Beneficial and limiting factors for return to work following anterior cruciate ligament reconstruction: a retrospective cohort study

PurposeEvidence-based advice for return to work (RTW) after anterior cruciate ligament (ACL) reconstruction is not available. Therefore, the objectives of this study were to determine when patients achieve full RTW, and to explore the beneficial and limiting factors for fully RTW after ACL reconstruction.MethodsA retrospective cohort study was performed after ACL reconstruction among 185 patients in one hospital. Data from patient files and a questionnaire were used to explore whether patient-, injury-, surgery-, sports-, work- and rehabilitation-related factors are beneficial or limiting for fully RTW after ACL reconstruction, using a backward stepwise logistic regression analysis.ResultsOf the 125 (68%) patients that returned the questionnaire, 36 were not part of the working population. Of the remaining 89 patients, 82 patients (92%) had returned fully to work at follow-up. The median time to fully RTW was 78 days. In the final regression model, which explained 29% of the variance, a significant OR of 5.4 (90% CI 2.2–13.1) for RTW > 78 days was observed for patients performing heavy knee-demanding work compared to patients performing light knee-demanding work. In addition, a significant and positive OR (1.6, 90% CI 1.2–1.9) for the number of weeks walking with the aid of crutches for RTW > 78 days was observed in the final model.ConclusionAfter ACL reconstruction, 92% of the patients fully return to work at a median time of 78 days. The significant predictors for fully RTW > 78 days are performing heavy knee-demanding work and a longer period of walking aided with crutches after ACL reconstruction.

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title: Computer assisted surgery for knee ligament reconstruction (Protocol)
abstract: This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: 
To assess the effects of computer assisted reconstruction surgery versus conventional operating techniques for ACL or PCL deficient knees in adults. 
 
We will test these effects according to the following specific subgroups: 
1. System used for CAS (e.g. per-operative use of X-rays, pre-operative use of radiology (CT, MRI, X-rays), per-operative landmarks or bone morphing). 
2. Type of ligament reconstruction: ACL or PCL, or both.

title: Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary.
abstract: Anterior Cruciate ligament (ACL) injuries are one of the most common and devastating knee injuries sustained whilst participating in sport. ACL reconstruction (ACLR) remains the standard approach for athletes who aim to return to high level sporting activities but the outcome from surgery is not assured. Secondary morbidities and an inability to return to the same competitive level are common following ACLR. One factor which might be linked to these sub-optimal outcomes may be a failure to have clearly defined performance criteria for return to activity and sport. This paper presents a commentary describing a structured return to sport rehabilitation protocol for athletes following ACLR. The protocol was developed from synthesis of the available literature and consensus of physiotherapists and strength and conditioning coaches based in the home country Institute of Sports within the United Kingdom.

title: Graft selection for anterior cruciate ligament reconstruction: a level I systematic review comparing failure rates and functional outcomes.
abstract: Tear of the anterior cruciate ligament (ACL) is the most common ligamentous injury of the knee. Reconstructing this ligament is often required to restore functional stability of the knee. Many graft options are available for ACL reconstruction, including different autograft and allograft tissues. Autografts include bone-patellar tendon-bone composites (PT), combined semitendinosus and gracilis hamstring tendons (HT), and quadriceps tendon. Allograft options include the same types of tendons harvested from donors, in addition to Achilles and tibialis tendons. Tissue-engineered anterior cruciate grafts are not yet available for clinical use, but may become a feasible alternative in the future. The purpose of this systematic review is to assess whether one of the popular grafts (PT and HT) is preferable for reconstructing the ACL. For this objective, the authors selected only true level I studies that compared these graft choices in functional clinical outcomes, failure rates, and other objective parameters following reconstruction of the ACL. In addition, this review discusses mechanical considerations related to different allograft tissues.

title: Tensile properties of the medial patellofemoral ligament: the effect of specimen orientation.
abstract: For recurrent patellar dislocation, reconstruction of the medial patellofemoral ligament (MPFL) with replacement autografts has often been performed but with only little data on the tensile properties of the MPFL to guide graft selection. With its complex anatomy and geometry, these properties are difficult to obtain. In this study, we showed how the orientation of the femur-MPFL-patella complex (FMPC) during uniaxial tensile testing can have a significant effect on its structural properties. Twenty two FMPCs were isolated from porcine stifle joints and randomly assigned to two groups of 11 each. For the first group, the specimens were loaded to failure with the patella oriented 30 degrees away from the direction of the applied load to mimic its orientation in situ, called natural orientation. In the second group, the patella was aligned in the direction of the tensile load, called non-natural orientation. The stiffness for the natural orientation group was 65±13 N/mm, 32% higher than that for the non-natural orientation group (50±17 N/mm; p<0.05). The ultimate loads were 438±128 N and 386±136 N, respectively (p>0.05). Ten out of 11 specimens in the natural orientation group failed at the femoral attachment (the narrowest portion of the MPFL) compared to 6 out of 11 in the non-natural orientation group. Our findings suggest that the specimen orientation that mimics the in-situ loading conditions of the MPFL should be used to obtain more representative data for the structural properties of the FMPC.

