High prevalence of associated injuries in anterior cruciate ligament tears: A detailed magnetic resonance imaging analysis of 254 patients.

OBJECTIVES: To evaluate the type and prevalence of associated injuries by using magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) tears. METHODS: Data from the Natural Corollaries and Recovery after ACL injury multicenter longitudinal cohort study were analyzed. Between May 2016 and October 2018, patients aged between 15 and 40 years, who had experienced an ACL tear within the last 6 weeks and sought medical attention at one of seven healthcare clinics in Sweden, were invited to participate. The mean time from injury to MRI was 19.6 ± 15.2 days. An orthopedic knee surgeon and a musculoskeletal radiologist reviewed all the MRI scans. The following structures were assessed: posterior cruciate ligament (PCL), medial collateral ligament (MCL) complex, lateral collateral ligament (LCL), popliteus tendon, medial meniscus (MM), lateral meniscus (LM), and cartilage. In addition, the presence of bone bruising, impaction fractures in the lateral femoral condyle (LFC) or posterolateral tibia (PLT), and Segond fractures were also assessed.  RESULTS: A total of 254 patients (48.4% males) with a mean age of 25.4 ± 7.1 years were included. The prevalence of associated injuries was as follows: PCL (0.4%), MCL {41.3% [superficial MCL and deep MCL (dMCL) 16.5%; isolated dMCL 24.8%]}, LCL (2.4%), MM (57.4%), LM (25.2%), cartilage (15.0%), bone bruising (92.9%), impaction fracture in the LFC (45.7%) and PLT (4.7%), and Segond fracture (7.5%). CONCLUSIONS: The prevalence of associated injuries in patients with ACL tears was high. The findings reported in this study may serve as a reference tool for orthopedic surgeons and radiologists in the diagnosis of associated injuries using MRI in patients with ACL tears.

High Prevalence of Superficial and Deep Medial Collateral Ligament Injuries on Magnetic Resonance Imaging in Patients With Anterior Cruciate Ligament Tears.

PURPOSE: To assess the prevalence of and factors associated with medial collateral ligament (MCL) complex injuries on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) tears. METHODS: Data were extracted from the Natural Corollaries and Recovery After ACL Injury (NACOX) multicenter longitudinal cohort study. Between May 2016 and October 2018, patients who presented to 1 of 7 health care clinics across Sweden with an ACL tear sustained no more than 6 weeks earlier and who were aged between 15 and 40 years at the time of injury were invited to participate. All the patients included in this study underwent MRI. The mean time from injury to MRI was 19.6 ± 15.2 days. An orthopaedic surgeon specializing in knee surgery and a musculoskeletal radiologist reviewed all MRI scans. Injuries to the superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament were identified. Stepwise forward multiple binary logistic regression analyses were used to evaluate patient characteristics (age, sex, body mass index, preinjury Tegner activity level, and activity at injury) and injuries on MRI (lateral meniscus [LM] injury, medial meniscus [MM] injury, pivot shift-type bone bruising, medial femoral condyle [MFC] bone bruising, and lateral femoral condyle [LFC] impaction) associated with the presence of MCL complex tears. RESULTS: In total, 254 patients (48.4% male patients) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries was 16.5% (42 of 254) and 24.8% (63 of 254), respectively. No isolated sMCL injuries were found. Posterior oblique ligament injuries were found in 12 patients (4.7%) with MCL (sMCL and dMCL) injuries. An LM injury (odds ratio [OR], 3.94; 95% confidence interval [CI], 1.73-8.94; P = .001) and LFC impaction (OR, 2.37; 95% CI, 1.11-5.07; P = .02) increased the odds of having an MCL injury, whereas an MM injury (OR, 0.26; 95% CI, 0.12-0.59; P = .001) reduced the odds. Isolated dMCL injuries were significantly associated with MFC bone bruising (OR, 4.21; 95% CI, 1.92-9.25; P < .001) and LFC impaction (OR, 3.86; 95% CI, 1.99-7.49; P < .001). CONCLUSIONS: The overall combined prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries in patients with ACL tears was high (16.5% + 24.8% = 41.3%). The presence of an LM injury and LFC impaction increased the odds of having an MCL injury, whereas the presence of an MM injury reduced the odds. MFC bone bruising and LFC impaction were associated with the presence of isolated dMCL injuries. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Analysis of the Swedish Knee Ligament Register: Concomitant injuries, revision surgery and smoking render worse results.

