Anterior Cruciate Ligament Return To Sport After Injury Research Articles

AN INVESTIGATION OF SEX-BASED DIFFERENCES IN PHYSICAL AND PSYCHOLOGICAL RECOVERY, AND RETURN TO SPORT, FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

INTRODUCTION & AIMS Despite the increasing rate of anterior cruciate ligament (ACL) tears and surgical reconstruction (ACLR), little is known about the post-operative recovery in males versus females. Understanding differences in the recovery between sexes will assist in better tailoring rehabilitation, return to sport (RTS) and counselling pathways. This study investigated sex-based differences in the physical and psychological recovery of both females and males after ACLR. METHODS This study recruited 104 patients (49 females, 55 males) undergoing ACLR. Patients were assessed pre-operatively and at 6, 12 and 24 months post-surgery, via patient-reported outcome measures (PROMs) including the International Knee Documentation Committee (IKDC) form, the Tegner Activity Scale (TAS) and the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) score. Patients embarked on an assessment of peak isokinetic knee extensor (PKET) and flexor (PKFT) torque and a 4-hop performance battery. Limb Symmetry Indices (LSIs) were calculated. The incidence of RTS was investigated. RESULTS All PROMs significantly improved (p<0.05), though females reported significantly lower ACL-RSI (p=0.002) and IKDC (p=0.007) scores. While no sex-based differences were observed in hop test LSIs, males demonstrated significantly higher mean LSIs for PKET at 6 (p=0.037) and 24 (0.047) months, and PKFT at 6 (p=0.007) and 12 (p=0.002) months. At 24-months post-surgery, a significantly greater (p=0.030) percentage of male patients had returned to pivoting sports. CONCLUSION This study demonstrates the disparity between sexes in physical and psychological recovery, as well as RTS status, in community-level patients undergoing ACLR. The development and implementation of enhanced post-operative patient-centered care may be warranted tailored to sex, encompassing rehabilitation, education, and counseling after ACLR to promote increased engagement in rehabilitation.

A RANDOMIZED CONTROLLED TRIAL INVESTIGATING PATIENT RECOVERY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION UNDERTAKEN WITH A QUADRICEPS VERSUS HAMSTRINGS TENDON AUTOGRAFT

INTRODUCTION & AIMS Anterior cruciate ligament (ACL) tears are common. However, a lack of high-quality evidence exists comparing different graft options in patients undergoing surgical reconstruction (ACLR). This randomized controlled trial (RCT) investigated the course of recovery in patients undergoing ACLR with either a quadriceps (QT) or hamstrings (HT) tendon autograft. METHODS This study randomized 112 patients to one of the two graft reconstruction cohorts (HT=55, QT=57), subsequently undergoing ACLR and a structured rehabilitation program. Patients were assessed pre-surgery and at 6 weeks and 3, 6, 12 and 24 months, with a range of patient-reported outcome measures (PROMs) including the International Knee Documentation Committee form (IKDC) and the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) score. Graft laxity, peak isokinetic knee extensor and flexor strength and a 6-hop performance battery were assessed. Limb Symmetry Indices (LSIs) were calculated. RESULTS All PROMs significantly improved (p<0.0001). Apart from the ACL-RSI score which was significantly better (p<0.05) in the HT group at 3, 6 and 12 months, no other group differences (p>0.05) were observed. No group differences (p=0.407) were observed for knee laxity. While the HT group demonstrated significantly greater (p<0.05) quadriceps strength LSIs at 6 and 12 months, the QT group demonstrated significantly greater (p<0.05) hamstrings strength LSIs at 6, 12 and 24 months. The HT group demonstrated significantly greater (p<0.05) LSIs for the single horizontal (6 months), lateral (6 and 12 months) and medial (6 months) hop tests. CONCLUSION The HT group reported a higher level of psychological readiness to return to sport, while demonstrating greater quadriceps strength (and hop test) LSIs. Greater hamstring strength LSIs were observed for the QT cohort. Longer-term review will continue to evaluate RTS and later-stage re-injury between the two graft constructs.

Psychological aspects associated with ACL rehabilitation and recurrence in football players: a systematic review

Although most football players recover good physical function after anterior cruciate ligament (ACL) surgery, some do not return to their sport or to the same pre-injury level, and there is a risk of recurrence. Therefore, this study aimed to examine research on psychological aspects of ACL rehabilitation and Return to Play (RTP), as well as their influence on possible recurrence in football and futsal players. The search was conducted using the Scopus, PubMed, WoS, CENTRAL databases, and grey literature sources DART-Europe and OpenGrey. A total of nine studies met the inclusion criteria. The results indicated as the most evaluated psychological factor the psychological readiness to RTP through the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI). Likewise, psychological interventions in ACL-injured football players have positive effects on mood states, reduces pain perception, and fear reinjury, among others. Risk profiles for recurrence included vulnerability to stress and high psychological readiness to RTP. Therefore, psychological interventions should be incorporated into the rehabilitation process and screening to identify players at risk for poor outcomes or recurrences. Additional research would help to understand the influence of other variables or optimal levels of psychological readiness to RTP. Keywords: anterior cruciate ligament; RTP; sports injury; psychology; rehabilitation.

French Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Development and Validation.

The 12-item Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale was developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR). A short (6-item) English version was also developed, which has shown to have good reliability and validity. We aimed to develop and validate a French version of the short ACL-RSI scale. We hypothesized that the same questions would remain in the selection as the English version and that the French version of the scale would have the same psychometric properties. Cohort study (diagnosis); Level of evidence, 3. The full 12-item French ACL-RSI scale was administered to 1000 patients who had undergone ACLR surgery. Reliability (Cronbach alpha) and factor analysis of the full scale were determined. Item selection and elimination process was conducted to develop a short (6-item) version. The same methodology was used to develop the English short ACL-RSI scale. A minimal (3-item) version was also developed and assessed. Internal consistency of the full version of the French ACL-RSI was found to be high (Cronbach alpha = .95), suggesting item redundancy. The short (6-item) version was also found to have high internal consistency (Cronbach alpha = .92) and was strongly correlated with the full version (r = 0.98). The minimal (3-item) version was also found to have high internal consistency, as well as a strong correlation with the full version (r = 0.94). The French version of the short (6-item) ACL-RSI scale was valid, discriminant, consistent, and reproducible. The minimal (3-item) version was also found to be useful and more efficient to collect the information provided by the full ACL-RSI in a French-speaking population.

A Prospective Randomized Controlled Trial Investigating Quadriceps Versus Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction

Background: Numerous graft options are available when undertaking anterior cruciate ligament (ACL) reconstruction (ACLR), although a lack of high-quality evidence exists comparing quadriceps (QT) and hamstring (HT) autografts. Purpose: To investigate patient outcomes in patients undergoing HT versus QT ACLR. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: After recruitment and randomization, 112 patients (HT = 55; QT = 57) underwent ACLR. Patients were assessed pre- and postoperatively (6 weeks and 3, 6, 12, and 24 months), with a range of patient-reported outcome measures (PROMs), graft laxity (KT-1000 arthrometer; primary outcome variable), active knee flexion and extension range of motion (ROM), peak isokinetic knee extensor and flexor strength, and a 6-hop performance battery. Limb symmetry indices (LSIs) were calculated for strength and hop measures. Secondary procedures, ACL retears, and contralateral ACL tears were reported. Results: All PROMs and knee ROM measures significantly improved (P < .0001), and no other group differences (P > .05) were observed—apart from the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) score, which was significantly better in the HT group at 3 (P = .008), 6 (P = .010), and 12 (P = .014) months. No significant changes were observed in side-to-side laxity from 6 to 24 months (P = .105), and no group differences were observed (P = .487) at 6 (HT mean, 1.2; QT mean, 1.3), 12 (HT mean, 1.1; QT mean, 1.3), and 24 (HT mean, 1.1; QT mean, 1.2) months. While the HT group demonstrated significantly greater (P < .05) quadriceps strength LSIs at 6 and 12 months, the QT group showed significantly greater (P < .05) hamstring strength LSIs at 6, 12, and 24 months. The HT group showed significantly greater (P < .05) LSIs for the single horizontal (6 months), lateral (6 and 12 months), and medial (6 months) hop tests for distance. Up until 24 months, 1 patient (QT at 22 months) had a retear, with 2 contralateral ACL tears (QT at 19 months; HT at 23 months). Secondary procedures included 5 in the HT group (manipulation under anesthesia, notch debridement, meniscal repair, and knee arthroscopy for scar tissue) and 6 in the QT group (notch debridement, meniscal repair, knee arthroscopy for scar tissue, tibial tubercle transfer, and osteochondral autologous transplantation). Conclusion: Apart from the ACL-RSI, the 2 autograft groups compared well for PROMs, knee ROM, and laxity. However, greater hamstring strength LSIs were observed for the QT cohort, with greater quadriceps strength (and hop test) LSIs in the HT cohort. The longer-term review will continue to evaluate return to sports and later-stage reinjury between the 2 graft constructs. Registration: ACTRN12618001520224p (Australian New Zealand Clinical Trials Registry).

Functional and Psychological Preparedness of Athletes Post ACL Repair.

