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1.	Agnvall, C., et al. (author) Range of Hip Joint Motion Is Correlated With MRI-Verified Cam Deformity in Adolescent Elite Skiers 2017 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 5:6 Journal article (peer-reviewed)abstract Background: Radiologically verified cam-type femoroacetabular impingement (FAI) has been shown to correlate with reduced internal rotation, reduced passive hip flexion, and a positive anterior impingement test. Purpose: To validate how a clinical examination of the hip joint correlates with magnetic resonance imaging (MRI)-verified cam deformity in adolescents. Methods: The sample group consisted of 102 adolescents with the mean age 17.7 +/- 1.4 years. The hip joints were examined using MRI for measurements of the presence of cam (alpha-angle >55) and clinically for range of motion (ROM) in both supine and sitting positions. The participants were divided into a cam and a noncam group based on the results of the MRI examination. Passive hip flexion, internal rotation, anterior impingement, and the FABER (flexion, abduction, and external rotation) test were used to test both hips in the supine position. With the participant sitting, the internal/external rotation of the hip joint was measured in 3 different positions of the pelvis (neutral, maximum anteversion, and retroversion) and lumbar spine (neutral, maximum extension, and flexion). Results: Differences were found between the cam and noncam groups in terms of the anterior impingement test (right, P = .010; left, P = .006), passive supine hip flexion (right: mean, 5; cam, 117; noncam, 122 [P = .05]; and left: mean, 8.5; cam, 116; noncam, 124.5 [P = .001]), supine internal rotation (right: mean, 4.9; cam, 24; noncam, 29 [P = .022]; and left: mean, 4.8; cam, 26; noncam, 31 [P = .028]), sitting internal rotation with the pelvis and lumbar spine in neutral (right: mean, 7.95; cam, 29; noncam, 37 [P = .001]; and left: mean, 6.5; cam, 31.5; noncam, 38 [P = .006]), maximum anteversion of the pelvis and extension of the lumbar spine (right: mean, 5.2; cam, 20; noncam, 25 [P = .004]; and left: mean, 5.85; cam, 20.5; noncam, 26.4 [P = .004]), and maximum retroversion of the pelvis and flexion of the spine (right: mean, 8.4; cam, 32.5; noncam, 41 [P = .001]; and left: mean, 6.2; cam, 36; noncam, 42.3 [P = .012]). The cam group had reduced ROM compared with the noncam group in all clinical ROM measures. Conclusion: The presence of cam deformity on MRI correlates with reduced internal rotation in the supine and sitting positions, passive supine hip flexion, and the impingement test in adolescents.
2.	Al-Ani, Z., et al. (author) Radiofrequency Microtenotomy or Physical Therapy for Achilles Tendinopathy: Results of a Randomized Clinical Trial 2021 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 9:12 Journal article (peer-reviewed)abstract Background: Achilles tendinopathy is a painful disorder, and various treatment options are available. Bipolar radiofrequency microtenotomy (RFM) has shown promising results in treating tendinosis. Purpose/Hypothesis: The purpose was to compare the results between treatment with bipolar RFM and physical therapy (PT) for patients with midportion Achilles tendinopathy. It was hypothesized that RFM would be equivalent or superior to PT. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 38 patients with midportion Achilles tendinopathy were evaluated for 2 years. The patients were randomized to receive either RFM or PT. There were 20 patients in the RFM group and 18 patients in the PT group. Clinical outcomes were assessed using the visual analog scale (VAS) for pain and the Foot and Ankle Outcome Score (FAOS). The degree of tendinosis was evaluated with magnetic resonance imaging (MRI) of the affected ankle performed before intervention and 2 years after intervention. Results: In both groups, the VAS scores at the 2-year follow-up were significantly improved compared with preintervention: from 7.2 ± 1.5 to 1.0 ± 1.4 for the RFM group and from 5.9 ± 1.3 to 3.1 ± 1.8 for the PT group (P <.01 for both). Compared with the PT group, the RFM group had significantly better VAS scores at both the 1- and 2-year follow-ups (P <.01 for both) and better scores on 4 of the 5 FAOS subscales at the 2-year follow-up (P <.01 for all). MRI revealed an improvement in the tendinosis score in both groups, without any significant difference between the groups. Conclusion: In this randomized study, the clinical assessments revealed significant improvements in the VAS, FAOS, and tendinosis score as seen on MRI 2 years after intervention with either RFM or PT in patients with midportion Achilles tendinopathy. The improvement was significantly better in the RFM group with regard to VAS and FAOS, but not in the MRI appearance. Registration: NCT03274557 (ClinicalTrials.gov identifier). © The Author(s) 2021.
3.	Andersson, Jonny K, 1972, et al. (author) Hand, Wrist, and Forearm Injuries in Male Professional Soccer Players: A Prospective Cohort Study of 558 Team-Seasons From 2001-2002 to 2018-2019 2021 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 9:1 Journal article (peer-reviewed)abstract Background: The literature on upper extremity injuries in professional soccer players is scarce, and further insight into the onset and cause of these injuries as well as potential differences between goalkeepers and outfield players is important. Purpose: To investigate the epidemiology of hand, wrist, and forearm injuries in male professional soccer players between 2001 and 2019. Study Design: Descriptive epidemiology study. Methods: Between the 2001-2002 and 2018-2019 seasons, 120 European male soccer teams were followed prospectively for a varying number of seasons (558 team-seasons in total). Time-loss injuries and player-exposures to training sessions and matches were recorded on an individual basis in 6754 unique players. Injury incidence was reported as the number of injuries per 1000 player-hours, and between-group differences were analyzed using Z statistics and rate ratios (RRs) with 95% CIs. Between-group differences in layoff time were analyzed. Results: In total, 25,462 injuries were recorded, with 238 (0.9%) of these affecting the hand (71.4%; n = 170), wrist (16.8%; n = 40), and forearm (11.8%; n = 28), producing an incidence of 0.065 injuries per 1000 hours. A majority of the injuries were traumatic with an acute onset (98.7%; n = 235). Fractures were the most common injuries recorded (58.8%; n = 140), often involving the metacarpal bones (25.2%; n = 60) and phalanges (10.1%; n = 24). The injury incidence was significantly higher for goalkeepers (115 injuries; 0.265 per 1000 hours) compared with outfield players (123 injuries; 0.038 per 1000 hours) (RR, 7.0 [95% CI, 5.4-9.0]). Goalkeepers also had a significantly longer mean layoff time than outfield players (23 +/- 27 vs 15 +/- 27 days; P = .016). Conclusion: Injuries to the hand, wrist, and forearm constituted less than 1% of all time-loss injuries in male professional soccer players. Fractures were most common and constituted more than half of all injuries. Goalkeepers had a 7-fold higher incidence and an over 1-week longer mean layoff time compared with outfield players.
4.	Ardern, C. L., et al. (author) 2018 International Olympic Committee Consensus Statement on Prevention, Diagnosis, and Management of Pediatric Anterior Cruciate Ligament Injuries 2018 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 6:3 Journal article (peer-reviewed)abstract In October 2017, the International Olympic Committee hosted an international expert group of physical therapists and orthopaedic surgeons who specialize in treating and researching pediatric anterior cruciate ligament (ACL) injuries. The purpose of this meeting was to provide a comprehensive, evidence-informed summary to support the clinician and help children with ACL injury and their parents/guardians make the best possible decisions. Representatives from the following societies attended: American Orthopaedic Society for Sports Medicine; European Paediatric Orthopaedic Society; European Society for Sports Traumatology, Knee Surgery, and Arthroscopy; International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; Pediatric Orthopaedic Society of North America; and Sociedad Latinoamericana de Artroscopia, Rodilla, y Deporte. Physical therapists and orthopaedic surgeons with clinical and research experience in the field and an ethics expert with substantial experience in the area of sports injuries also participated. This consensus statement addresses 6 fundamental clinical questions regarding the prevention, diagnosis, and management of pediatric ACL injuries. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision making with children and the potential long-term ramifications of the injury.
5.	Aufwerber, S, et al. (author) Does Early Functional Mobilization Affect Long-Term Outcomes After an Achilles Tendon Rupture? A Randomized Clinical Trial 2020 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 8:3, s. 2325967120906522- Journal article (peer-reviewed)abstract Functional deficits and health-related impairments are common after an Achilles tendon rupture (ATR). Rehabilitation protocols vary greatly, and few studies have allowed loading in combination with ankle motion immediately after surgery (ie, early functional mobilization [EFM]). It is unclear whether EFM may counteract the negative impact of ankle immobilization after an ATR. Purpose: The primary aim of this study was to assess the efficacy of EFM compared with standard treatment (ie, 2 weeks of unloading in a plaster cast followed by 4 weeks of weightbearing in an orthosis) regarding patient-reported and functional outcomes in patients with an ATR after acute operative repair. The secondary aim was to explore whether the occurrence of deep venous thrombosis (DVT) during the 2 postoperative treatments affected outcomes. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 135 patients who underwent ATR repair, randomized to either EFM, including immediate postoperative loading and ankle motion, or standard treatment, were evaluated with functional tests and 5 self-administered outcome questionnaires at 6 and 12 months postoperatively. Results: At 6 months, the EFM group scored higher on the RAND 36-Item Health Survey (RAND-36) questionnaire subscales of general health and vitality ( P < .05) compared with the control group. No significant differences between the groups were found on disease-specific questionnaires (Achilles tendon Total Rupture Score [ATRS] and Foot and Ankle Outcome Score [FAOS]). At 12 months, no significant differences on any of the patient-reported outcome measures or the functional heel-rise test were seen between the groups. The RAND-36 subscale of general health, however, exhibited higher values in the EFM group (82.6 ± 16.9) than the control group (77.1 ± 17.0) ( P = .051) at 12 months after the injury. Patients sustaining DVT postoperatively had lower self-reported outcomes on the ATRS, FAOS, and RAND-36 questionnaires at 6 and 12 months compared with patients not having sustained DVT (all P < .05). Conclusion: This study demonstrated that an accelerated postoperative protocol with immediate loading and ankle motion resulted in better general health and vitality at 6 months. However, there were no differences between the groups in the recovery of heel-rise function. Future studies should focus on the means to reduce the risk of DVT to improve patient outcomes after ATR. Registration: NCT02318472 (ClinicalTrials.gov identifier).
6.	Ayeni, Olufemi R, 1976, et al. (author) Diagnosing femoroacetabular impingement from plain radiographs: Do radiologists and orthopaedic surgeons differ? 2014 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 2:7 Journal article (peer-reviewed)abstract Background: A diagnosis of femoroacetabular impingement (FAI) requires careful history and physical examination, as well as an accurate and reliable radiologic evaluation using plain radiographs as a screening modality. Radiographic markers in the diagnosis of FAI are numerous and not fully validated. In particular, reliability in their assessment across health care providers is unclear. Purpose: To determine inter- and intraobserver reliability between orthopaedic surgeons and musculoskeletal radiologists. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Six physicians (3 orthopaedic surgeons, 3 musculoskeletal radiologists) independently evaluated a broad spectrum of FAI pathologies across 51 hip radiographs on 2 occasions separated by at least 4 weeks. Reviewers used 8 common criteria to diagnose FAI, including (1) pistol-grip deformity, (2) size of alpha angle, (3) femoral head-neck offset, (4) posterior wall sign abnormality, (5) ischial spine sign abnormality, (6) coxa profunda abnormality, (7) crossover sign abnormality, and (8) acetabular protrusion. Agreement was calculated using the intraclass correlation coefficient (ICC). Results: When establishing an FAI diagnosis, there was poor interobserver reliability between the surgeons and radiologists (ICC batch 1 = 0.33; ICC batch 2 = 0.15). In contrast, there was higher interobserver reliability within each specialty, ranging from fair to good (surgeons: ICC batch 1 = 0.72; ICC batch 2 = 0.70 vs radiologists: ICC batch 1 = 0.59; ICC batch 2 = 0.74). Orthopaedic surgeons had the highest interobserver reliability when identifying pistol-grip deformities (ICC = 0.81) or abnormal alpha angles (ICC = 0.81). Similarly, radiologists had the highest agreement for detecting pistol-grip deformities (ICC = 0.75). Conclusion: These results suggest that surgeons and radiologists agree among themselves, but there is a need to improve the reliability of radiographic interpretations for FAI between the 2 specialties. The observed degree of low reliability may ultimately lead to missed, delayed, or inappropriate treatments for patients with symptomatic FAI. © The Author(s) 2014.
