Prospective study of functional outcomes and return to sports after anterior cruciate ligament reconstruction in the knee.

PURPOSE: Individual factors of low rates of return to sport after anterior cruciate ligament (ACL) reconstruction were unclear. We evaluated the impact of various individual factors after ACL reconstruction for return to sport in athletes. METHODS: A prospective study was performed in 1274 athletes, who had undergone ACL autograft reconstruction. Individual factors survey about return to sport was performed during the second year after surgery. Athlete responses were analyzed with a multivariate logistic model adjusted for baseline patient characteristics and an adjusted Cox model. RESULTS: Younger age and involvement in higher-level sporting activities were associated with a significantly higher frequency and a significantly shorter time to return to sport (running, training, competition; p = 0.001 to 0.028). Men returned to sport more rapidly than women, for both training (p = 0.007) and competition (p = 0.042). Although there was no difference to return to sport between hamstring (HT) and patellar tendon (PT) autograft. We note that MacFL surgery (Mac Intosh modified with intra- and extra-articular autografts used the tensor fasciae latae muscle) was associated with a higher frequency (p = 0.03) and rapidity (p = 0.025) of return to training than HT. Sports people practicing no weight-bearing sports returned to training (p < 0.001) and competition (p < 0.001) more rapidly than other sports people. By contrast, the practicing pivoting sports with contact started running again sooner (p < 0.001). CONCLUSION: Younger age, male sex, higher level of sports, sportspeople practicing no weight-bearing sports, and MacFL surgery reduce time to return to sport after ACL reconstruction.

Re-ruptures and early outcomes after surgical repair of acute Achilles tendon ruptures: prospective, comparative multicenter study.

PURPOSE: The primary objective of this study was to compare the re-rupture rate, clinical results, and functional outcomes six months after the surgical repair of an acute Achilles tendon rupture between three different techniques (open repair, percutaneous repair with the Tenolig®, and minimally invasive repair). METHODS: A prospective, comparative, multicenter, non-randomized study was performed and included 111 patients who had an acute ruptured Achilles tendon: 74 underwent an open repair, 22 underwent a percutaneous repair using the Tenolig® and 15 had a minimally invasive repair. At six months follow-up we analyzed the number of re-ruptures, phlebitis, infections, complex regional pain syndrome, clinical outcomes (muscle atrophy, ankle dorsal flexion), functional scores (ATRS, VISA-A, EFAS, SF-12), and return to running. RESULTS: There were more re-ruptures (p=0.0001) after repair with the Tenolig® (27%) than with open repairs (1.3%) and minimally invasive repairs (0%). The rate of other complications was not different. No clinical differences were found between the three groups. Only some functional scores EFAS Total (p=0.006), and VISA-A (p=0.015) were worse in the Tenolig® group. All the other results were similar between the three groups. CONCLUSION: Despite heterogeneous studies in literature, the results of this comparative and prospective study between three surgical techniques of Achilles tendon repair confirmed that Tenolig® repair increased the rate of early re-rupture compared to open or minimally invasive techniques.

Evaluation kinaesthetic proprioceptive deficit after knee anterior cruciate ligament (ACL) reconstruction in athletes.

PURPOSE: The objective of this study was to evaluate kinaesthetic proprioceptive deficit after knee anterior cruciate ligament (ACL) reconstruction in two populations of athletes, those in the post-surgery period and those in re-training during the intensive program-training phase. METHODS: We performed a prospective study in ACL-operated athletes without previous knee injuries, with 32 athletes in each group. Time since surgery in the operated athletes in the post-surgery group was 21 to 35 days, and between three and 9 months in the re-training group. We also analysed a control group of 32 uninjured non-operated subjects with a similar sporting level. Proprioception was evaluated using the threshold to detection of passive motion (TDPM) test with Biodex-type isokinetic equipment comparing operated knees, non-operated knees and control uninjured non-operated group. The control group was tested twice, 1 day apart to control reproducibility, using the intraclass correlation coefficient (ICC). The p-value threshold for statistical significance between different groups in hypothesis testing was <.05. RESULTS: TDPM reproducibility was excellent (right knee: ICC = 0.80, left knee: ICC =0.72). We found a bilateral kinaesthetic deficit in post-surgery patients compared to the control group (p < 0.001 and p = 0.011), which was significantly higher on the operated side (p = 0.001). Re-training patients had no significant difference between operated and uninjured knees, but had a kinaesthetic deficit on operated limbs (p = 0.036) compared to the control group. CONCLUSION: There was a bilateral deficit in post-surgery athletes with a significant difference between injured and healthy knees, which could be explained by a change in the central nervous system. Compared to the control group, a proprioceptive deficit was only seen for re-training patients on the operated side and not in the healthy limb. Kinaesthetic recovery may be faster for the uninjured side as initial deficit is lower. Level of evidence II.

