Is it possible to predict the outcome of an anterior cruciate ligament injury?

This thesis centers on a well-studied cohort of 100 patients, which received a treatment regimen of initial rehabilitation and activity modification to cope with Anterior Cruciate Ligament (ACL) injury. The data, collected prospectively and longitudinally, cover a span of 15 years after initial injury. The overall aim of this thesis is to describe the course of an ACL injury treated with rehabilitation and activity modification and to identify early prognostic factors of both short- and long-term outcome. The methods for evaluating outcome include patient-reported outcome scores — such as Lysholm, Tegner, and KOOS — and plain radiographs to assess radiographic findings of osteoarthritis. Further assessments include clinical laxity tests — such as Lachman and pivot-shift tests — to evaluate clinical instability as a predictor for later ACL reconstruction, as well as lateral radiographs to explore the influence of posterior-inferior tibial slope in ACL injury. The main findings show that approximately 60% of ACL-injured patients can manage without ACL reconstruction by following the treatment algorithm. Most patients in this study were able to resume pre-injury activity level, and their long-term outcome proved comparable to studies of ACL reconstruction. The study also shows that Lachman and pivot-shift tests performed at 3 months post-injury are important prognostic factors regarding the need for reconstruction; however, it is not recommended to use these tests for making decisions about ACL reconstruction in the acute phase. Another prognostic factor is the slope of the medial tibial plateau, which proved steeper in patients injured when participating in contact sports and led to a fourfold increased risk for later reconstruction in flat-sloped knees. Finally, the acute injury mechanism — with a compression-type injury as opposed to a distraction-type injury — appears to influence both the risk for meniscal injuries, not only at index injury but even later, and the need for ACL reconstruction. A compression-type injury further appears to increase the risk for future osteoarthritis, although the presence of multiple confounding factors may blur its true effect. Our results suggest the initial injury mechanism, along with anthropometric variables and clinical laxity tests, can help in predicting the outcome of ACL injury. The high percentage of copers in our study makes the decision of early reconstruction in the clinical setting questionable. Based on the data presented, we recommend at least a 3-month rehabilitation period prior to making a decision about ACL reconstruction

Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome

Purpose: Clinical examination is an important part in the diagnosis of femoroacetabular impingement (FAI) syndrome. However, knowledge on reliability and validity of clinical diagnostic tests is scarce. The aims were to evaluate the inter-rater agreement and diagnostic accuracy of clinical tests to detect patients with FAI syndrome. Methods: Eighty-one patients (49% women) were recruited. Two experienced raters performed impingement and range of motion (ROM) tests. Three criteria had to be fulfilled for the diagnosis of FAI syndrome: (1) symptoms; (2) CAM and/or Pincer morphology; and (3) being responder to intra-articular block injection. For inter-rater agreement, the Cohen’s kappa statistics were used (0.41–0.60 = moderate, 0.61–0.80 = substantial agreement). For diagnostic accuracy, sensitivity, specificity, positive and negative predictive values were calculated. Results: Anterior impingement test (AIMT), FADIR test and FABER test showed kappa values above 0.6. All passive hip ROM, except extension, had kappa values above 0.4. AIMT and FADIR showed the highest sensitivity, i.e., 80%, with a specificity of 26% and 25%, respectively. Passive hip ROM in internal rotation with neutral hip position had a sensitivity of 29% and a specificity of 94%. Conclusion: The AIMT, FADIR and FABER tests were reliable between two experienced raters, while results from different raters for hip ROM should be interpreted with caution. The AIMT and FADIR test can only be used to rule out patients with FAI syndrome, while evaluation of ROM in internal rotation with neutral position may be more suitable to rule in patients with FAI syndrome. Level of evidence: II

Patient's subjective knee function 3-5 years following partial meniscectomy or meniscus repair compared to a normal population : A retrospective cohort study

