After Anterior Cruciate Ligament Reconstruction Surgery Research Articles

Choice of Patient-Reported Outcome Measures for Midterm Assessment After Anterior Cruciate Ligament Reconstruction Surgery

Background: Patient-reported outcome measures (PROMs) have become increasingly popular for assessing subjective elements of a patient's condition. Two frequently used knee-related PROMs after anterior cruciate ligament reconstruction (ACLR) surgery are the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and the Knee injury and Osteoarthritis Outcome Score (KOOS). However, completing the full versions of both measures represents a considerable responder burden. Purpose: To compare a variety of KOOS short forms with each other as well as the IKDC-SKF in a large sample of ACLR patients between 2 and 6 years after surgery. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: The KOOS and IKDC-SKF were administered between 2 and 6 years (mean, 3 years) after ACLR surgery to a cohort of 832 patients (men, n = 489; women, n = 343). Two single-item assessment numerical evaluations were also completed for knee function and satisfaction. The following short form versions were calculated from the full KOOS: the KOOS-12 short form, KOOS–Physical Function Short form (KOOS-PS), KOOS–Joint Replacement Short form (KOOS-JR), and KOOS–Global. Descriptive statistics were calculated for all PROMs and associations between measures were explored using nonparametric (Spearman rho) correlations. Floor or ceiling effects were considered present if >15% of patients reported the worst (floor effect) or best (ceiling effect) possible score. Age and sex comparisons were also made for each PROM. Results: Ceiling effects were present for all KOOS short form versions. They were highly evident for the KOOS-JR and KOOS-PS (37%-44%), but they were only marginally above the threshold for the KOOS-12 and KOOS–Global (16%). The KOOS-12 and KOOS–Global had the highest correlation with the IKDC-SKF but only explained 58% to 59% of the variance in scores. The KOOS-12 and KOOS–Global were very highly correlated (ρ = 0.98). Only moderate correlations were seen between the single-item assessments and the IKDC-SKF or various KOOS short forms. There was a negligible association between patient age and PROM scores, but there was no significant sex difference for any of the PROMs. Conclusion: The IKDC-SKF together with either the KOOS–Global or KOOS-12 may provide a comprehensive range of knee-related PROMs with minimized responder burden at 2 to 6 years after ACLR.

Establishing Clinically Significant Outcomes After Anterior Cruciate Ligament Reconstruction in Pediatric Patients.

The purpose of this study was to establish clinically significant outcome values for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after anterior cruciate ligament reconstruction (ACLR) in the pediatric and adolescent populations and to assess factors that were associated with achieving these outcomes. Patients between the age of 10 to 21 who underwent ACLR between 2016 and 2018 were identified and patient-reported outcomes (PROs) were collected preoperatively and postoperatively. Intraoperative variables collected included graft choice, graft size (diameter), graft fixation method, and concomitant procedures. PROs collected for analysis were the International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). MCID and PASS were calculated using receiver operating characteristic with area under the curve analyses for delta (ie, baseline-to-postoperative change) and absolute postoperative PRO scores, respectively. A total of 59 patients were included in the analysis. Of the entire study population, 53 (89.8%) reported satisfaction with their surgical outcome. The established MCID threshold values based on the study population were 33.3 for IKDC, 28.6 for (KOOS) Symptoms, 19.4 for Pain, 2.9 for activities of daily living (ADL), 45.0 for Sport, and 25.0 for Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 80.5 for IKDC, 75.0 (KOOS) Symptoms, 88.9 for Pain, 98.5 for ADL, 75.0 for Sport, and 68.8 for QoL. Clinically meaningful outcomes including MCID and PASS were established for pediatric ACLR surgery using selected PRO measures, IKDC, and KOOS. Patient age, sex, graft type, and graft size were not associated with greater achievement of these outcomes. In contrast, collision sports, fixed-object high-impact rotational landing sports, and concomitant meniscectomy surgery were associated with a decreased likelihood of achieving clinically significant improvement. However, findings must be interpreted with caution due to limitations in follow-up and sample size. Level IV: case series.

Periarticular Local Infiltrative Anesthesia and Regional Adductor Canal Block Provide Equivalent Pain Relief After Anterior Cruciate Ligament Reconstruction

