Does Playing Football (Soccer) Really Increase the Risk of Knee Osteoarthritis? A Systematic Review and Meta-analysis

OBJECTIVE: To evaluate the relationship between football (soccer) participation and tibiofemoral knee osteoarthritis (OA), considering the influence of competitive level and previous knee injuries. DESIGN: Etiology systematic review with meta-analysis. LITERATURE SEARCH: PubMed, Embase, AMED, and Cochrane were searched for relevant publications. STUDY SELECTION CRITERIA: Studies of football players that included a control group consisting of mainly sedentary nonfootball players, and the relationship of knee OA, were considered. The studies had to report radiographically verified knee OA and specify football activity. DATA SYNTHESIS: Eleven studies, involving 1805 football players and 4022 control individuals were included. Subgroups consisting of data regarding level of play and previous injuries were also synthesized. RESULTS: The overall prevalence of knee OA among football players was increased among professional and recreational players, compared with controls. When knee injuries were excluded, there was no difference in knee OA between football players and controls (OR = 1.25; 95% CI: 0.61, 2.54). Football players with a previous knee injury had a greater risk of knee OA when compared with football players with no history of previous knee injury (OR = 4.16; 95% CI: 1.97, 8.77). CONCLUSION: Football players were at increased risk of knee OA. However, after excluding participants with a history of previous knee injury, there were no differences in knee OA between football players and controls. Previous knee injury was important for developing knee OA. Playing football, in the absence of major knee injuries, did not increase the risk of knee OA. J Orthop Sports Phys Ther 2024;54(5):1-12. Epub 26 February 2024. doi:10.2519/jospt.2024.12029.

Better Safe Than Sorry? A Systematic Review with Meta-analysis on Time to Return to Sport After ACL Reconstruction as a Risk Factor for Second ACL Injury

OBJECTIVE: To compare the time to return to sport (RTS) between patients who did and did not suffer a second anterior cruciate ligament (ACL) injury after ACL reconstruction. DESIGN: Etiology systematic review with meta-analysis. LITERATURE SEARCH: Cochrane Library, Embase, Medline, AMED, and PEDro databases were searched in August 2021 and again in November 2022. STUDY SELECTION CRITERIA: Clinical studies reporting time to RTS after ACL reconstruction and second ACL injury were eligible. DATA SYNTHESIS: We pooled continuous data (time [months] and proportions [%]), with random-effects meta-analyses. Pooled estimates were summarized in forest plots. A qualitative data synthesis was also performed. RESULTS: Twenty-one studies were included in the meta-analysis and 33 in the qualitative synthesis. Pooled incidence of second ACL injury was 16.9% (95% confidence interval [CI]: 12.8, 21.6). Patients who suffered a second ACL injury returned to sport significantly earlier (25 days; 95% CI: 9.5, 40.4) than those who did not suffer another injury. There was no difference in time to RTS for professional athletes who suffered a second ACL injury and those who did not. The certainty of evidence was very low. CONCLUSION: There was very low-certainty evidence that patients who suffered a second ACL injury had returned to sport 25 days earlier than patients who did not have another injury. For professional athletes, there was no difference in time to RTS between athletes who suffered a second ACL injury and athletes who did not. J Orthop Sports Phys Ther 2024;54(3):1-15. Epub 30 November 2023. doi:10.2519/jospt.2023.11977.

The NordBord test reveals persistent knee flexor strength asymmetry when assessed two and five years after ACL reconstruction with hamstring tendon autograft

OBJECTIVE

Comparison of knee flexor strength limb symmetry index (LSI) between the NordBord-test and the Biodex-test, and to determine the relationship between knee flexor strength and function in patients 2 and 5 years after anterior cruciate ligament reconstruction (ACL-R) with hamstring tendon (HT) autografts.

DESIGN

Observational registry study.

SETTING

Primary care.

PATIENTS

Cross-sectional data from 96 patients (55% women) participating in a rehabilitation-registry after ACL-R with HT autografts.

MAIN OUTCOME MEASURES

Comparison of knee flexor strength symmetry between the Biodex-test and the NordBord-test. Secondly, the relationship between knee flexor strength test and perceived knee function, activity level, and hop performance.

RESULTS

The NordBord-test demonstrated greater strength deficits compared to the Biodex-test with a mean difference of 12.5% ± 15.1% 95 % CI [8.1; 16.9%] at 2 years, and 11.1% ± 11.9% 95 % CI [7.7; 14.6 %] at 5 years after ACL-R. Relative concentric knee flexor strength (Nm/kg) in the Biodex demonstrated significant weak-to-moderate correlations with activity level and hop performance (r = 0.33-0.67) at 2 and 5 years.

CONCLUSION

The NordBord-test identified deficits in knee flexor strength LSI not seen with the Biodex-test at 2 and 5 years after ACL-R. No significant correlations were found between the persistent knee flexor strength asymmetry and perceived function, activity level or hop performance.

Validity and Reliability of Finger-Strength Testing in 6 Common Grip Techniques for the Assessment of Bouldering Ability in Men

OBJECTIVE

To determine the criterion validity and test-retest reliability of isometric finger-strength testing in 6 differentiated grip techniques for the assessment of bouldering ability among male climbers.

METHODS

We recruited participants at climbing gyms in Sweden and through online advertisements. We included climbers over 15 years of age with a minimum bouldering performance level of 17 International Rock Climbing and Research Association (IRCRA) for men and 15 IRCRA for women. We tested unilateral, maximal isometric peak finger strength in the front 3 drag, half crimp, closed crimp, 35 sloper, 45 × 90-mm, and 90 × 90-mm pinch through maximal force deloaded of a force plate. We analyzed criterion validity, test-retest reliability, and capacity to determine bouldering performance ability using a stepwise multivariable regression model.

RESULTS

Women were excluded from the analysis due to insufficient sample size (n = 16). Thirty-two male participants were included in the primary analysis. The median (interquartile range) age in the advanced and elite group was 27 (25; 35) and 23 (22; 32) years, respectively. The half crimp for the participants' weak and strong hand displayed the highest ability to determine bouldering grade performance, explaining 48% to 58% of the variance. In the stepwise regression, maximal strength in the half crimp and the front 3 drag collectively explained 66% of the variance for performance.

CONCLUSION

Strength in the half crimp proved the most important performance indicator. The results of this study provide a reliable and valid framework for maximal isometric peak finger-strength testing in advanced and elite male boulderers.

Comparison of knee flexor strength recovery between semitendinosus alone versus semitendinosus with gracilis autograft for ACL reconstruction: a systematic review and meta-analysis

BACKGROUND

Whether there is a difference in harvesting the semitendinosus tendon alone (S) or in combination with the gracilis tendon (SG) for the recovery of knee flexor strength after anterior cruciate ligament (ACL) reconstruction remains inconclusive. Therefore, this study aimed to assess the recovery of knee flexor strength based on the autograft composition, S or SG autograft at 6, 12, and ≥ 24 months after ACL reconstruction.

METHODS

A systematic review and meta-analysis was conducted following the PRISMA guidelines. A comprehensive search was performed encompassing the Cochrane Library, Embase, Medline, PEDRo and AMED databases from inception to January 2023. Inclusion criteria were human clinical trials published in English, comprised of randomized controlled trials (RCTs), longitudinal cohort-, cross-sectional and case-control studies that compared knee flexor strength recovery between S and SG autografts in patients undergoing primary ACL reconstruction. Isokinetic peak torques were summarized for angular velocities of 60°/s, 180°/s, and across all angular velocities, assessed at 6, 12, and ≥ 24 months after ACL reconstruction. A random-effects model was used with standardized mean differences and 95% confidence intervals. Risk of bias was assessed with the RoBANS for non-randomized studies and the Cochrane RoB 2 tool for RCTs. Certainty of evidence was appraised using the GRADE working group methodology.

RESULTS

Among the 1,227 patients from the 15 included studies, 604 patients received treatment with S autograft (49%), and 623 received SG autograft (51%). Patients treated with S autograft displayed lesser strength deficits at 6 months across all angular velocities d = -0.25, (95% CI -0.40; -0.10, p = 0.001). Beyond 6 months after ACL reconstruction, no significant difference was observed between autograft compositions.

CONCLUSION

The harvest of S autograft for ACL reconstruction yields superior knee flexor strength recovery compared to SG autograft 6 months after ACL reconstruction, irrespective of angular velocity at isokinetic testing. However, the clinical significance of the observed difference in knee flexor strength between autograft compositions at 6 months is questionable, given the very low certainty of evidence and small effect size. There was no significant difference in knee flexor strength recovery between autograft compositions beyond 6 months after ACL reconstruction.

TRIAL REGISTRATION

CRD42022286773.

To achieve the unachievable-Patients' experiences of opting for delayed anterior cruciate ligament reconstruction after trying rehabilitation alone as primary treatment: A qualitative study

INTRODUCTION

About 50% of patients who sustain an anterior cruciate ligament (ACL) injury are treated without ACL reconstruction (ACL-R). A significant proportion of these patients opt for late ACL-R. Patients' experience of changing treatment has not yet been investigated and presented in the scientific literature.

AIM

To explore patients' experiences before and after changing treatment from ACL rehabilitation alone to ACL-R.

METHOD

Fifteen patients were interviewed in semi-structured interviews, which were recorded, transcribed, and analyzed with qualitative content analysis, based on the method described by Graneheim and Lundman. Patients were between 26 and 58 years old, and had tried rehabilitation for a minimum of 9 months prior to ACL-R.

RESULTS

Two themes, "Expecting what could not be achieved: the struggle to recover and not becoming stable", and "Internal completeness: expectations can be achieved", emerged from the analysis. Each theme was supported by three main categories and 5-6 subcategories. The first theme represents the journey before ACL-R, where patients experienced getting stronger, but perceived the knee as unstable. The second theme represents the journey after ACL-R, where patients expressed that they felt whole after their ACL-R, and where able to achieve their expections. Patients experienced a greater support from the healthcare system, and ultimately expressed a feeling of having achieved the unachievable after ACL-R.

SUMMARY

Patients who cross over from ACL rehabilitation to ACL-R experienced rehabilitation alone as insufficient to achieve the desired outcomes, which resulted in a need to opt for delayed ACL-R. Healthcare providers need to support patients, who primarily choose to undergo rehabilitation alone and later opt for ACL-R, throughout the whole rehabilitation process.

Physical symptoms among professional gamers within eSports, a survey study

BACKGROUND

There is a need to establish the prevalence of self-reported physical symptoms such as pain in professional gamers (PGs) and to analyse whether there are correlations between lifestyle factors and self-reported physical symptoms. The purpose of this study was to analyse the prevalence of self-reported physical symptoms including eye-related problems in PGs. A further aim was to analyse the association between physical symptoms and lifestyle factors such as sleep time, play time and physical activity.

