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Culvenor AG, West TJ, Bruder AM, Scholes MJ, Barton CJ, Roos EM, Oei EHG, McPhail SM, Souza RB, Lee J, Patterson BE, Girdwood MA, Couch JL, Crossley KM. Recruitment and baseline characteristics of young adults at risk of early-onset knee osteoarthritis after ACL reconstruction in the SUPER-Knee trial. BMJ Open Sport Exerc Med 2024; 10:e001909. [PMID: 38601122 PMCID: PMC11002429 DOI: 10.1136/bmjsem-2024-001909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
Objectives The study aims to (1) report the process of recruiting young adults into a secondary knee osteoarthritis prevention randomised controlled trial (RCT) after anterior cruciate ligament reconstruction (ACLR); (2) determine the number of individuals needed to be screened to include one participant (NNS) and (3) report baseline characteristics of randomised participants. Methods The SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER)-Knee RCT compares SUPER and minimal intervention for young adults (aged 18-40 years) with ongoing symptoms (ie, mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score subscales (KOOS4)) 9-36 months post-ACLR. The NNS was calculated as the number of prospective participants screened to enrol one person. At baseline, participants provided medical history, completed questionnaires (demographic, injury/surgery, rehabilitation characteristics) and underwent physical examination. Results 1044 individuals were screened to identify 567 eligible people, from which 184 participants (63% male) enrolled. The sample of enrolled participants was multicultural (29% born outside Australia; 2% Indigenous Australians). The NNS was 5.7. For randomised participants, mean±SD age was 30±6 years. The mean body mass index was 27.3±5.2 kg/m2, with overweight (43%) and obesity (21%) common. Participants were, on average, 2.3 years post-ACLR. Over half completed <8 months of postoperative rehabilitation, with 56% having concurrent injury/surgery to meniscus and/or cartilage. The most affected KOOS (0=worst, 100=best) subscale was quality of life (mean 43.7±19.1). Conclusion Young adults post-ACLR were willing to participate in a secondary osteoarthritis prevention trial. Sample size calculations should be multiplied by at least 5.7 to provide an estimate of the NNS. The SUPER-Knee cohort is ideally positioned to monitor and intervene in the early development and trajectory of osteoarthritis. Trial registration number ACTRN12620001164987.
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Affiliation(s)
- Adam G Culvenor
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Australian IOC Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Thomas J West
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Australian IOC Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Andrea M Bruder
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, La Trobe University, Melbourne, Victoria, Australia
| | - Mark J Scholes
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, La Trobe University, Melbourne, Victoria, Australia
| | - Christian J Barton
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Department of Physiotherapy, Podiatry and Prosthetics and Orthotics, La Trobe University, Melbourne, Victoria, Australia
| | - Ewa M Roos
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Edwin H G Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Steven M McPhail
- Australian Centre for Health Services Innovation & Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Clinical Informatics Directorate, Metro South Health, Woolloongabba, Queensland, Australia
| | - Richard B Souza
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, California, USA
| | - Jusuk Lee
- Department of Radiology and Biomedical Imaging, University of California, San Francicso, California, USA
| | - Brooke E Patterson
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Australian IOC Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Michael A Girdwood
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Australian IOC Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Jamon L Couch
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Australian IOC Research Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Kay M Crossley
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- Australian IOC Research Centre, La Trobe University, Melbourne, Victoria, Australia
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Liew JW, Turkiewicz A, Roemer FW, Frobell RB, Felson D, Englund M. Diagnostic Accuracy of Candidate Magnetic Resonance Imaging Knee Osteoarthritis Definitions Versus Radiograph in an Acute Anterior Cruciate Ligament Injury Cohort. Arthritis Care Res (Hoboken) 2024; 76:409-414. [PMID: 37781746 PMCID: PMC10922537 DOI: 10.1002/acr.25248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE We tested the diagnostic accuracy of previously proposed magnetic resonance imaging (MRI) osteoarthritis (OA) definitions in a cohort after acute anterior cruciate ligament (ACL) injury. METHODS We studied participants with posteroanterior and lateral knee radiographs and MRI 5 years after ACL injury, scored using the Anterior Cruciate Ligament Osteoarthritis Score. Radiographic OA (ROA) was defined using Osteoarthritis Research Society International scoring of osteophytes and joint space narrowing considering medial/lateral tibiofemoral and patellofemoral compartments. We tested three candidate MRI OA definitions that performed well in an older adult cohort. "Multicenter Osteoarthritis Study (MOST) simple" required cartilage score ≥2 (range 0-6) and osteophyte score ≥2 (0-7); "MOST optional" included cartilage score ≥2, osteophyte score ≥2, and either bone marrow lesions (BMLs) ≥1 (0-3) or synovitis ≥2 (0-3). The third, a Delphi panel definition, included nonzero scores for cartilage, osteophyte, BMLs, meniscus, and other structures. We calculated sensitivity and specificity with 95% confidence intervals (95% CIs) for each MRI definition versus ROA. RESULTS We included 113 participants (mean age 26 years, 26% female). At 5 years, 29 participants (26%) had ROA. "MOST simple" had a sensitivity of 52% (95% CI 33%-71%), and specificity of 76% (95% CI 66%-85%). Sensitivity and specificities for "MOST optional" were 28% (95% CI 29%-67%) and 83% (95% CI 74%-91%), respectively. The Delphi panel definition had a sensitivity of 48% (95% CI 29%-67%) and specificity of 77% (95% CI 67%-86%). CONCLUSION Simple MRI-based OA definitions requiring at least cartilage damage and an osteophyte have low sensitivity and high specificity in young persons after knee injury.
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Affiliation(s)
- Jean W. Liew
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Aleksandra Turkiewicz
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Frank W. Roemer
- Department of Radiology, Universitätsklinikum Erlangen & Friedrich-Alexander Universität Erlangen Nürnberg (FAU), Erlangen, Germany & Department of Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Richard B. Frobell
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - David Felson
- Section of Rheumatology, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Martin Englund
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
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Migliorini F, Pilone M, Memminger MK, Eschweiler J, Giorgino R, Maffulli N. All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review. J Orthop Traumatol 2024; 25:7. [PMID: 38376718 PMCID: PMC10879072 DOI: 10.1186/s10195-024-00751-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/13/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasingly common. Evidence comparing the outcomes of all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients is limited, and the current literature could benefit from a comprehensive systematic review. The present study compared all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients. The outcomes of interest were to compare joint laxity, patient-reported outcome measures (PROMs), return to sport, and complications. METHODS This study was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. No additional filters were used in the database search. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles that clearly stated the surgical technique (all- or trans-epiphyseal) were eligible. Only articles with a minimum of 6 months of follow-up were included. Only articles that clearly stated that surgeries were conducted in children with open physis were eligible. RESULTS Data from 1489 patients (1493 procedures) were collected, of which 32% (490 of 1489 patients) were female. The mean length of follow-up was 46.6 months. The mean age of the patients was 12.7 years. No difference was found in joint laxity (Table 3): positive pivot shift (P = 0.4), positive Lachman test (P = 0.3), and mean arthrometer laxity (P = 0.1). No difference was found in PROMs (Table 4): International Knee Documentation Committee (IKDC) (P = 0.3), Lysholm (P = 0.4), and Tegner (P = 0.7). The trans-epiphyseal technique was associated with a greater rate of patients unable to return to sports (1% versus 7%, P = 0.0001) and with a longer time to return to sports (7.7 versus 8.6 months, P = 0.01). Though the trans-epiphyseal technique was associated with a lower rate of return to sport, this difference was not statistically significant (P = 0.8). No difference was evidenced in the rate of patients who had reduced their league or level of sports activity (P = 0.6) or in the rate of patients who had returned to their previous league or level of sports activity (P = 0.7). No difference was found in the rate of complication: re-tear (P = 0.8), reoperation (P = 0.7), increased laxity (P = 0.9), and persistent instability sensation (P = 0.3). CONCLUSION Trans-epiphyseal ACL reconstruction was associated with a greater rate of patients unable to return to sport and with a longer time to return to sport compared with the all-epiphyseal technique in skeletally immature patients. Level of evidence Level III, systematic review.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopaedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
| | - Marco Pilone
- Residency Program in Orthopedics and Traumatology, University of Milan, Milan, Italy
| | - Michael Kurt Memminger
- Department of Orthopaedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
| | - Jörg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
- Department of Trauma and Reconstructive Surgery, BG Hospital Bergmannstrost, Halle, Germany
| | - Riccardo Giorgino
- Residency Program in Orthopedics and Traumatology, University of Milan, Milan, Italy
| | - Nicola Maffulli
- Department of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, ST4 7QB, Stoke on Trent, England
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, E1 4DG, London, England
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Lohmander LS, Roemer FW, Frobell RB, Roos EM. Treatment for Acute Anterior Cruciate Ligament Tear in Young Active Adults. NEJM EVIDENCE 2023; 2:EVIDoa2200287. [PMID: 38320141 DOI: 10.1056/evidoa2200287] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Anterior cruciate ligament (ACL) injury of the knee is common in young active adults and often has severe and sometimes lifelong consequences. The clinical management of this injury remains debated. A prior trial of early versus delayed optional ACL repair showed no differences in outcomes at 2 years. METHODS: We present the 11-year follow-up of a randomized clinical trial involving 121 young active adults (mean age 26yo, 74% male) with an acute sports-related ACL tear. We compared patient-reported and radiographic outcomes between those randomized to receive early ACL reconstruction (ACLR) followed by exercise therapy (N=62) and those treated with early exercise therapy plus optional delayed ACLR (N=59). The primary end point at 11 years was change from baseline in the mean of four subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) — pain, symptoms, function in sports and recreation, and knee-related quality of life (KOOS4; range of scores, 0 [worst] to 100 [best]; minimal important change=9). RESULTS: In all, 88% of the cohort followed up at 11 years (53/62 in the early vs. 54/59 in the optional late ACL repair groups), and 52% of those assigned to optional delayed ACLR underwent ACLR. Mean improvement in KOOS4 from baseline to 11 years was 46 points for those assigned to early ACLR plus exercise therapy and 45 points for those assigned to exercise therapy plus optional delayed ACLR (between-group difference, 1.6 points; 95% confidence interval [CI], −8.8 to 5.6; P=0.67 after adjustment for baseline score, full analysis set). About two thirds of the full cohort reported meeting the case definition for a “patient-acceptable symptom state” (KOOS4 patient-acceptable symptom state threshold value=79), whereas 44% had developed radiographic osteoarthritis of their injured knee. Mean summed incident radiographic osteoarthritis feature scores, scores range from 0 to 30 where higher scores indicate more severe joint damage, were 2.4 for the group assigned to early ACLR and 1.0 for the group assigned to exercise therapy plus optional delayed ACLR (mean difference, 1.0; 95% CI, 0.1 to 1.9). CONCLUSIONS: At 11-year follow-up, among young active adults with acute ACL tears assigned to early ACLR plus exercise versus initial exercise therapy with the option of delayed ACLR, there were no differences in patient-reported outcomes. (Funded by the Swedish Research Council; ISRCTN number, ISRCTN84752559.)
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Affiliation(s)
- L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Frank W Roemer
- Department of Radiology, Universitätsklinikum Erlangen, Erlangen, Germany
- Department of Radiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Radiology, Boston University School of Medicine, Boston
| | - Richard B Frobell
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Ewa M Roos
- Center for Muscle and Joint Health, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
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Migliorini F, Torsiello E, Trivellas A, Eschweiler J, Hildebrand F, Maffulli N. Bone-patellar tendon-bone versus two- and four-strand hamstring tendon autografts for ACL reconstruction in young adults: a Bayesian network meta-analysis. Sci Rep 2023; 13:6883. [PMID: 37106008 PMCID: PMC10140035 DOI: 10.1038/s41598-023-33899-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
Bone-patellar tendon-bone (BPTB), two- and four-strand hamstring tendon (4SHT and 2SHT, respectively) are the most common autografts used for anterior cruciate ligament (ACL) reconstruction. The present study compared BPTB, 2SHT, and 4SHT for ACL reconstruction in terms of joint laxity, patient reported outcome measures (PROMs), rate of failure and anterior knee pain (AKP). The time to return to sport and the peak torque between the autografts were also compared. Finally, prognostic factors leading to worse outcomes were also investigated. It was hypothesized that all grafts yield similar proprieties in terms of joint laxity, patient reported outcome measures (PROMs) and rate of failure, but that the BPTB autograft causes a greater rate of anterior knee pain (AKP). The literature search was conducted. All clinical trials comparing BTPB and/or 2SHT, and/or 4SHT were accessed. Grafts other than BTPB and/or 4SHT and/or 2SHT were not considered. Articles reporting outcomes of allografts or synthetic grafts were not eligible, nor were those concerning revision settings. Articles reporting ACL reconstruction in patients with multi-ligament damage were also not eligible. Data from 95,575 procedures were retrieved. The median length of follow-up was 36 months. The median age of the patients was 27.5 years. With regard to joint laxity, similarity was found in terms of Lachman and Pivot shift tests between all three autografts. The BPTB demonstrated the greatest stability in terms of instrumental laxity. BPTB demonstrated the greatest PROMs. BPTB demonstrated the greatest rate of AKP, while AKP in 2SHT and 4SHT was similar. Concerning failure, statistically significant inconsistency was found (P = 0.008). The 4SHT demonstrated the quickest return to sport, followed by BPTB, and 2SHT. There was evidence of a negative association between the time span between injury to surgery, Lysholm score (P = 0.04), and Tegner scale (P = 0.04). Furthermore, there was evidence of a weak positive association between the time span between injury to surgery and return to sport (P = 0.01). BPTB may result in lower joint laxity, greater PROMs, and greater peak flexion torque compared to 2SHT and 4SHT autografts. On the other hand, BPTB reported the lowest peak extension torque and the greatest rate of AKP. Finally, a longer time span between injury and surgery negatively influences outcome.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Ernesto Torsiello
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Andromahi Trivellas
- Department of Orthopaedic and Trauma Surgery, Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, 90095, USA
| | - Jörg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, England
- Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
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Schilling C, Tew M, Bunzli S, Shadbolt C, Lohmander LS, Balogh ZJ, Paolucci F, Choong PF, Dowsey MM, Clarke P. An Economic Model for Estimating Trial Costs with an Application to Placebo Surgery Trials. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:263-273. [PMID: 36575335 PMCID: PMC9931787 DOI: 10.1007/s40258-022-00775-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Waste in clinical trials remains rife. We developed an economic model to predict the cost of trials based on input costs, duration, power, number of sites, recruitment eligibility and consenting rates. METHODS We parameterised the model for three proxy placebo-controlled surgical trials using data from a systematic review, a bespoke cost survey, and from the literature. We used the model to compare target and actual trial performance for (i) a trial that was completed on time but with more sites, (ii) a trial that completed after a time extension, and (iii) an incomplete trial. RESULTS Successful trials more accurately anticipated the true recruitment rate that they achieved and those that overestimated this were most likely to fail. The costs of overestimating recruitment rates were dramatic: all proxy trials had significantly higher costs than planned, with additional funding of at least AUD$600,000 (50% above budget) required for trials that completed after adding more sites or more time, and over AUD$2 million (260% above budget) for incomplete trials. CONCLUSIONS This model shows the trade-offs between time and cost, or both, when recruitment is lower than anticipated. Greater consideration is needed to improve trial planning, reviewing, and funding of these trials to avoid costly overruns and incomplete trials.
