Functional Outcomes of Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscal Tears Using a Patient-Specific Score: A Randomized Controlled Trial.

BACKGROUND: It is unknown whether the treatment effects of partial meniscectomy and physical therapy differ when focusing on activities most valued by patients with degenerative meniscal tears. PURPOSE: To compare partial meniscectomy with physical therapy in patients with a degenerative meniscal tear, focusing on patients' most important functional limitations as the outcome. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This study is part of the Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45 years with non-obstructive meniscal tears (ESCAPE) trial, a multicenter noninferiority randomized controlled trial conducted in 9 orthopaedic hospital departments in the Netherlands. The ESCAPE trial included 321 patients aged between 45 and 70 years with a symptomatic, magnetic resonance imaging-confirmed meniscal tear. Exclusion criteria were severe osteoarthritis, body mass index >35 kg/m2, locking of the knee, and prior knee surgery or knee instability due to an anterior or posterior cruciate ligament rupture. This study compared partial meniscectomy with physical therapy consisting of a supervised incremental exercise protocol of 16 sessions over 8 weeks. The main outcome measure was the Dutch-language equivalent of the Patient-Specific Functional Scale (PSFS), a secondary outcome measure of the ESCAPE trial. We used crude and adjusted linear mixed-model analyses to reveal the between-group differences over 24 months. We calculated the minimal important change for the PSFS using an anchor-based method. RESULTS: After 24 months, 286 patients completed the follow-up. The partial meniscectomy group (n = 139) improved on the PSFS by a mean of 4.8 ± 2.6 points (from 6.8 ± 1.9 to 2.0 ± 2.2), and the physical therapy group (n = 147) improved by a mean of 4.0 ± 3.1 points (from 6.7 ± 2.0 to 2.7 ± 2.5). The crude overall between-group difference showed a -0.6-point difference (95% CI, -1.0 to -0.2; P = .004) in favor of the partial meniscectomy group. This improvement was statistically significant but not clinically meaningful, as the calculated minimal important change was 2.5 points on an 11-point scale. CONCLUSION: Both interventions were associated with a clinically meaningful improvement regarding patients' most important functional limitations. Although partial meniscectomy was associated with a statistically larger improvement at some follow-up time points, the difference compared with physical therapy was small and clinically not meaningful at any follow-up time point. REGISTRATION: NCT01850719 (ClinicalTrials.gov identifier) and NTR3908 (the Netherlands Trial Register).

Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45†years with non-obstructive meniscal tears (ESCAPE study): protocol of a randomised controlled trial.

INTRODUCTION: Recent studies show similar outcome between surgery and conservative treatment in patients with non-obstructive meniscal tears. However, surgery is still often preferred over conservative treatment. When conservative treatment is non-inferior to surgery, shifting the current standard treatment choice to conservative treatment alone could save over €30 millions of direct medical costs on an annual basis. Economic evaluation studies comparing surgery to conservative treatment are lacking. METHODS AND ANALYSIS: A multicentre randomised controlled trial (RCT) with an economic evaluation alongside was performed to assess the (cost)-effectiveness of surgery and conservative treatment for meniscal tears. We will include 402 participants between 45 and 70 years with an MRI-confirmed symptomatic, non-obstructive meniscal tears to prove non-inferiority of conservative treatment. Block randomisation will be web-based. The primary outcome measure is a physical function, measured by the International Knee Documentation Committee 'Subjective Knee Form'. Furthermore, we will perform a cost-effectiveness and cost-utility analysis from societal perspective and a budget impact analysis from a societal, government and insurer perspective. Secondary outcomes include general health, quality of life, activity level, knee pain, physical examination, progression of osteoarthritis and the occurrence of adverse events. ETHICS AND DISSEMINATION: This RCT will be performed in accordance with the Declaration of Helsinki and has been approved by the Ethics Committee (number NL44188.100.13). The results of this study will be reported in peer-reviewed journals and at international conferences. We further aim to disseminate our results to guideline committees. TRIAL REGISTRATION NUMBER: NCT01850719.

Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus.

AIM: The Royal Dutch Society for Physical Therapy (KNGF) instructed a multidisciplinary group of Dutch anterior cruciate ligament (ACL) experts to develop an evidence statement for rehabilitation after ACL reconstruction. DESIGN: Clinical practice guideline underpinned by systematic review and expert consensus. DATA SOURCES: A multidisciplinary working group and steering group systematically reviewed the literature and wrote the guideline. MEDLINE and the Cochrane Library were searched for meta-analyses, systematic reviews, randomised controlled trials and prospective cohort studies published between January 1990 and June 2015. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Included literature must have addressed 1 of 9 predetermined clinical topics: (1) preoperative predictors for postoperative outcome, (2) effectiveness of physical therapy, (3) open and closed kinetic chain quadriceps exercises, (4) strength and neuromuscular training, (5) electrostimulation and electromyographic feedback, (6) cryotherapy, (7) measurements of functional performance, (8) return to play and (9) risk for reinjury. SUMMARY: Ninety studies were included as the basis for the evidence statement. Rehabilitation after ACL injury should include a prehabilitation phase and 3 criterion-based postoperative phases: (1) impairment-based, (2) sport-specific training and (3) return to play. A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one rehabilitation stage to the next. Postoperative rehabilitation should continue for 9-12 months. To assess readiness to return to play and the risk for reinjury, a test battery, including strength tests, hop tests and measurement of movement quality, should be used.

