Return to sport following anterior cruciate ligament reconstruction

Perspectives on reasons why football and handball players sustain acute and severe knee injuries: a mixed-methods concept mapping study

ABSTRACT

Background

The high incidence of knee injuries in football/handball challenges effective prevention. Identifying tangible and modifiable factors associated with a knee injury may innovate preventive actions. Engaging key stakeholders can reveal crucial insights that could improve knee injury prevention in football/handball.

Objective

To investigate football/handball stakeholders' perspectives on reasons for acute and severe knee injuries to generate a conceptual model on important factors associated with knee injuries in football/handball.

Methods

Mixed-method participatory Group Concept Mapping was applied to collect statements from football/handball stakeholders (players/coaches/healthcare staff/researchers) on the question, 'What may explain why some players sustain a knee injury?'. Participants rated the importance and feasibility of screening for each statement. Multidimensional scaling and hierarchical cluster analysis produced a cluster map, forming the basis for developing a final conceptual model.

Results

Stakeholders (n=37) generated and sorted 100 statements. Cluster analysis followed by cluster map validation yielded seven themes: (1) the player's physical and motor skill profile, (2) preparation and training, (3) footwear and playing surface, (4) the sport's impact on the risk of injury, (5) mental and physical fatigue, (6) history of injury and 7) genetics and context. A final conceptual model illustrating factors associated with knee injuries in football/handball was developed. Forty-six statements were identified as both important and feasible to screen for.

Conclusions

Stakeholders' perspectives on knee injuries in football/handball revealed a complex interplay of factors. We developed a conceptual model fostering stakeholder dialogue for enhanced prevention. Key among its themes is 'preparation and training'.

Return to sports after an ACL reconstruction in 2024 - A glass half full? A narrative review

A successful return to sports (RTS) after an anterior cruciate ligament reconstruction (ACLR) is multifactorial, and therefore difficult and challenging. Unfortunately, low percentages of patients RTS, and for those who succeed, one-fifth of patients will sustain a second ACL injury. Over the past years, test batteries were developed to assess whether patients can RTS with a low risk for a second ACL injury risk. Low rates of patients who meet RTS criteria were found, coupled with the insufficiency of current RTS test batteries in predicting second ACL injuries suggesting poor sensitivity. The result of an RTS test is likely to reflect the content of a rehabilitation program, raising critical questions regarding what we are offering patients within the rehabilitation programme. Are we preparing our patients well enough for the high demands of complex situations within pivoting team sports? This narrative review offers insights from key lessons of the last 15 years on 1) RTS testing, 2) the content of rehabilitation, and 3) the RTS continuum, all from a "helicopter perspective".

Rehabilitation and Return to Play Protocols After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review

BACKGROUND

Rehabilitation after anterior cruciate ligament ACL reconstruction (ACLR) is crucial for safe return to play (RTP) and reducing the chances of a reinjury. Yet, there is no consensus on the ideal functional tests to assess rehabilitation progress in soccer players after ACLR.

PURPOSE

The primary objective was to highlight the existing gap in the literature concerning the most effective standardized rehabilitation protocols and testing for facilitating successful RTP among soccer players.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review using PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. Inclusion criteria encompassed original studies (level of evidence 1-4) that examined rehabilitation protocols, metrics of knee rehabilitation, and clinical outcomes after ACLR in soccer players.

RESULTS

This review incorporated 23 studies, predominantly retrospective case series, with a total number of 874 soccer players who underwent ACLR and rehabiliation. 5 (21.7%) studies utilized an accelerated rehabilitation protocol, while 7 (30.4%) of studies utilized a criterion-based rehabilitation. A wide heterogeneity of data was extracted including functional tests of rehabilitation and RTP such as strength test batteries, hop test batteries, and movement quality assessments. Of the 23 selected studies, 2 (8.7%) used all 3 test batteries, 8 (34.8%) used 2 test batteries, 12 (52.2%) used 1 test battery, and 1 (4.3%) used 0 of the test batteries. The mean time between surgery and RTP ranged from 3 to 8 months with only 2 (8.7%) studies reporting complications after ACLR. Lastly, out of the total studies examined, 9 (39.1%) assessed patient-reported outcome measures (PROMs), all of which demonstrated significant improvement from the initial assessment to the final follow up.

CONCLUSION

Soccer-specific rehabilitation after ACLR lacks standardization. Even though many studies have assessed protocols for optimal RTP and reduced secondary ACL injuries, there is a gap in the literature regarding the most effective protocols and RTP testing. The methodology reported by Kyritsis et al could serve as a foundation for future prospective randomized multicenter studies to establish a standard rehabilitation protocol and enable a successful return to soccer.

Comparative study of functional outcomes of arthroscopic anterior cruciate ligament reconstruction using anteromedial portal and translateral all-inside technique

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.

Preoperative predictors for return to physical activity following anterior cruciate ligament reconstruction (ACLR): a systematic review

BACKGROUND

Rates of return to physical activity after anterior cruciate ligament reconstruction surgery are sub-optimal. Optimising presurgical treatment may improve return rates. The purpose of this systematic review was to identify modifiable preoperative predictors for return to physical activity after anterior cruciate ligament reconstruction.

METHODS

Seven electronic databases (CINAHL, MEDLINE and SPORTDiscus via EBSCOhost, AMED, PsycINFO and EMBASE via OVID and Web of Science) were searched from inception to 31 March 2023. The population of focus was adults aged 18-65 who had undergone primary anterior cruciate ligament reconstruction. Studies needed to identify at least one potential modifiable preoperative predictor variable and the relationship between the predictor(s) and return to physical activity. All time-points of assessment and study designs were included. Data extraction was completed by one reviewer and verified by a second reviewer. Two reviewers completed the risk of bias assessment using the Quality in Prognostic Studies tool and Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The search identified 2281 studies, eight met the inclusion criteria. Five studies scored 'high', and three studies scored 'moderate' risk-of-bias. All preoperative predictors were of very low-quality evidence. Five different outcome measures were used to assess return to physical activity including Tegner, Marx, Physical Activity Scale, return to play at the elite level and return to preinjury level (undefined). This was measured between 1- and 10-years post-surgery. Nine preoperative physical, six psychosocial and five demographic/clinical factors were assessed and four were found to be predictive. These included quadriceps strength, psychological profile, patient estimated ability to return and graft type (patella tendon, BPTB).

CONCLUSION

Very-low level evidence suggests that increasing quadriceps strength, managing patient expectations of their treatment outcomes, improving motivation to resume preinjury activity levels and considering the use of a BPTB graft will support return to physical activity after ACLR.

TRIAL REGISTRATION

This study was prospectively registered in PROSPERO: CRD 42020222567.

Impact of Occupation on 12-Month Outcomes After Anterior Cruciate Ligament Reconstruction in Male Patients

Background

The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown.

Purpose/Hypothesis

The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity.

Study Design

Cohort study; Level of evidence, 3.

Methods

From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test.

Results

Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [P = .021]; mean passive, 2.76° vs 5.00°, respectively [P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months.

Conclusion

At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.

Psychological readiness to return to sports practice and risk of recurrence: Case studies

Returning to sport after the sports injury is a difficult decision because it's multicausal and the fact that a rash decision can result in numerous negative consequences. Given the importance of psychological variables for the correct rehabilitation of the injured athlete and his or her optimal return to sports practice, there seems to be little information on this subject. In this sense, the objective is to determine the relationship between the subjective psychological disposition of the athlete in the process of Return to Play (RTP) with the type of mood profile and his mental health. This is based on the fact that each athlete evaluates his or her recovery differently and has different levels of anxiety, depression, and stress. For this purpose, four athletes participated in the study. Two males and two females from the sports of indoor soccer and soccer, who had just returned to sports after a moderate or severe injury. The average age was 24.25 years. Various measurements were taken after practices and after matches, to assess mood, psychological readiness, anxiety, stress, and depression. The results confirm Morgan's iceberg profile and the influence that subjective psychological perceptions and assessed emotional states have on athletes' incorporation into their sports practice with a guarantee of success.

Revision anterior cruciate ligament reconstruction: Return to sports at a minimum 5-year follow-up

BACKGROUND

Between 43% and 75% of patients who undergo primary anterior cruciate ligament (ACL) surgery return to sport activity. However, after a revision ACL reconstruction (ACLR) the rate of return to sports is variable. A few publications have reported returns to sports incidence between 56% to 100% after revision ACLR.

AIM

To determine return to sports and functional outcomes after a single-stage revision ACLR with a 5-year minimum follow-up at a single institution.

