Five-Year Clinical Outcomes of a Randomized Trial of Anterior Cruciate Ligament Treatment Strategies: An Evidence-Based Practice Paper

REFERENCE/CITATION: Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ. 2013;346:F232. CLINICAL QUESTION: Does early anterior cruciate ligament (ACL) reconstruction with rehabilitation lead to better patient-reported outcomes and a lower incidence of osteoarthritis at 5 years postinjury compared with delayed ACL reconstruction with rehabilitation? STUDY SELECTION: This randomized controlled trial with extended follow-up at 5 years postrandomization was conducted in 2 Swedish orthopaedic departments. DATA EXTRACTION: The authors studied a total of 121 moderately active adults (age = 18–35 years) with an acute ACL rupture in a knee with no other history of trauma. Excluded were patients with a collateral ligament rupture, full-thickness cartilage defect, or extensive meniscal fixation. One patient assigned to the early ACL-reconstruction group did not attend the 5-year follow-up visit. Patients were randomly assigned to (1) an early ACL reconstruction plus structured rehabilitation group (n = 62, surgery within 10 weeks of injury) or (2) optional-delayed ACL reconstruction plus structured rehabilitation group (n = 59). The primary outcome measure was change in the average of 4 out of 5 subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS). The authors also assessed crude KOOS (combined 4 subscales), KOOS subscale scores, general physical and mental health (Short-Form 36), activity level (Tegner Activity Scale), mechanical knee stability (Lachman and pivot shift tests), meniscal surgery status, and presence of knee osteoarthritis on radiographs. MAIN RESULTS: Among patients randomized to the optional-delayed ACL-reconstruction group, 30 (51%) opted for an ACL reconstruction. The treatment groups had comparable 5-year patient-reported outcomes and changes in patient-reported outcomes (eg, knee pain, knee symptoms, activities of daily living, sport and recreational levels, knee-related quality of life, general physical health, and general mental health). Patients in the optional-delayed ACL-reconstruction group had greater mechanical knee instability than patients who received early ACL reconstruction; however, this was primarily among the patients opting for conservative management alone. In the overall sample, 61 knees (51%) required meniscal surgery over 5 years, regardless of treatment group. At 5 years, radiographs were available for 113 patients (93%). Overall, 29 patients (26%) had knee osteoarthritis at 5 years. Specifically, 13 patients (12%) developed tibiofemoral radiographic osteoarthritis (9 patients [16%] in the early ACL-reconstruction group, 4 [7%] in the optional-delayed ACL-reconstruction group) and 22 (19%) developed patellofemoral osteoarthritis (14 patients [24%] in the early ACL-reconstruction group, 8 [15%] in the optional-delayed ACL-reconstruction group). Patients with patellar tendon grafts (n = 40) had a greater incidence of ipsilateral patellofemoral osteoarthritis than patients with hamstrings tendon grafts (n = 51), but the 2 groups had similar incidences of ipsilateral tibiofemoral osteoarthritis. Six knees (5%) had both tibiofemoral and patellofemoral osteoarthritis. CONCLUSIONS: Early ACL reconstruction plus rehabilitation did not provide better results at 5 years compared with optional-delayed ACL reconstruction plus rehabilitation. Furthermore, the authors found no radiographic differences among patients with early ACL reconstruction, delayed ACL reconstruction, or no ACL reconstruction (rehabilitation alone)

Dehydration and Symptoms of Delayed-Onset Muscle Soreness in Normothermic Men

Context: A dehydrated individual who performs eccentric exercise may exacerbate skeletal muscle damage, leading to structural, contractile, and enzymatic protein denaturation, in addition to the myofiber and connective damage resulting from the eccentric muscle tension. Objective: To identify the effects of dehydration on 5 physiologic characteristics of delayed-onset muscle soreness (DOMS) in normothermic men after an eccentric exercise perturbation. Design: Randomized group test-retest design. Setting: Laboratory. Patients or Other Participants: Ten healthy male volunteers randomly assigned to either a euhydration (age = 26.2 ± 4.9 years, height = 174.1 ± 6.0 cm, mass = 86.5 ± 15.3 kg) or dehydration (age = 25.8 ± 2.2 years, height = 177.2 ± 3.1 cm, mass = 84.4 ± 3.8 kg) group. Intervention(s): Subjects performed treadmill walking for 45 minutes in either a thermoneutral (euhydration) or a hot, humid (dehydration) environment. After a rest period to allow for return to the normothermic condition, DOMS was induced with a 45-minute downhill run. Main Outcome Measures: We assessed 5 physiologic characteristics of DOMS before and at intervals after the eccentric exercise. The characteristics were perceived pain of the bilateral quadriceps and overall body, bilateral punctate tenderness of the superficial quadriceps muscles, bilateral knee-flexion passive range of motion, bilateral thigh circumference, and bilateral isometric quadriceps muscle strength. Thermoregulatory and cardiovascular measures were obtained to monitor participants\u27 heat load during exercise. Results: The experimental protocol produced a 0.9% increase in body mass of the euhydration group and a significant 2.7% decrease in body mass of the dehydration group. The downhill-running exercise perturbation induced DOMS in both the euhydrated and dehydrated participants, based on increased bilateral quadriceps and overall body perceived pain and punctate tenderness of the bilateral vastus medialis muscle. The signs and symptoms of DOMS after an eccentric exercise perturbation were not exacerbated by moderate dehydration of 2.7% body mass after rest and return to the normothermic condition. Conclusions: Significantly dehydrated participants who rested and returned to a normothermic condition did not experience increased characteristics of DOMS