Self-efficacy, symptoms and physical activity in patients with an anterior cruciate ligament injury: a prospective study

Self-efficacy belief may be of major importance for the outcome of rehabilitation after sports-related injuries. A new instrument, the Knee Self-Efficacy Scale (K-SES), was used to evaluate the role of perceived self-efficacy in patients with an anterior cruciate ligament (ACL) injury. The purpose of this prospective exploratory study was to describe the patients' perceived self-efficacy at various times post-injury and surgery, respectively, for responsiveness of the K-SES and to correlate the K-SES score with the patients' subjective symptoms. The purpose was also to describe the influence of gender, age and physical activity on the patients' perceived self-efficacy. Thirty recently injured patients with an ACL-deficient knee and 33 patients who had undergone ACL reconstruction reported their physical activity level and their perceived self-efficacy on four test occasions during a 1-year period. The patients' subjective knee symptoms were documented on two of the test occasions. A significant increase in the K-SES score was seen after injury as well as after surgery, during the course of rehabilitation. Pre-operatively, men's perceived self-efficacy was significantly (P=0.013) higher compared with women's self-efficacy. Patients with a high baseline (pre-injury) physical activity level (Tegner 7-10) perceived their self-efficacy as being significantly (P=0.005) higher pre-operatively compared with patients with a low baseline activity level (Tegner 3-6). "Younger" (age 17-29), recently injured patients, perceived their self-efficacy as being significantly (P=0.034) higher compared with "older" patients (age 30-54). At the 12-month test, 15 of 30 patients with an ACL-deficient knee and 15 of 33 patients who had undergone ACL reconstruction reported that they had returned or nearly returned to their baseline physical activity level. The subjective knee outcome score, as measured by the Knee Injury and Osteoarthritis Outcome Score (KOOS), improved significantly (P<0.01) during rehabilitation, apart from the KOOS subscale of "pain" (P=0.077) for patients who had undergone ACL reconstruction. There was a "low" to "strong" correlation (r(s)=0.0-0.7) between the K-SES and the five subscales in the KOOS. We conclude from the present study that K-SES has good responsiveness with significantly increased self-efficacy during the rehabilitation process for patients with an ACL-deficient knee as well as for patients who had undergone ACL reconstruction. The improvement in perceived self-efficacy could, however, only be partly explained by the improvement in subjective symptoms. Furthermore, self-efficacy differed significantly with gender, age and physical activity level early in the rehabilitation process.     

Anterior cruciate ligament injury after more than 20 years: I. Physical activity level and knee function

Little is known about physical activity level and knee function including jump capacity and fear of movement/reinjury more than 20 years after injury of the anterior cruciate ligament (ACL). Seventy persons with unilateral ACL injury participated (23 ± 2 years post‐injury): 33 treated with physiotherapy in combination with surgical reconstruction (ACL_R), and 37 treated with physiotherapy alone (ACL_PT). These were compared with 33 age‐ and gender‐matched controls. Assessment included knee‐specific and general physical activity level [Tegner activity scale, International Physical Activity Questionnaire (IPAQ)], knee function [Lysholm score, Knee injury and Osteoarthritis Outcome Score (KOOS)], jump capacity (one‐leg hop, vertical jump, side hops), and fear of movement/reinjury [Tampa Scale for Kinesiophobia (TSK)]. Outcomes were related to degree of osteoarthritis (OA). ACL‐injured had lower Lysholm, KOOS, and Tegner scores than controls (P < 0.001), while IPAQ score was similar. ACL‐injured demonstrated inferior jump capacity in injured compared with noninjured leg (6–25%, P < 0.001–P = 0.010 in the different jumps), while noninjured leg had equal jump capacity as controls. ACL groups scored 33 ± 7 and 32 ± 7 of 68 on TSK. Lower scores on Lysholm and KOOS symptom were seen for persons with moderate‐to‐high OA than for no‐or‐low OA, while there were no differences for physical activity and jump capacity. Regardless of treatment, there are still negative knee‐related effects of ACL injury more than 20 years later.     

