Association of depressive disorders and dementia with mortality among older people with hip fracture.

BACKGROUND: Hip fracture (HF) is a significant cause of mortality among older people. Almost half of the patients with HF have dementia, which increases the mortality risk further. Cognitive impairment is associated with depressive disorders (DDs) and both dementia and DDs are independent risk factors for poor outcome after HF. However, most studies that evaluate mortality risk after HF separate these conditions. AIMS: To investigate whether dementia with depressive disorders (DDwD) affects the mortality risk at 12, 24, and 36 months after HF among older people. METHODS: Patients with acute HF (n = 404) were included in this retrospective analysis of two randomized controlled trials performed in orthopedic and geriatric departments. Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive function was assessed using the Mini-Mental State Examination. A consultant geriatrician made final depressive disorder and dementia diagnoses using the Diagnostic and Statistical Manual of Mental Disorders criteria, with support from assessments and medical records. The 12-, 24- and 36-month mortality after HF was analyzed using logistic regression models adjusted for covariates. RESULTS: In analyses adjusted for age, sex, comorbidity, pre-fracture walking ability, and fracture type, patients with DDwD had increased mortality risks at 12 [odds ratio (OR) 4.67, 95% confidence interval (CI) 1.75-12.51], 24 (OR 3.61, 95% CI 1.71-7.60), and 36 (OR 4.53, 95% CI 2.24-9.14) months. Similar results were obtained for patients with dementia, but not depressive disorders, alone. CONCLUSION: DDwD is an important risk factor for increased mortality at 12, 24, and 36 months after HF among older people. Routinely assessments after HF for cognitive- and depressive disorders could identify patients at risk for increased mortality, and enable early interventions. TRIAL REGISTRATION: RCT2: International Standard Randomized Controlled Trial Number Register, trial registration number: ISRCTN15738119.

Side-hops challenge knee control in the frontal and transversal plane more than hops for distance or height among ACL-reconstructed individuals.

We compared knee landing mechanics with presumed relation to risk of anterior cruciate ligament (ACL) injury among three single-leg hop tests and between legs in individuals with unilateral ACL reconstruction. Thirty-four participants (>10 months' post-surgery, 23 females) performed the standardised rebound side hop (SRSH), maximal hop for distance (OLHD) and maximal vertical hop (OLVH). We calculated the following knee outcomes from motion capture and force plate data: finite helical axis inclination angles (approximates knee robustness), frontal and transversal plane angles at initial contact, peak angles of abduction and internal rotation during landing, and peak external moments of flexion, abduction and internal rotation during landing. Repeated-measures MANOVA analysis ('sex' as covariate) confirmed that SRSH induced greater angles and moments, particularly in the frontal plane, compared to OLHD and OLVH. There was between-leg asymmetry for peak knee flexion moment for males during OLHD and OLVH, and for females during SRSH. Our results advocate the SRSH over OLHD and OLVH for assessment of knee landing control to screen for movement patterns potentially related to ACL injury risk. However, clear differences in both knee kinematics and kinetics between OLHD and SRSH motivate the use of both tests to evaluate different aspects of landing control.

Return to Sports: A Risky Business? A Systematic Review with Meta-Analysis of Risk Factors for Graft Rupture Following ACL Reconstruction.

BACKGROUND: The risk of sustaining a graft rupture after anterior cruciate ligament reconstruction (ACLR) is high. Contributing risk factors are, however, still not clearly identified. OBJECTIVE: The aim of this systematic review was to identify and quantify risk factors for graft rupture after ACLR. METHODS: A systematic review with meta-analysis (PROSPERO CRD42020140129) based on PRISMA guidelines was performed. MEDLINE, CINAHL and EMBASE were searched from inception to September 2021. Prospective and retrospective studies addressing risk factors for graft rupture after ACLR in males/females of all ages were considered. Meta-analyses using a random effect model (effect measure: odds ratio [OR] with 95% confidence interval [CI]) were performed. The GRADE tool was used to assess evidence quality. RESULTS: Following full-text screening of 310 relevant papers, 117 were eventually included, incorporating up to 133,000 individuals in each meta-analysis. Higher Tegner activity level (≥ 7 vs < 7) at primary injury (OR 3.91, 95% CI 1.69-9.04), increased tibial slope (degrees) (OR 2.21, 95% CI 1.26-3.86), lower psychological readiness to return to sport (RTS) (OR 2.18, 95% CI 1.32-3.61), early surgery (< 12 vs ≥ 12 months) (OR 1.87, 95% CI 1.58-2.22), RTS (pre-injury level) (OR 1.87, 95% CI 1.21-2.91) and family history of ACL injury (OR 1.76, 95% CI 1.34-2.31) were all associated with increased odds of graft rupture. Higher age (OR 0.47, 95% CI 0.39-0.59), female sex (OR 0.88, 95% CI 0.79-0.98), fewer self-reported knee symptoms pre-reconstruction (OR 0.81, 95% CI 0.69-0.95) and concomitant cartilage injuries (OR 0.70, 95% CI 0.62-0.79) instead decreased the odds. Meta-analysis revealed no association between body mass index, smoking, joint laxity, RTS time, knee kinematics, muscle strength or hop performance and graft rupture. CONCLUSION: Conspicuous risk factors for graft rupture were mainly sports and hereditary related. Few studies investigated function-related modifiable factors or included sports exposure data.

