Influence of female sex and double-quadruple semitendinosus-gracilis graft on the incidence of postoperative symptomatic cyclops lesions after ACL reconstruction.

PURPOSE: Risk factors for the development of symptomatic cyclops lesion after anterior cruciate ligament reconstruction (ACLR) surgery are not entirely identified yet. This study aimed to investigate whether the choice of hamstring graft (semitendinosus-gracilis; STG vs. semitendinosus; ST) affects the risk of developing a symptomatic cyclops lesion after ACLR. METHODS: This retrospective cohort study included 1416 patients receiving either an ST graft (n = 1209) or an STG graft (n = 207) ACLR with a follow-up of at least 2 years. A persisting extension limitation was clinically determined, and cyclops lesions were confirmed by magnetic resonance imaging (MRI) and second-look arthroscopy. Graft-specific incidence of cyclops lesions was examined with χ2 test and combined with the factors number of graft bundles, graft diameter and sex evaluated with a binominal logistic regression model. RESULTS: In total, 46 patients developed symptomatic cyclops lesions (3.2%), with 36 having ACLR with an ST graft (3.0%) and 10 with an STG graft (4.8%) (n.s). The mean time from ACLR to the second-look arthroscopy for cyclops removal was 1.1 ± 0.6 years. Female patients were 2.5 times more likely to develop a cyclops lesion than male patients. Patients with an STG graft and larger graft diameters did not have a higher risk of developing cyclops lesions. Patients who received an STG graft with both tendons folded four times (double-quadruple) had significantly higher risk of developing a cyclops compared with all other numbers of graft bundles combined (8.3%, respectively 3.0%; p = 0.014). CONCLUSION: This study could not prove an increased risk of developing a symptomatic cyclops lesion for patients with an STG graft compared with an ST graft used for ACLR. However, patients with a double-quadruple ACLR had a higher percentage of cyclops lesions compared with all other numbers of graft bundles. Female sex was associated with an increased risk of developing cyclops lesions. LEVEL OF EVIDENCE: Level III.

Double-Leg and Single-Leg Jump Test Reference Values for Athletes With and Without Anterior Cruciate Ligament Reconstruction Who Play Popular Pivoting Sports, Including Soccer and Basketball: A Scoping Review.

OBJECTIVE: To synthesize and present reference values for double-leg and single-leg jump tests in healthy athletes who play pivoting sports, and athletes with anterior cruciate ligament reconstruction (ACLR) who play pivoting sports. DESIGN: Scoping review. LITERATURE SEARCH: We searched PubMed, the Cochrane Library, MEDLINE, Embase, and Web of Science until April 7, 2023. STUDY SELECTION CRITERIA: We included reference values in 2 different categories: (1) double-leg and/or single-leg jump test outcomes in pivoting-sport athletes with ACLR at a specific time point during rehabilitation, and (2) double-leg and/or single-leg jump test outcomes in healthy pivoting-sport athletes. DATA SYNTHESIS: We performed data synthesis for reference values from double-leg jump tests (squat jump and countermovement jump) and single-leg jump tests (vertical hop, single hop for distance, triple hop for distance, crossover hop for distance, medial triple hop for distance, lateral triple hop for distance, 6-m timed hop, side hop, drop jump, and 10-second repeated hop) that were performed according to a standardized test description. We summarized the data for type of sport, sex, sport participation level, and age group. RESULTS: Of the 27 included studies, nine reported reference values from healthy soccer players, six from healthy basketball players, and eleven from other healthy pivoting-sport athletes. LSI dominant/nondominant (LSI-D/ND) ranged between 97% and 106% for healthy soccer players, and between 99% and 120% for healthy basketball players. Four studies reported reference values from pivoting-sport athletes with ACLR from 7 to 10 months postsurgery. CONCLUSION: This scoping review summarizes double-leg and single-leg jump test reference values for athletes who play common pivoting sports, including soccer and basketball. J Orthop Sports Phys Ther 2024;54(6):1-14. Epub 20 March 2024. doi:10.2519/jospt.2024.12374.