Graft failure is more frequent after hamstring than patellar tendon autograft.

PURPOSE: The risk of graft failure after anterior cruciate ligament (ACL) reconstructions with hamstring or patellar tendon was evaluated in a French population of athletes. METHODS: Athletes who had undergone ACL autograft reconstruction and who received rehabilitation care at the European Center for Sports Rehabilitation (CERS; Capbreton, France) were screened for this prospective cohort study. Eligibility criteria included a simple hamstring autograft or patellar tendon autograft surgical technique. Patients were contacted by phone to participate in follow-up during the second year after surgery. The primary endpoint was the graft failure frequency, evaluated with a multivariate logistic model with adjustment for baseline patient characteristics. The secondary endpoint was time to graft failure, analyzed by an adjusted Cox model. RESULTS: A total of 2424 athletes were included after having a hamstring autograft (semitendinosus and gracilis) or a patellar tendon autograft between 2011 and 2014. Of the 988 athletes who responded to a follow-up phone call (40.7% response rate), 33 were excluded for new contralateral ACL rupture (3.3%), with 955 included for analysis (713 hamstring autografts; 242 patellar-tendon autografts). There were no significant differences between the baseline characteristics of the patients analyzed and the population which did not respond to the questionnaire. A significant difference in the frequency of graft failure was seen, 6.5% for hamstring autografts vs 2.1% for patellar-tendon autografts [adjusted odds ratio (OR) = 3.64, 95% CI (1.55; 10.67); p = 0.007]. Mean time to graft failure was 10.7 vs 17.4 months for hamstring and patellar-tendon autografts respectively [adjusted hazard ratio (HR) = 3.50, 95% CI (1.53; 10.11); p = 0.008]. Age less than 25 years significantly increased the frequency of graft failure [adjusted OR = 3.85 (1.89; 8.72); p < 0.001]. The rate of patients returning to competitive sport after the first graft was not significantly different for the two techniques: 70.8% for hamstring and 77.8% for patellar tendon [adjusted OR = 0.718; 95% CI (0.50; 1.02)]. CONCLUSIONS: Graft failure is significantly more frequent after hamstring than patellar tendon autografts in a French population, despite similar rates of return to competition. Athletes aged less than 25 years have a higher risk of failure than those aged ≥ 25 years. Our results are in accordance with recent Scandinavian studies. LEVEL OF EVIDENCE: II.

No beneficial effect of bracing after anterior cruciate ligament reconstruction in a cohort of 969 athletes followed in rehabilitation.

OBJECTIVE: Compare the clinical outcomes of different knee braces in the early phase of rehabilitation after anterior cruciate ligament reconstruction (ACLR) in athletes. MATERIALS AND METHODS: We conducted a retrospective database study of athletes during early rehabilitation in a tertiary referral hospital between 1 February 2008 and 30 October 2010 after ACLR using bone patellar tendon bone (BPTB) or hamstring autograft. Differences in mid-patellar knee circumference, pain, and range of motion were assessed at admission. All patients followed the same rehabilitation protocol. Patients who had complications preventing them from following the assigned rehabilitation program were analyzed separately. Patients who completed their rehabilitation program were also assessed for thigh muscle atrophy, extension deficit≥2°, quality of walking, PPLP1 and subjective IKDC scores. The type and frequency of complications and their frequency was documented. The above-mentioned parameters were analyzed in 3 different groups: rigid brace in full extension, articulated brace (0°-90° for first 3 weeks then 0-120°) or no brace. RESULTS: The analysis included 969 patients. Rehabilitation started at 4.5±2.9 days after surgery and ended at 32.4±3.0 days postoperative. At the beginning, flexion was lower in patients with a rigid brace (P<0.01). There was no difference in the frequency or severity of complications between the three study groups, nor was there a significant difference in the clinical outcomes listed above. CONCLUSION: Postoperative bracing after ACLR has not beneficial effect on clinical outcomes and the complication rate. Patients who wore the rigid brace had limited flexion early on.

