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Moran TE, Driskill EK, Tagliero AJ, Klosterman EL, Ramamurti P, Reahl GB, Miller MD. Combined tibial deflexion osteotomy and anterior cruciate ligament reconstruction improves knee function and stability: A systematic review. J ISAKOS 2024; 9:709-716. [PMID: 38945397 DOI: 10.1016/j.jisako.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/23/2024] [Accepted: 06/25/2024] [Indexed: 07/02/2024]
Abstract
IMPORTANCE Patients with excessive posterior tibial slope (PTS) may have higher risks of anterior cruciate ligament (ACL) reconstruction (ACL-R) failure, and clinical outcomes after revision of ACL-R procedures are typically poor. OBJECTIVE This study aimed to perform a systematic review of the literature summarizing the clinical and radiological outcomes of the surgical treatment of ACL insufficiency in the setting of excessive PTS using a tibial deflexion osteotomy combined with ACL-R. EVIDENCE REVIEW A systematic review of the literature was performed using PubMed, Cochrane Library, and OVID Medline databases from 1990 to present. Inclusion criteria were studies of outcomes of isolated tibial deflexion osteotomies performed with primary or revision ACL-R in the English language. Data extracted included study demographic information, type of tibial deflexion osteotomy and concomitant procedures, radiological outcomes, patient-reported outcome scores, and postoperative complications. FINDINGS Six studies, with 133 knees were identified. All included studies were retrospective case series, with a weighted mean follow-up of 3.39 years. In 106 of 133 (79.7%) knees, tibial deflexion osteotomy was performed concomitantly with an ACL-R, whereas in 27 of 133 (20.3%) knees, the procedures were staged. 22, 45, and 66 of 133 knees (16.5%, 33.8%, and 49.6%) underwent primary, first revision, and second or greater revision ACL-R, respectively. Three of 133 (2.25%) knees demonstrated recurrent ACL graft failure at the final follow-up. On average, PTS decreased from 15.2° preoperatively to 7.1° postoperatively. The mean International Knee Documentation Committee, Lysholm, and Tegner scores increased from 42.5, 46.4, and 4.2 preoperatively to 71.8, 89.0, and 6.7 postoperatively. CONCLUSIONS The results of this review suggest that combined ACL-R and tibial deflexion osteotomy may be effective in decreasing PTS and improving knee function and stability. STUDY DESIGN Systematic Review; Level of evidence 4.
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Affiliation(s)
- Thomas E Moran
- University of Virginia Health System, Department of Orthopaedic Surgery, USA.
| | | | - Adam J Tagliero
- University of Virginia Health System, Department of Orthopaedic Surgery, USA
| | - Emma L Klosterman
- University of Virginia Health System, Department of Orthopaedic Surgery, USA
| | - Pradip Ramamurti
- University of Virginia Health System, Department of Orthopaedic Surgery, USA
| | - G Bradley Reahl
- University of Virginia Health System, Department of Orthopaedic Surgery, USA
| | - Mark D Miller
- University of Virginia Health System, Department of Orthopaedic Surgery, USA
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Tollefson LV, Kennedy NI, Banovetz MT, Homan MD, Engebretsen L, Moatshe G, Wulf CA, Larson CM, LaPrade RF. Supratubercle Anterior Closing Wedge Osteotomy: No Changes in Patellar Height and Significant Decreases in Anterior Tibial Translation at 6 Months Postoperatively. Am J Sports Med 2024; 52:1990-1996. [PMID: 38828643 DOI: 10.1177/03635465241252982] [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] [Indexed: 06/05/2024]
Abstract
BACKGROUND Because of the increased prevalence of revision anterior cruciate ligament (ACL) reconstruction, there has been a desire to understand the role of posterior tibial slope on increased anterior tibial translation and increased ACL graft forces. One potential concern in supratubercle anterior closing wedge proximal tibial osteotomy (ACW-PTO) for decreasing the posterior tibial slope is the risk of altering the patellar height. PURPOSE To radiographically assess changes in (1) patellar height, (2) anterior tibial translation, and (3) posterior tibial slope after supratubercle ACW-PTO. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent supratubercle ACW-PTO by a single surgeon between July 2019 and June 2023 were included. Standardized lateral knee weightbearing radiographs to assess patellar height (via the Caton-Deschamps index), anterior tibial translation of the lateral tibial plateau relative to the lateral femoral condyle, and posterior tibial slope were obtained at 4 time points (preoperatively and 1 day, 3 months, and 6 months postoperatively). Paired t test was used to compare differences between preoperative, 1-day, and 3- and 6-month values for patellar height as measured using the Caton-Deschamps index and for posterior tibial slope. Paired t test was also used to compare differences in the preoperative and 6-month postoperative values for anterior tibial translation. RESULTS In 20 patients after ACW-PTO, the Caton-Deschamps index demonstrated a significant increase in patellar height on postoperative day 1 (P < .001) but no significant differences at 3 (P = .057) and 6 (P = .176) months postoperatively. Anterior tibial translation on standing lateral knee radiographs was significantly decreased by a mean of 8.9 mm from preoperatively to 6 months postoperatively (P < .001). Posterior tibial slope was significantly decreased by a mean of 11.2° from preoperatively to 6 months postoperatively (P < .001). CONCLUSION Supratubercle ACW-PTO performed for ACL reconstruction failure in the setting of an increased posterior tibial slope did not induce significant changes in patellar height postoperatively. Furthermore, after ACW-PTO, there was a significant decrease in anterior tibial translation and posterior tibial slope.
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Affiliation(s)
| | | | - Mark T Banovetz
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Glover MA, St Jeor JD, Parikh N, Rider DE, Bullock GS, Trasolini NA, Waterman BR. 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. Arthrosc Sports Med Rehabil 2024; 6:100911. [PMID: 39006786 PMCID: PMC11240041 DOI: 10.1016/j.asmr.2024.100911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 02/07/2024] [Indexed: 07/16/2024] Open
Abstract
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.
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Affiliation(s)
- Mark A Glover
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Jeffery D St Jeor
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Nihir Parikh
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Danielle E Rider
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia, U.S.A
| | - Garrett S Bullock
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Nicholas A Trasolini
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A
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Figueroa D, Figueroa ML, Figueroa F. Return to sports in female athletes after anterior cruciate ligament reconstruction: A systematic review and metanalysis. J ISAKOS 2024; 9:378-385. [PMID: 38242500 DOI: 10.1016/j.jisako.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/26/2023] [Accepted: 01/14/2024] [Indexed: 01/21/2024]
Abstract
IMPORTANCE Return to sport (RTS) is considered an indicator of successful recovery after anterior cruciate ligament reconstruction (ACLR). In recent years, there has been major interest in documenting RTS following anterior cruciate ligament (ACL) injury. Despite women being at increased risk for ACL injuries and a global increase in women's participation in sports, research has not adequately focused on female athletes. OBJECTIVE The purpose of this study is to conduct a systematic review and meta-analysis evaluating the RTS rate in female athletes after ACLR. We hypothesize that most of the female athletes can RTS. EVIDENCE REVIEW A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Electronic databases (PubMed, Embase, and Epistemonikos) were searched for articles reporting RTS rates and contextual data in female athletes. The following search terms were used: "anterior cruciate ligament reconstruction" OR "ACL reconstruction" AND "female" OR "women" AND "return to sports" OR "return to play" to retrieve all relevant articles published between 2003 and 2023. A quality assessment of the included studies was conducted. FINDINGS Fifteen articles were included, reporting on 1456 female athletes participating in pivoting sports. The included studies comprised 9 cohorts, 1 case-control study, 2 case series, 2 descriptive epidemiology studies, and 1 observational study. Eight out of fifteen studies focused solely on elite-level athletes. The participants had a mean age of 23.13 years. Soccer was the most prevalent sport among the participants, accounting for 49.7% of all athletes included. All 15 studies reported an RTS rate, yielding a meta-proportion of 69% [95% CI, 58-80%] for RTS. Nine articles reported the average time to RTS, which was 10.8 months [95% CI, 8.7-12.8 months]. CONCLUSIONS This systematic review demonstrates that a majority of female athletes (69 %) can RTS participation at an average of 10.8 months, however, the available information is insufficient, and quantitative data and reasons for not returning to play are lacking. Future studies should establish return-to-play criteria in this population and determine reasons for not returning to play. LEVEL OF EVIDENCE III.
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Affiliation(s)
- David Figueroa
- Departamento de Traumatologia, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, 7650568, Chile
| | - María Loreto Figueroa
- Departamento de Traumatologia, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, 7650568, Chile.
| | - Francisco Figueroa
- Departamento de Traumatologia, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, 7650568, Chile; Departamento de Traumatología, Hospital Dr. Sótero del Río, Santiago, 8207257, Chile
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Kemler B, Coladonato C, Sonnier JH, Campbell MP, Darius D, Erickson BJ, Tjoumakaris FP, Freedman KB. Evaluation of Failed ACL Reconstruction: An Updated Review. Open Access J Sports Med 2024; 15:29-39. [PMID: 38586217 PMCID: PMC10998505 DOI: 10.2147/oajsm.s427332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/23/2024] [Indexed: 04/09/2024] Open
Abstract
Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.
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Affiliation(s)
- Bryson Kemler
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Michael P Campbell
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Danielle Darius
- Department of Education, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
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Raeder C, Kämper M, Praetorius A, Tennler JS, Schoepp C. Metabolic, cognitive and neuromuscular responses to different multidirectional agility-like sprint protocols in elite female soccer players - a randomised crossover study. BMC Sports Sci Med Rehabil 2024; 16:64. [PMID: 38448940 PMCID: PMC10916312 DOI: 10.1186/s13102-024-00856-y] [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: 03/15/2023] [Accepted: 02/22/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE Resistance to fatigue is a key factor in injury prevention that needs to be considered in return-to-sport (RTS) scenarios, especially after severe knee ligament injuries. Fatigue should be induced under game-like conditions. The SpeedCourt (SC) is a movement platform for assessing multidirectional sprint performance, typical of game-sports, due to change-of-direction movements in response to a visual stimulus. Designing adequate fatigue protocols requires the suitable arrangement of several loading variables such as number of intervals, sprint distance or work/relief ratio (W:R). Therefore, this study analysed the acute fatigue effects of different SC protocols on metabolic load, cognitive function and neuromuscular performance. METHODS Eighteen female soccer players (mean ± SD; age: 23.1 ± 4.6 years) of the 1st German Division participated in this randomised, crossover study. Using a random allocation sequence, players completed four volume-equated protocols differing in W:R and sprint distance per interval (P1:12 × 30 m, W:R = 1:2 s; P2:12 × 30 m, W:R = 1:3 s; P3:18 × 20 m, W:R = 1:2 s; P4:18 × 20 m, W:R = 1:3 s). Pre- and post-exercise, metabolic load was measured per blood lactate concentration (BLaC), cognitive function per reaction time (RT), and neuromuscular performance including multiple rebound jumps (MRJ height, primary outcome variable; Reactive Strength Index, RSI) and 5 m sprint times (SP5). RESULTS Repeated-measures ANOVA revealed significant main time effects (p < .05) with improved performance post-exercise in RT (504 vs. 482 ms, d = 1.95), MRJ height (24.0 vs. 24.8 cm, d = 0.77), RSI (1.39 vs. 1.43, d = 0.52), and SP5 (1.19 vs. 1.17 s, d = 0.56). There was significant main time (p < .001) and time x protocol interaction effects in BLaC (p < .001). P1 induced higher BLaC values (4.52 ± 1.83 mmol/L) compared to P2 (3.79 ± 1.83 mmol/L; d = 0.74) and P4 (3.12 ± 1.83 mmol/L; d = 1.06), whereas P3 (4.23 ± 1.69 mmol/L) elicited higher BLaC values compared to P4 (d = 0.74). CONCLUSION All protocols caused an improved cognitive function and neuromuscular performance. The former may be related to enhanced noradrenergic activation or exercise specificity which induced an improved stimulus processing. The latter may be explained by a possible post-activation performance enhancement effect on jump and sprint performance. A shorter relief duration in W:R as opposed to sprint distance per interval produced higher BLaC values. The protocols may serve as reference data for improved RTS decision-making in elite female soccer players. TRIAL REGISTRATION Deutsches Register Klinischer Studien (DRKS), No.: DRKS00033496 , Registered 19. Februar 2024, Retrospectively Registered.
