Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation.

Multiligament knee injuries (MLKIs) represent a broad spectrum of pathology with potentially devastating consequences. Currently, disagreement in the terminology, diagnosis and treatment of these injuries limits clinical care and research. This study aimed to develop consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for patients with MLKI, while identifying important research priorities for further study. An international consensus process was conducted using validated Delphi methodology in line with British Journal of Sports Medicine guidelines. A multidisciplinary panel of 39 members from 14 countries, completed 3 rounds of online surveys exploring aspects of nomenclature, diagnosis, treatment, rehabilitation and future research priorities. Levels of agreement (LoA) with each statement were rated anonymously on a 5-point Likert scale, with experts encouraged to suggest modifications or additional statements. LoA for consensus in the final round were defined 'a priori' if >75% of respondents agreed and fewer than 10% disagreed, and dissenting viewpoints were recorded and discussed. After three Delphi rounds, 50 items (92.6%) reached consensus. Key statements that reached consensus within nomenclature included a clear definition for MLKI (LoA 97.4%) and the need for an updated MLKI classification system that classifies injury mechanism, extent of non-ligamentous structures injured and the presence or absence of dislocation. Within diagnosis, consensus was reached that there should be a low threshold for assessment with CT angiography for MLKI within a high-energy context and for certain injury patterns including bicruciate and PLC injuries (LoA 89.7%). The value of stress radiography or intraoperative fluoroscopy also reached consensus (LoA 89.7%). Within treatment, it was generally agreed that existing literature generally favours operative management of MLKI, particularly for young patients (LoA 100%), and that single-stage surgery should be performed whenever possible (LoA 92.3%). This consensus statement will facilitate clinical communication in MLKI, the care of these patients and future research within MLKI.

The Delaware-Oslo ACL Cohort treatment algorithm yields superior outcomes to usual care 9-12 years after anterior cruciate ligament reconstruction.

PURPOSE: Patient-reported outcomes were compared between participants who followed the treatment algorithm of the Delaware-Oslo ACL Cohort, consisting of progressive preoperative and postoperative rehabilitation, patient education, clinical testing and shared decision-making about treatment choice, and those who followed usual care 9-12 years after anterior cruciate ligament reconstruction (ACLR). METHODS: Participants with primary ACLR were included from the Norwegian arm of the Delaware-Oslo ACL Cohort and the Norwegian Knee Ligament Registry (usual care). The Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores and the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores were compared. KOOS scores for the usual care group were converted to IKDC-SKF scores with recently published validated crosswalk. The percentages of participants with scores above predefined thresholds for patient acceptable symptom state (PASS) were also calculated. RESULTS: Eighty of 100 (80%) participants from the Delaware-Oslo ACL Cohort and 1588 of 3248 (49%) from the usual care group participated in the follow-up. Participants from the Delaware-Oslo ACL Cohort had higher KOOS subscale (p < 0.001) and IKDC-SKF scores (p < 0.001), and a higher percentage reached PASS (84%-96% vs. 62%-76%, p ≤ 0.002) for KOOS Pain, symptoms, activities of daily living and sports compared to the usual care group. No significant differences were found for KOOS quality of life scores (not significant [n.s.]) or PASS percentages (80% vs. 74%, n.s.). CONCLUSION: Participants with ACLR who followed the Delaware-Oslo ACL Cohort treatment algorithm had reduced knee symptoms, superior function and higher percentages of satisfactory outcomes than participants who followed usual care. LEVEL OF EVIDENCE: Level II.

Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft at 7 Months After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Impaired quadriceps muscle strength after anterior cruciate ligament reconstruction (ACLR) is associated with worse clinical outcomes and a risk of reinjuries. Yet, we know little about quadriceps muscle strength in patients reconstructed with a quadriceps tendon (QT) graft, which is increasing in popularity worldwide. PURPOSE: To describe and compare isokinetic quadriceps strength in patients undergoing ACLR with a QT, hamstring tendon (HT), or bone-patellar tendon-bone (BPTB) autograft. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We included patients with QT grafts (n = 104) and matched them to patients with HT (n = 104) and BPTB (n = 104) grafts based on age, sex, and associated meniscal surgery. Data were collected through clinical strength testing at a mean of 7 ± 1 months postoperatively. Isokinetic strength was measured at 90 deg/s, and quadriceps strength was expressed as the limb symmetry index (LSI) for peak torque, total work, torque at 30° of knee flexion, and time to peak torque. RESULTS: Patients with QT grafts had the most impaired isokinetic quadriceps strength, with the LSI ranging between 67.5% and 75.1%, followed by those with BPTB grafts (74.4%-81.5%) and HT grafts (84.0%-89.0%). Patients with QT grafts had a significantly lower LSI for all variables compared with patients with HT grafts (mean difference: peak torque: -17.4% [95% CI, -21.7 to -13.2], P < .001; total work: -15.9% [95% CI, -20.6 to -11.1], P < .001; torque at 30° of knee flexion: -8.8% [95% CI, -14.7 to -2.9], P = .001; time to peak torque: -17.7% [95% CI, -25.8 to -9.6], P < .001). Compared with patients with BPTB grafts, patients with QT grafts had a significantly lower LSI for all variables (mean difference: peak torque: -6.9% [95% CI, -11.2 to -2.7], P < .001; total work: -7.7% [95% CI, -12.4 to -2.9], P < .001; torque at 30° of knee flexion: -6.3% [95% CI, -12.2 to -0.5], P = .03; time to peak torque: -8.8% [95% CI, -16.9 to -0.7], P = .03). None of the graft groups reached a mean LSI of >90% for peak torque (QT: 67.5% [95% CI, 64.8-70.1]; HT: 84.9% [95% CI, 82.4-87.4]; BPTB: 74.4% [95% CI, 72.0-76.9]). CONCLUSION: At 7 months after ACLR, patients with QT grafts had significantly worse isokinetic quadriceps strength than patients with HT and BPTB grafts. None of the 3 graft groups reached a mean LSI of >90% in quadriceps strength.

Clinical, Functional, and Physical Activity Outcomes 5 Years Following the Treatment Algorithm of the Delaware-Oslo ACL Cohort Study.

BACKGROUND: Anterior cruciate ligament (ACL) injuries can be treated with or without ACL reconstruction (ACLR), and more high-quality studies evaluating outcomes after the different treatment courses are needed. The purpose of the present study was to describe and compare 5-year clinical, functional, and physical activity outcomes for patients who followed our decision-making and treatment algorithm and chose (1) early ACLR with preoperative and postoperative rehabilitation, (2) delayed ACLR with preoperative and postoperative rehabilitation, or (3) progressive rehabilitation alone. Early ACLR was defined as that performed ≤6 months after the preoperative rehabilitation program, and late ACLR was defined as that performed >6 months after the preoperative rehabilitation program. METHODS: We included 276 patients from a prospective cohort study. The patients had been active in jumping, pivoting, and cutting sports before the injury and sustained a unilateral ACL injury without substantial concomitant knee injuries. The patients chose their treatment through a shared decision-making process. At 5 years, we assessed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, sports participation, quadriceps muscle strength, single-legged hop performance, and new ipsilateral and contralateral knee injuries. RESULTS: The 5-year follow-up rate was 80%. At 5 years, 64% of the patients had undergone early ACLR, 11% had undergone delayed ACLR, and 25% had had progressive rehabilitation alone. Understandably, the choices that participants made differed by age, concomitant injuries, symptoms, and predominantly level-I versus level-II preinjury activity level. There were no significant differences in any clinical, functional, or physical activity outcomes among the treatment groups. Across treatment groups, 95% to 100% of patients were still active in some kind of sports and 65% to 88% had IKDC-SKF and KOOS scores above the threshold for a patient acceptable symptom state. CONCLUSIONS: Patients with ACL injury who were active in jumping, pivoting, and cutting sports prior to injury; who had no substantial concomitant knee injuries; and who followed our decision-making and treatment algorithm had good 5-year knee function and high sport participation rates. Three of 4 patients had undergone ACLR within 5 years. There were no significant differences in any outcomes among patients treated with early ACLR, delayed ACLR, or progressive rehabilitation alone. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Meniscus or Cartilage Injury at the Time of Anterior Cruciate Ligament Tear Is Associated With Worse Prognosis for Patient-Reported Outcome 2 to 10 Years After Anterior Cruciate Ligament Injury: A Systematic Review.

