High School Girls' Volleyball Athletes' Self-Reported Management of Pain, Intentions to Report Overuse Injuries, and Intentions to Adhere to Medical Advice for Treating Overuse Injuries.

CONTEXT: Girls' high school volleyball is a popular sport with a high rate of overuse injuries and sport specialization. Health professionals perceive that high school athletes are reluctant to follow treatment plans involving sport activity reduction. This study's purpose was to describe high school girls' volleyball athletes' self-reported shoulder and knee pain, the likelihood of adhering to medical advice, and the association of factors that influence the likelihood of reporting overuse injuries and sport specialization. STUDY DESIGN: Cross-sectional. METHODS: Participants completed an online survey (demographics, sport participation measures, shoulder and knee pain information, medical adherence likelihood [4-point Likert: not at all likely to extremely likely], and factors influencing overuse injury reporting intentions). A 2 × 2 chi-square analysis compared factors that influence athletes' intentions to "not report an overuse injury" (eg, I thought my coach would get mad; yes/no) and sport specialization (nonhighly specialized/highly specialized athletes). RESULTS: There were 150 participants (highly specialized = 56%, grade: ninth = 33%, 10th = 28%, 11th = 22%, 12th = 17%). At least 60% reported shoulder and knee pain related to an overuse mechanism. Most reportedly did not seek rehabilitation led by a medical provider (shoulder pain = 66%, knee pain = 60%). Only 11% of athletes reported they were "extremely likely" to rest from sporting activity during the regular season if advised by a medical professional. Highly specialized athletes were more likely to report the pursuit of a college scholarship as a factor that influences their intention to report an overuse injury compared to nonhighly specialized athletes (13% vs 3%, respectively, P = .04). CONCLUSIONS: Most girls' volleyball athletes did not treat their pain with guided rehabilitation, which may increase their risk of a worse overuse injury or even acute injury. Clinicians, athletes, parents, and coaches need to work together to create a sport culture that empowers athletes to discuss their pain and overuse injuries with medical professionals.

The effectiveness of physical therapy in the rehabilitation of patients after arthroscopy of the knee joint.

OBJECTIVE: Aim: To determine the effectiveness of physical therapy on the functional state of law enforcement officers' knee joints after surgical intervention. PATIENTS AND METHODS: Materials and Methods: The research involved law enforcement officers from different units of the National Police of Ukraine (n = 56) who had suffered knee joint injuries in the line of duty, and underwent surgical intervention and rehabilitation procedures. RESULTS: Results: It was found that 78.2 % of respondents had suffered knee joint ligament injuries as a result of falls during rapid movement, while 43.9 % were in full gear (armored protection, helmet, etc.). It was determined that after surgical intervention, the functional state of the knee joint of law enforcement officers who followed the recommendations of physical therapy specialists and systematically performed special sets of physical exercises was significantly different (p < 0.001). Worse results were noted in people who partially followed the recommendations of rehabilitation therapists and performed part of the prescribed procedures and physical exercises. CONCLUSION: Conclusions: The effectiveness of the complex use of physical rehabilitation means for restoring the functioning of the knee joint after surgical intervention, which included arthroscopy, partial menisectomy of the damaged areas, debridement, vaporization of damaged cartilage, etc. was revealed. The positive effect of physical exercises on the functional state of the knee joint was proven. The sets of exercises that are advisable to use to restore the functioning of the knee joint were determined.

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability. METHODS: We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score-4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367. FINDINGS: Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5-13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications. INTERPRETATION: Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management. FUNDING: The UK National Institute for Health Research Health Technology Assessment Programme.

Does Accelerated Rehabilitation Provide Better Outcomes Than Restricted Rehabilitation in Postarthroscopic Repair of Meniscal Injury?

