UNASSIGNED: Anatomic anterior cruciate ligament (ACL) reconstruction is considered the gold standard treatment for ACL injuries because it aims to restore the knee\'s normal anatomy and stability, while also protecting long-term knee health. Long-term clinical and radiological outcomes after ACL reconstruction using the modified TT technique are unclear.
UNASSIGNED: To assess the clinical and radiological outcomes following ACL reconstruction using modified transtibial (TT) techniques at a minimum 12-month follow-up.
UNASSIGNED: A systematic review with meta-analysis.
UNASSIGNED: PubMed, EMBASE, Web of Science, the Cochrane Library, and MEDLINE databases were searched from the inception to December 1, 2022. PICO search strategy was used to identify studies applying modified TT techniques on patients with ACL reconstruction and a minimum follow-up of 12 months. Eligible studies were identified independently by two reviewers. We extracted data on patient demographics, surgical characteristics, patient reported outcomes including subjective evaluations and clinical outcomes. Radiological data including femoral and tibial tunnel position, femoral and tibial tunnel length, and femoral tunnel angle were also extracted. The tunnel position was evaluated using the quadrant method based on three-dimensional computed tomography (3D CT) images. The standardized mean difference (SMD) and 95 % confidence interval (CI) were calculated for clinical and radiological outcomes.
UNASSIGNED: Sixteen studies involving 628 patients were finally included. The SMD of Lysholm (90.39; 95 % CI 83.41-97.38), IKDC (86.07; 95 % CI 79.84-92.31), and Tegner (6.15; 95 % CI 3.96-8.33) scores were considered satisfactory. The depth of the femoral tunnel showed a pooled SMD of 30.08 % (95 % CI 28.25-31.91 %), and the height showed a pooled SMD of 37.72 % (95 % CI 35.75-39.70 %). The pooled SMD for the femoral tunnel angle in the coronal plane was 48.27°(95 % CI 43.14-53.40°), and the pooled SMD for the femoral tunnel length was 33.98 mm (95 % CI 29.03-38.93 mm).
UNASSIGNED: This investigation has shown that modified TT technique can create an anatomic femoral tunnel and maintain optimal tunnel length and angulation. Most patients had satisfactory subjective outcomes and physical examinations after ACL reconstruction using modified TT technique. This information may assist in guiding expectations of clinicians and patients following ACL reconstruction with modified TT technique.

BACKGROUND: The current literature comparing femoral tunnel techniques often reports on short-term outcomes after anterior cruciate ligament reconstruction (ACLR), but only a few studies have analyzed long-term outcomes. In addition, many studies have compared transtibial to anteromedial portal techniques without differentiating whether rigid or flexible reaming is used, making it difficult to infer how the techniques truly compare to one another.
OBJECTIVE: This study aimed to detect differences in patient-reported outcome scores in those treated with three different femoral tunnel drilling techniques.
METHODS: This study is a prospective cohort study.
METHODS: Of 650 patients treated for anterior cruciate ligament (ACL) injuries with ACLR, 350 were 5+ years out from surgery. Of these patients, 111 completed patient-reported outcome surveys (PROs). The Kruskal-Wallis H test was used to detect differences between patients treated with either of the three femoral tunnel drilling techniques: transtibial (TT), anteromedial portal with rigid reaming (AMP-RR), or anteromedial portal with flexible reaming (AMP-FR). Bonferroni correction was applied to the p-values to reduce the risk of making a type 1 error.
RESULTS: No differences were found between the three groups in demographics or postoperative PROs. However, there was a significant change between pre-surgery and post-surgery PROs. TT, when compared to AMP-RR, had a greater increase in satisfaction and greater improvement in a patient\'s ability to go up and down the stairs from pre-surgery to post-surgery. AMP-FR, when compared to TT, had greater improvement of the patient\'s knee stiffness/swelling. AMP-FR, when compared to AMP-RR, had greater improvement in knee pain during stairs and the ability to go down the stairs. No differences in return to sport, additional procedures on the affected knee (meniscal surgeries or cyclops lesion excisions), or revision surgery rates were found.
CONCLUSIONS: Overall, postoperative PROs did not show statistically significant differences between the three femoral tunnel drilling techniques. Differences, however, were identified in the responses to specific questions on PRO surveys, which may have otherwise been overlooked. It is important to recognize the differences between TT, AMP-RR, and AMP-FR in the improvement of stair climbing and swelling/stiffness as these likely directly affect a patient\'s satisfaction from pre-ACLR to post-ACLR.