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Affiliation(s)
- Chris Schilling
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Michelle Tew
- Melbourne School of Population and Global Health, Centre for Health Policy, University of Melbourne, Melbourne, Australia
| | - Samantha Bunzli
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Cade Shadbolt
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - L. Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, University of Lund, Lund, Sweden
| | - Zsolt J. Balogh
- School of Medicine and Public Health, Department of Traumatology, John Hunter Hospital, The University of Newcastle, Newcastle, Australia
| | - Francesco Paolucci
- College of Human and Social Futures, The Newcastle Business School, University of Newcastle, Newcastle, Australia
- Schools of Economics and Management, University of Bologna, Bologna, Italy
| | - Peter F. Choong
- Department of Surgery, The University of Melbourne, Melbourne, Australia
- Department of Orthopaedics, St. Vincent’s Hospital, Melbourne, Australia
| | - Michelle M. Dowsey
- Department of Surgery, The University of Melbourne, Melbourne, Australia
- Department of Orthopaedics, St. Vincent’s Hospital, Melbourne, Australia
| | - Philip Clarke
- Melbourne School of Population and Global Health, Centre for Health Policy, University of Melbourne, Melbourne, Australia
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Migliorini F, Oliva F, Eschweiler J, Torsiello E, Hildebrand F, Maffulli N. Knee osteoarthritis, joint laxity and PROMs following conservative management versus surgical reconstruction for ACL rupture: a meta-analysis. Br Med Bull 2022; 145:72-87. [PMID: 36412118 DOI: 10.1093/bmb/ldac029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Patients whose rupture of the anterior cruciate ligament (ACL) can be managed conservatively or undergo reconstruction surgery. SOURCE OF DATA Current scientific literature published in Web of Science, PubMed and Scopus. AREAS OF AGREEMENT Several studies published by July 2022 compare surgical and conservative management following ACL rupture. The latest evidence suggests that surgical management may expose patients to an increased risk of early-onset knee osteoarthritis (OA). AREAS OF CONTROVERSY The state of art does not recommend a systematic ACL reconstruction to all patients who tore their ACL. After the initial trauma, surgical reconstruction may produce even greater damage to the intra-articular structures compared to conservative management. GROWING POINTS The state of art does not recommend systematic surgical reconstruction to all patients who tore their ACL. The present study compared surgical reconstruction versus conservative management for primary ACL ruptures in terms of joint laxity, patient reported outcome measures (PROMs) and rate of osteoarthritis. AREAS TIMELY FOR DEVELOPING RESEARCH ACL reconstruction provides significant improvement in joint laxity compared to conservative management, but is associated with a significantly greater rate of knee osteoarthritis, despite similar results at PROM assessment.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074 Aachen, Germany
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi (SA), Italy
| | - Joerg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074 Aachen, Germany
| | - Ernesto Torsiello
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi (SA), Italy
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074 Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi (SA), Italy.,School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent ST4 7QB, UK.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK
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Ding DY, Tucker LY, Rugg CM. Comparison of Anterior Cruciate Ligament Tears Treated Nonoperatively Versus With Reconstruction: Risk of Subsequent Surgery. Am J Sports Med 2022; 50:652-661. [PMID: 34994581 DOI: 10.1177/03635465211066940] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears can be devastating injuries, leading to joint instability, meniscal tears, and subsequent arthritis. It is unknown whether ACL reconstruction (ACLR) alters the natural history of joint degeneration in the ACL-deficient knee compared with nonoperative treatment, and few studies have examined outcomes in middle-aged patients. PURPOSE The objective of this study was to compare the midterm risk of subsequent ipsilateral knee surgery in middle-aged patients after an ACL injury treated with initial conservative (nonoperative) management (CM) versus ACLR (operative management [OM]) within 6 months of the diagnosis. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS We performed an electronic database search from 2011 to 2012 for all patients aged 35 to 55 years with an initial diagnosis of magnetic resonance imaging-confirmed ACL tear. Patients who elected CM and those who underwent ACLR within 6 months of the diagnosis (OM) were identified. Index patient and clinical characteristics were collected from the health record. All patients were longitudinally observed until August 31, 2017. The primary outcome was subsequent ipsilateral knee surgeries, and secondary outcomes included contralateral knee surgeries, deep surgical-site infections, and venous thrombotic events. RESULTS The mean follow-up was 4.8 ± 0.6 years. The CM group included 463 patients (40.2%) and the OM group included 690 patients (59.8%). The mean ages were 43.9 ± 5.7 years and 42.7 ± 5.3 years for patients in the CM and OM groups, respectively (P < .001). Obesity and smoking were significantly more common in the CM group. During the follow-up, 180 patients (38.9%) in the CM group underwent subsequent ipsilateral knee surgery compared with 73 (10.6%) patients in the OM group (P < .001). The mean time to the first ipsilateral procedure was 0.9 ± 1.1 years in the CM and 2 ± 1.5 years in the OM group (P < .001). Delayed ipsilateral ACLRs were performed in 81 patients in the CM group (17.5%); non-ACLR ipsilateral knee surgeries were performed in 156 patients in the CM group (33.7%). Contralateral knee surgery rates were similar. In a regression model, after controlling for age, sex, the Charlson Comorbidity Index score, and smoking status, it was found that normal body mass index and CM group were risk factors for undergoing subsequent knee surgery or ipsilateral non-ACLR surgery. CONCLUSION Excluding delayed ACLR, subsequent ipsilateral knee surgeries were more common and occurred earlier in middle-aged patients with nonoperatively managed ACL tears compared with patients managed with reconstruction.
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Affiliation(s)
- David Y Ding
- Department of Orthopedic Surgery, Kaiser Permanente Northern California, San Francisco, California, USA
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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9
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Bunzli S, Nelson E, Wall L, Schilling C, Lohmander LS, Balogh ZJ, Tran P, Paolucci F, Clarke P, Choong PFM, Dowsey MM. Factors Underlying Patient and Surgeon Willingness to Participate in a Placebo Surgery Controlled trial: A Qualitative Investigation. ANNALS OF SURGERY OPEN 2021; 2:e104. [PMID: 37637882 PMCID: PMC10455200 DOI: 10.1097/as9.0000000000000104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/26/2021] [Indexed: 11/25/2022] Open
Abstract
Objective To investigate the factors underlying willingness to participate in a hypothetical trial among patients and surgeons, to inform the design of future placebo surgery controlled trials. Background Placebo surgery controlled trials are the gold standard for testing the efficacy of surgical procedures. However, these trials commonly fail to meet the target sample size and terminate underpowered. Methods From October 2019 to July 2020, eligible patients were identified from the orthopedic waiting list at a single tertiary hospital and surgeons were identified from orthopedic clinics at three tertiary hospitals in Australia. Qualitative interviews explored factors underlying willingness to participate in a hypothetical trial, including understanding of trial concepts; attitudes; and trial design preferences. Data collection and analysis were conducted in parallel. Recruitment ceased when no new concepts emerged. Interview data were analyzed using reflexive thematic analysis. Results The majority of surgeons and only a few patients indicated a willingness to participate in a placebo surgery controlled trial. Factors underlying willingness were captured in four themes: (1) Understanding and attitudes toward placebo; (2) Attitudes towards randomization/perception of equipoise; (3) Perception of risk; and (4) Ethical concerns. Conclusions To optimize recruitment in the future, trialists may consider embedding strategies into the recruitment process that validate patients' symptoms, encourage an altruistic mindset, address surgeon biases, and involve surgeons in explaining trial concepts to patients. Trialists may also consider designing three arm trials that meet surgeons' preferences for a "low" and "high" fidelity placebo.
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Affiliation(s)
- Samantha Bunzli
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Elizabeth Nelson
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Laura Wall
- Newcastle Business School, The University of Newcastle Faculty of Business and Law, Newcastle, NSW, Australia
| | - Chris Schilling
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - L. Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, University of Lund, Lund, Sweden
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Phong Tran
- Western Health, Footscray Hospital, Melbourne, VIC, Australia
| | - Francesco Paolucci
- Newcastle Business School, The University of Newcastle Faculty of Business and Law, Newcastle, NSW, Australia
| | - Philip Clarke
- Health Economics Research Centre, Oxford University, Oxford, United Kingdom
| | - Peter F. M. Choong
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Michelle M. Dowsey
- From the Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
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10
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van der List JP, Vermeijden HD, Sierevelt IN, Rademakers MV, Falke MLM, Helmerhorst GTT, Hoogeslag RAG, van der Wal WA, van Noort A, Kerkhoffs GMMJ. Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial. BMC Musculoskelet Disord 2021; 22:399. [PMID: 33931067 PMCID: PMC8088019 DOI: 10.1186/s12891-021-04280-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/20/2021] [Indexed: 01/11/2023] Open
Abstract
Background For active patients with a tear of the anterior cruciate ligament (ACL) who would like to return to active level of sports, the current surgical gold standard is reconstruction of the ACL. Recently, there has been renewed interest in repairing the ACL in selected patients with a proximally torn ligament. Repair of the ligament has (potential) advantages over reconstruction of the ligament such as decreased surgical morbidity, faster return of range of motion, and potentially decreased awareness of the knee. Studies comparing both treatments in a prospective randomized method are currently lacking. Methods This study is a multicenter prospective block randomized controlled trial. A total of 74 patients with acute proximal isolated ACL tears will be assigned in a 1:1 allocation ratio to either (I) ACL repair using cortical button fixation and additional suture augmentation or (II) ACL reconstruction using an all-inside autologous hamstring graft technique. The primary objective is to assess if ACL repair is non-inferior to ACL reconstruction regarding the subjective International Knee Documentation Committee (IKDC) score at two-years postoperatively. The secondary objectives are to assess if ACL repair is non-inferior with regards to (I) other patient-reported outcomes measures (i.e. Knee Injury and Osteoarthritis Outcome Score, Lysholm score, Forgotten Joint Score, patient satisfaction and pain), (II) objective outcome measures (i.e. failure of repair or graft defined as rerupture or symptomatic instability, reoperation, contralateral injury, and stability using the objective IKDC score and Rollimeter/KT-2000), (III) return to sports assessed by Tegner activity score and the ACL-Return to Sports Index at two-year follow-up, and (IV) long-term osteoarthritis at 10-year follow-up. Discussion Over the last decade there has been a resurgence of interest in repair of proximally torn ACLs. Several cohort studies have shown encouraging short-term and mid-term results using these techniques, but prospective randomized studies are lacking. Therefore, this randomized controlled trial has been designed to assess whether ACL repair is at least equivalent to the current gold standard of ACL reconstruction in both subjective and objective outcome scores. Trial registration Registered at Netherlands Trial Register (NL9072) on 25th of November 2020.
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Affiliation(s)
- Jelle P van der List
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands.
| | - Harmen D Vermeijden
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Inger N Sierevelt
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands.,Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Mark L M Falke
- Department of Orthopaedic Surgery, Flevoziekenhuis, Almere, The Netherlands
| | | | - Roy A G Hoogeslag
- Department of Orthopaedic Surgery, Centre for Orthopaedic Surgery OCON, Hengelo, The Netherlands
| | - Wybren A van der Wal
- Department of Orthopaedic Surgery, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - Arthur van Noort
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam UMC, University of Amsterdam, Academic Center for Evidence based Sports medicine (ACES), Amsterdam, The Netherlands.,Amsterdam UMC, Amsterdam Collaboration on Health & Safety in Sports (ACHSS), University of Amsterdam and Vrije Universiteit Amsterdam IOC Research Center, Amsterdam, The Netherlands
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11
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Wirth W, Eckstein F, Culvenor AG, Hudelmaier MI, Stefan Lohmander L, Frobell RB. Early anterior cruciate ligament reconstruction does not affect 5 year change in knee cartilage thickness: secondary analysis of a randomized clinical trial. Osteoarthritis Cartilage 2021; 29:518-526. [PMID: 33549723 DOI: 10.1016/j.joca.2021.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/30/2020] [Accepted: 01/20/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare 5-year change in femorotibial cartilage thickness in 121 young, active adults with an acute anterior cruciate ligament (ACL) tear randomized to a strategy of structured rehabilitation plus early ACL reconstruction (ACLR) or structured rehabilitation plus optional delayed ACLR. DESIGN 62 patients were randomized to early ACLR, 59 to optional delayed ACLR. Magnetic resonance imaging (MRI) was acquired within 4 weeks of injury, at two- and 5-years follow-up. Main outcome was 5-year change in overall femorotibial cartilage thickness. Secondary outcomes included the location-independent cartilage ChangeScore, summarizing thinning and thickening in 16 femorotibial subregions. An exploratory as-treated comparison was performed additionally. RESULTS Baseline and at least one follow-up MRI were available for 117 patients. Over 5 years, a comparable increase in overall femorotibial cartilage thickness was observed for patients randomized to early ACLR (n = 59) and patients randomized to optional delayed ACLR (n = 58, adjusted mean difference: -5 μm, 95% CI: [-118, 108]μm). However, the location-independent cartilage ChangeScore was greater in those treated with early ACLR than in patients treated with optional delayed ACLR (adjusted mean difference: 403 μm [119, 687]μm). As-treated analysis showed no between-group differences for the main outcome, while the location-independent cartilage ChangeScore was greater for patients treated with early (adjusted mean difference: 632 μm [268, 996]μm) or delayed ACLR (adjusted mean difference: 449 μm [108, 791]μm) than for patients treated with rehabilitation alone. CONCLUSIONS In young active adults with acute ACL-injury, choice of treatment strategy for the injured ACL did not modify the magnitude of 5-year change in overall femorotibial cartilage thickness. TRIAL REGISTRATION ISRCTN84752559.
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Affiliation(s)
- W Wirth
- Department for Imaging & Functional Musculoskeletal Research, Institute of Anatomy & Cell Biology, Paracelsus Medical University Salzburg & Nuremberg, Salzburg, Austria; Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Paracelsus Medical University, Salzburg, Austria; Chondrometrics GmbH, Ainring, Germany.
| | - F Eckstein
- Department for Imaging & Functional Musculoskeletal Research, Institute of Anatomy & Cell Biology, Paracelsus Medical University Salzburg & Nuremberg, Salzburg, Austria; Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Paracelsus Medical University, Salzburg, Austria; Chondrometrics GmbH, Ainring, Germany.
| | - A G Culvenor
- Department for Imaging & Functional Musculoskeletal Research, Institute of Anatomy & Cell Biology, Paracelsus Medical University Salzburg & Nuremberg, Salzburg, Austria; La Trobe Sport & Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, Australia.
| | - M I Hudelmaier
- Department for Imaging & Functional Musculoskeletal Research, Institute of Anatomy & Cell Biology, Paracelsus Medical University Salzburg & Nuremberg, Salzburg, Austria.
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden.
| | - R B Frobell
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden.
