Proprioception after rehabilitation and reconstruction in knees with deficiency of the anterior cruciate ligament: a prospective, longitudinal study

We assessed proprioception in the knee using the angle reproduction test in 20 healthy volunteers, ten patients with acute anterior instability and 20 patients with chronic anterior instability after reconstruction of the anterior cruciate ligament (ACL). In addition, the Lysholm-knee score, ligament laxity and patient satisfaction were determined. Acute trauma causes extensive damage to proprioception which is not restored by rehabilitation alone. Three months after operation, there remained a slight decrease in proprioception compared with the preoperative recordings, but six months after reconstruction, restoration of proprioception was seen near full extension and full flexion. In the mid-range position, proprioception was not restored. At follow-up, 3.7 +/- 0.3 years after reconstruction, there was further improvement of proprioception in the mid-range position. There was no difference between open and arthroscopic techniques. The highest correlation was found between proprioception and patient satisfaction. After reconstruction of the ACL reduced proprioception may explain the poor functional outcome in some patients, despite restoration of mechanical stability.     

Reconstruction of the anterior cruciate ligament. Single- versus double-bundle multistranded hamstring tendons

A total of 108 patients with unilateral instability of the knee, associated with rupture of the anterior cruciate ligament, was prospectively randomised for arthroscopic single- or double-bundle reconstruction of the ligament using hamstring tendons. The same post-operative rehabilitation protocol was used for all. The patients were followed up for a mean of 32 months (24 to 36). We measured the anterior laxity and joint position sense at different angles of flexion of the knee to determine whether both bundles in the double-bundle reconstruction contributed to the stability of the joint and proprioception. No significant difference was found between the two groups with regard to anterior laxity measured by the KT-2000 arthrometer with the knee at 20 degrees or 70 degrees flexion nor with regard to proprioception. A notchplasty was required less often in the double- compared with the single-bundle reconstruction. We did not find any advantage in a double-bundle as opposed to a single-bundle reconstruction in terms of stability or proprioception.     

Effect of reconstruction of the anterior cruciate ligament on proprioception of the knee and the heel strike transient

Abnormal proprioception of the knee joint has been documented after rupture of the anterior cruciate ligament (ACL) and may result in the loss of muscular reflexes. Excessive loading from the lack of muscular control may predispose the joint to osteoarthrosis. To investigate this problem, 10 patients were studied at an average of 31.6 months after ACL reconstruction. Three tests of joint proprioception and measurements of the vertical component of heel strike force during normal gait were used. A normal control group also was studied. For two of the proprioception tests (reproduction of passive motion and relative reproduction), there were no statistical differences among the uninjured (control) limbs, the normal contralateral limb of patients with a reconstructed ACL, and the extremity with a reconstructed ACL. In the third test (threshold of detection of motion), which previously has been shown to be adversely affected by ACL injury, the measurements for both extremities of patients with a reconstructed ACL were more accurate than those for the control group. The reconstructed extremity performed less accurately than the contralateral extremity (p < 0.05). The heel strike transient (vertical component of ground reaction force at heel strike) for uninjured and ACL-reconstructed limbs was not significantly different. In fact, the extremity with the reconstructed ACL had a lower transient than the uninjured extremity. Heel strike transients in patients with a reconstructed ACL were higher than those in the controls, but the differences were significant only when corrected for velocity of gait. These results indicate that a well done ACL reconstruction with appropriate rehabilitation can result in proprioception that is essentially equal to that of the contralateral limb.     

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.     

