No difference in anterior tibial translation with and without posterior cruciate ligament in less invasive total knee replacement

The relative advantages of cruciate retaining or cruciate resecting total knee replacement are still controversial. If the posterior cruciate ligament (PCL) is preserved, it should be properly balanced. In a previous study, it was demonstrated that increasing the flexion gap leads to an anterior translation of the tibia relative to the femur. Based on these results, we hypothesized that cutting the PCL increases the flexion gap and lessens anterior tibial translation.

Thermal evolution of lower limbs during a rehabilitation process after anterior cruciate ligament surgery

Infrared thermography (IRT) is a safe and non-invasive tool used for examining physiological functions based on skin temperature (Tsk) control. The aim of this paper was to establish the probable thermal difference between the beginning and the end of the anterior cruciate ligament (ACL) rehabilitation process after surgery. For this purpose thermograms from 25 ACL surgically operated patients (2 women, 23 men) were taken on the first and last day of a six-week rehabilitation program. A FLIR infrared camera according to the protocol established by the International Academy of Clinical Thermology (IACT). The results showed significant temperature increases in the posterior thigh area between the first and the last week of the rehabilitation process probably due to a compensatory mechanism. According to this, we can conclude that temperature of the posterior area of the injured and non-injured leg has increased from the first to the last day of the rehabilitation process.

Use of infrared thermography as a tool to monitor skin temperature along the recovery process of an anterior cruciate ligament surgery

Infrared thermography (IRT) is a safe and non-invasive tool used for examining physiological functions based on skin temperature (Tsk) control. Thermograms from 25 anterior cruciate ligament (ACL) surgically operated patients (2 female, 23 male) were taken with a FLIR infrared camera according to the protocol established by the International Academy of Clinical Thermology (IACT). This work consists of 4 studies. Studies 1 and 3 were related to establish the probable thermal difference among different moments of an ACL rupture after surgery: before starting the rehabilitation (P0), at the end of rehabilitation (P1) and 18 months from the end of rehabilitation (P2). For this purpose, on the other hand, studies 2 and 4 were related to establish the skin thermal difference (Tsk) between the injured and the non-injured leg in P0, P1 and P2. Results of the first study showed significant temperature increases in the posterior thigh area between P0 and P1 probably due to a compensatory mechanism. According to this, we can conclude that temperature of the posterior area of the injured and noninjured leg has increased from the first to the last day of the rehabilitation process. In the second study we found significant temperature differences between the injured and non-injured leg in both stages of rehabilitation (p<.01). On the one hand, the temperature of the injured leg is higher in the anterior view and the temperature of the non-injured leg is higher in the posterior view. By the time the patients had recovered from the reconstruction, thermal imbalances should have not been shown between symmetrical parts, but differences seemed to be still latent.. Study 3 shows that temperatures seem to be higher after a year and a half (P2) than in P1. Study 4 shows how thermal values 18 months later seemed to be normalized between both legs. No significant differences were found between the injured leg and the noninjured leg after one year and a half of the rehabilitation process. Considering results from Study 3 and 4 we can conclude that patients seemed to have recovered from a thermal point of view. The temperature in P2 was higher but symmetrical. RESUMEN La termografía infrarroja (IRT) es una herramienta segura y no invasiva utilizada para examinar funciones fisiológicas que se basan en el control de temperatura de la piel (Tsk). Termogramas de 25 pacientes intervenidos quirúrgicamente del ligamento cruzado anterior (LCA) (2 mujeres, 23 hombres) fueron tomadas con una cámara de infrarrojos FLIR de acuerdo con el protocolo establecido por la Academia Internacional de Termología Clínica (IACT). Este trabajo consiste en 4 estudios. Los estudios 1 y 3 describen la diferencia térmica entre los diferentes momentos tras la operación del ligamento cruzado anterior: antes de comenzar la rehabilitación (P0), al final de la rehabilitación (P1) y 18 meses tras finalizar la rehabilitación (P2). Por otra parte, los estudios 2 y 4 describen la diferencia de temperatura de la piel (Tsk) entre la pierna lesionada y la pierna no lesionada en P0, P1 y P2. Los resultados del primer estudio mostraron aumentos significativos de temperatura en la zona posterior de los muslos entre P0 y P1, probablemente debido a un mecanismo de compensación. De acuerdo con esto, se puede concluir que la temperatura de la zona posterior de la pierna lesionada y no lesionada se ha incrementado desde el primero hasta el último día del proceso de rehabilitación. En el segundo estudio se encontraron diferencias significativas de temperatura entre la pierna lesionada y no lesionada en ambas etapas de la rehabilitación (p<.01). Por un lado, la temperatura de la pierna lesionada es mayor en la vista anterior. Por otro lado, la temperatura de la pierna no lesionada es mayor en la vista posterior. Una vez que los pacientes se han recuperado de todo el proceso, no deberían existir desequilibrios térmicos entre partes simétricas del cuerpo, pero las diferencias todavía estaban latentes. El tercer estudio muestra que la temperatura es más alta en P2 que en P1. El cuarto estudio muestra cómo los valores térmicos entre ambas piernas en P2 se han normalizado entre ambas piernas. No se encontraron diferencias significativas entre la pierna lesionada y la pierna no lesionada después de 18 meses tras el proceso de rehabilitación. Considerando los resultados del studio 3 y 4, podemos concluir que se ha llegado a la recuperación total desde un punto de vista térmico. La temperatura es más elevada en P2 pero simétrica.

