Marko Kadija

Evaluation of isokinetic and isometric strength measures for monitoring muscle function recovery after anterior cruciate ligament reconstruction.

Abstract Knezevic, OM, Mirkov, DM, Kadija, M, Milovanovic, D, and Jaric, S. Evaluation of isokinetic and isometric strength measures for monitoring muscle function recovery after anterior cruciate ligament reconstruction. J Strength Cond Res 28(6): 1722–1731, 2014—Although various strength tests and their outcome measures have been proposed for anterior cruciate ligament (ACL) reconstruction (ACLR), their measurement properties still remain relatively underexplored. The aim of this study was to investigate the longitudinal construct validity of the standard isokinetic (IKT) and isometric test (IMT), and of the IMT of alternating consecutive maximal contractions (ACMC). In addition, the concurrent validity of ACMC was assessed and compared with the validity of IMT. The strength of quadriceps and hamstrings in 20 male athletes with an anterior cruciate ligament (ACL) injury were assessed before ACLR, 4 and 6 months after ACLR, by means of IMT, ACMC, and IKT performed at 60 and 180°·s−1. Significant between-session differences in muscle strength variables were found in the involved quadriceps (F > 6.5; p ⩽ 0.05), but not in the uninvolved leg (F < 2.5; p > 0.05). Coefficients of variations in the uninvolved leg (all below 13.5%) were lower than the involved leg (11.7–22.1%). Intraclass correlation coefficients were moderate-to-high for the uninvolved leg and low-to-high for quadriceps of the involved leg. The concurrent validity of ACMC with respect to the IKT (r = 0.57–0.92; p ⩽ 0.05) was comparable with the validity of IMT (r = 0.52–0.87; p ⩽ 0.05). We conclude that the explored longitudinal construct validity of most of the evaluated variables could be sufficiently sensitive to detect the effects of the applied rehabilitation procedures. In addition, the obtained sensitivity and concurrent validity and the potential advantages of ACMC over IMT, all suggest that ACMC could be a particularly promising method for routine testing of neuromuscular function after ACLR.

Early mortality after hip fracture: what matters?

Hip fractures in the elderly are followed by increased mortality, which is highest in the period immediately after the fracture. Predictors for early mortality have neither been well identified nor summarized. Identification of early postoperative mortality predictors enables the stratification of high‐risk patients and can help in the development of strategies aimed at reducing risk and improving outcome after hip fracture. The primary aim of this study was to investigate the incidence of 30‐day mortality. The secondary aim was to investigate factors related to early mortality.

Contralateral limb deficit after ACL-reconstruction: an analysis of early and late phase of rate of force development

ABSTRACT The aim of this study was to assess the effect of a unilateral anterior cruciate ligament reconstruction (ACLR) on maximum voluntary contraction (MVC) and explosive strength of both the involved limb and the uninvolved limb. Nineteen male athletes completed a standard isometric testing protocol 4 months post-ACLR, while 16 healthy participants served as a control group (CG). The explosive strength of the knee extensors and flexors was assessed as RFD obtained from the slope of the force–time curves over various time intervals. Both muscle groups of the involved limb had significantly lower MVC compared to the uninvolved. The involved limb also had significantly lower RFD in the late phase of contraction (140–250 ms) for both knee extensors and flexors (P < 0.05). There was no difference in MVC between the uninvolved limb and the CG. However, RFD of the uninvolved limb was lower compared to CG for both knee extensors (0–180 ms; P < 0.01) and flexors (0–150 ms; P < 0.05). ACLR leads to lower MVC and explosive strength of the involved limb. As a consequence of potential crossover (presumably neural-mediated) effects, explosive strength deficits could be bilateral, particularly in the early phase of the contraction (<100 ms).

Alternating Consecutive Maximum Contraction as a Test of Muscle Function in Athletes Following ACL Reconstruction.