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12
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Andreisek G. New Evidence for the Old Question If ACL Reconstruction Is Beneficial over Nonsurgical Therapy. Radiology 2021; 299:394-395. [PMID: 33689474 DOI: 10.1148/radiol.2021210146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Gustav Andreisek
- From the Department of Radiology, Cantonal Hospital Münsterlingen, Spital Thurgau AG, Spitalcampus 1, 8596 Münsterlingen, Switzerland; and University of Zurich, Zürich, Switzerland
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Roemer FW, Lohmander LS, Englund M, Guermazi A, Åkesson A, Frobell R. Development of MRI-defined Structural Tissue Damage after Anterior Cruciate Ligament Injury over 5 Years: The KANON Study. Radiology 2021; 299:383-393. [PMID: 33687286 DOI: 10.1148/radiol.2021202954] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background MRI is used to evaluate structural joint changes after anterior cruciate ligament (ACL) injury, but no long-term data are available for comparing different treatment approaches. Purpose To describe structural joint damage with MRI over a 5-year period in the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) study and to compare frequencies of such tissue damage for a nonsurgical versus a surgical treatment strategy. Materials and Methods In this secondary analysis of a prospective trial (ISRCTN 84752559), 119 participants with an acute ACL injury were evaluated. Participants were enrolled from 2002 through 2006, the 2-year follow-up started in 2008, and the 5-year follow-up started in 2011. A 1.5-T MRI examination was performed at baseline and at 2- and 5-year follow-up. MRI scans were read according to a validated scoring instrument. Kruskal-Wallis tests were used to assess whether the frequencies of structural damage differed between the three as-treated groups. Results Of 119 participants (mean age, 26 years ± 5 [standard deviation]), 91 men were evaluated. At 2- and 5-year follow-up, respectively, 13% (15 of 117) and 13% (15 of 115) of knees showed incident cartilage damage in the medial tibiofemoral joint, 11% (13 of 117) and 17% (20 of 115) of knees showed incident cartilage damage in the lateral tibiofemoral joint, and 4% (five of 117) and 8% (nine of 115) of knees showed incident cartilage damage in the patellofemoral joint. Osteophyte development was seen in 23% (27 of 117) and 29% (33 of 115) of knees in the medial tibiofemoral joint, in 36% (42 of 117) and 43% (49 of 115) of knees in the lateral tibiofemoral joint, and in 35% (41 of 117) and 37% (42 of 115) of knees in the patellofemoral joint. No major differences between the groups were found for incident or worsening cartilage damage, bone marrow lesions, and osteophytes at 2 or 5 years. The rehabilitation-alone group showed less Hoffa-synovitis at 2 (P = .02) and 5 (P = .008) years. Conclusion Young adults with anterior cruciate ligament injury showed no major difference in frequency of structural tissue damage on MRI scans at 2 and 5 years regardless of treatment. However, the rehabilitation-alone group had less inflammation at 2 and 5 years. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Andreisek in this issue.
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Affiliation(s)
- Frank W Roemer
- From the Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany (F.W.R.); Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA 02118 (F.W.R., A.G.); Department of Clinical Sciences Lund, Orthopaedics (F.W.R., L.S.L., R.F.), and Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund (M.E.), Lund University, Lund, Sweden; Department of Radiology, VA Boston Healthcare System, West Roxbury, Mass (A.G.); and Clinical Studies Sweden-Forum South, Skåne University Hospital, Lund, Sweden (A.Å.)
| | - L Stefan Lohmander
- From the Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany (F.W.R.); Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA 02118 (F.W.R., A.G.); Department of Clinical Sciences Lund, Orthopaedics (F.W.R., L.S.L., R.F.), and Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund (M.E.), Lund University, Lund, Sweden; Department of Radiology, VA Boston Healthcare System, West Roxbury, Mass (A.G.); and Clinical Studies Sweden-Forum South, Skåne University Hospital, Lund, Sweden (A.Å.)
| | - Martin Englund
- From the Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany (F.W.R.); Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA 02118 (F.W.R., A.G.); Department of Clinical Sciences Lund, Orthopaedics (F.W.R., L.S.L., R.F.), and Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund (M.E.), Lund University, Lund, Sweden; Department of Radiology, VA Boston Healthcare System, West Roxbury, Mass (A.G.); and Clinical Studies Sweden-Forum South, Skåne University Hospital, Lund, Sweden (A.Å.)
| | - Ali Guermazi
- From the Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany (F.W.R.); Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA 02118 (F.W.R., A.G.); Department of Clinical Sciences Lund, Orthopaedics (F.W.R., L.S.L., R.F.), and Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund (M.E.), Lund University, Lund, Sweden; Department of Radiology, VA Boston Healthcare System, West Roxbury, Mass (A.G.); and Clinical Studies Sweden-Forum South, Skåne University Hospital, Lund, Sweden (A.Å.)
| | - Anna Åkesson
- From the Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany (F.W.R.); Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA 02118 (F.W.R., A.G.); Department of Clinical Sciences Lund, Orthopaedics (F.W.R., L.S.L., R.F.), and Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund (M.E.), Lund University, Lund, Sweden; Department of Radiology, VA Boston Healthcare System, West Roxbury, Mass (A.G.); and Clinical Studies Sweden-Forum South, Skåne University Hospital, Lund, Sweden (A.Å.)
| | - Richard Frobell
- From the Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany (F.W.R.); Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA 02118 (F.W.R., A.G.); Department of Clinical Sciences Lund, Orthopaedics (F.W.R., L.S.L., R.F.), and Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund (M.E.), Lund University, Lund, Sweden; Department of Radiology, VA Boston Healthcare System, West Roxbury, Mass (A.G.); and Clinical Studies Sweden-Forum South, Skåne University Hospital, Lund, Sweden (A.Å.)
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Reijman M, Eggerding V, van Es E, van Arkel E, van den Brand I, van Linge J, Zijl J, Waarsing E, Bierma-Zeinstra S, Meuffels D. Early surgical reconstruction versus rehabilitation with elective delayed reconstruction for patients with anterior cruciate ligament rupture: COMPARE randomised controlled trial. BMJ 2021; 372:n375. [PMID: 33687926 PMCID: PMC7941216 DOI: 10.1136/bmj.n375] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess whether a clinically relevant difference exists in patients' perceptions of symptoms, knee function, and ability to participate in sports over a period of two years after rupture of the anterior cruciate ligament (ACL) between two commonly used treatment regimens. DESIGN Open labelled, multicentre, parallel randomised controlled trial (COMPARE). SETTING Six hospitals in the Netherlands, between May 2011 and April 2016. PARTICIPANTS Patients aged 18 to 65 with an acute rupture of the ACL, recruited from six hospitals. Patients were evaluated at three, six, nine, 12, and 24 months. INTERVENTIONS 85 patients were randomised to early ACL reconstruction and 82 to rehabilitation followed by optional delayed ACL reconstruction after a three month period (primary non-operative treatment). MAIN OUTCOMES Patients' perceptions of symptoms, knee function, and ability to participate in sporting activities were assessed with the International Knee Documentation Committee score (optimum score 100) at each time point over 24 months. RESULTS Between May 2011 and April 2016, 167 patients were enrolled in the study and randomised to one of two treatments (mean age 31.3; 67 (40.%) women), and 163 (98%) completed the trial. In the rehabilitation and optional delayed ACL reconstruction group, 41 (50%) patients underwent reconstruction during follow-up. After 24 months, the early ACL reconstruction group had a significantly better (P=0.026) but not clinically relevant International Knee Documentation Committee score (84.7 v 79.4 (difference between groups 5.3, 95% confidence interval 0.6 to 9.9). After three months of follow-up, the International Knee Documentation Committee score was significantly better (P=0.002) for the rehabilitation and optional delayed ACL reconstruction group (difference between groups -9.3, -14.6 to -4.0). After nine months of follow-up, the difference in the International Knee Documentation Committee score changed in favour of the early ACL reconstruction group. After 12 months, differences between the groups were smaller. In the early ACL reconstruction group, four re-ruptures and three ruptures of the contralateral ACL occurred during follow-up versus two re-ruptures and one rupture of the contralateral ACL in the rehabilitation and optional delayed ACL reconstruction group. CONCLUSIONS In patients with acute rupture of the ACL, those who underwent early surgical reconstruction, compared with rehabilitation followed by elective surgical reconstruction, had improved perceptions of symptoms, knee function, and ability to participate in sports at the two year follow-up. This finding was significant (P=0.026) but the clinical importance is unclear. Interpretation of the results of the study should consider that 50% of the patients randomised to the rehabilitation group did not need surgical reconstruction. TRIAL REGISTRATION Netherlands Trial Register NL 2618.
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Affiliation(s)
- Max Reijman
- Department of Orthopaedics and Sports Medicine, Room NC-424, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Vincent Eggerding
- Department of Orthopaedics and Sports Medicine, Room NC-424, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Eline van Es
- Department of Orthopaedics and Sports Medicine, Room NC-424, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Ewoud van Arkel
- Department of Orthopaedics, Haaglanden Medical Centre, The Hague, Netherlands
| | - Igor van den Brand
- Department of Orthopaedics, Elisabeth Tweesteden Hospital, Tilburg, Netherlands
| | - Joost van Linge
- Department of Orthopaedics, Reinier de Graaf Gasthuis, Delft, Netherlands
| | - Jacco Zijl
- Department of Orthopaedics, St Antonius Hospital, Nieuwegein, Netherlands
| | - Erwin Waarsing
- Department of Orthopaedics and Sports Medicine, Room NC-424, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Sita Bierma-Zeinstra
- Department of Orthopaedics and Sports Medicine, Room NC-424, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of General Practice, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Duncan Meuffels
- Department of Orthopaedics and Sports Medicine, Room NC-424, Erasmus MC University Medical Centre, PO Box 2040, 3000 CA Rotterdam, Netherlands
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Gorayeb RP, Forjaz MJ, Ferreira AG, Ferreira JJ. Use of Sham Interventions in Randomized Controlled Trials in Neurosurgery. J Neurol Surg A Cent Eur Neurosurg 2020; 81:456-462. [PMID: 32438420 DOI: 10.1055/s-0040-1709161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of sham interventions in randomized controlled trials (RCTs) is essential to minimize bias. However, their use in surgical RCTs is rare and subject to ethical concerns. To date, no studies have looked at the use of sham interventions in RCTs in neurosurgery. METHODS This study evaluated the frequency, type, and indication of sham interventions in RCTs in neurosurgery. RCTs using sham interventions were also characterized in terms of design and risk of bias. RESULTS From a total of 1,102 identified RCTs in neurosurgery, 82 (7.4%) used sham interventions. The most common indication for the RCT was the treatment of pain (67.1%), followed by the treatment of movement disorders and other clinical problems (18.3%) and brain injuries (12.2%). The most used sham interventions were saline injections into spinal structures (31.7%) and peripheral nerves (10.9%), followed by sham interventions in cranial surgery (26.8%), and spine surgery (15.8%). Insertion of probes or catheters for a sham lesions was performed in 14.6%.In terms of methodology, most RCTs using sham interventions were double blinded (76.5%), 9.9% were single blinded, and 13.6% did not report the type of blinding. CONCLUSION Sham-controlled RCTs in neurosurgery are feasible. Most aim to minimize bias and to evaluate the efficacy of pain management methods, especially in spinal disorders. The greatest proportion of sham-controlled RCTs involves different types of substance administration routes, with sham surgery the less commonly performed.
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Affiliation(s)
- Rodrigo Panico Gorayeb
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Maria João Forjaz
- National School of Public Health, Institute of Health Carlos III and REDISSEC, Madrid, Spain
| | | | - Joaquim José Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal.,Instituto de Medicina Molecular, Lisbon, Portugal
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Lien-Iversen T, Morgan DB, Jensen C, Risberg MA, Engebretsen L, Viberg B. Does surgery reduce knee osteoarthritis, meniscal injury and subsequent complications compared with non-surgery after ACL rupture with at least 10 years follow-up? A systematic review and meta-analysis. Br J Sports Med 2019; 54:592-598. [DOI: 10.1136/bjsports-2019-100765] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2019] [Indexed: 12/14/2022]
Abstract
ObjectiveWe compared long-term follow-up from surgical versus non-surgical treatment of ACL rupture regarding radiographic knee osteoarthritis (OA), secondary surgery, laxity and patient-reported outcome measures (PROMs).DesignSystematic review and meta-analysis.Data sourcesEmbase, MEDLINE, CINAHL and the Cochrane Library databases.Eligibility criteria for selecting studiesStudies directly comparing the minimally invasive surgical (arthroscopy or miniarthrotomy) and non-surgical treatment of ACL rupture with at least 10 years of follow-up in adult patients were included.ResultsFive studies met the eligibility criteria. A meta-analysis revealed a higher risk of radiographic knee OA and a lower risk of secondary meniscal surgery for patients in the surgical group. The risk of graft rupture/secondary ACL revision and secondary ACL reconstruction was equal in the surgical and non-surgical groups. Knee laxity was lower among patients in the surgical group in four studies. No difference was found in the PROMs (ie, International Knee Documentation Committee, Tegner, Knee Injury and Osteoarthritis Outcome, and Lysholm scores).ConclusionThe risk of radiographic knee OA was higher, but the risk of secondary meniscal injury was lower 10 years after surgical treatment of ACL rupture. The risk of graft rupture/secondary ACL revision or secondary reconstruction was unrelated to treatment type. The degree of knee laxity was reduced after surgical treatment in comparison with non-surgical treatment, while PROMs were similar. However, due to the methodological challenges highlighted in this systematic review, these findings must be interpreted with caution.PROSPERO registration numberCRD42019119468
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Ho CM, Thorstensson CA, Nordeman L. Physiotherapist as primary assessor for patients with suspected knee osteoarthritis in primary care-a randomised controlled pragmatic study. BMC Musculoskelet Disord 2019; 20:329. [PMID: 31301739 PMCID: PMC6626628 DOI: 10.1186/s12891-019-2690-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/24/2019] [Indexed: 12/18/2022] Open
Abstract
Background In Swedish primary care, the healthcare process for patients with knee osteoarthritis (KOA) can be initiated by a physician or physiotherapist assessment. However, it is unclear how the different assessments affect the healthcare processes and patient reported outcomes over time. The purpose of this study was to examine the differences in health-related quality of life (HrQoL), adjusted for pain and physical function, for patients with KOA when the healthcare process is initiated by a physiotherapist assessment compared to a physician assessment in primary care. Methods An assessor-blinded randomised controlled pragmatic trial. Using a computer-generated list of random numbers, patients seeking primary care during 2013–2017 with suspected KOA were randomised to either a physiotherapist or physician for primary assessment and treatment. Data was collected before randomisation and at 3, 6, and 12-month follow-ups. Primary outcome was HrQoL using EuroQol 5 dimensions 3 levels questionnaire, index (EQ-5D-3L index) and a visual analogue scale (VAS) (EQ-5D-3L VAS); pain intensity was measured with VAS (0–100) and physical function measured with the 30-s chair stand test. Mixed effect model analyses compared repeated measures of HrQoL between groups. The significance level was p < 0.05 and data was applied with intention-to-treat. Results Patients were randomised to either a physiotherapist (n = 35) or physician (n = 34) for primary assessment. All 69 patients were included in the analyses. There were no significant differences in HrQoL for patients assessed by a physiotherapist or a physician as primary assessor (EQ-5D-3L index, p = 0.18; EQ-5D-3L VAS, p = 0.49). We found that HrQoL changed significantly 12 months after baseline assessment for all patients regardless of assessor (EQ-5D-3L index, p < 0.001; EQ-5D-3 L VAS, p = 0.0049). No adverse events or side effects were reported. Conclusions There were no differences in HrQoL, when adjusted for pain and physical function, for patients with KOA when the healthcare process was initiated with physiotherapist assessment compared to physician assessment in primary care. Both assessments resulted in significantly higher HrQoL at the 12-month follow-up. The results imply that physiotherapists and physicians in primary care are equally qualified as primary assessors. Trial registration Retrospectively registered at http://clinicaltrial.gov, ID: NCT03715764. Electronic supplementary material The online version of this article (10.1186/s12891-019-2690-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chan-Mei Ho
- Region Västra Götaland, Närhälsan Health Unit, Primary Health Care, Lidköping, Sweden. .,Department of Health and Rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.
