Chronic ACL-deficient Knees Research Articles

Isolated Anterior Cruciate Ligament Reconstruction in the Chronic ACL-Deficient Knee With Degenerative Medial Arthrosis

Isolated anterior cruciate ligament (ACL) reconstruction may provide long-term symptom relief and improved function in patients with medial knee arthrosis and ACL-deficiency, while delaying or possibly eliminating the need for further surgical intervention. Fifty-three patients who had medial unicompartmental arthrosis and chronic ACL-deficient knees underwent ACL reconstruction alone. Subjective evaluation at mean 10 years postoperatively indicated statistically significant improvement compared to preoperative evaluation and better scores for patients who obtained normal knee range of motion. Objective evaluation, performed for 33 patients at a mean of 5.5 years postoperatively, indicated 25 normal or nearly normal International Knee Documentation Committee ratings; 2 patients have undergone subsequent osteotomy or total knee arthroplasty. Isolated ACL reconstruction provides long-term symptomatic pain relief, increased activity, and improved function. Anterior cruciate ligament reconstruction can effectively provide stability to the ACL-deficient knee with degenerative medial arthrosis without compromising range of motion or strength. Obtaining and maintaining full range of motion equal to the normal knee is important for the optimal result.

Arthroscopic and Magnetic Resonance Imaging Evaluation of Meniscus Lesions in the Chronic Anterior Cruciate Ligament–Deficient Knee

Arthroscopic and Magnetic Resonance Imaging Evaluation of Meniscus Lesions in the Chronic Anterior Cruciate Ligament–Deficient Knee

Arthroscopic and Magnetic Resonance Imaging Evaluation of Meniscus Lesions in the Chronic Anterior Cruciate Ligament–Deficient Knee

We performed this prospective study to evaluate the incidence of meniscus tears arthroscopically and the effectiveness of magnetic resonance imaging (MRI) in detecting these lesions in patients with chronic anterior cruciate ligament (ACL)-deficient knees. We reviewed 50 patients (46 male and 4 female) with a mean age of 27 years (range, 18 to 48 years) who underwent ACL reconstruction for chronic ACL tears. Injuries were classified as chronic because arthroscopy was performed after more than 6 weeks of injury. All 50 patients had clinical and MRI evaluation followed by knee arthroscopy. The MRI and arthroscopic findings were then analyzed by a single independent reviewer. The presence of meniscus tears and their morphologic types and locations were analyzed. The sensitivity, specificity, positive predictive value, and negative predictive value of MRI were calculated. On arthroscopy, a medial meniscus tear was found in 18 patients (36%), a lateral meniscus tear was found in 11 patients (22%), both menisci were torn in 8 patients (16%), and no meniscus lesion was found in 13 patients (26%). The most common morphologic type of tear seen in the medial meniscus was "complex" (n = 11 [42%]), and that in the lateral meniscus was "longitudinal" (n = 10 [53%]). The posterior horn of the meniscus was the most common tear site. The overall sensitivity, specificity, positive predictive value, and negative predictive value for detecting meniscus tears in chronic ACL-deficient knees on MRI were 90%, 89%, 87%, 93%, respectively. We conclude from our study that in chronic ACL-deficient patients, the prevalence of posterior horn medial meniscus tears seems to be high. Anterior horn tears and radial and horizontal patterns of meniscus tears seem to be rare in chronic ACL deficiency. MRI correlates well with arthroscopy and has high negative predictive values. Level I, prognostic prospective study.

MRI analysis of in vivo meniscal and tibiofemoral kinematics in ACL‐deficient and normal knees

