Risk factors for restricted motion after anterior cruciate reconstruction

Magnetic Resonance Imaging of Cyclops Lesion in Patients With Non-reconstructed Anterior Cruciate Ligament

Introduction The term cyclops lesion refers to localized anterior fibrosis, which is the abnormal proliferation of fibrous tissue in a joint that develops in the anterior aspect of the intercondylar notch. It is a known cause of extension loss of the knee after anterior cruciate ligament (ACL) reconstruction; however, it can be found in patients who have not undergone any surgical repair of the ACL. The term "cyclops lesion" was given based on the arthroscopic appearance of the fibrous nodule and vessels that resemble an eye. The purpose of this study is to highlight the existence of cyclops lesions in non-operated knees. Methods We conducted a study on 10 patients who were subjected to an MRI knee in a Siemens Magnetom Vida 3 Tesla (Erlangen, Germany) machine. We retrospectively analyzed all 10 cases in our institution from July 2021 to March 2022. These subjects had a previous history of trauma, and they presented with complaints of pain and difficulty in knee extension but no history of previous ligament repair. All patients underwent an MRI examination. When a cyclops lesion was revealed on MR imaging, the signal-intensity characteristics, location, and size were documented. Results There were a total of 10 patients included in the study, of whom eight were males and two were females. The most common clinical presentation in all our cases was difficulty in the extension of the knee, while there was associated instability and difficulty in walking in some patients. There was a demonstrable cyclops lesion near the tibial attachment of ACL in eight (80%) patients, whereas it was found to be located just lateral to the anterior intercondylar notch in the rest of the two (20%) patients. Conclusion MRI is an effective tool to evaluate unexplained pain, functional limitations, and limited range of motion in patients with suspected arthrofibrosis. MRI also helps determine the extent of fibrosis involvement and excludes other complications that may have a similar clinical picture.

Impact of Surgical Timing on Functional Outcomes after Anterior Cruciate Ligament Reconstruction

Objectives: Although acute anterior cruciate ligament reconstruction (ACLR) is often avoided because of postoperative joint stiffness, delayed ACLR can lead to a longer recovery time and can have a negative impact on physical function due to detraining. This study aimed to determine the effects of acute ACLR on postoperative outcomes, including muscle strength, performance, and return to sports. Methods: A total of 110 patients who underwent anatomical ACLR using hamstring autografts were included in this study and were divided into three groups: acute (ACLR performed within 2 weeks after ACL injury), 2-6 weeks (ACLR performed between 2 and 6 weeks after injury), and 6-12 weeks (ACLR performed between 6 and 12 weeks after injury). Several parameters were evaluated, including range of motion, knee joint stability, isokinetic knee strength, performance, and return to sports. Results: No significant differences were found in the range of motion or knee joint stability between the groups. The acute group exhibited significantly greater quadriceps strength at 3 months postoperatively than the other groups (p < 0.05). The single-leg hop test showed that 66.7%, 38.7%, and 33.3% of the patients in the acute, 2-6 weeks, and 6-12 weeks groups, respectively, recovered to an LSI of 90% or greater (p = 0.09, Cramer's V = 0.27). All patients in the acute group were able to return to sports (p = 0.14; Cramer's V = 0.28). Conclusions: Acute ACLR is advantageous for the early recovery of strength and performance without adverse events. Acute ACLR may shorten the time spent away from sports activities.

Low-level laser therapy attenuates arthrogenic contracture induced by anterior cruciate ligament reconstruction surgery in rats

