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Isaji Y, Uchino S, Inada R, Saito H. Effectiveness of psychological intervention following anterior cruciate ligament reconstruction: A systematic review and meta-analysis. Phys Ther Sport 2024; 69:40-50. [PMID: 39025000 DOI: 10.1016/j.ptsp.2024.07.003] [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: 05/01/2024] [Revised: 07/10/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE To determine the effectiveness of psychological interventions in postoperative anterior cruciate ligament reconstruction (ACLR) compared to standard rehabilitation. METHODS The databases searched were PubMed, MEDLINE, Cochrane Central Register of Controlled Trials, PEDro, Cumulative Index to Nursing & Allied Health Literature, and EMBASE were searched from each database inception to May 2023 for published studies. The methodological quality was assessed with the Cochrane Risk of Bias Assessment (RoB 2.0) tool. The evidence quality was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS Six papers were included in the meta-analysis. Psychological intervention significantly improved Tampa Scale for Kinesiophobia at 3 months (Standard Mean Difference [SMD], -0.51. 95% Confidence Interval [CI], -0.85 to -0.17) and pain (Knee Injury and Osteoarthritis Outcome Score for Pain, Numeric Rating Scale, Visual Analog Scale) at 3 months (SMD, -0.92. 95%CI, -1.69 to -0.15) and at 6 months following ACLR (MD, -1.25. 95%CI, -1.82 to -0.68) when compared with the standard rehabilitation, according to very low-quality data. Self-efficacy and knee strength did not show significant differences. CONCLUSION Very low-quality evidence suggests that psychological intervention following ACLR yields better short-term outcomes compared to standard rehabilitation, with uncertainty about its clinically significant benefits over standard rehabilitation.
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Affiliation(s)
- Yuichi Isaji
- Department of Physical Therapy, School of Health Sciences, Bukkyo University, Kyoto, Japan
| | - Shota Uchino
- REHASAKU Co., Ltd., Minato-ku, Tokyo, Japan; Center for Human Movement, Tokyo University of Technology, Tokyo, Japan
| | - Ryuta Inada
- Department of Rehabilitation, Shimada Hospital, Habikino, Japan
| | - Hiroki Saito
- Department of Physical Therapy, Tokyo University of Technology, Tokyo, Japan; Center for Human Movement, Tokyo University of Technology, Tokyo, Japan.
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Solie BS, Tollefson LV, Doney CP, O'Keefe JMJ, Thompson WC, LaPrade RF. Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations. Int J Sports Med 2024; 45:572-588. [PMID: 38527465 DOI: 10.1055/a-2270-3233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.
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Affiliation(s)
- Braidy S Solie
- Physical Therapy, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
- Research, Twin Cities Orthopedics, Edina, MN, United States
| | | | - Christopher P Doney
- Physical Therapy, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
| | - Jeremy M J O'Keefe
- Physical Therapy, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
| | - Will C Thompson
- Sports Science, Training HAUS, Twin Cities Orthopedics, Eagan, MN, United States
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Wang Y, Hinz M, Buchalter WH, Drumm AH, Eren E, Thomas Haytmanek C, Backus JD. Ankle ligament reconstruction-return to sport after injury scale and return to sports after ankle ligament reconstruction or repair-A systematic review. J Exp Orthop 2024; 11:e12077. [PMID: 38957230 PMCID: PMC11217671 DOI: 10.1002/jeo2.12077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 07/04/2024] Open
Abstract
Purpose To systematically review existing literature regarding the ankle ligament reconstruction-return to sport after injury (ALR-RSI) scale and to assess its correlation with Return to sport and functional outcomes as well as feasibility, reliability and consistency. Methods A systematic review of the literature based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) was conducted using PubMed, Embase and Cochrane Library. Studies that evaluated psychological readiness to return to sport after ankle ligament reconstruction or repair for the treatment of chronic lateral ankle instability using the ALR-RSI scale were included. The results from each study were pooled, and weighted means and overall rates were calculated. Results In total, 157 patients (53.2% male, mean age: 34.2 years) from three articles were included. Overall, 85.0% of patients reported successful return to sport, but only 48.9% of patients returned to the preoperative sporting level. All studies reported a significant difference in psychological scores between patients who returned to sport and those who did not. Pooled mean patient-reported outcome measures, reported as the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS, three studies) Score and Karlsson-Peterson Score (three studies), were 82.7 (range: 29-100) and 81.7 (range: 25-100), respectively. The ALR-RSI scale demonstrated strong correlations with the AOFAS Score and Karlsson-Peterson Score. Conclusion Patients who returned to sport after ankle ligament reconstruction or repair exhibited higher psychological readiness compared to those who did not. The ALR-RSI scale showed strong correlations with ankle function. Evaluation of psychological readiness using the ALR-RSI scale may provide an additional tool in the assessment of patients who underwent ankle ligament reconstruction or repair. Level of Evidence Level III, systematic review.
