Validity of GNRB® arthrometer compared to Telos™ in the assessment of partial anterior cruciate ligament tears.

PubMed

Lefevre, N; Bohu, Y; Naouri, J F; Klouche, S; Herman, S

2014-02-01

The main goal of this study was to compare the results of the GNRB(®) arthrometer to those of Telos™ in the diagnosis of partial thickness tears of the anterior cruciate ligament (ACL). A prospective study performed January-December 2011 included all patients presenting with a partial or full-thickness ACL tears without ACL reconstruction and with a healthy contralateral knee. Anterior laxity was measured in all patients by the Telos™ and GNRB(®) devices. This series included 139 patients, mean age 30.7 ± 9.3 years. Arthroscopic reconstruction was performed in 109 patients, 97 for complete tears and 12 single bundle reconstructions for partial thickness tears. Conservative treatment was proposed in 30 patients with a partial thickness tear. The correlation between the two devices was evaluated by the Spearman coefficient. The optimal laxity thresholds were determined with ROC curves, and the diagnostic value of the tests was assessed by the area under the curve (AUC). The differential laxities of full and partial thickness tears were significantly different with the two tests. The correlation between the results of laxity measurement with the two devices was fair, with the strongest correlation between Telos™ 250 N and GNRB(®) 250 N (r = 0.46, p = 0.00001). Evaluation of the AUC showed that the informative value of all tests was fair with the best results with the GNRB(®) 250 N: AUC = 0.89 [95 % CI 0.83-0.94]. The optimal differential laxity threshold with the GNRB(®) 250 N was 2.5 mm (Se = 84 %, Sp = 81 %). The diagnostic value of GNRB(®) was better than Telos™ for ACL partial thickness tears.

The iliotibial band and anterolateral capsule have a combined attachment to the Segond fracture.

PubMed

Albers, Marcio; Shaikh, Humza; Herbst, Elmar; Onishi, Kentaro; Nagai, Kanto; Musahl, Volker; Fu, Freddie H

2018-05-01

The purpose of this report was to describe the injury mechanism, surgical findings, and outcomes in a 21-year-old professional female football player who presented with a complete anterior cruciate ligament (ACL) rupture and Segond fracture. Interview and video analysis were performed to elicit the injury mechanism. Clinical examination and imaging revealed a complete ACL tear, Segond fracture, lateral meniscus tear, MCL sprain, and posterolateral corner sprain. Examination under anaesthesia revealed Grade 2 pivot shift and varus/valgus instability. Surgical examination revealed attachment of the posterior fibres of the iliotibial band and the lateral capsule to the Segond fragment. The fracture was reduced with suture fixation, and an anatomic ACL reconstruction was performed. Follow-up demonstrated rotatory and anterior tibial translation stability, and imaging at 7 months post-operatively revealed no movement and continued osseous integration of the Segond fragment. Level of evidence V.

Potential Market for New Meniscus Repair Strategies: Evaluation of the MOON Cohort

PubMed Central

Fetzer, Gary B.; Spindler, Kurt P.; Amendola, Annunziato; Andrish, Jack T.; Bergfeld, John A.; Dunn, Warren R.; Flanigan, David C.; Jones, Morgan; Kaeding, Christopher C.; Marx, Robert G.; Matava, Matthew J.; McCarty, Eric C.; Parker, Richard D.; Wolcott, Michelle; Vidal, Armando; Wolf, Brian R.; Wright, Rick W.

2013-01-01

Background An estimated 200,000 ACL reconstructions are performed each year in the United States. The presence of concomitant meniscus tears and subsequent treatment at the time of ACL reconstruction may determine long-term outcomes of these knees. The authors contend that a substantial number of these meniscal tears are treated in a fashion that reduces meniscal function and that new technologies are needed to treat meniscal tears in a fashion that preserves function. A large cohort of patients with meniscal tears is needed to demonstrate this need. The purpose of this study is to determine the incidence of meniscal tears, describe tear morphology, and selected treatment in the MOON prospective longitudinal cohort of ACL reconstruction. We also will demonstrate based on national statistics the large potential market that exists for future tissue engineering aimed at preserving meniscal function. Methods A multicenter cohort of 1014 patients undergoing ACL reconstruction between January 2002 and December 2003 were evaluated. All procedures were performed by nine fellowship trained sports medicine orthopaedic surgeons. Data on patient demographics, presence of a meniscus tear at time of ACL reconstruction, tear morphology, and meniscal treatment were collected prospectively. Meniscal tears were categorized into three potential tissue engineering treatment strategies: all-biologic repair, advanced repair, and scaffold replacement. Results 1014 ACL reconstructions were performed over the two year period. The median age at the time of surgery was 24 years. Thirty-six percent of the knees had medial meniscal tears and 44% of the knees had lateral meniscal tears. Longitudinal tears were the most common tear morphology. The most frequent treatment modality was partial meniscectomy (60%). Thirty percent of medial meniscal tears and 10% of lateral meniscal tears could be treated with all-biologic repair, 32% of medial meniscal tears and 28% of lateral meniscal tears could be treated with an advanced repair technique, and 35% of medial meniscal tears and 62% of lateral meniscal tears could be treated with scaffold replacement. Conclusions Although meniscal preservation is a generally accepted concept in the treatment of meniscal tears, the majority of tears in this young cohort undergoing ACL reconstruction were either not repairable types (radial) and/or in the avascular zone. Even with contemporary approaches to meniscal tear repair, we found significant limitations faced by the treating surgeon. The majority of tears in this population are currently treated by partial meniscectomy. The results of this cohort will hopefully, stimulate and focus future research and development of new tissue engineering strategies for a large potential market for meniscal function in an ACL reconstructed cohort. PMID:19634719

Anterior Cruciate Ligament Injuries in National Football League Athletes From 2010 to 2013: A Descriptive Epidemiology Study.

PubMed

Dodson, Christopher C; Secrist, Eric S; Bhat, Suneel B; Woods, Daniel P; Deluca, Peter F

2016-03-01

There is a high incidence of anterior cruciate ligament (ACL) injuries among National Football League (NFL) athletes; however, the incidence of reinjury in this population is unknown. This retrospective epidemiological study analyzed all publicly disclosed ACL tears occurring in NFL players between 2010 and 2013 to characterize injury trends and determine the incidence of reinjury. Descriptive epidemiological study. A comprehensive online search identified any NFL player who had suffered an ACL injury from 2010 to 2013. Position, playing surface, activity, and date were recorded. Each player was researched for any history of previous ACL injury. The NFL games database from USA Today was used to determine the incidence of ACL injuries on artificial turf and grass fields. Databases from Pro Football Focus and Pro Football Reference were used to determine the injury rate for each position. NFL players suffered 219 ACL injuries between 2010 and 2013. Forty players (18.3%) had a history of previous ACL injury, with 27 (12.3%) retears and 16 (7.3%) tears contralateral to a previous ACL injury. Five players (2.28%) suffered their third ACL tear. Receivers (wide receivers and tight ends) and backs (linebackers, fullbacks, and halfbacks) had significantly greater injury risk than the rest of the NFL players, while perimeter linemen (defensive ends and offensive tackles) had significantly lower injury risk than the rest of the players. Interior linemen (offensive guards, centers, and defensive tackles) had significantly greater injury risk compared with perimeter linemen. ACL injury rates per team games played were 0.050 for grass and 0.053 for turf fields (P > .05). In this retrospective epidemiological study of ACL tears in NFL players, retears and ACL tears contralateral to a previously torn ACL constituted a substantial portion (18.3%) of total ACL injuries. The significant majority of ACL injuries in players with a history of previous ACL injury were retears. Skilled offensive players and linebackers had the greatest injury risk, and significantly more ACL tears occurred among interior linemen than perimeter linemen. The month of August had the highest incidence of ACL injuries, probably because of expanded roster sizes at that point in the NFL season.

High-grade rotatory knee laxity may be predictable in ACL injuries.

PubMed

Musahl, Volker; Burnham, Jeremy; Lian, Jayson; Popchak, Adam; Svantesson, Eleonor; Kuroda, Ryosuke; Zaffagnini, Stefano; Samuelsson, Kristian

2018-06-21

Lateral compartment acceleration and translation have been used to quantify rotatory knee laxity in the setting of anterior cruciate ligament (ACL) injury; however, their relationship remains elusive. The purpose of this study was to examine the correlation between lateral compartment acceleration and translation during pivot shift testing. It was hypothesized that a correlation would exist in ACL-injured and uninjured knees, irrespective of sex, but would be greatest in knees with combined ACL and lateral meniscus tear. Seventy-seven patients (34 females, 25.2 ± 9.0 years) undergoing primary single-bundle ACL reconstruction were prospectively enrolled in a 2-year study across four international centers. Patients underwent preoperative examination under anesthesia of the injured and uninjured knee using Image Analysis software and surface mounted accelerometer. A moderate correlation between lateral compartment acceleration and translation was observed in ACL-injured knees [ρ = 0.36, p < 0.05), but not in uninjured knees (ρ = 0.17, not significant (n.s.)]. A moderate correlation between acceleration and translation was demonstrated in ACL-injured knees with lateral meniscus tears (ρ = 0.53, p < 0.05), but not in knees with isolated ACL-injury (ρ = 0.32, n.s.), ACL and medial meniscus tears (ρ = 0.14, n.s.), or ACL and combined medial and lateral meniscus tears (ρ = 0.40, n.s.). A moderate correlation between acceleration and translation was seen in males (ρ = 0.51, p < 0.05), but not in females (ρ = 0.21, n.s.). Largest correlations were observed in males with ACL and lateral meniscus tears (ρ = 0.75, p < 0.05). Lateral compartment acceleration and translation were moderately correlated in ACL-injured knees, but largely correlated in males with combined ACL and lateral meniscus tears. ACL and lateral meniscus injury in males might, therefore, be suspected when both lateral compartment acceleration and translation are elevated. Surgeons should have a greater degree of suspicion for high-grade rotatory knee laxity in ACL-injured males with concomitant lateral meniscus tears. Future studies should investigate how these two distinct components of rotatory knee laxity-lateral compartment acceleration and translation-are correlated with patient outcomes and affected by ACL surgery. Prospective cohort study; Level of evidence II.

Posterior meniscus root tears: associated pathologies to assist as diagnostic tools.

PubMed

Matheny, Lauren M; Ockuly, Andrew C; Steadman, J Richard; LaPrade, Robert F

2015-10-01

The purpose of this study was to investigate associated pathologies identified at arthroscopy in patients with meniscus root tears. This study was Institutional Review Board approved. All patients who underwent arthroscopic knee surgery where a complete meniscus root tear was identified were included in this study. Concurrent ligament tears and articular cartilage changes ≥Outerbridge grade 2 were recorded and stored in a data registry. Fifty patients (28 males, 22 females) [mean age = 36.5 years (range 17.1-68.1 years)] who were diagnosed with a medial or lateral meniscus root tear at arthroscopy were included in this study out of 673 arthroscopic surgeries (prevalence 7.4 %). Twenty-three (46 %) patients had a medial meniscus root tear, 26 (52 %) patients had a lateral meniscus root tear and one (2 %) patient had both. Thirty-four per cent of patients (n = 17) underwent partial meniscectomy, while 60 % (n = 31) underwent suture repair. During arthroscopy, 60 % (n = 30) of patients were diagnosed with an anterior cruciate ligament (ACL) tear. Patients with lateral meniscus root tears were 10.3 times (95 % CI 2.6-42.5) more likely to have ACL tears than patients with medial meniscus root tears (p = 0.012). Patients who had medial meniscus root tears were 5.8 times (95 % CI 1.6-20.5) more likely to have chondral defects than patients who had lateral meniscus root tears (p = 0.044). In this study, patients' preoperative functional scores and activity levels were low. Patients with lateral meniscal root tears were more likely to have an ACL tear. Patients with medial meniscal root tears were more likely to have an knee articular cartilage defect with an Outerbridge grade 2 or higher chondral defect. This study confirms the importance of comprehensive assessment of concurrent injuries to properly diagnose meniscus root tears. IV.

Growth Factors and Stem Cells for the Management of Anterior Cruciate Ligament Tears

PubMed Central

Rizzello, Giacomo; Longo, Umile Giuseppe; Petrillo, Stefano; Lamberti, Alfredo; Khan, Wasim Sardar; Maffulli, Nicola; Denaro, Vincenzo

2012-01-01

The anterior cruciate ligament (ACL) is fundamental for the knee joint stability. ACL tears are frequent, especially during sport activities, occurring mainly in young and active patients. Nowadays, the gold standard for the management of ACL tears remains the surgical reconstruction with autografts or allografts. New strategies are being developed to resolve the problems of ligament grafting and promote a physiological healing process of ligamentous tissue without requiring surgical reconstruction. Moreover, these strategies can be applicable in association surgical reconstruction and may be useful to promote and accelerate the healing process. The use of growth factors and stem cells seems to offer a new and fascinating solution for the management of ACL tears. The injection of stem cell and/or growth factors in the site of ligamentous injury can potentially enhance the repair process of the physiological tissue. These procedures are still at their infancy, and more in vivo and in vitro studies are required to clarify the molecular pathways and effectiveness of growth factors and stem cells therapy for the management of ACL tears. This review aims to summarize the current knowledge in the field of growth factors and stem cells for the management of ACL tears. PMID:23248722

Anterior Cruciate Ligament Injuries in National Football League Athletes From 2010 to 2013

PubMed Central

Dodson, Christopher C.; Secrist, Eric S.; Bhat, Suneel B.; Woods, Daniel P.; Deluca, Peter F.

2016-01-01

Background: There is a high incidence of anterior cruciate ligament (ACL) injuries among National Football League (NFL) athletes; however, the incidence of reinjury in this population is unknown. Purpose: This retrospective epidemiological study analyzed all publicly disclosed ACL tears occurring in NFL players between 2010 and 2013 to characterize injury trends and determine the incidence of reinjury. Study Design: Descriptive epidemiological study. Methods: A comprehensive online search identified any NFL player who had suffered an ACL injury from 2010 to 2013. Position, playing surface, activity, and date were recorded. Each player was researched for any history of previous ACL injury. The NFL games database from USA Today was used to determine the incidence of ACL injuries on artificial turf and grass fields. Databases from Pro Football Focus and Pro Football Reference were used to determine the injury rate for each position. Results: NFL players suffered 219 ACL injuries between 2010 and 2013. Forty players (18.3%) had a history of previous ACL injury, with 27 (12.3%) retears and 16 (7.3%) tears contralateral to a previous ACL injury. Five players (2.28%) suffered their third ACL tear. Receivers (wide receivers and tight ends) and backs (linebackers, fullbacks, and halfbacks) had significantly greater injury risk than the rest of the NFL players, while perimeter linemen (defensive ends and offensive tackles) had significantly lower injury risk than the rest of the players. Interior linemen (offensive guards, centers, and defensive tackles) had significantly greater injury risk compared with perimeter linemen. ACL injury rates per team games played were 0.050 for grass and 0.053 for turf fields (P > .05). Conclusion: In this retrospective epidemiological study of ACL tears in NFL players, retears and ACL tears contralateral to a previously torn ACL constituted a substantial portion (18.3%) of total ACL injuries. The significant majority of ACL injuries in players with a history of previous ACL injury were retears. Skilled offensive players and linebackers had the greatest injury risk, and significantly more ACL tears occurred among interior linemen than perimeter linemen. The month of August had the highest incidence of ACL injuries, probably because of expanded roster sizes at that point in the NFL season. PMID:26998501

Influence of Anterior Cruciate Ligament Tear on Thigh Muscle Strength and Hamstring-to-Quadriceps Ratio: A Meta-Analysis.

PubMed

Kim, Hyun-Jung; Lee, Jin-Hyuck; Ahn, Sung-Eun; Park, Min-Ji; Lee, Dae-Hee

2016-01-01

Theoretical compensation after anterior cruciate ligament (ACL) tear could cause quadriceps weakness and hamstring activation, preventing anterior tibial subluxation and affecting the expected hamstring-to-quadriceps ratio. Although quadriceps weakness often occurs after ACL tears, it remains unclear whether hamstring strength and hamstring-to-quadriceps ratio increase in ACL deficient knees. This meta-analysis compared the isokinetic muscle strength of quadriceps and hamstring muscles, and the hamstring-to-quadriceps ratio, of the injured and injured limbs of patients with ACL tears. This meta-analysis included all studies comparing isokinetic thigh muscle strengths and hamstring-to-quadriceps ratio in the injured and uninjured legs of patients with ACL tear, without or before surgery. Thirteen studies were included in the meta-analysis. Quadriceps and hamstring strengths were 22.3 N∙m (95% CI: 15.2 to 29.3 N∙m; P<0.001) and 7.4 N∙m (95% CI: 4.3 to 10.5 N∙m; P<0.001) lower, respectively, on the injured than on the uninjured side. The mean hamstring-to-quadriceps ratio was 4% greater in ACL deficient than in uninjured limbs (95% CI: 1.7% to 6.3%; P<0.001). Conclusively, Decreases were observed in both the quadriceps and hamstring muscles of patients with ACL tear, with the decrease in quadriceps strength being 3-fold greater. These uneven reductions slightly increase the hamstring-to-quadriceps ratio in ACL deficient knees.

Influence of Anterior Cruciate Ligament Tear on Thigh Muscle Strength and Hamstring-to-Quadriceps Ratio: A Meta-Analysis

PubMed Central

Ahn, Sung-Eun; Park, Min-Ji; Lee, Dae-Hee

2016-01-01

Theoretical compensation after anterior cruciate ligament (ACL) tear could cause quadriceps weakness and hamstring activation, preventing anterior tibial subluxation and affecting the expected hamstring-to-quadriceps ratio. Although quadriceps weakness often occurs after ACL tears, it remains unclear whether hamstring strength and hamstring-to-quadriceps ratio increase in ACL deficient knees. This meta-analysis compared the isokinetic muscle strength of quadriceps and hamstring muscles, and the hamstring-to-quadriceps ratio, of the injured and injured limbs of patients with ACL tears. This meta-analysis included all studies comparing isokinetic thigh muscle strengths and hamstring-to-quadriceps ratio in the injured and uninjured legs of patients with ACL tear, without or before surgery. Thirteen studies were included in the meta-analysis. Quadriceps and hamstring strengths were 22.3 N∙m (95% CI: 15.2 to 29.3 N∙m; P<0.001) and 7.4 N∙m (95% CI: 4.3 to 10.5 N∙m; P<0.001) lower, respectively, on the injured than on the uninjured side. The mean hamstring-to-quadriceps ratio was 4% greater in ACL deficient than in uninjured limbs (95% CI: 1.7% to 6.3%; P<0.001). Conclusively, Decreases were observed in both the quadriceps and hamstring muscles of patients with ACL tear, with the decrease in quadriceps strength being 3-fold greater. These uneven reductions slightly increase the hamstring-to-quadriceps ratio in ACL deficient knees. PMID:26745808

Preventing ACL Injuries in Females: What Physical Educators Need to Know

ERIC Educational Resources Information Center

Toscano, Lisa; Carroll, Brianne

2015-01-01

Anterior cruciate ligament (ACL) injuries happen at a frequent rate, especially in girls and women. While there are many factors that contribute to ACL tears, teaching proper landing techniques and strengthening certain muscles can decrease the incidence of ACL tears, especially in women. This article reviews some of the high-risk factors that…

Is There a Genetic Predisposition to Anterior Cruciate Ligament Tear? A Systematic Review.

PubMed

John, Rakesh; Dhillon, Mandeep Singh; Sharma, Siddhartha; Prabhakar, Sharad; Bhandari, Mohit

2016-12-01

Injuries to the anterior cruciate ligament (ACL) are among the most common knee ligament injuries and frequently warrant reconstruction. The etiopathogenesis of these injuries has focused mainly on mechanism of trauma, patient sex, and anatomic factors as predisposing causes. Several genetic factors that could predispose to an ACL tear have recently been reported. This systematic review summarizes the current evidence for a genetic predisposition to ACL tears. The principal research question was to identify genetic factors, based on the available literature, that could predispose an individual to an ACL tear. Systematic review. The PubMed, EMBASE, Cochrane, and HuGE databases were searched; the search was run from the period of inception until June 21, 2015. A secondary search was performed by screening the references of full-text articles obtained and by manually searching selected journals. Articles were screened with prespecified inclusion criteria. The quality of studies included in the review was assessed for risk of bias by 2 reviewers using the Newcastle-Ottawa Scale. A total of 994 records were identified by the search, out of which 17 studies (16 case-control studies and 1 cross-sectional study) were included in the final review. Two studies observed a familial predisposition to an ACL tear. Fourteen studies looked at specific gene polymorphisms in 20 genes, from which different polymorphisms in 10 genes were positively associated with an ACL tear. In addition to these polymorphisms, 8 haplotypes were associated with ACL tear. One study looked at gene expression analysis. Although specific gene polymorphisms and haplotypes have been identified, it is difficult to come to a conclusion on the basis of the existing literature. Several sources of bias have been identified in these studies, and the results cannot be extrapolated to the general population. More studies are needed in larger populations of different ethnicities. Gene-gene interactions and gene expression studies in the future may delineate the exact role of these gene polymorphisms in ACL tears. © 2016 The Author(s).

Societal and economic impact of anterior cruciate ligament tears.

PubMed

Mather, Richard C; Koenig, Lane; Kocher, Mininder S; Dall, Timothy M; Gallo, Paul; Scott, Daniel J; Bach, Bernard R; Spindler, Kurt P

2013-10-02

An anterior cruciate ligament (ACL) tear is a common knee injury, particularly among young and active individuals. Little is known, however, about the societal impacts of ACL tears, which could be large given the typical patient age and increased lifetime risk of knee osteoarthritis. This study evaluates the cost-effectiveness of ACL reconstruction compared with structured rehabilitation only. A cost-utility analysis of ACL reconstruction compared with structured rehabilitation only was conducted with use of a Markov decision model over two time horizons: the short to intermediate term (six years), on the basis of Level-I evidence derived from the KANON Study and the Multicenter Orthopaedic Outcomes Network (MOON) database; and the lifetime, on the basis of a comprehensive literature review. Utilities were assessed with use of the SF-6D. Costs (in 2012 U.S. dollars) were estimated from the societal perspective and included the effects of the ACL tear on work status, earnings, and disability. Effectiveness was expressed as quality-adjusted life years (QALYs) gained. In the short to intermediate term, ACL reconstruction was both less costly (a cost reduction of $4503) and more effective (a QALY gain of 0.18) compared with rehabilitation. In the long term, the mean lifetime cost to society for a typical patient undergoing ACL reconstruction was $38,121 compared with $88,538 for rehabilitation. ACL reconstruction resulted in a mean incremental cost savings of $50,417 while providing an incremental QALY gain of 0.72 compared with rehabilitation. Effectiveness gains were driven by the higher probability of an unstable knee and associated lower utility in the rehabilitation group. Results were most sensitive to the rate of knee instability after initial rehabilitation. ACL reconstruction is the preferred cost-effective treatment strategy for ACL tears and yields reduced societal costs relative to rehabilitation once indirect cost factors, such as work status and earnings, are considered. The cost of an ACL tear over the lifetime of a patient is substantial, and resources should be directed to developing innovations for injury prevention and for altering the natural history of an ACL injury.

Arthroscopic and magnetic resonance imaging evaluation of meniscus lesions in the chronic anterior cruciate ligament-deficient knee.

PubMed

Naranje, Sameer; Mittal, Ravi; Nag, Hiralal; Sharma, Raju

2008-09-01

We performed this prospective study to evaluate the incidence of meniscus tears arthroscopically and the effectiveness of magnetic resonance imaging (MRI) in detecting these lesions in patients with chronic anterior cruciate ligament (ACL)-deficient knees. We reviewed 50 patients (46 male and 4 female) with a mean age of 27 years (range, 18 to 48 years) who underwent ACL reconstruction for chronic ACL tears. Injuries were classified as chronic because arthroscopy was performed after more than 6 weeks of injury. All 50 patients had clinical and MRI evaluation followed by knee arthroscopy. The MRI and arthroscopic findings were then analyzed by a single independent reviewer. The presence of meniscus tears and their morphologic types and locations were analyzed. The sensitivity, specificity, positive predictive value, and negative predictive value of MRI were calculated. On arthroscopy, a medial meniscus tear was found in 18 patients (36%), a lateral meniscus tear was found in 11 patients (22%), both menisci were torn in 8 patients (16%), and no meniscus lesion was found in 13 patients (26%). The most common morphologic type of tear seen in the medial meniscus was "complex" (n = 11 [42%]), and that in the lateral meniscus was "longitudinal" (n = 10 [53%]). The posterior horn of the meniscus was the most common tear site. The overall sensitivity, specificity, positive predictive value, and negative predictive value for detecting meniscus tears in chronic ACL-deficient knees on MRI were 90%, 89%, 87%, 93%, respectively. We conclude from our study that in chronic ACL-deficient patients, the prevalence of posterior horn medial meniscus tears seems to be high. Anterior horn tears and radial and horizontal patterns of meniscus tears seem to be rare in chronic ACL deficiency. MRI correlates well with arthroscopy and has high negative predictive values. Level I, prognostic prospective study.

The triple PCL sign: bucket handle tears of both medial and lateral menisci in a chronically ACL-deficient knee.

PubMed

Kakel, Rafid; Russell, Robert; VanHeerden, Pieter

2010-10-11

Bucket handle tears of both menisci in the setting of acute or chronic anterior cruciate ligament (ACL) tears of the same knee have rarely been reported in the literature. This article presents a case of a bucket handle tear affecting both the medial and lateral menisci in a patient with chronic ACL rupture. Both bucket handle tears were displaced and locked in the intercondylar notch. A new magnetic resonance image (MRI) sign suggested on sagittal view is called the triple PCL sign, comprising the intact posterior cruciate ligament (PCL) and the 2 displaced fragments in the intercondylar notch from the two bucket handle tears. The precise diagnosis of this condition is of obvious importance for optimal operative planning. While finding the displaced fragment from the medial meniscus is expected to cause the double PCL sign, the torn ACL may have made it easier to visualize the bucket handle tear of the lateral meniscus in the same sagittal plane as the PCL. Only 5 other reports mention bimeniscal bucket handle tears of both the medial and lateral menisci in association with an ACL tear. None have shown the suggested triple PCL sign because of lack of overlap between the 2 bucket handle tears in the coronal plane while lying in the intercondylar notch causing them not to fall in the same sagittal plane. Our patient showed some overlap between the 2 meniscal fragments while lying in the notch to create the triple PCL sign on sagittal MRI. Copyright 2010, SLACK Incorporated.

Are Female Soccer Players at an Increased Risk of Second Anterior Cruciate Ligament Injury Compared With Their Athletic Peers?

PubMed

Allen, Melissa M; Pareek, Ayoosh; Krych, Aaron J; Hewett, Timothy E; Levy, Bruce A; Stuart, Michael J; Dahm, Diane L

2016-10-01

Female soccer players have a well-known risk for anterior cruciate ligament (ACL) injury, but few studies have reported on second ACL injuries in this population. To (1) report the rates of subsequent ACL injury (ipsilateral graft rupture or contralateral tear) in competitive female soccer players, (2) compare these rates with those of other female athletes of similar competitive level, (3) determine risk factors for second ACL injury, and (4) report clinical outcome scores in this population. Cohort study; Level of evidence, 3. The medical records at a single institution were reviewed for female patients who were injured during a competitive athletic event and treated with primary ACL reconstruction (ACLR) between 1998 and 2013. Patients were followed for a mean of 68.8 months postoperatively (range, 24-115.2 months). Clinical outcome was obtained via Lysholm and International Knee Documentation Committee (IKDC) scores. Soccer players were matched 1:1 to non-soccer athletes for age, activity level, and graft type. A total of 180 female ACLR patients with a mean ± SD age of 19.6 ± 6.9 years met the study inclusion and exclusion criteria (90 soccer players and 90 non-soccer players). Soccer players sustained more second ACL injuries, including both graft failures (11% vs 1%; P < .01) and contralateral ACL tears (17% vs 4%; P < .01), compared with non-soccer players. Of the 67 patients who returned to soccer after ACLR (mean age, 17.5 years; range, 13-27 years), significantly more had graft tears compared with those who did not return to soccer (15% vs 0%, respectively; P = .04); however, the difference in contralateral ACL tears (19% for returning players vs 9% for those who did not return; P = .34) was not significant. Relatively older age (odds ratio, 1.5 per year; P = .03) was a significant risk factor for ACL graft tear but not for contralateral ACL injury. Both groups had similar mean Lysholm (96 vs 95) and IKDC scores (95 vs 96) at final follow-up. Twenty-eight percent of all female soccer players and 34% of those players who returned to soccer had a second ACL tear. Soccer players had an increased rate of both graft tear and contralateral ACL injury compared with similar non-soccer athletes. Older age and return to soccer were significant risk factors for graft rupture. © 2016 The Author(s).

A Radiographic Assessment of Failed Anterior Cruciate Ligament Reconstruction: Can Magnetic Resonance Imaging Predict Graft Integrity?

PubMed

Waltz, Robert A; Solomon, Daniel J; Provencher, Matthew T

2014-07-01

Magnetic resonance imaging (MRI) showing an "intact" anterior cruciate ligament (ACL) graft may not correlate well with examination findings. Reasons for an ACL graft dysfunction may be from malpositioned tunnels, deficiency of secondary stabilizers, repeat injuries, or a combination of factors. To evaluate the concordance/discordance of an ACL graft assessment between an arthroscopic evaluation, physical examination, and MRI and secondarily to evaluate the contributing variables to discordance. Case series; Level of evidence, 4. A total of 50 ACL revisions in 48 patients were retrospectively reviewed. The ACL graft status was recorded separately based on Lachman and pivot-shift test data, arthroscopic findings from operative reports, and MRI evaluation and was categorized into 3 groups: intact, partial tear, or complete tear. Two independent evaluators reviewed all of the preoperative radiographs and MRI scans, and interrater and intrarater reliability were evaluated. Concordance and discordance between a physical examination, arthroscopic evaluation, and MRI evaluation of the ACL graft were calculated. Graft position and type, mechanical axis, collateral ligament injuries, chondral and meniscal injuries, and mechanism of injury were evaluated as possible contributing factors using univariate and multivariate analyses. Sensitivity and specificity of MRI to detect a torn ACL graft and meniscal and chondral injuries on arthroscopic evaluation were calculated. The interobserver and intraobserver reliability for the MRI evaluation of the ACL graft were moderate, with combined κ values of .41 and .49, respectively. The femoral tunnel position was vertical in 88% and anterior in 46%. On MRI, the ACL graft was read as intact in 24%; however, no graft was intact on arthroscopic evaluation or physical examination. The greatest discordance was between the physical examination and MRI, with a rate of 52%. An insidious-onset mechanism of injury was significantly associated with discordance between MRI and arthroscopic evaluation of the ACL (P = .0003) and specifically with an intact ACL graft on MRI (P = .0014). The sensitivity and specificity of MRI to detect an ACL graft tear were 60% and 87%, respectively. Caution should be used when evaluating a failed ACL graft with MRI, especially in the absence of an acute mechanism of injury, as it may be unreliable and inconsistent. © 2014 The Author(s).

Restricted Hip Rotation Is Correlated With an Increased Risk for Anterior Cruciate Ligament Injury.

PubMed

VandenBerg, Curtis; Crawford, Eileen A; Sibilsky Enselman, Elizabeth; Robbins, Christopher B; Wojtys, Edward M; Bedi, Asheesh

2017-02-01

The primary purpose was to compare ipsilateral hip internal rotation (IR) in male and female athletes with or without an anterior cruciate ligament (ACL) tear. A secondary purpose was to compare radiographic markers of femoroacetabular impingement (FAI) in patients with or without an ACL tear. In this prospective case-control study, based on a power analysis, a convenience sample of 25 ACL-injured and 25 control patients matched by age and gender were examined over 14 months. The ACL injury group included preoperative patients 12-40 years old with an ACL rupture within the previous 3 months with no prior lower extremity injuries, ligamentous laxity, or arthralgias. Controls included patients presenting with an upper extremity complaint with no history of knee injury. In the outpatient clinic, hip axial rotation range of motion was measured with a goniometer on physical examination and hip radiographs were evaluated for morphologic variations consistent with FAI. Univariate analysis of variance was used to examine differences between groups. Each group had 13 males and 12 females, average ages of 22.8 ± 7.2 years (ACL group) versus 24.5 ± 7.9 years (controls; P = .439). The average sum of hip rotation (internal plus external) in patients with an ACL tear was 60.3 ± 12.4° compared with 72.6 ± 17.2° in controls (P = .006). ACL-injured patients had decreased hip IR compared with controls, with respective mean measurements of 23.4 ± 7.6° versus 30.4 ± 10.4° (P = .009). For every 10° increase in hip IR, the odds of having an ACL tear decreased by a factor of 0.419 (P = .015). Risk of ACL injury is associated with restricted hip IR, and as hip IR increases, the odds of having an ACL tear decreases. In addition, ACL injury is associated with FAI in a generalized population of male and female athletes, although causality cannot be determined and most ACL-injured patients do not exhibit hip complaints. Level II, prognostic, prospective cohort study. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Biologic agents for anterior cruciate ligament healing: A systematic review

PubMed Central

Di Matteo, Berardo; Loibl, Markus; Andriolo, Luca; Filardo, Giuseppe; Zellner, Johannes; Koch, Matthias; Angele, Peter

2016-01-01

AIM To systematically review the currently available literature concerning the application of biologic agents such as platelet-rich plasma (PRP) and stem cells to promote anterior cruciate ligament (ACL) healing. METHODS A systematic review of the literature was performed on the use of biologic agents (i.e., PRP or stem cells) to favor ACL healing during reconstruction or repair. The following inclusion criteria for relevant articles were used: Clinical reports of any level of evidence, written in English language, on the use of PRP or stem cells during ACL reconstruction/repair. Exclusion criteria were articles written in other languages, reviews, or studies analyzing other applications of PRP/stem cells in knee surgery not related to promoting ACL healing. RESULTS The database search identified 394 records that were screened. A total of 23 studies were included in the final analysis: In one paper stem cells were applied for ACL healing, in one paper there was a concomitant application of PRP and stem cells, whereas in the remaining 21 papers PRP was used. Based on the ACL injury pattern, two papers investigated biologic agents in ACL partial tears whereas 21 papers in ACL reconstruction. Looking at the quality of the available literature, 17 out of 21 studies dealing with ACL reconstruction were randomized controlled trials. Both studies on ACL repair were case series. CONCLUSION There is a paucity of clinical trials investigating the role of stem cells in promoting ACL healing both in case of partial and complete tears. The role of PRP is still controversial and the only advantage emerging from the literature is related to a better graft maturation over time, without documenting beneficial effects in terms of clinical outcome, bone-graft integration and prevention of bony tunnel enlargement. PMID:27672573

Posterior root tear fixation of the lateral meniscus combined with arthroscopic ACL double-bundle reconstruction: technical note of a transosseous fixation using the tibial PL tunnel.

PubMed

Forkel, Philipp; Petersen, Wolf

2012-03-01

According to our observation in ACL reconstruction, we find root tears of the posterior horn of the lateral meniscus as a common concomitant injury in ACL-deficient knees. This might be a consequence of initial trauma or of the increased anterior-posterior translation of the tibia and an overload impact on the posterior meniscus root in ACL-deficient knees. A tear of the posterior horn of the medial meniscus causes a 25% increase in peak pressure in the medial compartment compared with that found in the intact condition. The repair restores the peak contact pressure to normal (Allaire et al. in J Bone Joint Surg Am 90(9):1922-1931, [2008]). A tear of the posterior horn of the lateral meniscus might have similar consequences. We hypothesize the surgical anatomical reattachment of the root at the tibia helping to restore knee joint kinematics and helping to advance ACL-graft function. This article presents an arthroscopical technique to reattach the posterior meniscus root in combination with ACL double-bundle reconstruction. The procedure uses the tibial PL tunnel to fix the meniscus suture.

Incidence and patterns of meniscal tears accompanying the anterior cruciate ligament injury: possible local and generalized risk factors.

PubMed

Mansori, Ashraf El; Lording, Timothy; Schneider, Antoine; Dumas, Raphael; Servien, Elvire; Lustig, Sebastien

2018-05-26

Injury to the anterior cruciate ligament (ACL) is frequently accompanied by tears of the menisci. Some of these tears occur at the time of injury, but others develop over time in the ACL-deficient knee. The aim of this study was to evaluate the effects of the patient characteristics, time from injury (TFI), and posterior tibial slope (PTS) on meniscal tear patterns. Our hypothesis was that meniscal tears would occur more frequently in ACL-deficient knees with increasing age, weight, TFI, PTS, and in male patients. Of the ACL-injured patients, 362 were analyzed, and details of meniscal lesions were collected. The medial and lateral tibial slopes (MTS, LTS) were measured via computed tomography. Patient demographics, TFI, MTS, and LTS were correlated with the diagnosed meniscal tears. Of the patients, 113 had a medial meniscus (MM) tear, 54 patients had a lateral meniscus (LM) tear, 34 patients had tears of both menisci, and 161 patients had no meniscal tear. The most common tear location was the posterior horn (PH) of the MM, followed by tear involving the whole MM. Patient age, BMI, and TFI were significantly associated with the incidence of MM tear. Female patients had a higher incidence of injury than males in all tear sites except in the body and PH. Male patients had more vertical and peripheral tears. The median MTS and LTS for patients with MM tears were 7.0°and 8.7°, respectively, while those of patients with LM tears were 6.9° and 8.1°. Steeper LTS was significantly associated with tears of LM and of both menisci. Older age, male sex, increased BMI, and prolonged TFI were significant factors for the development of MM tears. An increase in the tibial slope, especially of the lateral plateau, seems to increase the risk of tear of the LM and of both menisci. Level III.

Patterns of meniscal tears associated with anterior cruciate ligament lesions in athletes.

PubMed

Binfield, P M; Maffulli, N; King, J B

1993-09-01

In this study, 400 clinically anterior cruciate ligament (ACL) deficient knees were arthroscoped and studied prospectively in the period January 1986 to April 1992. An ACL tear was always confirmed, and 41 per cent of these patients did not have an associated meniscal tear. In 30.25 per cent the lateral meniscus was torn; in 21.25 per cent the ACL tear was associated with a medial meniscus tear, and in the remaining 7 per cent both menisci were torn. The most frequently associated meniscal injury was the bucket handle tear of the medial meniscus (9 per cent), followed by the posterior horn tear of the lateral meniscus, which showed the same frequency as the ragged (or degenerated) tear of the lateral meniscus (6 per cent). The horizontal tear of the posterior part of the lateral meniscus showed a prevalence of 4.3 per cent. This picture is probably dependent on a secondary referral nature of the centre surveyed, in which the average time between injury and arthroscopy was 23.3 months.

Knee arthroscopy in Chinese children and adolescents: an eight-year prospective study.

PubMed

Maffulli, N; Chan, K M; Bundoc, R C; Cheng, J C

1997-02-01

In the period January 1985 to December 1992, 69 Chinese boys and 20 Chinese girls (average 14.6 years, age range 6 to 16 years) with a total of 92 involved knees underwent examination under anaesthesia and knee arthroscopy. Two thirds of the patients were engaged in sports activities. A haemarthrosis was present in 51 patients. In one patient, Staphylococcus aureus was shown, and in two children a serous-purulent aspirate grew Mycobacterium tuberculosis. The lateral meniscus was torn in four knees and the medial meniscus in six. An intact discoid lateral meniscus was found in five girls. Three partial anterior cruciate ligament (ACL) tears, three complete ACL tears and two posterior cruciate ligament tears were diagnosed. One child had an osteochondral defect of the lateral femoral condyle accompanying an ACL and a lateral meniscal tear. Nonspecific synovitis of unknown etiology was diagnosed in six patients who had presented subacutely with at least a 2-month history of a symptomatic monoarticular knee effusion with low grade local inflammation and no history of major trauma. The synovitis gradually resolved over a 6- to 10-month period after arthroscopy. Knee arthroscopy in children and adolescent patients is safe, gives a high diagnostic accuracy, and allows treatment of a variety of intraarticular conditions. This study also demonstrates that the range of intraarticular knee problems found in Chinese children and adolescents differs from that described in their Western counterparts.

Stable Meniscal Tears Left In Situ at the Time of Arthroscopic Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PubMed

Rothermich, Marcus A; Cohen, Jared A; Wright, Rick

2016-04-01

Meniscal tears can be incidentally encountered at the time of anterior cruciate ligament (ACL) reconstruction. In these cases, the surgeon has several treatment options that include benign neglect, debridement, trephination, and repair. The authors performed a systematic review of the literature studying the various treatment options for meniscal tears discovered at the time of ACL reconstruction. This systematic review included eight articles that had relevant data regarding benign neglect compared with debridement, trephination, or repair of incidentally encountered meniscal tears. Combined data from these studies resulted in a total of 646 meniscal tears treated with benign neglect with follow-up information available. Importantly, there were differences in reoperation rates between medial and lateral meniscal tears left in situ. However, stable medial and lateral meniscal tears treated with benign neglect did not have different subjective or objective outcomes than those treated with surgical intervention. This systematic review concludes that when stable meniscal tears are encountered at the time of arthroscopic ACL reconstruction, benign neglect can be used for a successful outcome. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Role of tear location on outcomes of open primary repair of the anterior cruciate ligament: A systematic review of historical studies.

PubMed

van der List, Jelle P; DiFelice, Gregory S

2017-10-01

The general opinion is that outcomes of open primary repair of the anterior cruciate ligament (ACL) in the historical literature were disappointing. Since good outcomes of primary repair of proximal tears have recently been reported, we aimed to assess the role of tear location on open primary repair outcomes in the historical literature. All studies reporting outcomes of open primary ACL repair published between the inception of PubMed, Embase and Cochrane and 2000 were identified. Studies were included if tear location was reported. Outcome scores, return to sports, stability examinations, failures and patient satisfaction were collected and reviewed in the total study cohort and in a subgroup of studies treating only proximal tears. Spearman correlation analysis was performed between the percentage of proximal tears in the studies and all outcomes. Twenty-nine studies were included reporting outcomes of open primary in 1457 patients of which 72% had proximal and 23% midsubstance tears. Mean age was 30years, 65% were males, and mean follow-up was 3.6years. Good outcomes were noted in the total cohort, and excellent outcomes were noted following repair of proximal tears. Positive correlation was found between the percentage proximal tears in the studies and percentage satisfied patients (p=0.010). Tear location seems to have played a role on the outcomes of open primary ACL repair. Outcomes of open primary repair in patients with proximal tears were excellent, which confirms there may be a potential role for primary repair as treatment for proximal ACL tears. Copyright © 2017 Elsevier B.V. All rights reserved.

An unusual mechanism for injury of the anterior cruciate ligament in figure skating.

PubMed

Wilson, Eugene K; Lahurd, Alexandra P; Wilckens, John H

2012-03-01

A 20-year-old competitive figure skater presented with an acute disabling knee injury that occurred in the overhead, non-weight-bearing knee during the performance of a Biellmann spin. Examination and magnetic resonance imaging confirmed the diagnosis of a complete anterior cruciate ligament (ACL) tear. To our knowledge, no previous cases of acute injury of the ACL sustained during the execution of a Biellmann spin have been reported. The ACL injury we report is unique because it occurred without the blade contacting the ice. The mechanism of injury has some features that are similar to those of other noncontact ACL injuries, with the addition of centrifugal force as a potential contributor to the injury.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury.

PubMed

Dekker, Travis J; Godin, Jonathan A; Dale, Kevin M; Garrett, William E; Taylor, Dean C; Riboh, Jonathan C

2017-06-07

Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children and adolescents than adults. The reasons for higher subsequent injury rates in this population are incompletely understood. We analyzed a continuous cohort of patients who were <18 years of age. Subjects underwent isolated, primary ACL reconstruction with autograft between 2006 and January 1, 2014, and had a minimum 2-year follow-up. Return-to-sport characteristics were described, and multivariable Cox regression modeling was used to identify predictors of a second ACL injury. Candidate variables included patient factors (age, sex, physeal status, tibial slope, notch width index), surgical characteristics (graft type, surgical technique), measures of recovery (time to return to sport, duration of physical therapy), and patients' preoperative and postoperative sports involvement (primary and secondary sports, number of sports). A total of 112 subjects met inclusion criteria; of these patients, 85 (76%) had complete follow-up data and were analyzed. The mean age (and standard deviation) was 13.9 ± 2.1 years (range, 6 to 17 years); 77% had open physes. The mean follow-up was 48.3 ± 15.3 months. Seventy-seven patients (91%) returned to sports, and 84% returned to the same sport. The mean Marx activity score at the time of the latest follow-up was 13.7 ± 3.5 points. Patients were involved in fewer sports after ACL reconstruction, 1.48 ± 0.92 compared with 1.83 ± 1.01 sports before reconstruction (p = 0.002). Sixteen patients (19%) sustained an ACL graft rupture, 11 patients (13%) sustained a contralateral ACL tear, and 1 of these patients (1%) sustained both. The overall prevalence of a second ACL injury was 32%. Time to return to sport was the only significant predictor of a second ACL injury, with a slower return being protective (hazard ratio per month, 0.87 [95% confidence interval, 0.73 to 0.99]; p = 0.04). Pediatric athletes return to sports at a high rate (91%) after ACL reconstruction. Unfortunately, the prevalence of a second ACL injury is high at 32%. Within this population, an earlier return to sport is predictive of a second ACL injury. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Success of Meniscal Repair at ACL Reconstruction

PubMed Central

Toman, Charles; Spindler, Kurt P.; Dunn, Warren R.; Amendola, Annunziata; Andrish, Jack T.; Bergfeld, John A.; Flanigan, David; Jones, Morgan; Kaeding, Christopher C.; Marx, Robert G.; Matava, Matthew J.; McCarty, Eric C.; Parker, Richard D.; Wolcott, Michelle; Vidal, Armando; Wolf, Brian R.; Huston, Laura J.; Harrell, Frank E.; Wright, Rick W.

2013-01-01

Background Meniscal repair is performed in an attempt to prevent posttraumatic arthritis resulting from meniscal dysfunction after meniscal tears. The socioeconomic implications of premature arthritis are significant in the young patient population. Investigations and techniques focusing on meniscus preservation and healing are now at the forefront of orthopaedic sports medicine. Hypothesis Concomitant meniscal repair with ACL reconstruction is a durable and successful procedure at two year follow-up. Study Design Case Series; Level of evidence, 4. Methods All unilateral primary ACL reconstructions entered in 2002 in a prospective cohort who had meniscal repair at the time of ACLR were evaluated. Validated patient oriented outcome instruments were completed preoperatively and then again at the two-year postoperative time point. Reoperation after the index procedure was also documented and confirmed by operative reports. Results 437 unilateral primary ACL reconstructions were performed with 86 concomitant meniscal repairs (57 medial, 29 lateral) in 84 patients during the study period. Patient follow-up was obtained on 94% (81/86) of the meniscal repairs, allowing confirmation of meniscal repair success (defined as no repeat arthroscopic procedure) or failure. The overall success rate for meniscal repairs was 96% (76/79 patients) at two-year follow-up. Conclusions Meniscal repair is a successful procedure in conjunction with ACL reconstruction. When confronted with a “repairable” meniscal tear at the time of ACL reconstruction, orthopaedic surgeons can expect an estimated >90% clinical success rate at two-year follow-up using a variety of methods as shown in our study. PMID:19465734

Successful anterior cruciate ligament reconstruction and meniscal repair in osteogenesis imperfecta.

PubMed

Park, Jae-Young; Cho, Tae-Joon; Lee, Myung Chul; Han, Hyuk-Soo

2018-03-20

A case of anterior cruciate ligament (ACL) reconstruction with meniscal repair in an osteogenesis imperfecta patient is reported. A 24-year-old female with osteogenesis imperfecta type 1a suffered from a valgus extension injury resulting in tear of ACL and medial meniscus. She underwent an arthroscopic-assisted ACL reconstruction and medial meniscus repair. Meniscal tear at the menisco-capsular junction of the posterior horn of medial meniscus was repaired with three absorbable sutures via inside-out technique. ACL reconstruction was then performed with a bone-patellar tendon-bone allograft. The patient was followed up for 1 year with intact ACL grafts and healed medial meniscus. This case report showed that successful ACL reconstruction and meniscal repair is possible in an osteogenesis imperfecta patient.Level of evidence V.

[Intra-articular reinforcement of a partially torn anterior cruciate ligament (ACL) using newly developed UHMWPE biomaterial in combination with Hexalon ACL/PCL screws: ex-vivo mechanical testing of an animal knee model].

PubMed

Fedorová, P; Srnec, R; Pěnčík, J; Dvořák, M; Krbec, M; Nečas, A

2015-01-01

PURPOSE OF THE STUDY Recent trends in the experimental surgical management of a partial anterior cruciate ligament (ACL) rupture in animals show repair of an ACL lesion using novel biomaterials both for biomechanical reinforcement of a partially unstable knee and as suitable scaffolds for bone marrow stem cell therapy in a partial ACL tear. The study deals with mechanical testing of the newly developed ultra-high-molecular-weight polyethylene (UHMWPE) biomaterial anchored to bone with Hexalon biodegradable ACL/PCL screws, as a new possibility of intra-articular reinforcement of a partial ACL tear. MATERIAL AND METHODS Two groups of ex vivo pig knee models were prepared and tested as follows: the model of an ACL tear stabilised with UHMWPE biomaterial using a Hexalon ACL/PCL screw (group 1; n = 10) and the model of an ACL tear stabilised with the traditional, and in veterinary medicine used, extracapsular technique involving a monofilament nylon fibre, a clamp and a Securos bone anchor (group 2; n = 11). The models were loaded at a standing angle of 100° and the maximum load (N) and shift (mm) values were recorded. RESULTS In group 1 the average maximal peak force was 167.6 ± 21.7 N and the shift was on average 19.0 ± 4.0 mm. In all 10 specimens, the maximum load made the UHMWPE implant break close to its fixation to the femur but the construct/fixation never failed at the site where the material was anchored to the bone. In group 2, the average maximal peak force was 207.3 ± 49.2 N and the shift was on average 24.1 ± 9.5 mm. The Securos stabilisation failed by pullout of the anchor from the femoral bone in nine out of 11 cases; the monofilament fibre ruptured in two cases. CONCLUSIONS It can be concluded that a UHMWPE substitute used in ex-vivo pig knee models has mechanical properties comparable with clinically used extracapsular Securos stabilisation and, because of its potential to carry stem cells and bioactive substances, it can meet the requirements for an implant appropriate to the unique technique of protecting a partial ACL tear. In addition, it has no critical point of ACL substitute failure at the site of its anchoring to the bone (compared to the previously used PET/PCL substitute). Key words: knee stabilisation, stifle surgery, ultra-high-molecular-weight polyethylene, UHMWPE, nylon monofilament thread, biodegradable screw, bone anchor.

[Evaluation of the clinical results in patients with symptomatic partial tears of the anterior cruciate ligament diagnosed arthroscopically].

PubMed

Zeman, P; Cibulková, J; Nepraš, P; Koudela, K; Matějka, J

2013-01-01

The study presents a retrospective evaluation of clinical data and arthroscopic findings in a group of our patients with symptomatic knee instability due to a partial tear of the anterior cruciate ligament (ACL). The group included 31 patients diagnosed with symptomatic partial ACL tears, i.e. an isolated tear of the posterolateral (PL) or the anteromedial (AM) bundle. The patients' average age was 26.5 years. A side-to-side difference in ventral knee laxity was assessed using the anterior drawer test and the Lachman test under general anaesthesia before arthroscopy was commenced; rotational knee laxity was evaluated by the pivot shift test. An objective evaluation of side-to-side ventral laxity differences in both knees was performed on the GNRB® arthrometer with an applied pressure of 134 N and 250 N in the conscious patient. During arthroscopic examination, findings on the two ACL bundles were recorded. All 31 patients were diagnosed with symptomatic partial ACL tears, of them 22 had a PL bundle lesion and nine had an AM bundle tear. All patients with PL bundle lesions only reported problems in association with pivot sports, and all patients with AM bundle tears had problems regardless of any sports activities. In all patients with isolated AM bundle tears, the lesion was located close to its femoral attachment. In the patients with PL bundle tears, femoral location was found in 68% and tibial location in 32% of the patients. In the patients with partial PL bundle lesions, + and ++ results in the pivot shift test were recorded in 32% and 68% of the treated patients, respectively. The Lachman test showed + and ++ results in 71% and 9% of the patients, respectively. The anterior drawer test had negative results in 87% and positive + results in 13% of the patients. The side-to-side difference on the GNRB arthrometer ranged from 0.4 to 2.3 mm at a pressure of 134 N and from 1.2 to 4.2 mm at 250 N in the patients with isolated PL bundle lesions. In the patients with AM bundle lesions, the results were as follows: pivot shift test, 89% negative. 11% positive +; Lachman test, 56% negative, 44% positive +; anterior drawer test, 89% +, 11% ++; GNRB test, 2.2 to 4.4 mm at 134 N, and 4.3 to 7.1 at 250 N. The diagnosis of partial ACL lesions, i.e., isolated tears of the AM or the PL bundle, requires accurate knowledge of knee anatomy and its biomechanics. In accordance with other authors our results showed that an arthroscopic examination of both bundles of the ligament as well as knee laxity evaluation under general anaesthesia are most essential for making the definite diagnosis in partial ACL tears. They also confirmed that, in isolated AM bundle lesions, ventral laxity is present more often particularly at a higher degree of knee flexion while, in PL bundle lesions, rotational laxity is more frequent and ranges from 0 to 30 degrees of knee flexion. To make the definite diagnosis of partial ACL tears, patient medical history, clinical knee examination including instability type and degree assessment under general anaesthesia and, most importantly, arthroscopic findings on both ACL bundles are necessary.

Chondral Injuries and Irreparable Meniscal Tears Among Adolescents With Anterior Cruciate Ligament or Meniscal Tears Are More Common in Patients With Public Insurance.

PubMed

Williams, Ariel A; Mancini, Nickolas S; Solomito, Matthew J; Nissen, Carl W; Milewski, Matthew D

2017-07-01

Access to health care services is a critical component of health care reform and may differ among patients with different types of insurance. Hypothesis/Purpose: The purpose was to compare adolescents with private and public insurance undergoing surgery for anterior cruciate ligament (ACL) and/or meniscal tears. We hypothesized that patients with public insurance would have a delayed presentation from the time of injury and therefore would have a higher incidence of chondral injuries and irreparable meniscal tears and lower preoperative International Knee Documentation Committee (IKDC) scores than patients with private insurance. Cross-sectional study; Level of evidence, 3. This was a retrospective study of patients under 21 years of age undergoing ACL reconstruction and/or meniscal repair or debridement from January 2013 to March 2016 at a single pediatric sports medicine center. Patients were identified by a search of Current Procedural Terminology (CPT) codes. A chart review was performed for insurance type; preoperative diagnosis; date of injury, initial office visit, and surgery; preoperative IKDC score; intraoperative findings; and procedures. The study group consisted of 119 patients (mean age, 15.0 ± 1.7 years). Forty-one percent of patients had private insurance, while 59% had public insurance. There were 27 patients with isolated meniscal tears, 59 with combined meniscal and ACL tears, and 33 with isolated ACL tears. The mean time from injury to presentation was 56 days (range, 0-457 days) in patients with private insurance and 136 days (range, 0-1120 days) in patients with public insurance ( P = .02). Surgery occurred, on average, 35 days after the initial office visit in both groups. The mean preoperative IKDC score was 53 in both groups. Patients with meniscal tears with public insurance were more likely to require meniscal debridement than patients with private insurance (risk ratio [RR], 2.3; 95% CI, 1.7-3.1; P = .02). Patients with public insurance were more likely to have chondral injuries of grade 2 or higher (RR, 4.4; 95% CI, 3.9-5.0; P = .02). In adolescent patients with ACL or meniscal tears, patients with public insurance had a more delayed presentation than those with private insurance. They also tended to have more moderate-to-severe chondral injuries and meniscal tears, if present, that required debridement rather than repair. More rapid access to care might improve the prognosis of young patients with ACL and meniscal injuries with public insurance.

Short term results of anterior cruciate ligament augmentation in professional and amateur athletes.

PubMed

Yazdi, Hamidreza; Torkaman, Ali; Ghahramani, Morteza; Moradi, Amin; Nazarian, Ara; Ghorbanhoseini, Mohammad

2017-06-01

Anterior cruciate ligament (ACL) reconstruction is a widely accepted procedure; however, controversies exist about ACL augmentation. The purpose of this study was to assess the clinical outcomes of ACL augmentation in professional and amateur athletes with isolated single bundle ACL tears. A consecutive series of professional and amateur athletes with partial ACL tears who underwent selective bundle reconstruction were analyzed. Stability was assessed with the Lachman test, anterior-drawer test, pivot-shift test and KT-1000 arthrometer. Functional assessment was performed using the subjective Lysholm questionnaire. Fifty-six patients were enrolled. The mean follow-up period was 19.3 months. All patients had posterolateral bundle (PLB) tears, and no anteromedial bundle (AMB) tears were found. The Lysholm score improved significantly from 78 (SD = 2.69) preoperatively to 96 (SD = 3.41) postoperatively (P value <0.0001). The pivot-shift test, Lachman test and anterior-drawer test results were negative in all cases postoperatively. Anterior tibial translation from neutral was 4.9 mm (SD = 2.7) preoperatively, and decreased significantly to 2.1 (SD = 0.6) postoperatively, measured with a KT-1000 arthrometer (P value <0.00001). In this study, we showed that ACL augmentation had good results in symptomatic professional and amateur athletes, and although further studies are needed to investigate long-term results, we recommend this surgery for all symptomatic athletic patients, especially those who would like to maintain an active lifestyle. Level of evidence IV.

The Location of Anterior Cruciate Ligament Tears: A Prevalence Study Using Magnetic Resonance Imaging

PubMed Central

van der List, Jelle P.; Mintz, Douglas N.; DiFelice, Gregory S.

2017-01-01

Background: Over the past decade, there has been a resurgence of interest in anterior cruciate ligament (ACL) preservation. Proximal and distal avulsion tears have been treated with arthroscopic primary repair, while augmented repair, remnant tensioning, primary repair with biological scaffold, and remnant preservation have been proposed for different types of midsubstance tears. Currently, the incidence of these different tear types is unknown. Purpose: To propose a magnetic resonance imaging (MRI) classification system for different tear types based on clinical relevance and to assess the distribution of these different ACL tear types. Study Design: Case series; Level of evidence, 4. Methods: A retrospective search in an institutional radiographic database was performed for patients who underwent knee MRI at our institution between June 2014 and June 2016. Patients younger than 18 years and those with reports of chronic tears, partial tears, multiligamentous injuries, were excluded. Tear types were graded as proximal avulsion (distal remnant length >90% of total ligament length, type I), proximal (75%-90%, type II), midsubstance (25%-75%, type III), distal (10%-25%, type IV), and distal avulsion (<10%, type V). An orthopaedic surgeon, a radiologist, and a research fellow graded the tear type on 30 MRIs to determine reliability, and the research fellow graded all MRIs. Inter- and intraobserver reliability were measured using kappa statistics. Results: A total of 353 patients (57% male; mean age, 37.1 years; range, 18.1-81.2 years) were included. Interobserver reliability was 0.670 (95% confidence interval, 0.505-0.836), and intraobserver reliability ranged from 0.741 to 0.934. Incidence of type I tears was 16%, type II tears 27%, type III tears 52%, type IV tears 1%, and type V tears 3% (2.5% with bony avulsion). Type I tears were more common in patients older than 35 years compared with those younger than 35 years (23% vs 8%; P < .001). Conclusion: This classification system was reliable in assessing tear location in acute ACL injuries. Type I tears were seen in 16%, type II in 27%, and type III in 52% of patients in our cohort. These data suggest that there may be greater potential application for ACL preservation techniques. PMID:28680889

Force measurements in the medial meniscus posterior horn attachment: effects of anterior cruciate ligament removal.