To compare postoperative pain and recovery after anterior cruciate ligament reconstruction (ACLR) in patients who received an adductor canal block (ACB) or periarticular local infiltrative anesthesia (LIA). A retrospective review of a prospectively collected ACL registry was performed. Patients underwent ACLR at a single institution between January 2015 and September 2020 and received long-acting local anesthesia with a preoperative ultrasound-guided ACB or periarticular LIA after surgery. Visual analog scale (VAS) pain scores, milligram morphine equivalents (MME) consumed in the post-anesthesia care unit (PACU), and total hospital recovery time were compared. Univariate analysis was used to compare VAS pain and MME totals between overall groups and groups propensity score matched for age, sex, body mass index, graft type, and meniscal treatment. Results are presented as mean (95%CI) unless otherwise indicated. There were 265 knees (253 patients) included (LIA, 157 knees; ACB, 108 knees). Overall, VAS pain scores before hospital discharge (LIA: 2.6 [2.4-2.8] vs ACB: 2.4 [2.1-2.7]; P= .334) and total MMEs were similar (LIA: 17.6 [16.4-18.8] vs ACB: 18.5 [17.2-19.8] (MME); P=.134). Median time to discharge also did not significantly differ (LIA: 137.5 [IQR: 116-178] vs. ACB: 147 [IQR: 123-183] (min); P= .118). Matched subanalysis (LIA and ACB; n= 94) did not reveal significant differences in VAS pain before discharge (LIA: 2.4 [2.1-2.7] vs ACB: 2.7 [2.4-3.0]; P= .134) or total MMEs (LIA: 18.6 (17.2-20.0) vs ACB: 17.9 (16.4-19.4); P= .520). The use of ACB or LIA resulted in similar early pain levels, opioid consumption, and hospital recovery times after ACLR surgery. III, retrospective comparison study.

Cyclops lesion – The entity causing loss of knee extension after ACL reconstruction surgery: A case report

Cyclops is a fibrous nodule on the tibial side of the knee and it is one of the common complications that arises after anterior cruciate ligament (ACL) reconstruction surgery that causes loss of knee extension. In this literature, we have discussed about a young gentleman who presented with unresolved swelling and inability to extend knee joint fully 1 year after ACL reconstruction surgery. Cyclops lesion was identified by clinical examination and magnetic resonance imaging (MRI). An arthroscopic excision of the cyclops lesion was successfully done on this patient which resulted in a resolution of swelling and progressive improvement of knee extension.

The Impact of Meniscal Treatment on Functional Outcomes Six Months After Anterior Cruciate Ligament Reconstruction (107)

Objectives:The incidence of anterior cruciate ligament (ACL) injuries continues to rise, and meniscal injuries are commonly associated with these tears. Treatment of meniscal injuries can impart delayed weightbearing range-of-motion restrictions, which can affect the post-operative rehabilitation protocol. These limitations after a meniscal repair could change how patients are managed and progressed through rehab. The effect of the meniscal treatment and subsequent restrictions on strength recovery after ACL reconstruction (ACLR) is unclear and may affect return-to-play assessments. The purpose of this study was to compare strength, jumping performance and patient reported outcomes between isolated ACLR patients and those undergoing surgical intervention for meniscal pathology at the time of ACLR surgery at a scheduled functional testing assessment an average of 6 months after surgery. Our hypothesis is that those undergoing meniscal repair will have lower strength recovery due to post-operative restrictions.Methods:In this retrospective cohort study, ACLR patients and healthy controls completed patient-reported outcomes (IKDC and KOOS), underwent bilateral isokinetic and isometric strength tests of the knee extensor and flexor groups, as well as functional hop testing as part of a return-to-sport test battery at 5-7 months post-operatively. ACLR patients were stratified as isolated ACLR, ACLR+Meniscectomy (ACLR-MS), ACLR+Meniscal Repair (ACLR-MR) and compared to healthy controls. Patients treated with meniscus repair were restricted to partial weight bearing and to 90 degrees of knee flexion for the first 6 weeks post-surgery. Comparisons were performed between meniscal treatment groups with regard to demographics, patient reported outcomes scales, knee extensor and flexor strength, while stratifying by graft type.Results:305 participants, including 165 ACLR patients (50 isolated ACLR, 71 ACLR + Meniscal Repair, 44 ACLR + Meniscectomy) and 140 healthy controls were included with an average time post-operatively to functional testing of 5.96±0.47 months. Heathy controls demonstrated higher subjective knee function, unilateral peak extensor torque, and limb symmetry than all meniscal subgroups (p<.001). There were no differences between the IKDC, KOOS subscales, or in unilateral or limb symmetry measures of peak knee extensor or flexor torque between ACLR, ACLR+MS, and ACLR+MR patients (all p-values>.05).Conclusions:Persistent weakness, asymmetry and reduced subjective outcome scores measured at approximately 6 months post index surgery were not influenced by meniscus treatment. Knee flexor and extensor strength, limb symmetry, and patient reported outcomes did not significantly differ across patients undergoing isolated ACLR, ACL + Meniscus Repair, and ACL + meniscectomy. These findings suggest that the weightbearing and range-of-motion restrictions associated with meniscus repair recovery do not result in loss of early strength or patient reported outcomes, and they can be progressed through therapy accordingly.

