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Wenning M, Sofack GN, Zöller D, Mauch M, Heitner AH, Paul J, Zahn P, Ritzmann R. Predicting the Recovery of Isokinetic Knee Strength 6 Months After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2024; 12:23259671241264845. [PMID: 39247527 PMCID: PMC11375688 DOI: 10.1177/23259671241264845] [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: 12/13/2023] [Accepted: 02/02/2024] [Indexed: 09/10/2024] Open
Abstract
Background The limb symmetry index (LSI) is a metric of strength restoration. It is key to successfully return to sports after anterior cruciate ligament (ACL) reconstruction. The threshold for return to sports is generally considered an LSI of ≥85%. Purpose To develop a statistical model for predicting the recovery of knee extension and flexion strength (with LSI ≥85%) at 6 months after ACL reconstruction. Study Design Case-control study; Level of evidence: 3. Methods Patients who underwent arthroscopic ACL reconstruction between November 2015 and December 2020 were included. The patients were classified into 2 groups: "pass" if the LSI at 6 months postoperatively was ≥85% and "fail" if the LSI was <85%. Factors in 25 categories with 74 levels, including patient characteristics, periarticular procedures, intra-articular lesions and treatment, and perioperative management, were collected. A multivariable logistic regression combined with backward variable elimination was used to determine the predictive parameters for recovery of knee extension and flexion strength. Results A total of 948 patients were included. Graft site, preoperative isokinetic strength, treatment of meniscal injury, and injured side (left vs right) were identified as general predictors for both knee extension and flexion strength. For knee extension strength, age at injury and partial weightbearing duration were identified as additional predictors. For knee flexion strength, type of meniscal injury, surgeon volume, cartilage procedures, and periarticular procedures were identified as additional predictors. The Nagelkerke R 2 of the final model was 0.178, and the c-statistic was 0.716 (95% CI, 0.676-0.754). The Hosmer-Lemeshow test indicated good calibration (P = .879). Conclusion Several factors including preoperative isokinetic strength, treatment of meniscal injuries, left vs. right side and graft site were found to predict recovery of ≥85% LSI in knee extension and flexion strength. Despite the numerous factors that were analyzed, the predictive power was moderate (c-statistic = 0.716), indicating there were other nonincluded factors that significantly influence strength performance at 6 months postoperatively.
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Affiliation(s)
- Markus Wenning
- Department of Orthopaedic and Trauma Surgery, University Medical Center, Faculty of Medicine, University of Freiburg, Germany
- Orthopaedic Surgery, BDH Klinik Waldkirch, Waldkirch, Germany
| | - Ghislain N Sofack
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Germany
| | - Daniela Zöller
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Germany
| | - Marlene Mauch
- Praxisklinik Rennbahn, Basel, Switzerland
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | | | | | - Peter Zahn
- Department of Orthopaedic and Trauma Surgery, University Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Ramona Ritzmann
- Praxisklinik Rennbahn, Basel, Switzerland
- Department of Sport and Sport Science, University of Freiburg, Germany
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Raj S, Ridha A, Searle HKC, Khatri C, Ahmed I, Metcalfe A, Smith N. Quadriceps tendon versus hamstring tendon graft for primary anterior cruciate ligament reconstruction: A systematic review and meta-analysis of randomised trials. Knee 2024; 49:226-240. [PMID: 39043018 DOI: 10.1016/j.knee.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/13/2024] [Accepted: 07/02/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) is most commonly performed with hamstring tendon (HT) or bone-patellar tendon-bone (BTB) autografts, although the quadriceps tendon (QT) autograft has recently increased in popularity. This systematic review and meta-analysis review compares QT and HT autografts for primary ACLR with a sole focus on randomised controlled trials (RCTs). METHODS A prospective protocol was registered on PROSPERO (CRD42023427339). The search included MEDLINE, Embase and Web of Science until February 2024. Only comparative RCTs were included. The primary outcome was the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form score. Secondary outcomes included: other validated patient-reported outcome measures (PROMs), objective strength scores, complications, and return to sport and work. RESULTS From 2,609 articles identified, seven were included (n = 474 patients). This meta-analysis did not identify a significant difference in post-operative IKDC scores (5 articles; p = 0.73), Lysholm scores (3 studies; p = 0.80) or Tegner activity scales (2 studies; p = 0.98). There were no differences in graft failure rates (4 studies; p = 0.92) or in overall adverse events (4 studies; p = 0.83) at 24 months post-ACLR as per meta-analysis. Donor site morbidity scores were significantly lower in the QT group (MD -4.67, 95% CI -9.29 to -0.05; 2 studies, 211 patients; p = 0.05, I2 = 34%). CONCLUSION There were no differences between QT and HT in PROMs, graft failure rates or overall complications based on low- to moderate-quality evidence. There may possibly be lower donor site morbidity with the QT autograft, however, the evidence is not sufficient to draw definitive conclusions.
