Anterior Crucial Ligament Reconstruction Research Articles

Repair of bucket handle meniscus tears improves patient outcomes versus partial meniscectomy at the time of ACL reconstruction.

The aim of this study was to examine demographic and surgical factors that influence patient-reported knee function in patients who undergo anterior crucial ligament reconstruction (ACLR) with concurrent bucket-handle meniscal tear (BHMT) procedures. We hypothesized that repair of BHMT in the setting of concomitant ACLR and shorter time from injury to surgery would lead to improved patient-reported outcomes. Forty-one patients (mean age: 28.0 ± 9.8 years, 72% male) with BHMT at the time of ACLR completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) via online survey at an average of 15.2 months postop. Patient demographics and surgical characteristics, including time from injury to surgery, were compared between repair (n = 22) and meniscectomy (n = 19) groups using one-way analysis of variances; distributions of sex, graft source, BHMT compartment and zone were compared between groups using χ 2 tests. The association between IKDC-SKF score, demographics and surgical characteristics was evaluated using multivariable linear regression. A priori alpha level was p < 0.05. Meniscal repair and meniscectomy groups differed based on graft source and BHMT zone but not IKDC-SKF score (p = 0.085). Patients undergoing ACLR with autograft (p = 0.003) and with red-red zone BHMT (p < 0.001) more often underwent meniscal repair. The regression model demonstrated longer time from injury to surgery (p = 0.049), red-red tear zone (p = 0.04) and meniscectomy (p = 0.008); these were predictive of poorer IKDC-SKF scores. BHMT repair was more likely performed in ACL autograft and on red-red zone tears. Longer time from injury to surgery is an indicator of poorer IKDC-SKF score, as this may increase the risk of concomitant pathologies. White-white zone BHMTs are associated with better IKDC-SKF scores than red-red zone BHMTs, which may be due to the smaller volume of tissue removed during meniscectomy of white-white zone tears and the avoidance of iatrogenic complications of meniscal repair. Level III, therapeutic study.

Seven percent of primary anterior crucial ligament reconstruction patients have arthroscopic resection of cyclops lesions within 2 years: A cohort study of 2556 patients.

After anterior cruciate ligament reconstruction (ACL-R), a localised scar tissue called cyclops lesion may develop anterior to the graft causing knee extension deficits, pain, oedema, clicking and reduced knee function. This study determined the incidence of arthroscopic resection of a cyclops lesion within 2 years after ACL-R and investigated the associations of patient characteristics and surgical techniques with the need for arthroscopic resection of a cyclops lesion. This study included patients who underwent primary ACL-R with adult surgical technique from 2005 to 2019 at Aarhus University Hospital, Denmark. The cohort was identified in a national registry. To identify patients who had resected a cyclops lesion within the first 2 years after ACL-R, patients' surgical records were reviewed. In 2005-2019, 2556 patients underwent primary ACL-R; 176 developed cyclops lesions that were resected within 2 years, equivalent to an incidence of 6.9% (95% confidence interval [CI]: 5.9-7.9). When stratified by the femoral drilling technique used, this incidence was 8.9% (95% CI: 7.7-10.3) with the anteromedial technique and 1.9% (95% CI: 1.0-3.1) with the transtibial technique. The incidence was 8.5% (95% CI: 6.8-10.3) in women and 5.7% (95% CI: 4.6-7.1) in men. Age, graft choice and the presence of cartilage or meniscal lesions did not affect the incidence. The overall incidence of a cyclops lesion removal within 2 years post-ACL-R was 6.9%. This was five times higher with the anteromedial femoral drilling technique than with the transtibial technique. Women had a 47% higher incidence of cyclops lesion removal than men. This is relevant for the surgeon when planning an ACL-R. Level II.

