Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus

Management of Meniscus Pathology with Concomitant Anterior Cruciate Ligament Injury

PURPOSE OF REVIEW

The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies.

RECENT FINDINGS

Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.

Adiposity and cartilage lesions following ACL reconstruction

OBJECTIVE

To determine if global, central, or peripheral adiposity is associated with prevalent and worsening cartilage lesions following anterior cruciate ligament reconstruction (ACLR).

METHODS

In 107 individuals one-year post-ACLR, adiposity was assessed globally (body mass index), centrally (waist circumference), and peripherally (knee subcutaneous adipose tissue thickness) from magnetic resonance imaging (MRI). Tibiofemoral and patellofemoral cartilage lesions were assessed from knee MRIs at 1- and 5-years post-ACLR. Poisson regression evaluated the relation of adiposity with prevalent and worsening tibiofemoral and patellofemoral cartilage lesions adjusting for age, sex, and activity level.

RESULTS

The prevalence ratios of adiposity with tibiofemoral (presence in 49%) and patellofemoral (44%) cartilage lesions ranged from 0.99 to 1.03. Adiposity was more strongly associated with longitudinal changes in tibiofemoral (worsening in 21%) and patellofemoral (44%) cartilage lesions. One-unit increase in global (kg/m2), central (cm), and peripheral (mm) adiposity was associated with a higher risk of worsening tibiofemoral cartilage lesions by 17% (risk ratios [95% confidence interval (CI)]: 1.17 [1.09 to 1.23]), 5% (1.05 [1.02 to 1.08]), and 9% (1.09 [1.03 to 1.16]), and patellofemoral cartilage lesions by 5% (1.05 [1.00 to 1.12]), 2% (1.02 [1.00 to 1.04]) and 2% (1.02 [1.00 to 1.04]), respectively.

CONCLUSION

Greater adiposity was a risk factor for worsening cartilage lesions up to 5 years post-ACLR. Clinical interventions aimed at mitigating excess adiposity may be beneficial in preventive approaches for early post-traumatic osteoarthritis.

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

INTRODUCTION

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

METHODS

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

REGISTRATION DETAILS

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

Blood Flow Restriction Enhances Recovery After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating neuromuscular and clinical outcomes of blood flow restriction (BFR) training after anterior cruciate ligament reconstruction (ACLR) compared to non-BFR rehabilitation protocols.

METHODS

A systematic review was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines by querying PubMed, MEDLINE, Scopus, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials databases from inception through December 2023 to identify Level I-II RCTs evaluating outcomes of BFR training after ACLR compared to non-BFR rehabilitation. A meta-analysis was performed using random-effects models with standardized mean difference (SMD) for pain, muscle strength, and muscle volume, while mean difference (MD) was calculated for patient-reported outcome measures.

RESULTS

Eight RCTs, consisting of 245 patients, met inclusion criteria, with 115 patients undergoing non-BFR rehabilitation versus 130 patients undergoing BFR after ACLR. Mean patient age was 27.2 ± 6.7 years, with the majority of patients being male (63.3%, n=138/218). The length of the BFR rehabilitation protocol was most commonly between 8-12 weeks (range, 14 days - 16 weeks). The majority of studies set the limb/arterial occlusion pressure in the BFR group at 80%. When compared to non-BFR rehabilitation, BFR resulted in significant improvement in isokinetic muscle strength (SMD: 0.77, p=0.02, I2: 58%), IKDC score (MD: 10.97, p=<.00001, I2: 77%), and pain (SMD: 1.52, p=.04, I2: 87%), but not quadriceps muscle volume (SMD: 0.28, p=0.43, I2: 76%).

CONCLUSION

The use of BFR following ACLR led to improvements in pain, IKDC score and isokinetic muscle strength, with variable outcomes based on quadriceps strength, volume and thickness when compared to non-BFR rehabilitation.

Toward designing human intervention studies to prevent osteoarthritis after knee injury: A report from an interdisciplinary OARSI 2023 workshop

Objective

The global impact of osteoarthritis is growing. Currently no disease modifying osteoarthritis drugs/therapies exist, increasing the need for preventative strategies. Knee injuries have a high prevalence, distinct onset, and strong independent association with post-traumatic osteoarthritis (PTOA). Numerous groups are embarking upon research that will culminate in clinical trials to assess the effect of interventions to prevent knee PTOA despite challenges and lack of consensus about trial design in this population. Our objectives were to improve awareness of knee PTOA prevention trial design and discuss state-of-the art methods to address the unique opportunities and challenges of these studies.

Design

An international interdisciplinary group developed a workshop, hosted at the 2023 Osteoarthritis Research Society International Congress. Here we summarize the workshop content and outputs, with the goal of moving the field of PTOA prevention trial design forward.

Results

Workshop highlights included discussions about target population (considering risk, homogeneity, and possibility of modifying osteoarthritis outcome); target treatment (considering delivery, timing, feasibility and effectiveness); comparators (usual care, placebo), and primary symptomatic outcomes considering surrogates and the importance of knee function and symptoms other than pain to this population.

Conclusions

Opportunities to test multimodal PTOA prevention interventions across preclinical models and clinical trials exist. As improving symptomatic outcomes aligns with patient and regulator priorities, co-primary symptomatic (single or aggregate/multidimensional outcome considering function and symptoms beyond pain) and structural/physiological outcomes may be appropriate for these trials. To ensure PTOA prevention trials are relevant and acceptable to all stakeholders, future research should address critical knowledge gaps and challenges.