Self-efficacy of knee function as a pre-operative predictor of outcome 1 year after anterior cruciate ligament reconstruction

The knee self-efficacy scale (K-SES) has been shown to have good reliability, validity and responsiveness during rehabilitation for patients' perceived self-efficacy of knee function. Determinants of self-efficacy of knee function 1 year after ACL reconstruction have been found to be the patients' internal locus of control and knee symptoms in sports and recreation. The predictive ability of perceived self-efficacy of knee function measured by the K-SES has not been studied in terms of patient outcome after an ACL reconstruction. The purpose of this study was to explore the potential for pre-operative self-efficacy of knee function measured by the K-SES to predict patient outcome in terms of physical activity, knee symptoms and muscle function 1 year after an ACL reconstruction. Thirty-eight patients were evaluated for outcome in terms of physical activity with the Tegner activity scale and the physical activity scale (PAS), knee symptoms with the Lysholm knee scoring scale and the knee injury and osteoarthritis outcome score (KOOS) and knee function with ability tests for muscle function 1 year after ACL reconstruction. Multiple regression and logistic multiple regression analysis were used to evaluate the K-SES as a possible predictor of outcome. The patients' present perceived self-efficacy of knee function (K-SES(Present)) pre-operatively was a significant predictor (P = 0.016) of the patients returning to their intensity and frequency of physical activity (PAS) 1 year after ACL reconstruction, when adjusted for age, gender and pre-injury physical activity level (Tegner(Pre-injury)) (odds ratio = 2.1). The patients' perceived future self-efficacy of knee function (K-SES(Future)) pre-operatively was a significant predictor (P = 0.045) of their self-rated knee function in sports/recreational activities (KOOS(Sports/recreation)) at the 1-year follow-up, when adjusted for age, gender and Tegner(Pre-injury )(R (2 )=0.25). The pre-operative K-SES(Future) was also a significant predictor (P = 0.023) of the patients' knee-related quality of life (KOOS(Qol)), at the 1-year follow-up, when adjusted for age, gender and Tegner(Pre-injury) (R (2 )=0.23). The pre-operative K-SES(Future) was furthermore a significant predictor of an acceptable outcome 1 year after surgery, on the Lysholm knee scoring scale (P = 0.003, odds ratio = 1.7), as well as on KOOS(Sports/recreation) (P = 0.002, odds ratio = 1.6) and knee-related quality of life (KOOS(Qol)) (P = 0.037, odds ratio = 1.4), when adjusted for age, gender and Tegner(Pre-injury). The pre-operative K-SES(Future) was also a significant predictor (P = 0.04) of an acceptable outcome 1 year after surgery, on the one-leg hop for distance (odds ratio = 2.2), when adjusted for age, gender and Tegner(Pre-injury). In conclusion, this study indicates that patients' perceived self-efficacy of knee function pre-operatively is of predictive value for their return to acceptable levels of physical activity, symptoms and muscle function 1 year after ACL reconstruction.     

Factors affecting outcome after anterior cruciate ligament injury: a prospective study with a six-year follow-up

The aim of this study was to investigate whether gender, age, stable personality traits, associated meniscus and/or articular cartilage injuries, treatment (non-operative or reconstructive surgery), additional subsequent trauma to the anterior cruciate ligament (ACL)-injured knee and activity level before injury affect the intermediate outcome after ACL injury. The primary outcome was the Knee injury and Osteoarthritis Outcome Score (KOOS). Fifty-seven patients, 18-50 years old with an acute, unilateral ACL tear were included in the study. At the time of inclusion, the patients completed the Tegner score, regarding activity level before injury, and Swedish universities Scales of Personality (SSP). At follow-up, after 5.6 years they completed the KOOS, the Tegner score and a general questionnaire concerning ACL reconstruction and subsequent knee trauma. The subjects who had sustained additional trauma subsequent to their ACL injury had a significantly worse outcome according to the KOOS than those who had not. Furthermore, low ratings in the embitterment scale in the SSP were correlated to a better outcome in the KOOS. Treatment did not affect the KOOS total score. However, the non-operatively treated subjects had a significantly better outcome according to the knee-related quality-of-life domain in the KOOS.     

