1
|
Daniel AV, Smith PA. Primary All-Soft Tissue Quadriceps Tendon Autograft Anterior Cruciate Ligament Reconstruction With Suture Tape Augmentation Resulted in Satisfactory Patient Outcomes and a Low Graft Failure Rate in High School and Collegiate Athletes. Arthroscopy 2024:S0749-8063(24)00234-2. [PMID: 38518869 DOI: 10.1016/j.arthro.2024.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE To evaluate ≥2-year patient outcomes after primary all-soft tissue quadriceps tendon autograft (ASTQ) anterior cruciate ligament reconstruction (ACLR) with suture tape augmentation (STA) in skeletally mature high school and collegiate athletes. METHODS All high school and collegiate athletes who underwent primary ASTQ ACLR with STA with a minimum of 2-year follow-up were analyzed retrospectively. Patients were administered validated patient-reported outcome measures (PROMs) pre- and postoperatively. The minimal clinically important difference was calculated for each PROM based on this study population and applied to the individual patient. Return to sport, subsequent surgical intervention including contralateral ACLR, and KT-1000 arthrometer measurements for knee laxity were collected. Complications were assessed by physical examination, radiologic studies, or obtained via telephone. RESULTS In total, 60 patients were included in the final data analysis, with a mean age of 16.8 years (95% confidence interval 13-23) and mean final follow-up of 37.1 months (95% confidence interval 33.1-41.1). Twelve patients (20%) required subsequent surgery on the ipsilateral knee, which included 7 patients having a subsequent meniscal procedure and 3 patients who underwent arthrolysis. None sustained a graft failure, and 6 patients sustained a contralateral ACL injury necessitating surgery. All PROMs improved at the final follow-up (P < .001). In addition, KT-1000 arthrometer measurements significantly improved postoperatively at 1-year clinical follow-up (P < .001). Most patients obtained the minimal clinically important difference thresholds for each PROM at the final follow-up. There were 48 patients (80%) who participated in pivoting sports. The return-to-sport rate at same level was 54 patients (90%), with 6 patients (10%) not returning to the same level because of graduation. CONCLUSIONS ASTQ ACLR with STA in a young athletic patient population may result in a low graft failure rate while maintaining satisfactory patient outcomes at short-term follow-up, including a return to sport at the same level of 90%. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Adam V Daniel
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A..
| | | |
Collapse
|
2
|
Yuan W, Qi W, Hu T, Zhang J, An MY, Zhao G, Wang XP, Li C, Liu Y. Outcomes of RigidFix Cross Pin Fixation in Femoral and Tibial Tunnel for Anterior Cruciate Ligament Reconstruction. Orthop Surg 2024; 16:337-345. [PMID: 38088239 PMCID: PMC10834228 DOI: 10.1111/os.13934] [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: 08/29/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES There is no clear consensus so far on which fixation method is most favorable for the tibial tunnel in anterior cruciate ligament reconstruction (ACLR). The purpose of this paper is to investigate the outcome of RigidFix cross pins fixation in the tibial tunnel and to explore the advantages of RigidFix applied both in the femoral and tibial tunnel with hamstring tendon graft in anterior cruciate ligament reconstruction. METHODS This retrospective study included 53 patients (male/female, 45/8) who underwent anterior cruciate ligament reconstruction using autologous hamstring tendons between January 2013 and December 2017 at our institute. The participants in group A (n = 36) received anterior cruciate ligament reconstruction with RigidFix cross pins fixation in both femoral and tibial tunnels, while those in group B (n = 17) with RigidFix cross pins fixation in the femoral tunnel and Interference screw fixation in the tibial tunnel. The visual analogue scale (VAS) score, International Knee Documentation Committee subjective knee form 2000 (IKDC2000) score, Lysholm knee scoring scale, Tegner activity score and the side-to-side difference were compared at 2 and 5 years postoperatively. The graft diameter, number of strands in graft and the average diameter of each strand were also compared between the two groups. The categorical parameters were analyzed by chi-square test and the continuous variables conforming to a normal distribution were analyzed by Student's t-test. RESULTS At 2 years postoperation, the VAS score (1.61 ± 0.55), side-to-side difference (1.50 ± 0.58) in group A were significantly lower than that in group B, and the IKDC2000 score (88.81 ± 3.88), Tegner activity score (6.14 ± 0.60) in group A were significantly higher than that in group B. At 5 years postoperation, the VAS score (1.64 ± 0.68), side-to-side difference (1.73 ± 0.63) in group A were significantly lower than that in group B, and the IKDC2000 score (89.09 ± 3.85), Tegner activity score (6.58 ± 0.94) in group A were slso significantly higher than that in group B. There was statistical difference in the change of the side-to-side difference between the two groups (group A vs. B, 0.22 ± 0.08 vs. 0.34 ± 0.11, p < 0.001). There were also statistical differences in the graft diameter (group A vs. B, 7.83 ± 0.74 vs. 7.41 ± 0.51, p = 0,038), number of strands in graft (5.67 ± 0.72 vs. 4.00 ± 0.00, p < 0.001) and the average diameter of each strand (1.41 ± 0.22 vs. 1.85 ± 0.13, p < 0.001) between the two groups. CONCLUSION RigidFix cross pins fixation in the tibial tunnel for anterior cruciate ligament reconstruction can achieve better 5-year results when compared with the interference screw, and the hamstring tendon can be folded into a thicker graft when RigidFix cross pins were applied in both femoral and tibial tunnels.
Collapse
Affiliation(s)
- Wei Yuan
- Medical School of Chinese PLA, Beijing, China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Wei Qi
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Tingting Hu
- The Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jia Zhang
- Medical School of Chinese PLA, Beijing, China
| | | | - Gang Zhao
- Medical School of Chinese PLA, Beijing, China
| | - Xiao-Ping Wang
- Department of Orthopedics, PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Chunbao Li
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yujie Liu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
3
|
Nukuto K, Gale T, Yamamoto T, Musahl V, Anderst W. Bone morphology features associated with knee kinematics may not be predictive of ACL elongation during high-demand activities. Knee Surg Sports Traumatol Arthrosc 2023; 31:5096-5103. [PMID: 37728761 DOI: 10.1007/s00167-023-07560-3] [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: 07/18/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE Bony morphology has been proposed as a potential risk factor for anterior cruciate ligament (ACL) injury. The relationship between bony morphology, knee kinematics, and ACL elongation during high-demand activities remains unclear. The purpose of this study was to determine if bone morphology features that have been associated with ACL injury risk and knee kinematics are also predictive of ACL elongation during fast running and double-legged drop jump. METHODS Nineteen healthy athletes performed fast running and double-legged drop jump within a biplane radiography imaging system. Knee kinematics and ACL elongation were measured bilaterally after using a validated registration process to track bone motion in the radiographs and after identifying ACL attachment sites on magnetic resonance imaging (MRI). Bony morphological features of lateral posterior tibial slope (LPTS), medial tibial plateau (MTP) depth, and lateral femoral condyle anteroposterior width (LCAP)/lateral tibial plateau anteroposterior width (TPAP) were measured on MRI. Relationships between bony morphology and knee kinematics or ACL elongation were identified using multiple linear regression analysis. RESULTS No associations between bony morphology and knee kinematics or ACL elongation were observed during fast running. During double-legged drop jump, a greater range of tibiofemoral rotation was associated with a steeper LPTS (β = 0.382, p = 0.012) and a deeper MTP depth (β = 0.331, p = 0.028), and a greater range of anterior tibial translation was associated with a shallower MTP depth (β = - 0.352, p = 0.018) and a larger LCAP/ TPAP (β = 0.441, p = 0.005); however, greater ACL elongation was only associated with a deeper MTP depth (β = 0.456, p = 0.006) at toe-off. CONCLUSION These findings indicate that observed relationships between bony morphology and kinematics should not be extrapolated to imply a relationship also exists between those bone morphology features and ACL elongation during high-demand activities. These new findings deepen our understanding of the relationship between bony morphology and ACL elongation during high-demand activities. This knowledge can help identify high-risk patients for whom additional procedures during ACL reconstruction are most appropriate.
Collapse
Affiliation(s)
- Koji Nukuto
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex 3820 South Water Street, Pittsburgh, PA, 15203, USA
| | - Tom Gale
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex 3820 South Water Street, Pittsburgh, PA, 15203, USA
| | - Tetsuya Yamamoto
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex 3820 South Water Street, Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William Anderst
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex 3820 South Water Street, Pittsburgh, PA, 15203, USA.
| |
Collapse
|
4
|
Bühl L, Müller S, Nüesch C, Boyer KA, Casto E, Mündermann A, Egloff C. Ambulatory knee biomechanics and muscle activity 2 years after ACL surgery: InternalBrace TM-augmented ACL repair versus ACL reconstruction versus healthy controls. BMC Musculoskelet Disord 2023; 24:785. [PMID: 37794432 PMCID: PMC10548591 DOI: 10.1186/s12891-023-06916-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/24/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Little is known about knee mechanics and muscle control after augmented ACL repair. Our aim was to compare knee biomechanics and leg muscle activity during walking between the legs of patients 2 years after InternalBraceTM-augmented anterior cruciate ligament repair (ACL-IB) and between patients after ACL-IB and ACL reconstruction (ACL-R), and controls. METHODS Twenty-nine ACL-IB, 27 sex- and age-matched ACL-R (hamstring tendon autograft) and 29 matched controls completed an instrumented gait analysis. Knee joint angles, moments, power, and leg muscle activity were compared between the involved and uninvolved leg in ACL-IB (paired t-tests), and between the involved legs in ACL patients and the non-dominant leg in controls (analysis of variance and posthoc Bonferroni tests) using statistical parametric mapping (SPM, P < 0.05). Means and 95% confidence intervals (CI) of differences in discrete parameters (DP; i.e., maximum/minimum) were calculated. RESULTS Significant differences were observed in ACL-IB only in minimum knee flexion angle (DP: 2.4°, CI [-4.4;-0.5]; involved > uninvolved) and maximum knee flexion moment during stance (-0.07Nm/kg, CI [-0.13;-0.00]; involved < uninvolved), and differences between ACL-IB and ACL-R only in maximum knee flexion during swing (DP: 3.6°, CI [0.5;7.0]; ACL-IB > ACL-R). Compared to controls, ACL-IB (SPM: 0-3%GC, P = 0.015; 98-100%, P = 0.016; DP: -6.3 mm, CI [-11.7;-0.8]) and ACL-R (DP: -6.0 mm, CI [-11.4;-0.2]) had lower (maximum) anterior tibia position around heel strike. ACL-R also had lower maximum knee extension moment (DP: -0.13Nm/kg, CI [-0.23;-0.02]) and internal knee rotation moment (SPM: 34-41%GC, P < 0.001; DP: -0.03Nm/kg, CI [-0.06;-0.00]) during stance, and greater maximum semitendinosus activity before heel strike (DP: 11.2%maximum voluntary contraction, CI [0.1;21.3]) than controls. CONCLUSION Our results suggest comparable ambulatory knee function 2 years after ACL-IB and ACL-R, with ACL-IB showing only small differences between legs. However, the differences between both ACL groups and controls suggest that function in the involved leg is not fully recovered and that ACL tear is not only a mechanical disruption but also affects the sensorimotor integrity, which may not be restored after surgery. The trend toward fewer abnormalities in knee moments and semitendinosus muscle function during walking after ACL-IB warrants further investigation and may underscore the importance of preserving the hamstring muscles as ACL agonists. LEVEL OF EVIDENCE Level III, case-control study. TRIAL REGISTRATION clinicaltrials.gov, NCT04429165 (12/06/2020).
Collapse
Affiliation(s)
- Linda Bühl
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland.
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland.
| | - Sebastian Müller
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
| | - Corina Nüesch
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
- Department of Spine Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Katherine A Boyer
- Department of Kinesiology, University of Massachusetts Amherst, Amherst, MA, 01003, USA
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Erica Casto
- Department of Kinesiology, University of Massachusetts Amherst, Amherst, MA, 01003, USA
| | - Annegret Mündermann
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
- Department of Spine Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Christian Egloff
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
| |
Collapse
|
5
|
Xu F, Li Y, Yu Y, Wang G, Cai G. Evaluation of biomechanical properties and biocompatibility: are partially absorbable cords eligible for anterior cruciate ligament reconstruction? Front Bioeng Biotechnol 2023; 11:1216937. [PMID: 37854884 PMCID: PMC10580803 DOI: 10.3389/fbioe.2023.1216937] [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: 05/04/2023] [Accepted: 09/05/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction: Independent augmentation technology based on reinforcing devices has been reported to signifi-cantly reduce the elongation behavior of graft and improve knee stability after anterior cruciate ligament reconstruction (ACLR). Using biodegradable devices could reduce the risk of severe inflammatory reactions due to particle accumulation from foreign bodies. Given the limitations of the mechanical properties of biodegradable materials, partially biodegradable composite devices may offer a compromise strategy. Methods: Three types of partially absorbable core-sheath sutures, including low-absorbable cord (LA-C), medium-absorbable cord (MA-C) and high-absorbable cord (HA-C), were braided using unabsorbable ultra-high molecular weight polyethylene (UHMWPE) yarn and absorbable polydioxanone (PDO) monofil-ament bundle based on the desired configuration. The feasibility of these partially absorbable cords were verified by biomechanical testing, material degradation testing, and cell experiments, all performed in vitro. Results: Reinforcement of an 8 mm graft with the cords decreased dynamic elongation by 24%-76%, was positively related to dynamic stiffness, and increased the failure load by 44%-105%, during which LA-C showed maximum enhancement. Human ligament-derived fibroblasts showed good proliferation and vitality on each cord over 2 weeks and aligned themselves in the direction of the fibers, especially the UHMWPE portion. Discussion: This study supports the potential of partially degradable UHMWPE/PDO cords, particularly LA-C, for graft protection. Nervertheless, a higher proportion of biodegradable material results in lower stiffness, which may impair the protective and lead to mechanical instability during degradation.
