- Email: [email protected]
The anterior cruciate ligament clinical pathway: Towards a systematic evaluation of ACL injured patients
ORTHTR 10859 No. of Pages 6
ORIGINAL PAPER / SPECIAL ISSUE
Orthopaedics Traumatology
Sports Orthop. Traumatol. xx, xx–xx (2016) ß Elsevier GmbH www.SOTjournal.com http://dx.doi.org/10.1016/j.orthtr.2016.03.050
and
Summary Purpose: To systematically record preand post-operative clinical data after ACL reconstruction in an institutional clinical pathway. Material and methods: From 2011 to 2014, 285 patients had an ACL reconstruction with a bone patellar tendon bone (BPTB) (n = 123) or a hamstring (HS) (n = 162) auto-graft. Isokinetic quadriceps and hamstrings force, anterior and rotational knee laxity, hop tests and subjective knee function were evaluated. Results: All outcomes improved significantly throughout the follow-up. Anterior knee laxity was significantly improved by ACL reconstruction (p < 0.01). Quadriceps force deficit was significantly greater in BPTB group compared to HS group at all time points (p < 0.01). The same holds true for functional performance (p < 0.05). Discussion and conclusion: The present study highlighted the progression of ACL-reconstructed patients throughout their rehabilitation. The results of this institutional clinical pathway may serve as an internal and external benchmark, as well as a potential baseline to individualize patient care including return-to-sports. Keywords Knee – anterior cruciate ligament – surgery – knee function
A. Urhausen et al.
Der VKB-Behandlungspfad €glicht eine ermo systematische Erfassung klinischer Patientendaten Zusammenfassung Ziel: Im Rahmen eines institutionalisierten klinischen Behandlungspfades pr€aund postoperative klinische Daten von Patienten nach Rekonstruktion des vorderen Kreuzbandes (VKB) zu erfassen. Material und Methode: Zwischen 2011 und 2014 wurden 285 Patienten mit einer autologen VKB Ersatzplastik versorgt, davon erhielten 123 eine Patellarsehnenplastik (BPTB) und 162 eine
ORIGINAL PAPER / SPECIAL ISSUE
The anterior cruciate ligament clinical pathway: Towards a systematic evaluation of ACL injured patients Anouk Urhausen1,5, Caroline Mouton2, Roland Krecke1,5, Christian Nu€hrenbo€rger3, Alexander Hoffmann4, Dietrich Pape2,4, Romain Seil2,4 1 Department of Physiotherapy, Centre Hospitalier de Luxembourg – Clinique d’Eich, Luxembourg 2 Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg 3 Department of Sports Medicine, Centre Hospitalier de Luxembourg – Clinique d’Eich, Luxembourg 4 Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg – Clinique d’Eich, Luxembourg 5 Faculty of Health Sciences, LUNEX-International University of Health, Exercise and Sports, Luxembourg Eingegangen/submitted: 13.01.2016; u¨berarbeitet/revised: 18.03.2016; akzeptiert/accepted: 18.03.2016 Online verfu¨gbar seit/Available online: xxx
Introduction
O
ver two million anterior cruciate ligament (ACL) injuries occur worldwide each year [13]. Scandinavian registers reported that the annual incidence of primary ACL reconstructions is around 85 per 100 000 citizens in patients aged from 16 to 39 years [6]. The majority of these injuries (74%) are non-contact injuries and occur during landing and cutting movements [9,12]. Two thirds of ACL injuries occur during sporting activities [5]. After ACL reconstruction, only 63% of the patients were reported to return to their pre-injury level of activity [2]. In these patients, the overall re-injury rate (graft rupture or contralateral ACL injury) reaches in average 15% and can increase to 23% in athletes younger than 25 years who return to sports [16]. These unsatisfying outcomes illustrate the need for a better understanding of ACL injuries, as well as A. Urhausen et al.
an improvement in patient followup, rehabilitation and safe return to sports practice. In the absence of national ACL registries, the establishment of standardized, institutional clinical pathways may be a strategy to overcome this by providing an overview of the spectrum of ACL-injured patients and their outcomes [10]. In our institution, a clinical pathway for ACL tears was developed to monitor patients on a systematic basis. The ultimate goal of this data recording is to allow for a postoperative benchmarking of ACL reconstructed patients and. In addition, this may eventually allow to adapt individual postoperative patient care and rehabilitation in order to finally allow for a successful and safe return to sports. As an early step in this process, the purpose of this preliminary analysis was to establish reference values of muscle force, hop performances, anterior and rotational knee laxity as well
The anterior cruciate ligament clinical pathway
1
ORIGINAL PAPER / SPECIAL ISSUE Sports Orthop. Traumatol. xx, xx–xx (2016)
Grazilis-/Semitendinosusplastik (HS). Die isokinetische Kraft im Oberschenkel, die anteriore und Rotations-Laxit€at, die Sprungleistung sowie die subjektive Kniefunktion wurden untersucht. Ergebnisse: W€ahrend der gesamten Nachbehandlungsphase war eine signifikante Verbesserung aller Resultate zu sehen. Die anteriore Laxit€at war nach der VKB-Rekonstruktion signifikant verringert (p < 0.01). Der Vergleich der HS und BPTB-Plastik best€atigte ein gr€oßeres Defizit der Kraft im Quadriceps (p < 0.01) sowie der funktionellen Leistung (p < 0.05) bei Patienten mit einer BPTB-Plastik.