METHODS

All patients operated between 2010 and 2016 with a minimum 5 years of follow-up were included. Type of sport, intensity, frequency, expectation, time to return to sport and failure rate were recorded. Lysholm, Tegner and International Knee Documentation Committee forms were evaluated prior to the first ACLR surgery, at 6 mo after primary surgery and after revision ACLR at 5 years minimum of follow-up. Objective stability was tested with the knee arthrometer test (KT-1000 knee arthrometer, Medmetric Corp).

RESULTS

A total of 41 patients who underwent revision ACLR during that period of time were contacted and available for follow-up. Median patient age at time of revision was 29 years old [interquartile range (IQR): 24.0-36.0], and 39 (95.0%) were male. The median time from revision procedure to follow-up was 70 mo (IQR: 58.0-81.0). Regarding return to sports, 16 (39.0%) were at the same level compared to preinjury period, and 25 patients (61.0%) returned at a lower level. Sixty-three percent categorized the sport as very important and 37.0% as important. One patient (2.4%) failed with a recurrent ACL torn. Mean preoperative Lysholm and subjective International Knee Documentation Committee scores were 58.8 [standard deviation (SD) 16] and 50 (SD 11), respectively. At follow-up, mean Lysholm and subjective International Knee Documentation Committee scores were 89 (SD 8) and 82 (SD 9) (P = 0.0001). Mean Tegner score prior to primary ACLR was 6.7 (SD 1.3), 5.1 (1.5 SD) prior to revision ACLR and 5.6 (1.6 SD) at follow-up (P = 0.0002). Overall, knee arthrometer test measurement showed an average of 6 mm (IQR: 4.0-6.0) side-to-side difference of displacement prior to revision ACLR and 3mm (IQR: 1.5-4.0) after revision.

CONCLUSION

Almost 40.0% of patients returned to preinjury sports level and 60.0% to a lower level. These may be useful when counseling a patient regarding sports expectations after a revision ACLR.

Have We Forgotten Our Patient? An Exploration of Patient Experiences After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Limited information is available on the experiences of patients during rehabilitation after anterior cruciate ligament reconstruction (ACLR).

AIM

The current study aimed to identify factors that differentiated positive and negative patient experiences during rehabilitation after ACLR.

METHOD AND DESIGN

A survey-based study with an online platform was used to identify factors that differentiated positive and negative patient experiences during rehabilitation after ACLR. Seventy-two patients (age 27.8 [8.8] y) after ACLR participated. Data were analyzed and themes were identified by comparing categories and subcategories on similarity.

MAIN FINDINGS

Positive patient experiences were room for own input, supervision, attention, knowledge, honesty, and professionalism of the physiotherapist. Additionally, a varied and structured rehabilitation program, adequate facilities, and contact with other patients were identified as positive patient experiences. Negative experiences were a lack of attention, lack of professionalism of the physiotherapists, a lack of sport-specific field training, a lack of goal setting, a lack of adequate facilities, and health insurance costs.

CONCLUSIONS

The current study identified factors that differentiated positive and negative patient experiences during rehabilitation after ACLR. These findings can help physiotherapists in understanding the patient experiences during rehabilitation after ACLR.

Therapeutic Patient Education after Anterior Cruciate Ligament Reconstruction: Evaluation of the Knowledge and Certitudes with a Self-Report Questionnaire

Therapeutic education aims to help patients acquire skills and knowledge, and to improve psychosocial aspects to manage chronic disease. After anterior cruciate ligament reconstruction (ACLR), only 35 to 60% of the patients are able to go back to their previous sport. Return to sport depends on the motivation of the patient. No therapeutic education has already been proposed. We aimed to evaluate the effect of therapeutic education sessions on knowledge improvement during inpatient rehabilitation after ACLR, compared to patients operated with the same surgical technic, but who had no therapeutic education because of outpatient rehabilitation. Sessions were performed by a multidisciplinary team. The evaluation of the knowledge was performed with a true or false 12-items self-report questionnaire. Fifty-four patients were studied and compared to 54 patients with no therapeutic education. The educated and the non-educated groups were comparable. The number of correct answers increased from 73% before therapeutic education to 95% at the end of the hospitalization (p < 0.001). This improvement persisted over time with 91.5% of correct answers at four months (p = 0.94). The non-educated group had 70% of correct answers. This was significantly lower than the results obtained from the educated group at four months (p < 0.001). It was comparable to the result obtained before therapeutic education (p = 0.91). Therapeutic patient education performed during hospitalization for rehabilitation enables patients to have a better knowledge of the stages from rehabilitation to return to sport and the risks of complication after ACLR.

Application and Surgical Technique of ACL Reconstruction Using Worldwide Registry Datasets: What Can We Extract?

Anterior cruciate ligament (ACL) injuries are among the most common knee injuries. The purpose of this study was to compare surgical reconstruction of the ACL between different countries and regions in order to describe differences regarding epidemiological data, reconstruction frequency, and graft choice. A systematic literature search was performed using the ACL study group website in order to identify the relevant knee ligament registers. Four national registries were included, comprising those from Sweden, the UK, New Zealand, and Norway. A large variation was found concerning the total number of primary ACL reconstructions with a reported range from 4.1 to 51.3 per 100,000 inhabitants. The country-specific delay between injury and reconstruction varied between an average of 6.0 months and 17.6 months. The leading sports activities resulting in ACL injury included soccer, alpine skiing, handball, rugby, and netball. Moreover, a strong variability in graft choice for primary reconstruction was found. The comparison of ACL registers revealed large differences, indicating different clinical implications regarding conservative or surgical therapy and choice of the preferable graft. ACL registers offer a real-world clinical perspective with the aim to improve quality and patient safety by investigating factors associated with subsequent surgical outcomes.

Preoperative predictors for a successful return to sport following anterior cruciate ligament reconstruction (ACLR): a protocol for a systematic review and meta-analysis

INTRODUCTION

Return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR) is the primary goal for most patients. However, the decision of when to RTS is difficult for patients and clinicians as it is based on limited available evidence. Over the past decade, a number of predictor variables have been associated with RTS after ACLR. We present a Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols compliant protocol for a systematic review and meta-analysis of preoperative predictors for RTS/preinjury levels of physical activity following ACLR.

METHODS AND ANALYSIS

A literature search will be performed in six electronic databases (CINAHL, AMED, MEDLINE, SPORTDiscus and PsycINFO via EBSCOhost and Web of Science) from inception to December 2020. Prospective, retrospective and cross-sectional study designs will be included. To be included, studies will need to identify at least one preoperative predictor and identify the relationship between the predictor(s) and RTS/preinjury levels of physical activity following ACLR. Blinded assessment with consensus agreement will be applied for inclusion of studies, data extraction, risk of bias assessment using the Quality in Prognostic Studies tool and the Grading of Recommendations Assessment, Development and Evaluation framework. If data allows and studies are considered homogeneous, data will be pooled through a meta-analysis. If heterogenous, a narrative synthesis will be completed. Subgroup and sensitivity analyses will be completed, where appropriate.

ETHICS AND DISSEMINATION

Ethical permission is not required for this study. The results will be published in a peer-reviewed journal and presented at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42020222567.

A Criterion Based Rehabilitation Protocol for ACL Repair with Internal Brace Augmentation

The anterior cruciate ligament (ACL) is one of the main stabilizing structures of the knee and its rupture is a common injury in young active adults. ACL reconstruction has been the preferred operative management of an ACL rupture for several decades; however, success rates are variable. Recently, interest in arthroscopic primary repair of the ligament has increased. The repair is augmented with an Internal Brace (IB), which is an ultra-high strength suture tape that bridges the ligament. This technique protects the ligament during the healing and the ligament is encouraged to heal naturally, whilst not requiring any external braces. It acts as a stabiliser to permit early mobilization and optimise rehabilitation. As understanding of rehabilitation has progressed, there has been an increased focus on early weight-bearing and achieving full range of movement. While detailed criterion-based rehabilitation protocols exist for ACL reconstruction, this is not the case for ACL repair. The purpose of this commentary is to present a novel criterion-based rehabilitation protocol following ACL repair surgery augmented with an IB.

LEVEL OF EVIDENCE

V.

Patient expectations and perceived social support related to return to sport after anterior cruciate ligament reconstruction in adolescent athletes

OBJECTIVE

Examine the relationship between pre-operative competitive status and return to sport expectations post-operatively among adolescents undergoing ACL reconstruction. Assess the association between perceived levels of social support and doubts in returning to sport after ACL reconstruction.

DESIGN

Cross-sectional.

SETTING

Outpatient sports medicine clinic at a single institution.

PARTICIPANTS

12-18 years old with an ACL tear who were planning to undergo ACL reconstruction.