Outcome and knee-related quality of life after anterior cruciate ligament reconstruction: a long-term follow-up

The aim of the present investigation was to study patient-reported long-term outcome after anterior cruciate ligament (ACL) reconstruction. On an average 11.5 years after ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft 56 patients were asked to answer four different questionnaires about their knee function and knee-related quality of life. Another aim was to study whether there were any correlations between clinical tests, commonly used for evaluating patients with ACL injuries, which were performed 2 years after ACL reconstruction, and patient-reported outcome in terms of knee function and knee-related quality of life on an average 9.5 years later. All patients who had unilateral BPTB ACL reconstructions were examined at 2 years and on an average 11.5 years after surgery. At 2 years one-leg hop test for distance, isokinetic muscle torque measurement, sagittal knee laxity, Lysholm knee scoring scale and Tegner activity scale were used for clinical evaluation. At the follow-up on an average 9.5 years later the patients were evaluated with knee injury osteoarthritis outcome score (KOOS), short form health survey (SF 36), Lysholm knee scoring scale and Tegner activity scale. The SF-36 showed that the patients had a similar health condition as an age- and gender-matched normal population in Sweden on an average 11.5 years after ACL reconstruction. There was no correlation between the results of one-leg hop test for distance, isokinetic muscle torque measurement, sagittal knee laxity evaluated 2 years after surgery and the result of KOOS (function in sport and recreation, knee-related quality of life) and SF-36 evaluated on an average 11.5 years after surgery. We also compared patients that 2 years after surgery demonstrated a side-to-side difference in anterior–posterior knee laxity of more than 3 mm with those with 3 mm or less and found no significant group differences in terms of knee function as determined with KOOS. We found no correlation between the results of KOOS and SF-36 at the long-term follow-up and the time between injury and surgery, age at surgery or gender, respectively. We conclude that there is no correlation between patient-reported knee function in sport and recreation and knee-related quality of life on an average 11.5 years after BPTP ACL reconstruction and the evaluation methods used 2 years after surgery.     

Reconstruction of the anterior cruciate ligament with the iliotibial band autograft in patients with chronic knee instability

We performed combined internal and external anterior cruciate ligament (ACL) reconstruction with the iliotibial band autograft in 169 consecutive patients with chronic ACL insufficiency who were followed up for 24-61 months. Of these, 155 (91%) agreed to an additional independent observer follow-up after 24-92 months. Eight patients (5%) had sustained a rerupture/elongation of the graft and were operated on again; nine (6%) had sustained a tear of the contralateral ACL. Knee function and activity increased after the reconstruction. Lysholm scores improved from median 81 preoperatively to 99 at follow-up and Tegner scores from median 4 to 7. At follow-up 97 (71%) were active at the same level as prior to injury. In 17 of the 40 patients (12%) dropping to a lower activity level this was due to knee problems. The side-to-side difference in anterior-posterior knee laxity was more than 3 mm in 18 knees (13%) and more than 5 mm in 3 knees (2%). Including eight reruptures, this results in a "stability" failure rate of 8.8%. The overall IKCD rating showed normal knee function in 88 (73%) and nearly normal knee function in 30 (25%). Anterior knee pain was present in 14 (10%) of the patients at follow-up. Patients with isolated ACL injury had higher Lysholm scores and Tegner scores than patients with associated injuries. No clinical signs of varus knee development were seen. Of the 155 patients 94% would have the procedure repeated if necessary with the knowledge that they have today. The combined internal and external iliotibial band procedure can restore knee stability and function in the majority of chronic ACL-insufficient knees.     

Return to knee-strenuous sport after anterior cruciate ligament reconstruction: a report from a rehabilitation outcome registry of patient characteristics

Purpose

To characterise patients who returned to knee-strenuous sports after an anterior cruciate ligament (ACL) reconstruction.

