Novel use of motor-sparing genicular nerve blocks for knee injuries in the emergency department.

Knee injuries are quite prevalent in the Emergency Department (ED) and often present with severe pain, necessitating effective pain management strategies. Traditional pain management approaches, including opioid medications, may carry undesirable side effects and potential risks, leading to the growing interest in non-opioid alternatives. Nerve blocks have emerged as promising options for targeted pain relief in the ED. Motor-sparing nerve blocks have gained importance due to their ability to provide effective analgesia without compromising motor function [1]. The case series demonstrates the successful use of ultrasound-guided genicular nerve blocks(GNB) in the Emergency Department, providing targeted pain relief without compromising motor function. GNBs offer a valuable alternative to traditional nerve blocks(femoral, fascia iliaca, adductor canal) and opioid-based pain control strategies in the ED. As the evidence base grows, GNBs may become a more established component of ED pain management protocols, enhancing patient outcomes and safety in the management of acute knee injuries. The incorporation of ultrasound-guided motor-sparing nerve blocks in ED pain management protocols may hold great promise in optimising pain control and enhancing patient comfort. Trial Registration: N/A.

Does MRI alter management in patients 60 years and older with chronic knee pain: correlation with radiographs and clinical parameters.

OBJECTIVE: To determine if MRI altered management in patients ≥ 60 years old with chronic knee pain. MATERIALS AND METHODS: Consecutive patients ≥ 60 years old with knee MRI and radiographs within 90 days were included. Exclusion criteria included mass/malignancy, recent trauma, and infection. Standing AP and PA flexion views were evaluated using Kellgren-Lawrence (KL) and International Knee Documentation Committee (IKDC) scales. Pertinent clinical history was recorded. MRIs were considered to alter management if subchondral fracture was identified or subsequent arthroscopy was performed due to an MRI finding. RESULTS: Eighty-five knee MRI/radiograph exams were reviewed; mean 68.2 years (60-88), 47:38 F:M. Twenty knee MRIs (24%) had either a subchondral fracture (n = 9) or meniscal tear (n = 11) prompting arthroscopy. On PA flexion view, 0/20 of these studies had KL grade 4 and 70% (14/20) had KL grade 0-1 compared to the remaining MRIs having 15.4% (10/65) KL grade 4 and 38.5% (25/65) KL grade 0-1 (p = 0.03). A 10-pack-year tobacco history, 38% vs 18%, was associated with a subchondral fracture or arthroscopy (p = 0.06). Subchondral fractures were more prevalent in older patients (mean 72.4 vs 67.7 years; p = 0.03). CONCLUSION: In patients ≥ 60 years old with chronic knee pain, MRI altered management in ~ 24% of cases; 70% in patients with KL grade 0-1, and none in patients with KL grade 4. MRI may benefit older patients with minimal osteoarthritis but not those with end-stage disease. Patients with ≥ 10 pack years of smoking may also benefit from MRI.

If we build it together, will they use it? A mixed-methods study evaluating the implementation of Prep-to-Play PRO: an injury prevention programme for women's elite Australian Football.

OBJECTIVES: We evaluated the implementation of Prep-to-Play PRO, an injury prevention programme for women's elite Australian Football League (AFLW). METHODS: The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) of Prep-to-Play PRO were assessed based on the proportion of AFLW players and/or staff who: were aware of the programme (R), believed it may reduce anterior cruciate ligament injury (E), attempted to implement any/all programme components (A), implemented all intended components as practically as possible (I) and intended future programme implementation (M). Quantitative and qualitative data were triangulated to assess 58 RE-AIM items (evidence of yes/no/unsure/no evidence) and the 5 RE-AIM dimensions (fully achieved=evidence of yes on >50% dimension items, partially achieved=50% of items evidence of yes and 50% unsure or 50% mix of unsure and unanswered, or not met=evidence of yes on <50% dimension items). RESULTS: Multiple sources including AFLW training observations (n=7 total), post-implementation surveys (141 players, 25 staff), semistructured interviews (19 players, 13 staff) and internal programme records (9 staff) contributed to the RE-AIM assessment. After the 2019 season, 8 of 10 (80%) AFLW clubs fully met all five RE-AIM dimensions. All 10 clubs participating in the AFLW fully achieved the reach (R) dimension. One club partially achieved the implementation (I) dimension, and one club partially achieved the effectiveness (E) and adoption (A) dimensions. CONCLUSION: The Prep-to-Play PRO injury prevention programme for the AFLW achieved high implementation, possibly due to the programme's deliberately flexible approach coupled with our pragmatic definition of implementation. Engaging key stakeholders at multiple ecological levels (organisation, coaches, athletes) throughout programme development and implementation likely enhanced programme implementation.

