Unilateral Anterior Cruciate Ligament Rupture Research Articles

Effects of exercise prehabilitation before anterior cruciate ligament reconstruction on functional outcomes during pre- and postoperative rehabilitation — protocol for a single-blinded randomised controlled trial

BackgroundAlthough a benefit of preoperative training prior to anterior cruciate ligament (ACL) reconstruction is likely, there is no consensus on the optimal content (criteria-based programme), supervision (one-on-one guidance or self-administered training) and general setting of preoperative training after ACL injuries. The purpose of this trial is to investigate the efficacy of an individually adaptive, guided, structured and criteria-based preoperative rehabilitation programme in comparison to a non-guided and self-administered home training programme.MethodsThe planned single-blinded randomised controlled trial study was approved by the ethics committee of the German Sport University on June 14, 2022 (ethics application no. 093/2022) and prospectively registered (DRKS-ID: DRKS00030312; date of registration: 26.09.2022). N = 114 participants between 16 and 60 years of age with a unilateral ACL rupture and scheduled ACL reconstruction with a hamstring or quadriceps tendon autograft will be randomly (block-randomisation, 1:1 allocation) and blinded assigned to one of two groups: intervention group (structured, criteria-based, guided prehabilitation training) and comparator group (non-guided, self-administered home training). After surgical reconstruction, patients of both groups participate in the same standard, functional measurement-guided, postoperative rehabilitation programme. Stepwise increasing the functional requirements of the assessments, all participants participate in testing at the day of anamnesis (t1), 1–7 days before surgical reconstruction (t2), day of surgical reconstruction (t3) and 30 (t4), 60 (t5), 90 (t6) and 180 (t7) days post-reconstruction.The primary outcome is the overall self-reported knee condition, assessed by the sum score of all sub-scales of the Knee injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes include functional outcomes (range of motion, knee flexors and extensors and plantar flexors strength/torque, functional postural control, jumping ability), workability and return to sport (RTS) (psychological readiness, RTS success).DiscussionThe planned study targets to fill a gap in the evidence regarding effective designs of prehabilitation training before surgical ACL reconstruction. Potential difficulties that could affect the conduct of the study are lack of treatment adherence of the patients and high dropout.Trial registrationGerman Register of Clinical Trials DRKS-ID: DRKS00030312. Registered on 26 September 2022.

Acute effects of ipsilateral semitendinosus and gracilis autograft anterior cruciate ligament reconstruction on lower limb muscle activation

There is little information regarding the acute repercussions of anterior cruciate ligament (ACL) reconstruction on muscle activation, especially on the proximal hip muscles. Thus, this study analyzed the acute effects of ACL reconstruction with doubled semitendinosus/gracilis (ST/G) autografts on lower limb muscle activation. Fourteen male recreational athletes that presented a primary unilateral ACL rupture and underwent the ACL reconstruction with an ST/G graft. Surface electromyographic (sEMG) signal were recorded from each participant during the maximal voluntary isometric contraction (MVIC) of the gluteus maximus and gluteus medius, vastus lateralis and vastus medialis, semitendinosus, biceps femoris, and medial gastrocnemius muscles and also during bipodal mini-squatting with open and closed eyes, before surgery and 15 days postoperatively. (sEMG) signal were normalized to isometric peak electromyography.The postoperative assessment showed reduced muscle activation in the gluteus maximus (p = 0.013, d:0.48) in non-operated limb and also in the muscle gluteus medius (p = 0.013, d:0.79), vastus medialis (p = 0.035, d:0.63) semitendinosus (p = 0.001, d:2.46), biceps femoris (p<0.001, d:1.5), and medial gastrocnemius (p = 0.001, d:1.45) during MVIC in the operated limb. The postoperative assessment also revealed alterations in the sEMG activity of the hip and local thigh muscles in the operated and non-operated limbs during mini-squatting with opened eyes and closed eyes (p<0.05). ACL reconstruction surgery with a doubled ST/G autograft may promote immediate changes in lower limb muscle activation of the operated and non-operated limb.

Gait analysis among patients with quadriceps weakness after anterior cruciate ligament reconstruction post 9 months

Background: One of the most frequent musculoskeletal injuries in young adults is anterior cruciate ligament (ACL) damage. Following ACL reconstruction, there have been reports of changes in the lower extremity joints' kinematics and kinetics, including decreased knee ROM during the stance and swing phases of walking and weakened knee joint flexor and extensor muscles. Objective: To analyze the gait parameter among patients with Quadriceps weakness after Anterior Cruciate Ligament Reconstruction (ACLR) post 9 months. Methods: A descriptive cross-sectional study was carried out on 143 soccer players with age range of 18-39 years, who had unilateral ACL rupture managed through arthroscopic-assisted ACLR Endo-button procedure post 9 months. Written informed consent from the participants was taken before data collection. Observational gait analysis (OGA) with 66 check-off option is used to identify the gait deviations among the patients. Results: In ankle during the weight acceptance phase, inadequate dorsiflexion (36.4%) and plantar flexion (23.8%) were reported; during single limb support, early heel off was (4.2%) and inadequate dorsiflexion (44.1%) and during single limb advancement, toe drag was (18.2%) and inadequate dorsiflexion (65%). In knee during the weight acceptance phase, inadequate extension (59.4%) and flexion (16.1%) were reported; during single limb support. Conclusion: OGA revealed gait deviations as inadequate dorsiflexion, inadequate extension, and inadequate flexion due to eccentric loss of quadriceps widely after ACL reconstruction post 9 months.

