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Zsidai B, Kaarre J, Narup E, Samuelsson K. Timing of Anterior Cruciate Ligament Surgery. Clin Sports Med 2024; 43:331-341. [PMID: 38811113 DOI: 10.1016/j.csm.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
This narrative review examines the current literature for the influence of the surgical timing in the setting of anterior cruciate ligament (ACL) reconstruction on various outcomes. Although the exact definition of early and delayed ACL reconstruction (ACLR) is a subject of controversy, surgical timing influences arthrofibrosis and postoperative stiffness, quadriceps strength, postoperative knee function, and the incidence of intra-articular injuries to the menisci and cartilage. Additionally, there is a shortage of evidence regarding the role of ACLR timing in the setting of multiligament knee injury and when concurrent procedures are performed during the operative treatment of the ACL-injured knee.
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Affiliation(s)
- Bálint Zsidai
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Janina Kaarre
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA, USA
| | - Eric Narup
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Göteborgsvägen 31, 431 30 Mölndal, Sweden
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Aman ZS, Blaber OK, R McDermott E, DeFoor MT, DePhillipo NN, Dickens JF, Dekker TJ. Acute Anterior Cruciate Ligament Reconstruction Performed Within 10 Days of Injury Does Not Increase Risk of Postoperative Arthrofibrosis: A Systematic Review and Meta-analysis. Am J Sports Med 2024; 52:1888-1896. [PMID: 38258480 DOI: 10.1177/03635465231192987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND The optimal timing of anterior cruciate ligament (ACL) reconstruction (ACLR) remains a controversial topic. Previous reviews have demonstrated that there are no differences between early and delayed ACLR; however, these studies have been limited by heterogeneous definitions of acute ACL injury. PURPOSE To evaluate postoperative patient functional outcomes and risk for arthrofibrosis after acute arthroscopic ACLR performed ≤10 days after injury. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using multiple medical databases. Inclusion criteria were studies that evaluated postoperative range of motion outcomes for patients undergoing ACLR ≤10 days after initial ACL injury. For included comparative studies comparing patient groups undergoing ACLR ≤10 days and patients undergoing "delayed" ACLR after ≥3 weeks of initial injury, quantitative analysis was performed to assess for differences in postoperative arthrofibrosis, reoperation rates, and patient-reported outcomes between groups. DerSimonian-Laird binary random-effects models were constructed to quantitatively describe the association between the ACLR time period and patient outcomes by generating effect estimates in the form of odds ratios with 95% CIs. Qualitative analysis was performed to describe variably reported patient outcomes and the risk of arthrofibrosis after ACLR for noncomparative studies. RESULTS Screening yielded 6 full-text articles with 448 patients who underwent ACLR (296 ACLR <10 days, 152 ACLR >3 weeks), with a pooled mean age of 28.1 years. For studies amenable to quantitative analysis, there were no significant differences between ACLR performed ≤10 days and ACLR performed at the 3-week point or after in terms of postoperative stiffness (3 studies; odds ratio, 1.27; P = .508), Tegner scores (2 studies; mean difference, -0.056; P = .155), or reoperation for stiffness (3 studies; odds ratio, 0.869; P = .462). The overall incidence of postoperative arthrofibrosis after 12 months of follow-up was 11 of 296 (3.7%) for ACLRs performed ≤10 days versus 6 of 152 (3.9%) for those performed at the 3-week point or after. CONCLUSION ACLR performed ≤10 days after the inciting injury does not increase the risk of postoperative arthrofibrosis and demonstrates similar patient-reported outcomes compared with ACLR performed at the 3-week point or after.
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Affiliation(s)
- Zachary S Aman
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Olivia K Blaber
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Emily R McDermott
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Mikalyn T DeFoor
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Nicholas N DePhillipo
- Department of Orthopedics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan F Dickens
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Travis J Dekker
- Department of Orthopaedic Surgery, 10th Medical Group, US Air Force Academy, Colorado Springs, Colorado, USA
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Smeets A, Ghafelzadeh Ahwaz F, Bogaerts S, Berger P, Peers K. Comparison of immediate versus optional delayed surgical repair for treatment of acute anterior cruciate ligament injury through a parallel, multicentric, pragmatic randomized controlled trial - IODA trial. BMC Sports Sci Med Rehabil 2024; 16:22. [PMID: 38238809 PMCID: PMC10797880 DOI: 10.1186/s13102-024-00816-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Standard care for anterior cruciate ligament (ACL) injuries often includes surgical reconstruction of the ACL. However, two randomized controlled trials [1, 2] (RCT) concluded that conservative treatment does not result in inferior clinical outcomes compared to immediate ACL reconstruction. More research is needed to verify these results and assess whether patient-specific parameters determine if a patient would benefit from one treatment option over the other. METHODS This is a pragmatic, multi-center RCT with two parallel groups. Patients with an acute ACL injury will be recruited from Belgian hospitals. Patients will be randomized to conservative treatment (rehabilitation + optional delayed surgery) or immediate ACL reconstruction (< 12 weeks). The primary outcome is the Knee injury and Osteoarthritis Outcome Score (KOOS) at 7 months (short term) and 1-year long term) post-injury. These following additional outcomes will be administered at 4 and 7 months (short term) and 1, 2, and 3 years post-injury (long term): patient-reported outcomes concerning knee symptoms, knee function and quality of life, functional knee tests, time to return to pre-injury activity level and return to work, structural knee joint damage and cartilage health (only at 4 months and 3 years post-injury), as well as adverse events such as re-rupture rates. Furthermore, the secondary objective is to identify (through a predictive analysis) individuals who would benefit the most from early reconstruction versus those who should rather be treated conservatively. DISCUSSION This large RCT will assess the clinical effectiveness of both surgical and conservative treatment. In addition, it will be the first study that provides insights into which patient-specific factors predict successful outcomes after conservative treatment of ACL injuries. These results will be the first step toward early patient identification regarding treatment decisions. This is urgently needed to avoid (1) delayed surgeries and prolonged rehabilitation and (2) unnecessary surgeries. TRIAL REGISTRATION this trial was registered on ClinicalTrials.gov (NCT05747079) on 10/02/2023.
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Affiliation(s)
- Annemie Smeets
- Research group of Physical & Rehabilitation Medicine, Department of Development & Regeneration, KU Leuven, Leuven, Belgium
- Research group of Musculoskeletal Rehabilitation, Department of Rehabilitation Sciences & Physiotherapy, KU Leuven, Leuven, Belgium
| | - Feryal Ghafelzadeh Ahwaz
- Research group of Physical & Rehabilitation Medicine, Department of Development & Regeneration, KU Leuven, Leuven, Belgium.