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Affiliation(s)
- Siddarth Raj
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom.
| | - Ali Ridha
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Henry K C Searle
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Chetan Khatri
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Imran Ahmed
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Andrew Metcalfe
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
| | - Nicholas Smith
- Department of Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, United Kingdom; Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, Coventry, United Kingdom
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Wen Y, Latham CM, Moore AN, Thomas NT, Lancaster BD, Reeves KA, Keeble AR, Fry CS, Johnson DL, Thompson KL, Noehren B, Fry JL. Vitamin D status associates with skeletal muscle loss after anterior cruciate ligament reconstruction. JCI Insight 2023; 8:e170518. [PMID: 37856482 PMCID: PMC10795826 DOI: 10.1172/jci.insight.170518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/17/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUNDAlthough 25-hydroxyvitamin D [25(OH)D] concentrations of 30 ng/mL or higher are known to reduce injury risk and boost strength, the influence on anterior cruciate ligament reconstruction (ACLR) outcomes remains unexamined. This study aimed to define the vitamin D signaling response to ACLR, assess the relationship between vitamin D status and muscle fiber cross-sectional area (CSA) and bone density outcomes, and discover vitamin D receptor (VDR) targets after ACLR.METHODSTwenty-one young, healthy, physically active participants with recent ACL tears were enrolled (17.8 ± 3.2 years, BMI 26.0 ± 3.5 kg/m2). Data were collected through blood samples, vastus lateralis biopsies, dual energy x-ray bone density measurements, and isokinetic dynamometer measures at baseline, 1 week, 4 months, and 6 months after ACLR. The biopsies facilitated CSA, Western blotting, RNA-seq, and VDR ChIP-seq analyses.RESULTSACLR surgery led to decreased circulating bioactive vitamin D and increased VDR and activating enzyme expression in skeletal muscle 1 week after ACLR. Participants with less than 30 ng/mL 25(OH)D levels (n = 13) displayed more significant quadriceps fiber CSA loss 1 week and 4 months after ACLR than those with 30 ng/mL or higher (n = 8; P < 0.01 for post hoc comparisons; P = 0.041 for time × vitamin D status interaction). RNA-seq and ChIP-seq data integration revealed genes associated with energy metabolism and skeletal muscle recovery, potentially mediating the impact of vitamin D status on ACLR recovery. No difference in bone mineral density losses between groups was observed.CONCLUSIONCorrecting vitamin D status prior to ACLR may aid in preserving skeletal muscle during recovery.FUNDINGNIH grants R01AR072061, R01AR071398-04S1, and K99AR081367.
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Affiliation(s)
- Yuan Wen
- Center for Muscle Biology, College of Health Sciences
- Department of Physiology, College of Medicine
- Division of Biomedical Informatics, Department of Internal Medicine, College of Medicine
| | | | | | | | | | | | - Alexander R. Keeble
- Center for Muscle Biology, College of Health Sciences
- Department of Physiology, College of Medicine
| | | | | | - Katherine L. Thompson
- Dr. Bing Zhang Department of Statistics, University of Kentucky, Lexington, Kentucky, USA
| | - Brian Noehren
- Center for Muscle Biology, College of Health Sciences
- Department of Orthopaedic Surgery & Sports Medicine, and
| | - Jean L. Fry
- Center for Muscle Biology, College of Health Sciences
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Cerci MH, Yilmaz AK, Kehribar L, Surucu S, Aydin M, Mahirogullari M. Evaluation of Isokinetic Knee Strengths after ACL Reconstruction with Quadrupled Semitendinosus Suspensory Femoral and Tibial Fixation versus Four-Strand Semitendinosus and Gracilis Suspensory Femoral and Tibial Screw Fixation. J Clin Med 2023; 12:4004. [PMID: 37373696 DOI: 10.3390/jcm12124004] [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: 02/26/2023] [Revised: 05/06/2023] [Accepted: 05/15/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION The purpose of this study was to demonstrate that patients undergoing ACL reconstruction with quadrupled semitendinosus suspensory femoral and tibial fixation have comparable results in muscle strength and knee function to those undergoing ACL reconstruction with four-strand semitendinosus-gracilis suspensory femoral fixation and a bioabsorbable tibial interference screw fixation. MATERIALS AND METHODS Between 2017 and 2019, 64 patients who were operated on by the same surgeon were included. Patients underwent ACL reconstruction technique with quadrupled semitendinosus suspensory femoral and tibial button fixation in Group 1, and patients underwent ACL reconstruction with coupled four-strand semitendinosus-gracilis suspensory femoral fixation and a bioabsorbable tibial interference screw in Group 2. Evaluation of patients was performed with the Lysholm and Tegner activity scale preoperatively and at the 1st and 6th months postoperatively. At the 6-month visit, isokinetic testing of the operated and non-operated limbs was performed in both groups. RESULTS There was no significant difference in the age, weight, and BMI values of the patients in Groups 1 and 2 (p < 0.05). According to the strength values of the operated sides of the patients in Group 1 and Group 2, there was no significant difference in the angular velocities of 60° s-1, 180° s-1, and 240° s-1 in both extension and flexion phases between the operated sides of Groups 1 and 2 (p < 0.05). CONCLUSIONS Patients who have ACL reconstruction with quadrupled semitendinosus suspensory femoral and tibial fixation have comparable muscle strength and knee function to those who undergo ACL reconstruction with four-strand semitendinosus-gracilis suspensory femoral fixation and a bioabsorbable tibial interference screw.