PubMed

Markolf, Keith L; Jackson, Steven R; McAllister, David R

2012-02-01

Tears of the medial meniscus posterior horn attachment (PHA) occur clinically, and an anterior cruciate ligament (ACL)-deficient knee may be more vulnerable to this injury. The PHA forces from applied knee loadings will increase after removal of the ACL. Controlled laboratory study. A cap of bone containing the medial meniscus PHA was attached to a load cell that measured PHA tensile force. Posterior horn attachment forces were recorded before and after ACL removal during anteroposterior (AP) laxity testing at ±200 N and during passive knee extension tests with 5 N·m tibial torque and varus-valgus moment. Selected tests were also performed with 500 N joint load. For AP tests with no joint load, ACL removal increased laxity between 0° and 90° and increased PHA force generated by applied anterior tibial force between 30° and 90°. For AP tests with an intact ACL, application of joint load approximately doubled PHA forces. Anteroposterior testing of ACL-deficient knees was not possible with joint load because of bone cap failures from high PHA forces. Removal of the ACL during knee extension tests under joint load significantly increased PHA forces between 20° and 90° of flexion. For unloaded tests with applied tibial torque and varus-valgus moment, ACL removal had no significant effect on PHA forces. Applied anterior tibial force and external tibial torque were loading modes that produced relatively high PHA forces, presumably by impingement of the medial femoral condyle against the medial meniscus posterior horn rim. Under joint load, an ACL-deficient knee was particularly susceptible to PHA injury from applied anterior tibial force. Because tensile forces developed in the PHA are also borne by meniscus tissue near the attachment site, loading mechanisms that produce high PHA forces could also produce complete or partial radial tears near the posterior horn, a relatively common clinical observation.

Posteromedial meniscal tears may be missed during anterior cruciate ligament reconstruction.

PubMed

Peltier, Adrien; Lording, Timothy D; Lustig, Sébastien; Servien, Elvire; Maubisson, Laurent; Neyret, Philippe

2015-04-01

This study aimed to assess the benefit of using an arthroscopic intercondylar view and a posterior medial viewing portal during anterior cruciate ligament (ACL) reconstruction in the diagnosis of posterior horn of the medial meniscus (PHMM) tears. A secondary objective was to determine clinical and radiological risk factors for the PHMM. Forty-one patients undergoing isolated ACL reconstruction were prospectively evaluated. At ACL reconstruction, the PHMM was assessed using a standard 30° arthroscope in 3 sequential stages: a "classic" anterolateral portal view, an intercondylar view, and a view through a posteromedial portal. Thirty-nine patients were included (12 female patients and 27 male patients). A posteromedial tear of the medial meniscus was found in 17 patients using the anterolateral portal view. The intercondylar view identified 4 new additional lesions and extensions of 3 previously identified lesions. The posteromedial portal view identified 6 new lesions and 5 extensions of known lesions compared with the anterolateral portal view. Two lesions seen through the posteromedial portal were not identified by either the anterolateral portal view or the intercondylar view. Tears of the PHMM may be underdiagnosed by intraoperative assessment using only an anterolateral portal view during ACL reconstruction. The intercondylar view combined with a posteromedial portal aids in the diagnosis of PHMM tears and should be considered in routine ACL reconstruction to assess meniscal status, particularly when the interval from injury to surgery is prolonged. Level IV, therapeutic case series. Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Return to sport: Does excellent 6-month strength and function following ACL reconstruction predict midterm outcomes?

PubMed

Sousa, Paul L; Krych, Aaron J; Cates, Robert A; Levy, Bruce A; Stuart, Michael J; Dahm, Diane L

2017-05-01

The purpose of this study was to determine whether patients with excellent 6-month functional testing after ACL reconstruction had (1) higher risk of subsequent ACL tears, (2) superior knee function, and (3) increased activity levels compared to those with delayed clearance for return to sports at midterm follow-up. A total of 223 patients underwent primary ACL reconstruction by a single surgeon and had functional and isokinetic testing performed 6 months post-operatively between 1998 and 2005. Of the 223 patients, 52 (23 %) made the excellent group and were allowed return to sport at 6 months, and the remaining 171 (77 %) constituted the delayed group. Rate of ACL graft tear and native contralateral ACL tear was compared between groups. In addition, IKDC and Tegner scores were compared at a mean 4-year follow-up. The graft rupture rate was similar in the excellent group (3.8 %, n = 2) compared to the delayed group (4.7 %, n = 8; p = 0.30). However, there was a higher rate of contralateral ACL tear in the excellent group (15.4 %, n = 8 vs. 5.3 %, n = 9; p = 0.003). The excellent 6-month group had superior IKDC scores (94.3 ± 6.4 vs. 90.9 ± 9.7; p = 0.04) and Tegner scores (6.6 ± 1.8 vs. 5.7 ± 1.6; p = 0.01). Patients with an excellent performance on their isokinetic strength and functional testing at 6 months after ACL reconstruction have superior knee function and higher activity levels at midterm follow-up. However, these patients appear to be at greater risk of contralateral ACL injury, which may be related to their increased activity level. When isokinetic and functional testing is used for return-to-sport decisions, physicians should caution patients about the risk of contralateral ACL injury for high performing patients. Retrospective Review with Control, Level III.

Comparison of Medial and Lateral Meniscus Root Tears

PubMed Central

Koo, Ji Hyun; Choi, Sang-Hee; Lee, Seung Ah; Wang, Joon Ho

2015-01-01

The meniscus root plays an essential role in maintaining the circumferential hoop tension and preventing meniscal displacement. Studies on meniscus root tears have investigated the relationship of osteoarthritis and an anterior cruciate ligament tear. However, few studies have directly compared the medial and lateral root tears. To assess the prevalence of meniscal extrusion and its relationship with clinical features in medial and lateral meniscus root tears, we performed a retrospective review of the magnetic resonance imaging (MRI) results of 42 knee patients who had meniscus posterior horn root tears and who had undergone arthroscopic operations. The presence of meniscal extrusion was evaluated and the exact extent was measured from the tibial margin. The results were correlated with arthroscopic findings. Clinical features including patients’ ages, joint abnormalities, and previous trauma histories were evaluated. Twenty-two patients had medial meniscus root tears (MMRTs) and twenty patients had lateral meniscus root tears (LMRTs). Meniscal extrusion was present in 18 MMRT patients and one LMRT patient. The mean extent of extrusion was 4.2mm (range, 0.6 to 7.8) in the MMRT group and 0.9mm (range, -1.9 to 3.4) in the LMRT group. Five patients with MMRT had a history of trauma, while 19 patients with LMRT had a history of trauma. Three patients with MMRT had anterior cruciate ligament (ACL) tears, while 19 patients with LMRT had ACL tears. The mean age of the patients was 52 years (range: 29–71 years) and 30 years (range: 14–62 years) in the MMRT and LMRT group, respectively. There was a significant correlation between a MMRT and meniscal extrusion (p<0.0001), and between an ACL tear and LMRT (p<0.0001). A history of trauma was significantly common in LMRT (p<0.0001). LMRT patients were significantly younger than MMRT patients (p<0.0001). Kellgren-Lawrence (K-L) grade differed significantly between MMRT and LMRT group (p<0.0001). Meniscal extrusion is common in patients with MMRTs. However, it is rare in patients with LMRTs, which are more commonly associated with a history of trauma and ACL tears. PMID:26488288

Comparison of Medial and Lateral Meniscus Root Tears.

PubMed

Koo, Ji Hyun; Choi, Sang-Hee; Lee, Seung Ah; Wang, Joon Ho

2015-01-01

The meniscus root plays an essential role in maintaining the circumferential hoop tension and preventing meniscal displacement. Studies on meniscus root tears have investigated the relationship of osteoarthritis and an anterior cruciate ligament tear. However, few studies have directly compared the medial and lateral root tears. To assess the prevalence of meniscal extrusion and its relationship with clinical features in medial and lateral meniscus root tears, we performed a retrospective review of the magnetic resonance imaging (MRI) results of 42 knee patients who had meniscus posterior horn root tears and who had undergone arthroscopic operations. The presence of meniscal extrusion was evaluated and the exact extent was measured from the tibial margin. The results were correlated with arthroscopic findings. Clinical features including patients' ages, joint abnormalities, and previous trauma histories were evaluated. Twenty-two patients had medial meniscus root tears (MMRTs) and twenty patients had lateral meniscus root tears (LMRTs). Meniscal extrusion was present in 18 MMRT patients and one LMRT patient. The mean extent of extrusion was 4.2mm (range, 0.6 to 7.8) in the MMRT group and 0.9mm (range, -1.9 to 3.4) in the LMRT group. Five patients with MMRT had a history of trauma, while 19 patients with LMRT had a history of trauma. Three patients with MMRT had anterior cruciate ligament (ACL) tears, while 19 patients with LMRT had ACL tears. The mean age of the patients was 52 years (range: 29-71 years) and 30 years (range: 14-62 years) in the MMRT and LMRT group, respectively. There was a significant correlation between a MMRT and meniscal extrusion (p<0.0001), and between an ACL tear and LMRT (p<0.0001). A history of trauma was significantly common in LMRT (p<0.0001). LMRT patients were significantly younger than MMRT patients (p<0.0001). Kellgren-Lawrence (K-L) grade differed significantly between MMRT and LMRT group (p<0.0001). Meniscal extrusion is common in patients with MMRTs. However, it is rare in patients with LMRTs, which are more commonly associated with a history of trauma and ACL tears.

Surgical retrieval, isolation and in vitro expansion of human anterior cruciate ligament-derived cells for tissue engineering applications.

PubMed

Gupta, Ashim; Sharif, Kevin; Walters, Megan; Woods, Mia D; Potty, Anish; Main, Benjamin J; El-Amin, Saadiq F

2014-04-30

Injury to the ACL is a commonly encountered problem in active individuals. Even partial tears of this intra-articular knee ligament lead to biomechanical deficiencies that impair function and stability. Current options for the treatment of partial ACL tears range from nonoperative, conservative management to multiple surgical options, such as: thermal modification, single-bundle repair, complete reconstruction, and reconstruction of the damaged portion of the native ligament. Few studies, if any, have demonstrated any single method for management to be consistently superior, and in many cases patients continue to demonstrate persistent instability and other comorbidities. The goal of this study is to identify a potential cell source for utilization in the development of a tissue engineered patch that could be implemented in the repair of a partially torn ACL. A novel protocol was developed for the expansion of cells derived from patients undergoing ACL reconstruction. To isolate the cells, minced hACL tissue obtained during ACL reconstruction was digested in a Collagenase solution. Expansion was performed using DMEM/F12 medium supplemented with 10% fetal bovine serum (FBS) and 1% penicillin/streptomycin (P/S). The cells were then stored at -80 ºC or in liquid nitrogen in a freezing medium consisting of DMSO, FBS and the expansion medium. After thawing, the hACL derived cells were then seeded onto a tissue engineered scaffold, PLAGA (Poly lactic-co-glycolic acid) and control Tissue culture polystyrene (TCPS). After 7 days, SEM was performed to compare cellular adhesion to the PLAGA versus the control TCPS. Cellular morphology was evaluated using immunofluorescence staining. SEM (Scanning Electron Microscope) micrographs demonstrated that cells grew and adhered on both PLAGA and TCPS surfaces and were confluent over the entire surfaces by day 7. Immunofluorescence staining showed normal, non-stressed morphological patterns on both surfaces. This technique is promising for applications in ACL regeneration and reconstruction.

Surgical Retrieval, Isolation and In vitro Expansion of Human Anterior Cruciate Ligament-derived Cells for Tissue Engineering Applications

PubMed Central

Gupta, Ashim; Sharif, Kevin; Walters, Megan; Woods, Mia D.; Potty, Anish; Main, Benjamin J.; El-Amin, Saadiq F.

2014-01-01

Injury to the ACL is a commonly encountered problem in active individuals. Even partial tears of this intra-articular knee ligament lead to biomechanical deficiencies that impair function and stability. Current options for the treatment of partial ACL tears range from nonoperative, conservative management to multiple surgical options, such as: thermal modification, single-bundle repair, complete reconstruction, and reconstruction of the damaged portion of the native ligament. Few studies, if any, have demonstrated any single method for management to be consistently superior, and in many cases patients continue to demonstrate persistent instability and other comorbidities. The goal of this study is to identify a potential cell source for utilization in the development of a tissue engineered patch that could be implemented in the repair of a partially torn ACL. A novel protocol was developed for the expansion of cells derived from patients undergoing ACL reconstruction. To isolate the cells, minced hACL tissue obtained during ACL reconstruction was digested in a Collagenase solution. Expansion was performed using DMEM/F12 medium supplemented with 10% fetal bovine serum (FBS) and 1% penicillin/streptomycin (P/S). The cells were then stored at -80 ºC or in liquid nitrogen in a freezing medium consisting of DMSO, FBS and the expansion medium. After thawing, the hACL derived cells were then seeded onto a tissue engineered scaffold, PLAGA (Poly lactic-co-glycolic acid) and control Tissue culture polystyrene (TCPS). After 7 days, SEM was performed to compare cellular adhesion to the PLAGA versus the control TCPS. Cellular morphology was evaluated using immunofluorescence staining. SEM (Scanning Electron Microscope) micrographs demonstrated that cells grew and adhered on both PLAGA and TCPS surfaces and were confluent over the entire surfaces by day 7. Immunofluorescence staining showed normal, non-stressed morphological patterns on both surfaces. This technique is promising for applications in ACL regeneration and reconstruction. PMID:24836540

Sex-Specific Predictors of Intra-articular Injuries Observed During Anterior Cruciate Ligament Reconstruction.

PubMed

Kluczynski, Melissa A; Marzo, John M; Rauh, Michael A; Bernas, Geoffrey A; Bisson, Leslie J

2015-02-01

Male patients tend to have more meniscal and chondral injuries at the time of anterior cruciate ligament (ACL) reconstruction than females. No studies have examined sex-specific predictors of meniscal and chondral lesions in ACL-injured patients. To identify sex-specific predictors of meniscal and chondral lesions, as well as meniscal tear management, in patients undergoing ACL reconstruction. Cohort study; Level of evidence, 3. Data were collected prospectively from 689 patients (56.2% males) undergoing ACL reconstruction between 2005 and 2014. Predictors of meniscal tears, meniscal tear management, and chondral injuries were determined using multivariate logistic regression models stratified by sex. Predictors were age, body mass index (BMI; 25-29.99 and ≥30 vs ≤24.99 kg/m(2)), mechanism (contact vs noncontact) and type (high-impact sports [basketball, football, soccer, and skiing] and other sports vs not sports-related) of injury, interval from injury to surgery (≤6 vs >6 weeks), and instability episodes (vs none). Odds ratios and 95% CIs were reported. Males had more lateral (46% vs 27.8%; P < .0001) and medial (40.2% vs 31.5%; P = .01) meniscal tears, as well as more lateral (72.1% vs 27.9%; P < .0001) and medial (61.4% vs 38.6%; P = .01) meniscectomies than females. For males, age predicted chondral injuries and medial meniscectomy; BMI ≥30 kg/m(2) predicted medial meniscal tears; high-impact and other sports predicted medial meniscal tears, medial meniscectomies, and medial meniscal repairs; injuries ≤6 weeks from surgery predicted lateral meniscal repairs; and instability episodes predicted medial meniscal tears, medial tears left in situ, medial meniscectomies, and medial meniscal repairs. For females, age predicted chondral injuries, BMI ≥30 kg/m(2) predicted lateral meniscectomies and repairs, and instability episodes predicted medial meniscectomies. Sex differences were observed. For males, predictors included age, BMI, sports-related injuries, injuries ≤6 weeks from surgery, and instability episodes. For females, predictors included age, BMI, and instability episodes.

Anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow nucleated cells: a case series

PubMed Central

Centeno, Christopher J; Pitts, John; Al-Sayegh, Hasan; Freeman, Michael D

2015-01-01

Introduction This was a prospective case series designed to investigate treatment for anterior cruciate ligament (ACL) tears using an injection of autologous bone marrow concentrate. Methods Consecutive adult patients presenting to a private outpatient interventional musculoskeletal and pain practice with knee pain, ACL laxity on exam, and magnetic resonance imaging (MRI) evidence of a grade 1, 2, or 3 ACL tears with less than 1 cm retraction were eligible for this study. Eligible patients were treated with an intraligamentous injection of autologous bone marrow concentrate, using fluoroscopic guidance. Pre- and postprocedural sagittal MRI images of the ACLs were analyzed using ImageJ software to objectively quantify changes between pre- and posttreatment scans. Five different types of measurement of ACL pixel intensity were examined as a proxy for ligament integrity. In addition pain visual analog scale (VAS) and Lower Extremity Functional Scale (LEFS) values were recorded at baseline and at 1 month, 3 months, 6 months, and annually postinjection. Objective outcomes measured were pre- to post-MRI measurement changes, as analyzed by the ImageJ software. Subjective outcomes measured were changes in the VAS and LEFS, and a self-rated percentage improvement. Results Seven of ten patients showed improvement in at least four of five objective measures of ACL integrity in their postprocedure MRIs. In the entire study group, the mean gray value, median, raw integrated density, and modal gray value all decreased toward low-signal ACLs (P=0.01, P=0.02, P=0.002, and P=0.08), indications of improved ligament integrity. Seven of ten patients responded to the self-rated metrics follow up. The mean VAS change was a decrease of 1.7 (P=0.25), the mean LEFS change was an increase of 23.3 (P=0.03), and mean reported improvement was 86.7%. Conclusion Based on this small case series, autologous bone marrow concentrate shows promise in the treatment of grade 1, 2, and possibly grade 3 ACL tears without retraction. Further investigation using a controlled study design is warranted. PMID:26261424

The Degree of Knee Extension Does Not Affect Postoperative Stability or Subsequent Graft Tear Rate After Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft.

PubMed

Benner, Rodney W; Shelbourne, K Donald; Gray, Tinker

2016-04-01

There is concern that high degrees of hyperextension may lead to an increase in graft laxity or graft failure after anterior cruciate ligament (ACL) reconstruction. Patients with a high degree of hyperextension will have a higher rate of graft tear/failure and lower subjective scores after surgery compared with patients with less knee extension. Cohort study, Level of evidence, 2. Of 2329 patients who underwent ACL reconstruction with patellar tendon autograft between 1998 and 2008, there were 625 patients who met the inclusion criteria of having primary ACL surgery, no bilateral ACL injuries, no existing osteoarthritis, and having either ≥6° of knee hyperextension before and after surgery (group A: n = 318; mean hyperextension, 8° ± 2° [range, 6°-15°]) or ≤3° of knee hyperextension before and after surgery (group B: n = 307; mean hyperextension, 0° ± 3° [range, 3° hyperextension to -4° short of 0° neutral]). KT-1000 arthrometer manual maximum difference between knees, range of motion measurements, and subjective follow-up with International Knee Documentation Committee (IKDC) and Cincinnati Knee Ratings Scale (CKRS) surveys were used to evaluate results. Subsequent graft tear related to specific injury within 5 years of surgery was recorded. Graft failure was defined as a KT-1000 manual maximum difference of >5 mm. Follow-up was obtained from 278 (87%) in group A and 275 (90%) in group B at a mean of 4.1 ± 1.1 years after surgery. The KT-1000 arthrometer manual maximum difference between knees was 2.0 ± 1.4 in group A and 2.1 ± 1.6 in group B (P = .701). Subsequent ACL graft tear/failure occurred in 22 patients (6.9%) in group A and 30 patients (9.8%) in group B (P = .246). Further subanalysis showed that the graft tear/failure rate was 6 of 81 (7.4%) for patients with ≥10° of hyperextension versus 16 of 237 (6.8%) for patients with 6° to 9° of hyperextension. There was no difference in IKDC or CKRS scores between groups after surgery (P = .933 and .155, respectively). Obtaining full hyperextension that is anatomically normal for most patients does not affect objective stability, ACL graft tear/failure rates, or subjective scores after ACL reconstruction with patellar tendon autograft. © 2016 The Author(s).

Lateral femoral notch depth is not associated with increased rotatory instability in ACL-injured knees: a quantitative pivot shift analysis.

PubMed

Kanakamedala, Ajay C; Burnham, Jeremy M; Pfeiffer, Thomas R; Herbst, Elmar; Kowalczuk, Marcin; Popchak, Adam; Irrgang, James; Fu, Freddie H; Musahl, Volker

2018-05-01

A deep lateral femoral notch (LFN) on lateral radiographs is indicative of ACL injury. Prior studies have suggested that a deep LFN may also be a sign of persistent rotatory instability and a concomitant lateral meniscus tear. Therefore, the purpose of this study was to evaluate the relationship between LFN depth and both quantitative measures of rotatory knee instability and the incidence of lateral meniscus tears. It was hypothesized that greater LFN depth would be correlated with increased rotatory instability, quantified by lateral compartment translation and tibial acceleration during a quantitative pivot shift test, and incidence of lateral meniscus tears. ACL-injured patients enrolled in a prospective ACL registry from 2014 to 2016 were analyzed. To limit confounders, patients were only included if they had primary ACL tears, no concurrent ligamentous or bony injuries requiring operative treatment, and no previous knee injuries or surgeries to either knee. Eighty-four patients were included in the final analysis. A standardized quantitative pivot shift test was performed pre-operatively under anesthesia in both knees, and rotatory instability, specifically lateral compartment translation and tibial acceleration, was quantified using tablet image analysis software and accelerometer sensors. Standard lateral radiographs and sagittal magnetic resonance images (MRI) of the injured knee were evaluated for LFN depth. There were no significant correlations between LFN depth on either imaging modality and ipsilateral lateral compartment translation or tibial acceleration during a quantitative pivot shift test or side-to-side differences in these measurements. Patients with lateral meniscus tears were found to have significantly greater LFN depths than those without on conventional radiograph and MRI (1.0 vs. 0.6 mm, p < 0.05; 1.2 vs. 0.8 mm, p < 0.05, respectively). There was no correlation between lateral femoral notch depth on conventional radiographs or MRI and quantitative measures of rotatory instability. Concomitant lateral meniscus injury was associated with significantly greater LFN depth. Based on these findings, LFN depth should not be used as an indicator of excessive rotatory instability, but may be an indicator of lateral meniscus injury in ACL-injured patients. Prognostic level IV.

Three distinct mechanisms predominate in non-contact anterior cruciate ligament injuries in male professional football players: a systematic video analysis of 39 cases

PubMed Central

Waldén, Markus; Krosshaug, Tron; Bjørneboe, John; Andersen, Thor Einar; Faul, Oliver

2015-01-01

Background Current knowledge on anterior cruciate ligament (ACL) injury mechanisms in male football players is limited. Aim To describe ACL injury mechanisms in male professional football players using systematic video analysis. Methods We assessed videos from 39 complete ACL tears recorded via prospective professional football injury surveillance between 2001 and 2011. Five analysts independently reviewed all videos to estimate the time of initial foot contact with the ground and the time of ACL tear. We then analysed all videos according to a structured format describing the injury circumstances and lower limb joint biomechanics. Results Twenty-five injuries were non-contact, eight indirect contact and six direct contact injuries. We identified three main categories of non-contact and indirect contact injury situations: (1) pressing (n=11), (2) re-gaining balance after kicking (n=5) and (3) landing after heading (n=5). The fourth main injury situation was direct contact with the injured leg or knee (n=6). Knee valgus was frequently seen in the main categories of non-contact and indirect contact playing situations (n=11), but a dynamic valgus collapse was infrequent (n=3). This was in contrast to the tackling-induced direct contact situations where a knee valgus collapse occurred in all cases (n=3). Conclusions Eighty-five per cent of the ACL injuries in male professional football players resulted from non-contact or indirect contact mechanisms. The most common playing situation leading to injury was pressing followed by kicking and heading. Knee valgus was frequently seen regardless of the playing situation, but a dynamic valgus collapse was rare. PMID:25907183

Sex-Specific Predictors of Intra-articular Injuries Observed During Anterior Cruciate Ligament Reconstruction

PubMed Central

Kluczynski, Melissa A.; Marzo, John M.; Rauh, Michael A.; Bernas, Geoffrey A.; Bisson, Leslie J.

2015-01-01

Background: Male patients tend to have more meniscal and chondral injuries at the time of anterior cruciate ligament (ACL) reconstruction than females. No studies have examined sex-specific predictors of meniscal and chondral lesions in ACL-injured patients. Purpose: To identify sex-specific predictors of meniscal and chondral lesions, as well as meniscal tear management, in patients undergoing ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected prospectively from 689 patients (56.2% males) undergoing ACL reconstruction between 2005 and 2014. Predictors of meniscal tears, meniscal tear management, and chondral injuries were determined using multivariate logistic regression models stratified by sex. Predictors were age, body mass index (BMI; 25-29.99 and ≥30 vs ≤24.99 kg/m2), mechanism (contact vs noncontact) and type (high-impact sports [basketball, football, soccer, and skiing] and other sports vs not sports-related) of injury, interval from injury to surgery (≤6 vs >6 weeks), and instability episodes (vs none). Odds ratios and 95% CIs were reported. Results: Males had more lateral (46% vs 27.8%; P < .0001) and medial (40.2% vs 31.5%; P = .01) meniscal tears, as well as more lateral (72.1% vs 27.9%; P < .0001) and medial (61.4% vs 38.6%; P = .01) meniscectomies than females. For males, age predicted chondral injuries and medial meniscectomy; BMI ≥30 kg/m2 predicted medial meniscal tears; high-impact and other sports predicted medial meniscal tears, medial meniscectomies, and medial meniscal repairs; injuries ≤6 weeks from surgery predicted lateral meniscal repairs; and instability episodes predicted medial meniscal tears, medial tears left in situ, medial meniscectomies, and medial meniscal repairs. For females, age predicted chondral injuries, BMI ≥30 kg/m2 predicted lateral meniscectomies and repairs, and instability episodes predicted medial meniscectomies. Conclusion: Sex differences were observed. For males, predictors included age, BMI, sports-related injuries, injuries ≤6 weeks from surgery, and instability episodes. For females, predictors included age, BMI, and instability episodes. PMID:26535384

An Athlete's Nightmare: Tearing the ACL

MedlinePlus

... rather than "muscle dominant." Golf great Tiger Woods will miss the remainder of the 2008 season due to an ACL injury and a double stress fracture in his left leg. Photo: Ross Kinnaird/Getty Images Dr. Boden believes that one ...

[Comparison of the Arthroscopic Finding in the Knee Joint and the MRI - Retrospective Study].

PubMed

Šimeček, K; Látal, P; Duda, J; Šimeček, M

2017-01-01

PURPOSE OF THE STUDY Our retrospective study presents the comparison of the preoperative magnetic resonance imaging of the knee joint - MRI - and the arthroscopic finding - ASC. Its aim is to find out how a positive or a negative finding of MRI corresponds with the operative finding and how much the experience of radiologist contributes to the conformity. MATERIAL AND METHODS The MRI findings of knee joints treated surgically at two departments in 2013 and 2014 were assessed. The MRI was performed in a total of 470 patients who subsequently underwent an arthroscopic surgery. A conformity or a non-conformity in anterior, posterior horn and complete rupture of both menisci and in partial or complete tear of anterior cruciate ligament - LCA was searched for. The sensitivity, specificity and accuracy of MRI were established. The difference between experienced and less experienced radiologists was evaluated. The analysis of the radiology report, surgical protocol of ASC and medical history in the documentation was performed. The cartilage was not subject to evaluation. The finding of Grade 1 meniscus tear on MRI was evaluated as negative. Grade 2 and Grade 3 were evaluated as positive. RESULTS Comparison of the preoperative MRI and the arthroscopic finding 1. The group with MRI reported 3 % of diagnostic arthroscopies. The control group without MRI (551 ASC) reported 15 % diagnostic arthroscopies. 2. Low sensitivity of MRI (0.67) in negative findings of ASC. It concerned 7 cases in which a pathological finding was identified on a MRI scan, but not by ASC. In two cases the repeated arthroscopy confirmed that a pathology inside the knee joint was overlooked by the arthroscopist. In the remaining five cases, the clinical finding improved without a repeated surgery. 3. High sensitivity of MRI is shown in the most frequent finding - posterior horn of medial meniscus (0.94). 4. Lower sensitivity (0.76) in partial and (0.83) in complete ACL tear. It increases to 0.93 if partial and complete tear are put together. Both MRI and ASC detect the pathology of ligament, but do not agree in terms of terminology. 5. Lower sensitivity (0.78) was seen in posterior horn of lateral meniscus, most likely due to its complicated anatomy. 6. Specificity of complete tear of medial meniscus tear is 0.99. Lower specificity in the posterior horn of medial meniscus (0.81) shows a higher number of positive MRI findings in negative ASC findings. Some posterior horn tear can be overlooked by an inexperienced surgeon. The MRD findings need to be studied. 7. High specificity (0.99) was described in negative findings. In three cases only, the surgeon discovered a pathological finding, not revealed by MRI scan. It always concerned a tear within the posterior horn of the medial meniscus. 8. Specificity (0.88, 0.93 or 0.86, respectively) in partial, complete and all ACL damages in total. 9. We concluded that contributing to the degree of agreement between MRI and ASC is also the experience of a radiologist. The most experienced radiologist evaluated 190 of 470 MRI scans, the remaining twelve radiologists assessed 280 scans. The posterior horn of the medial meniscus - sensitivity or specificity evaluated by an experienced radiologist (0.98 and 0.88, respectively) and inexperienced radiologist (0.91 and 0.79). The specificity and sensitivity in complete ACL tears - by experienced radiologist (0.91 and 0.94, respectively) and inexperienced radiologist (0.81 and 0.90, respectively). The test accuracy of the experienced radiologist in evaluating the most frequent injuries of soft knee structures was by 9-10 % higher than of the inexperienced radiologist. DISCUSSION The results obtained by the other authors show that the sensitivity and specificity range from 0.6 to 0.9. They agree that the MRI is unsuitable for assessing the cartilage. We confirm that the results are worse when evaluating the posterior horn of the lateral meniscus. We have also proven that the radiologist s experience does play an important role. It can be the reason for a high degree of difference between the results of various authors. Some of them give preference to a clinical examination or a diagnostic arthroscopy instead of the MRI. At our department, MRI is indicated if we are convinced it can help with the indication or where it will suggest what to focus on during the surgery. CONCLUSIONS A preoperative MRI scan can prevent an unnecessary arthroscopy. It displays structures to the surgeon which shall be reviewed in detail during the surgery. We recommend paying attention to Grade 2 MRI findings, positive MRI findings on the posterior horn of medial meniscus and to MRI findings on partial ACL tears. Such menisci and ligaments shall be carefully reviewed. Clinical preoperative examination and cooperation between the surgeon, the "arthroscopist", and the radiologist is essential. The experience of the radiologist also plays a role when evaluating the MRI scan. We have introduced MRI ward rounds. Key words: MRI, knee joint, knee arthroscopy, sensitivity, specificity, accuracy.

Surgical Treatment of Combined Posterior Root Tears of the Lateral Meniscus and ACL Tears

PubMed Central

Pan, Fengyu; Hua, Shan; Ma, Zhuang

2015-01-01

Background The treatment of anterior cruciate ligament (ACL) rupture complicated with posterior lateral meniscus root (PLMR) tears remains controversial. The goal of this study was to evaluate clinical outcomes of PLMR tear refixation versus left untreated at the time of reconstruction. Material/Methods From August 2001 to January 2012, 31 patients who undergone repair of PLMR tears were evaluated and compared with a matched control group with untreated PLMR tears. Clinical evaluation consisted of the Lysholm scale, subjective International Knee Documentation Committee (IKDC) questionnaires, and radiographic evaluation with MRI. Results Regarding to the Lysholm score and the subjective questionnaire score, there were no statistical difference between the 2 groups. However, patients after operative treatment reach higher functional scores and lower rates of osteoarthritis (normal: group A, 80%, and group B, 48%, respectively) with statistical significance (P<0.05) compared to the matched control group. Conclusions Surgical and conservative treatment of the PLMR can both effectively improve knee function. However, a tendency towards higher functional scores and lower rates of osteoarthritis for patients with operative treatment was observed. PMID:25959903

Anterior Cruciate Ligament Injuries in the National Hockey League: Epidemiology and Performance Impact.

PubMed

Longstaffe, Robert; Leiter, Jeff; MacDonald, Peter

2018-03-27

To determine the incidence of anterior cruciate ligament (ACL) injuries in the National Hockey League (NHL) and to examine the effects of this injury on return-to-play status and performance. Case series; level of evidence, 4. This was a 2-phase study. Phase I used the NHL electronic injury surveillance system and Athlete Health Management System to collect data on ACL injuries and man games lost over 10 seasons (2006/2007-2015/2016). Data collected in phase I were received in deidentified form. Phase II examined the performance impact of an ACL injury. Players were identified through publically available sources, and performance-related statistics were analyzed. Data collected in phase II were not linked to data collected in phase I. A paired t test was used to determine any difference in the matching variables between controls and cases in the preinjury time period. A General linear model (mixed) was used to determine the performance impact. Phase I: 67 ACL injuries occurred over 10 seasons. The incidence for all players was 0.42/1000 player game hours (forward, 0.61; defenseman, 0.32, goalie, 0.08) and by game exposure was 0.2/1000 player game exposures (forward, 0.33; defenseman, 0.11; goalie, 0.07). Forwards had a greater incidence rate of ACL tears with both game hours and game exposures when compared with defensemen and goalies (P < 0.001, <0.001; P = 0.008, <0.001, respectively). Phase II: 70 ACL tears (60 players) were identified. Compared with controls, players who suffered an ACL tear demonstrated a decrease in goals/season (P < 0.04), goals/game (P < 0.015), points/season (0.007), and points/game (0.001). Number of games and seasons played after an ACL injury did not differ compared with controls (P = 0.068, 0.122, respectively). Anterior cruciate ligament injuries occur infrequently, as it relates to other hockey injuries. Despite a high return to play, the performance after an ACL injury demonstrated a decrease in points and goals per game and per season.

Trends in primary and revision anterior cruciate ligament reconstruction among National Basketball Association team physicians.

PubMed

Mall, Nathan A; Abrams, Geoffrey D; Azar, Frederick M; Traina, Steve M; Allen, Answorth A; Parker, Richard; Cole, Brian J

2014-06-01

Anterior cruciate ligament (ACL) tears are common in athletes. Techniques and methods of treatment for these injuries continue to vary among surgeons. Thirty National Basketball Association (NBA) team physicians were surveyed during the NBA Pre-Draft Combine. Survey questions involved current and previous practice methods of primary and revision ACL reconstruction, including technique, graft choice, rehabilitation, and treatment of combined ACL and medial collateral ligament injuries. Descriptive parametric statistics, Fisher exact test, and logistic regression were used, and significance was set at α = 0.05. All 30 team physicians completed the survey. Eighty-seven percent indicated they use autograft (81% bone-patellar tendon-bone) for primary ACL reconstruction in NBA athletes, and 43% indicated they use autograft for revision cases. Fourteen surgeons (47%) indicated they use an anteromedial portal (AMP) for femoral tunnel drilling, whereas 5 years earlier only 4 (13%) used this technique. There was a significant (P = .009) positive correlation between fewer years in practice and AMP use. NBA team physicians' use of an AMP for femoral tunnel drilling has increased over the past 5 years.

Artificial Ligaments: Promise or Panacea?

ERIC Educational Resources Information Center

Lubell, Adele

1987-01-01

The Food and Drug Administration has approved a prosthetic ligament for limited use in persons with damaged anterior cruciate ligaments (ACL). This article addresses ligament repair, ACL tears, current treatment, development of the Gore-Tex artificial ligament, other artificial ligaments in process, and arguments for and against their use.…

Reliability of magnetic resonance imaging in evaluating meniscal and cartilage injuries in anterior cruciate ligament-deficient knees.

PubMed

Wong, Kenneth Pak Leung; Han, Audrey XinYun; Wong, Jeannie Leh Ying; Lee, Dave Yee Han

2017-02-01

The accuracy of magnetic resonance (MR) imaging in assessing meniscal and cartilage injuries in anterior cruciate ligament (ACL)-deficient knees as compared to arthroscopy was evaluated in the present study. The results of all preoperative MR imaging performed within 3 months prior to the ACL reconstruction were compared against intraoperative arthroscopic findings. A total of 206 patients were identified. The location and type of meniscal injuries as well as the location and grade of the cartilage injuries were studied. The negative predictive value, positive predictive value, sensitivity, specificity and accuracy of MR imaging for these 206 cases were calculated and analysed. In patients with an ACL injury, the highest incidence of concomitant injury was that of medial meniscus tears, 124 (60.2 %), followed by lateral meniscus tears, 105 (51.0 %), and cartilage injuries, 66 (32.0 %). Twenty-three (11.2 %) patients sustained injuries to all of the previously named structures. MR imaging was most accurate in detecting medial meniscus tears (85.9 %). MR imaging for medial meniscus tears also had the highest sensitivity (88.0 %) and positive predictive value (88.7 %), while MR imaging for cartilage injuries had the largest specificity (84.1 %) and negative predictive value (87.1 %). It was least accurate in evaluating lateral meniscus tears (74.3 %). The diagnostic accuracy of medial meniscus imaging is significantly influenced by age and the presence of lateral meniscus tears, while the duration between MR imaging and surgery has greater impact on the likelihood of lateral meniscus and cartilage injuries actually being present during surgery. The majority of meniscus tears missed by MR imaging affected the posterior horn and were complex in nature. Cartilage injuries affecting the medial femoral condyle or medial patella facet were also often missed by MR imaging. MR imaging remains a reliable tool for assessing meniscus tears and cartilage defects preoperatively. It is most accurate when evaluating medial meniscus tears. However, MR imaging should be used with discretion especially if there is a high index of suspicion of lateral meniscus tears. IV.

UTE-T2* mapping detects sub-clinical meniscus injury after anterior cruciate ligament tear

PubMed Central

Williams, A.; Qian, Y.; Golla, S.; Chu, C.R.

2018-01-01

SUMMARY Objective Meniscus tear is a known risk factor for osteoarthritis (OA). Quantitative assessment of meniscus degeneration, prior to surface break-down, is important to identification of early disease potentially amenable to therapeutic interventions. This work examines the diagnostic potential of ultrashort echo time-enhanced T2* (UTE-T2*) mapping to detect human meniscus degeneration in vitro and in vivo in subjects at risk of developing OA. Design UTE-T2* maps of 16 human cadaver menisci were compared to histological evaluations of meniscal structural integrity and clinical magnetic resonance imaging (MRI) assessment by a musculoskeletal radiologist. In vivo UTE-T2* maps were compared in 10 asymptomatic subjects and 25 ACL-injured patients with and without concomitant meniscal tear. Results In vitro, UTE-T2* values tended to be lower in histologically and clinically normal meniscus tissue and higher in torn or degenerate tissue. UTE-T2* map heterogeneity reflected collagen disorganization. In vivo, asymptomatic meniscus UTE-T2* values were repeatable within 9% (root-mean-square average coefficient of variation). Posteromedial meniscus UTE-T2* values in ACL-injured subjects with clinically diagnosed medial meniscus tear (n = 10) were 87% higher than asymptomatics (n = 10, P < 0.001). Posteromedial menisci UTE-T2* values of ACL-injured subjects without concomitant medial meniscal tear (n = 15) were 33% higher than asymptomatics (P = 0.001). Posterolateral menisci UTE-T2* values also varied significantly with degree of joint pathology (P = 0.001). Conclusion Significant elevations of UTE-T2* values in the menisci of ACL-injured subjects without clinical evidence of subsurface meniscal abnormality suggest that UTE-T2* mapping is sensitive to subclinical meniscus degeneration. Further study is needed to determine whether elevated subsurface meniscus UTE-T2* values predict progression of meniscal degeneration and development of OA. PMID:22306000

Primary repair of the anterior cruciate ligament: A paradigm shift.

PubMed

van der List, Jelle P; DiFelice, Gregory S

2017-06-01

Over the last century, many surgical treatments have been developed in the orthopedic field, including treatments of anterior cruciate ligament (ACL) injuries. These treatments ideally evolve in a process of trial and error with prospective comparison of new treatments to the current treatment standard. However, these evolutions are sometimes not linear and periodically undergo paradigm shifts. In this article, we review the evolution of ACL treatment and explain how it underwent a paradigm shift. Open primary ACL repair was the most common treatment in the 1970s and 1980s, but because multiple studies noted deterioration of outcomes at mid-term follow-up, in addition to several randomized clinical trials (RCTs) that noted better outcomes following ACL reconstruction, the open primary repair technique was abandoned. At the end of the primary repair era, however, several studies showed that outcomes of open primary repair were good to excellent and did not deteriorate when this technique was selectively performed in patients with proximal ACL tears, whereas primary repair led to disappointing and unpredictable results in patients with mid-substance tears. Unfortunately, enrollment of patients in the aforementioned RCTs was already finished, ultimately leading to abandoning of open primary repair, despite the advantages of ligament preservation. In this review, we discuss (I) why the evolution of ACL treatment underwent a paradigm shift, (II) which factors may have played a role in this and (III) what the future role of arthroscopic primary ACL repair is in the evolution of ACL treatments. Copyright © 2016. Published by Elsevier Ltd.

Simulation of Anterior Cruciate Ligament Deficiency in a Musculoskeletal Model with Anatomical Knees

PubMed Central

Guess, Trent M; Stylianou, Antonis

2012-01-01

Abnormal knee kinematics and meniscus injury resulting from anterior cruciate ligament (ACL) deficiency are often implicated in joint degeneration even though changes in tibio-femoral contact location after injury are small, typically only a few millimeters. Ligament reconstruction surgery does not significantly reduce the incidence of early onset osteoarthritis. Increased knowledge of knee contact mechanics would increase our understanding of the effects of ACL injury and help guide ACL reconstruction methods. Presented here is a cadaver specific computational knee model combined with a body-level musculoskeletal model from a subject of similar height and weight as the cadaver donor. The knee model was developed in the multi-body framework and includes representation of the menisci. Experimental body-level measurements provided input to the musculoskeletal model. The location of tibio-menisco-femoral contact as well as contact pressures were compared for models with an intact ACL, partial ACL transection (posterolateral bundle transection), and full ACL transection during a muscle driven forward dynamics simulation of a dual limb squat. During the squat, small changes in femur motion relative to the tibia for both partial and full ACL transection push the lateral meniscus in the posterior direction at extension. The central-anterior region of the lateral meniscus then becomes “wedged” between the tibia and femur during knee flexion. This “wedging” effect does not occur for the intact knee. Peak contact pressure and contact locations are similar for the partial tear and complete ACL transection during the deep flexion portion of the squat, particularly on the lateral side. The tibio-femoral contact location on the tibia plateau shifts slightly to the posterior and lateral direction with ACL transection. PMID:22470411

Acute injury of anterior cruciate ligament during karate training.

PubMed

Huang, Kuo-Chin; Hsu, Wei-Hsiu; Wang, Ting-Chung

2007-06-01

A 38-year-old black-belt karate practitioner presented with acute disabling injury of his knee after swift-withdrawal of a reverse-roundhouse-kick. Examination confirmed the diagnosis of grade III ACL tear. Although there are reports documenting injury rate in modern karate, no previous cases of karate-related ACL injuries have been reported. The trauma mechanism is different than ACL injuries during other non-contact and contact sports. The current case report indicates that ACL injury can occur without any contact of the lower limb as a result of dynamic muscular forces during karate training.

Visibility of Anterolateral Ligament Tears in Anterior Cruciate Ligament-Deficient Knees With Standard 1.5-Tesla Magnetic Resonance Imaging.

PubMed

Hartigan, David E; Carroll, Kevin W; Kosarek, Frank J; Piasecki, Dana P; Fleischli, James F; D'Alessandro, Donald F

2016-10-01

To attempt to visualize the ligament with standard 1.5-tesla magnetic resonance imaging (MRI) in the acute anterior cruciate ligament (ACL)-torn knee, and if it is visible, attempt to characterize it as torn or intact at its femoral, meniscal, and tibial attachment sites. This was a retrospective MRI study based on arthroscopic findings of a known ACL tear in 72 patients between the years 2006 and 2010. Patients all had hamstring ACL reconstructions, no concomitant lateral collateral ligament, or posterolateral corner injury based on imaging and physical examination, and had a preoperative 1.5-tesla MRI scan with standard sequences performed within 3 weeks of the injury. Two fellowship-trained musculoskeletal radiologists retrospectively reviewed the preoperative MRI for visualization of the anterolateral ligament (ALL) for concomitant tears. Inter- and intraobserver reliability was calculated. Learning effect was analyzed to determine if radiologists' agreement improved as reads progressed. Both radiologists were able to visualize the ALL in 100% of the scans. Overall, ALL tears were noted in 26% by radiologist 1 and in 62% by radiologist 2. The agreement between the ligament being torn or not had a kappa of 0.54 between radiologists. The agreements in torn or not torn between radiologists in the femoral, meniscal, and tibial sites were 0.14, 0.15, and 0.31. The intraobserver reliability by radiologist 1 for femoral, meniscal, and tibial tears was 0.04, 0.57, and 0.54 respectively. For radiologist 2, they were 0.75, 0.61, and 0.55. There was no learning effect noted. ALL tears are currently unable to be reliably identified as torn or intact on standard 1.5-tesla MRI sequences. Proper imaging sequences are of crucial importance to reliably follow these tears to determine their clinical significance. Level IV, therapeutic case series study. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 1: Secondary Role of the Anterolateral Ligament in the Setting of an Anterior Cruciate Ligament Injury.

PubMed

Rasmussen, Matthew T; Nitri, Marco; Williams, Brady T; Moulton, Samuel G; Cruz, Raphael Serra; Dornan, Grant J; Goldsmith, Mary T; LaPrade, Robert F

2016-03-01

Recent investigations have described the structural and functional behavior of the anterolateral ligament (ALL) of the knee through pull-apart and isolated sectioning studies. However, the secondary stabilizing role of the ALL in the setting of a complete anterior cruciate ligament (ACL) tear has not been fully defined for common simulated clinical examinations, such as the pivot-shift, anterior drawer, and internal rotation tests. Combined sectioning of the ALL and ACL would lead to increased internal rotation and increased axial plane translation during a pivot-shift test when compared with isolated sectioning of the ACL. Controlled laboratory study. Ten fresh-frozen human cadaveric knees were subjected to a simulated pivot-shift test with coupled 10-N·m valgus and 5-N·m internal rotation torques from 0° to 60° of knee flexion and a 5-N·m internal rotation torque and an 88-N anterior tibial load, both from 0° to 120° of knee flexion via a 6 degrees of freedom robotic system. Kinematic changes were measured and compared with the intact state for isolated sectioning of the ACL and combined sectioning of the ACL and ALL. Combined sectioning of the ACL and ALL resulted in a significant increase in axial plane tibial translation during a simulated pivot shift at 0°, 15°, 30°, and 60° of knee flexion and a significant increase in internal rotation at 0°, 15°, 30°, 45°, 60°, 75°, 90°, 105°, and 120° when compared with the intact and ACL-deficient states. Based on the model results, ALL sectioning resulted in an additional 2.1 mm (95% CI, 1.4-2.9 mm; P < .001) of axial plane translation during the pivot shift when compared with ACL-only sectioning, when pooling evidence over all flexion angles. Likewise, when subjected to IR torque, the ACL+ALL-deficient state resulted in an additional 3.2° of internal rotation (95% CI, 2.4°-4.1°; P < .001) versus the intact state, and the additional sectioning of the ALL increased internal rotation by 2.7° (95% CI, 1.8°-3.6°; P < .001) versus the ACL-deficient state. The results of this study confirm the ALL as an important lateral knee structure that provides rotatory stability to the knee. Specifically, the ALL was a significant secondary stabilizer throughout flexion during an applied internal rotation torque and simulated pivot-shift test in the context of an ACL-deficient knee. Residual internal rotation and a positive pivot shift after ACL reconstruction may be attributed to ALL injury. For these patients, surgical treatment of an ALL tear may be considered. © 2015 The Author(s).

The knee meniscus: management of traumatic tears and degenerative lesions

PubMed Central

Beaufils, Philippe; Becker, Roland; Kopf, Sebastian; Matthieu, Ollivier; Pujol, Nicolas

2017-01-01

Meniscectomy is one of the most popular orthopaedic procedures, but long-term results are not entirely satisfactory and the concept of meniscal preservation has therefore progressed over the years. However, the meniscectomy rate remains too high even though robust scientific publications indicate the value of meniscal repair or non-removal in traumatic tears and non-operative treatment rather than meniscectomy in degenerative meniscal lesions In traumatic tears, the first-line choice is repair or non-removal. Longitudinal vertical tears are a proper indication for repair, especially in the red-white or red-red zones. Success rate is high and cartilage preservation has been proven. Non-removal can be discussed for stable asymptomatic lateral meniscal tears in conjunction with anterior cruciate ligament (ACL) reconstruction. Extended indications are now recommended for some specific conditions: horizontal cleavage tears in young athletes, hidden posterior capsulo-meniscal tears in ACL injuries, radial tears and root tears. Degenerative meniscal lesions are very common findings which can be considered as an early stage of osteoarthritis in middle-aged patients. Recent randomised studies found that arthroscopic partial meniscectomy (APM) has no superiority over non-operative treatment. Thus, non-operative treatment should be the first-line choice and APM should be considered in case of failure: three months has been accepted as a threshold in the ESSKA Meniscus Consensus Project presented in 2016. Earlier indications may be proposed in cases with considerable mechanical symptoms. The main message remains: save the meniscus! Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160056. Originally published online at www.efortopenreviews.org PMID:28698804

Healing of the Acutely Injured Anterior Cruciate Ligament: Functional Treatment with the ACL-Jack, a Dynamic Posterior Drawer Brace

PubMed Central

Reischl, Nikolaus; Rönn, Karolin; Magnusson, Robert A.; Gautier, Emanuel; Jakob, Roland P.

2016-01-01

Background. The injured anterior cruciate ligament (ACL) has a limited healing capacity leading to persisting instability. Hypothesis/Purpose. To study if the application of a brace, producing a dynamic posterior drawer force, after acute ACL injury reduces initial instability. Study Design. Cohort study. Methods. Patients treated with the ACL-Jack brace were compared to controls treated with primary ACL reconstruction und controls treated nonsurgically with functional rehabilitation. Measurements included anterior laxity (Rolimeter), clinical scores (Lysholm, Tegner, and IKDC), and MRI evaluation. Patients were followed up to 24 months. Results. Patients treated with the ACL-Jack brace showed a significant improvement of anterior knee laxity comparable to patients treated with ACL reconstruction, whereas laxity persisted after nonsurgical functional rehabilitation. The failure risk (secondary reconstruction necessary) of the ACL-Jack group was however 21% (18 of 86) within 24 months. Clinical scores were similar in all treatment groups. Conclusion. Treatment of acute ACL tears with the ACL-Jack brace leads to improved anterior knee laxity compared to nonsurgical treatment with functional rehabilitation. PMID:28053787

High prevalence of all complex Segond avulsion using ultrasound imaging.

PubMed

Klos, Burt; Scholtes, Marlon; Konijnenberg, Stephan

2017-04-01

The aim of this study was to determine the prevalence of a Segond avulsion fractures in acute ACL tears with ultrasound and to investigate whether other injuries can predict the avulsion. One hundred thirty-eight ultrasound analyses of acute knee trauma were collected and scored for diagnosed injuries. The reports of patients with an ACL tear (N = 87) were evaluated to determine possible increased prevalence of Segond avulsion fracture with ultrasound. The associations between the diagnosed injuries and presence of a Segond avulsion were scored. The sports carried out at the time of injury were evaluated as possible prognostic factor. In 25/87 (29%) of the patients with an ACL tear, a Segond avulsion was observed in ultrasound. Lateral femoral condyle (LFC) impaction showed the strongest individual association with a Segond avulsion and was the best predicting variable. LFC impaction, sustained during low-risk pivoting sport, shows a stronger association with a Segond avulsion, as compared to LFC impaction sustained during high-risk pivoting sports. Ultrasound shows a higher prevalence of Segond avulsions as literature shows with MRI or radiography. LFC impaction is the best variable in predicting this type of avulsion. Ultrasound examination should be considered, if this fracture was not diagnosed with MRI or radiographic analysis. IV.

Failure Rate and Clinical Outcomes of Anterior Cruciate Ligament Reconstruction Using Autograft Hamstring Versus a Hybrid Graft.

PubMed

Leo, Brian M; Krill, Michael; Barksdale, Leticia; Alvarez-Pinzon, Andres M

2016-11-01

To compare the revision rate and subjective outcome measures of autograft hamstring versus a soft tissue hybrid graft combining both autograft hamstring and tibialis allograft for isolated anterior cruciate ligament (ACL) reconstruction. A single-center retrospective, nonrandomized, comparative study of isolated ACL reconstruction revision rates for subjects who underwent arthroscopic reconstruction of the ACL using autograft hamstring or a soft tissue hybrid graft using both autograft hamstring and tibialis allograft was performed. Patients with isolated ACL tears were included and underwent anatomic single-bundle reconstruction using an independent tunnel drilling technique and a minimum of 24 months' follow-up. The primary outcome assessed was the presence or absence of ACL rerupture. Secondary clinical outcomes consisted of the International Knee Documentation Committee, University of California at Los Angeles (UCLA) ACL quality of life assessment, and the visual analog pain scale. Between February 2010 and April 2013, 95 patients with isolated ACL tears between ages 18 and 40 met the inclusion criteria and were enrolled. Seventy-one autograft hamstring and 24 soft tissue hybrid graft ACL reconstructions were performed during the course of this study. The follow-up period was 24 to 32 months (mean 26.9 months). There were no statistically significant differences in patient demographics or Outerbridge classification. No statistically significant differences in ACL retears (5.6% auto, 4.2% hybrid; P = .57) were found between groups. Clinical International Knee Documentation Committee and UCLA ACL quality of life assessment improvement scores revealed no statistically significant differences in autograft and hybrid graft reconstructions (41 ± 11, 43 ± 13; P = .65) (38 ± 11, 40 ± 10; P = .23). The mean pain level decreased from 8.1 to 2.8 in the autograft group and 7.9 to 2.5 in the hybrid group (P = .18). The use of a hybrid soft tissue graft has a comparable rerupture rate and clinical outcome to ACL reconstruction using autograft hamstring. Level III, retrospective comparative study. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Cellular and Morphological Alterations in the Vastus Lateralis Muscle as the Result of ACL Injury and Reconstruction.

PubMed

Noehren, Brian; Andersen, Anders; Hardy, Peter; Johnson, Darren L; Ireland, Mary Lloyd; Thompson, Katherine L; Damon, Bruce

2016-09-21

Individuals who have had an anterior cruciate ligament (ACL) tear and reconstruction continue to experience substantial knee extensor strength loss despite months of physical therapy. Identification of the alterations in muscle morphology and cellular composition are needed to understand potential mechanisms of muscle strength loss, initially as the result of the injury and subsequently from surgery and rehabilitation. We performed diffusion tensor imaging-magnetic resonance imaging and analyzed muscle biopsies from the vastus lateralis of both the affected and unaffected limbs before surgery and again from the reconstructed limb following the completion of rehabilitation. Immunohistochemistry was done to determine fiber type and size, Pax-7-positive (satellite) cells, and extracellular matrix (via wheat germ agglutinin straining). Using the diffusion tensor imaging data, the fiber tract length, pennation angle, and muscle volume were determined, yielding the physiological cross-sectional area (PCSA). Paired t tests were used to compare the effects of the injury between injured and uninjured limbs and the effects of surgery and rehabilitation within the injured limb. We found significant reductions before surgery in type-IIA muscle cross-sectional area (CSA; p = 0.03), extracellular matrix (p < 0.01), satellite cells per fiber (p < 0.01), pennation angle (p = 0.03), muscle volume (p = 0.02), and PCSA (p = 0.03) in the injured limb compared with the uninjured limb. Following surgery, these alterations in the injured limb persisted and the frequency of the IIA fiber type decreased significantly (p < 0.01) and that of the IIA/X hybrid fiber type increased significantly (p < 0.01). Significant and prolonged differences in muscle quality and morphology occurred after ACL injury and persisted despite reconstruction and extensive physical therapy. These results suggest the need to develop more effective early interventions following an ACL tear to prevent deleterious alterations within the quadriceps. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

Validation of Noncontact Anterior Cruciate Ligament Tears Produced by a Mechanical Impact Simulator Against the Clinical Presentation of Injury.

PubMed

Bates, Nathaniel A; Schilaty, Nathan D; Nagelli, Christopher V; Krych, Aaron J; Hewett, Timothy E

2018-06-01

Anterior cruciate ligament (ACL) injuries are catastrophic events that affect athletic careers and lead to long-term degenerative knee changes. As injuries are believed to occur within the first 50 milliseconds after initial contact during a rapid deceleration task, impact simulators that rapidly deliver impulse loads to cadaveric specimens have been developed. However, no impactor has reproducibly and reliably created ACL injures in a distribution that mimics clinical observation. To better understand ACL injury patterns through a cadaveric investigation that applied in vivo-measured external loads to the knee during simulated landings. Controlled laboratory study. A novel mechanical impact simulator reproduced kinetics from in vivo-recorded drop landing tasks on 45 cadaveric knees. Specimens were exposed to a randomized order of variable knee abduction moment, anterior tibial shear, and internal tibial rotation loads before the introduction of an impulse load at the foot. This process was repeated until a hard or soft tissue injury was induced on the joint. Injuries were assessed by an orthopaedic surgeon, and ligament strain was recorded by implanted strain gauges. The mechanical impact simulator induced ACL injuries in 87% of specimens, with medial collateral ligament (MCL) injuries in 31%. ACL tear locations were 71% femoral side, 21% midsubstance, and 9% tibial side. Peak strain before failure for ACL-injured specimens was 15.3% ± 8.7% for the ACL and 5.1% ± 5.6% for the MCL ( P < .001). The ACL injuries induced by the mechanical impact simulator in the present study have provided clinically relevant in vitro representations of in vivo ACL injury patterns as cited in the literature. Additionally, current ligament strains corroborate the literature to support disproportionate loading of the ACL relative to the MCL during athletic tasks. These findings indicate that the mechanical impact simulator is an appropriate model for examining independent mechanical variables, treatment techniques, and preventive interventions during athletic tasks leading up to and including an ACL injury. Accordingly, this system can be utilized to further parse out contributing factors to an ACL injury as well as assess the shortcomings of ACL reconstruction techniques in a dynamic, simulated environment that is better representative of in vivo injury scenarios.

Management of Anterior Cruciate Ligament Injury: What's In and What's Out?

