Cruciate Ligament Surgery Research Articles

Failed anterior cruciate ligament reconstruction: analysis of factors leading to instability after primary surgery

Background Revision anterior cruciate ligament (ACL) surgery can be expected to become more common as the number of primary reconstruction keeps increasing. This study aims to investigate the factors causing instability after primary ACL reconstruction, which may provide an essential scientific base to prevent surgical failure. Methods One hundred and ten revision ACL surgeries were performed at our institute between November 2001 and July 2012. There were 74 men and 36 women, and the mean age at the time of revision was 27.6 years (range 16-56 years). The factors leading to instability after primary ACL reconstruction were retrospectively reviewed. Results Fifty-one knees failed because of bone tunnel malposition, with too anterior femoral tunnels (20 knees), posterior wall blowout (1 knee), vertical femoral tunnels (7 knees), too posterior tibial tunnels (12 knees), and too anterior tibial tunnels (10 knees). There was another knee performed with open surgery, where the femoral tunnel was drilled through the medial condyle and the tibial tunnel was too anterior. Five knees were found with malposition of the fixation. One knee with allograft was suspected of rejection and a second surgery had been made to take out the graft. Three knees met recurrent instability after postoperative infection. The other factors included traumatic (48 knees) and unidentified (12 knees). Conclusion Technical errors were the main factors leading to instability after primary ACL reconstructions, while attention should also be paid to the risk factors of re-injury and failure of graft incorporation.

The Optimal Timing for Anterior Cruciate Ligament Reconstruction With Respect to the Risk of Postoperative Stiffness

The aim of this meta-analysis was to compare the risk of stiffness between early and delayed anterior cruciate ligament (ACL) surgery in studies that use a modern accelerated rehabilitation protocol. Medline, Embase, and the Cochrane library were searched for studies that compared outcomes for early and delayed ACL reconstruction with a modern accelerated rehabilitation protocol. Risk ratios for stiffness were pooled using random effects meta-analysis. A total of 8 studies were included in this review. The 3 randomized trials found no difference in the risk of postoperative stiffness at cutoff points of <2, <3, and <10 weeks between early surgery and delayed surgery. An analysis of the 7 studies whose outcomes could be pooled revealed no significant increase in risk of adverse outcomes with early surgery using a variety of cutoff points (1, 2, 10, 12, and 20 weeks). Sensitivity analysis of individual outcomes failed to show any significant difference between early and delayed surgery with respect to arthrofibrosis, stiffness, range of motion deficits, extension deficits, and flexion deficits. If a modern surgical technique and an accelerated rehabilitation protocol are used, there is no increased risk of knee stiffness if an ACL reconstruction is performed as early as 1 week after injury. Level II, meta-analysis of Level I and II studies.

Simple and effective Rehabilitation Programme (SERP) for Patients Undergoing Arthroscopic Anterior Cruciate Ligament (ACL) Reconstruction in Indian Scenario

Introduction: Rehabilitation after surgery for an Anterior Cruciate Ligament (ACL) reconstruction is a lengthy process. Return to sports and other activities take months. There are many variations of ACL rehabilitation. Most of the protocols are extensive and do not suite the Indian scenario where the compliance of the patient and cost of physiotherapy are the major limiting factors. Hence, we decided to develop and validate a Simple and Effective Rehabilitation Programme (SERP) for patients undergoing ACL reconstruction in our scenario. Materials and methodology: Fifty patients with isolated ACL tear with or without partial menisectomy were selected for this systematic review from November 2010 to July 2012. All 50 patients underwent arthroscopic ipsilateral quadruple hamstring tendon reconstruction (semitendinosis and gracilis double folded) using endobutton (Smith and Nephew) for femoral fixation and bio absorbable interference screw for tibial graft fixation. They were subjected to SERP. SERP is a home based programme consisting of 5 phases spanning over 6 months. Test- retest was done using Modified Cincinnati Rating system Questionnaire on a prospective basis. The results were than analysed. Results: Applying the Modified Cincinnati Rating System Questionnaire, results were tabulated. 84% of the patients had excellent results and 16 % had good results at the end of 3 months. At the end of 6 months, 94 % of patients had excellent results and 6% had good results. The result remained the same after 1 year of follow-up. There were no fair or poor results. Conclusion: SERP is a home based programme which is understandable, convenient and reliable for patients who are undergoing arthroscopic ACL reconstruction; especially in our setting with excellent functional outcome.

