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Gill VS, Tummala SV, Sullivan G, Han W, Haglin JM, Marks L, Tokish JM. Functional Return-to-Sport Testing Demonstrates Inconsistency in Predicting Short-Term Outcomes Following Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2024; 40:2135-2151.e2. [PMID: 38216071 DOI: 10.1016/j.arthro.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/26/2023] [Accepted: 12/17/2023] [Indexed: 01/14/2024]
Abstract
PURPOSE To systematically review the relationship between functional testing at the time of return to sport (RTS) and short-term outcomes, such as second anterior cruciate ligament (ACL) tear and return to a preinjury level of sport, among athletes who underwent anterior cruciate ligament reconstruction (ACLR). METHODS A systematic literature search was performed in MEDLINE, EMBASE, Scopus, and Web of Science to identify studies examining athletes who underwent functional RTS testing and were followed for at least 12 months following ACLR. Studies were screened by 2 reviewers. A standardized template was used to extract information regarding study characteristics, ACLR information, functional test results, and risk factors associated with retear or reduced RTS. RESULTS Of the 937 studies identified, 22 met the inclusion criteria. The average time between ACLR and RTS testing was 8.5 months. Single leg hop for distance performance had no association with retear risk in any study and no association with RTS rates in most studies. Quadriceps strength had conflicting results in relation to retear risk, whereas it had no relationship with RTS rates. Rates of reinjury and RTS were similar between patients who passed and did not pass combined hop and strength batteries. Asymmetric knee extension and hip moments, along with increased knee valgus and knee flexion angles, demonstrated increased risk of retear. CONCLUSIONS Individual hop and strength tests that are often used in RTS protocols following ACLR may have limited and inconsistent value in predicting ACL reinjury and reduced RTS when used in isolation. Combined hop and strength test batteries also demonstrate low sensitivity and negative predictive value, highlighting conflicting evidence to suggest RTS testing algorithm superiority. LEVEL OF EVIDENCE Level IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Vikram S Gill
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, U.S.A..
| | | | | | - Will Han
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, U.S.A
| | - Jack M Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Arizona, U.S.A
| | - Lisa Marks
- Division of Education, Department of Library Services, Mayo Clinic, Arizona, U.S.A
| | - John M Tokish
- Department of Orthopedic Surgery, Mayo Clinic, Arizona, U.S.A
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Kara M. Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft: Letter to the Editor. Am J Sports Med 2024; 52:NP12-NP13. [PMID: 38822652 DOI: 10.1177/03635465241247805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
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Alhamdi H, Foissey C, Vieira TD, Sonnery-Cottet B, Rajput V, Bahroun S, Fayard JM, Thaunat M. High failure rate after medial meniscus bucket handle tears repair in the stable knee. Orthop Traumatol Surg Res 2024; 110:103737. [PMID: 37898297 DOI: 10.1016/j.otsr.2023.103737] [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] [Received: 04/05/2023] [Revised: 10/12/2023] [Accepted: 10/24/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND It is nowadays recommended to "Save the meniscus". This paradigm is based on the affirmation that an extended meniscectomy exposes to the risk of long-term secondary osteoarthritis and the global failure rate of a longitudinal tear repair remains low, whether it is the medial or lateral meniscus, with or without anterior cruciate ligament (ACL) reconstruction. However, each kind of lesion has to be studied separate. PURPOSE The study aimed to focus on a homogeneous population of isolated repair of the bucket handle tear (BHT) of the medial meniscus (MM) in patients with stable knees to evaluate failure rate at a minimum of three years of follow-up. The secondary objectives were to evaluate any risk factors or protective factors of failure, clinical outcomes, and secondary amount of meniscectomy in failure cases compared to the amount of meniscus fixed in the first surgery. METHODS All patients who underwent arthroscopic repair of a BHT of the MM situated in the red-on-red or red-on white (RW) zone on a stable knee between January 2010 and December 2018 were evaluated retrospectively. Failure was defined as a need for reoperation for recurrence of meniscal symptoms (pain, locking) on the medial side with per-operative confirmation of the absence of healing. The following parameters were studied: demographics (age, gender, BMI), time from injury to surgery, clinical scores (Tegner, Lysholm, International Knee Documentation Committee [IKDC]), surgical findings (extent and zone of the tear), surgical management (number and type of suture). RESULTS Thirty-nine patients were included. The mean follow-up was 77.2±24.4 [36-141] months. Twenty-seven (69%) failures were recorded. In 56% (15/27) of the reoperations, the meniscectomy amount was smaller than what it would have been done in the first surgery. All clinical scores improved significantly from pre- to post-operatively; all patients met minimal clinically important differences for all the scores. No risk factors were found significant in the multivariate analysis. CONCLUSION Repairing an isolated BHT of the MM is associated with a high failure rate. Despite the failure, we observed that the meniscectomy area was smaller than documented in the primary surgery in most of the cases and repair must still be considered as the first option. LEVEL OF EVIDENCE IV; retrospective cohort series.
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Affiliation(s)
- Hassan Alhamdi
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France; Centre Orthopédique Santy, Lyon, France
| | - Constant Foissey
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France; Centre Orthopédique Santy, Lyon, France
| | - Thais Dutra Vieira
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France; Centre Orthopédique Santy, Lyon, France
| | - Bertrand Sonnery-Cottet
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France; Centre Orthopédique Santy, Lyon, France
| | - Vishal Rajput
- The Mid Yorkshire Hospitals NHS trust, Yorkshire, United Kingdom
| | - Sami Bahroun
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France; Centre Orthopédique Santy, Lyon, France
| | - Jean Marie Fayard
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France; Centre Orthopédique Santy, Lyon, France
| | - Mathieu Thaunat
- Ramsay Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, FIFA Medical Center of Excellence, Lyon, France; Centre Orthopédique Santy, Lyon, France.