MAIN OUTCOME MEASURES

Psychovitality questionnaire responses and Multidimensional Scale of Perceived Social Support (MSPSS) questionnaire scores.

RESULTS

86% of participants expected to return to sports in six months or less after surgery; there was no significant difference in expected time to return to sport between competitive vs. recreational athletes. Competitive athletes were less likely to be content returning to a lower activity level after surgery compared to recreational athletes. There were no significant differences in MSPSS scores between those who did and did not report doubts in their ability to return to their previous sports.

CONCLUSION

Most of our adolescent athlete population expected to return to sport after ACL reconstruction within six months of surgery. Those with and without doubts in their ability to return to sports did not significantly differ in levels of perceived social support.

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft is associated with higher and earlier return to sports as compared to hamstring tendon graft

PURPOSE

To study the effect of age, duration of injury, type of graft and concomitant knee injuries on return to sports after anterior cruciate ligament (ACL) reconstruction.

METHOD

One-hundred and sixteen athletes underwent ACL reconstruction using either bone-patellar tendon-bone graft (BPTB; n = 58) or semitendinosus-gracilis graft (n = 58), depending upon their random number sequences. Five variables were analyzed in terms of their effect on return to sports-age, type of graft, time interval between injury and surgery, chondral damage and meniscal tears.

RESULTS

Fifty-three out of 73 (72.6%) athletes aged between 16 and 25 years and 21/43 (49%) athletes aged between 25 and 40 years returned to sports (p = 0.02). The mean time to return to sports was 9.7 ± 2.1 months and 10.8 ± 1.7 months in athletes aged < 25 years and 25-40 years, respectively (p = 0.04). ACL reconstruction with BPTB graft (43/58) was associated with higher rate of return to sports as compared to hamstring tendon graft (31/58; p = 0.02). The mean duration of return to sports with BPTB and STGPI graft was 9.7 ± 2.0 months and 10.7 ± 2.0 months, respectively (p = 0.02). 29/36 (80.5%) patients operated between 2 and 6 months, 18/29 (62%) operated in < 2 months, and 27/51 (53%) operated after 6 months of injury had returned to sports (p = 0.03). Athletes who were operated within 2 months of the injury were the earliest to return to sports (9.4 ± 2.1 months), followed by those operated within 2-6 months (9.9 ± 1.9 months) and lastly by the ones operated after 6 months of the injury (10.9 ± 2.1 months; p = 0.04).

CONCLUSIONS

The rate of return to sports was observed to be higher in athletes younger than 25 years as compared to older athletes (> 25 years). ACL reconstruction with BPTB graft was associated with higher and earlier returns to sports as compared to hamstring graft. The rate of return to sports was highest if surgery was performed between 2 and 6 months after the injury.

LEVEL OF EVIDENCE

III.

Importance of functional performance and psychological readiness for return to preinjury level of sports 1 year after ACL reconstruction in competitive athletes

PURPOSE

This study aimed to identify independent predictive factors for return to sports (RTS) after anterior cruciate ligament (ACL) reconstruction in competitive-level athletes and to determine optimal cut-off values for these factors at 6 months after surgery.

METHODS

A total of 124 competitive athletes (50 males and 74 females; mean age, 17.0 years; preinjury Tegner activity scale > 7) who underwent primary ACL reconstruction were enrolled. Assessments at 6 months after surgery consisted of knee functional tests [quadriceps index, hamstrings index, and single-leg hop for distance (SLH)] and 2 self-report questionnaires [IKDC subjective score and ACL-Return to Sport after Injury scale (ACL-RSI)]. At 1 year after surgery, athletes were classified into the RTS group (n = 101) or non-RTS group (n = 23) based on self-reported sports activities. After screening possible predictive factors of RTS, multivariate logistic regression and receiver operating characteristic curve analyses were performed to identify independent factors.

RESULTS

Multivariate logistic regression analysis identified SLH (odds ratio, 2.861 per 10 unit increase; P < 0.001) and ACL-RSI (odds ratio, 1.810 per 10 unit increase; P = 0.001) at 6 months as independent predictors of RTS at 1 year after surgery. Optimal cut-off values of SLH and ACL-RSI were 81.3% (sensitivity = 0.891; specificity = 0.609) and 55 points (sensitivity = 0.693; specificity = 0.826), respectively.

CONCLUSION

In competitive athletes, SLH < 81% and ACL-RSI < 55 points at 6 months after surgery were associated with a greater risk of unsuccessful RTS at 1 year after surgery. SLH and ACL-RSI at 6 months could serve as screening tools to identify athletes who have difficulties with returning to sports after ACL reconstruction.

LEVEL OF EVIDENCE

III.

Passing return to sports tests after ACL reconstruction is associated with greater likelihood for return to sport but fail to identify second injury risk

BACKGROUND

A limited number of patients return to sport (RTS) after an anterior cruciate ligament reconstruction (ACLR) and patients who RTS have a relatively high risk for second ACL injury. The purpose of the current study was to compare the results of a test battery between patients who returned to the pre-injury level of sport (RTS group) and patients who did not (NO-RTS group). It was hypothesized that the RTS group showed better test results.

METHODS

Sixty-four patients (age 27.8 ± 8.8 years) were included. The results of a multicomponent test battery (jump-landing task assessed with the Landing Error Scoring System (LESS), three hop tests, isokinetic strength test for quadriceps and hamstring) were compared between groups with a 2 × 2 ANOVA.

RESULTS

The RTS group showed a significantly lower LESS score (p = 0.010), significantly higher absolute scores on hop tests with both legs (injured leg: single leg hop test p = 0.013, triple leg hop test p = 0.024, side hop test p = 0.021; non-injured leg: single leg hop test p = 0.011, triple leg hop test p = 0.023, side hop test p = 0.032) and significantly greater hamstring strength in the injured leg (p = 0.009 at 60°/s, p = 0.012 at 180°/s and p = 0.013 at 300°/s). No differences in test results were identified between patients who sustained a second ACL injury and patients who did not.

CONCLUSION

Patients after ACLR with better jump-landing patterns, hop performance and greater hamstring strength have greater likelihood for RTS. However, our findings show that RTS criteria fail to identify patients who are at risk for a second ACL injury.

Forward lunge before and after anterior cruciate ligament reconstruction: Faster movement but unchanged knee joint biomechanics

The forward lunge (FL) may be a promising movement to assess functional outcome after ACL reconstruction. Thus, we aimed to investigate the FL movement pattern before and after ACL reconstruction with a comparison to healthy controls to determine if differences were present. Twenty-eight ACL injured participants and 28 matched healthy controls were included. They performed FL movements while sagittal plane biomechanics of the knee and electromyography (EMG) of nine leg muscles was assessed. The ACL injured group was tested before and 10 months after surgery. The perceived knee function and activity level was assessed by questionnaires. The ACL injured group performed the FL significantly slower than the controls before surgery (mean difference: 0.41 s [95%CI: 0.04-0.79 s; p<0.05]) while they performed the FL as fast as the controls after surgery (~28% movement time reduction post-surgery). Perceived knee function and activity level improved significantly post-surgery. The knee joint flexion angle, extensor moment, power, angular velocity in the ACL injured group did not differ from pre to post-surgery. For the ACL injured group, the peak knee extensor moment observed both pre and post-surgery was significantly lower when compared to the controls. The EMG results showed minimal differences. In conclusion, at 10 months post-surgery, the FL was performed significantly faster and the movement time was comparable to that of the controls. While the perceived knee function and activity level improved post-surgery, the knee joint biomechanics were unchanged. This may reflect that knee joint function was not fully restored.

Association Between Isokinetic Knee Strength and Perceived Function and Patient Satisfaction With Sports and Recreational Ability After Matrix-Induced Autologous Chondrocyte Implantation

Background:

Returning to a sound level of activity after matrix-induced autologous chondrocyte implantation (MACI) is important to patients. Evaluating the patient’s level of satisfaction with his or her sports and recreational ability is critical.

Purpose:

To investigate (1) satisfaction with sports and recreational ability after MACI and (2) the role that knee strength plays in self-reported knee function and satisfaction.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

Isokinetic knee strength was assessed in 97 patients at 1, 2, and 5 years after MACI to calculate hamstrings-quadriceps ratios and peak knee extensor and flexor torque limb symmetry indices (LSIs). The Sports and Recreation subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS Sports/Rec) was completed. A satisfaction scale was used to evaluate how satisfied the patients were with their ability to return to recreational activities and their ability to participate in sport. Associations between knee strength LSI, KOOS Sports/Rec, and satisfaction with recreational and sporting activities were assessed through use of multivariable linear and logistic regression, with adjustment for confounders. Mediation analysis was conducted to assess the extent to which self-reported knee function mediated associations between strength LSI and satisfaction.

