‘I was young, I wanted to return to sport, and re-ruptured my ACL’ – young active female patients’ voices on the experience of sustaining an ACL re-rupture, a qualitative study

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“I never made it to the pros…” Return to sport and becoming an elite athlete after pediatric and adolescent anterior cruciate ligament injury: Current evidence and future directions

This article is an open access publication.The management of anterior cruciate ligament (ACL) injuries in the skeletally immature and adolescent patient remains an area of controversy in sports medicine. This study, therefore, summarizes and discusses the current evidence related to treating pediatric and adolescent patients who sustain an ACL injury. The current literature identifies a trend towards ACL reconstruction as the preferred treatment option for ACL injuries in the young, largely justified by the risk of further structural damage to the knee joint. Worryingly, a second ACL injury is all too common in the younger population, where almost one in every three to four young patients who sustain an ACL injury and return to high-risk pivoting sport will go on to sustain another ACL injury. The clinical experience of these patients emphasizes the rarity of an athlete who makes it to elite level after a pediatric or adolescent ACL injury, with or without reconstruction. If these patients are unable to make it to an elite level of sport, treatment should possibly be modified to take account of the risks associated with returning to pivoting and strenuous sport. The surveillance of young athletes may be beneficial when it comes to reducing injuries. Further research is crucial to better understand specific risk factors in the young and to establish independent structures to allow for unbiased decision-making for a safe return to sport after ACL injury.publishedVersionSeksjon for idrettsmedisinske fag / Department of Sport Medicin

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group

This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are credited. You may not alter, transform, or build upon this article without the permission of the Author(s).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.Institutt for idrettsmedisinske fag / Department of Sports Medicin

Clinical outcomes after anterior cruciate ligament injury: panther symposium ACL injury clinical outcomes consensus group

© 2020, The Author(s). Purpose: A stringent outcome assessment is a key aspect for establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. The aim of this consensus statement was to establish 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. Methods: To establish a standardized approach to 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, PA; USA, in June 2019. The group reached consensus on nine statements by using a modified Delphi method. Results: In general, outcomes after ACL treatment can be divided into four robust categories—early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption and clinical measures of knee function and structure. A comprehensive assessment following 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 re-injuries, validated knee-specific PROs and Health-Related Quality of Life questionnaires. In the mid- to long-term follow-up, the presence of osteoarthritis should be evaluated. Conclusion: 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. Level of evidence: V

Revision anterior cruciate ligament reconstruction - current evidence, predictors and outcome

