Non-operative Care of the Patient with an ACL-Deficient Knee

Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

Rehabilitation after an anterior cruciate ligament (ACL) reconstruction requires patience, devotion, and discipline. Rehabilitation should be individualized to each patient's specific need and sport. Return to sport is a continuum throughout the rehabilitation, and patients should not return to performance before passing a battery of muscle function tests and patient-reported outcomes, as well as change of direction-specific tests. Return to full participation should be an agreement between the patient, physical therapist, surgeon, and coach. For minimal risk for second ACL injury, patients should continue with maintenance and prevention training even after returning to sport.

The Role of MRI Scan in Sports-Related Anterior Cruciate Ligament Injuries: A Case Report-Based Literature Review

Sports-related knee injuries are a common presentation in general practice in Australia among patients of the adolescent age group. A complete understanding of the anatomy, mechanism of injury, history, focused clinical examination of the knee joint, and proper investigations can help make a proper diagnosis. Injuries can be prejudicial to ligaments, tendons, muscles, and bones. Here, we present a case of rupture of the anterior cruciate ligament (ACL) following a fall while playing football. The patient visited the emergency department where an initial radiography was performed, which was unremarkable, and was consequently discharged from the emergency department on painkillers. Later, he presented with swelling and worsening pain in general practice, and magnetic resonance imaging (MRI) confirmed a diagnosis of ACL rupture. Therefore, he was referred to an orthopedic surgeon for further treatment and management. The patient was managed conservatively and underwent physiotherapy.

To achieve the unachievable-Patients' experiences of opting for delayed anterior cruciate ligament reconstruction after trying rehabilitation alone as primary treatment: A qualitative study

INTRODUCTION

About 50% of patients who sustain an anterior cruciate ligament (ACL) injury are treated without ACL reconstruction (ACL-R). A significant proportion of these patients opt for late ACL-R. Patients' experience of changing treatment has not yet been investigated and presented in the scientific literature.

AIM

To explore patients' experiences before and after changing treatment from ACL rehabilitation alone to ACL-R.

METHOD

Fifteen patients were interviewed in semi-structured interviews, which were recorded, transcribed, and analyzed with qualitative content analysis, based on the method described by Graneheim and Lundman. Patients were between 26 and 58 years old, and had tried rehabilitation for a minimum of 9 months prior to ACL-R.

RESULTS

Two themes, "Expecting what could not be achieved: the struggle to recover and not becoming stable", and "Internal completeness: expectations can be achieved", emerged from the analysis. Each theme was supported by three main categories and 5-6 subcategories. The first theme represents the journey before ACL-R, where patients experienced getting stronger, but perceived the knee as unstable. The second theme represents the journey after ACL-R, where patients expressed that they felt whole after their ACL-R, and where able to achieve their expections. Patients experienced a greater support from the healthcare system, and ultimately expressed a feeling of having achieved the unachievable after ACL-R.

SUMMARY

Patients who cross over from ACL rehabilitation to ACL-R experienced rehabilitation alone as insufficient to achieve the desired outcomes, which resulted in a need to opt for delayed ACL-R. Healthcare providers need to support patients, who primarily choose to undergo rehabilitation alone and later opt for ACL-R, throughout the whole rehabilitation process.

[Treatment of acute injury of the anterior cruciate ligament : Always only reconstruction?]

The aim of treatment of a ruptured anterior cruciate ligament (ACL) is the return of the patient to an acceptable level of activity without giving way phenomena as well as adequate treatment of prognostically relevant concomitant lesions. The treatment of acute ACL ruptures can be either early reconstruction or a primary physiotherapy with optional later reconstruction. Which path is taken depends on possible concomitant injuries that require early surgical intervention (e.g., repairable meniscal injury or distal rupture of the medial collateral ligament) and on patient-specific factors (age, level of activity). Isolated ruptures of the ACL can also be primarily treated without surgery. Then the injured knee joint should first be so far conditioned by rehabilitative measures that pain, swelling and posttraumatic restriction of movement are improved and neuromuscular training can be started. A screening test consisting of jumping tests, patient-reported outcome measures and the testing for giving way phenomena can be suitable to differentiate compensators (copers) from noncompensators (non-copers). Surgical reconstruction of the ACL should be recommended to non-compensators in the sense of participatory decision-making. Activity modification (adapter) can also be considered as a treatment strategy. If instability events (giving way) or secondary meniscal lesions occur during nonsurgical therapy, cruciate ligament reconstruction should be considered.

Accelerometer-assessed physical activity patterns during the first two years after a non-surgically treated ACL injury

OBJECTIVES

To describe physical activity patterns and analyze changes during the first two years after a non-surgically treated ACL injury, and to assess correlations between accelerometer-assessed physical activity and self-reported knee function and knee-related quality of life.

DESIGN

Prospective cohort study.

PARTICIPANTS

128 patients (61 females, 25.2 ± 7.1 years) with acute ACL injury.

MAIN OUTCOME MEASURES

Physical activity patterns were measured with accelerometry. Self-reported knee function was assessed using the International Knee Documentation Committee Subjective Knee Form, and knee-related quality of life was assessed using the Anterior Cruciate Ligament Quality of Life questionnaire.

RESULTS

Moderate to vigorous physical activity (MVPA) and steps per day increased from baseline to 3 months (p < .001), with no further increase from 3 to 24 months (p > .05). Time in MVPA did not correlate to patient-reported outcome measures at 3, 6, 12, or 24 months (p > .05).