PURPOSE: To analyse the 52,199 patients in the Swedish Knee Ligament Register (SKLR) preoperatively, and the patients reaching 5- and 10-year follow-ups who underwent anterior cruciate ligament reconstruction (ACLR), revision ACLR and ACLR on the contralateral side (CACLR). The main hypothesis was that patients undergoing revision ACLR would have worse patient-reported outcome measurements (PROMs) than the primary ACLR group at 10 years and that smoking and concomitant injuries would result in poorer outcomes for all groups. METHODS: Data from 2005 to 2021 were extracted from the SKLR. Only patients whose ACLR surgery was registered in the SKLR were included for revision ACLR and CACLR. The PROMs consist of the Knee injury and Osteoarthritis Outcome Score (KOOS) and the knee-specific PROM (EQ-5D-3L). PROMs were analysed as a whole and in subgroups based on sex, smoking, graft choice and concomitant injuries. RESULTS: Poorer KOOS were seen for revisions compared with primary ACLRs at both the 5- and 10-year follow-ups (p = 0.003). Smokers had significantly poorer KOOS than nonsmokers (p < 0.001) preoperatively in all groups, however only in the primary ACLR group at 5 and 10 years. At 10 years, patients who had undergone CACLR had lower KOOS than primary ACLRs (p = 0.03). Concomitant injuries resulted in statistically, significantly poorer KOOS for both primary ACLRs and CACLRs preoperatively and at the follow-ups. CONCLUSION: The PROMs for revision ACLRs have worse KOOS scores at 10 years compared with the primary ACLRs. The presence of concomitant meniscal or cartilage injuries at the time of ACLR or CACLR were associated with worse PROMs. LEVEL OF EVIDENCE: Level III.

The Swedish version of the Anterior Cruciate Ligament Quality Of Life measure (ACL-QOL): translation and measurement properties.

PURPOSE: To translate the ACL-QOL from English to Swedish and evaluate measurement properties for use after surgical and non-surgical management of anterior cruciate ligament (ACL) injury. METHODS: The ACL-QOL was translated from English to Swedish and data were pooled from 13 cohorts to enable a comprehensive evaluation of measurement properties in line with COSMIN guidelines. We evaluated internal consistency, test-re-test reliability, measurement error, structural validity [confirmatory factor analysis (CFA)], construct validity and responsiveness (hypothesis testing), and floor/ceiling effects. Results were stratified by time since injury (≤ 1.5 years; 2-10 years, 15-25 years; > 30 years) and ACL management strategy [surgical (n = 1163), non-surgical (n = 570)]. RESULTS: The Swedish ACL-QOL had sufficient internal consistency (total and domain scores) for use in surgically managed (Cronbach's alpha ≥ 0.744) and non-surgically managed (≥ 0.770) ACL-injured individuals at all time-points. Test-re-test reliability was sufficient [intraclass correlation coefficients: all domains > 0.80, total score 0.93 (95% CI 0.86-0.96)]. The standard error of measurement was 5.6 for the total score and ranged from 7.0 to 10.3 for each domain. CFA indicated sufficient SRMR values when using the total score or five domains; however, CFI and RMSEA values did not meet cut-offs for good model fit. Hypothesis testing indicated sufficient construct validity and responsiveness. Floor effects were negligible and ceiling effects were negligible or minor. CONCLUSION: The Swedish version of the ACL-QOL has sufficient internal consistency, test-re-test reliability, construct validity and responsiveness, for use in people with ACL injury managed with or without ACL surgery. Model fit could be improved and investigation into the source of misfit is warranted.

What Factors Identified in Initial Osteoarthritis Management Are Associated With Poor Patient-reported Outcomes After THA? A Register-based Study.