Results:

Satisfaction with the ability to return to recreational activities was achieved in 82.4%, 85.6%, and 85.9% of patients at 1, 2, and 5 years, respectively, and satisfaction with sports participation was achieved in 55.7%, 73.2%, and 68.5% of patients at 1, 2, and 5 years, respectively. Knee extension torque LSIs were associated with KOOS Sports/Rec after adjustment for confounders over 1, 2, and 5 years (5-year regression coefficient, 6.0 points; 95% CI, 1.4-10.7; P = .012). KOOS Sports/Rec was associated with the likelihood of being satisfied at all time points (recreation: 5-year adjusted odds ratio [OR], 2.26; 95% CI, 1.48-3.46; P < .001; and sports: 5-year adjusted OR, 1.98; 95% CI, 1.47-2.68; P < .001). In a multivariable mediation model, the knee extension torque LSI was associated with satisfaction directly (standardized coefficient, 0.16; 95% CI, 0.03-0.28; P = .017) and indirectly via KOOS Sports/Rec (standardized coefficient, 0.19; 95% CI, 0.01-0.38; P = .027), the latter representing 55% of the total association of knee extension torque LSI with satisfaction.

Conclusion:

Knee extensor symmetry was associated with satisfaction in recreational and sporting ability, both directly and indirectly, via self-reported sports and recreation–related knee function. Restoring strength deficits after MACI is important for achieving optimal outcomes.

Factors Associated With a Return to Preinjury Level of Sport Performance After Anterior Cruciate Ligament Reconstruction Surgery

BACKGROUND

Many studies have investigated factors that predict a return to sport participation after anterior cruciate ligament (ACL) reconstruction, but it is unclear whether the same factors are associated with a return to preinjury level of sport performance.

PURPOSE

To identify factors that contribute to an athlete's return to preinjury level of performance after ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A cohort of 222 patients (132 male, 90 female) who had ACL reconstruction surgery and completed a 12-month postoperative assessment were followed out to a mean 3 years (range, 2-4 years) to determine whether they had returned to their self-reported preinjury levels of sport performance. Rates of return to preinjury performance were calculated. Measures that had been recorded at the 12-month postoperative review-demographic (age, sex), sport activity level (Marx Activity Rating Scale, return to competition sport), knee laxity, limb symmetry (single and triple crossover hop), subjective function/symptoms (International Knee Documentation Committee subjective), and psychological readiness (Anterior Cruciate Ligament Return to Sport After Injury scale)-were compared between patients who returned to their preinjury levels of performance and those who did not. Univariate and multivariate logistic regression models were also used to prospectively determine the association between these measures and return to preinjury level of sport performance.

RESULTS

A total of 135 (61%) patients reported that they had returned to their preinjury levels of performance, with return rates similar between males (59%) and females (63%) and between those who had returned to competition at 12 months (62%) and those who had not (60%). There was no significant age difference between patients who returned to their preinjury levels of sport performance and those who did not; however, higher psychological readiness (P < .0001), greater limb symmetry (P < .05), higher subjective knee scores (P = .01), and a higher activity level (P < .04) were all associated with a return to performance. In the multivariate model, psychological readiness was the only variable that remained a significant predictor (odds ratio = 1.03; 95% CI, 1.01-1.04; P < .0001).

CONCLUSION

A majority of athletes who returned to sport after ACL reconstruction reported that their performance was comparable with preinjury. Having a greater psychological readiness to return during rehabilitation was the most significant predictor of a subsequent return to comparable performance.

Psychosocial Barriers After Anterior Cruciate Ligament Reconstruction: A Clinical Review of Factors Influencing Postoperative Success

CONTEXT

Psychosocial factors arising after anterior cruciate ligament (ACL) injury may have a direct influence on an individual's decision to return to sport after ACL reconstruction (ACLR). While there is ample evidence to suggest that deficits in quadriceps strength, neuromuscular control, and clinical functional tasks exist after ACLR, the root and contribution of psychological dysfunction to an individual's success or return to sport after ACLR is still largely uncertain and unexplored. Given the discrepancy between successful functional outcomes and the percentage of athletes who return to sport, it is important to thoroughly address underlying factors, aside from physical function, that may be contributing to these lower return rates.

EVIDENCE ACQUISITION

Articles that reported on return to sport, psychological factors, and psychosocial factors after ACLR were collected from peer-reviewed sources available on Medline (1998 through August 2018). Search terms included the following: anterior cruciate ligament OR ACL AND return-to-sport OR return-to-activity, anterior cruciate ligament OR ACL AND psychological OR psychosocial OR biopsychosocial OR fear OR kinesiophobia OR self-efficacy, return-to-activity AND psychological OR psychosocial.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

Psychosocial factors relative to injury are important components of the rehabilitation process. To fully understand how psychosocial factors potentially influence return to sport, an athlete's emotions, experiences, and perceptions during the rehabilitation process must be acknowledged and taken into consideration.

CONCLUSION

Acknowledgment of these psychosocial factors allows clinicians to have a better understanding of readiness to return to sport from a psychological perspective. Merging of the current ACLR rehabilitation protocols with knowledge related to psychosocial factors creates a more dynamic, comprehensive approach in creating a positive and successful rehabilitation environment, which may help improve return-to-sport rates in individuals after ACLR.

Return to sports and re-rupture rate following anterior cruciate ligament reconstruction in amateur sportsman: long-term outcomes

BACKGROUND

The aim of this study was to retrospectively evaluate patient satisfaction, the return-to-sport rate and activity level at a long-term follow-up in a large cohort of amateur sportsmen who underwent primary anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 218 patients who underwent primary ACL reconstruction between 2004 and 2011, were successfully recontacted and retrospectively reviewed at an average follow-up of 10.5 years (range, 7 to 14 years). All surgeries were performed by one single surgeon. All of them underwent primary ACL reconstruction with autogenous hamstring tendon grafts. Assessment included Knee Osteoarthritis Outcome Score (KOOS) score, International Knee Documentation Committee (IKDC) Subjective Knee Form, Tegner activity level. Patients were also asked what kind of injury they sustained (either direct or indirect trauma), what kind of sport they were performing when they got injured, at what time they did return to sports and which sport they practised before and after surgery.

RESULTS

Fourteen patients underwent re-rupture. In 11 cases, this was due to a new trauma occurring at an average time of 22.9 (SD 23.8) months following primary surgery. In 3 cases rupture occurred during rehabilitation period. Mean postoperative KOOS score was 88.5 (SD 8.5), while mean IKDC subjective score was 87.5 (SD 10.9). At the time of follow-up, most patients (214 subjects, 98%) were participating in sport. 156 subjects returned to pre-injury level (71.6%).

CONCLUSIONS

The study reported long-term favourable subjective outcomes in amateur sportsman following ACL reconstruction, with a low re-rupture rate and a high percentage of subjects (93.6%) returning to sports participation 12 months after surgery. Most patients (71.6%) were able to return to their preprimary level of activity and sport. Younger age at the time of ACL reconstruction positively affected return to sports; however, younger patients were significantly more likely than older patients to undergo re-rupture.

The use of allograft tendons in primary ACL reconstruction

PURPOSE

Graft choice in primary anterior cruciate ligament (ACL) reconstruction remains controversial. The use of allograft has risen exponentially in recent years with the attraction of absent donor site morbidity, reduced surgical time and reliable graft size. However, the published evidence examining their clinical effectiveness over autograft tendons has been unclear. The aim of this paper is to provide a current review of the clinical evidence available to help guide surgeons through the decision-making process for the use of allografts in primary ACL reconstruction.

METHODS

The literature in relation to allograft healing, storage, sterilisation, differences in surgical technique and rehabilitation have been reviewed in addition to recent comparative studies and all clinical systematic reviews and meta-analyses.

RESULTS

Early reviews have indicated a higher risk of failure with allografts due to association with irradiation for sterilisation and where rehabilitation programs and post-operative loading may ignore the slower incorporation of allografts. More recent analysis indicates a similar low failure rate for allograft and autograft methods of reconstruction when using non-irradiated allografts that have not undergone chemically processing and where rehabilitation has been slower. However, inferior outcomes with allografts have been reported in young (< 25 years) highly active patients, and also when irradiated or chemically processed grafts are used.

CONCLUSION

When considering use of allografts in primary ACL reconstruction, use of irradiation, chemical processing and rehabilitation programs suited to autograft are important negative factors. Allografts, when used for primary ACL reconstruction, should be fresh frozen and non-irradiated. Quantification of the risk of use of allograft in the young requires further evaluation.

