Ankle Dorsiflexion displacement is associated with hip and knee kinematics in females following anterior cruciate ligament reconstruction

The purpose of this study was to examine associations between ankle dorsiflexion (ankle-DF) displacement and knee and hip kinematics and kinetics during a jump-landing task in females following anterior cruciate ligament reconstruction (ACLR). Females (n = 23) with a history of unilateral ACLR (≥ 6-months post-ACLR) underwent a three-dimensional lower extremity biomechanical evaluation. Pearson Product Moment (r) correlations assessed associations between ankle-DF displacement and knee and hip kinematic and kinetic variables. On the involved-limb, individuals with lesser ankle-DF displacement demonstrated greater knee abduction displacement during the loading phase (r = -0.645, p = 0.001). On the uninvolved-limb, individuals with greater ankle-DF displacement demonstrated greater hip flexion displacement (r = 0.599, p = 0.003) and knee flexion displacement (r = -0.545, p = 0.007). There were no other significant associations between ankle-DF displacement and ankle, knee, or hip biomechanical variables on either limb (p > 0.05). Our findings demonstrate that reduced ankle-DF motion appears to share a different relationship between the involved- and uninvolved-limbs in females post-ACLR.     

The incidence of patellofemoral osteoarthritis and associated findings 7 years after anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft

To evaluate the development of postoperative patellofemoral osteoarthritis, we performed a retrospective clinical and radiographic study of 100 patients who had undergone anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft an average of 7 years before the follow-up. Radiographic evaluation showed no patellofemoral osteoarthritis in 53 patients (group I), mild osteoarthritis in 34 patients (group II), moderate osteoarthritis in 12 patients, and severe osteoarthritis in 1 patient (group III, moderate and severe changes). The average shortening of the patellar tendon was 2.4 mm in group I, 3.9 mm in group II, and 6.8 mm in group III. The placement of the femoral or tibial tunnel of the graft, as measured from lateral radiographs, did not correlate significantly with the degree of patellofemoral osteoarthritis. Patients who developed patellofemoral osteoarthritis experienced worse final outcomes, were more often dissatisfied with the condition of the operated knee, experienced more frequent pain and swelling in the knee joint, and had poorer range of motion and poorer quadriceps muscle strength than did patients without patellofemoral osteoarthritis. Only three patients had an unstable knee, and degenerative changes in the tibiofemoral joint were uncommon.     

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.     

Evidence-based rehabilitation following anterior cruciate ligament reconstruction

Following a bone-patellar tendon-bone autograft (BPTB) or four-stranded semitendinosus/gracilis tendons autograft (ST/G) anterior cruciate ligament (ACL) reconstruction, the speed and safety with which an athlete returns to sports (or regains the pre-injury level of function) depends on the rehabilitation protocol. Considering the large differences in clinical and outpatient protocols, there is no consensus regarding the content of such a rehabilitation program. Therefore, we conducted a systematic review to develop an optimal evidence-based rehabilitation protocol to enable unambiguous, practical and useful treatment after ACL reconstruction. The systematic literature search identified 1,096 citations published between January 1995 and December 2006. Thirty-two soundly based rehabilitation programs, randomized clinical trials (RCT’s) and reviews were included in which common physical therapy modalities (instruction, bracing, cryotherapy, joint mobility training, muscle-strength training, gait re-education, training of neuromuscular function/balance and proprioception) or rehabilitation programs were evaluated following ACL reconstruction with a BPTB or ST/G graft. Two reviews were excluded because of poor quality. Finally, the extracted data were combined with information from background literature to develop an optimal evidence-based rehabilitation protocol. The results clearly indicated that an accelerated protocol without postoperative bracing, in which reduction of pain, swelling and inflammation, regaining range of motion, strength and neuromuscular control are the most important aims, has important advantages and does not lead to stability problems. Preclinical sessions, clear starting times and control of the rehabilitation aims with objective and subjective tests facilitate an uncomplicated rehabilitation course. Consensus about this evidence-based accelerated protocol will not only enhance the speed and safety with which an athlete returns to sports, but a standardized method of outcome measurement and reporting will also increase the evidential value of future articles.     

Rehabilitation concerns following anterior cruciate ligament reconstruction.

