Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

Conservative treatment versus surgical reconstruction for ACL rupture: A systemic review

Background

Anterior cruciate ligament (ACL) rupture is a prevalent sports injury with rising rates attributed to increased population participation in sports activities. ACL rupture can lead to severe knee complications including cartilage damage, torn meniscus, and osteoarthritis. Current treatment options include conservative measures and surgical interventions. However, debates persist regarding the optimal approach.

Purpose

This analysis intended to compare the function, knee stability, and incidence rate of secondary surgery between conservative and surgical treatments in ACL rupture patients.

Methods

A systematic search was performed via Embase, Ovid Medline, PubMed, Cochrane Library, Web of Science, and Google Scholar for reporting outcomes of conservative and surgical treatments after ACL rupture. The outcomes included patient-reported outcome measures (PROMs), knee stability, the need for secondary meniscal surgery, delayed ACL reconstruction surgery, and revision ACL reconstruction surgery. Outcomes were analyzed using mean differences or odd ratios (OR) with 95 % CIs.

Results

11 studies were included with 1516 patients. For PROMs, our evidence indicated no differences in KOOS Pain, KOOS Symptoms, KOOS Sport/Rec, KOOS ADL, and KOOS QOL. (all p > 0.05). for knee stability, pivot shift (OR, 0.14; p < 0.001), Lachman test (OR, 0.06; p < 0.001), and tibia translation (p < 0.001) were evaluated, and the available evidence favored surgical treatment over conservative treatment. For the incidence rate of any secondary surgery after the first diagnosis, the surgical group showed a lower rate of meniscal surgery with statistical significance (OR, 0.37; p < 0.001). The average rate of revision ACL reconstruction is 5.80 %, while the rate of delayed ACL reconstruction after conservative treatment is 18.51 %.

Conclusion

Currently, there is insufficient empirical evidence to advocate a systematic surgical reconstruction for any patient who tore his ACL. This review found no differences in function outcomes between conservative and surgical treatments. Regarding knee stability and secondary meniscal surgery, the results prefer the surgical treatments. The occurrence rate of revision and delayed ACL reconstruction are non-negligible factors that must be fully understood by both surgeons and patients before choosing a suitable treatment.

Which patients need anterior cruciate ligament reconstruction after initial treatment with rehabilitation? A scoping review

PURPOSE

Some patients with anterior cruciate ligament (ACL) injury initially treated with rehabilitation need ACL reconstruction (ACLR); yet, it is unclear what characterizes these patients. This review aimed to describe predictors for ACLR in patients initially treated with rehabilitation.

METHODS

A systematic literature search was performed in the Cochrane, Embase, Medline, SportsDiscus and Web of Science databases from inception to 21 February 2023. Articles describing characteristics in adult patients with ACL injury undergoing ACLR after a minimum of 5 weeks rehabilitation were included. It was a priori chosen that characteristics described in at least three articles were considered more certain and could be defined as a predictor for ACLR, and those described in less than three articles were considered less certain and therefore defined as possible predictors. Articles were screened by two independent reviewers. The study was originally intended as a systematic review with meta-analysis, but in case of limited data, we would convert it to a scoping review, as was the case for this review.

RESULTS

There were 22,836 studies identified, and 181 full texts were screened, of which 10 papers were finally included. Only lower age and higher preinjury activity level were identified as predictors for ACLR. Another 12 possible predictors were identified in single studies. Through an iterative process, potential predictors were categorized into four groups: patient demographics, knee function, patient-reported outcome measures and anatomical structures.

CONCLUSION

Lower age and higher preinjury activity level were the only predictors for ACLR after initial treatment with rehabilitation. While younger and highly active patients show a higher need for ACLR, more studies focussing on predictors and reasons for delayed ACLR are warranted.

LEVEL OF EVIDENCE

Level II.

Quadriceps tendon versus hamstring tendon graft for primary anterior cruciate ligament reconstruction: A systematic review and meta-analysis of randomised trials

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is most commonly performed with hamstring tendon (HT) or bone-patellar tendon-bone (BTB) autografts, although the quadriceps tendon (QT) autograft has recently increased in popularity. This systematic review and meta-analysis review compares QT and HT autografts for primary ACLR with a sole focus on randomised controlled trials (RCTs).

METHODS

A prospective protocol was registered on PROSPERO (CRD42023427339). The search included MEDLINE, Embase and Web of Science until February 2024. Only comparative RCTs were included. The primary outcome was the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form score. Secondary outcomes included: other validated patient-reported outcome measures (PROMs), objective strength scores, complications, and return to sport and work.

