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Schmidt S, Krahl D, Podszun J, Knecht S, Zimmerer A, Sobau C, Ellermann A, Ruhl A. Combining a digital health application with standard care significantly enhances rehabilitation outcomes for ACL surgery patients. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39189134 DOI: 10.1002/ksa.12430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 07/23/2024] [Accepted: 07/31/2024] [Indexed: 08/28/2024]
Abstract
INTRODUCTION Anterior cruciate ligament (ACL) rupture is one of the most common sports injuries. Regardless of the surgical treatment, patients require intensive education about the pathology, therapeutic options and physical therapy. However, it is often not possible for the patient to start physical therapy directly and schedule adequate consultations. Digital health applications are medical devices that can help bridge the gap between physiotherapy sessions and provide qualified, convenient and effective education and treatment. This study is needed to explore alternative methods to ensure continuous and effective rehabilitation for ACL patients who face delays in accessing traditional physiotherapy. The study aimed to compare app-assisted therapy plus standard of care (conventional orthopaedic and physiotherapeutic measures) versus isolated standard of care for patients with planned ACL surgery. METHODS A monocentric, two-arm, 1:1 randomized controlled study examined 80 patients after a cruciate ligament rupture with or without meniscal injury. Patients over 18 years with a confirmed diagnosis of ACL rupture and planned surgical reconstruction using autologous grafts were included. The study criteria additionally included willingness to use the Orthopy app and sufficient German language proficiency. The study excluded patients with severe concomitant injuries, prior knee surgeries, chronic pain conditions and those not compatible with app usage. Patients were randomized and their baseline data (t0) was collected. Subsequently, they received their treatment according to their treatment group. The study included a presurgery period (2-6 weeks) and a postsurgery period (14 weeks). Interim assessments were done via online questionnaires at t1 (if more than 3 weeks before surgery) and t3, t4 and t5 (postsurgery). Additional clinical assessments were conducted at t2 (presurgery) and t6 (14 weeks postsurgery). Primary outcome measures included the knee injury and osteoarthritis outcome score (KOOS), with subjective pain and function levels (numeric rating scale [NRS]) as secondary endpoints. RESULTS The clinical trial was able to show positive outcomes on the KOOS Pain and Symptoms subscale of the primary endpoint KOOS in the interventional group compared to the standard of care group. A statistically significant pain reduction could be seen at t1 (p = 0.0005), t2 (p = 0.0068) and t4 (approximately 6 weeks after surgery; p = 0.01). A significant reduction of symptoms at t1 (p = 0.0001), t2 (p = 0.0036) and t6 (p = 0.0377) were recognized. These findings are further supported by the significant benefit of the pain NRS at t4 and positive tendencies at t3, t5 and t6. The KOOS subscales quality of life (p = 0.0066), activities of daily living (p = 0.0009) and Sport (p = 0.0484) showed significant effects before surgery. CONCLUSION The Orthopy app is a medical device that is both safe and effective for use. Combining the Orthopy app and standard of care can significantly improve prehabilitation and rehabilitation in surgical treatment with ACL reconstruction compared with the isolated standard of care. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Sebastian Schmidt
- Department of Sports Medicine, ARCUS Kliniken, Pforzheim, Germany
- Department of Orthopaedic and Trauma Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Daniel Krahl
- Department of Sports Medicine, ARCUS Kliniken, Pforzheim, Germany
- Department of Orthopedic Surgery, Vincentius-Diakonissen-Kliniken gAG, Karlsruhe, Germany
| | | | - Sophie Knecht
- Medical Affairs, Orthopy Health GmbH, Hamburg, Germany
| | - Alexander Zimmerer
- Department of Orthopaedic and Trauma Surgery, Orthopädische Klinik Paulinenhilfe, Diakonieklinikum, Stuttgart, Germany
| | - Christian Sobau
- Department of Sports Medicine, ARCUS Kliniken, Pforzheim, Germany
| | - Andree Ellermann
- Department of Sports Medicine, ARCUS Kliniken, Pforzheim, Germany
| | - Alexander Ruhl
- Department of Sports Medicine, ARCUS Kliniken, Pforzheim, Germany
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Lisee C, Obudzinski S, Pietrosimone BG, Alexander Creighton R, Kamath G, Longobardi L, Loeser R, Schwartz TA, Spang JT. Association of Serum Biochemical Biomarker Profiles of Joint Tissue Inflammation and Cartilage Metabolism With Posttraumatic Osteoarthritis-Related Symptoms at 12 Months After ACLR. Am J Sports Med 2024; 52:2503-2511. [PMID: 39129267 PMCID: PMC11344971 DOI: 10.1177/03635465241262797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 05/15/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Anterior cruciate ligament injury and anterior cruciate ligament reconstruction (ACLR) are risk factors for symptomatic posttraumatic osteoarthritis (PTOA). After ACLR, individuals demonstrate altered joint tissue metabolism indicative of increased inflammation and cartilage breakdown. Serum biomarker changes have been associated with tibiofemoral cartilage composition indicative of worse knee joint health but not with PTOA-related symptoms. PURPOSE/HYPOTHESIS The purpose of this study was to determine associations between changes in serum biomarker profiles from the preoperative sample collection to 6 months after ACLR and clinically relevant knee PTOA symptoms at 12 months after ACLR. It was hypothesized that increases in biomarkers of inflammation, cartilage metabolism, and cartilage degradation would be associated with clinically relevant PTOA symptoms after ACLR. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Individuals undergoing primary ACLR were included (N = 30). Serum samples collected preoperatively and 6 months after ACLR were processed to measure markers indicative of changes in inflammation (ie, monocyte chemoattract protein 1 [MCP-1]) and cartilage breakdown (ie, cartilage oligomeric matrix protein [COMP], matrix metalloproteinase 3, ratio of type II collagen breakdown to type II collagen synthesis). Knee injury and Osteoarthritis Outcome Score surveys were completed at 12 months after ACLR and used to identify participants with and without clinically relevant PTOA-related symptoms. K-means cluster analyses were used to determine serum biomarker profiles. One-way analyses of variance and logistic regressions were used to assess differences in Knee injury and Osteoarthritis Outcome Score subscale scores and clinically relevant PTOA-related symptoms between biomarker profiles. RESULTS Two profiles were identified and characterized based on decreases (profile 1: 67% female; age, 21.4 ± 5.1 years; body mass index, 24.4 ± 2.4) and increases (profile 2: 33% female; age, 21.3 ± 3.2 years; body mass index, 23.4 ± 2.6) in sMCP-1 and sCOMP preoperatively to 6 months after ACLR. Participants with profile 2 did not demonstrate differences in knee pain, symptoms, activities of daily living, sports function, or quality of life at 12 months after ACLR compared to those with profile 1 (P = .56-.81; η2 = 0.002-0.012). No statistically significant associations were noted between biomarker profiles and clinically relevant PTOA-related symptoms (odds ratio, 1.30; 95% CI, 0.23-6.33). CONCLUSION Serum biomarker changes in MCP-1 and sCOMP within the first 6 months after ACLR were not associated with clinically relevant PTOA-related symptoms.
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Affiliation(s)
- Caroline Lisee
- Department of Kinesiology, University of Georgia, Athens, Georgia, USA
| | - Sarah Obudzinski
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brian G. Pietrosimone
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Exercise and Sports Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - R. Alexander Creighton
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ganesh Kamath
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lara Longobardi
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Richard Loeser
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Todd A. Schwartz
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jeffrey T. Spang
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Fleming BC, Baranker B, Badger GJ, Kiapour AM, Ecklund K, Micheli LJ, Murray MM. Bridge-Enhanced Anterior Cruciate Ligament Restoration: 6-Year Results From the First-in-Human Cohort Study. Orthop J Sports Med 2024; 12:23259671241260632. [PMID: 39143986 PMCID: PMC11322937 DOI: 10.1177/23259671241260632] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/02/2024] [Indexed: 08/16/2024] Open
Abstract
Background Bridge-enhanced anterior cruciate ligament restoration (BEAR) combines suture repair of the anterior cruciate ligament (ACL) with an extracellular matrix implant plus autologous blood to facilitate native ACL healing. Purpose/Hypothesis The purpose of this study was to compare the 6-year follow-up outcomes of patients who underwent the BEAR procedure with those of a nonrandomized concurrent control group receiving autograft ACL reconstruction (ACLR) in the first-in-human safety study of the BEAR implant (BEAR I trial). Based on the 2-year results, it was hypothesized that isometric hamstring strength after the BEAR procedure would be greater than that after ACLR and that there would be no other differences in outcomes at 6 years. Study Design Cohort study, Level of evidence, 2. Methods Ten patients underwent BEAR and 10 received ACLR with a 4-stranded hamstring autograft. Outcomes assessed included the record of subsequent surgeries, the International Knee Documentation Committee (IKDC) Subjective Knee Score, IKDC physical examination grade, the Knee injury and Osteoarthritis Outcome Score, instrumented knee laxity, functional outcomes (ie, muscle strength assessments and hop testing), and qualitative magnetic resonance imaging assessment. Comparisons between treatments were based on computations of the mean differences and the associated 95% CIs. Results One patient in the BEAR group and 3 patients in the ACLR group were lost to follow-up. In the period between 2 and 6 years, 1 patient in each group underwent revision surgery. There were no differences between groups at the 6-year follow-up in any of the outcome measures except for isometric hamstring strength, which was approximately equal to that of the contralateral knee in the BEAR group and <44% of that in the contralateral knee in the ACLR group (P < .01). Conclusion This preliminary study suggests that the outcomes of BEAR and ACLR with a hamstring tendon graft may be similar at the 6-year follow-up and warrants investigation of the BEAR procedure in a larger cohort of patients.
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Affiliation(s)
- Braden C. Fleming
- Department of Orthopaedics, Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ben Baranker
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, Vermont, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J. Micheli
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Tan EK, Ahmad Hanif KA, Mohamed Saaid F, Yeak RDK, Abdul Kahar J, Mahmud A, Nasir NM. Cost-Outcome Descriptive Study for Mobile App (UPSCALER) in the Rehabilitation of Anterior Cruciate Ligament (ACL) Injuries After Reconstructive Surgery. Cureus 2024; 16:e59886. [PMID: 38854226 PMCID: PMC11160346 DOI: 10.7759/cureus.59886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 06/11/2024] Open
Abstract
Anterior cruciate ligament (ACL) injuries are a significant concern in athletes, often leading to long-term complications and reduced quality of life. Despite advancements in surgical techniques, outcomes following ACL reconstruction remain suboptimal, largely due to poor adherence to postoperative rehabilitation. This study introduces a novel postoperative rehabilitation approach utilizing a smartphone application, UPSCALER, developed by the Universiti Putra Malaysia Sports Injury and Arthroscopic Surgery Center of Excellence. The application delivers a validated accelerated rehabilitation protocol through instructional videos tailored to each patient's recovery phase. Results from the study demonstrate promising outcomes, including improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales post-rehabilitation, potentially attributed to increased adherence facilitated by the application's accessibility. Furthermore, the study explores the cost-effectiveness of this approach compared to conventional methods. In conclusion, smartphone application-guided rehabilitation shows promise in improving ACL reconstruction outcomes, warranting further research to validate its effectiveness and long-term impact on patient recovery and healthcare costs.
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Affiliation(s)
- Eng Kee Tan
- Department of Orthopedics and Traumatology, Universiti Putra Malaysia, Serdang, MYS
| | | | | | - Raymond D K Yeak
- Department of Orthopedics and Traumatology, Universiti Putra Malaysia, Serdang, MYS
| | - Johan Abdul Kahar
- Department of Orthopedics and Traumatology, Universiti Putra Malaysia, Serdang, MYS
| | - Aidalina Mahmud
- Department of Community Health, Universiti Putra Malaysia, Serdang, MYS
| | - Nizlan M Nasir
- Department of Orthopedics and Traumatology, Universiti Putra Malaysia, Serdang, MYS
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Hopper H, Adsit M, Reiter CR, Satalich JR, Schmidt RC, Peri MI, Cyrus JW, Vap AR. Female Sex, Older Age, Earlier Surgery, Anticoagulant Use, and Meniscal Repair Are Associated With Increased Risk of Manipulation Under Anesthesia or Lysis of Adhesions for Arthrofibrosis After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2024; 40:1687-1699. [PMID: 38000486 DOI: 10.1016/j.arthro.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/02/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023]
Abstract
PURPOSE To determine what patient or surgical factors are associated with an increased risk of arthrofibrosis requiring manipulation under anesthesia (MUA) or lysis of adhesions (LOA) after anterior cruciate ligament reconstruction (ACLR). METHODS A systematic review was performed in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Cochrane, Embase, and Medline databases were searched for studies published through February 2023. Inclusion criteria were studies that identified risk factors for MUA and/or LOA after ACLR. Studies investigating arthrofibrosis after multiligamentous knee injuries or ACL repair were excluded. RESULTS Eleven studies including a total of 333,876 ACLRs with 4,842 subsequent MUA or LOA (1.45%) were analyzed. Increasing age was associated with an increased risk in 3 studies (P < .001, P < .05, P < .01) but was found to have no association another two. Other factors that were identified by multiple studies as risk factors for MUA/LOA were female sex (4 studies), earlier surgery (5 studies), use of anticoagulants other than aspirin (2 studies), and concomitant meniscal repair (4 studies). CONCLUSIONS In total, 1.45% of the patients who underwent ACLR and were included in this systematic review had to undergo a subsequent MUA/LOA to treat arthrofibrosis. Female sex, older age, earlier surgery, use of anticoagulants other than aspirin, and concomitant meniscal repair were associated with increased risk of MUA/LOA. The modifiable risks, including use of anticoagulants and time between injury and surgery, can be considered when making treatment decisions. LEVEL OF EVIDENCE Level IV, systematic review of Level III-IV studies.