| | - Carina A Thorstensson
- Department of Health and Rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.,Department of Neurobiology, Care sciences and Society, Unit of Physiotherapy, Karolinska Institutet, Stockholm, Sweden
| | - Lena Nordeman
- Department of Health and Rehabilitation, Unit of Physiotherapy, University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.,Region Västra Götaland, Närhälsan, Research and Development Primary Health Care, Research and Development Center Södra Älvsborg, Borås, Sweden
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18
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Marked and rapid change of bone shape in acutely ACL injured knees - an exploratory analysis of the Kanon trial. Osteoarthritis Cartilage 2019; 27:638-645. [PMID: 30654120 DOI: 10.1016/j.joca.2018.12.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/18/2018] [Accepted: 12/23/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND To investigate changes in knee 3D bone shape over the first 5 years after acute anterior cruciate ligament (ACL) injury in participants of the randomized controlled KANON-trial. METHODS Serial MR images over 5 years from 121 young (32 women, mean age 26.1 years) adults with an acute ACL tear in a previously un-injured knee were analyzed using statistical shape models for bone. A matched reference cohort of 176 individuals was selected from the Osteoarthritis Initiative (OAI). Primary endpoint was change in bone area of the medial femoral condyle; exploratory analyses compared results by treatment and examined other knee regions. Comparisons were made using repeated measures mixed model ANOVA with adjustment for age, sex and body mass index (BMI). RESULTS Mean medial femur bone area increased 3.2% (78.0 [95% CI 70.2 to 86.4] mm2) over 5 years after ACL injury and most prominently in knees treated with ACL reconstruction (ACLR). A higher rate of increase occurred over the first 2 years compared to the latter 3-years (66.2 [59.3 to 73.2] vs 17.6 [12.2 to 23.0] mm2) and was 6.7 times faster than in the reference cohort. The pattern and location of shape change in the extrapolated KANON data was very similar to that observed in another knee-osteoarthritis cohort. CONCLUSION 3D shape modelling after acute ACL injury revealed rapid bone shape changes, already evident at 3 months. The bone-change pattern after ACL injury demonstrated flattening and bone growth on the outer margins of the condyles similar to that reported in established knee osteoarthritis.
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19
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Watt FE, Corp N, Kingsbury SR, Frobell R, Englund M, Felson DT, Levesque M, Majumdar S, Wilson C, Beard DJ, Lohmander LS, Kraus VB, Roemer F, Conaghan PG, Mason DJ. Towards prevention of post-traumatic osteoarthritis: report from an international expert working group on considerations for the design and conduct of interventional studies following acute knee injury. Osteoarthritis Cartilage 2019; 27:23-33. [PMID: 30125638 PMCID: PMC6323612 DOI: 10.1016/j.joca.2018.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 07/17/2018] [Accepted: 08/06/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE There are few guidelines for clinical trials of interventions for prevention of post-traumatic osteoarthritis (PTOA), reflecting challenges in this area. An international multi-disciplinary expert group including patients was convened to generate points to consider for the design and conduct of interventional studies following acute knee injury. DESIGN An evidence review on acute knee injury interventional studies to prevent PTOA was presented to the group, alongside overviews of challenges in this area, including potential targets, biomarkers and imaging. Working groups considered pre-identified key areas: eligibility criteria and outcomes, biomarkers, injury definition and intervention timing including multi-modality interventions. Consensus agreement within the group on points to consider was generated and is reported here after iterative review by all contributors. RESULTS The evidence review identified 37 studies. Study duration and outcomes varied widely and 70% examined surgical interventions. Considerations were grouped into three areas: justification of inclusion criteria including the classification of injury and participant age (as people over 35 may have pre-existing OA); careful consideration in the selection and timing of outcomes or biomarkers; definition of the intervention(s)/comparator(s) and the appropriate time-window for intervention (considerations may be particular to intervention type). Areas for further research included demonstrating the utility of patient-reported outcomes, biomarkers and imaging outcomes from ancillary/cohort studies in this area, and development of surrogate clinical trial endpoints that shorten the duration of clinical trials and are acceptable to regulatory agencies. CONCLUSIONS These considerations represent the first international consensus on the conduct of interventional studies following acute knee joint trauma.
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Affiliation(s)
- F E Watt
- Arthritis Research UK Centre for Osteoarthritis Pathogenesis, Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Oxford, OX3 7FY, United Kingdom.
| | - N Corp
- Arthritis Research UK Primary Care Centre, Institute for Primary Care & Health Sciences, Keele University, Keele, UK.
| | - S R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Biomedical Research Centre, Leeds, UK.
| | - R Frobell
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, Sweden.
| | - M Englund
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, Sweden.
| | - D T Felson
- Clinical Epidemiology Research & Training Unit, Boston University School of Medicine, Boston, MA, USA; NIHR Biomedical Research Centre, University of Manchester, Manchester, UK.
| | - M Levesque
- Immunology Development, Abbvie Bioresearch Center, Worcester, MA, USA.
| | - S Majumdar
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, USA.
| | - C Wilson
- Dept of Trauma and Orthopaedics, University Health Board, Cardiff, UK.
| | - D J Beard
- Surgical Intervention Trials Unit (SITU), Nuffield Department of Orthopaedics, Rheumatology and Musculokeletal Sciences, University of Oxford, Oxford, UK.
| | - L S Lohmander
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, Sweden.
| | - V B Kraus
- Duke Molecular Physiology Institute and Division of Rheumatology, Duke University School of Medicine, Durham, USA.
| | - F Roemer
- Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany; Department of Radiology, Boston University School of Medicine, Boston, MA, USA.
| | - P G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Biomedical Research Centre, Leeds, UK.
| | - D J Mason
- Arthritis Research UK Biomechanics and Bioengineering Centre, School of Biosciences, Cardiff University, Cardiff, UK.
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20
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Khaiyat OA, Norris J. Electromyographic activity of selected trunk, core, and thigh muscles in commonly used exercises for ACL rehabilitation. J Phys Ther Sci 2018; 30:642-648. [PMID: 29706723 PMCID: PMC5909019 DOI: 10.1589/jpts.30.642] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/29/2018] [Indexed: 01/10/2023] Open
Abstract
[Purpose] Most of rehabilitation programmes for Anterior Cruciate Ligament (ACL) injury focus on quadriceps-hamstrings activation imbalances and less is known about kinetically linked muscles. This study investigated electromyographic activity of selected trunk, core, and thigh muscles during common rehabilitation exercises for ACL injury. [Subjects and Methods] Twelve active female volunteers participated in this cross-sectional laboratory study. Surface EMG was used to compare activation of eight trunk, hip/core, and lower limb muscles: Erector Spinae (ES), Rectus Abdominis (RA), Gluteus Maximus (GM), Vastus Lateralis (VL), Rectus Femoris (RF), Vastus Medialis (VM), Biceps Femoris (BF), and Semitendinosus (ST) during Forward Lunge, Double Leg Raise, Glute Bridge, Sit-Up, and Squat. [Results] Forward lunge produced significantly higher activation in the VM (61.1 ± 19.4), VL (59.2 ± 12.9), and RF (32.0 ± 2.6). Double leg raise generated highest activity in the RF (26.6 ± 2.8) and RA (43.3 ± 4.4); and Glute Bridge in the GM (44.5 ± 19.0) and BF (22.4 ± 4.3). Sit-up produced the highest activation in the RF (36.6 ± 4.7) followed by RA (18.9 ± 3.8). Squat produced a higher activation in VL (55.0 ± 12.9), VM (51.5 ± 18.2), and ES (40.4 ± 18.3). [Conclusion] This study provide further evidence for developing training programmes for ACL injury prevention and rehabilitation. A combination of exercises to reinstate quadriceps-hamstrings activation balance and enhance core stability is recommended.
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Affiliation(s)
- Omid A Khaiyat
- School of Health Sciences, Liverpool Hope University: Hope Park, Liverpool L16 9JD, UK
| | - Jessica Norris
- School of Health Sciences, Liverpool Hope University: Hope Park, Liverpool L16 9JD, UK
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21
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Wu B, Lorezanza D, Badash I, Berger M, Lane C, Sum JC, Hatch GF, Schroeder ET. Perioperative Testosterone Supplementation Increases Lean Mass in Healthy Men Undergoing Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial. Orthop J Sports Med 2017; 5:2325967117722794. [PMID: 28840147 PMCID: PMC5555502 DOI: 10.1177/2325967117722794] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Rehabilitation after repair of the anterior cruciate ligament (ACL) is complicated by the loss of leg muscle mass and strength. Prior studies have shown that preoperative rehabilitation may improve muscle strength and postoperative outcomes. Testosterone supplementation may likewise counteract this muscle loss and potentially improve clinical outcomes. Purpose: The purpose was to investigate the effect of perioperative testosterone administration on lean mass after ACL reconstruction in men and to examine the effects of testosterone on leg strength and clinical outcome scores. It was hypothesized that testosterone would increase lean mass and leg strength and improve clinical outcome scores relative to placebo. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Male patients (N = 13) scheduled for ACL reconstruction were randomized into 2 groups: testosterone and placebo. Participants in the testosterone group received 200 mg of intramuscular testosterone weekly for 8 weeks beginning 2 weeks before surgery. Participants in the placebo group received saline following the same schedule. Both groups participated in a standard rehabilitation protocol. The primary outcome was the change in total lean body mass at 6 and 12 weeks. Secondary outcomes were extensor muscle strength, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score. Results: There was an increase in lean mass of a mean 2.7 ± 1.7 kg at 6 weeks postoperatively in the testosterone group compared with a decrease of a mean 0.1 ± 1.5 kg in the placebo group (P = .01). Extensor muscle strength of the uninjured leg also increased more from baseline in the testosterone group (+20.8 ± 25.6 Nm) compared with the placebo group (–21.4 ± 36.7 Nm) at 12 weeks (P = .04). There were no significant between-group differences in injured leg strength or clinical outcome scores. There were no negative side effects of testosterone noted. Conclusion: Perioperative testosterone supplementation increased lean mass 6 weeks after ACL reconstruction, suggesting that this treatment may help minimize the effects of muscle atrophy associated with ACL injuries and repair. This study was not powered to detect differences in strength or clinical outcome scores to assess the incidence of testosterone-related adverse events. Clinical Relevance: Supraphysiological testosterone supplementation may be a useful adjunct therapy for counteracting muscle atrophy after ACL reconstruction. Further investigation is necessary to determine the safety profile and effects of perioperative testosterone administration on leg strength and clinical outcomes after surgery. Registration: NCT01595581 (ClinicalTrials.gov).
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Affiliation(s)
- Brian Wu
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Dan Lorezanza
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ido Badash
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Max Berger
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Christianne Lane
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jonathan C Sum
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - George F Hatch
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - E Todd Schroeder
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Driban JB, Lohmander S, Frobell RB. Posttraumatic Bone Marrow Lesion Volume and Knee Pain Within 4 Weeks After Anterior Cruciate Ligament Injury. J Athl Train 2017; 52:575-580. [PMID: 28653872 PMCID: PMC5488848 DOI: 10.4085/1062-6050-52.1.09] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
CONTEXT After an anterior cruciate ligament (ACL) injury, a majority of patients have a traumatic bone marrow lesion (BML, or bone bruise). The clinical relevance of posttraumatic lesions remains unclear. OBJECTIVE To explore the cross-sectional associations between traumatic BML volume and self-reported knee pain and symptoms among individuals within 4 weeks of ACL injury. DESIGN Cross-sectional exploratory analysis of a randomized clinical trial. SETTING Orthopaedic departments at 2 hospitals in Sweden. PATIENTS OR OTHER PARTICIPANTS As part of a randomized trial (knee anterior cruciate ligament nonoperative versus operative treatment [KANON] study), 121 young active adults (74% men, age = 26 ± 5 years, height = 1.8 ± 0.1 m, weight = 76 ± 13 kg) with an ACL tear were studied. MAIN OUTCOME MEASURE(S) The BML volume in the proximal tibia and distal femur was segmented using magnetic resonance images obtained within 4 weeks of injury. A radiologist evaluated the presence of depression fractures on the images. Pain and symptoms of the injured knee (Knee Injury and Osteoarthritis Outcome Score [KOOS] pain and symptoms subscales) were obtained the same day as imaging. We used linear regression models to assess the associations. RESULTS Most knees had at least 1 BML (96%), and the majority (57%) had a depression fracture. Whole-knee BML volume was not related to knee pain for the entire cohort (β = -0.09, P = .25). Among those without a depression fracture, larger whole-knee BML volume was associated with increased knee pain (β = -0.46, P = .02), whereas no association was found for those with a depression fracture (β = 0.0, P = .96). Larger medial (β = -0.48, P = .02) but not lateral (β = -0.03, P = .77) tibiofemoral BML volume was associated with greater pain. We found no association between BML volume and knee symptoms. CONCLUSIONS We confirmed the absence of relationships between whole-knee BML volume and pain and symptoms within 4 weeks of ACL injury. Our findings extend previous reports in identifying weak associations between larger BML volume in the medial compartment and greater pain and between BML volume and greater pain among those without a depression fracture.
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Filbay SR, Roos EM, Frobell RB, Roemer F, Ranstam J, Lohmander LS. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial. Br J Sports Med 2017; 51:1622-1629. [PMID: 28515057 PMCID: PMC5754848 DOI: 10.1136/bjsports-2016-097124] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2017] [Indexed: 12/29/2022]
Abstract
Aim Identify injury-related, patient-reported and treatment-related prognostic factors for 5-year outcomes in acutely ACL-ruptured individuals managed with early reconstruction plus exercise therapy, exercise therapy plus delayed reconstruction or exercise therapy alone. Methods Exploratory analysis of the Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment (KANON) trial (ISRCTN84752559). Relationships between prognostic factors (baseline cartilage, meniscus and osteochondral damage, baseline extension deficit, baseline patient-reported outcomes, number of rehabilitation visits, graft/contralateral ACL rupture, non-ACL surgery and ACL treatment strategy) and 5-year Knee Injury and Osteoarthritis Outcome Score (KOOS) pain, symptoms, sport/recreation and quality of life (QOL) scores were explored using multivariable linear regression. Estimates were adjusted for sex, age, body mass index, preinjury activity level, education and smoking. Results For all participants (n=118), graft/contralateral ACL rupture, non-ACL surgery and worse baseline 36-item Short-Form Mental Component Scores were associated with worse outcomes. Treatment with exercise therapy alone was a prognostic factor for less knee symptoms compared with early reconstruction plus exercise therapy (regression coefficient 10.1, 95% CI 2.3 to 17.9). Baseline meniscus lesion was associated with worse sport/recreation function (−14.4, 95% CI −27.6 to –1.3) and osteochondral lesions were associated with worse QOL (−12.3, 95% CI −24.3 to –0.4) following early reconstruction plus exercise therapy. In the same group, undergoing additional non-ACL surgery and worse baseline KOOS scores were prognostic for worse outcome on all KOOS subscales. Following delayed reconstruction, baseline meniscus damage was a prognostic factor for less pain (14.3, 95% CI 0.7 to 27.9). Following exercise therapy alone, undergoing non-ACL surgery was prognostic for worse pain. Conclusions Treatment-dependent differences in prognostic factors for 5-year outcomes may support individualised treatment after acute ACL rupture in young active individuals. Trial registration number Current Controlled Trials ISRCTN84752559.