Collapse
Affiliation(s)
- Fei Xu
- Kunming Medical University, Kunming Yunnan, China
- Department of Pain Treatment, The First People’s Hospital of Yunnan Province, Kunming Yunnan, China
| | - Yanlin Li
- Kunming Medical University, Kunming Yunnan, China
- Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, China
| | - Yang Yu
- Kunming Medical University, Kunming Yunnan, China
- Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, China
| | - Guoliang Wang
- Kunming Medical University, Kunming Yunnan, China
- Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, China
| | - Guofeng Cai
- Kunming Medical University, Kunming Yunnan, China
- Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, China
| |
Collapse
|
6
|
Bachmaier S, Monaco E, Smith PA, Frank RM, Matzkin EG, Wijdicks CA. Biomechanical Comparison of 3 Adjustable-Loop Suspensory Devices for All-Inside ACL Reconstruction: A Time-Zero Full-Construct Model. Orthop J Sports Med 2023; 11:23259671231201461. [PMID: 37786476 PMCID: PMC10541758 DOI: 10.1177/23259671231201461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 10/04/2023] Open
Abstract
Background Little is known about the stability of adjustable-loop devices (ALDs) for anterior cruciate ligament (ACL) reconstruction (ACLR). Purpose To evaluate the stabilization behavior of 3 different types of ALDs for all-inside ACLR in a full-construct surgical technique-based manner. Study Design Controlled laboratory study. Methods The femoral and tibial devices of Ultrabutton (Smith & Nephew), Infinity (Conmed), and TightRope II (Arthrex) were applied to quadrupled bovine tendon grafts (n = 8 each) with tibial-sided traction applied (350 N) for graft tensioning in a simulated fully extended knee. Knotless femoral graft fixation was based on either a suture-locking device (SLD; Ultrabutton), button-locking device (BLD; Infinity), or dual-locking device (DLD; TightRope II). All constructs were progressively loaded (50 N/500 cycles) from 50 to 300 N for 3000 cycles (0.75 Hz), including complete unloading situations and pull to failure (50 mm/min). Construct elongation, stiffness, and ultimate load were analyzed. Results BLD showed significantly greater initial elongation (-2.69 ± 0.15 mm) than DLD (-3.19 ± 0.21 mm; P < .001) but behaved similarly to SLD (-2.93 ± 0.23 mm). While DLD and SLD had the smallest initial elongation at the same significance level, they behaved opposite to each other with gradually increasing peak loading. At the end of testing, DLD had the lowest (-0.64 ± 0.32 mm) and SLD the highest (3.41 ± 1.01 mm) total elongation (P < .003 for both). SLD displayed significantly higher dynamic elongation (6.34 ± 0.23 mm) than BLD (3.21 ± 0.61 mm) and DLD (2.56 ± 0.31 mm) (P < .001 for both). The failure load of BLD (865.0 ± 183.8 N) was significantly lower (P < .026) compared with SLD and DLD (>1000 N). The predominant failure mode was suture rupture and tibial bone breakage with button subsidence (SLD, n = 4). No significant difference in stiffness between constructs was found. Conclusion While DLD successfully restricted critical construct elongation, BLD partially and SLD completely exceeded the clinical failure threshold (>3 mm) of plastic elongation with loop lengthening during increasing cyclic peak loading with complete unloading. Higher failure loads of SLD and DLD implants (>1000 N) were achieved at similar construct stiffness to BLD. Clinical Relevance A detailed biomechanical understanding of the stabilization potential is pertinent to the continued evolution of ALDs to improve clinical outcomes.
Collapse
Affiliation(s)
| | - Edoardo Monaco
- Department of Orthopaedics and Traumatology Sant’Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | | | - Rachel M. Frank
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | |
Collapse
|
7
|
Kim-Wang SY, Spritzer CE, Owusu-Akyaw K, Coppock JA, Goode AP, Englander ZA, Wittstein JR, DeFrate LE. The Predicted Position of the Knee Near the Time of ACL Rupture Is Similar Between 2 Commonly Observed Patterns of Bone Bruising on MRI: Response. Am J Sports Med 2023; 51:NP22-NP24. [PMID: 37392078 DOI: 10.1177/03635465231172184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
|
8
|
Leung A, DeSandis B, O’Brien L, Hammoud S, Zarzycki R. Postoperative considerations based on graft type after anterior cruciate ligament reconstruction a narrative review. ANNALS OF JOINT 2023; 8:26. [PMID: 38529227 PMCID: PMC10929311 DOI: 10.21037/aoj-22-51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/09/2023] [Indexed: 03/27/2024]
Abstract
Background and Objective Graft selection for anterior cruciate ligament reconstruction (ACLR) affects rehabilitation throughout the course of postoperative care. Methods A search of PubMed and EBSCO was performed and abstracts independently reviewed by two authors. This search was also supplemented with additional evidence relevant to each phase of ACLR rehabilitation. Key Content and Findings Direct implications of graft type on clinical decisions vary throughout treatment phases, transitioning from potential differences in acute postoperative pain management immediately after surgery to facilitating sufficient and appropriate lower extremity loading in subsequent weeks. Regardless of graft type, surgical limb weakness persists throughout the course of rehabilitation; however, harvest site selection for autografts contributes to disproportionate weakness of the harvested muscle group and the potential for surgical-induced tendinopathy. In later phases of rehabilitation, as athletes are transitioning into return to sport (RTS), treatment decisions and protocols are less affected by graft type but expectations for meeting clinical milestones and the time required to do so does differ between graft types. Conclusions Targeted strengthening interventions to address muscle weakness following graft harvest in autografts should be continued throughout the rehabilitation process. Lingering deficits in quadriceps strength symmetry may also influence time to meet progression and RTS criteria following graft harvest from the extensor mechanism.
Collapse
Affiliation(s)
- Anne Leung
- Department of Physical Therapy, Arcadia University, Glenside, PA, USA
| | | | | | - Sommer Hammoud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Rothman Institute, Philadelphia, PA, USA
| | - Ryan Zarzycki
- Department of Physical Therapy, Arcadia University, Glenside, PA, USA
| |
Collapse
|
9
|
Runer A, Keeling L, Wagala N, Nugraha H, Özbek EA, Hughes JD, Musahl V. Current trends in graft choice for anterior cruciate ligament reconstruction - part I: anatomy, biomechanics, graft incorporation and fixation. J Exp Orthop 2023; 10:37. [PMID: 37005974 PMCID: PMC10067784 DOI: 10.1186/s40634-023-00600-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/04/2023] Open
Abstract
Graft selection in anterior cruciate ligament (ACL) reconstruction is critical, as it remains one of the most easily adjustable factors affecting graft rupture and reoperation rates. Commonly used autografts, including hamstring tendon, quadriceps tendon and bone-patellar-tendon-bone, are reported to be biomechanically equivalent or superior compared to the native ACL. Despite this, such grafts are unable to perfectly replicate the complex anatomical and histological characteristics of the native ACL. While there remains inconclusive evidence as to the superiority of one autograft in terms of graft incorporation and maturity, allografts appear to demonstrate slower incorporation and maturity compared to autografts. Graft fixation also affects graft properties and subsequent outcomes, with each technique having unique advantages and disadvantages that should be carefully considered during graft selection.
Collapse
Affiliation(s)
- Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
- Department for Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Laura Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nyaluma Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hans Nugraha
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Emre Anil Özbek
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
10
|
Moon J, Koo D, Kim S, Panday SB. Effect of sprinting velocity on anterior cruciate ligament and knee load during sidestep cutting. Front Bioeng Biotechnol 2023; 11:1033590. [PMID: 36824350 PMCID: PMC9941960 DOI: 10.3389/fbioe.2023.1033590] [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: 08/31/2022] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Abstract
The purpose of the study was to investigate the effect of an increase in sprinting velocity on the anterior cruciate ligament (ACL) load, knee joint load, and activation of femoral muscles using the musculoskeletal modeling approach. Fourteen high school male athletes were recruited (age: 17.4 ± 0.7 years, height: 1.75 ± 0.04 m, weight: 73.3 ± 8.94 kg), with the right foot dominant and physical activity level of about 3-4 h per day. The kinematics, kinetics, and co-contraction index (CCI) of the extensors and flexors of the right leg's femoral muscles were calculated. The anterior cruciate ligament load was estimated using the musculoskeletal modeling method. In the results, it was observed that the anterior cruciate ligament load (p < 0.017) increased as sidestep cutting velocity increased, resulting in increased adduction (p < 0.017) and the internal rotation moment of the knee joint. This was significantly higher than when sprinting at a similar velocity. The co-contraction index result, which represents the balanced activation of the femoral extensor and flexor muscles, showed a tendency of decrement with increasing sprinting velocity during sidestep cutting (p < 0.017), whereas no significant differences were observed when running at different sprinting conditions. Therefore, we postulate that factors such as knee joint shear force, extended landing posture with increasing sprinting velocity, internal rotation moment, and femoral muscle activity imbalance influence the increase of anterior cruciate ligament load during a sidestep cutting maneuver.
Collapse
Affiliation(s)
- Jeheon Moon
- Department of Physical Education, Korea National University of Education, Chungbuk, Republic ofKorea
| | - Dohoon Koo
- Department of Exercise Prescription, Jeonju University, Chonbuk, Republic ofKorea
| | - Sungmin Kim
- Institute of School Physical Education, Korea National University of Education, Chungbuk, Republic ofKorea
| | - Siddhartha Bikram Panday
- Department of Physical Education, Hanyang University, Seoul, Republic ofKorea,Department of Art and Sportainment, Hanyang University, Seoul, Republic ofKorea,*Correspondence: Siddhartha Bikram Panday,
| |
Collapse
|
11
|
Foody JN, Bradley PX, Spritzer CE, Wittstein JR, DeFrate LE, Englander ZA. Elevated In Vivo ACL Strain Is Associated With a Straight Knee in Both the Sagittal and the Coronal Planes. Am J Sports Med 2023; 51:422-428. [PMID: 36625427 DOI: 10.1177/03635465221141876] [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] [Indexed: 01/11/2023]
Abstract
BACKGROUND Noncontact anterior cruciate ligament (ACL) injuries typically occur during deceleration movements such as landing or cutting. However, conflicting data have left the kinematic mechanisms leading to these injuries unclear. Quantifying the influence of sagittal and coronal plane knee kinematics on in vivo ACL strain may help to elucidate noncontact ACL injury mechanisms. PURPOSE/HYPOTHESIS The purpose of this study was to measure in vivo sagittal and coronal plane knee kinematics and ACL strain during a single-leg jump. We hypothesized that ACL strain would be modulated primarily by motion in the sagittal plane and that limited coronal plane motion would be measured during this activity. STUDY DESIGN Descriptive laboratory study. METHODS Seventeen healthy participants (8 male/9 female) underwent magnetic resonance imaging (MRI) followed by high-speed biplanar radiography, obtained as participants performed a single-leg jump. Three-dimensional models of the femur, tibia, and associated ACL attachment site footprints were created from the MRIs and registered to the radiographs to reproduce the position of the knee during the jump. ACL strain, knee flexion/extension angles, and varus/valgus angles were measured throughout the jump. Spearman rank correlations were used to assess relationships between mean ACL strain and kinematic variables. RESULTS Mean ACL strain increased with decreasing knee flexion angle (ρ = -0.3; P = .002), and local maxima in ACL strain occurred with the knee in a straight position in both the sagittal and the coronal planes. In addition, limited coronal plane motion (varus/valgus angle) was measured during this activity (mean ± SD, -0.5°± 0.3°). Furthermore, we did not detect a statistically significant relationship between ACL strain and varus/valgus angle (ρ = -0.01; P = .9). CONCLUSION ACL strain was maximized when the knee was in a straight position in both the sagittal and coronal planes. Participants remained in <1° of varus/valgus position on average throughout the jump. As a ligament under elevated strain is more vulnerable to injury, landing on a straight knee may be an important risk factor for ACL rupture. CLINICAL RELEVANCE These data may improve understanding of risk factors for noncontact ACL injury, which may be useful in designing ACL injury prevention programs.
Collapse
Affiliation(s)
- Jacqueline N Foody
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.,Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Patrick X Bradley
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
| | | | - Jocelyn R Wittstein
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Louis E DeFrate
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.,Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
| | - Zoë A Englander
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| |
Collapse
|
12
|
Saitoh A, Hiranaka T, Arimoto A, Tanaka A, Suda Y, Koide M, Fujishiro T, Okamoto K. Intraoperative avulsion fracture of the intercondylar eminence in Oxford mobile-bearing unicompartmental knee arthroplasty: Case report. Knee 2023; 40:220-226. [PMID: 36512893 DOI: 10.1016/j.knee.2022.11.017] [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: 05/25/2021] [Revised: 09/29/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Unicompartmental knee arthroplasty (UKA) can provide good postoperative results and long term survival, but there may be complications. We present a rare case of avulsion fracture of the intercondylar eminence during UKA surgery. CASE PRESENTATION An 88-year-old man had right-knee pain with anteromedial osteoarthritis. Oxford partial knee UKA (Zimmer Biomet, Warsaw, IN) was performed by the senior author by the under-vastus approach using Microplasty instruments. During the final check of the range of motion, an avulsion fracture of the intercondylar eminence occurred at the terminal extension. A 4.0 mm cannulated cancellous screw was inserted into the intercondylar eminence from just in front of the anterior cruciate ligament to the posterior tibial cortex. Six months postoperatively, bony fusion was confirmed by lateral radiography. Two years after the surgery, the patient was fully satisfied. The flexion angle was 125°, but still with an extension limit of 10°. DISCUSSION Avulsion fracture of the intercondylar eminence can be caused by hyperextension and/or the ACL becoming tighter in full extension of the knee. In this patient, avulsion fracture also probably occurred due to increased tension of the ACL in the fully extended position. After making the horizontal cut, we inserted a thin metal plate to prevent deeper vertical cuts, but an excessive horizontal cut was a possible cause of the fracture. As treatment for avulsion fracture of the intercondylar eminence, fixation of the cannulated cancellous screw resulted in uneventful bone fusion. We recommend having a cannulated cancellous screw at hand for such complications and for other potential intraoperative problems, such as tibial plateau fracture. Further investigation into limited postoperative extension might be needed. CONCLUSION Our patient had intraoperative avulsion fracture of the intercondylar eminence, a relatively rare complication of Oxford UKA which is probably caused by the extension being tight and/or an excessive horizontal cut. Having a cannulated cancellous screw at hand is advised, and attention should be paid to postoperative limit of extension.
