<p><strong>Objective</strong>: To perform an environmental survey of clinical practice amongst surgeons and physiotherapists in making return to sport (RTS) decisions following ACL reconstruction (ACLR); to gain a better understanding of how clinicians and patients define successful return to sport; and to compare patients’ level of satisfaction with their current level of activity following ACLR.</p> <p><strong>Design: </strong>Multidisciplinary cross sectional study.</p> <p><strong>Setting</strong>: Online</p> <p><strong>Participants:</strong> Orthopaedic surgeons and registered physiotherapists; and patients who had undergone ACLR within the previous 6-18 months.</p> <p><strong>Interventions: </strong>Surgeons and physiotherapists completed separate web surveys, each consisting of 10 closed format questions that included sections on demographics, outcome measures, treatment procedures, and RTS decisions. Patients completed a web survey consisting of 19 questions about their activity level, their experience surrounding the process of rehabilitation after ACLR, and their decisions surrounding RTS.</p> <p><strong>Main Outcome Measures</strong><strong>: </strong>Descriptive and subjective data were collected for all groups. Clinician responses were compared for differences in frequencies of clinical outcome measures used to decide RTS readiness. Frequency data were collected for all groups for the definition of successful RTS following ACLR using a self-report form. The relationship between patient satisfaction and current level of activity following ACLR was compared using the Tegner Activity Scale and Single Assessment Numeric Evaluation (SANE).</p> <p><strong>Results:</strong> All patients were unanimous in their definition of successful RTS post ACLR as the ability to fully participate in pre-injury level of sport with no limitations or deficits (100%), and restoring functional stability (100%). Mean Tegner activity level scores of respondents decreased a mean of 3.4 (SD ± 2.5) from pre-injury to current level of activity (p < 0.011). However, no significant decrease from pre-injury level of activity to expected level of activity post surgery was seen. A statistically significant correlation was demonstrated between patients’ level of satisfaction and current level of activity (r = 0.84, p = 0.02), with higher levels of activity associated with increased levels of satisfaction. Overall, the majority of clinician respondents reported that jump tests, range of motion (ROM), Lachman clinical test of stability, pain, swelling, functional movement and giving way contributed to their RTS decisions. Unanimous consensus existed between clinicians for the ability to participate in any level of sport, with or without limitations, as the definition of successful RTS following ACLR.</p> <p><strong>Conclusions:</strong> Following ACLR, medically cleared patients had not met their high expectations of functional stability and ability to return to their pre-injury level of sport. The discordance between unmet expectations and current level of sporting activity was reflected in lower rates of patient satisfaction. Most clinicians reported using primarily impairment based not self-report measures to contribute to their RTS decisions. Clinicians and patients expressed subtle differences in their definition of successful RTS.</p> <p><strong>Clinical Relevance: </strong>Establishing an operational definition of success, and professional consensus on measures which include patient reported outcomes is an important next step in the development of goal oriented RTS guidelines.</p> / Master of Science Rehabilitation Science (MSc)

Die Magnetresonanztomografie ist zur nicht invasiven Einschätzung der Transplantat-integrität einer vorderen Kreuzbandersatzplastik in der postoperativen Phase hilfreich. Bei klinischen Studien wurde die MRT zur Beobachtung des Transplantatremodelings eingesetzt, jedoch in keinem Fall die Signalintensität mit biomechanischen Befunden korreliert. In der vorliegenden Studie wurde erstmals das quantitative MR-Signal in Form eines Signal/Noise-Quotienten mit biomechanischen Parametern über zwei Jahre am Langzeit Tiermodell verglichen und miteinander korreliert. 