Brace or no-brace after ACL graft? Four-year results of a prospective clinical trial

Effect of knee bracing on clinical outcomes following anterior cruciate ligament reconstruction: A prospective randomised controlled study

Objectives

While there is a consensus against bracing after anterior cruciate ligament (ACL) reconstruction, the question of its potential benefits, especially in cases involving meniscus repair, as well as its routine use by the majority of clinicians, remains a topic of debate. This study aims to assess the effectiveness of bracing in relation to clinical scores after ACL reconstruction, regardless of meniscus surgery.

Methods

This randomised controlled study involved patients aged 15-55 years who underwent arthroscopic ACL reconstruction surgery. All eligible patients were assigned into two groups: one group received an adjustable frame with a four-point fixation knee brace for a four-week period, while the other did not.A single experienced surgeon performed standard anatomical single-bundle ACL reconstruction. All patients, irrespective of whether they underwent meniscus repair, followed the same rehabilitation protocol. Knee functional questionnaires, including the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner Activity Scale, Visual Analogue Scale (VAS), and examinations, were collected preoperatively, at six months, one year, and two years postoperatively. The study employed an intention-to-treat analysis and multilevel mixed-effects generalised linear models to compare continuous outcomes between the groups, adjusting for the times of follow-up.

Results

A total of 84 patients (42 patients per group) comprised of 75 males (89 %) and average age of 30 ± 9.4 years old. Patient-reported function, physical examination findings, and surgical characteristics were comparable between the two groups. (P-value >0.05) Both groups demonstrated significant improvement in IKDC and Lysholm scores at the end of the two-year follow-up period. (P-value <0.0001) In multivariate analysis, bracing was significantly associated with lower Tegner activity scale than the non-brace group after adjustment for VAS and time (coefficient -0.49, 95 % confidence interval -0.87, -0.10, P-value = 0.013). None of the graft ruptures were reported, and there was no significant difference of return to sports between the groups at the end of the follow-up.

Conclusion

The study suggests that knee bracing after ACL reconstruction, regardless of any additional meniscus procedures, fails to enhance subjective or objective outcomes and could potentially have a negative impact on the Tegner activity scale, although the difference is not clinically significant. The routine use of a postoperative brace should be discontinued.

Level of evidence

Level I, Randomised controlled trial with no negative criteria.

Brace-Free Rehabilitation after Isolated Anterior Cruciate Ligament Reconstruction with Hamstring Tendon Autograft Is Not Inferior to Brace-Based Rehabilitation-A Randomised Controlled Trial

PURPOSE

The postoperative use of a rehabilitative knee brace after isolated primary anterior cruciate ligament (ACL) reconstruction (ACLR) using a hamstring tendon (HT) autograft is controversial. A knee brace may provide subjective safety but can cause damage if applied incorrectly. The aim of this study is to evaluate the effect of a knee brace on clinical outcomes following isolated ACLR using HT autograft.

METHODS

In this prospective randomised trial, 114 adults (32.4 ± 11.5 years, 35.1% women) underwent isolated ACLR using HT autograft after primary ACL rupture. Patients were randomly assigned to wear either a knee brace (n = 58) or no brace (n = 56) for 6 weeks postoperatively. An initial examination was performed preoperatively, and at 6 weeks and 4, 6, and 12 months. The primary endpoint was the subjective International Knee Documentation Committee (IKDC) score to measure participants' subjective perceptions. Secondary endpoints included objective knee function assessed by IKDC, instrumented knee laxity measurements, isokinetic strength tests of the knee extensors and flexors, Lysholm Knee Score, Tegner Activity Score, Anterior Cruciate Ligament-Return to Sport after Injury Score, and quality of life determined by Short Form-36 (SF36).

RESULTS

There were no statistically significant or clinically meaningful differences in IKDC scores between the two study groups (3.29, 95% confidence interval (CI) -1.39 to 7.97, p = 0.03 for evidence of non-inferiority of brace-free compared with brace-based rehabilitation). The difference in Lysholm score was 3.20 (95% CI -2.47 to 8.87); the difference in SF36 physical component score 0.09 (95% CI -1.93 to 3.03). In addition, isokinetic testing did not reveal any clinically relevant differences between the groups (n.s.).