Collapse
Affiliation(s)
- Akira Saitoh
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Takafumi Hiranaka
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan.
| | - Akihiko Arimoto
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Atsuki Tanaka
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Yoshihito Suda
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Motoki Koide
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Takaaki Fujishiro
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Koji Okamoto
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| |
Collapse
|
13
|
Kim-Wang SY, Spritzer CE, Owusu-Akyaw K, Coppock JA, Goode AP, Englander ZA, Wittstein JR, DeFrate LE. The Predicted Position of the Knee Near the Time of ACL Rupture Is Similar Between 2 Commonly Observed Patterns of Bone Bruising on MRI. Am J Sports Med 2023; 51:58-65. [PMID: 36440714 DOI: 10.1177/03635465221131551] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bone bruises observed on magnetic resonance imaging (MRI) can provide insight into the mechanisms of noncontact anterior cruciate ligament (ACL) injury. However, it remains unclear whether the position of the knee near the time of injury differs between patients evaluated with different patterns of bone bruising, particularly with regard to valgus angles. HYPOTHESIS The position of the knee near the time of injury is similar between patients evaluated with 2 commonly occurring patterns of bone bruising. STUDY DESIGN Descriptive laboratory study. METHODS Clinical T2- and T1-weighted MRI scans obtained within 6 weeks of noncontact ACL rupture were reviewed. Patients had either 3 (n = 20) or 4 (n = 30) bone bruises. Patients in the 4-bone bruise group had bruising of the medial and lateral compartments of the femur and tibia, whereas patients in the 3-bone bruise group did not have a bruise on the medial femoral condyle. The outer contours of the bones and associated bruises were segmented from the MRI scans and used to create 3-dimensional surface models. For each patient, the position of the knee near the time of injury was predicted by moving the tibial model relative to the femoral model to maximize the overlap of the tibiofemoral bone bruises. Logistic regressions (adjusted for sex, age, and presence of medial collateral ligament injury) were used to assess relationships between predicted injury position (quantified in terms of knee flexion angle, valgus angle, internal rotation angle, and anterior tibial translation) and bone bruise group. RESULTS The predicted injury position for patients in both groups involved a flexion angle <20°, anterior translation >20 mm, valgus angle <10°, and internal rotation angle <10°. The injury position for the 3-bone bruise group involved less flexion (odds ratio [OR], 0.914; 95% CI, 0.846-0.987; P = .02) and internal rotation (OR, 0.832; 95% CI, 0.739-0.937; P = .002) as compared with patients with 4 bone bruises. CONCLUSION The predicted position of injury for patients displaying both 3 and 4 bone bruises involved substantial anterior tibial translation (>20 mm), with the knee in a straight position in both the sagittal (<20°) and the coronal (<10°) planes. CLINICAL RELEVANCE Landing on a straight knee with subsequent anterior tibial translation is a potential mechanism of noncontact ACL injury.
Collapse
Affiliation(s)
- Sophia Y Kim-Wang
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Charles E Spritzer
- Department of Radiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kwadwo Owusu-Akyaw
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - James A Coppock
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Adam P Goode
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zoë A Englander
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jocelyn R Wittstein
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Louis E DeFrate
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
| |
Collapse
|
14
|
Koo YJ, Seon JK, Lee G, Koo S. Influences of Partial Anterior Cruciate Ligament Injury On Anterior Cruciate Ligament Tensional Force and Kinematic Stability During Walking. J Biomech Eng 2022; 145:1143182. [PMID: 35838323 DOI: 10.1115/1.4054982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Indexed: 11/08/2022]
Abstract
Injuries in the anterior cruciate ligament (ACL), including partial tear and lengthening of the ACL, change the dynamic function of the knee. However, there is a lack of information on the effect of ACL partial tear on knee kinematics during walking. This study aimed to investigate the effects of different levels of ACL injuries on the knee stability and ACL tensional force to identify the critical injury level. Motion data of five normal subjects were acquired along with the ground reaction force. A knee model with 14 ligaments was developed using cadaveric specimen data. The initial length and stiffness of the ACL were changed to develop ACL-injured knee models. Musculoskeletal simulations of the knee models were performed using the measured gait data. The average tibial anterior translation increased significantly by 2.6 ± 0.7 mm when the ACL stiffness decreased to 25% of its original stiffness. The average tibial anterior translation increased significantly by 2.6 ± 0.3 mm at an increase in initial length of 10%. The knee with partial ACL tear had a non-linear decrease in ACL forces owing to the increase in the level of ACL injury, while the knee with ACL lengthening had linear decreased ACL forces. The partial tear of the ACL caused translational instability, while the complete tear caused both rotational and translational instabilities during the musculoskeletal walking simulation. This study presents the effects of partial ACL injuries on joint kinematics and ACL tensional force during the dynamic motion of walking.
Collapse
Affiliation(s)
- Young-Jun Koo
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Jong Keun Seon
- Department of Orthopedic Surgery, Chonnam National University Bitgoeul Hospital, Gwangju, Republic of Korea
| | - Giuk Lee
- School of Mechanical Engineering, Chung-Ang University, Seoul, Republic of Korea
| | - Seungbum Koo
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| |
Collapse
|
15
|
Full thickness quadriceps tendon grafts with bone had similar material properties to bone-patellar tendon-bone and a four-strand semitendinosus grafts: a biomechanical study. Knee Surg Sports Traumatol Arthrosc 2022; 30:1786-1794. [PMID: 34591124 DOI: 10.1007/s00167-021-06738-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Despite increasing interest in utilizing quadriceps tendon (QT) grafts in anterior cruciate ligament reconstruction (ACLR), data on the optimal quadriceps graft thickness are limited. The purpose of this study was to characterize the mechanical properties for the quadriceps tendon, comparing full-thickness (FT) QT grafts with and without bone to a partial-thickness (PT) QT graft, and comparing the three QT grafts to four-stranded semitendinosus (4-SST) and bone-patellar tendon-bone (BTB) grafts and one experimental graft, the two-stranded rectus femoris (RF). METHODS Forty-eight (n = 48) young cadaveric grafts (mean age 32 ± 6 years) were utilized for testing with N = 8 specimens in each of the following groups; (1) FT QT with bone, (2) FT QT without bone, (3) PT QT without bone, (4) BTB, (5) RF, and (6) 4-SST. Each specimen was harvested and rigidly fixed in custom clamps to a dynamic tensile testing machine for biomechanical evaluation. Graft ultimate load and stiffness were recorded. Independent groups one-factor ANOVAs and Tukey's pairwise comparisons were performed for statistical analyses. RESULTS FT QT with bone and 4-SST grafts demonstrated similar ultimate loads to BTB grafts (both n.s), whereas PT QT demonstrate statistically significantly lower ultimate loads to BTB grafts (n.s) and 4-SST grafts (n.s). Furthermore, no statistically significant differences were observed between the ultimate loads of FT QT vs. PT QT grafts without bone (n.s) or between FT QT with vs. without bone (n.s). FT QT grafts with bone did not demonstrate statistically significantly greater ultimate loads than PT QT grafts without bone (n.s). The RF graft demonstrated statistically significantly lower ultimate loads to BTB grafts (p < 0.005) and 4-SST grafts (p < 0.014). CONCLUSIONS Full thickness QT grafts with bone had similar material properties to BTB and a 4-SST grafts, while Partial thickness QT graft without bone had significantly lower material properties than BTB and 4-SST, in a biomechanical setting.
Collapse
|
16
|
Christensen KW, Turner J, Coughenour K, Maghdouri-White Y, Bulysheva AA, Sergeant O, Rariden M, Randazzo A, Sheean AJ, Christ GJ, Francis MP. Assembled Cell-Decorated Collagen (AC-DC) Fiber Bioprinted Implants with Musculoskeletal Tissue Properties Promote Functional Recovery in Volumetric Muscle Loss. Adv Healthc Mater 2022; 11:e2101357. [PMID: 34879177 PMCID: PMC8890793 DOI: 10.1002/adhm.202101357] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/26/2021] [Indexed: 02/03/2023]
Abstract
Musculoskeletal tissue injuries, including volumetric muscle loss (VML), are commonplace and often lead to permanent disability and deformation. Addressing this healthcare need, an advanced biomanufacturing platform, assembled cell-decorated collagen (AC-DC) bioprinting, is invented to rapidly and reproducibly create living biomaterial implants, using clinically relevant cells and strong, microfluidic wet-extruded collagen microfibers. Quantitative analysis shows that the directionality and distribution of cells throughout AC-DC implants mimic native musculoskeletal tissue. AC-DC bioprinted implants further approximate or exceed the strength and stiffness of human musculoskeletal tissue and exceed collagen hydrogel tensile properties by orders of magnitude. In vivo, AC-DC implants are assessed in a critically sized muscle injury in the hindlimb, with limb torque generation potential measured over 12 weeks. Both acellular and cellular implants promote functional recovery compared to the unrepaired group, with AC-DC implants containing therapeutic muscle progenitor cells promoting the highest degree of recovery. Histological analysis and automated image processing of explanted muscle cross-sections reveal increased total muscle fiber count, median muscle fiber size, and increased cellularization for injuries repaired with cellularized implants. These studies introduce an advanced bioprinting method for generating musculoskeletal tissue analogs with near-native biological and biomechanical properties with the potential to repair myriad challenging musculoskeletal injuries.
Collapse
Affiliation(s)
| | - Jonathan Turner
- Department of Biomedical Engineering and Orthopaedic Surgery, University of Virginia; Charlottesville, Virginia, USA
| | | | | | - Anna A. Bulysheva
- Depeartment of Electrical and Computer Engineering, Old Dominion University, Norfolk, VA, USA
| | - Olivia Sergeant
- Department of Biomedical Engineering and Orthopaedic Surgery, University of Virginia; Charlottesville, Virginia, USA
| | - Michael Rariden
- Department of Biomedical Engineering and Orthopaedic Surgery, University of Virginia; Charlottesville, Virginia, USA
| | - Alessia Randazzo
- Department of Biomedical Engineering and Orthopaedic Surgery, University of Virginia; Charlottesville, Virginia, USA
| | - Andrew J. Sheean
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, USAF 59 MDW, San Antonio, TX, USA
| | - George J. Christ
- Department of Biomedical Engineering and Orthopaedic Surgery, University of Virginia; Charlottesville, Virginia, USA
| | | |
Collapse
|
17
|
Musahl V, Nazzal EM, Lucidi GA, Serrano R, Hughes JD, Margheritini F, Zaffagnini S, Fu FH, Karlsson J. Current trends in the anterior cruciate ligament part 1: biology and biomechanics. Knee Surg Sports Traumatol Arthrosc 2022; 30:20-33. [PMID: 34927221 DOI: 10.1007/s00167-021-06826-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022]
Abstract
A trend within the orthopedic community is rejection of the belief that "one size fits all." Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient's anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identification and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients.Level of evidenceV.
Collapse
Affiliation(s)
- Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Ehab M Nazzal
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA.
| | - Gian Andrea Lucidi
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA.,IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Rafael Serrano
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Jon Karlsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| |
Collapse
|
18
|
Brinlee AW, Dickenson SB, Hunter-Giordano A, Snyder-Mackler L. ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline. Sports Health 2021; 14:770-779. [PMID: 34903114 PMCID: PMC9460090 DOI: 10.1177/19417381211056873] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
CONTEXT Anterior cruciate ligament (ACL) reconstruction (ACLR) and postoperative rehabilitation continues to be a multidisciplinary focus in both research and clinical environments. Recent research on ACLR warrants a reexamination of clinicians' current rehabilitation practices to optimize the strikingly variable clinical outcomes after ACLR and return to sport. The purpose of the article and updated guidelines is to use contemporary evidence to systematically revisit our practice guidelines and validate our clinical milestones with data from our university-based practice. EVIDENCE ACQUISITION Using the PubMed search engine, articles that reported on ACLR rehabilitation and protocols, guidelines, graft type, healing and strain, return to sport, psychological considerations, and secondary injury prevention published from 1979 to 2020 were identified using the search terms ACLR protocols, guidelines, ACLR rehabilitation, ACL graft, ACL open kinetic chain (OKC) exercise and closed kinetic chain (CKC) exercise, ACLR return to sport, ACLR psychological factors, and ACL injury prevention. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 5. RESULTS Clinical milestones after ACLR were validated using clinical data collected from 2013 to 2017 at a university-based practice. Variables including knee joint range of motion, effusion, Knee Outcome Survey-Activities of Daily Living Scale, and quadriceps strength index were tracked throughout rehabilitation and analyzed to help inform an updated ACLR rehabilitation guideline. CONCLUSION Incorporating the latest research, combined with direct clinical data, provides a current, realistic, and clinically benchmarked strategy for ACLR rehabilitation. Commonly held clinical beliefs regarding rehabilitation after ACL injury must be challenged by the latest research to improve patient outcomes and decrease the risk of reinjury. Key updates to the practice guidelines include the use of frequent and accurate quadriceps strength testing, delayed return-to-sport timeline, immediate use of open kinetic chain exercise, criterion-based progressions for running, sprinting, plyometrics, agility, cutting/pivoting, return to competition, and the inclusion of a secondary prevention program after return to sport. STRENGTH OF RECOMMENDATION TAXONOMY (SORT) B.
