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Mann O, Al-Dadah O. Anterior cruciate ligament reconstruction: Effect of graft tunnel position on early to mid-term clinical outcomes. World J Orthop 2024; 15:744-753. [PMID: 39165872 PMCID: PMC11331329 DOI: 10.5312/wjo.v15.i8.744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/30/2024] [Accepted: 07/09/2024] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND Patient reported outcome measures (PROMs) can be used to assess knee function following anterior cruciate ligament (ACL) reconstruction. Intra-operatively, femoral and tibial tunnels are created to accommodate the new ACL graft. It is postulated that there is an optimum position and orientation of these tunnels and that outcomes from this procedure are affected by their position. AIM To evaluate the influence of graft tunnel position on early to mid-term clinical outcomes following ACL reconstruction. METHODS Six PROMs were collected following ACL reconstruction which included the Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee, Lysholm, Tegner, EuroQol-5 Dimension-5 level, and Short Form 12-item Health Survey. A total of 8 radiological parameters were measured from post-operative X-rays relating to graft tunnel positions. This data was analysed to assess for any correlations between graft tunnel position and post-operative PROMs. RESULTS A total of 87 patients were included in the study with a mean post-operative follow-up of 2.3 years (range 1 to 7 years). Posterior position of tibial tunnel was associated with improved KOOS quality of life (rho = 0.43, P = 0.002) and EQ-5D VAS (rho = 0.36, P = 0.010). Anterior position of EndoButton femoral tunnel was associated with an improved EQ-5D index (rho = -0.38, P = 0.028). There were no other significant correlations between any of the other radiological parameters and PROM scores. CONCLUSION Overall, graft tunnel position had very little correlation with clinical outcomes following ACL reconstruction. A few (posterior) tibial tunnel and (anterior) EndoButton femoral tunnel measurements were associated with better PROMs.
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Affiliation(s)
- Oliver Mann
- The Medical School, Newcastle University, Newcastle upon Tyne NE2 4HH, United Kingdom
| | - Oday Al-Dadah
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, United Kingdom
- Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, Harton Lane, South Tyneside NE34 0PL, United Kingdom
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Petit CB, Slone HS, Diekfuss JA, Barber Foss KD, Warren SM, Montalvo AM, Lamplot JD, Myer GD, Xerogeanes JW. Sex-Specific Outcomes After Anterior Cruciate Ligament Reconstruction Using an All-Soft Tissue Quadriceps Tendon Autograft in a Young Active Population. Am J Sports Med 2024; 52:2450-2455. [PMID: 39097771 DOI: 10.1177/03635465241262018] [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: 08/05/2024]
Abstract
BACKGROUND The ideal graft for anterior cruciate ligament (ACL) reconstruction (ACLR) in young athletes has a high return-to-sport (RTS) rate and a low reinjury rate. Quadriceps tendon autografts are being used with increasing frequency for ACLR in this population, despite a paucity of evidence to support their use. PURPOSE To report the RTS rate, ipsilateral reinjury rate, and contralateral ACL injury rate in a young athletic population undergoing primary ACLR using an all-soft tissue quadriceps tendon (ASTQT) autograft. STUDY DESIGN Cases series; Level of evidence, 4. METHODS Patients aged 14 to 22 years who underwent primary ACLR using an ASTQT autograft by a single surgeon between January 1, 2005, and April 30, 2020, were identified via electronic medical records and contacted ≥24 months after ACLR to complete a survey regarding subsequent ipsilateral or contralateral ACL injuries and RTS. Patients who had undergone previous ACLR (ipsilateral or contralateral) were excluded. RESULTS A total of 656 patients (330 male, 326 female; mean age, 17.9 years) were identified, and 395 patients completed the survey (60.2%; 174 male, 221 female; mean age, 17.8 years) with a mean follow-up of 73 ± 29 months (range, 24-139 months). The RTS rate was high (male: 87.7%; female: 82.8%; P = .19). Male and female patients had similar rates of revision ACLR (male: 12.6%; female: 10.0%; P = .40) and contralateral ACL injuries (male: 13.8%; female: 11.3%; P = .46). CONCLUSION A high RTS rate and similar rates of ipsilateral and contralateral ACL injuries were found for male and female patients in a young athletic population undergoing primary ACLR using an ASTQT autograft. These results help one to better understand the utility of ASTQT grafts to support successful ACLR in young athletic populations, for which ASTQT grafts appear to yield favorable outcomes.
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Affiliation(s)
- Camryn B Petit
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
- Medical College of Georgia, Augusta, Georgia, USA
| | - Harris S Slone
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jed A Diekfuss
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kim D Barber Foss
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shayla M Warren
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alicia M Montalvo
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
| | - Joseph D Lamplot
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Campbell Clinic Orthopaedics, Germantown, Tennessee, USA
| | - Gregory D Myer
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
- The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, USA
- Youth Physical Development Centre, Cardiff Metropolitan University, Cardiff, UK
| | - John W Xerogeanes
- Emory Sports Performance And Research Center, Flowery Branch, Georgia, USA
- Emory Sports Medicine Center, Atlanta, Georgia, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, Georgia, USA
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Aldhilan MM, Alshahrani AH, Almogbil IH. Heterotopic ossification postsuperficial medial collateral ligament pie-crusting: a case report. J Surg Case Rep 2024; 2024:rjae305. [PMID: 39011292 PMCID: PMC11247377 DOI: 10.1093/jscr/rjae305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/25/2024] [Indexed: 07/17/2024] Open
Abstract
Anterior cruciate ligament and meniscus tears are common among sports injuries. There are different techniques for addressing anterior cruciate ligament and meniscus tears, with distinct indications, advantages, and disadvantages. We present the case of a 23-year-old male who underwent right anterior cruciate ligament reconstruction and posterior horn medial meniscus repair using an all-inside technique via superficial medial collateral ligament (sMCL) pie-crusting. Clinical examination and radiological investigations a few months later identified calcifications on the medial side of the right knee. We diagnosed the patient with heterotopic ossification post-sMCL pie-crusting; no apparent causal factors were present. To our knowledge, there have been no documented instances of heterotopic ossification following sMCL pie-crusting. In conclusion, heterotopic ossification may occur after sMCL pie-crusting; further studies are needed on this subject.
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Affiliation(s)
- Mansour M Aldhilan
- Department of Orthopedic Surgery, Ar Rass General Hospital, Ar rass 58872, Saudi Arabia
| | - Abdullah H Alshahrani
- Department of Orthopedic Surgery, College of Medicine, Qassim University, Buraydah 52571, Saudi Arabia
| | - Ismail H Almogbil
- Department of Orthopedic Surgery, College of Medicine, Qassim University, Buraydah 52571, Saudi Arabia
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4
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Chen P, Wang L, Dong S, Ding Y, Jia S, Zheng C. Can Symmetry of Single-Leg Vertical Jump Height Represent Normal Lower Limb Biomechanics of Athletes After Anterior Cruciate Ligament Reconstruction? Sports Health 2024; 16:596-605. [PMID: 37554095 PMCID: PMC11195865 DOI: 10.1177/19417381231190119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND After anterior cruciate ligament reconstruction (ACLR), single-leg horizontal hop distance limb symmetry index (LSI) >90% is recommended as a cutoff point for safe return to sport (RTS). However, athletes after ACLR have abnormal lower limb biomechanics despite an adequate single-leg hop distance LSI, implying that athletes are at high risk of reinjury. Symmetry of single-leg vertical jump height appears to be more difficult to achieve and can be a better representation of knee function than single-leg horizontal hop distance. HYPOTHESIS Athletes after ACLR with single-leg jump height LSI >90% had similar biomechanical characteristics to healthy athletes. STUDY DESIGN Controlled laboratory study. LEVEL OF EVIDENCE Level 3. METHODS A total of 46 athletes after ACLR were divided into low jump height (LJH, jump height LSI <90%, n = 23) and high jump height (HJH, jump height LSI >90%, n = 23) groups according to symmetry of single-leg vertical jump height, while 24 healthy athletes acted as a control (CONT) group. One-way analysis of variance was used to compare the kinematic and kinetic characteristics of the LJH, HJH, and CONT groups during single-leg vertical jump. RESULTS Both the LJH and HJH groups demonstrated greater limb asymmetry (lower LSI) during landing compared with the CONT group in knee extension moment (P < 0.05), peak knee flexion angle (P < 0.05), and knee power (P < 0.05). CONCLUSION Symmetry in single-leg vertical jump height does not represent normal lower limb biomechanics in athletes after ACLR. CLINICAL RELEVANCE Symmetrical jump height may not signify ideal biomechanical or RTS readiness, but single-leg vertical jump test can be used as a supplement to horizontal hop test or other functional tests to reduce the likelihood of false-negative results in the absence of detailed biomechanical evaluation.
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Affiliation(s)
- Peng Chen
- School of Sports Medicine, Wuhan Sports University, Wuhan, Hubei Province, China
- Key Laboratory of Sports Engineering of General Administration of Sport of China, Wuhan Sports University, Wuhan, Hubei Province, China
| | - Ling Wang
- School of Sports Medicine, Wuhan Sports University, Wuhan, Hubei Province, China
- Key Laboratory of Sports Engineering of General Administration of Sport of China, Wuhan Sports University, Wuhan, Hubei Province, China
| | - Shiyu Dong
- College of Basic Medicine of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Yue Ding
- School of Sports Medicine, Wuhan Sports University, Wuhan, Hubei Province, China
- Key Laboratory of Sports Engineering of General Administration of Sport of China, Wuhan Sports University, Wuhan, Hubei Province, China
| | - Shaohui Jia
- School of Sports Medicine, Wuhan Sports University, Wuhan, Hubei Province, China
- Hubei Provincial Key Laboratory of Sports Training and Monitoring, Wuhan Sports University, Wuhan, Hubei Province, China
| | - Cheng Zheng
- Department of Sports Medicine, Affiliated Hospital, Wuhan Sports University, Wuhan, Hubei Province, China
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Dauty M, Louguet B, Menu P, Grondin J, Crenn V, Daley P, Fouasson-Chailloux A. Enlightenment on Knee Flexors Strength Loss in Cases of Posterior Knee Pain After Anterior Cruciate Ligament Reconstruction. J Sport Rehabil 2024; 33:317-324. [PMID: 38684207 DOI: 10.1123/jsr.2023-0346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 03/01/2024] [Accepted: 03/12/2024] [Indexed: 05/02/2024]
Abstract
CONTEXT The persistence and the recurrence of posterior medial knee pain (PKP) after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon graft are often overlooked during rehabilitation. DESIGN Cross-sectional observational study. METHODS The study aimed (1) to evaluate the prevalence of these types of PKP before 4 months post-ACLR, (2) to measure their consequences on the knee flexors strength, and (3) to evaluate the role of the type of ACLR. From a cohort of patients operated on with hamstring tendon procedures, the persistent and the recurrent PKP were sought at 4 months post-ACLR. The evolution of isokinetic muscle strength recovery in PKP subjects was compared with those of nonpainful subjects. The functional deficit was measured at 6/7 months post-ACLR by a hop test. RESULTS Three hundred seventeen subjects (25.8 [6.0] y) were included. At 4 months post-ACLR, 2 populations were identified based on the recurrent onset of PKP (PKP+, n = 40) or the absence of knee pain (PKP-, n = 277). The prevalence of PKP was 8.3%. At the fourth month post-ACLR, the PKP+ group had a higher flexor strength deficit compared with the PKP- group (limb symmetry index at 60°/s: 67.2% [12.4%] vs 84.3% [12.6%]; P < .05). At 6/7 months, the loss of strength persisted (limb symmetry index at 60°/s: 82.3% [13.4%] vs 87.7% [12.8%]; P < .05). The hop test deficit was comparable, and no difference was shown according to the type of graft. CONCLUSIONS Persistent and recurrent PKP during the rehabilitation period were not uncommon and were associated with a worsening of flexors strength loss on the ACLR side.
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Affiliation(s)
- Marc Dauty
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, ONIRIS, Nantes Université, Nantes, France
| | - Bastien Louguet
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
| | - Pierre Menu
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, ONIRIS, Nantes Université, Nantes, France
| | - Jérôme Grondin
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
| | - Vincent Crenn
- Clinique Chirugicale Othopédique et Traumatiologique, CHU Nantes, Nantes Université, Nantes, France
| | - Pauline Daley
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
| | - Alban Fouasson-Chailloux
- Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, CHU Nantes, Nantes Université, Nantes, France
- Service de Médecine du Sport, CHU Nantes, Nantes Université, Nantes, France
- Institut Régional de Médecine du Sport (IRMS), Nantes, France
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, ONIRIS, Nantes Université, Nantes, France
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Yañez R, Silvestre R, Roby M, Neira A, Azar C, Madera S, Ortiz-Bernardin A, Carpes FP, De la Fuente C. Finite element graft stress for anteromedial portal, transtibial, and hybrid transtibial femoral drillings under anterior translation and medial rotation: an exploratory study. Sci Rep 2024; 14:11922. [PMID: 38789542 PMCID: PMC11126698 DOI: 10.1038/s41598-024-61061-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
Stress concentration on the Anterior Cruciate Ligament Reconstruction (ACLr) for femoral drillings is crucial to understanding failures. Therefore, we described the graft stress for transtibial (TT), the anteromedial portal (AM), and hybrid transtibial (HTT) techniques during the anterior tibial translation and medial knee rotation in a finite element model. A healthy participant with a non-medical record of Anterior Cruciate Ligament rupture with regular sports practice underwent finite element analysis. We modeled TT, HTT, AM drillings, and the ACLr as hyperelastic isotropic material. The maximum Von Mises principal stresses and distributions were obtained from anterior tibial translation and medial rotation. During the anterior tibia translation, the HTT, TT, and AM drilling were 31.5 MPa, 34.6 Mpa, and 35.0 MPa, respectively. During the medial knee rotation, the AM, TT, and HTT drilling were 17.3 MPa, 20.3 Mpa, and 21.6 MPa, respectively. The stress was concentrated at the lateral aspect of ACLr,near the femoral tunnel for all techniques independent of the knee movement. Meanwhile, the AM tunnel concentrates the stress at the medial aspect of the ACLr body under medial rotation. The HTT better constrains the anterior tibia translation than AM and TT drillings, while AM does for medial knee rotation.