29 Schafe wurden einer Rekonstruktion des vorderen Kreuzbandes mit autologem Achillessehnen-Split-Transplantat unterzogen und nach 6, 12, 24, 52 und 104 Wochen geopfert. Vor Opferung wurden die Kniegelenke aller Tiere sowohl nativ, als auch mit Kontrastmittel (Gadolinium-Diethylentriaminpentaessigsäure) MR-tomografisch (1,5 Tesla, T1-Wichtung, 2 mm Schichtdicke, sagital/schräge Orientierung) untersucht. Anschließend wurden die Hinterläufe explantiert und biomechanisch getestet. Der Signal/Noise-Quotient wurde berechnet und die Daten mit der Versagenslast, der Reißfestigkeit und der Steifigkeit des Transplantates korreliert. In der frühen Phase des Transplantatremodelings konnte ein Anstieg der Signalintensität bei gleichzeitiger Abnahme der biomechanischen Eigenschaften beobachtet werden. Im weiteren Verlauf nahm die Signalintensität wieder ab und respektive die biomechanischen Kenndaten zu. In der Korrelationsanalyse zeigte sich ein signifikanter negativ linearer Zusammenhang zwischen den Signal/Noise-Quotienten und allen biomechanischen Parametern. Die Korrelationen mit Kontrastmittelunterstützung waren im Allgemeinen grösser. Schlussfolgernd kann gesagt werden, dass das quantitative MR-Signal ein nützliches Hilfsmittel ist, den Prozess des Transplantatremodelings nicht-invasiv zu verfolgen. Die Ergebnisse sind für das Verständnis der beeinflussenden Faktoren des Transplantatremodelings auch für den Menschen ausgesprochen nutzbringend. In Hinblick auf mögliche Unterschiede zwischen dem Tiermodell und dem Menschen stellen die hier präsentierten Daten eine wissenschaftliche Grundlage dar, das Remodeling beim Menschen weiter nicht invasiv zu untersuchen / Magnetic resonance imaging (MRI) is helpful for the noninvasive evaluation of the graft integrity of an anterior cruciate ligament graft in the postoperative phase. In clinical studies the MRI was used for the observation of the graft remodeling, correlated however in no case the signal intensity with biomechanical findings. In the present study the quantitative MR-signal in form of a signal/noise quotient was compared for the first time with biomechanical parameters over two years in a long-term animal model and correlated with each other. Twenty-nine sheep underwent anterior cruciate ligament reconstruction with an autologous Achilles tendon split graft and were sacrificed after 6, 12, 24, 52 and 104 weeks. Before sacrificing, all animals underwent plain and contrast-enhanced (gadolinium-diethylenetriamine pentacetic acid) magnetic resonance imaging (1.5 Tesla, T1-weighted, 2-mm sections, sagital oblique orientation) of their operated knees. The signal/noise quotient was calculated and data were correlated to the maximum load to failure, tensile strength and stiffness of the grafts. A high signal intensity reflects a decrease of biomechanical properties of the graft during early remodeling. In the further process the signal intensity decreased and biomechanical characteristic data increased again. Correlation analyses revealed significant negative linear correlations between the signal/noise quotient and all tested biomechanical parameters. The correlations with contrast-enhanced MRI were generally stronger. In conclusion, it can be said that the quantitative MR-Signal is a useful tool to follow the graft remodeling process in a noninvasive manner. The results may also be useful for understanding the variables of graft remodeling after ACL reconstruction in humans. The present data may present a scientific base for comparing animal and human data with respect to possible differences in the graft remodeling process

Title from first page of PDF document. Includes bibliographical references (p. 31-34).

Introduction: The Anterior Cruciate ligament (ACL) is one of the most important ligaments in the knee providing joint stability. Rupture of ACL is the most common sports injury. About half of the patients undergo surgical reconstruction. The Orthopaedic clinic in Region Örebro county underwent a reorganization in 2016. Aim: The aim of this study was to evaluate the two-year risk of re-arthroscopy in the same knee after primary ACL-reconstruction. Material and Methods: A retrospective cohort study. All patients from 1st January 2005 until 31st December 2017 with primary ACL reconstruction in Region Örebro county were included. Data was collected from medical records and The Swedish National Anterior Cruciate Ligament Register. Results: 431 patients were included. The total risk of re-arthroscopy was 13.0%. Meniscal surgeries and age did not affect the outcome. Fixation method in femur and tibia affected the outcome, as did choice of graft. There was a small numerical difference before (13.4%) vs after (12.1%) the reorganization, but it was not statistically significant either unadjusted or adjusted for age and meniscal surgeries (p=0.721). Conclusions: Our study indicates that choice of graft and fixation method in femur and tibia affect the re-arthroscopy rate. Regarding graft, the semitendinosus tendon alone was the better option, and for fixation both for femur and tibia it seems like Tightrope was the best option and screw the worst. The reorganization did not affect the outcome but might have other benefits.

