After Anterior Cruciate Ligament Tear Research Articles

Return to sport and re-tears after anterior cruciate ligament reconstruction in children and adolescents

BackgroundThe primary objective of this study was to determine the time to and level of return to sports after anterior cruciate ligament (ACL) reconstruction in children and adolescents. The secondary objectives were to evaluate the risk of early ACL re-tear after return to sports and the risk of ACL tear in the contralateral knee. HypothesisThe time to return to sports in young patients is considerably longer than in adults. MethodsA prospective multicentre study was conducted at 12 centres specialised in knee ligament surgery, in children and adolescents younger than 18 years, between 1 January 2015 and 31 October 2015. The patients were divided into a paediatric group with open physes and a skeletally mature group with closed physes. We recorded the time to return to sport, the type of sport resumed, and the occurrence of early re-tears on the same side. A poor outcome was defined as a re-tear or an objective IKDC score of C or D. A contralateral ACL tear was not considered a poor outcome. ResultsOf 278 included patients, 100 had open physes and 178 closed physes. In the open physes group, return to running occurred after 10.4±4.7 months, return to pivoting/contact sport training after 13.1±3.9 months, and return to pivoting/contact sport competitions after 13.8±3.8 months. Of the 100 patients, 80% returned to the same sport and 63.5% to pivoting/contact sport competitions. Re-tears occurred in 9% of patients, after 11.8±4.1 months, and contralateral tears in 6% of patients, after 17.2±4.4 months. In all, 19.4% of patients had a poor outcome, including 10.4% with an IKDC score of C or D and 9% with re-tears. In the group with closed physes, return to running occurred after 8.8±5.1 months, return to pivoting/contact sport training after 11.7±4.7 months, and return to pivoting/contact sport competitions after 12.3±4.2 months. Of the 178 patients, 76.9% returned to the same sport and 55.6% to pivoting/contact sport competitions. The re-tear rate was only 2.8% and the contralateral tear rate 5%. In all, 14.7% of patients had poor outcome, including 11.9% with an IKDC score of C or D and 2.8% with re-tears. No risk factors for re-tears were identified; the quadruple-bundle semitendinosus technique showed a non-significant association with re-tears. ConclusionIn young children, the return to sport time after ACL reconstruction is considerably longer than 1 year and the return to competitions occurs later and is more difficult. The results of this study indicate that reservations are in order when informing the family about return to sports prospects after ACL reconstruction. The return to pivoting/contact sport competitions should not be allowed until 14 months after surgery in young skeletally immature patients, and the risk of re-injury is high within the first 2 years. Level of evidenceIV, retrospective study.

How to assess the return to physical activities following anterior cruciate ligament injury?

Several outcomes could be used to assess return to physical activities (RTPA) after anterior cruciate ligament (ACL) injury: qualitative outcomes like return to main sport or pre-injury level; quantitative outcomes like weekly hours of practice or Tegner score. Performing a relevant clinical assessment is challenging, especially for patients who practice at a moderate sport level. Our objective was to compare the use of different outcomes to assess RTPA after functional and surgical treatment of ACL injury. Forty patients were included after surgery (group ST; 31.7 ± 10.6 years-old, 15.0 ± 5.0 months after ACL reconstruction);18 after functional treatment (group FT; 38.1 ± 14.8 years-old, 23.0 ± 6.0 months after ACL tear). Qualitative criteria were subjectively assessed answering yes/no when questioned concerning their RTPA. Objective criteria were defined as variations between pre-injury and post-treatment of Tegner score, weekly hours of practice, “Tegner.h” (global volume of activity equal to Tegner score multiplied by weekly hours of practice) for main physical activity (MPA) and global activity (3 MPA included). Return to subjective global pre-injury level was 22% for FT group vs. 25% for ST group ( P = 0.999). Return to pre-injury (i) level of MPA was 17 vs. 23% ( P = 0.736); (ii) Tegner score for the MPA was 56 vs. 30% ( P = 0.083); and (iii) global Tegner.h was 61 vs. 18% ( P = 0.002) for FT versus ST group, respectively. Evolution of Global Tegner.h score, MPA Tegner.h score and Global weekly hours of practice were congruent for FT group, but not for ST group. We found low RTPA rates with some discrepancies between different outcomes of RTPA. Global Tegner.h could be an interesting alternative to Tegner score of the MPA for assessment of RTPA in non-operated patients who have a moderate physical activity level.