Valid and reliable diagnostic performance of dual-energy CT in anterior cruciate ligament rupture

ObjectivesTo determine whether dual-energy CT (DECT) can be used to accurately and reliably detect anterior cruciate ligament (ACL) rupture.Materials and methodsParticipants with unilateral ACL rupture were prospectively enrolled, and the bilateral knees were scanned by DECT. A tissue-specific mapping algorithm was applied to improve the visualization of the ACLs. The 80-keV CT value, mixed-keV CT value, electron density (Rho), and effective atomic number (Zeff) were measured to quantitatively differentiate torn ACLs from normal ACLs. MRI and arthroscopy served as the reference standards.ResultsFifty-one participants (mean age, 27.0 ± 8.7 years; 31 men) were enrolled. Intact and torn ACLs were explicitly differentiated on color-coded DECT images. The 80-keV CT value, mixed-keV CT value, and Rho were significantly lower for the torn ACLs than for the intact ACLs (p < 0.001). The optimal cutoff values were an 80-keV CT value of 61.8 HU, a mixed-keV CT value of 60.9 HU, and a Rho of 51.8 HU, with AUCs of 98.0% (95% CI: 97.0–98.9%), 99.2% (95% CI: 98.6–99.7%), and 99.8% (95% CI: 99.6–100.0%), respectively. Overall, DECT had almost perfect reliability and validity in detecting ACL integrity (sensitivity = 97.1% [95% CI: 88.1–99.8%]; specificity = 98.0% [95% CI: 89.5–99.9%]; PPV = 98.0% [95% CI: 93.0–99.8%]; NPV = 97.1% [95% CI: 91.7–99.4%]; accuracy = 97.5% [95% CI: 94.3–99.2%]). There was no evidence of a difference between MRI and DECT in the diagnostic performance (p > 0.99).ConclusionDECT has excellent diagnostic accuracy and reliability in qualitatively and quantitatively diagnosing ACL rupture.Clinical relevance statementDECT could validly and reliably diagnose ACL rupture using both qualitative and quantitative methods, which may become a promising substitute for MRI to evaluate the integrity of injured ACLs and the maturity of postoperative ACL autografts.Key Points• On color-coded DECT images, an uncolored ACL was a reliable sign for qualitatively diagnosing ACL rupture.• The 80-keV CT value, mixed-keV CT value, and Rho were significantly lower for the torn ACLs than for the intact ACLs, which contributed to the quantitative diagnosis of ACL rupture.• DECT had an almost perfect diagnostic performance for ACL rupture, and diagnostic capability was comparable between MRI and DECT.

Functional outcomes after anterior cruciate ligament reconstruction: unravelling the role of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries

BackgroundNumerous individual, temporal, injury- and surgery-specific factors impact the functional capacity during rehabilitation, return to sports (RTS), and re-injury prevention after an anterior cruciate ligament (ACL) reconstruction.PurposeThis multicentre cohort study evaluated the isolated and interactive contributions of time between injury and surgery, time since reconstruction, age, gender, pain, graft type, and concomitant injuries as to inertial sensor-assessed motor function after ACL reconstructions in multiple linear mixed model regressions.MethodsAnonymized data were retrieved from a nationwide German registry. In this cohort study, patients with an acute unilateral ACL rupture, with or without concomitant ipsilateral knee injuries, and having passed an arthroscopically assisted anatomic reconstruction were included. Potential predictors were age [years], gender/sex, time since reconstruction [days], time between injury and reconstruction [days], concomitant intra-articular injuries (isolated ACL tear, meniscal tear, lateral ligament, unhappy triad), graft type (hamstrings, patellar, or quadriceps tendon autograft), and pain during each measurement (visual analogue scale 0–10 cm). Repeated inertial motion unit-assessments of a comprehensive battery of classic functional RTS test were performed in the course of the rehabilitation and return to sports: Joint position sense/kinesthesia (Angle reproduction error [degrees]), Dynamic Balance Composite score [cm] of the Y-Balance test), drop jumps (Knee displacement [cm]), Vertical hop (Hopping height [mm]), Speedy jumps (Duration [seconds]), Side hops (Number of hops [n]), single leg hop for distance (hopping distance [cm]). Repeated measures multiple linear mixed models investigated the impact and nesting interaction of the potential predictors on the functional outcomes.ResultsData from 1441 persons (mean age 29.4, SD 11.8 years; 592 female, 849 male) were included. Most had an isolated ACL rupture: n = 938 (65.1%). Minor shares showed lateral ligament involvement: n = 70 (4.9%), meniscal tear: n = 414 (28.7%), or even unhappy triad: n = 15 (1%). Several predictors such as time between injury and reconstruction, time since reconstruction (estimates for ndays ranged from + .05 (i.e., an increase of the hopping distance of 0.05 cm per day since reconstruction occurs) for single leg hop for distance to + 0.17 for vertical hopping height; p < 0.001), age, gender, pain, graft type (patellar tendon graft: estimates between + 0.21 for Y-balance and + 0.48 for vertical hop performance; p < 0.001), and concomitant injuries contribute to the individual courses of functional abilities of the reconstructed side after ACL reconstruction. The unimpaired side was mostly influenced by sex, age, the time between injury and reconstruction (estimates between − 0.0033 (side hops) and + 0.10 (vertical hopping height), p < 0.001)), and time since reconstruction.ConclusionsTime since reconstruction, time between injury and reconstruction, age, gender, pain, graft type, and concomitant injuries are not independent but nested interrelating predictors of functional outcomes after anterior cruciate ligament reconstruction. It might not be enough to assess them isolated; the knowledge on their interactive contribution to motor function is helpful for the management of the reconstruction (earlier reconstructions should be preferred) deficit-oriented function-based rehabilitation (time- and function based rehabilitation instead of solely a time- or function based approach) and individualized return to sports strategies.