The novel test based on isometric alternating consecutive maximal contractions performed by two antagonistic muscles has been recently proposed as a test of muscle function in healthy subjects. The aim of this study was to evaluate reliability and sensitivity of a novel test as a test of knee muscles function in athletes recovering from anterior cruciate ligament reconstruction. Fifteen male athletes with recent ligament reconstruction (4.0 ± 0.1 months following the surgery) and 15 sport and physical education students participated in the study. Peak torques of the quadriceps and hamstring muscles assessed both through the alternating consecutive maximal contractions and standard isokinetic test performed at 60 º/s and 180 º/s served for calculation of the hamstrings-to-quadriceps ratio and the bilateral difference in strength. When applied on individuals recovering from anterior cruciate ligament reconstruction, the novel test revealed a high within-day reliability and sensitivity for detecting imbalances both between antagonistic and between contralateral muscles. The present findings suggest that alternating consecutive maximal contractions could be used as a test of muscle function that is either complementary or alternative to the isokinetic test, particularly in the laboratories where the isokinetic devices are not available. Potential advantages of the novel test could be both a brief testing procedure and a possibility to conduct it using relatively inexpensive devices such as custom made kits containing a single one-axis force transducer.

Is anemia at admission related to short-term outcomes of elderly hip fracture patients?

Hip fracture in elderly people is associated with high morbidity and mortality. Therefore, it is important to identify risk factors that potentially influence outcomes after hip surgery. The main purpose of this study was to evaluate the relationship of anemia at admission and short-term outcomes after hip fracture. We studied 343 community-dwelling patients who underwent surgery for hip fracture from March 2009 to March 2010. Functional mobility at discharge, postoperative complications, hospital length of stay and in-hospital mortality were analyzed in respect to presence and severity of anemia at admission. Anemia (defined as hemoglobin levels < 13.0 g/dl for men and < 12.0g/dl for women) was present in 185 (53.9%) patients, of whom 54 (29.2%) were severely anemic (defined as hemoglobin level 10.0g/dl or below). In multivariate analysis anemia was associated with age, gender (female), type of fracture (intertrochanteric) and American Society of Anesthesiologists (ASA) classification (3 or 4), while severity of anemia was associated with recovery of ambulatory ability at discharge. There was no difference in the incidence of postoperative complication, in-hospital mortality and length of hospital stay between the groups at discharge. Overall anemia at admission is an indicator of poor general health status. Ambulatory recovery in hip fracture patients is independently related to severity of anemia at admission.

Forearm reconstruction after loss of radius: Case report

INTRODUCTION Osteomyelitis of the radius resulting in the radial clubhand is a very rare condition and few studies have been published about its prognosis and treatment. CASE OUTLINE This is a case report of hematogenous osteomyelitis of the radius with a complete loss of the radius leaving only the distal radial metaphysis to carry the carpus. In order to achieve best functional results, four-step operative protocol was performed for reconstruction; lengthening of the forearm by external fixator, radioulnar transposition to create a one-bone forearm, plate removal and transposition of brachioradialis to the extensor pollicis longus as well as proximal row carpectomy. After nine years of the last operation, the function of the elbow and hands is good with acceptable cosmetic result. The forearm is 5 cm shorter and there has been a persistent mild limitation of palmar flexion. CONCLUSION Creation of the one-bone forearm normalizes the elbow and wrist function, corrects forearm malalignment, and improves forearm growth potential.

Missed opportunities for prevention of hip fracture in older patients

BACKGROUND/AIM Osteoporotic fractures are a major cause of morbidity in the population. Therefore, fracture prevention strategies should be a major concern, and one of the priorities in the primary health care system. The aim of the study was to assess fracture and fall risk factors, and fracture risk level in patients with acute hip fracture, and to evaluate if there had been adequate osteoporosis treatment prior to fracture in this group of patients. METHODS Fracture and fall risk factors were assessed in 342 patients, > or = 65 years old, hospitalized due to acute hip fracture at the Clinic for Orthopedic Surgery and Traumatology, Clinical Centre of Serbia in a 12-month period. Fall risk factors were assessed with the Fracture Risk Assessment (FRAX) algorithm, and patients were classified in respect to fracture risk level. RESULTS Hip fracture occurred in the majority of the patients in the high risk group (74.2%), where no additional bone mineral density testing was needed. Less than 10% of the patients had a diagnosis of osteoporosis before injury, while less than 2% were treated. Cognitive impairment (95.3%), visual impairment (58.2%), lower index of daily activities (51.8%), and depression (47.1%) were the most frequently observed fall risk factors. CONCLUSION The results of our investigation reveal insufficient identification of clinical fracture risk factors in the primary care setting, inadequate treatment of osteoporosis and, consequently, ineffective prevention of hip fractures in the geriatric population. The introduction of FRAX into clinical practice enables more effective acknowledgment of patients with elevated fracture risk, even if bone density measurement is not available. The results of this study have a special significance for everyday clinical practice, because they impose a need for reviewing the existing approaches to osteoporosis prevention, and precise definiment of hip prevention strategies.