Is there a potential relationship between prior h amstring strain injury and increased risk for future a nterior cruciate ligament injury?

Hamstring strain injuries (HSIs) are the most prevalent injury in a number of sports, and while anterior cruciate ligament (ACL) injuries are less common, they are far more severe and have long-term implications, such as an increased risk of developing osteoarthritis later in life. Given the high incidence and severity of these injuries, they are key targets of injury preventive programs in elite sport. Evidence has shown that a previous severe knee injury (including ACL injury) increases the risk of HSI; however, whether the functional deficits that occur after HSI result in an increased risk of ACL injury has yet to be considered. In this clinical commentary, we present evidence that suggests that the link between previous HSI and increased risk of ACL injury requires further investigation by drawing parallels between deficits in hamstring function after HSI and in women athletes, who are more prone to ACL injury than men athletes. Comparisons between the neuromuscular function of the male and female hamstring has shown that women display lower hamstring-to-quadriceps strength ratios during isokinetic knee flexion and extension, increased activation of the quadriceps compared with the hamstrings during a stop-jump landing task, a greater time required to reach maximal isokinetic hamstring torque, and lower integrated myoelectrical hamstring activity during a sidestep cutting maneuver. Somewhat similarly, in athletes with a history of HSI, the previously injured limb, compared with the uninjured limb, displays lower eccentric knee flexor strength, a lower hamstrings-to-quadriceps strength ratio, lower voluntary myoelectrical activity during maximal knee flexor eccentric contraction, a lower knee flexor eccentric rate of torque development, and lower voluntary myoelectrical activity during the initial portion of eccentric contraction. Given that the medial and lateral hamstrings have different actions at the knee joint in the coronal plane, which hamstring head is previously injured might also be expected to influence the likelihood of future ACL. Whether the deficits in function after HSI, as seen in laboratory-based studies, translate to deficits in hamstring function during typical injurious tasks for ACL injury has yet to be determined but should be a consideration for future work.

Anterior cruciate ligament reconstruction with special reference to magnetic resonance imaging of the postoperative outcome