CONCLUSIONS

Brace-free rehabilitation is non-inferior to a brace-based protocol regarding physical recovery 1 year after isolated ACLR using HT autograft. Consequently, the use of a knee brace might be avoided after such a procedure.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Physiotherapy After Anterior Cruciate Ligament Reconstruction a Literature Review

Introduction: The anterior cruciate ligament (ACL) is the main stabiliser that inhibits excessive anterior translation of the tibia and prevents excessive rotational movements of the knee joint. ACL injuries occur at a frequency of 30 to 78 per 100,000 people a year, leading to instability and impaired function of the knee joint. Continuous development of knowledge on the anatomy and functions of the anterior cruciate ligament, along with the improvement of surgical and physiotherapeutic techniques, allowed for the development of satisfactory modern methods for treating ACL lesions.Objective: The aim of the study is to review literature on modern methods of physiotherapy after the reconstruction of the anterior cruciate ligament.Material and methods: Pubmed, Google Scholar and ScienceDirect scientific databases were searched using a combination of keywords: anterior cruciate ligament, ACL, reconstruction, physiotherapy, protocol. The inclusion criteria were: publication date from the last 10 years and a detailed description of the physiotherapy protocol included.Results: Six publications meeting the inclusion criteria were included in the analysis. Selected physiotherapy protocols consisted of 3 to 5 phases. Phase 1 was focused on reducing pain and swelling in all cases. The purpose of the following phases was to increase the range of motion and to strengthen muscle strength as well as neuromuscular coordination. The final stage consisted of dynamic exercises allowing to prepare for a chosen sports activity.Conclusion: Contemporary protocols for physiotherapy after ACL reconstruction are based on early recovery of range of motion in the knee joint, early increase in load on the operated limb as well as shortening (or excluding) the period of immobilisation and the use of orthoses.

Factors Influencing Treatment Outcome and Proprioception after Electrocoagulation of the Femoral Insertion of the Anterior Cruciate Ligament

(1) Background: Studies have established that exercises shaping the sense of deep sensation are an important element of medical rehabilitation of patients after vaporization of the femoral insertion of the anterior cruciate ligament and affect the restoration of correct movement patterns, thus reducing the risk of injuries. The aim of this study was to determine the factors influencing the treatment outcome and deep-feeling function after applying a specific rehabilitation scheme 12 weeks after anterior cruciate ligament electrocoagulation surgery. (2) Methods: The study group consisted of 41 patients after partial rupture of the anterior cruciate ligament, who underwent electrocoagulation of the femoral cruciate ligament attachment and microfracture of the femoral attachment area. All patients were operated on by the same surgeon and then rehabilitated according to the same medical rehabilitation protocol. The anthropometric and clinical data were collected through an anterior drawer test, Lachman test, assessment of the range of movements in the knee joint, muscle strength test, Unterberger test and Lysholm questionnaire. The assessment was performed before the surgery, and then on days 7-10, after 6 and 12 weeks of rehabilitation treatment. (3) Results: Statistical improvement of the parameters was demonstrated by strength of the quadriceps and hamstrings muscle, the Unterberger test, and the Lysholm scale after surgery. A negative correlation was found between the Unterberger test and Lysholm scale at the end of the research period and it differed depending on the gender and the dominant limb. The Lysholm scale and muscle strength were independent of sex, dominant extremity and associated damage of the meniscus and cartilage. The Lysholm scale 6 weeks after surgery negatively correlated with BMI. (4) Conclusions: Stability of the knee joint and improvement of proprioception were demonstrated 12 weeks after treatment with an ACL electrocoagulation and rehabilitation regimen. The factors contributing to a better treatment outcome were greater muscle strength, less thigh asymmetry, better sense of depth, younger age and lower body weight.

Comparable Instrumented Knee Joint Laxity and Patient-Reported Outcomes After ACL Repair With Dynamic Intraligamentary Stabilization or ACL Reconstruction: 5-Year Results of a Randomized Controlled Trial

BACKGROUND

Technical innovation has led to the renaissance of anterior cruciate ligament (ACL) repair in the past decade.

