Impact of Partial and complete rupture of anterior cruciate ligament on medial meniscus: A cadavaric study

Background:

The clinical relationship between medial meniscus tear and anterior cruciate ligament (ACL) rupture has been well documented. However, the mechanism of this clinical phenomenon is not exactly explained. Our aim is to investigate the biomechanical impact of partial and complete ACL rupture on different parts of medial meniscus.

Materials and Methods:

Twelve fresh human cadaveric knee specimens were divided into four groups: ACL intact (ACL-I), anteromedial bundle transection (AMB-T), posterolateral bundle transection (PLB-T), and ACL complete transection (ACL-T) group. Strain on the anterior horn, body part, and posterior horn of medial meniscus were measured under 200 N axial compressive tibial load at 0°, 30°, 60°, and 90° of knee flexion, respectively.

Results:

Compared with the control group (ACL-I), the ACL-T group had a higher strain on whole medial meniscus at 0°, 60°, and 90° of flexion. But at 30°, it had a higher strain on posterior horn of meniscus only. As to PLB-T group, strain on whole meniscus increased at full extension, while strain increased on posterior horn at 30° and on body of meniscus at 60°. However, AMB-T only brought about higher strain at 60° of flexion on body and posterior horn of meniscus.

Conclusions:

Similar to complete rupture, partial rupture of ACL can also trigger strain concentration on medial meniscus, especially posterior horn, which may be a more critical reason for meniscus injury associated with chronic ACL deficiency.     

Evaluation of the clinical signs of anterior cruciate ligament and meniscal injuries

Background:

The diagnostic accuracy of anterior drawer (AD) sign, Lachman test and the pivot shift test for anterior cruciate ligament injury and McMurray test for medial and lateral meniscus is varied with sensitivity and specificity ranging from 2 to 100%. Generally, it is accepted that the pivot shift test is the most specific test to diagnose anterior cruciate ligament (ACL) tears and that the Lachman test is more sensitive than AD sign. This study was undertaken to calculate the sensitivity, specificity, positive predictive value, negative predictive value, and efficiency for the above-mentioned diagnostic tests.

Materials and Methods:

Twenty-eight male patients with clinical ACL injury were examined in the outpatient department and under anaesthesia, the findings were compared with arthroscopy.

Result:

The sensitivity and specificity for the Lachman test, AD sign and pivot shift test performed in the outpatient setting are 78.6 and 100%, 89.3 and 100%, and 75 and 100%, respectively. The sensitivity and specificity for the Lachman test, AD sign, and pivot shift test performed under anesthesia are 92.9 and 100%, 92.9 and 100%, and 100 and 100%, respectively. The sensitivity and specificity of the McMurray test for medial and lateral meniscus were 35.7 and 85.7% and 22.2 and 100%, respectively.

Conclusion:

The Lachman test, AD sign and pivot shift test are highly specific tests to diagnose ACL laxity in a non-acute setting; pivot shift test under anesthesia is the most sensitive and specific test for diagnosing ACL laxity in a non-acute setting and the McMurray test is not a sensitive test to diagnose meniscal injury in the presence of ACL injury.     

Postoperative change in medial meniscal length in concurrent all-inside meniscus repair with anterior cruciate ligament reconstruction

Purpose

Meniscus repair can restore meniscal function that transfers the axial compressive force to circumferential tensile strain. However, few reports have investigated the relationship between concurrent meniscus repair with acute anterior cruciate ligament (ACL) reconstruction and postoperative meniscal position. This study aimed to evaluate medial meniscal size and clinical results in patients who underwent ACL reconstruction and concomitant all-inside medial meniscus repair.

Methods

Twenty patients underwent ACL reconstruction and concurrent medial meniscus repair of a peripheral longitudinal tear using the FasT-Fix meniscal repair device. Medial tibial plateau length (MTPL) and width (MTPW) were determined by radiographic images. We evaluated the Lysholm score, anteroposterior instability, meniscal healing and magnetic resonance imaging (MRI)-based medial meniscal length (MML) and width (MMW). Correlations between MRI-based meniscal size, radiographic measurement and height were investigated.

