Nonoperative Treatment of PCL Injuries: Goals of Rehabilitation and the Natural History of Conservative Care.

PURPOSE OF REVIEW: To review the current practices of nonoperative management of posterior cruciate ligament (PCL) injuries, the natural history of conservative care, and the latest PCL rehabilitation strategies. RECENT FINDINGS: PCL injuries often occur as part of a multiligamentous knee injury and occasionally occur in isolation. Although patients may be able to tolerate or compensate for a PCL-deficient knee, long-term outcomes after conservative care demonstrate a high rate of arthrosis in the medial and patellofemoral compartments resulting from altered knee kinematics and loads. Good subjective outcomes and a high rate of return to sport have been reported after nonoperative treatment of isolated PCL injuries. However, PCL laxity grade on objective exam does not typically correlate with subjective outcomes, nor does it correlate with the risk of developing osteoarthritis. Although more research is needed on the optimal PCL rehabilitation strategies, general principles include avoiding posterior tibial translation in the initial period to optimize ligament healing, followed by progressive range of motion and strengthening of the quadriceps and core musculature. At 12 weeks, patients may begin an interval running program, followed by agility work and progressive sports-specific training to allow for return to sports. Nonoperative treatment of isolated PCL injuries results in good subjective outcomes and high rate of return to sport.

Return to Sport for Skeletally Immature Athletes After ACL Reconstruction: Preventing a Second Injury Using a Quality of Movement Assessment and Quantitative Measures to Address Modifiable Risk Factors.

BACKGROUND: Reinjury rates after anterior cruciate ligament reconstruction (ACLR) are highest among young athletes, who consequently suffer from low rates of return to play. Historically, quantitative measures have been used to determine readiness to return to sport; however, they do not assess modifiable risk factors related to the quality of movement. PURPOSE: To determine the effectiveness of a criteria-based rehabilitation progression and return-to-sport criteria on efficient return to activity and prevention of second injury in young athletes post-ACLR. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between December 2010 and 2013, 42 skeletally immature athletes (mean chronologic age, 12 years; range, 10-15 years) who underwent ACLR using ipsilateral hamstring tendon autograft were prospectively evaluated. All athletes progressed through a criteria-based rehabilitation progression; were assessed at specific time frames for strength, biomechanical, and neuromuscular risk factors predictive of injury; and were provided targeted interventions. The final return to sport phase consisted of quantitative testing as well as a quality of movement assessment of several functional movements with progressive difficulty and sports-specific loading. Clearance for unrestricted activity was determined by achieving satisfactory results on both qualitative and quantitative assessments with consideration for the demands of each sport. RESULTS: The mean time for return to unrestricted competitive activity was 12 months. All but 3 (7%) athletes returned to their primary sport. Thirty-five athletes (83%) returned to unrestricted activity. Of the 6 (14%) who sustained a second injury, 3 (50%) were injured in sports they were not cleared for. All ACL reinjuries occurred in a cutting sport. Half of reinjuries occurred within 1 year of surgery, while the remaining occurred between 1 and 2 years. Eighty-three percent of reinjuries involved highly competitive cutting athletes. CONCLUSION: In our cohort, the combination of qualitative and quantitative data served as a good indicator for reducing risk and determining readiness to return to sport.

Glycemic Control in Simultaneous Islet-Kidney Versus Pancreas-Kidney Transplantation in Type 1 Diabetes: A Prospective 13-Year Follow-up.

OBJECTIVE: In patients with type 1 diabetes and end-stage renal disease, combined transplantation of a kidney together with a pancreas or isolated pancreatic islets are options to improve glycemic control. The aim of this study was to compare their long-term outcome with regard to metabolic control and surgical complication rate, as well as function of the transplanted kidney. RESEARCH DESIGN AND METHODS: We conducted a prospective cohort study in consecutive patients receiving either a pancreas or islet transplant simultaneously with or after kidney transplantation (simultaneous pancreas-kidney [SPK]/pancreas-after-kidney [PAK] or simultaneous islet-kidney [SIK]/islet-after-kidney [IAK] transplantation). RESULTS: Ninety-four patients who had undergone SPK/PAK transplantation were compared with 38 patients who had undergone SIK/IAK transplantation over a period of up to 13 years. HbA1c levels declined from 7.8 ± 1.3% (62 ± 14 mmol/mol) to 5.9 ± 1.1% (41 ± 12 mmol/mol), and from 8.0 ± 1.3% (64 ± 14 mmol/mol) to 6.5 ± 1.1% (48 ± 12 mmol/mol), respectively, in the SPK/PAK and SIK/IAK groups (P < 0.001 for both) and remained stable during follow-up, despite a reduction in the rate of severe hypoglycemia by >90%. The 5-year insulin independence rate was higher in the SPK/PAK group (73.6 vs. 9.3% in the SIK/IAK group), as was the rate of relaparotomy after transplantation (41.5 vs. 10.5% in the SIK/IAK group). There was no difference in the rate of kidney function decline. CONCLUSIONS: During a long-term follow-up, SPK/PAK transplantation as well as SIK/IAK transplantation resulted in a sustained improvement of glycemic control with a slightly higher glycated hemoglobin level in the SIK/IAK group. While insulin independence is more common in whole-organ pancreas recipients, islet transplantation can be conducted with a much lower surgical complication rate and no difference in kidney function decline.

Anterior cruciate ligament prevention strategies: are they effective in young athletes - current concepts and review of literature.

PURPOSE OF REVIEW: Participation in sports is on the rise, with young athletes training year round and specializing at earlier ages, predisposing them to sports-related injuries. Once thought to be rare, injuries of the anterior cruciate ligament (ACL) are being seen with a greater frequency in the paediatric population. Numerous preventive training programmes have been developed. The purpose of this review is to discuss risk factors and the effectiveness of preventive programmes in the young athlete. RECENT FINDINGS: Most ACL prevention programmes take a multifaceted approach, targeting dynamic neuromuscular and proprioceptive deficits. Focus often lies on noncontact mechanisms of injury, jump and landing techniques, and improving movement patterns during pivoting, cutting and change in direction. However, the effectiveness of these programmes in skeletally immature athletes needs to be evaluated. SUMMARY: Early specialization and increased demand for peak performance at a time of major physiological change, lack of physical fitness and neuromuscular deficits have contributed to an increase in ACL injuries in young athletes. Various preventive training programmes have been developed, but their effectiveness is debatable. We encourage young athletes to partake in preseason training programmes focused on strengthening, neuromuscular and proprioceptive training units under the appropriate supervision of qualified personnel.

All-epiphyseal, all-inside anterior cruciate ligament reconstruction technique for skeletally immature patients.

Anterior cruciate ligament (ACL) injuries are an increasingly recognized problem in the juvenile population. Unfortunately, outcomes with conservative treatment are extremely poor. Adult reconstruction techniques are inappropriate to treat skeletally immature patients because of the risk of physeal complications, including limb-length discrepancy and angular deformities. "Physeal-sparing" reconstruction techniques exist, but their ability to restore knee stability is not well understood. We describe an all-epiphyseal ACL reconstruction for use in skeletally immature patients. This is an all-inside technique with the femoral tunnel drilled retrograde and the tibial tunnel drilled retrograde; both tunnels are entirely within the epiphysis. Fixation of the hamstring autograft is achieved with soft-tissue buttons on both the femur and tibia. We present case examples for 2 patients who underwent the all-inside, all-epiphyseal reconstruction and our postoperative rehabilitation protocol. We present a novel surgical technique for an all-inside, all-epiphyseal ACL reconstruction in skeletally immature patients.