Bone Bruise Patterns in Skeletally Immature Patients With Anterior Cruciate Ligament Injury: Shock-Absorbing Function of the Physis

Background: Bone bruises are frequently found on magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) injury and have been related to the force associated with the trauma. Yet, little is known about the bone bruise distribution pattern of skeletally immature (SI) patients, as the presence of an open physis may play a role in energy dissipation given its unique structure. Purpose: To describe and compare the location and distribution of tibial and femoral bone bruises, observed on MRI, between 2 groups of ACL-injured knees: the first group with an open physis and the second with a closed physis. Additionally, based on the bone bruise distribution pattern, the secondary aim of the study was to propose a new classification of bone bruise in SI patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review was conducted to identify all cases of primary ACL tears in patients ≤16 years old, with MRI within 6 weeks of injury between January 2012 and December 2016. Overall, 106 patients were identified: 53 with open physis (skeletally immature [SI] group) and 53 with closed physis as control (skeletally mature [SM] group). MRI scans were reviewed to assess for the presence and location of bone bruises. Longitudinal bone bruise distribution was described as epiphyseal and metaphyseal in both femur and tibia. The proposed classification for tibia and femur has 2 parts: the location of the bone bruise in the (I) lateral, (II) medial, or (III) medial and lateral parts of the bone; and if the bone bruise (a) does not or (b) does cross the physis. For the tibia, if the bone bruise is also present in the central portion, a letter C is added. Results: The SI group had significantly fewer bone bruises cross the physis and extend into the metaphysis than did the SM group for both the tibia (25% vs 85%, respectively; P < .0001) and the femur (4% vs 42%; P < .0001). The most common patterns observed in the SI group were type IIICa in the tibia (medial/lateral and central, not extending into the metaphysis: 42%) and type Ia in the femur (lateral, not extending into the metaphysis: 59%). Conclusion: The data from this study shows that patients with an open physis at the occurrence of an acute ACL rupture have unique bone bruise patterns as compared with those with a closed physis. In the SI patients, the bone bruise pattern is significantly less frequently observed in the tibial and femoral metaphysis.

Is ACL reconstruction a prerequisite for the patients having recreational sporting activities?

ObjectiveWhether surgical or conservative treatment is more effective in allowing patients to return to physical activity after anterior cruciate ligament (ACL) injury is controversial. We sought to compare mid-term outcome measures between isolated ACL tear patients who underwent reconstruction followed by closed kinetic chain exercises and those who underwent neuromuscular training only. MethodsWe retrospectively evaluated patients with ACL tears who underwent post-surgery CKC strength training after ACL reconstruction (Group A), and patients who only underwent neuromuscular training (Group B) with a minimum follow-up time of 5 years. Surgical techniques, rehabilitation, assessment of subjective knee function, one-leg hop test, assessment of joint position sense, muscle strength, and the health profile of the patient were evaluated. ResultsOverall, 43 patients were included in Group A (mean age, 32.56 ± 4.89; Tegner activity scale, 5) and 39 patients in Group B (31.67 ± 7.27; 5). Patients in both groups returned to their regular physical activity level after a similar time frame (Group A: average, 12 months; Group B, average, 13.4 months). The mean Lysholm knee score was 88.52 ± 7.65 in Group A and 86.21 ± 13.72 in Group B. Mean distances for the one-leg hop test for Group A were 135.21 ± 31.66 and 145.36 ± 42.10 mm in the reconstructed and uninjured knees, respectively. In Group B, the mean hop distances were 132.47 ± 28.13 and 147.89 ± 21.45 mm in the rehabilitated and uninjured knees, respectively. No statistical difference was observed between the groups for any of the parameters evaluated, including assessment of subjective knee function, one-leg hop test, assessment of joint position sense, muscle strength, and the health profile. ConclusionOur data suggest that early surgical reconstruction may not be a prerequisite to returning to recreational physical activities after injury in patients with ACL tears. Level of evidenceLevel IV, therapeutic study.

High Rates of Osteoarthritis Develop After Anterior Cruciate Ligament Surgery: An Analysis of 4108 Patients

Background: Posttraumatic osteoarthritis (PTOA) after anterior cruciate ligament (ACL) reconstruction ultimately translates into a large economic effect on the health care system owing to the young ages of this population. Purpose/Hypothesis: The purposes were to perform a meta-analysis to determine the prevalence of osteoarthritis after an ACL reconstruction, examining the effects of length of time after surgery, preoperative time interval from injury to surgery, and patient age at the time of surgery. It was hypothesized that the prevalence of PTOA increased with time from surgery and that increased time from injury to surgery and age were also risk factors for the development of PTOA. Study Design: Meta-analysis. Methods: A meta-analysis of the prevalence of radiographic PTOA after ACL reconstruction was performed of studies with a minimum of 5 years’ follow-up, with a level of evidence of 1, 2, or 3. The presence of osteoarthritis was defined according to knee radiographs evaluated with classification based on Kellgren and Lawrence, Ahlbäck, International Knee Documentation Committee, or the Osteoarthritis Research Society International. Metaregression models quantified the relationship between radiographic PTOA prevalence and the mean time from injury to surgery, mean patient age at time of surgery, and mean postoperative follow-up time. Results: Thirty-eight studies (4108 patients) were included. Longer postsurgical follow-up time was significantly positively associated with a higher proportion of PTOA development. The model-estimated proportion of PTOA (95% CI) at 5, 10, and 20 years after surgery was 11.3% (6.4%-19.1%), 20.6% (14.9%-27.7%), and 51.6% (29.1%-73.5%), respectively. Increased chronicity of the ACL tear before surgery and increased patient age were also associated with a higher likelihood of PTOA development. Conclusion: The prevalence of osteoarthritis after an ACL reconstruction significantly increased with time. Longer chronicity of ACL tear and older age at the time of surgery were significantly positively correlated with the development of osteoarthritis. A timely referral and treatment of symptomatic patients are vital to diminish the occurrence of PTOA.