The presence of a deep lateral femoral notch sign in ACL-injured patients is associated with a 2.7° steeper posterior tibial slope and a 19% higher frequency of lateral meniscal injuries.

PURPOSE: The purpose of this study was to study the relationship between the presence of a deep lateral femoral notch sign (DLFNS) in anterior cruciate ligament (ACL)-injured patients and a higher posterior lateral tibial slope (LPTS), a reduced meniscal bone angle (MBA), a higher LPTS/MBA ratio and a higher incidence of concomitant injuries in primary ACL tears. METHODS: A retrospective case-control study was performed in patients submitted to primary ACL reconstruction with an available preoperative magnetic resonance imaging (MRI) scan. Patients with ACL tears and a femoral impactation with a depth ≥2 mm were assorted to the DLFNS group and patients with ACL tear and without a DLFNS to the control group. LPTS and MBA were measured in MRI. The presence of concomitant injuries (meniscal, posterior cruciate ligament, medial collateral ligament, lateral collateral ligament and bone injuries) was assessed in MRI. Quantitative data are presented in the median ± interquartile range (IQR). RESULTS: There were 206 patients included in the study, with 46 patients assorted to the DLFNS group and 160 patients to the control group. In the DLFNS group, the median LPTS was 6.7° (IQR: 4.0-8.2) versus 4.0° in the control group (IQR: 2.2-6.5) (p = 0.003). The LPTS/MBA ratio was significantly higher in the DLFNS group, with a median of 0.32 (IQR: 0.19-0.44), in comparison to the control group, with a median of 0.19 (IQR: 0.11-0.31) (p < 0.001). The multivariable logistic regression analysis showed that the LPTS is an independent risk factor to having a DLFNS (odds ratio [OR] = 1.161; 95% confidence interval [CI]: 1.042-1.293, p = 0.007). There was a higher incidence of concomitant lateral meniscal injuries in the DLFNS group (67% vs. 48%, p = 0.017). CONCLUSIONS: In patients with ACL tears, the presence of a DLFNS is associated with a steeper lateral posterior tibial slope, as well as a higher incidence of concomitant lateral meniscal injuries. LEVEL OF EVIDENCE: Level III.

Anterior cruciate ligament injuries in elite ski jumping reliably allow return to competition but severely affect future top performance.

PURPOSE: In recent years, anterior cruciate ligament (ACL) injuries have been frequently observed in ski jumping. However, available data in this discipline are very scarce. Therefore, the purpose of this study was to investigate whether an ACL injury in elite-level ski jumping limits the performance level after ACL reconstruction (ACLR). METHODS: Both male and female elite-level ski jumpers from five national A-teams who suffered an ACL injury were identified retrospectively by searching available media reports and Fédération Internationale de Ski (FIS) database. World Cup (WC) results and time-out-of-competition before ACL injury and after ACLR were compared. Only athletes who suffered the injury during or after the 2009-2010 season and who participated in at least one WC competition before the injury were included in this study. The level of athletes' performance from two full seasons before until three seasons after the injury was compared. RESULTS: Eighteen elite-level ski jumpers (11 males/seven females) were eligible for the study. All male and four female athletes returned to professional competition after ACLR. One female athlete ended her career due to prolonged recovery and two have not yet recovered due to a recent injury. The mean return-to-competition (RTC) time was 14.6 months in males and 13.5 months in females. The mean WC placement decreased after the ACL injury: two seasons before injury the mean position was 17.9 ± 11.0 (n = 12), one season before it was 22.4 ± 12.8 (n = 15). After recovery, the mean placement in seasons 1-3 was: 26.4 ± 8.9 (n = 7), 25.7 ± 10.3 (n = 13), 33.6 ± 12.2 (n = 10) (p = 0.008). Among the athletes returning to competition, only six males and three females reached their preinjury level and only one male and one female (compared to seven males and three females preinjury) reached an individual top-3 placement after ACLR, accounting for less than 10% of podiums compared to preinjury. CONCLUSION: Only 60% of the professional ski jumpers reached the preinjury level and less than 15% reached a top-3 placement after the ACL injury. These results support the fact that ACL tear during a ski jumping career may be a significant factor limiting high-level performance. In terms of clinical relevance, the findings implicate the need to analyse the reasons of these very low rates of return to elite-level performance, to analyse ACL injury and RTC rates at lower levels of performance and to develop specific prevention strategies in order to reduce the number of ACL injuries in this sport. LEVEL OF EVIDENCE: Level IV.

