Vitamin D as an intervention for improving quadriceps muscle strength in patients after anterior cruciate ligament reconstruction: study protocol for a randomized double-blinded, placebo-controlled clinical trial.

BACKGROUND: The goal of anterior cruciate ligament reconstruction (ACLR) is to restore the preinjury level of knee function to return to play (RTP). However, even after completing the rehabilitation programme, some patients may have persistent quadriceps muscle weakness affecting knee function which ultimately leads to a failure in returning to play. Vitamin D has been long recognized for its musculoskeletal effects. Vitamin D deficiency may impair muscle strength recovery after ACLR. Correcting vitamin D levels may improve muscle strength. METHODS: This is a double-blinded, randomized controlled trial to investigate the effects of vitamin D supplementation during the post-operative period on quadriceps muscle strength in anterior cruciate ligament (ACL)-injured patients. Patients aged 18-50 with serum vitamin D < 20 ng/ml, unilateral ACL injury, > 90% deficit in total quadriceps muscle volume on the involved leg compared with uninvolved leg, Tegner score 7 + , and no previous knee injury/surgery will be recruited. To assess patient improvement, we will perform isokinetic and isometric muscle assessments, ultrasound imaging for quadriceps thickness, self-reported outcomes, KT-1000 for knee laxity, biomechanical analysis, and Xtreme CT for bone mineral density. To investigate the effect of vitamin D status on quadriceps strength, blood serum samples will be taken before and after intervention. DISCUSSION: Patients with low vitamin D levels had greater quadriceps fibre cross-sectional area loss and impaired muscle strength recovery after ACL. The proposed study will provide scientific support for using vitamin D supplementation to improve quadriceps strength recovery after ACLR. TRIAL REGISTRATION: ClinicalTrials.gov NCT05174611. Registered on 28 November 2021.

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.

Analgesic effect of nitrous oxide during manual therapy after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial.

BACKGROUND: Many patients during manual therapy after anterior ligament reconstruction will experience severe pain, which has a negative impact on their rehabilitation. However, there is rarely an analgesic method for these patients during rehabilitation. Nitrous oxide with rapid analgesic and sedative effects is often used to relieve pain in minor procedures. The purpose of this study is to determine whether or not nitrous oxide analgesia decreases pain compared to oxygen during manual therapy after anterior ligament reconstruction. METHODS/DESIGN: This single-center, randomized, double-blind and controlled trial will recruit 120 patients. Patients ≥ 18 years old undergoing manual therapy after anterior ligament reconstruction (1 month post-operative) with acute pain (VAS ≥ 4) are included. The main exclusion criteria included the following: pulmonary embolism, intestinal obstruction, pneumothorax. Patients will be randomly allocated to the intervention group (A) and the control group (B) in a ratio of 1:1. Doctors, therapists, patients, and data collectors are all blind to the study. The manual therapy will be performed by therapists. Nurses who implemented the intervention handed the doctors envelopes containing the patients' codes and allocation of A or B. Group A will receive a pre-prepared nitrous oxide/oxygen mixture plus conventional treatment (no analgesic) given as 30-min treatment sessions, once daily, and group B will receive oxygen plus conventional treatment (no analgesic) under the same conditions. Assessments will be taken 2 min before the intervention (T0), 5 min after the beginning of the intervention (T1), and 5 min after the intervention finished (T2). The primary outcome is pain score. Secondary outcomes include vital signs, side effects, joint range of motion, adjuvant analgesia need, therapist and patient satisfaction, and whether willing to receive the same gas again. EXPECTED OUTCOMES: We expect nitrous oxide inhalation to have a beneficial effect on the pain of patients who receive manual therapy after anterior ligament reconstruction. DISCUSSION: If this treatment appears beneficial, it could improve patients' satisfaction and quality of life potentially and even be implemented widely in hospital and rehabilitation settings. TRIAL REGISTRATION: ClinicalTrials.gov identifier, ChiCTR2200061175 (Version 2.0 June 15, 2022), https://www.chictr.org.cn .

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.

Long term effect of the Pilates method in a reconstructed knee with osteoarthritis: A case report.

