Ligament Laxity Leads To Worse ACL Reconstruction Outcomes

I was involved with a recent MOON (Multi-center Orthopaedic Outcomes Network) study that demonstrates that patients with loose ligaments and hyperextension have worse results and more frequent graft failures. Read details HERE

MOON-MARS Revision ACL Graft Study Presented Toronto AOSSM Meeting

A combined MOON (Multi-Center Orthopaedic Outcomes Network)- MARS (Multi-Center ACL Revision Study) looked at patellofemoral (kneecap) cartilage changes after allograft or autograft primary ACL reconstruction as identified at the time of revision ACL reconstruction. This study presented by Robert Magnussen of Ohio St. at the Toronto AOSSM (American Orthopaedic Society for Sports Medicine) meeting in July. 134 patients had undergone MOON primary ACL reconstruction followed by MARS revision ACL reconstruction. Progression was identified as progression of one grade worse or a 25% increase in size of the lesion. 31 (23%) had worsening progression of arthritis. Results showed allografts had a 15.5 times higher risk of progression. Odds also increased 10% with each unit increase of BMI. Age, sex, activity level, meniscus status, injury mechanism had no impact. The association between graft choice and damage was surprising. Previously it was thought maybe a patellar tendon (BTB) autograft might be at more riskk. Allografts with more laxity may place more pressure on cartilage, but we cannot be sure. Further work will be necessary to sort this out.

MOON ACL Reconstruction Award Winning Study

At the AOSSM Annual Meeting the 10 year outcomes for the MOON Group were presented by Kurt Spindler MD. The study won the AOSSM O'Donoghue Award for best clinical study for 2017. The MOON Group is a 7 site study focusing on primary ACL reconstructions. 

Findings in this study of 1592 ACL reconstructions with 83% follow up showed several factors impacting the IKDC and KOOS Sports and Recreation and KOOS Quality of Life with worse scores. These included: Grade 3 and 4 cartilage wear in any compartment, previous medial meniscectomy, revision ACL reconstruction, higher BMI, smoking, reoperation or subsequent surgery and lower baseline scores. Factors not predicting worse scores included surgeon, medial and lateral meniscus surgery, sport played, graft chosen, MCL or LCL injury or higher laxity.

Factors that predicted worse Marx score can be seen in this slide. These findings can be used to better predict outcome and counsel patients as to expectations for ACL reconstruction.

ACL Reconstruction Rehabilitation Part 3

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the

MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We based the protocol on a series of Systematic Reviews we performed to establish the evidence for best practice ACL rehabilitation. Previously we discussed the first 2 reviews. Here we will review the findings in our 3rd review which was an update of the original 2. It can be found HERE. In this study we discussed an additional study evaluating the use of Continuous Passive Motion machines which once again showed no advantage. Several additional studies had been published evaluating bracing and none demonstrated any advantage in the postoperative rehabilitation period. Additional studies evaluated early ROM and quad strengthening without any increase in laxity. Eccentric strengthening was safe and showed improved strength gains compared to concentric strengthening when initiated at 3 weeks and continuing for 12 weeks. Accelerated rehab shortening to 5 months the recovery did not result in worse outcomes  or safety issues. Additional electrical stimulation studies showed safety, but no significant efficacy in ACL rehabilitation.

Most additional studies performed since our last review reiterated our additional findings. I will be presenting specific findings for revision ACL reconstruction rehabilitation at the July 2016 American Orthopaedic Society for Sports Medicine and we will blog those results when available next week.

ACL Reconstruction Rehabilitation Part 2

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the
MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We published the systematic review evidence we based the protocol on in 3 separate studies. in Part 1 I reviewed the findings in our first publication. The second publication can be found HERE. Findings in this study included a review of open (isokinetic) vs. closed chain exercises. Closed chain exercises occur when the foot is planted on the floor or on a firm surface such as a leg press machine. These type of exercises may be more protective for the healing ACL graft,  but it appears open chain exercises are safe 6 weeks after ACL reconstruction.

Neuromuscular stimulation has been extensively studied utilizing a variety of parameters and has not been shown to be critically important. It is safe and can be utilized at the therapist's discretion most commonly when the patient is struggling to recruit the quadriceps muscle for strengthening.

Accelerated rehabilitation has gained much attention, but there remains little evidence that it can be truly lowered below the 4 month time frame safely. One randomized study looked at 8 vs. 5 months and found no problems with this length of rehabilitation, but to many of us this doesn't represent significant acceleration. Future research will be necessary to address this further.

Water exercise may decrease swelling and appears to be safe. Slide board exercises can be incorporated at 6 weeks without harm. Stair climber is as safe as stationary cycling at 4 weeks.

Additional principles will be reviewed in Part 3 reviewing our 3rd study evaluating ACL rehab PT

Meniscus Repair 2

The role of the meniscus in cushioning the joint and protecting the articular cartilage makes preserving them a key part of knee health. For a meniscus tear unfortunately meniscectomy (removing the torn portion) is the appropriate treatment 90% of the time. This is because in most situations a repair will not be successful. The reasons repair is not attempted is due to the lack of blood supply in 1/3-1/2 of the meniscus that precludes healing of a repair. Additionally, if the configuration of the tear is not appropriate then repair is not possible. In the 10% of situations when repair is possible it is typically highly successful in the short term with > 90% success without reoperation within the first 2 years. Our ability to predict ahead of time whether or not repair will be possible has been evaluated. In a study performed in conjunction with my partners and published in  the American Journal of Sports medicine we found we were able to predict the chance to repair a meniscus 74% of the time. This makes it easier to tell patients what to expect after surgery regarding recovery and rehabilitation. Read the Abstract HERE.

We evaluated the MOON meniscus repair results at 2 years in a study published in the American Journal of Sports Medicine and found that in 82 tears of which we were able to obtain follow up on 77 (94%) there was a success rate of 96% with no further surgery required for the meniscus within the first 2 years following repair in 74 of the 77 repairs. Read the full study HERE. In future blogs I will discuss the longer results we have noted at 5 years or more following meniscus repair.

Sports and ACL Injuries

This blog was created to provide patients with information regarding sports injuries, their treatment and outcomes. I hope to provide more detailed information than can be readily found on the internet. It will highlight research findings from my own work as well as my Sports Division at Washington University. Additionally I will feature research findings coming from our work as part of the Mult-center Orthopaedic Outcomes Network (MOON) and the Multi-center ACL Revision Study (MARS). There will be posts on all anatomical areas and conditions seen in sports injuries. I look forward to your comments and ideas to improve the blog.