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Affiliation(s)
- Roberto Yañez
- Biomechanics unit, Innovation centre, MEDS clinic, Santiago, Chile
- Orthopaedic knee service, MEDS clinic, Santiago, Chile
| | - Rony Silvestre
- Biomechanics unit, Innovation centre, MEDS clinic, Santiago, Chile
| | - Matias Roby
- Biomechanics unit, Innovation centre, MEDS clinic, Santiago, Chile
- Orthopaedic knee service, MEDS clinic, Santiago, Chile
| | - Alejandro Neira
- Escuela de Kinesiologia, Facultad de Medicina y Ciencias de la Salud, Universidad Mayor, Santiago, Chile
| | - Camilo Azar
- Orthopaedic knee service, MEDS clinic, Santiago, Chile
| | - Samuel Madera
- Ingenieria Civil Mecanica, Facultad de Igenieria, Universidad de Chile, Santiago, Chile
| | | | - Felipe P Carpes
- Laboratory of Neuromechanics, Universidade Federal do Pampa, Uruguaiana, Brazil
| | - Carlos De la Fuente
- Exercise and Rehabilitation Sciences Institute, Postgraduate, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, RM, Chile.
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Kembhavi R, Bagewadi RM, Hublikar AA, Nerune SM. Incidental Arthroscopic Finding of Rheumatoid Arthritis in a Post-traumatic Ligamentous Injury to Knee Joint. J Orthop Case Rep 2024; 14:88-93. [PMID: 38784878 PMCID: PMC11111253 DOI: 10.13107/jocr.2024.v14.i05.4444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/13/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction The relationship between physical trauma and subsequent symptoms of rheumatoid arthritis (RA) has been described in the past though onset of newer disease of RA in apparently normal patient is doubtful. Trauma can cause precipitation of RA symptoms. Such trauma includes fractures, joint injuries, road traffic accidents, and also surgeries and deliveries. Although post-traumatic osteoarthritis following anterior cruciate ligament (ACL) injury is more common pathology, association of RA following ACL injury has not been reported in the literature. This case report highlights on one rare incidental diagnosis of RA postoperatively in a patient with traumatic ACL tear with previously no features of RA and how patient was managed successfully both by surgical and by medical management. Case Report A 30-year-old male patient presented to us with complaints of pain over right knee associated with recurrent swelling, instability, clicking sounds, and occasional locking episodes since 6 months following twisting injury with no other symptoms in other joints of the body. Based on clinicoradiological workup, the diagnosis of traumatic complete ACL tear with medial meniscus bucket handle tear of body and posterior horn with early osteoarthritic changes was made. The patient was operated with ACL reconstruction with quadrupled hamstring graft, partial medial meniscectomy and debridement + microfracture for cartilage defects. The patient was worked up for inflammatory arthritis post operatively considering unusual synovitis of knee. Based on histopathological and serological investigations (rheumatoid factor and anticitrullinated protein antibody), the patient was put on disease modifying antirheumatoid drugs for 1 year. At 1-year follow-up, the patient was back to his normal activities with full range of movements with Lysholm Knee Score of 89. Conclusion Traumatic ACL tear can result in onset of RA following trauma and needs to be worked up further when there are findings of unusual synovitis or cartilage damage arthroscopically. Such association is rare and concomitant diagnosis of RA or other inflammatory arthritis can be easily missed out if not addressed properly.
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Affiliation(s)
- Raghavendra Kembhavi
- Department of Orthopaedics, Shri B. M. Patil Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India
| | - Rajakumar M Bagewadi
- Department of Orthopaedics, Shri B. M. Patil Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India
| | - Anmol A Hublikar
- Department of Orthopaedics, Shri B. M. Patil Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India
| | - Savitri M Nerune
- Department of Pathology, Shri B. M. Patil Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India
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Zhou W, Liu X, Hong Q, Wang J, Luo X. Association between passing return-to-sport testing and re-injury risk in patients after anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis. PeerJ 2024; 12:e17279. [PMID: 38699196 PMCID: PMC11064852 DOI: 10.7717/peerj.17279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 04/01/2024] [Indexed: 05/05/2024] Open
Abstract
Background Inconsistent results have been obtained regarding the association between return-to-sport (RTS) testing and the risk of subsequent re-injury following anterior cruciate ligament reconstruction (ACLR). We therefore conducted a systematic review and meta-analysis to assess the potential association between passing of RTS and the risk of re-injury for patients after ACLR. Methods This meta-analysis was registered in INPLASY with the registration number INPLASY202360027. The electronic databases MedLine, EmBase, and the Cochrane library were systematically searched to identify eligible studies from their inception up to September 2023. The investigated outcomes included knee injury, secondary ACL, contralateral ACL injury, and graft rupture. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the random-effects model. Results A total number of nine studies involving 1410 individuals were selected for the final quantitative analysis. We noted that passing RTS test was not associated with the risk of subsequent knee injury (OR: 0.95; 95% CI: 0.28-3.21; P = 0.929), secondary ACL injury (OR: 0.98; 95% CI: 0.55-1.75; P = 0.945), and contralateral ACL injury (OR: 1.53; 95% CI: 0.63-3.71; P = 0.347). However, the risk of graft rupture was significantly reduced (OR: 0.49; 95% CI: 0.33-0.75; P = 0.001). Conclusions This study found that passing RTS test was not associated with the risk of subsequent knee injury, secondary ACL injury, and contralateral ACL injury, while it was associated with a lower risk of graft rupture. Thus, it is recommended that patients after ACLR pass an RTS test in clinical settings.
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Affiliation(s)
- Wenqi Zhou
- Department of Sport Medicine, Sichuan Orthopedic Hospital, Chengdu, Sichuan, China
| | - Xihui Liu
- Department of Sport Medicine, Sichuan Orthopedic Hospital, Chengdu, Sichuan, China
| | - Qiaomei Hong
- Department of Sport Medicine, Sichuan Orthopedic Hospital, Chengdu, Sichuan, China
| | - Jingping Wang
- Department of Sport Medicine, Sichuan Orthopedic Hospital, Chengdu, Sichuan, China
| | - Xiaobing Luo
- Department of Sport Medicine, Sichuan Orthopedic Hospital, Chengdu, Sichuan, China
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9
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Tollefson LV, Kennedy MI, Kennedy NI, LaPrade RF. Anatomic Anterolateral Ligament Reconstruction with Iliotibial Band Graft and Concomitant Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2024; 13:102906. [PMID: 38690330 PMCID: PMC11056646 DOI: 10.1016/j.eats.2023.102906] [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: 09/28/2023] [Accepted: 12/05/2023] [Indexed: 05/02/2024] Open
Abstract
Anterior cruciate ligament (ACL) reconstruction (ACLR) attempts to restore native ACL function. Persistent anterolateral instability is a common symptom after ACLR that can lead to worse patient outcomes. Additional surgeries, like anterolateral ligament reconstruction (ALLR), can augment the ACL graft and help increase anterolateral rotational stability. Certain indications for ACLR with ALLR include high-grade pivot shift, increased posterior tibial slope (>12°), revision ACLR, and concomitant ligamentous or meniscal injuries. We describe an anatomic ALLR technique using an 8 cm long × 1 cm wide strip of the inferior aspect of the iliotibial band fixed at the native attachment sites of the ALL.
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10
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Sritharan P, Milantoni V, Abdel Khalik H, Kay J, Slawaska-Eng D, Johnson J, de Sa D. Evaluating the quality of systematic reviews of comparative studies in autograft-based anterior cruciate ligament reconstruction using the AMSTAR-2 tool: A systematic umbrella review. Knee Surg Sports Traumatol Arthrosc 2024; 32:583-598. [PMID: 38372015 DOI: 10.1002/ksa.12062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE There remains a lack of consensus around autograft selection in anterior cruciate ligament reconstruction (ACLR), though there is a large body of overlapping systematic reviews and meta-analyses. Systematic reviews and their methodological quality were aimed to be further assessed, using a validated tool known as assessing the methodological quality of systematic reviews (AMSTAR-2). METHODS MEDLINE, Embase and CENTRAL were searched from inception to 23 April 2023 for systematic reviews (with/without meta-analysis) comparing primary ACLR autografts. A final quality rating from AMSTAR-2 was provided for each study ('critically low', 'low', 'moderate' or 'high' quality). Correlational analyses were conducted for ratings in relation to study characteristics. RESULTS Two thousand five hundred and ninety-eight studies were screened, and 50 studies were ultimately included. Twenty-four studies (48%) were rated as 'critically low', 17 (34%) as 'low', seven (14%) as 'moderate' and two (4%) as 'high' quality. The least followed domains were reporting on sources of funding (1/50 studies), the impact of risk of bias on results of meta-analyses (11/36 studies) and publication bias (17/36 studies). There was a significant increase in the frequency of studies graded as 'moderate' compared to 'low' or 'critically low' quality over time (p = 0.020). CONCLUSION The methodological quality of systematic reviews comparing autografts in ACLR is low, with many studies being rated lower due to commonly absent aspects of systematic review methodology such as investigating sources of funding and publication bias. More recent studies were generally more likely to be of higher quality. Authors are advised to consult AMSTAR-2 prior to conducting systematic reviews in ACLR. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Praveen Sritharan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Vincent Milantoni
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Hassaan Abdel Khalik
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey Kay
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - David Slawaska-Eng
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jansen Johnson
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
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11
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Chen P, Wang L, Zhou W, Wang L. Efficacy on knee function of Kinesio taping among individuals with anterior cruciate ligament reconstruction: A systematic review. PLoS One 2024; 19:e0299008. [PMID: 38421970 PMCID: PMC10903864 DOI: 10.1371/journal.pone.0299008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/04/2024] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVE This study aims to evaluate systematically the efficacy of Kinesio taping (KT) on the knee function of individuals who undergo anterior cruciate ligament reconstruction (ACLR). METHODS This study was registered in PROSPERO (registration number CRD42023399885) on February 26, 2023. Randomized controlled trials (RCTs) about the effects on the knee function of KT among individuals after ACLR were electronically searched from PubMed, Web of Science, Embase, The Cochrane Library, and EBSCO from inception to July 02, 2023. The outcome measures included six continuous variables: quadriceps strength, hamstring strength, knee swelling, knee flexion angle, Lysholm knee function score, and Visual Analog Scale (VAS) pain scores. The Cochrane Risk Bias Assessment Tool was used to evaluate the quality of the included literature. RESULTS Seven RCTs including 278 patients who underwent ACLR were included in the systematic review. One of three (33%) studies found a remarkable increase in quadricep strength associated with the use of KT compared with the control group. Two of two (100%) studies found substantial increases in hamstring strength associated with KT. Two of four (50%) studies reported KT reduced knee swelling. Two of five (40%) studies reported considerable improvements in knee flexion angle in the groups that used KT. All three (100%) studies found KT did not improve Lysholm knee function scores. Three of four (75%) studies noted a significant reduction in VAS pain scores associated with KT. CONCLUSION KT may help improve hamstring strength and reduce knee swelling and pain in patients after ACLR. Further studies are needed to determine the effects of KT on quadricep strength and knee flexion angle.