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Holmgren D, Noory S, Moström E, Grindem H, Stålman A, Wörner T. Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft: Response. Am J Sports Med 2024; 52:NP13-NP14. [PMID: 38822651 DOI: 10.1177/03635465241247804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
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Qiu J, Ong MTY, Choi CY, He X, Lau LCM, Fu SC, Fong DTP, Yung PSH. Associations of patient characteristics, rate of torque development, voluntary activation of quadriceps with quadriceps strength, and knee function before anterior cruciate ligament reconstruction. Res Sports Med 2024; 32:491-503. [PMID: 36254570 DOI: 10.1080/15438627.2022.2132860] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/28/2022] [Indexed: 10/24/2022]
Abstract
Good preoperative knee function (KF) and quadriceps strength (QS) relate to good prognoses after anterior cruciate ligament reconstruction (ACLR). This study aimed to investigate the associations between patient characteristics, rate of torque development (RTD), voluntary activation (VA) of the quadriceps against preoperative KF and QS. A cross-sectional study was conducted. Forty patients with a primary, unilateral ACL injury who had finished the preoperative rehabilitation and scheduled for an ACLR were included. KF was evaluated using the International Knee Documentation Committee score. QS was measured by maximal voluntary isometric contractions. RTD was divided into the early (RTD0-50) and the late (RTD100-200) phases. Quadriceps VA was measured using the superimposed burst technique. Our results showed that patients with poor preoperative KF had more deficits in RTD0-50 (P = 0.025), higher BMI(P = 0.043), and more meniscus injuries (MI) (P = 0.001) than those with good KF. Patients with asymmetrical QS showed lower BMI (P = 0.020) and shorter time from injury (TFI) (P = 0.027) than those with symmetrical QS. Additionally, a higher pre-injury Tegner score combined with greater RTD100-200 contributed to greater QS on the injured limb (R2 = 0.357, P = 0.001). To conclude, BMI, TFI, concomitant MI, pre-injury physical activity level, and quadriceps RTD are related to QS and KF before ACLR.
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Affiliation(s)
- Jihong Qiu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michael Tim-Yun Ong
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chi-Yin Choi
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xin He
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lawrence Chun-Man Lau
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sai-Chuen Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Daniel T P Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Patrick Shu-Hang Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Sell TC, Zerega R, King V, Reiter CR, Wrona H, Bullock GS, Mills N, Räisänen A, Ledbetter L, Collins GS, Kvist J, Filbay SR, Losciale JM. Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) Scores over Time After Anterior Cruciate Ligament Reconstruction: A Systematic Review with Meta-analysis. SPORTS MEDICINE - OPEN 2024; 10:49. [PMID: 38689130 PMCID: PMC11061071 DOI: 10.1186/s40798-024-00712-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 04/02/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Psychological readiness is an important consideration for athletes and clinicians when making return to sport decisions following anterior cruciate ligament reconstruction (ACLR). To improve our understanding of the extent of deficits in psychological readiness, a systematic review is necessary. OBJECTIVE To investigate psychological readiness (measured via the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI)) over time after ACL tear and understand if time between injury and surgery, age, and sex are associated with ACL-RSI scores. METHODS Seven databases were searched from the earliest date available to March 22, 2022. Articles reporting ACL-RSI scores after ACL tear were included. Risk of bias was assessed using the ROBINS-I, RoB-2, and RoBANS tools based on the study design. Evidence certainty was assessed for each analysis. Random-effects meta-analyses pooled ACL-RSI scores, stratified by time post-injury and based on treatment approach (i.e., early ACLR, delayed ACLR, and unclear approach). RESULTS A total of 83 studies were included in this review (78% high risk of bias). Evidence certainty was 'weak' or 'limited' for all analyses. Overall, ACL-RSI scores were higher at 3 to 6 months post-ACLR (mean = 61.5 [95% confidence interval (CI) 58.6, 64.4], I2 = 94%) compared to pre-ACLR (mean = 44.4 [95% CI 38.2, 50.7], I2 = 98%), remained relatively stable, until they reached the highest point 2 to 5 years after ACLR (mean = 70.7 [95% CI 63.0, 78.5], I2 = 98%). Meta-regression suggests shorter time from injury to surgery, male sex, and older age were associated with higher ACL-RSI scores only 3 to 6 months post-ACLR (heterogeneity explained R2 = 47.6%), and this reduced 1-2 years after ACLR (heterogeneity explained R2 = 27.0%). CONCLUSION Psychological readiness to return to sport appears to improve early after ACL injury, with little subsequent improvement until ≥ 2-years after ACLR. Longer time from injury to surgery, female sex and older age might be negatively related to ACL-RSI scores 12-24 months after ACLR. Due to the weak evidence quality rating and the considerable importance of psychological readiness for long-term outcomes after ACL injury, there is an urgent need for well-designed studies that maximize internal validity and identify additional prognostic factors for psychological readiness at times critical for return to sport decisions. REGISTRATION Open Science Framework (OSF), https://osf.io/2tezs/ .
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Affiliation(s)
- Timothy C Sell
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Ryan Zerega
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Victoria King
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | | | - Hailey Wrona
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Garrett S Bullock
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston Salem, NC, USA
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK
| | - Nilani Mills
- University of New South Wales, Sydney, NSW, Australia
| | - Anu Räisänen
- Department of Physical Therapy Education-Oregon, College of Health Sciences-Northwest, Western University of Health Sciences, Oregon, USA
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Canada
| | | | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joanna Kvist
- Unit of Physiotherapy, Department of Health, Medicine, and Caring Medicine, University of Linkoping, Linköping, Sweden
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden
| | - Stephanie R Filbay
- Department of Physiotherapy, Centre for Health, Exercise and Sports Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Justin M Losciale
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada.
- Arthritis Research Canada, Vancouver, Canada.
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Qiu J, Choi CY, Man GCW, He X, Yu M, Cao M, Wang Q, Ng JP, Yung PSH, Ong MTY. Serum vitamin D insufficiency is correlated with quadriceps neuromuscular functions in patients with anterior cruciate ligament injury: A preliminary study. Asia Pac J Sports Med Arthrosc Rehabil Technol 2024; 35:76-80. [PMID: 38292822 PMCID: PMC10827444 DOI: 10.1016/j.asmart.2023.11.001] [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: 08/07/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 02/01/2024] Open
Abstract
Background This study aimed to investigate the correlations of serum vitamin D insufficiency with quadriceps neuromuscular function in patients with anterior cruciate ligament (ACL) injury. Methods A cross-sectional study was conducted. Eighteen patients with a primary, unilateral ACL injury who had insufficient serum vitamin D concentrations (<30 ng/ml) were recruited for the study. Bilateral quadriceps neuromuscular function, including maximal strength, the speed of rapid contraction, and inhibition, were measured on an isokinetic dynamometer with the hip and the knee joint flexion at 90° and 45°, respectively. Quadriceps strength was measured by maximal voluntary isometric contractions (MVIC); the speed of rapid contraction was quantified by the rate of torque development (RTD), which was divided into the early (RTD0-50) and the late phase (RTD100-200); quadriceps inhibition was quantified by the central activation ratio (CAR). Serum vitamin D concentration was quantitatively determined by serum 25(OH)D concentration measured by the 25(OH)D ELISA kit. The Spearman rank correlation analysis was used to examine the correlation between the vitamin D concentration and bilateral quadriceps MVIC, RTD0-50, RTD100-200, and CAR, respectively. Results The results of Spearman rank correlation analyses showed that the serum 25(OH)D concentration was significantly correlated with bilateral quadriceps MVIC (injured: r = 0.574, p = 0.013; uninjured: r = 0.650, p = 0.003) and RTD0-50 (r = 0.651, p = 0.003), and CAR (r = 0.662, p = 0.003) on the uninjured limb. However, no significant correlations were found between the serum 25(OH)D concentration and the other outcomes. Conclusions The serum vitamin D concentration correlates with quadriceps neuromuscular function in patients with ACL injury who had vitamin D insufficiency.