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Affiliation(s)
- YuChia Wang
- Steadman Philippon Research InstituteVailColoradoUSA
| | - Maximilian Hinz
- Steadman Philippon Research InstituteVailColoradoUSA
- Department of Sports OrthopaedicsTechnical University of MunichMunichGermany
| | | | | | | | - C. Thomas Haytmanek
- Steadman Philippon Research InstituteVailColoradoUSA
- The Steadman ClinicVailColoradoUSA
| | - Jonathon D. Backus
- Steadman Philippon Research InstituteVailColoradoUSA
- The Steadman ClinicVailColoradoUSA
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Knapik DM, Kamitani A, Smith MV, Motley J, Haas AK, Matava MJ, Wright RW, Brophy RH. Relationship between Kinesiophobia and Dynamic Postural Stability after Anterior Cruciate Ligament Reconstruction: A Prospective Cohort Study. J Knee Surg 2024. [PMID: 38677296 DOI: 10.1055/a-2315-8034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Anterior cruciate ligament (ACL) injuries in young, active patients generally require ACL reconstruction (ACLR) to restore mechanical and postural stability. The fear of movement or reinjury (kinesiophobia) has become increasingly recognized in the post-ACLR population; however, the association between restoration of postural stability and kinesiophobia remains largely unknown. The purpose of this study was to investigate changes in mean Tampa Scale of Kinesiophobia-11 (TSK-11), dynamic motion analysis (DMA) scores, and time on the testing platform, as well as any correlation between TSK-11 and mean overall and individual translational and rotational DMA scores during the first 12 months following ACLR. DESIGN Cohort study. METHODS Patients undergoing ACLR were prospectively enrolled and dynamic postural stability and kinesiophobia based on the TSK-11 were collected within 2 days prior to surgery and at 6 and 12 months following ACLR. Dynamic postural stability was quantified by calculating a DMA score, with score calculated in three translational (anterior/posterior [AP], up/down [UD], medial/lateral [ML]) and three rotational (left/right [LR], flexion/extension, and internal/external rotation) independent planes of motions. Correlations between DMA and TSK-11 scores at each time point were analyzed. RESULTS A total of 25 patients meeting inclusion criteria were analyzed. Mean overall DMA and TSK-11 scores increased with each successive testing interval. At 6-month follow-up, a weakly positive association between TSK-11 and DMA scores was appreciated based on overall DMA, AP, UD, ML, and LR. At 12 months, a moderately positive correlation was appreciated between TSK-11 and the translational, but not rotational, planes of motion. CONCLUSIONS Following ACLR, lower level of kinesiophobia were found to be moderately associated with improved dynamic stability, especially in the translation planes of motion.
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Affiliation(s)
- Derrick M Knapik
- Division of Sports Medicine, Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Aguri Kamitani
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Matthew V Smith
- Division of Sports Medicine, Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - John Motley
- STAR Sports Therapy and Rehabilitation, Chesterfield, Missouri
| | - Amanda K Haas
- Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Matthew J Matava
- Division of Sports Medicine, Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | - Rick W Wright
- Department of Orthopaedic Surgery, Vanderbilt University, Nashville, Tennessee
| | - Robert H Brophy
- Division of Sports Medicine, Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- Washington University in St. Louis, School of Medicine, St. Louis, Missouri
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Lee JH, Lee GB, Chung W, Han SB, Jang KM. Addition of anterolateral ligament reconstruction to primary anterior cruciate ligament reconstruction could benefit recovery of functional outcomes. Sci Rep 2024; 14:11440. [PMID: 38769088 PMCID: PMC11106076 DOI: 10.1038/s41598-024-62444-x] [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: 01/08/2024] [Accepted: 05/16/2024] [Indexed: 05/22/2024] Open
Abstract
This study aimed to compare functional outcomes sequentially up to 1 year after combined anterior cruciate ligament reconstruction (ACLR) and anterolateral ligament reconstruction (ALLR) and isolated ACLR. Fifty patients who underwent ACLR with versus without ALLR were analyzed at four different time points (preoperatively and 3, 6, and 12 months postoperatively). For the functional outcomes, muscle strength and acceleration time (AT) were measured using an isokinetic dynamometer. Proprioception was evaluated using joint position sense and dynamic postural stability. Patient-reported outcomes were measured using the Tampa Scale for Kinesiophobia (TSK-11) scores. Functional performance was assessed using single-leg hop distance (SLHD) and Limb Symmetry Index. In the operated knees, quadriceps (at 6 months postoperatively, p = 0.003) and hamstring (at 6 and 12 months postoperatively, p < 0.001) strength were significantly higher in the combined ACLR and ALLR group than the isolated ACLR group. The TSK-11 (at 6 and 12 months postoperatively, p < 0.001) was significantly lower in the combined ACLR and ALLR group than the isolated ACLR group. SLHD was significantly higher in the combined ACLR and ALLR group than the isolated ACLR group (at 6 months, p = 0.022 and at 12 months, p = 0.024). The addition of ALLR to primary ACLR yielded better muscle performance, fear of movement, and functional performance than isolated ACLR.