Purpose Evaluate patient-reported knee function after arthroscopic partial meniscectomy (APM) and meniscus suture repair in two different age cohorts compared with a normal population. Method Arthroscopic meniscus surgery was performed on 421 patients at Skåne University Hospital from 2010 to 2014, with a mean (SD) follow-up of 4.2 (1.4) years. Patients and controls were divided into two age cohorts; 18-34 years (younger) and 35-54 years (middle-aged) as well as according to surgery performed; either solely meniscus surgery or with concurrent anterior cruciate ligament reconstruction (ACLR). The outcome is measured with the five subscales of the Knee and Osteoarthritis Outcome Score (KOOS). Results No significant difference in outcome after all studied types of meniscus surgeries between younger-aged and middle-aged patients. Younger patients with APM or meniscus suture repair, with or without, ACLR score lower than the normal population in all subscales of KOOS (p<0.001), except in Activities of Daily Living (ADL) for meniscus suture patients. Middle-aged patients with APM score lower in all subscales than the normal population (p≤0.009). Those with meniscus suture repair score lower than the normal population only for the subscales Sport/Rec and quality of life (p<0.001). Both younger-aged and middle-aged patients achieve better KOOS values after meniscus suture repair and ACLR than after all other combinations of surgery. Conclusion Patients with meniscus injuries do not reach the same KOOS score as the normal population, irrespective of age or type of meniscus surgery performed. However, combined with ACLR in younger-aged and middle-aged patients, meniscus suture gives a better subjective outcome than isolated meniscus surgery

Risk factors for a contralateral anterior cruciate ligament injury.

Contralateral anterior cruciate ligament (ACL) injuries are together with the risk of developing osteoarthritis of the knee and the risk of re-rupture/graft failure important aspects to consider after an ACL injury. The aim of this review was to perform a critical analysis of the literature on the risk factors associated with a contralateral ACL injury. A better understanding of these risk factors will help in the treatment of patients with unilateral ACL injuries and in the development of interventions designed to prevent contralateral ACL injuries. A Medline search was conducted to find studies investigating risk factors for a contralateral ACL injury, as well as studies where a contralateral ACL injury was the outcome of the study. Twenty studies describing the risk of a contralateral ACL rupture, or specific risk factors for a contralateral ACL injury, were found and systematically reviewed. In 13 of these studies, patients were followed prospectively after a unilateral ACL injury. The evidence presented in the literature shows that the risk of sustaining a contralateral ACL injury is greater than the risk of sustaining a first time ACL injury. Return to a high activity level after a unilateral ACL injury was the most important risk factor of sustaining a contralateral ACL injury. There was inconclusive evidence of the relevance of factors such as female gender, family history of ACL injuries, and a narrow intercondylar notch, as risk factors for a contralateral ACL injury. Risk factors acquired secondary to the ACL injury, such as altered biomechanics and altered neuromuscular function, affecting both the injured and the contralateral leg, most likely, further increase the risk of a contralateral ACL injury. This literature review indicates that the increased risk of sustaining a contralateral ACL injury should be contemplated, when considering the return to a high level of activity after an ACL injury

Physical impairments in longstanding hip and groin pain : Cross-sectional comparison of patients with hip-related pain or non-hip-related groin pain and healthy controls

Objectives: To compare physical impairments between patients with hip-related pain and those with non-hip-related groin pain, and to compare both patient groups with healthy controls. Design: Cross-sectional. Participants: Eighty-one hip and groin pain patients were consecutively included and categorized into having hip-related pain or non-hip-related groin pain. Twenty-eight healthy controls were recruited. Settings: Tertiary care. Main outcome measures: All participants performed physical impairment testing including hip ROM, muscle function, and functional tasks. An analysis of covariates was used for analysis between patients groups and controls. Results: Patients with hip-related pain showed reduced hip ROM in internal rotation compared to patients with non-hip-related groin pain and controls (p ≤ 0.026, d −0.65; −0.97). No differences in muscle function or performance in functional tasks were observed between patients with hip-related pain and those with non-hip-related groin pain (p ≥ 0.136, d 0.00; 0.68). Both patient groups had worse muscle function and worse performance in functional tasks compared to controls (p ≤ 0.048, d −0.67; −1.83). Conclusions: Both patients with and without hip-related pain had worse muscle function and worse performance in functional tasks compared to matched controls but no differences were observed between the patient groups. Only patients with hip-related pain had reduced ROM in internal rotation