This study was conducted to see whether those who had anterior cruciate ligament (ACL) reconstructions on their dominant legs performed better than those who had them on their nondominant legs 1-10 years after the surgery. An examination of people who sustained injuries to their dominant (n = 25) and nondominant (n = 25) legs between 1 and 10 years after ACL repair was undertaken in a cross-sectional research with 50 people aged 20-38. Everyone takes the fear avoidance belief questionnaire for physical activity (FABQ-PA), the lower extremity functional scale (LEFS), and the anterior cruciate ligament return to sport after injury (ACL-RSI) survey. There was no statistically significant difference between the groups on the ACL-RSI, LEFS, and FABQ-PA (U = 254, P = 0.26; U = 314.4, P = 0.95; and U = 279.4, P = 0.53 correspondingly). Functional performance and patient mental health should be evaluated 1-10 years after ACL surgery. However, there is no correlation between which leg was the dominant one and the results. As a result, it has been shown that both dominant and nondominant leg injuries heal similarly over time. Future studies should examine additional variables that affect healing and return-to-sport results to improve rehabilitation and optimize long-term functional outcomes for individuals after ACL repair.

Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) subcategories are affected by subjective running ability and medial single-leg hop distance in postreconstruction patients at 6 months.

This study aimed to investigate the intricate relationship between physical function factors and each subcategory score of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale among patients following ACL reconstruction. Participants comprised 59 patients who had undergone primary ACL reconstruction using hamstring tendon. The ACL-RSI was completed 6 months after reconstruction and five physical functions were measured in patients on the same day. Simple linear regression was performed multiple times to investigate the relationship between ACL-RSI subcategory scores as a dependent variable and each independent variable (knee strength, leg anterior reach distance, single-leg hop [SLH] distances, side bridge endurance, and subjective running ability). Multiple regression analysis was performed using a stepwise method, with factors showing a risk rate <0.05 in simple linear regression analyses as independent variables and the ACL-RSI in each subcategory score as the dependent variable. Multiple regression analysis showed that subjective running ability affected all subcategories (p ≤ 0.001), and that the limb symmetry index of medial SLH distance affected both the Emotions (p = 0.047) and Confidence (p = 0.009) subcategories. Higher subjective running ability and greater limb symmetry in the medial SLH were thus positively associated with each dimension of psychological readiness. This study highlights the differential impact of physical function factors on specific subcategories of the ACL-RSI scale, providing clinicians with insights for designing targeted rehabilitation strategies. This original paper suggests the importance of analysing factors related to subcategory scores in addition to total ACL-RSI score, and could contribute to the understanding of determinants for a successful return to sport following ACL reconstruction. Level IV.

Short-term fear of movement improves less after anterior cruciate ligament reconstruction with concomitant meniscus repair

BackgroundPsychological response is important in return-to-sport decisions for athletes recovering from anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to compare psychological response after ACLR with a concomitant meniscus repair compared to isolated ACLR. MethodsThirty-five individuals completed the Tampa Scale of Kinesiophobia (TSK) and Anterior Cruciate Ligament Return-to-Sport after Injury (ACL-RSI) scale before ACLR and 2, 4, and 6 months after ACLR. Participants were dichotomized based on presence of concomitant meniscus repair (Yes/No). Separate group X time repeated measures analyses of variance were conducted for both scales. ResultsParticipants were 65.7% female, 19.1 ± 4.7 years old with BMI of 24.9 ± 4.4 kg/m2. Sixteen individuals had an isolated ACLR with 19 individuals having an ACLR with concomitant meniscus repair. For the TSK, there was a group × time interaction effect(p = 0.028), with improvement in TSK scores for the isolated ACLR group (ACLR:2 months = 24.8 ± 3.7; 4 months = 22.0 ± 5.7; 6 months: 19.9 ± 5.9; Meniscus Repair:2 months = 25.5 ± 4.7; 4 months = 24.1 ± 5.0; 6 months: 23.8 ± 4.7). Six months after ACLR, TSK scores were worse in the meniscus repair group(p = 0.036). For the ACL-RSI, there was no interaction(p = 0.07). ConclusionConcomitant meniscus repair with ACLR results in less post-operative improvement in kinesiophobia through 6 months after ACLR compared to isolated ACLR.

THE EFFECT OF TIME AND SEX ON POST-ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION PSYCHOLOGICAL PATIENT REPORTED OUTCOME MEASURE SCORES.

