CONTEXT:The purpose of this study was to describe young athletes' trajectories of perceived quality of life (QOL) following anterior cruciate ligament injury and reconstruction, and to explore how athletes conceptualize QOL during recovery. DESIGN:A mixed methods study integrating quantitative QOL trajectories with qualitative description of athletes' individual experiences. METHODS:Semistructured interviews were conducted with 13 Australian athletes (mean age: 21, 7 males and 6 females) 1-year after anterior cruciate ligament reconstruction. During interviews, participants rated their perceived QOL at 3 timepoints (preinjury, preoperative, and 1-y postoperative) using a visual analog scale (0-100). Participants were asked to discuss their injury, surgical, and recovery experiences, including perceptions and conceptualizations of QOL across time. Descriptive analyses were used to characterize QOL trajectories. Interview transcripts were coded and analyzed independently by 2 reviewers using inductive thematic analysis to identify themes related to the changes in QOL. RESULTS:Athletes' mean self-reported QOL exhibited a V-shaped trajectory: preinjury (80 [11]), preoperative (39 [22]), to 1-year postoperative (78 [12]). Qualitative analysis identified an overarching theme of sport injury-related growth, which provided insight into how athletes perceived and made sense of improvements in QOL. Sport injury-related growth was characterized by 4 distinct mechanisms: satisfaction with surgery (optimism regarding surgical outcomes), gratitude (identifying benefits of the injury experience), cognitive reframing (shifting focus to life domains unaffected by injury), and resilience (recognizing personal strength). CONCLUSION:Young athletes generally regained acceptable levels of perceived QOL at 1-year postoperative following anterior cruciate ligament reconstruction. The presence of sport injury-related growth mechanisms may help explain these favorable trajectories and should be considered when interpreting postoperative outcomes.

Abstract Purpose To evaluate return‐to‐sport (RTS) outcomes following primary and revision anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon autografts in a highly active male athletic population. Methods This retrospective cohort study included 140 highly active male athletes who underwent ACLR with a quadriceps tendon autograft by a single surgeon between 2014 and 2021. Participants were divided into primary (n = 93) and revision (n = 47) groups. All participants were surveyed regarding RTS outcomes at 2–3 years postoperatively. Survey outcomes included return to some kind of sport, return to preinjury sport (any level), return to preinjury sport at the same or higher level and self‐perceived ability to perform at the pre‐injury level. Descriptive statistics were calculated and presented. Results In the primary reconstruction cohort, 98.9% of athletes successfully returned to some sport, 90.3% to their pre‐injury sport, and 73.1% to their pre‐injury sport at the same or higher level. Of those who returned to their pre‐injury sport, 70.2% reported performing at their pre‐injury level. Of those who returned to their pre‐injury sport at the same or higher level, 79.4% reported performing at their pre‐injury level. In the revision cohort, 85.1% of athletes successfully returned to some sport, 57.4% to their pre‐injury sport and 40.4% to their pre‐injury sport at the same or higher level. Of athletes in the revision cohort who returned to their pre‐injury sport, 55.6% reported performing at their pre‐injury level. Of those who returned at the same or higher level, 57.9% reported performing at their pre‐injury level. Conclusion Quadriceps tendon autografts yielded high RTS rates in highly active male athletes after primary reconstruction and rates in the revision setting comparable to previous literature. A high proportion of the patients felt they could perform as well as prior to their injury. Level of Evidence Level III, retrospective cohort study.

BACKGROUND: Anterior Cruciate Ligament (ACL) ruptures affect over 20,000 individuals in the UK each year. To date, three randomised controlled trials have compared the two main treatment options of surgical and non-surgical management following rupture and report conflicting findings. Recent qualitative research has also reported uncertainty and confusion among patients regarding decision-making about their choice of treatment. A theory- and evidence-based shared decision-making intervention was co-developed in a prior study to support patients to decide on treatment. The aim of this study was to understand implementation factors associated with implementing a shared decision-making intervention for patients following an anterior cruciate ligament (ACL) rupture. METHODS: Individual qualitative interviews, analysed using a framework approach underpinned by the Extended Normalisation Process Theory (ENPT). Data were mapped to the four ENPT constructs: potential, capacity, capability and contribution. Conducted as part of a non-randomised feasibility study in an orthopaedic and physiotherapy service at an acute National Health Service Teaching Hospital in the Midlands, UK. Five patients with a first time ACL rupture and five physiotherapists with experience of using the shared decision-making intervention. RESULTS: Implementation factors, including barriers and enablers to future implementation and normalisation, associated with implementing a shared decision-making intervention for patients following ACL rupture have been identified and mapped to ENPT. Both patients and physiotherapists demonstrated a clear understanding of the SDM intervention’s purpose (coherence) and individual intention to operationalise it within the pathway (potential, capacity). The intervention was further discussed to support interactional work between patients and clinicians during consultations and physiotherapists were positive about its workability and adaptability to meet patients’ needs (capability). Physiotherapists described the intervention’s role in altering the social roles of both themselves and of patients, which supported the set-up and action of SDM conversations (capacity). The communication of equipoise and context created for intervention delivery was identified to be critical to engagement (potential). The intervention was described as non-burdensome, patient participants reported they would recommend it to others following diagnosis of an ACL rupture and physiotherapist participants described utilising the intervention with patients outside the trial (contribution, capability). CONCLUSION: Implementation factors, explored through the lens of ENPT, have supported understanding of future normalisation of the intervention in clinical practice. Areas of focus ahead of further research, for example understanding equipoise, have also been identified. TRIAL REGISTRATION: ISRCTN17801081. Registration date: 23.01.2024.