CONTEXT: Meniscal injury is a common pathology, and the postoperative rehabilitation program is essential to patients after surgery. However, the optimal rehabilitation plan after meniscus suture is still controversial. OBJECTIVE: To compare the clinical outcomes between accelerated rehabilitation and restricted programs in patients with meniscus suture (with or without anterior cruciate ligament reconstruction, ACLR). EVIDENCE ACQUISITION: Four databases, including PubMed, Ovid, Embase, and the Cochrane Library, were searched up to November 2021. This study only included studies comparing the clinical outcomes between accelerated (immediate range of motion and weight-bearing) and restricted rehabilitation (immobilization and progressive weight-bearing) for meniscus suture. All selected studies were divided into 2 subgroups: isolated meniscus suture or combined with ACLR. The Lysholm score, Tegner score, and Knee Injury and Osteoarthritis Outcome Score were evaluated in simple meniscus sutures no less than 1 year. Failure rate was evaluated in both groups, and the tunnel enlargement was additionally evaluated in patients who underwent ACLR. EVIDENCE SYNTHESIS: Eleven studies with 612 patients were eligible for analysis. The accelerated group included 4 studies with 330 participants, while the restricted group included 7 studies with 282 participants. For the patients after isolated meniscus suture, the accelerated group achieved higher Lysholm scores (mean difference = -4.66; 95% confidence interval, -8.6 to -0.73; P = .02; I2 = 88%) than the restricted group. For the patients after meniscus suture with ACLR, patients undergoing accelerated rehabilitation were associated with a significantly larger tibial tunnel enlargement in the anterior-posterior view (mean difference = -7.08; 95% confidence interval, -10.92 to -3.24; P = .0003; I2 = 0%) and lateral view (mean difference = -10.33; 95% confidence interval, -16.9 to -3.75; P = .002; I2 = 17%). CONCLUSION: This meta-analysis evaluated the effects of postoperative rehabilitation in either accelerated or restricted programs in patients with meniscus lesions after repair. A significant higher mean self-reported function was discovered at final follow-ups in the accelerated group. However, a significant increase in tibial tunnel enlargement was also found in accelerated group.

Translation, cross-cultural adaptation, validation and responsiveness in the Brazilian Portuguese version of the Knee Injury and Osteoarthritis Outcome Score (KOOS-BR).

PURPOSE: To carry out the translation, cultural adaptation, and validation in the Brazilian Portuguese version of Knee Osteoarthritis Outcome Score (KOOS-BR) in individuals with knee osteoarthritis (KOA). METHODS: Patients with KOA (n = 136) answered KOOS-BR, Short-Form Health Survey (SF-36) and Numerical Pain Scale (NPS) to access construct validity. KOOS-BR was answered again with an interval of five to eight days. The following were performed: Cronbach's alpha to assess internal consistency, intraclass correction coefficient (ICC2,1) to assess reproducibility, standard error of measurement (SEM) and minimal detectable change (MDC) as error measurements. Dimensionality was tested through confirmatory factor analysis (CFA). Responsiveness was investigated by the correlation between KOOS-BR subscales with global perceived effect (GPE) before and after physical therapy treatment for 6 weeks. Floor and ceiling effects (< 15%) were also assessed. RESULTS: KOOS-BR version showed good test-retest reliability in all KOOS-BR subscales (ICC = 0.77-0.84), with proper internal consistency (α = 0.71-0.94). KOOS-BR showed a moderate direct correlation with physical health domains of SF-36 (r = 0.39-0.68; p < 0.001) and a moderate inverse correlation with pain intensity (r = - 0.51 to - 0.57; p < 0.001). KOOS-BR proved to be responsive, the correlation between the KOOS-BR subscales and GPE before and after treatment ranged from 0.42 to 0.60 (p < 0.001). There was no ceiling and floor effect. CONCLUSION: KOOS-BR is reliable, valid, and responsive in patients with KOA. LEVEL OF EVIDENCE: II.

Patient- and Physical Therapist-Level Predictors of Patient-Reported Therapeutic Alliance: An Observational, Exploratory Study of Cohorts With Knee and Low Back Pain.