Development and validation of a clinical prediction model for return to work after arthroscopic anterior crucial ligament reconstruction

BackgroundOccupational reintegration after anterior cruciate ligament (ACL) rupture is an important clinical issue including economic and health-related perspectives. This study aims to develop and validate a clinical prediction model of return to work in patients with ACL reconstruction surgery considering evidence-based clinical, anthropometric and occupational factors. MethodsData of 562 patients with an ACL rupture receiving an arthroscopic ACL reconstruction were used for analysis. A model for the binary outcome of experiencing an inability to work period of less or more than 14 days (model 1), and a model for finding predictor variables that are linearly associated with a continuous longer inability to work period of over 14 days (model 2) was calculated. Pre-operative determinants including patient characteristics and peri-operative factors were used as predictors for both models. ResultsFor model 1, the highest increase in odds was observed for the occupational type of work, followed by injury of the medial collateral ligament together with partial weight bearing. Small protective effects were observed for female sex, meniscal suture and work with light occupational strain. The type of occupational work, together with revision surgery, a longer duration of limited range of motion and the presence of cartilage therapy were risk factors for longer inability to work. Discrimination and calibration statistics were satisfactory in internal validation. ConclusionWithin the framework of clinical consideration, these prediction models will serve as an estimator for patients, their treating physicians and the socioeconomic partners to forecast the individual cost and benefit of ACL injury.

Interlimb differences in T1ρ MRI relaxation times linked with symptomatic knee osteoarthritis following anterior cruciate ligament reconstruction

BackgroundLower proteoglycan density, as estimated by greater T1ρ magnetic resonance imaging (MRI) relaxation times, may be an indicator of early osteoarthritis development. We examined associations between femoral cartilage inter-limb T1ρ MRI relaxation time ratios and clinically relevant knee symptoms at 12 months following anterior crucial ligament reconstruction (ACLR). MethodsTwenty-nine individuals completed the Knee Osteoarthritis Outcome Score (KOOS) and underwent MRI 12 months following ACLR for this cross-sectional study. Participants were categorized as symptomatic or asymptomatic for clinically relevant knee symptoms consistent with osteoarthritis based on a standard KOOS classification. T1ρ MRI relaxation times were segmented in the weightbearing regions of lateral and medial femoral condyle (LFC and MFC). Inter-limb T1ρ MRI relaxation time ratios were calculated by normalizing the ACLR to the uninjured knee. T-tests were used to compare LFC and MFC interlimb T1ρ relaxation time ratios between individuals with and without knee symptoms. A Receiver Operating Characteristic (ROC) Curve analysis was used to determine a critical inter-limb T1ρ relaxation time ratio identifying symptomatic patients. Odds ratios (OR) and 95% confidence intervals (CI) estimated the association between the critical value and clinically relevant knee symptoms. ResultsSymptomatic individuals had significantly higher LFC inter-limb T1ρ MRI relaxation time ratios compared to asymptomatic individuals (p = 0.04). Individuals with an LFC inter-limb T1ρ MRI relaxation time ratio >1.11 were more likely to have symptoms (OR 8.5; 95%CI = 1.25–57.93). ConclusionIndividuals with greater inter-limb LFC T1ρ MRI relaxation time ratios 12 months post-ACLR may be more likely to exhibit symptoms consistent with knee OA.

The Multivariate Relationship Between Primary Anterior Cruciate Ligament Reconstruction Timing and Revision Rates: A 10-Year Analysis.

Background and objectiveThe optimal timing of anterior crucial ligament reconstruction (ACLR) remains a matter of controversy. A revision procedure is performed to improve knee function, correct instability, and enable a safe return to daily function when primary ACLR fails. The present study aimed to determine if the timing of primary ACLR is predictive of revision surgery.MethodsAll patients who underwent primary ACLR at the West Virginia University from January 2008 to December 2018 were identified. Patients were initially grouped into early (≤30 days) and late (>30 days) ACLR based on the onset of the initial injury. The major outcome measure of this study was the incidence of revision ACLR following primary ACLR.ResultsA total of 233 primary ACLRs were included. The incidence of ACLR revisions was 9.4%. The timing of primary ACLR, when categorized into early and late ACLRs, was not found to influence revision risk (p=0.384). Additionally, the damaged anatomical structures based on the postoperative diagnosis at the time of ACLR did not influence the odds of revision ACLR (p=0.9721).ConclusionOur study found that the timing of primary ACLR did not influence the revision rates when categorizing primary surgery time into early and late subgroups.

