Trends in Pediatric Anterior Cruciate Ligament Reconstruction in Australia: An Analysis of Australian Medicare Benefits Schedule Database From 2001 to 2020.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common and increasingly prevalent in the pediatric population. However, there remain sparse epidemiological data on the surgical treatment of these injuries. The objective of this study is to assess the trends in the rate of pediatric ACL reconstruction in Australia over the past 2 decades. METHODS: The incidence of ACL reconstruction from 2001 to 2020 in patients 5 to 14 years of age was analyzed using the Australian Medicare Benefits Schedule (MBS) database. Data were stratified by sex and year. An offset term was introduced using population data from the Australian Bureau of Statistics to account for population changes over the study period. RESULTS: A total of 3719 reconstructions for the management of pediatric ACL injuries were performed in Australia under the MBS in the 20-year period from 2001 to 2020. There was a statistically significant annual increase in the total volume and per capita volume of pediatric ACL reconstructions performed across the study period ( P <0.0001). There was a significant increase in the rate of both male and female reconstructions ( P <0.0001), with a greater proportion of reconstructions performed on males (n=2073, 56%) than females (n=1646, 44%). In 2020, the rate of pediatric ACL reconstructions decreased to a level last seen in 2015, likely due to the effects of COVID-19. CONCLUSIONS: The incidence of ACL reconstruction in skeletally immature patients has increased in Australia over the 20-year study period. This increase is in keeping with evidence suggesting poor outcomes with nonoperative or delayed operative management.

Use of electromyographic biofeedback in rehabilitation following anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

BACKGROUND: Rehabilitation following anterior cruciate ligament (ACL) reconstruction surgery is essential to regain functionality and return to previous activity level. Electromyographic biofeedback may be an effective intervention for rehabilitation of patients following ACL surgery. OBJECTIVE: To synthesize the available evidence on the effect of electromyographic biofeedback in the treatment of quadriceps strength following ACL surgery. DESIGN: Systematic review with meta-analysis. DATA SOURCES: PubMed, EMBASE, CENTRAL and Epistemonikos were searched. ELIGIBILITY CRITERIA: Randomized clinical trials with patients undergoing ACL reconstruction surgery comparing biofeedback with a standard rehabilitation control group. DATA EXTRACTION AND DATA SYNTHESIS: Two authors selected articles and performed data extraction. The analysed outcomes were strength, function, pain, knee extension and balance. The risk of bias of individual studies was assessed using the Cochrane Risk of Bias Tool. Results were combined through random-effects meta-analysis, reporting mean differences. RESULTS: Eight articles were included in the qualitative analysis, and four articles were included in the quantitative analysis. The interventions lasted between 4 and 12 weeks. Three studies evaluated the effect of biofeedback on quadriceps strength; of these, two studies showed a significant difference in favour of the biofeedback group. In addition, biofeedback was found to improve knee extension [standardized mean difference - 1.3, 95% confidence interval (CI) - 1.74 to -0.86] and balance (one study). There was no significant difference in Lysholm score (mean difference -6.21, 95% CI -17.51 to 5.08; I2 =59%) or pain between the biofeedback group and the control group. CONCLUSION: Electromyographic biofeedback in knee rehabilitation could be useful following ACL reconstruction surgery. KEY MESSAGES: SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42020193768).

Photobiomodulation therapy in dogs undergoing TPLO after cranial cruciate ligament rupture shows promise but no statistically significant difference in a randomized trial.

OBJECTIVE: Effect of photobiomodulation therapy (PBMT) in patients with CCLR after TPLO surgery by measuring C-reactive protein (CRP), percentage weight bearing, lameness using a short form of a composite measure pain scale, evaluated by the clinician and owners, and surgical site infection. SAMPLE: 54 client-owned dogs with CCLR undergoing unilateral TPLO surgery were enrolled in this study between April 5, 2021, through April 10, 2022. METHODS: The study population was randomly assigned to either a treatment group receiving PMBT (24 dogs) or a control group (30 dogs). PMBT was performed on the treatment group immediately after induction, and 6 hours, 24 hours, 48 hours, and 8 weeks postoperatively. The control group received sham PMBT (device turned off) at the same time. Evaluation of CRP, CMPS-SF, evidence of SSI, and %WB were evaluated for all dogs 24 hours preoperatively, and then 24 hours, 48 hours, and 8 weeks postoperatively. Owners completed CMPS-SF and subjective evaluations weekly for 8 weeks postoperatively. RESULTS: No statistically significant differences were found between treatment groups when evaluating CRP, %WB, and CMPS-SF by the clinician and weekly evaluation of the CMPS-SF by owners. Although no statistically significant differences were found in patients developing surgical site infections between treatment groups, SSI was only observed in patients in the control group (5/30, 16.6%). Most were minor/superficial infections (4/30 13.3%), and a single dog (1/30, 3.3%) had a major/deep surgical site infection. CLINICAL RELEVANCE: Although with promising but not statistically significant differences between groups, surgical site infections may be reduced after PBMT application.

