Psychological Readiness to Return to Sport at 6 Months Is Higher After Bridge-Enhanced ACL Restoration Than Autograft ACL Reconstruction: Results of a Prospective Randomized Clinical Trial

Ryan M Sanborn, Gary J Badger, BEAR Trial Team, Yi-Meng Yen, Martha M Murray, Melissa A Christino, Benedikt Proffen, Nicholas Sant, Samuel Barnett, Braden C Fleming, Dennis E Kramer, Lyle J Micheli, Ryan M Sanborn, Gary J Badger, BEAR Trial Team, Yi-Meng Yen, Martha M Murray, Melissa A Christino, Benedikt Proffen, Nicholas Sant, Samuel Barnett, Braden C Fleming, Dennis E Kramer, Lyle J Micheli

Abstract

Background: Previous clinical studies have shown that psychological factors have significant effects on an athlete's readiness to return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR).

Hypothesis: We hypothesized that patients who underwent bridge-enhanced ACL restoration (BEAR) would have higher levels of psychological readiness to return to sport compared with patients who underwent ACLR.

Study design: Randomized controlled trial; Level of evidence, 1.

Methods: A total of 100 patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were randomized to either the BEAR procedure (n = 65) or autograft ACLR (n = 35 [33 hamstring and 2 bone--patellar tendon-bone]) and underwent surgery within 45 days of injury. Objective, functional, and patient-reported outcomes, including the ACL--Return to Sport after Injury (ACL-RSI) scale, were assessed at 6, 12, and 24 months postoperatively.

Results: Patients who underwent the BEAR procedure had significantly higher ACL-RSI scores at 6 months compared with those who underwent ACLR (71.1 vs 58.2; P = .008); scores were similar at 12 and 24 months. Baseline factors independently predictive of higher ACL-RSI scores at 6 months were having a BEAR procedure and participating in level 1 sports prior to injury, explaining 15% of the variability in the scores. Regression analysis of baseline and 6-month outcomes as predictors indicated that the International Knee Documentation Committee (IKDC) score at 6 months explained 45% of the 6-month ACL-RSI variance. Subsequent analysis with IKDC excluded from the model indicated that decreased pain, increased hamstring and quadriceps strength in the surgical limb, and decreased side-to-side difference in anteroposterior knee laxity were significant predictors of a higher ACL-RSI score at 6 months, explaining 34% of the variability in scores. Higher ACL-RSI score at 6 months was associated with earlier clearance to return to sports.

Conclusion: Patients who underwent the BEAR procedure had higher ACL-RSI scores at 6 months postoperatively. Better ACL-RSI scores at 6 months were related most strongly to higher IKDC scores at 6 months and were also associated with lower pain levels, better muscle recovery, and less knee laxity at 6 months.

Registration: NCT02664545 (ClinicalTrials.gov identifier).

Keywords: ACL reconstruction; ACL-RSI; BEAR; anterior cruciate ligament; bridge-enhanced ACL restoration; psychological readiness; return to sport.

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: This study received funding support from the Translational Research Program at Boston Children’s Hospital, the Children’s Hospital Orthopaedic Surgery Foundation, the Children’s Hospital Sports Medicine Foundation, the Football Players Health Study at Harvard University, the National Institutes of Health, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases through grants R01-AR065462 and R01-AR056834. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Medical School, Harvard University or its affiliated academic health care centers, the National Football League Players Association, Boston Children’s Hospital, or the National Institutes of Health. Y.-M.Y. has received education payments from Kairos Surgical and consulting fees from Smith & Nephew. M.M.M. is a founder, paid consultant, and equity holder in Miach Orthopaedics, which was formed to work on upscaling production of the BEAR scaffold. M.M.M. has also received honoraria from Musculoskeletal Transplant Foundation. M.A.C. has received hospitality payments from Smith & Nephew. B.P. has received consulting fees and has stock/stock options in Miach Orthopaedics. N.S. has received consulting fees from Miach Orthopaedics. B.C.F. is a paid associate editor for The American Journal of Sports Medicine and is the spouse of M.M.M. with inherently the same conflicts. D.E.K. has received education payments from Kairos Surgical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

© The Author(s) 2022.