Results

All patients showed complete healing of the repaired meniscus in arthroscopic evaluation. However, one patient needed a subsequent meniscus repair during the follow-up period. Lysholm score and anteroposterior instability improved significantly. A better correlation was observed between MMW and MTPW than between MML and MTPL. Concurrent all-inside medial meniscus repair with ACL reconstruction significantly increased MML percentage (%MML) (100 MML/MTPL) but did not affect MMW percentage (%MMW) (100 MMW/MTPW).

Conclusions

Concurrent all-inside medial meniscus repair with ACL reconstruction had satisfactory clinical results. %MML was increased by concurrent medial meniscus repair without affecting %MMW. Our results suggest that medial meniscus repair associated with ACL reconstruction may restore meniscal function by adjusting the anteroposterior length of the torn medial meniscus.     

非接触性前十字韧带损伤初次重建术后失效的危险因素

目的探讨非接触性前十字韧带(anterior cruciate ligament,ACL)损伤初次重建术后失效的危险因素。方法2015年11月至2017年5月连续收治并随访2年以上的非接触性ACL损伤而行ACL初次重建的患者178例。随访2年内25例患者出现MRI证实的ACL移植物完全断裂或轴移试验阳性或KT-1000侧侧差值超过5 mm或MRI上静态胫骨前移超过5 mm判定为术后失效,纳入术后失效组;按照1∶2的比例匹配术后2年内未失效者50例,纳入术后未失效组。比较两组患者性别、年龄、体质指数(body mass index,BMI)、患侧分布、半月板损伤侧分布、受伤至手术时间、术前麻醉下KT-1000侧侧差值、轴移试验、随访时间、术前下肢负重位全长X线片上胫骨平台后倾角及胫骨前移的差异,采用多因素Logistic回归分析确定ACL损伤初次重建术后失效的危险因素。结果术后失效组的胫骨平台后倾角为17.21°±2.20°,大于术后未失效组的14.36°±2.72°,差异有统计学意义(t=4.395,P<0.001);术后失效组的术前胫骨前移为(8.29±3.42)mm,大于术后未失效组的(4.09±3.06)mm,差异有统计学意义(t=5.504,P<0.001)。两组性别、年龄、BMI、患侧分布、半月板损伤侧分布、受伤至手术时间、麻醉下KT-1000侧侧差值、轴移试验分度、随访时间的差异均无统计学意义(P>0.05)。多因素回归分析结果显示胫骨平台后倾角≥17°是ACL术后失效的独立危险因素(OR=15.62,P=0.002),胫骨前移≥6 mm是ACL术后失效的独立危险因素(OR=9.91,P=0.006);而性别、年龄、BMI、半月板是否损伤、轴移试验分度、KT-1000侧侧差值与术后失效无相关性(P>0.05)。结论术前下肢负重位全长X线片上胫骨平台后倾角≥17°和胫骨前移≥6 mm可增加ACL损伤初次重建术后失效的风险。     

Proprioception in anterior cruciate ligament deficient knees and its relevance in anterior cruciate ligament reconstruction

Injury to the anterior cruciate ligament (ACL) not only causes mechanical instability but also leads to a functional deficit in the form of diminished proprioception of the knee joint. “Functional” recovery is often incomplete even after “anatomic” arthroscopic ACL reconstruction, as some patients with a clinically satisfactory repair and good ligament tension continue to complain of a feeling of instability and giving way, although the knee does not sublux on clinical testing. Factors that may play a role could be proprioceptive elements, as the intact ACL has been shown to have significant receptors. Significant data have come to light demonstrating proprioceptive differences between normal and injured knees, and often between injured and reconstructed knees. ACL remnants have been shown to have proprioceptive fibers that could enhance functional recovery if they adhere to or grow into the reconstructed ligament. Conventionally the torn remnants are shaved off from the knee before graft insertion; modern surgical techniques, with remnant sparing methods have shown better outcomes and functional recovery, and this could be an avenue for future research and development. This article analyzes and reviews our understanding of the sensory element of ACL deficiency, with specific reference to proprioception as an important component of functional knee stability. The types of mechanoreceptors, their distribution and presence in ACL remnants is reviewed, and suggestions are made to minimize soft tissue shaving during ACL reconstruction to ensure a better functional outcome in the reconstructed knee.     