PURPOSE/HYPOTHESIS

The present study aimed to compare instrumented knee joint laxity and patient-reported outcomes (PROs) after ACL repair with those after primary ACL reconstruction for acute isolated ACL tears. It was hypothesized that ACL repair would lead to comparable knee joint stability and PROs at 5 years postoperatively in comparison with ACL reconstruction.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 85 patients with acute ACL tears were randomized to undergo either ACL repair using dynamic intraligamentary stabilization (DIS) or primary ACL reconstruction with a semitendinosus tendon autograft. The primary outcome was the side-to-side difference in anterior tibial translation (ΔATT) assessed by Rolimeter testing at 5 years postoperatively. Follow-up examinations were performed at 1, 2, and 5 years. PROs were assessed using the Tegner activity scale, the International Knee Documentation Committee (IKDC) subjective score, and the Lysholm score. Furthermore, the rates of recurrent instability, other complications, and revision surgery were recorded. A power analysis was performed a priori, and the Friedman test, Mann-Whitney U test, and Bonferroni correction were applied for statistical comparisons with significance set at P < .05.

RESULTS

The mean age at inclusion was 28.3 ± 11.5 years in the ACL repair group and 27.1 ± 11.5 years in the ACL reconstruction group. At 5 years postoperatively, a total of 64 patients (ACL repair: n = 34 of 43 [79%]; ACL reconstruction: n = 30 of 42 [71%]) were available for follow-up. At 5 years, ΔATT was 1.7 ± 1.6 mm in the ACL repair group and 1.4 ± 1.3 mm in the ACL reconstruction group (P = .334). Preinjury PROs were restored as soon as 1 year after surgery and plateaued until 2 and 5 years postoperatively in both groups. At the 5-year follow-up, the mean Lysholm score was 97.0 ± 5.4 versus 94.5 ± 5.5 (P = .322), respectively, and the mean IKDC subjective score was 94.1 ± 9.9 versus 89.9 ± 7.8 (P = .047), respectively, in the ACL repair group versus ACL reconstruction group. At 5 years postoperatively, 12 patients in the ACL repair group (35%; age <25 years: n = 10/12; Tegner score ≥7: n = 10/12) had recurrent instability, of whom 10 underwent single-stage revision ACL reconstruction. In the ACL reconstruction group, there were 6 patients with recurrent instability (20%; age <25 years: n = 6/6; Tegner score ≥7: n = 5/6); however, in 5 patients, staged revision was required. Differences between both groups regarding recurrent instability (P = .09) or ACL revision surgery (P = .118) were not statistically significant. Recurrent instability was associated with age <25 years and Tegner score >7 in both groups.

CONCLUSION

At 5 years after ACL repair with DIS, instrumented knee joint laxity and PROs were comparable with those after ACL reconstruction. Although no significant difference was found between repair and reconstruction, a critical appraisal of the rates of recurrent instability (35% vs 20%, respectively) and revision surgery (38% vs 27%, respectively) is needed. Young age and a high preinjury activity level were the main risk factors for recurrent instability in both groups. However, single-stage revision ACL reconstruction was possible in each case in the ACL repair group. Although ACL reconstruction remains the gold standard in the treatment of ACL tears, the present study supports the use of ACL repair with DIS as a feasible option to treat acute ACL tears in patients aged ≥25 years with low to moderate activity levels (Tegner score <7).

REGISTRATION

DRKS00015466 (German Clinical Trials Register).

Prescription of knee braces after anterior cruciate ligament reconstruction: Fact or fiction?

Objectives: This study aims to compare the clinical results of patients rehabilitated with or without a rehabilitative knee brace (RKB) after anterior cruciate ligament (ACL) reconstruction.

Patients and methods: This retrospective, comparative study was conducted at between January 2013 and December 2017. A total of 119 patients (112 males, 7 females; mean age: 32.0±8.6 years; range, 18 to 45 years) with acute ACL ruptures treated with arthroscopic ACL reconstruction and rehabilitated with (n=56) or without RKB (n=63) participated in the study. The minimum follow-up time was 24 months. The ACL quality of life (QoL) questionnaire, Lysholm Knee Scoring Scale, and Tegner Activity Level Scale were used for the evaluation of the QoL, knee function, and activity level, respectively. The time to return to sports was recorded. The side-to-side difference in the anterior translation of the tibia was measured using a KT-1000 arthrometer.

Results: The mean follow-up time was 38.4±9.1 (range, 24 to 56) months. Baseline demographics and clinical characteristics were similar between groups. Regarding QoL, knee function, and activity level, no significant difference was observed between patients who used RKB and those who did not use it at the postoperative 12th month (p=0.95, p=0.56, p=0.98, respectively) and the latest follow-up (p=0.21, p=0.73, p=0.99, respectively). The mean time to return to sports (nearly 11 months for both groups) and side-to-side difference in the anterior tibial translation at the latest follow-up was also similar between groups (p=0.15 and p=0.15, respectively). There was no graft rupture during the follow-up in both groups. The complication rates were 7.9% and 7.1% for no brace and brace groups, respectively, without a statistically significant difference (p=0.87).

