Osseous metaplasia as a cause of loss of extension after anterior cruciate ligament reconstruction

We report a case of osseous metaplasia of an autologous anterior cruciate ligament (ACL) reconstruction that was implicated in blocking extension of the knee. Nonoperative treatment was unsuccessful. Arthroscopic excision of the ACL and osseous metaplasia abolished the fixed flexion deformity. The osseous metaplasia was an additional factor in causing the block to extension along with an anteriorly placed femoral tunnel, raising the question that nonisometry of the graft may be involved in the pathogenesis of the osseous metaplasia.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 4 (April), 2001: pp 405–407     

Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction

Arthrofibrosis is one of the recognized complications following traditional anterior cruciate ligament (ACL) reconstruction. With the advent of arthroscopic assisted ACL reconstructions, the extent of potential arthrofibrosis appeared to be less. However, 13 patients after intra-articular ACL reconstruction using a patella tendon autograft developed a similar symptom complex. In addition to postoperative loss of full extension, there was an audible and palpable clunk with terminal extension. These patients had similar arthroscopic findings of a nodule that formed anterolateral to the tibial tunnel placement of the graft. The arthroscopic appearance of the soft tissue mass with its surface vessels was reminiscent of a "cyclops." After arthroscopy with debridement and manipulation of the knee, extension was improved in all cases. The average range of motion immediately after the procedure was 6.0-130 degrees, compared with 16-103 degrees preoperatively. The range of motion at last follow-up averaged 3.8 degrees of extension and 138 degrees of flexion. All patients had greater than 130 degrees of flexion. There were no complications attributed to the manipulation and arthroscopic lysis of adhesions, and no patient experienced loss of graft integrity or knee stability. The "cyclops" nodule was examined grossly and microscopically and demonstrated peripheral fibrous tissue with a central region of granulation tissue in all specimens. In addition, two specimens were noted to include bony fragments and three specimens contained cartilaginous tissue.     

Results of arthroscopic treatment of symptomatic loss of extension following anterior cruciate ligament reconstruction

Symptomatic loss of knee extension is an important cause of postoperative morbidity following anterior cruciate ligament reconstruction. In a series of 342 consecutive reconstructions performed by the senior author, 17 knees in 16 patients had symptomatic extension deficits (>5 degrees) refractory to a minimum of 4 months of intensive physical therapy that required arthroscopic debridement. Thirteen knees in 12 patients were available for evaluation at a mean follow-up of 3.9+/-1.7 years and form the treatment group. Twenty-six knees in 26 patients who underwent reconstruction but did not develop arthrofibrosis were matched to the treatment group and served as controls. At a mean of 12+/-8 months following reconstruction, patients in the treatment group underwent examination under anesthesia, arthroscopic debridement, revision notchplasty as necessary, and controlled manipulation. Postoperatively, patients were assigned to a closely supervised rehabilitation protocol emphasizing restoration of knee extension. At final evaluation, knee extension deficits had improved from a preoperative mean of 10 degrees (SD 5 degrees) to 3 degrees (SD 4 degrees) (P<.001). Multiple functional rating scales also were used to evaluate the treatment and control groups. With the numbers available, there was no statistically significant difference in function at final evaluation between the treatment and control groups. The best treatment for loss of knee extension is preventive. Complications are avoided by careful patient selection, appropriate timing of surgery, attention to operative detail, and aggressive rehabilitation. However, patients reaching a plateau in rehabilitation with significant residual extension deficits, patellofemoral symptoms, or both predictably benefit from arthroscopic debridement.     