A whole genome sequencing approach to anterior cruciate ligament rupture-a twin study in two unrelated families.

Predisposition to anterior cruciate ligament (ACL) rupture is multi-factorial, with variation in the genome considered a key intrinsic risk factor. Most implicated loci have been identified from candidate gene-based approach using case-control association settings. Here, we leverage a hypothesis-free whole genome sequencing in two two unrelated families (Family A and B) each with twins with a history of recurrent ACL ruptures acquired playing rugby as their primary sport, aimed to elucidate biologically relevant function-altering variants and genetic modifiers in ACL rupture. Family A monozygotic twin males (Twin 1 and Twin 2) both sustained two unilateral non-contact ACL ruptures of the right limb while playing club level touch rugby. Their male sibling sustained a bilateral non-contact ACL rupture while playing rugby union was also recruited. The father had sustained a unilateral non-contact ACL rupture on the right limb while playing professional amateur level football and mother who had participated in dancing for over 10 years at a social level, with no previous ligament or tendon injuries were both recruited. Family B monozygotic twin males (Twin 3 and Twin 4) were recruited with Twin 3 who had sustained a unilateral non-contact ACL rupture of the right limb and Twin 4 sustained three non-contact ACL ruptures (two in right limb and one in left limb), both while playing provincial level rugby union. Their female sibling participated in karate and swimming activities; and mother in hockey (4 years) horse riding (15 years) and swimming, had both reported no previous history of ligament or tendon injury. Variants with potential deleterious, loss-of-function and pathogenic effects were prioritised. Identity by descent, molecular dynamic simulation and functional partner analyses were conducted. We identified, in all nine affected individuals, including twin sets, non-synonymous SNPs in three genes: COL12A1 and CATSPER2, and KCNJ12 that are commonly enriched for deleterious, loss-of-function mutations, and their dysfunctions are known to be involved in the development of chronic pain, and represent key therapeutic targets. Notably, using Identity By Decent (IBD) analyses a long shared identical sequence interval which included the LINC01250 gene, around the telomeric region of chromosome 2p25.3, was common between affected twins in both families, and an affected brother’. Overall gene sets were enriched in pathways relevant to ACL pathophysiology, including complement/coagulation cascades (p = 3.0e-7), purine metabolism (p = 6.0e-7) and mismatch repair (p = 6.9e-5) pathways. Highlighted, is that this study fills an important gap in knowledge by using a WGS approach, focusing on potential deleterious variants in two unrelated families with a historical record of ACL rupture; and providing new insights into the pathophysiology of ACL, by identifying gene sets that contribute to variability in ACL risk.

Tibiofemoral Relationship 3 Weeks After Anatomic Triple-Bundle Anterior Cruciate Ligament Reconstruction With 10 N of Initial Tension Is Closer to Normal Knee Versus That With 20 N of Initial Tension

PurposeThis study aimed to clarify the effect of initial graft tension on the ensuing tibiofemoral relationship and on 2-year clinical outcomes after anatomic triple-bundle anterior cruciate ligament (ACL) reconstruction. MethodsA total of 31 patients with primary unilateral ACL rupture (mean age, 25.1 years) were enrolled. Anatomic triple-bundle ACL reconstruction was performed using semitendinosus tendon autografts, and patients were grouped according to the total initial tension at graft fixation: 20 N for 16 patients between January 2012 and December 2012 and 10 N for 15 patients between January 2013 and December 2013. Three-dimensional computed tomography scans were performed preoperatively and at 3 weeks and 6 months postoperatively. The side-to-side difference of the 3-dimensional tibial position relative to the femur was compared at each time point. The side-to-side difference in anterior laxity was sequentially compared preoperatively, immediately after surgery, and at 6 months and 2 years postoperatively. Clinical outcomes at 2 years were likewise compared. ResultsOne patient in each group was excluded because of secondary ACL injury. At 3 weeks postoperatively, 2.5 ± 1.3 and 1.0 ± 1.3 mm of posterior tibial displacement and 3.8° ± 2.4° and 2.0° ± 1.7° of external rotation were observed in the 20- and 10-N initial tension groups, respectively, with significant differences (P = .006 and .033). At 6 months postoperatively, anterior displacement was 0.1/0.1 mm and external rotation was 0.8°/0.4° in both groups, without any significant differences. The 2-year clinical outcomes were satisfactory, including mean side-to-side difference in anterior knee laxity of 0.5 mm in both groups. ConclusionThe tibiofemoral relationship 3 weeks after anatomic triple-bundle ACL reconstruction with 10 N of initial tension is less constrained than that with 20 N. Six-month tibiofemoral relationship and 2-year clinical outcomes are satisfactory in both groups. Level of EvidenceIII, retrospective comparative trial