| | - Stijn Bogaerts
- Research group of Physical & Rehabilitation Medicine, Department of Development & Regeneration, KU Leuven, Leuven, Belgium
- Department of Physical & Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Berger
- Department of Orthopaedic Surgery, University of Leuven, Leuven, Belgium
| | - Koen Peers
- Research group of Physical & Rehabilitation Medicine, Department of Development & Regeneration, KU Leuven, Leuven, Belgium
- Department of Physical & Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
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Vermeijden HD, Yang XA, Rademakers MV, Kerkhoffs GMMJ, van der List JP, DiFelice GS. Early and Delayed Surgery for Isolated ACL and Multiligamentous Knee Injuries Have Equivalent Results: A Systematic Review and Meta-analysis. Am J Sports Med 2023; 51:1106-1116. [PMID: 35099334 DOI: 10.1177/03635465211069356] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early surgery for acute ligamentous injuries has recently shown good clinical and functional outcomes. PURPOSE To assess the advantages of early vs delayed surgery in patients undergoing isolated anterior cruciate ligament (ACL) or multiligament-injured knee (MLIK) surgery. STUDY DESIGN Meta-analyses of Level 1, 2, and 3 studies; Level of evidence, 4. METHODS A systematic search was performed via PubMed, EMBASE, and Cochrane for studies reporting outcomes of timing of surgery after isolated ACL injury or in the MLIK setting using accelerated rehabilitation protocols. Two analyses were conducted to differentiate early and delayed treatment (3- and 6-week cutoffs). Collected outcomes included meniscal or chondral lesions, failure and reoperation rates, range of motion (ROM) deficits, other complications, muscle strength, instrumented laxity, and functional outcomes. Outcomes were reported in risk ratios (RR) or mean differences with 95% CIs. RESULTS For timing of isolated ACL surgery, 16 studies were included with 2093 patients. High-grade evidence indicated that there were no differences in meniscal or chondral lesions, failure and reoperation rates, stiffness, ROM deficits, complications, muscle strength, instrumented laxity, and functional outcomes between patients treated early and late (all P > .05). When including only studies that set no preoperative criteria for early surgery, the findings were similar. Regarding MLIK surgery, 14 studies were included with 1172 patients. Low evidence was noted for the following: patients treated early had significantly fewer meniscal injuries (RR, 0.7; P = .04) and chondral injuries (RR, 0.5; P < .001), while no differences were found in reoperation rates, complications, stiffness, ROM deficits, muscle strength, instrumented laxity, and functional outcomes between the groups. Other than higher Lysholm scores in the early group for the 3-week analysis (mean difference, 6.8; P = .01), there were no differences between cutoff analyses. CONCLUSION This systematic review with meta-analysis found no differences in clinical and functional outcomes between early and delayed surgery for isolated ACL injuries. For MLIK injuries, there were also no differences in surgical outcomes between early and delayed surgery.
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Affiliation(s)
- Harmen D Vermeijden
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, the Netherlands
- Amsterdam Movement Science, Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Xiuyi A Yang
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Maarten V Rademakers
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, the Netherlands
| | - Gino M M J Kerkhoffs
- Amsterdam Movement Science, Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Academic Center for Evidence Based Sports Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Collaboration on Health and Safety in Sports, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam IOC Research Center, Amsterdam, the Netherlands
| | - Jelle P van der List
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, the Netherlands
- Amsterdam Movement Science, Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gregory S DiFelice
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Kirby JC, Whitehead TS, Webster KE, Feller JA, McClelland JA, Klemm HJ, Devitt BM. Impact of Occupation on 12-Month Outcomes After Anterior Cruciate Ligament Reconstruction in Male Patients. Orthop J Sports Med 2023; 11:23259671221130377. [PMID: 36846817 PMCID: PMC9950609 DOI: 10.1177/23259671221130377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/07/2022] [Indexed: 02/25/2023] Open
Abstract
Background The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown. Purpose/Hypothesis The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity. Study Design Cohort study; Level of evidence, 3. Methods From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test. Results Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [P = .021]; mean passive, 2.76° vs 5.00°, respectively [P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months. Conclusion At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.
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Affiliation(s)
| | - Timothy S. Whitehead
- OrthoSport Victoria, Richmond, Victoria, Australia.,Timothy S. Whitehead, MBBS(Hons), OrthoSport Victoria, 89 Bridge
Road, Richmond, VIC 3121, Australia (
)
| | - Kate E. Webster
- School of Allied Health, Human Services and Sport, La Trobe
University, Melbourne, Victoria, Australia
| | - Julian A. Feller
- OrthoSport Victoria, Richmond, Victoria, Australia.,School of Allied Health, Human Services and Sport, La Trobe
University, Melbourne, Victoria, Australia
| | - Jodie A. McClelland
- School of Allied Health, Human Services and Sport, La Trobe
University, Melbourne, Victoria, Australia
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Anterior Screw Insertion Results in Greater Tibial Tunnel Enlargement Rates after Single-Bundle Anterior Cruciate Ligament Reconstruction than Posterior Insertion: A Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020390. [PMID: 36837591 PMCID: PMC9967347 DOI: 10.3390/medicina59020390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/19/2023]
Abstract
Background and Objectives: Tunnel enlargement (TE) is a widely reported phenomenon after anterior cruciate ligament reconstruction (ACLR). Given the paucity of knowledge in the literature, it remains unclear whether screw position in the tunnel affects TE. This retrospective cohort study evaluated differences in postoperative tunnel enlargement rates (TER) and clinical results between anterior and posterior tibial interference screw insertion during single-bundle ACLR using autologous hamstring grafts. Materials and Methods: A group of consecutive patients that underwent primary arthroscopic single-bundle ACLR in our hospital were screened and divided into two groups based on the position of the tibial interference screw (determined by Computer Tomography within 3 days after surgery): anterior screw position group (A) and posterior screw position group (B). The bone tunnel size was measured using magnetic resonance imaging (MRI) performed 1 year after surgery. International Knee Documentation Committee (IKDC) score and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were used for clinical results 1 year postoperatively. Results: 87 patients were included. The TER of Group A is higher than that of Group B (43.17% vs. 33.80%, p = 0.024). Group A showed a significant increase (12.1%) in enlargement rates at the joint line level than group B (43.77% vs. 31.67%, p = 0.004). Moreover, KOOS and IKDC scores improved in both groups. There were no significant differences in clinical outcomes between the two groups. Conclusions: One year after ACLR, patients with posterior screw showed significantly lower TE than patients with anterior screw. However, the position of screw did not lead to differences in clinical results over our follow-up period. Posterior screw position in the tibial tunnel maybe a better choice in terms of reducing TE. Whether the different screw positions affect the long-term TE and long-term clinical outcomes needs to be confirmed by further studies.
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Scholes C, Ektas N, Harrison-Brown M, Jegatheesan M, Rajesh A, Kirwan G, Bell C. Persistent knee extension deficits are common after anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomised controlled trials. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-022-07299-3. [PMID: 36705690 DOI: 10.1007/s00167-022-07299-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 12/20/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE Knee extension deficits complicate recovery from ACL injury and reconstruction; however, the incidence of knee extension loss is not well defined. The aim of this review was to identify the incidence of loss of extension (LOE) following ACL rupture and reconstruction, explore the definitions of knee extension deficits reported and identify prognostic factors affecting LOE incidence. METHODS A systematic search was conducted in Medline, Cochrane Library and PEDro for studies in publication up to November 2021, with no restrictions on publication year. References were screened and assessed for inclusion using predetermined eligibility criteria. Randomised controlled trials (RCTs) that quantified knee angle, loss of extension or incidence of extension deficit were included for quality assessment and data extraction. Statistical summaries were generated and meta-analyses performed in two parts to examine: (i) the probability of a datapoint being zero incidence compared to a nonzero incidence and (ii) the relationship between the predictors and nonzero LOE incidence. RESULTS A sample of 15,494 studies were retrieved using the search criteria, with 53 studies meeting eligibility criteria. The pooled results from 4991 participants were included for analysis, with 4891 participants who had undergone ACLR. The proportion of included studies judged at an overall low risk of bias was small (7.8%). The observed group and study were the most important predictors for whether a datapoint reported an incidence of extension deficit. Time to follow-up (P < 0.001) and graft type (P = 0.02) were found to have a significant influence on nonzero LOE incidence (%). Covariate adjusted estimates of average LOE indicated 1 in 3 patients presenting with LOE at 12 month follow-up, reducing to 1 in 4 at 2 years. CONCLUSIONS This review examined the definitions for the measurement and interpretation of postoperative knee extension and established the trajectory of knee extension deficit after ACL injury and reconstruction. While factors associated with loss of extension were identified, the exact trajectory of knee extension deficits was difficult to infer due to discrepancies in measurement techniques and patient variation. On average, 1 in 3 patients may present with loss of extension of at least 3 degrees at 12-month follow-up, decreasing to 1 in 4 at 2 years. These results may be used by clinicians as an upper threshold for acceptable complication rates following ACLR. Future work should focus on LOE as a clinically relevant complication of ACL injury and treatment with appropriate attention to standardisation of definitions, measurements and better understanding of natural history. PROSPERO REGISTRATION NUMBER CRD42018092295. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
| | | | | | - Maha Jegatheesan
- Orthopaedics Department, Queen Elizabeth II Jubilee Hospital, Coopers Plains, QLD, Australia
| | - Ashwin Rajesh
- Orthopaedics Department, Queen Elizabeth II Jubilee Hospital, Coopers Plains, QLD, Australia
| | - Garry Kirwan
- Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Coopers Plains, QLD, Australia
| | - Christopher Bell
- Orthopaedics Department, Queen Elizabeth II Jubilee Hospital, Coopers Plains, QLD, Australia.