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Affiliation(s)
- Stephanie R Filbay
- Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ewa M Roos
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Richard B Frobell
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Faculty of Medicine, Lund, Sweden
| | - Frank Roemer
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Faculty of Medicine, Lund, Sweden.,Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany.,Quantitative Imaging Center (QIC), Department of Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Faculty of Medicine, Lund, Sweden
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The Association Between Knee Confidence and Muscle Power, Hop Performance, and Postural Orientation in People With Anterior Cruciate Ligament Injury. J Orthop Sports Phys Ther 2016; 46:477-82. [PMID: 27117728 DOI: 10.2519/jospt.2016.6374] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Design Cross-sectional. Background The association between muscle function and lack of knee confidence in people with anterior cruciate ligament (ACL) injury has not been well investigated. Such knowledge would help in the design of training programs for this population. Objective To investigate associations between self-reported knee confidence and muscle function in patients with ACL injury. Methods Cross-sectional data from 54 patients (mean age, 30 years; range, 20-39 years; 28% women) with ACL injury, treated with training and reconstructive surgery (n = 36) or training only (n = 18), were assessed 3 ± 1 years after injury. Univariate and multivariable ordinal regression analyses were conducted to test the association between the patient's knee confidence (question 3 from the Knee injury and Osteoarthritis Outcome Score as the dependent variable) and performance on tests of muscle power, hop performance, and postural orientation (test for substitution patterns score) as independent variables (absolute value on the injured leg, and limb symmetry index [LSI; injured leg/uninjured leg × 100] or absolute difference between the injured and uninjured legs). Results Sixteen patients reported no trouble with lack of knee confidence, 24 mild trouble, 10 moderate trouble, and 4 severe or extreme trouble. Univariate analyses revealed significant associations between worse knee confidence and lower (worse) LSIs for knee extension power, vertical jump, and side hop, and worse test for substitution patterns scores. In the multivariable analysis, worse vertical jump LSI (P = .043) and worse side hop LSI (P = .012) significantly accounted for 25% of the variation in perceived knee confidence. Conclusion Between-leg differences during demanding tasks are associated with knee confidence in individuals with ACL injury. J Orthop Sports Phys Ther 2016;46(6):477-482. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6374.
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Kiadaliri AA, Englund M, Lohmander LS, Carlsson KS, Frobell RB. No economic benefit of early knee reconstruction over optional delayed reconstruction for ACL tears: registry enriched randomised controlled trial data. Br J Sports Med 2016; 50:558-63. [PMID: 26935859 DOI: 10.1136/bjsports-2015-095308] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND To analyse 5-year cost-effectiveness of early versus optional delayed acute anterior cruciate ligament (ACL) reconstruction. METHODS 121 young, active adults with acute ACL injury to a previously uninjured knee were randomised to early ACL reconstruction (n=62, within 10 weeks of injury) or optional delayed ACL reconstruction (n=59; 30 with ACL reconstruction within 6-55 months); all patients received similar structured rehabilitation. Real life data on health care utilisation and sick leave were obtained from regional and national registers. Costs and quality-adjusted life years (QALYs) were discounted at 3%. Full-analysis set (based on study randomisation) and as-treated analysis (according to actual treatment over 5 years) principles were applied. RESULTS Mean cost of early ACL reconstruction was €4695 higher than optional delayed ACL reconstruction (p=0.19) and provided an additional 0.13 QALYs (p=0.11). Full-analysis set showed incremental net benefit of early versus optional delayed ACL reconstruction was not statistically significantly different from zero at any level. As-treated analysis showed that costs for rehabilitation alone were €13 650 less than early ACL reconstruction (p<0.001). Results were robust to sensitivity analyses. CONCLUSIONS In young active adults with acute ACL injury, a strategy of early ACL reconstruction did not provide extra economic value over a strategy of optional delayed ACL reconstruction over a 5-year period. Results from this and previous reports of the KANON-trial imply that early identification of individuals who would benefit from either early ACL reconstruction or rehabilitation alone might reduce resource consumption and decrease risk of unnecessary overtreatment. TRIAL REGISTRATION ISRCTN84752559.
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Affiliation(s)
- Aliasghar A Kiadaliri
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Martin Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA
| | - L Stefan Lohmander
- Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark Department of Orthopedics and Traumatology, University of Southern Denmark, Odense, Denmark
| | - Katarina Steen Carlsson
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden The Swedish Institute of Health Economics, Lund, Sweden
| | - Richard B Frobell
- Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Krych AJ, Woodcock JA, Morgan JA, Levy BA, Stuart MJ, Dahm DL. Factors associated with excellent 6-month functional and isokinetic test results following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:1053-9. [PMID: 24531355 DOI: 10.1007/s00167-014-2869-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 01/22/2014] [Indexed: 01/11/2023]
Abstract
PURPOSE To identify patient concomitant injury and surgical characteristics associated with 6-month excellent functional and isokinetic testing results following anterior cruciate ligament (ACL) reconstruction. METHODS Patients that underwent ACL reconstruction by a single surgeon had isokinetic and functional testing performed with excellent 6-month outcome defined as greater than 85 % in isokinetic strength and 90 % in functional tests (excellent 6-month group vs. delayed 6-month group). Patient concomitant injury and surgical factors were then analysed in univariate and multivariate statistical models to assess which characteristics predicted the excellent 6-month group. RESULTS The 224 patients included 93 males and 131 females, with median age of 22 (range 12-59) years, body mass index (BMI) of 25.4 (range 17-44), and median Tegner activity score of 6 (range 2-10). Fifty-two patients (23 %) were included in the excellent 6-month group, while 172 patients (77 %) were in the delayed 6-month group. In univariate analysis, favourable factors with the excellent 6-month outcome group were younger age (24 vs. 27; p = 0.01), lower BMI (24.5 vs. 26.2; p = 0.03), and minimal articular cartilage damage (71 vs. 56 %; p = 0.048). In multivariate analysis, a negative effect was observed for patients older than 30 years that had ACL reconstruction with autograft (p = 0.0004). CONCLUSION Factors significantly associated with excellent 6-month functional and isokinetic test results following ACL reconstruction included younger age, lower BMI, and minimal cartilage degeneration. The use of allograft was associated with improved functional and strength testing after ACL reconstruction in patients over 30 years of age. LEVEL OF EVIDENCE Prognostic/therapeutic study, Level III.
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Affiliation(s)
- Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St., SW, Rochester, MN, 55905, USA
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Eckstein F, Wirth W, Lohmander LS, Hudelmaier MI, Frobell RB. Five-year followup of knee joint cartilage thickness changes after acute rupture of the anterior cruciate ligament. Arthritis Rheumatol 2015; 67:152-61. [PMID: 25252019 DOI: 10.1002/art.38881] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 09/11/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Anterior cruciate ligament (ACL) rupture involves an increased risk of osteoarthritis. The purpose of this study was to explore changes in cartilage thickness over 5 years after ACL rupture. METHODS A total of 121 young active adults (ages 18-35 years; 26% women) from the Knee ACL, Nonsurgical versus Surgical Treatment (KANON) study, who had acute traumatic rupture of the ACL were studied. Sagittal magnetic resonance images were acquired within 4 weeks of ACL rupture (baseline) and at the 2-year and 5-year followup assessments. Medial and lateral femorotibial cartilage was segmented (with blinding to acquisition order), and the mean cartilage thickness was computed across 16 femorotibial subregions. Total femorotibial cartilage thickness change was the primary analytic focus. Maximal subregional mean cartilage thickness loss (ordered value 1 [OV1]) and gain (ordered value 16 [OV16]), independent of its specific location in individual knees, were the secondary analytic focus. RESULTS Overall femorotibial cartilage thickness increased by 31 μm/year over 5 years (95% confidence interval 18, 44). The increase was similar in men and women and was significantly greater in those younger, as compared with those older, than the median age (25.3 years). The rate of total cartilage thickness change did not differ significantly between the first 2 years and the later 3 years. However, the maximal annualized subregional cartilage loss (OV1) and gain (OV16) were both significantly greater (P < 0.001 and P < 0.05, respectively) during the earlier interval than during the later interval (-115 versus -54 μm [OV1] and 116 versus 69 μm [OV16]). CONCLUSION Cartilage thickening was observed over 5 years following ACL injury, particularly in the medial femorotibial compartment and in younger subjects. Major perturbations in cartilage homeostasis were seen over the first 2 years after ACL rupture, with simultaneous subregional thinning and thickening occurring within the same cartilage plate or compartment.
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Affiliation(s)
- F Eckstein
- Institute of Anatomy, Paracelsus Medical University, Salzburg and Nuremberg, Salzburg, Austria, and Chondrometrics GmbH, Ainring, Germany
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Reiman MP, Thorborg K. Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence? Br J Sports Med 2015; 49:782-4. [PMID: 25677797 DOI: 10.1136/bjsports-2014-093821] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2015] [Indexed: 01/11/2023]
Abstract
Femoroacetabuler impingement (FAI) is becoming increasingly recognised as a potential pathological entity for individuals with hip pain. Surgery described to correct FAI has risen exponentially in the past 10 years with the use of hip arthroscopy. Unfortunately, the strength of evidence supporting both the examination and treatment of FAI does not appear to accommodate this exponential growth. In fact, the direction currently taken for FAI is similar to previously described paths of other orthopaedic and sports medicine pathologies (eg, shoulder impingement, knee meniscus tear) for which we have learned valuable lessons. The time has come for improved terminology, study design, and focus on delineation of successful treatment variables in the interest of those individuals with clinical indications of FAI so that we can appropriately address their needs.
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Affiliation(s)
- Michael P Reiman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Kristian Thorborg
- Sports Orthopedic Research Centre-Copenhagen (SORC-C), Amager-Hvidovre University Hospital, Copenhagen, Denmark Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Amager-Hvidovre University Hospital, Copenhagen, Denmark
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Wu BW, Berger M, Sum JC, Hatch GF, Schroeder ET. Randomized control trial to evaluate the effects of acute testosterone administration in men on muscle mass, strength, and physical function following ACL reconstructive surgery: rationale, design, methods. BMC Surg 2014; 14:102. [PMID: 25481088 PMCID: PMC4267143 DOI: 10.1186/1471-2482-14-102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 12/01/2014] [Indexed: 11/24/2022] Open
Abstract
Background The anterior cruciate ligament (ACL) is one of four major ligaments in the knee that provide stability during physical activity. A tear in the ACL is characterized by joint instability that leads to decreased activity, knee dysfunction, reduced quality of life and a loss of muscle mass and strength. While rehabilitation is the standard-of-care for return to daily function, additional surgical reconstruction can provide individuals with an opportunity to return to sports and strenuous physical activity. Over 200,000 ACL reconstructions are performed in the United States each year, and rehabilitation following surgery is slow and expensive. One possible method to improve the recovery process is the use of intramuscular testosterone, which has been shown to increase muscle mass and strength independent of exercise. With short-term use of supraphysiologic doses of testosterone, we hope to reduce loss of muscle mass and strength and minimize loss of physical function following ACL reconstruction compared to standard-of-care alone. Methods/design This study is a double-blinded randomized control trial. Men 18–50 years of age, scheduled for ACL reconstruction are randomized into two groups. Participants randomized to the testosterone group receive intramuscular testosterone administration once per week for 8 weeks starting 2 weeks prior to surgery. Participants randomized to the control group receive a saline placebo intramuscularly instead of testosterone. Lean mass, muscle strength and physical function are measured at 5 time points: 2 weeks pre-surgery, 1 day pre-surgery, and 6, 12, 24 weeks post-surgery. Both groups follow standard-of-care rehabilitation protocol. Discussion We believe that testosterone therapy will help reduce the loss of muscle mass and strength experienced after ACL injury and reconstruction. Hopefully this will provide a way to shorten the rehabilitation necessary following ACL reconstruction. If successful, testosterone therapy may also be used for other injuries involving trauma and muscle atrophy. Trial registration NTC01595581, Registration: May 8, 2012
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Affiliation(s)
- Brian W Wu
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Hunter DJ, Lohmander LS, Makovey J, Tamez-Peña J, Totterman S, Schreyer E, Frobell RB. The effect of anterior cruciate ligament injury on bone curvature: exploratory analysis in the KANON trial. Osteoarthritis Cartilage 2014; 22:959-68. [PMID: 24867633 DOI: 10.1016/j.joca.2014.05.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 04/30/2014] [Accepted: 05/14/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Investigate the 5-year longitudinal changes in bone curvature after acute anterior cruciate ligament (ACL) injury, and identify predictors of such changes. METHODS In the KANON-trial (ISRCTN 84752559), 111/121 young active adults with an acute ACL tear to a previously un-injured knee had serial 1.5 T MR images from baseline (within 5 weeks from injury) to 5 years after injury. Of these, 86 had ACL reconstruction (ACLR) performed early or delayed, 25 were treated with rehabilitation alone. Measures of articulating bone curvature were obtained from computer-assisted segmentation of MR images. Curvature (mm(-1)) was determined for femur, tibia, medial/lateral femur, trochlea, medial/lateral tibia. Age, sex, treatment, BMI, meniscal injury, osteochondral fracture on baseline MR images were tested for association. RESULTS Over 5 years, curvature decreased in each region (P < 0.001) suggesting flattening of convex shapes and increased concavity of concave shapes. A higher BMI was associated with flattening of the femur (P = 0.03), trochlea (P = 0.007) and increasing concavity of the lateral tibia (LT) (P = 0.011). ACLR, compared to rehabilitation alone, was associated with flatter curvature in the femur (P < 0.001), medial femoral condyle (P = 0.006) and trochlea (P = 0.003). Any meniscal injury at baseline was associated with a more flattened curvature in the femur (P = 0.038), trochlea (P = 0.039), lateral femoral condyle (P = 0.034) and increasing concavity of the LT (P = 0.048). CONCLUSION ACL injury is associated with significant changes in articulating bone curvature over a 5 year period. Higher BMI, baseline meniscal injury and undergoing ACL reconstruction (as distinct from undergoing rehabilitation alone) are all associated with flattening of the articulating bone.
