Anterior Cruciate Ligament Patients Research Articles

Femoral Tunnel Placement During Anterior Cruciate Ligament Reconstruction

Background Recent studies have questioned the ability of the transtibial technique to place the anterior cruciate ligament graft within the footprint of the anterior cruciate ligament on the femur. There are limited data directly comparing the abilities of transtibial and tibial tunnel—independent techniques to place the graft anatomically at the femoral attachment site of the anterior cruciate ligament in patients. Hypothesis Because placement with the tibial tunnel–independent technique is unconstrained by the tibial tunnel, it would allow for more anatomic tunnel placement compared with the transtibial technique. Study Design Cross-sectional study; Level of evidence, 3. Methods High-resolution, multiplanar magnetic resonance imaging and advanced 3-dimensional modeling techniques were used to measure in vivo femoral tunnel placement in 8 patients with the transtibial technique and 8 patients with a tibial tunnel–independent technique. Femoral tunnel placement in 3 dimensions was measured relative to the center of the native anterior cruciate ligament attachment on the intact contralateral knee. Results The tibial tunnel–independent technique placed the graft closer to the center of the native anterior cruciate ligament attachment compared with the transtibial technique. The transtibial technique placed the tunnel center an average of 9 mm from the center of the anterior cruciate ligament attachment, compared with 3 mm for the tibial tunnel–independent technique. The transtibial technique resulted in a more anterior and superior placement of the tunnel compared with the tibial tunnel– independent technique. Conclusion The tibial tunnel–independent technique allowed for more anatomic femoral tunnel placement compared with the transtibial technique.

Patellar chondropathy prevalence at anterior cruciate ligament reconstruction: Analysis of 250 cases

Anterior knee instability caused by anterior cruciate ligament (ACL) deficiency results in meniscal as well as chondral femorotibial and/or femoropatellar damages over a more or less long duration delay. This study's objectives were, in chronically deficient ACL patients, to assess onset delay for developing chondral patella lesions and also analyse these lesions characteristics in relation to laxity duration. Chondral patellar lesions in ACL deficient knees get worse with time. We reviewed 250 charts of patients who had undergone arthroscopically assisted surgery for knee anterior laxity. The arthroscopic procedures were conducted between January 1995 and January 2005. Chondral damages were evaluated at surgery according both to International Cartilage Repair Society (ICRS) and Bauer and Jackson classifications. The data were analyzed using the Kruskal-Wallis test and the Fisher exact test. Of the 250 analysed charts, 72 patients (28.8%) were found to present chondral patella lesions. The majority of these lesions were superficial and involved the lateral facet area. We observed a statistically significant ICRS worsening grade in relation to laxity duration. Few publications in the literature report patellar involvement in anterior laxity of the knee. However, our results are comparable to those of the rare series found. The pathomechanics of these lesions has not yet been precisely identified and requires further biomechanical studies. Patellar damage is frequent with anterior laxity (28.8% in our series) and duration is correlated with statistically significant aggravation of these lesions. Currently, the assessment of these patellar lesions is considered less important than meniscal and femorotibial lesions, even though the natural history of ACL disruption seems to be evolving toward degeneration of all the compartments of the knee, including the femoropatellar compartment.

Reply to Chmielewski and Snyder-Mackler

##### REPLY: In the letter of Chmielewski and Snyder-Mackler, the authors pointed out that the clinical classification scheme used in their studies is not comparable to ours to separate anterior cruciate ligament (ACL) patients without “giving-way symptoms” (copers) from ACL patients with

Changes In Brain Activity Patterns During A Sensorimotor Task Due To Acl-reconstruction