LEVELS OF EVIDENCE

III.

A research update on the state of play for return to sport after anterior cruciate ligament reconstruction

Most athletes who undergo anterior cruciate ligament (ACL) reconstruction surgery plan to return to some level of sporting activity. However, rates of return to pre-injury sport are often less than might be expected and many factors influence whether individuals return to sport after this surgery. They include surgical and rehabilitation factors as well as social, psychological and demographic characteristics. The fate of the younger athlete who sustains an ACL injury is a topic that has received recent attention due to accumulating evidence that younger athletes are at considerable risk for not only one, but multiple ACL injuries. Little is known about how to determine when it is safe to return to sport following ACL reconstruction or how to predict whether an athlete will be able to successfully return. The notion that a set of return to sport criteria can be applied to reduce the risk of further injury has become popular with many different criteria proposed. Another risk of returning to sport following ACL reconstruction is that of sustaining injury to the menisci or articular surfaces, which may in turn increase the risk of developing osteoarthritis. Although there is some evidence that ACL reconstruction reduces the risk of osteoarthritis there is stronger evidence that it does little to protect the knee from long term degeneration. Therefore, it should be recognized that return to sport following ACL reconstruction is associated with a risk of further injury and potential development of osteoarthritis.Level of evidence: V.

Long-term Comparison of Semitendinosus and Gracilis Tendon Versus Patellar Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A 17-Year Follow-up of a Randomized Controlled Trial

BACKGROUND

Short-term and mid-term differences between hamstring and patellar tendon autografts for anterior cruciate ligament (ACL) reconstruction are well documented. Systematic reviews highlight the lack of long-term results between the two grafts.

HYPOTHESIS

Seventeen years after ACL reconstruction, no difference will be found in functional outcome, quality of life, and graft failure between patients with patellar tendon (PT) or semitendinosus and gracilis tendon (STG) autografts; however, a significant difference will be seen in the prevalence of osteoarthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Sixty-four patients were included in this prospective study (32 in each group). A single surgeon performed primary ACL reconstruction in alternating sequence. Forty-eight patients (24 in each group) were evaluated 17 years after ACL reconstruction: A clinical assessment was made based on the International Knee Documentation Committee (IKDC) form, instrumented laxity was measured with KT-1000 arthrometer, and radiography of the operated knee was conducted and assessed for degenerative disease. The Lysholm questionnaire and the Short Form-36 version 2 questionnaire were filled out by the patients.

RESULTS

At the 17-year follow-up, no statistically significant differences were seen with respect to graft failure (2 reruptures in the semitendinosus and gracilis tendon [STG] group [6.3%] and 3 reruptures in the PT group [9.4%]) and functional outcome. Increased instrumented laxity (>3 mm) measured with KT-1000 arthrometer was seen in significantly more patients in the STG group (8 in the STG group compared with 2 in the PT group; P = .03) with a mean side-to-side difference of 2.17 ± 1.86 mm in the STG group compared with 1.33 ± 1.93 mm in the PT group. A significant difference was found in frequency of knee osteoarthritis (OA)-100% in the PT group compared with 71% in the STG group ( P = .004). Patients in the PT group tended to have higher grade OA according to the IKDC grading system, with an average grade of 1.46 in the PT group compared with 1 in the STG group ( P = .055). The degenerative changes in the PT group were more common in the medial and patellofemoral compartments ( P = .003 and P = .04, respectively).

CONCLUSION

Both autografts provided good to excellent subjective outcomes. No significant differences were noted in graft failure and clinical instability. However, significantly more patients in the STG group had increased instrumented anteroposterior translation measured with KT-1000 arthrometer, and there was a greater prevalence of knee OA at 17 years after surgery in the PT group.

Factors Associated With Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction Surgery

BACKGROUND

Anterior cruciate ligament (ACL) injury has a significant psychological effect, and a negative psychological state is a commonly cited reason for a reduction or cessation of sports participation after ACL reconstruction (ACLR) surgery.

PURPOSE

To identify factors that contribute to an athlete's psychological readiness to return to sport (RTS) after ACLR.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A cohort of 635 athletes (389 male, 246 female) who underwent ACLR and had been cleared to RTS completed the Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale at an average 12 months (range, 11-24 months) after surgery. Demographics (age, sex), sporting outcomes (preinjury frequency), surgical timing (injury to surgery interval), clinical factors (laxity), functional measures (single-limb hop symmetry), and symptoms of pain and function (International Knee Documentation Committee subjective) were also taken, and univariate and multiple regression models were used to determine the association between these and the psychological readiness of the athlete to RTS (ACL-RSI scores). Data for the entire cohort were initially analyzed; then, patients were grouped according to whether they had returned to competitive sport, and the analysis repeated for each group (return/nonreturn).

RESULTS

Univariate analysis for the entire group showed that all of the following had a positive effect on psychological readiness: male sex (β = 5.8; 95% CI, 2-10), younger age (β = -0.2; 95% CI, -0.4 to 0.01), a shorter interval between injury and surgery (β = -0.1; 95% CI, -0.1 to -0.02), a higher frequency of preinjury sport participation (β = 5.4; 95% CI, 2-9), greater limb symmetry (β = 0.5; 95% CI, 0.3-0.6), and higher subjective knee scores (β = 1.3; 95% CI, 1.1-1.4). In the multivariate model, subjective knee scores and age significantly accounted for 37% of the variance in psychological readiness ( r² = 0.37, P < .0001). The only difference between the groups who had and had not returned to sport was that female sex was a significant contributor for the nonreturn group.

CONCLUSION

Self-reported symptoms and function were most associated with psychological readiness to RTS after ACLR surgery. Male patients who participated frequently in sport before ACL injury had higher psychological readiness. Conversely, female patients had a more negative outlook and may therefore benefit more from interventions designed to facilitate a smooth transition back to sport.

Decision to Return to Sport Participation After Anterior Cruciate Ligament Reconstruction, Part II: Self-Reported and Functional Performance Outcomes

CONTEXT

  Anterior cruciate ligament (ACL) reconstruction (ACLR) is the most commonly used method for helping athletes regain function and return to preinjury activity levels after ACL injury. Outcomes after ACLR have suggested that athletes return to a level of function that would support a return to sport participation; however, in a recent meta-analysis, pooled return rates were only 55%. It is unclear whether this discrepancy is a result of functional impairments.

OBJECTIVE

  To compare patient-reported outcomes (PROs), dynamic balance, dynamic functional performance, strength, and muscular endurance in athletes who returned to sport (RTS) and athletes who did not return to sport (NRTS) after ACLR.

DESIGN

  Case-control study.

SETTING

  University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Two groups of participants with primary unilateral ACLR: 18 RTS individuals (7 males, 11 females; age = 23 ± 11 years, height = 163.58 ± 40.41 cm, mass = 70.00 ± 21.75 kg, time since surgery = 4.02 ± 3.20 years) and 12 NRTS individuals (5 males, 7 females; age = 26 ± 13 years, height = 171.33 ± 48.24 cm, mass = 72.00 ± 21.81 kg, time since surgery = 3.68 ± 2.71 years).

INTERVENTION(S)

  The PROs consisted of the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score, Tegner Activity Scale, and Marx Activity Scale. Functional performance outcome measures were the anterior and posteromedial reach on the Star Excursion Balance Test, a battery of single-legged-hop tests, isokinetic quadriceps and hamstrings strength at 60°/s and 180°/s, and a novel step-down-to-fatigue test. All measures were taken during a single laboratory session.

MAIN OUTCOME MEASURE(S)

  The Limb Symmetry Index was calculated for all functional performance measures. Mann-Whitney U tests were used to compare measures between groups ( P < .10).

RESULTS

  Compared with the RTS group, the NRTS group had lower scores on the International Knee Documentation Committee Subjective Knee Evaluation Form (RTS median = 92.52, range = 66.67-97.70; NRTS median = 82.76, range = 63.22-96.55; P = .03) and Knee Injury and Osteoarthritis Outcome Score Symptoms subscale (RTS median = 88, range = 54-100; NRTS median = 71, range = 54-100; P = .08). No differences were observed for any functional performance measures.

CONCLUSIONS

  The NRTS athletes displayed lower PROs despite demonstrating similar function on a variety of physical performance measures. These results further support existing evidence that physical performance alone may not be the ideal postoperative outcome measure. Measures of patients' symptoms and self-perceived physical function may also greatly influence postoperative activity choices.

Decision to Return to Sport After Anterior Cruciate Ligament Reconstruction, Part I: A Qualitative Investigation of Psychosocial Factors

CONTEXT

  Return-to-sport criteria after anterior cruciate ligament (ACL) injury are often based on "satisfactory" functional and patient-reported outcomes. However, an individual's decision to return to sport is likely multifactorial; psychological and physical readiness to return may not be synonymous.