Rehabilitation and leucine supplementation as possible contributors to an athlete's muscle strength in the reathletization phase following anterior cruciate ligament surgery.

OBJECTIVES: To determine the interest of a muscle rehabilitation program following anterior cruciate ligament reconstruction (ligamentoplasty) and the influence of leucine supplementation on the muscle strength of athletes undergoing reathletization. MATERIAL AND METHODS: The authors have analyzed prospectively, in double blind, two groups of athletes (22 versus 23) who had randomly received either leucine supplementation or a placebo. Muscle strength was measured at the beginning and the end of the program In terms of thigh perimeter, isokinetic testing results, single-leg test and percentage of body fat. The reathletization program was identical in the two groups for an average of 2.7weeks. RESULTS: By the end of the program, both groups had increased their thigh perimeter at 10 and 15cm from the patella (respectively 1.2cm and 1.3cm, P<0.0001). Fat mass had decreased by 1.28% (P=0.017). Values of isokinetic muscle strength for the injured limb improved by 13 to 55% with highly significant differences. The leucine group generally showed more improved muscle parameters than the placebo group, with only one significant positive result with regard to thigh muscle perimeter at 10cm from the patella (P=0.009). CONCLUSION: With or without leucine, the rehabilitation program leads to improved muscle quality. Taking leucine appears to promote muscle recovery of the injured limb with regard to a single parameter (thigh muscle perimeter at 10cm from the patella), while the other parameters showed no significant improvement. A complementary study associating the recovery phase with other dietary supplements might help to optimize these preliminary results.

Analysis of return to competition and repeat rupture for 298 anterior cruciate ligament reconstructions with patellar or hamstring tendon autograft in sportspeople.

OBJECTIVES: To establish the influence of the type of surgical technique, competitive level, type of sport and the time before returning to competition on the reinjury rate after anterior cruciate ligament (ACL) surgery. METHODS: The authors followed-up 540 competitive sportspeople who had undergone ACL surgery via patellar or hamstring tendon autograft (HTA) techniques in 2003 and 2004. The sportspeople (all of whom had competed at a regional or higher level) were asked to fill out a questionnaire during their fourth postoperative year. RESULTS: The 298 respondees (reply rate: 55.1%) had the same characteristics as the initial (operated) population. The reinjury rates after HTA and patellar tendon autograft (PTA) were 12.7 and 6.1%, respectively. There was no statistically significant difference between these two values (P=0.14). Age and gender were not correlated with the frequency of reinjury. The reinjury rate rose slightly with increasing competitive level (regional level: 8.1%; national level: 10.4%; international level: 12.5%) but these differences were not statistically significant. Soccer had the highest reinjury rate (20.8%). Regardless of the surgical technique, sportspeople returning to competition within seven months of surgery had a greater risk of reinjury than those returning after this time point (15.3 versus 5.2%, P=0.014). The risk dropped from 13.9 to 2.6% (P=0.047) for PTA and from 16.6 to 7.6% (P=0.2) for HTA. Of the four reinjuries in sportspeople returning to competition with the first six months postoperative, three occurred within one month of resumption. CONCLUSION: Post-HTA reinjury rates are higher than post-PTA rates but the difference is not statistically significant. For sportspeople at a regional or higher level, the time interval before the return to competition has an influence on the risk of reinjury.

Validity and reproducibility of the PPLP scoring scale in the follow-up of athletes after anterior cruciate ligament reconstruction.

