Return to play after anterior cruciate ligament reconstruction

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Three-month functional training programme improves knee joint function in athletes post-ACL reconstruction surgery

OBJECTIVE

Rehabilitation and recovery duration following anterior cruciate ligament reconstructive surgery play a pivotal role in restoring optimal knee functionality in athletes. This study aimed to explore the impact of a 3-month functional training programme aligned with enhanced recovery after surgery on recuperation subsequent to anterior cruciate ligament reconstructive surgery.

DESIGN

A quasi-experimental study.

SUBJECTS

A cohort of 34 patients aged 14 to 24, who underwent anterior cruciate ligament reconstructive surgery and adhered to enhanced recovery after surgery protocols during the perioperative period, were allocated to an experimental group and a control group according to their eligibility, capacity, and willingness to engage in the functional training programme.

METHODS

The participants in the experimental group underwent a 3-month regimen of functional training following anterior cruciate ligament reconstructive surgery, whereas the control group followed a conventional recovery approach. Evaluations were conducted both prior to and following the 3-month recovery interval, utilizing the Y-Balance Test, Functional Movement Screening, and Isokinetic Knee Test.

RESULTS

Assessment outcomes of the Y-Balance Test, Isokinetic Knee Test, and Functional Movement Screening exhibited significant enhancement (p < 0.05) within the experimental group, as opposed to the control group. These findings underscore that those athletes who undertook the 3-month functional training regimen within the experimental group exhibited heightened dynamic balance capabilities, increased knee joint mobility, and enhanced stability compared with their counterparts in the control group.

CONCLUSION

Consequently, this underscores the efficacy of the 3-month functional training protocol aligned with enhanced recovery after surgery, as a means to effectively facilitate recuperation subsequent to anterior cruciate ligament reconstructive surgery.

Assessing the Impact of Psychological Readiness on Performance and Symmetry in Functional Testing After ACL Reconstruction in Pediatric and Adolescent Patients

Background

Readiness for return to sports involves both physical and psychological aspects of recovery; however, the relationship between psychological and physical variables after anterior cruciate ligament (ACL) reconstruction (ACLR) is poorly understood.

Hypothesis

ACLR patients with a higher psychological readiness would demonstrate better functional testing results at 6 months.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Participants were evaluated at 6 months after ACLR with various patient-reported outcome metrics: Hospital for Special Surgery Pediatric Functional Activity Brief Scale, pediatric or adult International Knee Documentation Committee Questionnaire (IKDC), Patient-Reported Outcomes Measurement Information System (PROMIS) - Psychological Stress Experience and ACL - Return to Sport After Injury (ACL-RSI) scale. Functional testing included quadriceps, hamstrings, and gluteal strength testing; Y-balance test; single-leg single hop, crossover hop, and triple hop tests; and timed 6-m hop test. Pearson correlation coefficient and multivariable regression were used to determine associations between the limb symmetry index (LSI) on functional testing and patient-reported outcomes. Those with LSI deficits <20% (better performance) were compared with those with deficits >20% (worse performance).

Results

A total of 229 participants (89 male, 140 female) with a median age of 17 years (range, 10.3-30.6 years) were enrolled. IKDC had a moderate negative correlation with PROMIS - Psychological Stress Experience (r = -0.39; 95% CI = -0.49, -0.27; P < .001) and a moderate positive correlation with ACL-RSI (r = 0.55; 95% CI = 0.46, 0.64; P < .001). A total of 151 patients completed functional testing. ACL-RSI demonstrated a positive correlation with single-hop LSI (r = 0.21; 95% CI = 0.05, 0.35; P = .01) and timed 6-m hop (r = 0.28; 95% CI, 0.42; P = .001). When adjusting for sex, age, and graft type, patients who had <20% deficit on the single-hop test scored 16.6 points higher on ACL-RSI (P = .001), and those with <20% deficit on crossover hop testing scored a mean 13.9 points higher on ACL-RSI (P = .04).

Conclusion

Higher psychological readiness for return to sport was associated with better performance and greater symmetry on hop testing 6 months after ACLR, suggesting a potential link between physical and psychological recovery.

The Effects of a Combined Pre- and Post-Operative Anterior Cruciate Ligament Reconstruction Rehabilitation Program on Lower Extremity Muscle Imbalance

This study examined whether the 5-week pre-operative progressive exercise rehabilitation program with weekly monitoring contributed to a significantly lower muscle activity imbalance in the treatment group, both before and immediately after anterior cruciate ligament reconstruction (ACLR), as well as during the next 5 weeks in comparison to the control group. Twelve professional soccer players took part in the study (from among the top three Polish levels of competition) (age: 26 ± 5 years, body mass: 73 ± 7 kg, stature: 180 ± 6 cm, training experience: 15 ± 4 years). The participants were randomly assigned to the treatment group (n = 6) or to the control group (n = 6). Both groups performed the same pre- and post-operative progressive exercise rehabilitation program, while the rehabilitation of the treatment group was extended by supplementary body-weight functional stabilization training. The three-way repeated-measures ANOVA revealed a statistically significant interaction for muscle × group × time (p < 0.0001; F = 24.897; η2 = 0.806). The post-hoc analysis for the interaction effect of muscle × group × time indicated a significantly higher muscle activity imbalance for every measured muscle in the control group at any time point than in the treatment group (from p = 0.036 to p < 0.0001). The muscle activity imbalance was significantly higher from the 1st to 4th weeks than in the last week before surgery for quadriceps (p < 0.016 for all) and hamstrings (p < 0.001). However, in the case of gluteal muscles’ activity imbalance, it was significantly higher at every time point of the post-operative phase than in the last week before surgery (p < 0.001). The results of this study showed that the 5-week pre-operative rehabilitation program with weekly monitoring influenced outcomes of the post-operative phase. Nevertheless, performing both pre- and post-ACLR rehabilitation significantly reduced the muscle activity imbalance of lower limbs, but in the case of the quadriceps muscles, not to a sufficient level.

Return to Sports After Anterior Cruciate Ligament Reconstruction: Validity and Reliability of the SPORTS Score at 6 and 12 Months

Background:

The Subjective Patient Outcome for Return to Sports (SPORTS) score is a single-item scale that measures athletes' ability to return to their preinjury sport based on effort and performance.

Purpose/Hypothesis:

The purpose of this study was to examine the psychometric properties of the SPORTS score and a modified score within the first year after anterior cruciate ligament reconstruction (ACLR). The modified version replaced “same sport” with “any sport” in the answer choices. It was hypothesized that both versions of the SPORTS score would have acceptable floor and ceiling effects and internal responsiveness, moderate convergent validity, and excellent test-retest reliability.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Patients were recruited preoperatively from 2 academic medical centers. The authors collected responses to the 1-item SPORTS scores at 6 and 12 months after ACLR and the Tegner activity scale, Lysholm knee score, Knee injury and Osteoarthritis Outcome Score (KOOS)–sport/recreation subscale, and Marx activity rating scale preoperatively and 6 and 12 months after ACLR. Ceiling and floor effects and responsiveness were assessed using descriptive statistics and cross-tabulations, respectively, at both follow-up time points. Spearman correlations and intraclass correlation coefficients were used to examine convergent validity and test-retest reliability, respectively.

Results:

Follow-up rates at 6 and 12 months were 100% and 99%, respectively. Test-retest follow-up was 77%. Floor effects for the SPORTS scores were not observed, while ceiling effects at 12 months ranged from 38% to 40%. Cross-tabulation of the SPORTS scores showed that 64% to 66% of patients reported a change in their score from 6 to 12 months, with significant differences noted between the proportions that improved versus worsened for return to any sport. Convergent validity was observed at 6 and 12 months via moderate correlations with the Tegner, Lysholm, KOOS–sport/recreation, and Marx scores (r = 0.31 to 0.47). Fair to good test-retest reliability (intraclass correlation coefficient, 0.58 and 0.60) was found at 12 months after ACLR.

Conclusion:

The SPORTS score appears to be a reliable, responsive, and valid 1-item scale that can be used during the first year after ACLR. No differences in psychometric properties were found between the SPORTS score and the modified version.