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Affiliation(s)
- Christian Raeder
- Department of Arthroscopy Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany.
| | - Meike Kämper
- Women´s Soccer Department, MSV Duisburg, Duisburg, Germany
| | - Arthur Praetorius
- Department of Arthroscopy Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
| | - Janina-Sophie Tennler
- Department of Arthroscopy Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
| | - Christian Schoepp
- Department of Arthroscopy Surgery, Sports Traumatology and Sports Medicine, BG Klinikum Duisburg, Duisburg, Germany
- Department of Trauma and Reconstructive Surgery, University Hospital Essen, Essen, Germany
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Momaya A, Harris C, Hargreaves M. Why Your Patient May Need an ACL Reconstruction Plus Lateral Extra-Articular Tenodesis Procedure. Int J Sports Phys Ther 2024; 19:251-257. [PMID: 38439781 PMCID: PMC10909304 DOI: 10.26603/001c.94015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Anterior cruciate ligament (ACL) tears are one of the most common knee injuries experienced by active individuals engaging in cutting sports. Despite improved surgical techniques and rehabilitation, the return to sport rate and re-tear rates remain unsatisfactory. Lateral extra-articular tenodesis (LET) is a procedure that has been growing in interest when performed in conjunction with ACL reconstruction. The benefits of adding an LET procedure to an ACL surgery may include greater rotational stability, decreased re-tear rates, and improved return to play. Level of evidence: V.
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Doxey SA, Kleinsmith RM, Huyke-Hernández FA, Schweitzer A, Only AJ, Tompkins M, Kweon CY, Cunningham BP. Improved Patient-reported Outcomes in Patients Aged 16 and Younger at Two Years After Anterior Cruciate Ligament Reconstruction Despite Relatively High Rates of Reinjury and Repeat Surgery. J Pediatr Orthop 2024; 44:106-111. [PMID: 38031490 DOI: 10.1097/bpo.0000000000002567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) in adolescent patients, particularly those aged 16 and under, are increasingly common procedure that lacks robust clinical and patient-reported outcome (PRO) data. The purpose of this study was to report 2-year PROs of patients receiving ACLR aged 16 or younger using the single assessment numerical evaluation (SANE) and knee injury and osteoarthritis outcome score (KOOS). Secondary aims included characterizing treatment characteristics, return to sport (RTS), and clinical outcomes. METHODS The institutional PRO database was queried for patients receiving ACLR from 2009 to 2020. Patients aged older than 16, revision procedures, concomitant ligament repairs/reconstructions, and patients without full outcome data at 2 years were excluded. Outcomes over 2 years after ACLR included SANE, KOOS, reinjuries, reoperations, and time to RTS. RESULTS A total of 98 patients were included with an average age of 15.0 years. Most patients were females (77.6%). Bone-tendon-bone autograft (69.4%) was the most used. Average RTS was 8.7 months (range: 4.8 to 24.0 mo), with 90% of patients eventually returning to sport. A total of 23 patients (23.5%) experienced a reinjury and 24.5% (n = 24) underwent reoperation. Timing to RTS was not associated with reinjury, but patients who returned between 9.5 and 13.7 months did not sustain reinjuries. Mean KOOS and SANE scores at 2 years were 87.1 and 89.1, respectively, with an average improvement of +18.4 and +22.9, respectively. Change in KOOS was negatively impacted by reinjury to the anterior cruciate ligament graft and reoperation (anterior cruciate ligament failure: +10.0 vs 19.3, P = 0.081, respectively; reoperation: +13.2 vs +20.1, P = 0.051, respectively), though these did not reach statistical significance. CONCLUSION Patients experienced improved SANE and KOOS scores after ACLR. Rates of reinjury and reoperation were relatively high and negatively impacted PRO scores but were not associated with the timing of RTS. Adolescent patients should be counseled regarding the risk of subsequent ipsilateral and contralateral knee injury after ACLR. LEVEL OF EVIDENCE Level IV-case series.
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Affiliation(s)
- Stephen A Doxey
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
| | - Rebekah M Kleinsmith
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
| | - Fernando A Huyke-Hernández
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
| | - Adam Schweitzer
- Department of Orthopaedic Surgery, Des Moines University College of Osteopathic Medicine, Des Moines, IA
| | - Arthur J Only
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
| | - Marc Tompkins
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
| | | | - Brian P Cunningham
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington
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Gao H, Hu H, Sheng D, Sun L, Chen J, Chen T, Chen S. Risk Factors for Ipsilateral Versus Contralateral Reinjury After ACL Reconstruction in Athletes: A Systematic Review and Meta-analysis. Orthop J Sports Med 2023; 11:23259671231214298. [PMID: 38145217 PMCID: PMC10748928 DOI: 10.1177/23259671231214298] [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: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 12/26/2023] Open
Abstract
Background Anterior cruciate ligament (ACL) reinjury after ACL reconstruction (ACLR) can occur on the ipsilateral or contralateral side. Limited evidence exists regarding the difference between the incidence of reinjury to either knee, which is important in developing interventions to prevent ACL reinjury. Purpose To compare the reinjury rate of the ACL on the ipsilateral side versus the contralateral side in athletes after ACLR and investigate the risk factors that may cause different reinjury rates between the sides. Study Design Systematic review; Level of evidence, 4. Methods A systematic review was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies that involved ACL reinjury in athletes after ACLR were reviewed. Considering several risk factors, including age and sex, a comparison of ACL reinjury incidence on the ipsilateral and contralateral sides was performed using a meta-analysis. Results Of the 17 selected studies, 3 were found to be at high risk of bias, and thus, 14 (n = 3424 participants) studies were included in the meta-analysis. In this athletic population, the contralateral ACL had a significantly higher rupture rate than the ipsilateral graft (risk ratio [RR], 1.41; P < .0001). Female athletes were found to have a greater risk of ACL reinjury on the contralateral versus the ipsilateral side (RR, 1.65; P = .0005), but different results were found in male athletes. (RR, 0.81; P = .21). There was no statistical difference in the incidence rate of ACL reinjury to either side in adolescent athletes (RR, 1.15; P = .28). Conclusion The contralateral ACL was more vulnerable to reinjury than the ipsilateral side in athletes after ACLR. Female athletes were more likely to reinjure their contralateral native ACL, while the same trend was not found in their male counterparts. The reinjury rate was comparable in both knees in adolescent athletes.
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Affiliation(s)
- Han Gao
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
- H.G., H.H., and D.S. contributed equally to this study
| | - Haichen Hu
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
- H.G., H.H., and D.S. contributed equally to this study
| | - Dandan Sheng
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
- H.G., H.H., and D.S. contributed equally to this study
| | - Luyi Sun
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Tianwu Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Shiyi Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
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10
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Oladeji L, Reynolds G, Gonzales H, DeFroda S. Anterior Cruciate Ligament Return to Play: Where Are We Now? J Knee Surg 2023. [PMID: 37459893 DOI: 10.1055/a-2130-4909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure, and it is crucial to assess an athlete's readiness to safely return to sports following ACLR to minimize the risk of reinjury. Despite this, determining optimal return to play (RTP) criteria following ACLR that is accurate, accessible, and reproducible remains challenging. This review aims to discuss commonly employed RTP criteria domains, including functional assessments, patient-reported outcomes, and psychological tests, as well as emerging technologies such as magnetic resonance imaging (MRI) that may play a role as a gold standard in RTP assessment. The findings of this review suggest RTP decision making after ACL surgery is nuanced and traditionally used objective measures do not perfectly predict RTS rates or clinical outcomes. In the future, a standardized MRI screening tool could help predict reinjury. The role of functional and psychological patient-reported outcome measures needs to defined, and objective criteria should be rigorously evaluated for whether they accurately screen an athlete's physical readiness and should be expanded to include more sport-specific movement analysis.
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Affiliation(s)
- Lasun Oladeji
- Department of Orthopaedic Surgery, University of Missouri Columbia, Columbia, Missouri
| | - Grace Reynolds
- Department of Orthopaedic Surgery, University of Missouri Columbia, Columbia, Missouri
| | - Hyeri Gonzales
- Department of Orthopaedic Surgery, University of Missouri Columbia, Columbia, Missouri
| | - Steven DeFroda
- Department of Orthopaedic Surgery, University of Missouri Columbia, Columbia, Missouri
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11
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Kuhns BD, Sholtis CD, Reuter JM, Goldblatt J, Bronstein R, Baumhauer JF, Maloney MD, Mannava S. Impact of Sports Participation on Achievement of Clinically Relevant Outcomes 2 Years After ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671231187327. [PMID: 37655256 PMCID: PMC10467379 DOI: 10.1177/23259671231187327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/13/2023] [Indexed: 09/02/2023] Open
Abstract
Background Clinically relevant threshold values associated with patient-reported outcome measures after orthopaedic procedures such as anterior cruciate ligament reconstruction (ACLR) are important for relating these scores to meaningful postoperative improvement. Purpose/Hypothesis The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) for the Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) after ACLR. It was hypothesized that preoperative sport participation would have an impact on PASS achievement. Study Design Case series; Level of evidence, 4. Methods Included were consecutive patients who underwent primary assisted ACLR between January 4 and August 1, 2016. Patients were administered the PROMIS-CAT Physical Function (PF) and Pain Interference domains preoperatively and at a minimum 2 years postoperatively, with external anchor questions used to determine the PASS. Receiver operating characteristic (ROC) curves were constructed for the entire study population as well as separately for athletes and nonathletes to determine PROMIS PASS thresholds for each population. A previously published PROMIS-PF minimal clinically important difference was used to evaluate postoperative improvement. A post hoc multivariate nominal logistic multivariate analysis was constructed to assess the effects of preoperative patient characteristics on the likelihood of attaining both the minimal clinically important difference and PASS. Results In total, 112 patients were included in the study, with 79 (71%) having recreational or higher levels of athletic participation. The PASS for the study population was 56.0 (area under the ROC curve, 0.86) and was unaffected by baseline PROMIS-PF scores but was affected by preoperative athletic participation (56.0 for athletes, 49.0 for nonathletes). A post hoc analysis found 57 patients (51%) achieved the PASS for the PROMIS-PF (cutoff, 56.0), but when the athlete and nonathlete thresholds were applied to their respective patient groups, 66% of athletes and 64% of nonathletes achieved the PASS postoperatively. The multivariate analysis found that sport participation (odds ratio, 6.2; P = .001) but not age, sex, body mass index, or preoperative PROMIS affected the likelihood of achieving the PASS on the PROMIS-PF. Conclusion Preoperative athletic participation significantly affected the ability to achieve PASS.
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Affiliation(s)
- Benjamin D. Kuhns
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Connor D. Sholtis
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - John M. Reuter
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - John Goldblatt
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert Bronstein
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Judith F. Baumhauer
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Michael D. Maloney
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
| | - Sandeep Mannava
- Department of Orthopaedics & Physical Performance, University of Rochester Medical Center, Rochester, New York, USA
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Achermann S, Marty J, Beck A, Rieger B, Hirschmüller A, Baur H. [Return to Sport (RTS) After Anterior Cruciate Ligament Reconstruction: Which Factors Influence the RTS Decision?]. SPORTVERLETZUNG SPORTSCHADEN : ORGAN DER GESELLSCHAFT FUR ORTHOPADISCH-TRAUMATOLOGISCHE SPORTMEDIZIN 2023; 37:133-140. [PMID: 37348535 DOI: 10.1055/a-2025-1090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND It is unknown which valid criteria should be considered to justify the decision for return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR). The research question is whether gender, age, the outcome of the isokinetic maximal strength measurement and the single-leg hop test (quantitative/qualitative) influence the decision for RTS nine months after ACLR. METHODS This study is a retrospective data analysis. The research question was evaluated with a multiple logistic regression analysis (MLR). The dependent variable, RTS yes/no, is based on the decision of the orthopaedist in charge of treatment nine months (±30 days) after ACLR. The following possible influencing factors were investigated: gender, age, limb symmetry index (LSI) of maximal knee extension and knee flexion strength at 60°/sec., LSI of single-leg hop test and evaluation of knee valgus. RESULTS Data of 71 patients were included for MLR. The odds ratios (OR) for RTS increased with female gender (OR, 4.808; p=0.035), a higher LSI of maximal strength of knee extension (OR, 1.117; p=0.009) and a higher LSI of the single-leg hop test (OR, 1.125; p=0.020). Age, the LSI of maximal strength of knee flexion and knee valgus had no influence on the RTS decision. CONCLUSION Gender and the limb symmetry indexes of the maximal strength of knee extension and of the single-leg hop test are associated with RTS nine months after ACLR. These results should be considered to optimise rehabilitation after ACLR.
