Effectiveness of a home-based re-injury prevention program on motor control, return to sport and recurrence rates after anterior cruciate ligament reconstruction: study protocol for a multicenter, single-blind, randomized controlled trial (PReP)

Late-stage rehabilitation after anterior cruciate ligament reconstruction: A multicentre randomised controlled trial (PReP)

BACKGROUND

At the completion of formal rehabilitation after anterior cruciate ligament reconstruction, functional capacity is only restored in a small proportion of affected individuals. Therefore, the end of formal rehabilitation is not the end of functional rehabilitation.

OBJECTIVE

To compare adherence to and effectiveness of a late-stage rehabilitation programme with usual care after anterior cruciate ligament (ACL) reconstruction.

METHODS

This prospective, double-blind, multicentre, parallel group, randomised controlled trial, included people aged 18 to 35 years after formal rehabilitation completion (mean [SD] 241 [92] days post-reconstruction). Participants were block-randomised to a 5-month neuromuscular performance intervention (Stop-X group) or usual care (medically prescribed standard physiotherapy, individual formal rehabilitation, home-exercises). All outcomes were measured once/month. Primary outcome was the normalised knee separation distance on landing after drop jump. Baseline-adjusted linear mixed models were calculated.

RESULTS

In total, 112 participants (Stop-X: 57; Usual care: 55,) were analysed. Initially, mean (SD) intervention frequency (units/week) was higher in the Stop-X than the Usual care group: 2.65 (0.96) versus 2.48 (1.14) units/week in the first and 2.28 (1.02) versus 2.14 (1.31) units/week in the second month. No between-group*time(*baseline)-differences were found for the primary outcome. Between-group*time-effects favoured the Stop-X-group at 2 months (fewer self-reported knee problems during sport, KOOS-SPORT) (estimate = 64.3, 95 % CI 24.4-104.3 for the Stop-X), more confidence to return to sport (ACL-RSI) (62.4, 10.7-114.2), fewer pain-associated knee problems (KOOS-PAIN) (82.8, 36.0-129.6), improved everyday activity abilities (KOOS-ADL) (71.1, 6.4-135.7), and improved limb symmetry index in the front hop for distance at 3 and 4 months (0.34, 0.10-0.57; 0.31, 0.08-0.54). No between-group*time-effects occurred for kinesiophobia, symptom-associated knee problems or balance hops performance. At the end of the intervention, 79 % of the Stop-X and 70 % of the Usual care participants (p < 0.05) had successfully returned to their pre-injury sport type and level.

CONCLUSIONS

The Stop-X intervention was slightly superior to usual care as part of late-stage rehabilitation after ACL-reconstruction. The small benefit might justify its use after formal rehabilitation completion.

The effectiveness of the STOP-X training program on the knee valgus angle and balance in female basketball players with dynamic knee valgus: a randomized controlled trial

BACKGROUND

Dynamic knee valgus (DKV) accompanied by poor balance is the cause of anterior cruciate ligament (ACL) injury in athletes, and the identification and correction of these factors are always of interest to researchers. Therefore, the purpose of this research was to investigate the effect of the STOP-X program on the knee valgus angle and static and dynamic balance in female basketball players with DKV defects.

METHODS

The present study was a quasi-experimental study. Thirty female basketball players with DKV defects were purposefully identified by the single-leg landing (SLL) test and were randomly assigned to two control (n = 15) and experimental (n = 15) groups. Static balance status was evaluated with the BASS STICK test, and dynamic balance status was evaluated with the Y-balance test (YBT). The experimental group performed the STOP-X program for 25-40 min for eight weeks (three times per week), and the control group performed their traditional warm-up program. Data were analyzed by means of 2 × 2 repeated measures ANOVA followed by post hoc comparison (Bonferroni) at the significance level of (P < 0.05) with SPSS version 26.

RESULTS

The results showed that with the use of the STOP-X program, there was a significant difference between the experimental and control groups in variables of the static balance (F = 56.45; P = 0.001; ES = 0.66, PC=↑59.64%), total dynamic balance score (F = 107.57; P = 0.001; ES=↑0.79, PC=↑19.84%), and knee valgus angle (F = 119.46; P = 0.001; ES = 0.81, PC=↓34.36%).

