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Heusdens CHW, Zazulia K, Roelant E, Dossche L, van Tiggelen D, Roeykens J, Smits E, Vanlauwe J, Van Dyck P. Study protocol: a single-blind, multi-center, randomized controlled trial comparing dynamic intraligamentary stabilization, internal brace ligament augmentation and reconstruction in individuals with an acute anterior cruciate ligament rupture: LIBRƎ study. BMC Musculoskelet Disord 2019; 20:547. [PMID: 31739784 PMCID: PMC6862787 DOI: 10.1186/s12891-019-2926-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/31/2019] [Indexed: 01/15/2023] Open
Abstract
Background The current gold standard for the treatment of an anterior cruciate ligament (ACL) rupture is reconstruction with tendon graft. Recently, two surgical ACL repair techniques have been developed for treating an acute ACL rupture: Dynamic Intraligamentary Stabilization (DIS, Ligamys®) and Internal Brace Ligament Augmentation (IBLA, InternalBrace™). We will conduct a single-blind, multi-center, randomized controlled trial which compares DIS, IBLA and reconstruction for relative clinical efficacy and economic benefit. Methods Subjects, aged 18–50 years, with a proximal, primary and repairable ACL rupture will be included. DIS is preferably performed within 4 weeks post-rupture, IBLA within 12 weeks and reconstruction after 4 weeks post-rupture. Patients are included in study 1 if they present within 0–4 weeks post-rupture and surgery is feasible within 4 weeks post-rupture. Patients of study 1 will be randomized to either DIS or IBLA. Patients are included in study 2 if they present after 4 weeks post-rupture and surgery is feasible between 5 and 12 weeks post-rupture. Patients of study 2 will be randomized to either IBLA or reconstruction. A total of 96 patients will be included, with 48 patients per study and 24 patients per study arm. Patients will be followed-up for 2 years. The primary outcome is change from baseline (pre-rupture) in International Knee Documentation Committee score to 6 months post-operatively. The main secondary outcomes are the EQ-5D-5 L, Tegner score, Lysholm score, Lachman test, isokinetic and proprioceptive measurements, magnetic resonance imaging outcome, return to work and sports, and re-rupture/failure rates. The statistical analysis will be based on the intention-to-treat principle. The economic impact of the surgery techniques will be evaluated by the cost-utility analysis. The LIBRƎ study is to be conducted between 2018 and 2022. Discussion This LIBRƎ study protocol is the first study to compare DIS, IBLA and ACL reconstruction for relative clinical efficacy and economic benefit. The outcomes of this study will provide data which could aid orthopaedic surgeons to choose between the different treatment options for the surgical treatment of an acute ACL rupture. Trial registration This study is registered at ClinicalTrials.gov; NCT03441295. Date registered 13.02.2018.
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Affiliation(s)
- Christiaan H W Heusdens
- Department of Orthopaedics, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.
| | - Katja Zazulia
- Department of Orthopaedics, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Ella Roelant
- Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Lieven Dossche
- Department of Orthopaedics, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Damien van Tiggelen
- Department of Traumatology and Rehabilitation, Queen Astrid Military Hospital, Bruynstraat 1, 1120, Neder-Over-Heembeek, Belgium
| | - Johan Roeykens
- Department of Rehabilitation, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Elke Smits
- Department of Medical management, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Johan Vanlauwe
- Department of Orthopaedics and Traumatology, University Hospital Brussels, Laarbeeklaan 101, 1090, Jette, Belgium
| | - Pieter Van Dyck
- Department of Radiology, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
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Bierbaum M, Schöffski O, Schliemann B, Kösters C. Cost-utility analysis of dynamic intraligamentary stabilization versus early reconstruction after rupture of the anterior cruciate ligament. HEALTH ECONOMICS REVIEW 2017; 7:8. [PMID: 28168633 PMCID: PMC5293706 DOI: 10.1186/s13561-017-0143-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/06/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the cost-effectiveness of the dynamic intraligamentary stabilization (DIS) technique in comparison with reconstructive surgery (ACLR) in the treatment of isolated anterior cruciate ligament (ACL) ruptures from the perspective of the community of insured citizens in Germany. METHODS Because of the specific decision problem at hand, namely that with DIS the procedure has to take place within 21 days after the initial trauma, a decision tree was developed. The time horizon of the model was set to 3 years. Input data was taken from official tariffs, payer data, the literature and assumptions based on expert opinion when necessary. RESULTS The decision tree analysis identified the DIS strategy as the superior one with 2.34 QALY versus 2.26 QALY for the ACLR branch. The higher QALY also came with higher costs of 5,398.05 € for the DIS branch versus 4,632.68 € for the ACLR branch respectively, leading to an ICER of 9,092.66 € per QALY. Results were robust after sensitivity analysis. Uncertainty was examined via probabilistic sensitivity analysis resulting in a slightly higher ICER of 9,567.13 € per QALY gained. CONCLUSION The DIS technology delivers an effective treatment for the ACL rupture at a favorable incremental cost-effectiveness ratio.