PURPOSE: Due to a reconstruction of the anterior cruciate ligament (ACL) afferent proprioceptive information from the knee joint may be altered. Researchers speculate about consequences at the cortical level. In order to examine changes in central activation patterns spectral features of the EEG were measured during a sensorimotor task in ACL patients and controls. METHODS: Ten patients 12,9±4,9 months after ACL-reconstruction (26±5 years; 76,27±13,10 kg; 181±10 cm) and 12 healthy controls (24±3 years; 75,53±9,70 kg; 181±8 cm) participated in the study. The sensorimotor task consist in an active reproduction of a target angle without visual feedback in a 2 (groups) x 2 (extremities) x 4 (trials each for 3 min) design. Before each trial the participants performed the task five times with visual feedback. During the task cortical activity were recorded at 17 electrode positions using international EEG standards (10:20 System). The data were Fast Fourier transformed to determine power at Theta (4,75–6,75 Hz), Alpha-1 (7,0–9,5 Hz), Alpha-2 (9,75–12,5 Hz)andBeta-1 (12,75–18,5 Hz). RESULTS: The behavioural data show significant higher aberrations from the target angle in the ACL reconstructed limbs (p<05) compared to the controls whereas there are no differences between the uninvolved limbs and controls. The brain activity results in significant higher frontal Theta power (F3: p<05, F4: p<01, F8:p<01) in both extremities of the ACL-group versus the controls. The Alpha-2 spectral power shows significant differences between the ACL reconstructed limb and the control group at parietal positions (P3: p<05, P4: p<05). No such differences where found between the uninvolved side and the control group. CONCLUSIONS: This finding provides neurophysiological evidence for the formation of a neurocognitive strategy during a reproduction performance after ACL reconstruction. The results of these findings are discussed in terms of differences in focussed attention with involvement of the anterior cingulate cortex (frontal Theta) and sensory processing in the parietal somatosensory cortex (Alpha-2). Overall the results suggests that the EEG can be used to monitor changes after ACL reconstruction in patterns of brain activity during performance.

The effect of protein and carbohydrate supplementation on strength training outcome of rehabilitation in ACL patients

Patients with anterior cruciate ligament (ACL) injury experience atrophy and weakening of the extensor as well as the hamstrings muscles at the injured leg. Especially, the weakness of the quadriceps muscle has been ascribed to hamper daily physical tasks. The purpose of the present study was therefore to investigate if nutrient supplementation during 12 weeks of conservative rehabilitation strength training could enhance hypertrophy and strength of the quadriceps muscle in ACL-injured patients. Twenty-six ACL-injured men and women were included and randomly distributed into three supplementation groups: Protein+Carbohydrate (PC), Isocaloric-Carbohydrate (IC), or Placebo (PL), ingesting the supplementation immediately after each of 36 training sessions. Determined from images of thigh cross-sections (magnetic resonance imaging) the hypertrophy of the quadriceps muscle differed significantly between groups at the distal part, with the PC group demonstrating the largest hypertrophy. Peak torque of the quadriceps muscle at constant velocity 60 degrees.s-1 was significantly elevated in the PC group only, and the time to reach peak torque tended to decrease as well only in the PC group. The results from this study demonstrate that restoration of the distal vasti muscle mass and knee extension muscle strength with resistance training is promoted further by protein-containing nutrient supplementation immediately after single exercise sessions. Thus, exercise-related protein supplementation may seem important for surgery-related rehabilitation of skeletal muscle.

The anterior cruciate ligament deficiency as a model of brain plasticity

This paper describes a plausible mechanism for the development of brain plastic changes due to a peripheral joint injury, such as anterior cruciate ligament (ACL) rupture. Evidence for the hypothesis is based on mainly three indications derived from the literature review: (a) the existence of two different categories of ACL patients, the copers and non-copers, presenting different features of functional deficiencies, (b) the demand of a sufficient post-traumatic time (more than 6 months) for the dysfunction development and (c) the fact that the dysfunction is not limited to the injured limb but also concerns the non-injured one. Considering the fact that ACL contains mechanoreceptors, which inform the central nervous system (CNS) about joint sense position and kinaesthesia, it can be suggested that this kind of injury might be regarded as a neurophysiological dysfunction, not being a simple musculoskeletal injury. The rupture of the ACL could lead to the cessation/depletion or differentiation of the ascending afferent pathway from the injured joint towards CNS, inducing to the joint de-afferentation and consequently CNS reorganization and joint de-efferentation. In case of presumable evidence of the proposed hypothesis, its clinical application could concern several aspects of the intervention procedures. For example, a number of clinical findings, such as the functional differences presented between two separate clinical groups of patients (copers and non-copers) could be justified or the rehabilitation strategies might have to be revised, provided that certain therapeutic components have influence on facilitating brain plastic changes that induce to beneficial functional outcomes.

