ACL Allograft Reconstruction Outcomes Presentation


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Restrospective analysis of ACL rehabilitation outcomes at our clinic

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ACL Allograft Reconstruction Outcomes Presentation

  1. 1. A Retrospective ACL Rehabilitation Outcomes Analysis Los Gatos Orthopedic Sports Therapy Jesse R. Modica, SPT, MS Regis University Ross M. Nakaji, PT, OCS, SCS, ATC, CSCS Matthew W. Thompson, PT, DPT, CSCS
  2. 2. Objectives <ul><li>Present purpose, methods, and results of retrospective rehabilitation outcomes analysis of patients following ACL reconstruction. </li></ul><ul><li>Report validity, reliability, and minimum detectable change (MDC) of the Lysholm Knee Score </li></ul><ul><li>Discuss collaboratively how the results of this outcomes analysis could influence practice patterns at LGOST in the future </li></ul>
  3. 3. Evidence in Practice <ul><li>Large component of EBP is transparent outcomes analyses </li></ul><ul><li>Examine reliability and validity of functional assessment questionnaires </li></ul><ul><li>Use of Hypothesis Oriented Algorithm for Change (HOAC) model to guide treatment interventions (Rothstein, et al) </li></ul>
  4. 4. Purpose <ul><li>To retrospectively analyze the rehabilitation outcomes of patients over the past 4 years with Achilles Tendon Allograft ACL reconstruction who completed rehabilitation at LGOST. </li></ul>
  5. 5. Methods <ul><li>Inclusion Criteria </li></ul><ul><li>- Primary ACL Reconstruction </li></ul><ul><li>- Achilles Tendon Allograft </li></ul><ul><li>- Ages 12-60 </li></ul><ul><li>Exclusion Criteria </li></ul><ul><li>- ACL Revision Procedure </li></ul><ul><li>- Infection </li></ul><ul><li>-Multiple Ligament Tears </li></ul>
  6. 6. Methods <ul><li>Chart Review </li></ul><ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Involvement: How many structures were involved (i.e. menisci, PCL, collateral ligaments, etc) </li></ul><ul><li>Days Since Surgery (DSS: to Initial Eval) </li></ul><ul><li>Lysholm Knee Score (3-4 administration periods) </li></ul><ul><li>Muscle Strength </li></ul><ul><ul><li>1. Straight Leg Raise (quads, hip flexors) </li></ul></ul><ul><ul><li>2. Prone Hip Extension (gluteals) </li></ul></ul><ul><li>Initial Evaluation Extensor Lag (EL1) </li></ul><ul><li>Days to EL Elimination (ELX) </li></ul><ul><li>Functional Outcomes </li></ul><ul><ul><li>1. Single to Double Leg Jump (% of uninvolved limb) </li></ul></ul><ul><ul><li>2. Time to ascend/descend 10 flights of stairs (s) </li></ul></ul><ul><li>Total Number of Visits </li></ul><ul><li>Duration of Treatment Rehabilitation </li></ul><ul><li>Return to Prior Level of Function? </li></ul>
  7. 7. Results <ul><li>N = 18 patients met the inclusion criteria who’s charts were reviewed </li></ul><ul><li>10 Males : 8 Females </li></ul><ul><li>Mean (SD) Age = 32.8(12.0) </li></ul>
  8. 8. Results
  9. 9. Days Since Surgery <ul><li>Historically, most LGOST patients with post-surgical ACL with Allograft are seen within the first two weeks of rehabilitation. </li></ul>
  10. 10. Strength Testing <ul><li>Patients demonstrated gains in involved leg hip flexor, knee extensor, and hip extensor strength relative to uninvolved extremity. </li></ul>71% 92% 86% 94%
  11. 11. Strength Testing <ul><li>Addressing proximal strength preserves normal lower chain biomechanics… </li></ul><ul><li>A recent study on hip kinematics with cutting movements supports the premise that reduced sagital plane movement and excessive transverse plane movement during the initial phase of cutting may influence loading at the knee joint. </li></ul><ul><li>(Pollard, Sigward, & Powers; 2007) </li></ul><ul><li>In-season injury prevention program leads to significantly reduced excessive hip internal rotation and greater peak hip abduction during a functional jump-landing task. </li></ul><ul><li>(Pollard, Sigward, Ota, Langford & Powers; 2006) </li></ul>
  12. 12. Lysholm Knee Score <ul><li>Reliability: Excellent (0.95 ICC) compared to Cincinnati (0.88 ICC) which demonstrated greater variability. However, Cincinnati is also a reasonable outcome tool. (Marx et al., 2001) </li></ul><ul><li>Validity: The Lysholm, Cincinnati, Activities of Daily Living and American Academy of Orthopedic Surgeons Knee Scores all demonstrated acceptable face and content validity in a study of athletes. (Marx et al., 2001) </li></ul><ul><li>Minimum Detectable Change (MDC): “A documented change in Lysholm Knee Score <10 points may be attributable to measurement error” (Briggs et al., 2006) </li></ul><ul><li>Translation: Changes >10 points can be attributed to clinical improvement </li></ul>
  13. 13. Lysholm Knee Score <ul><li>Data collected during various time periods </li></ul><ul><ul><li>LYS1: Initial Evaluation </li></ul></ul><ul><ul><li>LYS2: Between weeks 4-11 </li></ul></ul><ul><ul><li>LYS3: Between weeks 12-20 </li></ul></ul><ul><ul><li>LYSDC: Lysholm at D/C (most recent score) </li></ul></ul><ul><li>Multiple Lysholm scores may have been assessed during LYS2 & LYS3. Earlier value used during LYS2 and most recent value used during LYS3. </li></ul><ul><li>Streamlining FAQ data collection would make data analysis more consistent and managable. </li></ul>
