Anterior Cruciate Ligament Reconstruction Recovery and Rehabilitation: A Systematic Review

Combining a digital health application with standard care significantly enhances rehabilitation outcomes for ACL surgery patients

INTRODUCTION

Anterior cruciate ligament (ACL) rupture is one of the most common sports injuries. Regardless of the surgical treatment, patients require intensive education about the pathology, therapeutic options and physical therapy. However, it is often not possible for the patient to start physical therapy directly and schedule adequate consultations. Digital health applications are medical devices that can help bridge the gap between physiotherapy sessions and provide qualified, convenient and effective education and treatment. This study is needed to explore alternative methods to ensure continuous and effective rehabilitation for ACL patients who face delays in accessing traditional physiotherapy. The study aimed to compare app-assisted therapy plus standard of care (conventional orthopaedic and physiotherapeutic measures) versus isolated standard of care for patients with planned ACL surgery.

METHODS

A monocentric, two-arm, 1:1 randomized controlled study examined 80 patients after a cruciate ligament rupture with or without meniscal injury. Patients over 18 years with a confirmed diagnosis of ACL rupture and planned surgical reconstruction using autologous grafts were included. The study criteria additionally included willingness to use the Orthopy app and sufficient German language proficiency. The study excluded patients with severe concomitant injuries, prior knee surgeries, chronic pain conditions and those not compatible with app usage. Patients were randomized and their baseline data (t0) was collected. Subsequently, they received their treatment according to their treatment group. The study included a presurgery period (2-6 weeks) and a postsurgery period (14 weeks). Interim assessments were done via online questionnaires at t1 (if more than 3 weeks before surgery) and t3, t4 and t5 (postsurgery). Additional clinical assessments were conducted at t2 (presurgery) and t6 (14 weeks postsurgery). Primary outcome measures included the knee injury and osteoarthritis outcome score (KOOS), with subjective pain and function levels (numeric rating scale [NRS]) as secondary endpoints.

RESULTS

The clinical trial was able to show positive outcomes on the KOOS Pain and Symptoms subscale of the primary endpoint KOOS in the interventional group compared to the standard of care group. A statistically significant pain reduction could be seen at t1 (p = 0.0005), t2 (p = 0.0068) and t4 (approximately 6 weeks after surgery; p = 0.01). A significant reduction of symptoms at t1 (p = 0.0001), t2 (p = 0.0036) and t6 (p = 0.0377) were recognized. These findings are further supported by the significant benefit of the pain NRS at t4 and positive tendencies at t3, t5 and t6. The KOOS subscales quality of life (p = 0.0066), activities of daily living (p = 0.0009) and Sport (p = 0.0484) showed significant effects before surgery.

CONCLUSION

The Orthopy app is a medical device that is both safe and effective for use. Combining the Orthopy app and standard of care can significantly improve prehabilitation and rehabilitation in surgical treatment with ACL reconstruction compared with the isolated standard of care.

LEVEL OF EVIDENCE

Level I.

Comparison of the quadrant method measuring four points and bernard method in femoral tunnel position evaluation on 3-dimensional reconstructed computed tomography after anatomical single-bundle anterior cruciate ligament reconstruction

PURPOSE

This prospective study aimed to compare the postoperative evaluation of the quadrant method measuring four points and Bernard method in femoral tunnel position evaluation on 3-Dimensional (3D) reconstructed computed tomography (CT) following the arthroscopic single-bundle anterior cruciate ligament (ACL) reconstruction.

METHODS

Thirty-eight patients with ACL tears that were reconstructed using single-bundle ACL reconstruction between May 2021 and March 2023 were included in this study. Postoperative 3D CT images were obtained after the operation. The femoral tunnel position was measured by use of the quadrant method measuring four points and Bernard method.

RESULTS

Average mean position of the femoral tunnel insertion center on the 3D CT image was at 26.16 ± 6.27% in the x-coordinate and at 24.36 ± 5.52% in the y-coordinate according to the Bernard method. Meanwhile, the position of the femoral insertion of the ACL measured by the quadrant method measuring four points was 24.2% ± 6.86% in the x-coordinate and 21.16% ± 5.14% in the y-coordinate.

CONCLUSIONS

Both the quadrant method measuring four points and Bernard method were effective in femoral tunnel position evaluation on 3D reconstructed CT. Application of the quadrant method measuring four points on 3D CT showed the advantage that measurement can be taken regardless of the shape of the bone tunnel.

Intermittent cyclic stretch of engineered ligaments drives hierarchical collagen fiber maturation in a dose- and organizational-dependent manner

Hierarchical collagen fibers are the primary source of strength in tendons and ligaments; however, these fibers largely do not regenerate after injury or with repair, resulting in limited treatment options. We previously developed a static culture system that guides ACL fibroblasts to produce native-sized fibers and early fascicles by 6 weeks. These constructs are promising ligament replacements, but further maturation is needed. Mechanical cues are critical for development in vivo and in engineered tissues; however, the effect on larger fiber and fascicle formation is largely unknown. Our objective was to investigate whether intermittent cyclic stretch, mimicking rapid muscle activity, drives further maturation in our system to create stronger engineered replacements and to explore whether cyclic loading has differential effects on cells at different degrees of collagen organization to better inform engineered tissue maturation protocols. Constructs were loaded with an established intermittent cyclic loading regime at 5 or 10 % strain for up to 6 weeks and compared to static controls. Cyclic loading drove cells to increase hierarchical collagen organization, collagen crimp, and tissue tensile properties, ultimately producing constructs that matched or exceeded immature ACL properties. Further, the effect of loading on cells varied depending on degree of organization. Specifically, 10 % load drove early improvements in tensile properties and composition, while 5 % load was more beneficial later in culture, suggesting a shift in mechanotransduction. This study provides new insight into how cyclic loading affects cell-driven hierarchical fiber formation and maturation, which will help to develop better rehabilitation protocols and engineer stronger replacements. STATEMENT OF SIGNIFICANCE: Collagen fibers are the primary source of strength and function in tendons and ligaments throughout the body. These fibers have limited regenerate after injury, with repair, and in engineered replacements, reducing treatment options. Cyclic load has been shown to improve fibril level alignment, but its effect at the larger fiber and fascicle length-scale is largely unknown. Here, we demonstrate intermittent cyclic loading increases cell-driven hierarchical fiber formation and tissue mechanics, producing engineered replacements with similar organization and mechanics as immature ACLs. This study provides new insight into how cyclic loading affects cell-driven fiber maturation. A better understanding of how mechanical cues regulate fiber formation will help to develop better engineered replacements and rehabilitation protocols to drive repair after injury.