7.	Carmont, Michael R, 1972, et al. (author) Age and Tightness of Repair Are Predictors of Heel-Rise Height After Achilles Tendon Rupture. 2020 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 8:3 Journal article (peer-reviewed)abstract Achilles tendon rupture leads to weakness of ankle plantarflexion. Treatment of Achilles tendon rupture should aim to restore function while minimizing weakness and complications of management.To determine the influence of factors (age, sex, body mass index [BMI], weight, time from injury to operative repair, and tightness of repair) in the initial surgical management of patients after an acute Achilles tendon rupture on 12-month functional outcome assessment after percutaneous and minimally invasive repair.Cohort study; Level of evidence, 3.From May 2012 to January 2018, patients sustaining an Achilles tendon rupture receiving operative repair were prospectively evaluated. Tightness of repair was quantified using the intraoperative Achilles tendon resting angle (ATRA). Heel-rise height index (HRHI) was used as the primary 12-month outcome variable. Secondary outcome measures included Achilles tendon total rupture score (ATRS) and Tegner score. Stepwise multiple regression was used to create a model to predict 12-month HRHI.A total of 122 patients met the inclusion criteria for data analysis (mean ± SD age, 44.1 ± 10.8 years; 78% male; mean ± SD BMI, 28.1 ± 4.3 kg/m2). The elapsed time to surgery was 6.5 ± 4.0 days. At 12-month follow-up, patients had an HRHI of 82% ± 16% and performed 82% ± 17% of repetitions compared with the noninjured side. Participants had a mean ATRS of 87 ± 15 and a median Tegner score of 5 (range, 1-9), with a reduction in Tegner score of 2 from preinjury levels. The relative ATRA at 12 months was -4.8° ± 3.9°. Multiple regression identified younger age (B = ±0.006; P < .001) and greater intraoperative ATRA (B = 0.005; P = .053) as predictors of more symmetrical 12-month HRHI (R2 = 0.19; P < .001; n = 120).Age was found to be the strongest predictor of outcome after Achilles tendon rupture. The most important modifiable risk factor was the tightness of repair. It is recommended that repair be performed as tight as possible to optimize heel-rise height 1 year after Achilles tendon rupture and possibly to reduce tendon elongation.
8.	Carmont, Michael R, 1972, et al. (author) Functional Outcomes of Achilles Tendon Minimally Invasive Repair Using 4- and 6-Strand Nonabsorbable Suture: A Cohort Comparison Study 2017 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 5:8 Journal article (peer-reviewed)abstract Background: The aim of management of Achilles tendon rupture is to reduce tendon lengthening and maximize function while reducing the rerupture rate and minimizing other complications. Purpose: To determine changes in Achilles tendon resting angle (ATRA), heel-rise height, patient-reported outcomes, return to play, and occurrence of complications after minimally invasive repair of Achilles tendon ruptures using nonabsorbable sutures. Methods: Between March 2013 and August 2015, a total of 70 patients (58 males, 12 females) with a mean age of 42 8 years were included and evaluated at 6 weeks and 3, 6, 9, and 12 months after repair of an Achilles tendon rupture. Surgical repair was performed using either 4-strand or 6-strand nonabsorbable sutures. After surgery, patients were mobilized, fully weightbearing using a functional brace. Early active movement was permitted starting at 2 weeks. Results: There were no significant differences in the ATRA, Achilles Tendon Total Rupture Score (ATRS), and Heel-Rise Height Index (HRHI) between the 4- and 6-strand repairs. The mean (SD) relative ATRA was -13.1 degrees (6.6 degrees) (dorsiflexion) following injury; this was reduced to 7.6 degrees (4.8 degrees) (plantar flexion) directly after surgery. During initial rehabilitation at 6 weeks, the relative ATRA was 0.6 degrees (7.4 degrees) (neutral) and -7.0 degrees (5.3 degrees) (dorsiflexion) at 3 months, after which ATRA improved significantly with time to 12 months (P = .005). At 12 months, the median ATRS was 93 (range, 35-100), and the mean (SD) HRHI and Heel-Rise Repetition Index were 81% (0.22%) and 82.9% (0.17%), respectively. The relative ATRA at 3 and 12 months correlated with HRHI (r = 0.617, P < .001 and r = 0.535, P < .001, respectively). Conclusion: Increasing the number of suture strands from 4 to 6 does not alter the ATRA or HRHI after minimally invasive Achilles tendon repair. The use of a nonabsorbable suture during minimally invasive repair when used together with accelerated rehabilitation did not prevent the development of an increased relative ATRA. The ATRA at 3 months after surgery correlated with heel-rise height at 12 months.
9.	Devitt, Brian M, et al. (author) The Role of Lateral Extra-articular Tenodesis in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis and Best-Evidence Synthesis 2017 In: The Orthopaedic Journal of Sports Medicine. - : Sage Publications. - 2325-9671. ; 5:10 Journal article (peer-reviewed)abstract The role of lateral extra-articular tenodesis (LEAT) to augment primary anterior cruciate ligament reconstruction (ACLR) remains controversial.
10.	Diermeier, T., et al. (author) Patient-Reported and Quantitative Outcomes of Anatomic Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autografts 2020 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 8:7 Journal article (peer-reviewed)abstract Background: The pivot-shift test has become more consistent and reliable and is a meaningful outcome measurement after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: The purpose of this investigation was to assess patient-reported outcomes (PROs) and the quantitative pivot shift (QPS) preoperatively, at time zero immediately after anatomic ACLR, and after 24 months as well as the relationship between PROs and the QPS. It was hypothesized that anatomic ACLR would restore rotatory stability measured by the pivot-shift test and that QPS measurements would be positively correlated with PROs. Study Design: Cohort study; Level of evidence, 2. Methods: The ACL-injured and contralateral uninjured knees from 89 of 107 (83.2%) enrolled patients at 4 international centers were evaluated using a standardized pivot-shift test. Tibial acceleration was assessed with an inertial sensor, and lateral compartment translation was measured using an image analysis system preoperatively, at time zero immediately postoperatively, and at follow-up after 2 years. PROs were assessed at 12 and 24 months postoperatively with the International Knee Documentation Committee (IKDC) subjective knee form, Cincinnati Knee Rating System (CKRS), Marx activity rating scale, and activity of daily living score (ADLS). Results: The mean patient age at surgery was 27 years (range, 15-45 years). A positive pivot shift preoperatively (side-to-side difference in tibial acceleration, 2.6 +/- 4.0 m/s(2); side-to-side difference in anterior tibial translation, 2.0 +/- 2.0 mm) was reduced at time zero postoperatively (side-to-side difference in tibial acceleration, -0.5 +/- 1.3 m/s(2); side-to-side difference in anterior tibial translation, -0.1 +/- 1.0 mm). All PROs improved from preoperatively to final follow-up at 24 months: from 56.5 to 85.5 points for the IKDC (P= .0001), from 28.8 to 32.4 points for the CKRS (P= .04), from 11.2 to 7.9 points for the Marx (P< .0001), and from 75.7 to 91.6 points for the ADLS (P< .0001). Neither preoperative nor time zero postoperative rotatory laxity assessed by the pivot-shift test correlated with PROs at 24-month follow-up. A graft retear was observed in 4 patients (4.5%) within 2 years of follow-up. Conclusion: Anatomic ACLR resulted in significantly improved and acceptable PROs at 2-year follow-up and a low failure rate. Anatomic ACLR restored QPS measurements of anterior tibial translation and tibial acceleration to those of the contralateral knee immediately after surgery while still under anesthesia, but there was no correlation between the QPS preoperatively or at time zero after ACLR and PROs at 2-year follow-up.
11.	Diermeier, Theresa, et al. (author) Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group 2020 In: Orthopaedic Journal of Sports Medicine. - 2325-9671. ; 8 Journal article (peer-reviewed)abstract Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.
12.	Ellenbecker, TS, et al. (author) Visual Observation of Apparent Infraspinatus Muscle Atrophy in Male Professional Tennis Players 2020 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 8:10, s. 2325967120958834- Journal article (peer-reviewed)abstract Previous studies have reported visually observed apparent muscle atrophy in the infraspinous fossa of the dominant arm of overhead athletes. Several mechanisms have been proposed as etiological factors, including eccentric overload, compressive spinoglenoid notch paralabral cysts, and cumulative tensile suprascapular neurapraxia. Purpose: To report the prevalence of apparent infraspinatus atrophy in male professional tennis players and to determine whether the suspected atrophy correlates with objectively measured weakness of external rotation. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 153 male professional tennis players underwent a musculoskeletal screening examination that included visual inspection of the infraspinous fossa. Infraspinatus atrophy was defined as hollowing or loss of soft tissue bulk inferior to the scapular spine in the infraspinous fossa of one extremity that was visibly different from the contralateral extremity. This finding was observed and independently agreed upon by both an orthopaedic surgeon and a physical therapist during the examination. Also assessed were rotator cuff instrument-assisted manual muscle testing, visual observation of scapular kinesis (or motion), and glenohumeral joint range of motion for internal and external rotation and horizontal adduction. Results: In the 153 players, dominant-arm infraspinatus atrophy was observed in 92 players (60.1%), and only 1 player (0.7%) was identified with nondominant infraspinatus atrophy. A Pearson correlation showed a significant relationship between the presence of dominant-arm infraspinatus atrophy and dominant-arm external rotation strength measured in neutral abduction/adduction (at the side) ( P = .001) as well as between the presence of dominant-arm infraspinatus atrophy and bilateral external rotation strength measured at 90° of glenohumeral joint abduction ( P = .009 for dominant arm and .002 for nondominant arm). No significant correlation was found with scapular dyskinesis, glenohumeral range of motion, or instrument-assisted manual muscle testing of the supraspinatus (empty-can test). Conclusion: Visually observed infraspinatus muscle atrophy is a common finding in the dominant shoulder of asymptomatic male professional tennis players and is significantly correlated with external rotation weakness. This condition is present in uninjured players without known shoulder pathology and is not related to glenohumeral joint internal rotation, total rotation range of motion, or scapular dysfunction. Players with visually observed infraspinatus atrophy should be evaluated for external rotation strength and may require preventive strengthening.
