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Janssen RPA, van Melick N, van Mourik JBA, Reijman M, van Rhijn LW. Similar clinical outcome between patellar tendon and hamstring tendon autograft after anterior cruciate ligament reconstruction with accelerated, brace-free rehabilitation: a systematic review. J ISAKOS 2017. [DOI: 10.1136/jisakos-2016-000110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Di Miceli R, Marambio CB, Zati A, Monesi R, Benedetti MG. Do Knee Bracing and Delayed Weight Bearing Affect Mid-Term Functional Outcome after Anterior Cruciate Ligament Reconstruction? JOINTS 2017; 5:202-206. [PMID: 29270556 PMCID: PMC5738480 DOI: 10.1055/s-0037-1606617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Purpose The aim of this study was to assess the effect of knee bracing and timing of full weight bearing after anterior cruciate ligament reconstruction (ACLR) on functional outcomes at mid-term follow-up. Methods We performed a retrospective study on 41 patients with ACLR. Patients were divided in two groups: ACLR group, who received isolated ACL reconstruction and ACLR-OI group who received ACL reconstruction and adjunctive surgery. Information about age at surgery, bracing, full or progressive weight bearing permission after surgery were collected for the two groups. Subjective IKDC score was obtained at follow-up. Statistical analysis was performed to compare the two groups for IKDC score. Subgroup analysis was performed to assess the effect of postoperative regimen (knee bracing and weight bearing) on functional outcomes. Results The mean age of patients was 30.8 ± 10.6 years. Mean IKDC score was 87.4 ± 13.9. The mean follow-up was 3.5 ± 1.8 years. Twenty-two (53.7%) patients underwent ACLR only, while 19 (46.3%) also received other interventions, such as meniscal repair and/or collateral ligament suture. Analysis of overall data showed no differences between the groups for IKDC score. Patients in the ACLR group exhibited a significantly better IKDC score when no brace and full weight bearing after 4 weeks from surgery was prescribed in comparison with patients who worn a brace and had delayed full weight bearing. No differences were found with respect to the use of brace and postoperative weight bearing regimen in the ACLR-OI group. Conclusion Brace and delayed weight bearing after ACLR have a negative influence on long-term functional outcomes. Further research is required to explore possible differences in the patients operated on ACLR and other intervention with respect to the use of a brace and the timing of full weight bearing to identify optimal recovery strategies. Level of Evidence Level III, retrospective observational study.
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Affiliation(s)
- Riccardo Di Miceli
- SC Medicina Fisica e Riabilitativa, Istituto Ortopedico Rizzoli di Bologna, Bologna, Italy
| | | | - Alessandro Zati
- SC Medicina Fisica e Riabilitativa, Istituto Ortopedico Rizzoli di Bologna, Bologna, Italy
| | - Roberta Monesi
- SC Medicina Fisica e Riabilitativa, Istituto Ortopedico Rizzoli di Bologna, Bologna, Italy
| | - Maria Grazia Benedetti
- SC Medicina Fisica e Riabilitativa, Istituto Ortopedico Rizzoli di Bologna, Bologna, Italy
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Chang NJ, Lee KW, Chu CJ, Shie MY, Chou PH, Lin CC, Liang PI. A Preclinical Assessment of Early Continuous Passive Motion and Treadmill Therapeutic Exercises for Generating Chondroprotective Effects After Anterior Cruciate Ligament Rupture. Am J Sports Med 2017; 45:2284-2293. [PMID: 28520463 DOI: 10.1177/0363546517704847] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) injury is a well-known risk factor for the development of posttraumatic osteoarthritis (PTOA). However, whether using continuous passive motion (CPM) with or without additional treadmill exercise (TRE) in early ACL injury might provide chondroprotective effects and further decrease the risk of PTOA has yet to be determined. HYPOTHESIS CPM may offer an enhanced chondroprotective effect, but TRE may attenuate that effect due to the mechanical stress on the joint and inflammatory cytokines in the joint. STUDY DESIGN Controlled laboratory study. METHODS Thirty adult New Zealand White male rabbits were randomly allocated to sedentary (SED), CPM, TRE, or CPM+TRE groups. Each rabbit underwent an ACL transection (ACLT) on the right knee, with the contralateral knee used as an internal control (sham). The 4 joint surfaces (ie, medial and lateral femoral condyles and tibial plateaus) were evaluated 4 weeks after surgery for gross appearance, histological characteristics, and quantitative osteoarthritis (OA) scores. RESULTS Overall, at the end of testing, the CPM group experienced the best protective therapeutic effects in all compartments. In gross appearance, CPM resulted in normal articular surfaces, while the TRE and SED groups exhibited surface abrasion. Histological analysis showed significant differences in articular cartilage status. The CPM group had significantly better histological OA scores ( P < .01), corresponding to the smoothest cartilage surface and sound chondrocyte and collagen arrangement. This group also showed abundant glycosaminoglycan (GAG) content and a sound growth microenvironment, with significantly lower expression levels of the inflammatory cytokine tumor necrosis factor α and the apoptotic marker caspase 3. In contrast, the TRE and SED groups showed several features of damage: distinct graded cartilage abrasion; damaged collagen fibers, corresponding to noticeable collagen type X (osteoarthritic cartilage); reduced cartilage thickness; fewer cartilaginous cells; and the appearance of chondrocyte clusters. These groups also showed loss of GAG, corresponding to higher levels of inflammatory cytokines and apoptosis of articular chondrocytes. Furthermore, the CPM+TRE group displayed visible pathological changes in the superficial cartilage, indicating that early loading exercise may contribute to osteoarthritis. The sham treatment showed no difference in the changes in all compartments between groups. CONCLUSION Immediate CPM therapy produces a superior in situ microenvironment for reducing the occurrence of PTOA after ACL injury without reconstruction in rabbits. CLINICAL RELEVANCE These data suggest that immediate application of CPM therapy may be necessary to create a sound microenvironment in joints and possibly to decrease the risk of PTOA without or while awaiting ACL reconstruction. In contrast, both early active loading exercise and inactivity lead to the development of PTOA.
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Affiliation(s)
- Nai-Jen Chang
- Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Kuan-Wei Lee
- Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chih-Jou Chu
- Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Ming-You Shie
- 3D Printing Medical Research Center, China Medical University Hospital, North District, Taichung City, Taiwan
| | - Pei-Hsi Chou
- Department of Sports Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chih-Chan Lin
- Laboratory Animal Center, Department of Medical Research, Chi-Mei Medical Center, Yongkang District, Tainan City, Taiwan
| | - Peir-In Liang
- Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
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Can Early Rehabilitation Prevent Posttraumatic Osteoarthritis in the Patellofemoral Joint after Anterior Cruciate Ligament Rupture? Understanding the Pathological Features. Int J Mol Sci 2017; 18:ijms18040829. [PMID: 28420082 PMCID: PMC5412413 DOI: 10.3390/ijms18040829] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 04/11/2017] [Accepted: 04/11/2017] [Indexed: 11/26/2022] Open
Abstract
Knee instability resulting from anterior cruciate ligament (ACL) rupture is a high-risk factor for posttraumatic osteoarthritis (PTOA) in the patellofemoral joint (PFJ). However, whether non-weight-bearing and weight-bearing treatments have chondroprotective effects remains unclear. Twenty-four adult New Zealand White male rabbits were employed in this study. All animals received ACL transection in the right knee and sham surgery in the left knee. The rabbits were randomly assigned to the following groups: (I) In the sedentary (SED) group, the rabbits (n = 6) were simply kept in their cage; (II) In the continuous passive motion (CPM) group, the rabbits (n = 6) performed CPM exercise for 7 days, starting from the first postoperative day; (III) In the active treadmill exercise (TRE) group, the rabbits (n = 6) performed TRE for 2 weeks; (IV) In the CPM + TRE group, the rabbits (n = 6) executed CPM exercise, followed by TRE. Two joint surfaces (the retropatella and femoral trochlear groove) were assessed at 4 weeks after operation. Although the gross appearance in each group was comparable, histological examination revealed significant differences in the articular cartilage status. The CPM group exhibited a greater thickness of articular cartilage, maintenance of tidemark continuity, abundant glycosaminoglycan (GAG), and significantly lower inflammatory cytokine 9, e.g., tumor necrosis factor-alpha (TNF-α) 0 levels, with modest cell apoptosis (i.e., caspase-3). By contrast, the TRE group displayed the worst pathological features: an irregular cartilage surface and chondrocyte disorganization, reduced cartilage thickness, breakdown of the tidemark, depletion of collagen fibers, loss of GAG, and the highest levels of TNF-α and caspase-3 expression. Furthermore, the CPM + TRE group had more favorable outcomes than the SED group, indicating that suitable exercise is needed. The sham treatment displayed no variance in the changes in the two joint surfaces among groups. These data indicate that the application of early CPM rehabilitation is suggested for subjects in order to decrease the risk of PTOA without ACL reconstruction in the PFJ compartment in rabbits. The early TRE program, however, had harmful outcomes. Additionally, inactivity was discovered to initiate the development of PTOA.