CONCLUSION

In addition to reducing the knee valgus angle, applying the STOP-X injury prevention program can improve static and dynamic balance in female basketball players with DKV defects. Therefore, it can be recommended that sports trainers benefit from these advantages by adding STOP-X training to routine basketball exercises.

The End of the Formal Rehabilitation Is Not the End of Rehabilitation: Knee Function Deficits Remain After Anterior Cruciate Ligament Reconstruction

OBJECTIVE

To rate athletes' functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction.

METHODS

In our prospective multicenter cohort study, 88 (42 females) adults aged 18-35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not.

RESULTS

At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be "over-cut-off-performers."

CONCLUSIONS

The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.

Quadriceps and hamstring anterior cruciate ligament reconstruction differ only marginally in function after the rehabilitation: a propensity score-matched case-control study

PURPOSE

To determine potential quadriceps versus hamstring tendon autograft differences in neuromuscular function and return to sport (RTS)-success in participants after an anterior cruciate ligament (ACL) reconstruction.

METHODS

Case-control study on 25 participants operated on with an arthroscopically assisted, anatomic ipsilateral quadriceps femoris tendon graft and two control groups of 25 participants each, operated on with a semitendinosus tendon or semitendinosus-gracilis (hamstring) tendon graft ACL reconstruction. Participants of the two control groups were propensity score matched to the case group based on sex, age, Tegner activity scale and either the total volume of rehabilitation since reconstruction (n = 25) or the time since reconstruction (n = 25). At the end of the rehabilitation (averagely 8 months post-reconstruction), self-reported knee function (KOOS sum scores), fear of loading the reconstructed knee during a sporting activity (RSI-ACL questionnaire), and fear of movement (Tampa scale of kinesiophobia) were followed by hop and jump tests. Front hops for distance (jumping distance as the outcome) were followed by Drop jumps (normalised knee joint separation distance), and concluded by qualitative ratings of the Balanced front and side hops. Between-group comparisons were undertaken using 95% confidence intervals comparisons, effect sizes were calculated.

RESULTS

The quadriceps case group (always compared with the rehabilitation-matched hamstring graft controls first and versus time-matched hamstring graft controls second) had non-significant and only marginal higher self-reported issues during sporting activities: Cohen's d = 0.42, d = 0.44, lower confidence for RTS (d = - 0.30, d = - 0.16), and less kinesiophobia (d =  - 0.25, d = 0.32). Small and once more non-significant effect sizes point towards lower values in the quadriceps graft groups in the Front hop for distance limb symmetry values in comparison to the two hamstring control groups (d =  - 0.24, d = - 0.35). The normalised knee joint separation distance were non-significantly and small effect sized higher in the quadriceps than in the hamstring groups (d = 0.31, d = 0.28).

CONCLUSION

Only non-significant and marginal between-graft differences in the functional outcomes at the end of the rehabilitation occurred. The selection of either a hamstring or a quadriceps graft type cannot be recommended based on the results. The decision must be undertaken individually.

LEVEL OF EVIDENCE

III.

The awareness of injury prevention programmes is insufficient among French- and German-speaking sports medicine communities in Europe

PURPOSE

Evaluate the current state of sports injury prevention perception, knowledge and practice among sports medicine professionals located in Western Europe and involved in injury prevention.

METHODS

Members of two different sports medicine organizations (GOTS and ReFORM) were invited to complete a web-based questionnaire (in German and in French, respectively) addressing perception, knowledge and implementation of sports injury prevention through 22 questions.

RESULTS

766 participants from a dozen of countries completed the survey. Among them, 43% were surgeons, 23% sport physicians and 18% physiotherapists working mainly in France (38%), Germany (23%) and Belgium (10%). The sample rated the importance of injury prevention as "high" or "very high" in a majority of cases (91%), but only 54% reported to be aware of specific injury prevention programmes. The French-speaking world was characterized by lower levels of reported knowledge, unfamiliarity with existing prevention programmes and less weekly time spent on prevention as compared to their German-speaking counterparts. Injury prevention barriers reported by the respondents included mainly insufficient expertise, absence of staff support from sports organizations and lack of time.