Introduction This study outlines the revision and content validity process for the Domestic and Community Skills Assessment, Third Edition (DACSA-3). The DACSA-3 is an occupational therapy instrumental activities of daily living (IADL) assessment, which can be used to assess a person with a mental health condition.Methods The DACSA-3 was developed by considering past development and research, technology changes, and current occupational therapy theories. Nine content experts (occupational therapists with mental health experience) were involved in a qualitative and quantitative review of the DACSA-3 to establish content validity using the content validity ratio (CVR) and content validity index (CVI), with recommended minimum thresholds of 0.78.Consumer and community involvement The DACSA-3 was reviewed by two content reviewers (professionals with lived mental health experience) to ensure that recovery oriented language was included.Results The Initial Interview was retained and updated. The Supporting Interview was removed, because it lacked construct validity. The Observation Checklist was renamed to Context List and updated to include environmental and personal factors that may influence task performance. The Objective Assessment subtests were updated and reduced from 17 to 14 subtests. The money handling, personal presentation, and postage handling subtests were removed, because they were no longer relevant or did not fit the occupational category of IADL. The scoring criteria for each subtest were improved by aligning with the rating scale definitions to prevent discrepancies between ratings and clinical judgement. The CVR of DACSA-3 items ranged from 0.78 to 1.00, and the CVI of the DACSA-3 was 0.98.Conclusion The DACSA-3 is a revised, contemporary occupational therapy assessment of IADL, which has content validity. The CVR and CVI exceeded the minimum recommended thresholds, and thus, the content validity of the DACSA-3 was established. Modifications were made to the DACSA-3 to reduce the administration time and it no longer contains a screening tool.

BackgroundArtificial intelligence (AI), particularly large language models (LLMs) like ChatGPT, has demonstrated potential in healthcare applications, but its effectiveness in clinical rehabilitation contexts remains underexplored. This study investigated whether GPT-4 (accessed through its online interface ChatGPT) can deliver high-quality, adaptive responses in sports physical therapy comparable to or surpassing those of human professionals.MethodsFifty-three sports physical therapy questions were developed by senior experts and answered by GPT-4 and three junior expert physical therapists (JEPs). Responses were tailored for different target audiences: patients, physical therapists, and expert physical therapists. GPT-4 was prompted using structured engineering techniques. A blinded panel of three senior physical therapists/researchers assessed responses for quality and adaptiveness, and identified which responses were superior.ResultsAcross all target audiences, GPT-4 outperformed JEPs in both quality and adaptiveness of responses (p < 0.001). For responses aimed at patients, GPT-4 was rated best in 26 (55%) questions. For responses aimed at physical therapists, GPT-4 was rated best in 34 (64%) questions. Performance varied by topic, but GPT-4 consistently provided more expert-adapted and contextually appropriate information. GPT-4's responses were especially superior in areas like pain, osteoarthritis, and anterior cruciate ligament rehabilitation.ConclusionThis study demonstrated that GPT-4 is capable to generate high-quality, adaptive responses in the field of orthopedic sports physical therapy, which can surpass the performance of JEPs in a controlled setting.