OBJECTIVES: (1) To assess prognostic factors for patient-reported outcome measures (PROMs) and physical activity 2 to 10 years after anterior cruciate ligament reconstruction (ACLR) or anterior cruciate ligament (ACL) injury, and (2) to assess differences in prognostic factors between patients treated with ACLR and with rehabilitation alone. DESIGN: Prognosis systematic review. LITERATURE SEARCH: Systematic searches were performed in PubMed, Web of Science, and SPORTDiscus. STUDY SELECTION CRITERIA: We selected prospective cohort studies and randomized clinical trials that included adults or adolescents undergoing either ACLR or rehabilitation alone after ACL rupture. Studies had to assess the statistical association between potential prognostic factors (factors related to patient characteristics, injury, or knee symptoms/function measured at baseline or within 1 year) and outcomes (PROMs and physical activity). DATA SYNTHESIS: Our search yielded 997 references. Twenty studies met the inclusion criteria. Seven studies with low or moderate risk of bias remained for data synthesis. RESULTS: Moderate-certainty evidence indicated that concomitant meniscus and cartilage injuries were prognostic factors for worse PROMs 2 to 10 years after ACLR. Very low-certainty evidence suggested that body mass index, smoking, and baseline PROMs were prognostic factors for worse outcome. Very low-certainty evidence suggested that female sex and a worse baseline Marx Activity Rating Scale score were prognostic factors for a worse Marx Activity Rating Scale score 2 to 10 years after ACLR. There was a lack of studies on prognostic factors after rehabilitation alone. CONCLUSION: Concomitant meniscus and cartilage injuries were prognostic factors for worse long-term PROMs after ACLR. The certainty was very low for other prognostic factors. J Orthop Sports Phys Ther 2020;50(9):490-502. Epub 1 Aug 2020. doi:10.2519/jospt.2020.9451.

Evidence too weak to guide surgical treatment decisions for anterior cruciate ligament injury: a systematic review of the risk of new meniscal tears after anterior cruciate ligament injury.

OBJECTIVE: To investigate the risk of new meniscal tears after treatment for anterior cruciate ligament (ACL) injury, in children and adults with and without ACL reconstruction. DESIGN: Prognosis systematic review (PROSPERO registration number CRD42016036788). METHODS: We searched Embase, Ovid Medline, Cochrane, CINAHL, SPORTDiscus, PEDro and Google Scholar from inception to 3rd May 2018. Eligible articles included patients with ACL injury (diagnosis confirmed by MRI and/or diagnostic arthroscopy), reported the number of meniscal tears at the time of ACL injury diagnosis/start of treatment and reported the number of new meniscal tears that subsequently occurred. Articles with fewer than 20 patients at follow-up, and articles limited to ACL revision surgery or multi-ligament knee injuries were excluded. Two independent reviewers screened articles, assessed eligibility, assessed risk of bias and extracted data. We judged the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group methodology. RESULTS: Of 75 studies included in the systematic review, 54 studies with 9624 patients and 501 new meniscal tears were appropriate for quantitative analysis. Heterogeneity precluded data pooling. The risk of new meniscal tears was 0%-21% when follow-up was <2 years, 0%-29% when follow-up was 2 to 5 years, 5%-52% when follow-up was 5 to 10 years and 4%-31% when follow-up was longer than 10 years. The proportion of studies with high risk of selection, misclassification and detection bias was 84%, 69% and 68%, respectively. Certainty of evidence was very low. CONCLUSION: New meniscal tears occurred in 0%-52% of patients between 4 months and 20 years (mean 4.9±4.4 years) following treatment for ACL injury. The certainty of evidence was too low to guide surgical treatment decisions. This review cannot conclude that the incidence of new meniscal tears is lower if ACL injury is treated with surgery compared with treatment with rehabilitation only.