Changes of electroencephalography power spectrum during joint position perception test after anterior cruciate ligament rupture

OBJECTIVE To measure the electroencephalography (EEG) of the patients with anterior cruciate ligament (ACL) rupture when performing joint position perception movement task, to compare the differences between the ACL rupture side and the unaffected side, to identify the EEG change in the power spectrum caused by the ACL rupture, and to provide evidence for the diagnosis, treatment and rehabi-litation for ACL injury as well as knee instability. METHODS Sixteen male patients, selected from the Department of Sports Medicine, Peking University Third Hospital from November 2014 to April 2015, with only ACL rupture on one side used isokinetic muscle strength testing equipment were enrolled in the study to perform unilateral active knee joint positional movement and passive knee joint positional movement tasks. EEG was recorded to compare between the affected and unaffected limb of ACL rupture patients when doing single leg movement tasks, including passive knee joint position test and active knee joint position sensation test. The target position of the active knee joint position movement task and the passive knee joint position movement task was 30 degrees of knee flexion. RESULTS During the passive knee joint position test, there was no significant difference in EEG power spectrum of Delta[F (1, 15)=0.003, P=0.957, ηP2 =0.001], Theta[F (1, 15)=0.002, P=0.962, ηP2 < 0.001], Alpha[F (1, 15)=0.002, P=0.966, ηP2 =0.001], Beta[F (1, 15)=0.008, P=0.929, ηP2 =0.001] at Fz, Cz, and Pz between the affected and unaffected limbs in the ACL patients. During the active knee joint position movement task, the EEG power spectrum of Delta, Theta, Alpha, Beta at Fz and Cz location, on the affected side was significant higher than on the unaffected side. CONCLUSION This study compared the differences between the ACL rupture side and the unaffected side during active knee position movement task and passive knee position movement task, and identifyied the EEG changes in the power spectrum caused by the ACL rupture, It was found that the central changes caused by unilateral ACL rupture still existed during contralateral (unaffected) side movement. The EEG power spectrum of the affected side during active exercise was significantly higher than that of the unaffected side This study provides new electrophysiological evidence for the study of ACL injury.

Intraoperative pivot-shift accelerometry combined with anesthesia improves the measure of rotatory knee instability in anterior cruciate ligament injury

PurposeThe knee stiffness acquired following an Anterior Cruciate Ligament (ACL) injury might affect clinical knee tests, i.e., the pivot-shift maneuver. In contrast, the motor effects of spinal anesthesia could favor the identification of rotatory knee deficiencies prior to ACL reconstruction. Hence, we hypothesized that the intra-operative pivot-shift maneuver under spinal anesthesia generates more acceleration in the lateral tibial plateau of patients with an injured ACL than without.MethodsSeventy patients with unilateral and acute ACL rupture (62 men and 8 women, IKDC of 55.1 ± 13.8 pts) were assessed using the pivot-shift maneuver before and after receiving spinal anesthesia. A triaxial accelerometer was attached to the skin between Gerdys’ tubercle and the anterior tuberosity to measure the subluxation and reduction phases. Mixed ANOVA and multiple comparisons were performed considering the anesthesia and leg as factors (alpha = 5%).ResultsWe found a higher acceleration in the injured leg measured under anesthesia compared to without anesthesia (5.12 ± 1.56 m.s− 2 vs. 2.73 ± 1.19 m.s− 2, p < 0.001), and compared to the non-injured leg (5.12 ± 1.56 m.s− 2 vs. 3.45 ± 1.35 m.s− 2, p < 0.001). There was a presence of significant interaction between leg and anesthesia conditions (p < 0.001).ConclusionsThe pivot-shift maneuver performed under anesthesia identifies better rotatory instability than without anesthesia because testing the pivot-shift without anesthesia underestimates the rotatory subluxation of the knee by an increased knee stiffness. Thus, testing under anesthesia provides a unique opportunity to determine the rotational instability prior to ACL reconstruction.

Narrow Notch Width is a Risk Factor for Anterior Cruciate Ligament Injury in the Pediatric Population: A Multicenter Study

PurposeThe purposes of this study were to evaluate the notch width index (NWI) as a risk factor for anterior cruciate ligament (ACL) rupture in the pediatric and adolescent patient population via multicenter analysis and to detect any differences in the NWI among cohorts having sustained either a unilateral or bilateral ACL rupture.MethodsA consecutive series of patients ≤19 years old was enrolled from January 1999 through July 2010 at 2 academic pediatric orthopaedic tertiary-care hospitals. Demographic and anatomic morphology data were collected for 3 cohorts: unilateral ACL ruptures, bilateral ACL ruptures, and a control group. A single blinded reviewer determined notch width measurements via T2 coronal magnetic resonance imaging sequences in a standardized manner, using a previously described technique.ResultsOf the 68 patients included for analysis, 22 sustained unilateral ACL rupture, 23 sustained bilateral ruptures, and 23 comprised the control group. There was a statistically significant difference appreciated in direct comparison of the NWI in the bilateral rupture group and the control group, as well as between the unilateral rupture group and the control group. There was no statistically significant difference between the NWI in the unilateral versus the bilateral rupture group.ConclusionGiven the known inconsistencies in the existing literature, our findings provide further support of a narrow NWI as a significant contributing factor to both unilateral and bilateral ACL injury risk in the pediatric and adolescent patient population.Level of EvidenceIII, retrospective cohort study.