Collapse
Affiliation(s)
| | - Scott B. Dickenson
- Department of Physical Therapy,
University of Delaware, Newark, Delaware
| | - Airelle Hunter-Giordano
- Department of Physical Therapy,
University of Delaware, Newark, Delaware,Airelle Hunter-Giordano,
PT, DPT, OCS, SCS, Department of Physical Therapy, University of Delaware, 540
South College Avenue, Suite 160, Newark, DE 19713 (
) (Twitter: @AirelleGiordano)
| | | |
Collapse
|
19
|
Csapo R, Heinrich D, Vigotsky AD, Marx C, Sinha S, Fink C. Developing a Technique for the Imaging-Based Measurement of ACL Elongation: A Proof of Principle. Diagnostics (Basel) 2021; 11:diagnostics11112126. [PMID: 34829473 PMCID: PMC8622620 DOI: 10.3390/diagnostics11112126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/07/2021] [Accepted: 11/15/2021] [Indexed: 11/29/2022] Open
Abstract
Towards the goal of obtaining non-invasive biomarkers reflecting the anterior cruciate ligament’s (ACL) loading capacity, this project aimed to develop a magnetic resonance imaging (MRI)-based method facilitating the measurement of ACL elongations during the execution of knee stress tests. An MRI-compatible, computer-controlled, and pneumatically driven knee loading device was designed to perform Lachman-like tests and induce ACL strain. A human cadaveric leg was used for test purposes. During the execution of the stress tests, a triggered real-time cine MRI sequence with a temporal resolution of 10 Hz was acquired in a parasagittal plane to capture the resultant ACL elongations. To test the accuracy of these measurements, the results were compared to in situ data of ACL elongation that were acquired by measuring the length changes of a surgical wire directly sutured to the ACL’s anteromedial bundle. The MRI-based ACL elongations ranged between 0.7 and 1.7 mm and agreed very well with in situ data (root mean square errors, RMSEs ≤ 0.25 mm), although peak elongation rates were underestimated by the MRI (RMSEs 0.19–0.36 mm/s). The high accuracy of elongation measurements underlines the potential of the technique to yield an imaging-based biomarker of the ACL’s loading capacity.
Collapse
Affiliation(s)
- Robert Csapo
- Centre for Sport Science and University Sports, University of Vienna, 1150 Wien, Austria
- Correspondence: ; Tel.: +43-1-4277-59160
| | - Dieter Heinrich
- Department of Sport Science, University of Innsbruck, 6020 Innsbruck, Austria;
| | - Andrew D. Vigotsky
- Departments of Biomedical Engineering and Statistics, Northwestern University, Evanston, IL 60208, USA;
| | - Christian Marx
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Tirol, 6060 Hall, Austria; (C.M.); (C.F.)
| | - Shantanu Sinha
- Department of Radiology, University of California San Diego, San Diego, CA 92093, USA;
| | - Christian Fink
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Tirol, 6060 Hall, Austria; (C.M.); (C.F.)
- Gelenkpunkt Sports and Joint Surgery, 6020 Innsbruck, Austria
| |
Collapse
|
20
|
Logerstedt DS, Ebert JR, MacLeod TD, Heiderscheit BC, Gabbett TJ, Eckenrode BJ. Effects of and Response to Mechanical Loading on the Knee. Sports Med 2021; 52:201-235. [PMID: 34669175 DOI: 10.1007/s40279-021-01579-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Abstract
Mechanical loading to the knee joint results in a differential response based on the local capacity of the tissues (ligament, tendon, meniscus, cartilage, and bone) and how those tissues subsequently adapt to that load at the molecular and cellular level. Participation in cutting, pivoting, and jumping sports predisposes the knee to the risk of injury. In this narrative review, we describe different mechanisms of loading that can result in excessive loads to the knee, leading to ligamentous, musculotendinous, meniscal, and chondral injuries or maladaptations. Following injury (or surgery) to structures around the knee, the primary goal of rehabilitation is to maximize the patient's response to exercise at the current level of function, while minimizing the risk of re-injury to the healing tissue. Clinicians should have a clear understanding of the specific injured tissue(s), and rehabilitation should be driven by knowledge of tissue-healing constraints, knee complex and lower extremity biomechanics, neuromuscular physiology, task-specific activities involving weight-bearing and non-weight-bearing conditions, and training principles. We provide a practical application for prescribing loading progressions of exercises, functional activities, and mobility tasks based on their mechanical load profile to knee-specific structures during the rehabilitation process. Various loading interventions can be used by clinicians to produce physical stress to address body function, physical impairments, activity limitations, and participation restrictions. By modifying the mechanical load elements, clinicians can alter the tissue adaptations, facilitate motor learning, and resolve corresponding physical impairments. Providing different loads that create variable tensile, compressive, and shear deformation on the tissue through mechanotransduction and specificity can promote the appropriate stress adaptations to increase tissue capacity and injury tolerance. Tools for monitoring rehabilitation training loads to the knee are proposed to assess the reactivity of the knee joint to mechanical loading to monitor excessive mechanical loads and facilitate optimal rehabilitation.
Collapse
Affiliation(s)
- David S Logerstedt
- Department of Physical Therapy, University of the Sciences in Philadelphia, Philadelphia, PA, USA.
| | - Jay R Ebert
- School of Human Sciences (Exercise and Sport Science), University of Western Australia, Perth, WA, Australia.,Orthopaedic Research Foundation of Western Australia, Perth, WA, Australia.,Perth Orthopaedic and Sports Medicine Research Institute, Perth, WA, Australia
| | - Toran D MacLeod
- Department of Physical Therapy, Sacramento State University, Sacramento, CA, USA
| | - Bryan C Heiderscheit
- Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI, USA
| | - Tim J Gabbett
- Gabbett Performance Solutions, Brisbane, QLD, Australia.,Centre for Health Research, University of Southern Queensland, Ipswich, QLD, Australia
| | - Brian J Eckenrode
- Department of Physical Therapy, Arcadia University, Glenside, PA, USA
| |
Collapse
|
21
|
Maintenance of Ligament Homeostasis of Spheroid-Colonized Embroidered and Functionalized Scaffolds after 3D Stretch. Int J Mol Sci 2021; 22:ijms22158204. [PMID: 34360970 PMCID: PMC8348491 DOI: 10.3390/ijms22158204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/18/2021] [Accepted: 07/23/2021] [Indexed: 01/12/2023] Open
Abstract
Anterior cruciate ligament (ACL) ruptures are usually treated with autograft implantation to prevent knee instability. Tissue engineered ACL reconstruction is becoming promising to circumvent autograft limitations. The aim was to evaluate the influence of cyclic stretch on lapine (L) ACL fibroblasts on embroidered scaffolds with respect to adhesion, DNA and sulphated glycosaminoglycan (sGAG) contents, gene expression of ligament-associated extracellular matrix genes, such as type I collagen, decorin, tenascin C, tenomodulin, gap junctional connexin 43 and the transcription factor Mohawk. Control scaffolds and those functionalized by gas phase fluorination and cross-linked collagen foam were either pre-cultured with a suspension or with spheroids of LACL cells before being subjected to cyclic stretch (4%, 0.11 Hz, 3 days). Stretch increased significantly the scaffold area colonized with cells but impaired sGAGs and decorin gene expression (functionalized scaffolds seeded with cell suspension). Stretching increased tenascin C, connexin 43 and Mohawk but decreased decorin gene expression (control scaffolds seeded with cell suspension). Pre-cultivation of functionalized scaffolds with spheroids might be the more suitable method for maintaining ligamentogenesis in 3D scaffolds compared to using a cell suspension due to a significantly higher sGAG content in response to stretching and type I collagen gene expression in functionalized scaffolds.
Collapse
|
22
|
Smith S, Rush J, Glaviano NR, Murray A, Bazett-Jones D, Bouillon L, Blackburn T, Norte G. Sex influences the relationship between hamstrings-to-quadriceps strength imbalance and co-activation during walking gait. Gait Posture 2021; 88:138-145. [PMID: 34034026 DOI: 10.1016/j.gaitpost.2021.05.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/03/2021] [Accepted: 05/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND While traditionally viewed as a beneficial adaptation to preserve stability in the presence of knee pathology, excessive muscle co-activation may be detrimental for joint health when extrapolated to repetitive movement patterns over time. Lesser hamstrings strength relative to the quadriceps (low H:Q strength ratio) may influence neuromuscular patterns about the knee, as it is reported to increase risk for lower extremity injury among healthy females. RESEARCH QUESTION Does the relationship between H:Q strength ratio and H:Q co-activation differ between sexes during walking and jogging? METHODS We used a descriptive laboratory study to assess hamstrings and quadriceps strength and muscle activity patterns during the loading response of treadmill walking gait (1.34 m/s) and jogging (2.68 m/s) in healthy males (n = 11) and females (n = 12). Concentric-concentric peak isokinetic torque (60°/s) was used to derive the H:Q strength ratio, which was treated as an explanatory variable for H:Q co-activation indices (medial, lateral, composite) and constituent EMG amplitudes. Bivariate correlations (Pearson r or Spearman ρ) were used for analysis. RESULTS In females, lesser H:Q strength ratios were associated with greater lateral co-activation (r=-.715, P = .007) and biceps femoris EMG amplitude (ρ=-.532, P = .046) during the loading response of walking gait. When controlling for sex differences in knee flexion, the relationship between lesser H:Q strength ratios and greater lateral co-activation was preserved (partial r=-.699, P = .012); yet, biceps femoris EMG was no longer correlated (partial r=-.331, P = .175). Significant relationships were not observed among male participants during walking or in either sex during jogging (all P > .05). SIGNIFICANCE Collectively, these data provide evidence of a sex-specific neuromuscular pattern with implications for joint health. Excessive lateral co-activation may consequently promote a greater valgus moment and ligamentous strain. Future investigations would benefit from understanding the influence of hamstrings-dominant exercise programs on the neuromuscular patterns of the knee.
Collapse
Affiliation(s)
- Samantha Smith
- Athletic Training Program, School of Exercise and Rehabilitation Sciences, University of Toledo, Toledo, OH, USA.
| | - Justin Rush
- Exercise Science Program, School of Exercise and Rehabilitation Sciences, University of Toledo, Toledo, OH, USA.
| | - Neal R Glaviano
- Department of Kinesiology, University of Connecticut, Storrs, CT, USA.
| | - Amanda Murray
- Physical Therapy Program, School of Exercise and Rehabilitation Sciences, University of Toledo, Toledo, OH, USA.
| | - David Bazett-Jones
- Athletic Training Program, School of Exercise and Rehabilitation Sciences, University of Toledo, Toledo, OH, USA.
| | - Lucinda Bouillon
- Physical Therapy Program, School of Exercise and Rehabilitation Sciences, University of Toledo, Toledo, OH, USA.
| | - Troy Blackburn
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Grant Norte
- Athletic Training Program, School of Exercise and Rehabilitation Sciences, University of Toledo, Toledo, OH, USA.
| |
Collapse
|
23
|
Mojaddarasil M, Sadigh MJ. On the impact force analysis of two-leg landing with a flexed knee. Comput Methods Biomech Biomed Engin 2021; 24:1862-1875. [PMID: 34027762 DOI: 10.1080/10255842.2021.1925257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article looks into the effects of the initial knee flexion angle at the contact time on the peak of the impulsive lower limb forces during landing, and how these effects are related to muscular activities. The impact dynamics of drop landing is studied via a musculoskeletal model with eight Hill-type lower-limb muscles. A method is proposed for the representation of two landing strategies: landing with high and low joint stiffness. Then, in each landing strategy, the effect of the initial knee flexion angle on the peak ground reaction force (GRF), the peak knee ligaments force and the peak tibiofemoral contact force is investigated by considering different initial contact postures. It is observed that while landing with a flexed knee decreases the peak GRF in both landing strategies, it decreases the peak tibiofemoral and knee ligaments forces only in landing with low joint stiffness. Specifically, by increasing the initial knee flexion from 0° to 70°, the peak tibiofemoral and knee ligaments forces decrease monotonically by 54% and 82%, in landing with low joint stiffness. For high joint stiffness, however, as the initial knee flexion increases from 10° to 70°, the peak tibiofemoral force is seen to increase monotonically by 42% and the peak knee ligaments force is seen to have a non-monotonic behavior, first decreasing by 42%, and then, increasing by 250%. These results can be considered in training landing strategies to reduce the risk of knee injury.
Collapse
Affiliation(s)
- Marzieh Mojaddarasil
- Department of Mechanical Engineering, Isfahan University of Technology, Isfahan 84156-83111, Iran
| | | |
Collapse
|
24
|
Sikidar A, Marieswaran M, Kalyanasundaram D. Estimation of forces on anterior cruciate ligament in dynamic activities. Biomech Model Mechanobiol 2021; 20:1533-1546. [PMID: 33880694 DOI: 10.1007/s10237-021-01461-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/10/2021] [Indexed: 01/13/2023]
Abstract
In this work, a nonlinear strain rate dependent plugin developed for the OpenSim® platform was used to estimate the instantaneous strain rate (ISR) and the forces on the ACL's anteromedial (aACL) and posterolateral (pACL) bundles during walking and sudden change of direction of running termed as 'plant-and-cut' (PC). The authors obtained the kinematics data for walking via optical motion capture. PC movements, along with running kinematics, were obtained from the literature. A nonlinear plugin developed for ligaments was interfaced with OpenSim® platform to simulate walking and PC motions with a flexed knee and an extended knee. PC phase is sandwiched between an approach phase and take-off phase and was studied at various event velocities (1.8, 3, and 4.2 m s-1), and angles of PC (23°, 34°, and 45°) as encountered in adult ball games. In both cases of PC-with-extended knee and PC-with-flexed-knee, the maximum forces on both the ACL bundles were observed after the take-off phase. A maximum force of ~ 35 N kg-1 of body weight (BW) was observed on aACL after the take-off phase for an event velocity of 4.2 m s-1. In the posterolateral bundle (pACL), the maximum forces (~ 40 N kg-1 of BW) were observed towards the end of the mid-swing phase (after the take-off phase) for the various combinations of the parameters studied. The forces observed in the simulation of PC-with-flexed-knee and PC-with-extended-knee has resulted in magnitude higher than sustainable by the adults. This study is novel in attempting to incorporate differing rates-of-strain that have been shown to alter soft tissue properties into the OpenSim® musculoskeletal model. The proposed model can be used by researchers to predict the forces during various kinematic activities for other soft tissues.