OBJECTIVE: To identify patient- and physical therapist-level predictors for therapeutic alliance at the end of an episode of physical therapy for knee or low back pain (LBP). DESIGN: Secondary analysis of observational cohort. SETTING: Outpatient physical therapy clinics. PARTICIPANTS: Patients receiving physical therapy for knee (n=189) or LBP (n=252) and physical therapists (n=19). Candidate predictor variables included demographics, patient clinical characteristics, and physical therapist attitudes and beliefs (Pain Attitudes and Beliefs Scale for Physical Therapists) and confidence in providing patient-centered care (Self-Efficacy in Patient-Centeredness Questionnaire). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patient-reported therapeutic alliance was measured using the 12-item Work Alliance Inventory-Short Revised (WAI-SR). RESULTS: Final linear mixed models indicated different patient- and physical therapist-level factor contributions in predicting final WAI-SR scores across cohorts with knee and LBP. Female sex was a consistent patient-level predictor for both knee (estimated ß=1.57, P<.05) and LBP (ß=1.42, P<.05), with age (ß=-0.07, P<.01) and baseline function (ß=0.06, P<.01) contributing to cohorts with knee and LBP, respectively. Physical therapist-level predictors included female sex (ß=6.04, P<.05), Pain Attitudes and Beliefs Scale for Physiotherapists behavioral (ß=0.65, P<.01), and Self-Efficacy in Patient-Centeredness Questionnaire (SEPCQ) Exploring Patient Perspective (ß=-0.75, P<.01) subscale scores for LBP, with SEPCQ Sharing Information and Power subscale scores (ß=0.56, P<.05) contributing to both cohorts with knee (ß=0.56, P<.05) and LBP (ß=0.74, P<.01). Random effects for patients nested within physical therapists were observed for both cohorts. CONCLUSIONS: These findings provide preliminary evidence for inconsistent relationships among patient- and physical therapist-level factors and therapeutic alliance across cohorts with knee and LBP.

Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 2: surgical techniques, outcomes and rehabilitation.

Isolated and combined posterior cruciate ligament (PCL) injuries are associated with severe limitations in daily, professional, and sports activities as well as with devastating long-term effects for the knee joint. As the number of primary and recurrent PCL injuries increases, so does the body of literature, with high-quality evidence evolving in recent years. However, the debate about the ideal treatment approach such as; operative vs. non-operative; single-bundle vs. double-bundle reconstruction; transtibial vs. tibial inlay technique, continues. Ultimately, the goal in the treatment of PCL injuries is restoring native knee kinematics and preventing residual posterior and combined rotatory knee laxity through an individualized approach. Certain demographic, anatomical, and surgical risk factors for failures in operative treatment have been identified. Failures after PCL reconstruction are increasing, confronting the treating surgeon with challenges including the need for revision PCL reconstruction. Part 2 of the evidence-based update on the management of primary and recurrent PCL injuries will summarize the outcomes of operative and non-operative treatment including indications, surgical techniques, complications, and risk factors for recurrent PCL deficiency. This paper aims to support surgeons in decision-making for the treatment of PCL injuries by systematically evaluating underlying risk factors, thus preventing postoperative complications and recurrent knee laxity. LEVEL OF EVIDENCE: V.

Statistical validity and reliability of the Persian version of the Western Ontario Meniscal Evaluation Tool (WOMET) according to the COSMIN checklist.

BACKGROUND: The Western Ontario Meniscal Evaluation Tool (WOMET) is the only questionnaire available to assess quality of life in patients with isolated meniscal injuries. The aims of this study were to prepare the Persian version of the WOMET (PWOMET) and validate it in Iranian patients with isolated meniscal tears. METHODS: In the first stage, the English version of WOMET was translated into Persian. Content validity, and qualitative and quantitative (impact score) face validity were tested by specialists and in a sample of 30 patients. In the second stage, PWOMET was assessed for the evaluation of psychometric properties in 100 patients with isolated meniscal injury and 50 healthy people based on the COSMIN checklist. Construct validity was tested based on structural validity (factor analysis) and hypothesis testing. Correlation with the total scores on the SF-36, IKDC and KOOS were used for concurrent criterion validity. Test-retest reliability and internal consistency were calculated using intraclass correlation coefficient (ICC) and Cronbach's alpha, respectively. In addition the standard error of measurement (SEM) and smallest detectable change were calculated. Interpretability was investigated as the ceiling and floor effects and minimal important difference. RESULTS: The PWOMET had acceptable qualitative face validity and content validity. The impact score (quantitative face validity) was more than 1.5 for all items. For construct validity, structural validity (factor analysis) and hypothesis testing ability were confirmed. Correlations between the PWOMET total score and IKDC, SF-36, KOOS scores were 0.61, 0.54 and 0.63, respectively (p < 0.001), thus confirming concurrent criterion validity. The intraclass correlation coefficient, Cronbach's alpha, SEM and smallest detectable change for the PWOMET were 0.73, 0.89, 9.43 and 26.13, respectively. The PWOMET had no ceiling or floor effects, and minimal important difference was 9.07. CONCLUSION: The PWOMET provides valid and reliable scores for assessment of the quality of life in patients with isolated meniscal injury.

Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review.