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Abstract
Anterior cruciate ligament (ACL) reconstruction is a common and predominantly successful surgical intervention. But are there specific preoperative patient characteristics or intraoperative surgeon decisions that lead to better or worse outcomes? And can understanding brain function changes of patients after ACL reconstruction reveal insights into the ways that postsurgical rehabilitation can be improved to further enhance outcomes? These intriguing and clinically applicable questions are addressed in this webinar titled "Improving ACL Reconstruction Outcomes," hosted jointly by JOSPT and JBJS. The webinar is based on 2 published research articles-one from JBJS and the other from JOSPT. Participants in this continuing education activity are asked to read both articles carefully before watching the webinar. JBJS co-author Kurt Spindler, MD, discusses findings from a longitudinal analysis that identified certain baseline patient characteristics and intraoperative choices that predicted higher and lower SF-36 Physical Component scores after ACL reconstruction. JOSPT co-author Dustin Grooms, PhD, ATC, shares recently published results of a controlled laboratory study that employed functional MRI to investigate brain-activation differences between patients who did and did not undergo ACL reconstruction. Moderated by Kevin Wilk, PT, DPT, FAPTA, a leading authority on rehabilitation of sports injuries, the webinar includes additional insights from expert commentators Eric McCarty, MD, and Karin Grävare Silbernagel, PT, PhD, ATC.
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Song F, Jiang D, Wang T, Wang Y, Chen F, Xu G, Kang Y, Zhang Y. Mechanical Loading Improves Tendon-Bone Healing in a Rabbit Anterior Cruciate Ligament Reconstruction Model by Promoting Proliferation and Matrix Formation of Mesenchymal Stem Cells and Tendon Cells. Cell Physiol Biochem 2017; 41:875-889. [DOI: 10.1159/000460005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 12/21/2016] [Indexed: 12/17/2022] Open
Abstract
Background/Aims: This study investigated the effect of mechanical stress on tendon-bone healing in a rabbit anterior cruciate ligament (ACL) reconstruction model as well as cell proliferation and matrix formation in co-culture of bone-marrow mesenchymal stem cells (BMSCs) and tendon cells (TCs). Methods: The effect of continuous passive motion (CPM) therapy on tendon-bone healing in a rabbit ACL reconstruction model was evaluated by histological analysis, biomechanical testing and gene expressions at the tendon-bone interface. Furthermore, the effect of mechanical stretch on cell proliferation and matrix synthesis in BMSC/TC co-culture was also examined. Results: Postoperative CPM therapy significantly enhanced tendon-bone healing, as evidenced by increased amount of fibrocartilage, elevated ultimate load to failure levels, and up-regulated gene expressions of Collagen I, alkaline phosphatase, osteopontin, Tenascin C and tenomodulin at the tendon-bone junction. In addition, BMSC/TC co-culture treated with mechanical stretch showed a higher rate of cell proliferation and enhanced expressions of Collagen I, Collagen III, alkaline phosphatase, osteopontin, Tenascin C and tenomodulin than that of controls. Conclusion: These results demonstrated that proliferation and differentiation of local precursor cells could be enhanced by mechanical stimulation, which results in enhanced regenerative potential of BMSCs and TCs in tendon-bone healing.
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Bini RR. Patellofemoral and tibiofemoral forces during knee extension: simulations to strength training and rehabilitation exercises. FISIOTERAPIA EM MOVIMENTO 2017. [DOI: 10.1590/1980-5918.030.s01.ao26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction: Limited evidence has been shown on ways to optimize the mechanical design of machines in order to minimize knee loads. Objective: This study compared six computer simulated models of open kinetic knee extension exercises for patellofemoral pressure and tibiofemoral forces. Methods: A musculoskeletal model of the lower limb was developed using six different cam radius to change resistive forces. A default machine, a constant cam radius, a torque-angle model, a free-weight model and two optimized models were simulated. Optimized models reduced cam radius at target knee flexion angles to minimize knee forces. Cam radius, human force, tibiofemoral compressive and shear force, and patellofemoral pressure were compared for the six models using data from five knee flexion angles. Results: Large reductions in cam radius comparing the free-weight model to other models (73-180%) were limited to the large human force for the constant cam model to other models (9-36%). Larger human force (13 -36%) was estimated to perform knee extension using a constant cam radius compared other models without large effects in knee joint forces. Conclusion: Changes in cam design effected human without a potential impact in knee loads.
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Wu HH, Liu M, Dines JS, Kelly JD, Garcia GH. Depression and psychiatric disease associated with outcomes after anterior cruciate ligament reconstruction. World J Orthop 2016; 7:709-717. [PMID: 27900267 PMCID: PMC5112339 DOI: 10.5312/wjo.v7.i11.709] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/26/2016] [Accepted: 08/18/2016] [Indexed: 02/06/2023] Open
Abstract
While most patients with an anterior cruciate ligament (ACL) injury indicate satisfaction with surgical intervention, a significant proportion still do not return to pre-injury level of function or sport. Psychiatric comorbidities, such as depression, have recently been associated with poor clinical outcomes after ACL reconstruction (ACLR). To date, no article has yet examined how depression affects ACLR outcomes and how potential screening and intervention for psychological distress may affect postoperative activity level. The purpose of this review is to delineate potential relationships between depression and ACLR outcome, discuss clinical implications and identify future directions for research.
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Takazawa Y, Nagayama M, Ikeda H, Kawasaki T, Ishijima M, Saita Y, Kaneko H, Kobayashi Y, Hada S, Kaneko K. Anterior cruciate ligament injuries in elite and high school rugby players: a 11-year review. PHYSICIAN SPORTSMED 2016; 44:53-8. [PMID: 26559443 DOI: 10.1080/00913847.2016.1116362] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Over a 11-year period, we investigated the incidence of anterior cruciate ligament (ACL) injuries and the clinical outcomes after ACL reconstruction with hamstring autografts in two homogenous cohorts of rugby players. METHODS Two teams, including those in elite (94 players) and high school (290 players) clubs, were followed. RESULTS Isolated ACL injuries occurred in 28 players (12 elite, 16 high school). The incidence during match play was 1.26 per 1000 player-hours (95% confidence interval [95% CI]: 0.48-2.05) among elite players and 0.97 per 1000 player-hours (95% CI: 0.30-1.64) among high school players. After ACL reconstruction, 26 players (12 elite, 14 high school) were successfully contacted for follow-up at a mean of 71.9 months. None (0%) of the elite and 4 (29%) of the high school players experienced graft ruptures. Seven (58%) elite and 10 (91%) high school players were fearful of reinjury; the mean time to overcome this fear was 6.1 ± 4.9 months among elite players and 17.5 ± 26.0 months among high school players. CONCLUSION In conclusion, young rugby players experienced inferior outcomes after ACL reconstruction with hamstring autografts compared with their older counterparts.