Pediatric orthopedic injury prevention for team sports post COVID-19

Queries of youth orthopedic sports injuries from the U.S. National Electronic Surveillance System, a database from the Consumer Product Safety Commission, demonstrate decreased orthopedic injuries related to team sports during the COVID-19 pandemic, indicative of reduced sports participation. Multiple articles have shown that COVID-19 had a marked effect on the physical and psychological wellbeing of the youth. The lockdown resulted in a cessation in school attendance and sports activities, especially team sports. Though increased emphasis has been placed on children infected by COVID-19, less attention has been given to healthy children. Numerous articles discussed the physical and psychological benefits for the youth returning to physical activity and sports; however, few have addressed detraining and deconditioning concerns postpandemic. This article discusses a safe return to team sports for the youth experiencing physical and psychological changes related to the pandemic. Orthopedic injuries are anticipated to increase as restrictions are relaxed. A multidisciplinary team presents a review of common youth sports orthopedic injuries, a discussion of psychological issues youths have experienced during COVID and why sports participation is beneficial for youth, and a risk assessment for pain and limited range of motion for youth returning to sports. The intent of this article is to increase awareness of the physical and psychological changes experienced by youth due to their inability to participate in team sports during the pandemic. Family medicine and primary care providers need to recognize the increased risks for injury and proactively encourage the youth to return to sports in a safe manner.

The majority of athletes fail to return to play following anterior cruciate ligament reconstruction due to reasons other than the operated knee

PURPOSE

The purpose of this study is to evaluate the reasons why athletes do not return to play (RTP) following anterior cruciate ligament (ACL) reconstruction from a large single-centre database.

METHODS

The institutional ACL registry was screened for patients that had undergone a primary ACLR and had RTP status reported at 24-month follow-up. The reasons that patients were unable to RTP at 24 months were evaluated. The ACL-Return to Sport Index (ACL-RSI) was evaluated at baseline and 24-month follow-up to evaluate psychological ability to RTP.

RESULTS

At 2 years, 1140 patients returned to play, and 222 had not returned to play. The most common reasons athletes were unable to return was fear of reinjury (27.5%), lack of confidence in performance on return (19.4%) and external life factors (16.6%), i.e. work commitments and family reasons. Other reasons for athletes not returning to play were residual knee pain (10%) and subsequent injury (5%). The ACL-RSI score was significantly lower at diagnosis (40.3 vs. 49.3; p = 0.003) and 2 years (41.8 vs. 78.7; p < 0.0001) in athletes who did not return to play vs. those that did RTP.

CONCLUSION

The majority of patients that report they have not returned to play do so due to external life and psychological factors associated with their injury, including fear of reinjury and lack of confidence in performance. A small minority of patients were unable to return due to residual knee symptoms or reinjury. Pre-operative psychological assessment and intervention may identify those less likely to RTP and provide an opportunity for targeted interventions to further improve RTP outcomes.

LEVEL OF EVIDENCE

III.

Rehabilitation duration and time of starting sport-related activities associated with return to the previous level of sports after anterior cruciate ligament reconstruction

OBJECTIVES

To determine predictors for return to previous level of sports after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cross-sectional; SETTING: Athletic teams.

PARTICIPANTS

Ninety-one athletes who had ACLR with hamstring-tendon autograft within 1-5 years participated in this study. Athletes indicated their sport participation levels, injury profile, rehabilitation duration, and time to start sport-related activities (running, cutting-pivoting) after ACLR. Athletes answered whether they returned to the same previous level of frequency, duration, and intensity of sports.

MAIN OUTCOME MEASURES

Athletes' characteristics, injury and surgical factors, duration of post-operative rehabilitation program, and time to start sport-related activities after ACLR were evaluated by univariate logistic regression to determine predictors for return to previous level of sports.

RESULTS

Nine athletes (10%) returned to their self-described previous level of sports. Predictors for returning to previous level of sports were rehabilitation duration >4 months (OR:6.78; p = .011), time to start running ≤4 months (OR:8.62; p = .047) and cutting-pivoting <6 months after surgery (OR:5.02; p = .030).

CONCLUSION

Longer post-operative rehabilitation duration and time to start sport-related activities after ACLR predicted return to previous level of sports. Spending adequate time in post-operative rehabilitation program and time-based resumption of sports-related activities after ACLR might be key factors for returning to previous sports level.

CRITERION-BASED REHABILITATION PROGRAM WITH RETURN TO SPORT TESTING FOLLOWING ACL RECONSTRUCTION: A CASE SERIES

Background

Less than 50% of those sustaining an anterior cruciate ligament (ACL) injury return to their preinjury level of sports participation or participate in competitive sport at two to seven years post ACL reconstruction (ACLR). After ACLR, it has been reported that frequency of subsequent ACL tears has reached as high as 31%.

Purpose

The purpose of this case series was to evaluate return to sport and reinjury rates following the use of a criterion-based rehabilitation protocol with a final return to sport test that utilizes minimal equipment following ACL reconstruction.

Study Design

Case series.

Methods

Following ACL reconstruction, participants were included if they had a goal of returning to their pre-injury sport or level of activity, were between 16 and 50 years of age at the time of evaluation, had at least 25 physical therapy visits covered by insurance, and planned to complete physical therapy until clearance for return to sport.

Results

Forty-three participants met the inclusion criteria and enrolled in the study. Twenty-one participants completed the full course of rehabilitation including passing their return to sport test and nineteen participants completed the two-year follow-up. Data obtained at two years indicated that 84% were able to return to their preinjury level of sports competition. A smaller percentage (16%) were able to return to a reduced level of sport and only one participant reported a second ACL injury.

Conclusion

Participants that completed the full course of rehabilitation and passed return to sport testing had a larger percentage that were able to return to preinjury participation levels than currently reported in the literature. This case series did not exclude participants based on graft type, single vs double bundle procedure, ACL revision surgeries, nor concomitant procedures or injuries.

Level of Evidence

Level 4.

Online Videos Provide Poor Information Quality, Reliability, and Accuracy Regarding Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

PURPOSE

To investigate the information quality available on YouTube regarding rehabilitation and return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR).

METHODS

By use of The Onion Router software and predefined search terms, 140 YouTube videos regarding rehabilitation and RTS after ACLR were systematically included. Three scoring systems were used to analyze the included videos: (1) Journal of the American Medical Association (JAMA) benchmark criteria; (2) Global Quality Score (GQS); and (3) self-developed scores for rehabilitation after ACLR and RTS after ACLR, following American Academy of Orthopaedic Surgeons guidelines and current evidence.

RESULTS

The vast majority of the included videos offered poor information quality, reliability, and accuracy. Videos that were uploaded by medically trained professionals showed significantly higher information quality regarding rehabilitation (P = .006 for JAMA score, P < .001 for GQS, and P = .001 for rehabilitation score) and regarding RTS (P < .001 for JAMA score, P < .001 for GQS, and P < .001 for RTS score) compared with commercial videos or personal-testimony videos. Multivariate linear regression also revealed medically trained professionals as significant predictors of higher information quality regarding rehabilitation (β = 0.496 [P < .001] for JAMA score, β = 1.3 [P < .001] for GQS, and β = 3.7 [P < .001] for rehabilitation score) and RTS (β = 0.754 [P < .001] for JAMA score, β = 1.3 [P < .001] for GQS, and β = 5.3 [P < .001] for RTS score).

CONCLUSIONS

The average information quality, reliability, and accuracy of YouTube videos regarding rehabilitation and RTS after ACLR are poor. The information quality of related YouTube videos from medically trained professionals is significantly higher compared with commercial videos or personal-testimony videos.

CLINICAL RELEVANCE

Current YouTube videos regarding rehabilitation and RTS after ACLR do not meet the necessary quality standards. Physicians should also be able to provide alternative sources of high-quality information.

TIMELINE OF GAINS IN QUADRICEPS STRENGTH SYMMETRY AND PATIENT-REPORTED FUNCTION EARLY AFTER ACL RECONSTRUCTION

Background

Quadriceps weakness is a predictor of long-term knee function and strength recovery can vary from months to years after anterior cruciate ligament reconstruction (ACLR). However, few studies evaluate quadriceps strength and self-reported function within the first several weeks after ACLR.