Intraarticular viscosupplementation following arthroscopic anterior cruciate ligament reconstruction: A systematic review

BackgroundPain, swelling and joint stiffness are the major problems following arthroscopic ACL reconstruction (ACLR) surgery that restrict early return to sports and athletic activities. The patients often receive prolonged analgesic medications to control the inflammatory response and resume the pre-injury activities. This systematic review aims to evaluate the safety and efficacy of intraarticular (IA) hyaluronic acid (HA) injection following ACLR.Material and methodsA literature search of electronic databases and a manual search of studies reporting clinical effectiveness of IA HA following ACLR was performed on 1^st November 2020. The quality of the methodology and risk of bias was assessed using the Cochrane Collaboration Risk of Bias Tool and Newcastle-Ottawa scale for randomized-controlled trial and prospective cohort studies, respectively.ResultsOf 324 studies retrieved, four studies (3 RCTs and one prospective cohort study) were found to be suitable for inclusion in this review. These studies had a low to moderate risk of bias. There were 182 patients in the HA group and 121 patients in the control group. The demographic characteristics of the patients were similar in all studies. The pooled analysis of studies evaluating pain at different follow up periods (2-week, 4–6 weeks, 8–12 weeks) after ACLR revealed no significant difference between the HA and control groups (p > 0.05). The knee swelling was significantly less in the HA group at two weeks (MD -7.85, 95% CI: [-15.03, −0.68], p = 0.03, I2 = 0%), but no such difference was noted after 4–6 weeks and 8–12 weeks. The functional outcome score was not significantly different between the groups (SMD 0.00, 95% CI: 0.38 to 0.38, p = 0.99, I² = 0%).ConclusionsAlthough the individual study demonstrated a short-term positive response regarding pain control and swelling reduction, the pooled analysis did not find any clinical benefit of IA HA injection following ACLR surgery.Level of evidenceII.     

Intraarticular versus intraarticular and extraarticular reconstruction for chronic anterior cruciate ligament instability

One hundred twenty-seven patients were evaluated for the results of surgical stabilization in chronic anterior cruciate ligament instability. Eighty-four patients had been treated with intraarticular reconstruction alone, while 43 patients had been treated with a combination of intraarticular and extraarticular stabilization. Patients were evaluated by questionnaire to assess subjective and functional status by clinical examination of objective findings, and by roentgenograms and instrumented ligamentous stability testing. The follow-up interval averaged 45.2 months for the entire group (range, 24-90 months). Using a 200-point scale, the rating for the group treated with intraarticular reconstruction alone was 169.1, while the average rating for the group treated with combined intraarticular and extraarticular stabilization was 166.2. Overall, an excellent or good result was obtained in 67% of patients in the intraarticular only group and in 70% of the patients in the combined reconstruction group. There were no significant differences between the two groups in terms of changes seen on roentgenograms or in terms of residual laxity measured by instrumented testing. Thus, there is no demonstrable benefit derived from combined intraarticular and extraarticular stabilization procedures for chronic anterior cruciate ligament instability, provided that a well-placed intraarticular substitute of sufficient strength is functional.     

Skin dimpling as a complication of hamstring harvesting following anterior cruciate ligament reconstruction

Surgical intervention to repair a torn anterior cruciate ligament (ACL) with autogenous hamstring tendons has become popular. However, hamstring graft harvesting complications can occur. This article presents a case of skin dimpling over the pes anserinus during active hamstring contraction in a 32-year-old man following arthroscopic ACL reconstruction.     

Loose intra-articular body following anterior cruciate ligament reconstruction

We report a case of intra-articular fracture of a bioabsorbable fixation device from the femoral tunnel in an anterior cruciate ligament reconstruction using a bone-tendon-bone graft. Thirteen months after successful reconstruction surgery, the patient experienced episodes of locking and medial joint pain. There was no history of trauma and no symptoms of instability or swelling. On revision arthroscopy, a fractured tip of a bioabsorbable RIGIDfix cross pin (Mitek, Westwood, MA) was identified in the medial compartment of the knee. There was a broad area of chondral erosion affecting the medial femoral condyle and a small defect to the medial tibial plateau where the loose body had been lodged. The bone-tendon-bone graft was intact without disruption. After arthroscopy, the patient was symptom free for 3 weeks but then developed further symptoms of locking. Magnetic resonance imaging showed another loose body within the knee. A repeat arthroscopy was performed 6 weeks after the earlier procedure and another piece of the polylactic acid RIGIDfix cross pin was removed, this time from the lateral gutter. This case raises concern about the potential for breakage and resultant loose body formation that may occur after bioabsorbable cross-pin fixation and, particularly, the associated chondral damage that can occur if early intervention is not conducted.     