Figures

Figure 1.
Figure 1.
CONSORT (Consolidated Standards of Reporting Trials) diagram detailing patient flow through the study. ACL, anterior cruciate ligament; ACLR, ACL reconstruction; BEAR, bridge-enhanced ACL restoration; BPTB, bone--patellar tendon–bone; KT, KT-1000 arthrometer testing; M, months; RSI, ACL--Return to Sport after Injury.
Figure 2.
Figure 2.
Mean ACL-RSI scores for BEAR and ACLR groups at 6, 12, and 24 months postoperatively. *P < .05. ACL, anterior cruciate ligament; ACLR, ACL reconstruction; BEAR, bridge-enhanced ACL restoration; ACL-RSI, ACL--Return to Sport after Injury.
Figure 3.
Figure 3.
Plot for time to clearance for return to sports based on a cutoff ACL-RSI score of 65 at 6 months after surgery. ACL, anterior cruciate ligament; ACL-RSI, ACL--Return to Sport after Injury.

References

    1. Ardern CL, Österberg A, Tagesson S, Gauffin H, Webster KE, Kvist J. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. Br J Sports Med. 2014;48(22):1613–1619.
    1. Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE. Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2013;41(7):1549–1558.
    1. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45(7):596–606.
    1. Barnett S, Murray MM, Badger GJ; et al. BEAR Trial Team. Earlier resolution of symptoms and return of function after bridge-enhanced anterior cruciate ligament repair as compared with anterior cruciate ligament reconstruction. Orthop J Sports Med. 2021;9(11):23259671211052530.
    1. Brewer BW, Cornelius AE, Van Raalte JL, et al. Age-related differences in predictors of adherence to rehabilitation after anterior cruciate ligament reconstruction. J Athl Train. 2003;38(2):158.
    1. Brewer BW, Cornelius AE, Van Raalte JL, et al. Rehabilitation adherence and anterior cruciate ligament reconstruction outcome. Psychol Health Med. 2004;9(2):163–175.
    1. Brewer BW, Cornelius AE, Van Raalte JL, Tennen H, Armeli S. Predictors of adherence to home rehabilitation exercises following anterior cruciate ligament reconstruction. Rehabil Psychol. 2013;58(1):64.
    1. Christino MA, Fantry AJ, Vopat BG. Psychological aspects of recovery following anterior cruciate ligament reconstruction. J Am Acad Orthop Surg. 2015;23(8):501–509.
    1. Christino MA, Fleming BC, Machan JT, Shalvoy RM. Psychological factors associated with anterior cruciate ligament reconstruction recovery. Orthop J Sports Med. 2016;4(3):2325967116638341.
    1. Czuppon S, Racette BA, Klein SE, Harris-Hayes M. Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. Br J Sports Med. 2014;48(5):356–364.
    1. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient: a prospective outcome study. Am J Sports Med. 1994;22(5):632–644.
    1. Ellis HB, Sabatino M, Nwelue E, Wagner KJ III, Force E, Wilson P. The use of psychological patient reported outcome measures to identify adolescent athletes at risk for prolonged recovery following an ACL reconstruction. J Pediatr Orthop. 2020;40(9):e844–e852.
    1. Flanigan DC, Everhart JS, Pedroza A, Smith T, Kaeding CC. Fear of reinjury (kinesiophobia) and persistent knee symptoms are common factors for lack of return to sport after anterior cruciate ligament reconstruction. Arthroscopy. 2013;29(8):1322–1329.
    1. Grindem H, Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A pair-matched comparison of return to pivoting sports at 1 year in anterior cruciate ligament-injured patients after a nonoperative versus an operative treatment course. Am J Sports Med. 2012;40(11):2509–2516.
    1. Hefti E, Müller W, Jakob R, Stäubli H-U. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc. 1993;1(3-4):226–234.
    1. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee Subjective Knee Form. Am J Sports Med. 2001;29(5):600–613.
    1. Kostyun RO, Burland JP, Kostyun KJ, Milewski MD, Nissen CW. Male and female adolescent athletes’ readiness to return to sport after anterior cruciate ligament injury and reconstruction. Clin J Sport Med. 2021;31(4):383–387.
    1. Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13(5):393–397.
    1. Langford JL, Webster KE, Feller JA. A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery. Br J Sports Med. 2009;43(5):377–378.
    1. Lentz TA, Zeppieri G, Jr, George SZ, et al. Comparison of physical impairment, functional, and psychosocial measures based on fear of reinjury/lack of confidence and return-to-sport status after ACL reconstruction. Am J Sports Med. 2015;43(2):345–353.