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Affiliation(s)
- Sibylle Achermann
- School of Health Professions, Bern University of Applied Sciences: Berner Fachhochschule, Bern, Switzerland
| | - Julia Marty
- Altius Swiss Sportmed Center, Rheinfelden, Switzerland
| | - Andreas Beck
- Altius Swiss Sportmed Center, Rheinfelden, Switzerland
| | | | | | - Heiner Baur
- School of Health Professions, Bern University of Applied Sciences: Berner Fachhochschule, Bern, Switzerland
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13
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Sroufe MD, Sumpter AE, Thompson XD, Moran TE, Bruce Leicht AS, Diduch DR, Brockmeier SF, Miller MD, Gwathmey FW, Werner BC, Pietrosimone B, Hart JM. Comparison of Patient-Reported Outcomes, Strength, and Functional Performance in Primary Versus Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2023; 51:2057-2063. [PMID: 37212572 DOI: 10.1177/03635465231169535] [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] [Indexed: 05/23/2023]
Abstract
BACKGROUND Clinical outcomes after revision anterior cruciate ligament reconstruction (ACLR) are not well understood. HYPOTHESIS Patients undergoing revision ACLR would demonstrate worse patient-reported outcomes and worse limb symmetry compared with a cohort undergoing primary ACLR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS 672 participants (373 with primary ACLR, 111 with revision ACLR, and 188 uninjured) completed functional testing at a single academic medical center. Descriptive information, operative variables, and patient-reported outcomes (International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Tegner Activity Scale score) were assessed for each patient. Quadriceps and hamstring strength tests were conducted using a Biodex System 3 Dynamometer. Single-leg hop for distance, triple hop test, and the 6-m timed hop test were also assessed. Limb symmetry index (LSI) between the ACLR limb and contralateral limb was calculated for strength and hop testing. Normalized peak torque (N·m/kg) was calculated for strength testing. RESULTS No differences were found in group characteristics, excluding body mass (P < .001), or in patient-reported outcomes. There were no interactions between revision status, graft type, and sex. Knee extension LSI was inferior (P < .001) in participants who had undergone primary (73.0% ± 15.0%) and revision (77.2% ± 19.1%) ACLR compared with healthy, uninjured participants (98.8% ± 10.4%). Knee flexion LSI was inferior (P = .04) in the primary group (97.4% ± 18.4%) compared with the revision group (101.9% ± 18.5%). Difference in knee flexion LSI between the uninjured and primary groups, as well as between the uninjured and revision groups, did not reach statistical significance. Hop LSI outcomes were significantly different across all groups (P < .001). Between-group differences in extension in the involved limb (P < .001) were noted, as the uninjured group exhibited stronger knee extension (2.16 ± 0.46 N·m/kg) than the primary group (1.67 ± 0.47 N·m/kg) and the revision group (1.78 ± 0.48 N·m/kg). As well, differences in flexion in the involved limb (P = .01) were found, as the revision group exhibited stronger knee flexion (1.06 ± 0.25 N·m/kg) than the primary group (0.97 ± 0.29 N·m/kg) and the uninjured group (0.98 ± 0.24 N·m/kg). CONCLUSION At 7 months postoperatively, patients who had undergone revision ACLR did not demonstrate inferior patient-reported outcomes, limb symmetry, strength, or functional performance compared with patients who had undergone primary ACLR. Patients who had undergone revision ACLR exhibited greater strength and LSI than their counterparts with primary ACLR, but these parameters were still inferior to those of uninjured controls.
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Affiliation(s)
- Madison D Sroufe
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Anna E Sumpter
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Xavier D Thompson
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Thomas E Moran
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | | | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Brian Pietrosimone
- Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joe M Hart
- Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina, USA
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14
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Goes RA, Pereira R, Oliveira FLD, Castelhanito P, Serra Cruz R, Rocha de Faria JL. Single Femoral Tunnel for Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Graft and Lemaire's Extra-Articular Tenodesis as a Good Alternative for Combined Anterior Cruciate Ligament and Anterolateral Ligament Revision Surgeries. Arthrosc Tech 2023; 12:e903-e914. [PMID: 37424656 PMCID: PMC10323833 DOI: 10.1016/j.eats.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 02/12/2023] [Indexed: 07/11/2023] Open
Abstract
The literature has shown a significant decrease in failure rates when the anterior cruciate ligament (ACL) reconstruction was associated with an extra-articular reinforcement technique such as the anterolateral ligament (ALL) or the iliotibial band tenodesis (ITBT) using the modified Lemaire technique. As much as there is a progressive decrease in the failure rates of ACL reconstructions when the ALL reconstruction technique is associated, there are still and will be cases that will result in graft rupture. These cases will require more alternatives for revision, which are always challenging for the surgeon, where the lateral approaches represent complicating factors, especially because of the distortion of the lateral anatomy (by the previous approach for ALL reconstruction), previous reconstruction tunnels, and the presence of fixation materials. We present here a safe technique that offers great stability to the fixation of the graft and is easy to perform, using a single tunnel for the passage of the ACL and ITBT grafts, allowing a single fixation for both. In this way, we performed a lower-cost surgery, with a lower risk of lateral condyle fracture and tunnel confluence. This technique is indicated to be used in cases of revision after failure of combined ACL reconstruction with ALL.
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Affiliation(s)
- Rodrigo Araújo Goes
- North Lisbon University Hospital Centre (CHULN) - Santa Maria Hospital, Lisbon, Portugal
- The Division of Traumatology and Ortopedics (DITRO) of National Institute of Traumatology and Orthopedics of Brazil (INTO), Rio de Janeiro, Brazil
- Free Assistant of the Chair of Orthopedics at the Faculty of Medicine of Lisbon - FMUL, Lisbon, Portugal
| | - Rafael Pereira
- North Lisbon University Hospital Centre (CHULN) - Santa Maria Hospital, Lisbon, Portugal
| | | | - Pedro Castelhanito
- North Lisbon University Hospital Centre (CHULN) - Santa Maria Hospital, Lisbon, Portugal
| | - Raphael Serra Cruz
- The Division of Traumatology and Ortopedics (DITRO) of National Institute of Traumatology and Orthopedics of Brazil (INTO), Rio de Janeiro, Brazil
| | - José Leonardo Rocha de Faria
- The Division of Traumatology and Ortopedics (DITRO) of National Institute of Traumatology and Orthopedics of Brazil (INTO), Rio de Janeiro, Brazil
- School of Medicine from University of São Paulo, USP Riberão Preto, SP, Brazil
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15
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Composite Score of Readiness (CSR) as a Data Reduction Technique for Monitoring the RTS Process in Footballers following ACL Reconstruction. Symmetry (Basel) 2023. [DOI: 10.3390/sym15020298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
In recent years, many studies on the safe return to sport (RTS) have been published, but there are still no clear and validated guidelines. After ACL reconstruction between limbs, asymmetry of muscle strength affects knee mechanics during walking and running, and asymmetrical joint kinematics and kinetics are considered as a strong risk factor of musculoskeletal injury. Therefore, proper diagnosis of any motor deficits remaining after ACL reconstruction seems particularly important. The aim of this study was to analyze how many tests should be included in the RTS test battery and which of them are most indicative for functional deficits related to anterior cruciate ligament (ACL) reconstruction. Sixty-five male football players (age 18–25 years) were divided into three groups: ACL group—after ACL rupture and reconstruction, mild injury group—post mild lower limb injuries, and the control group—without injuries. They performed five tests: Functional Movement Screen, Tuck Jump Assessment, Y-balance Test, Hop Test for Distance, and Isokinetic Test. The Composite Score of Readiness (CSR) index was calculated and expressed as the sum of z-scores. The multiple regression model for all tests was calculated, and then redundant variables were excluded. We observed that all tests significantly influenced the final CSR index. The Y-balance Test, Tuck Jump Assessment, and Isokinetic Test for knee flexion influenced the final CSR index the most, which means that these tests are greatly indicative of functional deficits related to ACL reconstruction. The strength of the extensor (quadriceps) muscle and the quadriceps/hamstring ratio appeared to be non-sensitive for testing functional deficits related to ACL reconstruction. If the test battery includes 4–5 tests, it better differentiates the athletes following ACL reconstruction from those after mild injuries, even if they all were cleared to play.
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16
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Moran TE, MacLean IS, Anderson GR, Barras LA, Graf RM, Diduch DR, Miller MD. Lateral Extra-Articular Tenodesis Staple Risks Penetration of Anterior Cruciate Ligament Reconstruction Tunnel. Arthrosc Sports Med Rehabil 2022; 5:e193-e200. [PMID: 36866320 PMCID: PMC9971869 DOI: 10.1016/j.asmr.2022.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 12/25/2022] Open
Abstract
Purpose To identify the risk of anterior cruciate ligament (ACL) femoral tunnel penetration with the use of a staple for lateral extra-articular tenodesis (LET) graft fixation and to determine whether this varied between 2 different techniques for ACL femoral tunnel drilling. Methods Twenty paired, fresh-frozen, cadaver knees underwent ACL reconstruction with a LET. Left and right knees were randomized to ACL reconstruction with femoral tunnel creation by use of either a rigid guide pin and reamer through the accessory anteromedial portal or by the use of a flexible guide pin and reamer through the anteromedial portal. Immediately after tunnel creation, the LET was performed and fixated with a small Richard's staple. Fluoroscopy was used to obtain a lateral view of the knee to determine staple position, and visualization of the ACL femoral tunnel was performed with the arthroscope to investigate penetration of the staple into the femoral tunnel. The Fisher exact test was conducted to determine whether there was any difference in tunnel penetration between tunnel creation techniques. Results The staple was noted to penetrate the ACL femoral tunnel in 8 of 20 (40%) extremities. When stratified by tunnel creation technique, the Richards staple violated 5 of 10 (50%) of the tunnels made via the rigid reaming technique compared with 3 of 10 (30%) of those created with a flexible guide pin and reamer (P = .65). Conclusions A high incidence of femoral tunnel violation is seen with lateral extra-articular tenodesis staple fixation. Level of Evidence Level IV, controlled laboratory study. Clinical Relevance The risk of penetrating the ACL femoral tunnel with a staple for LET graft fixation is not well understood. Yet, the integrity of the femoral tunnel is important for the success of ACL reconstruction. Surgeons can use the information in this study to consider adjustments to operative technique, sequence, or fixation devices used when performing ACL reconstruction with concomitant LET to avoid the potential for disruption of ACL graft fixation.
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Affiliation(s)
- Thomas E. Moran
- Address correspondence to Thomas E. Moran, M.D., Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Rd., Charlottesville, VA 22903.
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Muacevic A, Adler JR, Moros G, Mylonas D, Kouzelis A, Gliatis J. Isokinetic Muscle Strength and Knee Function in Anatomical Anterior Cruciate Ligament Reconstruction With Hamstring Autografts: A Prospective Randomized Comparative Study Between Suspensory and Expandable Femoral Fixation in Male Patients. Cureus 2022; 14:e32482. [PMID: 36644094 PMCID: PMC9836015 DOI: 10.7759/cureus.32482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
Background Clinical performance, anterior knee stability, and isokinetic strength after anterior cruciate ligament (ACL) reconstruction with hamstring autografts are mainly influenced by graft selection, femoral tunnel preparation, and type of femoral fixation. Expandable femoral fixation devices are expected to provide a stronger initial fixation with circular graft compression, a blind-ended tunnel in the femur with less enlargement, and a theoretical double-band ACL equivalent through graft rotation. This study aimed to evaluate isokinetic strength and functional capacity after ACL reconstruction with hamstring tendons using two different anatomical femoral fixation techniques (expandable vs fixed-looped button). Methodology A total of 48 male patients with ACL deficient knees were randomized to two different femoral fixation groups, namely, the expandable (AperFix) and the standard cortical (Button) group. The primary outcome measures were isokinetic hamstrings and quadriceps strength capabilities and the hamstrings/quadriceps ratio at 60 degrees/second (°/s) and 180°/s using a Cybex before and at three, six, nine, 12, and 24 months after surgery. Secondary measurements were anteroposterior knee stability at two years (using KT-1000 arthrometer) and the functional outcome using the International Knee Documentation Committee (IKDC 2000) form, the Tegner activity scale, and the Lysholm knee score. Data were compared using a paired t-test and analysis of variance, with a p < 0.05 level of significance. Results Most patients regained the 60°/s quadriceps strength between three and 12 months (62.5% for the Button group vs. 50% for the AperFix group), as well as the 180°/s strength (79.17% vs 70.83%); however, at the 24-month evaluation, seven (29.17%) patients in the Button group and five (20.83%) in the AperFix group had significant deficits. The 60°/s flexor strength was regained in the first six months in 19 (79.17%) patients in the Button group and in 16 (66.7%) patients in the AperFix group, whereas the percentages for the 180°/s strength were 79.17% and 75%, respectively. Beyond the 24-month evaluation, only three (12.5%) patients in the Button group and four (16.67%) in the AperFix group had significant flexor deficits. Regarding the H/Q ratio, at 60°/s, the mean recovery time was six and 7.5 months for the Button and AperFix groups, respectively, whereas 15 and 12 patients, respectively, did not recover during the two-year duration. At 180°/s, a mean recovery time of six months was needed for the button group, and nine patients did not recover two years later. For the AperFix group, nine months were needed, and 12 patients did not recover in two years. Clinical performance and anterior knee stability showed no statistically significant differences between groups. Conclusions Although there were no significant differences in clinical performance, knee stability, and isokinetic strength testing between expandable and cortical button femoral fixation groups, return to play was doubtful at two years postoperatively.