Diskussion und Schlussfolgerung: Die Studie objektiviert die progressive Verbesserung der erfassten Funktionswerte w€ahrend der Nachbehandlungsphase von Patienten nach VKBRekonstruktion. Die vorliegenden Ergebnisse des klinischen Behandlungspfades erm€oglichen interne und externe Referenzdaten, die in der individuellen Patientenversorgung einschließlich der Entscheidung zur Wiederaufnahme der sportlichen Aktivit€aten Ber€ucksichtigung finden sollte. €rter €sselwo Schlu Knie – vorderes Kreuzband – Kreuzbandersatzplastik – Kniefunktion
as subjective knee function of a prospective cohort of ACL reconstructed patients.
Material and methods Patients All ACL injured patients who were seen in our clinic were offered to enter a systematic and standardized followup regardless of the treatment decision (operative or nonoperative). Patients were included in the clinical pathway if they had an ACL tear, which was diagnosed clinically and documented on magnetic resonance imaging. They were recruited from March 2011 to September 2014 and were required to sign a consent agreement according to the National Ethics Committee for Research which approved the study protocol (N8 201101/05 version 1.0). Data acquisition was notified to the National Data Protection Committee. Only patients who underwent an anatomic single-bundle ACL reconstruction with a bone patellar tendon bone (BPTB) or 3 to 4-strand hamstring (HS) grafts were included in this study. Patients with associated cartilage damage and/or meniscal surgery (resection & repair) were included. Description of the ACL clinical pathway The clinical pathway is a centerbased registry [15]. Data were collected prospectively by surgeons, physiotherapists, study nurses and researchers and were saved in a
secure database (Table 1). Patients were evaluated before surgery (preop.), at 6 weeks, 3, 6 and 12 months after the ACL reconstruction. Several objective measurements were included in the pathway. Static anterior and rotational knee laxity measurements were performed with the GNRB® (GeNouRoB) and the Rotameter respectively before and at 3, 6 and 12 months after surgery according to previously published protocols [11]. As for anterior knee laxity, 3 separate trials were performed up to 200 N and the average of the 2 last trials was recorded. For rotational knee laxity, 4 separate trials were performed in internal rotation up to 6 Nm and the average of the 2 last trials was recorded. To evaluate muscle function, knee flexors and extensors force were recorded before and 3, 6 and 12 months after the surgery on the dynamometer Con-Trex®. The average peak torques of 4 repetitions of the concentric hamstring and quadriceps force as well as eccentric hamstring force were saved. Finally, to evaluate functional performance, patients were asked to perform three single-leg hop tests (hop for distance, vertical jump and side hop) at 6 and 12 months after ACL reconstruction according to the protocols previously published by Gustavsson et al. [7]. Admission criteria for the hop tests were: a deficit of the knee flexors and extensors of the operated knee compared to the healthy contralateral knee under 40%, an IKDC score over 70, no
Table 1. Data collection of the clinical pathway preoperatively (pre-op), at 6 weeks (w), 3, 6 and 12 months (m) after ACL-reconstruction.
IKDC + KOOS + VAS Anterior laxity + rotational laxity Isokinetics Hop test
2
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The anterior cruciate ligament clinical pathway
Pre-op
6w
3m
6m
12 m
ORIGINAL PAPER / SPECIAL ISSUE Sports Orthop. Traumatol. xx, xx–xx (2016)
swelling and no knee pain, free ROM, a negative pivot shift as well as subjective knee stability. To evaluate subjective outcomes, the Knee Injury and Osteoarthritis Outcome Score (KOOS) [14] and the International Knee Documentation Committee (IKDC) subjective forms [8] were completed by the patient before, 6 weeks, 3, 6 and 12 months after the surgery. Analysis The side-to-side differences in anterior displacement and knee rotation were expressed in millimeters and degrees respectively. Muscle force and hop performance were computed as the difference in percent of the operated leg compared with the contralateral healthy leg. Subjective knee function in sport and quality of life were calculated on a score of 100. Statistical analysis was performed using version 23.0 of the SPSS software. First, the normality of distribution of each outcome variable was tested using the Kolmogorov–Smirnov test for BPTB and HS grafts separately. If the outcomes were normally distributed, an ANOVA was computed to determine whether the outcomes varied between the different time points of the follow-up. A Bonferroni correction was computed for multiple comparisons. If the outcomes were not normally distributed, a Kruskal– Wallis test was computed to determine
whether the outcomes varied between the different time points of the followup. Significance was set at p < 0.05.
