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

Is 9 months the sweet spot for male athletes to return to sport after anterior cruciate ligament reconstruction?

OBJECTIVE

Most studies examining the time to return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR) do not account for the athlete's physical readiness. This study aimed to investigate the status of male athletes at 2 years after ACLR, the factors affecting a return to pivoting sports, and the association between time to RTS and subsequent knee injury risk for those athletes who met discharge criteria.

METHODS

We prospectively followed 530 male athletes (mean age 26.7±7.7 years) participating in pivoting sports throughout rehabilitation and at 2 years after ACLR. Pair-wise analyses were conducted to compare athletes who returned to pivoting sports and those who did not. We performed a Cox regression analysis to assess the association between subsequent non-contact or indirect contact knee injuries and time to RTS. Pearson's χ2 test was used to compare athletes who RTS in ≤9 months to those who RTS in >9 months after ACLR.

RESULTS

In total, 379 (72%) athletes returned to pivoting sports at 2 years after ACLR. Athletes who completed rehabilitation and met discharge criteria (n=190) were almost 6 times more likely to return to their preinjury sport (OR 5.71; 95% CI 3.39 to 9.62). Of those who did not complete their rehabilitation (n=340), 132 (39%) did not return to pivoting sports. For athletes who met discharge criteria, time to RTS was not associated with the risk of new knee or ACL injury. There was no increased risk for new knee (HR 0.892, 95% CI 0.39 to 2.07, p=0.79) or ACL (HR 0.718, 95% CI 0.24 to 2.17, p=0.56) injury whether athletes returned before or after the 9-month mark following ACLR.

CONCLUSIONS

Completing rehabilitation and meeting objective criteria significantly increased the odds for male athletes to return to pivoting sports. Time to RTS did not impact the risk for a new knee or ACL injury if athletes met objective criteria.

Questioning the rules of engagement: a critical analysis of the use of limb symmetry index for safe return to sport after anterior cruciate ligament reconstruction

OBJECTIVE

To evaluate the association between limb symmetry index (LSI) in quadriceps and hamstrings strength together with hop tests, as a proxy of recovery, and the deviation from being symmetrical (LSI 100%), with a safe return to sport (RTS) after anterior cruciate ligament reconstruction (ACL-R).

METHODS

Athletes between 15 and 30 years old with a preinjury Tegner activity level ≥6 were eligible for inclusion. Data were extracted from a rehabilitation-specific registry, Project ACL (Gothenburg, Sweden) at the time of or after RTS for each athlete. The outcome of interest in this study was a safe RTS-not suffering a second ACL injury within 2 years from RTS-addressed by using the LSI in five different ways with results from the test battery which include five tests of muscle function at or after the time of RTS. Logistic regression analyses were performed with safe RTS as a dependent variable and presented with ORs and 95% CIs.

RESULTS

In total, 233 athletes (51.1% women) were included. The best-differentiating cut-offs for strength and hop tests showed non-significantly poor discriminatory ability between athletes who had a safe RTS and those who did not (Youden J 0.09-0.24 and area under the curve 0.50-0.59). Athletes who had ≥80% or ≥85% LSI had significantly lower odds of safe RTS compared with athletes who did not meet the cut-offs of safe RTS (OR=0.32 (95% CI 0.12 to 0.87) and OR=0.39 (95% CI 0.18 to 0.84), respectively). There was no effect of a 1% increase in LSI or deviation from 100% symmetry on safe RTS.

CONCLUSION

The use of LSI from tests of muscle function to determine safe RTS after ACL-R, that is, RTS without sustaining a second ACL injury within 2 years, cannot differentiate between athletes who had a safe RTS and those who did not, regardless of whether LSI was used as cut-offs, incremental or as deviation from symmetry. Thus, it is of clinical importance that clinicians do not solely rely on the LSI to clear athletes for RTS.

Rehabilitation and assessment practices following anterior cruciate ligament injury: A survey of Australian physiotherapists

OBJECTIVE

This study aimed to investigate the current beliefs and practices among Australian physiotherapists regarding the management of anterior cruciate ligament (ACL) injuries.

DESIGN

Cross-sectional survey.

SETTING

Online survey.

PARTICIPANTS

Australian physiotherapists.

OUTCOME MEASURES

The survey assessed beliefs and practices regarding non-operative management, ACL reconstruction, pre- and post-operative rehabilitation, and return to sport (RTS) criteria. Frequencies and percentages summarized survey responses, and chi-square or Fisher's exact tests assessed whether beliefs and practices were influenced by experience (≤6 years or >6 years) and annual caseload (<6 or ≥6 patients).

RESULTS

In total, 419 physiotherapists were included, with 367 completing the survey in its entirety. Most physiotherapists (86.8%) consider non-surgical management alternatives for patients. Two-thirds (59.8%) recommend a minimum of 9-12 months before RTS, emphasizing recovery of knee strength (93.9%) and psychological readiness (93.9%). Of those who assessed strength, 32.5% use manual muscle testing, and 37.4% assess strength from hop testing. The 63.5% of respondents who reported barriers to implementing best practice ACL management, cited lack of resources (69.1%) and patient non-compliance (67.8%) as the most common reasons.