    1. Lentz TA, Zeppieri G, Jr, Tillman SM, et al. Return to preinjury sports participation following anterior cruciate ligament reconstruction: contributions of demographic, knee impairment, and self-report measures. J Orthop Sports Phys Ther. 2012;42(11):893–901.
    1. Marshall JL, Warren RF, Wickiewicz TL. Primary surgical treatment of anterior cruciate ligament lesions. Am J Sports Med. 1982;10(2):103–107.
    1. Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF. Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med. 2001;29(2):213–218.
    1. McPherson AL, Feller JA, Hewett TE, Webster KE. Psychological readiness to return to sport is associated with second anterior cruciate ligament injuries. Am J Sports Med. 2019;47(4):857–862.
    1. Meierbachtol A, Yungtum W, Paur E, Bottoms J, Chmielewski TL. Psychological and functional readiness for sport following advanced group training in patients with anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2018;48(11):864–872.
    1. Mentiplay BF, Perraton LG, Bower KJ, et al. Assessment of lower limb muscle strength and power using hand-held and fixed dynamometry: a reliability and validity study. PloS One. 2015;10(10):e0140822.
    1. Müller U, Krüger-Franke M, Schmidt M, Rosemeyer B. Predictive parameters for return to pre-injury level of sport 6 months following anterior cruciate ligament reconstruction surgery. Knee Surg Sports Traumatol Arthrosc. 2015;23(12):3623–3631.
    1. Murray MM, Fleming BC, Badger GJ, et al. Bridge-enhanced anterior cruciate ligament repair is not inferior to autograft anterior cruciate ligament reconstruction at 2 years: results of a prospective randomized clinical trial. Am J Sports Med. 2020;48(6):1305–1315.
    1. Murray MM, Flutie BM, Kalish LA, et al. The bridge-enhanced anterior cruciate ligament repair (BEAR) procedure: an early feasibility cohort study. Orthop J Sports Med. 2016;4(11):2325967116672176.
    1. Murray MM, Kalish LA, Fleming BC, et al. Bridge-enhanced anterior cruciate ligament repair: two-year results of a first-in-human study. Orthop J Sports Med. 2019;7(3):2325967118824356.
    1. Murray MM, Kiapour AM, Kalish LA, et al. Predictors of healing ligament size and magnetic resonance signal intensity at 6 months after bridge-enhanced anterior cruciate ligament repair. Am J Sports Med. 2019;47(6):1361–1369.
    1. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19(5):513–518.
    1. O’Connor RF, King E, Richter C, Webster KE, Falvey ÉC. No relationship between strength and power scores and anterior cruciate ligament return to sport after injury scale 9 months after anterior cruciate ligament reconstruction. Am J Sports Med. 2020;48(1):78–84.
    1. Sadeqi M, Klouche S, Bohu Y, Herman S, Lefevre N, Gerometta A. Progression of the psychological ACL-RSI score and return to sport after anterior cruciate ligament reconstruction: a prospective 2-year follow-up study from the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST). Orthop J Sports Med. 2018;6(12):2325967118812819.
    1. Webster KE, Feller JA. Development and validation of a short version of the anterior cruciate ligament return to sport after injury (ACL-RSI) scale. Orthop J Sports Med. 2018;6(4):2325967118763763.
    1. Webster KE, Feller JA. Return to level I sports after anterior cruciate ligament reconstruction: evaluation of age, sex, and readiness to return criteria. Orthop J Sports Med. 2018;6(8):2325967118788045.
    1. Webster KE, Feller JA. Who passes return-to-sport tests, and which tests are most strongly associated with return to play after anterior cruciate ligament reconstruction? Orthop J Sports Med. 2020;8(12):2325967120969425.
    1. Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport. 2008;9(1):9–15.
    1. Webster KE, Nagelli CV, Hewett TE, Feller JA. Factors associated with psychological readiness to return to sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2018;46(7):1545–1550.
    1. Wright RW, Preston E, Fleming BC, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation---part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg. 2008;21(3):217–224.
    1. Wright RW, Preston E, Fleming BC, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation---part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg. 2008;21(3):225–234.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться