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ACL Injury: Difference between revisions
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==Classification== | ==Classification== | ||
[[File:diagram-classification-of-acl-avulsion-fractures-1.jpg|thumb|right|300px|Type 1 - minimally/non-displaced fragment | [[File:diagram-classification-of-acl-avulsion-fractures-1.jpg|thumb|right|300px| | ||
Type 2 - anterior elevation of the fragment | * Type 1 - minimally/non-displaced fragment | ||
Type 3 - complete seperation of the fragment. 3b - Involves the majority of the eminence. | * Type 2 - anterior elevation of the fragment | ||
Type 4 - comminuted avulsion or a rotation of the fragment.]] | * Type 3 - complete seperation of the fragment. 3b - Involves the majority of the eminence. | ||
* Type 4 - comminuted avulsion or a rotation of the fragment. | |||
]] | |||
The most commonly used classification is from Zarincznyj in 1997, which was modified from Meyers and McKeevers in 1959. Under this system, injuries are classified into four types. | The most commonly used classification is from Zarincznyj in 1997, which was modified from Meyers and McKeevers in 1959. Under this system, injuries are classified into four types. | ||
==ACL Surgery== | == Assessment == | ||
{| class="wikitable" | |||
!Test | |||
!Sens | |||
!Spec | |||
!LR + | |||
!LR - | |||
!Kappa | |||
|- | |||
|Lachman's Test<ref>Cooperman JM, Riddle DL, Rothstein JM. Reliability and validity of judgments of the integrity of the anterior cruciate ligament of the knee using the Lachman’s test. Phys Ther. 1990;70:225-233.</ref><ref name=":0">Van Eck CF, van den Bekerom MPJ, Fu FH, et al. Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surg Sports Traumatol Arthrosc. 2013;21(8):1895-1903.</ref> | |||
|81% | |||
|81% | |||
|4.26 | |||
|0.24 | |||
|0.19 | |||
|- | |||
|Prone Lachman's Test<ref>Mulligan EP, Harwell JL, Robertson WJ. Reliability and diagnostic accuracy of the Lachman test performed in a prone position. J Orthop Sports Phys Ther. 2011;41(10):749-757.</ref> | |||
|70% | |||
|80% | |||
|3.5 | |||
|0.57 | |||
|0.6 | |||
|- | |||
|Anterior Drawer<ref name=":0" /><ref>Wood L, Peat G, Wilkie R, et al. A study of the noninstrumented physical examination of the knee found high observer variability. J Clin Epidemiol. 2006;59:512-520.</ref> | |||
|38% | |||
|81% | |||
|2.0 | |||
|0.77 | |||
|0.34 | |||
|- | |||
|Pivot Shift Test<ref name=":0" /> | |||
|28% | |||
|81% | |||
|1.47 | |||
|0.89 | |||
| | |||
|- | |||
|Loss of Extension Test | |||
|78% | |||
|95% | |||
|15.6 | |||
|0.23 | |||
| | |||
|} | |||
== Management == | |||
===ACL Surgery=== | |||
Once torn, it doesn’t heal. Reconstruction does not make it normal – posttraumatic osteoarthritis can occur regardless of management | Once torn, it doesn’t heal. Reconstruction does not make it normal – posttraumatic osteoarthritis can occur regardless of management | ||
===Surgical vs non-surgical management=== | ====Surgical vs non-surgical management==== | ||
*RCT of 121 “young active adults” | *RCT of 121 “young active adults” | ||
*Rehab (plus delayed surgery if needed) vs rehab plus early surgery | *Rehab (plus delayed surgery if needed) vs rehab plus early surgery | ||
*5 year follow up: no differences in ability to return to sport, knee function, or rate of meniscal injury | *5 year follow up: no differences in ability to return to sport, knee function, or rate of meniscal injury | ||
*50% crossover (50% in rehab group crossed over to surgery) | *50% crossover (50% in rehab group crossed over to surgery) | ||
*Take-away: 50% can be managed non-operatively | *Take-away: 50% can be managed non-operatively<ref>Frobel R et al, Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial | ||
BMJ 2013;346:f232</ref> | |||