Background: Fatigue during intense activity challenges the neuromuscular system and can reveal deficits not evident during lower-demand functional tasks. In individuals with anterior cruciate ligament reconstruction (ACLR), differences in graft source may be associated with graft-specific neuromuscular adaptations. Although fatigue-related neuromuscular deficits after ACLR have been reported, few studies have examined whether these responses differ according to graft type during running. This study investigated the effects of running-induced fatigue on lower-limb muscle activity during the stance phase in ACLR patients with different graft types, compared with healthy controls. Methods: Fifty-three active males were allocated into four groups: single-bundle hamstring tendon (SB-HT), double-bundle hamstring tendon (DB-HT), allograft, and healthy controls. Participants completed a treadmill-based fatigue protocol that was terminated when they reached a Borg score > 17, which served as the primary criterion for confirming a high level of perceived fatigue. Heart rate ≥ 85% of estimated maximum heart rate was recorded as a complementary physiological indicator of high-intensity exertion. Electromyography (EMG) amplitudes of eight lower-limb muscles were recorded during the early and late stance phases of running, before and after fatigue. A two-way mixed-model ANOVA evaluated the effects of graft type and fatigue condition. Results: Fatigue reduced semitendinosus (p = 0.042, ηp2 = 0.091) and gluteus medius (p < 0.001, ηp2 = 0.442) activation during early stance regardless of group. Late-stance group effects were significant for the tibialis anterior, gastrocnemius, rectus femoris, biceps femoris, semitendinosus, and gluteus medius (p ≤ 0.05). Across stance phases, the SB-HT group showed greater hamstring and gluteus medius activation than healthy controls (p = 0.003–0.041), while the allograft group showed greater tibialis anterior, gastrocnemius, and rectus femoris activation during late stance (p = 0.005–0.043). The only significant group × fatigue interaction was observed for vastus medialis (p = 0.002, ηp2 = 0.279), reflecting a fatigue-related reduction in the DB-HT group. Conclusions: Graft type was associated with distinct lower-limb EMG activation patterns during running after ACLR. Fatigue revealed a DB-HT-specific reduction in vastus medialis activation, while the allograft and SB-HT groups showed different compensatory activation profiles. These findings suggest that graft-specific neuromuscular adaptations during fatigue should be considered when developing rehabilitation protocols to improve functional stability and future joint health.

BACKGROUND:The risk of posttraumatic arthritis is elevated after anterior cruciate ligament (ACL) injury, and this can influence follow-up patient-reported outcome measures (PROMs). Biomarkers of chondral and matrix metabolism may represent a means of quantitatively evaluating the posttraumatic arthritis pathological process. PURPOSE:To assess for a longitudinal association between 3 systemic (blood and/or urine) biomarkers of chondral and matrix metabolism as measured on the day of ACL reconstruction with poor PROMs 6 years later. STUDY DESIGN:Descriptive laboratory study. METHODS:From a prospective longitudinal study, urine and serum samples were taken immediately before primary ACL reconstruction in 642 patients (mean age, 25.02 years; 60.3% men). Three biomarkers of chondral and matrix metabolism were measured using immunoassays: urinary C-terminal cross-linked telopeptide of type 2 collagen (u-CTX-II), serum N-propeptide of collagen 2A (s-PIIANP), and serum matrix metalloproteinase-3 (MMP-3). Six years postoperatively, patients completed the International Knee Documentation Committee (IKDC) Subjective Knee Form and Knee injury and Osteoarthritis Outcome Score-4 (KOOS-4) PROMs. PROMs were dichotomized based on Patient Acceptable Symptom State (PASS) thresholds. After exclusion of patients with outlier biomarker values and missing data, univariate (n = 411 for KOOS-4 and n = 419 for IKDC) and multivariate (n = 366 for KOOS-4 and n = 373 for IKDC) logistic regression models were developed with baseline biomarker concentrations and surgical and demographic parameters as predictive variables. RESULTS:In the multivariate model, higher baseline s-MMP-3 (OR, 0.98; P = .009) and increased articular cartilage pathology at surgery (OR, 0.87; P = .040) were associated with not achieving a KOOS-4 PASS. Higher baseline s-MMP-3 (OR, 0.98; P = .031), increased articular cartilage pathology at surgery (OR, 0.88; P = .045), and higher preoperative body mass index (BMI) (OR, 0.91; P = .027) were associated with not achieving a IKDC PASS. A medial meniscus tear that was resected was associated with achieving the IKDC PASS relative to no medial meniscus tear (OR, 3.34; P = .017). In the univariate modeling, older age and higher BMI were additionally associated with not achieving a KOOS-4 PASS (all P≤ .017). In the IKDC univariate modeling, lower baseline s-PIIANP, higher u-CTX-II, increasing age, and a lower preoperative Marx score were additionally associated with failing to achieve the PASS threshold (all P≤ .043). CONCLUSION:Increased s-MMP-3 concentration on the day of surgery was associated with failing to achieve the PASS threshold for both the KOOS-4 and IKDC PROMs at the 6-year time point after ACL reconstruction. CLINICAL RELEVANCE:This day of surgery blood test may be helpful in identifying patients at risk of a poor outcome 6 years after ACL reconstruction. In turn, this could help define a target group for evaluating interventions aimed at preventing posttraumatic arthritis.