Collapse
Affiliation(s)
- Arnab Sikidar
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, 110016, India
| | - M Marieswaran
- Department of Sports Biomechanics, School of Sports Sciences, Central University of Rajasthan, Bandar Sindi, Ajmer, Rajasthan, 305817, India
| | - Dinesh Kalyanasundaram
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, 110016, India.
- Department of Biomedical Engineering, All India Institute of Medical Sciences, New Delhi, 110029, India.
| |
Collapse
|
25
|
Englander ZA, Lau BC, Wittstein JR, Goode AP, DeFrate LE. Patellar Tendon Orientation and Strain Are Predictors of ACL Strain In Vivo During a Single-Leg Jump. Orthop J Sports Med 2021; 9:2325967121991054. [PMID: 33796591 PMCID: PMC7983247 DOI: 10.1177/2325967121991054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/23/2020] [Indexed: 11/25/2022] Open
Abstract
Background: There is little in vivo data that describe the relationships between patellar
tendon orientation, patellar tendon strain, and anterior cruciate ligament
(ACL) strain during dynamic activities. Quantifying how the quadriceps load
the ACL via the patellar tendon is important for understanding ACL injury
mechanisms. Hypothesis: We hypothesized that flexion angle, patellar tendon orientation, and patellar
tendon strain influence ACL strain during a single-leg jump. Specifically,
we hypothesized that patellar tendon and ACL strains would increase
concurrently when the knee is positioned near extension during the jump. Study Design: Descriptive laboratory study. Methods: Models of the femur, tibia, ACL, patellar tendon, and quadriceps tendon
attachment sites of 8 male participants were generated from magnetic
resonance imaging (MRI). High-speed biplanar radiographs during a single-leg
jump were obtained. The bone models were registered to the radiographs,
thereby reproducing the in vivo positions of the bones, ligament, and tendon
attachment sites. Flexion angle, patellar tendon orientation, patellar
tendon strain, and ACL strain were measured from the registered models. ACL
and patellar tendon strains were approximated by normalizing their length at
each knee position to their length at the time of MRI. Two separate
bivariate linear regression models were used to assess relationships between
flexion angle and patellar tendon orientation and between ACL strain and
patellar tendon strain. A multivariate linear regression model was used to
assess whether flexion angle and patellar tendon strain were significant
predictors of ACL strain during the inflight and landing portions of the
jump. Results: Both flexion angle and patellar tendon strain were significant predictors
(P < .05) of ACL strain. These results indicate that
elevated ACL and patellar tendon strains were observed concurrently when the
knee was positioned near extension. Conclusion: Concurrent increases in patellar tendon and ACL strains indicate that the
quadriceps load the ACL via the patellar tendon when the knee is positioned
near extension. Clinical Relevance: Increased ACL strain when the knee is positioned near extension before
landing may be due to quadriceps contraction. Thus, landing with
unanticipated timing on an extended knee may increase vulnerability to ACL
injury as a taut ligament is more likely to fail.
Collapse
Affiliation(s)
- Zoë A Englander
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.,Duke Sport Science Institute, Department of Orthopaedics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian C Lau
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Duke Sport Science Institute, Department of Orthopaedics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jocelyn R Wittstein
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Duke Sport Science Institute, Department of Orthopaedics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Adam P Goode
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Louis E DeFrate
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.,Duke Sport Science Institute, Department of Orthopaedics, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
| |
Collapse
|
26
|
Davies WT, Ryu JH, Graham-Smith P, Goodwin JE, Cleather DJ. Stronger Subjects Select a Movement Pattern That May Reduce Anterior Cruciate Ligament Loading During Cutting. J Strength Cond Res 2021; 36:1853-1859. [DOI: 10.1519/jsc.0000000000003999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
27
|
Charles JP, Fu FH, Anderst WJ. Predictions of Anterior Cruciate Ligament Dynamics From Subject-Specific Musculoskeletal Models and Dynamic Biplane Radiography. J Biomech Eng 2021; 143:1087889. [PMID: 33030199 DOI: 10.1115/1.4048710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Indexed: 01/13/2023]
Abstract
In vivo knee ligament forces are important to consider for informing rehabilitation or clinical interventions. However, they are difficult to directly measure during functional activities. Musculoskeletal models and simulations have become the primary methods by which to estimate in vivo ligament loading. Previous estimates of anterior cruciate ligament (ACL) forces range widely, suggesting that individualized anatomy may have an impact on these predictions. Using ten subject-specific (SS) lower limb musculoskeletal models, which include individualized musculoskeletal geometry, muscle architecture, and six degree-of-freedom knee joint kinematics from dynamic biplane radiography (DBR), this study provides SS estimates of ACL force (anteromedial-aACL; and posterolateral-pACL bundles) during the full gait cycle of treadmill walking. These forces are compared to estimates from scaled-generic (SG) musculoskeletal models to assess the effect of musculoskeletal knee joint anatomy on predicted forces and the benefit of SS modeling in this context. On average, the SS models demonstrated a double force peak during stance (0.39-0.43 xBW per bundle), while only a single force peak during stance was observed in the SG aACL. No significant differences were observed between continuous SG and SS ACL forces; however, root mean-squared differences between SS and SG predictions ranged from 0.08 xBW to 0.27 xBW, suggesting SG models do not reliably reflect forces predicted by SS models. Force predictions were also found to be highly sensitive to ligament resting length, with ±10% variations resulting in force differences of up to 84%. Overall, this study demonstrates the sensitivity of ACL force predictions to SS anatomy, specifically musculoskeletal joint geometry and ligament resting lengths, as well as the feasibility for generating SS musculoskeletal models for a group of subjects to predict in vivo tissue loading during functional activities.
Collapse
Affiliation(s)
- James P Charles
- Evolutionary Morphology and Biomechanics Lab, Musculoskeletal Biology, University of Liverpool, Liverpool L7 8TX, UK; Biodynamics Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15260
| | - Freddie H Fu
- Biodynamics Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15260
| | - William J Anderst
- Biodynamics Lab, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15260
| |
Collapse
|
28
|
Crowe MM, Martin JT, Grier AJ, Spritzer CE, Richard MJ, Ruch DS. In Vivo Mechanical Function of the Distal Radial Ulnar Ligaments During Rotation of the Wrist. J Hand Surg Am 2020; 45:1012-1021. [PMID: 32800375 PMCID: PMC7655646 DOI: 10.1016/j.jhsa.2020.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 05/10/2020] [Accepted: 06/23/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate changes in length of the volar and dorsal radioulnar ligaments (VRULs and DRULs), and the distal radioulnar joint (DRUJ) space during unweighted and weighted rotation of the wrist using magnetic resonance imaging and biplanar fluoroscopy. METHODS Fourteen wrists in 7 normal adult volunteers were imaged to define the 3-dimensional geometry of the DRUJ and the insertion sites of the superficial and deep bundles of the VRULs and DRULs. Subjects were imaged at 10 positions of forearm rotation ranging from full pronation to full supination, with or without a 5-pound weight. Lengths of the superficial and deep VRUL and DRUL bundles and DRUJ space were measured (in millimeters) at each position to evaluate ligament function and DRUJ stability. RESULTS In the unweighted and weighted trials, maximal elongation of both deep and superficial VRUL bundles occurred in supination and maximal lengths of the deep and superficial DRUL bundles occurred in pronation. Maximum DRUJ space occurred during pronation and a minimum occurred in 30° of supination. In weighted trials, there was a significant increase in deep and superficial VRUL bundle length at positions between 30° of pronation and 30° of supination; however, there was no effect of weight on DRULs length. In weighted trials, there was a significant increase in DRUJ space at positions between full pronation and 15° of supination. CONCLUSIONS This study demonstrates elongation of the VRULs in supination and the DRULs in pronation. There was no evidence of reciprocal loading of superficial/deep ligament bundles on either the dorsal or the volar aspects of the DRUJ. The effect of loading the wrist during rotation was apparent primarily in the VRULs, but not the DRULs. The DRUJ space was lowest at approximately 30° of supination. CLINICAL RELEVANCE These results add information to the literature regarding the complicated biomechanics of the triangular fibrocartilage complex and DRUJ. Future work should evaluate changes in biomechanics caused by triangular fibrocartilage complex tears to determine how tear severity and location relate to clinical symptoms.
Collapse
Affiliation(s)
- Matthew M. Crowe
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - John T. Martin
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - A. Jordan Grier
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | | | - Marc J. Richard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - David S. Ruch
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| |
Collapse
|
29
|
Techniques for In Vivo Measurement of Ligament and Tendon Strain: A Review. Ann Biomed Eng 2020; 49:7-28. [PMID: 33025317 PMCID: PMC7773624 DOI: 10.1007/s10439-020-02635-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022]
Abstract
The critical clinical and scientific insights achieved through knowledge of in vivo musculoskeletal soft tissue strains has motivated the development of relevant measurement techniques. This review provides a comprehensive summary of the key findings, limitations, and clinical impacts of these techniques to quantify musculoskeletal soft tissue strains during dynamic movements. Current technologies generally leverage three techniques to quantify in vivo strain patterns, including implantable strain sensors, virtual fibre elongation, and ultrasound. (1) Implantable strain sensors enable direct measurements of tissue strains with high accuracy and minimal artefact, but are highly invasive and current designs are not clinically viable. (2) The virtual fibre elongation method tracks the relative displacement of tissue attachments to measure strains in both deep and superficial tissues. However, the associated imaging techniques often require exposure to radiation, limit the activities that can be performed, and only quantify bone-to-bone tissue strains. (3) Ultrasound methods enable safe and non-invasive imaging of soft tissue deformation. However, ultrasound can only image superficial tissues, and measurements are confounded by out-of-plane tissue motion. Finally, all in vivo strain measurement methods are limited in their ability to establish the slack length of musculoskeletal soft tissue structures. Despite the many challenges and limitations of these measurement techniques, knowledge of in vivo soft tissue strain has led to improved clinical treatments for many musculoskeletal pathologies including anterior cruciate ligament reconstruction, Achilles tendon repair, and total knee replacement. This review provides a comprehensive understanding of these measurement techniques and identifies the key features of in vivo strain measurement that can facilitate innovative personalized sports medicine treatment.
Collapse
|
30
|
Rangel A, Colaço L, Nguyen N, Grosset JF, Egles C, Migonney V. Adapting Mechanical Characterization of a Biodegradable Polymer to Physiological Approach of Anterior Cruciate Ligament Functions. Ing Rech Biomed 2020. [DOI: 10.1016/j.irbm.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
31
|
Kono K, Konda S, Yamazaki T, Tanaka S, Sugamoto K, Tomita T. In vivo length change of ligaments of normal knees during dynamic high flexion. BMC Musculoskelet Disord 2020; 21:552. [PMID: 32799837 PMCID: PMC7429735 DOI: 10.1186/s12891-020-03560-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 08/03/2020] [Indexed: 01/14/2023] Open
Abstract
Background Few studies compared the length change of ligaments of normal knees during dynamic activities of daily living. The aim of this study was to investigate in vivo length change of ligaments of the normal knees during high flexion. Methods Eight normal knees were investigated. Each volunteer performed squatting, kneeling, and cross-leg motions. Each sequential motion was performed under fluoroscopic surveillance in the sagittal plane. The femoral, tibial, and fibular attachment areas of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), deep medial collateral ligament (dMCL), superficial medial collateral ligament (sMCL), and lateral collateral ligament (LCL) were determined according to osseous landmarks. After 2D/3D registration, the direct distance from the femoral attachment to the tibial or fibular attachment was measured as the ligament length. Results From 20° to 90° with flexion, the ACL was significantly shorter during cross-leg motion than during squatting. For the PCL, dMCL, sMCL, and LCL, there were no significant differences among the 3 motions. Conclusion The ACL was shorter during cross-leg motion than during squatting in mid-flexion. This suggests that the ACL is looser during cross-leg motion than during squatting. On the other hand, the length change of the PCL, MCL, and LCL did not change even though the high flexion motions were different.