Variability in leg muscle power and hop performance after anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this prospective study was to describe the variability in leg muscle power and hop performance up to 2 years among patients following ACL reconstruction and specifically to illustrate the effects of various criteria for an acceptable level of muscle function. METHODS: Eighty-two patients (56 men and 26 women)with a mean age of 28 years, who underwent ACL reconstruction using either hamstring tendons (n = 46) or a patellar tendon (n = 36), were assessed pre-operatively and 3, 6, 12 and 24 months post-surgery with a battery of three lower extremity muscle power tests and a battery of three hop tests. RESULTS: Leg symmetry index (LSI) values at group level ranged between 73 and 100% at all follow-ups. When the tests were evaluated individually, patients reached an average LSI of ≥ 90% at 24 months. The success rate at 24 months for the muscle power test battery, that is,patients with an LSI of ≥ 90% in all three tests, was 48 and 44% for the hop test battery. The success rate at 24 months for both test batteries on all six muscle function tests was 22%. The criterion of an LSI of ≥ 80% resulted in 53% of the patients having an acceptable level on all six tests,while with a criterion of an LSI of ≥ 100%, none of the patients reached an acceptable level. CONCLUSION: At group level and in single muscle function tests, the muscle function outcome 1 and 2 years after ACL reconstruction is satisfactory in the present study and on a par with the results presented in the literature. However,when using more demanding criteria for a successful muscle function outcome, using batteries of tests or increasing the acceptable LSI level from ≥ 90% to ≥ 95%or ≥ 100%, the results are considered to be poor. It is suggested that this should be taken into consideration when presenting results after ACL rehabilitation, deciding on the criteria for a safe return to sports, or designing rehabilitation programmes after ACL reconstruction. LEVEL OF EVIDENCE: Prognostic prospective cohort study, Level I.

Reliability of maximal isometric knee strength testing with modified hand-held dynamometry in patients awaiting total knee arthroplasty: useful in research and individual patient settings? A reliability study.

BACKGROUND: Patients undergoing total knee arthroplasty (TKA) often experience strength deficits both pre- and post-operatively. As these deficits may have a direct impact on functional recovery, strength assessment should be performed in this patient population. For these assessments, reliable measurements should be used. This study aimed to determine the inter- and intrarater reliability of hand-held dynamometry (HHD) in measuring isometric knee strength in patients awaiting TKA. METHODS: To determine interrater reliability, 32 patients (81.3% female) were assessed by two examiners. Patients were assessed consecutively by both examiners on the same individual test dates. To determine intrarater reliability, a subgroup (n = 13) was again assessed by the examiners within four weeks of the initial testing procedure. Maximal isometric knee flexor and extensor strength were tested using a modified Citec hand-held dynamometer. Both the affected and unaffected knee were tested. Reliability was assessed using the Intraclass Correlation Coefficient (ICC). In addition, the Standard Error of Measurement (SEM) and the Smallest Detectable Difference (SDD) were used to determine reliability. RESULTS: In both the affected and unaffected knee, the inter- and intrarater reliability were good for knee flexors (ICC range 0.76-0.94) and excellent for knee extensors (ICC range 0.92-0.97). However, measurement error was high, displaying SDD ranges between 21.7% and 36.2% for interrater reliability and between 19.0% and 57.5% for intrarater reliability. Overall, measurement error was higher for the knee flexors than for the knee extensors. CONCLUSIONS: Modified HHD appears to be a reliable strength measure, producing good to excellent ICC values for both inter- and intrarater reliability in a group of TKA patients. High SEM and SDD values, however, indicate high measurement error for individual measures. This study demonstrates that a modified HHD is appropriate to evaluate knee strength changes in TKA patient groups. However, it also demonstrates that modified HHD is not suitable to measure individual strength changes. The use of modified HHD is, therefore, not advised for use in a clinical setting.

Muscle strength and functional performance in patients with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: a two to five-year followup.