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Affiliation(s)
- Yuji Takazawa
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
| | - Masataka Nagayama
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
| | - Hiroshi Ikeda
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
| | - Takayuki Kawasaki
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
| | - Muneaki Ishijima
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
| | - Yoshitomo Saita
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
| | - Haruka Kaneko
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
| | - Yohei Kobayashi
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
| | - Shinnosuke Hada
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
| | - Kazuo Kaneko
- a Department of Orthopaedics , Juntendo University School of Medicine , Tokyo , Japan
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van Melick N, van Cingel REH, Brooijmans F, Neeter C, van Tienen T, Hullegie W, Nijhuis-van der Sanden MWG. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med 2016; 50:1506-1515. [PMID: 27539507 DOI: 10.1136/bjsports-2015-095898] [Citation(s) in RCA: 436] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2016] [Indexed: 12/26/2022]
Abstract
AIM The Royal Dutch Society for Physical Therapy (KNGF) instructed a multidisciplinary group of Dutch anterior cruciate ligament (ACL) experts to develop an evidence statement for rehabilitation after ACL reconstruction. DESIGN Clinical practice guideline underpinned by systematic review and expert consensus. DATA SOURCES A multidisciplinary working group and steering group systematically reviewed the literature and wrote the guideline. MEDLINE and the Cochrane Library were searched for meta-analyses, systematic reviews, randomised controlled trials and prospective cohort studies published between January 1990 and June 2015. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Included literature must have addressed 1 of 9 predetermined clinical topics: (1) preoperative predictors for postoperative outcome, (2) effectiveness of physical therapy, (3) open and closed kinetic chain quadriceps exercises, (4) strength and neuromuscular training, (5) electrostimulation and electromyographic feedback, (6) cryotherapy, (7) measurements of functional performance, (8) return to play and (9) risk for reinjury. SUMMARY Ninety studies were included as the basis for the evidence statement. Rehabilitation after ACL injury should include a prehabilitation phase and 3 criterion-based postoperative phases: (1) impairment-based, (2) sport-specific training and (3) return to play. A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one rehabilitation stage to the next. Postoperative rehabilitation should continue for 9-12 months. To assess readiness to return to play and the risk for reinjury, a test battery, including strength tests, hop tests and measurement of movement quality, should be used.
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Affiliation(s)
- Nicky van Melick
- Funqtio, Steyl, The Netherlands.,Radboud University Medical Center, Research Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Robert E H van Cingel
- Sport Medisch Centrum Papendal, Arnhem, The Netherlands.,Research Group Musculoskeletal Rehabilitation, HAN University of Applied Sciences, Nijmegen, The Netherlands
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Anderson MJ, Browning WM, Urband CE, Kluczynski MA, Bisson LJ. A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament. Orthop J Sports Med 2016; 4:2325967116634074. [PMID: 27047983 PMCID: PMC4794976 DOI: 10.1177/2325967116634074] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There has been a substantial increase in the amount of systematic reviews and meta-analyses published on the anterior cruciate ligament (ACL). PURPOSE To quantify the number of systematic reviews and meta-analyses published on the ACL in the past decade and to provide an overall summary of this literature. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of all ACL-related systematic reviews and meta-analyses published between January 2004 and September 2014 was performed using PubMed, MEDLINE, and the Cochrane Database. Narrative reviews and non-English articles were excluded. RESULTS A total of 1031 articles were found, of which 240 met the inclusion criteria. Included articles were summarized and divided into 17 topics: anatomy, epidemiology, prevention, associated injuries, diagnosis, operative versus nonoperative management, graft choice, surgical technique, fixation methods, computer-assisted surgery, platelet-rich plasma, rehabilitation, return to play, outcomes assessment, arthritis, complications, and miscellaneous. CONCLUSION A summary of systematic reviews on the ACL can supply the surgeon with a single source for the most up-to-date synthesis of the literature.
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Affiliation(s)
| | | | | | | | - Leslie J. Bisson
- The State University of New York at Buffalo, Buffalo, New York, USA
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Marshall T, Gelber J, Spindler K. Postoperative Knee Bracing After Anterior Cruciate Ligament Reconstruction. OPER TECHN SPORT MED 2016. [DOI: 10.1053/j.otsm.2015.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Vaishya R, Agarwal AK, Ingole S, Vijay V. Current practice variations in the management of anterior cruciate ligament injuries in Delhi. J Clin Orthop Trauma 2016; 7:193-9. [PMID: 27489416 PMCID: PMC4949409 DOI: 10.1016/j.jcot.2015.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 12/27/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of this study was to determine the current practices and preferences of the arthroscopic surgeons of Delhi in the diagnosis, treatment and rehabilitation of patients with anterior cruciate ligament (ACL) injury. METHODS It was a cross-sectional descriptive study conducted among arthroscopic surgeons of Delhi. A survey was conducted using a questionnaire that was sent either by e-mail or by direct contact to all sixty arthroscopic surgeons of Delhi. RESULTS Forty-eight (80%) surgeons responded to our questionnaire. Maximum participants (83.3%) used semitendinosus/gracilis tendon autograft for ACL reconstruction (ACLR) and only 2.1% were using bone-patellar-tendon-bone (BPTB) autograft. Most preferred method of graft fixation was an 'interference screw' on the tibial side and an 'endobutton' on the femoral side, which was preferred by 95.83% and 93.75% surgeons, respectively. Almost all respondents (97%) used a bio-absorbable interference screw for tibial side graft fixation. Postoperative bracing was advised for <3 weeks by 47.9% surgeons and for 3-6 weeks by 31.3%. The results were analysed using statistical analysis. CONCLUSION Surgeon preferences in ACLR differ considerably among the arthroscopic surgeons of Delhi. There is majority consensus for using Hamstring autograft (single bundle) with a suspensory fixation on the femoral side and an aperture fixation on the tibial side. Transportal technique of making the femoral tunnel and preservation of amputation stump were the preferred methods. However, differences exist over the timing of surgery, rehab after surgery, pain management, etc.
