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Waghe VR, Tikhile P, Patil DS. The Integral Role of Physiotherapy in Combined Complete Anterior Cruciate Ligament and Posterior Cruciate Ligament Arthroscopic Reconstruction: A Case Report. Cureus 2024; 16:e57556. [PMID: 38707081 PMCID: PMC11069625 DOI: 10.7759/cureus.57556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries are infrequent in clinical practice, often leading to severe knee instability and functional limitations. A 30-year-old male presented with right knee pain and swelling following a two-wheeler accident. Diagnostic investigations confirmed complete ACL and PCL tears. The surgical intervention comprised arthroscopic-assisted ACL reconstruction using semitendinosus and gracilis tendons, accompanied by arthroscopic PCL reconstruction. Postoperatively, structured physiotherapy rehabilitation was initiated. After 12 weeks of rehabilitation, significant improvements in range of motion and muscular strength were observed. Tailored physiotherapy facilitated prompt recovery, enhancing functional mobility and independent ambulation. This case highlights the efficacy of comprehensive surgical intervention followed by structured rehabilitation in achieving favorable outcomes in patients with combined ACL and PCL injuries. Tailored physiotherapy plays a crucial role in optimizing functional recovery and facilitates the enhancement of the patient's functional mobility and independent ambulation.
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Affiliation(s)
- Vaishnavi R Waghe
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Priya Tikhile
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Deepali S Patil
- Musculoskeletal Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Belozo FL, Belozo RSMN, Ricardo Lopes C, Yamada AK, Silva VRR. Anterior cruciate ligament: A brief narrative review of main risk factors for injury and re-injury. J Bodyw Mov Ther 2024; 38:92-99. [PMID: 38763622 DOI: 10.1016/j.jbmt.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 11/26/2023] [Accepted: 01/13/2024] [Indexed: 05/21/2024]
Abstract
Anterior cruciate ligament (ACL) injury is one of the main injuries in professional and amateur athletes of different sports. Hundreds of thousands of ACL ruptures occurs annually, and only 55% of the athletes return to competitive level, with a 15 times higher chance of suffering a second injury. 60% of these injuries occur without physical contact and since they occur in the acute process, they can cause joint effusion, muscle weakness and functional incapacity. In the long term, they can contribute to a premature process of osteoarthritis. This narrative review is of particular interest for clinicians, practitioners, coaches and athletes to understand the main factors that contribute to an injury and/or re-injury and thus, to optimize their training to reduce and/or prevent the risk of injury and/or reinjury of ACL. Therefore, we aimed reports a narrative overview of the literature surrounding communication and explore through a theoretical review, the main risk factors for an ACL injury and/or re-injury, as well as bringing practical and correct methods of training applications. The lack of theoretical/practical knowledge on the part of rehabilitation and/or training professionals may impair the treatment of an athlete and/or student. High-quality research that can testing different training methods approaches in randomized controlled trials is needed.
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Affiliation(s)
- Felipe L Belozo
- College of Physical Education - Network Faculty, Nova Odessa, Sao Paulo, Brazil
| | - Rebeca S M N Belozo
- College of Physical Education - Network Faculty, Nova Odessa, Sao Paulo, Brazil
| | - Charles Ricardo Lopes
- Methodist University of Piracicaba, Piracicaba, SP, Brazil; Faculty Adventist of Hortolândia, Hortoslândia, SP, Brazil
| | - André K Yamada
- Methodist University of Piracicaba, Piracicaba, SP, Brazil
| | - Vagner R R Silva
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Grace N, McNair PJ, Young SW. Progressive submaximal effort hamstring muscle endurance is reduced after reconstruction of the anterior cruciate ligament. Musculoskelet Sci Pract 2024; 70:102898. [PMID: 38241881 DOI: 10.1016/j.msksp.2023.102898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Endurance capability in the muscles controlling the knee is poorly understood post anterior cruciate ligament (ACL) reconstruction, despite many sporting activities requiring notable muscle endurance. The hamstring muscles, when active, provide important anatomical support to protect the reconstructed graft. In the absence of good hamstring endurance, fatigue may predispose individuals to re-injury. OBJECTIVE To assess whether ACL reconstruction (ACLR) with a hamstring graft leads to reduced hamstring endurance 9-13 months post-surgery. STUDY DESIGN A cross-sectional inter-limb comparison study was undertaken with participants 9-13 months after an ACLR with a hamstring graft, and a group of age, sex, and activity-matched controls. There were 22 participants in each group. METHOD Submaximal hamstring endurance was measured using a progressive fatigue test on an isokinetic dynamometer at a joint angular velocity of 120°/second. The dependant variable was the maximum number of repetitions performed. Statistical comparisons were made across injured, uninjured and control group limbs. RESULTS There was a significant (p < 0.05) deficit in hamstring endurance observed between the injured leg (mean: 111 repetitions, SD 49) and uninjured leg (mean: 136 repetitions, SD 67) of the ACL group, but not between the uninjured and control group legs (mean: 124 repetitions, SD 50). CONCLUSION The 18% deficit in submaximal hamstring endurance across the ACL-reconstructed individual's limbs is indicative of a notable loss in muscle performance at 9-13 months post-surgery. These results provide initial evidence for supporting further research examining the inclusion of hamstring endurance training in ACL rehabilitation programmes post-surgery.
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Affiliation(s)
- Nuala Grace
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Peter J McNair
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand.