Therapeutic approaches to treat joint contracture after anterior cruciate ligament (ACL) reconstruction have not been established. Arthrofibrosis accompanied by joint inflammation following ACL reconstruction is a major cause of arthrogenic contracture. In this study, we examined whether anti-inflammatory treatment using low-level laser therapy (LLLT) can prevent ACL reconstruction-induced arthrogenic contracture. Rats underwent ACL transection and reconstruction surgery in their right knees. Unoperated left knees were used as controls. After surgery, rats were reared with or without daily LLLT (wavelength: 830 nm; power output: 150 mW; power density: 5 W/cm2; for 120 s/day). We assessed the passive extension range of motion (ROM) after myotomy at one and two weeks post-surgery; the reduction in ROM represents the severity of arthrogenic contracture. ROM was markedly decreased by ACL reconstruction at both time points; however, LLLT partially attenuated the decrease in ROM. One week after ACL reconstruction, the gene expression of the proinflammatory cytokine interleukin-1beta in the joint capsule was significantly upregulated, and this upregulation was significantly attenuated by LLLT. Fibrotic changes in the joint capsule, including upregulation of collagen type I and III genes, shortening of the synovium, and thickening were caused by ACL reconstruction and seen at both time points. LLLT attenuated these fibrotic changes as well. Our results indicate that LLLT after ACL reconstruction could attenuate the formation of arthrogenic contracture through inhibition of inflammation and fibrosis in the joint capsule. Thus, LLLT may become a novel therapeutic approach for ACL reconstruction-induced joint contracture.

Effects of Each Phase of Anterior Cruciate Ligament Reconstruction Surgery on Joint Contracture in Rats

BACKGROUND

Although anterior cruciate ligament reconstruction surgery is known to cause joint contracture, the mechanisms of this process are unknown. We aimed to assess the effects of transection of this ligament and each phase of reconstruction surgery on contracture formation.

MATERIALS AND METHODS

Rats were divided into groups according to treatment received: sham (arthrotomy), ligament transection, ligament transection plus bone drilling, and ligament reconstruction. Surgery was performed on the right knee. Untreated left knees in the sham group were used as controls.

RESULTS

At 7 and 28 d post-surgery, range of motion before myotomy, mainly representing myogenic contracture, was restricted in the sham and ligament transection groups, and more so in the bone drilling and reconstruction groups. Restricted range of motion after myotomy, representing arthrogenic contracture, was detected at both timepoints in the bone drilling and reconstruction groups, but not in the sham or ligament transection groups. At 3 d post-surgery, although a large blood clot was observed in all three treatment groups, only the bone drilling and reconstruction groups showed significant joint swelling. At 7 d post-surgery, inflammatory-cell infiltration into the joint capsule was most apparent in the bone drilling and reconstruction groups, and joint capsule fibrosis was also most apparent in these groups at 7 and 28 d post-surgery.

CONCLUSIONS

Our results suggest that (1) myogenic contracture after anterior cruciate ligament reconstruction is caused by arthrotomy and aggravated by bone drilling, and (2) arthrogenic contracture is mostly due to bone drilling, which triggers an inflammation-fibrosis cascade.

Formation process of joint contracture after anterior cruciate ligament reconstruction in rats

Knee joint contracture is often induced by anterior cruciate ligament reconstruction (ACLR). However, the temporal and spatial arthrofibrotic changes following inflammatory events, which occur in parallel with the formation of joint contractures after ACLR, are unknown. This study aimed to reveal: (a) time-dependent changes in myogenic and arthrogenic contractures; and (b) the process of arthrofibrosis development after ACLR. ACLR was performed on knees of rats unilaterally. Passive ranges of motions (ROMs) before and after myotomy, as well as inflammatory and fibrotic reactions, were examined before and after the surgery at various periods up to 56 days. Both ROMs before and after myotomy exhibited their lowest value on day 7 and increased thereafter in a time-dependent manner; nevertheless, significant restrictions remained by day 56. Myotomy partially increased ROMs at all time points, indicating contribution of the myogenic component to ACLR-induced contracture. Inflammatory and fibrotic reactions peaked on day 7. Arthrofibrosis, characterized by the thickening of the joint capsule and the shortening of the synovial length, was established by day 7 and was not completely resolved by day 56. Our results indicate that: (a) both myogenic and arthrogenic contractures generated through ACLR develop maximally by day 7 after surgery and subside thereafter, but persist at least until day 56; and (b) arthrofibrosis is established by day 7 after surgery and is not completely resolved by day 56. These findings suggest that treatment and intervention for preventing joint contracture after ACLR should be performed within the first 7 days after surgery.