Despite extensive research in the field of anterior cruciate ligament (ACL) reconstruction, primary ACL reconstruction failure and a high re-rupture rate remain a problem. Far too many patients experience a second devastating hit – the need to undergo a revision ACL reconstruction. This thesis aims to review current evidence, predictors and outcome related to revision ACL reconstruction. For this purpose, seven studies were conducted and they were stratified into three distinct themes – Current evidence, The impact of a concomitant medial collateral ligament (MCL) injury and Outcome after revision. Registry-based data formed the foundation of this thesis, for which the Swedish national knee ligament registry and a local rehabilitation registry were utilized. Additionally, evidence from all three Scandinavian knee ligament registries was synthesized. In Theme I, the evidence provided from the Scandinavian knee ligament registries was systematically reviewed to find predictors of ACL revision and to determine the robustness of these predictors by applying the Fragility index. Young age was the strongest and most robust predictor of ACL revision, where an approximately 5-fold increase in the risk of revision was found for adolescents compared with the oldest age group (patients over 35 years of age). Patient sex did not influence the risk of revision. The use of hamstring tendon (HT) autografts was associated with an increased risk of revision compared with patellar tendon (PT) autografts, although a larger HT graft diameter was protective in terms of ACL revision. Notably, there was great variability in current Scandinavian knee ligament registry studies in terms of the statistical robustness of significant predictors of ACL revision. Nearly one third of the analyses had a fragility index of zero, which indicates high statistical fragility and questions the robustness of current predictors of revision reported by the registries. Theme II explored the impact of a concomitant MCL injury on the risk of ACL revision and how the treatment of these injuries affects outcome. Patients without a concomitant MCL injury ran an approximately 30% lower risk of revision ACL reconstruction compared with patients who had a concomitant MCL injury at primary ACL reconstruction. Specifically, the risk of ACL revision was increased for patients in whom the concomitant MCL injury was treated non-surgically, while patients receiving surgical treatment for an MCL injury did not display any difference in the risk of revision compared with patients without a concomitant MCL injury. The ACL graft choice between HT and PT did not influence the risk of revision in patients undergoing ACL reconstruction with a concomitant non-surgically treated MCL injury. In terms of functional outcome, patients with and without a non-surgically treated MCL injury were able to attain similar outcomes in terms of return to sport, tests of muscle function and patient-reported outcome (PRO) at one year postoperatively. However, only 10% of the patients with a concomitant non-surgically treated MCL injury had returned to their pre-injury level of sport, compared with 26% of the patients without an MCL injury at one year after ACL reconstruction. In Theme III, a systematic review of the Scandinavian knee ligament registries found that the PRO was significantly lower after an ACL revision compared with the primary ACL reconstruction, although a few assessments between the 1- to 5-year follow-ups revealed a clinically relevant difference. The largest impairments after a revision compared with a primary ACL reconstruction were found in sport and recreational activities, as well as in quality of life. In Study VII, when a cohort that had undergone both a primary and a revision ACL reconstruction was assessed, there were minor differences between the two occasions according to the one-year PRO. However, the prevalence of cartilage injuries increased significantly at the revision ACL reconstruction (35.1%) compared with the primary ACL reconstruction (18.3%), which could indicate potential for a further deterioration in knee function after ACL revision with time. Clinically relevant predictors of significantly inferior PROs one year after revision ACL reconstruction were the use of an allograft and a concomitant injury to the posterolateral corner at the time of revision ACL reconstruction

Ligament Injuries and Instability

Acute ankle ligament injuries, especially in the athletic population, are very common. Chronic lateral ankle ligament instability develops in approximately 10-30% of all patients who have previously sustained an acute ligament injury. Ligament injuries can be divided into grades I-III, depending on how serious the injury is. Non-surgical treatment, including strength, agility and reflex training, using balance boards, is strongly recommended as the first treatment and is considered successful in alleviating symptoms of giving way in more than half of the patients. However, with failed non-surgical treatment, there are several options, both surgical repair and reconstruction. These can be further subdivided into direct repair, non-anatomic reconstruction and anatomic reconstruction. At least 60 different procedures have been described, like the original Broström technique, or more complex procedures, using tendon transfers, i.e. tenodesis. It is emphasised that the anatomic procedures, either direct repair or anatomic reconstruction, are preferred. Even though non-anatomic reconstruction leads to the good restoration of ligament laxity, it abnormally increases the inversion stiffness at the subtalar joint, compared with anatomic procedures, and reduces range of motion, and no reconstruction of this type is biomechanically correct. There is therefore an increased risk of developing osteoarthritis of the ankle with inferior functional outcome in the medium to long term. These procedures should be avoided as the first-line surgical choice, and anatomic repair procedures and anatomic reconstructions should instead be preferred

Unique simultaneous avulsion fracture of both the proximal and distal insertion sites of the anterior cruciate ligament

February is a busy month for the ambulance skiing patrol at the skiing resorts in Norway and on this day, a call regarding an 11-year-old boy on one of the hills reached the team. What no one knew at that moment was that this boy had suffered a unique injury and that his X-rays would reveal something that, prior to this, had never been described in the history of mankind. This patient had suffered a simultaneous avulsion fracture of both the femoral and tibial insertion sites of the anterior cruciate ligament without suffering any other injuries to the knee. The injury was treated conservatively and at 1-year follow-up, the patient was completely recovered. © 2018 BMJ Publishing Group Ltd. All rights reserved