Prevention of knee stiffness following ligament reconstruction: Understanding the role of Arthrogenic Muscle Inhibition (AMI).

The knee is a joint that is often injured in sport, with a large and increasing number of ligament tears and repairs; postoperative complications can lead to poor outcome, such as stiffness. Beyond the well-known and well-described intra- and extra-articular causes of postoperative stiffness, the present study introduces the concept of a central reflex motor inhibition mechanism called arthrogenic muscle inhibition (AMI). AMI occurs after trauma and can be defined as active knee extension deficit due to central impairment of Vastus Medialis Obliquus (VMO) contraction, often associated with spinal reflex hamstring contracture. This explains the post-traumatic flexion contracture that is so common after knee sprain. The clinical presentation of AMI is easy to detect in consultation, in 4 grades from simple VMO inhibition to fixed flexion contracture by posterior capsule retraction in chronic cases. After recent anterior cruciate ligament (ACL) tear, more than 55% of patients show AMI, reducible in 80% of cases by simple targeted exercises initiated in consultation. Practically, in patients who have sustained knee sprain, it is essential to screen for this reflex mechanism and assess reducibility, as AMI greatly aggravates the risk of postoperative stiffness. In case of hemarthrosis, we recommend joint aspiration, which provides immediate benefit in terms of pain and motor inhibition. In case of persistent AMI, classical electrostimulation and "cushion crush", as used by all physiotherapists, are ineffective. To reduce the risk of postoperative stiffness, no surgery should be considered until AMI has resolved. LEVEL OF EVIDENCE: expert opinion.

Dry Needling for Arthrogenic Muscle Inhibition of Quadriceps Femoris in Patients after Reconstruction of Anterior Cruciate Ligament: a Protocol for a Randomized Controlled Trial.

Background: : Dry needling (DN) is recommended as a therapeutic modality for various neuromusculoskeletal disorders. No study has been performed on the impact of DN on arthrogenic muscle inhibition (AMI) after anterior cruciate ligament reconstruction (ACLR). This study protocol is aimed to investigate the impacts of DN on AMI of quadriceps femoris, corticomotor, and spinal reflex excitability in patients with ACLR. Methods: : A double-blind, between-subject, randomized, controlled trial will be conducted to measure changes in AMI after DN. Twenty-four subjects with ACLR will be recruited to receive a DN or a sham DN, providing that they met the inclusion criteria. Three sessions of DN on the quadriceps femoris will be applied during a one-week period. The primary outcome measures are the active motor threshold, motor evoked potential, and Hmax - Mmax ratio. The secondary outcomes are the International Knee Documentation Committee subjective knee form questionnaire score and maximum quadriceps isometric torque. Data will be collected at baseline, immediately after the first session, after the third session, and at the one-month follow-up visit. Discussion: : The results of this study will provide preliminary evidence regarding the effects of DN on AMI of quadriceps femoris in patients with ACLR.

Application of 3D-Printed Personalized Guide for Lateral Femoral Positioning in Anterior Cruciate Ligament Reconstruction of the Knee.