RESULTS

From 2,609 articles identified, seven were included (n = 474 patients). This meta-analysis did not identify a significant difference in post-operative IKDC scores (5 articles; p = 0.73), Lysholm scores (3 studies; p = 0.80) or Tegner activity scales (2 studies; p = 0.98). There were no differences in graft failure rates (4 studies; p = 0.92) or in overall adverse events (4 studies; p = 0.83) at 24 months post-ACLR as per meta-analysis. Donor site morbidity scores were significantly lower in the QT group (MD -4.67, 95% CI -9.29 to -0.05; 2 studies, 211 patients; p = 0.05, I2 = 34%).

CONCLUSION

There were no differences between QT and HT in PROMs, graft failure rates or overall complications based on low- to moderate-quality evidence. There may possibly be lower donor site morbidity with the QT autograft, however, the evidence is not sufficient to draw definitive conclusions.

Development of an intervention for patients following an anterior cruciate ligament rupture: an online nominal group technique consensus study

OBJECTIVES

(1) To develop an intervention for to support patients diagnosed with an anterior cruciate ligament (ACL) rupture with decision-making regarding treatment. (2) To define evidence-based recommendations for the treatment of patients following an ACL rupture.

DESIGN

Nominal group technique consensus study.

SETTING

Online meetings with patients and key stakeholders working and receiving treatment in the National Health Service, UK.

PARTICIPANTS

Consensus meetings composed of eight voting participants and five non-voting facilitators. Voting participants included five clinicians, one outpatient therapy manager and two patients with experience in an ACL rupture and reconstructive surgery. Non-voting facilitators supported group discussions and/or observed study procedures. This included a clinical academic expert, two methodology experts and two patient representatives.

METHOD

Two online meetings were held. Pre-elicitation material was distributed ahead of the first meeting. Premeeting voting was conducted ahead of both meetings. A draft of the shared decision-making intervention and recommendations were shared ahead of the second meeting. Components were discussed and ranked for inclusion based on a 70% agreement threshold.

RESULTS

The meetings led to the development of a shared decision-making intervention to support treatment decision-making following an ACL rupture. The intervention includes two components: (1) a patient information leaflet and key questions diagram and (2) option grid. The evidence-based recommendations encompass core components of treatment reaching the 70% threshold agreed by the group. The recommendations cover: (1) advice and education, (2) exercise guidance, (3) intervention delivery, (4) outcome measure use and (5) shared decision-making.

CONCLUSION

This study has successfully developed a shared decision-making intervention to support ACL treatment decision-making, ready for testing in a future feasibility study. Evidence-based recommendations for the treatment of patients following ACL injury, ready for testing in a National Health Service (UK) setting, are also presented.

TRIAL REGISTRATION NUMBER

NCT05529511.

Cost-utility analysis of early reconstruction surgery versus conservative treatment for anterior cruciate ligament injury in a lower-middle income country

BACKGROUND

The ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia.

METHODS

A decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 - three times the Indonesian GDP per capita in 2021 - the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE).

RESULTS

The early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%.

CONCLUSIONS

Based on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact.

Research priorities of members of the British Association for Surgery of the Knee

Aims

This study aims to identify the top unanswered research priorities in the field of knee surgery using consensus-based methodology.

Methods

Initial research questions were generated using an online survey sent to all 680 members of the British Association for Surgery of the Knee (BASK). Duplicates were removed and a longlist was generated from this scoping exercise by a panel of 13 experts from across the UK who provided oversight of the process. A modified Delphi process was used to refine the questions and determine a final list. To rank the final list of questions, each question was scored between one (low importance) and ten (high importance) in order to produce the final list.

Results

This consensus exercise took place between December 2020 and April 2022. A total of 286 clinicians from the BASK membership provided input for the initial scoping exercise, which generated a list of 105 distinct research questions. Following review and prioritization, a longlist of 51 questions was sent out for two rounds of the Delphi process. A total of 42 clinicians responded to the first round and 24 responded to the second round. A final list of 24 research questions was then ranked by 36 clinicians. The topics included arthroplasty, infection, meniscus, osteotomy, patellofemoral, cartilage, and ligament pathologies. The management of early osteoarthritis was the highest-ranking question.

Conclusion

A Delphi exercise involving the BASK membership has identified the future research priorities in knee surgery. This list of questions will allow clinicians, researchers, and funders to collaborate in order to deliver high-quality research in knee surgery and further advance the care provided to patients with knee pathology.

