Reliability in Novel Field-Based Fitness Measurements and Postexercise Scores from a Physical Fitness Test Battery in Older Adults.

INTRODUCTION: Physical fitness is strongly associated with daily physical function, health, and longevity in older adults. Field-based tests may provide a reasonable alternative compared to advanced laboratory testing. Separating postexercise test scores from reactivity measurements requires sufficient test-retest reliability. Postexercise test scores with reliability analyses of field-based fitness tests in older adults are lacking. The present study aimed to examine the test-retest reliability of some novel easily accommodated fitness test measurements and compare pretest scores with postexercise results in these tests along with other field-based fitness tests in older adults. METHODS: Totally 1,407 community-dwelling older adults (69% female), x̄ = 71.5 ± 5.0 (65-84 years), performed twelve field-based fitness tests at pretest 1, pretest 2 and a posttest after an 8-week exercise period (twice weekly 1 h of combined strength and aerobic training). T tests, intra-class correlation, limits of agreement, standard error of measurement, and coefficient of variance were performed between pre-1 and pre-2 tests, and repeated measures ANOVA and partial eta squared effect size for postexercise differences for men and women in 5-year age groups ranging from 65 to 84 years. RESULTS: Between pre-1 and pre-2 tests a significant difference was noted in some of the novel fitness test measurements but generally not, e.g., in isometric trunk flexion and step-up height on either leg among all sex and age groups. In most of these novel fitness test measurements, no significant differences occurred between the two pretests. Examples of results from the pre-2 test to the posttest were isometric trunk flexion 45° endurance and isometric trunk extension endurance improved significantly for both sexes in age groups 65-74 years. Women, but not men, improved the maximal step-up height for both legs in most age groups. The speed in the 50 sit-to-stand improved significantly for most age groups in both sexes. Six-min walk distance improved significantly for most age groups in women but among men only in 65-69 years. In the timed-up-and-go test, significant improvements were seen for all age groups in women and in men 70-79 years. No postexercise improvements were generally observed for grip strength or balance. CONCLUSIONS: In most of the novel fitness test measures, no significant difference was noted between the two pretests in the assessed sex and age groups. Results after the 8-week exercise period varied between sex and age groups, with significant improvements in several of the twelve studied fitness tests. These findings may be valuable for future projects utilizing easily accommodated physical fitness tests in older adults.

Diameter of quadrupled semitendinosus autograft in primary anterior cruciate ligament reconstruction did not impact early revision rate or functional outcome in a large cohort of patients.

PURPOSE: To determine whether the diameter of the quadrupled semitendinosus tendon (ST) graft in primary anterior cruciate ligament reconstruction (ACLR) is related to the risk of revision ACLR within 2 years of primary ACLR, postoperative knee laxity and patient reported knee outcome. Furthermore, to investigate whether smaller graft than estimated is related to revision ACLR. METHODS: Patients who underwent primary ACLR with a quadrupled ST autograft at our institution, from January 2005 to December 2017 were identified. Data from the Swedish National Knee Ligament Registry (SNKLR) were collected up to two years or until revision surgery was registered within two years after primary ACLR. Knee laxity was assessed, pre-operatively and at 6-months follow up using the KT-1000 arthrometer (134 N anterior tibial load). The Knee injury and Osteoarthritis Outcome Score (KOOS) were collected preoperatively and at two years postoperatively from SNKLR. Based on anthropometric measurements (body height and weight) and sex the estimated quadrupled ST graft diameter was calculated. RESULTS: A total of 4,519 patients who underwent ACLR with a quadrupled ST autograft were included. The mean graft diameter was 8.3 mm± 0.7 mm; 8.0 mm± 0.6 mm for women and 8.6 mm ± 0.7 mm for men. The quadrupled ST graft diameter was not significantly correlated to revision ACLR. There was no significant difference in the ST graft diameter regarding post-operative knee laxity. The correlations between ST graft diameter and KOOS were weak, except for the "Sport and Recreation" subscale (P=.012). CONCLUSIONS: The quadrupled ST graft diameter was not significantly related to the need for early revision ACLR nor was related to postoperative knee laxity or patient reported outcome except for the KOOS "Sport and Recreation" subscale. Smaller ST graft than estimated was not a risk factor for revision ACLR. The outcome after ACLR is multifactorial and ST graft diameter is of no significant importance.

Patient's Height and Sex Predict Graft Diameter. A Cohort Study of 4,519 Patients With Primary Anterior Cruciate Ligament Reconstruction Using Semitendinosus Autograft.