Objective: This research aims to investigate the effectiveness of 3D computer-assisted customized guided positioning of the lateral femoral tunnel compared to conventional methods for Anterior Cruciate Ligament (ACL) reconstruction surgery. Methods: A total of 80 patients with a complete ACL tear who underwent arthroscopic reconstruction with autologous tendon transplantation (semitendinosus-gracilis tendon) were included in this study. The patients were admitted to our hospital between March 2020 and January 2022 and were randomly divided into two groups: the conventional group (n = 40) and the personalized guide group (n = 40), based on the positioning method. The conventional group underwent ACL restoration using standard surgical techniques, while the personalized guide group opted for the more precise computer-assisted personalized guide method. The lateral femoral tunnel times were compared between both groups. Additionally, the International Knee Documentation Committee (IKDC) and Lysholm scores were assessed, and the lateral femoral location was evaluated using X-ray imaging at 2 weeks postoperatively. Results: After surgery, both groups showed a statistically significant increase (P < .05) in Lysholm and IKDC scores compared to their pre-surgery scores. However, the two groups had no evident difference (P > .05). X-ray evaluation at 2 weeks post-surgery revealed no significant difference between the two groups in NL/ML, AL/BL, α, and ß angles (P > .05). The preparation time for the femoral tunnel was significantly shorter in the personalized guide group (6.18 ± 0.92 min) compared to the traditional group (15.94 ± 3.12 min) (P < .05). Conclusions: The computer-assisted 3D personalized guide positioning method is more effective in locating the lateral femoral tunnel for ACL reconstruction of the knee and can substantially reduce the positioning time. This study provides valuable insights for clinicians when selecting surgical methods.

Reliability, validity, and responsiveness of the Indonesian version of the Lysholm knee score and Tegner activity scale in patients with anterior cruciate ligament reconstruction.

OBJECTIVES: This study aims to examine the reliability, validity, and responsiveness of the Lysholm knee score (LKS) and Tegner activity scale (TAS) in Indonesian patients with anterior cruciate ligament reconstruction (ACLR). DESIGN: Cross-sectional study. SETTING: The LKS and TAS were translated into Indonesian through standardized procedures with the owners' permission, and the test-retest reliabilities, validities, and responsiveness were performed. PARTICIPANTS: Data of LS, TAS, Short Form (SF)-36, as well as MRI results were collected from 206 patients with unilateral ACLR. MAIN OUTCOME MEASURES: LKS and TAS. RESULTS: The questionnaires showed an adequate interclass correlation coefficient of 0.81-0.84 for the test-retest reliabilities, while an appropriate Cronbach's alpha value of 0.83 was obtained for internal consistency using LKS. They also had moderate-high correlations with the selected measures, which have similar constructs (r values, 0.44-0.68) except for the TAS with SF-36 physical function (PF; r value, 0.32). Meanwhile, low associations were observed with other measures with different constructs (r, 0.21-0.31). The results showed that Guyatt's responsiveness index for LKS and TAS changed in the SF-36's PF from 0.50 to 1.60 after one year. CONCLUSIONS: The Indonesian version of LKS and TAS have acceptable reliabilities, validities, and responsiveness in ACLR patients.

Effectiveness of early onset of rehabilitation on the postural stability after anterior cruciate ligament reconstruction.

PURPOSE: The objective of this study was to evaluate the early onset of rehabilitation on restoring the postural stability of patients after anterior cruciate ligament reconstruction (ACLR) at the 3rd postoperative month. METHODS: Forty patients after ACLR and twenty healthy controls took part in the investigation. The patients were divided into two groups, depending on the start of their proprioceptive rehabilitation program: an experimental group - on the 5th day after the surgery and a control group - on around the 30th postoperative day. Postural stability was investigated by static posturographic tests on stable and foam surfaces with open and closed eyes. RESULTS: The patients from the experimental group showed lower amplitudes and velocities of the postural sways than the patients from the control group at the 3rd postoperative month. We found that the early start of the proprioceptive rehabilitation affects more the amplitude than the velocity of the postural sway which remains significantly high in both directions compared to the conventional rehabilitation. CONCLUSION: The early start of the rehabilitation has a beneficial role in the recovery of the postural stability in the 3rd postoperative month, especially in more challenging conditions for keeping the equilibrium, which contributes to the minimizes the risk of a second anterior cruciate ligament injury after patients' return to their usual sport and daily activities routine.

Functional outcomes of a criterion-based rehabilitation protocol for anterior cruciate ligament reconstruction in amateur athletes: A randomised clinical trial.

