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Miles O, Tham S, Morrison W, Ek E, Palmer J, McCombe D. Immunohistochemical Investigation of Mechanoreceptors Within the Injured Scapholunate Ligament. J Hand Surg Am 2023:S0363-5023(23)00546-4. [PMID: 38043032 DOI: 10.1016/j.jhsa.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/29/2023] [Accepted: 10/05/2023] [Indexed: 12/04/2023]
Abstract
PURPOSE Scapholunate ligaments (SLLs) play a well-established role in maintaining carpal alignment and kinematics, and are innervated with sensory mechanoreceptors located within the ligaments. They are involved in the afferent arc of dynamic wrist stability. The aim of this study was to describe the changes in these mechanoreceptor populations in injured SLLs. METHODS Injured SLLs were collected from human wrists at the time of SLL reconstruction or limited wrist fusion, where the ligament remnants would otherwise be discarded. These specimens were formalin-fixed and paraffin-embedded for immunohistochemical analysis to identify mechanoreceptors, which were then classified by type and location within the ligament. RESULTS A total of 15 ligaments were collected, with the interval from injury ranging from 39 days-20 years. Eleven ligaments were collected less than one year after injury, and four ligaments were collected two years or more after injury. A total of 66 mechanoreceptors were identified, with 50 mechanoreceptors identified in nine of the 11 specimens collected less than one year after injury. In this group, 54% of the mechanoreceptors resided in the volar subunit, 20% in the dorsal subunit, and 26% in the proximal subunit. Two of the four specimens collected two years or later after injury contained mechanoreceptors, all of which were located in the dorsal subunit. Increasing time from injury demonstrated a decline in mechanoreceptor numbers within the volar subunit. CONCLUSIONS Mechanoreceptors were consistently located in the SLL, particularly in the volar subunit of specimens collected less than one year after injury. CLINICAL RELEVANCE Ligament reconstruction techniques aim to primarily reconstitute the biomechanical function of the disrupted SLL; however, re-establishing the afferent proprioceptive capacity of the SLL may be a secondary objective. This suggests the need to consider the reconstruction of its volar subunit particularly in those managed within one year of injury.
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Affiliation(s)
- Oliver Miles
- Plastic, Reconstructive and Hand Surgery Unit, St. Vincent's Hospital Melbourne, Fitzroy, Australia; O'Brien Institute, St. Vincent's Institute of Medical Research, Fitzroy, Australia.
| | - Stephen Tham
- Plastic, Reconstructive and Hand Surgery Unit, St. Vincent's Hospital Melbourne, Fitzroy, Australia; O'Brien Institute, St. Vincent's Institute of Medical Research, Fitzroy, Australia; Victorian Hand Surgery Associates. St Vincent's Hospital, Fitzroy, Australia
| | - Wayne Morrison
- O'Brien Institute, St. Vincent's Institute of Medical Research, Fitzroy, Australia; University of Melbourne Department of Surgery, St. Vincent's Hospital, Fitzroy, Australia
| | - Eugene Ek
- Mebourne Orthopaedic Group, Windsor, VIC, Australia
| | - Jason Palmer
- O'Brien Institute, St. Vincent's Institute of Medical Research, Fitzroy, Australia
| | - David McCombe
- O'Brien Institute, St. Vincent's Institute of Medical Research, Fitzroy, Australia; Victorian Hand Surgery Associates. St Vincent's Hospital, Fitzroy, Australia; University of Melbourne Department of Surgery, St. Vincent's Hospital, Fitzroy, Australia
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Warth RJ, Zandiyeh P, Rao M, Gabr RE, Tashman S, Kumaravel M, Narayana PA, Lowe WR, Harner CD. Quantitative Assessment of In Vivo Human Anterior Cruciate Ligament Autograft Remodeling: A 3-Dimensional UTE-T2* Imaging Study. Am J Sports Med 2020; 48:2939-2947. [PMID: 32915640 DOI: 10.1177/0363546520949855] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The timing of return to play after anterior cruciate ligament (ACL) reconstruction is still controversial due to uncertainty of true ACL graft state at the time of RTP. Recent work utilizing ultra-short echo T2* (UTE-T2*) magnetic resonance imaging (MRI) as a scanner-independent method to objectively and non-invasively assess the status of in vivo ACL graft remodeling has produced promising results. PURPOSE/HYPOTHESIS The purpose of this study was to prospectively and noninvasively investigate longitudinal changes in T2* within ACL autografts at incremental time points up to 12 months after primary ACL reconstruction in human patients. We hypothesized that (1) T2* would increase from baseline and initially exceed that of the intact contralateral ACL, followed by a gradual decline as the graft undergoes remodeling, and (2) remodeling would occur in a region-dependent manner. STUDY DESIGN Case series; Level of evidence, 4. METHODS Twelve patients (age range, 14-45 years) who underwent primary ACL reconstruction with semitendinosus tendon or bone-patellar tendon-bone autograft (with or without meniscal repair) were enrolled. Patients with a history of previous injury or surgery to either knee were excluded. Patients returned for UTE MRI at 1, 3, 6, 9, and 12 months after ACL reconstruction. Imaging at 1 month included the contralateral knee. MRI pulse sequences included high-resolution 3-dimensional gradient echo sequence and a 4-echo T2-UTE sequence (slice thickness, 1 mm; repetition time, 20 ms; echo time, 0.3, 3.3, 6.3, and 9.3 ms). All slices containing the intra-articular ACL were segmented from high-resolution sequences to generate volumetric regions of interest (ROIs). ROIs were divided into proximal/distal and core/peripheral sub-ROIs using standardized methods, followed by voxel-to-voxel registration to generate T2* maps at each time point. This process was repeated by a second reviewer for interobserver reliability. Statistical differences in mean T2* values and mean ratios of T2*inj/T2*intact (ie, injured knee to intact knee) among the ROIs and sub-ROIs were assessed using repeated measures and one-way analyses of variance. P < .05 represented statistical significance. RESULTS Twelve patients enrolled in this prospective study, 2 withdrew, and ultimately 10 patients were included in the analysis (n = 7, semitendinosus tendon; n = 3, bone-patellar tendon-bone). Interobserver reliability for T2* values was good to excellent (intraclass correlation coefficient, 0.84; 95% CI, 0.59-0.94; P < .001). T2* values increased from 5.5 ± 2.1 ms (mean ± SD) at 1 month to 10.0 ± 2.9 ms at 6 months (P = .001), followed by a decline to 8.1 ± 2.0 ms at 12 months (P = .129, vs 1 month; P = .094, vs 6 months). Similarly, mean T2*inj/T2*intact ratios increased from 62.8% ± 22.9% at 1 month to 111.1% ± 23.9% at 6 months (P = .001), followed by a decline to 92.8% ± 29.8% at 12 months (P = .110, vs 1 month; P = .086, vs 6 months). Sub-ROIs exhibited similar increases in T2* until reaching a peak at 6 months, followed by a gradual decline until the 12-month time point. There were no statistically significant differences among the sub-ROIs (P > .05). CONCLUSION In this preliminary study, T2* values for ACL autografts exhibited a statistically significant increase of 82% between 1 and 6 months, followed by an approximate 19% decline in T2* values between 6 and 12 months. In the future, UTE-T2* MRI may provide unique insights into the condition of remodeling ACL grafts and may improve our ability to noninvasively assess graft maturity before return to play.
