Barbara Wondrasch

Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction.

PurposeThe purpose of this article is to present recommendations for new muscle strength and hop performance criteria prior to a return to sports after anterior cruciate ligament (ACL) reconstruction.MethodsA search was made of relevant literature relating to muscle function, self-reported questionnaires on symptoms, function and knee-related quality of life, as well as the rate of re-injury, the rate of return to sports and the development of osteoarthritis after ACL reconstruction. The literature was reviewed and discussed by the European Board of Sports Rehabilitation in order to reach consensus on criteria for muscle strength and hop performance prior to a return to sports.ResultsThe majority of athletes that sustain an (ACL) injury do not successfully return to their pre-injury sport, even though most athletes achieve what is considered to be acceptable muscle function. On self-reported questionnaires, the athletes report high ratings for fear of re-injury, low ratings for their knee function during sports and low ratings for their knee-related quality of life.ConclusionThe conclusion is that the muscle function tests that are commonly used are not demanding enough or not sensitive enough to identify differences between injured and non-injured sides. Recommendations for new criteria are given for the sports medicine community to consider, before allowing an athlete to return to sports after an ACL reconstruction.Level of evidence IV.

Autologous Chondrocyte Implantation Postoperative Care and Rehabilitation Science and Practice

Autologous chondrocyte implantation is an advanced, cell-based orthobiological technology used for the treatment of chondral defects of the knee. It has been in clinical use since 1987 and has been performed on 12 000 patients internationally; but despite having been in clinical use for more than 15 years, the evidence base for rehabilitation after autologous chondrocyte implantation is notably deficient. The authors review current clinical practice and present an overview of the principles behind autologous chondrocyte implantation rehabilitation practices. They examine the main rehabilitation components and discuss their practical applications within the overall treatment program, with the aim of facilitating the formulation of appropriate, individualized patient rehabilitation protocols for autologous chondrocyte implantation.

Effect of Accelerated Weightbearing After Matrix-Associated Autologous Chondrocyte Implantation on the Femoral Condyle on Radiographic and Clinical Outcome After 2 Years: A Prospective, Randomized Controlled Pilot Study

Background There is no consensus about the optimal time for weightbearing activities after matrix-associated autologous chon-drocyte implantation (MACI) of the femoral condyle. Hypothesis A comprehensive protocol after MACI on the femoral condyle with accelerated weightbearing leads to a better functional and radiographic outcome compared with the same comprehensive protocol with delayed weightbearing. Study Design Randomized controlled trial; Level of evidence, 1. Methods Thirty-one patients (22 male, 9 female) after MACI on the femoral condyle were randomly assigned to the accelerated weightbearing group (group A) or the delayed weightbearing group (group B). Aside from increase and time of full weightbearing, both groups adhered to the same rehabilitation protocol and exercises. Patients were assessed preoperatively and at 4, 12, 24, 52, and 104 weeks after surgery. Clinical evaluation was performed by determining the subjective form of the International Knee Documentation Committee (IKDC), the Tegner activity scale, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Radiological outcome was evaluated by the MOCART score and the size and amount of bone marrow edema and effusion. Results In both groups, there were no differences with regard to the clinical outcome. For the radiological outcome, group A showed a higher prevalence of bone marrow edema after 6 months without correlation to the clinical outcome (P 5 .06-.1). However, after 104 weeks, there were no differences in the radiological outcome between group A and group B. Conclusion A rehabilitation protocol with accelerated weightbearing leads to good clinical and functional outcome after 2 years without jeopardizing the healing graft.

Clinical and Radiological Outcomes 5 Years After Matrix-Induced Autologous Chondrocyte Implantation in Patients With Symptomatic, Traumatic Chondral Defects