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Affiliation(s)
- Jihong Qiu
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Chi-Yin Choi
- Department of Orthopaedices and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Gene Chi-Wai Man
- Department of Orthopaedices and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Xin He
- Department of Orthopaedices and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Mingqian Yu
- Department of Orthopaedices and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Mingde Cao
- Department of Orthopaedices and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Qianwen Wang
- Department of Orthopaedices and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Jonathan Patrick Ng
- Department of Orthopaedices and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Patrick Shu-Hang Yung
- Department of Orthopaedices and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Michael Tim-Yun Ong
- Department of Orthopaedices and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
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Rai P, Puri S, Gupta LM, Singh C, Ghai A, Mishra AK, Prasad M, Padhi PP, Shejale N, Pande A. Comparative study of functional outcomes of arthroscopic anterior cruciate ligament reconstruction using anteromedial portal and translateral all-inside technique. Med J Armed Forces India 2023; 79:S181-S188. [PMID: 38144650 PMCID: PMC10746831 DOI: 10.1016/j.mjafi.2022.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 05/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background Anterior Cruciate Ligament (ACL) injuries are common in the active population of the Armed Forces. Symptomatic instability prompts individuals to seek a cure or a sheltered appointment. Despite the increasing numbers of ACL reconstructions performed, the outcomes have not been so spectacular with only a meager percentage of our patients returning to preinjury levels of activity. With the premise that an all-inside ACL reconstruction is likely to result in better functional outcomes, the aim of this study was to compare the short-term functional outcomes of a large consecutive series of patients undergoing ACL reconstruction using the translateral all-inside ACL reconstruction technique (AI) and standard anteromedial portal technique (AM) with a minimum follow-up of one year. Methods A total of 240 patients with isolated ACL tear underwent ACL reconstruction via the AI or AM technique. Their preoperative and postoperative scores were compared to look for any significant differences in functional outcomes. Results The two groups were matched for age, BMI, mechanism of injury, and interval from injury to surgery. There was no difference in their preoperative scores. Postoperatively, although there were significant improvements across both groups, there was no significant difference between the groups at any point of time. Conclusion The AI technique has garnered interest in recent literature in addressing ACL injuries. This study found no discernible benefit of the AI technique when compared to the AM technique in terms of functionality following an ACL reconstruction at any point of time up to 1 year following surgery.
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Affiliation(s)
- Pankaj Rai
- Classified Specialist (Orthopaedics), 5 AFH, Air Force Station, Jorhat, India
| | - Sanjay Puri
- Classified Specialist (Orthopaedics), INHS, Asvini, Colaba, Mumbai, India
| | - Lalit Mohan Gupta
- Classified Specialist (Orthopaedics), Command Hospital (Western Command), Chandimandir, India
| | - Chandermohan Singh
- Senior Advisor (Orthopaedics), Command Hospital (Eastern Command), Kolkata, India
| | - Amresh Ghai
- Consultant (Orthopaedics), Base Hospital, Delhi Cantt, India
| | | | - Manish Prasad
- Associate Professor, Department of Orthopaedics, Armed Forces Medical College, Pune, India
| | | | - Naveen Shejale
- Classified Specialist (Orthopaedics), INHS, Asvini, Colaba, Mumbai, India
| | - Ashish Pande
- Classified Specialist (Orthopaedics), Base Hospital, Lucknow, India
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Harput G, Demirci S, Nyland J, Soylu AR, Tunay VB. Sports activity level after ACL reconstruction is predicted by vastus medialis or vastus medialis obliquus thickness, single leg triple hop distance or 6-m timed hop, and quality of life score. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3483-3493. [PMID: 37198499 DOI: 10.1007/s00590-023-03571-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/05/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE Recovery after anterior cruciate ligament reconstruction (ACLR) may take > 2 years, and younger athletes have higher re-injury risk. The purpose of this prospective longitudinal study was to determine how the early to mid-term Tegner Activity Level Scale (TALS) scores of athletically active males ≥ 2 years post-ACLR follow-up was predicted by bilateral isokinetic knee extensor and flexor torque, quadriceps femoris thickness, single leg hop test performance, and self-reported knee function (Knee Injury and Osteoarthritis Outcome Score (KOOS); International Knee Documentation Committee (IKDC) Subjective Assessment score). METHODS After ACLR with a hamstring tendon autograft and safely returning to sports at least twice weekly, 23 men (18.4 ± 3.5 years of age) were evaluated at final follow-up (mean = 4.5, range = 2-7 years). Exploratory forward stepwise multiple regression was used to determine the relationship between independent surgical and non-surgical lower limb variables peak concentric isokinetic knee extensor-flexor torque at 60°/sec and 180°/sec, quadriceps femoris muscle thickness, single leg hop test profile results, KOOS subscale scores, IKDC Subjective Assessment scores, and time post-ACLR on TALS scores at final follow-up. RESULTS Subject TALS scores were predicted by KOOS quality of life subscale score, surgical limb vastus medialis obliquus (VMO) thickness, and surgical limb single leg triple hop for distance (SLTHD) performance. Subject TALS scores were also predicted by KOOS quality of life subscale score, non-surgical limb vastus medialis (VM) thickness, and non-surgical limb 6 m single leg timed hop (6MSLTH) performance. CONCLUSION TALS scores were influenced differently by surgical and non-surgical lower extremity factors. At ≥ 2 years post-ACLR, ultrasound VM and VMO thickness measurements, single leg hop tests that challenge knee extensor function, and self-reported quality of life measurements predicted sports activity levels. The SLTHD test may be better than the 6MSLTH for predicting long-term surgical limb function.