BACKGROUND: Some patients report long-term pain or no improvement in health-related quality of life (HRQoL) or are dissatisfied after THA. However, factors associated with these poorer patient-reported outcomes after surgery are inconsistent and have typically been studied in the late phase of hip osteoarthritis (OA) among patients already eligible for surgery. Earlier identification of risk factors would provide time to address modifiable factors, helping to improve patients' pain, HRQoL, and satisfaction after surgery and reduce the burden on orthopaedic clinics by referring patients who are better prepared for surgery. QUESTIONS/PURPOSES: We analyzed data from patients with hip OA referred to a first-line OA intervention program in primary healthcare at a stage when they had not been referred for THA, and asked: (1) What percentage of patients who proceed to THA report lack of improvement in pain, lack of improvement in HRQoL as measured by the EQ-5D, or are not satisfied with surgery 1 year after THA? (2) What associations exist between baseline factors at referral to this first-line OA intervention program and these poorer patient-reported outcomes 1 year after THA? METHODS: We included 3411 patients with hip OA (mean age 67 ± 9 years, 63% [2160 of 3411] women) who had been referred for first-line OA interventions between 2008 and 2015 and subsequently underwent THA for OA. All patients were initially identified through the Swedish Osteoarthritis Register, which follows and evaluates patients in a standardized national first-line OA intervention program. Then, we identified those who were also registered in the Swedish Arthroplasty Register with a THA during the study period. We included only those with complete patient-reported outcome measures for pain, HRQoL, and satisfaction preoperatively and 1-year postoperatively, representing 78% (3411 of 4368) of patients, who had the same baseline characteristics as nonrespondents. Multiple logistic regression was used to assess the associations between 14 baseline factors and the aforementioned patient-reported outcomes of pain, HRQoL, and satisfaction 1 year after THA, adjusted for all included factors. RESULTS: Five percent (156 of 3411) of the study population lacked improvement in pain, 11% (385 of 3411) reported no improvement in HRQoL, and 10% (339 of 3411) reported they were not satisfied with surgery 1 year after THA. Charnley Class C (multiple-joint OA or another condition that affects the ability to walk) was associated with all outcomes: lack of improvement in pain (OR 1.84 [95% CI 1.24 to 2.71]; p = 0.002), lack of improvement in HRQoL (OR 1.83 [95% CI 1.42 to 2.36]; p < 0.001), and not being satisfied (OR 1.40 [95% CI 1.07 to 1.82]; p = 0.01). Older age was associated with a lack of improvement in pain (OR per year 1.03 [95% CI 1.01 to 1.05]; p = 0.02), lack of improvement in HRQoL (OR per year 1.04 [95% CI 1.03 to 1.06]; p < 0.001), and not being satisfied (OR per year 1.03 [95% CI 1.01 to 1.05]; p < 0.001). Depression was associated with a lack of improvement in pain (OR 1.54 [95% CI 1.00 to 2.35]; p = 0.050) and with not being satisfied (OR 1.50 [95% CI 1.11 to 2.04]; p = 0.01) but not with a lack of improvement in HRQoL (OR 1.04 [95% CI 0.76 to 1.43]; p = 0.79). Having four or more comorbidities was associated with a lack of improvement in HRQoL (OR 2.08 [95% CI 1.39 to 3.10]; p < 0.001) but not with a lack of improvement in pain and not being satisfied. CONCLUSION: The results of this study showed that older age, Charley Class C, and depression in patients with first-line OA interventions were risk factors associated with poorer outcomes regarding pain, HRQoL, and satisfaction after THA. Screening patients with hip OA for depression early in the disease course would provide increased time to optimize treatments and may contribute to better patient-reported pain, HRQoL, and satisfaction after future THA. Further research should focus on identifying the optimal time for surgery in patients with depression, as well as what targeted interventions for depression can improve outcome of surgery in these patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

High prevalence of meniscal ramp lesions in anterior cruciate ligament injuries.

PURPOSE: To evaluate the prevalence of and factors associated with meniscal ramp lesions on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) injuries. METHODS: Data from the Natural Corollaries and Recovery after ACL injury multicentre longitudinal cohort study (NACOX) were analysed. Only patients who underwent MRI were included in this study. All MRI scans were reviewed by an orthopaedic knee surgeon and a musculoskeletal radiologist. The patients were divided into two groups, those with and without ramp lesions according to MRI findings. Univariable and stepwise forward multiple logistic regression analyses were used to evaluate patient characteristics (age, gender, body mass index, pre-injury Tegner activity level, activity at injury) and concomitant injuries on MRI (lateral meniscus, medial collateral ligament [MCL], isolated deep MCL, lateral collateral ligament, pivot-shift-type bone bruising, posteromedial tibial [PMT] bone bruising, medial femoral condyle bone bruising, lateral femoral condyle [LFC] impaction and a Segond fracture) associated with the presence of meniscal ramp lesions. RESULTS: A total of 253 patients (52.2% males) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of meniscal ramp lesions was 39.5% (100/253). Univariate analyses showed that contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising, LFC impaction and the presence of a Segond fracture increased the odds of having a meniscal ramp lesion. Stepwise forward multiple logistic regression analysis revealed that the presence of a meniscal ramp lesion was associated with contact sports at ACL injury [odds ratio (OR) 2.50; 95% confidence intervals (CI) 1.32-4.72; P = 0.005], pivot-shift-type bone bruising (OR 1.29; 95% CI 1.01-1.67; P = 0.04), PMT bone bruising (OR 4.62; 95% CI 2.61-8.19; P < 0.001) and the presence of a Segond fracture (OR 4.38; 95% CI 1.40-13.68; P = 0.001). CONCLUSION: The overall prevalence of meniscal ramp lesions in patients with ACL injuries was high (39.5%). Contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising and the presence of a Segond fracture on MRI were associated with meniscal ramp lesions. Given their high prevalence, meniscal ramp lesions should be systematically searched for on MRI in patients with ACL injuries. Knowledge of the factors associated with meniscal ramp lesions may facilitate their diagnosis, raising surgeons' and radiologists' suspicion of these tears. LEVEL OF EVIDENCE: III.