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Affiliation(s)
- Jin Hyuck Lee
- Department of Sports Medical Center, Anam Hospital, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Gyu Bin Lee
- Department of Sports Medical Center, Anam Hospital, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - WooYong Chung
- Department of Sports Medical Center, Anam Hospital, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Seung-Beom Han
- Department of Orthopedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul, 02841, Republic of Korea
| | - Ki-Mo Jang
- Department of Sports Medical Center, Anam Hospital, Korea University College of Medicine, Seoul, 02841, Republic of Korea.
- Department of Orthopedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul, 02841, Republic of Korea.
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Manojlovic M, Ninkovic S, Matic R, Versic S, Modric T, Sekulic D, Drid P. Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review of Recent Evidence. Sports Med 2024:10.1007/s40279-024-02035-y. [PMID: 38710914 DOI: 10.1007/s40279-024-02035-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND The available literature referring to the return to play (RTP) and performance after anterior cruciate ligament reconstruction (ACLR) has already been comprehensively summarized in team sports such as basketball or American Football. Therefore, in this sense, it is necessary to synthesize evidence relating to the mentioned parameters in soccer players who underwent ACLR. OBJECTIVE The aim of this systematic review was to examine RTP and the performance of soccer players after ACLR. METHODS Three electronic databases, Web of Science, Scopus, and PubMed, have been comprehensively searched to identify relevant articles. The following inclusion criteria were applied: (1) the sample of respondents consisted of soccer players irrespective of their age, sex, or level of competition; (2) athletes experienced anterior cruciate ligament injury and underwent ACLR; (3) outcomes estimated referred to the RTP, RTP at the preinjury level of competition, RTP time, performance, and career duration of soccer players; (4) studies were written in the English language. The methodological quality of the research was evaluated using the Methodological Index for Non-Randomized Studies (MINORS). RESULTS Databases searched yielded a total of 694 studies, of which 17 fulfilled the eligibility criteria and were included in the final analysis. These included 3657 soccer players, 2845 males and 812 females, who underwent ACLR and most commonly competed at the elite, national, amateur, and recreational levels. The results obtained indicated that 72% of soccer players successfully RTP and 53% RTP at the preinjury level of participation after ACLR. In addition, recent evidence provided in this literature review demonstrated that mean RTP time was 264 days or 8.7 months. Moreover, the majority of the studies unambiguously suggested that performance related to statistical aspects noticeably deteriorated compared with both the preinjury period and noninjured athletes. The mean career length of soccer players following ACL surgery was approximately between 4 and 5 years. CONCLUSION Although a high percentage of athletes RTP after a relatively short period of absence from the sports field compared with other sports closely related to soccer, ACLR negatively impacts soccer players' performance and career duration.
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Affiliation(s)
- Marko Manojlovic
- Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia.
| | - Srdjan Ninkovic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
- Department of Orthopedic Surgery and Traumatology, Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Radenko Matic
- Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
| | - Sime Versic
- Faculty of Kinesiology, University of Split, Split, Croatia
| | - Toni Modric
- Faculty of Kinesiology, University of Split, Split, Croatia
| | - Damir Sekulic
- Faculty of Kinesiology, University of Split, Split, Croatia
| | - Patrik Drid
- Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
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Chen MW, Wang LX. Letter to the Editor: "Prospective study of functional outcomes and return to sports after anterior cruciate ligament reconstruction in the knee". INTERNATIONAL ORTHOPAEDICS 2024; 48:1365-1366. [PMID: 38462588 DOI: 10.1007/s00264-024-06138-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Mao-Wei Chen
- The Second Affiliated Hospital of Zhejiang Chinese Medical University, Xinhua Hospital of Zhejiang Province, Chaowang Road 318#, Hangzhou, 310005, Zhejiang, China
| | - Li-Xuan Wang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Shangtang Road 158#, Hangzhou, 310014, Zhejiang, China.