Outcome of transtibial AperFix system in anterior cruciate ligament injuries

Background:

The anterior cruciate ligament (ACL) is one of the major stabilizing factor of the knee that resist anterior translation, valgus and varus forces. ACL is the most commonly ruptured ligament of the knee. The graft fixation to bone is considered to be the weakest link of the reconstruction. According to the parallel forces to the tibial drill hole and the quality of tibial metaphyseal bone is inferior to femoral bone stock, graft fixation to the tibia is more difficult to secure. AperFix system (Cayenne Medical, Inc., Scottsdale, Arizona, USA) which consists femoral and tibial component that includes bioinert polymer polyetheretherketone (PEEK) is one of the new choice for ACL reconstruction surgery. aim of this study was to assess the clinical outcomes and fixation durability of the AperFix (Cayenne Madical, Inc., Scottsdale, Arizona, USA) system and to determine the effect of patient''s age in arthroscopic reconstruction of the anterior cruciate ligament.

Materials and Methods:

Patients with symptomatic anterior cruciate ligament rupture underwent arthroscopic reconstruction. Patients were evaluated in terms of range of motion (ROM) values; Lysholm, Cincinati and Tegner activity scales; laxity testing and complications. Femoral tunnel widening was assessed by computer tomography scans. Early postoperative and last followup radiographs were compared.

Results:

Fifty one patients were evaluated with mean followup of 29 months (range 25–34 months). Mean age at the surgery was 26.5 ± 7.2 years. Lysholm, Cincinati and Tegner activity scales were significantly higher from preoperative scores (Lysholm scores: Preoperative: 51.4 ± 17.2, postoperative: 88.6 ± 7.7 [P < 0.001]; Tegner activity scores: Preoperative 3.3 ± 1.38, postoperative: 5.3 ± 1.6 [P < 0.001]; Cincinati scores: Preoperative: 44.3 ± 17, postoperative: 81.3 ± 13.9 [P < 0.001]). The mean femoral tunnel diameter increased significantly from 9.94 ± 0.79 mm postoperatively to 10.79 ± 0.95 mm (P < 0.05). The mean ROM deficit (involved vs. contra knee) was −7.2 ± 16 (P < 0.001). There was no significant difference for knee score, ROM deficits (<30 years: −7.3 ± 15 and >30 years −7.06 ± 19) and femoral tunnel enlargement (<30 years: 0.83 ± 0.52 and >30 years 0.87 ± 0.43) of the patients with below and above 30 year. There was no significant difference for knee scores and femoral tunnel enlargement between patients with meniscal injuries and don’t have meniscus lesions.

Conclusion:

The AperFix system gives satisfactory clinical and radiological results with low complication rate. However, long term clinical and radiological results are needed to decide the ideal anterior cruciate ligament reconstruction method.     

前交叉韧带重建术后膝关节功能及三维运动步态分析

目的 探讨前交叉韧带(ACL)重建术后膝关节稳定性、功能及三维步态运动学情况.方法 回顾性分析2015年7月到2017年7月在佛山市中医院运动学科采用自体腘绳肌腱行ACL重建并进行了二次关节镜探查的270例病例,其中男164例,女106例.采用Lysholm评分、国际膝关节评分委员会(IKDC)评分、Tenger评分、...     

Anatomic double-bundle anterior cruciate ligament reconstruction

Objective: To retrospectively evaluate the early results of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction and compare with the results of native ACL of the contralateral knee.M...     

