Glattke, Kaycee

Objective The aim of the study was to assess the interrater reliability between seven individuals assessing quadriceps femoris cross-sectional area, echo intensity, and corrected echo intensity. Design A retrospective subanalysis of data collected in a randomized controlled clinical trial (IRB 19-008473. NCT ID NCT04302558). Patients aged 13–50 yrs with an anterior cruciate ligament tear requiring surgical reconstruction were assessed for cross-sectional area of the rectus femoris, vastus intermedius, vastus lateralis, vastus medialis, and vastus medialis obliquis, and echo intensity of the rectus femoris. Musculoskeletal ultrasound imaging of the quadriceps was performed by one physical therapist, and quantitative assessments were performed by four physicians and three physical therapists. Results Physicians and physical therapists had good reliability for cross-sectional area of the rectus femoris (median interclass correlation 0.86 doctor of medicine (MD) and 0.84 physical therapist), cross-sectional area of the vastus medialis obliquis (0.82 and 0.82), and echo intensity mean (0.92 and 0.92). Rectus femoris cross-sectional area had the smallest coefficient of variation (26.512.7%), whereas subcutaneous fat had the largest coefficient of variation (93.3% left, 86.4% middle, 86.1% right). Conclusions These findings demonstrate reliability between physicians and physical therapists in interpretation of ultrasound images of the quadriceps. The inconsistency demonstrates the need for a consistent training across disciplines to ensure accurate image interpretation.

ABSTRACT Introduction: Medical conferences are an integral aspect of medical education as they allow attendees to stay up to date with recent advancements in medicine, to develop presentation and communication skills, and to network and establish connections with professionals in their field of interest. But, when the coronavirus disease 2019 (COVID-19) pandemic was declared in March 2020, face-to-face medical conferences were suspended, and conference organizers began shifting their meetings to virtual platforms. These new virtual conferences afforded medical residents and fellows the unique opportunity to attend conferences from the comfort of their own home or workplace; however, the virtual meeting platforms did not provide attendees with the same networking experiences as in-person conferences. Since the end of the COVID-19 public health emergency, medical conferences are now faced with the question of whether they should remain virtual, shift back to in-person meetings, or develop a hybrid model of both options. Thus, the purpose of this study was to analyze medical resident and fellow sentiments and preferences by comparing virtual and in-person conference formats. Methods: A voluntary electronic survey was distributed to medical residents and fellows across the United States through their program coordinators and directors. Results: The main findings of this study suggest that medical residents and fellows largely prefer in-person conferences (85%) as compared to a virtual format because of the networking opportunities afforded to them along with the development of camaraderie with their peers. The findings in this study suggest that the largest benefit in attending a virtual conference is the flexibility to attend from any location (79% important or very important), which offered convenience, flexibility, and comfort to participants (n = 100). Conclusion: These results support our hypothesis that despite the convenience and portability afforded by attending conferences virtually, medical residents and fellows still ultimately prefer to attend conferences in person. Overall, the findings in this study are of relevance to conference organizers in understanding the driving forces behind attendance and should be considered in determining meeting format.

Background: There is limited evidence related to the effects of autograft type on functional performance after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: This study aimed to compare biomechanical outcomes during a drop vertical jump (DVJ) between patients with a hamstring tendon (HT) autograft, quadriceps tendon (QT) autograft with bone block, QT autograft without bone block, and bone–patellar tendon–bone autograft at 6 months postoperatively in an adolescent population. The authors’ hypothesized there would be differences in DVJ biomechanics between athletes depending on the type of autograft used. Study Design: Controlled laboratory study. Methods: Patients aged 8 to 18 years who underwent primary ACLR were included for analysis. Kinematic and kinetic data collected during a DVJ using a 3-dimensional computerized marker system were assessed at 6 months after ACLR and compared with the uninjured contralateral limb. Results: A total of 155 participants were included. There were no significant differences in terms of age, sex, or affected leg ( P≥ .1973) between groups. The HT group was significantly associated with a larger knee valgus moment at initial contact compared with the QT group (28 × 10 –2 vs −35 × 10 –2 N·m/kg, respectively; P = .0254) and a significantly larger maximum hip adduction moment compared with the QT with bone block group (30 × 10 –2 vs −4 × 10 –2 N·m/kg, respectively; P = .0426). Both the QT with bone block (–12 × 10 –2 vs −3 × 10 –2 N·m/kg, respectively; P = .0265) and QT (–13 × 10 –2 vs −3 × 10 –2 N·m/kg, respectively; P = .0459) groups demonstrated significantly decreased mean knee extension moments compared with the HT group. Conclusion: The findings of this study suggest that utilizing an HT autograft resulted in a significantly increased knee valgus moment at initial contact compared with a QT autograft without bone block at 6 months after ACLR in adolescent patients performing a DVJ. A QT autograft was found to be associated with significantly decreased extensor mechanism function compared with an HT autograft. Clinical Relevance: This study adds unique kinematic and kinetic information regarding various ACLR autograft options and highlights the biomechanical deficits that should be taken into consideration in rehabilitation.

