Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus

Toward designing human intervention studies to prevent osteoarthritis after knee injury: A report from an interdisciplinary OARSI 2023 workshop

Objective

The global impact of osteoarthritis is growing. Currently no disease modifying osteoarthritis drugs/therapies exist, increasing the need for preventative strategies. Knee injuries have a high prevalence, distinct onset, and strong independent association with post-traumatic osteoarthritis (PTOA). Numerous groups are embarking upon research that will culminate in clinical trials to assess the effect of interventions to prevent knee PTOA despite challenges and lack of consensus about trial design in this population. Our objectives were to improve awareness of knee PTOA prevention trial design and discuss state-of-the art methods to address the unique opportunities and challenges of these studies.

Design

An international interdisciplinary group developed a workshop, hosted at the 2023 Osteoarthritis Research Society International Congress. Here we summarize the workshop content and outputs, with the goal of moving the field of PTOA prevention trial design forward.

Results

Workshop highlights included discussions about target population (considering risk, homogeneity, and possibility of modifying osteoarthritis outcome); target treatment (considering delivery, timing, feasibility and effectiveness); comparators (usual care, placebo), and primary symptomatic outcomes considering surrogates and the importance of knee function and symptoms other than pain to this population.

Conclusions

Opportunities to test multimodal PTOA prevention interventions across preclinical models and clinical trials exist. As improving symptomatic outcomes aligns with patient and regulator priorities, co-primary symptomatic (single or aggregate/multidimensional outcome considering function and symptoms beyond pain) and structural/physiological outcomes may be appropriate for these trials. To ensure PTOA prevention trials are relevant and acceptable to all stakeholders, future research should address critical knowledge gaps and challenges.

Assessing the efficacy of the Stop OsteoARthritis (SOAR) program: A randomized delayed-controlled trial in persons at increased risk of early onset post-traumatic knee osteoarthritis

OBJECTIVE

Assess the efficacy of an 8-week virtual, physiotherapist (PT)-guided knee health program (Stop OsteoARthritis (SOAR)) to improve knee extensor strength in individuals at risk of post-traumatic knee osteoarthritis (PTOA).

METHOD

In this superiority, randomized delayed-control trial, persons aged 16-35 years, 1-4 years after a self-reported knee joint injury were randomly assigned (1:1) to receive the SOAR program immediately (experimental group) or after a 9-week delay (control group). SOAR includes 1) one-time Knee Camp (virtual PT-guided group education, knee assessment, 1:1 exercise and physical activity (PA) goal-setting); 2) Weekly personalized home-based exercise and PA program with tracking; 3) Weekly 1:1 PT counseling (virtual). The primary outcome was a change in isokinetic knee extensor strength (baseline to 9-weeks). Additional outcomes included change in self-reported knee-related quality-of-life (QOL), self-efficacy, self-management and kinesiophobia, and PA (accelerometer) at 9 and 18-weeks. Linear regression models estimated the effect of the 8-week intervention at the primary endpoint (9-week).

RESULTS

49 of 54 randomized participants completed the study (91%). Participants were a mean ± standard deviation age of 27 ± 5.0 years, and 2.4 ± 0.9 years post-injury. No mean between group differences for the primary (0.05; 95% confidence interval (CI): -0.10, 0.19) or other outcomes were seen at 9 weeks except for greater improvements in perceived self-management (Partner in Health Scale; 11.3/96, 95%CI: 5.5, 17.1) and kinesiophobia (Tampa Scale of Kinesiophobia; -4.4/33, 95%CI: -7.0, -1.8).

CONCLUSION

For active persons with elevated risk of PTOA, an 8-week SOAR program did not change knee-related strength, QOL, self-efficacy, or PA, on average, but may benefit the ability to self-manage knee health and kinesiophobia.

Usefulness of Current Patient-Reported Outcome Scales for ACL Injury: A Mixed-Methods Evaluation of Stakeholder-Perceived Utility of Specific Constructs and Items Across the Rehabilitation Timeline

Background

Numerous patient-reported outcome measures (PROMs) have been used in patients with anterior cruciate ligament reconstruction (ACLR), often with overlapping constructs of interest and limited content validity. Inefficient scale application increases burden and diminishes overall usefulness for both the patient and practitioner.