Arthroscopic reconstruction of anterior cruciate ligament: 4-strand versus 5-strand hamstring autograft

INTRODUCTION: In present study, we aimed to compare the functional outcome after 4-strand versus 5-strand hamstring autograft for anterior crucial ligament reconstruction using Tegner Lysholm score. MATERIALS AND METHODS: Study included 70 cases (35 in each group) of complete anterior cruciate ligament tear confirmed radiologically on MRI. After doing anterior cruciate ligament reconstruction with 4- and 5-strand hamstrings autograft, the patients were assessed for the functional outcome using Tegner Lysholm score at post-operative interval of 3, 6 and 9 months. Data were analyzed using SPSS software version 21. RESULTS: Tegner Lysholm score at baseline was 41.63 and 42.01 in 4- and 5-strand group which increased progressively to 93.45 and 85.13 at the end of 9 months. The improvement was significantly more in 5-strand group (P < 0.05). Overall, at the end of follow-up, excellent results were seen in 71.4% versus 60% patients while good to fair results were seen in 20% versus 28.6% and 8.6% versus 8.6% patients in 4- and 5-strand groups, respectively. Poor outcome in terms of revision surgery was required in one case (2.9%) of 4-strand group. CONCLUSION: Study concluded that single 5-strand graft offers good functional outcome in cases of anterior crucial ligament reconstruction. A 5-strand hamstring graft provides an increase in diameter than 4-strand graft, which leads to stronger graft and reduced revision rate. It is especially useful in the cases of undersized hamstring graft or stability issues.

No Differences In Clinical Outcomes Between Rectangular and Round Tunnel Techniques For Anterior Crucial Ligament Reconstruction

To compare the clinical outcomes between conventional round tunnel and rectangular tunnel in anatomic anterior cruciate ligament (ACL) reconstruction. This was a retrospective comparative cohort study between March 2015 and September 2018. The primary ACL reconstructions using anteromedial portal technique with minimum of 2 years follow-up were enrolled for this study. The exclusion criteria were patients with revision ACL reconstruction, high tibial osteotomy, multiligament injuries, and associated fractures around the knee. Outcome measures included the subjective International Knee Documentation Committee score, Tegner activity score, knee laxity testing, and measurement of the centers of the femoral and tibial tunnels on postoperative computed tomography (CT) images. Forty-seven patients with ACL reconstruction with rectangular tunnel (group 1) and 108 patients with ACL reconstructions with conventional rounded tunnel (group 2) were included consecutively. There were no significant differences between groups in terms of clinical scores or knee laxity, as well as femoral and tibial tunnel positions on CT. One patient in group 2 had ACL failure because of trauma and was treated with revision surgery. Two patients had incomplete tibial fracture, but they healed spontaneously and showed no residual laxity at final follow-up. The intraobserver and interobserver reliability for the radiological measurements ranged from 0.78 to 0.86. There were no differences in radiological and clinical results between rectangular tunnel group and conventional round tunnel group for arthroscopic ACL reconstruction. ACL reconstruction with a rectangular tunnel could be considered as a reliable technique, but care should be taken during tunnel establishment because of risk of fractures and malposition of rectangular tunnel.

Effects on Quadriceps Muscle Strength Using EMG in Supervised vs Unsupervised Post-Operative Anterior Crucial Ligament Reconstruction

Anterior crucial ligament (ACL) injury is one of the most common ligament injuries in the knee. TheACL injury is the anterior ligament tear or sprain (ACL). The objective of this paper is to compare theeffectiveness, recovery rate and the variance in the affected and non-affected limbs muscle strength/activation potential readings of both knees in supervised v/s unsupervised groups of patients afterundergone ACL reconstruction surgery at RML Hospital Delhi. The participants were divided into twogroups (A-Supervised, and B-Unsupervised) through random sampling. The supervised exercise in groupa performed according to the WILK protocol at RML hospital, and un-supervised group B performed thesame WILK protocol at home. The method adopted for this study is to compare both Pre-operative andPost-Operative quadriceps(vastus medialis and vastus latralis) EMG readings of the respondents has beenrecorded using NEURON SPECTRUM 5 using NEUROSOFT Neuro-MEP.NET software at RML HospitalDelhi. The study findings indicated the significant difference in recovery rate as well as the difference inbetween supervised v/s unsupervised groups i.e. The average pre-operative-VM values of EMG- affectedfor supervised was 97.1?V, and for unsupervised was 94.2?V and the average post-operative-VM values ofEMG for supervised was 130.1?V (36% variance), and for unsupervised was 95.2 ?V (1% variance). Theaverage pre-operative-VM values of EMG- normal for supervised was 135.8 ?V, and for unsupervised was139 ?V and the average post-operative-VM values of EMG for supervised was 135.1 ?V (-7% variance),and for unsupervised was 135.7 ?V (-6% variance).