Is Lateral Femoral Notch Depth Associated with Rotatory Instability in ACL Deficient Knees: A Quantitative Pivot Shift Analysis

Objectives:Persistent rotatory knee instability after anterior cruciate ligament (ACL) reconstruction is relatively common. While the causes of this persistent instability are multifactorial, bony morphologic characteristics have been proposed to play a role. Therefore, the purpose of this study was to evaluate the relationship between the well-described lateral femoral notch (LFN) depth and quantitative measures of rotatory knee stability. We hypothesized that greater LFN depth would be associated with increased rotatory knee instability.Methods:A consecutive series of patients undergoing primary ACL reconstruction at our university medical center from June 2014 to April 2016 were analyzed. Inclusion criteria included primary ACL tear, no concurrent ligamentous or bony injury requiring operative treatment, no history of previous knee injury or surgery to the ACL-injured extremity, and no history of injury or surgery to the contralateral knee. A standardized pivot shift test was performed by the senior surgeon preoperatively under anesthesia in both knees and quantified using tablet image analysis software and accelerometer sensors as previously described and validated. Lateral knee radiographs and sagittal magnetic resonance images (MRI) of the injured knee were evaluated for depth of the LFN as previously described. A line tangent to the lateral femoral condyle articular surface was drawn across the notch. Notch depth was measured perpendicular from this line to the deepest point of the LFN. Pearson correlation coefficient was used to analyze correlations between continuous variables. Chi-square test was used to analyze relationships between notch depth and presence/absence of medial or lateral meniscus tears. Analyses were performed with SPSS 22.0 and significance was set at a p<0.05.Results:Fifty patients met inclusion criteria and were included in this study (mean age 24 years, range 13-45; 28 females, 22 males). Mean LFN depth as measured via x-ray was 0.8 mm (SD=0.63, n=50) and via MRI was 1.0 mm (SD=0.73, n=47). Twenty-two (44%) patients had a medial meniscus tear and 27 (54%) had a lateral meniscus tear. LFN on x-ray had moderate but significant positive correlations with ipsilateral lateral compartment acceleration (r=0.402, p=0.004) and acceleration side-to-side differences (r=0.407, p=0.003). LFN depth on MRI had moderate but significant positive correlations with ipsilateral lateral compartment acceleration (r=0.334, p=0.022) and acceleration side-to-side differences (r=0.363, p=0.012). LFN depth on x-ray was significantly associated with the presence of a lateral meniscus tear (p=0.014). There were no significant associations between LFN depth (x-ray or MRI) on ipsilateral or contralateral lateral compartment translation, contralateral lateral compartment acceleration, or the presence of medial meniscus tears.Conclusion:The results from this study demonstrated that a well described bony morphologic feature - LFN depth - was correlated with higher lateral compartment acceleration as measured by quantitative pivot shift analysis. Furthermore, greater LFN depth was associated with an increased incidence of lateral meniscus tears, which supports findings from previous studies. Assessment of LFN depth may help clinicians identify patients with greater rotatory instability prior to ACL reconstruction and potentially direct surgical treatment to account for additional rotatory knee instability.Table 1: Mean Quantitative Pivot Shift Values of the Injured and Uninjured KneeInjuredUninjuredSide-to-Side DifferenceCompartment Acceleration (m/s2)5.14 (SD=0.73)3.45 (SD=0.95)1.68 (SD=2.09)Lateral Compartment Translation (mm)3.67 (SD=2.30)1.22 (SD=0.75)2.46 (SD=2.24)

Factors Associated With Improved Function and Maintenance of Sports Activities at 5 to 10 Years After Autologous Hamstring ACL Reconstruction in Young Men.