Disrupted knee - disrupted me: a strenuous process of regaining balance in the aftermath of an anterior cruciate ligament injury.

BACKGROUND: Individuals describe both short and long term consequences after an anterior cruciate ligament (ACL) injury. Functional impairments are well documented while psychological, social and contextual factors need to be further investigated. By the use of a qualitative method incorporating a biopsychosocial lens, we aimed to explore individuals' experiences of living and coping with an ACL rupture with a specific focus on experiences significant to overall life, activity in daily living and physical activity more than one year after injury. METHODS: Twelve participants were chosen strategically by a purposive sampling. Four men and eight women (19-41 years) with an ACL rupture 2-25 years ago, were included. Semi-structured interviews were used and analysed with qualitative content analysis. RESULTS: The results consisted of one overarching theme: 'A strenuous process towards regaining balance' which built on three categories 'Disrupted knee', 'Disrupted me' and 'Moving forward with new insights'. The overarching theme captures the participants' experiences of a strenuous process towards regaining both physical and mental balance in the aftermath of an ACL injury. The results illuminate how participants were forced to cope with a physically 'disrupted knee', as well as facing mental challenges, identity challenges and a 'disrupted me'. By gradual acceptance and re-orientation they were moving forward with new insights - although still struggling with the consequences of the injury. CONCLUSIONS: Individuals with an ACL injury experience both physical, psychological, and social challenges several years after injury. In addition to the functional impairments, diverse psychological, social and contextual 'disruptions' and struggles may also be present and influence the rehabilitation process. It is important that physiotherapists identify individuals who face such challenges and individually tailor the rehabilitation and support. A biopsychosocial approach is recommended in the clinical practice and future studies focusing on psychosocial processes in the context of ACL rehabilitation are warranted.

Properties of tests for knee joint threshold to detect passive motion following anterior cruciate ligament injury: a systematic review and meta-analysis.

BACKGROUND: Threshold to detect passive motion (TTDPM) tests of the knee joint are commonly implemented among individuals with anterior cruciate ligament (ACL) injury to assess proprioceptive acuity. Their psychometric properties (PMPs), i.e. reliability, validity and responsiveness, are however unclear. This systematic review aimed to establish the PMPs of existing knee joint TTDPM tests among individuals with ACL injury. METHODS: The databases PubMed, AMED, CINAHL, SPORTDiscus, Web of Science, Scopus, CENTRAL and ProQuest were searched to identify studies that assessed the properties of knee joint TTDPM tests in individuals with ACL injury. The risk of bias for each included study was assessed at the outcome level for each test. Overall quality and levels of evidence for each property were rated according to established criteria. Meta-analyses with mean differences were conducted using random-effects models when adequate data were available. RESULTS: Fifty-one studies covering 108 TTDPM tests and 1632 individuals with unilateral ACL injury were included. A moderate-to-strong level of evidence indicated insufficient quality for all of the following: convergent validity, known-groups validity, discriminative validity, responsiveness between subgroups, and responsiveness to intervention. Subgroup meta-analyses for known-groups validity did however find that a starting angle of 15° resulted in significantly worse TTDPM for knees with ACL injury compared to those of asymptomatic persons (mean difference 0.28°; 95% CI 0.03 to 0.53; P = 0.03), albeit based on only three studies. Due to the lack of evidence, it was not possible to estimate the quality of reliability, measurement error, and criterion validity, nor responsiveness from a criterion and construct approach. CONCLUSIONS: Among persons with ACL injury, existing tests of knee joint TTDPM lack either sufficient quality or evidence for their reliability, validity and responsiveness. Significantly worse thresholds for ACL-injured knees compared to those of asymptomatic controls from a 15° starting angle and trends towards significance for some validity measures nevertheless encourage the development of standardised tests. Further research investigating the influence of modifiable test components (e.g. starting angle and motion direction) on the PMPs of knee joint TTDPM tests following ACL injury is warranted.