ChatGPT Provides Unsatisfactory Responses to Frequently Asked Questions Regarding Anterior Cruciate Ligament Reconstruction

PURPOSE

To determine whether the free online artificial intelligence platform ChatGPT could accurately, adequately, and appropriately answer questions regarding anterior cruciate ligament (ACL) reconstruction surgery.

METHODS

A list of 10 questions about ACL surgery was created based on a review of frequently asked questions that appeared on websites of various orthopaedic institutions. Each question was separately entered into ChatGPT (version 3.5), and responses were recorded, scored, and graded independently by 3 authors. The reading level of the ChatGPT response was calculated using the WordCalc software package, and readability was assessed using the Flesch-Kincaid grade level, Simple Measure of Gobbledygook index, Coleman-Liau index, Gunning fog index, and automated readability index.

RESULTS

Of the 10 frequently asked questions entered into ChatGPT, 6 were deemed as unsatisfactory and requiring substantial clarification; 1, as adequate and requiring moderate clarification; 1, as adequate and requiring minor clarification; and 2, as satisfactory and requiring minimal clarification. The mean DISCERN score was 41 (inter-rater reliability, 0.721), indicating the responses to the questions were average. According to the readability assessments, a full understanding of the ChatGPT responses required 13.4 years of education, which corresponds to the reading level of a college sophomore.

CONCLUSIONS

Most of the ChatGPT-generated responses were outdated and failed to provide an adequate foundation for patients' understanding regarding their injury and treatment options. The reading level required to understand the responses was too advanced for some patients, leading to potential misunderstanding and misinterpretation of information. ChatGPT lacks the ability to differentiate and prioritize information that is presented to patients.

CLINICAL RELEVANCE

Recognizing the shortcomings in artificial intelligence platforms may equip surgeons to better set expectations and provide support for patients considering and preparing for ACL reconstruction.

Does Insurance Provide Adequate Coverage for Physical Therapy Visits for Common Orthopedic Diagnoses? A Survey Study

OBJECTIVES

This study aimed to analyze the association between physical therapists' recommended number of visits for a full recovery from common orthopedic injuries/surgeries and the extent of insurance coverage for these visits.

METHODS

A prospective observational study was conducted with board-certified physical therapists. A qualitative questionnaire was used to gather physical therapists' demographics and the recommended number of physical therapy visits to achieve a full recovery after 11 common orthopedic diagnoses. Physical therapists also were asked to report whether they believe that insurance provides an adequate number of visits overall. In addition to the qualitative survey, insurance coverage details of major Alabama companies were obtained for comparison. Descriptive statistics of the participating therapists were analyzed for sex, age, degree/training, and years of experience. Kruskal-Wallis statistics were used to analyze variance between the aforementioned groupings when compared with the reported average number of sessions.

RESULTS

The survey (N = 251) collected data on the average number of physical therapy sessions that are necessary for a complete recovery as recommended by physical therapists for 11 common orthopedic diagnoses. From this survey, the average number of necessary visits ranged from 11.3 visits (ankle sprains) to 37.3 visits (anterior cruciate ligament reconstruction), with the overall average number of visits being 23.8. Only 24% of physical therapists believed that insurance companies provided enough coverage. Insurance coverage varied but often required additional procedures to allocate the adequate number of visits for the studied orthopedic pathologies.

CONCLUSIONS

The majority of practicing physical therapists in Alabama perceive insufficient insurance coverage for physical therapy visits for most orthopedic diagnoses. This study has implications for healthcare decision making and patient-centered rehabilitation goals. Physicians and physical therapists can use this information to optimize treatment decisions and rehabilitation goals. Patients will benefit from improved physical and economic well-being. This study has the potential to drive further research and influence national insurance policies to better serve patients' needs.

Cross-cultural adaptation and measurement properties of the Persian version of the modified Cincinnati knee rating system

Purpose

To validate and assess the cross-sectional adaptation of the modified Cincinnati knee rating system (MCRKS) Persian translation.

Methods

To assess test-pretest reliability, 102 participants were asked to fill out the MCRKS (Per) scale after anterior cruciate ligament (ACL) reconstruction surgery. Internal consistency (Cronbach's α), reliability (intraclass correlation coefficients), construct validity (Pearson's r) and sensitivity (floor/ceiling effect) were determined. In addition, patients completed other relevant measures as the ACL return to sports after injury (ACL-RSI) survey, hospital for special surgery ACL satisfaction survey (HSS ACL-SS), visual analogue scale (VAS) of pain and patient's satisfaction, Tegner activity score (TAS), single assessment numeric evaluation, and Lysholm score.

Results

Using MCRKS (Per), the internal consistency (Cronbach's α) was 0.9 (if item deleted: 0.81-0.86); the construct validity (Pearson's r) varied between -0.50 (for VAS pain scale) and 0.79 (for Lysholm score); the reliability (ICC value) varied between 0.82 and 0.97; furthermore, no ceiling or floor effect was present.

Conclusion

The MCRKS (Per) has adequate measurement properties and is considered a valid, reliable and sensitive instrument which can identify clinical outcomes after ACLR surgery.

Level of Evidence

Level IV.

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

INTRODUCTION

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

METHODS

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

REGISTRATION DETAILS

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

A comparative study on 3D printing-assisted arthroscopic IDEAL point femoral tunnel positioning for anterior cruciate ligament reconstruction versus conventional arthroscopic positioning

BACKGROUND

This study aimed to investigate the feasibility and precision of using a 3D-printed template for femoral tunnel placement in guiding the optimal positioning of the Internal anatomical stop and Low tension maintenance (IDEAL) bone tunnel during single-bundle anterior cruciate ligament (ACL) reconstruction.

METHODS

A retrospective analysis was conducted on 40 patients who underwent arthroscopic single-bundle ACL reconstruction at our hospital between April 2021 and November 2021. In the direct vision group, the IDEAL bone tunnel was positioned using radiofrequency localization directly visualized at the stump. In the 3D-printed positioning group, preoperative CT scans and Digital Imaging and Communications in Medicine (DICOM) data were employed. Following the Quadrant method by Bernard, the femoral tunnel's depth was set at 25% and its height at 29%. Postoperative plain CT scans enabled the reconstruction of 3D models for both groups. The accuracy of femoral tunnel placement was then compared.

