1
|
Smith C, Grooms DR, Bradley H. Enhancing Return to Alpine Skiing: Integrating Perceptual-Motor-Cognitive Considerations in Testing and Progressions: A Clinical Commentary. Int J Sports Phys Ther 2024; 19:923-934. [PMID: 38966833 PMCID: PMC11221336 DOI: 10.26603/001c.120285] [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: 10/04/2023] [Accepted: 06/12/2024] [Indexed: 07/06/2024] Open
Abstract
Alpine skiing poses significant risks for anterior cruciate ligament (ACL) injury at both recreational and professional levels, which is compounded by high rates of re-injury. Despite the existence of return to sport (RTS) and return to snow protocols, the frequency of ACL re-injury has not been mitigated, raising doubts about protocol effectiveness. Current RTS protocols primarily focus on biomechanical and neuromuscular factors in isolation, neglecting the important perceptual-motor-cognitive changes associated with ACL injuries and the high cognitive demands of skiing. The purpose of this clinical commentary is to address the perceptual-motor-cognitive demands specific to alpine skiing, evaluate RTS testing for skiers, and propose updated standards for testing and return to snow progressions that incorporate these considerations. Level of Evidence 5.
Collapse
Affiliation(s)
| | - Dustin R Grooms
- Ohio Musculoskeletal and Neurological Institute Ohio University
- Division of Athletic Training, School of Applied Health Sciences and Wellness, College of Health Sciences and Professions Ohio University
- Division of Physical Therapy, School of Rehabilitation and Communication Sciences, College of Health Sciences and Professions Ohio University
| | | |
Collapse
|
2
|
Rupp MC, Winkler PW, Willinger L, Runer A. Editorial Commentary: Early Outcomes of Suture Tape Augmentation in Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction Are Promising but Require Long-term Proof. Arthroscopy 2024:S0749-8063(24)00328-1. [PMID: 38705543 DOI: 10.1016/j.arthro.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 05/07/2024]
Abstract
The management of anterior cruciate ligament (ACL) injuries continually evolves, with new interest in all-soft tissue quadriceps tendon autograft, as well as new interest in suture tape augmentation of the graft, particularly in high-risk patients with young age; female sex; lower-limb alignment, tibial, or femoral abnormalities; hyperlaxity; concomitant meniscal and/or additional ligamentous injuries; or participation in high-risk sports. Load-sharing suture tape enhances the biomechanical stability of the reconstructed ACL, especially during the initial ingrowth and ligamentization phase, and biomechanical evidence highlights a reduced risk of graft elongation and failure under the loads encountered during daily physical activities and sport. Optimal tape tensioning could be achieved in knee hyperextension, when the ACL is at maximal length, to avoid overconstraint. The published 2-year outcomes of this technique are excellent. Current comparative studies, however, have not shown superiority. Additional controlled studies and studies with longer-term follow-up are needed, as well as comparison to extra-articular tenodesis augmentation.
Collapse
Affiliation(s)
| | | | | | - Armin Runer
- Technical University of Munich (P.W.W., L.W., A.R.)
| |
Collapse
|
3
|
Daniel AV, Smith PA. Primary All-Soft Tissue Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation Resulted in Satisfactory Patient Outcomes and a Low Graft Failure Rate in High School and Collegiate Athletes. Arthroscopy 2024:S0749-8063(24)00234-2. [PMID: 38518869 DOI: 10.1016/j.arthro.2024.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE To evaluate ≥2-year patient outcomes after primary all-soft tissue quadriceps tendon autograft (ASTQ) anterior cruciate ligament reconstruction (ACLR) with suture tape augmentation (STA) in skeletally mature high school and collegiate athletes. METHODS All high school and collegiate athletes who underwent primary ASTQ ACLR with STA with a minimum of 2-year follow-up were analyzed retrospectively. Patients were administered validated patient-reported outcome measures (PROMs) pre- and postoperatively. The minimal clinically important difference was calculated for each PROM based on this study population and applied to the individual patient. Return to sport, subsequent surgical intervention including contralateral ACLR, and KT-1000 arthrometer measurements for knee laxity were collected. Complications were assessed by physical examination, radiologic studies, or obtained via telephone. RESULTS In total, 60 patients were included in the final data analysis, with a mean age of 16.8 years (95% confidence interval 13-23) and mean final follow-up of 37.1 months (95% confidence interval 33.1-41.1). Twelve patients (20%) required subsequent surgery on the ipsilateral knee, which included 7 patients having a subsequent meniscal procedure and 3 patients who underwent arthrolysis. None sustained a graft failure, and 6 patients sustained a contralateral ACL injury necessitating surgery. All PROMs improved at the final follow-up (P < .001). In addition, KT-1000 arthrometer measurements significantly improved postoperatively at 1-year clinical follow-up (P < .001). Most patients obtained the minimal clinically important difference thresholds for each PROM at the final follow-up. There were 48 patients (80%) who participated in pivoting sports. The return-to-sport rate at same level was 54 patients (90%), with 6 patients (10%) not returning to the same level because of graduation. CONCLUSIONS ASTQ ACLR with STA in a young athletic patient population may result in a low graft failure rate while maintaining satisfactory patient outcomes at short-term follow-up, including a return to sport at the same level of 90%. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Adam V Daniel
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A..