PubMed Central

Raines, Benjamin Todd; Naclerio, Emily; Sherman, Seth L

2017-01-01

Sports medicine physicians have a keen clinical and research interest in the anterior cruciate ligament (ACL). The biomechanical, biologic, and clinical data researchers generate, help drive injury management and prevention practices globally. The current concepts in ACL injury and surgery are being shaped by technological advances, expansion in basic science research, resurging interest in ACL preservation, and expanding efforts regarding injury prevention. As new methods are being developed in this field, the primary goal of safely improving patient outcomes will be a unifying principle. With this review, we provide an overview of topics currently in controversy or debate, and we identify paradigm shifts in the understanding, management, and prevention of ACL tears. PMID:28966380

The potential of optical coherence tomography for diagnosing meniscal pathology

NASA Astrophysics Data System (ADS)

Hang-Yin Ling, Carrie; Pozzi, Antonio; Thieman, Kelley M.; Tonks, Catherine A.; Guo, Shuguang; Xie, Huikai; Horodyski, MaryBeth

2010-04-01

Meniscal tears are often associated with anterior cruciate ligament (ACL) injury and may lead to pain and discomfort in humans. Maximal preservation of meniscal tissue is highly desirable to mitigate the progression of osteoarthritis. Guidelines of which meniscal tears are amenable to repair and what part of damaged tissues should be removed are elusive and lacking consensus. Images of microstructural changes in meniscus would potentially guide the surgeons to manage the meniscal tears better, but the resolution of current diagnostic techniques is limited for this application. In this study, we demonstrated the feasibility of using optical coherence tomography (OCT) for the diagnosis of meniscal pathology. Torn medial menisci were collected from dogs with ACL insufficiency. The torn meniscus was divided into three tissue samples and scanned by OCT and scanning electron microscopy (SEM). OCT and SEM images of torn menisci were compared. Each sample was evaluated for gross and microstructural abnormalities and reduction or loss of birefringence from the OCT images. The abnormalities detected with OCT were described for each type of tear. OCT holds promise in non-destructive and fast assessment of microstructural changes and tissue birefringence of meniscal tears. Future development of intraoperative OCT may help surgeons in the decision making of meniscal treatment.

Thermographic and microscopic evaluation of LARS knee ligament tearing.

PubMed

Pătraşcu, Jenel Marian; Amarandei, Mihaela; Kun, Karla Noemy; Borugă, Ovidiu; Totorean, Alina; Andor, Bogdan; Florescu, Sorin

2014-01-01

Damage to knee articular ligaments causes important functional problems and adversely affects particularly the stability of the knee joint. Several methods were developed in order to repair damage to the anterior cruciate ligament (ACL), which employ autografts, allografts, as well as synthetic ligaments. One such synthetic scaffold, the ligament advanced reinforcement system (LARS) synthetic ligament is made of non-absorbing polyethylene terephthalate fibers whose structure allow tissue ingrowths in the intra-articular part, improving the stability of the joint. The LARS ligament is nowadays widely used in modern knee surgery in the Europe, Canada, China or Japan. This paper evaluates LARS ligament from two perspectives. The first regards a study done by the Orthopedics Clinic II, Timisoara, Romania, which compared results obtained by employing two techniques of ACL repair - the Bone-Tendon-Bone (BTB) or LARS arthroscopic, intra-articular techniques. This study found that patients treated with the BTB technique presented with an IKDC score of 45.82±1.14 units preoperative, with increasing values in the first nine months after each implant post-surgical ligament restoration, reaching an average value of 75.92 ± 2.88 units postoperative. Patients treated with the LARS technique presented with an IKDC score of 43.64 ± 1.11 units preoperative, and a score of 77.32 ± 2.71 units postoperative. The second perspective describes the thermographic and microscopic analysis of an artificial knee ligament tearing or loosening. The objective of the study was to obtain information regarding the design of artificial ligaments in order to expand their lifespan and avoid complications such as recurring synovitis, osteoarthritis and trauma of the knee joint. Thermographic data has shown that tearing begins from the inside out, thus improving the inner design of the ligament would probably enhance its durability. An optical microscope was employed to obtain images of structural damage in the inner layers, for use in further analysis of the tears. In conclusion, the LARS artificial ligament, like the BTB technique, displays both advantages and disadvantages. It is important to understand that these two options of ACL lesion repair are not competing. LARS could, in addition to its use in primary ACL ruptures, be utilized in revisions of autologous graft rupture post primary ACL repair.

Lateral meniscus posterior root tear contributes to anterolateral rotational instability and meniscus extrusion in anterior cruciate ligament-injured patients.

PubMed

Minami, Takao; Muneta, Takeshi; Sekiya, Ichiro; Watanabe, Toshifumi; Mochizuki, Tomoyuki; Horie, Masafumi; Katagiri, Hiroki; Otabe, Koji; Ohara, Toshiyuki; Katakura, Mai; Koga, Hideyuki

2018-04-01

The purposes of this study were to investigate (1) meniscus status and clinical findings in anterior cruciate ligament (ACL)-injured patients to clarify associations between the meniscus posterior root tear (PRT) and knee instability, and (2) magnetic resonance imaging (MRI) findings of the PRT to clarify sensitivity and specificity of MRI and prevalence of meniscus extrusion. Three hundred and seventeen patients with primary ACL reconstruction were included. PRTs for both medial and lateral sides were confirmed by reviewing surgical records. Preoperative MRI was reviewed to evaluate sensitivity and specificity of the PRT and meniscus extrusion width (MEW). Clinical information regarding the number of giving-way episodes, preoperative KT-1000 measurements and preoperative pivot shift was also assessed. Thirty-nine patients had a lateral meniscus (LM) PRT, whereas only four patients had a medial meniscus PRT. One hundred and seventeen patients had no meniscus tear (control). Twenty-eight patients (71.8%) showed positive signs of the LMPRT based on at least one view of MR images, with the coronal view showing the highest sensitivity. MEW in the LMPRT group was significantly larger than that in the control group. The preoperative pivot shift test grade in the LMPRT group was significantly greater than that in the control group. There were no significant differences in other parameters. In ACL-injured patients, the LMPRT was associated with ALRI as well as with meniscus extrusion. The coronal view of MRI was useful in identifying the LMPRT, although its sensitivity was not high. Therefore, surgeons should prepare to repair PRTs at the time of ACL reconstruction regardless of MRI findings, and they should make every effort to repair the LMPRT. III.

Partial anterior cruciate ligament tears treated with intraligamentary plasma rich in growth factors

PubMed Central

Seijas, Roberto; Ares, Oscar; Cuscó, Xavier; Álvarez, Pedro; Steinbacher, Gilbert; Cugat, Ramón

2014-01-01

AIM: To evaluate the effect of the application of plasma rich in growth factors (PRGF)-Endoret to the remaining intact bundle in partial anterior cruciate ligament (ACL) tears. METHODS: A retrospective review of the rate of return to play in football players treated with the application of PRGF-Endoret in the remaining intact bundle in partial ACL injuries that underwent surgery for knee instability. Patients with knee instability requiring revision surgery for remnant ACL were selected. PRGF was applied in the wider part of posterolateral bundle and the time it took patients to return to their full sporting activities at the same level before the injury was evaluated. RESULTS: A total of 19 patients were reviewed. Three had a Tegner activity level of 10 and the remaining 16 level 9. The time between the injury and the time of surgery was 5.78 wk (SD 1.57). In total, 81.75% (16/19) returned to the same pre-injury level of sport activity (Tegner 9-10). 17 males and 2 females were treated. The rate of associated injury was 68.42% meniscal lesions and 26.31% cartilage lesions. The KT-1000 values were normalized in all operated cases. One patient was not able to return to sport due to the extent of their cartilage lesions. The 15 patients with Tegner activity level 9 returned to play at an average of 16.20 wk (SD 1.44) while the 3 patients with Tegner activity level 10 did so in 12.33 wk (SD 1.11). CONCLUSION: With one remaining intact bundle the application of PRGF-Endoret in instability cases due to partial ACL tear showed high return to sport rates at pre- injury level in professional football players. PMID:25035842

Proprioceptive deficit in individuals with unilateral tearing of the anterior cruciate ligament after active evaluation of the sense of joint position.

PubMed

Cossich, Victor; Mallrich, Frédéric; Titonelli, Victor; de Sousa, Eduardo Branco; Velasques, Bruna; Salles, José Inácio

2014-01-01

To ascertain whether the proprioceptive deficit in the sense of joint position continues to be present when patients with a limb presenting a deficient anterior cruciate ligament (ACL) are assessed by testing their active reproduction of joint position, in comparison with the contralateral limb. Twenty patients with unilateral ACL tearing participated in the study. Their active reproduction of joint position in the limb with the deficient ACL and in the healthy contralateral limb was tested. Meta-positions of 20% and 50% of the maximum joint range of motion were used. Proprioceptive performance was determined through the values of the absolute error, variable error and constant error. Significant differences in absolute error were found at both of the positions evaluated, and in constant error at 50% of the maximum joint range of motion. When evaluated in terms of absolute error, the proprioceptive deficit continues to be present even when an active evaluation of the sense of joint position is made. Consequently, this sense involves activity of both intramuscular and tendon receptors.

The Relationship between Anterior Cruciate Ligament Injury and Osteoarthritis of the Knee

PubMed Central

Simon, David; Saltzman, Bryan M.; Rollins, Meaghan; Bach, Bernard R.; MacDonald, Peter

2015-01-01

Anterior cruciate ligament (ACL) tears are a common injury, particularly in the athletic and youth populations. The known association between ACL injury and subsequent osteoarthritis (OA) of the knee merits a more in-depth understanding of the relationship between the ACL-injured knee and osteoarthritis. ACL injury, especially with concomitant meniscal or other ligamentous pathology, predisposes the knee to an increased risk of osteoarthritis. ACL insufficiency results in deterioration of the normal physiologic knee bending culminating in increased anterior tibial translation and increased internal tibial rotation. This leads to increased mean contact stresses in the posterior medial and lateral compartments under anterior and rotational loading. However, surgical reconstruction of the ACL has not been shown to reduce the risk of future OA development back to baseline and has variability based on operative factors of graft choice, timing of surgery, presence of meniscal and chondral abnormalities, and surgical technique. Known strategies to prevent OA development are applicable to patients with ACL deficiency or after ACL reconstruction and include weight management, avoidance of excessive musculoskeletal loading, and strength training. Reconstruction of the ACL does not necessarily prevent osteoarthritis in many of these patients and may depend on several external variables. PMID:25954533

Meniscus root repair.

PubMed

Vyas, Dharmesh; Harner, Christopher D

2012-06-01

Root tears are a subset of meniscal injuries that result in significant knee joint pathology. Occurring on either the medial or lateral side, root tears are defined as radial tears or avulsions of the posterior horn attachment to bone. After a root tear, there is a significant increase in tibio-femoral contact pressure concomitant with altered knee joint kinematics. Previous cadaver studies from our institution have shown that root repair of the medial meniscus is successful in restoring joint biomechanics to within normal limits. Indications for operative management of meniscal root tears include (1) a symptomatic medial meniscus root tear with minimal arthritis and having failed non-operative treatment, and (2) a lateral root tear in associated with an ACL tear. In this review, we describe diagnosis, imaging, patient selection, and arthroscopic surgical technique of medial and lateral meniscus root injuries. In addition we highlight the pearls of repair technique, associated complications, post-operative rehabilitation regimen, and expected outcomes.

Lessons learned from the last 20 years of ACL-related in vivo-biomechanics research of the knee joint.

PubMed

Pappas, Evangelos; Zampeli, Franceska; Xergia, Sofia A; Georgoulis, Anastasios D

2013-04-01

Technological advances in recent years have allowed the easy and accurate assessment of knee motion during athletic activities. Subsequently, thousands of studies have been published that greatly improved our understanding of the aetiology, surgical reconstruction techniques and prevention of anterior cruciate ligament (ACL) injuries. The purpose of this review is to summarize the evidence from biomechanical studies on ACL-related research. High-impact articles that enhanced understanding of ACL injury aetiology, rehabilitation, prevention and adaptations after reconstruction were selected. The importance of restoring internal tibial rotation after ACL reconstruction has emerged in several studies. Criteria-based, individualized rehabilitation protocols have replaced the traditional time-based protocols. Excessive knee valgus, poor trunk control, excessive quadriceps forces and leg asymmetries have been identified as potential high risk biomechanical factors for ACL tear. Injury prevention programmes have emerged as low cost and effective means of preventing ACL injuries, particularly in female athletes. As a result of biomechanical research, clinicians have a better understanding of ACL injury aetiology, prevention and rehabilitation. Athletes exhibiting neuromuscular deficits predisposing them to ACL injury can be identified and enrolled into prevention programmes. Clinicians should assess ACL-reconstructed patients for excessive internal tibial rotation that may lead to poor outcomes.

Editorial Commentary: The Downstream Effects of Limited Hip Rotation and Femoroacetabular Impingement on the Anterior Cruciate Ligament: Could a Little Hip Stretching Every Day (or Surgery) Keep the Knee Doctor Away?

PubMed

Boykin, Robert E

2018-03-01

Patients with radiographic evidence of femoroacetabular impingement and decreased hip internal rotation have a higher rate of anterior cruciate ligament (ACL) tears. Limited internal rotation of the hip increases strain and potentially resultant fatigue failure of the ACL. Although causation has not been proven, a better understanding of the lower extremity kinetic chain may allow improved ACL prevention strategies through measures (operative or nonoperative) to improve rotation of the hip. Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Surgical Management of Simultaneous Anterior Cruciate Ligament and Patellar Tendon Ruptures: A Systematic Review.

PubMed

Meheux, Carlos J; Jack, Robert A; McCulloch, Patrick C; Lintner, David M; Harris, Joshua D

2017-12-28

This study performs a systematic review to determine (1) if a significant difference exists in return to preinjury activity level between one- and two-stage treatment of combined anterior cruciate ligament (ACL) and patellar tendon (PT) tears; and (2) if a significant difference exists in the number of postoperative complications between the two differing surgical treatment approaches. A systematic review was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and registered on PROSPERO. MEDLINE, Cochrane Central Register of Controlled Trials, SCOPUS, and Sport Discus were searched for English language level I-IV evidence studies on either one- (simultaneous) or two-stage (sequential) surgical treatment of simultaneously sustained ipsilateral ACL and PT tears. The approach to initial evaluation, diagnosis, treatment, and outcomes were qualitatively analyzed. Methodological quality assessment of all included studies was completed using the Methodological Index for Non-randomized Studies (MINORS). The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool was used to assess quality of evidence and provide strength of recommendation. Statistical analyses were done using Fischer's exact test. Eleven articles (18 patients; 83% males; mean age, 31.1 ± 10.1 years; mean follow-up, 2.2 ± 1.7 years; and mean MINORS 7.8/16) were analyzed. Eight patients had a one-stage procedure (primary PT repair and ACL reconstruction), and 10 patients underwent a two-stage procedure (primary PT repair first followed by ACL reconstruction) with mean 28 ± 45.7 weeks (5 weeks-3 years) between surgeries. The rate for return to preinjury activity level after surgery was not significantly different between one- (88%) and two-stage (100%) ( p  = 0.444). There was a significantly higher complication rate ( p  = 0.023) in the one-stage (stiffness, instability, and patella baja) versus two-stage surgery (no complications). There was no significant difference in return to preinjury activity level between one- and two-stage PT repair and ACL reconstruction. However, the one-stage combined surgery had a significantly higher complication rate compared with two-stage surgery. The level of evidence is IV. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

MRI of the knee.

PubMed

Skinner, Sarah

2012-11-01

Magnetic resonance imaging (MRI) is the gold standard in noninvasive investigation of knee pain. It has a very high negative predictive value and may assist in avoiding unnecessary knee arthroscopy; its accuracy in the diagnosis of meniscal and anterior cruciate ligament (ACL) tears is greater than 89%; it has a greater than 90% sensitivity for the detection of medial meniscal tears; and it is probably better at assessing the posterior horn than arthroscopy.

Magnetic resonance evaluation of the knee in children and adolescents with achondroplasia.

PubMed

Akyol, Yakup; Averill, Lauren W; Atanda, Alfred; Kecskemethy, Heidi H; Bober, Michael B; Mackenzie, William G

2015-06-01

Achondroplasia is the most common form of skeletal dysplasia. Although the radiographic features are well described, MRI features of the knee in achondroplasia have not been reported. To describe common MRI characteristics of the knee joint in symptomatic children and adolescents with achondroplasia. We retrospectively evaluated 10 knee MRI examinations in 8 children and young adults (age range 11-20 years, mean 16.3 years) with achondroplasia. We measured modified Insall-Salvati index, knee flexion angle, anterior cruciate ligament (ACL)-Blumensaat line angle, ACL-tibial angle, posterior cruciate ligament (PCL) angle, intercondylar notch width index, and intercondylar notch depth index. We compared our findings with an age- and gender-matched control group of 20 children (age range 15-18 years; mean 16 years) with normal knee MRIs. All 10 knees in the achondroplasia group had discoid lateral meniscus; 8 meniscal tears were identified. Patella baja was present in half of the study cases. Greater knee flexion and increased ACL-Blumensaat line and PCL angles were seen in all achondroplasia knees. ACL-tibial angle was similar in the study and in the control group. Children with achondroplasia had deeper A-shape femoral notches that extended more anteriorly than those seen in the control group. MRI findings were confirmed in all seven knees with arthroscopic correlation. Discoid lateral meniscus, often with tear, is a consistent feature in knee MRIs of symptomatic children and adolescents with achondroplasia. Other findings include patella baja, knee flexion, deep A-shape intercondylar notch, increased ACL-Blumensaat line angle and taut PCL.

Meniscal healing after meniscal repair: a CT arthrography assessment.

PubMed

Pujol, Nicolas; Panarella, Ludovico; Selmi, Tarik Ait Si; Neyret, Philippe; Fithian, Donald; Beaufils, Philippe

2008-08-01

Studies evaluating healing of repaired meniscus are rare and primarily retrospective. The aim of this study was to assess whether there were different healing rates for arthroscopic meniscal repair with respect to the different zones of the meniscus. This study was conducted to assess outcomes and to document anatomic characteristics of the repaired meniscus with postoperative arthrography combined with computed tomography (arthro-CT), particularly the dimensions and healing of the repaired meniscus. Case series; Level of evidence, 4. Fifty-three arthroscopic meniscal repairs were prospectively evaluated between 2002 and 2004 in 2 orthopaedic departments. There were 36 medial and 17 lateral torn menisci. All ACL tears (n = 31, 58.5%) underwent reconstruction. Patients were preoperatively evaluated by magnetic resonance imaging. Clinical evaluation included International Knee Documentation Committee (IKDC) scores before the operation and 6 and 12 months afterward. Healing criteria were evaluated at 6 months by arthro-CT scan. Three parameters were evaluated--healing in thickness (Henning criteria), overall healing rate, and reduction in the width of the remaining meniscus. According to the objective IKDC score, 26 patients were graded A, 20 B, and 4 C (92% good results). The mean subjective IKDC score was 78.9 (standard deviation [SD], 16.2). According to Henning's criteria, 58% of the menisci healed completely, 24% partially, and 18% failed. The overall healing rate was 73.1% (SD, 38.5). Twenty tears located in the posterior part had a healing rate of 59.8% (SD, 46.0). Nineteen tears extending from the posterior to the middle part had a healing rate of 79.2% (SD, 28.2). Isolated tears located in the posterior part had a lower healing rate (P < .05). There was a 9% +/- 1.2% reduction in the width of the remaining medial meniscus in the middle and posterior repaired portions (P < .02). There was a 15% +/- 14% reduction in the width of the remaining lateral meniscus in the middle repaired portion (P < .01). Complete healing of the posterior segment was associated with reduction in the width of the meniscus (P < .04). A modern technique using all-inside fixation or outside-in sutures provided good clinical and anatomic outcomes. No statistically significant effect on ACL reconstruction or laterality (medial vs lateral) on overall healing after meniscal repair was identified. Partial healing occurred often, with a stable tear on a narrowed and painless meniscus. The posterior segment healing rate remained low, suggesting a need for further technical improvements.

Incidence and treatment of intra-articular lesions associated with anterior cruciate ligament tears.

PubMed

Todor, Adrian; Nistor, Dan; Buescu, Cristian; Pojar, Adina; Lucaciu, Dan

2014-01-01

The aim of the study is to retrospectively review the patients admitted and treated in the "Alexandru Rădulescu" Orthopedics and Traumatology Clinic, Cluj-Napoca for an anterior cruciate ligament tear over a 2-year period and document the intra-articular lesions found at arthroscopy as well as the treatment used for these associated lesions. The case records of 88 patients operated for anterior cruciate ligament tear over a period of 2 years were reviewed. There were 67 males and 21 females with a mean age of 28.9 years, ranging from 14 to 49 years. After recording the patient demographics, we documented all the intra-articular lesions found during knee arthroscopy, as well as all procedures undertaken concomitant with the ACL reconstruction. 50 of the 88 patients (56.8%) had associated intra-articular lesions at the time of anterior cruciate ligament reconstruction. The most common injury found was a meniscus tear, 48 patients (54.5%) had a meniscal pathology at the time of ligament reconstruction, medial meniscus being the most frequent injured one, found in 37 patients. Meniscectomy and meniscus suture were the procedures performed for these lesions, meniscectomy being more frequent. Chondral defects were the next associated injuries found with an incidence of 15.9% of the cases. The medial side of the knee was the most common site of chondral pathology. ACL tears are frequently associated with other intra-articular lesions, especially medial meniscus tears and chondral defects affecting the medial compartment. Such pathology most often needs surgical attention during the anterior cruciate ligament reconstruction.

Return-to-Sport and Performance After Anterior Cruciate Ligament Reconstruction in National Basketball Association Players

PubMed Central

Harris, Joshua D.; Erickson, Brandon J.; Bach, Bernard R.; Abrams, Geoffrey D.; Cvetanovich, Gregory L.; Forsythe, Brian; McCormick, Frank M.; Gupta, Anil K.; Cole, Brian J.

2013-01-01

Background: Anterior cruciate ligament (ACL) rupture is a significant injury in National Basketball Association (NBA) players. Hypotheses: NBA players undergoing ACL reconstruction (ACLR) have high rates of return to sport (RTS), with RTS the season following surgery, no difference in performance between pre- and postsurgery, and no difference in RTS rate or performance between cases (ACLR) and controls (no ACL tear). Study Design: Case-control. Methods: NBA players undergoing ACLR were evaluated. Matched controls for age, body mass index (BMI), position, and NBA experience were selected during the same years as those undergoing ACLR. RTS and performance were compared between cases and controls. Paired-sample Student t tests, chi-square, and linear regression analyses were performed for comparison of within- and between-group variables. Results: Fifty-eight NBA players underwent ACLR while in the NBA. Mean player age was 25.7 ± 3.5 years. Forty percent of ACL tears occurred in the fourth quarter. Fifty players (86%) RTS in the NBA, and 7 players (12%) RTS in the International Basketball Federation (FIBA) or D-league. Ninety-eight percent of players RTS in the NBA the season following ACLR (11.6 ± 4.1 months from injury). Two players (3.1%) required revision ACLR. Career length following ACLR was 4.3 ± 3.4 years. Performance upon RTS following surgery declined significantly (P < 0.05) regarding games per season; minutes, points, and rebounds per game; and field goal percentage. However, following the index year, controls’ performances declined significantly in games per season; points, rebounds, assists, blocks, and steals per game; and field goal and free throw percentage. Other than games per season, there was no significant difference between cases and controls. Conclusion: There is a high RTS rate in the NBA following ACLR. Nearly all players RTS the season following surgery. Performance significantly declined from preinjury level; however, this was not significantly different from controls. ACL re-tear rate was low. Clinical Relevance: There is a high RTS rate in the NBA after ACLR, with no difference in performance upon RTS compared with controls. PMID:24427434

Return-to-Sport and Performance After Anterior Cruciate Ligament Reconstruction in National Basketball Association Players.

PubMed

Harris, Joshua D; Erickson, Brandon J; Bach, Bernard R; Abrams, Geoffrey D; Cvetanovich, Gregory L; Forsythe, Brian; McCormick, Frank M; Gupta, Anil K; Cole, Brian J

2013-11-01

Anterior cruciate ligament (ACL) rupture is a significant injury in National Basketball Association (NBA) players. NBA players undergoing ACL reconstruction (ACLR) have high rates of return to sport (RTS), with RTS the season following surgery, no difference in performance between pre- and postsurgery, and no difference in RTS rate or performance between cases (ACLR) and controls (no ACL tear). Case-control. NBA players undergoing ACLR were evaluated. Matched controls for age, body mass index (BMI), position, and NBA experience were selected during the same years as those undergoing ACLR. RTS and performance were compared between cases and controls. Paired-sample Student t tests, chi-square, and linear regression analyses were performed for comparison of within- and between-group variables. Fifty-eight NBA players underwent ACLR while in the NBA. Mean player age was 25.7 ± 3.5 years. Forty percent of ACL tears occurred in the fourth quarter. Fifty players (86%) RTS in the NBA, and 7 players (12%) RTS in the International Basketball Federation (FIBA) or D-league. Ninety-eight percent of players RTS in the NBA the season following ACLR (11.6 ± 4.1 months from injury). Two players (3.1%) required revision ACLR. Career length following ACLR was 4.3 ± 3.4 years. Performance upon RTS following surgery declined significantly (P < 0.05) regarding games per season; minutes, points, and rebounds per game; and field goal percentage. However, following the index year, controls' performances declined significantly in games per season; points, rebounds, assists, blocks, and steals per game; and field goal and free throw percentage. Other than games per season, there was no significant difference between cases and controls. There is a high RTS rate in the NBA following ACLR. Nearly all players RTS the season following surgery. Performance significantly declined from preinjury level; however, this was not significantly different from controls. ACL re-tear rate was low. There is a high RTS rate in the NBA after ACLR, with no difference in performance upon RTS compared with controls.

Complications and Adverse Events of a Randomized Clinical Trial Comparing 3 Graft Types for ACL Reconstruction.

PubMed

Mohtadi, Nicholas; Barber, Rhamona; Chan, Denise; Paolucci, Elizabeth Oddone

2016-05-01

Complications/adverse events of anterior cruciate ligament (ACL) surgery are underreported, despite pooled level 1 data in systematic reviews. All adverse events/complications occurring within a 2-year postoperative period after primary ACL reconstruction, as part of a large randomized clinical trial (RCT), were identified and described. Prospective, double-blind randomized clinical trial. Patients and the independent trained examiner were blinded to treatment allocation. University-based orthopedic referral practice. Three hundred thirty patients (14-50 years; 183 males) with isolated ACL deficiency were intraoperatively randomized to ACL reconstruction with 1 autograft type. Graft harvest and arthroscopic portal incisions were identical. Patients were equally distributed to patellar tendon (PT), quadruple-stranded hamstring tendon (HT), and double-bundle (DB) hamstring autograft ACL reconstruction. Adverse events/complications were patient reported, documented, and diagnoses confirmed. Two major complications occurred: pulmonary embolism and septic arthritis. Twenty-four patients (7.3%) required repeat surgery, including 25 separate operations: PT = 7 (6.4%), HT = 9 (8.2%), and DB = 8 (7.3%). Repeat surgery was performed for meniscal tears (3.6%; n = 12), intra-articular scarring (2.7%; n = 9), chondral pathology (0.6%; n = 2), and wound dehiscence (0.3%; n = 1). Other complications included wound problems, sensory nerve damage, muscle tendon injury, tibial periostitis, and suspected meniscal tears and chondral lesions. Overall, more complications occurred in the HT/DB groups (PT = 24; HT = 31; DB = 45), but more PT patients complained of moderate or severe kneeling pain (PT = 17; HT = 9; DB = 4) at 2 years. Overall, ACL reconstructive surgery is safe. Major complications were uncommon. Secondary surgery was necessary 7.3% of the time for complications/adverse events (excluding graft reinjury or revisions) within the first 2 years. Level 1 (therapeutic studies). This article reports on the complications/adverse events that were prospectively identified up to 2 years postoperatively, in a defined patient population participating in a large double-blind randomized clinical trial comparing PT, single-bundle hamstring, and DB hamstring reconstructions for ACL rupture.

The effect of isolated valgus moments on ACL strain during single-leg landing: A simulation study

PubMed Central

Shin, Choongsoo S.; Chaudhari, Ajit M.; Andriacchi, Thomas P.

2009-01-01

Valgus moments on the knee joint during single-leg landing have been suggested as a risk factor for anterior cruciate ligament (ACL) injury. The purpose of this study was to test the influence of isolated valgus moment on ACL strain during single-leg landing. Physiologic levels of valgus moments from an in vivo study of single-leg landing were applied to a three-dimensional dynamic knee model, previously developed and tested for ACL strain measurement during simulated landing. The ACL strain, knee valgus angle, tibial rotation, and medial collateral ligament (MCL) strain were calculated and analyzed. The study shows that the peak ACL strain increased nonlinearly with increasing peak valgus moment. Subjects with naturally high valgus moments showed greater sensitivity for increased ACL strain with increased valgus moment, but ACL strain plateaus below reported ACL failure levels when the applied isolated valgus moment rises above the maximum values observed during normal cutting activities. In addition, the tibia was observed to rotate externally as the peak valgus moment increased due to bony and soft-tissue constraints. In conclusion, knee valgus moment increases peak ACL strain during single-leg landing. However, valgus moment alone may not be sufficient to induce an isolated ACL tear without concomitant damage to the MCL, because coupled tibial external rotation and increasing strain in the MCL prevent proportional increases in ACL strain at higher levels of valgus moment. Training that reduces the external valgus moment, however, can reduce the ACL strain and thus may help athletes reduce their overall ACL injury risk. PMID:19100550

Comparison of clinical outcomes and second-look arthroscopic findings after ACL reconstruction using a hamstring autograft or a tibialis allograft.

PubMed

Yoo, Seung-Hyun; Song, Eun-Kyoo; Shin, Young-Rok; Kim, Sung-Kyu; Seon, Jong-Keun

2017-04-01

The purpose of this prospective randomized clinical study was to compare the clinical and radiological outcomes, including tibial tunnel widening and the progression of osteoarthritis after ACL reconstruction using a hamstring autograft or a tibialis allograft. In addition, we compared the graft tear and synovial coverage of grafts in patients that underwent the second-look arthroscopy. Among 184 patients with an ACL injury who underwent ACL reconstruction, 68 patients of autograft group and 64 patients of tibialis allograft group were included for this study after minimum of 2-year follow-up. The Lachman and pivot-shift tests, Tegner activity score, Lysholm knee score, and IKDC score were compared between the two groups. The quadriceps and hamstring isokinetic strengths using dynamometer were also compared. Degree of OA was determined using the Kellgren-Lawrence grading system on the weight-bearing radiographs. In total, 51 patients (26 patients in autograft group and 25 in the tibialis allograft group) underwent the second-look arthroscopy, in which we compared the apparent tear of graft and synovial coverage of grafts. At the final follow-up, there were no statistical significances in the two groups in Lachman and pivot-shift tests (n.s.). The Tegner activity, Lysholm knee score, and IKDC scores were similar in the two groups. Moreover, no significant differences were observed in the muscle power (n.s.). Some patients showed the progression of OA (five in autograft and four in allograft groups) without intergroup difference (n.s.). Regarding the findings of second-look arthroscopy, although there was no significant difference in graft tear, synovial coverage was better in autograft group than in allograft group. Even though hamstring autografts and tibialis allografts provided good functional outcomes without significant differences, the second-look arthroscopy revealed that hamstring autografts produced better synovial coverage than tibialis allograft. I.

Translation, cross-cultural adaptation and validation of the French version of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale.

PubMed

Bohu, Y; Klouche, S; Lefevre, N; Webster, K; Herman, S

2015-04-01

The aim of this study was to translate, adapt and validate in French the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), a 12-item English language scale assessing the psychological impact of returning to sports after ACL reconstruction. The ACL-RSI scale was forward and back translated, cross-culturally adapted and validated using international guidelines. The study population included all patients who were active in sports and underwent primary arthroscopic ACL reconstruction. The control group included subjects with no history of knee trauma. At the 6-month follow-up, the study population completed the ACL-RSI scale twice within 3-4 days, Knee injury and Osteoarthritis Outcome Score (KOOS) and subjective International Knee Documentation Committee (IKDC) scores. Statistical tests assessed the construct validity, discriminant validity, internal consistency, reliability and feasibility of the ACL-RSI scale. Ninety-one patients with ACL tears and 98 control subjects were included: mean age 31.7 ± 8.1 and 21.8 ± 2, respectively. The ACL-RSI scores were correlated with all KOOS sub-categories (r = 0.22-0.64, p < 0.05) as well as the subjective IKDC score (r = 0.42, p < 0.00001). The mean scores of the study and control groups were significantly different (62.8 ± 19.4 vs. 89.6 ± 11.5, p < 0.00001), and scores were significantly better in patients who returned to the same sport (72.1 ± 21.4 vs. 60.3 ± 18.1, p = 0.008). Internal consistency was high (α = 0.96). Test-retest reproducibility was excellent: ρ = 0.90 (0.86-0.94), p < 0.00001. Administration time was 1.32 ± 0.7 mn, and all items were answered. This study showed that the cross-cultural adaptation of the English version of the ACL-RSI was successful and validated in a French-speaking population. The discriminant capacity of the scale between patients who underwent reconstruction and healthy subjects was confirmed. II.

Suture versus FasT-Fix all-inside meniscus repair at time of anterior cruciate ligament reconstruction.

PubMed

Choi, Nam-Hong; Kim, Byeong-Yeon; Hwang Bo, Byung-Hun; Victoroff, Brian N

2014-10-01

To compare meniscal healing and functional outcomes after all-inside meniscal repair between sutures and meniscal fixation devices. Sixty patients with a tear within the red-red or red-white zones of the posterior horn of the medial or lateral meniscus in conjunction with an anterior cruciate ligament (ACL) tear were included in this study. Meniscal repairs were performed with sutures in 35 patients and the FasT-Fix device (Smith & Nephew Endoscopy, Andover, MA) in 25 patients concomitantly with hamstring ACL reconstruction. Postoperative evaluations included Lysholm knee score, Tegner activity scale, Lachman and pivot-shift tests, and KT-1000 arthrometer (MEDmetric, San Diego, CA) testing. Follow-up magnetic resonance imaging (MRI) scans were obtained postoperatively for all patients to evaluate meniscal healing. The mean follow-up period was 47.2 months. In the suture group, 31 patients (86.1%) were asymptomatic and 4 (13.9%) were symptomatic. In the FasT-Fix group, 20 patients (80%) were asymptomatic and 5 (20%) were symptomatic. Postoperative functional evaluation and knee stability showed no statistically significant difference between the 2 groups. Follow-up MRI showed that 26 menisci (74.3%) were healed, 3 menisci (8.6%) were partially healed, and 6 menisci (17.1%) were not healed in the suture group. In the FasT-Fix group, 15 menisci (64%) were healed, 7 menisci (24%) were partially healed, and 3 menisci (12%) were not healed. Follow-up MRI showed no statistically significant difference between the 2 groups. In the FasT-Fix group, follow-up MRI showed a newly developed cyst posterior to the medial meniscus in 2 patients. A new tear anterior to the previous tear was found in 1 patient. In the suture group, follow-up MRI showed no cysts or new tears. All-inside meniscal repairs using either sutures or the FasT-Fix device showed satisfactory results in patients with concomitant hamstring ACL reconstruction. There was no statistically significant difference in meniscal healing evaluated by MRI and functional outcomes between the 2 techniques. Level III, retrospective comparative study. Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Prevention, treatment, and rehabilitation of anterior cruciate ligament injuries in children

PubMed Central

Lang, Pamela J; Sugimoto, Dai; Micheli, Lyle J

2017-01-01

As more children and adolescents participate in competitive organized sports, there has been an increase in the reported incidence of anterior cruciate ligament (ACL) injuries in these age groups. ACL injuries in skeletally immature athletes present a challenge, as reconstruction must preserve the physis of the distal femur and of the proximal tibia to avoid growth disturbances. Historically, a skeletally immature athlete with an ACL injury was treated with a brace and activity modification until skeletal maturity, with ACL reconstruction being performed at that time in the “non-copers” who experienced instability. More recently, evidence has shown that delayed reconstruction may lead to increased damage to the meniscus and articular cartilage. As a result, early reconstruction is favored to protect the meniscus and allow continued physical activity. While adolescents at or those near skeletal maturity may be treated with standard reconstruction techniques, they may result in growth disturbances in younger athletes with significant growth remaining. In response to the growing need for ACL reconstruction techniques in skeletally immature individuals, physeal-sparing and physeal-respecting reconstruction techniques have been developed. In addition to the advancements in surgical technique, ACL injury prevention has also gained attention. This growing interest in ACL prevention is in part related to the high risk of ACL re-tear, either of the ACL graft or of the contralateral ACL, in children and adolescents. Recent reports indicate that well-designed neuromuscular training programs may reduce the risk of primary and subsequent ACL injuries. PMID:28652828

Effectiveness of Knee Injury and Anterior Cruciate Ligament Tear Prevention Programs: A Meta-Analysis

PubMed Central

Collins, Jamie E.; Yang, Heidi Y.; Goczalk, Melissa G.; Katz, Jeffrey N.; Losina, Elena

2015-01-01

Objective Individuals frequently involved in jumping, pivoting or cutting are at increased risk of knee injury, including anterior cruciate ligament (ACL) tears. We sought to use meta-analytic techniques to establish whether neuromuscular and proprioceptive training is efficacious in preventing knee and ACL injury and to identify factors related to greater efficacy of such programs. Methods We performed a systematic literature search of studies published in English between 1996 and 2014. Intervention efficacy was ascertained from incidence rate ratios (IRRs) weighted by their precision (1/variance) using a random effects model. Separate analyses were performed for knee and ACL injury. We examined whether year of publication, study quality, or specific components of the intervention were associated with efficacy of the intervention in a meta-regression analysis. Results Twenty-four studies met the inclusion criteria and were used in the meta-analysis. The mean study sample was 1,093 subjects. Twenty studies reported data on knee injury in general terms and 16 on ACL injury. Maximum Jadad score was 3 (on a 0–5 scale). The summary incidence rate ratio was estimated at 0.731 (95% CI: 0.614, 0.871) for knee injury and 0.493 (95% CI: 0.285, 0.854) for ACL injury, indicating a protective effect of intervention. Meta-regression analysis did not identify specific intervention components associated with greater efficacy but established that later year of publication was associated with more conservative estimates of intervention efficacy. Conclusion The current meta-analysis provides evidence that neuromuscular and proprioceptive training reduces knee injury in general and ACL injury in particular. Later publication date was associated with higher quality studies and more conservative efficacy estimates. As study quality was generally low, these data suggest that higher quality studies should be implemented to confirm the preventive efficacy of such programs. PMID:26637173

Arthroscopic medial meniscal repair with or without concurrent anterior cruciate ligament reconstruction: A subgroup analysis.

PubMed

Uzun, Erdal; Misir, Abdulhamit; Kizkapan, Turan Bilge; Ozcamdalli, Mustafa; Akkurt, Soner; Guney, Ahmet

2018-01-01

There are few large-scale, long-term studies comparing medial meniscal repairs with or without concurrent anterior cruciate ligament (ACL) reconstruction. A total of 140 patients who underwent arthroscopic medial meniscal repair were divided into two groups: Group A, meniscus repair only and Group B, meniscus repair with concurrent ACL reconstruction. Clinical assessments in- cluded physical examination findings, Lysholm score, and the International Knee Documentation Committee (IKDC) form. Barret criteria were used for the clinical assessment of healing status. Magnetic resonance imaging (MRI)was obtained to confirmhealing and failure. Subgroups of participants were compared in terms of suture technique, type of tear, and location of tear. KT-2000 arthrometer testing was used for objective evaluation of anterior-posterior knee movement. Mean follow-up duration was 61 (34-85) months. Clinical outcomes in both groups were significantly improved compared to baseline (P=0.001 vs. P=0.001); however, there was no significant between-group difference in postoperative Lysholm and IKDC scores (P=0.830). The outcomes of three participants (seven percent) in Group A and 11 (11.3%) in Group B were considered as treatment failures (P=0.55). Red-red zone tears had higher scores. Mean postoperative KT2000 arthrometer values of failed participants in Groups A and B were 4.66mm (range, four to six) and 5.2mm (range, two to seven), respectively. Concurrentmedialmeniscus repair and ACL reconstruction did not have clinical superiority over meniscus repair alone. Repairs in the red-red zone appeared to be associated with better outcomes. Copyright © 2017 Elsevier B.V. All rights reserved.

Pain in donor site after BTB-ACL reconstruction with PRGF: a randomized trial.

PubMed

Seijas, Roberto; Cuscó, Xavier; Sallent, Andrea; Serra, Iván; Ares, Oscar; Cugat, Ramón

2016-06-01

Anterior cruciate ligament (ACL) tears are highly incident injuries in young athletes within our work area. The use of the patellar graft, despite being the treatment of choice, presents post-operative problems such as anterior knee pain, which limits its use and leads to preference being taken for alternative grafts. Our aim was to evaluate if the application of PRGF reduces anterior knee pain in donor site in BTB-ACL reconstruction. 43 patients were included in the double-blinded and randomized clinical trial comparing two patient groups who underwent ACL reconstruction using patellar tendon graft, comparing anterior knee pain with and without the application of PRGF at the donor site after harvesting the graft. The PRGF group showed decreased donor site pain in comparison to the control group, with significant differences in the first two months of follow-up. The application of PRGF decreased donor site pain compared to the control group.

Arthroscopic and 3D CT Scan Evaluation of Femoral Footprint of the Anterior Cruciate Ligament in Chronic ACL Deficient Knees.

PubMed

Das, Anupam; Yadav, C S; Gamanagatti, Shivanand; Pandey, R M; Mittal, Ravi

2018-06-13

The outcome of single-bundle anterior cruciate ligament (ACL) reconstruction depends largely on the anatomic placement of bone tunnel. The lateral intercondylar ridge (LIR) and bifurcate ridge (BR) are useful bony landmarks for femoral tunnel placement. The purpose of our study was to compare the bony landmarks of ACL footprint on femur by three-dimensional computed tomography (3D CT) scan and arthroscopy in chronic ACL-deficient knees. Fifty patients above 18 years of age who were diagnosed of having ACL tear were selected for the study. All the cases were more than 6 months old since the injury. Preoperative 3D CT scan of the affected knee was obtained for each of them. They underwent single-bundle anatomic ACL reconstruction. Measurements were done on the preoperative 3D CT and arthroscopy to quantify the position of the LIR and BR. The proximodistal distance of lateral femoral condyle was 21.41+/-2.5 mm on CT scan and 22.02+/-2.02 mm on arthroscopy. On preoperative 3D CT scan, the midpoint of the LIR was found to be located at a mean distance of 11.17±2.11 mm from the proximal margin of the lateral femoral condyle. On arthroscopy, it was at 10.18+/-1.52 mm from the proximal margin the lateral femoral condyle. The "bifurcate ridge"(BR) was not visible in any of the cases during arthroscopy or CT scan. We concluded that LIR is an easily identifiable bony landmark on arthroscopy in all cases. It can also be identified on CT scans. BR is not identified both on arthroscopy and CT scans in chronic ACL tears. The arthroscopic measurements of bony landmarks are quite close to those of CT scan. Midpoint of LIR is at 52.185% of the proximodistal distance on CT scan evaluation and it is at 46.21% on arthroscopic evaluation. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Impact of Patient Sex on Clinical Outcomes

PubMed Central

Teitsma, Xavier M.; van der Hoeven, Henk; Tamminga, Rob; de Bie, Rob A.

2014-01-01

Background: The Combined Quality Care Anterior Cruciate Ligament registry provides data for clinical research regarding primary anterior cruciate ligament (ACL) surgery. Purpose: To explore the data with regard to the clinical outcomes between sexes after ACL reconstruction in a Dutch population. Study Design: Cohort study; Level of evidence, 3. Methods: Data involving patients diagnosed with an ACL tear and eligible for surgery were recorded. Isokinetic muscle strength, functional muscle performance, and anterior-posterior translation of the knee joint were documented preoperatively and at 3, 6, 9, and 12 months postoperatively. Patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner rating scales during each examination using a web-based questionnaire. Results: Approximately 90% of ACL injuries occurred during sport activities. The mean (SD) age at surgery was 28 (11) years for both men and women, and the majority of patients were treated with hamstring tendon autografts (94%). Four percent received bone–patellar tendon–bone autografts, and 2% of the patients received other grafts. Preoperatively, the KOOS, Lysholm, and Tegner scores were significantly higher in males. Twelve months postoperatively, both sexes showed comparable isokinetic strength (P = .336), knee laxity (P = .680), and hop test for distance (P = .122) when comparing the injured with the uninjured side. Self-reported knee function was comparable between sexes as assessed by the KOOS (P = .202), Lysholm (P = .872), and Tegner (P = .767) questionnaires during the 12-month follow-up. Conclusion: One year after ACL surgery, all patients had improved greatly, showing only minor differences between sexes. The male group showed slightly better results when evaluating self-reported knee questionnaires. Comparable outcomes and knee function between sexes can therefore be presumed with patients who are treated with hamstring tendon autografts in a Dutch population. Clinical Relevance: These results can be used during the clinical evaluation of patients who are eligible for ACL reconstruction. PMID:26535365

Self-Reported Fear Predicts Functional Performance and Second ACL Injury After ACL Reconstruction and Return to Sport: A Pilot Study.

PubMed

Paterno, Mark V; Flynn, Kaitlyn; Thomas, Staci; Schmitt, Laura C

Outcomes after anterior cruciate ligament reconstruction (ACLR) are highly variable. Previous studies have failed to report the relationship between fear, objective measures of function, and reinjury rates. The purpose of this study was to determine whether fear was related to functional performance measures and risk of second ACL injury after ACLR and return to sport (RTS). Fear will be associated with performance on functional testing and second ACL injury rate. Prospective cohort study. Level 2. A total of 40 patients cleared to RTS after ACLR completed the Tampa Scale of Kinesiophobia (TSK-11), hop testing, and quadriceps strength testing, bilaterally. Patients were tracked for 12 months after RTS to identify the incidence of second ACL injury. Chi-square analyses determined whether patients with high fear (TSK-11, ≥17) were more likely to have lower levels of activity, greater asymmetry on functional testing, and higher reinjury rates. Patients with greater fear on the TSK-11 (≥17) at RTS were 4 times (odds ratio [OR], 3.73; 95% CI, 0.98-14.23) more likely to report lower levels of activity, 7 times (OR, 7.1; 95% CI, 1.5-33.0) more likely to have a hop limb symmetry lower than 95%, and 6 times (OR, 6.0; 95% CI, 1.3-27.8) more likely to have quadriceps strength symmetry lower than 90%. Patients who went on to suffer an ipsilateral second ACL injury had a greater TSK-11 score at the time of RTS (mean, 19.8 ± 4.0) than those who did not suffer a second ACL injury (mean, 16.4 ± 3.6) ( P = 0.03). Patients with a TSK-11 score of 19 or greater at the time of RTS were 13 times (relative risk, 13.0; 95% CI, 2.1-81.0) more likely to suffer a second ACL tear within 24 months after RTS. Patients with greater self-reported fear were less active, presented with lower single-leg hop performance and isometric quadriceps strength, and had an increased risk of suffering a second ACL injury in the 24 months after RTS. Self-reported fear of movement/reinjury after ACLR at the time of RTS may be an important measure to incorporate into discharge criteria prior to release to return to pivoting and cutting sports after ACLR.

Intra-ligamentary autologous conditioned plasma and healing response to treat partial ACL ruptures.

PubMed

Koch, Matthias; Matteo, Berardo Di; Eichhorn, Jürgen; Zellner, Johannes; Mayr, Felix; Krutsch, Werner; Achenbach, Leonard; Woehl, Rebecca; Nerlich, Michael; Angele, Peter

2018-05-01

Conservative treatment of partial ACL ruptures is associated with a high failure rate, and often patients undergo ACL reconstruction. ACL preservation by trephination of the ACL origin and application of Autologous Conditioned Plasma (ACP) seems to be an intriguing new treatment option to favour ACL tissue healing and avoid traditional reconstruction. The aim of this study was to describe the mid-term outcomes of this new ACL preserving technique. Twenty-four patients (mean age 41.8 years) affected by partial rupture of one or both ACL bundles were included in the present trial. The partial ACL tears were arthroscopically assessed and classified according to a new five step grading system. All patients were treated by trephination of the femoral ACL stump and intra-ligamentary application of ACP. The postoperative outcome was evaluated by both subjective scores and stability testing up to a mean of 25.1 months' follow-up. Adverse events and failure rate were also documented. Clinical outcome was good to excellent with IKDC subjective 82.7 (SD 11.8), Lysholm 87.6 (SD 8.1), Tegner 5.3 (SD 2.1), Cincinnati 88.7 (SD 14.8). The failure rate (i.e. persisting knee instability assessed clinically or by rolimeter) was 12.5%. At objective measurements, knee joints showed a firm endpoint in Lachman test, negative pivot shift phenomenon and a significant reduction in AP-laxity compared to pre-operative status by rolimeter testing (p = 0.002). Return to sport practice was achieved after mean 4.8 months (SD 4.1). ACL stump trephination and concomitant intra-ligamentary application of ACP revealed promising results at mid-term follow-up to treat partial ACL lesions.

The Cost-Effectiveness of Anterior Cruciate Ligament Reconstruction in Competitive Athletes.

PubMed

Stewart, Bruce A; Momaya, Amit M; Silverstein, Marc D; Lintner, David

2017-01-01

Competitive athletes value the ability to return to competitive play after the treatment of anterior cruciate ligament (ACL) injuries. ACL reconstruction has high success rates for return to play, but some studies indicate that patients may do well with nonoperative physical therapy treatment. To evaluate the cost-effectiveness of the treatment of acute ACL tears with either initial surgical reconstruction or physical therapy in competitive athletes. Economic and decision analysis; Level of evidence, 2. The incremental cost, incremental effectiveness, and incremental cost-effectiveness ratio (ICER) of ACL reconstruction compared with physical therapy were calculated from a cost-effectiveness analysis of ACL reconstruction compared with physical therapy for the initial management of acute ACL injuries in competitive athletes. The ACL reconstruction strategy and the physical therapy strategy were represented as Markov models. Costs and quality-adjusted life-years (QALYs) were evaluated over a 6-year time horizon and were analyzed from a societal perspective. Quality of life and probabilities of clinical outcomes were obtained from the peer-reviewed literature, and costs were compiled from a large academic hospital in the United States. One-way, 2-way, and probabilistic sensitivity analyses were used to assess the effect of uncertainty in variables on the ICER of ACL reconstruction. The ICER of ACL reconstruction compared with physical therapy was $22,702 per QALY gained. The ICER was most sensitive to the quality of life of returning to play or not returning to play, costs, and duration of follow-up but relatively insensitive to the rates and costs of complications, probabilities of return to play for both operative and nonoperative treatments, and discount rate. ACL reconstruction is a cost-effective strategy for competitive athletes with an ACL injury.

Repair of Meniscal Ramp Lesions Through a Posteromedial Portal During Anterior Cruciate Ligament Reconstruction: Outcome Study With a Minimum 2-Year Follow-up.

PubMed

Thaunat, Mathieu; Jan, Nicolas; Fayard, Jean Marie; Kajetanek, Charles; Murphy, Colin G; Pupim, Barbara; Gardon, Roland; Sonnery-Cottet, Bertrand

2016-11-01

To evaluate the results of arthroscopic all-inside suture repair of medial meniscal ramp lesions through a posteromedial portal during anterior cruciate ligament (ACL) reconstruction. All patients who underwent a suture of the posterior segment of the medial meniscus using a suture hook device through a posteromedial portal during ACL reconstruction with minimum 2 year-follow-up were included in the study. Repair was performed for longitudinal tears within the rim of less than 3 mm (capsulomeniscal junction or red-red zone) or 3 to 5 mm (red-white zone) of an unstable torn meniscus. Patients were assessed pre- and postoperatively with IKDC score and Tegner activity scale. Instrumented knee testing was performed with the Rolimeter arthrometer. Complications including reoperation for failed meniscal repair were also recorded. One hundred thirty-two patients met the inclusion criteria. The mean follow-up time was 27 months (range, 24 to 29 months). The average subjective IKDC rose from 63.8 ± 13.5 (range, 27 to 92) preoperatively to 85.7 ± 12 (range, 43 to 100) at last follow-up (P < .0001). The Rolimeter test decreased from a side-to-side difference in anterior knee laxity of 7 mm (range, 5 to 14 mm) to a mean value of 0.4 mm (range, -3 to 5 mm) at last follow-up (P < .0001). The Tegner activity scale at the last follow-up (6.9 ± 1.72) was slightly lower than that before surgery (7.2 ± 1.92; P = .0017). Nine patients (6.8%) had failure of the meniscal repair. In 5 cases, recurrent tears were related to a newly formed tear located anterior to the initial tear. Our results show that arthroscopic meniscal repair of ramp lesions during ACL reconstruction through a posteromedial portal provided a high rate of meniscus healing at the level of the tear and appeared to be safe and effective in this group of patients. Level IV, therapeutic study, case series (no control group). Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

No economic benefit of early knee reconstruction over optional delayed reconstruction for ACL tears: registry enriched randomised controlled trial data.

PubMed

Kiadaliri, Aliasghar A; Englund, Martin; Lohmander, L Stefan; Carlsson, Katarina Steen; Frobell, Richard B

2016-05-01

To analyse 5-year cost-effectiveness of early versus optional delayed acute anterior cruciate ligament (ACL) reconstruction. 121 young, active adults with acute ACL injury to a previously uninjured knee were randomised to early ACL reconstruction (n=62, within 10 weeks of injury) or optional delayed ACL reconstruction (n=59; 30 with ACL reconstruction within 6-55 months); all patients received similar structured rehabilitation. Real life data on health care utilisation and sick leave were obtained from regional and national registers. Costs and quality-adjusted life years (QALYs) were discounted at 3%. Full-analysis set (based on study randomisation) and as-treated analysis (according to actual treatment over 5 years) principles were applied. Mean cost of early ACL reconstruction was €4695 higher than optional delayed ACL reconstruction (p=0.19) and provided an additional 0.13 QALYs (p=0.11). Full-analysis set showed incremental net benefit of early versus optional delayed ACL reconstruction was not statistically significantly different from zero at any level. As-treated analysis showed that costs for rehabilitation alone were €13 650 less than early ACL reconstruction (p<0.001). Results were robust to sensitivity analyses. In young active adults with acute ACL injury, a strategy of early ACL reconstruction did not provide extra economic value over a strategy of optional delayed ACL reconstruction over a 5-year period. Results from this and previous reports of the KANON-trial imply that early identification of individuals who would benefit from either early ACL reconstruction or rehabilitation alone might reduce resource consumption and decrease risk of unnecessary overtreatment. ISRCTN84752559. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Anterior cruciate ligament reconstruction: principles of treatment.

PubMed

Paschos, Nikolaos K; Howell, Stephen M

2016-11-01

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in sports medicine. Several areas of controversy exist in ACL tear management which have engaged surgeons and researchers in debates towards identifying an ideal approach for these patients.This instructional review discusses the principles of ACL reconstruction in an attempt to provide guidelines and initiate a critical thinking approach on the most common areas of controversy regarding ACL reconstruction.Using high-level evidence from the literature, as presented in randomised controlled trials, systematic reviews, and meta-analyses, operative versus conservative treatment, timing of surgery, and rehabilitation are discussed. Also, the advantages and disadvantages of the most common types of autografts, such as patellar tendon and hamstrings as well as allografts are presented.Key considerations for the anatomical, histological, biomechanical and clinical data ('IDEAL') graft positioning are reviewed. Cite this article: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 2016;398-408. DOI: 10.1302/2058-5241.1.160032.

Anterior cruciate ligament reconstruction: principles of treatment

PubMed Central

Paschos, Nikolaos K.; Howell, Stephen M.

2016-01-01

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in sports medicine. Several areas of controversy exist in ACL tear management which have engaged surgeons and researchers in debates towards identifying an ideal approach for these patients. This instructional review discusses the principles of ACL reconstruction in an attempt to provide guidelines and initiate a critical thinking approach on the most common areas of controversy regarding ACL reconstruction. Using high-level evidence from the literature, as presented in randomised controlled trials, systematic reviews, and meta-analyses, operative versus conservative treatment, timing of surgery, and rehabilitation are discussed. Also, the advantages and disadvantages of the most common types of autografts, such as patellar tendon and hamstrings as well as allografts are presented. Key considerations for the anatomical, histological, biomechanical and clinical data (‘IDEAL’) graft positioning are reviewed. Cite this article: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 2016;398-408. DOI: 10.1302/2058-5241.1.160032. PMID:28461919

Anterior cruciate ligament tears for the primary care sports physician: what to know on the field and in the office.

PubMed

Heard, Wendell M R; VanSice, Wade C; Savoie, Felix H

2015-11-01

Anterior cruciate ligament (ACL) injuries are relatively common and can lead to knee dysfunction. The classic presentation is a non-contact twisting injury with an audible pop and the rapid onset of swelling. Prompt evaluation and diagnosis of ACL injuries are important. Acute treatment consists of cessation of the sporting activity, ice, compression, and elevation with evaluation by a physician familiar with ACL injuries and their management. The diagnosis is made with the use of patient history and physical examination as well as imaging studies. Radiographs may show evidence of a bony injury. MRI confirms the diagnosis and evaluates the knee for concomitant injuries to the cartilage, menisci and other knee ligaments. For active patients, operative treatment is often recommended while less-active patients may not require surgery. The goal of this review is to discuss the diagnosis of an ACL injury and provide clear management strategies for the primary-care sports medicine physician.

Advantages of RNA-seq compared to RNA microarrays for transcriptome profiling of anterior cruciate ligament tears.

PubMed

Rai, Muhammad Farooq; Tycksen, Eric D; Sandell, Linda J; Brophy, Robert H

2018-01-01

Microarrays and RNA-seq are at the forefront of high throughput transcriptome analyses. Since these methodologies are based on different principles, there are concerns about the concordance of data between the two techniques. The concordance of RNA-seq and microarrays for genome-wide analysis of differential gene expression has not been rigorously assessed in clinically derived ligament tissues. To demonstrate the concordance between RNA-seq and microarrays and to assess potential benefits of RNA-seq over microarrays, we assessed differences in transcript expression in anterior cruciate ligament (ACL) tissues based on time-from-injury. ACL remnants were collected from patients with an ACL tear at the time of ACL reconstruction. RNA prepared from torn ACL remnants was subjected to Agilent microarrays (N = 24) and RNA-seq (N = 8). The correlation of biological replicates in RNA-seq and microarrays data was similar (0.98 vs. 0.97), demonstrating that each platform has high internal reproducibility. Correlations between the RNA-seq data and the individual microarrays were low, but correlations between the RNA-seq values and the geometric mean of the microarrays values were moderate. The cross-platform concordance for differentially expressed transcripts or enriched pathways was linearly correlated (r = 0.64). RNA-Seq was superior in detecting low abundance transcripts and differentiating biologically critical isoforms. Additional independent validation of transcript expression was undertaken using microfluidic PCR for selected genes. PCR data showed 100% concordance (in expression pattern) with RNA-seq and microarrays data. These findings demonstrate that RNA-seq has advantages over microarrays for transcriptome profiling of ligament tissues when available and affordable. Furthermore, these findings are likely transferable to other musculoskeletal tissues where tissue collection is challenging and cells are in low abundance. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:484-497, 2018. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

High Rate of Missed Lateral Meniscus Posterior Root Tears on Preoperative Magnetic Resonance Imaging

PubMed Central

Krych, Aaron J.; Wu, Isabella T.; Desai, Vishal S.; Murthy, Naveen S.; Collins, Mark S.; Saris, Daniel B.F.; Levy, Bruce A.; Stuart, Michael J.