OBJECTIVE: To explore the role of psychological, social and contextual factors across the recovery stages (ie, acute, rehabilitation or return to sport (RTS)) following a traumatic time-loss sport-related knee injury. MATERIAL AND METHODS: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and Arksey and O'Malley framework. Six databases were searched using predetermined search terms. Included studies consisted of original data written in English that identified or described a psychological, social or contextual factor related to recovery after a traumatic time-loss sport-related knee injury. Two authors independently conducted title-abstract and full-text reviews. Study quality was assessed using the Mixed Methods Appraisal Tool. Thematic analysis was undertaken. RESULTS: Of 7289 records, 77 studies representing 5540 participants (37% women, 84% anterior cruciate ligament tears, aged 14-60 years) were included. Psychological factors were investigated across all studies, while social and contextual factors were assessed in 39% and 21% of included studies, respectively. A cross-cutting concept of individualisation was present across four psychological (barriers to progress, active coping, independence and recovery expectations), two social (social support and engagement in care) and two contextual (environmental influences and sport culture) themes. Athletes report multiple barriers to recovery and valued their autonomy, having an active role in their recovery and diverse social support. CONCLUSION: Diverse psychological, social and contextual factors are present and influence all stages of recovery following a traumatic sport-related knee injury. A better understanding of these factors at the time of injury and throughout rehabilitation could assist with optimising injury management, promoting RTS, and long-term health-related quality-of-life.

Large variability exists in the management of posterolateral corner injuries in the global surgical community.

PURPOSE: The management of posterolateral corner (PLC) injuries has significantly evolved over the past 2 decades. The purpose of this study was to determine the current worldview of key concepts on the diagnosis, treatment strategy, and rehabilitation for patients presenting with PLC injuries. METHODS: A 12-question multiple-choice online survey was designed to address key questions in the diagnosis, treatment, and rehabilitation of PLC injuries. The survey was distributed to the most important international sports medicine societies worldwide. Clinical agreement was defined as > 80% of agreement in responses and general agreement was defined as > 60% of agreement in responses. RESULTS: 975 surgeons completed the survey with 49% from Europe, 21% from North America, 12% from Latin America, 12% from Asia, and smaller percentages from Africa and Oceania. Less than 14% of respondents manage more than ten PCL injuries yearly. Clinical agreement of > 80% was only evident in the use of MRI in the diagnosis of PLC injury. Responses for surgical treatment were split between isometric fibular-based reconstruction techniques and anatomically based fibular and tibial-based reconstructions. A general agreement of > 60% was present for the use of a post-operative brace in the early rehabilitation. CONCLUSION: In the global surgical community, there remains a significant variability in the diagnosis, treatment, and postoperative management of PLC injuries. The number of PLC injuries treated yearly by most surgeons remains low. As global clinical consensus for PLC remains elusive, societies will need to play an important role in the dissemination of evidence-based practices for PLC injuries. LEVEL OF EVIDENCE: IV.

Ability of Isokinetic Dynamometer to Predict Isotonic Knee Extension 1-Repetition Maximum.

CONTEXT: Resistance training exercise prescription is often based on exercises performed at a percentage of a 1-repetition maximum (1RM). Following knee injury, there is no consensus when a patient can safely perform 1RM testing. Resistance training programs require the use of higher loads, and loads used in knee injury rehabilitation may be too low to elicit gains in strength and power. A maximum isometric contraction can safely be performed during early stages of knee rehabilitation and has potential to predict an isotonic knee extension 1RM. OBJECTIVE: To determine whether a 1RM on an isotonic knee extension machine can be predicted from isometric peak torque measurements. DESIGN: Descriptive laboratory study. SETTING: University research laboratory. PARTICIPANTS: A total of 20 (12 males and 8 females) healthy, physically active adults. MAIN OUTCOME MEASURES: An isokinetic dynamometer was used to determine isometric peak torque (in N·m). 1RM testing was performed on a knee extension machine. Linear regression was used to develop a prediction equation, and Bland-Altman plots with limits of agreement calculations were used to validate the equation. RESULTS: There was a significant correlation (P < .001, r = .926) between peak torque (283.0 [22.6] N·m) and the knee extension 1RM (69.1 [22.6] kg). The prediction equation overestimated the loads (2.3 [9.1] kg; 95% confidence interval, -15.6 to 20.1 kg). CONCLUSIONS: The results show that isometric peak torque values obtained on an isokinetic dynamometer can be used to estimate 1RM values for isotonic knee extension. Although the prediction equation tends to overestimate loads, the relatively wide confidence intervals indicate that results should be viewed with caution.