BACKGROUND: Osteoarthritis (OA) is one of the most debilitating diseases, and a patient with a reconstructed knee could develop it early and lives with this condition for an average of 30-years. Furthermore, most studies focus on short-term results, not long-term. The purpose of this article is to show how a patient with reconstructed knees and OA improved clinical outcomes using the Pilates Method (PM) in the long term. METHODS AND MATERIALS: The patient was treated with common medical treatment for 10 years and then treated with the PM for 15 years. Authors used the biomechanics-based approaches, radiographic examination of the knees, magnetic resonance imaging, the numeric pain rating scale, range of motion (ROM), the Polestar fitness screening test (PFST), the knee injury and osteoarthritis outcome score questionnaire (KOOS), and the physical function performance-based tests (PFPBT) recommended by Osteoarthritis Research Society International (OARSI). RESULTS: There was an improvement in the evaluated outcomes when using the PM in the long term: a decrease in pain-related scores (constant pain = - 4; worst pain = - 5), improved ROM in 15°, improved stability in both knees (right Lackman Test (LT) = -1; left LT = - 2). When comparing the patient with healthy women in the middle age through the PFPBT her scores are above average, with no restrictions in performing daily activities and a good quality of life according with the KOOS questionnaire. CONCLUSION: This case study suggests that long-term Pilates training may be useful for the treatment of pain, stiffness, and function in patients with reconstructed knees and OA.

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.

Michigan Initiative for Anterior Cruciate Ligament Rehabilitation (MiACLR): A Protocol for a Randomized Clinical Trial.

OBJECTIVE: Restoring quadriceps muscle strength following anterior cruciate ligament reconstruction (ACLR) may prevent the posttraumatic osteoarthritis that affects over 50% of knees with ACLR. However, a fundamental gap exists in our understanding of how to maximize muscle strength through rehabilitation. Neurological deficits and muscle atrophy are 2 of the leading mechanisms of muscle weakness after ACLR. High-intensity neuromuscular electrical stimulation (NMES) and eccentric exercise (ECC) have been shown to independently target these mechanisms. If delivered in succession, NMES and then ECC may be able to significantly improve strength recovery. The objectives of this study were to evaluate the ability of NMES combined with ECC to restore quadriceps strength and biomechanical symmetry and maintain cartilage health at 9 and 18 months after ACLR. METHODS: This study is a randomized, double-blind, placebo-controlled, single-center clinical trial conducted at the University of Michigan. A total of 112 participants between the ages of 14 and 45 years and with an anterior cruciate ligament rupture will be included. Participants will be randomly assigned 1:1 to NMES combined with ECC or NMES placebo combined with ECC placebo. NMES or NMES placebo will be delivered 2 times per week for 8 weeks beginning 10 to 14 days postoperatively and will be directly followed by 8 weeks of ECC or ECC placebo delivered 2 times per week. The co-primary endpoints are change from baseline to 9 months and change from baseline to 18 months after ACLR in isokinetic quadriceps strength symmetry. Secondary outcome measures include isometric quadriceps strength, quadriceps activation, quadriceps muscle morphology (cross-sectional area), knee biomechanics (sagittal plane knee angles and moments), indexes of patient-reported function, and cartilage health (T1ρ and T2 relaxation time mapping on magnetic resonance imaging). IMPACT: The findings from this study might identify an intervention capable of targeting the lingering quadriceps weakness after ACLR and in turn prevent deterioration in cartilage health after ACLR, thereby potentially improving function in this patient population.

Preoperative hypnosis for pain management after arthroscopic repair of anterior cruciate ligament.

BACKGROUND: The practice of hypnoanalgesia in orthopedics is rare and the literature is poor. AIM: The purpose of this pilot study was to verify the efficacy of hypnosis for the management of postoperative analgesia after arthroscopic repair of anterior cruciate ligament. METHODS: This was a prospective clinical trial over a period of 6 months (March - August 2015) including 25 patients scheduled for arthroscopic repair of anterior cruciate ligament under spinal anesthesia. All these patients had preoperative hypnosis in addition to the standard multimodal analgesia protocol (group H) and were compared to historical group (group S) who received only a standard multimodal analgesia protocol. RESULTS: Pain scores were significantly lower for the hypnosis group during the first 48 hours postoperatively (p = 0,006). The total dose of morphine at 48 hours was: 13,6 mg (95% CI [4,58; 22,62]) in the group H and 10,2 mg (95% CI [1,64 ; 18,76]) in group S with no statistically significant difference (p = 0,178) Conclusion: Results of this pilot study in orthopedic surgery suggested that hypnosis reduced postoperative pain scores as demonstrated in other surgeries.

Infiltration Between Popliteal Artery and Capsule of the Knee Block to Augment Continuous Femoral Nerve Catheter for Adolescent Anterior Cruciate Ligament Reconstruction: A Case Series.

Infiltration between popliteal artery and capsule of the knee (IPACK) is a novel technique that can provide additional analgesic relief, although there are no studies to date in the adolescent population. In 3 adolescent patients undergoing anterior cruciate ligament surgery, IPACK block augmented continuous femoral nerve block by providing posterior knee analgesia with no or only minimal opioid needs in the post-anesthesia care unit and did not produce sciatic motor weakness.