*In my opinion we don’t know if those other 50% eventually managed operatively would have better outcomes than sham surgery | *In my opinion we don’t know if those other 50% eventually managed operatively would have better outcomes than sham surgery | ||
===Subsequent OA and Meniscal Tears=== | ====Subsequent OA and Meniscal Tears==== | ||
*Metanalysis 2019, comparing surgery vs non-surgical treatment with 10 year follow up | *Metanalysis 2019, comparing surgery vs non-surgical treatment with 10 year follow up | ||
*Patient reported outcomes the same | *Patient reported outcomes the same | ||
| Line 27: | Line 74: | ||
*Lower rate of secondary meniscal injury and meniscal surgery | *Lower rate of secondary meniscal injury and meniscal surgery | ||
*Reduced laxity | *Reduced laxity | ||
*Significant methodological flaws in the included studies and heterogeneity | *Significant methodological flaws in the included studies and heterogeneity<ref>Lien-Iversen, T., Morgan, D. B., Jensen, C., Risberg, M. A., Engebretsen, L., & Viberg, B. (2019). Does surgery reduce knee osteoarthritis, meniscal injury and subsequent complications compared with non-surgery after ACL rupture with at least 10 years follow-up? A systematic review and meta-analysis. British Journal of Sports Medicine, bjsports–2019–100765. </ref> | ||
===Copers vs non-copers=== | ====Copers vs non-copers==== | ||
*Copers – use neuro-musculo-skeletal strategies to dynamically stabilise their ACL-deficient knee even with pivoting | *Copers – use neuro-musculo-skeletal strategies to dynamically stabilise their ACL-deficient knee even with pivoting | ||
*Non-copers – knee instability, higher rates of surgery | *Non-copers – knee instability, higher rates of surgery | ||
*Not possible to classify this early on | *Not possible to classify this early on | ||
*in one study 70% of those initially classified as non-copers, were copers after 1 year of non-operative management. And only 60% of potential copers were true copers. | *in one study 70% of those initially classified as non-copers, were copers after 1 year of non-operative management. And only 60% of potential copers were true copers.<ref>Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2008). Individuals With an Anterior Cruciate Ligament-Deficient Knee Classified as Noncopers May Be Candidates for Nonsurgical Rehabilitation. Journal of Orthopaedic & Sports Physical Therapy, 38(10), 586–595. doi:10.2519/jospt.2008.2750 </ref> | ||
===ACL Reconstruction=== | ====ACL Reconstruction==== | ||
*Indications?? | *Indications?? | ||
**Recurrent instability | **Recurrent instability | ||
| Line 46: | Line 92: | ||
*Delay surgery until normal range of motion, effusion largely resolved and able to walk comfortably (to reduce risk of athrofibrosis i.e. stiffness) | *Delay surgery until normal range of motion, effusion largely resolved and able to walk comfortably (to reduce risk of athrofibrosis i.e. stiffness) | ||
===ACL Graft Selection=== | ====ACL Graft Selection==== | ||
*Bone-Patella-Bone | *Bone-Patella-Bone | ||
**possible earlier graft fixation and stability due to included portion of bone | **possible earlier graft fixation and stability due to included portion of bone | ||
| Line 57: | Line 103: | ||
*Other: Allografts, quadriceps graft, | *Other: Allografts, quadriceps graft, | ||
===ACL Postoperative=== | ====ACL Postoperative==== | ||
Graft re-rupture (from surgical failure or re-trauma) | * Graft re-rupture (from surgical failure or re-trauma) | ||
Outcomes worse for revision ACL repair | * Outcomes worse for revision ACL repair | ||
Increased risk tear contralateral knee – 7% cumulative incidence | * Increased risk tear contralateral knee – 7% cumulative incidence | ||
5770 reconstructed knees – 60% returned to pre-injury level, and 44% returned to competitive sport. | * 5770 reconstructed knees – 60% returned to pre-injury level, and 44% returned to competitive sport. | ||