Is it time to develop specific return to running criteria for ACL rehabilitation? An international survey of physiotherapists criteria for return to running following ACL injury.

OBJECTIVE: To determine return to running criteria currently used by physiotherapists following anterior cruciate ligament (ACL) injury. DESIGN: Self-reported online international survey. METHODS: An online survey of physiotherapists across Australia, the Netherlands and France. RESULTS: A total of 476 respondants participated in the survey across Australia (n = 153), the Netherlands (n = 162), and France (n = 161). For return to running criteria following a non-operative approach, the majority of respondents chose swelling (40.55%, n = 193/476), pain (38.24%, n = 182/476), knee extensor strength (34.34%, n = 163/476), single leg squat (31.93%, n = 152/476) and knee flexor strength (29.83%, n = 142/476). After ACL reconstruction, the highest responses were also swelling (41.18%, n = 196/476), pain (37.18%, n = 177/476), knee extensor strength (37.18%, n = 177/476) and single leg squat (33.19%, n = 158/476). From the identified themes the most common cutoff variables were pain between 0 and 3/10, swelling < grade 1+ and limb symmetry on strength and hop tests >70 %. CONCLUSION: Physiotherapists in Australia, France, and the Netherlands use many different return to running criteria and most of them use more than one criterion. Despite this, there was little consensus on the cut-off physiotherapists use to apply these criteria.

A hamstring autograft diameter ≤ 8 mm is a safe option for smaller, lighter and female athletes who want to return to pivoting sports after ACL reconstruction : Results from a retrospective evaluation of a local ACL register.

PURPOSE: To investigate the association between hamstring autograft diameter and ACL graft failure rate in athletes who successfully returned to pivoting sports after ACL reconstruction. METHODS: Retrospective evaluation of ACL graft failure rates in athletes who underwent ACL reconstruction with all-inside hamstring autograft and successfully returned to pivoting sports following postoperative rehabilitation. Athletes were divided into a ≤ 8 mm group and a > 8 mm group. Data about return to pivoting sports and ACL graft failures after ACL reconstruction were collected via a digital questionnaire. ACL graft failures were in all cases confirmed by an orthopaedic surgeon and/or MRI. The association between hamstring autograft diameter and ACL graft failure rate was investigated using a Fisher's exact test in the subgroup of athletes who completed the digital questionnaire and returned to pivoting sports. RESULTS: Two-hundred and twenty-nine of the 422 athletes who completed the digital questionnaire (54.2%) returned to a pivoting sport and were included for final analyses. Ninety-seven (42.4%) of the athletes who returned to sport were in the ≤ 8 mm group (8 graft failures) and 132 (57.6%) in the > 8 mm group (10 graft failures). There were significantly more women (49.5 and 13.6% respectively; p < 0.001) and significantly smaller (1.75 and 1.81 m respectively; p < 0.001), lighter (72.2 and 79.6 kg respectively; p < 0.001) and younger (23.6 and 26.1 years old respectively; p = 0.015) athletes in the ≤ 8 mm group compared to the > 8 mm group. There was no significant association between hamstring autograft diameter and ACL graft failure rate. CONCLUSION: A hamstring autograft diameter of ≤ 8 mm is a legitimate option for smaller, lighter and female athletes without increasing the risk for ACL graft failure. LEVEL OF EVIDENCE: III.

Anterior Cruciate Ligament Rehabilitation for the 10- to 18-Year-Old Adolescent Athlete: Practice Guidelines Based on International Delphi Consensus.