| | | |
Collapse
|
4
|
Piussi R, Simonson R, Zsidai B, Grassi A, Karlsson J, Della Villa F, Samuelsson K, Senorski EH. Better Safe Than Sorry? A Systematic Review with Meta-analysis on Time to Return to Sport After ACL Reconstruction as a Risk Factor for Second ACL Injury. J Orthop Sports Phys Ther 2024; 54:1-15. [PMID: 38032099 DOI: 10.2519/jospt.2023.11977] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
OBJECTIVE: To compare the time to return to sport (RTS) between patients who did and did not suffer a second anterior cruciate ligament (ACL) injury after ACL reconstruction. DESIGN: Etiology systematic review with meta-analysis. LITERATURE SEARCH: Cochrane Library, Embase, Medline, AMED, and PEDro databases were searched in August 2021 and again in November 2022. STUDY SELECTION CRITERIA: Clinical studies reporting time to RTS after ACL reconstruction and second ACL injury were eligible. DATA SYNTHESIS: We pooled continuous data (time [months] and proportions [%]), with random-effects meta-analyses. Pooled estimates were summarized in forest plots. A qualitative data synthesis was also performed. RESULTS: Twenty-one studies were included in the meta-analysis and 33 in the qualitative synthesis. Pooled incidence of second ACL injury was 16.9% (95% confidence interval [CI]: 12.8, 21.6). Patients who suffered a second ACL injury returned to sport significantly earlier (25 days; 95% CI: 9.5, 40.4) than those who did not suffer another injury. There was no difference in time to RTS for professional athletes who suffered a second ACL injury and those who did not. The certainty of evidence was very low. CONCLUSION: There was very low-certainty evidence that patients who suffered a second ACL injury had returned to sport 25 days earlier than patients who did not have another injury. For professional athletes, there was no difference in time to RTS between athletes who suffered a second ACL injury and athletes who did not. J Orthop Sports Phys Ther 2024;54(3):1-15. Epub 30 November 2023. doi:10.2519/jospt.2023.11977.
Collapse
|
5
|
Bonell Monsonís O, Spörri J, Warsen M, Bolling C, Gouttebarge V, Verhagen E. We know a lot about little and little about a lot: A contextualized scoping review on injury prevention in alpine ski racing. Scand J Med Sci Sports 2024; 34:e14533. [PMID: 37955281 DOI: 10.1111/sms.14533] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/19/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Our goal was to summarize and contextualize the available literature on alpine ski racing injury epidemiology, injury etiology, injury prevention measures, injury prevention context, and implementation issues. MATERIALS AND METHODS We searched four electronic databases using predetermined search terms. We included original studies that assessed injury, injury risk factors, and injury mechanisms, and assessed and reported the effect of an injury prevention measure in alpine ski racing. Two authors independently conducted title-abstract screening, and one performed the full-text review. For data synthesis and categorization, we used the Translating Research into the Injury Prevention Practice framework and a modified and adapted version of the Haddon matrix. RESULTS Of the 157 included studies, most corresponded to injury epidemiology and etiology, whereas few studies encompassed injury prevention measure development, implementation and evaluation. Preventive interventions targeting equipment, rules and regulations, course design and snow preparation were the most prevalent in the literature. Furthermore, various contextual factors in the current literature have been found, including gender, competition level, countries and federations, and time periods within a season. CONCLUSIONS We provided an in-depth and comprehensive overview of the current state-of-the-art in the alpine ski racing context. We know a lot about little and little about a lot across all the areas associated with injury prevention in such context. The limitations in the literature yield a road map for designing future injury prevention studies to address the key gaps identified. A more comprehensive context-driven approach throughout all stages of injury prevention would benefit the ultimate implementation of effective preventive strategies.