Results Between March 2011 and September 2014, 285 patients, thereof 123 (43%) with a BPTB autograft and 162 (57%) with a HS graft reconstruction were recruited. Eighty seven (30%) participants were females. At the time of surgery, the participants’ demographics were as follows (mean SD): age 29 10 years, weight 75 13 kg, and height 175 9 cm. The time between ACL injury and surgery was in average 400 694days. The side-to-side difference in anterior displacement was significantly decreased after the ACL reconstruction compared to the preoperative status both in the BPTB and HS groups (Table 2; p < 0.01). As for internal rotation, the side-to-side difference was not significantly different throughout the follow-up. No difference in knee laxity measurements could be observed between the BPTB and HS groups at any moment of the follow-up. The deficit in concentric quadriceps force (Fig. 1A) significantly differed between time points in both grafts (p < 0.01). The BPTB group displayed a greater concentric quadriceps force deficit than the HS group at all time points after surgery (p < 0.01), although the baseline preoperative
deficit between both groups was similar. The deficit in concentric hamstrings force (Fig. 1B) did also differ significantly between time points in both grafts (p < 0.01). For both grafts, the deficit was similar before and 3 months after surgery and then significantly decreased at 6 months (p < 0.01). No further evolution was observed between the deficit at 6 and 12 months after the surgery (ns). The deficit in eccentric hamstrings force (Fig. 1C) differed significantly between time points in both grafts (p < 0.01). While the eccentric hamstrings force deficit was significantly greater in HS grafts 3 months after the surgery compared to BPTB grafts (p < 0.01), the deficit was similar at 6 and 12 months after the reconstruction. As for the functional performance, deficits of the operated leg in hop tests were significantly lower at 12 months compared to 6 months after surgery (Table 3). The BPTB group displayed increased deficits compared to the HS group both at 6 and 12 months after the ACL reconstruction (p < 0.05). Subjective scores were not normally distributed. Non-parametric tests were therefore used to compare the scores between the different time points of the follow-up as well as between grafts. Median KOOS scores increased throughout the postoperative follow-up for both HS (p < 0.01; Fig. 2A) and BPTB (p < 0.01; Fig. 2B)
Table 2. Side-to-side differences before and at 3, 6 and 12 months after surgery in the hamstring (HS) and bone patella tendon bone (BPTP) graft groups in anterior displacement measured with the GNRB in millimeters (mm) and in knee rotation measured with the rotameter in degrees (8). Preoperatively HS
3 months BPTB
HS
6 months BPTB
HS
12 months BPTB
HS
BPTB
N 71 97 95 116 68 100 32 49 GNRB (mm) 2.1 (1.7) 2.4 (1.7) 1.0 (1.6)a 1.0 (1.3) 1.1 (1.7)a 1.4 (1.3) 0.6 (1.9)a 1.1 (1.4) Rotameter (8) 2.1 (2.9) 1.8 (2.9) 1.8 (3.5)a 2.1 (2.9) 2.3 (2.5)a 2.3 (2.8) 1.7 (2.8)a 1.0 (2.8) Side-to side difference significantly lower compared to preoperative results (p < 0.01).
a
A. Urhausen et al.
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ORIGINAL PAPER / SPECIAL ISSUE Sports Orthop. Traumatol. xx, xx–xx (2016)
groups. The same observation was made for IKDC score (HS: median 61, 60, 75, 84, 95 for preoperative, 6 weeks, 3 months, 6 months and 12 months after the ACL reconstruction respectively; BPTB: median 68, 54, 70, 77, 90 for preoperative, 6 weeks, 3 months, 6 months and 12 months after the ACL reconstruction respectively). Twelve months after the ACL reconstruction, no difference was observed in median KOOS and IKDC scores between both grafts.
Discussion
Figure 1 Deficit between legs in concentric quadriceps force (A), concentric hamstring force (B) and eccentric hamstring force (C) in patients with a hamstring (HS) (blue) and bone patella tendon bone (BPTB) (orange) graft evaluated before surgery and 3, 6 and 12 months after the ACL reconstruction.
4
A. Urhausen et al.
The anterior cruciate ligament clinical pathway
The present study allowed to establish references values for IKDC and KOOS scores, anterior and rotational knee laxity, knee flexors and extensors force and hop tests at different time points of a follow-up for ACLreconstructed patients. These references allowed to highlight the average progression of the latter through the course of their rehabilitation. Patients with a BPTB graft displayed higher deficits in concentric quadriceps force and hop tests compared to patients operated with a HS graft. To the opposite, the former displayed higher subjective scores. The present clinical pathway integrates the different aspects of injuries, as defined by the International Classification of Functioning, Disability and Health, such as impairment of the body functions and structure, limitation in activities and restriction in participation [1,4]. These results may be used as quality control indicators. The decreasing side-to-side difference in anterior knee laxity measurements indicates an objective stabilization of the knee after surgery. The force deficits observed in the operated leg and hop tests decreased throughout the follow-up while subjective IKDC and KOOS scores increased. Whether one or several of the aspects evaluated in this clinical pathway are in relation with
ORIGINAL PAPER / SPECIAL ISSUE Sports Orthop. Traumatol. xx, xx–xx (2016)
Table 3. Deficit between legs in the three hop tests performed of the hamstring (HS) and bone patella tendon bone (BPTP) graft groups at 6 and 12 months after surgery. 6 months
N Vertical jump Hop for distance Side hop
12 months
HS
BPTB
HS
BPTB
47 11 (13) 7 (12) 12 (17)
74 20 (16)b 12 (12)b 18 (22)
28 5 (10) 2 (7)a 3 (12)a
44 13 (10)a,b 7 (10)a,b 9 (14)a,b
Deficit significantly lower at 12 months compared to 6 months after the ACL reconstruction (p < 0.05). Deficit significantly greater in BPTB group compared to HS group (p < 0.05).
a
b
A.
100
*
** *
80
*
*
*
* 60
* 40
Before surgery (n=75)
*
6 weeks aer surgery (n=86) 3 months aer surgery (n=96) 20
6 months aer surgery (n=70) 12 months aer surgery (n=33)
0 KOOS Pain
B.
KOOS Symptoms
KOOS ADL
KOOS Sport
KOOS QoL
100
80
60
40
Before surgery (n=96) 6 weeks aer surgery (n=108)
20
3 months aer surgery (n=116) 6 months aer surgery (n=101) 12 months aer surgery (n=50)
0 KOOS Pain
KOOS Symptoms
KOOS ADL
KOOS Sport
KOOS QoL
Figure 2 Median scores of the KOOS subscales (pain, symptoms, activity in daily living (ADL), sports and quality of life (QoL)) for hamstring (HS) (A) and bone patella tendon bone (BPTB) (B) reconstructed patients evaluated before surgery and 6 weeks and 3, 6, 12 months after the ACL reconstruction. * Median score for HS group significantly different than for BPTB group.