13.	Engler, Ian D, et al. (author) Revision Rates After Primary Allograft ACL Reconstruction by Allograft Tissue Type in Older Patients. 2023 In: Orthopaedic journal of sports medicine. - 2325-9671. ; 11:9 Journal article (peer-reviewed)abstract While there is extensive literature on the use of allograft versus autograft in anterior cruciate ligament (ACL) reconstruction, there is limited clinical evidence to guide the surgeon in choice of allograft tissue type.To assess the revision rate after primary ACL reconstruction with allograft and to compare revision rates based on allograft tissue type and characteristics.Cohort study; Level of evidence, 3.Patients who underwent primary allograft ACL reconstructions at a single academic institution between 2015 and 2019 and who had minimum 2-year follow-up were included. Exclusion criteria were missing surgical or allograft tissue type data. Demographics, operative details, and subsequent surgical procedures were collected. Allograft details included graft tissue type (Achilles, bone-patellar tendon-bone [BTB], tibialis anterior or posterior, semitendinosus, unspecified soft tissue), allograft category (all-soft tissue vs bone block), donor age, irradiation duration and intensity, and chemical cleansing process. Revision rates were calculated and compared by allograft characteristics.Included were 418 patients (age, 39 ± 12years; body mass index, 30 ± 9kg/m2). The revision rate was 3% (11/418) at a mean follow-up of 4.9 ± 1.4years. There were no differences in revision rate according to allograft tissue type across Achilles tendon (3%; 3/95), BTB (5%; 3/58), tibialis anterior or posterior (3%; 5/162), semitendinosus (0%; 0/46), or unspecified soft tissue (0%; 0/57) (P = .35). There was no difference in revision rate between all-soft tissue versus bone block allograft (6/283 [2%] vs 5/135 [4%], respectively; P = .34). Of the 51% of grafts with irradiation data, all grafts were irradiated, with levels varying from 1.5 to 2.7 Mrad and 82% of grafts having levels of <2.0 Mrad. There was no difference in revision rate between the low-dose and medium-to high-dose irradiation cohorts (4% vs 6%, respectively; P = .64).Similarly low (0%-6%) revision rates after primary ACL reconstruction were seen regardless of allograft tissue type, bone block versus all-soft tissue allograft, and sterilization technique in 418 patients with mean age of 39 years. Surgeons may consider appropriately processed allograft tissue with or without bone block when indicating ACL reconstruction in older patients.
14.	Filbay, Stephanie, et al. (author) Prognostic Factors for Patient-Reported Outcomes at 32 to 37 Years After Surgical or Nonsurgical Management of Anterior Cruciate Ligament Injury 2021 In: The Orthopaedic Journal of Sports Medicine. - : Sage Publications. - 2325-9671. ; 9:8 Journal article (peer-reviewed)abstract Background: Knowledge to inform the identification of individuals with a poor long-term prognosis after anterior cruciate ligament (ACL) injury is limited. Identifying prognostic factors for long-term outcomes after ACL injury may inform targeted interventions to improve outcomes for those with a poor long-term prognosis. Purpose: To determine whether ACL treatment (early augmented or nonaugmented ACL repair plus rehabilitation, rehabilitation alone, or rehabilitation plus delayed ACL reconstruction [ACLR]) and 4-year measures (quadriceps and hamstrings strength, single-leg hop, knee laxity, flexion and extension deficit, self-reported knee function, activity level) are prognostic factors for patient-reported outcomes at 32 to 37 years after acute ACL injury. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 251 patients aged 15 to 40 years with acute ACL rupture between 1980 and 1985 were allocated to early ACL repair (augmented or nonaugmented) plus rehabilitation or to rehabilitation alone, based on birth year. One hundred ninety of 234 completed 32- to 37-year follow-up questionnaires (response rate, 81%); 18 people were excluded, resulting in 172 patients available for analysis (mean age, 59 +/- 6 years; 28% female). Potential prognostic factors assessed 4 years after ACL injury were ACL treatment (early ACL repair, rehabilitation alone, or delayed ACLR), isokinetic quadriceps and hamstrings strength, single-leg hop performance, knee flexion and extension deficit, knee laxity, Tegner activity scale, and Lysholm score. Outcomes included Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and the Anterior Cruciate Ligament Quality of Life (ACL-QOL) measure. Linear regression adjusted for age, sex, baseline meniscal injury, and contralateral ACL injury was used to assess potential prognostic factors for 32- to 37-year outcomes. Multiple imputation accounted for missing data. Results: A fair/poor Lysholm score (vs excellent/good) at 4 years was a prognostic factor for worse KOOS Pain (adjusted regression coefficient, -12 [95% confidence interval (CI), -19 to -4]), KOOS Symptoms (-15 [95% CI, -23 to -7]), KOOS Sport and Recreation (-19 [95% CI, -31 to -8]), and ACL QOL (-9 [95% CI, -18 to -1]) scores. A 4-year single-leg hop limb symmetry index <90% was a prognostic factor for worse KOOS Pain (adjusted regression coefficient, -9 [95% CI, -17 to -1]) and ACL QOL (-13 [95% CI, -22 to -3]) scores at long-term follow-up. A lower activity level, delayed ACLR, and increased knee laxity were prognostic factors in the crude analysis. Rehabilitation alone versus early repair, quadriceps and hamstring strength, and flexion and extension deficit were not related to 32- to 37-year outcomes. Conclusion: Reduced self-reported knee function and single-leg hop performance 4 years after ACL injury were prognostic factors for worse 32- to 37-year outcomes. Estimates exceeded clinically important thresholds, highlighting the importance of assessing these constructs when managing individuals with ACL injuries.
15.	Flosadottir, Vala, et al. (author) Translation, Cross-Cultural Adaptation, and Validation of the Activity Rating Scale for Disorders of the Knee 2017 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 5:9 Journal article (peer-reviewed)abstract Background: The Activity Rating Scale (ARS) for disorders of the knee evaluates the level of activity by the frequency of participation in 4 separate activities with high demands on knee function, with a score ranging from 0 (none) to 16 (pivoting activities 4 times/wk). Purpose: To translate and cross-culturally adapt the ARS into Swedish and to assess measurement properties of the Swedish version of the ARS. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The COSMIN guidelines were followed. Participants (N = 100 [55 women]; mean age, 27 years) who were undergoing rehabilitation for a knee injury completed the ARS twice for test-retest reliability. The Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale (TAS), and modernized Saltin-Grimby Physical Activity Level Scale (SGPALS) were administered at baseline to validate the ARS. Construct validity and responsiveness of the ARS were evaluated by testing predefined hypotheses regarding correlations between the ARS, KOOS, TAS, and SGPALS. The Cronbach alpha, intraclass correlation coefficients, absolute reliability, standard error of measurement, smallest detectable change, and Spearman rank-order correlation coefficients were calculated. Results: The ARS showed good internal consistency (α ≈ 0.96), good test-retest reliability (intraclass correlation coefficient >0.9), and no systematic bias between measurements. The standard error of measurement was less than 2 points, and the smallest detectable change was less than 1 point at the group level and less than 5 points at the individual level. More than 75% of the hypotheses were confirmed, indicating good construct validity and good responsiveness of the ARS. Conclusion: The Swedish version of the ARS is valid, reliable, and responsive for evaluating the level of activity based on the frequency of participation in high-demand knee sports activities in young adults with a knee injury.
16.	Fu, SC, et al. (author) Systematic Review of Biological Modulation of Healing in Anterior Cruciate Ligament Reconstruction 2014 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 2:3, s. 2325967114526687- Journal article (peer-reviewed)abstract Whether biological modulation is effective to promote healing in anterior cruciate ligament (ACL) reconstruction remains unclear. Purpose: To perform a systematic review of both clinical and experimental evidence of preclinical animal studies on biological modulation to promote healing in ACL reconstruction. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic search was performed using the PubMed, Ovid, and Scopus search engines. Inclusion criteria were clinical and animal studies involving subjects with ACL injury with the use of biological modulation to promote healing outcomes. Methodological quality of clinical studies was evaluated using the Critical Appraisal Skill Programme (CASP) appraisal tool, and animal studies were evaluated by a scoring system based on a published checklist of good animal studies. Results: Ten clinical studies and 50 animal studies were included. Twenty-five included studies were regarded as good quality, with a methodological score ≥5. These studies suggested that transforming growth factor–beta (TGF-β), mesenchymal stem cells, osteogenic factors, and modalities that reduce local inflammation may be beneficial to promote graft healing in ACL reconstruction. Conclusion: This systematic review suggests that biological modulation is able to promote healing on top of surgical treatment for ACL injuries. This treatment strategy chiefly works through promotion of healing at the tunnel-graft interface, but the integrity of the intra-articular midsubstance of the graft would be another target for biological modulation.
17.	Greiner, Justin J., et al. (author) Factors Associated With Knee Extension Strength Symmetry After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft 2024 In: ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE. - 2325-9671. ; 12:3 Journal article (peer-reviewed)abstract Background: Diminished postoperative knee extension strength may occur after anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) autograft. Factors influencing the restoration of knee extensor strength after ACLR with QT autograft remain undefined. Purpose: To identify factors that influence knee extensor strength after ACLR with QT autograft. Study Design: Case-control study; Level of evidence, 3. Methods: The authors performed a retrospective review of patients who underwent primary ACLR with QT autograft at a single institution between 2010 and 2021. Patients were included if they completed electromechanical dynamometer testing at least 6 months after surgery. Exclusion criteria consisted of revision ACLR, <6 months of follow-up, concomitant procedure (osteotomy, cartilage restoration), and concomitant ligamentous injury requiring surgery. Knee extension limb symmetry index (LSI) was obtained by comparing the peak torque of the operated and nonoperated extremities. Univariable and multivariable analyses were performed to identify factors associated with knee extension LSI in the patient, injury, rehabilitation, and preoperative patient-reported outcomes score domains. Results: A total of 107 patients (58 male; mean age, 22.8 years) were included. Mean knee extension LSI of the overall cohort was 0.82 +/- 0.18 at 7.5 +/- 2.0 months; 35 patients (33%) had a value of >= 0.90. Multivariable analysis demonstrated significant negative associations between knee extension LSI and female sex (-0.12; P < .001), increased age at the time of surgery (-0.01; P = .018), and larger QT graft width (-0.049; P = .053). Conclusion: Factors influencing knee extensor LSI after ACLR with QT autograft in this study population spanned patient and surgical factors, including female sex, older age at the time of surgery, and wider graft harvest. Surgeons should consider the association between these factors and lower postoperative knee extensor LSI to optimize patient outcomes.
18.	Grävare Silbernagel, Karin, 1965, et al. (author) Sex Differences in Outcome After an Acute Achilles Tendon Rupture. 2015 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 3:6 Journal article (peer-reviewed)abstract Tendon healing differs between the sexes. Comparisons in outcome between the sexes after an Achilles tendon rupture are often not possible because of the small cohort (<20%) of women.