Background: To date, few studies have been published reporting the 5-year follow-up of clinical and radiological outcomes for chondral defects treated with matrix-induced autologous chondrocyte implantation (MACI). Hypothesis: A significant improvement in clinical and radiological outcomes after treatment of symptomatic, traumatic chondral defects of the knee with the MACI implant will be maintained up to 5 years after surgery. Study Design: Case series; Level of evidence, 4. Methods: A prospective evaluation of the MACI procedure was performed in 21 patients with chondral defects of the knee. After the MACI procedure, patients were clinically assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS), the Tegner-Lysholm score, the International Knee Documentation Committee (IKDC) Subjective Knee Form, and the modified Cincinnati score at years 1, 2, and 5. The quality of repair tissue was assessed by magnetic resonance imaging using the magnetic resonance observation of cartilage repair tissue (MOCART) score at months 3 and 6 and years 1, 2, and 5. Results: Significant improvements (P < .05) were observed for all 5 KOOS subcategories at year 1 and were maintained through year 5 in 90.5% of patients (19/21). Treatment failure occurred in only 9.5% of patients (2/21). Significant improvements (P < .05) from baseline to year 5 were also observed for the IKDC score (30.1 to 74.3), the modified Cincinnati score (38.1 to 79.6), and the Tegner-Lysholm activity score (1.8 to 4.3). Similarly, the MOCART score significantly improved (P < .001) from baseline to year 5 (52.9 to 75.8). After 5 years, complete filling (83%) and integration (82%) of the graft were seen in the majority of patients. Signs of subchondral bone edema were still present in 47% of patients at 5 years. No product-specific adverse events were reported over the 5-year follow-up period. Conclusion: Patients treated with a MACI implant demonstrated significant clinical improvement and good quality repair tissue 5 years after surgery. The MACI procedure was shown to be a safe and effective treatment for symptomatic, traumatic chondral knee defects in this study.

Results 2 Years After Matrix-Associated Autologous Chondrocyte Transplantation Using the Novocart 3D Scaffold An Analysis of Clinical and Radiological Data

Background: A range of scaffolds is available from various manufacturers for cartilage repair through matrix-associated autologous chondrocyte transplantation (MACT), with good medium- to long-term results. Purpose: To evaluate clinical and magnetic resonance imaging (MRI) outcomes 2 years after MACT on the knee joint using the Novocart 3D scaffold based on a bilayered collagen type I sponge. Study Design: Case series; Level of evidence, 4. Methods: Of 28 initial patients, 23 were clinically and radiologically evaluated 24 months after transplantation. Indications for MACT were chondral or osteochondral lesions on the knee joint with a defect size >2 cm2, no instability, and no malalignment (axis deviation <5°). Then, MRI was performed on a 3-T scanner to assess the magnetic resonance observation of cartilage repair tissue (MOCART) and 3-dimensional (3D) MOCART scores. A variety of subjective scores (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Noyes sports activity rating scale, Tegner activity scale, and visual analog scale [VAS] for pain) were used for clinical evaluation. Results: Two years after MACT, the MRI evaluation showed a mean MOCART score of 73.2 ± 12.4 and a 3D MOCART score of 73.4 ± 9.7. Clinical results showed mean values of 69.8 ± 15.2 for the IKDC; 51.6 ± 21.2, 86.5 ± 13.9, 54.5 ± 23.6, 65.0 ± 8.0, and 91.5 ± 10.6 for the KOOS subscales (Quality of Life, Pain, Sports and Recreation, Symptoms, and Activities of Daily Living, respectively); 77.5 ± 12.7 for the Noyes scale; 4.4 ± 1.6 for the Tegner activity scale; and 1.8 ± 1.7 for the VAS, with statistically significant improvement in all scores other than KOOS-Symptoms. Conclusion: Undergoing MACT using the Novocart 3D scaffold is an applicable method to treat large focal chondral and osteochondral defects, with good short-term clinical and radiological results.

Clinical and Radiological Long-term Outcomes After Matrix-Induced Autologous Chondrocyte Transplantation A Prospective Follow-up at a Minimum of 10 Years