Relationship Between Timing of Anterior Cruciate Ligament Reconstruction and Chondral Injuries: A Systematic Review and Meta-analysis

Background: After anterior cruciate ligament (ACL) injury, the optimal timing of ACL reconstruction and the influence of this timing on chondral damage remain unclear. Purpose: To assess the effect of timing of ACL reconstruction on the presence of chondral injuries via a systematic review and meta-analysis. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: Two reviewers independently performed systematic literature searches of 5 online databases using the Cochrane methodology for systematic reviews. Eligibility criteria were any comparative study of patients aged >16 years that assessed the relationship between timing of primary ACL reconstruction surgery and rates of chondral injuries. Meta-analysis was conducted using a random-effects model. Results: After screening, 14 studies (n = 3559 patients) out of 2363 titles met the inclusion criteria: 3 randomized controlled trials (n = 272), 3 prospective cohort studies (n = 398), and 8 retrospective cohort studies (n = 2889). In analysis of the studies, chondral injury rates were compared between ACL reconstructions performed before and after 3 time points: 3, 6, and 12 months after injury (eg, ≤3 vs >3 months). The rates of chondral injury increased with each time point. The increase was mostly due to low-grade injuries at 3 months (estimated odds ratio, 1.914; 95% CI, 1.242-2.949; P = .003), with the increase in high-grade injuries becoming predominant after 12 months (estimated odds ratio, 3.057; 95% CI, 1.460-6.40; P = .003). Conclusion: Our findings suggest that delaying ACL reconstruction surgery results in a higher rate of chondral injuries and the severity of these lesions worsens with time. These findings are comparable with those of our previously published study, which demonstrated a higher risk of meniscal tears associated with delayed ACL surgery. When ACL reconstruction is indicated, surgery ≤3 months after injury is associated with a lower risk of intra-articular damage. Registration: CRD42016032846 (PROSPERO).

The effect of meniscal pathology and management with ACL reconstruction on patient-reported outcomes, strength, and jump performance ten months post-surgery

BackgroundThe purpose of this study was to examine the differences in patient-reported outcome measures, isokinetic strength, plyometric ability and ability to meet return to play criteria ten months after anterior cruciate ligament (ACL) reconstruction surgery between those who underwent meniscectomy, those who underwent meniscal repair and those with no meniscal intervention alongside ACL reconstruction surgery. MethodsThree hundred and thirteen athletes with clinically and radiologically confirmed ACL ruptures were included in this study. Participants were grouped according to their intra-operative procedures (isolated ACL reconstruction surgery n = 155, ACL reconstruction surgery with meniscectomy n = 128, ACL reconstruction surgery with meniscal repair n = 30). Participants completed patient-reported outcome measures questionnaires (Marx Activity Rating Scale, the ACL Return to Sport after Injury and the International Knee Documentation Committee Score) and completed a battery of objective functional testing including isokinetic dynamometry and jump performance testing (countermovement jump and drop jump) between 9 and 11 months after surgery. ResultsNo significant between-group differences were identified in any metric relating to patient-reported outcome measures (p = .611), strength and jump measures (p = .411) or the ability to achieve symmetry-based return to play criteria (p = .575). ConclusionsClinically, these results suggest that concomitant meniscal surgery has no significant effects on patient-reported outcome measures, strength and jump metrics at the return to play stage post-operatively and can inform the pre-operative counselling of those awaiting ACL reconstruction surgery with likely meniscal intervention.

Persistent quadriceps activation failure reduces in ACL reconstructed patients submitted to strength training based on force steadiness and visual feedback

Background:Quadriceps activation failure after anterior cruciate ligament reconstruction (ACLr) is related to the inhibition of alpha-motor units and results in muscle weakness. The quadriceps activation failure limits the rehabilitation outcomes, especially strength gains that are essential to the return to sport and to minimize the risk for the onset of knee osteoarthritis. Exercises involving force steadiness could reduce the variability of motor unit discharge rate and contribute to the force enhancement. On the other hand, force steadiness during isometric contractions involves controlling the fluctuations in the force signals, which might be enhanced by visual feedback. Therefore, the combination of force steadiness and visual feedback could have potential benefits for patients with persistent quadriceps activation failure.Objectives:To determine the effect of strength training with force steadiness and visual feedback on knee extension torque, knee stability, and knee pain in patients with persistent quadriceps activation failure after ACLr.Methods:Twenty-five patients (43.7±12.2 years-old, 69.8±10.8 kg, and 1.69±0.09 m, 10 men) with persistent quadriceps activation failure after ACLr non-responders to a conventional rehabilitation protocol were included in this case series. All protocols were approved by the local institutional ethics board. Persistent quadriceps activation failure was diagnosed based on the clinical history, temporal diphase with physical therapy protocol, non-gain of quadriceps strength after around 20 sessions of physiotherapy in the 9th month of rehabilitation, quadriceps weakness in the clinical examination, and abnormal isokinetic assessment (peak extensor torque<100 Nm, asymmetry in peak extensor torque>50%, or asymmetry in peak torque>70 Nm). All patients were submitted to an ACLr surgery performed by the same surgeon with semitendinosus-gracilis autograft. The intervention considered three sessions/week and lasted until 20 sessions or auto-perception of functional knee stability. The intervention and torque measurements were performed with an isokinetic device. A warmed up for 10 minutes on a cycle ergometer without load (60 rpm) was performed. After, they performed knee extension following a trapezoid curve feedback. Due to strength unbalances between ACLr and non-ACLr limbs, we used five series of 8 and 5 repetitions, respectively. The training was performed at a workload between 60% and 70%. Knee extension peak torque was determined at baseline and after training protocol. Proportions of responders and non-responders were extracted considering a threshold of 25.02 Nm. Knee pain (any painful feeling at the knee developed between the last and new session) and stability (same knee stiff sensation when they had not suffered the ACL injury) were also assessed as a binary proportion. A mixed ANOVA with 2 factors [time (before and after intervention), and limb (ACLr and non-ACLr limb)] was performed to compare the knee extension peak torque. To compare the proportion of intervention responders, knee stability, and pain before and after intervention the 2-tailed McNemar test was performed.Results:Training improved knee extension peak torque in the ACLr limb (98.2±47.2 to 155.2±78.9, Δ=57.0 Nm, p=0.031) and the non-ACLr (169.6±86.9 to 209.5±101.8, Δ=39.9 Nm, p=0.178). At baseline, lower torque was found in the ACLr limb (169.6±86.9 vs. 98.2±47.2, Δ=71.4, p=0.003) and remain different after training protocol (209.5±101.8 vs. 155.2±78.9, Δ= 54.3, p=0.026). Most of the patients (84%) increased knee extension peak torque (p<0.001), 72% increased self-reported knee stability (p<0.001), and 52% decreased knee pain (p<0.001).Conclusion:Strength training with force steadiness and visual feedback was an effective intervention to improve knee extensor torque in ACLr patients with persistent quadriceps activation failure identified 9 months after an auto-graph ACL surgery. We found that 21 out of 25 patients were able to respond positively to the intervention. The intervention also improved the self-report of stability and pain. Although the difference in torque between limbs suggests that the asymmetries persisted after the intervention. This intervention might be the first rehabilitation stage in persistent quadriceps activation failure. The next rehabilitation stage to normalize the inter-limb strength needs to be explored.