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Affiliation(s)
- Ryan J Warth
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Payam Zandiyeh
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mayank Rao
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Refaat E Gabr
- Department of Diagnostic & Interventional Imaging, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Scott Tashman
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Manickam Kumaravel
- Department of Diagnostic & Interventional Imaging, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ponnada A Narayana
- Department of Diagnostic & Interventional Imaging, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Walter R Lowe
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christopher D Harner
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Zhang L, Jiang K, Chai H, Zhou M, Bai J. A Comparative Animal Study of Tendon Grafts Healing After Remnant-Preserving Versus Conventional Anterior Cruciate Ligament Reconstruction. Med Sci Monit 2016; 22:3426-3437. [PMID: 27669454 PMCID: PMC5042118 DOI: 10.12659/msm.900265] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of this study was to determine if anterior cruciate ligament (ACL) reconstruction by remnant preservation promotes cell proliferation, vascularization, proprioception recovery, and improved biomechanical properties of the tendon grafts. MATERIAL AND METHODS 75 New Zealand rabbits were randomly assigned into the control group (group A), conventional ACL reconstruction group (group B), ACL reconstruction using remnant preservation and graft through remnant sleeve technique group (group C), and ACL reconstruction using remnant preservation and remnant tensioning technique group (group D). The remnant and healing of tendon grafts in groups C and D were observed at 3, 6, and 12 weeks after surgery, and the mRNA expression levels of VEGF, NT-3 and GAP-43 in ACL (group A) or tendon graft samples (groups B, C, and D) were determined by real-time PCR. Tendon graft cell count, microvessel density (MVD), and proprioceptors were determined by H&E staining, CD34, and S-100 immunohistochemical staining. The biomechanical properties of the tendon graft at week 12 in groups B, C, and D were examined by using a tensile strength test. RESULTS Remnant and tendon grafts were not healed at 3, 6, and 12 weeks after the operation in groups C and D. VEGF, NT-3, and GAP-43 mRNA expressions in groups B, C, and D were higher than those in group A (P<0.05), but no significant difference was observed between groups B, C, and D (P>0.05). Furthermore, tendon graft cell count, MVD, proprioception, and biomechanical properties showed no significant differences (P>0.05) among groups B, C, and D at various time points. CONCLUSIONS There was no significant difference in cell proliferation, vascularization, proprioception recovery, or biomechanical properties of the tendon grafts between remnant-preserving and conventional ACL reconstruction methods.
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Affiliation(s)
- Lei Zhang
- Department of Bone and Soft Tissue, Tumor Hospital Affiliated to Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Kan Jiang
- Department of Arthroscopy, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Hao Chai
- Department of Arthroscopy, The Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Mei Zhou
- Department of Pathology, Tumor Hospital Affiliated to Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Jingping Bai
- Department of Bone and Soft Tissue, Tumor Hospital Affiliated to Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
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Gokalp O, Akkaya S, Akkaya N, Buker N, Gungor HR, Ok N, Yorukoglu C. Preoperative and postoperative serial assessments of postural balance and fall risk in patients with arthroscopic anterior cruciate ligament reconstruction. J Back Musculoskelet Rehabil 2016; 29:343-350. [PMID: 26836842 DOI: 10.3233/bmr-160659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Impaired postural balance due to somatosensory data loss with mechanical instability has been shown in patients with ACL deficiency. OBJECTIVE To assess postural balance in patients with ACL insufficiency prior to surgery and following reconstruction with serial evaluations. METHODS Thirty patients (mean age of 27.7 ± 6.7 years) who underwent arthroscopic reconstruction of ACL with bone-patellar tendon-bone autograft were examined for clinical and functional variables at preoperative day and postoperative 12th week. Posturographic analysis were performed by using Tetrax Interactive Balance System (Sunlight Medical Ltd, Israel) at preoperative day, at 4th, 8th, and 12th weeks following reconstruction. Data computed by posturographic software by the considerations of the oscillation velocities of body sways is fall risk as a numeric value (0-100, lower values indicate better condition). RESULTS All of the patients (mean age of 27.7 ± 6.7 years) had significant improvements for clinical, functional evaluations and fall risk (p< 0.05). Mean fall risk was within high-risk category (59.9 ± 22.8) preoperatively. The highest fall risk was detected at postoperative 4th week. Patients had high fall risk at 8th week similar to preoperative value. Mean fall risk decreased to low level risk at 12th week. Preoperative symptom duration had relationships with preoperative fall risk and postoperative improvement of fall risk (p= 0.001, r= -0.632, p= 0.001, r= -0.870, respectively). The improvement of fall risk was higher in patients with symptoms shorter than 6 months (p= 0.001). CONCLUSIONS According to these results, mean fall risk of patients with ACL insufficiency was within high risk category preoperatively, and fall risk improves after surgical reconstruction, but as the duration of complaints lengthens especially longer than 6 months, the improvement of fall risk decreases following reconstruction.
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Affiliation(s)
- Oguzhan Gokalp
- Department of Orthopedics and Traumatology, Medicine Faculty, Pamukkale University, Denizli, Turkey
| | - Semih Akkaya
- Department of Orthopedics and Traumatology, Medicine Faculty, Pamukkale University, Denizli, Turkey
| | - Nuray Akkaya
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Pamukkale, Denizli, Turkey
| | - Nihal Buker
- School of Physical Therapy and Rehabilitation, University of Pamukkale, Denizli, Turkey
| | - Harun R Gungor
- Department of Orthopedics and Traumatology, Medicine Faculty, Pamukkale University, Denizli, Turkey
| | - Nusret Ok
- Department of Orthopedics and Traumatology, Medicine Faculty, Pamukkale University, Denizli, Turkey
| | - Cagdas Yorukoglu
- Department of Orthopedics and Traumatology, Medicine Faculty, Pamukkale University, Denizli, Turkey
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Roper JA, Terza MJ, Tillman MD, Hass CJ. Adaptation Strategies of Individuals With Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2016; 4:2325967115627611. [PMID: 26894200 PMCID: PMC4748157 DOI: 10.1177/2325967115627611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Despite the strong implications for rehabilitation design, the capability of individuals with anterior cruciate ligament reconstruction (ACLR) to adapt and store novel gait patterns have not been well studied. Purpose: To investigate how reconstructive surgery may affect the ability to adapt and store novel gait patterns in persons with ACLR while walking on a split-belt treadmill. Study Design: Controlled laboratory study. Methods: Gait adaptation was compared between 20 participants with ACLR and 20 healthy controls during split-belt treadmill walking. Gait adaptation was assessed in slow- and fast-adapting parameters by (1) the magnitude of symmetry during late adaptation and (2) the amount of the asymmetry during de-adaptation. Results: Healthy individuals adapted a new walking pattern and stored the new walking pattern equally in both the dominant and nondominant limbs. Conversely, individuals with ACLR displayed impairments in both slow-adapting and fast-adapting derived gait adaptation and significant differences in behavior between the reconstructed and uninjured limb. Conclusion: While surgical reconstruction and physical therapy are aimed at improving mechanical stability to the knee, the study data suggest that fundamental features of motor control remain altered. After ACLR, participants display an altered ability to learn and store functional gait patterns.