Pseudocyclops: two cases of ACL graft partial tears mimicking cyclops lesions on MRI

Arthroscopic reconstruction of the anterior cruciate ligament (ACL) using autografts or allografts is a common surgical procedure, particularly in young athletes. Although the procedure has excellent success rates, complications such as mechanical impingement, graft rupture, and arthrofibrosis can occur, often necessitating additional surgery. Magnetic resonance (MR) imaging has become a valuable tool in evaluating complications after ACL reconstruction. We report two cases of ACL reconstruction complicated by arthroscopically proven partial graft tears. In both cases the torn anterior graft fibers were flipped into the intercondylar notch, mimicking anterior arthrofibrosis, i.e., a "cyclops lesion," on MR imaging. Careful review of the direction of graft fibers on MR imaging in the "pseudocyclops" lesions can help differentiate these partial tears from the fibrosis of a true cyclops. The "pseudocyclops" lesion is a previously undescribed MR imaging sign of partial ACL graft tear. Larger studies are required to determine the sensitivity and specificity of the sign, as well as the clinical importance of these partial graft tears.

Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression

The management of patients after anterior cruciate ligament reconstruction should be evidence based. Since our original published guidelines in 1996, successful outcomes have been consistently achieved with the rehabilitation principles of early weight bearing, using a combination of weight-bearing and non-weight-bearing exercise focused on quadriceps and lower extremity strength, and meeting specific objective requirements for return to activity. As rehabilitative evidence and surgical technology and procedures have progressed, the original guidelines should be revisited to ensure that the most up-to-date evidence is guiding rehabilitative care. Emerging evidence on rehabilitative interventions and advancements in concomitant surgeries, including those addressing chondral and meniscal injuries, continues to grow and greatly affect the rehabilitative care of patients with anterior cruciate ligament reconstruction. The aim of this article is to update previously published rehabilitation guidelines, using the most recent research to reflect the most current evidence for management of patients after anterior cruciate ligament reconstruction. The focus will be on current concepts in rehabilitation interventions and modifications needed for concomitant surgery and pathology.

LEVEL OF EVIDENCE

Therapy, level 5.

Preoperative factors correlating with prolonged range of motion deficit after anterior cruciate ligament reconstruction

BACKGROUND

Impaired postoperative range of motion remains one of the most frequent complications after anterior cruciate ligament reconstruction.

PURPOSE

This study was undertaken to determine the preoperative factors associated with prolonged range of motion deficit after anterior cruciate ligament reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between January 2007 and March 2008, a consecutive series of 217 patients underwent anterior cruciate ligament reconstruction and were reviewed at 6 weeks and 3 months after surgery. In this series, all data of patients who required a further surgery for arthrolysis until December 2009 were studied. Goniometric range of motion measurement was performed the day before surgery and at 6 weeks and 3 months postoperatively. Bone contusions were analyzed on preoperative magnetic resonance imaging (MRI). All MRI scans were performed in the 6 months before surgery. Seven potential risk factors-age, sex, limited preoperative range of motion, meniscal lesions, bone contusion(s), operative delay less than 45 days, and rehabilitation-were assessed using univariate analysis. The correlations between the significant factors previously identified were analyzed further using multivariate logistic regression analysis.

RESULTS

Limited preoperative range of motion (P < .001), typical bone contusions of the lateral compartment (P < .001), operative delay less than 45 days (P = .003), and female sex (P = .049) were found to be significantly correlated with delayed recovery. The limited preoperative mobility and the presence of typical contusions were strongly correlated (P < .001). In the group of patients who underwent surgery within 45 days, delayed recovery was strongly correlated with limited preoperative mobility (P = .0008) and to the presence of typical contusions (P < .001). Arthrolysis was correlated with delayed range of motion (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.9-50; P =.001) and bone bruise (OR, 7.6; 95% CI, 1.7-46.1; P = .002).

CONCLUSION

Preoperative limited range of motion and typical bone bruises of the lateral femoral condyle and tibial plateau are major risk factors for a difficult rehabilitation after anterior cruciate ligament reconstruction.