Differences in brain structure and theta burst stimulation-induced plasticity implicate the corticomotor system in loss of function after musculoskeletal injury.

Traumatic musculoskeletal injury (MSI) may involve changes in corticomotor structure and function, but direct evidence is needed. To determine the corticomotor basis of MSI, we examined interactions among skeletomotor function, corticospinal excitability, corticomotor structure (cortical thickness and white matter microstructure), and intermittent theta burst stimulation (iTBS)-induced plasticity. Nine women with unilateral anterior cruciate ligament rupture (ACL) 3.2 ± 1.1 yr prior to the study and 11 matched controls (CON) completed an MRI session followed by an offline plasticity-probing protocol using a randomized, sham-controlled, double-blind, cross-over study design. iTBS was applied to the injured (ACL) or nondominant (CON) motor cortex leg representation (M1LEG) with plasticity assessed based on changes in skeletomotor function and corticospinal excitability compared with sham iTBS. The results showed persistent loss of function in the injured quadriceps, compensatory adaptations in the uninjured quadriceps and both hamstrings, and injury-specific increases in corticospinal excitability. Injury was associated with lateralized reductions in paracentral lobule thickness, greater centrality of nonleg corticomotor regions, and increased primary somatosensory cortex leg area inefficiency and eccentricity. Individual responses to iTBS were consistent with the principles of homeostatic metaplasticity; corresponded to injury-related differences in skeletomotor function, corticospinal excitability, and corticomotor structure; and suggested that corticomotor adaptations involve both hemispheres. Moreover, iTBS normalized skeletomotor function and corticospinal excitability in ACL. The results of this investigation directly confirm corticomotor involvement in chronic loss of function after traumatic MSI, emphasize the sensitivity of the corticomotor system to skeletomotor events and behaviors, and raise the possibility that brain-targeted therapies could improve recovery.NEW & NOTEWORTHY Traumatic musculoskeletal injuries may involve adaptive changes in the brain that contribute to loss of function. Our combination of neuroimaging and theta burst transcranial magnetic stimulation (iTBS) revealed distinct patterns of iTBS-induced plasticity that normalized differences in muscle and brain function evident years after unilateral knee ligament rupture. Individual responses to iTBS corresponded to injury-specific differences in brain structure and physiological activity, depended on skeletomotor deficit severity, and suggested that corticomotor adaptations involve both hemispheres.

Bracing versus non-bracing after anterior cruciate ligament reconstruction surgery

Background and objectives: Anterior cruciate ligament reconstruction is a common procedure which can allow patients to return to their active lifestyle. Knee braces have been prescribed frequently to protect the anterior cruciate ligament graft after reconstruction. The aim of this study was to see the effect of postoperative bracing with non-bracing after one year follow-up. Methods: Thirty consecutive patients with a unilateral anterior cruciate ligament rupture were reconstructed. The first 15 patients were supplied postoperatively with a knee brace for 6 weeks. The next 15 patients were not supplied with a brace. The follow-up was based on the Lysholm functional score, Tegner activity level, manual Lachman test and pain by visual analog scale, each variable were recorded before surgery, 12 weeks, 24 weeks and one year after the surgery. Results: After one year follow up, the results of this study showed no statistically significant differences between the brace and non-brace groups with regard to Lysholm score (mean with brace was 87.26, with- out brace was 87.80), Tegner activity level (mean with brace was 6.26, without brace was 6.40 ) and manual Lachman test; however, the pain score was less with brace group in the short term follow up (at 12th postoperative week) but no statistically significant differences was found between the groups after 1 year follow up. Conclusions: Weather using functional brace or not after anterior cruciate ligament reconstruction depends on the orthopedic surgeon and the psychology and pain threshold of the patient.

Unanticipated jump-landing quality in patients with anterior cruciate ligament reconstruction: How long after the surgery and return to sport does the re-injury risk factor persist?

