Changes in stair ascent biomechanics two to eight years after ACL reconstruction are associated with patient-reported outcomes

BackgroundAnterior cruciate ligament (ACL) injury is often followed by quadriceps deficits that are apparent with gait analysis. The deficit frequently remains after ACL reconstruction (ACLR). As such, evaluation of ACLR patients could be enhanced by a simple method to detect quadriceps deficits. Analyzing forward trunk flexion during stair ascent has been suggested as an assessment of quadriceps function that can be visualized with relatively simple instrumentation.AimThe purpose of this study was to determine if trunk flexion angle (TFA) during stair ascent is associated with quadriceps function (as measured by the peak knee flexion moment (KFM)) at 2 and 8 years post-ACLR and if changes are associated with patient-reported outcomes (PRO).MethodsFourteen subjects with unilateral primary ACLR performed three stair-ascending trials at two-time periods: 2 years (baseline) and 8 years (follow-up) post-ACLR. Paired Student t-tests determined differences in KFM and TFA. Associations between KFM, TFA, and PRO were determined through Pearson correlations.ResultsPeak KFM during stair ascent significantly increased from baseline to follow-up (p = 0.01). Though there was no significant difference in TFA (p = 0.84) compared to baseline, 50% of subjects showed decreases in TFA. Further, subjects with reduced TFA during stair ascent at follow-up had significantly increased peak KFM (p = 0.029) and improvements in PRO (p = 0.001).DiscussionThe results suggest that TFA during stair ascent can provide a simple method to assess changes in quadriceps function and pain over time following ACLR. Further analysis is needed to draw conclusions between knee osteoarthritis development and increases in TFA.     

Knee joint infection after ACL reconstruction: prevalence, management and functional outcomes

Purpose

Septic arthritis after an ACL reconstruction is a rare but serious complication. Functional outcomes of these patients have not been studied in depth in large series. The aim of this study was to determine the prevalence and management of knee joint infection following ACL reconstruction and to assess the functional outcomes.

Methods

A retrospective assessment of knee joint infections occurring after arthroscopically assisted ACL reconstructions done from 2006 to 2009 in two hospitals by the same surgical team is presented. Patients with signs and symptoms of joint infection along with blood and synovial effusion laboratory parameters suggestive of infection were considered as septic arthritis. All the patients were treated with antibiotic therapy according to antibiotic sensitivity and had at least one arthroscopic lavage. Final outcomes were assessed and compared with a control group using the KT-1000 arthrometer, functional testing and radiological examination.

Results

Fifteen (1.8 %) out of 810 patients included in the study were considered as a joint infection. Microbiology showed that coagulase-negative Staphylococcus was present in 10 patients, Staphylococcus Aureus in three patients (2 MSSA and 1 MRSA) and Propinebacterium sp. in one patient. In one patient, the micro-organism was unknown. At a mean follow-up of 39.3 ± 13 months, the Lysholm score was 77.7 ± 15.3, the IKDC score was 70.4 ± 19.5, and the KT-1000 compared to the non-injured contralateral knee showed a mean difference of 1.3 ± 2 mm. Functional outcomes in the control group were slightly better than those obtained in the infected group (Lysholm score; 90.7 ± 9.4, p = 0.007. IKDC score; 86.6 ± 6.8, p = 0.004). All but one patient retained their reconstructed ACL.

Conclusions

The prevalence of septic arthritis after an ACL reconstruction in this series was 1.8 %. Arthroscopic lavages along with antibiotic treatment led us to preserve all but one graft. Functional outcomes in the infected patients were not as good as those obtained in patients without infection.

Level of evidence

Therapeutic case series, Level IV.     

Long-term results after reconstruction of the ACL with hamstrings autograft and transtibial femoral drilling

Purpose

To evaluate the long-term clinical, patient-reported and radiological outcome of patients reconstructed for anterior cruciate ligament (ACL) insufficiency. We wanted to examine the relationship between clinical findings and patient-reported scores.