A. Urhausen et al.
an increased risk for a recurrent ACL injury is still unknown. These results may however be considered in the future to better determine when a safe return to sport is appropriate [3]. The clinical pathway is a center-based registry, based on collaboration between a single healthcare institution and an institution of healthcare research. To secure a continuous and complete flow of data strong multidisciplinary collaboration was necessary. This required an increase in interdisciplinary thinking among healthcare providers and the permission of the respective institutions to create the conditions for collaborative participation of several professional groups in various healthcare sectors (i.e. from nurses to physiotherapists) for the benefit of the patients. It consisted of systematic electronic recordings of medical data including information of clinical, surgical and functional outcomes. This facilitates internal quality control and will allow for ‘‘external benchmarking’’. In addition, such a collective effort may address another limitation of the current registries which is the limited depth and potential incompleteness of the recorded data. The present study is not without limitations. The differences observed between BPTB and HS groups may be partly explained by the heterogeneity of the population. Indeed, the graft choice may differ according to
The anterior cruciate ligament clinical pathway
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ORIGINAL PAPER / SPECIAL ISSUE Sports Orthop. Traumatol. xx, xx–xx (2016)
gender, age, sport level as well as previous and associated knee injuries. Further studies establishing specific references dedifferentiating patient’s profiles according to the previously cited aspects are thus required in order to individualize care [1,4]. All patients were recruited from the same hospital so that the references may be specific of the local patient population. As such, they maybe used with caution in other geographical areas. Besides the patients, which did not meet the hop tests, inclusion criteria were not taken into consideration in the results of the hop performance. The number of patients who were not able to hop 6 or 12 months after surgery may have biased our results.
Conclusion To conclude this study allowed to establish references values for the knee function of an ACL-reconstructed population through their rehabilitation period. At the end of the follow-up, patients displayed in average normalized values compared to a non-injured population. Although patients with a BPTB graft displayed higher deficits in concentric quadriceps force and hop tests compared to patients operated with a HS graft, they displayed higher subjective scores. In the future, standardized references considering gender, age, pre-injury level of practice and associated injuries are needed in order to have specific references and to find the most adapted management for each patient profile.
Conflict of interest There is no conflict of interest.
Acknowledgements The authors would like to acknowledge the members of the Department of Physiotherapy of the Centre Hospitalier de Luxembourg – Clinique d’Eich (Anne Frisch, Danielle Schaack, Jeroˆme Pauls, Laurent Radrizzi, Louis Wennig) as well as the clinical research nurse, Christiane Klinckers.
[10]
[11] [1] E. Ageberg, et al., Sex differences in patient-reported outcomes after anterior cruciate ligament reconstruction: data from the Swedish knee ligament register, Am. J. Sports Med. 38 (7) (2010) 1334–1342. [2] C.L. Ardern, et al., Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play, Br. J. Sports Med. 45 (7) (2011) 596–606. [3] C.L. Ardern, et al., Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery, Am. J. Sports Med. 39 (3) (2011) 538–543. [4] N. Desai, et al., Outcomes after ACL reconstruction with focus on older patients: results from The Swedish National Anterior Cruciate Ligament Register, Knee Surg. Sports Traumatol. Arthrosc. 22 (2) (2014) 379–386. [5] R.B. Frobell, L.S. Lohmander, H.P. Roos, Acute rotational trauma to the knee: poor agreement between clinical assessment and magnetic resonance imaging findings, Scand. J. Med. Sci. Sports 17 (2) (2007) 109–114. [6] L.P. Granan, et al., The Scandinavian ACL registries 2004–2007: baseline epidemiology, Acta Orthop. 80 (5) (2009) 563–567. [7] A. Gustavsson, et al., A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction,
ScienceDirect A. Urhausen et al.
[9]
References
Available online at www.sciencedirect.com
6
[8]
The anterior cruciate ligament clinical pathway
[12]
[13]
[14]
[15]
[16]
Knee Surg. Sports Traumatol. Arthrosc. 14 (8) (2006) 778–788. L.D. Higgins, et al., Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form, Joint Bone Spine 74 (6) (2007) 594–599. T. Krosshaug, et al., Mechanisms of anterior cruciate ligament injury in basketball: video analysis of 39 cases, Am. J. Sports Med. 35 (3) (2007) 359–367. G.B. Maletis, M.C. Inacio, T.T. Funahashi, Analysis of 16,192 anterior cruciate ligament reconstructions from a community-based registry, Am. J. Sports Med. 41 (9) (2013) 2090–2098. C. Mouton, et al., Combined anterior and rotational laxity measurements allow characterizing personal knee laxity profiles in healthy individuals, Knee Surg. Sports Traumatol. Arthrosc. 23 (12) (2015) 3571–3577. O.E. Olsen, et al., Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis, Am. J. Sports Med. 32 (4) (2004) 1002–1012. P.A. Renstrom, Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sport: recent evidence and a personal reflection, Br. J. Sports Med. 47 (6) (2013) 367–372. E.M. Roos, et al., Knee Injury and Osteoarthritis Outcome Score (KOOS) – development of a self-administered outcome measure, J. Orthop. Sports Phys. Ther. 28 (2) (1998) 88–96. R. Seil, et al., There is no such thing like a single ACL injury: profiles of ACLinjured patients, Orthop Traumatol Surg Res 102 (1) (2016) 105–110. A.J. Wiggins, et al., Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis, Am. J. Sports Med. (2016), http://dx.doi.org/ 10.1177/036354651562155, Published online before print January 15, 2016.