OBJECTIVES:To determine the change in modified star excursion balance test scores in patients between 6 and 12 months following anterior cruciate ligament (ACL) reconstruction and the change in the proportion of patients who met recommended thresholds at each timepoint. A secondary aim was to assess whether change over time differed according to age, sex, graft type or activity level. DESIGN:Longitudinal cohort. SETTING:Orthopaedic Clinic. PARTICIPANTS:115 patients that completed 6- and 12-month testing after ACL reconstruction. MAIN OUTCOME MEASURES:Modified star excursion balance test scores (composite and individual reach scores). RESULTS:There was a significant increase of test scores for the surgical limb at 12-months compared to 6-months (p < 0.005) with no differences in limb symmetry index. Most patients (92%) reached threshold composite scores >90% equivalent to individual leg length at 6-months. This proportion did not change at 12-months. Patient-related factors had no effect on change in test scores across time. CONCLUSIONS:The modified star excursion balance test may be more applicable to assess dynamic balance performance 6-months post-surgery. Almost all patients met pre-determined criteria for dynamic balance performance by 6-months following surgery. There was no impact of patient age, sex, graft type or activity level on change in performance between 6- and 12-months.

Background: In this systematic review with meta-analysis, we aimed to compare the kinematic and kinetic variables of the involved limb with the contralateral limb in individuals who had undergone an anterior cruciate ligament reconstruction (ACLR) recorded during walking from short-term (<6 months) to mid-term (6–<12 months) and long-term (≥12 months) periods after surgery. Methods: Five electronic databases (Scopus, PubMed, EMBASE, PEDro, CENTRAL) were systematically searched for articles potentially eligible for inclusion from inception until November 2025. Biomechanical gait patterns were assessed short-term (<6 months), mid-term (6–<12 months), and long-term (≥12 months) post-surgery. Gait biomechanics were extracted from the included articles. Comparisons were made between the affected limb and the contralateral limb. Standardized mean differences (SMDs) with 95% confidence intervals (CI) were computed using a random-effects model. Results: The systematic search revealed 3522 hits, and according to a priori defined in-/exclusion criteria, 32 studies with male and female individuals aged 18–55 years involving 1026 participants were included. Meta-analysis indicated that the peak knee flexion angle was significantly lower in the ACLR compared to the contralateral limb (19 studies: small SMDs = −0.39, 95% CI −0.58 to −0.19, p < 0.0001, I2 = 66%). More specifically, the peak knee flexion angle was 2.63° (95% CI −3.81 to −1.44) lower in the ACLR compared to the contralateral limb. The analysis of time post-surgery revealed significant differences in the short-term (four studies: large SMDs = −1.14, 95% CI −1.61 to −0.67, p < 0.00001, I2 = 56%) and mid-term (five studies: small SMDs = −0.52, 95% CI −0.74 to −0.29, p < 0.0001, I2 = 0%) periods after surgery but not for the long-term follow-up (10 studies: small SMDs = −0.10, 95% CI −0.27 to 0.07, p = 0.26, I2 = 32%). Meta-analysis indicated that the peak knee flexion moment was significantly lower in the ACLR compared to the contralateral limb (11 studies: small SMDs = −0.37, 95% CI −0.59 to −0.14, p = 0.0001, I2 = 46%). A lower peak knee flexion moment was observed in the ACLR limb for both less than 12 months (three studies: moderate SMDs = −0.76, 95% CI −1.44 to −0.07, p = 0.03, I2 = 66%) and over 12 months (eight studies: small SMDs = −0.25, 95% CI −0.43 to −0.07, p = 0.01, I2 = 46%) after surgery time points compared to the contralateral limb. Conclusion: These findings suggest a time-dependent compensatory mechanism, where protective adaptations (e.g., reduced flexion/extension moments) may initially offload the reconstructed limb, with some asymmetries resolving over time. Clinically, these results underscore the need for rehabilitation strategies tailored to address phase-specific deficits, promoting symmetrical loading and functional recovery.