Methods

The 96 first successive patients that underwent ACL reconstruction using transtibial technique, hamstrings autograft and tunnel placement ad modum Howell were evaluated 10 years post-operatively. Subjective outcomes were Lysholm score, IKDC 2000 subjective score and Tegner activity scale. The clinical examination included evaluation of rotational and sagittal laxity. Evaluation of osteoarthritis was done radiologically.

Results

Eighty-three patients (86 %) were available for follow-up at mean 10.2 years post-operatively. Three patients had revision ACL surgery prior to the 10-year evaluation. The mean Lysholm score, subjective IKDC 2000 score and Tegner activity scale were 89 (SD 13), 83 (SD 15) and 5 (range, 3–9), respectively. Six patients (8 %) had moderate or severe osteoarthritis. Eighty-six per cent of patients had normal or near-normal anterior–posterior ACL laxity. Twenty per cent of patients had positive pivot shift and 42 % had a pivot glide. The former group had a significant lower Lysholm score compared to the rest of the patients.

Conclusions

Although the mean Lysholm score was classified as good (89) at the 10-year follow-up, a positive pivot shift was found in 20 % of these patients. Compared to patients with normal rotational laxity or pivot glide, this patient group reported significant lower subjective satisfaction at the long-term follow-up.

Level of evidence

Case series, Level IV.     

ACL graft re-rupture after double-bundle reconstruction: factors that influence the intra-articular pattern of injury

Purpose  

To determine the most common rupture patterns of previously reconstructed DB-ACL cases, seen at the time of revision surgery, and to determine the influence of age, gender, time between the initial ACL reconstruction and re-injury, tunnel angle and etiology of failure.     

Patellar and hamstring autografts are associated with different jump task loading asymmetries after ACL reconstruction

After anterior cruciate ligament reconstruction (ACLR), there is a higher re‐injury rate to the contralateral limb in athletes who undergo surgery using a bone‐patellar‐tendon‐bone (BPTB) autograft than using a semitendinosus and gracilis hamstring tendon (HT) autograft. This may be influenced by differing lower‐limb loading asymmetries present when athletes of each graft type return to play (RTP). The aim of this study was to compare bilateral countermovement jump (CMJ) phase‐specific impulse asymmetries between athletes with BPTB and HT autografts 9 months post‐ACLR, and to identify the relationship between impulse and isokinetic strength asymmetries. Male field sport athletes with a BPTB (n = 22) or HT (n = 22) autograft were tested approximately 9 months post‐ACLR. An uninjured control group (n = 22) was also tested on a single occasion. Phase‐specific bilateral absolute impulse asymmetries were calculated during the CMJ and compared between groups using Kruskal‐Wallis and post‐hoc testing. A linear regression model was used to assess the relationship between impulse asymmetries and isokinetic concentric knee extensor strength asymmetries. BPTB athletes demonstrated greater impulse asymmetries than HT athletes during the eccentric (P = 0.01) and concentric (P = 0.008) phases of the jump. Isokinetic strength asymmetry was a significant predictor of CMJ concentric impulse asymmetry in both BPTB (r² = 0.39) and HT athletes (r² = 0.18) but not eccentric impulse asymmetry in any group. The greater loading asymmetries demonstrated by BPTB than HT athletes 9 months after ACLR may contribute to the differing incidence rates of contralateral ACL injury. The findings suggest that graft‐specific loading asymmetries should be targeted during rehabilitation prior to RTP.     