| | - Simon W Young
- Dept of Surgery, University of Auckland, Auckland, New Zealand; Dept of Orthopaedic Surgery, North Shore Hospital, Private Bag 93-503, Auckland, 0740, New Zealand
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Högberg J, Piussi R, Lövgren J, Wernbom M, Simonsson R, Samuelsson K, Hamrin Senorski E. Restoring Knee Flexor Strength Symmetry Requires 2 Years After ACL Reconstruction, But Does It Matter for Second ACL Injuries? A Systematic Review and Meta-analysis. SPORTS MEDICINE - OPEN 2024; 10:2. [PMID: 38180584 PMCID: PMC10769975 DOI: 10.1186/s40798-023-00666-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 12/05/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND It is unknown whether knee flexor strength recovers after anterior cruciate ligament (ACL) reconstruction with a hamstring tendon (HT) autograft and whether persistent knee flexor strength asymmetry is associated to a second ACL injury. OBJECTIVE We aimed to systematically review (1) whether knee flexor strength recovers after ACL reconstruction with HT autografts, and (2) whether it influences the association with a second ACL injury. A third aim was to summarize the methodology used to assess knee flexor strength. DESIGN Systematic review and meta-analysis reported according to PRISMA. METHODS A systematic search was performed using the Cochrane Library, Embase, Medline, PEDRo, and AMED databases from inception to December 2021 and until completion in January 2023. Human clinical trials written in English and conducted as randomized controlled trials, longitudinal cohort, cross-sectional, and case-control studies on patients with index ACL reconstructions with HT autografts harvested from the ipsilateral side were considered. Knee flexor strength was measured isokinetically in both the reconstructed and uninjured limb to enable the calculation of the limb symmetry index (LSI). The Risk of Bias Assessment Tool for Non-Randomized Studies was used to assess risk of bias for non-randomized studies and the revised Cochrane Risk of Bias tool was used for randomized controlled trials. For the meta-analysis, the LSI (mean ± standard error) for concentric knee flexor strength at angular velocities of 60°/second (s) and 180°/s preoperatively and at 3 months, 6 months, 12 months, and 24 months were pooled as weighted means with standard errors. RESULTS The search yielded 64 studies with a total of 8378 patients, which were included for the assessment of recovery of knee flexor strength LSI, and a total of 610 patients from four studies that investigated the association between knee flexor strength and second ACL injuries. At 1 year after ACL reconstruction, the knee flexor strength LSI had recovered to 89.0% (95% CI 87.3; 90.7%) and 88.3% (95% CI 85.5; 91.1%) for the velocities of 60°/s and 180°/s, respectively. At 2 years, the LSI was 91.7% (95% CI 90.8; 92.6%) and 91.2% (95% CI 88.1; 94.2%), for velocities of 60°/s and 180°/s, respectively. For the association between knee flexor strength and second ACL injuries, there was insufficient and contradictory data. CONCLUSIONS There was low to very low certainty of evidence indicating that the recovery of knee flexor strength LSI, defined as ≥ 90% of the uninjured side, takes up to 2 years after ACL reconstruction with HT autografts. Whether knee flexor strength deficits influence the association of second ACL injuries is still uncertain. There was considerable heterogeneity in the methodology used for knee flexor strength assessment, which together with the low to very low certainty of evidence, warrants further caution in the interpretation of our results. REGISTRATION NUMBER CRD42022286773.
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Affiliation(s)
- Johan Högberg
- Sportrehab Sports Medicine Clinic, Stampgatan 14, 411 01, Gothenburg, Sweden.
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden.
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, 405 30, Gothenburg, Sweden.
| | - Ramana Piussi
- Sportrehab Sports Medicine Clinic, Stampgatan 14, 411 01, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, 405 30, Gothenburg, Sweden
| | - Johan Lövgren
- Active Physio Sports Medicine Clinic, Brogatan 23, 431 30, Gothenburg, Sweden
| | - Mathias Wernbom
- Sportrehab Sports Medicine Clinic, Stampgatan 14, 411 01, Gothenburg, Sweden
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, 405 30, Gothenburg, Sweden
- The Rydberg Laboratory for Applied Sciences, Halmstad University, Box 823, 301 18, Halmstad, Sweden
| | - Rebecca Simonsson
- Sportrehab Sports Medicine Clinic, Stampgatan 14, 411 01, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, 405 30, Gothenburg, Sweden
| | - Kristian Samuelsson
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Eric Hamrin Senorski
- Sportrehab Sports Medicine Clinic, Stampgatan 14, 411 01, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Box 455, 405 30, Gothenburg, Sweden
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Cleary CJ, Weir JP, Vopat BG, Herda AA. Evaluation of raw segmental bioelectrical impedance variables throughout anterior cruciate ligament reconstruction rehabilitation. Physiol Meas 2022; 43. [PMID: 36575155 DOI: 10.1088/1361-6579/acaa87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022]
Abstract
Background.Raw bioelectrical impedance analysis (BIA) variables are related to physical function in healthy and diseased populations. Therefore, BIA may be an insightful, noninvasive method of assessment to track following anterior cruciate ligament reconstruction (ACLR).Objectives.Evaluate phase angle, reactance and impedance at 50 kHz (PhA50, Xc50, andZ50, respectively) in the operative (OP) and non-operative (NOP) limbs during ACLR rehabilitation.Approach.Seventeen patient (12 M, 5 F; 18.8 ± 4.8 years) clinic reports were evaluated prior to ACLR (PRE), two- (2 W), six- (6 W), and twelve-weeks (12 W) post-ACLR and at return to sport testing (RTS).Setting.All observations occurred during the participant's physical therapy visits.Measurements.A multi-frequency BIA device measured segmental PhA, Xc, andZ. Linear mixed effects models were used to assess any leg and time interaction and changes over leg and time, independently. Any interactions or main effects were considered significant atp< 0.05.Main results.Significant legxtime interactions were observed for each variable. PhA50and Xc50of NOP were higher (p< 0.001) than OP at each time point by an average of by 0.9° and 4.9 Ω, respectively. In OP, PhA50and Xc50decreased from PRE to 2 W and increased from 6 to 12 W and 12 W to RTS (p< 0.01, for all). At RTS, PhA50and Xc50were similar to PRE in OP (p> 0.05). ForZ50, the OP leg did not change over time (p> 0.05).Z50was greater in NOP at 2 and 6 W (p< 0.01, for both). There were differences in PhA50in NOP between PRE and 6 W and from 6 W to RTS (p< 0.05 for both). Xc50did not change (p> 0.05), andZ50PRE was lower than at 2 W (p< 0.05).Significance.A multi-frequency BIA device can detect changes in segmental BIA variables following ACLR.
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Affiliation(s)
- Christopher J Cleary
- Department of Health, Sport, and Exercise Sciences, University of Kansas Edwards Campus, Overland Park, Kansas, United States of America
| | - Joseph P Weir
- Department of Health, Sport, and Exercise Sciences, University of Kansas Lawrence Campus, Lawrence, Kansas, United States of America
| | - Bryan G Vopat
- University of Kansas Medical Center, Department of Orthopedic Surgery and Sports Medicine, Kansas City, Kansas, United States of America
| | - Ashley A Herda
- Department of Health, Sport, and Exercise Sciences, University of Kansas Edwards Campus, Overland Park, Kansas, United States of America
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Abstract
Weakening muscle strength around the knee tends to render it vulnerable to aging-related damage. This study aimed to examine the association between knee flexor muscle strength and its cross-sectional area (CSA). We also evaluated aging-related changes in flexor muscle strength and CSA. We retrospectively analyzed 252 patients with acute-onset knee pain (<1 month) between September 2006 and August 2009 in accordance with the Strengthening the Reporting of Observational studies in Epidemiology statement. The CSA of each knee flexor muscle (biceps femoris, sartorius, gracilis, semitendinosus (ST), and semimembranosus (SM)) was measured on magnetic resonance imaging axial images at the suprapatellar level. We evaluated flexor muscle strength (peak torque in N.m) using a Cybex dynamometer at 60°/second and 180°/second and its correlation with CSA. In total, 252 patients (mean age, 34.5 years; range, 11 to 66 years; 184 men and 68 women) were included in this study. No significant intergroup differences in demographic data such as sex or body mass index were found. Mean CSA was 605.4 mm2 for the SM, 444.7 mm2 for the biceps femoris, 282 mm2 for the sartorius, 55.4 mm2 for the ST, and 34.1 mm2 for the gracilis. Mean peak torques were 67.4 N.m and 52.7 N.m at 60°/second and 180°/second, respectively. CSA was positively correlated with flexion strengths of 60°/second (R = 0.363, P < .001) and 180°/second (R = 0.354, P < .001). Muscle strength was associated with CSA in all muscles but the gracilis (R = 0.056, P = .375). Flexion strength decreased significantly with aging from the thirties. Total CSA decreased with aging (r = -0.247, P < .001). The CSA of the biceps femoris, sartorius, SM, and ST decreased significantly, whereas that of the gracilis tended to decrease non-significantly with aging. Flexor muscle strength was associated with total muscle CSA on magnetic resonance imaging and the CSA of every muscle except the gracilis. Flexion strength decreased significantly with aging after the twenties, while total CSA decreased significantly with aging. The CSA of all flexor muscles decreased significantly with aging, whereas that of the gracilis decreased only slightly.