Basic principles of aggressive rehabilitation after anterior cruciate ligament reconstruction

Rehabilitation after ACL (anterior cruciate ligament) reconstruction has drastically changed over the last decade, with the adoption of a more aggressive approach, right from the first day after surgery. Progress in the effectiveness of rehabilitation is based on improvements in operative techniques, as well as on the encouraging results of histological studies regarding graft healing. Despite a huge amount of research papers on this topic, a rehabilitation golden standard still has not been established, due to the complexity of this problem. In this review, we point out the basic principles of rehabilitation after arthroscopically assisted ACL reconstruction based on actual practices, as well as the importance of specific procedures for the prevention of complications during the postoperative period. The importance of range-of-motion exercises, early weight bearing, an appropriate gait scheme, patella mobilisation, pain and oedema control, as well as stretching and balance exercises is explained. The functional advantages of closed kinetic chain exercises, as well as their influence on the graft are also described, in comparison to open kinetic chain exercises. The fundamentals of returning to sports are revealed and the specific aspects of rehabilitation regarding graft choice are pointed out. While waiting for new clinical investigations, which are expected to enable the establishment of a rehabilitation golden standard, the outlined principles should be followed. The complexity of this injury requires treatment in highly specialised institutions.

The influence of the position of the medial portal and of lower leg flexion on the length of the femoral tunnel in anatomic anterior cruciate ligament reconstruction: A cadaveric study

Background/Aim. The key to successful anterior cruciate ligament reconstruction lies in the proper positioning of the femoral tunnel within the anatomical footprint and in providing for an adequate length of this tunnel without perforation to the lateral cortex. The aim of this study was to determine the change in the length of the femoral tunnel drilled during anatomic anterior cruciate ligament (ACL) reconstruction, depending on: the position of the limb being operated on, the degree of knee flexion, as well as the angle between the drill and the medial aspect of the lateral condyle. Methods. This study was performed on 16 cadaveric knees (6 male and 10 female) of the average age of 83. After the subcutaneous tissue was dissected, the femoral insertion of the ACL was identified. Then, 18 tunnels were drilled through the center of the femoral insertion with the help of 2 mm thick Kirschner wires. This was performed in two stages. In the first phase the leg was positioned on an arthroscopic leg holder, while in the second phase the leg was positioned on the table. In each phase the knee was placed in three different flexion positions (110°, 120° and 130°) and for each position three tunnels were drilled (70°, 60° and 50°) in relation to the medial aspect of the lateral condyle. Results. The average length of the femoral tunnel drilled with the leg positioned on the operating table (36.6 ± 4.7 mm) was highly statistically significantly greater (p = 0.000) in comparison with the length of the femoral tunnel obtained by positioning the leg on a fixed arthroscopic leg holder (35.4±4.3 mm). The greatest lengths of the femoral tunnel were obtain with the leg flexed at 130o and the reamer positioned at 50o angle in relation to the medial aspect of the lateral condyle (43 mm on the operating table and 41 mm on a fixed leg holder), while the shortest tunnel (33 mm on the operating table and 31 mm on a fixed leg holder) was obtained with the lower leg flexed at 110o and the reamer positioned at a 70o angle. Conclusion. The optimal position of the leg on a fixed leg holder for obtaining a femoral tunnel of sufficient length requires lower leg flexion of 120o and the position of the medial portal which enables the positioning of the reamer at a 60o angle in relation to the medial aspect of the lateral condyle. With the leg positioned on the operating table, it becomes unnecessary to push the leg into flexion greater than 110o; rather a longer femoral tunnel is achieved by lateralization of the medial portal.