Loss Of Knee Extension Research Articles

Thymol turbidity test is associated with the risk of cyclops syndrome following anterior cruciate ligament reconstruction

BackgroundCyclops nodule formation is a serious complication after anterior cruciate ligament (ACL) reconstruction. The purpose of our study was to investigate whether an increase in thymol turbidity test (TTT) values is involved in the development of cyclops nodule formation or cyclopoid scar formation following ACL reconstruction.MethodsBetween 2011 and 2014, 120 cases underwent outside-in ACL reconstruction. Forty-seven patients who had high TTT values were individually matched for age, sex, body mass index, and meniscus injury to a low TTT value group of 47 patients. The primary outcome was the occurrence of cyclops nodule formation or cyclopoid scar formation. All 94 patients were divided into 3 groups using surgical records and intra-operative video to enable a sub-analysis. The groups were a no-cyclops group, a cyclopoid group, and a cyclops group. Blood examinations, including TTT, and knee range of motion evaluations were performed before surgery, 3 months after surgery, and 1 year after surgery.ResultsThere were no differences in preoperative demographic data between the two groups. TTT values did not significantly influence cyclopoid scar formation (OR, 1.67; 95% CI, 0.62 to 4.66; p = 0.362). However, patients with cyclops nodule formation showed significantly higher TTT values than the control patients. (OR, 9.34; 95% CI, 1.94 to 90.3; p = 0.002). Knee extension loss was observed in the cyclopoid and cyclops groups 3 months after reconstruction. In the cyclops group, arthroscopic resection of the cyclops nodule was performed 3 months after reconstruction. Eventually, almost full range of motion was restored in all patients.ConclusionsHigh TTT values before ACL reconstruction were an indicator of cyclops nodule formation. Furthermore, cyclopoid scar formations may not be the result of an individual’s immune reaction but that of extension loss in the early post-reconstruction phase.

How does frequency of manual therapy influence outcome for people with knee osteoarthritis? A feasibility study

Purpose: Manual therapy (MT) includes the application of physiotherapist-generated techniques to joint structures. It has proven benefit for increasing movement and decreasing pain for people with knee osteoarthritis (OA). However, aspects of dose such as optimal treatment frequency are unknown. The purpose of this study was to investigate feasibility of conducting a randomised controlled trial (RCT) to investigate differences in outcome at 6 months between MT delivered at a frequency of once or twice per week. Methods: Community-dwelling adults were recruited in Dunedin, New Zealand. Those who met ACR clinical classification for knee OA, and with loss of knee extension, were randomised to MT once per week (MT1), MT twice per week (MT2), or usual care (UC). Treatment groups received six sessions of MT. All participants received standard care of advice, education and exercise. Study feasibility outcomes included recruitment and retention rates; compliance to, and acceptability of study procedures to participants and researchers; and monitoring of adverse reactions. Pre-defined criteria of success were set. Clinical outcomes were knee extension and self-reported pain, function and quality of life (QoL) using KOOS. Blinded assessment was at 3-weeks, 6-weeks and 6-months. We report 6-month outcomes here. Descriptive statistics report feasibility outcomes and characteristics of the study population. Within group and between groups change in clinical outcomes were analysed using the Student t-test or Wilcoxon rank sum test. Results: Forty-five participants were recruited in a 4-month period: mean age 60 (SD 15) years, 23 (59%) females. Retention rate was 87% at 6-months. Compliance to allocated treatment frequency showed 80% of participants were 100% compliant. Study procedures were acceptable. There were no severe adverse reactions attributable to MT. All clinical outcomes improved at 6-months (Table 1).Table 1Change in clinical outcomes from baseline to 6-monthsGroupKnee Extension gained(degrees) Mean (SD)Pain Mean (SD)Function Mean (SD)QoL Mean (SD)MT27.6 (4.4)*9.9 (17.1)‡15.2 (18.6)*8.5 (15)NSMT14.2 (2.7)*9.1 (13.5)‡10.2 (10.3)*9.8 (12.4)*UC3.2 (3.1)*10.1 (17.2)NS7.2 (16.7)NS4.5 (19.2)NS* P < 0.01; ‡P < 0.05; NS = not significant Open table in a new tab * P < 0.01; ‡P < 0.05; NS = not significant For between group differences at 6-months: MT was significantly better than UC for increasing knee extension (P < 0.05), and MT2 was significantly better than MT1 (P < 0.03). There were no significant between group differences at 6-months for pain, function or QoL. Conclusions: The study design was feasible, with high compliance to treatment frequency. This is important, as the main aim of the research is to identify optimal treatment frequency. An 87% retention rate was less than a pre-defined criterion (90%). This will inform sample size calculation for a future RCT, as will data variance. We acknowledge the preliminary nature of clinical outcomes. However, there were encouraging changes in knee extension and patient self-reported measures, suggesting the study question is worth pursuing in a fully powered RCT with similar design. While sample size was adequate for a feasibility study, it may be too small to detect clinically relevant differences. Despite large standard deviations, and wide 95% CI (data not shown), MT2 appeared to show greater improvement in clinical outcomes than other groups. If this trend were repeated in a fully powered study, it would support more frequent treatment sessions. Improvements may reflect benefit of repeated contact with research physiotherapists, and usefulness of the standardised intervention. Both the feasibility and clinical outcomes support conduct of a future RCT, and results will inform sample size calculation and minor changes to study design.