Collapse
Affiliation(s)
- Oriol Bonell Monsonís
- Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, Amsterdam UMC, University Medical Centers - Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Musculoskeletal Health and Sports, Amsterdam, The Netherlands
| | - Jörg Spörri
- Sports Medical Research Group, Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Centre for Prevention and Sports Medicine, Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marit Warsen
- Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, Amsterdam UMC, University Medical Centers - Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Caroline Bolling
- Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, Amsterdam UMC, University Medical Centers - Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC Location University of Amsterdam, Orthopedic Surgery and Sports Medicine, Amsterdam, The Netherlands
| | - Vincent Gouttebarge
- Amsterdam Movement Sciences, Musculoskeletal Health and Sports, Amsterdam, The Netherlands
- Amsterdam UMC Location University of Amsterdam, Orthopedic Surgery and Sports Medicine, Amsterdam, The Netherlands
- Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Evert Verhagen
- Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, Amsterdam UMC, University Medical Centers - Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Musculoskeletal Health and Sports, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Müller PO, Taylor J, Jordan MJ, Scherr J, Verhagen E, Collins D, Spörri J. Call for the application of a biopsychosocial and interdisciplinary approach to the return-to-sport framework of snow sports athletes. BMJ Open Sport Exerc Med 2023; 9:e001516. [PMID: 37608842 PMCID: PMC10441041 DOI: 10.1136/bmjsem-2022-001516] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
Snow sports such as alpine skiing or snowboarding are associated with a high risk of injury and reinjury and are subject to a very special environment with specific rehabilitation challenges that must be addressed. Due to geographic decentralisation, seasonal climatic limitations, alternation of training in off-snow and on-snow settings and unique loading patterns of practising these sports, special rehabilitation structures and processes are required compared with other sports. In addition, returning to preinjury performance requires a high level of confidence and a resumption of risk-taking in demanding situations such as high-speed skiing and high-amplitude jumps. A biopsychosocial and interdisciplinary approach can be viewed as a holistic, athlete-centred approach that promotes interprofessional communication and collaboration. This is particularly central for managing the physical/biological, psychological and social demands of injury management for snow sports. It can help ensure that rehabilitation content is well coordinated and tailored to individual needs. This is because transitions between different rehabilitation phases and caring professionals are well aligned, and rehabilitation is understood not only as purely 'physical recovery' but also as 'psychological recovery' considering the snow sports-specific setting with specific social norms. Ultimately, this may improve the rehabilitation success of snow sports athletes.
Collapse
Affiliation(s)
- Philippe O Müller
- Sports Medical Research Group, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Centre for Prevention and Sports Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jim Taylor
- University of San Francisco, San Francisco, California, USA
| | - Matthew J Jordan
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Johannes Scherr
- Sports Medical Research Group, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Centre for Prevention and Sports Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Evert Verhagen
- Amsterdam Collaboration on Health & Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, Amsterdam UMC, University Medical Centres, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Musculoskeletal Health & Sports, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Dave Collins
- Grey Matters Performance Ltd, London, UK
- Human Performance Science Research Group, Institute for Sport, Physical Education and Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Jörg Spörri
- Sports Medical Research Group, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Centre for Prevention and Sports Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
7
|
Farinelli L, Csapo R, Meena A, Abermann E, Hoser C, Fink C. Concomitant Injuries Associated With ACL Rupture in Elite Professional Alpine Ski Racers and Soccer Players: A Comparative Study With Propensity Score Matching Analysis. Orthop J Sports Med 2023; 11:23259671231192127. [PMID: 37655251 PMCID: PMC10467387 DOI: 10.1177/23259671231192127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/03/2023] [Indexed: 09/02/2023] Open
Abstract
Background For elite professional soccer players and alpine skiers, injuries associated with anterior cruciate ligament (ACL) rupture, such as meniscal, cartilage, or collateral ligament lesions, could result in a delayed return to sport compared with isolated ACL injury. Purpose/Hypothesis The purpose of the study was to provide a detailed description of associated injuries at the time of primary ACL reconstruction in elite soccer players and alpine skiers. It was hypothesized that soccer players and skiers would present different typical injury patterns due to different injury mechanisms. Study Design Cohort study; Level of evidence, 3. Methods Surgical reports and arthroscopic images of elite professional soccer players and alpine skiers who underwent primary ACL reconstruction at a single institution between January 2010 and June 2022 were analyzed retrospectively. The presence and location of multiligamentous injury, meniscal tears, and chondral lesions were compared between the athlete groups. A propensity score matching analysis with 1:1 ratio was performed between skiers and soccer players to limit the effect of selection bias. Results Included were ACL reconstruction data representative of 37 soccer players and 44 alpine skiers. Meniscal pathology was found in 32 (86%) soccer players and 30 (68%) skiers. Chondral injuries were reported in 11 (30%) soccer players and 15 (34%) skiers. Results of the propensity score matching analysis in 15 pairs of soccer players and skiers indicated that soccer players had a significantly higher rate of medial meniscal injuries (73% vs 27%; P = .03) and lateral posterior root tears (33% vs 0%; P = .04) compared with skiers. Conclusion A higher prevalence of combined chondral and meniscal injuries versus isolated ACL injuries was observed in both groups of athletes. Professional soccer players were characterized by higher prevalence of medial meniscal tears and lateral posterior root lesions compared with professional alpine skiers.