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Affiliation(s)
- Jaimie A Roper
- Applied Physiology and Kinesiology Department, College of Health and Human Performance, University of Florida, Gainesville, Florida, USA
| | - Matthew J Terza
- Applied Physiology and Kinesiology Department, College of Health and Human Performance, University of Florida, Gainesville, Florida, USA
| | - Mark D Tillman
- Department of Kinesiology and Health Promotion, College of Health and Human Services, Troy University, Troy, Alabama, USA
| | - Chris J Hass
- Applied Physiology and Kinesiology Department, College of Health and Human Performance, University of Florida, Gainesville, Florida, USA
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Eriksson K, Woo SLY, Bartlett J. Review of Clancy's article on anterior and posterior cruciate ligament reconstruction in rhesus monkeys. J ISAKOS 2016. [DOI: 10.1136/jisakos-2015-000041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ji X, Chen Q, Thoreson AR, Qu J, An KN, Amadio PC, Steinmann SP, Zhao C. Rotator cuff repair with a tendon-fibrocartilage-bone composite bridging patch. Clin Biomech (Bristol, Avon) 2015; 30:976-80. [PMID: 26190097 PMCID: PMC4631669 DOI: 10.1016/j.clinbiomech.2015.06.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND To compare the mechanical performance of a rotator cuff repaired with a novel tendon-fibrocartilage-bone composite bridging patch vs the traditional Mason-Allen repair in an in vitro canine model. METHODS Twenty shoulders and 10 bridging patches from patellar tendon were harvested. The patches were trimmed and sliced into 2 layers. An infraspinatus tendon tear was created in each shoulder. Modified Mason-Allen sutures were used to repair the infraspinatus tendon to the greater tuberosity, with or without the bridging patch (bridging patch group and controls, respectively). Shoulders were loaded to failure under displacement control at a rate of 0.5mm/s. FINDINGS The ultimate tensile load was significantly higher in the bridging patch group than control (mean [SD], 365.46 [36.45] vs 272.79 [48.88] N; P<.001). Stiffness at the greater tuberosity repair site and the patch-infraspinatus tendon repair site was significantly higher than the control repair site (93.96 [27.72] vs 42.62 [17.48] N/mm P<.001; 65.94 [24.51] vs 42.62 [17.48] N/mm P=.02, respectively). INTERPRETATION The tendon-fibrocartilage-bone composite bridging patch achieved higher ultimate tensile load and stiffness at the patch-greater tuberosity repair site compared with traditional repair in a canine model. This composite tissue transforms the traditional tendon-to-bone healing interface (with dissimilar tissues) into a pair of bone-to-bone and tendon-to-tendon interfaces, which may improve healing quality and reduce retear rate.
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Affiliation(s)
- Xiaoxi Ji
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA,Trauma Center, Shanghai First People’s Hospital, Shanghai Jiao Tong University, Shanghai 200080 China
| | - Qingshan Chen
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | - Andrew R. Thoreson
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | - Jin Qu
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | - Kai-Nan An
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | - Peter C. Amadio
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA
| | | | - Chunfeng Zhao
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55905 USA,Corresponding Author: Chunfeng Zhao, M.D. Division of Orthopedic Research, Mayo Clinic, 200 First St SW, Rochester, MN USA 55905, , Tel: 507-538-1717; Fax: 507-284-5392
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Labanca L, Laudani L, Casabona A, Menotti F, Mariani PP, Macaluso A. Early compensatory and anticipatory postural adjustments following anterior cruciate ligament reconstruction. Eur J Appl Physiol 2015; 115:1441-51. [DOI: 10.1007/s00421-015-3126-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 02/04/2015] [Indexed: 01/09/2023]
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Hjorthaug GA, Madsen JE, Nordsletten L, Reinholt FP, Steen H, Dimmen S. Tendon to bone tunnel healing--a study on the time-dependent changes in biomechanics, bone remodeling, and histology in a rat model. J Orthop Res 2015; 33:216-23. [PMID: 25367445 DOI: 10.1002/jor.22756] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 09/29/2014] [Indexed: 02/04/2023]
Abstract
Tendons and ligaments attach to bone through a transitional connective tissue with complex biomechanical properties. This unique tissue is not regenerated during healing, and surgical reattachment therefore often fails. The present study was designed to evaluate tendon healing in a bone tunnel and to evaluate the utilized rat model. Wistar rats (n = 61) were operated with the Achilles tendon through a bone tunnel in the distal tibia. Healing was evaluated at 2, 3, 4, and 12 weeks by biomechanical testing, bone mineral density and histology. After 2 weeks median (interquartile range) pull-out force was 2.2 N (1.9). The pull-out force increased chronologically, by 12 weeks fivefold to 11.2 N (11.4). Energy absorption, stiffness, and bone mineral density increased similarly. The histological analyses showed inflammation at early stages with increasing callus by time. Our data showed a slow healing response the first 4 weeks followed by an accelerated healing period, favoring that most of the gain in mechanical strength occurred later than 4 weeks postoperatively. These findings support the concern of a vulnerable tendon bone tunnel interface in the early stages of healing.
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Affiliation(s)
- Geir Aasmund Hjorthaug
- Department of Orthopaedic Surgery, Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Kirkeveien 166, N-0450, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
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McLean SG, Mallett KF, Arruda EM. Deconstructing the Anterior Cruciate Ligament: What We Know and Do Not Know About Function, Material Properties, and Injury Mechanics. J Biomech Eng 2015; 137:020906. [DOI: 10.1115/1.4029278] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Indexed: 12/20/2022]
Abstract
Anterior cruciate ligament (ACL) injury is a common and potentially catastrophic knee joint injury, afflicting a large number of males and particularly females annually. Apart from the obvious acute injury events, it also presents with significant long-term morbidities, in which osteoarthritis (OA) is a frequent and debilitative outcome. With these facts in mind, a vast amount of research has been undertaken over the past five decades geared toward characterizing the structural and mechanical behaviors of the native ACL tissue under various external load applications. While these efforts have afforded important insights, both in terms of understanding treating and rehabilitating ACL injuries; injury rates, their well-established sex-based disparity, and long-term sequelae have endured. In reviewing the expanse of literature conducted to date in this area, this paper identifies important knowledge gaps that contribute directly to this long-standing clinical dilemma. In particular, the following limitations remain. First, minimal data exist that accurately describe native ACL mechanics under the extreme loading rates synonymous with actual injury. Second, current ACL mechanical data are typically derived from isolated and oversimplified strain estimates that fail to adequately capture the true 3D mechanical response of this anatomically complex structure. Third, graft tissues commonly chosen to reconstruct the ruptured ACL are mechanically suboptimal, being overdesigned for stiffness compared to the native tissue. The net result is an increased risk of rerupture and a modified and potentially hazardous habitual joint contact profile. These major limitations appear to warrant explicit research attention moving forward in order to successfully maintain/restore optimal knee joint function and long-term life quality in a large number of otherwise healthy individuals.