CONCLUSION

There is a lack of awareness regarding injury prevention concepts among sports medicine professionals of the European French- and German-speaking world. This gap varied according to the professional occupation and working country. Relevant future paths for improvement include specific efforts to build awareness around sports injury prevention.

LEVEL OF EVIDENCE

Level IV.

Contributors to self-report motor function after anterior cruciate ligament reconstruction

Numerous functional factors may interactively contribute to the course of self-report functional abilities after anterior cruciate ligament  (ACL)-reconstruction. This study purposes to identify these predictors using exploratory moderation-mediation models in a cohort study design. Adults with post unilateral ACL reconstruction (hamstring graft) status and who were aiming to return to their pre-injury type and level of sport were included. Our dependent variables were self-reported function, as assessed by the the KOOS subscales sport (SPORT), and activities of daily living (ADL). The independent variables assessed were the KOOS subscale pain and the time since reconstruction [days]. All other variables (sociodemographic, injury-, surgery-, rehabilitation-specific, kinesiophobia (Tampa Scale of Kinesiophobia), and the presence or absence of COVID-19-associated restrictions) were further considered as moderators, mediators, or co-variates. Data from 203 participants (mean 26 years, SD 5 years) were finally modelled. Total variance explanation was 59% (KOOS-SPORT) and 47% (KOOS-ADL). In the initial rehabilitation phase (< 2 weeks after reconstruction), pain was the strongest contributor to self-report function (KOOS-SPORT: coefficient: 0.89; 95%-confidence-interval: 0.51 to 1.2 / KOOS-ADL: 1.1; 0.95 to 1.3). In the early phase (2-6 weeks after reconstruction), time since reconstruction [days] was the major contributor (KOOS-SPORT: 1.1; 0.14 to 2.1 / KOOS-ADL: 1.2; 0.43 to 2.0). Starting with the mid-phases of the rehabilitation, self-report function was no longer explicitly impacted by one or more contributors. The amount of rehabilitation [minutes] is affected by COVID-19-associated restrictions (pre-versus-post: - 672; - 1264 to - 80 for SPORT / - 633; - 1222 to - 45 for ADL) and by the pre-injury activity scale (280; 103 to 455 / 264; 90 to 438). Other hypothesised contributors such as sex/gender or age were not found to mediate the time or pain, rehabilitation dose and self-report function triangle. When self-report function is rated after an ACL reconstruction, the rehabilitation phases (early, mid, late), the potentially COVID-19-associated rehabilitation limitations, and pain intensity should also be considered. As, for example, pain is the strongest contributor to function in the early rehabilitation phase, focussing on the value of the self-report function only may, consequently, not be sufficient to rate bias-free function.

Relationship of strength, joint kinesthesia, and plantar tactile sensation to dynamic and static postural stability among patients with anterior cruciate ligament reconstruction

Objective: Postural stability is essential for high-level physical activities after anterior cruciate ligament reconstruction (ACLR). This study was conducted to investigate the relationship of muscle strength, joint kinesthesia, and plantar tactile sensation to dynamic and static postural stability among patients with anterior cruciate ligament reconstruction. Methods: Forty-four patients over 6 months post anterior cruciate ligament reconstruction (age: 27.9 ± 6.8 years, height: 181.7 ± 8.7 cm, weight: 80.6 ± 9.4 kg, postoperative duration: 10.3 ± 3.6 months) participated in this study. Their static and dynamic postural stability, muscle strength, hamstring/quadriceps ratio, joint kinesthesia, and plantar tactile sensation were measured. Partial correlations were used to determine the correlation of the above-mentioned variables with time to stabilization (TTS) and root mean square of the center of pressure (COP-RMS) in anterior-posterior (AP) and mediolateral (ML) directions. Results: Both TTS_AP and TTS_ML were related to muscle strength and joint kinesthesia of knee flexion and extension; COP-RMS_AP was correlated with plantar tactile sensations at great toe and arch, while COP-RMS_ML was correlated with joint kinesthesia of knee flexion, and plantar tactile sensation at great toe and heel. Dynamic stability was sequentially correlated with strength and joint kinesthesia, while static stability was sequentially correlated with plantar tactile sensation and joint kinesthesia. Conclusion: Among patients with anterior cruciate ligament reconstruction, strength is related to dynamic postural stability, joint kinesthesia is related to dynamic and static postural stability, and plantar tactile sensation is related to static postural stability. Strength has a higher level of relationship to dynamic stability than joint kinesthesia, and plantar tactile sensation has a higher level of relationship to static stability than joint kinesthesia.