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Affiliation(s)
- Raju Vaishya
- Professor, Senior Consultant Orthopaedics, Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
| | - Amit Kumar Agarwal
- Consultant Orthopaedics, Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
- Corresponding author. Tel.: +91 9968578514.
| | - Sachin Ingole
- Orthopaedic Registrar, Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
| | - Vipul Vijay
- Consultant Orthopaedics, Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
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Pinheiro LQ, Neri Junior E, Fernandes RM, Cardozo RT, Rezende PR. Reconstruction of the anterior cruciate ligament: comparison of analgesia using intrathecal morphine, intra-articular morphine and intra-articular levobupivacaine. Rev Bras Ortop 2015; 50:300-4. [PMID: 26229934 PMCID: PMC4519662 DOI: 10.1016/j.rboe.2015.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/03/2014] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To compare the analgesic effect of intra-articular administration of morphine and levobupivacaine (separately or in combination) with intrathecal administration of morphine in patients undergoing anterior cruciate ligament (ACL) reconstruction using autologous grafts from the patellar tendon. METHODS This was a retrospective analysis on data gathered from the medical files of 60 patients aged 20 to 50 years who underwent knee video arthroscopy for ACL reconstruction. The patients were divided into four groups of 15 individuals (A, B, C and D) according to the agent administered into the joint and around the incision: 20 mL of saline solution with 5 mg of morphine in A; 20 mL of 0.5% levobupivacaine solution in B; 10 mL of solution with 2.5 mg of morphine plus 10 mL of 0.5% levobupivacaine solution in C; and morphine administered intrathecally in D. RESULTS All the groups presented low pain scores during the first 12 h after the surgery. Groups B and C presented significantly greater pain scores than shown by group D (control), 24 h after the surgery. There was no statistical difference in pain scores between group A and group D. CONCLUSION The patients in group A presented analgesia comparable to that of the patients in group D, whereas the procedure of group C was no capable of reproducing the analgesic effect observed in group D, as observed 24 h after the surgery. Further studies are needed in order to show the exact mechanism of action, along with the ideal dose and concentration for applying opioids to joints.
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Affiliation(s)
| | - Edmundo Neri Junior
- Serviço de Ortopedia e Traumatologia de Ribeirão Preto, Ribeirão Preto, SP, Brazil
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Wright RW, Haas AK, Anderson J, Calabrese G, Cavanaugh J, Hewett TE, Lorring D, McKenzie C, Preston E, Williams G. Anterior Cruciate Ligament Reconstruction Rehabilitation: MOON Guidelines. Sports Health 2015; 7:239-43. [PMID: 26131301 PMCID: PMC4482298 DOI: 10.1177/1941738113517855] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Context: Anterior cruciate ligament (ACL) reconstruction rehabilitation has evolved over the past 20 years. This evolution has been driven by a variety of level 1 and level 2 studies. Evidence Acquisition: The MOON Group is a collection of orthopaedic surgeons who have developed a prospective longitudinal cohort of the ACL reconstruction patients. To standardize the management of these patients, we developed, in conjunction with our physical therapy committee, an evidence-based rehabilitation guideline. Study Design: Clinical review. Level of Evidence: Level 2. Results: This review was based on 2 systematic reviews of level 1 and level 2 studies. Recently, the guideline was updated by a new review. Continuous passive motion did not improve ultimate motion. Early weightbearing decreases patellofemoral pain. Postoperative rehabilitative bracing did not improve swelling, pain range of motion, or safety. Open chain quadriceps activity can begin at 6 weeks. Conclusion: High-level evidence exists to determine appropriate ACL rehabilitation guidelines. Utilizing this protocol follows the best available evidence.
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Affiliation(s)
- Rick W Wright
- Washington University in Saint Louis, St Louis, Missouri
| | - Amanda K Haas
- Washington University in Saint Louis, St Louis, Missouri
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Rohman E, Steubs JT, Tompkins M. Changes in involved and uninvolved limb function during rehabilitation after anterior cruciate ligament reconstruction: implications for Limb Symmetry Index measures. Am J Sports Med 2015; 43:1391-8. [PMID: 25828078 DOI: 10.1177/0363546515576127] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Functional testing is used to assess anterior cruciate ligament (ACL) reconstruction rehabilitation, with the goal of symmetric ability. The pattern of change in the uninvolved limb's function during rehabilitation is not established. HYPOTHESES (1) Involved and uninvolved limb ability increases during rehabilitation, but the uninvolved limb ability increases to a lesser degree. (2) Hop tests will show larger initial asymmetry and will improve the most with rehabilitation. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This was a retrospective case series of 122 patients who underwent ACL reconstruction at our ambulatory surgery center and received multiple postoperative Standard Functional Tests (SFTs) between October 2009 and October 2013. Ten of the 12 individual tests within the SFT battery were analyzed. The patients' earliest and latest SFTs were compared for changes in Limb Symmetry Index (LSI) and absolute function in each limb. We also analyzed the subgroup with SFTs (n = 38) at both 4 and 6 months postoperatively. RESULTS In all patients with multiple SFTs, involved limb performance increased in all tests except eyes-closed stork. Uninvolved limb performance increased in 4 SFT component tests and decreased in none. LSI significantly improved in 6 tests, all of which also showed involved limb improvement that was significant. Of these 6 tests, 5 showed initial LSI below 90%: single-leg squat, retro step-up, single-leg hop, crossover triple hop, and timed hop. Retro step-up and single-leg hop showed LSI improvements greater than 10 percentage points. In patients with 4- and 6-month data, involved limb performance increased in all tests except single-leg triple hop. Uninvolved limb performance increased in 5 SFT component tests and decreased in none. LSI significantly improved in 4 tests, all of which had initial LSI below 90%, and showed involved limb improvement that was significant. Retro step-up, single-leg hop, and crossover triple hop showed LSI improvements greater than 10 percentage points. CONCLUSION During ACL reconstruction rehabilitation, LSI improvements indicated absolute increases in involved limb ability and were not attributable to uninvolved limb deterioration. The single-leg squat, retro step-up, single-leg hop, crossover triple hop, and timed hop are suggested as highly useful tests, since all showed initial LSI below 90%, with significant LSI improvement after rehabilitation.
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Affiliation(s)
- Eric Rohman
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - J Tyler Steubs
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marc Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA TRIA Orthopaedic Center, Bloomington, Minnesota, USA
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Pinheiro LQ, Neri Junior E, Fernandes RM, Cardozo RT, Rezende PR. Reconstrução do ligamento cruzado anterior: comparação da analgesia com morfina intratecal, morfina intra‐articular e levobupivacaína intra‐articular. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2014.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Jones MH, Spindler KP, Fleming BC, Duryea J, Obuchowski NA, Scaramuzza EA, Oksendahl HL, Winalski CS, Duong CL, Huston LJ, Parker RD, Kaeding CC, Andrish JT, Flanigan DC, Dunn WR, Reinke EK. Meniscus treatment and age associated with narrower radiographic joint space width 2-3 years after ACL reconstruction: data from the MOON onsite cohort. Osteoarthritis Cartilage 2015; 23:581-8. [PMID: 25559582 PMCID: PMC4601556 DOI: 10.1016/j.joca.2014.12.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 12/16/2014] [Accepted: 12/23/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify risk factors for radiographic signs of post-traumatic osteoarthritis (OA) 2-3 years after anterior cruciate ligament (ACL) reconstruction through multivariable analysis of minimum joint space width (mJSW) differences in a specially designed nested cohort. METHODS A nested cohort within the Multicenter Orthopaedic Outcomes Network (MOON) cohort included 262 patients (148 females, average age 20) injured in sport who underwent ACL reconstruction in a previously uninjured knee, were 35 or younger, and did not have ACL revision or contralateral knee surgery. mJSW on semi-flexed radiographs was measured in the medial compartment using a validated computerized method. A multivariable generalized linear model was constructed to assess mJSW difference between the ACL reconstructed and contralateral control knees while adjusting for potential confounding factors. RESULTS Unexpectedly, we found the mean mJSW was 0.35 mm wider in ACL reconstructed than in control knees (5.06 mm (95% CI 4.96-5.15 mm) vs 4.71 mm (95% CI 4.62-4.80 mm), P < 0.001). However, ACL reconstructed knees with meniscectomy had narrower mJSW compared to contralateral normal knees by 0.64 mm (95% C.I. 0.38-0.90 mm) (P < 0.001). Age (P < 0.001) and meniscus repair (P = 0.001) were also significantly associated with mJSW difference. CONCLUSION Semi-flexed radiographs can detect differences in mJSW between ACL reconstructed and contralateral normal knees 2-3 years following ACL reconstruction, and the unexpected wider mJSW in ACL reconstructed knees may represent the earliest manifestation of post-traumatic osteoarthritis and warrants further study.