title: A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen.
abstract: The literature has shown that anterior cruciate ligament (ACL) tear rates vary by gender, by sport, and in response to injury-reduction training programs. However, there is no consensus as to the magnitudes of these tear rates or their variations as a function of these variables. For example, the female-male ACL tear ratio has been reported to be as high as 9:1. Our purpose was to apply meta-analysis to the entire applicable literature to generate accurate estimates of the true incidences of ACL tear as a function of gender, sport, and injury-reduction training.



A PubMed literature search was done to identify all studies dealing with ACL tear incidence. Bibliographic cross-referencing was done to identify additional articles. Meta-analytic principles were applied to generate ACL incidences as a function of gender, sport, and prior injury-reduction training.



Female-male ACL tear incidences ratios were as follows: basketball, 3.5; soccer, 2.67; lacrosse, 1.18; and Alpine skiing, 1.0. The collegiate soccer tear rate was 0.32 for female subjects and 0.12 for male subjects. For basketball, the rates were 0.29 and 0.08, respectively. The rate for recreational Alpine skiers was 0.63, and that for experts was 0.03, with no gender variance. The two volleyball studies had no ACL tears. Training reduced the ACL tear incidence in soccer by 0.24 but did not reduce it at all in basketball.



Female subjects had a roughly 3 times greater incidence of ACL tears in soccer and basketball versus male subjects. Injury-reduction programs were effective for soccer but not basketball. Recreational Alpine skiers had the highest incidences of ACL tear, whereas expert Alpine skiers had the lowest incidences. Volleyball may in fact be a low-risk sport rather than a high-risk sport. Alpine skiers and lacrosse players had no gender difference for ACL tear rate. Year-round female athletes who play soccer and basketball have an ACL tear rate of approximately 5%.

title: Systematic Review: Annual Incidence of ACL Injury and Surgery in Various Populations
abstract: Accurate documentation of injury incidence is critical for study of injury risk factors and prevention. Comparisons of published incidences of anterior cruciate ligament (ACL) injuries and surgical reconstructions are difficult, however, because of the variations in units. Some studies report absolute time-based denominators (such as annual incidence or incidence per 100,000 person years), whereas others report exposure-based denominators (such as incidence per 1,000 player hours or athlete exposures). We converted exposure-based units into annual incidences to compare various studies. National population studies show annual incidence rates of up to 0.05% per person per year in Australia. Professional athletes in basketball, soccer, and the other football codes report an annual incidence of 0.15%–3.7% in studies with at least a moderate sample size. Annual ACL incidence in amateur sporting groups was generally higher than the entire population but lower than among professional athletes. Converting incidence rates to annual units allowed better comparisons to be made between population rates across different studies.