Precision Anterior Cruciate Ligament Reconstruction

Precision anterior cruciate ligament reconstruction (ACLR) refers to the individualized approach to prerehabilitation, surgery (including anatomy, bony morphology, and repair/reconstruction of concomitant injuries), postrehabilitation, and functional recovery. This individualized approach is poised to revolutionize orthopedic sports medicine, aiming to improve patient outcomes. The purpose of this article is to provide a summary of precision ACLR, from the time of diagnosis to the time of return to play, with additional insight into the future of ACLR.

Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

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

Value-Based, Environmentally Sustainable Anterior Cruciate Ligament Surgery

Orthopedic surgeons are increasingly recognizing the broader societal impact of their clinical decisions, which includes value-based and environmentally sustainable care. Within anterior cruciate ligament reconstruction, value-based care-or most cost-effective care-includes an outpatient surgical setting with regional anesthesia, use of autograft, meniscus repair when indicated, and use of traditional metal implants such as interference screws and staples. Environmentally sustainable care includes slimming down surgical packs and trays to avoid opening unnecessary equipment, avoiding desflurane as an inhaled anesthetic agent, and minimizing waste in the operating room-a priority that addresses both cost and environmental impact.

Multicomponent supervised tele-rehabilitation versus home-based self-rehabilitation management after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial

INTRODUCTION

Our study aims to assess the effectiveness of multicomponent supervised tele-rehabilitation compared to home-based self-rehabilitation management in patients following anterior cruciate ligament reconstruction (ACLR).

METHODS

The current study is designed as a single-center, single-blinded, randomized controlled, two-arm trial. Participants will be randomized and allocated at a 1:1 ratio into either a multicomponent supervised tele-rehabilitation group or a home-based self-rehabilitation group. All participants receive uniform preoperative education through the HJT software. Participants in the intervention group undergo multicomponent supervised tele-rehabilitation, while those in the control group follow a home-based self-rehabilitation program. All the participants were assessed and measured for the included outcomes at the outpatient clinic before the procedure, and in 2, 4, 8, 12, and 24 weeks after ACLR by two assessors. The primary outcome was the percentage of patients who achieve a satisfactory active ROM at the 12 weeks following the ACLR. The satisfactory active ROM was also collected at 2, 4, 8, and 24 weeks after ACLR. The secondary outcomes were active and passive range of motion (ROM), pain, muscle strength, and function results.

REGISTRATION DETAILS

Ethical approval has been obtained from the West China Hospital Ethics Committee (approval number 2023-1929, December 2023). The trial has been registered on ClinicalTrials.gov (registration number NCT06232824, January 2024).

Implementing a shared decision-making intervention to support treatment decisions for patients following an anterior cruciate ligament rupture - a protocol for the POP-ACLR feasibility study

BACKGROUND

Treatment for anterior cruciate ligament (ACL) rupture may follow a surgical or nonsurgical pathway. At present, there is uncertainty around treatment choice. Two shared decision-making tools have been codesigned to support patients to make a decision about treatment following an ACL rupture. The shared decision-making tools include a patient information leaflet and an option grid. We report the protocol for a mixed-methods feasibility study, with nested qualitative interviews, to understand feasibility, acceptability, indicators of effectiveness and implementation factors of these shared decision-making tools (combined to form one shared decision-making intervention).

METHODS

A single-centre non-randomised feasibility study will be conducted with 20 patients. Patients diagnosed with an ACL rupture following magnetic resonance imaging will be identified from an orthopaedic clinic. The shared decision-making intervention will be delivered during a clinical consultation with a physiotherapist. The primary feasibility outcomes include the following: recruitment rate, fidelity, acceptability and follow-up questionnaire completion. The secondary outcome is the satisfaction with decision scale. The nested qualitative interview will explore experience of using the shared decision-making intervention to understand acceptability, implementation factors and areas for further refinement.

DISCUSSION

This study will determine the feasibility of using a newly developed shared decision-making intervention designed to support patients to make a decision about treatment of their ACL rupture. The acceptability and indicators of effectiveness will also be explored. In the long term, the shared decision-making intervention may improve service and patient outcomes and ensure cost-effectiveness for the NHS; ensuring those most likely to benefit from surgical treatment proceed along this pathway.

TRIAL REGISTRATION

Pending registration on ISRCTN.

Intra-Articular Platelet-Rich Plasma Injection After Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial

Importance

Platelet-rich plasma (PRP) has been considered a promising treatment for musculoskeletal disorders. The effects of PRP on clinical outcomes of anterior cruciate ligament reconstruction (ACLR) are controversial.

Objective

To compare subjective outcomes and graft maturity in patients undergoing ACLR with and without postoperative intra-articular PRP injection.