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Affiliation(s)
| | - K P Spindler
- Cleveland Clinic, USA; Vanderbilt University Medical Center, USA.
| | - B C Fleming
- Brown University/Rhode Island Hospital, USA.
| | - J Duryea
- Brigham and Women's Hospital/Harvard Medical School, USA.
| | | | | | | | | | - C L Duong
- Vanderbilt University Medical Center, USA.
| | - L J Huston
- Vanderbilt University Medical Center, USA.
| | | | - C C Kaeding
- The Ohio State University Wexner Medical Center, USA.
| | | | - D C Flanigan
- The Ohio State University Wexner Medical Center, USA.
| | - W R Dunn
- University of Wisconsin School of Medicine and Public Health, USA.
| | - E K Reinke
- Vanderbilt University Medical Center, USA.
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Dunn WR, Wolf BR, Harrell FE, Reinke EK, Huston LJ, Spindler KP. Baseline predictors of health-related quality of life after anterior cruciate ligament reconstruction: a longitudinal analysis of a multicenter cohort at two and six years. J Bone Joint Surg Am 2015; 97:551-7. [PMID: 25834079 PMCID: PMC4372989 DOI: 10.2106/jbjs.n.00248] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Limited information exists regarding predictors of general quality of life following anterior cruciate ligament (ACL) reconstruction with up to six-year follow-up. We hypothesized that certain variables evaluated at the time of ACL reconstruction will predict the general quality of life as measured by the Short Form-36 (SF-36). METHODS All unilateral ACL reconstructions from 2002 to 2004 in patients currently enrolled in a prospective multicenter cohort were evaluated. Patients preoperatively completed the SF-36 validated outcome instrument. Surgeons documented intra-articular pathological conditions and treatment, as well as the ACL reconstruction surgical technique. At baseline and at a minimum of two and six years postoperatively, patients completed the SF-36. Longitudinal analysis was performed for the two-year and six-year end points. RESULTS Of the initial 1512 subjects, at least one follow-up questionnaire was obtained from 1411 subjects (93%). The cohort was 44% female, and the median patient age at enrollment was twenty-three years. The mean scores were 41.9 points for the Physical Component Summary (PCS) and 51.7 points for the Mental Component Summary (MCS) at baseline, 53.6 points for the PCS and 52.0 points for the MCS at two years, and 54.0 points for the PCS and 52.4 points for the MCS at six years. Significant predictors of a higher PCS score were a higher baseline PCS score, younger age, lower baseline body mass index, having >50% of the lateral meniscus excised, or having no treatment done on a lateral meniscal tear. In contrast, significant predictors of a lower PCS score were a shorter follow-up time since surgery, revision ACL reconstruction, smoking at baseline, fewer years of education, and chondromalacia of the lateral tibial plateau. The mean utility gained at six years after ACL reconstruction was 5.3 quality-adjusted life years (QALYs). CONCLUSIONS Large improvements in the PCS (with an effect size of 1.2) were noted at two years and were maintained at six years after ACL reconstruction. Lower education and smoking were significant predictors of lower PCS and MCS scores. ACL reconstruction resulted in a relatively high gain of QALYs.
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Affiliation(s)
- Warren R Dunn
- University of Wisconsin Medical Center, Centennial Building, 1685 Highland Avenue, Madison, WI 53705
| | - Brian R Wolf
- University of Iowa Sports Medicine Center, 2701 Prairie Meadow Drive, Iowa City, IA 52242
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Suite 11000, 2525 West End Avenue, Nashville, TN 37203-1738
| | - Emily K Reinke
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, 4200 Medical Center East, South Tower, Nashville, TN 37232-8774
| | - Laura J Huston
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, 4200 Medical Center East, South Tower, Nashville, TN 37232-8774
| | - Kurt P Spindler
- Cleveland Clinic, Sports Medicine A-41, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address:
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The Impact of the Multicenter Orthopaedic Outcomes Network (MOON) Research on Anterior Cruciate Ligament Reconstruction and Orthopaedic Practice. J Am Acad Orthop Surg 2015; 23:154-63. [PMID: 25667401 PMCID: PMC4344406 DOI: 10.5435/jaaos-d-14-00005] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
With an estimated 200,000 anterior cruciate ligament reconstructions performed annually in the United States, there is an emphasis on determining patient-specific information to help educate patients on expected clinically relevant outcomes. The Multicenter Orthopaedic Outcomes Network consortium was created in 2002 to enroll and longitudinally follow a large population cohort of anterior cruciate ligament reconstructions. The study group has enrolled >4,400 anterior cruciate ligament reconstructions from seven institutions to establish the large level I prospective anterior cruciate ligament reconstruction outcomes cohort. The group has become more than a database with information regarding anterior cruciate ligament injuries; it has helped to establish a new benchmark for conducting multicenter, multisurgeon orthopaedic research. The changes in anterior cruciate ligament reconstruction practice resulting from the group include the use of autograft for high school, college, and competitive athletes in their primary anterior cruciate ligament reconstructions. Other modifications include treatment options for meniscus and cartilage injuries, as well as lifestyle choices made after anterior cruciate ligament reconstruction.
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Kolman S, Keenan MA, Spiegel D, Namdari S, Hosalkar H, Baldwin KD. What's new in orthopaedic rehabilitation. J Bone Joint Surg Am 2014; 96:1925-34. [PMID: 25410515 DOI: 10.2106/jbjs.n.00875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Samuel Kolman
- Richard D. Wood Center, 2nd Floor, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399
| | - Mary Ann Keenan
- Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, Two Silverstein, Philadelphia, PA 19104
| | - David Spiegel
- Richard D. Wood Center, 2nd Floor, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399
| | - Surena Namdari
- Rothman Institute at Jefferson, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107
| | | | - Keith D Baldwin
- Richard D. Wood Center, 2nd Floor, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399
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Berschin G, Sommer B, Behrens A, Sommer HM. Whole Body Vibration Exercise Protocol versus a Standard Exercise Protocol after ACL Reconstruction: A Clinical Randomized Controlled Trial with Short Term Follow-Up. J Sports Sci Med 2014; 13:580-589. [PMID: 25177185 PMCID: PMC4126295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 04/02/2014] [Indexed: 06/03/2023]
Abstract
The suitability and effectiveness of whole body vibration (WBV) exercise in rehabilitation after injury of the anterior cruciate ligament (ACL) was studied using a specially designed WBV protocol. We wanted to test the hypothesis if WBV leads to superior short term results regarding neuromuscular performance (strength and coordination) and would be less time consuming than a current standard muscle strengthening protocol. In this prospective randomized controlled clinical trial, forty patients who tore their ACL and underwent subsequent ligament reconstruction were enrolled. Patients were randomized to the whole body vibration (n=20) or standard rehabilitation exercise protocol (n=20). Both protocols started in the 2(nd) week after surgery. Isometric and isokinetic strength measurements, clinical assessment, Lysholm score, neuromuscular performance were conducted weeks 2, 5, 8 and 11 after surgery. Time spent for rehabilitation exercise was reduced to less than a half in the WBV group. There were no statistically significant differences in terms of clinical assessment, Lysholm score, isokinetic and isometric strength. The WBV group displayed significant better results in the stability test. In conclusion, preliminary data indicate that our whole body vibration muscle exercise protocol seems to be a good alternative to a standard exercise program in ACL-rehabilitation. Despite of its significant reduced time requirement it is at least equally effective compared to a standard rehabilitation protocol. Key pointsIn this prospective randomized controlled clinical trial, we tested the hypothesis if WBV leads to superior short term results regarding neuromuscular performance (strength and coordination) and would be less time consuming than a current standard muscle strengthening protocol in forty patients who underwent ACL reconstruction.Time spent for rehabilitation exercise was reduced to less than a half in the WBV group as compared to the standard exercise group. Both protocols showed no differences regarding clinical assessment, Lysholm score, isokinetic and isometric strength.Despite a more than 50% reduction in time spent for exercise sessions, the WBV group achieved significant better results in the stability test.In conclusion, the presented WBV program can be considered as a practical alternative to a standard exercise program during ACL-rehabilitation.
