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OBJECTIVE: Compare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture. DESIGN: Living systematic review and meta-analysis. DATA SOURCES: Six databases, six trial registries and prior systematic reviews. Forward and backward citation tracking was employed. ELIGIBILITY CRITERIA: Randomised controlled trials that compared primary reconstructive surgery and primary rehabilitative treatment with or without optional reconstructive surgery. DATA SYNTHESIS: Bayesian random effects meta-analysis with empirical priors for the OR and standardised mean difference and 95% credible intervals (CrI), Cochrane RoB2, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. RESULTS: Of 9514 records, 9 reports of three studies (320 participants in total) were included. No clinically important differences were observed at any follow-up for self-reported knee function (low to very low certainty of evidence). For radiological knee osteoarthritis, we found no effect at very low certainty of evidence in the long term (OR (95% CrI): 1.45 (0.30 to 5.17), two studies). Meniscal damage showed no effect at low certainty of evidence (OR: 0.85 (95% CI 0.45 to 1.62); one study) in the long term. No differences were observed between treatments for any other secondary outcome. Three ongoing randomised controlled trials were identified. CONCLUSIONS: There is low to very low certainty of evidence that primary rehabilitation with optional surgical reconstruction results in similar outcome measures as early surgical reconstruction for ACL rupture. The findings challenge a historical paradigm that anatomic instability should be addressed with primary surgical stabilisation to provide optimal outcomes. PROSPERO REGISTRATION NUMBER: CRD42021256537.

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BACKGROUND: The STarT-MSK-Tool is an adaptation of the well established STarT-Back-Tool, used to risk-stratify patients with a wider range of musculoskeletal presentations. OBJECTIVE: To formally translate and cross-culturally adapt the Keele STarT-MSK risk stratification tool into German (STarT-MSKG) and to establish its reliability and validity. METHODS: A formal, multi-step, forward and backward translation approach was used. To assess validity patients aged ≥18 years, with acute, subacute or chronic musculoskeletal presentations in the lumbar spine, hip, knee, shoulder, or neck were included. The prospective cohort was used with initial data collected electronically at the point-of-consultation. Retest and 6-month follow-up questionnaires were sent by email. Test-retest reliability, construct validity, discriminative ability, predictive ability and floor or ceiling effects were analysed using intraclass correlation coefficient, and comparisons with a reference standard (Orebro-Musculoskeletal-Pain-Questionnaire: OMPQ) using correlations, ROC-curves and regression models. RESULTS: The participants' (n = 287) mean age was 47 (SD = 15.8) years, 51% were female, with 48.8% at low, 43.6% at medium, and 7.7% at high risk. With ICC = 0.75 (95% CI 0.69; 0.81) test-retest-reliability was good. Construct validity was good with correlations for the STarT-MSKG-Tool against the OMPQ-Tool of rs = 0.74 (95% CI 0.68, 0.79). The ability of the tool [comparison OMPQ] to predict 6-month pain and disability was acceptable with AUC = 0.77 (95% CI 0.71, 0.83) [OMPQ = 0.74] and 0.76 (95% CI 0.69, 0.82) [OMPQ = 0.72] respectively. However, the explained variance (linear/logistic regression) for predicting 6-month pain (21% [OMPQ = 17%]/logistic = 29%) and disability (linear = 20%:[OMPQ = 19%]/logistic = 26%), whilst being comparable to the existing OMPQ reference standard, fell short of the a priori target of ≥30%. CONCLUSIONS: The German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. Comparison with the OMPQ suggests it is a good alternative.

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Author response to the JOSPT Letter to the Editor-in-Chief "Concerns About the Methodology and Data Collection in a Systematic Review". J Orthop Sports Phys Ther 2022;52(1):50-51. doi:10.2519/jospt.2022.0201-R.

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INTRODUCTION: The treatment of an anterior cruciate ligament rupture is still controversial. In particular, this applies to the question of conservative versus surgical treatment. The answer to this question is often based on consequential damage such as the development of posttraumatic osteoarthritis, secondary damage to the meniscus or cartilage, and participation in sports. If there are significant differences in these parameters between the individual treatment options, the results will be of great importance for the development of evidence-based treatment pathways. Therefore, the aim of this work was to evaluate the development of knee osteoarthritis after rupture of the anterior cruciate ligament and the corresponding treatment (conservative or surgical). MATERIAL AND METHODS: To answer the above question, a systematic literature search was conducted in Medline via Pubmed, the Cochrane Library and in CINAHL. Only systematic reviews with a minimum follow-up period of 10 years were included. The search was conducted in January 2020 and updated in January 2021. Investigated cohorts included patients with a rupture of the anterior cruciate ligament who had undergone either conservative or surgical treatment. Osteoarthritis was diagnosed either radiologically (recognized scores) or clinically (pain and impaired function). Appropriate reviews were qualitatively evaluated using the AMSTAR-2 questionnaire. RESULTS: The literature research initially identified n = 42 reviews from which 14 reviews were included. After full-text review and qualitative evaluation, only n = 2 systematic reviews remained for evaluation. The results of both papers show imprecise data with a high variability. However, it can be assumed with high probability that the development of osteoarthritis of the knee is increased after a rupture of the anterior cruciate ligament. There is no evidence that the incidence of joint degeneration may be reduced by reconstruction of the anterior cruciate ligament, nor is there a difference when comparing conservative and surgical treatment directly. CONCLUSION: Patients with an anterior cruciate ligament rupture are likely to be at a greater risk of developing progressive joint degeneration. A protective effect of cruciate ligament surgery has not been found in the evaluated studies. A general argument in favour of cruciate ligament surgery aiming to achieve a protective effect on hyaline articular cartilage seems obsolete based on the results and should therefore not be used in patient education in the future.