CONCLUSIONS

Physical activity increased from acute phase to 3 months after non-surgically treated ACL injury, but almost one in four patients did not reach recommended levels of physical activity. Physical activity did not correlate with knee function or quality of life. Patients may need improved support to return to physical activity after ACL injury.

LEVEL OF EVIDENCE

Level II.

TRIAL REGISTRATION

NCT02931084.

Patients older than 55 years regain sporting and recreational activities after arthroscopic anterior cruciate ligament reconstruction

PURPOSE

(1) To compare sporting and recreational activity levels before and at a minimum 6 year follow-up, and (2) to assess the clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction in patients older than 55 years.

METHODS

A retrospective evaluation of prospectively collected data of 150 patients with a mean age of 64 ± 4.5 (57-74) years was evaluated 8.6 ± 1.4 (6-11) years after primary ACL reconstruction using hamstring autograft. All patients were assessed using the International Knee Documentation Committee scoring system (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity level, and visual analog scale (VAS) for pain. The level of recreational activities was assessed using a sport-specific questionnaire. All patients were categorized according to Isolated and Combined ACL injury groups.

RESULTS

The data of 125 patients were analyzed at the last follow-up. While 25 patients were lost to follow-up, 117 of 125 patients were active before their injury in at least one sports discipline compared to 121 of 125 patients after ACL reconstruction. One hundred and two (82%) patients had returned to their recreational activities at the final follow-up. The mean IKDC subjective score increased from 49.5 ± 23.2 (11.5-100) to 76.2 ± 14.8 (33.3-100) (p < 0.0001). The mean KOOS sport increased significantly from 36 ± 36.2 (0-100) to 74.1 ± 25.5 (0-100) (p < 0.0001). The mean VAS score improved from 6.0 ± 2.6 (0-10) to 1.0 ± 1.4 (0-6) (p < 0.0001). There was no significant difference in the median Tegner activity level (preoperative 5 (2-8) vs. follow-up 5 (2-8) (n.s). There was no significant difference in the number of sports disciplines and duration when comparing pre-injury and mid-term follow-up activity after ACL reconstruction. High-impact activities experienced a significant decline, while a significant increase in participation in low-impact activities was recorded.

CONCLUSION

The majority of patients with symptomatic instability regained their pre-injury recreational activity level with excellent clinical and functional outcomes after arthroscopic ACL reconstruction. Nevertheless, a change from high-to low-impact activities has been observed.

LEVEL OF EVIDENCE

Level IV.

Risk factors for secondary meniscus tears can be accurately predicted through machine learning, creating a resource for patient education and intervention

PURPOSE

This study sought to develop and internally validate a machine learning model to identify risk factors and quantify overall risk of secondary meniscus injury in a longitudinal cohort after primary ACL reconstruction (ACLR).

METHODS

Patients with new ACL injury between 1990 and 2016 with minimum 2-year follow-up were identified. Records were extensively reviewed to extract demographic, treatment, and diagnosis of new meniscus injury following ACLR. Four candidate machine learning algorithms were evaluated to predict secondary meniscus tears. Performance was assessed through discrimination using area under the receiver operating characteristics curve (AUROC), calibration, and decision curve analysis; interpretability was enhanced utilizing global variable importance plots and partial dependence curves.

RESULTS

A total of 1187 patients underwent ACLR; 139 (11.7%) experienced a secondary meniscus tear at a mean time of 65 months post-op. The best performing model for predicting secondary meniscus tear was the random forest (AUROC = 0.790, 95% CI: 0.785-0.795; calibration intercept = 0.006, 95% CI: 0.005-0.007, calibration slope = 0.961 95% CI: 0.956-0.965, Brier's score = 0.10 95% CI: 0.09-0.12), and all four machine learning algorithms outperformed traditional logistic regression. The following risk factors were identified: shorter time to return to sport (RTS), lower VAS at injury, increased time from injury to surgery, older age at injury, and proximal ACL tear.

CONCLUSION

Machine learning models outperformed traditional prediction models and identified multiple risk factors for secondary meniscus tears after ACLR. Following careful external validation, these models can be deployed to provide real-time quantifiable risk for counseling and timely intervention to help guide patient expectations and possibly improve clinical outcomes.

LEVEL OF EVIDENCE

III.

Anterior cruciate ligament reconstruction results in better patient reported outcomes but has no advantage for activities of daily living or the subsequent development of osteoarthritis. A systematic review and meta-analysis

BACKGROUND

Surgical reconstruction of ACL injuries is a common strategy but superiority over conservative treatment has not been established. The aim was to perform a systematic review and meta-analysis comparing outcomes between operative and non-operative treatment of ACL injuries.

METHODS

Systematic review of Medline, Embase, Scopus, and Google Scholar, including all level 1-3 studies from 2000 to 2021. Patient reported outcome scores and objective measures for knee stability were included. Risk of bias was assessed using the Cochrane Collaboration's tools. GRADE was used to assess the quality of the body of evidence. Heterogeneity was assessed using χ2 and I² statistics.