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Affiliation(s)
- Gereon Berschin
- Department of Sports Science and Motology, Philipps-University Marburg , Marburg, Germany
| | - Björn Sommer
- Department of Neurosurgery, University of Erlangen-Nuremberg , Erlangen, Germany
| | - Antje Behrens
- Department of Sports Science and Motology, Philipps-University Marburg , Marburg, Germany
| | - Hans-Martin Sommer
- Department of Sports Science and Motology, Philipps-University Marburg , Marburg, Germany
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Cox CL, Huston LJ, Dunn WR, Reinke EK, Nwosu SK, Parker RD, Wright RW, Kaeding CC, Marx RG, Amendola A, McCarty EC, Wolf BR, Harrell FE, Spindler KP. Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx activity level outcomes after anterior cruciate ligament reconstruction? A 6-year multicenter cohort study. Am J Sports Med 2014; 42:1058-67. [PMID: 24647881 PMCID: PMC4195485 DOI: 10.1177/0363546514525910] [Citation(s) in RCA: 180] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and future treatment. HYPOTHESIS Articular cartilage lesions and meniscus tears/treatment would predict International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level at 6 years after ACLR. STUDY DESIGN Cohort study (prognosis); Level of evidence, 1. METHODS Between 2002 and 2004, a total of 1512 ACLR patients were prospectively enrolled and followed longitudinally, with the IKDC, KOOS, and Marx activity score completed at entry, 2 years, and 6 years. A logistic regression model was built incorporating variables from patient demographics, surgical technique, articular cartilage injuries, and meniscus tears/treatment to determine the predictors (risk factors) of IKDC and KOOS scores and Marx activity level at 6 years. RESULTS A minimum follow-up on 86% (1307/1512) of the cohort was completed at 6 years. The cohort was 56% male and had a median age of 23 years at the time of enrollment, with 76% reporting a noncontact injury mechanism. Incidence of concomitant injury at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 25%; lateral femoral condyle [LFC] 20%; medial tibial plateau [MTP], 6%; lateral tibial plateau [LTP], 12%; patella, 20%; trochlear, 9%) and meniscus (medial, 38%; lateral, 46%). Both articular cartilage lesions and meniscus tears were significant predictors of 6-year outcomes on the IKDC and KOOS. Grade 3 or 4 articular cartilage lesions (excluding patella) significantly reduced IKDC and KOOS scores at 6 years. The IKDC demonstrated worse outcomes with the presence of a grade 3 or 4 chondral lesion on the MFC, MTP, and LFC. Likewise, the KOOS score was negatively affected by cartilage injury. The sole significant predictor of reduced Marx activity level was the presence of a grade 4 lesion on the MFC. Lateral meniscus repairs did not correlate with inferior results, but medial meniscus repairs predicted worse IKDC and KOOS scores. Lateral meniscus tears left alone significantly improved prognosis. Small partial meniscectomies (<33%) on the medial meniscus fared worse; conversely, larger excisions (>50%) on either the medial or lateral menisci improved prognosis. Analogous to previous studies, other significant predictors of lower outcome scores were lower baseline scores, higher body mass index, lower education level, smoking, and anterior cruciate ligament revisions. CONCLUSION Both articular cartilage injury and meniscus tears/treatment at the time of ACLR were significant predictors of IKDC and KOOS scores 6 years after ACLR. Similarly, having a grade 4 MFC lesion significantly reduced a patient's Marx activity level score at 6 years.
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Affiliation(s)
- Charles L. Cox
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Laura J. Huston
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Warren R. Dunn
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Emily K. Reinke
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Samuel K. Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Richard D. Parker
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Rick W. Wright
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO
| | - Christopher C. Kaeding
- Department of Orthopaedic Surgery, The Ohio State University School of Medicine, Columbus, OH
| | - Robert G. Marx
- Sports Medicine Division, Hospital for Special Surgery, New York, NY
| | - Annunziata Amendola
- Department of Orthopaedic Surgery, University of Iowa School of Medicine, Iowa City, IA
| | - Eric C. McCarty
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, CO
| | - Brian R. Wolf
- Department of Orthopaedic Surgery, University of Iowa School of Medicine, Iowa City, IA
| | - Frank E. Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Kurt P. Spindler
- Vanderbilt Orthopaedic Institute, Vanderbilt University Medical Center, Nashville, TN
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Farr J, Jaggers R, Lewis H, Plackis A, Sim SB, Sherman SL. Evidence-based approach of treatment options for postoperative knee pain. PHYSICIAN SPORTSMED 2014; 42:58-70. [PMID: 24875973 DOI: 10.3810/psm.2014.05.2058] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Optimal pain management is critical after knee surgery to avoid adverse events and to improve surgical outcomes. Pain may affect surgical outcomes by contributing to limitations in range of motion, strength, and functional recovery. The causes of postoperative pain are multifactorial; therefore, an appropriate pain management strategy must take into account preoperative, intraoperative, and postoperative factors to create a comprehensive and individualized plan for the patient. Preoperative assessment includes management of patient expectations, recognition of conditions and early counseling for high-risk patients (ie, opioid dependence, psychiatric comorbidities), and use of preemptive analgesia techniques (ie, preoperative IV medications, peripheral nerve blocks, incisional field blocks). Intraoperative strategies include meticulous surgical technique, limiting the use of tourniquets (ie, duration and pressure), and using preventive analgesia methods (ie, postoperative field block, continuous nerve catheters, intra-articular injection). Postoperative analgesia may be facilitated by cryotherapy, early mobilization, bracing, and rehabilitation. Certain modalities (ie, continuous passive motion devices, transcutaneous electrical nerve stimulation units, iontophoresis) may be important adjuncts in the perioperative period as well. There may be an evolving role for alternative medicine strategies. Early recognition and treatment of exaggerated postoperative pain responses may mitigate the effects of complex regional pain syndrome or the development of chronic pain.
