Knee strength outcomes in adolescents by age and sex during late-stage rehabilitation after anterior cruciate ligament reconstruction

ObjectiveTo determine if knee strength differences exist according to age group and sex among adolescents during late-stage anterior cruciate ligament reconstruction (ACLR) rehabilitation.DesignRetrospective cohort study.MethodsConsecutive patients who had undergone ACLR with a hamstring autograft completed isokinetic knee strength assessment. Patients were categorized into early (ages 11–14 years) and middle (ages 15–17 years) adolescence. A two-way MANOVA was used to examine strength differences according to age group and sex.Results144 patients were included in the analysis (56.9% females, age = 15.3 ± 1.5 years; days since surgery = 228.2 ± 41.2). Differences in quadriceps peak torque were identified between age groups on the involved (p = 0.001) and uninvolved limbs (p < 0.001), however, no differences in quadriceps peak torque were found between age groups when normalized to body mass (p = 0.16–0.49). Differences between groups according to sex were identified for each strength outcome (p < 0.01), with decreased normalized quadriceps (12–13%) and hamstring (13–16%) peak torque for females. No interactions between age group and sex were noted, F(8, 133) = 1.48, p = 0.17.ConclusionEarly adolescents produced less quadriceps and hamstring peak torque compared to middle adolescents after ACLR. No differences were found between age groups when normalized to body mass.     

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.     

Isokinetic muscle strength after anterior cruciate ligament reconstruction

The purpose of the present study was to investigate the isokinetic muscle strength 6 months after reconstruction of the anterior cruciate ligament (ACL). In order to recommend full-load come-back in sport, sufficient muscle strength may be important. Ninety female elite team handball players (mean 24.1 years) were postoperatively tested with Biodex. The operated limb was compared with the contralateral limb: 82.2% had a hamstring strength of a minimum of 49.6 Nm, corresponding to at least 90% of the non-operated limb, while only 12.2% fulfilled the recommended strength of 117.7 Nm for quadriceps femoris. Patients over 26 years showed significantly lower muscle strength in the operated limb than their younger counterparts. Increased focus on quadriceps femoris muscle strength during rehabilitation may improve the knee function faster after ACL reconstruction.     

Graft healing in anterior cruciate ligament reconstruction

Graft healing within the bone tunnel after anterior cruciate ligament (ACL) reconstruction is still a complex, poorly understood biological process that is influenced by multiple surgical and postoperative variables. However, remarkable advances in knowledge of this process have been made based primarly on animal models. According to the findings of this review, some surgical and postoperative variables are known to directly affect time-course and quality of graft-tunnel healing. The type of graft, graft motion, and fixation methods have shown to directly affect time-course and quality of graft-tunnel healing. Therefore, the application of early and aggressive rehabilitation protocols should be cautious when using soft-tissue graft, allografts, and direct or aperture type of fixation for ACL reconstruction. With regard to graft placement, several cadaveric models showed biomechanical advantages of a more anatomical graft location; however, there are no studies that explore the relationship between graft placement and healing process. The precise effect of graft tensioning, graft/tunnel diameter disparity, and graft length within the bone tunnel in the graft healing process remains unclear and requires more research. To enhance graft-tunnel healing, tissue-engineering approaches, including the use of growth factors, mesenchymal stem cells, and periosteum graft augmentation, have been tested on animal models. These have shown promising results in terms of enhancement of bone-graft healing rate.     

Experience with the Leeds-Keio artificial ligament for anterior cruciate ligament reconstruction

Artificial anterior ligament reconstruction was very popular between 1975 and 1990. Recently, disappointing results have been published. We reviewed 68 patients who had received an artificial anterior cruciate ligament reconstruction 1 year and 5 years after their operation. The Leeds-Keio device was used as a scaffold. The ligament failed in 32 knees. This was arthroscopically confirmed in 20 cases. The other 12 knees were grossly unstable, with a reappearance of pivot shift, anterior drawer sign and high KT 1000. Generally, we found a marked increase in laxity over the period of investigation. Several biopsies were taken during arthroscopic examination of suspected ruptures. They showed lack of collagenisation and ingrowth.     

MR imaging of anterior cruciate ligament reconstruction poor outcomes

Purpose

Is to study the diagnostic value of MR imaging in assessment of poor outcomes of ACL reconstruction using second look arthroscopy of the knee as a gold standard.

Patients and methods

51 patients were included in this study who did ACL reconstruction followed by MRI and second look arthroscopy. Arthroscopy study was performed within 7–15 days from MR examination. The time interval between ACL reconstruction and MRI examination was 10 months to 9 years. MR images were evaluated for; (1) ACL graft failure assessing the primary and secondary signs, (2) Tibial and femoral tunnel location, and (3) Complication of ACL graft reconstruction. MR imaging results were compared with the arthroscopic results.