Corresponding author: Prof. Romain Seil, Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg – Clinique d’Eich, Luxembourg. E-Mail: [email protected]
ORIGINAL PAPER / SPECIAL ISSUE
Orthopaedics Traumatology
Sports Orthop. Traumatol. xx, xx–xx (2016) ß Elsevier GmbH www.SOTjournal.com http://dx.doi.org/10.1016/j.orthtr.2016.03.050
and
Summary Purpose: To systematically record preand post-operative clinical data after ACL reconstruction in an institutional clinical pathway. Material and methods: From 2011 to 2014, 285 patients had an ACL reconstruction with a bone patellar tendon bone (BPTB) (n = 123) or a hamstring (HS) (n = 162) auto-graft. Isokinetic quadriceps and hamstrings force, anterior and rotational knee laxity, hop tests and subjective knee function were evaluated. Results: All outcomes improved significantly throughout the follow-up. Anterior knee laxity was significantly improved by ACL reconstruction (p < 0.01). Quadriceps force deficit was significantly greater in BPTB group compared to HS group at all time points (p < 0.01). The same holds true for functional performance (p < 0.05). Discussion and conclusion: The present study highlighted the progression of ACL-reconstructed patients throughout their rehabilitation. The results of this institutional clinical pathway may serve as an internal and external benchmark, as well as a potential baseline to individualize patient care including return-to-sports. Keywords Knee – anterior cruciate ligament – surgery – knee function
A. Urhausen et al.
Der VKB-Behandlungspfad €glicht eine ermo systematische Erfassung klinischer Patientendaten Zusammenfassung Ziel: Im Rahmen eines institutionalisierten klinischen Behandlungspfades pr€aund postoperative klinische Daten von Patienten nach Rekonstruktion des vorderen Kreuzbandes (VKB) zu erfassen. Material und Methode: Zwischen 2011 und 2014 wurden 285 Patienten mit einer autologen VKB Ersatzplastik versorgt, davon erhielten 123 eine Patellarsehnenplastik (BPTB) und 162 eine
ORIGINAL PAPER / SPECIAL ISSUE
The anterior cruciate ligament clinical pathway: Towards a systematic evaluation of ACL injured patients Anouk Urhausen1,5, Caroline Mouton2, Roland Krecke1,5, Christian Nu€hrenbo€rger3, Alexander Hoffmann4, Dietrich Pape2,4, Romain Seil2,4 1 Department of Physiotherapy, Centre Hospitalier de Luxembourg – Clinique d’Eich, Luxembourg 2 Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg 3 Department of Sports Medicine, Centre Hospitalier de Luxembourg – Clinique d’Eich, Luxembourg 4 Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg – Clinique d’Eich, Luxembourg 5 Faculty of Health Sciences, LUNEX-International University of Health, Exercise and Sports, Luxembourg Eingegangen/submitted: 13.01.2016; u¨berarbeitet/revised: 18.03.2016; akzeptiert/accepted: 18.03.2016 Online verfu¨gbar seit/Available online: xxx
Introduction
O
ver two million anterior cruciate ligament (ACL) injuries occur worldwide each year [13]. Scandinavian registers reported that the annual incidence of primary ACL reconstructions is around 85 per 100 000 citizens in patients aged from 16 to 39 years [6]. The majority of these injuries (74%) are non-contact injuries and occur during landing and cutting movements [9,12]. Two thirds of ACL injuries occur during sporting activities [5]. After ACL reconstruction, only 63% of the patients were reported to return to their pre-injury level of activity [2]. In these patients, the overall re-injury rate (graft rupture or contralateral ACL injury) reaches in average 15% and can increase to 23% in athletes younger than 25 years who return to sports [16]. These unsatisfying outcomes illustrate the need for a better understanding of ACL injuries, as well as A. Urhausen et al.
an improvement in patient followup, rehabilitation and safe return to sports practice. In the absence of national ACL registries, the establishment of standardized, institutional clinical pathways may be a strategy to overcome this by providing an overview of the spectrum of ACL-injured patients and their outcomes [10]. In our institution, a clinical pathway for ACL tears was developed to monitor patients on a systematic basis. The ultimate goal of this data recording is to allow for a postoperative benchmarking of ACL reconstructed patients and. In addition, this may eventually allow to adapt individual postoperative patient care and rehabilitation in order to finally allow for a successful and safe return to sports. As an early step in this process, the purpose of this preliminary analysis was to establish reference values of muscle force, hop performances, anterior and rotational knee laxity as well
The anterior cruciate ligament clinical pathway
1
ORIGINAL PAPER / SPECIAL ISSUE Sports Orthop. Traumatol. xx, xx–xx (2016)
Grazilis-/Semitendinosusplastik (HS). Die isokinetische Kraft im Oberschenkel, die anteriore und Rotations-Laxit€at, die Sprungleistung sowie die subjektive Kniefunktion wurden untersucht. Ergebnisse: W€ahrend der gesamten Nachbehandlungsphase war eine signifikante Verbesserung aller Resultate zu sehen. Die anteriore Laxit€at war nach der VKB-Rekonstruktion signifikant verringert (p < 0.01). Der Vergleich der HS und BPTB-Plastik best€atigte ein gr€oßeres Defizit der Kraft im Quadriceps (p < 0.01) sowie der funktionellen Leistung (p < 0.05) bei Patienten mit einer BPTB-Plastik.