Purpose

To isolate specific PROM items across a diverse set of constructs that patients and practitioners perceive as having the greatest value at various stages of recovery and return to sport (RTS) in patients after ACLR.

Study Design

Cross-sectional study.

Methods

A combined 77 stakeholders participated in this 2-phase mixed-methods investigation. In phase 1, a total of 27 patients and 21 practitioners selected individual PROM items from various constructs that had the greatest utility or importance. In phase 2, the highest rated items were further tested in a head-to-head comparison with 29 stakeholders who attended the 2022 ACL Injury Research Retreat. In addition to the utility assessment, practitioners answered other questions related to importance and timing of PROM assessments.

Results

In phase 1, both patients and practitioners shared the same top item in 6 of the 8 (75%) constructs assessed. In phase 2, the construct of psychological burden was rated as "extremely important" by 59% of respondents, followed by physical function (54%), symptoms (35%), and donor site issues (10%). The PROM items of confidence, perceived likelihood of reinjury, and difficulty stopping quickly were rated by a respective 93%, 89%, and 86% of the sample as either "very useful" or "extremely useful." All constructs except donor site issues were rated by most stakeholders to be absolutely necessary to evaluate treatment progress and RTS readiness at the 6-month postoperative time and at RTS.

Conclusion

Overall, psychological burden, with specific items related to confidence and reinjury likelihood, were rated as most important and useful by both patients and practitioners. The second most important and useful PROM item was related to higher intensity function (eg, decelerating or jumping/landing activities during sports).

Ultrasound assessment of the infrapatellar fat pad can detect Hoffa-synovitis in patients following anterior cruciate ligament reconstruction: A pilot study

Introduction

Osteoarthritis (OA) commonly occurs following anterior cruciate ligament reconstruction (ACLR), affecting over 50 % of patients within 10-15 years post-ACLR. The Hoffa-synovitis of the infrapatellar fat pad (IPFP) has been implicated as a major contributor to OA pathogenesis. While MRI is typically used to evaluate the IPFP, it is cost-prohibitive for routine screening. This study aimed to validate ultrasound as an alternative for detecting IPFP Hoffa-synovitis in participants post-ACLR.

Methods

In this cross-sectional study, 15 participants (18-35 years, 1-5 years post-ACLR) underwent two imaging sessions separated by one week. First, a standardized bilateral anterior knee ultrasound assessment was used to examine IPFP echo-intensity. Second, MRI scans of both knees were graded by a board-certified musculoskeletal radiologist for Hoffa-synovitis according to the Anterior Cruciate Ligament Osteoarthritis Score grading system. IPFP echo-intensity were quantified on each ultrasound image, and a limb symmetry index (LSI) was calculated to assess between-limb differences. We used an independent t-test and Cohen's d effect sizes to compare IPFP echo-intensity LSI between people with and without MRI-confirmed Hoffa-synovitis.

Results

Four of the 15 participants (27 %) exhibited MRI-confirmed Hoffa-synovitis. Significantly higher IPFP echo-intensity LSI values were found in participants with Hoffa-synovitis (32.1 ± 12.1 %) compared to those without (10.5 ± 10.4 %), confirming the ultrasound's ability to distinguish between the two groups (t = -3.44; p = 0.004; d = 2.01).

Discussion

Ultrasound detects bilateral IPFP signal intensity alterations in participants post-ACLR with MRI-confirmed Hoffa-synovitis. This work should be seen as a proof-of-concept, and further validation in a larger, more diverse sample is essential for verifying these results.

The Delaware-Oslo ACL Cohort treatment algorithm yields superior outcomes to usual care 9-12 years after anterior cruciate ligament reconstruction

PURPOSE

Patient-reported outcomes were compared between participants who followed the treatment algorithm of the Delaware-Oslo ACL Cohort, consisting of progressive preoperative and postoperative rehabilitation, patient education, clinical testing and shared decision-making about treatment choice, and those who followed usual care 9-12 years after anterior cruciate ligament reconstruction (ACLR).