PURPOSE: To determine whether anthropometric measurements (height and weight), sex, age, and preinjury Tegner Activity Scale (TAS) were predictors of the quadrupled semitendinosus (ST) graft diameter in primary anterior cruciate ligament reconstruction. METHODS: A total of 4,519 patients who underwent primary anterior cruciate ligament reconstruction with a quadrupled ST autograft were included. Anthropometric measurements (height and weight), sex, age, and preinjury TAS were collected. Correlation coefficients and multiple linear regression analysis were used to determine the relationships among graft diameter and anthropometrics measurements (height and weight), sex, age, and preinjury TAS. RESULTS: The diameter of the quadrupled ST graft was correlated positively to height (r = 0.021, P < .001), age (r = 0.005, P < .001), and weight (r = 0.004, P = .001) and negatively to female sex (r = -0.297, P < .001). A regression equation was estimated to predict the ST graft diameter for men as 4.245 + 0.021 × height (cm) + 0.004 × age (years) + 0.005 × weight (kg) and for women as 3.969 + 0.021 × height (cm) + 0.004 × age (years) + 0.005 × weight (kg). CONCLUSIONS: Height, age, and weight were positively correlated, whereas female sex was negatively correlated, to the diameter of the quadrupled ST graft. Knowledge of these factors can be used for the preoperative estimation of the graft diameter which can be helpful for appropriate graft choice. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Addition of the Gracilis Tendon to a Semitendinosus Tendon Autograft Is Not Associated With Knee Muscle Strength, Subjective Knee Function, or Revision Surgery After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To evaluate and compare isokinetic knee muscle (extension and flexion) strength, single-leg hop (SLH) test performance, anterior knee laxity, subjective knee function, and the 2-year revision surgery risk between patients who underwent anterior cruciate ligament reconstruction (ACLR) with semitendinosus tendon (ST) autografts and patients who underwent ACLR with ST and gracilis tendon (ST-G) autografts. METHODS: We identified patients aged 16 years or older who underwent primary ACLR with hamstring tendon autografts at our institution from January 2005 to December 2020 and had no associated ligament injuries. Isokinetic knee muscle strength and SLH test performance were assessed 6 months postoperatively. Anterior knee laxity (KT-1000 arthrometer, 134 N) was assessed preoperatively and 6 months postoperatively. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and 1 and 2 years postoperatively. Patients who underwent revision ACLR at any institution in Sweden within 2 years of primary surgery were identified through the Swedish National Knee Ligament Registry. RESULTS: A total of 6,974 patients (5,479 with ST and 1,495 with ST-G) were included. There were no significant differences in extension and flexion strength or SLH test performance between the groups. Preoperatively, there was no significant difference in knee laxity between the ST and ST-G groups. Postoperatively, the ST-G group had significantly increased mean side-to-side (STS) laxity (2.1 ± 2.3 mm vs 1.7 ± 2.2 mm, P < .001) and showed a trend toward increased STS laxity according to the International Knee Documentation Committee form, with significantly fewer patients with STS laxity of 2 mm or less (58.4% vs 65.8%) and significantly more patients with STS laxity between 3 and 5 mm (35.0% vs 29.9%) or greater than 5 mm (6.6% vs 4.3%) (P < .001). The only significant difference in subjective knee function was for the KOOS Quality of Life subscale score in favor of the ST group preoperatively (37.3 ± 21.4 vs 35.1 ± 19.9, P = .001). No other significant differences between the groups were found preoperatively and 1 and 2 years postoperatively for any of the KOOS subscales. The overall revision ACLR rate within 2 years of primary surgery was 2.0% (138 of 6,974 patients). The revision ACLR risk in the ST-G group (1.7%, 25 of 1,495 patients) was not significantly different from that in the ST group (2.1%, 113 of 5,479 patients) (hazard ratio, 0.80; 95% confidence interval, 0.50-1.24; P = .32). CONCLUSIONS: The addition of the gracilis tendon to an ST autograft was not associated with knee muscle strength, SLH test performance, subjective knee function, or the risk of revision surgery after ACLR. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Resource utilization in mental illness - evaluation of an instrument for measuring direct costs of treatment for patients with severe mental illness (SMI).

PURPOSE: Serious mental illnesses (SMIs) exert a considerable financial burden on health-care systems. In this study, the resource utilization in mental illness (RUMI) tool was developed and employed to evaluate resource utilization in patients with SMI. MATERIALS AND METHODS: Data from 107 patients with SMI treated in four psychiatric outpatient clinics in Sweden were collected. The relationships between costs for physical and psychiatric care, social services, and the justice system, to self-reported health and quality of life, educational level, Global Assessment of Functioning (GAF), the Clinical Global Impressions scale score (CGI), and body mass index (BMI) were studied. RESULTS: Sixteen out of 107 patients accounted for 74% of the total costs. The mean and median cost for 6 months included in the survey for social services, family and social welfare and healthcare, psychiatric and physical treatment interventions, mean 8349 EUR, median 2599 EUR per patient (currency value for 2021). Education and psychosocial function (GAF) were both negatively correlated with costs for the social services (education, r=-0.207, p < 0.014; GAF, r=-0.258, p < 0.001). CGI was correlated with costs for physical and psychiatric healthcare (r = 0.161, p < 0.027), social services support (r = 0.245, p = 0.002) and total cost (r = 0.198, p = 0.007). BMI correlated with costs for psychiatric and physical health settings interventions (r = 0.155, p < 0.019) and for somatic and psychiatric medicines (r = 0.154, p < 0.019). CONCLUSION: The RUMI scale was acceptable and enabled estimation of resource utilization in a comparable manner across different care settings. Such comparable data have potential to provide a basis for budgeting and resource allocation.

Age, time from injury to surgery and hop performance after primary ACLR affect the risk of contralateral ACLR.