Hypothesis/Purpose

To examine changes over time in quadriceps strength symmetry, quadriceps peak torque, and self-reported knee function prior to and at six, 12, and 24 weeks post-ACLR. The hypotheses were 1) quadriceps strength symmetry, bilateral quadriceps peak torque, and patient-reported function would improve over time from pre-ACLR to 24 weeks post-ACLR and 2) significant improvements in patient-reported function, but not strength symmetry, would occur between time points.

Study Design

Prospective, cohort study.

Methods

Thirty participants completed four testing sessions: pre-surgery and six, 12, and 24 weeks post-ACLR. Isometric quadriceps strength testing was performed at six weeks and isokinetic quadriceps strength was measured at all other testing points. Quadriceps index was calculated to evaluate between limb quadriceps strength symmetry. The Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) were administered at each time point. A repeated-measures analysis of variance evaluated changes over time, with post-hoc comparisons to determine at which time-point significant changes occurred.

Results

Quadriceps strength symmetry, involved limb quadriceps peak torque and all patient-reported outcome scores increased over time (p<0.02). Post-hoc tests showed that neither self-reported outcomes, nor quadriceps index improved between pre-surgery and six-weeks post-ACLR. From six to 12 weeks post-ACLR, scores on IKDC and KOOS Pain, Symptoms, Quality of Life, and Sport subscales improved (p≤0.003). From 12 to 24 weeks post-ACLR, quadriceps strength symmetry, involved limb quadriceps peak torque, KOOS-Symptoms, Quality of Life, and Sport subscales and the IKDC improved (p≤0.01). Uninvolved limb quadriceps peak torque did not change across any time point (p≥0.18).

Conclusion

Patient-reported knee function increased between six and 24 weeks post-ACLR, while increases in involved limb quadriceps strength and quadriceps strength symmetry were not noted until 12-24 weeks post-ACLR.

Level of Evidence

2b, individual cohort study.

Symmetry does not Indicate Recovery: Single-leg Hop Before and After a Lower Extremity Injury

Current recommendations for return-to-play decision-making involve comparison of the injured limb to the uninjured limb. However, the use of the uninjured limb as a comparison for hop testing lacks empirical evidence. Thus, the purpose of this study was to determine the effects of lower extremity injury on limb symmetry and performance on the single-leg hop for distance. Two-hundred thirty-six adolescent athletes completed the single-leg hop for distance before the beginning of the season (pre-injury). Forty-four adolescent athletes sustained a lower extremity injury (22 ankle and 12 knee) and missed at least three days of sports participation. All individuals had completed the single-leg hop for distance before the beginning of the season (pre-injury) and at discharge (post-injury). Injured limb single-leg hop for distance significantly decreased at return-to-play from pre-injury with a mean decrease of 48.9 centimeters; the uninjured limb also significantly decreased, with a mean decrease of 33.8 centimeters. Limb symmetry did not significantly change pre- to post-injury with a mean difference of 1.5%. Following a lower extremity injury, single-leg hop for distance performance degrades not only for the injured limb but also the uninjured limb. However, limb symmetry did not change following a lower extremity injury.

Evolution of Functional Recovery using Hop Test Assessment after ACL Reconstruction

The purpose of this study was to evaluate improvements in functional performance through the use of the Limb Symmetry Index of Single and Triple Hop tests between 12 and 52 weeks after anterior cruciate ligament reconstruction, and to compare these values with usual time-based and performance-based criteria used during the return to sport continuum. Repeated functional assessments using Single and Triple Hop Tests at 12, 16, 22, 26, 39 and 52 postoperative weeks were evaluated. At each session, the median and interquartile range of Limb Symmetry Index of tests were calculated and compared with the usual criteria: return to participation:≥85%, between 12-16 w; return to play:≥90%, between 26-39 w. The results indicate that the median increased over time to 39 postoperative weeks and then stabilized. For Single Hop Test, wide variability was seen at 12 and 16 weeks (interquartile range=20%); this was lower from 22 to 52 weeks (interquartile range=8-6%). At 12 weeks for Single Hop Test, the median was 83.6% and did not meet>85% criteria for return to participation. Hop tests could be interesting functional tests to follow the functional recovery and help decision-making regarding return to participation and return to play.

Cognitive-behavioral-based physical therapy to enhance return to sport after anterior cruciate ligament reconstruction: An open pilot study

OBJECTIVES

To describe feasibility, adherence, acceptability, and outcomes of a cognitive-behavioral-based physical therapy (CBPT-ACLR) intervention for improving postoperative recovery after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Pilot study.

SETTING

Academic medical center.

PARTICIPANTS

Eight patients (mean age [SD] = 20.1 [2.6] years, 6 females) participated in a 7-session telephone-based CBPT-ACLR intervention beginning preoperatively and lasting 8 weeks after surgery.

MAIN OUTCOME MEASURES

At 6 months, patients completed Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life (QOL) subscales, International Knee Documentation Committee (IKDC), Tampa Scale of Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), and Knee Self-Efficacy Scale (K-SES), return to sport (Subjective Patient Outcome for Return to Sports), and satisfaction. Minimal clinically important difference (MCID) was used for meaningful change.

RESULTS

Seven (88%) patients completed all sessions. Seven (88%) patients exceeded MCID on the TSK, 6 (75%) on the PCS, 5 (63%) on the KOOS sports/recreation subscale, 4 (50%) on the IKDC, and 3 (38%) on the KOOS QOL subscale. Three (38%) patients returned to their same sport at the same level of effort and performance. All patients were satisfied with their recovery.

CONCLUSIONS

A CBPT-ACLR program is feasible and acceptable for addressing psychological risk factors after ACLR.

Suture Augmented Versus Standard Anterior Cruciate Ligament Reconstruction: A Matched Comparative Analysis

PURPOSE

To compare outcomes between standard anterior cruciate ligament reconstruction (ACLR) using hamstring grafts with and without suture augmentation (SA).

METHODS

Patients who underwent ACLR with hamstring autografts or allografts with minimum 2-year follow-up were retrospectively reviewed. Patients undergoing ACLR with SA were matched 1:1 by age, gender, body mass index, graft type, and revision status to standard ACLR. Range of motion, pain, postoperative activity, patient-reported outcome measures (PROMs), and complications were collected. Paired 2-tailed Student's t-tests and Pearson's χ²-tests were used for continuous and categorical variables, respectively. A multivariate analysis of variance was conducted. Return to preinjury activity level was assessed using Spearman's rho and Pearson's χ²-tests.

RESULTS

Sixty patients at a mean age of 29.50 ± 6.60 years, 43.4% male, body mass index 26.27 ± 3.37, and follow-up of 29.54 ± 5.37 months were included. Preoperative PROMs were not significantly different (P >. 05). Postoperative range of motion was similar between groups (P = .457). Postoperative average daily (0.60 ± 1.25 vs 1.66 ± 1.90) and maximum daily pain (1.57 ± 1.83 vs 3.35 ± 2.28) were significantly lower for SA (P < .014). SA predicted improvement in PROMs (P < .05) and maximum pain scores (P = .001). SA was significantly correlated with improved time to return to preinjury activity level (9.17 ± 2.06 vs 12.88 ± 3.94 months; P = .002) and percentage of preinjury activity level (93.33% ± 13.22% vs 83.17% ± 17.69%; P = .010). There was a trend toward improved rate of return to preinjury activity level for SA (76.7% vs 56.7%; P = .100).

CONCLUSIONS

Our study demonstrates that SA hamstring ACLRs were associated with improved PROMs, less pain, and a higher percentage of and earlier return to preinjury activity level when compared with standard hamstring ACLRs without evidence of overconstraint.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Improvements in Thigh Strength Symmetry Are Modestly Correlated With Changes in Self-Reported Function After Anterior Cruciate Ligament Reconstruction

Background:

The association between quadriceps strength and functional outcomes after anterior cruciate ligament reconstruction (ACLR) is a focus of current research, while evaluations of hamstring strength are limited, despite the frequent use of hamstring autografts.