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Affiliation(s)
- D J Hunter
- Rheumatology Department, Royal North Shore Hospital and Kolling Institute, University of Sydney, Sydney, NSW, Australia.
| | - L S Lohmander
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Lund, Sweden; Research Unit for Musculoskeletal Function and Physiotherapy and Department of Orthopaedics and Traumatology, University of Southern Denmark, Odense, Denmark
| | - J Makovey
- Rheumatology Department, Royal North Shore Hospital and Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - J Tamez-Peña
- Escuela de Medicina, Tecnológico de Monterrey, Monterrey, NL, México; Qmetrics Technologies, Rochester, NY, USA
| | | | - E Schreyer
- Qmetrics Technologies, Rochester, NY, USA
| | - R B Frobell
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Lund, Sweden
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Hare KB, Lohmander LS, Roos EM. The challenge of recruiting patients into a placebo-controlled surgical trial. Trials 2014; 15:167. [PMID: 24884948 PMCID: PMC4030043 DOI: 10.1186/1745-6215-15-167] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 04/30/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Randomized placebo-controlled trials represent the gold standard in evaluating healthcare interventions but are rarely performed within orthopedics. Ethical concerns or well-known challenges in recruiting patients for surgical trials in general have been expressed and adding a placebo component only adds to this complexity. The purpose of this study was to report the challenges of recruiting patients into an orthopedic placebo-controlled surgical trial, to determine the number of patients needed to be screened and allocated in order to include one participant into the trial, and to identify reasons associated with participation in a placebo-controlled randomized surgical trial. METHODS Data were extracted from an ongoing placebo-controlled randomized controlled trial (RCT) on meniscectomy versus placebo surgery. We calculated the number of patients needed to be screened in order to include the required number of participants into the RCT. Participating patients were asked about their rationale for joining the study and which type of information was most useful for deciding upon participation. RESULTS A total of 476 patients entered the screening group, of which 190 patients fulfilled the inclusion and exclusion criteria. 102 patients declined to participate in the study due to various reasons and 46 were later excluded (no meniscus lesion on the magnetic resonance imaging scan or withdrawn consent). A total of 40 patients were finally included in the RCT. To include one patient into the RCT, 11.9 individuals needed to be screened. A total of 69% of participating patients considered the oral information to be the most important and the most common reason for participating was the contribution to research (90%). CONCLUSIONS Patients are willing to participate in an orthopedic placebo-controlled surgical trial. Oral information given by the surgeon to the patient and the contribution to research are important aspects to enhance patient recruitment. TRIAL REGISTRATION ClinicalTrials.gov NCT01264991, registered 21 December 2010.
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Affiliation(s)
- Kristoffer B Hare
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
- Department of Orthopedics, Slagelse Hospital, Ingemannsvej 18, 4200 Slagelse, Region Zealand, Denmark
| | - L Stefan Lohmander
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
- Department of Orthopedics, Clinical Sciences Lund, University of Lund, Paradisgatan 2, 221 00 Lund, Sweden
| | - Ewa M Roos
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
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Signal intensity on magnetic resonance imaging after allograft double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22:1002-8. [PMID: 24474586 DOI: 10.1007/s00167-014-2856-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 01/12/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate magnetic resonance imaging (MRI) graft signal intensity after allograft double-bundle (DB) anterior cruciate ligament (ACL) reconstruction and determine the relationship between signal intensity and time from surgery. METHODS Twenty-six patients with an intact graft on MRI after anatomic allograft DB ACL reconstruction up to 1 year post-operatively were included. All subjects underwent post-operative MRI using a 1.5-T magnet. Sagittal proton density-weighted images (PDWI) and sagittal T2-weighted images (T2WI) were analysed. Using the region-of-interest (ROI) function on imaging software, the anteromedial (AM) and posterolateral (PL) bundles of the graft and the posterior cruciate ligament (PCL) were outlined. Mean signal intensity of the three ROIs were recorded as absolute signal intensity. Signal intensity (SI ratio) was calculated based on the signal intensity of the PCL. Correlation coefficients were calculated to determine the relationship between signal intensity and time from surgery. RESULTS SI ratio of the PL bundle was higher than that of the AM bundle for both the PDWI (1.7 ± 1.5 vs. 2.5 ± 1.7, p < 0.05) and T2WI (1.3 ± 0.4 vs 1.6 ± 0.6, p < 0.05). There were weak correlations between AM SI ratio and time from surgery (r = 0.38, p < 0.05 on PDWI), and moderate correlations between PL SI ratio and time from surgery (r = 0.43, p < 0.05 on PDWI) (r = 0.44, p < 0.05 on T2WI). CONCLUSIONS The PL bundle displayed increased signal intensity compared to the AM bundle and based on previous studies may indicate a longer healing process. Plain MRI may be useful to assess graft healing after ACL reconstruction. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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Smith TO, Postle K, Penny F, McNamara I, Mann CJV. Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. Knee 2014; 21:462-70. [PMID: 24238648 DOI: 10.1016/j.knee.2013.10.009] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 08/28/2013] [Accepted: 10/14/2013] [Indexed: 02/06/2023]
Abstract
AIMS The purpose of this study was to determine the optimal clinical and cost-effective strategy for managing people following ACL rupture. METHODS A systematic review of the published (AMED, CINAHL, MEDLINE, EMBASE, PubMed, psycINFO and the Cochrane Library) and unpublished literature (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials and the UK National Research Register Archive) was conducted on April 2013. All randomised and non-randomised controlled trials evaluating clinical or health economic outcomes of isolated ligament reconstruction versus non-surgical management following ACL rupture were included. Methodological quality was assessed using the PEDro appraisal tool. When appropriate, meta-analysis was conducted to pool data. RESULTS From a total of 943 citations, sixteen studies met the eligibility criteria. These included 1397 participants, 825 who received ACL reconstruction versus 592 who were managed non-surgically. The methodological quality of the literature was poor. The findings indicated that whilst reconstructed ACL offers significantly greater objective tibiofemoral stability (p<0.001), there appears limited evidence to suggest a superiority between reconstruction versus non-surgical management in functional outcomes. There was a small difference between the management strategies in respect to the development of osteoarthritis during the initial 20 years following index management strategy (Odds Ratio 1.56; p=0.05). CONCLUSIONS The current literature is insufficient to base clinical decision-making with respect to treatment opinions for people following ACL rupture. Whilst based on a poor evidence, the current evidence would indicate that people following ACL rupture should receive non-operative interventions before surgical intervention is considered.
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Affiliation(s)
- T O Smith
- University of East Anglia, Norwich, UK.
| | - K Postle
- University of East Anglia, Norwich, UK
| | - F Penny
- Norfolk and Norwich University Hospital, Norwich, UK
| | - I McNamara
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C J V Mann
- Norfolk and Norwich University Hospital & University of East Anglia, Norwich, UK
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Salpakoski A, Törmäkangas T, Edgren J, Kallinen M, Sihvonen SE, Pesola M, Vanhatalo J, Arkela M, Rantanen T, Sipilä S. Effects of a multicomponent home-based physical rehabilitation program on mobility recovery after hip fracture: a randomized controlled trial. J Am Med Dir Assoc 2014; 15:361-8. [PMID: 24559642 DOI: 10.1016/j.jamda.2013.12.083] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/17/2013] [Accepted: 12/23/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate whether a home-based rehabilitation program for community-dwelling older people with recent hip fracture is more effective than standard care in improving mobility recovery and reducing disability. DESIGN Randomized, controlled, parallel-group trial. SETTING Rehabilitation in participants' homes; measurements in university-based laboratory and local hospital. PARTICIPANTS Clinical population of community-dwelling men and women (aged 60+) recovering from hip fracture. Participants were randomly assigned into control (n = 41) or intervention (n = 40) groups on average 42 ± 23 days after discharge home. INTERVENTION A yearlong multicomponent home-based rehabilitation aimed at promoting mobility recovery and physical functional capacity after hip fracture. The intervention included evaluation and modification of environmental hazards, guidance for safe walking, nonpharmacological pain management, a progressive home exercise program, physical activity counseling, and standard care. MEASUREMENTS Measurements were outlined according to the tiers of the disablement process, with the ability to negotiate stairs as the main outcome. Prefracture ability to negotiate stairs was enquired at the hospital on average 10 ± 5 days after fracture. Subsequently, current perceived ability to negotiate stairs was reported immediately before the intervention (on average 9 weeks after surgery) and 3, 6, and 12 months thereafter. Other measurements included leg extension power deficit (LEP), functional balance (Berg Balance Scale) and lower extremity performance (Short Physical Performance Battery). Effects of the intervention were analyzed with generalized estimation equations and longitudinal repeated measures mixture path models. RESULTS The intervention reduced perceived difficulties in negotiating stairs (interaction, group × time P = .001) from prefracture to 12 months compared with the control condition. The mixture path model revealed that less difficulty in negotiating stairs at 6 and 12 months correlated with better functional balance at 3 and 6 months in the intervention group but not controls (group difference P = .007 and P < .001, respectively). CONCLUSION The individualized home-based rehabilitation program improved mobility recovery after hip fracture over standard care. To be efficacious in reducing or reversing disability after hip fracture, rehabilitation needs to be individualized, include many components, be progressive, and span a sufficiently long period. Current Controlled Trials (ISRCTN53680197).
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Affiliation(s)
- Anu Salpakoski
- Gerontology Research Center and Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland.
| | - Timo Törmäkangas
- Gerontology Research Center and Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Johanna Edgren
- Gerontology Research Center and Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Mauri Kallinen
- Department of Medical Rehabilitation, Oulu University Hospital, Oulu, Finland
| | - Sanna E Sihvonen
- University of Applied Sciences, School of Health and Social Studies, Jyväskylä, Finland
| | - Maija Pesola
- Department of Orthopedics and Traumatology, Central Finland Central Hospital, Jyväskylä, Finland
| | - Jukka Vanhatalo
- Department of Physical and Rehabilitation Medicine, Central Finland Central Hospital, Jyväskylä, Finland
| | - Marja Arkela
- Department of Physical and Rehabilitation Medicine, Central Finland Central Hospital, Jyväskylä, Finland
| | - Taina Rantanen
- Gerontology Research Center and Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Sarianna Sipilä
- Gerontology Research Center and Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland
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Ericsson YB, Roos EM, Frobell RB. Lower extremity performance following ACL rehabilitation in the KANON-trial: impact of reconstruction and predictive value at 2 and 5 years. Br J Sports Med 2013; 47:980-5. [DOI: 10.1136/bjsports-2013-092642] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ 2013; 346:f232. [PMID: 23349407 PMCID: PMC3553934 DOI: 10.1136/bmj.f232] [Citation(s) in RCA: 298] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare, in young active adults with an acute anterior cruciate ligament (ACL) tear, the mid-term (five year) patient reported and radiographic outcomes between those treated with rehabilitation plus early ACL reconstruction and those treated with rehabilitation and optional delayed ACL reconstruction. DESIGN Extended follow-up of prospective randomised controlled trial. SETTING Orthopaedic departments at two hospitals in Sweden. PARTICIPANTS 121 young, active adults (mean age 26 years) with acute ACL injury to a previously uninjured knee. One patient was lost to five year follow-up. INTERVENTION All patients received similar structured rehabilitation. In addition to rehabilitation, 62 patients were assigned to early ACL reconstruction and 59 were assigned to the option of having a delayed ACL reconstruction if needed. MAIN OUTCOME MEASURE The main outcome was the change from baseline to five years in the mean value of four of the five subscales of the knee injury and osteoarthritis outcome score (KOOS(4)). Other outcomes included the absolute KOOS(4) score, all five KOOS subscale scores, SF-36, Tegner activity scale, meniscal surgery, and radiographic osteoarthritis at five years. RESULTS Thirty (51%) patients assigned to optional delayed ACL reconstruction had delayed ACL reconstruction (seven between two and five years). The mean change in KOOS(4) score from baseline to five years was 42.9 points for those assigned to rehabilitation plus early ACL reconstruction and 44.9 for those assigned to rehabilitation plus optional delayed reconstruction (between group difference 2.0 points, 95% confidence interval -8.5 to 4.5; P=0.54 after adjustment for baseline score). At five years, no significant between group differences were seen in KOOS(4) (P=0.45), any of the KOOS subscales (P ≥ 0.12), SF-36 (P ≥ 0.34), Tegner activity scale (P=0.74), or incident radiographic osteoarthritis of the index knee (P=0.17). No between group differences were seen in the number of knees having meniscus surgery (P=0.48) or in a time to event analysis of the proportion of meniscuses operated on (P=0.77). The results were similar when analysed by treatment actually received. CONCLUSION In this first high quality randomised controlled trial with minimal loss to follow-up, a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear. TRIAL REGISTRATION Current Controlled Trials ISRCTN84752559.
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Affiliation(s)
- Richard B Frobell
- Department of Orthopaedics, Clinical Sciences Lund, Lund University, SE-22185 Lund, Sweden.
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Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ (CLINICAL RESEARCH ED.) 2013. [PMID: 23349407 DOI: 10.1136/bmj.f232.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare, in young active adults with an acute anterior cruciate ligament (ACL) tear, the mid-term (five year) patient reported and radiographic outcomes between those treated with rehabilitation plus early ACL reconstruction and those treated with rehabilitation and optional delayed ACL reconstruction. DESIGN Extended follow-up of prospective randomised controlled trial. SETTING Orthopaedic departments at two hospitals in Sweden. PARTICIPANTS 121 young, active adults (mean age 26 years) with acute ACL injury to a previously uninjured knee. One patient was lost to five year follow-up. INTERVENTION All patients received similar structured rehabilitation. In addition to rehabilitation, 62 patients were assigned to early ACL reconstruction and 59 were assigned to the option of having a delayed ACL reconstruction if needed. MAIN OUTCOME MEASURE The main outcome was the change from baseline to five years in the mean value of four of the five subscales of the knee injury and osteoarthritis outcome score (KOOS(4)). Other outcomes included the absolute KOOS(4) score, all five KOOS subscale scores, SF-36, Tegner activity scale, meniscal surgery, and radiographic osteoarthritis at five years. RESULTS Thirty (51%) patients assigned to optional delayed ACL reconstruction had delayed ACL reconstruction (seven between two and five years). The mean change in KOOS(4) score from baseline to five years was 42.9 points for those assigned to rehabilitation plus early ACL reconstruction and 44.9 for those assigned to rehabilitation plus optional delayed reconstruction (between group difference 2.0 points, 95% confidence interval -8.5 to 4.5; P=0.54 after adjustment for baseline score). At five years, no significant between group differences were seen in KOOS(4) (P=0.45), any of the KOOS subscales (P ≥ 0.12), SF-36 (P ≥ 0.34), Tegner activity scale (P=0.74), or incident radiographic osteoarthritis of the index knee (P=0.17). No between group differences were seen in the number of knees having meniscus surgery (P=0.48) or in a time to event analysis of the proportion of meniscuses operated on (P=0.77). The results were similar when analysed by treatment actually received. CONCLUSION In this first high quality randomised controlled trial with minimal loss to follow-up, a strategy of rehabilitation plus early ACL reconstruction did not provide better results at five years than a strategy of initial rehabilitation with the option of having a later ACL reconstruction. Results did not differ between knees surgically reconstructed early or late and those treated with rehabilitation alone. These results should encourage clinicians and young active adult patients to consider rehabilitation as a primary treatment option after an acute ACL tear. TRIAL REGISTRATION Current Controlled Trials ISRCTN84752559.
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Affiliation(s)
- Richard B Frobell
- Department of Orthopaedics, Clinical Sciences Lund, Lund University, SE-22185 Lund, Sweden.