PURPOSE: To evaluate factors affecting the risk of contralateral anterior cruciate ligament reconstruction (ACLR) within 5 years of primary ACLR. METHODS: Primary ACLRs performed at Capio Artro Clinic, Stockholm, Sweden, during the period 2005-2014, were reviewed. The outcome of the study was the occurrence of contralateral ACLR within 5 years of primary ACLR. Univariable and multivariable logistic regression analyses were employed to identify preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for contralateral ACLR. RESULTS: A total of 5393 patients who underwent primary ACLR were included. The incidence of contralateral ACLR within 5 years was 4.7%. Univariable analysis revealed that age ≥ 25 years, BMI ≥ 25 kg/m2, time from injury to surgery ≥ 12 months and the presence of a cartilage injury reduced the odds, whereas female gender, pre-injury Tegner activity level ≥ 6, quadriceps and hamstring strength and a single-leg-hop test LSI of ≥ 90% increased the odds of contralateral ACLR. Multivariable analysis showed that the risk of contralateral ACLR was significantly affected only from age ≥ 25 years (OR 0.40; 95% CI 0.28-0.58; P < 0.001), time from injury to surgery ≥ 12 months (OR 0.48; 95% CI 0.30-0.75; P = 0.001) and a single-leg-hop test LSI of ≥ 90% (OR 1.56; 95% CI 1.04-2.34; P = 0.03). CONCLUSION: Older age (≥ 25 years) and delayed primary ACLR (≥ 12 months) reduced the odds, whereas a symmetrical (LSI ≥ 90%) 6-month single-leg-hop test increased the odds of contralateral ACLR within 5 years of primary ACLR. Knowledge of the factors affecting the risk of contralateral ACLR is important when it comes to the appropriate counselling for primary ACLR. Patients should be advised regarding factors affecting the risk of contralateral ACLR. LEVEL OF EVIDENCE: Level III.

Delayed Anterior Cruciate Ligament Reconstruction Increases the Risk of Abnormal Prereconstruction Laxity, Cartilage, and Medial Meniscus Injuries.

PURPOSE: To determine the association between a delay in anterior cruciate ligament reconstruction (ACLR), age, sex, body mass index (BMI) and cartilage injuries, meniscus injuries, meniscus repair, and abnormal prereconstruction laxity. METHODS: Patients who underwent primary ACLR at our institution from January 2005 to March 2017, with no associated ligament injuries, were identified. Logistic regression analyses were used to evaluate whether delay in ACLR, age, sex, and BMI were risk factors for cartilage and meniscus injuries, meniscus repair, and abnormal (side-to-side difference >5 mm) prereconstruction laxity. RESULTS: A total of 3976 patients (mean age 28.6 ± 10.6 years, range 10-61 years) were included. The risk of cartilage injury increased with a delay in ACLR (12-24 months: odds ratio [OR] 1.20; 95% confidence interval [CI] 1.05-1.29; P = .005; and > 24 months: OR 1.20; 95% CI 1.11-1.30; P < .001) and age ≥30 years (OR 2.27; 95% CI 1.98-2.60; P < .001). The risk of medial meniscus (MM) injury increased with a delay in ACLR (12-24 months: OR 1.20; 95% CI 1.07-1.29; P = .001; and >24 months: OR 1.22; 95% CI 1.13-1.30; P < .001), male sex (OR 1.16; 95% CI 1.04-1.30; P = .04) and age ≥30 years (OR 1.20; 95% CI 1.04-1.33; P = .008). The risk of lateral meniscus (LM) injury decreased with a delay in ACLR of >3 months and age ≥30 years (OR 0.75; 95% CI 0.66-0.85; P < .001), whereas it increased with male sex (OR 1.32; 95% CI 1.22-1.41; P < .001). MM repairs relative to MM injury decreased with a delay in ACLR (6-12 months: OR 0.70; 95% CI 0.54-0.92; P = .01; 12-24 months: OR 0.69; 95% CI 0.57-0.85; P < .001; >24 months: OR 0.61; 95% CI 0.52-0.72; P < .001) and age ≥30 years (OR 0.60; 95% CI 0.48-0.74; P < .001). LM repairs relative to LM injury only decreased with age ≥30 years (OR 0.34; 95% CI 0.26-0.45; P < .001). The risk of having abnormal knee laxity increased with a delay in ACLR of >6 months and MM injury (OR 1.52; 95% CI 1.16-1.97; P = .002), whereas it decreased with a BMI of ≥25 (OR 0.68; 95% CI 0.52-0.89; P = .006). CONCLUSIONS: A delay in ACLR of >12 months increased the risk of cartilage and MM injuries, whereas a delay of >6 months increased the risk of abnormal prereconstruction laxity and reduced the likelihood of MM repair. To reduce meniscus loss and the risk of jeopardizing knee laxity, ACLR should be performed within 6 months after the injury. LEVEL OF EVIDENCE: Level III, retrospective therapeutic comparative study.

Age, time from injury to surgery and quadriceps strength affect the risk of revision surgery after primary ACL reconstruction.