Methods

Data from isotonic tests of muscle function and patient-reported outcome measures, Tegner activity scale (Tegner and Lysholm in Clin Orthop Relat Res 198:43–49, 1985), physical activity scale, knee injury and osteoarthritis scale and knee self-efficacy scale were extracted from a registry. The 157 included patients, 15–30 years of age, had undergone primary ACL reconstruction and were all involved in knee-strenuous sports, i.e. pre-injury Tegner of 6 or higher. Return to sport was studied in two different ways: return to pre-injury Tegner and return to knee-strenuous sport (Tegner 6).

Results

Fifty-two patients (33 %), who returned to pre-injury Tegner, 10 months after surgery, were characterised by better subjective knee function measured with the knee injury and osteoarthritis outcome score (p < 0.05), compared with patients who did not. These patients also had higher perceived self-efficacy of knee function (p < 0.01), measured with knee self-efficacy scale. Eighty-four patients (54 %) who returned to knee-strenuous sports, i.e. Tegner 6 or higher, were characterised by higher goals for physical activity (p < 0.01) and higher self-efficacy of future knee function (p < 0.05). Strength measurements showed that women who returned to sports were stronger in leg extension than women who did not. No differences were found in Limb Symmetry Index for knee strength or jumping ability.

Conclusion

Patients who returned to sports after ACL reconstruction had better subjective knee function and higher self-efficacy of knee function. Results highlight that further emphasis should be placed at psychological factors during rehabilitation of patients after ACLR.

Level of evidence

II.

     

Factors affecting return to sports after anterior cruciate ligament reconstruction with patellar tendon and hamstring graft: a prospective clinical investigation

In athletes, anterior cruciate ligament (ACL) reconstruction is recommended after injury to restore the normal knee function and allow subsequent return to sport. Successful ACL reconstruction with patellar tendon (PT) and hamstring tendon (HT) grafts combined with a well-structured rehabilitation program could bring athletes back to their previous level of sport activities. We prospectively followed-up 100 athletes who underwent ACL reconstruction with either PT (n=50) or HT grafts (n=50). Evaluation was done pre-operatively and post-operatively (3, 6, 12, and 24 months) using International Knee Documentation Committee (IKDC), Lysholm, Noyes, and Tegner scales. Subjective assessment numeric evaluation (SANE), knee activity rating scale (Marx) and a psychological profile questionnaire (psychovitality) were also utilized. Objective evaluations included isokinetic tests and computerized knee motion analysis. Data gathered were statistically analyzed using the Mann–Whitney non-parametric U-test. Among the 100 patients who have undergone ACL reconstruction, 65% returned to the same level of sports, 24% changed sports and 11% ceased sport activities. No significant difference (P>0.05) in outcome between PT and HT grafts were observed. No significant differences (P>0.05) were noted between athletes who “returned” to their previous sport and those who “did not return” to sports at the same level when using the IKDC, Lysholm, Noyes, and Tegner knee evaluation scales. However, significant difference was observed with the knee scores obtained by those who returned and those who completely ceased participation in sport activities. Computerized laxity test revealed that 90% of these patients have less than 3 mm side-to-side difference with no significant difference between HT and PT groups. Patients who “returned to sports” obtained significantly better scores with the Marx scale (P=0.001) and the psychovitality questionnaire (P=0.001) than those who did not. Conventional knee scales including IKDC, Lysholm, Noyes, and Tegner remain as reliable means of evaluating outcome of ACL reconstruction. However, the data obtained from these are not sufficient to determine which among the patients who had knee reconstruction can successfully return to sport. The use of the Marx knee activity rating scale and the evaluation of the athletes’ psychological profile are additional scales that can be useful in determining which among the patients treated have a better chance of returning to their pre-injury activity levels.     