Collapse
Affiliation(s)
- Luca Farinelli
- Department of Clinical and Molecular Sciences, Clinical Orthopaedics, Ancona, Italy
| | - Robert Csapo
- Centre for Sport Science and University Sports, University of Vienna, Vienna, Austria
| | - Amit Meena
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria
| | - Elisabeth Abermann
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria
| | - Christian Hoser
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria
| | - Christian Fink
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and Technology, Private University for Health Sciences, Innsbruck, Austria
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria
| |
Collapse
|
8
|
Runer A, Keeling L, Wagala N, Nugraha H, Özbek EA, Hughes JD, Musahl V. Current trends in graft choice for anterior cruciate ligament reconstruction - part I: anatomy, biomechanics, graft incorporation and fixation. J Exp Orthop 2023; 10:37. [PMID: 37005974 PMCID: PMC10067784 DOI: 10.1186/s40634-023-00600-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/04/2023] Open
Abstract
Graft selection in anterior cruciate ligament (ACL) reconstruction is critical, as it remains one of the most easily adjustable factors affecting graft rupture and reoperation rates. Commonly used autografts, including hamstring tendon, quadriceps tendon and bone-patellar-tendon-bone, are reported to be biomechanically equivalent or superior compared to the native ACL. Despite this, such grafts are unable to perfectly replicate the complex anatomical and histological characteristics of the native ACL. While there remains inconclusive evidence as to the superiority of one autograft in terms of graft incorporation and maturity, allografts appear to demonstrate slower incorporation and maturity compared to autografts. Graft fixation also affects graft properties and subsequent outcomes, with each technique having unique advantages and disadvantages that should be carefully considered during graft selection.
Collapse
Affiliation(s)
- Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
- Department for Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Laura Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nyaluma Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hans Nugraha
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Emre Anil Özbek
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
9
|
Singh H, Glassman I, Sheean A, Hoshino Y, Nagai K, de Sa D. Less than 1% risk of donor-site quadriceps tendon rupture post-ACL reconstruction with quadriceps tendon autograft: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:572-585. [PMID: 36255474 DOI: 10.1007/s00167-022-07175-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The purpose of this study is to develop a comprehensive complications profile for quadriceps tendon-autograft anterior cruciate ligament reconstruction (QT ACL-R). METHODS A traditional and grey literature search was conducted in accordance with PRISMA and R-AMSTAR guidelines. PubMed, EMBASE, MEDLINE, CINAHL, Cochrane, Web of Science, and many grey literature sources were searched from inception to May 29, 2022. All studies were searched and screened in duplicate with included studies being of all levels of evidence, reporting complications, and with patients of all ages undergoing primary ACL reconstruction with quadriceps tendon autograft in the last 15 years. Studies were excluded if they had cadaveric or animal subjects or were reviews. Risk of bias assessment was conducted using MINORS criteria for non-randomised studies and Cochrane's RoB 2.0 for randomised studies. Data were summarised with weighted event rates generated under a random-effects model. RESULTS A total of 55 studies (5315 reconstructions) were included: 32 used quadriceps tendon with bone block (B-QT), 19 used all-soft tissue quadriceps tendon (S-QT), and four did not report the QT graft subtype used. Included patients had an age range of 6.2-58 years and an average reported follow-up time of 28.1 months (range, 6-90 months) for non-randomised studies and 34.3 months (range, 0.233-120 months) for randomised studies. Pooled incidence rates for clinically relevant major complications included contralateral ACL injury at 6.0%, postoperative meniscal issues at 5.4%, cyclops lesions at 4.8%, graft failure at 4.1%, patellar fracture at 2.2%, hardware removal at 1.7%, infection at 1.5%, and donor-site quadriceps tendon rupture at 0.7%. Pooled incidence rates for clinically relevant minor complications included anterior knee pain at 9.7%, kneeling pain at 9.5%, sensation deficits at 4.4%, loss of extension at 4.2%, donor-site tendinopathy at 3.9%, cosmetic issues at 1.8%, and hematoma at 1.5%. CONCLUSIONS QT ACL-R resembles other graft types in its rates and types of postoperative complications. In this exploratory systematic review, no complications of QT ACL-R were found to be disproportionately represented in the literature. This graft type should remain an option with comparable complication rates to other graft choices. LEVEL OF EVIDENCE Level IV. REGISTRATION This study was preregistered under PROSPERO with preregistration code CRD42022302078.