There are differences in early morbidity after ACL reconstruction when comparing patellar tendon and semitendinosus tendon graft. A prospective randomized study of 107 patients

The main objective of this study was to study solely early postoperative morbidity following anterior cruciate ligament (ACL) reconstruction by comparing the gold standard procedure, the bone‐patellar tendon‐bone graft (BTB), and one of the most common alternatives, the semitendinosus tendon graft (ST). The prospective study included 107 randomized patients (50 BTB and 57 ST). The follow‐up period was set to 20–35 weeks postoperatively (mean 26.8±3.5 weeks). One patient suffered early graft rupture and 89 (84%) of the remaining 106 patients were able to attend the follow‐up within the given time limit. There were no differences in sick leave between the groups. The Lysholm score, Tegner activity level score and Visual Analog Scales (VAS) with the questions “How does your knee function?” and “How does your knee affect your activity level?” revealed no differences between the groups. Subjective patellofemoral pain, patellofemoral compartment findings and donor site morbidity were more common in the BTB group, P<0.05. Lachman test grade 1+ was more common in the ST group, P<0.05, but there was no significant difference in instrumented Lachman side‐to‐side comparison. The ST group scored better in the one‐leg hop test than the BTB group, P<0.05. No correlations between these clinical and functional findings and subjective knee function scores were found. In conclusion, ACL reconstruction with ST tendon graft presented fewer short‐term postoperative problems as compared to reconstruction with BTB.     

Knee-flexion torque and morphology of the semitendinosus after ACL reconstruction

PURPOSE: The present study aimed to clarify the relationship between deficits in knee-flexion torque and morphological changes in the semitendinosus muscle-tendon complex after harvesting the semitendinosus tendon for anterior cruciate ligament (ACL) reconstruction. METHODS: Isometric knee-flexion torque at 45 and 90 degrees of knee flexion was measured in limbs of 23 patients (22 +/- 4 yr) who underwent unilateral ACL reconstruction (12-43 months postoperation) using ipsilateral semitendinosus tendon. Magnetic resonance imaging scans were used to calculate the muscle volume and the muscle length of the semitendinosus and to confirm the presence of the regenerated semitendinosus tendon. RESULTS: The percentage of the knee-flexion torque of the ACL-reconstructed limb compared with that of the contralateral limb was lower at 90 degrees than at 45 degrees . The regeneration of the semitendinosus tendon-like structure was confirmed in 21 of the 23 patients. However, muscle volume and muscle length of the semitendinosus in the ACL-reconstructed limb were significantly smaller compared with in the contralateral limb. CONCLUSION: Deficits in knee-flexion torque at deep knee flexion were associated with the atrophy and shortening of the semitendinosus after harvesting the semitendinosus tendon for ACL reconstruction.     

Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction

Purpose  

The purpose of this article is to present recommendations for new muscle strength and hop performance criteria prior to a return to sports after anterior cruciate ligament (ACL) reconstruction.     

风筝皮瓣在拇指损伤修复及功能重建中的应用

目的研究风筝皮瓣在拇指损伤修复及其功能重建中的应用效果。方法选取我院2008--2012年间收治的100例拇指损伤患者,将其随机分为实验组和对照组各50例。对照组采用腹部皮片植皮,实验组取掌背动脉风筝皮瓣修复拇指掌侧缺损,并使用皮瓣桡侧神经吻合及髂骨移植等方式重建拇指骨结构及感觉功能。对术后皮瓣存活情况、患者神经功能及拇指运动功能进行评价。结果实验组50例患者皮瓣全部存活（100％）,再造拇指形态良好;对照组50例存活48例（96％）,且外形及质地等均较差。实验组优良率为100％,显著高于对照组的88％（P〈0．05）。实验组感觉恢复更好,S3级以上者实验组有45例（90％）,显著高于对照组的36例（72％）。两点分辨距离（2PD）实验组平均为（7．9±0．6）mm显著优于对照组的（10．4±1．2）mm（P〈0．05）。结论风筝皮瓣取用简单,旋转方便,血运可靠,成活率高,对于拇指损伤修复及功能重建有较好治疗效果。     

Two to five year results of primary ACL reconstruction using doubled tibialis anterior allograft