[Surgical interventions have been shown to improve the function in patients with foot drop after a stroke]. / Enkel senförflyttning kan ge ökad funktion vid droppfot efter stroke.

Foot drop (FD) can be caused by a variety of diseases and injuries. FD leads to walking difficulties and reduced balance which also can lead to a higher risk of falling. Patient with a stroke often have an equinovarus deformity of the foot together with the DF. There is a need to optimize and standardize the treatment for patients with FD across different medical specialities. Surgical interventions, with goals of producing a balanced functional foot, have been shown to improve the function and quality of life and decrease the use of braces and walking aids in patients with FD after a CVI. In Sweden data regarding FD surgery is collected in the National Quality Registry for Foot and Ankle Surgery (Riksfot), but there is also an ongoing multicentre study, investigating the patient-reported and functional results of surgery due to FD caused by a CVI.

Properties of Knee Joint Position Sense Tests for Anterior Cruciate Ligament Injury: A Systematic Review and Meta-analysis.

BACKGROUND: Knee proprioception is believed to be deficient after anterior cruciate ligament (ACL) injury. Tests of joint position sense (JPS) are commonly used to assess knee proprioception, but their psychometric properties (PMPs) are largely unknown. PURPOSE: To evaluate the PMPs (reliability, validity, and responsiveness) of existing knee JPS tests targeting individuals with ACL injury. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: PubMed, Allied and Complementary Medicine, CINAHL, SPORTDiscus, Web of Science, Scopus, CENTRAL, and ProQuest databases were searched to identify studies that assessed PMPs of knee JPS tests in individuals with ACL injury. The risk of bias for each included study was assessed and rated at the outcome level for each knee JPS test. Overall quality and levels of evidence for each PMP were rated according to established criteria. Meta-analyses with mean differences were conducted using random effects models when adequate data were available. RESULTS: Included were 80 studies covering 119 versions of knee JPS tests. Meta-analyses indicated sufficient quality for known-groups and discriminative validity (ACL-injured knees vs knees of asymptomatic controls and contralateral noninjured knees, respectively), owing to significantly greater absolute errors for ACL-injured knees based on a strong level of evidence. A meta-analysis showed insufficient quality for responsiveness, which was attributed to a lack of significant change over time after diverse interventions with a moderate level of evidence. Statistical heterogeneity (I 2 > 40%) was evident in the majority of meta-analyses. All remaining PMPs (reliability, measurement error, criterion validity, convergent validity, and other PMPs related to responsiveness) were assessed qualitatively, and they failed to achieve a sufficient quality rating. This was a result of either the study outcomes not agreeing with the statistical cutoff values/hypotheses or the level of evidence being rated as conflicting/unknown or based on only a single study. CONCLUSION: Knee JPS tests appear to have sufficient validity in differentiating ACL-injured knees from asymptomatic knees. Further evidence of high methodologic quality is required to ascertain the reliability, responsiveness, and other types of validity assessed here. We recommend investigations that compare the modifiable methodologic components of knee JPS tests on their PMPs to develop standardized evidence-based tests.

Risk Factors for Contra-Lateral Secondary Anterior Cruciate Ligament Injury: A Systematic Review with Meta-Analysis.

