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To determine the stabilizing role of anterolateral ligament reconstruction (ALLR) and modified Lemaire lateral extra-articular tenodesis (LET) performed in combination with anterior cruciate ligament reconstruction (ACLR) and to determine whether either procedure was superior to the other.

PURPOSE: To (1) perform a systematic review of level I randomized controlled trials (RCTs) detailing the incidence of anterior knee pain and kneeling pain following anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) autograft and (2) investigate the effect of bone grafting the patellar harvest site on anterior knee and kneeling pain. METHODS: A systematic review of level I studies from 1980 to 2023 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome evaluated was the presence of donor site morbidity in the form of anterior knee pain or kneeling pain. A secondary subanalysis was performed to assess for differences in the incidence of postoperative pain between patient groups undergoing ACLR with BPTB receiving harvest site bone grafting and those in whom the defect was left untreated. RESULTS: Following full-text review, 15 studies reporting on a total of 696 patients met final inclusion criteria. Patients were followed for an average of 4.78 years (range, 2.0-15.3), and the mean age ranged from 21.7 to 38 years old. The incidence of anterior knee pain, calculated from 354 patients across 10 studies, ranged from 5.4% to 48.4%. The incidence of postoperative pain with kneeling was determined to range from 4.0% to 75.6% in 490 patients from 9 studies. Patients treated with bone grafting of the BPTB harvest site had no significant difference in incidence of any knee pain compared with those who were not grafted, with incidences of 43.3% and 40.2%, respectively. CONCLUSIONS: Based on the current level I RCT data, the incidences of anterior knee pain and kneeling pain following ACLR with BPTB autograft range from 5.4% to 48.4% and 4.0% to 75.6%, respectively. LEVEL OF EVIDENCE: Level I, systematic review of RCTs.

Background: Evidence indicates that an external focus (EF) of attention on the intended effect of one’s movement results in better motor performance and motor control than an internal focus (IF) on one’s own body. Despite this, an IF is predominantly encouraged through instructions and feedback provided by clinicians during sports and rehabilitation from injuries such as anterior cruciate ligament (ACL) injury. Aim: The aim of this pilot study was to investigate the influence of EF and IF on motor control and performance on a bilateral leg extension and flexion task. The secondary aim was to investigate potential differences in the outcomes between a control group and a group with ACL reconstruction (ACLR). Method: Fourteen controls and four individuals with ACLR performed a bilateral leg extension and flexion task with instructions that encouraged either an IF, EF or neutral focus (NF) of attention. The instructions encouraged participants to either keep the individual tubes located on the footplates under the soles of the feet (EF) or the feet themselves (IF) level with each other. A three-dimensional motion capture system was used to record kinematics. Motor control was assessed based on the movement smoothness according to the knee angular velocity profile and performance was assessed based on the absolute mean deviation of the tubes/footplates from parallel. Results: For the control group, IF instructions resulted in significantly better motor control than EF instructions for left knee movement smoothness (p=0.02) and NF instructions resulted in significantly better motor control than EF on a majority of dependent variables. Conclusion: For our task, EF instructions did not result in better outcomes compared to IF instructions which might be explained because the task was proprioceptive demanding with less involvement of the vision. The reason for better motor control with NF instructions compared to EF instructions might be because of differences in angular ve

Bakgrund: Främre korsbandsskador är vanliga i idrotten och korsbandsrekonstruktion bedöms främst vara aktuellt för unga personer med höga krav på knäfunktion, till exempel elitidrottare. Rehabiliteringen är en lång och krävande process där både fysiologiska och psykologiska aspekter är viktiga. Motivation är associerat med återgång till idrott och elitidrottare återgår till idrott på samma nivå i högre utsträckning jämfört med icke-elitidrottare. Däremot är det oklart vad som motiverar elitidrottaren till rehabilitering. Syfte: Syftet var att undersöka sex elitidrottares upplevelser och erfarenheter kring motivation till rehabilitering i syfte att återgå till elitidrott efter en främre korsbandsrekonstruktion.Metod:Kvalitativ deskriptiv design. Semistrukturerade intervjuer genomfördes och bearbetades med kvalitativ innehållsanalys. Totalt intervjuades sex elitidrottande män och kvinnor inom idrotterna ishockey, innebandy och basket. Resultat: Analysen resulterade i sex kategorier: ”Rehabiliteringen är ett maraton och inte en sprint”, ”Viktigt med stöd från laget och omgivningen”, ”Olika psykologiska aspekter hos elitidrottare påverkar”, ”Att vara, eller inte vara elitidrottare”, ”Motivation är sällan svart eller vitt”, ”Fysioterapeutens viktiga roll under rehabiliteringen” samt femton underkategorier. Konklusion: Stöd från laget, anhöriga och vänner var viktigt, likaså samarbetet med fysioterapeuten som också ledde till en känsla av trygghet. Informanterna beskrev att motivation kom både inifrån och utifrån. Resultatet kan hjälpa såväl fysioterapeuter som idrottare att identifiera och applicera strategier för att öka motivationen under rehabiliteringen., Background: Anterior cruciate ligament injuries are common in sports and reconstructions are largely considered relevant for young people with high demands on knee function e.g., elite athletes. Rehabilitation is a long and demanding process in which physical and psychological aspects are important. Motivation is associated with return to sport and elite athletes return to sport at the same level in greater extent than non-elite-athletes. However, it is unclear what motivates the elite athletes to rehabilitate. Purpose: The aim was to investigate six elite athletes’ views and experiences about motivation to rehabilitation with the purpose to return to elite sports after an anterior cruciate ligament reconstruction. Method: Qualitative descriptive design. Semi-structured interviews that were analyzed trough a qualitative content analysis. Six elite athletes from the sports ice-hockey, floorball and basketball were interviewed.Result:The analysis resulted in six categories: ”Rehabilitation is a marathon and not a sprint”, ”The importance of support from the team and the surrounding”, “Different psychological aspects in elite athletes influence”, To be, or not to be an elite athlete”, ”Motivation is rarely black or white”, ”The physiotherapist´s important role during the rehabilitation” and fifteen sub-categories. Conclusion: Support from the team, relatives and friends was considered important as well as collaboration with the physiotherapist which also led to a feeling of security. The informants described that motivation was both internal and external. The result may assist both physiotherapist and athletes to identify and apply strategies to increase motivation during rehabilitation.

Bakgrund: Främre korsbandsskador är vanliga i idrotten och korsbandsrekonstruktion bedöms främst vara aktuellt för unga personer med höga krav på knäfunktion, till exempel elitidrottare. Rehabiliteringen är en lång och krävande process där både fysiologiska och psykologiska aspekter är viktiga. Motivation är associerat med återgång till idrott och elitidrottare återgår till idrott på samma nivå i högre utsträckning jämfört med icke-elitidrottare. Däremot är det oklart vad som motiverar elitidrottaren till rehabilitering. Syfte: Syftet var att undersöka sex elitidrottares upplevelser och erfarenheter kring motivation till rehabilitering i syfte att återgå till elitidrott efter en främre korsbandsrekonstruktion.Metod:Kvalitativ deskriptiv design. Semistrukturerade intervjuer genomfördes och bearbetades med kvalitativ innehållsanalys. Totalt intervjuades sex elitidrottande män och kvinnor inom idrotterna ishockey, innebandy och basket. Resultat: Analysen resulterade i sex kategorier: ”Rehabiliteringen är ett maraton och inte en sprint”, ”Viktigt med stöd från laget och omgivningen”, ”Olika psykologiska aspekter hos elitidrottare påverkar”, ”Att vara, eller inte vara elitidrottare”, ”Motivation är sällan svart eller vitt”, ”Fysioterapeutens viktiga roll under rehabiliteringen” samt femton underkategorier. Konklusion: Stöd från laget, anhöriga och vänner var viktigt, likaså samarbetet med fysioterapeuten som också ledde till en känsla av trygghet. Informanterna beskrev att motivation kom både inifrån och utifrån. Resultatet kan hjälpa såväl fysioterapeuter som idrottare att identifiera och applicera strategier för att öka motivationen under rehabiliteringen., Background: Anterior cruciate ligament injuries are common in sports and reconstructions are largely considered relevant for young people with high demands on knee function e.g., elite athletes. Rehabilitation is a long and demanding process in which physical and psychological aspects are important. Motivation is associated with return to sport and elite athletes return to sport at the same level in greater extent than non-elite-athletes. However, it is unclear what motivates the elite athletes to rehabilitate. Purpose: The aim was to investigate six elite athletes’ views and experiences about motivation to rehabilitation with the purpose to return to elite sports after an anterior cruciate ligament reconstruction. Method: Qualitative descriptive design. Semi-structured interviews that were analyzed trough a qualitative content analysis. Six elite athletes from the sports ice-hockey, floorball and basketball were interviewed.Result:The analysis resulted in six categories: ”Rehabilitation is a marathon and not a sprint”, ”The importance of support from the team and the surrounding”, “Different psychological aspects in elite athletes influence”, To be, or not to be an elite athlete”, ”Motivation is rarely black or white”, ”The physiotherapist´s important role during the rehabilitation” and fifteen sub-categories. Conclusion: Support from the team, relatives and friends was considered important as well as collaboration with the physiotherapist which also led to a feeling of security. The informants described that motivation was both internal and external. The result may assist both physiotherapist and athletes to identify and apply strategies to increase motivation during rehabilitation.