The aim of the study was to report the 2–5 year results of primary ACL reconstruction with doubled tibialis anterior allograft. Seventy-three patients who underwent primary ACL reconstruction with doubled tibialis anterior allografts with minimum 2 year follow-up were included in the study. Sixty-four patients were available for follow-up. The median age was 27 years (16–55). There were 33 men and 31 women. The median follow-up was 44.5 months (24–55 months). There were two complications, 1 DVT with subsequent PE, and 1 hardware problem. Four patients had failure of their graft, and six patients required repeat arthroscopy. The median Lysholm score was 88 (range 70–95), and the median Tegner activity score was 6.5 (range 3–10). The median IDKC was 92 (range 73–100). According to the IDKC score, 60% of patients were rated as excellent, 27% as good, and 13% as fair. A total of 25 were able to attend the clinical assessment. On KT-1000, 15 (60%) patients had less than 3 mm side-side difference. Eighteen patients (72%) had no pivot shift. ACL reconstruction with allograft tibialis anterior tendon provided good functional results with a low-failure rate at 2–5 years. There was a statistically significant difference in outcome between men and women, with men performing better on the Lysholm and the IDKC scales.     

Short-term functional and clinical outcomes after ACL reconstruction with hamstrings autograft: transtibial versus anteromedial portal technique

Purpose

Several studies have suggested that drilling the femoral tunnel through an anteromedial arthroscopic portal during anterior cruciate ligament reconstruction allows more anatomic placement of the graft. However, no studies have investigated whether the anteromedial approach results in better outcomes compared to the traditional transtibial drilling approach when a hamstring autograft is used. The purpose of the present study is to investigate short-term functional and clinical outcome differences between male patients recovering from anterior cruciate ligament reconstruction with a hamstring autograft using the transtibial femoral tunnel drilling approach versus the anteromedial approach.

Methods

Lysholm score, functional test and isokinetic data were collected at 3 and 6 months after surgery in 51 male patients who received a standardized rehabilitation in a large outpatient facility. Multivariate and univariate analyses of variance were used to assess group, time and interaction effects.

Results

All outcomes except isokinetic knee flexion at 180°/s improved from 3 to 6 months for both groups (p ≤ 0.05). The anteromedial approach group had better Lysholm scores at 3 months (p ≤ 0.05) and better performance in the timed lateral movement functional tests at 3 and 6 months (p ≤ 0.05). No other comparisons were significant (n.s).

Conclusions

Both groups had comparable outcomes on most measures. The differences in the Lysholm score and lateral movement functional tests may suggest a quicker return of function and performance for the anteromedial approach group. Clinicians should take into consideration the surgical technique as they progress patients recovering from ACL reconstruction through the different phases of the rehabilitation protocol.

Level of evidence

Therapeutic study, Level II.     

The influence of femoral tunnel position in single-bundle ACL reconstruction on functional outcomes and return to sports

Purpose

The purpose of this study was to radiographically investigate the influence of femoral tunnel placement in ACL reconstruction on early outcomes and return to sports due to anatomic and nonanatomic positioning.

Methods

A prospective study was conducted from 2008 to 2010, with 86 athletes who underwent ACL reconstruction between anteromedial (AM) footprint and high AM position. Knee functional outcomes (IKDC objective and subjective, Tegner score, and Lysholm scale) return to sports and complications were analyzed at 6- and 12-month follow-up.

Results

At follow-up, it was observed that tunnel projection along Blumensaat’s line was correlated with functional outcomes on Tegner scale (at 6 and 12 months) and IKDC subjective (at 12 months). There was a significant difference in mean tunnel projection along Blumensaat’s line when analyzing return to sports (73 ± 1.4 and 79 ± 1.7 %, respectively, for projections on return vs. no return to sports, p = 0.02) and complications (73 ± 1.3 vs. 78 ± 1.6 %, respectively, for projections on no complications vs. complications, p = 0.03). No differences were stated on coronal view. These correlations between tunnel positioning on functional outcomes could not be explained by demographic or baseline characteristics.