METHODS

This study was designed as a cross-sectional study with data based on an electronic survey, created specifically for this study, through discussion and screening of established validated questionnaires for physical symptoms in musculoskeletal conditions: the Karolinska Sleep Questionnaire and the Nordic Musculoskeletal Questionnaire. The survey comprised age and years of experience as a PG as descriptive variables, as well as questions on sleep, play time, physical activity and physical symptoms for the purpose of analysis. The directors of 10 professional gaming corporations were contacted by email with a link to the study-specific survey to distribute to all employees.

RESULTS

A total of 40 answers to the electronic survey were retrieved from 40 PGs, of which 62.5% (n = 25) had experienced at least one physical symptom in the three months prior to answering the survey. There was a significant association between playing time and physical symptoms (OR = 8.0; 95% CI 1.4-44.6, p = 0.018), where playing for more than 35 h a week was positively associated with eight times higher odds of experiencing physical symptoms.

CONCLUSION

There is a high prevalence of physical symptoms, such as headache and eye symptoms, in professional eSports gamers. There was an association between playing more than 35 h per week with the prevalence of physical symptoms.

Restoring Knee Flexor Strength Symmetry Requires 2 Years After ACL Reconstruction, But Does It Matter for Second ACL Injuries? A Systematic Review and Meta-analysis

BACKGROUND

It is unknown whether knee flexor strength recovers after anterior cruciate ligament (ACL) reconstruction with a hamstring tendon (HT) autograft and whether persistent knee flexor strength asymmetry is associated to a second ACL injury.

OBJECTIVE

We aimed to systematically review (1) whether knee flexor strength recovers after ACL reconstruction with HT autografts, and (2) whether it influences the association with a second ACL injury. A third aim was to summarize the methodology used to assess knee flexor strength.

DESIGN

Systematic review and meta-analysis reported according to PRISMA.

METHODS

A systematic search was performed using the Cochrane Library, Embase, Medline, PEDRo, and AMED databases from inception to December 2021 and until completion in January 2023. Human clinical trials written in English and conducted as randomized controlled trials, longitudinal cohort, cross-sectional, and case-control studies on patients with index ACL reconstructions with HT autografts harvested from the ipsilateral side were considered. Knee flexor strength was measured isokinetically in both the reconstructed and uninjured limb to enable the calculation of the limb symmetry index (LSI). The Risk of Bias Assessment Tool for Non-Randomized Studies was used to assess risk of bias for non-randomized studies and the revised Cochrane Risk of Bias tool was used for randomized controlled trials. For the meta-analysis, the LSI (mean ± standard error) for concentric knee flexor strength at angular velocities of 60°/second (s) and 180°/s preoperatively and at 3 months, 6 months, 12 months, and 24 months were pooled as weighted means with standard errors.

RESULTS

The search yielded 64 studies with a total of 8378 patients, which were included for the assessment of recovery of knee flexor strength LSI, and a total of 610 patients from four studies that investigated the association between knee flexor strength and second ACL injuries. At 1 year after ACL reconstruction, the knee flexor strength LSI had recovered to 89.0% (95% CI 87.3; 90.7%) and 88.3% (95% CI 85.5; 91.1%) for the velocities of 60°/s and 180°/s, respectively. At 2 years, the LSI was 91.7% (95% CI 90.8; 92.6%) and 91.2% (95% CI 88.1; 94.2%), for velocities of 60°/s and 180°/s, respectively. For the association between knee flexor strength and second ACL injuries, there was insufficient and contradictory data.

CONCLUSIONS

There was low to very low certainty of evidence indicating that the recovery of knee flexor strength LSI, defined as ≥ 90% of the uninjured side, takes up to 2 years after ACL reconstruction with HT autografts. Whether knee flexor strength deficits influence the association of second ACL injuries is still uncertain. There was considerable heterogeneity in the methodology used for knee flexor strength assessment, which together with the low to very low certainty of evidence, warrants further caution in the interpretation of our results.

REGISTRATION NUMBER

CRD42022286773.

Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction

BACKGROUND

Different fixation methods in anterior cruciate ligament reconstruction (ACLR) have been associated with different revision rates, specifically in the early postoperative period. However, most previous research has either grouped together different fixation types or evaluated femoral-sided fixation or tibial-sided fixation separately. Therefore, the purpose of this study was to determine ACL revision rates for specific combinations of femoral and tibial fixation methods within 2 years of primary hamstring tendon autograft ACLR based on data from the Swedish National Knee Ligament Registry (SNKLR).

METHODS

Patients that underwent primary hamstring tendon autograft ACLR between 2005 and 2018 in the SNKLR were included. The collected data included patient characteristics (age, sex, body mass index [BMI]), activity at time of injury, surgical information (concomitant injuries, time from injury to surgery, fixation types at the femur and tibia), and subsequent revision ACLR. Revision rate within 2 years of the index procedure was chosen, as ACLR fixation is most likely to contribute to ACLR revision within the first 2 years, during graft maturation.

RESULTS

Of the 23,238 included patients undergoing primary hamstring ACLR, 581 (2.5%) underwent revision ACLR within 2 years of the index procedure. Among the combinations used for > 300 patients, the femoral metal interference screw/tibial metal interference screw fixation combination had the highest revision rate followed by metal interference screw/resorbable screw and Endobutton/AO screw fixation combinations, with respective revision rates of 4.0, 3.0, and 3.0%. The lowest revision rate within 2 years of ACLR was found in the Endobutton/metal interference screw with backup Osteosuture fixation combination, used in 433 cases, with a failure rate of 0.9%.

CONCLUSION

Different early ACL revision rates were found across different combinations of femoral and tibial fixation devices within 2 years of primary hamstring tendon autograft ACLR. Metal interference screw fixation, particularly when performed on both the femoral and tibial sides, most frequently resulted in revision ACLR. These findings may be helpful for surgeons in selecting appropriate fixation devices for hamstring ACLR.

LEVEL OF EVIDENCE

IV.

Only 10% of Patients With a Concomitant MCL Injury Return to Their Preinjury Level of Sport 1 Year After ACL Reconstruction: A Matched Comparison With Isolated ACL Reconstruction

BACKGROUND

There is a need for an increased understanding of the way a concomitant medial collateral ligament (MCL) injury may influence outcome after anterior cruciate ligament (ACL) reconstruction.

HYPOTHESIS

Patients with a concomitant MCL injury would have inferior clinical outcomes compared with a matched cohort of patients undergoing ACL reconstruction without an MCL injury.

STUDY DESIGN

Matched registry-based cohort study; case-control.

LEVEL OF EVIDENCE

Level 3.

METHODS

Data from the Swedish National Knee Ligament Registry and a local rehabilitation outcome registry were utilized. Patients who had undergone a primary ACL reconstruction with a concomitant nonsurgically treated MCL injury (ACL + MCL group) were matched with patients who had undergone an ACL reconstruction without an MCL injury (ACL group), in a 1:3 ratio. The primary outcome was return to knee-strenuous sport, defined as a Tegner activity scale ≥6, at the 1-year follow-up. In addition, return to preinjury level of sport, muscle function tests, and patient-reported outcomes (PROs) were compared between the groups.

RESULTS

The ACL + MCL group comprised 30 patients, matched with 90 patients in the ACL group. At the 1-year follow-up, 14 patients (46.7%) in the ACL + MCL group had return to sport (RTS) compared with 44 patients (48.9%) in the ACL group (P = 0.37). A significantly lower proportion of patients in the ACL + MCL group had returned to their preinjury level of sport compared with the ACL group (10.0% compared with 25.6%, adjusted P = 0.01). No differences were found between the groups across a battery of strength and hop tests or in any of the assessed PROs. The ACL + MCL group reported a mean 1-year ACL-RSI after injury of 59.4 (SD 21.6), whereas the ACL group reported 57.9 (SD 19.4), P = 0.60.

CONCLUSION

Patients with a concomitant nonsurgically treated MCL injury did not return to their preinjury level of sport to the same extent as patients without an MCL injury 1 year after ACL reconstruction. However, there was no difference between the groups in terms of return to knee strenuous activity, muscle function, or PROs.

CLINICAL RELEVANCE

Patients with a concomitant nonsurgically treated MCL injury may reach outcomes similar to those of patients without an MCL injury 1 year after an ACL reconstruction. However, few patients return to their preinjury level of sport at 1 year.

Comparison of Improvement in Patient-Reported Knee Function After Revision and Multiple-Revision ACL Reconstruction Compared With Primary ACL Reconstruction

Background

Graft failure after anterior cruciate ligament reconstruction (ACLR) is a debilitating complication often requiring revision surgery. It is widely agreed upon that functional knee outcomes after revision ACLR (r-ACLR) are inferior compared with those after primary reconstruction. However, data are scarce on outcomes after multiple-revision ACLR (mr-ACLR).

Purpose

To compare patient-reported knee function in terms of Knee injury and Osteoarthritis Outcome Score (KOOS) preoperatively and 1-year postoperatively after primary ACLR, r-ACLR, and mr-ACLR and evaluate the pre- to postoperative improvement in KOOS scores for each procedure.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients from the Swedish National Knee Ligament Registry who underwent their index ACLR between 2005 and 2020 with a minimum age of 15 years at the time of surgery were included in this study. All patients had pre- and postoperative KOOS data. The 1-year postoperative KOOS and the pre- to postoperative changes in KOOS were assessed between patients who underwent primary ACLR and those who underwent subsequent r-ACLR and mr-ACLR.

Results

Of 20,542 included patients, 19,769 (96.2%) underwent primary ACLR, 760 (3.7%) underwent r-ACLR, and 13 (0.06%) underwent mr-ACLR. Patients who underwent r-ACLR had significantly smaller pre- to postoperative changes on all KOOS subscales compared with patients undergoing primary ACLR (P < .0001 for all). Furthermore, patients in the mr-ACLR group had significantly smaller changes in the KOOS-Pain subscale compared with patients in the r-ACLR group (-9 ± 23.3 vs 2.5 ± 18; P = .024).

Conclusion

The study results indicated that while improvement is seen after primary ACLR, r-ACLR, and mr-ACLR, the greatest improvement in functional outcomes is observed after primary ACLR. Patients who underwent at least 1 r-ACLR, specifically mr-ACLR, had lower postoperative outcome scores, indicating that primary ACLR may provide the best chance for recovery after ACL injury.

Greater self-efficacy, psychological readiness and return to sport amongst paediatric patients compared with adolescents and young adults, 8 and 12 months after ACL reconstruction

PURPOSE

The purpose of this study was to evaluate differences in rehabilitation-specific outcomes between paediatric patients, adolescents and young adults within the first 2 years after anterior cruciate ligament (ACL) reconstruction. A further aim was to determine whether patient age was associated with an increased risk of not achieving symmetrical muscle function within the first 2 years after ACL reconstruction.