BackgroundInadequate reactions to unforeseen external stimuli are regarded as a major cause for non-contact anterior cruciate ligament (ACL) injuries. We aimed to delineate a potential deficit in the ability to perform unanticipated jump-landing manoeuvres, its sustainability and potential as a new outcome measure after ACL-reconstruction. MethodsPhysically active adults (n = 27, 13 females, 14 males, 29.7 standard deviation 3.1 years) with a history of unilateral ACL rupture and subsequent reconstruction (6 months to 7 years ago), cleared for return to sports, were included. All participants performed counter-movement jumps with unanticipated single leg landings. Visual information shown after jump take-off indicated the required landing leg. Jump time [s] and successfulness [yes/no], vertical peak ground reaction forces at landing [N], as well as time to stabilisation after landing [s] and path length of the centre of pressure (CoP, [mm]) were calculated. Limb symmetry ratios were determined and analysed for their association with the time since surgery. FindingsTime since ACL reconstruction was logarithmically (basis 10) associated with side symmetry improvements in peak ground reaction force (R2 = 0.23, p < .01) and time to stabilisation (R2 = 0.18, p < .01) during and after landing in unanticipated/unpredictable single-leg jump landing tasks. The asymmetry found persists up to 18–26 months post-surgery. InterpretationA deficit in unanticipated jump-landing ability seems to persist far beyond surgical restoration of mechanical stability and resumption of initial physical activities levels. The assessment of the ability to suddenly adapt movements to unanticipated visual stimuli may be a relevant complementary component within current functional testing canon in monitoring therapy success and return to sport testing.

Knee extensor and flexor strength before and after anterior cruciate ligament reconstruction in a large sample of patients: influence of graft type

ABSTRACTObjective: Hamstring and patellar tendon autografts are the most frequently-used graft types for anterior cruciate ligament (ACL) reconstruction, with no consensus on their respective effects on thigh muscle strength. The objective of this study was to re-examine isokinetic knee extensor and flexor strength before and after ACL reconstruction with patellar and hamstring tendon grafts using a single-center and a relatively large database, where surgical, rehabilitation and testing procedures were strictly standardized for all patients.Methods: A total of 464 patients with a unilateral ACL rupture underwent arthroscopic ACL reconstruction with either patellar or hamstring tendon grafts. Isokinetic concentric strength was evaluated prior to surgery and at 5- and 9-month postoperative follow-ups in different patient subgroups (n = 140, 464 and 215, respectively).Results: Knee extensor strength was lower in patients operated with the patellar tendon graft at the 5-month (p < 0.05) but not at the 9-month follow-up. Knee flexor strength was lower in patients operated with the hamstring tendon graft at both postoperative time points (p < 0.05). The prevalence of quadriceps weakness was high (66–91%) in both patient groups at both follow-ups.Conclusion: Overall, postoperative recovery of thigh muscle function seems to be better with the patellar than with the hamstring tendon graft due to the fact that both, knee extensor and flexor strength, were more impaired after ACL reconstruction with the hamstring tendon autograft.

A comparison of patellofemoral cartilage morphology and deformation in anterior cruciate ligament deficient versus uninjured knees

Anterior cruciate ligament (ACL) deficient patients have an increased rate of patellofemoral joint (PFJ) osteoarthritis (OA) as compared to the general population. Although the cause of post-injury OA is multi-factorial, alterations in joint biomechanics may predispose patients to cartilage degeneration. This study aimed to compare in vivo PFJ morphology and mechanics between ACL deficient and intact knees in subjects with unilateral ACL ruptures. Eight male subjects underwent baseline MRI scans of both knees. They then performed a series of 60 single-legged hops, followed by a post-exercise MRI scan. This process was repeated for the contralateral knee. The MR images were converted into three-dimensional surface models of cartilage and bone in order to assess cartilage thickness distributions and strain following exercise. Prior to exercise, patellar cartilage was significantly thicker in intact knees as compared to ACL deficient knees by 1.8%. In response to exercise, we observed average patellar cartilage strains of 5.4 ± 1.1% and 2.5 ± 1.4% in the ACL deficient and intact knees, respectively. Importantly, the magnitude of patellar cartilage strain in the ACL deficient knees was significantly higher than in the intact knees. However, while trochlear cartilage experienced a mean strain of 2.4 ± 1.6%, there was no difference in trochlear cartilage strain between the ACL deficient and uninjured knees. In summary, we found that ACL deficiency was associated with decreased patellar cartilage thickness and increased exercise-induced patellar cartilage strain when compared to the uninjured contralateral knees.

RegentK Improves the Gait Mechanics of Patients with Acute Anterior Cruciate Ligament Rupture Immediately after Application: Clinical Trial

Background: The purpose of this study was to investigate the immediate response to RegentK (Regeneration-Therapy by Khalifa) of patients with an acute rupture of the anterior cruciate ligament (ACL), regarding the gait mechanics and functional tests, in comparison to norm data. Patients and Methods: 9 male patients with an acute unilateral ACL rupture underwent an orthopedic exam and gait analysis immediately before and after the 1-h RegentK treatment; the results were compared to norm data of 10 healthy participants matched with the RegentK group for age and body mass index. An infrared camera system collected kinematic gait data on the injured limb; the gait kinetics were recorded with 2 force plates. Results: Immediately after the treatment, significant improvements with regard to limping, the quadriceps knee force, and the passive knee range of motion (ROM) occurred. The gait characteristics showed a significantly increased gait velocity (+0.17 m/s), step frequency (+8 steps/min), and injured-limb step length (+5 cm). The faster gait velocity involved increased sagittal ankle and hip ROM, increased maximal vertical ground reaction forces, internal ankle plantar flexion and hip flexion moments. Conclusions: RegentK seems to immediately affect functional parameters such as passive knee joint motion and quadriceps strength and seems to enable patients to walk more dynamically, generally expressed through an increased walking speed.