19.	Hamrin Senorski, Eric, 1989, et al. (author) Factors Affecting the Achievement of a Patient-Acceptable Symptom State 1 Year After Anterior Cruciate Ligament Reconstruction: A Cohort Study of 343 Patients From 2 Registries. 2018 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 6:4 Journal article (peer-reviewed)abstract There is insufficient knowledge regarding the influence of concomitant injuries on the recovery of short-term subjective knee function after anterior cruciate ligament (ACL) reconstruction.To determine whether patient characteristics, concomitant injuries, and graft choice during ACL reconstruction can predict which patients achieve acceptable knee function 1 year after reconstruction.Case-control study; Level of evidence, 3.Data from 1 physical therapist-specific and 1 surgeon-specific register were used. Patients who had completed the Knee injury and Osteoarthritis Outcome Score (KOOS) at 1-year follow-up were included. Additional intraoperative information was extracted from a database. The primary outcome was achieving a patient-acceptable symptom state (PASS) for each subscale of the KOOS. Univariable and multivariable logistic regression models were used, with patient sex, age, and preinjury level of physical activity as covariates.A total of 343 patients (51% females) were included. The proportion of patients achieving PASS 1 year after ACL reconstruction varied between 40% and 85% among the KOOS subscales. Younger age at reconstruction and male sex provided favorable odds of achieving acceptable knee function across the KOOS subscales. Patients without cartilage injury had increased odds of achieving PASS in the KOOS sport and recreation subscale; the increase was 1.63-fold (95% CI, 1.01-2.64; P = .045). Patients receiving patellar tendon autograft had a 0.41-fold (95% CI, 0.19-0.85; P = .017) decrease in odds of achieving PASS on the KOOS quality of life (QoL) subscale. In the multivariable analysis, increased odds of achieving PASS on the KOOS QoL subscale were associated with the absence of meniscal injury (odds ratio, 1.62; 95% CI, 1.04-2.54; P = .035), and increased odds were found for hamstring tendon autograft (OR, 2.63; 95% CI, 1.25-5.56; P = .011).More than half of the patients reported an acceptable symptom state on 4 of the 5 KOOS subscales 1 year after ACL reconstruction. A lack of consistency was noted related to the effect of concomitant knee injuries and graft choice on acceptable knee function. However, younger age and male sex were favorable, nonmodifiable characteristics that increased the odds of early acceptable function.
20.	Identeg, Fredrik, 1990, et al. (author) Poor Associations Between Radiographic Tibiofemoral Osteoarthritis and Patient-Reported Outcomes at 16 Years After Anterior Cruciate Ligament Reconstruction 2020 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 8:9 Journal article (peer-reviewed)abstract Background: Radiographic tibiofemoral (TF) osteoarthritis (OA) is common in patients after anterior cruciate ligament (ACL) reconstruction at long-term follow-up. The association between radiographic OA and patient-reported outcomes has not been thoroughly investigated. Purpose: To determine the association between radiographic TF OA and patient-reported outcome measure (PROM) scores at 16 years after ACL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: This study was based on 2 randomized controlled studies comprising 193 patients who underwent unilateral ACL reconstruction. A long-term follow-up was carried out at 16.4 +/- 1.7 years after surgery and included a radiographic examination of the knee and recording of PROM scores. Correlation analyses were performed between radiographic OA (Kellgren-Lawrence [K-L], Ahlback, and cumulative Fairbank grades) and the PROMs of the International Knee Documentation Committee (IKDC) subjective knee form, Lysholm score, and Tegner activity scale. A linear univariable regression model was used to assess how the IKDC score differed with each grade of radiographic OA. Results: Of 193 patients at baseline, 147 attended the long-term follow-up. At long-term follow-up, 44.2% of the patients had a K-L grade of >= 2 in the injured leg, compared with 6.8% in the uninjured leg. The mean IKDC score at follow-up was 71.2 +/- 19.9. Higher grades of radiographic OA were significantly correlated with lower IKDC and Lysholm scores (r= -0.36 to -0.22). Patients with a K-L grade of 3 to 4 had significantly lower IKDC scores compared with patients without radiographic OA (K-L grade 0-1). Adjusted beta values were -15.7 (95% CI, -27.5 to -4.0;P= .0093;R-2= 0.09) for K-L grade 3 and -25.2 (95% CI, -41.7 to -8.6;P= .0033;R-2= 0.09) for K-L grade 4. Conclusion: There was a poor but significant correlation between radiographic TF OA and more knee-related limitations, as measured by the IKDC form and the Lysholm score. Patients with high grades of radiographic TF OA (K-L grade 3-4) had a statistically significant decrease in IKDC scores compared with patients without radiographic TF OA at 16 years after ACL reconstruction. No associations were found between radiographic TF OA and the Tegner activity level.
21.	Itthipanichpong, Thun, et al. (author) Validity and Reliability of the Thai Versions of the Lysholm Knee Scoring Scale and Tegner Activity Scale 2023 In: The Orthopaedic Journal of Sports Medicine. - : Sage Publications. - 2325-9671. ; 11:2 Journal article (peer-reviewed)abstract Background: Functional or quality of life questionnaires are important tools in clinical investigations. The Lysholm Knee Scoring Scale and Tegner Activity Scale are knee-specific questionnaires that are widely used to assess knee function.Purpose: To translate both questionnaires into Thai and to assess the validity and reliability of the Thai versions of the Lysholm and adjusted Tegner scales.Study Design: Cohort study (diagnosis); Level of evidence, 3.Methods: The Lysholm and Tegner scales were translated into Thai by using the forward-backward translation protocol. Because cultural modifications were made to the sports used to measure activity on the Tegner scale, the authors of this study refer to the Thai version as the “Thai adjusted Tegner scale.” The reliability and validity of the translated scales were evaluated by obtaining the responses of 60 consecutive patients (mean age, 40.5 years; 34 male, 26 female); the patients also completed the Thai version of the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). Criterion validity was tested by correlating the scores from both translated questionnaires with those from the Thai IKDC-SKF, while reliability was assessed by measuring test-retest reliability and internal consistency.Results: The Thai Lysholm scale showed a strong correlation with the Thai IKDC-SKF (r = 0.89), while the Thai adjusted Tegner scale showed a moderate correlation with the Thai IKDC-SKF (r = 0.60). The intrarater and test-retest reliability measures were excellent for the Thai Lysholm (intraclass correlation coefficient [ICC], 0.94 and 0.98, respectively) and moderate to good for the Thai adjusted Tegner (ICC, 0.73 and 0.86, respectively). The internal consistency for the Thai Lysholm was acceptable at all the time points (Cronbach alpha, 0.71-0.73).Conclusion: The Thai Lysholm and Thai adjusted Tegner scales adequately retained the characteristics of the original versions. They can be considered reliable instruments for Thai patients with knee-related problems.
22.	Jonsdottir, Unnur Saedis, 1982, et al. (author) Factors That Affect Return to Sports After an Achilles Tendon Rupture: A Qualitative Content Analysis 2023 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 11:1 Journal article (peer-reviewed)abstract Background: Achilles tendon rupture is common among physically active individuals, yet a high percentage fail to return to their former activity after the injury. Quantifiable factors such as type of treatment, hours of rehabilitation, and age have not been associated with return-to-play rates. A factor that influences recovery is the participant’s experience before and throughout the rehabilitation process, which can be explored using a qualitative content analysis. Purpose: To explore and describe what influences the participant to return to physical activity after an Achilles tendon rupture. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Twenty participants (14 men; mean age, 46 years) were interviewed as part of this study. All participants had ruptured their Achilles tendon 4 to 6 years before the interviews. From the interviews, codes were extracted that evolved into 19 subcategories, 6 categories, and 1 theme. Results: The overarching theme that emerged was “Help me and then I can fix this.” The 6 categories were (1) one’s own drive to succeed, (2) having a supportive social network, (3) trusting the support from the health and social systems, (4) receiving and adapting information from others drives persistence in returning to activity, (5) impact of the injury on psychological factors; and (6) influence of physiological aspects. Conclusion: To be able to recover properly from an Achilles tendon rupture and return to activity, the study participants described the importance of obtaining the support needed to be able to gain optimal rehabilitation. In the participants’ opinion, for a greater chance of successful treatment and rehabilitation, it was vital to be provided with good support.
23.	Kaarre, Janina, 1996, et al. (author) Comparison of Improvement in Patient-Reported Knee Function After Revision and Multiple-Revision ACL Reconstruction Compared With Primary ACL Reconstruction 2023 In: ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE. - 2325-9671. ; 11:12 Journal article (peer-reviewed)abstract Background: Graft failure after anterior cruciate ligament reconstruction (ACLR) is a debilitating complication often requiring revision surgery. It is widely agreed upon that functional knee outcomes after revision ACLR (r-ACLR) are inferior compared with those after primary reconstruction. However, data are scarce on outcomes after multiple-revision ACLR (mr-ACLR).Purpose: To compare patient-reported knee function in terms of Knee injury and Osteoarthritis Outcome Score (KOOS) preoperatively and 1-year postoperatively after primary ACLR, r-ACLR, and mr-ACLR and evaluate the pre- to postoperative improvement in KOOS scores for each procedure.Study Design: Cohort study; Level of evidence, 3.Methods: Patients from the Swedish National Knee Ligament Registry who underwent their index ACLR between 2005 and 2020 with a minimum age of 15 years at the time of surgery were included in this study. All patients had pre- and postoperative KOOS data. The 1-year postoperative KOOS and the pre- to postoperative changes in KOOS were assessed between patients who underwent primary ACLR and those who underwent subsequent r-ACLR and mr-ACLR.Results: Of 20,542 included patients, 19,769 (96.2%) underwent primary ACLR, 760 (3.7%) underwent r-ACLR, and 13 (0.06%) underwent mr-ACLR. Patients who underwent r-ACLR had significantly smaller pre- to postoperative changes on all KOOS subscales compared with patients undergoing primary ACLR (P < .0001 for all). Furthermore, patients in the mr-ACLR group had significantly smaller changes in the KOOS-Pain subscale compared with patients in the r-ACLR group (-9 +/- 23.3 vs 2.5 +/- 18; P = .024).Conclusion: The study results indicated that while improvement is seen after primary ACLR, r-ACLR, and mr-ACLR, the greatest improvement in functional outcomes is observed after primary ACLR. Patients who underwent at least 1 r-ACLR, specifically mr-ACLR, had lower postoperative outcome scores, indicating that primary ACLR may provide the best chance for recovery after ACL injury.
24.	Kay, Jeffrey, et al. (author) Anterior Cruciate Ligament Rupture: A Family Affair. 2015 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 3:11 Journal article (peer-reviewed)
25.	Koca, Firathan, et al. (author) Comparison of Knee Function and Activity Level Between Bilateral and Unilateral ACL Reconstruction : A Matched-Group Analysis With Minimum 5-Year Follow-up 2022 In: The Orthopaedic Journal of Sports Medicine. - : Sage Publications Inc. - 2325-9671. ; 10:4 Journal article (peer-reviewed)abstract Background: There is a lack of knowledge regarding knee function and activity level after bilateral anterior cruciate ligament reconstruction (ACLR) at midterm follow-up. Purpose: To compare activity level, patient-reported knee function, and quality of life in patients with bilateral ACLR and matched controls with unilateral ACLR at a minimum 5-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with bilateral ACLR who were aged <= 40 years and had a second ACLR performed between 2010 and 2015 were identified in the authors local database. Surgical data and preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) were extracted. The patients were sent a letter with questionnaires including the KOOS, EuroQol 5-Dimensions (EQ-5D), and EuroQol visual analog scale (EQ-VAS) and were asked study-specific questions by telephone regarding activity level and knee function at a minimum 5-year follow-up. For every patient with bilateral ACLR, a control matched for age +/- 2 years, sex, year ACLR was performed, and preinjury activity level or sport at the time of injury were identified in the database. Results: A total of 98 patients (mean age +/- SD, 33.3 +/- 7.3 years) with bilateral ACLR and 98 patients with unilateral ACLR (mean age +/- SD, 33.1 +/- 7.7 years) were included. The mean postoperative follow-up was 7.6 +/- 1.8 years (from the second ACLR) for patients with bilateral ACLR and 7.8 +/- 1.7 years for patients with unilateral ACLR. Patients with bilateral ACLR reported lower scores on all KOOS subscales, the EQ-5D, and the EQ-VAS at follow-up (P < .05). There was no difference in activity level between the groups at follow-up, but patients with bilateral ACLR were less satisfied with their activity level and knee function (P < .05). Conclusion: Patient-reported knee function and health-related quality of life were inferior in patients with bilateral ACLR compared with patients with unilateral ACLR. Patients with bilateral ACLR cannot expect the same knee function and quality of life as patients with unilateral ACLR.
