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Opoku M, Fang M, Lu W, Li Y, Xiao W. Acute anterior cruciate ligament rupture: can repair become an alternative to reconstruction: a meta-analysis of randomized controlled trials and cohort studies. J Orthop Surg Res 2024; 19:331. [PMID: 38825707 PMCID: PMC11145936 DOI: 10.1186/s13018-024-04812-x] [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: 02/28/2024] [Accepted: 05/23/2024] [Indexed: 06/04/2024] Open
Abstract
PURPOSE To perform a meta-analysis to compare clinical outcomes of anterior cruciate ligament (ACL) repair and ACL reconstruction for acute ACL rupture. METHOD We searched Pubmed, Embase, the Cochrane Library, and Web of Science databases to seek relevant studies. Clinical outcomes included failure rate, hardware removal rate, anteroposterior (AP) knee laxity, and patient-reported outcomes. In addition, subgroup analysis was carried out according to repair techniques, rupture locations, and study designs. Funnel plots were used to detect publication bias. All statistical analysis was performed using STATA (version 14.2, StataCorp). RESULTS A total of 10 articles were included in this study, comprising 5 randomized controlled trials (RCTs) and 5 cohort studies, involving a total of 549 patients. We found no statistical differences between the ACL repair and ACL reconstruction in the following outcomes: failure rate, AP knee laxity, International Knee Documentation Committee (IKDC) score, Lysholm score, Knee Injury and Osteoarthritis Outcome (KOOS) Score, and Tegner score. However, the ACL repair group had a higher hardware removal rate. Except for AP knee laxity results on different repair techniques, there was no statistical difference in other subgroup analyses. CONCLUSION Compared with ACL reconstruction, ACL repair shows similar results in clinical outcomes, and it is promising to be an effective alternative treatment for acute ACL rupture. Larger samples and higher-quality studies are needed to support our results and further explore the advantages of ACL repair in other aspects. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Michael Opoku
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Mingqing Fang
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, 410083, China
| | - Wenhao Lu
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Yusheng Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China.
| | - Wenfeng Xiao
- Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, 410008, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China.
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Li S, Wang S, Shao J, Wang J, Liu W, Chen L, Li Z, Zhang C, Song J. Toward the Improvement of the Mechanical and Tribological Properties of Braided Ligament for ACL Reconstruction: A "Carrot and Stick" Strategy. Adv Healthc Mater 2024:e2304133. [PMID: 38484144 DOI: 10.1002/adhm.202304133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/21/2024] [Indexed: 05/03/2024]
Abstract
Bone tunnel enlargement has been troubling the clinical adoption of braided artificial ligaments for decades, to which mechanical and tribological performance promotion shall be an effective and promising approach. Herein, a "carrot and stick" strategy has been introduced with two types of polyethylene terephthalate (PET) fibers to fabricate hybrid textures, which is expected to advance fatigue and tribological performance without yielding essential mechanical strength and biocompatibility. Owing to advancements in such a "carrot and stick" strategy, the obtained grafts present three promising properties: i) enhancement of mechanical strength; ii) coefficient of friction (COF) reduction of 25% at the greatest extent, thus lowering the risk of bone tunnel enlargement; iii) final displacement shrinkage of graft length after cyclic loadings, favored in the clinic for isometric reconstruction. The results obtained in this study show that the "carrot and stick" strategy can be a creative and convenient method to optimize the service life, saving the complication rate of artificial ligaments for clinical applications.
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Affiliation(s)
- Shenglin Li
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107, China
- Shenzhen Institute for Drug Control, Shenzhen Testing Center of Medical Devices, Shenzhen, 518057, China
| | - Shuhan Wang
- Shenzhen Institute for Drug Control, Shenzhen Testing Center of Medical Devices, Shenzhen, 518057, China
| | - Jiasheng Shao
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107, China
| | - Jiali Wang
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107, China
| | - Wenliang Liu
- Shenzhen Institute for Drug Control, Shenzhen Testing Center of Medical Devices, Shenzhen, 518057, China
| | - Linxin Chen
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107, China
| | - Zeng Li
- Department of Orthopedics, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, China
| | - Chao Zhang
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107, China
| | - Jian Song
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107, China
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Maginnis C, Root C, Schiavo JH, Ierulli VK, Vopat B, Mulcahey MK. Analysis of Graft Types Augmented With an Internal Brace for ACL Reconstruction: A Systematic Review. Am J Sports Med 2024:3635465231196157. [PMID: 38269417 DOI: 10.1177/03635465231196157] [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: 01/26/2024]
Abstract
BACKGROUND New techniques are being developed to decrease the failure rate of anterior cruciate ligament (ACL) grafts and prevent revision surgery. One such technique involves high-strength suture tape (ST), also referred to as internal bracing. Recent literature has highlighted the use of ST for ACL reconstruction, but no study has compared ST augmentation between graft types. PURPOSE To compare the use of ST augmentation for ACL reconstruction based on the type of graft used (ie, bone-patellar tendon-bone [BPTB], quadriceps, hamstring). STUDY DESIGN Systematic review; Level of evidence, 5. METHODS An online search of multiple databases was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was completed April 2022 to identify studies related to ST augmentation of ACL grafts. RESULTS Of 926 studies identified, 10 met inclusion criteria. Five studies (50%) used hamstring tendon (HT), 3 (30%) used quadriceps tendon (QT), 1 (10%) used BPTB, and 1 (10%) used both HT and QT grafts. HT autografts augmented with ST had decreased dynamic and peak elongation (15%-56%), increased load to failure, and increased initial and final dynamic stiffness compared with controls. There was no significant difference in postoperative physical examination findings (range of motion, Lachman, pivot shift), except that ST-augmented grafts had significantly less laxity after surgery compared with HT alone (0.8 vs 1.9 mm; P < .05). QT allografts with ST augmentation showed increased graft strength. Human QT autograft studies showed higher Knee injury and Osteoarthritis Outcome Score scores compared with controls. BPTB allografts with ST augmentation had decreased cyclic displacement by 31% (P = .015) and increased load (758 ± 128 N; P < .001) and stiffness (156 ± 23 N/mm; P = .003) compared with nonaugmented groups. The complication rate was low or showed no increase in the ST augmentation groups compared with control groups. CONCLUSION HT, QT, and BPTB grafts augmented with ST demonstrate an effective method for ACL reconstruction. All graft types with ST augmentation showed no evidence of clinical disadvantage, with some studies indicating significant biomechanical or clinical advantages compared with conventional ACL reconstruction.
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Affiliation(s)
- Connor Maginnis
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | - Cooper Root
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Julie H Schiavo
- Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | - Victoria K Ierulli
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Bryan Vopat
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Medical Center, Maywood, Illinois, USA
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4
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Hwang NM, Samuel JT, Thompson AA, Mayfield CK, Abu-Zahra MS, Kotlier JL, Petrigliano FA, Liu JN. Reporting Bias in the Form of Positive Spin Is Highly Prevalent in Abstracts of Systematic Reviews on Primary Repair of the Anterior Cruciate Ligament. Arthroscopy 2024:S0749-8063(23)01022-8. [PMID: 38171422 DOI: 10.1016/j.arthro.2023.12.018] [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: 08/08/2023] [Revised: 12/04/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE To analyze reporting bias in the form of spin present in systematic reviews and meta-analyses on the topic of primary anterior cruciate ligament (ACL) repair. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed throughout this study. Peer-reviewed systematic reviews were collected from 3 databases (PubMed, Scopus, and SPORTDiscus), and their abstracts were assessed for the 15 most common types of spin. Articles were excluded if they were not published in English, had no evidence, were retracted, were published without an abstract, did not have full text available, or included cadaveric or nonhuman subjects. Full text quality was assessed using AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews Version 2). Fisher exact tests were used to examine associations between the different types of spin and other study characteristics such as AMSTAR 2 confidence rating, study design, and level of evidence. RESULTS Spin was present in the abstracts of 13 of 15 articles (86.7%). There were significant associations between PRISMA adherence and lower incidences of spin types 3, 6, and 8 (P = .029 for each). A critically low AMSTAR 2 confidence rating was significantly associated with an increased incidence of spin type 9 (P = .01), and a higher AMSTAR 2 score was significantly associated with decreased spin type 4 and type 5 (P = .039 and P = .048, respectively). A more recent year of publication was correlated with a lower incidence of spin type 14 (P = .044). CONCLUSIONS Spin is present in most systematic reviews and meta-analyses regarding primary repair of the ACL, with two-thirds of abstracts spinning evidence in favor of ACL repair. Standardized guidelines including the PRISMA guidelines and the AMSTAR 2 assessment tool were negatively correlated with spin. More recently published articles were found to contain significantly less spin, as were articles published in journals with higher Clarivate Impact Factors and Scopus CiteScores. LEVEL OF EVIDENCE Level V, systematic review of Level III through V studies.
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Affiliation(s)
- N Mina Hwang
- University of Southern California Epstein Family Center for Sports Medicine at Keck Medicine of University of Southern California, Los Angeles, California, U.S.A
| | - Justin T Samuel
- City University of New York School of Medicine, New York, New York, U.S.A
| | - Ashley A Thompson
- University of Southern California Epstein Family Center for Sports Medicine at Keck Medicine of University of Southern California, Los Angeles, California, U.S.A
| | - Cory K Mayfield
- University of Southern California Epstein Family Center for Sports Medicine at Keck Medicine of University of Southern California, Los Angeles, California, U.S.A
| | - Maya S Abu-Zahra
- University of Southern California Epstein Family Center for Sports Medicine at Keck Medicine of University of Southern California, Los Angeles, California, U.S.A
| | - Jacob L Kotlier
- University of Southern California Epstein Family Center for Sports Medicine at Keck Medicine of University of Southern California, Los Angeles, California, U.S.A
| | - Frank A Petrigliano
- University of Southern California Epstein Family Center for Sports Medicine at Keck Medicine of University of Southern California, Los Angeles, California, U.S.A..
| | - Joseph N Liu
- University of Southern California Epstein Family Center for Sports Medicine at Keck Medicine of University of Southern California, Los Angeles, California, U.S.A
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Lutter C, Hiller N, Sass J, Hembus J, Jones G, Vogel D, Groß J, Bader R, Tischer T. Refixation of the anterior cruciate ligament: A biomechanical analysis of suture techniques in a porcine model. J Exp Orthop 2024; 11:e12011. [PMID: 38497044 PMCID: PMC10941523 DOI: 10.1002/jeo2.12011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/02/2024] [Indexed: 03/19/2024] Open
Abstract
Purpose Refixation of acute anterior cruciate ligament (ACL) tears represents an increasingly popular treatment option. Systematic evaluations of various suture technique parameters are still pending. We therefore aimed to evaluate the mechanical pull-out outcomes of various suture methods for optimization of ACL refixation. Methods Sixty fresh knees from mature domestic pigs were dissected and the femoral attachment of the ACL was peeled off. The 60 knees were divided in 10 groups and sutured as follows: (A) one suture (1, 2, 4 and 6 passes), (B) two sutures (2, 4 and 6 passes each; sutures knotted together as a loop) and (C) two sutures (2, 4 and 6 passes each, sutures knotted separately). The pull-out test was conducted using a validated electrodynamic testing machine. First occurrence of failure, maximum pull-out load and stiffness were measured. Suture failure was defined as pull-out of the ACL. Results Two-point fixation, using two sutures, with at least two passes, showed the most favourable biomechanical stability. The maximum pull-out load was significantly higher with two sutures (529.5 N) used compared to one (310.4 N), p < 0.001. No significant differences were found for maximum pull-out loads between two-point fixation versus one-point fixation but stiffness was significantly higher with two-point fixation (107.4 N/mm vs. 79.4 N/mm, p < 0.001). More passes resulted in higher maximum pull-out loads. Conclusion The results suggest using two independent sutures, refixed separately and at least two suture passes, is appropriate for ACL refixation. More suture passes provide additional strength but are technically challenging to achieve during surgery. Level of Evidence Level IV.
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Affiliation(s)
- Christoph Lutter
- Department of OrthopaedicsRostock University Medical CenterRostockGermany
| | - Natalie Hiller
- Department of OrthopaedicsRostock University Medical CenterRostockGermany
| | - Jan‐Oliver Sass
- Department of OrthopaedicsRostock University Medical CenterRostockGermany
| | - Jessica Hembus
- Department of OrthopaedicsRostock University Medical CenterRostockGermany
| | - Gareth Jones
- School of Clinical and Applied SciencesLeeds Beckett UniversityLeedsUK
| | - Danny Vogel
- Department of OrthopaedicsRostock University Medical CenterRostockGermany
| | - Justus Groß
- Department for General, Visceral, Thoracic, Vascular and Transplantation SurgeryUniversity Hospital RostockRostockGermany
| | - Rainer Bader
- Department of OrthopaedicsRostock University Medical CenterRostockGermany
| | - Thomas Tischer
- Department of OrthopaedicsRostock University Medical CenterRostockGermany
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Uchino S, Taguri M. Epidemiology of cruciate ligament surgery in Japan: A repeated cross-sectional study from 2014 to 2021. PLoS One 2023; 18:e0288854. [PMID: 38134038 PMCID: PMC10745212 DOI: 10.1371/journal.pone.0288854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Understanding the incidence and trends of cruciate ligament (CL) surgeries in Japan is crucial for providing effective healthcare services. This study aimed to use open data available from the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) to analyze changes in CL surgeries over time and the characteristics of the Japanese population by sex and age. We retrospectively identified CL surgeries of the knee joint registered from April 2014 to March 2022 using the NDB open data. Data on sex, age, and practice were extracted to determine the number of cases per 100,000 population. Trends in the annual incidence of CL surgeries were evaluated using Poisson regression analysis. A total of 142,931 CL surgeries were performed from 2014 to 2021, with arthroscopic ligament reconstruction accounting for 98% of cases. The number of surgeries significantly increased from 16,975 in 2014 to 19,735 in 2019 (P<0.001). CL surgeries were most common in the 15-19 and 20-29 years age groups, with variations between males and females. The incidence of CL surgery in Japan has increased, with characteristics varying by sex and age, including middle-aged and older patients. Further investigation of general patterns in CL surgery in Japan would be valuable.