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Affiliation(s)
- Gulcan Harput
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Serdar Demirci
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Balıkesir University, Balıkesir, Turkey
| | - John Nyland
- Kosair Charities College of Health and Natural Sciences, Athletic Training Program, Norton Orthopedic Institute, Spalding University, 901 South 4Th Street, Louisville, KY, USA.
| | - Abdullah Ruhi Soylu
- Department of Biophysics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Volga Bayrakci Tunay
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
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Cronström A, Häger CK, Thorborg K, Ageberg E. Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study. Am J Sports Med 2023; 51:3112-3120. [PMID: 37681565 PMCID: PMC10543957 DOI: 10.1177/03635465231192983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/05/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Sports function and psychological readiness to return to sports (RTS) are important outcomes when evaluating rehabilitation after anterior cruciate ligament reconstruction (ACLR). It is, however, unclear which specific factors contribute most to these outcomes. PURPOSE To determine associations between demographic characteristics, objective measurements of physical function, patient-reported outcome measure scores, sports-related function assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation subscale, and psychological readiness to RTS assessed with the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale at 1 year after ACLR. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS At a mean of 12.5 ± 2.0 months after ACLR, 143 participants (50.3% female), with a mean age of 25.0 ± 5.7 years, were assessed for demographic characteristics, physical factors (hop performance, muscle strength, ankle and hip range of motion), and psychological factors (KOOS Pain and Symptoms subscales, Perceived Stress Scale, fear of reinjury) as well as the KOOS Sport and Recreation subscale and ACL-RSI scale. Backward linear regression models were used to evaluate factors associated with sports function and psychological readiness to RTS. RESULTS Lower isokinetic knee extension peak torque (limb symmetry index) (B = 18.38 [95% CI, 3.01-33.75]), lower preinjury activity level (B = 2.00 [95% CI, 0.87-3.14]), greater knee pain (B = 0.90 [95% CI, 0.70-1.10]), shorter time between injury and reconstruction (B = 0.16 [95% CI, 0.05-0.26]), and greater fear of reinjury (B = 0.11 [95% CI, 0.01-0.20]) were associated with a worse KOOS Sport and Recreation subscore (R2 = 0.683). A shorter hop distance (B = 0.15 [95% CI, 0.00-0.29]) was associated with a lower ACL-RSI score (R2 = 0.245). CONCLUSION A combination of knee muscle strength, activity level, knee pain, timing of surgery, and fear of reinjury accounted for approximately 70% of the variation in sports function at 1 year after ACLR. In contrast, there was only 1 weak association between physical function and psychological readiness to RTS at this time point. Thus, factors associated with current sports function are much better known than features related to psychological readiness to RTS.
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Affiliation(s)
- Anna Cronström
- Department of Health Sciences, Lund University, Lund, Sweden
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Charlotte K. Häger
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Kristian Thorborg
- Department of Health Sciences, Lund University, Lund, Sweden
- Department of Orthopaedic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Ageberg
- Department of Health Sciences, Lund University, Lund, Sweden
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施 政, 李 彦, 余 洋, 李 凯, 唐 文, 宁 梓, 何 任, 王 坤, 王 国. [Return to sports WeChat applet for evaluating the rehabilitation effects after anterior cruciate ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2023; 37:1086-1093. [PMID: 37718420 PMCID: PMC10505628 DOI: 10.7507/1002-1892.202305021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/11/2023] [Indexed: 09/19/2023]
Abstract
Objective To clarify the intervention guidance of return to sports WeChat applet and evaluate the rehabilitation effectiveness after anterior cruciate ligament (ACL) reconstruction. Methods Between September 2020 and September 2022, 80 patients who met the selection criteria and underwent ACL anatomical single bundle reconstruction were selected as the research objects. According to the double-blind random method, they were divided into the applet group and the regular group, with 40 cases in each group. Patients in the applet group were rehabilitated under the guidance of the return to sports WeChat applet, and the patients were asked to perform the test once a month after operation, including patients' subjective scores [Tegner score, knee injury and osteoarthritis outcome score (KOOS), International Knee Documentation Committee (IKDC) score, American Hospital for Special Surgery (HSS) score], psychological assessment [ACL recovery sports injury scale (ACL-RSI) score], jumping test, balance test, bending angle test. Patients in the regular group were followed up by doctors and nurses regularly by telephone every month. All the patients were reexamined at 3, 6, 9, and 12 months after operation, and the range of motion of the knee joint with 6 degrees of freedom (flexion and extension angle, varus and valgus angle, internal and external rotation angle, anteroposterior displacement, superior and inferior displacement, and internal and external displacement) recorded by Opti_Knee three-dimensional knee joint motion measurement gait analysis system was observed. The anterior tibial translation difference (ATTD) was measured by Ligs knee measuring instrument when a forward thrust of 120 N was applied to the posterior part of the proximal tibia. Tegner score, IKDC score, KOOS score (including KOOS-Pain score, KOOS-Symptoms score, KOOS-Activities of daily living score, KOOS-Sport score, and KOOS-Quality of life score), HSS score, ACL-RSI score, jumping ability, balance ability, patients' satisfaction with the rehabilitation process, and ACL healing grading according to ACL continuity and signal intensity shown by MRI. Results There were significant differences in various indicators between different time points after operation in the two groups ( P<0.05). At 3 months after operation, except that the ACL-RSI score of the applet group was significantly higher than that of the regular group ( P<0.05), there was no significant difference in the other indicators between the two groups ( P>0.05). At 6 months after operation, the ACL-RSI score, IKDC score, Tegner score, KOOS scores of different items, HSS score, balance and jumping ability of the applet group were significantly higher than those of the regular group ( P<0.05), and there was no significant difference in the other indicators between the two groups ( P>0.05). At 9 months after operation, there was no significant difference in all indicators between the two groups ( P>0.05). At 12 months after operation, 27 cases (67.5%) in the applet group and 21 cases (52.5%) in the regular group returned to sport, with a significant difference of the return to sports incidence between the two groups [ RR(95% CI)=1.50 (1.00, 2.25), P=0.049]. In the applet group, 27 cases were very satisfied with the rehabilitation process, 10 cases were satisfied, 2 cases were basically satisfied, and 1 case was not satisfied, while 19, 13, 5, and 3 cases in the regular group, respectively. The satisfaction degree of the applet group was significantly better than that of the regular group ( P=0.049). MRI examination of the two groups showed that the ACL was continuous without secondary rupture or necrosis. The ACL healing grade of the applet group was 31 cases of grade 1 and 9 cases of grade 2, and that of the regular group was 28 cases of grade 1 and 12 cases of grade 2, there was no significant difference in ACL healing grade between the two groups ( P=0.449). Conclusion The application of return to sports WeChat applet in the rehabilitation of patients after ACL reconstruction can significantly reduce the fear of return to sports and improve the rate of return to sports. The return to sports WeChat applet is convenient to operate, with high utilization rate and high patient compliance, which significantly improves the satisfaction.