Results

Second look arthroscopy revealed 23 patients with full- thickness ACL graft tears, 17 partial -thickness ACL graft tears and 11 intact ACL grafts. Complete ACL graft discontinuity, focal ACL graft thinning and preserved 100% graft thickness were the most valuable primary MRI signs in the diagnosis of full thickness ACL graft tear, partial tear and intact graft respectively.

Conclusion

We found MR imaging to be reliable for the evaluation of ACL graft poor outcomes including graft failure and complications.     

Double semitendinosus anterior cruciate ligament reconstruction: 10-year results

In a series of 30 consecutive patients who suffered from chronic instability of the knee joint, reconstruction of the torn anterior cruciate ligament was performed with a looped semitendinosus tendon, reinforced by an extra-articular anterolateral procedure. Of these 30, 27 could be followed up 9–11 years after the operation. The evaluation included the International Knee Documentation Committee (IKDC) questionnaire and was completed by testing with a Kneelax arthrometer at 132 N and by anteroposterior standing X-ray, in order to evaluate the degenerative changes. At the time of the check-up: 96% of the study group considered that they had normal or nearly normal knees, and 81% had recovered to the same sports activity level as before their injury. The degenerative changes noted at the index operation did not progress notably, except in two cases. Laxities of 7 knees were normal, with a side-to-side difference of less than 2 mm; 15 were nearly normal, with a mean difference of 3.45 mm; and 5 were abnormal, with a mean difference of 6.2 mm. The study shows that the procedure is efficient in restoring a satisfactory stability for most patients and stabilises the evolution of the degenerative lesions as shown by standing X-ray. Received: 30 December 1996 Accepted: 25 July 1997     

Complications of anterior cruciate ligament reconstruction: MR imaging

Arthroscopic reconstruction of the anterior cruciate ligament (ACL) using autografts or allografts is being performed with increasing frequency, particularly in young athletes. Although the procedure is generally well tolerated, with good success rates, early and late complications have been documented. As clinical manifestations of graft complications are often non-specific and plain radiographs cannot directly visualize the graft and the adjacent soft tissues, MR imaging has a definite role in the diagnosis of complications after ACL reconstruction and may direct subsequent therapeutic management. Our purpose is to review the normal MR imaging of the ACL graft and present the MR imaging findings of a wide spectrum of complications after ACL reconstruction, such as graft impingement, graft rupture, cystic degeneration of the graft, postoperative infection of the knee, diffuse and localized (i.e., cyclops lesion) arthrofibrosis, and associated donor site abnormalities. Awareness of the MR imaging findings of complications as well as the normal appearances of the normal ACL graft is essential for correct interpretation. Electronic Publication     

Treatment of limited motion after anterior cruciate ligament reconstruction

Limited motion or arthrofibrosis after anterior cruciate ligament (ACL) reconstruction causes significant pain and functional impairment. Based on physical findings and loss of motion compared with the opposite normal knee, classification systems for the diagnosis and treatment of arthrofibrosis have been developed. The operative techniques and preoperative and postoperative rehabilitation and management are discussed. Range of motion (ROM) problems after ACL reconstruction have been minimized by improved surgical techniques and perioperative rehabilitation programs. The most effective treatment for arthrofibrosis is prevention by delaying ACL reconstruction until the patient has a normal gait and full ROM and minimal swelling in the injured knee and by appropriate ROM exercises after surgery. Received: 13 October 1997 Accepted: 23 June 1998     

Anatomic anterior cruciate ligament reconstruction: the two-incision technique

This article describes the anatomical two-incision reconstruction of anterior cruciate ligament (ACL) of knee. The major part of currently single incision tibial endoscopic techniques attempts to reproduce the most isometric anteromedial bundle of ACL. Often a relatively vertical femoral tunnel, respect to the notch, is drilled, which is not really efficacious in providing rotatory stability. The single incision technique was developed to obviate the necessity of the lateral femoral incision and dissection. This technical note describes a two-incision ACL reconstruction using an instrumentation, which avoids a large lateral femoral soft tissue dissection, and discusses the rational use of the two-incision ACL reconstruction technique.     