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Affiliation(s)
- Haleigh Hopper
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, U.S.A..
| | - Matthew Adsit
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, U.S.A
| | - Charles R Reiter
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, U.S.A
| | - James R Satalich
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, U.S.A
| | - R Cole Schmidt
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, U.S.A
| | - Maria I Peri
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, U.S.A
| | - John W Cyrus
- Virginia Commonwealth University, Richmond, Virginia, U.S.A
| | - Alexander R Vap
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, U.S.A
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Degenhardt H, Hirschmüller A, Minzlaff P. [Current approach in the follow-up treatment of joint-preserving operations on the knee joint in German-speaking countries]. SPORTVERLETZUNG SPORTSCHADEN : ORGAN DER GESELLSCHAFT FUR ORTHOPADISCH-TRAUMATOLOGISCHE SPORTMEDIZIN 2024; 38:40-47. [PMID: 38447941 DOI: 10.1055/a-2210-0401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Postoperative follow-up after joint-preserving knee surgery involves conventional physiotherapy as well as other approaches and devices such as CPM and CAM splints, TENS devices, BFR exercise, prehabilitation, and digital health applications. The aim of this survey was to investigate current standards, trends and control methods in postoperative care to identify fields of concern and to compare them with the current literature. MATERIAL AND METHODS We conducted a structured anonymous online survey of specialists in orthopaedics and trauma surgery listed by the German-speaking Society for Arthroscopy and Joint Surgery (AGA). The questionnaire included 36 closed-ended questions on the follow-up of joint-preserving surgery of the knee joint. RESULTS Questionnaires from 528 participants with long-term professional experience (86.6% with more than 10 years) were analysed. Standardised post-treatment schemes are used by 97.2% and their evidence is estimated to be high (59.1%) / very high (14.8%). Problems of rehabilitation are seen in 10-20% of cases by 87.3% (persistent muscular atrophy 30.9%). After reconstructive surgery, CPM splints (70.1%), CAM splints (42.1%), orthoses (85.0%) and TENS devices (40.0%) are prescribed. More potent approaches for the treatment of postoperative muscle deficits are desired by 89.4%. BFR exercise is known by 41.7% and is used regularly by 8%. Communication with treating physiotherapists is infrequent (written: 27.5%). Digital rehabilitation management would be supported by 83.3%; 22.7% are not aware of digital health applications. 87.9% of participants believe that prehabilitation can affect postoperative outcomes. CONCLUSION Follow-up of knee joint-preserving surgeries is usually standardised and regularly reviewed for up-to-date evidence. The evidence for recommendations made is considered high. Orthoses are usually used after reconstructive surgery, persistent muscle atrophy is a major problem, BFR training is only known to a limited extent, and there is currently a lack of standardised training protocols. Communication with physiotherapists needs to be improved. Digital rehabilitation management is rarely used but would be supported by the majority of surgeons.
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Affiliation(s)
- Hannes Degenhardt
- Orthopädie und Unfallchirurgie, Klinikum Freising, Freising, Deutschland
- Sektion Sportorthopädie, Technische Universität München, München, Deutschland
| | - Anja Hirschmüller
- Altius Swiss Sportmed Center, Rheinfelden, Schweiz
- Universitätsklinikum Freiburg, Klinik für Orthopädie und Traumatologie, Freiburg, Deutschland
| | - Philipp Minzlaff
- Sektion Sportorthopädie, Technische Universität München, München, Deutschland
- Sportorthopädie Orthoclinic Agatharied, Krankenhaus Agatharied, Hausham, Deutschland
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Elabd OM, Alghadir AH, Ibrahim AR, Hasan S, Rizvi MR, Sharma A, Iqbal A, Elabd AM. Functional outcomes of accelerated rehabilitation protocol for anterior cruciate ligament reconstruction in amateur athletes: a randomized clinical trial. J Rehabil Med 2024; 56:jrm12296. [PMID: 38385715 PMCID: PMC10910537 DOI: 10.2340/jrm.v56.12296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 01/11/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) rupture is the most common knee injury among athletes, and can result in long-term complications and career-ending conditions for sportspeople. There is no consensus in the literature on the effectiveness of rehabilitation after ACL reconstruction, or the best protocol to follow for functional outcome improvement. OBJECTIVE To determine the impact of an accelerated rehabilitation protocol on knee functional outcomes in amateur athletes with anterior cruciate ligament reconstruction (ACLR). DESIGN Two-arm, parallel-group randomized comparative design. PATIENTS A total of 100 amateur male athletes (mean age 22.01 ± 1.79 years) with ACLR were randomly divided into experimental and control groups (n = 50/group). METHODS An accelerated rehabilitation protocol and a conventional rehabilitation protocol were used for the experimental group. In contrast, only the conventional rehabilitation protocol was used for the control group. The rehabilitation was delivered in 5 weekly sessions for 22 weeks. The primary outcome measure, knee pain, was measured using a visual analogue scale (VAS). Extensive test batteries, for hop tests, Knee Injury and Osteoarthritis Outcome Score (KOOS), and knee effusion, were measured, aiming to add more objective criteria to determine functional performance. RESULTS Both groups (n = 50/group) were well-matched (p = 0.816), with insignificant differences in their demographic characteristics (p > 0.05). A multivariate analysis of variance (MANOVA) test showed no significant difference between the 2 groups (p = 0.781) at baseline. A 2-way MANOVA (2 × 2 MANOVA) of within- and between-group variations indicated overall significant treatment, time, and treatment × time interaction effects (p < 0.001) in favour of the accelerated rehabilitation group. CONCLUSION The accelerated rehabilitation protocol was more effective in improving functional outcomes than a conventional rehabilitation protocol in amateur athletes with ACLR.
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Affiliation(s)
- Omar M Elabd
- Department of Orthopedics and its Surgeries, Faculty of Physical Therapy, Delta University for Science and Technology, Gamasa, Egypt
| | - Ahmad H Alghadir
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11433, Saudi Arabia
| | - Abeer R Ibrahim
- Basic Science Department, Faculty of Physical Therapy, Cairo University, Egypt; Department of Physiotherapy, College of Applied Medical Sciences, Umm Al-Qura University, Saudi Arabia
| | - Shahnaz Hasan
- Department of Physiotherapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah University, Al-Majmaah, Saudi Arabia
| | - Moattar R Rizvi
- Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute and Studies (MRIIRS), Faridabad, India
| | - Ankita Sharma
- Department of Physiotherapy, School of Allied Health Sciences, Manav Rachna International Institute and Studies (MRIIRS), Faridabad, India
| | - Amir Iqbal
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11433, Saudi Arabia.
| | - Aliaa M Elabd
- Basic Science Department, Faculty of Physical Therapy, Benha University, Egypt
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Gardner EC, Podbielski C, Dunphy E. Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Physical Therapists/Care Providers. TELEMEDICINE REPORTS 2024; 5:18-35. [PMID: 38469166 PMCID: PMC10927236 DOI: 10.1089/tmr.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 03/13/2024]
Abstract
Background While the importance of structured rehabilitation following anterior cruciate ligament reconstruction (ACLR), particularly in the return-to-sport phase, is known, for most patients, supervised physical therapy is often completed before this time point. The recent emergence of telerehabilitation and other digital health interventions has the potential to address this "rehabilitation gap." Methods The study was conducted as a cross-section, online survey collecting qualitative and quantitative data from open and closed questions. Inclusion criteria included local qualified physical therapists or other professionals working with ACLR patients. Results Eighty-three percent of respondents experienced a "rehabilitation gap" with their ACLR patients. Few reported currently utilizing apps or websites (9.74%). The majority (41/58) reported experience with telerehabilitation, and 84% felt that there was a role for digital rehabilitation strategies to address the "rehabilitation gap." The vast majority (94.74%) of participants felt that standard commercial insurance did not permit sufficient rehabilitation. Discussion While the majority of our respondents acknowledged the existence of a "rehabilitation gap," as well as familiarity with and confidence in telerehabilitation, few were using this technique at the time of our survey. This suggests an opportunity for development in this space.
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Affiliation(s)
- Elizabeth C. Gardner
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Corey Podbielski
- Outpatient Physical Therapy, Gaylord Speciality Healthcare, Wallingford, Connecticut, USA
| | - Emma Dunphy
- Research Department of Primary Care and Populational Health, Upper Third Floor, UCL Medical School (Royal Free Campus), London, United Kingdom
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Romandini I, Cance N, Dan MJ, Pineda T, Pairot de Fontenay B, Demey G, Dejour DH. A non-weight bearing protocol after ACL reconstruction improves static anterior tibial translation in patients with elevated slope and increased weight bearing tibial anterior translation. J Exp Orthop 2023; 10:142. [PMID: 38114884 PMCID: PMC10730494 DOI: 10.1186/s40634-023-00694-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/14/2023] [Indexed: 12/21/2023] Open
Abstract
PURPOSE Aim of this study is to evaluate the impact of a non-weight bearing (NWB) protocol within 21 post-operative days after anterior cruciate ligament (ACL) reconstruction on static and dynamic anterior tibial translations (SATT and DATT, respectively). The hypothesis is that delayed WB would improve ATT at 9 months follow-up. METHODS A series of patients treated with ACL reconstruction was retrospectively reviewed, comparing a group with immediate post-operative weight bearing (WB group) and a group without post-operative weight bearing (NWB group). The NWB protocol was applied to patients with posterior tibial slope (PTS) ≥ 12°, pre-operative SATT ≥ 5 mm, and/or meniscal lesions of root or radial type. SATT, and PTS were measured on 20° flexion monopodal lateral x-rays, while DATT on Telos™ x-rays at pre-operative and 9-months follow-up. RESULTS One hundred seventy-nine patients were included (50 NWB group, 129 WB group). The SATT worsened in the WB group with a mean increase of 0.7 mm (SD 3.1 mm), while in the NWB group, the SATT improved with a mean decrease of 1.4 mm (SD 3.1 mm) from the pre-operative to 9 months' follow-up (p < 0.001). The side-to-side Telos™ evaluation showed a significant improvement in DATT within both the groups (p < 0.001), but there was no difference between the two groups (p = 0.99). CONCLUSION The post-operative protocol of 21 days without WB led to an improvement in SATT at 9 months without an influence on DATT, and it is recommended for patients with a SATT ≥ 5 mm and/or a PTS ≥ 12° as part of an "à la carte" approach to ACL reconstruction. LEVEL OF EVIDENCE Level IV, Retrospective case series.
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Affiliation(s)
- Iacopo Romandini
- Orthopedic Surgery Department, Lyon Ortho Clinic, Clinique de La Sauvegarde, 29 Avenue Des Sources, 69009, Lyon, France.
- IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica 2, Via Pupilli 1, Bologna, 40136, Italy.
| | - Nicolas Cance
- Orthopedic Surgery Department, Lyon Ortho Clinic, Clinique de La Sauvegarde, 29 Avenue Des Sources, 69009, Lyon, France
| | - Michael J Dan
- Orthopedic Surgery Department, Lyon Ortho Clinic, Clinique de La Sauvegarde, 29 Avenue Des Sources, 69009, Lyon, France
- Surgical and Orthopaedic Research Laboratory, Prince of Wales Clinical School, University of New South Wales, 2052, Sydney, Australia
| | - Tomas Pineda
- Orthopedic Surgery Department, Lyon Ortho Clinic, Clinique de La Sauvegarde, 29 Avenue Des Sources, 69009, Lyon, France
- Hospital El Carmen, Santiago, Chile
| | - Benoit Pairot de Fontenay
- Orthopedic Surgery Department, Lyon Ortho Clinic, Clinique de La Sauvegarde, 29 Avenue Des Sources, 69009, Lyon, France
| | - Guillaume Demey
- Orthopedic Surgery Department, Lyon Ortho Clinic, Clinique de La Sauvegarde, 29 Avenue Des Sources, 69009, Lyon, France
| | - David H Dejour
- Orthopedic Surgery Department, Lyon Ortho Clinic, Clinique de La Sauvegarde, 29 Avenue Des Sources, 69009, Lyon, France
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Kader N, Jones S, Serdar Z, Banaszkiewicz P, Kader D. Home-based rehabilitation following anterior cruciate ligament reconstruction in the Kurdistan region of Iraq: epidemiology and outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:481-488. [PMID: 36445460 PMCID: PMC9707130 DOI: 10.1007/s00590-022-03431-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/09/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE This study, set in in the Kurdistan region of Iraq, describes the epidemiology and outcomes of anterior cruciate ligament reconstruction (ACLR) followed by home-based rehabilitation alone. METHODS A cohort observational study of patients aged ≥ 16 years with an ACL rupture who underwent an ACLR under a single surgeon. Followed by a home-based rehabilitation programme of appropriate simplicity for completion in the home setting; consisting of stretching, range of motion and strengthening exercises. Demographics, mechanism of injury, operative findings, and outcome data (Lysholm, Tegner Activity Scale (TAS), and revision rates) were collected from 2016 to 2021. Data were analysed using descriptive statistics. RESULTS The cohort consisted of 545 patients (547 knees), 99.6% were male with a mean age of 27.8 years (SD 6.18 years). The mean time from diagnosis to surgery was 40.6 months (SD 40.3). Despite data attrition Lysholm scores improved over the 15-month follow-up period, matched data showed the most improvement occurred within the first 2 months post-operatively. Post-operative TAS results showed an improvement in level of function, but did not reach pre-injury levels by final follow-up. At final follow-up, six (1.1%) patients required an ACLR revision. CONCLUSION Patients who completed a home-based rehabilitation programme in Kurdistan had low revision rates and improved Lysholm scores 15 months post-operatively. To optimise resources, further research should investigate the efficacy of home-based rehabilitation for trauma and elective surgery in low- to middle-income countries and the developed world.
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Affiliation(s)
- Nardeen Kader
- grid.451349.eSt George’s University Hospitals NHS Foundation Trust, London, UK
| | - Samantha Jones
- South West London Elective Orthopaedic Centre, Epsom, UK
| | - Ziyad Serdar
- Shar Teaching Hospital, Sulaymaniyah, Kurdistan Iraq
| | - Paul Banaszkiewicz
- grid.42629.3b0000000121965555Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, Tyne and Wear UK
- grid.415506.30000 0004 0400 3364Queen Elizabeth Hospital Gateshead, Gateshead, UK
| | - Deiary Kader
- South West London Elective Orthopaedic Centre, Epsom, UK
- grid.449828.b0000 0004 0404 9231University of Kurdistan Hewlêr, Erbil, Iraq
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11
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Dunphy E, Button K, Murray E, Hamilton FL. Beyond guidelines: A qualitative clinical stakeholder study of optimal management of anterior cruciate ligament rehabilitation. Musculoskeletal Care 2023; 21:117-129. [PMID: 35852464 DOI: 10.1002/msc.1673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 11/06/2022]
Abstract
AIMS This study gathered expert perspectives in the management of anterior cruciate ligament (ACL) rehabilitation to explore current practice, variations in care and optimal management strategies. MATERIALS AND METHODS This was a qualitative semi-structured interview study. The participants' experiences were considered in terms of their roles as employees, managers, clinicians and professional gatekeepers. Purposive and snowball sampling were used to recruit physiotherapists and orthopaedic surgeons. Participants were included if they had a proven record in clinical management or research involving ACL patients. Persons were excluded if they could not speak English. Interviews were conducted in person, via skype or over the phone at a time convenient to the participant. Data was analysed using a framework analysis and critical realist approach. RESULTS Results included 24 interviews that were conducted with 19 physiotherapists and 5 surgeons. Themes of variation in current care and optimal care were explored including subthemes of patient centred practice, evidence based medicine, resources, self-management, multidisciplinary teamwork, training and expertise were explored. Participant's perceptions of current care were that it was a location 'lottery' that significantly varied for patients across the UK. CONCLUSIONS Stakeholders identified that optimal management should be patient centred and incorporate adequate equipment, specific training for physiotherapists and a closely communicating multidisciplinary team. Research is needed to explore cost effective models of optimal rehabilitation that include return to sport strategies.