RESULTS

The central locations of the bone tunnels in the direct vision group were at a mean depth of 25.74 ± 1.84% and a height of 29.22 ± 2.97%. In the 3D printing localization group, these values were 25.39 ± 2.98% for depth and 28.89 ± 2.50% for height, respectively. No significant differences were found in tunnel positioning between the groups. Both groups demonstrated statistically significant improvements in International Knee Documentation Committee Subjective Knee Form (IKDC) and Lysholm scores postoperatively, with no significant differences observed 12 months post-surgery.

CONCLUSION

The findings of this study suggest that 3D printing-assisted arthroscopic IDEAL point femoral tunnel positioning and conventional arthroscopic positioning are feasible and effective for ACL reconstruction. Using 3D printing technology to design femoral anchor points in ACL reconstruction allows for the customization of anterior fork reconstruction and precise bone tunnel positioning, supporting the goal of individualized and accurate reconstruction.

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

PURPOSE

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

METHODS

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

RESULTS

Eight RCTs, consisting of 245 patients, met inclusion criteria, with 115 patients undergoing non-BFR rehabilitation compared with 130 patients undergoing BFR after ACLR. Mean patient age was 27.2 ± 6.7 years, with most patients being male (63.3%, n = 138/218). The length of the BFR rehabilitation protocol was most commonly between 8 and 12 weeks (range, 14 days to 16 weeks). Most studies set the limb/arterial occlusion pressure in the BFR group at 80%. When compared with non-BFR rehabilitation, BFR resulted in significant improvement in isokinetic muscle strength (SMD: 0.77, P = .02, I2: 58%), International Knee Documentation Committee score (mean difference: 10.97, P ≤ .00001, I2: 77%), and pain (SMD: 1.52, P = .04, I2: 87%), but not quadriceps muscle volume (SMD: 0.28, P = .43, I2: 76%).

CONCLUSIONS

The use of BFR after ACLR led to improvements in pain, International Knee Documentation Committee score, and isokinetic muscle strength, with variable outcomes on the basis of quadriceps strength, volume, and thickness when compared with non-BFR rehabilitation.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis of Level I and II studies.

Previous Knee Surgery, Anteromedial Portal Drilling, Quadriceps Tendon Autograft, and Meniscal Involvement Associated With Delayed Return to Sport After Anterior Cruciate Ligament Reconstruction in Amateur Athletes

Purpose

To identify prognostic factors associated with a delayed return-to-sport (RTS) time in amateur athletes who return to full participation after a primary isolated anterior cruciate ligament (ACL) reconstruction.

Methods

A retrospective review was performed among athletes who underwent ACL reconstruction between October 2014 and October 2021. Inclusion criteria were any amateur athletes with an ACL reconstruction who had a documented RTS and greater than 1-year follow-up. Nonathletes, those with multiligamentous knee injury, and those missing documented RTS timelines were excluded. RTS was defined as participation in athletics at a level equivalent to or greater than the preinjury level participation. Demographic and prognostic factors, including previous knee surgery, meniscal involvement, level of participation, surgical approach, and graft type, were recorded along with RTS time and analyzed via Poisson regression.

Results

In total, 91 athletes, average age 18.8 (± 6.7) years, who underwent ACL reconstruction at a single institution from 2014 to 2021 were identified with an average follow-up time of 4.6 (± 2.5) years (range 1.1, 9.0). Meniscal involvement (1.11; 95% confidence interval [CI] 1.08-1.15, P < .001) and previous knee surgery (1.43; 95% CI 1.29-1.58; P < .001) were related to a delayed RTS. Quadriceps tendon and bone-patellar tendon-bone autografts, as well as allograft, showed a significant association with a longer RTS time when compared with hamstring autograft (1.16, 95% CI 1.13-1.20, P < .001; 1.04, 95% CI 1.01-1.07, P = .020; 1.11, 95% CI 1.03-1.19, P = .004, respectively), as did anteromedial portal drilling, when compared with the outside in approach for femoral drilling (1.19, 95% CI 1.16-1.23, P < .001).

Conclusions

Previous knee surgery, anteromedial femoral drilling, quadriceps tendon autograft, and meniscus tear were most associated with a delayed timeline for RTS among young athletes who were able to return.

Level of Evidence

Level IV, prognostic case series.

Effects of clamshell exercises in terminal extension lag after ACL reconstruction

BACKGROUND

Terminal extension lag (TEL) is common following anterior cruciate ligament reconstruction (ACLR). Clamshell exercises have been suggested as a potential intervention to address TEL, but limited research has been conducted in this area.

OBJECTIVE

This study aimed to determine the effects of Clamshell exercises in terminal extension lag after anterior cruciate ligament reconstruction.

METHODS

This randomized controlled trial included 40 participants with a history of ACLR between 1 and 3 years prior. Participants were randomly assigned to either the experimental group (Group A) or the control group (Group B). Group A received conventional exercises along with isolated hip strengthening rehabilitation, while Group B received conventional exercises without specific hip strengthening. The primary outcomes were pain levels (Numeric Pain Rating Scale), knee function (International Knee Documentation Committee scores, (IKDC)), range of motions (goniometer) and strength (sphygmomanometer).

RESULTS

In between the group comparison shows that all outcome measures (NPRS, IKDC, Goniometer, Sphygmomanometer) show significant results (p < 0.05). Within-group comparisons (paired sample t-test) show that there was a significant difference (p < 0.05) in all outcome measures of both groups.

CONCLUSION

The addition of Clamshell exercises to the rehabilitation program resulted in a significantly greater reduction in TEL compared to the control group. These findings suggest that Clamshell exercises were found to be an effective intervention for addressing TEL after ACLR.

Outcomes from different aspects indicate the all-inside technique may serve as an ideal option for anterior cruciate ligament reconstruction

PURPOSE

To evaluate the postoperative outcomes of the all-inside technique in arthroscopic anterior cruciate ligament reconstruction (ACLR).

METHODS

Patients who underwent ACLR using the all-inside technique between 2018 and 2021 were retrospectively assessed. All patients were followed up for at least 2 years. Functional recovery and pain relief were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS) and visual analogue scale (VAS). Instrumented laxity was assessed via side-to-side difference using the Kneelax3 arthrometer. Graft maturity was estimated using the signal-to-noise quotient value based on magnetic resonance imaging (MRI). Adverse events during and after the surgery were recorded.