Purpose/Hypothesis:

The purpose of this study was to determine the relationship between changes in quadriceps and hamstring strength symmetry and self-reported outcomes before ACLR and at 12 and 24 weeks after surgery. We hypothesized that improvements in quadriceps and hamstring strength symmetry would be correlated with improvements in self-reported outcome measures within the first 6 months after ACLR.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Thirty patients who underwent ACLR with a hamstring autograft were enrolled. Quadriceps and hamstring strength and Knee injury and Osteoarthritis Outcome Score (KOOS) values were assessed before and at 12 and 24 weeks after ACLR; limb symmetry indexes for strength were calculated at each time point. The Friedman and Wilcoxon signed-rank tests were used to analyze changes in KOOS values over time. Spearman rank-order correlations were used to test the relationship between changes in strength and KOOS values between each time point.

Results:

Hamstring and quadriceps limb symmetry significantly increased with time (P ≤ .03). Fair correlations were observed between changes in the hamstring index and changes in the KOOS Symptoms subscore from before surgery to 12 weeks postoperatively (r = 0.48; P ≤ .05). Changes in the quadriceps index (QI) were moderately correlated with changes in the KOOS Sport/Recreation subscore (r = 0.60; P = .001), and fair correlations were seen between the QI and the KOOS Quality of Life subscore (r = 0.39; P ≤ .04) from preoperatively to 12 weeks after surgery. Moderate correlations were seen between the QI and the KOOS Sport/Recreation subscore (r = 0.57; P = .005) from 12 to 24 weeks after surgery.

Conclusion:

Improvements in quadriceps and hamstring strength symmetry were modestly associated with improvements in athletes’ perceived function in the first 6 months after ACLR. Specifically, improvements in hamstring symmetry were associated with improvements in knee symptoms within the first 12 weeks postoperatively, while improvements in quadriceps symmetry were associated with improvements in self-reported sport function throughout the first 6 months after ACLR. The restoration of strength symmetry within the first 6 months may be a critical component of rehabilitation aimed at maximizing function after ACLR. Further investigation is warranted to comprehensively evaluate whether the timing of strength gains predicts future function, including those who successfully return to their preinjury activity level after ACLR.

Use of ultrasonography to evaluate the dynamics of the infrapatellar fat pad after anterior cruciate ligament reconstruction: a feasibility study

PURPOSE

There has been no specific study on the quantitative morphological changes that occur in the infrapatellar fat pad (IPFP) after anterior cruciate ligament (ACL) reconstruction. We used ultrasonography to evaluate the dynamics of the IPFP in knees after ACL reconstruction using the contralateral knees as controls.

METHODS

We enrolled 31 patients 3 months after they underwent ACL reconstruction. The thickness of the superficial part of the IPFP was measured using longitudinally oriented ultrasound images of the anterior part of both knees at 90° and 10° flexion. We then used these data to calculate the ratio of the change in thickness.

RESULTS

At 90° knee flexion, the superficial part of the IPFP was significantly thinner in the reconstructed knees (9.3 ± 3.4 mm) than in the contralateral knees (11.8 ± 4.6 mm). The thickness change ratio was significantly smaller in the reconstructed knees (188.6 ± 64.7%) than in the contralateral knees (249.7 ± 73.8%).

CONCLUSION

When assessed 3 months after ACL reconstruction, the thickness of the superficial part of the IPFP at 90° knee flexion and the thickness change ratio of the IPFP were both significantly lower in the reconstructed knees than in the contralateral knees.

Anterior Cruciate Ligament Injury: Return to Play, Function and Long-Term Considerations

Anterior cruciate ligament tears are common and affect young individuals who participate in jumping and pivoting sports. After injury many individuals undergo ligament reconstruction (ACLR) but do not return to play, suffer recurrent injury and osteoarthritis. Outcome studies show that after ACLR, 81% of individuals return to sports, 65% return to their preinjury level and 55% return to competitive sports. Systematic reviews place the risk of ipsilateral retears at 5.8% and contralateral injuries at 11.8%, with recent reports of over 20% failure rate. Approximately 20% to 50% of patients will have evidence of OA within 10 to 20 yr. Factors important in reducing complications include timing of surgery, individualized return to play protocols, and prevention programs for injury. Further understanding of the factors that increase return to play percentages, reduce the risk of recurrent injury and improve long-term outcomes after ACL injury is needed to reduce the burden of these injuries on society.

Therapy and Rehabilitation for Upper Extremity Injuries in Athletes

The approach to rehabilitation of upper extremity injuries in athletes differs from traditional rehabilitation protocols. In general, athletes have higher functional demands and wish to return to competitive sport in a timely manner. Comprehensive rehabilitation must therefore be balanced with a timely and safe return to sport. Several rehabilitation programs and adjunctive therapies are available to hasten convalescence while minimizing the athlete's risks of reinjury. Here, we review techniques for soft tissue mobilization and strength training in athletic populations. We also discuss orthotics, taping, and alternative therapies used in rehabilitation and evaluate the evidence in support of these modalities.

Speed, resistance, and unexpected accelerations modulate feed forward and feedback control during a novel weight bearing task

We developed a method to investigate feed-forward and feedback movement control during a weight bearing visuomotor knee tracking task. We hypothesized that a systematic increase in speed and resistance would show a linear decrease in movement accuracy, while unexpected perturbations would induce a velocity-dependent decrease in movement accuracy. We determined the effects of manipulating the speed, resistance, and unexpected events on error during a functional weight bearing task. Our long term objective is to benchmark neuromuscular control performance across various groups based on age, injury, disease, rehabilitation status, and/or training. Twenty-six healthy adults between the ages of 19-45 participated in this study. The study involved a single session using a custom designed apparatus to perform a single limb weight bearing task under nine testing conditions: three movement speeds (0.2, 0.4, and 0.6Hz) in combination with three levels of brake resistance (5%, 10%, and 15% of individual's body weight). Individuals were to perform the task according to a target with a fixed trajectory across all speeds, corresponding to a∼0 (extension) to 30° (flexion) of knee motion. An increase in error occurred with speed (p<0.0001, effect size (eta²): η²=0.50) and resistance (p<0.0001, η²=0.01). Likewise, during unexpected perturbations, the ratio of perturbed/non-perturbed error increased with each increment in velocity (p<0.0014, η²=0.08), and resistance (p<0.0001, η²=0.11). The hierarchical framework of these measurements offers a standardized functional weight bearing strategy to assess impaired neuro-muscular control and/or test the efficacy of therapeutic rehabilitation interventions designed to influence neuromuscular control of the knee.

Using an accelerometer and the step-up-and-over test to evaluate the knee function of patients with anterior cruciate ligament reconstruction

BACKGROUND

Evaluating the dynamic knee function of patients after anterior cruciate ligament reconstruction is a challenge. A variety of objective tests have been developed but for various reasons few are regularly used in the clinic. It may be practical to perform the step-up-and-over test with an accelerometer.

METHODS

A control group (N=26) and an experimental group with a reconstructed anterior cruciate ligament (N=25) completed questionnaires quantifying subjective knee function and fear of re-injury and then completed the step-up-and-over test.

FINDINGS

Results showed that the experimental group performed differently than the control group for the step-up-and-over test's Lift Symmetry and Impact Symmetry (P<0.05) and performance on these measures was related to the participant's subjective knee function (ρ=-0.46, P<0.01; ρ=-0.33, P<0.05, respectively). Supplemental results for individual leg performance and the patient's fear of re-injury are also reported and discussed.

INTERPRETATION

Performance on the step-up-and-over test is different for participants with anterior cruciate ligament reconstruction than for those with intact anterior cruciate ligaments, and that performance is related to one's opinion of their knee's function.

Variables Affecting Return to Play After Anterior Cruciate Ligament Injury in the National Football League

BACKGROUND

Anterior cruciate ligament (ACL) injuries are common in the National Football League (NFL). Limited literature exists regarding return to play (RTP) and the factors affecting RTP after ACL reconstruction in NFL players.

PURPOSE/HYPOTHESIS

To determine RTP rates after ACL reconstruction in NFL players and to ascertain which variables affect RTP in these players. We hypothesized that RTP in this population will be less than in the general population and similar to the limited studies published previously.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 92 NFL athletes who sustained ACL injuries requiring ACL reconstruction from 2013 to 2015 were retrospectively studied to determine rate of RTP and the variables affecting RTP.