Design, Setting, and Participants

This surgeon- and investigator-masked randomized clinical trial included patients treated at a national medical center in China who were aged 16 to 45 years and scheduled to undergo ACLR. Participants were enrolled between March 21, 2021, and August 18, 2022, and followed up for 12 months, with the last participant completing follow-up on August 28, 2023.

Interventions

Participants were randomized 1:1 to the PRP group (n = 60), which received 3 doses of postoperative intra-articular PRP injection at monthly intervals, or to the control group (n = 60), which did not receive postoperative PRP injection. Both groups had the same follow-up schedule.

Main Outcomes and Measures

The primary outcome was the mean score for 4 subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS4) (range, 0-100, with higher scores indicating better knee function and fewer symptoms) at 12 months postoperatively. Secondary outcomes were patient-reported outcomes, graft maturity (on magnetic resonance imaging), and physical examinations at 3, 6, and 12 months.

Results

Among the 120 randomized participants (mean [SD] age, 29.0 [8.0] years; 84 males [70%]), 114 (95%) were available for the primary outcome analysis. The mean KOOS4 scores at 12 months were 78.3 (SD, 12.0; 95% CI, 75.2-81.4) in the PRP group and 76.8 (SD, 11.9; 95% CI, 73.7-79.9) in the control group (adjusted mean between-group difference, 2.0; 95% CI, -2.3 to 6.3; P = .36). Secondary outcomes were not statistically significantly different between the 2 groups except for sports and recreation level and graft maturity at 6 months. Intervention-related adverse events included pain at the injection site and knee swelling after injection.

Conclusions and Relevance

In this randomized clinical trial among patients undergoing ACLR, the addition of postoperative intra-articular PRP injection did not result in superior improvement of knee symptoms and function at 12 months compared with no postoperative injection. Further studies are required to determine appropriate indications for PRP in musculoskeletal disorders.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2000040262.

Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study

AIM

To develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction.

DESIGN

Mixed-methods study describing the development of a patient decision aid.

SETTING

A draft decision aid was developed by a multidisciplinary steering group (including various types of health professionals and researchers, and consumers) informed by the best available evidence and existing patient decision aids.

PARTICIPANTS

People who ruptured their ACL when they were under 18 years old (ie, adolescents), their parents, and health professionals who manage these patients. Participants were recruited through social media and the network outreach of the steering group.

PRIMARY AND SECONDARY OUTCOMES

Semistructured interviews and questionnaires were used to gather feedback on the decision aid. The feedback was used to refine the decision aid and assess acceptability. An iterative cycle of interviews, refining the aid according to feedback and further interviews, was used. Interviews were analysed using reflexive thematic analysis.

RESULTS

We conducted 32 interviews; 16 health professionals (12 physiotherapists, 4 orthopaedic surgeons) and 16 people who ruptured their ACL when they were under 18 years old (7 were adolescents and 9 were adults at the time of the interview). Parents participated in 8 interviews. Most health professionals, patients and parents rated the aid's acceptability as good-to-excellent. Health professionals and patients agreed on most aspects of the decision aid, but some health professionals had differing views on non-surgical management, risk of harms, treatment protocols and evidence on benefits and harms.

CONCLUSION

Our patient decision aid is an acceptable tool to help children and adolescents choose an appropriate management option following ACL rupture with their parents and health professionals. A clinical trial evaluating the potential benefit of this tool for children and adolescents considering ACL reconstruction is warranted.

Robot-assisted anterior cruciate ligament reconstruction based on three-dimensional images

Background Tunnel placement is a key step in anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to evaluate the accuracy of bone tunnel drilling in arthroscopic ACL reconstruction assisted by a three-dimensional (3D) image-based robot system. Methods Robot-assisted ACL reconstruction was performed on twelve freshly frozen knee specimens. During the operation, three-dimensional images were used for ACL bone tunnel planning, and the robotic arm was used for navigation and drilling. Twelve patients who underwent traditional arthroscopic ACL reconstruction were included. 3D computed tomography was used to measure the actual position of the ACL bone tunnel and to evaluate the accuracy of the robotic and traditional ACL bone tunnel. Results On the femoral side, the positions of robotic and traditional surgery tunnels were 29.3 ± 1.4% and 32.1 ± 3.9% in the deep-to-shallow direction of the lateral femoral condyle (p = 0.032), and 34.6 ± 1.2% and 21.2 ± 9.4% in the high-to-low direction (p < 0.001), respectively. On the tibial side, the positions of the robotic and traditional surgical tunnels were located at 48.4 ± 0.9% and 45.8 ± 2.8% of the medial-to-lateral diameter of the tibial plateau (p = 0.008), 38.1 ± 0.8% and 34.6 ± 6.0% of the anterior-to-posterior diameter (p = 0.071), respectively. Conclusions In this study, ACL reconstruction was completed with the assistance of a robot arm and 3D images, and the robot was able to drill the bone tunnel more accurately than the traditional arthroscopic ACL reconstruction.