Treatment decision-making process after an anterior cruciate ligament injury: patients', orthopaedic surgeons' and physiotherapists' perspectives.

OBJECTIVE: To investigate the treatment decision-making process after an anterior cruciate ligament (ACL) injury from patients', orthopaedic surgeons' and physiotherapists' perspectives. METHODS: The study is a part of the NACOX study, which is designed to describe the natural corollaries after ACL injury. For the present study, a subgroup 101 patients were included. Patients, their orthopaedic surgeons and their physiotherapists, answered a Shared Decision-Making Process (SDMP) questionnaire, when treatment decision for ACL reconstruction surgery (ACLR) or non-reconstruction (non-ACLR) was taken. The SDMP questionnaire covers four topics: " informed patient", " to be heard", " involvement" and " agreement". RESULTS: Most (75-98%) patients considered their needs met in terms of being heard and agreement with the treatment decision. However, fewer in the non-ACLR group compared to the ACLR group reported satisfaction with information from the orthopaedic surgeon (67% and 79%), or for their own involvement in the treatment decision process (67% and 97%). CONCLUSION AND PRACTICE IMPLICATIONS: Most patients and caregivers considered that patients' needs to be informed, heard and involved, and to agree with the decision about the treatment process, were fulfilled to a high extent. However, patients where a non-ACLR decision was taken experienced being involved in the treatment decision to a lower extent. This implies that the non-ACLR treatment decision process needs further clarification, especially from the patient involvement perspective.

BAck iN the Game (BANG) - a smartphone application to help athletes return to sport following anterior cruciate ligament reconstruction: protocol for a multi-centre, randomised controlled trial.

BACKGROUND: Sustaining injury is a common consequence of playing sport. At least one in every three recreational athletes with anterior cruciate ligament (ACL) reconstruction do not return to their preinjury sport following treatment. Psychological factors including confidence and fear of new injury exert large effects on returning to sport. The primary aim of this trial is to test whether a custom smartphone application delivering cognitive-behavioural therapy is effective for improving the number of people who return to their preinjury sport and level following ACL reconstruction. METHODS: Participants scheduled for primary ACL reconstruction are recruited prior to surgery from one of six trial sites in Sweden. We aim to recruit 222 participants (111 in each group) for the BANG trial. Participants are randomly allocated to receive either usual rehabilitation care alone or usual rehabilitation care plus the Back in the Game smartphone application intervention. Back in the Game is a 24-week Internet-delivered programme, based on cognitive-behavioural therapy. The primary outcome is return to the preinjury sport and level at 12 months follow-up. The secondary outcomes assess physical activity participation, new knee injuries, psychological factors, quality of life and physical function. Physical activity participation and new injuries are self-reported every two weeks for 12 months, then every 4 weeks to 24 months follow-up. Psychological readiness to return to sport, knee self-efficacy, motivation to participate in leisure time physical activity, knee-related quality of life, and self-reported knee function are also assessed at 3, 6, 9, 12 and 24 months after surgery. A clinical assessment of strength, knee range of motion, effusion and hopping performance is completed by a blinded assessor at 12 months to assess physical function. DISCUSSION: This protocol outlines how we plan to assess the efficacy of a custom smartphone application, delivering cognitive-behavioural therapy to address fear, confidence and recovery expectations, for improving return to sport following serious sports-related musculoskeletal injury. The BANG trial employs a pragmatic design to best reflect the reality of, and inform, clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03959215 . Registered 22 May 2019.

Socioeconomic status of patients in a Swedish national self-management program for osteoarthritis compared with the general population-a descriptive observational study.