Background: Evidence indicates that an external focus (EF) of attention on the intended effect of one’s movement results in better motor performance and motor control than an internal focus (IF) on one’s own body. Despite this, an IF is predominantly encouraged through instructions and feedback provided by clinicians during sports and rehabilitation from injuries such as anterior cruciate ligament (ACL) injury. Aim: The aim of this pilot study was to investigate the influence of EF and IF on motor control and performance on a bilateral leg extension and flexion task. The secondary aim was to investigate potential differences in the outcomes between a control group and a group with ACL reconstruction (ACLR). Method: Fourteen controls and four individuals with ACLR performed a bilateral leg extension and flexion task with instructions that encouraged either an IF, EF or neutral focus (NF) of attention. The instructions encouraged participants to either keep the individual tubes located on the footplates under the soles of the feet (EF) or the feet themselves (IF) level with each other. A three-dimensional motion capture system was used to record kinematics. Motor control was assessed based on the movement smoothness according to the knee angular velocity profile and performance was assessed based on the absolute mean deviation of the tubes/footplates from parallel. Results: For the control group, IF instructions resulted in significantly better motor control than EF instructions for left knee movement smoothness (p=0.02) and NF instructions resulted in significantly better motor control than EF on a majority of dependent variables. Conclusion: For our task, EF instructions did not result in better outcomes compared to IF instructions which might be explained because the task was proprioceptive demanding with less involvement of the vision. The reason for better motor control with NF instructions compared to EF instructions might be because of differences in angular ve

Background: Following anterior cruciate ligament reconstruction (ACLR), many athletes do not return to their sport, often driven by concerns about re-injury. Psychological support strategies might help, but are not routinely included in rehabilitation after ACLR. The BAck iN the Game (BANG) intervention is a 24-week eHealth program delivered via smartphone application (app), beginning directly after ACLR, with a self-directed approach that aims to target the specific challenges athletes encounter in rehabilitation. Aim: To describe athletes' experiences of using the BANG app during rehabilitation, to support returning to sport following ACLR. Method: Participants were athletes, in contact and/or non-contact pivoting sports, who had ACLR with the goal to return to sports. Semi-structured, individual interviews were conducted 6-10 months after their ACLR; all had access to the BANG intervention. Verbatim transcripts were analysed with a qualitative content analysis. Results: The 19 participants were 17-30 years, mean 21.6 years (SD 3.5); 7 men and 12 women. The analysis generated three main categories. (A) Interacting with the app illustrated how, when, or why the participants engaged with the app. The app was helpful because of its varying content, the notifications served as reminders and participants stopped using the app when no longer needing it. (B) Challenging experiences with the app illustrated that the app itself came with some difficulties e.g., content not appearing with the right timing and material not tailored to their sport. (C) Supportive experiences with the app reflected how the app facilitated the participants' rehabilitation progress; it included positive aspects of the app content and navigation, boosting their confidence to return to sport, and motivated them to continue with rehabilitation. Conclusion: The analysis of the interviews illustrates athletes' awareness in interacting with, and the challenging and supportive experiences of using the

Introduction: ACL reconstruction is one of the most performed surgical procedures in recent years, which is why the best technique has been modified, from only an extra-articular repair to a reconstruction as anatomical as possible, in order to provide functional stability to the joint. Development: The development addresses the background and evolution of anterior cruciate ligament reconstruction, explains the classification, type of graft to be used according to its advantages and disadvantages. In addition, anterior cruciate ligament injuries are discussed. Concluding with future lines of research with respect to the subject matter addressed in the article. Conclusions: Ligament injuries are traumatic entities that usually affect young patients. In order to achieve a satisfactory result in the treatment it is necessary to know its anatomy, classification, type of graft to be used according to its advantages and disadvantages. Complications in this condition can be surgical and medical., Introducción: La reconstrucción del LCA es uno de los procedimientos quirúrgicos más realizados en los últimos años, es por ello que la mejor técnica se ha ido modificando, desde sólo una reparación extra articular a una reconstrucción lo más anatómica posible, con la finalidad de brindar estabilidad funcional a la articulación   Desarrollo: El desarrollo aborda los antecedentes y evolución de la reconstrucción de ligamento cruzado anterior, se explica la clasificación, tipo de injerto a emplear según sus ventajas y desventajas. Además, se aborda lesiones del ligamento cruzo anterior. Concluyendo con las futuras líneas de investigación con respecto a la temática abordada en el artículo.   Conclusiones: Las lesiones del ligamento son entidades traumáticas que afectan por lo general a pacientes jóvenes. Para lograr un resultado satisfactorio en el tratamiento es necesario el conocimiento de su anatomía, clasificación, tipo de injerto a emplear según sus ventajas y desventajas. Las complicaciones en esta afección pueden ser de tipo quirúrgica y médica.

[Resumen] Introducción: La rotura de ligamento cruzado anterior (LCA) es una de las lesiones con mayor incidencia, especialmente, en el mundo del deporte. La rehabilitación tras la cirugía requiere un largo periodo de tiempo y tiene como principal intervención al ejercicio terapéutico. La electroterapia es otra de las posibles intervenciones que podrían aportar beneficios a la recuperación de esta lesión. Objetivo: Conocer la eficacia de la electroterapia en pacientes que han sido intervenidos quirúrgicamente para la reconstrucción del LCA en comparación con un grupo control que no está sometido a electroterapia. Material y método: Se ha realizado la búsqueda de ensayos clínicos aleatorizados (ECA) y revisiones sistemáticas en Pubmed, Cochrane y Web of Science con estimulación eléctrica neuromuscular (NMES), estimulación eléctrica nerviosa transcutánea (TENS) y estimulación con corriente directa transcraneal (tDCS) desde enero de 2016 hasta el 25 de abril de 2023. Resultados: Se han identificado 7 ECA con una calidad metodológica media de 7,14 en la escala PEDro y 4 revisiones sistemáticas. La mayoría de los ECA emplearon corrientes tipo NMES, seguida de tDCS y, solo en un caso, se empleó TENS. En 4 de los 5 artículos que analizaban la fuerza se encontró un aumento significativamente mayor que en el control. Los 3 trabajos que analizaron la circunferencia de la rodilla y el muslo obtuvieron también mejorías significativas. Solo en 1 de los 4 artículos que evaluaron el dolor se encontró una mejoría significativa y ninguno de los 3 que analizaban la funcionalidad mostraron diferencias significativas entre los grupos. Solo 1 estudio valoró el equilibrio y no encontró diferencias significativas con respecto al grupo control. Las 4 revisiones sistemáticas analizaban la eficacia de la NMES y concluyen que es beneficiosa para la ganancia de fuerza. Parece que el periodo de estimulación debe iniciarse cuanto antes para una mayor efectividad. Conclusiones: La NMES aplicada e, [Abstract] Background: The anterior cruciate ligament tear is one of the most common injuries, especially in the world of sports. The rehabilitation following this surgery requires a long period of time and the main intervention is therapeutic exercise. Electrical therapy is another potential intervention that could provide benefits for the recovery of this injury. Objective: To determine the effectiveness of electrical therapy in patients who underwent surgical reconstruction of the anterior cruciate ligament compared to a control group not undergoing electrical therapy. Methods: A research for randomized clinical trial (RCT) and systematic reviews was conducted in Pubmed, Cochrane and Web of Science including studies published from January 2016 to April 25, 2023 involving neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS) and transcranial direct current stimulation (tDCS). Outcomes: 7 RCTs with a mean methodological quality of 7.14 on the PEDro scale and 4 systematic reviews were included. The majority of RCTs used NMES, followed by tDCS and TENS was only used in one case. 4 out of 5 articles analyzing strength found a significantly bigger increase compared to the control group. The 3 studies examining knee and thigh circumference also reported significant improvements. Only 1 of the 4 articles pain showed a significant improvement and none of the 3 articles analyzing functionality showed significant differences between groups. Only 1 study assessed balance and found no significant differences compared to the control group. The 4 systematic reviews analyzed the effectiveness of NMES and concluded that it is beneficial for strength gain. Early initiation of the stimulation period appears to be more effective. Conclusions: Early application of NMES may be beneficial in improving strength, pain and functionality in patients undergoing surgical reconstruction of the anterior cruciate ligament. Further studies are needed to, [Resumo] Introdución: A rotura de ligamento cruzado anterior (LCA) é unha das lesións con maior incidencia, especialmente, no mundo do deporte. A rehabilitación tras a cirurxía require un longo período de tempo e ten como principal intervención o exercicio terapéutico. A electroterapia é outra das posibles intervencións que poderían aportar beneficios á recuperación desta lesión. Obxectivo: Coñecer a eficacia da electroterapia en pacientes que foron intervidos cirurxicamente para a reconstrucción do LCA en comparación cun grupo control que non está sometido a electroterapia. Material e métodos: Realizouse unha búsqueda de ensaios clínicos aleatorizados (ECA) e revisións sistemáticas en Pubmed, Cochrane e Web of Science con estimulación eléctrica neuromuscular (NMES), estimulación eléctrica nerviosa transcutánea (TENS) e estimulación con corrente directa transcraneal (tDCS) desde xaneiro de 2016 ata o 25 de abril de 2023. Resultados: Identificáronse 7 ECA cunha calidade metodolóxica media de 7,14 na escala PEDro e 4 revisións sistemáticas. A mayoría dos ECA empregaron correntes tipo NMES, seguida de tDCS e, só nun caso, empregouse TENS. En 4 dos 5 artigos que analizaban a forza atopouse un aumento significativamente maior que no control. Os 3 traballos que analizaron a circunferencia do xeonllo e do muslo obtiveron melloras significativas. Só en 1 dos 4 artigos que avaliaron a dor como atopouse unha mellora significativa e ningún dos 3 que analizaron a funcionalidade mostraron diferenzas significativas entre os grupos. Só 1 estudo valorou o equilibrio e non encontrou diferenzas significativas con respecto ao grupo control. As 4 revisión sistemáticas analizaron a eficacia da NMES e conclúen que é beneficiosa para a ganancia de forza. Semella que o período de estimulación debe comenzar o antes posible para maior efectividade. Conclusións: A NMES aplicada en fases tempranas pode ser beneficiosa para mellorar a forza, a dor e a funcionalidade en pacientes con reconstruci