METHODS

The patient data in the present study were extracted from the rehabilitation outcome registry, Project ACL. Patients aged 11-25 years registered for primary ACL reconstruction with a hamstring tendon autograft between April 1, 2013 and November 23, 2020 were included. A total of 691 patients met the inclusion criteria and were included in the study; 41 paediatric patients (females 11-13, males 11-15 years), 347 adolescents (females 14-19, males 16-19 years) and 303 young adults (females 20-25, males 20-25 years).

RESULTS

The comparison between groups revealed that 70% of paediatric patients, 39% of adolescents and 35% of young adults had returned to knee-strenuous sport at 8 months and that 90% of paediatric patients, 71% of adolescents and 62% of young adults had returned to sport at 12 months. Paediatric patients also reported higher scores compared with both the other patient groups on the Knee Self-Efficacy Scale (K-SES) and the Anterior Cruciate Ligament Return to Sport after Injury scale (ACL-RSI) at 8 and 12 months.

CONCLUSIONS

A larger proportion of paediatric patients had returned to sport compared with adolescents and young adults 8 and 12 months after ACL reconstruction. Paediatric patients also reported higher self-efficacy and greater psychological readiness to return to sport at 8 and 12 months than the other two groups. No differences in terms of muscle function tests when comparing paediatric patients, adolescents and young adults were found.

LEVEL OF EVIDENCE

II.

A practical guide to the implementation of AI in orthopaedic research - part 1: opportunities in clinical application and overcoming existing challenges

Artificial intelligence (AI) has the potential to transform medical research by improving disease diagnosis, clinical decision-making, and outcome prediction. Despite the rapid adoption of AI and machine learning (ML) in other domains and industry, deployment in medical research and clinical practice poses several challenges due to the inherent characteristics and barriers of the healthcare sector. Therefore, researchers aiming to perform AI-intensive studies require a fundamental understanding of the key concepts, biases, and clinical safety concerns associated with the use of AI. Through the analysis of large, multimodal datasets, AI has the potential to revolutionize orthopaedic research, with new insights regarding the optimal diagnosis and management of patients affected musculoskeletal injury and disease. The article is the first in a series introducing fundamental concepts and best practices to guide healthcare professionals and researcher interested in performing AI-intensive orthopaedic research studies. The vast potential of AI in orthopaedics is illustrated through examples involving disease- or injury-specific outcome prediction, medical image analysis, clinical decision support systems and digital twin technology. Furthermore, it is essential to address the role of human involvement in training unbiased, generalizable AI models, their explainability in high-risk clinical settings and the implementation of expert oversight and clinical safety measures for failure. In conclusion, the opportunities and challenges of AI in medicine are presented to ensure the safe and ethical deployment of AI models for orthopaedic research and clinical application. Level of evidence IV.

Physical inactivity 5-8 years after anterior cruciate ligament reconstruction is associated with knee-related self-efficacy and psychological readiness to return to sport

Objectives

To investigate whether patient demographics and patient-reported outcomes (PROs), respectively, are associated with physical inactivity (PI) 5-8 years after primary anterior cruciate ligament reconstruction (ACLR).

Methods

This case control observational study included individuals who had undergone primary ACLR between the ages of 15 and 65 years and had responded to PROs 18 months postoperatively. These individuals were asked to answer a questionnaire regarding their present level of physical activity (PA) at 5-8 years after ACLR. Patient-demographic data and results from the Knee injury and Osteoarthritis Outcome Score, the Knee Self-Efficacy Scale and the ACL Return to Sport (RTS) after Injury scale from 18 months after ACLR were extracted from a rehabilitation-specific register. Univariable logistic regression analyses were performed with PI (<150 min PA per week/≥150 min PA/week) as the dependent variable.

Results

Of 292 eligible participants, 173 (47% women; mean±SD age = 31±11 years) responded to the PA questionnaire. In all, 14% (n=25; 28% women) were classified as physically inactive. Participants with lower levels of present and future self-efficacy, OR 1.35 (CI 1.05 to 1.72) and OR 1.20 (CI 1.12 to 1.45), and lower levels of psychological readiness to RTS, OR 1.19 (CI 1 to 1.43), at the 18-month follow-up, had higher odds of being physically inactive 5-8 years after ACLR. None of the patient demographic variables was able to predict PI.

Conclusion

Lower levels of knee-related self-efficacy and psychological readiness to RTS, 18 months after ACLR, were associated with PI 5-8 years after surgery.

A comparison between physical therapy clinics with high and low rehabilitation volumes of patients with ACL reconstruction

BACKGROUND

Treatment volume can impact outcomes after surgical procedures of the knee between surgeons with high- and low-patient-volumes. However, the difference between physical therapeutic clinics with high- and low-volumes has not been widely researched. This registry study aims to investigate how patient volume affects knee function outcomes after anterior cruciate ligament (ACL) reconstruction at physical therapy (PT) clinics in terms of odds for a second ACL injury, return to pre-injury level of activity, perceived knee function, and recovery of strength and hop performance.

METHOD

Data were extracted from the Project ACL, a local rehabilitation registry. High- and low-volume clinics were defined based on the number of patients who attended different clinics. High-volume clinics were defined as those with > 100 patient registrations in Project ACL during the study period while low-volume clinics were those with ≤ 100 patient registrations. High- and low-volume clinics were compared, based on muscle function and patient-reported outcomes across 4 follow-ups, 2-, 4-, 8-, and 12 months, during the first year after ACL reconstruction, and odds of second ACL injury up to 2 years after ACL reconstruction.

RESULT

Of the 115 rehabilitation clinics included, 111 were classified as low-volume clinics and included 733 patients, and 4 as high-volume clinics which included 1221 patients. There were 31 (1.6%) second ACL injuries to the ipsilateral or contralateral side within the first 12 months and 68 (4.0%) within 2 years. No difference in the incidence of a second ACL injury, within 12 months follow-up odds ratio (OR) 0.95 [95% CI 0.46-1.97] or within 2 years follow-up OR 1.13 [95% CI 0.68-1.88], was found between high- and low-volume clinics. There were early (2 months) and non-clinically relevant differences in patient-reported outcomes (PROs) and physical activity levels early after ACL reconstruction in favor of high-volume clinics. One year after ACL reconstruction, no differences were observed between high- and low-volume clinics in terms of PROs, muscle function, and return to pre-injury level of activity.

CONCLUSION

No clinically relevant difference in the incidence of secondary ACL injuries in patients who underwent rehabilitation after ACL reconstruction at high- or low-volume physical therapist clinics was found. In addition, no clinically relevant differences in outcomes were found during the first year in terms of patient-reported outcomes, recovery of muscle function, or return to pre-injury level of activity.

Swedish Olympic athletes report one injury insurance claim every second year: a 22-year insurance registry-based cohort study

PURPOSE

To describe injury incidence, time trends in injury incidence, and injury characteristics among Swedish Olympic athletes over 22 years based on insurance data, as a first step to inform injury preventive measures among Olympic athletes.

METHODS

The cohort comprised 762 elite athletes (54% males; age 26.5 ± 5.9 years) in 38 sports in the Swedish Olympic Committee support program 'Top and Talent' between 1999 and 2020, with total 3427 athlete-years included. Acute and gradual onset injuries were reported to the insurance registry by the athletes' medical staff.

RESULTS

A total of 1635 injuries in 468 athletes were registered. The overall injury incidence was 47.7 injuries/100 athlete-years (one injury per athlete every second year). An increasing trend in injury incidence was observed in the first decade 2001 to 2010 (annual change 6.0%, 95% CI 3.3-8.8%), while in the second decade 2011 to 2020 no change was evident (0.4%, 95% CI - 1.9 to 2.7%). Gymnastics, tennis, and athletics had the highest incidence (100.0, 99.3, and 93.4 injuries/100 athlete-years, respectively). Among sport categories, mixed and power sports had the highest incidence (72.8 and 69.5 injuries/100 athlete-years, respectively). Higher incidences were seen in the younger age groups (≤ 25 years) in mixed and skill sports. The injury incidence was comparable between male and female athletes, and summer and winter sports. Most injuries occurred in the lower limb, and specifically the knee (24%), foot/ankle (15%) and spine/pelvis (13%).

CONCLUSION

The results on injury patterns in different sports and age groups may guide preventive focus for health and performance teams working with Olympic athletes.

LEVEL OF EVIDENCE

II.

Effect of Concomitant Lateral Meniscal Management on ACL Reconstruction Revision Rate and Secondary Meniscal and Cartilaginous Injuries

BACKGROUND

Simultaneous meniscal tears are often present with anterior cruciate ligament (ACL) injuries, and in the acute setting, the lateral meniscus (LM) is more commonly injured than the medial meniscus.

PURPOSE

To investigate how a concomitant LM injury, repaired, resected, or left in situ during primary ACL reconstruction (ACLR), affects the ACL revision rate and cartilaginous and meniscal status at the time of revision within 2 years after the primary ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data for 31,705 patients with primary ACLR, extracted from the Swedish National Knee Ligament Registry, were used. The odds of revision ACLR, and cartilaginous as well as meniscal injuries at the time of revision ACLR, were assessed between the unexposed comparison group (isolated ACLR) and the exposed groups of interest (ACLR + LM repair, ACLR + LM resection, ACLR + LM repair + LM resection, or ACLR + LM injury left in situ).

RESULTS

In total, 719 (2.5%) of the included 29,270 patients with 2 years follow-up data underwent revision ACLR within 2 years after the primary ACLR. No significant difference in revision rate was found between the groups. Patients with concomitant LM repair (OR, 3.56; 95% CI, 1.57-8.10; P = .0024) or LM resection (OR, 1.76; 95% CI, 1.18-2.62; P = .0055) had higher odds of concomitant meniscal injuries (medial or lateral) at the time of revision ACLR than patients undergoing isolated primary ACLR. Additionally, higher odds of concomitant cartilage injuries at the time of revision ACLR were found in patients with LM resection at index ACLR compared with patients undergoing isolated primary ACLR (OR, 1.73; 95% CI, 1.14-2.63; P = .010).

CONCLUSION

The results of this study demonstrated higher odds of meniscal and cartilaginous injuries at the time of revision ACLR within 2 years after primary ACLR + LM resection and higher odds of meniscal injury at the time of revision ACLR within 2 years after primary ACLR + LM repair compared with isolated ACLR. Surgeons should be aware of the possibility of concomitant cartilaginous and meniscal injuries at the time of revision ACLR after index ACLR with concomitant LM injury, regardless of the index treatment type received.

Differences in postoperative knee function based on concomitant treatment of lateral meniscal injury in the setting of primary ACL reconstruction

BACKGROUND

Concomitant lateral meniscal (LM) injuries are common in acute anterior cruciate ligament (ACL) ruptures. However, the effect of addressing these injuries with various treatment methods during primary ACL reconstruction (ACLR) on patient-reported outcomes (PROs) is unknown. Therefore, the purpose of this study was to compare postoperative Knee injury and Osteoarthritis Outcome Score (KOOS) at 2-, 5-, and 10-years after isolated primary ACLR to primary ACLR with various treatment methods to address concomitant LM injury.

