Biomechanical analysis of knee hyperextension and of the impingement of the anterior cruciate ligament: a cinematographic MRI study with impact on tibial tunnel positioning in anterior cruciate ligament reconstruction

This study analyzed the interaction between the anterior cruciate ligament (ACL) and the intercondylar notch roof (INR) in hyperextension of the knee using magnetic resonance cinematography. Cinematographic image series of 15 knees were investigated. Two independent observers identified the image that displayed the beginning of contact between the ACL and the INR. They determined knee extension on this image and on the image that displayed maximum hyperextension of the knee. Correlations between a variable representing impingement and the inclination angle of the INR, the anterior laxity of the knee, and full hyperextension were examined. Theoretical, impingement-free tibial tunnel positions for the knees were calculated as a percentage of the anteroposterior tibial width. All ACLs of the knees in this study made contact with the INR. The average extension angle at the beginning of impingement was –6.3 ± 3.8°. There were significant correlations between impingement and maximum manual displacement as measured with the arthrometer ¶(r = 0.77; P < 0.001), maximum hyperextension (r = 0.67; P = 0.007), and notch roof angle (r = –0.73; P = 0.002). There were biomechanically acceptable tunnel positions for all knees but one. Hyperextension is physiologically associated with impingement of the ACL. In uninjured knees there was a correlation between ACL impingement and hyperextension, inclination of the INR, and maximum manual displacement of the tibia. Impingement free tibial tunnel positioning is possible in most knees without notchplasty.     

Intercondylar roof impingement pressure after anterior cruciate ligament reconstruction in a porcine model

Anterior cruciate ligament (ACL) graft impingement against the intercondylar roof has been postulated, but not thoroughly investigated. The roof impingement pressure changes with different tibial and femoral tunnel positions in ACL reconstruction. Anterior tibial translation is also affected by the tunnel positions of ACL reconstruction. The study design included a controlled laboratory study. In 15 pig knees, the impingement pressure between ACL and intercondylar roof was measured using pressure sensitive film before and after ACL single bundle reconstruction. ACL reconstructions were performed in each knee with two different tibial and femoral tunnel position combinations: (1) tibial antero-medial (AM) tunnel to femoral AM tunnel (AM to AM) and (2) tibial postero-lateral (PL) tunnel to femoral High-AM tunnel (PL to High-AM). Anterior tibial translation (ATT) was evaluated after each ACL reconstruction using robotic/universal force-moment sensor testing system. Neither the AM to AM nor the PL to High-AM ACL reconstruction groups showed significant difference when compared with intact ACL in roof impingement pressure. The AM to AM group had a significantly higher failure load than PL to High-AM group. This study showed how different tunnel placements affect the ACL-roof impingement pressure and anterior-posterior laxity in ACL reconstruction. Anatomical ACL reconstruction does not cause roof impingement and it has a biomechanical advantage in ATT when compared with non-anatomical ACL reconstructions in the pig knee. There is no intercondylar roof impingement after anatomical single bundle ACL reconstruction.     

The anterior inferior tibiofibular ligament and talar impingement: a cadaveric study

