The anterior cruciate ligament

Effects of knee bracing on postural control after anterior cruciate ligament rupture

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To investigate the effects of functional knee braces on postural control in patients with anterior cruciate ligament (ACL) rupture.

BACKGROUND

ACL rupture leads to both mechanical knee instability and deficits in proprioception. Although elastic knee braces do not increase mechanical stability, patients report improved stability when wearing a brace. Elastic braces were found to reduce the loss of proprioception. It is, however, still unclear whether they also improve postural control, which involves the processing of proprioceptive input at a higher level.

METHODS

We studied 58 patients with isolated unilateral ACL rupture using computerized dynamic posturography and compared overall stability index (OSI) scores for injured and uninjured legs with and without a knee brace. In addition, patients were classified as copers and non-copers depending on knee function.

RESULTS

Within subjects, OSI scores were 3.0 ± 1.1° for uninjured legs when unbraced, 2.8±1.3° for uninjured legs when braced (p=0.17), 3.7 ± 1.5° for unbraced injured legs, and 2.9 ± 1.3° for braced injured legs (p<0.001). For the injured legs of copers and non-copers, OSI scores were 3.4° ± 1.2° for copers and 4.0° ± 1.6° for non-copers in the unbraced condition (p=0.11) and 2.7 ± 1.0° for copers and 3.1 ± 1.4° for non-copers in the braced condition (p=0.26).

CONCLUSION

Elastic knee braces increase postural stability by approximately 22% in patients with ACL rupture. There was no difference in postural stability between uninjured and injured legs in the braced condition. One possible explanation is that bracing improves both proprioception and postural control.

Reconstruction of a Hard Connective Tissue Utilizing a Pressed Silk Sheet and Type-I Collagen as the Scaffold for Fibroblasts

A pressed silk sheet is a new biomaterial composed of a network of numerous cocoon filaments and having excellent mechanical strength and shape stability compared to a cotton-gauze sheet. To reconstruct a hard connective tissue using the silk sheet and type-I collagen as the scaffold for fibroblasts, three different three-dimensional floating culture systems were designed. "On sheet" system: fibroblasts were seeded on the silk sheet coated with collagen and the cell-attached sheet was cultured. "In gel" system: fibroblasts and the silk sheet were co-embedded in a collagen gel and the gel was cultured. "On vitrigel" system: fibroblasts were seeded on both sides of a collagen vitrigel involving the silk sheet and the vitrigel was cultured. The fibroblasts in all culture systems grew and formed disk-shaped connective tissue models involving the silk sheet by 14 days of culture. The "on sheet" and "on vitrigel" models retained a maximum elastic load of about 23 kgf and an ultimate tensile load of about 3.6 kgf, which were almost the same as for the individual silk sheet. However, the "in gel" system showed a low value for the tensile load. Cell damage following application of mechanical stress was lowest in the "on vitrigel" system. These data demonstrated the advantage of the "on vitrigel" system in reconstructing hard connective tissues. Such a novel culture method would contribute to a regenerative medicine for the failure of ligaments, tendons, and other connective tissues.

Effectiveness of three extraction techniques in the development of a decellularized bone–anterior cruciate ligament–bone graft

In this study, porcine bone-anterior cruciate ligament-bone (B-ACL-B) grafts were decellularized using one of three protocols incorporating surfactants lauryl sulfate (SDS), Triton X-100, and/or an organic solvent (tributyl phosphate (TnBP)). The effectiveness of Triton-SDS, Triton-Triton or Triton-TnBP treatments in removing cellular materials was determined and possible changes in biochemical composition and mechanical properties due to each treatment were investigated. Treatment with Triton-SDS was most effective at removing cell nuclei and intracellular protein (vimentin) from the ACL but affected both the collagen and glycosaminoglycan (GAG) components of the extracellular matrix while increasing the tensile stiffness of the ligament. Triton-Triton was the least effective of the three treatments in terms of cellular extraction, but did not significantly change the mechanical and biochemical properties of the ACL. Triton-TnBP matched the level of decellularization achieved by Triton-SDS in terms of visible cell nuclei; however, the extraction of intracellular vimentin was less consistent. TnBP treatment also slightly decreased the collagen content of the ACL but did not alter its mechanical properties. Overall, all three decellularization treatments maintained adequate mechanical and biochemical properties of B-ACL-B grafts to justify the further investigation of all three decellularization protocols. The selection of a superior treatment will depend on future studies of the propensity of treated tissues for repopulation by host ACL fibroblasts and, ultimately, on any immunogenic and/or remodeling host response induced in vivo.