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Affiliation(s)
- Soo Yeon Park
- Department of Physical Education, Graduate School of Education, Yong In University, Yongin-si, Gyeongki-do, Republic of Korea
| | - Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sung Hyun Hwang
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Taeg Su Ko
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea
| | - Hee Sung Lee
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea
- *Correspondence: Hee Sung Lee, Department of Medicine, Graduate School, Kyung Hee University, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Republic of Korea (e-mail: )
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7
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Barnett SC, Murray MM, Badger GJ, Yen YM, Kramer DE, Sanborn R, Kiapour A, Proffen B, Sant N, Fleming BC, Micheli LJ. Earlier Resolution of Symptoms and Return of Function After Bridge-Enhanced Anterior Cruciate Ligament Repair As Compared With Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:23259671211052530. [PMID: 34778483 PMCID: PMC8581796 DOI: 10.1177/23259671211052530] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/09/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Bridge-enhanced anterior cruciate ligament repair (BEAR) has noninferior
patient-reported outcomes when compared with autograft anterior cruciate
ligament reconstruction (ACLR) at 2 years. However, the comparison of BEAR
and autograft ACLR at earlier time points—including important outcomes such
as resolution of knee pain and symptoms, recovery of strength, and return to
sport—has not yet been reported. Hypothesis: It was hypothesized that the BEAR group would have higher outcomes on the
International Knee Documentation Committee and Knee injury and
Osteoarthritis Outcome Score, as well as improved muscle strength, in the
early postoperative period. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 100 patients aged 13 to 35 years with complete midsubstance
anterior cruciate ligament injuries were randomized to receive a suture
repair augmented with an extracellular matrix implant (n = 65) or an
autograft ACLR (n = 35). Outcomes were assessed at time points up to 2 years
postoperatively. Mixed-model repeated-measures analyses were used to compare
BEAR and ACLR outcomes. Patients were unblinded after their 2-year
visit. Results: Repeated-measures testing revealed a significant effect of group on the
International Knee Documentation Committee Subjective Score
(P = .015), most pronounced at 6 months after surgery
(BEAR = 86 points vs ACLR = 78 points; P = .001). There was
a significant effect of group on the Knee injury and Osteoarthritis Outcome
Score-Symptoms subscale scores (P = .010), largely
attributed to the higher BEAR scores at the 1-year postoperative time point
(88 vs 82; P = .009). The effect of group on hamstring
strength was significant in the repeated-measures analysis
(P < .001), as well as at all postoperative time
points (P < .001 for all comparisons). At 1 year after
surgery, approximately 88% of the patients in the BEAR group and 76% of the
ACLR group had been cleared for return to sport (P =
.261). Conclusion: Patients undergoing the BEAR procedure had earlier resolution of symptoms and
increased satisfaction about their knee function, as well as improved
resolution of hamstring muscle strength throughout the 2-year follow-up
period. Registration: NCT02664545 (ClinicalTrials.gov identifier)
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Affiliation(s)
- Samuel C Barnett
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | | | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ryan Sanborn
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ata Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt Proffen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicholas Sant
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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Manchado-Herrera I, Motta LM, Blanco G, González J, Garcés GL. Anterior tibial translation and patient-reported outcomes after anterior cruciate ligament reconstruction with a tape locking screw: A 5-year follow-up study. Orthop Traumatol Surg Res 2021; 107:102790. [PMID: 33333269 DOI: 10.1016/j.otsr.2020.102790] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/22/2020] [Accepted: 06/01/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Tape Locking Screw system (TLS) is a recognised technique used in anterior cruciate ligament reconstruction (ACLR). However, only a few previous studies have reported associated outcomes, all of which had been examined over a short-term period. The aim of this study was to assess the time-dependent changes in the objective and patient-reported outcome measures (PROM) in a group of patients with anterior cruciate ligament deficiency who have been operated on with this technique. HYPOTHESIS Previously reported satisfactory short-term outcomes following TLS persist for several years after the operation. PATIENTS AND METHODS This study was a retrospective observational study including 26 patients, who were followed after unilateral ACLR with TLS. Anterior tibial translation (ATT) was measured in both knees using the KT-1000 arthrometer and two PROMs: International Knee Documentation Committee (IKDC) and Lysholm subjective form scores were examined preoperatively, 6 months postoperatively, and annually for 5 years thereafter in all patients. RESULTS One patient suffered a rupture of the graft, and one patient had a screw loosening. Two patients were lost for follow-up, so 22 patients were the final study group. Median (25-75%) ATT side-to-side differences between the injured and uninjured sides were 4 (3,5-4)mm preoperatively, 0,75 (0-1)mm 1 year postoperatively, and 0,75 (0-1)mm 5 years after the operation (P<0.001). Median (25-75%) IKDC scores were 44.25 (35.6-55.15), 92.55 (87.08-96.6), and 95.4 (90.8-97.7) points preoperatively and 1 year (P<0.001) and 5 years postoperatively, respectively. Median (25-75%) Lysholm scores were 52 (38.75-64.5), 95.5 (94.75-99.25), and 97.5 (95-99) points preoperatively and 1 year (P<0.001) and 5 years postoperatively, respectively. DISCUSSION ACLR with TLS might already achieve favourable outcomes 1 year postoperatively, when measured objectively (ATT) and with PROMs. These outcomes persist 5 year postoperatively. LEVEL OF EVIDENCE IV: retrospective cohort study.
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Affiliation(s)
- Ignacio Manchado-Herrera
- Hospital Perpetuo Socorro, Las Palmas, Spain; University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Luci M Motta
- Hospital Perpetuo Socorro, Las Palmas, Spain; University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | - Jesús González
- Statistical Research Unit, Hospital Dr Negrin, Las Palmas, Spain
| | - Gerardo L Garcés
- Hospital Perpetuo Socorro, Las Palmas, Spain; University of Las Palmas de Gran Canaria, Las Palmas, Spain.