Background Knowing the potential hamstring tendon length is relevant for planning ligament reconstructions in children and adolescents, as it is not uncommon to encounter small hamstring tendons intraoperatively. The aim of this study is to predict semitendinosus and gracilis tendon length based on anthropometric values in children and adolescents. The secondary aim is to analyse hamstring tendon autograft characteristics in a closed socket anterior cruciate ligament reconstructions and to evaluate the relationship with anthropometric variables. The hypothesis of this study was that height is predictor of hamstring tendon length and thereby graft characteristics. Methods This observational study included two cohorts of adolescents undergoing ligament reconstructions between 2007–2014 and 2017–2020. Age, sex, height and weight were recorded preoperatively. Semitendinosus and gracilis tendon length and graft characteristics were measured intraoperatively. Regression analysis was performed on tendon length and anthropometric values. Subgroup analyses of the closed socket ACL reconstruction were performed and the relation between anthropometric values and graft characteristics were analysed. Results The population consisted of 171 adolescents from 13 to 17 years of age, with a median age of 16 years [IQR 16–17]. The median semitendinosus tendon length was 29 cm [IQR 26–30] and gracilis tendon length was 27 cm [IQR 25–29]. Height was a significant predictor of semitendinosus and gracilis tendon length. Subgroup analysis of the closed socket ACL reconstructions showed that in 75% of the procedure, the semitendinosus tendon alone was sufficient to create a graft with a minimum diameter of 8.0 mm. Conclusions Height is a significant predictor of semitendinosus and gracilis tendon length in adolescents between 13 and 17 years of age and outcomes are similar to data in adults. In 75% of the closed socket ACL recon

Anterior cruciate ligament (ACL) rupture is a very common knee joint injury. Torn ACLs are currently reconstructed using tendon autografts. However, half of the patients develop osteoarthritis (OA) within 10 to 14 years postoperatively. Proposedly, this is caused by altered knee kine(ma)tics originating from changes in graft mechanical properties during the in vivo remodeling response. Therefore, the main aim was to use subject-specific finite element knee models and investigate the influence of decreasing graft stiffness and/or increasing graft laxity on knee kine(ma)tics and cartilage loading. In this research, 4 subject-specific knee geometries were used, and the material properties of the ACL were altered to either match currently used grafts or mimic in vivo graft remodeling, i.e., decreasing graft stiffness and/or increasing graft laxity. The results confirm that the in vivo graft remodeling process increases the knee range of motion, up to >300 percent, and relocates the cartilage contact pressures, up to 4.3 mm. The effect of remodeling-induced graft mechanical properties on knee stability exceeded that of graft mechanical properties at the time of surgery. This indicates that altered mechanical properties of ACL grafts, caused by in vivo remodeling, can initiate the early onset of osteoarthritis, as observed in many patients clinically.

Background: Following anterior cruciate ligament reconstruction (ACLR), many athletes do not return to their sport, often driven by concerns about re-injury. Psychological support strategies might help, but are not routinely included in rehabilitation after ACLR. The BAck iN the Game (BANG) intervention is a 24-week eHealth program delivered via smartphone application (app), beginning directly after ACLR, with a self-directed approach that aims to target the specific challenges athletes encounter in rehabilitation. Aim: To describe athletes' experiences of using the BANG app during rehabilitation, to support returning to sport following ACLR. Method: Participants were athletes, in contact and/or non-contact pivoting sports, who had ACLR with the goal to return to sports. Semi-structured, individual interviews were conducted 6-10 months after their ACLR; all had access to the BANG intervention. Verbatim transcripts were analysed with a qualitative content analysis. Results: The 19 participants were 17-30 years, mean 21.6 years (SD 3.5); 7 men and 12 women. The analysis generated three main categories. (A) Interacting with the app illustrated how, when, or why the participants engaged with the app. The app was helpful because of its varying content, the notifications served as reminders and participants stopped using the app when no longer needing it. (B) Challenging experiences with the app illustrated that the app itself came with some difficulties e.g., content not appearing with the right timing and material not tailored to their sport. (C) Supportive experiences with the app reflected how the app facilitated the participants' rehabilitation progress; it included positive aspects of the app content and navigation, boosting their confidence to return to sport, and motivated them to continue with rehabilitation. Conclusion: The analysis of the interviews illustrates athletes' awareness in interacting with, and the challenging and supportive experiences of using the

Purpose The results after anterior cruciate ligament reconstruction (ACLR) are evaluated by laxity measures, functional tests, and patients’ perception by patient-reported outcome measures (PROMs). It is not known, if one of these evaluation instruments is representative or if outcome scores from all must be reported to obtain a full evaluation of the condition. The aim was to study the correlations between these three types of outcomes 1 year after primary ACLR. Method All adult patients (range 18–45 years) who had an ACLR between 1.1.2019 and 31.12.2021 were offered 1-year follow-up by an independent observer. Preoperative information about knee laxity and peroperative information about the condition of menisci and cartilage were registered. At 1-year follow-up clinical and instrumented knee stability and function assessed by four different hop tests were registered. Patients completed four PROMs (the Subjective International Knee Documentation Committee (IKDC) score, the Knee Numeric-Entity Evaluation Score (KNEES-ACL), the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm score) and Tegner activity scale and answered anchor questions regarding satisfaction and willingness to repeat the operation. Results A total of 190 adults attended the 1-year follow-up and 151 had all assessments. There were only a few positive and weak correlations between performance tests and PROMS and between clinical measurements and PROMS (r = 0.00–0.38), and the majority were of negligible strength. Tegner score had in general the highest correlation (low to moderate). The highest correlation was 0.53 (moderate) between the anchor question about patient satisfaction and Lysholm/IKDC scores. There was no difference in the correlations depending on meniscal condition. Conclusions In ACLR patients there was no clinically relevant correlation between scores obtained by PROMs, a battery of functional performance tests and instrume, Purpose: The results after anterior cruciate ligament reconstruction (ACLR) are evaluated by laxity measures, functional tests, and patients’ perception by patient-reported outcome measures (PROMs). It is not known, if one of these evaluation instruments is representative or if outcome scores from all must be reported to obtain a full evaluation of the condition. The aim was to study the correlations between these three types of outcomes 1 year after primary ACLR. Method: All adult patients (range 18–45 years) who had an ACLR between 1.1.2019 and 31.12.2021 were offered 1-year follow-up by an independent observer. Preoperative information about knee laxity and peroperative information about the condition of menisci and cartilage were registered. At 1-year follow-up clinical and instrumented knee stability and function assessed by four different hop tests were registered. Patients completed four PROMs (the Subjective International Knee Documentation Committee (IKDC) score, the Knee Numeric-Entity Evaluation Score (KNEES-ACL), the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm score) and Tegner activity scale and answered anchor questions regarding satisfaction and willingness to repeat the operation. Results: A total of 190 adults attended the 1-year follow-up and 151 had all assessments. There were only a few positive and weak correlations between performance tests and PROMS and between clinical measurements and PROMS (r = 0.00–0.38), and the majority were of negligible strength. Tegner score had in general the highest correlation (low to moderate). The highest correlation was 0.53 (moderate) between the anchor question about patient satisfaction and Lysholm/IKDC scores. There was no difference in the correlations depending on meniscal condition. Conclusions: In ACLR patients there was no clinically relevant correlation between scores obtained by PROMs, a battery of functional performance tests and instrumented laxity of the knee at 1-year fo