title: The symptomatic anterior cruciate-deficient knee. Part I: the long-term functional disability in athletically active individuals.
abstract: This study reports on the disability of 103 patients with symptomatic chronic laxity of the an tenor cruciate ligament that was uncomplicated by other associated major ligament deficiency or prior lig ament reconstructive procedures. All of the patients were evaluated at an average of 5.5 years after injury but a subgroup of thirty-nine patients was evaluated at an average of 11.2 years after injury. All had been ac tive in sports, with two-thirds participating in high school or college athletics. The diagnosis of a tear of the anterior cruciate ligament was made by the original treating physician in only seven (6.8 per cent) of the 103 knees. Sixty-four patients (62 per cent) stated that the pain that followed the injury restricted normal ac tivities for longer than three weeks. Eighty-five patients (82 per cent) had returned to some form of sports ac tivity. This gave a false initial impression that the in jury was not eventually disabling for sports, as a sig nificant reinjury occurred in thirty-six patients (35 per cent) within six months and in fifty-three patients (51 per cent) within one year after the original injury. At follow-up five years later, only thirty-six patients (35 per cent) were participating in strenuous sports. A significantumber of patients withlonger follow-up had knee symptoms that affected their routine daily and recreational activities. A subjective moderate to severe over-all disability was reported by thirty-two patients (31 per cent) for walking activities alone, by forty-five patients (44 per cent) for over-all routine activities of daily living, and by seventy-seven patients (74 per cent) for turning or twisting sports ac tivities. Pain occurred in thirty-one patients (30 per cent) during walking activities, in forty-eight patients (47 per cent) during recreational activities, and in seventy-one patients (69 per cent) during strenuous sports activities. Twenty-two patients (21 per cent) complained of giving-way during walking activities; thirty-four patients (33 per cent), during recreational sports; and sixty-six patients (65 per cent), during 4 Supported in part by National Institutes of Health Grants AM2I 172 and AM27517 from the Musculoskeletal Disease Program of the National Institute of Arthritis, Diabetes, Digestive and Kidney Dis eases. t Cincinnati Sports Medicine and Orthopaedic Center, 1 Lytle Place, Cincinnati, Ohio 45202. @ Department ofOrthopaedic Surgery, Hospital ofthe University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. Â§Department of OrthopaedicSurgery,Universityof Pittsburgh, Pittsburgh, Pennsylvania 15213. strenuous sports. Joint swelling occurred four to five times as frequently in the patients who had had the in jury for the longest time (average, 11.2 years). If the patient had had a meniscectomy, there was a statisti cally significant twofold to fourfold increase in symp toms of pain and swelling related to activity. Giving way was not affected, as this is related to instability of the anterior cruciate ligament. Significant roentgeno graphic changes of arthritis were noted in nineteen (21 per cent) of ninety-one patients starting at an average of 109 months after injury. Seventeen patients (44 per cent) in the subset with the longest follow-up had sig nificant roentgenographic changes. These changes cor related statistically with participation in strenuous sports activities, with running activities, and with giving-way. Important qualifications to this retrospective study are: (1) the patients studied were limited to those with tears of the anterior cruciate ligament who sought treatment for relief of their symptoms, (2) these pa tients continued to be active athletically and thus con tinued to abuse their knees, and (3) none of the patients had had proper initial treatment, rehabilitation, or counseling which might have prevented joint deterio ration. As a whole, the results show the significant functional disability found in the patient with a symp tomatic anterior cruciate-deficient knee, initially for sports activities but later, following reinjury, for meniscal damage, joint arthritis, and the activities of daily living. A dilemma still exists concerning the proper treat ment of a knee with a deficient anterior cruciate ligament, largely because of a lack of knowledge of the extent of the functional disability caused by such an injury'5'8'9â€•2â€•@ 21.23.25.27 Our goal was to study a sufficient number of pa tients whose knees demonstrated anterior cruciate laxity alone, without the superimposed variables introduced by previous operative procedures or complicated by other types of ligament instability. The study group also had to contain a sufficient number of patients whose injuries had been sustained at least five years and ten years previously, to allow statistical evaluation of long-term disability. Of importance in this study, as contrasted to many prior studies, is the rigorous grading of symptoms and their severity as related to the specific type of activity during which they occurred. 154 THE JOURNAL OF BONE AND JOINT SURGERY on December 4, 2006 www.ejbjs.org Downloaded from THE SYMPTOMATIC ANTERIOR CRUCIATE-DEFICIENT KNEE 155 years earlier (range, three months to 33.3 years). Twelve patients had been injured one year earlier and thirty-three, two years earlier. For a portion of the analysis, the group was divided into sixty-four patients who had been injured less than five years earlier and thirty-nine patients who had been injured at or more than five years earlier. The symptoms of pain, swelling, and giving-way were ranked as slight, moderate, or severe, as follows: slight â€”? occasional recurrent minor discomfort, not inter fering with activity; moderate â€”? symptoms usually brought on by an activity, interfering with activity, and relieved by stopping activity or rest; and severe â€”? symp toms occurring with activity, persisting and lasting over night or days, significantly interfering with activity (usu ally the patient must stop activity). Of the 103 patients in this study, fifty-one had had a meniscectomy, including six patients who had two menis cectomies. A total ofsixty-five menisci had been removed, of which forty-seven were medial, thirteen were lateral, and five were unknown. Fourteen patients had had both menisci removed. Fourteen meniscectomies had been per formed within three weeks after the initial injury and thirty-seven, within one year after injury. The remainder of the procedures were distributed throughout the remain ing years. Roentgenograms of ninety-one of the 103 knees were graded for degenerative arthritic changes, as follows: mm imum â€”? squaring of femoral and tibial margins, sub chondral sclerosis, no joint narrowing, and no significant osteophyte formation; moderate â€”? narrow joint-cartilage space, significant subchondral sclerosis, and osteophyte formation; or severe â€”? the aforementioned criteria plus obliteration of the joint-cartilage space.

title: Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies.
abstract: An estimated 80,000 anterior cruciate ligament (ACL) tears occur annually in the United States. The highest incidence is in individuals 15 to 25 years old who participate in pivoting sports. With an estimated cost for these injuries of almost a billion dollars per year, the ability to identify risk factors and develop prevention strategies has widespread health and fiscal importance. Seventy percent of ACL injuries occur in noncontact situations. The risk factors for non-contact ACL injuries fall into four distinct categories: environmental, anatomic, hormonal, and biomechanical. Early data on existing neuromuscular training programs suggest that enhancing body control may decrease ACL injuries in women. Further investigation is needed prior to instituting prevention programs related to the other risk factors.