Background:There are limited data regarding associated factors of return to sports activities at more than 5 years after anterior cruciate ligament (ACL) reconstruction.Purpose:To test interrelationships between patient characteristics, concomitant articular lesions, graft laxity, and maintenance of sports activities at 5 to 10 years after ACL reconstruction. It was hypothesized that at 5 to 10 years after the operation in young adult men, maintenance of greater activity level and better knee function would be associated with greater preinjury activity level, younger age at reconstruction, absence of concomitant articular lesions, and minimal graft laxity at follow-up.Study Design:Case series; Level of evidence, 4.Methods:One hundred six men with autologous hamstring ACL reconstruction between the ages of 18 and 35 years were reviewed at 5 to 10 years after surgery. Excluded patients had contralateral ACL tear, revision reconstruction, or another injury impairing function. Fifty-five patients were eligible and available for follow-up. Independent variables included preinjury Tegner score, time interval from injury to surgery, smoking status, age, articular lesions, KT side-to-side difference, and pivot-shift grade. Main outcome measures were Tegner activity level, International Knee Documentation Committee (IKDC) subjective score, and Knee injury and Osteoarthritis Outcome Scale (KOOS) score at 5 to 10 years after surgery.Results:Greater Tegner activity level at follow-up was associated in a regression model with greater preinjury Tegner activity level (correlation coefficient, 0.423; P = .01), lower KT difference (correlation coefficient, –0.278; P = .04), and negative pivot shift (correlation coefficient, –0.277; P = .05). Younger age at operation predicted return to greater Tegner activity level in a univariate analysis (correlation coefficient, –0.266; P = .05) but not in a regression model (not significant). Chondral lesions at surgery predicted lower IKDC subjective scores (71.4 ± 14.3 vs 84.1 ± 11.5; P < .01) and KOOS scores but did not affect maintenance of sports activities.Conclusion:At 5 to 10 years after autologous hamstring ACL reconstruction in young men, predictors of greater sports activity level are primarily high preinjury activity level and reestablishment of knee laxity. Younger age at operation and moderate chondral lesions have lower impact in this respect.

Effects of Surgical Factors on Cartilage Can Be Detected Using Quantitative Magnetic Resonance Imaging After Anterior Cruciate Ligament Reconstruction

Background: Quantitative magnetic resonance (qMR) can be used to measure macromolecules in tissues and is a potential method of observing early cartilage changes in the development of posttraumatic osteoarthritis. Hypothesis/Purpose: We hypothesized that specific patient and surgical factors affecting cartilage matrix composition after anterior cruciate ligament (ACL) reconstruction (ACLR) can be detected using T1ρ and T2 relaxation times. Our purpose was to demonstrate this ability in a multicenter feasibility study. Study Design: Case series; Level of evidence, 4. Methods: A total of 54 patients who underwent ACLR underwent bilateral MRI at baseline before surgery and 6 months postoperatively. Operative findings were recorded. T1ρ and T2 relaxation times were calculated for 6 cartilage regions: the medial femur, lateral femur, medial tibia, lateral tibia, patella, and trochlea. A paired t test compared relaxation times at baseline and 6 months, univariate regression identified regions that influenced patient-reported outcome measures, and analysis of covariance was used to determine the surgical factors that resulted in elevated relaxation times at 6 months. Results: The injured knee had significantly prolonged T1ρ and T2 relaxation times in the tibiofemoral compartment at baseline and 6 months but had shorter values in the patellofemoral compartment compared with the uninjured knee. Prolonged T1ρ and T2 times at 6 months were noted for both the injured and uninjured knees. At 6 months, prolongation of T1ρ and T2 times in the tibial region was associated with lower patient-reported outcome measures. ACLR performed within 30 days of injury had significantly shorter T1ρ times in the tibial regions, and lateral meniscal tears treated with repair had significantly shorter T1ρ times than those treated with excision. Conclusion: Prolonged relaxation times in multiple regions demonstrate how the injury affects the entire joint after an ACL tear. Changes observed in the uninjured knee may be caused by increased loading during rehabilitation, especially in the patellofemoral articular cartilage and distal femur. Relaxation times in the tibial regions may be predictive of patient symptoms at 6 months. These same regions are affected by surgical timing as early as 30 days after injury, but this may partially be reflective of the severity of the preoperative injury and the choice of treatment of meniscal tears.

Biomarker Changes in Anterior Cruciate Ligament–Deficient Knees Compared With Healthy Controls

To establish how synovial fluid biomarker concentrations change in patients after anterior cruciate ligament(ACL) tears, with and without associated cartilage injury, with comparisons made to healthy controls. Patients were prospectively enrolled between January 2013 and December 2014. Inclusion criteria included any patient undergoing knee arthroscopy. Patients with a confirmed ACL tear were allocated to either the ACL tear with cartilage injury group or the ACL tear without cartilage injury group based on intraoperative assessment. Patients who underwent an arthroscopic procedure with no injury history or symptoms in their contralateral knee were asked to provide samples to serve as healthy controls. These subjects may or may not have been the same ones with noted ACL pathology. The concentrations of 20 biomarkers were determined using a multiplex magnetic bead immunoassay. Biomarker concentrations were then compared between the 3 study groups (ACL tears with and without cartilage injury, and uninjured contralateral knees) using an analysis of variance test with pairwise comparisons. The minimal clinically important difference was calculated based on the standard error of measurement. The study included synovial fluid samples from 134 knees: 34 ACL tears without cartilage injury (mean age 34.0years), 28 ACL tears with cartilage injury (mean age 36.3years), and 72 healthy controls (mean age 41.1years). Analysis of variance testing showed significant differences among groups for matrix metalloproteinase-3 (F= 81.8; P < .001), tissue inhibitor of metalloproteinase (TIMP)-1 (F= 7.9; P ≤ .001), TIMP-2 (F= 4.5; P= .015); fibroblast growth factor-2 (F= 4.9; P= .011), interleukin-6 (F= 8.2; P= .001), and macrophage inflammatory protein-1 beta (F= 7.3; P= .001). Pairwise comparisons showed no significant differences between ACL tears with, and without cartilage injury, but did show that both groups of ACL tears had significantly higher concentrations of (first P value= ACL tears with and then ACL tears without cartilage injury): matrix metalloproteinase-3 (P < .001; P < .001), TIMP-1 (P < .001; P= .011), interleukin-6 (P= .009; P= .038), and macrophage inflammatory protein-1 beta (P= .003; P= .045) compared with contralateral controls. ACL tears without associated cartilage damage had significantly lower concentrations of TIMP-2 (P= .011) and fibroblast growth factor-2 (P= .014) compared with controls. All biomarker concentration differences that reached statistical significance were also larger than calculated minimal clinically important differences. The current study identified 6 pro- and anti-inflammatory synovial fluid biomarkers whose concentrations after ACL injury were significantly different compared with uninjured controls. No significant differences in synovial fluid biomarker concentrations were seen between ACL injured knees with and without associated cartilage damage. Level III, retrospective comparative study of prospectively gathered data.