Background: It is unclear whether matrix-associated autologous chondrocyte transplantation (MACT) results in objective and subjective clinical improvements at 10 years after surgery. Hypothesis: Matrix-associated autologous chondrocyte transplantation will result in clinical and radiological improvements in patients with symptomatic, traumatic chondral defects of the knee joint. Study Design: Case series; Level of evidence, 4. Methods: A total of 16 patients with chondral defects of the knee were treated with MACT between November 2000 and April 2002 and evaluated for up to 10 years after the intervention. The International Knee Documentation Committee (IKDC) form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner activity score, Brittberg score, Noyes sports activity rating scale, and visual analog scale (VAS) for pain as well as 3-T magnetic resonance imaging (MRI) using the magnetic resonance observation of cartilage repair tissue (MOCART) score and functional evaluation by the limb symmetry index (LSI) formed the basis of this study. The Friedman test and the Wilcoxon signed-rank test were performed for a comparison between all time points and 2 separate time points, respectively. If significant differences were revealed, a Bonferroni adjustment to the α level was applied so that P values <.007 (<.05/7) were regarded as significant in the paired comparisons. Results: Significant improvements (P < .05) from baseline to 120 months postoperatively were observed for the IKDC score (mean, 44.1 ± 26.9 to 59.0 ± 27.4), Noyes sports activity rating score (mean, 37.7 ± 30.1 to 62.1 ± 31.3), and KOOS Quality of Life and Pain subscores, whereas no statistically significant improvement was detected for the Brittberg score, Tegner activity score, or VAS score. After 5 years, a slight downward tendency of all clinical scores was evident. After 10 years, the mean MOCART score was 70.4 ± 16.1. Complete filling of the defect was observed in 73.9% of cases, and osteophytes were present in 78.3%. In 65.2% of the cases, a subchondral bone edema <1 cm was visible, whereas in 21.7% of the cases, a subchondral bone edema >1 cm was seen. The mean LSI for the single-legged hop test was 95.6% ± 16.2% and for the triple hop test for distance was 91.3% ± 12.2%. The mean VAS score for self-perceived stability was 60.2 ± 3.5 (range, 0-9.5) for the injured and 60.7 ± 3.8 (range, 0-10) for the uninjured leg. No adhesions or effusions were seen regarding the clinical and radiological outcomes. Conclusion: The significantly improved results on 3 outcome measures after 10 years suggest that MACT represents a suitable option in the treatment of local cartilage defects in the knee.

The Feasibility of a 3-Month Active Rehabilitation Program for Patients With Knee Full-Thickness Articular Cartilage Lesions: The Oslo Cartilage Active Rehabilitation and Education Study

STUDY DESIGN Case series. OBJECTIVES To evaluate the feasibility of an active rehabilitation program for patients with knee full-thickness articular cartilage lesions. BACKGROUND No studies have yet evaluated the effect of active rehabilitation in patients with knee full-thickness articular cartilage lesions or compared the effects of active rehabilitation to those of surgical interventions. As an initial step, the feasibility of such a program needs to be described. METHODS Forty-eight patients with a knee full-thickness articular cartilage lesion and a Lysholm score below 75 participated in a 3-month active rehabilitation program consisting of cardiovascular training, knee and hip progressive resistance training, and neuromuscular training. Feasibility was determined by monitoring adherence to the program, clinical changes in knee function, load progression, and adverse events. Patients were tested before and after completing the rehabilitation program by using patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Evaluation Form 2000) and isokinetic muscle strength and hop tests. To monitor adherence, load progression, and adverse events, patients responded to an online survey and kept training diaries. RESULTS The average adherence rate to the rehabilitation program was 83%. Four patients (9%) showed adverse events, as they could not perform the exercises due to pain and effusion. Significant and clinically meaningful improvement was found, based on changes on the International Knee Documentation Committee Subjective Knee Evaluation Form 2000, the Knee injury and Osteoarthritis Outcome Score quality of life subscale, isokinetic muscle strength, and hop performance (P<.05), with small to large effect sizes (standardized response mean, 0.3-1.22). CONCLUSION The combination of a high adherence rate, clinically meaningful changes, and positive load progression and the occurrence of only a few adverse events support the potential usefulness of this program for patients with knee full-thickness cartilage lesions. This study was registered with the public trial registry ClinicalTrials.gov (NCT00885729). LEVEL OF EVIDENCE Therapy, level 4.

Ability to Return to Sports 5 Years After Matrix-Associated Autologous Chondrocyte Transplantation in an Average Population of Active Patients

Background: Cartilage injuries often occur during sports activities, and return to sports after cartilage surgery is an important outcome parameter for different treatment methods in the competitive as well as the recreationally active population. Hypothesis: At the time of midterm follow-up after matrix-associated autologous chondrocyte transplantation (MACT), return to recreational sports at the preinjury level will be possible. Study Design: Case series; Level of evidence, 4. Methods: Seventy patients (51 men, 19 women; age [mean ± standard deviation], 34.9 ± 8.6 y; range, 18-55 y) were clinically evaluated 5 years after MACT through subjective clinical scores such as the Knee Injury and Osteoarthritis Outcome Score (KOOS) sport and recreation subscales, the Tegner activity scale, and the Noyes sports activity rating scale. The level of sports participation was included in the investigation. Results: The results 5 years after MACT showed mean values of 60.1 for the KOOS–sport, 67.4 for the Noyes, and 3.8 for the Tegner scores, meaning that regular sports activity such as cycling or running on flat ground, as well as medium-level manual labor, is possible. We noted that 74.3% of our patients returned to at least their preinjury sports level. Conclusion: Midterm postoperative results after MACT show that in a moderately active population, participation in regular sports is possible for most patients, at least at their preinjury recreational level and intensity, and there is a good rate of return to sports.