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Affiliation(s)
- Martin Bierbaum
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Nuremberg, Germany
| | - Oliver Schöffski
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Nuremberg, Germany
| | - Benedikt Schliemann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Clemens Kösters
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Sonesson S, Kvist J. Dynamic and static tibial translation in patients with anterior cruciate ligament deficiency initially treated with a structured rehabilitation protocol. Knee Surg Sports Traumatol Arthrosc 2017. [PMID: 26210960 DOI: 10.1007/s00167-015-3714-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE To compare dynamic and static tibial translation, in patients with anterior cruciate ligament deficiency, at 2- to 5-year follow-up, with the tibial translation after 4 months of rehabilitation initiated early after the injury. Secondarily, to compare tibial translation in the injured knee and non-injured knee and explore correlations between dynamic and static tibial translation. METHODS Twelve patients with ACL rupture were assessed at 3-8 weeks after ACL injury, after 4 months of structured rehabilitation, and 2-5 years after ACL injury. Sagittal tibial translation was measured during the Lachman test (static translation) and during gait (dynamic translation) using a CA-4000 electrogoniometer. RESULTS Static tibial translation was increased bilateral 2-5 years after ACL injury, whereas the dynamic tibial translation was unchanged. Tibial translation was greater in the injured knee compared with the non-injured knee (Lachman test 134 N 9.1 ± 1.0 vs. 7.0 ± 1.7 mm, P = 0.001, gait 5.6 ± 2.1 vs. 4.7 ± 1.8 mm, P = 0.011). There were no correlations between dynamic and static tibial translation. CONCLUSION Dynamic tibial translation was unchanged in spite of increased static tibial translation in the ACL-deficient knee at 2- to 5-year follow-up compared to directly after rehabilitation. Dynamic tibial translation did not correlate with the static tibial translation. A more normal gait kinematics may be maintained from completion of a rehabilitation programme to mid-term follow-up in patients with ACL deficiency treated with rehabilitation only. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Sofi Sonesson
- Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University, SE-581 83, Linköping, Sweden.
| | - Joanna Kvist
- Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University, SE-581 83, Linköping, Sweden
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VandenBerg C, Crawford EA, Sibilsky Enselman E, Robbins CB, Wojtys EM, Bedi A. Restricted Hip Rotation Is Correlated With an Increased Risk for Anterior Cruciate Ligament Injury. Arthroscopy 2017; 33:317-325. [PMID: 27840056 DOI: 10.1016/j.arthro.2016.08.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 08/01/2016] [Accepted: 08/19/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The primary purpose was to compare ipsilateral hip internal rotation (IR) in male and female athletes with or without an anterior cruciate ligament (ACL) tear. A secondary purpose was to compare radiographic markers of femoroacetabular impingement (FAI) in patients with or without an ACL tear. METHODS In this prospective case-control study, based on a power analysis, a convenience sample of 25 ACL-injured and 25 control patients matched by age and gender were examined over 14 months. The ACL injury group included preoperative patients 12-40 years old with an ACL rupture within the previous 3 months with no prior lower extremity injuries, ligamentous laxity, or arthralgias. Controls included patients presenting with an upper extremity complaint with no history of knee injury. In the outpatient clinic, hip axial rotation range of motion was measured with a goniometer on physical examination and hip radiographs were evaluated for morphologic variations consistent with FAI. Univariate analysis of variance was used to examine differences between groups. RESULTS Each group had 13 males and 12 females, average ages of 22.8 ± 7.2 years (ACL group) versus 24.5 ± 7.9 years (controls; P = .439). The average sum of hip rotation (internal plus external) in patients with an ACL tear was 60.3 ± 12.4° compared with 72.6 ± 17.2° in controls (P = .006). ACL-injured patients had decreased hip IR compared with controls, with respective mean measurements of 23.4 ± 7.6° versus 30.4 ± 10.4° (P = .009). For every 10° increase in hip IR, the odds of having an ACL tear decreased by a factor of 0.419 (P = .015). CONCLUSIONS Risk of ACL injury is associated with restricted hip IR, and as hip IR increases, the odds of having an ACL tear decreases. In addition, ACL injury is associated with FAI in a generalized population of male and female athletes, although causality cannot be determined and most ACL-injured patients do not exhibit hip complaints. LEVEL OF EVIDENCE Level II, prognostic, prospective cohort study.