How to evaluate precisely return to sport after anterior cruciate ligament tear with operative or conservative treatment on patients with moderate sport level?

Several ways exist to assess return to sport (RTS) after anterior cruciate ligament tear (ACLT): main sport or anterior level, pivoting contact sports or competition. Performing a relevant evaluation is difficult especially for moderate level patients. Our objective was to evaluate the reliability of these different outcomes after ACLT; then to assess the concordance between each other. Fifty-eight patients with moderate sport level were included (mean age 33.6 ± 12.4 years; 38 men vs. 20 women; 69% of operated, at 17.1 ± 5.3 months; Tegner before injury at 6.3 ± 1.9 vs. 4.9 ± 1.7 after RTS). Return to sport was declarative patients answering yes/no to main sport, previous level, pivoting contact sport, competition. A global level of RTS was measured as the variation of Tegner score and weekly hours of practice before/after ACLT (Tegner score × weekly hours of practice). Fifty-one percent of patients returned to main sport, 28% to anterior level (of whom 56% to anterior level of main sport), 31% to same global activity level, 19% to competition, 43% to pivoting contact sport. “Tegner.hour score” has decreased by 16.3 ± 33.6 after surgery. There was a strong discordance between declarative RTS and return to similar global activity level with Kappa coefficient respectively of 0.19, 0.17, 0.05 and 0.29 for main sport, previous level, pivoting contact sport, competition. We confirmed low RTS rates with a clear discordance between different outcomes of RTS. Considering the global activity volume calculated with Tegner score (Tegner.hour) is an interesting alternative scale to evaluate RTS for moderate sport level patients.

ACL Surgery in Youth Athletes Works Well

Research Article| September 01 2016 ACL Surgery in Youth Athletes Works Well AAP Grand Rounds (2016) 36 (3): 25. https://doi.org/10.1542/gr.36-3-25 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation ACL Surgery in Youth Athletes Works Well. AAP Grand Rounds September 2016; 36 (3): 25. https://doi.org/10.1542/gr.36-3-25 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: anterior cruciate ligament, anterior cruciate ligament reconstruction, athlete, return to sport, sports, anterior cruciate ligament injuries Source: Chicorelli AM, Micheli LJ, Kelly M, et al. Return to sport after anterior cruciate ligament reconstruction in the skeletally immature athlete. Clin J Sport Med. 2016; 26(4): 266– 271; doi: https://doi.org/10.1097/JSM.0000000000000275Google Scholar Investigators from Boston Children’s Hospital (BCH) and The Ohio State Medical Center conducted a retrospective case series of skeletally immature athletes to assess their return to sport participation after anterior cruciate ligament (ACL) repair. Children were identified by chart review and were eligible if they were ≤14 years old and had ACL reconstructive surgery at BCH from 2001–2009. Eligible children were mailed an initial questionnaire about their ACL injury, cause of the injury (sport-related or non–sport-related trauma), type of sport at the time of injury, and return to sport after ACL surgery. A follow-up questionnaire was administered to those who completed the initial questionnaire to assess whether they returned to the same perceived pre-injury level of play (higher, same, lower, or did not return to sports) and whether this level of play was maintained. Patient demographics and the type of graft used in the ACL repair were obtained from chart review. Multivariate Cox proportional hazards regression was used to determine whether time to return to sports was influenced by age, sex, BMI, trauma as a cause of injury, or type of surgical graft. There were 250 initial questionnaires completed (75% response rate). Of these, 142 completed a follow-up questionnaire (57% response rate). Non–sport-related trauma was the cause of ACL injury in 24% of respondents. Among those with sport-related trauma as the cause of injury, the most common sport played at the time of injury was soccer. Most (96%) respondents returned to sport participation, with 75% stating that they returned to at least the same level of play. The median time to return was 9 months after ACL repair. Age, sex, trauma, and type of graft were not significant predictors of time to return to sport. The investigators conclude that most children with ACL injury are able to return to sport participation after ACL repair, with the median time to return being 9 months after repair. Dr. Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Operative treatment of ACL injuries in youth athletes is controversial because of concern about injury to the growth plates.1 Historically, the skeletally immature athlete with an ACL tear had been restricted from sports for 1–5 years until skeletal maturity, and then an ACL reconstruction was performed with an additional 9-month delay after surgery until the athlete was allowed to play sports. Delaying ACL reconstruction often negatively affects the athlete’s quality of life and may limit future participation in sports.2 In addition, prolonged nonoperative treatment waiting for skeletal maturity to occur can lead to repeat episodes of knee instability and meniscal or chondral damage and arthritis.3 Today, surgical techniques have been... You do not currently have access to this content.