OBJECTIVE

  To determine the psychosocial factors that influence the decision to return to sport in athletes 1 year post-ACL reconstruction (ACLR).

DESIGN

  Qualitative study.

SETTING

  Academic medical center.

PATIENTS OR OTHER PARTICIPANTS

  Twelve participants (6 males, 6 females) were purposefully chosen from a large cohort. Participants were a minimum of 1-year postsurgery and had been active in competitive athletics preinjury.

DATA COLLECTION AND ANALYSIS

  Data were collected via semistructured interviews. Qualitative analysis using a descriptive phenomenologic process, horizontalization, was used to derive categories and themes that represented the data. The dynamic-biopsychosocial model was used as a theoretical framework to guide this study.

RESULTS

  Six predominant themes emerged that described the participants' experiences after ACLR: (1) hesitation and lack of confidence led to self-limiting tendencies, (2) awareness was heightened after ACLR, (3) expectations and assumptions about the recovery process influenced the decision to return to sport after ACLR, (4) coming to terms with ACL injury led to a reprioritization, (5) athletic participation helped reinforce intrinsic personal characteristics, and (6) having a strong support system both in and out of rehabilitation was a key factor in building a patient's confidence. We placed themes into components of the dynamic-biopsychosocial model to better understand how they influenced the return to sport.

CONCLUSIONS

  After ACLR, the decision to return to sport was largely influenced by psychosocial factors. Factors including hesitancy, lack of confidence, and fear of reinjury are directly related to knee function and have the potential to be addressed in the rehabilitation setting. Other factors, such as changes in priorities or expectations, may be independent of physical function but remain relevant to the patient-clinician relationship and should be considered during postoperative rehabilitation.

Altered movement during single leg hop test after ACL reconstruction: implications to incorporate 2-D video movement analysis for hop tests

PURPOSE

There is a lack of objective factors which can be used in guiding the return to sport (RTS) decision after an anterior cruciate ligament reconstruction (ACLR). The purpose of the current study was to conduct qualitative analysis of the single leg hop (SLH) in patients after ACLR with a simple and clinical friendly method and to compare the possible difference in movement pattern between male and female patients.

METHODS

Sixty-five patients performed the single leg hop (SLH) test at 6.8 ± 1.0 months following isolated ACLR. Digital video camcorders recorded frontal and sagittal plane views of the patient performing the SLH. Knee flexion at initial contact (IC), peak knee flexion, knee flexion range of motion (RoM), and knee valgus RoM were calculated. In addition, limb symmetry index (LSI) scores were calculated.

RESULTS

No differences were found in movement pattern between males and females. Movement analysis revealed that males had a decrease in knee flexion at IC (p = 0.018), peak knee flexion (p = 0.002), and knee flexion RoM (p = 0.017) in the injured leg compared to the non-injured leg. Females demonstrated a decrease in peak knee flexion (p = 0.011) and knee flexion RoM (p = 0.023) in the injured leg compared to the non-injured leg. Average LSI scores were 92.4% for males and 94.5% for females.

CONCLUSIONS

Although LSI scores were > 90%, clinical relevant altered movement patterns were detected in the injured leg compared to the non-injured leg. Caution is warranted to solely rely on LSI scores to determine RTS readiness.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION

The University of Groningen, ID 2012.362.

LEVEL OF EVIDENCE

III.

Functional performance 2-9 years after ACL reconstruction: cross-sectional comparison between athletes with bone-patellar tendon-bone, semitendinosus/gracilis and healthy controls

PURPOSE

The purpose of this cross-sectional study was to provide descriptive data on functional performance in men and women with ACLR, to compare bone-patellar tendon-bone (BPTB) with semitendinosus/gracilis (STG) within the same sex and to compare the ACLR subjects with healthy controls.

METHODS

Eligible participants comprised 100 men (43 % BPTB) and 84 women (41 % BPTB) after ACLR, of whom 30 men (STG n = 19; BPTB n = 11) and 18 women (STG n = 12; BPTB n = 6) were untraceable/not willing and 15 men (STG n = 9; BPTB n = 6) and 18 women (STG n = 12; BPTB n = 3) were not able to take part in the measurements because of injury. Besides men BPTB (n = 24), men STG (n = 27), women BPTB (n = 23) and women STG (n = 23), healthy men (n = 22) and women (n = 22) participated. Measurements consisted of questionnaires, isokinetic peak torque and endurance tests, a hop test battery and drop jump including video analysis.

RESULTS

Only the occurrence of dynamic knee valgus differed between ACLR and healthy subjects.

CONCLUSION

Two to nine years after ACLR, 16 % of athletes could not participate because of a lower extremity injury. In the remaining group, this study showed similar results for males and females with BPTB compared with STG. Also, similar results are found for quantity of movement comparing operated and healthy subjects. For quality of movement, only the occurrence of dynamic knee valgus in landing from a jump is higher in operated subjects compared with healthy controls. This supports the relevance of a focus on quality of movement as part of ACLR rehabilitation programmes and return to sports criteria.

LEVEL OF EVIDENCE

III.

Anterior cruciate ligament reconstruction: principles of treatment

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in sports medicine. Several areas of controversy exist in ACL tear management which have engaged surgeons and researchers in debates towards identifying an ideal approach for these patients.

This instructional review discusses the principles of ACL reconstruction in an attempt to provide guidelines and initiate a critical thinking approach on the most common areas of controversy regarding ACL reconstruction.

Using high-level evidence from the literature, as presented in randomised controlled trials, systematic reviews, and meta-analyses, operative versus conservative treatment, timing of surgery, and rehabilitation are discussed. Also, the advantages and disadvantages of the most common types of autografts, such as patellar tendon and hamstrings as well as allografts are presented.

Key considerations for the anatomical, histological, biomechanical and clinical data (‘IDEAL’) graft positioning are reviewed.

Cite this article: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 2016;398-408. DOI: 10.1302/2058-5241.1.160032.

Psychological factors are important to return to pre-injury sport activity after anterior cruciate ligament reconstruction: expect and motivate to satisfy

PURPOSE

To describe individuals' expectations, motivation, and satisfaction before, during, and after rehabilitation for ACL reconstruction and to explore how these factors were associated with return to pre-injury sport activity at 1-year follow-up.

METHODS

Sixty-five individuals (34 males), median age 22 (15-45) years, scheduled for ACL reconstruction participated. Participants completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and questions about expectations, satisfaction, and motivation pre-operatively and at 16 and 52 weeks after surgery.

RESULTS

Prior to surgery, 86 % of participants stated that their goal was to return to their pre-injury sport activity. Those who had returned to their pre-injury sport activity at 52 weeks were more motivated during rehabilitation to return to their pre-injury activity level, more satisfied with their activity level and knee function at 52 weeks, and scored significantly higher on the IKDC-SKF [median 92.0 (range 66.7-100.0)] at 52 weeks, compared to those who had not returned [median 77.6 (range 50.6-97.7)].

CONCLUSION

Prior to ACL reconstruction, most participants expected to return to their pre-injury activity level. Higher motivation during rehabilitation was associated with returning to the pre-injury sport activity. The participants who had returned to their pre-injury sport activity were more satisfied with their activity level and knee function 1 year after the ACL reconstruction. Facilitating motivation might be important to support individuals in achieving their participation goals after ACL reconstruction.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Return to knee-strenuous sport after anterior cruciate ligament reconstruction: a report from a rehabilitation outcome registry of patient characteristics

PURPOSE

To characterise patients who returned to knee-strenuous sports after an anterior cruciate ligament (ACL) reconstruction.

METHODS

Data from isotonic tests of muscle function and patient-reported outcome measures, Tegner activity scale (Tegner and Lysholm in Clin Orthop Relat Res 198:43-49, 1985), physical activity scale, knee injury and osteoarthritis scale and knee self-efficacy scale were extracted from a registry. The 157 included patients, 15-30 years of age, had undergone primary ACL reconstruction and were all involved in knee-strenuous sports, i.e. pre-injury Tegner of 6 or higher. Return to sport was studied in two different ways: return to pre-injury Tegner and return to knee-strenuous sport (Tegner 6).

RESULTS

Fifty-two patients (33 %), who returned to pre-injury Tegner, 10 months after surgery, were characterised by better subjective knee function measured with the knee injury and osteoarthritis outcome score (p < 0.05), compared with patients who did not. These patients also had higher perceived self-efficacy of knee function (p < 0.01), measured with knee self-efficacy scale. Eighty-four patients (54 %) who returned to knee-strenuous sports, i.e. Tegner 6 or higher, were characterised by higher goals for physical activity (p < 0.01) and higher self-efficacy of future knee function (p < 0.05). Strength measurements showed that women who returned to sports were stronger in leg extension than women who did not. No differences were found in Limb Symmetry Index for knee strength or jumping ability.