RESULTS

Twelve studies were included in the analysis. All studies had a high risk of bias and were of low quality. The pooled estimates for IKDC (p = 0.040) favored surgical treatment. There were significant differences for activities of daily living (p = 0.0001) in favor of conservative treatment. There were significant differences for knee stability (p = 0.016) in favor of surgical treatment. The risk of osteoarthritis was not significantly different between the two treatment modalities (p = 0.219). Patients undergoing surgery had a 57% higher risk of osteoarthritis.

CONCLUSION

ACL reconstruction results in a significantly more stable knee with superior clinical and functional outcomes. However, these advantages over conservative treatment were not observed for routine activities of daily living, and subjective patient perceived outcomes favor nonsurgical treatment. Surgical treatment did not reduce the risk of later developing osteoarthritis. Regardless, due to low study quality and high risk of bias, these findings must be interpreted with caution.

Translation, Validity, and Reliability of the Dutch Anterior Cruciate Ligament-Quality of Life Questionnaire

Background

The Anterior Cruciate Ligament-Quality of Life (ACL-QoL) questionnaire is a valid and reliable injury-specific instrument to assess the impact of an ACL rupture on the daily life of a patient.

Purpose

To translate the ACL-QoL into Dutch (ACL-QoL-NL) and to study its psychometric properties in patients with an ACL rupture.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

The original ACL-QoL questionnaire was translated from English to Dutch according to international guidelines. The study population consisted of 122 patients with a confirmed ACL rupture who completed the ACL-QoL-NL as well as 4 questionnaires: the International Knee Documentation Committee subjective score, Knee injury and Osteoarthritis Outcome Score, 36-item Short Form Health Survey, and Lysholm Knee Score. We determined the internal consistency, construct validity, and prevalence of floor and ceiling effects of the ACL-QoL-NL total score as well as its 5 subscales. To determine test-retest reliability, we analyzed the data of 68 patients who had a stable knee condition and who completed the ACL-QoL-NL a second time after a 2-week interval.

Results

The confirmatory factor analysis showed that the original structure of the ACL-QoL-NL was confirmed, except for 4 of 31 items. Internal consistency of the total scale and all 5 subscales was good. More than 75% of the predefined hypotheses on the correlations between the ACL-QoL-NL and the 4 questionnaires were met, indicating good construct validity. No significant floor or ceiling effects were observed. Test-retest reliability was good, and no systematic bias between test and retest was found. Standard error of measurement for the total score was 4.8 points out of 100, and the smallest detectable changes at the group and individual levels were 1.6 and 13.2 points, respectively.

Conclusion

The ACL-QoL-NL questionnaire was successfully translated from English to Dutch and demonstrated good internal consistency, validity, and reliability, with no presence of floor or ceiling effects.

Returning Athletes to Sports Following Anterior Cruciate Ligament Tears

PURPOSE OF REVIEW

The purpose of this review is to discuss treatment options, rehabilitation protocols, return-to-play criteria, and expected outcomes after non-operative and operative treatment of anterior cruciate ligament (ACL) tears among an athletic population.

RECENT FINDINGS

Non-operative treatment may be a viable option for some athletes with an ACL tears but can be difficult to predict "copers," and those that resume to sports return at lower performance level and/or less intense activities. Most studies assessing function after ACL reconstruction demonstrate favorable outcomes using patient-reported outcome studies. However, return-to-play and graft re-rupture rates vary substantially based on patient characteristics and level and type of athletic activity. Grafts used to reconstruct ACL produce similar objective outcomes and favorable patient-reported outcomes but have variable re-rupture rates depending on study and differ largely on morbidity associated with graft harvest. Various treatment methods including non-operative and operative techniques have been demonstrated to be efficacious in returning athletes to athletic activity depending on patient age and level of activity. Adherence to fundamental rehabilitation principles and accepted return-to-play guidelines can optimize outcomes and limit re-injury to the injured or contralateral limb.

Online information about the management of anterior cruciate ligament ruptures in Australia: A content analysis

BACKGROUND

Most people who suffer an anterior cruciate ligament (ACL) injury search for information online.

OBJECTIVES

Summarise the proportion of webpages on ACL rupture management that present evidence-based information.

DESIGN

Content analysis.

METHODS

We examined webpage information on ACL ruptures identified through (1) Google searches using terms synonymous with 'anterior cruciate ligament rupture' and searching 'knee surgeon' linked to each Australian capital city, and (2) websites of professional associations. The primary outcome was the proportion of webpages that suggest people can return to at least some form of sport with non-surgical management. Secondary outcomes included webpage information on return to sport with ACL reconstruction (ACLR) and non-surgical management, benefits, harms, and risk of osteoarthritis related to these options, and activity modification.

RESULTS

Out of 115 webpages analysed, 48% suggested people can return to at least some form of sport with non-surgical management. Almost half of webpages suggested most people will return to some form of sport following ACLR (41%) and mentioned benefits of ACLR (43%). Fewer webpages mentioned benefits of non-surgical management (14%), approximately two in three people return to pre-injury level of sport following ACLR (4%), risk of re-injury following ACLR (23%), most people return to sport within 9 months of ACLR (27%), activity modification as a management approach (20%), and ACLR will reduce the risk of osteoarthritis (23%).

CONCLUSION

Most online information on ACL rupture management isn't aligned with the best available evidence. Inaccurate information could mislead patients' treatment choices and create unrealistic expectations for return to sport.

Transtibial pull-out repair of lateral meniscus posterior root is beneficial for graft maturation after anterior cruciate ligament reconstruction: a retrospective study

PURPOSE

To determine the repair of LMPR lesions would improve the ACL graft maturation.