Objectives: The purpose of this study is to evaluate the effect of low-intensity blood flow restriction (LI- BFR) training utilized in a pre-rehabilitative setting for patients undergoing anterior cruciate ligament reconstruction (ACLR) on postoperative outcomes by minimizing postoperative atrophy and impairment of the quadriceps. We hypothesize that postoperative strength and hypertrophy of the quadriceps will be greater in a population that undergoes preoperative LI-BFR training than that of a population that undergoes low-intensity sham control (LI-SHAM) training. Methods: Twenty-eight subjects undergoing primary ACLR underwent 2 weeks of either a BFR intervention or a SHAM intervention at a rate of 2 sessions per week before surgery. Quadriceps strength and cross-sectional area were measured as well as other exploratory outcomes were measured before and after the intervention before surgery and at 5 different time points after surgery, through 6 months postoperative. Quadriceps strength was assessed through handheld dynamometry and a leg press test and quadriceps cross-sectional area was assessed using musculoskeletal ultrasound imaging. Results: Adjusting for sex, time, and strength/hypertrophy at baseline, there were no significant differences found between treatment groups for the primary endpoints. Compared to 24-48 hours pre- op, this suggests that the post-op average hypertrophy remains significantly lower through 24 weeks post-op, while leg strength is similar at 24 weeks post-op as measured by handheld dynamometer and even significantly larger at 24 weeks as measured by the leg press test. Conclusions: A 2-week preoperative program of LI-BFR training may not be effective to improve postoperative quadriceps strength and hypertrophy after ACLR.

Objectives: Evidence is limited related to the effects of autograft type on functional performance during gait lab-based functional testing after ACL reconstruction (ACLR), especially the quadriceps autograft. The goal of this study was to compare biomechanical outcomes as measured by 3D motion analysis during the drop vertical test between quadriceps autograft with bone block (QB), quadriceps autograft without bone block (Q), hamstring autograft (HS), and bone-patellar tendon-bone autograft (BTB) six-months postoperatively in an adolescent population. We hypothesized that the quadriceps groups would demonstrate decreased knee extension moments as compared to the hamstring autograft group without other significant differences. Methods: Patients aged 8-18 years who underwent primary ACLR were included. Patients with previous history of ipsilateral knee surgery were excluded. Kinematic and kinetic data collected during a drop vertical jump test in a formal gait lab using a computerized video-based system (Motion Analysis Corp. CORTEX software) was collected six months after ACLR and compared to the uninjured contralateral limb. The Kruskal Wallis test and subsequent pairwise comparisons were carried out for each studied parameter. Primary outcomes included transverse plane hip power, hip internal rotation moment, knee valgus angles, and knee extensor moments between the graft types. Secondary outcomes included hip abduction moment, knee valgus moment, and knee external rotation moment. Results: A total of 155 subjects’ charts were included for review, with 54, 40, 35, and 26 subjects in the HS, QB, Q, and BTB groups respectively. There were no significant differences in terms of age, sex, or affected leg (p > 0.1973). Athletic activity for each subject was also noted when appropriate, including soccer (37), basketball (34), and American football (30). The QB group had smaller knee extension moments maximums (-0.97 N*m/kg vs. -0.35 N*m/kg, p = 0.0323) and smaller knee extension moment averages (-0.12 N*m/kg vs. -0.03 N*m/kg, p = 0.0265) as compared to the HS group. The Q group demonstrated smaller knee extension moment averages (-0.13 N*m/kg vs. -0.03 N*m/kg, p = 0.459) as compared to the HS group. Analysis of secondary outcomes revealed that the HS group demonstrated larger knee valgus moments at initial contact (0.28 N*m/kg vs -0.35 N*m/kg, p = 0.0254) as compared to the Q group. The HS group demonstrated significantly larger hip adduction moment maximums (0.30 N*m/kg vs -0.04 N*m/kg, p = 0.0426) and smaller knee external rotation moment averages (-0.02 N*m/kg vs 0.02 N*m/kg, p = 0.0206) as compared to the QB group. No other secondary outcomes were statistically significant between any of the groups. Conclusions: The findings of this study suggest that the quadriceps autograft may confer improved knee coronal plane biomechanics in regard to ACL reinjury rates when compared to a hamstring autograft at 6 months after ACLR in adolescent patients performing a drop vertical jump. The hamstring autograft group was significantly associated with larger knee valgus moments at initial contact as compared to the quadriceps autograft without bone block and significantly larger hip adduction moments compared to the quadriceps autograft with bone block. Both quadriceps grafts were shown to demonstrate significantly decreased knee extension moments as compared to a hamstring autograft. Further long-term clinical studies may be useful in determining whether the apparent biomechanical differences seen between autograft types are correlated with reinjury rates.