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Affiliation(s)
| | - Ali Kerim Yilmaz
- Departments of Recreation, Faculty of Yaşar Doğu Sport Sciences, Ondokuz Mayıs University, Samsun 55100, Turkey
| | - Lokman Kehribar
- Department of Orthopedics and Traumatology, Samsun University, Samsun 55090, Turkey
| | - Serkan Surucu
- Department of Orthopedics and Traumatology, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Mahmud Aydin
- Orthopedics and Traumatology, Haseki Education Research Hospital, Istanbul 34096, Turkey
| | - Mahir Mahirogullari
- Orthopedics and Traumatology, Sisli Memorial Hospital, Istanbul 34384, Turkey
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Cognetti DJ, Lynch TB, Rich E, Bedi A, Dhawan A, Sheean AJ. Quadriceps Dysfunction Following Joint Preservation Surgery: A Review of the Pathophysiologic Basis and Mitigation Strategies. Curr Rev Musculoskelet Med 2023:10.1007/s12178-023-09844-0. [PMID: 37243966 PMCID: PMC10382434 DOI: 10.1007/s12178-023-09844-0] [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] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE OF REVIEW To characterize quadriceps muscle dysfunction associated with knee joint preservation surgery, with a focus on its pathophysiology and promising approaches to mitigate its impact on clinical outcomes. RECENT FINDINGS Quadriceps dysfunction (QD) associated with knee joint preservation surgery results from a complex interplay of signaling, related to changes within the joint and from those involving the overlying muscular envelope. Despite intensive rehabilitation regimens, QD may persist for many months postoperatively and negatively impact clinical outcomes associated with various surgical procedures. These facts underscore the need for continued investigation into the potential detrimental effects of regional anesthetic and intraoperative tourniquet use on postoperative quadriceps function, with an outward focus on innovation within the field of postoperative rehabilitation. Neuromuscular stimulation, nutritional supplementation, cryotherapy, blood flow restriction (BFR), and open-chain exercises are all potential additions to postoperative regimens. There is compelling literature to suggest that these modalities are efficacious and may diminish the magnitude and duration of postoperative QD. A clear understanding of QD, with respect to its pathophysiology, should guide perioperative treatment and rehabilitation strategies and influence ongoing rehabilitation-based research and innovation. Moreover, clinicians must appreciate the magnitude of QD's effect on diminished clinical outcomes, risk for re-injury and patients' ability (or inability) to return to pre-injury level of activity following knee joint preservation procedures.
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Affiliation(s)
- Daniel J Cognetti
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA.
| | - Thomas B Lynch
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA
| | - Elizabeth Rich
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Aman Dhawan
- Department of Orthopaedics and Rehabilitation, Milton S. Hershey Medical Center, Penn State Health, Hershey, PA, 17033, USA
| | - Andrew J Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, TX, 78234, USA
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Giraldo-Vallejo JE, Cardona-Guzmán MÁ, Rodríguez-Alcivar EJ, Kočí J, Petro JL, Kreider RB, Cannataro R, Bonilla DA. Nutritional Strategies in the Rehabilitation of Musculoskeletal Injuries in Athletes: A Systematic Integrative Review. Nutrients 2023; 15:819. [PMID: 36839176 PMCID: PMC9965375 DOI: 10.3390/nu15040819] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/08/2023] Open
Abstract
It is estimated that three to five million sports injuries occur worldwide each year. The highest incidence is reported during competition periods with mainly affectation of the musculoskeletal tissue. For appropriate nutritional management and correct use of nutritional supplements, it is important to individualize based on clinical effects and know the adaptive response during the rehabilitation phase after a sports injury in athletes. Therefore, the aim of this PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science PERSiST-based systematic integrative review was to perform an update on nutritional strategies during the rehabilitation phase of musculoskeletal injuries in elite athletes. After searching the following databases: PubMed/Medline, Scopus, PEDro, and Google Scholar, a total of 18 studies met the inclusion criteria (Price Index: 66.6%). The risk of bias assessment for randomized controlled trials was performed using the RoB 2.0 tool while review articles were evaluated using the AMSTAR 2.0 items. Based on the main findings of the selected studies, nutritional strategies that benefit the rehabilitation process in injured athletes include balanced energy intake, and a high-protein and carbohydrate-rich diet. Supportive supervision should be provided to avoid low energy availability. The potential of supplementation with collagen, creatine monohydrate, omega-3 (fish oils), and vitamin D requires further research although the effects are quite promising. It is worth noting the lack of clinical research in injured athletes and the higher number of reviews in the last 10 years. After analyzing the current quantitative and non-quantitative evidence, we encourage researchers to conduct further clinical research studies evaluating doses of the discussed nutrients during the rehabilitation process to confirm findings, but also follow international guidelines at the time to review scientific literature.