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Affiliation(s)
- Scott G. McLean
- Human Performance Innovation Laboratory, School of Kinesiology, University of Michigan, Ann Arbor, MI 48109 e-mail:
| | - Kaitlyn F. Mallett
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109 e-mail:
| | - Ellen M. Arruda
- Department of Mechanical Engineering, Department of Biomedical Engineering, Program in Macromolecular Science and Engineering, University of Michigan, Ann Arbor, MI 48109 e-mail:
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Platelet-rich plasma enhances autograft revascularization and reinnervation in a dog model of anterior cruciate ligament reconstruction. J Surg Res 2013; 183:214-22. [PMID: 23472861 DOI: 10.1016/j.jss.2013.01.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 12/10/2012] [Accepted: 01/10/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Autologous platelet-rich plasma (PRP) has been investigated as a potential promoter of tendon healing that affects the anterior cruciate ligament (ACL) graft maturation process. However, the influence of PRP on revascularization and reinnervation during the ACL graft remodeling has never been investigated. MATERIALS AND METHODS We randomly assigned healthy and mature beagles to one of four groups. In group 1 (PRP group), we treated the ACL grafts with PRP. In group 2 (control group), we treated the ACL grafts with saline. In group 3 (sham group), we exposed only the knee joints. In group 4 (normal control group), no surgery was performed on the knees. We dissected the ligament tissue at 2, 6, and 12 wk after surgery and performed real-time polymerase chain reaction using primers for cluster of differentiation molecule 31, vascular endothelial growth factor, thrombospondin-1 (TSP-1), neurotrophin-3, growth-associated protein-43 (GAP-43), and nerve growth factor. RESULTS We observed the increased expression of vascular endothelial growth factor, TSP-1, neurotrophin-3, GAP-43, and nerve growth factor mRNA in group 1 at 2, 6, and 12 wk after surgery, compared with that in group 2 (P < 0.05). We also detected increased levels of cluster of differentiation molecule 31 expression in group 1 (P < 0.05) at 2 and 6 wk after surgery. The levels of TSP-1 and GAP-43 mRNA were significantly increased in group 3 compared with those in group 4 at 2 wk after surgery (P < 0.05). CONCLUSIONS During graft remodeling, we observed a time-dependent change in gene expression after ACL reconstruction surgery. In addition, these results demonstrate that PRP alters the expression of some target genes at certain times, particularly during the early stages of graft remodeling. Platelet-rich plasma could promote revascularization and reinnervation, which might explain the enhancing effect of PRP on ACL graft maturation.
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Static and dynamic postural control in competitive athletes after anterior cruciate ligament reconstruction and controls. Knee Surg Sports Traumatol Arthrosc 2012; 20:1603-10. [PMID: 22124847 DOI: 10.1007/s00167-011-1806-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 11/09/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE To evaluate the test-retest reliability and compare the static and dynamic postural control values in competitive athletes following anterior cruciate ligament (ACL) reconstruction and controls. METHODS Thirty athletes, 8.4 ± 1.8 months after ACL reconstruction, and thirty healthy matched controls were asked to execute single-leg stance and single-legged drop jump tests onto a force plate. Amplitude and velocity in anteroposterior and mediolateral directions, and mean total velocity were measured for static evaluation. Peak vertical ground reaction force (PVGRF) during landing and takeoff and loading rate were measured for dynamic evaluation. To evaluate test-retest reliability, 15 participants of each group repeated the tests 6-8 days after the first session. Mixed model of analysis of variance was used to determine differences between the involved, uninvolved, and control limbs. The test-retest reliability was measured using intraclass correlation coefficient and standard error of measurement. RESULTS Greater postural sway has been observed in the operated leg of ACL-reconstructed athletes compared with the non-operated side (P < 0.01) and the matched limb of the control group (P < 0.01). During landing, PVGRF and loading rate on the uninvolved limb of the athletes who had undergone ACL reconstruction were greater in comparison with those of the control group (P < 0.001). Both static and dynamic postural measures have high test-retest reliability, ranging from 0.73 to 0.88. CONCLUSIONS Static and dynamic postural measures are reliable tests to evaluate functional performance of athletes following ACL reconstruction. Eight months postsurgery, competitive athletes still demonstrated postural asymmetries, compared to matched controls, which might result in their susceptibility to future ACL injury. LEVEL OF EVIDENCE Prognostic study, case-control, Level III.
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Xie GM, Huang fu XQ, Zhao JZ. The Effect of Remnant Preservation on Patterns of Gene Expression in a Rabbit Model of Anterior Cruciate Ligament Reconstruction. J Surg Res 2012; 176:510-6. [DOI: 10.1016/j.jss.2011.10.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 10/14/2011] [Accepted: 10/25/2011] [Indexed: 11/29/2022]
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Angoules AG, Mavrogenis AF, Dimitriou R, Karzis K, Drakoulakis E, Michos J, Papagelopoulos PJ. Knee proprioception following ACL reconstruction; a prospective trial comparing hamstrings with bone-patellar tendon-bone autograft. Knee 2011; 18:76-82. [PMID: 20149662 DOI: 10.1016/j.knee.2010.01.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 01/13/2010] [Accepted: 01/21/2010] [Indexed: 02/07/2023]
Abstract
We prospectively studied knee proprioception following ACL reconstruction in 40 patients (34 men and six women; mean age 31 years). The patients were allocated into two equal groups; group A underwent reconstruction using hamstrings autograft, and group B underwent reconstruction using bone-patellar tendon-bone autograft. Proprioception was assessed in flexion and extension by the joint position sense (JPS) at 15°, 45° and 75°, and time threshold to detection of passive motion (TTDPM) at 15° and 45°, preoperatively and at 3, 6 and 12 months postoperatively. The contralateral healthy knee was used as internal control. No statistical difference was found between the ACL-operated and the contralateral knees in JPS 15°, 45° and 75° at 6 and 12 months, in both study groups. No statistical difference was found between the ACL-operated and the contralateral knees in TTDPM 15° at 6 and 12 months, nor regarding TTDPM 45° at 3, 6 and 12 months, in group A. No statistical difference was found in JPS and TTDPM between the two grafts, at any time period. Knee proprioception returned to normal with ACL reconstruction at 6 months postoperatively, without any statistically significant difference between the autografts used.
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Affiliation(s)
- A G Angoules
- Department of Orthopaedics, Asclepeion Hospital of Voula, Greece.