METHODS

This study was based on data from the Swedish National Knee Ligament Registry. Patients ≥ 15 years with data on postoperative KOOS who underwent primary ACLR between the years 2005 and 2018 were included in this study. The study population was divided into five groups: 1) Isolated ACLR, 2) ACLR + LM repair, 3) ACLR + LM resection, 4) ACLR + LM injury left in situ, and 5) ACLR + LM repair + LM resection. Patients with concomitant medial meniscal or other surgically treated ligament injuries were excluded.

RESULTS

Of 31,819 included patients, 24% had LM injury. After post hoc comparisons, significantly lower scores were found for the KOOS Symptoms subscale in ACLR + LM repair group compared to isolated ACLR (76.0 vs 78.3, p = 0.0097) and ACLR + LM injury left in situ groups (76.0 vs 78.3, p = 0.041) at 2-year follow-up. However, at 10-year follow-up, no differences were found between ACLR + LM repair and isolated ACLR, but ACLR + LM resection resulted in significantly lower KOOS Symptoms scores compared to isolated ACLR (80.4 vs 82.3, p = 0.041).

CONCLUSION

The results of this study suggest that LM injury during ACLR is associated with lower KOOS scores, particularly in the Symptoms subscale, at short- and long-term follow-up. However, this finding falls below minimal clinical important difference and therefore may not be clinically relevant.

LEVEL OF EVIDENCE

III.

Lower rates of return to sport in patients with generalised joint hypermobility two years after ACL reconstruction: a prospective cohort study

BACKGROUND

Generalised joint hypermobility (GJH) has been associated with an increased risk of suffering an anterior cruciate ligament (ACL) injury. Patients with GJH exhibit lower muscle strength and poorer scores for patient-reported outcomes after ACL reconstruction, compared with patients without GJH. The aim of this study was to examine differences in the percentages of patients who return to sport (RTS) or pre-injury level of activity (RTP), muscle function and patient-reported outcomes at the time of RTS or RTP, as well as the time of RTS or RTP in patients with GJH compared with patients without GJH in the first two years after ACL reconstruction.

METHODS

This prospective study used data from an ACL- and rehabilitation-specific register located in Gothenburg, Sweden. Patients aged between 16 and 50, who had a primary ACL injury treated with reconstruction, were included. Data up to two years after ACL reconstruction were used and consisted of achieving RTS and RTP, results from isokinetic muscle function tests for knee extension and flexion and patient-reported outcomes (Knee Self-Efficacy Scale, Knee injury and Osteoarthritis Outcome Score and ACL-Return to Sport after Injury scale) at the time of RTS, as well as the time of RTP. A Beighton Score of ≥ 5/9 was used to define GJH. A Tegner Activity Scale of ≥ 6 was used to define RTS, while a Tegner equal to or above pre-injury level was used to define RTP.

RESULTS

A total of 1,198 patients (54.7% women) with a mean age of 28.5 ± 8.6 years were included. A smaller proportion of patients with GJH achieved RTS compared with patients without GJH (49.2% vs. 57.3%, Odds ratio: 0.720, p = 0.041). Furthermore, patients with GJH were marginally less symmetrical on the knee extension strength test, expressed as a Limb Symmetry Index, at the time of RTP compared with patients without GJH (87.3 ± 13.5 vs. 91.7 ± 14.3, Cohen's d = 0.142, p = 0.022). No further differences were found between groups regarding any muscle function tests or patient-reported outcomes.

CONCLUSION

A smaller proportion of patients with GJH achieved RTS compared with patients without GJH. Patients with GJH displayed less symmetrical knee extension strength at the time of RTP compared with patients without GJH.

Generalised joint hypermobility leads to increased odds of sustaining a second ACL injury within 12 months of return to sport after ACL reconstruction

OBJECTIVES

To determine the 12-month risk of a second anterior cruciate ligament (ACL) injury in a population of patients with and without generalised joint hypermobility (GJH) who return to sports (RTS) at competition level after ACL reconstruction (ACL-R).

METHODS

Data were extracted from a rehabilitation-specific registry for 16-50-year-old patients treated with ACL-R between 2014 and 2019. Demographics, outcome data and the incidence of a second ACL injury within 12 months of RTS, defined as a new ipsilateral or contralateral ACL, were compared between patients with and without GJH. Univariable logistic regression and Cox proportional hazards regression were performed to determine the influence of GJH and time of RTS on the odds of a second ACL injury, and ACL-R survival without a second ACL injury after RTS.

RESULTS

A total of 153 patients, 50 (22.2%) with GJH and 175 (77.8%) without GJH, were included. Within 12 months of RTS, 7 (14.0%) patients with GJH and 5 (2.9%) without GJH had a second ACL injury (p=0.012). The odds of sustaining a second ipsilateral or contralateral ACL injury were 5.53 (95% CI 1.67 to 18.29) higher in patients with GJH compared with patients without GJH (p=0.014). The lifetime HR of a second ACL injury after RTS was 4.24 (95% CI 2.05 to 8.80; p=0.0001) in patients with GJH. No between-group differences were observed in patient-reported outcome measures.

CONCLUSION

Patients with GJH undergoing ACL-R have over five times greater odds of sustaining a second ACL injury after RTS. The importance of joint laxity assessment should be emphasised in patients who aim to return to high-intensity sports following ACL-R.

No Effect of Return to Sport Test Batteries with and without Psychological PROs on the Risk of a Second ACL Injury: A Critical Assessment of Four Different Test Batteries

Background

Patients report psychological barriers as important when returning to sport, however, psychological outcome measures are seldom included in return to sport (RTS) assessment. There is a need for clinical trials to integrate psychological patient-reported outcomes (PROs) in return to sport batteries assessing patients treated with ACL reconstruction.

Objective

The aim of this study was to determine the association between passing clinical tests of muscle function and psychological PROs and sustaining a second ACL injury in patients who RTS after primary ACL reconstruction.

Design

Retrospective Cohort study.

Methods

Patients' sex, age, height and weight, and the results of strength and hop tests, as well as answers to PRO's (including Tegner activity scale, the ACL Return to Sport after Injury scale (ACL-RSI) as well as the Quality of Life (QoL) subscale of the Knee injury and Osteoarthritis Outcome Score [KOOS]), were extracted from a rehabilitation-specific registry. Four different test batteries comprising muscle function tests and PROs were created to assess whether patients were ready to RTS. Passing each of the test batteries (yes/no) was used as an independent variable. A multivariable Cox proportional hazard model analysis was performed, with sustaining a second ACL injury (either ipsi- or contralateral; yes/no) within two years of RTS as the dependent variable.

Results

A total of 419 patients (male, n=214; 51%) were included, of which 51 (12.2%) suffered a second ACL injury within the first two years after RTS. There were no differences in passing rates in the different RTS test batteries comprising muscle function tests and PROs for patients who suffered a second ACL injury compared to patients who did not.

Conclusion

No association between passing the RTS clinical tests batteries comprising muscle function and psychological PROs used, and the risk of a second ACL injury could be found.

Level of Evidence

3©The Author(s).

Effect of Quadriceps and Hamstring Strength Relative to Body Weight on Risk of a Second ACL Injury: A Cohort Study of 835 Patients Who Returned to Sport After ACL Reconstruction

Background

Anterior cruciate ligament (ACL) injuries are common sports-related injuries with a high risk of reinjury after return to sport (RTS). Rehabilitation aims to regain symmetrical knee strength and function to minimize the risk of a second ACL injury after RTS.

Purpose

To determine the effect of absolute quadriceps and hamstring strength, normalized by body weight, on the risk of a second ACL injury during the first 2 years after RTS in patients who have undergone ACL reconstruction (ACLR).

Study Design

Cohort study; Level of evidence, 3.

Methods

Data from patients after index ACLR at the time of RTS were extracted from a rehabilitation registry-Project ACL. Patients who had performed isokinetic tests for quadriceps and hamstring strength and hop tests before RTS were included. The endpoint was a second ACL injury or a follow-up of 2 years after RTS after ACLR.

Results

A total of 835 patients (46% women), with a mean age of 23.9 ± 7.7 years, were included. During the study period, 69 (8.3%) second ACL injuries (ipsilateral and contralateral) occurred. Greater relative quadriceps strength in the injured leg increased the risk of a second ACL injury (relative risk [RR], 1.69 [95% CI, 1.05-2.74]; P = .032). In patients who had recovered symmetrical quadriceps strength (limb symmetry index ≥90%), there was no effect of quadriceps strength on the risk of second ACL injury (RR, 1.33 [95% CI, 0.69-2.56]; P = .39). Quadriceps strength on the healthy side or hamstring strength, regardless of side, had no effect on the risk of a second ACL injury.

Conclusion

Greater relative quadriceps strength in the injured leg at the time of RTS after ACLR was associated with an increased risk of a second ACL injury. There was no effect of relative quadriceps strength on the risk of a second ACL injury in patients who had recovered symmetrical quadriceps strength.

Treatment of Primary Dorsal Wrist Ganglion-A Systematic Review

Purpose  The aim of this study was to compare the rates of recurrence and wound infection in patients with primary dorsal wrist ganglion treated with aspiration (with or without an injection of an additive), open excision, or arthroscopic resection. Methods  This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered on PROSPERO. Systematic electronic searches in PubMed (MEDLINE), EMBASE, Web of Science, and the Cochrane Library of Controlled Trials were performed on May 5, 2020, and June 1, 2021, respectively. All clinical studies written in English determining the recurrence and wound infection rates after treatment of primary dorsal wrist ganglion with aspiration, open excision, or arthroscopic resection in patients over the age of 16 years were eligible for inclusion. Quality assessment was guided by the Cochrane Collaboration's tool for randomized controlled trials (RCTs) and the methodological index for nonrandomized studies (MINORS) tool for observational studies. Results  The literature searches resulted in 1,691 studies. After screening, five RCTs, enrolling 233 patients, and six observational studies, enrolling 316 patients with primary dorsal wrist ganglions were included. Quality assessment of the included RCTs and observational studies determined the existing level of evidence pertaining to primary dorsal wrist ganglion treatment to be low. About 11 studies reported on recurrence rate, which ranged between 7 and 72% for patients initially treated with aspiration (with or without an injection of an additive). In comparison, the recurrence rate for the open excision and arthroscopic resection groups ranged between 6 to 41% and 0 to 16%, respectively. Four studies investigated wound-related complications, for which zero infections were reported, irrespective of treatment. Conclusion  The evidence summarized in this systematic review demonstrates a considerable variability in recurrence rate following aspiration and open or arthroscopic resection of a primary dorsal wrist ganglion. The greatest variability in recurrence was displayed among studies on aspiration. The overall infection rate after treatment of dorsal wrist ganglions seems to be low regardless of the treatment type. However, the divergent results of individual studies highlight a pressing need for prospective controlled trials assessing outcomes following dorsal wrist ganglion treatment. Level of Evidence  Systematic review on level 1 to 4 clinical therapeutic studies.