[Rupture of the anterior cruciate ligament. Diagnostics and therapy]

Rupture of the anterior cruciate ligament (ACL) is the most common ligamentous knee injury. The knee is stabilized by the cruciate ligaments and the collateral ligaments. The ACL originates from the inner surface of the lateral condyle of the femur, runs in an anterior medial direction and inserts at the tibial plateau in the intercondyle area. The most common injury is an indirect knee trauma, typically a joint torsion in sports. Patients often describe a snapping noise followed by hemarthrosis. Concomitant injuries are lesions of the medial collateral ligament, the medial meniscus (unhappy triad) and chondral fractures. The age peak is between 15 and 30 years with a higher incidence in females. The cardinal symptom of the ACL rupture is the giving way phenomenon. The clinical diagnosis is provided by a positive Lachman test, a positive pivot shift test and the anterior drawer test. Fractures can be excluded by X-ray examination. Magnetic resonance imaging (MRI) allows the evaluation of the internal knee structures. ACL repair is carried out by arthroscopically assisted bone-tendon-bone or semitendinosus grafting techniques. Early rehabilitation is important for a good functional outcome.

Return to official Italian First Division soccer games within 90 days after anterior cruciate ligament reconstruction: a case report

STUDY DESIGN

Case report.

BACKGROUND

To present the rehabilitative course, decision-making, and clinical milestones that allowed a top-level professional soccer player to return to full competitive activity 90 days after surgery.

CASE DESCRIPTION

The patient was a 35-year-old forward player who sustained an isolated complete tear of the left anterior cruciate ligament (ACL) in the midst of the competitive 2001-2002 season. He was in contention for a position on the Italian World Cup Team that was to be played 135 days after his injury, only if he demonstrated that he could return to play at the highest level before the team was selected. The patient underwent an arthroscopically assisted ACL reconstruction with a double-loop semitendinosus-gracilis autograft 4 days after the injury. Eight days after surgery he began rehabilitation at a rate of 2 sessions a day, 5 days a week, plus 1 session every Saturday morning. These sessions were performed in a pool for aquatic exercises, in a gymnasium for flexibility, coordination, and strength exercises, and on a soccer field for recovery of technical and tactical skills, with continuous monitoring of training intensity.

OUTCOMES

The surgical technique and the progressive rehabilitation program allowed the patient to play for 20 minutes in an official First Division soccer game 77 days after surgery and to play a full game 90 days after surgery. Eighteen months postsurgery, the player had participated in 62 First Division matches, scoring 26 times, and had received no further treatment for his knee.

DISCUSSION

This case report suggests that early return to high-level competition after ACL reconstruction is possible in some instances. Some factors that may have favored the early return include optimal physical fitness before surgery, a strong psychological determination, an isolated ACL lesion, a properly placed and tensioned graft, a personalized progression of volume and intensity of exercise loads, and an appropriate density of rehabilitative training consisting of a mix of gymnasium, pool, and field exercises.

Comparison of functional outcome after anterior cruciate ligament reconstruction resulting in low, normal and increased laxity

The aim of the study was to analyse and compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using patellar tendon autografts in three groups of patients. The groups were determined by knee laxity as measured with the KT-1000 arthrometer at the follow-up two to five years after the reconstruction. Group A (n=15) had an anterior side-to-side laxity difference of <-3 mm (i.e. the reconstructed knee was less lax than the contralateral non-injured knee), Group B (n=376) had a difference of > or = -1, but < or = +2 mm and Group C (n=38) had a difference of > or g=6 mm. All the patients had a normal contralateral knee. In Group A, 7/15 (47%) patients and, in Group B, 82/375 (22%) patients had an extension deficit of > or =5 degrees (P=0.052). The corresponding values in terms of flexion deficit were 8/15 (53%) and 99/375 (26%) respectively (P=0.04) (one missing value in Group B). In Group C, 14/38 (37%) had an extension deficit (P=0.04; Group B vs Group C). Group C displayed worse results than Group B in terms of the Lysholm score and the one-leg-hop test (P=0.001 and P=0.011 respectively). The corresponding comparison between Group A and Group B revealed no significant differences. We conclude that a considerable number of patients showed persisting deficits in range of motion (ROM) after an ACL reconstruction. No major differences were found if they were analysed in subgroups with decreased, near normal or with increased knee laxity. The worst residual functional impairment, as measured with the Lysholm score and one-leg-hop test, was found in the group with increased knee laxity and most ROM deficits in the knees with decreased laxity.