Review of Microwave Near-Field Sensing and Imaging Devices in Medical Applications.

Microwaves can safely and non-destructively illuminate and penetrate dielectric materials, making them an attractive solution for various medical tasks, including detection, diagnosis, classification, and monitoring. Their inherent electromagnetic properties, portability, cost-effectiveness, and the growth in computing capabilities have encouraged the development of numerous microwave sensing and imaging systems in the medical field, with the potential to complement or even replace current gold-standard methods. This review aims to provide a comprehensive update on the latest advances in medical applications of microwaves, particularly focusing on the near-field ones working within the 1-15 GHz frequency range. It specifically examines significant strides in the development of clinical devices for brain stroke diagnosis and classification, breast cancer screening, and continuous blood glucose monitoring. The technical implementation and algorithmic aspects of prototypes and devices are discussed in detail, including the transceiver systems, radiating elements (such as antennas and sensors), and the imaging algorithms. Additionally, it provides an overview of other promising cutting-edge microwave medical applications, such as knee injuries and colon polyps detection, torso scanning and image-based monitoring of thermal therapy intervention. Finally, the review discusses the challenges of achieving clinical engagement with microwave-based technologies and explores future perspectives.

Medial meniscus extrusion is associated with meniscus tears in US and MRI: A case control study.

OBJECTIVES: To study the medial meniscus extrusion (MME) in subjects with and without medial meniscal tears on magnetic resonance imaging (MRI), supine ultrasound (US), and weight-bearing US. METHODS: Forty-seven cases (mean age 43.7 years) with medial meniscus tears and 53 healthy controls (mean age 36.6 years) were assessed. Two experienced sonographers performed the US evaluations, and a fellowship-trained musculoskeletal radiologist assessed the menisci on MRI. Independent and paired T-tests and ICC were used for statistical analyses. RESULTS: On supine US, the mean MME was 3.9 mm for the cases and 2.3 mm for the controls (p < 0.001). On weight-bearing US, the values were 4.2 and 2.8 mm (p < 0.001), and on MRI 3.0 and 2.0 mm (p < 0.001), respectively. The mean difference between supine and weight-bearing US extrusion was 0.38 mm for the cases and 0.49 mm for the controls (p = 0.291). Correlation between supine US and MRI MME measurements was good (ICC = 0.660, CIs [0.533-0.758]). CONCLUSIONS: MME can be assessed using US with good correlation to MRI. US-observed extrusion was significantly increased in supine and standing positions for medial meniscus tears. The mean difference between examination positions was reduced with medial meniscus tears although this result was statistically insignificant.

Transphyseal arthroscopic anterior cruciate ligament reconstruction in children under 12 years.