INTRODUCTION: Although current rehabilitation protocols following anterior cruciate ligament reconstruction (ACLR) are based on the graft remodeling process, there is uncertainty about its time schedule. Moreover, there are individual differences in neuromotor learning and flexibility after ACLR. The current study was conducted to investigate the functional outcomes of the criterion-based rehabilitation protocol in amateur athletes following ACLR. METHODS: Fifty amateur male athletes who had ACLR were assigned randomly into two equal groups. The experimental group received a criterion-based rehabilitation protocol. The control group received a conventional physical therapy program. Both groups had five treatment sessions per week for six months. The primary outcome was pain intensity measured by VAS. Secondary outcomes included functional assessments measured by the limb symmetry index (LSI) of the hop test battery, knee effusion, and the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Mixed-design-MANOVA indicated significant treatment, time, and treatment × time interaction. The interaction was significant for all outcome measures in favor of subjects who received a criterion-based rehabilitation protocol. Within-group analysis revealed a significant reduction in pain in both groups and improvements in all variables related to the KOOS or LSI of the hop test battery. Knee effusion was significantly reduced post-treatment in patients who received a criterion-based protocol when compared to their controls. CONCLUSIONS: Although application of a criterion-based rehabilitation protocol for 6 months after ACLR is more effective than a conventional program, its duration should be expanded beyond this period to allow patients to reach their return to play goals.

[Effect of dietary supplements and whey protein on muscle mass and strength of the operated limb after anterior cruciate ligament reconstruction: a systematic review].

Muscle weakness and atrophy of the quadriceps muscle after anterior cruciate ligament reconstruction may persist for up to 6 months after surgery and cause re-injury to the ipsilateral or contralateral limbs. Many authors state that adequate nutritional status during the rehabilitation period can contribute to faster postoperative recovery of muscle mass and strength of the lower limb, be an adjunct to exercise, or serve an alternative treatment strategy. The purpose of the research was to conduct a systematic review of the literature and evaluate the degree of influence of dietary supplements on muscle mass and strength of the operated limb after reconstruction of the anterior cruciate ligament (ACL). Material and methods. The search for articles was carried out in international databases PubMed, Google Scholar, Cochrane Library. The time frame of the search was 22 years. To be included in the review, studies had to meet the PICOS criteria: participants were men and women over 18 years of age after ACL reconstruction; intervention - supplementation after and/or before and after ACL reconstruction; comparison - placebo group or no supplementary interventions; results - assessment of the dynamics of changes in muscle mass (cross-sectional area, muscle thickness or size of skeletal muscle fibers) and / or maximum strength (dynamic or isometric) of the operated limb; research design - randomized controlled trials (RCT). The quality of selected RCTs was assessed using the Cochrane Collaboration Risk of Bias (RoB 2) tool. Results. A total of 1397 articles were found after searching in the databases. This systematic review included 6 RCTs with a total number of patients 186. The following dietary supplements were used: leucine - 1 article, glucosam ine - 1 article, creatine - 1 article, vitamins E and C - 2 articles. One study evaluated the effect of whey protein supplementation in combination with neuromuscular electrical stimulation on isometric strength of the operated limb. When comparing the data of 3 groups in the pre- and postoperative periods, there were no statistically significant differences between the groups. When considering the protocols for taking dietary supplements based on creatine, glucosamine, vitamins E and C, none of the studies demonstrated statistically significant improvements in the parameters of maximum strength or muscle hypertrophy of the operated limb in the main groups compared with the control groups. Also, no results have been obtained indicating that these dietary supplements can slow down muscl e atrophy after surgery. In another study that evaluated the effect of leucine supplementation, by the end of the rehabilitation program, the muscle strength of the operated limb tended to increase more in the leucine group than in the placebo group, but without a statistically significant difference. At 10 cm from the patella, the femoral circumference of the operated limb in the leucine group increased more than in the placebo group, and the differences were statistically significant (р=0.009). Two studies were rated as high risk of bias, three as moderate risk, and one as low risk. Conclusion. None of the supplements used had a statistically significant effect on the muscle strength of the operated limb after ACL reconstru ction. In terms of thigh muscle hypertrophy, the only significant improvement was associated with leucine supplementation and an increase in thigh circumference at a distance of 10 cm from the patella.

Association Between Graft Type and Risk of Repeat Revision Anterior Cruciate Ligament Reconstruction: A Cohort Study of 1747 Patients.