Rehabilitation and leucine supplementation as possible contributors to an athlete's muscle strength in the reathletization phase following anterior cruciate ligament surgery

To determine the interest of a muscle rehabilitation program following anterior cruciate ligament reconstruction (ligamentoplasty) and the influence of leucine supplementation on the muscle strength of athletes undergoing reathletization. The authors have analyzed prospectively, in double blind, two groups of athletes (22 versus 23) who had randomly received either leucine supplementation or a placebo. Muscle strength was measured at the beginning and the end of the program In terms of thigh perimeter, isokinetic testing results, single-leg test and percentage of body fat. The reathletization program was identical in the two groups for an average of 2.7weeks. By the end of the program, both groups had increased their thigh perimeter at 10 and 15cm from the patella (respectively 1.2cm and 1.3cm, P<0.0001). Fat mass had decreased by 1.28% (P=0.017). Values of isokinetic muscle strength for the injured limb improved by 13 to 55% with highly significant differences. The leucine group generally showed more improved muscle parameters than the placebo group, with only one significant positive result with regard to thigh muscle perimeter at 10cm from the patella (P=0.009). With or without leucine, the rehabilitation program leads to improved muscle quality. Taking leucine appears to promote muscle recovery of the injured limb with regard to a single parameter (thigh muscle perimeter at 10cm from the patella), while the other parameters showed no significant improvement. A complementary study associating the recovery phase with other dietary supplements might help to optimize these preliminary results.

Retraction Note: Graft fixation alternatives in anterior cruciate ligament reconstruction

Reconstruction of the anterior cruciate ligament is a frequently performed procedure that has had outstanding results. Outcomes are dependent upon an early postoperative physical therapy program that stresses early motion. Early rehabilitation demands rigid intraoperative mechanical fixation of the graft since therapy begins before biologic incorporation of the graft in the bone tunnels. Regardless of the graft substitute chosen, many methods of fixation are available. The best fixation technique depends on several factors, including graft choice and surgeon comfort. The figures are not documented in this paper. We review current methods available for graft fixation in anterior cruciate ligament surgery.

Biological Approach to Anterior Cruciate Ligament Surgery

We present a novel technique for reconstruction of the anterior cruciate ligament with autologous ipsilateral hamstring tendons , assisted by platelet-rich plasma (PRP). PRP serves as a source of growth factors and cytokines to speed up the process of ligamentization and tendon-bone consolidation. Before implantation, the hamstring tendons are treated with liquid-activated PRP, so that a fibrin scaffold is formed within the tendons. The intratendinous location of the PRP scaffold was confirmed in Achilles tendons of sheep after injecting liquid-activated PRP stained with Indian blue ink. In the technique described, the tibial tunnel is produced using 2 trephines of different diameters, which allows to harvest 2 bone blocks with different diameters. The bone blocks are also treated with PRP before reimplantation . The tibial tunnel, which is wider distally, allows unconstrained positioning and drilling of the femoral socket within the isometric area. The graft is secured in the femur using transcondylar fixation. For tibial fixation, the PRP-treated bone blocks are introduced within the tunnel, firmly compacted, and left in the precise position that facilitated reconstruction of the tibial anatomy. Liquid-activated PRP is injected in both bone tunnels. To reduce morbidity associated with autografts , a platelet and fibrin scaffold is introduced in the donor region, and the preserved fascia of the pes anserinus is carefully sutured.