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Affiliation(s)
- Shota Uchino
- Department of Data Science, Graduate School of Data Science, Yokohama City University, Kanazawa-ku, Yokohama, Japan
- REHASAKU Co., Ltd., Minato-ku, Tokyo, Japan
| | - Masataka Taguri
- Department of Health Data Science, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
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Shah A, Van Thiel G. Anterior cruciate ligament reconstruction with a biocomposite interference screw maintains graft fixation survival and improves clinical outcomes at 1 year: A multicenter prospective case series. Heliyon 2023; 9:e20921. [PMID: 37867815 PMCID: PMC10585286 DOI: 10.1016/j.heliyon.2023.e20921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023] Open
Abstract
A biocomposite interference screw with an open architecture was developed to provide a greater available surface area for bone ingrowth compared with conventional solid interference screws. We herein describe a prospective, single-cohort study conducted using this interference screw in anterior cruciate ligament (ACL) reconstruction. Sixty subjects (mean age, 34.9 years; standard deviation, 10.6) undergoing ACL repair using the biocomposite interference screw were enrolled at 3 sites in the United States. Subjects were followed preoperatively (baseline) and postoperatively at 6 months and 1 year. The primary endpoint was graft fixation survival rate at 6 months and 1 year. Secondary endpoints included graft survival (failure defined as that occurring for any reason); International Knee Documentation Committee (IKDC) score (exam and subjective forms); Tegner Activity form; Lysholm score; and EQ (EuroQuol)-5D-5L index score and visual analogue scale. There was a 100 % rate of graft fixation survival at 6 months (54/54; 95 % confidence interval [CI]: 100-100) and 1 year (50/50; 95 % CI: 100-100). One patient experienced a complete tear of the ACL 5 months following index surgery, resulting in graft survival rates of 98.1 % (53/54; 95 % CI: 94.6-100) at 6 months at 98.0 % (49/50; 95 % CI: 94.1-100) at 1 year. Significant improvements (p < .0001) were obtained between baseline and 6 months for the majority of patient-reported outcomes, and were maintained out to 1-year follow up. There was no significant difference over baseline in the IKDC sub-scale of symptoms. Nine patients (15.0 %) experienced serious adverse events during the course of the study; three of these patients' adverse events were considered possibly or definitely related to the procedure device (ACL tear, pulmonary embolism/deep vein thrombosis, and a patellar fracture). In conclusion, this biocomposite interference screw has a favorable safety and efficacy profile at 1 year, with no failures of graft fixation, noted during that time.
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Affiliation(s)
- Anup Shah
- Orthopedic Surgery, Banner University Medical Group, Arizona, United States
| | - Geoffrey Van Thiel
- Orthopedic Surgery-Sports Medicine, OrthoIllinois, Illinois, United States
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Mohan R, Kwaees TA, Thomas T, Pydisetty R. Cohort study of short-term outcomes after ACL-reconstruction using autograft with internal brace reinforcement versus isolated autograft demonstrating no significant difference. J Orthop 2023; 43:115-120. [PMID: 37593689 PMCID: PMC10429725 DOI: 10.1016/j.jor.2023.07.030] [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: 04/28/2023] [Revised: 07/23/2023] [Accepted: 07/28/2023] [Indexed: 08/19/2023] Open
Abstract
Background The gold standard treatment for Anterior Cruciate Ligament injury is reconstruction (ACL-R). Graft failure is the concern and ensuring a durable initial graft with rapid integration is crucial. Graft augmentation with implantable devices (internal brace reinforcement) is a technique purported to reduce the risk of rupture and hasten recovery. Few studies have examined these techniques, in particular when compared to non-augmented grafts. This study assesses the short-term outcome of ACL-R using augmented and non-augmented hamstring tendon autografts. Methods This was a retrospective cohort study comparing augmented and non-augmented ACL-R. All procedures were performed in a single centre using the same technique. The Knee injury and Osteoarthritis Outcome Score [KOOS] was used to assess patient-reported outcomes. Results There were 70 patients in the augmented and 111 patients in the control group. Mean graft diameter in the augmented group was 8.82 mm versus 8.44 mm in the non-augmented. Six strand graft was achievable in 73.5% of the augmented group compared to 33% in the non-augmented group. Two graft failures were reported in the non-augmented group and none in the augmented group. Patient satisfaction rates were higher in the augmented group. There was a statistically insignificant improvement in the postoperative KOOS in the augmented group compared to the non-augmented group (p 0.6). Irrespective of augmentation status, no correlation was found between the functional score and age, or femoral tunnel width. Conclusion No statistically significant difference was demonstrated in the short-term functional outcome of ACL reconstruction using an augmented or non-augmented hamstring graft. Augmented ACL-R may achieve superior graft diameters, failure rates and patient reported outcomes when compared to nonaugmented ACL-R. Prospective trials are needed to examine this further.
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Affiliation(s)
- Rahul Mohan
- Mersey and West Lancashire Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, L35 5DR, United Kingdom
| | - Tariq Adam Kwaees
- Mersey and West Lancashire Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, L35 5DR, United Kingdom
| | - Terin Thomas
- Mersey and West Lancashire Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, L35 5DR, United Kingdom
| | - Ravi Pydisetty
- Mersey and West Lancashire Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, L35 5DR, United Kingdom
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Fayard JM, Foissey C, Pacoret V, Abid H, Vieira TD, Gabr A, Thaunat M. Return to Sports After ACL Augmentation With Anterolateral Reconstruction (ALR) Harvesting Gracilis Only Compared With ACL Reconstruction With ALR Harvesting Both Hamstring Tendons. Am J Sports Med 2023; 51:2918-2927. [PMID: 37548031 DOI: 10.1177/03635465231187038] [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] [Indexed: 08/08/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) repair (ACL-Rp) is known to be a valuable alternative to ACL reconstruction (ACL-Rc) in selected indications. The majority of the ACL-Rp techniques recommend the use of a synthetic brace. The use of the gracilis allows both a biological internal brace and anterolateral ligament reconstruction (ALR). PURPOSE The primary objective was to compare the early ability to return to sports between patients who underwent ACL-Rp using a gracilis autograft as an internal brace augmentation with ALR and patients who underwent the conventional ACL-Rc with ALR technique sacrificing both the gracilis and the semitendinosus. The secondary objective was to compare the failure rate, clinical scores, and return to sports at a minimum follow-up of 2 years. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective analysis was undertaken. A total of 49 patients who underwent ACL-Rp with ALR between December 2018 and May 2019 were propensity matched at a 1:1 ratio to those who underwent ACL-Rc with ALR during the same period. The decision to perform ACL-Rp with ALR was based on preoperative selection and intraoperative arthroscopic findings: proximal avulsion tear, partial ACL tear, low- to midlevel sports participation, and good tissue quality. The ability to return to sports was assessed using isokinetic tests and the Knee Santy Athletic Return to Sport test functional test at 6 months postoperatively. At the final follow-up, knee laxity parameters, return to sports, and clinical outcome (Lysholm score, Tegner Activity Scale score, International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Anterior Cruciate Ligament-Return to Sport after Injury score) were recorded. RESULTS The ACL-Rp group had significantly less hamstring strength deficit when compared with their counterparts who underwent ACL-Rc (0.2% vs 10.2% in concentric, P < .001; 2.5% vs 14% in eccentric, P < .001). The mean Knee Santy Athletic Return to Sport test score was significantly higher in the ACL-Rc group (69.7% ± 16.6% [range, 19%-100%] vs 61% ± 16.8% [range, 19%-100%]; P = .001). In the ACL-Rp group, 61% (30/49) of the patients were authorized to return to pivot sports versus 41% (20/49) in the ACL-Rc group (P = .04). At a mean final follow-up of 31.4 ± 3.5 months, no significant differences were demonstrated between groups with respect to clinical scores and knee laxity parameters. There was a trend for a higher failure rate in the ACL-Rp group without any significance (ACL-Rp: 6.1% [3/49] vs ACL-Rc: 0%; P = .08). CONCLUSION At 6 months after operation, harvesting only the gracilis with this ACL-Rp and augmentation with ALR technique was linked to a better early ability to return to sports compared with the ACL-Rc with ALR technique harvesting both the gracilis and semitendinosus. This technique had a limited effect on early flexion strength and provided a satisfactory rerupture rate.
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Affiliation(s)
- Jean-Marie Fayard
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Constant Foissey
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Victor Pacoret
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Hichem Abid
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Ayman Gabr
- University College London Hospital, London, United Kingdom
| | - Mathieu Thaunat
- Centre Orthopédique Santy, Lyon, France
- Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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10
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D’Ambrosi R, Meena A, Arora ES, Attri M, Schäfer L, Migliorini F. Reconstruction of the anterior cruciate ligament: a historical view. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:364. [PMID: 37675316 PMCID: PMC10477645 DOI: 10.21037/atm-23-87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/17/2023] [Indexed: 09/08/2023]
Abstract
Management of anterior cruciate ligament (ACL) tears has continuously evolved since its first description in approximately 170 A.D. by Claudius Galenus of Pergamum and Rome. The initial immobilization using casts was replaced by a variety of surgical and conservative approaches over the past centuries. The first successful case of ACL repair was conducted by Mayo Robson in 1885, suturing cruciate at the femoral site. In the nineteenth century, surgical techniques were focused on restoring knee kinematics and published the first ACL repair. The use of grafts for ACL reconstruction was introduced in 1917 but gained popularity in the late 1900s. The introduction of arthroscopy in the 1980s represented the greatest milestones in the development of ACL surgery, along with the refinements of indications, development of modern strategies, and improvement in rehabilitation methods. Despite the rapid development and multitude of new treatment approaches for ACL injuries in the last 20 years, autografting has remained the treatment of choice. Compared to the initial methods, arthroscopic procedures are mainly performed, and more resistant and safer fixation devices are available. This results in significantly less trauma from the surgery and more satisfactory long-term results. The most commonly used procedures are still patellar tendon or hamstring autograft. Additionally, popular, but less common, is the use of quadriceps tendon (QT) grafts and allografts. In parallel with surgical developments, biological reconstruction focusing on the preservation of ACL remnants through the use of cell culture techniques, partial reconstruction, tissue engineering, and gene therapy has gained popularity. In 2013, Claes reported the discovery of a new ligament [anterolateral ligament (ALL)] in the knee that could completely change the treatment of knee injuries. The intent of these modifications is to significantly improve the primary restriction of rotational laxity of the knee after ACL injury. Kinematic studies have demonstrated that anatomic ACL reconstruction and anterolateral reconstruction are synergistic in controlling pivot displacement. Recently, there has been an increased focus on the application of artificial intelligence and machine learning to improve predictive capability within numerous sectors of medicine, including orthopedic surgery.
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Affiliation(s)
- Riccardo D’Ambrosi
- CASCO Department, IRCCS Orthopedic Institute Galeazzi, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Amit Meena
- Department Orthopaedic Sports Medicine, Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada
| | - Ekjot Singh Arora
- Department of Orthopedic, Fortis Escorts Heart Institute, New Delhi, India
| | - Manish Attri
- Department of Orthopedic, Central Institute of Orthopedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Luise Schäfer
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Aachen, Germany
- Department of Orthopedic and Trauma Surgery, Eifelklinik St. Brigida, Simmerath, Germany
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Itthipanichpong T, Tangboonnitiwong N, Limskul D, Tanpowpong T, Kuptniratsaikul S, Thamrongskulsiri N. Arthroscopic Anterior Cruciate Ligament Primary Repair With Synthetic Augmentation and Fixation With the Knotless Suture Anchor. Arthrosc Tech 2023; 12:e1009-e1013. [PMID: 37533897 PMCID: PMC10390709 DOI: 10.1016/j.eats.2023.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/15/2023] [Indexed: 08/04/2023] Open
Abstract
An anterior cruciate ligament (ACL) tear is one of the most common ligament injuries in athletes. The arthroscopic ACL reconstruction procedure is the gold standard for treatment. However, the improvement in injury classification and suture materials has subsequently made arthroscopic ACL primary repair an alternative surgical treatment option. This Technical Note describes an arthroscopic ACL primary repair with synthetic augmentation made of several high-strength sutures and fixation with the knotless suture anchor. The reinforced synthetic material acts as a structural tie to support the ACL while it heals.
