REHABILITATION FOLLOWING RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT
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A closely supervised rehabilitation program is mandatory if maximum benefit is to be derived from anterior cruciate ligament (ACL) reconstruction. The author describes a postoperative rehabilitation protocol based on kinesiologic, histologic, and biomechanical factors affecting the ACL.Background The intent of double-bundle anterior cruciate ligament reconstruction is to reproduce the normal anterior cruciate ligament anatomy and improve knee joint rotational stability. However, no consensus has been reached on the advantages of this technique over the single-bundle technique. Hypothesis We hypothesized that double-bundle anterior cruciate ligament reconstruction could provide better intraoperative stability and clinical outcome than single-bundle reconstruction. Type of study: Cohort study; Level of evidence, 2. Methods Forty patients with anterior cruciate ligament injury in one knee were recruited; 20 were allocated to a double-bundle anterior cruciate ligament reconstruction group and 20 to a single-bundle anterior cruciate ligament reconstruction group. Intraoperative stabilities at 30° of knee flexion were compared between the 2 groups using a navigation system. Clinical outcomes including Lysholm knee scores, Tegner activity scores, Lachman and pivot-shift test results, and radiographic stabilities were also compared between the 2 groups after a minimum of 2 years of follow-up. Results Intraoperative anterior and rotational stabilities after anterior cruciate ligament reconstruction in the double-bundle group were significantly better than those in single-bundle group (P = .020 and P < .001, respectively). Nineteen patients (95%) in each group were available at a minimum 2-year follow-up. Clinical outcomes including Lysholm knee and Tegner activity scores were similar in the 2 groups at 2-year follow-up (P > .05). Furthermore, stability results of the Lachman and pivot-shift tests, and radiologic findings at 2-year follow-up failed to reveal any significant intergroup differences (P > .05). Conclusion Although double-bundle anterior cruciate ligament reconstruction produces better intraoperative stabilities than single-bundle anterior cruciate ligament reconstruction, the 2 modalities were found to be similar in terms of clinical outcomes and postoperative stabilities after a minimum of 2 years of follow-up.
Lachman test
Pivot-shift test
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Day-case anterior cruciate ligament reconstruction has the potential benefit of reduced hospital stay and reduced cost of care. The goal of this preliminary report was to compare the outcome of day-case arthroscopic anterior cruciate ligament reconstruction with those of in-patient care in terms of pain control and short-term functional outcome.This was a prospective comparative study involving patients who had anterior cruciate ligament reconstruction performed in our unit between January 2019 to July 2021 for isolated anterior cruciate ligament rupture. The patients were offered the option of in-patient and day-case anterior cruciate ligament reconstruction. All cases were isolated anterior cruciate ligament ruptures with no other ligament injury.A total of twenty-one-day case and twenty-five in-patient anterior cruciate ligament reconstruction were managed during the period of the study. The median numeric pain scores at day 2 and 7 in the day case group was 8.0 (IQR=2.0) and 5.0 (IQR= 3.0) respectively and in-patient group was 7.0 (IQR =1.5) and 4.0 (IQR= 2.0) respectively. The international knee documentation score (IKDC) at 6 months in the day case and in-patient groups were 68.6 (IQR= 9.3) and 67.2 (IQR= 25.0) respectively. The Mann-Whitney U test indicated that patients who had ACL reconstruction on in-patient care basis had statistically significant lower visual analogue scale pain scores on the second (z=-2.58, P = 0.01) and seventh (z=-3.41 P = 0.001) post-operative days compared to patients who had ACL reconstruction on day case basis. There was no statistically significant difference in the median IKDC scores of both groups at 6 months. The cost of care in the day case group was 40% lower than those of the in-patient group.Although the cost of care in the day case group appeared lower as compared to the in-patient group, the day case group had higher post-operative pain scores compared to the in-patient group. Although the post-operative functional scores were similar in both groups, this was not statistically significant.