Effect of Accelerated Weightbearing After Matrix-Associated Autologous Chondrocyte Implantation on the Femoral Condyle A Prospective, Randomized Controlled Study Presenting MRI-Based and Clinical Outcomes After 5 Years

Background: Long-term effects of different weightbearing (WB) modalities after matrix-associated autologous chondrocyte implantation (MACI) on changes in knee articular cartilage and clinical outcomes are needed to establish more evidence-based recommendations for postoperative rehabilitation. Hypothesis: There will be no differences between accelerated WB compared with delayed WB regarding knee articular cartilage or patient self-reported knee function or activity level 5 years after MACI. Furthermore, significant correlations between magnetic resonance imaging (MRI)–based outcomes and patient-reported outcome measures 5 years postoperatively will exist. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: After MACI, 31 patients (23 male, 8 female) were randomly assigned to the accelerated WB group (AWB group) or to the delayed WB group (DWB group). With the exception of time and increase to full WB, both groups underwent the same rehabilitation program. The AWB group was allowed full WB after 6 weeks and the DWB group after 10 weeks. Assessments were performed 3 months, 2 years, and 5 years postoperatively, but this long-term follow-up study only included changes from 2 to 5 years postoperatively. The magnetic resonance observation of cartilage repair tissue (MOCART) score (primary outcome), the MRI-based variables of bone edema and effusion, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Tegner scale were included. In addition, the association between MRI-based outcomes and the KOOS at 5 years postoperatively was investigated. Results: There was a significant decrease in the MOCART score and a significant increase in bone edema 2 and 5 years postoperatively but no significant group differences. The only significant correlation between the MRI-based variables and the KOOS was found for bone edema and the KOOS subscale of pain (r = −0.435, P < .05) at 5-year follow-up. Conclusion: There were no significant differences in the MRI-based or clinical outcomes between the AWB group and DWB group 5 years after MACI. While the clinical outcomes remained stable, a decline of the MRI-based findings was observed between 2 and 5 years postoperatively. Furthermore, a significant association between bone edema and pain was found. No occurrence of unintended effects was observed.

Within-assessor reliability and minimal detectable change of gait kinematics in a young obese demographic

INTRODUCTION Three-dimensional gait analysis (3DGA) in obese populations is a difficult task due to a great amount of subcutaneous fat. This makes it more challenging to identify anatomical landmarks, thus leading to inconsistent marker placement. Therefore, the purpose of this study was to investigate the test-retest reliability for kinematic measurements of obese children and adolescents. METHODS Nine males and two females with an age-based BMI above the 97th percentile (age: 14.6±2.6years, BMI: 33.4±4.4kg/m2) were administered to two 3DGA sessions. To quantify reliability of discrete parameters the intraclass correlation coefficient (ICC2,k), standard error of measurement (SEM) and minimal detectable change (MDC) were calculated. To quantify waveform similarity, the coefficient of multiple correlation (CMC) and the linear fit method (LFM) were used. RESULTS From 28 kinematic parameters, 23 showed acceptable ICCs (≥0.70) and the remaining parameters demonstrated moderate values. These were peak hip extension during stance (0.58), mean pelvis rotation (0.60), mean anterior pelvic tilt (0.64), peak knee flexion during swing (0.67) and peak hip abduction during swing (0.69). The SEM was below 5° for all parameters. The MDC for the sagittal, frontal, and transversal plane were on average 7.5°±2.2, 4.6°±1.3 and 6.0°±0.9 respectively. Both the LFM and CMC showed, in general, moderate to good reliability except for pelvis tilt and hip rotation. CONCLUSION Data demonstrated acceptable error margins especially for the sagittal and frontal plane. Low reliability for the pelvis tilt indicates that great effort is necessary to position the pelvic markers consistently during repeated sessions.