26.	Lazarides, A. L., et al. (author) Advanced Patellar Tendinopathy Is Associated With Increased Rates of Bone-Patellar Tendon-Bone Autograft Failure at Early Follow-up After Anterior Cruciate Ligament Reconstruction 2018 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 6:11 Journal article (peer-reviewed)abstract Background: Revision anterior cruciate ligament (ACL) reconstruction can be potentially devastating for a patient. As such, it is important to identify prognostic factors that place patients at an increased risk for graft failure. There are no data on the effects of patellar tendinopathy on failure of ACL reconstruction when using a bone-patellar tendon-bone (BPTB) autograft. Purpose/Hypothesis: The purpose of this study was to investigate the association of patellar tendinopathy with the risk of graft failure in primary ACL reconstruction when using a BPTB autograft. The hypothesis was that patellar tendinopathy would result in higher rates of graft failure when using a BPTB autograft for primary ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: All patients undergoing ACL reconstruction at a single institution from 2005 to 2015 were examined. A total of 168 patients undergoing primary ACL reconstruction with a BPTB autograft were identified. Patients' magnetic resonance imaging scans were reviewed for the presence and grade of patellar tendinopathy by 2 musculoskeletal fellowship-trained radiologists; both were blinded to the aim of the study, patient demographics, surgical details, and outcomes. Patients were divided into 2 groups: failure (defined as presence of symptomatic laxity or graft insufficiency) and success of the ACL graft. Statistical analyses were run to examine the association of patellar tendinopathy with failure of ACL reconstruction using a BPTB autograft. Results: At a mean follow-up of 18 months, there were 7 (4.2%) patients with graft failure. Moderate or severe patellar tendinopathy was associated with ACL graft failure (P = .011). Age, sex, and side of reconstruction were not associated with the risk of graft failure, although the majority of patients who failed were younger than 20 years. The use of patellar tendons with moderate to severe tendinopathy was associated with a relative risk of ruptures of 6.1 (95% CI, 1.37-27.34) as compared with autograft tendons without tendinopathy. Conclusion: Moderate or severe patellar tendinopathy significantly increases the risk of graft failure when using a BPTB autograft for primary ACL reconstruction. Patellar tendinopathy should be considered when determining the optimal graft choice for patients undergoing primary ACL reconstruction with autograft tendons.
27.	Lindman, Ida, et al. (author) Improvements After Arthroscopic Treatment for Femoroacetabular Impingement Syndrome in High-Level Ice Hockey Players : 2-Year Outcomes by Player Position 2021 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 9:3 Journal article (peer-reviewed)abstract Background: Ice hockey players often undergo arthroscopic treatment for femoroacetabular impingement syndrome (FAIS); however, only a few studies have reported postoperative patient-reported outcomes. It has been debated whether player position is related to FAIS. Purpose: To evaluate the change in patient-reported outcome measures (PROMs) in high-level ice hockey players from presurgery to 2 years after arthroscopic treatment for FAIS. The secondary aim was to evaluate differences in outcomes among player positions and whether stick handedness is related to the side of the symptomatic hip. Study Design: Case series; Level of evidence, 4. Methods: Ice hockey players undergoing treatment for FAIS between 2011 and 2019 were prospectively included. Preoperative and 2-year follow-up scores were collected for the following PROMs: HAGOS (Copenhagen Hip and Groin Outcome Score), iHOT-12 (12-item International Hip Outcome Tool), EQ-5D (EuroQol–5 Dimensions) and EQ-VAS (EuroQol–Visual Analog Scale), Hip Sports Activity Scale, and visual analog scale for overall hip function. Player position and stick handedness were collected from public sources. Preoperative and follow-up outcomes were compared for the entire cohort and among player positions. Results: The cohort included 172 ice hockey players with a mean age of 28 years, a mean body mass index of 25.6, and a mean symptom duration of 46.3 months. In the 120 players with 2-year follow-up data, there was significant improvement in all PROMs as compared with presurgery: HAGOS subscales (symptoms, 47.5 vs 68.0; pain, 57.0 vs 75.8; activities of daily living, 62.5 vs 81.0; sports, 40.0 vs 64.7; physical activity, 30.9 vs 57.2; quality of life, 32.5 vs 57.8), iHOT-12 (45.2 vs 66.7), EQ-5D (0.59 vs 0.75), EQ-VAS (68.3 vs 73.2), and visual analog scale for overall hip function (49.6 vs 69.2) (P <.0001 for all). At 2-year follow-up, 83% reported satisfaction with the procedure. There was no difference in the improvement in PROMs among player positions. Further, there was no significant relationship between stick handedness and side of symptomatic hip; however, because of the number of bilateral procedures and large number of left-handed shooters, no conclusions could be drawn. Conclusion: High-level ice hockey players undergoing arthroscopic treatment for FAIS reported improvements in PROMs 2 years after surgery, regardless of player position.
28.	Lindman, Ida, et al. (author) Return to Sport for Professional and Subelite Ice Hockey Players After Arthroscopic Surgery for Femoroacetabular Impingement Syndrome 2022 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671 .- 2325-9671. ; 10:5 Journal article (peer-reviewed)abstract Background: Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain, which can prevent ice hockey players from sports participation. Hip arthroscopy is often performed to relieve pain and enable the player to return to sport (RTS) and return to performance (RTP). Purpose: To determine the RTS and RTP rates for ice hockey players at the professional and subelite levels after hip arthroscopy for FAIS. Study Design: Case series; Level of evidence, 4. Methods: High-level ice hockey players who underwent hip arthroscopy for FAIS between 2011 and 2019 were identified using a local hip arthroscopy registry. The player's level was confirmed with ice hockey-specific web pages and was stratified as subelite or professional. Data on the players' careers were extracted from these web pages. Player position was divided into goalkeepers, defensemen, and forwards. Data on participation in games included the season before onset of symptoms, the season before surgery, and the first and second seasons after surgery. RTS was defined as returning to ice hockey after surgery, and RTP was considered as returning to the same league at a comparable level to before symptoms. Results: A total of 80 ice hockey players were included. Comparing presymptom performance with the first season after surgery, the RTS rate was 72%, of which 94% of the players returned to the same or higher level of play. Comparing the presurgery season with the first season after surgery, the RTS rate was 78%. At the second season after surgery, 64% of players still played ice hockey, with a significantly higher return rate among professional players compared with subelite players (96% vs 69%; P = .014). Overall, 85% goalkeepers, 74% forwards, and 60% defensemen returned to sport. Only 28% played at least the same number of games during the first season after surgery as they did during the presymptom season. Conclusion: High-level ice hockey players who underwent hip arthroscopy for FAIS had a high RTS rate, in which the majority returned to the same league. However, only 28% played the same number of games the first season after surgery as they did at the presymptom level. Professional ice hockey players returned more frequently than players on the subelite level.
29.	Lindorsson, Sophia, et al. (author) Intramuscular Pressure and Patient-Reported Outcomes in Patients Surgically Treated for Anterior Chronic Exertional Compartment Syndrome 2023 In: Orthopaedic Journal of Sports Medicine (OJSM). - : SAGE Publications. - 2325-9671. ; 11:2 Journal article (peer-reviewed)abstract Background:Chronic exertional compartment syndrome (CECS) causes exercise-induced leg pain. The diagnosis is confirmed by intramuscular pressure (IMP) measurements. Fasciotomy has been demonstrated to be a successful treatment for CECS; however, few studies have examined postoperative IMP and long-term outcomes. Purpose:To evaluate long-term outcomes and postoperative IMP in patients surgically treated for anterior CECS, and to identify possible preoperative or postoperative factors associated with overall satisfaction with treatment at follow-up. Study Design:Case-control study; Level of evidence, 3. Methods:A consecutive series of 209 patients who underwent fasciotomy of the anterior compartment for CECS between 2009 and 2019 and had at least 1 year of follow-up were approached for inclusion. A total of 144 patients (69%), with a follow-up time of 1 to 11.5 years, were ultimately included. All patients underwent preoperative and postoperative 1-minute postexercise IMP measurements of the anterior compartment and completed a questionnaire covering pain and activity parameters at both time points. The follow-up questionnaire included an additional question on overall satisfaction with treatment, and surgical details were collected from the patient's medical records. Results:The median IMP was significantly lower at follow-up than at baseline (17 mm Hg [range, 5-91 mm Hg] vs 49 mm Hg [range, 25-130 mm Hg]; P < .001). The overall satisfaction rate was 77%, and 83% reported a decreased pain level. The group of patients who were satisfied with the treatment included more men and had a higher Delta IMP and a lower revision rate (P < .05). Among the 16 patients (11%) who had undergone revision fasciotomies before follow-up, the satisfaction rate was 56%, and 64% reported a decrease in pain level. Conclusion:Fasciotomy significantly reduced 1-minute postexercise IMP in patients with CECS and resulted in satisfaction and decreased pain in more than three-quarters of the patients at long-term follow-up. The male sex and a significant decrease in IMP were both positively associated with treatment satisfaction. Patients who underwent revision surgery before the follow-up had lower satisfaction rates and less pain reduction than the overall group.
30.	Lundblad, Matilda, 1982, et al. (author) No Association Between Return to Play After Injury and Increased Rate of Anterior Cruciate Ligament Injury in Men’s Professional Soccer 2016 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 4:10 Journal article (peer-reviewed)abstract Background: Studies have shown that previous injury, not necessarily anatomically related, is an important injury risk factor. However, it is not known whether a player runs an increased risk of anterior cruciate ligament (ACL) injury after returning to play from other injury types. Purpose: To analyze whether professional soccer players are more susceptible to ACL injury after returning to play from any previous injury. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 101 elite male soccer players suffering a first-time complete ACL injury between 2001 and 2014 were included and matched according to team, age, and playing position with control players who did not have a current injury (1:1 match). For each injured player, the 90-day period prior to the ACL injury was analyzed for injuries and compared with that of control players by using odds ratios (ORs) and 95% CIs. Results: The odds of a player with an ACL injury sustaining a previous injury in the 90-day period did not differ significantly from that of controls (OR, 1.20; 95% CI, 0.66-2.17; P =.65). Testing the frequency of absence periods due to injury between the groups revealed that the odds of a player with an ACL injury having a previous period of absence due to injury did not differ compared with controls (OR, 1.14; 95% CI, 0.64-2.01; P =.77). Conclusion: Players with ACL injury did not have a greater occurrence of absence due to injury in the 3 months preceding their ACL injury compared with matched controls. This indicates that previous injury of any type does not increase the risk of suffering an ACL injury. © 2016, © The Author(s) 2016.
31.	Meredith, Sean J., et al. (author) Return to Sport After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Return to Sport Consensus Group 2020 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 8:6 Journal article (peer-reviewed)abstract Background: A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level. Purpose: The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making. Study Design: Consensus statement. Methods: An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence. Results: Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries. Conclusion: The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery.