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Affiliation(s)
- John E. Giraldo-Vallejo
- Grupo de Investigación NUTRAL, Facultad de Ciencias de Nutrición y Alimentos, Universidad CES, Medellín 050021, Colombia
- Research Division, Dynamical Business & Science Society—DBSS International SAS, Bogotá 110311, Colombia
| | - Miguel Á. Cardona-Guzmán
- Grupo de Investigación NUTRAL, Facultad de Ciencias de Nutrición y Alimentos, Universidad CES, Medellín 050021, Colombia
| | - Ericka J. Rodríguez-Alcivar
- Grupo de Investigación NUTRAL, Facultad de Ciencias de Nutrición y Alimentos, Universidad CES, Medellín 050021, Colombia
| | - Jana Kočí
- Research Division, Dynamical Business & Science Society—DBSS International SAS, Bogotá 110311, Colombia
- Department of Education, Faculty of Education, Charles University, 11636 Prague, Czech Republic
| | - Jorge L. Petro
- Research Division, Dynamical Business & Science Society—DBSS International SAS, Bogotá 110311, Colombia
- Research Group in Physical Activity, Sports and Health Sciences (GICAFS), Universidad de Córdoba, Montería 230002, Colombia
| | - Richard B. Kreider
- Exercise & Sport Nutrition Laboratory, Human Clinical Research Facility, Texas A&M University, College Station, TX 77843, USA
| | - Roberto Cannataro
- Research Division, Dynamical Business & Science Society—DBSS International SAS, Bogotá 110311, Colombia
- Galascreen Laboratories, Department of Pharmacy, Health, and Nutritional Sciences, University of Calabria, 87036 Rende, Italy
| | - Diego A. Bonilla
- Grupo de Investigación NUTRAL, Facultad de Ciencias de Nutrición y Alimentos, Universidad CES, Medellín 050021, Colombia
- Research Division, Dynamical Business & Science Society—DBSS International SAS, Bogotá 110311, Colombia
- Department of Education, Faculty of Education, Charles University, 11636 Prague, Czech Republic
- Sport Genomics Research Group, Department of Genetics, Physical Anthropology and Animal Physiology, Faculty of Science and Technology, University of the Basque Country (UPV/EHU), 48940 Leioa, Spain
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Wenning M, Mauch M, Heitner AH, Heinrich S, Sofack GN, Behrens M, Ritzmann R. General, spinal or regional anaesthesia does not affect strength performance 6 months after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2023; 31:487-494. [PMID: 35908113 PMCID: PMC9898431 DOI: 10.1007/s00167-022-07052-w] [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: 01/12/2022] [Accepted: 06/09/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE The recovery of strength is a key element in successfully returning to sports after ACL reconstruction. The type of anaesthesia has been suspected an influential factor in the post-operative recovery of muscle function. METHODS In this retrospective analysis, n = 442 consecutive patients undergoing primary isolated ACL reconstruction using a hamstring autograft were analysed by pre- and post-operative isokinetic tests in a single orthopaedic centre. These were subdivided into four cohorts: (1) general anaesthesia (n = 47), (2) general anaesthesia with prolonged (48 h) on-demand femoral nerve block (n = 37), (3) spinal anaesthesia (n = 169) and (4) spinal anaesthesia with prolonged (48 h) on-demand femoral nerve block (n = 185). Primary outcome was the change from pre- to post-operative isokinetic strength during knee extension and flexion. RESULTS Using one-way ANOVA, there was no significant influence of the type of anaesthesia. The main effect of anaesthesia on change in extension forces was not significant, and effect sizes were very small (n.s.). Similarly, the main effect of anaesthesia on change in flexion forces was statistically not significant (n.s.). CONCLUSIONS The findings of this study support the interpretation that the type of anaesthesia has no significant effect on the ability to recover thigh muscle strength 6 months after isolated hamstring ACL reconstruction. With regard to the recovery of athletic performance and return-to-sports testing criteria, there is no reason to avoid regional anaesthesia. LEVEL OF EVIDENCE III.