Tranexamic Acid in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background: Hemarthrosis after anterior cruciate ligament (ACL) reconstruction procedures can delay rehabilitation and have toxic effects on the cartilage and synovium. Tranexamic acid is widely used in adult reconstruction procedures; however, its use in ACL reconstruction is a novel topic of study. Purpose: To analyze the available literature on hemarthrosis, pain, functional outcomes, and complications after administration of tranexamic acid in ACL reconstruction procedures. Study Design: Meta-analysis. Methods: A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of ACL reconstruction procedures. The studied outcomes included postoperative joint drain output, hemarthrosis grade, visual analog scale scores for pain, range of motion, Lysholm score, postoperative rates of deep venous thrombosis, and pulmonary embolism. Outcomes were pooled to perform a meta-analysis. Results: Five prospective randomized controlled trials met inclusion criteria for analysis. Four studies administered intravenous tranexamic acid in bolus or infusion form before ACL reconstruction, while 2 studies administered tranexamic acid via intra-articular injection. Specifically, tranexamic acid was administered intravenously (preoperative 15-mg/kg bolus 10 minutes before tourniquet inflation with or without 10 mg/kg/h for 3 hours postoperatively) or intra-articularly (10 mL [100 mg/mL] intraoperatively), and 1 study consisted of tranexamic acid administration in combined intravenous and intra-articular forms (15-mg/kg bolus 10 minutes before tourniquet inflation and intra-articular 3 g 10 minutes before tourniquet deflation). Tranexamic acid use in ACL reconstruction cases resulted in a mean reduction of 61.5 mL in postoperative drain output at 24 hours (95% CI, –95.51 to −27.46; P = .0004), lower hemarthrosis grade (P < .00001), improved Lysholm scores, and reduction in visual analog scale scores for pain (−1.96 points; 95% CI, −2.19 to −1.73; P < .00001) extending to postoperative week 6. Range of motion was improved in the immediate postoperative period, and the need for joint aspiration within 2 weeks was reduced (P < .001). There was no difference in venous thromboembolic event rate between the experimental and control groups. Conclusion: The use of intravenous tranexamic acid in ACL reconstruction surgery results in reduced joint drain output and hemarthrosis and improved pain scores and range of motion in the initial postoperative period without increased complications or thromboembolic events.

Return to Sport Composite Test After Anterior Cruciate Ligament Reconstruction (K-STARTS): Factors Affecting Return to Sport Test Score in a Retrospective Analysis of 676 Patients

Return to sport (RTS) to the preinjury level is the main purpose after anterior cruciate ligament (ACL) reconstruction but the factors affecting the RTS are not completely known. Knee Santy Athletic Return to Sport (K-STARTS) is a composite test designed to assess readiness for RTS after ACL reconstruction. To determine the key factors that influence K-STARTS scores in a large cohort of patients after ACL reconstruction. Case-control study. Level 3. A retrospective analysis of prospectively collected data was undertaken. All patients who underwent ACL reconstruction surgery between March 2016 and May 2017 and also had a K-STARTS assessment at 6 months postoperatively were included. To identify factors influencing the K-STARTS score, an analysis of variance was performed. Age, sex, sports level, delay between injury and surgery, concomitant lesions, graft type, additional lateral tenodesis procedure, and participation in the RTS program were analyzed to identify factors influencing the K-STARTS score. A total of 676 patients were included in the study. The K-STARTS score was significantly higher in male patients than in female patients (13.9 vs 12.4; P < 0.001), in younger patients (those aged <30 years vs older patients; 14.2 vs 12; P < 0.001), ACL reconstructions performed with hamstring tendon autografts compared with bone-patellar tendon-bone (13.5 vs 13.1; P = 0.03) and in those who completed a specific RTS program in addition to standard rehabilitation, compared with those who did not participate (17.1 vs 13.1; P < 0.001). However, the only factor that significantly influenced the K-STARTS score beyond the minimal detectable change threshold was the completion of the additional RTS program. The preinjury frequency of sports participation, whether the dominant limb was injured, time from injury to surgery, the presence of associated meniscal injuries, and whether a lateral tenodesis was performed did not significantly influence the K-STARTS score. Completion of a specific RTS program, in addition to standard rehabilitation, was the most important factor influencing the K-STARTS composite functional and psychological RTS test score at 6 months after ACL reconstruction. This study shows that the completion of a specific RTS program affects positively the RTS test score at 6 months after ACL reconstruction.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons.

Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology. 22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics. Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection. A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability. The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Comparison of Ultrasound-Guided Femoral and Infrapatellar Nerve Block Effects after Anterior Cruciate Ligament Repair Surgery

Background: There are various protocols for pain management after anterior cruciate ligament (ACL) reconstruction surgery. Objective: This study aimed to compare two blocking protocols, including femoral nerve block (FNB) and infrapatellar nerve block (IPNB) in terms of pain severity, patient satisfaction, and muscle force preservation. Materials and Methods: This single-blind clinical trial study investigated the patients who underwent elective knee arthroscopic ACL surgery randomly either by ultrasound-guided FNB or IPNB. Subsequently, the patients were evaluated 1, 3, 6, 12, and 24 h following NB for pain severity, patient satisfaction level, and muscle force. Results: The pain score (both at rest and in flexion) was significantly lower in the first three h after the intervention in the FNB group. Moreover, the mean score of the patients’ satisfaction in the first hours was significantly higher in the FNB group after the procedure. Additionally, the IPNB group obtained a significantly faster mean time required for the first dose of opioid request. The mean dose of used opioids over 24 h was significantly lower in the FNB group. There was a significant difference between the groups in terms of the muscle strength score within 24 h; moreover, the FNB group obtained a significantly greater delay in muscle recovery. Conclusion: The FNB is associated with greater pain relief and satisfaction in patients who underwent arthroscopic ACL reconstruction surgery, compared to the IFNB technique. However, a further delay in the recovery of quadriceps muscle force is evident in the FNB group.

Comparison of Ultrasound-Guided Femoral and Infrapatellar Nerve Block Effects after Anterior Cruciate Ligament Repair Surgery

Background: There are various protocols for pain management after anterior cruciate ligament (ACL) reconstruction surgery. Objective: This study aimed to compare two blocking protocols, including femoral nerve block (FNB) and infrapatellar nerve block (IPNB) in terms of pain severity, patient satisfaction, and muscle force preservation. Materials and Methods: This single-blind clinical trial study investigated the patients who underwent elective knee arthroscopic ACL surgery randomly either by ultrasound-guided FNB or IPNB. Subsequently, the patients were evaluated 1, 3, 6, 12, and 24 h following NB for pain severity, patient satisfaction level, and muscle force. Results: The pain score (both at rest and in flexion) was significantly lower in the first three h after the intervention in the FNB group. Moreover, the mean score of the patients’ satisfaction in the first hours was significantly higher in the FNB group after the procedure. Additionally, the IPNB group obtained a significantly faster mean time required for the first dose of opioid request. The mean dose of used opioids over 24 h was significantly lower in the FNB group. There was a significant difference between the groups in terms of the muscle strength score within 24 h; moreover, the FNB group obtained a significantly greater delay in muscle recovery. Conclusion: The FNB is associated with greater pain relief and satisfaction in patients who underwent arthroscopic ACL reconstruction surgery, compared to the IFNB technique. However, a further delay in the recovery of quadriceps muscle force is evident in the FNB group.

The Effect of Depression on Patient Reported Outcomes Measurement and Information System Computer Adaptive Test (PROMIS-CAT) scores and Return-to-Sport following ACL Reconstruction