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Affiliation(s)
- 政良 施
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 彦林 李
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 洋 余
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 凯 李
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 文婷 唐
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 梓文 宁
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 任杰 何
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 坤 王
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
| | - 国梁 王
- 昆明医科大学第一附属医院运动医学科(昆明 650032)Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P. R. China
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Foissey C, Batailler C, Shatrov J, Servien E, Lustig S. Is combined robotically assisted unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction a good solution for the young arthritic knee? INTERNATIONAL ORTHOPAEDICS 2023; 47:963-971. [PMID: 35962232 DOI: 10.1007/s00264-022-05544-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/04/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Anterior cruciate ligament (ACL) deficiency can be a consequence or a cause of femoro-tibial osteoarthritis (OA). Several studies have published satisfactory outcomes of unicompartimental knee arthroplasty (UKA) and combined ACL reconstruction despite its absence classically being considered a contraindication. A major challenge in the ACL deficient knee is obtaining appropriate gap balancing and limb axis. Robotically assisted UKA allows for precise control of these factors; however, it's utilisation as a tool with combined ACL reconstruction and UKA has not been described. The purpose of this study was to evaluate the clinical and radiological outcomes of robotically assisted UKA with combined ACL reconstruction. METHODS This was a retrospective single-centre study of ten patients operated by a single surgeon from 2016 to 2020. All surgery was performed using a cemented fixed bearing UKA prosthesis (Journey uni, Smith and Nephew®) (8 medial, 2 lateral) inserted with the assistance of an image-free robotic-assisted system (BlueBelt, Navio, Smith and Nephew®). All ACL reconstructions were performed using hamstring autograft. Clinical assessment included International Knee Score (IKS) score, Tegner score and patient satisfaction. Radiological assessment was performed to assess radiolucent lines, progression of OA in the other compartments, Hip-Knee-Ankle angle and Posterior Tibial Slope. RESULTS There were eight females (80%), mean age was 57 ± 7 [48-70], mean BMI was 26 ± 3 [22-31]. The mean follow-up was 45 months ± 13 months [24-66]. Mean post-operative IKS knee and function score were respectively 96 ± 4.5 [88-100] and 93 ± 8.2 [74-100], mean Tegner score was 4.5 ± 1.4 [3-6]. Nine patients (90%) returned to sport; one patient (10%) was dissatisfied because of residual pain preventing a return to a desired level of sport. 100% of the radiological objectives were achieved. No radiolucent lines were seen at the last follow-up. There were two re-operations (20%) for stiffness requiring arthroscopic arthrolysis at two and three months respectively following surgery, with full recovery of the flexion at the last follow-up in both cases. No other complications were observed. CONCLUSION Robotic UKA associated with ACL reconstruction provides satisfactory early patient outcomes and accurate implant positioning. The first results in terms of return to sports were promising.
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Affiliation(s)
- Constant Foissey
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande rue de la Croix-Rousse, 69004, Lyon, France.
| | - Cécile Batailler
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande rue de la Croix-Rousse, 69004, Lyon, France
| | - Jobe Shatrov
- Sydney Orthopaedic Research Institute (SORI), St. Leonards, Sydney, Australia
| | - Elvire Servien
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande rue de la Croix-Rousse, 69004, Lyon, France
- LIBM - EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, Lyon, France
| | - Sébastien Lustig
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 103 Grande rue de la Croix-Rousse, 69004, Lyon, France
- Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, F69622, Lyon, France
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Wang Y, Li Q, Xue X, Xu X, Tao W, Liu S, Li Y, Wang H, Hua Y. Neuroplasticity of pain processing and motor control in CAI patients: A UK Biobank study with clinical validation. Front Mol Neurosci 2023; 16:1096930. [PMID: 36866356 PMCID: PMC9971622 DOI: 10.3389/fnmol.2023.1096930] [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: 11/13/2022] [Accepted: 01/16/2023] [Indexed: 02/16/2023] Open
Abstract
Background Pain plays an important role in chronic ankle instability (CAI), and prolonged pain may be associated with ankle dysfunction and abnormal neuroplasticity. Purpose To investigate the differences in resting-state functional connectivity among the pain-related brain regions and the ankle motor-related brain regions between healthy controls and patients with CAI, and explore the relationship between patients' motor function and pain. Study design A cross-database, cross-sectional study. Methods This study included a UK Biobank dataset of 28 patients with ankle pain and 109 healthy controls and a validation dataset of 15 patients with CAI and 15 healthy controls. All participants underwent resting-state functional magnetic resonance imaging scanning, and the functional connectivity (FC) among the pain-related brain regions and the ankle motor-related brain regions were calculated and compared between groups. The correlations between the potentially different functional connectivity and the clinical questionnaires were also explored in patients with CAI. Results The functional connection between the cingulate motor area and insula significantly differed between groups in both the UK Biobank (p = 0.005) and clinical validation dataset (p = 0.049), which was also significantly correlated with Tegner scores (r = 0.532, p = 0.041) in patients with CAI. Conclusion A reduced functional connection between the cingulate motor area and the insula was present in patients with CAI, which was also directly correlated with reduction in the level of patient physical activity.
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Affiliation(s)
- Yiran Wang
- Department of Sports Medicine, Fudan University, Shanghai, China
| | - Qianru Li
- Department of Sports Medicine, Fudan University, Shanghai, China
| | - Xiao'ao Xue
- Department of Sports Medicine, Fudan University, Shanghai, China
| | - Xiaoyun Xu
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Weichu Tao
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Sixu Liu
- Department of Biomedical Engineering, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yunyi Li
- Department of Biomedical Engineering, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - He Wang
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China,Human Phenome Institute, Fudan University, Shanghai, China,Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence, Ministry of Education, Fudan University, Shanghai, China,He Wang ✉
| | - Yinghui Hua
- Department of Sports Medicine, Fudan University, Shanghai, China,Yiwu Research Institute of Fudan University, Yiwu, China,*Correspondence: Yinghui Hua ✉
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Mojica ES, Bi AS, Vasavada K, Moran J, Buzin S, Kahan J, Alaia EF, Jazrawi LM, Medvecky MJ, Alaia MJ. Poorer functional Outcomes in Patients with Multi-Ligamentous Knee Injury with Concomitant Patellar Tendon Ruptures at 5 years Follow-Up. Knee Surg Sports Traumatol Arthrosc 2023; 31:325-331. [PMID: 36048200 DOI: 10.1007/s00167-022-07110-3] [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: 03/06/2022] [Accepted: 08/04/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Multi-ligamentous knee injuries (MLKIs) are high-energy injuries that may infrequently present with concomitant patellar tendon rupture. There is limited information in the literature regarding these rare presentations, with even less information regarding clinical outcomes. Using propensity-score matching, the purpose of this study was to compare the outcomes of MLKIs with and without patellar tendon ruptures and to investigate the overall predictors of these outcomes. METHODS Twelve patients who underwent surgical repair for combined MLKI and patellar tendon rupture from 2011 to 2020 with minimum 1-year follow-up data were identified from two separate institutions. Patients were propensity-score matched with a 1:1 ratio with controls based on age, body mass index (BMI), gender, and time from surgery. Patient-reported outcomes included International Knee Documentation Committee (IKDC) Subjective Knee Form, Lysholm and Tegner scores. RESULTS Twelve MLKIs with concomitant patellar tendon injuries were identified out of a multicenter cohort of 237 (5%) patients sustaining MLKI and were case matched 1:1 with 12 MLKIs without extensor mechanism injuries. The average follow-up was 5.5 ± 2.6 years. There were no differences in Schenck Classification injury patterns. There were significant differences found across IKDC (Patellar Tendon mean: 53.1 ± 24.3, MLKI mean 79.3 ± 19.6, P < 0.001) and Lysholm scores (Patellar Tendon mean: 63.6 ± 22.3, MLKI mean 86.3 ± 10.7, P < 0.001) between the two, illustrating poorer outcomes for patients with concomitant patellar tendon ruptures. CONCLUSION In the setting of MLKI, patients who have a concomitant patellar tendon rupture have worse functional outcomes compared to those without. This information will be important for patient counseling and might be considered to be added to Schenck classification, reflecting its prognostic value. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Edward S Mojica
- Orthopedic Surgery, Division of Sports Medicine, New York University Langone Health, New York, NY, USA.