Purpose The results after anterior cruciate ligament reconstruction (ACLR) are evaluated by laxity measures, functional tests, and patients’ perception by patient-reported outcome measures (PROMs). It is not known, if one of these evaluation instruments is representative or if outcome scores from all must be reported to obtain a full evaluation of the condition. The aim was to study the correlations between these three types of outcomes 1 year after primary ACLR. Method All adult patients (range 18–45 years) who had an ACLR between 1.1.2019 and 31.12.2021 were offered 1-year follow-up by an independent observer. Preoperative information about knee laxity and peroperative information about the condition of menisci and cartilage were registered. At 1-year follow-up clinical and instrumented knee stability and function assessed by four different hop tests were registered. Patients completed four PROMs (the Subjective International Knee Documentation Committee (IKDC) score, the Knee Numeric-Entity Evaluation Score (KNEES-ACL), the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm score) and Tegner activity scale and answered anchor questions regarding satisfaction and willingness to repeat the operation. Results A total of 190 adults attended the 1-year follow-up and 151 had all assessments. There were only a few positive and weak correlations between performance tests and PROMS and between clinical measurements and PROMS (r = 0.00–0.38), and the majority were of negligible strength. Tegner score had in general the highest correlation (low to moderate). The highest correlation was 0.53 (moderate) between the anchor question about patient satisfaction and Lysholm/IKDC scores. There was no difference in the correlations depending on meniscal condition. Conclusions In ACLR patients there was no clinically relevant correlation between scores obtained by PROMs, a battery of functional performance tests and instrume, Purpose: The results after anterior cruciate ligament reconstruction (ACLR) are evaluated by laxity measures, functional tests, and patients’ perception by patient-reported outcome measures (PROMs). It is not known, if one of these evaluation instruments is representative or if outcome scores from all must be reported to obtain a full evaluation of the condition. The aim was to study the correlations between these three types of outcomes 1 year after primary ACLR. Method: All adult patients (range 18–45 years) who had an ACLR between 1.1.2019 and 31.12.2021 were offered 1-year follow-up by an independent observer. Preoperative information about knee laxity and peroperative information about the condition of menisci and cartilage were registered. At 1-year follow-up clinical and instrumented knee stability and function assessed by four different hop tests were registered. Patients completed four PROMs (the Subjective International Knee Documentation Committee (IKDC) score, the Knee Numeric-Entity Evaluation Score (KNEES-ACL), the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm score) and Tegner activity scale and answered anchor questions regarding satisfaction and willingness to repeat the operation. Results: A total of 190 adults attended the 1-year follow-up and 151 had all assessments. There were only a few positive and weak correlations between performance tests and PROMS and between clinical measurements and PROMS (r = 0.00–0.38), and the majority were of negligible strength. Tegner score had in general the highest correlation (low to moderate). The highest correlation was 0.53 (moderate) between the anchor question about patient satisfaction and Lysholm/IKDC scores. There was no difference in the correlations depending on meniscal condition. Conclusions: In ACLR patients there was no clinically relevant correlation between scores obtained by PROMs, a battery of functional performance tests and instrumented laxity of the knee at 1-year fo

BackgroundAfter anterior cruciate ligament (ACL) reconstruction, patient-reported outcomes are improved 10 years post-surgery; however, cytokine concentrations remain elevated years after surgery with over 80% of those with combined ACL and meniscus injuries having posttraumatic osteoarthritis (PTOA) within 10-15 years. The purpose of this multicenter, randomized, placebo-controlled trial is to assess whether a 6-month course of oral montelukast after ACL reconstruction reduces systemic markers of inflammation and biochemical and imaging biomarkers of cartilage degradation.MethodsWe will enroll 30 individuals undergoing primary ACL reconstruction to participate in this IRB-approved multicenter clinical trial. This trial will target those at greatest risk of a more rapid PTOA onset (age range 25-50 with concomitant meniscus injury). Patients will be randomly assigned to a group instructed to take 10 mg of montelukast daily for 6 months following ACL reconstruction or placebo. Patients will be assessed prior to surgery and 1, 6, and 12 months following surgery. To determine if montelukast alters systemic inflammation following surgery, we will compare systemic concentrations of prostaglandin E2, monocyte chemoattractant protein-1, and pro-inflammatory cytokines between groups. We will also compare degradative changes on magnetic resonance imaging (MRI) collected 1 and 12 months following surgery between groups with reductions in early biomarkers of cartilage degradation assessed with urinary biomarkers of type II collagen breakdown and bony remodeling.DiscussionThere is a complex interplay between the pro-inflammatory intra-articular environment, underlying bone remodeling, and progressive cartilage degradation. PTOA affects multiple tissues and appears to be more similar to rheumatoid arthritis than osteoarthritis with respect to inflammation. There is currently no treatment to delay or prevent PTOA after ACL injury. Since there is a larger and more persistent i

A ruptured anterior cruciate ligament (ACL) is often reconstructed with a multiple-strand autograft of a semitendinosus tendon alone or combined with a gracilis tendon. Up to 10% of patients experience graft rupture. This potentially results from excessive local tissue strains under physiological loading which could either result in direct mechanical failure of the graft or induce mechanobiological weakening. Since the original location in the hamstring tendon cannot be traced back from an autograft rupture site, this study explored whether clinical outcome could be further improved by avoiding specific locations or regions of human semitendinosus and/or gracilis tendons in ACL grafts due to potential mechanical or biochemical inferiority. Additionally, it examined numerically which clinically relevant graft configurations experience the lowest strains – and therefore the lowest rupture risk – when loaded with equal force. Remnant full-length gracilis tendons from human ACL reconstructions and full-length semitendinosus- and ipsilateral gracilis tendons of human cadaveric specimens were subjected to a stress-relaxation test. Locations at high risk of mechanical failure were identified using particle tracking to calculate local axial strains. As biochemical properties, the water-, collagen-, glycosaminoglycan- and DNA content per tissue region (representing graft strands) were determined. A viscoelastic lumped parameter model per tendon region was calculated. These models were applied in clinically relevant virtual graft configurations, which were exposed to physiological loading. Configurations that provided lower stiffness – i.e., experiencing higher strains under equal force – were assumed to be at higher risk of failure. Suitability of the gracilis tendon proper to replace semitendinosus muscle-tendon junction strands was examined. Deviations in local axial strains from the globally applied strain were of similar magnitude as the applied strain. Locations of m

BackgroundSurgical and anesthetic techniques have enabled a shift to the ambulatory setting for the majority of patients with anterior cruciate ligament (ACL) tears. While this change likely reflects improvements in acute pain management, little is known about national trends in pediatric perioperative pain management after ACL reconstruction (ACLR).PurposeTo describe recent trends in the United States in perioperative pain management for pediatric ACLR.Study designCross-sectional study; Level of evidence, 3.MethodsPediatric patients (age, ≤18 years) who underwent ACLR with peripheral nerve blocks between January 2008 and December 2017 were identified in the Pediatric Health Information System database. We modeled the use of oral and intravenous analgesic medications over time using Bayesian logistic mixed models. Models were adjusted for patient age, sex, race, primary payer, and treatment setting (ambulatory, observation, or inpatient).ResultsThe study criteria produced a sample of 18,605 patients. Older children were more likely to receive intravenous acetaminophen, intravenous ketorolac, and oral and intravenous opioids. Younger children were more likely to receive ibuprofen. In our adjusted logistic model, treatment setting was found to be an independent predictor of the utilization of all medications. We found an increase in the overall utilization of oral acetaminophen (adjusted odds ratio [adj OR], 1.14 [95% CI, 1.04-1.23]), intravenous acetaminophen (adj OR, 1.42 [95% CI, 1.22-1.65]), and oral opioids (adj OR, 1.16 [95% CI, 1.06-1.28]) over the study period at a typical hospital. We found significant heterogeneity in medication use across hospitals, with the most heterogeneity in intravenous acetaminophen. Other studied descriptive variables did not appear to predict practices.ConclusionAfter adjusting for patient characteristics and treatment settings, pain management strategies varied among hospitals and over time. Patient age and treatment setting predic