RESULTS

Sixty-two percent (57/92) of NFL athletes returned to NFL game play prior to the end of the 2015-2016 postseason. ACL injuries were noted in 10 different player positions, with 81.5% of all injuries as isolated ACL injuries (75/92) and 18.5% with concomitant knee injuries. A significant difference in ability to RTP was found for players who sustained in-season injuries compared with those who sustained off-season/preseason injuries (P = .02). No significant differences in RTP were found for players who played less than 4 years in the NFL compared with those who played longer. The mean draft round of players who returned was 3.96, with the odds ratio favoring RTP at 4.44 (P = .003) for players drafted in the first 3 rounds of the NFL draft compared with those drafted in the fourth round or later. No significant differences were found with regard to playing surface, laterality, concomitant injury, previous ipsilateral or contralateral ACL reconstruction, final outcome of the game, or contact compared with noncontact injuries.

CONCLUSION

The RTP rates we reported after ACL reconstruction in NFL players are similar to prior studies; however, running backs and wide receivers had lower rates of RTP than previously reported. As previously published, quarterbacks were found to have high RTP rates. Most ACL injuries take place during the preseason or early regular season. Early selection in the NFL draft was a strong predictor of ability to RTP.

Return to Sports Activity and Work After Autologous Chondrocyte Implantation of the Knee: Which Factors Influence Outcomes?

BACKGROUND

Autologous chondrocyte implantation (ACI) has been associated with satisfying results in everyday activities. Clinical results after ACI treatment of femorotibial lesions are superior in comparison with patellofemoral lesions. There is limited information regarding at which level recreational, amateur, and professional athletes can resume sports and physical activities as well as work after ACI and what parameters influence return to work and sports.

HYPOTHESIS

Return to sports activity and work is dependent on defect characteristics such as location and size.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 130 patients with isolated full-thickness cartilage defects of the knee joint treated with ACI between June 2000 and October 2007 were retrospectively studied by an established questionnaire that assessed sports-specific questions such as frequency, duration, and intensity. Engagement in 32 different sports disciplines was evaluated. In addition, work-specific data were evaluated according to classifications established by the REFA Association. Results were evaluated depending on patient- and defect-specific parameters.

RESULTS

The mean ± SD patient age at ACI was 36.2 ± 9.2 years, with a mean defect size of 4.4 ± 1.7 cm(2). Defects were located at the femorotibial compartment in 55.7% of cases, whereas lesions of the patellofemoral compartment were found in 44.3%. Mean duration of inability to work after ACI was 13.6 ± 11.0 weeks and did not appear to be influenced by patient age. Defect location and defect size did not appear to significantly influence return-to-work rates, but work intensity before surgery significantly influenced return-to-work rates and duration of absence from work. Workplace adaptations were necessary in only 9.2% of cases postoperatively. With regard to postoperative sports activity, 73.1% of patients were able to return to sports. Neither defect location nor size significantly influenced return to physical activity. Patients participated in a mean of 2.3 different sports during their lifetime. Both duration of exercise and number of sessions per week significantly decreased from before to after surgery. Detailed analysis of 32 different sporting activities revealed that high-impact as well as start-stop sports were generally abandoned in favor of endurance and low-intensity exercises. A lifetime level of competitiveness was maintained in 31.3% of cases, while return to elite sports at the time of the survey became highly unlikely (0.8%).

CONCLUSION

The study results illustrate that treatment of articular cartilage defects of the knee joint leads to satisfactory results concerning everyday activities. With the exception of physical labor, no essential adaptations needed to be made at work. Regarding sports activity, return to low- and moderate-intensity levels appears realistic in the majority of cases, whereas the likelihood of returning to activities with high stress applied on the knee joint is low. Neither defect location nor size appears to significantly influence postoperative sports activity or return-to-work rates.

Isokinetic Identification of Knee Joint Torques before and after Anterior Cruciate Ligament Reconstruction

The aim of this study was to evaluate the serial change of isokinetic muscle strength of the knees before and after anterior cruciate ligament reconstruction (ACLR) in physically active males and to estimate the time of return to full physical fitness. Extension and flexion torques were measured for the injured and healthy limbs at two angular velocities approximately 1.5 months before the surgery and 3, 6, and 12 months after ACLR. Significant differences (p ≤ 0.05) in peak knee extension and flexion torques, hamstring/quadriceps (H/Q) strength ratios, uninvolved/involved limb peak torque ratios, and the normalized work of these muscles between the four stages of rehabilitation were identified. Significant differences between extension peak torques for the injured and healthy limbs were also detected at all stages. The obtained results showed that 12 months of rehabilitation were insufficient for the involved knee joint to recover its strength to the level of strength of the uninvolved knee joint. The results helped to evaluate the progress of the rehabilitation and to implement necessary modifications optimizing the rehabilitation training program. The results of the study may also be used as referential data for physically active males of similar age.

Return to work in miners following anterior cruciate ligament reconstruction

INTRODUCTION

The aim of the study is retrospectively investigated durations for returning to work following anatomic ACL reconstruction by hamstring autograft in miners and the reasons in patients who were delayed to return to work.

METHODS

Miners with symptomatic anterior cruciate ligament rupture underwent arthroscopic reconstruction. Patients were evaluated in terms of range of motion (ROM) values; Lysholm, Cincinati and Tegner activity scales; laxity testing and complications. By modifying the method used by Fitzgerald et al. we decided for the criteria returning to work.

RESULTS

Thirty three patients were evaluated with mean followup of 22.7 ± 8.3 months (range 13-46 months). Mean age at the surgery was 27.8 (18-38) years. Lysholm, Cincinati and Tegner activity scales were signifi cantly higher from preoperative scores (Lysholm scores: preoperative: 60.7 ± 12.5, postoperative: 90.3 ± 4.8 (P < 0.001); Tegner activity scores: Preoperative 3.5 ± 1.4, postoperative: 6.2 ± 1.5 (P < 0.001); Cincinati scores: Preoperative: 14.8 ± 5.3, postoperative: 26.9 ± 1.6 (P < 0.001). The average time for returning to work was determined as 15,3 ± 4 weeks. There was no significant difference for knee scores and time for returning to work between patients with meniscal injuries and don't have meniscus lesions.

CONCLUSION

The reasons for delays in returning to work was work accident. Hematoma or effusion and pain inside the knee were the most significant reason which affected returning to work.

A conceptual framework for a sports knee injury performance profile (SKIPP) and return to activity criteria (RTAC)

Injuries to the knee, including intra-articular fractures, ligamentous ruptures, and meniscal and articular cartilage lesions, are commonplace within sports. Despite advancements in surgical techniques and enhanced rehabilitation, athletes returning to cutting, pivoting, and jumping sports after a knee injury are at greater risk of sustaining a second injury. The clinical utility of objective criteria presents a decision-making challenge to ensure athletes are fully rehabilitated and safe to return to sport. A system centered on specific indicators that can be used to develop a comprehensive profile to monitor rehabilitation progression and to establish return to activity criteria is recommended to clear athletes to begin a progressive and systematic approach to activities and sports. Integration of a sports knee injury performance profile with return to activity criteria can guide clinicians in facilitating an athlete's safe return to sport, prevention of subsequent injury, and life-long knee joint health.

Factors associated with returning to football after anterior cruciate ligament reconstruction

PURPOSE

The aim of the present investigation was to identify possible factors associated with returning to football on an average 3.2 ± 1.4 years after anterior cruciate ligament (ACL) reconstruction in both male and female football players.

METHODS

The players were recruited from a patient database of football players that have undergone an ACL reconstruction between 2004 and 2007 at the Capio Artro Clinic, Sophiahemmet in Stockholm, Sweden. Special attention was paid to gender, age, type of graft for ACL reconstruction, associated injuries, anterior knee laxity, thigh muscle torques and symptoms/problems during, and/or after physical activity. In the beginning of the summer of 2009, 205 players (37.9 %) out of 541 players filled out a questionnaire designed to evaluate physical activity and knee function in a sports-specific setting. A detailed dropout analysis showed that females responded to a higher degree than males. No other significant differences between responders and non-responders were found.

