Clinical and Cost Effectiveness of Pre-Operative Physiotherapy for Patients Undergoing Anterior Cruciate Ligament Reconstruction in Riyadh, Saudi Arabia.

Purpose: To examine the clinical and cost effectiveness of a pre-operative physiotherapy programme for the management of Saudi patients with ACL injury. Methods: A pragmatic quasi-randomised controlled trial (RCT) was conducted to evaluate a newly developed pre-operative physiotherapy protocol. A total of 84 patients with ACL injury participated in the study; 45 in the Control group and 39 in the Intervention group (median age 27.5 years, IQR 8.5). The intervention protocol consisted of twelve 45-minute long sessions over 4 weeks and included 3 types of exercise: a warm-up session, muscle strengthening exercises and balance exercises. Measurements were taken upon enrollment and two weeks post-surgery. Outcomes included the knee injury and osteoarthritis outcome score (KOOS), ROM, muscle strength, pain, health state and quality of life (QoL). Cost-effectiveness of the intervention was examined using the incremental cost-effectiveness ratio (ICER) was used based on resource use and quality-adjusted life years (QALY). Data analysis described the measurements using medians and interquartile ranges (IQR) and assessed differences between the two groups using Mann-Whitney U-test. Results: Patients in the intervention group showed significant improvement in the primary outcomes compared to the control group as demonstrated by the KOOS scores (p < 0.001). Muscle strength was higher in the intervention group for both quadriceps and hamstring muscles (p < 0.01) with improvement in range of motion especially during flexion (p < 0.001). In addition, QoL was significantly better in the intervention group (p < 0.001). The measured ICER indicated that the intervention can be deemed to be cost-effective (£1150 per QALY gained). Conclusion(s): The present study suggests that a standardised pre-operative physiotherapy programme was clinically and cost effective for patients undergoing ACL reconstruction in KSA. Clinicians and decision makers are to be aware of these findings as they may provide justification for resource allocation in the management of patient with this condition. Implications: Based on the findings of the present study, pre-operative physiotherapy should be integrated into the Saudi healthcare system as a routine practice in hospitals and rehabilitation clinics. Based on the findings in relation to cost-effectiveness of the intervention in the present research, effectiveness of pre-operative physiotherapy in regards to the short term may potentially justify the resources that are required to implement it for use

The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: A systematic review.

OBJECTIVE: To evaluate the effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury. METHODS: The following databases were searched: PubMed, Ovid, The Cochrane Library and Web of Science. Studies published between the inception of the databases and December 2015 were sought using appropriate keywords in various combinations. This search was supplemented with a manual search of the references of selected studies. Studies were assessed for methodological quality using the Physiotherapy Evidence Database scale. RESULTS: A total of 500 studies were identified, of which eight studies met the inclusion criteria and were included in the present review. The average Physiotherapy Evidence Database score for the studies included was 5.8, which reflects an overall moderate methodological quality.The eight studies investigated a total of 451 subjects of which 71% (n=319) were males. The age of the participants in the eight studies ranged from 15 to 57 years. The duration of the intervention in the studies ranged from 3 to 24 weeks. This review found that pre-operative physiotherapy rehabilitation is effective for improving the outcomes of treatment following anterior cruciate ligament injury, including increasing knee-related function and improving muscle strength. However, whilst there was a significant improvement in quality of life from baseline following intervention, no significant difference in quality of life was found between the control and intervention groups. CONCLUSIONS: There is evidence to suggest that pre-operative physiotherapy rehabilitation is beneficial to patients with anterior cruciate ligament injury

Degeneration in ACL Injured Knees with and without Reconstruction in Relation to Muscle Size and Fat Content—Data from the Osteoarthritis Initiative

Anterior cruciate ligaments (ACL) injuries represent a major risk factor for early osteoarthritis (OA).To evaluate the prevalence and 4-year progression of knee OA measured with 3T MR-imaging in individuals with ruptured, reconstructed or normal ACL and to assess the impact of thigh muscle characteristics.A total of 54 knees (23/54 male, 31/54 female) were recruited from the Osteoarthritis Initiative (OAI). At baseline, 15/54 subjects had prevalent ACL ruptures and 15/54 subjects had prevalent ACL reconstruction (24/54 normal ACL). Western Ontario and McMasters Universities Arthritis Index (WOMAC) scores, Physical Activity Scores of the Elderly (PASE) and thigh muscle characteristics including strength, fat infiltration (Goutallier score) and thigh muscle cross-sectional area (CSA) MR measurements were obtained at baseline. Whole-organ MR-imaging Scores (WORMS) were obtained at baseline and at a 4-year follow-up time-point. Multivariate regression models, adjusting for covariates (age, gender, body mass index), were used for statistical analysis.At baseline, subjects with prevalent ACL ruptures had worse WORMS total scores (mean±SEM, 44.1±3.5) than subjects with ACL reconstruction (30.8±4.0; P = 0.015) and worse than subjects with normal ACL (21.3±3.0; P<0.001). Cartilage scores were worse in both femorotibial compartments in ACL injured knees than in knees with normal ACL (P<0.05). Knees with ACL reconstruction showed an increased degeneration of the medial meniscus (P = 0.036), cartilage degeneration at the medial femoral condyle (P = 0.011). In a multivariate regression model, including both ACL groups and total muscle characteristics as influence parameters, high thigh muscle CSA, high muscle/ fat ratio and low Goutallier scores were associated with less degenerative changes at the knee, independent of ACL status. Knees with ACL reconstruction showed an increased progression of cartilage degeneration at the medial tibia compared to the normal ACL group (P = 0.027).High thigh muscle CSA is associated with less degenerative changes at the knee, independent of the ACL status and may potentially be advantageous in the prevention of early OA