Qualifications of Safe Return to Play Criteria

Anterior cruciate ligament (ACL) injury has various negative implications for thigh muscle function, including reduction of muscle strength and instability of torque. Conservative treatment and / or surgical procedures may be preferred by considering patient’s age, activity level, additional injury and the patient’s expectations. Aim of ACL surgery in athletes is to allow a safe return to preoperative activity level. Literatures have shown different criterias about returning to sports. Some of these criterias are time after surgery, negative Lachman and Pivot shift tests, range of motion, extension/flexion muscle strength of the knee, functional knee tests and lower limb symmetry indexes. Although these criteria provide, second-injury risks are high within 2 years of primary ACL reconstruction. The risk of re-injury rates for the ACL vary between 0 and 19% for the ipsilateral side and between 7 and 24% for the uninjured contralateral knee. The purpose of this study was to investigate value of knee function between the return to normal knee function following ACL reconstruction (ipsilateral and uninjured contralateral side) and the healthy knees, and present recommendation for reduce the risk of rerupture. Totally 14 healthy male and 15 male patients who had unilateral ACL reconstruction, followed knee rehabilitation programme regularly and returned to normal knee function following after minimum 8th month the operation participated in the study. We applied Tegner activity level, Lysholm knee score, operated, intact and healthy knee range of motion, one leg hop test, flamingo balance test, isokinetic muscle strength test and proprioception test in the study. No statistically significant differences were found in the demographic data, activity level, and knee score between groups (p>0,05). The test that assesses passive joint position sense at 30˚ showed statistically significant differences between operated and intact non-operated knee (p<0,05). This data was better at operated knee. There were statistically significant differences in functional tests, isokinetic hamstring muscle test at operated knee and proprioception test between patients and control groups (p<0,05). Arthrogenic muscle inhibition occurs bilaterally after unilateral ACL ruptures. Thus, normal lower limb symmetry determined by tests. On the other hand; muscle strength, motor coordination, proprioception and knee function may be insufficient compared to healthy control groups. For this reason, we should consider that it is important to improve bilateral lower extremity functions at ACL rehabilitation program. Datas of operated and non-operated knee and control groupOperated sideNon-operated sideControl groupFlexion ROM (˚)130131,67130,5Extension ROM (˚)1,2700Flamingo balance test EV1,531,332,5One leg hop test (cm)108,22123142,67Prop active 30˚ AEV5,735,81,45Prop active 45˚ AEV5,276,132,18Prop active 75˚ AEV5,274,22,3Prop passive 30˚ AEV2,276,131,79Prop passive 45˚ AEV4,333,81,33Prop passive 75˚ AEV3,073,61,51Extension PT (Nm)168,9193,2179,07Extension PT/BW (%)222,27253,87250,93Extension IPT (Nm)99,21112,8108,57Extension TWD (Nm)1437,291575,41526,86Flexion PT (Nm)91,87100,6111Flexion PT/BW (%)118,13129,47157,5Flexion IPT (Nm)61,8668,2772,14Flexion TWD (Nm)797,93818,67885,86ROM: Range of motions, cm:centimeter, EV: Error value, Prop: Proprioception, AEV: Absolute error value, PT: Peak torque, PT/BW: Peak torque/body weight, IPT: Initial peak torque, TWD: Total work done, Nm: Newtonmeter

The Effect of Kinesiotaping Implementation After Anterior Cruciate Ligament Reconstruction