RESULTS

Fifty-four per cent (n = 111) had returned to football, and 46 % (n = 94) had not. Using logistic regression analyses, we found that the female gender (p = 0.036, OR 0.518), cartilage injury (p = 0.013, OR 0.368), and pain during physical activity (p = 0.002, OR 0.619) were significant negative predictors for returning to football after ACL reconstruction and rehabilitation. For players with all three significant factors, only 10 % returned to football compared to 76.5 % of those without any of these factors.

CONCLUSIONS

Female gender, cartilage injury, and knee pain during physical activity were independent negative predictors for returning to football after ACL reconstruction. At a mean follow-up of 3.2 ± 1.4 years after ACL reconstruction, pain during physical activity was reported to be the most common symptom/problem in football players. The clinical relevance of this study is to improve the treatment of ACL injured football players focusing on female gender and knee pain. Furthermore, ACL injury prevention should be highlighted in football players, especially female players.

Functional Testing Differences in Anterior Cruciate Ligament Reconstruction Patients Released Versus Not Released to Return to Sport

BACKGROUND

No standardized return-to-activity or sport guidelines currently exist after anterior cruciate ligament (ACL) reconstruction. Isokinetic testing and unilateral hop testing, which have construct validity, are often used to make the determination of when a patient is ready to return to sport. Neither of these measures has been reported to be predictive of subsequent injuries.

PURPOSE

To compare the performance on 2 functional tests of ACL reconstruction patients released to return to activity versus those who have not been released based on clinical impairment measures.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 98 patients were examined by the treating orthopaedic surgeon 6 months after ACL reconstruction for traditional impairment measures, including swelling, range of motion, strength, and graft stability. After this examination, all subjects completed the functional testing, consisting of the Functional Movement Screen (FMS) and the Lower Quarter Y Balance Test (YBT-LQ), by an experienced tester who was blinded to the results of the clinical examination. On the basis of the clinical examination, all patients were grouped as being ready to return to sport or not being ready. Performance on the functional tests, as measured by overall performance and side-to-side asymmetry, was compared between the 2 groups using independent-samples t tests (P < .05).

RESULTS

No difference existed between the groups with regard to the descriptive characteristics, with the exception that the group not cleared was younger (21.0 ± 7.4 years) than the group that was cleared (25.6 ± 13.2 years). Performance on the YBT-LQ revealed that no differences existed between groups when examining reach symmetry for any of the reach directions. In addition, no differences were found between groups when looking at the average reach score normalized to limb length for either the surgical or nonsurgical leg. Patients in the cleared group exhibited a similar score on the FMS (12.7 ± 2.9) compared with the noncleared group (12.8 ± 2.7). Similarly, no differences were observed for the number of asymmetries; however, both groups averaged 1 asymmetry during the testing.

CONCLUSION

Clinical impairment measures do not appear to be related to measured functional ability. Performance on both functional tests, the FMS and YBT-LQ, at 6 months would suggest that the typical patient in both groups would be at a greater risk of lower extremity injury, based on currently published research.

Intrinsic factors associated with return to sport after anterior cruciate ligament reconstruction: A systematic review

OBJECTIVES

The anterior cruciate ligament is the most commonly injured ligament in the knee, with an average of only 64% of affected athletes returning to their pre-injury level of sport. Intrinsic factors associated with an increased likelihood of return to sport may be addressed during rehabilitation to improve the outcome of the reconstruction. The objectives of this review were to systematically appraise publications from six electronic databases describing intrinsic factors that may be associated with return to sport after anterior cruciate ligament reconstruction.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Methodological quality appraisal was performed according to the Critical Appraisal Skills Programme for cohort studies. We performed a descriptive synthesis of the findings that associated intrinsic factors with return to sport.

RESULTS

Ten studies were included in the review. The findings show that fear of re-injury is a common reason for not returning to participation in sport. Younger patients may be more likely to return to sport, but findings regarding gender were equivocal, with male competitive athletes appearing to be more likely to return to sport than their female counterparts. Good knee function is not always associated with a higher likelihood to return to sport.

CONCLUSION

Fear of re-injury and age should be considered in the management of sports participants after anterior cruciate ligament reconstruction.

Return to play following anterior cruciate ligament reconstruction

In athletes, significant advances in anterior cruciate ligament reconstruction techniques and rehabilitation have led to improved surgical outcomes and increased expectations for return to play. Although an expeditious return to sport has become an achievable and often realistic goal, the factors that most influence safe, timely, and successful return to play remain unknown. The literature offers mainly anecdotal evidence to guide the team physician in the decision-making process, with a paucity of criteria and consensus guidelines available to help determine return to sport. Attempts have been made to introduce criteria-based progression in the rehabilitation process, but validation of subjective and objective criteria has been difficult. Nevertheless, several pertinent factors in the preoperative, intraoperative, and postoperative periods may affect return to play following anterior cruciate ligament reconstruction. Further research is warranted to validate reliable, consensus guidelines with objective criteria to facilitate the return to play process.

Local application of strontium in a calcium phosphate cement system accelerates healing of soft tissue tendon grafts in anterior cruciate ligament reconstruction: experiment using a rabbit model

BACKGROUND

Healing of soft tissue tendon grafts within the bone tunnel in anterior cruciate ligament (ACL) reconstruction is known to be slower than that of bone-patellar tendon-bone grafts. There are attempts to accelerate healing of the graft within the bone tunnel. One of the methods is the use of strontium-enriched calcium phosphate cement (Sr-CPC). Early results in animal studies have been encouraging, although it is not known whether the accelerated healing was solely caused by the effect of strontium within the cement or by the calcium phosphate cement (CPC) itself.

HYPOTHESIS

There would be differences between Sr-CPC and conventional CPC in terms of the effect on healing of soft tissue tendon grafts within the bone tunnels in ACL reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 30 single-bundle ACL reconstruction procedures were performed in 15 rabbits with the use of an Achilles tendon allograft. The graft on the left limb was coated with Sr-CPC, while that on the right limb was coated with CPC. Three animals each were sacrificed for histological and histomorphometric analyses at 3, 6, 9, 12, and 24 weeks after surgery.

RESULTS

In the Sr-CPC group, early formation of Sharpey fibers was present at 6 weeks after surgery, while early remodeling of a graft-fibrocartilage-bone junction was noted at 12 weeks. In the CPC group, early formation of Sharpey fibers was only found at 9 to 12 weeks after surgery. At 24 weeks, a direct enthesis was found in both groups. According to the histomorphometric score, graft healing in the Sr-CPC group took place 3 weeks faster than that in the CPC group at and before 12 weeks; however, there was no difference between the groups at 24 weeks.

CONCLUSION

The local application of strontium in a CPC system leads to accelerated graft healing within the bone tunnels.

CLINICAL RELEVANCE

The use of Sr-CPC to enhance graft-bone healing may improve the clinical results of ACL reconstruction using soft tissue tendon grafts.

Assessment of functional impairment after knee anterior cruciate ligament reconstruction using cardiorespiratory parameters: a cross-sectional study

BACKGROUND

A dynamic sub-maximum exercise with the same absolute intensity, performed with different muscle groups, may present exacerbated cardiorespiratory responses. Therefore, cardiorespiratory responses to unilateral exercise may identify bilateral differences. The purpose of this study was to verify whether the cardiorespiratory responses to lower limb exercise display counter-lateral differences, and if they could be used to assist athletes and health professionals involved in rehabilitation.

METHODS

Nine individuals participated in this cross-sectional study. They had been treated in a private rehabilitation clinic and submitted to intra-articular reconstruction of the anterior cruciate ligament. The cycling exercise with the same sub-maximal intensity and with one lower limb was used to gather data. Cardiorespiratory responses to exercise were compared between exercises performed with the involved and uninvolved limb after five minutes of exercise.

RESULTS

Cardiorespiratory responses to exercise performed with the involved limb presented higher values after five minutes of cycling: oxygen uptake (+7%), carbon dioxide production (+10%), minute ventilation (+20%), breathing frequency (+19%), ventilatory equivalent for oxygen (+14%), end-tidal pressure of O2 oxygen (+4%), end-tidal pressure of O2 carbon dioxide (-9%) and heart rate (+9%).

