Shockwave therapy improves anterior cruciate ligament reconstruction

Background

Shockwave was shown to enhance the healing of anterior cruciate ligament (ACL) reconstruction in rabbits. This study evaluated the effect of extracorporeal shockwave therapy (ESWT) on ACL reconstruction in human subjects. We hypothesized that ESWT may improve human ACL reconstruction.

Methods

Fifty-three patients were randomized into two groups with 26 patients in ESWT group and 27 patients in control group. The ESWT group underwent single-bundle hamstring autograft ACL reconstruction and received ESWT immediately after surgery. The control group underwent ACL surgery without ESWT. Both groups received the same rehabilitation postoperatively. The evaluations included Lysholm score, IKDC score and KT-1000, radiograph, bone mineral density, and magnetic resonance imaging.

Results

ESWT group showed significantly better Lysholm score than control group at 1 and 2 y postoperatively (P < 0.001 and 0.001, respectively). No significant difference was noted in IKDC score between the two groups (P = 0.080 and 0.076, respectively). The KT-1000 values were significantly better in ESWT group than control group at 2 y postoperatively (P = 0.027). The tibia tunnel on X-ray was significantly smaller in ESWT group compared with control group at 2 y (P = 0.018). The bone mineral density values showed no discernable difference between the two groups at 6 mo and 2 y (P = 0.522 and 0.984, respectively). On magnetic resonance imaging, ESWT group showed significant decrease in tibia tunnel enlargement at 6 mo and 2 y compared with the control group (P = 0.024 and <0.001, respectively).

Conclusions

ESWT significantly improves the subjective Lysholm score and decreases the middle 1/3 tibia tunnel enlargement after single hamstring autograft ACL reconstruction.     

The efficacy of regional anesthesia for outpatient anterior cruciate ligament reconstruction

Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. Until recently, the majority of these procedures have been performed on an inpatient basis. This retrospective study evaluated 67 consecutive patients who underwent an arthroscopically assisted, autogenous bone—patellar ligament—bone ACL reconstruction that was supervised by the same surgeon. General endotracheal anesthesia was used for 36 patients and a femoral sciatic nerve block was used in 31 patients. Only patients who underwent either isolated ACL reconstructions, or those combined with either medial or lateral meniscectomies, were included. No statistically significant differences in either the mean anesthesia time or operative time existed between the general anesthesia and regional anesthesia groups. Patients receiving regional anesthesia did require a significantly longer recovery room stay than those who received general anesthesia. Most of the patients who received general anesthesia had inpatient procedures. In the general anesthesia group, 31 of 36 patients spent at least one night in the hospital. Three of 30 patients who received regional anesthesia required hospital admission. There were no differences between anesthesia-related complication between groups. The cost saving of performing ACL reconstructions under regional anesthesia compared with general anesthesia was calculated to be $2,907 per case and predominantly reflected the outpatient approach used in these cases. This study supports the use of femoral sciatic nerve block anesthesia as a safe and reliable alternative to general anesthesia for patients undergoing outpatient ACL reconstruction. The use of this technique was not found to compromise operating room efficiency. Patients receiving regional anesthesia did require a slightly longer recovery room stay. ACL reconstruction performed under regional anesthesia with same-day discharge was well tolerated by our patients and it provides a cost-efficient alternative to ACL reconstructions performed as inpatient procedures.     

A comparison of outpatient and inpatient anterior cruciate ligament reconstruction surgery

The feasibility of outpatient anterior cruciate ligament (ACL) surgery has not been reported in the literature. We evaluated outpatient ACL surgery by comparing outpatient versus inpatient pain control, narcotic consumption, postoperative complications, recovery time, and cost analysis. Thirty-seven ACL reconstructions were performed in 37 patients over a 16-month period. Twenty-five of the patients had surgery performed as outpatients and 12 as inpatients. One of the outpatients required hospitalization because of excessive nausea and vomiting and another for urinary retention. Only 2 of the 25 outpatients (8%) believed that they should have been hospitalized for pain control. Based on a visual analog scale, pain severity, pain frequency, and pain relief were measured, and no statistically significant difference (P < .05) was noted between the groups, although the data suggested that the inpatients were slightly more comfortable. There were no differences in rehabilitation or in regaining full range of motion of the operated knee. Also, the only postoperative complication in both groups occurred in an inpatient who developed arthrofibrosis. Cost analysis showed that outpatient ACL reconstruction was cost effective. The average inpatient cost was $9,220 (2.4 hospital days) compared with the average outpatient cost of $3,905. This reflected a savings of 58%. These results show that outpatient ACL reconstruction surgery is possible in the appropriate patient without harm to the patient and with a significant cost savings.     