INTRODUCTION:Various knee-related patient-reported outcome measures (PROMs) have been used for patients who undergo surgical treatment for patellofemoral instability. There has been limited evaluation of their suitability and no agreement about an optimal set of measures. OBJECTIVES:To evaluate the Knee injury and Osteoarthritis Outcome Score (KOOS) and published shorter versions to determine their suitability for patients with patellofemoral instability. METHODS:The study cohort consisted of patients who underwent surgical stabilization with medial patellofemoral ligament reconstruction for recurrent lateral patellar dislocations. The full KOOS was administered preoperatively and the 6, 12, and 24 months postoperative. Four short form versions were calculated: KOOS-12, KOOS-Physical Function, KOOS-Joint Replacement, and KOOS-Global. Floor and ceiling effects were determined (threshold >15%). Individual items were evaluated to identify where >67% of patients had preoperative responses of "≥ moderate" (demonstrating item relevance). The standardized response mean (SRM) was calculated to assess responsiveness from baseline to each postoperative assessment time, as well as between postoperative assessments. RESULTS:289 patients completed the full KOOS at least once. No ceiling effects were present at any time point for the quality of life (QoL) or symptoms subscales, KOOS-12, or KOOS-global. Only 11 of the items passed the >67% threshold for item relevance. These included all Sport/Recreation (SR) and QoL items, as well as one item (knee stiffness after sitting/resting later in the day) from the symptom subscale and one item (pain frequency) from the pain subscale. Given these individual item results, a two-subscale "composite" score was calculated that included the 9 items of the KOOS SR and QoL subscales (KOOS-SR ​+ ​QoL). Excellent responsiveness was seen for all preoperative to postoperative comparisons, especially the composite SR ​+ ​QoL measure (SRM >1). Between 6- and 12-month assessments, the composite SR ​+ ​QoL score was also shown to be the most responsive measure. CONCLUSION:The composite KOOS SR ​+ ​QoL score may be an improved option for measuring patient-related outcomes in this more active population, as it focuses on the most relevant constructs for this patient group. The full 42-item KOOS was shown to have limited applicability in this patient group. LEVEL OF EVIDENCE:Level II.

PURPOSE:To investigate the clinical utility of the newly developed Upper Limb-Motor Learning Strategy Tool (UL-MLST) within the upper limb therapy models for children with cerebral palsy. MATERIAL AND METHOD:A qualitative interpretive phenomenological approach was used, incorporating four components of clinical utility to explore clinicians' experience of using the UL-MLST in practice. Semi-structured interviews were conducted with a convenience sample of seven Australian-based occupational therapists who attended a three-session Online Training Program on the use of the UL-MLST and later used the tool in their clinical practice 4 to 6 weeks after the program. Interviews were analysed for themes and subthemes using thematic analysis and constant comparison methods. RESULTS:Six themes were generated from the interviews. Two themes highlighted unanimously that the UL-MLST "Builds the clinicians' capacity" and "Strengthens the clinicians and family partnerships." The remaining four themes identified, were "Strengths" of using the UL-MLST, "Navigating practical constraints" of its use, "Suggested changes," and its "Future use." CONCLUSIONS:The clinicians' experience of using the UL-MLST confirmed its clinical utility highlighting that it is appropriate, practicable and acceptable for use with upper limb therapy models for children with cerebral palsy, and that its accessibility is highly important.

The Performance Quality Rating Scale for Somatosensation after Stroke (PQRS-SS) guides observation of survivors of stroke performing client-selected occupations, using common operational definitions. We aimed to determine the inter- and intra-rater reliability, standard error of measurement, and feasibility (via interviews and thematic analysis) of the PQRS-SS version 3. Videos of 22 survivors of stroke with somatosensory impairment completing 38 client-selected occupations on two occasions (76 clips) were viewed by four clinicians twice, 6 weeks apart (PQRS-SS version 3). Intraclass correlation coefficients (ICC), standard error of measurement (SEM), and interview data are reported. For PQRS-SS version 3, inter-rater reliability was moderate to excellent (ICC2,1 = 0.71, ICC2,4 = 0.91) and intra-rater reliability was good (ICC3,1 = 0.76-0.87). Clinician raters reported the PQRS-SS version 3 was easy to use. The PQRS-SS version 3 is ready for use by trained, experienced clinicians and is ready for ongoing psychometric testing.

Objectives To understand feasibility, acceptability and indicators of effectiveness of a shared decision-making (SDM) intervention with patients following an anterior cruciate ligament (ACL) rupture.Design Non-randomised feasibility study with embedded qualitative interviews.Setting Orthopaedic and physiotherapy service at an acute National Health Service (NHS) Teaching Hospital in the Midlands, UK, between 29 January and 5 June 2024.Participants Patients diagnosed with an ACL rupture following MRI.Intervention Delivery of a SDM intervention which comprised of two components: (1) patient information leaflet and (2) option grid.Outcome measures The primary outcome was to determine feasibility for a definitive trial using four outcomes: (1) recruitment rate, (2) fidelity of intervention delivery, (3) acceptability and (4) follow-up questionnaire completion. The secondary outcome was to explore indicators of the intervention’s effectiveness using quantitative data from patient reported outcome measures (acceptability questionnaire and satisfaction with decision scale) and qualitative data from patient and clinician interviews.Results 21 patients were approached to take part in the study, 20 were recruited with a mean age of 32.2 (SD 9.7), 40% were female. The recruitment rate was 95.2%, fidelity of intervention 100%, acceptability 94% and follow-up questionnaire completion 100%. The mean overall satisfaction with decision scale score was 24.85/30 (SD 3.82). There were no adverse events. Data from qualitative interviews with patients (n=5) and physiotherapists (n=5) suggested the SDM was acceptable and appeared effective in: (1) supporting decision-making about treatment, (2) conversations between patients and clinicians, (3) improving patient knowledge, (4) providing patients with access to health language and (5) supporting patients to ask questions deemed important to them.Conclusion The novel SDM intervention is acceptable to both patients and physiotherapists. Indicators of effectiveness explored through quantitative and qualitative data suggest the intervention to be beneficial to decision-making processes for patients and clinicians deciding on treatment following an ACL rupture. All four feasibility outcomes were achieved, indicating a full trial is feasible to run in the NHS.Trial registration number ISRCTN17801081.