INTER-SEGMENT COORDINATION VARIABILITY POST ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION SEPTEMBER 2015 DEVIN K. KELLY, B.S., UNIVERSITY OF MASSACHUSETTS AMHERST M.S., UNIVERSITY OF MASSACHUSETTS AMHERST Directed by: Dr. Joseph Hamill There is an increased risk for ipsilateral graft rupture and contralateral ACL rupture following ACL reconstruction surgery (ACLR) despite return to sport clearance. The reason for this increased risk is not well understood. Previous literature has shown that decreased coordination variability is indicative of an injured system regardless of the absence of pain. PURPOSE: To quantify inter-segment coordination variability during three portions of the stance phase of gait in athletes at three progressive time points post-surgery compared to the contralateral limb (NI) and healthy controls. METHODS: Three-dimensional kinematic and kinetic data were collected for 10 ACLR and 10 healthy athletes matched for age, gender, and activity level. The ACLR group was measured at 4 weeks, 12 weeks, and when cleared to run post-surgery. Kinematic data were used in a modified vector coding technique to determine inter-segment coordination variability of lower extremity couples of interest. Statistical significance was determined using two factor multivariate ANOVAs (limb x visit) for early (1-33%), mid (34-66%), and late (67-100%) stance with alpha level set at .05. Tukey post-hoc tests were performed where appropriate. RESULTS: ACLR athletes have decreased inter-segment coordination variability of the involved lower extremity during the late stance phase of gait compared to both the contralateral limb and healthy controls at 4 weeks post-surgery. By 12 weeks post-surgery there were improvements in joint function as exemplified by inter-segment coordination variability of the ACLR involved limb becoming similar to the healthy control limb. CONCLUSION: Inter-segment coordination variability during late stance in the present study is not an indication for the increased risk for ipsilateral graft rupture and contralateral ACL rupture in ACLR athletes.

No description available.

O teste do pivot shift é a manobra semiológica mais específica para o diagnóstico da lesão do ligamento cruzado anterior (LCA). É também o único teste que se correlaciona com a probabilidade de desenvolvimento de osteoartrose em joelhos com instabilidade rotacional persistente, após a reconstrução do LCA. Entretanto, há uma grande variabilidade na técnica utilizada para a realização deste teste, comprometendo a sua reprodutibilidade e a sua quantificação objetiva. O teste do pivot shift é influenciado pela associação entre a lesão do LCA e a de outras estruturas anatômicas do joelho. A padronização e a mensuração quantitativa do pivot shift auxiliam na categorização objetiva da frouxidão ligamentar do joelho. O objetivo desta tese foi o de compilar uma série de contribuições do autor, num total de seis publicações, na linha de pesquisa sobre a padronização, quantificação e interpretação do teste do pivot shift. A padronização do teste contribuiu para o aumento da reprodutibilidade da manobra semiológica. Nossos estudos laboratoriais em peças de cadáver demonstraram que a padronização do teste do pivot shift diminuiu de forma significativa a variação da aceleração da redução da tíbia no pivot shift (joelho esquerdo 3,0 ± 1,3 e joelho direito 2,5 ± 0,7 mm/s2) comparada ao teste realizado pela técnica de preferência do cirurgião (joelho esquerdo 4,3 ± 3,3 e joelho direito 3,4 ± 2,3 mm/s2) em cadáver cirurgicamente preparado para apresentar um pivot shift positivo com diferentes gradações em cada joelho. A validação de dispositivos não-invasivos de avaliação da frouxidão ligamentar do joelho, contribuiu para que o teste possa ser medido quantitativamente. Quando comparamos um método invasivo de referência para a mensuração do pivot shift (sensores eletromagnéticos fixados ao osso do fêmur e da tíbia) com três métodos não-invasivos (sensores eletromagnéticos fixados a pele, acelerômetro e um método de análise de imagens), constatamos que todos os métodos não-invasivos apresentaram correlação (r) positiva estatisticamente significante (p <0,01) com o método de referência. Os sensores fixos à pele tiveram r = 0,67 e r = 0,88 para os parâmetros de translação e de aceleração respectivamente. O acelerômetro apresentou r = 0,75 para o parâmetro de aceleração e o método de análise de imagens r = 0,24 para o parâmetro de translação anterior da tíbia. Portanto, neste estudo, métodos não invasivos, adequados