Distal femoral flexion deformity from growth disturbance treated with a two-level osteotomy and internal lengthening nail

Salter Harris fractures of the distal femur can lead to growth disturbance with resulting leg length inequality and knee deformity. We have looked at a case series (3) of patients who presented with a distal femur flexion malunion and shortening treated with a distal femoral osteotomy and plating and a proximal femoral osteotomy with a magnetic internal lengthening nail. Does a two-level osteotomy and internal fixation approach provide a reliable result both radiographically and functionally? The average knee extension loss was 12°, LLD 47 mm, PDFA 65°, MAD 2 mm. The patients were treated with an acute, posterior, opening wedge osteotomy of the distal femur stabilized with a lateral plate and screws and grafted with cancellous chips and putty. A second osteotomy was made proximally in the femur percutaneously, and the internal lengthening nail was inserted. Lengthening was done at approximately 1 mm/day. The average extension gain was 12°; amount of lengthening at the proximal site was 40 mm, LLD was 3 mm. The average PDFA was 81°, and MAD 3 mm. There were no complications. Functional results were excellent. Bone healing index was 24 days/cm. The average distance from the distal osteotomy to the joint line was 57 mm. The technique of two-level femur osteotomy stabilized with a plate and lengthening nail yielded excellent results with acceptable correction of deformity, full knee extension, and improved function. There were no complications including implant failure, infection, need for blood transfusion, knee stiffness, nonunion, compartment syndrome, or malunion.

Posterior Capsulotomy of the Knee: Treatment of Minimal Knee Extension Deficit

The loss of knee extension, even if minimal, is disabling and considerably affects the individual's quality of life. This loss of extension can be a consequence of prior surgery, including a previous anterior cruciate ligament reconstruction. Although this loss of extension may be treated through an isolated arthroscopic procedure, a more severe case may warrant an invasive approach. In these cases, a posterior capsulotomy of the knee may be done if all conservative measures have been exhausted. This procedure has been proven to be safe and effective in the re-establishment of full extension in the setting of a minor flexion contracture of the knee. The purpose of this Technical Note was to describe our preferred technique when performing an open posterior capsulotomy of the knee for the treatment of minimal extension deficit.

Results of Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autografts: Objective Factors Associated With the Development of Osteoarthritis at 20 to 33 Years After Surgery