title: Patterns of meniscal injury in the anterior cruciate-deficient knee: a review of the literature.
abstract: The importance of addressing meniscal pathology associated with anterior cruciate ligament (ACL) insufficiency stems from the increased incidence of meniscal tears with chronic instability. The combined effect of instability and meniscal lesions can lead to the development of knee arthrosis. A predominance of lateral meniscal tears has been demonstrated with acute ACL rupture, whereas the incidence of medial meniscal tears increases significantly with chronic ACL insufficiency. The percentage of repairable meniscal tears is higher on the medial than the lateral side and decreases overall with the chronicity of ACL insufficiency. The likelihood of a successful meniscal repair is enhanced significantly when combined with ACL reconstruction. This review suggests that maximal meniscal preservation is best achieved with ACL reconstruction. This review suggests that maximal meniscal preservation is best achieved with ACL reconstruction shortly after injury and simultaneous repair of coexisting peripheral meniscus tears.

title: Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endoButton femoral fixation: A prospective study.
abstract: This prospective study was conducted to compare the single-socket and the bi-socket anterior cruciate ligament (ACL) reconstruction techniques in terms of outcome.



Nonrandomized control trial.



There were 160 consecutive patients with unilateral chronic ACL insufficiency who underwent endoscopic single- or bi-socket ACL reconstruction alternately using multiple-stranded medial hamstring tendon and EndoButton (Smith & Nephew, Andover, MD) femoral fixation. All patients underwent the same postoperative rehabilitation protocol. Of them, 106 patients (57 single, 49 bi) were available for 2-year follow-up.



According to the IKDC Knee Ligament Evaluation Form, 23 patients (40%) of the single-socket group were subjectively graded as normal, 30 (53%) as nearly normal, and 4 (7%) as abnormal. Twenty-six patients (53%) of the bi-socket group were graded as normal, 21 (43%) as nearly normal, and 2 (4%) as abnormal (P =.19). The mean side-to-side anterior laxity difference (KT-1000 manual maximum force) was 0.9 +/- 1.8 mm for the single-socket group and 0.7 +/- 1.2 mm for the bi-socket group (P =.44). Fifty-three of 57 patients (93%) in the single-socket group and all patients in the bi-socket group showed anterior laxity differences of +/-3 mm or less (P =.12). There were no differences in thigh muscle strength between the groups.



Both single- and bi-socket ACL reconstruction using autogenous multiple-stranded hamstring tendons with EndoButton fixation provided satisfactory anterior stability, and there were no statistically significant differences in subjective results or measured restored stability between the 2 groups.

title: The Effect of Anterior Cruciate Ligament Reconstruction on the Risk of Knee Reinjury
abstract: Although there is evidence that very active, young patients are better served with anterior cruciate ligament reconstruction, there is a lack of objective data demonstrating that future knee injury is prevented by these procedures.  Anterior cruciate ligament reconstruction protects against reinjury of the knee that would require reoperation.  Retrospective cohort study.  A cohort of 6576 active-duty army personnel who had been hospitalized for anterior cruciate ligament injury from 1990 to 1996 were identified. Using the Total Army Injury and Health Outcomes Database, the authors followed these individuals for up to 9 years and collected clinical, demographic, and occupational data. These data were evaluated with bivariate and multivariable analyses to determine the effect of anterior cruciate ligament reconstruction on the rate of knee reinjury that required operation.  Of the 6576 study subjects, 3795 subjects (58%) underwent anterior cruciate ligament reconstruction and 2781 (42%) did not. The rate of reoperation was significantly lower among the anterior cruciate ligament reconstruction group (4.90/100 person-years) compared with those treated conservatively (13.86/100 person-years; P < .0001). Proportional hazard regression analyses adjusted for age, race, sex, marital status, education, and physical activity level confirmed that anterior cruciate ligament reconstruction was protective against meniscal and cartilage reinjury (P < .0001). Secondary medial meniscal injury was more common than secondary lateral meniscal injury (P < .003). Younger age was the strongest predictor of failure of conservative management leading to late anterior cruciate ligament reconstruction (P < .0001).  Anterior cruciate ligament reconstruction protected against reoperation in this young, active population; younger subjects were more likely to require late anterior cruciate ligament reconstruction.  Strong consideration should be given to anterior cruciate ligament reconstruction after anterior cruciate ligament injury in young, active individuals.