para uso em consultório médico, puderam quantificar de forma reprodutível os parâmetros da aceleração e da translação anterior da tíbia no teste do pivot shift. A aplicação clínica destes resultados foi proposta pelo autor por meio de um novo algoritmo para o tratamento individualizado das lesões do LCA, em uma de suas recentes publicações. Embora este algoritmo precise ser validado, a sua proposta abre perspectiva para novos estudos que objetivem melhores resultados no tratamento de pacientes com lesão do ligamento cruzado anterior. / The pivot shift test is the most specific semiologic maneuver to diagnose the anterior cruciate ligament (ACL) injuries. It is also the only test capable of predicting the development of osteoarthritis in the presence of persistent rotatory knee laxity after an ACL reconstruction. However, the test has great technique variability among surgeons compromising reliability and objective quantification. The pivot shift test is influenced by the pattern of the ACL tear and associated lesions. The standardization and the quantitative measurement of the pivot shift can aid in the knee rotary laxity categorization and can provide valuable information on possible additional affected structures besides the ACL, thus contributing for an individualized treatment algorithm for this ligament injury. The purpose of this thesis was to compile a series of author\'s contributions, in a total of six publications, in the field of standardization, measurement and interpretation of the pivot shift test. The standardized technique for the pivot shift test improved the maneuver reliability. Our laboratory studies utilizing cadaveric knees demonstrated that the standardized technique significantly reduced the variation of the acceleration of the tibial reduction during the pivot shift test among surgeons (left knee 3.0 ± 1.3 mm/s2; right knee 2.5 ± 0.7 mm/s2) compared to the surgeons\' preferred technique (left knee 4.3 ± 3.3 mm/s2; right knee 3.4 ± 2.3 mm/s2) in a surgically prepared cadaver for a different positive grade pivot shift in each knee. The validation of non-invasive devices for the knee ligament laxity evaluation aided in the quantitative measurement of the pivot shift. The comparison of an invasive reference method for the pivot shift measurement (electromagnetic tracking device fixed to the femur and tibia) with three non-invasive devices (electromagnetic tracking device attached to the skin, accelerometer and image analysis system) showed statistically significant (p > 0.01) positive correlation (r) for all of them. The electromagnetic tracking device attached to the skin had r = 0,67 and r = 0,88 for the anterior translation and acceleration parameters respectively. The accelerometer has r = 0,75 for the acceleration parameter and the image analysis system had r = 0,24 for the anterior tibial translation parameter. Therefore, in this study, non-invasive methods, affordable for a clinical use, could reliably quantify the acceleration and anterior tibial translation parameters during the pivot shift test. The clinical application of these results was proposed by the author by means of a new algorithm for individualized treatment of the ACL injuries in one of his recent publications. Although this algorithm is yet to be validated, its proposal opens perspective for new studies that aim for better treatment results in patients with an anterior cruciate ligament injury.

Made available in DSpace on 2014-12-17T15:16:10Z (GMT). No. of bitstreams: 1 NiciaFBM_DISSERT.pdf: 1728497 bytes, checksum: a256b529408b17ed552e700e78441abd (MD5) Previous issue date: 2010-05-14 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior / Muscle fatigue is a phenomenon that promotes physiological and biomechanical disorders and their changes in healthy subjects have been widely studied and have significant importance for care in preventing injuries, but we do not have many information about its effects in patients after ACL reconstruction. Thus, this study is to analyze the effects of fatigue on neuromuscular behavior of quadriceps after ACL reconstruction. To reach this objective, participants were forty men, twenty healthy (26,90 ? 6,29 years) and twenty after ACL reconstruction (29,75 ? 7,01 years) with a graft of semitendinosus and gracilis tendons, between four to six months after surgery. At first, there was an assessment of joint position sense (JPS) at the isokinetic dynamometer at a speed of 5?