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Affiliation(s)
- M. Wenning
- Rennbahnklinik, Muttenz, Basel, Switzerland ,Department of Orthopedic and Trauma Surgery, Faculty of Medicine, University Medical Center, University of Freiburg, Hugstetter Str. 55, 79104 Freiburg, Germany
| | - M. Mauch
- Department of Biomechanics, Rennbahnklinik, Kriegackerstrasse 100, Muttenz, CH-4132, Basel, Switzerland
| | | | - S. Heinrich
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University Medical Center, University of Freiburg, Freiburg, Germany
| | - G. N. Sofack
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - M. Behrens
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - R. Ritzmann
- Rennbahnklinik, Muttenz, Basel, Switzerland ,Department of Sport and Sport Science, University of Freiburg, Freiburg, Germany
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Spada JM, Paul RW, Tucker BS. Blood Flow Restriction Training preserves knee flexion and extension torque following anterior cruciate ligament reconstruction: A systematic review. J Orthop 2022; 34:233-239. [PMID: 36120478 PMCID: PMC9478494 DOI: 10.1016/j.jor.2022.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 11/29/2022] Open
Abstract
Background There is inconsistency in the literature comparing the outcomes of Blood Flow Restriction Training versus Traditional Post-Operative Rehabilitation after anterior cruciate ligament reconstruction. Purpose This study aimed to determine if Blood Flow Restriction Training can limit the loss of knee extension and knee flexion muscle torque during early recovery from anterior cruciate ligament reconstruction better than Traditional Post-Operative Rehabilitation. Methods Three databases (PubMed, Embase, and Scopus) were searched for level 1 randomized controlled trials pertaining to Blood Flow Restriction Training after anterior cruciate ligament reconstruction. To maximize consistency among included studies, only studies which used knee flexion and knee extension muscle torque as the primary outcome measures were included. Search terms included "cruciate + occlusion", "cruciate + blood flow restriction", and "cruciate + occlusion training". Results Two level 1 trials with training protocols of 8 and 16 weeks yielded isokinetic knee flexion torque data in support of Blood Flow Restriction Training. Both trials demonstrated that Blood Flow Restriction Training also yielded significantly increased isokinetic knee extension torque compared to control groups. Conclusion The highest-quality level 1 trials evaluating knee extension and knee extension strength via isokinetic torque agree that Blood Flow Restriction Training limits post-operative losses of knee flexion and extension strength. No adverse events were reported in either study. Except for patients of whom Blood Flow Restriction is contraindicated, clinicians may consider utilizing Blood Flow Restriction Training from week 2 of the post-operative period through the conclusion of outpatient rehabilitation using low intensities, multiple times per week; however, further studies comparing Blood Flow Restriction Training protocols are necessary before an optimal protocol could be confidently recommended.
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Affiliation(s)
- Joshua M. Spada
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Ryan W. Paul
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Pogorzała A, Kądzielawska E, Kubaszewski Ł, Dąbrowski M. Factors Influencing Treatment Outcome and Proprioception after Electrocoagulation of the Femoral Insertion of the Anterior Cruciate Ligament. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13569. [PMID: 36294149 PMCID: PMC9603566 DOI: 10.3390/ijerph192013569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
(1) Background: Studies have established that exercises shaping the sense of deep sensation are an important element of medical rehabilitation of patients after vaporization of the femoral insertion of the anterior cruciate ligament and affect the restoration of correct movement patterns, thus reducing the risk of injuries. The aim of this study was to determine the factors influencing the treatment outcome and deep-feeling function after applying a specific rehabilitation scheme 12 weeks after anterior cruciate ligament electrocoagulation surgery. (2) Methods: The study group consisted of 41 patients after partial rupture of the anterior cruciate ligament, who underwent electrocoagulation of the femoral cruciate ligament attachment and microfracture of the femoral attachment area. All patients were operated on by the same surgeon and then rehabilitated according to the same medical rehabilitation protocol. The anthropometric and clinical data were collected through an anterior drawer test, Lachman test, assessment of the range of movements in the knee joint, muscle strength test, Unterberger test and Lysholm questionnaire. The assessment was performed before the surgery, and then on days 7-10, after 6 and 12 weeks of rehabilitation treatment. (3) Results: Statistical improvement of the parameters was demonstrated by strength of the quadriceps and hamstrings muscle, the Unterberger test, and the Lysholm scale after surgery. A negative correlation was found between the Unterberger test and Lysholm scale at the end of the research period and it differed depending on the gender and the dominant limb. The Lysholm scale and muscle strength were independent of sex, dominant extremity and associated damage of the meniscus and cartilage. The Lysholm scale 6 weeks after surgery negatively correlated with BMI. (4) Conclusions: Stability of the knee joint and improvement of proprioception were demonstrated 12 weeks after treatment with an ACL electrocoagulation and rehabilitation regimen. The factors contributing to a better treatment outcome were greater muscle strength, less thigh asymmetry, better sense of depth, younger age and lower body weight.