Conclusion: According to the results of this study, there was no significant difference between the rehabilitative brace and no brace groups in clinical outcomes after ACL reconstruction.

Anterior Cruciate Ligament Reconstruction Recovery and Rehabilitation: A Systematic Review

BACKGROUND

The success of anterior cruciate ligament (ACL) reconstruction is influenced by effective rehabilitation. Previously published, comprehensive systematic reviews evaluating rehabilitation after ACL reconstruction have studied Level-I and II evidence published through 2012. Interval studies continue to evaluate the efficacy of various rehabilitative modalities.

METHODS

A total of 824 articles from 2012 to 2020 were identified using multiple search engines. Fifty Level-I or II studies met inclusion criteria and were evaluated using the Consolidated Standards of Reporting Trials (CONSORT) criteria and National Institutes of Health (NIH) Study Quality Assessment Tools.

RESULTS

Accelerated rehabilitation can be effective for patients with semitendinosus-gracilis grafts. Blood flow restriction (BFR) training with high-intensity exercise is not effective for ACL reconstruction recovery. Postoperative bracing does not offer any advantages or improve limb asymmetry. Cryotherapy is an effective analgesic when used perioperatively. The early introduction of open kinetic chain exercises may improve ACL reconstruction outcomes, and high-intensity plyometric exercise is not effective. Estimated pre-injury capacity (EPIC) levels may be more accurate than the Limb Symmetry Index (LSI) when using functional test results to predict reinjury rates, and hip external rotation strength may be the most accurate predictor of the hop test performance. Nerve blocks can provide postoperative analgesia with minimal complication risk. Neuromuscular electrical stimulation is effective when used independently and in combination with rehabilitative exercises. Psychological readiness should be evaluated both objectively and subjectively before allowing patients to safely return to sport. Electromyography biofeedback may help to regain muscular function, and whole-body vibration therapy can improve postural control. Supervised rehabilitation is more effective than unsupervised rehabilitation.

CONCLUSIONS

Various rehabilitative modalities following ACL reconstruction are effective in improving surgical outcomes and return-to-sport rates. Further evidence and improved study design are needed to further validate modalities including accelerated rehabilitation, BFR training, functional testing, and return-to-sport criteria.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Repair With Dynamic Intraligamentary Stabilization Versus Primary Reconstruction of Acute Anterior Cruciate Ligament Tears: 2-Year Results From a Prospective Randomized Study

BACKGROUND

Anterior cruciate ligament (ACL) repair has once again become a focus of research because of the development of new techniques.

PURPOSE/HYPOTHESIS

The purpose was to compare the functional results and recurrent instability rates in patients undergoing ACL repair with dynamic intraligamentary stabilization (DIS) versus primary ACL reconstruction (ACLR) for acute isolated ACL tears. The hypothesis was that functional results and knee joint stability after ACL repair with DIS would be comparable with that after ACLR.

STUDY DESIGN

Randomized clinical trial; Level of evidence, 1.

METHODS

A total of 85 patients with acute ACL tears were randomized to undergo either ACL repair with DIS or primary ACLR. The preinjury activity level and function were recorded. Follow-up examinations were performed at 6 weeks and 6, 12, and 24 months postoperatively. Anterior tibial translation (ATT) was evaluated using Rolimeter testing. The Tegner activity scale, International Knee Documentation Committee (IKDC) subjective form, and Lysholm knee scoring scale scores were obtained. Clinical failure was defined as ΔATT >3 mm in combination with subjective instability. Recurrent instability and other complications were recorded.

RESULTS

There were 83 patients (97.6%) who were successfully followed until 2 years. ATT was significantly increased in the DIS group compared with the ACLR group (ΔATT, 1.9 vs 0.9 mm, respectively; P = .0086). A total of 7 patients (16.3%) in the DIS group had clinical failure and underwent single-stage revision. In the ACLR group, 5 patients (12.5%) had failure of the reconstruction procedure; 4 of these patients required 2-stage revision. The difference in the failure rate was not significant (P = .432). There were 4 patients (3 in the DIS group and 1 in the ACLR group) who showed increased laxity (ΔATT >3 mm) without subjective instability and did not require revision. Recurrent instability was associated with young age (<25 years) and high Tegner scores (>6) in both groups. No significant differences between ACL repair with DIS and ACLR were found for the Tegner, IKDC, and Lysholm scores at any time.