Purpose To identify the clinical practice preferences of orthopaedic surgeons regarding anterior cruciate ligament reconstruction (ACLR) rehabilitation through a survey of members of the Arthroscopy Association of North American (AANA) and the American Orthopaedic Society for Sports Medicine (AOSSM). Methods An online survey was distributed to members of AANA and AOSSM between November 2020 and September 2021. Participants reported on their clinical preferences for ACLR protocol development and patient selection, use of technology in ACLR recovery and rehabilitation, and preferences for advancing through multiple phases of the rehabilitative process. Results Responses from 46 orthopaedic surgeons were analyzed. Patient‐reported outcome measures were not found to be utilized often at various phases of the perioperative period. Thirty‐eight (82.6%) participants reported utilization of postoperative bracing. There was no consensus on when participants allow their patients to advance through rehabilitation, but most report waiting 3 to 4 months for advancement to jogging/lateral movement, 6 to 8 months for return to noncontact sport, and 9 months of more for return to unrestricted sport. Many participants utilize functional and strength testing with associated limb symmetry indices to determine patient readiness to return to sport, with 18, 26, and 25 participants reporting use of functional testing and 28, 26, and 27 participants reporting use of strength testing at the return to jogging/lateral movements, noncontact return to sport, and unrestricted return‐to‐sport phases, respectively. Conclusions This study provides an insight into the rehabilitative protocols and modalities utilized for ACLR by orthopaedic surgeons in practice across the United States. There is notably substantial variation in rehabilitative patterns and preferences, particularly with regards to what constitutes criteria for progressing patients through the phases of returning to unrestricted sport. Additionally, our findings show that while many surgeons believe that quantitative assessment technology could be beneficial in decision‐making for returning patients to sport, there are still many barriers that stand in the way of its implementation into clinical practice. Clinical Relevance Postoperative rehabilitative protocols after ACLR vary by surgeon.

Background: The success of anterior cruciate ligament (ACL) reconstruction is influenced by effective rehabilitation. Previously published, comprehensive systematic reviews evaluating rehabilitation after ACL reconstruction have studied Level-I and II evidence published through 2012. Interval studies continue to evaluate the efficacy of various rehabilitative modalities. Methods: A total of 824 articles from 2012 to 2020 were identified using multiple search engines. Fifty Level-I or II studies met inclusion criteria and were evaluated using the Consolidated Standards of Reporting Trials (CONSORT) criteria and National Institutes of Health (NIH) Study Quality Assessment Tools. Results: Accelerated rehabilitation can be effective for patients with semitendinosus-gracilis grafts. Blood flow restriction (BFR) training with high-intensity exercise is not effective for ACL reconstruction recovery. Postoperative bracing does not offer any advantages or improve limb asymmetry. Cryotherapy is an effective analgesic when used perioperatively. The early introduction of open kinetic chain exercises may improve ACL reconstruction outcomes, and high-intensity plyometric exercise is not effective. Estimated pre-injury capacity (EPIC) levels may be more accurate than the Limb Symmetry Index (LSI) when using functional test results to predict reinjury rates, and hip external rotation strength may be the most accurate predictor of the hop test performance. Nerve blocks can provide postoperative analgesia with minimal complication risk. Neuromuscular electrical stimulation is effective when used independently and in combination with rehabilitative exercises. Psychological readiness should be evaluated both objectively and subjectively before allowing patients to safely return to sport. Electromyography biofeedback may help to regain muscular function, and whole-body vibration therapy can improve postural control. Supervised rehabilitation is more effective than unsupervised rehabilitation. Conclusions: Various rehabilitative modalities following ACL reconstruction are effective in improving surgical outcomes and return-to-sport rates. Further evidence and improved study design are needed to further validate modalities including accelerated rehabilitation, BFR training, functional testing, and return-to-sport criteria. Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.