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Paudel YR, Sommerfeldt M, Voaklander D. Increasing incidence of anterior cruciate ligament reconstruction: a 17-year population-based study. Knee Surg Sports Traumatol Arthrosc 2023; 31:248-255. [PMID: 35948850 DOI: 10.1007/s00167-022-07093-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/25/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Anterior cruciate ligament (ACL) injuries are one of the most frequently studied injuries in orthopedic care and research. However, limited epidemiological data are available in Canada regarding trend and distribution of anterior cruciate ligament reconstruction (ACLR). In this paper, our purpose was to assess trends of ACLR between 2002/03 and 2018/19 by age, sex, season of surgery, and location (inpatient vs outpatient) of surgery. METHODS In this descriptive epidemiological study of retrospective data available from Alberta Ministry of Health, we report annual incidence of ACLR between 2002/03 until 2018/19 among Albertans aged 10 years and older. Information was collected by authors from physician claims database for primary ACLR and revision ACLR and linked with other databases. Incidence proportions (number of ACLR/100,000 population) were calculated and compared by age category and gender over the study period. RESULTS A total of 28,401 primary ACLR and 2085 revision ACLR were identified during the study period. Age-standardized annual incidence of primary ACLR increased from 40.6 to 51.2 per 100,000 population aged 10 years and older. Average annual increase in ACLR incidence was higher among females (1.8% per years) compared to males (0.96% per year). The overall peak incidence and peak incidence among males was observed in 20-29 year age group, whereas peak incidence in females was observed in 10-19 years of age. The number of ACLR in females outnumbers those among males for 10-19 year age group. Generally, a lower proportion of ACLR were conducted in summer compared to other seasons. Primary ACLR conducted in outpatient setting increased from 72% in 2002/03 to 97% in 2018/19. CONCLUSION The incidence of ACLR is increasing in Alberta, especially among females and among younger cohorts under 20 years of age. This information can help clinicians to provide patient education and policy-makers to design and implement targeted ACL injury prevention programs. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yuba Raj Paudel
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
| | - Mark Sommerfeldt
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Don Voaklander
- School of Public Health, University of Alberta, Edmonton, AB, Canada
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Reduced performance after return to competition in ACL injuries: an analysis on return to competition in the 'ACL registry in German Football'. Knee Surg Sports Traumatol Arthrosc 2023; 31:133-141. [PMID: 35819462 PMCID: PMC9859836 DOI: 10.1007/s00167-022-07062-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/24/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE ACL injuries are one of the most severe injuries in football, but medical consequences and performance outcomes after return to competition are only rarely investigated. Aim of this study was to analyse the time of return to competition (RTC) in German professional, semi-professional and amateur football. Also, this investigation highlights the rate of career ending and performance outcome after RTC in different playing levels by the measurement of playing level, performed matches and played minutes. METHODS Database of this investigation is the 'ACL registry in German Football' with prospectively collected injury data. Between 2014 and 2018, four seasons in professional (1st-3rd league), semi-professional (4th-6th league) and amateur leagues (7th league) were analysed regarding the return to competition period and performance parameters. Data were collected for three subsequent seasons after injury and compared with the pre-injury and injury season. Data collection was performed using standardized methods. RESULTS A total of 607 ACL injuries were registered during the 4-year period with a mean RTC time of 337.1 day (SD: 183). After primary ACL ruptures, the fastest RTC was found in professional football (247.3 days), while in semi-professional (333.5 d; p < 0.0001) and amateur football (376.2 d; p < 0.0001) a prolonged absence was detected. Re-ruptures occurred in 17.8% (n = 108) and showed similar trend with fastest RTC in professionals (289.9 days; p = 0.002). Within the first three seasons after injury, 92 players (36.7%) in semi-professional and 24 (20%) in professionals had to end their career. Keeping the level of play was only possible for 48 (47.5%) of professionals, while only 47 (29.6%) of semi-professionals and 43 (28.1%) of amateurs were able to. Only in professional football, no significant difference could be seen in the played minutes and games after 2 years compared to the pre-injury season. CONCLUSION Lower playing levels and re-ruptures are the main factors for a prolonged return to competition after ACL rupture in German football. Significant reduction in playing level and a high rate of career endings were found for all levels of play. However, only professional players were able to regain their playing minutes and games 2 years after injury, while lower classed athletes did not reach the same amount within 3 years. LEVEL OF EVIDENCE Level III.
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Deviandri R, van der Veen HC, Lubis AMT, van den Akker-Scheek I, Postma MJ. "Cost-effectiveness of ACL treatment is dependent on age and activity level: a systematic review". Knee Surg Sports Traumatol Arthrosc 2023; 31:530-541. [PMID: 35997799 PMCID: PMC9898360 DOI: 10.1007/s00167-022-07087-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE To systematically review the literature on health-economic evaluations of anterior cruciate ligament (ACL) injury between reconstruction surgery (ACLR) and non-operative treatment (NO) and suggest the most cost-effective strategy between the two. METHODS All economic studies related to ACLR versus NO post-ACL injury, either trial based or model based, published until April 2022, were identified using PubMed and Embase. The methodology of the health-economic analysis for each included study was categorized according to the four approaches: cost-minimization analysis (CMA), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), and cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list. RESULTS Of the seven included studies, two compared the strategies of early ACLR and NO alone, and five compared early ACLR and NO with optional delayed ACLR. All studies performed a CUA, and one study performed a CBA additionally. The CHEC scores of the included studies can be considered good, ranging from 15 to 18 from a maximum of 19. Applying the common standard threshold of $50,000 per QALY, six studies in young people with high-activity levels or athletes showed that early ACLR would be preferred over either NO alone or delayed ACLR. Of six studies, two even showed early ACLR to be the dominant strategy over either NO alone or delayed ACLR, with per-patient cost savings of $5,164 and $1,803 and incremental per-patient QALY gains of 0.18 and 0.28, respectively. The one study in the middle-aged people with a moderate activity level showed that early ACLR was not more cost-effective than delayed ACLR, with ICER $101,939/QALY using the societal perspective and ICER $63,188/QALY using the healthcare system perspective. CONCLUSION Early ACLR is likely the more cost-effective strategy for ACL injury cases in athletes and young populations with high-activity levels. On the other hand, non-operative treatment with optional delayed ACLR may be the more cost-effective strategy in the middle age population with moderate activity levels. LEVEL OF EVIDENCE Systematic review of level III studies.