RESULTS

A total of 78 patients were included in this study, with a mean age of 28.1 ± 7.6 years. The IKDC (p < 0.001), Lysholm (p < 0.001) and KOOS (p < 0.001 for all subgroups) scores at the final follow-up were significantly higher than those before the surgery. The VAS scores (p < 0.05) were significantly lower than those before surgery. The side-to-side difference results indicated that 50 patients had a difference of less than 3 mm, indicating a tight graft, whereas only 1 patient had a difference of >5 mm, indicating a loose graft. The median signal-to-noise quotient of the graft on MRI was 1.4 (P25, P75: 1.0, 2.0). No intraoperative adverse events were observed. Postoperative adverse events included three cases of infection, three cases of graft rerupture, two cases of cyclops lesion and one case of surgical intervention for a meniscal tear.

CONCLUSION

ACLR using the all-inside technique offers promising results in patients with ACL rupture.

LEVEL OF EVIDENCE

Level IV.

What is the impact of Kinesio taping on anterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

As a therapeutic intervention for several musculoskeletal illnesses, the benefits and effectiveness of Kinesio taping (KT) are currently unclear. This systematic review and meta-analysis's (MA) goal is to evaluate the effectiveness of KT for anterior cruciate ligament (ACL) reconstruction and its impact on clinical outcomes.

METHODS

A comprehensive search of online databases was done to discover relevant studies. Inclusion criteria included controlled or randomized clinical trials that were published in English. Changes in pain, flexion strength, and extension strength were among the outcomes of interest. RevMan 5.4 was used to extract and analyze data.

RESULTS

After satisfying the inclusion requirements, five studies were included in the MA. Pooled analysis showed that, in comparison with the intervention group, the control group had a statistically significant improvement in flexion strength (Standardized mean difference (SMD) = 0.44, 95% Confidence interval (CI) [0.01, 0.87], p = 0.04). Extension strength and pain, however, did not significantly differ between the intervention and control groups (SMD = 30, 95% CI [- 0.12, 0.72], p = 0.16), (SMD = 0.26, 95% CI [- 0.14, 0.66], p = 0.20), respectively.

CONCLUSIONS

This analysis suggests limited to no benefits of KA post-ACL reconstruction. While the control group surprisingly showed better improvement in flexion strength, no significant differences were found in extension strength and pain. Further rigorous trials are needed to confirm its utility in rehabilitation.

Rehabilitation and Return to Play Protocols After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review

BACKGROUND

Rehabilitation after anterior cruciate ligament ACL reconstruction (ACLR) is crucial for safe return to play (RTP) and reducing the chances of a reinjury. Yet, there is no consensus on the ideal functional tests to assess rehabilitation progress in soccer players after ACLR.

PURPOSE

The primary objective was to highlight the existing gap in the literature concerning the most effective standardized rehabilitation protocols and testing for facilitating successful RTP among soccer players.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review using PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. Inclusion criteria encompassed original studies (level of evidence 1-4) that examined rehabilitation protocols, metrics of knee rehabilitation, and clinical outcomes after ACLR in soccer players.

RESULTS

This review incorporated 23 studies, predominantly retrospective case series, with a total number of 874 soccer players who underwent ACLR and rehabiliation. 5 (21.7%) studies utilized an accelerated rehabilitation protocol, while 7 (30.4%) of studies utilized a criterion-based rehabilitation. A wide heterogeneity of data was extracted including functional tests of rehabilitation and RTP such as strength test batteries, hop test batteries, and movement quality assessments. Of the 23 selected studies, 2 (8.7%) used all 3 test batteries, 8 (34.8%) used 2 test batteries, 12 (52.2%) used 1 test battery, and 1 (4.3%) used 0 of the test batteries. The mean time between surgery and RTP ranged from 3 to 8 months with only 2 (8.7%) studies reporting complications after ACLR. Lastly, out of the total studies examined, 9 (39.1%) assessed patient-reported outcome measures (PROMs), all of which demonstrated significant improvement from the initial assessment to the final follow up.

CONCLUSION

Soccer-specific rehabilitation after ACLR lacks standardization. Even though many studies have assessed protocols for optimal RTP and reduced secondary ACL injuries, there is a gap in the literature regarding the most effective protocols and RTP testing. The methodology reported by Kyritsis et al could serve as a foundation for future prospective randomized multicenter studies to establish a standard rehabilitation protocol and enable a successful return to soccer.

Comparative Effectiveness of Supervised and Home-Based Rehabilitation after Anterior Cruciate Ligament Reconstruction in Competitive Athletes

Background: After the increasingly common anterior cruciate ligament reconstruction (ACLR) procedure in competitive athletes, rehabilitation is crucial for facilitating a timely return to sports (RTS) and preventing re-injury. This pilot study investigates the patient-reported outcomes of postoperative rehabilitation in competitive athletes, comparing supervised rehabilitation (SVR) and home-based rehabilitation (HBR). Methods: After ACLR, 60 (out of 74 screened) athletes were recruited and equally divided into HBR and SVR groups using non-probability convenience sampling, with each group comprising 15 males and 15 females. The rehabilitation outcomes in the respective groups were evaluated at 8 months using measures (Tegner Activity Scale [TAS], International Knee Documentation Committee subjective knee form [IKDC-SKF], ACL Return to Sport after Injury [ACL-RSI]) and objective parameters (isometric muscle strength, hamstring/quadricep asymmetry). RTS was evaluated at 9 months, with ACL re-injury rates recorded approximately 6 months post-RTS. Results: Both groups exhibited decreased TAS scores (HBR: 8 to 6, SVR: 8 to 7), with the SVR group demonstrating superior postoperative IKDC-SKF scores (81.82 vs. 68.43) and lower ACL-RSI scores (49.46 vs. 55.25). Isometric and isokinetic muscle strength, along with asymmetry values, was higher in the SVR group 8 months post-ACLR (p < 0.05). The SVR group showed a higher RTS rate to the same level (76.6% vs. 53.3%), while the re-injury rate was the same in both the rehabilitation groups (3.3%). Conclusions: Although both rehabilitation approaches yielded comparable outcomes, SVR may demonstrate some superior biomechanical improvements in athletes, resulting in a higher RTS rate. However, the psychological outcomes and re-injury rates did not significantly differ between the groups, emphasizing the need to address individual psychological needs during rehabilitation. Further investigation is recommended with a larger sample size to address the differences of gender among competitive athletes.