Predicting physical therapy visits needed to achieve minimal functional goals after arthroscopic knee surgery

STUDY DESIGN

Retrospective, cross-sectional regression modeling.

OBJECTIVE

To predict physical therapy visits following arthroscopic knee surgery.

BACKGROUND

The number of physical therapy visits required to achieve a set of specific minimal-level goals (full knee extension, straight leg raise, normalized gait pattern, bicycle pedaling, and independent home exercises) that are related to decreased complication rates has not previously been modeled.

METHODS AND MEASURES

A multiple regression model to predict postoperative physical therapy visits was developed using subject demographics and 2 simple clinical measures, degree of straight leg raise lag and total range of motion. All data were collected from 148 patient charts. Model validity was examined by the predicted residual sum of squares technique and a second independent sample of 157 charts.

RESULTS

Diagnosis group, surgery group, and range of motion were the significant variables predicting visits in the final model (R2 = 0.384). Results of model validation analyses using predicted residual sum of squares technique (R2 = 0.346) and the second set of data (R2 = 0.282) were satisfactory. Analysis of residuals (difference of observed and predicted visits) showed prediction of the number of physical therapy visits within 3 visits for approximately 75% of the cases in both sets of data.

CONCLUSIONS

Using the model to predict physical therapy visits following arthroscopic knee surgery was more accurate than using diagnosis alone, except for lateral retinacular release. This study demonstrates how regression models could be used to explain variance in physical therapy visits for a given set of minimal functional goals.

Long-term results of anterior cruciate ligament reconstruction using ilio-tibial tract and semitendinosis tendon

During the 3-year period from June 1984 to July 1987, 115 anterior cruciate ligament reconstructions were performed by a combined intra- and extra-articular technique using the anterior three-quarters of the ilio-tibial band and the semitendinosis tendon. Post-operative rehabilitation included limited mobilization in flexion for 6 weeks post-surgery. Eighty-four knees (78% follow-up) were reviewed at a mean of 8 years (range 6.3-9.7 years). The long-term results of surgery were assessed using the Lysholm score, Noyes activity rating, the International Knee Documentation Committee (IKDC) knee ligament standard evaluation and manual maximum KT-1000 side-to-side difference measurements were made. In addition 45 knees were examined radiographically. Reconstruction within 6 weeks of injury led to a significantly higher chance of concurrent meniscal trauma being suitable for repair (P=0.002). At early reconstruction coincidental macroscopic chondral damage was noted in 23% and limited to the patella while at delayed reconstruction 45% of knees showed chondral damage which also involved tibio-femoral compartments in some cases. Overall 87% returned to their pre-injury sporting level and only one ceased through knee problems. Ninety-three percent had a manual maximum KT-1000 side-to-side difference at final review no greater than 3 mm. The Lysholm score rated results as 91% excellent or good while the overall IKDC evaluated 85% as normal or near normal, 14% abnormal and 1% (one case) as severely abnormal. Twenty-seven percent of acute and 10% of delayed reconstructions developed some degree of arthrofibrosis (P=0.049) and this significantly predisposed the knee to early degenerative change (P=0.002).

MR imaging of cyclops lesions

OBJECTIVE

Localized anterior fibrosis (cyclops lesion) is a known cause of extension loss of the knee after anterior cruciate ligament (ACL) reconstruction. We describe MR imaging as a noninvasive diagnostic tool to examine cyclops lesions.

SUBJECTS AND METHODS

Thirty-three MR studies of 31 patients with residual persistent extension loss after ACL reconstruction using patellar tendon autograft were reviewed and compared with results of second arthroscopy. We used MR imaging to describe the ACL graft signal intensity and course, tibial and femoral tunnel placement. quantitative measurements of notch size and shape, and the presence or absence of cyclops lesions. When a cyclops lesion was revealed on MR imaging, the signal-intensity characteristics, location, and size were documented. Preoperative MR imaging findings were then correlated with findings at arthroscopy.