Rehabilitation following anterior cruciate ligament reconstruction is a subject of controversy in the orthopaedic and rehabilitation literature. With an increasing number of these operations currently being performed and with the advent of arthroscopically assisted ACL reconstruction over the past several years, particular rehabilitation needs and problems have been identified in association with these patients. Various authors have stressed one or a combination of a few basic themes which outline the basic rehabilitation concerns following ACL reconstruction. The most fundamental concern is the need to initiate motion very soon after surgery. Prolonged postoperative immobilisation is known to cause serious complications after ACL reconstruction which can be avoided by early motion. Positions or activities which may apply excessive stress to a newly reconstructed ACL must also be considered. The amount of protection required by the graft will vary depending upon the type of graft used and the quality of fixation obtained intraoperatively. Most authors agree that nonweightbearing, active resistive quadriceps exercises should be avoided for an extended period, while closed chain exercises may be initiated much earlier. Strength recovery is obviously important for the quadriceps postoperatively, but maximal strength returns of all of the muscles about the knee must be pursued. Hamstring strength is of particular concern as this may provide an active support to the reconstructed ACL. Sensory loss in the knee after ACL disruption should also be addressed during rehabilitation, prior to a patient's return to full athletic activity. Progressive neuromuscular re-education exercises which rely on sensory input from intact pericapsular structures are encouraged. A final concern is the role of bracing after ACL reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Trends in rehabilitation following anterior cruciate ligament reconstruction

In summary, the use of an autogenous intra-articular reconstruction has been identified as an effective treatment modality to stabilize the ACL-deficient knee. However, despite the fact that rehabilitation programs are becoming more aggressive and less time consuming, the patient who elects to have his knee stabilized surgically continues to face a long recovery period. Continued research in surgical and rehabilitative management is necessary to reduce this time and expense if ACL reconstruction is to be practical for all.     

Tibial plateau fracture following anterior cruciate ligament reconstruction

A case is presented of a tibial plateau fracture after previous anterior cruciate ligament reconstruction using patellar tendon autograft. The tibial plateau fracture occurred through the transosseous tibial tunnel and followed a torsional injury to the involved extremity. The stress riser effect of the transosseous tibial tunnel and the anatomic location of the cortical defect probably facilitated development of the fracture. Minimally invasive fixation of the fracture was effective in preserving knee stability without need for revision anterior cruciate ligament reconstruction.     

Kinetic changes associated with extended knee landings following anterior cruciate ligament reconstruction in females

ObjectivesTo determine the relationship between knee flexion excursion symmetry and lower extremity kinematics, kinetics, and muscle, joint, and ligament forces in females 1–3 years after ACL reconstruction.DesignCross-sectional.SettingLaboratory.ParticipantsTwenty-one, college-aged females.Main outcome measuresLower extremity kinetics and kinematics, including estimated muscle, tibiofemoral, and ligament forces were assessed using 3D motion analysis and a musculoskeletal modeling approach. Participants demonstrating greater than 10% asymmetry in knee flexion excursion were classified as landing with an “extended knee”. Group and between-limb differences were compared.ResultsTen participants were classified as landing with an “extended knee” on the involved limb, while eleven exhibited a symmetric landing pattern. Participants landing with an “extended knee” demonstrated reduced knee extension moment and quadriceps force in the involved limb (p < 0.05).ConclusionsThese findings indicate that an “extended knee” landing pattern was associated with reduced knee extension moment and quadriceps muscle force in females 1–3 years after ACL reconstruction. This may represent an altered strategy that clinicians may choose to identify and address during rehabilitation.     

Tibiofemoral relationship following anatomic triple-bundle anterior cruciate ligament reconstruction

Purpose

The purpose of this study was to investigate the tibiofemoral relationship sequentially before and after anatomic triple-bundle (TB) anterior cruciate ligament (ACL) reconstruction in the same patients.

Methods

Nine patients with complete unilateral ACL rupture participated in this study. Anatomic TB ACL reconstruction was performed using autogenous semitendinosus tendon grafts. Computed tomography images were obtained before surgery as well as 3 weeks and 6 months afterwards. During image acquisition, the patient’s knees were fully extended in the supine position. Using three-dimensional computer models, anterior–posterior and medial–lateral displacement of the tibia relative to the femur were evaluated for each period, as were internal–external and varus–valgus rotation, followed by calculation of side-to-side differences in parameters. As the control group, 7 healthy volunteers were evaluated.

Results

The tibia was located anteriorly by 1.4 ± 0.9 mm and rotated internally by 2.1 ± 1.7° before surgery, while the tibia was located posteriorly by 2.0 ± 1.2 mm and rotated externally by 3.4 ± 3.5° 3 weeks after surgery. Six months after surgery, there was no significant difference between the patient and control groups.

Conclusions

The anteriorly located and internally rotated tibia in ACL-deficient knees was over-constrained (posterior displacement and external rotation) 3 weeks after anatomic TB ACL reconstruction, but returned to the normal position 6 months afterwards. Therefore, anatomic tunnel placement, appropriate initial tension, and moderate rehabilitation can be the key for return to the normal tibiofemoral relationship after ACL reconstruction.

Level of evidence

Therapeutic study, Level IV.     