Return to training in soccer players after anterior cruciate ligament reconstruction: reflections and considerations

This clinical and rehabilitative overview focuses on the return to unrestricted sporting activity, aiming to consolidate the scientific evidence surrounding the structural progression of athletes, particularly footballers, undergoing anterior cruciate ligament reconstruction (ACLR). A multidisciplinary approach necessitates a shared language and standardized methodologies. Unfortunately, significant disparities persist in the structural strategies guiding the decision-making process for returning to on-field activities, the latter stages of rehabilitation, and subsequent restoration of technical and tactical football abilities. Divergences in definitions, terminologies, and rehabilitation protocols can substantially influence final outcomes. Presently, scientific consensus studies regarding the decision-making process during the final stages of on-field rehabilitation are lacking. Nevertheless, this overview outlines and defines pivotal language parameters crucial for effective communication and the seamless integration of clinical and rehabilitative data among the diverse professionals involved in facilitating the athlete's return to peak performance. In conclusion, the successful resumption of competitive sporting activities for footballer's post ACLR demands a collaborative decision-making approach encompassing various professionals. Additionally, it necessitates a cohesive transition from rehabilitation to on-field work, aiming at reinstating athleticism, technical prowess, and tactical acumen.

Late-stage rehabilitation after anterior cruciate ligament reconstruction: A multicentre randomised controlled trial (PReP)

BACKGROUND

At the completion of formal rehabilitation after anterior cruciate ligament reconstruction, functional capacity is only restored in a small proportion of affected individuals. Therefore, the end of formal rehabilitation is not the end of functional rehabilitation.

OBJECTIVE

To compare adherence to and effectiveness of a late-stage rehabilitation programme with usual care after anterior cruciate ligament (ACL) reconstruction.

METHODS

This prospective, double-blind, multicentre, parallel group, randomised controlled trial, included people aged 18 to 35 years after formal rehabilitation completion (mean [SD] 241 [92] days post-reconstruction). Participants were block-randomised to a 5-month neuromuscular performance intervention (Stop-X group) or usual care (medically prescribed standard physiotherapy, individual formal rehabilitation, home-exercises). All outcomes were measured once/month. Primary outcome was the normalised knee separation distance on landing after drop jump. Baseline-adjusted linear mixed models were calculated.

RESULTS

In total, 112 participants (Stop-X: 57; Usual care: 55,) were analysed. Initially, mean (SD) intervention frequency (units/week) was higher in the Stop-X than the Usual care group: 2.65 (0.96) versus 2.48 (1.14) units/week in the first and 2.28 (1.02) versus 2.14 (1.31) units/week in the second month. No between-group*time(*baseline)-differences were found for the primary outcome. Between-group*time-effects favoured the Stop-X-group at 2 months (fewer self-reported knee problems during sport, KOOS-SPORT) (estimate = 64.3, 95 % CI 24.4-104.3 for the Stop-X), more confidence to return to sport (ACL-RSI) (62.4, 10.7-114.2), fewer pain-associated knee problems (KOOS-PAIN) (82.8, 36.0-129.6), improved everyday activity abilities (KOOS-ADL) (71.1, 6.4-135.7), and improved limb symmetry index in the front hop for distance at 3 and 4 months (0.34, 0.10-0.57; 0.31, 0.08-0.54). No between-group*time-effects occurred for kinesiophobia, symptom-associated knee problems or balance hops performance. At the end of the intervention, 79 % of the Stop-X and 70 % of the Usual care participants (p < 0.05) had successfully returned to their pre-injury sport type and level.

CONCLUSIONS

The Stop-X intervention was slightly superior to usual care as part of late-stage rehabilitation after ACL-reconstruction. The small benefit might justify its use after formal rehabilitation completion.

No sign of weakness: a systematic review and meta-analysis of hip and calf muscle strength after anterior cruciate ligament injury

OBJECTIVE

We aimed to determine hip and lower-leg muscle strength in people after ACL injury compared with an uninjured control group (between people) and the uninjured contralateral limb (between limbs).

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Scopus, Cochrane CENTRAL and SportDiscus to 28 February 2023.

ELIGIBILITY CRITERIA

Primary ACL injury with mean age 18-40 years at time of injury. Studies had to measure hip and/or lower-leg muscle strength quantitatively (eg, dynamometer) and report muscle strength for the ACL-injured limb compared with: (i) an uninjured control group and/or (ii) the uninjured contralateral limb. Risk of bias was assessed according to Cochrane Collaboration domains.

RESULTS

Twenty-eight studies were included (n=23 measured strength ≤12 months post-ACL reconstruction). Most examined hip abduction (16 studies), hip extension (12 studies) and hip external rotation (7 studies) strength. We found no meaningful difference in muscle strength between people or between limbs for hip abduction, extension, internal rotation, flexion or ankle plantarflexion, dorsiflexion (estimates ranged from -9% to +9% of comparator). The only non-zero differences identified were in hip adduction (24% stronger on ACL limb (95% CI 8% to 42%)) and hip external rotation strength (12% deficit on ACL limb (95% CI 6% to 18%)) compared with uninjured controls at follow-ups >12 months, however both results stemmed from only two studies. Certainty of evidence was very low for all outcomes and comparisons, and drawn primarily from the first year post-ACL reconstruction.

CONCLUSION

Our results do not show widespread or substantial muscle weakness of the hip and lower-leg muscles after ACL injury, contrasting deficits of 10%-20% commonly reported for knee extensors and flexors. As it is unclear if deficits in hip and lower-leg muscle strength resolve with appropriate rehabilitation or no postinjury or postoperative weakness occurs, individualised assessment should guide training of hip and lower-leg strength following ACL injury.

PROSPERO REGISTRATION NUMBER

CRD42020216793.

Recruitment and baseline characteristics of young adults at risk of early-onset knee osteoarthritis after ACL reconstruction in the SUPER-Knee trial

Objectives

The study aims to (1) report the process of recruiting young adults into a secondary knee osteoarthritis prevention randomised controlled trial (RCT) after anterior cruciate ligament reconstruction (ACLR); (2) determine the number of individuals needed to be screened to include one participant (NNS) and (3) report baseline characteristics of randomised participants.