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Affiliation(s)
- Jack Farr
- Cartilage Restoration Center of Indiana, Greenwood, IN
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Barrow AE, Pilia M, Guda T, Kadrmas WR, Burns TC. Femoral suspension devices for anterior cruciate ligament reconstruction: do adjustable loops lengthen? Am J Sports Med 2014; 42:343-9. [PMID: 24158183 DOI: 10.1177/0363546513507769] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cortical suspension devices are commonly used for femoral graft fixation during anterior cruciate ligament (ACL) reconstructive surgery. Adjustable-length fixation devices provide technical advantages over fixed-length loops but may be more susceptible to lengthening during cyclic loading. HYPOTHESIS Both fixed-length and adjustable-length femoral cortical suspension devices would withstand ultimate loads greater than those normally experienced by the native ACL and would prevent clinically significant lengthening during prolonged cyclic loading. STUDY DESIGN Controlled laboratory study. METHODS Mechanical testing was performed on 3 ACL graft cortical suspensory devices by use of an extended cyclic loading (4500 cycles at 10-250 N) and pull-to-failure protocol. Two adjustable-length devices were additionally tested with the free suture ends tied. RESULTS Total displacement after 4500 cycles of tensioning at variable loads (expressed as mean ± SD) was 42.45 mm (±7.01 mm) for the Arthrex TightRope RT, 5.76 mm (±0.35 mm) for the Biomet ToggleLoc, and 1.34 mm (±0.03 mm) for the Smith & Nephew EndoButton CL Ultra (P < .001). The Arthrex TightRope reached clinical failure of 3 mm lengthening after fewer cycles (1349 ± 316) than the Biomet ToggleLoc (2576 ± 73) (P < .001). The Smith & Nephew EndoButton did not reach clinical failure during cyclic testing. With the free suture ends tied, after 4500 cycles, the Arthrex TightRope had a significant decrease in lengthening to 13.36 ± 1.86 mm (P < .037) There was also a significant difference in ultimate load between the TightRope (809.11 ± 52.94 N) and the other 2 constructs (P < .001). CONCLUSION The ultimate load of all graft-fixation devices exceeded the forces likely to be experienced in a patient's knee during the early postoperative rehabilitation period. However, the adjustable-length fixation devices experienced a clinically significant increase in loop lengthening during cyclic testing. This lengthening is partially caused by suture slippage into the adjustable-length loop. CLINICAL RELEVANCE Adjustable-length ACL graft cortical suspension devices lengthen under cyclic loads because free suture ends are pulled into the adjustable loop. This may allow for graft-fixation device lengthening during the acute postoperative period.
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Affiliation(s)
- Aaron E Barrow
- Travis C. Burns, Deparment of Orthopedics and Rehabilitation, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234.
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Abstract
OBJECTIVE To review recent evidence in order to update previous systematic reviews on methods of rehabilitation after anterior cruciate ligament (ACL) reconstruction. DATA SOURCES PubMed, Embase, and the Cochrane Controlled Trials Register were searched for the period January 2006 to December 2010, using terms related to ACL, rehabilitation, and randomized controlled trial (RCT). The search was done in triplicate, and the results reconciled (85 studies identified). STUDY SELECTION Relevant studies in English that were peer-reviewed RCTs or prospective comparative studies evaluating methods of ACL rehabilitation were included (n = 29). Evidence was evaluated by all 3 authors using the CONSORT criteria. DATA EXTRACTION The data extracted included number of patients, ACL reconstruction method, randomization method, intervention, length of, and loss to, follow-up, outcomes assessed, bias, and findings. The review included evidence on postoperative bracing, accelerated rehabilitation, home-based rehabilitation, proprioceptive and neuromuscular training, and miscellaneous topics that were investigated by single trials. MAIN RESULTS In 6 studies of postoperative bracing, no study found a clinically significant benefit of bracing or of restricted range of knee motion for pain control, knee laxity, or rehabilitation. Postoperative treatment without the use of a brace was not associated with less favorable outcomes. In 5 studies of accelerated strengthening, beginning eccentric quadriceps strengthening and isokinetic hamstring strengthening 2 weeks after ACL surgery improved or accelerated strength gains. Immediately postoperative weight-bearing, range of knee motion from 0° to 90° of flexion, and strengthening with closed-chain exercises were probably all safe. Home-based rehabilitation was evaluated in 2 studies. One study demonstrated that this intervention was at least as successful as a standard accelerated program over the long term. The other study included very low compliance expectations and other methodologic problems that precluded a useful assessment of benefit. Nine trials of neuromuscular strengthening (including perturbation, vibration, and/or balance training by various means) compared with strength, traditional rehabilitation, or placebo found some small short-term benefits to proprioceptive training and no harm from any of the treatments. Vibration training in addition to other strengthening may lead to faster proprioceptive recovery but the benefits to overall functional outcome are less clear. A study of vitamin C and E supplementation found a correlation between higher presurgery vitamin C levels and greater strength at 3 months, but this strength increase was not related to postsurgical vitamin C supplementation. Hyaluronic acid injection at 8 weeks improved ambulation and peak torque more than other doses or placebo, but poor outcomes in the control group raise questions about the quality of the standard rehabilitation program. Running interval training and continuous active motion had unclear effects. Using the uninjured leg for single-leg cycling prevented the usual loss of aerobic fitness in the postoperative period. Preoperative and postoperative video instruction decreased expectations of pain and increased self-efficacy although it made no difference to performance. CONCLUSIONS The review of rehabilitation interventions after ACL reconstruction suggests that both accelerated and home-based rehabilitation, neuromuscular training programs, hyaluronic acid injection, and single (uninjured) leg cycling may be beneficial. Preoperative and postoperative informational videos may be valuable for psychological well-being. Insufficient evidence was found to recommend bracing.
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The basic science of continuous passive motion in promoting knee health: a systematic review of studies in a rabbit model. Arthroscopy 2013; 29:1722-31. [PMID: 23890952 PMCID: PMC4955557 DOI: 10.1016/j.arthro.2013.05.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 05/23/2013] [Accepted: 05/31/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE To determine whether the basic science evidence supports the use of continuous passive motion (CPM) after articular cartilage injury in the knee. METHODS A systematic review was performed identifying and evaluating studies in animal models that focused on the basic science of CPM of the knee. Databases included in this review were PubMed, Biosis Previews, SPORTDiscus, PEDro, and EMBASE. All functional, gross anatomic, histologic, and histochemical outcomes were extracted and analyzed. RESULTS Primary outcomes of CPM analyzed in rabbit animal models (19 studies) included histologic changes in articular cartilage (13 studies), biomechanical changes and nutrition of intra-articular tissue (3 studies), and anti-inflammatory biochemical changes (3 studies). Nine studies specifically examined osteochondral defects, 6 of which used autogenous periosteal grafts. Other pathologies included were antigen-induced arthritis, septic arthritis, medial collateral ligament reconstruction, hemarthrosis, and chymopapain-induced proteoglycan destruction. In comparison to immobilized knees, CPM therapy led to decreased joint stiffness and complications related to adhesions while promoting improved neochondrogenesis with formation and preservation of normal articular cartilage. CPM was also shown to create a strong anti-inflammatory environment by effectively clearing harmful, inflammatory particles from within the knee. CONCLUSIONS Current basic science evidence from rabbit studies has shown that CPM for the knee significantly improves motion and biological properties of articular cartilage. This may be translated to potentially improved outcomes in the management of articular cartilage pathology of the knee. CLINICAL RELEVANCE If the rabbit model is relevant to humans, CPM may contribute to improved knee health by preventing joint stiffness, preserving normal articular tissue with better histologic and biologic properties, and improving range of motion as compared with joint immobilization and intermittent active motion.
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Spindler KP, Parker RD, Andrish JT, Kaeding CC, Wright RW, Marx RG, McCarty EC, Amendola A, Dunn WR, Huston LJ, Harrell FE. Prognosis and predictors of ACL reconstructions using the MOON cohort: a model for comparative effectiveness studies. J Orthop Res 2013; 31:2-9. [PMID: 22912340 PMCID: PMC3508257 DOI: 10.1002/jor.22201] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 07/09/2012] [Indexed: 02/04/2023]
Abstract
Injury to the anterior cruciate ligament (ACL) threatens an active lifestyle and exposes the patient to risk of early osteoarthritis (OA). ACL reconstruction is typically chosen by individuals to allow a return to their previous work and sports activities. Primary ACL reconstruction (ACLR) has in general been effective at restoring functional stability, but patients' modifiable predictors of both short- and long-term validated outcomes and OA are largely unknown. The Multicenter Orthopaedic Outcomes Network (MOON) consortium was established in 2002 to enroll and longitudinally follow a population cohort of ACL reconstructed patients. The objective was to establish patient-specific predictive models of clinically important outcomes. Over the past 10 years, the overarching aims of this NIAMS-funded prospective multicenter cohort of ACL reconstructions has been threefold: (1) to identify both short- and long-term prognosis and predictors of sports function, activity level, and general health through validated patient-reported outcomes, (2) to identify the symptoms and signs of OA, and (3) to quantify the incidence of ACL reconstruction graft and/or contralateral ACL failures and additional surgical procedures. This manuscript summarizes the Kappa Delta Ann Doner Vaughan Award paper and presentation at the 2012 ORS/AAOS Annual Meeting.
