Safer Return to Play After Anterior Cruciate Ligament Reconstruction: Evaluation of a Return-to-Play Checklist

Background:

Questions remain regarding the traditional protocols used in rehabilitation and clearance for return to sports after anterior cruciate ligament reconstruction (ACLR).

Purpose/Hypothesis:

To investigate the impact on injury rates after return to sports by developing and validating a Safer Return to Play Following ACL Reconstruction Checklist consisting of subjective and objective functional tests that can be quickly and easily implemented into a sports medicine practice. It was hypothesized that patients who successfully passed the checklist before returning to sports would experience lower rates of ipsilateral and contralateral knee injuries at a 2-year follow-up as compared with patients who returned to play before completing the checklist.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

First, a systematic review was performed to generate a list of the most common outcome measures used to assess return to play after ACLR. To refine our checklist, we conducted a survey with an expert panel of 10 medical professionals utilizing the Delphi technique. After the creation of the checklist, validation was performed by prospectively evaluating patients who had undergone ACLR for injury of the ipsilateral or contralateral knee, with a minimum 2-year follow-up.

Results:

After our systematic review of 60 studies, 7 criteria were included in the final checklist. During the period studied, October 2014 to December 2017, a total of 222 patients met the inclusion criteria and were enrolled in the study. At a minimum 2 years of follow-up, there were 146 patients who successfully passed the checklist and 38 who did not. Overall, 24 (16.4%) patients who had passed the checklist sustained an injury to either knee, as compared with 10 (26.3%) from the group that did not pass the checklist (P = .162). Of the group that passed the checklist, 8 (5.5%) patients sustained an injury to the ipsilateral knee, as compared with 7 (18.4%) in the group that did not pass (P = .017).

Conclusion:

Prospective validation of our checklist demonstrated that patients who successfully passed the checklist before returning to play experienced a significantly lower incidence of ipsilateral anterior cruciate ligament injury as compared with patients who did not pass the checklist.

Acute Opioid Withdrawal Mimicking Postoperative Joint Infection Following anterior cruciate ligament (ACL) Reconstruction: A Case Report

BACKGROUND A short course of opioid narcotics is often prescribed for postoperative anterior cruciate ligament (ACL) reconstruction pain management. Unfortunately, there is a well-documented incidence of opioid withdrawal syndrome (OWS) following short-term use of these medications. OWS can present with symptoms such as influenza-like illness. It is important to differentiate OWS from infectious illnesses, especially after surgery. CASE REPORT We present a case of OWS in a patient who underwent ACL reconstruction 7 days prior. The patient's OWS symptoms were similar to symptoms of a postoperative infection. The knee was aspirated, and the analysis of the aspirate was not concerning for an infection. The patient's symptoms spontaneously resolved on postoperative day 10. This is the first documented case of OWS mimicking ACL reconstruction joint infection. CONCLUSIONS OWS after surgery may present with symptoms similar to joint infection. It is important to consider OWS as a potential complication after surgery and differentiate it from infection to avoid any further unnecessary invasive treatments for the patient.

Osteochondral Autograft Transplantation for Proximal Lunate Articular Defects

BACKGROUND

 No consensus treatment option for focal osteochondral defects of the proximal lunate exist in the literature. Surgical management has thus far been limited to salvage procedures such as proximal row carpectomy and partial arthrodesis.

CASE DESCRIPTION

 We report our experience using the osteochondral autograft transplantation surgery (OATS) procedure in two young, active patients with focal osteochondral defects of the proximal lunate. At mean follow-up of 6 years, sustained improvements in pain, motion, and function were observed. Both patients reported high levels of satisfaction and neither experienced any complications.

LITERATURE REVIEW

 To our knowledge, this is the first report describing the use of OATS to treat proximal lunate defects.

CLINICAL RELEVANCE

 OATS is a valuable surgical option for treating focal chondral defects of the proximal lunate, with positive outcomes at greater than 5 years postoperatively. This may be an especially useful technique for younger, active patients, and those wishing to maintain maximum functionality.