Histological Assessment of Degeneration of Anterior Cruciate Ligament in Arthritic Knee

Purpose: To assess the histological findings of anterior cruciate ligament (ACL)degeneration inanarthritic knee and its correlation with the gross appearance of the ACL, the patient s age and the functional status of the knee. Materials and Methods: Histological evaluations of the ACL were carried outon 80 patients who had total knee arthroplasty. Five types of ACL degeneration were noted; 1) mucoid degeneration, 2) liquefaction, 3) hyaline degeneration, 4) calcification, and 5)fissuring. A scoring system for the level of ACL degeneration was made. Each type of degeneration was scored and the degree of ACL degeneration was graded by summing each score. The correlation between ACL degeneration and patient's age, gross appearance, and functional evaluation of knee by Knee Society Score (KSS) was analyzed. The gross appearance of the ACL was classified as normal, (thinned or hypertrophied), and tear. Results: The scores for the histological degeneration of theACL ranged from 2 to 10,andthere was no correlation between the patient's ageand the scores (p>0.05). Thegross appearance of the ACL was normal in 19 cases, abnormal in 57, and tear in 4 with an average score of histological degeneration in 3.47 (2-6), 5.95 (3-10), and 9.0 (8-10) respectively. The score for the histological degeneration of the ACL was correlated with the gross appearance of the ACL and a functional evaluation by the K55 (p

Revision anterior cruciate ligament surgery

Anterior cruciate ligament (ACL) reconstruction surgery is one of the most frequently performed operative procedures in orthopaedic surgery. There are estimates that 100,000 new ACL injuries occur annually. Marked improvements have occurred in the last 15 years with regard to graft selection, tunnel placement, graft fixation, and rehabilitation that have resulted in predictable outcomes for ACL surgery using patellar tendon, hamstring, quadriceps tendon, autograft, and allograft tissues. Nevertheless, most studies report a clinical failure rate of between 10% and 15% at short- and intermediate-term follow-ups. 1 Bach Jr, B.R. Jones G.T. Sweet F.A. Hager C.A. Arthroscopy-assisted anterior cruciate ligament reconstruction using patellar tendon substitution. Two- to four-year follow-up results. Am J Sports Med. 1994; 22: 758-767 Crossref PubMed Scopus (176) Google Scholar , 2 Bach Jr, B.R. Levy M.E. Bojchuk J. Tradonsky S. Bush-Joseph C.A. Khan N.H. Single-incision endoscopic anterior cruciate ligament reconstruction using patellar tendon autograft. Minimum two-year follow-up evaluation. Am J Sports Med. 1998; 26: 30-40 PubMed Google Scholar , 3 Bach Jr, B.R. Tradonsky S. Bojchuk J. Levy M.E. Bush-Joseph C.A. Khan N.H. Arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft. Five- to nine-year follow-up evaluation. Am J Sports Med. 1998; 26: 20-29 PubMed Google Scholar Increasing numbers of ACL reconstruction failures are being seen. 4 Williams III, R.J. Warren R.F. Carson E.W. Wickiewicz T.L. Revision anterior cruciate ligament reconstruction The Hospital for Special Surgery experience. Tech Orthop. 1998; 13: 375-383 Crossref Scopus (7) Google Scholar , 5 Steadman J.R. Saterbak A.M. Revision anterior cruciate ligament reconstruction Techniques and tips—The Vail experience. Tech Orthop. 1998; 13: 384-390 Crossref Scopus (6) Google Scholar , 6 Clancy Jr, W.G. Pietropaoli M.P. Revision anterior cruciate ligament reconstruction using the “anatomic-endoscopic” method. Tech Orthop. 1998; 13: 391-410 Crossref Scopus (7) Google Scholar , 7 Bach Jr, B.R. Mazzocca A. Fox J.A. Revision anterior cruciate ligament surgery. in: Grana W.A. Orthopaedic knowledge online. American Academy of Orthopaedic Surgeons, Rosemont, IL2003 Google Scholar , 8 Brown Jr, C.H. Carson E.W. Revision anterior cruciate ligament surgery. Clin Sports Med. 1999; 18: 109-171 Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar , 9 Barber F.A. McGuire D.A. Johnson D.H. Should allografts be used for routine anterior cruciate ligament reconstructions?. Arthroscopy. 2003; 19: 421-425 Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar , 10 Noyes F.R. Barber-Westin S.D. Revision anterior cruciate ligament reconstruction Report of 11-year experience and results in 114 consecutive patients. Instr Course Lect. 2001; 50: 451-461 PubMed Google Scholar , 11 Uribe J.W. Hechtman K.S. Zvijac J.E. Tjin A.T.E.W. Revision anterior cruciate ligament surgery Experience from Miami. Clin Orthop. 1996; 325: 91-99 Crossref PubMed Scopus (134) Google Scholar The purpose of this article is to discuss the etiology of failure, approaches to the failed ACL patient, surgical technique issues, and results of revision ACL surgery. 7 Bach Jr, B.R. Mazzocca A. Fox J.A. Revision anterior cruciate ligament surgery. in: Grana W.A. Orthopaedic knowledge online. American Academy of Orthopaedic Surgeons, Rosemont, IL2003 Google Scholar