RESULTS

The sensitivity, specificity, and accuracy of revealing a cyclops lesion on MR imaging were 85.0%, 84.6%, and 84.8%, respectively. We found no statistically significant differences in the size of intercondylar notches for patients with and patients without cyclops lesions.

CONCLUSION

MR imaging was sensitive, specific, and accurate in revealing cyclops lesions in a subgroup of patients with extension loss after ACL reconstruction.

Evaluation and surgical management of peripheral nerve problems

OBJECTIVE

To illustrate how an understanding of the basic biological responses of peripheral nerves to injury is important in formulating a rational treatment plan.

METHODS

Peripheral nerve anatomy and physiology are described in a context that is relevant to understanding the different grades of peripheral nerve injury. Methods of evaluating and treating peripheral nerve injuries both medically and surgically are reviewed. Relevant scientific studies with potential clinical impact are also discussed.

RESULTS

The clinical symptoms, physical findings, and electrodiagnostic and imaging test results relevant to the diagnosis of peripheral nerve problems are reviewed. Conventional and new medical or surgical strategies in the management of peripheral nerve injuries and mass lesions are described.

CONCLUSION

The diagnosis and treatment of peripheral nerve injuries follow logically from an understanding of the biological responses of peripheral nerves after injury and during recovery.

Arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft. Five- to nine-year follow-up evaluation

We retrospectively reviewed the results of 97 patients with anterior cruciate ligament reconstructions using an arthroscopically assisted two-incision technique without extraarticular augmentation at an intermediate followup of 5 to 9 years postoperatively. Evaluation included detailed history, physical examination, functional testing, KT-1000 arthrometer measurements, multiple scoring systems, and radiographs. The results were compared with those from a previous study that evaluated a smaller patient cohort using the identical surgical technique at a 2- to 4-year followup. The postoperative physical examination and KT-1000 arthrometer results were statistically improved when compared with preoperative findings. A negative pivot shift result was noted in 83% of patients, and a 1+ result in 17% of patients. Seventy percent of patients had < 3 mm difference on manual maximum side-to-side testing. Functional testing averaged less than 2% asymmetry for vertical jump, single-legged hop, or timed 6-meter hop. The Tegner activity level was significantly improved from prereconstruction ratings and similar to preinjury ratings. The mean Lysholm score was 87. The modified Hospital for Special Surgery scores resulted in good or excellent results in 82% of the patients (mean, 87 points). The mean Noyes sports function score was 89, and the reoperation rate for a symptomatic knee flexion contracture was 12%. Ninety-seven percent of patients indicated that they would undergo the procedure again. When compared with this same population at 2 to 4 years, we saw no deterioration in scoring scale results.

Single-incision endoscopic anterior cruciate ligament reconstruction using patellar tendon autograft. Minimum two-year follow-up evaluation

We conducted a retrospective, minimum 2-year follow-up study to evaluate the effectiveness of a single-incision endoscopic anterior cruciate ligament reconstruction technique using patellar tendon autograft without extraarticular augmentation and followed by accelerated rehabilitation. One hundred three patients were evaluated (mean followup, 36 months; range, 24 to 55). There were significant improvements in physical examination test results (Lachman, anterior drawer, and pivot shift) postoperatively, and 94 patients (91%) had negative pivot shift results. KT-1000 arthrometric testing showed a significant reduction in manual maximum anterior translation and side-to-side differences at followup. Good range of motion was achieved. Patients with asymmetric prone heel heights usually had hyperextension in the contralateral knee. Functional tests showed 4% to 6% differences in side-to-side comparisons for a timed single-legged hop, single-legged hop for distance, and vertical jump. Postoperatively, the results of the Tegner scale were similar to preinjury scores. The mean results of the Hospital for Special Surgery scale (90), Lysholm score (89), and Noyes sport function score (90) were all excellent or good. Only 5 patients (5%) required reoperations for flexion contractures. Ninety-six patients (93%) reported they were "mostly" or "completely" satisfied, and 98 (95%) would recommend the procedure to others. These results demonstrated encouraging outcome using this single-incision technique.