| | - Andrew S Bi
- Orthopedic Surgery, Division of Sports Medicine, New York University Langone Health, New York, NY, USA
| | - Kinjal Vasavada
- Orthopedic Surgery, Division of Sports Medicine, New York University Langone Health, New York, NY, USA
| | - Jay Moran
- Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Scott Buzin
- Orthopedic Surgery, Division of Sports Medicine, New York University Langone Health, New York, NY, USA
| | - Joseph Kahan
- Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Erin F Alaia
- Orthopedic Surgery, Division of Sports Medicine, New York University Langone Health, New York, NY, USA
| | - Laith M Jazrawi
- Orthopedic Surgery, Division of Sports Medicine, New York University Langone Health, New York, NY, USA
| | - Michael J Medvecky
- Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Michael J Alaia
- Orthopedic Surgery, Division of Sports Medicine, New York University Langone Health, New York, NY, USA
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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.
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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
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Glasbrenner J, Raschke MJ, Kittl C, Herbst E, Peez C, Briese T, Michel PA, Herbort M, Kösters C, Schliemann B. Comparable Instrumented Knee Joint Laxity and Patient-Reported Outcomes After ACL Repair With Dynamic Intraligamentary Stabilization or ACL Reconstruction: 5-Year Results of a Randomized Controlled Trial. Am J Sports Med 2022; 50:3256-3264. [PMID: 36005281 PMCID: PMC9527444 DOI: 10.1177/03635465221117777] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Technical innovation has led to the renaissance of anterior cruciate ligament (ACL) repair in the past decade. PURPOSE/HYPOTHESIS The present study aimed to compare instrumented knee joint laxity and patient-reported outcomes (PROs) after ACL repair with those after primary ACL reconstruction for acute isolated ACL tears. It was hypothesized that ACL repair would lead to comparable knee joint stability and PROs at 5 years postoperatively in comparison with ACL reconstruction. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 85 patients with acute ACL tears were randomized to undergo either ACL repair using dynamic intraligamentary stabilization (DIS) or primary ACL reconstruction with a semitendinosus tendon autograft. The primary outcome was the side-to-side difference in anterior tibial translation (ΔATT) assessed by Rolimeter testing at 5 years postoperatively. Follow-up examinations were performed at 1, 2, and 5 years. PROs were assessed using the Tegner activity scale, the International Knee Documentation Committee (IKDC) subjective score, and the Lysholm score. Furthermore, the rates of recurrent instability, other complications, and revision surgery were recorded. A power analysis was performed a priori, and the Friedman test, Mann-Whitney U test, and Bonferroni correction were applied for statistical comparisons with significance set at P < .05. RESULTS The mean age at inclusion was 28.3 ± 11.5 years in the ACL repair group and 27.1 ± 11.5 years in the ACL reconstruction group. At 5 years postoperatively, a total of 64 patients (ACL repair: n = 34 of 43 [79%]; ACL reconstruction: n = 30 of 42 [71%]) were available for follow-up. At 5 years, ΔATT was 1.7 ± 1.6 mm in the ACL repair group and 1.4 ± 1.3 mm in the ACL reconstruction group (P = .334). Preinjury PROs were restored as soon as 1 year after surgery and plateaued until 2 and 5 years postoperatively in both groups. At the 5-year follow-up, the mean Lysholm score was 97.0 ± 5.4 versus 94.5 ± 5.5 (P = .322), respectively, and the mean IKDC subjective score was 94.1 ± 9.9 versus 89.9 ± 7.8 (P = .047), respectively, in the ACL repair group versus ACL reconstruction group. At 5 years postoperatively, 12 patients in the ACL repair group (35%; age <25 years: n = 10/12; Tegner score ≥7: n = 10/12) had recurrent instability, of whom 10 underwent single-stage revision ACL reconstruction. In the ACL reconstruction group, there were 6 patients with recurrent instability (20%; age <25 years: n = 6/6; Tegner score ≥7: n = 5/6); however, in 5 patients, staged revision was required. Differences between both groups regarding recurrent instability (P = .09) or ACL revision surgery (P = .118) were not statistically significant. Recurrent instability was associated with age <25 years and Tegner score >7 in both groups. CONCLUSION At 5 years after ACL repair with DIS, instrumented knee joint laxity and PROs were comparable with those after ACL reconstruction. Although no significant difference was found between repair and reconstruction, a critical appraisal of the rates of recurrent instability (35% vs 20%, respectively) and revision surgery (38% vs 27%, respectively) is needed. Young age and a high preinjury activity level were the main risk factors for recurrent instability in both groups. However, single-stage revision ACL reconstruction was possible in each case in the ACL repair group. Although ACL reconstruction remains the gold standard in the treatment of ACL tears, the present study supports the use of ACL repair with DIS as a feasible option to treat acute ACL tears in patients aged ≥25 years with low to moderate activity levels (Tegner score <7). REGISTRATION DRKS00015466 (German Clinical Trials Register).