Collapse
Affiliation(s)
- Kenichi Kono
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Shoji Konda
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Takaharu Yamazaki
- Deapartment of Information Systems, Faculty of Engineering, Saitama Institute of Technology, 1690 Fusaiji, Fukaya, Saitama, 369-0293, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kazuomi Sugamoto
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Tetsuya Tomita
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| |
Collapse
|
32
|
Englander ZA, Spritzer CE, DeFrate LE. In vivo attachment site to attachment site length and strain of the ACL and its bundles during the full gait cycle measured by MRI and high-speed biplanar radiography: Response. J Biomech 2020; 109:109918. [PMID: 32660758 DOI: 10.1016/j.jbiomech.2020.109918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/19/2020] [Accepted: 06/21/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Zoë A Englander
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | | | - Louis E DeFrate
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, USA.
| |
Collapse
|
33
|
Englander ZA, Wittstein J, Goode AP, Garrett WE, DeFrate LE. Reconsidering Reciprocal Length Patterns of the Anteromedial and Posterolateral Bundles of the Anterior Cruciate Ligament During In Vivo Gait. Am J Sports Med 2020; 48:1893-1899. [PMID: 32515986 PMCID: PMC7693121 DOI: 10.1177/0363546520924168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Some cadaveric studies have indicated that the anterior cruciate ligament (ACL) consists of anteromedial and posterolateral bundles that display reciprocal function with regard to knee flexion. However, several in vivo imaging studies have suggested that these bundles elongate in parallel with regard to flexion. Furthermore, the most appropriate description of the functional anatomy of the ACL is still debated, with the ACL being described as consisting of 2 or 3 bundles or as a continuum of fibers. HYPOTHESIS As long as their origination and termination locations are defined within the ACL attachment site footprints, ACL bundles elongate in parallel with knee extension during gait. STUDY DESIGN Descriptive laboratory study. METHODS High-speed biplanar radiographs of the right knee joint were obtained during gait in 6 healthy male participants (mean ± SD: body mass index, 25.5 ± 1.2 kg/m2; age, 29.2 ± 3.8 years) with no history of lower extremity injury or surgery. Three-dimensional models of the right femur, tibia, and ACL attachment sites were created from magnetic resonance images. The bone models were registered to the biplanar radiographs, thereby reproducing the in vivo positions of the knee joint. For each knee position, the distances between the centroids of the ACL attachment sites were used to represent ACL length. The lengths of 1000 virtual bundles were measured for each participant by randomly sampling locations on the attachment site surfaces and measuring the distances between each pair of locations. Spearman rho rank correlations were performed between the virtual bundle lengths and ACL length. RESULTS The virtual bundle lengths were highly correlated with the length of the ACL, defined as the distance between the centroids of the attachment sites (rho = 0.91 ± 0.1, across participants; P < 5 × 10-5). The lengths of the bundles that originated and terminated in the anterior and medial aspects of the ACL were positively correlated (rho = 0.81 ± 0.1; P < 5 × 10-5) with the lengths of the bundles that originated and terminated in the posterior and lateral aspects of the ACL. CONCLUSION As long as their origination and termination points are specified within the footprint of the attachment sites, ACL bundles elongate in parallel as the knee is extended. CLINICAL RELEVANCE These data elucidate ACL functional anatomy and may help guide ACL reconstruction techniques.
Collapse
Affiliation(s)
- Zoë A. Englander
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Jocelyn Wittstein
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Adam P. Goode
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA,Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - William E. Garrett
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Louis E. DeFrate
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA,Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
| |
Collapse
|
34
|
Bachmaier S, DiFelice GS, Sonnery-Cottet B, Douoguih WA, Smith PA, Pace LJ, Ritter D, Wijdicks CA. Treatment of Acute Proximal Anterior Cruciate Ligament Tears-Part 1: Gap Formation and Stabilization Potential of Repair Techniques. Orthop J Sports Med 2020; 8:2325967119897421. [PMID: 32064293 PMCID: PMC6990615 DOI: 10.1177/2325967119897421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/16/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Recently, there has been a resurgence of interest in primary repair of the anterior cruciate ligament (ACL), with fixation techniques evolving. However, to date, there have been no biomechanical studies comparing fixed to adjustable fixation repair techniques. Hypothesis: Adjustable ACL repair provides for improved stabilization compared with fixed techniques with respect to both gap formation and residual load-bearing capability. Study Design: Controlled laboratory study. Methods: A total of 4 different ACL repair techniques (n = 5 per group), including single– and double–cinch loop (CL) cortical button fixation as well as knotless single–suture anchor fixation, were tested using a porcine model. For adjustable single-CL loop fixation, additional preconditioning (10 cycles at 0.5 Hz) was performed. The force after fixation and the actuator displacement to achieve a time-zero preload of 10 N were measured for fixed techniques. Incrementally increasing cycling (1 mm/500 cycles) from 1 to 8 mm was performed for 4000 cycles at 0.75 Hz before pull to failure (50 mm/min). The final residual peak load and gap formation for each test block were analyzed as well as ultimate strength. Results: Knot tying of a single-CL over a button (mean ± SD, 0.66 ± 0.23 mm) and knotless anchor fixation (0.20 ± 0.12 mm) resulted in significant time-zero gaps (P < .001) and significantly higher overall gap formation at reduced residual loading (analysis of covariance, P < .001) compared with both the double-CL loop and adjustable fixation techniques. The adjustable group showed the highest failure load and stiffness, at 305.7 N and 117.1 N/mm, respectively. The failure load of the knotted single-CL group was significantly reduced compared with all other groups (P < .001). Conclusion: Adjustable single-CL cortical button fixation with intraoperative preconditioning optimized time-zero ACL tension and led to significantly improved stabilization and reduced gap formation, with the highest ultimate strength. Single-CL loop knot tying over the button and knotless anchor fixation resulted in time-zero gaps to achieve slight tension on the ACL and significantly higher gap formation at reduced load-bearing capability. Clinical Relevance: Although the clinical relevance of gap formation is uncertain, a biomechanical understanding of the stabilization potential of current ACL repair techniques is pertinent to the continued evolution of surgical approaches to enable better clinical outcomes.
Collapse
Affiliation(s)
| | | | | | - Wiemi A Douoguih
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | | | - Lee J Pace
- Connecticut Children's Specialty Group, Hartford, Connecticut, USA
| | - Daniel Ritter
- Department of Orthopedic Research, Arthrex, Munich, Germany
| | | |
Collapse
|
35
|
Noonan BC, Bachmaier S, Wijdicks CA, Bedi A. Independent Suture Tape Reinforcement of Tripled Smaller-Diameter and Quadrupled Grafts for Anterior Cruciate Ligament Reconstruction With Tibial Screw Fixation: A Biomechanical Full Construct Model. Arthroscopy 2020; 36:481-489. [PMID: 31901386 DOI: 10.1016/j.arthro.2019.06.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 06/14/2019] [Accepted: 06/22/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the effect of independent suture tape reinforcement on the dynamic elongation and stiffness behavior as well as ultimate strength of tripled smaller-diameter and quadrupled soft-tissue grafts for anterior cruciate ligament reconstruction (ACLR) with tibial screw fixation in a biomechanical in vitro study. METHODS Tripled smaller-diameter (8 mm) and quadrupled (9 mm) bovine tendon grafts with and without suture tape reinforcement (n = 8 in each group) were tested using femoral suspensory and tibial interference screw fixation. The suture tape was femoral sided and fixed independent from the graft by passing it through the suspensory button and securing the 2 open tibial strands with a secondary interference screw. Dynamic testing was performed in position and force control at 250 N and 400 N, followed by pull to failure with the mode of failure noted. Dynamic elongation, stiffness, and ultimate strength were analyzed. RESULTS Tripled constructs showed a significantly worse structural performance than quadrupled constructs at higher loads. Reinforcement of tripled and quadrupled grafts substantially decreased total elongation by 56% (4.54 ± 0.75 mm vs 2.01 ± 0.50 mm, P < .001) and 39% (3.25 ± 0.49 mm vs 1.98 ± 0.51 mm, P < .001), respectively, by significantly increasing dynamic stiffness. No statistical significance was found between the reinforced groups. Failure loads of reinforced tripled (1,074 ± 148 N vs 829 ± 100 N, P = .003) and quadrupled (1,125 ± 157 N vs 939 ± 76 N, P = .023) grafts were also significantly improved. CONCLUSIONS Independent reinforcement of soft-tissue grafts with suture tape strengthened the performance especially of tripled smaller-diameter grafts for ACLR with tibial screw fixation by significantly improving dynamic elongation at increased stiffness and ultimate strength. Quadrupled reinforced grafts showed no over-constraining and structurally behaved similarly to tripled grafts with reinforcement. CLINICAL RELEVANCE Independent reinforcement for ACLR may provide an option for protecting autografts or allografts against irreversible lengthening during the maturation and remodeling phases of healing.
Collapse
Affiliation(s)
| | | | - Coen A Wijdicks
- Department of Orthopaedic Research, Arthrex, Munich, Germany.
| | - Asheesh Bedi
- MedSport and Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| |
Collapse
|
36
|
Bachmaier S, DiFelice GS, Sonnery-Cottet B, Douoguih WA, Smith PA, Pace LJ, Ritter D, Wijdicks CA. Treatment of Acute Proximal Anterior Cruciate Ligament Tears-Part 2: The Role of Internal Bracing on Gap Formation and Stabilization of Repair Techniques. Orthop J Sports Med 2020; 8:2325967119897423. [PMID: 32064294 PMCID: PMC6987493 DOI: 10.1177/2325967119897423] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 09/18/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The latest biomechanical studies on some form of internal bracing have shown improved stabilization for anterior cruciate ligament (ACL) repair, but gap formation and load-sharing function have not yet been reported. HYPOTHESIS Internal bracing of an adjustable ACL repair construct provides improved stabilization with reduced gap formation and higher residual loading on the ACL. STUDY DESIGN Controlled laboratory study. METHODS Internally braced ACL repair constructs with single- and double-cinch loop (CL) cortical buttons, a knotless suture anchor, and a single-CL cortical button with adjustable loop fixation (CLS-ALD) were tested (n = 20 each) in a porcine model at 4 different loads (n = 5 each) over 4000 cycles at 0.75 Hz (n = 80 total). The CLS-ALD technique allowed for additional preconditioning (10 cycles at 0.5 Hz). Test results of the isolated internal brace groups served as a baseline for comparison. Lastly, specimens were pulled to failure (50 mm/min) with a cut internal brace. Final loading and gap formation on the ACL repair construct as well as ultimate strength were analyzed. RESULTS A statistical significance for peak loads over peak elongation was found between the CLS-ALD and all other reinforced groups (analysis of covariance, P < .001). Accordingly, the adjustable repair technique showed improved load-bearing capability with the internal brace compared with all other fixed repair groups and revealed significantly higher loads than the knotted single-CL group. Also, significantly reduced gap formation was found for the CLS-ALD compared with all other groups (P < .001), with no gap formation up to 150 N with a final gap of 0.85 ± 0.31 mm at 350 N. A significantly higher ultimate failure load (866.2 ± 104.0 N; P < .001) was found for the button-fixed internal brace group compared with all other groups. CONCLUSION Internal bracing had a crucial role in improving the stabilization potential of ACL repair at loads occurring during normal daily activity. The added strength of the internal brace allowed for reducing peak loads on the ACL repair construct as well as restricting gap formation to below 3 mm at loads up to 350 N. CLINICAL RELEVANCE Improvements in the mechanical characteristics of current ACL repair techniques that enable reduced gap formation and allow for early range of motion and accelerated rehabilitation may strengthen the self-healing response with the formation of stable scar tissue.
Collapse
Affiliation(s)
| | | | | | - Wiemi A. Douoguih
- MedStar Washington Hospital Center, Washington, District of
Columbia, USA
| | | | - Lee J. Pace
- Connecticut Children’s Specialty Group, Hartford, Connecticut,
USA
| | - Daniel Ritter
- Department of Orthopedic Research, Arthrex, Munich, Germany
| | | |
Collapse
|
37
|
Englander ZA, Baldwin EL, Smith WA, Garrett WE, Spritzer CE, DeFrate LE. In Vivo Anterior Cruciate Ligament Deformation During a Single-Legged Jump Measured by Magnetic Resonance Imaging and High-Speed Biplanar Radiography. Am J Sports Med 2019; 47:3166-3172. [PMID: 31593498 PMCID: PMC7042957 DOI: 10.1177/0363546519876074] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The in vivo mechanics of the anterior cruciate ligament (ACL) and its bundles during dynamic activities are not completely understood. An improved understanding of how the ACL stabilizes the knee is likely to aid in the identification and prevention of injurious maneuvers. PURPOSE/HYPOTHESIS The purpose was to measure in vivo ACL strain during a single-legged jump through use of magnetic resonance imaging (MRI) and high-speed biplanar radiography. We hypothesized that ACL strain would increase with the knee near extension, and a peak in ACL strain would occur just before landing from the jump, potentially due to quadriceps contraction in anticipation of landing. STUDY DESIGN Descriptive laboratory study. METHODS Models of the femur, tibia, and ACL attachment sites of 8 male participants were generated from MRI scans through use of solid modeling. High-speed biplanar radiographs were obtained from these participants as they performed a single-legged jump. The bone models were registered to the biplanar radiographs, thereby reproducing the in vivo positions of the joint throughout the jump. ACL and bundle elongations were defined as the centroid to centroid distances between attachment sites for each knee position. ACL strain was defined as ACL length normalized to its length measured in the position of the knee at the time of MRI. RESULTS Peaks in ACL strain were observed before toe-off and 55 ± 35 milliseconds before initial ground contact. These peaks were associated with the knee positioned at low flexion angles. Mean ACL strain was inversely related to mean flexion angle (rho = -0.73, P < .001), such that ACL strain generally increased with knee extension throughout the jumping motion. ACL bundle lengths were significantly (rho > 0.85, P < .001) correlated with overall ACL length. CONCLUSION These findings provide insight into how landing in extension can increase the risk of ACL injury. Specifically, this study shows that peak ACL strain can occur just before landing from a single-legged jump. Thus, when an individual lands on an extended knee, the ACL is relatively taut, which may make it particularly vulnerable to injury, especially in the presence of a movement perturbation or unanticipated change in landing strategy. CLINICAL RELEVANCE This study provides a novel measurement of dynamic ACL strain during an athletic maneuver and lends insight into how landing in extension can increase the likelihood of ACL failure.
Collapse
Affiliation(s)
- Zoë A. Englander
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Edward L. Baldwin
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Wyatt A.R. Smith
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - William E. Garrett
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | | | - Louis E. DeFrate
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA,Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
| |
Collapse
|
38
|
Englander ZA, Garrett WE, Spritzer CE, DeFrate LE. In vivo attachment site to attachment site length and strain of the ACL and its bundles during the full gait cycle measured by MRI and high-speed biplanar radiography. J Biomech 2019; 98:109443. [PMID: 31679755 DOI: 10.1016/j.jbiomech.2019.109443] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to measure in vivo attachment site to attachment site lengths and strains of the anterior cruciate ligament (ACL) and its bundles throughout a full cycle of treadmill gait. To obtain these measurements, models of the femur, tibia, and associated ACL attachment sites were created from magnetic resonance (MR) images in 10 healthy subjects. ACL attachment sites were subdivided into anteromedial (AM) and posterolateral (PL) bundles. High-speed biplanar radiographs were obtained as subjects ambulated at 1 m/s. The bone models were registered to the radiographs, thereby reproducing the in vivo positions of the bones and ACL attachment sites throughout gait. The lengths of the ACL and both bundles were estimated as straight line distances between attachment sites for each knee position. Increased attachment to attachment ACL length and strain were observed during midstance (length = 28.5 ± 2.6 mm, strain = 5 ± 4%, mean ± standard deviation), and heel strike (length = 30.5 ± 3.0 mm, strain = 12 ± 5%) when the knee was positioned at low flexion angles. Significant inverse correlations were observed between mean attachment to attachment ACL lengths and flexion (rho = -0.87, p < 0.001), as well as both bundle lengths and flexion (rho = -0.86, p < 0.001 and rho = -0.82, p < 0.001, respectively). AM and PL bundle attachment to attachment lengths were highly correlated throughout treadmill gait (rho = 0.90, p < 0.001). These data can provide valuable information to inform design criteria for ACL grafts used in reconstructive surgery, and may be useful in the design of rehabilitation and injury prevention protocols.