The envelope of motion of the cervical spine and its influence on the maximum torque generating capability of the neck muscles

The posture of the head and neck is critical for predicting and assessing the risk of injury during high accelerations, such as those arising during motor accidents or in collision sports. Current knowledge suggests that the head's range-of-motion (ROM) and the torque-generating capability of neck muscles are both dependent and affected by head posture. A deeper understanding of the relationship between head posture, ROM and maximum torque-generating capability of neck muscles may help assess the risk of injury and develop means to reduce such risks. The aim of this study was to use a previously-validated device, known as Neck Flexibility Tester, to quantify the effects of head's posture on the available ROM and torque-generating capability of neck muscles. Ten young asymptomatic volunteers were enrolled in the study. The tri-axial orientation of the subjects' head was controlled via the Neck Flexibility Tester device. The head ROM was measured for each flexed, extended, axially rotated, and laterally bent head's orientation and compared to that in unconstrained neutral posture. Similarly, the torque applied about the three anatomical axes during Isometric Maximum Voluntary Contraction (IMVC) of the neck muscles was measured in six head's postures and compared to that in fully-constrained neutral posture. The further from neutral the neck posture was the larger the decrease in ROM and IMVC. Head extension and combined two-plane rotations postures, such as extension with lateral bending, produced the largest decreases in ROM and IMVC, thus suggesting that these postures pose the highest potential risk for injury.

Results of ACL reconstruction with tibial Retroscrew fixation: Comparison of clinical outcomes and tibial tunnel widening

ACL reconstruction with the RetroScrew™ shows superior clinical outcomes compared to historical Achilles allograft studies with antegrade screws. Addition of antegrade screw augmentation to retrograde fixation causes an increase in tibial tunnel widening.

INTRODUCTION

In traditional antegrade screw fixation of Anterior cruciate ligament (ACL) soft tissue allografts, the screw is secured in the opposite direction of graft tension, potentially altering the appropriate tension on the graft. The RetroScrew (Arthrex) is a bioabsorbable screw placed in a retrograde fashion, potentially improving the tension of the graft by placing the screw in a proximal-to-distal direction. In addition, the RetroScrew theoretically decreases tibial tunnel widening by closing the aperture of the tibial tunnel, which prevents ingress of synovial fluid. Early tunnel expansion has been implicated due to excessive transverse and longitudinal graft motion. The clinical effects of tunnel expansion have yet to be fully understood. The purpose of this study is to assess the clinical results and tunnel width after ACL soft tissue fixation in the tibia with the RetroScrew.

METHODS

Fifty-nine patients who underwent ACL reconstruction performed by two surgeons using the RetroScrew device returned for postoperative evaluation at an average of 25 months following surgery with a minimum follow-up of 12 months. Clinical evaluation, SF-36, IKDC and KT-1000 scores were recorded, and knee radiographs were used to measure tibial tunnel widening. Thirty-five patients had backup antegrade screw fixation in conjunction with the RetroScrew, and 24 patients had RetroScrew fixation alone. The results were compared to two previously reported studies on ACL reconstruction with Achilles tendon allograft that used antegrade screws.

RESULTS

The average IKDC score was 87 (range: 44-100), with mean KT-1000 side-to-side difference of 1.2 mm (range: 0-5 mm). Tibial tunnel widening was 4.93 mm (SD 3.32) on AP radiographs and 4.40 mm (SD 2.72) on lateral radiographs greater than the native tunnel drilling. Patients with additional backup fixation had significantly more tunnel widening than patients without backup fixation (P < 0.05). There was one failure based on KT-1000 measurements. When compared to previous studies using ACL allografts, RetroScrew patients had statistically superior Lachman exams, KT-1000 side-to-side differences and decreased tibial tunnel widening (P < 0.05) when antegrade fixation was excluded.