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Affiliation(s)
- Peng Chen
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Ling Wang
- School of Sports Medicine, Wuhan Sports University, Wuhan, Hubei Province, China
| | - Wenxing Zhou
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Lin Wang
- Sports Medicine and Rehabilitation Center, Shanghai University of Sport, Shanghai, China
- Shanghai Shangti Orthopaedic Hospital, Shanghai, China
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12
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Daniel AV, Myer GD, Pashuck TD, Smith PA. Low Preoperative Brief Resilience Scale Scores Are Associated With Inferior Preoperative and Short-Term Postoperative Patient Outcomes Following Primary Autograft Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2024; 6:100858. [PMID: 38274089 PMCID: PMC10809004 DOI: 10.1016/j.asmr.2023.100858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/01/2023] [Indexed: 01/27/2024] Open
Abstract
Purpose To assess preoperative Brief Resilience Scale (BRS) scores as they relate to postoperative patient outcomes following primary autograft anterior cruciate ligament reconstruction (ACLR). Methods All patients who underwent primary autograft ACLR from 2016 to 2021 and had a patient-reported follow-up of 1 year and a clinical follow-up of 6 months were included in final data analysis. Patients completed validated PROMs pre- and postoperatively. All patients were objectively assessed with range of motion (ROM) and KT-1000 arthrometer testing. Return to sport (RTS) data were obtained for all applicable patients. Patients were divided into 3 groups based on ± ½ the standard deviation for the mean preoperative BRS score. Results In total, 170 patients who underwent primary autograft ACLR with a mean age of 20.1 years (range, 13-57 years) and a mean final follow-up time of 2.9 years (range, 1.0-5.8 years) were included in the final analysis. The mean preoperative BRS scores for the high-resilience (HR, n = 67), average-resilience (AR, n = 42), and low-resilience (LR, n = 61) groups were 28.1 (95% CI, 27.8-28.9), 24.5 (95% CI, 24.3-24.6), and 21.1 (95% CI, 20.5-21.7), respectively (P < .001). The HR group demonstrated significantly higher preoperative and postoperative patient-reported outcome measures (PROMs) compared to the AR and LR groups, with more differences seen with the LR group. The HR group demonstrated better knee extension in postoperative month 3 compared to the LR group (0.6° [95% CI, -1.2° to 0.1°] vs -2.3° [95% CI, -3.3° to -1.3°], P = .006). The HR group demonstrated a faster RTS time compared to the LR group (6.4 months [95% CI, 6.1-6.7] vs 7.6 months [95% CI, 7.1-8.1], P = .002). No differences were seen in RTS rate, knee flexion, or KT-1000 arthrometer measurements between the 3 groups. Conclusions Low preoperative BRS scores were associated with inferior PROMs preoperatively and in the short-term postoperative period compared to those with higher preoperative BRS scores. Additionally, patients with lower preoperative BRS scores demonstrated a higher degree of knee extension loss 3 months postoperatively as well as a slower RTS. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
| | - Gregory D. Myer
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia, U.S.A
| | - Troy D. Pashuck
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Patrick A. Smith
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
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13
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Thiel GE, Puga TB, Perleberg TD, Figuerres BF, Dennis JF. Achilles Allograft Fiber Track Graft Preparation Technique for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2024; 13:102844. [PMID: 38435240 PMCID: PMC10907893 DOI: 10.1016/j.eats.2023.09.019] [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: 07/23/2023] [Accepted: 09/20/2023] [Indexed: 03/05/2024] Open
Abstract
Anterior cruciate ligament rupture is a common orthopaedic injury, with reconstruction the treatment of choice for active individuals. Graft selection is an important consideration for surgical planning. Achilles tendon allograft is a graft choice most likely used in cases of revision anterior cruciate ligament reconstruction. This technical note discusses an approach to Achilles tendon allograft preparation that respects and follows the rotation of the fibers of the Achilles tendon. Key considerations in the use of this technique include (1) identifying the rotational fiber tracks, (2) performing careful dissection along the identified tracks of the fibers, and (3) ensuring an appropriate graft width based on patient size, all of which are crucial for the success of this unique technique. The preservation of the rotational fibers provided by this technique may have the potential to result in increased tensile strength and better clinical outcomes.
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Affiliation(s)
- Grace E. Thiel
- College of Osteopathic Medicine, Kansas City University, Kansas City, Missouri, U.S.A
| | - Troy B. Puga
- College of Osteopathic Medicine, Kansas City University, Kansas City, Missouri, U.S.A
| | - Tyler D. Perleberg
- College of Osteopathic Medicine, Kansas City University, Kansas City, Missouri, U.S.A
| | - Benedict F. Figuerres
- Department of Orthopedics and Sports Medicine, The University of Kansas Health System St. Francis Campus, Topeka, Kansas, U.S.A
| | - Jennifer F. Dennis
- Department of Pathology and Anatomical Sciences, Kansas City University, Kansas City, Missouri, U.S.A
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14
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Viswanathan VK, Iyengar KP, Jain VK. The role of peroneus longus (PL) autograft in the reconstruction of anterior cruciate ligament (ACL): A comprehensive narrative review. J Clin Orthop Trauma 2024; 49:102352. [PMID: 38356688 PMCID: PMC10862405 DOI: 10.1016/j.jcot.2024.102352] [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: 01/18/2024] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
Background Peroneus longus tendon (PLT) is a known graft utilised in the ligamentous reconstructions of knee. The current review was performed to analyze the available evidence regarding PLT in the arthroscopic anterior cruciate ligament (ACL) reconstruction. Methods A comprehensive search of literature was performed on March 1, 2023 using 5 databases (for manuscripts published between 2010 and 2023). All studies reporting ACL reconstruction with PL graft in adults ≥18 years were considered; and final studies were shortlisted based on specific exclusion criteria. Results The search identified 684 articles, among which 26 manuscripts were finally selected. PLT has been used in primary ACL reconstruction (ACLR), revision ACLR, ACLR in multiligamentous injuries and those at risk for anterior knee pain. The full-thickness PLT graft is variable in its dimensions with the mean size ranging between 7 and 8.8 mm (half-PLT grafts ≤8.1 mm). The ultimate strength of doubled PLT graft is significantly higher than native ACL and comparable to the quadrupled hamstring.There was statistically insignificant difference in the laxity and functional outcome of knee following ACLR with PLT, as compared with other autografts (p > 0.05). PLT harvest is associated with satisfactory clinical foot and ankle outcomes, as well as excellent regenerative ability. Overall, studies have demonstrated lower complications with PLT (p < 0.05). Conclusion The dimensions of harvested PLT graft are more consistent than HT. It has similar functional outcome and survival, as compared to other autografts. It also has lower risk for donor-site morbidity and lower complications than HT. PLT is a promising, alternative autograft choice in patients undergoing ACLR.
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Affiliation(s)
| | | | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
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15
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Vitharana TN, King E, Moran K. Sensorimotor Dysfunction Following Anterior Cruciate Ligament Reconstruction- an Afferent Perspective: A Scoping Review. Int J Sports Phys Ther 2024; 19:1410-1437. [PMID: 38179582 PMCID: PMC10761632 DOI: 10.26603/001c.90862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 10/19/2023] [Indexed: 01/06/2024] Open
Abstract
Background Sensorimotor dysfunction is thought to occur following anterior cruciate ligament (ACL) injury which may have implications on future reinjury risk. Dysfunction has been demonstrated within the efferent component of the sensorimotor system. However, no reviews have examined the two main components of the afferent system: the visual and somatosensory systems. Hypothesis/Purpose This study aimed to report differences in function (central processing and local processing) within the (1) somatosensory and (2) visual systems between individuals following anterior cruciate ligament reconstruction (ACLR) and healthy controls (between-subject). The study also aimed to report differences in function within the two systems between the two limbs of an individual following ACLR (within-subject). Study Design Scoping review. Methods A search was conducted in PubMed, SPORTDiscus, CINAHL, Medline and Embase up until September 2021. Level I-IV studies assessing somatosensory and visual systems were included if they compared ACLR limbs to the uninjured contralateral limb (within-subject) or a healthy control limb (between-group). The function of somatosensory and visual systems was assessed across both central processing (processing of information in the central cortex) and local processing (all other assessments outside of central processing of information). Results Seventy studies were identified (52 somatosensory, 18 visual). Studies examining somatosensory central processing demonstrated significant differences; 66% of studies exhibited within-subject differences and 100% of the studies exhibited between-group differences. Studies examining local somatosensory processing had mixed findings; 40% of the 'joint position sense (JPS)' and 'threshold to detect motion (TTDM)' studies showed significant within-subject differences (JPS=0.8°-3.8° and TTDPM=0.2°-1.4°) and 42% demonstrated significant between-group differences (JPS=0.4°-5° and TTDPM=0.3°-2.8°). Eighty-three percent of visual central processing studies demonstrated significant dysfunction between-groups with no studies assessing within-subject differences. Fifty percent of the studies examining local visual processing demonstrated a significant between-group difference. Conclusion Significant differences in central processing exist within somatosensory and visual systems following ACLR. There is mixed evidence regarding local somatosensory and visual processing. Increased compensation by the visual system and local visual processing dysfunction may occur in conjunction with somatosensory dysfunction.
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Affiliation(s)
- Thilina N Vitharana
- Sports Medicine Sports Surgery Clinic
- School of Health and Human Performance Dublin City University
| | - Enda King
- Qatar Orthopaedic and Sports Medicine Hospital
- Department of Life Sciences University of Roehampton
| | - Kieran Moran
- School of Health and Human Performance Dublin City University
- Insight Centre for Data Analytics Dublin City University
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16
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Aldag L, Dallman J, Henkelman E, Herda A, Randall J, Tarakemeh A, Morey T, Vopat BG. Various Definitions of Failure Are Used in Studies of Patients Who Underwent Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100801. [PMID: 37766857 PMCID: PMC10520319 DOI: 10.1016/j.asmr.2023.100801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023] Open
Abstract
Purpose To conduct a literature review to assess the definitions of anterior cruciate ligament reconstruction (ACLR) failure used throughout the orthopaedic literature. Methods A systematic search of Embase, Ovid Medline, SPORTDiscus, and Web of Science was conducted by a university librarian to identity level I-IV clinical studies on ACLR failure. Inclusion criteria consisted of patients who underwent ACLR and included a definition of failure of ACLR. Patients who underwent anterior cruciate ligament (ACL) repairs, animal/cadaver studies, review studies, non-English language articles, and non-full text articles were excluded. Failure data were extracted from each study and categorized. Other data that were extracted included follow-up time after ACLR, failure reoperation rate, and failure reoperation procedure. Descriptive statistics was used to analyze the data. Results Out of 2,775 studies, 104 (3.75%) met inclusion criteria and were analyzed in this review. The most common definition of ACLR failure included the use of a physical examination, specifically Lachman's test (21/104 [20.2%]), anterior laxity assessment, or a Pivot-Shift test (24/104 [35.2%]) or undergoing or requiring revision ACLR (39/104 [37.5%]). Although some studies used quantitative tests or imaging to help define "failure," others simply defined it as graft rerupture that was otherwise not defined (22/104 [22.5%]). Other common definitions included: the use of imaging (magnetic resonance imaging/radiographs) to confirm graft re-rupture (37/104 [35.6%]), patient-reported outcomes (recurrent instability)/patient reported outcomes measures (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner) (18/104 [17.3%]), and the use of an arthrometer (KT-1000/2000, Rollimeter, or Kneelax) (17/104 [16.3%]). The least common definitions included graft failure or rerupture confirmed by arthroscopy (13/104 [12.5%]) and nonrevision surgery (2/104 [1.0%]). The failure rate of this procedure ranged from 0% to 100% depending on the definition of "failure." Conclusion In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. The most common criteria for failure of ACLR were the results of physical examination tests (35%), the need for undergoing a revision ACLR (36%), and the use of imaging to diagnose the failure (34%). About 17% of studies included in this review used patient-reported outcomes, specifically recurrent instability, or PROMs (IKDC, KOOS, Tegner) in their assessment of failure of ACLR. The least used definitions of "failure" of ACLR included nonrevision ACLR surgery (2%). Although some studies used similar tests or categories in their definition of failure, there were a variety of score and grade cutoff points between them. Level of Evidence Level IV, systematic review of Level II-IV studies.
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Affiliation(s)
- Levi Aldag
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Johnathan Dallman
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Erik Henkelman
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Ashley Herda
- Department of Health, Sport, and Exercise Sciences, University of Kansas, Lawrence, Kansas, U.S.A
| | - Jeffrey Randall
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Armin Tarakemeh
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Tucker Morey
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
| | - Bryan G. Vopat
- Department of Orthopaedic Surgery and Sports Medicine, the University of Kansas Health System, Kansas City, Kansas, U.S.A
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17
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Adhitya IPGS, Kurniawati I, Sawa R, Wijaya TF, Dewi NPAC. The Risk Factors and Preventive Strategies of Poor Knee Functions and Osteoarthritis after Anterior Cruciate Ligament Reconstruction: A Narrative Review. Phys Ther Res 2023; 26:78-88. [PMID: 38125289 PMCID: PMC10730125 DOI: 10.1298/ptr.r0028] [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: 08/25/2023] [Accepted: 10/31/2023] [Indexed: 12/23/2023]
Abstract
Anterior cruciate ligament reconstruction (ACLR) is the standard surgical treatment for ACL injury, which typically uses a graft to replace the torn ligament in the knee that uses small incisions with minimally invasive surgery. The optimal knee functions following ACLR depend on rehabilitation processes before and after the surgery. Knee function is the ability of the knee to perform various types of functional movements like walking, squatting, running, jumping, and pivoting where patients expect to achieve maximum knee function or at least more than 80% of its initial condition before the injury to avoid being categorized as poor knee function after ACLR. Patients use patient-reported outcome measures to collect data on their health status and quality of life after ACLR. Post-traumatic osteoarthritis (PTOA) is a type of OA that manifests in local cartilage injury caused by chondrocyte death, and matrix dispersion occurs following a joint injury like ACL injury. Gender, time from injury to surgery, and graft type were considered as risk factors for poor knee function after ACLR, while overweight, meniscus tear, and cartilage defect as risk factors for PTOA. However, age is an internal risk factor for both poor knee function and PTOA following ACLR. This review suggests several strategies to prevent both conditions, including a pre-operative program, comprehensive rehabilitation, body weight control, and return to sport (RTS) consideration based on physical capacity, proper time, and psychological readiness.