Radiological method for preoperative determination of isometric attachment points of an anterior cruciate ligament graft

The purpose of this study was to develop a radiological method which would be preoperatively available to help determine the best graft placement (with respect to isometricity as well as absence of graft impingement) for all knees. The radiological method is described in full detail. We also present the most significant experimental work supporting our development. Firstly, we studied the path followed by radioopaque objects inserted in the mobile tibia around the fixed femur. Secondly, we compared the distances measured between selected femoral and tibial points radiologically (according to our method) and clinically (with a currently available isometer). The main results were: (1) every tibial point considered moves on an arc of a circle centered on a corresponding femoral point. We should then speak of pairs of isometric points instead of a single femoral isometric zone; (2) the more posterior the tibial point, the more anterior and distal the corresponding femoral point and vice versa; (3) the distance variations induced by rotation did not exceed 1.5 to 2.5 mm when measured either radiologically or clinically; (4) on the radiological and clinical measurements, the difference of length variations during flexion was also very small (mean 0.22 mm; SD 1.2 mm). We conclude that this very simple method allows us to find the femoral transition line for every knee (whatever its size, shape or dynamics). It aids preoperative planning in anterior cruciate ligament graft reconstruction.     

Effectiveness and safety of cryotherapy after arthroscopic anterior cruciate ligament reconstruction. A systematic review of the literature

Cryotherapy is widely used in rehabilitation; however, its effectiveness after anterior cruciate ligament (ACL) reconstruction remains uncertain. To investigate the effectiveness and safety of cryotherapy following ACL reconstruction through a systematic review, randomized and quasi-randomized clinical trials were searched in the databases: MEDLINE, EMBASE, CENTRAL, PEDro, SportDiscus, CINAHL, LILACS (June 2013). The primary outcomes measures were pain, edema and adverse events; the secondary outcomes were knee function, analgesic medication use, range of motion, blood loss, hospital stay, quality of life and patient satisfaction. The methodological quality of studies was evaluated using the Cochrane Collaboration risk-of-bias tool. Ten trials (a total of 573 patients) were included. Results of meta-analysis showed that the use of cold compression devices produced a significant reduction in pain scores 48 h after surgery (p < 0.00001), compared to no cryotherapy. The risk for adverse events did not differ between patients receiving cryotherapy versus no treatment (p = 1.00). The limited evidence currently available is insufficient to draw definitive conclusions on the effectiveness of cryotherapy for other outcomes. There is a need for well designed, good quality randomized trials to answer other questions related to this intervention and increase the precision of future systematic reviews.     

前交叉韧带重建术后三维MRI表现

目的 探讨前交叉韧带(ACL)重建术后ACL移植物和骨隧道的3D MRI表现和演变规律.方法 回顾性分析26例双束ACL重建和16例单束ACL重建患者行3D MRI术后随访56例次的资料,用多平面重组法显示和评价移植物、骨隧道、固定器及并发症,计算术后不同时期低信号及高信号移植物的比例和骨隧道周围骨髓水肿的出现率.结果 发现低信号移植物24例次,高信号移植物32例次.移植物固定2例股骨端采用横杆,1例股骨端使用纽扣,其余部位使用可吸收螺钉.术后3个月、6～9个月和12个月及以上低信号移植物比例分别为20/25、0/14和4/10,高信号移植物比例分别为5/25、14/14和6/10,骨隧道周围骨髓水肿出现比例分别为54/54、10/32和4/26.发现1例移植物撕裂,4例胫骨隧道偏前伴ACL移植物髁间窝顶撞击,3例股骨隧道偏前,2例可吸收螺钉与骨隧道不匹配.结论 3D MRI可准确显示ACL重建术后移植物、骨隧道和固定器的状态及并发症信息,移植物信号在术后呈先增高再恢复低信号的过程.     

The load of an implanted graft during and after fixation in anterior cruciate ligament reconstruction

Although the importance of initial graft load has been discussed in the literature, it has not been confirmed whether a surgeon can provide the desired load to an implanted graft in anterior cruciate ligament reconstruction. The purpose of this study was to compare the set force (initial load given to the graft before fixation) and residual load in the implanted graft using three different fixation techniques. A total of ninety porcine knees were tested using bone–patellar tendon–bone autograft. Each bone–tendon–bone autograft was fixed to the tibia with either the interference-fit screw, fixation post, or button technique. Graft load was monitored during fixation procedures, and for 10 min after fixation. Residual graft load with each fixation technique exhibited unique features. Highest graft load was obtained by the interference-screw fixation technique; however, the graft was usually over-loaded beyond the intended set force with this technique. In the fixation-post technique, the load of the graft increased while the screw was retightened. The graft load in the button-fixation technique was low, probably due to slight slippage of the button. When the graft was fixed under maximum manual tension, the graft loads at completion of fixation for the interference fit screw, fixation post, and button techniques were 116.3, 54.2, and 25.9 N respectively.     