Background: Few studies exist that report objective radiographic and physical examination results at >20 years after anterior cruciate ligament (ACL) reconstruction. Hypothesis: The risk of osteoarthritis (OA) at >20 years after surgery would be statistically significantly higher if an increased severity of factors was present. Study Design: Cohort study; Level of evidence, 2. Methods: Between 1982 and 1994, 1428 knees met the inclusion criteria of being primary ACL surgery, having no existing OA or other ligamentous laxity, and having no known graft tear. Prospective data analyzed included demographics; meniscus and articular cartilage status; ratings of bilateral standing posteroanterior weightbearing, lateral, and Merchant view radiographs; KT-1000 arthrometer measurements; and range of motion measurements. Radiographs were graded for joint space narrowing, sclerosis, and osteophytes according to International Knee Documentation Committee (IKDC) criteria. Multivariate and univariate logistic models were used to determine the effect of potential predictors on the odds of having radiographic evidence of OA. IKDC and Cincinnati Knee Rating System (CKRS) subjective surveys were conducted. Results: A minimum 20-year objective follow-up was obtained for 423 knees at a mean of 22.5 ± 2.1 years postoperatively. If a patient lacked normal extension or flexion at discharge, the odds of lacking normal extension or flexion at follow-up were 19.7 and 7.97, respectively (P < .001). Radiographic ratings were normal for 35.2%, nearly normal for 36.2%, abnormal for 20.1%, and severely abnormal for 8.5%. Multivariate analysis showed that the predictive factors for the presence of OA in the long-term were medial meniscectomy, older age at surgery, and less than normal knee extension at discharge. The odds ratios for statistically significant factors for the presence of any OA at follow-up were 2.02 for knee extension loss at discharge, 2.98 for medial meniscectomy, 1.65 for lateral meniscectomy, 1.06 for age at follow-up, 1.62 for chronic injury type, and 2.17 for articular cartilage damage. The IKDC and CKRS subjective scores were progressively and statistically significantly lower as the level of OA was greater. Conclusion: The prevalence rate of developing moderate to severe OA at >20 years after ACL reconstruction was 28.6%. Significant factors predictive of OA in the long-term were older age at surgery, medial meniscectomy, and knee extension loss.

Dose hyperextension maneuver prevent knee extension loss after arthroscopic ACL reconstruction?

Dose hyperextension maneuver prevent knee extension loss after arthroscopic ACL reconstruction?

Notchplasty for the Arthroscopic Treatment of Limited Knee Extension

Knee osteoarthritis may lead to narrowing of the intercondylar notch due to osteophyte formation, thereby causing changes in native knee biomechanics. The normal close contact between the condyles and the anterior cruciate ligament (ACL) during knee extension may be compromised due to narrowing of the notch and result in ACL damage, progression of knee osteoarthritis, and loss of knee extension. Outcomes after a notchplasty procedure are well reported for ACL reconstruction in young patients. However, there remains a lack of studies evaluating this procedure in the setting of knee osteoarthritis in patients with a symptomatic loss of knee extension. The purpose of this Technical Note is to present our preferred surgical technique for the treatment of loss of knee extension in the setting of knee osteoarthritis in conjunction with osteophyte formation in the intercondylar notch.

Spontaneous Rupture of Quadriceps Tendon: A Report of Two Cases and Review of the Literature

Abstract Introduction Spontaneous rupture of the quadriceps tendon is rare. A sudden snap in the knee and feeling of giving way and occasionally falling are associated with rupture of the tendon. Subsequently, the loss of extensor mechanism of the knee limits ambulation. The aim of this report is to highlight this rare entity and to demonstrate that simple tendon repair could also give good results. Presentation of case The two patients were middle aged who were apparently healthy with active lifestyles prior to their injuries. The first patient is a 61-year-old lady who was descending the staircase when she suddenly felt her knee gave way. She supported herself on the rail and subsequently started ambulating with a stick until presentation. The second patient is a 57-year-old male who was doing a pre-game work out in a lawn tennis court when he felt a sudden pull on his right knee and he slumped. After some weeks, his pain subsided but he noticed poor clearance during gait. A big defect, just above the patella was found in the usual position of the quadriceps tendon in each patient. Simple end-to-end tendon repairs were done for both patients with excellent restoration of the extensor mechanism. Discussion Spontaneous rupture of a strong tendon such as quadriceps is not common. The sudden episode of pain, knee swelling, a gap in the quadriceps and loss of knee extension make clinical diagnosis unmistakable. However, radiological exclusion of patella fracture is important. Conclusion Restoration of the extensor mechanism of the knee is a sine qua non for effective ambulation. The quadriceps pull would always create a gap in the tendon and healing is only possible by surgical apposition of the tendon ends and in our cases by direct suturing.

Anterior tibial tubercle osteotomy using cerclage wire fixation in total knee replacement: a modification of the usual technique.