Impingement by the distal fascicle of the anterior inferior tibiofibular ligament (AITFL) is a relatively new entity among the known causes of anterolateral impingement syndromes of the ankle. This study investigated the anatomy of the anterior inferior tibiofibular ligament and its possible role in talar impingement in 47 ankles of 27 cadavers. The length, width, insertion point to the fibula and the interactions with talus were noted, as was the relationship of the fascicle and talus during different ankle movements before and after incision of the lateral ligaments. A distal fascicle of the AITFL was found in 39 of the 47 ankles (83%) and appeared as a single-complete ligament in the remaining 8 ankles (17%). The fascicle averaged 16.1+/-2.94 mm in length (range 10-21) and 4.2+/-1.00 mm in width (range, 3-7). The insertion point of the fascicle on the fibula averaged 10.3+/-2.27 mm (5-13) distal to the joint level. Contact between the ligament and the lateral dome of the talus was observed in 42 specimens (89.3%). Bending of the fascicle was observed in 8 of these 42 ankles with forced dorsiflexion. These 8 specimens were significantly wider and longer than the specimens without bending of the fascicle. Incision of the anterior talofibular ligament led to bending in dorsiflexion in additional 11 ankles. The total 19 fascicles with bending after incision of the anterior talofibular ligament were significantly longer and inserted more distally than the remaining 20 fascisles without bending. Manual traction simulating distraction during arthroscopic procedures relieved the contact. These findings show that the presence of the distal fascicle of the AITFL and its contact with the talus is a normal finding. However, it may become pathological due to anatomical variations and/or instability of the ankle resulting from torn lateral ligaments. When observed during an ankle arthroscopy, the surgeon should look for the criteria described in the present study to decide whether it is pathological and needs to be resected.     

Avulsion of anterior cruciate ligament from femoral condyle: an unusual case report and a review of the literature

We report a rare case of avulsion of anterior cruciate ligament from the lateral femoral condyle and describe the arthroscopic management of such a case along with a review of the literature.     

The MR imaging features of the posterior intermalleolar ligament in patients with posterior impingement syndrome of the ankle

Objective. To describe the MR imaging features of the posterior intermalleolar ligament (IML) in patients with posterior impingement syndrome (PIS) of the ankle. Design and patients. Three patients (one male and two females, 13–25 years of age) are presented. Each patient presented clinically with symptoms of PIS of the ankle. Plain film examination was negative for a structural cause of the PIS in all patients. MR images were obtained with a 1.5 T scanner using an extremity coil. Clinical data and, in one patient, findings at ankle arthroscopy, were correlated with the results of MR imaging. Results. Ankle MR images from the three patients with a clinical diagnosis of PIS are presented. Findings in all patients included: (1) absence of another structural cause of the PIS (i.e., an os trigonum, trigonal process, fracture, loose bodies, etc.), (2) identification of the IML as a structure discrete from the posterior talofibular and tibiofibular ligaments, and (3) prominence of the IML as indicated by (a) identification of the IML in three different imaging planes, and (b) a caliber of the IML comparable to that of the conventional posterior ankle ligaments visualized in the same imaging plane. Arthroscopic resection of a meniscoid IML resulted in resolution of the PIS in one of the patients presented. Conclusions. MR imaging is an effective means of investigating the IML as a potential cause of PIS. The identification of a prominent IML in the absence of another structural cause of PIS indicates that impingement of the IML is the most likely cause of PIS. Received: 11 March 1999 Revision requested: 5 May 1999 Revision received: 2 June 1999 Accepted: 4 June 1999     

The tibialis tendon as a valuable anterior cruciate ligament allograft substitute: biomechanical properties

The study evaluates the biomechanical properties of single-strand and single-loop tibialis (anterior and posterior) tendon allografts. A comparison was made with bone-patellar tendon-bone (BPTB) allografts. Sixty-four tendon allografts were evaluated in this study. Sixteen of these were single-strand tibialis anterior (TA) and 16 single-strand tibialis posterior (TP) tendons. Sixteen single-loop TA and TP tendons were also tested. The fourth group was composed of 16 BPTB allografts. The biomechanical properties determined were maximal load, stiffness, cross-sectional area and elongation. The results of this study showed that the maximal load of the single-loop tibialis tendons (1,553 ± 62 N) was greater than of the BPTB (1,139 ± 99 N), TA (776 ± 43 N) and TP (888 ± 64 N) tendons. The stiffness of the single-loop tibialis tendons (236 ± 10 N/mm) was also greater than of the BPTB (168 ± 13 N/mm), TA (60 ± 2 N/mm) and TP (73 ± 5 N/mm) tendons. The cross-sectional area of the BPTB tendons was 67 ± 5 mm², of the single-loop tibialis tendons 36 ± 2 mm², of the TA tendons 20 ± 1 mm², and of the TP tendons 23 ± 1 mm². The elongation of the single-loop tibialis tendons and of the BPTB tendons was almost similar (7 ± 0.4 mm). The same applied to the TA and TP tendons (14 ± 0.6 mm). The results of this in vitro mechanical study suggest that fresh-frozen single-loop TA and TP tendons, and BPTB allografts are an acceptable substitute for hamstrings in anterior cruciate ligament 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.     