自体及同种异体肌腱重建前交叉韧带术后本体感觉恢复的比较研究

目的比较自体及同种异体肌腱重建前交叉韧带(anterior cruciate ligament,ACL)术后本体感觉恢复情况,探讨两种移植物对本体感觉恢复的影响。方法分析2008年1月-2010年1月行ACL重建的40例患者临床资料,其中20例采用自体肌腱重建(自体组),20例采用同种异体肌腱重建(异体组)。两组患者性别、年龄、病程、膝关节活动度、国际膝关节文献委员会(IKDC)评分及Lysholm评分等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。术中均采用单束重建方法,ACL止点残迹保留在胫骨或股骨髁间窝残端。术后随访测量膝关节活动度,行IKDC评分及Lysholm评分评定膝关节功能,采用双膝关节被动角度再生试验评定本体感觉恢复情况。结果两组患者术后切口均Ⅰ期愈合,无感染及关节腔内积血等并发症发生。患者均获随访,随访时间12～18个月,平均13.5个月。术后12个月膝关节活动度、IKDC评分及Lysholm评分均较术前显著改善,差异有统计学意义(P<0.05)。术后3个月,自体组患侧膝关节在30、60、90°位时与健侧比较,差异均无统计学意义(P>0.05);异体组患侧膝关节在30°位时与健侧比较,差异无统计学意义(P>0.05),在60、90°位时比较差异有统计学意义(P<0.05)。术后12个月,两组患侧膝关节在30、60、90°位时与健侧比较,差异均无统计学意义(P>0.05)。术后3个月,两组患侧膝关节在30°位时比较,差异无统计学意义(P>0.05);60、90°位时比较差异有统计学意义(P<0.05)。术后12个月,两组患侧膝关节在30、60、90°位时比较,差异均无统计学意义(P>0.05)。结论自体肌腱重建ACL术后膝关节的本体感觉恢复早于同种异体肌腱。     

Proprioception of the knee before and after anterior cruciate ligament reconstruction

Purpose: The purpose of this study was to determine, first, if there is measurable deficit in proprioception in an anterior cruciate ligament (ACL)-deficient knee, either compared to the contralateral knee or external controls; second, if this deficit, if present, improves after ACL reconstruction; and third, if improvement occurs, what the time course of improvement is. Type of Study: Prospective cohort study. Methods: Patients undergoing ACL reconstruction at the University of Chicago, demonstrating a full and painless range of motion and no other knee ligament injury or history of previous knee surgery, were eligible. Twenty-six patients, with an average age of 25 years (range, 16 to 48) were enrolled. Average time from injury to reconstruction was 8 weeks. The patients' contralateral knee served as an internal control, and 26 age-matched and gender-matched healthy volunteers were enrolled as an external control group. ACL reconstructions were performed using a single-incision technique with either bone–patellar tendon–bone or quadrupled hamstring autograft. They were allowed immediate weightbearing as tolerated and participated in a standardized rehabilitation program, with the goal of returning to sport at approximately 6 months. Proprioception testing was carried out using an electrogoniometer, in a seated position. Joint position sense (JPS) and threshold to detection of passive motion (TDPM) were measured preoperatively and at 3 and 6 weeks and 3 and 6 months postoperatively. Results: Mean KT-2000 values 6 months postoperatively were 1.38 mm (±2). Modified Lysholm score improved significantly (P < .01). Calculated r values were 0.65 for JPS and 0.96 for TDPM. No significant differences in postoperative proprioception were found between hamstring and patellar tendon grafts or among patients with meniscus injury, meniscus repair, or chondral injury. Preoperatively, the mean TDPM in both the injured and contralateral knees was significantly higher (worse) than in the external control knees (P = .008; P = .016). Evaluation of changes in proprioception from preoperative to 6 months postoperative showed significant improvement in both injured and contralateral knees (P = .04; P = .01). At 6-month follow-up, there was no significant difference from controls. Conclusions: TDPM was a more reliable method than JPS for testing proprioception before and after ACL reconstruction in this study. Bilateral deficits in knee joint proprioception (TDPM) were documented after unilateral ACL injury. Reconstruction of a mechanical restraint (ACL graft) was believed to have a significantly positive impact on early and progressive improvement in proprioception.     