Methods

The SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER)-Knee RCT compares SUPER and minimal intervention for young adults (aged 18-40 years) with ongoing symptoms (ie, mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score subscales (KOOS4)) 9-36 months post-ACLR. The NNS was calculated as the number of prospective participants screened to enrol one person. At baseline, participants provided medical history, completed questionnaires (demographic, injury/surgery, rehabilitation characteristics) and underwent physical examination.

Results

1044 individuals were screened to identify 567 eligible people, from which 184 participants (63% male) enrolled. The sample of enrolled participants was multicultural (29% born outside Australia; 2% Indigenous Australians). The NNS was 5.7. For randomised participants, mean±SD age was 30±6 years. The mean body mass index was 27.3±5.2 kg/m2, with overweight (43%) and obesity (21%) common. Participants were, on average, 2.3 years post-ACLR. Over half completed <8 months of postoperative rehabilitation, with 56% having concurrent injury/surgery to meniscus and/or cartilage. The most affected KOOS (0=worst, 100=best) subscale was quality of life (mean 43.7±19.1).

Conclusion

Young adults post-ACLR were willing to participate in a secondary osteoarthritis prevention trial. Sample size calculations should be multiplied by at least 5.7 to provide an estimate of the NNS. The SUPER-Knee cohort is ideally positioned to monitor and intervene in the early development and trajectory of osteoarthritis.

Trial registration number

ACTRN12620001164987.

Effect of knee bracing on clinical outcomes following anterior cruciate ligament reconstruction: A prospective randomised controlled study

Objectives

While there is a consensus against bracing after anterior cruciate ligament (ACL) reconstruction, the question of its potential benefits, especially in cases involving meniscus repair, as well as its routine use by the majority of clinicians, remains a topic of debate. This study aims to assess the effectiveness of bracing in relation to clinical scores after ACL reconstruction, regardless of meniscus surgery.

Methods

This randomised controlled study involved patients aged 15-55 years who underwent arthroscopic ACL reconstruction surgery. All eligible patients were assigned into two groups: one group received an adjustable frame with a four-point fixation knee brace for a four-week period, while the other did not.A single experienced surgeon performed standard anatomical single-bundle ACL reconstruction. All patients, irrespective of whether they underwent meniscus repair, followed the same rehabilitation protocol. Knee functional questionnaires, including the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner Activity Scale, Visual Analogue Scale (VAS), and examinations, were collected preoperatively, at six months, one year, and two years postoperatively. The study employed an intention-to-treat analysis and multilevel mixed-effects generalised linear models to compare continuous outcomes between the groups, adjusting for the times of follow-up.

Results

A total of 84 patients (42 patients per group) comprised of 75 males (89 %) and average age of 30 ± 9.4 years old. Patient-reported function, physical examination findings, and surgical characteristics were comparable between the two groups. (P-value >0.05) Both groups demonstrated significant improvement in IKDC and Lysholm scores at the end of the two-year follow-up period. (P-value <0.0001) In multivariate analysis, bracing was significantly associated with lower Tegner activity scale than the non-brace group after adjustment for VAS and time (coefficient -0.49, 95 % confidence interval -0.87, -0.10, P-value = 0.013). None of the graft ruptures were reported, and there was no significant difference of return to sports between the groups at the end of the follow-up.

Conclusion

The study suggests that knee bracing after ACL reconstruction, regardless of any additional meniscus procedures, fails to enhance subjective or objective outcomes and could potentially have a negative impact on the Tegner activity scale, although the difference is not clinically significant. The routine use of a postoperative brace should be discontinued.

Level of evidence

Level I, Randomised controlled trial with no negative criteria.

A slight degree of osteoarthritis appears to be present after anterior cruciate ligament reconstruction compared with contralateral healthy knees at a minimum of 20 years: A systematic review of the literature

Purpose

The aim of the present systematic review was to quantitatively synthesize the best literature evidence regarding osteoarthritis developing after anterior cruciate ligament reconstruction (ACLR), including only studies with a follow-up duration of at least 20 years.

Material and Methods

A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on four electronic databases (PubMed, Scopus, EMBASE and Cochrane Library). The outcome measures extracted from the studies were failure rate, subsequent knee surgery on the same knee, radiographic development of osteoarthritis measured with Kellgren-Lawrence, International Knee Documentation Committee (IKDC) radiographic score and Ahlbäck classification. The health of both the ACLR knee and the contralateral knee was compared.

Results

A total of 1552 patients were included in the study, of which 1290 (83.11%) were operated on using a patellar tendon graft, 190 (12.24%) with hamstrings, 27 (1.73%) with an iliotibial band and 45 (2.89%) with patellar tendon plus a ligament augmentation device (LAD). The mean age at the time of surgery was 25.18 ± 1.91 years, and the mean follow-up time was 23.34 ± 2.56 years. Analysing IDKC Score at final follow-up, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 33.2% (324/976) of the patients showed a moderate to severe degree (Grade C or D) of osteoarthritis, while for Kellgren-Lawrence, ACLR Group showed a higher degree of OA compared with contralateral healthy knee (p < 0.01), but only 28.9% (196/678) of the patients showed a moderate to severe degree (Grade III or IV) of osteoarthritis. In total, 1552 patients were registered, 155 reruptures (9.98%) and a total of 300 (19.3%) new surgeries, of which 228 meniscectomy (14.69%), 21 (1.35%) knee arthroplasty and 17 (1.09%) hardware removal were recorded.

Conclusions

ACL reconstruction appears to result in mild osteoarthritis in the long term in most of the patients and only less than 33.2% develop a moderate to severe degree of knee OA according to IKDC radiographic score. A slight degree of osteoarthritis appears to be present in ACLR knees compared with contralateral healthy knees.