BACKGROUND: The risk of sustaining a contra-lateral anterior cruciate ligament (C-ACL) injury after primary unilateral ACL injury is high. C-ACL injury often contributes to a further decline in function and quality of life, including failure to return to sport. There is, however, very limited knowledge about which risk factors that contribute to C-ACL injury. OBJECTIVE: To systematically review instrinsic risk factors for sustaining a C-ACL injury. METHODS: A systematic review with meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Four databases (MEDLINE, CINAHL, EMBASE, Sport Discus) were searched from inception to January 2020. Inclusion criteria were prospective or retrospective studies investigating any intrinsic risk factor for future C-ACL injury. Meta-analysis was performed and expressed as odds ratios (OR) if two or more articles assessed the same risk factor. RESULTS: 44 moderate-to-high quality studies were eventually included in this review, whereof 35 studies were eligible for meta-analysis, including up to 59 000 individuals. We identified seven factors independently increasing the odds of sustaining a C-ACL injury (in order of highest to lowest OR): (1) returning to a high activity level (OR 3.26, 95% CI 2.10-5.06); (2) Body Mass Index < 25 (OR 2.73, 95% CI 1.73-4.36); (3) age ≤ 18 years (OR 2.42, 95% CI 1.51-3.88); (4) family history of ACL injury (OR 2.07, 95% CI 1.54-2.80); (5) primary ACL reconstruction performed ≤ 3 months post injury (OR 1.65, 95% CI: 1.32-2.06); (6) female sex (OR 1.35, 95% CI 1.14-1.61); and (7) concomitant meniscal injury (OR 1.21, 95% CI 1.03-1.42). The following two factors were associated with decreased odds of a subsequent C-ACL injury: 1) decreased intercondylar notch width/width of the distal femur ratio (OR 0.43, 95% CI 0.25-0.69) and 2) concomitant cartilage injury (OR 0.83, 95% CI 0.69-1.00). There were no associations between the odds of sustaining a C-ACL injury and smoking status, pre-injury activity level, playing soccer compared to other sports or timing of return to sport. No studies of neuromuscular function in relation to risk of C-ACL injury were eligible for meta-analysis according to our criteria. CONCLUSION: This review provides evidence that demographic factors such as female sex, young age (≤ 18 years) and family history of ACL injury, as well as early reconstruction and returning to a high activity level increase the risk of C-ACL injury. Given the lack of studies related to neuromuscular factors that may be modifiable by training, future studies are warranted that investigate the possible role of factors such as dynamic knee stability and alignment, muscle activation and/or strength and proprioception as well as sport-specific training prior to return-to-sport for C-ACL injuries. PROSPERO: CRD42020140129.

Kinematic analyses including finite helical axes of drop jump landings demonstrate decreased knee control long after anterior cruciate ligament injury.

The purpose was to evaluate the dynamic knee control during a drop jump test following injury of the anterior cruciate ligament injury (ACL) using finite helical axes. Persons injured 17-28 years ago, treated with either physiotherapy (ACLPT, n = 23) or reconstruction and physiotherapy (ACLR, n = 28) and asymptomatic controls (CTRL, n = 22) performed a drop jump test, while kinematics were registered by motion capture. We analysed the Preparation phase (from maximal knee extension during flight until 50 ms post-touchdown) followed by an Action phase (until maximal knee flexion post-touchdown). Range of knee motion (RoM), and the length of each phase (Duration) were computed. The finite knee helical axis was analysed for momentary intervals of ~15° of knee motion by its intersection (ΔAP position) and inclination (ΔAP Inclination) with the knee's Anterior-Posterior (AP) axis. Static knee laxity (KT100) and self-reported knee function (Lysholm score) were also assessed. The results showed that both phases were shorter for the ACL groups compared to controls (CTRL-ACLR: Duration 35±8 ms, p = 0.000, CTRL-ACLPT: 33±9 ms, p = 0.000) and involved less knee flexion (CTRL-ACLR: RoM 6.6±1.9°, p = 0.002, CTRL-ACLR: 7.5 ±2.0°, p = 0.001). Low RoM and Duration correlated significantly with worse knee function according to Lysholm and higher knee laxity according to KT-1000. Three finite helical axes were analysed. The ΔAP position for the first axis was most anterior in ACLPT compared to ACLR (ΔAP position -1, ACLPT-ACLR: 13±3 mm, p = 0.004), with correlations to KT-1000 (rho 0.316, p = 0.008), while the ΔAP inclination for the third axis was smaller in the ACLPT group compared to controls (ΔAP inclination -3 ACLPT-CTRL: -13±5°, p = 0.004) and showed a significant side difference in ACL injured groups during Action (Injured-Non-injured: 8±2.7°, p = 0.006). Small ΔAP inclination -3 correlated with low Lysholm (rho 0.391, p = 0.002) and high KT-1000 (rho -0.450, p = 0.001). Conclusions Compensatory movement strategies seem to be used to protect the injured knee during landing. A decreased ΔAP inclination in injured knees during Action suggests that the dynamic knee control may remain compromised even long after injury.

One-leg rise performance and associated knee kinematics in ACL-deficient and ACL-reconstructed persons 23 years post-injury.