BACKGROUND: The incidence of anterior cruciate ligament (ACL) injuries in children is on the rise. Despite this trend, the optimal management of these injuries remains a matter of ongoing debate. In this light, our study seeks to assess the clinical, radiological, and functional outcomes of transphyseal ACL reconstruction in preadolescent patients in the medium-term. METHODS: This prospective study included preadolescent patients aged up to 12 years who underwent ACL transphyseal reconstruction between 2010 and 2020 and had a minimum follow-up of 2 years. Clinical assessments encompassed joint stability and range of motion. Furthermore, leg length discrepancy (LLD) and femorotibial alignment were evaluated both clinically and radiologically using full-length lower limb standing radiographs. Pre- and postoperative functional outcomes were assessed using the International Knee Documentation Committee (IKDC) and Lysholm scales, and the return to normal sports activity was evaluated using the ACL-Return to Sport after Injury (ACL-RSI) scale. Complications and relevant follow-up data were also recorded. Statistical analyses were conducted to evaluate these outcomes. RESULTS: A total of 35 preadolescent patients, consisting of 24 males and 11 females, with a mean age at surgery of 11.2 ± 0.7 years (8.7-12), were included in the study. The mean follow-up was 52.3 ± 20.7 months (24.1-95.9). No significant growth disturbances or clinically relevant LLD were evidenced. All patients demonstrated clinically stable knees with full range of motion at the 2-year follow-up. There were statistically significant improvements in pre- and postoperative IKDC (39.3 ± 13.5 vs. 99.7 ± 0.8, p < 0.005) and Lysholm scores (48.2 ± 15.1 vs. 99.6 ± 1.4, p < 0.005). All but two patients were able to return to their pre-injury level of sports activity, with a mean ACL-RSI score of 93.5 ± 1.3. The analysis revealed an 8.6% rerupture rate and an 11.4% rate of contralateral ACL injuries, with 5-year survival rates of 92.3% and 88.8%, respectively. Subgroup analyses based on age, gender, surgical delay, or associated meniscal lesions did not reveal any significant differences in functional outcomes. Additionally, there was no discernible relationship between age or timing of ACL reconstruction and the risk of meniscal injuries. CONCLUSIONS: Our study reinforces the value of ACL reconstruction in skeletally immature preadolescent patients, with transphyseal technique proven to be a safe, effective, and technically simpler option, even for children under the age of 12. The findings indicate excellent functional outcomes, a high rate of successful return to sporting activities, and minimal to no incidence of growth-related complications in the medium-term. LEVEL OF EVIDENCE: Level II, prospective comparative cohort study, before and after intervention.

Preoperative Rehabilitation Enhances Mental and Physical Well-Being in Anterior Cruciate Ligament-Injured Individuals: A Mixed Methods Study.

CONTEXT: Rehabilitation after an anterior cruciate ligament injury is recommended to be started soon after the injury. When surgery is required, research supports the delivery of physiotherapy before anterior cruciate ligament reconstruction (prehabilitation) to optimize recovery and positive outcomes. Individuals attending prehabilitation have never been questioned regarding their adherence to prehabilitation, perception of utility in meeting needs, upcoming events, or anticipated recovery goals. DESIGN: Mixed methods cross-sectional study: Methods: 25 individuals before anterior cruciate ligament reconstruction (43% of eligible individuals from 12 clinics during the delivery period) were surveyed on their mindset and recovery expectancies. Semistructured interviews conducted in 9 of 25 participants assessed their lived experience of prehabilitation. RESULTS: Participants reported that preventing a reinjury (96% of responses) and feeling confident during daily activities about their knee (92%) were the higher rating expectations at this stage of their treatment course. Three themes were developed from the interviews and analyses. (1) Participants reported that prehabilitation was a period full of challenges with memories of the injury and uncertainties. (2) They viewed prehabilitation as a step to move forward by finding support and self-motivating. (3) They believed that prehabilitation would have positive impacts on the treatment outcomes. Participants were confident that prehabilitation would accelerate the recovery of muscle volume (88%) and strength (84%). CONCLUSION: Participants had positive experiences of prehabilitation, aligning with the findings on functional outcomes in the existing literature on prehabilitation.

Utilization of the gastrocnemius flap for post-traumatic knee reconstruction: a systematic review.

PURPOSE: High-energy injuries to the knee may lead to extensive soft tissue loss, fractures, and potential loss of extensor function. The gastrocnemius flap is a prominent reconstructive option for patients with injuries involving the knee and proximal third of the lower extremity. To the best of our knowledge, there has not been an informative review that has evaluated outcomes of patients who have undergone post-traumatic knee reconstruction with a pedicled medial or lateral gastrocnemius flap. The goal of this study is to assess outcomes in patients who have undergone gastrocnemius flap reconstruction after traumatic injuries to the knee. METHODS: The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology. Four databases were utilized including PubMed, Cochrane Reviews, Embase, and CINAHL. Our search criteria consisted of the following keywords: gastrocnemius, flap, knee, and traum*. RESULTS: A total of 204 studies were imported for screening, from which five papers met our final inclusion/exclusion criteria. The most common studies utilized in this review were case series followed by retrospective chart reviews. In total, 43 patients with traumatic soft tissue knee defects were included with an average patient age of 27.28 years. All patients had successful and clinical viable flaps post-operatively, and there were a total of five patients who had complications. CONCLUSION: The gastrocnemius flap has demonstrated to be an effective option for individuals undergoing post-traumatic knee reconstruction. Infection rates, loss of mobility, and scarring represent a minority of complications that may be seen when this reconstructive technique is utilized. Still, additional randomized controlled trials and retrospective studies are required in order to further evaluate for other potential complications that may occur in this patient population.