Individualized Anterior Cruciate Ligament Surgery

Background: Reconstruction of the anterior cruciate ligament (ACL) has become a commonly performed procedure. However, biomechanical studies have demonstrated that conventional single-bundle ACL reconstruction techniques are only successful in limiting anterior tibial translation but less effective for restoring rotatory laxity. Purpose: This study aimed to compare the results of single- and double-bundle ACL reconstruction using an anatomic technique, individualized based on the patient’s native ACL size. The authors hypothesized that there would be no difference between the results of anatomic single-bundle (ASB) and anatomic double-bundle (ADB) reconstruction when the surgical technique is individualized. Study Design: Cohort study; Level of evidence, 2. Methods: Depending on intraoperative measurements of the ACL insertion site size, patients were selected for either ASB (n = 32) or ADB (n = 69) ACL reconstruction. In all groups, hamstring tendons autograft was used with suspensory fixation on the femoral side and bioabsorbable interference screw fixation on the tibial side. The outcomes were evaluated by an independent blinded observer using the Lysholm score, subjective International Knee Documentation Committee (IKDC) form, KT-1000 arthrometer for anteroposterior stability, and pivot-shift test for rotational stability. The average follow-up was 30 months (range, 26-34 months). There were no statistically significant differences in the baseline demographics of the 2 groups. Results: There was no significant difference between the ADB and ASB groups for Lysholm score (93.9 vs 93.5), subjective IKDC score (93.3 vs 93.1), anterior tibial translation (1.5- vs 1.6-mm side-to-side difference), and pivot shift (92% vs 90% with negative pivot-shift examination). Conclusion: Anatomic double-bundle reconstruction is not superior to anatomic single-bundle reconstruction when an individualized ACL reconstruction technique is used.

Validation of a Novel Smartphone Accelerometer-Based Knee Goniometer

Loss of full knee extension following anterior cruciate ligament surgery has been shown to impair knee function. However, there can be significant difficulties in accurately and reproducibly measuring a fixed flexion of the knee. We studied the interobserver and the intraobserver reliabilities of a novel, smartphone accelerometer-based, knee goniometer and compared it with a long-armed conventional goniometer for the assessment of fixed flexion knee deformity. Five healthy male volunteers (age range 30 to 40 years) were studied. Measurements of knee flexion angle were made with a telescopic-armed goniometer (Lafayette Instrument, Lafayette, IN) and compared with measurements using the smartphone (iPhone 3GS, Apple Inc., Cupertino, CA) knee goniometer using a novel trigonometric technique based on tibial inclination. Bland-Altman analysis of validity and reliability including statistical analysis of correlation by Pearson's method was undertaken. The iPhone goniometer had an interobserver correlation (r) of 0.994 compared with 0.952 for the Lafayette. The intraobserver correlation was r = 0.982 for the iPhone (compared with 0.927). The datasets from the two instruments correlate closely (r = 0.947) are proportional and have mean difference of only -0.4 degrees (SD 3.86 degrees). The Lafayette goniometer had an intraobserver reliability +/- 9.6 degrees. The interobserver reliability was +/- 8.4 degrees. By comparison the iPhone had an interobserver reliability +/- 2.7 degrees and an intraobserver reliability +/- 4.6 degrees. We found the iPhone goniometer to be a reliable tool for the measurement of subtle knee flexion in the clinic setting.

Patellar Stress Fracture After Transosseous Extensor Mechanism Repair

Extensor mechanism injuries are unusual and require early operative intervention to optimally restore extensor mechanism continuity, strength, and function. Quadriceps tendon ruptures typically occur in patients older than 40 years and can be associated with degenerative tendon changes, obesity, systemic illnesses, and trauma. Patellar tendon ruptures are usually seen in younger patients as a result of eccentric trauma. In the acute setting, primary repair is usually undertaken. For tears within the quadriceps or patellar tendon substance, direct repair can be performed, with or without augmentation. When the rupture occurs at the junction of the tendon and the patella, transosseous sutures or suture anchors can be used to reapproximate the tendon-bone interface. Stress fractures of the patella are reportedly rare. They can be seen in association with knee arthroplasty, anterior cruciate ligament (ACL) surgery, and rarely after impact sports. The fracture pattern is usually transverse. Longitudinal stress fractures do not typically disrupt the extensor mechanism and have not, to our knowledge, ever been identified as a postoperative complication of extensor mechanism repair. One instance of a traumatic transverse patellar fracture and extensor mechanism disruption after patellar tendon repair has been described, and a transosseous suture technique was used in that case. No instances of patellar fracture after quadriceps tendon repair have been reported. We report 3 cases of longitudinal patellar stress fractures after extensor mechanism repair using a transosseous suture technique, 2 of which occurred after quadriceps tendon repair and 1 of which occurred after patellar tendon repair.