UNASSIGNED: This study aimed to evaluate the pressure distribution and comfort of transtibial prosthesis wearers using an affordable ethyl-vinyl acetate (EVA) roll-on (AERO) liner.
UNASSIGNED: Fifteen unilateral transtibial prosthesis users wore patella tendon bearing (PTB) sockets with a polyethylene foam (PE-lite) liner were enrolled this study. AERO liners were provided to all participants. Six force sensors were applied to the residual limb to evaluate pressure distribution during treadmill walking, and the socket comfort score (SCS) was used to evaluate comfortability. Fourier transform infrared (FT-IR) spectroscopy was performed on the EVA and PE-lite liners.
UNASSIGNED: Eleven participants used prefabricated AERO liners and four participants used custom-made AERO liners. The pressure distribution was analysed by the coefficient of variation (CV): PE-lite was 75.7 ± 6.0 and AERO liner 83.3 ± 4.1. Residual limb pressure was significantly decreased when using the AERO liner (p = .0007), with a large effect size (r = 0.87). Mean SCS was 7.5 ± 1.3 and 8.9 ± 1.1 for PE-lite and AERO liner respectively.
UNASSIGNED: Better pressure distribution and comfort were observed when the participants used the AERO liner. AERO had a greater proportion of calcium carbonate (CaCO3). These findings suggest that the AERO liner is a better off-the-shelf option for persons using traditional prosthetic sockets and liners.

UNASSIGNED: In non-impaired human locomotion, sagittal-plane slope adaptation of the foot-ankle complex is a volitional function driven by neuromotor control to support upright posture and forward ambulation. Loss of this adaptation due to transtibial amputation can lead to instability and compensatory motions as most commercially-available prosthetic feet do not permit automatic slope adjustments. A selection of slope-adaptive feet (SAF) have been developed to promote biomimetic ankle motion while ambulating over slopes. This review evaluated the current literature to assess the effects of SAF prostheses on sloped gait performance in unilateral transtibial prosthesis users.
UNASSIGNED: Four databases (PubMed, Embase, CINAHL, IEEE Xplore) were searched on April 28, 2022, for relevant articles. Search keywords covered the general terms \"transtibial,\" \"amputation,\" \"slope,\" \"adaptive,\" and \"gait\", and included articles comparing a SAF prosthesis to a non-SAF prosthesis condition. Data were extracted for analysis and results were grouped according to outcomes to identify trends and aid interpretation of slope adaptation effects on gait.
UNASSIGNED: Of the 672 articles screened, 24 met the selection criteria and were included in this review, published between 2009 and 2022. The non-SAF condition included dynamic response feet and SAF prostheses with the adaptability function inactive. Outcomes included biomechanical variables (joint dynamics, gait symmetry, toe clearance), clinical outcome measures, and energy expenditure. All SAF demonstrated some form of foot-ankle slope gradient adaptability, but effects on other joint dynamics were inconsistent. Minimum toe clearance during incline and decline walking was greater when using SAF compared to non-SAF in all reporting studies.
UNASSIGNED: Results generally suggest improvements in gait quality, comfort, and safety with use of SAF compared to non-SAF during slope walking. However, variations in tested SAF and walking gradients across studies highlight the need for research to elucidate walking condition effects and advantages of specific designs.
UNASSIGNED: Slope-adaptive prosthetic feet may improve user gait quality and comfort and enhance gait safety by increasing minimum toe clearance. Patients who encounter slopes regularly should be considered as potential users of SAF if indicated appropriately.

Numerous studies have suggested that the primary cause of failure in transtibial anterior cruciate ligament reconstruction (ACLR) is often attributed to non-anatomical placement of the bone tunnels, typically resulting from improper tibial guidance. We aimed to establish the optimal tibial tunnel angle for anatomical ACLR by adapting the transtibial (TT) technique. Additionally, we aimed to assess graft bending angle (GBA) and length changes during in vivo dynamic flexion of the knee. Twenty knee joints underwent a CT scan and dual fluoroscopic imaging system (DFIS) to reproduce relative knee position during dynamic flexion. For the single-legged lunge, subjects began in a natural standing position and flexed the right knee beyond 90° When performing the lunge task, the subject supported the body weight on the right leg, while the left leg was used to keep the balance. The tibial and femoral tunnels were established on each knee using a modified TT technique for single-bundle ACLR. The tibial tunnel angulation to the tibial axis and the sagittal plane were measured. Considering that ACL injuries tend to occur at low knee flexion angles, GBA and graft length were measured between 0° and 90° of flexion in this study. The tibial tunnel angulated the sagittal plane at 42.8° ± 3.4°, and angulated the tibial axis at 45.3° ± 5.1° The GBA was 0° at 90° flexion of the knee and increased substantially to 76.4 ± 5.5° at 0° flexion. The GBA significantly increased with the knee extending from 90° to 0° (p < 0.001). The ACL length was 30.2mm±3.0 mm at 0° flexion and decreased to 27.5mm ± 2.8 mm at 90° flexion (p = 0.072). To achieve anatomic single-bundle ACLR, the optimal tibial tunnel should be angulated at approximately 43° to the sagittal plane and approximately 45° to the tibial axis using the modified TT technique. What\'s more, anatomical TT ACLR resulted in comparable GBA and a relatively constant ACL length from 0° to 90° of flexion. These findings provide theoretical support for the clinical application and the promotion of the current modified TT technique with the assistance of a robot to achieve anatomical ACLR.

