Responders to first-line osteoarthritis treatment had reduced frequency of hip and knee joint replacements within 5 years: an observational register-based study of 44,311 patients.

BACKGROUND AND PURPOSE: First-line treatment (education, exercise) for patients with hip and knee osteoarthritis (OA) aims to reduce pain and improve function. We aimed to compare progression to joint replacement within 5 years between responders and non-responders to first-line treatment for hip and knee OA, respectively. METHODS: This observational study included data for 30,524 knee OA and 13,787 hip OA patients from the Swedish Osteoarthritis Register, linked with the Swedish Arthroplasty Register, Statistics Sweden, and the Swedish Prescribed Drug Register. The primary prognostic factor was change in pain between baseline and 3-month follow-up, measured on a numeric rating scale (0-10, best to worst) where an improvement of ≥ 2 was classified as responder and ≤ 1 as non-responder. The main outcome was progression to joint replacement surgery within 5 years, assessed using baseline adjusted multivariable Cox regression analyses. RESULTS: At 5 years, in hip OA, 35% (95% confidence interval [CI] 32.2-37.2) of the responders and 48% (CI 45.9-49.5) of the non-responders and in knee OA 14% (CI 13.0-15.3) of the responders and 20% (CI 18.8-20.8) of the non-responders had progressed to joint replacement. Being a responder to the treatment was associated with having a lower probability of progression to surgery for both hip OA (hazard ratio [HR] 0.4, CI 0.4-0.5) and knee OA (HR 0.6, CI 0.5-0.6). CONCLUSION: Patients with hip or knee OA who experienced pain relief after a first-line OA treatment program were less likely to progress to joint replacement surgery.

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.

Are Exercise Therapy Protocols For The Treatment of Hip-Related Pain Adequately Described? A Systematic Review of Intervention Descriptions.

Background: Hip-related pain is an umbrella term encompassing pain from non-arthritic hip joint pathologies, such as femoroacetabular impingement syndrome, hip dysplasia, and labral tears. Exercise therapy is commonly recommended for these conditions, but the reporting completeness of these interventions is currently unclear. Purpose: The aim of this systematic review was to assess the reporting completeness of exercise therapy protocols for people with hip-related pain. Study design: Systematic review according to PRISMA guidelines. Materials and Methods: A systematic search was conducted, searching the MEDLINE, CINAHL, and Cochrane databases. The search results were independently screened by two researchers. Inclusion criteria were studies using exercise therapy in people with non-arthritic hip-related pain. Two independent researchers used the Cochrane risk of bias tool version 2 to analyze risk of bias, and the Consensus on Exercise Reporting Template (CERT) checklist and score (1-19) to synthesize reporting completeness. Results: Fifty-two studies used exercise therapy for hip-related pain, but only 23 were included in the synthesis as 29 studies had no description of the intervention. CERT scores ranged from 1 to 17 (median 12, IQR 5-15). The most well-described items were tailoring (87%), and the least well-described items were motivation strategies (9%) and starting level (13%). Studies used exercise therapy alone (n=13), or in combination with hip arthroscopy (n=10). Conclusion: Only 23 of 52 eligible studies reported sufficient details to be included in the CERT synthesis. The median CERT score was 12 (IQR 5-15), with no study reaching the maximum score of 19. Lack of reporting makes it difficult to replicate interventions in future research, and to draw conclusions on efficacy and dose-response to exercise therapy for hip-related pain. Level of evidence: Level 1, systematic review.

Less hip range of motion is associated with a greater alpha angle in people with longstanding hip and groin pain.