BACKGROUND: Research indicates reduced knee function and stability decades after anterior cruciate ligament (ACL) injury. Assessment requires reliable functional tests that discriminate such outcomes from asymptomatic knees, while providing suitable loading for different populations. The One-leg rise (OLR) test is common in clinics and research but lacks scientific evidence for its implementation. Our cross-sectional study compared performance including knee kinematics of the OLR between ACL-injured persons in the very long term to controls and between legs within these groups, and assessed the within-session reliability of the kinematics. METHODS: Seventy ACL-injured individuals (mean age 46.9 ± 5.4 years) treated with either reconstructive surgery and physiotherapy (ACLR; n = 33) or physiotherapy alone (ACLPT; n = 37), on average 23 years post-injury, and 33 age- and sex-matched controls (CTRL) attempted the OLR. Participants completed as many repetitions as possible to a maximum of 50 while recorded by motion capture. We compared between all groups and between legs within groups for total repetitions and decomposed the OLR into movement phases to compare phase completion times, maximum and range of knee abduction and adduction angles, and mediolateral knee control in up to 10 repetitions per participant. RESULTS: ACLPT performed significantly fewer OLR repetitions with their injured leg compared to the CTRL non-dominant leg (medians 15 and 32, respectively) and showed significantly greater knee abduction than ACLR and CTRL (average 2.56°-3.69° depending on phase and leg). Distribution of repetitions differed between groups, revealing 59% of ACLPT unable to complete more than 20 repetitions on their injured leg compared to 33% ACLR and 36% CTRL for their injured and non-dominant leg, respectively. Within-session reliability of all kinematic variables for all groups and legs was high (ICC 3,10 0.97-1.00, 95% CI 0.95-1.00, SEM 0.93-1.95°). CONCLUSIONS: Negative outcomes of OLR performance, particularly among ACLPT, confirm the need to address aberrant knee function and stability even decades post-ACL injury. Knee kinematics derived from the OLR were reliable for asymptomatic and ACL-injured knees. Development of the OLR protocol and analysis methods may improve its discriminative ability in identifying reduced knee function and stability among a range of clinical populations.

Psychometric properties of knee proprioception tests targeting healthy individuals and those with anterior cruciate ligament injury managed with or without reconstruction: a systematic review protocol.

INTRODUCTION: An anterior cruciate ligament (ACL) injury affects knee proprioception and sensorimotor control and might contribute to an increased risk of a second ACL injury and secondary knee osteoarthritis. Therefore, there is a growing need for valid, reliable and responsive knee proprioception tests. No previous study has comprehensively reviewed all the relevant psychometric properties (PMPs) of these tests together. The aim of this review protocol is to narrate the steps involved in synthesising the evidence for the PMPs of specific knee proprioception tests among individuals with an ACL injury and knee-healthy controls. METHODS AND ANALYSIS: The Preferred Reporting Items for Systematic reviews and Meta-Analyses will be followed to report the review. A combination of four conceptual groups of terms-(1) construct (knee proprioception), (2) target population (healthy individuals and those with an ACL injury managed conservatively or with a surgical reconstruction), (3) measurement instrument (specific knee proprioception tests) and (4) PMPs (reliability, validity and responsiveness)-will be used for electronic databases search. PubMed, AMED, CINAHL, SPORTDiscus, Web of Science, Scopus, the Cochrane Central Register of Controlled Trials and ProQuest will be searched from their inception to November 2018. Two reviewers will independently screen titles, abstracts and full text articles, extract data and perform risk of bias assessment using the updated COnsensus-based Standards for the selection of health Measurement INstruments risk of bias checklist for the eligible studies. A narrative synthesis of the findings and a meta-analysis will be attempted as appropriate. Each PMP of knee proprioception tests will be classified as 'sufficient', 'indeterminate' or 'insufficient'. The overall level of evidence will be ascertained using an established set of criteria. ETHICS AND DISSEMINATION: Ethical approval or patient consent is not required for a systematic review. The review findings will be submitted as a series of manuscripts for peer-review and publication in scientific journals. PROSPERO REGISTRATION NUMBER: CRD42018108014.

Curve analyses reveal altered knee, hip, and trunk kinematics during drop-jumps long after anterior cruciate ligament rupture.

