Knee brace after bone-tendon-bone anterior cruciate ligament reconstruction Randomized, prospective study with 2-year follow-up

In a prospective study 60 patients were randomized to brace and no-brace groups after bone-tendon-bone anterior cruciate ligament reconstruction. The brace group wore a rehabilitation orthosis for 12 weeks postoperatively, while the no-brace group was mobilized immediately, and crutches were discarded 2 weeks postoperatively. The groups were comparable with respect to age, gender, time from injury to surgery, knee score (Lysholm), activity level (Tegner), degree of laxity and isokinetic muscle torque. Although compared with the preoperative situation patients in both groups had significantly improved, there were no differences between the groups 1 and 2 years postoperatively in terms of functional outcome (Lysholm and Tegner scores), stability of the knee or isokinetic muscle torque. Received: 13 June 1996 Accepted: 23 November 1996     

Range of motion training in brace vs. plaster immobilization after anterior cruciate ligament reconstruction: a prospective randomized comparison with a 2-year follow-up

The purpose of this prospective and randomized study was to compare rehabilitation with early range of motion (ROM) training vs immobilization following anterior cruciate ligament (ACL) reconstruction. Fifty patients, undergoing an ACL reconstruction with a bone-patellar tendon-bone graft, were postoperatively allocated randomly to either a plaster cast or a brace for 5 weeks. The brace group had ROM exercises from postoperative day 7. The commencement of ROM exercises was postponed 4 weeks for the plaster group compared to the brace group, but progressed subsequently with equal speed. There was no difference between the groups in the ROM of flexion or extension 20 weeks after the ACL reconstruction and later. Twenty-four months after surgery, the muscle strength deficit in the hamstring muscles (isokinetic measurements; percent difference, injured vs uninjured) was significantly larger in the brace group (mean +/- SD: 5.9 +/- 7.8%, P < 0.01) than in the plaster group (- 0.9 +/- 11.8%, NS) (brace vs plaster group, P < 0.05). Furthermore, there was also a tendency in the brace group to a larger strength deficit in the quadriceps muscle (brace: 11.1 +/- 13.2%, P < 0.001; plaster: 3.8 +/- 12.9%, NS) (brace vs plaster group, P= 0.07). There was no difference between the groups in the total sagittal knee laxity, as measured with an arthrometer, or in the subjective knee function or activity level (Lysholm score together with the Tegner activity level) between the groups. It is concluded that the postoperative treatment with early range of motion training after ACL reconstruction gave as good ROM, knee stability, subjective knee function and activity level as the treatment with immobilization. It is hypothesized that the larger strength deficit observed after rehabilitation with early range of motion training is secondary to the more intensive training and physical therapist involvement that was demanded in order to achieve full ROM following immobilization.     

Post-operative problems following anterior cruciate ligament reconstruction

Seventy adult patients were studied during the postoperative rehabilitation period following anterior cruciate ligament reconstruction in order to investigate the role of pre-, intra-, and postoperative factors in range of motion and graft problems. A standard bone-patellar tendon-bone autograft was used for the reconstruction. Pre-and intraoperative factors such as concomitant injuries, time from injury to surgery, age, sex, and tunnel placement were recorded. Tunnel placement was recorded on intraoperative radiographs of the final guide pin placement and compared to pin placement on cadaver knees. The results indicated a significant relation between early reconstruction (<1 month) following the injury and range of motion problems during the early rehabilitation period (P<0.001). This relation disappeared by the end of the first postoperative year. Prolonged surgery was also associated with early motion problems (P<0.05). Graft laxity or failure was correlated with an earlier return of range of motion (P<0.05). We hypothesized that graft failure can have a biologic cause rather than a mechanical one since intraoperative X-rays indicated a near-anatomic tunnel placement in this patient group when compared to ideal placement in the cadaver knees.     

Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon A 5–8-year follow-up

We reviewed 89 arthroscopically assisted patellar tendon anterior cruciate ligament (ACL) reconstructions for chronic isolated injuries with an average follow-up of 7 years (range 5.4 to 8.6 years). Pain was present in 7 knees (8%). Giving-way symptoms were reported by 7 patients (8%). A KT-2000 side-to-side difference over 5 mm at 30 lbs was recorded in 12 cases (16%). The pivot shift was glide in 17 cases (19%) and clunk in 10 (11%). A 3°– 5° extension loss compared with the normal side was present in 20 knees (22%) and 6°–10° in 4 knees (4%). The intra-articular exit of the femoral tunnel was misplaced in the anterior 50% of the condyles along the roof of the notch in 10% of the knees. This positioning significantly (P = 0.003) increased the frequency of graft failure (62.5%) compared with the cases with a more posterior placement (graft failure 12%). An anterior position of the intra-articular exit of the tibial tunnel (in the anterior 15% of the sagittal width of the tibia) significantly (P = 0.01) increased the frequency of extension loss > 5°. Medial meniscectomy was associated with a 35% incidence of narrowing of the medial joint space, which was significantly higher compared with knees with normal menisci (9%; P = 0.04) or with medial meniscal repair (7%; P = 0.05). In conclusion this study showed satisfactory anterior stability (KT-2000 side-to-side difference up to 5 mm and pivot absent or glide) in 83% of the knees. This percentage increases to 88% in the knees with a correct posterior and proximal femoral tunnel placement. Accuracy in tunnel positioning is essential for the success of ACL surgery. Meniscal repair was effective in decreasing joint space narrowing and should be attempted when possible. Received: 15 November 1996 Accepted: 17 March 1997     

关节镜下自体髌腱移植重建前交叉韧带的疗效观察

目的探讨使用自体骨-1/3髌腱-骨移植重建损伤的前交叉韧带(ACL)的临床疗效。方法本研究包括40例单纯性前交叉韧带断裂伴症状性胫骨前脱位的病例,均采用自体骨-1/3髌腱-骨重建。术后进行为期6个月的康复训练。术前和术后随访时行患侧膝关节X线检查,行体格检查及功能评分。结果总共36例(90%)获得随访,时间平均31个月。30例(83%)Lachman征及旋转移位试验阴性。Lysholm评分由术前平均(55.7±3.1)分增加至术后最后一次随访时的(90.1±2.7)分(P0.001)。而Tegner评分则由术前平均(5.0±1.4)分增加至术后(6.25±1.2)分(P0.001)。与术前X线检查相比,无退行性改变。结论采用自体骨-1/3髌腱-骨重建前交叉韧带后2年以上随访结果发现,83%的患者膝关节不稳现象消失,至术后最后一次随访时膝关节功能评分较术前显著增加。以该方法重建ACL有效地恢复了受伤膝关节功能。     

Knee isokinetic performance following anterior cruciate ligament reconstruction: patellar tendon versus hamstrings graft

Objective: To compare knee isokinetic performance six months after reconstruction of the anterior cruciate ligament using grafts from either the patellar tendon or the hamstrings among patients who underwent the same rehabilitation protocol.

Methods: Thirty-four patients were evaluated (17 with grafts from the patellar tendon and 17 with grafts from the hamstrings). Operated and non-operated knees were compared with regards to the variables of peak torque, work and the hamstring/quadriceps relationship at velocities of 60º/s and 180º/s and power of 180º/s after six months of surgery.

Results: The patients with ACL reconstruction using the patellar tendon (BPTB) showed quadriceps deficits for all variables, but the flexor musculature was balanced. In the hamstring group, both the extensors and the flexors showed deficits for the variables analyzed, except for hamstring power at 180º/s.

Conclusion: Patients in the patellar tendon group had a greater quadriceps deficit compared with those in the hamstrings group. Patients in the hamstrings group had a greater muscular deficit in the flexor mechanism compared with the contralateral knee. An unbalanced H/Q ratio was observed regardless of graft type, but this was more evident in the BPTB group.     

Anterior cruciate ligament reconstruction with fresh-frozen patellar tendon allografts: sixty cases with 2 years' minimum follow-up

A prospective study was performed on 101 patients who underwent an arthroscopic anterior cruciate ligament (ACL) reconstruction with fresh-frozen patellar tendon allograft (bone-patellar tendon-bone). We present the results of the first 60 patients with a minimum follow-up of 2 years. Thirty four were men and 26 women with a mean age of 23. In 45 patients, a postoperative arthroscopy was performed, and tissue biopsies of the reconstructed ACL were obtained. Patients were evaluated according to the International Knee Documentation Committee evaluation form. After a mean follow-up of 47 months, the overall results were normal or nearly normal in 85%. Under postoperative arthroscopy, the macroscopic appearance of the implant was similar to that of a normal ligament. The ACL allograft was covered with a normal. well-vascularized synovium. There were no cases of infection, disease transmission or tissue rejection. We conclude that the use of fresh-frozen patellar tendon allografts is a good method of ACL reconstruction.     