Hamstring autografts are associated with a high rate of contamination in anterior cruciate ligament reconstruction

Purpose

To quantitatively evaluate the rate, type, and level of contamination of anterior cruciate ligament (ACL) hamstring autografts after harvesting and preparation or dropping onto the operating room (OR) floor.

Methods

Two hamstring autograft specimens were prospectively retrieved from each graft in a consecutive series of 50 patients undergoing primary isolated ACL reconstruction (100 specimens total). One specimen was retrieved immediately after harvesting and dropped onto the OR floor (dropped group). The other was retrieved just after graft implantation and before fixation (control group). Each specimen was incubated for aerobic and anaerobic growth, and the number of colony-forming units (CFU)/g was measured. Patients’ clinical course was monitored for signs of surgical site infection (SSI).

Results

The control and dropped groups had positive culture rates of 11/50 (22%) and 16/50 (32%), respectively, with no significant difference between groups (n.s.). The most common organism in the control group was Staphylococcus epidermidis (45.5%) followed by S. aureus (36.4%). In the dropped group, the most common organism was S. epidermidis (31.3%) followed by Bacillus species (25%). The median (range) CFU/g among positive specimens in the dropped and control groups was 65 (8–150) and 10 (2–60), respectively (P = 0.0003). No patient developed postoperative SSI.

Conclusion

Intraoperative hamstring autograft contamination rates were high. Hence, routine prophylactic decontamination of all hamstring autografts after harvesting and preparation and before implantation is recommended.

Level of evidence

Controlled laboratory study.

     

Strength and functional symmetry is associated with post-operative rehabilitation in patients following anterior cruciate ligament reconstruction

Purpose

To investigate strength and functional symmetry during common tests in patients after anterior cruciate ligament reconstruction (ACLR), and its association with post-operative rehabilitation.

Methods

At a median 11.0 months post-surgery (range 10–14), 111 ACLR patients were assessed. A rehabilitation grading tool was employed to evaluate the duration and supervision of rehabilitation, as well as whether structured jumping, landing and agility exercises were undertaken. Patients completed the Noyes Activity Score (NSARS), maximal isokinetic knee extensor and flexor strength assessment, and a 4-hop test battery. Limb Symmetry Indices (LSIs) were calculated, presented for the entire group and also stratified by activity level. ANOVA evaluated differences between the operated and unaffected limbs across all tests. Correlations were undertaken to assess the relationship between post-operative rehabilitation and objective test LSIs.

Results

The unaffected limb was significantly better (p < 0.0001) than the operated limb for all tests. Only 52–61 patients (47–55%) demonstrated LSIs ≥ 90% for each of the hop tests. Only 34 (30.6%) and 61 (55.0%) patients were ≥ 90% LSI for peak quadriceps and hamstring strength, respectively. Specifically in patients actively participating in jumping, pivoting, cutting, twisting and/or turning sports, 21 patients (36.8%) still demonstrated an LSI < 90% for the single hop for distance, with 37 patients (65.0%) at < 90% for peak knee extension strength. Rehabilitation was significantly associated with the LSIs for all tests.

Conclusion

Rehabilitation was significantly correlated with limb symmetry, and lower limb symmetry was below recommended criterion for many community-level ACLR patients, including those already engaging in riskier activities. It is clear that many patients are not undertaking the rehabilitation required to address post-operative strength and functional deficits, and are being cleared to return to sport (or are returning on their own accord) without appropriate evaluation and further guidance.

Level of evidence

IV.

     

Two-bundle, four-tunnel anterior cruciate ligament reconstruction

We reviewed 33 patients who underwent anterior cruciate ligament (ACL) reconstruction using a two-bundle, four-tunnel technique. The posterolateral bundle (PLB) and anteromedial bundle (AMB) were individually reconstructed with gracilis and semitendinosus tendon auto-grafts, respectively, using separate tibial and femoral tunnels. At final follow-up (24 months post surgery, range 18–31) the International Knee Documentation Committee’s (IKDC) objective final evaluation scores were 69 A, 19 B, 12% C. The mean global subjective IKDC score was 86±12 points. Ninety-four percent of the patients had returned to sport after an average of 9 months following surgery and 75% returned to their preinjury sporting level. One patient had suffered a graft rupture as a result of a further sports injury. Eighty-four percent of the patients had a negative pivot shift (IKDC A), 9% a glide (IKDC B), and 6% a “clunk” (IKDC C). The mean postoperative side-to-side laxity, measured with KT1000 arthrometry at manual maximum, was 0.9 mm (SD 1.9). Eighty-one percent of the patients had less than 3 mm difference, with only one patient having greater than 5 mm. Our early experience with this new technique appears to demonstrate satisfactory results that are at least equivalent to other techniques and show an apparent trend towards improved control of anterior laxity.     