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Rice D, Lewis G, McNair P. Impaired Regulation of Submaximal Force after ACL Reconstruction: Role of Muscle Spindles. Int J Sports Med 2020; 42:550-558. [PMID: 33176382 DOI: 10.1055/a-1292-4461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ongoing motor deficits are routinely present following anterior cruciate ligament (ACL) reconstruction, including the ability to regulate muscle force. While such deficits are known, it is unclear why this occurs. The goal of the current study was to investigate the potential influence of muscle spindle input on submaximal force regulation and muscle activity at the knee in people following ACL reconstruction. Fourteen participants (8 female) who were 6-24 months post-ACL reconstruction and 15 control participants (8 female) undertook submaximal force matching and force modulation tasks before and after 20 min of vibration applied to the patella tendon. Across all tasks, the ACL reconstruction participants were poorer at force matching (P=0.007). The effect of vibration was not significant in either group for the force matching tasks (P=0.06), although there was a reduction in maximum voluntary contraction post-vibration in the control group (P<0.001). The ACL reconstruction group also showed evidence of greater activation of the medial hamstring muscles in comparison to controls (P=0.04). Individuals who have undergone ACL reconstruction have a diminished ability to accurately match and regulate submaximal muscle force, but this does not appear to be related to impaired muscle spindle input. Neuromuscular retraining programs that involve force regulation tasks may be necessary to optimize rehabilitation after ACL reconstruction.
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Affiliation(s)
- David Rice
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand.,Department of Anaesthesia and Perioperative Medicine, North Shore Hospital, Auckland, New Zealand
| | - Gwyn Lewis
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Peter McNair
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
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Rhim HC, Lee JH, Han SB, Shin KH, Suh DW, Jang KM. Role of the Triceps Surae Muscles in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Matched Case-Control Study. J Clin Med 2020; 9:jcm9103215. [PMID: 33036346 PMCID: PMC7600692 DOI: 10.3390/jcm9103215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 11/23/2022] Open
Abstract
A limited number of studies has investigated the gastrocnemius and soleus in patients undergoing anterior cruciate ligament reconstruction (ACLR). This study investigated the muscle strength (Nm kg−1 × 100) and reaction time (acceleration time (AT), milliseconds) of thigh and calf muscles in patients undergoing ACLR. Thirty-two patients with ACLR and 32 normal control subjects were included. One year postoperatively, the strength of thigh muscles was significantly reduced after ACLR compared with that of controls (hamstring: 80 ± 31.3 vs. 142 ± 26.4, p < 0.001, quadriceps: 159 ± 63.7 vs. 238 ± 35.3, p < 0.001). However, the strength of calf muscles was not significantly different compared with that of controls (gastrocnemius: 77 ± 22.9 vs. 81 ± 22.5, p = 0.425, soleus: 54 ± 15.9 vs. 47 ± 16.1, p = 0.109). The AT of calf muscles was significantly faster after ACLR than that of controls (gastrocnemius: 26 ± 9.8 vs. 31 ± 9, p = 0.030, soleus: 18 ± 6.7 vs. 22 ± 8.5, p = 0.026). The AT of thigh muscles was significantly elongated after ACLR than that of controls (hamstring: 72 ± 18 vs. 55 ± 12.4, p < 0.001, quadriceps: 63 ± 17.6 vs. 47 ± 17, p < 0.000). The strength of thigh muscles was reduced, and the ATs of thigh muscles were slower one year after ACLR. However, the AT of the triceps surae was faster than that of controls. This may implicate a compensatory mechanism of the triceps surae for the weakness and delayed activation in hamstring and quadriceps muscles.
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Affiliation(s)
- Hye Chang Rhim
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Korea; (H.C.R.); (S.-B.H.); (K.-H.S.)
| | - Jin Hyuck Lee
- Department of Sports Medical Center, Anam Hospital, Korea University College of Medicine, Seoul 02841, Korea;
| | - Seung-Beom Han
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Korea; (H.C.R.); (S.-B.H.); (K.-H.S.)
| | - Kyun-Ho Shin
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Korea; (H.C.R.); (S.-B.H.); (K.-H.S.)
| | - Dong Won Suh
- Department of Orthopaedic Surgery, Barunsesang Hospital, Seongnam 13497, Korea;
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Korea; (H.C.R.); (S.-B.H.); (K.-H.S.)
- Department of Sports Medical Center, Anam Hospital, Korea University College of Medicine, Seoul 02841, Korea;
- Correspondence: ; Tel.: +82-292-06-406
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Lee JH, Park JS, Jeong WK. Which muscle performance can be improved after arthroscopic Bankart repair? J Shoulder Elbow Surg 2020; 29:1681-1688. [PMID: 32147338 DOI: 10.1016/j.jse.2019.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 11/28/2019] [Accepted: 12/10/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND There are no published reports available regarding neuromuscular control recovery in nonathletic patients after arthroscopic (A/S) Bankart repair. This study aimed to compare neuromuscular control and performance of the rotator cuff muscles between patients who underwent A/S Bankart repair and normal controls. METHODS In total, 32 nonathletic patients who underwent A/S Bankart repair were compared with 32 asymptomatic nonathletic volunteers. Neuromuscular control index (time to peak torque and acceleration time), muscle strength ratio, muscle strength, and muscle endurance of the internal rotators (IRs) and external rotators (ERs) were measured using an isokinetic device at an angular velocity of 180°/s, with 90° shoulder abduction. RESULTS The neuromuscular control indices of both IRs and ERs were significantly lower in patients who underwent A/S Bankart repair than in normal controls (time to peak torque, IRs: 1059 ± 143 ms vs. 679 ± 226 ms, P = .011; ERs: 595 ± 286 ms vs. 379 ± 123 ms, P = .044; acceleration time, IRs: 75 ± 16 ms vs. 62 ± 15 ms, P = .039, ERs: 70 ± 19 ms vs. 54 ± 18 ms, P = .047). Muscle endurance was significantly lower in patients who underwent A/S Bankart repair than in normal controls (IRs: 670 ± 1 J vs. 718 ± 2 J, P = .002, ERs: 422 ± 6 J vs. 501 ± 2 J, P = .044). The neuromuscular control index showed a significant negative correlation with muscle endurance for both IRs and ERs after the operation (IRs: r = -0.737, P = .003, ERs: r = -0.617, P = .019). CONCLUSION Compared with normal controls, patients who underwent A/S Bankart repair did not show complete recovery of neuromuscular control of IRs and ERs, although their muscle strength ratio and muscle strength had fully recovered.
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Affiliation(s)
- Jin Hyuck Lee
- Department of Sports Medical Center, Korea University College of Medicine Anam Hospital, Seoul, Republic of Korea
| | - Ji Soon Park
- Department of Orthopaedic Surgery, Healthpoint Hospital, Abu Dhabi, UAE
| | - Woong Kyo Jeong
- Department of Sports Medical Center, Korea University College of Medicine Anam Hospital, Seoul, Republic of Korea; Department of Orthopaedic Surgery, College of Medicine, Korea University, Seoul, Republic of Korea.