METHOD

A total of 49 patients underwent ACL reconstruction were included in this study. Patients were furtherly sub-grouped according to the status of LMPR: intact (17), repair (16) and resected (16). Assessments performed pre- and 2 years post-operatively included patients-reported scores and arthrometer side-to-side difference. Magnetic resonance imaging was used 2 years after the surgery to compare the lateral meniscal extrusion (LME), anterior tibial subluxation of the medial compartment (ATSMC), anterior tibial subluxation of the lateral compartment (ATSLC), the difference of ATSMC and ATSLC, and signal/noise quotient (SNQ) of ACL graft.

RESULTS

In LMPR resected group, it showed greater post-operative ATSMC-ATSLC difference when compared with pre-operatively (P = 0.006) and with the other 2 groups (intact: P = 0.031; repair: P = 0.048). SNQ of ACL graft was higher in LMPR resected group than those in LMPR intact (P = 0.004) and repair group (P = 0.002). The LMPR repair group showed significant reduction in LME post-operatively (P = 0.001). Post-operative measures on ATSLC-ATSMC difference (β = 0.304, P = 0.049) and LME (β = 0.492, P = 0.003) showed significant association with graft SNQ.

CONCLUSIONS

Transtibial repair of LMPR concomitant with ACL reconstruction restored translational stability, reduced meniscus extrusion, making it beneficial for ACL graft maturation.

Rehabilitation After Anterior Cruciate Ligament Injury: Review of Current Literature and Recommendations

PURPOSE OF REVIEW

Anterior cruciate ligament reconstruction (ACLR) is a common surgical procedure with an estimated 120,000 cases performed in the USA each year. Physical therapy plays a critical role in the successful recovery of both surgically and non-surgically managed patients. Interestingly, ACL rehabilitation protocols vary greatly with little consensus among practitioners. Nonetheless, there has been agreement over the last decade to shift from conservative, standardized length protocols to more accelerated, individualized protocols that vary in length and modalities based on patient-specific findings and preferences. This review summarizes the most recent trends, opinions, and modalities in ACL rehabilitation research, with a specific focus on novel methods to treat the specific psychosocial needs of ACL deficient patients.

RECENT FINDINGS

We found that new protocols emphasize early weight bearing, open kinetic chain (OKC) exercises, and other alternative modalities such as neuromuscular electrical stimulation and blood flow restriction. We also found a recent trend toward the use of clinical milestones to determine when a patient is ready for the next phase of a "step-up" rehabilitation program. One particularly nascent topic of research is the inclusion of methods to treat the psychosocial impacts of ACL injury, recovery, and the anxiety around return to sport. Rehabilitation strategy has become increasingly patient-dependent, and the new modalities being utilized are accelerating patient recovery. Return to sport is a particularly important factor for many ACLR patients, and recovery has an important psychological component that has only recently been addressed in the literature, with positive preliminary findings.

Long-term Return to Sports After Anterior Cruciate Ligament Injury: Reconstruction vs No Reconstruction-A Comparison of 2 Case Series

BACKGROUND

Reconstruction is considered to provide the best opportunity for return to sports (RTS) after anterior cruciate ligament (ACL) rupture. However, recent studies report that <50% of athletes return to preinjury sporting levels and that RTS rates at 1 year after injury are the same for athletes undergoing reconstruction and nonoperative management. Long-term studies are essential to confirm these findings and guide decisions regarding surgery.

PURPOSE

First, to compare long-term sports participation after ACL reconstruction and nonreconstruction and, second, to relate RTS level to strength and stability.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHOD

Patients with ACL deficiency (n = 101) who were referred for physical therapy at the time of diagnosis were followed long term: 56 were treated surgically 2.5 years (interquartile range [IQR], 1-4) after injury and 45 were treated nonoperatively. At long-term follow-up, the reconstructed group was at 9 years (IQR, 7-11) after injury and aged 33.3 ± 6.2 years (mean ± SD, 70% male; 61% meniscal injury), and the nonreconstructed group was at 11 years (IQR, 7-14) after injury and aged 38.7 ± 8.3 years (67% male; 58% meniscal injury). Measures of objective stability, subjective stability, and quadriceps/hamstring strength were compared between groups using independent-samples t tests. Current RTS level, scored on a 6-point scale, was compared between groups using chi-square tests. Spearman rho correlated RTS with outcome measures.

RESULTS

Of the total group of patients, 96% with reconstruction and 93% without continued to play sports. In the reconstructed and nonreconstructed groups, 4% and 7% did not RTS, and 8% and 17% returned to safe sports, respectively: 13% and 12% to running, 20% and 26% to sports involving limited twisting, 12% and 24% to recreational pivoting sports, and 43% and 14% to competitive pivoting sports. The only significant difference was in return to competitive pivoting sports (P = .003). Five patients with reconstruction ruptured the contralateral ACL, and 1 ruptured his graft. Most patients treated nonoperatively modified their sports participation. Their RTS levels correlated significantly with quadriceps strength (r = 0.65; P < .001), hamstring strength (r = 0.721; P < .001), and subjective stability (r = 0.405; P = .01).