CONCLUSION

Patients who underwent Achilles allograft ACL reconstruction with the RetroScrew had improved clinical results compared to historical controls using antegrade fixation. Tibial tunnel widening was increased when using additional antegrade screw fixation, suggesting that the amount of bioabsorbable material within the tibial tunnel was related to the degree of tunnel widening.

Short-/intermediate-term outcomes after medial patellofemoral ligament reconstruction in the treatment of chronic lateral patellofemoral instability

PURPOSE

Disruption of the medial patellofemoral ligament (MPFL) is now considered the essential lesion of recurrent lateral patellar dislocation in patients with normal lower extremity alignment. Reconstruction of the MPFL is a technique gaining significant success in the treatment of patients with this disabling condition.

HYPOTHESIS

Reconstruction of the MPFL in patients with chronic patellar instability and normal lower extremity alignment will improve knee function and symptoms, with a high percentage of patients achieving good to excellent results at early follow-up.

STUDY DESIGN

Case series; Level of evidence; 4.

METHODS

A consecutive series of patients with lateral patellofemoral instability who underwent MPFL reconstruction were reviewed. Reconstruction was performed with either soft tissue allograft (23 patients) or hamstring tendon autograft (12 patients). Outcomes were determined by patient scores from the Kujala Anterior Knee Pain Scale, recurrence of patellar instability, and patient function at a minimum of 12 months of postoperative follow-up.

RESULTS

Thirty-five patients were followed for a mean of 21.0 months (range, 12-45 months) after surgery. The Kujala subjective knee score improved significantly from 49.0 preoperatively to 89.5 postoperatively (P < 0.001). No statistical significance was found between postoperative Kujala scores and graft type, or time from initial injury to surgical reconstruction. A firm endpoint to lateral translation of the patella, and no feelings of apprehension were noted in all patients at most recent follow-up. The majority of patients noted that they were more active than before reconstructive surgery, with 86% participating in "strenuous" to "very strenuous" activities at the time of follow-up. No recurrent dislocations were reported.

CONCLUSION

Reconstruction of the MPFL provides excellent stability and functional outcomes for patients with recurrent patellar instability.

Cervical spine injuries in American football

American football is a high-energy contact sport that places players at risk for cervical spine injuries with potential neurological deficits. Advances in tackling and blocking techniques, rules of the game and medical care of the athlete have been made throughout the past few decades to minimize the risk of cervical injury and improve the management of injuries that do occur. Nonetheless, cervical spine injuries remain a serious concern in the game of American football. Injuries have a wide spectrum of severity. The relatively common 'stinger' is a neuropraxia of a cervical nerve root(s) or brachial plexus and represents a reversible peripheral nerve injury. Less common and more serious an injury, cervical cord neuropraxia is the clinical manifestation of neuropraxia of the cervical spinal cord due to hyperextension, hyperflexion or axial loading. Recent data on American football suggest that approximately 0.2 per 100,000 participants at the high school level and 2 per 100,000 participants at the collegiate level are diagnosed with cervical cord neuropraxia. Characterized by temporary pain, paraesthesias and/or motor weakness in more than one extremity, there is a rapid and complete resolution of symptoms and a normal physical examination within 10 minutes to 48 hours after the initial injury. Stenosis of the spinal canal, whether congenital or acquired, is thought to predispose the athlete to cervical cord neuropraxia. Although quite rare, catastrophic neurological injury is a devastating entity referring to permanent neurological injury or death. The mechanism is most often a forced hyperflexion injury, as occurs when 'spear tackling'. The mean incidence of catastrophic neurological injury over the past 30 years has been approximately 0.5 per 100,000 participants at high school level and 1.5 per 100,000 at the collegiate level. This incidence has decreased significantly when compared with the incidence in the early 1970s. This decrease in the incidence of catastrophic injury is felt to be the result of changes in the rules in the mid-1970s that prohibited the use of the head as the initial contact point when blocking and tackling. Evaluation of patients with suspected cervical spine injury includes a complete neurological examination while on the field or the sidelines. Immobilization on a hard board may also be necessary. The decision to obtain radiographs can be made on the basis of the history and physical examination. Treatment depends on severity of diagnosed injury and can range from an individualized cervical spine rehabilitation programme for a 'stinger' to cervical spine decompression and fusion for more serious bony or ligamentous injury. Still under constant debate is the decision to return to play for the athlete.