The objectives of this study were to analyze simultaneously meniscal and tibiofemoral kinematics in healthy volunteers and anterior cruciate ligament (ACL)-deficient patients under axial load-bearing conditions using magnetic resonance imaging (MRI). Ten healthy volunteers and eight ACL-deficient patients were examined with a high-field, closed MRI system. For each group, both knees were imaged at full extension and partial flexion ( approximately 45 degrees ) with a 125N compressive load applied to the foot. Anteroposterior and medial/lateral femoral and meniscal translations were analyzed following three-dimensional, landmark-matching registration. Interobserver and intraobserver reproducibilities were less than 0.8 mm for femoral translation for image processing and data analysis. The position of the femur relative to the tibia in the ACL-deficient knee was 2.6 mm posterior to that of the contralateral, normal knee at extension. During flexion from 0 degrees to 45 degrees , the femur in ACL-deficient knees translated 4.3 mm anteriorly, whereas no significant translation occurred in uninjured knees. The contact area centroid on the tibia in ACL-deficient knees at extension was posterior to that of uninjured knees. Consequently, significantly less posterior translation of the contact centroid occurred in the medial tibial condyle in ACL-deficient knees during flexion. Meniscal translation, however, was nearly the same in both groups. Axial load-bearing MRI is a noninvasive and reproducible method for evaluating tibiofemoral and meniscal kinematics. The results demonstrated that ACL deficiency led to significant changes in bone kinematics, but negligible changes in the movement of the menisci. These results help explain the increased risk of meniscal tears and osteoarthritis in chronic ACL deficient knees.

Tennis specific limitations in players with an ACL deficient knee

Background: Complete rupture of the anterior cruciate ligament (ACL) causes significant alteration of knee joint kinematics. Untreated patients often develop joint instability, chronic articular degeneration, and knee dysfunction. Demands on...

Inflammatory Cytokine Profiles Associated With Chondral Damage in the Anterior Cruciate Ligament–Deficient Knee

Patients with chronic anterior cruciate ligament (ACL) deficiency are at high risk of articular cartilage damage and the development of osteoarthritis (OA). It has been hypothesized that biochemical factors, such as cytokines, contribute to the process. The purpose of our study was to determine the concentrations of potentially chondrodestructive and chondroprotective cytokines in the chronic ACL-deficient knee, and to determine if the cytokine profile or other factors correlated with the amount of chondral damage present in the knee. A consecutive series of patients who consented to the Institutional Review Board-approved study. Synovial fluid lavages were obtained from 31 patients with ACL-deficient knees. Four patients had lavages aspirated from their contralateral normal knee. These lavages were analyzed for interleukin (IL)-1alpha, IL-1beta, IL-1ra, and tumor necrosis factor (TNF)-alpha. At arthroscopy, the amount of chondral damage was graded based on the Outerbridge classification. Concentrations of chondrodestructive IL-1beta and TNF-alpha were significantly higher in patients with ACL ruptures than in the contralateral normal knees. The more severe the chondral damage, the higher the concentration of IL-1beta and TNF-alpha. Chondroprotective cytokine concentrations decreased with increasing grades of chondral damage. We found a linear correlation between the severity of chondral damage and the time from injury (r2 = .954). A difference was seen in the cytokine profiles between the normal and injured knees. This difference varied based on the severity of chondral damage, which was associated with time from injury. Cytokine levels are associated with chondral damage.

Considerations for Osteotomy in the ACL Deficient Knee

Abstract: The natural history of the isolated ACL deficient knee with or without reconstruction remains unclear. Although multifactorial in nature, evidence demonstrates these knees gradually deteriorate over time. Mechanical overload from knee malalignment has been identified to contribute not only to early failure of ACL reconstruction, but also to more rapid deterioration of the joint. However, assessing limb alignment as a contributing factor still remains largely overlooked in the ligamentously unstable knee, and reconstruction has generally focused on the soft tissue constraints. Therefore, the emphasis of this paper is that mechanical axis deviation in the chronic ACL deficient knee needs to be addressed as a means of treating the instability and protecting the joint. Over time, untreated malalignment can worsen ligamentous laxity and lead to symptomatic chronic instability. On reviewing the literature regarding the ACL deficient knee, some emphasis has been placed on the varus knee in the coronal plane, however little exists on the effect of malalingment, particularly in the sagittal plane. Previous authors have identified the varus component and advocate early intervention for the varus, anterior cruciate deficient knee. Most of these studies examined the effect of a closing wedge osteotomy in the chronically ACL deficient knee. In this review, the authors discuss the indications for realignment and the surgical technique utilizing an opening wedge technique at the time of ACL reconstruction. In addition, the importance of this paper is to discuss coronal and sagittal plane alignment and the need to assess and correct alignment in the unstable ACL deficient knee.