Level of Evidence

Level IV.

[Current approach in the follow-up treatment of joint-preserving operations on the knee joint in German-speaking countries]

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.

Evidence-based rehabilitation medicine: definition, foundation, practice and development

To determine the definition, foundation, practice, and development of evidence-based rehabilitation medicine (EBRM) and point out the development direction for EBRM. Retrieve the database of PubMed, Cochrane Library, Embase, China national knowledge infrastructure (CNKI), Wanfang, and China science and technology journal database (CSTJ). The search was conducted from the establishment of the database to June 2023. The key words are "rehabilitation medicine and evidence based" in Chinese and English. After reading the abstract or full text of the literature, a summary analysis is conducted to determine the definition, foundation, practice, and development of EBRM. A total of 127 articles were included. The development of 14 sub majors in EBRM are not balanced, evidence-based musculoskeletal rehabilitation medicine (EBMRM) (31 articles, mainly focuses on osteoarthritis, osteoporosis and musculoskeletal pain), evidence-based neurorehabilitation medicine (EBNM) (34 articles, mainly concentrated in stroke, traumatic brain injury and spinal cord injury) and evidence-based education rehabilitation medicine (EBEDRM) (17 articles, mainly focuses on educational methodology), evidence-based nursing rehabilitation medicine (EBNRM) (2 articles), evidence-based engineering rehabilitation medicine (EBENRM) (7 articles), evidence-based traditional Chinese rehabilitation medicine (EBTCRM) (3 articles), evidence-based internal rehabilitation medicine (EBIRM) (11 articles), evidence-based intensive care rehabilitation medicine (EBICRM) (4 articles), evidence-based oncology rehabilitation medicine (EBORM) (6 articles), evidence-based physical therapy medicine (EBPTM) (3 articles), evidence-based cardiopulmonary rehabilitation medicine (EBCRM) (6 articles), evidence-based speech therapy medicine (EBSTM)/evidence-based occupation therapy medicine (EBOTM)/evidence-based geriatric rehabilitation medicine (EBGRM) (1 article). The EBMRM, EBNM and EBEDRM are relatively well developed. The development of EBNRM, EBENRM, EBTCRM, EBIRM, EBICRM, EBGRM, EBORM, EBCRM, EBPTM, EBSTM and EBOTM is relatively slow, indicating these eleven fields should be pay more attention in future.

The Delaware-Oslo ACL Cohort treatment algorithm yields superior outcomes to usual care 9-12 years after anterior cruciate ligament reconstruction

PURPOSE

Patient-reported outcomes were compared between participants who followed the treatment algorithm of the Delaware-Oslo ACL Cohort, consisting of progressive preoperative and postoperative rehabilitation, patient education, clinical testing and shared decision-making about treatment choice, and those who followed usual care 9-12 years after anterior cruciate ligament reconstruction (ACLR).

METHODS

Participants with primary ACLR were included from the Norwegian arm of the Delaware-Oslo ACL Cohort and the Norwegian Knee Ligament Registry (usual care). The Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores and the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores were compared. KOOS scores for the usual care group were converted to IKDC-SKF scores with recently published validated crosswalk. The percentages of participants with scores above predefined thresholds for patient acceptable symptom state (PASS) were also calculated.

RESULTS

Eighty of 100 (80%) participants from the Delaware-Oslo ACL Cohort and 1588 of 3248 (49%) from the usual care group participated in the follow-up. Participants from the Delaware-Oslo ACL Cohort had higher KOOS subscale (p < 0.001) and IKDC-SKF scores (p < 0.001), and a higher percentage reached PASS (84%-96% vs. 62%-76%, p ≤ 0.002) for KOOS Pain, symptoms, activities of daily living and sports compared to the usual care group. No significant differences were found for KOOS quality of life scores (not significant [n.s.]) or PASS percentages (80% vs. 74%, n.s.).

CONCLUSION

Participants with ACLR who followed the Delaware-Oslo ACL Cohort treatment algorithm had reduced knee symptoms, superior function and higher percentages of satisfactory outcomes than participants who followed usual care.

LEVEL OF EVIDENCE

Level II.

Who's Afraid of Electrical Stimulation? Let's Revisit the Application of NMES at the Knee

BACKGROUND: Restoring quadriceps strength is essential for successful rehabilitation of knee injuries, but many athletes return to their previous activity with persisting muscle weakness. Strong evidence supports using neuromuscular electrical stimulation (NMES) to improve quadriceps strength; however, there is a lack of widespread clinical implementation. We believe there is a critical need to provide clinical approaches that promote using NMES to improve patients' quadriceps strength and ensuring clinicians provide high-value rehabilitation care. CLINICAL QUESTION: What is best practice when using NMES to facilitate strength after injury, what are barriers to its use, and how can they be addressed? KEY RESULTS: We discuss the low clinical implementation of NMES, perceived barriers to using NMES, and provide recommendations for setup and dosage parameters for effective use of NMES. CLINICAL APPLICATION: We aim for this commentary, with accompanying videos, to serve as a resource for clinicians who are using commercially available NMES units in clinical practice. J Orthop Sports Phys Ther 2024;54(2):1-6. Epub 31 October 2023. doi:10.2519/jospt.2023.12028.