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Affiliation(s)
- Thun Itthipanichpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Napol Tangboonnitiwong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Danaithep Limskul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Thanathep Tanpowpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Somsak Kuptniratsaikul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
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12
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Thierbach M, Müller M, Stange R, Kronenberg D, Aurich M, Wildemann B. Wrap It! Preventive Antimicrobial Treatment Shows No Negative Effects on Tenocytes and Tendons-A Comprehensive Approach. J Clin Med 2023; 12:4104. [PMID: 37373797 DOI: 10.3390/jcm12124104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Although the rate of infection after the reconstruction of a ruptured anterior cruciate ligament (ACL) is low, prophylactic incubation of the graft with vancomycin (Vanco-wrap or vancomycin soaking) is routinely performed. A cytotoxic effect of vancomycin is reported for several cell types, and the prophylactic treatment might prevent infection but harm the tissue and cells. AIM A comprehensive study was performed to investigate the effect of vancomycin on tendon tissue and isolated tenocytes using cell viability, molecular and mechanical analysis. MATERIAL AND METHODS Rat tendons or isolated tenocytes were incubated in increasing concentrations of vancomycin (0-10 mg/mL) for different times, and cell viability, gene expression, histology and Young's modulus were analyzed. RESULTS The clinically used concentration of vancomycin (5 mg/mL for 20 min) had no negative effect on cell viability in the tendons or the isolated tenocytes, while incubation with the toxic control significantly reduced cell viability. Increasing the concentration and prolonging the incubation time had no negative effect on the cells. The expression of Col1a1, Col3a1 and the tenocyte markers mohawk, scleraxis and tenomodulin was not affected by the various vancomycin concentrations. The structural integrity as measured through histological and mechanical testing was not compromised. CONCLUSION The results proved the safe application of the Vanco-wrap on tendon tissue. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Manuela Thierbach
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital/Friedrich Schiller University Jena, 07747 Jena, Germany
| | - Michelle Müller
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital/Friedrich Schiller University Jena, 07747 Jena, Germany
| | - Richard Stange
- Department of Regenerative Musculoskeletal Medicine, Institute for Musculoskeletal Medicine, Westfälische Wilhelms-Universität Münster, 48149 Münster, Germany
| | - Daniel Kronenberg
- Department of Regenerative Musculoskeletal Medicine, Institute for Musculoskeletal Medicine, Westfälische Wilhelms-Universität Münster, 48149 Münster, Germany
| | - Matthias Aurich
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital/Friedrich Schiller University Jena, 07747 Jena, Germany
- DOUW-Section of Trauma and Reconstructive Surgery, University Hospital Halle (Saale), 06120 Halle, Germany
- BG Trauma Center Bergmannstrost, 06112 Halle, Germany
| | - Britt Wildemann
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital/Friedrich Schiller University Jena, 07747 Jena, Germany
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Shom P, Varma AR, Prasad R. The Anterior Cruciate Ligament: Principles of Treatment. Cureus 2023; 15:e40269. [PMID: 37448400 PMCID: PMC10336184 DOI: 10.7759/cureus.40269] [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: 09/14/2022] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
The anterior cruciate ligament (ACL) is a crucial connective tissue in the knee joint (tibiofemoral joint). Although the surgical anatomy of this ligament has been studied and interpreted for decades, it remains a topic of discussion among surgeons. The ACL has two bundles, the anteromedial (AM) and the posterolateral (PL) bundle. ACL tears are among the most frequently sustained injuries to the tibiofemoral joint. The ACL is an important rotational stabilizer of the knee joint. The human knee joint can be classified as a complex structure, as it has many ligaments supporting its stability and ensuring required joint mobility. Previously, the outcomes of primary ACL surgery were poor; however, with time, the modalities have improved substantially. There are two methods of performing the reconstruction procedure, the single-bundle method, in which only the AM bundle is reconstructed, and the double-bundle method, in which both the AM and PL bundles of the ACL are reconstructed. Double bundle arthroscopic ACL reconstruction has been recognized as the gold standard procedure. The grafts used for the reconstruction procedure are the tendon of the patella graft and the grafts of the hamstrings. However, one of the drawbacks of performing this surgery is the development of complications, like osteoarthritis. This complication is observed majorly in sports professionals. This article aims to sum up the anatomy of the ACL, its regular tears, the various surgical aspects of managing it, and the advancement of treatment options in the past centuries. Although much has been achieved, detailed scientific studies should be carried out to improve the prognosis and decrease the risk of development of complications.
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Affiliation(s)
- Prannoy Shom
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anuj R Varma
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Roshan Prasad
- Medicine and Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Farid A, Gommers SA, Sierevelt IN, van Eijk F, van Kampen PM, Haverkamp D. Graft failure and revision rate after ACL repair with dynamic intraligamentary stabilization. One-year results of a prospective case series of 155 patients. J Exp Orthop 2023; 10:52. [PMID: 37145187 PMCID: PMC10163193 DOI: 10.1186/s40634-023-00614-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/27/2023] [Indexed: 05/06/2023] Open
Abstract
PURPOSE The aim of this study was to assess graft failure, revision rate, and functional outcomes after treatment of acute ACL rupture with dynamic intraligamentary stabilization (DIS) Ligamys device one year post surgery. Additionally, differences in functional outcome between patients with and without anteroposterior laxity were assessed. It was hypothesized that the failure rate of DIS was non-inferior to that of previously reported ACL reconstruction (10%). METHODS In this prospectively designed multicenter study, including patients with an acute ACL rupture, DIS was performed within 21 days after rupture. Primary outcome was failure of the graft at 1 year post surgery, defined as 1) re-rupture of the graft, 2) revision of DIS, or 3) a > 3 mm side-to-side difference in anterior tibial translation compared to the non-operated knee (∆ATT), measured by the KT1000 device. Additional analysis was performed using a 5 mm threshold. The subjective International Knee Documentation Committee Score (IKDC) and Numerical Rating Scales (NRS) for pain and confidence were used to evaluate functional outcome. RESULTS A total of 155 patients were included with a mean age at surgery of 27.8 years (SD 9.4). The mean interval from rupture to DIS was 16.4 days (SD 5.2). At a median follow-up of 13 months (IQR 12-18) the failure rate of the graft was 30.2% (95%CI:22.0-39.4); 11 patients (7%) required secondary reconstructive surgery and of the 105 patients who attended ATT measurement, 24 patients (23%) had an ∆ATT > 3 mm. Secondary analysis, based on a 5 mm threshold, revealed a failure rate of 22.4% (95%CI: 15.2; 31.1). A total of 39 patients (25%) reported at least one complication, comprising mainly arthrofibrosis, traumatic re-rupture and pain. In these patients, removal of the monoblock was performed in 21 cases (13.5%). At follow-up no significant differences in functional outcomes between patients with ∆ATT > 3 mm and stable ATT were observed. CONCLUSION This prospective multicenter study found a high failure rate at one year follow-up of 30% (7% revision surgery and 23% > 3 mm side-to-side difference in anterior tibial translation) in patients treated by primary repair of the ACL with DIS, and did therefore not demonstrate non-inferiority to ACL reconstruction. For patients who did not require secondary reconstructive surgery, this study found good functional outcomes, also in case of persistent anteroposterior knee laxity (∆ATT > 3 mm). LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ajmal Farid
- Department of Orthopaedic Surgery, Xpert Clinics Orthopedie, Amsterdam, The Netherlands
- Department of Orthopaedic Surgery, Bergman Clinics, Rijswijk, The Netherlands
| | - Sophie A Gommers
- Department of Orthopaedic Surgery, Xpert Clinics Orthopedie, Amsterdam, The Netherlands
| | - Inger N Sierevelt
- Department of Orthopaedic Surgery, Xpert Clinics Orthopedie, Amsterdam, The Netherlands
- Spaarne Gasthuis Academy, Orthopedic Department, Hoofddorp, The Netherlands
| | - Floor van Eijk
- Department of Orthopaedic Surgery, Bergman Clinics, Rijswijk, The Netherlands
| | | | - Daniël Haverkamp
- Department of Orthopaedic Surgery, Xpert Clinics Orthopedie, Amsterdam, The Netherlands.
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Mousavi H, Akbari-Aghdam H, Entezari R. The effect of tranexamic acid injection during anterior cruciate ligament reconstruction surgery on postoperative bleeding, pain and swelling. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:639-644. [PMID: 35779145 DOI: 10.1007/s00590-022-03318-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Anterior Cruciate Ligament (ACL) reconstruction is a common surgery in orthopedics. Strategies that could reduce the bleeding during the surgery could be helpful. Here, we aimed to assess the effects of tranexamic acid injection in ACL reconstruction on patient's functions. METHODS This is a clinical trial performed in 2019-2020 in XX on 61 patients with teared ACL who were candidates of surgical reconstruction. Patients were divided into two groups receiving 15 mg/kg of intravenous tranexamic acid and normal saline. Data regarding the following items were collected: amounts of drain discharge, the severity of the swelling, the pain severity in 1, 7 and 14 days after the surgeries and restrictions in joint range of motion (ROM) in 30 and 60 days after the surgeries. RESULTS We observed significantly lower swelling severities in patients who received tranexamic acid in different measuring times (P = 0.029). These cases also had significantly lower pain severity after 30 days post-operation (P = 0.041). We also observed that patients in the tranexamic acid group had significantly lower ROM restriction than controls (P < 0.001). The total knee scores were similar in both groups (P > 0.05). CONCLUSION Administration of intravenous tranexamic acid significantly improved swelling, pain and lower ROM restriction in patients undergoing ACL reconstruction.
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Affiliation(s)
- Hamid Mousavi
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Hezar Jarib St., Isfahan, Isfahan Province, Iran
| | - Hossein Akbari-Aghdam
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Hezar Jarib St., Isfahan, Isfahan Province, Iran
| | - Reza Entezari
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical Sciences, Hezar Jarib St., Isfahan, Isfahan Province, Iran.
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Wouters DB. Repair of a meniscus tear within 3 weeks after trauma significantly reduces the likelihood of a recurrent tear compared with later repairs. Knee Surg Sports Traumatol Arthrosc 2023; 31:2246-2250. [PMID: 36995377 DOI: 10.1007/s00167-023-07381-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 03/01/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE To evaluate the potential benefit of meniscus tear repair within 3 weeks after rupture compared with more than 3 weeks after rupture. METHODS Ninety-one patients (95 menisci) underwent repair within 3 weeks after meniscus rupture [Group 1] and 15 patients (17 menisci) [Group 2] underwent repair more than 3 weeks after rupture. The posterior part of the ruptured meniscus was repaired with Contour Arrows®, using a Crossbow as the insertion instrument, whereas the middle third was repaired by inserting PDS 2.0 stitches using a Meniscus Mender® outside-in device. The patients were followed-up for a mean(SD) 8.9 years (range: 1-12 years). RESULTS Of the 91 patients (95 menisci) in Group 1, 88 (96.7%) healed without complications. One meniscus in one patient did not heal after 11 months, requiring resection. Two other menisci in two other patients showed partially healed tears. This part was removed while preserving most of the meniscus (failure rate: 3/91 patients: 3.3%). The other 88 patients recovered without complaints and participated in sports without restraint. Four menisci in four patients experienced a second sports-related incident, resulting in a renewed tear between 12 months and 3 years. These tears were repaired successfully again. Of the 15 patients in Group 2, 12 (80.0%) healed without complications. The ruptured part of the remaining menisci in the other three patients, (20%) was removed, with all patients remaining symptom-free until the end of follow-up. Rates of treatment failure differed significantly in these two groups (3.3% vs 20.0%, p = 0.04). CONCLUSIONS The overall failure rate was significantly lower in patients who underwent meniscus repair within 3 weeks than in those who underwent repair at 3 weeks (or more) after the trauma. Thus, early repair of meniscus tears is beneficial, and can prevent failure of meniscus repair surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Diederick B Wouters
- Department of Surgery, ETZ Hospital, Hilvarenbeekse weg 60, 5022GC, Tilburg, The Netherlands.
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Weng PW, Chen CH, Lin YC, Chen KH, Yeh YY, Lai JM, Chiang CJ, Wong CC. Platelet-Rich Fibrin-Augmented Gap-Bridging Strategy in Rabbit Anterior Cruciate Ligament Repair. Am J Sports Med 2023; 51:642-655. [PMID: 36752674 DOI: 10.1177/03635465221149993] [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] [Indexed: 02/09/2023]
Abstract
BACKGROUND We assessed the efficacy of a novel platelet-rich fibrin (PRF)-augmented repair strategy for promoting biological healing of an anterior cruciate ligament (ACL) midsubstance tear in a rabbit model. The biological gap-bridging effect of a PRF scaffold alone or in combination with rabbit ligamentocytes on primary ACL healing was evaluated both in vitro and in vivo. HYPOTHESIS A PRF matrix can be implanted as a provisional fibrin-platelet bridging scaffold at an ACL defect to facilitate functional healing. STUDY DESIGN Controlled laboratory study. METHODS The biological effects of PRF on primary rabbit ligamentocyte proliferation, tenogenic differentiation, migration, and tendon-specific matrix production were investigated for treatment of cells with PRF-conditioned medium (PRFM). Three-dimensional (3D) lyophilized PRF (LPRF)-cell composite was fabricated by culturing ligamentocytes on an LPRF patch for 14 days. Cell-scaffold interactions were investigated under a scanning electron microscope and through histological analysis. An ACL midsubstance tear model was established in 3 rabbit groups: a ruptured ACL was treated with isolated suture repair in group A, whereas the primary repair was augmented with LPRF and LPRF-cell composite to bridge the gap between ruptured ends of ligaments in groups B and C, respectively. Outcomes-gross appearance, magnetic resonance imaging, and histological analysis-were evaluated in postoperative weeks 8 and 12. RESULTS PRFM promoted cultured ligamentocyte proliferation, migration, and expression of tenogenic genes (type I and III collagen and tenascin). PRF was noted to upregulate cell tenogenic differentiation in terms of matrix production. In the 3D culture, viable cells formed layers at high density on the LPRF scaffold surface, with notable cell ingrowth and abundant collagenous matrix depositions. Moreover, ACL repair tissue and less articular cartilage damage were observed in knee joints in groups B and C, implying the existence of a chondroprotective phenomenon associated with PRF-augmented treatment. CONCLUSION Our PRF-augmented strategy can facilitate the formation of stable repair tissue and thus provide gap-bridging in ACL repair. CLINICAL RELEVANCE From the translational viewpoint, effective primary repair of the ACL may enable considerable advancement in therapeutic strategy for ACL injuries, particularly allowing for proprioception retention and thus improved physiological joint kinematics.
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Affiliation(s)
- Pei-Wei Weng
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei, Taiwan
| | - Chih-Hwa Chen
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Cheng Lin
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Hao Chen
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Biomedical Materials and Engineering, Taipei Medical University, Taipei, Taiwan
| | - Yi-Yen Yeh
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jen-Ming Lai
- Department of Orthopaedic Surgery, Woodlands Health, Singapore
| | - Chang-Jung Chiang
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chin-Chean Wong
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei, Taiwan
- International PhD Program for Cell Therapy and Regenerative Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Amini M, Venkatesan JK, Liu W, Leroux A, Nguyen TN, Madry H, Migonney V, Cucchiarini M. Advanced Gene Therapy Strategies for the Repair of ACL Injuries. Int J Mol Sci 2022; 23:ijms232214467. [PMID: 36430947 PMCID: PMC9695211 DOI: 10.3390/ijms232214467] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/07/2022] [Accepted: 11/19/2022] [Indexed: 11/23/2022] Open
Abstract
The anterior cruciate ligament (ACL), the principal ligament for stabilization of the knee, is highly predisposed to injury in the human population. As a result of its poor intrinsic healing capacities, surgical intervention is generally necessary to repair ACL lesions, yet the outcomes are never fully satisfactory in terms of long-lasting, complete, and safe repair. Gene therapy, based on the transfer of therapeutic genetic sequences via a gene vector, is a potent tool to durably and adeptly enhance the processes of ACL repair and has been reported for its workability in various experimental models relevant to ACL injuries in vitro, in situ, and in vivo. As critical hurdles to the effective and safe translation of gene therapy for clinical applications still remain, including physiological barriers and host immune responses, biomaterial-guided gene therapy inspired by drug delivery systems has been further developed to protect and improve the classical procedures of gene transfer in the future treatment of ACL injuries in patients, as critically presented here.