PURPOSE: A higher alpha angle has been proposed to correlate with lower hip range of motion, but the association in people with longstanding hip and groin pain is currently unclear. The aims were to: (1) assess the association between range of motion and alpha angle in patients with longstanding hip and groin pain; (2) examine if a cut-off value in range of motion variables could identify patients with an alpha angle above or below 60°. METHODS: Seventy-two participants were consecutively recruited from an orthopaedic department after referral for hip- and groin-related pain. Passive hip range of motion was measured in flexion, internal rotation with 90° hip flexion, internal rotation in neutral hip position, external rotation with 90° hip flexion, and abduction. The alpha angle was calculated from a frog-leg lateral radiograph. Linear regression examined the association between range of motion and alpha angle, and an ROC-curve analysis was performed to identify the sensitivity and specificity of range of motion cut-offs. RESULTS: Lower range of motion in internal rotation in flexion, external rotation, and abduction were associated with higher alpha angle. Internal rotation of 27° or less displayed good sensitivity (81%) and specificity (85%) to detect an alpha angle above 60°, while a cut-off of 41° in external rotation and 27° in abduction showed a sensitivity of 72% and specificity of 50% and 60%, respectively. CONCLUSION: Less internal rotation in flexion, external rotation, and abduction are associated with a greater alpha angle in a cohort of people with longstanding hip and groin pain. A cut-off of 27° in internal rotation has good sensitivity and specificity to identify people with an alpha angle above or below 60° and have the potential to be used in the clinical setting to identify patients that require further imaging, or that are unlikely to have cam morphology. LEVEL OF EVIDENCE: II.

Decompression of the greater occipital nerve improves outcome in patients with chronic headache and neck pain - a retrospective cohort study.

BACKGROUND: Compression of the greater occipital nerve (GON) may contribute to chronic headache, neck pain, and migraine in a subset of patients. We aimed to evaluate whether GON decompression could reduce pain and improve quality of life in patients with occipital neuralgia and chronic headache and neck pain. METHODS: In this retrospective cohort study, selected patients with neck pain and headache referred to a single neurosurgical center were analyzed. Patients (n = 22) with suspected GON neuralgia based on nerve block or clinical criteria were included. All patients presented with occipital pain spreading frontally and to the neck in various degree. Surgical decompression was performed under local anesthesia. Follow-up was made by an assessor not involved in the treatment of the patients, by telephone 2-5 years after the surgical procedure and an interview protocol was used to collect information. The data from the follow-up protocols were then analyzed and reported. RESULTS: When analyzing the follow-up protocols, decreased headache/migraine was reported in 77% and neck pain was reduced in 55% of the patients. CONCLUSIONS: Decompression of GON(s) may reduce neck pain and headache in selected patients with persistent headache, neck pain, and clinical signs of GON neuralgia. Based on the limitations of the present retrospective study, the results should be considered with caution.

Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome.

PURPOSE: Clinical examination is an important part in the diagnosis of femoroacetabular impingement (FAI) syndrome. However, knowledge on reliability and validity of clinical diagnostic tests is scarce. The aims were to evaluate the inter-rater agreement and diagnostic accuracy of clinical tests to detect patients with FAI syndrome. METHODS: Eighty-one patients (49% women) were recruited. Two experienced raters performed impingement and range of motion (ROM) tests. Three criteria had to be fulfilled for the diagnosis of FAI syndrome: (1) symptoms; (2) CAM and/or Pincer morphology; and (3) being responder to intra-articular block injection. For inter-rater agreement, the Cohen's kappa statistics were used (0.41-0.60 = moderate, 0.61-0.80 = substantial agreement). For diagnostic accuracy, sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: Anterior impingement test (AIMT), FADIR test and FABER test showed kappa values above 0.6. All passive hip ROM, except extension, had kappa values above 0.4. AIMT and FADIR showed the highest sensitivity, i.e., 80%, with a specificity of 26% and 25%, respectively. Passive hip ROM in internal rotation with neutral hip position had a sensitivity of 29% and a specificity of 94%. CONCLUSION: The AIMT, FADIR and FABER tests were reliable between two experienced raters, while results from different raters for hip ROM should be interpreted with caution. The AIMT and FADIR test can only be used to rule out patients with FAI syndrome, while evaluation of ROM in internal rotation with neutral position may be more suitable to rule in patients with FAI syndrome. LEVEL OF EVIDENCE: II.

Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018.

