The psychosocial impact of ACL tear injury in collegiate male and female athletes

BACKGROUND: Poor mental health and the varying stressors that provoke psychological disturbance are considerable issues that plague the United States young adult population. Within the collegiate student-athlete cohort, where athletes are subjected to unique pressures placed on them secondary to performance demands, significant injury such as an ACL tear requiring surgical reconstruction and a rigorous rehabilitation course remains a major contributor to psychological and physical disruption. Females in particular may be at higher risk of psychological instability due to hormonal and personality factors, increased injury rates, and gender bias that still exists in the collegiate sports world. LITERATURE REVIEW FINDINGS: Despite recognition of the mental health sequelae of injury in this cohort, sports medicine personnel report discomfort in approaching emotional difficulties and mentoring athletes on the utilization of psychological skills. In conjunction, referral to sports psychologists remains low. The use of a universal self-report survey can help athletes and sports medicine providers acknowledge the psychological impact of injury and take proactive action to provide the athlete with the necessary psychological support needed to fully recover and return to play. PROPOSED PROJECT: The goal of this cross-sectional study is to use a previously validated psychometric tool to assess and compare differences in acute psychological response to ACL tear in male and female collegiate soccer players. If there is a consistent gender disparity observed based on survey scores, sports medicine specialists could develop heightened awareness toward a specific gender that is at high-risk for psychological instability following injury and provide immediate psychological intervention if an event occurs. CONCLUSIONS: The use of a psychometric survey to assess mental health in the collegiate athlete population should be standard practice. If used correctly, the tool has the ability to assess injury response and the need for psychological intervention for all athletes suffering from chronic injuries. The benefits are widespread among all parties of the sports medicine team and the end result is increased stability and mental well-being within the athletic environment. SIGNIFICANCE: The clinical significance of the study extends beyond identifying gender and demographic risk factors and aims to stress the importance of recognizing psychological distress following injury and the necessity of appropriate psychological intervention in a large population of student-athletes across the country

Personalized Hip and Knee Joint Replacement

This open access book describes and illustrates the surgical techniques, implants, and technologies used for the purpose of personalized implantation of hip and knee components. This new and flourishing treatment philosophy offers important benefits over conventional systematic techniques, including component positioning appropriate to individual anatomy, improved surgical reproducibility and prosthetic performance, and a reduction in complications. The techniques described in the book aim to reproduce patients’ native anatomy and physiological joint laxity, thereby improving the prosthetic hip/knee kinematics and functional outcomes in the quest of the forgotten joint. They include kinematically aligned total knee/total hip arthroplasty, partial knee replacement, and hip resurfacing. The relevance of available and emerging technological tools for these personalized approaches is also explained, with coverage of, for example, robotics, computer-assisted surgery, and augmented reality. Contributions from surgeons who are considered world leaders in diverse fields of this novel surgical philosophy make this open access book will invaluable to a wide readership, from trainees at all levels to consultants practicing lower limb surger

TRAK ACL: Development of a self-management Digital Health Intervention to support optimal care in ACL rehabilitation: Scoping Review, Qualitative Study and Feasibility RCT

Background: Outcomes vary after Anterior Cruciate Ligament (ACL) reconstruction surgery and many patients do not return to previous levels of activity. This may be related to variations in evidence based rehabilitation care. It is NHS policy to avoid inappropriate variations in healthcare and to use digital health interventions (DHI) to improve access and outcomes. / Aim: This thesis explored causes of variability in care and the feasibility of a DHI to overcome them. / Objectives: 1. To identify resources used in trials of optimal ACL rehabilitation; 2. To explore stakeholder views around criteria for optimal care and reasons for variation. 3. To explore opinions of digital tools in evolving care models. 4. To determine the feasibility of undertaking a definitive randomised controlled trial (RCT) to determine effectiveness and cost-effectiveness of a specific DHI to support ACL rehabilitation. / Methods: Methods were selected to match objectives: Objective 1 was addressed with a systematically conducted scoping review; Objectives 2 & 3 through qualitative interviews with orthopaedic surgeons and physiotherapists; and Objective 3 by a randomised feasibility trial comparing a specific DHI plus Treatment as Usual (TAU) with TAU. / Results: The scoping review established that ACL rehabilitation in RCTs includes specialist equipment, a gym environment and an experienced physiotherapist. Interviews revealed that practitioners were committed to evidence-based care, but were sometimes limited by systemic factors, including lack of resources, infrequent appointments or ambiguous pathways of care. Interviewees cautiously welcomed DHIs to support care but identified concerns. Feasibility results showed 86% recruitment rate, 78% retention rate and 100% completion rate on 4 out of 5 outcomes including the primary outcome of a future trial, the Knee Osteoarthritis Outcome Score. Fidelity to the DHI showed user engagement was heavily skewed. / Conclusion: This work provides evidence to explain observed unacceptable variations in care for this patient group and suggests that a digital health intervention could help address these. A definitive trial is both warranted and feasible