Intermittent Cyclic Stretch of Engineered Ligaments Drives Hierarchical Collagen Fiber Maturation in a Dose- and Organizational-Dependent Manner

Hierarchical collagen fibers are the primary source of strength in tendons and ligaments, however these fibers do not regenerate after injury or with repair, resulting in limited treatment options. We previously developed a culture system that guides ACL fibroblasts to produce native-sized fibers and fascicles by 6 weeks. These constructs are promising ligament replacements, but further maturation is needed. Mechanical cues are critical for development in vivo and in engineered tissues; however, the effect on larger fiber and fascicle formation is largely unknown. Our objective was to investigate whether intermittent cyclic stretch, mimicking rapid muscle activity, drives further maturation in our system to create stronger engineered replacements and to explore whether cyclic loading has differential effects on cells at different degrees of collagen organization to better inform engineered tissue maturation protocols. Constructs were loaded with an established intermittent cyclic loading regime at 5 or 10% strain for up to 6 weeks and compared to static controls. Cyclic loading drove cells to increase hierarchical collagen organization, collagen crimp, and tissue mechanics, ultimately producing constructs that matched or exceeded immature ACL properties. Further, the effect of loading on cells varied depending on degree of organization. Specifically, 10% load drove early improvements in mechanics and composition, while 5% load was more beneficial later in culture, suggesting a cellular threshold response and a shift in mechanotransduction. This study provides new insight into how cyclic loading affects cell-driven hierarchical fiber formation and maturation, which will help to develop better rehabilitation protocols and engineer stronger replacements.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Level of evidence

Level I, Randomised controlled trial with no negative criteria.

Establishing Normal Variances and Expectations for Quadriceps Limb Symmetry Index Benchmarks Based on Time from Surgery After Anterior Cruciate Ligament Reconstruction

The anticipated timeline for muscle strength as well as return to running and sports are some of the most common inquiries by patients undergoing anterior cruciate ligament reconstruction. Despite the popularity of this procedure, the answers to these inquiries are not well described in the literature. The purpose of this study was to evaluate the range of quadriceps strength percentage and function benchmarks at various points after anterior cruciate ligament reconstruction surgery based on sex, age, and graft.

Design

Observational Cohort Study.

Methods

Patients who underwent anterior cruciate ligament reconstruction (ACLR) were evaluated at various points after their surgery with handheld dynamometer assessments. Additional hop and balance testing was performed and patients were evaluated for clearance for running and sport via a physical therapist directed functional movement assessment (FMA). The progression of quadriceps symmetry throughout the postoperative period was examined with multi-level models, estimates of time to reach 70%, 80%, and 90% quadriceps symmetry were obtained from the fitted model.

Results

A total of 164 patients were evaluated. Patients either received bone-tendon-bone (BTB) autograft (n=118) or BTB allograft (n=46) for their ACL graft. Average age was 31.1 years-of-age (SD: 13.6). Males undergoing ACLR using BTB autograft (n=53) were able to achieve 80% quadriceps symmetry earlier than females (n=65) (5.7 months vs 7.1 months), were cleared to return to run sooner (5.6 months vs 6.8 months) and passed an FMA exam earlier (8.5 months vs 10 months). Males undergoing ACLR with allograft (n=13) were able to achieve 80% quadriceps symmetry earlier than females (n=33) (3.9 months vs 5.4 months) and were cleared to run sooner (4.5 months vs 5.8 months).

Conclusion

Patients undergoing BTB autograft obtain 80% quadriceps symmetry at an average of 5.7 months for males and 7.1 months for females. Individuals under the age of 25 obtain their quadriceps symmetry faster and are cleared to return to running faster than individuals over 25. Male sex is associated with decreased amount of time to obtain clearance for running and for full activity. Male sex is associated with decreased amount of time to regain quadriceps symmetry however this was not significant.

Level of Evidence

4 (Case series).

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

INTRODUCTION

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

METHOD AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

PROSPERO REGISTRATION NUMBER

CRD42023437115.

Clinical and Radiological Outcomes After Combined ACL and MPFL Reconstruction Versus Isolated ACL Reconstruction for ACL Injury With Patellar Instability

BACKGROUND

An anterior cruciate ligament (ACL) injury accompanied by patellar instability (PI) is a topic that has gained orthopaedic surgeons' attention recently. Untreated PI is reportedly associated with worse clinical outcomes after isolated ACL reconstruction (ACLR) in patients after an ACL injury with PI. Nevertheless, the appropriate surgical approach and its long-term therapeutic effects in these patients remain unclear.

PURPOSE

(1) To compare the clinical and radiological outcomes between isolated ACLR (iACLR) and combined ACLR and medial patellofemoral ligament reconstruction (cAMR) in patients after an ACL injury with PI and (2) to explore the correlations between these 2 procedures and clinical and radiological outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 106 patients diagnosed with an ACL injury accompanied by PI between January 2016 and April 2021 were analyzed in this study. There were 34 patients excluded because of missing postoperative radiological data. Among the remaining 72 patients, 34 patients underwent iACLR, while 38 patients underwent cAMR. Demographic characteristics, intraoperative findings, and patient-reported outcomes (Lysholm score, subjective International Knee Documentation Committee score, and Tegner activity score) were prospectively collected. Patellar alignment parameters and worsening patellofemoral osteoarthritis (PFOA) features (evaluated with the modified Whole-Organ Magnetic Resonance Imaging Score) were analyzed longitudinally on magnetic resonance imaging. The Kujala score was used to evaluate the functional recovery of the patellofemoral joint, and redislocations of the patella were prospectively recorded. Finally, multivariate logistic regression analysis was used to explore the correlations between these 2 procedures and clinical (not achieving the minimal detectable change [MDC] for the Lysholm score) and radiological (worsening PFOA features) outcomes.