Early rehabilitation of acute anterior cruciate ligament injury—a randomized clinical trial

The efficacy of a 6-week rehabilitation program was evaluated in 100 consecutive patients, age 15–42 years, with acute anterior cruciate ligament (ACL) injury. Arthroscopy revealed associated lesions in 82% of the patients. Except for resections on menisci with large and unstable lesions, no surgery was performed. The patients were randomly assigned to supervised training or self-monitored training after instruction. Results: At the 6-week follow-up there was no difference between the groups with regard to pain at rest, pain during walking, or experience of giving-way episodes, Tegner activity level or Lysholm knee score. Only 2 of the 100 patients were observed without joint mobility restriction. The only significant difference between the groups was the improvement of muscle function in men in the supervised training group. Conclusion: Six weeks' rehabilitation is too short a time period from original injury to obtain normal mobility and restored knee function.     

Outcome after knee dislocations: a 2–9 years follow-up of 85 consecutive patients

Dislocation of the knee is a relatively rare injury with modern arthroscopic techniques, operative reconstruction has become the standard of care. The primary aim of this study was to prospectively follow a large, consecutive series of patients with knee dislocation to document associated injuries, surgical treatment, knee function, and knee osteoarthritis (OA) at a minimum of 2 years follow-up. Hundred and twenty-two consecutive patients with a traumatic knee dislocation (Schenck II–IV) were treated at the Oslo University Hospital, Ulleval, between May 1996 and December 2004. Follow-up evaluation of 85 patients consisted of evaluation of knee joint laxity using the KT1000, the Lachman test, the pivot shift test, the reversed pivot shift, the posterior drawer test, the dial test, and the varus–valgus tests compared to the uninjured knee. Knee function was evaluated using the Lysholm score, the Tegner activity level score, the IKDC2000 score, and four single leg hop tests. Radiographic evaluation was performed using the Kellgren & Lawrence classification grade 0–4. Knee function at a minimum of 2 years after surgery disclosed a Lysholm score of a median of 83, a Tegner activity score of 5, and above 83% on all single leg hop tests compared to the uninjured side. Knee function was lower in the patients with a knee dislocation caused by high-energy trauma compared to low energy trauma. Eighty-seven percent had Kellgren & Lawrence grade 2 or higher for the injured knee compared to 35% for the uninjured knee.     

Predictive factors for 12‐month outcome after anterior cruciate ligament reconstruction

There is a lack of knowledge regarding predictive factors for a successful clinical outcome after an anterior cruciate ligament (ACL) reconstruction. The aim was to investigate pre‐operative factors that may predict good outcomes as measured with the subscales Function in sports and recreation and Quality of life in Knee injury Osteoarthrithis Outcome Score (QOL‐KOOS), one‐leg hop test and Tegner Activity Scale 12 months after ACL reconstruction. Sixty‐four patients, operated with either patellar or hamstring tendon graft, were included. Demographics, range of motion, anterior knee laxity, pivot shift, muscle‐torques, anterior knee pain (AKP) and knee function were registered pre‐operatively and used in a multiple regression model. Results show less degree of AKP and low influence on knee function to be the most important predictors for good outcome in Sport/Rec‐KOOS (explained 31% of variances). Less AKP was in addition the most important predictor for QOL‐KOOS (14%). Patellar‐tendon graft, in favor of hamstring tendon graft, explained 8% of the improvement in the Tegner Activity Scale. In conclusion, a low degree of AKP was found to be the most important predictor for good clinical outcome 12 months after ACL reconstruction. Future studies, including psychological parameters, should use analyses that have the potential to control for independency between variables.     