CONCLUSION

Patients who returned to sports after ACL reconstruction had better subjective knee function and higher self-efficacy of knee function. Results highlight that further emphasis should be placed at psychological factors during rehabilitation of patients after ACLR.

LEVEL OF EVIDENCE

II.

Anterior Cruciate Ligament Injury, Reconstruction, and the Optimization of Outcome

Anterior cruciate ligament reconstruction (ACLR) provides an established surgical intervention to control pathological tibiofemoral translational and rotational movement. ACLR is a safe and reproducible intervention, but there remains an underlying rate of failure to return to preinjury sporting activity levels. Postoperative pathological laxity and graft reinjury remain concerns. Previously, unrecognized meniscal lesions, disruption of the lateral capsule, and extracapsular structures offer potential avenues to treat and to therefore improve kinematic outcome and functional results, following reconstruction. Addressing laterally based injuries may also improve the durability of intraarticular ACLR. Improving the anterior cruciate ligament (ACL) graft replication of the normal ACL attachment points on the femur and the tibia, using either double bundle or anatomical single bundle techniques, improves kinematics, which may benefit outcome and functionality, following reconstruction.

Functional outcome after transphyseal anterior cruciate ligament reconstruction in young patients with open growth plates

BACKGROUND

This study evaluates sports ability, rotational laxity and potential growth changes in children after transphyseal ACL reconstruction with metaphyseal fixation technique, considering physis biology by placing drill holes vertically in the femoral anatomic origin in order to reduce volumetric injury to the physis.

METHODS

In this retrospective trial of 42 patients data were collected. Thirty-seven were reviewed measuring rotational laxity and anteroposterior tibial translation using the Laxitester (ORTEMA Sport Protection, Markgroeningen, Germany) and the KT1000. Clinical examination was evaluated with the IKDC 2000 knee examination form. Leg axis was determined with digital photography and leg length was assessed clinically. Sports ability was assessed with questionnaires including subjective IKDC, Tegner Activity Scale, Activity Rating Scale and a questionnaire on sports and level of sports.

RESULTS

Mean follow-up was 24.9months. Mean age at surgery was 13.2years in boys and 13.1years in girls. IKDC 2000 grading was A or B in 28 patients and C in nine patients. Significant increased anterior tibial translation was observed in neutral position and in external tibia rotation. No growth abnormalities were seen. Fifty-seven percent of the patients were able to participate in competitive sports at follow-up.

CONCLUSION

Transphyseal ACL reconstruction with metaphyseal fixation in children with open growth plates can be done with low risk of growth changes. Return to competitive sports is possible although low rotational laxity still exists.

LEVEL OF EVIDENCE

IV.

Inflammatory cytokine levels in synovial fluid 3, 4 days postoperatively and its correlation with early-phase functional recovery after anterior cruciate ligament reconstruction: a cohort study

Background

Synovial fluid was collected prior to and at 3 to 4 days after ACL reconstruction to investigate the correlation between inflammatory cytokine levels in the acute phase after surgery and physical functional recovery at 3 months postoperatively.

Methods

 For this purpose, 79 patients with ACL reconstruction using semitendinosus tendons were included in the study. Median days from injury to surgery were 80 days (13–291 days). Synovial fluid was obtained just before surgery and at 3 to 4 days after surgery. Physical activity of each patient was evaluated at 3 months postoperatively, and scored from 0 (hard to walk) to 5 (run). Patients able to jog (score 4) or run (score 5) were considered as the “quick recovery” group and others (scores 1–3) as the “delayed recovery” group.

Results

Physical activity recovery scores in the early surgery group (preoperative period less than 60 days; Group I) were significantly better than those in the delayed surgery group (Group II). Among the cytokines tested, TNF-alpha and IL10 levels in synovial fluid were significantly higher in Group II at 3 to 4 days postoperatively, while levels of these cytokines were quite comparable preoperatively between the groups. Increased IL1-beta expression was noted in the delayed recovery group at 3 to 4 days postoperatively. In addition, levels of IL6, IL10 and IFN-gamma also tended to increase in patients with delayed recovery.

Conclusion

Delayed ACL reconstruction increases levels of inflammatory cytokines in synovial fluid after surgery and correlates with a prolonged recovery of short-period physical activity of the patients.

Combined Intra-articular and Extra-articular Reconstruction in Anterior Cruciate Ligament-Deficient Knee: 25 Years Later

PURPOSE

To determine whether an anterior cruciate ligament (ACL)-reconstructed knee with hamstring autograft has a greater incidence of degenerative changes when an extra-articular reconstruction is added and to determine the effect of the combined reconstruction on knee stability and function at long-term follow-up.

METHODS

For this retrospective study, patients who underwent ACL reconstruction between January 2002 and December 2003 were selected and classified into 2 groups, I and II. Group I consisted of patients operated by a standard ACL reconstruction, and group II consisted of patients in whom, owing to the presence of risk factors (severe pivot shift graded +++ or high-risk sports), an extra-articular reconstruction performed with ileo-tibial tract according to McIntosh as modified by Cocker Arnold technique, was used in conjunction with intra-articular ACL reconstruction. At final follow-up, Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores were used. An arthrometric KT-1000 evaluation was done. Comparative weight-bearing radiographs were taken, including a skyline view for the patellofemoral joint and analyzed according to Fairbank, Kellgren, and IKDC classification.

RESULTS

Seventy-two of the 75 (96%) patients in group I and 68 of the 75 patients in group II were available at the final follow-up (minimum 10 years). Subjective scores improved significantly in both groups, with no significant difference. Objectively, the number of patients receiving C and D IKDC objective activity scores in group I (7/56; 12.5%) was significantly higher than in group II (0/60) (P = .01). Considering as a failure a side-to-side arthrometric difference more than 5 mm or a pivot shift test graded as ++ or +++, or any giving way episode occurring postoperatively, we found 8 cases in group I and no cases in group II (P = .01) despite the presence of risk factors that group I did not include. Radiologic evaluation showed less arthritic changes in group II in both tibiofemoral and patellofemoral joints.

CONCLUSIONS

On the basis of the results of this study, adding an extra-articular reconstruction to an anatomically placed intra-articular ACL reconstruction, followed by a modern rehabilitation protocol, does not increase the risk of osteoarthritis and may be able to reduce the rate of failure.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

PATIENT-SPECIFIC AND SURGERY-SPECIFIC FACTORS THAT AFFECT RETURN TO SPORT AFTER ACL RECONSTRUCTION

CONTEXT

Anterior cruciate ligament (ACL) reconstruction is frequently performed to allow individuals to return to their pre-injury levels of sports participation, however, return to pre-injury level of sport is poor and re-injury rates are unacceptably high. Re-injury is likely associated with the timeframe and guidelines for return to sport (RTS). It is imperative for clinicians to recognize risk factors for re-injury and to ensure that modifiable risk factors are addressed prior to RTS. The purpose of this commentary is to summarize the current literature on the outcomes following return to sport after ACL reconstruction and to outline the biologic and patient-specific factors that should be considered when counseling an athlete on their progression through rehabilitation.

EVIDENCE ACQUISITION

A comprehensive literature search was performed to identify RTS criteria and RTS rates after ACL reconstruction with consideration paid to graft healing, anatomic reconstruction, and risk factors for re-injury and revision. Results were screened for relevant original research articles and review articles, from which results were summarized.

STUDY DESIGN

Clinical Review of the Literature.

RESULTS

Variable RTS rates are presented in the literature due to variable definitions of RTS ranging from a high threshold (return to competition) to low threshold (physician clearance for return to play). Re-injury and contralateral injury rates are greater than the risk for primary ACL injury, which may be related to insufficient RTS guidelines based on time from surgery, which do not allow for proper healing or resolution of post-operative impairments and elimination of risk factors associated with both primary and secondary ACL injuries.

CONCLUSIONS

RTS rates to pre-injury level of activity after ACLR are poor and the risk for graft injury or contralateral injury requiring an additional surgery is substantial. Resolving impairments while eliminating movement patterns associated with injury and allowing sufficient time for graft healing likely gives the athlete the best chance to RTS without further injury. Additional research is needed to identify objective imaging and functional testing criteria to improve clinical decision making for RTS after ACLR.

LEVEL OF EVIDENCE

Level 5.