Change in the cross-sectional area of a patellar tendon graft after anterior cruciate ligament reconstruction

The purpose of this study was to clarify the change in the cross-sectional area (CSA) of a patellar tendon graft after anterior cruciate ligament (ACL) reconstruction, and its relationship with postoperative knee laxity. Forty patients (25 men and 15 women) were included in this study. Intraoperative CSA measurements were performed with an instrumented areamicrometer, while a magnetic resonance imaging (MRI) evaluation was utilized for the assessment postoperatively. For intraoperative measurement, the average CSA of a 10-mm wide patellar tendon graft was 32.3 ± 7.0 mm², while the average CSA measured at follow-up (mean: 14.8 months) was 48.8 mm², showing a significant mean increase ratio of 49.4%. This value corresponded to 115% of the native ACL. The average CSA measured in 30 patients at 6 months was 49.7 mm², almost equal to the value at the final follow-up (49.8 mm²) in the same patient group. Among potentially influential factors, postoperative notch width (available space for the ACL graft) had significant correlation with the CSA of the graft at follow-up. Finally, both intra- and postoperative CSA values did not correlate with postoperative knee laxity, indicating that a bigger graft does not guarantee a better laxity.     

Dynamic joint loading following hamstring and patellar tendon anterior cruciate ligament reconstruction

This study compared lower limb dynamic joint loading after hamstring (HS) and patellar tendon (PT) anterior cruciate ligament (ACL) reconstruction. A three-dimensional motion analysis and force plate system were used to determine sagittal plane kinematics and kinetics in 20 subjects who had undergone ACL reconstruction (10 HS, 10 PT) whilst they performed both horizontal and vertical hopping tasks. Results for both activities showed significantly smaller knee flexion angles and external flexion moments in the operated than the non-operated limbs in PT subjects but no difference between limbs in HS subjects. There was no difference in the summated moment (hip plus knee plus ankle) between limbs for either graft type. The peak vertical ground reaction force was greater in the operated than the non-operated limb in PT subjects during the horizontal hop. These data show functional knee kinematic and kinetic differences between the two graft types that point to an earlier or better functional recovery in patients undergoing ACL reconstruction with HS graft than PT graft.     

Double semitendinosus anterior cruciate ligament reconstruction: 10-year results

In a series of 30 consecutive patients who suffered from chronic instability of the knee joint, reconstruction of the torn anterior cruciate ligament was performed with a looped semitendinosus tendon, reinforced by an extra-articular anterolateral procedure. Of these 30, 27 could be followed up 9–11 years after the operation. The evaluation included the International Knee Documentation Committee (IKDC) questionnaire and was completed by testing with a Kneelax arthrometer at 132 N and by anteroposterior standing X-ray, in order to evaluate the degenerative changes. At the time of the check-up: 96% of the study group considered that they had normal or nearly normal knees, and 81% had recovered to the same sports activity level as before their injury. The degenerative changes noted at the index operation did not progress notably, except in two cases. Laxities of 7 knees were normal, with a side-to-side difference of less than 2 mm; 15 were nearly normal, with a mean difference of 3.45 mm; and 5 were abnormal, with a mean difference of 6.2 mm. The study shows that the procedure is efficient in restoring a satisfactory stability for most patients and stabilises the evolution of the degenerative lesions as shown by standing X-ray. Received: 30 December 1996 Accepted: 25 July 1997     

Revision of failed gore-tex anterior cruciate ligament reconstruction

The Gore-Tex synthetic knee ligament was widely used in the early 1980s because of encouraging early results. However, the long-term failure rate is unfavorable. Gore-Tex failures are divided into four categories: effusion, graft rupture, loosening/ osteolysis, and infection. Revision surgery is challenging and requires a systematic approach to achieve optimal results.     

Closing patellar tendon defects after anterior cruciate ligament reconstruction: absence of any benefit