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Affiliation(s)
- R. Deviandri
- grid.4494.d0000 0000 9558 4598Department of Orthopedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands ,grid.444161.20000 0000 8951 2213Department of Physiology, Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia ,Division of Orthopedics, Arifin Achmad Hospital, Pekanbaru, Indonesia
| | - H. C. van der Veen
- grid.4494.d0000 0000 9558 4598Department of Orthopedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - A. M. T. Lubis
- grid.9581.50000000120191471Department of Orthopedics-Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - I. van den Akker-Scheek
- grid.4494.d0000 0000 9558 4598Department of Orthopedics, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - M. J. Postma
- grid.4494.d0000 0000 9558 4598Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands ,grid.4830.f0000 0004 0407 1981Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands ,grid.440745.60000 0001 0152 762XDepartment of Pharmacology & Therapy, Universitas Airlangga, Surabaya, Indonesia ,grid.11553.330000 0004 1796 1481Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
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11
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Shen X, Liu T, Xu S, Chen B, Tang X, Xiao J, Qin Y. Optimal Timing of Anterior Cruciate Ligament Reconstruction in Patients With Anterior Cruciate Ligament Tear: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2242742. [PMID: 36394870 PMCID: PMC9672975 DOI: 10.1001/jamanetworkopen.2022.42742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE The timing of surgery has been regarded as a key factor in anterior cruciate ligament reconstruction (ACLR), and early vs delayed ACLR remains a controversial topic. OBJECTIVE To synthesize up-to-date published data from randomized clinical trials (RCTs) comparing early vs elective delayed ACLR for patients with ACL deficiency, in terms of clinical outcomes and complications. DATA SOURCES The PubMed, Cochrane Library, and Web of Science databases were systematically searched until September 9, 2022. STUDY SELECTION All published RCTs comparing clinical and functional outcomes and complications associated with early ACLR vs elective delayed ACLR. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted relevant data and assessed the methodological quality following the PRISMA guidelines. MAIN OUTCOMES AND MEASURES Due to the clinical heterogeneity, the random-effects model was preferred. The primary outcomes were functional outcomes and complications. The Mantel-Haenszel test was used to evaluate dichotomous variables and the inverse variance method was used to assess continuous variables. RESULTS This meta-analysis included 972 participants in 11 RCTs stratified by follow-up duration. The following factors did not differ between early and delayed ACLR: operative time (mean difference, 4.97; 95% CI, -0.68 to 10.61; P = .08), retear (OR, 1.52; 95% CI, 0.52-4.43; P = .44), and infection (OR, 3.80; 95% CI, 0.77-18.79; P = .10). There were also no differences between groups in range of motion, knee laxity, International Knee Documentation Committee (IKDC rating scale), and Tegner score. IKDC score (mean difference, 2.77; 95% CI, 1.89-3.66; P < .001), and Lysholm score at 2-year follow-up (mean difference, 2.61; 95% CI, 0.74-4.48; P = .006) significantly differed between early and delayed ACLR. In addition, the timing of surgery was redefined in the included RCTs and subgroup analyses were performed, which validated the robustness of the principal results. CONCLUSION AND RELEVANCE This systematic review and meta-analysis found that early ACLR was not superior to delayed ACLR in terms of most factors analyzed, except for IKDC and Lysholm scores. This information should be available to patients with ACL deficiency and clinicians as part of the shared decision-making process of treatment selection.
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Affiliation(s)
- Xianyue Shen
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Tong Liu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Shenghao Xu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Bo Chen
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Xiongfeng Tang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jianlin Xiao
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Yanguo Qin
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
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12
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Chan YC, Yau WP. Association of Smoking With Graft Rupture After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2022; 10:23259671221127244. [PMID: 36263312 PMCID: PMC9575463 DOI: 10.1177/23259671221127244] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/27/2022] [Indexed: 11/09/2022] Open
Abstract
Background The effect of smoking on graft rupture after anterior cruciate ligament (ACL) reconstruction is not well understood. Hypothesis It was hypothesized that there will be no relationship between tobacco use and graft rupture after ACL reconstruction, as reflected by postoperative magnetic resonance imaging (MRI) and arthroscopic examination. Study Design Cohort study; Level of evidence, 3. Methods Included were 233 patients who received primary ACL reconstruction with hamstring tendon autograft between January 1, 2013, and December 31, 2019, and who underwent MRI evaluation at 20.2 ± 1.9 months postoperatively. The patients were categorized by smoking history into 2 groups: 39 smokers and 194 nonsmokers. The 2 groups did not differ significantly in age, sex, operative technique, preinjury Tegner score, or mean time until postoperative MRI. The primary outcome was graft rupture rate, with rupture confirmed by either arthroscopic assessment or postoperative MRI diagnosis. The secondary outcome measure was degree of graft ligamentization, evaluated by measuring the signal-to-noise quotient (SNQ) of the graft. Results The overall ACL graft rupture rate was 6.0%. The rupture rate was significantly higher in smokers than in nonsmokers (12.8% vs 4.6%, respectively; P = .0498). Smokers also had a significantly higher whole-graft SNQ compared with nonsmokers (4.7 ± 4.4 vs 3.3 ± 3.7, respectively; P = .028), suggesting less satisfactory ligamentization in smokers. Conclusion Smoking was associated with a higher risk of graft rupture of ACL reconstruction and a higher SNQ of the intact graft as shown on postoperative MRI.
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Affiliation(s)
- Yat-Chi Chan
- Queen Mary Hospital, The University of Hong Kong, Hong Kong Special
Administrative Region of the People’s Republic of China.,The Duchess of Kent Children’s Hospital at Sandy Bay, The University
of Hong Kong, Hong Kong Special Administrative Region of the People’s Republic of
China
| | - W. P. Yau
- Queen Mary Hospital, The University of Hong Kong, Hong Kong Special
Administrative Region of the People’s Republic of China.,The Duchess of Kent Children’s Hospital at Sandy Bay, The University
of Hong Kong, Hong Kong Special Administrative Region of the People’s Republic of
China.,W. P. Yau, MBBS, FRCSEd(Orth), FHKCOS, FHKAM, Department of
Orthopaedics and Traumatology, Queen Mary Hospital, No. 102 Pokfulam Road, 5/F,
Professorial Block, Room 509, Hong Kong, Hong Kong Special Administrative Region
of the People’s Republic of China ()
(Twitter: @WpYau)
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13
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ARIMAA A, KNIFSUND J, KESKINEN H, KIVIMÄKI M, AALTO V, OKSANEN T, MÄKELÄ K, VAHTERA J, LANKINEN P. Return to work following anterior cruciate ligament reconstruction. Acta Orthop 2022; 93:554-559. [PMID: 35700049 PMCID: PMC9205185 DOI: 10.2340/17453674.2022.3139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Amongst people of working age, the return to work (RTW) after anterior cruciate ligament (ACL) reconstruction is an important marker of success of surgery. We determined when patients are able to return to work after ACL reconstruction and identified factors that are associated with the timing of RTW. PATIENTS AND METHODS We used logistic regression analyses to examine patient-related factors that may be associated with the length of RTW (above vs. below the median 59 days) after arthroscopic ACLR in a large cohort of patients working in the public sector in Finland (n = 803; n = 334 male, n = 469 female; mean age 41 years [SD 8.6]). RESULTS The mean length of RTW was 65 days (SD 41). Higher odds ratios (OR) were observed for age groups 40-49 and ≥ 50 years compared with ≤ 30 years old (OR 2.0, 95% confidence interval 1.3-3.1 and 2.0, 1.2-3.4, respectively); for lower level non-manual and manual work compared with higher level non-manual work (3.0, 2.0-4.3 and 4.9, 3.4-7.0, respectively); and for those who had been on sick leave > 30 days in the preceding year (2.0, 1.4-2.9). Sex, comorbid conditions, preceding antidepressant treatment and concomitant procedures were not associated with the length of RTW. INTERPRETATION Factors associated with prolonged sick leave beyond the median time of 59 days are higher age, lower occupational status, and preoperative sick leaves.