Low scores on psychological patient reported outcomes measures (PROMs), including the anterior cruciate ligament-return to sport after injury (ACL-RSI) and injury-psychological readiness to return to sport (I-PRRS), after anterior cruciate ligament (ACL) reconstruction (ACLR) have been associated with a maladaptive psychological response to injury and poor prognosis. The purpose of this study was to assess the effect of time post-ACLR and sex on ACL-RSI and I-PRRS scores and generate normative reference curves. It was hypothesized that males would demonstrate higher ACL-RSI and I-PRRS scores than females in the first 1-year post-ACLR. Case series. Outpatient sports medicine and orthopedic clinic. 507 patients post-primary ACLR 12-to-30-years-old with 796 ACL-RSI or I-PRRS scores one or more times between 0- and 1-year post-ACLR (age at ACLR: 17.9 ± 3.0 y). An honest broker provided anonymous data from our institution's knee injury clinical database. Generalized additive models for location, scale, and shape and generalized least squares analyses were used to assess the effect of time post-ACLR and sex on ACL-RSI and I-PRRS scores. ACL-RSI and I-PRRS scores increased over time post-ACLR, and males had higher scores compared to females up until approximately five months post-ACLR with scores converging thereafter. Males report higher ACL-RSI and I-PRRS scores compared to females in the initial stages of rehabilitation, but scores converge between sexes at times associated with return to play following ACLR. Normative reference curves can be used to objectively appraise patients' ACL-RSI and I-PRRS scores at any time point post-ACLR. This may lead to timely identification of patients with scores or changes in scores over time post-ACLR associated with a maladaptive psychological response to injury and a poor prognosis and optimized ACLR outcomes.

Psychological Readiness, Injury-Related Fear, and Persistent Knee Symptoms After Anterior Cruciate Ligament Reconstruction.

Poor psychological responses after anterior cruciate ligament reconstruction (ACLR) have been associated with a failure to return to sport and increased secondary injury risk. However, we do not know whether poor psychological responses after ACLR influence patient-reported knee function and knee symptoms. To examine the association between psychological factors (ie, psychological readiness and injury-related fear) and the presence of persistent knee symptoms in individuals 6 to 12 months after ACLR. Cross-sectional study. Research laboratory. In total, 101 participants, aged 13 to 25 years old, between 6 and 12 months after primary unilateral ACLR were enrolled in the study. Persistent knee symptoms were identified using an established criterion based on the subscales of the Knee injury and Osteoarthritis Outcome Score. Participants also completed the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) and the Tampa Scale of Kinesiophobia-11 (TSK-11) to assess psychological readiness and injury-related fear, respectively. Higher ACL-RSI scores indicate higher psychological readiness, and higher TSK-11 scores indicate higher injury-related fear. Twenty-nine participants (29%) met the criteria for persistent knee symptoms. For every 1 SD lower in the ACL-RSI score, participants had 2.1 times greater odds of persistent knee symptoms after ACLR (95% CI = 1.3, 3.6). For every 1 SD higher in the TSK-11 score, participants had 1.9 times greater odds of persistent knee symptoms after ACLR (95% CI = 1.1, 3.3). Both the ACL-RSI and TSK-11 were considered good at classifying persistent knee symptoms, as the areas under the curve were 0.78 and 0.73, respectively. Individuals with a lower level of psychological readiness and more injury-related fear after ACLR had greater odds of persistent knee symptoms. Overall, these results highlight the potential clinical benefit of a comprehensive, biopsychosocial approach to managing health and wellness for individuals after ACLR.

The Role of Strength-Related Factors on Psychological Readiness for Return to Sport Following Anterior Cruciate Ligament (ACL) Reconstruction.

Psychological readiness following anterior cruciate ligament reconstruction (ACLR) correlates with different return to sport outcomes. However, the relationship between strength and power and psychological readiness remains unexplored. The aim of this study was to investigate the relationship between anterior cruciate ligament return to sport after injury (ACL-RSI) scores and various hamstrings and quadriceps strength and power variables. Twelve participants (20.7 ± 2.5 years old; 174.2 ± 7.5 cm; 70.2 ± 8.5 kg; 18.2 ± 8.3% of body fat) who had an ACLR nine months or more before the study completed the ACL-RSI questionnaire and isokinetic strength testing of the hamstrings and quadriceps (60°·s-1 and 180°·s-1). Based on ACL-RSI scores, they were divided into "cases" and "controls", deemed not psychologically ready and psychologically ready to return to previous sport performance (PILOS), respectively. The main findings are that quadriceps' and hamstrings' rate of torque development (RTD) and time since surgery were determinants of psychological readiness following ACLR. Furthermore, compared to controls, cases showed significantly lower quadriceps torque at angles close to full knee extension (40 deg and 30 deg from extension). They also showed lower RTD than controls, but no difference in peak torque. These results suggest that physiotherapists should facilitate athletes' return to sport (RTS) by focusing on the restoration of RTD and strength at angles close to full knee extension.

Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study

Background: Sports function and psychological readiness to return to sports (RTS) are important outcomes when evaluating rehabilitation after anterior cruciate ligament reconstruction (ACLR). It is, however, unclear which specific factors contribute most to these outcomes. Purpose: To determine associations between demographic characteristics, objective measurements of physical function, patient-reported outcome measure scores, sports-related function assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation subscale, and psychological readiness to RTS assessed with the Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale at 1 year after ACLR. Study Design: Cross-sectional study; Level of evidence, 3. Methods: At a mean of 12.5 ± 2.0 months after ACLR, 143 participants (50.3% female), with a mean age of 25.0 ± 5.7 years, were assessed for demographic characteristics, physical factors (hop performance, muscle strength, ankle and hip range of motion), and psychological factors (KOOS Pain and Symptoms subscales, Perceived Stress Scale, fear of reinjury) as well as the KOOS Sport and Recreation subscale and ACL-RSI scale. Backward linear regression models were used to evaluate factors associated with sports function and psychological readiness to RTS. Results: Lower isokinetic knee extension peak torque (limb symmetry index) (B = 18.38 [95% CI, 3.01-33.75]), lower preinjury activity level (B = 2.00 [95% CI, 0.87-3.14]), greater knee pain (B = 0.90 [95% CI, 0.70-1.10]), shorter time between injury and reconstruction (B = 0.16 [95% CI, 0.05-0.26]), and greater fear of reinjury (B = 0.11 [95% CI, 0.01-0.20]) were associated with a worse KOOS Sport and Recreation subscore (R2 = 0.683). A shorter hop distance (B = 0.15 [95% CI, 0.00-0.29]) was associated with a lower ACL-RSI score (R2 = 0.245). Conclusion: A combination of knee muscle strength, activity level, knee pain, timing of surgery, and fear of reinjury accounted for approximately 70% of the variation in sports function at 1 year after ACLR. In contrast, there was only 1 weak association between physical function and psychological readiness to RTS at this time point. Thus, factors associated with current sports function are much better known than features related to psychological readiness to RTS.

Association of Psychological Readiness to Return to Sports With Subjective Level of Return at 12 Months After ACL Reconstruction.

Return-to-sports (RTS) rates after anterior cruciate ligament (ACL) reconstruction (ACLR) differ according to the level at which patients return. It is unclear whether the level of RTS is affected by psychological readiness to return. To examine the association between psychological readiness to RTS and subjective RTS level 12 months after ACLR. Case-control study; Level of evidence, 3. A total of 47 patients who underwent unilateral primary ACLR surgery were enrolled. Assessments at 6 and 12 months postoperatively consisted of knee strength testing (isokinetic quadriceps and hamstring strength), the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF), and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale to measure psychological readiness to RTS. Patients were assigned to 1 of 3 subgroups based on their subjective assessment of RTS level at 12 months postoperatively: RTS at or above preinjury level (RTS≥Pre; n = 19), RTS below preinjury level (RTS<Pre; n = 24), or no RTS (n = 4). Two-way mixed-model analysis of variance was used to examine the effects of RTS subgroup, postoperative time point, and group × time interaction with patient characteristics, knee strength, and IKDC-SKF and ACL-RSI scores. Multivariate logistic regression analysis was performed to determine which factors were associated with RTS subgroupings. Significant differences were found among the RTS≥Pre, RTS<Pre, and no-RTS groups in age, ACL-RSI score at 6 and 12 months, quadriceps strength at 6 and 12 months, and IKDC-SKF score at 6 and 12 months (P < .001 for all). Multivariate logistic regression analysis revealed that RTS at or above preinjury level was associated with higher ACL-RSI score at 12 months postoperatively (odds ratio [OR], 1.11; 95% CI, 1.05-1.20; P = .003) and younger age (OR, 0.80; 95% CI, 0.61-0.92; P = .012). The ACL-RSI score was significantly different among the study groups, and the ACL-RSI score at 12 months postoperatively and younger age were associated with RTS at or above preinjury level.

Validation of the ACL-RSI Scale in Pediatric and Adolescent Patients

Background: The Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale is a 12-item questionnaire assessing psychological readiness to return to sport after anterior cruciate ligament reconstruction. It has been validated for use in adults in multiple languages and in an abbreviated 6-question short form. Additionally, literature has been published using this scale in pediatric and adolescent populations, however it has not yet been validated for use with them. Purpose: To validate the ACL-RSI scale for use with pediatric and adolescent patients. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Scores of 6- and 12-item ACL-RSI scales for patients undergoing return-to-sport readiness testing 6 to 8 months after anterior cruciate ligament reconstruction were analyzed. Convergent validity testing was performed against the International Knee Documentation Committee (IKDC)/Pediatric IKDC score, Single Assessment Numeric Evaluation (SANE) score, and peak torque asymmetry of knee flexion and extension using Spearman correlations. Discriminant validity testing was performed against age (Spearman correlation), body mass index (Spearman correlation), and sex (Mann-Whitney U test). Reliability testing was performed by calculating Cronbach’s alpha. Floor and ceiling effects were assessed by calculating the number of minimum and maximum scores in the cohort. Results: A total of 51 patients were included in the final analysis. The mean age at surgery was 15.2 ± 2.2 years, and 51.0% were female. The 6- and 12-item ACL-RSI scales demonstrated a strong significant positive correlation with IKDC/Pediatric IKDC scores (R = 0.723 and 0.717, respectively; P < .001) and moderate significant positive correlation with Single Assessment Numeric Evaluation scores (R = 0.516 and 0.502, respectively; P < .001) Age at surgery, body mass index, and sex were not correlated with either ACL-RSI scale. Cronbach’s alpha values of the 12- and 6-item ACL-RSI scales in this population were 0.959 and 0.897, respectively. For both the 12- and the 6-item ACL-RSI scales, no floor or ceiling effects were found as the minimum score (0) was not observed in either version, and the maximum score (100) was only observed twice (3.9%) in both versions. Conclusion: The ACL-RSI scale is valid to use with pediatric and adolescent patients. The 6-item scale may be a better choice because it has fewer redundancies and minimizes the risk of questionnaire fatigue.

