Research On Returning To Sports After Anterior Cruciate Ligament Reconstruction

Background The incidence of anterior cruciate ligament(ACL)injury is high for many years.In order to restore the dynamic stability of the knee joint,patients tend to choose to undergo anterior cruciate ligament reconstruction(ACLR)in order to return to sports(RTS).The rate of return to sports is not ideal.Many studies believe that Patients can return to sports six months after ACLR,but many experts question the use of aggressive rehabilitation to induce patients to return to sports as soon as possible.From the biological point of view of postoperative recovery,some scholars believe that it should take 12 months or even longer to return to sports.Six authorities including American Medical Society for Sports Medicine(AMSSM),suggested that it is a great risk to use only the postoperative time as the criterion of return,and it is a good choice to use a set of objective test as the basis of decision.Among the evaluation criteria,the isometric muscle force and the one-legged test of neuromuscular control were widely used.However,the strength ratio(Hamstring/Quadriceps,H/Q)and Limb System Index(LSI)were used for reference extensively.So far,there is little research into specific force data for return to sports.Some scholars put forward that LSI,which is based on the test of non-injury leg after ACLR,is defective as the reference index.In addition,existing research shows that patients who meet the criteria for return six months after ACLR they will continue to suffer reinjuries over the next two years.Therefore,the existing 6-month postoperative return criteria need to be reviewed and evaluated.need to be reviewed and evaluated.At present,there are no specialized reports of return to sports after ACLR in China.In practice,non-athletes return to sports with higher autonomy decision-making power,but lack of specific indicators as a guide.The athletes tend to return to sport too early because of the influence of many external factors,and they often face the hidden danger of re-injury after returning.Objective 1.To understand the present situation of returning to sports after ACLR in China,and explore the related demographic factors affecting returning to sports.2.To explore the diagnostic prediction index of non-athletes who return to sports after ACLR,and try to find the critical value of prediction index.To provide the decision basis of rehabilitation path and safe return to sports for the patients who implement ACLR.3.To evaluate the knee joint function of athletes before returning,follow-up 2 years for re-injury rate,and verify the safety of the reentry opportunity.Method 1.524 homogeneous ACLR cases were selected from three medical institutions(the sports hospital of the State Sports Administration,Jishuitan Hospital in Beijing and Huashan Hospital in Shanghai.)in the past four years(June 2012 to March 2016).The patient's case information was collected and followed up for 1 to 2 years.The return criteria are as follows: 1)return to physical activity;2)Tegner score? 5.All subjects were divided into returned groups and Unreturned groups,Descriptive statistical analysis of sex,age,BMI,timing of surgery,combined injury,pre-injury Tegner score,KOOS score and time of return to sports in all cases.The inter-group measurement data were compared with the independent sample t test(or mann-whitney test),and the grade data were checked by chi-square test,P<0.05 is considered to be statistically significant.2.147 male patients who underwent single bundle reconstruction from September 2014 to March 2016 and the graft was autogenous hamstring muscle tendon were selected from Huashan Hospital in Shanghai.All subjects were tested and evaluated in six categories within 2 weeks of 6 months after surgery:(1)demographic: age,BMI,timing of surgery,combined injury,pre-injury Tegner score.(2)clinical examination: effusion,activity(ROM),stability(front drawer test,Lachman test,pivot shift test,KT-1000).(3)MRI evaluation: maturity of cartilage and soft tissue(T2 * mapping).(4)Isokinetic muscle strength test: 60°/s,180°/s knee extension and flexion peak moment,and calculate its relative peak moment,H/Q and symmetric index(LSI):(operating leg score/healthy side leg score)× 100%.(5)lower extremity performance tests: Figure 8 hop test?up-down test?side-to-side hop test?single-hop for distant.Single-hop for distant recorded the distance/height,other three tests recorded the completion time(s),and calculated the symmetrical index(LSI)respectively.(6)subjective rating scale: ACL-RSI and Marx rating scales were completed.Return to the sports standard is: 1)return to the pre-injury sports;2)Tegner score reached pre-injury level.Based on the dependent variable of return to sports at 12 months after ACLR,the multivariate statistical regression analysis was carried out to calculate the dominance ratio by incorporating the different indexes into the two-class Logistic regression model.Logistic regression results were used to predict the level of exercise before return injury.ROC curves describe the sensitivity and specificity of each predictive variable.Using 1-specificity as horizontal coordinates and sensitivity as longitudinal coordinates,the curve was drawn by spss19.0(IBM),and the area under the curve was calculated.(Area under current,AUC).The most specific and sensitive variable values are recorded as actual values.3.Professional athletes who have accepted ACLR and have successfully returned to competitive sports(Tegner ? 