Handout: Early Surgery Speaker Bailey (55 min)

Transcription

1 Session smp-11 Handouts Title: Should we focus on extended prehab or getting surgery ASAP after an ACL tear? Date: Friday, February 23,2018 Start/End Time: 11:00al-1:00aL Speakers: Lane Bailey, PT, PhD; Ryan Zarzycki, PT, PhD Handout: I. Early Surgery Speaker Bailey (55 min) A Look At The Numbers 1. Injury to chondral and meniscal tissues is commonly found with both acute and chronic anterior cruciate ligament (ACL) ruptures 1. McDonald L, Boorman-Padgett J, et al. ACL Deficiency Increases Forces on the Medial Femoral Condyle and the Lateral Meniscus with Applied Rotatory Loads, JBJS 2016;98: Chondral injuries are reported in up to 23% of individuals undergoing acute ACL reconstruction and 54% of those undergoing delayed ACL reconstruction 1. Indelicato PA, Bittar ES. A perspective of lesions associated with ACL insufficiency of the knee. A review of 100 cases. Clin Orthop Relat Res Sep;198: Meniscal injury is observed in up to 89% of those undergoing delayed ACL reconstruction Let s Define Our Terms: How Early is Too Early??? 1. EARLY WITHIN REASON! 1. Restore Knee Extension 2. Reduce Joint Effusion, Capsular and Soft-Tissue Irritation 3. Regain Quadriceps Muscle Activation 2. Ideal is 8-21 days 1. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M (1991) Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med 19: Mechanical Changes to the Knee 1. Increased translation (Anterior & Internal Rotation) 1. Noyes FR1, Jetter AW2, Grood ES3, Harms SP2, Gardner EJ2, Levy MS4. Anterior cruciate ligament function in providing rotational stability assessed by medial and lateral tibiofemoral compartment translations and subluxations. Am J Sports Med Defrate LE, Papannagari R, Gill TJ, Moses JM, Pathare NP, Li G. The 6 degrees of freedom kinematics of the knee after anterior cruciate ligament deficiency: an in vivo imaging analysis. Am J Sports Med. 2006;34:

2 3. Shefelbine SJ, Ma CB, Lee KY, et al. MRI analysis of in vivo meniscal and tibiofemoral kinematics in ACL-deficient and normal knees. J Orthop Res. 2006;24: Increased Shear Forces & Contact Pressures 1. McDonald L, Boorman-Padgett J, et al. ACL Deficiency Increases Forces on the Medial Femoral Condyle and the Lateral Meniscus with Applied Rotatory Loads, JBJS 2016;98: More Posteriorly Directed a. Arner, Tashman et al, Effects of ACL deficiency on Loading Mechanics for Men & Cartilage OJSM Increased Risk for Subsequent Subluxation(s) 1. Noyes FR1, Jetter AW2, Grood ES3, Harms SP2, Gardner EJ2, Levy MS4. Anterior cruciate ligament function in providing rotational stability assessed by medial and lateral tibiofemoral compartment translations and subluxations. Am J Sports Med Mar;43(3): doi: / Dec Arner, Tashman et al, Effects of ACL deficiency on Loading Mechanics for Meniscus andcartilage OJSM 2016 Demands to Secondary Restraints 1. Medial Meniscus Load 1. Allen CR, Wong EK, Livesay GA, Sakane M, Fu FH, Woo SLY. Importance of the medial meniscus in the anterior cruciate ligament deficient knee. J Orthop Res. 2000;18(1): Keene GC, Bickerstaff D, Rae PJ, Paterson RS. The natural history of meniscal tears in anterior cruciate ligament insufficiency. Am J Sports Med. 1993;21(5): Levy I, Torzilli P, Warren R. The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am. 1982;64(6): Lateral Meniscus Load 1. Noyes FR, Chen RC, Barber-Westin SD, Potter HG. Greater than 10- year results of red-white longitudinal meniscal repairs in patients 20 years of age or younger. Am J Sports Med. 2011;39(5): Li G, Moses JM, Papannagari R, Pathare NP, DeFrate LE, Gill TJ. Anterior cruciate ligament deficiency alters the in vivo motion of the tibiofemoral cartilage contact points in both the anteroposterior and mediolateral directions. J Bone Joint Surg Am Aug;88(8): While the knee is subluxated, the lateral meniscus encounters greater forces than encountered in ACL-intact knees without this subluxation 1. Keene GC, Bickerstaff D, Rae PJ, Paterson RS. The natural history of meniscal tears in anterior cruciate ligament insufficiency. Am J Sports Med Sep-Oct;21(5):672-9.