The most common graft in anterior cruciate ligament (ACL) surgery involves using the central one-third of the patellar tendon. Knowledge concerning the postoperative disability after harvesting the patellar tendon is, however, limited. The aim of this study was to evaluate the impact patellar tendon suture and bone grafting of the patellar bone defect might have in terms of functional outcome and patellofemoral pain after harvesting the bone-tendon-bone graft, compared with leaving the harvested site non-sutured and non-grafted. Sixty patients, scheduled for arthroscopically assisted ACL reconstruction, were randomly allocated to two groups. In group I, suture of the patellar tendon and bone grafting of the patellar defect were performed. In group II, the tendon gap and the patellar defect were left open. Preoperatively, there was no significant difference between the groups when comparing objective knee stability, as measured with a KT-1000 laxity meter, Lysholm score, Tegner activity level, IKDC score, or patellofemoral pain score. Both groups had a significantly improved Lysholm score at the 2-year follow-up, without any difference between them. Tegner's activity level was significantly lower at follow-up, compared with the pre-injury level in both groups. The patellofemoral pain score improved significantly after the reconstruction, without any difference between the groups. Ultrasonography did not reveal any difference between the groups in terms of healing of the tendon gap. This study revealed no differences in donor site morbidity, functional outcome, patellofemoral pain score or knee joint stability between the two treatment groups. The conclusion is that suture of the patellar tendon and bone grafting of the patellar defect do not improve the functional results or reduce donor site morbidity after arthroscopically assisted ACL. Received: 17 December 1996 Accepted: 30 July 1997     

Is bracing after anterior cruciate ligament reconstruction necessary? A 2-year follow-up of 78 consecutive patients rehabilitated with or without a brace

The aim of this study was to evaluate the effect of a standard postoperative rehabilitation knee brace on function, stability and postoperative complications at the 2-year follow-up after anterior cruciate ligament (ACL) reconstructive surgery. Seventy-eight consecutive patients with a unilateral chronic ACL rupture reconstructed by the same surgeon using the endoscopic “all-inside” technique, patellar tendon autograft and interference screw fixation were included in the study. The rehabilitation followed a standard protocol. Group A included 39 patients who were supplied postoperatively with a knee brace for 4 (range 3–6) weeks. Group B included 39 patients for whom a brace was not used. The median age was 27 (range 16–48) years in group A and 26 (range 14–51) years in group B. The median time period between the injury and the index operation was 24 (range 3–150) months in group A and 18 (range 3–360) months in group B. All 78 patients were re-examined by two independent observers after a median follow-up period of 25 (range 23–28) months in group A and 24 (range 22– 27) months in group B. The median KT-1000 total side-to-side difference between the reconstructed and the uninjured knees at 89 N was 3 (range –5.5–11) mm in group A and 3 (range –7–10) mm in group B (NS). When the anterior translation was tested separately at 89 N, the corresponding values were 3 (range –4–13) mm in group A and 3 (range –5–10) mm in group B (NS). The median one-leg hop quotient was 95% (range 50%–167%) of the uninjured leg in group A and 92% (range 64%–119%) in group B (NS). The median Lysholm score was 89 (range 39–100) points in group A and 85 (range 37–100) points in group B (NS). In group A, 27/39 (69%) patients and in group B 21/39 (54%) patients were classified as excellent or good (NS). The median Tegner activity level was 7 (range 3–9) in group A and 6 (range 3–9) in group B (NS). Using the IKDC scale, 27/39 (69%) in group A and 24/39 (62%) in group B were classified as normal or nearly normal (NS). The median sick leave in group A was 62 (range 0–357) days and 59 (range 0–243) days in group B (NS). No serious complications occurred during the first 6 postoperative weeks. Two serious complications were, however, registered after the 6th postoperative week. One patient in group A sustained a rupture of the reconstructed ACL 8 weeks postoperatively (3 weeks after removing the brace), and one patient in group B sustained an undislocated patellar fracture during the 7th postoperative week after a fall. This study indicates that the use of a postoperative rehabilitation brace after an arthroscopic ACL reconstruction did not appear to influence either objective stability or subjective function by the 2-year follow-up. Received: 23 December 1996 Accepted: 15 April 1997     

前交叉韧带重建军人患者快速康复与传统康复对术后功能恢复的影响

目的 比较快速康复训练与传统康复训练对军人患者前交叉韧带重建术后膝关节功能及运动恢复的影响.方法 回顾性分析2018-06至2019-06在东部战区总医院骨科行关节镜下前交叉韧带重建术的102例军人患者资料,分为快速康复组(51例)和传统康复组(51例).分别记录两组患者术前、术后疼痛视觉模拟量表(VAS)评分、Lys...     

Initial fixation strength of interference nail fixation for anterior cruciate ligament reconstruction with patellar tendon graft (experimental study)

The objective of this study was to evaluate initial fixation strength of a new interference nail fixation in anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft. Human cadaver knees were used. Fixation strengths ranged from 500 N to 600 N (mean 550 N). This corresponds to loads in the graft during aggressive rehabilitation. No slippage occurred at fixation site of specimens. Most of the failures appeared from the femoral side with tendon ruptures. With respect to primary fixation strength, interference nail fixation is a reasonable alternative for anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft.     