Clinical evaluation of arthroscopically assisted anterior cruciate ligament reconstruction: Patellar tendon versus gracilis and semitendinosus autograft

To evaluate the clinical results of anterior cruciate ligament (ACL) reconstruction in patients with ACL-deficient knee in 2 similar groups of patients. A prospective randomized comparison of patellar tendon (PT) versus semitendinosus and gracilis tendon (STG) autografts for ACL reconstruction. Between 1994 and 1996, 85 consecutive male patients with chronic ACL-deficient knees underwent arthroscopically assisted reconstruction with either autologous PT or double-loop STG (4-strand) graft. PT grafts were used in patients with even-numbered birth dates and STG grafts for those with odd-numbered birth dates. Preoperatively, no significant differences between the 2 groups were noted with respect to age, level of activity, and degree of laxity (chi-square analysis). A standardized rehabilitation program was used for both groups postoperatively that included immediate active extension and early weight bearing and gradual flexion. Return to sports was permitted 8 months postoperatively. Assessment of the patients was carried out using a questionnaire, clinical assessment, Lysholm knee scores, the International Knee Documentation Committee scale, and radiological examination. At a mean follow-up of 81 months, there was no significant difference between the 2 groups with respect to subjective complaints (recurrent giving way, functional level) or objective laxity evaluation, including KT-1000 measurement or return to sports. Loss of extension of < or =5 degrees was greater in the PT group (12 patients, 30 %) than in the STG group (8 patients, 17 %). There was loss of flexion of < or =15 degrees in 5 patients (12 %) in the PT group and 1 patient (2.2 %) in the STG group. Anterior knee pain was recorded in 10 patients (24 %) in the PT group and 3 patients (5 %) in the STG group. The Lysholm knee score was 91.6 and 92.7 for the PT and STG groups, respectively, and the Tegner activity score decreased from 8.9 preoperatively for both groups to 7.9 for the PT group and 7.8 for the STG group. In this study, the 2 groups had comparable results in terms of patient satisfaction, activity level, and knee function. Our study showed that patellofemoral problems and loss of knee motion are more frequent in patients with PT grafts than in those with STG grafts. Level I, Randomized Controlled Trial.

Effects of functional knee bracing on muscle-firing patterns about the chronic anterior cruciate ligament-deficient knee

Smith J, Malanga GA, Yu B, An K-N. Effects of functional knee bracing on muscle-firing patterns about the chronic anterior cruciate ligament-deficient knee. Arch Phys Med Rehabil 2003;84:1680–6. Objective To examine the effects of functional knee bracing on the muscle-firing patterns about the chronic anterior cruciate ligament (ACL)-deficient knee in successful brace users. Design Cross-sectional comparative clinical trial. Setting Motion analysis laboratory. Participants Ten active individuals with unilateral, isolated, chronic (>18mo postinjury), ACL-deficient knees who subjectively reported improved function with a functional knee bracing. Intervention Each subject completed 3 single-leg hop maneuvers on their ACL-deficient knee with and without their knee brace while surface electromyographic activity was recorded from the quadriceps, hamstring, and gastrocnemius muscles. Main outcome measure Muscle onset latency. Results Brace use significantly delayed the average onset of vastus lateralis activation before landing (123±47ms vs 109±30ms, P<.001), though significant interindividual variations existed. Bracing significantly altered the onset latency in 1 or more muscles in 9 of 10 subjects. In 4 subjects, a favorable change in the firing pattern was seen, whereas only 1 subject exhibited an unfavorable change. Without bracing, 5 of the 10 subjects fired the hamstrings or gastrocnemius muscles first; with bracing, 7 of 10 fired these muscles first. Conclusions Brace use in this population did not consistently result in more favorable muscle firing patterns during the single-leg hop maneuver. Interindividual responses to brace use indicate the need for further research to investigate the multiple strategies that may exist to stabilize the ACL-deficient knee. In the meantime, functional knee brace use among ACL-deficient patients remains empirical.