不同康复方案在关节镜下ACL重建患者中的应用价值对比

目的探讨不同康复方案在关节镜下前交叉韧带（anterior cruciate ligament,ACL）损伤重建患者中的应用价值。方法对南京市第一医院于2007年7月至2012年6月收治的80例ACL损伤患者进行回顾性分析,按照不同时间段的康复训练方法,分为观察组40例与对照组40例,分别进行本体感觉康复训练与普通康复训练。结果观察组术后6个月与1年的屈膝15°、45°、75°等的本体感觉恢复程度,均显著优于对照组,差异具有统计学意义（P〈0．05）;两组患者在术前、术后6个月、1年的Lysholm膝关节功能评分对比,差异不具有统计学意义（P〉0．05）。结论采用动态平衡性、经皮电神经刺激以及变异适应性等康复训练方案,有利于关节镜下ACL重建患者本体感觉的恢复,具有临床推广价值。     

The effect of bracing on proprioception of knees with anterior cruciate ligament injury.

This paper is a comprehensive review on the effect of bandaging, bracing, and neoprene sleeves on knee proprioception following anterior cruciate ligament (ACL) injury and reconstruction with a focus on studies that have measured joint position sense and threshold to detection of passive knee motion. Disruption of the ACL does not appear to alter joint position sense soon after injury, although there is evidence that in some subjects deterioration may occur over time. An ACL tear creates a deficit in the threshold to detection of passive knee motion soon after injury and in those with chronic tears. The magnitude of worsening is less then 1.0 degree of movement in flexion-extension and of questionable concern from a clinical and functional perspective. Application of a functional brace or neoprene sleeve to the ACL-deficient limb does not improve the threshold to detection of passive knee motion; however, application of an elastic bandage to a knee with an ACL tear improves joint position sense. Reconstruction of a torn ACL is associated with a deficit in the threshold to detection of passive knee motion, and during the first year of healing the use of a neoprene sleeve provides improvement. Two years following ACL reconstruction there is no deficit in the threshold to detection of passive knee motion and the use of a brace has no effect on this outcome.     

Anterior cruciate ligament augmentation under arthroscopy

We present a new surgical technique of anterior cruciate ligament (ACL) augmentation using autogenous hamstring tendons or allogenic fascia lata under arthroscopy for patients in whom considerable ACL remnants with mechanoreceptors are preserved. We review the clinical results of 40 patients who underwent this ACL augmentation, as assessed by manual instability tests, KT-2000 knee arthrometer, Lysholm and Gillquist score, joint position sense and magnetic resonance imaging (MRI), and compare them with those of ACL reconstruction. The side-to-side differences of anterior displacement measured by the KT-2000 knee arthrometer at 30 lbs, an average of 5.3 +/- 2.6 mm preoperatively, was significantly improved to an average of 0.7 +/- 1.8 mm in the augmentation group, while an average of 6.0 +/- 2.4 mm was improved to 1.8 +/- 2.1 mm in the reconstruction group. There was no statistically significant difference between the preoperative values in the two groups, but the postoperative values of the augmentation group were significantly less than those of the reconstruction group. The ratio of anterior terminal stiffness of the augmentation group was 1.2 +/- 1.8, and that of the ACL reconstruction group was 0.7 +/- 0.4. This was a statistically significant difference (P < 0.05). Thus, as for the KT-2000 knee arthrometer, the ACL augmentation group showed significantly better anteroposterior stability and terminal stiffness than the ACL reconstruction group. The final inaccuracy of joint position sense of the augmentation group was 0.7 degrees +/- 0.7 degrees, while that of the reconstruction group was 1.7 degrees +/- 1.2 degrees indicating a significant difference (P < 0.05). This study demonstrates that ACL augmentation, which can preserve ACL remnants with mechanoreceptors, is superior to ACL reconstruction from the viewpoint of position sense and joint stability.     