The Association of Physical Competence With Psychological Response Among Young Athletes at Time of Return to Sport After ACL Reconstruction.

The traditional index of return-to-sport (RTS) readiness after anterior cruciate ligament reconstruction (ACLR) is the achievement of physical competence criteria. Emerging research indicates that psychological response and self-perceptions of physical competence may be critical mechanisms for successful RTS among young athletes. Young athletes with higher actual physical competence (APC) and perceived physical competence (PPC) will demonstrate a more positive psychological response at the time of RTS after ACLR. Cross-sectional study; Level of evidence, 3. A total of 41 young athletes after primary ACLR completed testing within 8 weeks of medical clearance to RTS. APC was measured with isokinetic knee extension strength, single-limb crossover hop for distance, and the Knee injury and Osteoarthritis Outcome Score. PPC was measured with the Athletic Competence subscale of the Self-Perception Profile. Criteria for APC and PPC were based on established age- and activity-relevant cutoff scores. Different constructs of psychological response were assessed with the adapted Sport Motivation Scale, Brief Resilience Scale, and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) total and subscale scores (Emotions, Confidence, and Risk Appraisal). Multiple linear regression analyses were used to determine differences in measures of psychological response based on achievement of APC and PPC, while adjusting for age and sex. Of the 41 participants, 10 (24.4%) met all criteria for APC and 22 (53.7%) met the PPC criteria. The regression models estimating the ACL-RSI score (P < .001; adjusted R2 = 0.331), ACL-RSI Emotions score (P < .001; adjusted R2 = 0.427), and ACL-RSI Risk Appraisal score (P = .013; adjusted R2 = 0.212) were statistically significant. Although APC was not associated with any measure of psychological response, meeting PPC criteria, younger age, and male sex were found to be associated with a more positive psychological readiness to RTS, but not with motivation or resilience. Meeting PPC criteria was associated with higher psychological readiness to RTS among young athletes after ACLR, while meeting APC criteria was not associated with any construct of psychological response.

Responsiveness of the Indonesian Versions of the Anterior Cruciate Ligament-Return to Sport After Injury Score, the International Knee Documentation Committee Subjective Knee Form, and the Lysholm Score in Patients With ACL Injury.

The Indonesian versions of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), International Knee Documentation Committee subjective knee form (IKDC), and the Lysholm scores are considered valid and reliable for Indonesian-speaking patients with anterior cruciate ligament (ACL) injury. The purpose of this study was to determine the responsiveness of the ACL-RSI, IKDC, and Lysholm scores in an Indonesian-speaking population with ACL injury. It was hypothesized that they would have good responsiveness. Cohort study (diagnosis); Level of evidence, 2. Between March 1, 2021, and February 28, 2022, patients with an ACL injury at a single hospital in Indonesia were asked to complete the ACL-RSI, IKDC, and Lysholm scores before either reconstruction surgery or nonoperative treatment. At 6 months after treatment, the patients completed all 3 scores a second time, plus a global rating of change question. The distribution-based and the anchor-based methods were used to study responsiveness. For each scale, the standardized response mean, minimal clinically important difference (MCID), and minimal detectable change (MDC; at the group [MDCgr] and individual [MDCind] levels) for each scale were determined. Of 80 eligible patients, 75 (93.8%) completed the study. The standardized response means for the ACL-RSI, IKDC, and Lysholm scores were 1.59, 1.72, and 1.51, respectively, indicating good responsiveness. The MCIDs for the ACL-RSI, IKDC, and Lysholm scores were 6.8, 7.8, and 4.8, respectively; all MCIDs were larger than that of the MDCgr (1.1, 0.7, and 0.6, respectively). At the individual level, the MCID for the IKDC was larger than the MDCind (7.8 vs 5.8). However, the MCIDs for ACL-RSI and Lysholm scores were smaller than those of the MDCind (6.8 vs 10.9 and 4.8 vs 5.1, respectively). The Indonesian ACL-RSI, IKDC, and Lysholm scores indicated good responsiveness and can be used in the follow-up of patients after ACL injury, especially at the group level. In individual patients, IKDC was found to be more efficient than the ACL-RSI or Lysholm scores for detecting clinically important changes over time after ACL treatment.