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Kemler BR, Rao S, Willier DP, Jack RA, Erickson BJ, Cohen SB, Ciccotti MG. Rehabilitation and Return to Sport Criteria Following Ulnar Collateral Ligament Reconstruction: A Systematic Review. Am J Sports Med 2022; 50:3112-3120. [PMID: 34494905 DOI: 10.1177/03635465211033994] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ulnar collateral ligament (UCL) reconstruction (UCLR) is a viable treatment option for patients with UCL insufficiency, especially in the overhead throwing athlete. Within the clinical literature, there is still no universally agreed upon optimal rehabilitation protocol and timing for return to sport (RTS) after UCLR. HYPOTHESIS There will be significant heterogeneity with respect to RTS criteria after UCLR. Most surgeons will utilize time-based criteria rather than functional or performance-based criteria for RTS after UCLR. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS All level 1 to 4 studies that evaluated UCLR with a minimum 1-year follow-up were eligible for inclusion. Studies lacking explicit RTS criteria, studies that treated UCL injury nonoperatively or by UCL repair, or studies reporting revision UCLR were excluded. Each study was analyzed for methodologic quality, RTS, timeline of RTS, and RTS rate. RESULTS Overall, 1346 studies were identified, 33 of which met the inclusion criteria. These included 3480 athletes across 21 different sports. All studies reported RTS rates either as overall rates or via the Conway-Jobe scale. Timelines for RTS ranged from 6.5 to 16 months. Early bracing with progressive range of motion (ROM) (93.9%), strengthening (84.8%), and participation in an interval throwing program (81.8%) were the most common parameters emphasized in these rehabilitation protocols. While all studies included at least 1 of 3 metrics for the RTS value assessment, most commonly postoperative rehabilitation (96.97%) and set timing after surgery (96.97%), no article completely defined RTS criteria after UCLR. CONCLUSION Overall, 93.9% of studies report utilizing bracing with progressive ROM, 84.8% reported strengthening, and 81.8% reported participation in an interval throwing program as rehabilitation parameters after UCLR. In addition, 96.97% reported timing after surgery as a criterion for RTS; however, there is a wide variability within the literature on the recommended time from surgery to return to activity. Future research should focus on developing a comprehensive checklist of functional and performance-based criteria for safe RTS after UCLR.
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Affiliation(s)
- Bryson R Kemler
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Somnath Rao
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Donald P Willier
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert A Jack
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | | | - Steven B Cohen
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
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Moran TE, Ignozzi AJ, Burnett Z, Bodkin S, Hart JM, Werner BC. Deficits in Contralateral Limb Strength Can Overestimate Limb Symmetry Index After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e1713-e1719. [PMID: 36312704 PMCID: PMC9596901 DOI: 10.1016/j.asmr.2022.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/25/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss treatment options, rehabilitation protocols, return-to-play criteria, and expected outcomes after non-operative and operative treatment of anterior cruciate ligament (ACL) tears among an athletic population. RECENT FINDINGS Non-operative treatment may be a viable option for some athletes with an ACL tears but can be difficult to predict "copers," and those that resume to sports return at lower performance level and/or less intense activities. Most studies assessing function after ACL reconstruction demonstrate favorable outcomes using patient-reported outcome studies. However, return-to-play and graft re-rupture rates vary substantially based on patient characteristics and level and type of athletic activity. Grafts used to reconstruct ACL produce similar objective outcomes and favorable patient-reported outcomes but have variable re-rupture rates depending on study and differ largely on morbidity associated with graft harvest. Various treatment methods including non-operative and operative techniques have been demonstrated to be efficacious in returning athletes to athletic activity depending on patient age and level of activity. Adherence to fundamental rehabilitation principles and accepted return-to-play guidelines can optimize outcomes and limit re-injury to the injured or contralateral limb.
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Crowley SG, Pedersen A, Fortney TA, Swindell HW, Saltzman BM, Popkin CA, Trofa DP. Rehabilitation Variability Following Osteochondral Autograft and Allograft Transplantation of the Knee. Cartilage 2022; 13:19476035221093071. [PMID: 35762400 PMCID: PMC9247380 DOI: 10.1177/19476035221093071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The aim of this study is to assess the variability of postoperative rehabilitation protocols used by orthopedic surgery residency programs for osteochondral autograft transplantation (OAT) and osteochondral allograft transplantation (OCA) of the knee. DESIGN Online postoperative OAT and OCA rehabilitation protocols from US orthopedic programs and the scientific literature were reviewed. A custom scoring rubric was developed to analyze each protocol for the presence of discrete rehabilitation modalities and the timing of each intervention. RESULTS A total of 16 programs (10.3%) from 155 US academic orthopedic programs published online protocols and a total of 35 protocols were analyzed. Twenty-one protocols (88%) recommended immediate postoperative bracing following OAT and 17 protocols (100%) recommended immediate postoperative bracing following OCA. The average time protocols permitted weight-bearing as tolerated (WBAT) was 5.2 weeks (range = 0-8 weeks) following OAT and 6.2 weeks (range = 0-8 weeks) following OCA. There was considerable variation in the inclusion and timing of strength, proprioception, agility, and pivoting exercises. Following OAT, 2 protocols (8%) recommended functional testing as criteria for return to sport at an average time of 12.0 weeks (range = 12-24 weeks). Following OCA, 1 protocol (6%) recommended functional testing as criteria for return to sport at an average time of 12.0 weeks (range = 12-24 weeks). CONCLUSION A minority of US academic orthopedic programs publish OAT and OCA rehabilitation protocols online. Among the protocols currently available, there is significant variability in the inclusion of specific rehabilitation components and timing of many modalities. Evidence-based standardization of elements of postoperative rehabilitation may help improve patient care and subsequent outcomes.
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Affiliation(s)
- Stephen G. Crowley
- Albany Medical Center, Albany, NY,
USA,Stephen G. Crowley, Albany Medical Center,
Albany, NY 12208, USA.
| | | | - Thomas A. Fortney
- Center for Shoulder, Elbow and Sports
Medicine, Columbia University, New York, NY, USA
| | | | | | - Charles A. Popkin
- Center for Shoulder, Elbow and Sports
Medicine, Columbia University, New York, NY, USA
| | - David P. Trofa
- Center for Shoulder, Elbow and Sports
Medicine, Columbia University, New York, NY, USA
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A Systematic Review and Meta-Analysis of Strength Recovery Measured by Isokinetic Dynamometer Technology after Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autografts vs. Hamstring Tendon Autografts or Patellar Tendon Autografts. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116764. [PMID: 35682357 PMCID: PMC9180841 DOI: 10.3390/ijerph19116764] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 02/06/2023]
Abstract
Background: This systematic review and meta-analysis compared the isokinetic strength of the muscular knee joint between quadriceps tendon autografts (QTAs) and hamstring tendon autografts (HTAs) or patellar tendon autografts (PTAs) after anterior cruciate ligament (ACL) reconstruction by determining the isokinetic angular velocity and follow-up time points. The functional outcomes and knee stability at the same time points were also compared using isokinetic technology. Methods: Two independent reviewers searched the Medline (via PubMed search engine), Scopus, Web of Science and Cochrane Library databases to include full text comparative studies that assessed isokinetic strength test following ACL reconstruction. The DerSimonian and Laird method was used. Results: In total, ten studies were included; seven compared studies QTAs vs. HTAs, and three compared QTAs vs. PTAs. Five studies were included in the meta-analysis. Isokinetic strength data were reported 3, 6, 12 and 24 months after ACL reconstruction. Conclusions: The QTAs showed better and significant results with knee flexion compared with HTAs, similar results to PTAs at 6 and 12 months. While HTAs showed better and significant results with knee extension at 6 months and similar results at 12 months compared to QTAs. Furthermore, a standardized isokinetic strength test must be followed to achieve a more specific conclusion and better clinical comparison among participants.
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23
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Török L, Jávor P, Török K, Rárosi F, Hartmann P. Early Return to Play After Anterior Cruciate Ligament Reconstruction: Is It Worth the Risk? Ann Rehabil Med 2022; 46:97-107. [PMID: 35508928 PMCID: PMC9081394 DOI: 10.5535/arm.22010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/30/2022] [Indexed: 11/09/2022] Open
Abstract
Objective To compare the outcomes of a 6-month-long accelerated rehabilitation with a 12-month-long rehabilitation. There is no consensus on the optimal duration of rehabilitation after anterior cruciate ligament reconstruction (ACLR). Trends in the past decades have shifted towards accelerated programs, often resulting in a return to play (RTP) at 4–6 months, postoperatively. However, longer rehabilitation cycles have recently experienced renaissance due to a greater understanding of graft remodeling. Methods Adult athletes who underwent ACLR between 2015 and 2018 by the same surgeon were included and followed-up prospectively for 24 months. Participants were allocated into two groups based on their RTP (6 months vs. 12 months) and compared with graft elongation, reoperation rate, and sports career (quit or continue) outcomes. Results Fifty-four patients underwent accelerated rehabilitation and 92 completed conventional rehabilitation. The accelerated rehabilitation was significantly associated with graft elongation—the accelerated rehabilitation group (n=9) and the conventional rehabilitation group (n=0), p<0.001—and need for reoperation—the accelerated rehabilitation group (n=5) and the conventional rehabilitation group (n=1), p=0.026. Although the relationship between rehabilitation time and quitting competitive sports did not reach significance at 0.05 level (p=0.063), it was significant when p<0.1, thereby showing a clear trend. Conclusion Accelerated rehabilitation increased graft elongation risk. Knee laxity ≥3 mm measured at 6 months after ACLR should be accompanied by RTP time frame re-evaluation. Arthrometry checkups or routine magnetic resonance imaging shortly after RTP may be considered in cases of accelerated rehabilitation.
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Affiliation(s)
- László Török
- Department of Sports Medicine, University of Szeged, Szeged, Hungary.,Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Péter Jávor
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Katalin Török
- Department of Kinesiology, University of Physical Education, Budapest, Hungary
| | - Ferenc Rárosi
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Petra Hartmann
- Department of Traumatology, University of Szeged, Szeged, Hungary
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Crowley SG, Swindell HW, Saltzman BM, Ahmad CS, Popkin CA, Trofa DP. Rehabilitation Variability Following Femoral Condyle and Patellofemoral Microfracture Surgery of the Knee. Cartilage 2021; 13:1801S-1813S. [PMID: 34151611 PMCID: PMC8808894 DOI: 10.1177/19476035211025818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To assess the variability of postoperative rehabilitation protocols used by orthopedic surgery residency programs for microfracture of femoral condyle and patellofemoral lesions of the knee. DESIGN Online postoperative microfracture rehabilitation protocols from US orthopedic programs and the scientific literature were reviewed. A custom scoring rubric was developed to analyze each protocol for the presence of discrete rehabilitation modalities and the timing of each intervention. RESULTS A total of 18 programs (11.6%) from 155 US academic orthopedic programs' published online protocols and a total of 44 protocols were analyzed. Seventeen protocols (56.7%) recommended immediate postoperative bracing for femoral condyle lesions and 17 (89.5%) recommended immediate postoperative bracing for patellofemoral lesions. The average time to permitting weight-bearing as tolerated (WBAT) was 6.1 weeks (range, 0-8) for femoral condyle lesions and 3.7 weeks (range, 0-8 weeks) for patellofemoral lesions. There was considerable variation in the inclusion and timing of strength, proprioception, agility, and pivoting exercises. For femoral condyle lesions, 10 protocols (33.3%) recommended functional testing prior to return to sport at an average of 23.3 weeks postoperatively (range, 12-32 weeks). For patellofemoral lesions, 4 protocols (20.0%) recommended functional testing for return to sport at an average of 21.0 weeks postoperatively (range, 12-32 weeks). CONCLUSION A minority of US academic orthopedic programs publish microfracture rehabilitation protocols online. Among the protocols currently available, there is significant variability in the inclusion of specific rehabilitation components and timing of many modalities. Evidence-based standardization of elements of postoperative rehabilitation may help improve patient care and subsequent outcomes.
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Affiliation(s)
| | - Hasani W. Swindell
- Center for Shoulder, Elbow and Sports
Medicine, Columbia University, New York, NY, USA
| | | | - Christopher S. Ahmad
- Center for Shoulder, Elbow and Sports
Medicine, Columbia University, New York, NY, USA
| | - Charles A. Popkin
- Center for Shoulder, Elbow and Sports
Medicine, Columbia University, New York, NY, USA
| | - David P. Trofa
- Center for Shoulder, Elbow and Sports
Medicine, Columbia University, New York, NY, USA,David P. Trofa, Department of Orthopedic
Surgery, Columbia University Medical Center, New York, NY 10032, USA.