Background: There are 2 treatment options for adolescent athletes with anterior cruciate ligament (ACL) injuries-rehabilitation alone (nonsurgical treatment) or ACL reconstruction plus rehabilitation. However, there is no clear consensus on how to include strength and neuromuscular training during each phase of rehabilitation. Purpose: To develop a practical consensus for adolescent ACL rehabilitation to help provide care to this age group using an international Delphi panel. Study Design: Consensus statement. Methods: A 3-round online international Delphi consensus study was conducted. A mix of open and closed literature-based statements were formulated and sent out to an international panel of 20 ACL rehabilitation experts. Statements were divided into 3 domains as follows: (1) nonsurgical rehabilitation; (2) prehabilitation; and (3) postoperative rehabilitation. Consensus was defined as 70% agreement between panel members. Results: Panel members agreed that rehabilitation should consist of 3 criterion-based phases, with continued injury prevention serving as a fourth phase. They also reached a consensus on rehabilitation being different for 10- to 16-year-olds compared with 17- and 18-year-olds, with a need to distinguish between prepubertal (Tanner stage 1) and mid- to postpubertal (Tanner stages 2-5) athletes. The panel members reached a consensus on the following topics: educational topics during rehabilitation; psychological interventions during rehabilitation; additional consultation of the orthopaedic surgeon; duration of postoperative rehabilitation; exercises during phase 1 of nonsurgical and postoperative rehabilitation; criteria for progression from phase 1 to phase 2; resistance training during phase 2; jumping exercises during phase 2; criteria for progression from phase 2 to phase 3; and criteria for return to sports (RTS). The most notable differences in recommendations for prepubertal compared with mid- to postpubertal athletes were described for resistance training and RTS criteria. Conclusion: Together with available evidence, this international Delphi statement provides a framework based on expert consensus and describes a practice guideline for adolescent ACL rehabilitation, which can be used in day-to-day practice. This is an important step toward reducing practice inconsistencies, improving the quality of rehabilitation after adolescent ACL injuries, and closing the evidence-practice gap while waiting for further studies to provide clarity.

The Dutch language short Anterior Cruciate Ligament-Return to Sport after Injury scale has good to excellent construct validity, internal consistency, and test-retest reliability when assessing athletes undergoing rehabilitation after ACL injury or ACL reconstruction.

OBJECTIVES: To examine the validity and reliability of the Dutch language short Anterior Cruciate Ligament-Return to Sport after Injury scale (short ACL-RSI-NL) in recreational athletes undergoing rehabilitation after ACL injury or ACL reconstruction (ACLR). METHODS: The original 12-item version of the ACL-RSI had been translated into Dutch. Short ACL-RSI-NL items were derived from this 12-item Dutch version. Content validity was evaluated by a team consisting of eight ACL experts and eight athletes. A cohort of 115 athletes with ACL injury or after ACLR completed the short ACL-RSI-NL and related questionnaires at various time points during their rehabilitation. Construct validity (hypothesis testing using Spearman correlations), internal consistency (Cronbach's alpha), floor and ceiling effects (percentage of athletes having the lowest or highest score possible), and structural validity (exploratory factor analysis) were evaluated in the entire ACL athlete group. Test-retest reliability (using intra-class correlation, ICC; standard error of measurement, SEM; smallest detectable change, SDC, at both group and individual levels) was investigated in a subgroup of athletes with a stable outcome on psychological readiness within a two-week interval (n â€‹= â€‹27). RESULTS: The short ACL-RSI-NL demonstrated good construct validity (83% of hypotheses confirmed). Internal consistency was excellent (Cronbach's alpha 0.84), and there were no floor and ceiling effects (≤13.9% lowest or highest score). Test-retest reliability was good (ICC 0.89 with 95% CI 0.77-0.95, SEM 6.93, SDC individual level 19.2, SDC group level 3.7). Exploratory factor analysis confirmed the presence of a single underlying factor (accounting for 56.4% of the total variance of the score). CONCLUSION: The short ACL-RSI-NL exhibited good to excellent construct validity, internal consistency, and test-retest reliability. An averaged score ranging from 0 to 100 can be used to measure psychological readiness to return to sport. The short ACL-RSI-NL has potential for use in day-to-day practice to assess the psychological readiness of recreational athletes to return to sport after ACL injury or ACLR during their rehabilitation process. LEVEL OF EVIDENCE: Level II.