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12
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Lee OS, Lee YS. Changes in hamstring strength after anterior cruciate ligament reconstruction with hamstring autograft and posterior cruciate ligament reconstruction with tibialis allograft. Knee Surg Relat Res 2020; 32:27. [PMID: 32660642 PMCID: PMC7275600 DOI: 10.1186/s43019-020-00047-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/21/2020] [Indexed: 12/02/2022] Open
Abstract
Aim The aim of this study was to evaluate the changes in hamstring strength both after anterior cruciate ligament reconstruction (ACLR) with hamstring autograft followed by early rehabilitation and posterior cruciate ligament reconstruction (PCLR) with tibialis allograft followed by delayed rehabilitation. Methods Isokinetic strengths of the quadriceps and hamstring muscles and endurances were compared between a group of 20 patients undergoing PCLR using a tibialis anterior allograft and a 1:2 matched control group of 40 patients undergoing ACLR using a hamstring autograft at 2 years after the operations. Clinical results were also compared using stability tests and the Lysholm and the International Knee Documentation Committee scores. Results At 2 years after the operations, the torque deficit of the hamstring muscle in the involved leg compared to the uninvolved leg at both 60°/s and 120°/s was greater in the PCLR group than in the ACLR group (60°/s, 21.8 ± 14.0% versus 1.9 ± 23.9%, P = 0.0171; 120°/s, 15.3 ± 13.7% versus −0.7 ± 17.4%, p = 0.012, respectively). The peak torque of the hamstring muscle at 120°/s was significantly lower in the involved leg than in the uninvolved leg only in the PCLR group (71.3 ± 31.9 N∙m versus 81.9 ± 27.8 N∙m, P = 0.005). There was no significant difference in the clinical results between the groups except for a side-to-side difference in the tibial translation on Telos stress radiographs. Conclusion The strength of the hamstring of the PCLR leg with allograft was significantly weaker than that of the unoperated leg after 2 years, whereas that of the ACLR leg with hamstring autograft maintained a similar level of strength compared to that of the uninvolved leg. Level of evidence Level III, case–control study.
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Affiliation(s)
- O-Sung Lee
- Department of Orthopaedic Surgery, Mediplex Sejong Hospital, Incheon, South Korea
| | - Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea.
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Ishibashi Y, Adachi N, Koga H, Kondo E, Kuroda R, Mae T, Uchio Y. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication. J Orthop Sci 2020; 25:6-45. [PMID: 31843222 DOI: 10.1016/j.jos.2019.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/12/2019] [Accepted: 10/16/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS). METHODS The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature. CONCLUSIONS This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.
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Affiliation(s)
- Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Japan
| | - Yuji Uchio
- Department of Orthopaedic Surgery, Shimane University School of Medicine, Japan
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Lee RJ, Margalit A, Nduaguba A, Gunderson MA, Wells L. Obesity and recovery of muscle strength after anterior cruciate ligament reconstruction in pediatric patients. J Orthop Surg (Hong Kong) 2019; 26:2309499018806631. [PMID: 30352544 DOI: 10.1177/2309499018806631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE: To explore factors influencing muscle strength after anterior cruciate ligament (ACL) reconstruction (ACLR) in pediatric patients. We hypothesized that obesity/overweight, autograft hamstring tendon, and concomitant injuries would be associated with slower muscle recovery. METHODS: We retrospectively reviewed the records of pediatric ACLR patients during a 3-year period. Muscle recovery was defined as ≥85% of peak torque compared with the contralateral side. We categorized patients as either obese/overweight or normal weight. Statistical analysis was performed using Mann-Whitney U, analysis of variance, and χ2 tests ( α level < 0.05). RESULTS: The study group consisted of 330 patients, of whom 198 (60%) and 231 (70%) met quadriceps and hamstring recovery criteria, respectively, at final testing (mean: 7.0 ± 3.2 months). Patients recovered hamstring and quadriceps strength at a mean of 5.3 ± 2.2 months and 6.1 ± 2.3 months, respectively. Hamstring muscle recovery took significantly longer in obese/overweight patients (mean: 5.7 ± 2.2 months) versus normal-weight patients (mean: 5.1 ± 2.1 months; p = 0.025), but quadriceps recovery did not (obese/overweight mean: 6.5 ± 2.6 months; normal-weight mean: 5.9 ± 2.1 months; p = 0.173). CONCLUSION: Concomitant injuries and graft type were not associated with length of time to recovery of muscle strength. Obesity/overweight was associated with delay in recovery of hamstring but not quadriceps strength.
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Affiliation(s)
- R Jay Lee
- 1 Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Adam Margalit
- 1 Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Afam Nduaguba
- 2 Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa A Gunderson
- 2 Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lawrence Wells
- 2 Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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15
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Bahlau D, Favreau H, Eichler D, Lustig S, Bonnomet F, Ehlinger M. Clinical, functional, and isokinetic study of a prospective series of anterior cruciate ligament ligamentoplasty with pedicular hamstrings. INTERNATIONAL ORTHOPAEDICS 2019; 43:2557-2562. [PMID: 31446455 DOI: 10.1007/s00264-019-04392-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 08/13/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Few studies describe the specific results of anterior cruciate ligament reconstruction with pedicled hamstring graft (HG). Our goal was to report the isokinetic, clinical, and functional outcomes over the post-operative year following pedicled hamstring ligamentoplasty. METHODS Twenty-four patients with ACL rupture (mean age 27.4 years) were included prospectively. The technique used a four-stranded HG transplant pedicled to the tibia. The functional result (Lysholm knee score and subjective IKDC score), clinical result (KT-1000, Lachman test, joint amplitudes, objective IKDC score), and isokinetic complication occurrence were analyzed at six months and 12 months follow-up. The functional results, clinical parameters, and complications were analyzed at 30 months follow-up. The comparison of the variables with the various regressions was carried out by a Wilcoxon sign test. RESULTS Twenty-one patients were reviewed at six, nine, 12, and 30 months. The mean Lysholm knee score was 90/100 at six months, 96/100 at one year, and 95/100 at 30 months. The mean subjective IKDC score was 77/100 and 89/100 at six and 12 months, and 91/100 at 30 months. The mean difference in laxity compared with the healthy knee was 1.4 mm at six months, 1.9 mm at 12 months, and 2 mm at 30 months. The objective IKDC score was A or B for all patients at 12 and 30 months. The average quadriceps strength deficit decreased from 27 to 16% between six and 12 months post-operative (p = 0.0091) and the average flexor deficit from 23 to 12% (p = 0.0084). No complications were identified. CONCLUSION The abovementioned technique allows reaching functional, clinical, and isokinetic results comparable with the standard techniques while preserving the mechanical and biological interest of tibial insertion.
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Affiliation(s)
- David Bahlau
- Service de Chirurgie Orthopédique et de Traumatologie du membre inférieur, CHU Hautepierre 2, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098, Strasbourg Cedex, France
| | - Henri Favreau
- Service de Chirurgie Orthopédique et de Traumatologie du membre inférieur, CHU Hautepierre 2, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098, Strasbourg Cedex, France
| | - David Eichler
- Service de Chirurgie Orthopédique et de Traumatologie du membre inférieur, CHU Hautepierre 2, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098, Strasbourg Cedex, France
| | - Sébastien Lustig
- Département de Chirurgie Orthopédique, Centre Albert-Trillat, Hôpital de la Croix-Rousse, 103 boulevard de la Croix-Rousse, 69004, Lyon, France
| | - François Bonnomet
- Service de Chirurgie Orthopédique et de Traumatologie du membre inférieur, CHU Hautepierre 2, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098, Strasbourg Cedex, France
| | - Matthieu Ehlinger
- Service de Chirurgie Orthopédique et de Traumatologie du membre inférieur, CHU Hautepierre 2, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098, Strasbourg Cedex, France. .,Laboratoire ICube, CNRS UMR 7357, 30 Bd Sébastien Brant, 67400, Illkirch, France.