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Affiliation(s)
- Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany,Johannes Glasbrenner, MD, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, Münster, 48149, Germany ()
| | - Michael J. Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Philipp A. Michel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | | | - Clemens Kösters
- Department of Traumatology and Orthopedics, Maria-Josef-Hospital Greven, Greven, Germany
| | - Benedikt Schliemann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Tuphé P, Foissey C, Unal P, Vieira TD, Chambat P, Fayard JM, Thaunat M. Long-term Natural History of Unrepaired Stable Ramp Lesions: A Retrospective Analysis of 28 Patients With a Minimum Follow-up of 20 Years. Am J Sports Med 2022; 50:3273-3279. [PMID: 36074027 DOI: 10.1177/03635465221120058] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a lack of consensus about whether stable ramp lesions associated with anterior cruciate ligament (ACL) injuries need to be repaired. PURPOSE/HYPOTHESIS The purpose of this study was to evaluate how many stable ramp lesions left in situ during ACL reconstruction (ACLR) have subsequently failed after >20 years of follow-up. We hypothesized that ACL-reconstructed knees with ramp lesions left in situ without repair have a high risk of meniscal failure over the long term. STUDY DESIGN Case series; Level of evidence, 4. METHODS All patients who underwent arthroscopic ACLR by a single experienced surgeon between January 1998 and December 2000 were evaluated retrospectively. Included were all cases of longitudinal tears in the meniscocapsular junction or the red zone of the posterior horn of the medial meniscus that were left in situ and identified through the anterior portals. Successful anterior probing confirmed a meniscal tear of the posterior segment. A lesion was considered stable if it was ≤2 cm and did not extend beyond the lower pole of the femoral condyle. The following data were collected preoperatively and at the last follow-up: demographics, time to surgery, side-to-side laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner activity scale, and meniscal failure rate. We defined 2 groups based on our findings: medial meniscal failure versus no medial meniscal failure. RESULTS A total of 716 knees underwent primary ACLR during this period. The 39 (5.4%) stable unrepaired ramp lesions identified were included in the case series. Mean ± standard deviation follow-up was 262.1 ± 10.5 months. Eleven patients (28%) were lost to follow-up. Of the remaining patients, 8 (28.6%) had a medial meniscal failure, of which 6 (21.4%) were bucket-handle tears. The average time elapsed before complications was 87.8 ± 52 months (range, 6-156 months). The medial meniscal survival rate was 93% at 5 years, 75% at 10 years, and 71% at 15 and 20 years. The failure event mainly happened between 96 and 120 months (8 and 10 years) after ACLR. No risk factors for failure were found, but some trends appeared, such as older age, higher body mass index, and preoperative rotational instability. All postoperative scores were significantly improved at the last follow-up (P < .0001); 16 patients (57%) returned to their sport of choice. CONCLUSION With nearly one-third of patients developing meniscal complications, including a large share of bucket-handle tears and mostly occurring 8 years after the ACLR, it may not be wise to leave stable ramp lesions unrepaired.
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Affiliation(s)
- Pierre Tuphé
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Constant Foissey
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Pauline Unal
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Thais Dutra Vieira
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Pierre Chambat
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Jean-Marie Fayard
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Mathieu Thaunat
- Ramsay Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
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Franciozi CE, Minami FK, Ambra LF, Galvão PHSAF, Schumacher FC, Kubota MS. Remnant preserving ACL reconstruction with a functional remnant is related to improved laxity but not to improved clinical outcomes in comparison to a nonfunctional remnant. Knee Surg Sports Traumatol Arthrosc 2022; 30:1543-1551. [PMID: 33893826 DOI: 10.1007/s00167-021-06572-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 04/06/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE The Anterior cruciate ligament (ACL) remnant has been pointed out as a ligamentization enhancer. Nonetheless, the remaining tissue can be functional if it still provides some stability or nonfunctional. This study intends to compare the clinical results and knee stability of functional vs. nonfunctional remnant preservation ACL reconstruction (ACLR). METHODS One hundred and seventy-five patients with ACL injuries were included and underwent remnant preservation ACLR. They were divided into two groups accordingly to remnant tissue functionality: functional (Group F) and nonfunctional (Group NF). Primary outcome was defined as patient reported outcomes measured with Lysholm, IKDC and Tegner continuous scales and improvements. Secondary outcomes comprised of Lachman test, anterior drawer test, pivot shift test, extension and flexion deficit, graft coverage by remnant preserved tissue and failure rate (persistent instability or new ACL lesion). Menisci lesions, cartilage lesions and time to surgery were also recorded for each group. RESULTS One hundred and forty-four patients were available at a mean of 30.2 ± 10.1 months: 69 Functional and 75 Nonfunctional. Lysholm, IKDC and Tegner functional outcomes demonstrated no difference between the groups, Functional compared to Nonfunctional: 88.4 ± 10.5 vs. 92.2 ± 4.9, n.s. and 83.2 ± 11.3 vs. 87 ± 5.3, n.s. and 6 (5-10) vs. 6 (5-9), n.s., respectively. Lysholm and IKDC functional outcomes improvements demonstrated differences between the groups: Functional compared to Nonfunctional (39.3 ± 9.4 vs. 42.3 ± 7.4, p = 0.014 and 37.7 ± 10 vs. 41.0 ± 6.6, p = 0.032); however, they were not clinically significant. Functional group showed more stability on physical examination pre- and post-operatively (p < 0.001, p < 0.001). There was no difference regarding extension deficit (n.s.); however, functional group had more flexion deficit (p = 0.02). Nonfunctional group had better graft coverage (p = 0.001). There was no difference regarding failure rate: 4% vs. 9%, (n.s.). CONCLUSION Both remnant preservation ACLR techniques were able to achieve satisfactory functional outcomes. A functional remnant was not related to improved functional outcomes in comparison to a nonfunctional remnant; however, it was related to less laxity pre and postoperatively and inferior graft coverage. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Carlos Eduardo Franciozi
- Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Napoleão de Barros Street, 715, 5th Fl, Vila Clementino, São Paulo, Brazil.,Knee Institute - Heart Hospital (Hospital do Coração - Hcor), São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Flávio Kazuo Minami
- Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Napoleão de Barros Street, 715, 5th Fl, Vila Clementino, São Paulo, Brazil.
