No Effect of Return to Sport Test Batteries with and without Psychological PROs on the Risk of a Second ACL Injury: A Critical Assessment of Four Different Test Batteries.

Background: Patients report psychological barriers as important when returning to sport, however, psychological outcome measures are seldom included in return to sport (RTS) assessment. There is a need for clinical trials to integrate psychological patient-reported outcomes (PROs) in return to sport batteries assessing patients treated with ACL reconstruction. Objective: The aim of this study was to determine the association between passing clinical tests of muscle function and psychological PROs and sustaining a second ACL injury in patients who RTS after primary ACL reconstruction. Design: Retrospective Cohort study. Methods: Patients' sex, age, height and weight, and the results of strength and hop tests, as well as answers to PRO's (including Tegner activity scale, the ACL Return to Sport after Injury scale (ACL-RSI) as well as the Quality of Life (QoL) subscale of the Knee injury and Osteoarthritis Outcome Score [KOOS]), were extracted from a rehabilitation-specific registry. Four different test batteries comprising muscle function tests and PROs were created to assess whether patients were ready to RTS. Passing each of the test batteries (yes/no) was used as an independent variable. A multivariable Cox proportional hazard model analysis was performed, with sustaining a second ACL injury (either ipsi- or contralateral; yes/no) within two years of RTS as the dependent variable. Results: A total of 419 patients (male, n=214; 51%) were included, of which 51 (12.2%) suffered a second ACL injury within the first two years after RTS. There were no differences in passing rates in the different RTS test batteries comprising muscle function tests and PROs for patients who suffered a second ACL injury compared to patients who did not. Conclusion: No association between passing the RTS clinical tests batteries comprising muscle function and psychological PROs used, and the risk of a second ACL injury could be found. Level of Evidence: 3©The Author(s).

Return to Sport Activity After Meniscal Allograft Transplantation: At What Level and at What Cost? A Systematic Review and Meta-analysis.

CONTEXT:: Meniscal injuries are common among both sport- and non-sport-related injuries, with over 1.7 million meniscal surgeries performed worldwide every year. As meniscal surgeries become more common, so does meniscal allograft transplantation (MAT). However, little is known about the outcomes of MAT in active patients who desire to go back to preinjury activities. OBJECTIVE:: The purpose of this systematic review and meta-analysis was to evaluate return to sport, clinical outcome, and complications after MAT in sport-active patients. DATA SOURCES:: A systematic search of MEDLINE, EMBASE, and CINAHL electronic databases was performed on February 25, 2018. STUDY SELECTION:: Studies of level 1 through 4 evidence looking at MAT in physically active patients with reported return to activity outcomes and at least 2-year follow-up were included. STUDY DESIGN:: Systematic review and meta-analysis. LEVEL OF EVIDENCE:: Level 4. DATA EXTRACTION:: Details of sport-related outcomes and reoperations were extracted and pooled in a meta-analysis. RESULTS:: Nine studies were included in this systematic review. A majority (77%) of athletes and physically active patients were able to return to sport after MAT; two-thirds were able to perform at preinjury levels. Graft-related reoperations were reported in 13% of patients, while the joint replacement rate with partial or total knee prosthesis was 1.2%. CONCLUSION:: Physical activity after MAT appears possible, especially for low-impact sports. However, because of the limited number of studies, their low quality, and the short-term follow-up, the participation recommendation for high-impact and strenuous activities should be considered with caution until high-quality evidence of long-term safety becomes available.

The effect of changing one's country of residence on the decision to become an organ donor: the experience of religious immigrant women living in Sweden.