CONCLUSION

Surgically treated patients returned to competitive pivoting sports at 3 times the rate of those managed nonoperatively, confirming that reconstruction provides the best opportunity for continued participation in competitive pivoting sports. Regardless of grouping, RTS correlated with modifiable factors, including strength and stability. Higher rates of subsequent injuries observed after reconstruction may result from increased participation in competitive pivoting sports.

Current trends in the anterior cruciate ligament part II: evaluation, surgical technique, prevention, and rehabilitation

Clinical evaluation and management of anterior cruciate ligament (ACL) injury is one of the most widely researched topics in orthopedic sports medicine, giving providers ample data on which to base their practices. The ACL is also the most commonly treated knee ligament. This study reports on current topics and research in clinical management of ACL injury, starting with evaluation, operative versus nonoperative management, and considerations in unique populations. Discussion of graft selection and associated procedures follows. Areas of uncertainty, rehabilitation, and prevention are the final topics before a reflection on the current state of ACL research and clinical management of ACL injury. Level of evidence V.

Physical prognostic factors predicting outcome following anterior cruciate ligament reconstruction: A systematic review and narrative synthesis

BACKGROUND

Anterior cruciate ligament (ACL) injuries are common. Many patients undergo ACL reconstruction (ACLR), with rehabilitation key to successful outcome. Understanding physical prognostic factors is integral to clinical decision-making, but factors predicting outcome are inadequately defined. The objective was to establish physical prognostic factors predicting outcome following ACLR.

METHODS

A systematic review following a published protocol (CRD42019127732) searched MEDLINE, CINAHL, EMBASE, key journals and grey literature to November 28, 2020. Prospective cohort studies, participants ≥16 years of age who had undergone ACLR were included, with multi-ligament and/or ACL repair surgery, and studies not published in English excluded. Two independent reviewers conducted searches, extracted data, assessed risk of bias (QUIPS) and overall quality of evidence (GRADE). Meta-analysis was not possible, therefore narrative synthesis was performed.

RESULTS

13 studies (16 articles) were included (1 low, 12 high risk of bias). Low-level evidence supports postoperative degenerative changes and poor lower-limb strength predicting poorer outcome long term (KOOS). Very low-level evidence supports greater postoperative quadriceps strength predicting improved functional performance medium term; with lower body mass index predicting improvement of multiple outcome measures.

CONCLUSION

Limited evidence of low or very low-level indicates multiple prognostic factors predicting outcome following ACLR. A high-quality prognostic study is required.

Current perspectives and clinical practice of physiotherapists on assessment, rehabilitation, and return to sport criteria after anterior cruciate ligament injury and reconstruction. An online survey of 538 physiotherapists

OBJECTIVES

To evaluate the perspectives and clinical practice of physiotherapists regarding rehabilitation after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Online survey.

SETTING

Survey platform.

PARTICIPANTS

Greek physiotherapists.

OUTCOME MEASURES

The survey consisted of 7 sections: participant demographics, importance of ACLR rehabilitation, clinical measurements, practice, criteria to progress rehabilitation, return to running and return to sport.

RESULTS

Significant variability in measures and criteria used for clinical decision-making were found including: limb symmetry in strength and function, knee range of motion and effusion, progression, and return to sport criteria. The majority of the practitioners (28.3%) extrapolate knee strength from hop capacity. Return to running ranged from 3 to 5 months post-operatively reflecting that this was tied to physical capacities, not time from surgery. 70.0% of the Greek physiotherapists would allow return to sport ≤9 months after ACLR. Agreement was found in using: physical measures, function, and dynamic stability in ACLR rehabilitation, but the mode and interpretation varied substantially. Less than 29.0% of the physiotherapists reported using patient-reported outcome measures in their decision-making.

CONCLUSION

Current ACLR rehabilitation practices in Greece are largely not aligned with the contemporary scientific evidence and guidelines.

Determination of the Strongest Factor and Component in a Relationship between Lower-Extremity Assessment Protocol and Patient-Oriented Outcomes in Individuals with Anterior Cruciate Ligament Reconstruction: A Pilot Study

Although the Lower-Extremity Assessment Protocol (LEAP) assesses multidimensional aspects of a patient with anterior cruciate ligament (ACL) injury, there is a need to reduce the dimensionality of LEAP items to effectively assess patients. Therefore, the present study aimed to establish the validity of LEAP and to determine associated factors and components in a relationship between LEAP and the International Knee Documentation Committee (IKDC) questionnaire. Fifteen patients who had ACL reconstruction more than 1 year and less than 5 years earlier were recruited. Patients performed LEAP, including muscular strength, fatigue index, static balance, drop landing, and functional hopping assessment. They also completed the IKDC questionnaire and the Tegner Activity Score. Factor analysis and stepwise regression analysis were performed. The 14 components of LEAP were categorized into four factors (functional task, muscle strength, neuromuscular control, and fatigue), which accounted for 83.8% of the cumulative variance by factor analysis. In the stepwise regression analysis, the functional task (R² = 0.43, p = 0.008) in factors and single-leg hop (R² = 0.49, p = 0.004) in components were associated with patient-oriented outcomes, respectively. In conclusion, the functional task and single-leg hop may be used for providing valuable information about knee joints to patients and clinicians.

Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence on operative versus non-operative treatment for ACL injury.The purpose of this study was to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative veresus non-operative treatment of ACL injury reached consensus during the symposium. Nine statements achieved unanimous support; two reached strong consensus; one did not achieve consensus; and one was removed due to redundancy in the information provided.In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical anterior cruciate ligament reconstruction (ACLR) is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability or when episodes of giving way occur, anatomical ACLR is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury.Level of evidence: V.