Effect of exercise therapy versus surgery on mechanical symptoms in young patients with a meniscal tear: a secondary analysis of the DREAM trial.

OBJECTIVE: To compare the effect of early surgery versus exercise and education on mechanical symptoms and other patient-reported outcomes in patients aged 18-40 years with a meniscal tear and self-reported mechanical knee symptoms. METHODS: In a randomised controlled trial, 121 patients aged 18-40 years with a MRI-verified meniscal tear were randomised to surgery or 12-week supervised exercise and education. For this study, 63 patients (33 and 30 patients in the surgery and in the exercise group, respectively) reporting baseline mechanical symptoms were included. The main outcome was self-reported mechanical symptoms (yes/no) at 3, 6 and 12 months assessed using a single item from the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes were KOOS4 and the 5 KOOS-subscales and the Western Ontario Meniscal Evaluation Tool (WOMET). RESULTS: In total, 55/63 patients completed the 12-month follow-up. At 12 months, 9/26 (35%) in the surgery group and 20/29 (69%) in the exercise group reported mechanical symptoms. The risk difference and relative risk at any time point was 28.7% (95% CI 8.6% to 48.8%) and 1.83 (95% CI 0.98 to 2.70) of reporting mechanical symptoms in the exercise group compared with the surgery group. We did not detect any between-group differences in the secondary outcomes. CONCLUSION: The results from this secondary analysis suggest that early surgery is more effective than exercise and education for relieving self-reported mechanical knee symptoms, but not for improving pain, function and quality of life in young patients with a meniscal tear and mechanical symptoms. TRIAL REGISTRATION NUMBER: NCT02995551.

Generalised joint hypermobility leads to increased odds of sustaining a second ACL injury within 12 months of return to sport after ACL reconstruction.

OBJECTIVES: To determine the 12-month risk of a second anterior cruciate ligament (ACL) injury in a population of patients with and without generalised joint hypermobility (GJH) who return to sports (RTS) at competition level after ACL reconstruction (ACL-R). METHODS: Data were extracted from a rehabilitation-specific registry for 16-50-year-old patients treated with ACL-R between 2014 and 2019. Demographics, outcome data and the incidence of a second ACL injury within 12 months of RTS, defined as a new ipsilateral or contralateral ACL, were compared between patients with and without GJH. Univariable logistic regression and Cox proportional hazards regression were performed to determine the influence of GJH and time of RTS on the odds of a second ACL injury, and ACL-R survival without a second ACL injury after RTS. RESULTS: A total of 153 patients, 50 (22.2%) with GJH and 175 (77.8%) without GJH, were included. Within 12 months of RTS, 7 (14.0%) patients with GJH and 5 (2.9%) without GJH had a second ACL injury (p=0.012). The odds of sustaining a second ipsilateral or contralateral ACL injury were 5.53 (95% CI 1.67 to 18.29) higher in patients with GJH compared with patients without GJH (p=0.014). The lifetime HR of a second ACL injury after RTS was 4.24 (95% CI 2.05 to 8.80; p=0.0001) in patients with GJH. No between-group differences were observed in patient-reported outcome measures. CONCLUSION: Patients with GJH undergoing ACL-R have over five times greater odds of sustaining a second ACL injury after RTS. The importance of joint laxity assessment should be emphasised in patients who aim to return to high-intensity sports following ACL-R.

Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction.

This guideline was developed to inform clinical practice on rehabilitation after anterior cruciate ligament reconstruction (ACLR) and was performed in accordance with the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A Guideline Development Group systematically searched and reviewed evidence using randomised clinical trials and systematic reviews to evaluate the effectiveness of rehabilitation interventions and guide clinicians and patients on the content of the optimal rehabilitation protocol after ACLR.The guideline targets patients during rehabilitation after ACLR and investigates the effectiveness of the available interventions to the physiotherapist, alone or in combination (eg, exercise, modalities, objective progression criteria). Exercise interventions should be considered the mainstay of ACLR rehabilitation. However, there is little evidence on the dose-response relationship between volume and/or intensity of exercise and outcomes. Physical therapy modalities can be helpful as an adjunct in the early phase of rehabilitation when pain, swelling and limitations in range of motion are present. Adding modalities in the early phase may allow earlier pain-free commencement of exercise rehabilitation. Return to running and return to training/activity are key milestones for rehabilitation after ACLR. However, there is no evidence on which progression or discharge criteria should be used.While there is a very low level of certainty for most components of rehabilitation, most of the recommendations provided in this guideline were agreed to by expert clinicians. This guideline also highlights several new elements of ACLR management not reported previously.