Changes in the Mechanoreceptors of the Anterior Cruciate Ligament of Patients with Degenerative Arthritis

Purpose: To clarify the morphologic and quantitative changes of mechanoreceptors of the human ACL with degenerative arthritis. Materials and Methods: Eleven fresh specimens of anterior cruciate ligament (ACL) were obtained from patients with degenerative arthritis during TKA. As a control, two fresh specimens were taken from healthy men at the time of a traumatic above knee amputation. The whole ligaments were serially frozen and sectioned at a thickness of 40 . After immunohistochemical staining, the mechanoreceptors were observed under a light microscope. The ratios of sections showing mechanoreceptors were calculated. Statistical analyses were performed using the chi-square test. Results: In the two control specimens, nineteen mechanoreceptors were found, evenly distributed at the femoral and tibial ends. However, the average number of mechanoreceptors was 1.4 (total 15) in the arthritic ligaments (p

A new generation of artificial ligaments in reconstruction of the anterior cruciate ligament

We have undertaken a randomized clinical trial comparing two methods of reconstruction of the anterior cruciate ligament in patients with chronic instability. We used an ipsilateral bone-patellar-tendon-bone autograft in 27 patients and the Ligament Advancement Reinforcement System (LARS) artificial ligament in 26. Assessment before and at two, six, 12 and 24 months after surgery, included the history, physical examination, a modified International Knee Documentation Committee (IKDC) score, the Tegner score, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and instrumented laxity testing. There were no cases of reactive synovitis or of infection of the knee, and there was no difference regarding the failure rate between the two groups. The IKDC showed no significant differences between the two groups at any stage of the follow-up. The KOOS evaluation showed consistently better results in all subscales for the LARS group during the first year of follow-up. After 24 months these differences were no longer evident. Instrument-tested laxity was greater in the LARS group at all stages of follow-up, but the differences were not significant at 24 months. Our findings suggest that at follow-up at 24 months the LARS ligament seems to be a satisfactory treatment option, especially when an early return to high levels of activity is demanded.