BACKGROUND: First-line treatment for hip and knee osteoarthritis (OA) including education and supervised exercises, delivered as a self-management program, is considered one of the mainstays in OA treatment. However, the socioeconomic profile of the population that utilizes first-line treatment for hip and knee OA is unclear. The aim of this study was to describe the socioeconomic status (SES) of a population referred to a self-management program for OA, in comparison with that of the general Swedish population. METHODS: This is a cross-sectional study including 72,069 patients with hip or knee OA enrolled in the National Quality Register for Better management of patients with Osteoarthritis (BOA) between 2008 and 2016, and registered before participation in a structured OA self-management program. A reference cohort (n = 216,207) was selected from the general Swedish population by one-to-three matching by year of birth, sex and residence. Residential municipality, country of birth, marital status, family type, educational level, employment, occupation, disposable income and sick leave were analyzed. RESULTS: The BOA population had higher educational level than the reference group, both regarding patients with hip OA (77.5% vs 70% with ≥10 years of education), and with knee OA (77% vs 72% with ≥10 years of education). Their average disposable income was higher (median [IQR] in Euro (€), for hip €17,442 [10,478] vs €15,998 [10,659], for knee €17,794 [10,574] vs €16,578 [11,221]). Of those who worked, 46% of patients with hip OA and 45% of the reference group had a blue-collar occupation. The corresponding numbers for knee OA were 51 and 44% respectively. Sick leave was higher among those with hip and knee OA (26%) than those in the reference groups (13% vs 12%). CONCLUSIONS: The consistently higher SES in the BOA population compared with the general population indicates that this self-management program for OA may not reach the more socioeconomically disadvantaged groups, who are often those with a higher disease burden.

Jump performance in male and female football players.

PURPOSE: To examine differences between men and women football players in clinically feasible jumping measures. METHODS: Female football players (N = 46, ages 16-25) were matched based on age, training frequency, and playing position with 46 male players. All players performed the tuck jump and drop vertical jump (DVJ). DVJ was assessed quantitatively for valgus knee motion and probability of a high peak knee abduction moment (pKAM), as well as sagittal plane hip, knee, and ankle angles, and qualitatively with visual assessment of the player's knees upon landing; graded as good, reduced, or poor control. RESULT: Women had higher total tuck jump scores (5 ± 2) (more technique flaws), than men (3 ± 2, P < 0.01). The quantitative analysis of the DVJ found that men had greater asymmetries between limbs, but women landed bilaterally in more knee valgus (interaction P = 0.04, main effect of sex P = 0.02). There was no difference in pKAM (interaction n.s.). Women also landed in less hip flexion (P = 0.01) and ankle dorsiflexion (P = 0.01) than men. The qualitative DVJ analysis found that more women (48%) had poor knee control compared to men (11%, P < 0.01). CONCLUSIONS: The results indicate that women perform worse on the tuck jump assessment than men. The results support previous findings that women land in more knee valgus than men, but also found that men may have larger asymmetries in knee valgus. These results from clinically feasible measures provide some suggestions for clinicians to consider during ACL reconstruction rehabilitation to enhance performance.

Experiences of men living with Dupuytren's disease-Consequences of the disease for hand function and daily activities.

STUDY DESIGN: Qualitative descriptive. INTRODUCTION: Dupuytren's disease (DD) is a chronic hand condition causing impairment in hand function. Research describing persons' experiences of living with DD is limited. Understanding the subjective experience of illness is valuable for planning and implementing health-care services. PURPOSE OF THE STUDY: To explore experiences among men living with an impaired hand function due to DD and the consequences of the disease for daily activities. METHODS: Interviews were conducted with 21 men before surgery. The model of the patient evaluation process guided data collection. Data were analyzed using problem-driven content analysis. RESULTS: Participants described DD as a chronic disease caused by heredity, previous injury, hard work, or aging. DD was, according to the participants, an uncomfortable and sometimes painful condition, causing a feeling of constant stiffness in the affected hand. DD could cause participants to have fear of hurting the hand, feelings of shame or embarrassment, and a sense of being old. Participants handled the deteriorating hand function by avoiding or refraining from activities, adapting their performance, or performing activities with less quality. The ideal hand function was seen as being able to use the hands without effort. DISCUSSION: The diverse experiences of DD and if the hand is experienced as something that causes distress can be understood further using body-self dialectic and Gadow's states of embodiment, as well as the process of adapting and learning to live with the functional limitations. CONCLUSIONS: A clinical implication for hand therapy is to acknowledge patients' individual experiences and support self-modifications and development of new skills.

Jumping performance based on duration of rehabilitation in female football players after anterior cruciate ligament reconstruction.