CONCLUSION

Whereas ATT measured by Rolimeter testing was significantly increased after ACL repair with DIS, clinical failure was similar to that after ACLR. In addition, functional results after ACL repair with DIS for acute tears were comparable with those after ACLR. The current study supports the use of ACL repair with DIS as an option to treat acute ACL tears.

REGISTRATION

DRKS00015466 (German Clinical Trials Register).

The effect of knee bracing on the knee function and stability following anterior cruciate ligament reconstruction: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Knee brace has been commonly used as a device to protect the graft after reconstruction of anterior cruciate ligament (ACL). Studies have focused on the effects of braces after ACL reconstruction, and controversial results were reported. The current meta-analysis was conducted to identify whether knee braces could provide superior clinical outcomes on knee functional scores and stability evaluations.

HYPOTHESIS

Knee braces could not provide superior clinical outcomes on knee functional scores and stability evaluations.

MATERIALS AND METHODS

Two reviewers independently retrieved the literature on PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL). Data related to the knee functional scores and stability evaluations, including International Knee Documentation Committee (IKDC) evaluation, Lachman test, manual anterior drawer test, single leg hop test, pivot shift test, side-to-side difference, Lysholm score and Tegner score, were extracted and pooled using meta-analysis with fixed or random- effect models when applicable.

RESULTS

A total of 7 studies with 440 participants were finally included. The IKDC objective score was pooled using the odds ratio (OR) as effect size, which was demonstrated to be non-significantly different between the brace and no brace groups. All of the other clinical outcomes, including Lysholm score, Tegner score, side-to-side difference, single-leg hop test and VAS pain score, were pooled using the standard mean difference (SMD) as effect size. At final follow up, the aforementioned clinical outcomes were demonstrated to be similar between the brace and non-brace groups.

DISCUSSION

Knee bracing does not appear to improve the clinical outcomes on the function and stability for ACL-reconstructed knees. Thus, bracing for patients treated with ACL reconstruction should not be recommended routinely.

LEVEL OF EVIDENCE

I, Meta-analysis.

Quality and Variability of Online Available Physical Therapy Protocols From Academic Orthopaedic Surgery Programs for Medial Patellofemoral Ligament Reconstruction

BACKGROUND

Unlike the literature on anterior cruciate ligament reconstruction, studies on medial patellofemoral ligament (MPFL) reconstruction lack evidence-based guidelines regarding postoperative rehabilitation. An effective postoperative protocol may contribute greatly to a successful outcome following MPFL reconstruction, yet the quality and variability of these published protocols remain unknown.

PURPOSE

To assess the quality and variability of MPFL rehabilitation protocols publicly available on the internet and associated with US academic orthopaedic programs.

STUDY DESIGN

Systematic review.

METHODS

All available isolated MPFL reconstruction rehabilitation protocols from US academic orthopaedic programs participating in the Electronic Residency Application Service were collected and included in this review. These protocols were evaluated for inclusion of various rehabilitation components, the timing of suggested initiation of these activities, and whether the protocol used evaluation-based guidelines.

RESULTS

A total of 27 protocols were included. Of these, 25 (93%) recommended immediate postoperative bracing. Time to initiation of full weightbearing ranged from 2 to 8 weeks. The most common strengthening exercises endorsed were quadriceps sets (89%), straight-legged raise (85%), and leg press (81%). The most common proprioception exercises endorsed were balance board (41%), single-legged balance (41%), and TheraBand control (33%). The median time suggested to return to play was 17 weeks. No functional test appeared in the majority of the protocols. Of the 27 protocols, 20 (74%) used evaluation-based guidelines.

CONCLUSION

There is substantial variability in content and timing across rehabilitation protocols following MPFL reconstruction. This lack of clear guidelines can cause confusion among patients, therapists, and surgeons, leading to suboptimal patient outcomes and making it difficult to compare outcomes across the literature.