RESULTS

The mean follow-up duration was 28.9 ± 6.2 and 27.1 ± 6.8 months for the iACLR and cAMR groups, respectively (P = .231). Significantly higher Lysholm scores (88.3 ± 9.9 vs 82.1 ± 11.1, respectively; P = .016) and subjective International Knee Documentation Committee scores (83.6 ± 11.9 vs 78.3 ± 10.2, respectively; P = .046) were detected in the cAMR group compared with the iACLR group postoperatively. The rates of return to preinjury sports were 20.6% and 44.7% in the iACLR and cAMR groups, respectively (difference, 24.1% [95% CI, 3.3%-45.0%]; P = .030). Moreover, the rates of worsening PFOA features were 44.1% and 18.4% in the iACLR and cAMR groups, respectively (difference, 25.7% [95% CI, 4.9%-46.4%]; P = .018). In addition, significantly higher Kujala scores (87.9 ± 11.3 vs 80.1 ± 12.0, respectively; P = .006), lower redislocation rates (0.0% vs 11.8%, respectively; difference, 11.8% [95% CI, 0.9%-22.6%]; P = .045), and significantly better patellar alignment were detected in the cAMR group compared with the iACLR group postoperatively. Furthermore, multivariate logistic regression analysis determined that iACLR and partial lateral meniscectomy were significantly correlated with not achieving the MDC for the Lysholm score and worsening PFOA features in our study population.

CONCLUSION

In patients after an ACL injury with PI, cAMR yielded better clinical and radiological outcomes compared with iACLR, with better patellar stability and a lower proportion of worsening PFOA features. Furthermore, not achieving the MDC for the Lysholm score and worsening PFOA features were significantly correlated with iACLR and partial lateral meniscectomy. Our study suggests that cAMR may be a more appropriate procedure for patients after an ACL injury with PI, which warrants further high-level clinical evidence.

The Influence of Psychosocial Factors on Patients Undergoing Anterior Cruciate Ligament Reconstruction

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.

The impact of physiotherapy interventions on enhancing wound healing post knee osteoarthritis surgery: A meta-analysis

In knee osteoarthritis surgery, managing postoperative wound healing and minimizing scar formation are pivotal for patient recovery and satisfaction. These aspects are particularly challenging due to the nature of the surgical procedure and patient demographics. Physiotherapy interventions are increasingly recognized for their role in improving these postoperative outcomes. This meta-analysis sought to evaluate the efficacy of physiotherapy in enhancing wound healing, as measured by REEDA scores, and reducing scar formation, as indicated by Manchester Scar Scale (MSS) scores, following knee osteoarthritis surgery. Analysing data from eight studies, we found that physiotherapy significantly improved wound healing, evidenced by lower REEDA scores (SMD = -19.58, 95% CI: [-22.49, -16.66], p < 0.01), and reduced scar formation, reflected in lower MSS scores (SMD = -24.79, 95% CI: [-30.03, -19.55], p < 0.01). These findings highlight the crucial role of physiotherapy in postoperative care for knee osteoarthritis patients, emphasizing its impact on enhancing recovery and improving surgical outcomes.

The Role of Artificial Intelligence in Anterior Cruciate Ligament Injuries: Current Concepts and Future Perspectives

The remarkable progress in data aggregation and deep learning algorithms has positioned artificial intelligence (AI) and machine learning (ML) to revolutionize the field of medicine. AI is becoming more and more prevalent in the healthcare sector, and its impact on orthopedic surgery is already evident in several fields. This review aims to examine the literature that explores the comprehensive clinical relevance of AI-based tools utilized before, during, and after anterior cruciate ligament (ACL) reconstruction. The review focuses on current clinical applications and future prospects in preoperative management, encompassing risk prediction and diagnostics; intraoperative tools, specifically navigation, identifying complex anatomic landmarks during surgery; and postoperative applications in terms of postoperative care and rehabilitation. Additionally, AI tools in educational and training settings are presented. Orthopedic surgeons are showing a growing interest in AI, as evidenced by the applications discussed in this review, particularly those related to ACL injury. The exponential increase in studies on AI tools applicable to the management of ACL tears promises a significant future impact in its clinical application, with growing attention from orthopedic surgeons.

A Technique for Hamstring Donor-Site Injection With Anesthetic Cocktail in Remnant-Preserving Anterior Cruciate Ligament Reconstruction

Arthroscopic anterior cruciate ligament reconstruction is a common procedure that requires effective postoperative pain management for successful rehabilitation. Opioids are traditionally used for pain relief, but their side effects decrease their widespread use. Local anesthesia techniques have gained interest as an alternative to opioids. This Technical Note discusses the use of an anesthetic cocktail for pain relief at the hamstring's donor site in anterior cruciate ligament reconstruction. This approach may enhance early rehabilitation and patient satisfaction.

Limited preoperative knee extension in anterior cruciate ligament reconstruction using a hamstring tendon affects improvement of postoperative knee extensor strength

PURPOSE

This study aimed to determine the factors affecting knee extensor strength 6 months after anterior cruciate ligament (ACL) reconstruction using autograft hamstring tendon.

METHODS

144 patients who could undergo regular follow-up after ACL reconstruction were divided into 2 groups: those with greater than 90% (Group A: n = 95) and less than 85% (Group B: n = 49) isokinetic knee contraction at 60°/s 6 months post-ACL reconstruction. Basic information, injury status, limited preoperative knee extension, and knee extensor strength at 3 and 6 months postoperatively were compared between the groups. Multivariate logistic analysis was performed and included variables that showed statistically significant differences between the groups in the univariate analysis. In addition, the cut-off value for the limb symmetry index (LSI) at 3 months postoperatively needed to exceed an LSI of 90% at 6 months postoperatively was calculated using the receiver operating characteristics curve.

RESULTS

Age, preoperative waiting period, limited preoperative knee extension, and knee extensor strength at 3 months postoperatively were significantly different between the two groups. The multivariate logistic analysis showed that all the variables affected the improvement in knee extensor strength at 6 months postoperatively. Limited preoperative knee extension was the most significant factor (odds ratio: 15.1, 95% confidence interval: 2.57-118.56, p < 0.01). The LSI cut-off value at 3 months postoperatively was 72.0%.

CONCLUSION

Key factors in achieving the necessary knee extensor strength criteria for return to sports at 6 months post-ACL reconstruction include addressing limited preoperative knee extension and achieving an LSI ≥ 72% in knee extensor strength at 3 months postoperatively.

LEVEL OF EVIDENCE

Level III.