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Petushek EJ, Diekfuss JA, Lamplot JD, Mørtvedt AI, Hoey LC, Heo K, Petit CB, Barber Foss KD, Warren SM, Slutsky-Ganesh AB, Kenyon CD, McPherson AL, Biller ME, Newsome M, Jennings B, Xerogeanes JW, Myer GD. Usefulness of Current Patient-Reported Outcome Scales for ACL Injury: A Mixed-Methods Evaluation of Stakeholder-Perceived Utility of Specific Constructs and Items Across the Rehabilitation Timeline. Orthop J Sports Med 2024; 12:23259671231218964. [PMID: 38784528 PMCID: PMC11113051 DOI: 10.1177/23259671231218964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/29/2023] [Indexed: 05/25/2024] Open
Abstract
Background Numerous patient-reported outcome measures (PROMs) have been used in patients with anterior cruciate ligament reconstruction (ACLR), often with overlapping constructs of interest and limited content validity. Inefficient scale application increases burden and diminishes overall usefulness for both the patient and practitioner. Purpose To isolate specific PROM items across a diverse set of constructs that patients and practitioners perceive as having the greatest value at various stages of recovery and return to sport (RTS) in patients after ACLR. Study Design Cross-sectional study. Methods A combined 77 stakeholders participated in this 2-phase mixed-methods investigation. In phase 1, a total of 27 patients and 21 practitioners selected individual PROM items from various constructs that had the greatest utility or importance. In phase 2, the highest rated items were further tested in a head-to-head comparison with 29 stakeholders who attended the 2022 ACL Injury Research Retreat. In addition to the utility assessment, practitioners answered other questions related to importance and timing of PROM assessments. Results In phase 1, both patients and practitioners shared the same top item in 6 of the 8 (75%) constructs assessed. In phase 2, the construct of psychological burden was rated as "extremely important" by 59% of respondents, followed by physical function (54%), symptoms (35%), and donor site issues (10%). The PROM items of confidence, perceived likelihood of reinjury, and difficulty stopping quickly were rated by a respective 93%, 89%, and 86% of the sample as either "very useful" or "extremely useful." All constructs except donor site issues were rated by most stakeholders to be absolutely necessary to evaluate treatment progress and RTS readiness at the 6-month postoperative time and at RTS. Conclusion Overall, psychological burden, with specific items related to confidence and reinjury likelihood, were rated as most important and useful by both patients and practitioners. The second most important and useful PROM item was related to higher intensity function (eg, decelerating or jumping/landing activities during sports).
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Affiliation(s)
- Erich J. Petushek
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Jed A. Diekfuss
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Joseph D. Lamplot
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Anne-Inger Mørtvedt
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Lauren C. Hoey
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Kevin Heo
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Camryn B. Petit
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Kim D. Barber Foss
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Shayla M. Warren
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | | | - Charles D. Kenyon
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - April L. McPherson
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Michael E. Biller
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Michael Newsome
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Brian Jennings
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - John W. Xerogeanes
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
| | - Gregory D. Myer
- Investigation performed at Michigan Technological University, Houghton, Michigan, USA
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Sabate-Ferris A, de l'Escalopier N, Barbier O, Danis J, Demoures T, Joly B, van Rooij F, Saffarini M, Choufani C. Return to military duty following anterior cruciate ligament reconstruction is associated with preoperative Body Mass Index and postoperative physiotherapy. INTERNATIONAL ORTHOPAEDICS 2024; 48:675-681. [PMID: 37725152 DOI: 10.1007/s00264-023-05964-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE To determine the rate and time of return to duty following anterior cruciate ligament reconstruction (ACLR) in military members, and to determine whether their outcomes are influenced by patient characteristics or surgical parameters. METHODS We prospectively assessed 280 military members that underwent ACLR. 27 were excluded due to multi-ligamentous injuries or revision surgery, two did not provide informed consent and 62 were lost to follow-up. Patient demographics, pre-injury physical workload, complications and whether/when patients resumed duty and sports were noted, as well as clinical outcomes at a minimum follow-up of one year, including Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC), Lysholm, and Tegner scale. RESULTS The final cohort of 189 military members (82% men) had mean age of 25.5 ± 3.4 (range,19-38) at ACLR. At 3.3 ± 1.6 years (range, 1.0-6.3), the Tegner score was 6.1 ± 2.0, Lysholm was 87.0 ± 13.7, IKDC was 80.1 ± 15.7, and KOOS was 81.1 ± 14.8. Only 144 patients (76%) resumed duty, at 9.5 ± 5.3 months (range,1-28), and 141 patients (75%) resumed sport, at 10.2 ± 6.2 months (range,1-35). Multivariable analysis revealed that return to duty was less likely in patients with higher BMI (OR,0.89;p = 0.025), but more likely in patients that followed military physiotherapy (OR,2.76;p = 0.017) and with higher pre-injury physical workload (OR,3.93;p = 0.010). CONCLUSION At a follow-up of 3.3 ± 1.6 years, 76% returned to duty at 9.5 ± 5.3 months, and 75% returned to their main sport at 10.2 ± 6.2 months. Patients with higher BMI are significantly less likely to resume military duty and sports; those that followed military physiotherapy were most likely to resume duty, while those that had greater pre-injury physical workload were more likely to both resume duty and sport.