Diskussion und Schlussfolgerung: Die Studie objektiviert die progressive Verbesserung der erfassten Funktionswerte w€ahrend der Nachbehandlungsphase von Patienten nach VKBRekonstruktion. Die vorliegenden Ergebnisse des klinischen Behandlungspfades erm€oglichen interne und externe Referenzdaten, die in der individuellen Patientenversorgung einschließlich der Entscheidung zur Wiederaufnahme der sportlichen Aktivit€aten Ber€ucksichtigung finden sollte. €rter €sselwo Schlu Knie – vorderes Kreuzband – Kreuzbandersatzplastik – Kniefunktion
as subjective knee function of a prospective cohort of ACL reconstructed patients.
Material and methods Patients All ACL injured patients who were seen in our clinic were offered to enter a systematic and standardized followup regardless of the treatment decision (operative or nonoperative). Patients were included in the clinical pathway if they had an ACL tear, which was diagnosed clinically and documented on magnetic resonance imaging. They were recruited from March 2011 to September 2014 and were required to sign a consent agreement according to the National Ethics Committee for Research which approved the study protocol (N8 201101/05 version 1.0). Data acquisition was notified to the National Data Protection Committee. Only patients who underwent an anatomic single-bundle ACL reconstruction with a bone patellar tendon bone (BPTB) or 3 to 4-strand hamstring (HS) grafts were included in this study. Patients with associated cartilage damage and/or meniscal surgery (resection & repair) were included. Description of the ACL clinical pathway The clinical pathway is a centerbased registry [15]. Data were collected prospectively by surgeons, physiotherapists, study nurses and researchers and were saved in a
secure database (Table 1). Patients were evaluated before surgery (preop.), at 6 weeks, 3, 6 and 12 months after the ACL reconstruction. Several objective measurements were included in the pathway. Static anterior and rotational knee laxity measurements were performed with the GNRB® (GeNouRoB) and the Rotameter respectively before and at 3, 6 and 12 months after surgery according to previously published protocols [11]. As for anterior knee laxity, 3 separate trials were performed up to 200 N and the average of the 2 last trials was recorded. For rotational knee laxity, 4 separate trials were performed in internal rotation up to 6 Nm and the average of the 2 last trials was recorded. To evaluate muscle function, knee flexors and extensors force were recorded before and 3, 6 and 12 months after the surgery on the dynamometer Con-Trex®. The average peak torques of 4 repetitions of the concentric hamstring and quadriceps force as well as eccentric hamstring force were saved. Finally, to evaluate functional performance, patients were asked to perform three single-leg hop tests (hop for distance, vertical jump and side hop) at 6 and 12 months after ACL reconstruction according to the protocols previously published by Gustavsson et al. [7]. Admission criteria for the hop tests were: a deficit of the knee flexors and extensors of the operated knee compared to the healthy contralateral knee under 40%, an IKDC score over 70, no
Table 1. Data collection of the clinical pathway preoperatively (pre-op), at 6 weeks (w), 3, 6 and 12 months (m) after ACL-reconstruction.
IKDC + KOOS + VAS Anterior laxity + rotational laxity Isokinetics Hop test
2
A. Urhausen et al.
The anterior cruciate ligament clinical pathway
Pre-op
6w
3m
6m
12 m
ORIGINAL PAPER / SPECIAL ISSUE Sports Orthop. Traumatol. xx, xx–xx (2016)
swelling and no knee pain, free ROM, a negative pivot shift as well as subjective knee stability. To evaluate subjective outcomes, the Knee Injury and Osteoarthritis Outcome Score (KOOS) [14] and the International Knee Documentation Committee (IKDC) subjective forms [8] were completed by the patient before, 6 weeks, 3, 6 and 12 months after the surgery. Analysis The side-to-side differences in anterior displacement and knee rotation were expressed in millimeters and degrees respectively. Muscle force and hop performance were computed as the difference in percent of the operated leg compared with the contralateral healthy leg. Subjective knee function in sport and quality of life were calculated on a score of 100. Statistical analysis was performed using version 23.0 of the SPSS software. First, the normality of distribution of each outcome variable was tested using the Kolmogorov–Smirnov test for BPTB and HS grafts separately. If the outcomes were normally distributed, an ANOVA was computed to determine whether the outcomes varied between the different time points of the follow-up. A Bonferroni correction was computed for multiple comparisons. If the outcomes were not normally distributed, a Kruskal– Wallis test was computed to determine
whether the outcomes varied between the different time points of the followup. Significance was set at p < 0.05.