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The relationship between knee muscle strength and knee biomechanics during running at 6 and 12 months after anterior cruciate ligament reconstruction. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2019; 16:14-18. [PMID: 30984558 PMCID: PMC6445434 DOI: 10.1016/j.asmart.2018.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/12/2018] [Accepted: 11/20/2018] [Indexed: 11/20/2022]
Abstract
Background Knee joint kinematics and kinetics during running recover at 12 months, not 6 months, following anterior cruciate ligament (ACL) reconstruction surgery. Knee muscle strength is a criterion used to assess an individual's readiness to return-to-sports (RTS); however, the relationship between knee muscle strength and knee biomechanics is unclear. This study investigated the relationship between knee muscle strength and dynamic knee biomechanics during running at 6 and 12 months after ACL reconstruction surgery. Methods Knee joint kinematics and kinetics during running were analyzed in 21 patients (10 males, 11 females) who underwent ACL reconstruction for a unilateral ACL deficiency. Kinematics and Kinetics were measured by three-dimensional motion analysis system, and Knee flexion angle was calculated using Point cluster technique and internal extension moment was calculated by the inverse dynamics method. Patients were compared to a control group matched by age, height and weight. Isokinetic knee extension and flexion strength in ACL-reconstructed patients were measured at 6 and 12 months postsurgery, by separated gender. Results Knee flexion angle was significantly lower in ACL patients at 6 months postsurgery compared to the control group (F (2, 62)=5.78, P=0.014). There were significant lower peak knee flexion angles in male groups than female (F (1, 62)=6.33, P<0.01). Knee extension moments were significantly lower in both male and female ACL patients compared to the control group at 6 and 12 months postsurgery (F (2, 62)=12.05, P<0.01(6 months), P=0.034(12 months)), and there were significant correlations with knee extension moments and maximum torque of knee extension/flexion (P<0.05). At 12 months after surgery, knee joint kinematics in ACL patients were restored. Both peak knee angle and knee extension moment were significantly associated with maximum knee extension/flexion torque values in female patients at 12 months postsurgery. Conclusions Dynamic knee biomechanics during running were not restored 6 and 12 months after ACL reconstruction both male and female. It is necessary to strengthen knee extension and flexion muscles to restore knee kinetics during running, especially female patients.
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Başdelioğlu K, Meriç G, Pündük Z, Akseki D, Atik A, Sargın S. Outcomes of isokinetic tests and functional assessment of anterior cruciate ligament reconstruction: Transtibial versus single anatomic femoral tunnel technique. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2019; 53:86-91. [PMID: 30745028 PMCID: PMC6510667 DOI: 10.1016/j.aott.2019.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 01/14/2019] [Accepted: 01/17/2019] [Indexed: 01/15/2023]
Abstract
Objective The aim of the study was to compare the outcomes of the transtibial and anatomical femoral single tunnel surgical techniques in ACL reconstruction. Methods A total of 30 patients, with 16 patients (15 males and 1 female; mean age: 27.2 ± 7.04) with anatomical femoral single-tunnel technique (AFT) and 14 (12 males and 2 females; mean age: 29.4 ± 8.82) with transtibial technique (TT) were included into the study. All patients were evaluated with isokinetic tests at an angular velocity of 60°/s and 180°/s and the IKDC and Lysholm tests were performed preoperatively and in third, sixth, and 12th months postoperatively. The results were compared between the groups. The mean follow-up time was 17.1 ± 6.48 months. Results Postoperative third month changes in extension parameters of peak torque (AFT: −93.286, TT: −61.500), peak work (AFT: −77.071, TT: −47.500), peak torque ext/kg (AFT: −1.182, TT: −0.773), peak work ext/kg (AFT: −0.982, TT: −0.604), peak work (AFT: −55.143 TT: −33.063) at an angular velocity of 60°/s and postoperative third month change in extension parameter of peak power (AFT: −86.786 TT: −54.875) at an angular velocity of 180°/s were found to be better in the transtibial group (p < 0.05) and postoperative sixth month peak torque (AFT: 1.429, TT: −5.688) value at an angular velocity of 60°/s was found to be less in the anatomical femoral single-tunnel group (p < 0.05). The IKDC (AFT: 94.671, TT: 90.025) (p < 0.05) and Lysholm (AFT: 96.714, TT: 92.375) (p < 0.05) scores of the anatomical femoral single-tunnel group were better than the transtibial group regarding to the postoperative final follow-up. There are positive intermediate correlations between preoperative IKDC and Lysholm scores with preoperative and postoperative some isokinetic test ratio (r = 0.539; p = 0.031), and preoperative peak power extension (r = 0.541; p = 0.030) at the both angular velocity of 60°/s and 180°/s in the transtibial group. There was no significant difference between the two groups with regards to the Lachman, anterior drawer and pivot shift tests (p < 0.05). Conclusion There were differences in terms of isokinetic parameters in early outcomes but there was no statistical difference between isokinetic parameters at the end of 1st year between two groups. There were some correlations between IKDC and Lysholm scores with some isokinetic parameters. Level of Evidence Level III, Therapeutic Study.
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18
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Zult T, Gokeler A, van Raay JJAM, Brouwer RW, Zijdewind I, Farthing JP, Hortobágyi T. Cross-education does not improve early and late-phase rehabilitation outcomes after ACL reconstruction: a randomized controlled clinical trial. Knee Surg Sports Traumatol Arthrosc 2019; 27:478-490. [PMID: 30182287 DOI: 10.1007/s00167-018-5116-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 08/14/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE Limited evidence suggests that cross-education affords clinical benefits in the initial 8 weeks after anterior cruciate ligament (ACL) reconstruction, but it is unknown if such cross-education effects are reproducible and still present in later phases of rehabilitation. We examined whether cross-education, as an adjuvant to standard therapy, would accelerate the rehabilitation up to 26 weeks after ACL reconstruction by attenuating quadriceps weakness. METHODS ACL-reconstructed patients were randomized into experimental (n = 22) and control groups (n = 21). Both groups received standard care after ACL reconstruction. In addition, the experimental group strength trained the quadriceps of the non-operated leg during weeks 1-12 after surgery (i.e., cross-education). Self-reported knee function was assessed with the Hughston Clinic Knee score as the primary outcome. Secondary outcomes were maximal quadriceps and hamstring strength and single leg hop distance. All outcomes were measured 29 ± 23 days prior to surgery, as a reference, and at 5-week, 12-week, and 26-week post-surgery. RESULTS Both groups scored 12% worse on self-reported knee function 5-week post-surgery (95% CI 7-17) and showed 15% improvement 26-week post-surgery (95% CI - 20 to - 10). No cross-education effect was found. Interestingly, males scored 8-10% worse than females at each time point post-surgery. None of 33 secondary outcomes showed a cross-education effect. At 26-week post-surgery, both legs improved maximal quadriceps (5-14%) and hamstring strength (7-18%), and the non-injured leg improved 2% in hop distance. The ACL recovery was not affected by limb dominance and age. CONCLUSION 26 weeks of standard care improved self-reported knee function and maximal leg strength relative to pre-surgery and adding cross-education did not further accelerate ACL recovery. LEVEL OF EVIDENCE I. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION This randomized controlled clinical trial is registered at the Dutch trial register ( http://www.trialregister.nl ) under NTR4395.