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Affiliation(s)
- Mahnaz Amini
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
| | - Jagadeesh K. Venkatesan
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
| | - Wei Liu
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
| | - Amélie Leroux
- Laboratoire CSPBAT UMR CNRS 7244, Université Sorbonne Paris Nord, Avenue JB Clément, 93430 Villetaneuse, France
| | - Tuan Ngoc Nguyen
- Laboratoire CSPBAT UMR CNRS 7244, Université Sorbonne Paris Nord, Avenue JB Clément, 93430 Villetaneuse, France
| | - Henning Madry
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
| | - Véronique Migonney
- Laboratoire CSPBAT UMR CNRS 7244, Université Sorbonne Paris Nord, Avenue JB Clément, 93430 Villetaneuse, France
| | - Magali Cucchiarini
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
- Correspondence: or
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TWO TO 14 YEAR OUTCOMES OF COMBINED MENISCAL ALLOGRAFT TRANSPLANTATION WITH ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A SYSTEMATIC REVIEW. Arthroscopy 2022; 39:1584-1592.e1. [PMID: 36343764 DOI: 10.1016/j.arthro.2022.10.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To evaluate the clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with meniscal allograft transplantation (MAT) through systematic review of current available evidence. METHODS A systematic database search of PubMed, Embase, Web of Science and CINAHL was performed from inception up to 7 December 2021 in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Follow-up studies (inception cohort studies/non-randomized controlled trials/retrospective cohort studies) and case series that had more than 10 people published in English, which involved patients who underwent a combination of ACLR and MAT were included. Quality of these studies were appraised using the Cochrane Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Systematic review of International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores were conducted. RESULTS Seven studies involving 363 patients were included. The average mean follow up time was 4.08 years, ranging from 1.75 to 14 years. All studies used the Lysholm Knee Scoring system to report clinical outcomes, while two studies and four studies used the IKDC Questionnaire and Tegner activity scale respectively to measure clinical outcomes post-operatively. Comparing postoperative to pre-operative scores, we found an improvement above the minimal clinically important difference (MCID) for the Lysholm (Mean Difference (MD) range= 16.00 to 26.10) and Tegner activity scores (MD range = 1.50 to 1.90). All but one study reported an increase above the MCID for IKDC scores post-op (MD range= 5.60 to 23.00). CONCLUSIONS Combined MAT and ACLR have good two to 14 year clinical outcomes post operatively and is an optimal procedure for patients with concurrent ACL injuries with irreparable meniscus injuries. More prospective studies and studies evaluating outcome differences between concurrent ACLR with MAT and staged ACLR with MAT should be conducted. LEVEL OF EVIDENCE IV, systematic review and/or meta-analysis of studies with Levels I to IV.
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Li S, Wang S, Liu W, Zhang C, Song J. Current strategies for enhancement of the bioactivity of artificial ligaments: A mini-review. J Orthop Translat 2022; 36:205-215. [PMID: 36263385 PMCID: PMC9576487 DOI: 10.1016/j.jot.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/14/2022] [Accepted: 07/26/2022] [Indexed: 11/08/2022] Open
Abstract
Background and objective Anterior cruciate ligament (ACL) reconstruction calls for artificial ligaments with better bioactivity, however systematic reviews regarding bioactivity enhancement strategies, technologies, and perspectives of artificial ligaments have been rarely found. Methods Research papers, reviews, and clinical reports related to artificial ligaments were searched and summarized the current status and research trends of artificial ligaments through a systematic analysis. Results Having experienced ups and downs since the very first record of clinical application, artificial ligaments differing in material, and fabrication methods have been reported with different clinical performances. Various manufacturing technologies have developed and realized scaffold- and cell-based strategies. Despite encouraging in-vivo and in-vitro test results, the clinical results of such new designs need further clinical examinations. Conclusion As the demand for ACL reconstruction dramatically increases, novel artificial ligaments with better osteoinductivity and mechanical performance are promising. The translational potential of this article To develop novel artificial ligaments simultaneously possessing excellent osteoinductivity and satisfactory mechanical performance, it is important to grab a glance at recent research advances. This systematic analysis provides researchers and clinicians with comprehensive and comparable information on artificial ligaments, thus being of clinical translational significance.
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Affiliation(s)
- Shenglin Li
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107, China,Shenzhen Institute for Drug Control, Shenzhen Testing Center of Medical Devices, Shenzhen, 518057, China
| | - Shuhan Wang
- Shenzhen Institute for Drug Control, Shenzhen Testing Center of Medical Devices, Shenzhen, 518057, China
| | - Wenliang Liu
- Shenzhen Institute for Drug Control, Shenzhen Testing Center of Medical Devices, Shenzhen, 518057, China
| | - Chao Zhang
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107, China
| | - Jian Song
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-sen University, Shenzhen, 518107, China,Corresponding author.
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21
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Qu C, Yang H, Wang C, Wang C, Ying M, Chen Z, Yang K, Zhang J, Li K, Dimitriou D, Tsai TY, Liu X. A deep learning approach for anterior cruciate ligament rupture localization on knee MR images. Front Bioeng Biotechnol 2022; 10:1024527. [PMID: 36246358 PMCID: PMC9561886 DOI: 10.3389/fbioe.2022.1024527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose: To develop and evaluate a deep learning-based method to localize and classify anterior cruciate ligament (ACL) ruptures on knee MR images by using arthroscopy as the reference standard. Methods: We proposed a fully automated ACL rupture localization system to localize and classify ACL ruptures. The classification of ACL ruptures was based on the projection coordinates of the ACL rupture point on the line connecting the center coordinates of the femoral and tibial footprints. The line was divided into three equal parts and the position of the projection coordinates indicated the classification of the ACL ruptures (femoral side, middle and tibial side). In total, 85 patients (mean age: 27; male: 56) who underwent ACL reconstruction surgery under arthroscopy were included. Three clinical readers evaluated the datasets separately and their diagnostic performances were compared with those of the model. The performance metrics included the accuracy, error rate, sensitivity, specificity, precision, and F1-score. A one-way ANOVA was used to evaluate the performance of the convolutional neural networks (CNNs) and clinical readers. Intraclass correlation coefficients (ICC) were used to assess interobserver agreement between the clinical readers. Results: The accuracy of ACL localization was 3.77 ± 2.74 and 4.68 ± 3.92 (mm) for three-dimensional (3D) and two-dimensional (2D) CNNs, respectively. There was no significant difference in the ACL rupture location performance between the 3D and 2D CNNs or among the clinical readers (Accuracy, p < 0.01). The 3D CNNs performed best among the five evaluators in classifying the femoral side (sensitivity of 0.86 and specificity of 0.79), middle side (sensitivity of 0.71 and specificity of 0.84) and tibial side ACL rupture (sensitivity of 0.71 and specificity of 0.99), and the overall accuracy for sides classifying of ACL rupture achieved 0.79. Conclusion: The proposed deep learning-based model achieved high diagnostic performances in locating and classifying ACL fractures on knee MR images.
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Affiliation(s)
- Cheng Qu
- Department of Orthopedics, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Heng Yang
- College of Electrical Engineering, Sichuan University, Chengdu, China
| | - Cong Wang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Chongyang Wang
- Department of Orthopedics, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengjie Ying
- Department of Orthopedics, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zheyi Chen
- Department of Radiology, Shanghai Municipal Eighth People’s Hospital, Shanghai, China
| | - Kai Yang
- Department of Radiology, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Zhang
- College of Electrical Engineering, Sichuan University, Chengdu, China
| | - Kang Li
- West China Hospital, Sichuan University, Chengdu, China
| | - Dimitris Dimitriou
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zurich, Switzerland
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Tsung-Yuan Tsai, ; Xudong Liu,
| | - Xudong Liu
- Department of Orthopedics, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Tsung-Yuan Tsai, ; Xudong Liu,
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22
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Pandey V, Madi S, Thonse C, Joseph C, Rajan D, Varughese J, Thilak J, Jayaprasad PS, Acharya K, Ramamurthy KG, Reddy R, Amravathi R, Rao S, Gangavarapu S, Srinivas M, Jose S, Sundararjan SR. Trends in Primary Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Practice in Adult Patients Prevalent Among Arthroscopy Surgeons of Six Southern States of India. Indian J Orthop 2022; 56:1703-1716. [PMID: 36187588 PMCID: PMC9485326 DOI: 10.1007/s43465-022-00719-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although guidelines from multiple scientific studies decide the general trend in ACLR practice, there is often a variation between scientific guidelines and actual practice. METHODS A 17-member committee comprised of sports surgeons with experience of a minimum of 10 years of arthroscopy surgery finalized a survey questionnaire consisting of concepts in ACL tear management and perioperative trends, intraoperative and post-operative practices regarding single-bundle anatomic ACLR. The survey questionnaire was mailed to 584 registered sports surgeons in six states of south India. A single, non-modifiable response was collected from each member and analyzed. RESULTS 324 responses were received out of 584 members. A strong consensus was present regarding Hamstring tendons preference for ACLR, graft diameter ≥ 7.5 mm, viewing femoral footprint through the anterolateral portal, drilling femoral tunnel from anteromedial portal guided by ridges and remnants of femoral footprint using a freehand technique, suspensory devices to fix the graft in femur and interference screw in the tibia and post-operative bracing. A broad consensus was achieved in using a brace to minimize symptoms of instability of an ACL tear and antibiotic soaking of graft. There was no consensus regarding the timing of ACLR, preferred graft in athletes, pre-tensioning, extra-articular procedure, and return to sports. There was disagreement over hybrid tibial fixation and suture tapes to augment graft. CONCLUSION Diverse practices continue to prevail in the management of ACL injuries. However, some of the consensuses reached in this survey match global practices. Contrasting or inconclusive practices should be explored for potential future research.
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Affiliation(s)
- Vivek Pandey
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Sandesh Madi
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Chirag Thonse
- Vikram Hospital, Millers Road, Bangalore, 560052 India
| | - Clement Joseph
- Arthroscopy and Sports Medicine, SRM Institute for Medical Sciences, Vadapalani, Chennai, Tamil Nadu 600 026 India
| | - David Rajan
- Ortho-One Orthopaedic Speciality Centre, Trichy Road, Singanallur, Coimbatore, Tamil Nadu 641005 India
| | | | - Jai Thilak
- Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala 682 041 India
| | - P. S. Jayaprasad
- Kamineni Hospitals, L.B. Nagar, Bahadurguda, Hyderabad, Telangana 500068 India
| | - Kiran Acharya
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | | | - Raghuveer Reddy
- Krishna Institute of Medical Sciences Secunderabad, Hyderabad, India ,Care Hospitals in Banjara Hills, Hyderabad, India ,Sai Institute of Sports Injury and Arthroscopy in Banjara Hills, Hyderabad, 500 004 India
| | - Rajkumar Amravathi
- St John’s Medical College Hospital, Sarjapur Road, Bangalore, 560034 India
| | - Sharath Rao
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104 India
| | - Sridhar Gangavarapu
- Department of Orthopaedics, Medicover Hospitals, Gokhale Rd, Krishna Nagar, Maharani Peta, Visakhapatnam, Andhra Pradesh 530002 India
| | - Moparthi Srinivas
- Nandan Hospital, Suryarao Pet, Vijayawada, Andhra Pradesh 520002 India
| | - Sujit Jose
- Institute of Advanced Orthopaedics at MOSC Hospital and Medical College, Kolenchery, Ernakulam, Kerala 682311 India
| | - S. R. Sundararjan
- Arthroscopy and Sports Medicine, Ganga Hospital, Coimbatore, 641 043 India
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Thakur U, Gulati V, Shah J, Tietze D, Chhabra A. Anterior cruciate ligament reconstruction related complications: 2D and 3D high-resolution magnetic resonance imaging evaluation. Skeletal Radiol 2022; 51:1347-1364. [PMID: 34977965 DOI: 10.1007/s00256-021-03982-7] [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: 11/04/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 02/02/2023]
Abstract
Anterior cruciate ligament (ACL) injury is a common indication for sports-related major surgery and accounts for a large proportion of ligamentous injuries in athletes. The advancements in 2D and 3D MR imaging have provided considerable potential for a one-stop shop radiation-free assessment with an all-in-one modality examination of the knee, for both soft-tissue and bone evaluations. This article reviews ACL injuries and types of surgical managements with illustrative examples using high resolution 2D and 3D MR imaging. Various complications of ACL reconstruction procedures are highlighted with a focus on the use of advanced MR imaging and relevant arthroscopic correlations.
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Affiliation(s)
- Uma Thakur
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Vaibhav Gulati
- Department of Radiology, Imaging Associates at National Heart Institute, New Delhi, India
| | - Jay Shah
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - David Tietze
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA. .,Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA.
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24
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Nguyen T, Haider S, Tietze D, Xi Y, Thakur U, Shah J, Chhabra A. Anterior cruciate ligament foot plate anatomy: 3-dimensional and 2-dimensional MRI evaluation with arthroscopy assessment in a subset of patients. Eur Radiol 2022; 32:8386-8393. [PMID: 35713663 DOI: 10.1007/s00330-022-08920-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/06/2022] [Accepted: 05/30/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES ACL reconstruction tunnel location is an important predictor for outcomes after surgery. The aim was to establish 3D and 2D MRI radiological measurements for native ACL tibial footprint that can provide information to facilitate pre-operative planning for anatomical graft placement. The measurements were also correlated in a subset of patients on arthroscopy. METHODS Retrospective evaluation of a consecutive series of knee MRIs with both 2D and 3D MR imaging was performed in 101 patients with 43 men and 66 women and ages 39.5 ± 11.9 years. Two measurements were obtained, tibial to ACL and intermeniscal ligament to ACL (T-ACL) and (IM-ACL), respectively. In a cohort of 18 patients who underwent knee arthroscopy, the T-ACL and IML-ACL distances were also determined by an orthopedic surgeon using a standard scale. ICC, Pearson correlation, and Bland-Altman plot were generated. RESULTS For readers 1 and 2, the mean differences between 2D and 3D measurements of T-ACL and IM-ACL were 1.17 and 1.03 mm and 0.65 and 0.65 mm, respectively. The 2D measurements of T-ACL and IM-ACL were larger than the 3D measurements for both readers. The inter-reader reliability was excellent on 2D (0.81-0.96) and fair to excellent on 3D MRI (0.59-0.90). The mean arthroscopic IML-ACL was closer to that of 3D MRI compared to 2D MRI. The mean arthroscopic T-ACL was closer to 2D MRI than 3D MRI. CONCLUSIONS Both 2D and 3D MRI show inter-reader reliability with small inter-modality mean differences in the measurements from the tibial or inter-meniscal ligament margins. KEY POINTS • The mean differences between 2D and 3D measurements of tibia-ACL and intermeniscal ligament-ACL are small (< 1.2 mm). • As compared to arthroscopy, the mean T-ACL and IML-ACL were closer to measurements from 2D and 3D MRI, respectively. • Both 2D and 3D MRI can be reliably used to delineate ACL foot plate anatomy.