2018-01-01

Background: Lateral meniscus posterior root tears (LMPRTs), if left untreated, can cause devastating effects to the knee, with rapid articular cartilage degeneration and loss of the meniscus as a secondary stabilizer. Detection and surgical repair of these defects have been linked to favorable outcomes, but preoperative identification of LMPRTs continues to be challenging. Purpose: To determine the rate of LMPRTs diagnosed preoperatively on magnetic resonance imaging (MRI) in a consecutive series of arthroscopically confirmed LMPRTs. Study Design: Case series; Level of evidence, 4. Methods: A retrospective cohort of 45 consecutive patients with arthroscopically confirmed LMPRTs between 2010 and 2017 were included in this study. The preoperative MRI report for each patient was evaluated and compared with intraoperative findings. Each preoperative MRI study was then reviewed by 2 fellowship-trained musculoskeletal radiologists who worked in consensus. Results: A total of 45 patients (32 males, 13 females) with arthroscopically confirmed LMPRTs and a mean age of 27 years (range, 14-54 years) were included in the study. Only 15 of 45 LMPRTs (33%) were initially diagnosed on preoperative MRI. Past or concurrent anterior cruciate ligament (ACL) reconstruction was present in 37 of 45 cases (82%). Upon retrospective review, 15 of the 30 missed LMPRTs were “clearly evident,” 12 “subtly evident,” and 3 “occult” (unavoidably missed). There were no significant differences in the rate of LMPRT diagnosis based on history of prior knee surgery, meniscus extrusion, or tearing of the meniscofemoral ligament. Conclusion: Despite improved identification of other meniscus tear patterns on MRI, a high percentage of LMPRTs were still missed. In the setting of previous ACL reconstruction, if the root cannot be confidently identified, the MRI interpretation should indicate that “the root is poorly visualized” to alert the surgeon to thoroughly evaluate this structure. The surgeon should maintain a high index of suspicion and carefully probe the posterior root of the lateral meniscus at the time of arthroscopy, especially in cases of ACL injury. PMID:29662913

THE DIAGNOSTIC ACCURACY OF THE LEVER SIGN FOR DETECTING ANTERIOR CRUCIATE LIGAMENT INJURY

PubMed Central

Anderson, Amanda; Watson, Seth; Dimeff, Robert J.

2017-01-01

Background An alternative physical examination procedure for evaluating the integrity of the anterior cruciate ligament (ACL) has been proposed in the literature but has not been validated in a broad population of patients with a symptomatic complaint of knee pain for its diagnostic value. Purpose To investigate the diagnostic accuracy of the Lever Sign to detect ACL tears and compare the results to Lachman testing in both supine and prone positions. Study design Prospective, blinded, diagnostic accuracy study. Methods Sixty-two consecutive patients with a complaint of knee pain were independently evaluated for the status of the ACL's integrity with the Lever Sign and the Lachman test in a prone and supine by a blinded examiner before any other diagnostic assessments were completed. Results Twenty-four of the 60 patients included in the analysis had a torn ACL resulting in a prevalence of 40%. The sensitivity of the Lever Sign, prone, and supine Lachman tests were 38, 83, and 67 % respectively and the specificity was 72, 89, and 97% resulting in positive likelihood ratios of 1.4, 7.5, and 24 and negative likelihood ratios of 0.86, 0.19, and 0.34 respectively. The positive predictive values were 47, 83, and 94% and the negative predictive values were 63, 89, and 81% respectively. The diagnostic odds ratios were 1.6, 40, and 70 with a number needed to diagnose of 10.3, 1.4, and 1.6 respectively. Conclusions The results of this study suggest that Lever Sign, in isolation, does not accurately detect the status of the ACL. During the clinical examination, the Lever Sign should be used as an adjunct to the gold standard assessment technique of anterior tibial translation assessment as employed in the Lachman tests in either prone or supine position. Level of Evidence 2 PMID:29234557

Readability of the Most Commonly Accessed Arthroscopy-Related Online Patient Education Materials.

PubMed

Akinleye, Sheriff D; Krochak, Ryan; Richardson, Nicholas; Garofolo, Garret; Culbertson, Maya Deza; Erez, Orry

2018-04-01

To assess the readability and comprehension of written text by the most commonly visited websites containing patient education materials on common conditions that can be treated arthroscopically. We examined 50 websites, assessed independently by 2 orthopaedic surgery residents (S.A. and G.G.), with educational materials on 5 common conditions treated by arthroscopic surgeons: anterior cruciate ligament (ACL) tear, meniscus tear, hip labral tear, shoulder labral tear, and rotator cuff tear. Following a Google search for each condition, we analyzed the 10 most visited websites for each disorder using a widely used and validated tool for assessing the reading levels of written materials (Flesch-Kincaid formula). The average grade reading level of the 50 websites studied was 9.90 with a reading ease of 52.14 ("fairly difficult, high school"). Only 26% of the websites were at or below the national average of an eighth-grade reading level. Of the 5 conditions treated by arthroscopic surgery, ACL tear had the highest average grade reading level at 10.73 ± 1.54, whereas meniscus tear had the lowest at 9.31 ± 1.81. Every condition in this study had an average readability at or above the ninth-grade reading level. The most frequently accessed materials for patients with injuries requiring arthroscopic surgery exceeds the readability recommendations of the American Medical Association and National Institutes of Health, as well as the average reading ability of US adults. Given the fact that these are the most commonly visited websites by the lay public, there needs to be a greater emphasis on tailoring written information to the literacy levels of the patient population. This study emphasizes the discrepancy between the recommended versus the measured reading levels of online patient education materials related to conditions treated by arthroscopic surgeons. The subject matter of these conditions is inherently complex; thus, relying solely on text to inform patients increases the likelihood that the reading level of the material exceeds that of the majority of the lay public. Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Anterior cruciate ligament injury/reinjury in alpine ski racing: a narrative review

PubMed Central

Jordan, Matthew J; Aagaard, Per; Herzog, Walter

2017-01-01

The purpose of the present review was to: 1) provide an overview of the current understanding on the epidemiology, etiology, risk factors, and prevention methods for anterior cruciate ligament (ACL) injury in alpine ski racing; and 2) provide an overview of what is known pertaining to ACL reinjury and return to sport after ACL injury in alpine ski racing. Given that most of the scientific studies on ACL injuries in alpine ski racing have been descriptive, and that very few studies contributed higher level scientific evidence, a nonsystematic narrative review was employed. Three scholarly databases were searched for articles on ACL injury or knee injury in alpine ski racing. Studies were classified according to their relevance in relation to epidemiology, etiology, risk factors, and return to sport/reinjury prevention. Alpine ski racers (skiers) were found to be at high risk for knee injuries, and ACL tears were the most frequent diagnosis. Three primary ACL injury mechanism were identified that involved tibial internal rotation and anteriorly directed shear forces from ski equipment and the environment. While trunk muscle strength imbalance and genetics were found to be predictive of ACL injuries in development-level skiers, there was limited scientific data on ACL injury risk factors among elite skiers. Based on expert opinion, research on injury risk factors should focus on equipment design, course settings/speed, and athlete factors (eg, fitness). While skiers seem to make a successful recovery following ACL injury, there may be persistent neuromuscular deficits. Future research efforts should be directed toward prospective studies on ACL injury/reinjury prevention in both male and female skiers and toward the effects of knee injury on long-term health outcomes, such as the early development of osteoarthritis. International collaborations may be necessary to generate sufficient statistical power for ACL injury/reinjury prevention research in alpine ski racing. PMID:28435336

MRI signal intensity of anterior cruciate ligament graft after transtibial versus anteromedial portal technique (TRANSIG): design of a randomized controlled clinical trial.

PubMed

Ruiter, Simeon J S; Brouwer, Reinoud W; Meys, Tim W G M; Slump, Cornelis H; van Raay, Jos J A M

2016-08-10

There are two primary surgical techniques to reconstruct the anterior cruciate ligament (ACL), transtibial (TT) technique and anteromedial portal (AMP) technique. Currently, there is no consensus which surgical technique elicits the best clinical and functional outcomes. MRI-derived measures of the signal intensity (SI) of the ACL graft have been described as an independent predictor of graft properties. The purpose of this study is to compare the MRI derived SI measurements of the ACL graft one year after ACL reconstruction, in order to compare the outcomes of both the AMP and TT ACL reconstruction technique. Thirty-six patients will be included in a randomized controlled trial. Patients who are admitted for primary unilateral ACL reconstruction will be included in the study. Exclusion criteria are a history of previous surgery on the ipsilateral knee, re-rupture of the ipsilateral ACL graft, associated ligamentous injuries or meniscal tear of the ipsilateral knee, unhealthy contralateral knee, contra-indications for MRI and a preference for one of the two surgical techniques and/or orthopaedic surgeon. Primary outcome is MRI Signal intensity ratio (SIR) of the ACL graft. Secondary outcome measures are the International Knee Documentation Committee (IKDC) Knee Examination Form,the Knee injury and Osteoarthritis Outcome Scores (KOOS) and the Anterior Cruciate Ligament OsteoArthritis Score (ACLOAS). Differences between MRI SIR assessment with the current MRI protocol (proton density weighted imaging protocol) and the additional T2*-weighted gradient-echo protocol will be assessed. There is no consensus regarding the TT or AMP ACL reconstruction technique. SI measurements with MRI have been used in other clinical studies for evaluation of the ACL graft and maturation after ACL reconstruction compared to clinical and functional outcomes. This randomized controlled trial has been designed to compare the TT technique with the AMP technique with the use of MRI SI of the graft after ACL reconstruction. Netherlands Trial Registry NTR5410 (registered on August 24, 2015).

Evaluation of Meniscal Mechanics and Proteoglycan Content in a Modified Anterior Cruciate Ligament Transection Model

PubMed Central

Fischenich, Kristine M.; Coatney, Garrett A.; Haverkamp, John H.; Button, Keith D.; DeCamp, Charlie; Haut, Roger C.; Haut Donahue, Tammy L.

2014-01-01

Post-traumatic osteoarthritis (PTOA) develops as a result of traumatic loading that causes tears of the soft tissues in the knee. A modified transection model, where the anterior cruciate ligament (ACL) and both menisci were transected, was used on skeletally mature Flemish Giant rabbits. Gross morphological assessments, elastic moduli, and glycosaminoglycan (GAG) coverage of the menisci were determined to quantify the amount of tissue damage 12 weeks post injury. This study is one of the first to monitor meniscal changes after inducing combined meniscal and ACL transections. A decrease in elastic moduli as well as a decrease in GAG coverage was seen. PMID:24749144

Revision Anterior Cruciate Ligament Reconstruction

PubMed Central

Wilde, Jeffrey; Bedi, Asheesh; Altchek, David W.

2014-01-01

Context: Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures, with more than 200,000 ACL tears occurring annually. Although primary ACL reconstruction is a successful operation, success rates still range from 75% to 97%. Consequently, several thousand revision ACL reconstructions are performed annually and are unfortunately associated with inferior clinical outcomes when compared with primary reconstructions. Evidence Acquisition: Data were obtained from peer-reviewed literature through a search of the PubMed database (1988-2013) as well as from textbook chapters and surgical technique papers. Study Design: Clinical review. Level of Evidence: Level 4. Results: The clinical outcomes after revision ACL reconstruction are largely based on level IV case series. Much of the existing literature is heterogenous with regard to patient populations, primary and revision surgical techniques, concomitant ligamentous injuries, and additional procedures performed at the time of the revision, which limits generalizability. Nevertheless, there is a general consensus that the outcomes for revision ACL reconstruction are inferior to primary reconstruction. Conclusion: Excellent results can be achieved with regard to graft stability, return to play, and functional knee instability but are generally inferior to primary ACL reconstruction. A staged approach with autograft reconstruction is recommended in any circumstance in which a single-stage approach results in suboptimal graft selection, tunnel position, graft fixation, or biological milieu for tendon-bone healing. Strength-of-Recommendation Taxonomy (SORT): Good results may still be achieved with regard to graft stability, return to play, and functional knee instability, but results are generally inferior to primary ACL reconstruction: Level B. PMID:25364483

DOE Office of Scientific and Technical Information (OSTI.GOV)

Niitsu, Mamoru; Ikeda, Kotaroh; Fukubayashi, Tohru

Our goal was to assess the effect of joint position of semiflexed and extended knees in MR delineation of the anterior cruciate ligament (ACL). With a mobile knee brace and a flexible surface coil, the knee joint was either fully extended or bent to a semiflexed position (average 45{degrees} of flexion) within the magnet bore. Sets of oblique sagittal MR images were obtained for both extended and flexed knee positions. Thirty-two knees with intact ACLs and 43 knees with arthroscopically proven ACL tears were evaluated. Two observers compared paired MR images of both extended and flexed positions and rated themmore » by a relative three point scale. Anatomic correlation in MR images was obtained by a cadaveric knee with incremental flexion. The MR images of flexed knees were more useful than of extended knees in 53% of the case reviews of femoral attachments and 36% of reviews of midportions of normal ACLs. Compared with knee extensions, the MR images for knee flexion provided better clarity in 48% of reviews of disrupted sites and 52% of residual bundles of torn ACLs. Normal ACL appeared taut in the knee extension and lax in semiflexion. Compared with MR images of knees in extension, MR images of knees in flexion more clearly delineate the femoral side of the ligament with wider space under the intercondylar roof and with decreased volume-averaging artifacts, providing superior visualization of normal and torn ACLs. 13 refs., 7 figs., 1 tab.« less

Mechanisms of ACL injury in professional rugby union: a systematic video analysis of 36 cases.

PubMed

Montgomery, Connor; Blackburn, Jeff; Withers, Daniel; Tierney, Gregory; Moran, Cathal; Simms, Ciaran

2016-12-30

The mechanisms of ACL injury in rugby are not well defined. To describe the mechanisms of ACL injury in male professional rugby players using systematic video analysis. 36 cases from games played in top professional leagues and international matches were analysed. 5 analysts independently assessed all videos to record the estimated frame/time of initial ground contact, frame/time of ACL tear and a range of play specific variables. This included contact versus non-contact ACL injuries, injury timing, joint flexion angles and foot contact with the ground. 37 side-stepping manoeuvres from a control game were analysed to allow comparison of non-injury versus injury situations. 57% of ACL injuries occurred in a contact manner. 2 main scenarios were identified: (1) offensive running and (2) being tackled, indicating that the ball carrier might be at higher risk of ACL injury. The majority of non-contact ACL injuries resulted from a side-stepping manoeuvre. In most non-contact cases, initial ground contact was through heel strike. Statistical assessment of heel strike at initial ground contact versus non-heel strike cases showed a significant difference in injury versus non-injury outcomes, with heel strike associated with higher injury risk. Non-contact ACL injuries had lower median knee flexion angles and a more dorsiflexed ankle when compared with a control group (10° vs 20°, p≤0.001 and 10° vs 0°, p=0.033 respectively). Over half of ACL injuries in rugby in our analysis resulted from a contact mechanism. For non-contact injuries, lower knee flexion angles and heel-first ground contact in a side-stepping manoeuvre were associated with ACL injury. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Acute Management of Anterior Cruciate Ligament Injuries Using Novel Canine Models.

PubMed

Bozynski, Chantelle C; Stannard, James P; Smith, Pat; Hanypsiak, Bryan T; Kuroki, Keiichi; Stoker, Aaron; Cook, Cristi; Cook, James L

2016-10-01

The objective of this study was to compare treatment options for acute management of anterior cruciate ligament (ACL) injuries using preclinical models. Twenty-seven adult purpose-bred research hounds underwent knee surgery (sham control, exposed ACL, or partial-tear ACL) and were assessed over the following 8 weeks. Dogs were randomized into three treatment groups: standard of care (i.e., rest and nonsteroidal anti-inflammatory drugs [NSAIDs]), washout, or leukoreduced platelet-rich plasma (PRP) so that a total of nine dogs received each treatment. Data from the two ACL-injury groups were pooled for each treatment ( n  = 6 per treatment group) and analyzed for treatment effects. The washout and PRP groups experienced less lameness, pain, and effusion, and greater function and comfortable range of motion compared with the NSAID group, with the PRP group showing most benefits. PRP was associated with the lowest severity of ACL pathology based on arthroscopic assessment. Measurable levels of inflammatory and degradative biomarkers were present in synovial fluid with significant differences noted over time. Based on these findings, washout had positive clinical effects compared with the standard-of-care group especially within the first week of treatment, but became less beneficial over time. A single injection of leukoreduced PRP was associated with favorable clinical results. However, no treatment was significantly "protective" against progression toward osteoarthritis after ACL injury. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Effects of ACL Reconstructive Surgery on Temporal Variations of Cytokine Levels in Synovial Fluid

PubMed Central

Bigoni, Marco; Gandolla, Marta; Sacerdote, Paola; Piatti, Massimiliano; Castelnuovo, Alberto; Franchi, Silvia; Gorla, Massimo; Munegato, Daniele; Gaddi, Diego; Pedrocchi, Alessandra; Omeljaniuk, Robert J.; Locatelli, Vittorio; Torsello, Antonio

2016-01-01

Anterior cruciate ligament (ACL) reconstruction restores knee stability but does not reduce the incidence of posttraumatic osteoarthritis induced by inflammatory cytokines. The aim of this research was to longitudinally measure IL-1β, IL-6, IL-8, IL-10, and TNF-α levels in patients subjected to ACL reconstruction using bone-patellar tendon-bone graft. Synovial fluid was collected within 24–72 hours of ACL rupture (acute), 1 month after injury immediately prior to surgery (presurgery), and 1 month thereafter (postsurgery). For comparison, a “control” group consisted of individuals presenting chronic ACL tears. Our results indicate that levels of IL-6, IL-8, and IL-10 vary significantly over time in reconstruction patients. In the acute phase, the levels of these cytokines in reconstruction patients were significantly greater than those in controls. In the presurgery phase, cytokine levels in reconstruction patients were reduced and comparable with those in controls. Finally, cytokine levels increased again with respect to control group in the postsurgery phase. The levels of IL-1β and TNF-α showed no temporal variation. Our data show that the history of an ACL injury, including trauma and reconstruction, has a significant impact on levels of IL-6, IL-8, and IL-10 in synovial fluid but does not affect levels of TNF-α and IL-1β. PMID:27313403

Effects of ACL Reconstructive Surgery on Temporal Variations of Cytokine Levels in Synovial Fluid.

PubMed

Bigoni, Marco; Turati, Marco; Gandolla, Marta; Sacerdote, Paola; Piatti, Massimiliano; Castelnuovo, Alberto; Franchi, Silvia; Gorla, Massimo; Munegato, Daniele; Gaddi, Diego; Pedrocchi, Alessandra; Omeljaniuk, Robert J; Locatelli, Vittorio; Torsello, Antonio

2016-01-01

Anterior cruciate ligament (ACL) reconstruction restores knee stability but does not reduce the incidence of posttraumatic osteoarthritis induced by inflammatory cytokines. The aim of this research was to longitudinally measure IL-1β, IL-6, IL-8, IL-10, and TNF-α levels in patients subjected to ACL reconstruction using bone-patellar tendon-bone graft. Synovial fluid was collected within 24-72 hours of ACL rupture (acute), 1 month after injury immediately prior to surgery (presurgery), and 1 month thereafter (postsurgery). For comparison, a "control" group consisted of individuals presenting chronic ACL tears. Our results indicate that levels of IL-6, IL-8, and IL-10 vary significantly over time in reconstruction patients. In the acute phase, the levels of these cytokines in reconstruction patients were significantly greater than those in controls. In the presurgery phase, cytokine levels in reconstruction patients were reduced and comparable with those in controls. Finally, cytokine levels increased again with respect to control group in the postsurgery phase. The levels of IL-1β and TNF-α showed no temporal variation. Our data show that the history of an ACL injury, including trauma and reconstruction, has a significant impact on levels of IL-6, IL-8, and IL-10 in synovial fluid but does not affect levels of TNF-α and IL-1β.

Return to Sports and Subsequent Injury Rates After Revision Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft.

PubMed

Shelbourne, K Donald; Benner, Rodney W; Gray, Tinker

2014-06-01

The return-to-sport and reinjury rates are not well defined after revision anterior cruciate ligament (ACL) reconstruction. School-age athletes would have a higher rate of return to sports and reinjury to either knee after revision ACL surgery compared with college or recreational athletes. Cohort study; Level of evidence, 2. Patients were prospectively studied after revision ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft. Participants were grouped by competitive sport levels of school age (mean age, 16.6 ± 0.9 years; n = 84), college (19.6 ± 1.2 years; n = 58), or recreational adult (27.6 ± 4.1 years; n = 117). An activity survey was used to determine the specific sport and sport level patients participated in before and after surgery. The International Knee Documentation Committee (IKDC) knee survey and Cincinnati Knee Rating System (CKRS) survey responses were also obtained. The rate of return to the same sport at the same level was 62 of 84 school-age athletes (74%), 43 of 58 college athletes (74%), and 73 of 117 recreational athletes (62%) (P = .1065). The number of patients who had a subsequent ACL graft tear rate after revision surgery was 2 of 84 (2.3%) in the high school group, 3 of 58 (5.1%) in the college group, and 4 of 117 (3.4%) in the recreational group (P = .6706). The number of patients who had a subsequent ACL tear in the contralateral knee was 1 of 84 (1.1%) in the school-age group, 1 of 58 (1.7%) in the college group, and 2 of 117 (1.7%) in the recreational group (P = .9501). At 2 years postoperatively, the mean IKDC subjective total score was 86.1 ± 11.7 points and the mean CKRS total score was 89.7 ± 11.1 points. Revision ACL reconstruction with BPTB autograft and perioperative rehabilitation allowed high school and college athletes to return to sports at the preinjury level at a rate of 74%; the return rate for recreational-level adults was 62%. Reinjury rates in the first 5 years after revision surgery ranged from 2% to 5%, which is lower than what has been reported for young competitive athletes after primary surgery. © 2014 The Author(s).

Epidemiological profile of sports-related knee injuries in northern India: An observational study at a tertiary care centre.

PubMed

John, R; Dhillon, M S; Syam, K; Prabhakar, S; Behera, P; Singh, H

2016-01-01

Sports-related knee injuries occur commonly in athletes. However, there is no published epidemiological study from India till date. The purpose of this study was to identify common injuries sustained by Indian athletes participating in different sports and to study various associated demographic features. A secondary objective was to investigate different factors, which may affect return to sport by the athlete. Cross-sectional study (observational study). Sports injury clinic, PGIMER, Chandigarh. Out of 465 athletes who presented to us with sports-related knee injuries over a 5-year period, 363 athletes (from 24 different sports) with complete records were identified. Data were analysed for demographic features, type of sport, mechanism of injury, injury scenario, athlete's level of play, injury duration at presentation, injury patterns and type of management. Telephonic interviews were conducted with each athlete to enquire about return to sport and time lost in sport due to the knee injury. Factors associated with return to sport were investigated using statistical tests of association. Soccer was found to be the most common sport associated with knee injuries accounting for 30.6% of the injuries followed by kabaddi (20.9%). The most common mechanism was non-contact injury (64.4%). Competitive injuries were found to be significantly more than practice/training injuries (p < 0.0001). The most common injuries noted were ACL tears (n = 314) followed by meniscus injuries (n = 284) and the most common combination of injuries were an ACL tear with medial meniscus tear (n = 163). Only 39.8% of the athletes returned to sport. Mean duration of time lost in sport among those who returned to sport was 8.84 months. Return to sport was significantly associated with body mass index, level of competitiveness of the athlete and type of management (p = 0.017, 0.045 and <0.0001, respectively). Knee injuries take a huge toll on an athlete's career as observed in this study. Prevention of knee injuries is of paramount importance and more focussed epidemiological studies are needed for formulating policies to prevent sports injuries in both professional and amateur athletes. IV.

Relationship Between the Risk of Suffering a First-Time Noncontact ACL Injury and Geometry of the Femoral Notch and ACL: A Prospective Cohort Study With a Nested Case-Control Analysis.

PubMed

Whitney, Darryl C; Sturnick, Daniel R; Vacek, Pamela M; DeSarno, Mike J; Gardner-Morse, Mack; Tourville, Timothy W; Smith, Helen C; Slauterbeck, James R; Johnson, Robert J; Shultz, Sandra J; Hashemi, Javad; Beynnon, Bruce D

2014-08-01

The morphometric characteristics of the anterior cruciate ligament (ACL) and the femoral intercondylar notch within which it resides have been implicated as risk factors for injuries to this important stabilizer of the knee. Prior research has produced equivocal results with differing methodologies, and consequently, it is unclear how these characteristics affect the injury risk in male and female patients. The morphometric characteristics of the ACL and femoral intercondylar notch are individually and independently associated with the risk of suffering a noncontact ACL injury, and these relationships are different in male and female patients. Case-control study; Level of evidence, 3. Magnetic resonance imaging scans of the bilateral knees were obtained on 88 case-control pairs (27 male, 61 female) matched for age, sex, and participation on the same sports team. Patients had suffered a grade III, first-time, noncontact ACL tear. The femoral notch width at 4 locations, the thickness of the bony ridge at the anteromedial outlet of the femoral notch, the femoral notch volume, ACL volume, and ACL cross-sectional area were measured. Multivariate analysis of combined data from male and female patients revealed that decreased ACL volume (odds ratio [OR], 0.829), decreased femoral notch width (OR, 0.700), and increased bony ridge thickness at the anteromedial outlet of the femoral notch (OR, 1.614) were significant independent predictors of an ACL injury. Separate analyses of male and female patients indicated that the femoral notch ridge may be more strongly associated with a risk in female patients, while ACL volume is more strongly associated with a risk in male patients. However, statistical analysis performed with an adjustment for body weight strengthened the association between ACL volume and the risk of injuries in female patients. Morphometric features of both the ACL and femoral notch combine to influence the risk of suffering a noncontact ACL injury. When included together in a multivariate model that adjusts for body weight, the effects of the morphometric measurements are similar in male and female patients. If body weight is not taken into consideration, ACL volume is not associated with a risk in female patients. © 2014 The Author(s).

Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft.

PubMed

Mirouse, G; Rousseau, R; Casabianca, L; Ettori, M A; Granger, B; Pascal-Moussellard, H; Khiami, F

2016-11-01

The surgical revision rate following anterior cruciate ligament (ACL) surgery is 3% at 2 years and 4% at 5 years. Revision ACL surgery raises the question of the type of graft to be used. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata graft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery. A single-center retrospective continuous study included 30 sports players with a mean age of 26.8±8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multi-ligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at end of follow-up. Clinical assessment used subjective IKDC, Lysholm and KOOS scores. At a mean 4.6±1.6 years' follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective IKDC score increased from 57 [54.3; 58.5] preoperatively to 82 [68.3; 90] at last follow-up, and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8]; KOOS score at last follow-up was 94.7 [83; 100]. Functional results in revision ACL reconstruction by fascia lata graft were satisfactory, with similar return-to-sports rates as with other techniques. Fascia lata provides a reliable graft in revision ACL surgery. IV, retrospective study. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Should return to sport be delayed until two years after anterior cruciate ligament reconstruction? Biological and functional considerations

PubMed Central

Nagelli, Christopher V.; Hewett, Timothy E.

2016-01-01

Anterior cruciate ligament (ACL) tears are common knee injuries sustained by athletes during sports participation. A devastating complication of returning to sport following ACL reconstruction (ACLR) is a second ACL injury. Strong evidence now indicates that younger, more active athletes are at particularly high risk for a second ACL injury and this risk is greatest within the first two years following ACLR. Nearly one-third of the younger cohort that resumes sports participation will sustain a second ACL injury within the first two years after ACLR. The evidence indicates that the risk of second injury may abate over this time period. The incidence rate of second injuries in the first year after ACLR is significantly greater than the rate in the second year. The lower relative risk in the second year may be related to athletes achieving baseline joint health and function well after the current expected timeline (6 to 12 months) to be released to unrestricted activity. This highlights a considerable debate in the return to sport decision process as to whether an athlete should wait until two years after ACLR to return to unrestricted, sports activity. In this review, we present evidence in the literature that athletes achieve baseline joint health and function approximately two years after ACLR. We postulate that delay in returning to sports for nearly two years will significantly reduce the incidence of second ACL injuries. PMID:27402457

Collagen-Platelet Composite Enhances Biomechanical and Histologic Healing of the Porcine Anterior Cruciate Ligament

PubMed Central

Joshi, Shilpa M.; Mastrangelo, Ashley N.; Magarian, Elise M.; Fleming, Braden C.; Murray, Martha M.

2010-01-01

Background The anterior cruciate ligament (ACL) fails to heal after traumatic rupture. Furthermore, large-animal models have recently shown that 1-month functional ACL healing is augmented after suture repair when a bioactive scaffold is placed in the tear site. Hypothesis At the time of suture repair, placement of a bioactive scaffold in the ACL wound site would improve the structural properties of the tissue. Study Design Controlled laboratory study. Methods Twenty-seven knees in immature pigs underwent ACL transection and suture repair. A collagen-platelet composite (CPC) was used to supplement the repair in 14 knees. Knees were harvested at 4 weeks, 6 weeks, and 3 months. Mechanical testing and histologic analysis were performed. Results The addition of a CPC to a suture repair resulted in improvements in yield load and linear stiffness of the repair tissue at 3 months, as well as a significant increase in cell density. A reduction in yield load and stiffness occurred at the 6-week time point in both groups, a phase when revascularization was noted. Conclusion The addition of a CPC to a suture repair enhanced the structural properties of the ACL, and the improvement was associated with increased cellularity within the healing ligament. Clinical Relevance The addition of a bioactive scaffold to the wound site improved the functional healing of the ACL after suture repair. The decreased repair strength during revascularization may indicate a need to protect the repair site through this period. PMID:19940313

Double-layer versus single-layer bone-patellar tendon-bone anterior cruciate ligament reconstruction: a prospective randomized study with 3-year follow-up.

PubMed

Mei, Xiaoliang; Zhang, Zhenxiang; Yang, Jingwen

2016-12-01

To evaluate the clinical results of a randomized controlled trial of single-layer versus double-layer bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. Fifty-eight subjects who underwent primary ACL reconstruction with a BPTB allograft were prospectively randomized into two groups: single-layer reconstruction (n = 31) and double-layer reconstruction (n = 27). The following evaluation methods were used: clinical examination, KT-1000 arthrometer measurement, muscle strength, Tegner activity score, Lysholm score, subjective rating scale regarding patient satisfaction and sports performance level, graft retear, contralateral ACL tear, and additional meniscus surgery. Forty-eight subjects (24 in single-layer group and 24 in double-layer group) who were followed up for 3 years were evaluated. Preoperatively, there were no differences between the groups. At 3-year follow-up, the Lachman and pivot-shift test results were better in the double-layer group (P = 0.019 and P < 0.0001, respectively). KT measurements were better in the double-layer group (mean 2.9 versus 1.5 mm; P = 0.0025). The Tegner score was also better in the double-layer group (P = 0.024). There were no significant differences in range of motion, muscle strength, Lysholm score, subjective rating scale, graft retear, and secondary meniscal tear. In ACL reconstruction, double-layer BPTB reconstruction was significantly better than single-layer reconstruction regarding anterior and rotational stability at 3-year follow-up. The results of KT measurements and the Lachman and pivot-shift tests were significantly better in the double-layer group, whereas there was no difference in the anterior drawer test results. The Tegner score was also better in the double-layer group; however, there were no differences in the other subjective findings.

Certified Athletic Trainers' Knowledge and Perceptions of Posttraumatic Osteoarthritis After Knee Injury.

PubMed

Pietrosimone, Brian; Blackburn, J Troy; Golightly, Yvonne M; Harkey, Matthew S; Luc, Brittney A; DeFreese, J D; Padua, Darin A; Jordan, Joanne M; Bennell, Kim L

2017-06-02

  Posttraumatic osteoarthritis (PTOA) is a specific phenotype of osteoarthritis (OA) that commonly develops after acute knee injury, such as anterior cruciate ligament (ACL) or meniscal injury (or both). Athletic trainers (ATs) are well positioned to educate patients and begin PTOA management during rehabilitation of the acute injury, yet it remains unknown if ATs currently prioritize long-term outcomes in patients with knee injury.   To investigate ATs' knowledge and perceptions of OA and its treatment after ACL injury, ACL reconstruction, or meniscal injury or surgery.   Cross-sectional study.   An online survey was administered to 2000 randomly sampled certified ATs. We assessed participants' perceptions of knee OA, the risk of PTOA after ACL or meniscal injury or surgery, and therapeutic management of knee OA.   Of the 437 ATs who responded (21.9%), the majority (84.7%) correctly identified the definition of OA, and 60.3% indicated that they were aware of PTOA. A high percentage of ATs selected full meniscectomy (98.9%), meniscal tear (95.4%), ACL injury (90.2%), and partial meniscectomy (90.1%) as injuries that would increase the risk of developing OA. Athletic trainers rated undertaking strategies to prevent OA development in patients after ACL injury or reconstruction (73.8%) or meniscal injury or surgery (74.7%) as extremely or somewhat important. Explaining the risk of OA to patients with an ACL or meniscal injury was considered appropriate by 98.8% and 96.8% of respondents, respectively; yet a lower percentage reported that they actually explained these risks to patients after an ACL (70.8%) or meniscal injury (80.6%).   Although 84.7% of ATs correctly identified the definition of OA, a lower percentage (60.3%) indicated awareness of PTOA. These results may reflect the need to guide ATs on how to educate patients regarding the long-term risks of ACL and meniscal injuries and how to implement strategies that may prevent PTOA.

Assessment of neuromuscular risk factors for anterior cruciate ligament injury through tensiomyography in male soccer players.

PubMed

Alentorn-Geli, Eduard; Alvarez-Diaz, Pedro; Ramon, Silvia; Marin, Miguel; Steinbacher, Gilbert; Boffa, Juan José; Cuscó, Xavier; Ballester, Jordi; Cugat, Ramon

2015-09-01

To investigate the role of mechanical and contractile properties of skeletal muscles of the thigh, assessed through tensiomyography (TMG), as risk factors for anterior cruciate ligament (ACL) injury in male soccer players. Male soccer players with confirmed ACL tear included in this study underwent resting TMG assessment of thigh muscles of the uninjured side. The same values were obtained from a sex-, sports level-matched control group in both sides. The maximal displacement (Dm), delay time (Td), contraction time (Tc), sustained time (Ts), and half-relaxation time (Tr) were obtained for the following muscles in all subjects: vastus medialis (VM), vastus laterals (VL), rectus femoris (RF), semitendinosus (ST), and biceps femoris (BF). TMG values of the uninjured side in ACL-injured group were compared to mean values between both sides in the control subjects. There were 40 ACL-injured and 38 control individuals. The vast majority of TMG parameters were higher in the uninjured side of ACL-injured individuals compared to the control group. The VL-Tr, RF-Tc, RF-Ts, RF-Tr, and BF-Dm values were significantly higher in the uninjured side compared to the control group. Quadriceps muscles demonstrated more significant between-group differences than hamstring muscles. Specifically, RF was the muscle where most significant between-group differences were found. Resistance to fatigue and muscle stiffness in the hamstring muscles may be risk factors for ACL injury in male soccer players. In addition, a predominant impairment in TMG characteristics of the quadriceps over hamstrings may indicate an altered muscular co-contraction (imbalance) between both muscle groups, which might be another risk factor for ACL injury in this population. These findings should be taken into account when screening athletes at high risk of ACL injury and also to design adequate prevention programs for ACL injury in male soccer players.

Knee joint kinematics after dynamic intraligamentary stabilization: cadaveric study on a novel anterior cruciate ligament repair technique.

PubMed

Schliemann, Benedikt; Lenschow, Simon; Domnick, Christoph; Herbort, Mirco; Häberli, Janosch; Schulze, Martin; Wähnert, Dirk; Raschke, Michael J; Kösters, Clemens

2017-04-01

Dynamic intraligamentary stabilization (DIS) has been introduced for the repair of acute anterior cruciate ligament (ACL) tears as an alternative to delayed reconstruction. The aim of the present study was to compare knee joint kinematics after DIS to those of the ACL-intact and ACL-deficient knee under simulated Lachman/KT-1000 and pivot-shift tests. We hypothesized that DIS provides knee joint kinematics equivalent to an intact ACL. With the use of a robotic knee simulator, knee kinematics were determined in simulated Lachman/KT-1000 and pivot-shift tests at 0°, 15°, 30°, 60°, and 90° of flexion in eight cadaveric knees under the following conditions: (1) intact ACL, (2) ACL deficiency, (3) DIS with a preload of 60 N, and (4) DIS with a preload of 80 N. Statistical analyses were performed using two-factor repeated-measures analysis of variance. The significance level was set at a p value of <0.05. After DIS with a preload of either 60 N or 80 N, the anterior translation was significantly reduced in the simulated Lachman/KT-1000 and pivot-shift tests when compared to the ACL-deficient knee (p < 0.05). No significant differences were observed between the DIS reconstruction with a preload of 80 N and the intact ACL with regard to anterior laxity in either test. However, DIS with a preload of only 60 N was not able to restore knee joint kinematics to that of an intact knee in all degrees of flexion. DIS with a preload of 80 N restores knee joint kinematics comparable to that of an ACL-intact knee and is therefore capable of providing knee joint stability during ACL healing. DIS therefore provides a new technique for primary ACL repair with superior biomechanical properties in comparison with other techniques that have been described previously, although further clinical studies are required to determine its usefulness in clinical settings.

Editorial Commentary: "Defer No Time, Delays Have Dangerous Ends" (Henry VI, Shakespeare): Delayed Anterior Cruciate Ligament Reconstruction Has Consequences.

PubMed

Siegel, Mark G

2018-06-01

There continues to be controversy over the timing of anterior cruciate ligament (ACL) surgery. Early or delayed intervention after ACL injury is a topic that has not been settled. The issue is whether ACL tears should have surgery performed in an expedient manner. Or is delay an option with no repercussions to the health of the knee? My associates in nonsurgical specialties wave the New England Journal of Medicine to support their view that surgery is not needed. I routinely espouse the literature confirming that delay of surgery may cause future damage. It is now established that a failure to intervene in a timely manner does cause additional damage. I stand vindicated and can affirm to my colleagues that I have found the answer. There is no longer any doubt or equivocation. Delay in reconstructing an unstable knee does cause damage. Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Anterolateral ligament abnormalities in patients with acute anterior cruciate ligament rupture are associated with lateral meniscal and osseous injuries.

PubMed

Van Dyck, Pieter; Clockaerts, Stefan; Vanhoenacker, Filip M; Lambrecht, Valérie; Wouters, Kristien; De Smet, Eline; Gielen, Jan L; Parizel, Paul M

2016-10-01

To determine the frequency of anterolateral ligament (ALL) injury in patients with acute anterior cruciate ligament (ACL) rupture and to analyse its associated injury patterns. Ninety patients with acute ACL rupture for which MRI was obtained within 8 weeks after the initial trauma were retrospectively identified. Two radiologists assessed the status of the ALL on MRI by consensus. The presence or absence of an ALL abnormality was compared with the existence of medial and lateral meniscal tears diagnosed during arthroscopy. Associated collateral ligament and osseous injuries were documented with MRI. Forty-one of 90 knees (46 %) demonstrated ALL abnormalities on MRI. Of 49 knees with intact ALL, 15 (31 %) had a torn lateral meniscus as compared to 25 torn lateral menisci in 41 knees (61 %) with abnormal ALL (p = 0.008). Collateral ligament (p ≤ 0.05) and osseous injuries (p = 0.0037) were more frequent and severe in ALL-injured as compared with ALL-intact knees. ALL injuries are fairly common in patients with acute ACL rupture and are statistically significantly associated with lateral meniscal, collateral ligament and osseous injuries. • ALL injuries are fairly common in patients with acute ACL rupture. • ALL injuries are highly associated with lateral meniscal and osseous injuries. • MRI assessment of ACL-injured knees should include evaluation of the ALL.

Corneal confocal microscopy and dry eye findings in contact lens discomfort patients.

PubMed

Dogan, Aysun Sanal; Gurdal, Canan; Arslan, Nese

2018-02-01

To evaluate the corneal confocal microscopy and dry eye findings in patients with contact lens discomfort. The study included 3 groups of participants: Contact lens wearers using silicone hydrogel soft contact lenses who are symptomatic (CLD, n=15) or asymptomatic (ACL, n=11) and non-wearers as controls (n=14). Duration of contact lens wear, Ocular Surface Disease Index (OSDI) questionnaire responses, fluorescein tear break-uptime (FBUT), and corneal confocal microscopy findings were recorded. Mean age was 25.7±8.2 years and male/female ratio was 7/33. Demographic findings were similar regarding the groups. CLD patients had a longer lens use history than ACL (median 5 vs 2 years, p<0.001). OSDI scores were higher in CLD group than ACL or controls (p<0.001, p=0.002). FBUT was significantly lowest in CLD group, compared to controls and ACL (p<0.001, p=0.039). FBUT was also lower in ACL patients compared to controls (p=0.036). There was no difference between basal epithelium cell counts between all 3 groups. Anterior stromal activated keratocyte numbers were similar between contact lens using groups but was lower in controls (p=0.005). However, dendritiform cells in the sub-basal nerve layer were higher in CLD group compared to controls but similar to ACL (p<0.001, p=0.058). Graded sub-basal nerve tortuosity was more prominent in CLD group than the ACL (p=0.014). Patients with CLD had been wearing contact lenses for longer than those without symptoms. OSDI and FBUT scores were worse in CLD patients. In contact lens discomfort patients, there were increased dendritiform cells, indicating intensified inflammatory status of the cornea. Copyright © 2017 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

Do Cartilage Repair Procedures Prevent Degenerative Meniscus Changes? Longitudinal T1ρ and Morphological Evaluation at 3.0T

PubMed Central

Jungmann, Pia M.; Li, Xiaojuan; Nardo, Lorenzo; Subburaj, Karupppasamy; Lin, Wilson; Ma, C. Benjamin; Majumdar, Sharmila; Link, Thomas M.

2014-01-01

Background Cartilage repair (CR) procedures are widely accepted for treatment of isolated cartilage defects at the knee joint. However, it is not well known whether these procedures prevent degenerative joint disease. Hypothesis/Purpose CR procedures prevent accelerated qualitative and quantitative progression of meniscus degeneration in individuals with focal cartilage defects. Study Design Cohort Study; Level of evidence 2b Methods A total of 94 subjects were studied. CR procedures were performed on 34 patients (n=16 osteochondral transplantation, n=18 microfracture); 34 controls were matched. An additional 13 patients received CR and anterior cruciate ligament (ACL) reconstruction (CR&ACL) and 13 patients received only ACL reconstruction. 3.0T MRI with T1ρ mapping and sagittal fat-saturated intermediate-weighted fast spin echo (FSE) sequences was performed to analyze menisci quantitatively and qualitatively (Whole-Organ Magnetic Resonance Imaging Score, WORMS). CR and CR&ACL patients were examined 4 months (n=34; n=13), 1 (n=21; n=8) and 2 (n=9; n=5) years post CR. Control subjects were scanned at baseline and after 1 and 2 years, ACL patients after 1 and 2 years. Results At baseline, global meniscus T1ρ values were higher in individuals with CR (14.2±0.6ms; P=0.004) and in individuals with CR&ACL (17.1±0.9ms; P<0.001) when compared to controls (12.8±0.6ms). After two years, there was a statistical difference between T1ρ at the overlying meniscus above cartilage defects (16.4±1.0ms) and T1ρ of the subgroup of control knees without cartilage defects (12.1±0.8ms; P<0.001) and a statistical trend to the CR group (13.3±1.0 ms; P=0.088). At baseline, 35% of subjects with CR showed morphological meniscus tears at the overlying meniscus; 10% of CR subjects showed an increase of WORMS meniscus score within the first year, none progressed in the second year. Control subjects with (without) cartilage defects showed meniscus tears in 30% (5%) at baseline; 38% (19%) increased within the first, and 15% (10%) within the second year. Conclusions This study identified more severe meniscus degeneration after CR surgery compared to controls. However, progression of T1ρ values was not observed from 1 to 2 years after surgery. These results suggest, that CR may prevent degenerative meniscus changes. PMID:23104606

Short-term complications in intra- and extra-articular anterior cruciate ligament reconstruction. Comparison with the literature on isolated intra-articular reconstruction. A multicenter study by the French Arthroscopy Society.

PubMed

Panisset, J C; Pailhé, R; Schlatterer, B; Sigwalt, L; Sonnery-Cottet, B; Lutz, C; Lustig, S; Batailler, C; Bertiaux, S; Ehkirch, F P; Colombet, P; Steltzlen, C; Louis, M L; D'ingrado, P; Dalmay, F; Imbert, P; Saragaglia, D

2017-12-01

Lateral tenodesis (LT) is performed to limit the risk of iterative tear following anterior cruciate ligament (ACL) reconstruction in at-risk patients. By adding an extra procedure to isolated ACL graft, LT reconstruction increases operating time and may complicate postoperative course. The objective of the present study was to evaluate the rate of early complications. The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction. A prospective multicenter study included 392 patients: 70% male; mean age, 29.9 years; treated by associated ACL and LT reconstruction. All adverse events were inventoried. Mean hospital stay was 2 days, with 46% day-surgery. Walking was resumed at a mean 27 days, with an advantage for patients treated by the hamstring technique. The early postoperative complications rate was 12%, with 1.7% specifically implicating LT reconstruction: pain, hematoma, stiffness in flexion and extension, and infection. There was a 5% rate of surgical revision during the first year, predominantly comprising arthrolysis for extension deficit. The 1-year recurrence rate was 2.8%. The complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction, with no increase in infection or stiffness rates. The rate of complications specific to ALL reconstruction was low, at 1.7%, and mainly involved fixation error causing lateral soft-tissue impingement. IV, prospective multicenter study. Copyright © 2017. Published by Elsevier Masson SAS.

Segond Fractures Are Not a Risk Factor for Anterior Cruciate Ligament Reconstruction Failure.

PubMed

Gaunder, Christopher L; Bastrom, Tracey; Pennock, Andrew T

2017-12-01

Segond fractures may be identified when an anterior cruciate ligament (ACL) tear is diagnosed and likely represent an avulsion of the anterolateral ligament. It is currently unclear whether these fractures can be ignored at the time of ACL reconstruction or if they should be addressed surgically. To compare the incidence of Segond fractures in patients undergoing primary ACL reconstruction compared with those undergoing revision ACL reconstruction in an attempt to determine if the presence of a Segond fracture predisposes to ACL reconstruction failure. Cross-sectional study; Level of evidence, 3. A retrospective review of all patients undergoing primary or revision ACL reconstruction between 2007 and 2014 was performed. Demographic data (age, sex, body mass index), injury variables (acuity, mechanism of injury), and radiographic features (concomitant ligamentous injuries, growth plate status) were documented. Each Segond fracture was analyzed for its specific location, size, displacement, and healing using both radiographs and magnetic resonance imaging. Statistical analysis was performed using a P value of <.05. A total of 552 patients underwent primary ACL reconstruction, and 47 patients underwent revision ACL reconstruction who met inclusion criteria. The incidence of Segond fractures was 6% in the primary reconstruction group. The fracture fragment averaged 6.6 mm in height and 2.3 mm in width and was displaced a mean of 5.0 mm. The fracture fragment bed was localized at the tibial attachment site of the anterolateral ligament a mean 20.6 mm posterior to the Gerdy tubercle in nearly all patients. After ACL reconstruction, the Segond fracture healed in 90% of patients. The incidence of Segond fractures was 3 times as common in male patients ( P = .02); otherwise, its presence was not associated with any other demographic data, injury variables, or radiographic features ( P > .05). No patients undergoing revision surgery had a Segond fracture, and no patient with a Segond fracture had graft failure. Patients with a Segond fracture are at no higher risk to require revision ACL reconstruction compared with patients without a Segond fracture. This may be attributable to its high union rate. At the time of primary ACL reconstruction, if a Segond fracture is identified, it can be ignored (not repaired or reconstructed), and this approach does not appear to predispose to early ACL graft failure.

Randomized control trial to evaluate the effects of acute testosterone administration in men on muscle mass, strength, and physical function following ACL reconstructive surgery: rationale, design, methods.

PubMed

Wu, Brian W; Berger, Max; Sum, Jonathan C; Hatch, George F; Schroeder, E Todd

2014-12-06

The anterior cruciate ligament (ACL) is one of four major ligaments in the knee that provide stability during physical activity. A tear in the ACL is characterized by joint instability that leads to decreased activity, knee dysfunction, reduced quality of life and a loss of muscle mass and strength. While rehabilitation is the standard-of-care for return to daily function, additional surgical reconstruction can provide individuals with an opportunity to return to sports and strenuous physical activity. Over 200,000 ACL reconstructions are performed in the United States each year, and rehabilitation following surgery is slow and expensive. One possible method to improve the recovery process is the use of intramuscular testosterone, which has been shown to increase muscle mass and strength independent of exercise. With short-term use of supraphysiologic doses of testosterone, we hope to reduce loss of muscle mass and strength and minimize loss of physical function following ACL reconstruction compared to standard-of-care alone. This study is a double-blinded randomized control trial. Men 18-50 years of age, scheduled for ACL reconstruction are randomized into two groups. Participants randomized to the testosterone group receive intramuscular testosterone administration once per week for 8 weeks starting 2 weeks prior to surgery. Participants randomized to the control group receive a saline placebo intramuscularly instead of testosterone. Lean mass, muscle strength and physical function are measured at 5 time points: 2 weeks pre-surgery, 1 day pre-surgery, and 6, 12, 24 weeks post-surgery. Both groups follow standard-of-care rehabilitation protocol. We believe that testosterone therapy will help reduce the loss of muscle mass and strength experienced after ACL injury and reconstruction. Hopefully this will provide a way to shorten the rehabilitation necessary following ACL reconstruction. If successful, testosterone therapy may also be used for other injuries involving trauma and muscle atrophy. NCT01595581, REGISTRATION: May 8, 2012.

Intra-Articular Biocompatibility of Multistranded, Long-Chain Polyethylene Suture Tape in a Canine ACL Model.

PubMed

Smith, Patrick A; Bozynski, Chantelle C; Kuroki, Keiichi; Henrich, Sarah M; Wijdicks, Coen A; Cook, James L

2018-05-31

The purpose of this study was to assess intra-articular use of a nonabsorbable braided suture tape for its biocompatibility when implanted adjacent to the native anterior cruciate ligament (ACL) in a canine model. Establishing biocompatibility of suture tape in the knee is an important foundational step for clinicians considering use of suture tape augmentation for ACL reconstruction or repair. The study hypothesis was that a nonabsorbable braided suture tape would be biocompatible in the knee with no resultant adverse functional consequences, and no significant intra-articular synovial reactions or articular cartilage degeneration attributable to direct exposure to the suture tape, whether intact or transected. Nonabsorbable braided suture tape was arthroscopically implanted adjacent to the native ACL of dogs ( n  = 6). The suture was intact in half of the dogs and was transected in the other half as a "worst-case" scenario. Dogs were assessed for postoperative complications and morbidity. Arthroscopic grading of synovium and cartilage was performed at 4 and 6 months. Histologic assessments were performed at the 6-month endpoint and compared with the ACL partial tear ( n  = 9) and ACL reconstruction ( n  = 5) cohorts as well as historical sham controls. No postoperative complications were noted. No animal developed lameness or clinical dysfunction, and there were no severe inflammatory or immune responses, cartilage erosions, or premature osteoarthritis noted. Arthroscopic assessments revealed no to mild synovitis and no apparent cartilage damage in either group. Histologically, both the intact and transected suture tape groups were associated with significantly ( p  ≤ 0.05) less synovial and articular cartilage pathology compared with the partial ACL transection and patellar bone-tendon-bone ACL autograft reconstruction cohorts, and matched historical sham controls. The hypothesis was accepted as study results support the biocompatibility of suture tape in the canine knee. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Dutch language anterior cruciate ligament return to sport after injury scale (ACL-RSI) - validity and reliability.

PubMed

Slagers, Anton J; Reininga, Inge H F; van den Akker-Scheek, Inge

2017-02-01

The ACL-Return to Sport after Injury scale (ACL-RSI) measures athletes' emotions, confidence in performance, and risk appraisal in relation to return to sport after ACL reconstruction. Aim of this study was to study the validity and reliability of the Dutch version of the ACL-RSI (ACL-RSI (NL)). Total 150 patients, who were 3-16 months postoperative, completed the ACL-RSI(NL) and 5 other questionnaires regarding psychological readiness to return to sports, knee-specific physical functioning, kinesiophobia, and health-specific locus of control. Construct validity of the ACL-RSI(NL) was determined with factor analysis and by exploring 10 hypotheses regarding correlations between ACL-RSI(NL) and the other questionnaires. For test-retest reliability, 107 patients (5-16 months postoperative) completed the ACL-RSI(NL) again 2 weeks after the first administration. Cronbach's alpha, Intraclass Correlation Coefficient (ICC), SEM, and SDC, were calculated. Bland-Altman analysis was conducted to assess bias between test and retest. Nine hypotheses (90%) were confirmed, indicating good construct validity. The ACL-RSI(NL) showed good internal consistency (Cronbach's alpha 0.94) and test-retest reliability (ICC 0.93). SEM was 5.5 and SDC was 15. A significant bias of 3.2 points between test and retest was found. Therefore, the ACL-RSI(NL) can be used to investigate psychological factors relevant to returning to sport after ACL reconstruction.

Comparison of loading rate-dependent injury modes in a murine model of post-traumatic osteoarthritis

PubMed Central

Lockwood, Kevin A.; Chu, Bryce T.; Anderson, Matthew J.; Haudenschild, Dominik R.; Christiansen, Blaine A.

2014-01-01

Post-traumatic osteoarthritis (PTOA) is a common long-term consequence of joint injuries such as anterior cruciate ligament (ACL) rupture. In this study we used a tibial compression overload mouse model to compare knee injury induced at low speed (1 mm/s), which creates an avulsion fracture, to injury induced at high speed (500 mm/s), which induces midsubstance tear of the ACL. Mice were sacrificed at 0 days, 10 days, 12 weeks, or 16 weeks post-injury, and joints were analyzed with micro-computed tomography, whole joint histology, and biomechanical laxity testing. Knee injury with both injury modes caused considerable trabecular bone loss by 10 days post-injury, with the Low Speed Injury group (avulsion) exhibiting a greater amount of bone loss than the High Speed Injury group (midsubstance tear). Immediately after injury, both injury modes resulted in greater than 2-fold increases in total AP joint laxity relative to control knees. By 12 and 16 weeks post-injury, total AP laxity was restored to uninjured control values, possibly due to knee stabilization via osteophyte formation. This model presents an opportunity to explore fundamental questions regarding the role of bone turnover in PTOA, and the findings of this study support a biomechanical mechanism of osteophyte formation following injury. PMID:24019199

Impact of High-Fidelity Simulation and Pharmacist-Specific Didactic Lectures in Addition to ACLS Provider Certification on Pharmacy Resident ACLS Performance.

PubMed

Bartel, Billie J

2014-08-01

This pilot study explored the use of multidisciplinary high-fidelity simulation and additional pharmacist-focused training methods in training postgraduate year 1 (PGY1) pharmacy residents to provide Advanced Cardiovascular Life Support (ACLS) care. Pharmacy resident confidence and comfort level were assessed after completing these training requirements. The ACLS training requirements for pharmacy residents were revised to include didactic instruction on ACLS pharmacology and rhythm recognition and participation in multidisciplinary high-fidelity simulation ACLS experiences in addition to ACLS provider certification. Surveys were administered to participating residents to assess the impact of this additional education on resident confidence and comfort level in cardiopulmonary arrest situations. The new ACLS didactic and simulation training requirements resulted in increased resident confidence and comfort level in all assessed functions. Residents felt more confident in all areas except providing recommendations for dosing and administration of medications and rhythm recognition after completing the simulation scenarios than with ACLS certification training and the didactic components alone. All residents felt the addition of lectures and simulation experiences better prepared them to function as a pharmacist in the ACLS team. Additional ACLS training requirements for pharmacy residents increased overall awareness of pharmacist roles and responsibilities and greatly improved resident confidence and comfort level in performing most essential pharmacist functions during ACLS situations. © The Author(s) 2013.

Improvement in the medial meniscus posterior shift following anterior cruciate ligament reconstruction.

PubMed

Inoue, Hiroto; Furumatsu, Takayuki; Miyazawa, Shinichi; Fujii, Masataka; Kodama, Yuya; Ozaki, Toshifumi

2018-02-01

Anterior cruciate ligament (ACL) reconstruction can reduce the risk of developing osteoarthritic knees. The goals of ACL reconstruction are to restore knee stability and reduce post-traumatic meniscal tears and cartilage degradation. A chronic ACL insufficiency frequently results in medial meniscus (MM) injury at the posterior segment. How ACL reconstruction can reduce the deformation of the MM posterior segment remains unclear. In this study, we evaluated the form of the MM posterior segment and anterior tibial translation before and after ACL reconstruction using open magnetic resonance imaging (MRI). Seventeen patients who underwent ACL reconstructions without MM injuries were included in this study. MM deformation was evaluated using open MRI before surgery and 3 months after surgery. We measured medial meniscal length (MML), medial meniscal height (MMH), medial meniscal posterior body width (MPBW), MM-femoral condyle contact width (M-FCW) and posterior tibiofemoral distance (PTFD) at knee flexion angles of 10° and 90°. There were no significant pre- and postoperative differences during a flexion angle of 10°. At a flexion angle of 90°, MML decreased from 43.7 ± 4.5 to 41.4 ± 4.5 mm (P < 0.001), MMH from 7.5 ± 1.4 to 6.9 ± 1.4 mm (P = 0.006), MPBW from 13.1 ± 2.0 to 12.2 ± 1.9 mm (P < 0.001) and M-FCW from 10.0 ± 1.5 to 8.5 ± 1.5 mm (P < 0.001) after ACL reconstruction. The PTFD increased from 2.1 ± 2.8 to 2.7 ± 2.4 mm after ACL reconstruction (P = 0.015). ACL reconstruction affects the contact pattern between the MM posterior segment and medial femoral condyle and can reduce the deformation of the MM posterior segment in the knee-flexed position by reducing abnormal anterior tibial translation. It possibly prevents secondary injury to the MM posterior segment and cartilage that progresses to knee osteoarthritis. IV.

Angiostrongylus cantonensis (Nematode: Metastrongiloidea): in vitro cultivation of infective third-stage larvae to fourth-stage larvae.

PubMed

Lin, Rong-Jyh; He, Jie-Wen; Chung, Li-Yu; Lee, June-Der; Wang, Jiun-Jye; Yen, Chuan-Min

2013-01-01

The present study to attempt to cultivate Angiostrongylus cantonensis from third-stage larvae (AcL3) to fourth-stage larvae (AcL4) in vitro in defined complete culture medium that contained with Minimum Essential Medium Eagle (MEM), supplemented amino acid (AA), amine (AM), fatty acid (FA), carbohydrate (CA) and 20% fetal calf serum (FCS) was successful. When AcL3 were cultured in the defined complete culture medium at 37°C in a 5% CO2 atmosphere, the larvae began to develop to AcL4 after 30 days of cultivation, and were enclosed within the sheaths of the third molts of the life cycle. Under these conditions, the larvae developed uniformly and reached to the fourth-stage 36 days. The morphology of AcL3 develop to AcL4 were recording and analyzing. Then comparison of A. cantonensis larval morphology and development between in vitro cultivation in defined complete culture medium and in vivo cultivation in infective BALB/c mice. The larvae that had been cultivated in vitro were smaller than AcL4 of infective BALB/c mice. However the AcL3 that were cultured using defined incomplete culture medium (MEM plus 20% FCS with AA+AM, FA, CA, AA+AM+FA, FA+CA, CA+AA+AM or not) did not adequately survive and develop. Accordingly, the inference is made that only the defined complete medium enable AcL3 develop to AcL4 in vitro. Some nematodes have been successfully cultured into mature worms but only a few researches have been made to cultivate A. cantonensis in vitro. The present study is the first to have succeeded in developing AcL3 to AcL4 by in vitro cultivation. Finally, the results of in vitro cultivation studies herein contribute to improving media for the effective development and growth of A. cantonensis. The gap in the A. cantonensis life cycle when the larvae are cultivated in vitro from third-stage larvae to fourth-stage larvae can thus be solved.