Quadriceps or hip exercises for patellofemoral pain? A randomised controlled equivalence trial.

OBJECTIVE: To assess effectiveness equivalence between two commonly prescribed 12-week exercise programmes targeting either the quadriceps or the hip muscles in patients with patellofemoral pain (PFP). METHODS: This randomised controlled equivalence trial included patients with a clinical diagnosis of PFP. Participants were randomly assigned to either a 12-week quadriceps-focused exercise (QE) or a hip-focused exercise (HE) programme. The primary outcome was the change in Anterior Knee Pain Scale (AKPS) (0-100) from baseline to 12-week follow-up. Prespecified equivalence margins of ±8 points on the AKPS were chosen to demonstrate comparable effectiveness. Key secondary outcomes were the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire pain, physical function and knee-related quality of life subscales. RESULTS: 200 participants underwent randomisation; 100 assigned to QE and 100 to HE (mean age 27.2 years (SD 6.4); 69% women). The least squares mean changes in AKPS (primary outcome) were 7.6 for QE and 7.0 for HE (difference 0.6 points, 95% CI -2.0 to 3.2; test for equivalence p<0.0001), although neither programme surpassed the minimal clinically important change threshold. None of the group differences in key secondary outcomes exceeded predefined equivalence margins. CONCLUSION: The 12-week QE and HE protocols provided equivalent improvements in symptoms and function for patients with PFP. TRIAL REGISTRATION NUMBER: NCT03069547.

Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes.

OBJECTIVE: Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Seven databases were searched in December 2021. ELIGIBILITY CRITERIA: Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury. RESULTS: We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%-25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1-5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5-10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (<19 years) suggests female athletes/girls had 32% reduced odds of returning to sport compared with male athletes/boys (OR 0.68, 95% CI 0.41 to 1.13, I2 0.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from -0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI -0.05 to 0.02) to -0.31 (KOOS-sport and recreation, 7 studies, 95% CI -0.36 to -0.26). CONCLUSIONS: Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls. PROSPERO REGISTRATION NUMBER: CRD42021205998.

When ACL reconstruction does not help: risk factors associated with not achieving the minimal important change for the KOOS Sport/Rec and QoL.

OBJECTIVES: To determine factors associated with not achieving a minimal important change (MIC) in the Knee injury and Osteoarthritis Outcome Score (KOOS) Function in Sport and Recreation (Sport/Rec), and Knee-Related Quality of Life (QoL) subscales 1 year after anterior cruciate ligament reconstruction (ACL-R). METHODS: This study used data from the Swedish National Knee Ligament Registry. Multivariable logistic regression models were used to identify factors associated with not achieving a MIC. The change in the preoperative and postoperative KOOS Sport/Rec and QoL subscale scores were dichotomised based on not achieving MIC for both subscales versus achieving MIC for either one or both subscales. The MICs for the Sport/Rec and QoL subscales were 12.1 and 18.3, respectively, and were used to combine both subscales into a single variable (Sport & QoL). RESULTS: Of 16 131 included patients, 44% did not achieve the MIC for the combined Sport/Rec and QoL subscales 1 year after ACL-R. From the multivariable stepwise logistic regression, older patients (OR 0.91, 95% CI 0.88 to 0.94; p<0.0001), males (OR 0.93, 95% CI 0.87 to 0.99; p=0.034) and patients receiving hamstring tendon autograft ACL-R (OR 0.70, 95% CI 0.60 to 0.81; p<0.0001) had lower odds of not achieving the MIC 1 year after ACL-R compared with younger patients, females and patients receiving patellar tendon autograft. Furthermore, patients with cartilage injuries (OR 1.17, 95% CI 1.09 to 1.27; p<0.0001) and higher pre-operative KOOS Sport/Rec and QoL scores (OR 1.34, 95% CI 1.31 to 1.36; p<0.0001) had higher odds of not achieving the MIC. CONCLUSION: Younger patients, females and patients with cartilage injuries and higher pre-operative Sport/Rec and QoL KOOS scores are less likely to benefit from ACL-R and subsequently, have a lower probability for improved Sport/Rec and QoL scores after ACL-R. Furthermore, graft choice may also affect the risk of not achieving the MIC. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol.