Conclusion

The clinical relevance of this study is that tunnel positioning along AM footprint and high AM position represented by tunnel projection along Blumensaat’s line is associated with early return to sports on previous Tegner level and better functional outcome in athletes.

Level of evidence

III.     

Worse knee confidence,fear of movement,psychological readiness to return-to-sport and pain are associated with worse function after ACL reconstruction

ObjectivesTo determine whether knee confidence, fear of movement, psychological readiness to return-to-sport or pain are associated with patient-reported and performance-based function and return to pivoting sport in individuals one-year after anterior cruciate ligament reconstruction (ACLR).DesignCross-sectional study.SettingUniversity-laboratory.Participants118 individuals one-year post-ACLR.Main outcome measuresThe KOOS-sport/recreation and IKDC and three hopping tasks were used to assess patient-reported and performance-based function, respectively. Questions regarding return to pivoting sport assessed return-to-sport status. Fear of movement (Tampa Scale), knee confidence (an item from KOOS, Visual Analogue Scale-VAS confidence during hopping tasks), knee pain (KOOS-pain, VAS pain during hopping tasks) and psychological readiness to return-to-sport (ACL-RSI) were also assessed.ResultsWorse fear of movement (p = 0.019), KOOS-pain (p < 0.001), ACL-RSI (p < 0.001), task-specific knee confidence and pain were associated with poorer patient-reported function. Worse task-specific knee confidence (p < 0.001) and pain (p < 0006) and ACL-RSI (p < 0.016) were associated with poorer performance-based function. Higher ACL-RSI scores were associated with higher odds of returning to pivoting sport one-year post-ACLR (p < 0.001).ConclusionIndividual’s fear of movement, knee confidence, psychological readiness to return-to-sport and pain are related to function. Evaluating and considering knee confidence, fear of movement, and psychological readiness should be an important part of comprehensive post-ACLR rehabilitation.     

Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction

Purpose

To evaluate the results of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction in patients with chronic ACL injury. It was hypothesized that patients who underwent combined ACL and ALL reconstruction would exhibit less residual laxity and better clinical outcomes.

Methods

Two groups of patients were evaluated and compared retrospectively. Both groups consisted only of patients with chronic (more than 12 months) ACL injuries. Patients in group 1 underwent anatomical intra-articular reconstruction of the ACL and patients in group 2 underwent anatomic intra-articular ACL reconstruction combined with ALL reconstruction. The presence of associated meniscal injury, the subjective International Knee Documentation Committee (IKDC) and Lysholm functional outcome scores in the postoperative period, KT-1000 evaluation, the presence of residual pivot shift and graft rupture rate were evaluated.

Results

One hundred and one patients who underwent reconstruction of chronic ACL injuries were evaluated. The median follow-up was 26 (24–29) months for group 1 and 25 (24–28) months for group 2. There were no significant differences between groups regarding gender, age, duration of injury until reconstruction, follow-up time or presence of associated meniscal injuries in the preoperative period. Regarding functional outcome scores, patients in group 2 presented better results on both the IKDC (p?=?0.0013) and the Lysholm (p?<?0.0001) evaluations. In addition, patients in group 2 had better KT-1000 evaluation (p?=?0.048) and a lower pivot shift rate at physical examination, presenting only 9.1% positivity versus 35.3% in the isolated ACL reconstruction (p?=?0.011). Regarding re-ruptures, group 1 presented 5 (7.3%) cases, and group 2 presented no cases.

Conclusion

The combined ACL and ALL reconstruction in patients with chronic ACL injury is an effective and safety solution and leads to good functional outcomes with no increase in complication rate. The clinical relevance of this finding is the possibility to indicate this type of procedure when patients present with more than 12 months after injury for surgery.

Level of evidence

Level III.