BACKGROUND: With an increasing number of primary anterior cruciate ligament reconstructions (ACLRs), the burden of revision ACLR (rACLR) has also increased. Graft choice for rACLR is complicated by patient factors and the remaining available graft options. PURPOSE: To examine the association between graft type at the time of rACLR and the risk of repeat rACLR (rrACLR) in a large US integrated health care system registry while accounting for patient and surgical factors at the time of revision surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data from the Kaiser Permanente ACLR registry were used to identify patients who underwent a primary isolated ACLR between 2005 and 2020 and then went on to have rACLR. Graft type used at rACLR, classified as autograft versus allograft, was the exposure of interest. Multivariable Cox proportional hazard regression was used to evaluate the risk of rrACLR, with ipsilateral and contralateral reoperation as secondary outcomes. Models included factors at the time of the rACLR (age, sex, body mass index, smoking status, staged revision, femoral fixation, tibial fixation, femoral tunnel method, lateral meniscal injury, medial meniscal injury, and cartilage injury) and a factor from the primary ACLR (activity at injury) as covariates. RESULTS: A total of 1747 rACLR procedures were included. The crude cumulative rrACLR incidence at 8-year follow-up was 13.9% for allograft and 6.0% for autograft. Cumulative ipsilateral reoperation incidence at 8-year follow-up was 18.3% for allograft and 18.9% for autograft; contralateral reoperation cumulative incidence was 4.3% for allograft and 6.8% for autograft. With adjustment for covariates, a 70% lower risk for rrACLR was observed for autograft compared with allograft (hazard ratio [HR], 0.30; 95% CI, 0.18-0.50; P < .0001). No differences were observed for ipsilateral reoperation (HR, 1.05; 95% CI, 0.73-1.51; P = .78) or contralateral reoperation (HR, 1.33; 95% CI, 0.60-2.97; P = .48). CONCLUSION: The use of autograft at rACLR was associated with a 70% lower risk of rrACLR compared with allograft in this cohort from the Kaiser Permanente ACLR registry. When accounting for all reoperations outside of rrACLR after rACLR, the authors found no significant difference in risk between autograft and allograft. To minimize the risk of rrACLR, surgeons should consider using autograft for rACLR when possible.

Physiotherapeutic approach to the preoperative period for the anterior cruciate ligament reconstruction: A systematic review.

INTRODUCTION: The tearing of the anterior cruciate ligament (ACL) is one of the most common type of knee injury. Current evidence show that there are specific predictors for postoperative success in ACL injuries, but there is a limited number of studies on preoperative rehabilitation. Therefore, the goals of this review were to emphasize physiotherapy approaches to the preoperative period and to verify its effectiveness at the time the athlete returns to sport. METHOD: We conducted a systematic search in these databases: Medline, Scielo, Lilacs, CINAHL, Web of Science, PeDro and Cochrane Library. RESULTS: Our searches identified 553 occurences; of these, 511 titles and abstracts underwent triage after removal of duplicates. We identified 120 full texts for a stricter screening, amongst them, three studies included in the review for complying with the elegibility criteria. CONCLUSION: Physiotherapic preoperative treatment exhibits weak evidence for strength gains and pain relief, as well as strong evidence of functional improvement compared to the control group. These results were reported 4 months after the ACLR, in average.

ACL Reconstruction: Which Additional Physiotherapy Interventions Improve Early-Stage Rehabilitation? A Systematic Review.

Despite the restoration of the mechanical stability of the knee joint after ACL reconstruction (ACLR), patients often experience postoperative limitations. To our knowledge, there are no systematic reviews analyzing additional physiotherapy interventions implementing standard rehabilitation programs in the early postoperative phase after ACLR. The objective of this study was to analyze the additional physiotherapy interventions implemented in standard rehabilitation programs that improve early-stage ACLR rehabilitation. For this systematic review, we followed the PRISMA guidelines. In March 2022 we conducted a literature review using electronic databases. Primary outcomes were pain, edema, muscle strength, ROM, and knee function. The risk of bias and scientific quality of included studies were assessed with the RoB 2, ROBINS-I and PEDro scale. For the review, we included 10 studies that met the inclusion criteria (total n = 3271). The included studies evaluated the effectiveness of Kinesio Taping, Whole-body vibration, Local Vibration Training, Trigger Point Dry Needling, High Tone Power Therapy, alternating magnetic field, and App-Based Active Muscle Training Program. Most of the additional physiotherapy interventions improved pain, edema, ROM, knee muscle strength, or knee function in early-stage postoperative ACL rehabilitation. Except for one study, no adverse events occurred in the included studies, which demonstrates the safety of the discussed physiotherapy interventions. Further in-depth research is needed in this area.

Topical Ozone Therapy-A Novel Modality in the Treatment of a Complicated Wound after Knee Joint Ligament Operation as a Consequence of Traffic Accident-Case Report.