There is no agreement on how to classify, define or diagnose hip-related pain-a common cause of hip and groin pain in young and middle-aged active adults. This complicates the work of clinicians and researchers. The International Hip-related Pain Research Network consensus group met in November 2018 in Zurich aiming to make recommendations on how to classify, define and diagnose hip disease in young and middle-aged active adults with hip-related pain as the main symptom. Prior to the meeting we performed a scoping review of electronic databases in June 2018 to determine the definition, epidemiology and diagnosis of hip conditions in young and middle-aged active adults presenting with hip-related pain. We developed and presented evidence-based statements for these to a panel of 37 experts for discussion and consensus agreement. Both non-musculoskeletal and serious hip pathological conditions (eg, tumours, infections, stress fractures, slipped capital femoral epiphysis), as well as competing musculoskeletal conditions (eg, lumbar spine) should be excluded when diagnosing hip-related pain in young and middle-aged active adults. The most common hip conditions in young and middle-aged active adults presenting with hip-related pain are: (1) femoroacetabular impingement (FAI) syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without a distinct osseous morphology (labral, chondral and/or ligamentum teres conditions), and that these terms are used in research and clinical practice. Clinical examination and diagnostic imaging have limited diagnostic utility; a comprehensive approach is therefore essential. A negative flexion-adduction-internal rotation test helps rule out hip-related pain although its clinical utility is limited. Anteroposterior pelvis and lateral femoral head-neck radiographs are the initial diagnostic imaging of choice-advanced imaging should be performed only when requiring additional detail of bony or soft-tissue morphology (eg, for definitive diagnosis, research setting or when planning surgery). We recommend clear, detailed and consistent methodology of bony morphology outcome measures (definition, measurement and statistical reporting) in research. Future research on conditions with hip-related pain as the main symptom should include high-quality prospective studies on aetiology and prognosis. The most common hip conditions in active adults presenting with hip-related pain are: (1) FAI syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without distinct osseous morphology including labral, chondral and/or ligamentum teres conditions. The last category should not be confused with the incidental imaging findings of labral, chondral and/or ligamentum teres pathology in asymptomatic people. Future research should refine our current recommendations by determining the clinical utility of clinical examination and diagnostic imaging in prospective studies.

Physiotherapist-led treatment for young to middle-aged active adults with hip-related pain: consensus recommendations from the International Hip-related Pain Research Network, Zurich 2018.

The 1st International Hip-related Pain Research Network meeting discussed four prioritised themes concerning hip-related pain in young to middle-aged adults: (1) diagnosis and classification of hip-related pain; (2) patient-reported outcome measures for hip-related pain; (3) measurement of physical capacity for hip-related pain; (4) physiotherapist-led treatment for hip-related pain. Thirty-eight expert researchers and clinicians working in the field of hip-related pain attended the meeting. This manuscript relates to the theme of physiotherapist-led treatments for hip-related pain. A systematic review on the efficacy of physiotherapist-led interventions for hip-related pain (published separately) was conducted and found that strong evidence for physiotherapist-led treatments was lacking. Prior to the meeting, draft consensus recommendations for consideration in the meeting were also developed based on the systematic review. The draft consensus recommendations were presented to all of the meeting participants via email, at least 1 week prior to the meeting. At the meeting, these recommendations were discussed, revised and voted on. Six recommendations for clinical practice and five recommendations for research were included and all gained consensus. Recommendations for clinical practice were that (i) Exercise-based treatments are recommended for people with hip-related pain. (ii) Exercise-based treatment should be at least 3 months duration. (iii) Physiotherapist-led rehabilitation after hip surgery should be undertaken. (iv) Patient-reported outcome measures, measures of physical impairment and measures of psychosocial factors should be used to monitor response to treatment. (v) Physical activity (that may include sport) is recommended for people with hip-related pain. (vi) Clinicians should discuss patient expectations, use shared-decision making and provide education. Recommendations for research were (i) Reporting of exercise programmes: Exercise descriptors such as load magnitude, number of repetitions and sets, duration of whole programme, duration of contractile element of exercise, duration of one repetition, time under tension, rest between repetitions, range of motion through which the exercise is performed, and rest between exercise sessions should be reported. (ii) Research should investigate the optimal frequency, intensity, time, type, volume and progression of exercise therapy. (iii) Research should examine the effect of patient education in people with hip-related pain. (iv) Research should investigate the effect of other treatments used in people with hip-related pain (for example: manual therapy, medications, injections). (v) Research should examine the impact of comorbidities and social determinants on treatment effectiveness in people with hip-related pain. Clinicians and researchers working with young to middle-aged active adults with hip-related pain may use these consensus recommendations to guide, develop, test and implement individualised, evidence-based physiotherapist-led rehabilitation programmes.

