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1.  Differences in gait characteristics between total hip, knee, and ankle arthroplasty patients: a six-month postoperative comparison 
The recovery of gait ability is one of the primary goals for patients following total arthroplasty of lower-limb joints. The aim of this study was to objectively compare gait differences of patients after unilateral total hip arthroplasty (THA), total knee arthroplasty (TKA) and total ankle arthroplasty (TAA) with a group of healthy controls.
A total of 26 TAA, 26 TKA and 26 THA patients with a mean (± SD) age of 64 (± 9) years were evaluated six months after surgery and compared with 26 matched healthy controls. Subjects were asked to walk at self-selected normal and fast speeds on a validated pressure mat. The following spatiotemporal gait parameters were measured: walking velocity, cadence, single-limb support (SLS) time, double-limb support (DLS) time, stance time, step length and step width.
TAA and TKA patients walked slower than controls at normal (p<0.05) and fast speeds (p<0.01). The involved side of TAA and TKA patients showed shorter SLS compared to controls at both normal and fast speeds (p<0.01). Regardless of walking speed, the uninvolved side of TAA and TKA patients demonstrated longer stance time and shorter step length than controls (p<0.01). TAA patients showed shorter SLS of the involved side, longer stance time and shorter step length of the uninvolved side compared to the contralateral side at both normal and fast speeds (p<0.001).
Gait disability after unilateral lower-limb joint arthroplasty was more marked for distal than for proximal joints at six months after surgery, with a proximal-to-distal progression in the impairment (TAA>TKA>THA). THA patients demonstrated no gait differences compared with controls. In contrast, TAA and TKA patients still demonstrated gait differences compared to controls, with slower walking velocity and reduced SLS in the involved limb. In addition, TAA patients presented marked side-to-side asymmetries in gait characteristics.
PMCID: PMC3674914  PMID: 23731906
Gait; Arthroplasty; Hip; Knee; Ankle
The use of an evidence‐based approach to practice requires “the integration of best research evidence with clinical expertise and patient values”, where the best evidence can be gathered from randomized controlled trials (RCTs), systematic reviews and meta‐analyses. Furthermore, informed decisions in healthcare and the prompt incorporation of new research findings in routine practice necessitate regular reading, evaluation, and integration of the current knowledge from the primary literature on a given topic. However, given the dramatic increase in published studies, such an approach may become too time consuming and therefore impractical, if not impossible. Therefore, systematic reviews and meta‐analyses can provide the “best evidence” and an unbiased overview of the body of knowledge on a specific topic. In the present article the authors aim to provide a gentle introduction to readers not familiar with systematic reviews and meta‐analyses in order to understand the basic principles and methods behind this type of literature. This article will help practitioners to critically read and interpret systematic reviews and meta‐analyses to appropriately apply the available evidence to their clinical practice.
PMCID: PMC3474302  PMID: 23091781
evidence‐based practice; meta‐analysis; systematic review
3.  Five-year results of the Innex total knee arthroplasty system 
International Orthopaedics  2009;34(8):1159-1165.
The clinical and radiographic results of 174 female and 86 male Innex (Zimmer, Warsaw, Indiana) mobile bearing total knee arthroplasty systems (245 patients) were evaluated, with particular emphasis on gender-related differences at five-year follow-up. Pre-operative Knee Society (KS) function and total scores were lower in women than in men. All KS scores showed a significant improvement at follow-up, but women still obtained lower KS function scores than men. Self-reported function was significantly better for male knees. No gender differences were observed for component alignment, while the occurrence of radiolucent lines, endosteal cavitations, and wear was significantly greater in male knees. Male Innex mobile bearing knees exhibited better clinical function and satisfaction than their female peers at five-year follow-up, despite inferior radiographic findings and higher revision rates.
PMCID: PMC2989097  PMID: 19826814
4.  Neuromuscular Function after Arthroscopic Partial Meniscectomy 
Quadriceps muscle strength, which is essential for the function and stability of the knee, has been found to be impaired even years after arthroscopic partial meniscectomy. However, the neuromuscular alterations that could account for such muscle weakness remain unclear.