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Affiliation(s)
- Curtis VandenBerg
- MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A..
| | - Eileen A Crawford
- MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | | | - Christopher B Robbins
- MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Edward M Wojtys
- MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Asheesh Bedi
- MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
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Soreide E, Granan LP, Hjorthaug GA, Espehaug B, Dimmen S, Nordsletten L. The Effect of Limited Perioperative Nonsteroidal Anti-inflammatory Drugs on Patients Undergoing Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2016; 44:3111-3118. [PMID: 27496908 DOI: 10.1177/0363546516657539] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) to patients undergoing anterior cruciate ligament reconstruction (ACLR) is controversial because it may impair tissue healing and clinical outcomes. PURPOSE To assess the effect of NSAID administration on patients undergoing ACLR. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Included patients were aged >15 years and were registered in the Norwegian Knee Ligament Registry from 2008 until 2013 after the primary ACLR. Patients with insufficient data regarding administration of NSAIDs and those with associated knee ligament injuries requiring surgical treatment were excluded from this study. Graft survival was estimated using Kaplan-Meier survival curves, and hazard ratios (HRs) for revision were evaluated using Cox regression analysis. Logistic regression analysis was used to calculate the odds ratio (OR) for a Knee Injury and Osteoarthritis Outcome Score (KOOS)-quality of life (QOL) subscale score <44 at 2-year follow-up. RESULTS A total of 7822 patients were included in the analysis for graft survival and assessment for risk of revision. Of these, 4144 patients were administered NSAIDs postoperatively. The mean duration of follow-up was 2.8 years (range, 0-5.9 years). Administration of NSAIDs did not influence graft survival (P = .568). Adjusted Cox regression analyses demonstrated the same finding regarding risk of revision (HR, 1.0; 95% CI, 0.8-1.3). ACLR using a bone-patellar tendon-bone autograft showed a reduced risk of revision (HR, 0.3; 95% CI, 0.1-0.8) among patients administered NSAIDs. In subgroup analyses of 3144 patients, administration of NSAIDs demonstrated a beneficial effect on the risk of a KOOS-QOL score <44 at 2-year follow-up (OR, 0.8; 95% CI, 0.6-0.9). CONCLUSION Administration of NSAIDs to patients after ACLR does not have a negative effect on graft survival, risk of revision, or risk of a KOOS-QOL score <44 at 2-year follow-up. We emphasize using caution when administering NSAIDs by keeping the duration and dosage of NSAIDs as short and low as possible to ensure sufficient pain relief while limiting unwanted exposure to any known and unknown adverse effects of these drugs.