METHODS

Participants with primary ACLR were included from the Norwegian arm of the Delaware-Oslo ACL Cohort and the Norwegian Knee Ligament Registry (usual care). The Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores and the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores were compared. KOOS scores for the usual care group were converted to IKDC-SKF scores with recently published validated crosswalk. The percentages of participants with scores above predefined thresholds for patient acceptable symptom state (PASS) were also calculated.

RESULTS

Eighty of 100 (80%) participants from the Delaware-Oslo ACL Cohort and 1588 of 3248 (49%) from the usual care group participated in the follow-up. Participants from the Delaware-Oslo ACL Cohort had higher KOOS subscale (p < 0.001) and IKDC-SKF scores (p < 0.001), and a higher percentage reached PASS (84%-96% vs. 62%-76%, p ≤ 0.002) for KOOS Pain, symptoms, activities of daily living and sports compared to the usual care group. No significant differences were found for KOOS quality of life scores (not significant [n.s.]) or PASS percentages (80% vs. 74%, n.s.).

CONCLUSION

Participants with ACLR who followed the Delaware-Oslo ACL Cohort treatment algorithm had reduced knee symptoms, superior function and higher percentages of satisfactory outcomes than participants who followed usual care.

LEVEL OF EVIDENCE

Level II.

Knee-Related Quality of Life Compared Between 20 and 35 Years After an Anterior Cruciate Ligament Injury Treated Surgically With Primary Repair or Reconstruction, or Nonsurgically

BACKGROUND

Quality of life (QoL) is affected up to 5 years after an anterior cruciate ligament (ACL) injury. Knee impairment and osteoarthritis (OA) development increase over time, and this may affect QoL at a long-term follow-up.

PURPOSE

To investigate changes in health- and knee-related QoL between 20 and 35 years after ACL injury and compare it between patients treated with or without ACL surgery, as well as to study how symptomatic OA (SOA) is associated with change in QoL.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between 1980 and 1983, 139 patients with acute ACL rupture were allocated to surgical or nonsurgical treatment of the ACL. Both groups completed a structured rehabilitation program. Of those patients, 59 were followed for 20 and 35 years after ACL rupture. After 10 crossovers, 33 patients were treated with primary repair or ACL reconstruction, and 26 were treated without ACL surgery. Combined radiographic OA and knee symptoms at 35 years was defined as SOA. QoL was assessed at 20 and 35 years after injury with the Knee injury and Osteoarthritis Outcome Score QoL (KOOS-QoL) subscale (range, 1-100), ACL-QoL questionnaire (total score and 5 subscales; range, 1-100), European QoL-5 Dimensions Questionnaire, and visual analog scale. Results were analyzed with paired and independent-sample t tests and chi-square tests.

RESULTS

Knee-related QoL was impaired at both 20 and 35 years after ACL injury, and differences were dependent on the measurement outcome. In the total cohort, KOOS-QoL did not change but both total ACL-QoL score (7.1 points; 95% CI, 2.2-11.9) and 4 of 5 subscales (5-10 points) decreased (P < .05). No differences were found between treatment groups. QoL decreased overall in patients with SOA, with a 21-point difference within-group change in KOOS-QoL (SOA or non-SOA) between 20 and 35 years of follow-up (P = .001; Cohen d = 1.0).

CONCLUSION

An ACL injury impairs knee-related QoL for up to 35 years, with no difference between treatment approaches (initial repair or later reconstruction compared with nonsurgical treatment). The deterioration decreases with longer follow-up. Clinicians should be aware of differences in QoL depending on the measurement outcome.

Appraising the Methodological Quality of Sports Injury Video Analysis Studies: The QA-SIVAS Scale

BACKGROUND

Video analysis (VA) is commonly used in the assessment of sports injuries and has received considerable research interest. Until now, no tool has been available for the assessment of study quality. Therefore, the objective of this study was to develop and evaluate a valid instrument that reliably assesses the methodological quality of VA studies.

METHODS

The Quality Appraisal for Sports Injury Video Analysis Studies (QA-SIVAS) scale was developed using a modified Delphi approach including expert consensus and pilot testing. Reliability was examined through intraclass correlation coefficient (ICC3,1) and free-marginal kappa statistics by three independent raters. Construct validity was investigated by comparing QA-SIVAS with expert ratings by using Kendall's tau analysis. Rating time was studied by applying the scale to 21 studies and computing the mean time for rating per study article.