PURPOSE: To determine if female football players who had longer durations of rehabilitation, measured in months, after anterior cruciate ligament reconstruction would have lower tuck jump scores (fewer technique flaws) and smaller asymmetries during drop vertical jump landing. METHODS: One-hundred-and-seventeen female football players, aged 16-25 years, after primary unilateral ACL reconstruction (median 16 months, range 6-39) were included. Athletes reported the duration of rehabilitation they performed after anterior cruciate ligament reconstruction. Athletes also performed the tuck jump and drop vertical jump tests. Outcome variables were: tuck jump score, frontal plane knee motion and probability of peak knee abduction moment during drop vertical jump landing. RESULTS: There was no difference in tuck jump score based on duration of rehabilitation (n.s.). No interaction (n.s.), difference between limbs (n.s.), or duration of rehabilitation (n.s.) was found for peak knee abduction moment during drop vertical jump landing. No interaction (n.s.) or difference between limbs (n.s.) was found for frontal plane knee motion, but there was a difference based on duration of rehabilitation (P = 0.01). Athletes with > 9 months of rehabilitation had more frontal plane knee motion (medial knee displacement) than athletes with < 6 months (P = 0.01) or 6-9 months (P = 0.03). CONCLUSION: As there was no difference in tuck jump score or peak knee abduction moment based on duration of rehabilitation, the results of this study press upon clinicians the importance of using objective measures to progress rehabilitation and clear athletes for return to sport, rather than time alone. LEVEL OF EVIDENCE: II.

Activity demands and instability are the most important factors for recommending to treat ACL injuries with reconstruction.

PURPOSE: The purpose of the study was to (1) study and compare the factors that Swedish orthopaedic surgeons and physical therapists consider important for recommending ACL reconstruction and, (2) to assess how orthopaedic surgeons and physical therapists consider their own and each others, as well as patients', roles are in the treatment decision. METHODS: A web-based survey assessing the relevance of 21 predetermined factors, in the choice to recommend ACL reconstruction, was sent to orthopaedic surgeons and physical therapists. Respondents were also asked to rate the importance of the assessment made by themselves, the other clinician (physical therapists rated the importance of surgeons, surgeons rated the importance of physical therapists), and the patients' preferences. RESULT: Orthopaedic surgeons agreed of eight, and physical therapists of seven factors as important in the choice to recommend ACL reconstruction. The factors both groups reported as important were; "patient's wishes to return to contact/pivoting sports", "instability in physical activity", "instability in activities of daily living despite adequate rehabilitation", "physically demanding occupation", and "young age". Both professions rated their own and each others assessments as well as patient's wishes as important for the decision to recommend ACL reconstruction. CONCLUSION: Orthopaedic surgeons and physical therapists agree about factors that are important for their decision to recommend ACL reconstruction, showing that both professions share a common ground in perceptions of factors that are important in recommending ACL reconstruction. LEVEL OF EVIDENCE: Diagnostic study: Level III.

Dynamic and static tibial translation in patients with anterior cruciate ligament deficiency initially treated with a structured rehabilitation protocol.

PURPOSE: To compare dynamic and static tibial translation, in patients with anterior cruciate ligament deficiency, at 2- to 5-year follow-up, with the tibial translation after 4 months of rehabilitation initiated early after the injury. Secondarily, to compare tibial translation in the injured knee and non-injured knee and explore correlations between dynamic and static tibial translation. METHODS: Twelve patients with ACL rupture were assessed at 3-8 weeks after ACL injury, after 4 months of structured rehabilitation, and 2-5 years after ACL injury. Sagittal tibial translation was measured during the Lachman test (static translation) and during gait (dynamic translation) using a CA-4000 electrogoniometer. RESULTS: Static tibial translation was increased bilateral 2-5 years after ACL injury, whereas the dynamic tibial translation was unchanged. Tibial translation was greater in the injured knee compared with the non-injured knee (Lachman test 134 N 9.1 ± 1.0 vs. 7.0 ± 1.7 mm, P = 0.001, gait 5.6 ± 2.1 vs. 4.7 ± 1.8 mm, P = 0.011). There were no correlations between dynamic and static tibial translation. CONCLUSION: Dynamic tibial translation was unchanged in spite of increased static tibial translation in the ACL-deficient knee at 2- to 5-year follow-up compared to directly after rehabilitation. Dynamic tibial translation did not correlate with the static tibial translation. A more normal gait kinematics may be maintained from completion of a rehabilitation programme to mid-term follow-up in patients with ACL deficiency treated with rehabilitation only. LEVEL OF EVIDENCE: IV.