Effect of Changing the Joint Kinematics of Knees With a Ruptured Anterior Cruciate Ligament on the Molecular Biological Responses and Spontaneous Healing in a Rat Model.

PubMed

Kokubun, Takanori; Kanemura, Naohiko; Murata, Kenji; Moriyama, Hideki; Morita, Sadao; Jinno, Tetsuya; Ihara, Hidetoshi; Takayanagi, Kiyomi

2016-11-01

The poor healing capacity of a completely ruptured anterior cruciate ligament (ACL) has been attributed to an insufficient vascular supply, cellular metabolism, and deficient premature scaffold formation because of the unique intra-articular environment. However, previous studies have focused on intra-articular factors without considering extra-articular factors, including the biomechanical aspects of ACL-deficient knees. Changing the joint kinematics of an ACL-ruptured knee will improve cellular biological responses and lead to spontaneous healing through the mechanotransduction mechanism. Controlled laboratory study. A total of 66 skeletally mature Wistar rats were randomly assigned to a sham-operated group (SO), ACL-transection group (ACL-T), controlled abnormal movement group (CAM), and an intact group (IN). The ACL was completely transected at the midportion in the ACL-T and CAM groups, and the CAM group underwent extra-articular braking to control for abnormal tibial translation. The SO group underwent skin and joint capsule incisions and tibial drilling, without ACL transection and extra-articular braking. The animals were allowed full cage activity until sacrifice at 1, 2, 4, 6, and 8 weeks postoperatively for histological, molecular biological, and biomechanical assessment. All injured ACLs in the ACL-T group were not healed, but those in the CAM group healed spontaneously, showing a typical ligament healing response. Regarding the molecular biological response, there was an upregulation of anabolic factors (ie, transforming growth factor-β) and downregulation of catabolic factors (ie, matrix metalloproteinase). Examination of the mechanical properties at 8 weeks after injury showed that >50% of the strength of the intact ACL had returned. Our results suggest that changing the joint kinematics of knees with a ruptured ACL alters the molecular biological responses and leads to spontaneous healing. These data support our hypothesis that the mechanotransduction mechanism mediates molecular responses and determines whether the ACL will heal. Elucidating the relationship between the mechanotransduction mechanism and healing responses in knees with completely ruptured ACLs may result in the development of novel nonsurgical treatment that enables the ACL to spontaneously heal in patients who are not suitable for reconstruction. © 2016 The Author(s).

Amount of Minutes Played Does Not Contribute to Anterior Cruciate Ligament Injury in National Basketball Association Athletes.

PubMed

Okoroha, Kelechi R; Marfo, Kojo; Meta, Fabien; Matar, Robert; Shehab, Ramsy; Thompson, Terry; Moutzouros, Vasilios; Makhni, Eric C

2017-07-01

There is limited information on the potential risk factors for sustaining an anterior cruciate ligament (ACL) tear in National Basketball Association (NBA) athletes. This study evaluated 83 NBA players who sustained an ACL injury between 1984 and 2015 to determine the influence of minutes played on injury risk. Minutes played in the injury game, during the season, and over their career were assessed, along with the ability to return to play, player efficiency rating, and playing time after return. Athletes in the NBA played significantly fewer minutes before sustaining an ACL injury (17.1 minutes) than their average minutes per game that season (23.5 minutes; P<.01) or over their career (24.0 minutes; P<.01). One-third of all injuries occurred during the first quarter of the season (preseason to November). There was a 95% rate of return (78 players) to NBA competition the season following ACL injury. Players who were drafted as lottery picks (draft pick 1 to 15) or those who were starters played significantly more minutes the season following injury than those who were not (both P<.01). Players who returned to play had decreased player efficiency ratings when compared with matched controls. This study found that minutes played in a single NBA game did not contribute to the risk of sustaining an ACL injury. Although there was a high rate of return to NBA competition the season following injury, those who were elite athletes played more minutes per game than those who were not. Athletes who returned to play sustained a decrease in player efficiency ratings compared with similar athletes without ACL injury. [Orthopedics. 2017; 40(4):e658-e662.]. Copyright 2017, SLACK Incorporated.

Degenerative Changes in the Knee 2 Years After Anterior Cruciate Ligament Rupture and Related Risk Factors: A Prospective Observational Follow-up Study.

PubMed

van Meer, Belle L; Oei, Edwin H G; Meuffels, Duncan E; van Arkel, Ewoud R A; Verhaar, Jan A N; Bierma-Zeinstra, Sita M A; Reijman, Max

2016-06-01

Anterior cruciate ligament (ACL) rupture is a well-known risk factor for development of knee osteoarthritis. Early identification of those patients at risk and early identification of the process of ACL rupture leading to osteoarthritis may aid in preventing the onset or progression of osteoarthritis. To identify early degenerative changes as assessed on magnetic resonance imaging (MRI) after 2-year follow-up in patients with a recent ACL rupture and to evaluate which determinants are related to these changes. Cohort study; Level of evidence, 2. Included in this study were 154 adults aged between 18 and 45 years with acute ACL rupture diagnosed by physical examination and MRI, without previous knee trauma or surgery, and without osteoarthritic changes on radiographs. A total of 143 patients completed the 2-year follow-up, and the results in this study apply to these 143 patients. All patients were treated according to the Dutch guideline on ACL injury. Of the 143 patients, 50 patients were treated nonoperatively during the 2-year follow-up period. Main outcome was early degenerative changes assessed on MRI defined as progression of cartilage defects and osteophytes in tibiofemoral and patellofemoral compartments. Patient characteristics, activity level, functional instability, treatment type, and trauma-related variables were evaluated as determinants. The median time between MRI at baseline and MRI at 2-year follow-up was 25.9 months (interquartile range, 24.7-26.9 months). Progression of cartilage defects in the medial and lateral tibiofemoral compartments was present in 12% and 27% of patients, and progression of osteophytes in tibiofemoral and patellofemoral compartments was present in 10% and 8% of patients, respectively. The following determinants were positively significantly associated with early degenerative changes: male sex (odds ratio [OR], 4.43; 95% CI, 1.43-13.66; P = .010), cartilage defect in the medial tibiofemoral compartment at baseline (OR, 3.66; 95% CI, 1.04-12.95; P = .044), presence of bone marrow lesions in the medial tibiofemoral compartment 1 year after trauma (OR, 5.19; 95% CI, 1.56-17.25; P = .007), joint effusion 1 year after trauma (OR, 4.19; 95% CI, 1.05-16.72; P = .042), and presence of meniscal tears (OR, 6.37; 95% CI, 1.94-20.88; P = .002). When the patients were categorized into 3 treatment groups (nonoperative, reconstruction <6 months after ACL rupture, and reconstruction ≥6 months after ACL rupture), there was no significant relationship between the treatment options and the development of early degenerative changes. Two years after ACL rupture, early degenerative changes were assessed on MRI. Concomitant medial cartilage defect and meniscal injury, male sex, persistent bone marrow lesions in the medial tibiofemoral compartment, and joint effusion are risk factors for degenerative changes. © 2016 The Author(s).

Compliance With Neuromuscular Training and Anterior Cruciate Ligament Injury Risk Reduction in Female Athletes: A Meta-Analysis

PubMed Central

Sugimoto, Dai; Myer, Gregory D.; Bush, Heather M.; Klugman, Maddie F.; McKeon, Jennifer M. Medina; Hewett, Timothy E.

2012-01-01

Context No consensus exists about the influence of compliance with neuromuscular training programs on reduction of the risk of anterior cruciate ligament (ACL) injury. Objective To systematically review and synthesize the published literature to determine if compliance with neuromuscular training is associated with reduced incidence of ACL injury in young female athletes. Data Sources We searched PubMed, SPORTDiscus, CINAHL, and MEDLINE for articles published from 1995 to 2010 using the key words anterior cruciate ligament prevention, ACL prevention, knee prevention, prospective knee prevention, neuromuscular training, and neuromuscular intervention. Study Selection Criteria for inclusion required that (1) the number of ACL injuries was reported, (2) a neuromuscular training program was used, (3) females were included as participants, (4) the study design was prospective and controlled, and (5) compliance data for the neuromuscular training program were provided. Data Extraction Extracted data included the number of ACL injuries, total number of participants per group, observation time period, number of participants who completed each session, number of sessions completed by an entire team, and number of total sessions. Attendance was calculated as the number of participants who completed each session converted into a percentage of the total number of participants. Intervention completion was calculated as the number of sessions completed by an entire team converted into a percentage of the total number of training sessions. These data were used to calculate an overall rate of compliance. Data Synthesis Six of 205 identified studies were included. Incidence rates of ACL injury were lower in studies with high rates of compliance with neuromuscular training than in studies with low compliance rates (incidence rate ratio = 0.27 [95% confidence interval = 0.07, 0.80]). Tertile analysis indicated rates of ACL injury incidence were lower in studies with high compliance rates than in studies with moderate and low compliance rates (incidence rate ratio = 0.18 [95% confidence interval = 0.02, 0.77]). Conclusions A potential inverse dose-response relationship exists between compliance with neuromuscular training and incidence of ACL injury. Attending and completing recommended neuromuscular sessions appears to be an important factor for preventing ACL injuries. PMID:23182020

Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players.

PubMed

Guzzini, Matteo; Mazza, Daniele; Fabbri, Mattia; Lanzetti, Riccardo; Redler, Andrea; Iorio, Carlo; Monaco, Edoardo; Ferretti, Andrea

2016-10-01

The growing popularity of elite soccer among female participants has led to increased incidents of anterior cruciate ligament (ACL) ruptures. Many authors underline a positive glide after ACL reconstruction (ACLR), especially in women. In fact, an isolated intra-articular ACLR may be inadequate to control rotational instability after a combined injury of the ACL and the peripheral structures of the knee. Extra-articular procedures are sometimes used in primary cases displaying excessive antero-lateral rotatory instability. The purpose of this case series was to report subjective and objective outcomes after combined ACL and lateral extra-articular tenodesis (LET) with a minimum 4-year follow-up in a selected high-risk population of elite female football players. Between January 2007 and December 2010, 16 elite Italian female football players were included in the study. All patients underwent the same surgical technique: anatomical ACLR with autogenous semitendinosus and gracilis tendons. After the intra-articular reconstruction was performed, an additional extra-articular MacIntosh modified Coker-Arnold procedure was carried out. Patients were assessed pre- and post-operatively with the subjective and objective International Knee Documentation Committee (IKDC) evaluation form, Tegner activity scale (TAS) and Lysholm score. Joint laxity was assessed with KT-1000 by measuring the side-to-side (S/S) differences in displacement at manual maximum (mm) testing. At a mean follow-up of 72.6 ± 8.1 months, two independent examiners reviewed all players. All of the patients had a fully recovered range of motion. Lachman test was negative in all patients (100 %). The evaluation of joint laxity and clinical evaluation showed a statistically significant improvement. No patients experienced complication or a re-rupture. The rationale of combining extra-articular procedures with ACLR is to restrict the internal rotation of the reconstructed knee, taking advantage of its long lever arm and thus providing more stability in the rotational axis and preventing the ACL graft from undergoing further excessive strain. The combination of an LET with ACLR in elite female football players demonstrated excellent results in terms of subjective scales, post-operative residual laxity and re-rupture rate with no complication, and a complete return to sport activity.

Anterior Cruciate Ligament Injuries in Baseball Players.

PubMed

Dugas, Jeffrey R; Bedford, Benjamin B; Andrachuk, John S; Scillia, Anthony J; Aune, Kyle T; Cain, E Lyle; Andrews, James R; Fleisig, Glenn S

2016-11-01

To determine common mechanisms of anterior cruciate ligament (ACL) injury in baseball players and to quantify the rate of return to play after primary surgical reconstruction and review intermediate clinical outcomes. Surgical injuries involving the ACL in youth, high school, collegiate, and professional baseball players were queried for an 11-year period (2001 to 2011). Over the study period, 42 baseball players were identified who had undergone arthroscopically assisted primary ACL reconstruction by 1 of 3 attending surgeons. Retrospective chart review was performed for all 42 patients to evaluate variables of age, level of competition, position, mechanism of injury, graft choice, and associated meniscal injuries. Twenty-six patients were reached for telephone survey and International Knee Documentation Committee questionnaire and they answered questions about their original injury and playing history. The most common mechanism of injury was fielding, followed by base running. Infielders and outfielders (32% each) were the most commonly injured position, followed by pitchers (29%). Among the 32 players for whom it could be determined, 30 (94%) were able to return to playing baseball at a mean follow-up of 4.2 years (range 1.0 to 9.9 years). The mean International Knee Documentation Committee score was 84.0 (range 63 to 91). Among the 26 patients contacted for telephone interview, no one required revision ACL surgery, but 3 required a subsequent procedure for meniscal tear. Twenty-five patients (96%) denied any episodes of instability in the knee after reconstruction. The overwhelming majority of baseball players that sustain ACL injuries do so while fielding or base running. Outfielders are significantly more likely than infielders to suffer ACL injuries while fielding versus base running. The results with respect to return to play are promising, as nearly all patients were able to return to baseball and none required a revision ACL surgery at a mean follow-up of 4.2 years. Level IV, therapeutic case series. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Anterior cruciate ligament deterioration correlates with patella osteoarthritis.

PubMed

Iriuchishima, Takanori; Ryu, Keinosuke; Aizawa, Shin; Yorifuji, Hiroshi; Ohyama, Tetsuji; Fu, Freddie H

2014-04-01

The correlation between anterior cruciate ligament (ACL) condition and patella osteoarthritic (OA) changes has not been well reported. The aim of this study was to reveal the correlation between ACL deterioration and the morphology of OA changes in the patella. The hypothesis was that significant correlation between ACL deterioration and patella OA morphology would be revealed in this study. Two hundred ninety-one cadaveric knees from 151 cadavers were included in this study with a median age of 83 years (54-98). Knees were opened with a sub-vastus approach and the ACL condition was classified as intact or deteriorated. Patella OA lesions were classified using Han's method: type 1, no or minimal lesion; type 2, medial facet lesion without involvement of the ridge; type 3, lateral facet lesion without involvement of the ridge; type 4, lesion involving the ridge only; type 5, medial facet lesion with involvement of the ridge; type 6, lateral facet lesion with involvement of the ridge; and type 7, global lesion. OA depth evaluation was performed following Outerbridge's classification. Statistical analysis of the collected data was performed using generalized estimating equations (GEE). The ACL was intact in 277 knees and deteriorated in 14 knees. Patella OA lesions were observed as follows: type 1, 29%; type 2, 15%; type 3, 2%; type 4, 12%; type 5, 18%; type 6, 2%; and type 7, 22%. Outerbridge's classification of over grade 2 OA depth was observed in 73.5% of subjects. When patella OA was divided into types 1-4 and types 5-7, ACL deterioration was correlated with the occurrence of type 5-7 patella OA [OR 6.44, 95%CI 2.27-18.25, p = 0.000]. When patella OA was divided into types 1-6 and type 7, ACL deterioration was correlated with the occurrence of type 7 patella OA [OR 6.02, 95%CI 2.57-14.09, p = 0.000]. When patella OA depth was divided into grades 1-3 and grade 4, ACL deterioration was highly correlated with the occurrence of grade 4 patella OA [OR 9.31, 95%CI 2.96-29.33, p = 0.025]. ACL deterioration is a strong risk factor of wider and deeper OA changes in the patella. For clinical relevance, subjects with ACL tear should be aware of the progression of patella OA.

Anterior cruciate ligament repair - past, present and future.

PubMed

Mahapatra, Piyush; Horriat, Saman; Anand, Bobby S

2018-06-15

This article provides a detailed narrative review on the history and current concepts surrounding ligamentous repair techniques in athletic patients. In particular, we will focus on the anterior cruciate ligament (ACL) as a case study in ligament injury and ligamentous repair techniques. PubMed (MEDLINE), EMBASE and Cochrane Library databases for papers relating to primary anterior cruciate ligament reconstruction were searched by all participating authors. All relevant historical papers were included for analysis. Additional searches of the same databases were made for papers relating to biological enhancement of ligament healing. The poor capacity of the ACL to heal is one of the main reasons why the current gold standard surgical treatment for an ACL injury in an athletic patient is ACL reconstruction with autograft from either the hamstrings or patella tendon. It is hypothesised that by preserving and repairing native tissues and negating the need for autograft that primary ACL repair may represent a key step change in the treatment of ACL injuries. The history of primary ACL repair will be discussed and the circumstances that led to the near-abandonment of primary ACL repair techniques will be reviewed. There has been a recent resurgence in interest with regards to primary ACL repair. Improvements in imaging now allow for identification of tear location, with femoral-sided injuries, being more suitable for repair. We will discuss in details strategies for improving the mechanical and biological environment in order to allow primary healing to occur. In particular, we will explain mechanical supplementation such as Internal Brace Ligament Augmentation and Dynamic Intraligamentary Stabilisation techniques. These are novel techniques that aim to protect the primary repair by providing a stabilising construct that connects the femur and the tibia, thus bridging the repair. In addition, biological supplementation is being investigated as an adjunct and we will review the current literature with regards to bio-enhancement in the form platelet rich plasma, bio-scaffolds and stem cells. On the basis of current evidence, there appears to be a role for bio-enhancement, however, this is not yet translated into clinical practice. Several promising avenues of further research now exist in the form of mechanical and biological augmentation techniques. Further work is clearly needed but there is renewed interest and focus for primary ACL repair that may yet prove the new frontier in ligament repair.

Gap formation following primary repair of the anterior cruciate ligament: A biomechanical evaluation.

PubMed

van der List, Jelle P; DiFelice, Gregory S

2017-03-01

Historically, inconsistent and unpredictable results of open primary anterior cruciate ligament (ACL) repair were reported. Recently, however, good results of arthroscopic primary ACL repair of proximal tears have been reported. Purpose of this study was to assess the direct postoperative gap formation and maximum failure load following simulated knee motion after primary ACL repair. Six matched-paired human cadaveric knees (mean age: 52years, range: 48 to 56years) were used. After primary proximal ACL repair with either suture button fixation or suture anchor fixation, knees were cycled five, 50 and 100 times with a simulated active quadriceps force. Gap formation between the femoral wall and ligament was measured using a digital caliper and maximum failure load was tested. Gap formation after five, 50 and 100cycles of the knee were 0.30mm (±0.23), 0.75mm (±0.55) and 0.97mm (±0.70), respectively, with no significant differences between both fixation techniques. The overall maximum failure load was 243N (±143) with no difference between both techniques. Most common failure mode was slipping of suture from the fixation. Following proximal ACL repair, gap formation of approximately one millimeter was measured after repetitious knee cycling with mean maximum failure load of 243N. These findings are likely to be sufficient for careful early active range of motion (ROM) when extrapolating from other available studies. Future studies with second-look arthroscopy are necessary to assess the gap formation and healing in patients treated with primary repair. Copyright © 2016 Elsevier B.V. All rights reserved.

Repair of meniscal tears with the absorbable Clearfix screw: results after 1-3 years.

PubMed

Frosch, K H; Fuchs, M; Losch, A; Stürmer, K M

2005-11-01

Total meniscus resection usually leads to osteoarthritis of the knee joint. Preservation and refixation of the injured menisci are therefore of great clinical importance. The present study examines 40 meniscal injuries in 37 patients that were arthroscopically treated with Clearfix meniscal screws (Mitek, Norderstedt, Germany) in the period from August 1999 to December 2002. The mean patient age was 27.7 (range 16-62) years. Nine patients were female. A total of 24 patients (27 meniscal tears) also had an anterior cruciate ligament (ACL) lesion, and 5 patients had cartilage injuries. Twenty-two patients were treated within the first 2 weeks following the trauma, 10 patients within 8 weeks, and 5 patients after 8 weeks. The lesions were a bucket-handle tear of the medial meniscus in 11 cases and a bucket-handle tear of the lateral meniscus in 2 cases. The posterior horn of the medial meniscus was torn in 13 cases, and the pars intermedia in 3 cases. The posterior horn of the lateral meniscus was torn in 8 cases, and the pars intermedia in 3 cases. The mean tear length was 2.9 (+/- 1.5) cm and was fixed with an average of 1.8 (+/- 0.7) screws. In 7 cases, the anterior horn was treated with an additional meniscal suture. A total of 35 patients were examined after an average of 18 (range 7-45) months. In the event of a moderate outcome, MRI was performed as part of the follow-up investigation. The average Lysholm score was 93 (+/- 7.4), the Tegner activity index was 6.3 (+/- 2.0) before the accident and 5.8 (+/- 2.0) at the follow-up, the Marshall knee score was 47 (+/- 3.8). The VAS pain assessment was 1.6 (+/- 1.3) and the VAS function assessment was 7.9 (+/- 1.6). Of the 7 patients with a moderate result, 2 patients without additional ligament lesions suffered re-ruptures after and 13 months, respectively. The other 5 patients with a moderate result each had multiple accompanying injuries or pre-existing damage to the affected knee joint. The Clearfix screws achieved a clinical success rate of 82% in isolated meniscal tears in stable knee joints and a clinical success rate of 100% with additional ACL reconstruction. In view of the good clinical results and the simple procedure for use, the implant should be recommended for meniscal refixation.

General practitioner diagnosis and management of acute knee injuries: summary of an evidence-based guideline.

PubMed

Robb, Gillian; Reid, Duncan; Arroll, Bruce; Jackson, Rod T; Goodyear-Smith, Felicity

2007-02-16

To summarise evidence and key recommendations for general practitioner diagnosis and management of acute soft-tissue knee injuries, based on the New Zealand guideline. A multidisciplinary team developed the guideline by critically appraising and grading retrieved literature using the Graphic Appraisal Tools for Epidemiology, Clinical decision rules and the Scottish Intercollegiate Guideline Network. Recommendations were derived from resulting evidence tables. For both diagnosis and management there is a paucity of good evidence to support diagnosis and treatment of internal derangements of the knee, hence some aspects of the guideline are guideline team consensus. Good evidence supports the use of the Ottawa Knee rules to guide decisions about the use of X-ray, and the Lachman test in diagnosing anterior cruciate ligament (ACL) tears. Evidence supports inclusion of proprioceptive training in rehabilitation programmes following ACL reconstruction and in people with ACL-deficient knees. There is good evidence that ultrasound is of little benefit, and there is no evidence that physiotherapy be routinely advocated following meniscectomy. This guideline provides an evidence-based framework for diagnosis and management of internal derangements of the knee following acute injury. Moreover, its development highlights significant gaps in the evidence base and identifies priorities for new research.

Enhancement of anatomical learning and developing clinical competence of first-year medical and allied health profession students.

PubMed

Keim Janssen, Sarah A; VanderMeulen, Stephane P; Shostrom, Valerie K; Lomneth, Carol S

2014-01-01

Hands-on educational experiences can stimulate student interest, increase knowledge retention, and enhance development of clinical skills. The Lachman test, used to assess the integrity of the anterior cruciate ligament (ACL), is commonly performed by health care professionals and is relatively easy to teach to first-year health profession students. This study integrated teaching the Lachman test into a first-year anatomy laboratory and examined if students receiving the training would be more confident, competent, and if the training would enhance anatomical learning. First-year medical, physician assistant and physical therapy students were randomly assigned into either the intervention (Group A) or control group (Group B). Both groups received the course lecture on knee anatomy and training on how to perform the Lachman test during a surface anatomy class. Group A received an additional 15 minutes hands-on training for the Lachman test utilizing a lightly embalmed cadaver as a simulated patient. One week later, both groups performed the Lachman test on a lightly embalmed cadaver and later completed a post-test and survey. Students with hands-on training performed significantly better than students with lecture-only training in completing the checklist, a post-test, and correctly diagnosing an ACL tear. Students in Group A also reported being more confident after hands-on training compared to students receiving lecture-only training. Both groups reported that incorporating clinical skill activities facilitated learning and created excitement for learning. Hands-on training using lightly embalmed cadavers as patient simulators increased confidence and competence in performing the Lachman test and aided in learning anatomy. © 2013 American Association of Anatomists.

Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors.

PubMed

Alentorn-Geli, Eduard; Myer, Gregory D; Silvers, Holly J; Samitier, Gonzalo; Romero, Daniel; Lázaro-Haro, Cristina; Cugat, Ramón

2009-07-01

Soccer is the most commonly played sport in the world, with an estimated 265 million active soccer players by 2006. Inherent to this sport is the higher risk of injury to the anterior cruciate ligament (ACL) relative to other sports. ACL injury causes the most time lost from competition in soccer which has influenced a strong research focus to determine the risk factors for injury. This research emphasis has afforded a rapid influx of literature defining potential modifiable and non-modifiable risk factors that increase the risk of injury. The purpose of the current review is to sequence the most recent literature that reports potential mechanisms and risk factors for non-contact ACL injury in soccer players. Most ACL tears in soccer players are non-contact in nature. Common playing situations precluding a non-contact ACL injury include: change of direction or cutting maneuvers combined with deceleration, landing from a jump in or near full extension, and pivoting with knee near full extension and a planted foot. The most common non-contact ACL injury mechanism include a deceleration task with high knee internal extension torque (with or without perturbation) combined with dynamic valgus rotation with the body weight shifted over the injured leg and the plantar surface of the foot fixed flat on the playing surface. Potential extrinsic non-contact ACL injury risk factors include: dry weather and surface, and artificial surface instead of natural grass. Commonly purported intrinsic risk factors include: generalized and specific knee joint laxity, small and narrow intercondylar notch width (ratio of notch width to the diameter and cross sectional area of the ACL), pre-ovulatory phase of menstrual cycle in females not using oral contraceptives, decreased relative (to quadriceps) hamstring strength and recruitment, muscular fatigue by altering neuromuscular control, decreased "core" strength and proprioception, low trunk, hip, and knee flexion angles, and high dorsiflexion of the ankle when performing sport tasks, lateral trunk displacement and hip adduction combined with increased knee abduction moments (dynamic knee valgus), and increased hip internal rotation and tibial external rotation with or without foot pronation. The identified mechanisms and risk factors for non-contact ACL injuries have been mainly studied in female soccer players; thus, further research in male players is warranted. Non-contact ACL injuries in soccer players likely has a multi-factorial etiology. The identification of those athletes at increased risk may be a salient first step before designing and implementing specific pre-season and in-season training programs aimed to modify the identified risk factors and to decrease ACL injury rates. Current evidence indicates that this crucial step to prevent ACL injury is the only option to effectively prevent the sequelae of osteoarthritis associated with this traumatic injury.

Anterior cruciate ligament injury: post-traumatic bone marrow oedema correlates with long-term prognosis.

PubMed

Filardo, Giuseppe; Kon, Elizaveta; Tentoni, Francesco; Andriolo, Luca; Di Martino, Alessandro; Busacca, Maurizio; Di Matteo, Berardo; Marcacci, Maurilio

2016-01-01

Bone marrow oedema (BME) in the knee is a feature of several pathological conditions, and it has been described with high frequency in patients with acute anterior cruciate ligament (ACL) injury. The aim of this study is to evaluate the significance of BME, assessed in MRIs performed for ACL injury, with regards to clinical outcome and return to sport. A total of 134 patients (98 men, 36 women) with ACL tear and MRI knee scan within six months from trauma were analysed. The presence of BME was evaluated on MRI images considering: extension and hyperintensity, the WORMS score oedema classification, and measuring the BME area. The clinical results were documented by IKDC-subjective score and the sport activity level by Tegner score at a minimum of five years follow up. BME was present in 74 knees (55.2 %), with a mean area of 523 ± 370 mm². The presence of BME showed a gradual decrease over time (p = 0.008), being detectable in MRIs performed more than three months after trauma in just 25.0 % of cases. Although 54 % of the patients without BME after three months returned to their previous sport level, no patients with oedema reached a full sport recovery (p = 0.01). In the group that underwent ACL reconstruction, the BME area was significantly correlated with a return to the previous sport level at the mid/long-term follow-up (p = 0.038). BME is a common finding, which decreases over time after injury. However, when BME is still detectable it correlates with clinical prognosis, and even in sport-active patients undergoing ACL reconstruction, a higher BME area is a negative predictive factor for a successful outcome at the mid/long-term follow-up.

Athletic performance and career longevity following anterior cruciate ligament reconstruction in the National Basketball Association.

PubMed

Kester, Benjamin S; Behery, Omar A; Minhas, Shobhit V; Hsu, Wellington K

2017-10-01

To identify the impact of anterior cruciate ligament (ACL) reconstruction on performance and career longevity for National Basketball Association (NBA) players. Seventy-nine players (80 knees) with acute ACL tears in the NBA between the 1984-2014 seasons, and 112 age, height, weight, and performance-matched controls were identified. Pre- and post-injury performance outcomes including seasons played, games played, games started, minutes per game, points per game, field goals, 3-point shots, rebounds, assists, steals, blocks, turnovers, personal fouls, usage percentage and player efficiency ratings were compared between cases and controls using independent samples t tests and Fisher's exact tests. Sixty-eight of seventy-nine players (86.1 %) returned to play in the NBA following ACL reconstruction. Mean length of post-operative play was 1.84 years shorter than matched controls (P = 0.001). There was a significantly higher rate of attrition from professional basketball for players with a history of ACL reconstruction (P = 0.014). In the first full season following surgery, players started in 15.5 fewer games (P = 0.001), they played in 17.3 fewer games (P < 0.001), and had combined player efficiency ratings 2.35 points lower (P = 0.001) when compared to matched controls. Over the length of their careers, players competed in 22.2 fewer games per season (P = 0.009). There is a high rate of return to sport in the NBA following ACL reconstruction, although playing time, games played, player efficiency ratings and career lengths are significantly impacted in the post-operative period. These data should be used to manage patients' expectations regarding their abilities to return to elite levels of athletic performance.

The female ACL: why is it more prone to injury?

PubMed

Ireland, Mary Lloyd

2002-10-01

Multiple factors are responsible for ACL tears. The key factor in the gender discrepancy appears to be dynamic, not static, and proximal, not distal. The factors involved in evaluating the female ACL are multiple. However, it is the dynamic movement patterns ot hip and knee position with increased flexion and a coordinated proximal muscle firing pattern to keep the body in a safe landing position that are the most critical factors. An ACL injury at an early age is a life-changing event. We can very successfully reconstruct and rehabilitate an ACL, but we cannot stop there. We must now go into the prevention arena. In the United States there is tremendous variation in the exposure and acquisition of skills of physical activities in our youth. Today, children are often playing inside, using computers and watching television-missing out on the opportunity to learn safe movement patterns. Therefore, physical movement classes should occur very early in life, teaching children to land safely and in control, similar to the cry of "get down, stay down" routinely heard during youth soccer. Similarly, specific strength training programs can address landing as well as foot movements during cutting in basketball. Coaches should issue stern warnings when athletes demonstrate a high-risk movement patterns such as one-leg landings, out-of-control baseline landings, or straight-leg landings. The warnings may serve to keep the athlete from "touching the hot stove again" for fear of getting burned. No athlete feels she will be the one to get injured. Therefore, prospective analysis is likely to be received more warmly by the athletes if the program is presented with an emphasis on performance improvement rather than injury prevention. With increased participation in these programs, multiple-center analysis will have the power necessary to determine which factors significantly predispose athletes to ACL injury. The future for injury prevention is bright. We must rise to the challenge.

A Hypothesis: Could Portable Natural Grass be a Risk Factor for Knee Injuries?

PubMed Central

Orchard, John; Rodas, Gil; Til, Lluis; ArdevÒl, Jordi; Chivers, Ian

2008-01-01

Previous study has shown a likely link between increased shoe- surface traction and risk of knee Anterior Cruciate Ligament (ACL) injury. Portable natural grass systems are being used more often in sport, but no study to date has investigated their relative safety. By their nature, they must have high resistance to falling apart and therefore newly laid systems may be at risk of creating excessive shoe-surface traction. This study describes two clusters of knee injuries (particularly non-contact ACL injuries), each occurring to players of one professional football team at single venue, using portable grass, in a short space of time. The first series included two ACL injuries, one posterolateral complex disruption and one lateral ligament tear occurring in two rugby league games on a portable bermudagrass surface in Brisbane, Australia. The second series included four non-contact ACL injuries over a period of ten weeks in professional soccer games on a portable Kentucky bluegrass/perennial ryegrass surface in Barcelona, Spain. Possible intrinsic risk factors are discussed but there was no common risk shared by the players. Although no measures of traction were made at the Brisbane venue, average rotational traction was measured towards the end of the injury cluster at Camp Nou, Barcelona, to be 48 Nm. Chance undoubtedly had a part to play in these clusters, but the only obvious common risk factor was play on a portable natural grass surface soon after it was laid. Further study is required to determine whether portable natural grass systems may exhibit high shoe-surface traction soon after being laid and whether this could be a risk factor for knee injury. Key pointsExcessive shoe-surface traction is a hypothesised risk factor for knee ligament injuries, including anterior cruciate ligament injuries.Portable natural grass systems (by their nature in order to prevent grass rolls or squares from falling apart) will tend to exhibit high resistance to tearing when first laid. This may lead to excessive shoe-surface traction.This dual case series describes two clusters of non-contact knee ligament injuries which occurred in circumstances of newly laid portable turf.Further research is warranted to undercover any link between non-contact knee ligament injuries and ground surfaces conditions. PMID:24150152

National Football League Skilled and Unskilled Positions Vary in Opportunity and Yield in Return to Play After an Anterior Cruciate Ligament Injury

PubMed Central

Yang, JaeWon; Hodax, Jonathan D.; Machan, Jason T.; Secrist, Eric S.; Durand, Wesley M.; Owens, Brett D.; Eltorai, Adam E.M.; Dodson, Christopher C.

2017-01-01

Background: Anterior cruciate ligament (ACL) injuries pose a significant risk to the careers of players in the National Football League (NFL). The relationships between draft round and position on return to play (RTP) among NFL players are not well understood, and the ability to return to preinjury performance levels remains unknown for most positions. Purpose: To test for differences in RTP rates and changes in performance after an ACL injury by position and draft round. We hypothesized that skilled positions would return at a lower rate compared to unskilled positions. We further hypothesized that early draft-round status would relate to a greater rate of RTP and that skilled positions and a lower draft round would correlate with decreased performance for players who return to sport. Study Design: Case-control study; Level of evidence, 3. Methods: Utilizing a previously established database of publicly available information regarding ACL tears among NFL players, athletes with ACL tears occurring between the 2010 and 2013 seasons were identified. Generalized linear models and Kaplan-Meier time-to-event models were used to test the study hypotheses. Results: The overall RTP rate was 61.7%, with skilled players and unskilled players returning at rates of 64.1% and 60.4%, respectively (P = .74). Early draft-round players and unskilled late draft-round players had greater rates of RTP compared to skilled late draft-round players and both unskilled and skilled undrafted free agents (UDFAs). Skilled early draft-round players constituted the only cohort that played significantly fewer games after an injury. Unskilled UDFAs constituted the only cohort to show a significant increase in the number of games started and ratio of games started to games played, starting more games in which they played, after an injury. Conclusion: Early draft-round and unskilled players were more likely to return compared to their later draft-round and skilled peers. Skilled early draft-round players, who displayed relatively high rates of RTP, constituted the only cohort to show a decline in performance. Unskilled UDFAs, who exhibited relatively low rates of RTP, constituted the only cohort to show an increase in performance. The significant effect of draft round and position type on RTP may be caused by a combination of differences in talent levels and in opportunities given to returning to play. PMID:28975136

Genome-wide association screens for Achilles tendon and ACL tears and tendinopathy

PubMed Central

Roos, Thomas R.; Roos, Andrew K.; Kleimeyer, John P.; Ahmed, Marwa A.; Goodlin, Gabrielle T.; Fredericson, Michael; Ioannidis, John P. A.; Avins, Andrew L.; Dragoo, Jason L.

2017-01-01

Achilles tendinopathy or rupture and anterior cruciate ligament (ACL) rupture are substantial injuries affecting athletes, associated with delayed recovery or inability to return to competition. To identify genetic markers that might be used to predict risk for these injuries, we performed genome-wide association screens for these injuries using data from the Genetic Epidemiology Research on Adult Health and Aging (GERA) cohort consisting of 102,979 individuals. We did not find any single nucleotide polymorphisms (SNPs) associated with either of these injuries with a p-value that was genome-wide significant (p<5x10-8). We found, however, four and three polymorphisms with p-values that were borderline significant (p<10−6) for Achilles tendon injury and ACL rupture, respectively. We then tested SNPs previously reported to be associated with either Achilles tendon injury or ACL rupture. None showed an association in our cohort with a false discovery rate of less than 5%. We obtained, however, moderate to weak evidence for replication in one case; specifically, rs4919510 in MIR608 had a p-value of 5.1x10-3 for association with Achilles tendon injury, corresponding to a 7% chance of false replication. Finally, we tested 2855 SNPs in 90 candidate genes for musculoskeletal injury, but did not find any that showed a significant association below a false discovery rate of 5%. We provide data containing summary statistics for the entire genome, which will be useful for future genetic studies on these injuries. PMID:28358823

Effect of Fatigue Protocols on Lower Limb Neuromuscular Function and Implications for Anterior Cruciate Ligament Injury Prevention Training: A Systematic Review.

PubMed

Barber-Westin, Sue D; Noyes, Frank R

2017-12-01

Approximately two-thirds of anterior cruciate ligament (ACL) tears are sustained during noncontact situations when an athlete is cutting, pivoting, decelerating, or landing from a jump. Some investigators have postulated that fatigue may result in deleterious alterations in lower limb biomechanics during these activities that could increase the risk of noncontact ACL injuries. However, prior studies have noted a wide variation in fatigue protocols, athletic tasks studied, and effects of fatigue on lower limb kinetics and kinematics. First, to determine if fatigue uniformly alters lower limb biomechanics during athletic tasks that are associated with noncontact ACL injuries. Second, to determine if changes should be made in ACL injury prevention training programs to alter the deleterious effects of fatigue on lower limb kinetics and kinematics. Systematic review; Level of evidence, 4. A systematic review of the literature using MEDLINE was performed. Key terms were fatigue, neuromuscular, exercise, hop test, and single-legged function tests. Inclusion criteria were original research studies involving healthy participants, use of a fatigue protocol, study of at least 1 lower limb task that involved landing from a hop or jump or cutting, and analysis of at least 1 biomechanical variable. Thirty-seven studies involving 806 athletes (485 female, 321 male; mean age, 22.7 years) met the inclusion criteria. General fatigue protocols were used in 20 investigations, peripheral protocols were used in 17 studies, and 21 different athletic tasks were studied (13 single-legged, 8 double-legged). There was no consistency among investigations regarding the effects of fatigue on hip, knee, or ankle joint angles and moments or surface electromyography muscle activation patterns. The fatigue protocols typically did not produce statistically significant changes in ground-reaction forces. Published fatigue protocols did not uniformly produce alterations in lower limb neuromuscular factors that heighten the risk of noncontact ACL injuries. Therefore, justification does not currently exist for major changes in ACL injury prevention training programs to account for potential fatigue effects. However, the effect of fatigue related to ACL injuries is worthy of further investigation, including the refinement of protocols and methods of analysis.

Complete vs partial-thickness tears of the posterior cruciate ligament: MR findings.

PubMed

Patten, R M; Richardson, M L; Zink-Brody, G; Rolfe, B A

1994-01-01

We sought to define the MRI appearance of both complete and partial-thickness tears of the posterior cruciate ligament (PCL) and to describe patterns of injury and associated MRI findings. Three radiologists retrospectively reviewed MR images and medical records on 32 patients with PCL tears (15 complete, 17 partial) and correlated MRI findings to results of clinical testing and surgery. The PCL had indistinct margins in 27 (84%) of 32 patients and was abnormally thick in 25 (78%) patients. In 31 (97%) patients, the torn PCL showed increased signal intensity on both T1- and T2-weighted pulse sequences. Although there was no statistically significant difference between patients with complete tears and those with partial tears with regard to thickness, margination, and signal intensity of the PCL, MR images in patients with complete tears were more likely to show focal areas of ligamentous discontinuity (10 of 15 cases) (p = 0.01). Associated knee injuries were seen in 21 (66%) patients and were seen more frequently in patients with complete PCL tears (p = 0.015). Bony injury (n = 11, 34%) and tears of the medial collateral ligament (n = 13, 41%) and menisci (n = 10, 31%) were common. No specific pattern of bony injury was found. Posterior cruciate ligament tears can be diagnosed readily by multiplanar MRI using both morphological and signal intensity characteristics. Although differentiation between complete and partial-thickness PCL tears by MRI criteria alone is more problematic, complete tears are more likely to show focal areas of discontinuity and partial tears are more likely to show at least some intact fibers.

Partial articular-sided rotator cuff tears: in situ repair versus tear completion prior to repair.

PubMed

Sethi, Paul M; Rajaram, Arun; Obopilwe, Elifho; Mazzocca, Augustus D

2013-06-01

Uncertainty exists over the ideal surgical treatment method for partial articular-sided rotator cuff tears, with options ranging from debridement to in situ repair to tear completion prior to repair. The purpose of this study was to determine whether in situ repair was a viable biomechanical treatment option compared with tear completion prior to repair of partial articular-sided rotator cuff tears. Fourteen fresh-frozen cadaveric shoulders were dissected. Partial articular-sided tears were created and repaired using in situ repair or tear completion prior to the repair. Strain and displacement were measured at 45°, 60°, and 90° of glenohumeral abduction. Testing was performed with a load of 100 N applied for 30 cycles. Data from the biomechanical testing displayed 4 conditions that showed improved characteristics of in situ repair over completion and repair: bursal-sided strain anteriorly at 45°, bursal-sided strain anteriorly at 90°, bursal-sided displacement anteriorly at 45°, and bursal-sided displacement anteriorly at 90°. The data indicate that in situ repair is a viable biomechanical treatment option compared with tear completion prior to repair of partial articular-sided rotator cuff tears. When clinically appropriate, the in situ repair may offer some biomechanical advantages, with lower strain and displacement observed on the bursal side compared with tear completion prior to repair. Copyright 2013, SLACK Incorporated.

A Canine Arthroscopic Anterior Cruciate Ligament Reconstruction Model for Study of Synthetic Augmentation of Tendon Allografts.

PubMed

Cook, James L; Smith, Pat; Stannard, James P; Pfeiffer, Ferris; Kuroki, Keiichi; Bozynski, Chantelle C; Cook, Cristi

2017-09-01

Novel graft types, fixation methods, and means for augmenting anterior cruciate ligament (ACL) reconstructions require preclinical validation prior to safe and effective clinical application. The objective of this study was to describe and validate a translational canine model for all-inside arthroscopic complete ACL reconstruction using a quadriceps tendon allograft with internal brace (QTIB). With institutional approval, adult research hounds underwent complete transection of the native ACL followed by all-inside ACL reconstruction using the novel QTIB construct with suspensory fixation ( n  = 10). Contralateral knees were used as nonoperated controls ( n  = 10). Dogs were assessed over a 6-month period using functional, diagnostic imaging, gross, biomechanical, and histologic outcome measures required for preclinical animal models. Study results suggest that the novel QTIB construct used for complete ACL reconstruction can provide sustained knee stability and function without the development of premature osteoarthritis in a rigorous and valid preclinical model. The unique configuration of the QTIB construct-the combination of a tendon allograft with a synthetic suture tape internal brace-allowed for an effective biologic-synthetic load-sharing ACL construct. It prevented early failure, allowed for direct, four-zone graft-to-bone healing, and functional graft remodeling while avoiding problems noted with use of all-synthetic grafts. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A lateral meniscus tear incarcerated behind the popliteus tendon: a case report.

PubMed

Eskander, Mark S; Drew, Jacob M; Osuch, Daniel B; Metzmaker, Jeff

2010-10-01

A 51-year-old male, sustained an injury to his left knee after being pinned between his motorcycle and a road barrier. In the ER, the patient complained of medial knee pain, and had a significant joint effusion. MRI demonstrated an ACL injury, medial meniscal tear, bone bruising and impaction at the lateral femoral condyle and tibial plateau, and a tear of the posterior horn of the lateral meniscus that was displaced behind the popliteus. Unfortunately, the patient also presented with a deep vein thrombosis and thus could not proceed to the operating room for two months. During this time, scar tissue developed around the lateral meniscus. The purpose of this report is to present an unusual variant of a common injury pattern previously unreported where the posterior horn of the lateral meniscus became incarcerated behind the popliteus tendon and was left in place. It is likely that our patient will develop osteoarthritis in the future, but considering the circumstances he received a favorable early clinical outcome. Early recognition and a mobile fragment are essential restoring a patient's original anatomical features and achieving an optimal clinical outcome. Copyright 2009 Elsevier B.V. All rights reserved.

Return to play after all-inside meniscal repair in competitive football players: a minimum 5-year follow-up.

PubMed

Alvarez-Diaz, Pedro; Alentorn-Geli, Eduard; Llobet, Federico; Granados, Nelson; Steinbacher, Gilbert; Cugat, Ramón

2016-06-01

The purpose of this study was to report the mid-to-long-term return to sports after all-inside meniscal repair in competitive football players. All football players undergoing all-inside meniscal repair with a minimum Tegner activity score of 9 and minimum follow-up of 5 years were eligible for inclusion. Patients were excluded if: (a) they had ipsilateral or contralateral: meniscectomy, posterior cruciate ligament tear, multi-ligament knee injuries, osteotomies, or meniscal transplant (b) they had meniscal tears in the anterior horn, and (c) they had bucket-handle tears. All patients included were contacted by phone and asked for current sport status or Tegner score. Preoperative Tegner scores were collected from the medical charts. All patients (n = 29) were men with a median (range) age of 27 (18-37) years and a follow-up of 6 (5-8) years. All meniscal injuries were complete and longitudinal tears. The median preinjury Tegner activity score was 9 (range 9-10). Two patients required revision arthroscopy (6.7 %) with partial meniscectomy before being able to return to competitive football due to suture failure. Twenty-six patients (89.6 %) returned to the same level of competition after recovering from surgery. At the last follow-up, 13 patients (45 %) were able to continue playing football at any level, and 8 (28 %) of them were able to return to the same pre-injury competitive level. The main reasons for the decreased level of activity (from competitive to recreational) or to give up football were job-related or changes in their personal life situation, but were not related to knee or meniscal disorders. Fourteen patients underwent meniscal repair alone, whereas 15 patients had an associated ACL reconstruction procedure. There were no significant differences in the collected variables between both subgroups. All-inside meniscal repair allows for excellent results with regard to return-to-play rates in competitive football. However, only half of the patients are still playing football in the mid-to-long-term follow-up, although reasons to give up football are not related to knee or meniscal disorders. Case series, Level-IV.

Effects of anterior cruciate ligament reconstruction on neuromuscular tensiomyographic characteristics of the lower extremity in competitive male soccer players.

PubMed

Alvarez-Diaz, Pedro; Alentorn-Geli, Eduard; Ramon, Silvia; Marin, Miguel; Steinbacher, Gilbert; Rius, Marta; Seijas, Roberto; Ballester, Jordi; Cugat, Ramon

2015-11-01

To investigate the effects of anterior cruciate ligament (ACL) reconstruction on mechanical and contractile properties of the skeletal muscles of the lower extremities in soccer players through tensiomyography (TMG). All soccer players with acute ACL tear included underwent resting TMG assessment of muscles of both lower extremities before and 1 year after ACL reconstruction. The muscles assessed were vastus medialis (VM), vastus laterals (VL), rectus femoris (RF), semitendinosus (ST), biceps femoris (BF), gastrocnemius medialis (GM), and gastrocnemius lateralis (GL). The TMG parameters obtained for each muscle were maximal displacement (D m), delay time (T d), contraction time (T c), sustained time (T s), and half-relaxation time (T r). The injured leg had a significant decrease in VL-T c, ST-T c, GM-T c, GL-T r, and GL-T d, and a significant increase in VM-T r and GM-T s in the postoperative compared to preoperative period. The non-injured leg demonstrated significant preoperative-postoperative changes in the VL, RF, and BF, but not in VM, ST, GM, and GL The magnitude of preoperative-postoperative differences in the injured leg was significantly higher in RF-T c, ST-T c, BF-D m, and GL-T r, but lower in RF-T r and GM-T s, compared to the non-injured leg. Both groups improved their symmetry between the quadriceps and hamstring muscle groups in both sides. The quadriceps muscles improved their resistance to fatigue and contraction velocity in both sides, and the hamstring muscles improved their contraction velocity and muscle tone in both sides as well. Improvements in contraction velocity and muscle tone were more evident in the quadriceps and hamstrings of the injured compared to the uninjured side. In addition, the intervention increased the percentage of symmetry between both sides in the TMG of the quadriceps muscles and the balance between ACL-agonist (hamstrings) and ACL-antagonist (quadriceps) muscle groups in both sides. This study shows how ACL reconstruction (and subsequent rehabilitation) can positively impact neuromuscular characteristics of the quadriceps and hamstrings. Therapeutic, Level II.

Hamstring Activity in the Anterior Cruciate Ligament Injured Patient: Injury Implications and Comparison With Quadriceps Activity.

PubMed

Frank, Rachel M; Lundberg, Hannah; Wimmer, Markus A; Forsythe, Brian; Bach, Bernard R; Verma, Nikhil N; Cole, Brian J

2016-08-01

To investigate the potential causes of diminished knee extension after acute anterior cruciate ligament (ACL) injury using both surface electromyography (sEMG) analysis of the quadriceps and hamstrings, and gait analysis to assess muscle action and tone. Consecutive patients with an acute ACL tear underwent sEMG and gait analysis within 2 weeks of injury, before ACL reconstruction. Standard motion analysis techniques were used and sEMG data were collected simultaneously with gait data. T-tests were used to determine differences between the ACL-deficient and control subjects in knee flexion angles, peak external knee joint moments, and total time that a muscle was activated ("on") during gait. External knee moments were expressed as a percentage of body weight times height. Ten patients (mean age 24 ± 4 years) were included at a mean 10.2 days between injury and analysis; 10 uninjured, matched control subjects were included for comparison. There were significant increases in minimum flexion angle at heel strike (5.92 ± 3.39 v -3.49 ± 4.55, P < .001) and midstance (14.1 ± 6.23 v 1.20 ± 4.21, P < .001) in the injured limb compared with controls. There were significantly lower maximum external extension moments at heel strike (-0.99 ± 0.46 v -2.94 ± 0.60, P < .001) and during the second half of stance in the injured limb compared with controls (-0.56 ± 1.14 v -3.54 ± 1.31, P < .001). The rectus femoris was "on" significantly less during gait in the injured leg compared with controls (49.1 ± 7.76% v 61.0 ± 14.8%, P = .044). There were no significant differences in hamstring activity "on" time during gait (P > .05). In patients with acute ACL injury, the ACL-deficient limb does not reach as much extension as controls. Although the rectus femoris is "on" for shorter periods during the gait cycle, there is no difference in hamstring time on during gait. This information may help clinicians better understand muscle function and gait patterns in the acute time period after ACL injury. Level III, case control study. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Knee Osteoarthritis Is Associated With Previous Meniscus and Anterior Cruciate Ligament Surgery Among Elite College American Football Athletes.

PubMed

Smith, Matthew V; Nepple, Jeffrey J; Wright, Rick W; Matava, Matthew J; Brophy, Robert H

Football puts athletes at risk for knee injuries such meniscus and anterior cruciate ligament (ACL) tears, which are associated with the development of osteoarthritis (OA). Previous knee surgery, player position, and body mass index (BMI) may be associated with knee OA. In elite football players undergoing knee magnetic resonance imaging at the National Football League's Invitational Combine, the prevalence of knee OA is associated with previous knee surgery and BMI. Retrospective cohort. Level 4. A retrospective review was performed of all participants of the National Football League Combine from 2005 to 2009 who underwent magnetic resonance imaging of the knee because of prior knee injury, surgery, or knee-related symptoms or concerning examination findings. Imaging studies were reviewed for evidence of OA. History of previous knee surgery-including ACL reconstruction, meniscal procedures, and articular cartilage surgery-and position were recorded for each athlete. BMI was calculated based on height and weight. There was a higher prevalence of OA in knees with a history of previous knee surgery (23% vs 4.0%, P < 0.001). The prevalence of knee OA was 4.0% in those without previous knee surgery, 11% in those with a history of meniscus repair, 24% of those with a history of ACL reconstruction, and 27% of those with a history of partial meniscectomy. Among knees with a previous ACL reconstruction, the rate of OA doubled in tibiofemoral compartments in which meniscal surgery was performed. BMI >30 kg/m 2 was also associated with a higher risk of OA ( P = 0.007) but player position was not associated with knee OA. Previous knee surgery, particularly ACL reconstruction and partial meniscectomy, and elevated BMI are associated with knee OA in elite football players. Future research should investigate ways to minimize the risk of OA after knee surgery in these athletes. Treatment of knee injuries in football athletes should consider chondroprotection, including meniscal preservation and cartilage repair, when possible.

Role of endolymphatic anion transport in forskolin-induced Cl- activity increase of scala media.

PubMed

Kitano, I; Mori, N; Matsunaga, T

1995-03-01

To determine the role of anion transport in the forskolin-induced Cl- increase of scala media (SM), effects of forskolin on the EP (endocochlear potential) and Cl- activity (ACl) in SM were examined with double-barrelled Cl(-)-selective microelectrodes. The experiments were carried out on guinea pig cochleae, using a few anion transport inhibitors: IAA-94 for a Cl- channel blocker, bumetanide (BU) for an Na+/K+/2Cl- cotransport blocker, and SITS and DIDS for Cl-/HCO3- exchange blockers. The application of forskolin (200 microM) into scala vestibuli (SV) caused a 20 mEq increase of endolymphatic ACl and a 15 mV elevation of EP, and IAA-94 with forskolin completely abolished these responses. Although each application of BU, SITS or DIDS did not completely suppress EP elevation, the concurrent application of these inhibitors completely suppressed EP with endolymphatic ACl increase. The results indicate the involvement of Cl- channels, Na+/K+/2Cl- cotransport and Cl-/HCO3- exchange in forskolin-induced increase of ACl and EP. The role of adenylate cyclase activation and Cl- transport in endolymph homeostasis was discussed.

Prevalence of triceps tendon tears on MRI of the elbow and clinical correlation.

PubMed

Koplas, Monica C; Schneider, Erika; Sundaram, Murali

2011-05-01

Triceps tendon injuries are reported to be very rare. To our knowledge, there have been no studies describing its prevalence or injury patterns on MR imaging. The purpose of this retrospective study was to determine the prevalence and patterns of triceps injuries based on a large series of consecutive MR examinations. Clinical correlation was obtained. From 801 consecutive elbow MR examinations over a 15-year period, 28 patients with 30 triceps tendon injuries were identified and graded as partial tendon tear and complete tendon tear. The patients' medical records were reviewed to determine age, gender, cause of tears, and management. The prevalence of triceps tendon injuries was 3.8%. There were 5 women and 23 men with partial or complete tears (mean age: 46.6 years; range: 2.7 to 75.1 years). The most common injury was partial tear, found in 18 patients. There were 10 patients with 12 complete tears (2 had re-torn following surgical repair). A tear was suspected in 12 out 28 (43%) patients prior to the MRI. The most common presenting symptom was pain. The most common cause was athletic injury (8 patients [29%], including weightlifting [2 patients]). Tendon tear was found to be a complication of infection in 6 patients, and in 3 patients the tears were a complication of steroid use. Thirteen tendon tears were surgically repaired (8 of these were complete tears). Triceps tendon injury is not as rare as commonly reported and may often be clinically underdiagnosed.

Anterior cruciate ligament injury alters preinjury lower extremity biomechanics in the injured and uninjured leg: the JUMP-ACL study.

PubMed

Goerger, Benjamin M; Marshall, Stephen W; Beutler, Anthony I; Blackburn, J Troy; Wilckens, John H; Padua, Darin A

2015-02-01

Information as to how anterior cruciate ligament (ACL) injury and reconstructive surgery (ACLR) alter lower extremity biomechanics may improve rehabilitation and return to play guidelines, reducing the risk for repeat ACL injury. To compare lower extremity biomechanics before ACL injury and after subsequent ACLR for the injured and uninjured leg. Baseline unilateral lower extremity biomechanics were collected on the dominant leg of participants without ACL injury when they entered the Joint Undertaking to Monitor and Prevent ACL (JUMP-ACL) study. Thirty-one participants with subsequent ACL injury, reconstructive surgery and full return to physical activity completed repeat, follow-up biomechanical testing, as did 39 uninjured, matched controls. Not all injured participants suffered injury to the dominant leg, requiring separation of those with ACL injury into two groups: ACLR-injured leg group (n=12) and ACLR-uninjured leg group (n=19). We compared the landing biomechanics of these three groups (ACLR-injured leg, ACLR-uninjured leg, control) before ACL injury (baseline) with biomechanics after ACL injury, surgery and return to physical activity (follow-up). ACL injury and ACLR altered lower extremity biomechanics, as both ACLR groups demonstrated increases in frontal plane movement (increased hip adduction and knee valgus). The ACLR-injured leg group also exhibited decreased sagittal plane loading (decreased anterior tibial shear force, knee extension moment and hip flexion moment). No high-risk biomechanical changes were observed in control group participants. ACL injury and ACLR caused movement pattern alterations of the injured and uninjured leg that have previously shown to increase the risk for future non-contact ACL injury. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Prevention of Lower Extremity Injuries in Basketball

PubMed Central

Taylor, Jeffrey B.; Ford, Kevin R.; Nguyen, Anh-Dung; Terry, Lauren N.; Hegedus, Eric J.

2015-01-01

Context: Lower extremity injuries are common in basketball, yet it is unclear how prophylactic interventions affect lower extremity injury incidence rates. Objective: To analyze the effectiveness of current lower extremity injury prevention programs in basketball athletes, focusing on injury rates of (1) general lower extremity injuries, (2) ankle sprains, and (3) anterior cruciate ligament (ACL) tears. Data Sources: PubMed, MEDLINE, CINAHL, SPORTDiscus, and the Cochrane Register of Controlled Trials were searched in January 2015. Study Selection: Studies were included if they were randomized controlled or prospective cohort trials, contained a population of competitive basketball athletes, and reported lower extremity injury incidence rates specific to basketball players. In total, 426 individual studies were identified. Of these, 9 met the inclusion criteria. One other study was found during a hand search of the literature, resulting in 10 total studies included in this meta-analysis. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 2. Data Extraction: Details of the intervention (eg, neuromuscular vs external support), size of control and intervention groups, and number of injuries in each group were extracted from each study. Injury data were classified into 3 groups based on the anatomic diagnosis reported (general lower extremity injury, ankle sprain, ACL rupture). Results: Meta-analyses were performed independently for each injury classification. Results indicate that prophylactic programs significantly reduced the incidence of general lower extremity injuries (odds ratio [OR], 0.69; 95% CI, 0.57-0.85; P < 0.001) and ankle sprains (OR, 0.45; 95% CI, 0.29-0.69; P < 0.001), yet not ACL ruptures (OR, 1.09; 95% CI, 0.36-3.29; P = 0.87) in basketball athletes. Conclusion: In basketball players, prophylactic programs may be effective in reducing the risk of general lower extremity injuries and ankle sprains, yet not ACL injuries. PMID:26502412

Combined reconstruction of the anterior cruciate ligament associated with anterolateral tenodesis effectively controls the acceleration of the tibia during the pivot shift.