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Affiliation(s)
| | - Ida Kurniawati
- Department of Histology, Faculty of Medicine and Health Sciences, Universitas Warmadewa, Indonesia
| | - Ryuichi Sawa
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Japan
| | - Tabita Febyola Wijaya
- Bachelor and Professional Program of Physical Therapy, College of Medicine, Universitas Udayana, Indonesia
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18
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Lifka S, Rehberger Y, Pastl K, Rofner-Moretti A, Reichkendler M, Baumgartner W. The Development and Biomechanical Analysis of an Allograft Interference Screw for Anterior Cruciate Ligament Reconstruction. Bioengineering (Basel) 2023; 10:1174. [PMID: 37892904 PMCID: PMC10604633 DOI: 10.3390/bioengineering10101174] [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: 09/21/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Graft fixation during cruciate ligament reconstruction using interference screws is a common and frequently used surgical technique. These interference screws are usually made of metal or bioabsorbable materials. This paper describes the development of an allograft interference screw from cortical human bone. During the design of the screw, particular attention was paid to the choice of the screw drive and the screw shape, as well as the thread shape. Based on these parameters, a prototype was designed and manufactured. Subsequently, the first biomechanical tests using a bovine model were performed. The test procedure comprised a torsion test to determine the ultimate failure torque of the screw and the insertion torque during graft fixation, as well as a pull-out test to asses the ultimate failure load of the graft fixation. The results of the biomechanical analysis showed that the mean value of the ultimate failure torque was 2633 Nmm, whereas the mean occurring insertion torque during graft fixation was only 1125 Nmm. The mean ultimate failure load of the graft fixation was approximately 235 N. The results of this work show a good overall performance of the allograft screw compared to conventional screws, and should serve as a starting point for further detailed investigations and studies.
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Affiliation(s)
- Sebastian Lifka
- Institute of Biomedical Mechatronics, Johannes Kepler University Linz, 4040 Linz, Austria
| | | | | | | | - Markus Reichkendler
- Department of Orthopedic and Trauma Surgery, District Hospital Schwaz, 6130 Schwaz, Austria
| | - Werner Baumgartner
- Institute of Biomedical Mechatronics, Johannes Kepler University Linz, 4040 Linz, Austria
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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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20
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Dash SK, Mishra D, Sahu H, Moharana AK, Angrish S, Ts D. Functional Outcomes Following Arthroscopic Anterior Cruciate Ligament (ACL) Reconstruction Using the Sironix Titanium Button and the Polyetheretherketone (PEEK) Button: A Retrospective Observational Study. Cureus 2023; 15:e46186. [PMID: 37908964 PMCID: PMC10613784 DOI: 10.7759/cureus.46186] [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] [Accepted: 09/29/2023] [Indexed: 11/02/2023] Open
Abstract
Background Anterior cruciate ligament (ACL) injury is most common among athletes compared to the general population. ACL reconstruction is a clinical standard for restoring joint mechanical stability and enabling sports return. The purpose of the study is to evaluate the safety and functional outcomes after arthroscopic ACL reconstruction using the Sironix titanium button and the polyetheretherketone (PEEK) button. Methods A total of 31 subjects who have undergone arthroscopic ACL reconstruction using the Sironix titanium button and PEEK button between August 2022 and January 2023 were included in the study. Demographic data, surgery details, and other baseline characteristics of the subjects were collected from the hospital records. The primary objective of the study was to assess the functional outcome using the International Knee Documentation Committee (IKDC) questionnaire. The secondary objectives were to determine the pre- and post-surgery activity levels using the Tegner Activity Score (TAS) and Lysholm score. Quality of life evaluation was done by using the Quality of Life (QoL) subscale from the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Single Assessment Numerical Evaluation (SANE). Device-related adverse effect information was recorded. Results The mean (SD) of the total IKDC score of 31 subjects at baseline and post-surgery was 51.4 (2.84) and 91.8 (2.59) out of 100, respectively. The mean (SD) of TAS pre-injury and post-surgery was 5.3 (1.47) and 5.4 (1.38) out of 10, respectively. The total mean (SD) value of the total Lysholm Score at baseline and post-surgery was 53.9 (3.72) and 91.4 (3.61) out of 100, respectively. The mean (SD) value of the quality of life subscale of the KOOS score was 91.2 (3.91) out of 100. The total mean (SD) value of the SANE score that had affected joint/region of interest today was 97.4 (1.78), while for the opposite side today, it was 99.5 (0.85) out of 100. There were no adverse device effects reported in this study. Conclusion Based on the score assessment, it was observed that the performance of Sironix knee implant devices, Proloop-Titanium adjustable loop button, T-Button A® Closed PEEK button, and Surestitch® All Inside Meniscal Repair Implant (Healthium Medtech Limited, Bengaluru, Karnataka, India) was effective and safe with no adverse effects. Therefore, Sironix knee implants are considered safe and effective in ACL reconstruction and meniscus repair surgery.
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Affiliation(s)
| | | | | | | | - Sachin Angrish
- Clinical Affairs, Healthium Medtech Limited, Bengaluru, IND
| | - Deepak Ts
- Clinical Affairs, Healthium Medtech Limited, Bengaluru, IND
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21
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Pehlivanoglu G, Yildiz KI. Freehand vs. Medial Portal Offset Aimer Technique for Accurate Femoral Tunnel Placement in Arthroscopic ACL Reconstruction. Indian J Orthop 2023; 57:1219-1225. [PMID: 37525732 PMCID: PMC10387000 DOI: 10.1007/s43465-023-00929-z] [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: 12/01/2021] [Accepted: 06/05/2023] [Indexed: 08/02/2023]
Abstract
Purpose In this study, our aim was to reveal the effect of the medial femoral offset aimer usage through the femoral tunnel entry and exit points and the tunnel length during femoral tunnel drilling in arthroscopic anterior cruciate ligament (ACL) reconstruction. Methods One hundred patients who underwent arthroscopic single-bundle ACL reconstruction were included in the study. Group 1 consisted of 50 patients who underwent femoral tunnel drilling using a medial portal offset aimer device, while Group 2 consisted of 50 patients who were operated on using the freehand technique. Both groups were compared in terms of femoral tunnel and graft tunnel lengths, femoral tunnel angle in the coronal plane, and the location of the femoral tunnel entry and exit points. Results The mean femoral tunnel and graft tunnel lengths were significantly longer in Group 2 (p = 0.000). There was no significant difference in terms of localization of the femoral tunnel entry point in both the axial and sagittal planes. The tunnel exit point was located significantly more posterior in Group 1 in the axial plane (p = 0.028). There was no significant difference in terms of the coronal plane femoral tunnel angle between the two groups. Conclusion In arthroscopic ACL reconstructions, more successful results may be obtained with the freehand technique compared to drilling with a femoral offset aimer. For an experienced orthopedic surgeon, using a medial portal offset aimer device during femoral tunnel drilling does not seem necessary. Supplementary Information The online version contains supplementary material available at 10.1007/s43465-023-00929-z.
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Affiliation(s)
- Gokhan Pehlivanoglu
- Orthopaedics and Traumatology Department, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Kadir Ilker Yildiz
- Orthopaedics and Traumatology Department, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Hisar St. No: 56, Sariyer, Istanbul, Turkey
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22
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Aslani H, Bonakdar S, Amoozade F, Gorji M, Gholami AH, Tajic K, Gholipour M. The Effect of Lower Limb Position on Anterior Cruciate Ligament Reconstruction on Uncommon Complications after Surgery. Adv Biomed Res 2023; 12:204. [PMID: 37694238 PMCID: PMC10492626 DOI: 10.4103/abr.abr_34_22] [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: 01/29/2022] [Revised: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 09/12/2023] Open
Abstract
Background To reduce the complications of orthopedic surgery, the desire for less invasive procedures, such as, knee arthroscopy to repair the anterior cruciate ligament, has increased. There are, currently, two common positions for limbs that are used during surgery depending on the surgeon's experience. Therefore, our aim was to investigate the effect of limb position on complications after anterior cruciate ligament reconstruction surgery. Materials and Methods From April 2016 to July 2020 at our orthopedic-sports trauma center, 688 patients between the ages of 18 and 50 with anterior cruciate ligament rupture underwent reconstruction surgery with a hamstring graft. Patients were divided into two groups in terms of limb position at the time of surgery. For three months, patients were evaluated for surgical complications, basic demographic information, and information during surgery. Results There was no statistically significant difference between the two groups in terms of demographic information, side of injury, preparation time, tourniquet time, operation time, and duration of hospitalization. At quarterly follow-up, there was no significant difference between the two groups in terms of postoperative complications (P = 0.976). Conclusions There is no difference between compartment syndrome and deep vein thrombosis in different situations, therefore, the surgeon should operate in any position he is skilled in. Also, surgeons should always pay special attention to these complications and provide necessary training to patients in order to prevent them.
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Affiliation(s)
- Hamidreza Aslani
- Sport Medicine and Knee Research Center, Milad Hospital, Tehran, Iran
| | - Sona Bonakdar
- Clinical Research Development Unit of Akhtar Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Farzad Amoozade
- Clinical Research Development Unit of Akhtar Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mona Gorji
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir H. Gholami
- Clinical Research Development Unit of Akhtar Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Katayoun Tajic
- Clinical Research Development Unit of Akhtar Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Morteza Gholipour
- Clinical Research Development Unit of Akhtar Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
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23
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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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24
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Gögele C, Vogt J, Hahn J, Breier A, Bernhardt R, Meyer M, Schröpfer M, Schäfer-Eckart K, Schulze-Tanzil G. Co-Culture of Mesenchymal Stem Cells and Ligamentocytes on Triphasic Embroidered Poly(L-lactide-co-ε-caprolactone) and Polylactic Acid Scaffolds for Anterior Cruciate Ligament Enthesis Tissue Engineering. Int J Mol Sci 2023; 24:ijms24076714. [PMID: 37047686 PMCID: PMC10095212 DOI: 10.3390/ijms24076714] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/26/2023] [Accepted: 03/28/2023] [Indexed: 04/07/2023] Open
Abstract
Successful anterior cruciate ligament (ACL) reconstructions strive for a firm bone-ligament integration. With the aim to establish an enthesis-like construct, embroidered functionalized scaffolds were colonized with spheroids of osteogenically differentiated human mesenchymal stem cells (hMSCs) and lapine (l) ACL fibroblasts in this study. These triphasic poly(L-lactide-co-ε-caprolactone) and polylactic acid (P(LA-CL)/PLA) scaffolds with a bone-, a fibrocartilage transition- and a ligament zone were colonized with spheroids directly after assembly (DC) or with 14-day pre-cultured lACL fibroblast and 14-day osteogenically differentiated hMSCs spheroids (=longer pre-cultivation, LC). The scaffolds with co-cultures were cultured for 14 days. Cell vitality, DNA and sulfated glycosaminoglycan (sGAG) contents were determined. The relative gene expressions of collagen types I and X, Mohawk, Tenascin C and runt-related protein (RUNX) 2 were analyzed. Compared to the lACL spheroids, those with hMSCs adhered more rapidly. Vimentin and collagen type I immunoreactivity were mainly detected in the hMSCs colonizing the bone zone. The DNA content was higher in the DC than in LC whereas the sGAG content was higher in LC. The gene expression of ECM components and transcription factors depended on cell type and pre-culturing condition. Zonal colonization of triphasic scaffolds using spheroids is possible, offering a novel approach for enthesis tissue engineering.
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Affiliation(s)
- Clemens Gögele
- Institute of Anatomy and Cell Biology, Paracelsus Medical University, Nuremberg and Salzburg, Prof. Ernst Nathan Str. 1, 90419 Nuremberg, Germany
| | - Julia Vogt
- Institute of Anatomy and Cell Biology, Paracelsus Medical University, Nuremberg and Salzburg, Prof. Ernst Nathan Str. 1, 90419 Nuremberg, Germany
| | - Judith Hahn
- Department Materials Engineering, Institute of Polymers Materials, Leibniz-Institut für Polymerforschung Dresden e.V. (IPF), Hohe Straße 6, 01069 Dresden, Germany
| | - Annette Breier
- Department Materials Engineering, Institute of Polymers Materials, Leibniz-Institut für Polymerforschung Dresden e.V. (IPF), Hohe Straße 6, 01069 Dresden, Germany
| | - Ricardo Bernhardt
- Department Materials Engineering, Institute of Polymers Materials, Leibniz-Institut für Polymerforschung Dresden e.V. (IPF), Hohe Straße 6, 01069 Dresden, Germany
| | - Michael Meyer
- FILK Freiberg Institute gGmbH (FILK), Meißner Ring 1-5, 09599 Freiberg, Germany
| | - Michaela Schröpfer
- FILK Freiberg Institute gGmbH (FILK), Meißner Ring 1-5, 09599 Freiberg, Germany
| | - Kerstin Schäfer-Eckart
- Bone Marrow Transplantation Unit, Medizinische Klinik 5, Klinikum Nürnberg, 90419 Nuremberg, Germany
| | - Gundula Schulze-Tanzil
- Institute of Anatomy and Cell Biology, Paracelsus Medical University, Nuremberg and Salzburg, Prof. Ernst Nathan Str. 1, 90419 Nuremberg, Germany
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25
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Shiraishi R, Ueda S. Relationship between the change in infrapatellar fat pad thickness assessed using ultrasonography and anterior knee pain on squatting after anterior cruciate ligament reconstruction. J Med Ultrason (2001) 2023; 50:237-243. [PMID: 36961646 PMCID: PMC11018648 DOI: 10.1007/s10396-023-01300-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 02/11/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE Anterior knee pain (AKP) may occur after anterior cruciate ligament (ACL) reconstruction. The present study investigated the relationship between the change in infrapatellar fat pad (IFP) thickness assessed using ultrasonography (US) and AKP on squatting in patients after ACL reconstruction. METHODS Patients were enrolled 3 months after ACL reconstruction using the bone-tendon-bone (BTB) technique. Subjects were divided into the AKP group (numerical rating scale [NRS] score ≥ 1) and control group (NRS score < 1) using a NRS of pain on squatting, and intergroup comparisons were performed. On US evaluation, measurement angles of the knee joint were 0° and 30° in the supine position. The IFP between the femoral intercondylar notch and patellar tendon was measured on short-axis images. The changes in IFP thickness were calculated from values measured at different angles of the knee joint. RESULTS Twenty-one patients (mean age 24.9 ± 9.3 years) were included in the present study: 12 in the AKP group (9 males, 3 females) and nine in the control group (5 males, 4 females). A significant difference in the change in IFP thickness at 3 months was observed between the AKP and control groups (0.67 ± 0.44 mm vs. 1.84 ± 0.34 mm, p < 0.001). There was a negative correlation between the change in IFP thickness and the NRS score (r = - 0.720, p < 0.001) in reconstructed knees. CONCLUSION A smaller change in IFP thickness assessed using US after ACL reconstruction was identified as a factor contributing to AKP on squatting.