title: Indications for ACL surgery.
abstract: Many patients are left disabled for sports after an anterior cruciate ligament (ACL) injury, whereas others appear to have minimal impairment. Some patients develop secondary meniscus tears and degenerative arthritis of the knee. Other patients show little joint deterioration. Because of the variability of patient impairment after an ACL injury and the lack of documentation that ACL surgery prevents degenerative arthritis, there is controversy over the indications for ligament surgery. The decision as to whether or not a particular patient needs ACL reconstruction requires an understanding of the natural history of ACL disruption, the effect of associated injuries, the role of arthrosis, and the ability of surgery to interrupt the disease process. In this article, we discuss these issues as they bear on treatment of the patient with an ACL disruption.

title: Guideline on anterior cruciate ligament injury
abstract: The Dutch Orthopaedic Association has a long tradition of development of practical clinical guidelines. Here we present the recommendations from the multidisciplinary clinical guideline working group for anterior cruciate ligament injury. The following 8 clinical questions were formulated by a steering group of the Dutch Orthopaedic Association. What is the role of physical examination and additional diagnostic tools? Which patient-related outcome measures should be used? What are the relevant parameters that influence the indication for an ACL reconstruction? Which findings or complaints are predictive of a bad result of an ACL injury treatment? What is the optimal timing for surgery for an ACL injury? What is the outcome of different conservative treatment modalities? Which kind of graft gives the best result in an ACL reconstruction? What is the optimal postoperative treatment concerning rehabilitation, resumption of sports, and physiotherapy? These 8 questions were answered and recommendations were made, using the “Appraisal of Guidelines for Research and Evaluation” instrument. This instrument seeks to improve the quality and effectiveness of clinical practical guidelines by establishing a shared framework to develop, report, and assess. The steering group has also developed 7 internal indicators to aid in measuring and enhancing the quality of the treatment of patients with an ACL injury, for use in a hospital or practice.

title: Geographic mapping of meniscus and cartilage lesions associated with anterior cruciate ligament injuries.
abstract: Detailed descriptions of meniscus and articular cartilage lesions associated with anterior cruciate ligament injury have not been presented in the literature. Our goal was to determine the associations between patient sex, age, and surgical delay and the frequency and location of meniscus and articular cartilage lesions seen at the time of the anterior cruciate ligament reconstruction.



Data were obtained retrospectively from a database of 1209 consecutive patients undergoing anterior cruciate ligament reconstruction between 1988 and 2002. All knee cartilage, meniscus, and ligament injuries were documented on anatomic maps at the time of surgery, and the data were analyzed.



Meniscus injuries were identified in 722 (65%) of the 1104 patients who met the criteria for inclusion in the study. Female patients were less likely to have a meniscus injury than male patients were (56% compared with 71%), and male patients were more likely to have combined medial and lateral meniscus injuries than female patients were (20% compared with 11%). Patients with a surgical delay of less than three months were less likely to have a medial meniscus injury (8% compared with 19%). Femoral articular cartilage injuries were identified in 472 patients (43%). Patients who were twenty-five years of age or older were more likely to have multiple cartilage lesions throughout the knee (7.7% compared with 1.3%) and to have more isolated medial femoral condyle lesions (24.2% compared with 13.3%). Patients with a surgical delay of more than one year were more likely to have a lesion (60% compared with 47% for all others), and a surgical delay of more than one year resulted in a greater proportion of large and grade-3 lesions of the lateral femoral condyle. Female patients had a greater proportion of grade-1 lesions of the medial femoral condyle (29% compared with 16%), whereas male patients had a greater proportion of grade-3 and 4 lesions of the medial femoral condyle (49% compared with 35%). In patients who were thirty-five years of age or older, meniscus injuries were more frequent and were located more frequently on the medial side; femoral articular cartilage lesions were also located more frequently on the medial side.



Increased age, male sex, and increased surgical delay all increase the frequency and severity of injuries of the meniscus and/or articular cartilage after an anterior cruciate ligament tear.

title: Is ACL reconstruction only for athletes? A study of the incidence of meniscal and cartilage injuries in an ACL-deficient athlete and non-athlete population: an Indian experience.
abstract: While anterior cruciate ligament (ACL) reconstruction is readily offered to athletes, non-athletes are often treated conservatively. We carried out a retrospective, cross-sectional analysis study to compare the incidence of meniscal and cartilage injuries in an athlete and non-athlete population in relation to time of presentation since injury. The results were used to assess the need and relevance of ACL reconstruction in the non-athlete population. The study included 1375 patients who underwent ACL reconstruction between 1998 and 2004. These patients were initially broadly divided into two categories: athletes (575) and non-athletes (800). Each category was then sub-divided into four subgroups based on time elapsed between the injury and presentation at our clinic (Group A, 3 months; Group B, 3-12 months; Group C, 1-3 years; Group D, more than 3 years). Arthroscopic findings were documented for medial and lateral meniscus and cartilage injuries, and comparisons were made between the incidence of associated injuries in the corresponding groups. There was a statistically significant increase in the incidence of meniscal injuries and cartilage injuries after 1 year in both the groups. There was no difference in the incidence of meniscal and cartilage injuries in athletes and non-athletes among the corresponding groups. (chi-square test, p = 0.05). These results demonstrate that both athletes and non-athletes are equally susceptible for long-term meniscal and cartilage injuries if ACL reconstruction is not carried out early.