Recent Advances in the Rehabilitation of Anterior Cruciate Ligament Injuries

Rehabilitation following anterior cruciate ligament surgery continues to change, with the current emphasis being on immediate weight bearing and range of motion, and progressive muscular strengthening, proprioception, dynamic stability, and neuromuscular control drills. The rehabilitation program should be based on scientific and clinical research and focus on specific drills and exercises designed to return the patient to the desired functional goals. The goal is to return the patient's knee to homeostasis and the patient to his or her sport or activity as safely as possible. Unique rehabilitation techniques and special considerations for the female athlete will also be discussed. The purpose of this article is to provide the reader with a thorough scientific basis for anterior cruciate ligament rehabilitation based on graft selection, patient population, and concomitant injuries.

Recent Evolution of Cruciate Ligament Surgery of the Knee

Recent Evolution of Cruciate Ligament Surgery of the Knee

Paper # 178: 2nd Place Winner of the John Joyce Award The Lateral Tibial Tunnel in Revision Anterior Cruciate Ligament Surgery: A Biomechanical Study of a New Technique

Paper # 178: 2nd Place Winner of the John Joyce Award The Lateral Tibial Tunnel in Revision Anterior Cruciate Ligament Surgery: A Biomechanical Study of a New Technique

Anterior cruciate ligament surgery. History and controversies

Anterior cruciate ligament surgery. History and controversies

Criteria-Based Management of an Acute Multistructure Knee Injury in a Professional Football Player: A Case Report

Case report. Joint stiffness, also called arthrofibrosis, remains the primary complication following any reconstructive knee surgery. Acute anterior cruciate ligament surgery, performed with concomitant multiple ligamentous repair and/or reconstruction, further increases the likelihood of developing impaired knee motion following surgery. The purpose of this case report is to present a criteria-based approach to the postoperative management of a multiligament knee injury. A 25-year-old male professional football player sustained a contact injury to his right knee while making a tackle during a regular season game in 2007. He underwent an acute anterior cruciate ligament reconstruction, with concomitant posterolateral corner repair, biceps femoris/iliotibial band repair, lateral collateral ligament repair, and a medial meniscocapsular junction repair. He completed 17 weeks of a multiphased rehabilitation program that emphasized immediate range of motion, low-load long-duration stretching, therapeutic exercise, neuromuscular reeducation/perturbation training, plyometrics, and sport-specific functional drills. Electrical neurostimulation was implemented during the early stages of rehabilitation to control postoperative pain and to promote a steady progression of therapeutic exercise activity. The patient was cleared to begin sport-specific activity 7 months after major multistructure reconstructive knee surgery. He began the 2008 season on the physically-unable-to-perform list, but was activated midseason and played in every game thereafter. During the 2009 and 2010 seasons, he played all regular season games and all playoff games as a starter, and continues to start as a defensive cornerback in the National Football League. This case report highlights the clinical decision-making process and management involved in an acute multiple ligamentous knee injury/reconstruction. Therapy, level 4.

