. Male patients had 66 times (95% confidence interval, 6 to 680 times) higher odds of having a positive culture indicating subdermal colonization compared with female patients (p < 0.001). CONCLUSIONS P. acnes is a common contaminant of the surgical field in primary shoulder arthroplasty. The subdermal layer may be the source of this contamination, and the prevalence of P. acnes in the surgical wound may be due to the surgeons manipulation with gloves and instruments. Our findings are consistent with those regarding the increased rates of P. acnes bacterial load and intraoperative growth in male patients compared with female patients. CLINICAL RELEVANCE P. acnes is likely to be spread throughout the surgical field from the subdermal layer via soft-tissue handling by the surgeon and instruments. Strategies need to be utilized to minimize this contact and to reduce the chance of colonization.

Anterior cruciate ligament reconstruction rehabilitation in the pediatric population.

Anterior cruciate ligament (ACL) reconstruction rehabilitation in the pediatric population offers some similarities and a few differences compared with adult ACL reconstruction rehabilitation. Many of the fundamental principles remain applicable to the pediatric population. The challenge for the orthopedic surgeon performing ACL reconstruction in this population is the knowledge that of all of the patients that they interface with this group has the highest likelihood to return to a high level of activity. Thus, their expectations are to have an outstanding outcome after this procedure. An understanding of this can help the physician to challenge the patient to assist in obtaining these results by actively participating in their rehabilitation.

Clinical outcomes after decompression of the nerve to the teres minor in patients with idiopathic isolated teres minor fatty atrophy.

BACKGROUND The purpose of this manuscript is to describe what we believe to be the first series of patients surgically treated for idiopathic isolated teres minor atrophy and to present the results of surgical decompression of the nerve to the teres minor. METHODS This is a retrospective cohort of 22 patients who underwent decompression of the nerve to the teres minor for isolated teres minor atrophy. Clinical data including duration of symptoms, additional diagnoses, concurrent procedures, preoperative physical examination findings, imaging data, and preoperative visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) scores were collected from the medical record. Postoperative patient-based clinical outcome measures including VAS, SST, and ASES scores were obtained during clinical examination or by telephone interview. RESULTS Average length of follow-up was 26 months. Nine patients had concurrent procedures performed. Preoperatively, 12 of 14 (86%) had external rotation weakness in Hornblowers position. Postoperatively, pain scores decreased an average of 4 points; ASES scores increased 31.7 ± 20.2 points; SST scores increased 3.1 ± 2.3 points. No external rotation weakness was noted postoperatively in any tested patient. Two patients developed adhesive capsulitis. No other complications occurred. CONCLUSIONS Isolated compression of the nerve to the teres minor is a rare and novel clinical entity. In properly selected cases, open release of the fascial sling enveloping the nerve branches to the teres minor can provide relief of symptoms and clinical improvement.