15-Year Follow-up of Neuromuscular Function in Patients With Unilateral Nonreconstructed Anterior Cruciate Ligament Injury Initially Treated With Rehabilitation and Activity Modification: A Longitudinal Prospective Study.

Background: It has been suggested that neuromuscular function is of importance in the overall outcome after anterior cruciate ligament (ACL) injury. Hypothesis: Good neuromuscular function can be achieved and maintained over time in subjects with ACL injury treated with rehabilitation and activity modification but without reconstructive surgery. Study Design: Case series; Level of evidence, 4. Methods: One hundred consecutive patients (42 women and 58 men) with acute ACL injury at a nonprofessional, recreational or competitive activity level were assessed 1, 3, and 15 years after injury. Their mean age at inclusion was 26 years (range, 15-43 years). All patients initially underwent rehabilitation and were advised to modify their activity level, especially by avoiding contact sports. Patients with recurrent giving-way episodes or secondary meniscal injuries that required fixation were subsequently excluded and underwent reconstruction of the ACL. Sixty-seven patients (71% of those available for follow-up) with unilateral nonreconstructed injury remained at the 15-year follow-up. Fifty-six of these 67 patients were examined with the single-legged hop test for distance and knee muscle strength. The limb symmetry index (LSI), calculated by dividing the result for the injured leg by that of the uninjured leg and multiplying by 100, was used for comparisons over time (paired t test). Results: The LSI for the single-legged hop test was higher at the 3-year follow-up (mean, 98.5%; standard deviation [SD], 7.6%) than at the 15-year follow-up (mean, 94.8%; SD, 10.5%) (mean difference, -3.7%; 95% confidence interval [Cl], -6.1% to -1.2%; P = .004). The LSI for isometric extension was higher at the 15-year follow-up (mean, 97.2%; SD, 13.7%) than at the 1-year follow-up (mean, 88.2%; SD, 15.4%) (mean difference, 9.0%; 95% Cl, 3.7% to 14.4%; P = .001). At the 15-year follow-up, between 69% and 85% of the patients had an LSI >= 90%. Conclusions: Good functional performance and knee muscle strength can be achieved and maintained over time in the majority of patients with ACL injury treated with rehabilitation and early activity modification but without reconstructive surgery

Recruitment to publicly funded trials - are surgical trials really different?

Good recruitment is integral to the conduct of a high-quality randomised controlled trial. It has been suggested that recruitment is particularly difficult for evaluations of surgical interventions, a field in which there is a dearth of evidence from randomised comparisons. While there is anecdotal speculation to support the inference that recruitment to surgical trials is more challenging than for medical trials we are unaware of any formal assessment of this. In this paper, we compare recruitment to surgical and medical trials using a cohort of publicly funded trials. Data: Overall recruitment to trials was assessed using of a cohort of publicly funded trials (n = 114). Comparisons were made by using the Recruitment Index, a simple measure of recruitment activity for multicentre randomised controlled trials. Recruitment at the centre level was also investigated through three example surgical trials. Results: The Recruitment Index was found to be higher, though not statistically significantly, in the surgical group (n = 18, median = 38.0 IQR (10.7, 77.4)) versus (n = 81, median = 34.8 IQR (11.7, 98.0)) days per recruit for the medical group (median difference 1.7 (− 19.2, 25.1); p = 0.828). For the trials where the comparison was between a surgical and a medical intervention, the Recruitment Index was substantially higher (n = 6, 68.3 (23.5, 294.8)) versus (n = 93, 34.6 (11.7, 90.0); median difference 25.9 (− 35.5, 221.8); p = 0.291) for the other trials. Conclusions: There was no clear evidence that surgical trials differ from medical trials in terms of recruitment activity. There was, however, support for the inference that medical versus surgical trials are more difficult to recruit to. Formal exploration of the recruitment data through a modelling approach may go some way to tease out where important differences exist.The first author was supported by a Medical Research Council UK Fellowship.Peer reviewedAuthor versio

Marked and Rapid Change of Bone Shape In Acutely Acl Injured Knees – An Exploratory Analysis Of The Kanon Trial

Background To investigate changes in knee 3D bone shape over the first 5 years after acute anterior cruciate ligament (ACL) injury in participants of the randomized controlled KANON-trial. Methods Serial MR images over 5 years from 121 young (32 women, mean age 26.1 years) adults with an acute ACL tear in a previously un-injured knee were analyzed using statistical shape models for bone. A matched reference cohort of 176 individuals was selected from the Osteoarthritis Initiative (OAI). Primary endpoint was change in bone area of the medial femoral condyle; exploratory analyses compared results by treatment and examined other knee regions. Comparisons were made using repeated measures mixed model ANOVA with adjustment for age, sex and BMI. Results Mean medial femur bone area increased 3.2% (78.0 [95% CI 70.2 to 86.4] mm2) over 5 years after ACL injury and most prominently in knees treated with ACL reconstruction. A higher rate of increase occurred over the first two years compared to the latter three-years (66.2 [59.3 to 73.2] vs. 17.6 [12.2 to 23.0] mm2) and was 6.7 times faster than in the reference cohort. The pattern and location of shape change in the extrapolated KANON data was very similar to that observed in another knee-osteoarthritis cohort. Conclusion 3D shape modelling after acute ACL injury revealed rapid bone shape changes, already evident at 3 months. The bone-change pattern after ACL injury demonstrated flattening and bone growth on the outer margins of the condyles similar to that reported in established knee osteoarthritis

The Health and Structural Consequences of Acute Knee Injuries Involving Rupture of the Anterior Cruciate Ligament

Although there is an abundance of literature regarding the development of knee osteoarthritis after rupture of the anterior cruciate ligament (ACL), the mechanism underlying this link is not clear. Recent studies have reported that several factors may be predictive of the development of osteoarthritis, including damage to the menisci and articular cartilage during the initial trauma, altered knee biomechanics after injury, and episodic instability. This article summarizes recent developments in the understanding of the joint damage resulting from an ACL tear, and the influence that current and future treatment methods may have on the long-term progression to osteoarthritis

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft With Suture Tape Augmentation

The anterior cruciate ligament (ACL) is the most commonly injured ligament in the knee, with injury usually occurring as a result of multidirectional sports. The incidence of ACL injury has continued to increase, with most patients opting for surgery to improve stability as well as permit a return to sport. Traditional methods of ACL reconstruction can achieve this but are not without their problems, including graft rupture, residual laxity, and donor-site morbidity. There is therefore a requirement for further research into newer, innovative surgical techniques to help improve complication rates. This article describes, with video illustration, ACL reconstruction using a reduced-size bone–patellar tendon–bone autograft with suture tape augmentation. The augmentation acts as a stabilizer during the early stages of graft incorporation while resisting against reinjury during an accelerated recovery. The ability to use a reduced-size graft decreases the donor-site burden, and retention of residual native ACL tissue, when possible, may help with proprioception

The complement system is activated in synovial fluid from subjects with knee injury and from patients with osteoarthritis

Concentrations of C4d, C3bBbP and sTCC in synovial fluid. (DOCX 37 kb