/s and target angle of 45? to analyze the absolute error of JPS. Next, we applied the a muscle fatigue protocol, running 100 repetitions of isokinetic knee flexion-extension at 90?/s. Concurrently with this protocol, there was the assessment of muscle performance, as the peak torque (PT) and fatigue index, and electromyographic activity (RMS and median frequency). Finally, we repeated the assessment of JPS. The statistical analysis showed that patients after ACL reconstruction have, even under normal conditions, the amended JPS compared with healthy subjects and that after fatigue, both have disturbances in the JPS, but this alteration is significantly exacerbated in patients after ACL reconstruction. About muscle performance, we could notice that these patients have a lower PT, although there are no differences between the dynamometric and EMG fatigue index. These findings show the necessity about the cares of pacients with ACL reconstruction in respect of the risks of articulate instability and overload in ligamentar graft / A fadiga muscular ? um fen?meno que envolve dist?rbios fisiol?gicos e biomec?nicos. A an?lise de suas altera??es, em indiv?duos sadios, possui grande import?ncia na preven??o de les?es, mas pouco se sabe sobre suas repercuss?es em pacientes ap?s reconstru??o do LCA. Dessa forma, o objetivo deste estudo foi avaliar os efeitos da fadiga no comportamento neuromuscular do quadr?ceps femoral de indiv?duos ap?s reconstru??o do LCA. Para tanto, participaram deste estudo quarenta homens, sendo vinte saud?veis (26,90 ? 6,29 anos) e vinte ap?s reconstru??o de LCA (29,75 ? 7,01 anos) com enxerto dos tend?es semitendinoso e gr?cil, entre 4 a 6 meses de p?s-operat?rio. Em princ?pio, realizou-se uma avalia??o do senso de posi??o articular (SPA) ativo, no dinam?metro isocin?tico, a uma velocidade de 5?/s e ?ngulo-alvo de 45?, sendo a vari?vel analisada o seu erro absoluto. Em seguida, aplicou-se uma avalia??o isom?trica m?xima em extens?o do joelho, a 60? de flex?o, por 10 segundos e um protocolo de fadiga muscular, sendo executadas 100 repeti??es isocin?ticas conc?ntricas de flexo-extens?o do joelho a 90?/s. Concomitantemente a esse protocolo, realizou-se a avalia??o do desempenho muscular, observando o pico de torque (PT), o ?ndice de fadiga (IFD) e a atividade eletromiogr?fica (Root Mean Square - RMS e freq??ncia mediana - Fm). Por fim, repetiu-se a avalia??o da SPA. As avalia??es detectaram que pacientes ap?s reconstru??o do LCA apresentaram, ainda em condi??es pr?-fadiga, o SPA alterado quando comparado com indiv?duos sadios e que quando fatigados, ambos possu?ram dist?rbios no SPA, sendo que essa altera??o foi significativamente mais exacerbada em pacientes ap?s reconstru??o de LCA. Quanto ao desempenho muscular, constatou-se que esses pacientes apresentam um menor PT, RMS e Fm quando comparado ao grupo controle, mas n?o possuem diferen?as quanto ao ?ndice de fadiga, dado pela Fm e pela dinamometria. Ademais, constatou-se que as vari?veis isocin?ticas e eletromiogr?ficas, em sua grande maioria, apresentam correla??es positivas. Os achados refor?am a necessidade dos cuidados aos pacientes ap?s reconstru??o do LCA, quando submetidos ? fadiga, no que diz respeito aos riscos de instabilidade articular e sobrecarga do enxerto ligamentar

O teste do pivot shift é a manobra semiológica mais específica para o diagnóstico da lesão do ligamento cruzado anterior (LCA). É também o único teste que se correlaciona com a probabilidade de desenvolvimento de osteoartrose em joelhos com instabilidade rotacional persistente, após a reconstrução do LCA. Entretanto, há uma grande variabilidade na técnica utilizada para a realização deste teste, comprometendo a sua reprodutibilidade e a sua quantificação objetiva. O teste do pivot shift é influenciado pela associação entre a lesão do LCA e a de outras estruturas anatômicas do joelho. A padronização e a mensuração quantitativa do pivot shift auxiliam na categorização objetiva da frouxidão ligamentar do joelho. O objetivo desta tese foi o de compilar uma série de contribuições do autor, num total de seis publicações, na linha de pesquisa sobre a padronização, quantificação e interpretação do teste do pivot shift. A padronização do teste contribuiu para o aumento da reprodutibilidade da manobra semiológica. Nossos estudos laboratoriais em peças de cadáver demonstraram que a padronização do teste do pivot shift diminuiu de forma significativa a variação da aceleração da redução da tíbia no pivot shift (joelho esquerdo 3,0 ± 1,3 e joelho direito 2,5 ± 0,7 mm/s2) comparada ao teste realizado pela técnica de preferência do cirurgião (joelho esquerdo 4,3 ± 3,3 e joelho direito 3,4 ± 2,3 mm/s2) em cadáver cirurgicamente preparado para apresentar um pivot shift positivo com diferentes gradações em cada joelho. A validação de dispositivos não-invasivos de avaliação da frouxidão ligamentar do joelho, contribuiu para que o teste possa ser medido quantitativamente. Quando comparamos um método invasivo de referência para a mensuração do pivot shift (sensores eletromagnéticos fixados ao osso do fêmur e da tíbia) com três métodos não-invasivos (sensores eletromagnéticos fixados a pele, acelerômetro e um método de análise de imagens), constatamos que todos os métodos não-invasivos apresentaram correlação (r) positiva estatisticamente significante (p <0,01) com o método de referência. Os sensores fixos à pele tiveram r = 0,67 e r = 0,88 para os parâmetros de translação e de aceleração respectivamente. O acelerômetro apresentou r = 0,75 para o parâmetro de aceleração e o método de análise de imagens r = 0,24 para o parâmetro de translação anterior da tíbia. Portanto, neste estudo, métodos não invasivos, adequados para uso em consultório médico, puderam quantificar de forma reprodutível os parâmetros da aceleração e da translação anterior da tíbia no teste do pivot shift. A aplicação clínica destes resultados foi proposta pelo autor por meio de um novo algoritmo para o tratamento individualizado das lesões do LCA, em uma de suas recentes publicações. Embora este algoritmo precise ser validado, a sua proposta abre perspectiva para novos estudos que objetivem melhores resultados no tratamento de pacientes com lesão do ligamento cruzado anterior. / The pivot shift test is the most specific semiologic maneuver to diagnose the anterior cruciate ligament (ACL) injuries. It is also the only test capable of predicting the development of osteoarthritis in the presence of persistent rotatory knee laxity after an ACL reconstruction. However, the test has great technique variability among surgeons compromising reliability and objective quantification. The pivot shift test is influenced by the pattern of the ACL tear and associated lesions. The standardization and the quantitative measurement of the pivot shift can aid in the knee rotary laxity categorization and can provide valuable information on possible additional affected structures besides the ACL, thus contributing for an individualized treatment algorithm for this ligament injury. The purpose of this thesis was to compile a series of author\'s contributions, in a total of six publications, in the field of standardization, measurement and interpretation of the pivot shift test. The standardized technique for the pivot shift test improved the maneuver reliability. Our laboratory studies utilizing cadaveric knees demonstrated that the standardized technique significantly reduced the variation of the acceleration of the tibial reduction during the pivot shift test among surgeons (left knee 3.0 ± 1.3 mm/s2; right knee 2.5 ± 0.7 mm/s2) compared to the surgeons\' preferred technique (left knee 4.3 ± 3.3 mm/s2; right knee 3.4 ± 2.3 mm/s2) in a surgically prepared cadaver for a different positive grade pivot shift in each knee. The validation of non-invasive devices for the knee ligament laxity evaluation aided in the quantitative measurement of the pivot shift. The comparison of an invasive reference method for the pivot shift measurement (electromagnetic tracking device fixed to the femur and tibia) with three non-invasive devices (electromagnetic tracking device attached to the skin, accelerometer and image analysis system) showed statistically significant (p > 0.01) positive correlation (r) for all of them. The electromagnetic tracking device attached to the skin had r = 0,67 and r = 0,88 for the anterior translation and acceleration parameters respectively. The accelerometer has r = 0,75 for the acceleration parameter and the image analysis system had r = 0,24 for the anterior tibial translation parameter. Therefore, in this study, non-invasive methods, affordable for a clinical use, could reliably quantify the acceleration and anterior tibial translation parameters during the pivot shift test. The clinical application of these results was proposed by the author by means of a new algorithm for individualized treatment of the ACL injuries in one of his recent publications. Although this algorithm is yet to be validated, its proposal opens perspective for new studies that aim for better treatment results in patients with an anterior cruciate ligament injury.

No description available.