Patella infera following arthroscopic anterior cruciate ligament reconstruction

Fifty patients who had an arthroscopic anterior cruciate ligament reconstruction for chronic insufficiency were reviewed at an average of 13.6 months following surgery. Among these patients, 32% complained of anterior knee pain that interfered with daily activities. Radiographic patella infera was present in 12% of patients using the Insall-Salvati ratio and in 16% using the Blackburne-Peel ratio. Radiographic patella infera did not correlate with the clinical problem of postoperative anterior knee pain. However, loss of knee extension of greater than 5 degrees correlated highly with pain (p=0.002).     

Return to sport following anterior cruciate ligament reconstruction

Rates of return to pre-injury sport following anterior cruciate ligament (ACL) reconstruction are less than might be expected from standard outcome measures and there appears to be a rapid decline in sporting participation after two to three years. There are many factors that influence whether an individual will return to sport following this type of surgery. They include not only surgical details and rehabilitation, but also social and psychological factors, as well as demographic characteristics. Age is of particular importance with older patients being less likely to resume their pre-injury sport. It is important that future research clearly identify the pre-injury characteristics of the study cohort when investigating return to sport, and also that there is consistent and precise terminology used to report rates of return to sporting activities. Little is known about how to determine when it is safe to return to sport following ACL reconstruction or how to predict whether an athlete will be able to successfully return to sport. Finally, it needs to be recognised that return to sport following ACL reconstruction is associated with a risk of further injury and the development of osteoarthritis.     

Case series utilizing drop-out casting for the treatment of knee joint extension motion loss following anterior cruciate ligament reconstruction

STUDY DESIGN: Case series. CASE DESCRIPTION: Four patients who had developed knee extension motion loss following anterior cruciate ligament reconstruction were referred to physical therapy for treatment. They were treated with drop-out casting and completed a Lower Extremity Functional Scale at baseline, at the time of application of the drop-out casting, and at discharge. OUTCOMES: Three males and 1 female with a mean age of 20.5 years (range, 18-22 years) were referred to physical therapy a mean of 31 days (range, 19-49 days) following bone-patella tendon-bone autograft anterior cruciate ligament reconstruction. The mean number of physical therapy sessions attended was 29.5 visits (range, 20-47 visits). The mean improvement in knee extension range of motion (ROM) and knee flexion ROM prior to the application of drop-out casting was 4.3 degrees (range, -1 degree to 10 degrees) and 24.3 degrees (range, 0 degree to 40 degrees), respectively. The mean improvement on the Lower Extremity Functional Scale was 10.3 points prior to drop-out casting. At time of discharge, the total mean improvement in knee extension ROM loss was 11.0 degrees (range, 4 degrees to 15 degrees), knee flexion ROM was 30.8 degrees (range, 22 degrees to 35 degrees), and Lower Extremity Functional Scale was 12 points (range, -5 to 21 points). Two of the patients were able to complete a running program without difficulty, while the other 2 patients had difficulty with higher-level activities. DISCUSSION: Despite the low incidence of knee extension ROM loss following surgery, the inability to achieve full knee extension does occur and can have debilitating consequences. When early emphasis of full passive knee extension has been inadequate, these results suggest that improving knee extension motion without inhibiting knee flexion motion is possible with the use of a drop-out cast. Future research should focus on comparison of drop-out casting to dynamic splinting, as well as the optimal frequency and duration of low-load long-duration stretching using a drop-out cast.     

Osteomyelitis of the tibia following anterior cruciate ligament reconstruction

INTRODUCTIONOsteomyelitis following anterior cruciate ligament (ACL) reconstruction is extremely rare.PRESENTATION OF CASEWe present a thirty year old man who presented with pain in his proximal tibia six years after ACL reconstruction. Haematological investigations were normal. He was diagnosed with osteomyelitis of his proximal tibia. He was successfully treated with washout and debridement of his tibial tunnel.DISCUSSIONThis case highlights the need to exclude osteomyelitis as a late complication of ACL reconstruction in patients with proximal tibial pain. We also report on an unusual pathogen as casue of osteomyelitis.CONCLUSIONOsteomyelitis in a tibial tunnel can present as a late complication of ACL reconstruction, even in the presence of normal haematological investigations.     