Background: Anterior cruciate ligament (ACL) rupture is a very common knee injury in the sport active population. There is much debate on which treatment (operative or non-operative) is best for the individual patient. In order to give a more personalized recommendation we aim to evaluate the effectiveness and cost-effectiveness of a treatment algorithm for patients with a complete primary ACL rupture. Methods: The ROTATE-trial is a multicenter, open-labeled cluster randomized controlled trial with superiority design. Randomization will take place on hospital level (n = 10). Patients must meet all the following criteria: aged 18 year or older, with a complete primary ACL rupture (confirmed by MRI and physical examination) and maximum of 6 weeks of non-operative treatment. Exclusion criteria consists of multi ligament trauma indicated for surgical intervention, presence of another disorder that affects the activity level of the lower limb, pregnancy, and insufficient command of the Dutch language. The intervention to be investigated will be an adjusted treatment decision strategy, including an advice from our treatment algorithm. Patient reported outcomes will be conducted at baseline, 3, 6, 12 and 24 months. Physical examination of the knee at baseline, 12 and 24 months. Primary outcome will be function of the knee measured by the International Knee Documentation Committee (IKDC) questionnaire. Secondary outcomes are, among others, the Tegner activity score, the Knee injury and Osteoarthritis Outcome Score (KOOS) and the 9-item Shared Decision Making Questionnaire (SDM-Q-9). Healthcare use, productivity and satisfaction with ((non-)operative) care are also measured by means of questionnaires. In total 230 patients will be included, resulting in 23 patients per hospital. Discussion: The ROTATE study aims to evaluate the effectiveness and cost-effectiveness of a treatment algorithm for patients with a complete primary ACL rupture compared to current

Knee proprioception deficits and neuroplasticity have been indicated following injury to the anterior cruciate ligament (ACL). Evidence is, however, scarce regarding brain response to knee proprioception tasks and the impact of ACL injury. This study aimed to identify brain regions associated with the proprioceptive sense of joint position at the knee and whether the related brain response of individuals with ACL reconstruction differed from that of asymptomatic controls. Twenty-one persons with unilateral ACL reconstruction (mean 23 months post-surgery) of either the right (n = 10) or left (n = 11) knee, as well as 19 controls (CTRL) matched for sex, age, height, weight and current activity level, performed a knee joint position sense (JPS) test during simultaneous functional magnetic resonance imaging (fMRI). Integrated motion capture provided real-time knee kinematics to activate test instructions, as well as accurate knee angles for JPS outcomes. Recruited brain regions during knee angle reproduction included somatosensory cortices, prefrontal cortex and insula. Neither brain response nor JPS errors differed between groups, but across groups significant correlations revealed that greater errors were associated with greater ipsilateral response in the anterior cingulate (r = 0.476, P = 0.009), supramarginal gyrus (r = 0.395, P = 0.034) and insula (r = 0.474, P = 0.008). This is the first study to capture brain response using fMRI in relation to quantifiable knee JPS. Activated brain regions have previously been associated with sensorimotor processes, body schema and interoception. Our innovative paradigm can help to guide future research investigating brain response to lower limb proprioception.

Knee proprioception deficits and neuroplasticity have been indicated following injury to the anterior cruciate ligament (ACL). Evidence is, however, scarce regarding brain response to knee proprioception tasks and the impact of ACL injury. This study aimed to identify brain regions associated with the proprioceptive sense of joint position at the knee and whether the related brain response of individuals with ACL reconstruction differed from that of asymptomatic controls. Twenty-one persons with unilateral ACL reconstruction (mean 23 months post-surgery) of either the right (n = 10) or left (n = 11) knee, as well as 19 controls (CTRL) matched for sex, age, height, weight and current activity level, performed a knee joint position sense (JPS) test during simultaneous functional magnetic resonance imaging (fMRI). Integrated motion capture provided real-time knee kinematics to activate test instructions, as well as accurate knee angles for JPS outcomes. Recruited brain regions during knee angle reproduction included somatosensory cortices, prefrontal cortex and insula. Neither brain response nor JPS errors differed between groups, but across groups significant correlations revealed that greater errors were associated with greater ipsilateral response in the anterior cingulate (r = 0.476, P = 0.009), supramarginal gyrus (r = 0.395, P = 0.034) and insula (r = 0.474, P = 0.008). This is the first study to capture brain response using fMRI in relation to quantifiable knee JPS. Activated brain regions have previously been associated with sensorimotor processes, body schema and interoception. Our innovative paradigm can help to guide future research investigating brain response to lower limb proprioception.

Knee proprioception deficits and neuroplasticity have been indicated following injury to the anterior cruciate ligament (ACL). Evidence is, however, scarce regarding brain response to knee proprioception tasks and the impact of ACL injury. This study aimed to identify brain regions associated with the proprioceptive sense of joint position at the knee and whether the related brain response of individuals with ACL reconstruction differed from that of asymptomatic controls. Twenty-one persons with unilateral ACL reconstruction (mean 23 months post-surgery) of either the right (n = 10) or left (n = 11) knee, as well as 19 controls (CTRL) matched for sex, age, height, weight and current activity level, performed a knee joint position sense (JPS) test during simultaneous functional magnetic resonance imaging (fMRI). Integrated motion capture provided real-time knee kinematics to activate test instructions, as well as accurate knee angles for JPS outcomes. Recruited brain regions during knee angle reproduction included somatosensory cortices, prefrontal cortex and insula. Neither brain response nor JPS errors differed between groups, but across groups significant correlations revealed that greater errors were associated with greater ipsilateral response in the anterior cingulate (r = 0.476, P = 0.009), supramarginal gyrus (r = 0.395, P = 0.034) and insula (r = 0.474, P = 0.008). This is the first study to capture brain response using fMRI in relation to quantifiable knee JPS. Activated brain regions have previously been associated with sensorimotor processes, body schema and interoception. Our innovative paradigm can help to guide future research investigating brain response to lower limb proprioception.

BackgroundSurgical and anesthetic techniques have enabled a shift to the ambulatory setting for the majority of patients with anterior cruciate ligament (ACL) tears. While this change likely reflects improvements in acute pain management, little is known about national trends in pediatric perioperative pain management after ACL reconstruction (ACLR).PurposeTo describe recent trends in the United States in perioperative pain management for pediatric ACLR.Study designCross-sectional study; Level of evidence, 3.MethodsPediatric patients (age, ≤18 years) who underwent ACLR with peripheral nerve blocks between January 2008 and December 2017 were identified in the Pediatric Health Information System database. We modeled the use of oral and intravenous analgesic medications over time using Bayesian logistic mixed models. Models were adjusted for patient age, sex, race, primary payer, and treatment setting (ambulatory, observation, or inpatient).ResultsThe study criteria produced a sample of 18,605 patients. Older children were more likely to receive intravenous acetaminophen, intravenous ketorolac, and oral and intravenous opioids. Younger children were more likely to receive ibuprofen. In our adjusted logistic model, treatment setting was found to be an independent predictor of the utilization of all medications. We found an increase in the overall utilization of oral acetaminophen (adjusted odds ratio [adj OR], 1.14 [95% CI, 1.04-1.23]), intravenous acetaminophen (adj OR, 1.42 [95% CI, 1.22-1.65]), and oral opioids (adj OR, 1.16 [95% CI, 1.06-1.28]) over the study period at a typical hospital. We found significant heterogeneity in medication use across hospitals, with the most heterogeneity in intravenous acetaminophen. Other studied descriptive variables did not appear to predict practices.ConclusionAfter adjusting for patient characteristics and treatment settings, pain management strategies varied among hospitals and over time. Patient age and treatment setting predic

BackgroundAfter anterior cruciate ligament (ACL) reconstruction, patient-reported outcomes are improved 10 years post-surgery; however, cytokine concentrations remain elevated years after surgery with over 80% of those with combined ACL and meniscus injuries having posttraumatic osteoarthritis (PTOA) within 10-15 years. The purpose of this multicenter, randomized, placebo-controlled trial is to assess whether a 6-month course of oral montelukast after ACL reconstruction reduces systemic markers of inflammation and biochemical and imaging biomarkers of cartilage degradation.MethodsWe will enroll 30 individuals undergoing primary ACL reconstruction to participate in this IRB-approved multicenter clinical trial. This trial will target those at greatest risk of a more rapid PTOA onset (age range 25-50 with concomitant meniscus injury). Patients will be randomly assigned to a group instructed to take 10 mg of montelukast daily for 6 months following ACL reconstruction or placebo. Patients will be assessed prior to surgery and 1, 6, and 12 months following surgery. To determine if montelukast alters systemic inflammation following surgery, we will compare systemic concentrations of prostaglandin E2, monocyte chemoattractant protein-1, and pro-inflammatory cytokines between groups. We will also compare degradative changes on magnetic resonance imaging (MRI) collected 1 and 12 months following surgery between groups with reductions in early biomarkers of cartilage degradation assessed with urinary biomarkers of type II collagen breakdown and bony remodeling.DiscussionThere is a complex interplay between the pro-inflammatory intra-articular environment, underlying bone remodeling, and progressive cartilage degradation. PTOA affects multiple tissues and appears to be more similar to rheumatoid arthritis than osteoarthritis with respect to inflammation. There is currently no treatment to delay or prevent PTOA after ACL injury. Since there is a larger and more persistent i

Between 1982 and 1986, 126 patients who had undergone ACL reconstruction were followed in a prospective manner. One year follow-up statistics were reviewed for the presence of 13 different complications. The most prevalent complications were quadriceps weakness, flexion contracture, and patellofemoral pain. Quadriceps weakness (strength less than 80% of the normal side) was present in 65% of patients and correlated positively with flexion contracture, patellar irritability, and ACL reconstructions using patellar tendon grafts. Flexion contracture of 5° or more was present in 24% of patients and correlated positively with increased age and patellar irritability. Patellofemoral pain was present in 19% of patients and correlated positively with flexion contracture. Clinical relevance: The three most common complications of knee ligament surgery are shown to be strongly interrelated. It is likely that a causal relationship is present in which flexion contracture causes patellofemoral irritability, and that both of these factors, alone or in combination, result in quadriceps weakness. If this theory is correct, then it is crucial that postoperative rehabilitation programs place a major emphasis on the avoidance of flexion contracture.