Experiences of rehabilitation in young elite athletes: an interview study

Even though injuries are common in elite youth sports, rehabilitation experiences are limited explored in young athletes. This study explored rehabilitation experiences in athletes with a previous injury studying at sports high schools. Twenty-six (14/12 females/males) young elite athletes (age 15-19 years) from 11 individual/team sports were interviewed in focus groups about the rehabilitation experiences following a sports injury. Data were analysed using content analysis. The results led to four main categories identified: 'High-quality rehabilitation', 'Lack of communication between healthcare and coach', 'Various consequences of injury' and 'No clear path to accessing rehabilitation'. The athletes valued that the healthcare providers had high expertise, were clear and signalled secureness and confidence. It was also important to receive help with rehabilitation as rapidly as possible. The athletes perceived that they felt responsible for providing information regarding rehabilitation progression between healthcare providers and their coach. It was also challenging not to be able to participate in training and competition while injured - causing a sense of frustration and fear of falling behind their peer athletes in terms of development and performance. The athletes described that no well-defined medical teams at the sports high schools were available- instead medical help was offered in several other ways. Based on our findings, the collaboration and communication between the healthcare providers and coaches need to be improved, addressing the rehabilitation content, progress and access to rehabilitation. Through these actions, the rehabilitation process will be more adjusted to the needs of young elite athletes.

Prevalence of post-traumatic osteoarthritis after anterior cruciate ligament injury remains high despite advances in surgical techniques

Aims

The aim of this study was to report the pooled prevalence of post-traumatic osteoarthritis (PTOA) and examine whether the risk of developing PTOA after anterior cruciate ligament (ACL) injury has decreased in recent decades.

Methods

The PubMed and Web of Science databases were searched from 1 January 1980 to 11 May 2022. Patient series, observational studies, and clinical trials having reported the prevalence of radiologically confirmed PTOA after ACL injury, with at least a ten-year follow-up, were included. All studies were analyzed simultaneously, and separate analyses of the operative and nonoperative knees were performed. The prevalence of PTOA was calculated separately for each study, and pooled prevalence was reported with 95% confidence intervals (CIs) using either a fixed or random effects model. To examine the effect of the year of injury on the prevalence, a logit transformed meta-regression analysis was used with a maximum-likelihood estimator. Results from meta-regression analyses were reported with the unstandardized coefficient (β).

Results

The pooled prevalence of PTOA was 37.9% (95% CI 32.1 to 44) for operatively treated ACL injuries with a median follow-up of 14.6 years (interquartile range (IQR) 10.6 to 16.7). For nonoperatively treated ACL injuries, the prevalence was 40.5% (95% CI 28.9 to 53.3), with a median of follow-up of 15 years (IQR 11.7 to 20.0). The association between the year of operation and the prevalence of PTOA was weak and imprecise and not related to the choice of treatment (operative β -0.038 (95% CI -0.076 to 0.000) and nonoperative β -0.011 (95% CI -0.101 to 0.079)).

Conclusion

The initial injury, irrespective of management, has, by the balance of probability, resulted in PTOA within 20 years. In addition, the prevalence of PTOA has only slightly decreased during past decades. Therefore, further research is warranted to develop strategies to prevent the development of PTOA after ACL injuries.

After Anterior Cruciate Ligament Injury, Patients With Medicaid Insurance Experience Delayed Care and Worse Clinical Outcomes Than Patients With Non-Medicaid Insurance

Purpose

To evaluate the effects of socioeconomic factors on the operative treatment of anterior cruciate ligament injuries and outcomes following surgical reconstruction.

Methods

A retrospective cohort study of primary anterior cruciate ligament reconstruction surgeries at a single institution performed from 2011 to 2015 with minimum 2-year follow-up was conducted. Patient demographics, insurance type, workers' compensation status, surgical variables, International Knee Documentation Committee score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups.

Results

In total, 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group, overall mean follow-up of 3.1 ± 0.8 years). The Medicaid group demonstrated lower annual income (P < .001) and a lower level of completed education compared with the non-Medicaid group (P < .001). Patients who received Medicaid had a greater duration between time of initial knee injury and surgery compared with the those in non-Medicaid group (11.8 ± 16.3 months vs 6.1 ± 16.5 months, P < .001). At the time of follow-up, patients in the non-Medicaid group had a significantly greater International Knee Documentation Committee score compared with patients who received Medicaid (82.5 ± 13.8 vs 75.3 ± 20.8, P = .036).

Conclusions

Patients with Medicaid insurance were seen in the clinic significantly later after initial injury and had worse outcomes compared with patients with other insurance types. Also, patients in higher annual income brackets had significantly better clinical outcomes scores at a minimum of 2 years postoperatively.

Level of Evidence

Level III, retrospective cohort study.

Is quadriceps strength associated with patellofemoral joint loading after anterior cruciate ligament reconstruction?

OBJECTIVE

To test whether quadriceps strength is associated with measures of patellofemoral (PF) joint loading during running and hopping in people after an anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cross-sectional study.

SETTING

Biomechanics laboratory.

PARTICIPANTS

Sixty-five participants (24 women; 41 men) 1-2 years post-ACLR.

MAIN OUTCOME MEASURES

Peak isometric quadriceps strength for the surgical limb was measured using a dynamometer. Motion analysis and ground reaction force data were combined with musculoskeletal modelling to measure PF joint loading variables for the reconstructed knee (peak knee flexion angle; peak/impulse of the PF joint contact force; time to peak PF joint contact force) during the stance phase of running and during the landing phase of a standardised forward hop. Linear regression analysis (adjusting for age and sex) assessed the association between quadriceps strength and PF joint loading variables.

RESULTS

Two significant, albeit modest, associations were revealed. Quadriceps strength was associated with the time to peak PF joint contact force during running (β = -0.001; 95%CI -0.002 to -0.000; R2 = 0.179) and the impulse of the PF joint contact force during hopping (β = 0.014; 95%CI 0.003 to 0.024; R2 = 0.159).

CONCLUSIONS

A strong link between quadriceps strength and PF joint loading was not evident in people 1-2 years post-ACLR.