Psychological factors are important to return to pre-injury sport activity after anterior cruciate ligament reconstruction: expect and motivate to satisfy.

PURPOSE: To describe individuals' expectations, motivation, and satisfaction before, during, and after rehabilitation for ACL reconstruction and to explore how these factors were associated with return to pre-injury sport activity at 1-year follow-up. METHODS: Sixty-five individuals (34 males), median age 22 (15-45) years, scheduled for ACL reconstruction participated. Participants completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and questions about expectations, satisfaction, and motivation pre-operatively and at 16 and 52 weeks after surgery. RESULTS: Prior to surgery, 86 % of participants stated that their goal was to return to their pre-injury sport activity. Those who had returned to their pre-injury sport activity at 52 weeks were more motivated during rehabilitation to return to their pre-injury activity level, more satisfied with their activity level and knee function at 52 weeks, and scored significantly higher on the IKDC-SKF [median 92.0 (range 66.7-100.0)] at 52 weeks, compared to those who had not returned [median 77.6 (range 50.6-97.7)]. CONCLUSION: Prior to ACL reconstruction, most participants expected to return to their pre-injury activity level. Higher motivation during rehabilitation was associated with returning to the pre-injury sport activity. The participants who had returned to their pre-injury sport activity were more satisfied with their activity level and knee function 1 year after the ACL reconstruction. Facilitating motivation might be important to support individuals in achieving their participation goals after ACL reconstruction. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Satisfaction With Knee Function After Primary Anterior Cruciate Ligament Reconstruction Is Associated With Self-Efficacy, Quality of Life, and Returning to the Preinjury Physical Activity.

PURPOSE: To assess whether patient-reported outcomes (psychological factors, appraisals of knee function, and physical activity participation) were associated with satisfaction with knee function after anterior cruciate ligament (ACL) reconstruction. METHODS: Participants who were aged 18 to 45 years and a minimum 12 months post primary ACL reconstruction completed a questionnaire battery evaluating knee self-efficacy, knee-related quality of life, self-reported function, and physical activity participation. Participants' responses to the question "If you were to spend the rest of your life with your knee just the way it has been in the last week, would you feel . . . (7-point ordinal scale; 1 = happy, 7 = unhappy)" were categorized as satisfied, mostly satisfied, or dissatisfied and used as the primary outcome. Ordinal regression was used to examine associations between independent variables and the primary outcome. RESULTS: A total of 177 participants were included at an average of 3 years after primary ACL reconstruction. At follow-up, 44% reported they would be satisfied, 28% mostly satisfied, and 28% dissatisfied with the outcome of ACL reconstruction. There were significant differences in psychological responses and appraisal of knee function between the 3 groups (P = .001), and significantly more people in the satisfied group had returned to their preinjury activity (58%) than in the mostly satisfied (28%) and dissatisfied (26%) groups (P = .001). Multivariable analysis demonstrated that the odds of being satisfied increased by a factor of 3 with higher self-efficacy, greater knee-related quality of life, and returning to the preinjury activity. CONCLUSIONS: People who had returned to their preinjury physical activity and who reported higher knee-related self-efficacy and quality of life were more likely to be satisfied with the outcome of ACL reconstruction. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Greater fear of re-injury and increased tibial translation in patients who later sustain an ACL graft rupture or a contralateral ACL rupture: a pilot study.

The aim was to compare fear of re-injury, patient reported function, static and dynamic tibial translation and muscle strength assessed before and 5 weeks after an anterior cruciate ligament (ACL) reconstruction between individuals who sustained a subsequent ACL graft rupture or a contralateral ACL injury within 5 years after the reconstruction, and individuals with no subsequent injury. Nineteen patients were investigated before, and 5 weeks after an ACL reconstruction with a quadruple hamstring tendon graft. At 5 years follow up, 3 patients had sustained an ACL graft rupture and 2 patients had sustained a contralateral ACL rupture. Fear of re-injury, confidence with the knee, patient reported function, activity level, static and dynamic tibial translation and muscle strength were assessed. The re-injured group reported greater fear of re-injury and had greater static tibial translation in both knees before the ACL reconstruction compared to those who did not sustain another ACL injury. There were no other differences between groups. In conclusion, fear of re-injury and static tibial translation before the index ACL reconstruction were greater in patients who later on suffered an ACL graft rupture or a contralateral ACL rupture. These factors may predict a subsequent ACL injury.

Predictors for additional anterior cruciate ligament reconstruction: data from the Swedish national ACL register.