OBJECTIVE: Investigate MRI evidence of anterior cruciate ligament (ACL) healing, patient-reported outcomes and knee laxity in patients with acute ACL rupture managed non-surgically with the Cross Bracing Protocol (CBP). METHODS: Eighty consecutive patients within 4 weeks of ACL rupture were managed with CBP (knee immobilisation at 90° flexion in brace for 4 weeks, followed by progressive increases in range-of-motion until brace removal at 12 weeks, and physiotherapist-supervised goal-oriented rehabilitation). MRIs (3 months and 6 months) were graded using the ACL OsteoArthritis Score (ACLOAS) by three radiologists. Mann-Whitney U tests compared Lysholm Scale and ACL quality of life (ACLQOL) scores evaluated at median (IQR) of 12 months (7-16 months) post-injury, and χ2 tests compared knee laxity (3-month Lachman's test and 6-month Pivot-shift test), and return-to-sport at 12 months between groups (ACLOAS grades 0-1 (continuous±thickened ligament and/or high intraligamentous signal) versus ACLOAS grades 2-3 (continuous but thinned/elongated or complete discontinuity)). RESULTS: Participants were aged 26±10 years at injury, 39% were female, 49% had concomitant meniscal injury. At 3 months, 90% (n=72) had evidence of ACL healing (ACLOAS grade 1: 50%; grade 2: 40%; grade 3: 10%). Participants with ACLOAS grade 1 reported better Lysholm Scale (median (IQR): 98 (94-100) vs 94 (85-100)) and ACLQOL (89 (76-96) vs 70 (64-82)) scores, compared with ACLOAS grades 2-3. More participants with ACLOAS grade 1 had normal 3-month knee laxity (100% vs 40%) and returned to pre-injury sport (92% vs 64%), compared with participants with an ACLOAS grades 2-3. Eleven patients (14%) re-injured their ACL. CONCLUSION: After management of acute ACL rupture with the CBP, 90% of patients had evidence of healing on 3-month MRI (continuity of the ACL). More ACL healing on 3-month MRI was associated with better outcomes. Longer-term follow-up and clinical trials are needed to inform clinical practice.

Unilateral tests of lower-limb function as prognostic indicators of future knee-related outcomes following anterior cruciate ligament injury: a systematic review and meta-analysis of 13 150 adolescents and adults.

OBJECTIVE: To investigate the prognostic capacity of individual hop tests, hop test batteries and other unilateral functional performance tests following anterior cruciate ligament (ACL) injury. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Six databases searched up to June 2021. ELIGIBILITY CRITERIA: Studies reporting associations between unilateral lower-limb function (eg, hop tests) following ACL injury and future (≥3 months) knee-related outcomes. RESULTS: Of 42 included studies (13 150 participants), all assessed the single-forward hop test and 32 assessed a repeated-forward hop test (crossover hop, triple hop, 6m-timed hop), mostly within a year after ACL injury/reconstruction. Results of meta-analyses indicated that higher single-forward and repeated-forward hop limb symmetry were associated with higher odds of return-to-sport 1-3 years post-ACL reconstruction (OR 2.15; 95% CI 1.30 to 3.54; OR 2.11; 95% CI 1.23 to 3.60, respectively). Higher single-forward and repeated-forward hop limb symmetry was associated with better self-reported symptoms and function 1-37 years after ACL injury (OR 2.51; 95% CI 1.62 to 3.88; OR 4.28; 95% CI 1.65 to 11.08, respectively). Higher limb symmetry on a repeated-forward hop does not appear to be associated with higher odds of successful rehabilitation without ACL reconstruction (OR 1.51; 95% CI 0.94 to 2.44). Achieving ≥90% limb symmetry on the single-forward hop was associated with reduced odds of knee osteoarthritis 5-37 years after ACL injury (OR 0.46; 95% CI 0.23 to 0.94). CONCLUSION: Very low certainty evidence suggests single-forward and repeated-forward hop tests are prognostic indicators for important knee-related outcomes in individuals after ACL injury and may help stratify individuals at risk of poor outcomes to target rehabilitation interventions. PROSPERO REGISTRATION NUMBER: CRD42018092197.