Simultaneous rupture of the patellar tendon and the anterior cruciate ligament: a case report and literature review

We report a case of simultaneous rupture of the patellar tendon and the anterior cruciate ligament. This condition was rarely reported in the literature and clinical diagnosis can be difficult. It is frequently associated with injuries of other knee structures. The preferred treatment is immediate primary repair of the patellar tendon and delayed reconstruction of the anterior cruciate ligament.     

Eccentric training in chronic painful impingement syndrome of the shoulder: results of a pilot study

Treatment with painful eccentric muscle training has been demonstrated to give good clinical results in patients with chronic Achilles tendinosis. The pain mechanisms in chronic painful shoulder impingement syndrome have not been scientifically clarified, but the histological changes found in the supraspinatus tendon have similarities with the findings in Achilles tendinosis. In this pilot study, nine patients (five females and four males, mean age 54 years) with a long duration of shoulder pain (mean 41 months), diagnosed as having shoulder impingement syndrome and on the waiting list for surgical treatment (mean 13 months), were included. Patients with arthrosis in the acromio-clavicular joint or with large calcifications causing mechanical impingement during horizontal shoulder abduction were not included. We prospectively studied the effects of a specially designed painful eccentric training programme for the supraspintus and deltoideus muscles (3×15 reps, 2 times/day, 7 days/week, for 12 weeks). The patients evaluated the amount of shoulder pain during horizontal shoulder activity on a visual analogue scale (VAS), and satisfaction with treatment. Constant score was assessed. After 12 weeks of treatment, five patients were satisfied with treatment, their mean VAS had decreased (62–18, P<0.05), and their mean Constant score had increased (65–80, P<0.05). At 52-week follow-up, the same five patients were still satisfied (had withdrawn from the waiting list for surgery), and their mean VAS and Constant score were 31 and 81, respectively. Among the satisfied patients, two had a partial suprasinatus tendon rupture, and three had a Type 3 shaped acromion. In conclusion, the material in this study is small and the follow-up is short, but it seems that although there is a long duration of pain, together with bone and tendon abnormalities, painful eccentric supraspinatus and deltoideus training might be effective. The findings motivate further studies.     

Effectiveness of a supervised rehabilitation compared with a home-based rehabilitation following anterior cruciate ligament reconstruction: A systematic review and meta-analysis

ObjectiveThis systematic review aimed to compare the effectiveness of supervised rehabilitation with regard to knee function with that of home-based rehabilitation in patients undergoing anterior cruciate ligament reconstruction (ACLR).MethodsThe databases searched were: the Cochrane Central Register of Controlled Trials (Central), EMBASE, MEDLINE (via Ovid) and PEDro. All randomized controlled trials comparing supervised rehabilitation (SVR) with home-based rehabilitation (HBR) following ACLR were included. Two reviewers evaluated the study quality using the Cochrane Risk of Bias Assessment (RoB 2.0) tool. Estimates are presented as standardized mean differences (SMD) with 95% confidence intervals (CIs). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.ResultsA total of nine studies met the inclusion criteria, and five studies were included in the meta-analysis. The key outcomes analyzed were self-reported knee function and knee muscle strength. Across all comparisons, there was very low-quality evidence of no significant difference between the SVR and HBR groups at 24 weeks.ConclusionsThe limited evidence available does not suggest that SVR results in superior outcomes than HBR in patients with ACLR. Additional studies are needed to clarify whether patient characteristics and study protocols with longer interventions effect the results.     