Anterior tibial tubercle (ATT) osteotomy facilitates exposure in knee arthroplasty. However, it is not without complications. We have introduced some technical modifications that reduce the surgical aggression by designing a short osteotomy that does not invade the intramedullary canal, and synthesizing it with three cerclage wires with a particular layout that increases the solidity of the system. A retrospective review was performed on the surgical revision of total knee replacement cases intervened in our center that required an ATT osteotomy from February 2014 to February 2015, and who had a minimum clinical follow-up of 12months. In all cases, there was an average proximal increase in ATT of 5mm and, however, did not result in any loss of knee extension. All the osteotomies achieved complete bone consolidation at 3months. There were no other complications. Our technique may be a valid option as it shows satisfactory results and demonstrates that a small increase in ATT does not affect the final clinical outcome.

Significant associated MRI findings in patients with anterior cruciate ligament stump entrapment.

Objective of this study was to determine the relationship between development of stump entrapment (SE) lesions and associated injuries in patients with knee extension deficits who underwent anterior cruciate ligament (ACL) reconstruction surgery. This retrospective study included 79 patients who had an arthroscopy-proven ACL rupture causing knee extension loss. Presence and type of the SE lesions, injuries of collateral-cruciate ligaments and bones, and tears of the menisci were evaluated and recorded on magnetic resonance imaging. The SE lesions were significantly more common in patients who had compressive posterior lateral tibial plateau fractures, tibia medial plateau edema and medial collateral ligament (MCL) injuries compared to the patients without stump lesions (p < 0.05). Posterior cruciate ligament (PCL) partial tears or sprains were significantly more common in patients with SE 1 lesions compared to the patients with SE 2 lesions (OR = 6.72; 95% CI: 1.56-28.93). SE is significantly more common in patients with compressive posterior lateral tibial plateau fractures, tibia medial plateau edemas and MCL injuries. PCL injury is more common in patients with type 1 SE.

Does the hyperextension maneuver prevent knee extension loss after arthroscopic anterior cruciate ligament reconstruction?

BackgroundDisruption of the anterior cruciate ligament (ACL) is one of the most frequent musculoskeletal injuries affecting physically active men and women. In the United States, an estimated 200,000 ACL reconstructions are performed annually. One of the most common complications of ACL reconstruction is loss of extension. The purpose of this study was to assess the effects of the hyperextension maneuver on preventing knee extension loss after arthroscopic ACL reconstruction.Materials and methodsIn this prospective randomized clinical trial study, 100 adult patients with a documented complete ACL tear were randomized to two groups. All patients underwent arthroscopic ACL reconstruction with quadrupled semitendinosus and gracilis autograft by the senior author based on the same technique and instruments. However, the hyperextension maneuver was only performed in 50 patients during autograft fixation on the tibial side (case group). The postoperative rehabilitation protocol was similar for both groups. The knee range of motion and extension limit was evaluated at 2, 6, 12, and 24 weeks and at 1 year postoperatively.ResultsOne hundred patients (88 male and 12 female) aged from 17−36 years (average 26.9 years) were included in our study. The two groups were similar regarding age, sex, and dominant side involvement (P >0.4).The difference between the two groups was significant only at 2 weeks (P <0.02). After 2 weeks, although the rate of limited extension was higher in the control group, no significant difference was seen between the groups.ConclusionAlthough the hyperextension technique during graft fixation on the tibial side may induce better range of motion in the first 2 weeks after ACL reconstruction surgery, this effect is not significant after 2 weeks.Level of evidenceTherapeutic level II.

Bilateral Simultaneous Quadriceps Tendon Rupture in a 24-Year-Old Obese Patient: A Case Report and Review of the Literature.