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Krogsgaard MR, Fischer-Rasmussen T, Dyhre-Poulsen P. Absence of sensory function in the reconstructed anterior cruciate ligament. J Electromyogr Kinesiol 2011; 21:82-6. [DOI: 10.1016/j.jelekin.2010.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 09/26/2010] [Accepted: 09/28/2010] [Indexed: 10/18/2022] Open
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Kyung HS, Oh CW, Lee HJ. Clinical Evaluation of Anterior Cruciate Ligament Reconstruction with Remnant-preserving Technique - Method Using Single Four-strand Semitendinosus Tendon -. ACTA ACUST UNITED AC 2011. [DOI: 10.4055/jkoa.2011.46.1.60] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hee-Soo Kyung
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyun-Ju Lee
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
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Lui P, Zhang P, Chan K, Qin L. Biology and augmentation of tendon-bone insertion repair. J Orthop Surg Res 2010; 5:59. [PMID: 20727196 PMCID: PMC2931497 DOI: 10.1186/1749-799x-5-59] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 08/21/2010] [Indexed: 02/06/2023] Open
Abstract
Surgical reattachment of tendon and bone such as in rotator cuff repair, patellar-patella tendon repair and anterior cruciate ligament (ACL) reconstruction often fails due to the failure of regeneration of the specialized tissue ("enthesis") which connects tendon to bone. Tendon-to-bone healing taking place between inhomogenous tissues is a slow process compared to healing within homogenous tissue, such as tendon to tendon or bone to bone healing. Therefore special attention must be paid to augment tendon to bone insertion (TBI) healing. Apart from surgical fixation, biological and biophysical interventions have been studied aiming at regeneration of TBI healing complex, especially the regeneration of interpositioned fibrocartilage and new bone at the healing junction. This paper described the biology and the factors influencing TBI healing using patella-patellar tendon (PPT) healing and tendon graft to bone tunnel healing in ACL reconstruction as examples. Recent development in the improvement of TBI healing and directions for future studies were also reviewed and discussed.
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Affiliation(s)
- Ppy Lui
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Lee BI, Kwon SW, Kim JB, Choi HS, Min KD. Comparison of clinical results according to amount of preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft. Arthroscopy 2008; 24:560-8. [PMID: 18442689 DOI: 10.1016/j.arthro.2007.11.011] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Revised: 10/31/2007] [Accepted: 11/14/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to analyze the clinical results of anterior cruciate ligament (ACL) reconstruction with the remnant-preserving technique by use of a hamstring graft and looped sutures according to the amount of the tibial remnant of the ACL. METHODS Sixteen subjects had undergone ACL reconstruction with the remnant-preserving technique by use of 4 strands of a hamstring tendon and a looped suture technique and were followed up for at least 12 months. The mean follow-up was 35.1 months. At the last follow-up examination, the patients were evaluated with the International Knee Documentation Committee scale and Hospital for Special Surgery score as subjective tests; stress radiographs, Lachman test, and anterior drawer test by use of the KT-2000 arthrometer (MEDmetric, San Diego, CA) as objective tests; and single-legged hop test, reproduction of passive positioning, threshold to detection of passive motion, and single-limb standing test as functional tests. On the basis of the extent of ACL remnant, patients were then divided into 2 groups. Group I comprised patients with more than 20%, and group II comprised those with less than 20%. For each of the 2 groups, a statistical comparison of the final results was made. RESULTS The mean Hospital for Special Surgery score improved from 65.8 (preoperatively) to 95.2 (at last follow-up). Functional evaluation revealed that the difference was not significant in terms of mechanical stability, but a significant difference was detected in functional outcome and proprioception. Regarding the threshold to detection of passive motion at 30 degrees (P = .030) and reproduction of passive positioning at 15 degrees (P = .032) and 30 degrees (P = .024), group I (> 20%) showed better results than group II (< 20%). CONCLUSIONS We confirmed that the remnant-preserving technique described showed good proprioceptive and functional outcomes with statistical significance. Therefore it may be expected that the more the tibial remnant is kept intact, the better the preservation of proprioceptive function will be. LEVEL OF EVIDENCE Level IV, prognostic case series.
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Affiliation(s)
- Byung-Ill Lee
- Department of Orthopedic Surgery, Soonchunhyang University Hospital, Seoul, South Korea.
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Friemert B, V Lübken F, Schmidt R, Jouini C, Gerngross H. [The influence of a controlled active motion splint on proprioception after anterior cruciate ligament plasty. A prospective randomized study]. Unfallchirurg 2006; 109:22-9. [PMID: 16163508 DOI: 10.1007/s00113-005-1006-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND A ruptured anterior cruciate ligament (ACL) leads to both mechanical and functional instability. Functional instability is caused by proprioceptive deficit. The aim of this study was to determine whether the proprioceptive deficit can be reduced by using a controlled active motion (CAM) splint postoperatively. PATIENTS AND METHODS A total of 50 patients with ACL rupture were randomized into two groups. After ACL plasty the PT group received postoperative physiotherapy, while the CAM group were managed with a CAM splint and physiotherapy. Proprioceptive ability was measured with a passive angle-reproduction test. RESULTS On the day of discharge 80% of the patients in the CAM group and 25% in the PT group had a reduced proprioceptive deficit. Overall the main measured value in the CAM group improved by 83.7%, but deteriorated by 39.3% in the PT group. There was no significant difference between the CAM group and a healthy control group. CONCLUSION Using a CAM splint in addition to physiotherapy after ACL plasty in comparison to physiotherapy alone decreases the proprioceptive deficit significantly. We recommend the use of a CAM splint in the postoperative management following ACL plasty.
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Affiliation(s)
- B Friemert
- Abt. Chirurgie, Bundeswehrkrankenhaus Ulm.
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Danielson P, Alfredson H, Forsgren S. Distribution of general (PGP 9.5) and sensory (substance P/CGRP) innervations in the human patellar tendon. Knee Surg Sports Traumatol Arthrosc 2006; 14:125-32. [PMID: 15983834 DOI: 10.1007/s00167-005-0636-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2004] [Accepted: 01/05/2005] [Indexed: 11/27/2022]
Abstract
There is no information on the pattern of blood vessel innervation, and in principle no information on innervation in general, in the human patellar tendon. In the present study, biopsies from the proximal part of normal and pain-free patellar tendons (11 men, mean age 33 years) were examined. The specimens were evaluated by using antibodies against the general nerve marker protein gene-product 9.5 (PGP 9.5) and the sensory neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP), and immunohistochemistry. It was observed that the arteries, and to some extent the small vessels, in the loose paratendinous connective tissue were supplied with PGP 9.5- as well as SP- and CGRP-innervations. There was a marked PGP 9.5-like immunoreaction (LI), and to some extent also SP- and CGRP-LI, in the large nerve fascicles in this tissue. In the tendon tissue proper, PGP 9.5-LI was detected in nerve fibers located in the vicinity of some of the blood vessels and in thin nerve fascicles. There was a low degree of SP- and CGRP-innervation in the tendon tissue proper. The observations give a morphologic correlate for the occurrence of nerve-mediated effects in the patellar tendon. Particularly it seems as if there is a marked nerve-mediated regulation of the blood vessels supplying the tendon, at the level where they course in the loose paratendinous connective tissue.