Influence du type d’orthèse de genou sur l’évolution clinique postopératoire d’une chirurgie du ligament croisé antérieur chez le sportif

Objectives To establish the influence of the type of brace on the postoperative clinical evolution after anterior cruciate ligament (ACL) surgery in competitive sportspeople. Methods The authors prospectively followed the evolution of three populations of ACL reconstruction: one who received a functional brace, the other a rigid brace and last no brace. The three groups followed the same rehabilitation program. The clinical parameters of evaluation were pain, perimeter patellar joint, range of motion, muscular atrophy, locking the quadriceps, and the quality of walking. We also used the IKDC subjective Knee Evaluation Form and PPLP scoring scale. Results There is no clinically significant difference at about a month of surgery between the three groups (407 patients). There is no difference with the PPLP scoring scale. No repeat rupture is occurred postoperatively. There is a significant difference in the IKDC subjective ( P = 0.03) between the group with functional brace and rigid brace. Conclusion With the same active rehabilitation program, the clinical evolution is identical with or without brace. The only difference is subjective (IKDC subjective Knee Evaluation Form).

Hamstring graft sizes differ between Chinese and Caucasians

The use of hamstring tendon autografts for anterior cruciate ligament (ACL) surgery has become more and more common. The purposes of this study were to determine whether anthropomorphic measurement correlated with tendon sizes in Chinese patient group and whether tendon sizes in Chinese and Caucasian patient groups differed. From 2008 to 2009, 100 patients that received double-bundle ACL reconstruction with autologous hamstring tendons were prospectively enrolled. The original lengths and triple-folded graft diameters of the individual semitendinosus (ST) and gracilis (Gr) tendons were recorded and correlated with the anthropometric data (height, weight, body mass index, gender, thigh length, shank length, leg length and bilateral thigh circumference) of the patients. Later, using height for predictions, the original heights of patients were added to the equations previously used for regression models to compare the tendon lengths in different ethnic groups. After stepwise multiple linear regression analysis, the height and leg lengths showed greatest correlation with the lengths of both tendons. The lengths of both the semitendinosus and gracilis tendons in Caucasian patients were significantly longer than in the Chinese patients. The results of this study showed that anthropomorphic measurements (height and leg length) correlated with tendon lengths. In addition, Caucasians had significantly longer hamstring tendons than the Chinese patients. Prospective cohort study (prevalence), Level I.

Vitamins E and C Modulate the Association Between Reciprocally Regulated Cytokines After an Anterior Cruciate Ligament Injury and Surgery

: The purpose of this study was to identify the influence of vitamin E and C supplementation on inflammatory cytokines and the association between reciprocally regulated cytokines after anterior cruciate ligament surgery. : A double-blind, placebo-controlled study was conducted in men undergoing anterior cruciate ligament surgery who were randomly assigned to one of two groups (n = 10/group): (1) antioxidant (vitamins E and C) or (2) matching placebos starting ∼2 wks before (baseline) and concluding 3 mos after surgery. Plasma inflammatory cytokines were measured in fasting blood draw samples before and after anterior cruciate ligament surgery. : Plasma interleukin (IL) 1β concentrations were double at 3 mos after surgery compared with baseline. Plasma IL-1β increased to a greater (P < 0.05) extent relative to IL-4 in the placebo group (mean ± SE slope, 18.87 ± 0.68; r = 0.97) than in the antioxidant group (mean ± SE slope, 4.84 ± 0.42; r = 0.89). Similarly, the relative increase in IL-1β to IL-2 was greater (P < 0.05) in the placebo (mean ± SE slope, 2.70 ± 0.21) than in the antioxidant (mean ± SE slope, 1.08 ± 0.23) group. : Vitamins E and C were ineffective in ameliorating the increases in IL-1β but altered associations between reciprocally regulated cytokines after anterior cruciate ligament surgery.