Extrinsic Risk Factors for Primary Noncontact Anterior Cruciate Ligament Injury in Adolescents Aged between 14 and 18 years: A Systematic Review

BACKGROUND

Adolescents present a high incidence of ACL injury compared with other age groups. Examining the risk factors that predispose adolescents to primary noncontact ACL injury is a key strategy to decrease the number of injuries in this population.

OBJECTIVE

The aim of this systematic review was to summarise the existing literature investigating extrinsic risk factors that have been linked with primary noncontact ACL injury risk (identified either using ACL injury occurrence or using screening tests measuring biomechanical mechanisms for noncontact ACL injury) in adolescents including research investigating: (1) the association between extrinsic risk factors and primary noncontact ACL injury risk; and (2) whether primary noncontact ACL injury risk was different in populations or groups exposed to different extrinsic risk factors in adolescents.

METHODS

The same search strategy was used in MEDLINE, SPORTDiscus, CINAHL, PubMed and Embase. Articles were included if: written in English; published in peer-reviewed journals; investigating and discussing primary noncontact ACL injury risk associated with extrinsic risk factors; they were original research articles with an observational design; and participants presented a mean age ranging between 14 and 18 years. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (QATOCCS) was used to assess the quality and risk of bias of the articles included in this systematic review.

RESULTS

The systematic review included 16 eligible articles published up to August 2022 about extrinsic risk factors for primary noncontact ACL injury including: sport (8 studies); sport exposure amount (5); sport level (3); sport season (1); environment (2); equipment (1). Differences in biomechanical risk factors predisposing to ACL injury were reported by sport in female adolescents playing basketball and soccer; however, no good evidence of differences in primary noncontact ACL injury rate by sport was reported in both male and female adolescents. There was contrasting evidence about associations between sport exposure and biomechanical and neuromuscular risk factors predisposing to ACL injury or primary noncontact ACL injury rate in both male and female adolescent players from different sports. There was weak evidence of differences in biomechanical risk factors predisposing to ACL injury by environmental condition in both male and female adolescents playing soccer and season phase in male adolescents playing basketball. Lastly, few good-quality articles suggested that higher sport level might be associated with increased primary noncontact ACL injury rate in female adolescents playing basketball and floorball and that bracing might not prevent primary noncontact ACL injuries in both male and female adolescent players from different sports.

DISCUSSION

The findings emphasise the need for further research to clarify the evidence about extrinsic risk factors and primary noncontact ACL injury in adolescents to develop ACL injury prevention guidelines that would help practitioners and researchers identify adolescents at risk and design future interventions. Future epidemiological studies should collect data about extrinsic factors as well as data about primary noncontact injury separately from secondary injuries or contact injuries to better inform primary noncontact ACL injury prevention in adolescents.

REGISTRATION

https://doi.org/10.17605/OSF.IO/VM82F (11/08/2021).

Comparative efficacy and safety of different surgical approaches for the treatment of anterior cruciate ligament injury: a Bayesian network meta-analysis protocol

INTRODUCTION

Anterior cruciate ligament (ACL) rupture can be treated surgically or non-surgically, with several surgical interventions available at present. However, the comparatively effective surgical intervention with relatively fewer side effects remains unknown. This study aims to fill in this gap by conducting a Bayesian network meta-analysis (NMA) and provide a theoretical basis for the clinical application.

METHOD AND ANALYSIS

We will perform a Bayesian NMA and will include randomised controlled trials (RCTs) published in English or Chinese that compare surgical intervention (ie, standard ACL reconstruction, ACL remnant-preserving reconstruction and ACL repair with suture augmentation to conservative therapy or studies that compare one surgical intervention to another for the symptom relief and function recovery of patients with ACL rupture. Primary outcome will be the proportion of patients with symptomatic and functional improvement measured by the Knee Injury and Osteoarthritis Outcome Score before and 6 months after treatment, with scores ranging from 0 (worst) to 100 (best). Secondary outcomes will be knee-specific quality of life (ACL QoL), return to activity and level of sport participation (Tegner or modified Tegner score), health-related QoL (EuroQol Group 5-Dimension 5-Level, EQ-5D-5L), resource use, intervention-related complications and patient satisfaction. We have developed search strategies for PubMed, Embase, the Cochrane Library and Web of Science, retrieving RCTs that meet the inclusion criteria from database inception to 1 December 2023. The methodological quality of the included RCTs will be assessed based on the Cochrane risk of bias table. The relative ranking probability of the best intervention will be estimated using the surface under the cumulative ranking curve. The Bayesian NMA will be conducted by using WinBUGS V.1.4.3. The Grading of Recommendations Assessment, Development and Evaluation approach will be applied to determine our confidence in an overall treatment ranking from the NMA.