Gamification of Physical Therapy Exercises Using Commercial Entertainment Content: A Safety and Feasibility Study

Independent physiotherapy at home is a crucial element of rehabilitative care for a wide range of conditions as it constitutes a large portion of the overall therapy dose. However, up to 80% of individuals who are prescribed at-home physiotherapy do not consistently adhere to their treatment schedule, resulting in poor treatment outcomes. This is likely due to a lack of motivation and progress tracking in the current standard of care. We have developed a novel software prototype that allows users to control commercial entertainment content, such as video games or interactive music videos, with their movements during physiotherapy. By connecting therapy to proven entertainment content, we aim to improve on the current motivational deficits. This study investigated the safety and feasibility of this concept in a controlled environment over four physical therapy sessions with seven patients suffering from musculoskeletal and neurological conditions. As a secondary outcome, patients were asked about their enjoyment, perceived competence and effort using the Intrinsic Motivation Inventory (IMI) questionnaire. All participants were able to interact with the presented entertainment content and completed the study with no adverse events. Despite the diversity in pathology, age and training scenarios, the entertainment content maintained the patients' enjoyment with a high average rate of 6/7 on the IMI scale. Interacting with commercial entertainment content by doing physical therapy exercises was feasible, safe, and well-received over the six-week study period.

Hip rotation muscle strength is implicated in the progression of early post-traumatic osteoarthritis: A longitudinal evaluation up to 5 years following ACL reconstruction

INTRODUCTION

Following ACL reconstruction (ACLR), deficits in hip muscle strength and relationships to future outcomes are unknown.

METHODS

111 participants one year after ACLR, completed hip external rotation (ER) and internal rotation (IR) strength assessment. At 1 (n = 111) and 5 (n = 74) years post-ACLR, participants completed a battery of functional, symptomatic (Knee Osteoarthritis Outcome Score (KOOS)) and structural assessments (radiography, magnetic resonance imaging (MRI)). Cartilage health of the patellofemoral and tibiofemoral compartments was assessed with the semiquantitative MRI Osteoarthritis Knee Score. Hip rotation strength was compared between-limbs, and relationships between hip strength at 1 year and functional, symptomatic and cartilage outcomes at 1 and 5 years were investigated with regression models.

RESULTS

The index (ACLR) limb had weaker hip ER (but not IR) strength compared to the contralateral side (standardised mean difference ER = -0.33 (95%CI -0.60, -0.07; IR = -0.11 (95%CI -0.37, 0.15). Greater hip ER and IR strength was associated with superior function at 1 and 5 years, and better KOOS-Patellofemoral symptoms at 5 years. Greater hip ER strength was associated with lower odds of worsening tibiofemoral cartilage lesions at 5 years (odds ratio 0.01, 95%CI 0.00, 0.41).

CONCLUSION

Hip rotation strength may play a role in worsening function, symptoms and cartilage health after ACLR.

Does the one-leg rise test reflect quadriceps strength in individuals following anterior cruciate ligament reconstruction?

OBJECTIVE

To explore if one-leg rise test performance is associated with quadriceps strength following anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cross-sectional.

PARTICIPANTS

100 individuals (50 females, 50 males) aged 18-40 years, 9-36 months post-ACLR with ongoing knee symptoms (KOOS4 <80/100).

MAIN OUTCOME MEASURES

Number of one-leg rise repetitions (using an adjustable-height plinth) and isometric quadriceps strength using isokinetic dynamometry (60° flexion, normalised to body mass). Multivariable fractional polynomial regression models adjusted for sex explored relationships between one-leg rise performance (repetitions) and quadriceps strength (Nm/kg) for each limb.

RESULTS

A non-linear, increasing association between one-leg rise performance and quadriceps strength was observed, with the rate of increase attenuating at higher values of one-leg rise performance. Similar relationships were observed in the ACLR (β = 0.15, 95%CI 0.10 to 0.20; adjusted r2 = 0.51) and contralateral limb (β = 0.14, 95%CI 0.08 to 0.19; r2 = 0.42).

CONCLUSION

The one-leg rise test can be an indicator of quadriceps strength in individuals after ACLR, enabling clinicians to easily monitor quadriceps strength recovery without specialised equipment. With the relationship between one-leg rise performance and quadriceps strength attenuating with a larger number of one-leg rises achieved, other factors (e.g., motivation, endurance) likely contribute to one-leg rise performance at higher values.

Knee- and Overall Health-Related Quality of Life Following Anterior Cruciate Ligament Injury: A Cross-sectional Analysis of Australian and Canadian Cohorts

OBJECTIVE: To describe the knee- and overall health-related quality of life (QOL) 3 to 12 years after anterior cruciate ligament (ACL) tear, and to assess the association of clinical and structural features with QOL after ACL tear. DESIGN: Cross-sectional analysis of combined data from Australian (n = 76, 5.4 years postinjury) and Canadian (n = 50, 6.6 years postinjury) prospective cohort studies. METHODS: We conducted a secondary analysis of patient-reported outcomes and index knee magnetic resonance imaging (MRI) acquired in 126 patients (median 5.5 [range: 4-12] years postinjury), all treated with ACL reconstruction. Outcomes included knee (ACL Quality of Life questionnaire [ACL-QOL]) and overall health-related QOL (EQ-5D-3L). Explanatory variables were self-reported knee pain (Knee Injury and Osteoarthritis Outcome Score [KOOS-Pain subscale]) and function (KOOS-Sport subscale), and any knee cartilage lesion (MRI Osteoarthritis Knee Score). Generalized linear models were adjusted for clustering between sites. Covariates were age, sex, time since injury, injury type, subsequent knee injuries, and body mass index. RESULTS: The median [range] ACL-QOL score was 82 [24-100] and EQ-5D-3L was 1.0 [-0.2 to 1.0]. For every 10-point higher KOOS-Sport score, the ACL-QOL score increased by 3.7 points (95% confidence interval [CI]: 1.7, 5.7), whereas there was no evidence of an association with the EQ-5D-3L (0.00 points, 95% CI: -0.02, 0.02). There were no significant association between KOOS-Pain and ACL-QOL (4.9 points, 95% CI: -0.1, 9.9) or EQ-5D-3L (0.05 points, 95% CI: -0.01, 0.11), respectively. Cartilage lesions were not associated with ACL-QOL (-1.2, 95% CI: -5.1, 2.7) or EQ-5D-3L (0.01, 95% CI: -0.01, 0.04). CONCLUSION: Self-reported function was more relevant for knee-related QOL than knee pain or cartilage lesions after ACL tear. Self-reported function, pain, and knee structural changes were not associated with overall health-related QOL. J Orthop Sports Phys Ther 2023;53(7):1-12. Epub: 8 June 2023. doi:10.2519/jospt.2023.11838.