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25
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Revision Anterior Cruciate Ligament Reconstruction: Tibial Tunnel-First Graft-Sizing Technique. Arthrosc Tech 2021; 10:e2797-e2803. [PMID: 35004163 PMCID: PMC8719212 DOI: 10.1016/j.eats.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/14/2021] [Indexed: 02/03/2023] Open
Abstract
Revision anterior cruciate ligament reconstruction (R-ACLR) has become more common as the number of failed primary ACLRs increase. Although increasingly common, R-ACLR has a greater failure rate than a primary reconstruction. Technical errors, particularly in tunnel placement, account for a large proportion of graft failure in R-ACLR as well as re-revision cases. Tunnel placement and trajectory is particularly important in R-ACLR and becomes more challenging with each additional revision attempt. This is in part because any tunnels created for revision may converge with formerly drilled tunnels or face interference hardware creating, complicating proper graft fixation. While there are many approaches to revision ACL surgery, our technique describes a simple, tibial tunnel-first graft-sizing method initially reaming tunnels with very small diameters and sequentially working your way up to more anatomic diameters.
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26
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Bakhsh HR, Metikala S, Billy GG, Vairo GL. Association Between Self-Reported Kinesiophobia and Single-Leg Hop for Distance in Patients With ACL Reconstruction:A Systematic Review. Sports Health 2021; 14:674-680. [PMID: 34651507 DOI: 10.1177/19417381211049357] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Psychological readiness is a significant factor in determining successful return to sport (RTS) and physical activities after anterior cruciate ligament (ACL) reconstruction. Knowing the influence of kinesiophobia on physical tests that are used to guide RTS, such as the single-leg hop for distance (SLHD), would contribute to advancing clinical practice. OBJECTIVE To investigate the association between kinesiophobia and SLHD performance in patients after ACL reconstruction. DATA SOURCES A comprehensive search strategy entailed surveying 6 databases for relevant articles published from January 2009 to March 2021. STUDY SELECTION Articles published in English that were a minimum of level 3 evidence describing kinesiophobia, as measured by the Tampa Scale for Kinesiophobia, and related to SLHD performance in patients after ACL reconstruction. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 3. DATA EXTRACTION Study characteristics, sample population demographics, instrument(s), or approach(s) used to assess kinesiophobia and SLHD performance, and corresponding results. RESULTS A total of 152 potential studies were identified, 106 studies underwent screening, 40 were reviewed in full, and 7 studies were included. Meta-analysis could not be performed because of differences in experimental design among studies and instances of missing outcome data. Currently, moderate evidence indicates patients with ACL reconstruction that exhibit less kinesiophobia perform better on the SLHD test. CONCLUSION The outcomes of this review propose that sports health practitioners consider the influence of kinesiophobia on SLHD performance as a criterion for RTS and physical activities in patients after ACL reconstruction. Higher quality studies are necessary to establish the extent of association between these variables.
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Affiliation(s)
- Hadeel R Bakhsh
- Department of Rehabilitation, College of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Sreenivasulu Metikala
- Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Gregory G Billy
- Department of Orthopaedics & Rehabilitation, College of Medicine, Pennsylvania State University, University Park, Pennsylvania
| | - Giampietro L Vairo
- Department of Orthopaedics & Rehabilitation, College of Medicine, Pennsylvania State University, University Park, Pennsylvania.,Department of Kinesiology, College of Health and Human Development, Pennsylvania State University, University Park, Pennsylvania
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27
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Sanada T, Uchiyama E, Iwaso H, Fukai A. Muscle strength after the anterior cruciate ligament reconstruction via contralateral bone-tendon-bone autograft. J Exp Orthop 2021; 8:86. [PMID: 34617148 PMCID: PMC8494824 DOI: 10.1186/s40634-021-00399-y] [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: 06/15/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose The anterior cruciate ligament (ACL) reconstruction via a contralateral bone-tendon-bone (C-BTB) autograft was introduced to encourage early return to sports. The purpose of this study is to evaluate whether primary contralateral BTB ACL reconstruction can be adapted for early return-to-sports modification by investigating the chronological changes of muscle strength after surgery. Methods Fifteen patients who had underwent C-BTB ACL reconstruction were compared with a matched group of 15 patients of ipsilateral BTB (I-BTB) ACL reconstruction. The clinical outcomes of the time of return-to-sports, Tegner activity scale and the rate of second ACL injuries, the tibial anterior translation measurement, and knee extension and flexion muscle strength were assessed. Results Within 12 months after surgery, 14 of 15 patients from both groups returned to preinjury sports. The median time to return to sports after surgery was 6.5 months in the C-BTB group and 8.0 months in the I-BTB group (p = 0.021). No significant difference was noted with regard to the Tegner activity scale, reinjury rate or mean instrumental anterior tibial translation. The quadriceps muscle strength in the ACL-reconstructed knee compared with the opposite knee in both groups at 5 months after surgery was 120.6% in the C-BTB group and 70.0% in the I-BTB group (p < 0.001). However, the quadriceps muscle strength of the non-reconstructed limb, which instructed the graft harvested knee in the C-BTB and the intact knee in the I-BTB group, compared with that of the preoperative uninjured limb, was 74.5% in the C-BTB group and 118.7% in the I-BTB group (p = 0.0021) 5 months after surgery. Moreover, the quadriceps muscle strength of the reconstructed knee compared with the preoperative normal limb was 88.8% and 81.5% in the C-BTB and I-BTB groups, respectively (p = 0.38). Conclusions ACL reconstruction via the C-BTB autograft indicated better quadriceps muscle strength from early stage after surgery compared with I-BTB ACL reconstruction. However, the ostensible rapid symmetrical muscle strength recovery was attributed to strength deficits compared to the preoperative condition at the donor site limb and ACL-reconstructed limb. Level of evidence Level: Level: 4.
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Affiliation(s)
- Takaki Sanada
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshicho, Nakahara-Ku, Kawasaki, Kanagawa Prefecture, 211-8510, Japan.
| | | | - Hiroshi Iwaso
- Department of Sports Orthopaedic Surgery, Kanto Rosai Hospital, Kanto Rosai Hospital, 1-1 Kizuki Sumiyoshicho, Nakahara-Ku, Kawasaki, Kanagawa Prefecture, 211-8510, Japan
| | - Atsushi Fukai
- Faculty of Medical Technology, Teikyo University, Tokyo, Japan
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28
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Griffith R, Bolia IK, Fretes N, Murray IR, Meyer J, Weber AE, Gamradt SC, Petrigliano FA. Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 2: Ulnar Collateral Ligament of the Elbow Procedures. Orthop J Sports Med 2021; 9:23259671211021825. [PMID: 34395685 PMCID: PMC8358522 DOI: 10.1177/23259671211021825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 11/16/2022] Open
Abstract
Background: There is a lack of consensus to guide patient return to sport (RTS) after elbow ulnar collateral ligament surgery (eUCLS). Purpose: To describe the reported RTS criteria after eUCLS in the athletic population. Study Design: Scoping review; Level of evidence, 4. Methods: This scoping review was performed by adhering to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Scoping Review) guidelines. We searched 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced) and the gray literature for English-language studies that reported at least 1 RTS criterion in athletes after eUCLS. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation. Results: Included were 14 studies and 1335 athletes with a mean age of 21.4 ± 1.1 years. Time from surgery (range, 6-16 months) was the most common RTS criterion used, and it was reported by all 14 of the included articles. RTS criteria reported less often were pain (3/14; 21%), successful completion of a throwing program (3/14; 21%), muscle strength of the forearm muscles (1/14; 7%), and “normal” range of motion and muscle strength of the elbow and shoulder joints on the operated upper extremity (1/14; 7%). All studies used 1 to 5 of the above RTS criteria. Conclusion: Only 14 studies reported 1 or more RTS criteria after eUCLS in athletes, and time was the most common RTS criterion used. Our results highlight the need for a coordinated effort among surgeons, physical therapists, and athletic trainers in order to establish evidence-based RTS criteria after eUCLS in athletes so athletes can safely to sport and prolong their athletic careers.
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Affiliation(s)
- Rebecca Griffith
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Nickolas Fretes
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Iain R Murray
- Department of Orthopaedic Sports Medicine, Stanford University, Redwood City, California, USA
| | - John Meyer
- Meyer Institute of Sport, Los Angeles, California, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Seth C Gamradt
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
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29
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Harringe ML, Höög S, Svensson M. Gymnasts' experiences and perception of a cruciate ligament injury. J Sports Med Phys Fitness 2021; 62:812-821. [PMID: 34080816 DOI: 10.23736/s0022-4707.21.12358-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Gymnastics is a high injury risk sport including difficult technique. A cruciate ligament injury is common, though there are no evidence-based guidelines for return to gymnastics. The gymnasts' experiences may add specificity to a guideline. Therefore, the aim of the present study was to describe the gymnasts' experiences and perception of a cruciate ligament injury. METHODS An embedded mixed methods design. Semi-structured interviews in 14 gymnasts between March and August 2018. The gymnasts represented a variation in age, sex, discipline, level of gymnastics, re- ruptures, associated injuries and return to gymnastics. The Knee Injury and Osteoarthritis Outcome Score, compared with the Swedish anterior cruciate ligament registry, and the Tegner's activity score were supplements to the interviews. The interviews covered injury occasion, rehabilitation, return to gymnastics and current experience of the knee joint and were analyzed using qualitative content analysis with an inductive approach. RESULTS The Knee Injury and Osteoarthritis Outcome Score was consistent with the Swedish ACL registry on gymnasts and showed low levels in the subscales quality of life and sports/ recreation. One third reported Tegner's score < 6 supporting low levels in sports/ recreation. The text analysis resulted two parts "This really happened, cold facts" and "Prerequisites and hindrances for return to gymnastics". The gymnasts' narratives were similar and reached saturation. CONCLUSIONS A cruciate ligament injury is a large trauma, and the physical and psychological demands must be understood. The results of the present study may be included in a framework for return to gymnastics, where the individual prerequisites and goals should be determined. The timeline within this framework would depend on the extent of the injury, expected time for healing and physical as well as psychological demands with respect to gymnastics' level. It may also include suggestions for different psychological strategies and performance enhancement techniques to increase the gymnasts' self-efficacy, and encourage and motivate the gymnasts through the long and demanding rehabilitation.
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Affiliation(s)
- Marita L Harringe
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden - .,Aleris Sports Medicine and Orthopeadics, Sabbatsbergs Hospital, Stockholm, Sweden -
| | - Stefan Höög
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden.,Medical Support, Department of Environment and Development, Swedish Gymnastics Federation, Stockholm, Sweden
| | - Melanie Svensson
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden.,Aleris Sports Medicine and Orthopeadics, Sabbatsbergs Hospital, Stockholm, Sweden
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30
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Meredith SJ, Rauer T, Chmielewski TL, Fink C, Diermeier T, Rothrauff BB, Svantesson E, Hamrin Senorski E, Hewett TE, Sherman SL, Lesniak BP, Symposium P. Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group. J ISAKOS 2021; 6:138-146. [PMID: 34006577 DOI: 10.1136/jisakos-2020-000495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS after ACL injury and description of the RTS continuum, as well as provide clinical guidance on RTS testing and decision-making. METHODS An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. RESULTS Key points include that RTS is characterised by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries. CONCLUSION The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biological assessment of healing and recovery.
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Affiliation(s)
- Sean J Meredith
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA .,Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Thomas Rauer
- Klinik für Traumatologie, UniversitätsSpital Zürich, Zurich, Switzerland
| | | | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery Innsbruck, Innsbruck, Austria
| | - Theresa Diermeier
- Department of Sportorthopedic, Technical University of Munich, Munchen, Germany
| | - Benjamin B Rothrauff
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eleonor Svantesson
- Department of Orthopedics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden.,Gothenburg Sport Trauma Research Center, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Gothenburg Sport Trauma Research Center, Gothenburg, Sweden.,Department of Health and Rehabilitation, University of Gothenburg, Gothenburg, Sweden
| | | | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford Medicine, Stanford, California, USA
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Panther Symposium
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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31
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Pontillo M, Hines SM, Sennett BJ. Prediction of ACL Injuries from Vertical Jump Kinetics in Division 1 Collegiate Athletes. Int J Sports Phys Ther 2021; 16:156-161. [PMID: 33604145 PMCID: PMC7872458 DOI: 10.26603/001c.18819] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 07/24/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The incidence of ACL injuries continues to rise secondary to an increase in sport participation. Evidence supports the use of force plate testing to quantify kinetics during rehabilitation after injury and recovery; however, there is limited current research regarding if jump kinetics can identify athletes who are at higher risk for injury. Altered kinetics could potentially lead to abnormal force dissipation and resultant injury. PURPOSE The purpose of this investigation was to identify whether the force-time variables from vertical jumps could predict ACL injuries in collegiate athletes. STUDY DESIGN Retrospective cohort. METHODS Vertical jump testing is performed by all healthy varsity collegiate athletes at several intervals throughout the athletic year at a Division I institution using a commercially available force plate system with dedicated software. Athletes who sustained an ACL injury between 1/1/15 and 6/1/19 were identified (n=16) and compared to healthy athletes who participated in the same sports (n = 262). ACL injuries were considered for this study if they occurred no more than 10 weeks after a jump test. The outcome variables were load, explode, and drive, operationally defined as the average eccentric rate of force development, average relative concentric force, and concentric relative impulse, respectively, which the system normalized to T scores. Mann-Whitney U tests were used to assess group differences for load, explode, drive, and the ratio between the variables. Logistic regression was used to determine if the battery of variables could predict whether or not an athlete would sustain an ACL injury. The p-value was set to 0.10 for the Mann-Whitney U tests, and 0.05 for the logistic regression. RESULTS Significant differences between the ACL and healthy groups were seen for explode (p=0.08), drive (p=0.06), load:explode ratio (p=0.06), and explode:drive ratio (p=0.03). Explode and drive, when entered into the regression equation, showed the ability to predict injury, χ 2 = 6.8, df = 2, p=0.03. CONCLUSIONS The vertical jump force plate variables were able to identify athletes who sustained an ACL injury within 66 days of testing. Athletes who sustained an ACL injury demonstrated altered kinetics and less ability to transmit forces during the vertical jump. LEVEL OF EVIDENCE 3.