  14. 14. Lysholm Knee Score <ul><li>Patients Lysholm Knee Score increased over time to an 87% average, indicating only minor functional limitations and knee instability (Tegner & Lysholm, 1985) </li></ul><ul><li>No significant gender differences with D/C Lysholm scores (p = 0.35) </li></ul><ul><li>Note: n=10 scores collected for LYS3 </li></ul>* * Exceeds documented MDC *
  15. 15. Correlations <ul><li>Age vs. Jump Test </li></ul><ul><li>Age vs. # of Visits </li></ul><ul><li>Extensor Lag vs. Extensor Lag Elimination Time </li></ul><ul><li>Extensor Lag Elimination Time vs. # of Visits </li></ul><ul><li>Extensor Lag Elimination Time vs. Tx Duration </li></ul>
  16. 16. Age R = -0.79 R = -0.54
  17. 17. Extensor Lag R = 0.53
  18. 18. Extensor Lag Elimination Time R = 0.54 R = 0.57
  19. 19. Summary <ul><li>Good D/C Lysholm Scores and Functional Outcomes for patients with ACL Achilles Tendon Allograft Reconstruction </li></ul><ul><li>50% of patients concluded rehab with excellent result (>90%)* </li></ul><ul><li>22% of patients concluded with good result (84-90%)* </li></ul><ul><li>28% of patients concluded with fair result (65-83%)* </li></ul><ul><li>80% of patients with fair result terminated PT early (<15 visits) </li></ul><ul><li>100% Return to Prior Level of Function (subjective) </li></ul>* Tegner & Lysholm (1985)
  20. 20. Discussion <ul><li>What is the minimum data collection for this patient population? </li></ul><ul><ul><li>Lysholm every 4 weeks (+/- 1 week) </li></ul></ul><ul><ul><li>Stamp on chart to track pts MD follow-up visits </li></ul></ul><ul><ul><li>Extension Lag: Difference between maximal extension and joint position in SLR position. </li></ul></ul><ul><ul><li>Strength Testing </li></ul></ul><ul><ul><ul><li>ASLR </li></ul></ul></ul><ul><ul><ul><li>Hip Extension (Bullock-Saxton, JE; 1994) </li></ul></ul></ul><ul><ul><ul><li>Hip Abduction (as tolerated) (Nicholas, J; 1976) </li></ul></ul></ul><ul><ul><ul><li>Pre-surgical Lysholm Knee Score or streamline with referring physician uses of outcomes. </li></ul></ul></ul><ul><li>How do referring MD’s assess long term outcomes? </li></ul><ul><li>Is there a psychometric tool available that could perhaps aid the therapist with treatment intervention and prognostics? </li></ul><ul><li>Psychovitality Questionnaire useful to determine likelihood of return to sport (Gobbi & Francisco; 2006) </li></ul>
  21. 21. References <ul><li>Briggs, Kocher, Rodkey, & Steadman. Reliability, Validity, and Responsiveness of the Lysholm Knee Score and Tegner Activity Scale for Patients with Meniscal Injury of the Knee. Journal of Bone and Joint Surgery. 2006: 88(4); 698-705. </li></ul><ul><li>Bullock-Saxton, JE; Local Sensation Changes and Altered Hip Muscle Function Following Severe Ankle Sprain. Physical Therapy, 1994: 74 (1); 17-34. </li></ul><ul><li>Gauffin H, Tropp H; Altered Movements and Muscular Activation Patterns During the One Legged Jump in Patients with an Old ACL Rupture. American Journal of Sports Medicine. 1994: 20 (2); 182-192 </li></ul><ul><li>Gobbi and Francisco. Factors Affecting Return to Sports After Anterior Cruciate Ligament Reconstruction with Patellar Tendon and Hamstring Graft: A Prospective Clinical Investigation. Knee Surgery Sports Traumatology and Arthroscopy . 2006: 14; 1021-1028. </li></ul><ul><li>Indelli PF, Dillingham MF, Fanton GS, Schurman DJ. Anterior Cruciate Ligament Reconstruction Using Cryopreserved Allografts. Clinical Orthopedics . 2004: 420; 268-275 </li></ul><ul><li>Marx RG, Jones EC, Allen AA, Altchek DW, et al. Reliability, Validity, and Responsiveness to Change of Four Knee Outcome Scales for Athletic Patients. Journal of Bone and Joint Surgery. 2001: 83(10); 1459-1469. </li></ul><ul><li>Nicholas, J et. al., A Study of Thigh Muscle Weakness in Different Pathological States of the Lower Extremity. American Journal of Sports Medicine. 1976: 4(6); 241-248. </li></ul><ul><li>Pollard CD, Sigward SM, Ota S, Langford K, & Powers CM. The Influence of In-season Injury Prevention Training on Lower Extremity Kinematics During Landing in Female Soccer Players. Clinical Journal of Sports Medicine. 2006: 16(3); 223-227. </li></ul><ul><li>Pollard CD, Sigward SM, & Powers CM. Gender Differences in Hip Joint Kinematics and Kinetics During Side-step Cutting Maneuver. Clinical Journal of Sports Medicine . 2007: 17(1); 38-42. </li></ul><ul><li>Siebold R, Buelow JU, Bos L, Ellerman A. Primary ACL Reconstruction with Fresh Frozen Patellar versus Achilles’ Tendon Allografts. Archives of Orthopedic Trauma Surgery . 2003: 123; 180-185 </li></ul><ul><li>Tegner Y, Lysholm J. Rating systems in the Evaluation of Knee Ligament Injuries. Clinical Orthopedics and Related Research . 1985; 43-49. </li></ul>