PubMed

Hardy, Alexandre; Casabianca, Laurent; Hardy, Edouard; Grimaud, Olivier; Meyer, Alain

2017-04-01

The pivot shift test is quantified subjectively during assessment of patients presenting with suspected Anterior Cruciate Ligament (ACL) tears and has a low interobserver reproducibility. The Kinematic Rapid Assessment (KiRA) is a triaxial accelerometer that makes it possible to non-invasively quantify tibial acceleration during the pivot shift test. Abolishing pivot shift is considered to be a key element in surgical reconstruction but is incomplete in 25-38% of patients. Patients were included prospectively. Inclusion criteria were patients requiring ACL reconstruction associated with at least one of the following factors corresponding to the patient who have a high risk of rupture either by their sports activity, a failure case, or the notion of important rotational laxity: the patient practiced a competitive pivot-contact sport, revision ACL reconstruction (besides STG (semitendinosus-gracilis graft) repair), subjective explosive rotational laxity, Segond fracture, and TELOS value of >10 mm. Standardized pre- and postoperative pivot shift tests were immediately performed under anesthesia in both knees. Forty-three patients were included. Mean preoperative variations in tibial acceleration in the healthy and injured knees were 1.2 ± 0.1 and 2.7 ± 0.3 m/s 2 , respectively, p < 0.01. A statistically significant decrease in immediate postoperative mean variations in acceleration in the injured knee occurred: 1.5 ± 0.3 m/s 2 , p < 0.01. There was no longer any statistical difference between postoperative contralateral healthy knees and operated knees (n.s). Combined ACL reconstruction associated with anterolateral tenodesis suppress acute pathologic tibial acceleration in the pivot shift. III.

The reliability of physical examination tests for the diagnosis of anterior cruciate ligament rupture--A systematic review.

PubMed

Lange, Toni; Freiberg, Alice; Dröge, Patrik; Lützner, Jörg; Schmitt, Jochen; Kopkow, Christian

2015-06-01

Systematic literature review. Despite their frequent application in routine care, a systematic review on the reliability of clinical examination tests to evaluate the integrity of the ACL is missing. To summarize and evaluate intra- and interrater reliability research on physical examination tests used for the diagnosis of ACL tears. A comprehensive systematic literature search was conducted in MEDLINE, EMBASE and AMED until May 30th 2013. Studies were included if they assessed the intra- and/or interrater reliability of physical examination tests for the integrity of the ACL. Methodological quality was evaluated with the Quality Appraisal of Reliability Studies (QAREL) tool by two independent reviewers. 110 hits were achieved of which seven articles finally met the inclusion criteria. These studies examined the reliability of four physical examination tests. Intrarater reliability was assessed in three studies and ranged from fair to almost perfect (Cohen's k = 0.22-1.00). Interrater reliability was assessed in all included studies and ranged from slight to almost perfect (Cohen's k = 0.02-0.81). The Lachman test is the physical tests with the highest intrarater reliability (Cohen's k = 1.00), the Lachman test performed in prone position the test with the highest interrater reliability (Cohen's k = 0.81). Included studies were partly of low methodological quality. A meta-analysis could not be performed due to the heterogeneity in study populations, reliability measures and methodological quality of included studies. Systematic investigations on the reliability of physical examination tests to assess the integrity of the ACL are scarce and of varying methodological quality. Copyright © 2014 Elsevier Ltd. All rights reserved.

Loading of the Medial Meniscus in the ACL deficient knee: a Multibody Computational Study

PubMed Central

Razu, Swithin

2017-01-01

The menisci of the knee reduce tibiofemoral contact pressures and aid in knee lubrication and nourishment. Meniscal injury occurs in half of knees sustaining anterior cruciate ligament injury and the vast majority of tears in the medial meniscus transpire in the posterior horn region. In this study, computational multibody models of the knee were derived from medical images and passive leg motion for two female subjects. The models were validated against experimental measures available in the literature and then used to evaluate medial meniscus contact force and internal hoop tension. The models predicted that the loss of anterior cruciate ligament (ACL) constraint increased contact and hoop forces in the medial menisci by a factor of 4 when a 100 N anterior tibial force was applied. Contact forces were concentrated in the posterior horn and hoop forces were also greater in this region. No differences were found in contact or hoop tension between the intact and ACL deficient (ACLd) knees when only a 5 Nm external tibial torque was applied about the long axis of the tibia. Combining a 100 N anterior tibial force and a 5 Nm external tibial torque increased posterior horn contact and hoop forces, even in the intact knee. The results of this study show that the posterior horn region of the medial meniscus experiences higher contact forces and hoop tension, making this region more susceptible to injury, especially with the loss of anterior tibia motion constraint provided by the ACL. The contribution of the dMCL in constraining posterior medial meniscus motion, at the cost of higher posterior horn hoop tension, is also demonstrated. PMID:28089224

Loading of the medial meniscus in the ACL deficient knee: A multibody computational study.

PubMed

Guess, Trent M; Razu, Swithin

2017-03-01

The menisci of the knee reduce tibiofemoral contact pressures and aid in knee lubrication and nourishment. Meniscal injury occurs in half of knees sustaining anterior cruciate ligament injury and the vast majority of tears in the medial meniscus transpire in the posterior horn region. In this study, computational multibody models of the knee were derived from medical images and passive leg motion for two female subjects. The models were validated against experimental measures available in the literature and then used to evaluate medial meniscus contact force and internal hoop tension. The models predicted that the loss of anterior cruciate ligament (ACL) constraint increased contact and hoop forces in the medial menisci by a factor of 4 when a 100N anterior tibial force was applied. Contact forces were concentrated in the posterior horn and hoop forces were also greater in this region. No differences were found in contact or hoop tension between the intact and ACL deficient (ACLd) knees when only a 5Nm external tibial torque was applied about the long axis of the tibia. Combining a 100N anterior tibial force and a 5Nm external tibial torque increased posterior horn contact and hoop forces, even in the intact knee. The results of this study show that the posterior horn region of the medial meniscus experiences higher contact forces and hoop tension, making this region more susceptible to injury, especially with the loss of anterior tibia motion constraint provided by the ACL. The contribution of the dMCL in constraining posterior medial meniscus motion, at the cost of higher posterior horn hoop tension, is also demonstrated. Copyright © 2016 IPEM. Published by Elsevier Ltd. All rights reserved.

Dimensionality of the Knee Numeric-Entity Evaluation Score (KNEES-ACL): a condition-specific questionnaire.

PubMed

Comins, J D; Krogsgaard, M R; Kreiner, S; Brodersen, J

2013-10-01

The benefit of anterior cruciate ligament (ACL) reconstruction has been questioned based on patient-reported outcome measures (PROMs). Valid interpretation of such results requires confirmation of the psychometric properties of the PROM. Rasch analysis is the gold standard for validation of PROMs, yet PROMs used for ACL reconstruction have not been validated using Rasch analysis. We used Rasch analysis to investigate the psychometric properties of the Knee Numeric-Entity Evaluation Score (KNEES-ACL), a newly developed PROM for patients treated for ACL deficiency. Two-hundred forty-two patients pre- and post-ACL reconstruction completed the pilot PROM. Rasch models were used to assess the psychometric properties (e.g., unidimensionality, local response dependency, and differential item functioning). Forty-one items distributed across seven unidimensional constructs measuring impairment, functional limitations, and psychosocial consequences were confirmed to fit Rasch models. Fourteen items were removed because of statistical lack of fit and inadequate face validity. Local response dependency and differential item functioning were identified and adjusted. The KNEES-ACL is the first Rasch-validated condition-specific PROM constructed for patients with ACL deficiency and patients with ACL reconstruction. Thus, this instrument can be used for within- and between-group comparisons. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Hidden lesions of the posterior horn of the medial meniscus: a systematic arthroscopic exploration of the concealed portion of the knee.

PubMed

Sonnery-Cottet, Bertrand; Conteduca, Jacopo; Thaunat, Mathieu; Gunepin, François Xavier; Seil, Romain

2014-04-01

Anterior cruciate ligament (ACL) tears are frequently associated with meniscal lesions. Despite improvements in meniscal repair techniques, failure rates remain significant, especially for the posterior horn of the medial meniscus. To determine whether a systematic arthroscopic exploration of the posterior horn of the medial meniscus with an additional posteromedial portal is useful to identify otherwise unrecognized lesions. Case series; Level of evidence, 4. In a consecutive series of 302 ACL reconstructions, a systematic arthroscopic exploration of the posterior horn of the medial meniscus was performed. The first stage of the exploration was achieved through anterior visualization via a standard anterolateral portal. In the second stage, the posterior horn of the medial meniscus was visualized posteriorly via the anterolateral portal with the scope positioned deep in the notch. In the third stage, the posterior horn was probed through an additional posteromedial portal. A χ2 test and logistic regression analysis were performed to determine if the time from injury to surgery was associated with the meniscal tear pattern. A medial meniscal tear was diagnosed in 125 of the 302 patients (41.4%). Seventy-five lesions (60%) located in the meniscal body were diagnosed at the first stage of the arthroscopic exploration. Fifty lesions located in the ramp area were diagnosed: 29 (23.2%) at the second stage and 21 lesions (16.8%) at the third stage after minimal debridement of the superficial soft tissue layer. The latter type of lesion is called a "hidden lesion." Altogether, the prevalence of ramp lesions in this population was 40%. Meniscal body lesions (odds ratio, 2.6; 95% confidence interval, 1.18-5.18; P < .02) were found to be significantly correlated with a longer delay between injury and surgery. Posterior visualization and posteromedial probing of the posterior horn of the medial meniscus can help in discovering a higher rate of lesions that could be easily missed through a standard anterior exploration. In numerous cases, these lesions were "hidden" under a membrane-like tissue and were discovered after minimal debridement through a posteromedial portal.

The Degeneration of Meniscus Roots Is Accompanied by Fibrocartilage Formation, Which May Precede Meniscus Root Tears in Osteoarthritic Knees.

PubMed

Park, Do Young; Min, Byoung-Hyun; Choi, Byung Hyune; Kim, Young Jick; Kim, Mijin; Suh-Kim, Haeyoung; Kim, Joon Ho

2015-12-01

Fibrocartilage metaplasia in tendons and ligaments is an adaptation to compression as well as a pathological feature during degeneration. Medial meniscus posterior roots are unique ligaments that resist multidirectional forces, including compression. To characterize the degeneration of medial meniscus posterior root tears in osteoarthritic knees, with an emphasis on fibrocartilage and calcification. Cross-sectional study; Level of evidence, 3. Samples of medial meniscus posterior roots were harvested from cadaveric specimens and patients during knee replacement surgery and grouped as follows: normal reference, no tear, partial tear, and complete tear. Degeneration was analyzed with histology, immunohistochemistry, and real-time polymerase chain reaction. Uniaxial tensile tests were performed on specimens with and without fibrocartilage. Quantifiable data were statistically analyzed by the Kruskal-Wallis test with the Dunn comparison test. Thirty, 28, and 42 samples harvested from 99 patients were allocated into the no tear, partial tear, and complete tear groups, respectively. Mean modified Bonar tendinopathy scores for each group were 3.97, 9.31, and 14.15, respectively, showing a higher degree of degeneration associated with the extent of the tear (P < .05 for all groups). The characterization of root matrices revealed an increase in fibrocartilage according to the extent of the tear. Tear margins revealed fibrocartilage in 59.3% of partial tear samples and 76.2% of complete tear samples, with a distinctive cleavage-like shape. Root tears with a similar shape were induced within fibrocartilaginous areas during uniaxial tensile testing. Even in the no tear group, 56.7% of samples showed fibrocartilage in the anterior margin of the root, adjacent to the meniscus. An increased stained area of calcification and expression of the ectonucleotide pyrophosphatase/phosphodiesterase 1 gene were observed in the complete tear group compared with the no tear group (P < .0001 and P = .24, respectively). Fibrocartilage and calcification increased in medial meniscus posterior roots, associated with the degree of the tear. Both findings, which impair the ligament's resistance to tension, may play a pivotal role during the pathogenesis of degenerative meniscus root tears in osteoarthritic knees. Fibrocartilage and calcification may be useful as diagnostic markers as well as markers of degeneration, which may aid in determining the treatment modality in meniscus root tears. The presence of fibrocartilage in intact roots may suggest an impending tear in osteoarthritic knees. © 2015 The Author(s).

Simulated Activity But Real Trauma: A Systematic Review on Nintendo Wii Injuries Based on a Case Report of an Acute Anterior Cruciate Ligament Rupture

PubMed Central

Müller, Sebastian A.; Vavken, Patrick; Pagenstert, Geert

2015-01-01

Abstract Video gaming injuries are classically regarded as eccentric accidents and novelty diagnoses. A case of an anterior cruciate ligament (ACL) tear sustained during Wii boxing spurned us to review the literature for other Wii-related injuries and Wii-based posttraumatic rehabilitation. The English literature listed in PubMed was systematically reviewed by searching for “Wii (trauma or injury or fracture).” Full-text articles were included after duplicate, blinded review. The type and treatment of injury as well as the Wii-based rehabilitation programs found were analyzed. Additionally, a new case of an acute ACL tear-sustained playing, Wii boxing, is additionally presented. After exclusion of irrelevant articles, 13 articles describing Wii-related injuries were included reporting on 3 fractures, 6 nonosseous, 2 overuse injuries, and 2 rehabilitation programs using Wii for posttraumatic rehabilitation. Among the presented Wii-related injuries, only 12.5% were treated conservatively, whereas 87.5% underwent either surgical or interventional treatment. Because of the reported case, the literature search was limited to Wii-related injuries excluding other video games. Another limitation of this article lies in the fact that mainly case reports but no controlled trials exist on the topic. Assumingly, primarily the more severe injuries are reported in the literature with an unknown number of possibly minor injuries. Motion-controlled video games, such as Wii, are becoming increasingly popular as a recreational entertainment. Because of their wide acceptance and entertaining nature, they are also increasingly recognized as a tool in rehabilitation. However, although the activity is simulated, injuries are real. Our systematic review shows that Wii gaming can lead to severe injuries, sometimes with lasting limitations. PMID:25816033

Posterolateral complex knee injuries: magnetic resonance imaging with surgical correlation.

PubMed

Theodorou, D J; Theodorou, S J; Fithian, D C; Paxton, L; Garelick, D H; Resnick, D

2005-05-01

To describe the magnetic resonance imaging (MRI) findings of injuries of the posterolateral aspect of the knee and to evaluate the diagnostic capabilities of MRI in the assessment of these injuries. The MRI studies of 14 patients (mean age 33 years) with trauma to the posterolateral aspect of the knee were retrospectively reviewed, and the imaging findings were correlated with those of surgery. In all patients, MRI showed an intact iliotibial (ITB) band. MRI showed injury to the biceps tendon in 11 (79%), the gastrocnemius tendon in 1 (7%)), the popliteus tendon in 5 (36%), and the lateral collateral ligament (LCL) in 14 (100%) patients. Tear of the anterior cruciate ligament (ACL) was seen in 11 (79%) patients and tear of the posterior cruciate ligament (PCL) in 4 (29%) patients. With routine MRI, visualization of the popliteofibular or fabellofibular ligaments was incomplete. On MRI, the lateral meniscus and the medial meniscus were torn with equal frequency (n = 4; 29%). Osteochondral defects were seen in 5 (36%) cases and joint effusion in all 14 (100%) cases on MRI. Using surgical findings as the standard for diagnosis, MRI proved 86% accurate in the detection of injury to the ITB band, the biceps tendon (93%), the gastrocnemius tendon (100%), the popliteus tendon (86%), the LCL (100%), the ACL (79%), the PCL (86%), the lateral meniscus (90%), the medial meniscus (82%), and the osteochondral structures (79%). Surgical correlation confirmed the MRI findings of joint effusion in all cases. MRI is well suited for demonstrating the presence and extent of injuries of the major structures of the posterolateral complex of the knee, allowing characterization of the severity of injury.

Accuracy of MRI findings in chronic lateral ankle ligament injury: comparison with surgical findings.

PubMed

Park, H-J; Cha, S-D; Kim, S S; Rho, M-H; Kwag, H-J; Park, N-H; Lee, S-Y

2012-04-01

To evaluate the accuracy of magnetic resonance imaging (MRI) findings in chronic lateral ankle ligament injury in comparison with that of surgical findings. Forty-eight cases (25 men, 23 women, mean age 36 years) of clinically suspected chronic ankle ligament injury underwent MRI studies and surgery. Sagittal, coronal, and axial, T1-weighted, spin-echo, proton density and T2-weighted, fast spin-echo images with fat saturation were obtained in all patients. MRI examinations were read in consensus by two fellowship-trained academic musculoskeletal radiologists who evaluated the lateral ankle ligaments, including the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) without clinical information. The results of the MRI studies were then compared with the surgical findings. The MRI findings of ATFL injury showed a sensitivity of detection of complete tears of 75% and specificity of 86%. The sensitivity of detection of partial tears was 75% and the specificity was 78%. The sensitivity of detection of sprains was 44% and the specificity was 88%. Regarding the MRI findings of CFL injury, the sensitivity of detection of complete tears was 50% and the specificity was 98%. The sensitivity of detection of partial tear was 83% and the specificity was 93%. The sensitivity of detection of sprains was 100% and the specificity was 90%. Regarding the ATFL, the accuracies of detection were 88, 58, 77, and 85% for no injury, sprain, partial tear, and complete tear, respectively, and for the CFL the accuracies of detection were 90, 90, 92, and 96% for no injury, sprain, partial tear, and complete tear, respectively. The diagnosis of a complete tear of the ATFL on MRI is more sensitive than the diagnosis of a complete tear of the CFL. MRI findings of CFL injury are diagnostically specific but are not sensitive. However, only normal findings and complete tears were statistically significant between ATFL and CFL (p < 0.001). Copyright © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

The Effectiveness of a Functional Knee Brace on Joint-Position Sense in Anterior Cruciate Ligament-Reconstructed Individuals.

PubMed

Sugimoto, Dai; LeBlanc, Jessica C; Wooley, Sarah E; Micheli, Lyle J; Kramer, Dennis E

2016-05-01

It is estimated that approximately 350,000 individuals undergo anterior cruciate ligament (ACL) reconstruction surgery in each year in the US. Although ACL-reconstruction surgery and postoperative rehabilitation are successfully completed, deficits in postural control remain prevalent in ACL-reconstructed individuals. In order to assist the lack of balance ability and reduce the risk of retear of the reconstructed ACL, physicians often provide a functional knee brace on the patients' return to physical activity. However, it is not known whether use of the functional knee brace enhances knee-joint position sense in individuals with ACL reconstruction. Thus, the effect of a functional knee brace on knee-joint position sense in an ACL-reconstructed population needs be critically appraised. After systematically review of previously published literature, 3 studies that investigated the effect of a functional knee brace in ACL-reconstructed individuals using joint-position-sense measures were found. They were rated as level 2b evidence in the Centre of Evidence Based Medicine Level of Evidence chart. Synthesis of the reviewed studies indicated inconsistent evidence of a functional knee brace on joint-position improvement after ACL reconstruction. More research is needed to provide sufficient evidence on the effect of a functional knee brace on joint-position sense after ACL reconstruction. Future studies need to measure joint-position sense in closed-kinetic-chain fashion since ACL injury usually occurs under weight-bearing conditions.

Diagnostic value of medical history and physical examination of anterior cruciate ligament injury: comparison between primary care physician and orthopaedic surgeon.

PubMed

Geraets, Stijn E W; Meuffels, Duncan E; van Meer, Belle L; Breedveldt Boer, Hans P; Bierma-Zeinstra, Sita M A; Reijman, Max

2015-04-01

Well-designed validity studies on the clinical diagnosis of anterior cruciate ligament (ACL) injury are scarce. Our purpose is to assess the diagnostic value of ACL-specific medical history assessment and physical examination between primary and secondary care medical specialists. Medical history assessment and physical examination were performed by both an orthopaedic surgeon and a primary care physician, both blinded to all clinical information, in a secondary care population. A knee arthroscopy was used as reference standard. A total of 60 participants were divided into an index group with an arthroscopically proven complete ACL rupture and a control group with an arthroscopically proven intact ACL. The orthopaedic surgeon recognized 94 % of the participants with an ACL rupture through a positive medical history combined with a positive physical examination; of the participants with an intact ACL, 16 % were misclassified by the orthopaedic surgeon. The primary care physician recognized 62 % of the participants with an ACL rupture and misclassified 23 % of the participants with an intact ACL. Physical examination appeared to have no additional value for the primary care physician. Combined medical history and physical examination have strong diagnostic value in ACL rupture diagnostics performed by an orthopaedic surgeon, whereas for the primary care physician, only medical history appeared to be of value. For current practice, this could mean that only orthopaedic surgeons can perform an ACL physical examination with accuracy. III.

The effect of complete radial lateral meniscus posterior root tear on the knee contact mechanics: a finite element analysis.

PubMed

Bao, H R C; Zhu, D; Gong, H; Gu, G S

2013-03-01

In recent years, with technological advances in arthroscopy and magnetic resonance imaging and improved biomechanical studies of the meniscus, there has been some progress in the diagnosis and treatment of injuries to the roots of the meniscus. However, the biomechanical effect of posterior lateral meniscus root tears on the knee has not yet become clear. The purpose of this study was to determine the effect of a complete radial posterior lateral meniscus root tear on the knee contact mechanics and the function of the posterior meniscofemoral ligament on the knee with tear in the posterior root of lateral meniscus. A finite element model of the knee was developed to simulate different cases for intact knee, a complete radial posterior lateral meniscus root tear, a complete radial posterior lateral meniscus root tear with posterior meniscofemoral ligament deficiency, and total meniscectomy of the lateral meniscus. A compressive load of 1000 N was applied in all cases to calculate contact areas, contact pressure, and meniscal displacements. The complete radial posterior lateral meniscus root tear decreased the contact area and increased the contact pressure on the lateral compartment under compressive load. We also found a decreased contact area and increased contact pressure in the medial compartment, but it was not obvious compared to the lateral compartment. The lateral meniscus was radially displaced by compressive load after a complete radial posterior lateral meniscus root tear, and the displacement took place mainly in the body and posterior horn of lateral meniscus. There were further decrease in contact area and increases in contact pressure and raidial displacement of the lateral meniscus in the case of the complete posterior lateral meniscus root tear in combination with posterior meniscofemoral ligament deficiency. Complete radial posterior lateral meniscus root tear is not functionally equivalent to total meniscectomy. The posterior root torn lateral meniscus continues to provide some load transmission and distribution functions across the joint. The posterior meniscofemoral ligament prevents excessive radial displacement of the posterior root torn lateral meniscus and assists the torn lateral meniscus in transmitting a certain amount of stress in the lateral compartment.

Double-bundle anterior cruciate ligament reconstruction is superior to single-bundle reconstruction in terms of revision frequency: a study of 22,460 patients from the Swedish National Knee Ligament Register.

PubMed

Svantesson, Eleonor; Sundemo, David; Hamrin Senorski, Eric; Alentorn-Geli, Eduard; Musahl, Volker; Fu, Freddie H; Desai, Neel; Stålman, Anders; Samuelsson, Kristian

2017-12-01

Studies comparing single- and double-bundle anterior cruciate ligament (ACL) reconstructions often include a combined analysis of anatomic and non-anatomic techniques. The purpose of this study was to compare the revision rates between single- and double-bundle ACL reconstructions in the Swedish National Knee Ligament Register with regard to surgical variables as determined by the anatomic ACL reconstruction scoring checklist (AARSC). Patients from the Swedish National Knee Ligament Register who underwent either single- or double-bundle ACL reconstruction with hamstring tendon autograft during the period 2007-2014 were included. The follow-up period started with primary ACL reconstruction, and the outcome measure was set as revision surgery. An online questionnaire based on the items of the AARSC was used to determine the surgical technique implemented in the single-bundle procedures. These were organized into subgroups based on surgical variables, and the revision rates were compared with the double-bundle ACL reconstruction. Hazard ratios (HR) with 95% confidence interval (CI) was calculated and adjusted for confounders by Cox regression. A total of 22,460 patients were included in the study, of which 21,846 were single-bundle and 614 were double-bundle ACL reconstruction. Double-bundle ACL reconstruction had a revision frequency of 2.0% (n = 12) and single-bundle 3.2% (n = 689). Single-bundle reconstruction had an increased risk of revision surgery compared with double-bundle [adjusted HR 1.98 (95% CI 1.12-3.51), p = 0.019]. The subgroup analysis showed a significantly increased risk of revision surgery in patients undergoing single-bundle with anatomic technique using transportal drilling [adjusted HR 2.51 (95% CI 1.39-4.54), p = 0.002] compared with double-bundle ACL reconstruction. Utilizing a more complete anatomic technique according to the AARSC lowered the hazard rate considerably when transportal drilling was performed but still resulted in significantly increased risk of revision surgery compared with double-bundle ACL reconstruction [adjusted HR 1.87 (95% CI 1.04-3.38), p = 0.037]. Double-bundle ACL reconstruction is associated with a lower risk of revision surgery than single-bundle ACL reconstruction. Single-bundle procedures performed using transportal femoral drilling technique had significantly higher risk of revision surgery compared with double-bundle. However, a reference reconstruction with transportal drilling defined as a more complete anatomic reconstruction reduces the risk of revision surgery considerably. III.

Creative Self-Concept, Masculinity, Femininity and Three Models of Androgyny.

ERIC Educational Resources Information Center

Harrington, David M.; Andersen, Susan M.

Relationships between aspects of creativity and psychological masculinity and femininity are examined from the perspectives of balance, additive, and catalytic models of androgyny. Female (N=85) and male (N=105) subjects completed Gough's Adjective Check List, (ACL) in which the adjective, "creative," had been inserted. The ACL was…

[Using the CAS (computer-assisted surgery) system in arthroscopic cruciate ligament surgery--adaptation and application in clinical practice].

PubMed

Bernsmann, K; Rosenthal, A; Sati, M; Ansari, B; Wiese, M

2001-01-01

The anterior cruciate ligament (ACL) is of great importance for the knee joint function. In the case of a complete ligament injury there is hardly any chance for complete recovery. The clear advantages of an operative reconstruction by replacing the ACL has been shown in many trails. The accurate placement of the graft's insertions has a significant effect on the mid- and probably long-term outcome of this procedure. Reviewing the literature, there are poor long-term results of ACL replacement in 5 to 52% of all cases, depending on the score system. One of the main reasons for unacceptable results is graft misplacement. This led to the construction of a CAS system for ACL replacement. The system assists this surgical procedure by navigating the exact position of the drilling holes. The Potential deformation quantity of the transplant can be controlled by this system in real time. 40 computer-assisted ACL replacements have been performed under active use of the CAS system. The short-term results are encouraging, no special complications have been seen so far. Prospective long-term follow-up studies are ongoing. ACL reconstruction by manual devices has many sources of error. The CAS system is able to give the surgeon reasonable views that are unachieveable by conventional surgery. He is therefore able to control a source of error and to optimise the results. The feasibility of this device in clinical routine use has been proven.

[Clinical and radiographic correlation after anterior cruciate ligament reconstruction].

PubMed

González Perales, Aldo Alán; Negrete Corona, Jorge; Chávez Hinojosa, Edgard

2010-01-01

The purpose of this work is to correlate the clinical, functional and radiographic results of the anterior cruciate ligament (ACL) reconstruction with the angulation and orientation of the femoral and tibial tunnels. The ACL is one of the most frequently injured articular structures of the knee. The reason for this being that it is the primary limiting structure of anterior tibial translation; its tear causes kinematic alterations and results in long-term degenerative and functional changes. Repair can restore the kinematics. 26 patients, 20-50 years old, post-ACL reconstruction with the semitendinous-gracilis technique. From November 2006 to July 2007. Clinical and functional assessments: Tegner and Lysholm. Radiographic assessment: anteroposterior view with knee extension and lateral view with 30 degrees flexion. Pearson correlations (r) were used in the analysis. 26 patients (100%), 20 males (76.92%), 6 females (23.08%). Mean of 2.4 in the Lysholm scale (fair to good); standard deviation 1.2. Bernard-Lysholm quadrant r = -0.772. Tegner quadrant r = 0.790. The Lysholm and Tegner scale is associated with the graft quadrant. The situation of the tibial implant in the saggital plane is associated with the Lysholm scale. The correlation of patients with an inadequate placement with respect to the quadrants was associated with good-to-excellent results and fair-to-good results. Two patients had a poor clinical outcome; the orientation of the AP angle and the quadrant were within acceptable parameters, with the exception of the lateral angle-shaft axis.

A Systematic Evaluation of Field-Based Screening Methods for the Assessment of Anterior Cruciate Ligament (ACL) Injury Risk.

PubMed

Fox, Aaron S; Bonacci, Jason; McLean, Scott G; Spittle, Michael; Saunders, Natalie

2016-05-01

Laboratory-based measures provide an accurate method to identify risk factors for anterior cruciate ligament (ACL) injury; however, these methods are generally prohibitive to the wider community. Screening methods that can be completed in a field or clinical setting may be more applicable for wider community use. Examination of field-based screening methods for ACL injury risk can aid in identifying the most applicable method(s) for use in these settings. The objective of this systematic review was to evaluate and compare field-based screening methods for ACL injury risk to determine their efficacy of use in wider community settings. An electronic database search was conducted on the SPORTDiscus™, MEDLINE, AMED and CINAHL databases (January 1990-July 2015) using a combination of relevant keywords. A secondary search of the same databases, using relevant keywords from identified screening methods, was also undertaken. Studies identified as potentially relevant were independently examined by two reviewers for inclusion. Where consensus could not be reached, a third reviewer was consulted. Original research articles that examined screening methods for ACL injury risk that could be undertaken outside of a laboratory setting were included for review. Two reviewers independently assessed the quality of included studies. Included studies were categorized according to the screening method they examined. A description of each screening method, and data pertaining to the ability to prospectively identify ACL injuries, validity and reliability, recommendations for identifying 'at-risk' athletes, equipment and training required to complete screening, time taken to screen athletes, and applicability of the screening method across sports and athletes were extracted from relevant studies. Of 1077 citations from the initial search, a total of 25 articles were identified as potentially relevant, with 12 meeting all inclusion/exclusion criteria. From the secondary search, eight further studies met all criteria, resulting in 20 studies being included for review. Five ACL-screening methods-the Landing Error Scoring System (LESS), Clinic-Based Algorithm, Observational Screening of Dynamic Knee Valgus (OSDKV), 2D-Cam Method, and Tuck Jump Assessment-were identified. There was limited evidence supporting the use of field-based screening methods in predicting ACL injuries across a range of populations. Differences relating to the equipment and time required to complete screening methods were identified. Only screening methods for ACL injury risk were included for review. Field-based screening methods developed for lower-limb injury risk in general may also incorporate, and be useful in, screening for ACL injury risk. Limited studies were available relating to the OSDKV and 2D-Cam Method. The LESS showed predictive validity in identifying ACL injuries, however only in a youth athlete population. The LESS also appears practical for community-wide use due to the minimal equipment and set-up/analysis time required. The Clinic-Based Algorithm may have predictive value for ACL injury risk as it identifies athletes who exhibit high frontal plane knee loads during a landing task, but requires extensive additional equipment and time, which may limit its application to wider community settings.

Low Prevalence of Anterior and Posterior Cruciate Ligament Injuries in Patients With Achondroplasia.

PubMed

Brooks, Jaysson T; Ramji, Alim F; Lyapustina, Tatyana A; Yost, Mary T; Ain, Michael C

2017-01-01

Anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries and their subsequent reconstructions are common in the general population, but there has been no research regarding ACL or PCL injuries in patients with achondroplasia, the most common skeletal dysplasia. Our goals were to (1) evaluate the prevalence of ACL and PCL injuries in adolescents and adults with achondroplasia, (2) compare this prevalence with that reported for the general population, (3) determine how many patients with ACL or PCL injuries underwent ligament reconstruction as treatment, and (4) determine patient activity levels as they relate to the rate of ACL/PCL injuries and reconstructions. We reviewed medical records of 430 patients with achondroplasia seen in the senior author's clinic from 2002 through 2014. Demographic data were reviewed, as well as any documentation of ACL or PCL injury or reconstruction. We called all 430 patients by telephone, and 148 agreed to participate in our survey, whereas 1 declined. We asked these patients about their history of ACL or PCL injury or reconstruction, as well as current and past physical activity levels. No ACL or PCL injuries were found on chart review. One patient reached by telephone reported an ACL injury that did not require reconstruction. This yielded a theoretical prevalence of 3/430 (0.7%). Of the 148 patients surveyed, 43 (29%) reported low physical activity, 75 (51%) reported moderate physical activity, and 26 (17%) reported high physical activity. There was no significant difference in the rate of ACL injury when stratified by physical activity level (P=0.102). ACL and PCL injuries and reconstructions are extremely rare in patients with achondroplasia, which cannot be completely ascribed to a low level of physical activity. One possible explanation is that patients with achondroplasia, on an average, have a more anterior tibial slope compared with those without achondroplasia, which decreases the force generated within the ACL and may protect against ACL injury. Further research is needed to explore possible causes. Level IV-retrospective review.

Knee extension torque variability after exercise in ACL reconstructed knees.

PubMed

Goetschius, John; Kuenze, Christopher M; Hart, Joseph M

2015-08-01

The purpose of this study was to compare knee extension torque variability in patients with ACL reconstructed knees before and after exercise. Thirty two patients with an ACL reconstructed knee (ACL-R group) and 32 healthy controls (control group) completed measures of maximal isometric knee extension torque (90° flexion) at baseline and following a 30-min exercise protocol (post-exercise). Exercise included 30-min of repeated cycles of inclined treadmill walking and hopping tasks. Dependent variables were the coefficient of variation (CV) and raw-change in CV (ΔCV): CV = (torque standard deviation/torque mean x 100), ΔCV = (post-exercise - baseline). There was a group-by-time interaction (p = 0.03) on CV. The ACL-R group demonstrated greater CV than the control group at baseline (ACL-R = 1.07 ± 0.55, control = 0.79 ± 0.42, p = 0.03) and post-exercise (ACL-R = 1.60 ± 0.91, control = 0.94 ± 0.41, p = 0.001). ΔCV was greater (p = 0.03) in the ACL-R group (0.52 ± 0.82) than control group (0.15 ± 0.46). CV significantly increased from baseline to post-exercise (p = 0.001) in the ACL-R group, while the control group did not (p = 0.06). The ACL-R group demonstrated greater knee extension torque variability than the control group. Exercise increased torque variability more in the ACL-R group than control group. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

LOWER EXTREMITY KINEMATICS OF ACL-REPAIRED AND NON-INJURED FEMALES WHEN USING KNEE SAVERS®.

PubMed

Stone, Whitley J; Arnett, Scott W; Hoover, Donald L

2017-10-01

Knee Savers® (KS) are an ergonomic aid purported to lessen the risk of injuries linked to deep squats. While widely used in sports such as baseball and softball, KS have not been tested to determine their effect upon lower extremity kinematics in any population. The purpose of the study was to determine if KS influenced the lower extremity kinematics when females with previous anterior cruciate ligament (ACL)-reconstruction and healthy participants completed an end-range squat. A repeated measures, counter-balanced laboratory study design was used. Twenty female participants (mean (SD) - age: 21.65 (2.06) yrs, height: 175.26 (9.29) cm, weight: 64.66 (7.72) kg) with a history of ACL-repair (n=10) or non-injury (n=10) completed this study. Participants completed a standardized trial of three deep squats with and without KS. Movement was analyzed using 2D video analysis methods increasingly available in clinical environments. During the ascending phases of a squatting motion, there was significantly greater medial ( p  = .009) and lateral ( p  = .005) motion of the patella in the frontal plane for non-injured participants, when compared to the ACL-repaired group. No significant differences were found in sagittal plane lower extremity kinematics when squatting with and without KS. Ascending angular velocity was slower in ACL-repaired than non-injured females ( p  = .008) and slower with the KS than without KS for non-injured females ( p  = .007). When squatting with and without KS, the non-injured group experienced more frontal plane motion at the knee, compared to the ACL-repaired group. However, while KS are purported to influence lower extremity joint positions during the bottom phase of a deep squat, the data from the current study did not support this claim. Additionally, KS appear to slow ascending velocity for those without a history of ACL-repair. These findings may have clinically meaningful implications for athletes who use KS during sport activities. Level 2.

Factor Structure and Scale Reliabilities of the Adjective Check List Across Time

ERIC Educational Resources Information Center

Miller, Stephen H.; And Others

1978-01-01

Investigated factor structure and scale reliabilities of Gough's Adjective Check List (ACL) and their stability over time. Employees in a community mental health center completed the ACL twice, separated by a one-year interval. After each administration, separate factor analyses were computed. All scales had highly significant test-retest…

Should massive rotator cuff tears be reconstructed even when only partially repairable?

PubMed

Godenèche, Arnaud; Freychet, Benjamin; Lanzetti, Riccardo Maria; Clechet, Julien; Carrillon, Yannick; Saffarini, Mo

2017-07-01

(1) To evaluate midterm functional outcomes of arthroscopic repair of massive rotator cuff tears and (2) to determine the prognostic factors that could influence outcome. The hypothesis was that both partial and complete repairs would result in equivalent improvement of clinical score. From a prospective series of 525 rotator cuff repairs, we analysed records of the 73 patients who were treated for massive tears. The median follow-up was 41 months (range 29-55), and functional outcome was evaluated using the Constant score, shoulder strength, and subjective shoulder value. The median CS improved from 34 points to 81 points (p < 0.001). The scores were better for both types of two-tendon tears, posterosuperior (83, n = 33) and anterosuperior (85, n = 13) (n.s.), than for three-tendon tears (74, n = 27) (p < 0.001). The scores were also better when fatty infiltration was of stage I (84, n = 28) than of stage II (78, n = 34) (p < 0.001) or stage III (74, n = 11) (p = 0.04). The scores were only slightly higher for completely reparable tears (81.5, n = 50) than for partially reparable tears (79, n = 23) (n.s.). Ultrasonic examination revealed incomplete healing, in 10 of the 50 completely repaired tears, and in 11 of the 23 partially repaired tears. The results of the present study compare favourably with those in recent literature and confirm the hypothesis that both partial and complete repairs of massive rotator cuff tears produce equivalent improvements of Constant scores. The clinical relevance of these observations is that even if repairs of two-tendon tears result in superior functional outcomes, repairs of three-tendon tears produce equivalent 'relative' improvement that grants sufficient patient satisfaction and autonomy. Comparative case series, Level IV.

Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger.

PubMed

Morgan, Matthew D; Salmon, Lucy J; Waller, Alison; Roe, Justin P; Pinczewski, Leo A

2016-02-01

The current body of literature surrounding anterior cruciate ligament (ACL) survival and the variables contributing to further ACL injuries after primary ACL reconstruction in children and adolescents is limited, with no long-term evidence examining the incidence and contributing factors of further ACL injuries in this younger patient population. To determine the long-term survival of the ACL graft and the contralateral ACL (CACL) after primary reconstruction in patients aged ≤18 years and to identify the factors that increase the odds of subsequent ACL injuries. Case series; Level of evidence, 4. Patients having undergone primary ACL reconstruction at age ≤18 years between 1993 and 1998 who were included in a prospective database by a single surgeon were considered for this study. Single-incision endoscopic ACL reconstruction was performed with either an autologous bone-patellar tendon-bone graft or a hamstring tendon graft. At a minimum of 15 years after ACL reconstruction, patients completed a subjective survey involving the International Knee Documentation Committee (IKDC) questionnaire in addition to questions regarding current symptoms, further ACL injuries, family history of ACL injury, and current level of activity. A total of 288 adolescents (age range, 13-18 years) met the inclusion criteria, of whom 242 (84%) were reviewed at a mean of 16 years and 6 months after ACL reconstruction. Of these patients, 75 (31%) sustained a further ACL injury: 27 (11.2%) suffered an ACL graft rupture, 33 suffered a CACL injury (13.6%), and 15 sustained both an ACL graft rupture and a CACL injury (6.2%) over 15 years. Survival of the ACL graft was 95%, 92%, 88%, 85%, and 83% at 1, 2, 5, 10, and 15 years, respectively, and survival of the CACL was 99%, 98%, 90%, 83%, and 81%, respectively. Survival of the ACL graft was less favorable in those with a family history of ACL injury than in those without a family history (69% vs 90%, respectively; hazard ratio [HR], 3.6; P = .001). Survival of the CACL was less favorable in male patients than in female patients (75% vs 88%, respectively; HR, 2.1; P = .03) and in those who returned to competitive team ball sports than in those who did not (78% vs 89%, respectively; HR, 2.3; P = .05). After ACL reconstruction in patients aged ≤18 years, a further ACL injury occurred in 1 in 3 patients over 15 years. The 15-year survival rate of the ACL graft was 83%, and the 15-year survival rate of the CACL was 81%. The ACL graft and CACL were most vulnerable within the first 5 years after index surgery. A family history of ACL rupture significantly increased the risk for ACL graft ruptures, and a CACL injury was more common in male patients and those who returned to team ball sports. High IKDC scores and continued participation in sports were maintained over the long term after ACL reconstruction in the adolescent population. © 2016 The Author(s).

Diagnostic accuracy of 3T conventional shoulder MRI in the detection of the long head of the biceps tendon tears associated with rotator cuff tendon tears.

PubMed

Lee, Ro Woon; Choi, Soo-Jung; Lee, Man Ho; Ahn, Jae Hong; Shin, Dong Rock; Kang, Chae Hoon; Lee, Ki Won

2016-12-01

To evaluate the diagnostic performance (DP) of 3T (3 Tesla field strength) conventional shoulder magnetic resonance imaging (MRI) in detecting the long head of the biceps tendon (LHBT) tears in association with rotator cuff tendon tears. This study included 80 consecutive patients who underwent arthroscopic surgery for rotator cuff tendon tears. Two radiologists independently evaluated the preoperative 3T shoulder MRI for the presence of LHBT tears. The DP of MRI was evaluated using the results of arthroscopy as the reference standard. We also evaluated the DP of several MR signs of LHBT in detection of partial LHBT tears. Arthroscopic examination revealed 35 partial and 5 complete tears. According to the results of evaluation by reviewers 1 and 2, shoulder MRI exhibited sensitivities of 77.14 and 80 % and specificities of 71.11 and 73.33 % in detection of partial LHBT tears and sensitivities of 80 and 100 % and a specificity of 100% (both) in detection of complete LHBT tears. In detecting partial LHBT tears, increased T2 signal intensity of the LHBT exhibited high sensitivities (reviewers 1 and 2; 82.85 and 80 %, respectively) and the presence of intratendinous defects or C-signs exhibited the highest specificities (reviewers 1 and 2; 95.55 and 93.33 %, respectively), followed by abnormalities in shape and outer margins of the LHBT (reviewers 1 and 2; 91.11 and 82 %; 91.11 and 86.66 %, respectively). Non-contrast-enhanced 3T shoulder MRI is potentially highly accurate in detection of complete LHBT tears, but moderately accurate in detection of partial LHBT tears.

Restoration of shoulder biomechanics according to degree of repair completion in a cadaveric model of massive rotator cuff tear: importance of margin convergence and posterior cuff fixation.

PubMed

Oh, Joo Han; McGarry, Michelle H; Jun, Bong Jae; Gupta, Akash; Chung, Kyung Chil; Hwang, James; Lee, Thay Q

2012-11-01

Complete repair in massive rotator cuff tear may not be possible, allowing for only partial repair. However, the effect of partial repair on glenohumeral biomechanics has not been evaluated. Therefore, the purpose of this study was to compare the rotational range of motion (ROM), glenohumeral kinematics, and gap formation at the repaired tendon edge following massive cuff tear and repair according to the degree of repair completion. Posterior fixation will restore the altered biomechanics of massive rotator cuff tear. Controlled laboratory study. Eight cadaveric shoulders were tested at 0°, 30°, and 60° of abduction in the scapular plane. Muscle loading was applied based on physiological muscle cross-sectional area ratios. Maximum internal (MaxIR) and external rotations (MaxER) were measured. Humeral head apex (HHA) position and gap formation at the repaired tendon edge were measured using a MicroScribe from MaxIR to MaxER in 30° increments. Testing was performed for intact, massive cuff tear, complete repair, and 4 types of partial repair. A repeated-measures analysis of variance was used to determine significant differences. Massive tear significantly increased ROM and shifted HHA superiorly in MaxIR at all abduction angles (P < .05). The complete repair restored ROM to intact (P < .05), while all partial repairs did not. Abnormal HHA elevation due to massive tear was restored by all repairs (P < .05). Release of the anterior single row alone and release of the marginal convergence significantly increased gap formation at the anterior tendon edge (P < .05). This study emphasizes the importance of anterior fixation in massive cuff tear to restore rotational range of motion and decrease gap formation at the repaired tendon edge and of posterior fixation to restore abnormal glenohumeral kinematics due to massive cuff tear. If complete repair of massive cuff tear is not possible, posterior cuff (infraspinatus) repair is necessary to restore abnormal glenohumeral kinematics, and margin convergence anteriorly is recommended to decrease gap formation of the repaired tendon edge, which may provide a better biomechanical environment for healing.

Self-Assessment and Development Planning for Adult and Community Learning Providers.

ERIC Educational Resources Information Center

Kenway, Mike; Reisenberger, Anna

This document is designed to help adult and community learning (ACL) services across the United Kingdom complete the annual self-assessment reports (SARs). The guide begins with background information on the purposes of self-assessment, the new context of ACL and the elements and format of the new SARs. The remaining four sections examine the…

The Use of the Adjective Check List to Describe the Adult Basic Education Student.

ERIC Educational Resources Information Center

Wilson, Russell C.

The study's purpose was to use the Adjective Check List (ACL), a self-administered personality assessment instrument, to determine whether there were response differences between a sample of Adult Basic Education (ABE) students and the general test norms. The ACL was administered to 142 students in ABE high school completion programs in Des…

The Effects of Injury Prevention Programs on the Biomechanics of Landing Tasks: A Systematic Review With Meta-analysis.

PubMed

Lopes, Thiago Jambo Alves; Simic, Milena; Myer, Gregory D; Ford, Kevin R; Hewett, Timothy E; Pappas, Evangelos

2018-05-01

Anterior cruciate ligament (ACL) tear is a common injury in sports and often occurs during landing from a jump. To synthesize the evidence on the effects of injury prevention programs (IPPs) on landing biomechanics as they relate to the ligament, quadriceps, trunk, and leg dominance theories associated with ACL injury risk. Meta-analysis. Six electronic databases were searched for studies that investigated the effect of IPPs on landing task biomechanics. Prospective studies that reported landing biomechanics at baseline and post-IPP were included. Results from trunk, hip, and knee kinematics and kinetics related to the ACL injury theories were extracted, and meta-analyses were performed when possible. The criteria were met by 28 studies with a total of 466 participants. Most studies evaluated young females, bilateral landing tasks, and recreational athletes, while most variables were related to the ligament and quadriceps dominance theories. An important predictor of ACL injury, peak knee abduction moment, decreased ( P = .01) after the IPPs while other variables related to the ligament dominance theory did not change. Regarding the quadriceps dominance theory, after the IPPs, angles of hip flexion at initial contact ( P = .009), peak hip flexion ( P = .002), and peak knee flexion ( P = .007) increased, while knee flexion at initial contact did not change ( P = .18). Moreover, peak knee flexion moment decreased ( P = .005) and peak vertical ground-reaction force did not change ( P = .10). The exercises used in IPPs might have the potential to improve landing task biomechanics related to the quadriceps dominance theory, especially increasing peak knee and hip flexion angles. Importantly, peak knee abduction moment decreased, which indicates that IPPs influence a desired movement strategy to help athletes overcome dangerous ligament dominance loads arising from lack of frontal plane control during dynamic tasks. The lack of findings for some biomechanical variables suggests that future IPPs may be enhanced by targeting participants' baseline profile deficits, highlighting the need to deliver an individualized and task-specific IPP.

Change in KOOS and WOMAC Scores in a Young Athletic Population With and Without Anterior Cruciate Ligament Injury.

PubMed

Antosh, Ivan J; Svoboda, Steven J; Peck, Karen Y; Garcia, E'Stephan J; Cameron, Kenneth L

2018-06-01

Several studies have examined changes in patient-reported outcome measures (PROMs) after anterior cruciate ligament (ACL) injury, but no studies to date have prospectively evaluated changes from preinjury baseline through injury and follow-up among ACL-injured patients compared to the baseline and follow-up changes of uninjured patients. To examine changes in PROMs over time from preinjury baseline to at least 2 years after ACL reconstruction and to compare these changes with those of an uninjured control group having similar physical activity requirements. Cohort study; Level of evidence, 2. The authors conducted a prospective cohort study with a nested case-control analysis at a US service academy. All incoming first year students were recruited to participate in this study. Consenting participants completed a baseline questionnaire that included the KOOS (Knee injury and Osteoarthritis Outcome Score), WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), and MARS (Marx Activity Rating Scale). Participants who sustained a subsequent ACL injury completed assessments at the time of surgery and at 6, 12, and 24 months after surgery. Healthy participants were recruited to repeat the baseline assessments within 1 year of graduation. Inter- and intragroup differences at these time points were evaluated with dependent and independent t tests, respectively. We also compared these results with established minimum clinically important difference (MCID) values. Of 1268 first year students entering the academy, 1005 with no previous injuries consented to participate in this study (82% male, mean ± SD age 19 ± 1 years). Of those enrolled, 30 suffered an ACL injury and met the inclusion criteria for this study. Ninety uninjured control students who met the inclusion criteria completed follow-up assessments. There were statistically significant differences across all KOOS and WOMAC subscales between ACL-injured group and uninjured group at the time of the final follow-up assessment. Four KOOS subscales (Pain, Symptoms, Sports and Recreation Function, and Knee-Related Quality of Life) and the WOMAC Stiffness subscale demonstrated >8-point differences between groups, which exceeded the established MCID for these instruments. There were no significant differences between the ACL-injured group and uninjured groups noted for the MARS ( P = .635). At the time of final follow-up, the ACL-injured group also reported significant deficits on the WOMAC Stiffness subscale ( P = .032), the MARS ( P = .030), and all KOOS subscales, with the exception of Functional Activities of Daily Living, as compared with their preinjury baseline scores. These deficits exceeded the established MCID values for 3 KOOS subscales and the MARS. Patients with ACL injuries reported significant deficits on PROMs at least 2 years after surgical reconstruction in relation to preinjury baseline scores and an uninjured control group. Many of these deficits exceeded established MCID values.

Biomechanical Evaluation of Knee Joint Laxities and Graft Forces After Anterior Cruciate Ligament Reconstruction by Anteromedial Portal, Outside-In, and Transtibial Techniques

PubMed Central

Sim, Jae Ang; Gadikota, Hemanth R.; Li, Jing-Sheng; Li, Guoan; Gill, Thomas J.

2013-01-01

Background Recently, anatomic anterior cruciate ligament (ACL) reconstruction is emphasized to improve joint laxity and to potentially avert initiation of cartilage degeneration. There is a paucity of information on the efficacy of ACL reconstructions by currently practiced tunnel creation techniques in restoring normal joint laxity. Study Design Controlled laboratory study. Hypothesis Anterior cruciate ligament reconstruction by the anteromedial (AM) portal technique, outside-in (OI) technique, and modified transtibial (TT) technique can equally restore the normal knee joint laxity and ACL forces. Methods Eight fresh-frozen human cadaveric knee specimens were tested using a robotic testing system under an anterior tibial load (134 N) at 0°, 30°, 60°, and 90° of flexion and combined torques (10-N·m valgus and 5-N·m internal tibial torques) at 0° and 30° of flexion. Knee joint kinematics, ACL, and ACL graft forces were measured in each knee specimen under 5 different conditions (ACL-intact knee, ACL-deficient knee, ACL-reconstructed knee by AM portal technique, ACL-reconstructed knee by OI technique, and ACL-reconstructed knee by TT technique). Results Under anterior tibial load, no significant difference was observed between the 3 reconstructions in terms of restoring anterior tibial translation (P > .05). However, none of the 3 ACL reconstruction techniques could completely restore the normal anterior tibial translations (P <.05). Under combined tibial torques, both AM portal and OI techniques closely restored the normal knee anterior tibial translation (P > .05) at 0° of flexion but could not do so at 30° of flexion (P <.05). The ACL reconstruction by the TT technique was unable to restore normal anterior tibial translations at both 0° and 30° of flexion under combined tibial torques (P <.05). Forces experienced by the ACL grafts in the 3 reconstruction techniques were lower than those experienced by normal ACL under both the loading conditions. Conclusion Anterior cruciate ligament reconstructions by AM portal, OI, and modified TT techniques are biomechanically comparable with each other in restoring normal knee joint laxity and in situ ACL forces. Clinical Relevance Anterior cruciate ligament reconstructions by AM portal, OI, and modified TT techniques result in similar knee joint laxities. Technical perils and pearls should be carefully considered before choosing a tunnel creating technique. PMID:21908717

Online registration of monthly sports participation after anterior cruciate ligament injury: a reliability and validity study

PubMed Central

Grindem, Hege; Eitzen, Ingrid; Snyder-Mackler, Lynn; Risberg, May Arna

2013-01-01

Background Current methods measuring sports activity after anterior cruciate ligament (ACL) injury are commonly restricted to the most knee-demanding sport, and do not consider participation in multiple sports. We therefore developed an online activity survey to prospectively record monthly participation in all major sports relevant to our patient-group. Objective To assess the reliability, content validity, and concurrent validity of the survey, and evaluate if it provided more complete data on sports participation than a routine activity questionnaire. Methods One hundred and forty-five consecutively included ACL-injured patients were eligible for the reliability study. The retest of the online activity survey was performed two days after the test response had been recorded. A subsample of 88 ACL-reconstructed patients were included in the validity study. The ACL-reconstructed patients completed the online activity survey from the first to the twelfth postoperative month, and a routine activity questionnaire 6 and 12 months postoperatively. Results The online activity survey was highly reliable (κ ranging from 0.81 to 1). It contained all the common sports reported on the routine activity questionnaire. There was substantial agreement between the two methods on return to preinjury main sport (κ = 0.71 and 0.74 at 6 and 12 months postoperatively). The online activity survey revealed that a significantly higher number of patients reported to participate in running, cycling and strength training, and patients reported to participate in a greater number of sports. Conclusion The online activity survey is a highly reliable way of recording detailed changes in sports participation after ACL injury. The findings of this study support the content and concurrent validity of the survey, and suggest that the online activity survey can provide more complete data on sports participation than a routine activity questionnaire. PMID:23645830

Online registration of monthly sports participation after anterior cruciate ligament injury: a reliability and validity study.

PubMed

Grindem, Hege; Eitzen, Ingrid; Snyder-Mackler, Lynn; Risberg, May Arna

2014-05-01

The current methods measuring sports activity after anterior cruciate ligament (ACL) injury are commonly restricted to the most knee-demanding sports, and do not consider participation in multiple sports. We therefore developed an online activity survey to prospectively record the monthly participation in all major sports relevant to our patient-group. To assess the reliability, content validity and concurrent validity of the survey and to evaluate if it provided more complete data on sports participation than a routine activity questionnaire. 145 consecutively included ACL-injured patients were eligible for the reliability study. The retest of the online activity survey was performed 2 days after the test response had been recorded. A subsample of 88 ACL-reconstructed patients was included in the validity study. The ACL-reconstructed patients completed the online activity survey from the first to the 12th postoperative month, and a routine activity questionnaire 6 and 12 months postoperatively. The online activity survey was highly reliable (κ ranging from 0.81 to 1). It contained all the common sports reported on the routine activity questionnaire. There was a substantial agreement between the two methods on return to preinjury main sport (κ=0.71 and 0.74 at 6 and 12 months postoperatively). The online activity survey revealed that a significantly higher number of patients reported to participate in running, cycling and strength training, and patients reported to participate in a greater number of sports. The online activity survey is a highly reliable way of recording detailed changes in sports participation after ACL injury. The findings of this study support the content and concurrent validity of the survey, and suggest that the online activity survey can provide more complete data on sports participation than a routine activity questionnaire.

Translation and cross-cultural adaptation of the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale into Turkish.

PubMed

Harput, Gulcan; Tok, Damla; Ulusoy, Burak; Eraslan, Leyla; Yildiz, Taha Ibrahim; Turgut, Elif; Demirci, Serdar; Duzgun, Irem; Tunay, Volga Bayrakci; Baltaci, Gul; Ergun, Nevin

2017-01-01

To translate and culturally adapt the anterior cruciate ligament-return to sport after injury (ACL-RSI) scale into Turkish (ACL-RSI-Tr) and examine and evaluate the psychometric properties of the Turkish version in individuals who have undergone anterior cruciate ligament (ACL) reconstruction. The ACL-RSI was forward- and back-translated, culturally adapted and validated on ninety-three Turkish individuals who had undergone ACL reconstruction (5 females, 88 males; age 28.7 ± 8.6 years; body mass 80.1 ± 13.9 kg; height 178.8 ± 6.9 cm; body mass index 25.0 ± 3.7 kg/m 2 ). All patients completed the translated ACL-RSI, Tampa Scale of Kinesiophobia (TSK), Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentary Committee (IKDC) and Lysholm questionnaires. We then analysed the internal consistency, reliability and validity of the newly formed ACL-RSI-Tr scale. The ACL-RSI-Tr showed good internal consistency (Cronbach's alpha 0.86) and test-retest reliability (ICC 0.92) and was significantly correlated with the KOOS 'quality of life' (r = 0.58, p < 0.002), 'symptoms and stiffness' (r = 0.35, p = 0.001), 'pain' (r = 0.49, p < 0.001), 'sports' (r = 0.44, p < 0.001) and 'daily life' (r = 0.42, p < 0.001) subscales. The ACL-RSI-Tr also correlated significantly with the TSK (r = - 0.45, p < 0.001), Lysholm (r = 0.45, p < 0.001) and IKDC (r = 0.44, p < 0.001) scores. The Turkish version of the ACL-RSI scale was valid, discriminant, consistent and reliable in patients who had undergone ACL reconstruction. This score could be useful to evaluate the effect of psychological factors on return to sport following ACL surgery. Diagnostic study, Level I.

The popliteus tendon provides a safe and reliable location for all-inside meniscal repair device placement.

PubMed

Ouanezar, Hervé; Blakeney, William G; Latrobe, Charles; Saithna, Adnan; Fernandes, Levi Reina; Delaloye, Jean Romain; Thaunat, Mathieu; Sonnery-Cottet, Bertrand

2018-03-03

Repairs of the posterior horn of the lateral meniscus can be technically challenging. In contrast to medial meniscus repairs, the capsule around the posterior segment attachment of the lateral meniscus is quite thin. This study evaluates the clinical results of an arthroscopic all-inside repair technique for unstable, vertical, lateral meniscus tears, using a suture repair placed directly into the popliteus tendon. A retrospective analysis of prospectively collected data from the SANTI database was performed. All patients who had undergone combined ACL reconstruction with lateral meniscus all-inside repair, using sutures placed in the popliteus tendon, between 2011 and 2015, were included. Patients were reviewed clinically at 1 and 2 years' follow-up. At final follow-up, all patients were contacted to identify if they underwent further surgery or had knee pain, locking or effusion. Symptomatic patients were recalled for clinical evaluation by a physician and Magnetic Resonance Imaging of the knee. Operative notes for those undergoing further surgery were reviewed and rates and type of re-operation, including for failed lateral meniscal repair were recorded. Two hundred patients (mean age 28.6 ± 10.2 years) with a mean follow-up of 45.5 ± 12.8 months (range 24.7-75.2) were included. The mean Subjective International Knee Documentation Committee (IKDC) at final follow-up was 85.0 ± 11.3. The post-operative mean side-to-side laxity measured at 1 year was 0.6 ± 1.0 mm. Twenty-six patients underwent re-operation (13%) at a mean follow-up of 14.8 ± 7.8 months. The ACL graft rupture rate was 5.0%. Other causes for re-operation included medial meniscus tear (2.5%), cyclops lesion (1.5%) and septic arthritis (0.5%). The lateral meniscus repair failure rate was 3.5%. No specific complications relating to placement of sutures in the popliteus tendon were identified. Arthroscopic all-inside repair of unstable, vertical, lateral meniscus tears using a suture placed in the popliteus tendon is a safe technique. It is associated with a very low failure rate with no specific complications. Level IV.

Clinical results of a surgical technique using endobuttons for complete tendon tear of pectoralis major muscle: report of five cases

PubMed Central

2011-01-01

Background We herein describe a surgical technique for the repair of complete tear of the pectoralis major (PM) tendon using endobuttons to strengthen initial fixation. Methods Five male patients (3 judo players, 1 martial arts player, and 1 body builder) were treated within 2 weeks of sustaining complete tear of the PM tendon. Average age at surgery and follow-up period were 28.4 years (range, 23-33) and 28.8 months (range, 24-36). A rectangular bone trough (about 1 × 4 cm) was created on the humerus at the insertion of the distal PM tendon. The tendon stump was introduced into this trough, and fixed to the reverse side of the humeral cortex using endobuttons and non-absorbable suture. Clinical assessment of re-tear was examined by MRI. Shoulder range of motion (ROM), outcome of treatment, and isometric power were measured at final follow-up. Results There were no clinical re-tears, and MRI findings also showed continuity of the PM tendon in all cases at final follow-up. Average ROM did not differ significantly between the affected and unaffected shoulders. The clinical outcomes at final follow-up were excellent (4/5 cases) or good (1/5). In addition, postoperative isometric power in horizontal flexion of the affected shoulder showed complete recovery when compared with the unaffected side. Conclusions Satisfactory outcomes could be obtained when surgery using the endobutton technique was performed within 2 weeks after complete tear of the PM tendon. Therefore, our new technique appears promising as a useful method to treat complete tear of the PM tendon. PMID:21955511

Incomplete response to artificial tears is associated with features of neuropathic ocular pain.

PubMed

Galor, Anat; Batawi, Hatim; Felix, Elizabeth R; Margolis, Todd P; Sarantopoulos, Konstantinos D; Martin, Eden R; Levitt, Roy C

2016-06-01

Artificial tears are first-line therapy for patients with dry eye symptoms. It is not known, however, which patient factors associate with a positive response to therapy. The purpose of this study was to evaluate whether certain ocular and systemic findings are associated with a differential subjective response to artificial tears. Cross-sectional study of 118 individuals reporting artificial tears use (hypromellose 0.4%) to treat dry eye-associated ocular pain. An evaluation was performed to assess dry eye symptoms (via the dry eye questionnaire 5 and ocular surface disease index), ocular and systemic (non-ocular) pain complaints and ocular signs (tear osmolarity, tear breakup time, corneal staining, Schirmer testing with anaesthesia, and eyelid and meibomian gland assessment). The main outcome measures were factors associated with differential subjective response to artificial tears. By self-report, 23 patients reported no improvement, 73 partial improvement and 22 complete improvement in ocular pain with artificial tears. Patients who reported no or partial improvement in pain with artificial tears reported higher levels of hot-burning ocular pain and sensitivity to wind compared with those with complete improvement. Patients were also asked to rate the intensity of systemic pain elsewhere in the body (other than the eye). Patients who reported no or incomplete improvement with artificial tears had higher systemic pain scores compared with those with complete improvement. Both ocular and systemic (non-ocular) pain complaints are associated with a differential subjective response to artificial tears. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Tibial plateau fracture after anterior cruciate ligament reconstruction: Role of the interference screw resorption in the stress riser effect.

PubMed

Thaunat, Mathieu; Nourissat, Geoffroy; Gaudin, Pascal; Beaufils, Philippe

2006-06-01

We report a case of tibial plateau fracture after previous anterior cruciate ligament (ACL) reconstruction using patellar tendon autograft and bioabsorbable screws 4 years previously. The fracture occurred through the tibial tunnel. The interference screw had undergone complete resorption and the tunnel widening had increased. The resorption of the interference screw did not simultaneously promote and foster the growth of surrounding bone tissue. Therefore, the area of reactive tissue left by the screw resorption in an enlarged bone tunnel may lead to vulnerability of the tibial plateau. Stress risers would occur following ACL reconstruction if either resorption is not complete or bony integration is not complete.

Changes in Health-Related Quality of Life and Knee Function After Knee Injury in Young Female Athletes.

PubMed

McGuine, Timothy A; Winterstein, Andrew P; Carr, Kathleen; Hetzel, Scott

2014-04-01

Recent literature has called for greater attention to evidence-based practice in sports medicine with the documentation of overall status and impairments following injury. The prospective documentation of impairments associated with knee injuries in female athletes regarding their health-related quality of life (HRQoL) and knee function (KF) of high school and collegiate athletes is limited. Assessing the effect knee injuries have on young female athletes may allow clinicians to better understand the perspectives of the athletes who sustain these injuries. To document the changes over 12 months in self-reported HRQoL and KF in young females who have sustained a knee injury. Case series; Level of evidence, 4. A convenience sample of 242 females (mean age, 17.4 ± 2.4 years) who injured their knee participating in sport or recreational activities was utilized. Injuries were categorized as anterior cruciate ligament tears (ACL), anterior knee pain (AKP), patellar instability (PAT), meniscus tear (MNT), iliotibial band syndrome (ITB), collateral ligament sprain (COL), and other (OTH). HRQoL was assessed with the Short Form-12 v 2.0 survey (SF-12) physical component summary (PCS) and mental component summary (MCS). KF was assessed with the 2000 International Knee Documentation Committee survey (IKDC). Dependent variables included the paired differences in the 2000 IKDC as well as SF-12 composite scores from preinjury through 12 months postdiagnosis. Paired differences were assessed with repeated-measures analyses of variance (P ≤ .05). IKDC scores were lower through 12 months for ACL, AKP, and PAT; through 6 months for MNT; and through 3 months for COL and OTH. HRQoL PCS and MCS scores were lower through 3 to 12 months depending on the type of injury classification. Knee injuries can negatively affect KF and HRQoL for up to 12 months in young females. Sports medicine providers need to be aware of these impacts as they work to effectively treat individuals with these injuries.

Quality of Life in Symptomatic Individuals After Anterior Cruciate Ligament Reconstruction, With and Without Radiographic Knee Osteoarthritis.

PubMed

Filbay, Stephanie R; Ackerman, Ilana N; Dhupelia, Sanjay; Arden, Nigel K; Crossley, Kay M

2018-05-01

Study Design Clinical measurement, cross-sectional. Background Individuals who have undergone anterior cruciate ligament (ACL) reconstruction commonly experience long-term impairments in quality of life (QoL), which may be related to persistent knee symptoms or radiographic osteoarthritis (ROA). Understanding the impact of knee symptoms and ROA on QoL after ACL reconstruction may assist in the development of appropriate management strategies. Objectives To (1) compare QoL between groups of individuals after ACL reconstruction (including those who are symptomatic with ROA, symptomatic without ROA, and asymptomatic [unknown ROA status]), and (2) identify specific aspects of QoL impairment in symptomatic individuals with and without ROA post ACL reconstruction. Methods One hundred thirteen participants completed QoL measures (Knee injury and Osteoarthritis Outcome Score QoL subscale [KOOS-QoL], Anterior Cruciate Ligament Quality of Life [ACL-QoL], Assessment of Quality of Life-8 Dimensions [AQoL-8D]) 5 to 20 years after ACL reconstruction. Eighty-one symptomatic individuals underwent radiographs, and 32 asymptomatic individuals formed a comparison group. Radiographic osteoarthritis was defined as a Kellgren-Lawrence grade of 2 or greater for the tibiofemoral and/or patellofemoral joints. Mann-Whitney U tests compared outcomes between groups. Individual ACL-QoL items were used to explore specific aspects of QoL. Results In symptomatic individuals after ACL reconstruction, ROA was related to worse knee-related outcomes on the KOOS-QoL (median, 50; interquartile range [IQR], 38-69 versus median, 69; IQR, 56-81; P<.001) and the ACL-QoL (median, 51; IQR, 38-71 versus median, 66; IQR, 50-82; P = .04). The AQoL-8D scores showed that health-related QoL was impaired in both symptomatic groups compared to the asymptomatic group. The ACL-QoL item scores revealed greater limitations and concern surrounding sport and exercise and social/emotional difficulties in the symptomatic group with ROA. Conclusion Osteoarthritis is associated with worse knee-related QoL in symptomatic individuals after ACL reconstruction. Diagnosing ROA in symptomatic individuals after ACL reconstruction may be valuable, because these individuals may require unique management. Targeted strategies to facilitate participation in satisfying activities have potential to improve QoL in symptomatic people with ROA after ACL reconstruction. J Orthop Sports Phys Ther 2018;48(5):398-408. doi:10.2519/jospt.2018.7830.

Heave-pitch-roll analysis and testing of air cushion landing systems

NASA Technical Reports Server (NTRS)

Boghani, A. B.; Captain, K. M.; Wormley, D. N.

1978-01-01

The analytical tools (analysis and computer simulation) needed to explain and predict the dynamic operation of air cushion landing systems (ACLS) is described. The following tasks were performed: the development of improved analytical models for the fan and the trunk; formulation of a heave pitch roll analysis for the complete ACLS; development of a general purpose computer simulation to evaluate landing and taxi performance of an ACLS equipped aircraft; and the verification and refinement of the analysis by comparison with test data obtained through lab testing of a prototype cushion. Demonstration of simulation capabilities through typical landing and taxi simulation of an ACLS aircraft are given. Initial results show that fan dynamics have a major effect on system performance. Comparison with lab test data (zero forward speed) indicates that the analysis can predict most of the key static and dynamic parameters (pressure, deflection, acceleration, etc.) within a margin of a 10 to 25 percent.

Sonography on injury of the medial patellofemoral ligament after acute traumatic lateral patellar dislocation: Injury patterns and correlation analysis with injury of articular cartilage of the inferomedial patella.

PubMed

Zhang, Guang-Ying; Zheng, Lei; Shi, Hao; Qu, Su-Hui; Ding, Hong-Yu

2013-12-01

The purpose of this study was to investigate the accuracy of high-frequency ultrasonography in the diagnosis of injuries of medial patellofemoral ligaments (MPFLs), analyse the characteristics of MPFL injury and correlations between injury of the MPFL and articular cartilage of the inferomedial patella in patients with acute traumatic lateral patellar dislocation. High-frequency sonographic images of 49 patients with acute traumatic lateral patellar dislocations treated surgically were reviewed. The χ(2) tests were performed for statistical analysis. Twenty-eight cases of complete MPFL tear and 21 cases of partial MPFL tear were identified in operation, with 27 cases of MPFL tear located at their femoral attachment, 21 cases of tear at the patellar attachment and one case of midsubstance tear. The diagnostic accuracy of sonography regarding partial MPFL tear and complete MPFL tear was 89.8% and 89.8%. Among the patients with MPFL tear at the patellar attachment, eight and six cases were concomitant with chondral and osteochondral lesions in the inferomedial patella, respectively, in contrast to nine and six cases in patients with MPFL tear at the femoral attachment, respectively. There was no significant difference between the two locations described above regarding the prevalence rates of chondral or osteochondral lesions of the inferomedial patella (P=0.732, P=0.614). Among the patients with complete MPFL tear, 12 and 10 cases were concomitant with chondral and osteochondral lesions in the inferomedial patella, respectively, while six and two cases were concomitant with partial MPFL tear. There was no significant difference between the two types of injuries discussed above on the prevalence rates of chondral lesions of the inferomedial patella (P=0.305), but the prevalence rate of osteochondral lesions between the two types of injuries discussed above was statistically different (P=0.035). The MPFL is most easily injured at the femoral attachment, secondly at the patellar attachment. High-frequency ultrasonography is an accurate method in the diagnosis of an MPFL tear. There are neither significant differences on the prevalence rates of chondral or osteochondral lesions of the inferomedial patella between locations of MPFL injuries, nor significant difference on the prevalence rates of chondral lesions between MPFL injury types; but the complete MPFL tear is more often concomitant with inferomedial patellar osteochondral lesions than the partial MPFL tear. Copyright © 2013 Elsevier Ltd. All rights reserved.

Cost-Effectiveness Analysis of Early Reconstruction Versus Rehabilitation and Delayed Reconstruction for Anterior Cruciate Ligament Tears.

PubMed

Mather, Richard C; Hettrich, Carolyn M; Dunn, Warren R; Cole, Brian J; Bach, Bernard R; Huston, Laura J; Reinke, Emily K; Spindler, Kurt P

2014-07-01

An initial anterior cruciate ligament (ACL) tear can be treated with surgical reconstruction or focused rehabilitation. The KANON (Knee Anterior cruciate ligament, NON-surgical versus surgical treatment) randomized controlled trial compared rehabilitation plus early ACL reconstruction (ACLR) to rehabilitation plus optional delayed ACLR and found no difference at 2 years by an intention-to-treat analysis of total Knee injury and Osteoarthritis Outcome Score (KOOS) results. To compare the cost-effectiveness of early versus delayed ACLR. Economic and decision analysis; Level of evidence, 2. A Markov decision model was constructed for a cost-utility analysis of early reconstruction (ER) versus rehabilitation plus optional delayed reconstruction (DR). Outcome probabilities and effectiveness were derived from 2 sources: the KANON study and the Multicenter Orthopaedic Outcomes Network (MOON) database. Collectively, these 2 sources provided data from 928 ACL-injured patients. Utilities were measured by the Short Form-6 dimensions (SF-6D). Costs were estimated from a societal perspective in 2012 US dollars. Costs and utilities were discounted in accordance with the United States Panel on Cost-Effectiveness in Health and Medicine. Effectiveness was expressed in quality-adjusted life-years (QALYs) gained. Principal outcome measures were average incremental costs, incremental effectiveness (as measured by QALYs), and net health benefits. Willingness to pay was set at $50,000, which is the currently accepted standard in the United States. In the base case, the ER group resulted in an incremental gain of 0.28 QALYs over the DR group, with a corresponding lower overall cost to society of $1572. Effectiveness gains were driven by the low utility of an unstable knee and the lower utility for the DR group. The cost of rehabilitation and the rate of additional surgery drove the increased cost of the DR group. The most sensitive variable was the rate of knee instability after initial rehabilitation. When the rate of instability falls to 51.5%, DR is less costly, and when the rate of instability falls below 18.0%, DR becomes the preferred cost-effective strategy. An economic analysis of the timing of ACLR using data exclusively from the KANON trial, MOON cohort, and national average reimbursement revealed that early ACLR was more effective (improved QALYs) at a lower cost than rehabilitation plus optional delayed ACLR. Therefore, early ACLR should be the preferred treatment strategy from a societal health system perspective. © 2014 The Author(s).

Delayed Anterior Cruciate Ligament Reconstruction in Young Patients With Previous Anterior Tibial Spine Fractures.

PubMed

Mitchell, Justin J; Mayo, Meredith H; Axibal, Derek P; Kasch, Anthony R; Fader, Ryan R; Chadayammuri, Vivek; Terhune, E Bailey; Georgopoulos, Gaia; Rhodes, Jason T; Vidal, Armando F

2016-08-01

Avulsion fractures of the anterior tibial spine in young athletes are injuries similar to anterior cruciate ligament (ACL) injuries in adults. Sparse data exist on the association between anterior tibial spine fractures (ATSFs) and later ligamentous laxity or injuries leading to ACL reconstruction. To better delineate the incidence of delayed instability or ACL ruptures requiring delayed ACL reconstruction in young patients with prior fractures of the tibial eminence. Case series; Level of evidence, 4. We identified 101 patients between January 1993 and January 2012 who sustained an ATSF and who met inclusion criteria for this study. All patients had been followed for at least 2 years after the initial injury and were included for analysis after completion of a questionnaire via direct contact, mail, and/or telephone. If patients underwent further surgical intervention and/or underwent later ACL reconstruction, clinical records and operative reports pertaining to these secondary interventions were obtained and reviewed. Differences between categorical variables were assessed using the Fisher exact test. The association between time to revision ACL surgery and fracture type was assessed by Kaplan-Meier plots. The association between need for revision ACL surgery and age, sex, and mechanism of surgery was assessed using logistic regression. Nineteen percent of all patients evaluated underwent delayed ACL reconstruction after a previous tibial spine fracture on the ipsilateral side. While there were a higher proportion of ACL reconstructions in type II fractures, there was not a statistically significant difference in the number of patients within each fracture group who went on to undergo later surgery (P = .29). Further, there was not a significant association between fracture type, sex, or mechanism of injury as it related to the progression to later ACL reconstruction. However, there was a significant association between age at the time of injury and progression to later ACL reconstruction (P = .02). For every year increase in age at the time of injury, the odds of going on to undergo delayed ACL reconstruction were greater by a factor of 1.3 (95% CI, 1.1-1.6). Although an ATSF is a relatively rare injury, our cohort of patients suggests that a subset of young patients with all types of tibial spine fractures will require later ACL reconstruction. There is a need to counsel patients that a delayed ACL rupture is a potential risk after an ATSF, especially as children approach skeletal maturity. Further patient follow-up and prospective studies are required. © 2016 The Author(s).

Does partial tear repair of adjacent tendons improve the outcome of supraspinatus tendonfull-thickness tear reinsertion?

PubMed

Nich, C; Dhiaf, N; Di Schino, M; Augereau, B

2014-11-01

Partial tearing of the infraspinatus and/or subscapularis tendon(s) is frequently associated with supraspinatus full-thickness tears. However, limited data regarding its influence on supraspinatus surgical repair is available. Our aim was to assess the functional and anatomical outcomes of open repair of supraspinatus full-thickness tears combined with adjacent partial tearing, comparatively to a control. We retrospectively identified 22 patients (22 shoulders) with a partial tear, most of them being a delamination tear, of the infraspinatus and/or subscapularis tendons associated with a complete detachment of the supraspinatus tendon. Twenty-seven patients (27 shoulders) treated for an isolated complete detachment of the supraspinatus tendon by open repair served as controls. The mean age was 58 years. A proximalized trans-osseous reinsertion of the supraspinatus tendon was combined with a curettage-closure of the delamination tear. Patients were evaluated with standardized MRI at last follow-up. At a mean of 75-month follow-up, the presence of a partial tear of either infraspinatus or subscapularis, or both, did not influence function and healing rates of supraspinatus tendon repair. Conversely to the control, when a retear occurred, the functional score tended to worsen. Preoperatively, fatty muscular degeneration was more pronounced when a partial tear was present. Fatty degeneration worsened regardless of repair healing. Open reinsertion of a supraspinatus full-thickness tear associated with a thorough treatment of partial tear of adjacent tendons led to optimal functional and anatomical mid term outcomes. Our results suggest the presence of a partial tear of adjacent tendons could be associated with poorer function in case of supraspinatus tendon re-rupture. Level III case-control study. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Trends in serum relaxin concentration among elite collegiate female athletes

PubMed Central

Dragoo, Jason L; Castillo, Tiffany N; Korotkova, Tatiana A; Kennedy, Ashleigh C; Kim, Hyeon Joo; Stewart, Dennis R

2011-01-01

Purpose: This study was designed to investigate the relationship between serum relaxin concentration (SRC) and menstrual history and hormonal contraceptive use among elite collegiate female athletes. Evaluation of SRC in athletes is necessary, because relaxin has been associated with increased knee joint laxity and decreased anterior cruciate ligament (ACL) strength in animal models. Methods: National Collegiate Athletic Association Division I female athletes participating in sports at high risk for ACL tears – basketball, field hockey, gymnastics, lacrosse, soccer, and volleyball – were invited to participate. All participants completed a questionnaire about their menstrual history and hormonal contraceptive use. Venipuncture was performed to obtain samples of serum progesterone and relaxin. Samples were obtained during the mid-luteal phase from ovulating participants, and between the actual or projected cycle days 21 to 24, from anovulatory participants. Serum concentration of relaxin and progesterone was determined by ELISA and the data were analyzed using SPSS statistical software with significance set at P = 0.05. Results: 169 female athletes participated. The mean SRC among all participants was 3.08 ± 6.66 pg/mL). The mean SRC differed significantly between those participants using hormonal contraceptives (1.41 pg/mL) and those not using hormonal contraceptives (3.08 pg/mL, P = 0.002). Mean SRC was lowest among amenorrheic participants (1.02 pg/mL) and highest among oligomenorrheic participants (3.71 pg/mL) and eumenorrheic participants (3.06 pg/mL); these differences were not significant (P = 0.53). Mean serum progesterone concentration (SPC) differed significantly between those participants using hormonal contraceptives (2.80 ng/mL), and those not using hormonal contraceptives (6.99 ng/mL, P < 0.0001). Conclusions: There is a positive correlation between serum progesterone and SRC and an attenuation of SRC with hormonal contraceptive use. Our results underscore the significant role that hormonal contraceptives can play in decreasing relaxin levels, if future investigations establish a link between relaxin levels and ligamentous injury among female athletes. PMID:21339934

Tibial component considerations in bicruciate-retaining total knee arthroplasty: A 3D MRI evaluation of proximal tibial anatomy.

PubMed

Saxena, Vishal; Anari, Jason B; Ruutiainen, Alexander T; Voleti, Pramod B; Stephenson, Jason W; Lee, Gwo-Chin

2016-08-01

Restoration of normal anatomy and proper ligament balance are theoretical prerequisites for reproducing physiological kinematics with bicruciate-retaining total knee arthroplasty (TKA). The purpose of this study was to use a 3D MRI technique to evaluate the topography of the proximal tibia and outline considerations in tibial component design for bicruciate-retaining TKA. We identified 100 consecutive patients (50 males and 50 females) between ages 20 and 40 years with knee MRIs without arthritis, dysplasia, ACL tears, or prior knee surgery. A novel 3D MRI protocol coordinating axial, coronal, and sagittal images was used to measure: 1) medial and lateral posterior tibial slopes; 2) medial and lateral coronal slopes; and 3) distance from the anterior tibia to the ACL footprint. There was no overall difference in medial and lateral posterior tibial slopes (5.5° (95% CI 5.0 to 6.0°) vs. 5.4° (95% CI 4.8 to 6.0°), respectively (p=0.80)), but 41 patients had side-to-side differences greater than 3°. The medial coronal slope was greater than the lateral coronal slope (4.6° (95% CI 4.0 to 5.1°) vs. 3.3° (95% CI 2.9 to 3.7°), respectively (p<0.0001)). Females had less clearance between the anterior tibia and ACL footprint than males (10.8mm (95% CI 10.4 to 11.2mm) vs. 13.0mm (95% CI 12.5 to 13.5mm), respectively (p<0.0001)). Due to highly variable proximal tibial topography, a monoblock bicruciate-retaining tibial baseplate may not reproduce normal anatomy in all patients. Level IV - Anatomic research study. Copyright © 2015 Elsevier B.V. All rights reserved.

Complications in posteromedial arthroscopic suture of the medial meniscus.

PubMed

Jan, N; Sonnery-Cottet, B; Fayard, J-M; Kajetanek, C; Thaunat, M

2016-12-01

All-inside posteromedial suture for lesions of the posterior horn of the medial meniscus in anterior cruciate ligament (ACL) repair provides effective freshening and good healing. The posteromedial portal provides satisfactory healing rates without increasing morbidity or complications rates. Intra- and postoperative complications were collected for a consecutive single-center series of 132 patients undergoing posteromedial hook suture of the medial meniscus in ACL repair. Meniscal healing was assessed as the rate of recurrence of symptomatic medial meniscus lesions (Barret criteria) and on revision surgery, if any, in terms of the aspect and extent of the iterative lesion. The severity of any sensory disorder was assessed by questionnaire. The intraoperative complications rate was 1.5% (2 saphenous vein punctures). At a mean 31months (range, 28-35months), there was no loss to follow-up. Twelve patients (9%) showed symptomatic recurrence of the medial meniscus lesion, requiring 10 repeat surgeries. In 6 cases (4.5%), the iterative lesion involved a smaller, more central part of the meniscus anterior to the sutures, of "postage-stamp" effect, possibly implicating the suture hook and/or non-absorbable sutures. There were no cases of infection or fistula. Postoperative hematoma occurred in 7% of patients. In total, 1.8% reported dysesthesia areas equal to or greater than the size of a credit card (45cm 2 ). Some retears, or "partial failures", may implicate a new lesion caused by the suture hook and possibly prolonged by non-resorbable sutures. Hematoma and sensory disorder rates were comparable to those reported in isolated ACL repair without posteromedial portal. The present results show that posteromedial arthroscopic hook suture in posterior medial meniscus tear provides good healing rates without increased morbidity due to the supplementary portal. IV. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Arthroscopic evaluation of soft tissue injuries in tibial plateau fractures: retrospective analysis of 98 cases.

PubMed

Abdel-Hamid, Mohamed Zaki; Chang, Chung-Hsun; Chan, Yi-Sheng; Lo, Yang-Pin; Huang, Jau-Wen; Hsu, Kuo-Yao; Wang, Ching-Jen

2006-06-01

This investigation arthroscopically assesses the frequency of soft tissue injury in tibial plateau fracture according to the severity of fracture patterns. We hypothesized that use of arthroscopy to evaluate soft tissue injury in tibial plateau fractures would reveal a greater number of associated injuries than have previously been reported. From March 1996 to December 2003, 98 patients with closed tibial plateau fractures were treated with arthroscopically assisted reduction and osteosynthesis, with precise diagnosis and management of associated soft tissue injuries. Arthroscopic findings for associated soft tissue injuries were recorded, and the relationship between fracture type and soft tissue injury was then analyzed. The frequency of associated soft tissue injury in this series was 71% (70 of 98). The menisci were injured in 57% of subjects (56 in 98), the anterior cruciate ligament (ACL) in 25% (24 of 98), the posterior cruciate ligament (PCL) in 5% (5 of 98), the lateral collateral ligament (LCL) in 3% (3 of 98), the medial collateral ligament (MCL) in 3% (3 of 98), and the peroneal nerve in 1% (1 of 98); none of the 98 patients exhibited injury to the arteries. No significant association was noted between fracture type and incidence of meniscus, PCL, LCL, MCL, artery, and nerve injury. However, significantly higher injury rates for the ACL were observed in type IV and VI fractures. Soft tissue injury was associated with all types of tibial plateau fracture. Menisci (peripheral tear) and ACL (bony avulsion) were the most commonly injured sites. A variety of soft tissue injuries are common with tibial plateau fracture; these can be diagnosed with the use of an arthroscope. Level III, diagnostic study.

Development and Validation of a Short Version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale

PubMed Central

Webster, Kate E.; Feller, Julian A.

2018-01-01

Background: The Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale was developed to measure an athlete’s psychological readiness to return to sport after anterior cruciate ligament (ACL) injury and reconstruction surgery. The scale is being used with increasing frequency in both research and clinical settings. Purpose: To generate and validate a short version of the ACL-RSI scale. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The ACL-RSI scale was administered to 535 patients who had undergone ACL reconstruction surgery. Reliability (Cronbach alpha) was determined and factor analysis of the full scale was undertaken along with a process of item selection and elimination. A second group of 250 patients participated in a predictive validation analysis. This group completed the ACL-RSI scale at 6 months and reported return-to-sport outcomes 12 months following ACL reconstruction surgery. The predictive validity of both scales (full and short versions) was assessed by use of receiver operating characteristic (ROC) curve statistics. Results: The scale was found to have high internal consistency (Cronbach alpha, 0.96), which suggested that item redundancy was present. After an item selection process, the scale was reduced to a 6-item format. Cronbach alpha for the short version was 0.92, and factor analysis confirmed the presence of 1 factor accounting for 71% of the total variance. Scores for the short version were significantly different between patients who had and those who had not returned to sport. Six-month ACL-RSI scores for both the full and short versions had fair to good predictive ability for 12-month return-to-sport outcomes (full version: area under ROC curve, 0.77 [95% CI, 0.7-0.8]; short version: area under ROC curve, 0.75 [95% CI, 0.7-0.8]). Conclusion: A 6-item short version of the ACL-RSI scale was developed from a large cohort of patients undergoing ACL reconstruction. The short version appears to be as robust as the full version for discriminating between and predicting return-to-sport outcomes. The short version of the ACL-RSI may be of use in busy clinical settings to help identify athletes who may find return to sport challenging. PMID:29662909

Atraumatic tears of the ligamentum teres are more frequent in professional ballet dancers than a sporting population.

PubMed

Mayes, Susan; Ferris, April-Rose; Smith, Peter; Garnham, Andrew; Cook, Jill

2016-07-01

To compare the frequency of atraumatic ligamentum teres (LT) tear in professional ballet dancers with that of athletes, and to determine the relationship with clinical and imaging findings. Forty-nine male and female professional ballet dancers (98 hips) and 49 age and sex-matched non-dancing athletes (98 hips) completed questionnaires on hip symptoms and physical activity levels, underwent hip rotation range of movement (ROM) and hypermobility testing, and 3.0-Tesla magnetic resonance imaging (3 T MRI) on both hips to detect LT tears, acetabular labral tears, and articular cartilage defects, and to measure the lateral centre edge angles (LCE). A higher frequency of LT tear was found in dancers (55 %) compared with athletes (22 %, P = 0.001). The frequency and severity of LT tears in dancers increased with older age (P = 0.004, P = 0.006, respectively). The Hip and Groin Outcome Score (HAGOS) pain scores or hip rotation ROM did not differ significantly among participants with normal, partial, or complete tears of LT (P > 0.01 for all). Neither the frequency of generalised joint hypermobility (P = 0.09) nor the LCE angles (P = 0.32, P = 0.16, left and right hips respectively) differed between those with and those without LT tear. In most hips, LT tear co-existed with either a labral tear or a cartilage defect, or both. The higher frequency of atraumatic LT tears in professional ballet dancers suggests that the LT might be abnormally loaded in ballet, and caution is required when evaluating MRI, as LT tears may be asymptomatic. A longitudinal study of this cohort is required to determine if LT tear predisposes the hip joint to osteoarthritis.

Peri-articular local infiltration analgesia versus femoral nerve block for postoperative pain control following anterior cruciate ligament reconstruction: Prospective, comparative, non-inferiority study.

PubMed

Lefevre, N; Klouche, S; de Pamphilis, O; Herman, S; Gerometta, A; Bohu, Y

2016-11-01

Femoral nerve block (FNB) is considered as a major advance in anterior cruciate ligament (ACL) reconstruction as it reduces the need for parenteral opioids. However, the incidence of transient or even permanent neurological deficits due to the FNB is estimated at 1.94% after knee surgery. The primary objective of this study was to compare local infiltration analgesia (LIA) to FNB during ACL reconstruction procedures. The study hypothesis was that LIA was not less effective than FNB on early postoperative pain. A retrospective analysis of data collected prospectively in the FAST cohort included a series of continuous patients who underwent primary repair for isolated ACL with a hamstring graft in 2013-2014. Changes in our anesthesia practices over time allowed us to form three successive groups: Group 1 - FNB, Group 2 - FNB+LIA, Group 3 - LIA only. Ultrasound-guided FNB was done pre-operatively. The LIA was done at the end of the procedure by the surgeon with systematic infiltration of all skin incisions and the hamstring donor site; no intra-articular injections were performed. The primary endpoint was the average early postoperative pain (Days 0-3) described by the patient on a visual analogue scale (0-10). Sample size calculation pointed to 36 subjects being needed per group for a non-inferiority study. The study involved 126 patients: G1=42, G2=38, G3=46. The patients were comparable at enrolment. The average early postoperative pain levels were 3.1±2.4, 2.8±2.0 and 2.5±2.2, respectively (P=0.66). A trend toward higher intake of tramadol was noted in the LIA group on D0 to D3, with a significant trend test on Day 1 (P=0.03) and Day 2 (P=0.02). After reconstruction of isolated ACL tears with a hamstring graft, FNB is not more effective than LIA on patients' early postoperative pain. Patients who received a FNB consumed significantly less opioid-like analgesics. III - Prospective, comparative, non-randomized study. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ihara, Hidetoshi; Miwa, Megumi; Deya, Keizo

The purpose of this study was to evaluate using MRI the natural healing of the anterior cruciate ligament (ACL) when treated conservatively by early protective motion. Consecutive acute complete intraligamentous ruptures of the ACL in 50 cases that were allowed to heal without surgery were evaluated before and after 3 month treatment by MRI, arthroscopy, and stress radiographs. Twenty-nine of the 50 patients were also reevaluated 11 months from the initial injury, of which 7 were reevaluated again 24 months from the initial injury by MRI. The MR appearance of the treated ACL was categorized into four grades depending onmore » homogeneity, straight band, and size. MR assessment of the ACL after 3 month treatment demonstrated a well defined normal-sized straight band in 37 cases (74%). There was a significant relationship between the 3 and 11 month MR evaluations (r. = 0.801, p < 0.0001). There were also significant relationships between the MR and arthroscopic evaluations (r, = 0.455, p < 0.005) and between the MR and stress radiographic evaluations (r, = 0.348, p < 0.025) after the 3 month treatment. MRI can demonstrate ACL healing when treated conservatively with early protective mobilization. 40 refs., 3 figs., 2 tabs.« less

ACL Fibers Inserting on the Lateral Intercondylar Ridge Carry the Greatest Loads - Are Modern Anatomic Femoral Tunnel Positions Too Low?

PubMed Central

Nawabi, Danyal H.; Imhauser, Carl; Tucker, Scott; Nguyen, Joseph; Wickiewicz, Thomas L.; Pearle, Andrew

2014-01-01

Objectives: Histological studies have shown that the ACL has a direct and indirect insertion on the femur [1]. The direct insertion is located along the lateral intercondylar ridge and the indirect insertion is located ‘lower’ on the lateral wall of the notch. The trend towards anatomic ACL reconstruction using the anteromedial (AM) portal technique has resulted in ‘lower’ non-isometric femoral tunnel positions and increased graft failures [2]. To our knowledge, the load transfer properties of the direct and indirect ACL insertions have not been studied. This information may help in understanding the increased failures reported with AM portal drilling. The purpose of this study was, 1) to compare the load transferred across the native ACL at the direct and indirect femoral insertions and, 2) to determine the strain behavior of ACL grafts placed at different tunnel locations within the direct and indirect insertions. Methods: Ten fresh-frozen cadaveric knees (mean age, 52.5 years; range, 29-65) were mounted to a six degree of freedom robot. A 134N anterior load at 30 and 90° flexion and a combined valgus (8Nm) and internal (4Nm) rotational moment at 15° flexion were applied. The ACL was subsequently sectioned at the femoral footprint by detaching either the direct or indirect insertion (partially sectioned state), followed by the remainder of the ACL (completely sectioned state) (Figure 1). The kinematics of the intact knee were replayed after each stage of sectioning to determine the loads transferred across the direct and indirect ACL fibers. Loads were expressed as a percentage of the total load borne by the ACL. Strain behaviour was tested by generating 3D models of the femur and tibia from CT scans of each knee. Three tunnel locations (anteromedial bundle [AM], center [C], posterolateral bundle [PL]) each were selected for the direct and indirect insertions and a virtual ACL graft was inserted. The isometry of the virtual graft was calculated through a flexion path of 0 to 90°. Results: Under an anterior tibial load at 30° flexion, the direct insertion carried 83.9% of the total ACL load compared to 16.1% in the indirect insertion (p<0.001). The direct insertion also carried more load at 90° flexion (95.2% vs 4.8%; p<0.001). Under a combined rotatory load at 15° flexion, the direct insertion carried 84.2% of the total ACL load compared to 15.8% in the indirect insertion (p<0.001). A virtual ACL graft placed at the AM position in the direct insertion demonstrated the best strain behaviour with a mean 10.9% change in length. This value was significantly lower (p<0.001) than the isometry at all 3 tunnel positions in the indirect insertion (AM = 18.5%; C = 24.9%; PL = 30.9%). Conclusion: Fibers in the direct insertion of the ACL carry more load than fibers in the indirect insertion. Virtual ACL grafts placed in the ‘higher’ direct location are more isometric than in the ‘lower’ indirect location during range of motion testing. Clinical Relevance: ‘Low’ ACL grafts in the indirect ACL insertion, resulting from AM portal drilling techniques, may experience higher loads in-vivo due to unfavorable biomechanics. With the current shift towards anatomic ACL reconstruction, it may be beneficial to create a ‘higher’ femoral tunnel within the direct insertion at the lateral intercondylar ridge. This position remains anatomical but may also be biomechanically favorable.

Impact of an Advanced Cardiac Life Support Simulation Laboratory Experience on Pharmacy Student Confidence and Knowledge.

PubMed

Maxwell, Whitney D; Mohorn, Phillip L; Haney, Jason S; Phillips, Cynthia M; Lu, Z Kevin; Clark, Kimberly; Corboy, Alex; Ragucci, Kelly R

2016-10-25

Objective. To assess the impact of an advanced cardiac life support (ACLS) simulation on pharmacy student confidence and knowledge. Design. Third-year pharmacy students participated in a simulation experience that consisted of team roles training, high-fidelity ACLS simulations, and debriefing. Students completed a pre/postsimulation confidence and knowledge assessment. Assessment. Overall, student knowledge assessment scores and student confidence scores improved significantly. Student confidence and knowledge changes from baseline were not significantly correlated. Conversely, a significant, weak positive correlation between presimulation studying and both presimulation confidence and presimulation knowledge was discovered. Conclusions. Overall, student confidence and knowledge assessment scores in ACLS significantly improved from baseline; however, student confidence and knowledge were not significantly correlated.

[The role of arthroscopy in subacromial pathology. Retrospective study of a series of arthroscopic acromioplasties].

PubMed

Schiepers, P; Pauwels, P; Penders, W; Brandelet, B; Putz, P

2000-12-01

The authors report the results of a retrospective study of 59 arthroscopic acromioplasties. Objective shoulder assessment was made following the relative Constant score and UCLA rating scale. Subjective satisfaction of the patient was assessed on an analogic scale. The patients were divided into 3 groups, according to the subacromial pathology treated. The first group (27 shoulders in 23 patients) included patients with subacromial impingement without a complete rotator cuff tear. The objective result, between 80 and 90%, was close to results in others series reported. Distinction between patients with no tear or partial tear of the cuff showed better results for patients with partial tears. This surprising finding may be at least partially explained by the fact that these patients were older than those without a cuff tear. The results of this study, and the review of the literature, confirmed the value of subacromial decompression as a treatment for impingement without complete cuff tear resistant to at least 6 months of conservative treatment; comparison between surgical and arthroscopic series showed similar results. The second group (19 shoulders in 19 patients) included patients with impingement and complete cuff tear. The objective results and the literature review led us to specify indications. Subacromial decompression with debridment of the tear has given excellent results in older patients--over 60 for most authors--when the tear was limited. In our study, the function of the shoulder at revision was good when the tear was limited to the supraspinatus and part of the infraspinatus. The third group (13 shoulders in 10 patients) included patients with calcifying tendinitis. Arthroscopic acromioplasty was performed in every case; excision of the calcification was performed in less than half of the cases and did not influence the final result. The calcifications had disappeared at revision in all cases. This may suggest that the treatment of the associated impingement was the most important procedure in these cases.

Return to High School and College Level Football following ACL Reconstruction: A MOON Cohort Study

PubMed Central

McCullough, Kirk A.; Phelps, Kevin D.; Spindler, Kurt P.; Matava, Matthew J.; Dunn, Warren R.; Parker, Richard D.; Reinke, Emily K.

2013-01-01

Background While published studies on return to play for various sports exist in the literature, there is a relative paucity of data regarding the effect of ACL reconstruction on the ability of American high school and collegiate football players to return to play at the same level of competition as before their injury, or to progress to play at the next level of competition. Purpose The purpose of this study was threefold: 1) to identify the percentage of high school and collegiate American football players who successfully returned to play at their previous level of competition; 2) to investigate self-reported performance for those players able to return to play or reason(s) for not returning to play; 3) to elucidate risk factors responsible for players not being able to return to play or not returning to the same level of performance. Study Design Retrospective cohort study; level of evidence, 2. Methods This study was a retrospective analysis of prospective patients taken from the Multicenter Orthopaedic Outcomes Network (MOON) cohort who identified football as their primary or secondary sport. Identified patients were then questioned in a structured interview regarding their ACL injury, participation in football prior to their injury, and factors associated with returning to play. Data was analyzed for player position, concurrent meniscal/ligamentous/chondral pathology, surgical technique and graft used for ACL reconstruction, and issues pertaining to timing and ability to return to play. Results 147 players (68 high school, 26 collegiate) met our criteria and were contacted from the 2002 and 2003 MOON cohorts. Return-to-play rates for all high school and collegiate athletes were similar (63% and 69%, respectively). Based on player perception, 43% of the players were able to return to play at the same self-described performance level. Approximately 27% felt they did not perform at a level attained prior to their ACL tear, and 30% were unable to return to play at all. Although 2/3 of players reported some “other interest” contributing to their decision not to return, at both levels of competition fear of re-injury or further damage was cited by ~50% of the players who did not return to play. Analysis of patient-reported outcome scores at a minimum of two years after surgery between patients who returned to play and those that did not demonstrated clinically and statistically significant differences in the IKDC, Marx activity, and KOOS knee related quality of life subscales in the collegiate players. Similar clinical differences were not statistically significant in the high school students. Player position did not have a statistically significant effect on the ability to return to play for high school players, and 41% of “skilled” position players and 50% of “non-skilled” position players were able to return to play at the same performance level. Conclusion Return-to-play percentages for amateur American football players following ACL reconstruction are not as high as would be expected. While technical aspects of ACL reconstruction and the ensuing rehabilitation have been studied extensively, the psychological factors (primarily a fear of re-injury) influencing the ability to return to play following ACL surgery may be underestimated as a critical factor responsible for athletes not returning to play at any level of competition. PMID:22922520

Magnetic resonance imaging assessment of the rotator cuff: is it really accurate?

PubMed

Wnorowski, D C; Levinsohn, E M; Chamberlain, B C; McAndrew, D L

1997-12-01

Magnetic resonance imaging (MRI) is used increasingly for evaluating the rotator cuff. This study of 39 shoulders (38 patients) compared the accuracy of MRI interpretation of rotator cuff integrity by a group of community hospital radiologists (clinical community scenario, CCS) with that of a musculoskeletal radiologist (experienced specialist scenario, ESS), relative to arthroscopy. For the CCS subgroup, the sensitivity, specificity, positive predictive value (PV), negative PV, and accuracy for partial tears were: 0%, 68%, 0%, 82%, and 59%, respectively; for complete tears: 56%, 73%, 36%, 86%, and 69%, respectively; and for all tears combined: 85%, 52%, 50%, 87%, and 64%, respectively. For the ESS subgroup, the respective values for partial tears were: 20%, 88%, 20%, 88%, and 79%, respectively; for complete tears: 78%, 83%, 58%, 92%, and 82%, respectively; and for all tears: 71%, 71%, 59%, 81%, and 71%, respectively. We concluded that MRI assessment of the rotator cuff was not accurate relative to arthroscopy. MRI was most helpful if the result was negative, and MRI diagnosis of partial tear was of little value. Considering the high cost of shoulder MRI, this study has significant implications for the evaluation of patients with possible rotator cuff pathology.

Biomechanical consequences of a complete radial tear adjacent to the medial meniscus posterior root attachment site: in situ pull-out repair restores derangement of joint mechanics.

PubMed

Padalecki, Jeffrey R; Jansson, Kyle S; Smith, Sean D; Dornan, Grant J; Pierce, Casey M; Wijdicks, Coen A; Laprade, Robert F

2014-03-01

Complete radial tears near the medial meniscus posterior root attachment site disrupt the circumferential integrity of the meniscus (similar to a posterior root avulsion). These tears can compromise the circumferential integrity, and they have been reported in biomechanical studies to be comparable with the meniscectomized state. To quantify the tibiofemoral contact pressure and contact area changes that occur in cadaveric knees from complete posterior horn radial tears and subsequent repairs of the medial meniscus adjacent to the posterior root attachment site. Controlled laboratory study. Six nonpaired fresh-frozen human cadaveric knees each underwent 45 different testing conditions: 9 medial meniscus conditions (intact, root avulsion, root repair, serial radial tear at 3, 6, and 9 mm from the root attachment site, and in situ repair at the same 3 distances from the root attachment site) at 5 flexion angles (0°, 30°, 45°, 60°, and 90°), under a 1000-N axial load. Tekscan sensors were used to measure contact area and pressure in the medial and lateral compartments. The medial meniscus root avulsion and all radial tear conditions resulted in significantly decreased contact area and increased mean contact pressure compared with the intact state for knee flexion angles beyond 0° (P < .05). The root repair and in situ repairs restored contact area and pressure to levels statistically indistinguishable from those of the intact meniscus and increased contact area and decreased contact pressure compared with the corresponding tear conditions. Posterior horn radial tears adjacent to the medial meniscus root that extend to the meniscocapsular junction can lead to derangement of the loading profiles of the medial compartment that are similar to a root avulsion. Repair of these radial tears with an in situ pull-out technique restored joint mechanics to the intact state. Complete radial tears of the posterior horn of the medial meniscus, which occur relatively frequently, are biomechanically equivalent to root avulsions and could potentially lead to medial compartment arthrosis. An in situ repair offers an alternative treatment to meniscectomy and can reestablish the posterior anchor point, thus improving load distribution in the medial compartment. Future clinical studies of these repairs are recommended.

Arthroscopic repair of massive contracted rotator cuff tears: aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity.

PubMed

Kim, Sung-Jae; Kim, Sung-Hwan; Lee, Su-Keon; Seo, Jae-Wan; Chun, Yong-Min

2013-08-21

Few studies of large-to-massive contracted rotator cuff tears have examined the arthroscopic complete repair obtained by a posterior interval slide and whether the clinical outcomes or structural integrity achieved are better than those after partial repair without the posterior interval slide. The study included forty-one patients with large-to-massive contracted rotator cuff tears, not amenable to complete repair with margin convergence alone. The patients underwent either arthroscopic complete repair with a posterior interval slide and side-to-side repair of the interval slide edge (twenty-two patients; Group P) or partial repair with margin convergence (nineteen patients; Group M). The patient assignment was not randomized. The Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and range of motion were used to compare the functional outcomes. Preoperative and six-month postoperative magnetic resonance arthrography (MRA) images were compared within or between groups. At the two-year follow-up evaluation, the SST, ASES score, UCLA score, and range of motion had significantly improved (p < 0.001 for all) in both groups. However, no significant differences were detected between groups. Even though the difference in preoperative tear size on MRA images was not significant, follow-up MRA images identified a retear in twenty patients (91%) in Group P and a significant difference in tear size between groups (p = 0.007). The complete repair group with an aggressive release had no better clinical or structural outcomes compared with the partial repair group with margin convergence alone for large-to-massive contracted rotator cuff tears. In addition, the complete repair group had a 91% retear rate and a greater defect on follow-up MRA images. Even though this study had a relatively short-term follow-up, a complete repair of large-to-massive contracted rotator cuff tears, with an aggressive release such as posterior interval slide, may not have an increased benefit compared with partial repair without posterior interval slide.

Anatomic findings and complications after surgical treatment of chronic, partial distal biceps tendon tears: a case cohort comparison study.

PubMed

Ruch, David S; Watters, Tyler Steven; Wartinbee, Daniel A; Richard, Marc J; Leversedge, Fraser J; Mithani, Suhail K

2014-08-01

To describe pertinent anatomic findings during repair of chronic, partial distal biceps tendon tears and to compare the complications of surgery with a similar cohort of acute, complete tears. Group 1 included 14 patients (15 elbows) with partial tears managed operatively an average of 10 months from onset of injury or symptoms. Group 2 included a matched cohort of 16 patients (17 elbows) treated for complete, acute tears an average of 19 days from injury. A retrospective review of all 30 patients focused on demographic data, intraoperative findings, and postoperative complications. A single, anterior incision was used in all cases with multiple suture anchors or a bicortical toggling button for fixation of the repair. We evaluated 27 men and 3 women with an average age of 55 years (group 1) and 48 years (group 2). Intratendinous ganglion formation at the site of rupture of the degenerative tendon was observed in 5 cases of partial tears and none of the complete tears. Partial tears involved the lateral aspect or short head of the biceps tendon insertion in all cases. Postoperative complications included lateral antebrachial cutaneous nerve neuritis in 8 group 1 patients and 6 group 2 patients and transient posterior interosseus nerve palsy in 3 group 1 patients. Partial distal biceps tendon ruptures showed a consistent pattern of pathology involving disruption of the lateral side of the tendon insertion involving the small head of the biceps. Degenerative intratendinous ganglion formation was present in one third of cases. Repair of chronic, partial distal biceps tendon injuries may have a higher incidence of posterior interosseous and lateral antebrachial cutaneous nerve palsies. Therapeutic III. Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Efficacy of ACL injury risk screening methods in identifying high-risk landing patterns during a sport-specific task.

PubMed

Fox, A S; Bonacci, J; McLean, S G; Saunders, N

2017-05-01

Screening methods sensitive to movement strategies that increase anterior cruciate ligament (ACL) loads are likely to be effective in identifying athletes at-risk of ACL injury. Current ACL injury risk screening methods are yet to be evaluated for their ability to identify athletes' who exhibit high-risk lower limb mechanics during sport-specific maneuvers associated with ACL injury occurrences. The purpose of this study was to examine the efficacy of two ACL injury risk screening methods in identifying high-risk lower limb mechanics during a sport-specific landing task. Thirty-two female athletes were screened using the Landing Error Scoring System (LESS) and Tuck Jump Assessment. Participants' also completed a sport-specific landing task, during which three-dimensional kinematic and kinetic data were collected. One-dimensional statistical parametric mapping was used to examine the relationships between screening method scores, and the three-dimensional hip and knee joint rotation and moment data from the sport-specific landing. Higher LESS scores were associated with reduced knee flexion from 30 to 57 ms after initial contact (P = 0.003) during the sport-specific landing; however, no additional relationships were found. These findings suggest the LESS and Tuck Jump Assessment may have minimal applicability in identifying athletes' who exhibit high-risk landing postures in the sport-specific task examined. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

An Intact Anterior Cruciate Ligament at the Time of Posterior Cruciate Ligament-Retaining Total Knee Arthroplasty Was Associated With Reduced Patient Satisfaction and Inferior Pain and Stair Function.

PubMed

Jacobs, Cale A; Christensen, Christian P; Karthikeyan, Tharun

2016-08-01

Patients with an intact anterior cruciate ligament (ACL) at the time of ACL-sacrificing total knee arthroplasty (TKA) have been suggested to have inferior outcomes compared with those with a dysfunctional ACL. However, to date, no published clinical studies have evaluated the potential link between the condition of the ACL at the time of posterior cruciate ligament-retaining TKA and postoperative pain, function, and satisfaction. As such, the purpose of this study was to compare subjective function, movement-elicited pain, pain at rest, and patient satisfaction between those with an intact or dysfunctional ACL. We identified 562 posterior cruciate ligament-retaining TKAs with complete intraoperative and postoperative data. Patients were categorized based on the condition of the ACL at the time of TKA as either being intact or dysfunctional (absent or lax). Knee Society Function Scores, movement-elicited pain, pain at rest, and patient satisfaction were then compared between groups. At mean follow-up of 5.1 years, a significantly lower proportion of patients in the intact group were satisfied with their operation (intact: 391/453 [86.3%] vs dysfunctional: 102/109 [93.6%], P = .0496). Inspection of the individual activities revealed that the groups did not differ in walking ability or pain when walking; however, the intact group reported significantly reduced ability to navigate stairs with greater pain during that activity. The lack of difference in pain at rest between groups suggests that pain and functional impairments during more demanding activities such as navigating stairs may be associated with the lost function of the ACL rather than by altered central pain processing. Copyright © 2016 Elsevier Inc. All rights reserved.

Return to Sport After Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Athlete.

PubMed

Chicorelli, Anne M; Micheli, Lyle J; Kelly, Michael; Zurakowski, David; MacDougall, Robert

2016-07-01

Determine the percentage of skeletally immature athletes returning to sports after anterior cruciate ligament (ACL) injury and reconstruction. Retrospective case series. Boston Children's Hospital Division of Sports Medicine. Eligible participants were identified by chart review. Males and females aged ≤14 year old who were greater than 2 years after ACL reconstruction surgery seen between January 2001 and May 2009. A total of 250 patients completed the questionnaires. Age, sex, mechanism, and sport played at time of ACL injury. Response to the survey was 75% (250 of 333) which was analyzed using descriptive statistics to provide a summary of the study cohort. Kaplan-Meier survivorship analysis was applied to determine time to return to sports participation after ACL reconstruction with Greenwood formula used to calculate 95% confidence intervals around the estimated percentage returning at 6, 9, 12, 18, and 24-month follow-up. After undergoing ACL reconstruction, 96% of skeletally immature athletes are able to return to sports at the same skill level. Median time to return to sports was 9 months postoperative, with most athletes returning to sports (85%) by 12 months. After undergoing ACL reconstruction, most child athletes are able to return to sports and 50% of these athletes return within 9 months after surgery. After undergoing ACL reconstruction, 96% of athletes ≤14 year old are able to return to sports at the same skill level. Median time to return to sports was 9 months postoperative, with most athletes returning to sports (85%) by 12 months. In our study, patients cited physical limitation, loss of interest in sport, and fear of reinjury as reasons for not returning to previous level of sport. Return to sport may be improved by additional research into sports-specific training and rehabilitation in this cohort.

Willingness to pay for anterior cruciate ligament reconstruction.

PubMed

Hall, Michael P; Chiang-Colvin, Alexis S; Bosco, Joseph A

2013-01-01

The outcomes of ACL reconstructions in terms of patient satisfaction and function are well known. Most orthopaedic surgeons feel that Medicare and other payors do not reimburse enough for this surgery. The purpose of this study is to determine how much patients are willing to pay for this surgery and compare it to reimbursement rates. We constructed a survey which described the function and limitations of an ACL deficient knee and the expected function of that knee after an ACL reconstruction. We then asked the volunteers how much they would be willing to pay for an ACL reconstruction if it were their knee. We also gathered data on the yearly earnings and Tegner activity level of the volunteers. In all, 143 volunteers completed the survey. We computed correlation coefficients between willingness to pay and both yearly earnings and Tegner activity level. The average amount that the volunteers were willing to pay for an ACL reconstruction was $4,867.00. There was no correlation between yearly earnings and willingness to pay. The correlation coefficient was 0.34. There was a weak correlation between Tegner activity level and willingness to pay. This correlation coefficient was 0.81. The Medicare allowable rate for ACL reconstruction (CPT 29888) in the geographic area of the study was $1,132.00. The data demonstrates that patients are willing to pay much more than traditional payors for ACL reconstruction. These payors undervalue the benefit of this surgery to the patient. There is increasing pressure on orthopaedic surgeons to not participate in insurance plans that reimburse poorly. This places an increasing financial burden on the patient. This study suggests that patients may be willing to pay more for their surgery than their insurance plan and accept more of this burden.

Return to Sport in the Younger Patient With Anterior Cruciate Ligament Reconstruction

PubMed Central

Webster, Kate E.; Feller, Julian A.; Whitehead, Timothy S.; Myer, Gregory D.; Merory, Peter B.

2017-01-01

Background: Although anterior cruciate ligament (ACL) reconstruction is generally regarded as a successful procedure, only 65% of patients return to their preinjury sport. While return-to-sport rates are likely higher in younger patients, there is a paucity of data that focus on the younger patient and their return-to-sport experience after ACL reconstruction. Purpose: To investigate a range of return-to-sport outcomes in younger athletes who had undergone ACL reconstruction surgery. Study Design: Case series; Level of evidence, 4. Methods: A group of 140 young patients (<20 years old at surgery) who had 1 ACL reconstruction and no subsequent ACL injuries completed a survey regarding details of their sport participation at a mean follow-up of 5 years (range, 3-7 years). Results: Overall, 76% (95% CI, 69%-83%) of the young patient group returned to the same preinjury sport. Return rates were higher for males than females (81% vs 71%, respectively; P > .05). Of those who returned to their sport, 65% reported that they could perform as well as before the ACL injury and 66% were still currently participating in their respective sport. Young athletes who never returned to sport cited fear of a new injury (37%) or study/work commitments (30%) as the primary reasons for dropout. For those who had successfully returned to their preinjury sport but subsequently stopped participating, the most common reason cited for stopping was study/work commitments (53%). At a mean 5-year follow-up, 48% of female patients were still participating in level I (jumping, hard pivoting) sports, as were 54% of males. Conclusion: A high percentage of younger patients return to their preinjury sport after ACL reconstruction surgery. For patients in this cohort who had not sustained a second ACL injury, the majority continue to participate and are satisfied with their performance. PMID:28473996

Diagnostic Tools for Acute Anterior Cruciate Ligament Injury: GNRB, Lachman Test, and Telos.

PubMed

Ryu, Seung Min; Na, Ho Dong; Shon, Oog Jin

2018-06-01

The purpose of this study is to compare the accuracy of the GNRB arthrometer (Genourob), Lachman test, and Telos device (GmbH) in acute anterior cruciate ligament (ACL) injuries and to evaluate the accuracy of each diagnostic tool according to the length of time from injury to examination. From September 2015 to September 2016, 40 cases of complete ACL rupture were reviewed. We divided the time from injury to examination into three periods of 10 days each and analyzed the diagnostic tools according to the time frame. An analysis of the area under the curve (AUC) of a receiver operating characteristic curve showed that all diagnostic tools were fairly informative. The GNRB showed a higher AUC than other diagnostic tools. In 10 cases assessed within 10 days after injury, the GNRB showed statistically significant side-to-side difference in laxity (p＜0.001), whereas the Telos test and Lachman test did not show significantly different laxity (p=0.541 and p=0.413, respectively). All diagnostic values of the GNRB were better than other diagnostic tools in acute ACL injuries. The GNRB was more effective in acute ACL injuries examined within 10 days of injury. The GNRB arthrometer can be a useful diagnostic tool for acute ACL injuries.

Hamstring strain - aftercare

MedlinePlus

Pulled hamstring muscle; Sprain - hamstring ... There are 3 levels of hamstring strains: Grade 1 -- mild muscle strain or pull Grade 2 -- partial muscle tear Grade 3 -- complete muscle tear Recovery time depends ...