Anterior cruciate ligament (ACL) tear is a common sports injury of the knee. Arthroscopic reconstruction using autogenous graft material is widely used for patients with ACL instability. The grafts most commonly used are the patellar and the hamstring tendons, by various fixation techniques. Although clinical evaluation and conventional radiography are routinely used in follow-up after ACL surgery, magnetic resonance imaging (MRI) plays an important role in the diagnosis of complications after ACL surgery. The aim of this thesis was to study the clinical outcome of patellar and hamstring tendon ACL reconstruction techniques. In addition, the postoperative appearance of the ACL graft was evaluated using several MRI sequences. Of the 175 patients who underwent an arthroscopically assisted ACL reconstruction, 99 patients were randomized into patellar tendon (n=51) or hamstring tendon (n=48) groups. In addition, 62 patients with hamstring graft ACL reconstruction were randomized into either cross-pin (n=31) or interference screw (n=31) fixation groups. Follow-up evaluation determined knee laxity, isokinetic muscle performance and several knee scores. Lateral and anteroposterior view radiographs were obtained. Several MRI sequences were obtained with a 1.5-T imager. The appearance and enhancement pattern of the graft and periligamentous tissue, and the location of bone tunnels were evaluated. After MRI, arthroscopy was performed on 14 symptomatic knees. The results revealed no significant differences in the 2-year outcome between the groups. In the hamstring tendon group, the average femoral and tibial bone tunnel diameter increased during 2 years follow-up by 33% and 23%, respectively. In the asymptomatic knees, the graft showed homogeneous and low signal intensity with periligamentous streaks of intermediate signal intensity on T2-weighted MR images. In the symptomatic knees, arthroscopy revealed 12 abnormal grafts and two meniscal tears, each with an intact graft. Among 3 lax grafts visible on arthroscopy, MRI showed an intact graft and improper bone tunnel placement. For diagnosing graft failure, all MRI findings combined gave a specificity of 90% and a sensitivity of 81%. In conclusion, all techniques appeared to improve patients' performance, and were therefore considered as good choices for ACL reconstruction. In follow-up, MRI permits direct evaluation of the ACL graft, the bone tunnels, and additional disorders of the knee. Bone tunnel enlargement and periligamentous tissue showing contrast enhancement were non-specific MRI findings that did not signify ACL deficiency. With an intact graft and optimal femoral bone tunnel placement, graft deficiency is unlikely, and the MRI examination should be carefully scrutinized for possible other causes for the patients symptoms.

Effectiveness and safety of cryotherapy after arthroscopic anterior cruciate ligament reconstruction. A systematic review of the literature

Cryotherapy is widely used in rehabilitation; however, its effectiveness after anterior cruciate ligament (ACL) reconstruction remains uncertain. To investigate the effectiveness and safety of cryotherapy following ACL reconstruction through a systematic review, randomized and quasi-randomized clinical trials were searched in the databases: MEDLINE, EMBASE, CENTRAL PEDro, SportDiscus, CINAHL, LILACS (June 2013). the primary outcomes measures were pain, edema and adverse events; the secondary outcomes were knee function, analgesic medication use, range of motion, blood loss, hospital stay, quality of life and patient satisfaction. the methodological quality of studies was evaluated using the Cochrane Collaboration risk-of-bias tool. Ten trials (a total of 573 patients) were included. Results of meta-analysis showed that the use of cold compression devices produced a significant reduction in pain scores 48 h after surgery (p < 0.00001), compared to no cryotherapy. the risk for adverse events did not differ between patients receiving cryotherapy versus no treatment (p = 1.00). the limited evidence currently available is insufficient to draw definitive conclusions on the effectiveness of cryotherapy for other outcomes. There is a need for well designed, good quality randomized trials to answer other questions related to this intervention and increase the precision of future systematic reviews. (C) 2014 Elsevier B.V. All rights reserved.