Collapse
Affiliation(s)
- Zoë A Englander
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | | | | | - Louis E DeFrate
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, USA.
| |
Collapse
|
39
|
Shultz SJ, Schmitz RJ, Cameron KL, Ford KR, Grooms DR, Lepley LK, Myer GD, Pietrosimone B. Anterior Cruciate Ligament Research Retreat VIII Summary Statement: An Update on Injury Risk Identification and Prevention Across the Anterior Cruciate Ligament Injury Continuum, March 14-16, 2019, Greensboro, NC. J Athl Train 2019; 54:970-984. [PMID: 31461312 PMCID: PMC6795093 DOI: 10.4085/1062-6050-54.084] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sandra J. Shultz
- Applied Neuromechanics Research Laboratory, University of North Carolina at Greensboro
| | - Randy J. Schmitz
- Applied Neuromechanics Research Laboratory, University of North Carolina at Greensboro
| | - Kenneth L. Cameron
- John A. Feagin Jr Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, West Point, NY
| | - Kevin R. Ford
- Human Biomechanics and Physiology Laboratory, Department of Physical Therapy, High Point University, NC
| | - Dustin R. Grooms
- Ohio Musculoskeletal & Neurological Institute and Division of Athletic Training, School of Applied Health Sciences and Wellness, College of Health Sciences and Professions, Ohio University, Athens
| | | | - Gregory D. Myer
- The SPORT Center, Division of Sports Medicine, and Departments of Pediatrics and Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, OH
| | - Brian Pietrosimone
- MOTION Science Institute, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| |
Collapse
|
40
|
Nagai K, Gale T, Chiba D, Su F, Fu FH, Anderst W. The Complex Relationship Between In Vivo ACL Elongation and Knee Kinematics During Walking and Running. J Orthop Res 2019; 37:1920-1928. [PMID: 31042309 PMCID: PMC6719793 DOI: 10.1002/jor.24330] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/23/2019] [Indexed: 02/04/2023]
Abstract
In vivo anterior cruciate ligament (ACL) bundle (anteromedial bundle [AMB] and posterolateral bundle [PLB]) relative elongation during walking and running remain unknown. In this study, we aimed to investigate in vivo ACL relative elongation over the full gait cycle during walking and running. Ten healthy volunteers walked and ran at a self-selected pace on an instrumented treadmill while biplane radiographs of the knee were acquired at 100 Hz (walking) and 150 Hz (running). Tibiofemoral kinematics were determined using a validated model-based tracking process. The boundaries of ACL insertions were identified using high-resolution magnetic resonance imaging (MRI). The AMB and PLB centroid-to-centroid distances were calculated from the tracked bone motions, and these bundle lengths were normalized to their respective lengths on MRI to calculate relative elongation. Maximum AMB relative elongation during running (6.7 ± 2.1%) was significantly greater than walking (5.0 ± 1.7%, p = 0.043), whereas the maximum PLB relative elongation during running (1.1 ± 2.1%) was significantly smaller than walking (3.4 ± 2.3%, p = 0.014). During running, the maximum AMB relative elongation was significantly greater than the maximum PLB relative elongation (p < 0.001). ACL relative elongations were correlated with tibiofemoral six degree-of-freedom kinematics. The AMB and PLB demonstrate similar elongation patterns but different amounts of relative elongation during walking and running. The complex relationship observed between ACL relative elongation and knee kinematics indicates that ACL relative elongation is impacted by tibiofemoral kinematic parameters in addition to flexion/extension. These findings suggest that ACL strain is region-specific during walking and running. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1920-1928, 2019.
Collapse
Affiliation(s)
- Kanto Nagai
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daisuke Chiba
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Favian Su
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H. Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William Anderst
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
41
|
Davis DJ, Hinshaw TJ, Critchley ML, Dai B. Mid-flight trunk flexion and extension altered segment and lower extremity joint movements and subsequent landing mechanics. J Sci Med Sport 2019; 22:955-961. [DOI: 10.1016/j.jsams.2019.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/09/2019] [Accepted: 03/03/2019] [Indexed: 01/13/2023]
|
42
|
Kernkamp WA, Jens AJT, Varady NH, van Arkel ERA, Nelissen RGHH, Asnis PD, LaPrade RF, Van de Velde SK, Li G. Anatomic is better than isometric posterior cruciate ligament tunnel placement based upon in vivo simulation. Knee Surg Sports Traumatol Arthrosc 2019; 27:2440-2449. [PMID: 30367194 DOI: 10.1007/s00167-018-5233-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 10/17/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE To elucidate the effects of various tibial and femoral attachment locations on the theoretical length changes and isometry of PCL grafts in healthy knees during in vivo weightbearing motion. METHODS The intact knees of 14 patients were imaged using a combined magnetic resonance and dual fluoroscopic imaging technique while the patient performed a quasi-static lunge (0°-120° of flexion). The theoretical end-to-end distances of the 3-dimensional wrapping paths between 165 femoral attachments, including the anatomic anterolateral bundle (ALB), central attachment and posteromedial bundle (PMB) of the PCL, connected to an anterolateral, central, and posteromedial tibial attachment were simulated and measured. A descriptive heatmap was created to demonstrate the length changes on the medial condyle and formal comparisons were made between the length changes of the anatomic PCL and most isometric grafts. RESULTS The most isometric graft, with approximately 3% length change between 0° and 120° of flexion, was located proximal to the anatomic femoral PCL attachments. Grafts with femoral attachments proximal to the isometric zone decreased in length with increasing flexion angles, whereas grafts with more distal attachments increased in length with increasing flexion angles. The ALB and central single-bundle graft demonstrated a significant elongation from 0° to 120° of flexion (p < 0.001). The PMB decreased in length between 0° and 60° of flexion after which the bundle increased in length to its maximum length at 120° (p < 0.001). No significant differences in length changes were found between either the ALB or PMB and the central graft, and between the ALB and PMB at flexion angles ≥ 60° (n.s.). CONCLUSIONS The most isometric attachment was proximal to the anatomic PCL footprint and resulted in non-physiological length changes. Moving the femoral attachment locations of the PCL significantly affected length change patterns, whereas moving the tibia locations did not. The importance of anatomically positioned (i.e., distal to the isometric area) femoral PCL reconstruction locations to replicate physiological length changes is highlighted. These data can be used to optimize tunnel positioning in either single- or double-bundle and primary or revision PCL reconstruction cases. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Willem A Kernkamp
- Bioengineering Laboratory, Newton-Wellesley Hospital, Newton, MA, 02462, USA.,Sports Medicine Center, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.,Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Axel J T Jens
- Bioengineering Laboratory, Newton-Wellesley Hospital, Newton, MA, 02462, USA.,Focus Clinic Orthopedic Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Nathan H Varady
- Bioengineering Laboratory, Newton-Wellesley Hospital, Newton, MA, 02462, USA.,Sports Medicine Center, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Ewoud R A van Arkel
- Focus Clinic Orthopedic Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Rob G H H Nelissen
- Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter D Asnis
- Sports Medicine Center, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | | | - Samuel K Van de Velde
- Division of Pediatric Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Guoan Li
- Bioengineering Laboratory, Newton-Wellesley Hospital, Newton, MA, 02462, USA.
| |
Collapse
|
43
|
Cone SG, Howe D, Fisher MB. Size and Shape of the Human Anterior Cruciate Ligament and the Impact of Sex and Skeletal Growth: A Systematic Review. JBJS Rev 2019; 7:e8. [PMID: 31246862 DOI: 10.2106/jbjs.rvw.18.00145] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND High rates of anterior cruciate ligament (ACL) injury and surgical reconstruction in both skeletally immature and mature populations have led to many studies investigating the size and shape of the healthy ligament. The purposes of the present study were to compile existing quantitative measurements of the geometry of the ACL, its bundles, and its insertion sites and to describe effects of common covariates such as sex and age. METHODS A search of the Web of Science was conducted for studies published from January 1, 1900, to April 11, 2018, describing length, cross-sectional area, volume, orientation, and insertion sites of the ACL. Two reviewers independently screened and reviewed the articles to collect quantitative data for each parameter. RESULTS Quantitative data were collected from 92 articles in this systematic review. In studies of adults, reports of average ACL length, cross-sectional area, and volume ranged from 26 to 38 mm, 30 to 53 mm, and 854 to 1,858 mm, respectively. Reported values were commonly found to vary according to sex and skeletal maturity as well as measurement technique. CONCLUSIONS Although the geometry of the ACL has been described widely in the literature, quantitative measurements can depend on sex, age, and measurement modality, contributing to variability between studies. As such, care must be taken to account for these factors. The present study condenses measurements describing the geometry of the ACL, its individual bundles, and its insertion sites, accounting for common covariates when possible, to provide a resource to the clinical and scientific communities. CLINICAL RELEVANCE Quantitative measures of ACL geometry are informative for developing clinical treatments such as ACL reconstruction. Age and sex can impact these parameters.
Collapse
Affiliation(s)
- Stephanie G Cone
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Danielle Howe
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Matthew B Fisher
- Joint Department of Biomedical Engineering, North Carolina State University and the University of North Carolina-Chapel Hill, Raleigh, North Carolina.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina.,Department of Orthopaedics, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
44
|
Dai B, Garrett WE, Gross MT, Padua DA, Queen RM, Yu B. The effect of performance demands on lower extremity biomechanics during landing and cutting tasks. JOURNAL OF SPORT AND HEALTH SCIENCE 2019; 8:228-234. [PMID: 31193278 PMCID: PMC6523039 DOI: 10.1016/j.jshs.2016.11.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 04/29/2016] [Accepted: 08/01/2016] [Indexed: 06/09/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) injuries commonly occur during the early phase of landing and cutting tasks that involve sudden decelerations. The purpose of this study was to investigate the effects of jump height and jump speed on lower extremity biomechanics during a stop-jump task and the effect of cutting speed on lower extremity biomechanics during a side-cutting task. METHODS Thirty-six recreational athletes performed a stop-jump task under 3 conditions: jumping fast, jumping for maximum height, and jumping for 60% of maximum height. Participants also performed a side-cutting task under 2 conditions: cutting at maximum speed and cutting at 60% of maximum speed. Three-dimensional kinematic and kinetic data were collected. RESULTS The jumping fast condition resulted in increased peak posterior ground reaction force (PPGRF), knee extension moment at PPGRF, and knee joint stiffness and decreased knee flexion angle compared with the jumping for maximum height condition. The jumping for 60% of maximum height condition resulted in decreased knee flexion angle compared with the jumping for maximum height condition. Participants demonstrated greater PPGRF, knee extension moment at PPGRF, knee valgus angle and varus moment at PPGRF, knee joint stiffness, and knee flexion angle during the cutting at maximum speed condition compared with the cutting at 60% maximum speed condition. CONCLUSION Performing jump landing at an increased jump speed resulted in lower extremity movement patterns that have been previously associated with an increase in ACL loading. Cutting speed also affected lower extremity biomechanics. Jump speed and cutting speed need to be considered when designing ACL injury risk screening and injury prevention programs.
Collapse
Affiliation(s)
- Boyi Dai
- Division of Kinesiology and Health, University of Wyoming, Laramie, WY 82070, USA
| | - William E. Garrett
- Department of Orthopaedic Surgery, Duke University, Durham, NC 27710, USA
| | - Michael T. Gross
- Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Darin A. Padua
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Robin M. Queen
- Kevin Granata Biomechanics Lab, Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA 24061, USA
| | - Bing Yu
- Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| |
Collapse
|
45
|
In vivo assessment of the interaction of patellar tendon tibial shaft angle and anterior cruciate ligament elongation during flexion. J Biomech 2019; 90:123-127. [PMID: 31072596 DOI: 10.1016/j.jbiomech.2019.04.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/05/2019] [Accepted: 04/21/2019] [Indexed: 12/19/2022]
Abstract
A potential cause of non-contact anterior cruciate ligament (ACL) injury is landing on an extended knee. In line with this hypothesis, studies have shown that the ACL is elongated with decreasing knee flexion angle. Furthermore, at low flexion angles the patellar tendon is oriented to increase the anterior shear component of force acting on the tibia. This indicates that knee extension represents a position in which the ACL is taut, and thus may have an increased propensity for injury, particularly in the presence of excessive force acting via the patellar tendon. However, there is very little in vivo data to describe how patellar tendon orientation and ACL elongation interact during flexion. Therefore, this study measured the patellar tendon tibial shaft angle (indicative of the relative magnitude of the shear component of force acting via the patellar tendon) and ACL length in vivo as subjects performed a quasi-static lunge at varying knee flexion angles. Spearman rho rank correlations within each individual revealed that flexion angles were inversely correlated to both ACL length (rho = -0.94 ± 0.07, mean ± standard deviation, p < 0.05) and patellar tendon tibial shaft angle (rho = -0.99 ± 0.01, p < 0.05). These findings indicate that when the knee is extended, the ACL is both elongated and the patellar tendon tibial shaft angle is increased, resulting in a relative increase in anterior shear force on the tibia acting via the patellar tendon. Therefore, these data support the hypothesis that landing with the knee in extension is a high risk scenario for ACL injury.