Hip-related groin pain, patient characteristics and patient-reported outcomes in patients referred to tertiary care due to longstanding hip and groin pain: a cross-sectional study.

BACKGROUND: Due to advances in hip arthroscopy, the number of surgical procedures has increased dramatically. The diagnostic challenge in patients with longstanding hip and groin pain, as well as the increasing number of hip arthroscopies, may lead to a higher number of patients referred to tertiary care for consideration for surgery. Therefore, the aims were: 1) to describe the prevalence of hip-related groin pain in patients referred to tertiary care due to longstanding hip and groin pain; and 2) to compare patient characteristics and patient-reported outcomes for patients categorized as having hip-related groin pain and those with non-hip-related groin pain. METHODS: Eighty-one patients referred to the Department of Orthopedics at Skåne University Hospital for longstanding hip and groin pain were consecutively included and categorized into hip-related groin pain or non-hip-related groin pain using diagnostic criteria based on current best evidence (clinical examination, radiological examination and intra-articular block injection). Patient characteristics (gender (%), age (years), BMI (kg/m2)), results from the Hip Sports Activity Scale (HSAS), the SF-36, the Copenhagen Hip and Groin Outcome Score (HAGOS), and pain distribution (pain manikin) were collected. Parametric and non-parametric statistics were used as appropriate for between-group analysis. RESULTS: Thirty-three (47%) patients, (30% women, 70% men, p < 0.01), were categorized as having hip-related groin pain. The hip-related groin pain group had a higher activity level during adolescence (p = 0.013), and a higher pre-injury activity level (p = 0.034), compared to the non-hip-related groin pain group. No differences (mean difference (95% CI)) between hip-related groin pain and non-hip-related groin pain were observed for age (0 (- 4; 4)), BMI (- 1.75 (- 3.61; 0.12)), any HAGOS subscales (p ≥ 0.318), any SF-36 subscales (p ≥ 0.142) or pain distribution (p ≥ 0.201). CONCLUSIONS: Only half of the patients referred to tertiary care for long-standing hip and groin pain, who were predominantly men with a high activity level, had hip-related groin pain. Self-reported pain localization and distribution did not differ between patients with hip-related groin pain and those with non-hip-related groin pain, and both patient groups had poor perceived general health, and hip-related symptoms and function.

Arthroscopic Surgical Procedures Versus Sham Surgery for Patients With Femoroacetabular Impingement and/or Labral Tears: Study Protocol for a Randomized Controlled Trial (HIPARTI) and a Prospective Cohort Study (HARP).

Study Design Study protocol for a randomized controlled trial and a prospective cohort. Background The number of arthroscopic surgical procedures for patients with femoroacetabular impingement syndrome (FAIS) has significantly increased worldwide, but high-quality evidence of the effect of such interventions is lacking. Objectives The primary objective will be to determine the efficacy of hip arthroscopic procedures compared to sham surgery on patient-reported outcomes for patients with FAIS (HIP ARThroscopy International [HIPARTI] Study). The secondary objective will be to evaluate prognostic factors for long-term outcome after arthroscopic surgical interventions in patients with FAIS (Hip ARthroscopy Prospective [HARP] Study). Methods The HIPARTI Study will include 140 patients and the HARP Study will include 100 patients. The international Hip Outcome Tool-33 will be the primary outcome measure at 1 year. Secondary outcome measures will be the Hip disability and Osteoarthritis Outcome Score, Arthritis Self-Efficacy Scale, fear of movement (Tampa Scale of Kinesiophobia), Patient-Specific Functional Scale, global rating of change score, and expectations. Other outcomes will include active hip range of motion, hip muscle strength tests, functional performance tests, as well as radiological assessments using radiographs and magnetic resonance imaging. Conclusion To determine the true effect of surgery, beyond that of placebo, double-blinded placebo-controlled trials including sham surgery are needed. The HIPARTI Study will direct future evidence-based treatment of FAIS. Predictors for long-term development and progression of degenerative changes in the hip are also needed for this young patient group with FAIS; hence, responders and nonresponders to treatment could be determined. J Orthop Sports Phys Ther 2018;48(4):325-335. doi:10.2519/jospt.2018.7931.

Knee extensor strength and body weight in adolescent men and the risk of knee osteoarthritis by middle age.