Changes in landing mechanics in patients following anterior cruciate ligament reconstruction when wearing an extension constraint knee brace.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is associated with a high incidence of second tears (graft tears and contralateral ACL tears). These secondary tears have been attributed to asymmetrical lower extremity mechanics. Knee bracing is one potential intervention that can be used during rehabilitation that has the potential to normalize lower extremity asymmetry; however, little is known about the effect of bracing on movement asymmetry in patients following ACL reconstruction. HYPOTHESIS: Wearing a knee brace would increase knee joint flexion and joint symmetry. It was also expected that the joint mechanics would become more symmetrical in the braced condition. OBJECTIVE: To examine how knee bracing affects knee joint function and symmetry over the course of rehabilitation in patients 6 months following ACL reconstruction. STUDY DESIGN: Controlled laboratory study. LEVEL OF EVIDENCE: Level 3. METHODS: Twenty-three adolescent patients rehabilitating from ACL reconstruction surgery were recruited for the study. The subjects all underwent a motion analysis assessment during a stop-jump activity with and without a functional knee brace on the surgical side that resisted extension for 6 months following the ACL reconstruction surgery. Statistical analysis utilized a 2 × 2 (limb × brace) analysis of variance with a significant alpha level of 0.05. RESULTS: Subjects had increased knee flexion on the surgical side when they were braced. The brace condition increased knee flexion velocity, decreased the initial knee flexion angle, and increased the ground reaction force and knee extension moment on both limbs. Side-to-side asymmetry was present across conditions for the vertical ground reaction force and knee extension moment. CONCLUSION: Wearing a knee brace appears to increase lower extremity compliance and promotes normalized loading on the surgical side. CLINICAL RELEVANCE: Knee extension constraint bracing in postoperative ACL patients may improve symmetry of lower extremity mechanics, which is potentially beneficial in progressing rehabilitation and reducing the incidence of second ACL tears.

Using ground reaction force to predict knee kinetic asymmetry following anterior cruciate ligament reconstruction.

Asymmetries in sagittal plane knee kinetics have been identified as a risk factor for anterior cruciate ligament (ACL) re-injury. Clinical tools are needed to identify the asymmetries. This study examined the relationships between knee kinetic asymmetries and ground reaction force (GRF) asymmetries during athletic tasks in adolescent patients following ACL reconstruction (ACL-R). Kinematic and GRF data were collected during a stop-jump task and a side-cutting task for 23 patients. Asymmetry indices between the surgical and non-surgical limbs were calculated for GRF and knee kinetic variables. For the stop-jump task, knee kinetics asymmetry indices were correlated with all GRF asymmetry indices (P < 0.05), except for loading rate. Vertical GRF impulse asymmetry index predicted peak knee moment, average knee moment, and knee work (R(2)  ≥ 0.78, P < 0.01) asymmetry indices. For the side-cutting tasks, knee kinetic asymmetry indices were correlated with the peak propulsion vertical GRF and vertical GRF impulse asymmetry indices (P < 0.05). Vertical GRF impulse asymmetry index predicted peak knee moment, average knee moment, and knee work (R(2)  ≥ 0.55, P < 0.01) asymmetry indices. The vertical GRF asymmetries may be a viable surrogate for knee kinetic asymmetries and therefore may assist in optimizing rehabilitation outcomes and minimizing re-injury rates.

The effect of collagen organization on tensile strength loss in anterior cruciate ligament grafts post-reconstruction surgery

Gemstone Team LEGS

Subclinical femoral neuropathy after anterior cruciate ligament reconstruction

Background and aim of the study: Patients with anterior cruciate ligament (ACL) reconstruction and femoral catheter analgesia may develop quadriceps amyotrophy. We aimed to determine whether this amyotrophy might be related to a femoral neuropathy. Material and method: After Ethical Committee approval and patients' written informed consent, 17 patients ASA I and II scheduled to undergo ACL reconstruction were recruited. An electromyography (EMG) was performed before the operation in order to exclude a femoral neuropathy. A femoral nerve catheter was inserted before the surgery with the aid of a nerve stimulator, and 20 ml of 0.5% ropivacaine was injected. The operation was done under spinal or general anaesthesia. Postoperative analgesia was provided with 0.2% ropivacaine for 72 hours, in association with oxycodone, paracetamol and ibuprofen. A second EMG was performed 4 weeks after the ACL repair. A femoral neuropathy was defined as a reduction of the surface of the motor response of more than 20%, compared to the first EMG. A third EMG was performed at 6 months if a neuropathy was present. Results: Mean age of this group of patients was 27 years old (range 18-38 y.). Among the 17 patients, 4 developed a transient femoral neuropathy (incidence of 24%) without clinical complain. Conclusion: In this study, the incidence of subclinical femoral neuropathy after ACL reconstruction is high. This lesion may be caused by the femoral catheter (mechanical damage, toxicity of local anaesthesia) or by the Tourniquet. Further studies are needed to investigate the incidence of subclinical neuropathy, according to the type of analgesia (epidural analgesia, PCA) and surgery.