Professional players – 90% return to play by 12 months, sensible?? Shorter careers. | * Professional players – 90% return to play by 12 months, sensible?? Shorter careers.<ref> Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 2011;45:596-606.</ref> | ||
==Unknown Unknowns== | ==Unknown Unknowns== | ||
*Cultural norms in professional sport and other areas | *Cultural norms in professional sport and other areas | ||
*?Uncertainty of non-operative treatment | *?Uncertainty of non-operative treatment | ||
| Line 72: | Line 117: | ||
*ACL-deficient sport ?future meniscal and cartilage injury | *ACL-deficient sport ?future meniscal and cartilage injury | ||
*What is success, return to pivoting sport? What is in the athlete’s best interest? | *What is success, return to pivoting sport? What is in the athlete’s best interest? | ||
*“Doing nothing” is hard | *“Doing nothing” is hard<ref>Weiler, R. (2015). Unknown unknowns and lessons from non-operative rehabilitation and return to play of a complete anterior cruciate ligament injury in English Premier League football. British Journal of Sports Medicine, 50(5), 261–262. doi:10.1136/bjsports-2015-095141</ref> | ||
==Rehabilitation for Athletes== | ==Rehabilitation for Athletes== | ||
#Protection and controlled mobilisation | #Protection and controlled mobilisation | ||
#Controlled training | #Controlled training | ||
#More intensive training | #More intensive training | ||
#Return to play (many months) | #Return to play (many months)<ref>Bizzini, M., Hancock, D., & Impellizzeri, F. (2012). Suggestions From the Field for Return to Sports Participation Following Anterior Cruciate Ligament Reconstruction: Soccer. Journal of Orthopaedic & Sports Physical Therapy, 42(4), 304–312. doi:10.2519/jospt.2012.4005 </ref> | ||
==References== | ==References== | ||
Revision as of 18:02, 22 July 2021
This article is still missing information.
Classification
The most commonly used classification is from Zarincznyj in 1997, which was modified from Meyers and McKeevers in 1959. Under this system, injuries are classified into four types.
Assessment
| Test | Sens | Spec | LR + | LR - | Kappa |
|---|---|---|---|---|---|
| Lachman's Test[1][2] | 81% | 81% | 4.26 | 0.24 | 0.19 |
| Prone Lachman's Test[3] | 70% | 80% | 3.5 | 0.57 | 0.6 |
| Anterior Drawer[2][4] | 38% | 81% | 2.0 | 0.77 | 0.34 |
| Pivot Shift Test[2] | 28% | 81% | 1.47 | 0.89 | |
| Loss of Extension Test | 78% | 95% | 15.6 | 0.23 |
Management
ACL Surgery
Once torn, it doesn’t heal. Reconstruction does not make it normal – posttraumatic osteoarthritis can occur regardless of management
Surgical vs non-surgical management
- RCT of 121 “young active adults”
- Rehab (plus delayed surgery if needed) vs rehab plus early surgery
- 5 year follow up: no differences in ability to return to sport, knee function, or rate of meniscal injury
- 50% crossover (50% in rehab group crossed over to surgery)
- Take-away: 50% can be managed non-operatively[5]
- In my opinion we don’t know if those other 50% eventually managed operatively would have better outcomes than sham surgery
Subsequent OA and Meniscal Tears
- Metanalysis 2019, comparing surgery vs non-surgical treatment with 10 year follow up
- Patient reported outcomes the same
- Higher rate of radiographic knee OA
- Lower rate of secondary meniscal injury and meniscal surgery
- Reduced laxity
- Significant methodological flaws in the included studies and heterogeneity[6]
Copers vs non-copers
- Copers – use neuro-musculo-skeletal strategies to dynamically stabilise their ACL-deficient knee even with pivoting
- Non-copers – knee instability, higher rates of surgery
- Not possible to classify this early on
- in one study 70% of those initially classified as non-copers, were copers after 1 year of non-operative management. And only 60% of potential copers were true copers.[7]
ACL Reconstruction
- Indications??