High-level soccer players have a low rate of return to performance after hip arthroscopy for femoroacetabular impingement syndrome

PURPOSE

Femoroacetabular impingement syndrome (FAIS) is a known cause of impaired sports performance in athletes and the relationship between FAIS and soccer players has previously been described. Hip arthroscopy is a viable treatment option that can facilitate athletes' return to sport (RTS). The aim of this study was to evaluate the RTS and return to performance (RTP) with objective measurements in high-level soccer players after hip arthroscopy for FAIS.

METHOD

Soccer players, with a hip sports activity scale (HSAS) level of 7 or 8 before symptom onset and undergoing hip arthroscopy for FAIS between 2011 and 2019 were identified in the Gothenburg hip arthroscopic registry. A total of 83 high-level soccer players, with a mean age of 23.9 (SD 4.4) years at surgery, were included. To verify the activity level and further stratify players as elite or sub-elite, player statistics were collected from soccer-specific scout webpages and the Swedish national soccer association. The return to sport was defined as return to one game of soccer. Return to performance was defined as playing at the same level, or higher, and participating in at least 80% of the number of games played the season before symptom onset or the season before surgery either the first or second season after hip arthroscopy.

RESULTS

In total, 71 (85.5%, 95% confidence interval (CI) 76.1-92.3%) of the players returned to sport the first or second season after surgery. Compared to the season before symptom onset, 31 (37.3%, 95% CI 27.0-48.7%) players returned to performance the first or second season after surgery, and 32 (38.6%, 95% CI 28.1-49.9%) players returned to performance the first or second season after surgery compared to the season before surgery.

CONCLUSION

A high rate of elite and sub-elite soccer players return to soccer after hip arthroscopy for FAIS. However, less than half of the players RTP when evaluating performance through level of play and number of games played.

LEVEL OF EVIDENCE

Level IV.

Low occurrence of MRI spinal changes in elite climbing athletes; a cross-sectional study

OBJECTIVES

To examine the occurrence of magnetic resonance imaging (MRI) changes in the thoracolumbar spine among elite climbing athletes.

METHODS

All climbers of the Swedish national sport climbing team (n = 8), and individuals having trained for selection to the national team (n = 11), were prospectively included. A control group, matched in age and sex, were recruited. All participants underwent a thoracolumbar MRI (1.5 T, T1- and T2-weighted imaging), evaluated according to Pfirrmann classification, modified Endplate defect score, Modic changes, apophyseal injuries and spondylolisthesis. Pfirrmann ≥ 3, Endplate defect score ≥ 2 and Modic ≥ 1 was defined as degenerative findings.

RESULTS

Fifteen individuals, 8 women, participated in both the climbing group (mean age 23.1, SD 3.2 years) and the control group respectively (mean age 24.3, SD 1.5 years). In the climbing group, 6.1% of the thoracic and 10.6% of the lumbar intervertebral discs showed signs of degeneration according to Pfirrmann. One disc with a grade above 3 was present. Modic changes in the thoracic/lumbar spine were prevalent in 1.7%/1.3% of the vertebrae. Degenerative endplate changes according to the Endplate defect score were found in 8.9% and 6.6% of the thoracic and lumbar spinal segments of the climbing group, respectively. Two apophyseal injuries were found, while no participants displayed signs of spondylolisthesis. There was no difference in point-prevalence of radiographic spinal changes between climbers and controls (0.07 < p < 1.0).

CONCLUSION

In this small cross-sectional study, only a low proportion of elite climbers displayed changes of the spinal endplates or intervertebral discs, as opposed to other sports with high spinal loads. Most observed abnormalities were low grade degenerative changes and did not differ statistically compared to controls.

When ACL reconstruction does not help: risk factors associated with not achieving the minimal important change for the KOOS Sport/Rec and QoL

OBJECTIVES

To determine factors associated with not achieving a minimal important change (MIC) in the Knee injury and Osteoarthritis Outcome Score (KOOS) Function in Sport and Recreation (Sport/Rec), and Knee-Related Quality of Life (QoL) subscales 1 year after anterior cruciate ligament reconstruction (ACL-R).

METHODS

This study used data from the Swedish National Knee Ligament Registry. Multivariable logistic regression models were used to identify factors associated with not achieving a MIC. The change in the preoperative and postoperative KOOS Sport/Rec and QoL subscale scores were dichotomised based on not achieving MIC for both subscales versus achieving MIC for either one or both subscales. The MICs for the Sport/Rec and QoL subscales were 12.1 and 18.3, respectively, and were used to combine both subscales into a single variable (Sport & QoL).

RESULTS

Of 16 131 included patients, 44% did not achieve the MIC for the combined Sport/Rec and QoL subscales 1 year after ACL-R. From the multivariable stepwise logistic regression, older patients (OR 0.91, 95% CI 0.88 to 0.94; p<0.0001), males (OR 0.93, 95% CI 0.87 to 0.99; p=0.034) and patients receiving hamstring tendon autograft ACL-R (OR 0.70, 95% CI 0.60 to 0.81; p<0.0001) had lower odds of not achieving the MIC 1 year after ACL-R compared with younger patients, females and patients receiving patellar tendon autograft. Furthermore, patients with cartilage injuries (OR 1.17, 95% CI 1.09 to 1.27; p<0.0001) and higher pre-operative KOOS Sport/Rec and QoL scores (OR 1.34, 95% CI 1.31 to 1.36; p<0.0001) had higher odds of not achieving the MIC.

CONCLUSION

Younger patients, females and patients with cartilage injuries and higher pre-operative Sport/Rec and QoL KOOS scores are less likely to benefit from ACL-R and subsequently, have a lower probability for improved Sport/Rec and QoL scores after ACL-R. Furthermore, graft choice may also affect the risk of not achieving the MIC.

LEVEL OF EVIDENCE

Retrospective cohort study, level III.

Is absolute or relative knee flexor strength related to patient-reported outcomes in patients treated with ACL reconstruction with a hamstring tendon autograft? An analysis of eccentric Nordic hamstring strength and seated concentric isokinetic strength

BACKGROUND

There is a need for better understanding of how knee flexor strength influence patient-reported outcomes (PROs) after anterior cruciate ligament (ACL) reconstruction. Our aim was to investigate the relationship between the eccentric NordBord test and the seated concentric Biodex test with PROs, during the first year of rehabilitation after ACL reconstruction with hamstring tendon (HT) autograft.

METHODS

Patients with an index ACL reconstruction with an HT autograft participating in a rehabilitation registry were screened for inclusion. Outcomes of interest were the correlation between absolute (N/kg or Nm/kg) and relative (limb symmetry index) knee flexor strength measured in the NordBord and Biodex with the results of PROs. The significance level was set at p < 0.05 and Pearson's correlation coefficient was used.

RESULTS

137 patients were included (47% women) with a mean age of 24.8 ± 8.4 years. There were non-significant and weak correlations between relative strength for all PROs. Significant and weak correlations between absolute strength in the Biodex with the Knee Self-Efficacy Scale₁₈ (K-SES₁₈) present at 4 and 8 months, and for the ACL-Return to Sport after Injury scale (ACL-RSI) at 12 months was observed, accounting for 8.4-15.7% of the variance. Significant and weak correlations between absolute strength in the Nordbord with the Knee injury and Osteoarthritis Outcome Scale subscale Sports and Recreation at 4 months, the K-SES₁₈ present and the ACL-RSI at 8 months were observed, accounting for 9.4-14.4% of the variance.

CONCLUSION

Absolute knee flexor strength relative to bodyweight for both the Biodex and NordBord test appeared to have a stronger relationship with perceived knee function than relative knee flexor strength, although the observed correlations were weak.

Arthroscopic iliopsoas tenotomy after total hip arthroplasty: safe method for the right patient

PURPOSE

To evaluate the outcome of arthroscopic treatment for iliopsoas impingement after total hip arthroplasty (THA) 2 years after surgery using patient reported outcomes (PROM).

METHODS

In this study 12 patients (13 hips) were included from a local hip arthroscopy registry. Patients completed web-based PROMs preoperatively and at a minimum of 2 years postoperatively. The PROMs included the International Hip Outcome Tool short version (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), the European Quality of Life-5 Dimensions Questionnaire (EQ-5D), the Hip Sports Activity Scale (HSAS) for physical activity level, the Visual Analog Scale (VAS) for overall hip function and a single question regarding overall satisfaction with the surgery.

RESULTS

The mean age was 64.4 years (±15.1SD), mean body mass index (BMI) was 26.6 (±4.3SD), mean follow-up time was 49.8 months (±25SD). Comparing PROMs preoperatively with 2-year follow up showed an improvement for many of the PROMs used. The PROMs scores were iHOT-12 (24.9 vs 34.5, p = 0.13), HAGOS subscales (symptoms 38.2 vs 54.5, p = 0.05; pain 36 vs 53, p = 0.04; sport 14.1 vs 35.1, p = 0.03; daily activity 31 vs 47.5, p = 0.04; physical activity 21.8 vs 24, p = 0.76; quality of life 24 vs 35, p = 0.03), EQ-VAS (57.9 vs 58, p = 0.08), EQ-5D (0.34 vs 0.13, p = 0.07) and VAS for overall hip function (43.1 vs 46.2, p = 0.14). In total, 10 out of the 12 patients (83%) were satisfied with the intervention.

CONCLUSION

Patients undergoing surgery for iliopsoas impingement after previous THA showed improved self-reported hip function where most patients were satisfied with treatment.

When context creates uncertainty: experiences of patients who choose rehabilitation as a treatment after an ACL injury

Up to 50% of patients who suffer an anterior cruciate ligament (ACL) injury receive or opt for rehabilitation alone as initial treatment in Scandinavia. Knowledge of whether patients treated with rehabilitation alone after ACL injury are satisfied is lacking. This study aimed to explore the experiences of patients treated with rehabilitation alone after an ACL injury. Fourteen patients (35.9 (19-56) years old) who suffered an ACL injury treated with rehabilitation alone, a mean of 32 months before inclusion, were interviewed. The interview transcripts were analysed using qualitative content analysis with an inductive approach. The experiences of patients treated with rehabilitation after an ACL injury were summarised in one theme: 'Is the grass greener on the other side? Context characterised by uncertainty', supported by three main categories and nine subcategories. Uncertainty permeated the context of all levels of knee-related life following ACL injury: (1) in the past, patients felt uncertainty regarding treatment choices, (2) in the present, patients felt uncertainty regarding their physical capacity and knee self-efficacy, and (3) for the future, patients felt uncertainty regarding what might happen. With few exceptions, patients' experiences after an ACL injury treated with rehabilitation alone are characterised by uncertainty regarding their physical function, psychological impairments and possible future limitation of knee function. Uncertainty is experienced by patients in the past, the present and the future. Patients experience the knee as a symptomatic obstacle and need to adapt the physical activity to the presence of symptoms.