RESULTS

The QA-SIVAS scale consists of an 18-item checklist addressing the study design, data source, conduct, report, and discussion of VA studies in sports injury research. Inter- and intra-rater reliability were excellent with ICCs > 0.97. Expert ratings revealed a high construct validity (0.71; p < 0.001). Mean rating time was 10 ± 2 min per article.

CONCLUSION

QA-SIVAS is a reliable and valid instrument that can be easily applied to sports injury research. Future studies in the field of VA should adhere to standardized methodological criteria and strict quality guidelines.

Financial burden of anterior cruciate ligament reconstructions in football (soccer) players: an Australian cost of injury study

OBJECTIVES

To estimate the financial burden of anterior cruciate ligament (ACL) reconstructions in amateur football (soccer) players in Australia over a single year, including both direct and indirect cost.

METHODS

Available national direct and indirect cost data were applied to the annual incidence of ACL reconstructions in Australia. Age-adjusted and sex-adjusted total and mean costs (ACL and osteoarthritis (OA)) were calculated for amateur football (soccer) players in Australia using an incidence-based approach.

RESULTS

The estimated cost of ACL reconstructions for amateur football players is $A69 623 211 with a mean total cost of $A34 079. The mean indirect costs are 19.8% higher than the mean direct costs. The mean indirect costs are lower in female (11.5%, $A28 628) and junior (15.3%, $A29 077) football players. The mean ACL costs are 3-4-fold greater than the mean OA costs ($A27 099 vs $A6450, respectively), remaining consistent when stratified by sex and age group. Our model suggests that for every 10% increase in adherence to injury prevention programmes, which equates to approximately 102 less ACL injuries per year, $A9 460 224 in ACL costs could be saved.

CONCLUSION

While the number of ACL reconstructions per year among football players in Australia is relatively small, the annual financial burden is high. Our study suggests that if injury prevention exercises programmes are prioritised by stakeholders in football, significant cost-savings are possible.

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.

Accelerometer-assessed physical activity patterns during the first two years after a non-surgically treated ACL injury

OBJECTIVES

To describe physical activity patterns and analyze changes during the first two years after a non-surgically treated ACL injury, and to assess correlations between accelerometer-assessed physical activity and self-reported knee function and knee-related quality of life.

DESIGN

Prospective cohort study.

PARTICIPANTS

128 patients (61 females, 25.2 ± 7.1 years) with acute ACL injury.

MAIN OUTCOME MEASURES

Physical activity patterns were measured with accelerometry. Self-reported knee function was assessed using the International Knee Documentation Committee Subjective Knee Form, and knee-related quality of life was assessed using the Anterior Cruciate Ligament Quality of Life questionnaire.

RESULTS

Moderate to vigorous physical activity (MVPA) and steps per day increased from baseline to 3 months (p < .001), with no further increase from 3 to 24 months (p > .05). Time in MVPA did not correlate to patient-reported outcome measures at 3, 6, 12, or 24 months (p > .05).

CONCLUSIONS

Physical activity increased from acute phase to 3 months after non-surgically treated ACL injury, but almost one in four patients did not reach recommended levels of physical activity. Physical activity did not correlate with knee function or quality of life. Patients may need improved support to return to physical activity after ACL injury.

LEVEL OF EVIDENCE

Level II.

TRIAL REGISTRATION

NCT02931084.

Poorer patient-reported knee function and quality of life, but not activity level, after revision ACL reconstruction compared with primary ACL reconstruction: a matched-pair analysis with a minimum 5-year follow-up

BACKGROUND

An appropriate method for comparing knee function and activity level between patients with primary and revision anterior cruciate ligament reconstruction (ACLR) is to perform a matched-group analysis. The aim was to assess and compare knee function, knee-related quality of life and activity level between patients with revision ACLR and primary ACLR at a minimum of 5 years of follow-up.

METHODS

Patients aged ≤ 40 years old who underwent revision ACLR between 2010 and 2015 and a matched control group (primary ACLR) (1:1) with age ± 2 years, year of ACLR, sex, and pre-injury sport and Tegner Activity Scale (TAS) were retrospectively identified in our clinic database. The preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) and surgical data were extracted and analyzed. Patients were mailed KOOS and EQ-5D questionnaires at a minimum of 5-years after revision ACLR. Study-specific questions about knee function, limitation in sport, satisfaction, and activity level according to the TAS (all scales of 1-10, 10 best) were also asked by telephone.

