Adam G. Culvenor

Is patellofemoral joint osteoarthritis an under-recognised outcome of anterior cruciate ligament reconstruction? A narrative literature review

Patellofemoral joint (PFJ) osteoarthritis (OA) is a prevalent disease capable of being a potent source of knee symptoms. Although anterior cruciate ligament (ACL) injury and reconstruction (ACLR) are well-established risk factors for the development of tibiofemoral joint OA, PFJ OA after ACL reconstruction has gone largely unrecognised. This is despite the high prevalence of anterior knee pain after ACLR, which can reduce the capacity for physical activity and quality of life. The susceptibility of the PFJ to degenerative change after ACLR may have implications for current rehabilitation strategies. This review summarises the evidence describing the prevalence of PFJ OA after ACLR and examines why this compartment may be at increased risk of early onset OA after ACLR. Strategies that address the modifiable factors for risk of PFJ OA may aid in alleviating joint loads and symptoms for people after ACLR.

Early knee osteoarthritis is evident one year following anterior cruciate ligament reconstruction: a magnetic resonance imaging evaluation.

To determine the prevalence and factors associated with knee osteoarthritis (OA) defined by magnetic resonance imaging (MRI) and specific OA features on MRI 1 year after anterior cruciate ligament reconstruction (ACLR).

Changes in Knee Osteoarthritis, Symptoms, and Function After Anterior Cruciate Ligament Reconstruction A 20-Year Prospective Follow-up Study

Background: Progression of tibiofemoral (TF) and patellofemoral (PF) osteoarthritis (OA) and changes in knee function more than 15 years after anterior cruciate ligament reconstruction (ACLR) are not well understood. Purpose: To examine the progression of knee OA and changes in symptoms and function in isolated and combined injuries from 15 to 20 years after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 210 subjects with ACLR were prospectively followed. At the 15- and 20-year follow-ups, radiographs were obtained and classified by the Kellgren and Lawrence (K-L) grading system. Symptoms and function were evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS) as well as isokinetic quadriceps and hamstring muscle strength tests. Results: There were 168 subjects (80%) who returned for the 20-year follow-up, with a mean (±SD) age of 45 ± 9 years, mean body mass index of 27 ± 4, and median Tegner activity level of 4 (range, 0-9). The prevalence of radiographic TF and PF OA at the 20-year follow-up was 42% and 21%, respectively. Patients with ACL injuries and other combined injuries had significantly higher prevalence of radiographic TF OA compared with those who had isolated ACL injury (P < .0001). There was a 13% increase in radiographic TF OA (P = .001) and an 8% increase in PF OA (P = .015) from the 15- to the 20-year follow-up. A significant deterioration in knee symptoms and function was observed on the KOOS subscales (P ≤ .01), with the exception of quality of life (P = .14), as well as a decrease in quadriceps muscle strength and hamstring muscle strength (P < .0001). Conclusion: The prevalence of radiographic TF and PF OA was 42% and 21%, respectively. A significantly higher prevalence of TF OA was found for subjects with combined injuries compared with those who had isolated ACL injury. The majority of the subjects were stable radiographically over the 5 years between follow-ups. A statistically significant deterioration in symptoms and function was noted, but the mean changes were of questionable clinical importance.