A clinician-friendly test battery with a passing rate similar to a 'gold standard' return-to-sport test battery 1 year after ACL reconstruction: Results from a rehabilitation outcome registry

OBJECTIVES

To 1) present passing rates for different clinician-friendly (CF) test batteries and 2) determine the relationship between passing CF test batteries and passing gold standard (GS) return-to-sport (RTS) muscle function testing, 1 year after ACL reconstruction.

STUDY DESIGN

Cross-sectional registry study, level of evidence: 3.

SETTING

Primary care.

PARTICIPANTS

Data from 588 patients (52% women, mean age 29.3 ± 9.8 years) were extracted from the Project ACL registry.

MAIN OUTCOME MEASURES

The passing rates for the different test batteries.

RESULTS

The passing rate for GS test battery was 28% (95% CI, 24-32%) and the passing rate for the CF test battery with the lowest passing rate was 27% (95% CI 24-31%). The two CF test batteries with the strongest relationships with passing GS test battery showed that 51% (95% CI 43-59%) and 49% (95% CI 44-55%) of the patients who passed the respective CF test battery also passed the GS test battery.

CONCLUSION

A CF test battery can be as demanding to pass as a GS test battery, 1 year after ACL reconstruction. However, passing a CF test battery only gives patients a chance similar to a "coin flip" of also passing a GS RTS test battery.

Massive foreign body reaction and osteolysis following primary anterior cruciate ligament reconstruction with the ligament augmentation and reconstruction system (LARS): a case report with histopathological and physicochemical analysis

BACKGROUND

Autologous hamstrings and patellar tendon have historically been considered the gold standard grafts for anterior cruciate ligament reconstruction (ACLR). In the last decades, the utilization of synthetic grafts has re-emerged due to advantageous lack of donor site morbidity and more rapid return to sport. The Ligament Augmentation and Reconstruction System (LARS) has demonstrated to be a valid and safe option for ACLR in the short term. However, recent studies have pointed out the notable frequency of associated complications, including synovitis, mechanical failure, and even chondrolysis requiring joint replacement.

CASE PRESENTATION

We report the case of a 23-year-old male who developed a serious foreign body reaction with wide osteolysis of both femoral and tibial tunnels following ACLR with LARS. During first-stage arthroscopy, we performed a debridement of the pseudocystic mass incorporating the anterior cruciate ligament (ACL) and extending towards the tunnels, which were filled with autologous anterior iliac crest bone graft chips. Histological analysis revealed the presence of chronic inflammation, fibrosis, and foreign body giant cells with synthetic fiber inclusions. Furthermore, physicochemical analysis showed signs of fiber depolymerization, increased crystallinity and formation of lipid peroxidation-derived aldehydes, which indicate mechanical aging and instability of the graft. After 8 months, revision surgery was performed and ACL revision surgery with autologous hamstrings was successfully carried out.

CONCLUSIONS

The use of the LARS grafts for ACLR should be cautiously contemplated considering the high risk of complications and early failure.

Some, but not all, patients experience full symptom resolution and a positive rehabilitation process after ACL reconstruction: an interview study

PURPOSE

To gain a deeper understanding of patients' experiences over 5 years after anterior cruciate ligament (ACL) reconstruction.

METHODS

Seventeen semi-structured interviews were performed with patients treated with ACL reconstruction at least 5 years earlier without a second knee injury. Interviews were transcribed and analyzed using qualitative content analysis according to methods described by Graneheim and Lundman.

RESULTS

Patients' long-term experiences after an ACL reconstruction were summarized as: "to cope or not to cope, that is the question", and five main categories: (1) Adapting life after knee symptom: the past will not come back; (2) An arduous and demanding rehabilitation: sailing against the wind; (3) Accepting what cannot be changed: biting the bullet; (4) Being satisfied with results: end of a chapter; (5) Apprehensively peregrinating on an unknown road.

CONCLUSIONS

More than 5 years after ACL reconstruction, patients can experience full symptom resolution and the ACL injury process as positive, or experience persistent symptoms and are forced to accept negative life-changing choices due to the injury.

LEVEL OF EVIDENCE

IV.

Psychological Patient-reported Outcomes Cannot Predict a Second Anterior Cruciate Ligament Injury in Patients who Return to Sports after an Anterior Cruciate Ligament Reconstruction

Background

Psychological patient-reported outcomes (PROs) are recommended for use in test batteries to aid in decision-making, regarding whether patients are well prepared to return to sports (RTS) after anterior cruciate ligament (ACL) reconstruction. However, the values that should be regarded as "pass" or "fail" are still unclear.

Purpose

This study aimed to identify cut-off values for three commonly used psychological PROs that could differentiate patients who suffer a second ACL injury from patients who do not within two years of RTS in patients after ACL reconstruction with respect to recovery of symmetrical quadriceps strength.

Study design

Diagnostic/prognostic study.

Methods

Demographic data, isokinetic strength test data for quadriceps, as well as results for the ACL-Return to Sport after Injury scale (ACL-RSI), Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life, and Function in Sport and Recreation sub-scales, and the 18-item version of the Knee Self-Efficacy Scale (K-SES18) were extracted from a registry. Receiver operating characteristic (ROC) curves were calculated for each PRO. Accuracy of the cut-offs was presented with two summary measures for the ROC: the area under the curve (AUC) and Youden index.

Results

In total, 641 (355 men, 61%) patients (24.8 [SD 7.6] year old at ACL reconstruction) were included. The cut-off values were not able to differentiate patients who suffered a second ACL injury up to 24 months after RTS and ACL reconstruction from patients who did not. Additionally, achieving symmetrical quadriceps strength did not improve the cut-off psychometric properties.

Conclusion

Since cut-off values could not differentiate between patients who suffered a second ACL injury and those who did not, clinicians should not rely only on cut-off values or a single PRO of those analyzed in this study when making decisions on which patients are at risk of experiencing a second ACL injury when returning to sports after ACL reconstruction.

Level of Evidence

Level 3.

Lower rate of acceptable knee function in adolescents compared with young adults five years after acl reconstruction: results from the swedish national knee ligament register

Background

The number of studies with a large cohort of patients that primarily focus on patient-reported outcomes after ACL reconstruction in children and adolescents is limited. The purpose of the present study was to determine whether patient age affects the proportion of patients that achieve a patient-acceptable symptom state (PASS) on the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales one, two, five and 10 years after an ACL reconstruction.

Methods

The patient data in the present study were extracted from the Swedish National Knee Ligament Register (SNKLR). Patients aged between five and 35 years that underwent a primary ACL reconstruction between 1 January 2005 and 31 December 2017 and had completed the KOOS questionnaire at the one-, two-, five- or 10-year follow-up were included. A total of 2,848 patients met the inclusion criteria and were included in the study; 47 paediatric patients (females 5–13, males 5–15 years), 522 adolescents (females 14–19, males 16–19 years) and 2,279 young adults (females 20–35, males 20–35 years). The results from the KOOS were presented as the mean and 95% confidence interval (CI) for the mean. For comparisons between groups, the chi-square test was used for non-ordered categorical variables. For pairwise comparisons between groups, Fisher’s exact test (2-sided) was used for dichotomous variables. All the statistical analyses was set at 5%.

Results

Adolescents reported a significantly lower score than young adults on the KOOS4 at the two- (68.4 vs. 72.1; P < 0.05), five- (69.8 vs. 76.0; P < 0.05) and 10-year follow-ups (69.8 vs. 78.2; P < 0.05). Moreover, a significantly smaller proportion of adolescents achieved a PASS on each of the KOOS subscales when compared with young adults at the five-year follow-up (Symptoms: 83.3% vs. 91.6%; Pain: 42.9% vs. 55.3%; Function in daily living: 31.4% vs. 41.1%; Function in sports and recreational activities: 42.3% vs. 55.7%; Knee-related quality of life: 50.0% vs. 65.0%; P < 0.05).

Conclusions

A significantly smaller proportion of adolescents achieved a PASS on each of the KOOS subscales when compared with young adults five years after ACL reconstruction. The results of the present study provide important information for physicians and physiotherapists treating young patients after an ACL injury and they can aid in providing realistic expectations in terms of the mid- and long-term outcomes.

Level of evidence

Prospective Observational Register/Cohort Study, Level II.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05727-6.

'I was young, I wanted to return to sport, and re-ruptured my ACL' - young active female patients' voices on the experience of sustaining an ACL re-rupture, a qualitative study

Background

Despite anterior cruciate ligament (ACL) re-ruptures being common, research on patient experiences after knee trauma has primarily focused on the time after primary ACL reconstruction. Integrating qualitative research and patient experiences can facilitate researchers and clinicians in understanding the burden of an ACL re-rupture. The aim of the study was to explore the experiences of an ACL re-rupture journey in young active females aiming to return to knee-strenuous sports after primary ACL reconstruction.

Method

Fifteen young (19[range 16–23] years old) active females who suffered an ACL re-rupture were interviewed with semi-structured interviews. Qualitative content analysis using deductive approach based on Wiese-Bjornstal’s ‘integrated model of response to sport injury’ was used.

Results

The results are presented in two timelines 1) from first ACL injury to ACL re-rupture, and 2) from ACL re-rupture to present day, and further stratified according to the domains of the ‘integrated model of psychological response to injury’. Results in the first timeline are summarised into seven categories: Finding hope for the journey; Accepting my ACL injury; I succeeded; What matters now? Who am I?; Where will this end? What is going to happen? In the second timeline, eight categories were identified: Fighting spirit; A helping hand; Working hard; I am a new me; I am destroyed; Loneliness; Painful changes; and, I could have made it to the pro´s.

Conclusion

Young active females who suffered an ACL re-rupture did not express any positive experience following their first ACL injury, however, in contrast, expressed positive experiences and personal growth after going through the ACL re-rupture journey, characterized by a lot of struggling, and ultimately led to the experience of becoming a new, stronger person.

Scoping Review on ACL Surgery and Registry Data

Purpose of Review

To present an overview of registry-based anterior cruciate ligament (ACL) research, as well as provide insight into the future of ACL registries.