Introduction. Simultaneous bilateral quadriceps tendon ruptures (SBQTR) are uncommon knee injuries and most frequently occur in male patients, over 50 years of age. It can be associated with one or more predisposing risk factors like obesity, steroids use, and hyperparathyroidism. The main focus of this paper is to review SBQTR in obese patients. Case Report. We are reporting the youngest patient in the literature to date, a 24-year-old obese male patient, who presented to the emergency department complaining of bilateral knee pain and inability to walk after a fall during a basketball game. His clinical examination revealed the presence of a palpable suprapatellar gap and loss of knee extension bilaterally. Magnetic resonance imaging (MRI) confirmed that both of his quadriceps tendons were ruptured. A day after his diagnosis, the patient underwent successful operative repair followed by rehabilitation. At the two-year follow-up, the patient had full strength of both quadriceps muscles with no extension lag. Conclusion. The diagnosis of SBQTR can be challenging. Early diagnosis and treatment are associated with better functional outcome compared to delayed treatment. Physicians should have a high index of clinical suspicion in order not to miss such an injury and achieve favourable outcomes.

Knee Extension Range of Motion at 4 Weeks Is Related to Knee Extension Loss at 12 Weeks After Anterior Cruciate Ligament Reconstruction.

Background:The anterior cruciate ligament (ACL) is commonly torn, and surgical reconstruction is often required to allow a patient to return to their prior level of activity. Avoiding range of motion (ROM) loss is a common goal, but little research has been done to identify when ROM loss becomes detrimental to a patient’s future function.Purpose:To determine whether there is a relationship between early knee side-to-side extension difference after ACL reconstruction and knee side-to-side extension difference at 12 weeks. The hypothesis was that early (within the first 8 weeks) knee side-to-side extension difference will be predictive of knee side-to-side extension difference seen at 12 weeks.Study Design:Cohort study; Level of evidence, 3.Methods:Knee side-to-side extension difference measures were taken on 74 patients undergoing ACL reconstruction rehabilitation at the initial visit and 4, 8, and 12 weeks postoperatively. Visual analog scores (VAS) and International Knee Documentation Committee (IKDC) scores were also recorded at these time frames.Results:There was a strong relationship between knee extension ROM at 4 and 12 weeks (r = 0.639, P < .001) and 8 and 12 weeks (r = 0.742, P < .001). When the variables of knee extension ROM at initial visit and 4 and 8 weeks were entered into a regression analysis, the predictor variable explained 61% (R2 = 0.611) of variance for knee extension ROM at 12 weeks, with 4 weeks (R2 = 0.259) explaining the majority of this variance.Conclusion:This study found that a patient’s knee extension at 4 weeks was strongly correlated with knee extension at 12 weeks.Clinical Relevance:This information may be useful for clinicians treating athletic patients who are anxious for return to sport by providing them an initial goal to work toward in hopes of ensuring successful rehabilitation of their knee.

Magnetic resonance imaging of cyclops lesion as a cause of persistent morbidity after anterior cruciate ligament reconstruction

Localized anterior arthrofibrosis (cyclops lesion) is having around 1-9.8% frequency rate after anterior cruciate ligament (ACL) reconstruction. It has been reported to be a significant cause of loss of knee extension after reconstruction of the ACL of the knee. We present a case report of a patient with prior ACL reconstruction who presented with pain and loss of extension following surgery. MR imaging revealed the typical features of cyclops lesion. Repeat arthroscopy excision of the lesion is the only treatment to reduce the morbidity of the patient.

Prolonged Epidural Infusion Improves Functional Outcomes Following Knee Arthroscopy in Patients with Arthrofibrosis after Total Knee Arthroplasty: A Retrospective Evaluation.

A total of 20 consecutive patients with knee stiffness post total knee arthroplasty (TKA) underwent arthroscopic lysis of adhesions and manipulation plus indwelling epidural were evaluated retrospectively. Epidural catheters were placed preoperatively for an intended 6 weeks of postoperative analgesia to facilitate intensive physical therapy. The mean loss of knee extension immediately before incision was 13.5 ± 9.1 degrees (range, 0-35 degrees) and flexion was 77.65 ± 19.2 degrees (range, 45-125 degrees). At the 6-week and final (mean, 0.47 years) follow-up, the loss of extension was 1.5 ± 5.1 degrees (range, -10 to +7 degrees) and 5.4 ± 4.7 degrees (range, 0-15 degrees), respectively, and flexion was 99.7 ± 12.3 degrees (range, 75-120 degrees) and 98.5 ± 16.1 degrees (range, 75-130 degrees), respectively. Of the 20 patients, 2 missed their 6-week clinic visit. Improvements in motion immediately preoperative to 6-week and final follow-up were each significant (p < 0.01). At examination 6 weeks postoperatively, 94.4% of patients met the definition for clinical motion success and 70% maintained success at final follow-up. Visual analog scale improved significantly from 5.4 to 2.0 (p < 0.01) at 6 weeks postoperative in the 12 patients with this data recorded. On the basis of this data, use of tunneled epidurals with arthroscopic lysis of adhesions for arthrofibrosis after TKA is correlated with a high likelihood of functional success postoperatively as measured by range of motion improvement.