OBJECTIVES: To assess the extent to which knee extensor strength and weight in adolescence are associated with knee osteoarthritis (OA) by middle age. METHODS: We studied a cohort of 40 121 men who at age 18 years in 1969/1970 underwent mandatory conscription in Sweden. We retrieved data on isometric knee extensor strength, weight, height, smoking, alcohol consumption, parental education and adult occupation from Swedish registries. We identified participants diagnosed with knee OA or knee injury from 1987 to 2010 through the National Patient Register. We estimated the HR of knee OA using multivariable-adjusted Cox proportional regression model. To assess the influence of adult knee injury and occupation, we performed a formal mediation analysis. RESULTS: The mean (SD) knee extensor strength was 234 (47) Nm, the mean (SD) weight was 66 (9.3) kg. During 24 years (median) of follow-up starting at the age of 35 years, 2049 persons were diagnosed with knee OA. The adjusted HR (95% CI) of incident knee OA was 1.12 (1.06 to 1.18) for each SD of knee extensor strength and 1.18 (1.15 to 1.21) per 5 kg of body weight. Fifteen per cent of the increase in OA risk due to higher knee extensor strength could be attributed to knee injury and adult occupation. CONCLUSION: Higher knee extensor strength in adolescent men was associated with increased risk of knee OA by middle age, challenging the current tenet of low muscle strength being a risk factor for OA. We confirmed higher weight to be a strong risk factor for knee OA.

Worse self-reported outcomes but no limitations in performance-based measures in patients with long-standing hip and groin pain compared with healthy controls.

PURPOSE: This study aimed to evaluate patient-reported outcomes as well as lower extremity and trunk muscle function in patients with long-standing hip and groin pain, in comparison with matched, healthy controls. It was hypothesized that patients with long-standing hip and groin pain would report more deficiency on the Copenhagen Hip and Groin Outcome Score (HAGOS) and have worse outcomes on performance-based measures than healthy controls. METHODS: Nineteen patients with long-standing hip and groin pain and 19 healthy, activity level-, age-, gender-, and weight-matched controls were assessed with the HAGOS for self-reported outcomes, and a parallel squat (w/kg), single-leg triple jump (cm), single-leg rise (n), barbell roll-out (% of height), and plank test (s) for performance-based measures. Independent sample t test was performed to assess between-group differences. The paired t test was used to analyse between-limb differences in unilateral performance tasks. RESULTS: The patients had worse scores than the controls in all HAGOS subscales (p ≤ 0.001), while no statistically significant differences were observed for any performance measure between groups or between symptomatic and non-symptomatic limbs. CONCLUSIONS: Despite significant self-reported functional limitations on the HAGOS, there were no significant differences between groups in performance-based strength or power measures. The results of this study highlight the need to identify performance-based measures, sensitive to functional deficiencies in patients with long-standing hip and groin pain in order to complement the clinical picture obtained by patient-reported outcomes such as the HAGOS. LEVEL OF EVIDENCE: III.

The Association Between Knee Confidence and Muscle Power, Hop Performance, and Postural Orientation in People With Anterior Cruciate Ligament Injury.

Study Design Cross-sectional. Background The association between muscle function and lack of knee confidence in people with anterior cruciate ligament (ACL) injury has not been well investigated. Such knowledge would help in the design of training programs for this population. Objective To investigate associations between self-reported knee confidence and muscle function in patients with ACL injury. Methods Cross-sectional data from 54 patients (mean age, 30 years; range, 20-39 years; 28% women) with ACL injury, treated with training and reconstructive surgery (n = 36) or training only (n = 18), were assessed 3 ± 1 years after injury. Univariate and multivariable ordinal regression analyses were conducted to test the association between the patient's knee confidence (question 3 from the Knee injury and Osteoarthritis Outcome Score as the dependent variable) and performance on tests of muscle power, hop performance, and postural orientation (test for substitution patterns score) as independent variables (absolute value on the injured leg, and limb symmetry index [LSI; injured leg/uninjured leg × 100] or absolute difference between the injured and uninjured legs). Results Sixteen patients reported no trouble with lack of knee confidence, 24 mild trouble, 10 moderate trouble, and 4 severe or extreme trouble. Univariate analyses revealed significant associations between worse knee confidence and lower (worse) LSIs for knee extension power, vertical jump, and side hop, and worse test for substitution patterns scores. In the multivariable analysis, worse vertical jump LSI (P = .043) and worse side hop LSI (P = .012) significantly accounted for 25% of the variation in perceived knee confidence. Conclusion Between-leg differences during demanding tasks are associated with knee confidence in individuals with ACL injury. J Orthop Sports Phys Ther 2016;46(6):477-482. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6374.