Recent Findings

During the past decades, the ACL registries have had an important role in increasing our understanding of patients with ACL injuries and their treatment. The registry data has deepened our understanding of factors that have been associated with an increased risk of sustaining an ACL injury and for evaluation of treatment factors and their impact on patient-related outcomes. Recently, registry-based ACL research using artificial intelligence (AI) and machine learning (ML) has shown potential to create clinical decision-making tools and analyzing outcomes. Thus, standardization of collected data between the registries is needed to facilitate the further collaboration between registries and to facilitate the interpretation of results and subsequently improve the possibilities for implementation of AI and ML in the registry-based research.

Summary

Several studies have been based on the current ACL registries providing an insight into the epidemiology of ACL injuries as well as outcomes following ACL reconstruction. However, the current ACL registries are facing future challenges, and thus, new methods and techniques are needed to ensure further good quality and clinical applicability of study findings based on ACL registry data.

Return to Sport for Professional and Subelite Ice Hockey Players After Arthroscopic Surgery for Femoroacetabular Impingement Syndrome

Background:

Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain, which can prevent ice hockey players from sports participation. Hip arthroscopy is often performed to relieve pain and enable the player to return to sport (RTS) and return to performance (RTP).

Purpose:

To determine the RTS and RTP rates for ice hockey players at the professional and subelite levels after hip arthroscopy for FAIS.

Study Design:

Case series; Level of evidence, 4.

Methods:

High-level ice hockey players who underwent hip arthroscopy for FAIS between 2011 and 2019 were identified using a local hip arthroscopy registry. The player’s level was confirmed with ice hockey–specific web pages and was stratified as subelite or professional. Data on the players’ careers were extracted from these web pages. Player position was divided into goalkeepers, defensemen, and forwards. Data on participation in games included the season before onset of symptoms, the season before surgery, and the first and second seasons after surgery. RTS was defined as returning to ice hockey after surgery, and RTP was considered as returning to the same league at a comparable level to before symptoms.

Results:

A total of 80 ice hockey players were included. Comparing presymptom performance with the first season after surgery, the RTS rate was 72%, of which 94% of the players returned to the same or higher level of play. Comparing the presurgery season with the first season after surgery, the RTS rate was 78%. At the second season after surgery, 64% of players still played ice hockey, with a significantly higher return rate among professional players compared with subelite players (96% vs 69%; P = .014). Overall, 85% goalkeepers, 74% forwards, and 60% defensemen returned to sport. Only 28% played at least the same number of games during the first season after surgery as they did during the presymptom season.

Conclusion:

High-level ice hockey players who underwent hip arthroscopy for FAIS had a high RTS rate, in which the majority returned to the same league. However, only 28% played the same number of games the first season after surgery as they did at the presymptom level. Professional ice hockey players returned more frequently than players on the subelite level.

Disappointment and frustration, but long-term satisfaction: patient experiences undergoing treatment for a chronic Achilles tendon rupture—a qualitative study

Background

Delayed treatment of Achilles tendon ruptures is generally due to either misdiagnosis or patient delay. When the treatment is delayed more than 4 weeks, the rupture is defined as “chronic”, and almost always requires more invasive surgery and longer rehabilitation time compared with acute Achilles tendon ruptures. There is insufficient knowledge of patient experiences of sustaining and recovering from a chronic Achilles tendon rupture.

Methods

To evaluate patients’ experiences of suffering a chronic Achilles tendon rupture, semi-structured group interviews were conducted 4–6 years after surgical treatment using a semi-structured interview guide. The data were analyzed using qualitative content analysis described by Graneheim and Lundman.

Results

The experiences of ten patients (65 ± 14 years, 7 males and 3 females) were summarized into four main categories: (1) “The injury”, where the patients described immediate functional impairments, following either traumatic or non-traumatic injury mechanisms that were misinterpreted by themselves or the health-care system; (2) “The diagnosis”, where the patients expressed relief in receiving the diagnosis, but also disappointment and/or frustration related to the prior misdiagnosis and delay; (3) “The treatment”, where the patients expressed high expectations, consistent satisfaction with the surgical treatment, and addressed the importance of the physical therapist having the right expertise; and (4) “The outcomes”, where the patients expressed an overall satisfaction with the long-term outcome and no obvious limitations in physical activity, although some fear of re-injury emerged.

Conclusions

An Achilles tendon rupture can occur during both major and minor trauma and be misinterpreted by both the assessing health-care professional as well as the patient themselves. Surgical treatment and postoperative rehabilitation for chronic Achilles tendon rupture results in overall patient satisfaction in terms of the long-term outcomes. We emphasize the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03103-7.

Greater proportion of patients report an acceptable symptom state after ACL reconstruction compared with non-surgical treatment: a 10-year follow-up from the Swedish National Knee Ligament Registry

Objectives

To compare the proportion of patients with anterior cruciate ligament (ACL) injury reporting an acceptable symptom state, between non-surgical and surgical treatment during a 10-year follow-up.

Methods

Data were extracted from the Swedish National Knee Ligament Registry. Exceeding the Patient Acceptable Symptom State (PASS) for the Knee injury and Osteoarthritis Outcome Score (KOOS) was the primary outcome. The PASS and KOOS₄ (aggregated KOOS without the activities of daily living (ADL) subscale) were compared cross-sectionally at baseline and 1, 2, 5 and 10 years after ACL injury, where patients treated non-surgically were matched with the maximum number of patients with ACL reconstruction for age, sex and activity at injury.

Results

The non-surgical group consisted of 982 patients, who were each matched against 9 patients treated with ACL reconstruction (n=8,838). A greater proportion of patients treated with ACL reconstruction exceeded the PASS in KOOS pain, ADL, sports and recreation, and quality of life compared with patients treated non-surgically at all follow-ups. With respect to quality of life, significantly more patients undergoing ACL reconstruction achieved a PASS compared with patients receiving non-surgical treatment at all follow-ups except at baseline, with differences ranging between 11% and 25%; 1 year −25.4 (−29.1; −21.7), 2 years −16.9 (−21.2; −12.5), 5 years −11.0 (−16.9; −5.1) and 10 years −24.8 (−36.0; −13.6). The ACL-reconstructed group also reported statistically greater KOOS₄ at all follow-ups.

Conclusion

A greater proportion of patients treated with ACL reconstruction report acceptable knee function, including higher quality of life than patients treated non-surgically at cross-sectional follow-ups up to 10 years after the treatment of an ACL injury.

Greater Psychological Readiness to Return to Sport, as Well as Greater Present and Future Knee-Related Self-Efficacy, Can Increase the Risk for an Anterior Cruciate Ligament Re-Rupture: A Matched Cohort Study

PURPOSE

To determine the psychological characteristics and strength outcomes of patients who sustained an early anterior cruciate ligament (ACL) re-rupture after their primary ACL reconstruction and cross-sectionally compare them with a matched cohort of patients who did not sustain a reinjury during the first 2 years after primary ACL reconstruction.

METHODS

In this matched cohort study, data for quadriceps and hamstring strength and 3 hop tests and answers to standardized patient-reported outcomes (the Anterior Cruciate Ligament Return to Sport after Injury scale and a short version of the Knee Self-Efficacy Scale) were extracted from a rehabilitation outcome registry. Data for patients suffering a re-rupture were extracted, and patients were matched in terms of sex, age, and activity level with patients not suffering an ACL re-rupture within 2 years of primary reconstruction. The groups were compared 10 weeks and 4, 8, and 12 months after the primary reconstruction.

RESULTS

A total of 36 patients suffering an ACL re-rupture were matched with 108 patients not suffering a re-rupture after ACL reconstruction. Patients who suffered an ACL re-rupture had greater psychological readiness, that is, greater confidence in performance, lesser negative emotions, and lesser risk appraisal, to return to sport (RTS) at 8 months (81.2 vs 67.9 [95% Δconfidence interval {CI} 2.7-23.8) P = .014) and at 12 months (95.2 vs 67.1, (95% ΔCI 14.3-41.8) P ≤ .001), and greater knee-related self-efficacy at 8 months (8.6 vs 8.0 [95% ΔCI 0.1-1.2], P = .021) and 12 months (9.4 vs 8.1, [95% ΔCI 0.3-2.2] P = .012) after primary ACL reconstruction, compared with the matched group.

CONCLUSIONS

A stronger psychological profile, defined by a greater psychological readiness to RTS and knee-related self-efficacy, may be associated with an ACL re-rupture within 2 years of the primary reconstruction.

LEVEL OF EVIDENCE

Matched cohort study, level III.

Protocol for a multicenter prospective cohort study evaluating arthroscopic and non-surgical treatment for microinstability of the hip joint

BACKGROUND

Microinstability of the hip joint is a proposed cause of hip pain and reduced function in young individuals. The underlying mechanism is thought to be extraphysiological hip motion due to bony deficiency and/or soft tissue deficiency or decreased soft tissue function. Recently, the condition has gained increased attention, and despite the fact that treatment today includes both non-surgical and surgical approaches, there is limited evidence on diagnostic specificity and treatment effects. The aim of this study is to evaluate clinical outcomes of both non-surgical and surgical treatment for microinstability of the hip joint.

METHODS

A multicenter prospective cohort study is planned to evaluating the outcome of physical therapy aimed at stabilizing the hip joint, as well as arthroscopic plication of the hip joint capsule, if the physical therapy fails. Outcomes will be evaluated using hip-specific patient-reported outcome measures: the short version of the International Hip Outcome Tool and the Copenhagen Hip and Groin Outcome Score, strength and function tests, health-related quality of life as determined using the European Quality of Life-5 Dimensions and the European Quality of Life-Visual Analog Scale, sports activity levels according to the Hip Sport Activity Scale, and reported complications. Patients will be evaluated at 6, 12 and 24 months after each treatment.

DISCUSSION

It is important to evaluate the clinical outcomes of both non-surgical and surgical treatment for suspected microinstability of the hip joint, and the planned prospective evaluation will contribute to the understanding of non-surgical as well as surgical treatment outcomes, including complications.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04934462 . Registered June 22 2021.

Superior Outcome of Early ACL Reconstruction versus Initial Non-reconstructive Treatment With Late Crossover to Surgery: A Study From the Swedish National Knee Ligament Registry

BACKGROUND

Although comparable clinical and functional outcomes have been reported after nonsurgical and surgical anterior cruciate ligament (ACL) treatment, few studies have investigated the effects of early versus late ACL reconstruction with initial rehabilitation.

PURPOSE

To determine patient-reported knee function in patients who initially undergo nonreconstructive treatment after an ACL injury but who later choose to undergo ACL reconstruction as compared with (1) patients undergoing ACL reconstruction close to the index injury and (2) patients treated nonreconstructively at 1 to 10 years of follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Results from the Knee injury and Osteoarthritis Outcome Score (KOOS) were extracted from the Swedish National Knee Ligament Registry for patients treated with nonreconstruction, early ACL reconstruction, and initial nonreconstruction but subsequent ACL reconstruction (crossover group). The KOOS₄ (a mean of 4 KOOS subscales) was analyzed cross-sectionally at baseline and at the 1-, 2-, 5-, and 10-year follow-ups. Additionally, the Patient Acceptable Symptom State (PASS) was applied to all KOOS subscales from baseline to the 10-year follow-up.