Development and Validation of a Novel Knee-Specific Patient-Reported Outcomes Measure.

CONTEXT: Previous research suggests that several knee-specific patient-reported outcome measures have poor measurement properties. The patient-reported outcomes knee assessment tool (PROKAT) was created to improve assessment of knee-specific function. Examination of the measurement properties of this new measure is critical to determine its clinical value. OBJECTIVE: Examine the measurement properties of the PROKAT. DESIGN: Cross-sectional study. SETTING: Clinical athletic training setting. PATIENTS OR OTHER PARTICIPANTS: The pilot study included 32 student-athletes (mean age = 20.78 [1.01], males = 56.30%). The full study included 203 student-athletes (mean age = 21.46 [4.64], males = 54.70%) from 3 separate institutions. The participants were recruited for both the pilot and full study using face-to-face and electronic (eg, email and social media sites) communications. INTERVENTION(S): Evaluation of the measurement properties of the PROKAT occurred using the Rasch partial-credit model. MAIN OUTCOME MEASURES: Infit and outfit statistics, item step difficulties, person ability parameters, category function, item and test information functions, and Cronbach alpha. An independent samples t test was used to evaluate the differences in injured and noninjured athletes' scores. RESULTS: The Rasch partial-credit model analysis of pilot test items and qualitative participant feedback were used to modify the initial PROKAT. Evaluation of the revised PROKAT (32 items) indicated 27 items had acceptable model-data fit. The injured athletes scored significantly worse than the noninjured athletes (t188 = 12.89; P < .01). The ceiling effects for the PROKAT were minimal (3.9%). CONCLUSIONS: A major advantage of this study was the use of the Rasch measurement and the targeted population. Compared with alternative knee-specific patient-reported outcome measures (eg, Knee Injury Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Form), the PROKAT has low ceiling effects in athletic populations. In addition, evidence suggests the measure may be capable of distinguishing between injured and noninjured athletes.

Return to Sport and Work After High Tibial Osteotomy With Concomitant Medial Meniscal Allograft Transplant.

PURPOSE: (1) To examine the timeline of return to sport (RTS) and return to work (RTW) after high tibial osteotomy (HTO) with concomitant medial meniscal allograft transplant (MAT), (2) to evaluate the degree of function on RTS and RTW, and (3) to identify reasons patients do not return to sport- or work-related activity. METHODS: Patients undergoing HTO plus MAT were reviewed retrospectively at a minimum of 2 years postoperatively. The exclusion criterion was any concomitant procedure except cartilage restoration for focal full-thickness medial femoral condylar defects. Patients completed a subjective sport and work questionnaire, a visual analog scale for pain, the Single Assessment Numeric Evaluation, and a satisfaction questionnaire. RESULTS: Twenty-two patients (aged 35.1 ± 8.1 years) were included at 9.3 ± 3.7 years postoperatively. Sixteen patients participated in sports within 3 years before surgery, and 14 patients (87.5%) returned to sport by 9.7 ± 3.8 months postoperatively. Only 7 patients (43.8%) returned to their preinjury status. Eighteen patients were employed within 3 years before surgery, and all patients returned to work; however, only 16 patients (88.9%) returned at the same occupational intensity by 3.1 ± 2.4 months. The rates of RTW for light-, medium-, and heavy-intensity occupations were 100%, 75.0%, and 85.7%, respectively, whereas the duration of RTW was 2.1 months, 2.3 months, and 4.8 months, respectively. Of the patients, 20 (90.9%) reported at least 1 complaint postoperatively, with 13 patients (59.1%) returning to the operating room for recurrent symptoms, including 1 patient who received a knee replacement at 7.75 years postoperatively. CONCLUSIONS: In patients with medial meniscal deficiency and varus deformity, HTO plus MAT provided high rates of RTS (87.5%) and RTW (100%) by 9.7 months and 3.1 months, respectively. It is imperative that clinicians manage expectations because patients may RTS and RTW after HTO plus MAT; however, return to high-intensity activities or occupations may be unlikely or delayed. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Return to Sport and Sports-Specific Outcomes After Osteochondral Allograft Transplantation in the Knee: A Systematic Review of Studies With at Least 2 Years' Mean Follow-Up.