Results Between March 2011 and September 2014, 285 patients, thereof 123 (43%) with a BPTB autograft and 162 (57%) with a HS graft reconstruction were recruited. Eighty seven (30%) participants were females. At the time of surgery, the participants’ demographics were as follows (mean SD): age 29 10 years, weight 75 13 kg, and height 175 9 cm. The time between ACL injury and surgery was in average 400 694days. The side-to-side difference in anterior displacement was significantly decreased after the ACL reconstruction compared to the preoperative status both in the BPTB and HS groups (Table 2; p < 0.01). As for internal rotation, the side-to-side difference was not significantly different throughout the follow-up. No difference in knee laxity measurements could be observed between the BPTB and HS groups at any moment of the follow-up. The deficit in concentric quadriceps force (Fig. 1A) significantly differed between time points in both grafts (p < 0.01). The BPTB group displayed a greater concentric quadriceps force deficit than the HS group at all time points after surgery (p < 0.01), although the baseline preoperative
deficit between both groups was similar. The deficit in concentric hamstrings force (Fig. 1B) did also differ significantly between time points in both grafts (p < 0.01). For both grafts, the deficit was similar before and 3 months after surgery and then significantly decreased at 6 months (p < 0.01). No further evolution was observed between the deficit at 6 and 12 months after the surgery (ns). The deficit in eccentric hamstrings force (Fig. 1C) differed significantly between time points in both grafts (p < 0.01). While the eccentric hamstrings force deficit was significantly greater in HS grafts 3 months after the surgery compared to BPTB grafts (p < 0.01), the deficit was similar at 6 and 12 months after the reconstruction. As for the functional performance, deficits of the operated leg in hop tests were significantly lower at 12 months compared to 6 months after surgery (Table 3). The BPTB group displayed increased deficits compared to the HS group both at 6 and 12 months after the ACL reconstruction (p < 0.05). Subjective scores were not normally distributed. Non-parametric tests were therefore used to compare the scores between the different time points of the follow-up as well as between grafts. Median KOOS scores increased throughout the postoperative follow-up for both HS (p < 0.01; Fig. 2A) and BPTB (p < 0.01; Fig. 2B)
Table 2. Side-to-side differences before and at 3, 6 and 12 months after surgery in the hamstring (HS) and bone patella tendon bone (BPTP) graft groups in anterior displacement measured with the GNRB in millimeters (mm) and in knee rotation measured with the rotameter in degrees (8). Preoperatively HS
3 months BPTB
HS
6 months BPTB
HS
12 months BPTB
HS
BPTB
N 71 97 95 116 68 100 32 49 GNRB (mm) 2.1 (1.7) 2.4 (1.7) 1.0 (1.6)a 1.0 (1.3) 1.1 (1.7)a 1.4 (1.3) 0.6 (1.9)a 1.1 (1.4) Rotameter (8) 2.1 (2.9) 1.8 (2.9) 1.8 (3.5)a 2.1 (2.9) 2.3 (2.5)a 2.3 (2.8) 1.7 (2.8)a 1.0 (2.8) Side-to side difference significantly lower compared to preoperative results (p < 0.01).
a
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groups. The same observation was made for IKDC score (HS: median 61, 60, 75, 84, 95 for preoperative, 6 weeks, 3 months, 6 months and 12 months after the ACL reconstruction respectively; BPTB: median 68, 54, 70, 77, 90 for preoperative, 6 weeks, 3 months, 6 months and 12 months after the ACL reconstruction respectively). Twelve months after the ACL reconstruction, no difference was observed in median KOOS and IKDC scores between both grafts.
Discussion
Figure 1 Deficit between legs in concentric quadriceps force (A), concentric hamstring force (B) and eccentric hamstring force (C) in patients with a hamstring (HS) (blue) and bone patella tendon bone (BPTB) (orange) graft evaluated before surgery and 3, 6 and 12 months after the ACL reconstruction.
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The present study allowed to establish references values for IKDC and KOOS scores, anterior and rotational knee laxity, knee flexors and extensors force and hop tests at different time points of a follow-up for ACLreconstructed patients. These references allowed to highlight the average progression of the latter through the course of their rehabilitation. Patients with a BPTB graft displayed higher deficits in concentric quadriceps force and hop tests compared to patients operated with a HS graft. To the opposite, the former displayed higher subjective scores. The present clinical pathway integrates the different aspects of injuries, as defined by the International Classification of Functioning, Disability and Health, such as impairment of the body functions and structure, limitation in activities and restriction in participation [1,4]. These results may be used as quality control indicators. The decreasing side-to-side difference in anterior knee laxity measurements indicates an objective stabilization of the knee after surgery. The force deficits observed in the operated leg and hop tests decreased throughout the follow-up while subjective IKDC and KOOS scores increased. Whether one or several of the aspects evaluated in this clinical pathway are in relation with
ORIGINAL PAPER / SPECIAL ISSUE Sports Orthop. Traumatol. xx, xx–xx (2016)
Table 3. Deficit between legs in the three hop tests performed of the hamstring (HS) and bone patella tendon bone (BPTP) graft groups at 6 and 12 months after surgery. 6 months
N Vertical jump Hop for distance Side hop
12 months
HS
BPTB
HS
BPTB
47 11 (13) 7 (12) 12 (17)
74 20 (16)b 12 (12)b 18 (22)
28 5 (10) 2 (7)a 3 (12)a
44 13 (10)a,b 7 (10)a,b 9 (14)a,b
Deficit significantly lower at 12 months compared to 6 months after the ACL reconstruction (p < 0.05). Deficit significantly greater in BPTB group compared to HS group (p < 0.05).
a
b
A.
100
*
** *
80
*
*
*
* 60
* 40
Before surgery (n=75)
*
6 weeks aer surgery (n=86) 3 months aer surgery (n=96) 20
6 months aer surgery (n=70) 12 months aer surgery (n=33)
0 KOOS Pain
B.
KOOS Symptoms
KOOS ADL
KOOS Sport
KOOS QoL
100
80
60
40
Before surgery (n=96) 6 weeks aer surgery (n=108)
20
3 months aer surgery (n=116) 6 months aer surgery (n=101) 12 months aer surgery (n=50)
0 KOOS Pain
KOOS Symptoms
KOOS ADL
KOOS Sport
KOOS QoL
Figure 2 Median scores of the KOOS subscales (pain, symptoms, activity in daily living (ADL), sports and quality of life (QoL)) for hamstring (HS) (A) and bone patella tendon bone (BPTB) (B) reconstructed patients evaluated before surgery and 6 weeks and 3, 6, 12 months after the ACL reconstruction. * Median score for HS group significantly different than for BPTB group.