Gait analysis post anterior cruciate ligament reconstruction: knee osteoarthritis perspective

Force generation during sit-to-walk (STW) post-stroke is a poorly studied area, although STW is a common daily transfer giving rise to a risk of falling in persons with disability. The purpose of this study was to describe and compare strategies for anterior-posterior (AP) force generation prior to seat-off during the STW transfer in both subjects with stroke and in matched controls. During STW at self-selected speed, AP force data were collected by 4 force plates, beneath the buttocks and feet from eight subjects with stroke (>6 months after onset) and 8 matched controls. Subjects with post-stroke hemiparesis and matched controls generated a similar magnitude of total AP force impulses (F(1,71)=0.67; p=0.42) beneath buttocks and feet prior to seat-off during STW. However, there were significant group differences in AP force impulse generation beneath the stance buttock (i.e. the non-paretic buttock in the stroke group), with longer duration (F(1,71)=8.78; p<0.005), larger net AP impulse (F(1,71)=6.76; p<0.05) and larger braking impulse (F(1,71)=7.24; p<0.05) in the stroke group. The total braking impulse beneath buttocks and feet was about 4.5 times larger in the stroke group than in the control group (F(1,71)=8.84; p<0.005). An intra- and inter-limb dys-coordination with substantial use of braking impulses was demonstrated in the stroke group. This motor strategy differed markedly from the smooth force interaction in the control group. These results might be important in the development of treatment models related to locomotion post-stroke.     

Medial patellofemoral ligament reconstruction in patients with lateral patellar instability and trochlear dysplasia

BACKGROUND: Reconstruction of the medial patellofemoral ligament has been proven to restore stability in patients with lateral patellar instability. No study to date has examined the results in a patient population with the predisposing factor of femoral trochlear dysplasia. HYPOTHESIS: Reconstruction of the medial patellofemoral ligament restores stability and provides pain relief in patients who have lateral patellar instability in association with trochlear dysplasia. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty-four patients with chronic patellar instability and trochlear dysplasia were treated with medial patellofemoral ligament reconstruction using an adductor tendon autograft, bone-quadriceps tendon autograft, or bone-patellar tendon allograft. All patients were evaluated preoperatively and postoperatively with Kujala, Lysholm, and Tegner scores at a minimum of 24 months. RESULTS: Thirty-four patients were followed for a mean of 66.5 months (range, 24-130 months) after surgery. Kujala scores improved from 53.3 to 90.7, Lysholm scores improved from 52.4 to 92.1, and Tegner activity scores improved from 3.1 to 5.1. All improvements were highly statistically significant (P < .001). No statistical difference was found between the postoperative Lysholm, Kujala, and Tegner scores and the degree of dysplasia, graft type, or degree of symptoms. There were 85.3% and 91.1% good and excellent results based on Kujala and Lysholm scores, respectively. No recurrent dislocations have occurred. CONCLUSION: Medial patellofemoral ligament reconstruction provides excellent long-term pain relief and functional return in patients with patellar instability and femoral trochlear dysplasia. In addition, reconstruction prevents recurrent dislocation, despite the diminished bony constraint of a dysplastic trochlea.     

Age,rehabilitation and surgery characteristics are re-injury risk factors for adolescents following anterior cruciate ligament reconstruction

ObjectivesTo examine the effect of age on post-ACLR rehabilitative outcomes and identify surgical/rehabilitative characteristics as ACL re-injury risk factors in adolescents.DesignCohort study.SettingChildren’s hospital.Participants273 adolescents with first-time ACLR.Main outcome measuresDemographics, injury history, surgery, and outcomes documented during post-ACLR physical therapy (PT) sessions were extracted from medical records. Effects of age on outcomes were examined using multivariate regression. ACL re-injury risk factors were identified using survival analysis with Cox regression.ResultsRe-injury was recorded in 47 patients (17.2%) with a median follow-up time of 3.1 years and median re-injury time of 13.4 months post-surgery. Younger age (Hazard-Ratio, HR = 1.264 per year decrease; P = 0.005), receiving surgery within 1 month post-injury (HR = 3.378 vs. >3 months; P = 0.012), starting PT within 3 days post-surgery (HR = 3.068; P = 0.022), and decreased number of PT sessions (HR = 1.118 per 3-session decrease; P = 0.010) increased re-injury risk. Although age was associated with re-injury risk, age was not associated with any outcome (P > 0.059).ConclusionAdolescents who are younger, receive surgery and post-surgery PT sooner, or attend fewer PT sessions may be at an increased re-injury risk. Younger patients achieved similar outcomes despite elevated re-injury risk. Current discharge criteria are inadequate in identifying high re-injury risk patients.