BACKGROUND: Anterior cruciate ligament (ACL) ruptures may lead to knee dysfunctions later in life. Single-leg tasks are often evaluated, but bilateral movements may also be compromised. Our aim was to use curve analyses to examine double-leg drop-jump kinematics in ACL-reconstructed, ACL-deficient, and healthy-knee cohorts. METHODS: Subjects with unilateral ACL ruptures treated more than two decades ago (17-28years) conservatively with physiotherapy (ACLPT, n=26) or in combination with reconstructive surgery (ACLR, n=28) and healthy-knee controls (n=25) performed 40-cm drop-jumps. Three-dimensional knee, hip, and trunk kinematics were analyzed during Rebound, Flight, and Landing phases. Curves were time-normalized and compared between groups (injured and non-injured legs of ACLPT and ACLR vs. non-dominant and dominant legs of controls) and within groups (between legs) using functional analysis of variance methods. RESULTS: Compared to controls, ACL groups exhibited less knee and hip flexion on both legs during Rebound and greater knee external rotation on their injured leg at the start of Rebound and Landing. ACLR also showed less trunk flexion during Rebound. Between-leg differences were observed in ACLR only, with the injured leg more internally rotated at the hip. Overall, kinematic curves were similar between ACLR and ACLPT. However, compared to controls, deviations spanned a greater proportion of the drop-jump movement at the hip in ACLR and at the knee in ACLPT. CONCLUSIONS: Trunk and bilateral leg kinematics during double-leg drop-jumps are still compromised long after ACL-rupture care, independent of treatment. Curve analyses indicate the presence of distinct compensatory mechanisms in ACLPT and ACLR compared to controls.

Increased movement variability in one-leg hops about 20 years after treatment of anterior cruciate ligament injury.

BACKGROUND: Recent studies highlight the need for understanding movement control of adjacent joints when evaluating knee function following anterior cruciate ligament (ACL) injury. However, while short-term adaptations to lower-extremity joint coupling have been studied, little is known about any potential long-term adaptations in neuromuscular control displayed by ACL-injured individuals. The aim of our study was to determine whether coordination variability of the hip-knee joint couplings during the one-leg hop is altered about 20 years after injury in two ACL-injured groups compared to healthy knee controls. METHODS: Seventy persons performed one leg hops ~23 years after ACL injury and following different treatments: 33 participants treated with physiotherapy in combination with ACL-reconstruction (ACLR); 37 participants with physiotherapy alone (ACLPT). They were compared to 33 matched controls. A vector coding procedure was used to create joint couplings for knee and hip angles on all the cardinal planes for the Take-off and Landing phases. The standard deviation of each coupling was computed as a measure of coordination variability. FINDINGS: Both the ACL groups differed significantly from controls on their injured side with ~50% higher knee abduction-adduction/hip internal-external rotation variability during the Take-off phase; ~33% higher knee abduction-adduction/knee flexion-extension variability and greater knee abduction-adduction/hip flexion-extension variability (ACLR 50%; ACLPT 80%) during the Landing phase. There were no major differences between injured and non-injured sides in any group. INTERPRETATION: Increased variability in lower-extremity joint couplings has emerged as a conspicuous feature of ACL injured persons in the very long term compared to non-injured controls, independent of treatment. Further research of the processes leading to alterations in movement variability using longitudinal studies would facilitate better understanding of the functional adaptations leading to knee dysfunction in the short- and long-term after ACL injury.

ACL-reconstructed and ACL-deficient individuals show differentiated trunk, hip, and knee kinematics during vertical hops more than 20 years post-injury.

PURPOSE: Little is known regarding movement strategies in the long term following injury of the anterior cruciate ligament (ACL), and even less about comparisons of reconstructed and deficient knees in relation to healthy controls. The present purpose was to compare trunk, hip, and knee kinematics during a one-leg vertical hop (VH) ~20 years post-ACL injury between persons treated with surgery and physiotherapy (ACLR), solely physiotherapy (ACLPT), and controls (CTRL). Between-leg kinematic differences within groups were also investigated. METHODS: Sixty-six persons who suffered unilateral ACL injury on average 23 ± 2 years ago (32 ACLR, 34 ACLPT) and 33 controls performed the VH. Peak trunk, hip, and knee angles during Take-off and Landing phases recorded with a 3D motion capture system were analysed with multivariate statistics. RESULTS: Significant group effects during both Take-off and Landing were found, with ACLPT differing from CTRL in Take-off with a combination of less knee flexion and knee internal rotation, and from both ACLR and CTRL in Landing with less hip and knee flexion, knee internal rotation, and greater hip adduction. ACLR also presented different kinematics to ACLPT and CTRL in Take-off with a combination of greater trunk flexion, hip flexion, hip internal rotation, and less knee abduction, and in Landing with greater trunk flexion and hip internal rotation. Further, different kinematics and hop height were found between legs within groups in both Take-off and Landing for both ACL groups, but not for CTRL. CONCLUSION: Different kinematics for the injured leg for both ACL groups compared to CTRL and between treatment groups, as well as between legs within treatment groups, indicate long-term consequences of injury. Compensatory mechanisms for knee protection seem to prevail over time irrespective of initial treatment, possibly increasing the risk of re-injury and triggering the development of osteoarthritis. Detailed investigation of movement strategies during the VH provides important information and a more comprehensive evaluation of knee function than merely hop height. More attention should also be given to the trunk and hip in clinics when evaluating movement strategies after ACL injury. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