Outcome of anatomical double-bundle ACL reconstruction using hamstring tendons via an outside-in approach

To evaluate the clinical outcome of anatomical double-bundle anterior cruciate ligament (ACL) reconstruction using multistranded hamstring tendons via an outside-in approach. One hundred and twenty-one patients (mean age 28±10years) who underwent ACL reconstruction were examined. Using an outside-in femoral drill guide, an upper femoral tunnel for the anteromedial (AM) graft was created just below the superior articular cartilage margin of the medial wall of the lateral condyle through a small incision. A lower femoral tunnel for the posterolateral (PL) graft was drilled in the centre of the inferior-posterior half of the attachment area behind the resident's ridge in the same manner. Two tibial tunnels were created at the centre of the AM and PL bundle footprints of a normal ACL. Patients were evaluated at 24months postoperatively. According to the IKDC form, 52 knees (43%) were graded as normal, 64 (53%) as nearly normal, 1 (1%) as abnormal and 4 (3%) as graft rupture due to re-injury. Loss of knee extension of <5° was observed in one patient (1%). Among 111 patients who were directly evaluated, none showed loss of flexion of <5°. Lachman sign was negative in 103 patients (93%), while the pivot shift test result was negative or equivalent to that of the contralateral healthy knee in 103 patients (93%). The mean side-to-side difference in anterior laxity at manual maximum force with the KT-2000 arthrometer(®) was 0.9±1.1mm, and 94% of patients showed a range between -1 and +2mm. The anatomical double-bundle outside-in ACL reconstruction provided a satisfactory short-term outcome. Case series, Level IV.

Hamstring flexibility increases the same with 3 or 9 repetitions of stretching held for a total time of 90 s

ObjectiveTo determine if stretching for a constant total time with differing repetition durations and number of repetitions over a 6-week period produced different changes in hamstring flexibility measured by knee extension range of motion (ROM). DesignRandomized Control Trial. SettingUniversity laboratory. Subjects34 volunteers, 18–25 years old with tight hamstrings as determined by a greater than 30° loss of knee extension with hip flexed to 90° participated in the study. Main outcome measuresChange in knee extension ROM was assessed in participants who were randomly assigned to a control, or to a stretching group of either 10 s for 9 repetitions or 30 s for 3 repetitions, for a total stretch time of 90 s. Each group stretched 6 days a week for 6 weeks. ResultsPre to post stretch comparison indicated both stretching groups were successful in increasing joint ROM (11.6 ± 5.25°–13.4 ± 5.36°) over the control (F = 19.77, p < 0.003). However, there was no significant difference between the stretching groups (p = 0.9). ConclusionStretching for 6 weeks for total of 90 s showed increased joint ROM regardless of the number of repetitions or the duration of each individual stretch.

The in vivo relationship between anterior neutral tibial position and loss of knee extension after transtibial ACL reconstruction

BackgroundRestoration of anterior tibial stability while avoiding knee extension deficit are a common goal of anterior cruciate ligament (ACL) reconstruction. However, achieving this goal can be challenging. The purpose of this study was to determine whether side-to-side differences in anterior tibial neutral position and laxity are correlated with knee extension deficit in subjects 2years after ACL reconstruction. MethodsIn the reconstructed and contralateral knees of 29 subjects with transtibial reconstruction, anterior tibiofemoral neutral position was measured with MRI and three-dimensional modeling techniques; terminal knee extension at heel strike of walking and during a seated knee extension were measured via gait analysis; and anterior laxity was measured using the KT-1000. ResultsKnees that approached normal anterior stability and anterior tibial position had increased extension deficit relative to the contralateral knee. On average the reconstructed knee had significantly less (2.1±4.4°) extension during active extension and during heel strike of walking (3.0±4.3º), with increased anterior neutral tibial position (2.5±1.7mm) and anterior laxity (1.8±1.0mm). There was a significant correlation between side-to-side difference in anterior neutral tibial position with both measures of knee extension (walking, r=−0.711, p<0.001); active knee extension, r=−0.544, p=0.002). ConclusionThe results indicate a relationship between the loss of active knee extension and a change in anterior neutral tibial position following non-anatomic transtibial ACL reconstruction. Given the increasing evidence of a link between altered kinematics and premature osteoarthritis, these findings provide important information to improve our understanding of in vivo knee function after ACL reconstruction.