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Affiliation(s)
- Emma Dunphy
- Research Department of Primary Care and Population Health, eHealth Unit, London, UK
| | | | - Elizabeth Murray
- Research Department of Primary Care and Population Health, eHealth Unit, London, UK
| | - Fiona L Hamilton
- Research Department of Primary Care and Population Health, eHealth Unit, London, UK
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12
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Repac J, Alvarez LX, Lamb KE, Spector D. Effect of Nail Grips on Weight Bearing and Limb Function in 30 Dogs 2 Weeks Post Tibial Plateau Leveling Osteotomy. Animals (Basel) 2022; 12:2312. [PMID: 36139171 PMCID: PMC9494954 DOI: 10.3390/ani12182312] [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] [Received: 08/02/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 11/23/2022] Open
Abstract
The objective of this study was to assess the functional outcomes of dogs wearing nail grips in the first 2 weeks following tibial plateau leveling osteotomy (TPLO). Thirty dogs were included (n = 13 nail grips and n = 17 sham grips). Visual lameness scores (VLS), total pressure index (TPI), and client-specific outcome measures (CSOMs) were obtained by blinded observers on day 1 and day 14 +/- 3 post TPLO. CSOMs were also obtained on day 7. There were no differences in VLS and TPI between the treatment and sham group on day 14 (p = 0.44 and p = 0.59, respectively) or at any time point. CSOMs assessing walking on slippery flooring, ability to rise, and consistent use of surgical limb on a 5 min walk were also not different between groups (p = 0.78, p = 0.80, and p = 0.63) at any time point. Nail grips were well tolerated in dogs after orthopedic surgery. This study did not demonstrate a benefit for dogs wearing nail grips during the first two weeks after TPLO; however, further studies are warranted.
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Affiliation(s)
- Jennifer Repac
- College of Veterinary Medicine, University of Florida, Gainesville, FL 32608, USA
| | | | - Kenneth E. Lamb
- Lamb Statistical Consulting and Scientific Writing LLC, West Saint Paul, MN 55118, USA
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13
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Prescription of knee braces after anterior cruciate ligament reconstruction: Fact or fiction? Turk J Phys Med Rehabil 2022; 68:355-363. [DOI: 10.5606/tftrd.2022.8906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/22/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives: This study aims to compare the clinical results of patients rehabilitated with or without a rehabilitative knee brace (RKB) after anterior cruciate ligament (ACL) reconstruction.
Patients and methods: This retrospective, comparative study was conducted at between January 2013 and December 2017. A total of 119 patients (112 males, 7 females; mean age: 32.0±8.6 years; range, 18 to 45 years) with acute ACL ruptures treated with arthroscopic ACL reconstruction and rehabilitated with (n=56) or without RKB (n=63) participated in the study. The minimum follow-up time was 24 months. The ACL quality of life (QoL) questionnaire, Lysholm Knee Scoring Scale, and Tegner Activity Level Scale were used for the evaluation of the QoL, knee function, and activity level, respectively. The time to return to sports was recorded. The side-to-side difference in the anterior translation of the tibia was measured using a KT-1000 arthrometer.
Results: The mean follow-up time was 38.4±9.1 (range, 24 to 56) months. Baseline demographics and clinical characteristics were similar between groups. Regarding QoL, knee function, and activity level, no significant difference was observed between patients who used RKB and those who did not use it at the postoperative 12th month (p=0.95, p=0.56, p=0.98, respectively) and the latest follow-up (p=0.21, p=0.73, p=0.99, respectively). The mean time to return to sports (nearly 11 months for both groups) and side-to-side difference in the anterior tibial translation at the latest follow-up was also similar between groups (p=0.15 and p=0.15, respectively). There was no graft rupture during the follow-up in both groups. The complication rates were 7.9% and 7.1% for no brace and brace groups, respectively, without a statistically significant difference (p=0.87).
Conclusion: According to the results of this study, there was no significant difference between the rehabilitative brace and no brace groups in clinical outcomes after ACL reconstruction.
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14
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Culvenor AG, Girdwood MA, Juhl CB, Patterson BE, Haberfield MJ, Holm PM, Bricca A, Whittaker JL, Roos EM, Crossley KM. Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus. Br J Sports Med 2022; 56:1445-1453. [PMID: 35768181 DOI: 10.1136/bjsports-2022-105495] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes. DESIGN Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence. DATA SOURCES MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library. ELIGIBILITY CRITERIA Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults. RESULTS We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion. CONCLUSION The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.
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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
| | - 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
| | - Carsten B Juhl
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Funen, Denmark.,Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Copenhagen, Denmark
| | - 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
| | - Melissa J Haberfield
- La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Pætur M Holm
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Funen, Denmark.,The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | - Alessio Bricca
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Funen, Denmark.,The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | - Jackie L Whittaker
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Ewa M Roos
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Funen, Denmark
| | - 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
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15
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Zhang K, Beshay T, Murphy B, Sheean A, de Sa D. Quadriceps Tendon Anterior Cruciate Ligament Reconstruction: A Systematic Review of Postoperative Rehabilitation and Complication Profiles. Arthroscopy 2022; 38:2062-2072.e1. [PMID: 34942315 DOI: 10.1016/j.arthro.2021.12.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purposes of this study are to explore current elements for postoperative rehabilitation protocol after quadriceps tendon-anterior cruciate ligament reconstruction (QT-ACLR), outline general timelines for progression of those elements, and explore their associated complication rates and profiles. METHODS In accordance with PRISMA guidelines, 5 online databases (EMBASE, MEDLINE, CINAHL, Cochrane, and PubMed) were searched and screened in duplicate using predetermined criteria for studies on the aforementioned patient population. Descriptive statistics are presented. RESULTS A total of 56 studies were included, with 31 studies using quadriceps tendon with bone block (B-QT) and 26 studies using all-soft tissue quadriceps tendon (S-QT). The majority of studies permitted full weightbearing and range of motion (ROM) within the first 12 postoperative weeks, and motion-controlled braces within 6 weeks. Isometric exercises were initiated within 1 week after surgery, closed-chain exercises within 12 weeks, and open-chain and sports-specific exercises within 36 weeks. Complication profiles were similar between graft types and included graft failure (1.2%-1.6%), cyclops syndrome (0.4%-0.7%), and persistent stiffness (0.9%). CONCLUSIONS Current postoperative rehabilitation strategies in ACLR with QT offer a complication profile comparable to those reported with other graft types. Based on the included rehabilitation regimen, these protocols should focus on early ROM, specifically on achieving full extension, alongside isometric quadriceps strengthening. Progression to closed- and open-chain exercises should follow in a progressive manner, similar to existing protocols in ACLR. Adjuncts such as motion-controlled bracing and continuous passive motion machines may be used if graft protection is prioritized. This review highlights the need for comparison of defined protocols against one another in the setting of QT-ACLR. LEVEL OF EVIDENCE IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Kailai Zhang
- Department of Physical Medicine and Rehabilitation, McMaster University, Hamilton, Ontario, Canada.
| | - Tony Beshay
- Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Ben Murphy
- Niagara Orthopedic Institute Hamilton, Hamilton, Ontario, Canada
| | - Andrew Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas, U.S.A
| | - Darren de Sa
- Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
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16
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Prolonged Application of Continuous Passive Movement Improves the Postoperative Recovery of Tibial Head Fractures: A Prospective Randomized Controlled Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:1236781. [PMID: 35224090 PMCID: PMC8865989 DOI: 10.1155/2022/1236781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/28/2022] [Indexed: 11/25/2022]
Abstract
Methods 60 patients with THFs were randomly and equally divided into the CPM group and non-CPM group. Both groups immediately received CPM and conventional physical therapies during hospitalization. After discharge, the non-CPM group was treated with conventional physical therapy alone, while the CPM group received conventional physical training in combination with CPM treatment. At 6 weeks and 6 months postoperatively, the primary outcome which was knee ROM and the secondary outcome which was knee functionality and quality of life were evaluated. Results The CPM group had a significantly increased ROM at both follow-up time points. The Knee Society Score, UCLA activity score, and the EuroQoL as well as the pain analysis showed significantly better results of the CPM group than the non-CPM group. Conclusions The prolonged application of CPM therapy is an effective method to improve the postoperative rehabilitation of THFs.
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17
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Sanborn RM, Badger GJ, Yen YM, Murray MM, Christino MA, Proffen B, Sant N, Barnett S, Fleming BC, Kramer DE, Micheli LJ. Psychological Readiness to Return to Sport at 6 Months Is Higher After Bridge-Enhanced ACL Restoration Than Autograft ACL Reconstruction: Results of a Prospective Randomized Clinical Trial. Orthop J Sports Med 2022; 10:23259671211070542. [PMID: 35155707 PMCID: PMC8832603 DOI: 10.1177/23259671211070542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/07/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Previous clinical studies have shown that psychological factors have
significant effects on an athlete’s readiness to return to sport after
anterior cruciate ligament (ACL) reconstruction (ACLR). Hypothesis: We hypothesized that patients who underwent bridge-enhanced ACL restoration
(BEAR) would have higher levels of psychological readiness to return to
sport compared with patients who underwent ACLR. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 100 patients (median age, 17 years; median preoperative Marx
activity score, 16) with complete midsubstance ACL injuries were randomized
to either the BEAR procedure (n = 65) or autograft ACLR (n = 35 [33
hamstring and 2 bone--patellar tendon—bone]) and underwent surgery within 45
days of injury. Objective, functional, and patient-reported outcomes,
including the ACL--Return to Sport after Injury (ACL-RSI) scale, were
assessed at 6, 12, and 24 months postoperatively. Results: Patients who underwent the BEAR procedure had significantly higher ACL-RSI
scores at 6 months compared with those who underwent ACLR (71.1 vs 58.2;
P = .008); scores were similar at 12 and 24 months.
Baseline factors independently predictive of higher ACL-RSI scores at 6
months were having a BEAR procedure and participating in level 1 sports
prior to injury, explaining 15% of the variability in the scores. Regression
analysis of baseline and 6-month outcomes as predictors indicated that the
International Knee Documentation Committee (IKDC) score at 6 months
explained 45% of the 6-month ACL-RSI variance. Subsequent analysis with IKDC
excluded from the model indicated that decreased pain, increased hamstring
and quadriceps strength in the surgical limb, and decreased side-to-side
difference in anteroposterior knee laxity were significant predictors of a
higher ACL-RSI score at 6 months, explaining 34% of the variability in
scores. Higher ACL-RSI score at 6 months was associated with earlier
clearance to return to sports. Conclusion: Patients who underwent the BEAR procedure had higher ACL-RSI scores at 6
months postoperatively. Better ACL-RSI scores at 6 months were related most
strongly to higher IKDC scores at 6 months and were also associated with
lower pain levels, better muscle recovery, and less knee laxity at 6
months. Registration: NCT02664545 (ClinicalTrials.gov
identifier).
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Affiliation(s)
- Ryan M. Sanborn
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, Vermont, USA
| | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Martha M. Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Melissa A. Christino
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
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18
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Hourston GJM, Kankam HKN, McDonnell SM. A systematic review of anterior cruciate ligament primary repair rehabilitation. J Clin Orthop Trauma 2022; 25:101774. [PMID: 35127441 PMCID: PMC8803614 DOI: 10.1016/j.jcot.2022.101774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 12/16/2021] [Accepted: 01/17/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Rehabilitation after surgery of the injured anterior cruciate ligament (ACL) is crucial for satisfactory outcomes. Many trials have investigated this process after ACL reconstruction. The treatment of acute ACL ruptures with a repair technique has recently regained interest, although very little information is available about appropriate rehabilitation for such patients. The objective of this review was to evaluate studies on rehabilitation following ACL repair. METHODS A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted for patients undergoing a rehabilitation programme after ACL repair. The review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO, Registration number: CRD42020173450). Elements of rehabilitation care we included in our strategy are postoperative bracing, home-based rehabilitation, strengthening exercises, proprioception and neuromuscular training. We searched PubMed, CINAHL, EMBASE, and the Cochrane Library for randomised trials of any form investigating rehabilitation protocols after repair of the injured ACL. Two reviewers independently assessed eligibility of trials. RESULTS No trials were included. Available literature of lower evidence was included for discussion. CONCLUSIONS No information is available from randomised trials to indicate whether there is any difference between rehabilitation protocols for patients who have undergone primary ACL repair.
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Affiliation(s)
- George JM. Hourston
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
- Corresponding author. Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0QQ, UK.
| | - Hadyn KN. Kankam
- Department of Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
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19
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Fan Z, Yan J, Zhou Z, Gao Y, Tang J, Li Y, Zhang Z, Yang M, Lv J. Delayed Versus Accelerated Weight-bearing Rehabilitation Protocol Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. J Rehabil Med 2022; 54:jrm00260. [PMID: 35037693 PMCID: PMC8892302 DOI: 10.2340/jrm.v53.1438] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To compare accelerated and delayed weight-bearing rehabilitation of anterior cruciate ligament reconstruction regarding clinical outcome measures of knee function (International Knee Documentation Committee Subjective Knee Form (IKDC), Lysholm Knee Scoring Scale, Tegner Activity Scale, and Knee Injury and Osteoarthritis Outcome Score (KOOS)), knee laxity, range of movement, quadriceps, and bone tunnel enlargement. Design Systematic review and meta-analysis. Methods Systematic searches of Embase, MEDLINE, CINAHL, and the Cochrane Library databases, from inception to February 2021, for studies comparing delayed or accelerated weight-bearing rehabilitation protocol after anterior cruciate ligament reconstruction in adult patients. Results Nine studies met the eligibility criteria. A meta-analysis revealed a higher risk of knee laxity in the accelerated weight-bearing group. Accelerated weight-bearing may be related to higher IKDC scores, while there was no statistical difference for Lysholm, Tegner, and KOOS scores at a follow-up within 2 years. Four of 5 studies reported no statistical difference for quadriceps strength and range of movement scores, while 2 studies reported bone tunnel enlargement in the accelerated weight-bearing group. Conclusion This systematic review confirmed that accelerated weight-bearing caused more serious knee laxity and bone tunnel widening than delayed weight-bearing after anterior cruciate ligament reconstruction. We therefore recommend that clinicians should select postoperative rehabilitation programmes with caution.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jiayin Lv
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun 130033, P. R. China.