Objectives:Depression has been shown to have a negative effect on many orthopaedic surgical outcomes. The purpose of this study was to determine whether preoperative clinical diagnosis of depression and/or PROMIS (Patient-Reported Outcomes Measurement Information System) Depression scores predicted worse postoperative therapy compliance, functional outcomes, and return-to-sport after anterior cruciate ligament (ACL) reconstruction.Methods:A multi-surgeon series of consecutive patients who had undergone ACL reconstruction at a single institution between 1/4/16 and 7/19/16 were evaluated for inclusion. Patients who had completed preoperative PROMIS Depression (D), Physical Function (PF), and Pain Interference (PI) questionnaires were prospectively enrolled to complete minimum 2-year follow-up PROMIS and Return-to-Sport (ACL-RSI short-form) questionnaires. Chart review was conducted to determine depression diagnosis status, demographic data, and rehabilitation physical therapy (PT) compliance. PROMIS D score cutoff for mild depression was >52.5, based on previously established correlation to the validated Patient Health Questionnaire-9.Results:Ninety-five of 115 consecutive patients (81%) met inclusion criteria. Average follow-up was 34+/-1.9 months. Fourteen patients (15%) carried a clinical diagnosis of depression. Thirty-two (34%) had a preoperative PROMIS D score above the mild depression threshold; of those, 2 (2%) scored in the moderate depression range, and 3 (3%) scored in the severe depression range. Overall, the cohort (including depressed patients) showed improvement in PROMIS PF and PI scores postoperatively (p<0.001) (Table 1). Diagnosed depressed patients had a higher rate of PT non-compliance (30.8%±17.3% vs. 21.9%±12.6%; p=0.04) and lower postoperative physical function (50.8±7.7vs. 57.5±10.5; p=0.03), but no differences in post-operative PROMIS PI (50.8±6.9vs. 46.7±6.8; p=0.32), compared to patients without depression diagnosis. The percentage of missed therapy appointments showed a correlation with lower postoperative PROMIS PF scores (r=0.33, p=0.008) in our cohort. PROMIS depressed (PROMIS D>52.5) and undiagnosed depression patients (subgroup of preoperative PROMIS depressed without depression diagnosis) showed no difference in PT compliance or postoperative PROMIS PF or PI, compared to non-depressed patients (Table 2). Undiagnosed preoperative depressed patients (n=21/95 (22%)) also showed improvement in their depression scores postoperatively (mean PROMIS D = 57.4±5.0 preop vs. 44.5±6.6 postop; p<0.0001) (Figure 1) and 19/21 (90.5%) patients in this group showed resolution in their personal PROMIS D score to non-depressed range (p=.001). PROMIS depressed patients were less likely to participate in a sport (16/32 (50.0%) vs. 50/63 (79.3%); p=0.003), but PROMIS depressed athletes had no differences in return to sport rates (10/16 (63%) vs. 25/50 (50%); p=0.38) or responses to the ACL-RSI Short Form questionnaire (p>0.05 for all).Conclusion:Clinically diagnosed depression is predictive of worse rehabilitation therapy compliance and worse functional outcomes after ACL reconstruction surgery, but even depressed patients can be expected to show improvement. PROMIS Depression scores, particularly in those without a clinical diagnosis of depression, can be expected to resolve to non-depressed range after ACL reconstruction. Patients with depressed mood preoperatively but no depression diagnosis could be considered to have “situational depression” and can be reassured that depression will likely resolve after ACL reconstruction. Patients with depression diagnosis, however, should be counseled regarding tempered expectations after ACL reconstruction. Resources should be allocated to incorporate behavioral health counseling pre- and post-surgery in an attempt to maximize outcomes.

Clinical and Functional Outcomes of Anterior Cruciate Ligament Reconstruction With Autologous Hamstring Tendon in Patients Aged 50 Years or Older

To assess the clinical and functional outcomes, including the return to sports and the progression of arthritis, in patients aged 50 years or older after anterior cruciate ligament (ACL) reconstruction. A retrospective series of patients aged 50 years or older with ACL rupture who received ACL reconstruction surgery with autologous hamstring tendon was examined. Preoperative and postoperative functional outcomes were evaluated with the International Knee Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity score. Associated injuries, postoperative complications, and the rate of return to preinjury sports were documented. A paired t test and the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were used for statistical evaluation. A total of 67 patients with a mean age of 56.6 years were enrolled. The mean follow-up time was 30.2 months. Clinical improvement in the IKDC score (from 41.4 preoperatively to 88.9 postoperatively), Lysholm score (from 49.8 to 86.1), and Tegner activity score (from 2.7 to 4.4) was noted. Regarding clinically relevant values of the MCID, all patients (100%) showed a ΔLysholm score exceeding 8.9; 66 of 67 patients (98.5%) revealed a ΔIKDC score exceeding 16.7; and 47 of 67 patients (70.1%) showed a ΔTegner activity score of more than 1. For the PASS, none of the patients had an IKDC score over 75.9 preoperatively whereas 60 patients (89.5%) had a score exceeding 75.9 postoperatively. Associated lesions included meniscal injuries (73.1%) and osteochondral lesions (89.6%). Of the patients, 36 (53.7%) returned to preinjury sports and 18 (22.9%) returned to sports with less intensity. No major complication, rerupture, or deterioration of arthritis was noted. Patients aged 50 years or older receiving ACL reconstruction achieved significant improvements in IKDC, Lysholm, and Tegner scores. All patients reached the MCID for the ΔLysholm score; 98.5%, for the ΔIKDC score; and 70.1%, for the ΔTegner activity score. None of the patients reached the PASS for the preoperative IKDC value, whereas 89.5% reached the PASS postoperatively. Among patients aged 50 years or older, 53.7% returned to preinjury sports and 26.9% returned to sports with lower intensity. Level IV, therapeutic case series.

Male and Female Adolescent Athletes' Readiness to Return to Sport After Anterior Cruciate Ligament Injury and Reconstruction.