- Recurrent instability
- Associated tear when amenable to repair
- Associated ligament injury especially posterolateral corner
- Professional and elite players
- High-risk occupation (where instability could cause harm)
- ?Adolescents, risk of instability, ?protect against future meniscal and chondral damage.
- Delay surgery until normal range of motion, effusion largely resolved and able to walk comfortably (to reduce risk of athrofibrosis i.e. stiffness)
ACL Graft Selection
- Bone-Patella-Bone
- possible earlier graft fixation and stability due to included portion of bone
- anterior knee pain up to 1 year
- possible higher rate of OA.
- Hamstring
- Initial fixation may be slower and weaker (no bone), but quadruple strand is stronger than B-P-B
- Donor site pain resolves by 3 months
- hamstring strength normal by 12 months.
- Other: Allografts, quadriceps graft,
ACL Postoperative
- Graft re-rupture (from surgical failure or re-trauma)
- Outcomes worse for revision ACL repair
- Increased risk tear contralateral knee – 7% cumulative incidence
- 5770 reconstructed knees – 60% returned to pre-injury level, and 44% returned to competitive sport.
- Professional players – 90% return to play by 12 months, sensible?? Shorter careers.[8]
Unknown Unknowns
- Cultural norms in professional sport and other areas
- ?Uncertainty of non-operative treatment
- Loss of option of early ACL repair
- ACL-deficient sport ?future meniscal and cartilage injury
- What is success, return to pivoting sport? What is in the athlete’s best interest?
- “Doing nothing” is hard[9]
Rehabilitation for Athletes
- Protection and controlled mobilisation
- Controlled training
- More intensive training
- Return to play (many months)[10]
References
- ↑ Cooperman JM, Riddle DL, Rothstein JM. Reliability and validity of judgments of the integrity of the anterior cruciate ligament of the knee using the Lachman’s test. Phys Ther. 1990;70:225-233.
- ↑ 2.0 2.1 2.2 Van Eck CF, van den Bekerom MPJ, Fu FH, et al. Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surg Sports Traumatol Arthrosc. 2013;21(8):1895-1903.
- ↑ Mulligan EP, Harwell JL, Robertson WJ. Reliability and diagnostic accuracy of the Lachman test performed in a prone position. J Orthop Sports Phys Ther. 2011;41(10):749-757.
- ↑ Wood L, Peat G, Wilkie R, et al. A study of the noninstrumented physical examination of the knee found high observer variability. J Clin Epidemiol. 2006;59:512-520.
- ↑ Frobel R et al, Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial BMJ 2013;346:f232
- ↑ Lien-Iversen, T., Morgan, D. B., Jensen, C., Risberg, M. A., Engebretsen, L., & Viberg, B. (2019). Does surgery reduce knee osteoarthritis, meniscal injury and subsequent complications compared with non-surgery after ACL rupture with at least 10 years follow-up? A systematic review and meta-analysis. British Journal of Sports Medicine, bjsports–2019–100765.
- ↑ Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2008). Individuals With an Anterior Cruciate Ligament-Deficient Knee Classified as Noncopers May Be Candidates for Nonsurgical Rehabilitation. Journal of Orthopaedic & Sports Physical Therapy, 38(10), 586–595. doi:10.2519/jospt.2008.2750
- ↑ Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 2011;45:596-606.
- ↑ Weiler, R. (2015). Unknown unknowns and lessons from non-operative rehabilitation and return to play of a complete anterior cruciate ligament injury in English Premier League football. British Journal of Sports Medicine, 50(5), 261–262. doi:10.1136/bjsports-2015-095141
- ↑ Bizzini, M., Hancock, D., & Impellizzeri, F. (2012). Suggestions From the Field for Return to Sports Participation Following Anterior Cruciate Ligament Reconstruction: Soccer. Journal of Orthopaedic & Sports Physical Therapy, 42(4), 304–312. doi:10.2519/jospt.2012.4005
Literature Review
Literature Review
- Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf
- Articles from all years: PubMed search, Google Scholar search.
- TRIP Database: clinical publications about evidence-based medicine.
- Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,