关节镜下保留残端重建前交叉韧带的临床前瞻性对照研究

目的 前瞻性评估保留残端对于前交叉韧带重建临床疗效的意义.方法 2008年8月至2009年9月共70例有韧带残端存留的前交叉韧带损伤患者入选本研究组,随机分为保留残端组(n=35)和对照组(n=35).分别采取关节镜下保留残端重建前交叉韧带和切除残端的前交叉韧带重建手术技术,移植物均使用同种异体肌腱.术后随访分别进行膝关节功能评分(IKDC分级和Lysholm评分)、客观稳定性评估(Lachman试验、轴移试验和KT-1000测量)、本体感觉功能测量和二次关节镜手术探查.结果 70例患者中共61例(87%)获得随访,平均随访时间13.1个月.两组的功能评分无显著差异:Lysholm评分:保留残端组96.4分,对照组94.9分(P=0.71);IKDC分级中A和B级:保留残端组30例,对照组29例(P=0.586).两组的客观稳定性评估无显著差异:KT-1000测量的侧-侧差值:保留残端组1.69 mm,对照组1.65 mm(P=0.83);Lachman试验阴性例数:保留残端组29例,对照组28例(P=1.00);轴移试验阴性例数:保留残端组31例,对照组27例(P=0.225).本体感觉的角度重复试验结果无显著差异:保留残端组4.56°,对照组4.28°(P=0.522).二次手术探查时发现的移植物滑膜覆盖率无显著差异:保留残端组85%,对照组84.2%.结论 保留残端同时使用异体肌腱移植重建前交叉韧带,对术后膝关节主观功能评分、稳定性和本体感觉和移植物滑膜覆盖程度并无促进作用.

Abstract：

Objective To evaluate the clinical significance of arthroscopic anterior cruciate ligament (ACL)reconstruction using the remnant-preserved technique.Methods From August 2008 to September 2009,70 cases with the remnant of injured ACL were included in the trials,which were randomized into the remnant preservation(RP)group and the control group,35 cases in each group.All patients in the two groups underwent arthroscopic ACL reconstruction surgeries,with ACL-remnant preserving technique in RP group and ACL-remnant resection in control group,respectively.The injured ACL was reconstructed with allograft in all cases.Postoperative follow-up assessment included the International Knee Documentation Committee(IKDC)grading and Lysholm score,Lachman test,pivot shift test and KT-1000 measurement,proprioception measurements and the arthroscopic second look evaluation.Results Sixty-one(61/70,87%)cases were available for an average of 13.1 months follow-up assessment postoperatively.There were no significant differences between the RP and control group in functional outcome as evaluated with Lysholm score(96.4 vs.94.9,P = 0.71)and IKDC grading(cases with A and B gradings:30 vs.29,P = 0.586).Regarding objective stability,there were no differences between the 2 group in mean side-to-side difference of KT-1000(1.69 mm vs.1.65 mm,P =0.83),Lachman test(negative cases:29 vs.28,P = 1.00)and pivot shift test(negative cases:31 vs.27,P =0.225).There was also no difference between the groups in proprioception evaluation measured with angle repetitive test(4.56°vs.4.28°,P=0.522).During second look arthroscopic examination,the grafts synoveal coverage rates were found to be 85% in the RP group and 84.2% in the control group,without significant difference(P＞0.05).Conclusions Arthroscopic ACL reconstruction with the remnant preserving technique using tendon allograft do not improve the postoperative knee-joint function scores,stability,proprioception and synovial coverage of grafts.     

胫骨平台前外侧撕脱骨折合并前交叉韧带损伤的诊治

胫骨平台前外侧撕脱骨折(Segond骨折)合并前交叉韧带(ACL)损伤在临床中并不少见。对于Segond骨折合并ACL损伤患者如何诊治,越发的被重视起来。本文通过对Segond骨折合并ACL损伤的准确诊断、应急处理、恰当治疗、康复锻炼等方面作一综述,旨在对Segond骨折合并ACL损伤的诊治有所帮助,同时该合并伤应根据个体损伤情况制定个性化的方案。     