CONCLUSIONS

The exacerbated responses, including increase of the ventilatory equivalent and decrease of end-tidal pressure of carbon dioxide, indicate that this exercise protocol may be useful in the characterization of the functional deficit of the surgical limb during rehabilitation.

Factors influencing the implementation of anterior cruciate ligament injury prevention strategies by girls soccer coaches

Women are 3 times more likely to injure their anterior cruciate ligament (ACL) while playing soccer than men. ACL injury prevention programs (IPPs) involving stretching and strengthening drills can reduce the incidence of ACL injury when incorporated into routine training. The rate of implementation among coaches is largely unknown. The purpose of this study was to determine the rate of implementation of ACL IPP, to identify factors that influence implementation, and to acquire information to assist in design dissemination and implementation strategies. Study subjects were coaches of woman soccer players aged 11-22 years in Utah (n = 756). Data were gathered using a Web-based survey followed by a qualitative study in which "best practice coaches"-coaches who met criteria for successful implementation of ACL IPP-were interviewed via telephone. A minority of survey respondents, 19.8% (27/136), have implemented ACL IPP. Factors associated with successful implementation include length of coaching experience and presence of additional support staff such as a strength and conditioning coach or athletic trainer. Best practice coaches (14/136) unanimously agreed on the following: (a) there are performance-enhancing benefits of ACL IPP, (b) education on ACL injury prevention should be required for licensure, and (c) dissemination and implementation will require soccer associations to enact policies that require IPPs. In conclusion, a minority of girls soccer coaches have implemented ACL IPP and those that have do so because they believe that prevention improves performance and that soccer organizations should enact policies requiring ACL injury prevention education and implementation. Efforts to implement ACL IPP should be driven by soccer organizations, emphasize performance-enhancing benefits, and engage additional coaching staff.

Staged management of knee dislocation in polytrauma injured patients

INTRODUCTION

Knee dislocation in the polytrauma setting is rare. The optimal method that this injury should be managed remains controversial. We therefore undertook a study to evaluate the incidence and outcomes of knee dislocation in polytrauma patients treated in our institution.

PATIENTS AND METHODS

From January 2005 to February 2011, two hundred-seventy five polytrauma patients were managed in our institution. Knee dislocation was present in 14 patients (4%): 4 females, mean age 46 years (range 19-52), mean ISS 24 (range 18-34) and 10 males, mean age 45 years (18-48), mean ISS 28 (range 18-48). Knee dislocation was classified according to the Schenck classification. MRI was used routinely for accurate assessment of the knee lesions. Treatment protocol consisted of initially management with the ATLS guidelines, neurovascular assessment, emergency surgical care simultaneously with reanimation procedures and hospitalization at ICU. Upon full evaluation and stabilization of the patient's physiological status and acquisition of a knee MRI scan, one- to three-stage operative treatment was performed. Decision for one- or more-stage treatment was based on the evaluation of the systemic and local clinical status, injury classification, timing of surgery, and consequences that remained after associated injuries. Clinical outcome was evaluated by IKDC 2000 Subjective knee evaluation, IKDC Clinical Examination Scales and the Tegner-Lysholm scale. A specific accelerated rehabilitation program was completed according to the surgical treatment. The mean follow up was 2 years (range 19-48 months).

RESULTS

Patients had a different type of knee dislocations: five KD II, six KD III, two KD V2 and one KD V3. Clinical results were low in patients that underwent the three-staged protocol, and good and high in one- or two-staged operative treatment respectively at the two year follow up. The difference between the results in three groups of treated patients was visible but not statistically significant.

CONCLUSION

The physiological state of the patient along with the type of knee lesion dictates a timing and type of stage treatment. The best postoperative clinical results are fulfilled with the one-stage treatment and it should be the first choice of knee dislocation therapy. Two-stage treatment should be performed only if the general clinical status of polytrauma injured patient or local knee status does not allow a complete knee reconstructive surgery. Three-stage treatment results with the worst outcome and it should be avoided.

Use of a strontium-enriched calcium phosphate cement in accelerating the healing of soft-tissue tendon graft within the bone tunnel in a rabbit model of anterior cruciate ligament reconstruction

We investigated whether strontium-enriched calcium phosphate cement (Sr-CPC)-treated soft-tissue tendon graft results in accelerated healing within the bone tunnel in reconstruction of the anterior cruciate ligament (ACL). A total of 30 single-bundle ACL reconstructions using tendo Achillis allograft were performed in 15 rabbits. The graft on the tested limb was treated with Sr-CPC, whereas that on the contralateral limb was untreated and served as a control. At timepoints three, six, nine, 12 and 24 weeks after surgery, three animals were killed for histological examination. At six weeks, the graft–bone interface in the control group was filled in with fibrovascular tissue. However, the gap in the Sr-CPC group had already been completely filled in with new bone, and there was evidence of the early formation of Sharpey fibres. At 24 weeks, remodelling into a normal ACL–bone-like insertion was found in the Sr-CPC group. Coating of Sr-CPC on soft tissue tendon allograft leads to accelerated graft healing within the bone tunnel in a rabbit model of ACL reconstruction using Achilles tendon allograft.

Cite this article: Bone Joint J 2013;95-B:923–8.

Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction

PURPOSE

The aims of this study were to evaluate the functional recovery before and after ACL reconstruction and to evaluate the sensitivity to change in performance-based and self-reported outcomes prior to and after ACL reconstruction and to determine whether these changes represent clinically relevant improvement.

METHODS

Eighty-three athletes participated in this study. Athletes were tested after an ACL injury, after preoperative training, and 6 and 12 months after ACL reconstruction. Athletes completed quadriceps strength testing, hop testing, and self-reported questionnaires for knee function (International Knee Documentation Committee subjective knee form, Knee Outcome Survey-Activities of Daily Living Scale, and the Global Rating Scale of Perceived Function) at each testing period.

RESULTS

A significant interaction of limb by time was seen in normalized quadriceps strength, and single, triple, and 6-m timed hop, where the involved limb improved more than the uninvolved limb over time. A main effect of time was noted for performance-based limb symmetry indexes and self-reported measures.

CONCLUSION

Limb-to-limb asymmetries are reduced, and normal limb symmetry is restored after perturbation training and aggressive quadriceps strengthening and returned to similar levels 6 months after reconstruction. Performance-based values on the involved limb and self-reported outcomes are sensitive to change over time, and these were clinically relevant improvements.

Abnormal frontal plane knee mechanics during sidestep cutting in female soccer athletes after anterior cruciate ligament reconstruction and return to sport

BACKGROUND

Athletes who have undergone anterior cruciate ligament reconstruction (ACLR) have a high risk of reinjury upon the return to sports participation. While the mechanisms behind this increased risk of reinjury are unknown, it has been suggested that altered knee biomechanics during sports-specific activities may be a contributing factor. Purpose/

HYPOTHESIS

To compare frontal plane knee joint angles and moments during a sidestep cutting maneuver in female soccer athletes who have undergone ACLR with those in athletes with no history of knee injury. It was hypothesized that athletes with a history of ACLR would exhibit increased knee abduction angles and knee adductor moments compared with those with no history of injury.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve female soccer players with a history of ACLR served as the experimental group, and 12 female soccer players with no history of knee injury constituted the control group. Three-dimensional kinematics and ground-reaction forces were collected while each participant performed a sidestep cutting maneuver. Variables of interest included the knee abduction angle and knee adductor moment during the early deceleration phase of the cutting maneuver. Independent-samples t tests were used to evaluate differences between groups (P ≤ .05).

RESULTS

Participants in the ACLR group exhibited increased average knee abduction angles (ACLR: 3.8° vs control: 1.8°; P = .03) and peak knee adductor moments (ACLR: 1.33 N·m/kg vs control: 0.80 N·m/kg; P = .004) compared with the control group.

CONCLUSION

Female soccer players who have undergone ACLR and returned to sports participation exhibited increased knee abduction angles and knee adductor moments during the early deceleration phase of cutting compared with their healthy counterparts with no history of knee injury.