What Are the Primary Cost Drivers of Anterior Cruciate Ligament Reconstruction in the United States? A Cost-Minimization Analysis of 14,713 Patients

To analyze the individual costs associated with anterior crucial ligament reconstruction (ACLR), accounting for patient demographics, perioperative decision making, and location of the surgical procedure (hospital vs ambulatory surgery center), utilizing a cost-minimization analysis in a large national database. Univariate analysis and multiple linear regression were performed to determine which patient and surgical variables were the largest cost drivers for ACLR in the United States according to the State Ambulatory Surgery and Services Database. The average cost for ACLR (n= 14,713) was $24,707 (standard deviation, $15,644). When patient variables were considered, younger age (P < .001), male sex (P < .001), Hispanic ethnicity (P < .001), number of chronic medical conditions (P < .001), Medicare insurance (P < .001), and quartile of household income (P < .001) were all associated with higher costs after ACLR. For operative variables, time spent in the operating room (P < .001), meniscal repair (P < .001), and use of general anesthesia alone (P < .001) were all associated with higher costs for ACLR. There was no significant difference between cost of surgery performed at a private surgery center and cost at a hospital-owned center. In the multivariate regression, the 3 variables with the greatest influence on cost of ACLR were use of isolated general anesthesia (associated with an increase of $2,049), Hispanic ethnicity ($1,828), and >1 chronic medical condition ($1,749). Male sex, time in operating room, and older age also significantly increased ACLR cost. The greatest contributor to cost of ACLR was the use of general anesthesia alone. Time spent in the operating room increased ACLR cost by $108 per minute. Patient factors included greater age, male sex, Hispanic ethnicity, number of chronic medical conditions, Medicare insurance, and annual income. Meniscal repair and regional nerve block did not significantly affect cost as determined by multivariate regression.

Biomimetic tendon extracellular matrix composite gradient scaffold enhances ligament-to-bone junction reconstruction.

The native transitional region consists of several distinct yet contiguous tissue regions, composed of soft tissue, non-calcified fibrocartilage, calcified fibrocartilage, and bone. A stratified graft whose phases are interconnected with each other is essential for supporting the formation of functionally continuous multi-tissue regions. Various techniques have been attempted to improve adherence of the ligament/tendon graft to bone, including utilization of stem cells, growth factors and biomaterials, but these methods are often inadequate at recapitulating the complex structure-function relationships at native tissue interfaces. Here, we developed an easily-fabricated and effective biomimetic composite to promote the regeneration of ligament-bone junction by physically modifying the tendon extracellular matrix (ECM) into a Random-Aligned-Random composite using ultrasound treatment. The modified ECM enhanced expression of chondrogenesis and osteogenesis-associated epigenetic genes expression in vitro. In the rabbit anterior crucial ligament reconstruction model in vivo, results showed that the modified Random-Aligned-Random composite enhances the bone and fibrocartilage formation in the interface, proving to be more efficient than the unmodified tendon ECM. Therefore, these results demonstrated that the biomimetic Random-Aligned-Random composite could be a promising scaffold for ligament/tendon-bone junction repair.

Сучасний погляд на проблему застосування засобів фізичної реабілітації при артроскопічних оперативних втручаннях у хворих із ушкодженням передньої схрещеної зв’язки