Traumatic patellar dislocation in children : epidemiology, risk factors, the MPFL and treatment outcome

The knee joint is one of the most common injury sites in children, with the spectrum of injuries differing from those in adults. Traumatic lateral patellar dislocation (LPD) is the most common serious injury; the incidence is approximately 1/1000 in children 9-15 years of age. The risk for recurrent dislocation is high in this age group. The most important static stabilizer for lateral patellar dislocation is the medial patellofemoral ligament (MPFL). The injury to the MPFL and the anatomic patellar instability risk factors for lateral patellar dislocation are best described in the adult population. There is no consensus about the best treatment for the first-time traumatic lateral patellar dislocation in children. The aim of this thesis was firstly to describe the current spectrum of acute knee injuries presenting with knee hemarthrosis, with a detailed description of the most common injury, the traumatic lateral patellar dislocation. Secondly, the aim was to describe the patellofemoral joint morphology, the anatomic patellar instability risk factors and the medial patellofemoral ligament injury in the skeletally immature child. Thirdly, the aim was to evaluate if an acute refixation of the medial patellofemoral ligament injury vs. non-operative treatment for firsttime traumatic lateral patellar dislocation could reduce the high recurrence rate. All studies were prospective in design. Patients were skeletally immature, 9-14 years old, and previously had healthy knees before an acute knee trauma that caused hemarthrosis. They were following an algorithm to investigate the injury with standardized radiographs and MRI within two weeks from the index injury. In Study I, 117 patients with acute knee trauma were examined. Seventy percent had a serious knee injury that needed specific medical care. Fifty-six percent of these patients had no visible injury on their radiographs. Lateral patellar dislocation (41%), ACL injury (12%) and anterior tibial spine injury (7%) were the most common injuries and the majority were sports-related. Study II included 74 patients with first-time traumatic LPD. The medial patellofemoral injury was evaluated by MRI and arthroscopy. An injury to the MPFL at the patellar attachment site was diagnosed in 99% of patients, either as an isolated injury at the patellar site or as part of a multi-focal injury. Study III consisted of 103 patients with firsttime traumatic LPD and a control group of 69 patients with acute knee trauma without LPD. The morphology of the patellofemoral joint and anatomic patellar instability risk factors were analyzed and the two groups were compared. Central condylar height was higher in the group with lateral patellar dislocation, resulting in lower trochlear depth and higher sulcus angles. There was a significant difference in mean values of all established anatomic patellar instability risk factors between children with first-time traumatic LPD and the control group. The main divergent anatomic patellar instability risk factor was trochlear dysplasia (defined as trochlear depth < 3mm), which was seen in 74% in the LPD group compared to 4% in the control group. Trochlear dysplasia, together with lateral patellar tilt ( ³ 20°), had the strongest association with LPD. The 74 patients from Study II were in Study IV randomized in a RCT to either non-operative treatment (soft knee brace and physiotherapy) or operative treatment (arthroscopic assisted medial patellofemoral ligament refixation, soft cast splint and physiotherapy). The follow-up time was two years; the main outcome was redislocation and evaluation of subjective and objective knee function. A refixation of the MPFL injury in the acute phase in skeletally immature children with first-time traumatic lateral patellar dislocation significantly reduced the redislocation rate but did not improve the subjective and objective knee function compared with non-operative treated patients. The majority of the patients were satisfied with their knee function

Physiotherapy goal setting in anterior cruciate ligament rehabilitation : an exploration of training, practice and beliefs

Despite the growing interest into the role of physiotherapists providing psychological interventions within anterior cruciate ligament (ACL), literature surrounding goal setting practices within this field is minimal. The main purpose of this research was to explore physiotherapists’ approaches, training and beliefs into goal setting practices used within ACL rehabilitation. The thesis consisted of seven chapters, two of which were empirical studies. The empirical chapters aimed to gain further insight into physiotherapists understanding on the psychological aspects of patients following ACL surgery, theoretical knowledge of goal setting, experiences of implementing goals, training received on goal setting and future training needs. Study four involved a UK cross sectional online survey of one hundred and twenty four physiotherapists (N=124). The survey provided an insight of perceptions and goal setting approaches used within ACL rehabilitation. These findings were further explored in study five which involved a UK semi-structured interview study including twenty four physiotherapists (N=24), using an inductive approach. Study five provided a much deeper understanding in to physiotherapist’s goal setting practices, training and experiences within ACL rehabilitation and also revealed issues surrounding the initial consultation process. The research findings were conceptualised into a theoretical, innovative goal setting model. The goal of this model is to outline a multi-phase conceptual model of an appropriate ACL rehabilitation goal setting strategy for physiotherapists in an attempt to guide both practice, teaching and research