Collapse
Affiliation(s)
- Harasees Singh
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Isaac Glassman
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Andrew Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, ON, Canada.
| |
Collapse
|
10
|
Cronström A, Tengman E, Häger CK. Return to Sports: A Risky Business? A Systematic Review with Meta-Analysis of Risk Factors for Graft Rupture Following ACL Reconstruction. Sports Med 2023; 53:91-110. [PMID: 36001289 PMCID: PMC9807539 DOI: 10.1007/s40279-022-01747-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The risk of sustaining a graft rupture after anterior cruciate ligament reconstruction (ACLR) is high. Contributing risk factors are, however, still not clearly identified. OBJECTIVE The aim of this systematic review was to identify and quantify risk factors for graft rupture after ACLR. METHODS A systematic review with meta-analysis (PROSPERO CRD42020140129) based on PRISMA guidelines was performed. MEDLINE, CINAHL and EMBASE were searched from inception to September 2021. Prospective and retrospective studies addressing risk factors for graft rupture after ACLR in males/females of all ages were considered. Meta-analyses using a random effect model (effect measure: odds ratio [OR] with 95% confidence interval [CI]) were performed. The GRADE tool was used to assess evidence quality. RESULTS Following full-text screening of 310 relevant papers, 117 were eventually included, incorporating up to 133,000 individuals in each meta-analysis. Higher Tegner activity level (≥ 7 vs < 7) at primary injury (OR 3.91, 95% CI 1.69-9.04), increased tibial slope (degrees) (OR 2.21, 95% CI 1.26-3.86), lower psychological readiness to return to sport (RTS) (OR 2.18, 95% CI 1.32-3.61), early surgery (< 12 vs ≥ 12 months) (OR 1.87, 95% CI 1.58-2.22), RTS (pre-injury level) (OR 1.87, 95% CI 1.21-2.91) and family history of ACL injury (OR 1.76, 95% CI 1.34-2.31) were all associated with increased odds of graft rupture. Higher age (OR 0.47, 95% CI 0.39-0.59), female sex (OR 0.88, 95% CI 0.79-0.98), fewer self-reported knee symptoms pre-reconstruction (OR 0.81, 95% CI 0.69-0.95) and concomitant cartilage injuries (OR 0.70, 95% CI 0.62-0.79) instead decreased the odds. Meta-analysis revealed no association between body mass index, smoking, joint laxity, RTS time, knee kinematics, muscle strength or hop performance and graft rupture. CONCLUSION Conspicuous risk factors for graft rupture were mainly sports and hereditary related. Few studies investigated function-related modifiable factors or included sports exposure data.
Collapse
Affiliation(s)
- Anna Cronström
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.
- Department of Health Sciences, Lund University, Lund, Sweden.
| | - Eva Tengman
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Charlotte K Häger
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| |
Collapse
|
11
|
Runer A, Suter A, Roberti di Sarsina T, Jucho L, Gföller P, Csapo R, Hoser C, Fink C. Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome measures, but lower donor-site morbidity compared with hamstring tendon autograft: A matched-pairs study with a mean follow-up of 6.5 years. J ISAKOS 2022; 8:60-67. [PMID: 36216218 DOI: 10.1016/j.jisako.2022.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/26/2022] [Accepted: 08/29/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To compare clinical and functional outcomes of patients after primary anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon- (QT-A) and hamstring tendon (HT-A) autograft with a minimum follow-up (FU) of 5 years. METHODS Between 2010 and 2014, all patients undergoing ACLR were recorded in a prospectively administered database. All patients with primary, isolated QT-A ACLR and without any concomitant injuries or high grade of osteoarthritis were extracted from the database and matched to patients treated with HT-A. Re-rupture rates, anterior-posterior (ap) knee laxity, single-leg hop test (SLHT) performance, distal thigh circumference (DTC) and patient-reported outcome measures (PROMs) were recorded. Between group comparisons were performed using chi-square-, independent-samples T- or Mann-Whitney-U tests. RESULTS 45 QT-A patients were matched to 45 HT-A patients (n = 90). The mean FU was 78.9 ± 13.6 months. 