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Affiliation(s)
- Alexandre Sabate-Ferris
- Clinic of Orthopedic, Traumatology and Reconstructive Surgery, Percy Military Teaching Hospital, Clamart, France
| | - Nicolas de l'Escalopier
- Clinic of Orthopedic, Traumatology and Reconstructive Surgery, Percy Military Teaching Hospital, Clamart, France
| | - Olivier Barbier
- Department of Surgery, Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
- Orthopaedic Surgery and Traumatology Department, Saint-Anne Military Teaching Hospital, Toulon, France
| | - Julien Danis
- Clinic of Orthopedic, Traumatology and Reconstructive Surgery, Percy Military Teaching Hospital, Clamart, France
| | - Thomas Demoures
- Orthopaedic Surgery Department, Begin Military Teaching Hospital, Saint-Mandé, France
| | - Benjamin Joly
- Clinic of Orthopedic, Traumatology and Reconstructive Surgery, Percy Military Teaching Hospital, Clamart, France
| | | | - Mo Saffarini
- ReSurg SA, Rue Saint-Jean 22, 1260, Nyon, Switzerland
| | - Camille Choufani
- Orthopaedic Surgery and Traumatology Department, Saint-Anne Military Teaching Hospital, Toulon, France
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Ebert JR, Calvert ND, Radic R. A Prospective Randomized Controlled Trial Investigating Quadriceps Versus Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2024; 52:660-669. [PMID: 38284303 PMCID: PMC10905979 DOI: 10.1177/03635465231222279] [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: 07/15/2023] [Accepted: 11/06/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Numerous graft options are available when undertaking anterior cruciate ligament (ACL) reconstruction (ACLR), although a lack of high-quality evidence exists comparing quadriceps (QT) and hamstring (HT) autografts. PURPOSE To investigate patient outcomes in patients undergoing HT versus QT ACLR. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS After recruitment and randomization, 112 patients (HT = 55; QT = 57) underwent ACLR. Patients were assessed pre- and postoperatively (6 weeks and 3, 6, 12, and 24 months), with a range of patient-reported outcome measures (PROMs), graft laxity (KT-1000 arthrometer; primary outcome variable), active knee flexion and extension range of motion (ROM), peak isokinetic knee extensor and flexor strength, and a 6-hop performance battery. Limb symmetry indices (LSIs) were calculated for strength and hop measures. Secondary procedures, ACL retears, and contralateral ACL tears were reported. RESULTS All PROMs and knee ROM measures significantly improved (P < .0001), and no other group differences (P > .05) were observed-apart from the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) score, which was significantly better in the HT group at 3 (P = .008), 6 (P = .010), and 12 (P = .014) months. No significant changes were observed in side-to-side laxity from 6 to 24 months (P = .105), and no group differences were observed (P = .487) at 6 (HT mean, 1.2; QT mean, 1.3), 12 (HT mean, 1.1; QT mean, 1.3), and 24 (HT mean, 1.1; QT mean, 1.2) months. While the HT group demonstrated significantly greater (P < .05) quadriceps strength LSIs at 6 and 12 months, the QT group showed significantly greater (P < .05) hamstring strength LSIs at 6, 12, and 24 months. The HT group showed significantly greater (P < .05) LSIs for the single horizontal (6 months), lateral (6 and 12 months), and medial (6 months) hop tests for distance. Up until 24 months, 1 patient (QT at 22 months) had a retear, with 2 contralateral ACL tears (QT at 19 months; HT at 23 months). Secondary procedures included 5 in the HT group (manipulation under anesthesia, notch debridement, meniscal repair, and knee arthroscopy for scar tissue) and 6 in the QT group (notch debridement, meniscal repair, knee arthroscopy for scar tissue, tibial tubercle transfer, and osteochondral autologous transplantation). CONCLUSION Apart from the ACL-RSI, the 2 autograft groups compared well for PROMs, knee ROM, and laxity. However, greater hamstring strength LSIs were observed for the QT cohort, with greater quadriceps strength (and hop test) LSIs in the HT cohort. The longer-term review will continue to evaluate return to sports and later-stage reinjury between the 2 graft constructs. REGISTRATION ACTRN12618001520224p (Australian New Zealand Clinical Trials Registry).