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Kruse L, Gray B, Wright R. Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am 2012; 94:1737-48. [PMID: 23032584 PMCID: PMC3448301 DOI: 10.2106/jbjs.k.01246] [Citation(s) in RCA: 194] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rigorous rehabilitation after anterior cruciate ligament (ACL) reconstruction is necessary for a successful surgical outcome. A large number of clinical trials continue to assess aspects of this rehabilitation process. Prior systematic reviews evaluated fifty-four Level-I and II clinical trials published through 2005. METHODS Eighty-five articles from 2006 to 2010 were identified utilizing multiple search engines. Twenty-nine Level-I or II studies met inclusion criteria and were evaluated with use of the CONSORT (Consolidated Standards of Reporting Trials) criteria. Topics included in this review are postoperative bracing, accelerated strengthening, home-based rehabilitation, proprioception and neuromuscular training, and six miscellaneous topics investigated in single trials. RESULTS Bracing following ACL reconstruction remains neither necessary nor beneficial and adds to the cost of the procedure. Early return to sports needs further research. Home-based rehabilitation can be successful. Although neuromuscular interventions are not likely to be harmful to patients, they are also not likely to yield large improvements in outcomes or help patients return to sports faster. Thus, they should not be performed to the exclusion of strengthening and range-of-motion exercises. Vibration training may lead to faster and more complete proprioceptive recovery but further evidence is needed. CONCLUSIONS Several new modalities for rehabilitation after ACL reconstruction may be helpful but should not be performed to the exclusion of range-of-motion, strengthening, and functional exercises. Accelerated rehabilitation does not appear to be harmful but further investigation of rehabilitation timing is warranted. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- L.M. Kruse
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110. E-mail address for R.W. Wright:
| | - B. Gray
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110. E-mail address for R.W. Wright:
| | - R.W. Wright
- Department of Orthopedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110. E-mail address for R.W. Wright:
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Stasiak ME, Wiznia D, Alzoobaee S, Ciccotti MC, Imhauser CW, Voigt C, Torzilli PA, Deng XH, Rodeo SA. A novel device to apply controlled flexion and extension to the rat knee following anterior cruciate ligament reconstruction. J Biomech Eng 2012; 134:041008. [PMID: 22667683 DOI: 10.1115/1.4006341] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We designed and validated a novel device for applying flexion-extension cycles to a rat knee in an in vivo model of anterior cruciate ligament reconstruction (ACL-R). Our device is intended to simulate rehabilitation motion and exercise post ACL-R to optimize physical rehabilitation treatments for the improved healing of tendon graft ligament reconstructions. The device was validated for repeatability of the knee kinematic motion by measuring the force versus angular rotation response from repeated trials using cadaver rats. The average maximum force required for rotating an ACL reconstructed rat knee through 100 degrees of flexion-extension was 0.4 N with 95% variability for all trials within ±0.1 N.
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81
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Kruse LM, Gray BL, Wright RW. Anterior Cruciate Ligament Reconstruction Rehabilitation in the Pediatric Population. Clin Sports Med 2011; 30:817-24. [DOI: 10.1016/j.csm.2011.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Survey study of members of the Canadian Orthopaedic Association on the natural history and treatment of anterior cruciate ligament injury. Clin J Sport Med 2011; 21:249-58. [PMID: 21519299 DOI: 10.1097/jsm.0b013e318219a649] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe current preferences and opinions of members of the Canadian Orthopaedic Association (COA) pertaining to anterior cruciate ligament (ACL) reconstruction. DESIGN Survey study. PARTICIPANTS All orthopedic surgeon members of the COA residing in Canada were invited to participate. MAIN OUTCOME MEASURES The primary measure was a survey completed via an Internet-based survey manager. It was composed of 30 questions on the natural history of ACL-injured knees, and surgical and postsurgical treatment choices. RESULTS Two hundred eighty-three surgeons (50%) responded to the survey. One hundred forty-four performed ACL reconstruction in the past year. In terms of natural history, the only area of agreement was that hamstring and quadricep strength affects function in ACL-deficient knees (92%). A majority of surgeons indicated preference for hamstring autograft (73%), transtibial versus anteromedial portal for establishment of the femoral tunnel (70% vs 28%), and promotion of full weight bearing and range of motion immediately after surgery (72% and 75%, respectively). The most frequent surgeon-reported complication was tunnel widening (10%). A greater proportion of high-volume surgeons permitted earlier return to sport (P < 0.008). CONCLUSIONS In the rapidly evolving area of ACL reconstruction, no recent surveys of opinions and preferences of Canadian orthopedic surgeons have been published. In addition to providing information from a Canadian perspective, the findings from this study will allow surgeons to evaluate a range of treatment decisions based on the general opinions of their colleagues and also highlights areas of dissimilarity that can be targeted for more extensive research.
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Kim YH, Kim K, Park WM, Yoon KH. Reduction of knee range of motion during continuous passive motion due to misaligned hip joint centre. Comput Methods Biomech Biomed Engin 2011; 15:801-6. [PMID: 21491257 DOI: 10.1080/10255842.2011.561792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
When using continuous passive motion (CPM) devices, appropriate setting of the device and positioning of the patient are necessary to obtain maximum range of motion (ROM). In this study, the ROMs in both the knee joint and CPM device during CPM treatment were measured using a motion analysis system for three different CPM devices. Additionally, the trajectories of the angles at the knee for hip joint misalignments were evaluated using kinematic models of the three CPM devices. The results showed that discrepancies in ROM between the knee joints and the CPM device settings during CPM treatment were revealed regardless of the CPM device and that the effect of misalignment is dependent on the design of the CPM device. The present technology could be applied for the development of a better design configuration for the CPM device to reduce the discrepancy in ROM at the knee joint.
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Affiliation(s)
- Yoon Hyuk Kim
- Department of Mechanical Engineering & e-Spine Center, Kyung Hee University, Yongin, 446-701, Korea.
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Kokkinakis M, Ashmore A, El-Guindi M. Intraoperative complications using the Bio-Transfix femoral fixation implant in anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 2010; 130:375-9. [PMID: 19787359 DOI: 10.1007/s00402-009-0976-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Indexed: 01/10/2023]
Abstract
The use of biodegradable Transfix femoral fixation technique is a safe and well-accepted method when performing anterior cruciate ligament reconstruction. We report on three cases of deformation and back out of the Bio-Transfix implant over the lateral, distal femoral cortex, with failure of the passing wire when advancing the graft into the femoral tunnel in one of these patients. Two of the patients presented with symptoms of iliotibial band friction syndrome, while the third patient was asymptomatic. The graft had clinically integrated demonstrating AP and rotational stability. The symptoms relieved after removal of the failed Bio-Transfix implants in the symptomatic patients. The aetiology of the implant failure and the alternative methods to avoid such complications are discussed.
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Affiliation(s)
- Michail Kokkinakis
- Stoke Mandeville Hospital, 43 Aston House, Mandeville Road, Aylesbury, Buckinghamshire, UK.
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Affiliation(s)
- Kurt P Spindler
- Vanderbilt Sports Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-8774, USA.
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