Arthrogenic muscle inhibition after ACL reconstruction: a scoping review of the efficacy of interventions.

OBJECTIVE: To determine whether reported therapeutic interventions for arthrogenic muscle inhibition (AMI) in patients with ACL injuries, following ACL reconstruction, or in laboratory studies of AMI, are effective in improving quadriceps activation failure when compared with standard therapy in control groups. DESIGN: A scoping review of the efficacy of interventions was conducted in accordance with the methodological framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search terms included 'arthrogenic muscle inhibition', 'quadriceps activation following knee injuries', 'anterior cruciate' or 'knee' combined with 'quadriceps activation', 'quadriceps inhibition', 'corticomotor', 'arthrogenic', 'brain activation' and 'neuroplasticity'. Articles were evaluated for risk of bias using the PEDro (Physiotherapy Evidence Database) criteria. The overall quality of evidence for each intervention was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). DATA SOURCES: PubMed, EMBASE and Cumulative Index to Nursing and Allied Health Literature databases. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Isolated case reports and articles reporting outcomes in patients with chronic disease or major trauma were excluded. All other original research articles were included. RESULTS: 780 potential articles were identified. 20 met the inclusion criteria. These studies provided a moderate quality of evidence to support the efficacy of cryotherapy and physical exercises in the management of AMI. There was low-quality evidence for efficacy of neuromuscular electrical stimulation and transcutaneous electrical nerve stimulation, and very low-quality evidence for efficacy of ultrasound and vibration. CONCLUSIONS: This scoping review demonstrated moderate-quality evidence for the efficacy of cryotherapy and physical exercises in improving quadriceps activation failure after ACL injury and reconstruction. These therapeutic modalities are therefore recommended in the management of AMI.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Femoral Nerve for Postoperative Analgesia Following Ambulatory Anterior Cruciate Ligament Reconstruction: A Proof of Concept Study.

OBJECTIVES: The purpose of this prospective proof of concept study was to investigate the feasibility of using percutaneous peripheral nerve stimulation of the femoral nerve to treat pain in the immediate postoperative period following ambulatory anterior cruciate ligament reconstruction with a patellar autograft. MATERIALS AND METHODS: Preoperatively, an electrical lead (SPRINT, SPR Therapeutics, Inc., Cleveland, OH, USA) was percutaneously implanted with ultrasound guidance anterior to the femoral nerve caudad to the inguinal crease. Within the recovery room, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5-min crossover period, and then continuous active stimulation until lead removal postoperative Day 14-28. Statistics were not applied to the data due to the small sample size of this feasibility study. RESULTS: During the initial 5-min treatment period, subjects randomized to stimulation (n = 5) experienced a slight downward trajectory (decrease of 7%) in their pain over the 5 min of treatment, while those receiving sham (n = 5) reported a slight upward trajectory (increase of 4%) until their subsequent 5-min stimulation crossover, during which time they also experienced a slight downward trajectory (decrease of 11% from baseline). A majority of subjects (80%) used a continuous adductor canal nerve block for rescue analgesia (in addition to stimulation) during postoperative Days 1-3, after which the median resting and dynamic pain scores remained equal or less than 1.5 on the numeric rating scale, respectively, and the median daily opioid consumption was less than 1.0 tablet. CONCLUSIONS: This proof of concept study demonstrates that percutaneous femoral nerve stimulation is feasible for ambulatory knee surgery; and suggests that this modality may be effective in providing analgesia and decreasing opioid requirements following anterior cruciate ligament reconstruction. clinicaltrials.gov: NCT02898103.