BACKGROUND AND OBJECTIVES: For many years, medicine has been looking for effective methods to be used in the treatment of chronic wounds. Pharmacological treatment is insufficient and does not give expected results of treatment. In the comprehensive treatment of wounds, physical medicine methods have been used, which are characterized by high efficiency and safety as well as relatively low costs of the therapy. Efficient application of a novel therapeutic modality in the form of topical ozone therapy in the treatment of a difficult-to-heal wound of the left knee joint after surgery due to the rupture of the anterior cruciate ligament and damage to the medial meniscus because of a previous road accident in a 61-year-old female patient is presented. METHODS: Topical ozone therapy treatment in the form of the "Ozone bag" with the use of an oxygen-ozone mixture (2.86% ozone and 97.14% of oxygen) with a concentration of 40 µg/mL was applied to the wound area. The therapeutic cycle consisted of two series of 10 treatment sessions lasting 20 min each, performed every day for 5 days a week, and carried out for 6 weeks. RESULTS: Topical ozone therapy caused complete healing of the complicated wound remaining after orthopaedic surgery, which allowed the patient to live independently without experiencing pain, to move without elbow crutches, and to perform daily activities independently and ultimately to return to work.

Low-level laser therapy attenuates arthrogenic contracture induced by anterior cruciate ligament reconstruction surgery in rats.

Therapeutic approaches to treat joint contracture after anterior cruciate ligament (ACL) reconstruction have not been established. Arthrofibrosis accompanied by joint inflammation following ACL reconstruction is a major cause of arthrogenic contracture. In this study, we examined whether anti-inflammatory treatment using low-level laser therapy (LLLT) can prevent ACL reconstruction-induced arthrogenic contracture. Rats underwent ACL transection and reconstruction surgery in their right knees. Unoperated left knees were used as controls. After surgery, rats were reared with or without daily LLLT (wavelength: 830 nm; power output: 150 mW; power density: 5 W/cm2; for 120 s/day). We assessed the passive extension range of motion (ROM) after myotomy at one and two weeks post-surgery; the reduction in ROM represents the severity of arthrogenic contracture. ROM was markedly decreased by ACL reconstruction at both time points; however, LLLT partially attenuated the decrease in ROM. One week after ACL reconstruction, the gene expression of the proinflammatory cytokine interleukin-1beta in the joint capsule was significantly upregulated, and this upregulation was significantly attenuated by LLLT. Fibrotic changes in the joint capsule, including upregulation of collagen type I and III genes, shortening of the synovium, and thickening were caused by ACL reconstruction and seen at both time points. LLLT attenuated these fibrotic changes as well. Our results indicate that LLLT after ACL reconstruction could attenuate the formation of arthrogenic contracture through inhibition of inflammation and fibrosis in the joint capsule. Thus, LLLT may become a novel therapeutic approach for ACL reconstruction-induced joint contracture.

Efficacy of non-surgical management and functional outcomes of partial ACL tears. A systematic review of randomised trials.

BACKGROUND: The incidence of anterior cruciate ligament (ACL) injuries represents a large burden of knee injuries in both the general and sporting populations, often requiring surgical intervention. Although there is much research on complete ACL tears including outcomes and indications for surgery, little is known about the short- and long-term outcomes of non-operative, physiotherapy led intervention in partial ACL tears. The primary aim of this study was to evaluate studies looking at the effectiveness of physiotherapy led interventions in improving pain and function in young and middle-aged adults with partial ACL tears. Additionally, the secondary aim was to evaluate the completeness of exercise prescription in randomised trials for physiotherapy led interventions in the management in partial ACL tears. METHODS: A comprehensive and systematic search was performed on six databases (Medline, CINAHL, EMBASE, PEDro, Scopus, SPORTDiscus and Cochrane). The search strategy consisted of two main concepts: (i) partial ACL tears, and (ii) non-operative management. 7,587 papers were identified by the search. After screening of eligible articles by two independent reviewers, 2 randomised studies were included for analysis. The same two reviewers assessed the completeness of reporting using the Toigio and Boutellier mechanobiological exercise descriptions and Template for Intervention Description and Replication (TIDieR) checklist. Group mean standard deviations (SD) for the main outcomes was extracted from both papers for analysis. Prospero Registration Number: CRD42020179892. RESULTS: The search strategy identified two studies; one looking at Tai Chi and the other Pilates. The analysis indicated that Tai Chi was significant in reducing pain scores and both Tai Chi and Pilates were found to increase Muscle Peak Torque Strength (MPTS) at 180 degrees. Furthermore, Tai Chi showed a significant increase in proprioception. CONCLUSIONS: Physiotherapy led interventions such as Pilates, and Tai Chi may improve pain, proprioception and strength in young and middle-aged adults with partial ACL tears, however full scale, high-quality randomised studies are required with long term outcomes recorded.