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20
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Garcia-Mansilla I, Trivellas M, Singla A, Kelley B, Jones KJ. Quality and Variability of Physical Therapy Protocols Varies Widely for Osteochondral Allograft Transplantation of the Femoral Condyles. Cartilage 2022; 13:19476035221073999. [PMID: 35109692 PMCID: PMC9137295 DOI: 10.1177/19476035221073999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 10/14/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To assess the quality and variability of osteochondral allograft (OCA) transplantation rehabilitation protocols associated with academic orthopedic programs in the United States. DESIGN A systematic review was performed to collect all publicly available online rehabilitation protocols for femoral condyle OCA transplant from US academic orthopedic programs participating in the Electronic Residency Application Service. These protocols were evaluated for inclusion of different rehabilitation components as well as timing of suggested initiation of these activities. RESULTS A total of 22 protocols were included. Although 91% of protocols recommended bracing, wide variation exists in total time of utilization. Median time for full weight bearing (FWB) was 7 weeks (range 4-8). On average, each protocol mentioned 9 (range 2-18) different strengthening exercises. The median time suggested to return to high-impact activities was 9 months (range 8-12). Only 3 protocols (14%) offered criteria of advancement for each phase as well as criteria for discharge. CONCLUSION Very few of the academic orthopedic programs have published online rehabilitation protocols following OCA transplantation. Although there is wide variation between the protocols, it allowed the identification of trends or patterns that are more common. However, there is need for more standardized evidence-based rehabilitation protocols which are easy to understand and follow by patients.
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Affiliation(s)
| | - Myra Trivellas
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Amit Singla
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Benjamin Kelley
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kristofer J. Jones
- Department of Orthopaedic Surgery, Division of Sports Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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21
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Kiapour AM, Flannery SW, Murray MM, Miller PE, Fleming BC, Sant N, Portilla G, Sanborn R, Freiberger C, Henderson R, Barnett S, Ecklund K, Yen YM, Kramer DE, Micheli LJ, Fleming BC. Regional Differences in Anterior Cruciate Ligament Signal Intensity After Surgical Treatment. Am J Sports Med 2021; 49:3833-3841. [PMID: 34668789 PMCID: PMC8829819 DOI: 10.1177/03635465211047554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Magnetic resonance-based measurements of signal intensity have been used to track healing of surgically treated anterior cruciate ligaments (ACLs). However, it is unknown how the signal intensity values in different regions of the ligament or graft change during healing. HYPOTHESES (1) Normalized signal intensity of the healing graft or repaired ACL is heterogeneous; (2) temporal changes in normalized signal intensity values differ among the tibial, middle, and femoral regions; and (3) there are no differences in regional normalized signal intensity values 2 years postoperatively among grafts, repaired ACLs, and contralateral native ACLs. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Magnetic resonance imaging scans were analyzed from patients in a trial comparing ACL reconstruction (n = 35) with bridge-enhanced ACL repair (n = 65). The ACLs were segmented from images acquired at 6, 12, and 24 months postoperatively and were partitioned into 3 sections along the longitudinal axis (femoral, middle, and tibial). Linear mixed modeling was used to compare location-specific differences in normalized ligament signal intensity among time points (6, 12, and 24 months) and groups (ACL reconstruction, repair, and contralateral native ACL). RESULTS For grafts, the middle region had a higher mean normalized signal intensity when compared with the femoral region at all time points (P < .01) but compared with the tibial region only at 6 months (P < .01). For repaired ACLs, the middle region had a higher mean normalized signal intensity versus the femoral region at all time points (P < .01) but versus the tibial region only at 6 and 12 months (P < .04). From 6 to 24 months, the grafts showed the greatest reduction in normalized signal intensity in the femoral and middle regions (vs tibial regions; P < .01), while there were no regional differences in repaired ACLs. At 2 years after surgery, repaired ACLs had a lower normalized signal intensity in the tibial region as compared with reconstructed grafts and contralateral native ACLs (P < .01). CONCLUSION The results suggest that graft remodeling is location specific. Repaired ACLs were more homogeneous, with lower or comparable normalized signal intensity values at 2 years as compared with the contralateral native ACL and reconstructed grafts.
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Affiliation(s)
- Ata M. Kiapour
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | - Sean W. Flannery
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence RI 02818
| | - Martha M. Murray
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | - Patricia E. Miller
- Department of Orthopaedic Surgery and Sports Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
| | | | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence RI 02818
| | - Nicholas Sant
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Portilla
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan Sanborn
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christina Freiberger
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachael Henderson
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Barnett
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Boston Children's Hospital Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.,Investigation performed at Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Beletsky A, Naami E, Lu Y, Polce EM, Chahla J, Okoroha KR, Bush-Joseph C, Bach B, Yanke A, Forsythe B, Cole BJ, Verma NN. The Minimally Clinically Important Difference and Substantial Clinical Benefit in Anterior Cruciate Ligament Reconstruction: A Time-to-Achievement Analysis. Orthopedics 2021; 44:299-305. [PMID: 34590953 DOI: 10.3928/01477447-20210819-03] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study examined the time-dependent course of the minimally clinically important difference (MCID) and the substantial clinical benefit (SCB) achievement for International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales following anterior cruciate ligament reconstruction (ACLR). A prospective institutional registry was queried for patients receiving ACLR. The patient-reported outcome measures (PROMs) of interest included the IKDC score and KOOS sub-scales. One hundred forty-three patients (mean±SD age, 30.86±12.78 years; mean±SD body mass index, 25.51±4.64 kg/m2) were included in the analysis. Threshold values for the MCID/SCB were 18.9 of 29.6 on IKDC score, 15.7 of 25.3 on KOOS Symptom, 11.9 of 15.5 on KOOS Pain, 13.3 of 20.0 on KOOS ADL, 25.9 of 35.8 on KOOS Quality of Life (QoL), and 27.0 of 43.0 on KOOS Sport (area under the curve, 0.74-0.91). Overall, MCID achievement rates increased from 28.0% to 42.7% at 6 months to 41.9% to 70.8% at 12 months. Achievement rates of SCB increased from 16.1% to 30.4% at 6 months to 29.3% to 51.8% at 12 months. Statistically significant increases in MCID achievement (chi-square=47.95-79.36, all P<.001) and SCB achievement (chi-square=26.02-53.24, all P<.001) occurred from preoperative to 6-month time points across PROMs. From 6-month to 12-month time points, increases in MCID achievement occurred on IKDC score and KOOS QoL (chi-square=5.53-15.11, P<.001-.009). Statistically significant increases in MCID and SCB achievement occurred from preoperative to 6-month time points across IKDC score and KOOS subscales; however, statistically significant increases in achievement rates from 6 months to 1 year occurred on IKDC score, KOOS QoL, and KOOS Sport. This study underlines the importance of considering psychological factors and rehabilitative milestones when examining the achievement MCID and SCB after ACLR. [Orthopedics. 2021;44(5):299-305.].
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23
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Brophy RH, Huston LJ, Briskin I, Amendola A, Cox CL, Dunn WR, Flanigan DC, Jones MH, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Parker RD, Vidal AF, Wolcott ML, Wolf BR, Wright RW, Spindler KP. Articular Cartilage and Meniscus Predictors of Patient-Reported Outcomes 10 Years After Anterior Cruciate Ligament Reconstruction: A Multicenter Cohort Study. Am J Sports Med 2021; 49:2878-2888. [PMID: 34324369 PMCID: PMC9112230 DOI: 10.1177/03635465211028247] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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
BACKGROUND Articular cartilage and meniscal damage are commonly encountered and often treated at the time of anterior cruciate ligament reconstruction (ACLR). Our understanding of how these injuries and their treatment relate to outcomes of ACLR is still evolving. HYPOTHESIS/PURPOSE The purpose of this study was to assess whether articular cartilage and meniscal variables are predictive of 10-year outcomes after ACLR. We hypothesized that articular cartilage lesions and meniscal tears and treatment would be predictors of the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level outcomes at 10-year follow-up after ACLR. STUDY DESIGN Cohort study (prognosis); Level of evidence, 1. METHODS Between 2002 and 2008, individuals with ACLR were prospectively enrolled and followed longitudinally using the IKDC, KOOS, and Marx activity score completed at entry, 2, 6, and 10 years. A proportional odds logistic regression model was built incorporating variables from patient characteristics, surgical technique, articular cartilage injuries, and meniscal tears and treatment to determine the predictors (risk factors) of IKDC, KOOS, and Marx outcomes at 10 years. RESULTS A total of 3273 patients were enrolled (56% male; median age, 23 years at time of enrollment). Ten-year follow-up was obtained on 79% (2575/3273) of the cohort. Incidence of concomitant pathology at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 22%; lateral femoral condyle [LFC], 15%; medial tibial plateau [MTP], 4%; lateral tibial plateau [LTP], 11%; patella, 18%; trochlea, 8%) and meniscal pathology (medial, 37%; lateral, 46%). Variables that were predictive of poorer 10-year outcomes included articular cartilage damage in the patellofemoral (P < .01) and medial (P < .05) compartments and previous medial meniscal surgery (7% of knees; P < .04). Compared with no meniscal tear, a meniscal injury was not associated with 10-year outcomes. Medial meniscal repair at the time of ACLR was associated with worse 10-year outcomes for 2 of 5 KOOS subscales, while a medial meniscal repair in knees with grade 2 MFC chondrosis was associated with better outcomes on 2 KOOS subscales. CONCLUSION Articular cartilage injury in the patellofemoral and medial compartments at the time of ACLR and a history of medial meniscal surgery before ACLR were associated with poorer 10-year ACLR patient-reported outcomes, but meniscal injury present at the time of ACLR was not. There was limited and conflicting association of medial meniscal repair with these outcomes.
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Affiliation(s)
- Robert H Brophy
- Department of Orthopaedic Surgery, Washington University School of Medicine, Chesterfield, Missouri, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Laura J Huston
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Isaac Briskin
- Cleveland Clinic Department of Quantitative Health Sciences, Cleveland, Ohio, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Annunziato Amendola
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Charles L Cox
- Vanderbilt University, Nashville, Tennessee, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Warren R Dunn
- Fondren Orthopedic Research Institute, Houston, Texas, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Morgan H Jones
- Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Christopher C Kaeding
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Robert G Marx
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Matthew J Matava
- Department of Orthopaedics, Washington University School of Medicine, Chesterfield, Missouri, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Eric C McCarty
- CU Sports Medicine, Boulder, Colorado, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Richard D Parker
- Department of Orthopaedics, Cleveland Clinic Foundation, Garfield Heights, Ohio, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Armando F Vidal
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Michelle L Wolcott
- CU Sports Medicine, Boulder, Colorado, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Brian R Wolf
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Rick W Wright
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
| | - Kurt P Spindler
- Department of Orthopaedics, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Investigation performed at Washington University, Chesterfield, Missouri, USA, Vanderbilt, Nashville, Tennessee, USA, and Cleveland Clinic, Garfield Heights, Ohio, USA
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24
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Ogrodzka-Ciechanowicz K, Głąb G, Ciszek-Radwan E, Ślusarski J, Gądek A. The use of an alternating magnetic field in the resorption of postoperative joint effusion following anterior cruciate ligament reconstruction: A randomized double-blind controlled trial. Medicine (Baltimore) 2021; 100:e26572. [PMID: 34232202 PMCID: PMC8270597 DOI: 10.1097/md.0000000000026572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 05/20/2021] [Accepted: 06/09/2021] [Indexed: 01/04/2023] Open
Abstract
CONTEXT There are no scientific reports unambiguously describing the efficacy of alternating magnetic field therapy in patients after anterior cruciate ligament (ACL) reconstruction in the early postoperative period. OBJECTIVE This study aims to evaluate the efficacy of using an alternating magnetic field in the resorption of postoperative joint effusion in patients after ACL reconstruction. STUDY DESIGN A randomized, double-blind placebo-controlled study. SETTING Inpatients. PARTICIPANTS Forty patients were enrolled in the trial. However, the final study group consisted of 38 patients (28 men and 10 women) after ACL reconstruction who were randomly divided into an experimental group (19 patients) and a control group (19 patients). INTERVENTION Each group received magnetic field therapy in the postoperative period, but only 1 apparatus emitted a magnetic field (the experimental group). Patients used the apparatus every day for 30 minutes for the next 11 days. The parameters in both devices were the same-3 mT and 10 Hz. MAIN OUTCOME MEASURES The measurement of the knee circumference and range of motion were made. The knee circumference measurement was performed before magnetic field therapy began and for 11 days after magnetic field treatment. The active knee range of motion was evaluated before and after magnetic field therapy was completed. RESULTS There were no statistically significant differences between the groups in the reduction of post-operative joint effusion or knee joint function. CONCLUSION In patients after ACL reconstruction, in whom an alternating magnetic field was used to treat postoperative joint effusion, there were no beneficial effects on the analyzed variables compared to the control group.
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Affiliation(s)
| | - Grzegorz Głąb
- Institute of Clinical Rehabilitation, Faculty of Motor Rehabilitation, University of Physical Education in Krakow, Poland
| | - Elżbieta Ciszek-Radwan
- Institute of Clinical Rehabilitation, Faculty of Motor Rehabilitation, University of Physical Education in Krakow, Poland
| | - Jakub Ślusarski
- Trauma and Orthopaedics Clinical Department, University Hospital in Krakow, Poland
| | - Artur Gądek
- Trauma and Orthopaedics Clinical Department, University Hospital in Krakow, Poland
- Department of Orthopedics and Physiotherapy, Jagiellonian University Collegium Medicum, Poland
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Uzun E, Misir A, Guney A. Effect of Leg Dominance on Medium- to Long-Term Functional Outcomes, Quality of Life, and Revision Rates After Isolated ACL Reconstruction. Orthop J Sports Med 2021; 9:2325967121995808. [PMID: 33954220 PMCID: PMC8044576 DOI: 10.1177/2325967121995808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/30/2020] [Indexed: 11/20/2022] Open
Abstract
Background: The effect of leg dominance on short-term functional outcomes and return to sports after arthroscopic anterior cruciate ligament reconstruction (ACLR) has been evaluated. However, postoperative medium- to long-term recovery and revision rates are not well known. Purpose: To investigate whether leg dominance affects medium- to long-term clinical and functional scores and revision rates after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Included in this study were 235 patients (205 male and 30 female) who underwent isolated arthroscopic ACLR. Patients were divided according to the leg dominance status of their injured limb into 2 groups: dominant leg injured (120 patients) and nondominant leg injured (115 patients). Preoperative and postoperative functional outcomes and health-related quality of life (HRQoL) were evaluated using the visual analog scale for pain, Tegner activity scale, Lysholm knee score, International Knee Documentation Committee (IKDC) subjective knee evaluation form, 36-Item Short Form Health Survey (SF-36), and overall patient satisfaction. Moreover, the revision rates of the 2 groups were compared according to leg dominance, patient characteristics, and operative features. Results: The mean follow-up period was 8.0 ± 2.3 years (range, 5-13 years). A significant preoperative to postoperative improvement in range of motion and functional scores was noticed in both groups (P < .001 for all). However, the improvement was significantly higher in the dominant leg group for the Tegner (P = .001), Lysholm (P = .006), and IKDC (P < .001) scores as well as for the SF-36 domain scores for general health (P = .009), social role (P = .048), and emotional role (P = .032). Also, patient satisfaction was significantly higher in the dominant leg group (P = .007). The dominant leg group was associated with a lower revision rate compared with the nondominant leg group (5.8% vs 15.7%, respectively; P = .015). Conclusion: High recovery rates were seen after arthroscopic ACLR, regardless of leg dominance. However, leg dominance had a significant effect on postoperative medium- to long-term functional outcomes, HRQoL, and revision rates.