Persistence of neuromuscular activation deficit in the lower limb at 3-years of follow-up after ACL reconstruction surgery

BACKGROUND

Almost all patients experience neuromuscular disorders of the quadriceps after knee trauma or surgery such as anterior cruciate ligament (ACL) reconstruction. This phenomenon is described in literature as arthrogenic muscle inhibition (AMI). It can be detrimental to patients and cause complications. However, few studies have evaluated the long-term persistence of deficits arising from this, following ACL reconstruction.

PURPOSE

By comparing neuromuscular activation in the lower limb after ACL reconstruction with the unaffected lower limb, after more than 3-years of follow-up, this study aimed to evaluate the possible persistence of long-term deficits after surgery.

METHODS

Fifty-one patients who underwent ACL reconstruction in 2018 were included in the study, with a minimum follow-up of 3 years. The neuromuscular activation deficit was assessed using the Biarritz Activation Score-Knee (BAS-K), whose intra- and inter-observer reproducibility was also evaluated. The ACL-RSI, KOOS, SANE Leg, Tegner and IKDC scores were also evaluated.

RESULTS

The mean BAS-K score of the knee that underwent surgery was 21.8/50 versus 37.9/50 in the healthy knee (p < 0.05). The SANE leg score was 76.8/100 versus 97.6/100 (p < 0.05). The mean IKDC was 84.17 (±12.7). The mean KOOS was 86.2 (±9.2). The mean ACL-RSI was 70 (±7.9) and the Tegner score was 6.3 (±1.2). Intra- and inter-observer reproducibility was satisfactory for the BAS-K score.

CONCLUSION

We found that the neuromuscular activation deficit was high (roughly 42%) at more than 3-years of follow-up after ACL reconstruction. The deficit is not limited to the quadriceps and affects the whole limb. Our findings highlight the need for appropriate rehabilitation after ACL surgery, targeting the corticospinal level in particular.

LEVEL OF EVIDENCE III

prognostic retrospective case-control study.

Dynamic intermittent compression cryotherapy with intravenous nefopam results in faster pain recovery than static compression cryotherapy with oral nefopam: post-anterior cruciate ligament reconstruction

PURPOSE

To evaluate the effectiveness of dynamic intermittent compression cryotherapy (DICC) (CryoNov®) with an intravenous nefopam-based pain management protocol (DCIVNPP) in reducing post-operative pain following anterior cruciate ligament reconstruction (ACLR) compared to static compression cryotherapy (SCC) (Igloo®) and oral Nefopam.

METHODS

This was a retrospective analysis of prospectively collected data including 676 patients who underwent primary ACLR in 2022. Patients were either in the DCIVNPP group or in the SCC (control group), and were matched for age, sex, and Lysholm and Tegner scores (338 per arm). The primary outcome was pain on the visual analogue scale (VAS), analyzed in relation to the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds for VAS. The secondary outcome was side effects.

RESULTS

Postoperative pain in the DCIVNPP group was less severe on the VAS than in the control group (p < 0.05). The maximum difference in the VAS between groups was 0.57, which is less than the MCID threshold for VAS. The DCIVNPP group crossed the PASS threshold for VAS on Day 3, sooner than the control group. The side effect profiles were similar in both groups except for higher rates of dizziness and malaise in the DCIVNPP group, and higher rates of abdominal pain in the control group. Most of the side effects decreased over time in both groups, with no significant side effects after Day 3.

CONCLUSION

DCIVNPP effectively allows for faster pain recovery than in the control group. The difference in side effects between the protocols may be due to mode of administration of nefopam.

LEVEL OF EVIDENCE

III.

There Is Substantial Variation in Rehabilitation Protocols Following Anterior Cruciate Ligament Reconstruction: A Survey of 46 American Orthopaedic Surgeons

PURPOSE

To identify the clinical practice preferences of orthopaedic surgeons regarding anterior cruciate ligament reconstruction (ACLR) rehabilitation through a survey of members of the Arthroscopy Association of North American (AANA) and the American Orthopaedic Society for Sports Medicine (AOSSM).

METHODS

An online survey was distributed to members of AANA and AOSSM between November 2020 and September 2021. Participants reported on their clinical preferences for ACLR protocol development and patient selection, use of technology in ACLR recovery and rehabilitation, and preferences for advancing through multiple phases of the rehabilitative process.

RESULTS

Responses from 46 orthopaedic surgeons were analyzed. Patient-reported outcome measures were not found to be utilized often at various phases of the perioperative period. Thirty-eight (82.6%) participants reported utilization of postoperative bracing. There was no consensus on when participants allow their patients to advance through rehabilitation, but most report waiting 3 to 4 months for advancement to jogging/lateral movement, 6 to 8 months for return to noncontact sport, and 9 months of more for return to unrestricted sport. Many participants utilize functional and strength testing with associated limb symmetry indices to determine patient readiness to return to sport, with 18, 26, and 25 participants reporting use of functional testing and 28, 26, and 27 participants reporting use of strength testing at the return to jogging/lateral movements, noncontact return to sport, and unrestricted return-to-sport phases, respectively.

CONCLUSIONS

This study provides an insight into the rehabilitative protocols and modalities utilized for ACLR by orthopaedic surgeons in practice across the United States. There is notably substantial variation in rehabilitative patterns and preferences, particularly with regards to what constitutes criteria for progressing patients through the phases of returning to unrestricted sport. Additionally, our findings show that while many surgeons believe that quantitative assessment technology could be beneficial in decision-making for returning patients to sport, there are still many barriers that stand in the way of its implementation into clinical practice.

CLINICAL RELEVANCE

Postoperative rehabilitative protocols after ACLR vary by surgeon.

Postless Tape Augmentation for Anterior Cruciate Ligament (ACL) Reconstruction

Suture or tape augmentation for anterior cruciate ligament (ACL) reconstruction has been described as a technique to increase biomechanical strength and potentially improve clinical outcomes. However, the suture or tape used for augmentation usually requires independent tibial fixation from the ACL graft in the form of an anchor or post. This may introduce the potential for graft and augment tension mismatch, while increasing surgical cost. We present our technique for ACL reconstruction with postless tape augmentation. The ACL graft and tape are fixed at the same tension with interference fixation using a single tibial sheath and screw construct, which allows for ACL augmentation without the need for an additional post or implant.