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Affiliation(s)
- Toan Nguyen
- Department of Radiology, UT Southwestern Medical Center, Dallas, USA
| | - Shamrez Haider
- Department of Radiology, UT Southwestern Medical Center, Dallas, USA
| | - David Tietze
- Department of Orthopedic Surgery, UT Southwestern Medical Center, UT Southwestern, 5323 Harry Hines Blvd, Dallas, TX, USA
| | - Yin Xi
- Department of Radiology, UT Southwestern Medical Center, Dallas, USA
| | - Uma Thakur
- Department of Radiology, UT Southwestern Medical Center, Dallas, USA
| | - Jay Shah
- Department of Orthopedic Surgery, UT Southwestern Medical Center, UT Southwestern, 5323 Harry Hines Blvd, Dallas, TX, USA
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, USA. .,Department of Orthopedic Surgery, UT Southwestern Medical Center, UT Southwestern, 5323 Harry Hines Blvd, Dallas, TX, USA. .,Johns Hopkins University, Baltimore, USA. .,Walton Centre for Neuroscience, Liverpool, UK.
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25
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Evaluation of anterior cruciate ligament surgical reconstruction through finite element analysis. Sci Rep 2022; 12:8044. [PMID: 35577879 PMCID: PMC9110399 DOI: 10.1038/s41598-022-11601-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/21/2022] [Indexed: 11/08/2022] Open
Abstract
Anterior cruciate ligament (ACL) tear is one of the most common knee injuries. The ACL reconstruction surgery aims to restore healthy knee function by replacing the injured ligament with a graft. Proper selection of the optimal surgery parameters is a complex task. To this end, we developed an automated modeling framework that accepts subject-specific geometries and produces finite element knee models incorporating different surgical techniques. Initially, we developed a reference model of the intact knee, validated with data provided by the Open Knee(s) project. This helped us evaluate the effectiveness of estimating ligament stiffness directly from MRI. Next, we performed a plethora of “what-if” simulations, comparing responses with the reference model. We found that (a) increasing graft pretension and radius reduces relative knee displacement, (b) the correlation of graft radius and tension should not be neglected, (c) graft fixation angle of 20\documentclass[12pt]{minimal}
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\begin{document}$$^{\circ }$$\end{document}∘ can reduce knee laxity, and (d) single-versus double-bundle techniques demonstrate comparable performance in restraining knee translation. In most cases, these findings confirm reported values from comparative clinical studies. The numerical models are made publicly available, allowing for experimental reuse and lowering the barriers for meta-studies. The modeling approach proposed here can complement orthopedic surgeons in their decision-making.
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26
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ACL repair for athletes? J Orthop 2022; 31:61-66. [PMID: 35464814 PMCID: PMC9018522 DOI: 10.1016/j.jor.2022.04.001] [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: 03/29/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/20/2022] Open
Abstract
Background The current gold standard treatment for an anterior cruciate ligament (ACL) tear in an athlete is an arthroscopic ACL reconstruction with autografts. This restores the knee stability but is associated with unique complications like graft re-tear, kinesiophobia and graft donor site morbidity. ACL suture repair (ACLSR) is an attractive alternative method of surgical management of this injury. Current science of ACLSR The potential advantages of performing a repair are the preservation of native biology and proprioceptive function of ACL, elimination of a graft and preservation of bone stock. The purported benefits are better stability, reduction of kinesiophobia and faster rehabilitation. ACLSR is now performed only for proximal (femoral-sided) tears in the acute phase, when the tissue quality is good and using high-strength nonabsorbable sutures. There are several techniques for performing ACLSR but broadly speaking are either non-augmented, static augmented with suture tape, dynamic augmented or using bio-scaffolds. Clinical outcome of ACLSR There is a lot of literature on ACLSRs including case series, cohort studies and randomized controlled trials. The results from these studies are encouraging but mostly pertain to patient reported outcome measures, are in small numbers and in the short-term. The results are also inconsistent across different studies and not specifically performed for the athletic population. Moreover, most of these studies are from the innovator or designer surgeons and groups and have not been independently validated. Conclusion Currently, there is insufficient evidence to recommend ACLSR as a preferred method of managing even acute proximal tears in athletes. Improved rates of return to sports, lower retear rate and lesser kinesiophobia needs to be proven in athletes.
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27
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Wilson WT, Hopper GP, Banger MS, Blyth MJG, Riches PE, MacKay GM. Anterior cruciate ligament repair with internal brace augmentation: A systematic review. Knee 2022; 35:192-200. [PMID: 35366618 DOI: 10.1016/j.knee.2022.03.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/11/2022] [Accepted: 03/21/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Primary repair of anterior cruciate ligament (ACL) ruptures has re-emerged as a treatment option for proximal tears, with internal brace augmentation often utilised. The aim of this study is to provide an overview of the current evidence presenting outcomes of ACL repair with internal bracing to assess the safety and efficacy of this technique. METHODS All studies reporting outcomes of arthroscopic primary repair of proximal ACL tears, augmented with internal bracing from 2014-2021 were included. Primary outcome was failure rate and secondary outcomes were subjective patient reported outcome measures (PROMs) and objective assessment of anteroposterior knee laxity. RESULTS Nine studies were included, consisting of 347 patients, mean age 32.5 years, mean minimum follow up 2 years. There were 36 failures (10.4%, CI 7.4% - 14.1%). PROMs reporting was variable across studies. KOOS, Lysholm and IKDC scores were most frequently used with mean scores > 87%. The mean Tegner and Marx scores at follow-up were 6.1 and 7.8 respectively. The mean side to side difference measured for anteroposterior knee laxity was 1.2mm. CONCLUSIONS This systematic review with meta-analysis shows that ACL repair with internal bracing is a safe technique for treatment of proximal ruptures, with a failure rate of 10.4%. Subjective scores and clinical laxity testing also revealed satisfactory results. This suggests that ACL repair with internal bracing should be considered as an alternative to ACL reconstruction for acute proximal tears, with the potential benefits of retained native tissue and proprioception, as well as negating the need for graft harvest.
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Affiliation(s)
- W T Wilson
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK; NHS Greater Glasgow & Clyde, Glasgow, UK.
| | - G P Hopper
- NHS Greater Glasgow & Clyde, Glasgow, UK.
| | - M S Banger
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK.
| | | | - P E Riches
- Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK.
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28
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Hourston GJM, Kankam HKN, McDonnell SM. A systematic review of anterior cruciate ligament primary repair rehabilitation. J Clin Orthop Trauma 2022; 25:101774. [PMID: 35127441 PMCID: PMC8803614 DOI: 10.1016/j.jcot.2022.101774] [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: 07/26/2021] [Revised: 12/16/2021] [Accepted: 01/17/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Rehabilitation after surgery of the injured anterior cruciate ligament (ACL) is crucial for satisfactory outcomes. Many trials have investigated this process after ACL reconstruction. The treatment of acute ACL ruptures with a repair technique has recently regained interest, although very little information is available about appropriate rehabilitation for such patients. The objective of this review was to evaluate studies on rehabilitation following ACL repair. METHODS A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted for patients undergoing a rehabilitation programme after ACL repair. The review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO, Registration number: CRD42020173450). Elements of rehabilitation care we included in our strategy are postoperative bracing, home-based rehabilitation, strengthening exercises, proprioception and neuromuscular training. We searched PubMed, CINAHL, EMBASE, and the Cochrane Library for randomised trials of any form investigating rehabilitation protocols after repair of the injured ACL. Two reviewers independently assessed eligibility of trials. RESULTS No trials were included. Available literature of lower evidence was included for discussion. CONCLUSIONS No information is available from randomised trials to indicate whether there is any difference between rehabilitation protocols for patients who have undergone primary ACL repair.
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Affiliation(s)
- George JM. Hourston
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
- Corresponding author. Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0QQ, UK.
| | - Hadyn KN. Kankam
- Department of Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
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Different timing in allograft and autograft maturation after primary anterior cruciate ligament reconstruction does not influence the clinical outcome at mid-long-term follow-up. Knee Surg Sports Traumatol Arthrosc 2022; 30:2281-2290. [PMID: 34782927 PMCID: PMC8592808 DOI: 10.1007/s00167-021-06785-4] [Citation(s) in RCA: 2] [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: 04/06/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE The use of allografts in primary anterior cruciate ligament reconstruction (ACLR) is increasing although they are still supposed to be associated to greater risk of re-rupture due to a slower and less efficient graft maturation. The aim of this prospective randomized controlled study was to compare the graft maturation after ACLR with allograft and autograft by MRI at 6- and 12-month follow-up and integrate these data with the functional and clinical results observed at 6-, 12- and 60-month follow-up. METHODS Fifty patients with indication to primary ACLR were randomly and equally divided into hamstring autograft or allograft tendon groups. The graft maturation was measured at 6- and 12-month follow-up by the SNQ score and other radiological parameters on MRI scans. Clinical and functional recovery was evaluated by Lysholm score, Visual Analogues Scale, Tegner activity scale and modified Cincinnati knee rating system at 6, 12 and 60 months after surgery to estimate the predictive value of the radiological parameters for clinical outcomes. Return-to-sport (ACL-RSI) was measured 60 months after surgery. RESULTS Three patients had retear of the neo-ligament (two from Auto group and one from Allo group). All the clinical/functional parameters significantly improved over time, with no statistically significant difference between the groups. At 6 months, the SNQ value was significantly higher in the Auto than in the Allo group (12.9 vs 7.9, p = 0.038), but at 12 months they were comparable (9.8 vs 10.4). The 6-month SNQ values did not correlate with the clinical scores, whereas the 12-month SNQ values significantly correlated with the Cincinnati score, Lysholm score and Tegner activity scale collected at 60-month follow-up. CONCLUSION No clinical or functional differences have been found between the two treatment groups, supporting the suitability of using allograft in primary ACLR, when available. The results at MRI scans showed a different graft maturation trend in the two groups, with allografts being more reactive in the first 6 months. MRI together with the subjective evaluation allows to evaluate objectively the status of the neo-ligamentization process and therefore helps the surgeon to dictate the individual time for return-to-sport. LEVEL OF EVIDENCE Level I.
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30
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Shang Z, Li D, Chen J, Wang M, Zhang B, Wang X, Ma B. The Role of Biodegradable Magnesium and Its Alloys in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis Based on Animal Studies. Front Bioeng Biotechnol 2021; 9:789498. [PMID: 34869297 PMCID: PMC8636800 DOI: 10.3389/fbioe.2021.789498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/20/2021] [Indexed: 12/09/2022] Open
Abstract
Objective: The actual efficacy of magnesium and its alloy in anterior cruciate ligament reconstruction (ACLR) was systematically evaluated to reduce the risk of translation from animal experiments to the clinic. Methods: Databases of PubMed, Ovid-Embase, Web of Science, CNKI, Wanfang, VIP, and CBM were searched for literature in July 2021. Screening of search results, data extraction, and literature quality evaluation were undertaken independently by two reviewers. Results and discussion: Seven articles were selected for the meta-analysis. The results showed that the mechanical properties of the femoral-tendon graft–tibia complex fixed with magnesium and its alloys were comparable to those fixed with titanium and its alloys, and magnesium and its alloys were superior to titanium and its alloys in promoting new bone formation. In addition, the unique biodegradability made magnesium and its alloys an orthopedic implant with significant therapeutic potential. However, whether the degradation rate of magnesium and its alloy can match the rate of bone-tendon integration, and whether the bioconjugation of bone-tendon after degradation can meet the exercise load still needs to be explored in further detail. Simultaneously, it is necessary for future research to improve and standardize experimental design, result measurement, etc., so as to minimize the risk of transforming animal experimental results into clinical practice.
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Affiliation(s)
- Zhizhong Shang
- The First Clinical Medical School of Lanzhou University, Lanzhou, China
| | - Dongliang Li
- The First Clinical Medical School of Lanzhou University, Lanzhou, China
| | - Jinlei Chen
- The First Clinical Medical School of Lanzhou University, Lanzhou, China
| | - Mingchuan Wang
- The First Clinical Medical School of Lanzhou University, Lanzhou, China
| | - Baolin Zhang
- The First Clinical Medical School of Lanzhou University, Lanzhou, China
| | - Xin Wang
- The First Clinical Medical School of Lanzhou University, Lanzhou, China.,Department of Spine, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Bin Ma
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
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Hudson DM, Archer M, Rai J, Weis M, Fernandes RJ, Eyre DR. Age-related type I collagen modifications reveal tissue-defining differences between ligament and tendon. Matrix Biol Plus 2021; 12:100070. [PMID: 34825162 PMCID: PMC8605237 DOI: 10.1016/j.mbplus.2021.100070] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 12/21/2022] Open
Abstract
Tendon and ligament collagens differ in their post-translational lysine and cross-linking chemistry. In ligament collagen, hydroxylysyl aldehyde, permanent cross-linking dominates. Tendon collagen has a mix of cross-links based on lysyl and hydroxylysyl aldehydes. The profile in tendon appears more adapted to facilitating growth, structural remodeling and repair of the fibrillar matrix.