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Affiliation(s)
- Tjerk Zult
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Vision and Eye Research Unit, School of Medicine, Anglia Ruskin University, Young Street 213, Cambridge, CB1 1PT, UK.
| | - Alli Gokeler
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jos J A M van Raay
- Department of Orthopedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Reinoud W Brouwer
- Department of Orthopedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Inge Zijdewind
- Department of Neuroscience, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Tibor Hortobágyi
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Pottkotter KA, Di Stasi SL, Schmitt LC, Magnussen RA, Paterno MV, Flanigan DC, Kaeding CC, Hewett TE. Improvements in Thigh Strength Symmetry Are Modestly Correlated With Changes in Self-Reported Function After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2018; 6:2325967118807459. [PMID: 30534573 PMCID: PMC6280613 DOI: 10.1177/2325967118807459] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: The association between quadriceps strength and functional outcomes after anterior cruciate ligament reconstruction (ACLR) is a focus of current research, while evaluations of hamstring strength are limited, despite the frequent use of hamstring autografts. Purpose/Hypothesis: The purpose of this study was to determine the relationship between changes in quadriceps and hamstring strength symmetry and self-reported outcomes before ACLR and at 12 and 24 weeks after surgery. We hypothesized that improvements in quadriceps and hamstring strength symmetry would be correlated with improvements in self-reported outcome measures within the first 6 months after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: Thirty patients who underwent ACLR with a hamstring autograft were enrolled. Quadriceps and hamstring strength and Knee injury and Osteoarthritis Outcome Score (KOOS) values were assessed before and at 12 and 24 weeks after ACLR; limb symmetry indexes for strength were calculated at each time point. The Friedman and Wilcoxon signed-rank tests were used to analyze changes in KOOS values over time. Spearman rank-order correlations were used to test the relationship between changes in strength and KOOS values between each time point. Results: Hamstring and quadriceps limb symmetry significantly increased with time (P ≤ .03). Fair correlations were observed between changes in the hamstring index and changes in the KOOS Symptoms subscore from before surgery to 12 weeks postoperatively (r = 0.48; P ≤ .05). Changes in the quadriceps index (QI) were moderately correlated with changes in the KOOS Sport/Recreation subscore (r = 0.60; P = .001), and fair correlations were seen between the QI and the KOOS Quality of Life subscore (r = 0.39; P ≤ .04) from preoperatively to 12 weeks after surgery. Moderate correlations were seen between the QI and the KOOS Sport/Recreation subscore (r = 0.57; P = .005) from 12 to 24 weeks after surgery. Conclusion: Improvements in quadriceps and hamstring strength symmetry were modestly associated with improvements in athletes’ perceived function in the first 6 months after ACLR. Specifically, improvements in hamstring symmetry were associated with improvements in knee symptoms within the first 12 weeks postoperatively, while improvements in quadriceps symmetry were associated with improvements in self-reported sport function throughout the first 6 months after ACLR. The restoration of strength symmetry within the first 6 months may be a critical component of rehabilitation aimed at maximizing function after ACLR. Further investigation is warranted to comprehensively evaluate whether the timing of strength gains predicts future function, including those who successfully return to their preinjury activity level after ACLR.
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Affiliation(s)
- Kristy A Pottkotter
- Sports Medicine Physical Therapy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stephanie L Di Stasi
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Laura C Schmitt
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Robert A Magnussen
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - Mark V Paterno
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David C Flanigan
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - Christopher C Kaeding
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - Timothy E Hewett
- Orthopedics Biomechanics Laboratory and Sports Medicine Center, Mayo Clinic, Rochester, Minnesota, USA
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20
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Hsu WH, Fan CH, Yu PA, Chen CL, Kuo LT, Hsu RWW. Effect of high body mass index on knee muscle strength and function after anterior cruciate ligament reconstruction using hamstring tendon autografts. BMC Musculoskelet Disord 2018; 19:363. [PMID: 30305072 PMCID: PMC6180445 DOI: 10.1186/s12891-018-2277-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 09/24/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Increased body mass index (BMI) has been associated with poorer function in patients who have undergone anterior cruciate ligament (ACL) reconstruction. However, the effect of high BMI on muscle strength in these patients remained unclear. The current study aimed to compare knee muscle strength and Knee injury and Osteoarthritis Outcome Score (KOOS) in ACL-reconstructed patients with a variety of different BMIs. METHODS From November 2013 to March 2016, we prospectively enrolled 30 patients who underwent ACL reconstruction (18-60 years of age). Anthropometric parameters, body compositions, isokinetic muscle strength and KOOS were assessed preoperatively, and at post-operative 16th week and 28th week. The patients were stratified into two groups by BMI, i.e. normal BMI (18.5-24.9 kg/m2) and high BMI (≥25.0 kg/m2). RESULTS Twelve patients in the normal BMI group completed the follow-up, while sixteen patients did so in the high BMI group. In comparison of muscle strength between baseline and 28th week follow-up, the normal BMI group had significant increases in overall knee muscle strength, while the high BMI group only had increases in extensors of uninjured knee and flexors of the injured knee. However, there were significant increases in all KOOS subscales for the high BMI group. The high BMI patients reported increased KOOS, which may reflect the contribution of ligament stability in the presence of inadequate muscle strength. CONCLUSIONS The normal BMI patients had improvement in all knee muscle strength following ACL reconstruction, while high BMI patients only had increases in certain knee muscles. High BMI patients had a decreased quadriceps muscle symmetry index, as compared to their normal BMI counterparts. Increases in quadriceps muscle strength of the uninjured knee and ACL reconstruction were associated with improvements in KOOS in high BMI patients.