Return to Sports and Activity in Tumor Orthopaedics

INTRODUCTION

As survival rates associated with the multimodal treatment of malignant bone cancer (osteosarcoma and Ewing's sarcoma) are satisfactory, health-related quality of life and the return to activity and sports by the affected patients have attracted increasing attention in recent years. Nowadays, limbs can be salvaged for most patients using modular endoprostheses. Such patients are typically adolescents and young adults who have high activity levels and thereby high demands for multimodal cancer treatment. This study aimed to evaluate the activity levels and sporting proficiencies that can be attained after modular endoprosthetic treatment of bone sarcomas as well as the extent to which physiotherapeutic and sports interventions influence functional outcome and activity levels.

METHODS

This non-systematic review of the literature focused on the return to activity and sports after modular endoprosthetic treatment of lower extremities bone sarcomas in adolescents and young adults. The electronic database PubMed was screened for relevant publications on this issue. A treatment algorithm for return to activity and sports in tumor orthopaedics is proposed.

RESULTS AND DISCUSSION

The objective activity level (gait cycles per day and gait intensities) in patients treated for bone sarcomas is reduced in short- and long-term follow-ups compared with healthy controls and patients with other cancers (leukaemia). Although a negative impact is observed in terms of motor performance, it shows improvement over time. Functional assessment at 12 postoperative months is sensible as neoadjuvant chemotherapy is completed by then. In long-term follow-up, patients with bone sarcomas can achieve high sports activity levels, i.e., type of sport, frequency/week and UCLA score, after modular endoprosthetic reconstruction. The maximum level is attained at 5 years postoperatively. Nevertheless, there is a shift from high- and intermediate- to low-impact sports. Only 20% of the patients participate in school sports regularly without limitations. The localisation of bone sarcoma, but not the rate of postoperative complications, influences the postoperative activity level. Individualised sports-related interventions during and after multimodal treatment can improve the short-term activity levels; moreover, "serious games" can improve motor performance and postural control. There is no evidence that intense activity levels leads to early loosening of the endoprosthesis. There is insufficient valid data on activity and sports after modular endoprosthetic treatment of bone sarcomas of the upper extremities.

CONCLUSION

High preoperative activity levels of young patients with bone sarcomas must be considered in tumour orthopaedics. Limitations on sports activities have a significant negative impact on the quality of life and mental health of such patients. Therefore, tumour orthopaedic treatment has to focus on preserving an improvement in these factors. The overall existing evidence concerning this issue is weak. Additional studies to evaluate the ability to return to specific sports activities are desirable, as well as prospective interventional studies.

The Level of Kinesiophobia and Its Relationship with Physical Activity in People with a History of Ankle Sprain

Introduction: Kinesiophobia is one of the leading clinical factors in recovery from injury. The stressful situation of an ankle joint injury can cause severe withdrawal and fear of the patient to undertake physical activity, resulting in hypokinesia. Aims: The aim of the study was to demonstrate the relationship between the level of daily physical activity reported by the respondent after an ankle sprain and severity of the kinesiophobia phenomenon. Material and methods: The study comprised 78 people (mean age 23.1 years ± 3.3) with a history of ankle sprain injury. This population was divided into 2 groups, taking the given level of physical activity into account. GR1 consisted of 34 patients with an activity level of 0-3 hours a week of sports activity, GR2 was made up of 44 individuals reporting a level of physical activity > 3 hours a week. In order to obtain the necessary results, the respondents filled in their own personal data sheet; and 3 standardised questionnaires translated into Polish: Foot and Ankle Ability Measure (FAAM); Fear-Avoidance Beliefs Questionnaire (FABQ); Tampa Scale of Kinesiophobia (TSK-17). Results: A high level of physical activity helps to avoid limitations in ankle and foot functioning. A relationship was found between functional limitations and the intensity of fear regarding movement according to the FABQ questionnaire. The limitations of the foot function translate into higher results for the FABQ questionnaire. No other statistically significant relationships were found. Conclusions: Kinesiophobia is a protective factor in the acute disease/injury phase. Physiologically, its level should decrease as functional abilities are regained. If the functional limitations remain high, the fear of movement also increases. Regular, high-level physical activity significantly improves the functioning of the ankle and foot, and reduces the level of kinesiophobia.