RESULTS

Seventy-eight patients with a revision ACLR (mean age ± SD, 29.9 ± 6.0 years) matched with seventy-eight patients with a primary ACLR (30.2 ± 5.8 years) were included. The follow-up for the revision ACLR group was 7.0 ± 1.5 years and for the primary ACLR group 7.7 ± 1.6 years. The revision ACLR group reported poorer KOOS scores in all subscales (p < 0.05) except the Symptoms subscale, poorer EQ-5D VAS (mean 79.2 ± 20.1 vs 86.0 ± 20.1, p = 0.012), and less satisfaction with current knee function (median 7 (6-8) vs 8 (7-9), p < 0.001). Patients with revision ACLR also experienced greater limitation in sports (median 7 (4-8) vs 8 (6-9), p < 0.001). There were no significant differences in the EQ-5D (mean 0.86 ± 0.17 vs 0.89 ± 0.11, p = 0.427), activity level (median 2 (2-5) vs 4 (2-7), p = 0.229), or satisfaction with activity level (median 8 (5-9) vs 8 (6-10), p = 0.281) between the groups.

CONCLUSIONS

At a minimum 5-year follow-up, the revision ACLR group reported poorer knee function and quality of life, less satisfaction with knee function and a greater limitation in sports but no differences in activity level and satisfaction with activity level compared with the primary ACLR group.

A method for defining tissue injury criteria reveals that ligament deformation thresholds are multimodal

Soft tissue injuries (such as ligament, tendon, and meniscus tears) are the result of extracellular matrix damage from excessive tissue stretching. Deformation thresholds for soft tissues, however, remain largely unknown due to a lack of methods that can measure and compare the spatially heterogeneous damage and deformation that occurs in these materials. Here, we propose a full-field method for defining tissue injury criteria: multimodal strain limits for biological tissues analogous to yield criteria that exist for crystalline materials. Specifically, we developed a method for defining strain thresholds for mechanically-driven fibrillar collagen denaturation in soft tissues, using regional multimodal deformation and damage data. We established this new method using the murine medial collateral ligament (MCL) as our model tissue. Our findings revealed that multiple modes of deformation contribute to collagen denaturation in the murine MCL, contrary to the common assumption that collagen damage is driven only by strain in the direction of fibers. Remarkably, hydrostatic strain (computed here with an assumption of plane strain) was the best predictor of mechanically-driven collagen denaturation in ligament tissue, suggesting crosslink-mediated stress transfer plays a role in molecular damage accumulation. This work demonstrates that collagen denaturation can be driven by multiple modes of deformation and provides a method for defining deformation thresholds, or injury criteria, from spatially heterogeneous data. STATEMENT OF SIGNIFICANCE: Understanding the mechanics of soft tissue injuries is crucial for the development of new technology for injury detection, prevention, and treatment.  Yet, tissue-level deformation thresholds for injury are unknown, due to a lack of methods that combine full-field measurements of multimodal deformation and damage in mechanically loaded soft tissues. Here, we propose a method for defining tissue injury criteria: multimodal strain thresholds for biological tissues. Our findings reveal that multiple modes of deformation contribute to collagen denaturation, contrary to the common assumption that collagen damage is driven by strain in the fiber direction alone. The method will inform the development of new mechanics-based diagnostic imaging, improve computational modeling of injury, and be employed to study the role of tissue composition in injury susceptibility.

Anterior Cruciate Ligament Reconstruction Using Autologous Hamstrings Augmented with Ligament Augmentation and Reconstruction Systems (LARS) or Synthetic Meshwork of LARS Compared with Four-Strand Hamstring Tendon Grafts Alone, a Prospective, Randomized Clinical Study with 2- to 8-Year Follow-Up

Purpose

To compare the long-term outcomes of anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft alone (hamstring group) or with synthetics (Ligament Augmentation and Reconstruction System, LARS group) or synthetic meshwork of LARS (meshwork group).