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Affiliation(s)
- Ryo Shiraishi
- Rokuto Orthopedic Surgery Az, 46 Onoyama-cho, Naha City, Okinawa, 900-0026, Japan
- Department of Clinical Research and Quality Management, Graduate School of Medicine, University of The Ryukyus, 207 Uehara, Nishihara-cho, Okinawa, 903-0215, Japan
- Department of Rehabilitation Therapy, Chuzan Hospital, 6-2-1 Matsumoto, Okinawa City, Okinawa, 904-2151, Japan
| | - Shinichiro Ueda
- Department of Clinical Research and Quality Management, Graduate School of Medicine, University of The Ryukyus, 207 Uehara, Nishihara-cho, Okinawa, 903-0215, Japan.
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26
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Chen Y, Gong T, Jiang N, Zhao A, Wang T, Wang X, Han W. Dynamics analysis of the anterior cruciate ligament reconstruction surgery based on magnetic resonance imaging. Biotechnol Genet Eng Rev 2023:1-13. [PMID: 36877599 DOI: 10.1080/02648725.2023.2186324] [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: 01/10/2023] [Accepted: 02/23/2023] [Indexed: 03/07/2023]
Abstract
In clinical practice, anterior cruciate ligament (ACL) rupture is always repaired by the single-beam reconstruction method. Before the surgery, the surgeon made the diagnosis based on medical images, such as CT (computerized tomography) and MR (magnetic resonance) images. However, little is known about how biomechanics governs the biological nature for femoral tunnel position. In the present study, three volunteers' motion trails were captured by six cameras when they were doing squat movement. The medical image can reconstruct the structure of the ligaments and bones and a left knee model was reconstructed by MIMICS by MRI data of DICOM format. Finally, the effects of different femoral tunnel positions on ACL biomechanics were characterized by the inverse dynamic analysis method. The results showed that there were significant differences in the direct mechanical effects of the anterior cruciate ligament at different locations of the femoral tunnel (p < 0.05), the peak stress of ACL in the low tension area was 1097.24 ± 25.55 N, and the peak stress of ACL in the distal femur was 356.81 ± 15.39 N, both of which were much higher than that in the direct fiber area (118.78 ± 20.68 N).
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Affiliation(s)
- Yadong Chen
- School of Electrical Engineering, Shenyang University of Technology, Shenyang, China
| | - Tianxing Gong
- School of Electrical Engineering, Shenyang University of Technology, Shenyang, China
| | - Nan Jiang
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Aoxiang Zhao
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Tongyu Wang
- College of Medicine and Biological Information Engineering, Northeastern University, Shenyang, China
| | - Xiangdong Wang
- Sports Science Research Institute of the State Sports General Administration, China Institute of Sport Science, Beijing, China
| | - Wenfeng Han
- Sports Science Research Institute of the State Sports General Administration, General Hospital of northern theater command, Shenyang, China
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27
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Hossain GJ, Islam MS, Rahman Khan MM, Rafiqul Islam M, Rahman SM, Jahan MS, Halder RC, Rahaman SK, Al Mamun MB, Harun ME. A prospective study of arthroscopic primary ACL reconstruction with ipsilateral peroneus longus tendon graft: Experience of 439 cases. Medicine (Baltimore) 2023; 102:e32943. [PMID: 36862908 PMCID: PMC9981376 DOI: 10.1097/md.0000000000032943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Anterior cruciate ligament (ACL) tears are frequent ligamentous injuries that necessitate reconstruction in many cases. The patellar tendon and the hamstring tendon are the most frequently utilized autografts for reconstruction. However, both have certain disadvantages. We hypothesized that the peroneus longus tendon would be an acceptable graft for arthroscopic ACL reconstruction. The aim of this study is to determine whether a peroneus Longus tendon transplant is a functionally viable option for arthroscopic ACL reconstruction without compromising donor ankle activity. In this prospective study 439 individuals aged between 18 to 45 years, who underwent ACL reconstruction using ipsilateral Peroneus longus tendon autograft were observed. The injury to the ACL was initially assessed by physical examinations and further confirmed by magnetic resonance imaging (MRI). The outcome was assessed at 6, 12, and 24 months after the surgery using Modified Cincinnati, International Knee Documentation Committee (IKDC), and Tegner-Lysholm scores. The donor ankle stability was evaluated using foot and ankle disability index (FADI) and AOFAS scores, as well as hop tests. Significant (P < .001) improvement in the result of the IKDC score, Modified Cincinnati, and Tegner-Lysholm score was observed at the final follow-up. The Lachman test was mildly (1+) positive only in 7.70% of cases, the anterior drawer became negative in all cases, and the pivot shift test was negative in 97.43% of cases at 24 months after the surgery. FADI and AOFAS scores for donor's ankle functional assessment were impressive, as were single hop test, triple hop test, and cross over hop test results at 2 years. None of the patients had any neurovascular deficit. However, 6 cases of superficial wound infection were observed, 4 at the port site and 2 at the donor site. All resolved after appropriate oral antibiotic therapy. The peroneus longus tendon can be considered a safe, effective, and promising graft of choice for arthroscopic primary single-bundle ACL reconstruction because it has a good functional outcome and impressive donor ankle function after surgery.
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Affiliation(s)
- G.M. Jahangir Hossain
- National Institute of Traumatology & Orthopedic Rehabilitation, (NITOR) Dhaka-1207, Bangladesh
| | - Md. Samiul Islam
- National Institute of Traumatology & Orthopedic Rehabilitation, (NITOR) Dhaka-1207, Bangladesh
- *Correspondence: Md. Samiul Islam, Department of Orthopaedics, Unit-Red 2, National Institute of Traumatology & orthopedic rehabilitation, (NITOR) Dhaka-1207, Bangladesh (e-mail: )
| | | | - Muhammad Rafiqul Islam
- National Institute of Traumatology & Orthopedic Rehabilitation, (NITOR) Dhaka-1207, Bangladesh
| | - S.M. Mosheeur Rahman
- National Institute of Traumatology & Orthopedic Rehabilitation, (NITOR) Dhaka-1207, Bangladesh
| | - Md Sarwar Jahan
- National Institute of Traumatology & Orthopedic Rehabilitation, (NITOR) Dhaka-1207, Bangladesh
| | - Rabin Chandra Halder
- National Institute of Traumatology & Orthopedic Rehabilitation, (NITOR) Dhaka-1207, Bangladesh
| | - Syed Khaledur Rahaman
- National Institute of Traumatology & Orthopedic Rehabilitation, (NITOR) Dhaka-1207, Bangladesh
| | - Md Bahauddin Al Mamun
- National Institute of Traumatology & Orthopedic Rehabilitation, (NITOR) Dhaka-1207, Bangladesh
| | - Muhammad Eusuf Harun
- National Institute of Traumatology & Orthopedic Rehabilitation, (NITOR) Dhaka-1207, Bangladesh
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Adouni M, Faisal T, Dhaher Y. Effect of Surgical Design Variations on the Knee Contact Behavior during Anterior Cruciate Ligament Reconstruction. J Knee Surg 2023; 36:310-321. [PMID: 34375997 DOI: 10.1055/s-0041-1733879] [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] [Indexed: 02/07/2023]
Abstract
In this study, we aimed to develop an in-silico synthesis of the effect of critical surgical design parameters on articular contact behavior for a bone-patellar-tendon-bone anterior cruciate ligament reconstruction (ACL-R) surgery. A previously developed finite element model of the knee joint consisting of all relevant soft tissues was employed. The knee model was further updated with additional features to develop the parametric FE model of the biomechanical experiments that depicted the ACL-R surgery. The parametricity was created involving femoral tunnel architecture (orientations and locations) and graft fixation characteristics (pretension and angle of fixation). A global sensitivity analysis based on variance decomposition was used to investigate the contribution of the surgical parameters to the uncertainty in response to the ACL-R joint. Our examinations indicated that the total contact force was primarily influenced by either combined or individual action of the graft pretension and fixation angle, with a modest contribution of the graft insertion sites. The joint contact center and area were affected mainly by the angle of fixation and the tunnel placements. Graft pretension played the dominant role in the maximum contact pressure variability, an observation that has been well-documented in the literature. Interestingly, the joint contact behavior was almost insensitive to the tunnel's coronal and sagittal orientations. Our data provide an evaluation of how the surgical parameters affect the knee joint's contact behavior after ACL-R and may provide additional information to better explain the occurrence of osteoarthritis as an aftermath of such surgery.
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Affiliation(s)
- Malek Adouni
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois.,Department of Mechanical Engineering, Australian College of Kuwait, Kuwait City, Kuwait
| | - Tanvir Faisal
- Department of Bioengineering, University of Texas Southwest, Dallas, Texas
| | - Yasin Dhaher
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois.,Department of Mechanical Engineering, University of Louisiana at Lafayette, Louisiana.,Department of Physical Medicine and Rehabilitation, University of Texas Southwest, Dallas, Texas.,Department of Orthopedic Surgery, University of Texas Southwest, Dallas, Texas
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29
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Optimization of surgical exposure for harvesting gracilis-semitendinosus tendons. INTERNATIONAL ORTHOPAEDICS 2023; 47:131-140. [PMID: 36239745 DOI: 10.1007/s00264-022-05598-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE This study was conducted to provide anatomical data and surface markers for the safe and efficient exposure of surgical incisions for harvesting gracilis tendons (GT) and semitendinosus tendons (STT) while avoiding technical pitfalls and nerve injury during harvest for ligament reconstruction. METHODS Seventy-four Chinese cadaveric lower limbs were dissected to expose the infrapatellar branch of the saphenous nerve (IPBSN) and pes anserinus (PA). Measurements of the borders and accessory bands of the PA tendons were taken. The arrangement of PA tendons and distribution of the IPBSN were assessed. RESULTS The PA was roughly shaped like a quadrangle, with its superior border at the horizontal plane of the tibial tuberosity (TT). The GT and STT bifurcation point was located on the medial border of the PA. From medial side to lateral side, the sartorius tendons (ST), GT, and STT fused gradually and formed the lateral border of the PA at the distal end. The tendon arrangement of the PA was primarily affected by ST, which commonly covered GT and STT completely. Variant tendons were found in 41.9% of specimens. The insertion of the accessory bands was distal but close to the inferior border of the PA. Accessory bands were observed only in STT and ST, and STT accounted for the most. The width of the first accessory band of STT was similar to the width of the STT. Additionally, most of the IPBSNs were proximal to the horizontal plane of the TT. CONCLUSION For clearly exposing the GT and STT, it is crucial to expose the GT and STT bifurcation point on the medial border of the PA, whether directly or indirectly through the incision.The influence of ST insertion and the variability of tendons within the PA must be paid attention to during the operation. To protect IPBSNs highly, the incision should not be higher than the TT level.
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30
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Zhou T, Xu Y, Zhang A, Zhou L, Zhang Q, Ji Z, Xu W. Global research status of anterior cruciate ligament reconstruction: a bibliometric analysis. EFORT Open Rev 2022; 7:808-816. [PMID: 36541554 PMCID: PMC9880905 DOI: 10.1530/eor-21-0065] [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] [Indexed: 12/24/2022] Open
Abstract
Purpose The aim of this study is to comprehensively analyze the publications of anterior cruciate ligament reconstruction (ACLR) research and display the current research status in this field. Methods Articles regarding ACLR research published before October 7, 2021, were downloaded from the Web of Science Core Collection. Excel 2016 and Bibliometric website were used to analyze the annual article trends and international cooperation network. CiteSpace V and VOSviewer were used to perform co-occurrence and citation analyses for journals, institutions, authors, cocitation authors and keywords. Burst keyword detection was also performed with CiteSpace V. Results A total of 12 223 ACLR articles were identified. The American Journal of Sports Medicine (1636 publications, 92,310 citations), the Pennsylvania Commonwealth System of Higher Education (624 publications, 25,304 citations) and Freddie H. Fu (321 publications, 15,245 citations) were journals, institutions and authors with the most publications and citations, respectively. Patellar tendon was the keyword with the most occurrences (1618 times) and return to sport was the keyword with the most burst strength (burst strength: 46.99). Conclusion ACLR-related publications showed a rapid increasing trend since 1990. A large number of articles have been published by authors from different institutions and countries, some of which have gained great academic influence. Based on keyword analysis, patellar tendon is identified as the research hotspot and return to sport is identified as the current research frontier.