Мета: систематизувати та узагальнити науково-методичні знання і результати практичного досвіду фізичної реабілітації хворих після реконструкції передньої схрещеної зв’язки при артроскопічних оперативних втручаннях. Методи: теоретичний комплексний аналіз і синтез даних науково-методичної літератури та джерел мережі Інтернет. Результати. Проаналізовано методи лікування декомпенсованої передньої нестабільності колінного суглоба, спричиненої розривом передньої схрещеної зв’язки. Весь післяопераційний реабілітаційний період перебігає на тлі етапних процесів інкорпорації трансплантату в кісткових тунелях. Саме стадійність відновлення трансплантату є основою для виділення різних періодів реабілітації. Розглянуто сучасні підходи до застосування засобів фізичної реабілітації при артроскопічних оперативних втручаннях у хворих з ушкодженням передньої схрещеної зв’язки. Висновки. Лікування таких хворих необхідно проводити з обов’язковим урахуванням анатомо-функціональних особливостей, використовувати методи раннього і повноцінного відновлення пошкоджених структур суглоба, прагнути до підбору відновлювальних операцій, що не вимагають іммобілізації суглоба. Крім цього, адекватні відновні комплекси, що враховують тип фіксації трансплантату, функціональні особливості ураженої кінцівки й інші чинники, у тому числі ступінь порушення функції колінного суглоба, розроблено далеко не для всіх випадків ушкоджень та їх наслідків. На сьогодні актуальною є розробка програм фізичної реабілітації, що враховують тип фіксації використаного трансплантату при артроскопічних оперативних втручаннях.

Bracing can partially limit tibial rotation during stressful activities after anterior crucial ligament reconstruction with a hamstring graft

BackgroundHamstring graft has substantial differences with BPTB graft regarding initial mechanical strength, healing sequence, and vascularization, which may imply that a different approach during rehabilitation period is required. The purpose of this study was to investigate the influence of knee bracing on tibial rotation in ACL-reconstructed patients with a hamstring autograft during high loading activities. The hypothesis was that there would be a decrease in tibial rotation in the ACL-reconstructed braced knee as compared to the unbraced knee. MethodsTwenty male patients having undergone unilateral ACL reconstruction with a semitendinosus/gracilis autograft were assessed. Kinematic data were collected with an eight-camera optoelectronic system during two stressful tasks: (1) descending from a stair and subsequent pivoting; and (2) landing from a platform and subsequent pivoting. In each patient, three different experimental conditions were evaluated: (A) wearing a prophylactic brace (braced condition); (B) wearing a patellofemoral brace (sleeved condition); (C) without brace (unbraced condition). The intact knee without brace served as a control. ResultsTibial rotation was significantly lower in the intact knee compared to all three conditions of the ACL-reconstructed knee (P≤0.01 for both tasks). Presence of a brace or sleeve resulted in lower tibial rotation than in the unbraced condition (p=0.003 for descending/pivot and P=0.0004 for landing/pivot). The braced condition resulted in lower rotation than the sleeved condition for descending/pivoting (P=0.031) while no differences were found for landing/pivoting (P=0.230). ConclusionKnee bracing limited the excessive tibial rotation during pivoting under high loading activities in ACL-reconstructed knees with a hamstring graft. This partial restoration of normal kinematics may have a potential beneficial effect in patients recovering from ACL reconstruction with a hamstring autograft. Level of evidenceLevel III, case-control therapeutic study.

The effect of magnesium added to levobupivacaine for femoral nerve block on postoperative analgesia in patients undergoing ACL reconstruction

The aim of this prospective randomised double-blind study is to investigate the effect of magnesium added to local anaesthetics on postoperative VAS scores, total opioid consumption, time to first mobilisation, patient satisfaction and rescue analgesic requirements in arthroscopic ACL reconstruction surgery. A total of 107 American Society of Anaesthesiologists physical status grade I and II patients between 18 and 65 years of age who were scheduled to undergo elective anterior crucial ligament (ACL) reconstruction with hamstring autografts were enrolled in the study. The patients were randomly allocated to Groups L (n = 51) and LM (n = 56) using the closed-envelope method. Group LM was administered 19 ml of 0.25% levobupivacaine and 1 ml of 15% magnesium sulphate, while Group L was administered 20 ml of 0.25% levobupivacaine for femoral blockade. General anaesthesia was administered using laryngeal airway masks following neural blockade in both groups. The patients were evaluated for heart rate and mean arterial pressure, oxygen saturation, visual analogue score (VAS), verbal rating scale (VRS), rescue analgesic requirements, total opioid consumption, side effects and time to first mobilisation at the 1st, 2nd, 4th, 6th, 12th and 24th hours postoperatively. There was no statistically significant difference in terms of demographic data, mean arterial pressure, heart rate or oxygen saturation between groups. The area under the curve VAS and VRS scores were lower at 4, 6, 12 and 24 h in Group LM (p = 0.001, p = 0.016, respectively). The rescue analgesic requirement and the total opioid consumption were significantly lower in Group LM (p = 0.015, p = 0.019, respectively). The time to first mobilisation and the Likert score (completely comfortable; quite comfortable; slight discomfort; painful; very painful) were higher, and the block onset time was lower in Group LM (p = 0.014 and p = 0.012, respectively). There was no difference in terms of side effects. The addition of magnesium to levobupivacaine prolongs the sensory and motor block duration without increasing side effects, enhances the quality of postoperative analgesia and increases patient satisfaction; however, the addition of magnesium delays the time to first mobilisation and decreases rescue analgesic requirements.