Anterior cruciate ligament reconstruction in patients with or without accompanying injuries: A re-examination of subjects 5 to 9 years after reconstruction

Purpose: The purpose of this study was to compare the clinical and radioloaic results of an anterior cruciate ligament (ACL) reconstruction in patients with an isolated ACL tear and patients with an ACL tear and accompanying injuries. Type of Study: A retrospective investigation. Methods: Seventy-two patients who did not have previous knee surgery or surgery of the contralateral knee were re-examined 5 to 9 years after the primary ACL reconstruction. The clinical assessment was made using the International Knee Documentation Committee (IKDC) evaluation system, and the Lysholm and the Marshall knee scores. Also, radiographic evaluation and isokinetic strength testing were performed. There were 34 patients (25 men and 9 women) with an isolated ACL tear (group A), and 38 patients (23 men and 15 women) with an ACL tear and accompanying injuries (group B). The mean age was 29 years (SD 9; range, 15 to 49 years) in group A, and 34 years (SD 12; range, 15 to 61 years) in group B. Bone-patellar tendon-bone autograft with mini-arthrotomy technique and screw fixation was used in all patients. Postoperative rehabilitation was also similar in both groups. In group B, 10 medial and 12 lateral (partial or subtotal) arthroscopic meniscectomies were performed at the same time as the ACL reconstruction. Also, 18 of the 19 medial collateral ligament ruptures, the 2 lateral collateral ligament ruptures, and the 1 posterior cruciate ligament rupture were treated surgically at this operation. Results: Subjectively (overall assessment, pain, swelling, and giving way of the knee) and objectively (range of motion, stability, crepitation, isokinetic strength testing, and radiological changes of the knee), the groups did not have any significant differences in the 5- to 9-year results. Also, the final evaluation results using the IKDC and the Lysholm and the Marshall knee scores were similar in both groups. However, there were significantly more subsequent knee surgeries in the injured knee in group B than in group A. Conclusions: Our results show no large differences between patients with an isolated ACL tear and those with an ACL tear with accompanying injuries 5 to 9 years after an ACL reconstruction with a bone-patellar tendon-bone autograft. Tibiofemoral osteoarthritis was quite rare, and this may be partly attributable to the fact that the ACL reconstructions were successful, so that all the knees were stable at the re-examination. However, the future will show the final outcome for the patients.

Anterior knee symptoms after four-strand hamstring tendon anterior cruciate ligament reconstruction

Proponents of hamstring anterior cruciate ligament (ACL) reconstruction suggest that anterior knee symptoms (AKS) may be less than following the use of bone-patella-bone autograft. Our aim was to assess the incidence of AKS in a cohort of patients who had undergone hamstring reconstructions. Forty-four of 50 consecutive patients who had undergone arthroscopically assisted four-strand gracilis/semitendinosus hamstring ACL reconstructions were reviewed at a minimum follow-up of 24 months. The frequency and severity of anterior knee pain experienced during activities of daily living, sports, prolonged sitting, stair-climbing and kneeling was recorded by means of the Shelboume and Trumper anterior knee pain questionnaire. The location of both pain and any perceived sensory change was recorded using patient-drawn diagrams. Although mild or moderate symptoms occurred in a proportion of patients, only 2% experienced significant symptoms that caused limitation with daily activity, 7% with strenuous work or sport, 12% with kneeling, 5% with stairs and none with prolonged sitting. The pain was not specifically related to the incision for tendon harvest and drilling of the tibial tunnel. Areas of sensory change over the front of the knee were identifiable in 50% of patients, and of these, 86% demonstrated sensory change in the distribution of the infragenicular branch of the saphenous nerve. Although rarely a cause of limitation of activity, AKS can be a problem after hamstring ACL reconstruction and patients should be counselled accordingly.

The Possibilities of Using the Patellar Tendon in the Treatment of Anterior Cruciate Ligament Tears in Children

Summary: We describe a technique of reconstruction for complete midsubstance ruptures of the anterior cruciate ligament in patients with wide open physis, using the central third of the patellar tendon. This specific procedure is named the Clocheville technique. Results were very good in five cases and good in three cases at 2 years minimal follow-up. We neither noticed angular deformity, nor significant change in lower leg length. The Clocheville technique is an excellent alternative for young patients, with residual growth of the knee greater than 15 mm, if presenting an objective instability in activities of daily living or a proven meniscal tear that should be repaired.0749-8063/99/1501-1758$3.00/0

Gait adaptations before and after anterior cruciate ligament reconstruction surgery.