ETHICS AND DISSEMINATION

Ethical approval for this study is not required because no private or confidential patient data will be used in this study. Findings of this study would be disseminated through the publication in a peer-reviewed medical journal.

PROSPERO REGISTRATION NUMBER

CRD42023437115.

Comparison of knee flexor strength recovery between semitendinosus alone versus semitendinosus with gracilis autograft for ACL reconstruction: a systematic review and meta-analysis

BACKGROUND

Whether there is a difference in harvesting the semitendinosus tendon alone (S) or in combination with the gracilis tendon (SG) for the recovery of knee flexor strength after anterior cruciate ligament (ACL) reconstruction remains inconclusive. Therefore, this study aimed to assess the recovery of knee flexor strength based on the autograft composition, S or SG autograft at 6, 12, and ≥ 24 months after ACL reconstruction.

METHODS

A systematic review and meta-analysis was conducted following the PRISMA guidelines. A comprehensive search was performed encompassing the Cochrane Library, Embase, Medline, PEDRo and AMED databases from inception to January 2023. Inclusion criteria were human clinical trials published in English, comprised of randomized controlled trials (RCTs), longitudinal cohort-, cross-sectional and case-control studies that compared knee flexor strength recovery between S and SG autografts in patients undergoing primary ACL reconstruction. Isokinetic peak torques were summarized for angular velocities of 60°/s, 180°/s, and across all angular velocities, assessed at 6, 12, and ≥ 24 months after ACL reconstruction. A random-effects model was used with standardized mean differences and 95% confidence intervals. Risk of bias was assessed with the RoBANS for non-randomized studies and the Cochrane RoB 2 tool for RCTs. Certainty of evidence was appraised using the GRADE working group methodology.

RESULTS

Among the 1,227 patients from the 15 included studies, 604 patients received treatment with S autograft (49%), and 623 received SG autograft (51%). Patients treated with S autograft displayed lesser strength deficits at 6 months across all angular velocities d = -0.25, (95% CI -0.40; -0.10, p = 0.001). Beyond 6 months after ACL reconstruction, no significant difference was observed between autograft compositions.

CONCLUSION

The harvest of S autograft for ACL reconstruction yields superior knee flexor strength recovery compared to SG autograft 6 months after ACL reconstruction, irrespective of angular velocity at isokinetic testing. However, the clinical significance of the observed difference in knee flexor strength between autograft compositions at 6 months is questionable, given the very low certainty of evidence and small effect size. There was no significant difference in knee flexor strength recovery between autograft compositions beyond 6 months after ACL reconstruction.

TRIAL REGISTRATION

CRD42022286773.

The patient with a painful knee

Knee pain encompasses a wide array of differential diagnoses and can often pose a diagnostic challenge, as it can have traumatic or non-traumatic causes. A good clinical history, assessment and anatomical knowledge gives a strong foundation to narrow down the diagnosis, and understanding the correct imaging modality and findings further informs correct and timely management. This article reviews various disease processes including fractures, inflammatory, infective and neoplastic causes, and discusses the assessment and various imaging modalities to aid diagnosis in both primary and secondary care.

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

INTRODUCTION

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

AIM

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

METHOD

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

RESULTS

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

SUMMARY

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

Cost-effectiveness analysis of a pragmatic randomized trial evaluating surgical reconstruction versus rehabilitation in patients with long-standing anterior cruciate ligament injury

Aims

The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness.

Methods

A total of 316 patients were recruited and randomly assigned to either surgical reconstruction or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment). Healthcare resource use and health-related quality of life data (EuroQol five-dimension five-level health questionnaire) were collected in the trial at six, 12, and 18 months using self-reported questionnaires and medical records. Using intention-to-treat analysis, differences in costs, and quality-adjusted life years (QALYs) between treatment arms were estimated adjusting for baseline differences and following multiple imputation of missing data. The incremental cost-effectiveness ratio (ICER) was estimated as the difference in costs divided by the difference in QALYs between reconstruction and rehabilitation.