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an increased risk for a recurrent ACL injury is still unknown. These results may however be considered in the future to better determine when a safe return to sport is appropriate [3]. The clinical pathway is a center-based registry, based on collaboration between a single healthcare institution and an institution of healthcare research. To secure a continuous and complete flow of data strong multidisciplinary collaboration was necessary. This required an increase in interdisciplinary thinking among healthcare providers and the permission of the respective institutions to create the conditions for collaborative participation of several professional groups in various healthcare sectors (i.e. from nurses to physiotherapists) for the benefit of the patients. It consisted of systematic electronic recordings of medical data including information of clinical, surgical and functional outcomes. This facilitates internal quality control and will allow for ‘‘external benchmarking’’. In addition, such a collective effort may address another limitation of the current registries which is the limited depth and potential incompleteness of the recorded data. The present study is not without limitations. The differences observed between BPTB and HS groups may be partly explained by the heterogeneity of the population. Indeed, the graft choice may differ according to
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gender, age, sport level as well as previous and associated knee injuries. Further studies establishing specific references dedifferentiating patient’s profiles according to the previously cited aspects are thus required in order to individualize care [1,4]. All patients were recruited from the same hospital so that the references may be specific of the local patient population. As such, they maybe used with caution in other geographical areas. Besides the patients, which did not meet the hop tests, inclusion criteria were not taken into consideration in the results of the hop performance. The number of patients who were not able to hop 6 or 12 months after surgery may have biased our results.
Conclusion To conclude this study allowed to establish references values for the knee function of an ACL-reconstructed population through their rehabilitation period. At the end of the follow-up, patients displayed in average normalized values compared to a non-injured population. Although patients with a BPTB graft displayed higher deficits in concentric quadriceps force and hop tests compared to patients operated with a HS graft, they displayed higher subjective scores. In the future, standardized references considering gender, age, pre-injury level of practice and associated injuries are needed in order to have specific references and to find the most adapted management for each patient profile.
Conflict of interest There is no conflict of interest.
Acknowledgements The authors would like to acknowledge the members of the Department of Physiotherapy of the Centre Hospitalier de Luxembourg – Clinique d’Eich (Anne Frisch, Danielle Schaack, Jeroˆme Pauls, Laurent Radrizzi, Louis Wennig) as well as the clinical research nurse, Christiane Klinckers.
[10]
[11] [1] E. Ageberg, et al., Sex differences in patient-reported outcomes after anterior cruciate ligament reconstruction: data from the Swedish knee ligament register, Am. J. Sports Med. 38 (7) (2010) 1334–1342. [2] C.L. Ardern, et al., Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play, Br. J. Sports Med. 45 (7) (2011) 596–606. [3] C.L. Ardern, et al., Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery, Am. J. Sports Med. 39 (3) (2011) 538–543. [4] N. Desai, et al., Outcomes after ACL reconstruction with focus on older patients: results from The Swedish National Anterior Cruciate Ligament Register, Knee Surg. Sports Traumatol. Arthrosc. 22 (2) (2014) 379–386. [5] R.B. Frobell, L.S. Lohmander, H.P. Roos, Acute rotational trauma to the knee: poor agreement between clinical assessment and magnetic resonance imaging findings, Scand. J. Med. Sci. Sports 17 (2) (2007) 109–114. [6] L.P. Granan, et al., The Scandinavian ACL registries 2004–2007: baseline epidemiology, Acta Orthop. 80 (5) (2009) 563–567. [7] A. Gustavsson, et al., A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction,
ScienceDirect A. Urhausen et al.
[9]
References
Available online at www.sciencedirect.com
6
[8]
The anterior cruciate ligament clinical pathway
[12]
[13]
[14]
[15]
[16]
Knee Surg. Sports Traumatol. Arthrosc. 14 (8) (2006) 778–788. L.D. Higgins, et al., Reliability and validity of the International Knee Documentation Committee (IKDC) Subjective Knee Form, Joint Bone Spine 74 (6) (2007) 594–599. T. Krosshaug, et al., Mechanisms of anterior cruciate ligament injury in basketball: video analysis of 39 cases, Am. J. Sports Med. 35 (3) (2007) 359–367. G.B. Maletis, M.C. Inacio, T.T. Funahashi, Analysis of 16,192 anterior cruciate ligament reconstructions from a community-based registry, Am. J. Sports Med. 41 (9) (2013) 2090–2098. C. Mouton, et al., Combined anterior and rotational laxity measurements allow characterizing personal knee laxity profiles in healthy individuals, Knee Surg. Sports Traumatol. Arthrosc. 23 (12) (2015) 3571–3577. O.E. Olsen, et al., Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis, Am. J. Sports Med. 32 (4) (2004) 1002–1012. P.A. Renstrom, Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sport: recent evidence and a personal reflection, Br. J. Sports Med. 47 (6) (2013) 367–372. E.M. Roos, et al., Knee Injury and Osteoarthritis Outcome Score (KOOS) – development of a self-administered outcome measure, J. Orthop. Sports Phys. Ther. 28 (2) (1998) 88–96. R. Seil, et al., There is no such thing like a single ACL injury: profiles of ACLinjured patients, Orthop Traumatol Surg Res 102 (1) (2016) 105–110. A.J. Wiggins, et al., Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis, Am. J. Sports Med. (2016), http://dx.doi.org/ 10.1177/036354651562155, Published online before print January 15, 2016.
Corresponding author: Prof. Romain Seil, Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg – Clinique d’Eich, Luxembourg. E-Mail: [email protected]