Background: Recent data from the Danish anterior cruciate ligament (ACL) registry demonstrated increased reoperation rates for hamstring tendon autografts when an anatomic ACL reconstruction is performed. This is consistent with reports of greater time needed for hamstring tendon autografts to mature compared with other autografts. Purpose: To review the literature comparing graft failure rate between patellar and hamstring tendon autografts placed anatomically and to determine if there are differences in return to preinjury activity levels between autografts. Study Design: Systematic review with meta-analysis and meta-regression. Methods: The PubMed, MEDLINE, SPORTDiscus, and CINAHL databases were used to identify studies published from January 1, 2000, through March 7, 2014. To compare postoperative outcomes between patellar tendon and hamstring tendon autografts, summary event rates for graft failure and return to preinjury activity level were calculated. A meta-analysis was performed to calculate a summary odds ratio (OR) for graft failure between autografts using the studies that directly compared the 2 autografts. Meta-regression analyses were performed to assess the influence of postoperative follow-up time on graft failure rate. Results: A total of 28 studies reported graft failures for patellar tendon (6 studies) and hamstring tendon (26 studies) autografts used with anatomic ACL reconstruction; 4 of the 28 were comparison studies. Graft failure rate was not significantly different between patellar tendon (7.0% [95% CI, 4.6%-10.5%]) and hamstring tendon autografts (3.9% [95% CI, 2.7%-5.6%]). The odds of graft failure were slightly higher for hamstring tendon autografts (OR, 1.21 [95% CI, 0.63-2.33]), but this difference was not significant ( P = .57). The rate of patients returning to preinjury activity levels was not significantly different between patellar (n = 1 study; 58.1% [95% CI, 40.4%-73.9%]) and hamstring tendon autografts (n = 5 studies; 75.6% [95% CI, 43.7%-92.5%]). Overall graft failure rate was positively associated with postoperative follow-up time, but this effect was only significant with hamstring tendon autografts ( P < .05). Conclusion: Differences in graft failure rate between patellar tendon and hamstring tendon autografts were not significant. Although follow-up time was only found to have a significant influence on hamstring tendon graft failure rates, this was likely due to the smaller sample of studies assessing patellar tendon graft failures. Differences in return to preinjury activity levels could not be determined due to the lack of studies assessing that outcome. Both patellar and hamstring tendon autografts demonstrate a low risk of failure and moderately high return to activity level after anatomic ACL reconstruction.

Weakness of the quadriceps is a common occurrence in patients after knee injury or surgery; this weakness is due to a natural mechanism known as arthrogenic muscle inhibition. If inhibition of the quadriceps persists, it can become detrimental to a patient's function and lead to additional pathologies. A number of therapeutic interventions have be used in the rehabilitation of these patients, but few have proven to be successful. Electromyographic biofeedback is one modality that has demonstrated positive outcomes in patients by restoring quadriceps function. However, the reason for the effectiveness of this modality has yet to be fully explained in the area of rehabilitation. Neuroplasticity is a phenomenon that has gained much attention in rehabilitation, and its potential continues to grow. After an injury, the brain has the ability to enhance recovery by strengthening its neural circuitry. Through rehabilitation, clinicians can use attentional strategies to foster neuroplasticity and promote the recovery of their patients. In this article we provide reasoning for the effectiveness of electromyographic biofeedback using the evidence of neuroplasticity. With this information, we hope to provide clinicians a rationale for using this tool in the rehabilitation of patients with persistent quadriceps inhibition.

Clinical Scenario: Proper neuromuscular activation of the quadriceps muscle is essential for maintaining quadriceps (quad) strength and lower-extremity function. Quad activation (QA) failure is a common characteristic observed in patients with knee pathologies, defined as an inability to voluntarily activate the entire alpha-motor-neuron pool innervating the quad. One of the more popular techniques used to assess QA is the superimposed burst (SIB) technique, a force-based technique that uses a supramaximal, percutaneous electrical stimulation to activate all of the motor units in the quad during a maximal, voluntary isometric contraction. Central activation ratio (CAR) is the formula used to calculate QA level (CAR = voluntary force/SIB force) with the SIB technique. People who can voluntarily activate 95% or more (CAR = 0.95-1.0) of their motor units are defined as being fully activated. Therapeutic exercises aimed at improving quad strength in patients with knee pathologies are limited in their effectiveness due to a failure to fully activate the muscle. Within the past decade, several disinhibitory interventions have been introduced to treat QA failure in patients with knee pathologies. Transcutaneous electrical nerve stimulation (TENS) and cryotherapy are sensory-targeted modalities traditionally used to treat pain, but they have been shown to be 2 of the most successful treatments for increasing QA levels in patients with QA failure. Both modalities are hypothesized to positively affect voluntary QA by disinhibiting the motor-neuron pool of the quad. In essence, these modalities provide excitatory afferent stimuli to the spinal cord, which thereby overrides the inhibitory afferent signaling that arises from the involved joint. However, it remains unknown whether 1 is more effective than the other for restoring QA levels in patients with knee pathologies. By knowing the capabilities of each disinhibitory modality, clinicians can tailor treatments based on the rehabilitation goals of their patients. Focused Clinical Question: Is TENS or cryotherapy the more effective disinhibitory modality for treating QA failure (quantified via CAR) in patients with knee pathologies?Keywords: rehabilitation, neuromuscular system, muscle function Clinical ScenarioProper neuromuscular activation of the quadriceps muscle is essential for maintaining quadriceps strength and lower-extremity function. Quadriceps activation failure is a common characteristic observed in patients with knee pathologies, and it is defined as an inability to voluntarily activate the entire alpha-motor-neuron pool innervating the quadriceps. 1 One of the more popular techniques used to assess quadriceps activation is the superimposed burst (SIB) technique. 2 The SIB technique is a force-based technique that uses a supramaximal, percutaneous electrical stimulation to activate all of the motor units in the quadriceps during a maximal, voluntary isometric contraction of the quadriceps. Central activation ratio (CAR) is the formula used to calculate quadric...

There is no clear evidence in the literature as to whether minimally displaced fractures of the greater tuberosity should be reduced and stabilised by operative means or if the results of conservative treatment are good. The aim of this study was to find out if the amount of displacement in conservatively treated patients had an effect on shoulder function. We were able to examine 135 patients with fractures of the greater tuberosity treated between 1992 and 2000 at an average time of 3.7 (2±10) years after trauma. The results showed that patients with less than 4 millimeters of displacement had the same outcome with either simple shoulder slings or with Gilchrist bandages. Displacement of less than 4 millimeters appeared to have no effect on shoulder function. However, patients with a displacement of more than three millimeters obviously had a worse result compared to the patients with less displacement. We suggest cheaper shoulder slings for conservative treatment and operative treatment in patients with a displacement of more than three millimeters. Key wordsGreater tuberosity´displaced fractures´shoulder function Fig. 1 Minimally displaced fracture of the greater tuberosity. Original Article 180Downloaded by: University of Pittsburgh. Copyrighted material.

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