OBJECTIVES: Validate the use of the PPLP scoring scale in the follow-up of athletes after anterior cruciate ligament (ACL) reconstruction. PATIENT AND METHOD: We conducted a prospective follow-up study on athletes with ACL reconstruction during several time periods between 2003 and 2009, we analyzed the score validity, its reproducibility, its responsiveness to change and its relevance in the follow-up and monitoring of ACL reconstructive surgeries. RESULTS: The PPLP scoring scale was defined for the monitoring of ACL reconstruction in athletes. The PPLP tool is made of two parts: the first one (PPLP1) with a total of 100 points for postoperative follow-up and the second one also with a total of 100 points (PPLP2) adding up to the first score for determining a final post-op monitoring score of 200 points. The PPLP2 scoring scale is administered at a distance from the initial ACL reconstruction. For construct validity, we showed the differences in items' characteristics (coefficient r of 0.20 in 763 patients), and adequate correlation of the PPLP score to other scoring scales found in the literature (OAK, Lysholm, Tegner, Knee injury and Osteoarthritis Outcome Score [KOOS], Arpege, IKDC Subjective Knee Evaluation Form and Psychovitality Test). The intra/interexaminer reproducibility is excellent going from 0.92 to 1. The PPLP scoring scale shows a statistically significant responsiveness to change during the hospital stay, according to the postoperative delay but with great variations. Complicated clinical evolutions (among 3296 ACL reconstructions with postoperative follow-up) are well identified by a low PPLP score, mainly for complex regional pain syndrome Type 1 (CRPS1: 1.9%) with a mean PPLP1 score of 80.33 whereas uncomplicated clinical evolutions (80.8%) have a mean score of 94.28 with a significant difference (p<0.0001). PPL2 scoring scale is significantly correlated to the possibility of getting back to competition (p=0.012) and a high score is linked to a faster return to competition (follow-up of 258 patients). The optimal threshold score is 176, and not 170/200, as previously suggested. However, this score remains poorly discriminating in regards to sensitivity (79.7%), specificity (49.3%) and the percentage of athletes returning to competition 2.5 months after completing the PPL2 scoring tool (37.9%). CONCLUSION: The PPLP scoring scale was validated in the French language in terms of construct validity, reproducibility and sensitivity. This scoring scale is used for the follow-up and monitoring of ACL reconstruction in athletes, providing useful information on the quality of their recovery particularly during the postoperative phase and the possibilities of getting back to competition.

Ruptures of the anterior cruciate ligament in soccer.

Ruptures of the anterior cruciate ligament (ACL) are serious, common and costly injuries. The present 12-year investigation was undertaken to examine the frequency of ACL ruptures and identify the game events that may have contributed to the cause of these injuries in male soccer players across a French district. A retrospective questionnaire was used to record the players' age at the time of injury, laterality, standard of play, playing position and injured side. The characteristics of the injury situations were described in detail to investigate the game events involved in each case. A total of 934 ruptures was reported. Significantly more ruptures were sustained in a non-contact versus a contact situation (p<0.01). Of the total number of lesions, 34.5% occurred during a pivot action. The right knee was affected more than the left knee (p<0.001), irrespective of the dominant side of the player. Certain game events reported in the injury situations were shown to be related to player's age, standard and position. While these results have confirmed observations from previous investigations on ACL ruptures in soccer, the analysis of a considerably larger number of injury cases has brought new findings to the literature as well as recommendations for future research.

[Interest of an iterative specialized rehabilitation after an anterior cruciate ligament reconstruction in high level sport athletes]. / Intérêt d'une rééducation spécialisée à distance d'une chirurgie du ligament croisé antérieur chez le sportif de haut niveau.