32.	Nilsson, Andreas, 1973, et al. (author) Using the Amplitude of Pulse-Synchronous Intramuscular Pressure Oscillations When Diagnosing Chronic Anterior Compartment Syndrome. 2014 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 2:11 Journal article (peer-reviewed)abstract To diagnose chronic anterior compartment syndrome (CACS) among patients with exercise-induced leg pain, intramuscular pressure (IMP) is regarded as the gold standard. Two recent studies have suggested that the evidence for commonly used IMP criteria are weak, and the validity has therefore come under question.
33.	Nimkingratana, Puwapong, 1982, et al. (author) Returning to Work After Articular Cartilage Repair Intervention: A Systematic Review 2020 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 8:3 Journal article (peer-reviewed)abstract Background: The process of returning to work after cartilage treatment has not been studied in depth, even though a better understanding of potential outcomes could lead to significant benefits for the general population. Purpose: To determine which surgical interventions are most effective in helping patients return to work after cartilage repair and to identify factors that affect the ability to return to work. Study Design: Systematic review; Level of evidence, 4. Methods: This systematic review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in analyzing reports on articular cartilage treatment and return to work published from January 1966 (when the first system of classifying articular cartilage injuries based on the mechanism of injuries and type of lesions was developed) to January 2019. General surgical information and available clinical scores were used to assess outcomes. Results: Only 5 studies describing 283 patients were found to be relevant to our objectives and were therefore included in the analysis. Autologous chondrocyte implantation (ACI) and osteochondral allografts were the only 2 procedures for which information was included regarding patient return to work rates. The mean (overall) return-to-work time after a cartilage repair operation was 4.80 ± 3.02 months. ACI was the most common procedure (3 studies; 227 patients). Return to work after ACI or ACI with high tibial osteotomy (HTO) occurred in almost 100% of cases, whereas the rate of return to work was 51.78% for patients who underwent osteochondral allograft (P <.01); further, patients who had ACI or ACI+HTO returned to work sooner compared with patients who underwent osteochondral allograft. The Knee injury and Osteoarthritis Outcome Score (KOOS) and Single Assessment Numerical Evaluation (SANE) scores were significantly higher in patients who fully returned to work. No significant difference was found in rates of return to work after ACI related to sex, area of the lesion, or size of the defect. Conclusion: The vast majority of published results on articular cartilage repair do not include data on return to work. Although available data on articular cartilage repair in the general population reveal a high rate of return to work, including those patients treated with ACI, the data do not stratify patients by the type and demand of work. No randomized studies have examined return-to-work rates. Hence, authors should include these data in future studies. A refined definition of work intensity, rather than just return to work, may provide a clearer picture of the relative effectiveness of different surgical interventions. To that end, the authors propose a return to work prognostic score called the Prognostic Cartilage Repair Return to Work Score, or PROCART-RTW score. © The Author(s) 2020.
34.	Ozbek, E. A., et al. (author) Failure Rates and Complications After Multiple-Revision ACL Reconstruction: Comparison of the Over-the-Top and Transportal Drilling Techniques 2023 In: Orthopaedic Journal of Sports Medicine (OJSM). - 2325-9671. ; 11:7 Journal article (peer-reviewed)abstract Background:Multiple-revision anterior cruciate ligament reconstruction (ACLR) presents several technical challenges, often due to residual hardware, tunnel widening, malposition, or staged surgeries. Purpose:To compare failure and complication rates between the over-the-top (OTT) and transportal drilling (TD) techniques in patients undergoing surgery for failed revision ACLR. Study Design:Cohort study; Level of evidence, 3. Methods:The medical records of patients with at least 2 revision ACLRs using either the OTT or TD technique were reviewed retrospectively. Data on patient demographics, graft characteristics, number of revisions, concomitant procedures, complications, and failures were collected. Between-group comparisons of continuous and categorical variables were conducted with the independent-samples t test and the Fisher exact or chi-square test, respectively. Results:A total of 101 patients undergoing multiple-revision ACLR with OTT (n = 37, 37%) and TD (n = 64, 63%) techniques were included for analysis. The mean follow-up time was 60 months (range, 12-196 months). There were no significant differences in age, sex, body mass index, laterality, or follow-up length between groups (P > .05). Allograft was the graft used most frequently (n = 64; 67.3%) with no significant differences between groups in graft diameter (P > .05). There were no statistically significant differences between groups regarding rate of concurrent medial and lateral meniscus, cartilage, or lateral extra-articular procedures (P > .05). There was also no significant66 between-group difference in complication rate (OTT: n = 2 [5.4%]; TD: n = 8 [13%]) or graft failure rate (OTT: n = 4 [11%]; TD: n = 14 [22%]) (P > .05 for both). Conclusion:The results of this study showed notably high failure and complication rates in challenging multiple-revision ACLR. Complication and failure rates were similar between techniques, demonstrating that the OTT technique is a valuable alternative that can be used in a revision ACLR, particularly as a single-stage approach when the single-stage TD technique is not possible.
35.	Pedersen, M, et al. (author) Low Rates of Radiographic Knee Osteoarthritis 5 Years After ACL Reconstruction or Rehabilitation Alone: The Delaware-Oslo ACL Cohort Study 2021 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 9:8, s. 23259671211027530- Journal article (peer-reviewed)abstract Patients and clinicians often struggle to choose the optimal management strategy for posttraumatic knee osteoarthritis (OA) after an anterior cruciate ligament (ACL) injury. An evaluation of radiographic outcomes after a decision-making and treatment algorithm applicable in clinical practice can help to inform future recommendations and treatment choices. Purpose: To describe and compare 5-year radiographic outcomes and knee pain in individuals who had gone through our decision-making and treatment algorithm and chosen (1) early (<6 months) ACL reconstruction (ACLR) with pre- and postoperative rehabilitation, (2) delayed (>6 months) ACLR with pre- and postoperative rehabilitation, or (3) progressive rehabilitation alone. Study Design: Cohort study; Level of evidence, 2. Methods: We included 276 patients with unilateral ACL injury from a prospective cohort study. Patients chose management using a shared decision-making process and treatment algorithm, and 5-year postoperative radiographs of the index and contralateral knees were assessed using the Kellgren and Lawrence (K&L) classification and minimum joint space width measurements. We defined radiographic tibiofemoral OA as K&L grade ≥2 and knee pain as a Knee injury and Osteoarthritis Outcome Score for Pain ≤72. To further explore early radiographic changes, we included alternative cutoffs for radiographic knee OA using K&L grade ≥2/osteophyte (definite osteophyte without joint space narrowing) and K&L grade ≥1. Results: At 5 years, 64% had undergone early ACLR; 11%, delayed ACLR; and 25%, progressive rehabilitation alone. Radiographic examination was attended by 187 patients (68%). Six percent of the cohort had radiographic tibiofemoral OA (K&L grade ≥2) in the index knee; 4%, in the contralateral knee. Using the alternative cutoffs at K&L grade ≥2/osteophyte and K&L grade ≥1, the corresponding numbers were 20% and 33% in the index knee and 18% and 29% in the contralateral knee. Six percent had a painful index knee. There were no statistically significant differences in any radiographic outcomes or knee pain among the 3 management groups. Conclusion: There were no statistically significant differences in any 5-year radiographic outcomes or knee pain among the 3 management groups. Very few of the patients who participated in our decision-making and treatment algorithm had knee OA or knee pain at 5 years.
36.	Pereira, B. S., et al. (author) Current Concepts on Subtalar Instability 2021 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 9:8 Journal article (peer-reviewed)abstract Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.
37.	Piussi, R., et al. (author) Self-Reported Symptoms of Depression and Anxiety After ACL Injury: A Systematic Review 2022 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 10:1 Journal article (peer-reviewed)abstract Background: Depression and anxiety symptoms can occur in patients following an anterior cruciate ligament (ACL) injury, and the presence of these symptoms has been associated with poorer self-reported knee function in this type of injury. Purpose: To investigate the prevalence and severity of self-reported symptoms of depression and anxiety following an ACL injury. Study Design: Systematic review; Level of evidence, 4. Methods: PubMed, Cochrane Library, Embase, PsycINFO, AMED, and PEDro databases were searched using a combination of keywords relating to ACL, depression, anxiety, and their synonyms. Inclusion criteria were clinical studies written in English that reported on patients with an injured and/or reconstructed ACL and assessed symptoms of depression and/or anxiety. Data extraction was performed independently by 2 authors. Data synthesis was performed using an emergent synthesis approach. The quality of the included studies was assessed using the methodological index for non-randomized studies or the Mixed-Methods Appraisal Tool. Certainty of evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation. Results: After abstract screening, 37 studies were assessed in full text, of which 16 were included. The studies comprised 682 patients (417 male [61%]). The depression symptoms appeared to be more severe in elite athletes compared with recreational athletes. Symptoms decreased over time from moment of ACL reconstruction to up to 2 years postoperatively. The prevalence of self-reported symptoms of anxiety after an ACL injury was reported in 1 study (2%). There were no differences in anxiety symptoms between professional and amateur athletes or between adolescents and adults. The overall quality of the studies was low or very low. Conclusion: Patients who sustain an ACL injury can suffer from symptoms of depression, especially during the first 6 weeks after ACL reconstruction. Depressive symptoms are more common among professional versus nonprofessional athletes. Levels of anxiety symptoms were not above the cutoffs for a diagnosis of anxiety after an ACL injury. © The Author(s) 2022.
38.	Rahu, M., et al. (author) Do Articular-Sided Partial-Thickness Rotator Cuff Tears After a First-Time Traumatic Anterior Shoulder Dislocation in Young Athletes Influence the Outcome of Surgical Stabilization? 2018 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671. ; 6:6 Journal article (peer-reviewed)abstract Because of the high risk for redislocations after a first-time traumatic anterior shoulder dislocation with conservative treatment, recent publications have recommended early arthroscopic intervention, especially for young athletes. Concomitant rotator cuff tendon damage may occur when the shoulder dislocates; however, its presence and influence on clinical results have not been well described in this patient category. Hypothesis: In opposition to current opinion, a substantial number of articular-sided partial-thickness rotator cuff tears (APTRCTs) would be found at surgery after a first-time traumatic anterior shoulder dislocation in young athletes. However, the impact of these injuries on 2-year postoperative results would be negligible. Study Design: Cohort study; Level of evidence, 3. Methods: Sixteen male patients (mean age, 21 years [range, 16-25 years]) with a first-time traumatic anterior shoulder dislocation without bony Bankart lesions were included in this study. The indications for surgical treatment were age less than 25 years and being active in collision or contact sports at a competitive level. Arthroscopic surgery was performed at a mean 7.8 days (range, 2-14 days) after injury. Rowe and American Shoulder and Elbow Surgeons (ASES) scores as well as range of motion were evaluated at a minimum 2 years after an arthroscopic Bankart procedure, and a comparison of the clinical results between patients with and without APTRCTs was conducted. Results: An anterior-inferior capsulolabral injury was found in all patients. There were no bony Bankart lesions. An APTRCT was found in 9 of the 16 patients. At 2 years after surgical treatment, there were no significant differences between the patients with and without APTRCTs in terms of the Rowe score (90.0 and 87.1, respectively; P = .69) and ASES score (94.6 and 90.4, respectively; P = .67). Conclusion: APTRCTs were found in the superior part of the shoulder joint after a first-time traumatic anterior shoulder dislocation in a majority of young male athletes treated with surgical stabilization. There were no significant differences found between patients with and without APTRCTs in terms of the Rowe and ASES scores at 2 years after surgical treatment.