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Affiliation(s)
- Patrik Danielson
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, 901 87 Umeå, Sweden
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Forsgren S, Danielson P, Alfredson H. Vascular NK-1 receptor occurrence in normal and chronic painful Achilles and patellar tendons: studies on chemically unfixed as well as fixed specimens. ACTA ACUST UNITED AC 2005; 126:173-81. [PMID: 15664664 DOI: 10.1016/j.regpep.2004.09.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2004] [Revised: 08/31/2004] [Accepted: 09/19/2004] [Indexed: 11/17/2022]
Abstract
It is not known as to whether the Achilles and patellar tendons contain neurokinin-1 (NK-1) receptors. This is a drawback when considering the fact that pain symptoms are frequent in these and as recent studies show that the pain symptoms might be cured via interference with blood vessel function. In the present study, the human Achilles and patellar tendons were examined concerning immunohistochemical expression of the NK-1 receptor. Chemically unfixed and fixed specimens, TRITC and PAP stainings and a battery of NK-1 receptor antibodies, including antibodies against the C-terminus and the N-terminal region, were utilized. NK-1 receptor immunoreaction could be detected in inner parts of the walls of large blood vessels and in the walls of small blood vessels. To some extent, NK-1 immunoreaction was also detectable in small nerve fascicles and in tenocytes. It was found to be of utmost importance to apply both chemically unfixed and fixed specimens. The use of chemically unfixed tissue was found advantageous in order to depict the immunoreactions in the blood vessel walls. The observations represent new findings and are of relevance as substance P (SP) is known to be of importance where neurogenic angiogenesis contributes to diseases and as SP on the whole has profound effects concerning blood vessel regulation.
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Affiliation(s)
- Sture Forsgren
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, SE-901 87 Umeå, Sweden.
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22
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Hunt P, Scheffler SU, Unterhauser FN, Weiler A. A model of soft-tissue graft anterior cruciate ligament reconstruction in sheep. Arch Orthop Trauma Surg 2005; 125:238-48. [PMID: 15024579 DOI: 10.1007/s00402-004-0643-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2003] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Since there is to our knowledge no clinically valid and reproducible animal model of soft-tissue anterior cruciate ligament (ACL) reconstruction currently available, we developed one in sheep, in terms of graft suitability, postsurgical recovery, and knee stability. MATERIALS AND METHODS To find a suitable graft, anatomical dissections of the hind limbs of 7 sheep were performed. After a pilot study in 3 sheep, we reconstructed the ACL with an ipsilateral, longitudinally split, superficial digital flexor tendon autograft and anatomic graft fixation in 42 sheep (study 1) and with a full, superficial digital flexor tendon autograft and extracortical graft fixation in 48 sheep (study 2). Follow-up examinations ranged from 6 to 104 weeks (study 1) and 3 to 24 weeks (study 2). RESULTS All animals tolerated the graft harvest well and returned to physiological movement after about 4 weeks. Only 1 out of 93 ACL reconstructions failed. At final follow-up, the anteroposterior (AP) drawer displacement in both studies had almost regained the value of the intact contralateral knee. Maximum load-to-failure improved over time in both studies but was significantly lower at all time points compared with the intact ACL and the graft tissues. Tensile stress was significantly lower at final follow-up in both studies compared with the intact ACL and graft tissues. It attained 43.3% of the intact ACL and 58.3% of the graft tissue in study 1 and 28.9% and 22.8% in study 2, respectively. CONCLUSION The flexor tendon is suitable, and sheep appear to be an appropriate animal model for soft-tissue graft ACL reconstruction. They tolerate the graft harvest well and quickly return to full weight-bearing and physiological movement. Their knees become stable without showing signs of macroscopically evident osteoarthritis.
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Affiliation(s)
- Patrick Hunt
- Sports Traumatology and Arthroscopy Service, Trauma & Reconstructive Surgery, Charité, Campus Virchow Clinic, Humboldt University, Berlin, Germany
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23
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Pollet V, Barrat D, Meirhaeghe E, Vaes P, Handelberg F. The role of the Rolimeter in quantifying knee instability compared to the functional outcome of ACL-reconstructed versus conservatively-treated knees. Knee Surg Sports Traumatol Arthrosc 2005; 13:12-8. [PMID: 15221209 DOI: 10.1007/s00167-004-0497-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2003] [Accepted: 01/07/2004] [Indexed: 10/26/2022]
Abstract
The purpose of this study is to correlate the measurement of anterior knee laxity using the Rolimeter with the functional outcome of anterior cruciate ligament (ACL) deficient knees. We tested 29 patients (12 males/17 females) with an average age of 33 years (range 19-47) that had been treated for ACL rupture, either by reconstruction or conservatively. The average follow-up at time of testing was 33 months (range 6-67).Functional outcome was graded by means of a questionnaire based on the IKDC score, the sports activity rating scale (SARS), the Cincinnati knee-rating system and the activities of daily living (ADL) scale, and by two functional knee tests (the one-leg hop test and the cross-over hop test). The anterior knee laxity was measured for both knees with the Rolimeter, and the side-to-side difference was calculated. We have found no correlation between the joint laxity and the functional outcome score.(P>0.05). When we compared both groups, we found a significant, though very low, correlation between the laxity and the functional questionnaire for the reconstructed group. (r=0.51, P=0.036). Therefore, the joint laxity measurement does not necessarily reflect the functional outcome of ACL-deficient knees. An explanation can be found in the importance of the proprioception and neuromuscular control in compensating the ACL-deficient knee.
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Affiliation(s)
- V Pollet
- Department of Orthopaedic Surgery, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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24
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Bonfim TR, Jansen Paccola CA, Barela JA. Proprioceptive and behavior impairments in individuals with anterior cruciate ligament reconstructed knees. Arch Phys Med Rehabil 2003; 84:1217-23. [PMID: 12917863 DOI: 10.1016/s0003-9993(03)00147-3] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess sensory deficits and their effects on proprioceptive and motor function in patients who had undergone unilateral anterior cruciate ligament (ACL) reconstruction. DESIGN Four evaluations were conducted: (1) joint position perception of the knee for predetermined angles (0 degrees, 15 degrees, 30 degrees, 45 degrees, 60 degrees ); (2) threshold for detection of passive knee motion at 0 degrees, 15 degrees, 30 degrees, 45 degrees, and 60 degrees moving into flexion and at 15 degrees, 30 degrees, 45 degrees, and 60 degrees moving into extension; (3) latency onset of hamstring muscles; and (4) postural control during upright double- and single-leg stance. SETTING Movement laboratory in Brazil. PARTICIPANTS Ten participants who had surgical reconstruction of the ACL (reconstructed group) and 10 participants without knee injury (control group). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Absolute error, angular displacement, hamstring muscles latency, and mean sway amplitude. RESULTS Individuals with a reconstructed knee showed decreased joint position perception, a higher threshold for detection of passive knee motion, longer latency of hamstring muscles, and decreased performance in postural control. CONCLUSIONS After lesion and ACL reconstruction, sensory and motor behavior changes were still observed. This may be because of the lack of proprioceptive information resulting from the ACL lesion and/or substitution of ACL by the graft.