This study aims to compare the limb symmetry index (LSI) of the rate of torque development (RTD) of the quadriceps with that of the peak torque after anterior cruciate ligament reconstruction (ACLR) using semitendinosus and gracilis tendon (STG) autografts and to investigate the associations of the LSI of torque parameters with patient-reported knee function. The participants included 23 female athletes after ACLR with STG grafts. Isometric quadriceps tests were performed using an isokinetic dynamometer. The peak torque, RTD100 (0 to 100 ms) and RTD200 (100 to 200 ms) were determined using torque-time curves. Comparisons of the LSI of torque parameters was performed by ANOVA. Univariate regression analysis was used to examine the relationship between the LSI of torque parameters and the patient-reported knee function. The LSIs of the peak torque and RTD200 were significantly lower than that of the RTD100 (p = 0.049, p = 0.039, respectively). Regression analysis showed that the LSI of the peak torque was associated with the patient-reported knee function (R-2 = 0.40, p = 0.001). It would be useful to evaluate the peak torque in young female athletes under the age of 18 and at 8-10 months after ACLR with STG grafts.

BackgroundLytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described.PurposeTo describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting.Study designCohort study; Level of evidence, 3.MethodsA total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics.ResultsA total of 159 patients (13%) underwent tunnel grafting-64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group (P≤ .001). Patients who required 2-stage grafting had more previous ACLRs (P < .001) and were less likely to have received a bone-patellar tendon-bone or a soft tissue autograft at primary ACLR procedure (P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone-patellar tendon-bone allograft (P≤ .008) and less likely to receive a soft tissue autograft (P≤ .003) compared with the no bon

Objective: To investigate the association of psychological readiness at 9 months after anterior cruciate ligament reconstruction (ACLR) with knee strength and range-of-motion (ROM) at 3 and 9 months postoperatively. Design: Retrospective cohort study. Setting: Private orthopedic hospital. Participants: Seventy-eight patients after ACLR. Main outcomes measures: The participants completed the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale as an assessment of psychological readiness at 9 months after ACLR. Isometric and isokinetic quadriceps and hamstring strength were measured by a dynamometer at 3 and 9 months postoperatively. Knee extension and flexion ROM were measured in 5 degrees increments with a standard goniometer at 3 and 9 months postoperatively. Results: Univariate regression analysis showed that age, limb symmetry index (LSI) of quadriceps strength at 3 and 9 months, and knee extension ROM deficit (>5 degrees) at 3 and 9 months were associated with ACL-RSI scores at 9 months (P < 0.05). Age and LSI of quadriceps strength at 3 months remained significant predictors of ACL-RSI scores at 9 months in multiple regression analysis (R2 = 0.20, P < 0.001). Conclusions: Early improvements in quadriceps strength after ACLR may have a positive impact on psychological readiness at 9 months postoperatively.

This study aims to compare the limb symmetry index (LSI) of the rate of torque development (RTD) of the quadriceps with that of the peak torque after anterior cruciate ligament reconstruction (ACLR) using semitendinosus and gracilis tendon (STG) autografts and to investigate the associations of the LSI of torque parameters with patient-reported knee function. The participants included 23 female athletes after ACLR with STG grafts. Isometric quadriceps tests were performed using an isokinetic dynamometer. The peak torque, RTD100 (0 to 100 ms) and RTD200 (100 to 200 ms) were determined using torque-time curves. Comparisons of the LSI of torque parameters was performed by ANOVA. Univariate regression analysis was used to examine the relationship between the LSI of torque parameters and the patient-reported knee function. The LSIs of the peak torque and RTD200 were significantly lower than that of the RTD100 (p = 0.049, p = 0.039, respectively). Regression analysis showed that the LSI of the peak torque was associated with the patient-reported knee function (R-2 = 0.40, p = 0.001). It would be useful to evaluate the peak torque in young female athletes under the age of 18 and at 8-10 months after ACLR with STG grafts.

This study aims to compare the limb symmetry index (LSI) of the rate of torque development (RTD) of the quadriceps with that of the peak torque after anterior cruciate ligament reconstruction (ACLR) using semitendinosus and gracilis tendon (STG) autografts and to investigate the associations of the LSI of torque parameters with patient-reported knee function. The participants included 23 female athletes after ACLR with STG grafts. Isometric quadriceps tests were performed using an isokinetic dynamometer. The peak torque, RTD100 (0 to 100 ms) and RTD200 (100 to 200 ms) were determined using torque-time curves. Comparisons of the LSI of torque parameters was performed by ANOVA. Univariate regression analysis was used to examine the relationship between the LSI of torque parameters and the patient-reported knee function. The LSIs of the peak torque and RTD200 were significantly lower than that of the RTD100 (p = 0.049, p = 0.039, respectively). Regression analysis showed that the LSI of the peak torque was associated with the patient-reported knee function (R-2 = 0.40, p = 0.001). It would be useful to evaluate the peak torque in young female athletes under the age of 18 and at 8-10 months after ACLR with STG grafts.

Knee proprioception deficits and neuroplasticity have been indicated following injury to the anterior cruciate ligament (ACL). Evidence is, however, scarce regarding brain response to knee proprioception tasks and the impact of ACL injury. This study aimed to identify brain regions associated with the proprioceptive sense of joint position at the knee and whether the related brain response of individuals with ACL reconstruction differed from that of asymptomatic controls. Twenty-one persons with unilateral ACL reconstruction (mean 23 months post-surgery) of either the right (n = 10) or left (n = 11) knee, as well as 19 controls (CTRL) matched for sex, age, height, weight and current activity level, performed a knee joint position sense (JPS) test during simultaneous functional magnetic resonance imaging (fMRI). Integrated motion capture provided real-time knee kinematics to activate test instructions, as well as accurate knee angles for JPS outcomes. Recruited brain regions during knee angle reproduction included somatosensory cortices, prefrontal cortex and insula. Neither brain response nor JPS errors differed between groups, but across groups significant correlations revealed that greater errors were associated with greater ipsilateral response in the anterior cingulate (r = 0.476, P = 0.009), supramarginal gyrus (r = 0.395, P = 0.034) and insula (r = 0.474, P = 0.008). This is the first study to capture brain response using fMRI in relation to quantifiable knee JPS. Activated brain regions have previously been associated with sensorimotor processes, body schema and interoception. Our innovative paradigm can help to guide future research investigating brain response to lower limb proprioception.

Knee proprioception deficits and neuroplasticity have been indicated following injury to the anterior cruciate ligament (ACL). Evidence is, however, scarce regarding brain response to knee proprioception tasks and the impact of ACL injury. This study aimed to identify brain regions associated with the proprioceptive sense of joint position at the knee and whether the related brain response of individuals with ACL reconstruction differed from that of asymptomatic controls. Twenty-one persons with unilateral ACL reconstruction (mean 23 months post-surgery) of either the right (n = 10) or left (n = 11) knee, as well as 19 controls (CTRL) matched for sex, age, height, weight and current activity level, performed a knee joint position sense (JPS) test during simultaneous functional magnetic resonance imaging (fMRI). Integrated motion capture provided real-time knee kinematics to activate test instructions, as well as accurate knee angles for JPS outcomes. Recruited brain regions during knee angle reproduction included somatosensory cortices, prefrontal cortex and insula. Neither brain response nor JPS errors differed between groups, but across groups significant correlations revealed that greater errors were associated with greater ipsilateral response in the anterior cingulate (r = 0.476, P = 0.009), supramarginal gyrus (r = 0.395, P = 0.034) and insula (r = 0.474, P = 0.008). This is the first study to capture brain response using fMRI in relation to quantifiable knee JPS. Activated brain regions have previously been associated with sensorimotor processes, body schema and interoception. Our innovative paradigm can help to guide future research investigating brain response to lower limb proprioception.

