The pivot-shift test has become more consistent and reliable and is a meaningful outcome measurement after anterior cruciate ligament reconstruction (ACLR).The purpose of this investigation was to assess patient-reported outcomes (PROs) and the quantitative pivot shift (QPS) preoperatively, at time zero immediately after anatomic ACLR, and after 24 months as well as the relationship between PROs and the QPS. It was hypothesized that anatomic ACLR would restore rotatory stability measured by the pivot-shift test and that QPS measurements would be positively correlated with PROs.Cohort study; Level of evidence, 2.The ACL-injured and contralateral uninjured knees from 89 of 107 (83.2%) enrolled patients at 4 international centers were evaluated using a standardized pivot-shift test. Tibial acceleration was assessed with an inertial sensor, and lateral compartment translation was measured using an image analysis system preoperatively, at time zero immediately postoperatively, and at follow-up after 2 years. PROs were assessed at 12 and 24 months postoperatively with the International Knee Documentation Committee (IKDC) subjective knee form, Cincinnati Knee Rating System (CKRS), Marx activity rating scale, and activity of daily living score (ADLS).The mean patient age at surgery was 27 years (range, 15-45 years). A positive pivot shift preoperatively (side-to-side difference in tibial acceleration, 2.6 ± 4.0 m/s2; side-to-side difference in anterior tibial translation, 2.0 ± 2.0 mm) was reduced at time zero postoperatively (side-to-side difference in tibial acceleration, -0.5 ± 1.3 m/s2; side-to-side difference in anterior tibial translation, -0.1 ± 1.0 mm). All PROs improved from preoperatively to final follow-up at 24 months: from 56.5 to 85.5 points for the IKDC (P = .0001), from 28.8 to 32.4 points for the CKRS (P = .04), from 11.2 to 7.9 points for the Marx (P < .0001), and from 75.7 to 91.6 points for the ADLS (P < .0001). Neither preoperative nor time zero postoperative rotatory laxity assessed by the pivot-shift test correlated with PROs at 24-month follow-up. A graft retear was observed in 4 patients (4.5%) within 2 years of follow-up.Anatomic ACLR resulted in significantly improved and acceptable PROs at 2-year follow-up and a low failure rate. Anatomic ACLR restored QPS measurements of anterior tibial translation and tibial acceleration to those of the contralateral knee immediately after surgery while still under anesthesia, but there was no correlation between the QPS preoperatively or at time zero after ACLR and PROs at 2-year follow-up.
Abstract: The anterolateral complex (ALC) of the knee plays an important role in rotatory knee stability, especially in anterior cruciate ligament (ACL)-deficient patients. There is considerable awareness of anterolateral rotatory instability secondary to reported high failure rates after ACL reconstruction. As such, there has been a renewed interest in lateral extra-articular reconstruction procedures to stabilize the ALC. The concept of lateral extra-articular tenodesis (EAT) as the sole treatment of ACL injuries was popular in the 1970s, but fell out of favor due to unacceptably poor long-term outcomes. However, as greater understanding of rotatory knee instability has evolved, lateral stabilization procedures similar to those described in the 1970s have emerged to augment ACL reconstruction. These additional soft tissue techniques are not without risk, as many studies have demonstrated knee over-constraint after these procedures. Therefore, it is prudent to take an individualized approach to ACL reconstruction and to assess the value of additional soft tissue procedures in the face of persistent rotatory laxity. This review will address the role of the ALC in rotatory knee injury, the difficulty in diagnosing these injuries, and provide an objective review of additional stabilizing procedures after ACL reconstruction.
Surgical treatment of anterior cruciate ligament (ACL) injuries has improved in leaps and bounds over the past several decades. Surgeons have progressed from extra-articular tenodesis procedures that over-constrained the knee and reduced motion, to intra-articular reconstruction techniques that more accurately recreate the native ACL (1). Recently, tunnel and graft placement has improved to make ACL reconstruction even more anatomic, further improving the kinematics and joint health in reconstructed knees (2,3).
HISTORY: 16 year old male football player presented to the ER 1 week after sustaining a direct blow to his right thigh. He complained of increased thigh pain, difficulty bending his knee, and trouble sleeping. He reported that the pain had worsened steadily since the initial injury, with significantly increased pain in the last 12 hours. He denied any numbness or tingling. PHYSICAL EXAMINATION: Noticeable swelling of his right thigh with associated tenderness to palpation. Anterior compartment of thigh firm. + Pain with passive flexion of the knee, and 0/5 knee extension. Neurovascularly intact distally, palpable pedal pulses. DIFFERENTIAL DIAGNOSIS: 1. Delayed onset compartment syndrome 2. Thigh hematoma 3. Muscle strain 4. Fracture TEST AND RESULTS: 1. Imaging: Plain films of the hip, femur, and knee showed no acute bony abnormalities. A CT scan of the thigh showed a large hematoma in the anterior compartment. 2. Labs: WBC and CBC within normal limits. INR was 1.6 and PTT was 33 (normal is 20-31). FINAL WORKING DIAGNOSIS: Delayed onset thigh compartment syndrome due to a traumatic thigh hematoma and possible undiagnosed clotting abnormality. TREATMENT AND OUTCOMES: The patient was taken emergently to the operating room where an IT-band fasciotomy of the anterior thigh compartment was performed. The wound was packed open and closed on a delayed basis. His pain immediately improved postoperatively and he regained quadriceps function slowly over the following weeks. Pediatric hematology was consulted and initiated a thorough workup which ultimately led to a diagnosis of Factor VII deficiency. The patient was started on a Factor VII replacement regimen. At his six-week follow up his quadriceps strength was 4+/5 and he had started a strengthening program with physical therapy.
An individualized approach to anterior cruciate ligament reconstruction (ACLR) typically includes criteria-based postoperative rehabilitation. However, recent literature has suggested residual quadriceps weakness up to 12 months after ACLR, especially with a quadriceps tendon (QT) autograft.The QT would have poorer quadriceps strength symmetry at 5 to 8 months compared with the hamstring tendon (HS) and patellar tendon (BPTB), but there would be no significant difference at 9 to 15 months among all 3 groups.Cohort study; Level of evidence, 3.Patients who underwent anatomic primary ACLR with an autograft were reviewed retrospectively. Isometric quadriceps and hamstring strength measurements were obtained clinically at 5 to 8 months and 9 to 15 months postoperatively. Return-to-running and return-to-play criteria included greater than 80% and 90% quadriceps strength symmetry, respectively.A total of 73 patients with 5- to 8-month follow-up were identified, and 52 patients had 9- to 15-month data. The QT group had a significantly lower quadriceps index at 5 to 8 months (69.5 ± 17.4) compared with the BPTB (82.8 ± 14.6; P = .014) and the HS (86.0 ± 18.6; P = .001) groups. More patients with an BPTB autograft met criteria for return to running and return to play (60% and 47%, respectively) compared with the QT group (26% and 13%, respectively) at 5 to 8 months. Given the sample sizes available, we observed no significant difference in the quadriceps index and return-to-play and return-to-running criteria at 9 to 15 months among those undergoing ACLR with a QT, BPTB, or HS graft.Patients undergoing ACLR with a QT graft demonstrated clinically meaningful quadriceps asymmetry at 5 to 8 months and 9 to 15 months postoperatively. Additionally, fewer patients in the QT group met criteria for return to play and running at 5 to 8 months than the BPTB and HS groups. These data suggest that a longer time to return to play and specific rehabilitation protocols that emphasize quadriceps strengthening may be necessary because of residual quadriceps weakness after ACLR with a QT graft.