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32
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Webster KE, Feller JA. Who Passes Return-to-Sport Tests, and Which Tests Are Most Strongly Associated With Return to Play After Anterior Cruciate Ligament Reconstruction? Orthop J Sports Med 2020; 8:2325967120969425. [PMID: 33415177 PMCID: PMC7750778 DOI: 10.1177/2325967120969425] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/02/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Return-to-sport (RTS) testing after anterior cruciate ligament (ACL)
reconstruction (ACLR) surgery has become popular. It has been recommended
that such testing should incorporate several domains, or set of tests, but
it is unclear which are most associated with a successful RTS. Purpose: To determine (1) the proportion of patients who can pass a set of self-report
and functional tests at 6 months after ACLR; (2) age, sex, and activity
level differences between patients who pass and those who do not; and (3)
whether specific types of tests are associated with a return to competitive
sport at 12 months. Study Design: Cohort study; Level of evidence, 2. Methods: This was a prospective longitudinal study of 450 patients who had primary
ACLR. At 6 months postoperatively, patients completed 2 self-report
measures, the International Knee Documentation Committee (IKDC) subjective
knee form and ACL–Return to Sport after Injury (ACL-RSI) scale, and 3
functional measures: single hop and triple crossover hop for distance and
isokinetic quadriceps strength. Limb symmetry index scores of ≥90 for
functional tests, IKDC scores ≥85, and ACL-RSI scores ≥65 were considered
indicators of satisfactory recovery. Proportional statistics and contingency
analysis were used to determine associations between age, sex, preinjury
sports level, and (1) meeting test thresholds and (2) RTS at 12 months. Results: Only 17 (3.8%) patients met all 5 test criteria at 6 months, and 95 (21%)
patients did not pass any test. More of the younger patients (<21 years)
passed all of the functional tests (P < .01), and more
male patients met the IKDC threshold (P = .03). Patients
who played level I sports before injury had the same pass rates as those who
played level II/III sports. Patients who passed the thresholds for the
ACL-RSI and IKDC scales had 4 and 3 times the odds, respectively, of RTS at
12 months (both P < .0001). Meeting the threshold for
quadriceps strength or either of the hop tests at 6 months was not
associated with RTS. Conclusion: At 6 months after ACLR, few patients met all of the thresholds of the common
tests used to assess RTS ability, although younger patients had higher rates
of passing the functional tests. Self-perceived symptoms/function and
psychological readiness were associated with a return at 12 months.
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Affiliation(s)
- Kate E Webster
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia
| | - Julian A Feller
- OrthoSport Victoria, Epworth HealthCare, Melbourne, Australia
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33
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Goes RA, Cossich VRA, França BR, Campos AS, Souza GGA, Bastos RDC, Grangeiro Neto JA. RETURN TO PLAY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION. REV BRAS MED ESPORTE 2020. [DOI: 10.1590/1517-8692202026062019_0056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT The anterior cruciate ligament (ACL) tear represents more than half of all knee injuries in sports that involve body rotations and sudden changes of direction. Discharging the athlete for return to play (RTP) post-ACL reconstruction (ACLR) is a difficult task with multidisciplinary responsibility. For many years, a six-month period post-ACLR was adopted as the only criterion for RTP. However, it is now suggested that RTP should not be exclusively time-based, but to clinical data and systematic assessments. Despite the importance of post-ACLR factors for RTP, pre- and peri-ACLR factors must also be considered. Historically, ACLR is performed with the hamstring or autologous patellar tendons, although the choice of graft is still an open and constantly evolving theme. Anterolateral ligament reconstruction and repair of meniscal ramp tear associated with ACLR have recently been suggested as strategies for improving knee joint stability. Subjective questionnaires are easy to apply, and help identify physical or psychological factors that can hamper RTP. Functional tests, such as hop tests and strength assessment by means of isokinetic dynamometers, are fundamental tools for decision making when associated with clinical evaluation and magnetic resonance imaging. Recently, the capacity to generate force explosively has been incorporated into the muscle strength assessment. This is quantified through the rate of torque development (RTD). Due to characteristics inherent to the practice of sport, there is an extremely short time available for produce strength. Thus, RTD seems to better represent athletic demands than the maximum strength assessment alone. This review investigates the pre-, peri- and post-ACLR factors established in the literature, and shares our clinical practice, which we consider to be best practice for RTP. Level of evidence V; Specialist opinion.
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Affiliation(s)
- Rodrigo A. Goes
- Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad, Brazil
| | - Victor R. A. Cossich
- Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad, Brazil; Universidade Federal do Rio de Janeiro, Brazil
| | - Bráulio R. França
- Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad, Brazil; Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad, Brazil
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No difference in revision rates between anteromedial portal and transtibial drilling of the femoral graft tunnel in primary anterior cruciate ligament reconstruction: early results from the New Zealand ACL Registry. Knee Surg Sports Traumatol Arthrosc 2020; 28:3631-3638. [PMID: 32239269 DOI: 10.1007/s00167-020-05959-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/23/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE The use of an accessory anteromedial portal to drill the femoral graft tunnel in primary anterior cruciate ligament (ACL) reconstruction was introduced in the 2000s in an effort to achieve a more anatomic femoral tunnel position. However, some early studies reported an increase in revision ACL reconstruction compared to the traditional transtibial technique. The aim of this study was to analyse recent data recorded by the New Zealand ACL Registry to compare outcomes of ACL reconstruction performed using the anteromedial portal and transtibial techniques. METHODS Analysis was performed on primary isolated single-bundle ACL reconstructions recorded between 2014 and 2018 by the New Zealand ACL Registry. Patients were categorised into two groups according to whether an anteromedial portal or transtibial technique was used to drill the femoral graft tunnel. The primary outcome was revision ACL reconstruction and was compared between both groups through univariate and multivariate survival analyses. The secondary outcomes that were analysed included subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Marx activity score. RESULTS Six thousand one hundred and eighty-eight primary single-bundle ACL reconstructions were performed using either the anteromedial portal or transtibial drilling techniques. The mean time of follow-up was 23.3 (SD ± 14.0) months. Similar patient characteristics such as mean age (29 years, SD ± 11), sex (males = 58% versus 57%) and time to surgery (median 4 months, IQR 5) were observed between both groups. The rate of revision ACL reconstruction was 2.6% in the anteromedial portal group and 2.2% in the transtibial group (n.s.). The adjusted risk of revision ACL reconstruction was 1.07 (95% CI 0.62-1.84, n.s.). Patients in the anteromedial portal group reported improved scores for subscales of the KOOS and higher Marx activity scores at 1-year post-reconstruction. CONCLUSION There was no difference in the risk of revision ACL reconstruction between the two femoral tunnel drilling techniques at short-term follow-up. We observed minor differences in patient-reported outcomes at 1-year follow-up favouring the anteromedial portal technique, which may not be clinically relevant. Surgeons can achieve good clinical outcomes with either drilling technique. LEVEL OF EVIDENCE III.
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[Evaluation of muscle strength in rehabilitation: from subjective assessment scales to instrumental examinations]. Rehabilitacion (Madr) 2020; 55:2-4. [PMID: 33077184 DOI: 10.1016/j.rh.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/30/2020] [Indexed: 11/23/2022]
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Heinert BL, Collins T, Tehan C, Ragan R, Kernozek TW. Effect of Hamstring-to-quadriceps Ratio on Knee Forces in Females During Landing. Int J Sports Med 2020; 42:264-269. [PMID: 33022735 DOI: 10.1055/a-1128-6995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
ACL injuries in the athletic population are a common occurrence with over 70% associated with non-contact mechanisms. The hamstring to quadriceps ratio is a widely used clinical measure to assess an athlete's readiness to return to sport; however, its relationship to knee forces and ACL tension during landing is unknown. Baseline isokinetic testing was completed on 100 college-aged females. Subjects with strength ratios 0.4 (n=20) and those with ratios of 0.6 (n=20) returned for an assessment of their drop landing. A sagittal plane knee model determined the low ratio group demonstrated 16.6% larger ligament shear (p=0.000), a 26% increase in tibiofemoral shear force (p=0.026) and a 6% increase vertical force between the femur and tibial plateau (p=0.026) compared to the high hamstring ratio group within 100 ms upon impact. The lower ratio group also demonstrated 9.5% greater maximal quadriceps (p=0.028) force during landing. These findings suggest that the hamstring to quadriceps ratio may be related to knee forces and ACL loading during landing. This metric may augment clinical decision making regarding an athlete's readiness to return to sport or relative risk for re-injury.
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Affiliation(s)
- Becky L Heinert
- Sports Medicine Department, Gundersen Lutheran Health System Inc, La Crosse, United States
| | - Tia Collins
- Department of Health Professions, University of Wisconsin-La Crosse, La Crosse, United States
| | - Carly Tehan
- Department of Health Professions, University of Wisconsin-La Crosse, La Crosse, United States
| | - Robert Ragan
- Department of Physics, University of Wisconsin-La Crosse, La Crosse, United States
| | - Thomas W Kernozek
- Department of Health Professions, University of Wisconsin-La Crosse, La Crosse, United States
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Meredith SJ, Rauer T, Chmielewski TL, Fink C, Diermeier T, Rothrauff BB, Svantesson E, Hamrin Senorski E, Hewett TE, Sherman SL, Lesniak BP. Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group. Knee Surg Sports Traumatol Arthrosc 2020; 28:2403-2414. [PMID: 32347344 DOI: 10.1007/s00167-020-06009-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/16/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS and description of the RTS continuum, as well as to provide clinical guidance on RTS testing and decision-making. METHODS An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. RESULTS Key points include that RTS is characterized by achievement of the pre-injury level of sport and involves a criteria-based progression from return to participation to return to sport, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along a RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries. CONCLUSION The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biologic assessment of healing and recovery. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Sean J Meredith
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, 15203, PA, USA.
| | - Thomas Rauer
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, 15203, PA, USA
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery Innsbruck, Innsbruck, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), UMIT, Hall in Tirol, Austria
| | - Theresa Diermeier
- Department of Sportorthopedics, Klinikum rechts der Isar Technische Universitat Munchen, Munchen, Germany
| | - Benjamin B Rothrauff
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, 15203, PA, USA
| | - Eleonor Svantesson
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Gothenburg Sport Trauma Research Center, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Gothenburg Sport Trauma Research Center, Gothenburg, Sweden
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford Medicine, Stanford, CA, USA
| | - Bryson P Lesniak
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, 3200 S Water St, Pittsburgh, 15203, PA, USA
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Meredith SJ, Rauer T, Chmielewski TL, Fink C, Diermeier T, Rothrauff BB, Svantesson E, Hamrin Senorski E, Hewett TE, Sherman SL, Lesniak BP, Bizzini M, Chen S, Cohen M, Villa SD, Engebretsen L, Feng H, Ferretti M, Fu FH, Imhoff AB, Kaeding CC, Karlsson J, Kuroda R, Lynch AD, Menetrey J, Musahl V, Navarro RA, Rabuck SJ, Siebold R, Snyder-Mackler L, Spalding T, van Eck C, Vyas D, Webster K, Wilk K. Return to Sport After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Return to Sport Consensus Group. Orthop J Sports Med 2020; 8:2325967120930829. [PMID: 32647735 PMCID: PMC7328222 DOI: 10.1177/2325967120930829] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/20/2020] [Indexed: 12/28/2022] Open
Abstract
Background A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level. Purpose The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making. Study Design Consensus statement. Methods An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. Results Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries. Conclusion The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery.