Single-Shot Femoral Nerve Block Does Not Cause Long-Term Strength and Functional Deficits Following Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine if patients treated with a single-shot femoral nerve block have strength and functional deficits at 9-month follow-up. METHODS: Forty-three patients who underwent primary anterior cruciate ligament reconstructions were randomized to receive either a preoperative single-shot femoral nerve block or local infiltration anesthesia for primary pain control. All patients underwent a standardized comprehensive rehabilitation program postoperatively. Isokinetic strength and function was tested using a Biodex machine at 9 months or more postoperatively comparing the operative and nonoperative extremity. RESULTS: No significant difference in strength was found at an average of 10.6 months postoperatively (range, 9-15 months) between the femoral nerve block and control groups. In comparing strength deficits, we found no difference in slow isokinetic extension strength (22.4% vs 27.8%, P = .51), fast isokinetic extension strength (18.5% vs 12.5%, P = .41), slow isokinetic flexion strength (11.0% vs 15.1%, P = .55), and fast isokinetic flexion strength (8.2% vs 4.9%, P = .56) in the femoral nerve block versus control groups, respectively. In terms of functional outcomes, there also was no difference in deficits for single-leg hop distance (P = .12), timed single-leg hop (P = .74), and single-leg triple hop distance (P = .94). Maximal strength noted to be within 15% of the contralateral limb was achieved in 40% of patients and maximal function in 63% of patients at an average of 10.6 months postoperatively. A 13% complication rate was found in patients who received a femoral nerve block (1 with prolonged quadriceps inhibition and 2 with prolonged sensory disturbances). CONCLUSIONS: Our study found a 13% motor/sensory complication rate in patients who underwent femoral nerve block for pain control after anterior cruciate ligament reconstruction. Although these deficits may persist, they are not permanent and are not different when compared with controls at 9-month follow-up. However, maximal strength and function are not fully restored at normal return to play time and rehabilitation should continue long term to maximize recovery. LEVEL OF EVIDENCE: Level I, prospective randomized trial.

Fascial Manipulation® for persistent knee pain following ACL and meniscus repair.

Fascial Manipulation® (FM) is a manual therapy approach for the treatment of musculoskeletal pain. Anomalous fascial tension is common following surgery due to surgical scar, inadequate mobility and fear of movement. Fascial tension may result in pain and loss of mobility. This case report aims at investigating the effectiveness of FM® on pain and function in a patient following knee surgery. A 32 years old male patient, with persisting knee pain following anterior cruciate ligament reconstruction (hamstring graft) and meniscal repair, underwent the systematic FM® assessment process, the selected centers of coordination of myofascial units were treated. Knee Injury Osteoarthritis Outcome Score (KOOS) questionnaire was obtained prior treatment and after 4 treatment sessions. Results showed clinically significant improvements in all subscales of KOOS after 4 weeks, the effect was maintained in subsequent follow-ups at 3 months, 6 months, one year and two years.

Efficacy of Rivaroxaban for thromboprophylaxis after Knee Arthroscopy (ERIKA). A phase II, multicentre, double-blind, placebo-controlled randomised study.

Without thromboprophylaxis, knee arthroscopy (KA) carries a low to moderate risk of venous thromboembolism. Over 5 million arthroscopies are performed worldwide yearly. It was our study objective to assess the efficacy and safety of rivaroxaban for thromboprophylaxis after therapeutic KA. Patients undergoing KA in nine Italian teaching or community hospitals were allocated to once-daily rivaroxaban (10 mg) or placebo for seven days in a phase II, multicentre, double-blind, placebo-controlled randomised trial. The primary efficacy outcome was a composite of all-cause death, symptomatic thromboembolism and asymptomatic proximal DVT at three months; major bleeding represented the primary safety outcome. All patients underwent whole-leg ultrasonography at day 7(+1), or earlier if symptomatic. A total of 241 patients were randomised (122 rivaroxaban, 119 placebo), and 234 completed the study. The primary efficacy outcome occurred in 1/120 of the rivaroxaban group and in 7/114 of the placebo group (0.8 % vs 6.1 %, respectively, p=0.03; absolute risk difference, -5.3 %, 95 % CI, -11.4 to -0.8; crude relative risk 0.14, 95 % CI, 0.02 to 0.83; number-needed-to-treat=19). No major bleedings were observed. We found no association between different arthroscopic procedures and thrombotic events. Small sample size, high exclusion rate, and low number of anterior cruciate ligament reconstruction procedures are the main limitations of our study. In conclusion, a seven-day course of 10-mg rivaroxaban may be safely employed for thromboprophylaxis after KA. Whether prophylaxis after KA should be given to all patients, or to selected "high-risk" subjects, remains to be determined. A larger trial to verify our preliminary results is warranted.

Validity of the twitch interpolation technique for the assessment of quadriceps neuromuscular asymmetries.

This study examined the validity of the twitch interpolation technique for evaluating side-to-side asymmetries in quadriceps neuromuscular function. Fifty-six subjects with a wide range of asymmetries (19 healthy, 24 with unilateral and 13 with bilateral anterior cruciate ligament reconstruction) took part in the study. Supramaximal electrical paired stimuli were delivered to the quadriceps muscle during and immediately after a maximal voluntary contraction (MVC) of the knee extensors (twitch interpolation technique). MVC torque, voluntary activation and resting doublet-evoked torque were measured separately for the two sides, and percent side-to-side asymmetries were calculated for each parameter. MVC torque asymmetry was plotted against voluntary activation asymmetry and doublet-evoked torque asymmetry, and a multiple regression analysis was also conducted. Significant positive correlations were observed between MVC torque asymmetry and both voluntary activation asymmetry (r=0.40; p=0.002) and doublet-evoked torque asymmetry (r=0.53; p<0.001), and their relative contribution to MVC torque asymmetry was comparable (r=0.64; p<0.001). These results establish the validity of the twitch interpolation technique for the assessment of neuromuscular asymmetries. This methodology could provide useful insights into the contribution of some neural and muscular mechanisms that underlie quadriceps strength deficits.