Knee kinematics and joint moments during gait following anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Background Abnormal gait after anterior cruciate ligament reconstruction (ACLR) may contribute to development and/or progression of knee osteoarthritis. Objective To conduct a systematic review and meta-analysis of knee kinematics and joint moments during walking after ACLR. Methods We searched seven electronic databases and reference lists of relevant papers, for cross-sectional, human-based observational studies comparing knee joint kinematics and moments during level walking in individuals with ACLR, with the uninjured contralateral knee or healthy individuals as a control. Two independent reviewers appraised methodological quality (modified Downs and Black scale). Where possible, data were pooled by time post-ACLR (RevMan), otherwise narrative synthesis was undertaken. Results Thirty-four studies were included. Meta-analysis revealed significant sagittal plane deficits in ACLR knees. We found greater knee flexion angles (standardised mean difference: 1.06; 95% CI 0.39 to 1.74) and joint moments (1.61; 0.87 to 2.35) <6 months post-ACLR, compared to healthy controls. However, lower peak knee flexion angles were identified 1–3 years (−2.21; −3.16 to −1.26) and ≥3 years post-ACLR (−1.38, −2.14 to −0.62), and lower knee flexion moment 6–12 months post-ACLR (−0.76; −1.40 to −0.12). Pooled data provided strong evidence of no difference in peak knee adduction moment >3 years after ACLR (vs healthy controls) (0.09; −0.63 to 0.81). No transverse plane conclusions could be drawn. Conclusions Sagittal plane biomechanics, rather than the knee adduction moment, appear to be more relevant post-ACLR. Better understanding of sagittal plane biomechanics is necessary for optimal post-operative recovery, and to potentially prevent early onset and progression of knee OA after ACLR. Trial registration number PROSPERO systematic review protocol registration number CRD4201400882 2.

Patellofemoral osteoarthritis is prevalent and associated with worse symptoms and function after hamstring tendon autograft ACL reconstruction

Objectives To evaluate the compartmental distribution of knee osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR), to determine if patellofemoral or tibiofemoral OA is more strongly associated with knee symptoms and function, and to evaluate the contribution of associated injuries and surgical delay to the development of OA. Methods This cross-sectional study recruited 70 participants who underwent hamstring tendon (HT) ACLR 5–10 years previously. Radiographic OA was assessed according to the Osteoarthritis Research Society International (OARSI) criteria. Knee symptoms were assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Anterior Knee Pain Scale (AKPS), while function was assessed with three lower limb tasks (hop-for-distance, one-leg rise and side-hop). Multivariate and binary logistic regression analyses were performed to assess the relationship between OA and symptomatic/functional outcomes and associated injuries/surgical delay, respectively. Results Radiographic OA was observed in the patellofemoral (47%) and tibiofemoral joints (31%). Pain, symptoms and quality of life on the KOOS and the AKPS were associated with severity of patellofemoral OA (standardised regression coefficient (β)=−0.3 to −0.5, p=0.001–0.042), whereas only the KOOS-pain subscale was associated with tibiofemoral OA (β=−0.3, p=0.037). For each functional task, greater patellofemoral OA severity was associated with worse performance, independent of tibiofemoral OA severity (β=−0.3 to −0.4, p=0.001–0.026). Medial meniscal and patellofemoral chondral lesions at surgery were associated with tibiofemoral and patellofemoral OA development at follow-up, respectively, while a longer surgery delay was associated with patellofemoral OA. Conclusions Patellofemoral OA is common following HT ACLR and is associated with worse knee-related symptoms, including anterior knee pain, and decreased functional performance.

Quality of life in anterior cruciate ligament-deficient individuals: a systematic review and meta-analysis

Background Physical and psychological impairments impacting quality of life (QOL) are common following ACL reconstruction. Rehabilitation alone is an effective alternative to reconstruction for some patients, warranting the investigation of QOL in ACL-deficient individuals. Purpose To report and compare QOL in ACL-deficient individuals with population norms and ACL-reconstructed groups, and investigate relationships between participant characteristics and QOL. Study design Systematic review and meta-analysis. Methods We systematically identified and methodologically appraised all studies reporting QOL in ACL-deficient individuals ≥5 years following ACL rupture. Knee-related and health-related QOL scores in ACL-deficient cohorts were compared to ACL-reconstructed groups using a random-effects meta-analysis. Descriptive comparisons were made with population norms. Results Eleven studies reported QOL in 473 ACL-deficient individuals, a mean of 10 (range 5–23) years following ACL rupture. Eight studies reported knee-related QOL using the Knee injury and Osteoarthritis Outcome Score QOL subscale (KOOS-QOL); scores (mean±SD) ranging from 54±17 to 77±22 were impaired compared to population norms. Health-related QOL, measured with the SF-36 domain scores in five studies, was similar to population norms, but impaired compared to physically active populations. Meta-analysis revealed no significant differences in KOOS-QOL (mean difference (95% CI) 2.9 (−3.3 to 9.1)) and SF-36 scores (for all SF-36 domains except Vitality) between ACL-deficient and ACL-reconstructed groups. Conclusions This systematic review found impaired knee-related QOL in ACL-deficient individuals ≥5 years after ACL rupture, compared to population norms. Meta-analysis revealed similar knee-related QOL in ACL-deficient and ACL-reconstructed groups, and no difference in health-related QOL scores for seven of the eight SF-36 domains.