Acute and subacute anterior cruciate ligament reconstructions are associated with a higher risk of revision and reoperation.

PURPOSE: (1) Report concomitant cartilage and meniscal injury at the time of anterior cruciate ligament reconstruction (ACLR), (2) evaluate the risk of aseptic revision ACLR during follow-up, and (3) evaluate the risk of aseptic ipsilateral reoperation during follow-up. METHODS: Using a United States integrated healthcare system's ACLR registry, patients who underwent primary isolated ACLR were identified (2010-2018). Multivariable Cox proportional-hazards regression was used to evaluate the risk of aseptic revision, with a secondary outcome evaluating ipsilateral aseptic reoperation. Outcomes were evaluated by time from injury to ACLR: acute (< 3 weeks), subacute (3 weeks-3 months), delayed (3-9 months), and chronic (≥ 9 months). RESULTS: The final sample included 270 acute (< 3 weeks), 5971 subacute (3 weeks-3 months), 5959 delayed (3-9 months), and 3595 chronic (≥ 9 months) ACLR. Medial meniscus [55.4% (1990/3595 chronic) vs 38.9% (105/270 acute)] and chondral injuries [40.0% (1437/3595 chronic) vs 24.8% (67/270 acute)] at the time of ACLR were more common in the chronic versus acute groups. The crude 6-year revision rate was 12.9% for acute ACLR, 7.0% for subacute, 5.1% for delayed, and 4.4% for chronic ACLR; reoperation rates a 6-year follow-up was 15.0% for acute ACLR, 9.6% for subacute, 6.4% for delayed, and 8.1% for chronic ACLR. After adjustment for covariates, acute and subacute ACLR had higher risks for aseptic revision (acute HR 1.70, 95% CI 1.07-2.72, p = 0.026; subacute HR 1.25, 95% CI 1.01-1.55, p = 0.040) and aseptic reoperation (acute HR 2.04, 95% CI 1.43-2.91, p < 0.001; subacute HR 1.31, 95% CI 1.11-1.54, p = 0.002) when compared to chronic ACLR. CONCLUSIONS: In this cohort study, while more meniscal and chondral injuries were reported for ACLR performed ≥ 9 months after the date of injury, a lower risk of revision and reoperation was observed following chronic ACLR relative to patients undergoing surgery in acute or subacute fashions.

More anatomic tunnel placement for anterior cruciate ligament reconstruction by surgeons with high volume compared to low volume.

PURPOSE: Correct placement of the femoral and tibial tunnels in the anatomic footprint during anterior cruciate ligament reconstruction (ACLR) is paramount for restoring rotatory knee stability. Recent studies have looked at surgeon volume and its outcomes on procedures such as total knee arthroplasty and infection rates, but only few studies have specifically examined tunnel placement after ACLR based on surgeon volume. The purpose of this study was to compare the placement of femoral and tibial tunnels during ACLR between high-volume and low-volume surgeons. It was hypothesized that high-volume surgeons would have more anatomic tunnel placement compared with low-volume surgeons. METHODS: A retrospective review of all ACLR performed between 2015 and 2019 at an integrated health care system consisting of both academic and community hospitals with 68 orthopaedic surgeons was conducted. Surgeon volume was categorized as less than 35 ACLR per year (low volume) and 35 or more ACLR per year (high volume). Femoral tunnel placement for each patient was determined using an exact strict lateral radiograph (less than 6 mm of offset between the posterior halves of the medial and lateral condyles) taken after the primary ACLR using the quadrant method. The centre of the femoral tunnel was measured in relation to the posterior-anterior (PA) and proximal-distal (PD) dimensions (normal centre of anatomic footprint: PA 25% and PD 29%). Tibial tunnel placement for each patient was determined on the same lateral radiographs by measuring the mid-sagittal tibial diameter and the centre of the tibial attachment area of the ACL from the anterior tibial margin (normal centre of anatomic footprint: 43%). Each lateral radiograph was reviewed by one of two blinded reviewers. RESULTS: A total of 4500 patients were reviewed, of which 645 patients met all the inclusion/exclusion criteria and were included in the final analysis. There were 228 patients in the low-volume group and 417 patients in the high-volume group. Low-volume surgeons performed a mean of 5 ACLRs per year, whereas surgeons in the high-volume group performed a mean of 40 ACLRs per year. In the PA dimension, the low-volume group had significantly more anterior femoral tunnel placement compared with the high-volume group (32 ± 10% vs 28 ± 9%, p < 0.01). In the PD dimension, the low-volume group had statistically significant more proximal femoral tunnel placement compared to the high-volume group (32 ± 9% vs 35 ± 9%, p < 0.01). For the tibial tunnel, the low-volume group had significantly more posterior tibial tunnel placement compared with the high-volume group (41 ± 10% vs 38 ± 7%, p < 0.01). CONCLUSION: Low-volume surgeons placed their femoral tunnels significantly more anterior and proximal (high) during ACLR, and placed their tibial tunnels significantly more posterior, compared with high-volume surgeons. Prior research has indicated that anatomic placement of the femoral and tibial tunnels during ACLR leads to improved rotatory knee stability. The findings of this study demonstrate the importance of surgical volume and experience during ACLR. LEVEL OF EVIDENCE: III.