Aim To explore and elucidate women's knowledge of and willingness to take part in organ donation, and to explore if their opinions were changed by coming to Sweden. Methods The study was designed as a qualitative study using data from interviews with women from Bosnia and Herzegovina, Macedonia, Croatia and Kosovo. The inclusion criteria were women who were immigrants in Sweden and have lived in Sweden for more than 10 years. Five groups including forty-five women were invited to participate in the study and 39 agreed. The women were aged 29 to 73 years (mean 52.5 years). Results Regarding knowledge and information about organ donation, most women found it very important to be able to talk about such things. However, the knowledge and information about organ donation of almost all the women was at a very low level. None of the women changed their opinion on the organ donation and attitudes from their countries of origin. All women firmly emphasized and explained that by coming to another state they do not become a different person and retain all values they had and with which were born in home country. Conclusion It is important to study how to find new ways to communicate and work with minorities and vulnerable groups in order to discuss organ donation with all those who could be potential donors in the Swedish health care system.

Mapping functions in health-related quality of life: mapping from the Achilles Tendon Rupture Score to the EQ-5D.

PURPOSE: Health state utility values are derived from preference-based measurements and are useful in calculating quality-adjusted life years (QALYs), which is a metric commonly used in cost-effectiveness studies. The purpose of this study was to convert the Achilles Tendon Rupture Score (ATRS) to the preference-based European Quality of Life-5 Dimension Questionnaire (EQ-5D) by estimating the relationship between the two scores using mapping. METHODS: Data were collected from a randomised controlled trial, where 100 patients were treated either surgically or non-surgically for Achilles tendon rupture. Forty-three and forty-four patients in surgical group and non-surgical group completed the ATRS and the EQ-5D alongside each other during follow-up at three time points. Different models of the relationship between the ATRS and the EQ-5D were developed and analysed based on direct mapping and cross-validation. The model with the lowest mean absolute error was observed as the one with the best fit. RESULTS: Among the competing models, mapping based on using a combination of the ATRS items four, five, and six associated with limitation due to pain, during activities of daily living and when walking on uneven ground, produced the best predictor of the EQ-5D score. CONCLUSIONS: The present study provides a mapping algorithm to enable the derivation of utility values directly from the ATRS. This approach makes it feasible for researchers, as well as medical practitioners, to obtain preference-based values in clinical studies or settings where only the ATRS is being administered. The algorithm allows for the calculation of QALYs for use in cost-effectiveness analyses, making it valuable in the study of acute Achilles tendon ruptures. LEVEL OF EVIDENCE: II.

Cost-effectiveness analysis of surgical versus non-surgical management of acute Achilles tendon ruptures.

PURPOSE: An Achilles tendon rupture is a common injury that typically affects people in the middle of their working lives. The injury has a negative impact in terms of both morbidity for the individual and the risk of substantial sick leave. The aim of this study was to investigate the cost-effectiveness of surgical compared with non-surgical management in patients with an acute Achilles tendon rupture. METHODS: One hundred patients (86 men, 14 women; mean age, 40 years) with an acute Achilles tendon rupture were randomised (1:1) to either surgical treatment or non-surgical treatment, both with an accelerated rehabilitation protocol (surgical n = 49, non-surgical n = 51). One of the surgical patients was excluded due to a partial re-rupture and five surgical patients were lost to the 1-year economic follow-up. One patient was excluded due to incorrect inclusion and one was lost to the 1-year follow-up in the non-surgical group. The cost was divided into direct and indirect costs. The direct cost is the actual cost of health care, whereas the indirect cost is the production loss related to the impact of the patient's injury in terms of lost ability to work. The health benefits were assessed using quality-adjusted life years (QALYs). Sampling uncertainty was assessed by means of non-parametric boot-strapping. RESULTS: Pre-injury, the groups were comparable in terms of demographic data and health-related quality of life (HRQoL). The mean cost of surgical management was €7332 compared with €6008 for non-surgical management (p = 0.024). The mean number of QALYs during the 1-year time period was 0.89 and 0.86 in the surgical and non-surgical groups respectively. The (incremental) cost-effectiveness ratio was €45,855. Based on bootstrapping, the cost-effectiveness acceptability curve shows that the surgical treatment is 57% likely to be cost-effective at a threshold value of €50,000 per QALY. CONCLUSIONS: Surgical treatment was more expensive compared with non-surgical management. The cost-effectiveness results give a weak support (57% likelihood) for the surgical treatment to be cost-effective at a willingness to pay per QALY threshold of €50,000. This is support for surgical treatment; however, additionally cost-effectiveness studies alongside RCTs are important to clarify which treatment option is preferred from a cost-effectiveness perspective. LEVEL OF EVIDENCE: I.