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Affiliation(s)
- Tianping Zhou
- Department of Joint Surgery and Sports Medicine, Shanghai Changhai Hospital of Navy Medical University, Shanghai, P.R.China
| | - Yihong Xu
- Department of Joint Surgery and Sports Medicine, Shanghai Changhai Hospital of Navy Medical University, Shanghai, P.R.China,Correspondence should be addressed to W Xu;
| | - Aiai Zhang
- Department of Burn Surgery, Shanghai Changhai Hospital of Navy Medical University, Shanghai, P.R.China
| | - Lan Zhou
- School of Kinesiology, Shanghai University of Sport, Shanghai, China
| | - Qing Zhang
- Department of Joint Surgery and Sports Medicine, Shanghai Changhai Hospital of Navy Medical University, Shanghai, P.R.China
| | - Zhou Ji
- Department of Joint Surgery and Sports Medicine, Shanghai Changhai Hospital of Navy Medical University, Shanghai, P.R.China
| | - Weidong Xu
- Department of Joint Surgery and Sports Medicine, Shanghai Changhai Hospital of Navy Medical University, Shanghai, P.R.China,Correspondence should be addressed to W Xu;
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31
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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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Saueressig T, Braun T, Steglich N, Diemer F, Zebisch J, Herbst M, Zinser W, Owen PJ, Belavy DL. Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: a living systematic review and meta-analysis. Br J Sports Med 2022; 56:1241-1251. [PMID: 36038357 PMCID: PMC9606531 DOI: 10.1136/bjsports-2021-105359] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Compare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture. DESIGN Living systematic review and meta-analysis. DATA SOURCES Six databases, six trial registries and prior systematic reviews. Forward and backward citation tracking was employed. ELIGIBILITY CRITERIA Randomised controlled trials that compared primary reconstructive surgery and primary rehabilitative treatment with or without optional reconstructive surgery. DATA SYNTHESIS Bayesian random effects meta-analysis with empirical priors for the OR and standardised mean difference and 95% credible intervals (CrI), Cochrane RoB2, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. RESULTS Of 9514 records, 9 reports of three studies (320 participants in total) were included. No clinically important differences were observed at any follow-up for self-reported knee function (low to very low certainty of evidence). For radiological knee osteoarthritis, we found no effect at very low certainty of evidence in the long term (OR (95% CrI): 1.45 (0.30 to 5.17), two studies). Meniscal damage showed no effect at low certainty of evidence (OR: 0.85 (95% CI 0.45 to 1.62); one study) in the long term. No differences were observed between treatments for any other secondary outcome. Three ongoing randomised controlled trials were identified. CONCLUSIONS There is low to very low certainty of evidence that primary rehabilitation with optional surgical reconstruction results in similar outcome measures as early surgical reconstruction for ACL rupture. The findings challenge a historical paradigm that anatomic instability should be addressed with primary surgical stabilisation to provide optimal outcomes. PROSPERO REGISTRATION NUMBER CRD42021256537.
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Affiliation(s)
- Tobias Saueressig
- Science and Research, Physio Meets Science GmbH, Leimen, Baden-Württemberg, Germany
| | - Tobias Braun
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit, Bochum, North Rhine-Westphalia, Germany
- HSD Hochschule Döpfer (University of Applied Sciences), Cologne, North Rhine-Westphalia, Germany
| | - Nora Steglich
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit, Bochum, North Rhine-Westphalia, Germany
| | | | - Jochen Zebisch
- Science and Research, Physio Meets Science GmbH, Leimen, Baden-Württemberg, Germany
| | - Maximilian Herbst
- Science and Research, Physio Meets Science GmbH, Leimen, Baden-Württemberg, Germany
| | | | - Patrick J Owen
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Daniel L Belavy
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit, Bochum, North Rhine-Westphalia, Germany
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Intraoperative Administration of Adipose Stromal Vascular Fraction Does Not Improve Functional Outcomes in Young Patients with Anterior Cruciate Ligament Reconstruction. J Clin Med 2022; 11:jcm11216240. [PMID: 36362468 PMCID: PMC9654782 DOI: 10.3390/jcm11216240] [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: 10/04/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 01/24/2023] Open
Abstract
Adipose stromal vascular fraction (SVF) has a versatile cellular system for biologically augmented therapies. However, there have been no clinical studies investigating the benefits of the augmentation of anterior cruciate ligament reconstruction (ACLR) with SVF. We conducted a retrospective study in assessing the effects of intraoperative SVF administration on the functional outcomes in young patients with ACLR. The enrolled patients were divided into the control group (ACLR only) and the SVF group (ACLR with SVF). The functional outcomes in both groups were assessed by the Lysholm knee scoring system, the Tegner activity scale, and the International Knee Documentation Committee (IKDC) subjective evaluation form, and compared at several time points during a 12-month follow-up. We found that the sex distribution and pre-surgery scores were similar in the two groups, whereas the mean age of the SVF group was higher than that of the control group (p = 0.046). The between-group analysis and generalized estimating equation model analysis revealed that, while patients in the SVF group significantly improved all their functional outcomes at 12 months after surgery, this improvement was not significantly different from the results of patients in the control group (Lysholm, p = 0.553; Tegner, p = 0.197; IKDC, p = 0.486). No side effects were observed in either group. We concluded that the intraoperative administration of SVF does not improve or accelerate functional recovery after ACLR in young patients.
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El-Kady RAEH, ElGuindy AMF. Septic Arthritis Complicating Arthroscopic Anterior Cruciate Ligament Reconstruction: An Experience from a Tertiary-Care Hospital. Infect Drug Resist 2022; 15:3779-3789. [PMID: 35859912 PMCID: PMC9289172 DOI: 10.2147/idr.s369240] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/06/2022] [Indexed: 11/23/2022] Open
Abstract
Background Septic arthritis (SA) of the knee following anterior cruciate ligament reconstruction (ACLR) is considered a catastrophic complication in terms of reduced or loss function of the involved joint. The aims of this study were to gauge the incidence, risk factors, and causative organisms of SA after ACLR. Methods We conducted a retrospective review of 836 patients who underwent primary ACLR at our institution from October 2018 to September 2021. Patients’ demographics, onset of presentation, clinical symptoms, laboratory findings, and management details were obtained from patients’ electronic medical records. Results Out of the 836 primary ACLRs, 12 were complicated with SA (1.43%). Independent risk factors associated with SA included age (OR; 11.12, 95% CI; 1.3–94.97), obesity (OR; 8.51, 95% CI; 1.02–71.13), and diabetes mellitus (OR; 12.58, 95% CI; 2.39–66.3). Staphylococcus aureus was the most frequent culprit organism (66.7%), followed by Streptococcus species (25%), and Pseudomonas aeruginosa (8.3%). No fungal, mycobacterial, or polymicrobial growth were recovered from synovial fluid cultures. All of the infected cases underwent arthroscopic joint lavage and debridement in the operating room followed by intravenous antibiotics. Graft removal was not done in any of the involved patients, with eradication of infection in all cases. Conclusion SA after ACLR is uncommon, with S. aureus identified in about two-thirds of the patients. Prompt diagnosis and treatment are crucial to avoid graft loss and arthritis-associated joint damage. Orthopedic surgeons should consider rigorous implementation of infection control strategies to minimize the incidence of this devastating morbidity.
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Affiliation(s)
- Rania Abd El-Hamid El-Kady
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.,Department of Pathological Sciences, Fakeeh College for Medical Sciences, Jeddah, Kingdom of Saudi Arabia
| | - Ahmed Mahmoud Fouad ElGuindy
- Department of Orthopedic Surgery, Faculty of Medicine, Fayoum University, Fayoum, Egypt.,Department of Orthopedic and Spine Surgery, Dr. Soliman Fakeeh Hospital, Jeddah, Kingdom of Saudi Arabia
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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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Török L, Jávor P, Török K, Rárosi F, Hartmann P. Early Return to Play After Anterior Cruciate Ligament Reconstruction: Is It Worth the Risk? Ann Rehabil Med 2022; 46:97-107. [PMID: 35508928 PMCID: PMC9081394 DOI: 10.5535/arm.22010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/30/2022] [Indexed: 11/09/2022] Open
Abstract
Objective To compare the outcomes of a 6-month-long accelerated rehabilitation with a 12-month-long rehabilitation. There is no consensus on the optimal duration of rehabilitation after anterior cruciate ligament reconstruction (ACLR). Trends in the past decades have shifted towards accelerated programs, often resulting in a return to play (RTP) at 4–6 months, postoperatively. However, longer rehabilitation cycles have recently experienced renaissance due to a greater understanding of graft remodeling. Methods Adult athletes who underwent ACLR between 2015 and 2018 by the same surgeon were included and followed-up prospectively for 24 months. Participants were allocated into two groups based on their RTP (6 months vs. 12 months) and compared with graft elongation, reoperation rate, and sports career (quit or continue) outcomes. Results Fifty-four patients underwent accelerated rehabilitation and 92 completed conventional rehabilitation. The accelerated rehabilitation was significantly associated with graft elongation—the accelerated rehabilitation group (n=9) and the conventional rehabilitation group (n=0), p<0.001—and need for reoperation—the accelerated rehabilitation group (n=5) and the conventional rehabilitation group (n=1), p=0.026. Although the relationship between rehabilitation time and quitting competitive sports did not reach significance at 0.05 level (p=0.063), it was significant when p<0.1, thereby showing a clear trend. Conclusion Accelerated rehabilitation increased graft elongation risk. Knee laxity ≥3 mm measured at 6 months after ACLR should be accompanied by RTP time frame re-evaluation. Arthrometry checkups or routine magnetic resonance imaging shortly after RTP may be considered in cases of accelerated rehabilitation.
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Affiliation(s)
- László Török
- Department of Sports Medicine, University of Szeged, Szeged, Hungary.,Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Péter Jávor
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Katalin Török
- Department of Kinesiology, University of Physical Education, Budapest, Hungary
| | - Ferenc Rárosi
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Petra Hartmann
- Department of Traumatology, University of Szeged, Szeged, Hungary
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Green S, Karunakaran KD, Peng K, Berry D, Kussman BD, Micheli L, Borsook D. Measuring "pain load" during general anesthesia. Cereb Cortex Commun 2022; 3:tgac019. [PMID: 35611143 PMCID: PMC9123643 DOI: 10.1093/texcom/tgac019] [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] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/21/2022] [Indexed: 12/16/2022] Open
Abstract
Introduction Functional near-infrared spectroscopy (fNIRS) allows for ongoing measures of brain functions during surgery. The ability to evaluate cumulative effects of painful/nociceptive events under general anesthesia remains a challenge. Through observing signal differences and setting boundaries for when observed events are known to produce pain/nociception, a program can trigger when the concentration of oxygenated hemoglobin goes beyond ±0.3 mM from 25 s after standardization. Method fNIRS signals were retrieved from patients undergoing knee surgery for anterior cruciate ligament repair under general anesthesia. Continuous fNIRS measures were measured from the primary somatosensory cortex (S1), which is known to be involved in evaluation of nociception, and the medial polar frontal cortex (mPFC), which are both involved in higher cortical functions (viz. cognition and emotion). Results A ±0.3 mM threshold for painful/nociceptive events was observed during surgical incisions at least twice, forming a basis for a potential near-real-time recording of pain/nociceptive events. Evidence through observed true positives in S1 and true negatives in mPFC are linked through statistically significant correlations and this threshold. Conclusion Our results show that standardizing and observing concentrations over 25 s using the ±0.3 mM threshold can be an arbiter of the continuous number of incisions performed on a patient, contributing to a potential intraoperative pain load index that correlates with post-operative levels of pain and potential pain chronification.
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Affiliation(s)
- Stephen Green
- Corresponding author: 77 Lab, Massachusetts Institute of Technology, Department of Mechanical Engineering, 77 Massachusetts Avenue, Cambridge, Massachusetts, 02139, United States.
| | - Keerthana Deepti Karunakaran
- The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, United States
| | - Ke Peng
- Département en Neuroscience, Centre de Recherche du CHUM, l'Université de Montréal Montreal, 2900 Edouard Montpetit Blvd, Montreal, Quebec H3T 1J4, Canada
| | - Delany Berry
- The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, United States
| | - Barry David Kussman
- The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, United States
| | - Lyle Micheli
- Departments of Orthopedics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02114, United States
| | - David Borsook
- Département en Neuroscience, Centre de Recherche du CHUM, l'Université de Montréal Montreal, 2900 Edouard Montpetit Blvd, Montreal, Quebec H3T 1J4, Canada,Departments of Orthopedics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02114, United States,Departments of Psychiatry and Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, United States
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Memmel C, Krutsch W, Szymski D, Pfeifer C, Henssler L, Frankewycz B, Angele P, Alt V, Koch M. Current Standards of Early Rehabilitation after Anterior Cruciate Ligament Reconstruction in German Speaking Countries-Differentiation Based on Tendon Graft and Concomitant Injuries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074060. [PMID: 35409745 PMCID: PMC8997891 DOI: 10.3390/ijerph19074060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 02/01/2023]
Abstract
Background: Although anterior cruciate ligament reconstruction (ACLR) is a well-established procedure and is standardly performed by orthopedic surgeons all over the world, there does not seem to be a standard protocol for early rehabilitation. The purpose of this study was to give answers to the following questions: (i) Does (a) the use of a specific tendon graft, and (b) potentially additional therapy of concomitant pathologies influence surgeons’ choice of a distinct postoperative rehabilitation protocol after ACLR? (ii) To what extent do these rehabilitation recommendations differ? Methods: Retrospective analysis of currently used early rehabilitation protocols after ACLR in German-speaking countries (GER, AUT and SUI) was conducted. Rehabilitation criteria included weight bearing, range of motion (ROM), the utilization of braces, continuous passive/active motion therapy (CPM/CAM), rehabilitation training and sport-specific training. Tendon grafts were differentiated as hamstring (HAM) and bone−patellar tendon−bone grafts (BTB). Concomitant pathologies included meniscus injuries (+M) and unhappy triad injuries (+UTI). Results: Most of the surveyed protocols were differentiated according to the used tendon graft or additional therapy of concomitant injuries (ACLR-differentiated, n = 147 vs. ACLR without graft differentiation, n = 58). When comparing ACLR-HAM and ACLR-BTB, significant differences were found regarding weight bearing (p = 0.01), ROM (p = 0.05) and the utilization of braces (p = 0.03). Regarding ACLR+M, an overall significant decelerated rehabilitation could be detected. After ACLR+UTI-therapy, a significant delayed start to full weight bearing (p = 0.002) and ROM (p < 0.001) was found. Conclusions: Most orthopedic surgeons from German-speaking countries differentiate early rehabilitation after ACLR according to the tendon graft used and therapy of concomitant pathologies. No consensus about early rehabilitation after ACLR is available. However, tendencies for an accelerated rehabilitation after ACLR-BTB and a more restrained rehabilitation of multiple injured knees were detected.