Revision anterior cruciate ligament reconstruction

Revision ACL surgery is indicated in patients who present with pathologic anterior laxity on clinical examination that reproduces their symptoms of instability during activities of daily living or athletic activities. The goals of the revision ACL surgery are to stabilize the knee, prevent further injury to the articular cartilage and menisci, and maximize the patient's function. Successful revision ACL surgery requires a thorough preoperative evaluation, including a detailed history, physical examination, and radiographic evaluation. Preoperative planning begins with a determination of the mechanisms of failure for the initial ACL reconstruction. Often a primary, as well as secondary cause, for failure can be identified. The determination of the cause of failure is the first step in a carefully-constructed treatment plan, which includes consideration of skin incisions to be used, method of graft removal, hardware removal, the need for a staged procedure or concomitant surgery, graft material selection, tunnel placement, graft fixation, and postoperative rehabilitation protocol. Despite the most meticulous planning, unanticipated findings may be encountered in the operating room, and the preoperative plan should have enough flexibility to accommodate these developments. Finally, it is crucial to counsel the patient preoperatively to limit his or her expectations regarding their surgical outcome. Given the complexity of revision ACL reconstruction, patient expectations must be adjusted to realistically match the potential for success. With proper planning, attention to detail, and appropriate patient expectations, revision ACL surgery can result in a beneficial and satisfying patient outcome.     

Graft selection for anterior cruciate ligament reconstruction

The ideal anterior cruciate ligament (ACL) graft substitute would have no morbidity associated with its procurement, be readily available for use, and be capable of strong fixation with sufficient inherent strength to withstand an accelerated postoperative rehabilitation program. In addition, the long-term results of ACL reconstruction using the graft substitute should be favorable. Unfortunately, such an ideal graft material does not currently exist. At present, available choices for ACL graft substitutes include autograft tissue, allograft tissue, and synthetic devices. This article presents the reader with a review of the factors involved in selecting a material to serve as a graft substitute for ACL reconstruction and explores the advantages and disadvantages associated with the use of various graft tissues.     

Arthroscopic-assisted outpatient anterior cruciate ligament reconstruction using the semitendinosus and gracilis tendons

This study presents an average of 43-month results (range, 23 to 75 months) of 82 arthroscopically assisted, outpatient semitendinosus- gracilis anterior cruciate ligament reconstructions evaluated with the Cincinnati Knee Rating System. There were 44 acute and 38 chronic injuries. The results showed no significant effect of injury chronicity on all outcome variables except knee motion complications. Additionally, no significant difference was found between men and women in regards to outcome. At follow-up, 93% showed complete or partial graft function, 98% had a full range of knee motion, 83% had returned to sports with no problems, and 92% rated their knee condition as normal or very good. The mean overall point score (0 to 100 scale) for all patients was 92 ± 10 points. All patients with chronic injuries showed improvement from their preoperative status, including 11 who had articular cartilage lesions. Complications were few; only five patients (6%) needed additional treatment for limitation of knee motion, and no patient had an increase in patellofemoral crepitus. We concluded that this procedure produced desirable results and that patients with long- standing functional limitations significantly improved and were able to return to an active lifestyle.Arthroscopy 1998 Apr;14(3):268-77     

Rehabilitation after anterior cruciate ligament reconstruction

The "Frankfurt rehabilitation regimen" following anterior cruciate ligament reconstruction is presented. ACL rehabilitation is discussed in the light of knowledge on knee biomechanics and proprioception as well as clinical results of reconstruction. Special emphasis is given to exercise therapy.     