Knee proprioception deficits and neuroplasticity have been indicated following injury to the anterior cruciate ligament (ACL). Evidence is, however, scarce regarding brain response to knee proprioception tasks and the impact of ACL injury. This study aimed to identify brain regions associated with the proprioceptive sense of joint position at the knee and whether the related brain response of individuals with ACL reconstruction differed from that of asymptomatic controls. Twenty-one persons with unilateral ACL reconstruction (mean 23 months post-surgery) of either the right (n = 10) or left (n = 11) knee, as well as 19 controls (CTRL) matched for sex, age, height, weight and current activity level, performed a knee joint position sense (JPS) test during simultaneous functional magnetic resonance imaging (fMRI). Integrated motion capture provided real-time knee kinematics to activate test instructions, as well as accurate knee angles for JPS outcomes. Recruited brain regions during knee angle reproduction included somatosensory cortices, prefrontal cortex and insula. Neither brain response nor JPS errors differed between groups, but across groups significant correlations revealed that greater errors were associated with greater ipsilateral response in the anterior cingulate (r = 0.476, P = 0.009), supramarginal gyrus (r = 0.395, P = 0.034) and insula (r = 0.474, P = 0.008). This is the first study to capture brain response using fMRI in relation to quantifiable knee JPS. Activated brain regions have previously been associated with sensorimotor processes, body schema and interoception. Our innovative paradigm can help to guide future research investigating brain response to lower limb proprioception.

Background: Anterior cruciate ligament (ACL) rupture is a very common knee injury in the sport active population. There is much debate on which treatment (operative or non-operative) is best for the individual patient. In order to give a more personalized recommendation we aim to evaluate the effectiveness and cost-effectiveness of a treatment algorithm for patients with a complete primary ACL rupture. Methods: The ROTATE-trial is a multicenter, open-labeled cluster randomized controlled trial with superiority design. Randomization will take place on hospital level (n = 10). Patients must meet all the following criteria: aged 18 year or older, with a complete primary ACL rupture (confirmed by MRI and physical examination) and maximum of 6 weeks of non-operative treatment. Exclusion criteria consists of multi ligament trauma indicated for surgical intervention, presence of another disorder that affects the activity level of the lower limb, pregnancy, and insufficient command of the Dutch language. The intervention to be investigated will be an adjusted treatment decision strategy, including an advice from our treatment algorithm. Patient reported outcomes will be conducted at baseline, 3, 6, 12 and 24 months. Physical examination of the knee at baseline, 12 and 24 months. Primary outcome will be function of the knee measured by the International Knee Documentation Committee (IKDC) questionnaire. Secondary outcomes are, among others, the Tegner activity score, the Knee injury and Osteoarthritis Outcome Score (KOOS) and the 9-item Shared Decision Making Questionnaire (SDM-Q-9). Healthcare use, productivity and satisfaction with ((non-)operative) care are also measured by means of questionnaires. In total 230 patients will be included, resulting in 23 patients per hospital. Discussion: The ROTATE study aims to evaluate the effectiveness and cost-effectiveness of a treatment algorithm for patients with a complete primary ACL rupture compared to current

A ruptured anterior cruciate ligament (ACL) is often reconstructed with a multiple-strand autograft of a semitendinosus tendon alone or combined with a gracilis tendon. Up to 10% of patients experience graft rupture. This potentially results from excessive local tissue strains under physiological loading which could either result in direct mechanical failure of the graft or induce mechanobiological weakening. Since the original location in the hamstring tendon cannot be traced back from an autograft rupture site, this study explored whether clinical outcome could be further improved by avoiding specific locations or regions of human semitendinosus and/or gracilis tendons in ACL grafts due to potential mechanical or biochemical inferiority. Additionally, it examined numerically which clinically relevant graft configurations experience the lowest strains – and therefore the lowest rupture risk – when loaded with equal force. Remnant full-length gracilis tendons from human ACL reconstructions and full-length semitendinosus- and ipsilateral gracilis tendons of human cadaveric specimens were subjected to a stress-relaxation test. Locations at high risk of mechanical failure were identified using particle tracking to calculate local axial strains. As biochemical properties, the water-, collagen-, glycosaminoglycan- and DNA content per tissue region (representing graft strands) were determined. A viscoelastic lumped parameter model per tendon region was calculated. These models were applied in clinically relevant virtual graft configurations, which were exposed to physiological loading. Configurations that provided lower stiffness – i.e., experiencing higher strains under equal force – were assumed to be at higher risk of failure. Suitability of the gracilis tendon proper to replace semitendinosus muscle-tendon junction strands was examined. Deviations in local axial strains from the globally applied strain were of similar magnitude as the applied strain. Locations of m

Objective: To (1) describe return to running (RTR) programs used during rehabilitation after anterior cruciate ligament reconstruction (ACLR); and (2) provide clinical guidelines for RTR program after ACLR. Design: Scoping review. Literature search: We searched the MEDLINE (Pubmed), EMBASE, Web of Science and PEDro databases. Study selection criteria: We included randomized controlled trial (RCT), cases series, meta-analyses, both scoping and systematic reviews including a rehabilitation program after ACLR with a specific RTR program. A “Running program checklist” (RPC) was elaborated based on the Template for Intervention Description and Replication (TIDieR), and on the Consensus on Exercise Reporting Template (CERT) checklist. Data synthesis: The percentage and number of studies specifying each of the running program checklist items in their RTR program were reported. Number of items reported in each study and specific analysis item-by-item were also proposed. Results: The “When (2)" item was the most frequently found (92.19%) and, conversely, the “Who (1)" item appeared only in four studies (6.2%). One-third of the studies presented only one item of the RPC, and 48 of the 64 articles discussed less than three items. Two studies described in detail their RTR program by reporting 8 and 9 items out of the 10, respectively. No study presented 10 of the PRC items. Conclusion: There is a serious lack of information concerning RTR program following ACLR in the literature and further studies are needed to establish a program based on the best evidence., SCOPUS: re.j, info:eu-repo/semantics/published

Knee proprioception deficits and neuroplasticity have been indicated following injury to the anterior cruciate ligament (ACL). Evidence is, however, scarce regarding brain response to knee proprioception tasks and the impact of ACL injury. This study aimed to identify brain regions associated with the proprioceptive sense of joint position at the knee and whether the related brain response of individuals with ACL reconstruction differed from that of asymptomatic controls. Twenty-one persons with unilateral ACL reconstruction (mean 23 months post-surgery) of either the right (n = 10) or left (n = 11) knee, as well as 19 controls (CTRL) matched for sex, age, height, weight and current activity level, performed a knee joint position sense (JPS) test during simultaneous functional magnetic resonance imaging (fMRI). Integrated motion capture provided real-time knee kinematics to activate test instructions, as well as accurate knee angles for JPS outcomes. Recruited brain regions during knee angle reproduction included somatosensory cortices, prefrontal cortex and insula. Neither brain response nor JPS errors differed between groups, but across groups significant correlations revealed that greater errors were associated with greater ipsilateral response in the anterior cingulate (r = 0.476, P = 0.009), supramarginal gyrus (r = 0.395, P = 0.034) and insula (r = 0.474, P = 0.008). This is the first study to capture brain response using fMRI in relation to quantifiable knee JPS. Activated brain regions have previously been associated with sensorimotor processes, body schema and interoception. Our innovative paradigm can help to guide future research investigating brain response to lower limb proprioception.

Between 1982 and 1986, 126 patients who had undergone ACL reconstruction were followed in a prospective manner. One year follow-up statistics were reviewed for the presence of 13 different complications. The most prevalent complications were quadriceps weakness, flexion contracture, and patellofemoral pain. Quadriceps weakness (strength less than 80% of the normal side) was present in 65% of patients and correlated positively with flexion contracture, patellar irritability, and ACL reconstructions using patellar tendon grafts. Flexion contracture of 5° or more was present in 24% of patients and correlated positively with increased age and patellar irritability. Patellofemoral pain was present in 19% of patients and correlated positively with flexion contracture. Clinical relevance: The three most common complications of knee ligament surgery are shown to be strongly interrelated. It is likely that a causal relationship is present in which flexion contracture causes patellofemoral irritability, and that both of these factors, alone or in combination, result in quadriceps weakness. If this theory is correct, then it is crucial that postoperative rehabilitation programs place a major emphasis on the avoidance of flexion contracture.

Graft tunnel healing is important for the successful reconstruction of the anterior cruciate ligament by using the hamstring tendon autograft. There are studies that intra graft tunnel Bone Marrow Mesenchymal stem cells (BMSCs) or intra graft tunnel Vascular endothelial growth factor (VEGF) accelerated graft tunnel healing. This study aimed to investigate the effect of using BMSCs+VEGF injected intra-articular on graft tunnel healing. We reconstructed the anterior cruciate ligament (ACL) of 12 rabbits using an autograft hamstring tendon with and without intra-articular BMSCs+VEGF. Histological evaluation was done at 3 and 6 weeks after ACL reconstruction. On the surface between the graft and the bone tunnel obtained collagen fiber thickness or Sharpey fiber is significantly more than the control group (p< 0.05) in the evaluation of 3 weeks and 6 weeks either side of the tibia and the femur. To evaluate the progression of the treatment, treatment group and control group gained progression had significantly when compared to 3 weeks and 6 weeks. It can be concluded that intra-articular injection of VEGF+BMSCs can accelerate the integration of the graft tunnel from histology evaluation on 3 and 6 weeks.