Vibratory perception threshold in young and middle-aged patients at high risk of knee osteoarthritis compared to controls.

OBJECTIVE: Vibratory perception threshold (VPT) is impaired in patients with knee osteoarthritis (OA). It is, however, not known if sensory deficits precede or follow as a consequence of OA. The aim of this study was to investigate VPT in 2 independent groups of patients with high risk of future OA (young anterior cruciate ligament [ACL]-injured patients and middle-aged meniscectomized patients) and compare them to age-matched controls. METHODS: VPT was assessed at the medial malleolus (MM) and medial femoral condyle (MFC) in 2 independent groups of patients and matched controls: ACL-injured patients (n = 39, mean ± SD age 24.0 ± 5.2 years, mean ± SD BMI 24.0 ± 2.9 kg/m(2) , mean ± SD time since injury 21.9 ± 21.6 months) and controls (n = 28, mean ± SD age 25.6 ± 4.4 years, mean ± SD BMI 23.6 ± 2.2 kg/m(2) ), and meniscectomized patients (n = 22, mean ± SD age 49.6 ± 4.8 years, mean ± SD BMI 24.7 ± 2.7 kg/m(2) , mean ± SD time since surgery 49.6 ± 5.0 months) and controls (n = 25, mean ± SD age 49.4 ± 5.2 years, mean ± SD BMI 25.2 ± 4.9 kg/m(2) ). RESULTS: ACL-injured patients had a better VPT than controls at the MM (P = 0.030), which persisted after adjusting for age and sex (P = 0.034). At the MFC, there was a similar trend in favor of ACL injured patients (unadjusted P = 0.093, adjusted P = 0.122). No differences were seen in VPT at the MM between meniscectomized patients and controls, whereas there was a tendency for better VPT in meniscectomized patients at the MFC (unadjusted P = 0.085, adjusted P = 0.092). CONCLUSION: Impaired vibratory sensation could not be confirmed in 2 independent groups of patients compared to age-matched controls, suggesting that impaired vibratory sense is not present in knee-injured patients at high risk or in the very early phase of knee OA.

Sex differences in patient-reported outcomes after anterior cruciate ligament reconstruction: data from the Swedish knee ligament register.

BACKGROUND: Female gender is a risk factor for sustaining anterior cruciate ligament (ACL) injury. However, little is known about possible sex differences in patients with ACL injury/reconstruction. PURPOSE: To study sex differences in patient-reported outcomes before and at 1 and 2 years after ACL reconstruction and to present reference values. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2005 and 2008, 10164 patients (mean age, 27 years; SD, 9.8; 42% females) with primary ACL reconstruction were registered in the Swedish national knee ligament register. There were 4438 (44%) of these patients (42% females) who had completed the knee-specific questionnaire, Knee injury and Osteoarthritis Outcome Score (KOOS), and 5255 (52%) who had completed the generic score of health status, EQ-5D, before surgery and were included in this study. Independent t tests were used to study sex differences in KOOS and EQ-5D preoperatively, 1 and 2 years postoperatively, and over time. RESULTS: Preoperatively, female patients reported worse scores than male patients in 4 KOOS subscales (pain, symptoms, sport/recreation, quality of life) and EQ-5D, with the largest difference seen in KOOS sport/recreation (mean difference, 4.7; 95% confidence interval [CI], 3.0-6.3). At 1 year postoperatively, female patients reported worse scores than male patients in KOOS pain (mean difference, 1.4; 95% CI, 0.4-2.4) and KOOS sport/recreation (mean difference, 2.7; 95% CI, 0.9-4.4) and at 2 years postoperatively in KOOS sport/recreation (mean difference, 4.4; 95% CI, 2.1-6.7) and KOOS quality of life (mean difference, 2.4; 95% CI, 0.4-4.4). Female patients reported less improvement from 1 to 2 years postoperatively than male patients in KOOS sport/recreation (mean difference, 3.2; 95% CI, 0.3-6.1). In some age groups, female patients reported a clinically relevant worse KOOS sport/recreation score than male patients (mean difference > or =8). CONCLUSION: Female patients reported statistically significant worse outcomes than male patients before and at 1 and 2 years after ACL reconstruction. In some age groups, this difference was also clinically relevant. There were no clinically relevant sex differences in improvements over time. We suggest that possible sex differences be analyzed in future studies on evaluation after ACL injury/reconstruction.