Early Viscosupplementation After Anterior Cruciate Ligament Reconstruction

Background: Hyaluronic acid (HA) has been widely used to treat osteoarthritis given its biological and mechanical properties. Because HA is an “intra-articular” treatment approach that affects the joints, it could be used in the management of acute conditions, such as during the early postsurgical phase, to reduce inflammatory stress and improve articular function. Purpose: The aim of the present double-blind, randomized controlled trial was to evaluate pain control and functional recovery provided by a single injection of HA performed the day after anterior cruciate ligament (ACL) reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: The study enrolled 60 patients affected by primary, chronic, and symptomatic ACL tear requiring surgical reconstruction. All patients were treated with the same reconstructive technique and rehabilitation protocol. Exclusion criteria were (1) concurrent articular lesion requiring surgical treatment, (2) axial malalignment in the index limb, and (3) functional limitation or pain in the contralateral knee. The day after the procedure, the patients were randomized to receive a single injection of 3 mL HA or 3 mL saline solution after surgical drains were removed. All patients were evaluated at baseline and at 15, 30, 60, and 180 days and 12 months after surgery by use of the following tools: Short Form–36 Health Survey (SF-36), International Knee Documentation Committee (IKDC) subjective score, visual analog scale (VAS) for pain, VAS for general health status, and Tegner score. At each follow-up evaluation, the transpatellar circumference and active and passive range of motion (ROM) of both knees were recorded. Results: No severe adverse events were documented after early viscosupplementation. A significant improvement was documented in both treatment groups. Significant differences were documented in the transpatellar circumference at 60 days and in active ROM at 30 days postoperatively; patients who received HA had better values compared with the placebo group (P = .022 and .027, respectively). No statistically relevant intergroup differences were found in the clinical scores. Conclusion: The study documented no adverse events and had some positive findings in terms of active ROM recovery and transpatellar circumference reduction. However, the early postoperative application of viscosupplementation did not lead to significant improvement in clinical scores after ACL reconstruction. Registration: NCT02630407 (ClinicalTrials.gov identifier),

Incidence of and Factors Associated With the Decision to Undergo Anterior Cruciate Ligament Reconstruction 1 to 10 Years After Injury

Background: Among patients treated nonoperatively for 1 year after anterior cruciate ligament (ACL) disruption, little is known about the frequency of ACL reconstruction within the first year of injury and the effect of age range, sex, and meniscal tears on the incidence of ACL reconstruction between 1 and 10 years after injury. Purpose: To (1) define the rate of delayed ACL reconstruction (between 1 and 10 years after injury) in a population-based cohort of isolated ACL tears and (2) evaluate predictive factors associated with delayed reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: The study included a population-based cohort of 1841 patients with new-onset, isolated ACL tears that occurred between January 1, 1990, and December 31, 2010. The complete medical records were reviewed to confirm diagnosis and collect data on clinical characteristics and details of subsequent ACL surgery. To evaluate the incidence of ACL reconstruction between 1 and 10 years after injury, landmark survival analysis was performed with a landmark set at 1 year after injury. Early and late predictors of ACL reconstruction were analyzed using Cox proportional hazards regression. Results: A total of 661 patients were treated nonoperatively for the first year after ACL tears. Over a mean 10 years of follow-up, 213 patients (32%) underwent ACL reconstruction between 1 and 10 years after injury. Young age (hazard ratio [HR], 0.55 per decade increase in age; 95% CI, 0.48-0.62) and meniscal tear at injury (HR, 1.48; 95% CI, 1.12-1.95) were significant predictors of undergoing delayed reconstruction. The rate of delayed ACL reconstruction decreased significantly over the study period (P < .03). There was no association between sex (HR, 0.89; 95% CI, 0.67-1.16) and delayed ACL reconstruction. Among patients who had delayed ACL reconstruction, 40% experienced a secondary meniscal tear before surgery. Conclusion: In this study population of 1841 patients, 62% of patients received ACL reconstruction within 1 year of injury. Of patients treated nonoperatively for 1 year after ACL tears, 32% underwent delayed ACL reconstruction. Predictors of reconstruction beyond 1 year were young age (50% reduction in reconstruction per decade increased age) and baseline meniscal tear. Sex was not predictive for reconstruction beyond 1 year from injury.