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Affiliation(s)
- Endre Soreide
- Department of Orthopedic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Lars-Petter Granan
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Oslo Sport Trauma Research Center, Norwegian School of Sport Science, Oslo, Norway
| | - Geir A Hjorthaug
- Department of Orthopedic Surgery, Martina Hansens Hospital, Gjettum, Norway
| | - Birgitte Espehaug
- Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Sigbjørn Dimmen
- Department of Orthopedic Surgery, Lovisenberg Diakonale Hospital, Oslo, Norway
| | - Lars Nordsletten
- Department of Orthopedic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway
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Beaulieu ML, Carey GE, Schlecht SH, Wojtys EM, Ashton-Miller JA. On the heterogeneity of the femoral enthesis of the human ACL: microscopic anatomy and clinical implications. J Exp Orthop 2016; 3:14. [PMID: 27412665 PMCID: PMC4943914 DOI: 10.1186/s40634-016-0050-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/07/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Most ruptures of the native anterior cruciate ligament (ACL) and ACL graft occur at, or near, the femoral enthesis, with the posterolateral fibers of the native ligament being especially vulnerable during pivot landings. Characterizing the anatomy of the ACL femoral enthesis may help us explain injury patterns which, in turn, could help guide injury prevention efforts. It may also lead to improved anatomic reconstruction techniques given that the goal of such techniques is to replicate the knee's normal anatomy. Hence, the aim of this study was to investigate the microscopic anatomy of the ACL femoral enthesis and determine whether regional differences exist. METHODS Fifteen human ACL femoral entheses were histochemically processed and sectioned along the longitudinal axis of the ACL at 20, 40, 60, and 80 % of the width of the enthesis. Four thick sections (100 μm) per enthesis were prepared, stained, and digitized. From these sections, regional variations in the quantity of calcified and uncalcified fibrocartilage, the angle at which the ligament originates from the bone, and the shape profile of the tidemark were quantified. RESULTS At least 33 % more calcified fibrocartilage and 143 % more uncalcified fibrocartilage were found in the antero-inferior region, which corresponds to the inferior margin of the origin of the anteromedial ACL fibers, than all other regions (Ps < 0.05). In addition, the anteromedial fibers of the ACL originated from the femur at an angle six times greater than did its posterolateral fibers (P = 0.032). Finally, average entheseal tidemark profiles correlated bilaterally (Pearson's r = 0.79; P = 0.036), the most common profile being convex with a single re-entrant. CONCLUSIONS Systematic regional differences were found in fibrocartilage quantity and collagen fiber attachment angles. The marked differences may reflect differences in the loading history of the various regions of the ACL femoral enthesis. These differences, which could affect the potential for injury, should also be considered when developing new ACL reconstruction approaches.
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Affiliation(s)
- Mélanie L Beaulieu
- School of Kinesiology, University of Michigan, 1402 Washington Heights, Ann Arbor, MI, 48109, USA. .,Biomechanics Research Laboratory, Department of Mechanical Engineering, University of Michigan, 2350 Hayward Street, GG Brown Building, Ann Arbor, MI, 48109, USA.
| | - Grace E Carey
- School of Kinesiology, University of Michigan, 1402 Washington Heights, Ann Arbor, MI, 48109, USA.,Biomechanics Research Laboratory, Department of Mechanical Engineering, University of Michigan, 2350 Hayward Street, GG Brown Building, Ann Arbor, MI, 48109, USA
| | - Stephen H Schlecht
- Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109, USA
| | - Edward M Wojtys
- Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109, USA.,MedSport, University of Michigan, Domino's Farms, 24 Frank Lloyd Wright Drive, Lobby A, P.O. Box 391, Ann Arbor, MI, 48106, USA
| | - James A Ashton-Miller
- School of Kinesiology, University of Michigan, 1402 Washington Heights, Ann Arbor, MI, 48109, USA.,Biomechanics Research Laboratory, Department of Mechanical Engineering, University of Michigan, 2350 Hayward Street, GG Brown Building, Ann Arbor, MI, 48109, USA
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Beaulieu ML, Carey GE, Schlecht SH, Wojtys EM, Ashton-Miller JA. Quantitative comparison of the microscopic anatomy of the human ACL femoral and tibial entheses. J Orthop Res 2015; 33:1811-7. [PMID: 26134706 PMCID: PMC4628572 DOI: 10.1002/jor.22966] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 06/10/2015] [Indexed: 02/04/2023]
Abstract
The femoral enthesis of the human anterior cruciate ligament (ACL) is known to be more susceptible to injury than the tibial enthesis. To determine whether anatomic differences might help explain this difference, we quantified the microscopic appearance of both entheses in 15 unembalmed knee specimens using light microscopy, toluidine blue stain and image analysis. The amount of calcified fibrocartilage and uncalcified fibrocartilage, and the ligament entheseal attachment angle were then compared between the femoral and tibial entheses via linear mixed-effects models. The results showed marked differences in anatomy between the two entheses. The femoral enthesis exhibited a 3.9-fold more acute ligament attachment angle than the tibial enthesis (p<0.001), a 43% greater calcified fibrocartilage tissue area (p<0.001), and a 226% greater uncalcified fibrocartilage depth (p<0.001), with the latter differences being particularly pronounced in the central region. We conclude that the ACL femoral enthesis has more fibrocartilage and a more acute ligament attachment angle than the tibial enthesis, which provides insight into why it is more vulnerable to failure.