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Affiliation(s)
- Thátia R Bonfim
- Laboratório para Estudos do Movimento, Departamento de Educacão Fisica-Instituto de Biociências, Universidade Estadual Paulista, Rio Claro, Brasil.
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Ackermann PW, Ahmed M, Kreicbergs A. Early nerve regeneration after achilles tendon rupture--a prerequisite for healing? A study in the rat. J Orthop Res 2002; 20:849-56. [PMID: 12168677 DOI: 10.1016/s0736-0266(01)00159-0] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nerve regeneration during healing of Achilles tendon rupture in the rat was studied by immunohistochemistry including semi-quantitative assessment. Neuronal markers for regenerating and mature fibers, ie., growth associated protein 43 (GAP-43) and protein gene product 9.5 (PGP 9.5), respectively, were analyzed at different time points (1-16 weeks) post-rupture. In the paratenon, both the ruptured and intact contralateral tendon (control) consistently exhibited immunoreactivity to the two neuronal markers. However, in the proper tendinous tissue only the ruptured tendon showed immunoreactivity to GAP-43 and PGP 9.5. This expression was seen already at week 1 post-rupture to reach a peak at week 6 followed by a successive drop till week 16. Also the occurrence of sensory and autonomic fibers according to immunoreactivity for calcitonin gene-related peptide (CGRP) and neuropeptide Y (NPY), respectively, was analyzed. CGRP-positivity was abundantly seen from weeks 2-6 in both perivascular and sprouting free nerve endings in the proper tendon tissue undergoing healing. NPY appeared later, at weeks 6-8 post-rupture around blood vessels mainly located in the surrounding loose connective tissue. Apart from a role in vasoaction (CGRP, vasodilatory; NPY, vasoconstrictory). both neuropeptides have been implicated in fibroblast and endothelial cell proliferation required for angiogenesis. The present study shows that early healing of ruptured tendons is characterized by an orchestrated, temporal appearance of nerve fibers expressing peptides with different actions. The observed pattern of neuronal regeneration and neuropeptide expression may prove to be important for normal connective tissue healing.
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Affiliation(s)
- Paul W Ackermann
- Department of Orthopedics, Research Center, Karolinska Hospital, Stockholm, Sweden.
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Abstract
The idea of muscular reflexes elicited from sensory nerves of the cruciate ligaments is more than 100 years old, but the existence of such reflexes has not been proven until the recent two decades. First in animal experiments, a muscular excitation could be elicited in the hamstrings when the anterior cruciate ligament (ACL) was pulled, and tension in the ligament caused activity of the gamma motor neurones of the muscles around the knee. Impulses from the sensory nerves in ACL were activated during motion of the knee, in particular overstretching and combined extension and rotation. In humans, proprioception in the knee is decreased after ACL rupture. By mechanical or electrical stimulation of the ACL, an excitation in the hamstrings muscles can be elicited. During muscular activity, stimulation of the ACL or PCL results in a clear inhibition of the ongoing activity, both during static isometric and isokinetic muscle work, and also during dynamic activity (gait). This inhibitory reflex subjectively resembled giving way. The latency of the reflex was short in animals (about 3 ms) and long in humans (60-120 ms), probably caused by differences in the experimental setup and between species. The long latency in humans makes it unlikely that it is a directly protective reflex. Instead it may be involved in the updating of motor programs. Further research may characterize the reflex in details and map its pathways. The existence of this reflex indicate that the cruciate ligaments have an afferent function, which influences knee dynamics.
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Affiliation(s)
- Michael R Krogsgaard
- Department of Orthopaedic Surgery M, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.
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Weiler A, Unterhauser FN, Bail HJ, Hüning M, Haas NP. Alpha-smooth muscle actin is expressed by fibroblastic cells of the ovine anterior cruciate ligament and its free tendon graft during remodeling. J Orthop Res 2002; 20:310-7. [PMID: 11918311 DOI: 10.1016/s0736-0266(01)00109-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Contractile fibroblastic cells expressing the alpha-smooth muscle actin isoform, so-called myofibroblasts, have been identified to play a possible role during the healing of the medial collateral ligament by means of restoring the tissues in situ strain via extracellular matrix contraction. Recently, these cells have also been identified to be a normal part of the human anterior cruciate ligament. It has been hypothesized that myofibroblasts play a role in the wrinkling of the extracellular matrix. The goal of the present study was to identify myofibroblasts in the intact ovine anterior cruciate ligament and a free autologous tendon graft during remodeling after anterior cruciate ligament reconstruction. In 36 mature merino sheep the anterior cruciate ligament was replaced with an ipsilateral Achilles tendon split graft. Midsubstance tissue samples were immunostained for alpha-smooth muscle actin at 6, 9, 12, 24, 52, and 104 weeks. Myofibroblasts were identified in the intact ovine anterior cruciate ligament as well as in the Achilles tendon graft prior to implantation. During remodeling the first myofibroblasts were found at six weeks within newly formed fiber bundles. At 24, 52, and 104 weeks myofibroblast distribution and cell density were similar to those of the intact ovine anterior cruciate ligament. These findings indicate that alpha-smooth muscle actin containing fibroblastic cells are a regular part of the intact as well as the remodeled anterior cruciate ligament. There is evidence that myofibroblasts may be involved in maintaining tissue homeostasis in the mature ligament e.g., by means of crimp formation. The presence of these cells during the early remodeling may further indicate that alpha-smooth muscle actin containing fibroblastic cells are involved in the earliest stages of fiber bundle formation. The role and function of this special cell type for the anterior cruciate ligament needs to be further clarified.
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Affiliation(s)
- Andreas Weiler
- Unfall & Wiederherstellungschirurgie, Charité, Humboldt Universität zu Berlin, Germany.