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Affiliation(s)
- Erdal Uzun
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Abdulhamit Misir
- Department of Orthopedics and Traumatology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Ahmet Guney
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
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Karnuta JM, Dalton S, Bena J, Farrow LD, Featherall J, Jones MH, Miniaci AA, Parker RD, Rosneck JT, Saluan P, Strnad G, Spindler KP, Williams JS, Oak SR. Do Narcotic Use, Physical Therapy Location, or Payer Type Predict Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction? Orthop J Sports Med 2021; 9:2325967121994833. [PMID: 33997058 PMCID: PMC8085373 DOI: 10.1177/2325967121994833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/21/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Opioid use and public insurance have been correlated with worse outcomes in a number of orthopaedic surgeries. These factors have not been investigated with anterior cruciate ligament reconstruction (ACLR). PURPOSE/HYPOTHESIS To evaluate if narcotic use, physical therapy location, and insurance type are predictors of patient-reported outcomes after ACLR. It was hypothesized that at 1 year postsurgically, increased postoperative narcotic use would be associated with worse outcomes, physical therapy obtained within the authors' integrated health care system would lead to better outcomes, and public insurance would lead to worse outcomes and athletic activity. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS All patients undergoing unilateral, primary ACLR between January 2015 and February 2016 at a large health system were enrolled in a standard-of-care prospective cohort. Knee injury and Osteoarthritis Score (KOOS) and the Hospital for Special Surgery Pediatric-Functional Activity Brief Scale (HSS Pedi-FABS) were collected before surgery and at 1 year postoperatively. Concomitant knee pathology was assessed arthroscopically and electronically captured. Patient records were analyzed to determine physical therapy location, insurance status, and narcotic use. Multivariable regression analyses were used to identify significant predictors of the KOOS and HSS Pedi-FABS score. RESULTS A total of 258 patients were included in the analysis (mean age, 25.8; 51.2% women). In multivariable regression analysis, narcotic use, physical therapy location, and insurance type were not independent predictors of any KOOS subscales. Public insurance was associated with a lower HSS Pedi-FABS score (-4.551, P = .047) in multivariable analysis. Narcotic use or physical therapy location was not associated with the HSS Pedi-FABS score. CONCLUSION Increased narcotic use surrounding surgery, physical therapy location within the authors' health care system, and public versus private insurance were not associated with disease-specific KOOS subscale scores. Patients with public insurance had worse HSS Pedi-FABS activity scores compared with patients with private insurance, but neither narcotic use nor physical therapy location was associated with activity scores. Physical therapy location did not influence outcomes, suggesting that patients be given a choice in the location they received physical therapy (as long as a standardized protocol is followed) to maximize compliance.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Kurt P. Spindler
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
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Kim JG, Kim WS, Kim SG, Lee DH. Accelerated Versus Non-accelerated Rehabilitation After Primary Anterior Cruciate Ligament Reconstruction Using Hamstring Autografts: A Systematic Review and Meta-analysis of Comparative Studies. Indian J Orthop 2021; 55:405-415. [PMID: 33927819 PMCID: PMC8046886 DOI: 10.1007/s43465-021-00375-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/03/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to compare the clinical outcomes between accelerated rehabilitation (AR) and non-accelerated rehabilitation (NR) after anterior cruciate ligament reconstruction (ACLR) using hamstring autografts through a systematic review and meta-analysis. METHODS To compare the outcomes between AR and NR, we searched Medline, Embase, and the Cochrane Library. Studies comparing their clinical outcomes after ACLR using hamstring autografts were included. AR was characterized by the starting range of motion and weight-bearing within 3 days and return to sports within 6-9 months. A meta-analysis of clinical outcome parameters used in ≥ 3 studies was conducted. RESULTS Seven studies were included. The International Knee Documentation Committee subjective score was significantly higher in AR than in NR at the 3- (mean difference [MD], 7.30; 95% confidence interval [CI] 1.55-13.05; P = 0.013) and 6-month follow-ups (MD, 5.64; 95% CI 0.11-11.17; P = 0.046). The side-to-side difference in anterior tibial translation at the final follow-up assessed in four studies was significantly lower in NR than in AR (MD, 0.59; 95% CI 0.12-1.07; P = 0.015). Overall Tunnel widening at the final follow-up assessed in four studies was also smaller in NR than in AR (MD, 0.48; 95% CI 0.00-0.96; P = 0.0479). However, the mean side-to-side difference and overall tunnel widening between them was < 1 mm. CONCLUSION The early subjective clinical outcomes of AR after ACLR using hamstring autografts were superior to those of NR. Although tunnel widening and anterior instability were also significantly larger in AR than in NR, the difference was not clinically relevant.
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Affiliation(s)
- Jae Gyoon Kim
- grid.411134.20000 0004 0474 0479Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do 15355 Republic of Korea
| | - Won Seok Kim
- grid.411134.20000 0004 0474 0479Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do 15355 Republic of Korea
| | - Sang-Gyun Kim
- grid.411134.20000 0004 0474 0479Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do 15355 Republic of Korea
| | - Dae Hee Lee
- grid.264381.a0000 0001 2181 989XDepartment of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, Republic of Korea
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Murphy D, Louw QA, Moloney C, Leibbrandt D, Clifford AM. Hop Performance After Return to Sport in Anterior Cruciate Ligament-Reconstructed Gaelic Football and Hurling Athletes. J Sport Rehabil 2021; 30:707-716. [PMID: 33418539 DOI: 10.1123/jsr.2019-0488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 07/03/2020] [Accepted: 10/17/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE Anterior cruciate ligament (ACL) injuries are among the most severe injuries in the Gaelic Athletic Association. Hop tests measure functional performance after ACL reconstruction as they replicate the key requirements for a match situation. However, research examining functional recovery of ACL-reconstructed Gaelic athletes is lacking. The objective of this study is to determine if athletes restore normal hop symmetry after ACL reconstruction and to examine if bilateral deficiencies persist in hop performance following return to sport. METHODS A cross-sectional design was used to evaluate hop performance of 30 ACL-reconstructed Gaelic athletes who had returned to competition and 30 uninjured controls in a battery of hop tests including a single, 6-m, triple, and triple-crossover hop test. RESULTS In each test, the mean symmetry score of the ACL reconstruction group was above the cutoff for normal performance of 90% adopted by this study (98%, 99%, 97%, and 99% for the single, 6-m, triple, and triple-crossover hop, respectively). No significant differences in absolute hop scores emerged between involved and control limbs, with the exception of the single-hop test where healthy dominant limbs hopped significantly further than ACL-reconstructed dominant limbs (P = .02). No significant deficits were identified on the noninvolved side. CONCLUSIONS The majority of ACL-reconstructed Gaelic athletes demonstrate normal levels of hop symmetry after returning to competition. Suboptimal hop performance can persist on the involved side compared with control limbs. Targeted rehabilitation may be warranted after returning to competition to restore performance to levels of healthy uninjured athletes.
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Boo HC, Howe TS, Koh JS. Effect of leg dominance on early functional outcomes and return to sports after anterior cruciate ligament reconstruction. J Orthop Surg (Hong Kong) 2020; 28:2309499019896232. [PMID: 32067570 DOI: 10.1177/2309499019896232] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The effect of leg dominance on anterior cruciate ligament (ACL) injuries has been studied with some studies noting a propensity for injuries in the non-dominant leg. Its effect on post-ACL reconstruction recovery, however, is not well known. The authors hypothesize that dominant limb injuries undergo rehabilitation faster and positively affect early functional outcome scores and return to sports and set about studying these effects. METHODS This is a retrospective study of 254 patients from a single institution who underwent ACL reconstruction for acute ACL ruptures and the results were compared between patients with dominant and non-dominant limb injuries. Objective measurements including the KT-1000, single-leg hop distance and Biodex knee extension peak torque were used to evaluate recovery. Pre- and post-operative functional outcome scores such as the International Knee Documentation Committee (IKDC), Tegner activity score and Lysholm knee scale were documented. RESULTS Early functional outcomes were similar. Minimal clinically important difference (MCID) improvement in IKDC scores was achieved in 69.7% of the dominant versus 66.0% of the non-dominant injury group (p = 0.99), 75.2% versus 79.6% (p = 0.45) for the Lysholm knee scale, and 81.6% versus 84.9% (p = 0.50) for the Tegner activity score. The majority of patients in both subgroups had a return of at least 80% of peak knee flexion and extension peak torque at 5.4 months post-operatively; 92.9% of subjects with a non-dominant leg injury and 87.2% with a dominant leg injury had returned to their pre-injury sports 1 year from surgery. CONCLUSIONS Results from this study suggest that despite theoretical differences, leg dominance does not have a significant impact on short-term functional outcomes and return to sports. Objective measurements suggest that limb strength recovers at a comparable rate. Injuries to either leg demonstrate equally positive improvement post-ACL reconstruction given the same post-operative rehabilitation. LEVEL OF EVIDENCE III, retrospective comparative study. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- H C Boo
- Department of Orthopaedics, Singapore General Hospital, Singapore
| | - T S Howe
- Department of Orthopaedics, Singapore General Hospital, Singapore
| | - Joyce Sb Koh
- Department of Orthopaedics, Singapore General Hospital, Singapore
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TIMELINE OF GAINS IN QUADRICEPS STRENGTH SYMMETRY AND PATIENT-REPORTED FUNCTION EARLY AFTER ACL RECONSTRUCTION. Int J Sports Phys Ther 2020; 15:995-1005. [PMID: 33344016 DOI: 10.26603/ijspt20200995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Quadriceps weakness is a predictor of long-term knee function and strength recovery can vary from months to years after anterior cruciate ligament reconstruction (ACLR). However, few studies evaluate quadriceps strength and self-reported function within the first several weeks after ACLR. Hypothesis/Purpose To examine changes over time in quadriceps strength symmetry, quadriceps peak torque, and self-reported knee function prior to and at six, 12, and 24 weeks post-ACLR. The hypotheses were 1) quadriceps strength symmetry, bilateral quadriceps peak torque, and patient-reported function would improve over time from pre-ACLR to 24 weeks post-ACLR and 2) significant improvements in patient-reported function, but not strength symmetry, would occur between time points. Study Design Prospective, cohort study. Methods Thirty participants completed four testing sessions: pre-surgery and six, 12, and 24 weeks post-ACLR. Isometric quadriceps strength testing was performed at six weeks and isokinetic quadriceps strength was measured at all other testing points. Quadriceps index was calculated to evaluate between limb quadriceps strength symmetry. The Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) were administered at each time point. A repeated-measures analysis of variance evaluated changes over time, with post-hoc comparisons to determine at which time-point significant changes occurred. Results Quadriceps strength symmetry, involved limb quadriceps peak torque and all patient-reported outcome scores increased over time (p<0.02). Post-hoc tests showed that neither self-reported outcomes, nor quadriceps index improved between pre-surgery and six-weeks post-ACLR. From six to 12 weeks post-ACLR, scores on IKDC and KOOS Pain, Symptoms, Quality of Life, and Sport subscales improved (p≤0.003). From 12 to 24 weeks post-ACLR, quadriceps strength symmetry, involved limb quadriceps peak torque, KOOS-Symptoms, Quality of Life, and Sport subscales and the IKDC improved (p≤0.01). Uninvolved limb quadriceps peak torque did not change across any time point (p≥0.18). Conclusion Patient-reported knee function increased between six and 24 weeks post-ACLR, while increases in involved limb quadriceps strength and quadriceps strength symmetry were not noted until 12-24 weeks post-ACLR. Level of Evidence 2b, individual cohort study.
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Hughes JD, Lawton CD, Nawabi DH, Pearle AD, Musahl V. Anterior Cruciate Ligament Repair: The Current Status. J Bone Joint Surg Am 2020; 102:1900-1915. [PMID: 32932291 DOI: 10.2106/jbjs.20.00509] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jonathan D Hughes
- UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cort D Lawton
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY
| | - Danyal H Nawabi
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY
| | - Andrew D Pearle
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania
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The Influence, Barriers to and Facilitators of Anterior Cruciate Ligament Rehabilitation Adherence and Participation: a Scoping Review. SPORTS MEDICINE-OPEN 2020; 6:32. [PMID: 32681200 PMCID: PMC7367990 DOI: 10.1186/s40798-020-00258-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 06/30/2020] [Indexed: 01/04/2023]
Abstract
Background Outcomes following anterior cruciate ligament (ACL) reconstruction are considered poor. There are many factors which may influence patient outcomes. As such, the purpose of this review was to report on the influence, barriers to and facilitators of rehabilitation adherence and participation after ACL reconstruction, providing information to help clinicians and patients make quality decisions to facilitate successful rehabilitation. Methods A systematic search of five electronic databases was undertaken in identifying studies from inception to 18 July 2019. The search included English language articles reporting on the influence, barriers to and facilitators of adherence and participation in rehabilitation of patients who have undergone ACL reconstruction. Data extraction and synthesis of included studies were undertaken. Results Full text articles (n = 180) were assessed for eligibility following screening of titles and abstracts (n = 1967), yielding 71 studies for inclusion. Forty-four articles investigated ‘rehabilitation prescription and participation’ and 36 articles investigated ‘rehabilitation barriers and facilitators’. The results indicate that a moderately or minimally supervised rehabilitation program is at least as effective as a fully supervised high-frequency rehabilitation program, although a longer duration of supervised rehabilitation is associated with improvement in a multitude of functional outcomes. A number of psychological factors associated with rehabilitation adherence were also identified. The most commonly investigated concepts were self-motivation, athletic identity and social support. Patients perceived the therapeutic relationship, interaction with family and friends, self-motivation, fear of reinjury, organisation/lack of time and interpersonal comparison as the most common barriers to and facilitators of rehabilitation. Conclusions A longer duration of supervised rehabilitation is associated with an increased chance of meeting functional and return to sport criteria; however, the optimal supervised rehabilitation frequency is yet to be determined. Identification of the barriers to and facilitators of adherence and participation in ACL rehabilitation provides an opportunity for further research to be conducted to address personal, environmental and treatment-related factors, with the aim to improve rehabilitation outcomes.
