ACL injury from childhood to adult life
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Despite the humble anterior cruciate ligament (ACL) tear being one of the most common injuries in sports medicine, it is somewhat disappointing to review the literature on its long-term outcomes. There is little known about the impact of the injury itself in terms of long-term arthritis development or functional and quality-of-life scores, let alone the likely outcome of the various treatment options. While there is much focus on the paediatric reconstructive options in acute knee injury and the potential effects on return to play and growth plate disturbance, the longer-term outcomes following these injuries do not receive the same amount of attention. We were therefore delighted, here at 360, to read this paper from Oslo (Norway), which reports on a series of 44 patients, all of whom sustained an ACL injury before their 13th birthday.1 Patients were followed up to an average of eight years following injury and were treated with rehabilitation and, if necessary, a delayed reconstruction. Patients were evaluated with a range of clinical and patient-reported outcome measures (PROMs) including the hop tests, isokinetic muscle strength, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the International Knee Documentation Committee (IKDC) Subjective Knee Form, supplemented with clinical examination. In terms of the need for reconstruction, just over half of the patients (n = 24) had opted to undergo ACL reconstruction during the study follow-up period. The functional results were good for the cohort, with > 90% symmetry seen in hop tests; 68% achieved relative symmetry in muscle strength testing. There were no overall differences in either of the recorded PROMs; however, although over 90% of patients remained playing sports, two-thirds had restricted their activity.
Return to sports after in situ arthroscopic repair of partial rotator cuff tears
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Partial-thickness rotator cuff tears resulting in pain and loss of function are common in athletes, but the preferred treatment strategies remain controversial. In this population, while conservative management remains the consensus for initial treatment, failure leads to a progressive tear and results in some surgeons advocating the repair of the tear in situ (preserving intact tendon). Others support completing the tear with a subsequent primary repair. A study team from Buenos Aires (Argentina) retrospectively evaluated and reported the outcomes of 72 patients who had undergone arthroscopic in situ repair of partial-thickness rotator cuff tears that had failed conservative management.2 Outcomes reported included return to sport, range of movement, American Shoulder and Elbow Surgeons (ASES) score, visual analogue scale for pain, and complications. Mean age and follow-up were 42.2 years and 54 months, respectively. In total, 87% of patients returned to sports at a mean of 5.6 months, with 80% returning at the same level as prior to injury. Active range of movement, visual analogue scale (VAS) pain score, and ASES score improved significantly. No differences were identified between articular and bursal partial-thickness tears. These results demonstrated significant improvement and return to sports in this young population with partial-thickness rotator cuff tears after in situ repair, but no control was used for comparison. Therefore, while in situ repair demonstrates good outcomes in this population, superiority to tear completion with primary repair remains controversial and is not demonstrated by this investigation. Further comparative studies are needed to answer the question of whether in situ repair or tear completion with primary repair is superior for athletes with partial-thickness rotator cuff tears.
The shape of your plateau and ACL reconstruction outcomes
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This paper from Boston, Massachusetts (USA) examines the potential contribution of other factors to outcomes following anterior cruciate ligament (ACL) reconstruction – namely, in this case, the anatomical geometry of the tibial plateau.3 The authors hypothesized that there are a range of anatomical factors that will impact on the success, or otherwise, of an ACL reconstruction. These included the presence of a narrow femoral notch, increased posterior and coronal slopes, and decreased plateau concavity as predictors of poor outcomes. This series of 44 patients, all of whom had unilateral ACL reconstruction, were followed-up for seven years after surgery. Their plateau geometry in terms of notch width (after notchplasty), posterior slopes of the medial and lateral tibial plateau, maximum depth of the medial tibial plateau, and coronal tibial slope were measured from standardized MRIs. These were then correlated to the outcomes of interest (namely anteroposterior laxity and the Knee Injury and Osteoarthritis Outcome Score (KOOS)). Despite the relatively small number of patients in this series, the authors were able to draw some useful conclusions. Those patients with increased posterior slope had increased variations in knee laxity between the reconstructed and native side. This was also reflected in differences in the KOOS and Osteoarthritis Research Society International (OARSI) scores. A similar pattern was seen in patients with increased coronal slope and decreased medial tibial depth. These were the only factors that appeared to be associated with outcomes, and notch width (despite the attention paid to it in the literature) was not related to outcome in this series.
The 11+ Kids injury prevention programme
As children play more sports and suffer the associated injuries that can be expected in an immature skeleton, there has been a greater focus on injury prevention programmes in children. As the age-old adage goes, prevention is better than cure – but is it always cheaper? Investigators in Basel (Switzerland) set out to establish whether the potential reduction in injury-related healthcare costs offset the financial implications of the '11+ Kids' injury prevention programme.4 They compared the intervention against the usual warm-up in children’s football, and a cost-effectiveness analysis was undertaken as part of a cluster randomized controlled trial. The investigators had access to a range of data from the trial including injuries, healthcare resource use, and football exposure hours. Direct healthcare costs were calculated in Swiss Francs (CHF) per 1000 hours of football; this was then used to establish the potential cost-effectiveness based on both the trial itself and the prediction of a national implementation. The financial costs were calculated based on the 1002 players who participated in the study, with a mean age of 10.9 years (sd 1.2). The study observed 76 373 hours of football, during which 99 injuries occurred. The overall costs were lower in the intervention group than in the conservative group (CHF469 versus CHF228). The financial model suggested that the national implementation of the 11+ Kids programme would reduce healthcare costs in Switzerland by CHF1.48 million per year. Clearly, this is another case in which prevention is indeed better than cure.
References
1. Ekås GR , Moksnes H , Grindem H , Risberg MA , Engebretsen L . Coping with anterior cruciate ligament injury from childhood to maturation: a prospective case series of 44 patients with mean 8 years’ follow-up. Am J Sports Med2019;47:22-30. Google Scholar
2. Rossi LA , Atala N , Bertona A et al. . Return to sports after in situ arthroscopic repair of partial rotator cuff tears. Arthroscopy2019;35:32-37.CrossrefPubMed Google Scholar
3. Kiapour AM , Yang DS , Badger GJ et al. . Anatomic features of the tibial plateau predict outcomes of ACL reconstruction within 7 years after surgery. Am J Sports Med2019;47:303-311CrossrefPubMed Google Scholar
4. Rössler R , Verhagen E , Rommers N et al. . Comparison of the '11+ Kids' injury prevention programme and a regular warmup in children's football (soccer): a cost effectiveness analysis. Br J Sports Med2019;53:309-314.CrossrefPubMed Google Scholar