BACKGROUND:Anterior cruciate ligament (ACL) injuries and reconstruction are associated with alterations in chondral homeostasis and posttraumatic osteoarthritis. Biomarkers of chondral metabolism may have a role in quantitatively evaluating this phenomenon. PURPOSES:To describe changes in 3 systemic biomarkers of chondral metabolism and extracellular matrix remodeling during the first year after ACL reconstruction and to identify factors associated with biomarker concentrations at the baseline and 12-month postoperative timepoints. STUDY DESIGN:Controlled laboratory study. METHODS:From a longitudinal study, urine and serum samples were taken immediately before primary ACL reconstruction and at 6 and 12 months postoperatively. A total of 666 patients provided samples (mean ± SD age, 24.9 ± 7.2 years; 60.5% male). Immunoassays were used to measure concentrations of urinary C-terminal cross-linked telopeptide of type 2 collagen (CTX-II), a marker of type 2 collagen degradation; serum N-propeptide of collagen IIA (PIIANP), a marker of type 2 collagen synthesis; and serum matrix metalloproteinase 3 (MMP-3), a mediator of extracellular matrix remodeling. Linear mixed modeling and linear regression were used for data analysis. RESULTS:Urinary CTX-II concentrations decreased by 25% (95% CI, 19%-31%) from baseline to 6 months and by 37% (95% CI, 22%-42%) from baseline to 12 months, respectively (P < .001). Serum PIIANP increased by 40% (95% CI, 34%-47%) from baseline to 6 months (P < .001) with no significant change between 6 and 12 months. Serum MMP-3 increased by 35% (95% CI, 29%-42%) and 44% (95% CI, 37%-52%) from baseline to 6 months and from baseline to 12 months respectively (P < .001). At the baseline timepoint, age, body mass index (BMI), sex, and time from injury to surgery were factors associated with biomarker concentrations. At the 12-month timepoint, age, sex, BMI, and time from injury to surgery were associated with biomarker concentrations. CONCLUSION:Decreasing urinary CTX-II concentrations coupled with increasing serum PIIANP concentrations may suggest a reparative chondral response within the first 12 months after ACL reconstruction. Increasing serum MMP-3 concentrations suggested persistent and progressive extracellular matrix remodeling during this same period. Predominantly nonmodifiable demographic factors were associated with baseline and 12-month concentrations of the 3 biomarkers. CLINICAL RELEVANCE:Biomarkers of chondral metabolism may have future prognostic or decision-making roles in the management of patients with ACL injury. This could include predicting posttraumatic arthritis.

Objective: To compare urinary C-terminal cross-linked telopeptide of type II collagen (u-CTX-II) concentrations and trends as measured by two different commercially available enzyme-linked immunosorbent assays (ELISA) in a cohort of patients in the first year following anterior cruciate ligament (ACL) reconstruction. Design: 22 ACL-injured patients undergoing reconstructive surgery (mean age 25.2 (SD 8.0) years; 12 (54.5 %) male) had urine samples taken on the day of surgery (baseline) and at 6 and 12 months post-operatively. Concentrations of u-CTX-II were measured using the CloudClone (R) and the CartiLaps (R) ELISA. u-CTX-II concentrations were normalized to urinary creatinine (Cr). Results: The u-CTX-II concentrations were significantly different between the 2 assays at each timepoint (p <= 0.01). When measured using the CloudClone (R) Assay, mean (standard error) u-CTX-II concentrations were 26.5 (2.5) ng/mmol Cr, 29.4 (3.8) ng/mmol Cr and 40.6 (6.9) ng/mmol Cr at the baseline, 6-month and 12-month timepoints respectively. When measured using the CartiLaps (R) Assay, at the same respective timepoints, u-CTXII concentrations were 981.2 (256.5) ng/mmol Cr, 867.0 (234.3) ng/mmol Cr and 764.3 (220.3) ng/mmol Cr. Concentrations of u-CTX-II using the CloudClone (R) Assay increased with time (p = 0.04). Concentrations of uCTX-II using the CartiLaps (R) Assay decreased over time (p = 0.2). Conclusion: Using two commercially available assays, u-CTX-II differed significantly in terms of both concentration and trends in the first year following ACL reconstruction. The specific assay used is critical to consider when interpreting results and has implications for pooling data and meta-analysis.