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Affiliation(s)
- Sean J Meredith
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Thomas Rauer
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Terese L Chmielewski
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christian Fink
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Theresa Diermeier
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin B Rothrauff
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eleonor Svantesson
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric Hamrin Senorski
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Timothy E Hewett
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Seth L Sherman
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bryson P Lesniak
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Mario Bizzini
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shiyi Chen
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Moises Cohen
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stefano Della Villa
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lars Engebretsen
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hua Feng
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mario Ferretti
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andreas B Imhoff
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christopher C Kaeding
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jon Karlsson
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ryosuke Kuroda
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew D Lynch
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jacques Menetrey
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ronald A Navarro
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stephen J Rabuck
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rainer Siebold
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Lynn Snyder-Mackler
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tim Spalding
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carola van Eck
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dharmesh Vyas
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kate Webster
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kevin Wilk
- Investigation performed at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Longstaffe R, Leiter J, Gurney-Dunlop T, McCormack R, MacDonald P. Return to Play and Career Length After Anterior Cruciate Ligament Reconstruction Among Canadian Professional Football Players. Am J Sports Med 2020; 48:1682-1688. [PMID: 32379980 DOI: 10.1177/0363546520918224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND For many athletes, a tear of the anterior cruciate ligament (ACL) represents a significant injury that requires a prolonged period away from the sport with substantial rehabilitation. HYPOTHESIS There will be no difference in return to play (RTP) and career length after hamstring tendon (HT) ACL reconstruction in a group of Canadian Football League professional players as compared with what has been already been reported in the literature among professional football players. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data on athletes who sustained an ACL injury were collected by team physicians and head athletic trainers from 2002 to 2017 from 2 Canadian Football League teams. Patient details included age at the time of injury, initial injury date, position, practice versus game injury, and primary versus rerupture with injury-specific data, such as affected limb, concomitant injuries, graft choice, and procedure performed. RTP rates and career length data were collected through publically available internet sources. Comparisons between the non-RTP and RTP groups were made with independent-sample t tests. Binomial logistic regression was performed to determine variables (ie, games preinjury, graft type, meniscal injury, collateral ligament injury) that contributed to players not being able to RTP. RESULTS A total of 44 ACL reconstructions were performed over the study period (HT, n = 32 [72.7%]; bone-patellar tendon-bone [BPTB], n = 8 [18.2%]; allograft, n = 4 [9.1%]). Overall, 69.8% (n = 30) were able to RTP in at least 1 game, while 30.2% (n = 13) did not return. Mean time to return was 316.1 days (range, 220-427 days), or 10.4 months. For those players who did RTP, mean career length after ACL reconstruction was 2.8 seasons, or 34.4 games. The majority (56.8%) of injuries occurred early in the season. Breakdown by graft type demonstrated RTP rates among HT, BPTB, and allograft of 64.5% (n = 20), 87.5% (n = 7), and 75% (n = 3), respectively. Career length among HT, BPTB, and allograft was 2.9, 2.4, and 3 seasons. Logistic regression analysis found only concomitant medial collateral ligament (MCL) injuries to be a negative predictor for RTP. Meniscal injuries were associated with a decreased RTP rate and career length, but this was not statistically significant. CONCLUSION The RTP rates after ACL reconstruction in this study are similar to those reported in National Football League players. A concomitant injury to the MCL injury was a negative predictor of RTP. Meniscal injuries demonstrated a trend for decreased RTP rate and career length, but this was not a significant predictor. A large portion of injuries occur early in the season, and further study should be done to examine potential preventative strategies to reduce ACL injuries.
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Affiliation(s)
| | - Jeff Leiter
- Pan Am Clinic, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Robert McCormack
- University of British Columbia, New Westminster, British Columbia, Canada
| | - Peter MacDonald
- Pan Am Clinic, University of Manitoba, Winnipeg, Manitoba, Canada
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Lansdown DA, Xiao W, Zhang AL, Allen CR, Feeley BT, Li X, Majumdar S, Ma CB. Quantitative imaging of anterior cruciate ligament (ACL) graft demonstrates longitudinal compositional changes and relationships with clinical outcomes at 2 years after ACL reconstruction. J Orthop Res 2020; 38:1289-1295. [PMID: 31868948 PMCID: PMC7433779 DOI: 10.1002/jor.24572] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/11/2019] [Indexed: 02/04/2023]
Abstract
T1 ρ and T2 magnetic resonance imaging (MRI) may allow for a noninvasive assessment of ligamentization after anterior cruciate ligament (ACL) reconstruction. We hypothesized that ACL graft T1 ρ and T2 relaxation times would decrease over time, that T1 ρ and T2 relaxation times would be inversely correlated with Knee Osteoarthritis Outcome Scores (KOOS), and that T1 ρ and T2 values would be lower for autograft relative to allograft reconstruction. Thirty-nine patients (age: 30.5 ± 8.2 years) were followed prospectively after ACL reconstruction with hamstring autograft (N = 27) or soft-tissue allograft (N = 12). Magnetic resonance (MR) imaging and KOOS surveys were completed at 6, 12, 24, and 36 months after surgery. ACL graft was segmented to define T1 ρ and T2 relaxation times. Relaxation times were compared between time points with ANOVA tests. Log-transformed autograft and allograft relaxation times were compared with the Student t tests. The relationship between KOOS and relaxation times at 24 months was investigated with Spearman's rank correlation. ACL graft T1 ρ relaxation times were significantly higher at 6 months relative to 12 months (P = .042), 24 months (P < .001), and 36 months (P < .001). ACL graft T2 relaxation times were significantly higher at 6 months relative to 12 months (P = .036), 24 months (P < .001), and 36 months (P < .001). T1 ρ and T2 relaxation times were significantly lower for autograft reconstruction vs allograft reconstruction at 24 months postreconstruction. Two-year KOOS Sports, Pain, and Symptoms were significantly inversely correlated with T1 ρ and T2 relaxation times. T1 ρ and T2 sequences may offer a noninvasive method for monitoring ACL graft maturation that correlates with patient-reported knee function after ACL reconstruction.
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Affiliation(s)
- Drew A. Lansdown
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Weiyuan Xiao
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Alan L. Zhang
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Christina R. Allen
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Brian T. Feeley
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
| | - Xiaojuan Li
- Department of Biomedical Engineering, Cleveland Clinic, Lerner Research Institute, Cleveland, Ohio
| | - Sharmila Majumdar
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - C. Benjamin Ma
- Department of Orthopedic Surgery, Sports Medicine & Shoulder Surgery, University of California, San Francisco, San Francisco, California
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Webster KE, Hewett TE. Is There Value and Validity for the Use of Return to Sport Test Batteries After Anterior Cruciate Ligament Injury and Reconstruction? Arthroscopy 2020; 36:1500-1501. [PMID: 32259646 DOI: 10.1016/j.arthro.2020.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 02/02/2023]
Abstract
Is there value and validity for the use of return-to-sport (RTS) test batteries? With regard to RTS testing, there has been marked interest and rapid growth in studies that document RTS criteria after anterior cruciate ligament reconstruction. A set of criteria or "test-battery" is typically used to "clear" the athlete for RTS. Although most RTS testing is done with aim of assessing safety, the same measurements can be as used to determine the amount of functional capacity regained. It is suggested that RTS test batteries incorporate multiple domains of risk factors. If testing "works," patients who pass should have a lower risk of reinjury than patients who fail but nonetheless return to sport. More recent studies have attempted to cover a broad range of risk factors, with as many as 15 to 20 RTS tests. This is possibly due to a lack of clear evidence as to what are the most important risk factors for second injury. As a result, few patients pass these combined criteria. Findings from a meta-analysis showed that there is a low rate of passing RTS testing (23%). The findings from this and a second meta-analyses are quite similar, as both showed there was no effect of passing RTS test batteries on overall subsequent anterior cruciate ligament injury. There was a 7% to 9% reduction in risk difference of graft injuries with passing of RTS; however, there was a 4% to 9% risk difference or 176% to 235% increased risk of a contralateral injury with passing of RTS criteria. There remain several problems with RTS test batteries, which include low rates of meeting thresholds, many athletes return without meeting RTS thresholds, evidence for predictive value is limited, small sample sizes in many studies (only 2 studies >100 patients), and many studies don't document RTS rates. Additional issues include questions as to whether testing should be staged, how to monitor progression of rehabilitation, and should these RTS batteries be tailored to age groups?
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Affiliation(s)
- Kate E Webster
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Australia.
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Hop test does not correlate with neuromuscular control during drop vertical jump test: A prognostic comparative study utilizing healthy subjects. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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DeFrancesco CJ, Lebrun DG, Molony JT, Heath MR, Fabricant PD. Safer and Cheaper: An Enhanced Milestone-Based Return to Play Program After Anterior Cruciate Ligament Reconstruction in Young Athletes Is Cost-Effective Compared With Standard Time-Based Return to Play Criteria. Am J Sports Med 2020; 48:1100-1107. [PMID: 32182102 DOI: 10.1177/0363546520907914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Safe return to play (RTP) after anterior cruciate ligament (ACL) reconstruction is critical to patient satisfaction. Enhanced rehabilitation after ACL reconstruction with appropriate objective criteria for RTP may reduce the risk of subsequent injury. The cost-effectiveness of an enhanced RTP (eRTP) strategy relative to standard post-ACL reconstruction rehabilitation has not been investigated. PURPOSE To determine if an eRTP strategy after ACL reconstruction is cost-effective compared with standard rehabilitation. STUDY DESIGN Economic and decision analysis. METHODS A decision-analysis model was utilized to compare standard rehabilitation with an eRTP strategy, which includes additional neuromuscular retraining, advanced testing, and follow-up physician visits. Cost-effectiveness was evaluated from a payer perspective. Costs of surgical procedures and rehabilitation protocols, risks of graft rupture and contralateral ACL injury, risk reductions as a result of the eRTP strategy, and relevant health utilities were derived from the literature. An incremental cost-effectiveness ratio of <$100,000/quality-adjusted life-year was used to determine cost-effectiveness. Sensitivity analyses were performed on pertinent model parameters to assess their effect on base case conclusions. In the base case analysis, the eRTP strategy cost was conservatively estimated to be $969 more than the standard rehabilitation protocol. Completion of the eRTP strategy was considered to confer a 25% risk reduction for graft rupture in comparison with standard rehabilitation. RESULTS The eRTP strategy was more cost-effective than standard rehabilitation alone. Based on 1-way threshold analyses, the eRTP strategy was cost-effective as long as its additional cost over standard rehabilitation was <$2092 or the eRTP strategy decreased the incidence of contralateral ACL rupture by >13.8%. CONCLUSION The eRTP strategy in this study adds additional neuromuscular retraining and additional physician follow-up-as well as advanced testing goals upon which RTP is contingent-to traditional physical therapy. Our data suggest that these additions are cost-effective, even assuming only modest associated decreases in ACL graft failure. This study also determined that the only variable that had the potential to change the cost-effectiveness conclusion based on predetermined ranges was the additional cost of rehabilitation based on 1-way sensitivity analysis. CLINICAL RELEVANCE This study provides evidence of cost-effectiveness for payers, supporting the use of enhanced RTP programs. The sensitivity analyses herein may be used to determine if any given RTP program going forward is cost-effective, regardless of the exact components of the program.
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Affiliation(s)
| | - Drake G Lebrun
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Joseph T Molony
- Department of Rehabilitation Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Madison R Heath
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Peter D Fabricant
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Frantz TL, Everhart JS, Cvetanovich GL, Neviaser A, Jones GL, Hettrich CM, Wolf BR, Baumgarten KM, Bollier MJ, Bravman JT, Kuhn JE, Ma CB, Marx RG, McCarty EC, Ortiz SF, Zhang AL, Bishop JY. Are Patients Who Undergo the Latarjet Procedure Ready to Return to Play at 6 Months? A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group Cohort Study. Am J Sports Med 2020; 48:923-930. [PMID: 32045268 DOI: 10.1177/0363546520901538] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Latarjet procedure is growing in popularity for treating athletes with recurrent anterior shoulder instability, largely because of the high recurrence rate of arthroscopic stabilization, particularly among contact athletes with bone loss. PURPOSE (1) To evaluate return of strength and range of motion (ROM) 6 months after the Latarjet procedure and (2) to determine risk factors for failure to achieve return-to-play (RTP) criteria at 6 months. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS A total of 65 athletes (83% contact sports, 37% overhead sports; mean ± SD age, 24.5 ± 8.2 years; 59 male, 6 female) who enrolled in a prospective multicenter study underwent the Latarjet procedure for anterior instability (29% as primary procedure for instability, 71% for failed prior stabilization procedure). Strength and ROM were assessed preoperatively and 6 months after surgery. RTP criteria were defined as return to baseline strength and <20° side-to-side ROM deficits in all planes. The independent likelihood of achieving strength and motion RTP criteria at 6 months was assessed through multivariate logistic regression modeling with adjustment as needed for age, sex, subscapularis split versus tenotomy, preoperative strength/motion, percentage bone loss, number of prior dislocations, preoperative subjective shoulder function (American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability Index percentage), and participation in contact versus overhead sports. RESULTS Of the patients, 55% failed to meet ≥1 RTP criteria: 6% failed for persistent weakness and 51% for ≥20° side-to-side loss of motion. There was no difference in failure to achieve RTP criteria at 6 months between subscapularis split (57%) versus tenotomy (47%) (P = .49). Independent risk factors for failure to achieve either strength or ROM criteria were preoperative American Shoulder and Elbow Surgeons scores (per 10-point decrease: adjusted odds ratio [aOR], 1.61; 95% CI, 1.14-2.43; P = .006), Western Ontario Shoulder Instability Index percentage (per 10% decrease: aOR, 0.61; 95% CI, 0.38-0.92; P = .01), and a preoperative side-to-side ROM deficit ≥20° in any plane (aOR, 5.01; 95% CI, 1.42-21.5; P = .01) or deficits in external rotation at 90° of abduction (per 10° increased deficit: aOR, 1.64; 95% CI, 1.06-2.88; P = .02). CONCLUSION A large percentage of athletes fail to achieve full strength and ROM 6 months after the Latarjet procedure. Greater preoperative stiffness and subjective disability are risk factors for failure to meet ROM or strength RTP criteria.