Total knee replacements: design and pre-clinical testing methods

Total knee replacement (TKR) is a common and successful treatment for severe osteoarthritis of the knee. However, a large minority of people remain dissatisfied after the operation, despite adequate pain relief. Over 50 designs of TKR are used in the UK each year, but differentiating between these devices in terms of patient function and making the right choice for each patient remains challenging. The aim of this research was to characterise designs of TKR in the laboratory, using pre-clinical testing methods, in order to better understand TKR function, and make suggestions for improved implant design and testing. Conventional, medial-pivot, guided-motion and bicruciate retaining (BCR) TKRs were tested. Standard ASTM test methods used for CE-marking purposes were demonstrated to differentiate between devices, but did not produce enough information to adequately understand how a new device will behave clinically, or what the potential benefits of a new device would be to patients. Guided-motion devices are meant to replicate normal knee motion, but there has been concern that they might cause too much rotation of the knee, leading to anterolateral knee pain. Results from cadaveric testing suggest that they do not adequately mimic normal knee motion and small design changes may have little impact on performance. A BCR TKR, designed to improve stability in the replaced knee joint, was also tested. Knee kinematics were measured for three design phases and surgical feasibility was also assessed for this more complicated procedure. BCR TKR was shown to lead to more normal levels of anteroposterior tibiofemoral laxity, compared to a conventional, anterior-cruciate-ligament-sacrificing TKR. Inherent variability between people’s anatomy and osteoarthritis pathology suggests there will never be a single, perfect, TKR, but more comprehensive pre-clinical testing could improve the regulatory approval process and inform better device selection, leading to improved patient outcomes.Open Acces

The Effect of Robotic Technology on Perioperative Outcomes in Total Knee Arthroplasty

Introduction Robotic technology has recently regained momentum in total knee arthroplasty (TKA) but the effects of this technology on accuracy of implant positioning, intraoperative soft tissue injury and postoperative functional rehabilitation remain unknown. The objectives of this research thesis were to compare a comprehensive range of radiological objectives and perioperative outcomes in conventional jig-based TKA versus robotic-arm assisted TKA, and use optical motion capture technology to quantify the effects of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) resection on knee biomechanics. Methods A series of prospective cohort studies were undertaken in patients with established knee osteoarthritis undergoing primary conventional jig-based TKA versus robotic-arm assisted TKA. Predefined radiological and perioperative study outcomes were recorded by independent observers. Optical motion capture technology during robotic TKA was used to quantify the effects of ACL and PCL resection on knee biomechanics. Results Robotic-arm assisted TKA was associated with improved accuracy of implant positioning, reduced periarticular soft tissue injury, decreased bone trauma, improved postoperative functional rehabilitation, and reduced early systemic inflammatory response compared to conventional jig-based TKA. The Macroscopic Soft Tissue Injury (MASTI) classification system was developed and validated for grading intraoperative periarticular soft tissue injury and bone trauma during TKA. ACL resection created flexion-extension mismatch by increasing the extension gap more than the flexion gap, whilst PCL resection increased the flexion gap proportionally more than the extension gap and created mediolateral laxity in knee flexion but not in extension. Conclusion Robotic-arm assisted TKA was associated with increased accuracy of implant positioning, reduced iatrogenic soft tissue injury, and improved functional rehabilitation compared to conventional jig-based TKA. ACL and PCL resections created unique changes in knee biomechanics that affected flexion-extension gaps and mediolateral soft tissue tension during TKA. On the basis of this thesis, further clinical trials have been established to determine the long-term clinical significance of these findings

Arthroscopy

This book covers a physical examination, imaging, differential diagnoses, and treatment of articular pathologies. For each diagnosis, the book sets out the typical presentation, options for non-operative and operative management, and expected outcomes. Practical and user-friendly, Arthroscopy is a useful resource for medical students and practitioners seeking fast facts on diagnosis and management. Its format makes it a perfect quick reference and its content breadth covers commonly encountered orthopedic problems in practice