Tendons and ligaments tend to be pooled into a single category as dense elastic bands of collagenous connective tissue. They do have many similar properties, for example both tissues are flexible cords of fibrous tissue that join bone to either muscle or bone. Tendons and ligaments are both prone to degenerate and rupture with only limited capacity to heal, although tendons tend to heal faster than ligaments. Type I collagen constitutes about 80% of the dry weight of tendons and ligaments and is principally responsible for the core strength of each tissue. Collagen synthesis is a complex process with multiple steps and numerous post-translational modifications including proline and lysine hydroxylation, hydroxylysine glycosylation and covalent cross-linking. The chemistry, placement and quantity of intramolecular and intermolecular cross-links are believed to be key contributors to the tissue-specific variations in material strength and biological properties of collagens. As tendons and ligaments grow and develop, the collagen cross-links are known to chemically mature, strengthen and change in profile. Accordingly, changes in cross-linking and other post-translational modifications are likely associated with tissue development and degeneration. Using mass spectrometry, we have compared tendon and ligaments from fetal and adult bovine knee joints to investigate changes in collagen post-translational properties. Although hydroxylation levels at the type I collagen helical cross-linking lysine residues were similar in all adult tissues, ligaments had significantly higher levels of glycosylation at these sites compared to tendon. Differences in lysine hydroxylation were also found between the tissues at the telopeptide cross-linking sites. Total collagen cross-linking analysis, including mature trivalent cross-links and immature divalent cross-links, revealed unique cross-linking profiles between tendon and ligament tissues. Tendons were found to have a significantly higher frequency of smaller diameter collagen fibrils compared with ligament, which we suspect is functionally associated with the unique cross-linking profile of each tissue. Understanding the specific molecular characteristics that define and distinguish these specialized tissues will be important to improving the design of orthopedic treatment approaches.
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Key Words
- ACL, Anterior cruciate ligament
- Collagen
- Cross-linking
- DHLNL, dehydrohydroxylysinonorleucine
- HHL, histidinohydroxylysinonorleucine
- HHMD, histidinohydroxymerodesmosine
- HLNL, hydroxylysinonorleucine
- HP, hydroxylysine pyridinoline
- LC, liquid chromatography
- LCL, lateral collateral ligament
- LP, lysine pyridinoline
- Ligament
- MCL, medial collateral ligament
- MS, mass spectrometry
- Mass spectrometry
- P3H1, prolyl 3-hydroxylase 1
- P3H2, prolyl 3-hydroxylase 2
- PCL, posterior cruciate ligament
- Post-translational modifications
- QT, quadriceps tendon
- Tendon
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Affiliation(s)
- David M. Hudson
- Corresponding author at: BB1052 Health Science Building, 1959 NE Pacific St, Seattle, WA 98195, United States.
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Suture tape augmentation ACL repair, stable knee, and favorable PROMs, but a re-rupture rate of 11% within 2 years. Knee Surg Sports Traumatol Arthrosc 2021; 29:3706-3714. [PMID: 33386882 DOI: 10.1007/s00167-020-06399-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study is to investigate clinical and magnetic resonance imaging (MRI) outcomes after anterior cruciate ligament (ACL) repair using the suture tape augmentation (STA) technique. METHODS This prospective interventional case series included 35 patients who underwent STA ACL repair and were all followed up for 2 years. The ACL rupture was between 4 and 12 weeks old and per-operatively confirmed repairable. The International Knee Documentation Committee (IKDC), and Lysholm and Tegner scores were collected together with return to work (RTW), return to sport (RTS), re-rupture, and re-intervention rate. Lachman testing was performed and ACL healing was evaluated on MRI using a grading scale based on the ACL's morphology and signal intensity with grade 1 representing good ACL healing and grade 3 representing poor ACL healing. RESULTS The number of patients who returned to their pre-rupture level for IKDC, Lysholm, and Tegner scores at 2 years of follow-up are 17/26 (65.4%), 13/25 (52.0%), and 18/27 (66.7%) patients, respectively. Median RTW and RTS periods were 5.5 weeks (range 0-32 weeks) and 6 months (range 2-22 months), respectively. The Lachman side-to-side difference decreased significantly (P < 0.001) to less than 3 mm after surgery and remained stable. Four patients [11.4%, 95% CI (3.2, 26.7)] suffered from a re-rupture and three other patients [8.6%, 95% CI (1.8, 23.1)] needed a re-intervention for another reason than re-rupture. MRI follow-up of 31 patients showed overall grade 1 ACL healing in 14 (45.2%) patients, grade 2 ACL healing in 11 (35.5%) patients, and grade 3 ACL healing in 6 (19.4%) patients. A higher risk of re-rupture was associated with grade 3 ACL healing at 6 months post-operatively and a pre-operative Tegner score of ≥ 7. CONCLUSION This study shows that treatment of the acute, repairable ACL with the STA technique leads to a stable knee and favorable patient-reported outcome measures (PROMs). However, the re-rupture rate of 11.4% within the 2-year follow-up is a concern. LEVEL OF EVIDENCE IV.
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Bartolin PB, Boixadera R, Hudetz D. Experimental testing and finite element method analysis of the anterior cruciate ligament primary repair with internal brace augmentation. Med Eng Phys 2021; 95:76-83. [PMID: 34479695 DOI: 10.1016/j.medengphy.2021.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 11/25/2022]
Abstract
The internal brace (IB) technique is a promising treatment option for repairing the proximal rupture of the anterior cruciate ligament (ACL). This paper presents a biomechanical evaluation of the IB technique. Sixteen cadaveric sheep knees underwent monotonic tensile tests, cyclic loading, and passive flexion-extension testing. Data were compared in a series of eight control specimens with an intact ACL and eight repaired specimens where the ACL was cut and repaired using the IB. In parallel with the mechanical testing, finite element analysis (FEA) was performed to investigate the influence of IB loading on the femur-ACL-tibia complex (FATC). The 3D geometry of the FATC was reconstructed from CT scans of the sheep. The IB 3D model was integrated with the 3D FATC for FEA to obtain the femur-repaired ACL with IB - tibia complex (FRA-IB-TC) group. For the intact specimens, the mean (±SD) failure load in the tensile testing was 937 N (±192 N), while for the FRA-IB-TC specimens, it was 519 N (±52 N). The FRA-IB-TC remained biomechanically stable during the cyclic loading testing. The FEA demonstrated an increase in ACL stress to 24.59 MPa and displacement values of 0.391 mm. The IB construct exhibited shear and notch effects at the button-suture-bone fixation site. Testing on this sheep model allowed us a parametric analysis of the impact of the IB repair technique. However, the results will need to be confirmed in a human model. In conclusion, although the IB technique has biomechanical drawbacks, the mechanical properties of the technique are satisfactory.
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Affiliation(s)
- Petra Bonačić Bartolin
- PhD Student/Teaching Assistant at the Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.
| | - Rachel Boixadera
- Medical Student at University of Cambridge, Cambridge, United Kingdom
| | - Damir Hudetz
- Faculty of Medicine, Assistant Professor at the University of Osijek, Osijek, Croatia
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Wu J, Kator JL, Zarro M, Leong NL. Rehabilitation Principles to Consider for Anterior Cruciate Ligament Repair. Sports Health 2021; 14:424-432. [PMID: 34344237 DOI: 10.1177/19417381211032949] [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: 11/17/2022] Open
Abstract
CONTEXT Injury to the anterior cruciate ligament (ACL) is among the most common orthopaedic injuries, and reconstruction of a ruptured ACL is a common orthopaedic procedure. In general, surgical intervention is necessary to restore stability to the injured knee, and to prevent meniscal damage. Along with surgery, intense postoperative physical therapy is needed to restore function to the injured extremity. ACL reconstruction (ACLR) has been the standard of care in recent decades, and advances in surgical technology have reintroduced the prospect of augmented primary repair of the native ACL via a variety of methods. EVIDENCE ACQUISITION A search of PubMed database of articles and reviews available in English was performed through 2020. The search terms ACLR, anterior cruciate ligament repair, bridge enhanced acl repair, suture anchor repair, dynamic intraligamentary stabilization, internal bracing, suture ligament augmentation, and internal brace ligament augmentation were used. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 5. RESULTS No exact consensus exists on effective rehabilitation protocols after ACL repair techniques, as the variation in published protocols seem even greater than the variation in those for ACLR. For some techniques such as internal bracing and dynamic interligamentary stabilization, it is likely permissible for the patients to progress to full weightbearing and discontinue bracing sooner. However, caution should be applied with regard to earlier return to sport than after ACLR as to minimize risk for retear. CONCLUSION More research is needed to address how physical therapies must adapt to these innovative repair techniques. Until that is accomplished, we recommend that physical therapists understand the differences among the various ACL surgery techniques discussed here and work with the surgeons to develop a rehabilitation protocol for their mutual patients. STRENGTH OF RECOMMENDATION TAXONOMY (SORT) C.
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Affiliation(s)
- Jocelyn Wu
- Department of Orthopaedic Surgery, University of Maryland Baltimore, Baltimore, Maryland
| | - Jamie L Kator
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael Zarro
- Department of Physical Therapy, University of Maryland Baltimore, Baltimore, Maryland
| | - Natalie L Leong
- Department of Orthopaedic Surgery, University of Maryland Baltimore, Baltimore, Maryland.,Department of Surgery, Baltimore VA Medical Center, Baltimore, Maryland
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Mehier C, Ract I, Metten MA, Najihi N, Guillin R. Primary anterior cruciate ligament repair: magnetic resonance imaging characterisation of reparable lesions and correlation with arthroscopy. Eur Radiol 2021; 32:582-592. [PMID: 34255158 DOI: 10.1007/s00330-021-08155-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/05/2021] [Accepted: 06/14/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES A recent treatment algorithm suggests that proximal anterior cruciate ligament (ACL) tears with good-to-excellent tissue quality are amenable to primary repair. Our primary objective was to assess the ability of MRI to determine the exact tear location and tissue quality, using arthroscopy as a reference standard. METHODS In an initial sample of 71 patients with prior ACL surgery (repair or reconstruction), the diagnostic accuracy of MRI was assessed using arthroscopy as a reference standard. Each native ACL tear was graded according to Sherman's arthroscopic classifications during the surgical procedure. MRI scans were retrospectively reviewed for grading, blinded to arthroscopic findings and in consensus by two musculoskeletal radiologists. Tear location and tissue quality were graded using the MRI Sherman tear location (MSTL), MRI Sherman tissue quality (MSTQ) and simplified MRI Sherman tissue quality (S-MSTQ) classifications. Intra- and inter-observer agreement was assessed on a second sample of 77 patients. MRI classification accuracy was compared by McNemar's tests. Intra- and inter-observer agreement was assessed using Cohen's kappa coefficient. RESULTS Regarding tear location, diagnostic accuracy was 70% (50/71) based on the MSTL classification. Diagnostic accuracy for tissue quality was 52% (15/29) based on the MSTQ classification and 90% (26/29) for the S-MSTQ classification (p = 0.003). Inter-observer agreement was good for MSTL (κ = 0.78) and moderate-to-good for the MSTQ and S-MSTQ classifications (κ = 0.44 and 0.63 respectively). CONCLUSIONS MRI seems to be accurate in assessing tear location and tissue quality and may help clinicians to predict the reparability of ACL tears. KEY POINTS • MRI seems to be accurate in assessing tear location and tissue quality and may help clinicians to predict the reparability of ACL tears. • High intra-observer agreement was demonstrated when grading the tear location into one of five types. • The diagnostic accuracy of the simplified MRI tissue quality classification, involving deletion of the ligament stump signal criterion, was better than that observed with the MRI Sherman tissue quality classification, but was moderate to good in terms of inter- and intra-observer agreement.
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Affiliation(s)
- Clement Mehier
- Department of Radiology, Rennes University Hospital, 2 Rue Henri le Guilloux, 35000, Rennes, France.
| | - Isabelle Ract
- Department of Radiology, Rennes University Hospital, 2 Rue Henri le Guilloux, 35000, Rennes, France
| | - Marie-Astrid Metten
- University of Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Research Institute for Environmental and Occupational Health) - UMR_S 1085, F-35000, Rennes, France
| | - Nabil Najihi
- Department of Orthopaedic Surgery, St Laurent Hospital, 320 Av. Général George S. Patton, 35700, Rennes, France
| | - Raphael Guillin
- Department of Radiology, Rennes University Hospital, 2 Rue Henri le Guilloux, 35000, Rennes, France
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Chona D, Eriksson K, Young SW, Denti M, Sancheti PK, Safran M, Sherman S. Return to sport following anterior cruciate ligament reconstruction: the argument for a multimodal approach to optimise decision-making: current concepts. J ISAKOS 2021; 6:344-348. [PMID: 34088854 DOI: 10.1136/jisakos-2020-000597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 11/03/2022]
Abstract
Existing literature is varied in the methods used to make this determination in the treatment of athletes who have undergone recent anterior cruciate ligament (ACL) reconstruction. Some authors report using primarily time-based criteria, while others advocate for physical measures and kinematic testing to inform decision-making. The goal of this paper is to elucidate the most current medical evidence regarding identification of the earliest point at which a patient may safely return to sport. The present review therefore seeks to examine the evidence from a critical perspective-breaking down the biology of graft maturation, effect of graft choice, potential for image-guided monitoring of progression and results associated with time-based versus functional criteria-based return to play-to justify a multifactorial approach to effectively advance athletes to return to sport. The findings of the present study reaffirm that time is a prerequisite for the biological progression that must occur for a reconstructed ligament to withstand loads demanded by athletes during sport. Modifications of surgical techniques and graft selection may positively impact the rate of graft maturation, and evidence suggests that imaging studies may offer informative data to enhance monitoring of this process. Aspects of both functional and cognitive testing have also demonstrated utility in prior studies and consequently have been factored into modern proposed methods of determining the athlete's readiness for sport. Further work is needed to definitively determine the optimal method of clearing an athlete to return to sport after ACL reconstruction. Evidence to date strongly suggests a role of a multimodal algorithmic approach that factors in time, graft biology and functional testing in return-to-play decision-making after ACL reconstruction.Level of evidence: level V.