Comparison of post-operative outcomes following anterior cruciate ligament reconstruction between patients with vs. without elevated tibial tubercle-trochlear groove (TT-TG) distance

PURPOSE

It is unclear if an elevated tibial tubercle-trochlear groove (TT-TG) distance is a risk factor for poor outcomes following ACLR. Therefore, the purpose of this study was to determine whether patients with an elevated TT-TG have an increased risk of retear following primary ACLR compared to controls with a normal TT-TG.

METHODS

All patients who underwent primary ACLR between July 2018 and June 2019 with an available preoperative magnetic resonance imaging (MRI) were eligible for inclusion. TT-TG distance was measured on preoperative MRI scans by two independent investigators. Clinical outcomes, return-to-sport rates, and Lysholm scores were compared between patients with a TT-TG < 12.5 mm (normal) and those with a TT-TG ≥ 12.5 mm (elevated).

RESULTS

Overall, 159 patients were included, 98 with normal TT-TG distance and 61 with elevated TT-TG distance. Patients with an elevated TT-TG distance had worse post-operative Lysholm scores than patients with a normal TT-TG distance (83.0 vs. 95.0, p = 0.010). In patients who received a bone-patellar tendon-bone (BTB) graft, an elevated TT-TG distance was associated with higher rates of subjective instability (13.0% vs. 3.0%, p = 0.041), reoperation (13.0% vs. 1.5%, p = 0.012), and post-operative complications (25.0% vs. 8.2%, p = 0.026), as well as lower ACL psychological readiness scores (324.1 vs. 446.7, p = 0.015).

CONCLUSION

Patients with an elevated pre-operative TT-TG distance have worse Lysholm scores than patients with normal TT-TG distance. Patients with an elevated pre-operative TT-TG distance who underwent ACLR with BTB grafts had significantly higher rates of subjective instability, reoperation, and post-operative complications.

LEVEL OF EVIDENCE

III.

Why Sports Should Embrace Bilateral Asymmetry: A Narrative Review

(1) Background: Asymmetry is ubiquitous in nature and humans have well-established bilateral asymmetries in their structures and functions. However, there are (mostly unsubstantiated) claims that bilateral asymmetries may impair sports performance or increase injury risk. (2) Objective: To critically review the evidence of the occurrence and effects of asymmetry and sports performance. (3) Development: Asymmetry is prevalent across several sports regardless of age, gender, or competitive level, and can be verified even in apparently symmetric actions (e.g., running and rowing). Assessments of bilateral asymmetries are highly task-, metric-, individual-, and sport-specific; fluctuate significantly in time (in magnitude and, more importantly, in direction); and tend to be poorly correlated among themselves, as well as with general performance measures. Assessments of sports-specific performance is mostly lacking. Most studies assessing bilateral asymmetries do not actually assess the occurrence of injuries. While injuries tend to accentuate bilateral asymmetries, there is no evidence that pre-existing asymmetries increase injury risk. While training programs reduce certain bilateral asymmetries, there is no evidence that such reductions result in increased sport-specific performance or reduced injury risk. (4) Conclusions: Bilateral asymmetries are prevalent in sports, do not seem to impair performance, and there is no evidence that suggests that they increase injury risk.

Deficits in Contralateral Limb Strength Can Overestimate Limb Symmetry Index After Anterior Cruciate Ligament Reconstruction

Purpose

To evaluate whether contralateral limb strength represents a dynamic, rather than static, data point after anterior cruciate ligament reconstruction (ACL-R).

Methods

Patients who underwent isolated ACL-R at a single institution were identified. Patients completed an institutional Lower-Extremity Assessment Protocol (LEAP) testing protocol at 6 and 9 months postoperatively. Extension strength and flexion strength of the ipsilateral and contralateral limbs and limb symmetry index (LSI) were compared between the 6- and 9-month testing outcomes. Subgroup analysis compared patients demonstrating less than or greater than 10% change in contralateral limb flexion and extension strength between 6 and 9 months postoperatively.

Results

A total of 144 subjects were included in this study. On average, contralateral limb flexion and extension strength increased 2-4% between 6 and 9 months postoperatively. However, the contralateral limb increased >10% from 6 to 9 months in extension and flexion strength in 35/144 (24.3%) and 55/144 (38.2%) of patients, respectively. The cohort with >10% change between 6 and 9 months had significantly weaker contralateral extension and flexion strength at 6 months compared to the cohort that demonstrated <10% change (extension: 2.00 vs 2.39; P < .001; flexion: 0.84 vs 1.08; P < .001), but similar ipsilateral limb performance. Therefore, the >10% change cohort had a significantly greater LSI at 6 months compared to the <10% change cohort (67.3% vs 59.4%; P = .006). No demographic or operative factors correlated with which patients demonstrated >10% flexion or extension strength changes of the contralateral limb.

Conclusion

A large percentage of patients demonstrate significant changes in their contralateral limb flexion and extension strength between 6 and 9 months postoperatively that result from an initial contralateral limb strength deficit. This may limit the utility of the contralateral limb as a control for comparison to the operative extremity during return to sport assessment.

Therapeutic Patient Education after Anterior Cruciate Ligament Reconstruction: Evaluation of the Knowledge and Certitudes with a Self-Report Questionnaire

Therapeutic education aims to help patients acquire skills and knowledge, and to improve psychosocial aspects to manage chronic disease. After anterior cruciate ligament reconstruction (ACLR), only 35 to 60% of the patients are able to go back to their previous sport. Return to sport depends on the motivation of the patient. No therapeutic education has already been proposed. We aimed to evaluate the effect of therapeutic education sessions on knowledge improvement during inpatient rehabilitation after ACLR, compared to patients operated with the same surgical technic, but who had no therapeutic education because of outpatient rehabilitation. Sessions were performed by a multidisciplinary team. The evaluation of the knowledge was performed with a true or false 12-items self-report questionnaire. Fifty-four patients were studied and compared to 54 patients with no therapeutic education. The educated and the non-educated groups were comparable. The number of correct answers increased from 73% before therapeutic education to 95% at the end of the hospitalization (p < 0.001). This improvement persisted over time with 91.5% of correct answers at four months (p = 0.94). The non-educated group had 70% of correct answers. This was significantly lower than the results obtained from the educated group at four months (p < 0.001). It was comparable to the result obtained before therapeutic education (p = 0.91). Therapeutic patient education performed during hospitalization for rehabilitation enables patients to have a better knowledge of the stages from rehabilitation to return to sport and the risks of complication after ACLR.