Postural orientation in subjects with anterior cruciate ligament injury: development and first evaluation of a new observational test battery.

Anterior cruciate ligament (ACL) injury is associated with mechanical instability and defective neuromuscular function, and can lead to further injury, increased joint loading and osteoarthritis. Patients with ACL injury demonstrate altered postural orientation, manifested as observable "substitution patterns" (SPs) but no one has applied a clinically useful method to systematically study postural orientation in these patients. Here, we investigated the presence of such patterns in 24 adults with ACL injury and in 49 controls, in parallel with the development and a first evaluation of a new test battery, test for SPs. The rationale behind the test for SPs was to characterize postural orientation as the ability to maintain appropriate relationships between body segments and environment during weight-bearing movements. In this first study, patients displayed SPs more frequently and/or more clearly on their injured, but also their uninjured side than did controls. Inter-rater and intra-rater reproducibility was good at a group level. Future studies of validity, responsiveness and including other subgroups of patients with ACL injury will have to prove if the test for SPs can be used in the diagnostics of defective neuromuscular function following knee injury, when planning and carrying out training and rehabilitation and when deciding appropriate time to return to activity and sports after ACL injury.

Knee extension and flexion muscle power after anterior cruciate ligament reconstruction with patellar tendon graft or hamstring tendons graft: a cross-sectional comparison 3 years post surgery.

Hamstring muscles play a major role in knee-joint stabilization after anterior cruciate ligament (ACL) injury. Weakness of the knee extensors after ACL reconstruction with patellar tendon (PT) graft, and in the knee flexors after reconstruction with hamstring tendons (HT) graft has been observed up to 2 years post surgery, but not later. In these studies, isokinetic muscle torque was used. However, muscle power has been suggested to be a more sensitive and sport-specific measures of strength. The aim was to study quadriceps and hamstring muscle power in patients with ACL injury treated with surgical reconstruction with PT or HT grafts at a mean of 3 years after surgery. Twenty subjects with PT and 16 subjects with HT grafts (mean age at follow up 30 years, range 20-39, 25% women), who were all included in a prospective study and followed the same goal-based rehabilitation protocol for at least 4 months, were assessed with reliable, valid, and responsive tests of quadriceps and hamstring muscle power at 3 years (SD 0.9, range 2-5) after surgery. The mean difference between legs (injured minus uninjured), the hamstring to quadriceps (H:Q, hamstring divided by quadriceps) ratio, and the limb symmetry index (LSI, injured leg divided by uninjured and multiplied by 100) value, were used for comparisons between the groups (analysis of variance). The mean difference between the injured and uninjured legs was greater in the HT than in the PT group for knee flexion power (-21.3 vs. 7.7 W, p = 0.001). Patients with HT graft had lower H:Q ratio in the injured leg than the patients with PT graft (0.63 vs. 0.77, p = 0.012). They also had lower LSI for knee flexion power than those in the PT group (88 vs. 106%, p < 0.001). No differences were found between the groups for knee extension power. The lower hamstring muscle power, and the lower hamstring to quadriceps ratio in the HT graft group than in the PT graft group 3 years (range 2-5) after ACL reconstruction, reflect imbalance of knee muscles after reconstruction with HT graft that may have a negative effect on dynamic knee-joint stabilization.

Muscle strength and functional performance in patients with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: a two to five-year followup.

