Factors affecting return to sport following hamstrings anterior cruciate ligament reconstruction in non-elite athletes.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common injury affecting non-elite and elite athletes. Although most ACL reconstructions restore the mechanical stability of the injured knee, the rate of return to sport (RTS) is varied. HYPOTHESIS/PURPOSE: We aimed to identify why non-elite athletes fail to return to pre-injury sport level. The primary objective was to assess the frequency of RTS (including type of sport, timing, level, and duration), and the secondary objective was to assess the surgical (injury, type of surgery, re-injury) and patient (demographics, function, symptoms, social, psychological) factors affecting RTS, using a multivariate analysis. STUDY DESIGN: Level III, retrospective cohort study. METHODS: We evaluated 78 consecutive non-elite athletes undergoing hamstring ACL reconstruction using medical records and questionnaires. Mean follow-up was 50 months (24-224 months). Athletes were divided into return to sport (RTS) and not returning to sport (NRTS) groups for comparative and multivariate analyses, to identify independent predictors of RTS status. RESULTS: Mean age was 31.5 years (18-51), and 46 were male (59%). The RTS rate was 56.4% (44), with most athletes returning between 9 and 12 months, and then continuing to play for > 60 months. Fear of re-injury was the highest reported reason for NRTS. There were no significant differences in demographics, concomitant injury, adjuvant surgery, and type of sport between the two groups. Mean Tegner scores were significantly higher in RTS group post-injury (6.9 vs 4.6) and at present (6.6 vs 4.6). The International Knee Documentation Committee (IKDC) score for the RTS group also increased significantly from pre-injury 70.8 (49.1-93.4) to 83.9 (24.1-100) post-injury (p < 0.001). Fear of re-injury, lack of confidence, lack of time, and change in job were significant factors in the NRTS group. Playing soccer, giving way, and change of job independently predicted RTS status from multivariate analysis. CONCLUSION: A significant number of non-elite athletes did not RTS following ACL reconstruction, and this was influenced by a combination of activity level, sport, self-reported knee instability, and psycho-social factors. Importantly, some of these can be predicted and managed with improved, individualized post-operative physical and psychological rehabilitation programmes. These data also allow surgeons to better counsel athletes before ACL reconstruction on their likelihood of RTS.

Current concepts in the management of patellofemoral pain - The role of alignment.

BACKGROUND: Patellofemoral pain is a prevalent and significant clinical problem that is often reported to persist even following evidence based intervention. It is clear therefore that there is much about this complex patient group that is not presently fully understood. This is particularly concerning given the reported links between patellofemoral pain in adolescence and the subsequent development of osteoarthritis and anxiety. ASSESSMENT: Clinical assessment has historically focussed on biomechanical factors such as altered lower limb kinematics, muscle weakness and late muscle 'onset or activation' during activity. However when examined it is clear that study findings from patellofemoral populations are often inconsistent. Reasons for this are discussed and specifically the limitations around current 'gold standard' measurement methods, such as motion capture are outlined. A biomechanical approach is applied to demonstrate the importance of ensuring optimal patient alignment during rehabilitation, where optimal is defined as ensuring the most energy efficient muscle or muscles are used by the patient to perform a movement. This in turn ensures that the direction, magnitude and location of load applied to the skeleton during activity is optimal and therefore less likely to lead to injury. TREATMENT: The role of alignment in patellofemoral pain and the importance of correcting this during rehabilitation is discussed, and examples provided. Validated, reliable, and reproducible methods of measuring skeletal geometry, muscle geometry, muscle force and direction, and kinematics of activity must be developed as a priority in order for us to further our understanding and improve outcomes in this complex clinical population.

Diagnosis and management of chondral delamination injuries of the knee.

BACKGROUND: Chondral delamination with intact articular surface is an under-recognised entity with no previous reports on how it should be managed. The purpose of this article is to increase awareness of this entity and make recommendations for its management. METHODS: We present a small case series of three patients who presented with knee pain and subsequent MRI scans revealed chondral delamination with intact articular surface as the only explanation of symptoms. RESULTS: Two of the lesions were located in the patella and one on the lateral aspect of the medial femoral condyle. All three were treated with bioabsorbable pin fixation. The delaminated area was easily recognised at arthroscopy by its bogginess on probing. All three patients made an excellent recovery and the lesions healed on MRI. CONCLUSION: Chondral delamination with intact articular surface is best managed with bioabsorbable pin fixation so that it can be salvaged in order to optimise patient outcomes and avoid deterioration to a full thickness chondral lesion once the articular surface has separated.

A novel and cheap method of outside-in meniscal repair for anterior horn tears.

Outside-in meniscal repair techniques can involve the use of expensive passing devices that may not be readily available to all orthopaedic surgeons. There are many different ways to repair a meniscus, and we describe a quick and simple technique that requires no special equipment.