Clinical outcomes of arthroscopic partial resection of mucoid degeneration of anterior cruciate ligament.

Mucoid degeneration of the anterior cruciate ligament is rare condition; mucoid degeneration affects the range of motion of the knee with pain on terminal extension and terminal flexion. Arthroscopic treatment of the mucoid anterior cruciate ligament (ACL) is the treatment of choice. The purpose of this study was to provide demographic and clinical characteristic of mucoid degeneration of ACL and assess the outcomes of partial arthroscopic ACL resection. Patients who underwent partial ACL resection for mucoid degeneration between February 2007 and February 2019 were considered for study eligibility. Patients were evaluated for International Knee Documentation Committee (IKDC), The Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI), The Knee injury and Osteoarthritis Outcome Score (KOOS) and Tegner activity scale. Sixty patients underwent partial ACL resection for mucoid degeneration of the ACL. Nine patients were lost to follow-up, 43 were males, the average age was 52.12±12.09 and a mean follow-up of 83.55±44.79 months. At final follow-up six patients underwent ACL reconstruction for ACL rupture (11.7%) at an average of 15.66±12 months. Patient satisfaction was at 71%. Arthroscopic partial resection of the ACL led to good clinical outcome for treating mucoid degeneration of the ACL.

Poster 330: Quadriceps Autograft Leads to Improved Psychological Readiness for Return to Play Compared to Hamstring and Bone-Patellar Tendon-Bone Autografts Following ACL Reconstruction

Poster 330: Quadriceps Autograft Leads to Improved Psychological Readiness for Return to Play Compared to Hamstring and Bone-Patellar Tendon-Bone Autografts Following ACL Reconstruction

Poster 323: Factors Impacting Return to Sport Timing Following ACL Reconstruction

Objectives: Forty-one percent of sports injuries are knee injuries. One-fifth of knee injuries involve the anterior cruciate ligament (ACL). The high incidence of ACL injuries results in approximately 129,000 ACL reconstructions in the United States each year. Timing of return to sport (RTS) after ACL reconstruction (ACLR) depends on clearance by the medical team, patients meeting objective RTS criteria, and patient selected timing. A criterion-based approach to RTS commonly includes measurements of quadriceps strength, hop performance, and subjective knee function to guide the decision-making of orthopedic surgeons and physical therapists regarding patient readiness and safety to RTS. Therefore, the purpose of this study was to assess patient-related predictors (age, sex, graft type, psychological readiness, and the duration of physical therapy) of time to pass RTS criteria. We hypothesized that patients with more positive psychological readiness, those who were still completing physical therapy, and male patients would pass RTS testing at earlier time points, while graft type and age would have no effect. Methods: Fifty-four participants between the ages of 10 and 25 years and within 5 to 15 months of ACL reconstruction who were planning to return to at least 50 hours per year of cutting and pivoting activities were included. Patients with a previous history of surgery to either knee or concomitant posterior cruciate ligament reconstruction were excluded from the study. Participants completed clinic testing when RTS was being planned. Testing included unilateral quadriceps strength in each limb (isometric at 90° knee flexion using a crane scale and 1-repetition maximum using a knee extension machine), 4 single-legged hop tests (single, crossover and triple hop for distance; 6-meter timed hop), and self-reported knee function (International Knee Documentation Committee Subjective Knee Form 2000 [IKDC], Global Rating Scale). In order to pass, participants needed scores of at least 90% symmetry for both quadriceps strength measures and all 4 single-legged hop tests as well as 90% on the IKDC and Global Rating Scale. Participants repeated clinic testing until they passed the entire testing battery in a single session. On the day of passing all RTS criteria, psychological readiness was assessed using the ACL Return to Sport after Injury (ACL-RSI) survey. The ACL-RSI is a valid and reliable outcome tool that assesses the participant’s emotional wellbeing, confidence in performance, and risk appraisal. An additional survey question was used to identify if participants were still participating in physical therapy (PT) at the time of passing RTS testing or when they had finished working with a physical therapist. PT was categorized as either a) &lt;6 months of PT, b) 6-8 months of PT, or c) &gt;8 months of PT or still currently in PT. Multivariate linear regression was used to assess the association between age, sex, graft type, ACL-RSI score, and duration of PT on the time to passing RTS testing after ACL reconstruction. An alpha level of p&lt;0.05 was set a priori. Results: The mean age of the participants in this study was 17.3±2.7 years and 50% were female. Graft type and duration of physical therapy data are presented in Table 1. The mean time for passing all components of the RTS test battery was 10.3 ±2.6 months. At the time of passing RTS testing, the mean ACL-RSI score was 86.1±14.2%. Age, sex, graft type, ACL-RSI scores and duration of PT accounted for 44.5% of the variation in the time to pass RTS testing (p&lt;0.001). Sex (β=-0.426; p&lt;0.001), graft type (β=0.340; p=0.008), and age (β=0.194; p=0.111) were the strongest predictors of time to pass RTS testing with younger age correlating with shorter RTS times. Sex (Male: 8.6±3.1 months; Female: 11.1±3.5 months) and graft type (Hamstring: 7.7± 3.9 months; Quadriceps Tendon: 10.8±2.7 months; Patellar Tendon: 11.5±2.6 months; Allografts and IT band: 7.2±1.4 months), were significant predictors of time to pass RTS criteria while PT duration and ACL-RSI were not significant predictors. Conclusions: Female patients and patients with a patellar tendon or quadriceps graft took longer to meet objective RTS criteria after ACL reconstruction. Education with female patients and those with quadriceps and patellar tendon autografts may be required to establish realistic expectations for RTS readiness. While many factors impact graft choice, time to pass RTS criteria is an additional consideration for surgeons and patients. Additionally, previous studies have shown that male patients are more likely to experience graft retear following ACLR than females. This finding could be the result of male patients returning to sport earlier than females, giving the graft less time to heal. [Table: see text]