Results

At 18 months, patients in the surgical reconstruction arm reported higher QALYs (0.052 (95% confidence interval (CI) -0.012 to 0.117); p = 0.177) and higher NHS costs (£1,017 (95% CI 557 to 1,476); p < 0.001) compared to rehabilitation. This resulted in an ICER of £19,346 per QALY with the probability of surgical reconstruction being cost-effective of 51% and 72% at a willingness-to-pay threshold of £20,000 and £30,000 per QALY, respectively.

Conclusion

Surgical reconstruction as a management strategy for patients with long-standing ACL injury is more effective, but more expensive, at 18 months compared to rehabilitation management. In the UK setting, surgical reconstruction is cost-effective.

Inline dynamometry provides reliable measurements of quadriceps strength in healthy and ACL-reconstructed individuals and is a valid substitute for isometric electromechanical dynamometry following ACL reconstruction

BACKGROUND

Quadriceps strength testing is recommended to guide rehabilitation and mitigate the risk of second injury following anterior cruciate ligament (ACL) reconstruction. Hand-held dynamometry is a practical alternative to electromechanical dynamometry but demonstrates insufficient reliability and criterion validity in healthy and ACL-reconstructed participants respectively. The purpose of this study is to investigate the reliability and concurrent validity of inline dynamometry for measuring quadriceps strength. The hypotheses are that intra-class correlation coefficient (ICC) values will be >0.90 for reliability and concurrent validity.

METHODS

This was a cross sectional study using a within-participant, repeated measures design. Isometric quadriceps testing was performed at 60° knee flexion in 50 healthy and 52 ACL-reconstructed participants. Interrater reliability, intrarater reliability, and concurrent validity of inline dynamometry was investigated through calculation of ICCs, Bland-Altman analysis, linear regression, standard error of measurement (SEM) and minimal detectable change (MDC).

RESULTS

The lower bounds of the 95% confidence intervals were >0.90 for all reliability and validity ICCs in healthy and ACL-reconstructed participants, except for intrarater reliability in healthy participants using absolute scores (ICC = 0.936 [95% CI 0.890-0.963]). In ACL-reconstructed participants, Bland-Altman bias was 0.01 Nm/kg for absolute and average scores, limits of agreement were -11.74% to 12.59% for absolute scores, the SEM was 0.13Nm/kg (95% CI 0.10-0.17) and the MDC was 0.36Nm/kg (95% CI 0.28 - 0.47).

CONCLUSION

Inline dynamometry is a reliable and economical alternative to electromechanical dynamometry for the assessment of quadriceps strength following ACL-reconstruction.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT05109871).

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

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

Anterior cruciate ligament femoral footprint is oblong-ovate, triangular, or two-tears shaped in healthy young adults: three-dimensional MRI analysis

PURPOSE

This study aimed to evaluate the morphology of the anterior cruciate ligament (ACL) femoral footprint with three-dimensional magnetic resonance imaging (3D MRI) in healthy knees.

METHODS

Fifty subjects with healthy knees were recruited, utilising 3D-SPACE sequences for ACL evaluation. The ACL was manually segmented, and the shape, size and location of the ACL femoral footprint were evaluated on a reformatted oblique-sagittal plane, which aligned closely with the ACL attachment. Statistical analysis included one-way ANOVA for continuous variables and Fisher's exact test for categorical variables, with a P value < 0.05 considered significant.

RESULTS

Three types of ACL femoral footprint shape were identified, namely, oblong-ovate (OO) in 33 knees (66%), triangular (Tr) in 12 knees (24%) and two-tears (TT) in 5 knees (10%), with the mean areas being 58, 47 and 68 mm2, respectively. Within group TT, regions with similar sizes but different locations were identified: high tear (TT-H) and low tear (TT-L). Notably, group OO demonstrated a larger notch height index, whilst group TT was characterised by a larger α angle and lateral femoral condyle index. A noticeable variation was observed in the location of the femoral footprint centre across groups, with group TT-L and group Tr showing a more distal position relative to the apex of the deep cartilage. According to the Bernard and Hertel (BH) grid, the ACL femoral footprint centres in group TT-L exhibited a shallower and higher position than other groups. Furthermore, compared to group OO and TT-H, group Tr showed a significantly higher position according to the BH grid.

CONCLUSION

In this study, the morphology of the ACL femoral footprint in healthy young adults was accurately evaluated using 3D MRI, revealing three distinct shapes: OO, Tr and TT. The different ACL femoral footprint types showed similar areas but markedly different locations. These findings emphasise the necessity of considering both the shape and precise location of the ACL femoral footprint during clinical assessments, which might help surgeons enhance patient-specific surgical plans before ACL reconstruction.

LEVEL OF EVIDENCE

IV.

The challenge of evaluating our surgical procedures

Cite this article: Bone Joint J 2023;105-B(11):1133–1134.