Methods

Patients who underwent ACL reconstruction using four-strand hamstring tendon grafts (hamstring group), autologous hamstrings augmented with the LARS (LARS group), or synthetic meshwork of LARS (meshwork group) were selected in this prospective randomized clinical study. Patient-reported outcome measures (PROMs) were obtained preoperatively; at 6, 12, and 18 months postoperatively; and at final follow-up between 3 and 8 years. Second-look arthroscopic findings were used to evaluate graft morphology based on graft tension, graft tear, and synovial coverage.

Results

A total of 141 consecutive patients underwent ACL reconstruction, 47 patients in each group, and 21 patients were lost to follow-up during the study period. At the 6-month follow-up, the IKDC scores and Lysholm scores were significantly better in the LARS group (P < 0.05). At the 6- and 12-month follow-ups, the KOS-ADLS, KOOS-activities of daily living and quality of life, NSARS scores, GRC scores, Tegner scores, and ACL-RSI scores were significantly better in the LARS group (P < 0.05). For the LARS group, hamstring group, and meshwork group, the cumulative failure rates were 8.5%, 12.8%, and 4.3%, respectively. Malposition of the femoral tunnel was significantly associated with cumulative failure (P < 0.05). There was no difference between the groups in other outcomes at any other time, including radiographic and arthroscopic outcomes.

Conclusions

ACL reconstruction using autologous hamstring augmented with LARS resulted in significantly better clinical scores with a faster return to sports and comparative side-to-side differences in graft laxity by 6 and 12 months follow-up. Despite these findings, no statistically significant differences were seen among the three patient groups in terms of objective outcomes and clinical scores at the 18-month, 3-year and 8-year follow-ups. Additionally, a malpositioned femoral tunnel was associated with graft failure.

Knee- and Overall Health-Related Quality of Life Following Anterior Cruciate Ligament Injury: A Cross-sectional Analysis of Australian and Canadian Cohorts

OBJECTIVE: To describe the knee- and overall health-related quality of life (QOL) 3 to 12 years after anterior cruciate ligament (ACL) tear, and to assess the association of clinical and structural features with QOL after ACL tear. DESIGN: Cross-sectional analysis of combined data from Australian (n = 76, 5.4 years postinjury) and Canadian (n = 50, 6.6 years postinjury) prospective cohort studies. METHODS: We conducted a secondary analysis of patient-reported outcomes and index knee magnetic resonance imaging (MRI) acquired in 126 patients (median 5.5 [range: 4-12] years postinjury), all treated with ACL reconstruction. Outcomes included knee (ACL Quality of Life questionnaire [ACL-QOL]) and overall health-related QOL (EQ-5D-3L). Explanatory variables were self-reported knee pain (Knee Injury and Osteoarthritis Outcome Score [KOOS-Pain subscale]) and function (KOOS-Sport subscale), and any knee cartilage lesion (MRI Osteoarthritis Knee Score). Generalized linear models were adjusted for clustering between sites. Covariates were age, sex, time since injury, injury type, subsequent knee injuries, and body mass index. RESULTS: The median [range] ACL-QOL score was 82 [24-100] and EQ-5D-3L was 1.0 [-0.2 to 1.0]. For every 10-point higher KOOS-Sport score, the ACL-QOL score increased by 3.7 points (95% confidence interval [CI]: 1.7, 5.7), whereas there was no evidence of an association with the EQ-5D-3L (0.00 points, 95% CI: -0.02, 0.02). There were no significant association between KOOS-Pain and ACL-QOL (4.9 points, 95% CI: -0.1, 9.9) or EQ-5D-3L (0.05 points, 95% CI: -0.01, 0.11), respectively. Cartilage lesions were not associated with ACL-QOL (-1.2, 95% CI: -5.1, 2.7) or EQ-5D-3L (0.01, 95% CI: -0.01, 0.04). CONCLUSION: Self-reported function was more relevant for knee-related QOL than knee pain or cartilage lesions after ACL tear. Self-reported function, pain, and knee structural changes were not associated with overall health-related QOL. J Orthop Sports Phys Ther 2023;53(7):1-12. Epub: 8 June 2023. doi:10.2519/jospt.2023.11838.