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Affiliation(s)
- Mélanie L. Beaulieu
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan,Biomechanics Research Laboratory, Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Grace E. Carey
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan,Biomechanics Research Laboratory, Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Stephen H. Schlecht
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Edward M. Wojtys
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan,MedSport, University of Michigan, Ann Arbor, Michigan
| | - James A. Ashton-Miller
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan,Biomechanics Research Laboratory, Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan
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Beaulieu ML, Wojtys EM, Ashton-Miller JA. Risk of anterior cruciate ligament fatigue failure is increased by limited internal femoral rotation during in vitro repeated pivot landings. Am J Sports Med 2015; 43:2233-41. [PMID: 26122384 PMCID: PMC4615705 DOI: 10.1177/0363546515589164] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A reduced range of hip internal rotation is associated with increased peak anterior cruciate ligament (ACL) strain and risk for injury. It is unknown, however, whether limiting the available range of internal femoral rotation increases the susceptibility of the ACL to fatigue failure. HYPOTHESIS Risk of ACL failure is significantly greater in female knee specimens with a limited range of internal femoral rotation, smaller femoral-ACL attachment angle, and smaller tibial eminence volume during repeated in vitro simulated single-leg pivot landings. STUDY DESIGN Controlled laboratory study. METHODS A custom-built testing apparatus was used to simulate repeated single-leg pivot landings with a 4×-body weight impulsive load that induces knee compression, knee flexion, and internal tibial torque in 32 paired human knee specimens from 8 male and 8 female donors. These test loads were applied to each pair of specimens, in one knee with limited internal femoral rotation and in the contralateral knee with femoral rotation resisted by 2 springs to simulate the active hip rotator muscles' resistance to stretch. The landings were repeated until ACL failure occurred or until a minimum of 100 trials were executed. The angle at which the ACL originates from the femur and the tibial eminence volume were measured on magnetic resonance images. RESULTS The final Cox regression model (P = .024) revealed that range of internal femoral rotation and sex of donor were significant factors in determining risk of ACL fatigue failure. The specimens with limited range of internal femoral rotation had a failure risk 17.1 times higher than did the specimens with free rotation (P = .016). The female knee specimens had a risk of ACL failure 26.9 times higher than the male specimens (P = .055). CONCLUSION Limiting the range of internal femoral rotation during repetitive pivot landings increases the risk of an ACL fatigue failure in comparison with free rotation in a cadaveric model. CLINICAL RELEVANCE Screening for restricted internal rotation at the hip in ACL injury prevention programs as well as in individuals with ACL injuries and/or reconstructions is warranted.