LARS韧带重建前交叉韧带的近期疗效

目的探讨LARS韧带重建前交叉韧带(anterior cruciate ligament,ACL)的手术方法和近期疗效。方法回顾分析2008年11月-2010年4月于关节镜下采用LARS韧带重建并获完整随访的80例ACL损伤患者临床资料。男51例,女29例;年龄17～43岁,平均29.2岁。致伤原因:运动伤63例,交通事故伤14例,重物砸伤3例。左膝43例,右膝37例。病程10 d～11个月。前抽屉试验、Lachman试验和轴移试验均为阳性。术前Lysholm、Irgang、Larson评分分别为(55.4±5.7)、(48.3±6.2)、(54.8±7.4)分,国际膝关节评分委员会(IKDC)评分均低于正常值。MRI检查显示ACL损伤。术中保留ACL残余纤维束。结果术后切口均Ⅰ期愈合,无感染、下肢深静脉血栓形成等术后早期并发症发生。80例均获随访,随访时间7～24个月,平均16.8个月。术后3例股骨侧螺钉外露,2例胫骨侧螺钉松动,1例伸膝受限,均对症处理。随访期间均无LARS韧带断裂、关节纤维化等并发症发生。末次随访时前抽屉试验阳性2例,Lachman试验阳性3例,轴移试验阳性3例。术后6周及末次随访时Lysholm、Irgang、Larson评分与术前比较,差异均有统计学意义(P<0.05)。术后6周及末次随访时IKDC评分正常率分别为43.75%(35/80)及97.50%(78/80)。结论 LARS韧带黏弹性较差,术中需要在偏伸直位固定避免屈曲受限,屈曲位允许移植物有轻微松弛,掌握其特殊手术技巧后重建ACL能获得较好的近期疗效。     

Biomechanics of the anterior cruciate ligament:Physiology,rupture and reconstruction techniques

The influences and mechanisms of the physiology,rupture and reconstruction of the anterior cruciate ligament(ACL)on kinematics and clinical outcomes have been investigated in many biomechanical and clinical studies over the last several decades.The knee is a complex joint with shifting contact points,pressures and axes that are affected when a ligament is injured.The ACL,as one of the intra-articular ligaments,has a strong influence on the resulting kinematics.Often,other meniscal or ligamentous injuries accompany ACL ruptures and further deteriorate the resulting kinematics and clinical outcomes.Knowing the surgical options,anatomic relations and current evidence to restore ACL function and considering the influence of concomitant injuries on resulting kinematics to restore full function can together help to achieve an optimal outcome.     

Complete tear of the lateral meniscus posterior root is associated with meniscal extrusion in anterior cruciate ligament deficient knees

This study aimed to evaluate the relationship between preoperative lateral meniscal extrusion (LME) and arthroscopic findings of lateral meniscus posterior root tear (LMPRT) in knees with anterior cruciate ligament (ACL) tear. Thirty‐five knees that had LMPRTs with concomitant ACL tears on arthroscopy were evaluated. Patients were divided into two groups, partial and complete root tears, via arthroscopic findings at the time of ACL reconstruction. For comparison, we added two groups, using the same database; 20 normal knees (normal group) and 20 ACL‐injured knees without LM injury (intact LM group). We retrospectively measured preoperative LMEs using magnetic resonance imaging (MRI). Twenty‐three knees had partial LMPRTs. Complete LMPRTs were observed in 12 knees. The average LME was ?0.1 ± 0.4 mm in the normal group, 0.2 ± 0.5 mm in the intact LM group, 0.4 ± 0.8 mm in the partial LMPRT group, and 2.0 ± 0.6 mm in the complete LMPRT group. A significant difference in preoperative LMEs was observed between the complete LMPRT group and the other groups (p < 0.001). The receiver operating curve analysis, which distinguishes a partial tear from a complete tear, identified an optimal cut‐off point of 1.1 mm for preoperative LME. This LME cut‐off had a sensitivity of 100% and specificity of 83% for complete LMPRT. We found that preoperative LMEs were larger in complete LMPRTs associated with ACL injuries than in partial LMPRTs. Our results suggest that preoperative MRI‐detected LME may be a useful indicator for estimating LMPRT severity in ACL‐injured knees. Level of evidence: Retrospective comparative study level IV. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1894–1900, 2018.