The Ligament Augmentation Device: An Historical Perspective

Summary: Anterior cruciate ligament (ACL) injury is the most common ligament injury in the knee, and a significant number of patients may develop progressive instability and disability despite aggressive rehabilitation. Various materials have been used for its reconstruction. These include autografts, allografts, prosthetic ligaments, and synthetic augmentation of the biological tissue. The concept of ligament augmentation device (LAD) arose from the observation that biological grafts undergo a phase of degeneration and loss of strength before being incorporated. The LAD is meant to protect the biological graft during this vulnerable phase. However, it provokes an inflammatory reaction in the knee, and has been found to delay maturation of autogenous graft in humans. In experimental situations, the LAD has been found to share loads in a composite graft. It has also been found to be substantially stronger than the biological graft. However, in clinical situations no significant advantages have been observed with the use of LAD to augment patellar tendon or hamstring reconstruction of the chronic ACL-deficient knee or in the acute setting to augment repair of the torn ACL. There are very few reports of the use of LAD in reconstruction of the posterior cruciate ligament, and again these do not suggest any advantage in its use. Insertion of the LAD implies the introduction of a foreign material into the knee, has been associated with complications such as reactive synovitis and effusions, and may also be associated with an increased risk of infection. At present, there is no evidence that its routine use should be advocated in uncomplicated reconstructions of the ACL using biological grafts. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 4 (May-June), 1999: pp 422–432

Five-year results of single-incision arthroscopic anterior cruciate ligament reconstruction with patellar tendon autograft.

We performed a retrospective study on 80 patients who underwent single-incision arthroscopic anterior cruciate ligament reconstruction with patellar tendon autograft and interference fit screw fixation in 1989. Twelve patients were lost to followup, allowing a clinical assessment of 68 patients to be conducted by independent examiners at 1 and 5 years after surgery, with radiographic assessment at 5 years. Thirty-three patients had chronic anterior cruciate ligament-deficient knees. Three patients reruptured their grafts during sports at 29, 48, and 56 months. At 5 years, 64 patients (98%) had grade 0 or 1 Lachman and pivot shift tests with manual stability testing. Fifty patients (77%) were participating in level I or II activities according to the International Knee Documentation Committee scale. Twenty-nine patients (45%) experienced low levels of pain when performing at their highest activity level. Five (8%) had thigh atrophy greater than 1 cm, and three (5%) had an extension loss of more than 3 degrees. Eleven patients (17%) had tenderness over the graft site when kneeling. Fifteen of 62 patients (24%) had degenerative changes on radiographs, and this was more common in patients with chronic anterior cruciate ligament-deficient knees. Fifty-two patients (80%) had normal or nearly normal knees according to the overall International Knee Documentation Committee score.

膝前十字靭帯再建術後患者におけるｈｏｐ ｔｅｓｔによる機能評価

Sixty patients, with anterior cruciate ligament (ACL) reconstruction using the iliotibial tract, had their overall knee function assessed at least 2 years postoperatively using the one-leg hop test. For comparison, 30 physically active healthy volunteers with normal knees (15 men and 15 women) and 30 patients with chronic ACL-deficient knees (15 men and 15 women) were also examined. The hop index in the ACL-reconstructed group was significantly improved compared to that of ACL-deficient group, and almost reached the same level as the healthy volunteers. In the ACL-reconstructed group, the hop index gave a good reflection of subjective knee function (IKDC score) and sports level. The results indicated that the one-leg hop test is a useful method for quantitatively evaluating the function of ACL-reconstructed knees.

Stabilometric assessment in the anterior cruciate ligament-reconstructed knee.

To examine the hypotheses that anterior cruciate ligament (ACL) reconstruction improves the proprioception of the knee beyond the level of ACL-deficient knees, and that proprioception of the knee correlates well with knee function after ACL reconstruction. Fifty-three patients with ACL-reconstructed knees (22 men and 31 women), 30 physically active healthy volunteers with normal knees (15 men and 15 women), and 30 patients with chronic ACL-deficient knees (15 men and 15 women). A stabilometric assessment, which is considered to be a useful method for evaluating proprioception objectively, was used to compare the one-leg standing balance among three groups; and the relationship between subjective knee function, satisfaction, hop index, knee laxity, isokinetic thigh muscle strength, and one-leg standing balance in the ACL-reconstructed patients was also analyzed. The one-leg standing balance of the patients with ACL-reconstructed knees was still impaired compared with that of healthy volunteers (men, p < 0.05; women, p < 0.01), but significantly better than that of the patients with ACL-deficient knees (men, p < 0.001; women, p < 0.001). The one-leg standing balance of the patients with ACL-reconstructed knees correlated well with their functional outcomes such as subjective knee function (men, p < 0.001; women, p < 0.01), satisfaction (men, p < 0.01; women, p < 0.001), and hop index (men, p < 0.001; women, p < 0.001), whereas poor correlation was seen between functional outcomes and mechanical stability. The results suggest that knee function after ACL-reconstruction should be closely related with knee proprioception, and indicate that the usefulness of stabilometric assessment in the evaluation of the function of ACL-reconstructed knees.