[Arthroscopic treatment of arthrofibrosis after ACL reconstruction. Local and generalized arthrofibrosis]. / Arthroskopische Arthrolyse bei Arthrofibrose nach Ersatzplastik des vorderen Kreuzbandes. Lokale und generalisierte Arthrofibrose.

OBJECTIVE: Restoration of free knee motion taking into account knee extension, knee flexion, and patella mobility. INDICATIONS: Prolonged knee motion restriction after anterior cruciate ligament (ACL) reconstruction, persistent decreased patella mobility, or extension deficit. CONTRAINDICATIONS: Existing significant joint irritation or active reflex dystrophy with persistent distinctive pain syndrome. SURGICAL TECHNIQUE: Arthroscopic arthrolysis possible in most cases. Removal of adhesions in all compartments. Elimination of intraarticular cause of patella infera by removing infrapatellar scar tissue and fibrotic fat pad. In case of severe peripatellar fibrotic tissue, lateral release is useful with partial transection of lateral retinacula. In case of strong capsular contracture, additional medial release indicated to improve patella mobility. Important goal of arthrolysis: full range of knee extension. Arthrolysis for scar tissue removal in the posterior recessus through dorsomedial arthroscopic approach possible. In severe cases posteromedial arthrotomy for posterior capsule release required. Cyclops syndrome makes removal of all tissue adherent to the ACL necessary. An irregular ACL insertion or intercondylar notch stenosis may require notchplasty. Postoperative recurrence of fibrosis may require repeated arthroscopic surgery to improve mobility, such as notchplasty, osteophytes resection, scar removal, and releases. POSTOPERATIVE MANAGEMENT: Immediate postoperative pain-free physical therapy taking into account full range of extension and patella mobility. Passive exercises under traction. Lymphatic drainage. No exercising in pain throughout the entire postoperative physical therapy. Continuous passive motion treatment for 4 weeks postoperatively useful. No muscle strength or equipment training for at least 3 months postoperatively. RESULTS: Based on the observations in our working group, approximately pproximately 78% of patients develop knee osteoarthritis within 5 years.

A randomized controlled trial of electrostimulation effects on effussion, swelling and pain recovery after anterior cruciate ligament reconstruction: a pilot study.

OBJECTIVE: To evaluate rehabilitation results of electrostimulation especially on joint effusion, swelling and pain recovery after anterior cruciate ligament reconstruction. DESIGN: A randomized controlled trial; the assessor was not blinded to the group allocation. SETTING: Orthopaedics-traumatology and physical medicine-rehabilitation departments. SUBJECTS: Twenty-nine consecutive patients underwent anterior cruciate ligament reconstruction. INTERVENTIONS: Both groups began the voluntary exercise protocol one day post-surgery. The intervention group (n = 15) also received 30 sessions electrostimulation treatment protocol started four days after the operation. MAIN MEASURES: Numerical bulge-dancing patella signs for effusion assessment; differences in circumferences of the mid-centre of the patella between operated and non-operated knees for swelling assessment. A self-report of average daily resting pain assessed by visual analogue scale; Intenational Knee Documentation Committee scoring system and Tegner Activity Scale for subjective response assessment. RESULTS: Twenty-six subjects including 13 patients from the intervention group completed the study. Significantly less effusion and swelling were determined in the intervention group after seven days (1.8 ± 1.3 versus 2.4 ± 1.7 for effusion and 1.7 ± 1.2 versus 3.4 ± 1.5 for swelling) to 12 weeks (0.2 ± 0.7 versus 0.6 ± 0.8 for effusion and 0.2 ± 0.8 versus 0.8 ± 0.9 for swelling) postoperative (P < 0.05). Patients treated with electrostimulation had significantly lower pain scores from seven days up to 12 weeks after the operation (P < 0.05). CONCLUSION: Electrostimulation along with exercise therapy appears superior to exercise alone regarding knee effusion, swelling and pain recovery after anterior cruciate ligament reconstruction. Still, there is need for further clinical studies using a radiologic method to demonstrate this effect of electrostimulation.