We investigated (1) the side-to-side asymmetries in quadriceps muscle strength 6 months after arthroscopic partial meniscectomy, (2) the physiologic mechanisms (neural versus muscular) underlying muscle weakness, and (3) the impact of quadriceps weakness on muscle control at submaximal force levels.
Patients and Methods
We tested 14 volunteers (10 men, four women) with an average age of 44 ± 9 years (range, 24–59 years) at 6 ± 1 months after unilateral medial arthroscopic partial meniscectomy. We measured maximal voluntary strength and muscle activation during isometric, concentric, and eccentric contractions using isokinetic dynamometry and surface EMG, respectively. We assessed vastus lateralis muscle size and architecture using ultrasonography. We measured muscle control at submaximal force levels with a repositioning test (knee proprioception) and a low-force target-tracking task (steadiness, accuracy).
Isometric and concentric quadriceps strength and vastus lateralis EMG activity were lower on the involved than on the uninvolved side. Muscle architecture and muscle control did not differ between the involved and uninvolved sides.
Our results showed quadriceps weakness exists 6 months after arthroscopic partial meniscectomy. As suggested by the EMG results, this is likely attributable to neural impairments (activation failure) that affect muscle control at maximal but not submaximal force outputs.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2853681  PMID: 19936857
5.  Asymmetry in Quadriceps Rate of Force Development as a Functional Outcome Measure in TKA 
Quadriceps muscle strength is an important predictor of functional abilities in patients having TKA. However, because several daily activities are characterized by a limited time to generate force, it has been suggested that rate of force development (RFD) could better predict functional difficulties than maximal strength. We therefore hypothesized the side-to-side asymmetry would be larger for RFD than for maximal strength, and RFD asymmetry relates to subjective symptoms and/or functional daily living activities. We studied 31 subjects (17 women, 14 men) 6 ± 1 months after undergoing TKA for unilateral osteoarthritis. Symptoms and limitations during activities of daily living were quantified using the knee outcome survey-activities of daily living scale (KOS-ADLS). Quadriceps maximal strength and RFD at different times (50 to 200 ms from contraction onset) were quantified during unilateral maximal voluntary isometric actions. Side-to-side asymmetries (involved versus uninvolved side) were larger for RFD (approximately 36%) than for maximal strength (approximately 24%). Subjective knee function related to all RFD asymmetry variables, but not to maximal strength asymmetry. In addition to maximal strength, quadriceps RFD in the first 100 to 200 ms from contraction onset provides an alternative functional outcome measure for individuals undergoing TKA.
PMCID: PMC2795845  PMID: 19597897
6.  Money matters: exploiting the data from outcomes research for quality improvement initiatives 
European Spine Journal  2009;18(Suppl 3):348-359.
In recent years, there has been an increase in studies that have sought to identify predictors of treatment outcome and to examine the efficacy of surgical and non-surgical treatments. In addition to the scientific advancement associated with these studies per se, the hospitals and clinics where the studies are conducted may gain indirect financial benefit from participating in such projects as a result of the prestige derived from corporate social responsibility, a reputational lever used to reward such institutions. It is known that there is a positive association between corporate social performance and corporate financial performance. However, in addition to this, the research findings and the research staff can constitute resources from which the provider can reap a more direct benefit, by means of their contribution to quality control and improvement. Poor quality is costly. Patient satisfaction increases the chances that the patient will be a promoter of the provider to friends and colleagues. As such, involvement of the research staff in the improvement of the quality of care can ultimately result in economic revenue for the provider. The most advanced methodologies for continuous quality improvement (e.g., six-sigma) are data-driven and use statistical tools similar to those utilized in the traditional research setting. Given that these methods rely on the application of the scientific process to quality improvement, researchers have the adequate skills and mind-set to embrace them and thereby contribute effectively to the quality team. The aim of this article is to demonstrate by means of real-life examples how to utilize the findings of outcome studies for quality management in a manner similar to that used in the business community. It also aims to stimulate research groups to better understand that, by adopting a different perspective, their studies can be an additional resource for the healthcare provider. The change in perspective should stimulate researchers to go beyond the traditional studies examining predictors of treatment outcome and to see things instead in terms of the “bigger picture”, i.e., the improvement of the process outcome, the quality of the service.