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Freiberger C, Kiapour AM, Liu S, Henderson RN, Barnett S, Sant NJ, Proffen BL, Fleming BC, Ecklund K, Kramer DE, Micheli LJ, Murray MM, Yen YM. Higher Physiologic Platelet Counts in Whole Blood Are Not Associated With Improved ACL Cross-sectional Area or Signal Intensity 6 Months After Bridge-Enhanced ACL Repair. Orthop J Sports Med 2020; 8:2325967120927655. [PMID: 32656289 PMCID: PMC7331772 DOI: 10.1177/2325967120927655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/21/2020] [Indexed: 01/08/2023] Open
Abstract
Background: A bridge-enhanced anterior cruciate ligament (ACL) repair (BEAR) procedure places an extracellular matrix implant, combined with autologous whole blood, in the gap between the torn ends of the ligament at the time of suture repair to stimulate healing. Prior studies have suggested that white blood cell (WBC) and platelet concentrations significantly affect the healing of other musculoskeletal tissues. Purpose/Hypothesis: The purpose of this study was to determine whether concentrations of various blood cell types placed into a bridging extracellular matrix implant at the time of ACL repair would have a significant effect on the healing ligament cross-sectional area or tissue organization (as measured by signal intensity). We hypothesized that patients with higher physiologic platelet and lower WBC counts would have improved healing of the ACL on magnetic resonance imaging (MRI) (higher cross-sectional area and/or lower signal intensity) 6 months after surgery. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 61 patients underwent MRI at 6 months after bridge-enhanced ACL repair as part of the BEAR II trial. The normalized signal intensity and average cross-sectional area of the healing ligament were measured from a magnetic resonance stack obtained using a gradient echo sequence. The results were stratified by sex, and univariate and multivariate regression analyses determined significant correlations between blood cell concentrations on these 2 magnetic resonance parameters. Results: In unadjusted analyses, older age and male sex were associated with greater healing ligament cross-sectional area (P < .04) but not signal intensity (P > .15). Adjusted multivariable analyses indicated that in female patients, a higher monocyte concentration correlated with a higher ACL cross-sectional area (β = 1.01; P = .049). All other factors measured, including the physiologic concentration of platelets, neutrophils, lymphocytes, basophils, and immunoglobulin against bovine gelatin, were not significantly associated with either magnetic resonance parameter in either sex (P > .05 for all). Conclusion: Although older age, male sex, and monocyte concentration in female patients were associated with greater healing ligament cross-sectional area, signal intensity of the healing ligament was independent of these factors. Physiologic platelet concentration did not have any significant effect on cross-sectional area or signal intensity of the healing ACL at 6 months after bridge-enhanced ACL repair in this cohort. Given these findings, factors other than the physiologic platelet concentration and total WBC concentration may be more important in the rate and amount of ACL healing after bridge-enhanced ACL repair.
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Affiliation(s)
- Christina Freiberger
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ata M Kiapour
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shanshan Liu
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Rachael N Henderson
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samuel Barnett
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicholas J Sant
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt L Proffen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M Murray
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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Dunphy E, Hamilton FL, Button K, Murray E. A scoping review of the resources needed to deliver anterior cruciate ligament physiotherapy rehabilitation in randomised controlled trials. PHYSICAL THERAPY REVIEWS 2020. [DOI: 10.1080/10833196.2020.1762521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- E. Dunphy
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, London, UK
| | - F. L. Hamilton
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, London, UK
| | - K. Button
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - E. Murray
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, London, UK
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Murray MM, Fleming BC, Badger GJ, Freiberger C, Henderson R, Barnett S, Kiapour A, Ecklund K, Proffen B, Sant N, Kramer DE, Micheli LJ, Yen YM. Bridge-Enhanced Anterior Cruciate Ligament Repair Is Not Inferior to Autograft Anterior Cruciate Ligament Reconstruction at 2 Years: Results of a Prospective Randomized Clinical Trial. Am J Sports Med 2020; 48:1305-1315. [PMID: 32298131 PMCID: PMC7227128 DOI: 10.1177/0363546520913532] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preclinical studies suggest that for complete midsubstance anterior cruciate ligament (ACL) injuries, a suture repair of the ACL augmented with a protein implant placed in the gap between the torn ends (bridge-enhanced ACL repair [BEAR]) may be a viable alternative to ACL reconstruction (ACLR). HYPOTHESIS We hypothesized that patients treated with BEAR would have a noninferior patient-reported outcomes (International Knee Documentation Committee [IKDC] Subjective Score; prespecified noninferiority margin, -11.5 points) and instrumented anteroposterior (AP) knee laxity (prespecified noninferiority margin, +2-mm side-to-side difference) and superior muscle strength at 2 years after surgery when compared with patients who underwent ACLR with autograft. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS One hundred patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were enrolled and underwent surgery within 45 days of injury. Patients were randomly assigned to receive either BEAR (n = 65) or autograft ACLR (n = 35 [33 with quadrupled semitendinosus-gracilis and 2 with bone-patellar tendon-bone]). Outcomes-including the IKDC Subjective Score, the side-to-side difference in instrumented AP knee laxity, and muscle strength-were assessed at 2 years by an independent examiner blinded to the procedure. Patients were unblinded after their 2-year visit. RESULTS In total, 96% of the patients returned for 2-year follow-up. Noninferiority criteria were met for both the IKDC Subjective Score (BEAR, 88.9 points; ACLR, 84.8 points; mean difference, 4.1 points [95% CI, -1.5 to 9.7]) and the side-to-side difference in AP knee laxity (BEAR, 1.61 mm; ACLR, 1.77 mm; mean difference, -0.15 mm [95% CI, -1.48 to 1.17]). The BEAR group had a significantly higher mean hamstring muscle strength index than the ACLR group at 2 years (98.2% vs 63.2%; P < .001). In addition, 14% of the BEAR group and 6% of the ACLR group had a reinjury that required a second ipsilateral ACL surgical procedure (P = .32). Furthermore, the 8 patients who converted from BEAR to ACLR in the study period and returned for the 2-year postoperative visit had similar primary outcomes to patients who had a single ipsilateral ACL procedure. CONCLUSION BEAR resulted in noninferior patient-reported outcomes and AP knee laxity and superior hamstring muscle strength when compared with autograft ACLR at 2-year follow-up in a young and active cohort. These promising results suggest that longer-term studies of this technique are justified. REGISTRATION NCT02664545 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Martha M. Murray
- Martha M. Murray, MD, Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Ave, Hunnewell 2, Boston, MA 02115, USA ()
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Spindler KP, Huston LJ, Zajichek A, Reinke EK, Amendola A, Andrish JT, Brophy RH, Dunn WR, Flanigan DC, Jones MH, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Parker RD, Vidal AF, Wolcott ML, Wolf BR, Wright RW. Anterior Cruciate Ligament Reconstruction in High School and College-Aged Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates? Am J Sports Med 2020; 48:298-309. [PMID: 31917613 PMCID: PMC7319140 DOI: 10.1177/0363546519892991] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Physicians' and patients' decision-making process between bone-patellar tendon-bone (BTB) and hamstring tendon autografts for anterior cruciate ligament (ACL) reconstruction (ACLR) may be influenced by a variety of factors in the young, active athlete. PURPOSE To determine the incidence of both ACL graft revisions and contralateral ACL tears resulting in subsequent ACLR in a cohort of high school- and college-aged athletes who initially underwent primary ACLR with either a BTB or a hamstring autograft. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Study inclusion criteria were patients aged 14 to 22 years who were injured in sports, had a contralateral normal knee, and were scheduled to undergo unilateral primary ACLR with either a BTB or a hamstring autograft. All patients were prospectively followed for 6 years to determine whether any subsequent ACLR was performed in either knee after their initial ACLR. Multivariable regression modeling controlled for age, sex, ethnicity/race, body mass index, sport and competition level, baseline activity level, knee laxity, and graft type. The 6-year outcomes were the incidence of subsequent ACLR in either knee. RESULTS A total of 839 patients were eligible, of which 770 (92%) had 6-year follow-up for the primary outcome measure of the incidence of subsequent ACLR. The median age was 17 years, with 48% female, and the distribution of BTB and hamstring grafts was 492 (64%) and 278 (36%), respectively. The incidence of subsequent ACLR at 6 years was 9.2% in the ipsilateral knee, 11.2% in the contralateral normal knee, and 19.7% for either knee. High-grade preoperative knee laxity (odds ratio [OR], 2.4 [95% confidence interval [CI], 1.4-3.9]; P = .001), autograft type (OR, 2.1 [95% CI, 1.3-3.5]; P = .004), and age (OR, 0.8 [95% CI, 0.7-1.0]; P = .009) were the 3 most influential predictors of ACL graft revision in the ipsilateral knee. The odds of ACL graft revision were 2.1 times higher for patients receiving a hamstring autograft than patients receiving a BTB autograft (95% CI, 1.3-3.5; P = .004). No significant differences were found between autograft choices when looking at the incidence of subsequent ACLR in the contralateral knee. CONCLUSION There was a high incidence of both ACL graft revisions and contralateral normal ACL tears resulting in subsequent ACLR in this young athletic cohort. The incidence of ACL graft revision at 6 years after index surgery was 2.1 times higher with a hamstring autograft compared with a BTB autograft.
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Affiliation(s)
| | - Kurt P. Spindler
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laura J. Huston
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexander Zajichek
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily K. Reinke
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Annunziato Amendola
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jack T. Andrish
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert H. Brophy
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Warren R. Dunn
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David C. Flanigan
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Morgan H. Jones
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher C. Kaeding
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert G. Marx
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew J. Matava
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric C. McCarty
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Richard D. Parker
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Armando F. Vidal
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michelle L. Wolcott
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian R. Wolf
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rick W. Wright
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA, and Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Flagg KY, Karavatas SG, Thompson S, Bennett C. Current criteria for return to play after anterior cruciate ligament reconstruction: an evidence-based literature review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S252. [PMID: 31728376 DOI: 10.21037/atm.2019.08.23] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Anterior cruciate ligament reconstruction (ACLR) has continued to be a popular surgical option in the last decade, and frequently we have seen athletes complete successful surgical intervention and rehabilitation. Even more so, the time that it takes some athletes to return to play (RTP) has gained a lot of media attention. In light of these conditions, we set out to examine the status of research on rehabilitation protocols, tests and measures, and criteria for RTP after ACLR, especially bone-tendon-bone (BTB) procedures. An evidence-based literature review was conducted. PubMed and CINAHL database searches were performed using various combinations of the following keywords: ACL reconstruction, bone to bone graft, rehabilitation. The search was limited to systematic reviews of randomized control trials (RCT) published within the last 10 years in the English language. Ten systematic reviews were identified and nine of them were included in this review. Conflicting and inconsistent evidence exists for determining RTP criteria for athletes following ACLR. None of the systemic reviews established strong evidence for the specific qualities a patient should possess prior to returning to sport in order to minimize reinjury of the same knee or sustaining a new injury to the contralateral limb. There appears to be little consensus on what exactly should constitute RTP testing criteria following an ACLR. In addition, variance exists within the exact rehabilitation timeline and goals used to determine how ACLR rehabilitation protocols are structured. What is currently agreed upon for individuals participating in sports involving side to side/pivoting movements, ACLR is the preferred surgical procedure for returning these individuals back to their respective field of play after an ACL injury.
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Affiliation(s)
- Kala Y Flagg
- Department of Physical Therapy, CNAHS, Howard University, Washington, DC, USA
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Galea-O'Neill RJ, Bruder AM, Goulis J, Shields N. Modifiable factors and their association with self-reported knee function and activity after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Physiother Theory Pract 2019; 37:881-894. [PMID: 31526063 DOI: 10.1080/09593985.2019.1655821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine if body mass index (BMI), smoking status, prehabilitation or time to reconstruction are associated with recovery of self-reported knee function and activity after ACL reconstruction (ACLR). DATA SOURCES Four electronic databases were systematically searched. STUDY SELECTION English language articles were included if: (1) participants aged 16-70 years had primary or first revision ACLR with autograft, following complete rupture; and (2) the association between one of four modifiable factors: (1) BMI; (2) smoking; (3) prehabilitation; or (4) time to reconstruction with self-reported knee function and activity, ACL graft rupture or return to sport was evaluated. RESULTS Twelve articles (representing 11 studies) were included. Meta-analyses found low-quality evidence of no difference in self-reported knee function (d = -0.07, 95% CI -0.37 to 0.23, I2 = 0%) or activity levels (d = 0.11, 95% CI -0.2 to 0.41, I2 = 0%) between acute and subacute ACLR. There was no difference in the relative risk of ACL graft rupture with the timing of ACLR (one study). Meta-analysis demonstrated very low-quality evidence that smokers had worse self-reported functional outcomes after ACLR compared to non-smokers (d = -0.58, 95% CI -0.788 to -0.28, I2 = 59%). One study suggested an inverse relationship between BMI and knee-related quality of life after ACLR. One RCT suggested prehabilitation may reduce time to return to sport. CONCLUSION Low-quality evidence suggests there is no difference in delaying ACLR and very low-quality evidence suggests smokers have worse self-reported functional outcome after ACLR compared to non-smokers. High-quality RCTs are needed to confirm the relationship between the four modifiable factors studied and ACLR outcome.