Patient reported outcomes for patients who returned to sport compared with those who did not after hip arthroscopy: minimum 2-year follow-up

Previous studies assessed elite athletes’ return to sport (RTS) after hip arthroscopy, but few investigated a cohort including athletes from all levels of sport. This study compared athletes who returned to sport to those who did not, based on four patient-reported outcome (PRO) scores, including the Hip Outcome Score—Sports Specific Subscale (HOS-SSS). Between September 2008 and April 2012, hip arthroscopies were performed on 157 patients (168 hips) who reported playing a sport preoperatively and indicated their level of sports activity post-operatively. Two-year follow-up was available for 148 (94%) amateur and professional athletes with a total of 158 hips. Of these 60 cases (65 hips) did not return to sports (NRTS) and were in the NRTS group. The remaining 88 cases (93 hips) constituted the RTS group. The modified Harris Hip Score, Non-Arthric Hip Score, Hip Outcome-Activities of Daily Living (HOS-ADL), and HOS-SSS were used to assess outcomes. The HOS-SSS was used to assess specific sport-related movement. Both groups demonstrated significant improvement at 2 years post-operatively in visual analog score and four PRO scores (P < 0.001). There was no significant preoperative differences in HOS-SSS scores between groups; however, the RTS group had significantly higher HOS-SSS scores at 1 and 2 years post-surgery. Post-operatively, the RTS group had significantly better ability to jump, land from a jump, stop quickly and perform cutting/lateral movements (P < 0.05). In summary, patients who indicated RTSs demonstrated significantly higher PRO scores and abilities to perform several sport-related movements, compared with patients who did not.

Rates and Determinants of Return to Play After Anterior Cruciate Ligament Reconstruction in National Collegiate Athletic Association Division I Soccer Athletes: A Study of the Southeastern Conference

BACKGROUND

Factors and details regarding return to play in elite, collegiate female soccer athletes after an anterior cruciate ligament (ACL) injury and reconstruction have not been well studied.

PURPOSE

To evaluate return to play among collegiate female soccer players, specifically examining the effect of surgical and individual athlete characteristics on the return-to-play rate.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Sports medicine and athletic training staff at institutions from the National Collegiate Athletic Association Southeastern Conference (SEC) were contacted to request participation in the study. All institutions were sent a standardized spreadsheet with response choices and instructions regarding athlete inclusion criteria. Athlete, injury, surgical technique, and return-to-play data were requested for ACL reconstructions performed on female soccer athletes at the participating institutions over the previous 8 years. χ(2) analyses were used to compare the return-to-play rate by year in school, scholarship status, position, depth chart status, procedure, graft type, graft fixation, concomitant procedures, and previous ACL injuries.

RESULTS

All 14 of the SEC institutions chose to participate and provided data. A total of 80 ACL injuries were reported, with 79 surgical reconstructions and return-to-play data for 78 collegiate soccer athletes. The overall return-to-play rate was 85%. There was a statistical significance in return-to-play rates favoring athletes in earlier years of eligibility versus later years (P < .001). Athletes in eligibility years 4 and 5 combined had a return-to-play rate of only 40%. Scholarship status likewise showed significance (P < .001), demonstrating a higher return-to-play rate for scholarship athletes (91%) versus nonscholarship athletes (46%). No significant differences in return-to-play rates were observed based on surgical factors, including concomitant knee procedures, graft type, and graft fixation method.

CONCLUSION

Collegiate female soccer athletes have a high initial return-to-play rate. Undergoing ACL reconstruction earlier in the college career as well as the presence of a scholarship had a positive effect on return to play. Surgical factors including graft type, fixation method, tunnel placement technique, concomitant knee surgeries, and revision status demonstrated no significant effect on the return-to-play rate.

Return to work in miners following anterior cruciate ligament reconstruction

INTRODUCTION

The aim of the study is retrospectively investigated durations for returning to work following anatomic ACL reconstruction by hamstring autograft in miners and the reasons in patients who were delayed to return to work.

METHODS

Miners with symptomatic anterior cruciate ligament rupture underwent arthroscopic reconstruction. Patients were evaluated in terms of range of motion (ROM) values; Lysholm, Cincinati and Tegner activity scales; laxity testing and complications. By modifying the method used by Fitzgerald et al. we decided for the criteria returning to work.

RESULTS

Thirty three patients were evaluated with mean followup of 22.7 ± 8.3 months (range 13-46 months). Mean age at the surgery was 27.8 (18-38) years. Lysholm, Cincinati and Tegner activity scales were signifi cantly higher from preoperative scores (Lysholm scores: preoperative: 60.7 ± 12.5, postoperative: 90.3 ± 4.8 (P < 0.001); Tegner activity scores: Preoperative 3.5 ± 1.4, postoperative: 6.2 ± 1.5 (P < 0.001); Cincinati scores: Preoperative: 14.8 ± 5.3, postoperative: 26.9 ± 1.6 (P < 0.001). The average time for returning to work was determined as 15,3 ± 4 weeks. There was no significant difference for knee scores and time for returning to work between patients with meniscal injuries and don't have meniscus lesions.

CONCLUSION

The reasons for delays in returning to work was work accident. Hematoma or effusion and pain inside the knee were the most significant reason which affected returning to work.

Return to recreational sports activity after anterior cruciate ligament reconstruction: a one- to six-year follow-up study

INTRODUCTION

The aim of this study was to evaluate mid-term return to recreational sport in general population and identify factors related with sports return.

METHODS

Retrospective evaluation of 99 recreational sports players (Tegner score of 6) with ACL arthroscopic reconstructions with hamstring autograft, between 2006-2011. 74 male and 25 female with middle age of 30 years (14-52). We made a questionnaire focused on sports level before injury and after surgery, and different scales: Lysholm, Tegner Activity Level, IKDC and a Likert scale for quantify their motivation for return to sports.

RESULTS

With a medium follow-up of 36 months, 90 patients (91.9 %) had returned to recreational sport. 51 (51.52 %) had returned to sports at the same level, and these are those with lower BMI (average 23), higher IKDC and Lysholm scores (p < 0.01) and also they believe that sport is an important activity. Only 9 % of patients left sports. They were principally male athletes (88 %), with higher medium age (32), lesser time between injury and surgery (22 months), higher BMI (26), in comparison with athletes that return to sports.

CONCLUSIONS

The results suggest good mid-term return to recreational sports in general population. The following factors had a statistically significant influence on the return to sports activity: type of sport, sex and functional state of the operated knee (IKDC-Lysholm). Psychological and social factors may have a fundamental influence on return to sports activity.

Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery

CONTEXT

A recently updated meta-analysis of return-to-sport rates after anterior cruciate ligament (ACL) reconstruction demonstrated that 65% of athletes returned to their preinjury level of sport after surgery. The aim of this clinical review was to explore contextual factors associated with returning or not returning to the preinjury level after ACL reconstruction.

EVIDENCE ACQUISITION

Data were obtained from peer-reviewed literature via a search of the electronic databases Medline, Embase, CINAHL, and SPORTDiscus from database inception to January 2015. The keywords anterior cruciate ligament and return to sport were used. Additional literature was identified via hand-searching of the reference lists of relevant articles and the ePublication lists of key scientific journals. Random effects meta-analyses were used to pool the results of modifiable contextual factors and to examine their association with returning or not returning to the preinjury level of sport after surgery.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 2.

RESULTS

Lower fear of reinjury (standardized mean difference, 0.7), greater psychological readiness to return to sport (standardized mean difference, 1.0), and a more positive subjective assessment of knee function (standardized mean difference, 0.9) favored return to the preinjury level after surgery.

CONCLUSION

Returning or not returning to the preinjury level after ACL reconstruction is complex and multifactorial. Screening for potentially modifiable contextual factors, particularly psychological factors, early after ACL injury may help clinicians identify athletes who could be at risk of not returning to the preinjury level of sport and institute interventions that could improve returning to sport.

Return to play following anterior cruciate ligament reconstruction

In athletes, significant advances in anterior cruciate ligament reconstruction techniques and rehabilitation have led to improved surgical outcomes and increased expectations for return to play. Although an expeditious return to sport has become an achievable and often realistic goal, the factors that most influence safe, timely, and successful return to play remain unknown. The literature offers mainly anecdotal evidence to guide the team physician in the decision-making process, with a paucity of criteria and consensus guidelines available to help determine return to sport. Attempts have been made to introduce criteria-based progression in the rehabilitation process, but validation of subjective and objective criteria has been difficult. Nevertheless, several pertinent factors in the preoperative, intraoperative, and postoperative periods may affect return to play following anterior cruciate ligament reconstruction. Further research is warranted to validate reliable, consensus guidelines with objective criteria to facilitate the return to play process.