Sports medicine in COVID Era

With impact of COVID-19 gradually increasing in many countries of the world with each passing day, there is a need to relook into the conservative management for some common sports related injuries. Awareness of all kinds of sports injuries, their symptoms, and preventive measures including education on rehydration, nutrition, monitoring team members, behavioural skills and techniques will further help in preventing the potential sporting injuries. Further, telemedicine and online portals including eSanjeevani outpatient department services should be encouraged.

Treatment after ACL injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for ACL injuries continue to evolve. Evidence supporting best practice guidelines to manage ACL injury is largely based on studies with low-level evidence. An international consensus group of experts was convened determine consensus regarding best available evidence on operative versus non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative versus non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organising Committee and Session Chairs. Panel participants reviewed preliminary statements prior to the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty per cent agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus non-operative treatment of ACL injury reached consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting and pivoting sports, early anatomical ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomical ACL reconstruction is indicated. The consensus statements derived from international leaders in the field may assist clinicians in deciding between operative and non-operative treatment with patients after an ACL injury. Level of evidence: Level V

Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.

Physical prognostic factors predicting outcome following anterior cruciate ligament reconstruction: protocol for a systematic review

INTRODUCTION

Injuries of the anterior cruciate ligament (ACL) are a common musculoskeletal complication and can cause significant reduction in patient function and quality of life. Many undergo ACL reconstruction, with high-quality rehabilitation key to successful outcome. Knowledge of physical prognostic factors, such as quadriceps strength, is crucial to inform rehabilitation and has important implications for outcome following ACL reconstruction. However, these factors predicting outcome are poorly defined. Therefore, the aim of this systematic review is to establish physical prognostic factors predictive of outcome in adults following ACL reconstruction. Outcome will be subdivided into two groups of outcome measures, patient-reported and performance-based. Physical prognostic factors of interest will reflect a range of domains and may be modifiable/non-modifiable. Results will help decide most appropriate management and assist in planning and tailoring preoperative and postoperative rehabilitation.

METHODS AND ANALYSIS

This systematic review protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. MEDLINE, CINAHL and EMBASE databases, key journals and grey literature will be searched from inception to July 2019. Prospective cohort studies including participants aged ≥16 years who have undergone ACL reconstruction will be included, with articles focusing on multi-ligament reconstructions and ACL repair surgery, or not published in English excluded. Two independent reviewers will conduct searches, assess study eligibility, extract data, assess risk of bias (Quality in Prognostic Studies tool) and quantify overall quality of evidence (modified Grading of Recommendations, Assessment, Development and Evaluation guidelines). If possible, a meta-analysis will be conducted, otherwise a narrative synthesis will ensue focusing on prognostic factors, risk of bias of included studies and strength of association with outcomes.

ETHICS AND DISSEMINATION

Findings will be published in a peer-reviewed journal, presented at conferences and locally to physiotherapy departments. Ethical approval is not required for this systematic review.

PROSPERO REGISTRATION NUMBER

CRD42019127732.

A Technical Report on the Development of a Real-Time Visual Biofeedback System to Optimize Motor Learning and Movement Deficit Correction

This technical report describes the design and implementation of a novel biofeedback system to reduce biomechanical risk factors associated with anterior cruciate ligament (ACL) injuries. The system provided objective real-time biofeedback driven by biomechanical variables associated with increased ACL injury risk without the need of a present expert. Eleven adolescent female athletes (age = 16.7 ± 1.34 yrs; height = 1.70 ± 0.05 m; weight = 62.20 ± 5.63 kg) from the same varsity high school volleyball team were enrolled in the experiment. Participants first completed 10 bodyweight squats in the absence of the biofeedback (pretest), 40 bodyweight squats while interacting with the biofeedback, and a final 10 bodyweight squats in the absence of the biofeedback (posttest). Participants also completed three pretest drop vertical jumps and three posttest drop vertical jumps. Results revealed significant improvements in squat performance, as quantified by a novel heat map analysis, from the pretest to the posttest. Additionally, participants displayed improvements in landing mechanics during the drop vertical jump. This study demonstrates that participants were able to interact effectively with the real-time biofeedback and that biomechanical improvements observed during squatting translated to a separate task.

Real-time biofeedback integrated into neuromuscular training reduces high-risk knee biomechanics and increases functional brain connectivity: A preliminary longitudinal investigation

Prospective evidence indicates that functional biomechanics and brain connectivity may predispose an athlete to an anterior cruciate ligament injury, revealing novel neural linkages for targeted neuromuscular training interventions. The purpose of this study was to determine the efficacy of a real-time biofeedback system for altering knee biomechanics and brain functional connectivity. Seventeen healthy, young, physically active female athletes completed 6 weeks of augmented neuromuscular training (aNMT) utilizing real-time, interactive visual biofeedback and 13 served as untrained controls. A drop vertical jump and resting state functional magnetic resonance imaging were separately completed at pre- and posttest time points to assess sensorimotor adaptation. The aNMT group had a significant reduction in peak knee abduction moment (pKAM) compared to controls (p = .03, d = 0.71). The aNMT group also exhibited a significant increase in functional connectivity between the right supplementary motor area and the left thalamus (p = .0473 after false discovery rate correction). Greater percent change in pKAM was also related to increased connectivity between the right cerebellum and right thalamus for the aNMT group (p = .0292 after false discovery rate correction, r²  = .62). No significant changes were observed for the controls (ps > .05). Our data provide preliminary evidence of potential neural mechanisms for aNMT-induced motor adaptations that reduce injury risk. Future research is warranted to understand the role of neuromuscular training alone and how each component of aNMT influences biomechanics and functional connectivity.