Explanatory and pragmatic trials in orthopaedics - Have we done the right studies?

Recent decades have seen marked advances in the quality of clinical orthopaedic trauma research, and with this has come a rise in the number of randomised clinical trials (RCTs) being conducted in orthopaedic trauma. These trials have been largely valuable in driving evidence-based management of injuries which previously had clinical equipoise. However, though RCTs are traditionally seen as the 'gold standard' of high-quality research, this research method is comprised primarily of two entities, explanatory and pragmatic designs, each with its own strengths and limitations. Most orthopaedic trials lie within a continuum between these designs, with varying degrees of both pragmatic and explanatory features. In this narrative review we provide a summary of the nuances within orthopaedic trial design, the advantages and limitations of such designs, and suggest tools which may aid clinicians in the appropriate selection and evaluation of trial designs.

Physiotherapy Rehabilitation Post Patellar Dislocation (PRePPeD)-protocol for an external pilot randomised controlled trial and qualitative study comparing supervised versus self-managed rehabilitation for people after acute patellar dislocation

BACKGROUND

Patellar dislocations mainly affect adolescents and young adults. After this injury, patients are usually referred to physiotherapy for exercise-based rehabilitation. Currently, limited high-quality evidence exists to guide rehabilitation practice and treatment outcomes vary. A full-scale trial comparing different rehabilitation approaches would provide high-quality evidence to inform rehabilitation practice. Whether this full-scale trial is feasible is uncertain: the only previous trial that compared exercise-based programmes in this patient population had high loss to follow-up. This study aims to assess the feasibility of conducting a future full-scale trial comparing the clinical and cost-effectiveness of two different rehabilitation approaches for people with an acute patellar dislocation.

METHODS

Two-arm parallel external pilot randomised controlled trial and qualitative study. We aim to recruit at least 50 participants aged ≥ 14 years with an acute first-time or recurrent patellar dislocation from at least three English National Health Service hospitals. Participants will be randomised 1:1 to supervised rehabilitation (four to six, one-to-one, physiotherapy sessions of advice and prescription of tailored progressive home exercise over a maximum of 6 months) or self-managed rehabilitation (one physiotherapy session of self-management advice, exercise, and provision of self-management materials). Pilot objectives are (1) willingness to be randomised, (2) recruitment rate, (3) retention, (4) intervention adherence, and (5) intervention and follow-up method acceptability to participants assessed through one-to-one semi-structured interviews (maximum 20 participants). Follow-up data will be collected 3, 6, and 9 months after randomisation. Quantitative pilot and clinical outcomes will be numerically summarised, with 95% confidence intervals generated for the pilot outcomes using Wilson's and exact Poisson methods as appropriate.

DISCUSSION

This study will assess the feasibility of conducting a full-scale trial comparing supervised versus self-managed rehabilitation for people after acute first-time or recurrent patellar dislocation. This full-scale trial's results would provide high-quality evidence to guide rehabilitation provision for patients with this injury.

TRIAL REGISTRATION

ISRCTN registry ISRCTN14235231 . Registered on 09 August 2022.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

This study was prospectively registered in PROSPERO: CRD 42020222567.

When context creates uncertainty: experiences of patients who choose rehabilitation as a treatment after an ACL injury

Up to 50% of patients who suffer an anterior cruciate ligament (ACL) injury receive or opt for rehabilitation alone as initial treatment in Scandinavia. Knowledge of whether patients treated with rehabilitation alone after ACL injury are satisfied is lacking. This study aimed to explore the experiences of patients treated with rehabilitation alone after an ACL injury. Fourteen patients (35.9 (19-56) years old) who suffered an ACL injury treated with rehabilitation alone, a mean of 32 months before inclusion, were interviewed. The interview transcripts were analysed using qualitative content analysis with an inductive approach. The experiences of patients treated with rehabilitation after an ACL injury were summarised in one theme: 'Is the grass greener on the other side? Context characterised by uncertainty', supported by three main categories and nine subcategories. Uncertainty permeated the context of all levels of knee-related life following ACL injury: (1) in the past, patients felt uncertainty regarding treatment choices, (2) in the present, patients felt uncertainty regarding their physical capacity and knee self-efficacy, and (3) for the future, patients felt uncertainty regarding what might happen. With few exceptions, patients' experiences after an ACL injury treated with rehabilitation alone are characterised by uncertainty regarding their physical function, psychological impairments and possible future limitation of knee function. Uncertainty is experienced by patients in the past, the present and the future. Patients experience the knee as a symptomatic obstacle and need to adapt the physical activity to the presence of symptoms.