Hyperbaric oxygen therapy for acute ankle sprains

We conducted a randomized double-blind study of 32 subject with acute ankle sprains to compare treatment with hyperbaric oxygen at 2 atmospheres absolute pressure (N = 16) (treatment group) with treatment with air at 1.1 atmosphere absolute pressure (N = 16) (control group) in a hyperbaric chamber. Each group received three treatments at their respective pressures: one for 90 minutes and two for 60 minutes each. Mean age, severity grade, and time to treatment (treatment group, 34.3 +/- 6.3 hours; control group, 32.6 +/- 4.6 hours) were similar in both groups. Joint function measured by a functional index improved from 0.40 +/- 0.2 to 6.3 +/- 0.4 with hyperbaric oxygen and from 0.8 +/- 0.3 to 5.3 +/- 0.6 with air. The change from initial to final evaluation was significantly greater in the treatment group. Foot and ankle volume by water displacement decreased from 1451 +/- 57 ml to 1425 +/- 63 ml with hyperbaric oxygen and from 1403 +/- 50 ml of 1371 +/- 45 ml with air (no difference was noted between hyperbaric oxygen treatment and air treatment using a two-day analysis of variance). Subjective pain index fell from 3.3 +/- 0.5 to 0.8 +/- 0.3 with hyperbaric oxygen and from 2.6 +/- 0.3 to 0.3 +/- 0.2 with air. No differences were noted in passive or active range of motion when comparing hyperbaric oxygen treatment with air treatment. Time to recovery was the same in both groups (treatment, 16.0 +/- 6.3 days; control, 15.4 +/- 2.8 days). Regression analysis to determine the influence of time to treatment, initial severity of injury, hyperbaric oxygen, and age showed no effect of hyperbaric oxygen treatment on time to recovery.

Analgesic effect of intraarticular morphine, bupivacaine, and morphine/bupivacaine after arthroscopic knee surgery

In a double-blind randomized fashion, 38 patients were divided into four groups according to the intraarticular injection received after arthroscopic surgery. Patients in group I (n = 7) received saline, group II (n = 10) morphine, group III bupivacaine, and group IV (n = 11) morphine and bupivacaine. Before surgery and at 0.5, 1, 1.5, 2, 6, and 24 h postoperatively, pain levels were recorded. In addition, postoperative supplemental i.v. morphine requested by the patient was tabulated. Results showed that the mean consumption of supplemental analgesia was lowest in the morphine/bupivacaine group. Although there was a statistically significant difference in pain scores between the saline group and the other three groups during the early postoperative period, there was no significant difference in pain scores between the morphine, bupivacaine, and morphine/bupivacaine groups. We conclude that postoperative, intraarticular injection of analgesics is beneficial in reducing pain levels. The combination of morphine/bupivacaine appears to be the most beneficial analgesic due to its low supplemental analgesic requirements postoperatively.

Acute compartment syndrome of the lower extremity secondary to noncontact injury

We retrospectively reviewed the cases of three patients with injuries similar to the mechanism of an ankle sprain which resulted in compartment syndrome of the lower extremity. All three patients presented with sharp, proximal, anterolateral pain in the leg after an indirect, twisting injury. None of the injuries involved direct contact. Two of the three athletes initially presented to local hospitals, where the injury was misdiagnosed as an ankle sprain. The mechanism appears to be a muscle strain or tear with resultant hemorrhage in the compartment. All three patients returned to high-level athletics after prolonged recovery periods.

Injuries of the posterior cruciate ligament

A review of the anatomy and biomechanics of the posterior cruciate ligament, and the systematic approach for the diagnosis and treatment of isolated posterior cruciate ligament injuries and posterior cruciate ligament insufficiency in combination with other ligamentous instabilities is discussed.