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Affiliation(s)
- Jay R. Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Western Australia, Australia
- HFRC Rehabilitation Clinic, Perth, Western Australia, Australia
- Perth Orthopaedic & Sports Medicine Research Institute, Perth, Western Australia, Australia
| | - Nicholas D. Calvert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, Western Australia, Australia
- Perth Orthopaedic & Sports Medicine Research Institute, Perth, Western Australia, Australia
- Department of Orthopaedics, Royal Perth Hospital, Perth, Western Australia, Australia
- Perth Orthopaedic & Sports Medicine Centre, Perth, Western Australia, Australia
| | - Ross Radic
- Perth Orthopaedic & Sports Medicine Research Institute, Perth, Western Australia, Australia
- Department of Orthopaedics, Royal Perth Hospital, Perth, Western Australia, Australia
- Perth Orthopaedic & Sports Medicine Centre, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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11
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Momaya AM, Wood AS, Benson EM, Kwapisz AL. The Influence of Psychosocial Factors on Patients Undergoing Anterior Cruciate Ligament Reconstruction. Sports Health 2024; 16:230-238. [PMID: 38297441 PMCID: PMC10916773 DOI: 10.1177/19417381231223560] [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] [Indexed: 02/02/2024] Open
Abstract
CONTEXT Anterior cruciate ligament (ACL) injuries greatly impact patients in terms of future performance, reduced physical activity and athletic participation, and overall economic burden. Decades of research have investigated how to improve ACL reconstruction (ACLR) outcomes. Recently, there has been growing interest to understand the effects of psychosocial factors on patient outcomes. STUDY DESIGN Clinical review. EVIDENCE ACQUISITION A search of the PubMed database was performed in March 2023. Articles were reviewed by at least 2 authors to determine relevance. We highlighted publications of the past 5 years while incorporating previous pertinent studies. LEVEL OF EVIDENCE Level 5. RESULTS There is no standardization of psychosocial factors regarding ACLR. As such, there is a lack of consensus regarding which psychosocial measures to use and when. There is a need for clarification of the complex relationship between psychosocial factors and physical function. Despite this, psychosocial factors have the potential to help predict patients who are more likely to return to sport: (1) desire/motivation to return; (2) lower levels of kinesiophobia; (3) higher levels of self-efficacy, confidence, and subjective knee function; (4) risk acceptance; and (5) social support. However, there are no standardized interventions to improve psychosocial factors after ACLR. CONCLUSION Psychosocial factors affect outcomes after ACLR. However, the interplay between psychosocial factors and physical function is complex. There is emerging evidence that testing and interventions may improve ACLR outcomes. There is a lack of standardized interventions to determine or improve psychosocial factors after ACLR. Further research is needed to identify psychosocial factors and to develop standardized interventions for clinicians to implement to improve clinical outcomes.
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Affiliation(s)
- Amit M Momaya
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Audria S Wood
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth M Benson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Adam L Kwapisz
- Clinic of Orthopedics and Pediatric Orthopedics, Medical University of Lodz, Lodz, Poland
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Velasquez Garcia A, Iida N, Kuroiwa T, Hsu KL, de Marinis R, Abdo G, Ekdahl M. Substantial influence of psychological factors on return to sports after anterior shoulder instability surgery: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:5913-5923. [PMID: 37991534 DOI: 10.1007/s00167-023-07652-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE This systematic review and meta-analysis aimed to (1) determine the proportion of patients who underwent anterior shoulder instability surgery and did not return to sports for psychological reasons and (2) estimate differences in psychological readiness scores between patients who did and did not return to sports. METHODS The EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE and Cochrane Library databases were searched for relevant studies. The data synthesis included the proportion of patients who did not return to sports for psychological reasons and the mean differences in the psychological readiness of athletes who returned and those who did not return to sports. Non-binomial data were analysed using the inverse-variance approach and expressed as the mean difference with 95% confidence intervals. RESULTS The search yielded 700 records, of which 13 (1093 patients) were included. Fourteen psychological factors were identified as potential causes for not returning to sports. The rates of return to sports at any level or to the preinjury level were 79.3% and 61.9%, respectively. A total of 55.9% of the patients cited psychological factors as the primary reason for not returning to sports. The pooled estimate showed that patients who returned to sports had a significantly higher Shoulder Instability-Return to Sport After Injury score (P < 0.00001) than those who did not, with a mean difference of 30.24 (95% CI 24.95-35.53; I2 = 0%; n.s.). CONCLUSIONS Psychological factors have a substantial impact on the rate of return to sports after anterior shoulder instability surgery. Patients who returned to sports had significantly higher psychological readiness than those who did not return to sports. Based on these results, healthcare professionals should include psychological and functional measurements when assessing athletes' readiness to return to sports. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ausberto Velasquez Garcia
- Department of Orthopedic Surgery, Clinica Universidad de los Andes, Av. Plaza 2501, Las Condes, 7620157, Santiago, Chile.