Background:Quadriceps tendon (QT) autograft has emerged as an increasingly popular graft for anterior cruciate ligament reconstruction (ACLR). The modified Star Excursion Balance Test (MSEBT) measures dynamic balance and is frequently used in evaluating preparedness to return to sport as part of return-to-sport test batteries. There is limited information available about the MSEBT performance of patients who have undergone ACLR with QT autograft. Hypothesis/Purpose:The purpose was to compare the MSEBT performance at 12 months after primary ACLR of patients with QT autografts with the performance of patients with hamstring tendon (HS) autografts. It was hypothesized that there would be a difference in the 2 groups due to harvest from either an extensor or a flexor of the knee joint. Study Design:Cohort study; Level of evidence, 3. Methods:The cohort consisted of 132 patients (44 patients with QT, 88 patients with HS) who had undergone primary ACLR with either a QT or HS autograft, were <30 years of age at the time of surgery, and had participated in sports regularly before injury. Patients with contralateral anterior cruciate ligament injury or an additional lateral extra-articular tenodesis were excluded. The mean age of the patients was 22.1 years, and 18% were female. The anterior reach, posterolateral reach, and posteromedial reach on the MSEBT were recorded at 12 months postoperatively and normalized to leg length. The limb symmetry index (LSI) and the composite score (CS) were calculated for each measurement. Patient-reported outcome measures were also collected. Results:There were no significant differences between the mean LSI and the CS of the QT and HS groups for any reach direction of the MSEBT (LSI: QT = 99.9 and HS = 98.9 for anterior reach, QT = 100.9 and HS = 100.2 for posterolateral reach; QT = 101.1 and HS = 100.8 for posteromedial reach, CS: QT = 96.6 and HS = 96.9). Patient-reported outcome measures also showed no significant difference. Conclusion:There were no differences in symmetry between QT and HS grafts in MSEBT performance at 12 months, with both patient groups having >98% limb symmetry in each reach direction.

PURPOSE:There has been a resurgence in the use of a lateral extra-articular procedure (LEAP) in association with anterior cruciate ligament (ACL) reconstruction to reduce the risk of graft failure. The aim of this study was to examine whether the use of a LEAP in the setting of a primary ACL reconstruction was associated with an increased rate of reoperation for loss of range of motion or a symptomatic cyclops lesion. METHODS:A consecutive cohort of patients aged less than 30 years who received a primary hamstring or quadriceps tendon autograft ACL reconstruction between January 2016 and December 2021 was retrospectively analysed. The usage of a modified Ellison LEAP in this cohort increased from 0% in 2016 to 51% in 2021. Reoperation rates for loss of motion or a symptomatic cyclops lesion during the first year after surgery, as well as knee extension deficits at 12 months, were compared between LEAP and no-LEAP patients. Contingency analyses with risk ratio (RR) were calculated. RESULTS:A total of 1076 patients were included in this study [59.6% male, mean age 21.6 (SD 4.4) years, 84.9% hamstring tendon autografts]. In 17.3% (186/1076) of the patients the ACL reconstruction was augmented with a modified Ellison procedure. Of this group [67.2% male, mean age 18.8 (SD 3.7) years, 79.6% hamstring tendon autografts], 8.1% (confidence interval (CI) 4.2%-12%) required further surgery for restricted motion or a cyclops lesion in the first year after surgery, compared to 3.8% (CI 2.6%-5.1%) in the no-LEAP group (risk ratio (RR) 2.1, p = 0.012). The difference in reoperation rates between those with and those without LEAP was more marked for patients who received a quadriceps tendon autograft (13.2% vs. 3.2%, RR 4.1, p = 0.019), compared to patients treated with a hamstring tendon autograft (6.8% vs. 3.9%, RR 1.8, p = 0.122). There was no significant difference in extension deficit at 12 months between patients with and those without a LEAP (mean 1.02 ± SD 2.6 degrees vs. mean 0.97 ± SD 2.4 degrees, p = 0.85). CONCLUSION:Surgical intervention for a loss of range of motion or symptomatic cyclops lesion in the first postoperative year after primary ACL reconstruction was more common in patients who had an additional LEAP than in those who did not. The higher intervention rate was more apparent in patients who had a quadriceps tendon autograft ACL reconstruction. LEVEL OF EVIDENCE:Level III, retrospective comparative study.