Objective:The main aim of this study was to measure effects of kinesiotaping on pain and range of motion in the conservative treatment of postoperative anterior cruciate ligament(ACL) rupture.Material-Methods:A total of 26 patients(24 women, 2 men) who had unilateral ACL rupture 64.46±9.00 years old(46-81years), 13 had physiotherapy only(mean age 64.46±9.35 years),13 had physiotherapy and kinesiotape(mean age 64.46±9.01 years).The patients in both groups received physiotherapy program (ultrasound with 1 MHz, 1W/cm2 during 5minutes; CPM; strength exercise for quadriceps muscle and cold pack during 15 minute). Kinesiotape was applied to the knee and quadriceps of the patient’s leg using a prescribed application to facilitate muscle performance for the experimental group versus a only physiotherapy group.The patients were treated 20 times for four weeks. Socio-demographic variables (gender, age, body mass index, Kellgren-Lawrence system for classification of knee osteoarthritis, use of analgesic drug, pain during rest and activity (VAS=Visual Analog Scale), range of motion of knee flexion and extansion (universal goniometer), circumference measurements of the knee and the quadriceps muscle (up to 10 cm of patella) were measured at baseline, mid the treatment program and after the treatment program. Statistical analysis was conducted using SPSS 22.0 for Windows.Frequency and percentage (average, standard deviation)were used as descriptive statistics of the study.The Wilcoxon test was used to compare the differences between before and after treatment measurements.The Kruskal Wallis test was used to compare groups.Significance was accepted as p<0.05.Results:No significant differences were found in age and BMI between groups (p=0.898, 0.505). The data of stage 3(n=22) and 4(n=4) patients with osteoarthritis were gathered according to the Kellgren-Lawrence classification. Mean day of use of analgesic drug were 17.30±7.33 in KT group, 18.23±9.84 in physiotherapy group. When we compared pretreatment and posttreatment measures, significant differences were found in 2 groups. But KT group was better than the physiotherapy group in all parameters. Table 1 shows the comparison of the pre-treatment and post-treatment evaluation results between 2 groups. VAS scores during rest and activity, active flexion and extension of the knee, circumference measurements of the knee and the quadriceps muscle had better in KT group of patients when compare with physiotherapy program (p=0.008,0.000, 0.001, 0.000, 0.015, 0.045).Comparison of the pre-treatment and post-treatment evaluation results between 2 groupsKinesiotape GroupPhysiotherapy GrouppVAS restPretreatment2.07±2.492.38±2.720.705Midtreatment0.46±0.961.84±2.030.056Posttreatment0.07±0.272.07±2.360.008*p0.017*0.046*VAS activityPretreatment4.69±3.196.00±2.080.253Midtreatment0.84±0.804.30±1.700.000**Posttreatment0.15±0.373.61±1.750.000**p0.003*0.002*ROM active flexionPretreatment81.00±16.0583.53±21.060.608Midtreatment110.15±13.1599.61±20.040.090Posttreatment132.38±8.95112.84±18.420.001**p0.001**0.001**ROM active extensionPretreatment164.53±4.70166.92±4.510.358Midtreatment170.23±3.87167.69±4.340.128Posttreatment177.38±3.096168.69±3.770.000**p0.001**0.016*Circumference of kneePretreatment43.96±3.1443.65±3.610.797Midtreatment41.79±2.9242.75±3.380.281Posttreatment39.26±3.3942.04±3.030.015*p0.001**0.012*Circumference of quadricepsPretreatment48.03±4.5649.08±6.050.681Midtreatment48.46±4.1448.85±5.930.980Posttreatment52.35±4.1548.51±6.000.045*p0.001**0.025*Wilcoxon Test; Kruskal Wallis Test; ROM: Range of Motion; VAS: Vizuel Analog Scale; *p<0.05, **p<0.001.Conclusion:For KT group of patients, pain, range of motion and circumference measurements were improved after 20 sessions physiotherapy plus kinesiotape implementation in patients with anterior cruciate ligaman rupture. The findings showed decreased pain and increase range of motion.

Evaluation of plantar pressure distributions in patients with anteriorcruciate ligament deficiency: preoperative and postoperative changes.

Anterior cruciate ligament (ACL) deficiency results in several kinematic changes in the lower extremities. The aim of this study is to define the plantar pressure parameters in ACL-deficient patients and to show the effect of ACL reconstruction on dynamic plantar pressure. Forty patients with unilateral ACL rupture and 40 healthy controls were included in this study. Dynamic plantar pressures of both groups were recorded by the EMED SF-2 system during level walking. Thirteen of the patients who had ACL reconstructions with hamstring autografts (HS group) were reevaluated at an average of 14.5 months following the ACL reconstructions. ACL-deficient patients had significantly lower hindfoot (P = 0.007) but higher midfoot pressure values (P = 0.03) on their ipsilateral foot compared to control group subjects. Ipsilateral hindfoot pressures were also found to be significantly lower than those of the contralateral foot (P = 0.001). Hindfoot pressure values of the HS group were increased in postoperative measurements (P = 0.01). ACL-deficient patients have altered plantar pressure distributions and ACL reconstructions restore these changes to normal. Pedobarography might be used as a practical method for dynamic functional assessment of ACL-deficient patients.

Acute Proximal Anterior Cruciate Ligament Tears: Outcomes After Arthroscopic Suture Anchor Repair Versus Anatomic Single-Bundle Reconstruction

To compare clinical and radiologic results of primary anterior cruciate ligament (ACL) suture anchor repair and microfracturing with anatomic ACL single-bundle reconstruction in patients with acute proximal ACL avulsion tears. Between January 2010 and December 2013, 420 patients underwent ACL treatment. Forty-one patients were included in this study. The inclusion criteria were as follows: unilateral acute proximal ACL rupture, concomitant meniscus lesions, no previous knee ligament surgery, and no additional ligament injuries or absence of ligament injury of the contralateral knee. Preoperative magnetic resonance imaging confirming a proximal avulsion tear of the ACL was required. Patients had to undergo surgical treatment within 6 weeks after injury. Follow-up examination included Lachman and pivot-shift testing, KT-1000 measurement, and the International Knee Documentation Committee score. At a mean follow-up of 28 months (range, 24 to 31 month), 20 patients in each group were available. A mean KT-1000 arthrometer result of less than 3 mm indicated stability in all patients (P= .269). Three patients had a 1+Lachman test (P= .072) and 4 patients had a 1+ pivot-shift test in the ACL repair group (P= .342). The International Knee Documentation Committee score results did not differ significantly (P > .99), but there was a significant correlation between poor results and failure rate (P= .001) in the refixation group. The failure rate was 15% in the ACL refixation group and 0% in the reconstruction group (P= .231). Magnetic resonance imaging confirmed homogeneous signal and proper ACL position in 100% of patients in the control group and 86% in the ACL repair group. Proximal refixation of the ACL using knotless suture anchors and microfracturing restores knee stability and results in comparable functional outcomes to a control group treated with single-bundle ACL reconstruction. The results suggest that refixation of the ACL is a feasible treatment option in selected patients. Level III, case-control study.