Outcome and knee-related quality of life after anterior cruciate ligament reconstruction: a long-term follow-up

The aim of the present investigation was to study patient-reported long-term outcome after anterior cruciate ligament (ACL) reconstruction. On an average 11.5 years after ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft 56 patients were asked to answer four different questionnaires about their knee function and knee-related quality of life. Another aim was to study whether there were any correlations between clinical tests, commonly used for evaluating patients with ACL injuries, which were performed 2 years after ACL reconstruction, and patient-reported outcome in terms of knee function and knee-related quality of life on an average 9.5 years later. All patients who had unilateral BPTB ACL reconstructions were examined at 2 years and on an average 11.5 years after surgery. At 2 years one-leg hop test for distance, isokinetic muscle torque measurement, sagittal knee laxity, Lysholm knee scoring scale and Tegner activity scale were used for clinical evaluation. At the follow-up on an average 9.5 years later the patients were evaluated with knee injury osteoarthritis outcome score (KOOS), short form health survey (SF 36), Lysholm knee scoring scale and Tegner activity scale. The SF-36 showed that the patients had a similar health condition as an age- and gender-matched normal population in Sweden on an average 11.5 years after ACL reconstruction. There was no correlation between the results of one-leg hop test for distance, isokinetic muscle torque measurement, sagittal knee laxity evaluated 2 years after surgery and the result of KOOS (function in sport and recreation, knee-related quality of life) and SF-36 evaluated on an average 11.5 years after surgery. We also compared patients that 2 years after surgery demonstrated a side-to-side difference in anterior–posterior knee laxity of more than 3 mm with those with 3 mm or less and found no significant group differences in terms of knee function as determined with KOOS. We found no correlation between the results of KOOS and SF-36 at the long-term follow-up and the time between injury and surgery, age at surgery or gender, respectively. We conclude that there is no correlation between patient-reported knee function in sport and recreation and knee-related quality of life on an average 11.5 years after BPTP ACL reconstruction and the evaluation methods used 2 years after surgery.     

Composite Gore-Tex and autogenoussemitendinosus anterior cruciate ligament reconstruction: Long-term results and historical review

Over the past decade, anterior cruciate ligament reconstruction has evolved into a reproducible procedure withpredictably good results. However, there are still some failures. Some of these failures have obvious mechanical or technical etiologies. For others, the etiology remains unclear. This article examines an explanation for some of these failures and presents a reasonable revision technique to avoid a recurrent failure.     

Functional outcomes and health-related quality of life after robot-assisted anterior cruciate ligament reconstruction with patellar tendon grafts

During a short period of time, surgical robots had been propagated for automated tunnel placement in anterior cruciate ligament (ACL) reconstruction. Clinical outcome data are currently unavailable. Between 2000 and 2003, 152 patients underwent ACL replacement with the assistance of the Computer Assisted Surgical Planning and Robotics system (CASPAR, OrtoMaquet, Germany) at our hospital. After minimal invasive pin placement in both the tibia and femur, computed tomography was used to register anatomical landmarks and to plan graft tunnel alignment. The robot was used to drill tibial and femoral tunnels in an outside-in fashion according to pre-operative planning. There was one procedure-specific Serious Adverse Event (i.e., an intraoperative transection of the posterior cruciate ligament). After IRB approval, all patients were invited for a follow-up examination. Data from 100 patients (35 women, 65 men, mean age 35 [SD 11] years, median follow-up 61 [range 42–77] months) form the basis of this report. Side-to-side differences in anterior laxity were measured with the KT-1000 arthrometer. Patient-centered outcomes included the Lysholm-Score, the lower extremity functional scale (LEFS), and the Short Form 36 (SF36). The mean KT-1000 side-to-side difference was 0.89 [95% confidence interval (CI) 0.52–1.26] mm. Eight and five patients had a positive Lachman and pivot shift test, respectively. The Lysholm-Score averaged 86 (95% CI 83–89) points. Excellent, good, fair, and poor outcomes were reported by 38, 32, 20, and 10 patients. The LEFS averaged 85 (95% CI 82–88) points. The mean SF36 Physical Component Score was 48.4 (95% CI 46.5–50.3), indicating residual deficits compared to the population norm. All tibial graft tunnels did not cross the Blumensaat line, but were placed slightly anterior to the optimal center of 42% reported in previous studies. Compared to literature data, robot-assisted ACL reconstruction with BTB grafts may lead to higher knee stability, but poorer functional outcomes. The immense additional efforts with the procedure did not pay off in a benefit to patients.     