Factors affecting outcome after anterior cruciate ligament injury: a prospective study with a six-year follow-up

The aim of this study was to investigate whether gender, age, stable personality traits, associated meniscus and/or articular cartilage injuries, treatment (non-operative or reconstructive surgery), additional subsequent trauma to the anterior cruciate ligament (ACL)-injured knee and activity level before injury affect the intermediate outcome after ACL injury. The primary outcome was the Knee injury and Osteoarthritis Outcome Score (KOOS). Fifty-seven patients, 18-50 years old with an acute, unilateral ACL tear were included in the study. At the time of inclusion, the patients completed the Tegner score, regarding activity level before injury, and Swedish universities Scales of Personality (SSP). At follow-up, after 5.6 years they completed the KOOS, the Tegner score and a general questionnaire concerning ACL reconstruction and subsequent knee trauma. The subjects who had sustained additional trauma subsequent to their ACL injury had a significantly worse outcome according to the KOOS than those who had not. Furthermore, low ratings in the embitterment scale in the SSP were correlated to a better outcome in the KOOS. Treatment did not affect the KOOS total score. However, the non-operatively treated subjects had a significantly better outcome according to the knee-related quality-of-life domain in the KOOS.     

Anterior cruciate ligament patellar tendon reconstruction: it is probably better to leave the tendon defect open!

The purpose of our prospective study was to establish whether or not in anterior cruciate ligament (ACL) patellar tendon reconstruction the tendon defect has to be closed. In 50 consecutive ACL patellar tendon reconstructions, the tendon defect was randomly closed (group I) or left open (group II). The following data were recorded from all patients on the 4th and 14th days post operation: range of motion (ROM), pain at rest, pain and validity at isometric contraction, ability of bent leg raising (at 4th day) and straight leg raising (at 14th day). All the patients underwent ultrasonographic examination after 3 months and X-ray scanning at 6 months post operation. Forty patients underwent a CT-scan examination at 6 months. Thirty patients underwent isokinetic testing between 10 and 12 months post operation. Evaluating the immediate post operation data, no statistically significant differences emerged between the two groups. Ultrasonography showed in 68% of the knees of group I (defect closed) a thickened patellar tendon (PT), while in 60% of group II it was of normal thickness. No patients of either group developed patella infera by X-ray evaluation 6 months post operation. CT scans at 6 months showed that 100% of the knees of group I had a thickened PT in toto (nearly twice as thick as normal). Scar tissue was present not only in its central third but also in more than half of the cases in the medial and lateral third. In group II 75% of the patients had a normal thickness PT and 25% presented with only a minimal thickening. Scar tissue was distinguished only at its central third. Some 32% and 36% of the patients of group I and II, respectively, developed patellar irritability between the 5th and 8th month post operation. Isokinetic tests performed between the 10th and 12th months showed that the quadriceps deficit was slightly less in group II than in group I. Our study did not show very important clinical differences between the two groups but revealed that if the tendon defect is closed, an exuberant scar process arises involving the entire PT. This could mean, as reported in the literature, a high reduction in the biomechanical properties of the PT. For this reason it is probably better to leave the defect open.     

One-stage bilateral anterior cruciate ligament reconstruction with use of hamstring tendon autografts: a case report

This article presents an unusual problem of a patient with chronic bilateral ACL-deficient knees and constitutionally very thin patellar tendons. Author decided to perform one-stage bilateral ACL reconstructions using hamstring tendon autografts so as not to weaken his quadriceps muscles by compromising his extensor mechanism.     

Isokinetic muscle strength after anterior cruciate ligament reconstruction

The purpose of the present study was to investigate the isokinetic muscle strength 6 months after reconstruction of the anterior cruciate ligament (ACL). In order to recommend full-load come-back in sport, sufficient muscle strength may be important. Ninety female elite team handball players (mean 24.1 years) were postoperatively tested with Biodex. The operated limb was compared with the contralateral limb: 82.2% had a hamstring strength of a minimum of 49.6 Nm, corresponding to at least 90% of the non-operated limb, while only 12.2% fulfilled the recommended strength of 117.7 Nm for quadriceps femoris. Patients over 26 years showed significantly lower muscle strength in the operated limb than their younger counterparts. Increased focus on quadriceps femoris muscle strength during rehabilitation may improve the knee function faster after ACL reconstruction.