Treatment after anterior cruciate ligament injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative vs. non-operative treatment for ACL injury. The purpose of this study is to report the consensus statements on operative vs. non-operative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. Sixty-six international experts on the management of ACL injuries, representing 18 countries, were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the Scientific Organizing Committee and Session Chairs for the three working groups. Panel participants reviewed preliminary statements prior to the meeting and provided the initial agreement and comments on the statement via an online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Eighty percent agreement was defined a-priori as consensus. A total of 11 of 13 statements on operative v. non-operative treatment of ACL injury reached the consensus during the Symposium. Nine statements achieved unanimous support, two reached strong consensus, one did not achieve consensus, and one was removed due to redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended due to the high risk of secondary meniscus and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight plane activities, non-operative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and non-operative treatments with patients after an ACL injury.Level of evidence V.

Injury Risk Factors Integrated Into Self-Guided Real-Time Biofeedback Improves High-Risk Biomechanics

CONTEXT

Existing anterior cruciate ligament (ACL) injury prevention programs have failed to reverse the high rate of ACL injuries in adolescent female athletes.

OBJECTIVE

This investigation attempts to overcome factors that limit efficacy with existing injury prevention programs through the use of a novel, objective, and real-time interactive visual feedback system designed to reduce the biomechanical risk factors associated with ACL injuries.

DESIGN

Cross-over study.

SETTING

Medical center laboratory.

PARTICIPANTS

A total of 20 females (age = 19.7 [1.34] y; height = 1.74 [0.09] m; weight = 72.16 [12.45] kg) participated in this study.

METHODS

Participants performed sets of 10 bodyweight squats in each of 8 training blocks (ie, 4 real-time and 4 control blocks) and 3 testing blocks for a total of 110 squats. Feedback conditions were blocked and counterbalanced with half of participants randomly assigned to receive the real-time feedback block first and half receiving the control (sham) feedback first.

RESULTS

Heat map analysis revealed that during interaction with the real-time feedback, squat performance measured in terms of key biomechanical parameters was improved compared with performance when participants squatted with the sham stimulus.

CONCLUSIONS

This study demonstrates that the interactive feedback system guided participants to significantly improve movement biomechanics during performance of a body weight squat, which is a fundamental exercise for a longer term ACL injury risk reduction intervention. A longer training and testing period is necessary to investigate the efficacy of this feedback approach to effect long-term adaptations in the biomechanical risk profile of athletes.

Immediate arthroscopy following ORIF for tibial plateau fractures provide early diagnosis and treatment of the combined intra-articular pathologies

PURPOSE

To evaluate the effectiveness of immediate arthroscopy and clinical outcomes following open reduction and internal fixation (ORIF) of tibial plateau fractures.

METHODS

Sixty patients (36 men and 24 women, median age 56 (20-78) years) were divided into Group I (ORIF only: 26 patients, median age 58 (25-78) years) or Group II (ORIF with immediate arthroscopy: 34 patients, median age 55 (20-75) years) in tibial plateau fractures (Schatzker Type II-VI fractures). In the first part of this study, ORIF only was performed without arthroscopic treatment. In the second part, ORIF with immediate arthroscopic examination and treatment was performed. Clinical outcomes, utilizing range of motion (ROM), International Knee Documentation Committee (IKDC) score and hospital for special knee score (HSS) were assessed.

RESULTS

At the final follow-up, HSS score was 81 ± 11 points in Group I and 83 ± 9 points in Group II. The IKDC score was 85 ± 8 points in Group I and 86 ± 6 points in Group II. In Group II, concomitant intra-articular lesions in 10 patients (29%) were found and treated simultaneously. However, there were no significant differences in clinical scores or ROM between the two groups.

CONCLUSION

Immediate arthroscopy following ORIF for tibial plateau fracture is an effective procedure that provides accurate information for fracture reduction, leading to immediate treatment of concomitant intra-articular lesions without complications.

LEVEL OF EVIDENCE

III.

Nearly 90% participation in sports activity 12 years after non-surgical management for anterior cruciate ligament injury relates to physical outcome measures

PURPOSE

Traditionally reconstructive surgery is recommended for patients planning to return to sport (RTS), especially to pivoting sports after anterior cruciate (ACL) rupture. Recent trends focus on delaying or avoiding surgery as some studies have found similar rates of RTS following both surgical and conservative management. This study aimed to establish long-term RTS levels in ACL-ruptured individuals treated conservatively, and to investigate the relationship between outcome measures and RTS, in particular, pivoting sports.

METHOD

Fifty-five patients from a cohort of 132 ACL-deficient patients were followed-up for  12 (IQR 8,19) years post injury. Mean-aged 42 years, 22 patients were females and 33 males, 35 had meniscal injuries. Patients were treated with physiotherapy focussing on strength and dynamic stability training and not reconstructive surgery. Return to sport was measured on a 6-point scale. Outcome measures included: objective stability, subjective stability, quadriceps and hamstring strength. Spearman's rho and Chi-square tests were used to assess the relationship between RTS and outcome measures.