Gait analyses of rehabilitated individuals with anterior cruciate ligament (ACL) deficiency and reconstruction have identified the final adaptations of increased hip extensor torque and hamstring electromyography (EMG) and decreased knee extensor torque and quadriceps EMG during stance. The initial adaptations to injury and surgery are, however, unknown as are the factors that influence the development of the adaptations. Identification of the initial response to injury would provide a basis for determining whether the final adaptations are learned automatically or if they are the result of a lengthy training period in which various factors may affect their development. The purpose of the study was to evaluate the initial effects of ACL injury and reconstruction surgery on joint kinematics, kinetics, and energetics, during walking. Injured limbs from nine subjects with ACL injury were tested 2 wk after injury, and 3 and 5 wk after surgery. Ten healthy subjects were tested. Kinematic and ground reaction data were collected and combined with inverse dynamics to calculate the joint torques and powers. A knee extensor torque throughout most of stance was observed in the injured limbs at all test sessions. This result was in conflict with previous observations of reduced extensor torque or a flexor torque in rehabilitated patients with ACL reconstruction and patients with ACL deficiency. This result also differed from the typical midstance extensor then flexor torque in healthy control subjects. Trend analysis showed a significant (P < 0.001) change in average position at the hip and knee, extensor angular impulse at the hip, and positive work done at the hip 3 wk after surgery followed by a partial rehabilitation at 5 wk after surgery. Power and work produced at the knee were reduced fivefold (P < 0.001) after 5 wk of rehabilitation and did not recover to pre-surgical levels. The existence of a long-lasting knee extensor torque 2 wk after injury indicated that the adaptation process to ACL deficiency is lengthy, requiring many gait cycles, and that numerous factors could be involved in learning the adaptations.

The effect of Toradol on function following anterior cruciate ligament reconstruction

Functional recovery following anterior cruciate ligament (ACL) reconstruction was compared between patients who received ketoralac tromethamine (Toradol) and those who received parenteral narcotics. Initial postoperative rehabilitation following ACL reconstruction may be influenced by postoperative analgesia. The purpose of this study was to determine whether the attainment of functional milestones (FMs) differed between patients who received Toradol and those who received parenteral narcotics. One hundred and four consecutive ACL patients ranging in age from 14 to 41 years were monitored for postoperative day (POD) of achievement of crutch ambulation, stair negotiation, active knee flexion to 90° and discharge. Independent t-tests corrected for multiple measures were used to compare the groups. The results were as follows: POD of unassisted FMs (mean (SD); ∗P < 0.01 (corrected formultiple measures)) Flex to 90°∗ Crutches∗ Stairs∗ DC∗ Group I (Toradol), n = 47 1.6 (0.62) 1.3 (0.47) 1.8 (0.55) 2.2 (0.44) Group II (no Toradol), n = 57 2.0 (0.62) 1.8 (0.75) 2.2 (0.61) 2.7 (0.79) There was a significant delay in achievement of all FMs in patients who did not receive Toradol for analgesia.

Knee stability and muscle coordination in patients with anterior cruciate ligament injuries: An electromyographic approach

We present findings on the way in which to use electromyographic (EMG) measurements from muscles acting on the knee in planning rehabilitation of subjects after rupture of anterior cruciate ligament (ACL). ACL subjects demonstrated an earlier recruitment and a tendency to prolonged activity in muscles around the deficient knee as compared with a control group. Especially the hamstring lateralis and the gastrocnemius medialis (GM) muscles showed an earlier EMG onset and a longer EMG burst duration. The clinical relevance of the EMG findings was assessed by comparing the muscle coordination and relative levels of activity between a functionally excellent/good and a functionally poor ACL patient group. Significant differences between the two groups were noted in EMG onset and burst duration of the GM muscle. A rehabilitation program based on the EMG findings from the GM muscle was designed. In this program, the ACL subjects with poor stability were trained to change the EMG activity of the gastrocnemius muscles according to the recruitment pattern of the good/excellent ACL-group. We were able to train the subjects to change their muscle recruitment and to improve their knee stability. The stability of the knee joint depends on the stiffness of the muscles and ligaments around and within the knee. We discuss the importance of the gastrocnemius muscles with regard to knee joint stiffness.