The purpose of this study was to systematically review and meta-analyze randomized controlled trials (RCTs) reporting the comparative clinical and functional outcomes, postoperative complications, and radiological outcomes of single-bundle anterior cruciate ligament reconstruction (ACLR) performed using the transtibial (TT) approach or anteromedial (AM) technique. A systematic review of the literature was performed according to Cochrane and PRISMA guidelines. RCTs comparing TT and AM techniques were considered only. The quality of the studies was defined using the GRADE system, and the risk of bias was assessed with the RoB 2 tool. The primary endpoint was to systematically review and meta-analyze the clinical outcomes, residual laxity and failure rate of both AM and TT techniques. In the current meta-analysis 13 RCTs involving 989 patients who underwent arthroscopic single-bundle ACLR (486 TT and 503 AM) were included. Patients undergoing AM technique resulted in higher objective-IKDC (p < 0.001) and Lysholm scores (p = 0.002), despite a lower incidence of pathological anterior tibial translation (p < 0.001) and positive pivot-shift test (p < 0.001). No differences were detected in IKDC subjective score (p = 0.26), Tegner activity scale (p = 0.18) and graft failure (p = 0.07). ACL reconstruction through AM portal technique provides better clinical outcomes and lower incidence of residual rotational and anteroposterior laxity in comparison with the TT technique. No statistically significant difference in subjective outcomes and graft failure was reported.

Stress concentration on the Anterior Cruciate Ligament Reconstruction (ACLr) for femoral drillings is crucial to understanding failures. Therefore, we described the graft stress for transtibial (TT), the anteromedial portal (AM), and hybrid transtibial (HTT) techniques during the anterior tibial translation and medial knee rotation in a finite element model. A healthy participant with a non-medical record of Anterior Cruciate Ligament rupture with regular sports practice underwent finite element analysis. We modeled TT, HTT, AM drillings, and the ACLr as hyperelastic isotropic material. The maximum Von Mises principal stresses and distributions were obtained from anterior tibial translation and medial rotation. During the anterior tibia translation, the HTT, TT, and AM drilling were 31.5 MPa, 34.6 Mpa, and 35.0 MPa, respectively. During the medial knee rotation, the AM, TT, and HTT drilling were 17.3 MPa, 20.3 Mpa, and 21.6 MPa, respectively. The stress was concentrated at the lateral aspect of ACLr,near the femoral tunnel for all techniques independent of the knee movement. Meanwhile, the AM tunnel concentrates the stress at the medial aspect of the ACLr body under medial rotation. The HTT better constrains the anterior tibia translation than AM and TT drillings, while AM does for medial knee rotation.

UNASSIGNED: A large proportion of people die in the years following dysvascular partial foot amputation (PFA) or transtibial amputation (TTA) given the long-term consequences of peripheral vascular disease and/or diabetes. A critical appraisal of recent research is needed to understand the underlying cause of variation and synthesise data for use in consultations about amputation surgery and patient-facing resources. This systematic review aimed to describe proportionate mortality following dysvascular PFA and to compare this between PFA and TTA.
UNASSIGNED: The review protocol was registered in PROSPERO (CRD42023399161). Peer-reviewed studies of original research were included if they: were published in English between 1 January 2016, and 12 April 2024, included discrete cohorts with PFA, or PFA and TTA, and measured proportionate mortality following dysvascular amputation.
UNASSIGNED: Seventeen studies were included in the review. Following dysvascular PFA, proportionate mortality increased from 30 days (2.1%) to 1-year (13.9%), 3-years (30.1%), and 5-years (42.2%). One study compared proportionate mortality 1-year after dysvascular PFA and TTA, showing a higher relative risk of dying after TTA (RR 1.51).
UNASSIGNED: Proportionate mortality has not changed in recent years. These results are comparable to a previous systematic review that included studies published before 31 December 2015.Implications for rehabilitationIt is important to ensure data describing mortality in the years following dysvascular partial foot or transtibial amputation is up to date and accurate.Evidence about proportionate mortality has not changed in recent years and the results are comparable to previous systematic reviews.Data describing mortality outcomes can be used in decision aids that support conversations about the choice of amputation level.