RESULTS

A total of 1,074 crossover, 484 nonreconstruction, and 20,352 early ACL reconstruction cases were included. The crossover group reported lower KOOS₄ values than the group undergoing early ACL reconstruction at baseline and at all follow-ups (mean difference [95% CI]): baseline, -6.5 (-8.0 to -5.0); 1 year, -9.3 (-10.9 to -7.7); 2 years, -4.8 (-6.3 to -3.2); 5 years, -6.1 (-8.8 to -3.4); and 10 years, -10.9 (-16.3 to -5.2). Additionally, a smaller proportion of the crossover cohort achieved a PASS on KOOS subscales at baseline and through the 1-, 2-, 5-, and 10-year follow-ups as compared with the early ACL reconstruction cohort. No differences were observed between crossover and nonreconstruction cases on either the KOOS₄ or the PASS at any follow-up.

CONCLUSION

A greater proportion of patients treated with early ACL reconstruction reported acceptable knee function and superior overall knee function as compared with patients who decided to cross over from nonreconstructive treatment to ACL reconstruction.

Surgical treatment of chronic Achilles tendon rupture results in improved gait biomechanics

Background

Chronic Achilles tendon rupture is associated with persistent weakness at push-off with the affected foot and poor balance, resulting in significant alterations to normal gait. Surgical repair is the most common treatment for improving gait in patients with a Chronic Achilles tendon rupture, but, to date, the outcomes have not been quantified in the literature.

Methods

A total of 23 patients with a Chronic Achilles tendon rupture (mean age 61 ± 15 years) underwent three-dimensional gait analysis according to a standardized protocol using an optical tracking system. Data of spatiotemporal, kinematic and kinetic variables were collected preoperatively and one year postoperatively. In addition, the postoperative gait biomechanics were compared with the gait biomechanics of a control group consisting of 70 healthy individuals (mean age 49 ± 20 years). The prospectively collected data were analyzed by an independent t test.

Results

Postoperatively, increments were found in gait speed (mean difference − 0.12 m/s), stride length (− 0.12 m), peak ankle moment (− 0.64 Nm/kg), peak ankle power (− 1.38 W/kg), peak knee power (− 0.36 m) and reduced step width (0.01 m), compared with preoperative gait biomechanics (p < 0.014). Compared with the control group, patients with a Chronic Achilles tendon rupture exhibited slower postoperative gait speed (mean difference 0.24 m/s), wider step width (− 0.02 m), shorter stride length (0.16 m), longer relative stance phase (− 2.15%), lower peak knee flexion (17.03 degrees), greater peak knee extension (2.58 degrees), lower peak ankle moment (0.35 Nm/kg), peak ankle power (1.22 W/kg) and peak knee power (1.62 W/kg), (p < 0.010).

Conclusion

Surgical intervention and postoperative rehabilitation can be an effective treatment for alterations in gait after a Chronic rupture of the Achilles tendon. However, at one year postoperatively, patients still exhibit impairments in spatiotemporal variables and knee and ankle power compared with healthy controls.

Self-Reported Symptoms of Depression and Anxiety After ACL Injury: A Systematic Review

Background:

Depression and anxiety symptoms can occur in patients following an anterior cruciate ligament (ACL) injury, and the presence of these symptoms has been associated with poorer self-reported knee function in this type of injury.

Purpose:

To investigate the prevalence and severity of self-reported symptoms of depression and anxiety following an ACL injury.

Study Design

Systematic review; Level of evidence, 4.

Methods:

PubMed, Cochrane Library, Embase, PsycINFO, AMED, and PEDro databases were searched using a combination of keywords relating to ACL, depression, anxiety, and their synonyms. Inclusion criteria were clinical studies written in English that reported on patients with an injured and/or reconstructed ACL and assessed symptoms of depression and/or anxiety. Data extraction was performed independently by 2 authors. Data synthesis was performed using an emergent synthesis approach. The quality of the included studies was assessed using the methodological index for non-randomized studies or the Mixed-Methods Appraisal Tool. Certainty of evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation.

Results:

After abstract screening, 37 studies were assessed in full text, of which 16 were included. The studies comprised 682 patients (417 male [61%]). The depression symptoms appeared to be more severe in elite athletes compared with recreational athletes. Symptoms decreased over time from moment of ACL reconstruction to up to 2 years postoperatively. The prevalence of self-reported symptoms of anxiety after an ACL injury was reported in 1 study (2%). There were no differences in anxiety symptoms between professional and amateur athletes or between adolescents and adults. The overall quality of the studies was low or very low.

Conclusion:

Patients who sustain an ACL injury can suffer from symptoms of depression, especially during the first 6 weeks after ACL reconstruction. Depressive symptoms are more common among professional versus nonprofessional athletes. Levels of anxiety symptoms were not above the cutoffs for a diagnosis of anxiety after an ACL injury.

Different injury patterns exist among patients undergoing operative treatment of isolated PCL, combined PCL/ACL, and isolated ACL injuries: a study from the Swedish National Knee Ligament Registry

PURPOSE

To compare demographic characteristics and concomitant injury patterns in patients undergoing primary isolated posterior cruciate ligament reconstruction (PCL-R) and combined posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) reconstruction (PCL-R/ACL-R) with isolated ACL reconstruction (ACL-R) as a reference using data from the Swedish National Knee Ligament Registry (SNKLR).

METHODS

This cohort study based on the SNKLR comprised patients undergoing either PCL-R, ACL-R, or combined PCL-R/ACL-R between January 1, 2005 and December 31, 2019 in Sweden. Demographic and surgery-related data with regards to injury mechanism, concomitant intraarticular lesions and their treatment, neurovascular damage, and concomitant ligamentous injuries were extracted. Exclusion criteria included concomitant fractures of the femur, fibula, patella or tibia, and quadriceps or patellar tendon injury.

RESULTS

A total of 45,564 patients were included in this study. Isolated PCL-R, combined PCL-R/ACL-R, and isolated ACL-R were performed in 192 (0.4%), 203 (0.5%) and 45,169 (99.1%) patients, respectively. Sports were identified as the cause of 64% of PCL-Rs, 54% of PCL-R/ACL-Rs, and 89% of ACL-Rs, while a traffic-related mechanism was identified in 20% of PCL-Rs, 27% of PCL-R/ACL-Rs and 2% of ACL-Rs. Meniscus injury prevalence was 45% in ACL-Rs, 31% in PCL-R/ACL-Rs and 16% in isolated PCL-Rs (p < 0.001). Cartilage injuries were more common in PCL-R (37%) and PCL-R/ACL-R patients (40%) compared to ACL-R patients (26%, p < 0.001). Concomitant knee ligament injury was identified in 28-44% of PCL-R/ACL-R patients. Neurovascular injuries were present in 9% of PCL-R/ACL-Rs, 1% of PCL-Rs, and 0.3% of ACL-Rs (p < 0.001).

CONCLUSION

Differences in injury mechanisms among patient groups confirm that operatively treated PCL tears are frequently caused by both traffic and sports. Cartilage and ligament injuries were more frequent in patients with PCL-R compared to ACL-R. Consequently, combined PCL and ACL tears should raise suspicion for concomitant knee lesions with clinical relevance during the operative treatment of these complex injuries.

LEVEL OF EVIDENCE

III.

Greater heel-rise endurance is related to better gait biomechanics in patients surgically treated for chronic Achilles tendon rupture

PURPOSE

To determine the relationships among calf muscle function, tendon length and gait biomechanics in patients surgically treated for chronic Achilles tendon rupture.

METHODS

Twenty-one patients with chronic Achilles tendon rupture (mean age 62 ± 13 years) were evaluated by heel-rise endurance test, Achilles Tendon Resting Angle (ATRA), ultrasound measurement of tendon length and three-dimensional gait analysis. A bivariate two-sided correlation test was performed on all variables in all patients.

RESULTS

Better performance across all parameters of the heel-rise endurance test correlated with faster walking speed (r = 0.52-0.55), greater peak ankle power (r = 0.56-0.64), shorter stance phase (r = -0.52 to -0.76) and less peak ankle dorsiflexion angle (r = -0.49 to -0.64) during gait. Greater ATRA correlated with longer stance time (r = 0.47), greater peak ankle dorsiflexion angle (r = 0.48), less heel-rise repetitions (r = -0.52) and less heel-rise total work LSI (r = -0.44 to -0.59).

CONCLUSION

Greater calf muscle endurance, especially heel-rise total work, is moderately correlated (r = 0.49-0.76) to better ankle biomechanics during gait in patients surgically treated for CATR. The heel-rise endurance test may be a clinical proxy for power development in the ankle joint during gait.

LEVEL OF EVIDENCE

IV.

Adolescents Have Twice the Revision Rate of Young Adults After ACL Reconstruction With Hamstring Tendon Autograft: A Study From the Swedish National Knee Ligament Registry

Background:

Previous studies have identified young age as a risk factor for anterior cruciate ligament (ACL) revision. However, few studies have looked separately at pediatric patients and adolescents with regard to outcomes after ACL reconstruction.

Purpose:

To determine whether patient age at ACL reconstruction affects the risk of undergoing revision surgery in young patients.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study was based on data from the Swedish National Knee Ligament Registry. Patients aged 5 to 35 years who underwent a primary ACL reconstruction with a hamstring tendon autograft between January 1, 2005, and December 31, 2015, were included. The cohort was stratified into different age groups of pediatric patients, adolescents, and young adults to estimate patients with open, recently closed, and closed epiphyses, respectively. The primary endpoint was ACL revision. A multivariable Cox regression model was used to assess the ACL revision rate. The results were expressed as hazard ratios (HRs) and 95% CIs.

Results:

A total of 36,274 ACL reconstructions were registered during the study period. Of these, 2848 patients were included in the study: 47 pediatric patients (mean age, 13.6 years; range, 9-15 years), 522 adolescents (mean age, 17.4; range, 14-19 years), and 2279 young adults (mean age, 27.0; range, 20-35 years). A total of 31 patients (1.1%) underwent ACL revision within 2 years (0 pediatric patients, 9 adolescents [1.7%], and 22 young adults [1.0%]) and a total of 53 patients (2.6%) underwent ACL revision within 5 years (2 pediatric patients [6.9%], 15 adolescents [3.9%], and 36 young adults [2.2%]). The adolescent age group had a 1.91 times higher rate of ACL revision compared with the young adults (HR = 1.91 [95% CI, 1.13-3.21]; P = .015). There were no differences in revision rates between the pediatric age group and the young adults (HR = 2.93 [95% CI, 0.88-9.79]; P = .081).

Conclusion:

Adolescents had almost twice the rate of revision ACL reconstruction compared with young adults.