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Affiliation(s)
- Adam Pogorzała
- Institute of Applied Mechanics, Poznan University of Technology, 60-965 Poznan, Poland
| | - Ewa Kądzielawska
- Institute of Applied Mechanics, Poznan University of Technology, 60-965 Poznan, Poland
| | - Łukasz Kubaszewski
- Adult Spine Orthopaedics Department, Poznan University of Medical Sciences, 61-545 Poznan, Poland
| | - Mikołaj Dąbrowski
- Adult Spine Orthopaedics Department, Poznan University of Medical Sciences, 61-545 Poznan, Poland
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Beynnon BD, Pius AK, Tourville TW, Endres NK, Failla MJ, Choquette RH, DeSarno M, Toth MJ. The Duration of Thigh Tourniquet Use Associated With Anterior Cruciate Ligament Reconstruction Does Not Produce Cellular-Level Contractile Dysfunction of the Quadriceps Muscle at 3 Weeks After Surgery. Am J Sports Med 2022; 50:2925-2934. [PMID: 35980007 DOI: 10.1177/03635465221115823] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) trauma and ACL reconstruction (ACLR) are associated with the loss of strength and function of the muscles that span the knee joint. The underlying mechanism associated with this is not completely understood. PURPOSE To determine whether the duration of tourniquet use during ACLR has an effect on knee extensor muscle contractile function and size at the cellular (ie, fiber) level 3 weeks after surgery and at the whole-muscle level at 6 months after surgery. STUDY DESIGN Descriptive laboratory study and case series; Level of evidence, 4. METHODS Study participants sustained an acute, first-time ACL injury. All participants underwent ACLR with the use of a tourniquet placed in a standardized location on the thigh; the tourniquet was inflated (pressure range, 250-275 mm Hg), and the time of tourniquet use during surgery was documented. Participants were evaluated 1 week before surgery (to measure patient function, strength, and subjective outcome with the Knee injury and Osteoarthritis Outcome Score [KOOS] and International Knee Documentation Committee [IKDC] score), at 3 weeks after ACLR surgery (to obtain muscle biopsy specimens of the vastus lateralis and assess muscle fiber cross-sectional area, contractile function, and mitochondrial content and morphometry), and at 6 months after ACLR (to evaluate patient function, strength, and subjective outcomes via KOOS and IKDC scores). Data were acquired on both the injured/surgical limb and the contralateral, normal side to facilitate the use of a within-subjects study design. Results are based on additional analysis of data acquired from previous research that had common entry criteria, treatments, and follow-up protocols. RESULTS At 3 weeks after ACLR, the duration of tourniquet use at the time of surgery did not explain the variation in single-muscle fiber contractile function or cross-sectional area (myosin heavy chain [MHC] I and II fibers) or subsarcolemmal and intermyofibrillar mitochondrial content or morphometry. At 6 months after ACLR, the duration of tourniquet use was not associated with the peak isometric and isokinetic torque measurements, patient function, or patient-reported outcomes. CONCLUSION The duration of tourniquet use at the time of ACLR surgery did not explain variation in muscle fiber size, contractile function, or mitochondrial content at 3 weeks after surgery or strength of the quadriceps musculature or patient-reported function or quality of life at 6-month follow-up.
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Affiliation(s)
- Bruce D Beynnon
- Department Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Mechanical Engineering, University of Vermont, Burlington, Vermont, USA
- Department of Electrical and Biomedical Engineering, University of Vermont, Burlington, Vermont, USA
| | - Alexa K Pius
- Department Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Timothy W Tourville
- Department Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Rehabilitation and Movement Science, College of Nursing and Health Sciences, University of Vermont, Burlington, Vermont, USA
| | - Nathan K Endres
- Department Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Mathew J Failla
- Department Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Rehabilitation and Movement Science, College of Nursing and Health Sciences, University of Vermont, Burlington, Vermont, USA
| | - Rebecca H Choquette
- Department Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Mike DeSarno
- Department of Medical Biostatistics, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Michael J Toth
- Department Orthopedics and Rehabilitation, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Medicine, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Molecular Physiology and Biophysics, Robert Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