Anterior cruciate ligament reconstruction with alternative tibial tunnel: early results after accelerated weight-bearing

In this study an autologous graft of 50%–60% of the patellar tendon (mid-portion) was used for anterior cruciate ligament (ACL) reconstruction in 50 patients (19 women, 31 men; mean age 26 years). The distal part of the graft was fixed in a tunnel running from the centre of the anatomical tibial attachment of the ACL to the place where the bone block of the graft was removed from the tibial tubercle. A rehabilitation programme with accelerated weight-bearing postoperatively without external protection was followed. Evaluation consisting of function and stability tests, activity level and Lysholm’s subjective function score took place an average of 26 months postoperatively; 35 of 50 patients had an additional evaluation monthly for 1 year and 6 monthly after 1 year. The stability tested manually after an average of 26 months postoperatively was good in 45 patients; 5 of them had a positive Pivot shift test (one 1+, two 2+, two 3+). Only 2 of these patients complained of giving way of the knee. All patients regained good knee function. The average postoperative Lysholm score was 85 (SD 14.5) and the subjective stability of the knee was described as ‘good’ in 41 patients, and ‘poor’ in 9. The objective stability was good in 7 of these 9 patients. The mean Tegner score was 6.5 (SD 1.9). The mean time to resuming activities was 5.4 weeks for full weight-bearing, 10 weeks for running, 13.5 weeks for going back to work and 6 months for returning to previous sports. In the group of 35 patients who underwent an additional evaluation, no change in manual stability was found during observation except for 3 of them. No patellar ruptures were seen. The operation technique used in this study appears to allow accelerated knee rehabilitation after ACL reconstruction.     

The long-term course after treatment of acute anterior cruciate ligament ruptures. A 9 to 16 year followup

Acute total ACL (N = 60) and concomitant medial collateral ligament (N = 46) ruptures were repaired in 60 patients (mean age, 28 years) without augmentation. Menisci were removed in 23 knees. Fifty-three (88%) of the patients were reexamined 9 to 16 years later with special emphasis on manual and instrumented stability testing (Stryker, Genucom), knee function score (Lysholm), and activity level (Tegner). Standing roentgenograms (30 degrees of knee flexion) were taken in 69% of the patients. At followup, an ACL reconstruction had been performed in seven patients (12%) due to symptomatic instability. Sixty-four percent of the knees had a positive Lachman sign and 40% a positive pivot shift. Sagittal laxity difference was +3 mm or more in 57%. Knee function score was a mean of 86 +/- 12 points. The mean activity level had changed from recreational team sports (Level 7) to recreational individual sports (Level 5). Only patients with good knee stability were able to perform demanding sports and could continue at their desired activity level. Osteoarthritis of slight to moderate degree (Fairbank I/II) was found in 58% of the patients younger than 35 years of age at the time of trauma and in 87% of the older patients. Knees with intact menisci had less osteoarthritis than knees with removed menisci (P less than 0.05).     

Analysis of subjective, objective and functional examination tests after anterior cruciate ligament reconstruction A follow-up of 527 patients

This study included 527 patients (178 female and 349 male) with unilateral anterior cruciate ligament (ACL) rupture who underwent arthroscopic ACL reconstruction using bone-patellar tendon-bone autograft and interference screw fixation. The follow-up examination was performed by independent observers at a median of 38 (21-68) months after the index operation. At the follow-up, the Lysholm score was 86 (14-100) points, the Lysholm instability subscore was 22 (0-25) points and the Lysholm pain subscore was 19 (0-25) points. The Tegner activity level was 6 (1-10). The one-leg-hop test was 91 (0-167)% of the non-injured knee. The difference in the anterior side-to-side laxity as measured with the KT-1000 arthrometer at 89 Newton (N) was 1.5 (-5-13) mm and the total KT-1000 side-to-side difference at 89 N was 2 (-7-11) mm. Using the International Knee Documentation Committee (IKDC) evaluation system, 177 (33.6%) patients were classified as normal (group A), 211 (40%) as nearly normal (group B), 109 (20.7%) as abnormal (group C) and 30 (5.7%) as severely abnormal (group D). The highest correlation coefficients were recorded between the IKDC evaluation system and the Lysholm score (p = 0.66), the patients' subjective evaluation (p = 0.53), the Tegner activity level (p = 0.34), all the laxity tests (p > or = 0.34) and the one-leg-hop test (p = 0.28). The resumption of sporting activities and work as evaluated by the Tegner activity level correlated with the patients' subjective evaluation (p = 0.34) but did not correlate with the laxity tests, i.e., the manual Lachman test (p = -0.06) and the total and anterior KT-1000 tests (p = -0.06). Furthermore, none of the laxity tests correlated with the functional tests or the patients' subjective evaluation. We conclude that the IKDC evaluation system is a reliable and useful tool for evaluating the post-operative outcome after an ACL reconstruction.     