PURPOSE: To report current data on return-to-sport rates and sports-specific patient-reported outcomes after osteochondral allograft (OCA) transplantation for cartilage defects of the knee. METHODS: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines that included studies from 1975 to 2018 with a minimum 2-year mean follow-up that reported return-to-sport rates or sports-specific patient-reported outcomes. Outcomes, reoperations, and complications were provided in table format, and a subjective analysis was performed. RESULTS: This review included 13 studies with 772 patients who underwent OCA transplantation at a mean of 24 to 91 months' follow-up. The return-to-sport rate ranged from 75% to 82%. For patient-reported outcomes, the Knee Injury and Osteoarthritis Score Sport increased in 4 studies, the Tegner activity scale score increased in 3 studies but decreased in 1, and the Marx activity scale score increased in 1 study but decreased in 2. Studies reporting improvements in the Cincinnati Knee Score and Knee Injury and Osteoarthritis Score Sport reached the minimal clinically important difference. The reoperation rate was high (ranging from 34% to 53% in more than half of studies), with reoperations primarily performed for loose body removal or debridement. CONCLUSIONS: This systematic review of 13 studies suggests that OCA transplantation for cartilage defects allows most athletes to return to sport (range, 75%-82%). Most studies reported improvements in sports-specific patient-reported outcomes at follow-up and reached the minimal clinically important difference. However, the reoperation rate was high in several studies, with a large percentage of patients requiring loose body removal or debridement. The long-term survival of the allografts is largely unknown, but this study suggests OCA transplantation consistently improves function in athletes with chondral injuries. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Posterolateral corner of the knee: an expert consensus statement on diagnosis, classification, treatment, and rehabilitation.

PURPOSE: To develop a statement on the diagnosis, classification, treatment, and rehabilitation concepts of posterolateral corner (PLC) injuries of the knee using a modified Delphi technique. METHODS: A working group of three individuals generated a list of statements relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries to form the basis of an initial survey for rating by an international group of experts. The PLC expert group (composed of 27 experts throughout the world) was surveyed on three occasions to establish consensus on the inclusion/exclusion of each item. In addition to rating agreement, experts were invited to propose further items for inclusion or to suggest modifications of existing items at each round. Pre-defined criteria were used to refine item lists after each survey. Statements reaching consensus in round three were included within the final consensus document. RESULTS: Twenty-seven experts (100% response rate) completed three rounds of surveys. After three rounds, 29 items achieved consensus with over 75% agreement and less than 5% disagreement. Consensus was reached in 92% of the statements relating to diagnosis of PLC injuries, 100% relating to classification, 70% relating to treatment and in 88% of items relating to rehabilitation statements, with an overall consensus of 81%. CONCLUSIONS: This study has established a consensus statement relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries. Further research is needed to develop updated classification systems, and better understand the role of non-invasive and minimally invasive approaches along with standardized rehabilitation protocols. LEVEL OF EVIDENCE: Consensus of expert opinion, Level V.

The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction.

PURPOSE: Currently both autograft and allograft tissues are available for reconstruction of posterior cruciate, collateral and multi-ligament knee injuries. Decision-making is based on a complex interplay between anatomical structures, functional bundles and varying biomechanical requirements. Despite theoretically better biological healing and reduced risk of disease transmission autografts are associated with donor site morbidity as well as being limited by size and quantity. The use of allografts eliminates donor-site morbidity but raises cost and issues of clinical effectiveness. The purpose of this paper is to review current concepts and evidence for the use of allografts in primary posterior cruciate, collateral and multi-ligament reconstructions. METHODS: A narrative review of the relevant literature was conducted for PCL, collateral ligament and multi-ligament knee reconstruction. Studies were identified using a targeted and systematic search with focus on recent comparative studies and all clinical systematic reviews and meta-analyses. The rationale and principles of management underpinning the role of allograft tissue were identified and the clinical and functional outcomes were analysed. Finally, the position of postoperative physiotherapy and rehabilitation was identified. RESULTS: The review demonstrated paucity in high quality and up-to-date results addressing the issue especially on collaterals and multi-ligament reconstructions. There was no significant evidence of superiority of a graft type over another for PCL reconstruction. Contemporary principles in the management of posterolateral corner, MCL and multi-ligament injuries support the use of allograft tissue. CONCLUSION: The present review demonstrates equivalent clinical results with the use of autografts or allografts. It remains, however, difficult to generate a conclusive evidence-based approach due to the paucity of high-level research. When confronted by the need for combined reconstructions with multiple grafts, preservation of synergistic muscles, and adapted postoperative rehabilitation; the current evidence does offer support for the use of allograft tissue. LEVEL OF EVIDENCE: IV.