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Mesnard G, Fournier G, Joseph L, Shatrov JG, Lustig S, Servien E. Does meniscal repair impact muscle strength following ACL reconstruction? SICOT J 2022; 8:16. [PMID: 35579438 PMCID: PMC9112909 DOI: 10.1051/sicotj/2022016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/13/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose: Meniscal lesions are commonly associated with anterior cruciate ligament (ACL) rupture. Meniscal repair, when possible, is widely accepted as the standard of care. Despite advancements in surgical and rehabilitation techniques, meniscal repair may impact muscle recovery when performed in conjunction with ACL reconstruction. The objective of this study was to explore if meniscal repairs in the context of ACL reconstruction affected muscle recovery compared to isolated ACL reconstruction. Methods: Fifty-nine patients with isolated ACL reconstruction were compared to 35 patients with ACL reconstruction with an associated meniscal repair. All ACL reconstructions were performed using hamstring grafts with screw-interference graft fixation. Isokinetic muscle testing was performed between six and eight months of follow-up. Muscle recovery between both groups was compared. A further subgroup analysis was performed to compare muscle recovery function of gender and meniscal tear location. Tegner scores were assessed at six months’ follow-up. Results: No significant differences were found between the two groups regarding muscle recovery. No difference in muscle recovery was found concerning gender. Lesion of both menisci significantly increased the deficit of hamstrings muscular strength at 60°/s compared to a lesion of one meniscus (26.7% ± 15.2 vs. 18.1% ± 13.5, p = 0.018) and in eccentric test (32.4% ± 26.2 vs. 18.1% ± 13.5, p = 0.040). No significant differences were found concerning the Tegner score. Conclusion: Meniscal repairs performed during an ACL reconstruction do not impact muscle recovery at 6–8 months post-operatively compared to an isolated ACL reconstruction. However, reparations of both menisci appear to impact hamstring muscle recovery negatively. Level of evidence: III, Retrospective cohort study
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Affiliation(s)
- Guillaume Mesnard
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 69004 Lyon, France
| | - Gaspard Fournier
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 69004 Lyon, France
| | - Léopold Joseph
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 69004 Lyon, France
| | - Jobe Gennadi Shatrov
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 69004 Lyon, France - The University of Notre Dame, Australia, School of Medicine, 6160 Sydney, Australia
| | - Sébastien Lustig
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 69004 Lyon, France - Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 69622, Lyon, France
| | - Elvire Servien
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital, 69004 Lyon, France - LIBM - EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, 69100 Lyon, France
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12
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Drigny J, Ferrandez C, Gauthier A, Guermont H, Praz C, Reboursière E, Hulet C. Knee strength symmetry at 4 months is associated with criteria and rates of return to sport after anterior cruciate ligament reconstruction. Ann Phys Rehabil Med 2022; 65:101646. [PMID: 35167984 DOI: 10.1016/j.rehab.2022.101646] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 12/24/2021] [Accepted: 01/24/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Strength limb symmetry index (LSI) is a useful criterion to help in return-to-sport performance (RTP) after anterior cruciate ligament reconstruction (ACLR). OBJECTIVES We aimed to assess whether knee extensor and flexor LSI values at 4 months after ACLR are associated with those recommended at 8 months after ACLR for RTP (80%, 85% and 90%) and with successful RTP after 2 years. METHODS This was prospective cohort study of 113 participants who underwent primary ACLR. Personal factors such as demographic and sport information, injury and surgery characteristics were collected at 6 weeks after surgery. Isokinetic strength LSI (60°/s) was calculated at 4 months (LSI[4m]) and 8 months (LSI[8m]) for knee extensors (Q-LSI) and flexors (H-LSI). Participants were followed at 2 years after ACLR to determine their self-reported RTP. Multiple linear regression analysis was used to determine associations between personal factors and LSI at 4 and 8 months. Associations between passing the optimal cut-off thresholds and RTP were tested with chi-square tests and odds ratios (ORs) with effect sizes (ES). RESULTS Among the 113 participants (mean age 25.2 [SD 9.7] years; 42% females), extended tourniquet time and lower level of pre-injury sport were associated with lower Q-LSI[4m] and H-LSI[4m]. Bone-patellar tendon-bone graft was associated with lower Q-LSI[4m] and Q-LSI[8m], and older age was associated with lower Q-LSI[4m]. For knee extensors, Q-LSI[4m] >59% was associated with Q-LSI[8m] >80% (OR= 31.50, p <0.001, large ES) and increased odds of successful RTP (60% vs 31%, OR= 3.45, p= 0.003, medium ES). For knee flexors, H-LSI[4m] >72% was associated with H-LSI[8m] >90% (OR= 6.03, p <0.001, large ES) and increased odds of successful RTP (53% vs 23%, OR= 3.76, p= 0.013, small-to-medium ES). CONCLUSIONS After primary ACLR, 4-month post-operative strength symmetry was negatively associated with age, pre-injury sport and tourniquet time and bone-patellar tendon-bone graft. Four-month post-operative LSI was associated with 8-month post-operative LSI, and Q-LSI[4m] >59% or H-LSI[4m] >72% was associated with increased RTP rates after 2 years. CLINICALTRIALS.GOV: : NCT04071912.
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Affiliation(s)
- Joffrey Drigny
- Service de Médecine Physique et de Réadaptation, Service de Médecine du Sport, CHU de Caen Normandie, Normandie Univ, UNICAEN, INSERM, COMETE, GIP CYCERON, Caen 14000, France.