39.	Rizvanovic, Dzan, et al. (author) Influence of Surgeon Experience and Clinic Volume on Subjective Knee Function and Revision Rates in Primary ACL Reconstruction: A Study from the Swedish National Knee Ligament Registry 2024 In: The Orthopaedic Journal of Sports Medicine. - : SAGE PUBLICATIONS INC. - 2325-9671. ; 12:3 Journal article (peer-reviewed)abstract Background: Anterior cruciate ligament reconstruction (ACLR) performed by high-volume surgeons/clinics has been associated with increased graft individualization and decreased operating times, complication rates, and total costs. Purpose: To investigate the influence of surgeon/clinic volume on subjective knee function and revision surgery rates at 2 years after primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Data from the Swedish National Knee Ligament Registry were used to study patients who underwent primary ACLR between 2008 and 2019. Surgeons/clinics were categorized based on a combination of total caseload volume (cutoff: 50 ACLRs/surgeon, 500 ACLRs/clinic) and annual volume (cutoff: 29 ACLRs/year/surgeon, 56 ACLRs/year/clinic). The thresholds of minimal important change (MIC), Patient Acceptable Symptom State (PASS), and treatment failure (TF) relative to the Knee injury and Osteoarthritis Outcome Score (KOOS) and KOOS4 (mean score of the KOOS Pain, Symptoms, Sports/Rec, and QoL subscales) were applied. Adjusted multivariable logistic regression was performed to assess variables influencing the MIC, PASS, or TF of the KOOS and KOOS4. Adjusted Cox regression analysis was conducted to determine the hazard ratio of subsequent ACLR. Results: Of 35,371 patients, 16,317 had 2-year follow-up outcome data and were included. Patients who underwent primary ACLR by high-volume surgeons had significantly higher MIC and PASS rates and lower TF rates when compared with patients who underwent the procedure by low-volume surgeons: MICKOOS4: 70.6% vs 66.3%; PASS(KOOS4): 46.0% versus 38.3%; and TFKOOS4: 8.7% versus 11.8% (all P < .02). Significantly decreased odds of achieving MICKOOS4 (OR, 0.74; 95% CI, 0.62-0.88) and PASS(KOOS4) (OR, 0.71; 95% CI, 0.60-0.84) were found for ACLRs performed by low-volume surgeons. Clinic volume did not influence the odds of reaching MIC, PASS, or TF. Overall, 804 patients (2.3%) underwent subsequent ACLR at <2 years, with significantly higher revision rates among patients operated on at high-volume clinics (2.5% vs 1.7%; P < .001). However, in the adjusted Cox regression, surgeon/clinic volume had no influence on subsequent ACLR rates. High-volume surgeons/clinics had decreased time to surgery, operating time, perioperative complication rates, and use of thromboprophylaxis and nonroutine antibiotics (P < .001). Conclusion: Patients who underwent primary ACLR by high-volume surgeons experienced increased improvement and satisfaction regarding subjective knee function. Factors other than surgical volume influenced subsequent surgery rates. Patients might benefit from undergoing primary ACLR by high-volume providers.
40.	Ronnblad, E, et al. (author) Predictive Factors for Failure of Meniscal Repair: A Retrospective Dual-Center Analysis of 918 Consecutive Cases 2020 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 8:3, s. 2325967120905529- Journal article (peer-reviewed)abstract Meniscal surgery is one of the most common surgical procedures performed by orthopaedic surgeons. Over the past decade, awareness has increased regarding the importance of meniscal preservation to prevent the development of osteoarthritis in the knee joint. Removal of meniscal tissue can lead to a high risk of cartilage degeneration, and moreover, meniscus-preserving surgery rather than meniscal resection is likely to have better long-term outcomes. Success rates after meniscal repair range from 60% to 95%, but many reports are based on a small number of patients. Purpose/Hypothesis: The purpose of this study was to review all meniscal repairs and potential predictors for failure during a 12-year period. We hypothesized that meniscal anchors, lateral repairs, and repairs made in conjunction with an anterior cruciate ligament reconstruction (ACLR) would have fewer failures than meniscal arrows, medial repairs, and isolated repairs. We also hypothesized that younger patients and acute tears would be associated with fewer failures. Study Design: Case-control study; Level of evidence, 3. Methods: This study was a dual-center, retrospective analysis on consecutive meniscal repairs. The surgical protocols were reviewed, including type of tear, location, associated injury to the knee, and surgery. The study endpoint was failure of repair, defined as a need for reoperation and secondary partial or total meniscal resection, within 3 years. Kaplan-Meier analysis was performed to assess repair survival, with multivariate Cox regression to adjust for confounders. Results: A total of 954 meniscal repairs were performed on 918 patients (536 male patients [58%]; 382 female patients [42%]) with a mean age of 26 years (range, 12-60 years). The failure rate for the entire cohort was 22.5%. Bioabsorbable arrows had significantly more failures than all-inside sutures with anchors (hazard ratio [HR], 1.8; 95% CI, 1.2-2.5; P = .002). Medial meniscal repairs had a higher failure rate than lateral meniscal repairs (HR, 3.7; 95% CI, 2.3-6.0; P < .001). Simultaneous ACLR resulted in less failure than when no simultaneous ACLR was performed (HR, 0.5; 95% CI, 0.3-0.9; P = .009). Age at repair and acuity of tear did not affect the outcome ( P = .6 and .07, respectively). Conclusion: The failure rate after meniscal repair was significantly higher on the medial side, especially when using arrows. Meniscal repairs performed concomitantly with an ACLR result in fewer reoperations.
41.	Saarensilta, A, et al. (author) Early Tendon Morphology as a Biomarker of Long-term Patient Outcomes After Surgical Repair of Achilles Tendon Rupture: A Prospective Cohort Study 2023 In: Orthopaedic journal of sports medicine. - 2325-9671. ; 11:11, s. 23259671231205326- Journal article (peer-reviewed)
42.	Saarensilta, A, et al. (author) Effect of Surgeon Experience on Long-Term Patient Outcomes in Surgical Repair of Acute Achilles Tendon Rupture 2022 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 10:2, s. 23259671221077679- Journal article (peer-reviewed)abstract The effect of surgeon experience on patient outcomes after surgical Achilles tendon rupture (ATR) repair has so far been unknown. Purpose: To examine whether patient-reported and functional outcomes as well as adverse events after surgical ATR repair differ between orthopaedic specialist surgeons and resident surgeons. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively analyzed data from 295 patients treated with surgical ATR repair with standardized techniques. The level of surgeon experience (specialist vs resident) and number of adverse events (rerupture, infection, and deep venous thrombosis) were recorded. Patient-reported and functional outcomes were assessed 12 months postoperatively using the validated Achilles tendon total rupture score (ATRS) and the heel-rise test, respectively. Analysis of covariance was used to compare differences in outcomes between specialist surgeons and resident surgeons. Pearson chi-square or Fisher exact test was used for analysis of adverse events. Results: The mean ATRS at 12 months for patients operated on by resident surgeons was significantly higher compared with specialist surgeons (85.9 [95% CI, 80.3-91.5] vs 77.8 [95% CI, 73.8-81.9]; P = .028). In addition, the lateral difference (operated vs unoperated side) in mean total concentric work and number of heel-rise repetitions at 12 months was smaller in patients operated on by resident surgeons ( P = .011 and 0.015, respectively). The number of adverse events did not differ significantly between the 2 groups. Conclusion: Resident surgeons achieved patient-reported and functional outcomes at least as good as those of specialist surgeons in surgical ATR repair, with a similar risk of adverse events.
43.	Sansone, Mikael, et al. (author) Good Results After Hip Arthroscopy for Femoroacetabular Impingement in Top-Level Athletes. 2015 In: Orthopaedic journal of sports medicine. - : SAGE Publications. - 2325-9671. ; 3:2 Journal article (peer-reviewed)abstract Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction among athletes. Although arthroscopic surgery is an established treatment option for FAI, there are few studies reporting detailed outcomes using validated outcome measurements specifically designed for young and active athletes.
44.	Sonesson, Sofi, et al. (author) Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms : A 5-Year Follow-up of a Prospective, Randomized Study 2020 In: The Orthopaedic Journal of Sports Medicine. - : Sage Publications. - 2325-9671. ; 8:1 Journal article (peer-reviewed)abstract Background:Arthroscopic meniscal surgery is a common orthopaedic procedure in middle-aged patients, but the efficacy of this procedure has been questioned. In this study, we followed up the only randomized controlled trial that has shown a 1-year benefit from knee arthroscopic surgery with an exercise program compared with an exercise program alone.Purpose:To (1) evaluate whether knee arthroscopic surgery combined with an exercise program provided an additional 5-year benefit compared with an exercise program alone in middle-aged patients with meniscal symptoms, (2) determine whether baseline mechanical symptoms affected the outcome, and (3) compare radiographic changes between treatment groups.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:Of 179 eligible patients aged 45 to 64 years, 150 were randomized to either a 3-month exercise program (nonsurgery group) or to the same exercise program plus knee arthroscopic surgery (surgery group) within 4 weeks. Radiographs were assessed, according to the Kellgren-Lawrence grade, at baseline and at the 5-year follow-up. The primary outcome was the change in Knee injury and Osteoarthritis Outcome Score (KOOS)–Pain (KOOSPAIN) subscore from baseline to the 5-year follow-up. We performed an as-treated analysis.Results:A total of 102 patients completed the 5-year questionnaire. At the 5-year follow-up, both groups had significant improvement in KOOSPAIN subscores, although there was no significant change from the 3-year scores. There was no between-group difference in the change in the KOOSPAIN subscore from baseline to 5 years (3.2 points [95% CI, –6.1 to 12.4]; adjusted P = .403). In the surgery group, improvement was greater in patients without mechanical symptoms than in those with mechanical symptoms (mean difference, 18.4 points [95% CI, 8.7 to 28.1]; P < .001). Radiographic deterioration occurred in 60% of patients in the surgery group and 37% of those in the nonsurgery group (P = .060).Conclusion:Knee arthroscopic surgery combined with an exercise program provided no additional long-term benefit after 5 years compared with the exercise program alone in middle-aged patients with meniscal symptoms. Surgical outcomes were better in patients without mechanical symptoms than in patients with mechanical symptoms during the preoperative period. Radiographic changes did not differ between treatment groups.Registration:NCT01288768 (ClinicalTrials.gov identifier).