The Effects of Different Management Strategies or Rehabilitation Approaches on Knee Joint Structural and Molecular Biomarkers Following Traumatic Knee Injury: A Systematic Review of Randomized Controlled Trials for the OPTIKNEE Consensus

OBJECTIVE: To summarize the effectiveness of management strategies and rehabilitation approaches for knee joint structural and molecular biomarker outcomes following anterior cruciate ligament (ACL) and/or meniscal tear. DESIGN: Intervention systematic review. LITERATURE SEARCH: We searched the MEDLINE, Embase, CINAHL, CENTRAL, and SPORTDiscus databases from their inception up to November 3, 2021. STUDY SELECTION CRITERIA: We included randomized controlled trials (RCTs) investigating the effectiveness of management strategies or rehabilitation approaches for structural/molecular biomarkers of knee joint health following ACL and/or meniscal tear. DATA SYNTHESIS: We included 5 RCTs (9 papers) with primary ACL tear (n = 365). Two RCTs compared initial management strategies (rehabilitation plus early vs optional delayed ACL surgery), reporting on structural biomarkers (radiographic osteoarthritis, cartilage thickness, meniscal damage) in 5 papers and molecular biomarkers (inflammation, cartilage turnover) in 1 paper. Three RCTs compared different post-ACL reconstruction (ACLR) rehabilitation approaches (high vs low intensity plyometric exercises, accelerated vs nonaccelerated rehabilitation, continuous passive vs active motion), reporting on structural biomarkers (joint space narrowing) in 1 paper and molecular biomarkers (inflammation, cartilage turnover) in 2 papers. RESULTS: There were no differences in structural or molecular biomarkers between post-ACLR rehabilitation approaches. One RCT comparing initial management strategies demonstrated that rehabilitation plus early ACLR was associated with greater patellofemoral cartilage thinning, elevated inflammatory cytokine response, and reduced incidence of medial meniscal damage over 5 years compared to rehabilitation with no/delayed ACLR. CONCLUSION: Very low-certainty evidence suggests that different initial management strategies (rehabilitation plus early vs optional delayed ACL surgery) but not postoperative rehabilitation approaches may influence the incidence of meniscal damage, patellofemoral cartilage loss and cytokine concentrations over 5 years post-ACL tear. J Orthop Sports Phys Ther 2023;53(4):1-22. Epub: 20 February 2023. doi:10.2519/jospt.2023.11576.

Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes

OBJECTIVE

Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Seven databases were searched in December 2021.

ELIGIBILITY CRITERIA

Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury.

RESULTS

We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%-25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1-5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5-10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (<19 years) suggests female athletes/girls had 32% reduced odds of returning to sport compared with male athletes/boys (OR 0.68, 95% CI 0.41 to 1.13, I² 0.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from -0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI -0.05 to 0.02) to -0.31 (KOOS-sport and recreation, 7 studies, 95% CI -0.36 to -0.26).

CONCLUSIONS

Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls.

PROSPERO REGISTRATION NUMBER

CRD42021205998.

Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction

This guideline was developed to inform clinical practice on rehabilitation after anterior cruciate ligament reconstruction (ACLR) and was performed in accordance with the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A Guideline Development Group systematically searched and reviewed evidence using randomised clinical trials and systematic reviews to evaluate the effectiveness of rehabilitation interventions and guide clinicians and patients on the content of the optimal rehabilitation protocol after ACLR.The guideline targets patients during rehabilitation after ACLR and investigates the effectiveness of the available interventions to the physiotherapist, alone or in combination (eg, exercise, modalities, objective progression criteria). Exercise interventions should be considered the mainstay of ACLR rehabilitation. However, there is little evidence on the dose-response relationship between volume and/or intensity of exercise and outcomes. Physical therapy modalities can be helpful as an adjunct in the early phase of rehabilitation when pain, swelling and limitations in range of motion are present. Adding modalities in the early phase may allow earlier pain-free commencement of exercise rehabilitation. Return to running and return to training/activity are key milestones for rehabilitation after ACLR. However, there is no evidence on which progression or discharge criteria should be used.While there is a very low level of certainty for most components of rehabilitation, most of the recommendations provided in this guideline were agreed to by expert clinicians. This guideline also highlights several new elements of ACLR management not reported previously.

Unilateral tests of lower-limb function as prognostic indicators of future knee-related outcomes following anterior cruciate ligament injury: a systematic review and meta-analysis of 13 150 adolescents and adults

OBJECTIVE

To investigate the prognostic capacity of individual hop tests, hop test batteries and other unilateral functional performance tests following anterior cruciate ligament (ACL) injury.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Six databases searched up to June 2021.

ELIGIBILITY CRITERIA

Studies reporting associations between unilateral lower-limb function (eg, hop tests) following ACL injury and future (≥3 months) knee-related outcomes.