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Affiliation(s)
- Wei-Hsiu Hsu
- Sports Medicine Center, Chang Gung Memorial Hospital at Chia Yi, Chia Yi, Taiwan. .,Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia Yi, No 6 West section, Chia Pu Road, Puzih, Chia Yi Hsien, 613, Taiwan. .,School of Medicine, Chang Gung University, Tao-Yuan, Taiwan.
| | - Chun-Hao Fan
- Sports Medicine Center, Chang Gung Memorial Hospital at Chia Yi, Chia Yi, Taiwan
| | - Pei-An Yu
- Sports Medicine Center, Chang Gung Memorial Hospital at Chia Yi, Chia Yi, Taiwan.,Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia Yi, No 6 West section, Chia Pu Road, Puzih, Chia Yi Hsien, 613, Taiwan
| | - Chi-Lung Chen
- Sports Medicine Center, Chang Gung Memorial Hospital at Chia Yi, Chia Yi, Taiwan.,Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia Yi, No 6 West section, Chia Pu Road, Puzih, Chia Yi Hsien, 613, Taiwan.,School of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Liang-Tseng Kuo
- Sports Medicine Center, Chang Gung Memorial Hospital at Chia Yi, Chia Yi, Taiwan.,Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia Yi, No 6 West section, Chia Pu Road, Puzih, Chia Yi Hsien, 613, Taiwan.,School of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Robert Wen-Wei Hsu
- Sports Medicine Center, Chang Gung Memorial Hospital at Chia Yi, Chia Yi, Taiwan.,Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia Yi, No 6 West section, Chia Pu Road, Puzih, Chia Yi Hsien, 613, Taiwan
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21
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Zult T, Gokeler A, van Raay JJAM, Brouwer RW, Zijdewind I, Farthing JP, Hortobágyi T. Cross-education does not accelerate the rehabilitation of neuromuscular functions after ACL reconstruction: a randomized controlled clinical trial. Eur J Appl Physiol 2018; 118:1609-1623. [PMID: 29796857 PMCID: PMC6060748 DOI: 10.1007/s00421-018-3892-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/14/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Cross-education reduces quadriceps weakness 8 weeks after anterior cruciate ligament (ACL) surgery, but the long-term effects are unknown. We investigated whether cross-education, as an adjuvant to the standard rehabilitation, would accelerate recovery of quadriceps strength and neuromuscular function up to 26 weeks post-surgery. METHODS Group allocation was randomized. The experimental (n = 22) and control (n = 21) group received standard rehabilitation. In addition, the experimental group strength trained the quadriceps of the non-injured leg in weeks 1-12 post-surgery (i.e., cross-education). Primary and secondary outcomes were measured in both legs 29 ± 23 days prior to surgery and at 5, 12, and 26 weeks post-surgery. RESULTS The primary outcome showed time and cross-education effects. Maximal quadriceps strength in the reconstructed leg decreased 35% and 12% at, respectively, 5 and 12 weeks post-surgery and improved 11% at 26 weeks post-surgery, where strength of the non-injured leg showed a gradual increase post-surgery up to 14% (all p ≤ 0.015). Limb symmetry deteriorated 9-10% more for the experimental than control group at 5 and 12 weeks post-surgery (both p ≤ 0.030). One of 34 secondary outcomes revealed a cross-education effect: Voluntary quadriceps activation of the reconstructed leg was 6% reduced for the experimental vs. control group at 12 weeks post-surgery (p = 0.023). Both legs improved force control (22-34%) and dynamic balance (6-7%) at 26 weeks post-surgery (all p ≤ 0.043). Knee joint proprioception and static balance remained unchanged. CONCLUSION Standard rehabilitation improved maximal quadriceps strength, force control, and dynamic balance in both legs relative to pre-surgery but adding cross-education did not accelerate recovery following ACL reconstruction.
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Affiliation(s)
- Tjerk Zult
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Vision and Eye Research Unit, School of Medicine, Anglia Ruskin University, Young Street 213, Cambridge, CB1 1PT, UK.
| | - Alli Gokeler
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jos J A M van Raay
- Department of Orthopedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Reinoud W Brouwer
- Department of Orthopedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Inge Zijdewind
- Department of Neuroscience, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Tibor Hortobágyi
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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22
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Chung KS, Ha JK, Yeom CH, Ra HJ, Lim JW, Kwon MS, Kim JG. Are Muscle Strength and Function of the Uninjured Lower Limb Weakened After Anterior Cruciate Ligament Injury? Two-Year Follow-up After Reconstruction. Am J Sports Med 2015; 43:3013-21. [PMID: 26460100 DOI: 10.1177/0363546515606126] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND After an anterior cruciate ligament (ACL) injury, the uninjured contralateral lower limb may become weakened because of neuromuscular changes, proprioceptive deficits, and disuse of the limb; this weakness predisposes the limb to ACL injury. However, no results have been reported regarding weakness in the contralateral limb after ACL injury. HYPOTHESIS Muscle strength and functional status of the contralateral lower limb are reduced after unilateral ACL injury. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The ACL group consisted of 75 patients who underwent primary unilateral ACL reconstruction and were followed at 3, 6, 12, and 24 months postoperatively. A group of 75 healthy individuals (controls) were matched one-to-one with the ACL group for age, sex, body mass index, and initial Tegner activity level. The side that was evaluated in each control subject corresponded to the injured limb in the matched ACL subject. Isokinetic muscle strength, including extension peak torque per body weight (EPT) and flexion peak torque per body weight (FPT), was evaluated at angular velocities of 60 and 180 deg/s. Patients were also evaluated by single-legged hop test. RESULTS Compared with the EPT at 60 deg/s in the control group (290.9 ± 40.1 N · m/kg), the value in the ACL group 24-month follow-up (276.6 ± 42.8 N · m/kg) as well as other follow-up times was significantly lower (P < .05), whereas the EPT at 180 deg/s and the FPT at 60 and 180 deg/s in the ACL group were significantly lower than the control group at 3-month follow-up but were restored to normal levels at final follow-up. Results from the single-legged hop test demonstrated that the ACL group performed at a significantly lower level than the control group at 24-month follow-up (158.4 ± 25.3 vs 176.3 ± 24.7 cm; P < .05) as well as other follow-up times. However, both measurements improved significantly as the follow-up time progressed. CONCLUSION After ACL injury, isokinetic extensor muscle strength and functional status of the contralateral limb were reduced, even at 24 months after ACL reconstruction. However, both measurements improved significantly as the follow-up time progressed. In contrast, flexion muscle strength was restored to normal levels. Therefore, care should be taken to restore muscle strength and functional status in not only the ACL-reconstructed knee but also the uninjured limb.
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Affiliation(s)
- Kyu Sung Chung
- Department of Orthopedic Surgery, KEPCO Medical Center, Seoul, Korea
| | - Jeong Ku Ha
- Department of Orthopedic Surgery and Sports Medical Center and Sports Medical Research Institute, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - Cheol Hyun Yeom
- Department of Orthopedic Surgery and Sports Medical Center and Sports Medical Research Institute, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - Ho Jong Ra
- Department of Orthopedic Surgery, Gangneung Asan Hospital, College of Medicine, Ulsan University, Gangneung, Korea
| | - Jin Woo Lim
- Department of Orthopedic Surgery and Sports Medical Center and Sports Medical Research Institute, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - Min Soo Kwon
- Department of Orthopedic Surgery and Sports Medical Center and Sports Medical Research Institute, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - Jin Goo Kim
- Department of Orthopedic Surgery, KonKuk University Medical Center, Seoul, Korea
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