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Affiliation(s)
- Anssi ARIMAA
- Department of Orthopedics and Traumatology Turku, Turku University Hospital and University of Turku, Turku, Finland
| | - Jani KNIFSUND
- Department of Orthopedics and Traumatology Turku, Turku University Hospital and University of Turku, Turku, Finland
| | - Heli KESKINEN
- Department of Orthopedics and Traumatology Turku, Turku University Hospital and University of Turku, Turku, Finland
| | - Mika KIVIMÄKI
- Finnish Institute of Occupational Health, Helsinki, Finland,Department of Epidemiology and Public Health, University College London, London, UK
| | - Ville AALTO
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Tuula OKSANEN
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Keijo MÄKELÄ
- Department of Orthopedics and Traumatology Turku, Turku University Hospital and University of Turku, Turku, Finland
| | - Jussi VAHTERA
- Department of Public Health, University of Turku, Turku, Finland,Centre for Population Health Research, University of Turku and Turku University Hospital; Turku, Finland
| | - Petteri LANKINEN
- Department of Orthopedics and Traumatology Turku, Turku University Hospital and University of Turku, Turku, Finland,Satasairaala Central Hospital, Pori, Finland
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14
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Nakamae A, Sumen Y, Tsukisaka K, Deie M, Fujimoto E, Ishikawa M, Omoto T, Adachi N. A larger side-to-side difference in anterior knee laxity increases the prevalence of medial and lateral meniscal injuries in patients with ACL injuries. Knee Surg Sports Traumatol Arthrosc 2022; 30:1560-1567. [PMID: 33970292 DOI: 10.1007/s00167-021-06601-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/30/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The objective of this study was to investigate factors that influence the prevalence of medial and lateral meniscal injuries at the time of anterior cruciate ligament (ACL) reconstruction in patients with ACL injuries. METHODS Patients with ACL injuries at 9 institutions were enrolled in this multicentre study. Age, sex, duration between injury and surgery, pivot shift test grade, anterior knee laxity determined using the Kneelax 3 arthrometer, and other variables were assessed by logistic regression analysis. Meniscal conditions were evaluated via arthroscopy. RESULTS In all, 830 patients were enrolled. The prevalence of medial and lateral meniscal tears was 32.0% (266 knees) and 26.5% (220 knees), respectively. Significant factors that influenced the prevalence of medial meniscal injuries were age [odds ratio (OR) 1.03; P = 0.000], side-to-side differences in instrumented anterior knee laxity before surgery (OR 1.12; P = 0.002), duration between injury and surgery (≥ 12 months) (OR 1.86; P = 0.023), and pivot shift test grade (OR 1.36; P = 0.014). Significant factors of lateral meniscal injury were side-to-side differences in anterior knee laxity before surgery (OR 1.12; P = 0.003) and the male sex (OR 1.50; P = 0.027). CONCLUSION Greater anterior knee laxity, age, a longer duration between injury and surgery, and a higher pivot shift test grade predicted medial meniscal injury. Greater anterior knee laxity and the male sex predicted lateral meniscal injury. In patients with ACL injuries, the importance of side-to-side differences in anterior knee laxity should be rediscovered from the viewpoint of meniscal conditions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Atsuo Nakamae
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Yoshio Sumen
- Department of Orthopaedic Surgery, JA Onomichi General Hospital, 1-10-23, Hirahara, Onomichi, Hiroshima, 722-8508, Japan
| | - Kazuhiro Tsukisaka
- Department of Orthopaedic Surgery, Mazda Hospital, 2-15, Aosakiminami, Huchu-cho, Aki-gun, Hiroshima, 735-8585, Japan
| | - Masataka Deie
- Department of Orthopedic Surgery, Aichi Medical University, 21 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan
| | - Eisaku Fujimoto
- Department of Orthopedic Surgery, Chugoku Rosai Hospital, 1-5-1, Hiro-Tagaya, Kure, Hiroshima, 737-0193, Japan
| | - Masakazu Ishikawa
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takenori Omoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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15
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Waldhelm A, Allen S, Grand L, Bopp C, Foster K, Muckridge G, Schwarz N. Reliability and Differences Between Sexes in Landing Mechanics when Performing the Lateral Bound Test. Int J Sports Phys Ther 2022; 17:466-473. [PMID: 35391862 PMCID: PMC8975571 DOI: 10.26603/001c.33067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 01/23/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Anterior cruciate ligament injuries are prevalent among the athletic population, imposing a heavy economic burden, and the risk of re-injury. Most current biomechanical screening tasks are performed in the sagittal plane, and there is a need for more screening tools that assess sports specific movements in the frontal plane. The purpose of this study was to determine the reliability of and examine differences between sexes in the performance of the Lateral Bound Test (LBT). Materials/Methods Each subject performed three trials of a LBT which included jumping laterally from one leg over a hurdle and landing on the opposite leg. Two cameras were placed six feet from the landing marker. Maximum dynamic knee valgus using the frontal plane projection angle and knee flexion angle at initial contact and maximal knee flexion were measured upon landing leg using 2D video analysis software. Additionally, video of 10 individuals' trials were analyzed twice with one week between the analyses to obtain intra-rater reliability while 12 participants were retested one week later to determine test-retest reliability. Results Thirty healthy subjects, 16 males, 14 females participated. Intra-rater reliability was determined to be excellent for all variables (ICC>0.96). In contrast, the test-retest reliability had greater disparity. Test-retest reliability ranged from poor (ICC = 0.47) to excellent (ICC > 0.90). Significant differences existed between the sexes, including males being significantly taller, weighing more, and demonstrating greater bilateral dynamic knee valgus (p < 0.05). No significant differences existed between sexes for knee flexion angles. Conclusion The new LBT had excellent intra-rater reliability for assessing dynamic knee valgus and initial and maximum knee flexion angle when performing a functional movement in the frontal plane. Furthermore, males landed with more dynamic knee valgus than females which is contradictory to what has been observed with functional screening tools performed in the sagittal plane. Level of Evidence 3b (reliability study).