Tunnel osteolysis post-ACL reconstruction: a systematic review examining select diagnostic modalities, treatment options and rehabilitation protocols

PURPOSE

The purpose of this systematic review was to (1) identify the optimal diagnostic modality for tunnel widening in skeletally mature patients; (2) identify potentially modifiable risk factors for tunnel widening, such as graft type, and (3) determine what elements of a post-operative rehabilitation program exert the most influence on TW.

METHODS

The electronic databases MEDLINE, EMBASE, PubMed, and Cochrane Library were searched from database inception to January 2018. Studies that discussed tunnel widening following anterior cruciate ligament reconstruction (ACLR) of skeletally mature patients and written in English were included. Descriptive statistics, such as means, ranges, and measures of variance (e.g. standard deviations, 95% confidence intervals (CI)) are presented where applicable.

RESULTS

103 studies (6,383 patients) were included. Plain radiographs were the most commonly used diagnostic modality, but radiographs on average required 10 months longer than CT and 2 months longer on average than MRI to diagnose tunnel widening after ACLR. Although CT was the least commonly used modality, it was the shortest time to diagnose tunnel widening at 9.5 months after ACLR. Bone-patellar tendon-bone (BPTB) allograft had the largest average tunnel widening overall. BPTB autograft had the lowest average tunnel widening overall. Double-bundle hamstring graft configuration had a lower average tunnel widening than single-bundle configuration. Rehabilitation protocols after ACLR that used a full weight-bearing prescription in rehabilitation showed a greater average femoral tunnel widening than partial weight-bearing, and partial weight-bearing showed a greater average tibial tunnel widening than full weight-bearing.

CONCLUSIONS

Based on this systematic review and the descriptive data evaluated, CT demonstrated a time of 9.5 months on average from ACLR to diagnosing tunnel osteolysis post-ACLR. With respect to graft types, double-bundle hamstring autografts reported lower average femoral and tibial TW than single-bundle hamstring autografts. BPTB autografts reported the lowest average TW and BPTB allograft the largest average TW of all the grafts. Furthermore, extension-locked bracing had the lowest TW of all the brace protocols. Lastly, several other surgical technical parameters influencing tunnel osteolysis remain to be determined. No definitive recommendations can be made at this time due to the high heterogeneity of data and the lack of comparative studies analysed in this systematic review.

LEVEL OF EVIDENCE

IV.

A systematic review of randomised controlled trials assessing effectiveness of prosthetic and orthotic interventions

BACKGROUND

Assistive products are items which allow older people and people with disabilities to be able to live a healthy, productive and dignified life. It has been estimated that approximately 1.5% of the world's population need a prosthesis or orthosis.

OBJECTIVE

The objective of this study was to systematically identify and review the evidence from randomized controlled trials assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions.

METHODS

Literature searches, completed in September 2015, were carried out in fourteen databases between years 1995 and 2015. The search results were independently screened by two reviewers. For the purpose of this manuscript, only randomized controlled trials which examined interventions using orthotic or prosthetic devices were selected for data extraction and synthesis.

RESULTS

A total of 342 randomised controlled trials were identified (319 English language and 23 non-English language). Only 4 of these randomised controlled trials examined prosthetic interventions and the rest examined orthotic interventions. These orthotic interventions were categorised based on the medical conditions/injuries of the participants. From these studies, this review focused on the medical condition/injuries with the highest number of randomised controlled trials (osteoarthritis, fracture, stroke, carpal tunnel syndrome, plantar fasciitis, anterior cruciate ligament, diabetic foot, rheumatoid and juvenile idiopathic arthritis, ankle sprain, cerebral palsy, lateral epicondylitis and low back pain). The included articles were assessed for risk of bias using the Cochrane Risk of Bias tool. Details of the clinical population examined, the type of orthotic/prosthetic intervention, the comparator/s and the outcome measures were extracted. Effect sizes and odds ratios were calculated for all outcome measures, where possible.

CONCLUSIONS

At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high quality research to allow strong conclusions on their effectiveness and cost-effectiveness.

Patient satisfaction with health is substantially improved following ACL reconstruction

PURPOSE

To prospectively monitor health-related quality of life and return to work after arthroscopic anterior cruciate ligament (ACL) reconstruction in patients with isolated ACL tears.