Local dynamic stability (LDS) of gait has been used to differentiate between healthy and injured populations, establishing its potential as an indicator of healthy gait and a new objective measure to assess gait function following injury. For LDS to be a reliable assessment tool of healthy gait progression during rehabilitation, it must provide consistent and sensitive inter-session measures. Methodological factors such as trial duration, gait variable, and Lyapunov Exponent (LyE) algorithm can influence LDS estimation and its reliability. Young people are a high-risk population for sport-related injuries, and running is a key activity during rehabilitation and is regularly assessed. Therefore, the effects of run duration, gait variable, and LyE algorithm choice on the reliability and sensitivity of inter-session LDS measures in young people were investigated. Sixteen healthy participants ran on a treadmill on two separate sessions (difference of 7 ± 5 days). LDS was calculated using both the Rosenstein and Wolf algorithm for durations of 1-, 2-, 3-, 4- and 5-min of knee flexion angle and medio-lateral acceleration of the pelvis and thorax from each session. The relative and absolute reliability between sessions was calculated using the intraclass correlation coefficient and standard error of measurement. The sensitivity of inter-session LDS change was quantified by the minimal detectable change. Results showed that longer run durations produced higher relative reliability and a minimum run duration of 4 min is recommended to achieve moderate-to-good inter-session reliability across all gait variables and LyE algorithms. However, shorter durations of 2-3 min may still be sufficient when using medio-lateral pelvis acceleration or knee flexion angle, particularly with the Rosenstein algorithm, which also improves sensitivity to change. These findings provide practical guidance for methodological choices when calculating LDS in young people during running and support their potential use as reliable tools for monitoring gait function and tracking rehabilitation progress in young people following injury.

Background:Although high rates of graft and contralateral anterior cruciate ligament (ACL) ruptures have been reported in younger patients after ACL reconstruction (ACLR), recent evidence suggests that previously reported crude event rates underestimate the actual event risk. Purpose:To report rates of graft and contralateral ACL rupture after ACLR in a large series of younger patients using survival analysis. Study Design:Cohort study; Level of evidence, 3. Methods:Patients aged <18 years at the time of primary ACLR were identified from a single-surgeon database over 12 years ending January 2018. Patients with a previous contralateral ACL rupture or bilateral ACL ruptures were excluded. Overall, 388 patients (204 males, 184 females) were included in the final dataset. Bespoke survey data and clinic follow-up data were used to record graft rupture and contralateral ACL rupture events. Rates of graft and contralateral ACL rupture were calculated using Kaplan-Meier survival analysis. Log-rank tests were used to compare survival functions between several subgroups. Results:According to Kaplan-Meier survival analysis, the cumulative rates at 2, 5, and 10 years for graft rupture were 11%, 17%, and 22%, and the cumulative rates for contralateral ACL injury were 7%, 19%, and 33%. Males had significantly greater rates of graft rupture than females throughout a 10-year follow-up period (P < .001). Contralateral ACL rupture survival functions were not significantly different between the sexes, although rates were higher in females until 5 years postoperatively, after which contralateral ACL ruptures increased in males, with a cumulative rate of 39% at 10 years compared with 29% for females. Survival rates did not vary between different age groups (<16 vs ≥16 years), but females with a graft diameter of <7 mm on the femoral side had significantly greater graft rupture rates than females with grafts ≥7 mm (P = .04). Conclusion:The present study is one of the largest consecutive series of younger patients, with one of the longest follow-up periods, reporting a high risk for a second ACL injury. Over time, the cumulative risk for contralateral ACL rupture was higher than for graft rupture. In males, the risk for contralateral ACL rupture continued to increase after 5 years.

PURPOSE:Research on mental fatigue and its impact on sport performance has gained significant attention in sport science. A reoccurring observation in these studies is the variation among participants in terms of mental-fatigue perception, as well as impact on performance. Thus, this study investigated personality traits as moderators of these interindividual differences. METHODS:Athlete self-report measures of mental fatigue and well-being were recorded throughout the 2023 season of 1 female Australian Rules Football team using a 5-point Likert scale, alongside a personality-trait questionnaire assessing levels of openness, conscientiousness, extraversion, agreeableness, and neuroticism. RESULTS:Mental-fatigue levels fluctuated across the season, with game days presenting significantly (P < .05) lower levels than training days. Repeated-measurements correlations indicated that mental fatigue was positively correlated with wellness ratings of stress (r = .27), sleep (r = .20), soreness (r = .07), and readiness (r = .10). The personality traits of extraversion and openness moderated mental-fatigue levels with a significant negative association for extraversion (P < .001) and a positive association for openness (P < .001). CONCLUSION:The findings suggest that mental fatigue is a considerable factor in the elite athletic environment. Extraversion and openness moderate perceived mental fatigue across a season. These findings underscore the importance of considering individual differences when interpreting subjective fatigue and when designing support strategies for athletes.