18 patients (20.0%/QT-A: N = 8, 17.8%; HT-A: n = 10, 22.2%; p = .60) sustained a graft rupture and 17 subjects (18.9%/QT-A: n = 9, 20.0%; HT-A: n = 8, 17.8%; p = .79) suffered a contralateral ACL injury. In high active patients (Tegner activity level ≥ 7) rerupture rates increased to 37.5% (HT-A) and 22.2% (QT-A; p = .32), respectively. Patients with graft failure did not differ between both groups in terms of mean age at surgery (QT-A: 26.5 ± 11.6 years, HT-A: 23.3 ± 9.5 years, p = .63) or graft thickness (mean graft square area: QT-A: 43.6 ± 4.7 mm2, HT-A: 48.1 ± 7.9 mm2, p = .27). No statistical between-group differences were found in ap knee laxity side-to-side (SSD) measurements (QT-A: 1.9 ± 1.2 mm, HT-A: 2.1 ± 1.5 mm; p = .60), subjective IKDC- (QT-A: 93.8 ± 6.8, HT-A: 91.2 ± 7.8, p = .17), Lysholm- (QT-A 91.9 ± 7.2, HT-A: 91.5 ± 9.7, p = .75) or any of the five subscales of the KOOS score (all p > .05). Furthermore, Tegner activity level (QT-A: 6(1.5), HT-A: 6(2), p = .62), VAS for pain (QT-A: 0.5 ± 0.9, HT-A: 0.6 ± 1.0, p = .64), Shelbourne-Trumper score (QT-A: 96.5 ± 5.6, HT-A: 95.2 ± 8.2, p = .50), Patient and Observer Scar -Assessment scale (POSAS) (QT-A: 9.4 ± 3.2, HT-A: 10.7 ± 4.9, p = .24), SSD-DTC (QT-A: 0.5 ± 0.5, HT.- A: 0.5 ± 0.6, p = .97), return to sports rates (QT-A: 82.1%, HT-A: 86.7%) and SLHT (QT -A: 95.9 ± 3.8%, HT-A: 93.7 ± 7.0%) did not differ between groups. Donor-site morbidity (HT-A n = 14, 46.7%; QT-A n = 3, 11.5%; p = .008) was statistically significantly lower in the QT-A group. Five patients (11.1%) of the HT-group and three patients (6.7%) in the QT-group required revision surgery (p = .29). CONCLUSION Patient-reported outcome measures, knee laxity, functional testing results and re-rupture rates are similar between patients treated with QT- and HT- autografts. However, patients with QT-autograft have a smaller tibial postoperative scar length and lower postoperative donor-site morbidity. There is a tendency towards higher graft rupture rates in highly active patients treated with HT autograft. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Armin Runer
- Department of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria; Department for Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Aline Suter
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria
| | | | - Lena Jucho
- Department of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Gföller
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria
| | - Robert Csapo
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Centre for Sport Science and University Sports, University of Vienna, Vienna, Austria
| | | | - Christian Fink
- Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria; Private University for Health Sciences, Medical Informatics and Technology (UMIT), ISAG, Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Austria.
| |
Collapse
|
12
|
Guy S, Fayard JM, Saithna A, Bahroun S, Ferreira A, Carrozzo A, De Jesus S, Bulle S, Vieira TD, Sonnery-Cottet B. Risk of Graft Rupture After Adding a Lateral Extra-articular Procedure at the Time of ACL Reconstruction: A Retrospective Comparative Study of Elite Alpine Skiers From the French National Team. Am J Sports Med 2022; 50:1609-1617. [PMID: 35416071 DOI: 10.1177/03635465221085027] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Elite alpine skiing is associated with a particularly high risk of anterior cruciate ligament (ACL) injuries, including graft ruptures. Despite a considerable focus on prevention, a reduction in injury rates has not been observed since the 1980s. PURPOSE To determine whether elite alpine skiers undergoing ACL reconstruction (ACLR) with a lateral extra-articular procedure (LEAP) had a lower rate of ACL graft rupture when compared with those who underwent isolated ACLR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Elite skiers from the French ski team who had undergone ACLR, with or without a LEAP, and had a minimum follow-up of 2 years were identified from the national ski team database. Rates of secondary ACL injury were determined via interrogation of the database, review of medical notes, and a final telemedicine interview. A multivariable analysis using the penalized Cox model was performed to explore the relationship among graft rupture, surgical procedure type, and any potential explanatory variables. RESULTS Among 81 ACLR procedures analyzed, 50 were isolated and 31 were combined with a LEAP, which was performed using modified Lemaire or anterolateral ligament reconstruction. Graft rupture rates were 34.0% in the isolated ACLR group and 6.5% in the ACLR + LEAP group. Multivariable analysis demonstrated that adding a LEAP was associated with a significant reduction in risk of ACL graft rupture when compared with isolated ACLR (hazard ratio [HR], 5.286 [95% CI, 1.068-26.149]; P = .0412). Age (HR, 1.114; P = .1157), sex (HR, 1.573; P = .3743), and ACL graft type (HR, 1.417; P = .5394) were not significant risk factors. CONCLUSION Combined ACLR and LEAP were associated with a significant reduction in the rate of ACL graft rupture in elite alpine ski athletes. Those treated with isolated ACLR remain at extremely high risk of a second ACL injury.