Are Knee Biomechanics Different in Those With and Without Patellofemoral Osteoarthritis After Anterior Cruciate Ligament Reconstruction

Patellofemoral (PF) osteoarthritis (OA) is prevalent following anterior cruciate ligament reconstruction (ACLR). This study aimed to investigate differences in transverse plane rotation between knees with varus and valgus alignment during gait in people with and without PFOA after ACLR.

Infrapatellar fat pad size, but not patellar alignment, is associated with patellar tendinopathy

Patellar tendinopathy (PT) is one of the most common overuse injuries of the knee. Recent reports indicate that increased body mass is frequently associated with tendinopathy, not only biomechanically but biochemically. Abnormalities of other structures within the knee extensor mechanism [patellofemoral joint (PFJ) alignment and patellar tendon length] that can directly influence the strain distribution of the patellar tendon are inconsistently implicated in PT. The aim of this study was to compare the infrapatellar fat pad volume, patellar tendon length and PFJ alignment in people with chronic PT and a group of age‐, gender‐, height‐, and activity‐matched controls with normal tendons. Axial magnetic resonance (MR) images, from 26 participants with PT and 28 control participants were obtained. Fat pad size, patellar tendon length and PFJ alignment were measured digitally from the MR images, using measurement software, and the results compared between the PT group and control group. People with PT had a significantly larger fat pad than healthy controls when controlled for height (P=0.04). Patellar tendon length was not significantly different between groups (P=0.16), nor were there between‐group differences for the measures of PFJ alignment (P=0.07–0.76). Thus, the infrapatellar fat pad may play an important role in PT.

Professional pathways towards excellence in sports physiotherapy: opportunities and barriers

If you want to be around in 10 years you’ve got to do something to differentiate yourself from the pack. Christopher Evans The number of physiotherapists around the world is increasing. Data from the UK show that the number of registered physiotherapists increased by 41% between 2000 and 2009.1 In Canada, a 7.5% increase in the number of registered physiotherapists occurred between 2007 and 2011.2 The increase in the number of undergraduate and graduate entry physiotherapy programmes in Australia has also created higher numbers of qualified physiotherapists.3 While this growth in the international physiotherapy profession is positive, particularly in regard to meeting current and future needs of an ageing global population, a higher number of physiotherapists may create professional and personal challenges. Such challenges likely include greater market competition to attract consumers (ie, patients) in the private sector, and a greater number of candidates applying for particular physiotherapy positions; good for organisations, more difficult for individual …

Early Patellofemoral Osteoarthritis Features One Year After Anterior Cruciate Ligament Reconstruction: Symptoms and Quality of Life at Three Years.

To determine whether the presence of magnetic resonance imaging (MRI) osteoarthritis (OA) features in the patellofemoral or tibiofemoral joint (i.e., bone marrow lesions, cartilage lesions, and osteophytes) and/or functional impairments, 1 year following anterior cruciate ligament reconstruction (ACLR), can predict Knee Injury and Osteoarthritis Outcome Score (KOOS) at 3 years.