Direct active rehabilitation after reverse total shoulder arthroplasty: an international multicentre prospective cohort safety study with 1-year follow up.

OBJECTIVES: To gain insight in the safety of direct active rehabilitation without immobilisation in patients undergoing reverse total shoulder arthroplasty without subscapularis reattachment, measured by the occurrence of complications until 1-year follow up. Next, to explore improvement in shoulder function and in patient-reported outcome measures. DESIGN: An international multicentre prospective cohort safety study. SETTING: Patients indicated for reverse total shoulder arthroplasty, visiting the orthopaedics outpatient clinic at two hospitals in the Netherlands and one hospital in Curaçao between January 2019 and July 2021, were selected. PARTICIPANTS: 100 patients (68% female, mean age 74±7.0 years) undergoing unilateral primary shoulder replacement were included if: ≥50 years, diagnosed with shoulder osteoarthritis, rotator cuff arthropathy or avascular necrosis, and selected for reverse total shoulder arthroplasty. A sling was used for only 1 day, followed by a progressive active rehabilitation for ≥12 weeks with no precautions. MAIN OUTCOME MEASURES: Complications, range of motion and patient-reported outcome measures (Oxford Shoulder Score, Pain Numeric Rating Scale and EuroQol-5D for quality of life). Patients were evaluated preoperatively and 6 weeks, 3 months and 1 year postoperatively. RESULTS: In total, 17 complications were registered (17.0%) including five (5.0%) categorised as potentially related to the rehabilitation strategy: one dislocation, one acromion fracture and three cases with persistent pain. Anteflexion, abduction and external rotation, pain scores and the Oxford Shoulder Score all improved significantly (p<0.05) at all time points compared with preoperative. Quality of life improved significantly from 3 months onwards. These secondary outcomes improved further until 1 year postoperatively. CONCLUSION: Direct active rehabilitation after reverse total shoulder arthroplasty seems to be safe and effective. Potentially, this approach will lead to less dependent patients and faster recovery. Larger studies, preferably including a control group, should corroborate our results. TRIAL REGISTRATION NUMBER: NL7656.

Fast track rehabilitation after reversed total shoulder arthroplasty: a protocol for an international multicentre prospective cohort study.

INTRODUCTION: The use of reversed total shoulder arthroplasty (rTSA) has increased because of an increasing number of indications for this procedure and by ageing of the population. Usual postoperative care consists of immobilisation of the shoulder for a period of 2-6 weeks to allow healing of the subscapularis tendon and protection of the joint. However, new literature proved that reattachment of the subscapularis tendon is unnecessary. Therefore we hypothesised that immobilisation of the shoulder is not necessary and patients can start safely with mobilisation on the first postoperative day. We expect this fast track protocol to be safe and result in better short-term and long-term functional outcomes. METHODS AND ANALYSIS: In our prospective cohort, we will include at least 75 patients aged 50 years and older indicated for rTSA, with acute fracture treatment as an exclusion criterion. Patients will be selected and operated in three hospitals: two in the Netherlands and one in Curacao.Patients will visit the outpatient clinic preoperative, at 6 weeks, 3 months and 1 year postoperative. The data that will be collected includes baseline characteristics, reason for surgery, complications and adverse events, patient reported outcomes (Oxford Shoulder Score, EuroQol-5D and Numeric Rating Scale for pain) and range of motion of the shoulder.All patients will be instructed to use a sling only for 1 day and to follow a progressive physiotherapy schedule for 12 weeks. The primary outcome is the occurrence of complications and adverse events. ETHICS AND DISSEMINATION: The Medical Ethics Committee from the VUmc and Curacao reviewed this study protocol and granted exemption from ethical approval (METC VUmc 2019.111, METC Curacao 2019-02). Study results will be presented at (inter)national conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL7656).

UHMWPE Sublaminar Wires in Posterior Spinal Instrumentation: Stability and Biocompatibility Assessment in an Ovine Pilot Study.