OBJECTIVE: To study muscle strength and functional performance in patients with anterior cruciate ligament (ACL) injury with or without surgical reconstruction 2 to 5 years after injury. Good muscle function is important in preventing early-onset osteoarthritis (OA), but the role of reconstructive surgery in restoring muscle function is unclear. METHODS: Of 121 patients with ACL injury included in a randomized controlled trial on training and surgical reconstruction versus training only (the Knee, Anterior cruciate ligament, NON-surgical versus surgical treatment [KANON] study, ISRCTN: 84752559), 54 (mean age at followup 30 years, range 20-39, 28% women) were assessed a mean +/- SD of 3 +/- 0.9 years after injury with reliable, valid, and responsive test batteries for strength (knee extension, knee flexion, leg press) and hop performance (vertical jump, one-leg hop, side hop). The Limb Symmetry Index (LSI; injured leg divided by uninjured and multiplied by 100) value and absolute values were used for comparisons between groups (analysis of variance). An LSI >or=90% was considered normal. RESULTS: There were no differences between the surgical and nonsurgical treatment groups in muscle strength or functional performance. Between 44% and 89% of subjects had normal muscle function in the single tests, and between 44% and 56% had normal function in the test batteries. CONCLUSION: The lack of differences between patients treated with training and surgical reconstruction or training only indicates that reconstructive surgery is not a prerequisite for restoring muscle function. Abnormal muscle function, found in approximately one-third or more of the patients, may be a predictor of future knee OA.

A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction.

The purpose of this study was to develop a test battery of hop tests with high ability to discriminate (i.e. high test-retest reliability, sensitivity, specificity and accuracy) between the hop performance of the injured and the uninjured side in patients with an ACL injury and in patients who have undergone ACL reconstruction. Five hop tests were analysed: three maximum single hop tests and two hop tests while developing fatigue. Fifteen healthy subjects performed the five hop tests on three separate occasions in a test-retest design. Thirty patients, mean 11 months after an ACL injury and 35 patients, mean 6 months after ACL reconstruction were tested. ICC values ranged from 0.85 to 0.97 for the five hop tests, indicating that all the tests had high test-retest reliability. Sixty-seven percent to 100% of the healthy subjects had normal symmetry (i.e. <10% side-to-side difference) in the five hop tests. Abnormal symmetry in the five hop tests ranged from 43 to 77% for patients with an ACL injury and from 51 to 86% for patients who had undergone ACL reconstruction respectively. The three tests with the highest ability to discriminate hop performance were chosen for the test battery; they were the vertical jump, the hop for distance and the side hop. The test battery revealed a high level of sensitivity and accuracy in patients with an ACL injury (87 and 84%) and in patients who had undergone ACL reconstruction (91 and 88%), when at least one of the three tests was classified as abnormal. To summarise, the test battery consisting of both maximum single hop performances: the vertical jump and the hop for distance and hop performance while developing fatigue: the side hop, produced high test-retest reliability, sensitivity and accuracy. Further, the test battery produced higher values compared with any of the three hop tests individually revealing that only one out of ten patients had restored hop performance 11 months after an ACL injury and 6 months after ACL reconstruction. It is concluded that this test battery showed a high ability to discriminate between the hop performance of the injured and the uninjured side both in patients with an ACL injury and in patients who have undergone ACL reconstruction.

Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction.

A more sports-specific and detailed strength assessment has been advocated for patients after anterior cruciate ligament (ACL) injury and reconstruction. The purpose of this study was to develop a test battery of lower extremity strength tests with high ability to discriminate between leg power development on the injured and uninjured sides in patients after ACL injury and in patients who have undergone ACL reconstruction. Twenty-three patients were tested 6 months after ACL injury and 44 patients were tested 6 months after ACL reconstruction. Twenty-four of the 44 patients were operated on using a hamstrings graft and 20 patients were operated on using a patellar tendon graft. All the patients performed a test battery of three strength tests for each leg in a randomised order. The three strength tests were chosen to reflect quadriceps and hamstring muscular power in a knee-extension and a knee-flexion test (open kinetic chain) and lower-extremity muscular power in a leg-press test (closed kinetic chain). There was a higher sensitivity for the test battery to discriminate abnormal leg power compared with any of the three strength tests individually. Nine out of ten patients after ACL reconstruction and six out of ten of the patients after ACL injury exhibited abnormal leg power symmetry using the test battery. Thus, this test battery had high ability in terms of discriminating between the leg power performance on the injured and uninjured side, both in patients with an ACL injury and in patients who have undergone ACL reconstruction. It is concluded that a test battery consisting of a knee-extension, knee-flexion and leg-press muscle power test had high ability to determine deficits in leg power 6 months after ACL injury and reconstruction. Only a minority of the patients had restored leg muscle power. The clinical relevance is that the test battery may contribute to the decision-making process when deciding whether and when patients can safely return to strenuous physical activities after an ACL injury or reconstruction.