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Affiliation(s)
- Clemens Memmel
- Department of Paediatric Surgery and Orthopaedics, Clinic St. Hedwig, Barmherzige Brueder Regensburg, KUNO Paediatric University Medical Centre and FIFA Medical Centre of Excellence, University Medical Centre Regensburg, 93053 Regensburg, Germany
- Correspondence:
| | - Werner Krutsch
- Department of Trauma Surgery and FIFA Medical Centre of Excellence, University Medical Centre Regensburg, 93053 Regensburg, Germany; (W.K.); (D.S.); (C.P.); (L.H.); (B.F.); (P.A.); (V.A.); (M.K.)
- SportDocs Franken, 90455 Nuremberg, Germany
| | - Dominik Szymski
- Department of Trauma Surgery and FIFA Medical Centre of Excellence, University Medical Centre Regensburg, 93053 Regensburg, Germany; (W.K.); (D.S.); (C.P.); (L.H.); (B.F.); (P.A.); (V.A.); (M.K.)
| | - Christian Pfeifer
- Department of Trauma Surgery and FIFA Medical Centre of Excellence, University Medical Centre Regensburg, 93053 Regensburg, Germany; (W.K.); (D.S.); (C.P.); (L.H.); (B.F.); (P.A.); (V.A.); (M.K.)
- Department of Trauma Surgery, InnKlinikum Altoetting, 84503 Altoetting, Germany
| | - Leopold Henssler
- Department of Trauma Surgery and FIFA Medical Centre of Excellence, University Medical Centre Regensburg, 93053 Regensburg, Germany; (W.K.); (D.S.); (C.P.); (L.H.); (B.F.); (P.A.); (V.A.); (M.K.)
| | - Borys Frankewycz
- Department of Trauma Surgery and FIFA Medical Centre of Excellence, University Medical Centre Regensburg, 93053 Regensburg, Germany; (W.K.); (D.S.); (C.P.); (L.H.); (B.F.); (P.A.); (V.A.); (M.K.)
| | - Peter Angele
- Department of Trauma Surgery and FIFA Medical Centre of Excellence, University Medical Centre Regensburg, 93053 Regensburg, Germany; (W.K.); (D.S.); (C.P.); (L.H.); (B.F.); (P.A.); (V.A.); (M.K.)
| | - Volker Alt
- Department of Trauma Surgery and FIFA Medical Centre of Excellence, University Medical Centre Regensburg, 93053 Regensburg, Germany; (W.K.); (D.S.); (C.P.); (L.H.); (B.F.); (P.A.); (V.A.); (M.K.)
| | - Matthias Koch
- Department of Trauma Surgery and FIFA Medical Centre of Excellence, University Medical Centre Regensburg, 93053 Regensburg, Germany; (W.K.); (D.S.); (C.P.); (L.H.); (B.F.); (P.A.); (V.A.); (M.K.)
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, 4101 Basel, Switzerland
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Remnants-preserving ACL reconstruction using direct tendinous graft fixation: a new rat model. J Orthop Surg Res 2022; 17:7. [PMID: 34986843 PMCID: PMC8729105 DOI: 10.1186/s13018-021-02890-9] [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: 10/06/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) repair techniques are new emerging strategies prevailing, in selected cases, over standard reconstruction of the ACL with excision of its remnants. Mid-substance ACL tears represent a challenge for ACL repair techniques, and remnants-preserving ACL reconstruction (rp-ACLR) using an autograft remains the recommended treatment in this situation. However, morbidity associated with the autograft harvesting prompts the need for alternative surgical strategies based on the use of synthetic scaffolds. Relevant small animal models of mid-substance tears with ACL remnants preservation and reconstruction are necessary to establish the preliminary proof of concept of these new strategies. METHODS A rat model of rp-ACLR using a tendinous autograft after complete mid-substance ACL transection was established. Twelve weeks following surgery, clinical outcomes and knee joints were assessed through visual gait analysis, Lachman tests, thigh perimeter measurements, magnetic resonance imaging, micro-computed tomography, and histology, to evaluate the morbidity of the procedure, accuracy of bone tunnel positioning, ACL remnants fate, osteoarthritis, and autograft bony integration. Results were compared with those obtained with isolated ACL transection without reconstruction and to right non-operated knees. RESULTS AND DISCUSSION Most operated animals were weight-bearing the day following surgery, and no adverse inflammatory reaction has been observed for the whole duration of the study. Autograft fixation with cortical screws provided effective graft anchorage until sacrifice. Healing of the transected ACL was not observed in the animals in which no graft reconstruction was performed. rp-ACLR was associated with a reduced degeneration of the ACL remnants (p = 0.004) and cartilages (p = 0.0437). Joint effusion and synovitis were significantly lower in the reconstructed group compared to the transected ACL group (p = 0.004). Most of the bone tunnel apertures were anatomically positioned in the coronal and/or sagittal plane. The most deviated bone tunnel apertures were the tibial ones, located in median less than 1 mm posteriorly to anatomical ACL footprint center. CONCLUSION This study presents a cost-effective, new relevant and objective rat model associated with low morbidity for the preliminary study of bio-implantable materials designed for remnants-preserving ACL surgery after mid-substance ACL tear.
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Correlating degradation of functionalized polycaprolactone fibers and fibronectin adsorption using atomic force microscopy. Polym Degrad Stab 2022. [DOI: 10.1016/j.polymdegradstab.2021.109788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Green S, Karunakaran KD, Labadie R, Kussman B, Mizrahi-Arnaud A, Morad AG, Berry D, Zurakowski D, Micheli L, Peng K, Borsook D. fNIRS brain measures of ongoing nociception during surgical incisions under anesthesia. NEUROPHOTONICS 2022; 9:015002. [PMID: 35111876 PMCID: PMC8794294 DOI: 10.1117/1.nph.9.1.015002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/10/2021] [Indexed: 06/14/2023]
Abstract
Significance: Functional near-infrared spectroscopy (fNIRS) has evaluated pain in awake and anesthetized states. Aim: We evaluated fNIRS signals under general anesthesia in patients undergoing knee surgery for anterior cruciate ligament repair. Approach: Patients were split into groups: those with regional nerve block (NB) and those without (non-NB). Continuous fNIRS measures came from three regions: the primary somatosensory cortex (S1), known to be involved in evaluation of nociception, the lateral prefrontal cortex (BA9), and the polar frontal cortex (BA10), both involved in higher cortical functions (such as cognition and emotion). Results: Our results show three significant differences in fNIRS signals to incision procedures between groups: (1) NB compared with non-NB was associated with a greater net positive hemodynamic response to pain procedures in S1; (2) dynamic correlation between the prefrontal cortex (PreFC) and S1 within 1 min of painful procedures are anticorrelated in NB while positively correlated in non-NB; and (3) hemodynamic measures of activation were similar at two separate time points during surgery (i.e., first and last incisions) in PreFC and S1 but showed significant differences in their overlap. Comparing pain levels immediately after surgery and during discharge from postoperative care revealed no significant differences in the pain levels between NB and non-NB. Conclusion: Our data suggest multiple pain events that occur during surgery using devised algorithms could potentially give a measure of "pain load." This may allow for evaluation of central sensitization (i.e., a heightened state of the nervous system where noxious and non-noxious stimuli is perceived as painful) to postoperative pain levels and the resulting analgesic consumption. This evaluation could potentially predict postsurgical chronic neuropathic pain.
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Affiliation(s)
- Stephen Green
- Boston Children’s Hospital, Harvard Medical School, The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Keerthana Deepti Karunakaran
- Boston Children’s Hospital, Harvard Medical School, The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Robert Labadie
- Boston Children’s Hospital, Harvard Medical School, The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Barry Kussman
- Boston Children’s Hospital, Harvard Medical School, Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Arielle Mizrahi-Arnaud
- Boston Children’s Hospital, Harvard Medical School, Division of Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Andrea Gomez Morad
- Boston Children’s Hospital, Harvard Medical School, Division of Perioperative Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Delany Berry
- Boston Children’s Hospital, Harvard Medical School, The Center for Pain and the Brain, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - David Zurakowski
- Boston Children’s Hospital, Harvard Medical School, Division of Biostatistics, Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, United States
| | - Lyle Micheli
- Boston Children’s Hospital, Harvard Medical School, Sports Medicine Division, Department of Orthopedic Surgery, Boston, Massachusetts, United States
| | - Ke Peng
- Université de Montréal, Département en Neuroscience, Centre de Recherche du CHUM, Montréal, Quebec, Canada
| | - David Borsook
- Massachusetts General Hospital, Harvard Medical School, Departments of Psychiatry and Radiology, Boston, Massachusetts, United States
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Williams JR, Neal K, Alfayyadh A, Lennon K, Capin JJ, Khandha A, Manal K, Potter HG, Snyder-Mackler L, Buchanan TS. Knee cartilage T 2 relaxation times 3 months after ACL reconstruction are associated with knee gait variables linked to knee osteoarthritis. J Orthop Res 2022; 40:252-259. [PMID: 33783867 PMCID: PMC8481340 DOI: 10.1002/jor.25043] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/05/2021] [Accepted: 03/24/2021] [Indexed: 02/04/2023]
Abstract
Osteoarthritis development after ACL reconstruction (ACLR) is not well understood. Investigators have examined associations between knee biomechanical alterations and quantitative MRI (qMRI) variables, reflective of cartilage health, 12-60 months following ACLR; however, none have done so early after surgery. As part of an exploratory study, 45 individuals (age, 23 ± 7 years) underwent motion analysis during walking and qMRI 3 months after ACLR. For each limb, peak knee adduction moment (pKAM) and peak knee flexion moment (pKFM) were determined using inverse dynamics and peak medial compartment force was calculated using a neuromusculoskeletal model. T2 relaxation times in the medial compartment and linear regressions were used to determine the associations between gait variables and deep and superficial cartilage T2 relaxation times in six regions. pKAM was positively associated with deep layer T2 relaxation times within the femoral central and posterior regions when examined in the involved limb and from an interlimb difference perspective (involved limb - uninvolved limb). After adjusting for age, the association between interlimb difference of pKAM and interlimb difference of deep layer T2 relaxation times in the tibial central region became significant (p = .043). Interlimb difference of pKFM was negatively associated with interlimb difference of deep layer T2 relaxation times within the femoral central and posterior regions. These associations suggest that degenerative pathways leading to osteoarthritis may be detectable as early as 3 months after reconstruction. Preventative therapeutic techniques may need to be employed early in the rehabilitation process to prevent cartilage degradation.
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Affiliation(s)
- Jack R. Williams
- Department of Mechanical Engineering, University of
Delaware, Newark, DE
| | - Kelsey Neal
- Department of Mechanical Engineering, University of
Delaware, Newark, DE
| | | | - Kendra Lennon
- Department of Physical Therapy, University of Delaware,
Newark, DE
| | - Jacob J. Capin
- Biomechanics and Movement Science, University of Delaware,
Newark, DE,Department of Physical Therapy, University of Delaware,
Newark, DE,Physical Therapy Program, Department of Physical Medicine
and Rehabilitation, University of Colorado, Aurora, CO,Eastern Colorado VA Geriatric Research Education and
Clinical Center (GRECC), Aurora, CO
| | - Ashutosh Khandha
- Department of Biomedical Engineering, University of
Delaware, Newark, DE
| | - Kurt Manal
- Kinesiology and Applied Physiology, University of Delaware,
Newark, DE
| | - Hollis G. Potter
- Department of Radiology and Imaging, Hospital for Special
Surgery, New York, NY
| | - Lynn Snyder-Mackler
- Biomechanics and Movement Science, University of Delaware,
Newark, DE,Department of Physical Therapy, University of Delaware,
Newark, DE,Department of Biomedical Engineering, University of
Delaware, Newark, DE
| | - Thomas S. Buchanan
- Department of Mechanical Engineering, University of
Delaware, Newark, DE,Biomechanics and Movement Science, University of Delaware,
Newark, DE,Department of Biomedical Engineering, University of
Delaware, Newark, DE
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44
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Application and Surgical Technique of ACL Reconstruction Using Worldwide Registry Datasets: What Can We Extract? J Funct Morphol Kinesiol 2021; 7:jfmk7010002. [PMID: 35076508 PMCID: PMC8788449 DOI: 10.3390/jfmk7010002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/21/2021] [Accepted: 12/26/2021] [Indexed: 01/13/2023] Open
Abstract
Anterior cruciate ligament (ACL) injuries are among the most common knee injuries. The purpose of this study was to compare surgical reconstruction of the ACL between different countries and regions in order to describe differences regarding epidemiological data, reconstruction frequency, and graft choice. A systematic literature search was performed using the ACL study group website in order to identify the relevant knee ligament registers. Four national registries were included, comprising those from Sweden, the UK, New Zealand, and Norway. A large variation was found concerning the total number of primary ACL reconstructions with a reported range from 4.1 to 51.3 per 100,000 inhabitants. The country-specific delay between injury and reconstruction varied between an average of 6.0 months and 17.6 months. The leading sports activities resulting in ACL injury included soccer, alpine skiing, handball, rugby, and netball. Moreover, a strong variability in graft choice for primary reconstruction was found. The comparison of ACL registers revealed large differences, indicating different clinical implications regarding conservative or surgical therapy and choice of the preferable graft. ACL registers offer a real-world clinical perspective with the aim to improve quality and patient safety by investigating factors associated with subsequent surgical outcomes.