Knee sliced open by skate blade: complete patellar tendon rupture in an elite long track speed skater.

A long track speed skater sustained a deep horizontal cut to the right knee just distally to the patella, after he got hit by the skate blade of the pair mate. The injury included a complete patellar tendon rupture from the apex of the patella, a 1 mm deep transverse cut in the femoral condyle and a partial rupture of the anterior cruciate ligament. The tendon rupture was repaired with transosseous suture repair without augmentation. A knee brace was used for 8 weeks, with a gradual decrease in flexion restraints. A rehabilitation programme was overseen by a dedicated physiotherapist. At 6 months, he started a gradual return to skating sessions. After 1 year, he had symmetrical single-legged hop performance, but quadriceps weakness due to pain. The patient returned to competition speed skating at national levels after 11 months, and within the first postoperative year, he was breaking new personal records on the ice.

Knee Pathology in Young Adults After Pediatric Anterior Cruciate Ligament Injury: A Prospective Case Series of 47 Patients With a Mean 9.5-Year Follow-up.

BACKGROUND: The rate of secondary knee injuries after pediatric anterior cruciate ligament (ACL) injury is uncertain, and previous studies are limited because of poor methodology. PURPOSE: To evaluate the incidence of new meniscal injuries since the initial diagnostic magnetic resonance imaging (MRI) of young adults who sustained a pediatric ACL injury. In addition, to evaluate meniscal and cartilage injuries in the index knee and contralateral knee injuries on MRI at final follow-up (9.5 years). Furthermore, to assess leg length and alignment based on long-leg radiographs. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Study population at final follow-up included 47 young adults who sustained a pediatric ACL injury before age 13 years. They were followed prospectively since the time of injury for a mean 9.5 years at final follow-up. Imaging included diagnostic MRI of the index knee and 3.0-T MRI of both knees at 1-, 2-, and 9.5-year follow-up, in addition to long-leg radiographs at final follow-up. Forty-three patients underwent active rehabilitation without ACL reconstruction initially; 4 were treated with initial ACL reconstruction. At final follow-up, 27 (57%) had undergone ACL reconstruction. RESULTS: Fourteen patients had meniscal tears in the index knee at final follow-up (prevalence, 30%). The majority of these were in the same location as previously repaired tears (n = 9). Between diagnostic MRI and final follow-up, 16 patients had sustained new meniscal tears to a healthy meniscus (incidence, 34%). At final follow-up, meniscal injuries recorded at baseline or during follow-up were no longer visible and appeared healed in 17 patients (20 tears). MRI at final follow-up showed cartilage injuries in the index knee of 13 patients (28%) and contralateral injuries in 8 patients (meniscus, n = 2; cartilage, n = 5; subchondral fracture, n = 1). Two patients had a leg-length difference >15 mm, and 3 had side-to-side difference in knee alignment >5°. CONCLUSION: The incidence of new meniscal tears after pediatric ACL injury was 34% during a mean follow-up period of 9.5 years. At final follow-up, 27 patients (57%) had normal menisci, and none had developed knee osteoarthritis. Primary active rehabilitation, close follow-up, and delayed surgery if needed may be a viable and safe treatment option for some pediatric ACL injuries.

Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study.