Post-operative use of knee brace in bone-tendon-bone patellar tendon anterior cruciate ligament reconstruction: 5-year follow-up results of a randomized prospective study

Sixty patients were prospectively randomized to brace and no-brace groups after bone-tendon-bone patellar tendon anterior cruciate ligament (ACL) reconstruction. The brace group wore a rehabilitation knee brace for 12 weeks post-operatively, while the no-brace group was mobilized immediately, and crutches were discarded 2 weeks post-operatively. The groups were comparable with respect to age, gender, time from injury to surgery and concomitant injuries. There were no differences either pre-operatively or 5 years post-operatively (80% of patients reviewed) between the groups in terms of the knee score (Lysholm), activity level (Tegner), degree of laxity or isokinetic peak muscle torque. Thus it appears that knee braces are not needed in the post-operative rehabilitation after ACL reconstruction with the patellar tendon graft.     

Full-thickness cartilage lesion do not affect knee function in patients with ACL injury

There is debate in the literature regarding the impact of full-thickness cartilage lesion on knee function in patients with ACL injury. The hypothesis of the current study is that a full-thickness cartilage lesion at the time of ACL reconstruction does not influence knee function as measured by the Knee injury and Osteoarthritis Outcome Score (KOOS) in patients with ACL injury. Of the 4,849 primary ACL surgery cases in the Norwegian National Knee Ligament Registry as of 12 December 2007, 30 patients met the following inclusion criteria: a full-thickness cartilage lesion (International Cartilage Repair Society [ICRS] grades 3 and 4), age less than 40 years, no associated pathology or meniscus injury, and less than 1 year between knee injury and ACL reconstruction. Each of the 30 patients in this study group was matched with two control participants without cartilage lesions. Preoperatively, the patients completed the KOOS, and the surgeon recorded the location and size of the cartilage lesion and graded the cartilage injury according to ICRS standards. There were no significant differences between the case and control groups for any of the five subscales of the KOOS. A cartilage lesion was located in the medial compartment in 67% of the cases, in the lateral compartment in 20% of the cases, and in the patellofemoral joint in 13% of the cases. In conclusion, the combination of a full-thickness cartilage lesion and an ACL rupture did not result in inferior knee function at the time of the ACL reconstruction as measured by the KOOS.     

Who chooses anterior cruciate ligament reconstruction and why? A 2‐year prospective study

The purpose of this study was to investigate possible differences in age, gender, Tegner activity level prior to injury, knee joint laxity and the variables evaluated with knee osteoarthritis outcome score (KOOS) between patients who chose non-operative treatment (NT), early reconstruction (ER) and late reconstruction (LR). A second aim was to study whether patients who choose ER choose surgical treatment for the same reasons as patients who choose LR. Seventy-two patients with an acute (< 1 month) anterior cruciate ligament (ACL) tear, who had not yet decided to have surgery, were included in this study. They filled out the Tegner activity score, assessing preinjury activity level, KOOS and underwent KT-1000 arthrometer examination. The 36 subjects who later chose reconstruction were questioned about reasons for their decision. A high preinjury activity level was associated with the choice of ACL reconstruction, but the choice of treatment was not associated with age, gender or the outcome variables measured with KOOS or KT-1000. Fifteen out of the 20 (75%) subjects who chose ER based their decision on assumptions of future problems and not on experience of knee function. Fourteen out of 16 (88%) subjects, who chose reconstructive surgery later, based their decision on experience of knee function.     