PURPOSE: To identify preoperative, intraoperative and postoperative factors associated with revision anterior cruciate ligament reconstruction (ACLR) within 2 years of primary ACLR. METHODS: Patients who underwent primary ACLR at our institution, from January 2005 to March 2017, were identified. The primary outcome was the occurrence of revision ACLR within 2 years of primary ACLR. Univariate and multivariate logistic regression analyses were used to evaluate preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, graft diameter, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [side-to-side (STS) anterior laxity, limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for revision ACLR. RESULTS: A total of 6,510 primary ACLRs were included. The overall incidence of revision ACLR within 2 years was 2.5%. Univariate analysis showed that age < 25 years, BMI < 25 kg/m2, time from injury to surgery < 12 months, pre-injury Tegner activity level ≥ 6, LM repair, STS laxity > 5 mm, quadriceps strength and single-leg-hop test LSI of ≥ 90% increased the odds; whereas, MM resection and the presence of a cartilage injury reduced the odds of revision ACLR. Multivariate analysis revealed that revision ACLR was significantly related only to age < 25 years (OR 6.25; 95% CI 3.57-11.11; P < 0.001), time from injury to surgery < 12 months (OR 2.27; 95% CI 1.25-4.17; P = 0.007) and quadriceps strength LSI of ≥ 90% (OR 1.70; 95% CI 1.16-2.49; P = 0.006). CONCLUSION: Age < 25 years, time from injury to surgery < 12 months and 6-month quadriceps strength LSI of ≥ 90% increased the odds of revision ACLR within 2 years of primary ACLR. Understanding the risk factors for revision ACLR has important implications when it comes to the appropriate counseling for primary ACLR. In this study, a large spectrum of potential risk factors for revision ACLR was analyzed in a large cohort. Advising patients regarding the results of an ACLR should also include potential risk factors for revision surgery. LEVEL OF EVIDENCE: III.

Higher pyruvate levels after Achilles tendon rupture surgery could be used as a prognostic biomarker of an improved patient outcome.

PURPOSE: The primary aim of this study was to assess the relationship between the metabolites lactate and pyruvate in the healing tendon after Achilles tendon rupture (ATR) and patient-reported outcome at 6 and 12 months. A secondary aim was to evaluate which underlying factors regulate lactate and pyruvate concentrations. METHODS: Lactate and pyruvate concentrations were measured two weeks post-operatively in both the healing- and healthy Achilles tendon in 109 patients (90 men, 19 women; mean age 40 ± 7.9 years). Patient demographics, degree of physical activity, timing of surgery, operation time, patient-reported loading and step counts were investigated in relation to metabolite concentrations. At 6 and 12 months, the Achilles tendon Total Rupture Score (ATRS) questionnaire was used to assess patient outcome. RESULTS: The mean number of steps taken during the post-operative days 1-10 was the only factor significantly related to the mean concentration of lactate (R2 = 0.34, p = 0.038), and pyruvate (R2 = 0.46, p = 0.006). Pyruvate was demonstrated as the only factor significantly associated with ATRS at both 6 months (R2 = 0.32, p = 0.003) and at 12 months (R2 = 0.37, p = 0.004) using multiple linear regression. CONCLUSION: The mean concentration of pyruvate during early ATR healing may predict patient outcome at 6 and 12 months post-operatively and possibly be used as a biomarker of healing. Early mobilization with an increased number of steps taken is an important clinical strategy to improve the metabolite concentrations during healing. LEVEL OF EVIDENCE: III.

Knee laxity and functional knee outcome after contralateral ACLR are comparable to those after primary ACLR.

PURPOSE: To evaluate and compare knee laxity and functional knee outcome between primary and contralateral anterior cruciate ligament (ACL) reconstruction. METHODS: Patients who underwent primary and subsequent contralateral ACL reconstruction (ACLR) at Capio Artro Clinic, Stockholm, Sweden, from 2001 to 2017, were identified in our local database. The inclusion criteria were: the same patients who underwent primary and contralateral hamstring tendon or bone-patellar tendon-bone autograft ACLR and no associated ligament injuries. The KT-1000 arthrometer, with an anterior tibial load of 134 N, was used to evaluate knee laxity preoperatively and 6 months postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at the 1-year follow-up. RESULTS: A total of 326 patients with isolated primary and contralateral ACLR met the inclusion criteria (47.9% males; mean age at primary ACLR 23.9 ± 9.4 years and contralateral ACLR 27.9 ± 10.1 years). The arthrometric laxity measurements were available for primary and contralateral ACLR for 226 patients. The mean preoperative and postoperative anterior tibial translation (ATT), as well as the mean ATT reduction from preoperatively to postoperatively, did not differ significantly between primary and contralateral ACLR. The KOOS was available for primary and contralateral ACLR for 256 patients. No significant differences were found preoperatively and at the 1-year follow-up between primary and contralateral ACLR for any of the five KOOS subscales. CONCLUSION: The findings in this study showed that anterior knee laxity and functional knee outcome after contralateral ACLR are comparable to those after primary ACLR. It is important for clinicians to counsel patients about their expectations after contralateral ACLR. This study shows that the results after contralateral ACLR in terms of knee laxity and functional knee outcome are predictable and likely to be comparable to those after primary ACLR. LEVEL OF EVIDENCE: Level III.