BACKGROUND: Some athletes demonstrate excellent dynamic stability after anterior cruciate ligament (ACL) rupture and return to sport without ACL reconstruction (ACLR) (copers). Others demonstrate persistent instability despite rehabilitation (noncopers) and require surgical stabilization. Testing to determine coper classification can identify potential copers early after rupture. It is unclear how coper classification changes after a brief intervention and how early classification relates to long-term outcomes. PURPOSE: (1) To evaluate the consistency of early coper classification (potential coper vs noncoper) before and after progressive neuromuscular and strength training (NMST) among athletes early after acute ACL rupture and (2) to evaluate the association of early coper classification with 2-year success after ACL rupture. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This was a prospective analysis from the Delaware-Oslo ACL Cohort Study, composed of athletes consecutively enrolled early after ACL rupture. Participants (n = 271) were tested and classified as potential copers or noncopers according to established criteria before and after a 10-session NMST program. Success 2 years after ACLR or nonoperative rehabilitation was defined as meeting or exceeding sex- and age-matched norms for knee function, no ACL graft rupture, and ≤1 episode of giving way within the previous year. The McNemar test evaluated changes in coper classification pre- to posttraining. Logistic regression adjusted for baseline characteristics was used to evaluate the association of early coper classification and surgical status with 2-year success. RESULTS: Of 300 athletes enrolled, 271 (90%) completed the posttraining data collection, and 219 (73%) returned for the 2-year follow-up. The coper classifications were different between time points: nearly half of those classified initially as noncopers became potential copers ( P < .001). At the 2-year follow-up, 66% of the ACLR group and 74% of the nonoperative group were successful. Athletes who were potential copers posttraining and chose ACLR or nonoperative rehabilitation had 2.7 (95% CI, 1.3-5.6) and 2.9 (95% CI, 1.2-7.2) times the odds of success, respectively, as compared with noncopers who chose ACLR. CONCLUSION: Coper classification improved after NMST; more athletes became potential copers. Athletes who were potential copers after NMST were more likely to succeed 2 years later regardless of whether they had surgery, strongly supporting the addition of NMST before ACLR. Persistent noncopers fared poorly, indicating that more intensive rehabilitation may be needed.

Coping With Anterior Cruciate Ligament Injury From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8 Years' Follow-up.

BACKGROUND: There is no consensus regarding the best treatment approach for skeletally immature children with anterior cruciate ligament (ACL) injuries. High-quality studies with long-term follow-up are lacking, and evidence to support decision making is limited. PURPOSE: To evaluate functional and patient-reported outcome, surgical history, and complications among young adults who sustained an ACL injury before the age of 13 years and were treated with active rehabilitation and the option of delayed ACL reconstruction if needed. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Forty-six children aged <13 years with a total intrasubstance ACL injury were included. None of these patients had additional injuries that warranted early surgery. At final follow-up at a mean 8 years after the time of injury, 44 patients remained in the study. The same test battery was conducted at baseline, 1 and 2 years, and final follow-up at approximately 18 years of age. The test battery included functional tests (hop tests and isokinetic muscle strength tests of quadriceps and hamstrings), patient-reported outcome measures (including the Knee injury and Osteoarthritis Outcome Score and the International Knee Documentation Committee Subjective Knee Form), and clinical examination. Medical records were reviewed to assess surgical history and complications. RESULTS: At a mean 8 years of follow-up, 24 patients (55%) had undergone ACL reconstruction, and 16 (36%) had undergone meniscal surgery. Quadriceps muscle strength symmetry was >90% for 30 patients (68%). Mean leg symmetry indexes for hop and strength tests were consistently >90%, except for the single-hop test and hamstrings muscle strength for ACL-reconstructed knees. Mean ± SD International Knee Documentation Committee scores were 86.3 ± 13.7 for the ACL-reconstructed knees and 90.6 ± 11.8 for the nonreconstructed knees. At final follow-up, forty patients (91%) remained active in sports, but 29 (66%) restricted their activity level to nonpivoting sports. CONCLUSION: Active rehabilitation may have a role in treatment of children with ACL injury. Approximately 50% of children may cope well, even to adulthood, without a surgical intervention. The other half may develop instability that warrants ACL reconstruction, and one-third may require meniscal surgery.

Anterior Cruciate Ligament Injury-Who Succeeds Without Reconstructive Surgery? The Delaware-Oslo ACL Cohort Study.