Chronic pain and functional impairment after arthroscopic surgery for a knee injury

Arthroscopic interventions are widely used to treat the consequences of the meniscus and anterior cruciate ligament (ACL) injuries. However, the long-term consequences of these surgeries are not always favorable and not in all cases allow to avoid the development of chronic pain and posttraumatic osteoarthritis.Objective: to evaluate the incidence of persistent postoperative pain and the persistence of functional disorders in patients undergoing arthroscopic interventions on the menisci and ACL.Material and methods. The study group consisted of 147 patients (60 women and 87 men, mean age 38.8±12.5 years) who underwent arthroscopic surgery on the knee joint (KJ) in the traumatology and orthopedic department of V.A. Nasonova Research Institute of Rheumatology in 2018– 2021. The condition of patients was assessed by telephone survey and/or online questionnaire. The pain and fatigue levels were assessed on numerical rating scale (NRS, 0–10), as well as the severity of functional disorders on the Lysholm scale (LS).Results and discussion. Moderate or intense knee pain and increased fatigue (≥4 according to NRS) were noted in 11.3% and 14.7% of respondents, respectively. The state of the KJ according to LS in 35.3% of patients was assessed as excellent (95–100 points), in 29.3% – as good (84–94 points), in 21.3% – as satisfactory (65–83 points) and 14.0% – as unsatisfactory (≤64 points).Conclusion. More than 10% of patients after arthroscopic operations on the knee joint experience moderate or severe pain and fatigue, satisfactory and unsatisfactory functional results are observed in 35.4% of cases.

A method for defining tissue injury criteria reveals ligament deformation thresholds are multimodal

Soft tissue injuries (such as ligament, tendon, and meniscus tears) are the result of extracellular matrix damage from excessive tissue stretching. Deformation thresholds for soft tissues, however, remain largely unknown due to a lack of methods that can measure and compare the spatially heterogeneous damage and deformation that occurs in these materials. Here, we propose a method for defining tissue injury criteria : multimodal strain limits for biological tissues analogous to yield criteria that exist for crystalline materials. Specifically, we developed a method for defining injury criteria for mechanically-driven fibrillar collagen denaturation in soft tissues, using regional multimodal deformation and damage data. We established this new method using the murine medial collateral ligament (MCL) as our model tissue. Our findings revealed that multiple modes of deformation contribute to collagen denaturation in the murine MCL, contrary to the common assumption that collagen damage is driven by strain in the fiber direction alone. Remarkably, our results indicated that hydrostatic strain, or volumetric expansion, may be the best predictor of mechanically-driven collagen denaturation in ligament tissue, suggesting crosslink-mediated stress transfer plays a role in molecular damage accumulation. This work demonstrates that collagen denaturation can be driven by multiple modes of deformation and provides a method for defining deformation thresholds, or injury criteria, from spatially heterogeneous data.

Patients that maintain their pre-injury level of physical activity 3-5 years after ACL reconstruction are, 18 months after surgery, characterised by higher levels of readiness to return to sport

PURPOSE

To characterise patients who had returned to their pre-injury physical activity (PA) or higher at 18 months and maintained that level of PA 3-5 years after the primary ACL reconstruction and to describe the level, frequency, and type of PA participation during the first 5 years after ACL reconstruction  METHOD: Data, from follow-ups at 18 months and 3-5 years after an ACL reconstruction, were extracted from a rehabilitation-specific register. Patients, 15-65 years of age, were included. The data comprised patient-reported outcomes and the results from two questions with respect to the level, frequency, and type of PA. Comparisons were made between patients who had and had not maintained their pre-injury level of PA at the follow-up 3-5 years after an ACL reconstruction.

RESULTS

A total of 272 patients met the inclusion criteria. The mean follow-up time was 3.8 years (min-max: 2.9-5.1) after the ACL reconstruction. Of patients who had returned to their pre-injury or a higher level of PA at the 18 month follow-up (n = 114), 68% (n = 78) maintained that level at the 3- to 5-year follow-up after ACL reconstruction. These patients reported a higher level of psychological readiness to return to sport (98 versus 79; p = 0.013). Moreover, these patients were 6.0 years older (p = 0.016) and were characterised by male sex (56% versus 44%; p = 0.028) and a lower level of pre-injury PA (p = 0.013). At the follow-up 3-5 years after the ACL reconstruction, more than 90% met the recommendations for PA. However, the prevalence of physical inactivity had increased and the involvement in organised PA had decreased compared with the 18-month follow-up.