Meniscus Repair Does Not Result in an Inferior Short-term Outcome Compared With Meniscus Resection: An Analysis of 5,378 Patients With Primary Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare the preoperative and 1- and 2-year postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores between isolated anterior cruciate ligament reconstruction (ACLR) and ACLR with additional medial meniscus (MM) and/or lateral meniscus (LM) resection or repair. METHODS: A total of 5,378 patients who underwent primary ACLR, with no associated ligament injuries, at our institution from January 2005 to December 2015 were included. The KOOS subscale scores were used to evaluate patients preoperatively and at 1- and 2-year postoperative follow-up assessments. Patients who underwent isolated ACLR and those who underwent ACLR with additional MM resection, MM repair, LM resection, LM repair, MM plus LM resection, or MM plus LM repair were compared by use of an analysis of covariance, with age, sex, graft, and cartilage injury as covariates. RESULTS: Postoperatively, at both 1- and 2-year follow-up assessments, no significant differences were found between the groups for any of the 5 KOOS subscales. Preoperatively, a significant difference between the groups was found for the KOOS Symptoms (P < .001), Pain (P < .001), Activities of Daily Living (ADL) (P < .001), and Sport and Recreation (Sport/Rec) (P = .01) subscale scores. The lowest scores were found for the group undergoing ACLR and MM plus LM repair (Symptoms, 70.1 ± 17.3; Pain, 71.4 ± 18.5; ADL, 80.6 ± 20.5; and Sport/Rec, 35.7 ± 28.1), whereas the mean scores for the other groups ranged from 71.2 ± 18.7 to 76.5 ± 17.1 for Symptoms, from 76.1 ± 17.0 to 80.1 ± 15.5 for Pain, from 84.5 ± 16.8 to 88.1 ± 14.2 for ADL, and from 44.2 ± 28.3 to 49.1 ± 28.5 for Sport/Rec. CONCLUSIONS: Patients undergoing isolated ACLR and those undergoing ACLR with additional MM and/or LM resection or repair obtained equivalent results for each of the KOOS subscales at the 1- and 2-year postoperative follow-up assessments. Differences between the groups were only detectable preoperatively, with patients undergoing ACLR and MM plus LM repair showing the lowest scores for the KOOS Symptoms, Pain, ADL, and Sport/Rec subscales. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Deep venous thrombosis after Achilles tendon rupture is associated with poor patient-reported outcome.

PURPOSE: The aim of this study was to investigate whether patient subjective and functional outcomes after Achilles tendon rupture (ATR) are related to deep venous thrombosis (DVT) during leg immobilization. METHODS: A cohort study with prospectively collected randomized data was conducted between 2010 and 2017. Two-hundred and fifty-one Patients with an Achilles tendon rupture (mean age = 41 ± 8), treated with uniform surgical techniques, were retrospectively analyzed. DVT incidence at 2 and 6 weeks was assessed using compression duplex ultrasound. At 12 months patient-reported outcomes were assessed using the Achilles tendon Total Rupture Score (ATRS), Foot- and Ankle Outcome Score (FAOS), Physical Activity Scale (PAS) and functional outcome with the calf-muscle endurance test. ANOVA analyses were used and adjusted for assumed confounding factors (patient age, sex, BMI and rehabilitation). RESULTS: The total DVT incidence was 122 out of 251 (49%). Patients suffering a DVT exhibited significantly lower ATRS at 1 year compared to patients without DVT (mean 76 vs 83, 95% CI 71-79 vs 80-87; p < 0.01). Sixty-seven percent (95% CI 57-77%) of the patients devoid of DVT reported a good outcome (ATRS > 80) compared to 51% (95% CI 41-61%) of the patients sustaining a DVT (p < 0.05). Quality of life displayed significantly better outcome in the non-DVT versus DVT patients (mean = 75 (95% CI 71-79) vs. mean = 68 (95% CI 64-72); p < 0.05). A significant difference in total concentric work was observed between non-DVT and DVT patients (median = 1.9 kJ (IQR = 0.9 kJ) vs. median = 1.6 kJ (IQR = 1.0 kJ); p < 0.01). CONCLUSION: Sustaining a DVT during leg immobilization significantly impairs patient-reported outcome at 1 year after surgical repair of ATR. LEVEL OF EVIDENCE: III.

Early mobilization does not reduce the risk of deep venous thrombosis after Achilles tendon rupture: a randomized controlled trial.

PURPOSE: The hypothesis was that early functional mobilization would reduce the incidence of deep venous thrombosis (DVT) during leg immobilization after Achilles tendon rupture surgery. A secondary aim was to evaluate if the amount of weightbearing and daily steps influenced the risk of sustaining a DVT. METHODS: One-hundred and fifty patients with Achilles tendon rupture repair were randomized to treatment with early functional mobilization, encouraging full weightbearing and ankle motion in orthosis, or treatment-as-usual, i.e., 2 weeks of unloading in plaster cast followed by 4 weeks weightbearing in orthosis. At 2 and 6 weeks postoperatively, all patients were screened for DVT using compression duplex ultrasound. During the first 2 weeks postoperatively, patient-reported loading, pain and step counts were assessed. RESULTS: At 2 weeks, 28/96 (29%) of the patients in early functional mobilization group and 15/49 (31%) in the control group (n.s) had sustained a DVT. At 6 weeks, the DVT rate was 35/94 (37%) in the early functional mobilization and 14/49 (29%) in the control group (n.s). During the first postoperative week, the early functional mobilization group reported low loading and higher experience of pain vs. the control group (p = 0.001). Low patient-reported loading ≤ 50% (OR = 4.3; 95% CI 1.28-14.3) was found to be an independent risk factor for DVT, in addition to high BMI and higher age. CONCLUSIONS: Early functional mobilization does not prevent the high incidence of DVT during leg immobilization in patients with Achilles tendon rupture as compared to treatment-as-usual. The low efficacy of early functional mobilization is mainly explained by postoperative pain and subsequent low weightbearing. To minimize the risk of DVT, patients should be encouraged to load at least 50% of body weight on the injured leg 1 week after surgery. LEVEL OF EVIDENCE: Therapeutic, level 1.

