Single-Stage Multiple-Ligament Knee Reconstructions for Sports-Related Injuries: Outcomes in 194 Patients.

BACKGROUND: Outcomes after sports-related multiple-ligament knee reconstructions are limited. PURPOSE: To evaluate outcomes after single-stage surgical treatment of sports-related multiple-ligament knee injuries and to compare outcomes after anterior cruciate ligament (ACL)-based and posterior cruciate ligament (PCL)-based multiple-ligament knee reconstructions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Skeletally mature patients with at least 2 major knee ligaments torn during a sporting activity that required surgery with a minimum of 2 years' follow-up were included. The Lysholm score, Tegner activity scale, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 12-Item Short Form Health Survey Physical Component Summary were collected preoperatively and at a minimum of 2 years' follow-up. Clinical data, including range of motion and knee stability, were also recorded at final follow-up. RESULTS: A total of 276 patients with multiple-ligament knee injuries incurred during sport participation from 2010 to 2016 were identified. Of the 276 patients, 194 (70.5%) had complete follow-up at a mean 3.5 years (range, 2-8 years). There was a significant improvement in all outcome scores as compared with the preoperative scores (P < .001 for all scores). The median (first and third quartiles) Tegner activity score improved from 1 (0, 2) preoperatively to 6 (4, 7) postoperatively. Significant improvements were from 41 (22, 57) to 90 (78, 95) and 44 (24, 60) to 3 (1, 8) for median Lysholm and WOMAC scores, respectively. There was no significant difference in postoperative outcome scores between patients treated in the acute and chronic phases. Furthermore, there was no significant difference between PCL- and ACL-based multiple-ligament knee injuries. Eighteen (9.3%) patients developed arthrofibrosis requiring reintervention surgery. CONCLUSION: These results demonstrated that single-stage anatomic-based knee ligament reconstructions with immediate postoperative rehabilitation in the setting of sports-related multiligament injuries yielded significantly improved outcomes irrespective of the ligament injury pattern. In addition, there was no difference in outcomes between ACL- and PCL-based injuries in the setting of sports-related multiligament injuries.

The Warrior Athlete Part 2-Return to Duty in the US Military: Advancing ACL Rehabilitation in the Tactical Athlete.

Rehabilitation following an anterior cruciate ligament reconstruction is a crucial component of the healing and recovery process and full return to duty/play in the tactical modern-day warfighter. The burden of anterior cruciate ligament injuries and subsequent loss of readiness in these military warfighters highlights one of the most significant gaps in musculoskeletal injury care today. Emphasis must be placed on early weight-bearing and range of motion (ROM), namely in this athlete population, to best facilitate a timely care and recovery process. Preoperative rehabilitation should commence immediately following the diagnosis of an anterior cruciate ligament tear, because one of the best predictors of postoperative ROM is preoperative ROM. Recent advances in rehabilitation technology such as Alter-G treadmills, inertial measurement units, and blood flow restriction therapy systems, have demonstrated success in the early rehabilitation of tactical athletes. Alter-G treadmills allow for early weight-bearing with reduced impact and progression in ROM following operative management, while inertial measurement units have been applied to tailoring rehabilitation protocols specifically to an athlete's unique functional deficits. When used in conjunction with a fined tune rehabilitation protocol, implemented by a well versed clinical team, these treatment techniques can greatly expedite the return to duty process and limit long-term complications.

The Role of Blood Flow Restriction Therapy Following Knee Surgery: Expert Opinion.

Blood flow restriction (BFR) therapy is becoming increasingly popular in musculoskeletal injury rehabilitation. In particular, this form of therapy is being utilized more often in the postoperative setting following knee surgery, including anterior cruciate ligament reconstruction. BFR therapy provides patients and clinicians an alternative treatment option to standard muscle strengthening and hypertrophy guidelines in the setting of postoperative pain, weakness, and postoperative activity restrictions that contribute to muscle atrophy. The ability to complete exercise in a low load environment and achieve similar physiological adaptations as high-intensity strength training makes this modality appealing. With poor patient-related outcomes associated with continued muscle atrophy, pain, and muscle weakness, some researchers have investigated BFR training postoperatively following arthroscopic knee surgery with promising results. However, owing to the current paucity of research studies, inconsistency among reported protocols, and mixed results, it may be some time before a mass adoption of BFR therapy is made into the world of orthopaedic rehabilitation. Although the current data is inconclusive, we choose to utilize BFR in postoperative knee patients, regardless of weight-bearing status, for whom maintenance of existing muscle mass or improvement of decreased postoperative strength levels is important. Therefore, the purpose of this expert opinion is to review the background of BFR, describe the clinical evidence of BFR following knee surgery, and report the authors' current recommendations for application of BFR postoperatively.