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Affiliation(s)
- Deepak Chona
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Karl Eriksson
- Orthopedic Surgery, Stockholm South Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Simon W Young
- North Shore Hospital, University of Auckland, Auckland, New Zealand
| | - Matteo Denti
- Institute for Hospitalization and Care Scientific Galeazzi Orthopaedic Institute, Milano, Italy
| | - Parag K Sancheti
- Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra, India
| | - Marc Safran
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Seth Sherman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
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Blessing WA, Williamson AK, Kirsch JR, Grinstaff MW. The Prognosis of Arthrofibroses: Prevalence, Clinical Shortcomings, and Future Prospects. Trends Pharmacol Sci 2021; 42:398-415. [PMID: 33795150 DOI: 10.1016/j.tips.2021.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/18/2021] [Accepted: 02/28/2021] [Indexed: 02/06/2023]
Abstract
Fibrosis is the dysregulated biosynthesis of connective tissue that results from persistent infection, high serum cholesterol, surgery, trauma, or prolonged joint immobilization. As a disease that impacts connective tissue, it is prevalent across the body and disrupts normal extracellular and tissue organization. Ultimately, fibrosis impairs the tissue structural, mechanical, or biochemical function. This review describes the clinical landscape of joint fibrosis, that is, arthrofibrosis, including the risk factors and causes, as well as current clinical treatments and their shortcomings. Because treating arthrofibrosis remains an unmet clinical challenge, we present several animal models used for exploration of the physiopathology of arthrofibrosis and summarize their use for testing novel treatments. We then discuss therapeutics for the prevention or treatment of arthrofibrosis that are in preclinical development and in ongoing clinical trials. We conclude with recent findings from molecular biological studies of arthrofibroses that shed insight on future areas of research for improved treatments.
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Affiliation(s)
- William A Blessing
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
| | - Amanda K Williamson
- Departments of Biomedical Engineering, Chemistry, and Medicine, Boston University, Boston, MA 02215, USA
| | - Jack R Kirsch
- Departments of Biomedical Engineering, Chemistry, and Medicine, Boston University, Boston, MA 02215, USA
| | - Mark W Grinstaff
- Departments of Biomedical Engineering, Chemistry, and Medicine, Boston University, Boston, MA 02215, USA.
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ACL Repair: A Game Changer or Will History Repeat Itself? A Critical Appraisal. J Clin Med 2021; 10:jcm10050912. [PMID: 33652689 PMCID: PMC7956607 DOI: 10.3390/jcm10050912] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/05/2021] [Accepted: 02/22/2021] [Indexed: 01/13/2023] Open
Abstract
Until the past decade the common thought was that the anterior cruciate ligament (ACL) was not able to heal and restore knee stability. In this manuscript a brief review of studies of the developers and the early adaptors of four different modern ACL repair techniques are presented. The present status and considerations for the future of ACL repair and its research are shared. After promising short- to midterm ACL healing results by the developers, the results of the early adaptors show more variety in terms of rerupture and reintervention for other reasons. Risk factors for failure are a young age, high preinjury sports activity level, midsubstance ruptures and impaired integrity of the ACL bundles and the synovial sheath. There is a call for more clinical data and randomized clinical trials. Conclusion: an important finding of the past decade is that the ACL is able to heal and subsequently restabilize the knee. Patient selection is emphasized: the ideal patient is a non-high athlete older than 25 and has an acute proximal one bundle ACL rupture. Further research will have to show if ACL repair could be a game changer or if history will repeat itself.
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Suture Tape Augmentation Has No Effect on Anterior Tibial Translation, Gap Formation, or Load to Failure of Anterior Cruciate Ligament Repair: A Biomechanical Pilot Study. Arthrosc Sports Med Rehabil 2021; 3:e233-e239. [PMID: 33615270 PMCID: PMC7879211 DOI: 10.1016/j.asmr.2020.09.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/19/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose The purpose of our pilot study was to assess the effect of augmenting anterior cruciate ligament (ACL) repair with suture tape on biomechanical parameters including anterior tibial translation, gap formation, and load to failure. Methods Ten fresh-frozen nonpaired cadaveric knees were dissected, and baseline anterior-posterior stability of both ACL-intact and -deficient knees was obtained. The specimens were randomized to undergo ACL repair either with or without suture tape reinforcement, and anterior tibial translation, as well as gap formation, was measured after cyclic loading. Finally, all specimens were subjected to a single pullout force to determine maximum load to failure. We performed t test analysis to compare means between groups, and significance was defined as P < .05. Results On t test analysis, no statistically significant difference was found regarding anterior tibial translation between the ACL-intact group and either repair group or between the repair group without suture tape augmentation and the repair group with suture tape augmentation. No significant difference in gap formation was detected between the repair groups with and without suture tape augmentation at 100 cycles (1.25 mm vs 1.02 mm, P = .6), 250 cycles (2.87 mm vs 2.12 mm, P = .3), and 500 cycles (4.5 mm vs 4.55 mm, P = .5). The average load to failure of the repairs without suture tape augmentation was not significantly different from that of the repairs with suture tape augmentation (725.9 N vs 725.7 N, P = .99). Conclusions In this pilot study, we did not identify a difference between ACL repairs with and without suture tape augmentation regarding anterior tibial translation, gap formation, or maximum load to failure. Clinical Relevance Treatment of ACL tears with primary ACL repair is a highly debated topic, and studies such as this study to further our understanding of the biomechanical properties of augmented ACL repairs are important for surgeons when deciding the best treatments for their patients.
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Determinants of regeneration and strength of hamstrings after anterior cruciate ligament reconstruction-fate of hamstring tendon. INTERNATIONAL ORTHOPAEDICS 2021; 45:1751-1760. [PMID: 33409561 DOI: 10.1007/s00264-020-04932-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/29/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Arthroscopic reconstruction of anterior cruciate ligament (ACL) surgical procedure using hamstring autograft is the most common surgery performed in the arena of sports medicine and arthroscopy. Most studies in literature are ambiguous regarding the fate of hamstrings based on function, regenerative potential, and cross-sectional area (CSA). The aim of this research study is analysis of the fate of hamstring tendons (both semitendinosus and gracilis) during the time course for determinants of regeneration and strength. METHODS Fifty patients who were operated for unilateral isolated ACL reconstruction from July 2015 to June 2018 were evaluated for the fate of harvested hamstring tendons which included the following: regeneration, cross-sectional area (CSA), strength, and insertion of regenerated hamstrings by isometric torque and isokinetic strength. MRI of knee was performed for both knees concerning the semitendinosus (ST), gracilis (G), Sartorius, biceps femoris, and medial head of gastrocnemius. RESULTS Eighty-four percent men and 16% women within a mean patient age of 34 ± 4.12 years were evaluated and all 50 (100%) patients demonstrated hamstring regeneration by the MRI measurements at six months and at one year post-ACL reconstruction. The torque of isometric knee flexion measured in 60° was found to be remarkably lower in the ACL-reconstructed lower extremity compared to that of the contralateral limb (87.13 ± 20.18% of BW), at 90° (49.17 ± 15.09% BW), and at 105° (43.91 ± 13.17% BW), respectively (p < 0.01). However, at 30° flexion and 45° flexion, the difference was insignificant (116.48 ± 21.07% BW for 30° and 100.16 ± 25.12% BW for 45°). CONCLUSIONS It was found that the properties of musculotendinous units of ST and G were significantly transformed after their harvesting for ACL reconstruction and these weaknesses contribute to the flexion deficit of knee in the deeper range of flexion in the operated limb. Therefore, approaches facilitating tendon regeneration and preservation must be warranted.
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Comments on the article "high complication rate following dynamic intraligamentary stabilization for primary repair of the anterior cruciate ligament": the story of the cyclops syndrome is not over. Knee Surg Sports Traumatol Arthrosc 2021; 29:1011-1012. [PMID: 31209541 PMCID: PMC7917038 DOI: 10.1007/s00167-019-05527-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/29/2019] [Indexed: 11/20/2022]
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Anterior cruciate ligament tear patterns in young patients: An arthroscopic multicenter study. J Clin Orthop Trauma 2021; 16:168-175. [PMID: 33717953 PMCID: PMC7920093 DOI: 10.1016/j.jcot.2020.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/16/2020] [Accepted: 12/24/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In the last decade, there has been a renewed interest in anterior cruciate ligament (ACL) preservation surgeries in the younger patients. Several ACL preservation techniques such as primary repair, augmented repair, and scaffold repair have been described based on the particular tear type and pattern. The purpose of this study was to determine the distribution of tear patterns in young patients presenting with an acute ACL injury. METHODS A prospective observational study was performed at two tertiary children's hospitals. Patients under 18 years undergoing ACL reconstruction within 8 weeks of initial injury were included from 2017 to 2019. Tear patterns were classified by two orthopedic surgeons from each of the two centers during arthroscopic ACL reconstruction into 4 types: I. Avulsion off the femur, II. <10% of total ACL length tear from femoral end, III. Mid-substance tear and IV. Single bundle tear. For reliability, the four surgeons classified ACL injury (2 rounds each) based on de-identified intraoperative videos of 33 randomly selected surgical ACL cases. Inter and intra-rater reliability studies were calculated using Kappa statistics. RESULTS 224 patients (123 males, 101 females) with mean age of 16 (range: 9-18) years were enrolled in this study. Fifty-seven (25%) patients reported contact injury while 167 (75%) reported non-contact. Isolated ACL injury was recorded in 70 (31%) patients, while concomitant injuries were recorded in 154 patients (69%). The most common associated injury was lateral meniscus tear (35%), followed by lateral and medial meniscus tears (20%). According to our classification, 31 (14%) patients were Type I, 30 (13%) were Type II, 139 (62%) were Type III, 18 (8%) were Type IV. The intra-rater reliability was excellent for 2 reviewers, good for 1 and marginal for another. The overall inter-rater reliability for all 4 reviewers was marginal for both readings. There was no statistical difference in the occurrence of type of tear based on the mechanism of injury (contact vs non-contact) or age of the patients. CONCLUSIONS This is the first multicenter study using an arthroscopic assessment to classify the location of ACL tear in the young population. It gives us further insight on the possible application for surgeries to preserve the ACL in this group. Larger studies incorporating these findings with MRI evaluation and ACL repair techniques are needed to confirm the utility of this information to decide the eligibility for repair in pediatric patients.
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Vega JF, Strnad GJ, Briskin I, Cox CL, Farrow LD, Fadale P, Flanigan D, Hulstyn M, Imrey PB, Kaeding CC, Owens BD, Saluan P, Wright R, Yen YM, Spindler KP. Interrater Agreement of an Arthroscopic Anterior Cruciate Ligament Tear Classification System. Orthop J Sports Med 2020; 8:2325967120966323. [PMID: 33330736 PMCID: PMC7720329 DOI: 10.1177/2325967120966323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/07/2020] [Indexed: 01/13/2023] Open
Abstract
Background Anterior cruciate ligament (ACL) rupture is the most common ligament injury treated surgically by orthopaedic surgeons. The gold standard for the treatment of the majority of primary ACL tears is ACL reconstruction. However, novel methods of repair, such as bridge-enhanced ACL repair (BEAR), are currently being investigated as alternatives to reconstruction. To assess patients for midsubstance repair suitability, clarify the prognostic implications of injury location and damage, and evaluate the results of a repair technique, it is important to have a baseline classification system or grading scale that is reproducible across surgeons, particularly for multicenter collaboration. Currently, no such system or scale exists. Purpose To develop an arthroscopic ACL tear classification system and to evaluate its interobserver reliability. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods Eleven fellowship-trained orthopaedic surgeon investigators reviewed 75 video clips containing arthroscopic evaluation of a torn ACL and then completed the 6-question ACL Pathology Evaluation Form. Agreement statistics including exact agreement, Fleiss κ, Gwet agreement coefficient 1 (AC1), and Gwet AC2 were then calculated to assess interobserver reliability. Results In aggregate, the multiple assessments of observer reproducibility revealed that surgeon participants in this study, when evaluating the same injury, agreed roughly 80% of the time on whether (1) at least 50% of the tibial footprint remained, (2) the remaining tibial stump was ≥10 mm, and (3) the injury was therefore reparable using the BEAR procedure. Participants also agreed roughly 60% of the time on exactly how many suturable bundles were available. These characteristics are believed to be most important, among those studied, in determining whether a torn ACL is amenable to midsubstance repair. Conclusion This study is the first of its kind to demonstrate the interobserver reliability of arthroscopic classification of ACL tears. We have demonstrated that this classification system, though not ideally reproducible, is reliable enough across surgeons at multiple institutions for use in multicenter studies. Registration NCT03776162 (ClinicalTrials.gov identifier).
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Affiliation(s)
| | - José F Vega
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Gregory J Strnad
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Isaac Briskin
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles L Cox
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Lutul D Farrow
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Fadale
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - David Flanigan
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Hulstyn
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Peter B Imrey
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Brett D Owens
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Saluan
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Rick Wright
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Yi-Meng Yen
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Kurt P Spindler
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
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The "Motionless Gastrocnemius": A Reliable Sign for Safe Graft Harvesting. Arthrosc Tech 2020; 9:e1879-e1884. [PMID: 33381395 PMCID: PMC7768048 DOI: 10.1016/j.eats.2020.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/10/2020] [Indexed: 02/03/2023] Open
Abstract
Difficulties in graft harvesting of the hamstring have been the topic of many studies. These difficulties are related to the aponeurotic or fibrous attachments of the hamstrings with the medial head of the gastrocnemius muscle, soleus muscle, and leg fascia. Freeing the graft from these attachments is important because insufficient release prior to stripper insertion can lead to premature transection or amputation. We describe a reliable intraoperative physical examination sign to help understand the sufficient amount by which a tendon graft needs to be released prior to stripper insertion. The presence of the motionless gastrocnemius ("motionless gastroc") phenomenon is used in our clinic as a sign that the grafts have been sufficiently freed and that a tendon stripper can be used without fear of transection or graft amputation.
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45
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Butt U, Khan ZA, Zahir N, Khan Z, Vuletic F, Shah I, Shah JA, Siddiqui AM, Hudetz D. Histological and cellular evaluation of anterior cruciate ligament. Knee 2020; 27:1510-1518. [PMID: 33010768 DOI: 10.1016/j.knee.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/11/2020] [Accepted: 08/04/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND We hypothesized that the torn anterior cruciate ligament (ACL) demonstrates a great healing response after initial trauma and has competent cells leading to the healing but differs in its response based on the type of tear and duration of injury. This study aimed to evaluate the histological and cellular responses to the injured ACL. METHODS Fifty-two tissue samples from the ACL were harvested from patients undergoing arthroscopy. Detailed histological and cellular examinations were performed for ligament angiogenesis, fibrocytes, and synovial tissue infiltration. We compared the cellular response to injury in partially and completely ruptured ACLs. The duration of ACL injury and its response to cellular characteristics were also examined. Immunohistochemical studies using cluster of differentiation 34 (CD34) staining was used to evaluate endothelial cells and fibrocytes. RESULTS We found a significantly higher density of synovial and ligament angiogenesis and fibrocytes at the torn end of ACL (Mann-Whitney, P < 0.050). Numerous fibrocytes were identified in complete ACL tears versus partial tears (Mann-Whitney = 0.020). Increased cellular proliferation was identified at the ruptured end of ACL remnant (Kruskal-Wallis, P < 0.050). The cellular proliferation of ruptured ACL decreased after 12 months. CONCLUSIONS Based on our findings of the time-dependent decrease in the cellular response at the torn ends of the ACL, we recommend early intervention, preservation of the ACL remnant, and primary ACL repair or augmented reconstruction.