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Affiliation(s)
- Mélanie L. Beaulieu
- Address correspondence to Mélanie L. Beaulieu, PhD, Department of Radiology, University of Michigan, Domino's Farms, Suite B-1000, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106, USA ()
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Beaulieu ML, Oh YK, Bedi A, Ashton-Miller JA, Wojtys EM. Does limited internal femoral rotation increase peak anterior cruciate ligament strain during a simulated pivot landing? Am J Sports Med 2014; 42:2955-63. [PMID: 25245132 PMCID: PMC6380493 DOI: 10.1177/0363546514549446] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many factors contributing to anterior cruciate ligament (ACL) injury risk have been investigated. Recently, some ACL-injured individuals have presented with a decreased range of hip internal rotation compared with controls. The pathomechanics of why decreased hip range of motion increases risk of ACL injury have not yet been studied. HYPOTHESIS Peak relative strain of the anteromedial bundle of the ACL (AM-ACL) during a simulated single-leg pivot landing is inversely related to the available range of internal femoral rotation. STUDY DESIGN Controlled laboratory study. METHODS A series of pivot landings were simulated in 10 female and 10 male human knee specimens with a testing apparatus that applied a 2-bodyweight impulsive load, inducing knee compression, flexion moment, and internal tibial torque. The range of internal femoral rotation was (1) locked at ~0°, (2) limited with a hard stop to ~7°, (3) limited with a hard stop to ~11°, or (4) free, with rotation resisted by 2 springs to simulate the resistance of the active hip rotator muscles to stretch. The AM-ACL strain was quantified with a differential variable reluctance transducer. A linear mixed model was used to determine whether a significant linear relation existed between peak AM-ACL relative strain and range of internal femoral rotation. RESULTS Peak AM-ACL relative strain was inversely related to the available range of internal femoral rotation (R (2) = 0.91; P < .001), with strain increasing 1.3% for every 10° decrease in rotation; this represented a 20% increase in peak relative strain, given an average range of femoral rotation of 15° upon landing in healthy athletes. CONCLUSION Peak AM-ACL relative strain was inversely proportional to the available range of internal femoral rotation during simulated single-leg pivot landings. CLINICAL RELEVANCE Decreased range of internal femoral rotation results in greater ACL strain and may therefore increase the susceptibility to ACL rupture with athletic cutting and pivoting activities. Screening for a limited range of hip internal rotation should therefore become a component of not only ACL injury prevention programs but also evaluation protocols for those with ACL injuries and/or reconstructions.
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Affiliation(s)
- Mélanie L. Beaulieu
- Address correspondence to Mélanie L. Beaulieu, MSc, School of Kinesiology, University of Michigan, 401 Washtenaw Avenue, Ann Arbor, MI 48109, USA ()
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The Effects of a Lateral In-flight Perturbation on Lower Extremity Biomechanics During Drop Landings. J Appl Biomech 2014; 30:655-62. [DOI: 10.1123/jab.2013-0331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
One potential ACL injury situation is due to contact with another person or object during the flight phase, thereby causing the person to land improperly. Conversely, athletes often have flight-phase collisions but do land safely. Therefore, to better understand ACL injury causation and methods by which people typically land safely, the purpose of this study was to determine the effects of an in-flight perturbation on the lower extremity biomechanics displayed by females during typical drop landings. Seventeen collegiate female recreational athletes performed baseline landings, followed by either unexpected laterally-directed perturbation or sham (nonperturbation) drop landings. We compared baseline and perturbation trials using paired-samplesttests (P< .05) and 95% confidence intervals for lower-extremity joint kinematics and kinetics and GRF. The results demonstrated that perturbation landings compared with baseline landings exhibited more extended joint positions of the lower extremity at initial contact; and, during landing, greater magnitudes for knee abduction and hip adduction displacements; peak magnitudes of vertical and medial GRF; and maximum moments of ankle extensors, knee extensors, and adductor and hip adductors. We conclude that a lateral in-flight perturbation leads to abnormal GRF and angular motions and joint moments of the lower extremity.