OBJECTIVES: To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool - a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes. DESIGN: Prospective cohort. PARTICIPANTS: 43 nonprofessional pivoting sport athletes with ACLR. MAIN OUTCOME: Clinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes' beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability). RESULTS: The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1-1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely). CONCLUSION: The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.

OBJECTIVES: To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool - a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes. DESIGN: Prospective cohort. PARTICIPANTS: 43 nonprofessional pivoting sport athletes with ACLR. MAIN OUTCOME: Clinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes' beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability). RESULTS: The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1-1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely). CONCLUSION: The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.

Objective: The retrospective investigation was carried out to assess whether subjects who fulfilled our proposed recruitment criteria responded more favorably to anterior cruciate ligament reconstruction (ACLR) than those who did not. Methods: We retrospectively analyzed 109 skeletally mature subjects (78 men and 31 women) according to the following proposed criteria of recruitment: (1) pre-injury Tegner activity score ≥7 and a wish to return to a professional sports activity, (2) residual knee instability following injury and/or (3) age <20 years at the operation. The primary outcome was an improvement between assessment A (before operation) and B (mean follow-up of 1.6 years) in the average score for four of the five Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, difficulty in sports and recreational activities, and quality of life (KOOS4). Results: The proposed recruitment criteria for ACLR were met by 58 subjects (53%). There were 49 subjects (45%) who improved between assessment A and B. Subjects who met proposed recruitment criteria were more likely to improve clinically after ACLR (OR 5.7, 95% CI 2.5-13.3). Conclusions: Fulfillment of proposed recruitment criteria was a strong predictive factor for outcome improvement in short- to medium-term follow-up after ACLR. Level of evidence: Case-control study. Level of evidence 3.

Objective: The retrospective investigation was carried out to assess whether subjects who fulfilled our proposed recruitment criteria responded more favorably to anterior cruciate ligament reconstruction (ACLR) than those who did not. Methods: We retrospectively analyzed 109 skeletally mature subjects (78 men and 31 women) according to the following proposed criteria of recruitment: (1) pre-injury Tegner activity score ≥7 and a wish to return to a professional sports activity, (2) residual knee instability following injury and/or (3) age <20 years at the operation. The primary outcome was an improvement between assessment A (before operation) and B (mean follow-up of 1.6 years) in the average score for four of the five Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, difficulty in sports and recreational activities, and quality of life (KOOS4). Results: The proposed recruitment criteria for ACLR were met by 58 subjects (53%). There were 49 subjects (45%) who improved between assessment A and B. Subjects who met proposed recruitment criteria were more likely to improve clinically after ACLR (OR 5.7, 95% CI 2.5-13.3). Conclusions: Fulfillment of proposed recruitment criteria was a strong predictive factor for outcome improvement in short- to medium-term follow-up after ACLR. Level of evidence: Case-control study. Level of evidence 3.

Objective: The retrospective investigation was carried out to assess whether subjects who fulfilled our proposed recruitment criteria responded more favorably to anterior cruciate ligament reconstruction (ACLR) than those who did not. Methods: We retrospectively analyzed 109 skeletally mature subjects (78 men and 31 women) according to the following proposed criteria of recruitment: (1) pre-injury Tegner activity score ≥7 and a wish to return to a professional sports activity, (2) residual knee instability following injury and/or (3) age <20 years at the operation. The primary outcome was an improvement between assessment A (before operation) and B (mean follow-up of 1.6 years) in the average score for four of the five Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, difficulty in sports and recreational activities, and quality of life (KOOS4). Results: The proposed recruitment criteria for ACLR were met by 58 subjects (53%). There were 49 subjects (45%) who improved between assessment A and B. Subjects who met proposed recruitment criteria were more likely to improve clinically after ACLR (OR 5.7, 95% CI 2.5-13.3). Conclusions: Fulfillment of proposed recruitment criteria was a strong predictive factor for outcome improvement in short- to medium-term follow-up after ACLR. Level of evidence: Case-control study. Level of evidence 3.

BackgroundAlthough graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.HypothesisIn the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.Study designCohort study; Level of evidence, 2.MethodsPatients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.ResultsA total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with aut

Background: Anterior cruciate ligament (ACL) injuries are common, especially among athletes. The injury often leaves the patient with consequences, such as affected postural orientation, impaired functional performance, and muscle weakness, even after rehabilitation is completed. In addition to performance-based tests, patient-reported outcome measures (PROMS) may be used to measure the patient’s perceived functional abilities. A correlation worth evaluating is the potential association between postural orientation errors (POE) and future PROMs. Aim: The aim of this study was to investigate the association between the POEs seen in functional tests 6 months after reconstructive ACL-surgery (ACLR), and the perceived functional abilities 2 years later. Study Design: The study is a longitudinal, observational study. Methods: The study included 21 participants, 7 women and 14 men, who had undergone an ACL-reconstruction. POEs were visually evaluated while the participants performed 5 functional tasks approximately 6 months post-surgery. The tasks were scored segmentspecifically from 0-3, where 0 indicates no postural orientation errors and 3 higher level of POE. The tasks were divided into subscale Activity of Daily Living (ADL) and subscale Sport, and POE was calculated for each subscale, as well as total score for all tasks. PROMquestionnaires were sent out 2 years later. Spearman’s rank coefficient (rs) was used to determine any association. Result: The strongest association was observed between the POE subscale Sport and the PROM ACL-Quality of Life subscale Sport (rs= -0.576, p=0.006). In addition, significant moderate associations were observed in 6 of the other correlations between the different POE scores and PROMs (rs=-0.435 to -0.490, p<0.05). Conclusion: Assessment of POEs after ACLR may be used to indicate future perceived functional abilities, as this study shows associations between POEs after 6 months and future PROMs (2 years). This suggests that assessme

OBJECTIVES: To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool - a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes. DESIGN: Prospective cohort. PARTICIPANTS: 43 nonprofessional pivoting sport athletes with ACLR. MAIN OUTCOME: Clinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes' beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability). RESULTS: The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1-1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely). CONCLUSION: The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.

Objective: The retrospective investigation was carried out to assess whether subjects who fulfilled our proposed recruitment criteria responded more favorably to anterior cruciate ligament reconstruction (ACLR) than those who did not. Methods: We retrospectively analyzed 109 skeletally mature subjects (78 men and 31 women) according to the following proposed criteria of recruitment: (1) pre-injury Tegner activity score ≥7 and a wish to return to a professional sports activity, (2) residual knee instability following injury and/or (3) age <20 years at the operation. The primary outcome was an improvement between assessment A (before operation) and B (mean follow-up of 1.6 years) in the average score for four of the five Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, difficulty in sports and recreational activities, and quality of life (KOOS4). Results: The proposed recruitment criteria for ACLR were met by 58 subjects (53%). There were 49 subjects (45%) who improved between assessment A and B. Subjects who met proposed recruitment criteria were more likely to improve clinically after ACLR (OR 5.7, 95% CI 2.5-13.3). Conclusions: Fulfillment of proposed recruitment criteria was a strong predictive factor for outcome improvement in short- to medium-term follow-up after ACLR. Level of evidence: Case-control study. Level of evidence 3.

Objective: The retrospective investigation was carried out to assess whether subjects who fulfilled our proposed recruitment criteria responded more favorably to anterior cruciate ligament reconstruction (ACLR) than those who did not. Methods: We retrospectively analyzed 109 skeletally mature subjects (78 men and 31 women) according to the following proposed criteria of recruitment: (1) pre-injury Tegner activity score ≥7 and a wish to return to a professional sports activity, (2) residual knee instability following injury and/or (3) age <20 years at the operation. The primary outcome was an improvement between assessment A (before operation) and B (mean follow-up of 1.6 years) in the average score for four of the five Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, difficulty in sports and recreational activities, and quality of life (KOOS4). Results: The proposed recruitment criteria for ACLR were met by 58 subjects (53%). There were 49 subjects (45%) who improved between assessment A and B. Subjects who met proposed recruitment criteria were more likely to improve clinically after ACLR (OR 5.7, 95% CI 2.5-13.3). Conclusions: Fulfillment of proposed recruitment criteria was a strong predictive factor for outcome improvement in short- to medium-term follow-up after ACLR. Level of evidence: Case-control study. Level of evidence 3.

OBJECTIVES: To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool - a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes. DESIGN: Prospective cohort. PARTICIPANTS: 43 nonprofessional pivoting sport athletes with ACLR. MAIN OUTCOME: Clinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes' beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability). RESULTS: The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1-1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely). CONCLUSION: The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.

OBJECTIVES: To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool - a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes. DESIGN: Prospective cohort. PARTICIPANTS: 43 nonprofessional pivoting sport athletes with ACLR. MAIN OUTCOME: Clinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes' beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability). RESULTS: The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1-1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely). CONCLUSION: The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.