BACKGROUND: More than 50% of highly active patients with an anterior cruciate ligament (ACL) injury who choose nonsurgical treatment (active rehabilitation alone) have successful 2-year outcomes and comparable knee function to an uninjured population. Early predictive factors for a successful outcome may aid treatment decision making in this population. PURPOSE: To identify early predictors of a successful 2-year outcome in those who choose nonsurgical treatment of an ACL injury. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This prospective cohort study consisted of ACL-injured athletes who were consecutively screened for inclusion. A total of 300 patients were included from 2 sites (Oslo, Norway, and Delaware, USA), and the 118 patients who initially chose not to undergo ACL reconstruction were included. All patients participated in pivoting sports before the injury, and none had significant concomitant injuries. A successful 2-year outcome was defined as having 2-year International Knee Documentation Committee (IKDC) scores ≥15th normative percentile and not undergoing ACL reconstruction. Multivariable logistic regression models were built using demographic and knee function data (quadriceps muscle strength, 4 single-leg hop tests, IKDC score, and Knee Outcome Survey-Activities of Daily Living Scale [KOS-ADLS] score) collected at baseline or after a 5-week neuromuscular and strength training (NMST) rehabilitation program. RESULTS: After 2 years, 52 of 97 (53.6%) patients had a successful outcome. In the multivariable baseline model, older age, female sex, better performance on the single-leg hop test, and a higher KOS-ADLS score were significantly associated with successful 2-year outcomes. After the 5-week NMST rehabilitation program, older age, female sex, and a higher IKDC score increased the odds of a successful 2-year outcome. The 2 models had comparable predictive accuracy (post-NMST area under the curve [AUC], 0.78 [95% CI, 0.68-0.88]; baseline AUC, 0.81 [95% CI, 0.72-0.89]). CONCLUSION: Clinicians and patients can be more confident in a nonsurgical treatment choice (active rehabilitation alone) in athletes who are female, are older in age, and have good knee function, as measured by single-leg hop tests and patient-reported outcome measures, early after an ACL injury. Prediction models that include measures of knee function, assessed either before or after rehabilitation, can estimate 2-year prognoses for nonsurgical treatment and thereby assist shared treatment decision making.

2018 International Olympic Committee Consensus Statement on Prevention, Diagnosis, and Management of Pediatric Anterior Cruciate Ligament Injuries.

In October 2017, the International Olympic Committee hosted an international expert group of physical therapists and orthopaedic surgeons who specialize in treating and researching pediatric anterior cruciate ligament (ACL) injuries. The purpose of this meeting was to provide a comprehensive, evidence-informed summary to support the clinician and help children with ACL injury and their parents/guardians make the best possible decisions. Representatives from the following societies attended: American Orthopaedic Society for Sports Medicine; European Paediatric Orthopaedic Society; European Society for Sports Traumatology, Knee Surgery, and Arthroscopy; International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; Pediatric Orthopaedic Society of North America; and Sociedad Latinoamericana de Artroscopia, Rodilla, y Deporte. Physical therapists and orthopaedic surgeons with clinical and research experience in the field and an ethics expert with substantial experience in the area of sports injuries also participated. This consensus statement addresses 6 fundamental clinical questions regarding the prevention, diagnosis, and management of pediatric ACL injuries. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision making with children and the potential long-term ramifications of the injury.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries.

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric anterior cruciate ligament (ACL) injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery and Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America, and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis, and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries.

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

Quantifying Quadriceps Muscle Strength in Patients With ACL Injury, Focal Cartilage Lesions, and Degenerative Meniscus Tears: Differences and Clinical Implications.