PMCID: PMC2899321  PMID: 19294433
Research [H01.770.644]; Practice guidelines [N04.761.700.350.650]; Patient [M01.643]; Hospital costs [N05.300.375.500]; Six-sigma (not in IndexMedicus)
7.  Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial 
Objective To examine the effect of a comprehensive warm-up programme designed to reduce the risk of injuries in female youth football.
Design Cluster randomised controlled trial with clubs as the unit of randomisation.
Setting 125 football clubs from the south, east, and middle of Norway (65 clusters in the intervention group; 60 in the control group) followed for one league season (eight months).
Participants 1892 female players aged 13-17 (1055 players in the intervention group; 837 players in the control group).
Intervention A comprehensive warm-up programme to improve strength, awareness, and neuromuscular control during static and dynamic movements.
Main outcome measure Injuries to the lower extremity (foot, ankle, lower leg, knee, thigh, groin, and hip).
Results During one season, 264 players had relevant injuries: 121 players in the intervention group and 143 in the control group (rate ratio 0.71, 95% confidence interval 0.49 to 1.03). In the intervention group there was a significantly lower risk of injuries overall (0.68, 0.48 to 0.98), overuse injuries (0.47, 0.26 to 0.85), and severe injuries (0.55, 0.36 to 0.83).
Conclusion Though the primary outcome of reduction in lower extremity injury did not reach significance, the risk of severe injuries, overuse injuries, and injuries overall was reduced. This indicates that a structured warm-up programme can prevent injuries in young female football players.
Trial registration ISRCTN10306290.
PMCID: PMC2600961  PMID: 19066253
8.  FIFA Women's World Cup 2011: Pre-Competition Medical Assessment of female referees and assistant referees 
Precompetition screening was implemented for male referees during the 2010 Fédération Internationale de Football Association (FIFA) Word Cup. In contrast, female football referees have been neglected in this respect although they experience similar physical work loads compared to male referees.
The standardised football-specific Pre-Competition Medical Assessment (PCMA) was performed in 51 referees and assistant referees selected for the 2011 FIFA Women's World Cup.
Family history for sudden cardiac death (SCD) was positive in four referees (7.8%), but cardiac examinations did not reveal any pathological findings. Training-unrelated ECG changes were identified in three referees (5.9%), all without correlates in echocardiography or clinical examination. Most common echocardiography findings (66.6%, n=34) were asymptomatic tricuspid and mitral regurgitations.
During the present screening, no elite female referee was identified being at risk for SCD, and no referee had to be excluded from participating in the 2011 FIFA Women's World Cup.
PMCID: PMC3551197  PMID: 22976906
Cardiology; Cardiovascular; Women in sport; Cardiology prevention
9.  Implementation of the FIFA 11+ football warm up program: How to approach and convince the Football associations to invest in prevention 
British Journal of Sports Medicine  2013;47(12):803-806.
In the last decade, injury prevention has received a lot of attention in sports medicine, and recently international sports-governing bodies, such as the International Olympic Committee, declared the protection of the athletes’ health as one of their major objectives.
In 1994, the Fédération Internationale de Football Association (FIFA) established its Medical Assessment and Research Centre (F-MARC) with the aim ‘to prevent football injuries and to promote football as a health-enhancing leisure activity, improving social behaviour’. Since then, FIFA has developed and evaluated its injury-prevention programmes ‘The 11’ and ‘FIFA 11+’ have demonstrated in several scientific studies how simple exercise-based programmes can decrease the incidence of injuries in amateur football players. This paper summarises 18 years of scientific and on-field work in injury prevention by an international sports federation (FIFA), from formulating the aim to make its sport safer to the worldwide dissemination of its injury-prevention programme in amateur football.
PMCID: PMC3717809  PMID: 23813485
Injury Prevention; Soccer; Implementation

Results 1-9 (9)