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...     

Biomechanics and anterior cruciate ligament reconstruction

For years, bioengineers and orthopaedic surgeons have applied the principles of mechanics to gain valuable information about the complex function of the anterior cruciate ligament (ACL). The results of these investigations have provided scientific data for surgeons to improve methods of ACL reconstruction and postoperative rehabilitation. This review paper will present specific examples of how the field of biomechanics has impacted the evolution of ACL research. The anatomy and biomechanics of the ACL as well as the discovery of new tools in ACL-related biomechanical study are first introduced. Some important factors affecting the surgical outcome of ACL reconstruction, including graft selection, tunnel placement, initial graft tension, graft fixation, graft tunnel motion and healing, are then discussed. The scientific basis for the new surgical procedure, i.e., anatomic double bundle ACL reconstruction, designed to regain rotatory stability of the knee, is presented. To conclude, the future role of biomechanics in gaining valuable in-vivo data that can further advance the understanding of the ACL and ACL graft function in order to improve the patient outcome following ACL reconstruction is suggested.     

膝关节镜下微创重建前交叉韧带

为使膝关节前交叉韧带重建手术定位准确,固定更加牢固和早期功能康复,同时减少手术创伤。1997年10月至1999年4月应用膝关节镜下挤压螺钉固定骨-髌腱(中1/3)-骨自体移植重建前交叉韧带的新技术,重建前交叉韧带74例,并取得良好效果。结果 表明该方法手术创伤小,骨道定位准确,能做到等长重建。由于充分利用了髌腱这一较为理想的自体材料,两端带有骨块,重建的韧带最终可达到牢固的生物学固定。作根据临床实践,结合全部病例,重点总结介绍了关节镜下重建前交叉韧带的临床技术和经验。     

Revision anterior cruciate ligament reconstruction surgery

In 1995, it was reported that 60,000 to 75,000 anterior cruciate ligament (ACL) reconstructions were being performed annually in the United States. Successful long-term results are achieved in 75% to 95% of these patients, but 8% have unsatisfactory results due to recurrent instability and graft failure. With the increasing popularity of this procedure, ACL revision surgery has also become increasingly common. While the techniques described for ACL revision have been varied, the overall results in the literature do not compare favorably with primary ACL reconstruction. The proper execution of revision ACL reconstruction requires precise preoperative planning to assess the cause of initial failure and avoid repeating the same mistakes with revision reconstruction. Graft choice, hardware removal, revision notchplasty, tunnel placement, and method of fixation are key points for a successful result. The causes of ACL failure, the technical aspects of revision ACL surgery, and the reported results of revision ACL surgery are reviewed.     

膝前交叉韧带重建术后关节僵硬的原因分析及对策

[目的]探讨膝前交叉韧带重建术后关节僵硬的原因及对策。[方法]对2002—2006年15例膝前交叉韧带重建、术后发生关节僵硬的情况进行回顾性总结、分析。[结果]15例病例中，切开手术、石膏固定引起的10例（66．67％），手术操作失误引起的3例（20％），康复因素引起的2例（13．33％）。[结论]膝前交叉韧带重建术后关节僵硬与手术技术、治疗措施、康复训练密切相关；良好的手术技术、避免术后再固定、积极有效的功能锻炼是预防术后僵硬的关键。关节镜下松解是较好的治疗方式。     