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Affiliation(s)
- Andy Waldhelm
- South College, Doctor of Physical Therapy Program, Knoxville, TN, USA; University of South Alabama, Physical Therapy Department, Mobile, AL, USA
| | - Sydney Allen
- Physical Therapy Department, University of South Alabama, Mobile, AL, USA
| | - Lacy Grand
- Physical Therapy Department, University of South Alabama, Mobile, AL, USA
| | - Carolyn Bopp
- Physical Therapy Department, University of South Alabama, Mobile, AL, USA
| | - Kristian Foster
- Physical Therapy Department, University of South Alabama, Mobile, AL, USA
| | - Ginger Muckridge
- Physical Therapy Department, University of South Alabama, Mobile, AL, USA
| | - Neil Schwarz
- Department of Health, Kinesiology and Sport, University of South Alabama, Mobile, AL, USA
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16
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Smeets A, Ghafelzadeh Ahwaz F, Bogaerts S, De Groef A, Berger P, Kaux JF, Daniel C, Croisier JL, Delvaux F, Laenen A, Staes F, Peers K. Pilot study to investigate the feasibility of conducting a randomised controlled trial that compares Immediate versus Optional Delayed surgical repair for treatment of acute Anterior cruciate ligament injury: IODA pilot trial. BMJ Open 2022; 12:e055349. [PMID: 35277406 PMCID: PMC8919438 DOI: 10.1136/bmjopen-2021-055349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Standard care for anterior cruciate ligament (ACL) injuries includes surgical reconstruction of the ACL. However, two randomised controlled trials (RCTs) concluded that conservative treatment does not result in inferior clinical outcomes compared with immediate ACL reconstruction. More research is needed to in the first place verify these results, and second to assess whether patient-specific parameters determine whether a patient would benefit from one treatment option over the other. However, before running a full RCT, it seems necessary to perform a pilot study that assesses the feasibility of recruiting patients with ACL for such a RCT. This is because recruitment may be challenging as many patients have strong treatment beliefs. Therefore, this pilot study will assess whether a large RCT is feasible with regard to participant recruitment, adherence to the allocated treatment arm and protocol feasibility. These pilot findings will help deciding about progressing to a future full RCT. METHODS AND ANALYSIS This is a pragmatic, multicentre, randomised controlled pilot trial with two parallel groups. Patients with an acute ACL injury will be recruited from two Belgian hospitals. Patients will be randomised to either conservative treatment or surgical treatment. Patients will be followed-up at 3, 6 and 12 months postrandomisation. Recruitment feasibility will be evaluated by calculating the recruitment rate 4 months after the two sites have been initiated. Clear criteria for progression to a full trial are defined. Adherence to the protocol will be assessed by calculating the proportion of patients who complete the assessments. Furthermore the proportion of patients who cross-over between treatment arms during the follow-up period will be assessed. ETHICS AND DISSEMINATION The study was approved by the ethical committees: Ethische Commissie Onderzoek UZ/KU Leuven (S62004) and Comité d'Ethique Hospitalo-Facultaire Universitaire de Liège (2020212). Results will be made available to caregivers, researchers and funder. TRIAL REGISTRATION NUMBER This trial is registered on ClinicalTrials.gov (NCT04408690) on 29 May 2020.
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Affiliation(s)
- Annemie Smeets
- Department of Rehabilitation Sciences & Physiotherapy, KU Leuven, Leuven, Belgium
- Department of Physical Medicine and Rehabilitation, University Hospitals Leuven, Leuven, Belgium
| | - Feryal Ghafelzadeh Ahwaz
- Department of Physical Medicine and Rehabilitation, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Stijn Bogaerts
- Department of Physical Medicine and Rehabilitation, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - An De Groef
- Department of Rehabilitation Sciences & Physiotherapy, KU Leuven, Leuven, Belgium
| | - Pieter Berger
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Orthopedics, University Hospitals Leuven, Leuven, Belgium
| | - Jean-François Kaux
- Department of Physical Medicine and Sports Traumatology, Unversity Hospital of Liège, Liège, Belgium
| | - Christophe Daniel
- Department of Orthopedic Surgery, University Hospital of Liège, Liège, Belgium
| | - Jean-Louis Croisier
- Department of Physical Medicine and Sports Traumatology, Unversity Hospital of Liège, Liège, Belgium
- Department of Sports and Rehabilitation Sciences, University of Liège, Liège, Belgium
| | - François Delvaux
- Department of Sports and Rehabilitation Sciences, University of Liège, Liège, Belgium
| | - Annouschka Laenen
- Leuven Biostatistics and Statistical Bioinformatics Centre, KU Leuven, Leuven, Belgium
| | - Filip Staes
- Department of Rehabilitation Sciences & Physiotherapy, KU Leuven, Leuven, Belgium
| | - Koen Peers
- Department of Physical Medicine and Rehabilitation, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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17
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Li R, Zhang J, Chen X, Fang Z. The Relationship Between Lateral Femoral Condyle Index and Noncontact Anterior Cruciate Ligament Rupture. Int J Gen Med 2022; 15:1789-1794. [PMID: 35210843 PMCID: PMC8863190 DOI: 10.2147/ijgm.s347742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/02/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this study was to examine the relationship between distal femoral morphology and noncontact anterior cruciate ligament (ACL) rupture and the differences between digital X-ray imaging systems (DR) and magnetic resonance imaging (MRI) to evaluate distal femoral morphology. Methods A retrospective case-control study was performed on 120 patients. Two age- and sex-matched cohorts (each n = 60) were analyzed: primary ACL ruptures and a control group consisting of isolated meniscal tears. The lateral femoral condyle index (LFCI) was measured by DR and by MRI to quantify femoral sphericity. Differences among two groups were compared, and diagnostic performance of the risk factors was assessed. In addition, differences between DR and MRI to evaluate LFCI were examined. Results The LFCI by MRI was smaller in the knees with primary ACL rupture (median, 0.71; range, 0.62–0.78) than that of the control group (median, 0.77; range, 0.66–0.85) (p < 0.01). The LFCI was also significantly smaller in the knees with primary ACL rupture (median, 0.72; range, 0.63–0.77) than that of the control group (median, 0.79; range, 0.65–0.84) (p < 0.01) by DR. A cutoff of 0.74 of MRI yielded a sensitivity of 77% and a specificity of 78% to predict an ACL rupture, and of 0.75 of DR yield a sensitivity of 87% and a specificity of 77% to predict an ACL rupture. Conclusion This study showed that a decreased LFCI is associated with an ACL rupture, and both DR and MRI measurements can effectively predict the risk of ACL rupture. This helps expand the scope of the application of the LFCI and helps clinicians identify susceptible individuals who may benefit from targeted ACL rupture prevention counseling and intervention.
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Affiliation(s)
- Ruibo Li
- Department of Orthopaedics, Peoples’ Hospital of Deyang City, Deyang, 618000, Sichuan Province, People’s Republic of China
- Correspondence: Ruibo Li; Xi Chen, Department of Orthopaedics, Peoples’ Hospital of Deyang City, No. 173, Section 3, North Taishan Road, Deyang, 618000, Sichuan Province, People’s Republic of China, Tel +86 18280366719; +86 8382148102, Email ;
| | - Jianjun Zhang
- Department of Orthopaedics, Peoples’ Hospital of Deyang City, Deyang, 618000, Sichuan Province, People’s Republic of China
| | - Xi Chen
- Department of Orthopaedics, Peoples’ Hospital of Deyang City, Deyang, 618000, Sichuan Province, People’s Republic of China
| | - Zhi Fang
- Department of Orthopaedics, Peoples’ Hospital of Deyang City, Deyang, 618000, Sichuan Province, People’s Republic of China
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18
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Fan Z, Yan J, Zhou Z, Gao Y, Tang J, Li Y, Zhang Z, Yang M, Lv J. Delayed Versus Accelerated Weight-bearing Rehabilitation Protocol Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. J Rehabil Med 2022; 54:jrm00260. [PMID: 35037693 PMCID: PMC8892302 DOI: 10.2340/jrm.v53.1438] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To compare accelerated and delayed weight-bearing rehabilitation of anterior cruciate ligament reconstruction regarding clinical outcome measures of knee function (International Knee Documentation Committee Subjective Knee Form (IKDC), Lysholm Knee Scoring Scale, Tegner Activity Scale, and Knee Injury and Osteoarthritis Outcome Score (KOOS)), knee laxity, range of movement, quadriceps, and bone tunnel enlargement. Design Systematic review and meta-analysis. Methods Systematic searches of Embase, MEDLINE, CINAHL, and the Cochrane Library databases, from inception to February 2021, for studies comparing delayed or accelerated weight-bearing rehabilitation protocol after anterior cruciate ligament reconstruction in adult patients. Results Nine studies met the eligibility criteria. A meta-analysis revealed a higher risk of knee laxity in the accelerated weight-bearing group. Accelerated weight-bearing may be related to higher IKDC scores, while there was no statistical difference for Lysholm, Tegner, and KOOS scores at a follow-up within 2 years. Four of 5 studies reported no statistical difference for quadriceps strength and range of movement scores, while 2 studies reported bone tunnel enlargement in the accelerated weight-bearing group. Conclusion This systematic review confirmed that accelerated weight-bearing caused more serious knee laxity and bone tunnel widening than delayed weight-bearing after anterior cruciate ligament reconstruction. We therefore recommend that clinicians should select postoperative rehabilitation programmes with caution.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jiayin Lv
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun 130033, P. R. China.