Partial Controlled Early Postoperative Weightbearing Versus Nonweightbearing After Reconstruction of the Fibular (Lateral) Collateral Ligament: A Randomized Controlled Trial and Equivalence Analysis.

BACKGROUND: While early weightbearing protocols have been advocated after anterior cruciate ligament (ACL) reconstruction, early weightbearing after fibular (lateral) collateral ligament reconstruction has not been well defined. PURPOSE: (1) To determine if early partial controlled weightbearing after fibular collateral ligament (FCL) reconstruction resulted in an objective difference in laxity on varus stress radiographs at postoperative 6 months as compared with nonweightbearing, and (2) to determine if there was a difference in pain, edema, range of motion, and subjective patient-reported outcomes between these groups at 3 time points. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients were prospectively enrolled from January 2014 to April 2017. Patients who underwent isolated FCL reconstruction or combined ACL and FCL reconstructions were included in this study. Patients were randomly assigned to either a control group (nonweightbearing for 6 weeks) or a treatment group (partial controlled weightbearing at 40% body weight with crutches for 6 weeks). Patient-related data, including knee pain, edema, and range of motion, were collected for all patients at postoperative day 1, 6 weeks, and 6 months. Subjective outcomes were collected preoperatively and at 6 months postoperatively. The primary objective endpoint was varus stability, evaluated by bilateral varus stress radiographs obtained preoperatively and at 6 months postoperatively. RESULTS: Thirty-nine patients were enrolled in the study, with 6-month follow-up obtained for 36 (92%). There was a significant improvement between the preoperative side-to-side difference (SSD) (2.4 ± 1.0) and postoperative SSD (0.2 ± 1.0) for lateral compartment laxity on varus stress radiographs among all patients ( P < .001). Clinical and statistical equivalence was found between groups in terms of SSD on varus stress radiographs ( P < .001). The SSD in knee edema was significantly lower in the partial early weightbearing group (beta = -0.6 cm, P = .001), but there were no significant group differences in knee pain, flexion, or extension. All patients demonstrated significant improvements in subjective outcome scores between the preoperative and 6-month postoperative conditions ( P < .001 for every score measured). CONCLUSION: Clinical and statistical equivalence was found at postoperative 6 months between the early partial weightbearing and nonweightbearing groups among patients undergoing either an isolated FCL reconstruction or a combined ACL and FCL reconstruction. There were no significant differences observed between the groups regarding knee stability, pain, swelling, range of motion, or subjective outcomes. Given these findings, the authors recommend early partial weightbearing after isolated FCL reconstruction or combined ACL and FCL reconstruction.

POST OPERATIVE REHABILITATION OF GRADE III MEDIAL COLLATERAL LIGAMENT INJURIES: EVIDENCE BASED REHABILITATION AND RETURN TO PLAY.

The medial collateral ligament is the most commonly injured ligament of the knee, with injury generally sustained in the athletic population as a result of valgus contact with or without tibial external rotation. The capacity of the medial collateral ligament to heal has been demonstrated in both laboratory and clinical studies; however, complete ruptures heal less consistently and may result in persistent instability. When operative intervention is deemed necessary, anatomical medial knee reconstruction is recommended. Post-operative rehabilitation focuses on early motion and the return of normal neuromuscular firing patterns with progression based on attainment of specific phase criteria and goals. The purpose of this clinical commentary is to discuss the determinants of phase progression and the importance of objectively assessing readiness for advancement that is consistent with post-operative healing. Additional tests and validated measures to assess readiness for sport are also presented. LEVEL OF EVIDENCE: 5.