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Naoya Iida
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tomoyuki Kuroiwa
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kai-Lan Hsu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rodrigo de Marinis
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
- Shoulder and Elbow Unit, Hospital Dr. Sótero del Rio, Santiago, Chile
| | - Glen Abdo
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Graduate Medical Education, Internal Medicine Residence Program, St Mary's General Hospital, Passaic, NJ, USA
- Department of Basic Sciences, Touro College of Osteopathic Medicine, New York, NY, USA
| | - Max Ekdahl
- Department of Orthopedic Surgery, Clinica Universidad de los Andes, Av. Plaza 2501, Las Condes, 7620157, Santiago, Chile
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Stigert M, Ashnai F, Thomeé R, Hamrin Senorski E, Beischer S. Physical inactivity 5-8 years after anterior cruciate ligament reconstruction is associated with knee-related self-efficacy and psychological readiness to return to sport. BMJ Open Sport Exerc Med 2023; 9:e001687. [PMID: 38022759 PMCID: PMC10649614 DOI: 10.1136/bmjsem-2023-001687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives To investigate whether patient demographics and patient-reported outcomes (PROs), respectively, are associated with physical inactivity (PI) 5-8 years after primary anterior cruciate ligament reconstruction (ACLR). Methods This case control observational study included individuals who had undergone primary ACLR between the ages of 15 and 65 years and had responded to PROs 18 months postoperatively. These individuals were asked to answer a questionnaire regarding their present level of physical activity (PA) at 5-8 years after ACLR. Patient-demographic data and results from the Knee injury and Osteoarthritis Outcome Score, the Knee Self-Efficacy Scale and the ACL Return to Sport (RTS) after Injury scale from 18 months after ACLR were extracted from a rehabilitation-specific register. Univariable logistic regression analyses were performed with PI (<150 min PA per week/≥150 min PA/week) as the dependent variable. Results Of 292 eligible participants, 173 (47% women; mean±SD age = 31±11 years) responded to the PA questionnaire. In all, 14% (n=25; 28% women) were classified as physically inactive. Participants with lower levels of present and future self-efficacy, OR 1.35 (CI 1.05 to 1.72) and OR 1.20 (CI 1.12 to 1.45), and lower levels of psychological readiness to RTS, OR 1.19 (CI 1 to 1.43), at the 18-month follow-up, had higher odds of being physically inactive 5-8 years after ACLR. None of the patient demographic variables was able to predict PI. Conclusion Lower levels of knee-related self-efficacy and psychological readiness to RTS, 18 months after ACLR, were associated with PI 5-8 years after surgery.
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Affiliation(s)
- Maja Stigert
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sportrehab Sports Medicine Clinic, Gothenburg, Sweden
| | - Farshad Ashnai
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sportrehab Sports Medicine Clinic, Gothenburg, Sweden
| | - Roland Thomeé
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sportrehab Sports Medicine Clinic, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sportrehab Sports Medicine Clinic, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Susanne Beischer
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sportrehab Sports Medicine Clinic, Gothenburg, Sweden
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Suzuki M, Ishida T, Matsumoto H, Kaneko S, Inoue C, Aoki Y, Tohyama H, Samukawa M. Association of Psychological Readiness to Return to Sports With Subjective Level of Return at 12 Months After ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671231195030. [PMID: 37693806 PMCID: PMC10492488 DOI: 10.1177/23259671231195030] [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: 03/30/2023] [Accepted: 05/03/2023] [Indexed: 09/12/2023] Open
Abstract
Background Return-to-sports (RTS) rates after anterior cruciate ligament (ACL) reconstruction (ACLR) differ according to the level at which patients return. It is unclear whether the level of RTS is affected by psychological readiness to return. Purpose To examine the association between psychological readiness to RTS and subjective RTS level 12 months after ACLR. Study Design Case-control study; Level of evidence, 3. Methods A total of 47 patients who underwent unilateral primary ACLR surgery were enrolled. Assessments at 6 and 12 months postoperatively consisted of knee strength testing (isokinetic quadriceps and hamstring strength), the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF), and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale to measure psychological readiness to RTS. Patients were assigned to 1 of 3 subgroups based on their subjective assessment of RTS level at 12 months postoperatively: RTS at or above preinjury level (RTS≥Pre; n = 19), RTS below preinjury level (RTS Results Significant differences were found among the RTS≥Pre, RTS Conclusion The ACL-RSI score was significantly different among the study groups, and the ACL-RSI score at 12 months postoperatively and younger age were associated with RTS at or above preinjury level.