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Affiliation(s)
- Umer Butt
- AO Hospital, Karachi, Pakistan; Circle Bath Hospital, Bath, UK.
| | | | - Naila Zahir
- Department of Histopathology and Cytology, Dr. Essa Laboratory and Diagnostic Centre, Karachi, Pakistan
| | - Zeeshan Khan
- AO Hospital, Karachi, Pakistan; Hayatabad Medical Complex, Peshawar, Pakistan
| | - Filip Vuletic
- Department of Trauma and Orthopaedics, University Hospital Sveti Duh, Zagreb, Croatia
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Schneider KN, Schliemann B, Gosheger G, Theil C, Weller J, Buddhdev PK, Ahlbäumer G. Good to Excellent Functional Short-Term Outcome and Low Revision Rates Following Primary Anterior Cruciate Ligament Repair Using Suture Augmentation. J Clin Med 2020; 9:jcm9103068. [PMID: 32977649 PMCID: PMC7598184 DOI: 10.3390/jcm9103068] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 12/30/2022] Open
Abstract
The aim of this study was to evaluate the functional outcome of primary anterior cruciate ligament (ACL) repair using suture augmentation (SA) in 93 consecutive patients (67 female) with a minimum follow-up of 12 months. Patients’ outcomes were determined using International Knee Documentation Committee (IKDC) score, Lysholm score (LS) and Tegner score (TS). Knee-laxity was assessed using the KT-1000 arthrometer. Eighty-eight patients (67 female, mean age 42 years ± standard deviation (SD) 13) were available for follow-up after a mean time of 21 months (range 12–39). Three patients (3%) underwent revision surgery and were excluded from functional analysis. The mean IKDC score was 87.4 ± 11, mean LS was 92.6 ± 11, mean pre-traumatic TS was 6 ± 2 and mean postoperative TS was 6 ± 2, with a mean difference (TSDiff) of 1 ± 1. The interval from injury to surgery had no significant impact on the postoperative IKDC (p = 0.228), LS (p = 0.377) and TSDiff (p = 0.572). Patients’ age (>40 years), BMI (>30) and coexisting ligament or meniscal injuries did not seem to influence postoperative functional results. Primary ACL repair using SA provides good to excellent functional outcomes with a low probability of revision surgery at a minimum of 12 months.
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Affiliation(s)
- Kristian Nikolaus Schneider
- Department of Orthopedics and Trauma Surgery, Klinik Gut, St. Moritz, 7500 St. Moritz, Switzerland; (K.N.S.); (J.W.)
- Department of Orthopedics and Tumor Orthopedics, University Hospital of Münster, 48149 Münster, Germany; (G.G.); (C.T.)
| | - Benedikt Schliemann
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital of Münster, 48149 Münster, Germany;
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, University Hospital of Münster, 48149 Münster, Germany; (G.G.); (C.T.)
| | - Christoph Theil
- Department of Orthopedics and Tumor Orthopedics, University Hospital of Münster, 48149 Münster, Germany; (G.G.); (C.T.)
| | - Jan Weller
- Department of Orthopedics and Trauma Surgery, Klinik Gut, St. Moritz, 7500 St. Moritz, Switzerland; (K.N.S.); (J.W.)
| | - Pranai K Buddhdev
- Department of Trauma Surgery, Broomfield Hospital Essex, Chelmsford CM1 7ET, UK;
| | - Georg Ahlbäumer
- Department of Orthopedics and Trauma Surgery, Klinik Gut, St. Moritz, 7500 St. Moritz, Switzerland; (K.N.S.); (J.W.)
- Correspondence:
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47
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Pitaru AA, Lacombe JG, Cooke ME, Beckman L, Steffen T, Weber MH, Martineau PA, Rosenzweig DH. Investigating Commercial Filaments for 3D Printing of Stiff and Elastic Constructs with Ligament-Like Mechanics. MICROMACHINES 2020; 11:mi11090846. [PMID: 32933035 PMCID: PMC7570386 DOI: 10.3390/mi11090846] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
The current gold standard technique for treatment of anterior cruciate ligament (ACL) injury is reconstruction with autograft. These treatments have a relatively high failure and re-tear rate. To overcome this, tissue engineering and additive manufacturing are being used to explore the potential of 3D scaffolds as autograft substitutes. However, mechanically optimal polymers for this have yet to be identified. Here, we use 3D printing technology and various materials with the aim of fabricating constructs better matching the mechanical properties of the native ACL. A fused deposition modeling (FDM) 3D printer was used to microfabricate dog bone-shaped specimens from six different polymers—PLA, PETG, Lay FOMM 60, NinjaFlex, NinjaFlex-SemiFlex, and FlexiFil—at three different raster angles. The tensile mechanical properties of these polymers were determined from stress–strain curves. Our results indicate that no single material came close enough to successfully match reported mechanical properties of the native ACL. However, PLA and PETG had similar ultimate tensile strengths. Lay FOMM 60 displayed a percentage strain at failure similar to reported values for native ACL. Furthermore, raster angle had a significant impact on some mechanical properties for all of the materials except for FlexiFil. We therefore conclude that while none of these materials alone is optimal for mimicking ACL mechanical properties, there may be potential for creating a 3D-printed composite constructs to match ACL mechanical properties. Further investigations involving co-printing of stiff and elastomeric materials must be explored.
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Affiliation(s)
- Audrey A. Pitaru
- Division of Orthopaedic Surgery, McGill University, Montreal, QC H3A 1A1, Canada; (A.A.P.); (J.-G.L.); (M.E.K.); (M.H.W.); (P.A.M.)
- Department of Experimental Surgery, McGill University, Montreal, QC H3A 1A1, Canada
| | - Jean-Gabriel Lacombe
- Division of Orthopaedic Surgery, McGill University, Montreal, QC H3A 1A1, Canada; (A.A.P.); (J.-G.L.); (M.E.K.); (M.H.W.); (P.A.M.)
- Department of Experimental Surgery, McGill University, Montreal, QC H3A 1A1, Canada
| | - Megan E. Cooke
- Division of Orthopaedic Surgery, McGill University, Montreal, QC H3A 1A1, Canada; (A.A.P.); (J.-G.L.); (M.E.K.); (M.H.W.); (P.A.M.)
- Department of Experimental Surgery, McGill University, Montreal, QC H3A 1A1, Canada
| | - Lorne Beckman
- The Orthopaedics Research Lab, McGill University, Montreal, QC H3A 1A1, Canada; (L.B.); (T.S.)
| | - Thomas Steffen
- The Orthopaedics Research Lab, McGill University, Montreal, QC H3A 1A1, Canada; (L.B.); (T.S.)
| | - Michael H. Weber
- Division of Orthopaedic Surgery, McGill University, Montreal, QC H3A 1A1, Canada; (A.A.P.); (J.-G.L.); (M.E.K.); (M.H.W.); (P.A.M.)
- Department of Experimental Surgery, McGill University, Montreal, QC H3A 1A1, Canada
| | - Paul A. Martineau
- Division of Orthopaedic Surgery, McGill University, Montreal, QC H3A 1A1, Canada; (A.A.P.); (J.-G.L.); (M.E.K.); (M.H.W.); (P.A.M.)
- Department of Experimental Surgery, McGill University, Montreal, QC H3A 1A1, Canada
| | - Derek H. Rosenzweig
- Division of Orthopaedic Surgery, McGill University, Montreal, QC H3A 1A1, Canada; (A.A.P.); (J.-G.L.); (M.E.K.); (M.H.W.); (P.A.M.)
- Department of Experimental Surgery, McGill University, Montreal, QC H3A 1A1, Canada
- Injury, Repair and Recovery Program, Research Institute of McGill University Health Centre, Montreal, QC H3A 1A1, Canada
- Correspondence: ; Tel.: +01-514-934-1934 (ext. 43238)
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48
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Benos L, Stanev D, Spyrou L, Moustakas K, Tsaopoulos DE. A Review on Finite Element Modeling and Simulation of the Anterior Cruciate Ligament Reconstruction. Front Bioeng Biotechnol 2020; 8:967. [PMID: 32974307 PMCID: PMC7468435 DOI: 10.3389/fbioe.2020.00967] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/27/2020] [Indexed: 01/22/2023] Open
Abstract
The anterior cruciate ligament (ACL) constitutes one of the most important stabilizing tissues of the knee joint whose rapture is very prevalent. ACL reconstruction (ACLR) from a graft is a surgery which yields the best outcome. Taking into account the complicated nature of this operation and the high cost of experiments, finite element (FE) simulations can become a valuable tool for evaluating the surgery in a pre-clinical setting. The present study summarizes, for the first time, the current advancement in ACLR in both clinical and computational level. It also emphasizes on the material modeling and properties of the most popular grafts as well as modeling of different surgery techniques. It can be concluded that more effort is needed to be put toward more realistic simulation of the surgery, including also the use of two bundles for graft representation, graft pretension and artificial grafts. Furthermore, muscles and synovial fluid need to be included, while patellofemoral joint is an important bone that is rarely used. More realistic models are also required for soft tissues, as most articles used isotropic linear elastic models and springs. In summary, accurate and realistic FE analysis in conjunction with multidisciplinary collaboration could contribute to ACLR improvement provided that several important aspects are carefully considered.
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Affiliation(s)
- Lefteris Benos
- Institute for Bio-Economy and Agri-Technology, Centre for Research and Technology-Hellas, Thessaloniki, Greece
| | - Dimitar Stanev
- Department of Electrical and Computer Engineering, University of Patras, Patras, Greece.,School of Engineering, Institute of Bioengineering, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Leonidas Spyrou
- Institute for Bio-Economy and Agri-Technology, Centre for Research and Technology-Hellas, Thessaloniki, Greece
| | | | - Dimitrios E Tsaopoulos
- Institute for Bio-Economy and Agri-Technology, Centre for Research and Technology-Hellas, Thessaloniki, Greece
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49
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Comparison of the outcomes of anterior cruciate ligament reconstruction by using patellar tendon or hamstring tendon autografts that have been fixed with cross-pin system at femoral side. ANADOLU KLINIĞI TIP BILIMLERI DERGISI 2020. [DOI: 10.21673/anadoluklin.735533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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50
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Kvist J, Filbay S, Andersson C, Ardern CL, Gauffin H. Radiographic and Symptomatic Knee Osteoarthritis 32 to 37 Years After Acute Anterior Cruciate Ligament Rupture. Am J Sports Med 2020; 48:2387-2394. [PMID: 32736511 PMCID: PMC7443961 DOI: 10.1177/0363546520939897] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The long-term prevalence of knee osteoarthritis (OA) after anterior cruciate ligament (ACL) injury is unknown, especially in patients without a history of ACL surgery. PURPOSE To (1) describe the prevalence of radiographic OA, symptomatic OA, and knee replacement surgery 32 to 37 years after acute ACL injury and to (2) compare the prevalence of radiographic OA, symptomatic OA, and knee symptoms between patients allocated to early ACL surgery or no ACL surgery and patients who crossed over to ACL surgery. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Participants aged 15 to 40 years at the time of ACL injury were allocated to surgical (augmented or nonaugmented ACL repair) or nonsurgical ACL treatment within 14 days of injury. At 32 to 37 years after the initial injury, 153 participants were followed up with plain weightbearing radiographs and completed 4 subscales from the Knee injury and Osteoarthritis Outcome Score (KOOS). Radiographic OA was defined as Kellgren and Lawrence grade 2 or higher. Symptomatic OA was defined as radiographic OA plus knee symptoms measured with the KOOS. RESULTS Participants allocated to ACL surgery (n = 64) underwent surgery at a mean ± SD of 5 ± 4 days (range, 0-11 days) after injury. Of the 89 participants allocated to no ACL surgery, 53 remained nonsurgically treated, 27 had ACL surgery within 2 years, and 9 had ACL surgery between 3 and 21 years after injury. In the total sample, 95 participants (62%) had radiographic tibiofemoral OA, including 11 (7%) who had knee replacement. The prevalence of radiographic tibiofemoral OA was lower in the group allocated to ACL surgery compared with the group who never had ACL surgery (50% vs 75%; P = .005). The prevalence of symptomatic OA (50% in the total sample) and patellofemoral radiographic OA (35% in the total sample) was similar between groups. CONCLUSION Patients allocated to early ACL surgery, performed a mean 5 days after injury, had a lower prevalence of tibiofemoral radiographic OA at 32 to 37 years after injury compared with patients who never had ACL surgery. The prevalences of symptomatic OA, radiographic patellofemoral OA, and knee symptoms were similar irrespective of ACL treatment. Overall, the prevalence of OA after ACL injury was high. REGISTRATION NCT03182647 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Joanna Kvist
- Unit of Physiotherapy, Department of
Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Division of Physiotherapy, Department of
Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm,
Sweden,Joanna Kvist, RPT, Prof,
Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences,
Linköping University, 581 85 Linköping, Sweden (
) (Twitter: @JoannaKvist)
| | - Stephanie Filbay
- Unit of Physiotherapy, Department of
Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Centre for Sport, Exercise and
Osteoarthritis Research Versus Arthritis; Nuffield Department of Orthopaedics,
Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Christer Andersson
- Department of Biomedical and Clinical
Sciences, Linköping University, Linköping, Sweden
| | - Clare L. Ardern
- Unit of Physiotherapy, Department of
Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Division of Physiotherapy, Department of
Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm,
Sweden,Sport and Exercise Medicine Research
Centre, La Trobe University, Melbourne, Australia
| | - Håkan Gauffin
- Department of Biomedical and Clinical
Sciences, Linköping University, Linköping, Sweden
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