METHODS

Sixty consecutive patients with isolated ACL tears who underwent arthroscopic ACL reconstruction were prospectively monitored using the "Questions on Life Satisfaction Modules" (FLZ^M) and "Short-Form 12 (SF-12)" quality-of-life outcome measures. The Lysholm score and Tegner activity index were used as functional outcome measures. Additionally, return to work (months) together with level of physical workload was analysed. Outcome measures were assessed the day before surgery and at 6, 12 weeks and 6, 12, and 24 months post-operatively. Quality-of-life outcomes were correlated with functional outcome scores.

RESULTS

Satisfaction with health (FLZ^M) significantly improved within the first 2 years (p < 0.05), and the physical component scale (SF12) showed a significantly higher score after 3, 6, 12 and 24 months as compared with preoperative values (p < 0.05). "General life satisfaction (FLZ^M)" was initially decreased at 6 weeks (p < 0.05) but increased during the further follow-up period, reaching a score not significantly different from preoperative values. Mean Lysholm score improved from 66 preoperatively to 89 post-operatively (p < 0.05) and the median Tegner activity index improved from four to six points (p < 0.05) at final follow-up. Mean time to return to work was 7 weeks (range 1-34 weeks), and it strongly depended on physical workload. A positive correlation between quality of life and functional outcome (Lysholm score) was observed.

CONCLUSION

General life satisfaction is impaired during the early post-operative course, but returns to preoperative values after 2 years. Satisfaction with health reaches higher values after 6, 12 and 24 months post-operatively, and the SF-12 physical component scale was seen to improve during the follow-up period. Improved functional outcomes were observed to correlate with quality-of-life measurements. Thus, patients can preoperatively be informed that they will benefit from ACL reconstruction in terms of an improved knee function and satisfaction with health. Heavy physical workload must be considered as a risk factor for prolonged time lost to return to work. These patients have to be identified and informed about realistic expectations.

LEVEL OF EVIDENCE

II.

Do Knee Bracing and Delayed Weight Bearing Affect Mid-Term Functional Outcome after Anterior Cruciate Ligament Reconstruction?

Purpose  The aim of this study was to assess the effect of knee bracing and timing of full weight bearing after anterior cruciate ligament reconstruction (ACLR) on functional outcomes at mid-term follow-up. Methods  We performed a retrospective study on 41 patients with ACLR. Patients were divided in two groups: ACLR group, who received isolated ACL reconstruction and ACLR-OI group who received ACL reconstruction and adjunctive surgery. Information about age at surgery, bracing, full or progressive weight bearing permission after surgery were collected for the two groups. Subjective IKDC score was obtained at follow-up. Statistical analysis was performed to compare the two groups for IKDC score. Subgroup analysis was performed to assess the effect of postoperative regimen (knee bracing and weight bearing) on functional outcomes. Results  The mean age of patients was 30.8 ± 10.6 years. Mean IKDC score was 87.4 ± 13.9. The mean follow-up was 3.5 ± 1.8 years. Twenty-two (53.7%) patients underwent ACLR only, while 19 (46.3%) also received other interventions, such as meniscal repair and/or collateral ligament suture. Analysis of overall data showed no differences between the groups for IKDC score. Patients in the ACLR group exhibited a significantly better IKDC score when no brace and full weight bearing after 4 weeks from surgery was prescribed in comparison with patients who worn a brace and had delayed full weight bearing. No differences were found with respect to the use of brace and postoperative weight bearing regimen in the ACLR-OI group. Conclusion  Brace and delayed weight bearing after ACLR have a negative influence on long-term functional outcomes. Further research is required to explore possible differences in the patients operated on ACLR and other intervention with respect to the use of a brace and the timing of full weight bearing to identify optimal recovery strategies. Level of Evidence  Level III, retrospective observational study.

Functional Brace in ACL Surgery: Force Quantification in an In Vivo Study

Background:

A need exists for a functional anterior cruciate ligament (ACL) brace that dynamically supports the knee joint to match the angle-dependent forces of a native ACL, especially in the early postoperative period.

Purpose/Hypothesis:

The purpose of this study was to quantify the posteriorly directed external forces applied to the anterior proximal tibia by both a static and a dynamic force ACL brace. The proximal strap forces applied by the static force brace were hypothesized to remain relatively constant regardless of knee flexion angle compared with those of the dynamic force brace.

Study Design:

Controlled laboratory study.