3 2. Smith JP, Barrett GR. Medial and lateral meniscal tear patterns in anterior cruciate ligament-deficient knees: a prospective analysis of 575 tears. Am J Sports Med. 2001;29(4): Chondral Stress 1. Fairclough JA, Graham GP, Dent CM. Radiological sign of chronic anterior cruciate ligament deficiency. Injury Nov;21(6): McDonald L, Boorman-Padgett J, et al. ACL Deficiency Increases Forces on the Medial Femoral Condyle and the Lateral Meniscus with Applied Rotatory Loads, JBJS 2016;98: Tissue Adaptation 1. Soft-tissue Accommodation 1. Indelicato PA, Bittar ES. A perspective of lesions associated with ACL insufficiency of the knee: a review of 100 cases. Clin Orthop Relat Res. 1985;198: Hamstring Excitement 1. Warren LF, Marshall JL. The supporting structures and layers on the medial side of the knee: an anatomical analysis. J Bone Joint Surg Am. 1979;61(1): Semi-membranosis excitation 4. Proprioceptive Changes Fending-Off Osteoarthritis 1. Happens regardless of reconstruction 2. What s the impact of prolonged instability 1. Arner, Tashman et al, Effects of ACL deficiency on Loading Mechanics for Men & Cartilage OJSM Goal is to Preserve Quality of Life Practical Considerations! 1. Popular Press 2. Patient Expectations & Mechanical Instability 1. Houck J, Lerner A, Gushue D, Yack HJ. Self-reported giving-way episode during a stepping-down task: case report of a subject with an ACL-deficient knee. J Orthop Sports Phys Ther May;33(5):273-82; discussion Insurance Benefits II. Extended Prehab Zarzycki (55 min) Advantages of Preoperative Rehabilitation ( Prehabilitation ) prior to ACL Reconstruction 1. Overview a. What do we mean by prehab? i. Addressing impairments beyond a quiet knee (i.e. full ROM and minimal/no effusion) ii. Components include progressive OKC and CKC strengthening (focus on quadriceps and hamstring groups), plyometric training, agility training, neuromuscular training (e.g. perturbation training) b. General Theory

4 i. Optimal preoperative knee function will lead to better post-operative knee function Evidence in support of comprehensive prehabilitation programs a. Cohort study i. 5 week progressive exercise program consisting of strength training, plyometric exercises, balance/stability exercises, and perturbation training led to improved knee function (i.e. quad and hamstring strength, single legged hop performance immediately following the program. 2 b. RCT i. 6 week preoperative program led to improved functional performance and self-reported function following the program and at 12 weeks after ACLR. 8 c. Comparative effectiveness studies i. Delaware-Oslo cohort (DOC) compared to Norwegian National Knee Ligament Registry (NKLR). The DOC underwent progressive preoperative and postoperative program in a sports med clinic demonstrated better selfreported functional outcomes 2 years after ACLR. 4 ii. Delaware-Oslo cohort compared to MOON cohort. DOC demonstrated better self-reported functional outcomes at 2 years after ACLR Evidence specific to pre-operative quadriceps strength a. Athletes that delayed surgery (mean 40 days) had better quadriceps strength at 2 and 4 months after ACLR allowing them to progress sooner to sport-specific rehabilitation. 9 b. Increased peroperative quadriceps strength deficit results in lower limb symmetry index at 6 and 9 months after ACLR. 6 c. Systematic review of preoperative predictors of outcomes after ACLR. Less than 20% quadriceps strength deficit was predictive of higher functional scores. 10 d. Greater preoperative quadriceps strength is associated with higher self-reported function scores 2 years after ACLR. Recommend quadriceps deficit <20% prior to surgery. 1 e. Greater preoperative quadriceps strength is associated with higher self-reported function 6 months after ACLR Extended prehab can identify candidates for non-operative care a. A classification algorithm was developed to identify candidates for non-operative care (potential copers). Using this algorithm, 42% of the cohort (N=345) were classified as potential copers. 72% of these potential copers successfully returned to pre-injury sport activities without ACLR after comprehensive rehabilitation. 5 b. Classification of potential coper after per-operative rehabilitation predicted 2 year success in athletes managed both operatively and nonoperatively (Thoma, CSM platform, 2018) 5. Conclusion a. Extended prehab and greater quadriceps strength lead to better short term and long term functional outcomes. b. Classification of coper status following extended prehab identifies candidates for non-operative care. References

5 1. Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. Br J Sports Med. 2009;43(5): doi: /bjsm EITZEN I, MOKSNES H, LYNN SNYDER-MACKLER, RISBERG MA. A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury. J Orthop Sport Phys Ther. 2011;40(11): doi: /jospt a. 3. Failla MJ, Logerstedt DS, Grindem H, et al. Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction? Am J Sports Med. 2016;44(10): doi: / Grindem H, Granan LP, Risberg MA, Engebretsen L, Snyder-Mackler L, Eitzen I. How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry. Br J Sports Med. 2015;49(6): doi: /bjsports Hurd WJ, Axe MJ, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: Part 1, outcomes. Am J Sports Med. 2008;36(1): doi: [pii]. 6. de Jong SN, van Caspel DR, van Haeff MJ, Saris DBF. Functional assessment and muscle strength before and after reconstruction of chronic anterior cruciate ligament lesions. Arthroscopy. 2007;23(1):21-28, doi: /j.arthro Logerstedt D, Lynch A, Axe MJ, Snyder-Mackler L. Pre-operative quadriceps strength predicts IKDC2000 scores 6months after anterior cruciate ligament reconstruction. Knee. 2013;20(3): doi: /j.knee Shaarani SR, O Hare C, Quinn A, Moyna N, Moran R, O Byrne JM. Effect of prehabilitation on the outcome of anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(9): doi: / Shelbourne KD, Foulk DA. Timing of surgery in acute anterior cruciate ligament tears on the return of quadriceps muscle strength after reconstruction using an autogenous patellar tendon graft. Am J Sports Med. 1995;23(6): doi: / de Valk EJ, Moen MH, Winters M, Bakker EWP, Tamminga R, van der Hoeven H. Preoperative patient and injury factors of successful rehabilitation after anterior cruciate ligament reconstruction with single-bundle techniques. Arthroscopy. 2013;29(11): doi: /j.arthro III. Question & Answer (10 min)