45.	Stenberg, Johan, et al. (author) Clinical Outcome 3 Years After Autologous Chondrocyte Implantation Does Not Correlate With the Expression of a Predefined Gene Marker Set in Chondrocytes Prior to Implantation but Is Associated With Critical Signaling Pathways 2014 In: The Orthopaedic Journal of Sports Medicine. - : Sage Publications. - 2325-9671. ; 2:9, s. 1-14 Journal article (peer-reviewed)abstract BACKGROUND: There is a need for tools to predict the chondrogenic potency of autologous cells for cartilage repair.PURPOSE: To evaluate previously proposed chondrogenic biomarkers and to identify new biomarkers in the chondrocyte transcriptome capable of predicting clinical success or failure after autologous chondrocyte implantation.STUDY DESIGN: Controlled laboratory study and case-control study; Level of evidence, 3.METHODS: Five patients with clinical improvement after autologous chondrocyte implantation and 5 patients with graft failures 3 years after implantation were included. Surplus chondrocytes from the transplantation were frozen for each patient. Each chondrocyte sample was subsequently thawed at the same time point and cultured for 1 cell doubling, prior to RNA purification and global microarray analysis. The expression profiles of a set of predefined marker genes (ie, collagen type II α1 [COL2A1], bone morphogenic protein 2 [BMP2], fibroblast growth factor receptor 3 [FGFR3], aggrecan [ACAN], CD44, and activin receptor-like kinase receptor 1 [ACVRL1]) were also evaluated.RESULTS: No significant difference in expression of the predefined marker set was observed between the success and failure groups. Thirty-nine genes were found to be induced, and 38 genes were found to be repressed between the 2 groups prior to autologous chondrocyte implantation, which have implications for cell-regulating pathways (eg, apoptosis, interleukin signaling, and β-catenin regulation).CONCLUSION: No expressional differences that predict clinical outcome could be found in the present study, which may have implications for quality control assessments of autologous chondrocyte implantation. The subtle difference in gene expression regulation found between the 2 groups may strengthen the basis for further research, aiming at reliable biomarkers and quality control for tissue engineering in cartilage repair.CLINICAL RELEVANCE: The present study shows the possible limitations of using gene expression before transplantation to predict the chondrogenic and thus clinical potency of the cells. This result is especially important as the chondrogenic potential of the chondrocytes is currently part of quality control measures according to European and American legislations regarding advanced therapies.
46.	Strong, Andrew, et al. (author) Properties of knee joint position sense tests after anterior cruciate ligament injury : A systematic review and meta-analysis 2021 In: The Orthopaedic Journal of Sports Medicine. - : Sage Publications. - 2325-9671. ; 9:8 Research review (peer-reviewed)abstract Background: Knee proprioception is believed to be deficient after anterior cruciate ligament (ACL) injury. Tests of joint position sense (JPS) are commonly used to assess knee proprioception, but their psychometric properties (PMPs) are largely unknown.Purpose: To evaluate the PMPs (reliability, validity, and responsiveness) of existing knee JPS tests targeting individuals with ACL injury.Study design: Systematic review; Level of evidence, 4.Methods: PubMed, Allied and Complementary Medicine, CINAHL, SPORTDiscus, Web of Science, Scopus, CENTRAL, and ProQuest databases were searched to identify studies that assessed PMPs of knee JPS tests in individuals with ACL injury. The risk of bias for each included study was assessed and rated at the outcome level for each knee JPS test. Overall quality and levels of evidence for each PMP were rated according to established criteria. Meta-analyses with mean differences were conducted using random effects models when adequate data were available.Results: Included were 80 studies covering 119 versions of knee JPS tests. Meta-analyses indicated sufficient quality for known-groups and discriminative validity (ACL-injured knees vs knees of asymptomatic controls and contralateral noninjured knees, respectively), owing to significantly greater absolute errors for ACL-injured knees based on a strong level of evidence. A meta-analysis showed insufficient quality for responsiveness, which was attributed to a lack of significant change over time after diverse interventions with a moderate level of evidence. Statistical heterogeneity (I 2 > 40%) was evident in the majority of meta-analyses. All remaining PMPs (reliability, measurement error, criterion validity, convergent validity, and other PMPs related to responsiveness) were assessed qualitatively, and they failed to achieve a sufficient quality rating. This was a result of either the study outcomes not agreeing with the statistical cutoff values/hypotheses or the level of evidence being rated as conflicting/unknown or based on only a single study.Conclusion: Knee JPS tests appear to have sufficient validity in differentiating ACL-injured knees from asymptomatic knees. Further evidence of high methodologic quality is required to ascertain the reliability, responsiveness, and other types of validity assessed here. We recommend investigations that compare the modifiable methodologic components of knee JPS tests on their PMPs to develop standardized evidence-based tests.
47.	Strömbäck, Edit, et al. (author) Prevalence and consequences of injuries in powerlifting : a cross-sectional study 2018 In: The Orthopaedic Journal of Sports Medicine. - Thousand Oaks, California : Sage Publications. - 2325-9671. ; 6:5 Journal article (peer-reviewed)abstract Background: Powerlifting consists of the squat, bench press, and dead lift, and extreme loads are lifted during training and competitions. Previous studies, which have defined an injury as an event that causes an interruption in training or competitions, have reported a relatively low frequency of powerlifting injuries (1.0-4.4 injuries/1000 hours of training). No previous study has investigated the prevalence of injuries, defined as a condition of pain or impairment of bodily function that affects powerlifters’ training, in a balanced sample of men and women, and no studies have established possible risk factors for an injury.Purpose: To investigate the prevalence, localization, and characterization of injuries among Swedish subelite classic powerlifters, with an emphasis on differences between men and women, and to investigate whether training and lifestyle factors are associated with an injury.Study Design: Cross-sectional study; Level of evidence, 3.Methods: A total of 53 female and 51 male Swedish subelite powerlifters answered an online questionnaire including questions about background characteristics, training habits, and lifestyle factors. The main part of the questionnaire included questions about injuries and their consequences. An injury was defined as a condition of pain or impairment of bodily function that affects powerlifters’ training.Results: Seventy percent (73/104) of participants were currently injured, and 87% (83/95) had experienced an injury within the past 12 months. The lumbopelvic region, shoulder, and hip were the most commonly injured areas for both sexes. Women experienced a significantly greater frequency of injuries in the neck and thoracic region than men. Injuries seemed to occur during training, although only 16% (11/70) of those currently injured had to completely refrain from training. Training frequency, greater personal best in the dead lift, injury onset during bench-press and dead-lift training, use of straps, alcohol consumption, and dietary issues were associated with current injuries.Conclusion: Injuries are very common in subelite powerlifters. Men and women report similar injury frequencies but different anatomic locations. These injuries do not prevent powerlifters from training and competing, but they may change the content of training sessions. Why powerlifters develop injuries is still unclear; however, it is likely that the management of training loads and optimization of the lifting technique during the squat, bench press, and dead lift are of importance.
48.	Svantesson, Eleonor, et al. (author) Clinical Outcomes After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Clinical Outcomes Consensus Group. 2020 In: Orthopaedic journal of sports medicine. - 2325-9671. ; 8:7 Journal article (peer-reviewed)abstract A stringent outcome assessment is a key aspect of establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. To establish a standardized assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, Pennsylvania, USA, in June 2019. The aim was to establish a consensus on what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used, and at what follow-up time those outcomes should be assessed. The group reached consensus on 9 statements by using a modified Delphi method. In general, outcomes after ACL treatment can be divided into 4 robust categories: early adverse events, patient-reported outcomes (PROs), ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. A comprehensive assessment after ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained reinjuries, validated knee-specific PROs, and health-related quality of life questionnaires. In the midterm to long-term follow-up, the presence of osteoarthritis should be evaluated. This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment.
49.	Thorolfsson, Baldur, et al. (author) Adolescents Have Twice the Revision Rate of Young Adults After ACL Reconstruction With Hamstring Tendon Autograft: A Study From the Swedish National Knee Ligament Registry 2021 In: Orthopaedic Journal of Sports Medicine. - : SAGE Publications. - 2325-9671 .- 2325-9671. ; 9:10 Journal article (peer-reviewed)abstract Background: Previous studies have identified young age as a risk factor for anterior cruciate ligament (ACL) revision. However, few studies have looked separately at pediatric patients and adolescents with regard to outcomes after ACL reconstruction. Purpose: To determine whether patient age at ACL reconstruction affects the risk of undergoing revision surgery in young patients. Study Design: Cohort study; Level of evidence, 3. Methods: This study was based on data from the Swedish National Knee Ligament Registry. Patients aged 5 to 35 years who underwent a primary ACL reconstruction with a hamstring tendon autograft between January 1, 2005, and December 31, 2015, were included. The cohort was stratified into different age groups of pediatric patients, adolescents, and young adults to estimate patients with open, recently closed, and closed epiphyses, respectively. The primary endpoint was ACL revision. A multivariable Cox regression model was used to assess the ACL revision rate. The results were expressed as hazard ratios (HRs) and 95% CIs. Results: A total of 36,274 ACL reconstructions were registered during the study period. Of these, 2848 patients were included in the study: 47 pediatric patients (mean age, 13.6 years; range, 9-15 years), 522 adolescents (mean age, 17.4; range, 14-19 years), and 2279 young adults (mean age, 27.0; range, 20-35 years). A total of 31 patients (1.1%) underwent ACL revision within 2 years (0 pediatric patients, 9 adolescents [1.7%], and 22 young adults [1.0%]) and a total of 53 patients (2.6%) underwent ACL revision within 5 years (2 pediatric patients [6.9%], 15 adolescents [3.9%], and 36 young adults [2.2%]). The adolescent age group had a 1.91 times higher rate of ACL revision compared with the young adults (HR = 1.91 [95% CI, 1.13-3.21]; P = .015). There were no differences in revision rates between the pediatric age group and the young adults (HR = 2.93 [95% CI, 0.88-9.79]; P = .081). Conclusion: Adolescents had almost twice the rate of revision ACL reconstruction compared with young adults.
50.	Tigerstrand Grevnerts, Hanna, et al. (author) Decision Making for Treatment After ACL Injury From an Orthopaedic Surgeon and Patient Perspective: Results From the NACOX Study 2021 In: The Orthopaedic Journal of Sports Medicine. - : Sage Publications. - 2325-9671. ; 9:4 Journal article (peer-reviewed)abstract Background: In the treatment of anterior cruciate ligament (ACL) injuries, there is little evidence of when and why a decision for ACL reconstruction (ACLR) or nonoperative treatment (non-ACLR) is made. Purpose: To (1) describe the key characteristics of ACL injury treatment decisions and (2) compare patient-reported knee instability, function, and preinjury activity level between patients with non-ACLR and ACLR treatment decisions. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 216 patients with acute ACL injury were evaluated during the first year after injury. The treatment decision was non-ACLR in 73 patients and ACLR in 143. Reasons guiding treatment decision were obtained from medical charts and questionnaires to patients and orthopaedic surgeons. Patient-reported instability and function were obtained via questionnaires and compared between patients with non-ACLR and ACLR treatment decisions. The ACLR treatment group was classified retrospectively by decision phase: acute phase (decision made between injury day and 31 days after injury), subacute phase (decision made between 32 days and up to 5 months after injury), and late phase (decision made 5-12 months after injury). Data were evaluated using descriptive statistics, and group comparisons were made using parametric or nonparametric tests as appropriate. Results: The main reasons for a non-ACLR treatment decision were no knee instability and no problems with knee function. The main reasons for an ACLR treatment decision were high activity demands and knee instability. Patients in the non-ACLR group were significantly older (P = .031) and had a lower preinjury activity level than did those in the acute-phase (P < .01) and subacute-phase (P = .006) ACLR decision groups. There were no differences in patient-reported instability and function between treatment decision groups at baseline, 4 weeks after injury, or 3 months after injury. Conclusion: Activity demands, not patient-reported knee instability, may be the most important factor in the decision-making process for treatment after ACL injury. We suggest a decision-making algorithm for patients with ACL injuries and no high activity demands; waiting for >3 months can help distinguish those who need surgical intervention from those who can undergo nonoperative management.

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