title: Rehabilitation following acute anterior cruciate ligament injuries – a 12‐month follow‐up of a randomized clinical trial
abstract: The efficacy of two non‐operative rehabilitation programs was studied in a consecutive randomized controlled clinical trial of 100 patients after 12 months subsequent to an acute anterior cruciate ligament (ACL) injury. Follow up of randomization to two training models was evaluated after 3 and 12 months: A self‐monitored training program (SM) of traditional mobility and muscle strength training of the injured leg was compared to a supervised (SV) training model exercising postural function in closed kinetic‐chains. Nearly 50% of the patients in the SM group required supervision after 6 weeks. An intention‐to‐treat analysis was performed and showed significantly better values in most of the results of the supervised group at 3 and 12 months. An alternative analysis of subgroups showed a significant difference between transferred male patients and original SV male patients at 3 months but not at 12 months, indicating the importance of initial guiding after an ACL injury. No such difference was observed in the female patients.

title: A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics.
abstract: Anterior cruciate ligament (ACL) reconstruction is a common surgical knee procedure that requires intensive postoperative rehabilitation by the patient. A variety of randomized controlled trials have investigated aspects of ACL reconstruction rehabilitation. A systematic review of English language level 1 and 2 studies identified 54 appropriate randomized controlled trials of ACL rehabilitation. This part of the article discusses open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics.

title: Total knee arthroplasty and the unforeseen impact on return to work: a cross-sectional multicenter survey.
abstract: The number of patients receiving a TKA during working life is increasing but little is known about the impact of TKA on patients' reintegration into the workplace. In this cross-sectional survey it was found that 173 of 480 responders worked within 2 years prior to surgery. Sixty-three percent of the working patients stopped within two weeks prior to surgery and 102 patients returned within 6 months. One third never returned to work. Activities that most improved were operating foot pedals, operating vehicles, standing and walking on level terrain. Activities that least improved were kneeling, crouching and clambering. Fifty patients scored 5 or less on the Work Ability Index. Thirty patients were dissatisfied. TKA significantly, but unequally, reduces difficulties in carrying out knee-burdening work activities.

title: Declaration of Helsinki. Ethical Principles for Medical Research Involving Human Subjects
abstract: Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, and amended by the: 29th WMA General Assembly, Tokyo, Japan, October 1975 35th WMA General Assembly, Venice, Italy, October 1983 41st WMA General Assembly, Hong Kong, September 1989 48th WMA General Assembly, Somerset West, Republic of South Africa, October 1996 52nd WMA General Assembly, Edinburgh, Scotland, October 2000 53th WMA General Assembly, Washington 2002 (Note of Clarification on Paragraph 29 added) 55th WMA General Assembly, Tokyo 2004 (Note of Clarification on Paragraph 30 added) 59th WMA General Assembly, Seoul, October 2008

title: Self-assessed mental health problems and work capacity as determinants of return to work: a prospective general population-based study of individuals with all-cause sickness absence
abstract: BackgroundMental health problems are common in the work force and influence work capacity and sickness absence. The aim was to examine self-assessed mental health problems and work capacity as determinants of time until return to work (RTW).MethodsEmployed women and men (n=6140), aged 19–64 years, registered as sick with all-cause sickness absence between February 18 and April 15, 2008 received a self-administered questionnaire covering health and work situation (response rate 54%). Demographic data was collected from official registers. This follow-up study included 2502 individuals. Of these, 1082 were currently off sick when answering the questionnaire. Register data on total number of benefit compensated sick-leave days in the end of 2008 were used to determine the time until RTW. Self-reported persistent mental illness, the WHO (Ten) Mental Well-Being Index and self-assessed work capacity in relation to knowledge, mental, collaborative and physical demands at work were used as determinants. Multinomial and binary logistic regression analyses were used to estimate odds ratios with 95% confidence intervals (CI) for the likelihood of RTW.ResultsThe likelihood of RTW (≥105 days) was higher among those with persistent mental illness OR= 2.97 (95% CI, 2.10-4.20) and those with low mental well-being OR= 2.89 (95% CI, 2.31-3.62) after adjusting for gender, age, SES, hours worked and sick leave 2007. An analysis of employees who were off sick when they answered the questionnaire, the likelihood of RTW (≥105 days) was higher among those who reported low capacity to work in relation to knowledge, mental, collaborative and physical demands at work. In a multivariable analysis, the likelihood of RTW (≥105 days) among those with low mental well-being remained significant OR=1.93 (95% CI 1.46-2.55) even after adjustment for all dimensions of capacity to work.ConclusionSelf-assessed persistent mental illness, low mental well-being and low work capacity increased the likelihood of prolonged RTW. This study is unique because it is based on new sick-leave spells and is the first to show that low mental well-being was a strong determinant of RTW even after adjustment for work capacity. Our findings support the importance of identifying individuals with low mental well-being as a way to promote RTW.