BACKGROUND: Reduced quadriceps strength influences knee function and increases the risk of knee osteoarthritis. Thus, it is of significant clinical relevance to precisely quantify strength deficits in patients with knee injuries. PURPOSE: To evaluate isokinetic concentric quadriceps muscle strength torque values, assessed both from peak torque and at specific knee flexion joint angles, in patients with anterior cruciate ligament (ACL) injury, focal cartilage lesions, and degenerative meniscus tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were synthesized from patients included in 3 previously conducted research projects: 2 prospective cohort studies and 1 randomized controlled trial. At the time of inclusion, all patients were candidates for surgery. Isokinetic concentric quadriceps muscle strength measurements (60 deg/s) were performed at baseline (preoperative status) and after a period of progressive supervised exercise therapy (length of rehabilitation period: 5 weeks for ACL injury, 12 weeks for cartilage lesions and degenerative meniscus). Outcome measures were peak torque and torque at specific knee flexion joint angles from 20° to 70°. All patients had unilateral injuries, and side-to-side deficits were calculated. For comparisons between and within groups, we utilized 1-way analysis of variance and paired t tests, respectively. RESULTS: In total, 250 patients were included. At baseline, cartilage patients had the most severe deficit (39.7% ± 24.3%; P < .001). Corresponding numbers for ACL and degenerative meniscus subjects were 21.7% (±13.2%) and 20.7% (±16.3%), respectively. At retest, there was significant improvement in all groups (P < .001), with remaining deficits of 24.7% (±18.5%) for cartilage, 16.8% (±13.9%) for ACL, and 3.3% (±17.8%) for degenerative meniscus. Peak torque was consistently measured at 60° of knee flexion, whereas the largest mean deficits were measured at 30° at baseline and 70° at retest for the ACL group, at 70° at baseline and retest for the degenerative meniscus group, and at 60° at baseline and at 50° at retest for the cartilage group. CONCLUSION: This study underlines the importance of including torque at specific knee flexion joint angles from isokinetic assessments to identify the most severe quadriceps muscle strength deficits. Furthermore, it confirms the importance of progressive exercise therapy interventions before potential surgery in patients with knee injuries.

Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study.

BACKGROUND: Knee reinjury after ACL reconstruction is common and increases the risk of osteoarthritis. There is sparse evidence to guide return to sport (RTS) decisions in this population. OBJECTIVES: To assess the relationship between knee reinjury after ACL reconstruction and (1) return to level I sports, (2) timing of RTS and (3) knee function prior to return. METHODS: 106 patients who participated in pivoting sports participated in this prospective 2-year cohort study. Sports participation and knee reinjury were recorded monthly. Knee function was assessed with the Knee Outcome Survey-Activities of Daily Living Scale, global rating scale of function, and quadriceps strength and hop test symmetry. Pass RTS criteria were defined as scores >90 on all tests, failure as failing any. RESULTS: Patients who returned to level I sports had a 4.32 (p=0.048) times higher reinjury rate than those who did not. The reinjury rate was significantly reduced by 51% for each month RTS was delayed until 9 months after surgery, after which no further risk reduction was observed. 38.2% of those who failed RTS criteria suffered reinjuries versus 5.6% of those who passed (HR 0.16, p=0.075). More symmetrical quadriceps strength prior to return significantly reduced the knee reinjury rate. CONCLUSIONS: Returning to level I sports after ACL reconstruction leads to a more than 4-fold increase in reinjury rates over 2 years. RTS 9 months or later after surgery and more symmetrical quadriceps strength prior to return substantially reduce the reinjury rate.

Prevention and rehabilitation of paediatric anterior cruciate ligament injuries.

PURPOSE: To review the current knowledge on anterior cruciate ligament (ACL) injury prevention and ACL rehabilitation in individuals who have not yet reached musculoskeletal maturity. METHODS: This is a narrative review based on a targeted and systematic literature search for paediatric ACL injury risk factors, injury prevention and rehabilitation. RESULTS: The search strategies resulted in 119 hits on risk factor studies, 57 hits on prevention and 37 hits on rehabilitation. Modifiable risk factors for ACL injury are largely unknown in the paediatric population. ACL injury prevention using neuromuscular training is highly successful in the adolescent population, and existing injury prevention programmes are cost-effective. The efficacy of ACL injury prevention programmes in children is, however, investigated to a markedly lesser degree. Paediatric ACL injury rehabilitation is poorly described, although supervised active rehabilitation progressed through phases with functional milestones is generally encouraged. CONCLUSION: Although limited, current evidence supports implementation of injury prevention programmes in female football players from the age of 12. Supervised active rehabilitation where progression is guided by functional milestones is also advocated. Future identification of modifiable risk factors is needed to design prevention programmes for younger children. There is a need for international multicentre studies on treatment algorithms and rehabilitation to increase knowledge on the short- and long-term outcomes following existing algorithms. STUDY DESIGN: Narrative review, level III.