Does body scanning through visual imagery improve perception and function in patients after anterior cruciate ligament-reconstruction? An exploratory study.

INTRODUCTION: Many people who have undergone Anterior Cruciate Ligament (ACL)-reconstruction do not return to their pre-injury level, with nonphysical factors recognized as barriers to recovery. Fear of movement has been linked to body schema distortions, and interventions directed at the body schema have shown potential to improve function. OBJECTIVE: 1) Describe participants' ability to perform a visual imagery intervention (Body Scan); 2) investigate knee perception differences; 3) investigate if Body Scan led to improvements in perceptual differences; and 4) determine if some individuals improved in functional measures following the intervention. METHODS: A single-arm intervention study was undertaken in people >12-month post ACL-reconstruction (n = 30). Body Scan was delivered using a standardized script developed for this study. Participants were assessed regarding their capacity to perform the Body Scan, perceptual differences between the knees and how perception changed following the intervention. Functional measures (vertical hop, triple hop, mSEBT, quadriceps strength, and hamstring strength) were taken. RESULTS: 96.7% were able to perform a Body Scan, with 93.1% demonstrating a difference in perception between the knees. Of participants with perceptual differences, 92.5% demonstrated improvement in perception following the intervention. Ten participants had a clinically significant improvement in a functional measure following the intervention. CONCLUSION: Most participants could perform Body Scanning. The majority perceived perceptual differences between operated and non-operated knees, and reported more symmetric perception following the intervention. One-third of participants also showed improvements in a functional performance measure. Results suggest this intervention may be a helpful adjunct to rehabilitation post ACL-reconstruction, with further research warranted.

Optimizing anterior cruciate ligament reconstruction: Individualizing the decision-making process using data from the Kaiser Permanente ACLR Registry: 2018 OREF award paper.

Despite years of study, controversy remains regarding the optimal graft for anterior cruciate ligament reconstruction (ACLR), suggesting that a single graft type is not ideal for all patients. A large community based ACLR Registry that collects prospective data is a powerful tool that captures information and can be analyzed to optimize surgery for individual patients. The studies highlighted in this paper were designed to optimize and individualize ACLR surgery and have led to changes in surgeon behavior and improvements in patient outcomes. Kaiser Permanente (KP) is an integrated health care system with 10.6 million members and more than 50 hospitals. Every KP member who undergoes an ACLR is entered into the Registry, and prospectively monitored. The Registry uses a variety of feedback mechanisms to disseminate Registry findings to the ACLRR surgeons and appropriately influence clinical practices and enhance quality of care. Allografts were found to have a 3.0 times higher risk of revision than bone-patellar tendon-bone (BPTB) autografts. Allograft irradiation >1.8 Mrad, chemical graft processing, younger patients, BPTB allograft, and male patients were all associated with a higher risk of revision surgery. By providing feedback to surgeons, overall allograft use has decreased by 27% and allograft use in high-risk patients ≤21 years of age decreased 68%. We have identified factors that influence the outcomes of ACLR. Statement of Clinical Significance: We found that information derived from an ACLR Registry and shared with the participating surgeons directly decreased the use of specific procedures and implants associated with poor outcomes.