     

兔保留与切除残迹前交叉韧带重建生物力学的比较

目的比较兔保留与切除残迹前交叉韧带（ACL）重建的生物力学差异,探讨保留残迹的意义。方法新西兰兔10只,体重（2．66±0．32）kg。切断双侧ACL,右侧股骨与胫骨端各保留残迹2mm,左侧完全切除两端残迹。切取跟腱制备移植物,对应ACL印迹解剖位分别建立胫骨与股骨隧道,重建双侧ACL。于术后8周,行单轴拉力测试。SPSS19．0软件进行数据统计。结果术后8周,保留残迹组的最大载荷（t=2．931,P〈0．05）、屈服载荷（t=2．680,P〈0．05）、刚度（t=5．411,P〈0．05）明显高于切除残迹组,两组之间差异均有统计学意义;保留残迹组拉伸长度显著低于切除残迹组,两组差异有统计学意义（t=-3．872,P〈0．05）。两组损毁模式不同,保留残迹组多表现为移植物关节内断裂,而切除残迹组多表现为移植物自骨隧道拔出。Fisher精确检验表明两组的样本损毁模式有统计学差异（P〈0．05）。结论保留残迹ACL重建的生物力学特征优于切除残迹ACL重建,提示临床采用保留残迹技术重建ACL有可能促进移植物腱-骨愈合和“韧带化”,从而改进治疗效果。     

Biologic agents for anterior cruciate ligament healing: a systematic review

AIM To systematically review the currently available literature concerning the application of biologic agents such as platelet-rich plasma(PRP) and stem cells to promote anterior cruciate ligament(ACL) healing.METHODS A systematic review of the literature was performed on the use of biologic agents(i.e., PRP or stem cells) to favor ACL healing during reconstruction or repair. The following inclusion criteria for relevant articles were used: Clinical reports of any level of evidence, written in English language, on the use of PRP or stem cells during ACL reconstruction/repair. Exclusion criteria were articles written in other languages, reviews, or studies analyzing other applications of PRP/stem cells in knee surgery not related to promoting ACL healing.RESULTS The database search identified 394 records that were screened. A total of 23 studies were included in the final analysis: In one paper stem cells were applied for ACL healing, in one paper there was a concomitant application of PRP and stem cells, whereas in the remaining21 papers PRP was used. Based on the ACL injury pattern, two papers investigated biologic agents in ACL partial tears whereas 21 papers in ACL reconstruction.Looking at the quality of the available literature, 17 out of 21 studies dealing with ACL reconstruction were randomized controlled trials. Both studies on ACL repair were case series.CONCLUSION There is a paucity of clinical trials investigating the role of stem cells in promoting ACL healing both in case of partial and complete tears. The role of PRP is still controversial and the only advantage emerging from the literature is related to a better graft maturation over time, without documenting beneficial effects in terms of clinical outcome, bone-graft integration and prevention of bony tunnel enlargement.     

The biomechanical effects of geometric configuration of bone-tendon-bone autografts in anterior cruciate ligament reconstruction

This study provides biomechanical support for a new technique of autograft anterior cruciate ligament reconstruction featuring circular bone plugs and endosteal interference fit fixation. Six matched pairs of fresh frozen human knees were utilized. Femoral interference fit pull-out strength was determined from material-testing-machine-generated oscillograph recordings at a strain rate of 100%/s. Circular bone plugs, obtained with a circular oscillating saw, provided 19.9% greater interference fit pull-out strength compared with identically fixed trapezoidal bone plugs. Different geometric defects were compared in three- and four-point bending on an Instron machine with frozen patellae and an artificial bone composite. Circular defects have 107% greater strength than matched trapezoidal patellar defects in three-point bending. In a bone composite, circular defects are 53% stronger than triangular and 25% stronger in four-point bending than trapezoidal defects. A new technique of harvesting bone plugs with endosteal interference fit fixation is described and biomechanically supported. To date, this technique has been performed on over 500 cases clinically without evidence of patellar fracture or fixation failure. This study demonstrates the efficacy of this simple and reproducible technique compared with previously reported procedures.     

Protection of the bone-tendon-bone graft during anterior cruciate ligament reconstruction

Damage of graft fibers is a complication that can happen during arthroscopic reconstruction of the anterior cruciate ligament. It usually occurs while pulling the neoligament through the tibial tunnel, inserting the femoral screw, or doing additional notchplasty. Protection of the graft with a polyethylene tube can reduce the risk of graft laceration.