| | - Clémence Ferrandez
- Service de Médecine Physique et de Réadaptation, Service de Médecine du Sport, CHU de Caen Normandie, Caen 14000, France
| | - Antoine Gauthier
- Normandie Univ, UNICAEN, INSERM, COMETE, GIP CYCERON, Caen 14000, France
| | - Henri Guermont
- Service de Médecine du Sport, CHU de Caen Normandie, Caen 14000, France
| | - César Praz
- Département d'orthopédie et de traumatologie, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen 14000, France
| | | | - Christophe Hulet
- Département d'orthopédie et de traumatologie, Normandie Univ, UNICAEN, INSERM, COMETE, GIP CYCERON, Caen 14000, France
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Wang C, Ji Z, Wang L, Zhang Q, Wang H, Qie S. The efficacy of 5 rehabilitation treatments after anterior cruciate ligament reconstruction: A network meta-analysis. Medicine (Baltimore) 2021; 100:e27835. [PMID: 34766600 PMCID: PMC8592301 DOI: 10.1097/md.0000000000027835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/29/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The efficacy of traditional rehabilitation, proprioceptive training, and neuromuscular training after anterior cruciate ligament (ACL) reconstruction is also controversial. In order to help medical staff better choose the rehabilitation treatment plan after ACL reconstruction, we conducted this network meta-analysis. METHODS Chinese and English databases such as Wanfang, Weipu, China Zhiwang, and PubMed, Cochrane Library, Embase were retrieved. We collected clinical controlled trial papers on traditional rehabilitation therapy, proprioceptive training and neuromuscular training after ACL reconstruction for meta-analysis. RESULTS In this meta-analysis, 12 studies were included, including 486 patients who received rehabilitation treatment after ACL reconstruction. Based on network meta-analysis, it was found that 4 groups of direct comparison and 6 groups of indirect comparison were formed for 5 rehabilitation treatment schemes after ACL reconstruction. The curative effect of traditional rehabilitation training combined with proprioception training is better than that of traditional rehabilitation training (mean difference value of traditional rehabilitation training combined with proprioception training vs traditional rehabilitation training was 8.00, 95% confidence interval: 2.61,13.39). The efficacy of proprioceptive training is better than that of traditional rehabilitation training (mean difference value of proprioceptive training vs traditional rehabilitation training is 11.01, 95% confidence interval: 0.62,21.39). There was no statistical significance between the other rehabilitation trainings. According to the surface under cumulative ranking curve, the therapeutic effects of the 5 rehabilitation treatment programs after ACL reconstruction were ranked as follows: proprioceptive training (72%) > traditional rehabilitation training combined with neuromuscular training (70.8%) > traditional rehabilitation training combined with proprioception training (57.1%) > neuromuscular training (45.5%) > traditional rehabilitation training (4.6%). No publication bias was found in the funnel plot. CONCLUSION Combined with the results of meta-analysis and surface under cumulative ranking efficacy sequence diagram, it can be seen that traditional rehabilitation training combined with proprioceptive training and traditional rehabilitation training combined with neuromuscular training have significant efficacy. Due to the limitations of this study, the conclusions of this network meta-analysis still need to be further confirmed by a large sample size and well-designed randomized controlled trials.
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Affiliation(s)
- Congxiao Wang
- Rehabilitation Department, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Zhonglei Ji
- Rehabilitation Department, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Luyi Wang
- Rehabilitation Department, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Qiaorong Zhang
- Rehabilitation Department, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Hujun Wang
- Rehabilitation Department, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Shuyan Qie
- Rehabilitation Department, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
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Amestoy J, Pérez-Prieto D, Torres-Claramunt R, Sánchez-Soler JF, Leal-Blanquet J, Ares-Vidal J, Hinarejos P, Monllau JC. Patellofemoral Pain After Arthroscopy: Muscle Atrophy Is Not Everything. Orthop J Sports Med 2021; 9:23259671211013000. [PMID: 34262977 PMCID: PMC8246502 DOI: 10.1177/23259671211013000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 01/12/2021] [Indexed: 11/17/2022] Open
Abstract
Background It remains unclear as to why patellofemoral pain (PFP) appears in some patients after knee arthroscopy and what influence the quadriceps muscle has on its onset. Purpose To compare muscle thickness, neuromuscular contractility, and quadriceps femoris muscle strength between patients who develop PFP after arthroscopic partial meniscectomy and a control group and to compare functional outcomes between these entities. Study Design Cohort study; Level of evidence, 3. Methods A prospective longitudinal cohort study was carried out on patients scheduled for arthroscopic partial meniscectomy. Patients were excluded if they had preoperative PFP, previous knee surgery, or additional surgical procedures (eg, meniscal repair or microfracture). The following were performed preoperatively: magnetic resonance imaging to quantify muscle thickness, surface electromyography to analyze electrical contractility, and an isokinetic study to assess the strength of the quadriceps femoris muscle. Patients also completed a Lysholm functional questionnaire. Six weeks after the index procedure, patients were questioned about the presence of PFP, and the same tests were repeated. The PFP group included patients who developed anterior knee pain postoperatively, while the control group included those who did not develop pain. Results Of 90 initial study patients, 20 were included in the PFP group (23.8%) and 64 in the control group (76.2%); 6 patients were lost to follow-up. Both study groups were comparable on all of the analyzed preoperative variables. Patients in the PFP group had worse results in terms of muscle thickness (9.67 vs 16.55 cm2), electrical contractility (1226.30 vs 1946.11 µV), and quadriceps strength (12.27 vs 20.02 kg; all P < .001). They also presented worse functional results on the Lysholm score (63.05 vs 74.45; P < .001). Conclusion Patients who developed PFP after arthroscopic partial meniscectomy had more quadriceps femoris muscle atrophy as well as a greater decrease in electrical contractility and muscle strength at 6 weeks postsurgically as compared with a control group. The PFP group also had worse postoperative functional results.
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Affiliation(s)
| | - Daniel Pérez-Prieto
- Department for Orthopedics and Traumatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Raúl Torres-Claramunt
- Department for Orthopedics and Traumatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Francisco Sánchez-Soler
- Department for Orthopedics and Traumatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Leal-Blanquet
- Department for Orthopedics and Traumatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jesús Ares-Vidal
- Department for Radiology, Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - Pedro Hinarejos
- Department for Orthopedics and Traumatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Carles Monllau
- Department for Orthopedics and Traumatology, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
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