内减张技术辅助前交叉韧带重建的运动学分析

目的观察关节镜下内减张技术辅助解剖单束重建前交叉韧带(ACL)患膝术后膝关节运动学恢复情况。 方法将2017年1月至2018年12月于昆明医科大学第一附属医院运动医学科就诊共80例ACL断裂的患者纳入研究，其中40例采用内减张技术辅助ACL解剖单束重建(实验组)，40例采用常规术式(对照组)。采用Opti_Knee膝关节三维运动分析系统，记录术后3、6、12月膝关节在步态过程中三维6自由度(屈伸角、内外翻角、内外旋角、前后位移、上下位移及内外位移)活动范围(最大值与最小值的差值)，同时与40例正常成人测量数据进行对比。计数资料比较采用卡方检验，两两比较采用配对t检验，多组间比较采用SNK分析。 结果术后3、6、12个月实验组与对照组患者最大步长、最小步长、步频差异无统计学意义(P >0.05)，与正常成人差异无统计学意义(P>0.05)。实验组术后3、6月内外旋角(F＝51.141、13.204)和前后位移(F＝51.246、12.207)活动范围均小于对照组(P<0.05)，且与正常成人相近(P>0.05)，两组间屈伸角、内外翻角、上下位移及内外位移活动范围均差异无统计学意义(P>0.05)，与正常成人差异无统计学意义(P>0.05)。术后12月两组间6个自由度活动范围相比差异无统计学意义(P>0.05)，均与正常成人相近(P>0.05)。 结论与传统术式相比，采用内减张技术重建ACL可早期获得更满意的膝关节运动学恢复疗效，膝关节运动学分析可更客观评价膝关节功能及稳定性。     

关节镜下同种异体韧带重建前交叉韧带的临床研究

目的探讨关节镜下应用同种异体肌腱重建膝关节前交叉韧带的近期和远期效果。方法自2002年1月～2003年1月,对7例前交叉韧带断裂患者(全部为男性,平均年龄42.0岁)应用深低温同种异体胫前肌腱重建断裂的前叉韧带,术后指导患者行功能锻炼。采取IKDC(国际膝关节评分委员会)功能评分、Lysholm评分、Tengner评分标准对患者术前,术后8个月,术后6年膝关节主观功能评分;采用KT2000在屈膝30°、90°,134N下分别测量患者术前,术后8个月,术后6年胫骨前后移动的距离。结果 7例均获随访,随访达6～7年,平均6.5年。患者术前与其他两组(术后8个月和术后6年)IKDC、Lysholm、Tengner评分比较,差异均有统计学意义(P0.05)。术后8个月、术后6年之间三种评分比较,差异均没有统计学意义(P0.05);KT2000屈膝30°、90°,134N下胫骨前后移动距离,术前和其他两组(术后8个月和术后6年)之间比较,差异均有统计学意义(P0.05),而术后8个月和术后6年之间比较,差异均没有统计学意义(P0.05)。所有患者无出现重建的前交叉韧带再断裂现象。结论同种异体肌腱能简单有效地重建膝关节前叉韧带。正确选取韧带和适当推迟康复进程是确保疗效的要点之一。     

Inverted cyclops lesion after anterior cruciate ligament reconstruction

We report the case of an inverted cyclops lesion limiting extension of the knee joint after a four-strand hamstring anterior cruciate ligament (ACL) reconstruction. One case has been reported previously following a bone-tendon-bone reconstruction of the ACL but a similar case has not been reported.     

Elektromyographische Untersuchungen operativ versorgter Kniebandrupturen

In 52 patients (5 groups, average age 32.8 years) with operative treatment of knee ligament injuries cutaneous electromyograms (EMG) under dynamic and isometric conditions (100 N, 200 N, 300 N) were performed in an average of 61.2 weeks postoperatively. The subgroups consisted of 13 patients with operative reconstruction of the anterior cruciate ligament (ACL), 12 after reconstruction of the medial colateral ligament (MCL), 21 after combined ACL and MCL reconstruction and 6 patients with autologous or alloplastic ligament replacement, respectively. The control group consisted of seventeen young adults without a history of knee joint injuries. The intensified and filtered analogous signals of 8 investigated thigh muscles were digitalized and analysed with help of a specially developed computer program. In summary, group specific EMG-criteria reveal distinct ligamentomuscular inhibitory reflexes and, vice versa, EMG activities of thigh muscles may indicate tendencies for group specific criterions after operatively treated knee ligament injuries.     