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OBJECTIVE: To assess the diagnostic test accuracy of pain provocation tests for the sacroiliac joint. DESIGN: Systematic review of diagnostic test accuracy. LITERATURE SEARCH: Seven electronic databases and reference lists of included studies and previous reviews were searched. STUDY SELECTION CRITERIA: Studies investigating the diagnostic accuracy of clusters of clinical tests for sacroiliac joint pain were included. DATA SYNTHESIS: Bivariate random-effects meta-analysis was employed. Risk of bias and applicability concerns were assessed using the revised Quality Assessment of Diagnostic Accuracy Studies tool, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was used to judge credibility of evidence. RESULTS: From 2195 records identified in the search, 5 studies were included that assessed clusters of pain provocation tests for the sacroiliac joint. The estimated positive likelihood ratio was 2.13 (95% confidence interval [CI]: 1.2, 3.9), the negative likelihood ratio was 0.33 (95% CI: 0.11, 0.72), and the diagnostic odds ratio was 9.01 (95% CI: 1.72, 28.4). The GRADE ratings for the outcomes were of very low certainty. Assuming a point prevalence of sacroiliac joint pain of 20%, we calculated a positive posterior probability of 35% (95% CI: 32%, 37%) and negative posterior probability of 8% (95% CI: 6%, 10%). CONCLUSION: A positive result on a sacroiliac joint pain provocation test cluster gives the clinician 35% certainty of having correctly identified sacroiliac joint pain. Clusters of pain provocation tests for the sacroiliac joint do not provide sufficient diagnostic accuracy for ruling in the sacroiliac joint as the source of pain. Clinicians can rule out the sacroiliac joint as the source of pain with more confidence: the negative posttest probability indicates that the clinician can conclude with 92% certainty that a negative test result is correct. J Orthop Sports Phys Ther 2021;51(9):422-431. Epub 1 Jul 2021. doi:10.2519/jospt.2021.10469.

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Importance: Preoperative and postoperative exercise interventions are commonly used in patients with total hip arthroplasty despite a lack of established efficacy. Objective: To explore clinical outcomes associated with exercise training before and after hip arthroplasty. Data Sources: PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Google Scholar were searched from their inception to March 2020. Reference lists of included trials and related reviews were also searched. Study Selection: Randomized clinical trials of land-based exercise interventions before or after total hip arthroplasty were included. Data Extraction and Synthesis: This systematic review and meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction was independently performed in duplicate. Random-effects meta-analyses with restricted maximum likelihood were performed for pooling the data. Main Outcomes and Measures: The primary prespecified outcome was self-reported physical function. Secondary prespecified outcomes were self-reported pain intensity, quality of life, gait speed, lower body muscle strength, lower body flexibility, anxiety, hospital length of stay, and adverse events. Results: A total of 32 randomized clinical trials with 1753 patients were included in the qualitative synthesis, and 26 studies with 1004 patients were included in the meta-analysis. Compared with usual care or no or minimal intervention, postoperative exercise training was not associated with improved self-reported physical function, with a moderate level of certainty, at 4 weeks (standardized mean difference [SMD], 0.01; 95% CI, -0.18 to 0.20), 12 weeks (SMD, -0.08; 95% CI, -0.23 to 0.07) and 26 weeks (SMD, -0.04; 95% CI, -0.31 to 0.24) postoperatively, and low level of certainty at 1 year after surgical treatment (SMD, 0.01; 95% CI, -0.09 to 0.12). For preoperative exercise interventions, there was no association of exercised training with self-reported physical function compared with the control at the 12-week (SMD, -0.14; 95% CI, -0.61 to 0.32) or 1-year follow-ups (SMD, 0.01; 95% CI, -0.37 to 0.40) with very low certainty, and no association with length of stay (mean difference, -0.21; 95% CI, -0.74 to 0.31) at moderate certainty. Results for postoperative hip muscle strength were rated at very low certainty, with no statistical significance. Meta-analysis could not be performed for other outcomes. Conclusions and Relevance: This systematic review and meta-analysis found low- to moderate-quality evidence that postoperative exercise interventions were not associated with improved self-reported physical function compared with usual care or no or minimal intervention. Furthermore, there was very low-quality evidence that preoperative exercise programs were not associated with higher self-reported physical function and hospital length of stay compared with usual care or no or minimal intervention.

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