Higher age and present injury at the start of the season are risk factors for in-season injury in amateur male and female football players-a prospective cohort study.

PURPOSE: To describe the injury prevalence, injury pattern, and potential baseline risk factors for injuries in male and female adolescent and adult amateur football players. METHODS: This prospective study followed adolescent and adult amateur football players over one season March-October 2020. The study was completed by 462 players (130 men, age 20.0 ± 5.7, 14-46 years) who answered a baseline survey and a weekly web survey during the season. A total of 1456 weekly surveys were registered from males and 5041 from females. Injuries were recorded with the Oslo Sports Trauma Research Center Overuse Injury Questionnaire (OSTRC-O2). Potential baseline risk factors (age, performance of strength/conditioning training, participation in other sports, perceived importance of sporting success, self-rated training and match load, perceived balance between training/match load and recovery, previous/present injury at start of season, and injury beliefs) and their association with injury were analysed with Poisson regressions within each sex. RESULTS: Males reported 95 injuries (262 injury weeks, weekly prevalence 18.0% (95% CI 16.1-20.1)) and females 350 injuries (1206 injury weeks, weekly prevalence 23.9% (95% CI 22.8-25.1)). Gradual-onset injuries accounted for 57% of the injuries in males and 66% in females. For males, substantial injuries were most common in the hip/groin (weekly prevalence 3.8%), ankle (2.1%), posterior thigh (2.0%), and knee (2.0%); and for females, in the knee (4.3%), ankle (2.5%), and lower leg/Achilles tendon (2.0%). Significant risk factors for injury were higher age (rate ratio males 1.05 per year increase (95% CI 1.02-1.08), females 1.03 (95% CI 1.01-1.05)), and present injury at baseline (males 1.92 (95% CI 1.27-2.89), females 1.58 (95% CI 1.19-2.09)). CONCLUSION: At any given week, almost one in five male and one in four female amateur football players reported new or ongoing injuries. Hip/groin injuries were more frequent in males, while female players had a higher prevalence of knee injuries. Older players and those with an existing injury at the start of the season were more prone to new injury during the season. Rehabilitation of pre-season injury and complaints are key to reduce the injury burden in amateur football. LEVEL OF EVIDENCE: Level II. Trial registration number NCT04272047, Clinical trials.

The German version of the KOOS-Child questionnaire (Knee injury and Osteoarthritis Outcome Score for children) shows a good to excellent internal consistency and a high test-retest reliability in children with knee problems.

PURPOSE: The Knee Injury Osteoarthritis Outcome Score for children (KOOS-Child) is a self-administered, valid and reliable questionnaire for children and adolescents with knee disorders such as Osgood Schlatter disease, anterior knee pain, and patella dislocation. This study aimed to cross-culturally adapt the German version of the KOOS-Child questionnaire and test the reliability in two groups of children, one treated conservatively and the other surgically. METHODS: A forward-backward translation of the original questionnaire into the German language was conducted. Children and adolescents between 10 and 18 years of age with knee disorders were included. Two groups were compared: sample one consisted of 24 participants with knee pain [20.8% boys; mean age = 13.4 (1.8) years treated conservatively. These participants completed the KOOS-Child questionnaire twice within two weeks to assess test-retest reliability. The second sample included 23 subjects (21.7% boys; mean age = 15.3 (1.9) years] treated surgically due to a knee disorder. They completed the questionnaire before surgery and six months postoperatively. Test-retest reliability and internal consistency were assessed using Spearman's rank correlation and Cronbach's alpha. RESULTS: All subscales showed a good to excellent internal consistency at both measurement points in both groups (conservatively treated group: a = 0.88-0.95; surgery group a = 0.80-0.91), with the exception of the subscale knee problems (conservatively treated: a = 0.60 and 0.52; surgery: α = 0.77 and 0.66). Test-retest reliability was between r = 0.85 and 0.94. CONCLUSION: The predominantly good to excellent internal consistency and the high test-retest reliability justifies the use of the German adaptation of the KOOS-Child questionnaire as a reliable multidimensional instrument for measuring health status and therapeutic effects in adolescents' knee disorders.