Collapse
|
46
|
Englander ZA, Cutcliffe HC, Utturkar GM, Garrett WE, Spritzer CE, DeFrate LE. A Comparison of Knee Abduction Angles Measured by a 3D Anatomic Coordinate System Versus Videographic Analysis: Implications for Anterior Cruciate Ligament Injury. Orthop J Sports Med 2019; 7:2325967118819831. [PMID: 30729143 PMCID: PMC6350144 DOI: 10.1177/2325967118819831] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background Knee positions involved in noncontact anterior cruciate ligament (ACL) injury have been studied via analysis of injury videos. Positions of high ACL strain have been identified in vivo. These methods have supported different hypotheses regarding the role of knee abduction in ACL injury. Purpose/Hypothesis The purpose of this study was to compare knee abduction angles measured by 2 methods: using a 3-dimensional (3D) coordinate system based on anatomic features of the bones versus simulated 2-dimensional (2D) videographic analysis. We hypothesized that knee abduction angles measured in a 2D videographic analysis would differ from those measured from 3D bone anatomic features and that videographic knee abduction angles would depend on flexion angle and on the position of the camera relative to the patient. Study Design Descriptive laboratory study. Methods Models of the femur and tibia were created from magnetic resonance images of 8 healthy male participants. The models were positioned to match biplanar fluoroscopic images obtained as participants posed in lunges of varying flexion angles (FLAs). Knee abduction angle was calculated from the positioned models in 2 ways: (1) varus-valgus angle (VVA), defined as the angle between the long axis of the tibia and the femoral transepicondylar axis by use of a 3D anatomic coordinate system; and (2) coronal plane angle (CPA), defined as the angle between the long axis of the tibia and the long axis of the femur projected onto the tibial coronal plane to simulate a 2D videographic analysis. We then simulated how changing the position of the camera relative to the participant would affect knee abduction angles. Results During flexion, when CPA was calculated from a purely anterior or posterior view of the joint-an ideal scenario for measuring knee abduction from 2D videographic analysis-CPA was significantly different from VVA (P < .0001). CPA also varied substantially with the position of the camera relative to the participant. Conclusion How closely CPA (derived from 2D videographic analysis) relates to VVA (derived from a 3D anatomic coordinate system) depends on FLA and camera orientation. Clinical Relevance This study provides a novel comparison of knee abduction angles measured from 2D videographic analysis and those measured within a 3D anatomic coordinate system. Consideration of these findings is important when interpreting 2D videographic data regarding knee abduction angle in ACL injury.
Collapse
Affiliation(s)
- Zoë A Englander
- Department of Orthopaedics, Duke University, Durham, North Carolina, USA.,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | - Hattie C Cutcliffe
- Department of Orthopaedics, Duke University, Durham, North Carolina, USA.,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | | | - William E Garrett
- Department of Orthopaedics, Duke University, Durham, North Carolina, USA
| | | | - Louis E DeFrate
- Department of Orthopaedics, Duke University, Durham, North Carolina, USA.,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.,Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
| |
Collapse
|
47
|
Sinclair J, Brooks D, Stainton P. Sex differences in ACL loading and strain during typical athletic movements: a musculoskeletal simulation analysis. Eur J Appl Physiol 2019; 119:713-721. [PMID: 30610444 DOI: 10.1007/s00421-018-04062-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/21/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE Female athletes experience anterior cruciate ligament (ACL) injuries at a much greater rate than males, yet the mechanisms responsible for this are not well-understood. The current investigation aimed using a musculoskeletal simulation-based approach, to examine sex differences in ACL loading parameters during cut and hop movements. METHODS Fifteen male and fifteen female participants completed 45° cut and maximal one legged hop movements. Three-dimensional motion capture and ground reaction force data during the stance phase of the cut movement and landing phase of the one legged hop were obtained. Lower extremity muscle forces, ACL forces and ACL strains were extracted via a simulation-based approach using a musculoskeletal model, with an ACL insertion into the femur and tibia. RESULTS During the hop movement, females were associated with significantly greater peak ACL forces (male = 15.01 N/kg and female = 15.70 N/kg) and strains (male = 6.87% and female = 10.74%). In addition, for both the cut (male = 4.45 and female = 1.45) and hop (male = 2.04 and female = 1.46) movements, the soleus/gastrocnemius ratio was significantly larger in males. CONCLUSIONS The current investigation provides new information regarding sex differences during athletic movements that provide further insight regarding the increased incidence of ACL injuries in females.
Collapse
Affiliation(s)
- Jonathan Sinclair
- Centre for Applied Sport and Exercise Sciences, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, PR1 2HE, UK.
| | - Darrell Brooks
- School of Medicine, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Lancashire, UK
| | - Philip Stainton
- Centre for Applied Sport and Exercise Sciences, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, PR1 2HE, UK
| |
Collapse
|
48
|
Sutter EG, Liu B, Utturkar GM, Widmyer MR, Spritzer CE, Cutcliffe HC, Englander ZA, Goode AP, Garrett WE, DeFrate LE. Effects of Anterior Cruciate Ligament Deficiency on Tibiofemoral Cartilage Thickness and Strains in Response to Hopping. Am J Sports Med 2019; 47:96-103. [PMID: 30365903 PMCID: PMC6559720 DOI: 10.1177/0363546518802225] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Changes in knee kinematics after anterior cruciate ligament (ACL) injury may alter loading of the cartilage and thus affect its homeostasis, potentially leading to the development of posttraumatic osteoarthritis. However, there are limited in vivo data to characterize local changes in cartilage thickness and strain in response to dynamic activity among patients with ACL deficiency. PURPOSE/HYPOTHESIS The purpose was to compare in vivo tibiofemoral cartilage thickness and cartilage strain resulting from dynamic activity between ACL-deficient and intact contralateral knees. It was hypothesized that ACL-deficient knees would show localized reductions in cartilage thickness and elevated cartilage strains. STUDY DESIGN Controlled laboratory study. METHODS Magnetic resonance images were obtained before and after single-legged hopping on injured and uninjured knees among 8 patients with unilateral ACL rupture. Three-dimensional models of the bones and articular surfaces were created from the pre- and postactivity scans. The pre- and postactivity models were registered to each other, and cartilage strain (defined as the normalized difference in cartilage thickness pre- and postactivity) was calculated in regions across the tibial plateau, femoral condyles, and femoral cartilage adjacent to the medial intercondylar notch. These measurements were compared between ACL-deficient and intact knees. Differences in cartilage thickness and strain between knees were tested with multiple analysis of variance models with alpha set at P < .05. RESULTS Compressive strain in the intercondylar notch was elevated in the ACL-deficient knee relative to the uninjured knee. Furthermore, cartilage in the intercondylar notch and adjacent medial tibia was significantly thinner before activity in the ACL-deficient knee versus the intact knee. In these 2 regions, thinning was significantly influenced by time since injury, with patients with more chronic ACL deficiency (>1 year since injury) experiencing greater thinning. CONCLUSION Among patients with ACL deficiency, the medial femoral condyle adjacent to the intercondylar notch in the ACL-deficient knee exhibited elevated cartilage strain and loss of cartilage thickness, particularly with longer time from injury. It is hypothesized that these changes may be related to posttraumatic osteoarthritis development. CLINICAL RELEVANCE This study suggests that altered mechanical loading is related to localized cartilage thinning after ACL injury.
Collapse
Affiliation(s)
- E. Grant Sutter
- Department of Orthopaedic Surgery, Duke University, Durham,
NC
| | - Betty Liu
- Department of Biomedical Engineering, Duke University,
Durham, NC
| | | | | | | | | | - Zoë A. Englander
- Department of Biomedical Engineering, Duke University,
Durham, NC
| | - Adam P. Goode
- Department of Orthopaedic Surgery, Duke University, Durham,
NC
| | | | - Louis E. DeFrate
- Department of Orthopaedic Surgery, Duke University, Durham,
NC,Department of Biomedical Engineering, Duke University,
Durham, NC,Department of Mechanical Engineering and Materials Science,
Duke University, Durham, NC
| |
Collapse
|
49
|
Activities of daily living influence tibial cartilage T1rho relaxation times. J Biomech 2018; 82:228-233. [PMID: 30455059 DOI: 10.1016/j.jbiomech.2018.10.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 09/06/2018] [Accepted: 10/23/2018] [Indexed: 12/20/2022]
Abstract
Quantitative T1rho magnetic resonance imaging (MRI) can potentially help identify early-stage osteoarthritis (OA) by non-invasively assessing proteoglycan concentration in articular cartilage. T1rho relaxation times are negatively correlated with proteoglycan concentration. Cartilage compresses in response to load, resulting in water exudation, a relative increase in proteoglycan concentration, and a decrease in the corresponding T1rho relaxation times. To date, there is limited information on changes in cartilage composition resulting from daily activity. Therefore, the objective of this study was to quantify changes in tibial cartilage T1rho relaxation times in healthy human subjects following activities of daily living. It was hypothesized that water exudation throughout the day would lead to decreased T1rho relaxation times. Subjects underwent MR imaging in the morning and afternoon on the same day and were free to go about their normal activities between scans. Our findings confirmed the hypothesis that tibial cartilage T1rho relaxation times significantly decreased (by 7%) over the course of the day with loading, which is indicative of a relative increase in proteoglycan concentration. Additionally, baseline T1rho values varied with position within the cartilage, supporting a need for site-specific measurements of T1rho relaxation times. Understanding how loading alters the proteoglycan concentration in healthy cartilage may hold clinical significance pertaining to cartilage homeostasis and potentially help to elucidate a mechanism for OA development. These results also indicate that future studies using T1rho relaxation times as an indicator of cartilage health should control the loading history prior to image acquisition to ensure the appropriate interpretation of the data.
Collapse
|
50
|
Collins AT, Kulvaranon ML, Cutcliffe HC, Utturkar GM, Smith WAR, Spritzer CE, Guilak F, DeFrate LE. Obesity alters the in vivo mechanical response and biochemical properties of cartilage as measured by MRI. Arthritis Res Ther 2018; 20:232. [PMID: 30333058 PMCID: PMC6235204 DOI: 10.1186/s13075-018-1727-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/19/2018] [Indexed: 01/17/2023] Open
Abstract
Background Obesity is a primary risk factor for the development of knee osteoarthritis (OA). However, there remains a lack of in vivo data on the influence of obesity on knee cartilage mechanics and composition. The purpose of this study was to determine the relationship between obesity and tibiofemoral cartilage properties. Methods Magnetic resonance images (3T) of cartilage geometry (double-echo steady-state) and T1rho relaxation of the knee were obtained in healthy subjects with a normal (n = 8) or high (n = 7) body mass index (BMI) before and immediately after treadmill walking. Subjects had no history of lower limb injury or surgery. Bone and cartilage surfaces were segmented and three-dimensional models were created to measure cartilage thickness and strain. T1rho relaxation times were measured before exercise in both the tibial and femoral cartilage in order to characterize biochemical composition. Body fat composition was also measured. Results Subjects with a high BMI exhibited significantly increased tibiofemoral cartilage strain and T1rho relaxation times (P <0.05). Tibial pre-exercise cartilage thickness was also affected by BMI (P <0.05). Correlational analyses revealed that pre-exercise tibial cartilage thickness decreased with increasing BMI (R2 = 0.43, P <0.01) and body fat percentage (R2 = 0.58, P <0.01). Tibial and femoral cartilage strain increased with increasing BMI (R2 = 0.45, P <0.01; R2 = 0.51, P <0.01, respectively) and increasing body fat percentage (R2 = 0.40, P <0.05; R2 = 0.38, P <0.05, respectively). Additionally, tibial T1rho was positively correlated with BMI (R2 = 0.39, P <0.05) and body fat percentage (R2 = 0.47, P <0.01). Conclusions Strains and T1rho relaxation times in the tibiofemoral cartilage were increased in high BMI subjects compared with normal BMI subjects. Additionally, pre-exercise tibial cartilage thickness decreased with obesity. Reduced proteoglycan content may be indicative of pre-symptomatic osteoarthritic degeneration, resulting in reduced cartilage thickness and increased deformation of cartilage in response to loading.
Collapse
Affiliation(s)
- Amber T Collins
- Department of Orthopaedic Surgery, Duke University, Box 3093, Duke University Medical Center, Durham, NC, 27710, USA
| | - Micaela L Kulvaranon
- Department of Orthopaedic Surgery, Duke University, Box 3093, Duke University Medical Center, Durham, NC, 27710, USA
| | - Hattie C Cutcliffe
- Department of Orthopaedic Surgery, Duke University, Box 3093, Duke University Medical Center, Durham, NC, 27710, USA.,Department of Biomedical Engineering, Duke University, Campus Box 90281, 101 Science Drive, Durham, 27708, NC, USA
| | - Gangadhar M Utturkar
- Department of Orthopaedic Surgery, Duke University, Box 3093, Duke University Medical Center, Durham, NC, 27710, USA
| | - Wyatt A R Smith
- Department of Orthopaedic Surgery, Duke University, Box 3093, Duke University Medical Center, Durham, NC, 27710, USA
| | - Charles E Spritzer
- Department of Radiology, Duke University, Box 3808, Duke University Medical Center, Durham, 27710, NC, USA
| | - Farshid Guilak
- Department of Orthopaedic Surgery, Washington University and Shriners Hospitals for Children, Campus Box 8233, Couch Research Building, Room 3121, St. Louis, 63110, MO, USA
| | - Louis E DeFrate
- Department of Orthopaedic Surgery, Duke University, Box 3093, Duke University Medical Center, Durham, NC, 27710, USA. .,Department of Biomedical Engineering, Duke University, Campus Box 90281, 101 Science Drive, Durham, 27708, NC, USA. .,Department of Mechanical Engineering and Materials Science, Duke University, Campus Box 90300, Hudson Hall, Durham, 27708, NC, USA.
| |
Collapse
|