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11
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Roemer FW, Frobell R, Lohmander LS, Niu J, Guermazi A. Anterior Cruciate Ligament OsteoArthritis Score (ACLOAS): Longitudinal MRI-based whole joint assessment of anterior cruciate ligament injury. Osteoarthritis Cartilage 2014; 22:668-82. [PMID: 24657830 DOI: 10.1016/j.joca.2014.03.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 01/27/2014] [Accepted: 03/03/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop a whole joint scoring system, the Anterior Cruciate Ligament OsteoArthritis Score (ACLOAS), for magnetic resonance imaging (MRI)-based assessment of acute anterior cruciate ligament (ACL) injury and follow-up of structural sequelae, and to assess its reliability. DESIGN Baseline and follow-up 1.5 T MRI examinations from 20 patients of the KANON study, a randomized controlled study comparing a surgical and non-surgical treatment strategy, were assessed for up to six longitudinal visits using a novel MRI scoring system incorporating acute structural tissue damage and longitudinal changes including osteoarthritis (OA) features. Joint features assessed were acute osteochondral injury, traumatic and degenerative bone marrow lesions (BMLs), meniscus morphology and extrusion, osteophytes, collateral and cruciate ligaments including ACL graft, Hoffa-synovitis and effusion-synovitis. Cross-sectional (baseline) and longitudinal (all time points and change) intra- and inter-observer reliability was calculated using weighted (w) kappa statistics and overall percent agreement on a compartmental basis (medial tibio-femoral, lateral tibio-femoral, patello-femoral). RESULTS Altogether 87 time points were evaluated. Intra-observer reliability ranged between 0.52 (baseline, Hoffa-synovitis) and 1.00 (several features), percent agreement between 52% (all time points, Hoffa-synovitis) and 100% (several features). Inter-observer reliability ranged between 0.00 and 1.00, which is explained by low frequency of some of the features. Altogether, 73% of all assessed 142 parameters showed w-kappa values between 0.80 and 1.00 and 92% showed agreement above 80%. CONCLUSIONS ACLOAS allows reliable scoring of acute ACL injury and longitudinal changes. This novel scoring system incorporates features that may be relevant for structural outcome not covered by established OA scoring instruments.
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Affiliation(s)
- Frank W Roemer
- Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany; Quantitative Imaging Center (QIC), Department of Radiology, Boston University School of Medicine, Boston, MA, USA.
| | - Richard Frobell
- Department of Orthopaedics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - L Stefan Lohmander
- Department of Orthopaedics, Clinical Sciences Lund, Lund University, Lund, Sweden; Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Jingbo Niu
- Clinical Epidemiology and Training Unit, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Ali Guermazi
- Quantitative Imaging Center (QIC), Department of Radiology, Boston University School of Medicine, Boston, MA, USA
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Van Ginckel A, Verdonk P, Witvrouw E. Cartilage adaptation after anterior cruciate ligament injury and reconstruction: implications for clinical management and research? A systematic review of longitudinal MRI studies. Osteoarthritis Cartilage 2013; 21:1009-24. [PMID: 23685095 DOI: 10.1016/j.joca.2013.04.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 03/12/2013] [Accepted: 04/24/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To summarize the current evidence of magnetic resonance imaging (MRI)-measured cartilage adaptations following anterior cruciate ligament (ACL) reconstruction and of the potential factors that might influence these changes, including the effect of treatment on the course of cartilage change (i.e., surgical vs non-surgical treatment). METHODS A literature search was conducted in seven electronic databases extracting 12 full-text articles. These articles reported on in vivo MRI-related cartilage longitudinal follow-up after ACL injury and reconstruction in "young" adults. Eligibility and methodological quality was rated by two independent reviewers. A best-evidence synthesis was performed for reported factors influencing cartilage changes. RESULTS Methodological quality was heterogenous amongst articles (i.e., score range: 31.6-78.9%). Macroscopic changes were detectable as from 2 years follow-up next to or preceded by ultra-structural and functional (i.e., contact-deformation) changes, both in the lateral and medial compartment. Moderate-to-strong evidence was presented for meniscal lesion or meniscectomy, presence of bone marrow lesions (BMLs), time from injury, and persisting altered biomechanics, possibly affecting cartilage change after ACL reconstruction. First-year morphological change was more aggravated in ACL reconstruction compared to non-surgical treatment. CONCLUSION In view of osteoarthritis (OA) prevention after ACL reconstruction, careful attention should be paid to the rehabilitation process and to the decision on when to allow return to sports. These decisions should also consider cartilage fragility and functional adaptations after surgery. In this respect, the first years following surgery are of paramount importance for prevention or treatment strategies that aim at impediment of further matrix deterioration. Considering the low number of studies and the methodological caveats, more research is needed.
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Affiliation(s)
- A Van Ginckel
- Fellowship Research Foundation, FWO Aspirant, Flanders, Brussels, Belgium.
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Bibliography—Editors’ selection of current world literature. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e31829d7cd1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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