title: Translation and Validation of the Dutch Version of the International Knee Documentation Committee Subjective Knee Form
abstract: For knee-related surgery, there is a great demand for internationally useable subjective scoring systems. Before such measurements can be used, they should be translated and validated for the population they are used on. For the Dutch population, only the Western Ontario and McMaster Universities Osteoarthritis Index and Oxford 12 Questionnaire have been validated. However, these scores can only be used regarding osteoarthritis of the knee. In 2001, the International Knee Documentation Committee presented the Subjective Knee Form, which is a knee-specific rather than a disease-specific questionnaire.   The authors describe the translation procedure and validation of the Dutch Subjective Knee Form. After a forward backward translation protocol, the reliability, validity, and content validity were tested. The responses of 145 consecutive knee patients on 2 questionnaires containing the Short Form–36, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford 12 Questionnaire score, a visual analog scale, and the Dutch International Knee Documentation Committee Subjective Knee Form were used. Reliability was tested by measuring the test-retest reliability and internal consistency. Validity was tested by correlating the questionnaire to the other outcome measurements, and content validity was tested by measuring the floor and ceiling effects.  The reliability proved excellent with an intraclass coefficient of 0.96 for test-retest. Internal consistency was strong (Cronbach [.alpha],. 92). The construct, convergent, and divergent validities were good. The content validity was good; no floor or ceiling effect occurred.  The validation procedure shows that the Dutch International Knee Documentation Committee Subjective Knee Form is an excellent evaluation instrument for Dutch patients with knee-related injuries.

title: Knee injury and Osteoarthritis Outcome Score or International Knee Documentation Committee Subjective Knee Form: which questionnaire is most useful to monitor patients with an anterior cruciate ligament rupture in the short term?
abstract: To evaluate which questionnaire, the Knee Injury and Osteoarthritis Outcome Score (KOOS) or the International Knee Documentation Committee Subjective Knee Form (IKDC subjective), is most useful to evaluate patients with recent anterior cruciate ligament (ACL) ruptures or those within 1 year of an ACL reconstruction.



Patients with recent (0-6 months) ACL ruptures or those with indications for ACL reconstruction were included. All patients completed the questionnaires shortly after trauma or preoperatively and again 1 year later. The KOOS has 5 subscales, each scored separately. The IKDC subjective consists of one total score. The following measurement properties of the KOOS and IKDC subjective were assessed: content validity (n = 45), construct validity (n = 100), test-retest reliability (n = 50), and responsiveness (n = 50).



Regarding content validity, 2 KOOS subscales (Pain and Activities of Daily Living) were scored as nonrelevant. Two of the 18 questions on the IKDC subjective were assessed as nonrelevant. Only the KOOS subscale Sport and Recreation Function had acceptable construct validity (79% confirmation of the predefined hypotheses). None of the KOOS subscales had a sufficient score for responsiveness (<75% confirmation of the predefined hypotheses). The IKDC subjective scored acceptable for construct validity (84% confirmation of the predefined hypotheses) and responsiveness (86% confirmation of the predefined hypotheses). All KOOS subscales and the IKDC subjective had a reliability (intraclass correlation coefficient [ICC]) of 0.81 or higher.



The IKDC subjective is more useful than the KOOS questionnaire to evaluate both patients with recent ACL ruptures and those in the first year after ACL reconstruction.

title: The Dutch tariff: results and arguments for an effective design for national EQ-5D valuation studies.
abstract: The objective of this study was to estimate a Dutch EQ-5D tariff and to determine in a simulation study using the dataset of the original UK valuation study, the number of health states and respondents needed to estimate a reliable tariff. In all, 300 Dutch respondents directly valued 17 states compared to 3000 respondents and 42 states in the original MVH protocol. The results reaffirmed differences in health-related preferences between countries, justifying the estimation of national tariffs. The mean absolute error was 0.030. The design of this study is recommended for national EQ-5D valuation studies.