Osteochondroma leading to proximal tibiofibular synostosis as a cause of persistent ankle pain and lateral knee pain: a case report

This paper presents a case report of persistent ankle pain and lateral knee pain due to existing proximal tibiofibular synostosis.     

Embolism of the popliteal artery after anterior cruciate ligament reconstruction: a case report and literature review

Arterial complications after anterior cruciate ligament reconstruction (ACLR) are rare. We present a case report of a 44-year-old male patient with a subtotal occlusion of the popliteal artery, with sensory loss in the foot, 17 days after ACLR. Embolectomy and anticoagulant therapy led to full recovery of the peripheral arterial circulation. The sensory loss of the foot also fully recovered. To our knowledge, this is the first case report of an embolus of the popliteal artery after ACLR without relation to graft fixation. A literature review on vascular complications after ACLR is presented.     

Accessory soleus in the athletes: literature review and case report of a massive muscle in a soccer player

Accessory soleus is a rare congenital anatomical variant, which may manifest in the second/third decade of life as an exertional ankle pain and swelling or as an asymptomatic postero-medial mass. The incidence of this condition ranges from 0.7 to 5.5%. Many treatment options have been described in literature, including conservative treatment, excision, fasciotomy, release and closure of blood supply. We report a symptomatic massive accessory soleus (17 × 5 × 4 cm) in an 18-year-old male semi-professional soccer player. Excision of the accessory soleus was performed. The patient went back to the game 3 months after surgery. The literature review stated that either fasciotomy or excision of the muscle produce good results in the athletes.     

Healing results of meniscal tears left in situ during anterior cruciate ligament reconstruction: a review of clinical studies

The presence of peripheral meniscal tears is common at the time of anterior cruciate ligament (ACL) reconstruction. Techniques to preserve the maximum amount of meniscal tissue include “non operative” management (tear left alone, without repair or removal), meniscus repair, partial meniscectomy. There is a lack of consensus guidelines about the management of peripheral stable meniscal tears. When to remove, let alone or repair? We performed an evidence-based review of the outcomes of stable meniscal tears left in situ during ACL surgery, in order to assess the effectiveness of this popular procedure. Clinical and anatomical results (arthrography or second look arthroscopy) were analyzed. Our literature search yielded ten relevant studies (9 level IV, 1 level III). The mean time of follow-up was 16 months. Pain or mechanical symptoms related to the medial tibiofemoral joint were reported in 0–66% of cases. Subsequent medial meniscectomy or repair were performed in 0–33% of cases. Pain or mechanical symptoms related to the lateral tibiofemoral joint were reported in 0–18% cases. Subsequent lateral meniscectomy or repair were performed in 0–22% cases. A complete healing occurred in 50–61% cases for the medial meniscus and in 55–74% cases for the lateral meniscus. No definite conclusion can be made with regard to these results. The conservative approach is more effective for lateral menisci. The rate of bad results for the medial meniscus remains high when a conservative treatment is used. For the medial meniscus, repair of stable peripheral tears may be always indicated to decrease the risk of postoperative pain or subsequent meniscectomy.     

前交叉韧带损伤的MRI诊断与关节镜下所见的比较研究

目的：探讨MRI对前交叉韧带(ACL)损伤的诊断准确率极其对临床治疗的指导意义。方法：7l例关节镜手术患者术前行MRI检查，根据MRI诊断分为正常、部分损伤和断裂组，将MRI诊断结果与关节镜下所见进行对比。结果：以关节镜下所见为标准，MRI诊断准确率正常组为87．5％(7／8)，部分损伤组为61．9％(13／21)，断裂组为90．5％(38／42)。本组MRI诊断ACL损伤总诊断准确率为95．8％。ACL与胫骨平台夹角小于450和各序列扫描均未见ACL影像为诊断ACL完全断裂的可靠依据。结论：MRI是诊断ACL损伤的有效无创性检查方法，但部分损伤与完全断裂有时难以鉴别，ACL重建术前应常规行关节镜探查。     

Problems in regaining full extension of the knee after anterior cruciate ligament reconstruction: does arthrofibrosis exist?