STUDY DESIGN: An animal study. OBJECTIVE: To explore ultra-high molecular weight polyethylene (UHMWPE) sublaminar wires in spinal surgery and to assess stability and biocompatibility of the UHMWPE instrumentation in an ovine model. SUMMARY OF BACKGROUND DATA: Sublaminar wiring is a well-established technique in segmental scoliosis surgery. However, during introduction and/or removal of the metal sublaminar wires, neurological problems can occur. Abrasion after cutting metal wires for removal can lead to damage to the dural sac. Sublaminar wires have to withhold large forces and breakage of the wires can occur. Different types of sublaminar wires have been developed to address these problems. UHMWPE sublaminar wires can potentially substitute currently used metal sublaminar metal wires. In vivo testing and biocompatibility analysis of UHMWPE wires are recommended before clinical use in spinal surgery. MATERIALS AND METHODS: In 6 immature sheep, pedicle screws were instrumented at lumbar level L4 and attached with titanium rods to 4 thoracolumbar vertebrae using 3- and 5-mm-wide UHMWPE sublaminar wiring constructions in 5 animals. Titanium sublaminar wires were applied in 1 animal to function as a control subject. After a follow-up period of 16 weeks, the animals were sacrificed and the spines were isolated. Radiographs and computed tomography (CT) scans were made to assess stability of the instrumentation. The vertebrae were dissected for macroscopic and histologic evaluation. RESULTS: None of the wires had loosened and the instrumentation remained stable. CT scans and radiographs showed no signs of failure of the instrumentation and no neurological complications occurred. Although several bony bridges were seen on CT, growth was observed at the operated levels. Biocompatibility was assessed by macroscopical and histologic analysis, showing no signs of dural or epidural inflammation. CONCLUSIONS: This pilot animal study shows that UHMWPE sublaminar wiring is a safe technique. The UHMWPE wires are biocompatible and provide sufficient stability in spinal instrumentation. Heterotopic ossification because of periost reactions in the ovine spine led to some restrictions in this study.

Range of Motion in Segmental Versus Nonsegmental Ultrahigh Molecular Weight Polyethylene Sublaminar Wire Growth Guidance Type Constructs for Early-Onset Scoliosis Correction.

STUDY DESIGN: An in vitro biomechanical study in porcine thoracic spine segments comparing range of motion (ROM) in segmental versus multiple nonsegmental ultrahigh molecular weight polyethylene (UHMWPE) sublaminar wire constructs. OBJECTIVE: To determine the effect of varying instrumentation (wire) density in an UHMWPE sublaminar wire construct for patients with early-onset scoliosis (EOS) to find an optimal wire density, which allows maximum growth whereas still providing adequate correction and fixation. SUMMARY OF BACKGROUND DATA: UHMWPE sublaminar wires in a segmental construct did not negatively affect longitudinal spinal growth during a 24-week period in an ovine model; application in growth guidance system for EOS may therefore be feasible. To avoid ectopic bone formation as much as possible, a reduction of instrumented levels, without affecting spinal stabilization, is desirable. METHODS: ROM of 9 porcine thoracic spines (T6-T14) was determined in flexion/extension (FE), lateral bending (LB), and axial rotation up to ±â€Š4 Nm. Tests were performed for the uninstrumented spine in a segmental construct with UHMWPE sublaminar wires and dual pedicle screws at the most caudal level, and in four nonsegmental constructs that were attained by stepwise removal of the most caudal wire. RESULTS: Segmental instrumentation led to a decrease in total ROM by approximately 70% for both FE and LB. A stepwise increase in ROM with decreasing number of consecutively instrumented levels was most clearly observed in LB. However, consistent significant but also relevant substantial differences in ROM for both FE and LB were noted only when comparing two and one consecutively instrumented end levels (P < 0.05). CONCLUSION: A construct with two consecutive end levels instrumented with UHMWPE sublaminar wires seems to provide the best balance between spinal stabilization and minimizing the number of instrumented levels and thereby surgical exposure, which is crucial for allowing longitudinal growth. LEVEL OF EVIDENCE: N/A.