PURPOSE OF THE STUDY: The aim of this work was to assess the usefulness of specialized rehabilitation sessions after anterior cruciate ligament reconstruction in high-level athletes participating in regional-, national-, or international-level sports. MATERIAL AND METHODS: We conducted a retrospective comparison between two populations: in the first, rehabilitation was limited to the early postoperative period (PO); in the second, rehabilitation sessions were repeated, once in the early postoperative period and again 90 days later (POR). The second rehabilitation period lasted two or three weeks and included an open and closed-chain muscle training program controlled by physical therapists using isokinetic devices. The sessions also included proprioceptive exercises and cardiovascular exercise reconditioning with a therapeutic project developed by the Physical Medicine and Rehabilitation physician in collaboration with other health professionals and taking into consideration the surgical recommendations and the patient's clinical status. A questionnaire was addressed to all patients one year after the operation. The response rate was 55 %. Two groups were created at random: 74 patients were in the PO group and 75 in the POR group. The two populations were comparable in terms of gender (64 men, 10 women in PO versus 57 men and 18 women in POR), sports level (regional, national, international), type of surgery (41 hamsting, 33 bone-patellar tendon-bone in PO and 43 hamstring and 32 bone-patellar tendon-bone in POR) and sports (generally rugby, soccer, handball or ski). RESULTS: Our results were statistically in favor of the group POR in terms of resumption of sports activities: time to return to training (7.6 versus 8.7 months, p=0.03) and time to return to competition (9.06 versus 10.84 months, p=0.007). They were also in favor of the group POR for resumption of sports activities at the former level (52.05 % versus 19.44 %, p=0.001), pain (numerical scale: 1.52 versus 2.03, p=0.021) and subjective impression (IKDC subjective score: 87.58 % versus 81.64 %, p=0.003). There was no significant difference for resumption of training (90.50 % versus 81.69 %, p=0.2) or competition (71.80 % versus 56.76 %, p=0.1) at one year, but the results were close to the level of significance. DISCUSSION: Adapted preparation before returning to sports activities using a scheme elaborated by specialists (physicians, physical therapists, trainers) provided a statistically significant improvement in time and quality of resumed activity (return to prior level, pain, subjective IKDC score) in this specific population of high-level competition athletes. A larger series would be interesting to check the statistical significance of return to training and competition at one year. Another follow-up beyond one year (1.5 or two years for example) would also provide information on the percentage of definitive return to sports in these two populations.

[Stress fractures in disabled athletes' preparation for the paralympic games in Athens, 2004: an assessment]. / Fractures de fatigue en handisport lors de la pratique de l'athlétisme : bilan de la préparation aux jeux paralympiques d'Athènes 2004.

OBJECTIVES: To identify stress fracture frequency and the associated risk factors in disabled female athletes preparing the Paralympic Games in Athens in 2004. MATERIAL AND METHOD: The study is focused on four athletes (including one with a vision impairment) among the 31 women selected to participate in the Paralympic Games. The medical records of selected athletes not having been able to participate in the Games due to a stress fracture were analyzed. RESULTS: One case of stress fracture to the first metatarsal was reported of one below-knee amputee and an additional case to the second metatarsal of one hemiplegic athlete. Two of three athletes with physical disability were unable to participate in the Games because of stress fracture occurring during the preparatory phase. DISCUSSION - CONCLUSION: Among four athletes selected to take part in the Paralympic Games. If morphological predispositions are inherent to the sportswomen, the main favouring factor to be retained is their running asymmetry. Training programmes must therefore take this characteristic into account and must not offer heavy-load repetitive exercise (such as endurance or jogging) at the expense of technique. Over-intense training exposes the disabled athlete to this type of pathology and is likely to affect his chances of competing.

[Charcot-Marie-Tooth disease associated with syringomyelia revealed by urinary disorders]. / Association de maladie de Charcot-Marie-Tooth et de syringomyélie révélée par la survenue de troubles urinaires.

PURPOSE: Charcot-Marie-Tooth (CMT) disease is characterized by genetic and clinical heterogeneity. The occurrence of urinary disorders is unusual and requires further investigation. CMT disease and syringomyelia are not usually associated. Moreover, primary urinary signs in syringomyelia are not frequent. CASE REPORT: An 11-year-old girl with CMT disease 1A duplication presented with motor deficit of the leg associated with urinary disorders. Urodynamic study revealed neurogenic detrusor overactivity, and magnetic resonance imaging confirmed syringomyelia extending from T11 to an L1 located conus. DISCUSSION: Review of the literature confirmed the possibility of primary urinary signs in syringomyelia, with only one case of CMT and urinary signs described. In this case, the diagnosis was radicullar and medullar compression by a hypertrophic nerve formation called an "onion bulb" reflecting the demyelinisation and remyelinisation cycle. CONCLUSION: Urinary signs in CMT disease are exceptional and require investigation into the possibility of a central lesion.