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Swärd P, Frobell R, Englund M, Roos H, Struglics A. Cartilage and bone markers and inflammatory cytokines are increased in synovial fluid in the acute phase of knee injury (hemarthrosis)--a cross-sectional analysis. Osteoarthritis Cartilage 2012; 20:1302-8. [PMID: 22874525 DOI: 10.1016/j.joca.2012.07.021] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 07/21/2012] [Accepted: 07/28/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this cross-sectional study was to investigate concentrations of cartilage and bone markers, and pro-inflammatory cytokines in synovial fluid (SF) collected at different time-points from acutely injured knees with hemarthrosis and to compare these with SF concentrations of knees of age and gender-matched healthy reference subjects. METHODS SF was aspirated from the acutely injured knee of 111 individuals (mean age 27 years, span 13-64 years, 22% women). Concentrations of sulfated glycosaminoglycan (sGAG) were measured by Alcian blue precipitation whereas cartilage ARGS, bone biomarkers [osteocalcin (OCL), secreted protein acidic and rich in cysteine (SPARC) and osteopontin (OPN)] and pro-inflammatory cytokines [interleukin (IL)-1β, IL-6, IL-8 and tumor necrosis factor (TNF)-α] were analyzed using electrochemiluminescence. Samples were also analyzed with regard to time between injury and aspiration [same day (n = 29), 1 day (n = 31), 2-3 days (n = 19), 4-7 days (n = 20) and 8-23 days (n = 12)]. RESULTS SF concentrations of ARGS (P < 0.001), SPARC (P < 0.001), OPN (P < 0.001), and all cytokines (P < 0.001), but not sGAG (P = 0.06) or OCL (P = 0.992), were significantly higher in injured knees compared to knees of reference subjects. The cartilage markers sGAG and ARGS were significantly higher in knees aspirated later than 1 day after injury, whereas concentrations of SPARC and OPN and all cytokines were higher in knees aspirated the same day as the injury and at all time-points thereafter. CONCLUSIONS Our results suggest that an acute knee injury is associated with an instant local biochemical response to the trauma, which may affect cartilage and bone as well as the inflammatory activity.
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Affiliation(s)
- P Swärd
- Department of Orthopaedics, Clinical Sciences Lund, Lund University, Lund, Sweden.
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Chu CR, Beynnon BD, Dragoo JL, Fleisig GS, Hart JM, Khazzam M, Marberry KM, Nelson BJ. The feasibility of randomized controlled trials for early arthritis therapies (Earth) involving acute anterior cruciate ligament tear cohorts. Am J Sports Med 2012; 40:2648-52. [PMID: 23115253 PMCID: PMC5823007 DOI: 10.1177/0363546512465409] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Osteoarthritis (OA) is a leading cause of disability for which disease-modifying treatments are lacking. Anterior cruciate ligament (ACL) tear provides opportunities to study potential interventions from the initiation of heightened OA risk at the time of injury. This institutional review board (IRB)-approved prospective cross-sectional study (level of evidence: 2) was performed to test the hypothesis that adequate sample sizes of ACL-injured subjects to support randomized controlled trials (RCT) of early intervention strategies can be achieved. A total of 307 ACL-injured patients were entered into the database from 3-month collection periods at 7 clinical sites, with 65 subjects aged 18 to 30 years passing the inclusion/exclusion criteria. From sites that were IRB approved to ask, 89 of 96 (93%) subjects were willing to participate in an RCT. Extrapolating the 3-month data to a 1-year recruitment period would potentially yield 242 subjects aged 18 to 30 years willing to undergo randomization. This study shows that adequate sample sizes to perform RCT of early intervention strategies in ACL-injured cohorts comprising healthy young adults ages 18 to and 30 without prior joint injuries can be achieved within 1 to 2 years through recruitment at 5 to 7 orthopaedic sports medicine practices. Continued development of ACL-tear cohorts will provide the clinical base to critically evaluate new diagnostic and therapeutic strategies that can help transform clinical care of OA from palliation to prevention.
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Farshad M, Gerber C, Meyer DC, Schwab A, Blank PR, Szucs T. Reconstruction versus conservative treatment after rupture of the anterior cruciate ligament: cost effectiveness analysis. BMC Health Serv Res 2011; 11:317. [PMID: 22098703 PMCID: PMC3236993 DOI: 10.1186/1472-6963-11-317] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Accepted: 11/19/2011] [Indexed: 01/12/2023] Open
Abstract
Background The decision whether to treat conservatively or reconstruct surgically a torn anterior cruciate ligament (ACL) is an ongoing subject of debate. The high prevalence and associated public health burden of torn ACL has led to continuous efforts to determine the best therapeutic approach. A critical evaluation of benefits and expenditures of both treatment options as in a cost effectiveness analysis seems well-suited to provide valuable information for treating physicians and healthcare policymakers. Methods A literature review identified four of 7410 searched articles providing sufficient outcome probabilities for the two treatment options for modeling. A transformation key based on the expert opinions of 25 orthopedic surgeons was used to derive utilities from available evidence. The cost data for both treatment strategies were based on average figures compiled by Orthopaedic University Hospital Balgrist and reinforced by Swiss national statistics. A decision tree was constructed to derive the cost-effectiveness of each strategy, which was then tested for robustness using Monte Carlo simulation. Results Decision tree analysis revealed a cost effectiveness of 16,038 USD/0.78 QALY for ACL reconstruction and 15,466 USD/0.66 QALY for conservative treatment, implying an incremental cost effectiveness of 4,890 USD/QALY for ACL reconstruction. Sensitivity analysis of utilities did not change the trend. Conclusion ACL reconstruction for reestablishment of knee stability seems cost effective in the Swiss setting based on currently available evidence. This, however, should be reinforced with randomized controlled trials comparing the two treatment strategies.
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Affiliation(s)
- Mazda Farshad
- Department of Orthopedic Surgery, University of Zürich, Balgrist University Hospital, Zürich, Switzerland.
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Frobell RB. Change in cartilage thickness, posttraumatic bone marrow lesions, and joint fluid volumes after acute ACL disruption: a two-year prospective MRI study of sixty-one subjects. J Bone Joint Surg Am 2011; 93:1096-103. [PMID: 21776546 DOI: 10.2106/jbjs.j.00929] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about early morphologic change occurring with an acute injury of the anterior cruciate ligament. Magnetic resonance imaging was used in this study to investigate the two-year change in cartilage thickness, bone marrow lesions, and joint fluid of knees with acute anterior cruciate ligament injury treated surgically or nonsurgically and to identify factors associated with these changes. METHODS Sixty-one subjects (sixteen women and forty-five men with a mean age of twenty-six years) with acute anterior cruciate ligament injury to a previously uninjured knee were examined with use of a 1.5-T magnetic resonance imaging scanner at baseline and at three, six, twelve, and twenty-four months after the injury. Thirty-four subjects received rehabilitation and early anterior cruciate ligament reconstruction (a median of 44.5 days after the injury), eleven subjects received rehabilitation and a delayed anterior cruciate ligament reconstruction (408 days), and sixteen received rehabilitation alone. Morphologic measures were obtained from computer-assisted segmentation of magnetic resonance images. Factors tested for association were age, sex, activity level, treatment, and osteochondral fracture at baseline. RESULTS After twenty-four months, significant cartilage thinning occurred in the trochlea of the femur (mean, -4.3%; standard response mean = 0.88), whereas significant cartilage thickening occurred in the central medial aspect of the femur (mean, +2.7%; standard response mean = 0.46). A younger age at the time of injury was a risk factor for thickening in the central medial aspect of femur, whereas older age at injury was a risk factor for thinning in the trochlea of the femur. Treatment of the torn anterior cruciate ligament was not related to these changes nor was activity level or an osteochondral fracture at baseline. Posttraumatic bone marrow lesions in the lateral aspect of the tibia resolved completely in fifty-four of fifty-eight knees (median, six months) and lesions in the lateral aspect of the femur resolved completely in forty-four of forty-seven knees (median, three months); however, thirty new bone marrow lesions developed in the lateral aspect of twenty-one knees over the two-year period. None of the factors were related to the development of bone marrow lesions. CONCLUSIONS Morphologic change as visualized on magnetic resonance imaging occurs in the knee over the first two years after acute anterior cruciate ligament injury as demonstrated by cartilage thickening (central medial aspect of the femur), cartilage thinning (trochlea of the femur), the resolution of posttraumatic bone marrow lesions in the lateral part of the knee, and the development of new bone marrow lesions laterally. Age and male sex were independent risk factors for change in cartilage morphology.
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Affiliation(s)
- Richard B Frobell
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Lund, Sweden.
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Krogsgaard MR, Brodersen J, Comins J. A scientific approach to optimal treatment of cruciate ligament injuries. Acta Orthop 2011; 82:389-90; discussion 390-2. [PMID: 21657976 PMCID: PMC3235324 DOI: 10.3109/17453674.2011.588864] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- M R Krogsgaard
- Department of sportstraumatology and arthroscopy, Copenhagen University Hospital, Bispebjerg Copenhagen, Denmark and Department of general practice Faculty of health science Copenhagen University, Denmark
| | - J Brodersen
- Department of sportstraumatology and arthroscopy, Copenhagen University Hospital, Bispebjerg Copenhagen, Denmark and Department of general practice Faculty of health science Copenhagen University, Denmark
| | - J Comins
- Department of sportstraumatology and arthroscopy, Copenhagen University Hospital, Bispebjerg Copenhagen, Denmark and Department of general practice Faculty of health science Copenhagen University, Denmark
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Kerkhof HJ, Meulenbelt I, Akune T, Arden NK, Aromaa A, Bierma-Zeinstra SM, Carr A, Cooper C, Dai J, Doherty M, Doherty SA, Felson D, Gonzalez A, Gordon A, Harilainen A, Hart DJ, Hauksson VB, Heliovaara M, Hofman A, Ikegawa S, Ingvarsson T, Jiang Q, Jonsson H, Jonsdottir I, Kawaguchi H, Kloppenburg M, Kujala UM, Lane NE, Leino-Arjas P, Lohmander S, Luyten FP, Malizos KN, Nakajima M, Nevitt MC, Pols HA, Rivadeneira F, Shi D, Slagboom E, Spector TD, Stefansson K, Sudo A, Tamm A, Tamm AE, Tsezou A, Uchida A, Uitterlinden AG, Wilkinson JM, Yoshimura N, Valdes AM, van Meurs JB. Recommendations for standardization and phenotype definitions in genetic studies of osteoarthritis: the TREAT-OA consortium. Osteoarthritis Cartilage 2011; 19:254-64. [PMID: 21059398 PMCID: PMC3236091 DOI: 10.1016/j.joca.2010.10.027] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Revised: 10/15/2010] [Accepted: 10/26/2010] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To address the need for standardization of osteoarthritis (OA) phenotypes by examining the effect of heterogeneity among symptomatic (SOA) and radiographic osteoarthritis (ROA) phenotypes. METHODS Descriptions of OA phenotypes of the 28 studies involved in the TREAT-OA consortium were collected. We investigated whether different OA definitions result in different association results by creating various hip OA definitions in one large population based cohort (the Rotterdam Study I (RSI)) and testing those for association with gender, age and body mass index using one-way ANOVA. For ROA, we standardized the hip-, knee- and hand ROA definitions and calculated prevalence's of ROA before and after standardization in nine cohort studies. This procedure could only be performed in cohort studies and standardization of SOA definitions was not feasible at this moment. RESULTS In this consortium, all studies with SOA phenotypes (knee, hip and hand) used a different definition and/or assessment of OA status. For knee-, hip- and hand ROA five, four and seven different definitions were used, respectively. Different hip ROA definitions do lead to different association results. For example, we showed in the RSI that hip OA defined as "at least definite joint space narrowing (JSN) and one definite osteophyte" was not associated with gender (P =0.22), but defined as "at least one definite osteophyte" was significantly associated with gender (P=3×10(-9)). Therefore, a standardization process was undertaken for ROA definitions. Before standardization a wide range of ROA prevalence's was observed in the nine cohorts studied. After standardization the range in prevalence of knee- and hip ROA was small. CONCLUSION Phenotype definitions influence the prevalence of OA and association with clinical variables. ROA phenotypes within the TREAT-OA consortium were standardized to reduce heterogeneity and improve power in future genetics studies.