OBJECTIVE: To study muscle strength and functional performance in patients with anterior cruciate ligament (ACL) injury with or without surgical reconstruction 2 to 5 years after injury. Good muscle function is important in preventing early-onset osteoarthritis (OA), but the role of reconstructive surgery in restoring muscle function is unclear. METHODS: Of 121 patients with ACL injury included in a randomized controlled trial on training and surgical reconstruction versus training only (the Knee, Anterior cruciate ligament, NON-surgical versus surgical treatment [KANON] study, ISRCTN: 84752559), 54 (mean age at followup 30 years, range 20-39, 28% women) were assessed a mean +/- SD of 3 +/- 0.9 years after injury with reliable, valid, and responsive test batteries for strength (knee extension, knee flexion, leg press) and hop performance (vertical jump, one-leg hop, side hop). The Limb Symmetry Index (LSI; injured leg divided by uninjured and multiplied by 100) value and absolute values were used for comparisons between groups (analysis of variance). An LSI >or=90% was considered normal. RESULTS: There were no differences between the surgical and nonsurgical treatment groups in muscle strength or functional performance. Between 44% and 89% of subjects had normal muscle function in the single tests, and between 44% and 56% had normal function in the test batteries. CONCLUSION: The lack of differences between patients treated with training and surgical reconstruction or training only indicates that reconstructive surgery is not a prerequisite for restoring muscle function. Abnormal muscle function, found in approximately one-third or more of the patients, may be a predictor of future knee OA.

Clinically assessed knee joint laxity as a predictor for reconstruction after an anterior cruciate ligament injury: a prospective study of 100 patients treated with activity modification and rehabilitation.

BACKGROUND: The association of early knee joint laxity with the need for later reconstruction of the anterior cruciate ligament has not been extensively studied. HYPOTHESIS: The grade of knee laxity can be used as an early predictor of the need for later reconstruction. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: One hundred consecutive patients with an acute arthroscopically verified total anterior cruciate ligament rupture were followed prospectively for 15 years. Lachman and pivot-shift tests were performed with the patient under general anesthesia before arthroscopy. After 3 months, the tests were repeated in an ordinary clinical setting. All patients underwent rehabilitation as the first choice of treatment. Anterior cruciate ligament reconstruction was performed only in cases of significant reinjuries (n = 16) or reparable meniscal lesions (n = 6) at a mean of 4 years after injury (range, 4 months-11 years). After 15 years, 94 patients were available for follow-up. RESULTS: Of the later reconstructed patients (n = 18), 82% had a high-grade Lachman test under anesthesia compared with 63% of the nonreconstructed patients (n = 45; P = .048). At 3 months, 44% of the nonreconstructed patients (n = 32) had a high-grade Lachman test compared with 82% of the reconstructed patients (n = 18; P = .007). Twenty-five patients displayed a normal pivot-shift test at 3 months, of whom 1 underwent later reconstruction (P = .009). A high-grade pivot-shift test at 3 months was associated with an 11.4 relative risk for reconstruction. CONCLUSION: A positive pivot-shift test at 3 months after injury in an awake patient is the strongest predictor for the future need for reconstruction. Furthermore, a normal pivot-shift test at 3 months indicates a low risk for reconstruction and is characteristic for copers.

Normalized motor function but impaired sensory function after unilateral non-reconstructed ACL injury: patients compared with uninjured controls.

Improvement in motor function after anterior cruciate ligament (ACL) injury is achieved by appropriate rehabilitation. However, it has been questioned whether training after injury can lead to sensory improvement. We hypothesized that motor function can be restored after unilateral non-reconstructed ACL injury, whereas the sensory function cannot, i.e., there would be no difference in functional performance or knee muscle strength between subjects with ACL injury and uninjured controls, but the subjects with ACL injury would have poorer kinesthesia than the uninjured controls. This is a Cross-Sectional Study, wherein 56 (20 women and 36 men) individuals with unilateral non-reconstructed ACL injury were assessed at a mean of 15 years (SD 1.4 years) after the initial injury. All patients initially underwent rehabilitation and were advised to modify their activity level, in order to cope with the ACL insufficiency. At 15 years, they had good subjective function and acceptable activity level. Twenty-eight (14 women and 14 men) uninjured subjects served as controls. Patients and controls were assessed with the one-leg hop test for distance, isometric and isokinetic knee muscle strength, and kinesthesia (the threshold to detection of passive motion). The individuals with ACL injury had the same or better functional performance, measured by the one-leg hop test for distance, and knee muscle strength compared with the uninjured controls. Kinesthesia was poorer in the patient group than in the control group. The results indicate that motor function can be restored but that the sensory function is persistently disturbed after ACL injury.