Influence of Anterior Cruciate Ligament Tear on Thigh Muscle Strength and Hamstring-to-Quadriceps Ratio: A Meta-Analysis.

Theoretical compensation after anterior cruciate ligament (ACL) tear could cause quadriceps weakness and hamstring activation, preventing anterior tibial subluxation and affecting the expected hamstring-to-quadriceps ratio. Although quadriceps weakness often occurs after ACL tears, it remains unclear whether hamstring strength and hamstring-to-quadriceps ratio increase in ACL deficient knees. This meta-analysis compared the isokinetic muscle strength of quadriceps and hamstring muscles, and the hamstring-to-quadriceps ratio, of the injured and injured limbs of patients with ACL tears. This meta-analysis included all studies comparing isokinetic thigh muscle strengths and hamstring-to-quadriceps ratio in the injured and uninjured legs of patients with ACL tear, without or before surgery. Thirteen studies were included in the meta-analysis. Quadriceps and hamstring strengths were 22.3 N∙m (95% CI: 15.2 to 29.3 N∙m; P<0.001) and 7.4 N∙m (95% CI: 4.3 to 10.5 N∙m; P<0.001) lower, respectively, on the injured than on the uninjured side. The mean hamstring-to-quadriceps ratio was 4% greater in ACL deficient than in uninjured limbs (95% CI: 1.7% to 6.3%; P<0.001). Conclusively, Decreases were observed in both the quadriceps and hamstring muscles of patients with ACL tear, with the decrease in quadriceps strength being 3-fold greater. These uneven reductions slightly increase the hamstring-to-quadriceps ratio in ACL deficient knees.

Return to Sport Among French Alpine Skiers After an Anterior Cruciate Ligament Rupture

Background: There is little known about return to sport and performance after anterior cruciate ligament (ACL) tear in high-level alpine skiers. Purpose: To analyze the parameters that influence the return to sport and performance after an ACL tear in French alpine skiers from 1980 to 2013. Study Design: Descriptive epidemiology study. Methods: The study population included 239 male and 238 female skiers who competed on the national French alpine ski team for at least 1 season between 1980 and 2013 in the speed (downhill and super-G) and technical disciplines (giant slalom and slalom). Two groups were formed: group 1 (G1) included athletes who had sustained an ACL rupture, and group 2 (G2) included athletes who had never sustained an ACL rupture. Three performance indicators were selected: International Ski Federation (FIS) points calculation, FIS ranking, and podium finishes in the World Cup, World Championships, and Olympic Games. Results: The first-decile FIS points and international FIS ranking showed that G1 skiers obtained better performance than did G2 skiers. The mean ± SD career length of G1 skiers (men, 7.9 ± 4.7 years; women, 7.1 ± 4.1 years) was longer than that of G2 skiers (men, 4.5 ± 3.3 years; women, 4.2 ± 3.5 years). In addition, 12.8% (61 of 477) of the skiers achieved at least a podium finish during their careers: 23.0% (34 of 148) in G1 and 8.3% (27 of 329) in G2. The mean age at ACL rupture was 22.6 ± 4.1 years for men and 19.9 ± 3.5 years for women. In G1, 55 podiums were achieved before ACL rupture and 176 after in all competitions. Skiers who improved their performances after ACL rupture were significantly younger (men, 22.2 ± 3.0 years; women, 18.7 ± 2.2 years; P < .0001) at the time of injury than those showing a performance deterioration after ACL rupture (men, 25.3 ± 4.2 years; women, 22.4 ± 4.0 years). All skiers who had ACL tears continued their competitive careers after the injury. Conclusion: The overall results showed that it is possible to return to preinjury or even higher levels of performance after an ACL rupture and that age is the main element that guides postsurgical recovery.

Procedural intervention for arthrofibrosis after ACL reconstruction: trends over two decades.

Arthrofibrosis is a rare complication after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to (1) report a population-based incidence of arthrofibrosis (as defined by manipulation under anaesthesia or surgical lysis of adhesions) following ACL injury and reconstruction, (2) identify risk factors associated with development of arthrofibrosis, and (3) report outcomes of intervention for arthrofibrosis. This was a historical cohort study performed in Olmsted County, Minnesota. The Rochester Epidemiology Project (REP) was used to identify a population-based cohort of individuals with new-onset, isolated ACL tears between 1 January 1990 and 31 December 2010. The REP database provides access to all medical records for each resident of Olmsted County, regardless of the facility where the care was delivered. A total of 1841 individuals were identified with new-onset, isolated ACL tears and were confirmed with chart review. The intervention incidence for arthrofibrosis was then calculated, and various predictive factors including age, sex, calendar year, and meniscal injury were investigated. During follow-up, 5 patients (1.0%) in the non-operative cohort and 23 patients (1.7%) in the ACL reconstruction cohort received intervention for arthrofibrosis, corresponding to an incidence of 0.7 per 1000 person-years in the non-operative cohort and 1.9 per 1000 person-years in the ACL reconstruction cohort. Female patients were 2.5 times more likely to have arthrofibrosis than males. The mean preoperative range of motion was -8° to 83° and improved to a mean of -2° to 127° post-operatively. Arthrofibrosis remains a rare but potentially devastating complication after ACL reconstruction, and roughly 2% of patients had post-operative stiffness that required intervention. Female patients are at higher risk of arthrofibrosis. However, when patients develop severe motion complications after ACL injury, interventions are generally effective in preventing permanent arthrofibrosis.