A statistically compiled test battery for feasible evaluation of knee function after rupture of the Anterior Cruciate Ligament - derived from long-term follow-up data.

PURPOSE: Clinical test batteries for evaluation of knee function after injury to the Anterior Cruciate Ligament (ACL) should be valid and feasible, while reliably capturing the outcome of rehabilitation. There is currently a lack of consensus as to which of the many available assessment tools for knee function that should be included. The present aim was to use a statistical approach to investigate the contribution of frequently used tests to avoid redundancy, and filter them down to a proposed comprehensive and yet feasible test battery for long-term evaluation after ACL injury. METHODS: In total 48 outcome variables related to knee function, all potentially relevant for a long-term follow-up, were included from a cross-sectional study where 70 ACL-injured (17-28 years post injury) individuals were compared to 33 controls. Cluster analysis and logistic regression were used to group variables and identify an optimal test battery, from which a summarized estimator of knee function representing various functional aspects was derived. RESULTS: As expected, several variables were strongly correlated, and the variables also fell into logical clusters with higher within-correlation (max ρ = 0.61) than between clusters (max ρ = 0.19). An extracted test battery with just four variables assessing one-leg balance, isokinetic knee extension strength and hop performance (one-leg hop, side hop) were mathematically combined to an estimator of knee function, which acceptably classified ACL-injured individuals and controls. This estimator, derived from objective measures, correlated significantly with self-reported function, e.g. Lysholm score (ρ = 0.66; p<0.001). CONCLUSIONS: The proposed test battery, based on a solid statistical approach, includes assessments which are all clinically feasible, while also covering complementary aspects of knee function. Similar test batteries could be determined for earlier phases of ACL rehabilitation or to enable longitudinal monitoring. Such developments, established on a well-grounded consensus of measurements, would facilitate comparisons of studies and enable evidence-based rehabilitation.

Analysis of three-dimensional knee kinematics during stair descent two decades post-ACL rupture - Data revisited using statistical parametric mapping.

Changes in movement patterns following knee injuries have generally used analyses of pre-defined discrete event-related variables, whereas Statistical Parametric Mapping (SPM) assesses continuous data over time. We applied SPM to test differences for knee trajectories during stair descent between participants with past anterior cruciate ligament (ACL) rupture who underwent reconstruction or only physical therapy compared to healthy controls. Three-dimensional knee joint kinematics during stair descent were registered for 31 subjects with ACL reconstruction (ACLR), 36 subjects with ACL rupture managed with physical therapy only (ACLPT) (∼23years post-injury), and 32 uninjured controls. SPM was used to assess differences between groups for the entire three-component knee trajectory. A significant difference between the three groups was found for the first ∼10% of stance phase. Post-hoc analyses showed between-group differences when comparing the ACLPT to the control groups. Analyses of ACLPT versus control groups for individual vector components suggested a combination of less flexion at initial foot contact, and less adduction during weight acceptance (∼40% of stance). Altered knee kinematics were confirmed during weight acceptance of stair descent for the ACLPT group compared to controls, but not for ACLR group. Further exploration of the use of SPM and agreement with clinical gait assessment is warranted.

Altered postural control strategies in quiet standing more than 20 years after rupture of the anterior cruciate ligament.