CLINICAL RELEVANCE

Even though athletes are able to return to sport after ACLR, they are at an increased risk for reinjury. It may be the case that the increased frontal plane knee angles and moments exhibited by these athletes after ACLR could be contributing to this risk for reinjury. Therefore, it is important that rehabilitation programs after ACLR include the restoration of frontal plane knee mechanics.

Preoperative predictors for noncopers to pass return to sports criteria after ACL reconstruction

Less than 50% of athletes pass criteria to return to sports (RTS) 6 months after ACL reconstruction (ACLR). Using data on 38 noncopers, we hypothesized that preoperative age, quadriceps strength index (QI), and knee flexion moments (KFM) during gait would predict the ability to pass/fail RTS criteria and that preoperative quadriceps strength gains would be predictive of passing RTS criteria. Gait analysis and strength data were collected before and after a preoperative intervention and 6 months after ACLR. Age, QI, and KFM each contributed to the predictability to pass or fail RTS criteria 6 months after ACLR. Collectively, the variables predict 69% who would pass and 82% who would fail RTS criteria 6 months after ACLR. Younger athletes who have symmetrical quadriceps strength and greater KFM were more likely to pass RTS criteria. Further, 63% of those who increased preoperative quadriceps strength passed RTS criteria, whereas 73% who did not failed. Increasing quadriceps strength in noncopers before ACLR seems warranted.

Asymmetries in functional hop tests, lower extremity kinematics, and isokinetic strength persist 6 to 9 months following anterior cruciate ligament reconstruction

STUDY DESIGN

Within-subject and between-subject cross-sectional study.

OBJECTIVES

To investigate symmetry in hop-test performance, strength, and lower extremity kinematics 6 to 9 months following anterior cruciate ligament reconstruction (ACLR).

BACKGROUND

Despite the extensive body of literature involving persons following ACLR, no study has comprehensively evaluated measures of strength, lower extremity kinematics, and functional performance of functional hop tests in this population.

METHODS

The subjects were 22 men (mean ± SD age, 28.8 ± 11.2 years) who had ACLR using a bone-patellar tendon-bone autograft 6 to 9 (7.01 ± 0.93) months previously and 22 healthy male controls (age, 24.8 ± 9.1 years). Participants completed a self-report questionnaire and underwent isokinetic strength testing and functional and kinematic assessment of the single-, triple-, and crossover-hop tests. Two-way analyses of variance were used to test for differences between the ACLR group and the control group, and between the 2 lower extremities of the ACLR group.

RESULTS

Compared to the control group, the ACLR group had greater isokinetic knee extension torque deficits at all speeds (P ≤.001) and greater performance asymmetry for all 3 hop tests (P<.001). Compared to the noninvolved lower extremity, the involved lower extremity of the ACLR group exhibited less ankle dorsiflexion and knee flexion in the phases of propulsion (P ≤.014) and landing (P ≤.032). When compared to the control group, the involved lower extremity exhibited less ankle dorsiflexion in the propulsion phase (P<.001) but higher hip flexion in the landing phase (P = .014).

CONCLUSION

Six to 9 months following ACLR, patients continue to demonstrate functional hop and isokinetic knee extension deficits, as well as kinematic differences, during the propulsion and landing phases of the hop tests.

Return to sport following anterior cruciate ligament reconstruction

Rates of return to pre-injury sport following anterior cruciate ligament (ACL) reconstruction are less than might be expected from standard outcome measures and there appears to be a rapid decline in sporting participation after two to three years. There are many factors that influence whether an individual will return to sport following this type of surgery. They include not only surgical details and rehabilitation, but also social and psychological factors, as well as demographic characteristics. Age is of particular importance with older patients being less likely to resume their pre-injury sport. It is important that future research clearly identify the pre-injury characteristics of the study cohort when investigating return to sport, and also that there is consistent and precise terminology used to report rates of return to sporting activities. Little is known about how to determine when it is safe to return to sport following ACL reconstruction or how to predict whether an athlete will be able to successfully return to sport. Finally, it needs to be recognised that return to sport following ACL reconstruction is associated with a risk of further injury and the development of osteoarthritis.

Development of a silk and collagen fiber scaffold for anterior cruciate ligament reconstruction

The objective of this study was to determine a silk-collagen fiber ratio for an anterior cruciate ligament (ACL) reconstruction composite scaffold device. Composite fiber scaffolds with silk volumes ≥14 % and collagen volume <86 % demonstrated comparable or greater initial ultimate tensile stress relative to the human ACL. Silk scaffolds implanted subcutaneously and intraarticularly in rabbits demonstrated an 84 and 92 % reduction in strength with a 26 and 22 % reduction in volume after 8 weeks, respectively. The mechanical degradation findings of this preliminary study suggest that a composite scaffold with an initial UTS value of at least 129 MPa, or roughly a 48:52 silk to collagen volume ratio meets the minimal mechanical requirements necessary to proceed to a functional ACL reconstruction study in vivo.

Psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: a systematic review

This review describes the psychosocial factors that affect recovery following anterior cruciate ligament (ACL) injury and reconstructive surgery in athletes. A systematic search in literature with inclusion and exclusion criteria on PubMed, PsycINFO, and Embase was performed. Articles used in this review were divided in five different parts according to the biopsychosocial model of Wiese-Bjornstal, with the addition of intervention studies. The results showed that a high internal Health Locus of Control and a high self-efficacy were useful cognitive factors to facilitate the recovery. Athletes with a low level of fear of reinjury had the best knee outcome after the injury followed by a reconstruction. In addition, athletes who returned to sport had less fear of reinjury and were more experienced and established athletes compared with athletes who did not return to sport. Furthermore, researchers showed that there was a positive relation between goal setting and adherence, which in turn yielded a positive relation with the outcome of the rehabilitation of an ACL injury. There were several psychosocial interventions that appeared to be facilitating the rehabilitation process.

Return to high school- and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study

BACKGROUND

There is a relative paucity of data regarding the effect of anterior cruciate ligament (ACL) reconstruction on the ability of American high school and collegiate football players to return to play at the same level of competition as before their injury or to progress to play at the next level of competition.

PURPOSE

(1) To identify the percentage of high school and collegiate American football players who successfully returned to play at their previous level of competition, (2) to investigate self-reported performance for those players able to return to play or reason(s) for not returning to play, and (3) to elucidate risk factors responsible for players not being able to return to play or not returning to the same level of performance.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study was a retrospective analysis of prospective patients taken from the Multicenter Orthopaedic Outcomes Network (MOON) cohort who identified football as their primary or secondary sport. Identified patients were then questioned in a structured interview regarding their ACL injury, participation in football before their injury, and factors associated with returning to play. Data were analyzed for player position, concurrent meniscal/ligamentous/chondral injury, surgical technique and graft used for ACL reconstruction, and issues pertaining to timing and ability to return to play.

RESULTS

One hundred forty-seven players (including 68 high school and 26 collegiate) met our criteria and were contacted from the 2002 and 2003 MOON cohorts. Return to play rates for all high school and collegiate athletes were similar (63% and 69%, respectively). Based on player perception, 43% of the players were able to return to play at the same self-described performance level. Approximately 27% felt they did not perform at a level attained before their ACL tear, and 30% were unable to return to play at all. Although two thirds of players reported some "other interest" contributing to their decision not to return, at both levels of competition, fear of reinjury or further damage was cited by approximately 50% of the players who did not return to play. Analysis of patient-reported outcome scores at a minimum of 2 years after surgery between patients who returned to play and those who did not demonstrated clinically and statistically significant differences in the International Knee Documentation Committee form, Marx Activity Scale, and Knee injury and Osteoarthritis Outcome Score knee-related quality of life subscale in the collegiate players. Similar clinical differences were not statistically significant in the high school students. Player position did not have a statistically significant effect on the ability to return to play for high school players, and 41% of "skilled" position players and 50% of "nonskilled" position players were able to return to play at the same performance level.

CONCLUSION

Return to play percentages for amateur American football players after ACL reconstruction are not as high as would be expected. While technical aspects of ACL reconstruction and the ensuing rehabilitation have been studied extensively, the psychological factors (primarily a fear of reinjury) influencing the ability to return to play after ACL surgery may be underestimated as a critical factor responsible for athletes not returning to play at any level of competition.