title: The Reliability, Validity, and Responsiveness of the Lysholm Score and Tegner Activity Scale for Anterior Cruciate Ligament Injuries of the Knee
abstract: In 1982, the Lysholm score was first published as a physician-administered score in the American Journal of Sports Medicine. The Tegner activity scale was published in 1985.  The Lysholm and Tegner scores are valid as patient-administered scores and responsive at early time points after treatment of anterior cruciate ligament tears.   All patients were treated for an anterior cruciate ligament tear. For responsiveness, the Lysholm score (n = 1075) and Tegner activity level (n = 505) were measured preoperatively and 6, 9, 12, and 24 months postoperatively. For test-retest (n = 50), scores were measured at 2 years postoperatively and again within 4 weeks by questionnaire. For criterion validity (n = 170), patients completed the Short Form-12 and the International Knee Documentation Committee score in addition to Lysholm and Tegner instruments. For all other analyses, preoperative Lysholm score (n = 1783) or Tegner activity levels (n = 687) were collected.  There was acceptable test-retest reliability for both the Lysholm (intraclass correlation coefficient = 0.9) and Tegner (intraclass correlation coefficient = 0.8) scores. The minimum detectable change for Lysholm was 8.9 and for Tegner was 1. The Lysholm demonstrated acceptable internal consistency. The Lysholm correlated with the International Knee Documentation Committee (r = .8) and the Short Form-12 (r = .4), and Tegner correlated with the Short Form-12 (r = .2). Both scores had acceptable floor and ceiling effects and all hypotheses were significant. The Lysholm and Tegner were responsive to change at each of the time points.  After 25 years of changes in treatment of anterior cruciate ligament injuries, the Lysholm knee score and the Tegner activity scale demonstrated acceptable psychometric parameters as patient-administered scores and showed acceptable responsiveness to be used in early return to function after anterior cruciate ligament treatment.

title: Rating systems in the evaluation of knee ligament injuries.
abstract: Many different methods of evaluating disability after knee ligament injury exist. Most of them differ in design. Some are based on only patients' symptoms. Other include patients' symptoms, activity grading, performance in a test, and clinical findings. The rating in these evaluating systems can be either numerical, as in a score, or binary, with yes/no answers. Comparison between a symptom-related score and a score of more complex design showed that the symptom-related score gave a more differentiated picture of the disability. It was also shown that the binary rating system gave less detailed information than a score and that differences in a binary rating can depend on at what level the symptoms are regarded as "significant." A new activity grading scale, where work and sport activities were graded numerically, was constructed as complement to the functional score. When evaluating knee ligament injuries, stability testing, functional knee score, performance test, and activity grading are all important. However, the relative importance varies during the course of treatment, and therefore they should not all be included in one and the same score.

title: Arthroscopic assessment of cartilage repair: a validation study of 2 scoring systems.
abstract: This study tested the validity and reliability of the International Cartilage Repair Society (ICRS) cartilage repair assessment and the Oswestry Arthroscopy Score (OAS), which have been designed to assess repair of articular cartilage.



Prospective validation study of arthroscopic cartilage repair scores.



Arthroscopic videos were assessed by a panel of orthopaedic surgeons specializing in cartilage repair. Scoring was repeated after a 2-month interval. Scorers also answered a questionnaire to assess the face and content validity of the scoring systems. Validity of the 2 systems was compared and reliability and repeatability were measured. Pearson's correlation coefficient was used to measure equivalence reliability. The interclass correlation coefficient (ICC) was used to assess the repeatability and inter-rater reliability of each score, and internal consistency was assessed with Cronbach's alpha.



Face and content validity are acceptable for both scores. There is good agreement (equivalence reliability) between the scores (Pearson's correlation coefficient, r = .88; P < .001). Stability (interobserver reliability) and repeatability (test-retest reliability) are satisfactory for both scores with an ICC >0.7 for each score. Cronbach's alpha was 0.91 for ICRS and 0.82 for OAS, indicating better internal consistency for the ICRS score.



The ICRS and OAS arthroscopic scores have been validated for the assessment of cartilage repair and both have been found to be statistically reliable and repeatable. The ICRS score does not allow for graft hypertrophy and may overscore in this situation, whereas the OAS includes assessment of graft stiffness. Both scores show satisfactory stability and repeatability. Internal consistency is adequate for both scores, although it is higher for the ICRS score. Both the ICRS and OAS arthroscopic scores are effective tools in the evaluation of cartilage repair.

title: A reliable, valid and responsive questionnaire to score the impact of knee complaints on work following total knee arthroplasty: the WORQ.
abstract: The Work, Osteoarthritis or joint-Replacement Questionnaire (WORQ) was developed to assess physical difficulty experienced in work before or following total knee arthroplasty (TKA). Thirteen questions were designed. The WORQ was tested for internal consistency by factor analysis, internal reliability (Crohnbach's α), and construct validity. A test-retest reproducibility was performed for analyzing standard error of measurement (SEM agreement), reliability (ICC) and smallest detectable change (SDC) in individuals and groups. Lastly responsiveness (standardized response means [SRM]), floor and ceiling effects and interpretability (minimal important change [MIC]) were analyzed. It is shown that the WORQ is a reliable, valid and responsive questionnaire that can be used to evaluate the impact of knee complaints following TKA on patients' ability to work.