Low rate of return to pre-injury sport level in athletes after cartilage surgery: a 10-year follow-up study.

PURPOSE: Although articular surface is frequently damaged in athletes, results in terms of return to sport and level of activity after cartilage surgery remain rather unpredictable and poorly documented. The aim of this study is to evaluate the clinical outcome in terms of rate and level of return to sport in a group of competitive athletes who underwent matrix-assisted autologous chondrocyte transplantation (MACT), as well as the impact on their athletic career. METHODS: Thirty-one male patients (mean age 22.6 ± 6.3 years) p racticing sport at competitive level, affected by focal chondral/osteochondral lesions of the distal femur, were enrolled and treated with arthroscopic hyaluronan-based MACT. Patients were evaluated prospectively at 1-year intervals with the IKDC subjective, Tegner, and EuroQol VAS scores during their pre-operative visit and subsequent follow-ups for up to 10 years. Return to sport in terms of level, time and maintenance of the activity level was documented, together with surgical or clinical failures. RESULTS: A marked improvement in all scores was found: IKDC increased from 40.3 ± 13.4 to 81.7 ± 14.4 (p < 0.0005) at 12 months; a further improvement was observed at 2 years (89.5 ± 11.3; p = 0.008), then results were stable for up to 10 years (87.3 ± 13.6). The analysis of return to sport documented that 64.5% of patients were able to return at a competitive level, and 58.1% performed at the same pre-injury level, with activity rates decreasing over time. The rate of patients returning to competitive level was 84% in those without previous surgery (vs. 33% who had undergone previous surgery), 87% for those with traumatic lesions (vs. 33% and 50% for degenerative and OCD lesions, respectively), and 92.3% in younger patients (age < 20 years). Among these factors, multivariate analysis demonstrated that previous surgery was the single most influencing factor for returning to the same sport level (p = 0.010). CONCLUSIONS: These long-term results showed that chondrocyte-based regenerative approach has some limitations in terms of sport-related outcomes. The level of high functional knee restoration needed for such high-demanding activity level can be challenging to achieve, especially in patients with a more compromised joint homeostasis. Return to sport rate varies significantly according to specific patient and lesion characteristics and best results are obtained in young patients with traumatic lesions without previous surgery, which should be considered when treating athletes affected by cartilage lesions. LEVEL OF EVIDENCE: IV.

Rehabilitation before regenerative cartilage knee surgery: a new prehabilitation guideline based on the best available evidence.

INTRODUCTION: Focal cartilage defects are an increasingly relevant clinical problem especially in athletes. Cartilage regenerative surgery (CRS) including microfracture and autologous chondrocyte implantation (ACI) to treat such isolated cartilage defects in the knee joint has been well established in the last two decades. In contradiction to high-level evidence concerning the surgical technique, cell-related issues, and clinical results, the knowledge about the optimal rehabilitation process is still sparse although the importance of optimizing the rehabilitation process has recently led to new research focus in this field. The preoperative time frame may be used to start rehabilitation which may fasten the postoperative recovery and optimize clinical outcome ("Prehabilitation"-PREHAB). The aim of this article, therefore, was to review the available literature on prehabilitation concepts and to present a prehabilitation guideline for CRS patients based on the best evidence available. METHODS: A systemic literature research was conducted on rehabilitation for cartilage regenerative surgery as well as prehabilitation in knee joint procedures. From the available literature a prehabilitation concept was generated and tested in 10 ACI patients. RESULTS: As the literature search found no studies addressing prehabilitation in CRS patients, an evidence-based PREHAB program has been compiled based on the available evidence from (a) studies addressing postoperative rehabilitation in CRS patients and (b) PREHAB studies on other knee procedures including TKA. This presented prehabilitation guideline has been tested in > 50 CRS patients and was found to be feasible as all of the patients showed a good compliance and were able to perform the protocol as suggested. CONCLUSION: The presented PREHAB regimen may serve clinicians as a guideline for early rehabilitation of their CRS patients. Obviously, further research is mandatory to quantify its clinical effect and to demonstrate its cost-effectiveness and benefits in surgically treated patients.