Paper 40: Early Clinical Outcomes Following Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft in an Adolescent Population Suggest Higher Rates of Arthrofibrosis with Bone-Block than All Soft Tissue.

Objectives: There is an increased interest in quadriceps tendon autograft for anterior cruciate ligament (ACL) reconstruction in the adolescent population. It has emerged as a promising graft option that can be harvested with a bone-block (BB) or all soft tissue (AST). The preferred quadriceps graft remains controversial as there is evidence that bone to bone healing is stronger and faster, while AST grafts reportedly have a lower complication rate. The purpose of this study is to report early clinical outcomes following ACL reconstruction with BB versus AST quadriceps autograft in adolescent population. We hypothesized that both techniques would provide similar early clinical outcomes. Methods: A retrospective case-controlled study of patients under 20 years of age who underwent arthroscopic ACL reconstruction utilizing quadriceps tendon autograft from September 2017 to September 2021 was conducted. The cohort was divided in two groups: Group 1 included 35 patients who underwent ACL reconstruction with BB quadriceps tendon autograft. Group 2 included 58 patients who underwent ACL reconstruction with AST quadriceps tendon autograft. Data collected included demographics, range of motion, graft measurements, concomitant procedures, perioperative complications and arthrofibrosis rate, defined as reoperation for lysis of adhesions. Knee strength was objectively recorded at 3 months postoperatively using an isokinetic dynamometer (Humac, CSMI USA, Stoughton, MA, USA) and was used to calculate the Limb Symmetry Index (LSI), or the ratio between the involved limb and uninvolved limb and expressed as a percentage. Patient reported outcomes include International Knee Documentation Committee (IKDC) and Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale. Statistical analyses were then performed to compare groups. Results: A total of 93 patients were included for analysis, with mean age of 15.9 (range 10-20) and mean follow-up 17 months (ranged from 3 to 25). There was no difference between the study and control groups regarding age (p=0.10), BMI (p=0.70), concomitant procedures (p=0.39), but there was a predominance in females in group 1 (bone block) (64.9% vs 43.3%, p=0.02). The group 1(bone block) was associated with higher rate of arthrofibrosis with odds ratio of 3.98 (7/35 20% vs 3/58 5%, p=0.02) and lower LSI (55.6% vs 68.4%, p=0.01) at 3 months postoperatively. Group 1 (bone block) grafts were overall greater in femur width (9.47 vs 9.19, p=0.02), and length (69.85 vs 65.12, p=0.01). Logistic regression found BB quadriceps tendon graft (p=0.03) and extension deficit at 3 months postoperatively (p=0.01) the only risk factors for arthrofibrosis. Patients in group 1 (bone block) reported lower outcomes scores than group 2 (all soft tissue), measured by IKDC 63.94 vs 75.27 (p=0.01) and (ACL-RSI) 49.55 vs 63.25 (p=0.01) at 3 months postoperatively. Conclusions: Comparative analysis between bone block and all soft tissue quadriceps tendon autograft for ACL reconstruction in an adolescent population demonstrates that bone block QT autograft is associated with 4 times higher rate of arthrofibrosis requiring operative intervention for lysis of adhesions. If surgeons opted for a bone block QT autograft for ACL reconstruction in the adolescent population, our findings suggest that an early rehabilitation program with a focus on early restoration of full knee extension should be implemented in order to avoid arthrofibrosis.