Age, gender, quadriceps strength and hop test performance are the most important factors affecting the achievement of a patient-acceptable symptom state after ACL reconstruction.

PURPOSE: To assess the percentage of patients achieving an acceptable symptom state 2 years after primary anterior cruciate ligament reconstruction (ACLR) and to identify factors affecting its achievement, in a large cohort. METHODS: Patients who underwent primary ACLR at Capio Artro Clinic, Stockholm, Sweden, from 2005 to 2015, were identified in our clinic registry. Patients who had completed the Knee injury and Osteoarthritis Outcome Score (KOOS) at the 2-year follow-up were included. The primary outcome was the achievement of a patient-acceptable symptom state (PASS) for each KOOS subscale. A multivariate logistic regression analysis was used to determine whether patient age, gender, time from injury to surgery, pre-injury Tegner activity level, graft type, cartilage injury, the presence of medial meniscus (MM) or lateral meniscus (LM) resection or repair and the recovery of 6-month symmetrical (limb symmetry index [LSI] of ≥ 90%) isokinetic quadriceps or hamstring strength and single-leg-hop test performance were factors associated with the achievement of a PASS for each KOOS subscale. RESULTS: A total of 2335 primary ACLRs were included. More than 60% of the patients reported a PASS on four of the five KOOS subscales. Age ≥ 30 years and an LSI of ≥ 90% for 6-month isokinetic quadriceps strength increased the odds of achieving a PASS across all KOOS subscales. Female gender reduced the odds of achieving a PASS on the Pain (OR 0.76; 95% CI 0.62-0.94; P = 0.01), activities of daily living (ADL) (OR 0.79; 95% CI 0.64-0.97; P = 0.02) and sport and recreation (OR 0.72; 95% CI 0.58-0.89; P = 0.003) subscales. The presence of an MM repair reduced the odds of achieving a PASS on the Pain (OR 0.59; 95% CI 0.36-0.96; P = 0.03) subscale. Hamstring tendon (HT) autograft rather than bone-patellar tendon-bone (BPTB) autograft showed increased odds (OR 2.02; 95% CI 1.31-3.10; P = 0.001), whereas a cartilage injury showed reduced odds (OR 0.73; 95% CI 0.55-0.97; P = 0.03) of achieving a PASS on the sport and recreation subscale. An LSI of ≥ 90% for 6-month single-leg-hop test performance increased the odds of achieving a PASS on the ADL (OR 1.37; 95% CI 1.09-1.71; P = 0.005), Sport and Recreation (OR 1.40; 95% CI 1.11-1.77; P = 0.004), and quality of life (OR 1.28; 95% CI 1.00-1.63; P = 0.04) subscales. CONCLUSION: More than 60% of the patients reported an acceptable symptom state on four of the five KOOS subscales 2 years after primary ACLR. Age ≥ 30 years and female gender were the non-modifiable factors that consistently increased and reduced, respectively, the odds of achieving a PASS. A symmetrical 6-month isokinetic quadriceps strength and single-leg-hop test performance were the modifiable factors that consistently increased the opportunity of achieving a PASS 2 years after primary ACLR. LEVEL OF EVIDENCE: III.

One sixth of primary anterior cruciate ligament reconstructions may undergo reoperation due to complications or new injuries within 2 years.

PURPOSE: To analyse the incidence, types and risk factors for reoperation within 2 years of primary anterior cruciate ligament reconstruction (ACLR). METHODS: Our clinic registry was used to identify primary ACLRs, performed from 2005 to 2015, and reoperations performed on the ipsilateral knee within 2 years at our institution. Reoperations were identified using procedural codes and analysis of medical records. A logistic regression analysis was used to evaluate risk factors for reoperation. RESULTS: A total of 6030 primary ACLRs were included. A total of 1112 (18.4%) reoperations performed on 1018 (16.9%) primary ACLRs were identified. The most common reoperations were screw removal (n = 282, 4.7%), meniscus procedures (n = 238, 3.9%), cyclops removal/notchplasty (n = 222, 3.7%) and reoperations due to graft rupture (n = 146, 2.4%), including revision ACLR. Age < 30 years (OR 1.57; 95% CI 1.37-1.80; P < 0.001), female gender (OR 1.33; 95% CI 1.17-1.51; P < 0.001), medial meniscus repair (OR 1.55; 95% CI 1.23-1.97; P < 0.001), lateral meniscus resection (OR 1.26; 95% CI 1.07-1.49; P = 0.005) and lateral meniscus repair (OR 1.38; 95% CI 1.03-1.85; P = 0.02) at primary ACLR were found to be risk factors for reoperation. CONCLUSION: One sixth of all primary ACLRs underwent reoperation due to complications or new injuries within 2 years. The most common reoperations were screw removal, meniscus procedures, cyclops removal/notchplasty and reoperations due to graft rupture, including revision ACLR. Younger age (< 30 years), female gender, medial meniscus repair and lateral meniscus resection or repair at primary ACLR were associated with an increased risk of reoperation. This study provides clinicians with important data to inform patients about the short-term reoperation rates, the most common reoperation procedures and risk factors for reoperation after primary ACLR. LEVEL OF EVIDENCE: III.