RESULTS

Eighty-nine percent of ACL-deficient patients were currently participating in sport despite a 38% increase in anterior translation (p < 0.001) and a 7.5% loss of quadriceps strength (p = 0.004) compared to the contralateral side. Six patients (11%) did not RTS, ten (18%) returned to safe sports, five (9%) returned to running and 16 (29%) to non-strenuous sports involving limited twisting. Eighteen patients (33%) returned to pivoting sports, 12(22%) at recreational level and six (11%) at competitive level. The level of RTS was related to subjective stability (p = 0.002), and to quadriceps and hamstring strength of the injured leg (p < 0.001). Patients able to return to pivoting sports differed significantly from those not doing so in outcome measures including objective (p = 0.022) and subjective stability (p = 0.035), and quadriceps strength (p = 0.044).

CONCLUSIONS

Eighty-nine percent of ACL-ruptured individuals treated conservatively lead an active sporting life. One-third returned to pivoting sports.  Overall RTS was related to subjective and objective stability and quadriceps and to a lesser extent hamstring strength. This finding reinforced the importance of dynamic stability training as an initial treatment option in most cases.

LEVEL OF EVIDENCE

III.

Effects of Tai Chi on partial anterior cruciate ligament injury: A single-blind, randomized-controlled trial

Objectives

This study aims to investigate the effects of Tai Chi (TC) exercises on muscle strength, pain, proprioception, and knee function in patients with partial anterior cruciate ligament (ACL) injuries.

Patients and methods

Between March 2017 and January 2018, a total of 58 patients with partial ACL injuries (30 male, 28 female; mean age 25.5±6.4; range, 18 to 36 years) were included in the study. The patients were randomly divided into two groups: TC group (n=29) and control group (n=29). For both groups, an activity modification approach was applied. The TC group participated in a 24-week TC exercise program, while no exercise or home-based program was administered to the control group. Isokinetic knee extension and flexion muscle strengths were evaluated at angular velocities of 60°/sec and 180°/sec. The visual analog scale (VAS), isokinetic system, Lysholm Knee Scale (LKS), and International Knee Documentation Committee 2000 (IKDC-2000) were used for the evaluation of pain, proprioception, and knee function, respectively.

Results

Significant changes were found in the TC group for the knee extensor muscle strength measured at an angular velocity of 60°/sec (p=0.012) and 180°/sec (p=0.011), VAS pain (p=0.005), and proprioception (measured with isokinetic device) (p<0.001). While knee extensor muscle strength, pain, proprioception, LKS, and IKDC-2000 scores improved in the TC group, improvements were recorded only for LKS and IKDC-2000 scores in the control group.

Conclusion

Based on these results, we conclude that TC exercises can yield positive outcomes on the knee extensor muscle strength, pain, proprioception and knee function in patients with partial ACL injuries. Hence, TC exercises can be used as a novel method by researchers and clinicians in the treatment of partial ACL injuries.

Time for a Different Approach to Anterior Cruciate Ligament Injuries: Educate and Create Realistic Expectations

Following an anterior cruciate ligament (ACL) injury, patients are often reassured that timely surgery followed by intensive physiotherapy will "fix their knee". Not only does this message create a false perception of uncomplicated return to sport (RTS), it also ignores the large body of evidence demonstrating a high RTS re-injury rate following ACL reconstruction. In this article, we propose an individualised approach to the management of ACL injuries that targets a shift away from early surgery and towards conservative management, with surgery 'as needed' and rehabilitation tailored to the patient's RTS goals. Education on the natural history of ACL injuries will ensure patients are not misguided into thinking surgery and intensive rehabilitation guarantees great outcomes. Further, understanding that conservative management is not inferior to surgery-and not more likely to cause knee osteoarthritis-will help the patient make an informed decision. For patients who opt for surgical management, rehabilitation must target strength and functional performance, avoid rapid increases in training load, and be guided by an RTS timeframe that is no shorter than 9 months. The content of rehabilitation should be similar for patients who opt for non-operative management, although the RTS timeframe will likely be shorter. All patients should receive education on the relationship between injury risk and training load, and understand that a home-exercise program is not inferior to intensive physiotherapist-led exercise.

Challenges in the Management of Anterior Cruciate Ligament Ruptures in Skeletally Immature Patients

Although initially considered rare, anterior cruciate ligament (ACL) ruptures in pediatric patients recently have increased substantially as a result of greater awareness of the injury and increased participation in youth sports. Although pediatric patients with an ACL injury and a clinically stable joint may handle the injury well and return to sports activity without requiring surgical reconstruction, young, active patients with an ACL rupture and an unstable joint may be good candidates for ACL reconstruction to prevent ongoing instability and additional joint damage. ACL reconstruction techniques have been developed to prevent physeal injury in skeletally immature patients. The surgical treatment of skeletally immature patients with an ACL rupture may differ from that of adults with an ACL rupture and presents unique challenges with regard to reconstruction technique selection, graft preparation, rehabilitation, and return to sports activity. Orthopaedic surgeons should understand various physeal-sparing ACL reconstruction techniques and the general challenges associated with the surgical management of ACL ruptures in pediatric patients.