Results of a tri-national online survey on the current status of sports injury prevention among members of the German-Speaking Orthopaedic Sports Medicine Society (GOTS)

OBJECTIVES

 To assess the current opinions and state of knowledge in primary sports injury prevention among members of the German-Speaking Society for Orthopaedic and Traumatologic Sports Medicine (GOTS).

METHODS

 On 21 August 2019, a web-based questionnaire was sent to the members of the tri-national society GOTS (Austria, Germany and Switzerland). The survey was online until 21 November 2019 and included twenty-two questions, which were divided into five sections: 1) general importance of prevention (n = 4), 2) specifications of the study population (n = 3), 3) implementation of prevention (n = 8), 4) improvement opportunities in prevention (n = 4) and 5) future research areas (n = 3).

RESULTS

 A total of 272 participants completed the survey, representing a total survey participation of 17.7 % of all members. The study population consisted of orthopaedic surgeons (55 % with surgical and 21 % with non-operative orientation), medical students (10 %), physical therapists (8 %) and sports scientists (4 %). Ninety-four percent of all participants stated that they considered the importance of sports injury prevention to be "very high" (68 %) or "high" (26 %). However, almost 70 % of all participants stated that they spend less than one hour per week on injury prevention work. The term "prevention" was clearly defined and practicable for only 40 %, understandable but difficult to implement for 51 %, and unclear and difficult to implement for 9 % of the participants. Seventy-two percent of respondents were aware of existing prevention programs such as "Stop-X" or "FIFA 11 +", whereas 28 % of participants were uninformed regarding these programs.

CONCLUSIONS

 A strong divergence was identified between participants' perception of the importance of sports injury prevention and the existing implementation of preventive measures. Future funding of prevention programs, expansion of research strategies for injury prevention and better financial reimbursement are of utmost importance.

Secondary Injuries After Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review With Quantitative Analysis

BACKGROUND

In the skeletally mature anterior cruciate ligament (ACL) reconstruction population, patients aged <25 years are at significantly increased risk of graft failure and injury to the contralateral ACL. Skeletal immaturity often affects graft selection and reconstruction technique.

PURPOSE

To examine the incidence of ipsilateral graft failure and contralateral ACL injury in the skeletally immature patient population.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Using the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines, we reviewed all literature that involved ACL reconstruction performed on skeletally immature patients between May 1976 and May 2019. Patient demographics, surgical technique, and the prevalence of ipsilateral graft failure or subsequent contralateral ACL injury were recorded. Ipsilateral, contralateral, and secondary ACL injuries were then compared between sexes via chi-square tests.

RESULTS

A total of 24 articles (1254 children; 1258 knees) met inclusion criteria for analysis. Ipsilateral graft failures occurred in 105 of 1258 patients (8.3%), and there were no statistically significant sex differences in the prevalence of graft failures (female, 9.7%; male patients, 7.1%; P = .14). The prevalence of contralateral ACL injury was significantly greater in female (29/129; 22.5%) than male (18/206; 8.7%; P = .0004) patients in the 9 studies that reported contralateral injury. Skeletally immature female patients were at significantly increased risk of contralateral ACL injury (odds ratio = 3.0; P = .0006) when compared with their male counterparts.

CONCLUSION

In the literature to date, 1 in 3 female skeletally immature patients experienced an ipsilateral graft failure or contralateral ACL injury. Regardless of sex, the 24% prevalence of secondary injury after pediatric ACL reconstruction is almost identical to previously published secondary injury rates in skeletally mature patients <25 years old. As such, skeletal maturity alone does not seem to be a determinant of secondary injury; however, there is a clear need to improve postoperative rehabilitation, activity progression, and return-to-play testing to allow a safe return to sports that protects the long-term health of the reconstructed and contralateral limbs, especially for female patients.