Experience of registered nurses in assessing postoperative pain in hip fracture patients with dementia.

Aim To explore the experience of registered nurses in assessing pain in hip fracture in patients with dementia in the postoperative setting. Methods The study questionnaire contained 23 items mainly addressing demographic and social data, information about communication and pain assessment, attention and awareness of the health-care professionals on the ward and suggestions for improving nursing. Results The nurses claimed that they began their assessment of pain in patients with dementia first by observing the patient and making a visual assessment of pain, after which they began to communicate with these patients; majority of dementia patients with hip fractures displayed more facial expressions of pain than patients without dementia. All the nurses agreed that the more severe the patient's dementia was, the less clear the facial expressions and that this in turn made it difficult for the nurses to take care of such patients. Body language was the most common way the patients with dementia and hip fractures expressed their pain. Assessing the pain of a dementia patient with hip fracture and interpreting a non-verbally communicative patient was experienced as very difficult by all the nurses. Conclusion The nurses found that the fact that they had not attended any courses on dementia and pain assessment in those patients made their work more difficult; they need to know more and to have more information about those patients and their needs for a more comprehensive exchange of information between the hospital wards and the patients' care homes.

Analysis of the influence of anaesthesia on the clinical and quantitative assessment of the pivot shift: a multicenter international study.

PURPOSE: The main goal of this work was to evaluate the pivot shift test in awake and anesthetized patients by using two different quantitative methodologies and comparing the results with the standard clinical grading, taking advantage of a multicenter international study. METHODS: Patients between 16 and 50 years of age undergoing primary unilateral single-bundle anterior cruciate ligament (ACL) reconstruction were considered eligible. The pivot shift test was performed pre-operatively, with the patient awake and again with the patient under general anaesthesia. The pivot shift test was clinically graded as defined by the International Knee Documentation Committee. The instrumented assessment was performed by using two non-invasive acquisition systems; specifically, a system exploiting an inertial sensor and a video-based application developed on a commercial tablet using skin markers. Lateral compartment translation and the tibial acceleration reached during joint reduction were used as quantitative parameters. RESULTS: A total of 103 patients were enrolled in the study. Statistically significant difference was found between the distributions of clinical grade evaluated in awake patients and those under general anaesthesia (P < 0.01). Comparing awake patients to those under general anaesthesia, lower values were found both for tibial acceleration (3.7 ± 1.5 vs 6.0 ± 4.6 m/s2, P < 0.01) and lateral compartment translation of the involved limb (2.2 ± 1.7 vs 3.0 ± 2.2 mm, P < 0.01). CONCLUSIONS: This study indicated that significant differences in the grading of the pivot shift test exist between awake and anesthetized patients, regardless of the use of quantitative instruments during the evaluation. Actual clinical assessment reported indeed its weakness, presenting subjective variability and dependence on tester's experience. However, several factors might influence the validity of awake examination such as experience level of examiner and cultural factors, as seen in this international multicenter study. LEVEL OF EVIDENCE: Prospective comparative study, Level II.

Objective measures on knee instability: dynamic tests: a review of devices for assessment of dynamic knee laxity through utilization of the pivot shift test.

Current reconstructive methods used after anterior cruciate ligament (ACL) injury do not entirely restore native knee kinematics. Evaluation of dynamic knee laxity is important to accurately diagnose ACL deficiency, to evaluate reconstructive techniques, and to construct treatment algorithms for patients with ACL injury. The purpose of this study is to present recent progress in evaluation of dynamic knee laxity through utilization of the pivot shift test. A thorough electronic search was performed and relevant studies were assessed. Certain dynamic knee laxity measurement methods have been present for over 10 years (Navigation system, Electromagnetic sensor system) while other methods (Inertial sensor, Image analysis system) have been introduced recently. Methods to evaluate dynamic knee laxity through the pivot shift test are already potent. However, further refinement is warranted. In addition, to correctly quantify the pivot shift test, the involved forces need to be controlled through either standardization or mechanization of the pivot shift test.

Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials.

PURPOSE: The primary aim was to summarize and assess current evidence from randomized controlled trials (RCTs) on anterior cruciate ligament injuries, with special reference to graft type and surgical technique. The secondary aims were to identify the relative strengths and weaknesses of the selected studies, to resolve contradictions in the literature, and to evaluate the need for further studies. METHODS: A PubMed database search using the key words "anterior cruciate ligament" was performed. The search was limited to RCTs published in English between January 1995 and March 2009. Articles on the subject of graft type and surgical technique were identified. After initial screening and a subsequent quality appraisal based on the CONSORT (Consolidated Standards of Reporting Trials) Statement, a total of 39 articles were included in this review. RESULTS: There are no differences between the bone-patellar tendon-bone (BPTB) graft and the hamstring tendon (HT) graft in terms of laxity, clinical outcome, time to return to sports, patellofemoral crepitations, 1-leg hop test, range of motion, thigh muscle circumference, or anterior knee sensory deficit. The BPTB graft produces more anterior knee pain and kneeling pain than the HT graft, but the difference disappears with time. The harvest site affects muscle strength initially but not over time. There is a possible correlation between the development of osteoarthritis and the BPTB graft. The HT graft produces more tunnel widening than the BPTB graft, but there is no correlation between tunnel widening and clinical outcome or laxity. The semitendinosus and gracilis graft is associated with inferior knee flexion at higher angles, as compared with the semitendinosus graft. There are probably no differences between the BPTB graft and the bone-HT-bone graft in terms of laxity and clinical outcome. Semitendinosus and gracilis tendon harvesting probably reduces hamstring muscle strength for approximately 1 year. Double-bundle reconstruction produces less rotatory laxity than single-bundle reconstruction. Double-bundle reconstruction by use of an 8-strand HT graft probably produces less laxity than single-bundle reconstruction. There are no differences in clinical outcome when single-bundle and double-bundle anterior cruciate ligament reconstructions are compared. CONCLUSIONS: In the quality assessment several weaknesses in the study design of the RCTs were found. This emphasizes the need for further high-quality studies, especially with long-term follow-up. LEVEL OF EVIDENCE: Level II, systematic review of randomized controlled trials.

Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials.

PURPOSE: The primary aim was to investigate and assess the current evidence of randomized controlled trials (RCTs) on anterior cruciate ligament (ACL) injuries, with special reference to the choice of surgical techniques and aspects of rehabilitation. A secondary aim was to clarify relative strengths and weaknesses of the selected studies, resolve literature conflicts, and finally, evaluate the need for further studies. METHODS: A PubMed database search using the key words "anterior cruciate ligament" was performed. The search was limited to only RCTs published in English during the period of January 1995 to March 2009. Articles concerning surgical technique and rehabilitation were obtained. After initial screening and subsequent quality appraisal based on the CONSORT (Consolidated Standards of Reporting Trials) Statement, a total of 70 articles were included in this review. RESULTS: Initial graft tension and the use of a ligament augmentation device do not affect clinical outcome. Bioabsorbable screws and titanium screws produced equal clinical outcome, regardless of graft type. Radiographic signs of osteoarthritis develop in 50% of ACL-injured patients, regardless of treatment. Meniscectomy further increases the risk. Furthermore, the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction. Closed kinetic chain exercises produced less pain and laxity while promoting better subjective outcome than open kinetic chain exercises after patellar tendon reconstruction. CONCLUSIONS: In terms of quality assessment, several weaknesses pertaining to study design were discovered among the included RCTs, which intelligibly stress the need for further high-quality studies. LEVEL OF EVIDENCE: Level II, systematic review of RCTs.