CONCLUSIONS

Two out of three patients who have returned to their previous level of PA at 18 months can be expected to maintain that level, 3-5 years following ACL reconstruction. These patients were mainly characterised by a higher level of psychological readiness, especially in patients who participated in knee-strenuous sport and were younger than 20 years of age. The results of this study suggest that patients become more physically inactive over time, implicating the importance of clinicians helping patients find a suitable PA that may help patients maintain an active lifestyle.

The effectiveness and safety of blood flow restriction training for the post-operation treatment of distal radius fracture

INTRODUCTION

Distal radius fracture (DRF) is a common injury in the upper extremities. Blood flow restriction (BFR) has been proven to be effective in improving function in low-load training, which is suitable for post-op rehabilitation. We explored the effectiveness and safety of BFR therapy in DRF patients who underwent surgery.

MATERIALS AND METHODS

Thirty-five patients were randomly assigned to either the BFR or the regular training (RT; no BFR therapy) groups. All patients completed the same 4-week postoperative rehabilitation program, including anti-inflammatory treatments, strengthening and range of motion (ROM) training. In the BFR group, the pressure was 120 mmHg in strengthening training course. Pain, circumferences of wrists and forearms, ROM, muscle strength, and D-dimer levels were evaluated at weeks 0, 2, and 4. Radius union scoring system (RUSS) was measured at weeks 4 and 12. Finally, wrist functionality (Cooney modification) was evaluated at week 12.

RESULTS

The BFR group had significantly decreased pain levels compared with the RT group (p < 0.01, effect size= 2.33, -2.44 at weeks 2 and 4). Swelling was effectively relieved in both groups. The wrist swelling was less in the BFR group (p < 0.01, effect size = -2.17 at week 4). The isometric strength of wrist extension (p < 0.01, effect size = 1.5, 3.02 at weeks 2 and 4), flexion (p < 0.01, effect size = 1.33, 2.53 at weeks 2 and 4), and functionality significantly increased in the BFR group (p < 0.01, effect size = 2.80 at week 12). No risk of VT in the BFR group was found. BFR did not threaten bone healing.

CONCLUSIONS

In patients with DRF who underwent corrective surgery, BFR therapy effectively relieved pain and swelling, increased muscle strength and wrist function, and had no additional risks for bone healing and VT.

OPTIKNEE 2022: consensus recommendations to optimise knee health after traumatic knee injury to prevent osteoarthritis

The goal of the OPTIKNEE consensus is to improve knee and overall health, to prevent osteoarthritis (OA) after a traumatic knee injury. The consensus followed a seven-step hybrid process. Expert groups conducted 7 systematic reviews to synthesise the current evidence and inform recommendations on the burden of knee injuries; risk factors for post-traumatic knee OA; rehabilitation to prevent post-traumatic knee OA; and patient-reported outcomes, muscle function and functional performance tests to monitor people at risk of post-traumatic knee OA. Draft consensus definitions, and clinical and research recommendations were generated, iteratively refined, and discussed at 6, tri-weekly, 2-hour videoconferencing meetings. After each meeting, items were finalised before the expert group (n=36) rated the level of appropriateness for each using a 9-point Likert scale, and recorded dissenting viewpoints through an anonymous online survey. Seven definitions, and 8 clinical recommendations (who to target, what to target and when, rehabilitation approach and interventions, what outcomes to monitor and how) and 6 research recommendations (research priorities, study design considerations, what outcomes to monitor and how) were voted on. All definitions and recommendations were rated appropriate (median appropriateness scores of 7–9) except for two subcomponents of one clinical recommendation, which were rated uncertain (median appropriateness score of 4.5–5.5). Varying levels of evidence supported each recommendation. Clinicians, patients, researchers and other stakeholders may use the definitions and recommendations to advocate for, guide, develop, test and implement person-centred evidence-based rehabilitation programmes following traumatic knee injury, and facilitate data synthesis to reduce the burden of knee post-traumatic knee OA.