Kinematic study following double-bundle, anterior cruciate ligament reconstruction

The purpose of this study was to evaluate tibiofemoral kinematics after double-bundle anterior cruciate ligament (ACL) reconstructions and compare them with those of successful single-bundle reconstructions and contralateral normal knees using open MR images. We obtained MR images based on the flexion angle without weight-bearing, from 20 patients with successful unilateral single-bundle (10 patients) and double-bundle (10 patients) ACL reconstructions with tibialis anterior allografts and a minimum 1-year follow-up. The MR images of the contralateral uninjured knees were used as normal controls. Sagittal images of the mid-medial and mid-lateral sections of the tibiofemoral compartments were used to measure the translation of the femoral condyles relative to the tibia. The mean translations of the medial femoral condyles on the tibial plateaus during knee joint motion showed no significant differences among normal, single-bundle, and double-bundle ACL reconstructed knees (all p>0.05). The mean translations of the lateral femoral condyles showed a significant difference between normal and single-bundle reconstructed knees, or between single-bundle and double-bundle reconstructed knees (p<0.05). However, there was no significant difference between normal and double-bundle reconstructed knees (p=0.220). These findings suggest that double-bundle ACL reconstruction restores normal kinematic tibiofemoral motion better than single-bundle reconstruction.     

A unique complication following arthroscopic anterior cruciate ligament reconstruction

The use of the middle third of a patellar tendon with bone blocks is a common and well-accepted technique for arthroscopic reconstruction of the anterior cruciate ligament. We report here a disconcerting fracture/avulsion pattern of the patella/patellar tendon mechanism that occurred in the early postoperative period.     

Digital infrared thermal imaging following anterior cruciate ligament reconstruction

This case describes the selective use of digital infrared thermal imaging for a 48-year-old woman who was being treated by a physical therapist following left anterior cruciate ligament (ACL) reconstruction with a semitendinosus autograft.     

Tibial interference screw removal following anterior cruciate ligament reconstruction

A small number of patients developed pain and tenderness at the tibial tunnel following anterior cruciate ligament reconstruction. Twenty-three knees in 22 patients underwent removal of the tibial interference screw. Ten knees had a preoperative flexion contracture and underwent a concomitant procedure to address the loss of motion at the time of hardware removal. In the 13 knees with full extension, the interval between ligament reconstruction and screw removal averaged 16 months. Eleven of these knees also underwent arthroscopy, but no intraarticular causes of pain were identified. Roentgenographic analysis showed protrusion of the interference screw above the tibial cortex in three cases. Follow-up after hardware removal averaged 2 years. Tibial tunnel tenderness resolved in 21 of 23 knees, including those of the two patients who underwent hardware removal alone. Although it cannot be stated with certainty that tibial interferences screws may cause pain, this review suggests an association. This is an uncommon problem and it is estimated to be a factor in less than 3% of the authors' anterior cruciate ligament reconstructions. More common causes of knee pain should be sought before electing to remove the tibial interference screw.     

Revision anterior cruciate ligament reconstruction surgery.

Revision anterior cruciate ligament (ACL) reconstruction is indicated for selected patients with recurrent instability after a failed primary procedure. The cause of the failure must be carefully identified to avoid pitfalls that may cause the revision to fail as well. Associated instability patterns must be recognized and corrected to achieve a successful result. The choice of graft, the problem of retained hardware, and tunnel placement are the major challenges of revision ACL reconstruction. The patient must have reasonable expectations and understand that the primary goal of surgery is restoration of the ability to perform activities of daily living, rather than a return to competitive athletics. The results of revision ACL reconstructions are not as good as those after primary reconstructions; however, the procedure appears to be beneficial for most patients.