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Fridén T, Roberts D, Ageberg E, Waldén M, Zätterström R. Review of knee proprioception and the relation to extremity function after an anterior cruciate ligament rupture. J Orthop Sports Phys Ther 2001; 31:567-76. [PMID: 11665744 DOI: 10.2519/jospt.2001.31.10.567] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Several tests of human conscious knee proprioception have been described, but there is no consensus or reference standard established. Difficulties remain in the separation of information originating from muscles, tendons, and joints, and the tests cannot discriminate between loss of afferent signals or altered activity in the remaining receptors. There is convincing evidence from several descriptive studies that the afferent information is altered after a knee ligament injury and severely disturbed in some patients with anterior cruciate ligament (ACL) injuries. However, an inherent inferior proprioceptive ability may also exist in some individuals, which makes them vulnerable to injuries. The deficits in proprioception have mostly been studied and related to the consciously registered sense, whereas the extent of possible disturbances of the unconscious or reflectory mechanisms is largely unknown. The latter may, at least from a theoretical point of view, be predominantly contributing to the overall afferent regulation, and a possibility for major defects thus exists, since there is no knowledge of the quantified relation between the conscious and unconscious part. The clinical importance of the altered afferent information has not been evaluated properly, and the role of proprioception that contributes to function has yet to be investigated. A higher physiological sensitivity to detecting a passive joint motion closer to full extension has been found both experimentally and clinically, which may protect the joint due to the close proximity to the limit of joint motion. Proprioception has been found to have a relation to subjective knee function, and patients with symptomatic ACL deficiency seem to have larger deficits than asymptomatic individuals. Little is known about whether training can restore defects in sensory information or by which mechanisms possible compensatory pathways are established. In rehabilitation, each patient must, however, create muscle strength, alertness, and stiffness in harmony with the disturbed mechanics of the knee, which are present both after nonoperative treatment of the ACL and after a reconstruction of the ACL.
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Affiliation(s)
- T Fridén
- Department of Orthopedics, University Hospital, Lund, Sweden.
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Iwasa J, Ochi M, Adachi N, Tobita M, Katsube K, Uchio Y. Proprioceptive improvement in knees with anterior cruciate ligament reconstruction. Clin Orthop Relat Res 2000:168-76. [PMID: 11127653 DOI: 10.1097/00003086-200012000-00020] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The correlation between the prospective course of proprioceptive improvement and knee stability after anterior cruciate ligament reconstruction was investigated in 38 patients. Proprioception, on the basis of the patient's capacity to reposition the limb accurately, was evaluated at 3-month intervals for 24 months after hamstring graft anterior cruciate ligament surgery. Knee stability was evaluated concurrently with a KT-2000 knee arthrometer. Thirty patients experienced improvement in postoperative position sense in at least one of the examinations, although eight patients had no improvement at any time. Of the 30 patients who had improvement, 28 maintained improved position sense from 18 months to the final followup. Thirty patients maintained significantly better knee stability for a postoperative period of at least 24 months. These results indicated that a minimum of 18 months after anterior cruciate ligament reconstruction may be needed for complete restoration of the proprioceptive function in knees, although the mean position sense in all patients gradually improved from 9 months. Improvement in postoperative knee stability may have facilitated recovery of proprioception.
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Affiliation(s)
- J Iwasa
- Department of Orthopaedic Surgery, School of Medicine, Shimane Medical University, Japan
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Seitz H, Vécsei V, Menth-Chiari WA, Pichl W, Wielke B, Marlovits S. Comparison of femoral and tibial pullout forces in bone-patellar tendon-bone anterior cruciate ligament reconstructions with a new interference fixation device. Arthroscopy 1999; 15:173-8. [PMID: 10210075 DOI: 10.1053/ar.1999.v15.015017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Interference screws have become the standard method for fixing bone-patellar tendon-bone (BPTB) grafts. To avoid the inherent pitfalls and complications of interference screws, a 28-mm long and from 5 to 7 mm spreadable metal bolt with nontapping threads was developed for this study. The technical applicability and biomechanical characteristics of this new BPTB interference fixation device were investigated by dissection or tensile testing of 48 cadaveric knee specimens from young donors. No problems occurred with respect to bone plug anchoring during insertion of the spreading bolts. The clinically important linear load was 920+/-283 N for the femoral and 635+/-247 N for the tibial fixation site. Bone plug pullout was the mode of failure in all specimens. The results of this study indicate that the spreading bolt is a reasonable alternative to interference screws.
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Affiliation(s)
- H Seitz
- Department of Trauma Surgery, University of Vienna School of Medicine, Vienna General Hospital, Austria
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Affiliation(s)
- T Hogervorst
- Department of Orthopaedic Surgery, OLVG Hospital, Amsterdam, The Netherlands
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Nordsletten L, Aune AK, Madsen JE, Skjeldal S, Falch JA, Ekeland A. Anterior cruciate ligament strength. Can it be estimated by non-destructive testing? Scand J Med Sci Sports 1997; 7:203-5. [PMID: 9241024 DOI: 10.1111/j.1600-0838.1997.tb00140.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
For structural and material bone strength, non-destructive tests exist, while no such tests have been developed for ligaments. In the present study we compared the geometry and bone mineral content (BMC) of the rat tibia with the tensile strength of the anterior cruciate ligament (ACL). A significant correlation was found between the mediolateral diameter of the tibial condyle and ACL load to failure (r=0.83). Calculating the area of the condyle as an ellipse increased this correlation to r=0.93. No significant correlation was found to BMC. If this correlation is also found in humans, the mediolateral tibial head diameter may be used to estimate the strength of the ACL non-destructively.
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Affiliation(s)
- L Nordsletten
- Institute for Surgical Research, Rikshospitalet, Orthopaedic Department, Ullevål Hospital, Oslo, Norway.
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Madey SM, Cole KJ, Brand RA. Sensory innervation of the cat knee articular capsule and cruciate ligament visualised using anterogradely transported wheat germ agglutinin-horseradish peroxidase. J Anat 1997; 190 ( Pt 2):289-97. [PMID: 9061450 PMCID: PMC1467606 DOI: 10.1046/j.1469-7580.1997.19020289.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Wheat germ agglutinin-horseradish peroxidase conjugate (WGA-HRP) was injected into the dorsal root ganglia (L5-S1) of the cat and used as an anterograde tracer substance for intra-axonal labelling of peripheral nerve endings in joint capsule and cranial (anterior) cruciate ligament (CCL). We believed that the high specificity of WGA-HRP for neural tissue along with the high visibility of its reaction product could help resolve controversies concerning the sensory innervation of the cruciate ligaments. Substantial amounts of WGA-HRP were transported in tibial nerve axons to the level of the knee. However, using standard HRP histochemistry we found that the capsular tissue and ligament synovia disintegrated during the incubation reaction. This problem was avoided by air drying the tissue slices on glass slides prior to reaction. Abundant labelling occurred in the posterior capsule with dense filling of axons and terminal endings. Sensory endings displayed features consistent with Ruffini endings and pacinian corpuscles. Sensory endings were located throughout the CCL in its sagittal plane, in the subsynovial layers and between collagen fascicles. In each CCL we observed 5-17 ovoid and elongated endings with dense terminal arborisations. These endings were between 100 and 150 microns long, were encapsulated, and gave rise to 1 or 2 axons. Large (up to 1.5 mm in maximum extent) elongated regions of dense, inhomogeneous labelling were found in the body of several CCLs. These resembled Golgi tendon-like endings, with the exception of their large size. We conclude that anterograde transport of HRP to the knee is a useful technique for labelling mechanoreceptors and axons in knee tissue. However, recently developed immunohistochemical analysis of peripheral tissue using protein gene product 9.5 appears to be the method of choice and should be employed for further study of human and animal cruciate ligament innervation.
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Affiliation(s)
- S M Madey
- Department of Orthopaedic Surgery, University of Iowa, Iowa City 52242, USA
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