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Affiliation(s)
- Rebecca Joan Galea-O'Neill
- Department of Physiotherapy, Northern Hospital, Epping, Australia.,Department of Physiotherapy, Epworth Rehabilitation Camberwell, Camberwell, Australia
| | - Andrea Maree Bruder
- School of Allied Health, Human Services and Sport, Sports and Exercise Medicine Research Centre, La Trobe University, Victoria, Australia
| | - Jimmy Goulis
- Department of Physiotherapy, Northern Hospital, Epping, Australia
| | - Nora Shields
- School of Allied Health, Human Services and Sport, Sports and Exercise Medicine Research Centre, La Trobe University, Victoria, Australia
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Ferguson D, Palmer A, Khan S, Oduoza U, Atkinson H. Early or delayed anterior cruciate ligament reconstruction: Is one superior? A systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1277-1289. [PMID: PMID: 31093753 PMCID: PMC6647395 DOI: 10.1007/s00590-019-02442-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/23/2019] [Indexed: 01/16/2023]
Abstract
Background Anterior cruciate ligament (ACL) reconstruction is a rapidly developing orthopaedic field and an area of notable clinical equipoise. The optimal timing of surgery in an acute (< 3 weeks) or delayed (≥ 3 weeks) time frame remains unresolved with a 2010 meta-analysis concluding no difference between these two groups across multiple outcomes. In an era of evidence-based medicine, surgeons are still basing their decisions on when to operate on little more than anecdotal evidence and personal preference. Clear guidance is required to determine whether the timing of surgery can optimise outcomes in this largely young and active patient cohort. Methods A systematic literature search was performed in January 2018 of Embase, Medline and OpenGrey in accordance with (PRISMA) guidelines. A total of 658 articles were retrieved, with 6 suitable for inclusion, covering 576 ACL reconstructions. Four meta-analyses were performed assessing subjective measures of Tegner activity scale and Lysholm score, and objective measures of arthroscopically identified meniscal and chondral injury. Additional relevant outcome measures underwent narrative review. Study bias was assessed and reported using the Downs and Black checklist. Results A statistically significant difference of 0.39 points was found on the Tegner activity scale in favour of early surgery within 3 weeks (RR 0.39, CI 0.10, 0.67, p = 0.008). No statistically difference was found between groups for the patient-reported Lysholm score (RR − 0.18, CI − 2.40, 2.05, p = 0.17). There was no statistically significant difference between groups for intra-operative findings of meniscal lesions (RR 0.84, CI 0.66, 1.08, p = 0.17). A trend towards significance was observed for the incidence of chondral lesions in the early surgery group (RR 0.56, CI 0.31, 1.02, p = 0.06). All the studies were rated either fair or good on the Downs and Black checklist with no study excluded due to bias. Conclusions Although there was a statistically significant result for the Tegner activity scale in favour of early surgery, the magnitude of the effect is unlikely to translate into any clinically meaningful difference. At present, there remains no clear evidence to determine superiority of acute/early or delayed reconstruction of a ruptured anterior cruciate ligament. Further research through methodologically robust randomised controlled trials or through the UK National Ligament Registry may help to provide clearer guidance.
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Affiliation(s)
- D Ferguson
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - A Palmer
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK
| | - S Khan
- Royal National Orthopaedic Hospital, Stanmore, HA7 4LP, UK
| | - U Oduoza
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK
| | - H Atkinson
- Department of Trauma and Orthopaedic Surgery, North Middlesex University Hospital, London, N18 1QX, UK
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Zhou Y, Yang K. Prevention of arthrofibrosis during knee repair by extracorporeal shock wave therapy: Preliminary study in rabbits. Injury 2019; 50:633-638. [PMID: 30739764 DOI: 10.1016/j.injury.2019.01.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 01/31/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgery or trauma may induce extensive arthrofibrosis around joints and tendon for the restrictive range of motion. Although some approaches were proposed, this problem is not solved satisfactorily. Extracorporeal shock wave therapy (ESWT) has been used for orthopedic, musculoskeletal, and fibrotic disorders. Whether it could prevent the formation of arthrofibrosis during the joint repair is unknown. METHODS Intra-articular adhesions were created in the right knee of the rabbit by cortical bone shaving and subsequent cast immobilization. Arthrofibrosis in the control and ESWT group was evaluated and compared at week 4. RESULTS Macroscopic score of arthrofibrosis and contracture angle of the control group are significantly higher. Histologically, the apparent gap between patella and tibia, loose connective tissue, and much less density of the blood vessel are found in the ESWT group. CONCLUSIONS ESWT could noninvasively, effectively, and safely prevent the formation of arthrofibrosis during the knee repair.
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Affiliation(s)
- Yufeng Zhou
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore.
| | - Kai Yang
- SG Med International Pte Ltd, Singapore
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Effect of Physical Therapy Visits on Clinical Outcomes Following Anterior Cruciate Ligament Reconstruction With and Without Concurrent Meniscal Repair. J Sport Rehabil 2019; 28:24-32. [PMID: 28787223 DOI: 10.1123/jsr.2017-0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 06/18/2017] [Accepted: 07/17/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Health care payment reform has increased employers and health insurance companies' incentive to take measures to control the rising costs of medical care in the United States. To date, limited research has investigated the influence outpatient physical therapy (PT) visits have on clinical outcomes following anterior cruciate ligament reconstruction (ACLR) with and without a concurrent meniscal repair. OBJECTIVE To examine the relationship between the number of PT visits and patient-reported outcome scores following ACLR outpatient rehabilitation. STUDY DESIGN Retrospective cohort. LEVEL OF EVIDENCE 2b. METHODS Patients following ACLR with (n = 62) and without (n = 328) meniscal repair were identified through an electronic medical record database. RESULTS Patients with more PT visits had higher knee outcome survey-activities of daily living (KOS-ADL) change scores (P = .01) following ACLR without meniscal repair. Younger patients yielded significantly higher KOS-ADL change scores (P = .05) in the same cohort. Patients in the semisupervised PT visit strata recorded an 11.1 higher KOS-ADL change score compared with patients within the unsupervised PT visit stratum (P = .02). Younger patients also yielded significantly larger reductions in numeric pain (P = .01) following ACLR without meniscal repair. No significant differences were found between PT visits and either patient-reported outcome following ACLR with meniscal repair. CONCLUSIONS Our findings suggest that younger patients and those in a semisupervised PT visit model have superior patient-reported outcomes following ACLR without meniscal repair. Preliminary findings indicate no relationship with PT visits and patient-reported outcomes in patients after ACLR with meniscal repair surgery. CLINICAL RELEVANCE These findings promote an alternative model to outpatient PT following ACLR without meniscal repair that may be more clinically effective and value based. There appears to be a need for patients to undergo a balanced regimen of supervised PT and effective interventions that can be conducted independently.
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Pottkotter KA, Di Stasi SL, Schmitt LC, Magnussen RA, Paterno MV, Flanigan DC, Kaeding CC, Hewett TE. Improvements in Thigh Strength Symmetry Are Modestly Correlated With Changes in Self-Reported Function After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2018; 6:2325967118807459. [PMID: 30534573 PMCID: PMC6280613 DOI: 10.1177/2325967118807459] [Citation(s) in RCA: 5] [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] [Indexed: 01/15/2023] Open
Abstract
Background: The association between quadriceps strength and functional outcomes after anterior cruciate ligament reconstruction (ACLR) is a focus of current research, while evaluations of hamstring strength are limited, despite the frequent use of hamstring autografts. Purpose/Hypothesis: The purpose of this study was to determine the relationship between changes in quadriceps and hamstring strength symmetry and self-reported outcomes before ACLR and at 12 and 24 weeks after surgery. We hypothesized that improvements in quadriceps and hamstring strength symmetry would be correlated with improvements in self-reported outcome measures within the first 6 months after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: Thirty patients who underwent ACLR with a hamstring autograft were enrolled. Quadriceps and hamstring strength and Knee injury and Osteoarthritis Outcome Score (KOOS) values were assessed before and at 12 and 24 weeks after ACLR; limb symmetry indexes for strength were calculated at each time point. The Friedman and Wilcoxon signed-rank tests were used to analyze changes in KOOS values over time. Spearman rank-order correlations were used to test the relationship between changes in strength and KOOS values between each time point. Results: Hamstring and quadriceps limb symmetry significantly increased with time (P ≤ .03). Fair correlations were observed between changes in the hamstring index and changes in the KOOS Symptoms subscore from before surgery to 12 weeks postoperatively (r = 0.48; P ≤ .05). Changes in the quadriceps index (QI) were moderately correlated with changes in the KOOS Sport/Recreation subscore (r = 0.60; P = .001), and fair correlations were seen between the QI and the KOOS Quality of Life subscore (r = 0.39; P ≤ .04) from preoperatively to 12 weeks after surgery. Moderate correlations were seen between the QI and the KOOS Sport/Recreation subscore (r = 0.57; P = .005) from 12 to 24 weeks after surgery. Conclusion: Improvements in quadriceps and hamstring strength symmetry were modestly associated with improvements in athletes’ perceived function in the first 6 months after ACLR. Specifically, improvements in hamstring symmetry were associated with improvements in knee symptoms within the first 12 weeks postoperatively, while improvements in quadriceps symmetry were associated with improvements in self-reported sport function throughout the first 6 months after ACLR. The restoration of strength symmetry within the first 6 months may be a critical component of rehabilitation aimed at maximizing function after ACLR. Further investigation is warranted to comprehensively evaluate whether the timing of strength gains predicts future function, including those who successfully return to their preinjury activity level after ACLR.
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Affiliation(s)
- Kristy A Pottkotter
- Sports Medicine Physical Therapy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stephanie L Di Stasi
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Laura C Schmitt
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - Mark V Paterno
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David C Flanigan
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - Christopher C Kaeding
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - Timothy E Hewett
- Orthopedics Biomechanics Laboratory and Sports Medicine Center, Mayo Clinic, Rochester, Minnesota, USA
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Marshall NE, Keller RA, Dines J, Bush-Joseph C, Limpisvasti O. Current practice: postoperative and return to play trends after ACL reconstruction by fellowship-trained sports surgeons. Musculoskelet Surg 2018; 103:55-61. [PMID: 30361837 DOI: 10.1007/s12306-018-0574-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 10/19/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE Advances in anterior cruciate ligament (ACL) reconstruction have allowed for many progressions in postoperative management. However, there is no standardized protocol for immediate postoperative management or return to play. Our objective was to evaluate current trends in immediate postoperative and return to sport practices after ACL reconstruction. LEVEL OF EVIDENCE Cross sectional study, Level IV. METHODS Surveys were obtained from four large sports fellowship alumni networks. Demographics included years of practice and ACLs performed per year. Postoperative questions included weight bearing status, brace use and continuous passive motion (CPM) use. Return to play included time for return, brace use and metrics used for clearance to sport. RESULTS A total of 143 surveys were completed (32% response rate). Average years in practice were 15.1 years. Average ACL reconstructions performed per year was 20-50 in 44% and 50-100 in 29%. 26% used CPM in all patients, 8% if concomitant meniscal repair and 66% never. Bracing after surgery was used in 84% and 48% after return to play. Return to play was allowed at 6-9 months in 67% and overall 94% from 6 to 12 months. No consensus on return to play metrics was used, with the hop test being most important followed by specific time point after surgery. CONCLUSION Immediate weight bearing after surgery is commonplace with intermittent CPM use. Bracing is common postoperatively and half the time with return to play. Return to play is typically allowed after at least 6 months with no consensus on return to sport metrics. Years after fellowship and ACLs performed yearly had no correlation with postoperative practices.
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Affiliation(s)
- N E Marshall
- Kerlan Jobe Orthopaedic Clinic, 6801 Park Terrace Dr., Los Angeles, CA, 90045, USA.
| | - R A Keller
- Kerlan Jobe Orthopaedic Clinic, 6801 Park Terrace Dr., Los Angeles, CA, 90045, USA
| | - J Dines
- The Hospital for Special Surgery, 541 E 71st St., New York, NY, 10021, USA
| | - C Bush-Joseph
- Midwest Orthopedics at Rush, 1611 W Harrison St., Chicago, IL, 60612, USA
| | - O Limpisvasti
- Kerlan Jobe Orthopaedic Clinic, 6801 Park Terrace Dr., Los Angeles, CA, 90045, USA
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The Timing of Rehabilitation Commencement After Reconstruction of the Anterior Cruciate Ligament. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1096:53-7. [PMID: 29737496 DOI: 10.1007/5584_2018_210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
One of the most common injuries of the knee joint is a rupture of the anterior cruciate ligament (ACL). Most authors believe that early rehabilitation of patients after ACL reconstruction promotes better treatment outcomes. Less is known about the influence of the time that passes from injury to surgical reconstruction. Therefore, the goal of this study was to assess the dependence of treatment outcomes of ACL on injury-to-reconstruction and reconstruction-to-rehabilitation time lags. The study included 30 patients of the mean age 34 ± 7 years with trauma-related rupture of ACL and its surgical reconstruction. The time range from ligament rupture to its reconstruction was 120-180 days and from reconstruction to rehabilitation was 1-120 days. Postsurgical rehabilitation outcomes were assessed with the Lysholm knee scale and the IKDC 2000 subjective knee evaluation form. The scales were applied before and after rehabilitation. We found distinct improvements in all physical symptoms in the damaged knee joint, regardless of the time elapsed from trauma to ACL reconstruction and from ACL reconstruction to rehabilitation. The beneficial outcomes of rehabilitation were significantly inversely associated with the time elapsing from reconstruction to rehabilitation commencement but failed to depend on the time from ACL rupture to reconstruction. We conclude that rehabilitation should start as early as possible after ACL reconstruction to optimize the beneficial outcomes in terms of functional physical recovery, whereas the injury-to-reconstruction delay is less meaningful to this end.
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Boer BC, Hoogeslag RAG, Brouwer RW, Demmer A, Huis In 't Veld RMHA. Self-reported functional recovery after reconstruction versus repair in acute anterior cruciate ligament rupture (ROTOR): a randomized controlled clinical trial. BMC Musculoskelet Disord 2018; 19:127. [PMID: 29678170 PMCID: PMC5910573 DOI: 10.1186/s12891-018-2028-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 03/27/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction is today's surgical gold standard for ACL rupture. Although it provides satisfactory results, not all patients return to their previous activity level and moreover, early posttraumatic osteoarthritis is not prevented. As such, a renewed interest has emerged in ACL suture repair combined with dynamic augmentation. Compared to ACL reconstruction, the hypothesized advantages of ACL suture repair are earlier return to sports, reduction of early posttraumatic osteoarthritis and preservation of the patient's native ACL tissue and proprioceptive envelope of the knee. In recent literature, ACL suture repair combined with dynamic augmentation tends to be at least equally effective compared to ACL reconstruction, but no randomized comparative study has yet been conducted. METHODS/DESIGN This study is a prospective, stratified, block randomized controlled trial. Forty-eight patients with an ACL rupture will be assigned to either a suture repair group with dynamic augmentation and microfracture of the femoral notch, or an ACL reconstruction group with autologous semitendinosis graft and all-inside technique. The primary objective is to investigate the hypothesis that suture repair of a ruptured ACL results in at least equal effectiveness compared with an ACL reconstruction in terms of patient self-reported outcomes (IKDC 2000 subjective scale) 1 year postoperatively. Secondary objectives are to evaluate patient self-reported outcomes (IKDC 2000, KOOS, Tegner, VAS), re-rupture rate, rehabilitation time required for return to daily and sports activities, achieved levels of sports activity, clinimetrics (Rolimeter, LSI, Isoforce) and development of osteoarthritis, at short term (6 weeks, 3, 6 and 9 months and 1 year), midterm (2 and 5 years) and long term (10 years) postoperatively. DISCUSSION A renewed interest has emerged in ACL suture repair combined with dynamic augmentation in the treatment of ACL rupture. Recent cohort studies show good short- and midterm results for this technique. This randomized controlled trial has been designed to compare the outcome of suture repair of a ruptured ACL, combined with DIS as well as microfracture of the femoral notch, with ACL reconstruction using autologous semitendinosus. TRIAL REGISTRATION Clinical Trials Register NCT02310854 (retrospectively registered on December 1st, 2014).