Return to Work or Sport After Multiligament Knee Injury: A Systematic Review of 21 Studies and 524 Patients.

PURPOSE: To systematically review multiligament knee injury (MLKI) outcome studies to determine overall rates of return to work or sport after MLKI and risk factors for lack of return to work or sport after MLKI. METHODS: A search was performed of MLKI outcome studies from 1950 to March 1, 2017. Ninety-two studies were identified. All included reported return to work, return to sport, or Tegner activity scores. Rates of return to work or sport were determined for overall population and by obesity status, injury severity, and presence of peroneal nerve or vascular injury. RESULTS: A total of 524 patients (21 studies) were included. Return to high-level sport was low (22%-33%). Return to any level of sport was 53.6% overall (178/332), with a higher rate reported in studies with all surgical patients (59.1%, 114/193 patients) versus studies with mixed surgical and nonoperative treatment (46.0%, 64/139 patients) (P = .02). Rate of return to work with little or no modifications was 62.1% (146/200) and return to any work was 88.4% (190/215). Obese patients had lower postoperative Tegner scores than a general population (obese: mean 1.7 ± 1.2; nonobese: mean 4.5 ± 1.0; P < .001). Among studies without Schenck grade IV and V injuries, return to work with no or minimal modifications (100%, 12/12 patients) was higher than studies including grade IV and V patients (66.0%, 70/106 patients) (P = .017). Return to any work was higher in studies without vascular injuries (96.3%, 105/109) versus those including them (80.2%, 85/106) (P < .001). CONCLUSIONS: Return to sport after MLKI occurs in approximately 60% of surgically treated patients, though return to high-level sport is lower. Return to work is frequently possible after MLKI though it may require workplace or job duty modifications. Obesity, nonoperative treatment, higher injury severity, and vascular injury are associated with poorer functional outcomes. LEVEL OF EVIDENCE: Level IV, systematic review of level III and IV studies.

Clinical Outcomes, Return to Sports, and Patient Satisfaction After Anterior Cruciate Ligament Reconstruction in Young and Middle-Aged Patients in an Asian Population-A 2-Year Follow-up Study.

PURPOSE: To compare the clinical outcomes of arthroscopic anterior cruciate ligament (ACL) reconstruction in young and middle-aged Asians. METHODS: A retrospective study was performed using prospectively collected data from a tertiary institution ACL registry. All Asian patients with ACL tears who underwent primary arthroscopic ACL reconstruction by a single surgeon between 2008 and 2014, with minimum 2-year follow-up, were included. Patients with previous knee surgery or multiligamentous knee injuries were excluded. Two groups were formed: young patients (YP) (age <30) and middle-aged patients (MP) (age >40). They were compared preoperatively and 6 months, 1 year, and 2 years postoperatively for demographics, knee range of motion, anterior laxity, Tegner level, Lysholm and International Knee Documentation Committee grade, ability to return to preinjury level of activity, and patient satisfaction. RESULTS: YP (n = 84) and MP (n = 22) had differences in mean age (YP = 23.1 years, range 18-29 years; MP = 46.4 years, range 41-59 years, P < .001), preinjury Tegner level (YP = 7.4, MP = 6.4, P = .005), and preoperative Lysholm scores (YP = 65.3, MP = 53.0, P = .034). The incidence of meniscal and chondral injuries was similar. Two years postoperatively, both groups had comparable knee range of motion and anterior laxity. The Tegner score was different (YP = 6.3, MP = 5.2, P = .028), but the proportion of patients returning to preinjury Tegner level (YP = 45.2%, MP = 46.9%, P = .812), Lysholm scores (YP = 92.5, MP = 93.8, P = .794), proportion of patients with knees rated International Knee Documentation Committee A/B (YP = 77.4%, MP = 81.8%, P = .777), and satisfaction levels (YP = 98.5%, MP = 94.1%, P = .370) were similar. There were no graft ruptures or reoperations. CONCLUSIONS: In an Asian, predominantly male population, the clinical outcomes of arthroscopic ACL reconstruction in YP and MP are equally good at 2-year follow-up. MP can benefit as much as younger patients from ACL reconstruction in terms of restoration of knee function and return to preinjury activity level, are equally satisfied with outcomes, and should not be excluded from surgery on the basis of age alone. LEVEL OF EVIDENCE: Level III, retrospective comparative study.