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Affiliation(s)
- Travis L Frantz
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Joshua S Everhart
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Gregory L Cvetanovich
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Andrew Neviaser
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Grant L Jones
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Carolyn M Hettrich
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Brian R Wolf
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
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- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Keith M Baumgarten
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Matthew J Bollier
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Jonathan T Bravman
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - John E Kuhn
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - C Benjamin Ma
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Robert G Marx
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Eric C McCarty
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Shannon F Ortiz
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Alan L Zhang
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Julie Y Bishop
- Investigation performed at Sports Medicine Research Institute, The Ohio State University, Columbus, Ohio, USA
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Astur DC, Novaretti JV, Cavalcante ELB, Goes A, Kaleka CC, Debieux P, Krob JJ, de Freitas EV, Cohen M. Pediatric Anterior Cruciate Ligament Reruptures Are Related to Lower Functional Scores at the Time of Return to Activity: A Prospective, Midterm Follow-up Study. Orthop J Sports Med 2019; 7:2325967119888888. [PMID: 31840033 PMCID: PMC6904784 DOI: 10.1177/2325967119888888] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Skeletally immature patients show a higher rate of anterior cruciate ligament
(ACL) reruptures. A better understanding of the risk factors for an ACL
rerupture in this population is critical. Purpose/Hypothesis: The objective of this study was to analyze preoperative, intraoperative, and
postoperative characteristics of pediatric patients undergoing ACL
reconstruction and determine the relationship of these factors with an ACL
rerupture. It was hypothesized that patients with worse activity scores and
knee function at the time of return to activity would have a higher rate of
ACL reruptures at midterm follow-up. Additionally, it was hypothesized that
most ACL reruptures would occur before age 20 years in the study
population. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 65 skeletally immature patients (age <16 years) with ACL
ruptures underwent reconstruction with a quadruple hamstring tendon graft
between 2002 and 2016. Of these patients, 52 were available for the study.
Patient characteristics, surgical details, Tegner and Lysholm scores, and
ACL reconstruction outcomes were recorded. Patients were analyzed and
compared according to ACL rerupture occurrence. Results: Of the 52 patients, 18 (34.6%) experienced an ACL rerupture after
reconstruction. The majority of reruptures (77.8%) occurred before age 20
years. There were 2 patients who sustained ACL reruptures during the
rehabilitation period before they returned to activity. The majority of
reruptures occurred after 12 months (83.2%), with 66.6% occurring after 24
months. Upon returning to activity between 6 and 9 months postoperatively,
patients who ended up with intact ACL grafts reported 69% higher mean Tegner
scores (P = .006) and 64% higher mean Lysholm scores than
patients who sustained ACL reruptures (P < .001). Within
the limits of this study, we could identify no statistical relationship
between the rate of ACL reruptures and different sport types, surgical
techniques, or associated injuries (P > .05). Conclusion: Skeletally immature patients who underwent ACL reconstruction and sustained
ACL reruptures had lower Tegner and Lysholm scores upon returning to
activity than patients without ACL reruptures. In addition, most ACL
reruptures occurred in patients younger than 20 years (77.8%) and after 24
months postoperatively (66.6%).
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Affiliation(s)
- Diego Costa Astur
- Centro de Traumatologia do Esporte, Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - João Victor Novaretti
- Centro de Traumatologia do Esporte, Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Joseph J Krob
- University of Illinois College of Medicine, Peoria, Illinois, USA
| | | | - Moises Cohen
- Centro de Traumatologia do Esporte, Department of Orthopaedics and Traumatology, Universidade Federal de São Paulo, São Paulo, Brazil
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Kelly T, Gultekin S, Cross T, Feller J. Distal Avulsion of the Semitendinosus Tendon: A Case Report. Orthop J Sports Med 2019; 7:2325967119873843. [PMID: 31598530 PMCID: PMC6764053 DOI: 10.1177/2325967119873843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Thomas Kelly
- Liverpool Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Sinem Gultekin
- University of Sydney, Sydney, New South Wales, Australia
| | - Tom Cross
- Stadium Sports Medicine Clinic, Sydney, New South Wales, Australia.,Sydney Swans Football Club, Sydney, New South Wales, Australia
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47
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Abbreviated quantitative UTE imaging in anterior cruciate ligament reconstruction. BMC Musculoskelet Disord 2019; 20:426. [PMID: 31521135 PMCID: PMC6745079 DOI: 10.1186/s12891-019-2811-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/30/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Existing ultrashort echo time magnetic resonance imaging (UTE MRI) methods require prohibitively long acquisition times (~ 20-40 min) to quantitatively assess the clinically relevant fast decay T2* component in ligaments and tendons. The purpose of this study was to evaluate the feasibility and clinical translatability of a novel abbreviated quantitative UTE MRI paradigm for monitoring graft remodeling after anterior cruciate ligament (ACL) reconstruction. METHODS Eight patients who had Graftlink™ hamstring autograft reconstruction were recruited for this prospective study. A 3D double-echo UTE sequence at 3.0 Tesla was performed at 3- and 6-months post-surgery. An abbreviated UTE MRI paradigm was established based on numerical simulations and in vivo validation from healthy knees. This proposed approach was used to assess the T2* for fast decay component ([Formula: see text]) and bound water signal fraction (fbw) of ACL graft in regions of interest drawn by a radiologist. RESULTS Compared to the conventional bi-exponential model, the abbreviated UTE MRI paradigm achieved low relative estimation bias for [Formula: see text] and fbw over a range of clinically relevant values for ACL grafts. A decrease in [Formula: see text] of the intra-articular graft was observed in 7 of the 8 ACL reconstruction patients from 3- to 6-months (- 0.11 ± 0.16 ms, P = 0.10). Increases in [Formula: see text] and fbw from 3- to 6-months were observed in the tibial intra-bone graft ([Formula: see text]: 0.19 ± 0.18 ms, P < 0.05; Δfbw: 4% ± 4%, P < 0.05). Lower [Formula: see text] (- 0.09 ± 0.11 ms, P < 0.05) was observed at 3-months when comparing the intra-bone graft to the graft/bone interface in the femoral tunnel. The same comparisons at the 6-months also yielded relatively lower [Formula: see text] (- 0.09 ± 0.12 ms, P < 0.05). CONCLUSION The proposed abbreviated 3D UTE MRI paradigm is capable of assessing the ACL graft remodeling process in a clinically translatable acquisition time. Longitudinal changes in [Formula: see text] and fbw of the ACL graft were observed.
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Lu J, Chamberlain CS, Ji ML, Saether EE, Leiferman EM, Li WJ, Vanderby R. Tendon-to-Bone Healing in a Rat Extra-articular Bone Tunnel Model: A Comparison of Fresh Autologous Bone Marrow and Bone Marrow-Derived Mesenchymal Stem Cells. Am J Sports Med 2019; 47:2729-2736. [PMID: 31339739 DOI: 10.1177/0363546519862284] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite widespread acceptance of fresh autologous bone marrow (BM) for use in clinical practice, limited information exists to analyze if tendon-to-bone healing could be accelerated with local use of fresh autologous BM. PURPOSE To investigate the effect of fresh autologous BM on tendon-to-bone healing with a novel rat model. STUDY DESIGN Controlled laboratory study. METHODS An extra-articular bone tunnel was created and filled with an autologous tendon graft in skeletally mature Sprague-Dawley rats (N = 60). They were then randomly divided into 3 groups: BM group (injection of fresh autologous BM into the tendon-bone interface, n = 20), BM-derived mesenchymal stem cell (BMSC) group (injection of allogenic cultured BMSCs, n = 20), and the control group (tendon-bone interface without injection of BM or BMSCs, n = 20). Biomechanical, histological, and immunohistochemical analyses were performed at 2 and 6 weeks after surgery. RESULTS The BM group showed a relatively well-organized and dense connective tissue interface with better orientation of collagen fibers as compared with the BMSC group. At 2 weeks, the tendon-bone interface tissue thickness of the BMSC group was 140 ± 25 μm (mean ± SEM), which was significantly greater than the BM group (58 ± 15 μm). The BM group showed fewer M1 macrophages at the tendon-bone interface at 2 and 6 weeks (P < .001). In contrast, there were more M2 macrophages at the interface in the BM group 2 and 6 weeks postoperatively when compared with controls and the BMSC group (P < .001). Biomechanical tests revealed significantly higher stiffness in the BM group versus the control and BMSC groups at 2 and 6 weeks after surgery (P < .05). Load to failure showed similar trends to stiffness. CONCLUSION These findings indicate that local delivery of fresh autologous BM enhances tendon-to-bone healing better than the alternative treatments in this study. This effect may be partially due to the observed modulation of inflammatory processes, especially in M2 macrophage polarization. CLINICAL RELEVANCE Fresh autologous BM could be a treatment option for this disorder.
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Affiliation(s)
- Jun Lu
- Department of Orthopaedic Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Connie S Chamberlain
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ming-Liang Ji
- Department of Orthopaedic Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Erin E Saether
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ellen M Leiferman
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Wan-Ju Li
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ray Vanderby
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
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49
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Agarwalla A, Puzzitiello RN, Liu JN, Cvetanovich GL, Gowd AK, Verma NN, Cole BJ, Forsythe B. Timeline for Maximal Subjective Outcome Improvement After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2019; 47:2501-2509. [PMID: 30419175 DOI: 10.1177/0363546518803365] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tears are one of the most common traumatic knee injuries experienced by athletes. Return to sport is considered the pinnacle endpoint among patients receiving ACL reconstruction. However, at the time of return to sport, patients may not be participating at their previous levels of function, as defined by clinical metrics. PURPOSE To establish when patients perceive maximal subjective medical improvement according to patient-reported outcome measures (PROMs). STUDY DESIGN Systematic review. METHODS A systematic review of the PubMed database was conducted to identify studies that reported sequential PROMs up to a minimum of 2 years after ACL reconstruction. Pooled analysis was conducted for PROMs at follow-up points of 3 months, 6 months, 1 year, and 2 years. Clinically significant improvement was determined between pairs of intervals with the minimal clinically important difference. RESULTS This review contains 30 studies including 2253 patients who underwent ACL reconstruction. Clinically significant improvement in the KOOS (Knee injury and Osteoarthritis Outcome Score) was seen up to 1 year after ACL reconstruction, but no clinical significance was noted from 1 to 2 years. Clinically significant improvement in the IKDC (International Knee Documentation Committee) and Lysholm questionnaires was seen up to 6 months postoperatively, but no clinical significance was noted beyond that. CONCLUSION After ACL reconstruction, maximal subjective medical improvement is established 1 year postoperatively, with no further perceived clinical improvement beyond this time point according to current PROMs. The KOOS may be a more responsive metric to subjective improvements in this patient cohort than other patient-reported outcomes, such as the IKDC and Lysholm. CLINICAL RELEVANCE After ACL reconstruction, patients perceive interval subjective improvements until 1 year postoperatively.
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Affiliation(s)
- Avinesh Agarwalla
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Richard N Puzzitiello
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Gregory L Cvetanovich
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anirudh K Gowd
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
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50
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Slagers AJ, van den Akker-Scheek I, Geertzen JHB, Zwerver J, Reininga IHF. Responsiveness of the anterior cruciate ligament – Return to Sports after Injury (ACL-RSI) and Injury – Psychological Readiness to Return to Sport (I-PRRS) scales. J Sports Sci 2019; 37:2499-2505. [DOI: 10.1080/02640414.2019.1646023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Anton J. Slagers
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Groningen, The Netherlands
| | - Inge van den Akker-Scheek
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Orthopaedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan H. B. Geertzen
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Groningen, The Netherlands
| | - Johannes Zwerver
- Department of Sport and Exercise Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Inge H. F. Reininga
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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