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Affiliation(s)
- Barbara C Boer
- OCON Centre for Orthopaedic Surgery, Knee Unit, Hengelo, the Netherlands
| | - Roy A G Hoogeslag
- OCON Centre for Orthopaedic Surgery, Knee Unit, Hengelo, the Netherlands
| | - Reinoud W Brouwer
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, the Netherlands
| | - Anna Demmer
- OCON Centre for Orthopaedic Surgery, Knee Unit, Hengelo, the Netherlands
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Janssen RPA, van Melick N, van Mourik JBA, Reijman M, van Rhijn LW. ACL reconstruction with hamstring tendon autograft and accelerated brace-free rehabilitation: a systematic review of clinical outcomes. BMJ Open Sport Exerc Med 2018; 4:e000301. [PMID: 29682311 PMCID: PMC5905729 DOI: 10.1136/bmjsem-2017-000301] [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: 09/27/2017] [Revised: 01/05/2018] [Accepted: 02/19/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To investigate the clinical outcomes after hamstring tendon autograft ACL reconstruction (ACLR) with accelerated, brace-free rehabilitation. DESIGN Systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. DATA SOURCES Embase, MEDLINE Ovid, Web of Science, Cochrane CENTRAL and Google scholar from 1 January 1974 to 31 January 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Study designs reporting outcomes in adults after arthroscopic, primary ACLR with hamstring autograft and accelerated, brace-free rehabilitation. RESULTS Twenty-four studies were included in the review. The clinical outcomes after hamstring tendon autograft ACLR with accelerated brace-free rehabilitation were the following: (1) early start of open kinetic exercises at 4 weeks in a limited range of motion (ROM, 90°-45°) and progressive concentric and eccentric exercises from 12 weeks did not alter outcomes, (2) gender and age did not influence clinical outcomes, (3) anatomical reconstructions showed better results than non-anatomical reconstructions, (4) there was no difference between single-bundle and double-bundle reconstructions, (5) femoral and tibial tunnel widening occurred, (6) hamstring tendons regenerated after harvest and (7) biological knowledge did not support return to sports at 4-6 months. CONCLUSIONS After hamstring tendon autograft ACLR with accelerated brace-free rehabilitation, clinical outcome is similar after single-bundle and double-bundle ACLR. Early start of open kinetic exercises at 4 weeks in a limited ROM (90°-45°) and progressive concentric and eccentric exercises from 12 weeks postsurgery do not alter clinical outcome. Further research should focus on achievement of best balance between graft loading and graft healing in the various rehabilitation phases after ACLR as well as on validated, criterion-based assessments for safe return to sports. LEVEL OF EVIDENCE Level 2b; therapeutic outcome studies.
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Affiliation(s)
- Rob P A Janssen
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, The Netherlands
| | | | - Jan B A van Mourik
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, The Netherlands
| | - Max Reijman
- Orthopaedic Center Máxima, Máxima Medical Center, Eindhoven, The Netherlands
- Department of Orthopaedic Surgery, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lodewijk W van Rhijn
- Orthopaedic Surgery & Traumatology, Maastricht University Medical Center, Maastricht, The Netherlands
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Myers H, Christopherson Z, Butler RJ. RELATIONSHIP BETWEEN THE LOWER QUARTER Y-BALANCE TEST SCORES AND ISOKINETIC STRENGTH TESTING IN PATIENTS STATUS POST ACL RECONSTRUCTION. Int J Sports Phys Ther 2018; 13:152-159. [PMID: 30090673 PMCID: PMC6063058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND ACL injuries are common among sports populations and achieving adequate lower extremity strength is important prior to return to play. Access to isokinetic testing equipment that measures lower extremity strength is limited. Screening tools that measure functional criteria are accessible to clinicians, however the tools' relationship to strength constructs have not been investigated in an ACL reconstructed (ACLR) population. PURPOSE The primary objective was to determine if relationships exist between isokinetic peak knee extension torque (PKET), peak knee flexion torque (PKFT), hamstring to quadriceps (HQ) ratios, and YBT-LQ performance following ACLR. The secondary objective was to observe differences in isokinetic strength ability between high and low performers on the YBT-LQ. STUDY DESIGN Retrospective Chart Review. METHODS Medical records of forty-five ACL-reconstructed subjects, between five-12 months post-surgery were queried for functional assessment data collected during the institution's standard outcome testing battery. Variables of interest included: demographic and anthropomorphic measures, YBT-LQ performance, and involved limb isokinetic PKET, PKFT, and HQ ratios. Performance on each measure, as well as asymmetry between sides, was analyzed using a correlation matrix. RESULTS Statistically significant (p<0.01) relationships were identified between YBT-LQ anterior reach asymmetry and the PKET deficit (r=0.264). PKET and PKFT on the involved limb correlated to performance of anterior reach (r=0.591, p<0.01)(r=0.493, p<0.01), posteromedial reach (r=0.498, p<0.01)(r=0.577, p<0.01), and posterolateral reach (r=0.294, p<0.05)(r=0.445, p<0.01) respectively. Similar relationships existed on the uninvolved side, but to a lesser extent. High and low performers on the YBT-LQ demonstrated lower and higher extension torque deficits, respectively. CONCLUSION While each test measures unique constructs, there are associations between components of the tests. In the ACLR population, both the YBT-LQ and isokinetic strength testing can expose asymmetries and impact return to play decision making. LEVEL OF EVIDENCE 2b.
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Affiliation(s)
- Heather Myers
- Department of Physical Therapy and Occupational Therapy, Sports Medicine Division, Duke University Health System, Durham, NC, USA
| | - Zachary Christopherson
- Department of Physical Therapy and Occupational Therapy, Sports Medicine Division, Duke University Health System, Durham, NC, USA
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Bousquet BA, O'Brien L, Singleton S, Beggs M. POST-OPERATIVE CRITERION BASED REHABILITATION OF ACL REPAIRS: A CLINICAL COMMENTARY. Int J Sports Phys Ther 2018; 13:293-305. [PMID: 30090687 PMCID: PMC6063063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
The anterior cruciate ligament (ACL) is the most commonly reconstructed ligament of the knee. Most often, the goal of surgical reconstruction is to recreate stability within the knee and prevent joint degeneration. To date, clinical studies have not demonstrated the ability of various reconstruction techniques in establishing complete knee stability when comparing rates of osteoarthritis. Rates of osteoarthritis commonly resemble those of knees which have not be reconstructed and in this light, may not demonstrate a successful outcome. As modern medicine continues to develop and in the understanding of underlying biological processes grows, some surgeons have turned their attention back to an ACL repair technique. The purpose of this clinical commentary is to discuss the parameters associated with a phase progression for an isolated ACL repair. Physiological healing time frames, along with objective clinical assessment, following a criterion-based progression is described in accordance with post-operative healing parameters to serve as a reference for a rehabilitation specialist. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Brett A Bousquet
- Intermountain Hospital Park City Physical Therapy, Park City, UT, USA
- Howard Head Sports Medicine Center, Vail, CO, USA
- Fort Worth Orthopedics, Fort Worth, TX, USA
- Steadman Clinic, Vail, CO, USA
| | - Luke O'Brien
- Intermountain Hospital Park City Physical Therapy, Park City, UT, USA
- Howard Head Sports Medicine Center, Vail, CO, USA
- Fort Worth Orthopedics, Fort Worth, TX, USA
- Steadman Clinic, Vail, CO, USA
| | - Steve Singleton
- Intermountain Hospital Park City Physical Therapy, Park City, UT, USA
- Howard Head Sports Medicine Center, Vail, CO, USA
- Fort Worth Orthopedics, Fort Worth, TX, USA
- Steadman Clinic, Vail, CO, USA
| | - Michael Beggs
- Intermountain Hospital Park City Physical Therapy, Park City, UT, USA
- Howard Head Sports Medicine Center, Vail, CO, USA
- Fort Worth Orthopedics, Fort Worth, TX, USA
- Steadman Clinic, Vail, CO, USA
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Thrush C, Porter TJ, Devitt BM. No evidence for the most appropriate postoperative rehabilitation protocol following anterior cruciate ligament reconstruction with concomitant articular cartilage lesions: a systematic review. Knee Surg Sports Traumatol Arthrosc 2018; 26:1065-1073. [PMID: 29511820 DOI: 10.1007/s00167-018-4882-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/28/2018] [Indexed: 01/29/2023]
Abstract
PURPOSE Anterior cruciate ligament (ACL) rupture commonly occurs in conjunction with articular cartilage injury. However, there is no consensus on the most appropriate rehabilitation which should be carried out for ACL reconstruction (ACLR) and the surgical management of articular cartilage lesions of the knee. The purpose of this study was to systematically review the literature to investigate the recommended rehabilitation protocol for patients undergoing ACLR with concomitant articular cartilage injury with a view to develop guidelines on the most appropriate treatment. METHODS Two reviewers independently searched five database for randomised controlled trials (RCTs), non-randomised comparative and retrospective cohort studies (CS) describing the management of concomitant ACL rupture and articular cartilage injury and the postoperative rehabilitation regimen. Risk of bias was performed using a modified Downs & Black's checklist. The primary outcome was specific rehabilitation protocols including weight-bearing status, immobilisation, continuous passive motion (CPM), and return to play criteria. Secondary outcomes included patient-reported outcomes. A best evidence synthesis was performed. RESULTS The review yielded six studies which reported on rehabilitation techniques. All studies were of low methodological quality. There was considerable variability in not only the chondral lesion reported but also the treatment techniques utilised and especially the rehabilitation regimes. No consensus was found on weight-bearing status, postoperative immobilisation, the use of CPM, or return to play criteria. Given the quality of the papers, there was no evidence to recommend any specific rehabilitation regime in the postoperative management of concomitant ACLR and articular cartilage lesions. CONCLUSION This systematic review revealed that despite how common concomitant ACL rupture and articular cartilage injury is, there is no evidence to support one, most appropriate rehabilitation protocol. From a clinical perspective, decisions on postoperative rehabilitation for patients undergoing ACLR and treatment of articular cartilage lesions should be made on a case-by-case basis with criteria-based progression until more robust evidence becomes available. A list of specific rehabilitation protocols based on the cartilage restoration technique is provided. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ciaran Thrush
- OrthoSport Victoria Research Unit, Epworth Healthcare, Melbourne, Australia
| | - Tabitha J Porter
- OrthoSport Victoria Research Unit, Epworth Healthcare, Melbourne, Australia
| | - Brian M Devitt
- OrthoSport Victoria Research Unit, Epworth Healthcare, Melbourne, Australia.
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Spindler KP, Huston LJ, Chagin KM, Kattan MW, Reinke EK, Amendola A, Andrish JT, Brophy RH, Cox CL, Dunn WR, Flanigan DC, Jones MH, Kaeding CC, Magnussen RA, Marx RG, Matava MJ, McCarty EC, Parker RD, Pedroza AD, Vidal AF, Wolcott ML, Wolf BR, Wright RW. Ten-Year Outcomes and Risk Factors After Anterior Cruciate Ligament Reconstruction: A MOON Longitudinal Prospective Cohort Study. Am J Sports Med 2018; 46. [PMID: 29543512 PMCID: PMC6036619 DOI: 10.1177/0363546517749850] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The long-term prognosis and risk factors for quality of life and disability after anterior cruciate ligament (ACL) reconstruction remain unknown. Hypothesis/Purpose: Our objective was to identify patient-reported outcomes and patient-specific risk factors from a large prospective cohort at a minimum 10-year follow-up after ACL reconstruction. We hypothesized that meniscus and articular cartilage injuries, revision ACL reconstruction, subsequent knee surgery, and certain demographic characteristics would be significant risk factors for inferior outcomes at 10 years. STUDY DESIGN Therapeutic study; Level of evidence, 2. METHODS Unilateral ACL reconstruction procedures were identified and prospectively enrolled between 2002 and 2004 from 7 sites in the Multicenter Orthopaedic Outcomes Network (MOON). Patients preoperatively completed a series of validated outcome instruments, including the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and Marx activity rating scale. At the time of surgery, physicians documented all intra-articular abnormalities, treatment, and surgical techniques utilized. Patients were followed at 2, 6, and 10 years postoperatively and asked to complete the same outcome instruments that they completed at baseline. The incidence and details of any subsequent knee surgeries were also obtained. Multivariable regression analysis was used to identify significant predictors of the outcome. RESULTS A total of 1592 patients were enrolled (57% male; median age, 24 years). Ten-year follow-up was obtained on 83% (n = 1320) of the cohort. Both IKDC and KOOS scores significantly improved at 2 years and were maintained at 6 and 10 years. Conversely, Marx scores dropped markedly over time, from a median score of 12 points at baseline to 9 points at 2 years, 7 points at 6 years, and 6 points at 10 years. The patient-specific risk factors for inferior 10-year outcomes were lower baseline scores; higher body mass index; being a smoker at baseline; having a medial or lateral meniscus procedure performed before index ACL reconstruction; undergoing revision ACL reconstruction; undergoing lateral meniscectomy; grade 3 to 4 articular cartilage lesions in the medial, lateral, or patellofemoral compartments; and undergoing any subsequent ipsilateral knee surgery after index ACL reconstruction. CONCLUSION Patients were able to perform sports-related functions and maintain a relatively high knee-related quality of life 10 years after ACL reconstruction, although activity levels significantly declined over time. Multivariable analysis identified several key modifiable risk factors that significantly influence the outcome.
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Affiliation(s)
| | - Kurt P. Spindler
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laura J. Huston
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin M. Chagin
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael W. Kattan
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily K. Reinke
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Annunziato Amendola
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jack T. Andrish
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert H. Brophy
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Charles L. Cox
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Warren R. Dunn
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David C. Flanigan
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Morgan H. Jones
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher C. Kaeding
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert A. Magnussen
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert G. Marx
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew J. Matava
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric C. McCarty
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Richard D. Parker
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Angela D. Pedroza
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Armando F. Vidal
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michelle L. Wolcott
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian R. Wolf
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rick W. Wright
- Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
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