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Forsythe B, Lu Y, Agarwalla A, Ezuma CO, Patel BH, Nwachukwu BU, Beletsky A, Chahla J, Kym CR, Yanke AB, Cole BJ, Bush-Joseph CA, Bach BR, Verma NN. Delaying ACL reconstruction beyond 6 months from injury impacts likelihood for clinically significant outcome improvement. Knee 2021; 33:290-297. [PMID: 34739960 DOI: 10.1016/j.knee.2021.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The effect of surgical latency on outcomes of anterior cruciate ligament reconstruction (ACLR) is a topic that is heavily debated. Some studies report increased benefit when time from injury to surgery is decreased while other studies report no benefit. The purpose of our analysis was to compare achievement of clinically significant outcomes (CSOs) in patients with greater than six months of time from injury to ACLR to those with less than or equal to six months of time to surgery. METHODS Patients undergoing primary ACLR between January 2017 and January 2018 with minimum one year follow-up were included. International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were collected. Multivariate logistic regression was performed for outcome achievement and risk of revision ACLR and Weibull parametric survival analysis was performed for relative time to outcome achievement. The level of significance was set at α = 0.05. RESULTS 379 patients were included of which, 140 patients sustained ACL injury greater than six months prior to surgery. This group of patients experienced reduced likelihood to achieve patient-acceptable symptomatic state (PASS) on the IKDC (p = 0.03), KOOS Pain (p = 0.01) and a greater likelihood to undergo revision ACLR (p = 0.001). There was no impact of surgical timing on minimal clinically important difference (MCID). CONCLUSION Patients with greater than 6 months from injury to ACLR reported reduced likelihood to achieve CSOs, delayed achievement of CSOs, and increased rates of revision surgery.
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Affiliation(s)
- Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
| | - Yining Lu
- Dept. of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Avinesh Agarwalla
- Dept. of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Chimere O Ezuma
- School of Medicine, Vagelos Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Bhavik H Patel
- Dept. of Orthopaedic Surgery, University of Illinois - Chicago, Chicago, IL, USA
| | | | - Alexander Beletsky
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Craig R Kym
- Dept. of Orthopaedic Surgery, University of Illinois - Chicago, Chicago, IL, USA
| | - Adam B Yanke
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | | | - Bernard R Bach
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
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20
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A Systematic Review of Randomized Controlled Trials in Anterior Cruciate Ligament Reconstruction: Standard Techniques Are Comparable (299 Trials With 25,816 Patients). Arthrosc Sports Med Rehabil 2021; 3:e1211-e1226. [PMID: 34430902 PMCID: PMC8365213 DOI: 10.1016/j.asmr.2021.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/24/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose To provide an overview of all published randomized controlled trials (RCTs) in anterior cruciate ligament reconstruction (ACLR) summarizing the available evidence. Methods Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane FIGCentral Register of Controlled Trials, Ovid MEDLINE, and Embase for RCTs of ACLR from their inception to August 26, 2020. Outcome measure was whether RCTs reported statistically significant findings. RCTs were then classified according to their intervention groups in a narrative synthesis of the evidence. Results In total, 299 RCTs met the inclusion criteria and were included with a total number of 25,186 patients. Only 30 RCTs (10%) reported significant differences between the intervention and the control groups. These included 101 RCTs on grafts, 20 RCTs on tunnel placements, 48 RCTs on graft fixation, 42 RCTs on single-bundle compared with double-bundle reconstructions, 11 RCTs on additional procedures, 11 RCTs on graft tensioning, 5 RCTs on timing of surgery, 25 RCTs on technical variations from standard techniques, 6 RCTs on ACL repair, 5 RCTs on navigation, 16 RCTs on perioperative management, and 9 RCTs on other aspects of ACLR. Only 14 RCTs (4.7%) reported outcomes beyond 10 years with greater allograft failures compared with autografts, high incidence of osteoarthritic changes in reconstructed knees (22%-100%), with no significant differences in outcomes between bioabsorbable or metal screws for graft fixation, patellar versus hamstrings or single- versus double-bundle reconstructions. Conclusions The evidence indicates that a standard arthroscopic single- or double-bundle ACLR with hamstrings/patella autografts, transportal technique, and fixation techniques familiar to the surgeon leads to comparable results. This evidence offers surgeons the flexibility to use standard and cost-effective techniques and achieve comparable outcomes. Level of Evidence Level II; systematic review of Level I-II randomized controlled trials.
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21
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Eggerding V, Reijman M, Meuffels DE, van Es E, van Arkel E, van den Brand I, van Linge J, Zijl J, Bierma-Zeinstra SM, Koopmanschap M. ACL reconstruction for all is not cost-effective after acute ACL rupture. Br J Sports Med 2021; 56:24-28. [PMID: 33737313 PMCID: PMC8685656 DOI: 10.1136/bjsports-2020-102564] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To conduct a cost-utility analysis for two commonly used treatment strategies for patients after ACL rupture; early ACL reconstruction (index) versus rehabilitation plus an optional reconstruction in case of persistent instability (comparator). METHODS Patients aged between 18 and 65 years of age with a recent ACL rupture (<2 months) were randomised between either an early ACL reconstruction (index) or a rehabilitation plus an optional reconstruction in case of persistent instability (comparator) after 3 months of rehabilitation. A cost-utility analysis was performed to compare both treatments over a 2-year follow-up. Cost-effectiveness was calculated as incremental costs per quality-adjusted life year (QALY) gained, using two perspectives: the healthcare system perspective and societal perspective. The uncertainty for costs and health effects was assessed by means of non-parametric bootstrapping. RESULTS A total of 167 patients were included in the study, of which 85 were randomised to the early ACL reconstruction (index) group and 82 to the rehabilitation and optional reconstruction group (comparator). From the healthcare perspective it takes 48 460 € and from a societal perspective 78 179 €, to gain a QALY when performing early surgery compared with rehabilitation plus an optional reconstruction. This is unlikely to be cost-effective. CONCLUSION Routine early ACL reconstruction (index) is not considered cost-effective as compared with rehabilitation plus optional reconstruction for a standard ACL population (comparator) given the maximum willingness to pay of 20 000 €/QALY. Early recognition of the patients that have better outcome of early ACL reconstruction might make rehabilitation and optional reconstruction even more cost-effective.