The purpose of this study was to examine whether readiness to return to sport (RTS) differed between adolescent male and female athletes after anterior cruciate ligament reconstruction (ACLR). Longitudinal, prospective cohort. Outpatient office associated with tertiary-care hospital. A total of 93 adolescent athletes, 17 years of age and younger, who underwent ACLR surgery with a hamstring autograft were included. Male and female athletes. Anterior cruciate ligament-return to sport after injury (ACL-RSI) completed at 3 time points: (1) preoperatively (Pre-op), (2) approximately 3 months into rehabilitation (Post-op 1), and (3) during RTS phases of recovery (Post-op 2). There was a significant main effect for both sex (P < 0.010) and time (P < 0.0001) with male athletes having higher ACL-RSI scores than female athletes at all 3 time points; however, there was no significant time by sex interaction. All ACL-RSI scores increased significantly across time, regardless of sex. There were no statistically significant differences between ACL-RSI scores at all 3 time points between individuals who did and did not receive physician clearance. This study provides a longitudinal depiction of adolescent athletes' readiness to RTS after ACL injury throughout recovery. Both male and female athletes demonstrated diminished ACL-RSI scores before undergoing surgery, with increasing scores at both postoperative time points for both sexes. Overall, female athletes reported lower readiness to RTS at all 3 time points compared with male athletes.

The Association Between Tibial Slope and Revision Anterior Cruciate Ligament Reconstruction in Patients ≤21 Years Old: A Matched Case-Control Study Including 317 Revisions

Background: There is evidence that tibial slope may play a role in revision risk after anterior cruciate ligament reconstruction (ACLR); however, prior studies are inconsistent. Purpose: To determine (1) whether there is a difference in lateral tibial posterior slope (LTPS) or medial tibial posterior slope (MTPS) between patients undergoing revised ACLR and those not requiring revision and (2) whether the medial-to-lateral slope difference is different between these 2 groups. Study Design: Case-control study; Level of evidence, 3. Methods: We conducted a matched case-control study (2006-2015). Cases were patients aged ≤21 years who underwent revision surgery after primary unilateral ACLR; controls were patients aged ≤21 years without revision who were identified from the same source population. Controls were matched to cases by age, sex, body mass index, race, graft type, femoral fixation device, and post-ACLR follow-up time. Tibial slope measurements were made by a single blinded reviewer using magnetic resonance imaging. The Wilcoxon signed rank test and McNemar test were used for continuous and categorical variables, respectively. Results: No difference was observed between revised and nonrevised ACLR groups for LTPS (median: 6° vs 6°, P = .973) or MTPS (median: 4° vs 5°, P = .281). Furthermore, no difference was found for medial-to-lateral slope difference (median: −1 vs −1, P = .289). A greater proportion of patients with revised ACLR had an LTPS ≥12° (7.6% vs 3.8%) and ≥13° (4.7% vs 1.3%); however, this was not statistically significant after accounting for multiple testing. Conclusion: We failed to observe an association between revision ACLR surgery and LTPS, MTPS, or medial-to-lateral slope difference. However, there was a greater proportion of patients in the revision ACLR group with an LTPS ≥12°, suggesting that a minority of patients who have more extreme values of LTPS have a higher revision risk after primary ACLR. A future cohort study evaluating the angle that best differentiates patients at highest risk for revision is needed.

Factors Associated With a Return to Preinjury Level of Sport Performance After Anterior Cruciate Ligament Reconstruction Surgery

Background: Many studies have investigated factors that predict a return to sport participation after anterior cruciate ligament (ACL) reconstruction, but it is unclear whether the same factors are associated with a return to preinjury level of sport performance. Purpose: To identify factors that contribute to an athlete’s return to preinjury level of performance after ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: A cohort of 222 patients (132 male, 90 female) who had ACL reconstruction surgery and completed a 12-month postoperative assessment were followed out to a mean 3 years (range, 2-4 years) to determine whether they had returned to their self-reported preinjury levels of sport performance. Rates of return to preinjury performance were calculated. Measures that had been recorded at the 12-month postoperative review—demographic (age, sex), sport activity level (Marx Activity Rating Scale, return to competition sport), knee laxity, limb symmetry (single and triple crossover hop), subjective function/symptoms (International Knee Documentation Committee subjective), and psychological readiness (Anterior Cruciate Ligament Return to Sport After Injury scale)—were compared between patients who returned to their preinjury levels of performance and those who did not. Univariate and multivariate logistic regression models were also used to prospectively determine the association between these measures and return to preinjury level of sport performance. Results: A total of 135 (61%) patients reported that they had returned to their preinjury levels of performance, with return rates similar between males (59%) and females (63%) and between those who had returned to competition at 12 months (62%) and those who had not (60%). There was no significant age difference between patients who returned to their preinjury levels of sport performance and those who did not; however, higher psychological readiness (P < .0001), greater limb symmetry (P < .05), higher subjective knee scores (P = .01), and a higher activity level (P < .04) were all associated with a return to performance. In the multivariate model, psychological readiness was the only variable that remained a significant predictor (odds ratio = 1.03; 95% CI, 1.01-1.04; P < .0001). Conclusion: A majority of athletes who returned to sport after ACL reconstruction reported that their performance was comparable with preinjury. Having a greater psychological readiness to return during rehabilitation was the most significant predictor of a subsequent return to comparable performance.