Methods:

Seven healthy adult males (mean age, 27.4 ± 3.4 years; mean height, 1.8 ± 0.1 m; mean body mass, 84.1 ± 11.3 kg) were fitted with both a static and a dynamic force ACL brace. Participants completed 3 functional activities: unloaded extension, sit-to-stand, and stair ascent. Kinematic data were collected using traditional motion-capture techniques while posteriorly directed forces applied to the anterior aspect of both the proximal and distal tibia were simultaneously collected using a customized pressure-mapping technique.

Results:

The mean posteriorly directed forces applied to the proximal tibia at 30° of flexion by the dynamic force brace during unloaded extension (80.2 N), sit-to-stand (57.5 N), and stair ascent (56.3 N) activities were significantly larger, regardless of force setting, than those applied by the static force brace (10.1 N, 9.5 N, and 11.9 N, respectively; P < .001).

Conclusion:

The dynamic force ACL brace, compared with the static force brace, applied significantly larger posteriorly directed forces to the anterior proximal tibia in extension, where the ACL is known to experience larger in vivo forces. Further studies are required to determine whether the physiological behavior of the brace will reduce anterior knee laxity and improve long-term patient outcomes.

Clinical Relevance:

ACL braces that dynamically restrain the proximal tibia in a manner similar to physiological ACL function may improve pre- and postoperative treatment.

Quality and Variability of Online Available Physical Therapy Protocols From Academic Orthopaedic Surgery Programs for Anterior Cruciate Ligament Reconstruction

PURPOSE

To assess the quality and variability found across anterior cruciate ligament (ACL) rehabilitation protocols published online by academic orthopaedic programs.

METHODS

Web-based ACL physical therapy protocols from United States academic orthopaedic programs available online were included for review. Main exclusion criteria included concomitant meniscus repair, protocols aimed at pediatric patients, and failure to provide time points for the commencement or recommended completion of any protocol components. A comprehensive, custom scoring rubric was created that was used to assess each protocol for the presence or absence of various rehabilitation components, as well as when those activities were allowed to be initiated in each protocol.

RESULTS

Forty-two protocols were included for review from 155 U.S. academic orthopaedic programs. Only 13 protocols (31%) recommended a prehabilitation program. Five protocols (12%) recommended continuous passive motion postoperatively. Eleven protocols (26%) recommended routine partial or non-weight bearing immediately postoperatively. Ten protocols (24%) mentioned utilization of a secondary/functional brace. There was considerable variation in range of desired full-weight-bearing initiation (9 weeks), as well as in the types of strength and proprioception exercises specifically recommended. Only 8 different protocols (19%) recommended return to sport after achieving certain strength and activity criteria.

CONCLUSIONS

Many ACL rehabilitation protocols recommend treatment modalities not supported by current reports. Moreover, high variability in the composition and time ranges of rehabilitation components may lead to confusion among patients and therapists.

LEVEL OF EVIDENCE

Level II.

Current practice variations in the management of anterior cruciate ligament injuries in Delhi

BACKGROUND

The aim of this study was to determine the current practices and preferences of the arthroscopic surgeons of Delhi in the diagnosis, treatment and rehabilitation of patients with anterior cruciate ligament (ACL) injury.

METHODS

It was a cross-sectional descriptive study conducted among arthroscopic surgeons of Delhi. A survey was conducted using a questionnaire that was sent either by e-mail or by direct contact to all sixty arthroscopic surgeons of Delhi.

RESULTS

Forty-eight (80%) surgeons responded to our questionnaire. Maximum participants (83.3%) used semitendinosus/gracilis tendon autograft for ACL reconstruction (ACLR) and only 2.1% were using bone-patellar-tendon-bone (BPTB) autograft. Most preferred method of graft fixation was an 'interference screw' on the tibial side and an 'endobutton' on the femoral side, which was preferred by 95.83% and 93.75% surgeons, respectively. Almost all respondents (97%) used a bio-absorbable interference screw for tibial side graft fixation. Postoperative bracing was advised for <3 weeks by 47.9% surgeons and for 3-6 weeks by 31.3%. The results were analysed using statistical analysis.

CONCLUSION

Surgeon preferences in ACLR differ considerably among the arthroscopic surgeons of Delhi. There is majority consensus for using Hamstring autograft (single bundle) with a suspensory fixation on the femoral side and an aperture fixation on the tibial side. Transportal technique of making the femoral tunnel and preservation of amputation stump were the preferred methods. However, differences exist over the timing of surgery, rehab after surgery, pain management, etc.