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Affiliation(s)
- Vincent Eggerding
- Orthopedics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Max Reijman
- Orthopedics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | | | - Eline van Es
- Orthopedics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Ewoud van Arkel
- Orthopedics, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Igor van den Brand
- Orthopedics, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Noord-Brabant, The Netherlands
| | - Joost van Linge
- Orthopedics, Reinier de Graaf Gasthuis, Delft, Zuid-Holland, The Netherlands
| | - Jacco Zijl
- Department of Orthopaedic Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Sita Ma Bierma-Zeinstra
- Department of General Practice and Orthopedics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Marc Koopmanschap
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
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22
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van der List JP, Hagemans FJA, Zuiderbaan HA, van Dijke CF, Rademakers MV, van Noort A, Kerkhoffs GMMJ. Age, activity level and meniscus injury, but not tear location, tibial slope or anterolateral ligament injury predict coping with anterior cruciate ligament injury. Knee 2021; 29:222-232. [PMID: 33640621 DOI: 10.1016/j.knee.2021.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/04/2021] [Accepted: 01/25/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Early recognition of potential predictors on the success of conservative treatment of anterior cruciate ligament (ACL) is important, as appropriate treatment can be applied to each individual patient. The goal of this study is to assess the patient demographic and radiological parameters that predict coping with ACL injuries. METHODS All patients presenting with a complete ACL injury between 2014 and 2018 at our clinic were included. The role of patient demographics (age, gender, activity level, meniscus injury and time from injury to clinic), and ACL tear location, bone bruises, tibial slope, and anterolateral ligament (ALL) injury were assessed on the success of conservative treatment using univariate and multivariate analyses. RESULTS Sixty-five patients (32%) were copers and 141 (68%) were non-copers. Univariate analysis showed that copers were significantly older (40 vs. 27 years, P < 0.001), had lower preinjury activity level (Tegner 5.7 vs. 6.5, P < 0.001) and less often lateral meniscus tears (16% vs. 5%, P = 0.019) but not medial meniscus tears (17% vs. 14%, P = 0.609) than non-copers. Multivariate analysis revealed that increasing age (P < 0.001), Tegner level ≤ 6 (P = 0.003) and no meniscus injury (P = 0.045) were independent predictors of coping with ACL deficiency. CONCLUSIONS Older age, participation in lower activity sports levels and absence of meniscus injury were predictive of coping with ACL deficiency, whereas there was no such role for tear location, tibial slope, lateral bone bruise presence, ALL injury or gender. These findings might help to identify potential copers and guide surgeons early in the optimal treatment for patients with ACL injury.
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Affiliation(s)
- Jelle P van der List
- NorthWest Clinics, Department of Orthopaedic Surgery, Alkmaar, the Netherlands; Amsterdam UMC, University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam, the Netherlands; Spaarne Gasthuis, Department of Orthopaedic Surgery, Hoofddorp, the Netherlands.
| | - Frans J A Hagemans
- NorthWest Clinics, Department of Orthopaedic Surgery, Alkmaar, the Netherlands
| | - Hendrik A Zuiderbaan
- NorthWest Clinics, Department of Orthopaedic Surgery, Alkmaar, the Netherlands; Medical Clinics Velsen, Department of Orthopaedic Surgery, Velsen, the Netherlands
| | | | | | - Arthur van Noort
- Spaarne Gasthuis, Department of Orthopaedic Surgery, Hoofddorp, the Netherlands
| | - Gino M M J Kerkhoffs
- Amsterdam UMC, University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, the Netherlands; Amsterdam UMC, Amsterdam Collaboration on Health & Safety in Sports (ACHSS), University of Amsterdam and Vrije Universiteit Amsterdam IOC Research Center, Amsterdam, the Netherlands
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23
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Musahl V, Diermeier T, de Sa D, Karlsson J. "ACL surgery: when to do it?". Knee Surg Sports Traumatol Arthrosc 2020; 28:2023-2026. [PMID: 32621042 DOI: 10.1007/s00167-020-06117-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Theresa Diermeier
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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van der List JP, Hagemans FJA, Hofstee DJ, Jonkers FJ. The Role of Patient Characteristics in the Success of Nonoperative Treatment of Anterior Cruciate Ligament Injuries. Am J Sports Med 2020; 48:1657-1664. [PMID: 32401542 DOI: 10.1177/0363546520917386] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears can either be treated nonoperatively with physical therapy and then treated operatively if persistent instability is present, or be directly treated operatively. Advantages of early ACL reconstruction surgery include shorter time from injury to surgery and potentially fewer meniscal injuries, but performing early ACL reconstruction in all patients results in surgery in patients who might not need ACL reconstruction. It is important to assess in which patients nonoperative treatment is successful and which patients will require ACL reconstruction and thus might be better treated surgically in an earlier phase. PURPOSE To identify patient characteristics that predict the success of nonoperative treatment. STUDY DESIGN Cohort study (Prognosis); Level of evidence, 2. METHODS All patients with complete ACL injuries who were evaluated between 2014 and 2017 at our clinic were included. The minimum follow-up was 2 years. The initial treatment and ultimate ACL reconstruction were reviewed. Univariate analysis was performed using Mann-Whitney U tests and chi-square tests and multivariate analysis using binary logistic regression. RESULTS A total of 448 patients were included with a median age of 26 years and median Tegner level of 7 and mean Tegner level of 6.4. At initial consultation, 210 patients (47%) were treated nonoperatively with physical therapy and 126 of these patients (60%) ultimately required ACL reconstruction. Nonoperative treatment failed in 88.9% of patients <25 years of age, 56.0% of patients 25 to 40 years, and 32.9% of patients >40 years (P < .001); and 41.9% of patients with Tegner level 3 to 6, and 82.8% of patients with Tegner level 7 to 10. Age <25 years (odds ratio [OR], 7.4; P < .001) and higher Tegner levels (OR, 4.2; P < .001) were predictive of failing nonoperative treatment in multivariate analysis. Patients in the failed nonoperative group had longer time from diagnosis to surgery than the direct reconstruction group (6.2 vs 2.2 months; P < .001), and more frequently had new meniscal injuries (17.4% vs 3.1%; P < .001) at surgery. CONCLUSION Nonoperative treatment of ACL injuries failed in 60% of patients and was highly correlated with age and activity level. In patients aged 25 years or younger or participating in higher-impact sports, early ACL reconstruction should be considered to prevent longer delay between injury and surgery, as well as new meniscal injuries.
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Affiliation(s)
- Jelle P van der List
- Department of Orthopaedic Surgery, Northwest Clinics, Alkmaar, the Netherlands.,Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Frans J A Hagemans
- Department of Orthopaedic Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Dirk Jan Hofstee
- Department of Orthopaedic Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Freerk J Jonkers
- Department of Orthopaedic Surgery, Northwest Clinics, Alkmaar, the Netherlands
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25
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von Essen C, Eriksson K, Barenius B. Acute ACL reconstruction shows superior clinical results and can be performed safely without an increased risk of developing arthrofibrosis. Knee Surg Sports Traumatol Arthrosc 2020; 28:2036-2043. [PMID: 31559463 PMCID: PMC7347704 DOI: 10.1007/s00167-019-05722-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/11/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE To compare acute ACL reconstruction (ACLR) within 8 days of injury with delayed reconstruction after normalized range of motion (ROM), 6-10 weeks after injury. It was hypothesized that acute ACL reconstruction with modern techniques is safe and can be beneficial in terms of patient-reported outcomes and range of motion. METHODS The effect of acute and delayed ACLR was randomized studied on 70 patients with high recreational activity level, Tegner level 6 or more, between 2006 and 2013. Patient-reported outcomes, objective IKDC, KOOS, and manual stability measurements were documented during the 24-month follow-up period. RESULTS The acute ACLR group did not result in increased stiffness and showed superior outcome regarding strength and how the patient felt their knee functioning at 24 months. In addition, the acute group was not inferior to the delayed group in any assessment. Regarding patient-related outcomes in KOOS, both groups showed significant improvements in all subscales, but no difference was found between the groups. Functional return (FR) rate was almost double compared to the Swedish knee ligament register and treatment failure (TF) rate was reduced by half, no significant difference between the groups. No difference regarding cyclops removal, re-injury of ACL or meniscus was found between the two surgical timing groups. CONCLUSION Acute ACLR within 8 days of injury does not appear to adversely affect ROM or result in increased stiffness in the knee joint and was not inferior to the delayed group in any assessment when compared to delayed surgery. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Christoffer von Essen
- Department of Orthopaedics, Stockholm South Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Karl Eriksson
- Department of Orthopaedics, Stockholm South Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Björn Barenius
- Department of Orthopaedics, Stockholm South Hospital, Karolinska Institutet, Stockholm, Sweden
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