The Apex polyester fibre anterior cruciate ligament implant: operative procedure and early results

This paper describes the surgical method and instruments for placing and anchoring the Apex polyester fibre anterior cruciate ligament (ACL) reconstruction. It then reviews the early clinical findings and describes recent developments. At the time of review, 172 Apex replacements had been implanted in the UK in arthroscopically proven chronic ACL-deficient knees. These had been inserted at eight centres since 1987, and follow up was by a single observer assessing patients by questionnaire, clinical examination, stress X-ray and KT 1000 arthrometer. Patients less than 12 months from surgery were excluded, leaving 95 with a mean follow up of 27 months (range 13 to 66 months) on whom results are based. Assessment showed improved stability after operation and the Apex implant appears to provide a reliable method of stabilizing the ACL deficient knee within the confines of this short-term review. The authors feel that further trials are justified.

Functional Testing in the Anterior Cruciate Ligament-Deficient Knee

Functional testing of patients with anterior cruciate ligament (ACL) deficient knees and normal subjects during stressful activities such as running to a cut and running to a stop and during activities common to daily life, such as walking, stair climbing, and jogging, is presented. Analysis focused on the application of these tests to treatment planning and clinical evaluation. Functional testing during stressful activities indicates that some patients with ACL-deficient knees have higher than normal net hamstring moments during the early phase of these activities. These results suggest dynamic muscular substitution using the hamstrings in patients with chronic ACL-deficient knees. Patients tested during less stressful activities, such as walking and stair climbing, also demonstrated substantial differences from ACL-intact subjects. The majority of patients tended to reduce the net quadriceps moment when the knee was near full extension. Approximately 75% of the patients who were ACL-deficient developed this type of adaptation, which appears to be a subconscious method of avoiding the net anterior pull of the quadriceps mechanism when the knee is near full extension. Functional testing of the ACL-deficient knee provides meaningful information that cannot be obtained by simpler clinical tests. This information can be extremely useful in the selection and evaluation of patients with certain treatment modalities, since it seems to be directly related to some patients' ability to functionally adapt to the loss of the ACL.

A Stabilometric Technique for Evaluation of Functional Instability in Anterior Cruciate Ligament-Deficient Knee

Abstract The standing balance of 11 functionally stable and 15 functionally unstable knees in patients with chronic anterior cruciate ligament (ACL)-deficient joints was studied by means of stabilometry. All the patients had participated in sports on a competitive level before injury, and functional stability was defined as full return, without giving way, to the same sport at the same level as before injury. Forty physically active volunteers were studied as the reference group. When compared with the reference group, an impaired standing balance was found in the functionally unstable patients but not in the functionally stable patients. The results indicate that stabilometry is a useful method for evaluating knee functional instability objectively in competitive athletes with chronic ACL-deficient knees.

Arthroscopic-assisted anterior cruciate ligament reconstruction with the semitendinosus tendon: Comparison of results with and without braided polypropylene augmentation

Fifteen chronic anterior cruciate ligament-deficient knees were arthroscopically reconstructed with a semitendinosus tendon polypropylene (STP) augmented composite graft. A comparison group of 28 reconstructions with the semitendinosus tendon (ST) but without augmentation was simultaneously reviewed. The mean follow-up in the STP group was 31 months (range of 24–42 months) and in the ST group it was 34 months (range 26–54 months). Both patient groups had similar age, sex, preinjury functional sports level, injury-to-surgery interval, and associated meniscal pathology. Good-to-excellent subjective results were reported in 86% of STP patients and 78% of ST patients, whereas 86% of the STP patients and 88% of the ST patients returned to sports activity. Objective examination revealed 73% of the STP group and 82% of the ST group to have a negative or 1 + Lachman test result. A negative pivot shift was noted at follow-up in 80% of the STP group and in 82% of the ST group. KT-1000 testing revealed 60% of the STP patients and 61% of the ST patients to have ≤3 mm of side-to-side difference. In the STP group there was no evidence of graft breakage, deep infections, or sterile effusions. Overall subjective and functional results were uniformly better than objective results in both patient groups. Analysis of subjective, objective, and functional results reveal no difference in outcome between the STP and the ST patient groups.