There is no general use of thromboprophylaxis and prolonged antibiotic prophylaxis in anterior cruciate ligament reconstruction: a nation-wide survey of ACL surgeons in Sweden.

PURPOSE: The use of prophylaxis for thromboembolism and infection in anterior cruciate ligament (ACL) reconstruction is not well documented and no general guidelines have been established. The aim of this study was to evaluate the ACL surgeons' individual strategies of thromboprophylaxis, use of prolonged antibiotic prophylaxis and vancomycin-soaked ACL grafts, and if its use is supported in the current literature. Additionally, the rationale for use of tourniquet was analysed. METHODS: Questionnaires were distributed to all Swedish ACL surgeons who are registered in the Swedish Knee Ligament Register (SKLR), asking about prescription of thromboprophylaxis, prolonged antibiotic prophylaxis, the use of vancomycin-soaked graft and the use of a tourniquet during surgery. The responses were assessed for agreement and the thromboprophylaxis data were analysed in relation to the 2016 SKLR data. RESULTS: 115 (75%) ACL surgeons responded to the survey. 81.7% prescribed thromboprophylaxis only when risk factors, such as history of thrombosis and the use of oral contraceptives, were present. Female gender, older age and admitted patient were considered the risk factors with the lowest impact. The respondents were generally restrictive regarding the use of prolonged antibiotic prophylaxis. The use of vancomycin-soaked graft was used by only nine (8%) surgeons representing 406 (13%) of the surgeries. CONCLUSION: Swedish ACL surgeons are generally restrictive using thromboprophylaxis and only when risk factors are present. However, there is a lack of consensus in how to weigh the different risk factors and it does not completely adhere to the existing literature. Prolonged antibiotic prophylaxis is rarely used and the use of vancomycin soaking of graft is very limited and applies only to a small number of surgeons. The use of tourniquet is common. There is a need for ACL-specific guidelines regarding the use of thromboprophylaxis. LEVEL OF EVIDENCE: IV.

The Relationship Between Personality Traits and Muscle Injuries in Swedish Elite Male Football Players.

CONTEXT: The physical and mental demands of an elite football player are complex, which may explain why injuries are common in football. At elite level, muscle injuries of the lower-extremity are the most common among male football players, and the research hitherto is limited. OBJECTIVE: To investigate whether personality traits affect the incidence of muscle injuries among male football players from the first league in Sweden. DESIGN: Prospective cohort study. PARTICIPANTS: A male football team from the first league in Sweden was prospectively followed, in terms of muscle injuries of the lower-extremity during 8 seasons, between 2007 and 2015. INTERVENTION: All muscle injuries included in this study were evaluated and diagnosed with ultrasonography. Players from the team filled out the Swedish Universities Scales of Personality questionnaire. Swedish Universities Scales of Personality questionnaire consists of 91 items and is divided into 13 categories. MAIN OUTCOME MEASURES: The raw values of each scale were linearly transformed to T scores, having a mean (SD) of 50 (10). All variables were summarized with standard descriptive statistics, such as frequency, mean, and SD. As data were of interval scale and no variable distribution was severely skewed, differences between noninjured players, rarely injured players, and frequently injured players were analyzed with 1-way analysis of variance with post hoc tests by Tukey honestly significant difference test. RESULTS: No significant difference in personality traits were observed between noninjured players, rarely injured players, and frequently injured players regarding number of muscle injuries (P > .05). However, a trend (P = .07) was seen, where frequently injured players scored higher on stress susceptibility than rarely injured players. CONCLUSION: A player's stress susceptibility should be taken into consideration by the player, coaches, and medical staff when assessing the risk of a muscle injury. Also, preventive measures available for these players may need to be considered.

Long-term mortality and cause of death for patients treated in Intensive Care Units due to poisoning.

BACKGROUND: Poisoned patients treated in the Intensive Care Unit are common, representing up to 6% of all ICU admissions. The in-hospital mortality is generally low but little is known about the long-term mortality in these patients. The aim of this study was to describe long-term mortality and cause of death in patients treated in the ICU for poisoning. METHOD: A national observational study based on three registers: the National Patient Register, the Swedish Intensive Care Register and the Cause of Death Register. All patients ≥19 years admitted to a Swedish Intensive Care Unit between January 1, 2010 and December 31, 2011 with an ICD-10 code for poisoning were included. RESULTS: A total of 6730 patients were included. The one-year mortality was 4.5% (n = 303), with an overweight of men among the deceased (59.1%, P = 0.002). Patients aged 19-39 years had a 48 times increased one-year mortality compared to the age-matched general population and 94% of these patients died from suicide and/or accident, of which 70% were from a new poisoning. The two-year mortality was 7.2%. Women have a slightly higher overall long-term survival over two years (P< 0.001). CONCLUSION: The risk of premature death is markedly increased in younger patients one and two years after an ICU hospitalisation for non-fatal poisoning compared to the general population. A large majority die due to a new poisoning incident despite a previously known recent severe poisoning. EDITORIAL COMMENT: Admission to ICU with poisoning, and particularly self-poisoning, may be associated with long-term mortaliity. In this study of 6730 patients admitted to a Swedish ICU for poisoning, the in-hospital mortality was low for that admission, but there is an increased risk of later mortality in young patients one and two years after hospital discharge.