Consensus criteria for defining 'successful outcome' after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation.

BACKGROUND: No gold standard exists for identifying successful outcomes 1 and 2 years after operative and non-operative management of anterior cruciate ligament (ACL) injury. This limits the ability of a researcher and clinicians to compare and contrast the results of interventions. PURPOSE: To establish a consensus based on expert consensus of measures that define successful outcomes 1 and 2 years after ACL injury or reconstruction. METHODS: Members of international sports medicine associations, including the American Orthopaedic Society for Sports Medicine, the European Society for Sports Traumatology, Surgery, and Knee Arthroscopy and the American Physical Therapy Association, were sent a survey via email. Blinded responses were analysed for trends with frequency counts. A summed importance percentage (SIP) was calculated and 80% SIP operationally indicated consensus. RESULTS: 1779 responses were obtained. Consensus was achieved for six measures in operative and non-operative management: the absence of giving way, patient return to sports, quadriceps and hamstrings' strength greater than 90% of the uninvolved limb, the patient having not more than a mild knee joint effusion and using patient-reported outcomes (PRO). No single PRO achieved consensus, but threshold scores between 85 and 90 were established for PROs concerning patient performance. CONCLUSIONS: The consensus identified six measures important for successful outcome after ACL injury or reconstruction. These represent all levels of the International Classification of Functioning: effusion, giving way, muscle strength (body structure and function), PRO (activity and participation) and return to sport (participation), and should be included to allow for comparison between interventions.

Nonsurgical or Surgical Treatment of ACL Injuries: Knee Function, Sports Participation, and Knee Reinjury: The Delaware-Oslo ACL Cohort Study.

BACKGROUND: While there are many opinions about the expected knee function, sports participation, and risk of knee reinjury following nonsurgical treatment of injuries of the anterior cruciate ligament (ACL), there is a lack of knowledge about the clinical course following nonsurgical treatment compared with that after surgical treatment. METHODS: This prospective cohort study included 143 patients with an ACL injury. Isokinetic knee extension and flexion strength and patient-reported knee function as recorded on the International Knee Documentation Committee (IKDC) 2000 form were collected at baseline, six weeks, and two years. Sports participation was reported monthly for two years with use of an online activity survey. Knee reinjuries were reported at the follow-up evaluations and in a monthly online survey. Repeated analysis of variance (ANOVA), generalized estimating equation (GEE) models, and Cox regression analysis were used to analyze group differences in functional outcomes, sports participation, and knee reinjuries, respectively. RESULTS: The surgically treated patients (n = 100) were significantly younger, more likely to participate in level-I sports, and less likely to participate in level-II sports prior to injury than the nonsurgically treated patients (n = 43). There were no significant group-by-time effects on functional outcome. The crude analysis showed that surgically treated patients were more likely to sustain a knee reinjury and to participate in level-I sports in the second year of the follow-up period. After propensity score adjustment, these differences were nonsignificant; however, the nonsurgically treated patients were significantly more likely to participate in level-II sports during the first year of the follow-up period and in level-III sports over the two years. After two years, 30% of all patients had an extensor strength deficit, 31% had a flexor strength deficit, 20% had patient-reported knee function below the normal range, and 20% had experienced knee reinjury. CONCLUSIONS: There were few differences between the clinical courses following nonsurgical and surgical treatment of ACL injury in this prospective cohort study. Regardless of treatment course, a considerable number of patients did not fully recover following the ACL injury, and future work should focus on improving the outcomes for these patients. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.