Barriers to the return to sport after anterior cruciate ligament tear in operative vs. conservative patients

Return to sports (RTS) rates after anterior cruciate ligament tear (ACLT) is lower than expected despite good functional scores in operated (OP) as well as non-operated (NOP) patients. These barriers to RTS are not clear especially for NOP in the literature. The purpose was to evaluate the subjective and objective outcomes associated with no RTS after ACLT in OP vs. NOP. All patient within 6 months to 2 years from ligamentoplasty, and 1 to 2 years from injury for conservative treatment could be included. Exclusion criteria were history of ACL tear, posterior ligament surgery, neurologic injury and complex fracture. Return to sport (main sport, previous level, competition, with pivoting contact) was declarative but also measures as the variation of the global activity volume (Tegner score × weekly hours of practice). The subjective (stiffness, pain, effusion, instability, lack of strength, motivation or time, fear of re-injury) and objective barriers (demographic, clinical, functional and psychological scores) were collected. 18 NOP (women 61%, mean age; 38 y, leisure level) vs. 40 OP (men 77%, mean age: 32 y, competitors) were included 23 months after ACLT, 15 months after surgery. Half of the patients (50 vs. 45%) returned to their main sport. RTS at previous level for the main sport remained uncertain, 33% for NOP vs. 67% ( P = 0.1) for OP, whereas return to global activity level (based on Tegner score and sport hours) was 61% vs. 18% ( P = 0.002). The main reason for no RTS was fear of re-injury (73 for NOP vs. 59% for OP), lack of time (27 vs. 36%) and pain (33 vs. 23%), lack of motivation (27 vs. 9%, P < 0.05) and strength for OP (7 vs. 14%). Objective outcomes associated with no RTS were stiffness ( P = 0.011), low one-leg hop test performances ( P = 0.008); amyotrophy ( P = 0.004) and decreased physical self-perception ( P = 0.001) in OP; weak IKDC (71, P = 0.01) and KOOS (94, P = 0.008) scores for NOP. Low ACL-RSI scores were associated with fear of re-injury ( P = 0.001). Psychological factors (fear of re-injury, physical self-perception) largely influence RTS. These factors should help the decision for surgery or not after ACLT.

Postoperative discomfort after outpatient anterior cruciate ligament reconstruction: A prospective comparative study

IntroductionThe principal objective of the present study was to compare rates of postoperative discomfort after anterior cruciate ligament (ACL) reconstruction between inpatient (In) and outpatient (Out) management. Patients and methodA single-surgeon non-randomized prospective comparative study included patients undergoing primary surgery for isolated ACL tear by short hamstring graft in 2012–13. The Out group comprised patients eligible for and consenting to outpatient surgery and the In group, those not eligible or not consenting. The principal assessment criterion was onset of at least 1 symptom of postoperative discomfort (SPD): anxiety, nausea and vomiting, malaise, vertigo or stomach pain, between postoperative days 0 and 3. Secondary assessment criteria were difficulty in getting to sleep, getting up during the night, regular walking or going out, number of episodes of knee pain and waking because of pain. All criteria were assessed on-line by the patient. ResultsOne hundred and thirty-three patients filled out the questionnaire, 70 in the Out group and 63 in the In group; 42 females, 91 males; mean age, 30±9 years. Between D0 and D3, the proportion of patients with ≥l SPD was comparable between groups (Out 37% vs In 41%, P=0.62). Out-group patients had significantly less difficulty sleeping the first postoperative night (P=0.01), got up significantly more often during the first night after surgery (P<0.0001), more often walked regularly on day 1 (P=0.03), and were significantly less often woken by pain during the first night (P=0.003). Risk factors for SPD were female gender (OR=4.8±1.9) and postoperative complications (OR=3.8±2.5). ConclusionPatients undergoing ACL reconstruction on an outpatient basis did not show more symptoms of postoperative discomfort than those managed as conventional inpatients. Level of evidenceIV; prospective comparative study.

CSM 2014 Sports Physical Therapy Section Platform Presentations (Abstracts SPL1–SPL66)

CSM 2014 Sports Physical Therapy Section Platform Presentations (Abstracts SPL1–SPL66)

The 2013 Sisk Awards

The 2013 Sisk Awards