Inferior results after revision ACL reconstructions: a comparison with primary ACL reconstructions

Purpose

Anterior cruciate ligament (ACL) ruptures are common, especially among young athletes, and such injuries may have considerable impact on both sport careers and everyday life. ACL reconstructions are successful for most patients, but some suffer from persistent giving-way symptoms and/or re-ruptures requiring revision surgery. The aim of this study was to evaluate the results after revision ACL reconstructions and compare them with the results in a control group consisting of primary ACL reconstructions.

Methods

This retrospective study included 56 patients undergoing revision ACL reconstruction and 52 patients receiving primary ACL reconstructions. The follow-up evaluation included clinical examination, instrumented laxity testing, testing of muscle strength, Tegner activity score, Lysholm score, Knee injury and osteoarthritis outcome score (KOOS) and radiological grading of osteoarthritis.

Results

The median time from the last ACL reconstruction to follow-up was 90 months in the revision ACL reconstruction group and 96 months in the primary ACL reconstruction group. The revision group had significantly inferior KOOS and Lysholm scores compared with the primary group. Patients in the revision group also showed greater laxity measured with the pivot shift test, a larger reduction in the Tegner activity score, reduced muscle strength in the injured knee, and more severe radiological osteoarthritis; however, no difference in anterior-posterior translation was found.

Conclusion

Inferior results were found on several of the testing parameters in the revision group compared with the primary group. Patients should receive this information prior to revision ACL reconstructions.

Level of evidence

III.     

Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial

In this prospective randomised study two treatments after non-traumatic medial meniscal tear diagnosed with radiological examination and magnetic resonance imaging were compared; arthroscopic partial meniscectomy followed by supervised exercise or supervised exercise alone. The aim was to evaluate knee function and physical activity. Ninety patients (mean age 56 years) were evaluated using the Knee Injury and Osteoarthritis Outcome Score, the Lysholm Knee Scoring Scale, the Tegner Activity Scale and a Visual Analogue Scale for knee pain prior to the intervention, after 8 weeks of exercise and after 6 months. According to the outcome scores arthroscopic partial medial meniscectomy combined with exercise did not lead to greater improvement than exercise alone. After the intervention both groups reported decreased knee pain, improved knee function and a high satisfaction (P < 0.0001). Forty-one per cent of the patients returned to their pre-injury activity level after 6 months. In conclusion, when evaluated with outcome scores, arthroscopic partial medial meniscectomy followed by supervised exercise was not superior to supervised exercise alone in terms of reduced knee pain, improved knee function and improved quality of life.     

The importance of the meniscus in unstable knees. A comparative study

This study analyzes differences in knee function in ACL deficient knees with different meniscus status. Eighty patients, 12 women and 68 men, were matched in four groups according to sex, age, knee injuries, and follow-up time. Group I had two intact menisci; Group II, one meniscus successfully repaired; Group III, one meniscus removed; and Group IV, both menisci removed. The ACL was repaired acutely or reconstructed later in most cases and other significant ligament injuries were treated. All patients were reexamined clinically 6 to 8 years after injury. Knee function was recorded using the Lysholm knee function score. Activity level before injury and at followup was rated with the Tegner scale. Stability was tested and weightbearing roentgenograms were taken. There was a higher frequency of ACL reconstructions in Groups I and II, but instability was the same in all groups. No difference was found in Lysholm score (range, 86 to 92). The activity level was higher in Group IV at followup. A lower frequency of motion impairment was found in Group III, (20% versus 50%). Subjective evaluation was similar and positive in all groups. Group I had six meniscus ruptures during the follow-up period. In Group II three of the repaired menisci were removed, as were two of the contralateral menisci in Group III. Roentgenograms, available in 55 of 80 cases, showed osteoarthritis in 65%. There were no differences in the frequency of osteoarthritis among the first three groups, but Group IV had a higher incidence of osteoarthritic changes. Osteoarthritis did not result in lower knee function, poorer subjective evaluation, or increased impairment of motion.(ABSTRACT TRUNCATED AT 250 WORDS)