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Affiliation(s)
- Makoto Suzuki
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Tomoya Ishida
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Hisashi Matsumoto
- Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Satoru Kaneko
- Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Chiharu Inoue
- Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Yoshimitsu Aoki
- Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | | | - Mina Samukawa
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
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Heath MR. Editorial Commentary: Supporting Patients Psychologically and Reducing Kinesiophobia May Improve Anterior Cruciate Ligament Reconstruction Outcomes. Arthroscopy 2023; 39:2056-2057. [PMID: 37543389 DOI: 10.1016/j.arthro.2023.03.017] [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: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 08/07/2023]
Abstract
Athletes face an uphill battle after an anterior cruciate ligament tear if they want to return to their sport. Almost one-third of patients never return to their preinjury level of sport involvement, and many athletes dread this outcome. Although this distress is an understandable reaction, it can be demotivating, and psychological engagement in the recovery process is crucial to achieving desired outcomes. In particular, psychological readiness to return to sport is associated with greater likelihood of returning to sport. However, other psychological factors, including kinesiophobia, can negatively impact readiness to return to sport preoperatively and postoperatively. Supporting patients psychologically and reducing kinesiophobia throughout the recovery process may be essential to improving outcomes after an anterior cruciate ligament tear.
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Mir B, Vivekanantha P, Dhillon S, Cotnareanu O, Cohen D, Nagai K, de Sa D. Fear of reinjury following primary anterior cruciate ligament reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 31:2299-2314. [PMID: 36562808 DOI: 10.1007/s00167-022-07296-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE This review aims to elucidate the most commonly reported method to quantify fear of reinjury or kinesiophobia and to identify key variables that influence the degree of kinesiophobia following primary anterior cruciate ligament reconstruction (ACLR). METHODS A systematic search across three databases (Pubmed, Ovid (MEDLINE), and EMBASE) was conducted from database inception to August 7th, 2022. The authors adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Quality assessment of the included studies was conducted according to the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS Twenty-six studies satisfied the inclusion criteria and resulted in 2,213 total patients with a mean age of 27.6 years and a mean follow-up time of 36.7 months post-surgery. The mean MINORS score of the included studies was 11 out of 16 for non-comparative studies and 18 out of 24 for comparative studies. Eighty-eight percent of included studies used variations of the Tampa Scale of Kinesiophobia (TSK) to quantify kinesiophobia and 27.0% used Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI). The results of this study shows a common association between higher kinesiophobia and poor patient-reported functional status measured using International Knee Documentation Committee (IKDC) Scores, Activity of Daily Living (ADL), Quality of Life (QOL), and Sports/Recreation (S/R) subscales of Knee Osteoarthritis and Outcome Score (KOOS) and Lysholm scores. Postoperative symptoms and pain catastrophizing measured using the KOOS pain and symptom subscales and Pain Catastrophizing Score (PCS) also influenced the degree of kinesiophobia following ACLR. Patients with an increased injury to surgery time and being closer to the date of surgery postoperatively demonstrated higher levels of kinesiophobia. Less common variables included being a female patient, low preoperative and postoperative activity status and low self-efficacy. CONCLUSION The most common methods used to report kinesiophobia following primary ACLR were variations of the TSK scale followed by ACL-RSI. The most commonly reported factors influencing higher kinesiophobia in this patient population include lower patient-reported functional status, more severe postoperative symptoms such as pain, increased injury to surgery time, and being closer to the date of surgery postoperatively. Kinesiophobia following primary ACLR is a critical element affecting post-surgical outcomes, and screening should be implemented postoperatively to potentially treat in rehabilitation and recovery. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Basit Mir
- Ashford and St. Peter's Hospitals NHS Foundation Trust, Chertsey, Surrey, UK
| | | | | | - Odette Cotnareanu
- Faculty of Arts and Science, Queen's University, Kingston, ON, Canada
| | - Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main Street West, 4E14, Hamilton, ON, L8N 3Z5, Canada
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main Street West, 4E14, Hamilton, ON, L8N 3Z5, Canada.
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