A total of 194 patients was reviewed after ACL reconstruction using a patellar tendon graft or Leeds-Keio prosthesis supplemented with a MacIntosh lateral substitution. There were five groups of patients: patellar tendon with cast immobilisation in flexion (n=34); restricted extension but no cast (n=40); immediate full extension (n=40); immediate full extension with notch widening (n=40); Leeds-Keio ligament prosthesis (n=40). The incidence of a click or a block to extension requiring operation ranged from 59% following cast immobilisation to 2.5% with the Leeds-Keio ligament. The incidence was significantly less when a Leeds-Keio prosthesis was used, and these problems may be associated with biological materials only. Restricting extension after operation significantly increased the loss of extension, confirming the work of others. Loss of extension was due to a mechanical block in all cases examined arthroscopically. All were relieved by arthroscopic surgery, and no case of flexion contracture or arthrofibrosis was encountered. A simple mechanical block to extension caused by a Cyclops lesion should be clearly distinguished from flexion contracture and arthrofibrosis, conditions which are probably extremely rare and overdiagnosed.     

The effect of graft placement on the clinical outcome of the anterior cruciate ligament reconstruction: a prospective study

The effect of the graft placement on the clinical outcome of patients after anterior cruciate ligament (ACL) reconstruction has been studied sparsely. We conducted a prospective follow-up of 140 patients who underwent an arthroscopic ACL reconstruction with a hamstring graft. One hundred and four of them (74%) could be examined at the 2-year follow-up. Clinical examination included Lysholm, Tegner, and International Knee Documentation Committee rating scores, arthrometric anterior–posterior knee laxity assessment, and muscle strength assessments. The graft placement was measured from lateral radiographs using a system recommended for measuring the attachment positions of the cruciate ligaments as well as a method called ‘the sumscore of the graft placement’, which takes into account both the femoral and the tibial graft placements simultaneously. The sumscore was smaller in knees with normal anterior–posterior knee laxity in the Lachman test (P = 0.002) and normal rotational knee laxity in the pivot shift test (P = 0.01) than in those with abnormal laxity. The tibial graft placement was more anterior when the Lachman test was normal (P = 0.04). The Lysholm score was better when the femoral graft placement was more posterior (r = −0.20, P = 0.04). The optimal femoral graft placement was between 25 and 29% of length of the femoral condyle along the Blumensaat’s line from posterior to anterior. The optimal tibial graft placement was between 32 and 37% of the length of the tibial plateau from the anterior corner, and the optimal sumscore was between 61 and 66. The sumscore and its components (the femoral and tibial graft placements) showed a clear association with the clinical outcome of the patients. The best outcome was achieved when the sumscore was small; that is the graft placement showed posterior enough in the femur, and anterior enough in the tibia.     

Cyclops syndrome occurring after chronic partial rupture of the anterior cruciate ligament without surgical reconstruction

Cyclops syndrome is one of the specific causes of loss of extension of the knee following anterior cruciate ligament (ACL) reconstruction. This syndrome is manifest by progressive loss of knee extension associated with pain and audible clunk at terminal extension caused by a pedunculated nodule of fibrovascular proliferative tissue usually arising from a graft. Recent published reports, however, have described Cyclops syndrome also developing after a partial ACL rapture without surgical reconstruction. In most cases, Cyclops syndrome generally occurred within 2 months after reconstruction surgery or rupture. Here we report on the case of a patient with symptoms and arthroscopic and histological findings compatible with Cyclops syndrome that developed after a chronic partial ACL rupture that occurred 23 years ago. To our knowledge, this is the first case report of Cyclops syndrome occurring after chronic partial ACL rupture.