Collapse
Affiliation(s)
- Sylvain Guy
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Jean-Marie Fayard
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France.,Fédération Française de Ski, Annecy, France
| | - Adnan Saithna
- Arizona Brain, Spine & Sports Injuries Center, Scottsdale, Arizona, USA
| | - Sami Bahroun
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Alexandre Ferreira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Alessandro Carrozzo
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | | | | | - Thais Dutra Vieira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France
| |
Collapse
|
13
|
Swiss-Ski Power Test Results in Youth Competitive Alpine Skiers Are Associated With Biological Maturation and Skiing Performance. Int J Sports Physiol Perform 2022; 17:961-968. [PMID: 35338105 DOI: 10.1123/ijspp.2021-0184] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 11/25/2021] [Accepted: 01/02/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE To explore reasonable application purposes and potential confounders of the Swiss-Ski Power Test (SSPT) that is, since 2004, annually performed by all youth competitive alpine skiers of the under-16-years age category in Switzerland. METHODS Preseason SSPT results (8 individual tests on anaerobic and aerobic capacity, muscle strength, and speed and coordination) of 144 skiers (57 female and 87 male) age 14.5 (0.7) years were analyzed along with anthropometry and biological age. Skiing performance was quantified as the actual performance points according to the Swiss national ranking. After the SSPT tests, skiers were prospectively monitored over 12 months using the Oslo Trauma Research Center questionnaire. Data were analyzed using multivariate analysis of variance, Pearson correlations, and multiple linear/binary logistic regression models. RESULTS Biological maturation and SSPT results differed between sexes and age (P < .05). For males, SSPT results in the subdisciplines Swiss Cross, 1-leg 5-hop, and standing long jump were correlated to maturity offset, while for females only the obstacle run was related. High box jump and Swiss Cross scores were associated with skiing performance (P < .05). However, none of the SSPT subdisciplines was related to traumatic and overuse injuries (P < .05). CONCLUSIONS The SSPT is a broadly implementable and cost-effective field test providing a general fitness profile of youth skiers. Around the growth spurt, differences in biological maturation should be considered. While SSPT results showed association with skiing performance, the test in its current form is limited for identifying injury-relevant physical deficiencies. Consequently, more specific tests may be required.
Collapse
|
14
|
Magosch A, Urhausen AP, Mouton C, Tischer T, Seil R. Das Knie im Spitzensport. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00517-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
15
|
Spörri J, Müller E, Kröll J. "When you're down, stay down": A lesson for all competitive alpine skiers supported by an ACL rupture measured in vivo. JOURNAL OF SPORT AND HEALTH SCIENCE 2022; 11:14-20. [PMID: 34852295 PMCID: PMC8847912 DOI: 10.1016/j.jshs.2021.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/02/2021] [Accepted: 11/16/2021] [Indexed: 05/31/2023]
Abstract
BACKGROUND During an experiment, a ski racer equipped with various measurement devices suffered an anterior cruciate ligament (ACL) rupture in his right knee. The aim of this study was to describe the underlying injury mechanism from a functional perspective. METHODS Eight giant slalom turns (i.e., 4 left turns), followed by 1 left turn at which the ACL injury occurred, were recorded by 2 video cameras, electromyography of 4 relevant muscle groups, inertial measurement units to measure knee and hip angles, and pressure insoles to determine ground reaction forces. RESULTS Due to a loss of balance, the ski racer began to slide sideways at the apex of a left turn. During sliding, his right (outside) leg was actively abducted upward without touching the ground. The ski racer then attempted to stand up again by dropping his leg back towards the snow surface. The end of this dropping was accompanied by a decrease in electromyographic activity in the knee stabilizing muscles. Once the inside edge of the outer ski caught the snow surface, a rapidly increasing peak force, knee flexion, and an aggressive sudden activation of the vastus medialis muscle were observed, while biceps femoris and rectus femoris further decreased their activation levels. This likely resulted in excessive anterior translation of the tibia relative to the femur, causing damage to the ACL. CONCLUSION Our example emphasizes that ski racers should not get up until they stop sliding. Remember: "When you're down, stay down."