单隧道双束和单束ACL重建的生物力学比较研究

目的比较单隧道双束和单隧道单束ACL重建膝关节稳定性的差异。方法选用6侧人体膝关节标本,保留完整的关节囊及周围韧带,行单隧道双束和单束ACL重建,在MTS-858生物材料试验系统上测试膝关节在胫前加载(134N)和旋转加载(5N·m内旋胫骨)下屈曲0°、15°、30°、60°、90°位时的运动学反应。每个膝关节在4个不同条件下进行测试:ACL完整、ACL损伤、单隧道双束重建ACL以及单隧道单束重建ACL,其中单隧道双束及单束ACL均采用双股腘绳肌腱。结果 (1)胫前加载:双束组在屈曲30°、60°和90°位,单束组在屈曲90°位时关节前后稳定性获得良好恢复(P0.05);在屈曲60°位时双束组的胫前位移明显低于单束组,差异有统计学意义(P0.05)。(2)旋转加载:与ACL完整组相比较,双束组的胫骨内旋角度在屈曲0°、60°位时无明显变化(P0.05),屈曲90°位时明显减少(P0.05);单束组在屈曲0°时无明显变化(P0.05)。屈曲60°和90°位时双束组的胫骨内旋角度明显小于单束组,差异有统计学意义(P0.05)。结论与单隧道单束ACL重建相比,单隧道双束ACL重建能够更好地恢复膝关节前后稳定性及旋转稳定性。     

A modified arthroscopic anterior cruciate ligament double-bundle reconstruction technique with autogenous quadriceps tendon graft: remnant-preserving technique

Several techniques of anterior cruciate ligament (ACL) double-bundle reconstruction have been introduced to improve the functional outcome and restore normal kinematics of the knee. Meanwhile, a remnant-preserving technique was developed to preserve the proprioception and to enhance the revascularization of the reconstructed ACL. We developed double-bundle ACL reconstruction technique using autogenous quadriceps tendon graft while preserving the remnant. With this technique, two femoral sockets and one tibial tunnel are made. To preserve the remnant of the ACL, the rotational direction of the reamer was set to counterclockwise just before perforation of the tibial tunnel. To pass the graft more easily without disturbance of the remnant, the graft passage was achieved through the tibial tunnel. We suggest that the remnant-preserving technique could be an effective alternative considering its mechanical stability as well as the proprioception and vascularization recovery in arthroscopic double-bundle ACL reconstruction.     

急性完全性前交叉韧带损伤的膝关节镜下早期重建治疗

目的　探讨膝关节镜下对急性完全性前交叉韧带 (ACL)断裂的早期重建治疗 ,以尽早恢复膝关节稳定性。　方法　ACL急性断裂早期在关节镜下应用挤压螺钉固定骨 髌腱 (中 1/ 3) 骨复合体自体移植重建ACL ,止点重建或缝合修复治疗内侧副韧带断裂。　结果　 1998年 2月～ 1999年 3月共治疗急性完全性ACL断裂合并内侧副韧带断列患者 10例 ,术后平均随访 10个月 ,近期效果良好。　结论　急性ACL损伤早期可以在关节镜下完成重建 ,手术创伤小 ,治疗及时 ,可同时处理合并损伤 ,能早期恢复膝关节稳定性和运动功能。     

Proprioception in people with anterior cruciate ligament-deficient knees: comparison of symptomatic and asymptomatic patients