RESULTS

Of 42 included studies (13 150 participants), all assessed the single-forward hop test and 32 assessed a repeated-forward hop test (crossover hop, triple hop, 6m-timed hop), mostly within a year after ACL injury/reconstruction. Results of meta-analyses indicated that higher single-forward and repeated-forward hop limb symmetry were associated with higher odds of return-to-sport 1-3 years post-ACL reconstruction (OR 2.15; 95% CI 1.30 to 3.54; OR 2.11; 95% CI 1.23 to 3.60, respectively). Higher single-forward and repeated-forward hop limb symmetry was associated with better self-reported symptoms and function 1-37 years after ACL injury (OR 2.51; 95% CI 1.62 to 3.88; OR 4.28; 95% CI 1.65 to 11.08, respectively). Higher limb symmetry on a repeated-forward hop does not appear to be associated with higher odds of successful rehabilitation without ACL reconstruction (OR 1.51; 95% CI 0.94 to 2.44). Achieving ≥90% limb symmetry on the single-forward hop was associated with reduced odds of knee osteoarthritis 5-37 years after ACL injury (OR 0.46; 95% CI 0.23 to 0.94).

CONCLUSION

Very low certainty evidence suggests single-forward and repeated-forward hop tests are prognostic indicators for important knee-related outcomes in individuals after ACL injury and may help stratify individuals at risk of poor outcomes to target rehabilitation interventions.

PROSPERO REGISTRATION NUMBER

CRD42018092197.

SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) versus minimal intervention for young adults at risk of knee osteoarthritis after ACL reconstruction: SUPER-Knee randomised controlled trial protocol

INTRODUCTION

Anterior cruciate ligament injury and reconstruction (ACLR) is often associated with pain, functional loss, poor quality of life and accelerated knee osteoarthritis development. The effectiveness of interventions to enhance outcomes for those at high risk of early-onset osteoarthritis is unknown. This study will investigate if SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) is superior to a minimal intervention control for improving pain, function and quality of life in young adults with ongoing symptoms following ACLR.

METHODS AND ANALYSIS

The SUPER-Knee Study is a parallel-group, assessor-blinded, randomised controlled trial. Following baseline assessment, 184 participants aged 18-40 years and 9-36 months post-ACLR with ongoing symptoms will be randomly allocated to one of two treatment groups (1:1 ratio). Ongoing symptoms will be defined as a mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score (KOOS₄) subscales covering pain, symptoms, function in sports and recreational activities and knee-related quality of life. Participants randomised to SUPER will receive a 4-month individualised, physiotherapist-supervised strengthening and neuromuscular programme with education. Participants randomised to minimal intervention (ie, control group) will receive a printed best-practice guide for completing neuromuscular and strengthening exercises following ACLR. The primary outcome will be change in the KOOS₄ from baseline to 4 months with a secondary endpoint at 12 months. Secondary outcomes include change in individual KOOS subscale scores, patient-perceived improvement, health-related quality of life, kinesiophobia, physical activity, thigh muscle strength, knee function and knee cartilage morphology (ie, lesions, thickness) and composition (T2 mapping) on MRI. Blinded intention-to-treat analyses will be performed. Findings will also inform cost-effectiveness analyses.

ETHICS AND DISSEMINATION

This study is approved by the La Trobe University and Alfred Hospital Ethics Committees. Results will be presented in peer-reviewed journals and at international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12620001164987.

OPTIKNEE 2022: consensus recommendations to optimise knee health after traumatic knee injury to prevent osteoarthritis

The goal of the OPTIKNEE consensus is to improve knee and overall health, to prevent osteoarthritis (OA) after a traumatic knee injury. The consensus followed a seven-step hybrid process. Expert groups conducted 7 systematic reviews to synthesise the current evidence and inform recommendations on the burden of knee injuries; risk factors for post-traumatic knee OA; rehabilitation to prevent post-traumatic knee OA; and patient-reported outcomes, muscle function and functional performance tests to monitor people at risk of post-traumatic knee OA. Draft consensus definitions, and clinical and research recommendations were generated, iteratively refined, and discussed at 6, tri-weekly, 2-hour videoconferencing meetings. After each meeting, items were finalised before the expert group (n=36) rated the level of appropriateness for each using a 9-point Likert scale, and recorded dissenting viewpoints through an anonymous online survey. Seven definitions, and 8 clinical recommendations (who to target, what to target and when, rehabilitation approach and interventions, what outcomes to monitor and how) and 6 research recommendations (research priorities, study design considerations, what outcomes to monitor and how) were voted on. All definitions and recommendations were rated appropriate (median appropriateness scores of 7–9) except for two subcomponents of one clinical recommendation, which were rated uncertain (median appropriateness score of 4.5–5.5). Varying levels of evidence supported each recommendation. Clinicians, patients, researchers and other stakeholders may use the definitions and recommendations to advocate for, guide, develop, test and implement person-centred evidence-based rehabilitation programmes following traumatic knee injury, and facilitate data synthesis to reduce the burden of knee post-traumatic knee OA.

Editorial Commentary: Gait Symmetry After Anterior Cruciate Ligament Reconstruction Is Improved Using Functional Rehabilitation Braces That Resist Knee Motion

The effort of the rehabilitation journey to solve the several known functional and clinical problems after anterior cruciate ligament reconstruction should be directed toward implementing effective recovery strategies starting the day after surgery. Resistance training is a reliable approach to restore general knee function, but in the early postoperative stages, it may be difficult to apply proper loading strategies to obtain tangible improvements owing to surgery-related impairments. Accordingly, applying continuous light resistance during functional tasks such as gait may help to address this issue. As such, bracing models that provide resistance to knee motion have recently been developed and have been shown to help in restoring a proper walking pattern in terms of moment and range-of-motion symmetry. Therefore, the adoption of such bracing models may be regarded as a suitable option to consider to boost the achievement of rehabilitative milestones, therefore generally improving rehabilitation quality.