Evaluation of hamstring muscle strength and morphology after anterior cruciate ligament reconstruction

This study aimed to clarify the relationship between knee flexor strength and hamstring muscle morphology after anterior cruciate ligament (ACL) reconstruction using the semitendinosus (ST) tendon and to determine the causative factors of decreased knee flexor muscle strength. Fourteen male and ten female patients who resumed sports activities after surgery participated in the experiment. Isometric knee flexion torque was measured at 30°, 45°, 60°, 90°, and 105° of knee flexion. Magnetic resonance imaging (MRI) was used to calculate ST muscle length and hamstring muscle volume, and to confirm the status of ST tendon regeneration. The correlation between the MRI findings and flexor strength was analyzed. Regenerated ST tendon was confirmed in 21 of the 24 patients, but muscle volume (87.6%) and muscle length (74.5%) of the ST in the operated limb were significantly smaller than those in the normal limb. The percentage of the knee flexion torque of the operated limb compared with that of the normal was apparently lower at 105° (69.1%) and 90° (68.6%) than at 60° (84.4%). Tendon regeneration, ST muscle shortening, and ST muscle atrophy correlated with decreased knee flexion torque. These results indicated that preserving the morphology of the ST muscle‐tendon complex is important.     

Arthroscopic reconstruction of the anterior cruciate ligament with Leeds-Keio ligament in non-professional athletes

We report our experience using the Leeds-Keio artificial ligament for anterior cruciate ligament (ACL) reconstruction. The study relates the results of the first 40 patients subjected to arthroscopic reconstruction of the ACL with a Leeds-Keio ligament, with a mean follow-up of 73 months. No associated peripheral procedures were carried out on any patient. The average age of the patients at the time of the operation was 31 years (range 26–35 years). The rehabilitation protocol followed by all patients aimed at resumption of sport 4 months after the operation. Clinical assessment included IKDC and the Lysholm scoring scale. The KT-2000 system was used for instrumented evaluation of joint laxity. All patients underwent a radiographic check-up. Clinically there were 55% excellent or good results when using the IKDC scale, while with the Lysholm score, satisfactory results were obtained in 80%. Complete post-traumatic rupture of the ligament was observed in three patients. No patient suffered an episode of either hydrarthrosis or reactive synovitis, which indicates good tolerance to the ligament. The radiographic evaluation of the operated knees showed a close correlation between the appearance of degenerative phenomena and performance of arthroscopic meniscectomy. The results achieved with the Leeds-Keio artificial ligament 5 years after application, although not completely satisfactory and inferior to those obtained with autologous biological ligaments, should be considered an encouragement to promote new efforts in this interesting research field.     

Ankle morbidity after autogenous Achilles tendon harvesting for anterior cruciate ligament reconstruction

Although several alternative autografts with reduced morbidity of harvest site have been introduced, no donor site is free of morbidity concerns. The authors report on ankle status after autogenous Achilles tendon harvesting with a minimum 10-year follow-up. From October 1994 to October 1996, a consecutive series of 47 ankles underwent harvesting of the medial third or half of the ipsilateral autogenous Achilles tendon for primary anterior cruciate ligament reconstruction. Donor site statuses were evaluated using a modified Thermann’s scale. Postoperative isokinetic muscle strength testing was performed, and magnetic resonance images of donor sites were available for selected patients. Thirty-three ankles in the 32 patients were followed for more than 10 years. There were 27 men (84%) and 5 women (16%) with a mean age of 31 years (range 16–52 years) at the time of surgery. The mean duration of follow-up was 12 years and 1 month (range 10 years and 5 months to 13 years and 4 months). Mean postoperative modified Thermann’s scale score was 87 (range 45–95; SD 14.3). Twenty-five (76%) ankles achieved very good or good results. A slight decrease in calf circumference <1 cm was seen in the ten ankles, 1–2 cm in the four ankles. Nine ankles were mildly hypersensitive to meteorological changes. Peak torque of ankle plantar flexion was slightly lower on the index limb at both velocities in nine selected patients who carried out performance tests. However, there were no significant differences (5.2% at 30°/s and 2.7% at 120°/s, P = n.s. and P = n.s.). Of the 12 available follow-up magnetic resonance images, the average cross-sectional area of the remaining tendon was 82.01 mm² (range 69.05–107.35; SD 10.3), and their average thickness was 7.4 mm (range 6–10.35; SD 1.1). After a minimum 10-year follow-up, the harvesting of autogenous Achilles tendons was not found to significantly jeopardize ankle status. However, it also could not be independent of donor morbidity as an alternative. The level of evidence was retrospective level IV, as a therapeutic study.