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Affiliation(s)
- Hanneke J.M. Kerkhof
- Department of Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands,The Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging (NGI-NCHA), Rotterdam/Leiden, the Netherlands
| | - Ingrid Meulenbelt
- The Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging (NGI-NCHA), Rotterdam/Leiden, the Netherlands,Department of Molecular Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Toru Akune
- Department of Clinical Motor System Medicine, 22nd Century Medical and Research Center, The University of Tokyo, Tokyo, Japan
| | - Nigel K. Arden
- MRC Epidemiology Resource Centre University of Southampton, Southampton General Hospital, Southampton, United Kingdom,NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford England Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Oxford, United Kingdom
| | - Arpo Aromaa
- The National Institute for Health and Welfare (THL), Helsinki, Finland
| | | | - Andrew Carr
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford England Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Oxford, United Kingdom
| | - Cyrus Cooper
- MRC Epidemiology Resource Centre University of Southampton, Southampton General Hospital, Southampton, United Kingdom,NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford England Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Oxford, United Kingdom
| | - Jin Dai
- Center of Diagnosis and Treatment for Joint Disease, Nanjing DrumTower Hospital, The affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Michael Doherty
- Academic Rheumatology, Clinical Sciences Building, Nottingham City Hospital Hucknall Road, Nottingham, United Kingdom
| | - Sally A. Doherty
- Academic Rheumatology, Clinical Sciences Building, Nottingham City Hospital Hucknall Road, Nottingham, United Kingdom
| | - David Felson
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA, United States of America
| | - Antonio Gonzalez
- Laboratorio Investigacion and Rheumatology Unit, Hospital Clinico Universitario Santiago, Santiago de Compostela, Spain
| | - Andrew Gordon
- Academic Unit of Bone Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, United Kingdom,Sheffield NIHR Bone Biomedical research Unit, Centre for Biomedical Research, Northern General Hospital, Sheffield, United Kingdom
| | - Arsi Harilainen
- ORTON Orthopedic Hospital, Invalid Foundation, Helsinki, Finland
| | - Deborah J. Hart
- Department of Twin Research and Genetic Epidemiology, St. Thomas' Hospital, King's College London, London, United Kingdom
| | | | - Markku Heliovaara
- The National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Albert Hofman
- The Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging (NGI-NCHA), Rotterdam/Leiden, the Netherlands,Department of Epidemiology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Shiro Ikegawa
- Laboratory for Bone and Joint Diseases, Center for Genomic Medicine, RIKEN, Japan
| | - Thorvaldur Ingvarsson
- FSA University Hospital, Institution of Health Science, University of Akureyri, Akureyri, Iceland
| | - Qing Jiang
- Center of Diagnosis and Treatment for Joint Disease, Nanjing DrumTower Hospital, The affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Helgi Jonsson
- Department of Medicine, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Ingileif Jonsdottir
- deCODE Genetics, Reykjavik, Iceland,Department of Medicine, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Hiroshi Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Margreet Kloppenburg
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Urho M. Kujala
- Department of Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Nancy E. Lane
- University of California at San Francisco and University of California at Davis, Sacramento, United States of America
| | | | - Stefan Lohmander
- Department of Orthopedics, Clinical Sciences, Lund University, Lund, Sweden
| | - Frank P. Luyten
- Laboratory for Skeletal Development and Joint Disorders, Division of Rheumatology, Katholieke Universiteit Leuven, Belgium
| | | | - Masahiro Nakajima
- Laboratory for Bone and Joint Diseases, Center for Genomic Medicine, RIKEN, Japan
| | - Michael C. Nevitt
- University of California at San Francisco and University of California at Davis, Sacramento, United States of America
| | - Huibert A.P. Pols
- Department of Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Fernando Rivadeneira
- Department of Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands,The Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging (NGI-NCHA), Rotterdam/Leiden, the Netherlands,Department of Epidemiology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dongquan Shi
- Center of Diagnosis and Treatment for Joint Disease, Nanjing DrumTower Hospital, The affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Eline Slagboom
- The Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging (NGI-NCHA), Rotterdam/Leiden, the Netherlands,Department of Molecular Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tim D. Spector
- Department of Twin Research and Genetic Epidemiology, St. Thomas' Hospital, King's College London, London, United Kingdom
| | - Kari Stefansson
- deCODE Genetics, Reykjavik, Iceland,Department of Medicine, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Japan
| | - Agu Tamm
- Department of Internal Medicine, University of Tartu, Estonia
| | - Ann E. Tamm
- Department of Sport Medicine and Rehabilitation, Univerity of Tartu, Estonia
| | - Aspasia Tsezou
- Department of Biology and Genetics, University of Thessaly, Larissa, Greece
| | - Atsumasa Uchida
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Japan
| | - André G. Uitterlinden
- Department of Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands,The Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging (NGI-NCHA), Rotterdam/Leiden, the Netherlands,Department of Epidemiology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jeremy Mark Wilkinson
- Academic Unit of Bone Metabolism, Department of Human Metabolism, University of Sheffield, Sheffield, United Kingdom,Sheffield NIHR Bone Biomedical research Unit, Centre for Biomedical Research, Northern General Hospital, Sheffield, United Kingdom
| | - Noriko Yoshimura
- Department of Joint Disease Research, 22nd Century Medical and Research Center, The University of Tokyo Hospital, The University of Tokyo, Tokyo, Japan
| | - Ana M. Valdes
- Department of Twin Research and Genetic Epidemiology, St. Thomas' Hospital, King's College London, London, United Kingdom
| | - Joyce B.J. van Meurs
- Department of Internal Medicine, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands,The Netherlands Genomics Initiative-sponsored Netherlands Consortium for Healthy Aging (NGI-NCHA), Rotterdam/Leiden, the Netherlands
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Ahn JH, Chang MJ, Lee YS, Koh KH, Park YS, Eun SS. Non-operative treatment of ACL rupture with mild instability. Arch Orthop Trauma Surg 2010; 130:1001-6. [PMID: 20336305 DOI: 10.1007/s00402-010-1077-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Indexed: 11/26/2022]
Abstract
PURPOSE This study examined whether or not conservative treatment of an acutely injured anterior cruciate ligament (ACL) could be successful in a select group of patients. Routine ACL reconstruction surgery in all acute ACL-injured patients should be avoided. We hypothesize that acutely injured ACL with mild instability at the initial physical examination could be improved even if there is disruption of ACL fibers on magnetic resonance images (MRI). MATERIALS AND METHODS Among 232 acute ACL-injured patients who visited our institution from March 1997 to April 2006, 48 were treated non-operatively. Patients diagnosed with an acute ACL injury by MRI with Lachman test < or =grade 1 were treated non-operatively. In this study, 30 male and 18 female patients with a mean age of 31.8 years were enrolled. The initial and follow-up Lachman test and pivot shift test were performed 3 weeks after the injury. The Lysholm knee scoring scale, International Knee Documentation Committee (IKDC) score and KT-2000 were obtained at the last follow-up. RESULTS There were 12 complete (25%) and 36 incomplete ACL ruptures (75%). The patients were followed up clinically and with MRI for 21.5 and 11.3 months, respectively. The follow-up Lachman test improved to grade 0 in 41 patients (87%). Thirty-six patients (76%) showed no laxity in the follow-up pivot shift test. The last follow-up IKDC score was a mean value of 91.1 points. KT 2000 was performed in 40 patients with a mean side-to-side difference of 2.85 mm. Of 48 patients, 46 showed restored ACL continuity and 39 (84%) showed restored low signal intensity on MRI. CONCLUSION A selective group of ACL tears with mild instability (Lachman < or =grade 1), though these seem to be complete tears on MRI, can show restoration of their continuity and signals on the MRI. Joint laxity on physical examination was improved at follow-up. These results suggest that a select group of patients with an acute ACL injury can successfully undergo non-operative treatment. In addition, unnecessary early ACL reconstruction surgery should be avoided.
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Affiliation(s)
- Jin Hwan Ahn
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University, Kangnam-Ku, Seoul, Korea
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Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med 2010; 363:331-42. [PMID: 20660401 DOI: 10.1056/nejmoa0907797] [Citation(s) in RCA: 553] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The optimal management of a torn anterior cruciate ligament (ACL) of the knee is unknown. METHODS We conducted a randomized, controlled trial involving 121 young, active adults with acute ACL injury in which we compared two strategies: structured rehabilitation plus early ACL reconstruction and structured rehabilitation with the option of later ACL reconstruction if needed. The primary outcome was the change from baseline to 2 years in the average score on four subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS)--pain, symptoms, function in sports and recreation, and knee-related quality of life (KOOS(4); range of scores, 0 [worst] to 100 [best]). Secondary outcomes included results on all five KOOS subscales, the Medical Outcomes Study 36-Item Short-Form Health Survey, and the score on the Tegner Activity Scale. RESULTS Of 62 subjects assigned to rehabilitation plus early ACL reconstruction, 1 did not undergo surgery. Of 59 assigned to rehabilitation plus optional delayed ACL reconstruction, 23 underwent delayed ACL reconstruction; the other 36 underwent rehabilitation alone. The absolute change in the mean KOOS(4) score from baseline to 2 years was 39.2 points for those assigned to rehabilitation plus early ACL reconstruction and 39.4 for those assigned to rehabilitation plus optional delayed reconstruction (absolute between-group difference, 0.2 points; 95% confidence interval, -6.5 to 6.8; P=0.96 after adjustment for the baseline score). There were no significant differences between the two treatment groups with respect to secondary outcomes. Adverse events were common in both groups. The results were similar when the data were analyzed according to the treatment actually received. CONCLUSIONS In young, active adults with acute ACL tears, a strategy of rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction. The latter strategy substantially reduced the frequency of surgical reconstructions. (Funded by the Swedish Research Council and the Medical Faculty of Lund University and others; Current Controlled Trials number, ISRCTN84752559.)
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Affiliation(s)
- Richard B Frobell
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Lund, Sweden.
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Trulsson A, Roos EM, Ageberg E, Garwicz M. Relationships between postural orientation and self reported function, hop performance and muscle power in subjects with anterior cruciate ligament injury. BMC Musculoskelet Disord 2010; 11:143. [PMID: 20594339 PMCID: PMC2908077 DOI: 10.1186/1471-2474-11-143] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 07/01/2010] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Injury to the anterior cruciate ligament (ACL) is associated not only with knee instability and impaired neuromuscular control, but also with altered postural orientation manifested as observable "substitution patterns". However, tests currently used to evaluate knee function in subjects with ACL injury are not designed to assess postural orientation. Therefore, we are in the process of developing an observational test set that measures postural orientation in terms of the ability to stabilize body segments in relation to each other and to the environment. The aim of the present study was to characterise correlations between this novel test set, called the Test for Substitution Patterns (TSP) and commonly used tests of knee function. METHODS In a blinded set-up, 53 subjects (mean age 30 years, range 20-39, with 2-5 years since ACL injury) were assessed using the TSP, the Knee Injury and Osteoarthritis Outcome Score subscale sport/recreation (KOOS sport/rec), 3 hop tests and 3 muscle power tests. Correlations between the scores of the TSP and the other tests were determined. RESULTS Moderate correlations were found between TSP scores and KOOS sport/rec (rs = -0.43; p = 0.001) and between TSP scores and hop test results (rs = -0.40 to -0.46; p < or = 0.003), indicating that altered postural orientation was associated with worse self-reported KOOS sport/rec function and worse hop performance. No significant correlations were found between TSP scores and muscle power results. Subjects had higher TSP scores on their injured side than on their uninjured side (median 4 and 1 points; interquartile range 2-6 and 0-1.5, respectively; p < 0.0001). CONCLUSIONS We conclude that the Test for Substitution Patterns is of relevance to the patient and measures a specific aspect of neuromuscular control not quantified by the other tests investigated. We suggest that the TSP may be a valuable complement in the assessment of neuromuscular control in the rehabilitation of subjects with ACL injury.
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Affiliation(s)
- Anna Trulsson
- Department of Health Sciences, Division of Physiotherapy, Lund University, Sweden.
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Thorstensson CA, Lohmander LS, Frobell RB, Roos EM, Gooberman-Hill R. Choosing surgery: patients' preferences within a trial of treatments for anterior cruciate ligament injury. A qualitative study. BMC Musculoskelet Disord 2009; 10:100. [PMID: 19664258 PMCID: PMC2731720 DOI: 10.1186/1471-2474-10-100] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 08/10/2009] [Indexed: 02/07/2023] Open
Abstract
Background The objective was to understand patients' views of treatment after acute anterior cruciate ligament (ACL) injury, and their reasons for deciding to request surgery despite consenting to participate in a randomised controlled trial (to 'cross-over'). Methods Thirty-four in-depth qualitative interviews were conducted with young (aged 18–35), physically active individuals with ACL rupture who were participating in a RCT comparing training and surgical reconstruction with training only. 22/34 were randomised to training only but crossed over to surgery. Of these, 11 were interviewed before surgery, and 11 were interviewed at least 6 months after surgery. To provide additional information, 12 patients were interviewed before randomisation. Interviews were audio-recorded, transcribed and analysed using the Framework approach. Results Strong preference for surgery was commonplace and many patients said that they joined the RCT in order to bypass waiting lists. Patients who chose to cross-over described training as time consuming, boring and as unable to provide sufficient results within a reasonable timeframe. Some said their injured knees had given-way; others experienced new knee traumas; and many described their lack of trust in their knee. Patients believed that surgery would provide joint stability. Despite the ostensible satisfaction with surgery, more detailed exploration showed mixed views. Conclusion Participants in a trial of treatments for acute ACL injury express a variety of views and beliefs about those treatments, and trial participation happens in the absence of equipoise. Furthermore, opting for surgical reconstruction does not necessarily provide patients with satisfactory outcomes. Definition of successful outcome may require an individualised approach, incorporating patients' as well as surgeons' views before treatment decisions are made.
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Affiliation(s)
- Carina A Thorstensson
- Department of Research and Development, Spenshult Hospital for Rheumatic Diseases, Oskarström, Sweden.
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48
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Ageberg E, Roos HP, Silbernagel KG, Thomeé R, Roos EM. Knee extension and flexion muscle power after anterior cruciate ligament reconstruction with patellar tendon graft or hamstring tendons graft: a cross-sectional comparison 3 years post surgery. Knee Surg Sports Traumatol Arthrosc 2009; 17:162-9. [PMID: 18982311 DOI: 10.1007/s00167-008-0645-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 09/19/2008] [Indexed: 01/11/2023]
Abstract
Hamstring muscles play a major role in knee-joint stabilization after anterior cruciate ligament (ACL) injury. Weakness of the knee extensors after ACL reconstruction with patellar tendon (PT) graft, and in the knee flexors after reconstruction with hamstring tendons (HT) graft has been observed up to 2 years post surgery, but not later. In these studies, isokinetic muscle torque was used. However, muscle power has been suggested to be a more sensitive and sport-specific measures of strength. The aim was to study quadriceps and hamstring muscle power in patients with ACL injury treated with surgical reconstruction with PT or HT grafts at a mean of 3 years after surgery. Twenty subjects with PT and 16 subjects with HT grafts (mean age at follow up 30 years, range 20-39, 25% women), who were all included in a prospective study and followed the same goal-based rehabilitation protocol for at least 4 months, were assessed with reliable, valid, and responsive tests of quadriceps and hamstring muscle power at 3 years (SD 0.9, range 2-5) after surgery. The mean difference between legs (injured minus uninjured), the hamstring to quadriceps (H:Q, hamstring divided by quadriceps) ratio, and the limb symmetry index (LSI, injured leg divided by uninjured and multiplied by 100) value, were used for comparisons between the groups (analysis of variance). The mean difference between the injured and uninjured legs was greater in the HT than in the PT group for knee flexion power (-21.3 vs. 7.7 W, p = 0.001). Patients with HT graft had lower H:Q ratio in the injured leg than the patients with PT graft (0.63 vs. 0.77, p = 0.012). They also had lower LSI for knee flexion power than those in the PT group (88 vs. 106%, p < 0.001). No differences were found between the groups for knee extension power. The lower hamstring muscle power, and the lower hamstring to quadriceps ratio in the HT graft group than in the PT graft group 3 years (range 2-5) after ACL reconstruction, reflect imbalance of knee muscles after reconstruction with HT graft that may have a negative effect on dynamic knee-joint stabilization.
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Affiliation(s)
- Eva Ageberg
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Lund University Hospital, Lund 221 85, Sweden.
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The acutely ACL injured knee assessed by MRI: changes in joint fluid, bone marrow lesions, and cartilage during the first year. Osteoarthritis Cartilage 2009; 17:161-7. [PMID: 18760637 DOI: 10.1016/j.joca.2008.06.020] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 06/25/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate changes in the knee during the first year after acute rupture of the anterior cruciate ligament (ACL) of volumes of joint fluid (JF), bone marrow lesions (BMLs), and cartilage volume (VC), and cartilage thickness (ThCcAB) and cartilage surface area (AC). To identify factors associated with these changes. METHODS Fifty-eight subjects (mean age 26 years, 16 women) with an ACL rupture to a previously un-injured knee were followed prospectively using a 1.5T MR imager at baseline (within 5 weeks from injury), 3 months, 6 months, and 1 year. Thirty-four subjects were treated with ACL reconstruction followed by a structured rehabilitation program and 24 subjects were treated with structured rehabilitation only. Morphometric data were acquired from computer-assisted segmentation of MR images. Morphometric cartilage change was reported as mean change divided by the standard deviation of change (standard response mean, SRM). RESULTS JF and BML volumes gradually decreased over the first year, although BML persisted in 62% of the knees after 1 year. One year after the ACL injury, a reduction of VC, AC and ThCcAB (SRM -0.440 or greater) was found in the trochlea femur (TrF), while an increase of VC and ThCcAB was found in the central medial femur (cMF) (SRM greater than 0.477). ACL reconstruction was directly and significantly related to increased JF volume at 3 and 6 months (P<0.001), BML volume at 6 months (P=0.031), VC and ThCcAB in cMF (P<0.002) and decreased cartilage area in TrF (P=0.010) at 12 months. CONCLUSION Following an acute ACL tear, cMF and TrF showed the greatest consistent changes of cartilage morphometry. An ACL reconstruction performed within a mean of 6 weeks from injury was associated with increased ThCcAB and VC in cMF and decreased AC in TrF, compared to knees treated without reconstruction. This may suggest a delayed structural restitution in ACL reconstructed knees.
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Ageberg E, Thomeé R, Neeter C, Silbernagel KG, Roos EM. Muscle strength and functional performance in patients with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: A two to five-year followup. ACTA ACUST UNITED AC 2008; 59:1773-9. [PMID: 19035430 DOI: 10.1002/art.24066] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Eva Ageberg
- Clinical Sciences Lund, Lund University, Lund, Sweden.
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