CONCLUSION

This survey of Australian physiotherapists showed alignment with evidence-based ACL guidelines but highlighted differences from international practices and variations by experience and caseload.

Superolateral capsule pathway: a new arthroscopic viewing approach for spotting femoral fixation device in anterior cruciate ligament reconstruction

BACKGROUND

This study aimed to describe the arthroscopic superlateral capsule pathway technique for spotting femoral fixation device deployment, and to compare the results with normal procedure.

METHODS

A total of 69 patients underwent ACLR (Anterior Cruciate Ligament Reconstruction) with or without the SCP (superolateral capsule pathway) during procedure were retrospectively selected and evaluated. A total of 36 patients underwent SCP and 33 patients underwent ACLR without SCP. Mean follow-up was 6 months after surgery. All patient noted joint fluid, underwent VAS and Lysholm score at follow-up, and statistical analysis was performed.

RESULTS

No statistically significant differences were found in patient demographics, ACLR duration time (p = 0.076) and Lysholm score (p = 0.296). Significantly less postoperation pain was reported in the SCP group (p = 0.000), and fluid volume in SCP group was significantly lower (p = 0.001). The postoperative complications were rare in both group.

CONCLUSIONS

The superolateral capsule pathway approach is a minimally invasive and safe technique that can be used to accurately locate and implant suture button-based femoral fixation devices in anterior cruciate ligament reconstruction.

Injury prevention in Brazilian women's football: Perceptions of physiotherapists and practices within elite clubs

OBJECTIVES

To describe the perceptions of physiotherapists and the injury prevention practices implemented within elite women's football clubs in Brazil.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PARTICIPANTS

Head physiotherapists from 32 Brazilian elite clubs.

MAIN OUTCOME MEASURES

Structured questionnaire.

RESULTS

Physiotherapists identified ACL rupture as the primary target for prevention. The top-five perceived injury risk factors included 'early return to sport after injury', 'workload too high', 'previous injury', 'poor sleep/rest', and 'muscle strength/power deficit'. 'Adoption of return to sport criteria' was almost unanimously recognized as a very important preventive strategy. 'Poor infrastructure' was elected as the main barrier to implementing prevention programs. From a practical standpoint, at least two-third of clubs implemented multi-component exercise interventions for injury prevention. These interventions typically encompassed flexibility/mobility, balance/proprioception, lumbo-pelvic stability, and agility exercises, alongside exposure to sprinting. Strength training routines typically included traditional, functional, and eccentric exercises. Most teams also employed other prevention strategies, including adoption of return to sport criteria, internal workload monitoring, post-exercise recovery modalities, preseason risk factor screening, and application of rigid strapping tapes.

CONCLUSIONS

This study provided unprecedented insights into the physiotherapists' perceptions and injury prevention practices implemented within elite women's football clubs.

A new neural network model that detects graft ruptures and contralateral anterior cruciate ligament injuries

PURPOSE

The purpose of this study was to develop a neural network model for predicting second anterior cruciate ligament (ACL) injury risk following ACL reconstruction using patient features from medical records.

METHODS

Of 486 consecutive patients who underwent primary unilateral ACL reconstruction, 386 patients (198 women, 188 men) with a mean age of 25.1 ± 11.6 years were included in this study. Fifty-eight features, including demographic data, surgical, preoperative and postoperative data, were retrospectively collected from medical records, and features with an incidence of less than 5% were excluded. Finally, 14 features were used for the analysis. The multilayer perceptron was composed of four hidden layers with a rectified linear unit as activation and was trained to maximise the area under the receiver-operating characteristic curve (auROC). Subsequently, validation was carried out through a rigorous threefold cross-validation process. To ascertain the most efficacious combination of features with the highest auROC, a single feature with the least impact on auROC maximisation was systematically eliminated from the comprehensive variable set, ultimately resulting in the retention of a mere two variables.

RESULTS

The median follow-up period was 50.5 (24-142) months. Fifty-seven knees had a second ACL injury, with a graft rupture rate of 7.7% and a contralateral injury rate of 6.9%. The maximum auROC for predicting graft rupture was 0.81 with two features: young age and hamstring graft. Meanwhile, the maximum auROC for predicting contralateral ACL injury was 0.74 with seven features, including young age, presence of medial meniscus tear, small body mass index, hamstring graft, female sex and medial meniscus repair or treatment.

CONCLUSION

A neural network model with patient features from medical records detected graft ruptures and contralateral ACL injuries with acceptable accuracy. This model can serve as a new, useful tool in clinical practice to inform decisions about ACL reconstruction and retuning to sports postoperatively.

LEVEL OF EVIDENCE

Level IV.