Femoral nerve block with ropivacaine or bupivacaine in day case anterior crucial ligament reconstruction

Our aim was to evaluate analgesia, motor block and pharmacokinetics of ropivacaine 0.2% and 0.75% in a femoral nerve block (FNB) in day case patients for anterior crucial ligament (ACL)-reconstruction compared with bupivacaine 0.25% and placebo. Following ethics committee approval and informed consent, 280 patients were randomly allocated to four groups for single-shot FNB [30 ml ropivacaine 0.2% (group RO2.0), 0.75% (RO7.5), bupivacaine 0.25% (BU2.5) and NaCl 0.9% (NaCl)]. Analgesia (pain scores, primary outcome) and motor block were assessed at 4 h (dismissal) and up to 24 h. Plasma concentration was determined up to 240 min thereafter. Pain scores at 4 h were significantly higher for NaCl 4 (0-8) (median, range) (vs.) BU2.5 2 (0-8), RO2.0 3 (0-9) and RO7.5 2 (0-8) (NS within the LA groups). Patients of the NaCl group needed analgesics significantly more often (93%) within 4 h after surgery vs. 16% of group RO2.0, 19% of group RO7.5 and 19% of group BU2.5. Motor block was significantly increased with all local anesthetics without a significant difference within the LA groups 3 (0-5) in RO2.0, 3 (0-5) in RO7.5 and 3 (0-4) in BU2.5 vs. 0 (0-3) in group NaCl (median (range); scale from 0=full strength to 5=complete paralysis). Peak plasma concentrations differed significantly: RO7.5: 1.4 +/- 0.4 (0.73-2.6) [microg/ml, mean +/- SD (range)] after 33 +/- 14 (10-40) min, RO2.0: 0.6 +/- 0.3 (0.13-1.0) after 22+17 (10-60) and BU2.5: 0.3 +/- 0.16 (0.05-0.62) at 31 +/- 17 (10-60), respectively. FNB for ACL reconstruction with ropivacaine or bupivacaine provided better post-operative analgesia than placebo without reaching toxic plasma concentrations. Significant motor block was observed after 4 h in all groups including the lowest concentration of ropivacaine but occurred even with placebo.

Effects of 60Co gamma radiation dose on initial structural biomechanical properties of ovine bone—patellar tendon—bone allografts

Gamma radiation is established as a procedure for inactivating bacteria, fungal spores and viruses. Sterilization of soft tissue allografts with high dose (60)Co gamma radiation has been shown to have adverse effects on allograft biomechanical properties. In the current study, bone-patellar tendon-bone (BPTB) allografts from 32 mature sheep were divided into two treatment groups: low-dose radiation at 15kGy (n=16) and high-dose radiation at 25kGy (n=16) with the contralateral limb serving as a 0kGy (n=32) non-irradiated control. Half of the tendons from all treatment groups were biomechanically tested to determine bulk BPTB mechanical properties, cancellous bone compressive properties, and interference screw pull-out strength. The remaining tissues were prepared, implanted, and mechanically tested in an acute in vitro anterior crucial ligament (ACL) reconstruction. Low-dose radiation did not adversely affect mechanical properties of the tendon allograft, bone, or ACL reconstruction compared to internal non-irradiated control. However, high-dose radiation compromised bulk tendon load at failure and ultimate strength by 26.9 and 28.9%, respectively (P<0.05), but demonstrated no negative effect on the cancellous bone compressive properties or interference screw pull-out strength. Our findings suggest that low dose radiation (15kGy) does not compromise the mechanical integrity of the allograft tissue, yet high dose radiation (25kGy) significantly alters the biomechanical integrity of the soft tissue constituent.