Pyruvate and lactate as local prognostic biomarkers of patient outcome after achilles tendon rupture.

BACKGROUND: Acute Achilles tendon rupture (ATR) is a frequently disabling injury, which exhibits unclear variability in long-term functional and patient-reported outcomes. Biomarkers from early healing, which have been shown to be prognostic of long-term outcome would facilitate the development of improved treatment methods. HYPOTHESIS/PURPOSE: The aim of this study was to assess essential metabolites pyruvate and its product lactate, as early biomarkers in relation to long-term functional- and patient-reported outcome after ATR. STUDY DESIGN: Prospective cohort study. METHODS: A total of 124 patients (103 men, 21 women; mean age 40 ± 7 years) with ATR, treated with uniform anesthetic and surgical technique, were prospectively assessed. At two weeks post-injury pyruvate and lactate concentrations were assessed in both the injured and uninjured limbs using microdialysis followed by enzymatic quantification. The ratios of the concentration in the injured versus uninjured limb of pyruvate (pyruvate-r) and lactate (lactate-r) were calculated as well as the lactate/pyruvate ratios (L/P-r). At 12 months, patient-reported outcome was examined using self-reported questionnaires; Achilles tendon Total Rupture Score (ATRS), Foot and Ankle Outcome Score (FAOS), and physical activity score. At 12 months, functional outcome was studied using the validated heel-rise test. RESULTS: Elevated pyruvate-r, at two weeks, was significantly associated with total ATRS (R = 0.254, P = 0.028), less loss in physical activity (R = 0.241, P = 0.039), less experience of pain in FAOS (R = 0.275, P = 0.032), and a higher number of heel-rise repetitions on injured side (R = 0.230, P = 0.040) at 12 months. Increased lactate-r was related with less strength limitations in the calf (R = 0.283, P = 0.011), while the elevated lactate-pyruvate ratio, notably, was related to more limitations in walking on uneven surface (R = -0,243, P = 0.027). The findings were verified by multiple linear regression taking confounding factors into consideration. CONCLUSION: This study established that the metabolite pyruvate is a good potential biomarker, prognostic of patient outcome at the one-year follow-up after ATR surgery. These novel findings suggest that local biomarkers could be developed at an early-stage screen for new ATR treatments.

Revision anterior cruciate ligament reconstruction restores knee laxity but shows inferior functional knee outcome compared with primary reconstruction.

PURPOSE: To evaluate and compare knee laxity and functional knee outcome between primary and revision anterior cruciate ligament (ACL) reconstruction in the same cohort of patients. METHODS: Patients who underwent primary and revision ACL reconstruction (ACLR) at Capio Artro Clinic, Stockholm, Sweden, from 2000 to 2015, were identified in our local database. Inclusion criteria were: same patients who underwent primary hamstring tendons (HT) and revision bone-patellar tendon-bone (BPTB) autograft ACLR, no associated ligament injuries and no contralateral ACL injuries/reconstructions. The cause of revision ACLR was graft rupture for all patients. The KT-1000 arthrometer, with an anterior tibial load of 134-N, was used to evaluate knee laxity preoperatively and 6-month postoperatively. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at the 1-year follow-up. RESULTS: A total of 118 patients with primary and revision ACLR arthrometric laxity measurements were available (51.0% males; mean age at primary ACLR 21.7 ± 7.1 years and revision ACLR 24.3 ± 7.5 years). The mean preoperative and postoperative anterior side-to-side (STS) difference values were not significantly different between primary and revision ACLR. However, primary ACLR showed a significantly higher frequency of postoperative anterior STS difference > 5 mm compared with revision ACLR (8.4 vs 5.0%; P = 0.02). The KOOS was available for primary and revision ACLR for 73 patients (55.4% males; mean age at primary ACLR 21.6 ± 7 years and revision ACLR 24.7 ± 7.3 years). Preoperatively, revision ACLR showed significantly higher scores in all KOOS subscales, except for the activity of daily living (ADL) subscale. For the primary ACLR, the improvement from preoperatively to the 1-year follow-up was significantly greater in all KOOS subscales and, the postoperative scores were superior for Pain, ADL and Sports subscales compared with revision ACLR. CONCLUSIONS: The findings of this study showed that anterior knee laxity is restored with revision BPTB autograft ACLR after failed primary HT autograft ACLR, in the same cohort of patients. However, revision ACLR showed a significantly inferior functional knee outcome compared with primary ACLR. It is important for clinicians to inform and set realistic expectations for patients undergoing revision ACLR. Patients must be aware of the fact that having revision ACLR their knee function will not improve as much as with primary ACLR and the final postoperative functional outcome is inferior. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.