The relationship between quadriceps strength asymmetry and knee biomechanics asymmetry during walking in individuals with anterior cruciate ligament reconstruction

BackgroundLower extremity movement asymmetries may lead to re-injury and knee osteoarthritis after anterior cruciate ligament (ACL) reconstruction surgery. However, there is no consensus regarding the effect of quadriceps strength asymmetry on lower extremity movement asymmetry after ACL reconstruction. Research questionWhat is the relationship between quadriceps strength asymmetry and asymmetries in lower extremity kinematics and kinetics during walking in individuals who underwent ACL reconstruction surgery?. MethodsIsometric quadriceps strength, kinematic, and kinetic data during walking were collected from 24 men with unilateral ACL reconstruction. Knee joint angles and moments were reduced. Pearson correlation coefficients between asymmetry in selected knee biomechanics and isometric quadriceps strength asymmetry were determined. ResultsThe isometric quadriceps strength of the injured leg was significantly lower than that of the uninjured leg (P < 0.001). Knee flexion angles and knee extension moments were smaller in the injured leg than that in the uninjured leg during both loading response (P = 0.007, P = 0.047) and mid-stance phases (P = 0.005, P = 0.028). Isometric quadriceps strength asymmetry was significantly correlated with asymmetry in the peak knee flexion angle during loading response and mid-stance phases (r = −0.48, P = 0.017, r = −0.48, P = 0.017). Isometric quadriceps strength asymmetry was also significantly correlated with asymmetry in the peak knee extension moment during the mid-stance phase (r = −0.44, P = 0.033). SignificanceIndividuals with ACL reconstruction demonstrate knee movement asymmetry in the sagittal plane. Isometric quadriceps strength asymmetry is significantly correlated with asymmetry in knee flexion angles during the early stance phase and knee extension moments during the mid-stance phase. Rehabilitation programs should emphasise eccentric exercise to beneficially modify quadriceps neuromuscular control.

Blood Flow Restriction Training Does Not Improve Quadriceps Strength After Anterior Cruciate Ligament Reconstruction

Objectives: Blood flow restriction training (BFRT) involves obstruction of venous outflow of working muscles during exercise and may lead to more substantial recovery of quadriceps strength after anterior cruciate ligament (ACL) reconstruction. The purpose of this study is to examine the effects of BFRT in ACL reconstruction patients before and after exposure to BFRT. Methods: This study was a randomized controlled trial in which 36 patients who had torn their ACL and were scheduled to undergo ACL reconstructive surgery (ACLR) with an autograft were randomized to receive exercise with BFRT (N=18) or exercise without BFRT (N=18). Participants in both groups performed the same exercise, but either did or did not have blood flow restricted. The exercise component of the intervention consisted of all subjects performing a single-leg isokinetic leg press, at an intensity of 70% of the subjects’ one-repetition maximum, for four sets of ten repetitions two times per week for 8 weeks beginning at 8 weeks post-operatively. Patients randomized to the BFRT group performed the leg-press exercise with a blood flow restriction cuff applied to the thigh and set to a limb occlusion pressure of 80 percent. All participants were concurrently undergoing standard ACL rehabilitation at the same physical therapy clinic. Bilateral isometric (recorded at a knee angle of 90°) and isokinetic (60°/second) quadriceps strength were recorded using a Biodex dynamometer (System 4, Shirley, NY) prior to ACLR and after the conclusion of the 8-week intervention. Peak isometric and isokinetic quadriceps strength were utilized to generate isometric and isokinetic quadriceps symmetry indices ((ACLR limb strength/Healthy limb strength) x100). Change from baseline symmetry scores were then generated using the following equation: (post-intervention symmetry - pre-intervention symmetry)/pre-intervention symmetry in order to account for possible differences in strength between groups prior to intervention delivery. Change from baseline isometric and isokinetic quadriceps symmetry scores were then compared between groups (exercise with BFRT, exercise without BFRT) using one-way analysis of variance tests with an a priori α set to P≤ 0.05. Effect sizes (Cohen’s d) and 95% confidence intervals were also computed. Results: No significant differences were found for change from baseline isokinetic quadriceps symmetry index (P=0.39, BFRT mean=-0.05, Control mean=-0.19) or change from baseline isometric quadriceps symmetry index (P=0.62, BFRT mean=-0.04, control mean=-0.10). The effect sizes for isokinetic quadriceps symmetry index (d=0.28, 95% CI= -0.37, 0.93) and isometric quadriceps symmetry (d=0.16, 95% CI= -0.49, 0.80) were small with confidence intervals that crossed zero. Conclusion: An 8-week blood flow resistance training + exercise intervention did not increase quadriceps muscle strength in patients who had undergone ACL reconstruction. Based on our findings, application of blood flow restriction training in ACL reconstruction patients to improve quadriceps strength may not be warranted. Future studies may benefit from a longer follow-up and larger sample size.