PURPOSE: To identify predictors for additional anterior cruciate ligament (ACL) reconstruction. METHODS: Patients from the Swedish national ACL register who underwent ACL reconstruction between January 2005 and February 2013 (follow-up duration 6-104 months) were included. Cox regression analyses included the following independent variables regarding primary injury: age, sex, time between injury and primary ACL reconstruction, activity at primary injury, concomitant injuries, injury side, graft type, and pre-surgery KOOS and EQ-5D scores. RESULTS: Among ACL reconstruction procedures, 93% involved hamstring tendon (HT) autografts. Graft type did not predict additional ACL reconstruction. Final regression models only included patients with HT autograft (n = 20,824). Of these, 702 had revision and 591 contralateral ACL reconstructions. The 5-year post-operative rates of revision and contralateral ACL reconstruction were 4.3 and 3.8%, respectively. Significant predictors for additional ACL reconstruction were age (fourfold increased rate for <16-year-old patients vs. >35-year-old patients), time between injury and primary surgery (two to threefold increased rate for ACL reconstruction within 0-90 days vs. >365 days), and playing football at primary injury. CONCLUSION: This study identified younger age, having ACL reconstruction early after the primary injury, and incurring the primary injury while playing football as the main predictors for revision and contralateral ACL reconstruction. This suggests that the rate of additional ACL reconstruction is increased in a selected group of young patients aiming to return to strenuous sports after primary surgery and should be taken into consideration when discussing primary ACL reconstruction, return to sports, and during post-surgery rehabilitation. LEVEL OF EVIDENCE: II.

Static and dynamic tibial translation before, 5 weeks after, and 5 years after anterior cruciate ligament reconstruction.

PURPOSE: To evaluate static and dynamic tibial translation before, 5 weeks after, and 5 years after anterior cruciate ligament (ACL) reconstruction. To explore whether static and dynamic tibial translation are correlated. METHODS: Ten patients undergoing quadruple hamstring tendon graft ACL reconstruction were evaluated before, 5 weeks after, and 5 years after ACL reconstruction. Sagittal tibial translation was measured during the Lachman test (static translation) and during gait (dynamic translation) using a CA-4000 electrogoniometer. RESULTS: Five years after ACL reconstruction, static tibial translation did not differ between knees (Lachman test 90 N and 134 N n.s.). In contrast, there was greater maximal anterior tibial translation during gait in ACL-reconstructed knees than in uninjured knees (5.5 ± 1.4 vs. 4.5 ± 1.6 mm, P = 0.028). There were no differences in static or dynamic tibial translation between the 5-year follow-up and before ACL reconstruction or between the 5-year follow-up and the 5-week follow-up. There were no correlations between static and dynamic tibial translation. CONCLUSION: Although static tibial translation did not differ between knees 5 years after ACL reconstruction, dynamic tibial translation during gait was greater in ACL-reconstructed knees than in uninjured knees. Neither static nor dynamic tibial translation changed 5 years after ACL reconstruction as compared to before surgery and 5 weeks after surgery. Static tibial translation did not correlate with dynamic tibial translation. CLINICAL RELEVANCE: This study indicates that although the knee is stable during static measurements, kinematics during gait is impaired 5 years after ACL reconstruction. This may affect the return to sport and risk of osteoarthritis. LEVEL OF EVIDENCE: Case series, Level IV.

The measurement properties of the IKDC-subjective knee form.

PURPOSE: To evaluate the methodological quality of studies reporting on the measurement properties of the International Knee Documentation Committee subjective knee form (IKDC-SKF) and to evaluate their results following the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines. METHODS: Systematic search of articles published about the measurement properties of the IKDC-SKF, review of the studies' methodological quality, and synthesis of the results using the COSMIN guidelines. RESULTS: Twenty-six studies were identified and reviewed. There was strong evidence for good internal consistency, test-retest reliability, and responsiveness. There was moderate evidence for good content and structural validity. With the SF36 as a gold standard, the level of evidence for criterion validity was indeterminate. There was conflicting evidence for hypothesis testing and not enough evidence to evaluate measurement error and cross-cultural validity. There were no floor or ceiling effects. CONCLUSIONS: This review shows that the IKDC-SKF is a measurement instrument with good internal consistency, test-retest reliability, content and structural validity, and responsiveness and interpretability (no floor and ceiling effects). Further evaluation of measurement error, minimal important change, and hypotheses testing is recommended. The IKDC-SKF seems to be useful as a general instrument for all kinds of knee injuries, which might facilitate its clinical use in situations in which time is a factor. LEVEL OF EVIDENCE: Systematic review, Level III.