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Lee DK, Kim JH, Lee BH, Kim H, Jang MJ, Lee SS, Wang JH. Influence of Graft Bending Angle on Femoral Tunnel Widening After Double-Bundle ACL Reconstruction: Comparison of Transportal and Outside-In Techniques. Orthop J Sports Med 2021; 9:23259671211035780. [PMID: 34708137 PMCID: PMC8543726 DOI: 10.1177/23259671211035780] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/14/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Previous studies have suggested that increased mechanical stress due to acute
graft bending angle (GBA) is associated with tunnel widening and graft
failure after anterior cruciate ligament (ACL) reconstruction. Few studies
have compared the GBA between the outside-in (OI) and the transportal (TP)
techniques. Purpose: To evaluate the influence of GBA on clinical outcomes and tunnel widening
after ACL reconstruction with OI versus TP technique. Study Design: Cohort study; Level of evidence, 3. Methods: Included in the study were 56 patients who underwent double-bundle ACL
reconstruction (n = 28 in the OI group and n = 28 in the TP group). Clinical
outcomes (Lysholm, International Knee Documentation Committee, Tegner score,
and knee laxity) 1 year postoperatively were evaluated. Computed tomography
scans at 5 days and 1 year postoperatively were used for imaging
measurements, and the femoral tunnel was divided into the proximal third,
middle, and aperture sections. The GBA and cross-sectional area (CSA) were
measured using image analysis software and were compared between groups. A
correlation analysis was performed to determine if the GBA affected clinical
outcomes or tunnel widening. Results: No significant difference was observed in clinical outcomes between the
groups. The GBA of both the anteromedial (AM) and posterolateral bundles
were more acute in the OI group compared with the TP group
(P < .05). The CSA at the AM tunnel aperture
increased significantly in the OI group (84.2% ± 64.3%) compared with the TP
group (51.4% ± 36.7%) (P = .04). However, there were no
differences in the other sections. In the Pearson correlation test, GBA was
not correlated with tunnel widening or clinical outcomes. Conclusion: Regardless of technique, the GBA did not have a significant influence on
tunnel widening or clinical outcomes. Considering a wider AM tunnel
aperture, a more proximal and posterior AM tunnel position might be
appropriate with the OI technique.
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Affiliation(s)
- Do Kyung Lee
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, South Korea
| | - Byung Hoon Lee
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, South Korea
| | - Hyeonsoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Min Jae Jang
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea.
| | - Sung-Sahn Lee
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Health Science and Technology and Department of Medical Device Management and Research, SAIHST (Samsung Advanced Institute for Health Sciences & Technology), Sungkyunkwan University, Seoul, South Korea
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46
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Gupta R, Singh S, Kapoor A, soni A, Kaur R, Kaur N. Graft tunnel integration occurs early in the tibial tunnel compared with the femoral tunnel after anterior cruciate ligament reconstruction with preserved insertion hamstring tendon graft. Knee Surg Relat Res 2021; 33:37. [PMID: 34627401 PMCID: PMC8501577 DOI: 10.1186/s43019-021-00119-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preservation of hamstring tendon insertion at the time of anterior cruciate ligament (ACL) reconstruction is a well-known technique; however, its effect on graft integration is not well studied. The present study was conducted to study the graft integration inside the tibial and femoral tunnels, respectively, after ACL reconstruction using hamstring tendon graft with preserved insertion. METHODS Twenty-five professional athletes who underwent ACL reconstruction using hamstring tendon graft with preserved tibia insertion were enrolled in the study. Functional outcomes were checked at final follow-up using Lysholm score and Tegner activity scale. Magnetic resonance imaging (MRI) was done at 8 months and 14 months follow-up to study the graft tunnel integration of the ACL graft at both tibial and femoral tunnels. RESULTS The mean Fibrous interzone (FI) score (tibial tunnel) decreased from 2.61 (1-5) at 8 months to 2.04 (1-4) at 14 months follow-up (p = 0.02). The mean FI score (femoral side) decreased from 3.04 (2-5) at 8 months to 2.57 (2-4) at 14 months (p = 0.02). CONCLUSIONS Graft integration occurs early in the tibial tunnel as compared with the femur tunnel with preserved insertion hamstring tendon autograft. Trial registration CTRI/2019/07/020320 [registered on 22/07/2019]; http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=33884&EncHid=&modid=&compid=%27,%2733884det%27.
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Affiliation(s)
- Ravi Gupta
- Unit II, Orthopaedics Cum Project Director Sports Injury Centre and Medical Superintendent, Government Medical College Hospital, Chandigarh, India
| | - Sandeep Singh
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - Anil Kapoor
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - Ashwani soni
- Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India
| | - Ravinder Kaur
- Department of Radio-Diagnosis, Government Medical College Hospital, Chandigarh, India
| | - Narinder Kaur
- Department of Radio-Diagnosis, Government Medical College Hospital, Chandigarh, India
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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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48
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Akmese R, Ovali SA, Celebi MM, Malatyali B, Kocaoglu H. A Surgical Algorithm According to Pivot-Shift Grade in Patients With ACL Injury: A Prospective Clinical and Radiological Evaluation. Orthop J Sports Med 2021; 9:23259671211025494. [PMID: 34435069 PMCID: PMC8381438 DOI: 10.1177/23259671211025494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/28/2021] [Indexed: 01/26/2023] Open
Abstract
Background: Some patients have a positive pivot-shift finding and rotational instability
after anterior cruciate ligament (ACL) reconstruction (ACLR). Three major
pathologies known to affect the pivot-shift examination include ACL tear,
anterolateral ligament injury, and loss of posterior lateral meniscus root
function. Purpose: To describe a surgical algorithm determining indications for lateral
extra-articular tenodesis (LET) based on intraoperative pivot-shift
examination to prevent postoperative pivot shift and rotational instability
and to evaluate the 2-year clinical and functional outcomes. Study Design: Case series; Level of evidence, 4. Methods: The study included 47 consecutive patients (39 men and 8 women) who underwent
operative treatment for ACL injury between 2016 and 2017. Pivot-shift
examination was performed under anesthesia, and the pivot shift was graded
as grade 1 (glide), grade 2 (clunk), or grade 3 (gross). According to the
surgical algorithm, single-bundle ACLR was performed in patients with grade
1 pivot shift. In patients with grade 2 with loss of posterior lateral
meniscus root function, concurrent lateral meniscal repair was performed,
and in patients with grade 2 with an intact lateral meniscus posterior root,
concurrent extra-articular iliotibial band tenodesis was performed. Patients
with grade 3 underwent ACLR, lateral meniscal repair, and LET. Clinical and
radiographic evaluations were performed. Results: The mean age was 27.2 years (range, 16-56 years). In total, 26 (55.3%)
patients were evaluated as having pivot-shift grade 1; 16 (34%) patients,
grade 2; and 5 (10.6%) patients, grade 3. A total of 7 (14.9%) patients
underwent LET in addition to ACLR. Two of these patients had pivot-shift
grade 2, and LET was performed since the lateral meniscus posterior root was
intact. In 14 of 16 patients with grade 2, lateral meniscus root disruption
was detected, and lateral meniscal repair was performed. One patient was
excluded from the further follow-up because of graft failure. At a mean
postoperative follow-up of 29 months in 46 patients, the pivot-shift
examination was negative in all patients. The mean Lysholm and International
Knee Documentation Committee subjective scores were 95.35 ± 4.40 and 82.87 ±
9.36, respectively. Radiographic evidence of osteoarthritis was not
detected. Conclusion: Only 14.9% of patients needed LET. With proper ACL, lateral meniscal, and
anterolateral ligament surgery, it was possible to prevent positive
pivot-shift findings postoperatively.
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Affiliation(s)
- Ramazan Akmese
- Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Mehmet Mesut Celebi
- Department of Sports Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Batu Malatyali
- Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hakan Kocaoglu
- Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey
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49
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Lee DK, Kim JH, Lee SS, Lee BH, Kim H, Kim J, Wang JH. Femoral Tunnel Widening After Double-Bundle Anterior Cruciate Ligament Reconstruction With Hamstring Autograft Produces a Small Shift of the Tunnel Position in the Anterior and Distal Direction: Computed Tomography-Based Retrospective Cohort Analysis. Arthroscopy 2021; 37:2554-2563.e1. [PMID: 33745939 DOI: 10.1016/j.arthro.2021.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the femoral tunnel position remains in an anatomical footprint after tunnel widening and shifting. METHODS Patients who underwent unilateral double-bundle anterior cruciate ligament reconstruction with hamstring autograft and performed computed tomography scan evaluation at the time of 5 days and 1 year postoperatively were included in this retrospective cohort study. Three-dimensional models of the femur and femoral tunnels were reconstructed from computed tomography scan data. The location of the tunnel center and tunnel margins in the anatomical coordinate system, and the mean shifting distance of tunnel center and margin were measured with image analysis software during the period. The change of tunnel center location in Bernard quadrant was confirmed if the tunnel center remained within the boundaries of anatomical position after tunnel widening. RESULTS A total of 56 patients satisfied the inclusion criteria. The mean shifting distance of AM and PL tunnel centers were 1.7 ± 0.9 mm and 1.6 ± 0.6 mm. The Tunnel margin of the anteromedial (AM) and posteromedial (PL) tunnels were shifted to 2.5 ± 1.3 mm and 2.6 ± 1.4 mm in the anterior direction, and 1.4 ± 0.9 mm and 1.0 ± 0.7 mm in the distal direction, respectively. Among the anatomical located tunnel, 97% (32/33) and 87.1% (27/31) of AM and PL tunnel centers remained in a range of anatomical footprint. The tunnel center was shifted from the anatomical position into a nonanatomical position in 3% (1/33) of the AM tunnel and 12.9% (4/31) of PL tunnel after tunnel widening. The tunnel location which shifted nonanatomically were relatively anterior and distal position. CONCLUSIONS Tunnel widening shifts the tunnel position to the anterior and distal direction, which could change the initial tunnel position. Nevertheless, the majority of tunnel positions remained in the anatomical position after tunnel widening and shifting. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Do Kyung Lee
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Korea
| | - Sung-Sahn Lee
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Byung Hoon Lee
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyeonsoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jinwoo Kim
- Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Health Science and Technology, SAIHST, Sungkyunkwan University, Seoul, Korea; Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea.
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50
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Matar HE, Platt SR, Bloch BV, James PJ, Cameron HU. A Systematic Review of Randomized Controlled Trials in Anterior Cruciate Ligament Reconstruction: Standard Techniques Are Comparable (299 Trials With 25,816 Patients). Arthrosc Sports Med Rehabil 2021; 3:e1211-e1226. [PMID: 34430902 PMCID: PMC8365213 DOI: 10.1016/j.asmr.2021.03.017] [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: 12/20/2020] [Accepted: 03/24/2021] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To provide an overview of all published randomized controlled trials (RCTs) in anterior cruciate ligament reconstruction (ACLR) summarizing the available evidence. METHODS Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane FIGCentral Register of Controlled Trials, Ovid MEDLINE, and Embase for RCTs of ACLR from their inception to August 26, 2020. Outcome measure was whether RCTs reported statistically significant findings. RCTs were then classified according to their intervention groups in a narrative synthesis of the evidence. RESULTS In total, 299 RCTs met the inclusion criteria and were included with a total number of 25,186 patients. Only 30 RCTs (10%) reported significant differences between the intervention and the control groups. These included 101 RCTs on grafts, 20 RCTs on tunnel placements, 48 RCTs on graft fixation, 42 RCTs on single-bundle compared with double-bundle reconstructions, 11 RCTs on additional procedures, 11 RCTs on graft tensioning, 5 RCTs on timing of surgery, 25 RCTs on technical variations from standard techniques, 6 RCTs on ACL repair, 5 RCTs on navigation, 16 RCTs on perioperative management, and 9 RCTs on other aspects of ACLR. Only 14 RCTs (4.7%) reported outcomes beyond 10 years with greater allograft failures compared with autografts, high incidence of osteoarthritic changes in reconstructed knees (22%-100%), with no significant differences in outcomes between bioabsorbable or metal screws for graft fixation, patellar versus hamstrings or single- versus double-bundle reconstructions. CONCLUSIONS The evidence indicates that a standard arthroscopic single- or double-bundle ACLR with hamstrings/patella autografts, transportal technique, and fixation techniques familiar to the surgeon leads to comparable results. This evidence offers surgeons the flexibility to use standard and cost-effective techniques and achieve comparable outcomes. LEVEL OF EVIDENCE Level II; systematic review of Level I-II randomized controlled trials.
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Affiliation(s)
- Hosam E. Matar
- Nottingham Elective Orthopedic Services, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Simon R. Platt
- Department of Orthopedic Surgery, Gold Coast University Hospital, Southport, Australia
| | - Benjamin V. Bloch
- Nottingham Elective Orthopedic Services, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Peter J. James
- Nottingham Elective Orthopedic Services, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Hugh U. Cameron
- Holland Orthopedic & Arthritic Centre, Sunnybrook Health Sciences, University of Toronto, Toronto, Canada
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