STUDY DESIGN: Nonrandomized prospective study. OBJECTIVE: To evaluate proprioception in 2 groups of patients with anterior cruciate ligament (ACL) deficiency who had different severity of symptoms. BACKGROUND: Defective proprioception has previously been found in patients with ACL-deficient knees. It has been suggested that sensory receptors of the ACL and other knee joint ligaments contribute to proprioception and knee joint function and stability. METHODS AND MEASURES: A total of 17 patients with ACL deficiency (mean [SD] age, 28.8 +/- 5.6 years; range, 22-39 years) with few, if any, symptoms were compared with 20 patients with ACL deficiency (mean [SD] age, 26.6 +/- 6.1 years; range, 18-39 years) having instability and episodes of giving way. The groups were compared with each other and with an age-matched reference group of 19 nonimpaired subjects. Their mean (SD) age was 25.6 +/- 3.7 years (range, 20-37 years). Three tests of proprioception were used: threshold to detection of passive motion from 2 starting positions (20 degrees and 40 degrees of knee flexion) toward flexion and extension, active reproduction of a 30 degrees passive angle change, and visual reproduction of a 30 degrees passive angle change. The Wilcoxon rank sum test was used for between-group comparisons. RESULTS: Symptomatic patients had higher threshold to detection of passive motion in their injured side in the flexion trial from 20 degrees (median of 1.5 degrees vs median of 0.5 degree) and in the extension trial from 40 degrees (median of 1.0 degree vs median of 0.5 degree) than the asymptomatic patients. No differences were found in the other threshold tests, active or visual reproduction tests. CONCLUSIONS: Patients with severe symptoms related to ACL deficiency were found to have inferior proprioceptive ability in some measurements compared with patients with a good knee function. The findings indicate that proprioceptive deficits might influence the outcome of an ACL injury treated nonoperatively.     

关节镜下部分重建治疗膝关节前交叉韧带不完全断裂

目的 探讨前交叉韧带(ACL)不完全断裂的关节镜下诊断及镜下部分蕈建治疗的疗效和意义. 方法 2004年6月至2006年12月,经关节镜确诊ACL不完伞断裂29例,其中前内侧束断裂21例,后外侧束断裂8例.全部患者于关节镜下重建损伤部分的韧带组织,选用LARS韧带蕈建11例,自体四股腘绳肌腱移植重建18例,术中完整保留未断裂部分的切带纤维束. 结果全部患者均获随访,平均随访15个月(12～30个月),治疗康复12个月时,门诊进行统一标准膝关节功能评定,膝关节Lysholm评分手术前、后比较差异有统计学意义(P<0.05). 结论正常ACL的前内侧束和后外侧束各自有不同的功能,对于ACL不完全断裂,准确判断ACL的断裂程度十分重要.有效地重建断裂部分的ACL,能够恢复双束韧带的完整统一,更有益于良好地恢复关节功能,避免晚期并发症的发生,对恢复膝关节稳定和功能有着重要的意义.     

Osteochondral Grafting for Treatment of a Massive Chondral Defect in the Knee of a Young Adult With Anterior Cruciate Ligament Deficit

We report the case of a 28-year-old woman who underwent osteochondral grafting and anterior cruciate ligament (ACL) reconstruction for treatment of a massive cartilage defect in a knee joint with ACL deficit. Arthroscopy showed a full-thickness degenerative cartilage defect measuring 22 × 35 mm in the weight-bearing area of the medial femoral condyle, a totally resected lateral meniscus, and a loosened ACL. Therefore we performed osteochondral autograft transplantation and ACL reconstruction. Osteochondral plugs were harvested from a donor site in the patellofemoral joint of the contralateral knee and grafted into the recipient site in a “skipping” manner. Arthroscopic examination 1 year after surgery showed good preservation of the grafts and satisfactory bridging of the gaps between the plugs with fibrocartilage-like tissue. A recent follow-up examination, performed 36 months after surgery, has shown an excellent result, with a Lysholm score of 100, an International Knee Documentation Committee score of 95.4, and full range of knee motion with no symptoms. Plain radiographs at that time showed preservation of the medial joint space on the weighted anteroposterior view. No osteoarthritic changes were evident in the patellofemoral joint.