Gene expression of type I and type III collagen by mechanical stretch in anterior cruciate ligament cells

Mechanical stretch affects the healing and remodeling process of the anterior cruciate ligament (ACL) after surgery in important ways. In this study, the effects of mechanical stress on gene expression of type I and III collagen by cultured human ACL cells and roles of transforming growth factor (TGF)-beta1 in the regulation of mechanical strain-induced gene expression were investigated. Uniaxial cyclic stretch was applied on ACL cells at 10 cycles/min with 10% length stretch for 24 h. mRNA expression of the type I and type III collagen was increased by the cyclic stretch. TGF-beta1 protein in the cell culture supernatant was also increased by the stretch. In the presence of anti-TGF-beta1 antibody, stretch-induced increase in type I and type III mRNA expression was markedly ablated. The results suggest that the stretch-induced mRNA expression of the type I and type III collagen is mediated via an autocrine mechanism of TGF-beta1 released from ligament cells.

Patient satisfaction needs as related to knee stability and objective findings after ACL reconstruction using the LARS artificial ligament

The purposes of this study are to compare patient satisfaction with the objective measurement of knee stability and assess early complications following ACL reconstruction using a LARS artificial ligament. Forty-seven patients were reviewed 8-45 months after surgery. Assessment was made by the Knee and Osteoarthritis Outcome Score for patient satisfaction, a modified International Knee Documentation Committee form for clinical knee stability, and a Telos stress radiography for PA stability. Complications were assessed at interview and were double-checked with charts. The LARS artificial ligament may be a safe device to reconstruct an ACL tear. Documenting mechanical stability of the knee is inadequate when reporting follow-up studies and a questionnaire assessing patient satisfaction should be added to provide a better picture of the outcome and results.

Effects of pretwist on biomechanical properties of canine patellar tendon

The purpose of this study was to measure the effect produced on canine patellar tendon of a 90 degree pretwist on the following mechanical properties: failure stress, failure strain, average elastic modulus, and strain energy density. Forty adult mongrel dog cadavers, killed for other studies, were used. Paired patellar tendons were isolated with patellar and tibial bone and the central 4.0-4.6 mm of tendon used for testing. Specimens were elongated to failure using a Materials Testing System (MTS). Only those paired specimens both failing in substance were analyzed. Eight paired specimens were analyzed, both with 0 degree twist, for right-left reproducibility. Thirty-two paired specimens were randomly assigned to four groups: right 0 degree/left 90 degree clockwise pretwist; right 0 degree/left 90 degree counterclockwise; left 0 degree/right 90 degree clockwise; left 0 degree/right 90 degree counterclockwise. No statistically significant differences were present between the paired untwisted specimens in any mechanical property. In the pretwisted specimens, there were statistically significant differences between the group left/clockwise and right/counterclockwise and the group left/counterclockwise and right/clockwise with respect to the mechanical properties failure stress, average elastic modulus, and strain energy density. No statistically significant differences were observed between the two groups for failure strain. For the canine patella-patellar tendon-tibia complex (PPTTC), the mechanical properties failure stress, average elastic modulus, and strain energy density are sensitive to both side (left/right) of PPTTC and direction (clockwise/counterclockwise) of pretwist. Pretwist of patellar tendon grafts in anterior cruciate ligament reconstruction may produce significant changes in their mechanical properties that vary with the direction of twist.

The biomechanical effects of geometric configuration of bone-tendon-bone autografts in anterior cruciate ligament reconstruction

This study provides biomechanical support for a new technique of autograft anterior cruciate ligament reconstruction featuring circular bone plugs and endosteal interference fit fixation. Six matched pairs of fresh frozen human knees were utilized. Femoral interference fit pull-out strength was determined from material-testing-machine-generated oscillograph recordings at a strain rate of 100%/s. Circular bone plugs, obtained with a circular oscillating saw, provided 19.9% greater interference fit pull-out strength compared with identically fixed trapezoidal bone plugs. Different geometric defects were compared in three- and four-point bending on an Instron machine with frozen patellae and an artificial bone composite. Circular defects have 107% greater strength than matched trapezoidal patellar defects in three-point bending. In a bone composite, circular defects are 53% stronger than triangular and 25% stronger in four-point bending than trapezoidal defects. A new technique of harvesting bone plugs with endosteal interference fit fixation is described and biomechanically supported. To date, this technique has been performed on over 500 cases clinically without evidence of patellar fracture or fixation failure. This study demonstrates the efficacy of this simple and reproducible technique compared with previously reported procedures.

ACL Reconstruction

Patients who have anterior cruciate ligament injuries are likely to question their primary care physicians about their treatment options, which include surgical reconstruction. Although surgery cannot restore knees to their original condition, a successful reconstruction will provide stability to the knee and allow patients to lead fairly active lives.