9).Sex,age,BMI,Tegner score,length of exercise,timing of surgery were recorded.Three types of tests before returning to sports:(1)Clinical examination,(2)Isokinetic muscle strength test,(3)lower extremity performance tests.Followed-up for 2 years,every six months via email,phone and the questionnaire contacted the patient and asked if there was any reinjury.The criteria of re-injury are :(1)Occurs during training or competition;(2)Cause to leave practice or play for more than 7 days;(3)To be confirmed after examination by a doctor;(4)Appropriate treatment was given;(5)Cause any condition in which an athlete is required to leave practice or competition.The inter-group measurement data were compared with the independent sample t test(or Mann-Whitney test),and the grade data were checked by chi-square test,P<0.05 is considered to be statistically significant.ROC curves describe the sensitivity and specificity of each predictive variable Using 1-specificity as horizontal coordinates and sensitivity as longitudinal coordinates,the curve was drawn by spss19.0(IBM),and the area under the curve was calculated.(Area under current,AUC).The most specific and sensitive variable values are recorded as actual values.Results 1.(1)350 patients(66.8%)returned to physical activity,of which 255 were male and 95 were female,average age 29.5 ±6.8.average return time 11.4 ±4.6 months.(2)There was significant difference in age(29.5±6.8,34.0±7.0)?pre-injury Tegner(6.6±1.2,6.1±1.0)?BMI(23.6±3.2,25.7±3.4)between the returned group and the Unreturned group(P<0.05).(3)There was significant difference in KOOS-function(87.1±10.5;82.3±12.0)?KOOS-pain(85.8±10.7;94.1±7.4)?KOOSsymptom(76.6±1.2;86.1±1.0)between the returned group and the Unreturned group(P<0.05).2.(1)81 cases(55.1%)return to sports 12 months after ACLR.here was significant difference in Age(27.1± 6.6,32.5±7.1),BMI(25.4±3.1,27.6±3.3),ACL-RSI scores(68.2±14.5,48.6±21.8),combined meniscus injury(29.5%,65.7%)were statistically different between the returned group and the Unreturned group(P<0.05).(2)Demography indicators with predictive return to sports include: pre-injury Marx(OR =1.847,95% confidential interval: 1.429-2.388,p = 0.001),ACL-RSI psychological score(OR = 1.03,95% trusted intervals: 1.060-0.001,p =0.001),BMI(OR =0.803,95% trusted interval: 0.693-0.931,p =0.004),Isometric muscle force indicators with predictive return to sports include: 60°/s knee Flexion(OR = 6.748,95% trusted intervals: 2.260-20.152,p = 0.001),180°/s knee Flexion(OR = 19.308,95% trusted interval: 4.911-75.914,p = 0.001),Isokinetic peak torque LSI indicators with predictive return to sports include: 60°/s knee extension(OR = 95%,1.061 trusted interval: 1.018-1.105,p = 0.004),180 °/s knee Flexion(OR = 1.08,95% trusted interval: 1.029-1.142,p = 0.003),lower extremity performance indicators with predictive return to sports include: Updown test(OR = 0.697,95%credible intervals:.610-.796,p = 0.001),single hop for distant(Or = 1.051,95% trusted interval: 1.023-1.080,p = 0.001).(3)ROC curve area: 1)isometric force index: 60°/s knee Flexion(Area 0.787,sensitivity 75.30%,specificity 74.24%,threshold value 1.4 N·m/kg),180°/s knee Flexion,(Area 0.829,sensitivity 77.77%,specificity 83.33%,threshold 1.1 N·m/kg)under ROC curve;2)Functional index of lower limbs: up-donw test(ROC curve under area 0.888,sensitivity 84.84%,specificity 90.12%,threshold value 8.4s),single hop for distance(Area 0.816,sensitivity 86.41%,specificity 62.12%,threshold height 79.5% under the ROC curve).3.(1)13 patients(31.7%)were re-injured after 2 years,the average return time was 9.0±2.9(6-17 months).(2)There was a statistical difference in return timing between re-injury group(8.4±2.7)and normal group(11.0±2.4)(p< 0.05).Dominance ratio calculation(OR =10.35,95% rusted interval:5.3-132.5,p = 0.01),area under ROC curve 0.714,sensitivity 82.14%,specificity 69.23%,threshold value 8.5 months.Conclusion 1.The rate of return to physical activity after of anterior cruciate ligament reconstruction by self-tendinous hamstring tendon was 66.8%,The average time was 11.4 months,The age,Tegner score and BMI index of patients before injury are the demographic limiting factors about return to physical activity.ACLR after 12 months,rate of return to sports is 55.1% in Non-athletes.After two years of return to sports,the rate of re-injury is 33.1% in athletes.2.The demographic indicators with predictive value include BMI index,pre-injury Tegner score,pre-injury Marx score and ACL-RSI psychological score;The objective test indicators with predictive value include 60°/s and 180°/s flexural peak moment,60°/s knee extension peak moment LSI and 180°/S flexural peak moment LSI,as well as single hop for distance and up-down test.3.The diagnostic value of predictive index of return to sports include BMI?26.3,pre-injury Tegner?7.5?pre-injury Marx?10.5?ACL-RSI?54.5,60°/s knee flexion peak moment ?1.4 N·m/kg,3)180°/s knee Flexion peak moment ?1.1 N·m/kg,60°/s knee extension peak moment LSI ?80.5%?180°/s knee flexion peak moment LSI 86.5%,up-down test ?8.4s,single hop for distant ?79.5% Height.4.6 to 8 months after ACLR,the knee joint muscle strength and lower limb movement ability of athletes exists deficit still.9 to 11 months after ACLR,knee muscle strength and lower limb movement ability tended to recover,except up-down test.12 months later,Knee function improved further,but some athletes still had insufficient in up-down test.5.Compared with earlier than 8.5 months,the rate of Re-injury was 10 times lower after 8.5 months ACLR.It is recommended that the time of return should not be earlier than 8.5 months after ACLR and that it should be safe to continue to rehabilitation training until 12 months.