Anterior knee motion analysis

Sixteen patients with a clinically diagnosed chronic ACL deficient knee on one side and a contralateral ACL intact knee were evaluated by arthrometry and simultaneous radiography after epidural anesthesia was induced. The posterior cruciate ligament was intact in all knees. This paper reports only the anterior position of the tibia at the 89 N anterior force level of the KT-1000 arthrometer (as read from the dial) and the anterior tibial position recorded simultaneously by radiography at the 89 N dial tone. A 3 mm difference in anterior tibial position between the two knees of the same patient was considered diagnostic for ACL deficiency. Arthrometrically, 13 of the 16 patients were diagnosed accurately; radiographically, 13 of the 16 met the criterion. Moderately high significant positive correlation of paired values was obtained in ACL deficient knees by the two methods (correlation, 0.58 and two-tail probability, 0.02). In ACL intact knees there was no correlation of paired values (correlation, 0.01 and two-tail probability, 0.98). We found no numerical equivalency between the measurements obtained by the KT-1000 and simultaneous radiography. Neither did we find an apparent pattern to the differences, or formula we could use to interpolate findings of anterior tibial position from one measurement system to the other. We conclude that an examiner can substantiate a clinical diagnosis of chronic ACL deficiency with both methods. Arthrometry alone may be used to repeatedly follow conservatively treated ACL deficient knees without exposing the patient to radiation. Radiographs obtained under known anterior force levels provide a retrievable record to document the exact tibial position in relation to the femur.

The popliteus tendon and its fascicles at the popliteal hiatus: Gross anatomy and functional arthroscopic evaluation with and without anterior cruciate ligament deficiency

Gross anatomical dissection of the popliteus muscle, the popliteus tendon and its fascicles, and their relation to the lateral meniscus was carried out in 14 human adult cadaver knees. Videoarthroscopy through an anterolateral portal was then used to assess and document the functional integrity of the popliteus tendon and its fascicles forming the popliteal hiatus in vivo. A control group of cruciate ligament intact knees (n = 107) was compared with an anterior cruciate ligament (ACL)-deficient group (n = 68). The incidence of structural lesions of the popliteus system was 18.7% in the control knees, 95% in 40 acute ACL disruptions, and 85.7% in 28 chronic ACL-deficient knees. Functional arthroscopic evaluation of the popliteus tendon and its fascicles blending into the lateral meniscus was a valuable adjunct in assessing secondary posterolateral restraints in acute and chronic ACL-incompetent knees.

Reproducibility of Genucom knee analysis system testing

The Genucom knee analysis system was studied to determine the reproducibility of test results. In the first phase of the study we investigated the reproducibility of anterior/posterior stress tests at 30 degrees and 90 degrees of flexion and varus/valgus stress tests at 20 degrees of flexion in 10 control subjects during three seatings on 3 separate days. In the second phase we studied the effect of errors in the digitization procedure (a part of the patient installation process) on anterior/posterior translation measurements. In the third phase we studied the reproducibility of a battery of tests in patients with chronic unilateral ACL deficient knees. The test battery was repeated 8 times on each knee on 6 separate days. In Phase I, analysis of variance revealed no significant differences between tests within a single seating. The day-to-day variance of all subjects was not significant, but we found a significant interaction between day and subject which was due to significant day-to-day differences in individual subjects. We found in Phase II that changing the location of the tibial joint line digitization points in the anterior/posterior or proximal/distal direction affected anterior/posterior translation measurements. Effects were larger at 30 degrees of flexion than at 90 degrees and when both the medial and lateral points were moved. Movement of the femoral condylar points resulted in a similar pattern of effects. In Phase III, although we found significant differences between our two examiners, there were no significant intraexaminer test-to-test (within seating) effects. Additionally, while there was no significant day-to-day variance overall, we found a significant interaction between day and subject.(ABSTRACT TRUNCATED AT 250 WORDS)