A Novel Medial Collateral Ligament Reconstruction Procedure Using Semitendinosus Tendon Autograft in Patients With Multiligamentous Knee Injuries

Background: Several new procedures for medial collateral ligament (MCL) reconstruction using a hamstring tendon graft have been reported in the 2000s. However, the midterm and long-term clinical outcomes of these procedures have not been reported. Hypothesis: Postoperative medial stability of the knee that underwent our MCL reconstruction may not be significantly different from that of the noninjured knee. Study Design: Case series; Level of evidence, 4. Methods: A total of 37 patients who sustained multiligamentous knee injuries underwent combined MCL and cruciate ligament reconstruction at our institution between 1994 and 2007. Thirty of the 37 patients were clinically evaluated at least 2 years after surgery. Sixteen had combined MCL and anterior cruciate ligament (ACL) reconstruction, 5 had combined MCL and posterior cruciate ligament (PCL) reconstruction, and 9 had combined MCL, ACL, and PCL reconstruction. The International Knee Documentation Committee (IKDC) evaluation form and Lysholm score were used to evaluate postoperative knee function. Anteroposterior knee laxity was examined with a KT-2000 arthrometer. To assess objective medial instability, we performed a stress radiograph examination under valgus stress with the knee at 20° of flexion. Results: At the final follow-up, 1 patient showed a loss of knee extension of more than 3°. Five patients revealed a loss of knee flexion of 6° to 15° and 2 patients of 16° to 25°. Lysholm scores averaged 94.8 points. In the IKDC evaluation, 9 patients were graded as A, 17 were graded as B, 3 were graded as C, and 1 was graded as D. In the stress radiograph examination, the mean medial joint opening was 8.5 ± 1.6 mm in the reconstructed knee and 8.0 ± 1.2 mm in the healthy opposite knee. There was no significant difference in the medial joint opening between reconstructed and intact knees. Conclusion: Medial collateral ligament reconstruction for chronic combined knee instabilities can be safely performed using hamstring tendon autografts, and the clinical outcome with a minimum 2-year follow-up was favorable with satisfactory stability.

Anterior cruciate ligament remnants nodule: potential factor causing extension loss

Background Extension loss caused by anterior cruciate ligament (ACL) remnants nodule was usually reported by case reports. There is no systematic report analyzing ACL remnants nodule. The purpose of this study was to investigate the characteristics of extension loss caused by remnants of ACL after injury. Methods From June 2008 to December 2011, ACL remnants were observed by arthroscopy in 1012 cases with ACL injuries at the time of primary reconstruction. ACL remnants nodules were recorded. The time of extension loss occurrence caused by ACL remnants nodule, associated symptom and sign, magnetic resonance imaging (MRI), and arthroscopic findings were observed. Histological examination was performed on the lesion resected. Results Twenty-four cases with ACL remnants nodules were found by arthroscopy. Among them extension loss caused by remnants of ACL happened in 19 cases (male 13; female 6). The average extension loss were 9.1 (range, 5 202). The average time from injury to operation was 8.9 weeks (range, 3)26 weeks). The remnants of ACL depressed in the inter-condylar notch were found on MRI in 15 cases with extension loss. The rupture locations of ACL were all close to the upper insertion of ACL. The microscopic examination of the resected remnants of ACL revealed disorganized fibrous connective tissue and tissue of ACL ligament. Conclusions Among 1012 ACL injury cases, 24 ACL remnants nodules were found with arthroscopy and 19 nodules could cause knee extension loss. ACL remnants nodule should be paid attention to as a potential cause of extension loss.