AIM: To explore long-term consequences of anterior cruciate ligament (ACL) rupture on postural sway and control strategies during bilateral quiet standing, in subjects treated with or without reconstructive surgery compared to uninjured controls. METHOD: 70 individuals who had unilateral ACL rupture 23±2.4 years ago (33 received ACL reconstructive surgery, ACLR, and 37 had physiotherapy only, ACLPT) and 33 uninjured matched controls (CTRL) (mean age 46±5.3) stood quietly with eyes closed for 3min on a firm and on a compliant surface, respectively. Center of pressure (CoP) was registered with a force plate and postural sway was calculated from center of mass (CoM) derived from 3D kinematics. Sway density (SD) analyses of CoP assessed distance and duration of stable phases. The torque controlling postural sway was estimated from CoP-CoM. RESULTS: Comparisons across conditions to CTRL revealed larger CoP-CoM-area in ACLR (p=0.017, CI: 10.95, 143.10), but not in ACLPT. Mean distance between SD-peaks was greater for ACLR (p<0.001, CI: 1.73, 5.31) than for ACLPT (p=0.006, CI: 0.56, 4.12) relative to CTRL. Duration of SD-peaks was smaller for both ACLR and ACLPT (p<0.001, CI: -4.04, -1.23 and -3.82, -1.03, respectively) compared to CTRL. CoM-area in the ACL-groups did not differ from CTRL. CONCLUSIONS: ACL-injured subjects demonstrated greater postural control efforts than CTRL but without significant differences in postural sway. Control efforts were thus not directly associated with sway and further research should be focused on variance in postural control strategies.

Knee kinematics during stair descent 20 years following anterior cruciate ligament rupture with and without reconstruction.

BACKGROUND: Changes and asymmetries for walking gait have been explored extensively following injuries of anterior cruciate ligaments within ten years of injury or reconstruction. We examined longer term knee joint kinematics of reconstructed and non-reconstructed knees during stair descent compared to controls. METHODS: Three-dimensional knee kinematics during stair descent were registered for 33 subjects with ACL reconstruction, 36 subjects with ACL rupture managed with physiotherapy only and 31 uninjured controls. Injured subjects were 23.5 (2.1) years following injury. Linear mixed models were used to compare temporal variables and knee kinematics during stance phase between groups and contralateral sides. FINDINGS: Walking speed was slower for the both ACL-injured groups compared to controls and stance duration was longer for the injured than the uninjured sides of the physiotherapy-only group. Compared to controls, the physiotherapy-only group had significantly less adduction at initial foot contact of the injured and uninjured knees. The uninjured side of the physiotherapy-only group also had less flexion than controls at initial foot contact and during weight acceptance. Compared to the surgically-managed group, the injured sides of the physiotherapy-only groups had significantly less adduction at initial contact, peak adduction during weight acceptance, and peak flexion during propulsion. INTERPRETATION: Independent of treatment, altered knee kinematics exist more than 20 years following ACL injury during stair descent. We suggest that future studies investigating short and long-term kinematic outcomes of ACL injury could evaluate stair descent with particular emphasis on weight acceptance of stance, and potential associations to perceived knee function.

Dynamic knee stability estimated by finite helical axis methods during functional performance approximately twenty years after anterior cruciate ligament injury.

Finite helical axis (FHA) measures of the knee joint during weight-bearing tasks may capture dynamic knee stability following Anterior Cruciate Ligament (ACL) injury. The aim was to investigate dynamic knee stability during two-leg squat (TLS) and one-leg side hop (SH) in a long-term follow-up of ACL injury, and to examine correlations with knee laxity (KT-1000), osteoarthritis (OA, Kellgren-Lawrence) and knee function (Lysholm score). Participants were injured 17-28 years ago and then treated with surgery (n=33, ACLR) or physiotherapy only (n=37, ACLPT) and healthy-knee controls (n=33) were tested. Movements were registered with an optical motion capture system. We computed three FHA inclination angles, its' Anterior-Posterior (A-P) position, and an index quantifying directional changes (DI), during stepwise knee flexion intervals of ∼15°. Injured knees were less stable compared to healthy controls' and to contralateral non-injured knees, regardless of treatment: the A-P intersection was more anterior (indicating a more anterior positioning of tibia relative to femur) positively correlating with high laxity/low knee function, and during SH, the FHA was more inclined relative to the flexion-extension axis, possibly due to reduced rotational stability. During the TLS, A-P intersection was more anterior in the non-injured knee than the injured, and DI was higher, probably related to higher load on the non-injured knee. ACLR had less anterior A-P intersection than ACLPT, suggesting that surgery enhanced stability, although rotational stability may remain reduced. More anterior A-P intersection and greater inclination between the FHA and the knee flexion-extension axis best revealed reduced dynamic stability ∼23 years post-injury.