Collapse
Affiliation(s)
- Jörg Spörri
- Sports Medical Research Group, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich 8008, Switzerland; University Centre for Prevention and Sports Medicine, Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich 8008, Switzerland.
| | - Erich Müller
- Department of Sport Science and Kinesiology, University of Salzburg, Hallein-Ri 5400, Austria
| | - Josef Kröll
- Department of Sport Science and Kinesiology, University of Salzburg, Hallein-Ri 5400, Austria
| |
Collapse
|
16
|
Arundale AJH, Silvers-Granelli HJ, Myklebust G. ACL injury prevention: Where have we come from and where are we going? J Orthop Res 2022; 40:43-54. [PMID: 33913532 DOI: 10.1002/jor.25058] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 02/04/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are one of the most common and severe knee injuries across sports. As such, ACL injury prevention has been a focus of research and sports medicine practice for the past three-plus decades. Examining the current research and identifying both clinical strategies and research gaps, the aim of this review is to empower clinicians and researchers with knowledge of where the ACL injury prevention literature is currently and where it is going in the future. This paper examines the mechanism of ACL injury prevention, screening, implementation, compliance, adherence, coronavirus, and areas of future research. Clinical significance: The time lag between research and practical implementation in general healthcare settings can be as long as 17 years; however, athletes playing sports today are unable to wait that long. With effective programs already established, implementation and adherence to these programs is essential. Strategies such as coaching education, increasing awareness of free programs, identifying barriers, and overcoming implementation obstacles through creative collaboration are just a few ways that could help improve both ACL injury prevention implementation and adherence.
Collapse
Affiliation(s)
- Amelia J H Arundale
- Department of Rehabilitation, Icahn School of Medicine, Mount Sinai Health System, New York, New York, USA.,Red Bull Athlete Performance Center, Red Bull GmBH, Thalgua, Austria
| | - Holly J Silvers-Granelli
- Velocity Physical Therapy, Santa Monica, California, USA.,Major League Soccer, Medical Research Committee, New York, New York, USA
| | - Grethe Myklebust
- Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| |
Collapse
|
17
|
Della Villa F, Hägglund M, Della Villa S, Ekstrand J, Waldén M. High rate of second ACL injury following ACL reconstruction in male professional footballers: an updated longitudinal analysis from 118 players in the UEFA Elite Club Injury Study. Br J Sports Med 2021; 55:1350-1356. [PMID: 33846157 PMCID: PMC8606446 DOI: 10.1136/bjsports-2020-103555] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2021] [Indexed: 12/02/2022]
Abstract
Background Studies on subsequent anterior cruciate ligament (ACL) ruptures and career length in male professional football players after ACL reconstruction (ACLR) are scarce. Aim To investigate the second ACL injury rate, potential predictors of second ACL injury and the career length after ACLR. Study design Prospective cohort study. Setting Men’s professional football. Methods 118 players with index ACL injury were tracked longitudinally for subsequent ACL injury and career length over 16.9 years. Multivariable Cox regression analysis with HR was carried out to study potential predictors for subsequent ACL injury. Results Median follow-up was 4.3 (IQR 4.6) years after ACLR. The second ACL injury rate after return to training (RTT) was 17.8% (n=21), with 9.3% (n=11) to the ipsilateral and 8.5% (n=10) to the contralateral knee. Significant predictors for second ACL injury were a non-contact index ACL injury (HR 7.16, 95% CI 1.63 to 31.22) and an isolated index ACL injury (HR 2.73, 95% CI 1.06 to 7.07). In total, 11 of 26 players (42%) with a non-contact isolated index ACL injury suffered a second ACL injury. RTT time was not an independent predictor of second ACL injury, even though there was a tendency for a risk reduction with longer time to RTT. Median career length after ACLR was 4.1 (IQR 4.0) years and 60% of players were still playing at preinjury level 5 years after ACLR. Conclusions Almost one out of five top-level professional male football players sustained a second ACL injury following ACLR and return to football, with a considerably increased risk for players with a non-contact or isolated index injury.
Collapse
Affiliation(s)
- Francesco Della Villa
- Education and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy
| | - Martin Hägglund
- Football Research Group, Linköping University, Linköping, Sweden .,Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Stefano Della Villa
- Education and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy
| | - Jan Ekstrand
- Football Research Group, Linköping University, Linköping, Sweden.,Unit of Community Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Markus Waldén
- Football Research Group, Linköping University, Linköping, Sweden.,Unit of Community Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Orthopaedics, Hässleholm-Kristianstad Hospitals, Hässleholm, Sweden
| |
Collapse
|