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A long-term retrospective study (minimum 5 years) was done looking at three groups of anterior cruciate defi cient knee patients using both subjective and objective anterior cruciate tests. Twenty-seven chronic anterior cruciate ligament deficient knees reconstructed with the middle third of the patellar tendon and 28 chronic anterior cruciate ligament deficient knees reconstructed with the semitendinosus tendon were included in this consecutive group of patients and were felt to be directly comparable. It was found that the chronic an terior cruciate ligament deficient group reconstructed with the semitendinosus tendon had 4 excellent, 10 good, 7 poor, and 7 failures with an objective score averaging 4.5 of a possible 12, while the comparable group reconstructed with the middle third of the patellar tendon had 16 excellent, 7 good, 3 poor, and only 1 failure with a score of 10 of a possible 12 (P < 0.0032). For completeness sake, 20 anterior cruciate deficient knees from this group of consecutive patients that were reconstructed acutely with the semitendinosus tendon were also examined. This group had 8 excellent results, 9 good, 3 poor, and no failures with a score of 9.8 (P < 0.03 compared to the other group using the semiten dinosus tendon). This comparison between the two groups where the semitendinosus tendon was used in the anterior cruciate ligament reconstruction was made only to show the difference between studies dealing with knee reconstructions. There may be a significant difference between a study dealing with acutely recon structed knees versus one focusing on chronically re constructed knees, most likely because of both patient selection and time between injury and reconstruction. Subjectively, the activity forms gave postreconstruc tion activities of 112 of 200 for the chronically recon structed group using semitendinosus tendon, 115 for the chronically reconstructed group using the middle third of the patellar tendon, and 150 in the acutely reconstructed group using the semitendinosus tendon. The subjects rated their knee 6.2 (chronically recon structed with semitendinosus), 6.4 (chronically recon structed with middle third patellar tendon), and 7.9 (acutely reconstructed with semitendinosus) on a scale of 0 to 10. This paper will point out the superiority of using the middle third of the patellar tendon over the use of the semitendinosus tendon in chronically unstable knees. The semitendinosus tendon should not be used even with extraarticular augmentations. The data for the semitendinosus tendon in acute anterior cruciate liga ment reconstruction is included to show how different two groups of patients can be based on the time of reconstruction from the date of injury.
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Anterior cruciate ligament graft orientation has been proposed as a potential mechanism for failure of single-bundle anterior cruciate ligament reconstruction and has been considered important in the restoration of normal ambulatory knee mechanics.To evaluate the possibility that patients adapt their mechanics of walking to the orientation of the anterior cruciate ligament graft. This was determined by testing the hypothesis that peak external knee flexion moment (net quadriceps moment) during walking in patients with anterior cruciate ligament reconstruction is correlated with coronal and sagittal anterior cruciate ligament graft orientations.Cross-sectional study; Level of evidence, 3.Gait analysis was performed to assess dynamic knee function during walking in 17 subjects with unilateral anterior cruciate ligament reconstructions. Magnetic resonance imaging was used to measure coronal and sagittal anterior cruciate ligament graft orientations.A negative correlation was observed between peak external knee flexion moment during walking and coronal angle of the anterior cruciate ligament graft (1.0 m/s walking speed, r = -0.87, P < .001; 1.3 m/s, r = -0.66, P = .004; 1.6 m/s, r = -0.24, P > .05); no correlation was found with the sagittal graft angle (1.0 m/s walking speed, r = 0.21, P > .05; 1.3 m/s, r = 0.20, P > .05; 1.6 m/s, r = 0.13, P > .05).The negative correlation between peak external knee flexion moment during walking and the coronal angle of the anterior cruciate ligament graft indicates that as the anterior cruciate ligament graft is placed in a more vertical coronal orientation, patients reduce their net quadriceps usage during walking.This finding supports the hypothesis that graft placement plays a critical role in the restoration of normal ambulatory mechanics after anterior cruciate ligament reconstruction and thus could provide a partial explanation for the increased incidence of premature osteoarthritis at long-term follow-up in patients with anterior cruciate ligament reconstruction.
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Background Anatomic double-bundle reconstruction has been thought to better simulate the anterior cruciate ligament anatomy. It is, however, a technically challenging procedure, associated with longer operation time and higher cost. Hypothesis Double-bundle anterior cruciate ligament reconstruction using a single femoral and tibial tunnel can closely reproduce intact knee kinematics. Study Design Controlled laboratory study. Methods Eight fresh-frozen human cadaveric knee specimens were tested using a robotic testing system to investigate the kinematic response of the knee joint under an anterior tibial load (130 N), simulated quadriceps load (400 N), and combined torques (5 N·m valgus and 5 N·m internal tibial torques) at 0°, 15°, 30°, 60°, and 90° of flexion. Each knee was tested sequentially under 4 conditions: (1) anterior cruciate ligament intact, (2) anterior cruciate ligament deficient, (3) single-bundle anterior cruciate ligament reconstruction using quadrupled hamstring tendon, and (4) single-tunnel—double-bundle anterior cruciate ligament reconstruction using the same tunnels and quadrupled hamstring tendon graft as in the single-bundle anterior cruciate ligament reconstruction. Results Single-tunnel—double-bundle anterior cruciate ligament reconstruction more closely restored the intact knee kinematics than single-bundle anterior cruciate ligament reconstruction at low flexion angles (≤30°) under the anterior tibial load and simulated muscle load (P < .05). However, single-tunnel—double-bundle anterior cruciate ligament reconstruction overconstrained the knee joint at high flexion angles (≥60°) under the anterior tibial load and at 0° and 30° of flexion under combined torques. Conclusion This double-bundle anterior cruciate ligament reconstruction using a single tunnel can better restore anterior tibial translations to the intact level compared with single-bundle anterior cruciate ligament reconstruction at low flexion angles, but it overconstrained the knee joint at high flexion angles. Clinical Relevance This technique could be an alternative for both single-bundle and double-tunnel—double-bundle anterior cruciate ligament reconstructions to reproduce intact knee kinematics and native anterior cruciate ligament anatomy.