Low Vitamin D Impairs Strength Recovery After Anterior Cruciate Ligament Surgery

The purpose of this study was to identify strength gains after an anterior cruciate ligament injury and surgery and during inflammatory challenge in participants with disparate vitamin D levels. Plasma samples were obtained from those who had not previously experienced an anterior cruciate ligament injury and from injured patients 2 weeks before and 3 months after anterior cruciate ligament surgery. Plasma 25-hydroxyvitamin D and cytokine concentrations were measured in each blood sample. Single-leg peak isometric forces were measured 2 weeks presurgery and 3 months postsurgery. Compared with noninjured participants, inflammatory cytokines were elevated prior to and following anterior cruciate ligament reconstruction. During this inflammatory challenge, the peak isometric force increases after surgery were significantly lower in those with plasma 25-hydroxyvitamin D concentrations &lt;30 ng/mL compared with those with concentrations ≥30 ng/mL. The authors conclude that low vitamin D appears to hinder strength recovery after anterior cruciate ligament surgery and during inflammatory insult.

Precision of Tunnel Positioning in Navigated Anterior Cruciate Ligament Reconstruction

The aim of this study was to validate the precision of navigated tunnel positioning using a fluoroscopy-based computer-assisted technique. Ten human cadaveric knees were operated on under operating room conditions. After resection of the anterior cruciate ligament, referenced fluoroscopic images were acquired to plan the tunnel positions according to established radiologic measurement methods. Afterward, femoral and tibial K-wires were placed by use of navigated drill guides without arthroscopic control. Deviations between the planned and actually drilled tunnel positions at the joint level were analyzed by use of both navigated and radiologic assessment methods. Navigated analysis between planned and actually drilled tunnel position showed mean deviations of 0.4 mm (range, 0 to 1 mm; SD, 0.52 mm) at the femur and 0.5 mm (range, 0 to 1 mm; SD, 0.5 mm) at the tibia. The radiologic analysis showed mean deviations for the femoral tunnel of 0.83 mm for the depth (range, 0 to 1.46 mm; SD, 0.46 mm) and 0.54 mm for the height (range, 0 to 1.08 mm; SD, 0.41 mm). At the tibia, deviation of 0.74 mm (range, 0 to 1.2 mm; SD, 0.46 mm) was found. The fluoroscopy-based navigation system used in this study allows for precise tunnel positioning with deviations of 1 mm or less. This technique provides accurate tunnel placement in anterior cruciate ligament surgery.

Morphological Characterization of a Novel Scaffold for Anterior Cruciate Ligament Tissue Engineering

Tissue engineering offers an interesting alternative to current anterior cruciate ligament (ACL) surgeries. Indeed, a tissue-engineered solution could ideally overcome the long-term complications due to actual ACL reconstruction by being gradually replaced by biological tissue. Key requirements concerning the ideal scaffold for ligament tissue engineering are numerous and concern its mechanical properties, biochemical nature, and morphology. This study is aimed at predicting the morphology of a novel scaffold for ligament tissue engineering, based on multilayer braided biodegradable copoly(lactic acid-co-(e-caprolactone)) (PLCL) fibers The process used to create the scaffold is briefly presented, and the degradations of the material before and after the scaffold processing are compared. The process offers varying parameters, such as the number of layers in the scaffold, the pitch length of the braid, and the fibers' diameter. The prediction of the morphology in terms of pore size distribution and pores interconnectivity as a function of these parameters is performed numerically using an original method based on a virtual scaffold. The virtual scaffold geometry and the prediction of pore size distribution are evaluated by comparison with experimental results. The presented process permits creation of a tailorable scaffold for ligament tissue engineering using basic equipment and from minimum amounts of raw material. The virtual scaffold geometry closely mimics the geometry of real scaffolds, and the prediction of the pore size distribution is found to be in good accordance with measurements on real scaffolds. The scaffold offers an interconnected network of pores the sizes of which are adjustable by playing on the process parameters and are able to match the ideal pore size reported for tissue ingrowth. The adjustability of the presented scaffold could permit its application in both classical ACL reconstructions and anatomical double-bundle reconstructions. The precise knowledge of the scaffold morphology using the virtual scaffold will be useful to interpret the activity of cells once it will be seeded into the scaffold. An interesting perspective of the present work is to perform a similar study aiming at predicting the mechanical response of the scaffold according to the same process parameters, by implanting the virtual scaffold into a finite element algorithm.