BACKGROUND: In the process of transtibial prosthetic fitting, alignment is the process of positioning the prosthetic foot relative to the residual limb. Changes in frontal plane alignment can impact knee moments during walking, which can either cause or, when aligned properly, prevent injuries. However, clinical evaluation of dynamic knee moments is challenging, limiting prosthetists\' insights into dynamic joint loading. Typically, knee joint loading is assessed in static stance using the knee moment arm as a proxy for subsequent dynamic alignment. It remains uncertain if static alignment accurately represents actual dynamics during walking.
OBJECTIVE: Is the frontal knee moment arm in stance predictive for the knee moment arm and external knee adduction moment during gait in transtibial bone-anchored prosthesis users?
METHODS: In this cross-sectional study, twenty-seven unilateral transtibial bone-anchored prosthesis users underwent data acquisition on the M-Gait instrumented treadmill. Static and dynamic measurements were conducted, and knee moment arm and external knee adduction moment were calculated. Pearson\'s correlation and linear regression analyses were performed to examine relationships between static and dynamic knee moment arms and external knee adduction moments.
RESULTS: The static knee moment arm showed significant associations with dynamic knee moment arm at the ground reaction force peaks (First: r=0.60, r2=35%, p<0.001; Second: r=0.62, r2=38%, p=0.001) and knee adduction moment (First: r=0.42, r2=17%, p=0.030; Second: r=0.59, r2=35%, p=0.001). A 1 mm between-subject difference in static knee moment arm corresponded, on average, with a 0.9% difference in knee adduction moment at the first peak and a 1.5% difference at the second peak of the ground reaction force.
CONCLUSIONS: While static alignment is important to optimize adduction moments during stance it may only partly mitigate excessive moments during gait. The fair correlation and limited percentage of explained variance underscores the importance of dynamic alignment in optimizing the body\'s dynamic load during walking.

OBJECTIVE: To compare 5- to 10-year outcomes of anterior cruciate ligament (ACL) reconstruction in young men performed with bone-patellar tendon bone (BPTB) autograft and anteromedial portal to reconstruction with hamstring autograft and transtibial technique. It was hypothesised that in young adult men, at 5- to 10-year follow-up, superior restoration of knee laxity and activity levels would be demonstrated using BPTB autograft and anteromedial portal technique.
METHODS: Ninety-four men who had ACL reconstruction with BPTB autograft and anteromedial portal were eligible for comparison to 106 men who had reconstruction with hamstring autograft and transtibial technique. Inclusion criteria were: (1) age 18-35 years, (2) ACL tear caused by sports trauma only, (3) no concomitant ligament reconstruction and (4) 5- to 10-year follow-up. Outcome measures compared between the two groups included Lachman and pivot shift tests, KT side-to-side difference, Tegner and Marx scores, International Knee Documentation Committee (IKDC)-subjective score, Knee Osteoarthritis Outcome Scale (KOOS), Short Form (SF)-36, and single hop test for distance. P value ​< ​0.05 indicated statistical significance.
RESULTS: Forty-five patients with BPTB and 55 patients with hamstring ACL reconstruction were available for in-person assessment at 5-10 years after surgery. Outcomes in the BPTB group compared to the hamstring group showed KT difference 1.4 ​± ​1.9 mm vs. 2.8 ​± ​2.3 mm (p ​< ​0.01), pivot shift grade 2-3 in 4% vs. 34% (p ​< ​0.01), return to preinjury Tegner level in 51% vs. 36% (p ​= 0.1) and to preinjury Marx score in 29% vs. 11% (p ​= 0.02), and IKDC-subjective 88 ​± ​10 vs. 82 ​± ​13 vs (p ​< ​0.01), respectively. Statistically significant inter-relationships were found between KT side-to-side difference and the Tegner, Marx and IKDC-subjective scores at follow-up (r ​= ​-0.314, p ​< ​0.01; r ​= ​-0.263, p ​< ​0.01; r ​= ​-0.218, p ​= ​0.03, respectively).
CONCLUSIONS: Young men undergoing ACL reconstruction with patellar tendon autograft and anteromedial drilling outperform at 5- to 10-year follow-up in terms of graft stability and activity levels compared to young men undergoing reconstruction with hamstring autograft and transtibial drilling.
METHODS: III (Retrospective cross-sectional comparative study).