| | - Luiz Felipe Ambra
- Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Napoleão de Barros Street, 715, 5th Fl, Vila Clementino, São Paulo, Brazil
| | - Pedro Henrique Schmidt Alves Ferreira Galvão
- Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Napoleão de Barros Street, 715, 5th Fl, Vila Clementino, São Paulo, Brazil
| | - Felipe Conrado Schumacher
- Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Napoleão de Barros Street, 715, 5th Fl, Vila Clementino, São Paulo, Brazil
| | - Marcelo Seiji Kubota
- Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Napoleão de Barros Street, 715, 5th Fl, Vila Clementino, São Paulo, Brazil
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19
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Muller B, Yabroudi MA, Lynch A, Popchak AJ, Lai CL, van Dijk CN, Fu FH, Irrgang JJ. Return to preinjury sports after anterior cruciate ligament reconstruction is predicted by five independent factors. Knee Surg Sports Traumatol Arthrosc 2022; 30:84-92. [PMID: 33885946 DOI: 10.1007/s00167-021-06558-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 03/30/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE To determine factors that predict return to the same frequency and type of sports participation with similar activity demands as before injury. METHODS Individuals 1 to 5 years after primary ACL reconstruction completed a comprehensive survey related to sports participation and activity before injury and after surgery. Patient characteristics, injury variables, and surgical variables were extracted from the medical record. Return to preinjury sports (RTPS) was defined as: "Returning to the same or more demanding type of sports participation, at the same or greater frequency with the same or better Marx Activity Score as before injury." Variables were compared between individuals that achieved comprehensive RTPS and those that did not with univariate and multivariate logistic regression models. RESULTS Two-hundred and fifty-one patients (mean age 26.1 years, SD 9.9) completed the survey at an average of 3.4 years (SD 1.3) after ACL reconstruction. The overall rate of RTPS was 48.6%. Patients were more likely to RTPS if they were younger than 19 years old (OR = 4.07; 95%CI 2.21-7.50; p < 0.01) or if they were competitive athletes (OR = 2.07; 95%CI 1.24-3.46; p = 0.01). Patients were less likely to RTPS if surgery occurred more than 3 months after injury (OR = 0.31, 95%CI 0.17-0.58; p < 0.01), if there was a concomitant cartilage lesion (OR = 0.38; 95%CI 0.21-0.70; p < 0.01), and if cartilage surgery was performed (OR = 0.17; 95%CI 0.04-0.80; p = 0.02). CONCLUSION Five variables best predicted RTPS including age at time of surgery. Only time from injury to surgery is a potentially modifiable factor to improve RTPS; however, the reasons for which patients delayed surgery may also contribute to them not returning to sports. Regardless, younger patients, those that partake in sports on a competitive level, those that undergo surgery sooner, or do not have a cartilage injury or require cartilage surgery are more likely to return to pre-injury sports participation. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Bart Muller
- Department of Orthopaedic Surgery, Xpert Clinics, Laarderhoogtweg 12, 1101 EA, Amsterdam, The Netherlands
| | - Mohammad A Yabroudi
- Department of Rehabilitation Sciences, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Andrew Lynch
- Department of Physical Therapy, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Adam J Popchak
- Department of Physical Therapy, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Chung-Liang Lai
- Department of Physical Medicine and Rehabilitation, Taichung Hospital, Ministry of Health and Welfare, 199, sec. 1, San-Min Road, Taichung, Taiwan
| | - C Niek van Dijk
- Department of Orthopaedic Surgery, Xpert Clinics, Laarderhoogtweg 12, 1101 EA, Amsterdam, The Netherlands
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - James J Irrgang
- Department of Physical Therapy, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA. .,Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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20
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Female gender and medial meniscal lesions are associated with increased pain and symptoms following anterior cruciate ligament reconstruction in patients aged over 50 years. Knee Surg Sports Traumatol Arthrosc 2021; 29:2987-3000. [PMID: 33108528 DOI: 10.1007/s00167-020-06318-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Several studies report satisfactory clinical outcomes following ACLR in older patients, but none evaluated the effects of meniscal and cartilage lesions. The aim was to evaluate the influence of meniscal and cartilage lesions on outcomes of ACLR in patients aged over 50 years. METHODS The authors prospectively collected records of 228 patients that underwent primary ACLR, including demographics, time from injury to surgery, whether injuries were work related, and sports level (competitive, recreational, or none). At a minimum follow-up of 6 months, knee injury and osteoarthritis outcome scores (KOOS), International Knee Documentation Committee (IKDC) score and Tegner activity level were recorded, and differential laxity was measured as the side-to-side difference in anterior tibial translation (ATT) using instrumented laximetry devices. Regression analyses were performed to determine associations between outcomes and meniscal and cartilage lesions as well as nine independent variables. RESULTS A total of 228 patients aged 54.8 ± 4.3 years at index ACLR were assessed at a follow-up of 14.3 ± 3.8 months. KOOS subcomponents were 85 ± 13 for symptoms, 91 ± 10 for pain, 75 ± 18 for daily activities, 76 ± 18 for sport, and 88 ± 12 for quality of life (QoL). The IKDC score was A for 84 (37%) knees, B for 96 (42%) knees, C for 29 (13%) knees, and D for 8 (4%) knees. Tegner scores showed a decrease (median 0, range -4 to 4) and differential laxity also decreased (median - 4, range - 23.5 to 6.0). KOOS symptoms worsened with higher BMI (p = 0.038), for women (p = 0.007) and for knees that had medial meniscectomy (p = 0.029). KOOS pain worsened with higher BMI (p ≤ 0.001), for women (p = 0.002) and for knees with untreated (p = 0.047) or sutured (p = 0.041) medial meniscal lesions. Differential laxity increased with follow-up (p = 0.024) and in knees with lateral cartilage lesions (p = 0.031). CONCLUSION In primary ACLR for patients aged over 50 years, female gender and medial meniscal lesions significantly compromised KOOS symptoms and pain, while lateral cartilage lesions significantly increased differential laxity. Compared to knees with an intact medial meniscus, those with sutured or untreated medial meniscal lesions had worse pain, while those in which the medial meniscus was resected had worse symptoms. These findings are clinically relevant as they could help surgeons with patient selection and adjusting expectations according to their functional demands. LEVEL OF EVIDENCE III.
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21
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The projected volume of primary and revision total knee arthroplasty will place an immense burden on future health care systems over the next 30 years. Knee Surg Sports Traumatol Arthrosc 2021; 29:3287-3298. [PMID: 32671435 PMCID: PMC7362328 DOI: 10.1007/s00167-020-06154-7] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/10/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE Total knee arthroplasty (TKA) rates have increased substantially in the recent decades worldwide, with Germany being one of the leading countries in the prevalence of TKA. The aim of this study was to provide an overview of treatment changes during the last decade and to project the expected burden of primary and revision TKA (rTKA) for the next 30 years. METHODS Comprehensive nationwide data from Germany was used to quantify primary and revision TKA rates as a function of age and gender. Projections were performed with use of a Poisson regression models and a combination of exponential smoothing and autoregressive integrated moving average models on historical procedure rates in relation to official population projections from 2020 to 2050. RESULTS The incidence rate of primary TKAs is projected to increase by around 43% to 299 per 100,000 inhabitants [95% CI 231-368], leading to a projected total number of 225,957 primary TKAs in 2050 (95% CI 178,804-276,442). This increase has been related to a growing number of TKA performed in male patients, with the highest increase modelled in patients between 50 and 65 years of age. At the same time, the annual total number of revision procedures is forecast to increase even more rapidly by almost 90%, accounting for 47,313 (95% CI 15,741-78,885; IR = 62.7 per 100,000, 95% CI 20.8-104.5) procedures by 2050. Those numbers are primarily associated with a rising number of rTKAs secondary to periprosthetic joint infection (PJI). CONCLUSIONS Using this country- specific forecast approach, a rising number of primary TKA and an even more rapidly growing number of rTKA, especially for PJI, has been projected until 2050, which will inevitably provide a huge challenge for the future health care system. As many other industrialized nations will face similar demographic and procedure-specific developments, these forecasts should be alarming for many health care systems worldwide and emphasize the tremendous need for an appropriate financial and human resource management in the future. LEVEL OF EVIDENCE Level III, prognostic study, economic and decision analysis.
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