Novel radiopaque ultrahigh molecular weight polyethylene sublaminar wires in a growth-guidance system for the treatment of early-onset scoliosis: feasibility in a large animal study.

STUDY DESIGN: In vivo analysis in an ovine model. OBJECTIVE: To evaluate the feasibility of radiopaque ultrahigh molecular weight polyethylene (UHMWPE) sublaminar wires in a growth-guidance spinal system by assessing stability, biocompatibility, and growth potential. SUMMARY OF BACKGROUND DATA: Several growth-guidance systems have been developed for the treatment of early-onset scoliosis. The use of gliding pedicle screws and metal sublaminar wires during these procedures can cause metal-on-metal debris formation and neurological deficits. Novel radiopaque UHMWPE wires are introduced to safely facilitate longitudinal growth and provide stability in a growth-guidance system for early-onset scoliosis. METHODS: Twelve immature sheep received posterior segmental spinal instrumentation; pedicle screws were inserted at L5 and radiopaque UHMWPE (bismuth trioxide) wires were passed sublaminarly at each level between L3 and T12 and fixed to dual cobalt-chromium rods. Four age-matched animals that were not operated were evaluated to serve as a control group. Radiographs were obtained to measure growth of the instrumented segment. After 24 weeks, the animals were killed and the spines were harvested for histological evaluation and high-resolution peripheral quantitative computed tomographic analysis. RESULTS: No neurological deficits occurred and all instrumentation remained stable. One animal died from an unknown cause. Substantial growth occurred in the instrumented segments (L5-T11) in the intervention group (27 ± 2 mm), which was not significantly different to the control group, (30 ± 4 mm, P = 0.42). High-resolution peripheral quantitative computed tomographic analysis clearly showed safe routing and fixation of the UHMWPE wires and instrumentation. Despite the noted growth, ectopic bone formation with the formation of bony bridges was observed in all animals. Histology revealed no evidence of chronic inflammation or wear debris. CONCLUSION: This study shows the first results of radiopaque UHMWPE sublaminar wires as part of a growth-guidance spinal system. UHMWPE sublaminar wires facilitated near-normal longitudinal spinal growth. All instrumentation remained stable throughout follow-up; no wire breakage or loosening occurred and no adverse local-tissue response to these wires was observed. LEVEL OF EVIDENCE: N/A.

Large animal models in fusionless scoliosis correction research: a literature review.

BACKGROUND CONTEXT: Numerous prenatal, systemic, or local procedures have been described that have created an experimental scoliosis within different animal species. Compression-based fusionless scoliosis correction devices have been used to induce scoliosis (inverse approach) as an indication for their potential corrective efficacy in large animals. Deformities that most closely approximate the three-dimensional nature of an idiopathic-like scoliosis have been created in large animals using a posterior spinal tether. Fusionless scoliosis correction devices have subsequently been tested in these models. PURPOSE: To provide an overview of large animal models used for preclinical testing of fusionless scoliosis correction devices and to describe recent advances in the creation of an idiopathic-like scoliosis large animal model. STUDY DESIGN: Literature review of large animal models in fusionless scoliosis correction research. METHODS: MEDLINE electronic database was searched for studies in which large animal models for spinal or vertebral growth modulation or the creation of an experimental scoliosis were described. The literature search was limited to articles written in the English language. RESULTS: The pig appears to be the most suitable animal species for preclinical testing of fusionless scoliosis correction devices because of its large growth potential and the possibility for early weaning. With the inverse approach, it is difficult to gain insight into the possible corrective efficacy of the tested device, and therefore, a two-step approach is preferred. Using a posterior spinal tether, persistent spinal deformities are attained when the deformity has approximately doubled in comparison to the postoperative measure in a time span of approximately 12 weeks. Sufficient tether midline offset is required to render rib procedures unnecessary. CONCLUSIONS: An idiopathic-like scoliosis animal model can be created using a posterior spinal tether in a fully reversible procedure. Experimental results will need to be reproduced to establish a standard idiopathic-like scoliosis large animal model.