Cadaveric spasm
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Surgical management of the anterior cruciate ligament-deficient knee has evolved from primary repair to extracapsular augmentation to anterior cruciate ligament reconstruction using biologic tissue grafts. The technique of anterior cruciate ligament reconstruction has improved over the last few decades with the aid of knowledge gained from basic science and clinical research. The biology and biomechanics of anterior cruciate ligament reconstruction were analyzed in the previously published first part of this article. In this second part, current operative concepts of anterior cruciate ligament reconstruction as well as clinical correlations are discussed. The latest information regarding anterior cruciate ligament reconstruction is presented with a goal of demonstrating the correlation between the application of basic science knowledge and the improvement of clinical outcomes.
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Anterior cruciate ligament reconstruction is performed as an outpatient procedure in selected cases. Whether it can be safely performed on a routine basis in day clinic remains unclear. Our hypothesis was that routinely performing outpatient anterior cruciate ligament reconstruction would be equally safe as compared to inpatient procedures. A cohort of 355 patients who underwent outpatient primary reconstruction was analysed at an average follow-up of 3.8 years. Four patients (1.1%) could not be discharged or were readmitted within 24 hours. The 1-month readmission rate was 1.4%. The overall complication rate was 12.1% (43 cases) of which 4.2% (15 patients) occurred within the first 30 days. Performing anterior cruciate ligament reconstructions routinely in day clinic is associated with almost negligible readmission rates and has similar complication rates as for standard in-hospital anterior cruciate ligament reconstructions. Outpatient anterior cruciate ligament reconstructions can therefore be safely performed without specific preoperative patient selection protocols.
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Arthrometry has an established role in the measurement of knee laxity in anterior cruciate ligament injury and following reconstruction. The role of routine intraoperative arthrometry in anterior cruciate ligament reconstruction is poorly defined, and this study was designed to test the hypothesis that intraoperative arthrometry provides an objective method of documenting successful knee stabilisation following anterior cruciate ligament reconstruction. A consecutive cohort of 100 patients with unilateral isolated anterior cruciate ligament disruption were prospectively evaluated using a Rolimeter arthrometer. A maximal manual force method was utilised by a single examiner. This allowed for side-to-side comparisons with the uninjured contralateral knee. Analysis of tibial translation was recorded preoperatively with patients both awake and asleep, intraoperatively following anterior cruciate ligament reconstruction, and postoperatively at 2 weeks and 3 months. Statistical analysis was performed using Spearman's correlation coefficients. Intraoperative arthrometry of anterior cruciate ligament reconstructed knees revealed statistically significant correlation with measurements of uninjured knees (p < 0.0001). These findings were reproducible at 2 weeks (p < 0.0001) and at 3 months (p = 0.0002). Based on our findings, we conclude that intraoperative arthrometry can be simple and provide reproducible results. It is a useful method of immediately and objectively documenting successful anterior cruciate ligament reconstruction.
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Background Changes in electromechanical delay during muscle activation are expected when there are substantial alterations in the structural properties of the musculotendinous tissue. In anterior cruciate ligament reconstruction, specific tendons are being harvested for grafts. Thus, there is an associated scar tissue development at the tendon that may affect the corresponding electromechanical delay. Purpose This study was conducted to investigate whether harvesting of semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction will affect the electromechanical delay of the knee flexors. Study Design Case-control study; Level of evidence, 3. Methods The authors evaluated 12 patients with anterior cruciate ligament reconstruction with a semitendinosus and gracilis autograft, 2 years after the reconstruction, and 12 healthy controls. Each participant performed 4 maximally explosive isometric contractions with a 1-minute break between contractions. The surface electromyographic activity of the biceps femoris and the semitendinosus was recorded from both legs during the contractions. Results The statistical comparisons revealed significant increases of the electromechanical delay of the anterior cruciate ligament–reconstructed knee for both investigated muscles. Specifically, the electromechanical delay values were increased for both the biceps femoris ( P = .029) and the semitendinosus ( P = .005) of the reconstructed knee when compared with the intact knee. Comparing the anterior cruciate ligament–reconstructed knee against healthy controls revealed similar significant differences for both muscles (semitendinosus, P = .011; biceps femoris, P = .024). Conclusion The results showed that harvesting the semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction significantly increased the electromechanical delay of the knee flexors. Increased hamstring electromechanical delay might impair knee safety and performance by modifying the transfer time of muscle tension to the tibia and therefore affecting muscle response during sudden movements in athletic activities. However, further investigation is required to identify whether the increased electromechanical delay of the hamstrings can actually influence optimal sports performance and increase the risk for knee injury in athletes with anterior cruciate ligament reconstructions.
Semitendinosus muscle
Knee flexion
Biceps femoris muscle
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