Isometry testing for anterior cruciate ligament reconstruction revisited

The purpose of this study was to determine the effect, if any, that varying the distal testing position (tibial level) has on isometry data produced with a common anatomic proximal testing position at the native anterior cruciate ligament (ACL) origin. During ACL reconstruction in 25 knees, in vivo isometry measurements were recorded using two different isometry testing methods, which differed in the tibial level of the distal fixation testing point. Method 1 tested distally at a point 13 cm peripheral to the native aCL insertion on a vector in line with the tibial tunnel. Method 2 tested distally at a point central in the native ACL insertion at the level of the intercondylar floor. All tibial tunnels were standardized with similar sagittal tunnel-plateau angles and similar tunnel lengths. The proximal testing point was standardized at a point that was anatomically located at or near the central ACL origin 7 mm anterior to “over the top” in all knees. Using these methods, length changes between the proximal and distal testing points were recorded in each knee with each testing method, with the knee ranged from 70° of flexion to full extension and from 70° to 140° of flexion. From these data, a total excursion from 0° to 140° of flexion was calculated. A nonanatomic distal testing point (Method 1) produced a 6 mm ± 1 mm total excursion, whereas anatomic testing points (Method 2) in the same knees produced a 1 mm ± 1 mm total excursion. From these data, the authors conclude that the tibial level of the distal isometry testing point has a significant effect on the resultant isometry measurement such that anatomic testing points are most isometric. Isometers that produce data between nonanatomic testing points should not be used to position tunnels for ACL reconstruction and should not be used to assume the elongation forces an ACL substitute will see when fixed at different points. Conversely, the clinical relevance of this study is that both anatomic graft position and anatomic graft fixation position are important and, when achieved, should result in minimal graft elongation with early postoperative range of motion, leading to a more stable long-term result.     

前交叉韧带重建术的精确定位

目的探讨前交叉韧带（ＡＣＬ）重建的定位方法。方法取２０例新鲜或冷冻保存的尸体膝关节,通过做骨道至股骨和胫骨的ＡＣＬ附丽区,穿以钢丝并被动屈曲膝关节,测得其长度参数。用自行研制的等距测尺,连续观察测值的变化。结果在３０°～１２０°屈曲过程中,前上区纤维由短变长,前方制约作用逐渐增加;后上及中心区纤维的长度变化很小;前下区及后下区纤维由长变短,前方制约作用逐渐减少。结论股骨附丽区后上区和中心区应视为ＡＣＬ的重建位置。在陈旧损伤附丽区标志不明时,可使用等距测尺来决定重建位置中心。     

前交叉韧带原位双束重建技术的临床研究

目的探讨关节镜下个性化原位解剖重建前交叉韧带（ACL）的技术与结果。方法该技术包括3部分内容,首先在术前进行膝关节三维CT与MRI扫描了解患者韧带足迹与排列特点,其次在术中对髁问窝和ACL在股骨与胫骨的足迹进行测量,以明确可以进行双束重建。最后,根据患者的体质情况进行个性化康复训练。手术前后采用KT2000、Lysholm评分、IKDC评分、拉赫曼与轴移试验进行手术效果评估。SPSS15．0统计软件进行统计分析。结果选择82例患者,男52例,女30例,评均年龄25．2岁。根据术前CT与MRI评估发现,股骨外侧髁3种形态：四边形、中间形、三角形3种,其中四边形髁最适合进行双束重建,三角形髁需要术中仔细测量;股骨与胫骨的ACL足迹均有2种排列：直行与斜行,术中可据此进行骨道钻制。本组术中将ACL足迹长度大于14mm,且髁间窝宽度大于12mm的患者入选进行双束重建。手术前后,ACL足迹测量结果完全相符者65例,髁间窝宽度相符者71例。82例均进行个性化双束重建。术后平均随访时间15个月。术后三维CT显示骨道与术前设计相符,Lysholm评分由（49．3±9．2）分到（93．7±8．0）分,IKDC正常者77例,占94％。77例显示前后与旋转稳定均良好,4例双侧KT200检查显示3～4rnm前向松弛,但轴移阴性。1例失败需进行翻修。所有病例均对疗效满意。结论术前对股骨外髁形态、ACL股骨与胫骨足迹特点的判断对手术的设计至关重要,但手术中对髁间窝、ACL股骨与胫骨足迹的测量更具决定意义。采用个性化解剖位双束重建能较好地恢复患者膝关节稳定性。     

Intra-articular reconstruction of the anterior cruciate ligament

In this article, the author provides criteria for the recommendation of surgical intervention in acute and chronic anterior cruciate ligament insufficiency and describes various intra-articular procedures for both conditions. Intra-articular reconstruction of the anterior cruciate ligament with a vascularized patellar tendon graft is described in detail, as are the excellent results achieved with this procedure over the past 8 years.