Functional Brace in ACL Surgery: Force Quantification in an In Vivo Study

PubMed Central

LaPrade, Robert F.; Venderley, Melanie B.; Dahl, Kimi D.; Dornan, Grant J.; Turnbull, Travis Lee

2017-01-01

Background: A need exists for a functional anterior cruciate ligament (ACL) brace that dynamically supports the knee joint to match the angle-dependent forces of a native ACL, especially in the early postoperative period. Purpose/Hypothesis: The purpose of this study was to quantify the posteriorly directed external forces applied to the anterior proximal tibia by both a static and a dynamic force ACL brace. The proximal strap forces applied by the static force brace were hypothesized to remain relatively constant regardless of knee flexion angle compared with those of the dynamic force brace. Study Design: Controlled laboratory study. Methods: Seven healthy adult males (mean age, 27.4 ± 3.4 years; mean height, 1.8 ± 0.1 m; mean body mass, 84.1 ± 11.3 kg) were fitted with both a static and a dynamic force ACL brace. Participants completed 3 functional activities: unloaded extension, sit-to-stand, and stair ascent. Kinematic data were collected using traditional motion-capture techniques while posteriorly directed forces applied to the anterior aspect of both the proximal and distal tibia were simultaneously collected using a customized pressure-mapping technique. Results: The mean posteriorly directed forces applied to the proximal tibia at 30° of flexion by the dynamic force brace during unloaded extension (80.2 N), sit-to-stand (57.5 N), and stair ascent (56.3 N) activities were significantly larger, regardless of force setting, than those applied by the static force brace (10.1 N, 9.5 N, and 11.9 N, respectively; P < .001). Conclusion: The dynamic force ACL brace, compared with the static force brace, applied significantly larger posteriorly directed forces to the anterior proximal tibia in extension, where the ACL is known to experience larger in vivo forces. Further studies are required to determine whether the physiological behavior of the brace will reduce anterior knee laxity and improve long-term patient outcomes. Clinical Relevance: ACL braces that dynamically restrain the proximal tibia in a manner similar to physiological ACL function may improve pre- and postoperative treatment. PMID:28748195

Semi-automated detection of anterior cruciate ligament injury from MRI.

PubMed

Štajduhar, Ivan; Mamula, Mihaela; Miletić, Damir; Ünal, Gözde

2017-03-01

A radiologist's work in detecting various injuries or pathologies from radiological scans can be tiresome, time consuming and prone to errors. The field of computer-aided diagnosis aims to reduce these factors by introducing a level of automation in the process. In this paper, we deal with the problem of detecting the presence of anterior cruciate ligament (ACL) injury in a human knee. We examine the possibility of aiding the diagnosis process by building a decision-support model for detecting the presence of milder ACL injuries (not requiring operative treatment) and complete ACL ruptures (requiring operative treatment) from sagittal plane magnetic resonance (MR) volumes of human knees. Histogram of oriented gradient (HOG) descriptors and gist descriptors are extracted from manually selected rectangular regions of interest enveloping the wider cruciate ligament area. Performance of two machine-learning models is explored, coupled with both feature extraction methods: support vector machine (SVM) and random forests model. Model generalisation properties were determined by performing multiple iterations of stratified 10-fold cross validation whilst observing the area under the curve (AUC) score. Sagittal plane knee joint MR data was retrospectively gathered at the Clinical Hospital Centre Rijeka, Croatia, from 2007 until 2014. Type of ACL injury was established in a double-blind fashion by comparing the retrospectively set diagnosis against the prospective opinion of another radiologist. After clean up, the resulting dataset consisted of 917 usable labelled exam sequences of left or right knees. Experimental results suggest that a linear-kernel SVM learned from HOG descriptors has the best generalisation properties among the experimental models compared, having an area under the curve of 0.894 for the injury-detection problem and 0.943 for the complete-rupture-detection problem. Although the problem of performing semi-automated ACL-injury diagnosis by observing knee-joint MR volumes alone is a difficult one, experimental results suggest potential clinical application of computer-aided decision making, both for detecting milder injuries and detecting complete ruptures. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

A complete audit cycle of management of third/fourth degree perineal tears.

PubMed

Panigrahy, R; Welsh, J; MacKenzie, F; Owen, P

2008-04-01

We present a complete audit cycle of the management of third/fourth degree perineal tears in the three Glasgow maternity hospitals measured against the recommendations of the Royal College of Obstetricians and Gynaecologists (RCOG) Guideline No. 29 (www.rcog.org.uk). Following an initial 6-month data collection period, shortcomings in the practice were identified, circulated and an operative proforma was designed and introduced. A re-audit demonstrated improved compliance with the RCOG guidelines. We recommend the introduction of an operative proforma to aid management and documentation of third/fourth degree tear repairs.

The prevalence of proximal hamstring pathology on MRI in the asymptomatic population.

PubMed

Thompson, S M; Fung, S; Wood, D G

2017-01-01

Injury to the proximal hamstring complex (PHC) is becoming more frequently diagnosed. Patients attending our tertiary referral centre demonstrated 'pathological changes' in the unaffected normal contralateral PHC on MRI. The prevalence of PHC pathology, however, has not been previously documented in the literature in asymptomatic subjects. It is the hypothesis of this study that the natural history of asymptomatic pathological change on MRI in the PHC is not clear. The aim is to quantify the natural history of PHC degeneration. Two hundred and fifty-three consecutive patients with an asymptomatic PHC were reviewed retrospectively between 2009 and 2010. The PHC was assessed in multiple MRI planes by a specialist musculoskeletal consultant radiologist. Five hundred and six proximal hamstrings complexes were reviewed. Eighty-nine patients (35 %) were radiological normal both sides, median age 51 years (range 13-88). Thirty-four patients (13 %) had unilateral pathology, median age 55 years (range 25-89). Of these, 3 patients (1 %) had presence of a complete tear, median age 81 years (range 72-87). Sixteen patients (7 %) had tendinosis, median age 60 years (range 37-78). Fifteen patients (6 %) had a unilateral partial tear, median age 57 years (range 35-78). One hundred and thirty patients (52 %) had bilateral pathology, median age 65 years (range 25-89). Fifty-three patients (21 %) had the presence of bilateral tendinopathy alone, median age 56 years (range 25-89). Twenty-seven patients (11 %) had a partial tear on one side and tendinosis on the other, median age 68 years (range 38-89). Thirty-nine patients (15 %) had evidence of bilateral partial tears, median age 63 years (range 36-89), with 52 % demonstrating a torn conjoined and semi-membranosus tendon. The remaining 48 % had either an isolated tear of the conjoined or the semi-membranosus (the more commonly injured tendon 74 % of the time). Four patients (2 %) had bilateral complete ruptures with a median age of 68 years (range 59-78). Six patients (2 %) had a complete tear on one side and a partial tear on the other, median age 68 years (range 34-83). One patient had a complete tear on one side and tendinosis on the other, age 81 years. There is a higher prevalence of pathology in the asymptomatic population, 15 % have bilateral partial tears, and 2 % have bilateral complete tears. The semi-membranosus being the most affected, this may help clinically stratify the need for surgical intervention. I.

Clinical and Radiographic Outcomes of Meniscus Surgery and Future Targets for Biologic Intervention: A review of data from the MOON Group

PubMed Central

Westermann, Robert W.; Jones, Morgan; Wasserstein, David; Spindler, Kurt P.

2017-01-01

Meniscus injury and treatment occurred with the majority of anterior cruciate ligament reconstructions (ACLR) in the multicenter orthopaedic outcomes (MOON) cohort. We describe the patient reported outcomes, radiographic outcomes and predictors of pain from meniscus injuries and treatment in the setting of ACLR. Patient reported outcomes improve significantly following meniscus repair with ACLR, but differences exist based on the meniscus injury laterally (medial or lateral). Patients undergoing medial meniscus repair have worse patient-reported outcomes and more pain compared to those with uninjured menisci. However, lateral meniscal tears can be repaired with similar outcomes as uninjured menisci. Medial meniscal treatment (meniscectomy or repair) results in a significant loss of joint space at 2 years compared to uninjured menisci. Menisci treated with excision had a greater degree of joint space loss compared to those treated with repair. Clinically significant knee pain is more common following injuries to the medial meniscus and increased in patients who undergo early re-operation after initial ACLR. Future research efforts aimed at improving outcomes after combined ACLR and meniscus treatment should focus on optimizing biologic and mechanical environments that promote healing of medial meniscal tears sustained during ACL injury. PMID:28282214

Repair of a complete radial tear in the midbody of the medial meniscus using a novel crisscross suture transtibial tunnel surgical technique: a case report.

PubMed

James, Evan W; LaPrade, Christopher M; Feagin, John A; LaPrade, Robert F

2015-09-01

Complete radial meniscus tears have been reported to result in deleterious effects in the knee joint if left unrepaired. An emphasis on meniscal preservation is important in order to restore native meniscal function. In this case report, a complete radial tear of the medial meniscus midbody was repaired using a novel crisscross suture transtibial technique. This technique secured the anterior and posterior meniscal horns, which were released from their extruded and scarred position along the capsule, using crisscrossing sutures passed through two transtibial tunnels and secured over a bone bridge on the anterolateral tibia. In addition, the repair was supplemented with the injection of platelet-rich plasma and bone marrow aspirate concentrate to promote the healing of the meniscal tissue. Complete healing on second-look arthroscopy is presented, including in the previously unreported white-white meniscal zone.

Altered tibiofemoral contact mechanics due to lateral meniscus posterior horn root avulsions and radial tears can be restored with in situ pull-out suture repairs.

PubMed

LaPrade, Christopher M; Jansson, Kyle S; Dornan, Grant; Smith, Sean D; Wijdicks, Coen A; LaPrade, Robert F

2014-03-19

An avulsion of the posterior root attachment of the lateral meniscus or a radial tear close to the root attachment can lead to degenerative knee arthritis. Although the biomechanical effects of comparable injuries involving the medial meniscus have been studied, we are aware of no such study involving the lateral meniscus. We hypothesized that in situ pull-out suture repair of lateral meniscus root avulsions and of complete radial tears 3 and 6 mm from the root attachment would increase the contact area and decrease mean and peak tibiofemoral contact pressures, at all knee flexion angles, relative to the corresponding avulsion or tear condition. Eight human cadaveric knees underwent biomechanical testing. Eight lateral meniscus conditions (intact, footprint tear, root avulsion, root avulsion repair, radial tears at 3 and 6 mm from the posterior root, and repairs of the 3 and 6-mm tears) were tested at five different flexion angles (0°, 30°, 45°, 60°, and 90°) under a compressive 1000-N load. Avulsion of the posterior root of the lateral meniscus or an adjacent radial tear resulted in significantly decreased contact area and increased mean and peak contact pressures in the lateral compartment, relative to the intact condition, in all cases except the root avulsion condition at 0° of flexion. In situ pull-out suture repair of the root avulsion or radial tear significantly reduced mean contact pressures, relative to the corresponding avulsion or tear condition, when the results for each condition were pooled across all flexion angles. Posterior horn root avulsions and radial tears adjacent to the root attachment of the lateral meniscus significantly increased contact pressures in the lateral compartment. In situ pull-out suture repairs of these tears significantly improved lateral compartment joint contact pressures. In situ repair may be an effective treatment to improve tibiofemoral contact profiles after an avulsion of the posterior root of the lateral meniscus or a complete radial tear adjacent to the root. In situ repairs should be further investigated clinically as an alternative to partial lateral meniscectomy.

Long-term absorption of poly-L-lactic Acid interference screws.

PubMed

Barber, F Alan; Dockery, W Dee

2006-08-01

To evaluate the long term in vivo degradation of poly-L-lactic acid (PLLA) interference screws with computed tomography (CT) and radiography as used in patellar tendon autograft anterior cruciate ligament (ACL) reconstruction. A total of 20 patients who had undergone patellar tendon autograft ACL reconstruction fixed with PLLA screws at least 7 years earlier were evaluated by physical examination, radiography, and CT to determine whether PLLA screw reabsorption and bone ingrowth had occurred. This study was granted Institutional Review Board approval. Lysholm, Tegner, Cincinnati, and International Knee Documentation Committee (IKDC) scores were obtained. CT data were measured in Hounsfield units. In all, 15 men and 5 women were evaluated 104 months after surgery (range, 89 to 124 months). CT and radiography demonstrated that the bone plug had fused to the tunnel wall, and that no intact interference screw was left. A parallel, threaded, and corticated screw tract was visible adjacent to the bone plug. No bone ingrowth had occurred at the screw site, although, occasionally, minimal calcification was seen. This was never as dense as cancellous bone, and no trabeculae were ever present. No positive pivot-shift test results were obtained. Lysholm, Tegner, and Cincinnati scores were 83, 5.6, and 75, respectively, at follow-up. Average KT difference was 0.7 mm. PLLA interference screws completely degraded, and the resulting area demonstrated a low Hounsfield count, consistent with soft tissue 7 years after insertion. No significant bone ingrowth occurred at the screw site. Femoral and tibial ACL tunnels were absent of anything but fibrous tissue and usually had a sclerotic cortical lining. PLLA biodegradable ACL screws eventually disappear completely. PLLA material is not replaced by bone. ACL graft tunnels are filled with nonossified material. This study provides a baseline for comparison with other biodegradable interference screws that may encourage bone ingrowth as they degrade. Level IV (no or historical control).

A Comparison of the Self-Descriptions of High School Completion (GED) Dropouts and Persisters.

ERIC Educational Resources Information Center

Rolfe, Paula G.; Wilson, Russell C.

Differences in self-descriptive patterns of adults who dropped out of high school completion courses and those who completed their courses were examined using the Adjective Check List (ACL) to measure adult personality attributes. Subjects (N=142) were asked to endorse those adjectives which best described themselves and to skip those which did…

Independent Suture Tape Reinforcement of Small and Standard Diameter Grafts for Anterior Cruciate Ligament Reconstruction: A Biomechanical Full Construct Model.

PubMed

Bachmaier, Samuel; Smith, Patrick A; Bley, Jordan; Wijdicks, Coen A

2018-02-01

To compare the dynamic elongation, stiffness behavior, and ultimate failure load of standard with small diameter soft tissue grafts for anterior cruciate ligament (ACL) reconstruction with and without high-strength suture tape reinforcement. Both a tripled "small" diameter and a "standard" quadrupled tendon graft with and without suture tape reinforcement were tested using suspensory fixation (n = 8 each group). The suture tape was passed through the suspensory fixation button on the femur and tibia to ensure independent (safety belt) fixation from the graft in vitro. The testing of the constructs included position-controlled cyclic loading, force-controlled cyclic loading at 250 N and 400 N as well as pull to failure (50 mm/min). Reinforcement of a small diameter graft significantly reduced dynamic elongation of 38% (1.46 ± 0.28 mm vs 2.34 ± 0.44 mm, P < .001) and 50% (2.55 ± 0.44 mm vs 5.06 ± 0.67 mm, P < .001) after the 250 N and 400 N load protocol, respectively. Reinforcement of a standard diameter tendon graft decreased dynamic elongation of 15% (1.59 ± 0.34 mm vs 1.86 ± 0.17 mm, P = .066) and 26% (2.62 ± 0.44 mm vs 3.55 ± 0.44 mm, P < .001). No significant difference was found between both reinforced models. The ultimate failure loads of small and standard diameter reinforced grafts were 1592 ± 105 N and 1585 ± 265 N, resulting in a 64% (P < .001) and 40% (P < .001) increase compared with their respective controls. Independent suture tape reinforcement of soft tissue grafts for ACL reconstruction leads to significantly reduced elongation and higher ultimate failure load according to in vivo native ACL function data without stress-shielding the soft tissue graft. If in vitro results are translational to human knees in vivo, the suture tape reinforcement technique for ACL reconstruction may decrease the risk of graft tears, particularly in the case of small diameter soft tissue grafts. Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

A Review on Biomechanics of Anterior Cruciate Ligament and Materials for Reconstruction

PubMed Central

Marieswaran, M.; Jain, Ishita; Garg, Bhavuk; Sharma, Vijay

2018-01-01

The anterior cruciate ligament is one of the six ligaments in the human knee joint that provides stability during articulations. It is relatively prone to acute and chronic injuries as compared to other ligaments. Repair and self-healing of an injured anterior cruciate ligament are time-consuming processes. For personnel resuming an active sports life, surgical repair or replacement is essential. Untreated anterior cruciate ligament tear results frequently in osteoarthritis. Therefore, understanding of the biomechanics of injury and properties of the native ligament is crucial. An abridged summary of the prominent literature with a focus on key topics on kinematics and kinetics of the knee joint and various loads acting on the anterior cruciate ligament as a function of flexion angle is presented here with an emphasis on the gaps. Briefly, we also review mechanical characterization composition and anatomy of the anterior cruciate ligament as well as graft materials used for replacement/reconstruction surgeries. The key conclusions of this review are as follows: (a) the highest shear forces on the anterior cruciate ligament occur during hyperextension/low flexion angles of the knee joint; (b) the characterization of the anterior cruciate ligament at variable strain rates is critical to model a viscoelastic behavior; however, studies on human anterior cruciate ligament on variable strain rates are yet to be reported; (c) a significant disparity on maximum stress/strain pattern of the anterior cruciate ligament was observed in the earlier works; (d) nearly all synthetic grafts have been recalled from the market; and (e) bridge-enhanced repair developed by Murray is a promising technique for anterior cruciate ligament reconstruction, currently in clinical trials. It is important to note that full extension of the knee is not feasible in the case of most animals and hence the loading pattern of human ACL is different from animal models. Many of the published reviews on the ACL focus largely on animal ACL than human ACL. Further, this review article summarizes the issues with autografts and synthetic grafts used so far. Autografts (patellar tendon and hamstring tendon) remains the gold standard as nearly all synthetic grafts introduced for clinical use have been withdrawn from the market. The mechanical strength during the ligamentization of autografts is also highlighted in this work. PMID:29861784

Posttraumatic Bone Marrow Lesion Volume and Knee Pain Within 4 Weeks After Anterior Cruciate Ligament Injury

PubMed Central

Lohmander, Stefan; Frobell, Richard B.

2017-01-01

Context:  After an anterior cruciate ligament (ACL) injury, a majority of patients have a traumatic bone marrow lesion (BML, or bone bruise). The clinical relevance of posttraumatic lesions remains unclear. Objective:  To explore the cross-sectional associations between traumatic BML volume and self-reported knee pain and symptoms among individuals within 4 weeks of ACL injury. Design:  Cross-sectional exploratory analysis of a randomized clinical trial. Setting:  Orthopaedic departments at 2 hospitals in Sweden. Patients or Other Participants:  As part of a randomized trial (knee anterior cruciate ligament nonoperative versus operative treatment [KANON] study), 121 young active adults (74% men, age = 26 ± 5 years, height = 1.8 ± 0.1 m, weight = 76 ± 13 kg) with an ACL tear were studied. Main Outcome Measure(s):  The BML volume in the proximal tibia and distal femur was segmented using magnetic resonance images obtained within 4 weeks of injury. A radiologist evaluated the presence of depression fractures on the images. Pain and symptoms of the injured knee (Knee Injury and Osteoarthritis Outcome Score [KOOS] pain and symptoms subscales) were obtained the same day as imaging. We used linear regression models to assess the associations. Results:  Most knees had at least 1 BML (96%), and the majority (57%) had a depression fracture. Whole-knee BML volume was not related to knee pain for the entire cohort (β = −0.09, P = .25). Among those without a depression fracture, larger whole-knee BML volume was associated with increased knee pain (β = –0.46, P = .02), whereas no association was found for those with a depression fracture (β = 0.0, P = .96). Larger medial (β = –0.48, P = .02) but not lateral (β = –0.03, P = .77) tibiofemoral BML volume was associated with greater pain. We found no association between BML volume and knee symptoms. Conclusions:  We confirmed the absence of relationships between whole-knee BML volume and pain and symptoms within 4 weeks of ACL injury. Our findings extend previous reports in identifying weak associations between larger BML volume in the medial compartment and greater pain and between BML volume and greater pain among those without a depression fracture. PMID:28653872

Use of a Bioactive Scaffold to Stimulate ACL Healing Also Minimizes Post-traumatic Osteoarthritis after Surgery

PubMed Central

Murray, Martha M.; Fleming, Braden C.

2013-01-01

Background While ACL reconstruction is the treatment gold standard for ACL injury, it does not reduce the risk of post-traumatic osteoarthritis. Therefore, new treatments that minimize this postoperative complication are of interest. Bio-enhanced ACL repair, in which a bioactive scaffold is used to stimulate healing of an ACL transection, has shown considerable promise in short term studies. The long-term results of this technique and the effects of the bio-enhancement on the articular cartilage have not been previously evaluated in a large animal model. Hypothesis 1) The structural (tensile) properties of the porcine ACL at 6 and 12 months after injury are similar when treated with bio-enhanced ACL repair, bio-enhanced ACL reconstruction, or conventional ACL reconstruction, and all treatments yield results superior to untreated ACL transection. 2) After one year, macroscopic cartilage damage following bio-enhanced ACL repair is similar to bio-enhanced ACL reconstruction and less than conventional ACL reconstruction and untreated ACL transection. Study Design Controlled laboratory study (porcine model) Methods Sixty-two Yucatan mini-pigs underwent ACL transection and randomization to four experimental groups: 1) no treatment, 2) conventional ACL reconstruction, 3) “bio-enhanced” ACL reconstruction using a bioactive scaffold, and 4) “bio-enhanced” ACL repair using a bioactive scaffold. The biomechanical properties of the ligament or graft and macroscopic assessments of the cartilage surfaces were performed after 6 and 12 months of healing. Results The structural properties (i.e., linear stiffness, yield and maximum loads) of the ligament following bio-enhanced ACL repair were not significantly different from bio-enhanced ACL reconstruction or conventional ACL reconstruction, but were significantly greater than untreated ACL transection after 12 months of healing. Macroscopic cartilage damage after bio-enhanced ACL repair was significantly less than untreated ACL transection and bio-enhanced ACL reconstruction, and there was a strong trend (p=.068) that it was less than conventional ACL reconstruction in the porcine model at 12 months. Conclusions Bio-enhanced ACL repair produces a ligament that is biomechanically similar to an ACL graft and provides chondroprotection to the joint following ACL surgery. Clinical Relevance Bio-enhanced ACL repair may provide a new less invasive treatment option that reduces cartilage damage following joint injury. PMID:23857883

Descriptive Epidemiology of the Multicenter ACL Revision Study (MARS) Cohort

PubMed Central

2013-01-01

Background Revision anterior cruciate ligament (ACL) reconstruction has worse outcomes than primary reconstructions. Predictors for these worse outcomes are not known. The Multicenter ACL Revision Study (MARS) Group was developed to perform a multisurgeon, multicenter prospective longitudinal study to obtain sufficient subjects to allow multivariable analysis to determine predictors of clinical outcome. Purpose To describe the formation of MARS and provide descriptive analysis of patient demographics and clinical features for the initial 460 enrolled patients to date in this prospective cohort. Study Design Cross-sectional study; Level of evidence, 2. Methods After training and institutional review board approval, surgeons began enrolling patients undergoing revision ACL reconstruction, recording patient demographics, previous ACL reconstruction methods, intra-articular injuries, and current revision techniques. Enrolled subjects completed a questionnaire consisting of validated patient-based outcome measures. Results As of April 1, 2009, 87 surgeons have enrolled a total of 460 patients (57% men; median age, 26 years). For 89%, the reconstruction was the first revision. Mode of failure as deemed by the revising surgeon was traumatic (32%), technical (24%), biologic (7%), combination (37%), infection (<1%), and no response (<1%). Previous graft present at the time of injury was 70% autograft, 27% allograft, 2% combination, and 1% unknown. Sixty-two percent were more than 2 years removed from their last reconstruction. Graft choice for revision ACL reconstruction was 45% autograft, 54% allograft, and more than 1% both allograft and autograft. Meniscus and/or chondral damage was found in 90% of patients. Conclusion The MARS Group has been able to quickly accumulate the largest revision ACL reconstruction cohort reported to date. Traumatic reinjury is deemed by surgeons to be the most common single mode of failure, but a combination of factors represents the most common mode of failure. Allograft graft choice is more common in the revision setting than autograft. Concomitant knee injury is extremely common in this population. PMID:20889962

Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gross morphology and histology.

PubMed

Sánchez, Mikel; Anitua, Eduardo; Azofra, Juan; Prado, Roberto; Muruzabal, Francisco; Andia, Isabel

2010-04-01

To investigate whether the application of a particular platelet-rich plasma preparation rich in growth factors (PRGF) during anterior cruciate ligament (ACL) surgery gives a potential advantage for better tendon graft ligamentization. This study included 37 volunteers who underwent either conventional (control group, n = 15) or PRGF-assisted (n = 22) ACL reconstruction with an autogenous hamstring and required second-look arthroscopy to remove hardware or loose bodies, treat meniscal tears or plica syndrome, or resect cyclops lesions at 6 to 24 months after ACL surgery. The gross morphologies of the grafts were evaluated on second-look arthroscopy by use of the full arthroscopic score (0 to 4 points) to evaluate graft thickness and apparent tension (0 to 2 points) plus synovial coverage (0 to 2 points). At the same time, biopsy specimens were harvested uniformly from the grafted tendons. In these specimens the histologic transformation of the tendon graft to ACL-like tissue was evaluated by use of the Ligament Tissue Maturity Index, and a score to assess the progression of new connective tissue enveloping the graft was created by use of 3 criteria previously used to characterize changes during ligament healing: cellularity, vascularity, and collagen properties. The overall arthroscopic evaluation of PRGF-treated grafts showed an excellent rating in 57.1% of the knees (score of 4) and a fair rating in 42.9% (score of 2 or 3). In contrast, evaluation of untreated grafts showed an excellent rating in 33.3% of the knees, a fair rating in 46.7%, and a poor rating in 20% (score of 0 or 1). Overall, arthroscopic evaluations were not statistically different between PRGF and control groups (P = .051). PRGF treatment influenced the histologic characteristics of the tendon graft, resulting in tissue that was more mature than in controls (P = .024). Histologically evident newly formed connective tissue enveloping the graft was present in 77.3% of PRGF-treated grafts and 40% of controls. The appearance of the connective tissue envelope changed with increasing time from surgery. On the basis of the histologic findings, we suggest that the remodeling of PRGF-treated grafts involves the formation of synovial-like tissue enveloping the graft. This tissue is eventually integrated in the remodeled tendon graft, conferring a similar appearance to the normal ACL. The use of PRGF influenced the histologic characteristics of tendon grafts, resulting in more remodeling compared with untreated grafts. We have shown temporal histologic changes during the 6- to 24-month postoperative period of graft maturation, with newly formed connective tissue enveloping most grafts treated with PRGF. Level III, case-control study. Copyright 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Arthroscopic repair of partial-thickness and small full-thickness rotator cuff tears: tendon quality as a prognostic factor for repair integrity.

PubMed

Chung, Seok Won; Kim, Jae Yoon; Yoon, Jong Pil; Lyu, Seong Hwa; Rhee, Sung Min; Oh, Se Bong

2015-03-01

The healing failure rate is high for partial-thickness or small full-thickness rotator cuff tears. To retrospectively evaluate and compare outcomes after arthroscopic repair of high-grade partial-thickness and small full-thickness rotator cuff tears and factors affecting rotator cuff healing. Cohort study; Level of evidence, 3. Included in the study were 55 consecutive patients (mean age, 57.9 ± 7.2 years) who underwent arthroscopic repair for high-grade partial-thickness (n = 34) and small full-thickness (n = 21) rotator cuff tears. The study patients also underwent magnetic resonance imaging (MRI) preoperatively and computed tomography arthrography (CTA) at least 6 months postoperatively, and their functional outcomes were evaluated preoperatively and at the last follow-up (>24 months). All partial-thickness tears were repaired after being converted to full-thickness tears; thus, the repair process was almost the same as for small full-thickness tears. The tendinosis of the torn tendon was graded from the MRI images using a 4-point scale, and the reliabilities were assessed. The outcomes between high-grade partial-thickness tears that were converted to small full-thickness tears and initially small full-thickness tears were compared, and factors affecting outcomes were evaluated. The inter- and intraobserver reliabilities of the tendinosis grade were good (intraclass correlation coefficient, 0.706 and 0.777, respectively). Failure to heal as determined by CTA was observed in 12 patients with a high-grade partial-thickness tear (35.3%; complete failure in 4 and partial failure in 8) and in 3 patients with a small full-thickness tear (14.3%; complete failure in 1 and partial failure in 2). The patients with high-grade partial-thickness rotator cuff tears showed a higher tendinosis grade than did those with small full-thickness tears (P = .014), and the severity of the tendinosis was related to the failure to heal (P = .037). Tears with a higher tendinosis grade showed a 7.64-times higher failure rate (95% CI, 1.43-36.04) than did those with a lower tendinosis grade (P = .013). All functional outcome scores improved after surgery (all P < .001); however, there was no difference between groups. The high-grade partial-thickness rotator cuff tears showed more severe tendinosis compared with the small full-thickness tears in this study. Contrary to previous impressions that tear size or fatty infiltration is the factor that most influences healing, tendinosis severity assessed by preoperative MRI was the only factor associated with failure to heal, given the numbers available for analysis, in patients with partial-thickness and small full-thickness rotator cuff tears. Surgeons should pay more attention to tendon quality during repair surgery or rehabilitation in smaller rotator cuff tears, especially in high-grade partial-thickness tears with severe tendinosis. © 2014 The Author(s).

Knee function among elite handball and football players 1-6 years after anterior cruciate ligament injury.

PubMed

Myklebust, G; Bahr, R; Nilstad, A; Steffen, K

2017-05-01

The aim of the study was to describe objective and self-reported knee function for athletes who have returned to elite handball and football play after an ACL injury, comparing these to non-injured players at the same level. A total of 414 handball and 444 football players completed baseline tests from 2007 through 2014, examining lower extremity strength, dynamic balance, knee laxity, and knee function (KOOS questionnaire). Measures were compared between injured and non-injured legs and between injured legs and legs of controls. Eighty (9.3%) of the 858 players reported a previous ACL injury, 1-6 years post-injury (3.5±2.5 years), 49 handball (61.3%) and 31 football players (38.7%). We found no difference in strength or dynamic balance between previously ACL-injured (N=80) and non-injured players legs (N=1556). However, lower quadriceps (6.3%, 95% CI: 3.2-9.2) and hamstrings muscle strength (6.1%, 95% CI: 3.3-8.1) were observed in previously ACL-injured legs compared to the non-injured contralateral side (N=80). ACL-injured knees displayed greater joint laxity than the contralateral knee (N=80, 17%, 95% CI: 8-26) and healthy knees (N=1556, 23%, 95% CI: 14-33). KOOS scores were significantly lower for injured knees compared to knees of non-injured players. ACL-injured players who have successfully returned to elite sport have comparable strength and balance measures as their non-injured teammates. Subjective perception of knee function is strongly affected by injury history, with clinically relevant lower scores for the KOOS subscores Pain, Function, Sport, and Quality Of Life. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Modified arthroscopic suture fixation of a displaced tibial eminence fracture.

PubMed

Lehman, Ronald A; Murphy, Kevin P; Machen, M Shaun; Kuklo, Timothy R

2003-02-01

This study describes a new arthroscopic method using a whip-stitch technique for treating a displaced type III tibial eminence fracture. A 12-year-old girl who sustained a displaced type III tibial eminence fracture was treated with arthroscopic fixation using the Arthrosew disposable suture device (Surgical Dynamics, Norwalk, CT) to place a whip stitch into the anterior cruciate ligament (ACL). The Arthrex ACL guide (Arthrex, Naples, FL) was used to reduce the avulsed tibial spine fragment. Sutures were then passed through the tibial tunnel and secured over a bony bridge with the knee in 20 degrees of flexion. At 9 months, the patient has a full range of motion with normal Lachman and anterior drawer testing, and she has returned to competitive basketball. Radiographs show complete fracture healing. KT-1000 and isokinetic testing at 9-month follow-up show only minimal side-to-side differences. The Arthrosew device provides a significant advantage in the treatment of type III and IV fractures of the tibial eminence by obtaining arthroscopic fixation within the substance of the ACL, thus obviating arthrotomy and hardware placement. This technique also restores the proper length and tension to the ACL, and provides a simplified, reproducible method of treatment for this injury.

Warm and touching tears: tearful individuals are perceived as warmer because we assume they feel moved and touched.

PubMed

Zickfeld, Janis H; Schubert, Thomas W

2018-01-31

Recent work investigated the inter-individual functions of emotional tears in depth. In one study (Van de Ven, N., Meijs, M. H. J., & Vingerhoets, A. (2017). What emotional tears convey: Tearful individuals are seen as warmer, but also as less competent. British Journal of Social Psychology, 56(1), 146-160. Https://doi.org/10.1111/bjso.12162) tearful individuals were rated as warmer, and participants expressed more intentions to approach and help such individuals. Simultaneously, tearful individuals were rated as less competent, and participants expressed less intention to work with the depicted targets. While tearful individuals were perceived as sadder, perceived sadness mediated only the effect on competence, but not on warmth. We argue that tearful individuals might be perceived as warm because they are perceived as feeling moved and touched. We ran a pre-registered extended replication of Van de Ven et al. Results replicate the warmth and helping findings, but not the competence and work effects. The increase in warmth ratings was completely mediated by perceiving feeling moved and touched. Possible functions of feeling moved and touched with regard to emotional tears are discussed.

Goldmann tonometry tear film error and partial correction with a shaped applanation surface.

PubMed

McCafferty, Sean J; Enikov, Eniko T; Schwiegerling, Jim; Ashley, Sean M

2018-01-01

The aim of the study was to quantify the isolated tear film adhesion error in a Goldmann applanation tonometer (GAT) prism and in a correcting applanation tonometry surface (CATS) prism. The separation force of a tonometer prism adhered by a tear film to a simulated cornea was measured to quantify an isolated tear film adhesion force. Acrylic hemispheres (7.8 mm radius) used as corneas were lathed over the apical 3.06 mm diameter to simulate full applanation contact with the prism surface for both GAT and CATS prisms. Tear film separation measurements were completed with both an artificial tear and fluorescein solutions as a fluid bridge. The applanation mire thicknesses were measured and correlated with the tear film separation measurements. Human cadaver eyes were used to validate simulated cornea tear film separation measurement differences between the GAT and CATS prisms. The CATS prism tear film adhesion error (2.74±0.21 mmHg) was significantly less than the GAT prism (4.57±0.18 mmHg, p <0.001). Tear film adhesion error was independent of applanation mire thickness ( R 2 =0.09, p =0.04). Fluorescein produces more tear film error than artificial tears (+0.51±0.04 mmHg; p <0.001). Cadaver eye validation indicated the CATS prism's tear film adhesion error (1.40±0.51 mmHg) was significantly less than that of the GAT prism (3.30±0.38 mmHg; p =0.002). Measured GAT tear film adhesion error is more than previously predicted. A CATS prism significantly reduced tear film adhesion error bŷ41%. Fluorescein solution increases the tear film adhesion compared to artificial tears, while mire thickness has a negligible effect.

Injury patterns of the acromioclavicular ligament complex in acute acromioclavicular joint dislocations: a cross-sectional, fundamental study.

PubMed

Maier, Dirk; Jaeger, Martin; Reising, Kilian; Feucht, Matthias J; Südkamp, Norbert P; Izadpanah, Kaywan

2016-09-06

Horizontal instability impairs clinical outcome following acute acromioclavicular joint (ACJ) reconstruction and may be caused by insufficient healing of the superior acromioclavicular ligament complex (ACLC). However, characteristics of acute ACLC injuries are poorly understood so far. Purposes of this study were to identify different ACLC tear types, assess type-specific prevalence and determine influencing cofactors. This prospective, cross-sectional study comprised 65 patients with acute-traumatic Rockwood-5 (n = 57) and Rockwood-4 (n = 8) injuries treated operatively by means of mini-open ACJ reduction and hook plate stabilization. Mean age at surgery was 38.2 years (range, 19-57 years). Standardized pre- and intraoperative evaluation included assessment of ACLC tear patterns and cofactors related to the articular disc, the deltoid-trapezoidal (DT) fascia and bony ACJ morphology. Articular disc size was quantified as 0 = absent, 1 = remnant, 2 = meniscoid and 3 = complete. All patients showed complete ruptures of the superior ACLC, which could be assigned to four different tear patterns. Clavicular-sided (AC-1) tears were observed in 46/65 (70.8 %), oblique (AC-2) tears in 12/65 (18.5 %), midportion (AC-3) tears in 3/65 (4.6 %) and acromial-sided (AC-4) tears in 4/65 (6.1 %) of cases. Articular disc size manifestation was significantly (P < .001) more pronounced in patients with AC-1 tears (1.89 ± 0.57) compared to patients with AC-2 tears (0.67 ± 0.89). Other cofactors did not influence ACLC tear patterns. ACLC dislocation with incarceration caused mechanical impediment to anatomical ACJ reduction in 14/65 (21.5 %) of cases including all Rockwood-4 dislocations. Avulsion "in continuity" was a consistent mode of failure of the DT fascia. Type-specific operative strategies enabled anatomical ACLC repair of all observed tear types. Acute ACLC injuries follow distinct tear patterns. There exist clavicular-sided (AC-1), oblique (AC-2), midportion (AC-3) and acromial-sided (AC-4) tears. Articular disc size was a determinant factor of ACLC tear morphology. Mini-open surgery was required in Rockwood-4 and a relevant proportion of Rockwood-5 dislocations to achieve both anatomical ACLC and ACJ reduction. Type-specific operative repair of acute ACLC tears might promote biological healing and lower rates of horizontal ACJ instability following acute ACJ reconstruction.

Diagnostic accuracy of physical examination for anterior knee instability: a systematic review.

PubMed

Leblanc, Marie-Claude; Kowalczuk, Marcin; Andruszkiewicz, Nicole; Simunovic, Nicole; Farrokhyar, Forough; Turnbull, Travis Lee; Debski, Richard E; Ayeni, Olufemi R

2015-10-01

Determining diagnostic accuracy of Lachman, pivot shift and anterior drawer tests versus gold standard diagnosis (magnetic resonance imaging or arthroscopy) for anterior cruciate ligament (ACL) insufficiency cases. Secondarily, evaluating effects of: chronicity, partial rupture, awake versus anaesthetized evaluation. Searching MEDLINE, EMBASE and PubMed identified studies on diagnostic accuracy for ACL insufficiency. Studies identification and data extraction were performed in duplicate. Quality assessment used QUADAS tool, and statistical analyses were completed for pooled sensitivity and specificity. Eight studies were included. Given insufficient data, pooled analysis was only possible for sensitivity on Lachman and pivot shift test. During awake evaluation, sensitivity for the Lachman test was 89 % (95 % CI 0.76, 0.98) for all rupture types, 96 % (95 % CI 0.90, 1.00) for complete ruptures and 68 % (95 % CI 0.25, 0.98) for partial ruptures. For pivot shift in awake evaluation, results were 79 % (95 % CI 0.63, 0.91) for all rupture types, 86 % (95 % CI 0.68, 0.99) for complete ruptures and 67 % (95 % CI 0.47, 0.83) for partial ruptures. Decreased sensitivity of Lachman and pivot shift tests for partial rupture cases and for awake patients raised suspicions regarding the accuracy of these tests for diagnosis of ACL insufficiency. This may lead to further research aiming to improve the understanding of the true accuracy of these physical diagnostic tests and increase the reliability of clinical investigation for this pathology. IV.

Anatomical Individualized ACL Reconstruction.

PubMed

Rahnemai-Azar, Amir Ata; Sabzevari, Soheil; Irarrázaval, Sebastián; Chao, Tom; Fu, Freddie H

2016-10-01

The anterior cruciate ligament (ACL) is composed of two bundles, which work together to provide both antero-posterior and rotatory stability of the knee. Understanding the anatomy and function of the ACL plays a key role in management of patients with ACL injury. Anatomic ACL reconstruction aims to restore the function of the native ACL. Femoral and tibial tunnels should be placed in their anatomical location accounting for both the native ACL insertion site and bony landmarks. One main component of anatomical individualized ACL reconstruction is customizing the treatment according to each patient's individual characteristics, considering preoperative and intraoperative evaluation of the native ACL and knee bony anatomy. Anatomical individualized reconstruction surgery should also aim to restore the size of the native ACL insertion as well. Using this concept, while single bundle ACL reconstruction can restore the function of the ACL in some patients, double bundle reconstruction is indicated in others to achieve optimal outcome.

Touching the base: heart-warming ads from the 2016 U.S. election moved viewers to partisan tears.

PubMed

Seibt, Beate; Schubert, Thomas W; Zickfeld, Janis H; Fiske, Alan P

2018-03-07

Some political ads used in the 2016 U.S. election evoked feelings colloquially known as being moved to tears. We conceptualise this phenomenon as a positive social emotion that appraises and motivates communal relations, is accompanied by physical sensations (including lachrymation, piloerection, chest warmth), and often labelled metaphorically. We surveyed U.S. voters in the fortnight before the 2016 U.S. election. Selected ads evoked the emotion completely and reliably, but in a partisan fashion: Clinton voters were moved to tears by three selected Clinton ads, and Trump voters were moved to tears by two Trump ads. Viewers were much less moved by ads of the candidate they did not support. Being moved to tears predicted intention to vote for the candidate depicted. We conclude that some contemporary political advertising is able to move its audience to tears, and thereby motivates support.

Does the FIFA 11+ Injury Prevention Program Reduce the Incidence of ACL Injury in Male Soccer Players?

PubMed

Silvers-Granelli, Holly J; Bizzini, Mario; Arundale, Amelia; Mandelbaum, Bert R; Snyder-Mackler, Lynn

2017-10-01

The FIFA 11+ injury prevention program has been shown to decrease the risk of soccer injuries in men and women. The program has also been shown to decrease time loss resulting from injury. However, previous studies have not specifically investigated how the program might impact the rate of anterior cruciate ligament (ACL) injury in male soccer players. The purpose of this study was to examine if the FIFA 11+ injury prevention program can (1) reduce the overall number of ACL injuries in men who play competitive college soccer and whether any potential reduction in rate of ACL injuries differed based on (2) game versus practice setting; (3) player position; (4) level of play (Division I or II); or (5) field type. This study was a prospective cluster randomized controlled trial, which was conducted in 61 Division I and Division II National Collegiate Athletic Association men's soccer teams over the course of one competitive soccer season. The FIFA 11+ is a 15- to 20-minute on-the-field dynamic warm-up program used before training and games and was utilized as the intervention throughout the entire competitive season. Sixty-five teams were randomized: 34 to the control group (850 players) and 31 to the intervention group (675 players). Four intervention teams did not complete the study and did not submit their data, noting insufficient time to complete the program, reducing the number for per-protocol analysis to 61. Compliance to the FIFA 11+ program, athletic exposures, specific injuries, ACL injuries, and time loss resulting from injury were collected and recorded using a secure Internet-based system. At the end of the season, the data in the injury surveillance system were crosshatched with each individual institution's internal database. At that time, the certified athletic trainer signed off on the injury collection data to confirm their accuracy and completeness. A lower proportion of athletes in the intervention group experienced knee injuries (25% [34 of 136]) compared with the control group (75% [102 of 136]; relative risk [RR], 0.42; 95% confidence interval [CI], 0.29-0.61; p < 0.001). When the data were stratified for ACL injury, fewer ACL injuries were reported in the intervention group (16% [three of 19]) compared with the control group (84% [16 of 19]), accounting for a 4.25-fold reduction in the likelihood of incurring ACL injury (RR, 0.236; 95% CI, 0.193-0.93; number needed to treat = 70; p < 0.001). With the numbers available, there was no difference between the ACL injury rate within the FIFA 11+ group and the control group with respect to game and practice sessions (games-intervention: 1.055% [three of 15] versus control: 1.80% [12 of 15]; RR, 0.31; 95% CI, 0.09-1.11; p = 0.073 and practices-intervention: 0% [zero of four] versus control: 0.60% [four of four]; RR, 0.14; 95% CI, 0.01-2.59; p = 0.186). With the data that were available, there were no differences in incidence rate (IR) or injury by player position for forwards (IR control = 0.339 versus IR intervention = 0), midfielders (IR control = 0.54 versus IR intervention = 0.227), defenders (IR control = 0.339 versus IR intervention = 0.085), and goalkeepers (IR control = 0.0 versus IR intervention = 0.0) (p = 0.327). There were no differences in the number of ACL injuries for the Division I intervention group (0.70% [two of nine]) compared with the control group (1.05% [seven of nine]; RR, 0.30; CI, 0.06-1.45; p = 0.136). However, there were fewer ACL injuries incurred in the Division II intervention group (0.35% [one of 10]) compared with the control group (1.35% [nine of 10]; RR, 0.12; CI, 0.02-0.93; p = 0.042). There was no difference between the number of ACL injuries in the control group versus in the intervention group that occurred on grass versus turf (Wald chi square [1] = 0.473, b = 0.147, SE = 0.21, p = 0.492). However, there were more ACL injuries that occurred on artificial turf identified in the control group (1.35% [nine of 10]) versus the intervention group (0.35% [one of 10]; RR, 0.14; 95% CI, 0.02-1.10; p = 0.049). This program, if implemented correctly, has the potential to decrease the rate of ACL injury in competitive soccer players. In addition, this may also enhance the development and dissemination of injury prevention protocols and may mitigate risk to athletes who utilize the program consistently. Further studies are necessary to analyze the cost-effectiveness of the program implementation and to analyze the efficacy of the FIFA 11+ in the female collegiate soccer cohort. Level I, therapeutic study.

Distal Triceps Tendon Injuries.

PubMed

Keener, Jay D; Sethi, Paul M

2015-11-01

Acute triceps ruptures are an uncommon entity, occurring mainly in athletes, weight lifters (especially those taking anabolic steroids), and following elbow trauma. Accurate diagnosis is made clinically, although MRI may aid in confirmation and surgical planning. Acute ruptures are classified on an anatomic basis based on tear location and the degree of tendon involvement. Most complete tears are treated surgically in medically fit patients. Partial-thickness tears are managed according to the tear severity, functional demands, and response to conservative treatment. We favor an anatomic footprint repair of the triceps to provide optimal tendon to bone healing and, ultimately, functional outcome. Copyright © 2015 Elsevier Inc. All rights reserved.

Anterior cruciate ligament injury: A persistently difficult diagnosis.

PubMed

Parwaiz, Hammad; Teo, Alex Q A; Servant, Christopher

2016-01-01

Historically anterior cruciate ligament (ACL) injuries have been diagnosed poorly. A paper published in Injury in 1996 showed that less than 10% of patients with an ACL injury had the diagnosis made by the first physician to see them and that the average delay from first presentation to diagnosis was 21 months. The aim of our study was to investigate whether an improvement has been made over the last two decades in diagnosing ACL injuries. We identified 160 patients who had an ACL reconstruction performed by a single surgeon between October 2004 and December 2011 and for whom a complete data set was available. Data was extracted retrospectively from the hospital notes and a dedicated patient database. We performed a sub-group analysis comparing patients seen prior to the introduction of an acute knee injury clinic in April 2007 and patients seen after the introduction of the clinic. 75.1% (120/160) of patients presented first to an emergency department (ED) or to their general practitioner (GP), but only 14.4% (23/160) were diagnosed on initial presentation. The median number of healthcare professionals a patient saw prior to a diagnosis of ACL injury was 3. The median delay from injury to presentation was 0 weeks (range 0-885), injury to diagnosis 13 weeks (0-926), presentation to diagnosis 10 weeks (0-924), presentation to a specialist knee clinic 24 weeks (0-1006), and specialist knee clinic to surgery 13 weeks (0-102). The median total time from injury to surgery was 42 weeks (0-1047). Following the implementation of an acute knee injury clinic in 2007, the median delay from presentation to surgery dropped from 59 weeks to 36 weeks (p = 0.050) and there was a significant decrease in the median delay from specialist knee clinic to surgery from 23 to 11 weeks (p=0.002). Over the past two decades there appears to have been little improvement in the early diagnosis of ACL injuries, with only 14.4% of patients being diagnosed correctly at initial presentation. We recommend further education of emergency and primary care clinicians in the diagnosis of ACL injuries, emphasising the importance of the typical history of an ACL injury. The implementation of an acute knee injury clinic may help minimise delays to surgery, which should result in better patient outcomes. Copyright © 2015 Elsevier B.V. All rights reserved.

Three-dimensional Magnetic Resonance Imaging of the Anterolateral Ligament of the Knee: An Evaluation of Intact and Anterior Cruciate Ligament-Deficient Knees From the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group.

PubMed

Muramatsu, Koichi; Saithna, Adnan; Watanabe, Hiroki; Sasaki, Kana; Yokosawa, Kenta; Hachiya, Yudo; Banno, Tatsuo; Helito, Camilo Partezani; Sonnery-Cottet, Bertrand

2018-05-02

To determine the visualization rate of the anterolateral ligament (ALL) in uninjured and anterior cruciate ligament (ACL)-deficient knees using 3-dimensional (3D) magnetic resonance imaging (MRI) and to characterize the spectrum of ALL injury observed in ACL-deficient knees, as well as determine the interobserver and intraobserver reliability of a 3D MRI classification of ALL injury. A total of 100 knees (60 ACL deficient and 40 uninjured) underwent 3D MRI. The ALL was evaluated by 2 blinded orthopaedic surgeons. The ALL was classified as follows: type A, continuous, clearly defined low-signal band; type B, warping, thinning, or iso-signal changes; and type C, without clear continuity. The comparison between imaging performed early after ACL injury (<1 month) and delayed imaging (>1 month) was evaluated, as was intraobserver and interobserver reliability. Complete visualization of the ALL was achieved in all uninjured knees. In the ACL-deficient group, 24 knees underwent early imaging, with 87.5% showing evidence of ALL injury (3 normal, or type A, knees [12.5%], 18 type B [75.0%], and 3 type C [12.5%]). The remaining 36 knees underwent delayed imaging, with 55.6% showing evidence of injury (16 type A [44.4%], 18 type B [50.0%], and 2 type C [5.6%]). The difference in the rate of injury between the 2 groups was significant (P = .03). Multivariate analysis showed that the delay from ACL injury to MRI was the only factor (negatively) associated with the rate of injury to the ALL. Interobserver reliability and intraobserver reliability of the classification of ALL type were good (κ = 0.86 and κ = 0.93, respectively). Three-dimensional MRI allows full visualization of the ALL in all normal knees. The rate of injury to the ALL in acutely ACL-injured knees identified on 3D MRI is higher than previous reports using standard MRI techniques. This rate is significantly higher than the rate of injury to the ALL identified on delayed imaging of ACL-injured knees. Level IV, diagnostic, case-control study. Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Multi-rater Agreement in the Assessment of Anterior Cruciate Ligament Reconstruction Failure. A Radiographic and Video Analysis of the MARS Cohort

PubMed Central

Matava, Matthew J.; Arciero, Robert A.; Baumgarten, Keith M.; Carey, James L.; DeBerardino, Thomas M.; Hame, Sharon L.; Hannafin, Jo A.; Miller, Bruce S.; Nissen, Carl W.; Taft, Timothy N.; Wolf, Brian R.; Wright, Rick W.

2015-01-01

Background ACL reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. There is limited data regarding the agreement among orthopedic surgeons in terms of the etiology of primary ACL reconstruction failure and accuracy of graft tunnel placement. Purpose The purpose of this study is to test the hypothesis that experienced knee surgeons have a high level of inter-observer reliability in the agreement of the etiology of the primary ACL reconstruction failure, anatomical graft characteristics, tunnel placement. Methods Twenty cases of revision ACL reconstruction were randomly selected from the MARS database. Each case included the patient's history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. 10 MARS surgeons not involved with the primary surgery reviewed all 20 cases. Each surgeon completed a two-part questionnaire dealing with each surgeon's training and practice as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon's opinion as to the etiology of graft failure. Inter-rater agreement was determined for each question. Inter-rater agreement was determined for each question with the kappa coefficient and prevalence adjusted bias adjusted kappa (PABAK). Results The 10 reviewers were in practice an average of 14 years. All performed at least 25 ACL reconstructions per year and 9 were fellowship-trained in sports medicine. There was wide variability in agreement among knee experts as to the specific etiology of ACL graft failure. When specifically asked about technical error as the cause for failure, inter-observer agreement was only slight (prevalence adjusted bias adjusted kappa [PABAK]: 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK: 0.55), but only slight agreement whether a femoral tunnel was too anterior (PABAK: 0.24) and fair agreement whether it was too vertical (PABAK: 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK: 0.17). Conclusion This study suggests that more objective criteria are needed to accurately determine the etiology of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction. PMID:25537942

Curve analyses reveal altered knee, hip, and trunk kinematics during drop-jumps long after anterior cruciate ligament rupture.

PubMed

Hébert-Losier, Kim; Schelin, Lina; Tengman, Eva; Strong, Andrew; Häger, Charlotte K

2018-03-01

Anterior cruciate ligament (ACL) ruptures may lead to knee dysfunctions later in life. Single-leg tasks are often evaluated, but bilateral movements may also be compromised. Our aim was to use curve analyses to examine double-leg drop-jump kinematics in ACL-reconstructed, ACL-deficient, and healthy-knee cohorts. Subjects with unilateral ACL ruptures treated more than two decades ago (17-28years) conservatively with physiotherapy (ACL PT , n=26) or in combination with reconstructive surgery (ACL R , n=28) and healthy-knee controls (n=25) performed 40-cm drop-jumps. Three-dimensional knee, hip, and trunk kinematics were analyzed during Rebound, Flight, and Landing phases. Curves were time-normalized and compared between groups (injured and non-injured legs of ACL PT and ACL R vs. non-dominant and dominant legs of controls) and within groups (between legs) using functional analysis of variance methods. Compared to controls, ACL groups exhibited less knee and hip flexion on both legs during Rebound and greater knee external rotation on their injured leg at the start of Rebound and Landing. ACL R also showed less trunk flexion during Rebound. Between-leg differences were observed in ACL R only, with the injured leg more internally rotated at the hip. Overall, kinematic curves were similar between ACL R and ACL PT . However, compared to controls, deviations spanned a greater proportion of the drop-jump movement at the hip in ACL R and at the knee in ACL PT . Trunk and bilateral leg kinematics during double-leg drop-jumps are still compromised long after ACL-rupture care, independent of treatment. Curve analyses indicate the presence of distinct compensatory mechanisms in ACL PT and ACL R compared to controls. Copyright © 2018 Elsevier B.V. All rights reserved.

A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury.

PubMed

Eitzen, Ingrid; Moksnes, Håvard; Snyder-Mackler, Lynn; Risberg, May Arna

2010-11-01

Prospective cohort study without a control group. Firstly, to present our 5-week progressive exercise therapy program in the early stage after anterior cruciate ligament (ACL) injury. Secondly, to evaluate changes in knee function after completion of the program for patients with ACL injury in general and also when classified as potential copers or noncopers, and, finally, to examine potential adverse events. Few studies concerning early-stage ACL rehabilitation protocols exist. Consequently, little is known about the tolerance for, and outcomes from, short-term exercise therapy programs in the early stage after injury. One-hundred patients were included in a 5-week progressive exercise therapy program, within 3 months after injury. Knee function before and after completion of the program was evaluated from isokinetic quadriceps and hamstrings muscle strength tests, 4 single-leg hop tests, 2 different self-assessment questionnaires, and a global rating of knee function. A 2-way mixed-model analysis of variance was conducted to evaluate changes from pretest to posttest for the limb symmetry index for muscle strength and single-leg hop tests, and the change in scores for the patient-reported questionnaires. In addition, absolute values and the standardized response mean for muscle strength and single-leg hop tests were calculated at pretest and posttest for the injured and uninjured limb. Adverse events during the 5-week period were recorded. The progressive 5-week exercise therapy program led to significant improvements (P<.05) in knee function from pretest to posttest both for patients classified as potential copers and noncopers. Standardized response mean values for changes in muscle strength and single-leg hop performance from pretest to posttest for the injured limb were moderate to strong (0.49-0.84), indicating the observed improvements to be clinically relevant. Adverse events occurred in 3.9% of the patients. Short-term progressive exercise therapy programs are well tolerated and should be incorporated in early-stage ACL rehabilitation, either to improve knee function before ACL reconstruction or as a first step in further nonoperative management. Therapy, level 2b.

Kinematics of anterior cruciate ligament-deficient knees in a Chinese population during stair ascent.

PubMed

Zhao, Chang; Lin, Chuangxin; Wang, Wenhao; Zeng, Chun; Fang, Hang; Pan, Jianying; Cai, Daozhang

2016-08-08

The purpose of this study was to measure the tibiofemoral kinematics of anterior cruciate ligament (ACL) deficiency in a Chinese population and compare the kinematics with published data about a Caucasian population. Unilateral knees of 18 Chinese ACL-deficient (ACL-D) subjects were studied while subjects ascended stairs. Kinematic alteration was compared between ACL-D knees and contralateral ACL-intact (ACL-I) knees. The kinematic alteration of ACL deficiency was also compared between the Chinese population and published data about a Caucasian population. A statistical difference was found in the three-dimensional rotations between ACL-D and ACL-I knees. In the sagittal plane, ACL-I knees had a larger flexion angle than ACL-D knees during 40 to 50 % of the activity during stair ascent (P < 0.027) and throughout the gait cycle. A significant difference in rotational motion between ACL-D and ACL-I knees was also observed in the frontal plane during 40 to 60 % (P < 0.017) of the activity and in the transverse plane during 70 to 80 % (P < 0.028) of the activity. A greater tibial varus was demonstrated in the Chinese population while the published data revealed external tibial rotation and a statistical difference in translation in the Caucasian population. ACL-D knees show different kinematics than ACL-I knees in the Chinese population. ACL-I knees had a larger flexion angle than ACL-D knees in the middle stage of the activity during stair ascent. A significant difference in rotational motion between ACL-D and ACL-I knees was also observed in the frontal plane during the middle phase and in the transverse plane during the terminal phase of the activity. A greater tibial varus was demonstrated in the Caucasian population while the published data revealed external tibial rotation and a statistical difference in translation in the Caucasian population.

Cell-based and biomaterial approaches to connective tissue repair

NASA Astrophysics Data System (ADS)

Stalling, Simone Suzette

Connective tissue injuries of skin, tendon and ligament, heal by a reparative process in adults, filling the wound site with fibrotic, disorganized scar tissue that poorly reflects normal tissue architecture or function. Conversely, fetal skin and tendon have been shown to heal scarlessly. Complete regeneration is not intrinsically ubiquitous to all fetal tissues; fetal diaphragmatic and gastrointestinal injuries form scars. In vivo studies suggest that the presence of fetal fibroblasts is essential for scarless healing. In the orthopaedic setting, adult anterior cruciate ligament (ACL) heals poorly; however, little is known about the regenerative capacity of fetal ACL or fetal ACL fibroblasts. We characterized in vitro wound healing properties of fetal and adult ACL fibroblasts demonstrating that fetal ACL fibroblasts migrate faster and elaborate greater quantities of type I collagen, suggesting the healing potential of the fetal ACL may not be intrinsically poor. Similar to fetal ACL fibroblasts, fetal dermal fibroblasts also exhibit robust cellular properties. We investigated the age-dependent effects of dermal fibroblasts on tendon-to-bone healing in rat supraspinatus tendon injuries, a reparative injury model. We hypothesized delivery of fetal dermal fibroblasts would increase tissue organization and mechanical properties in comparison to adult dermal fibroblasts. However, at 1 and 8 weeks, the presence of dermal fibroblasts, either adult or fetal, had no significant effect on tissue histology or mechanical properties. There was a decreasing trend in cross-sectional area of repaired tendons treated with fetal dermal fibroblasts in comparison to adult, but this finding was not significant in comparison to controls. Finally, we synthesized a novel polysaccharide, methacrylated methylcellulose (MA-MC), and fabricated hydrogels using a well-established photopolymerization technique. We characterized the physical and mechanical properties of MA-MC hydrogels in vitro as well as in a subcutaneous mouse model. Stable MA-MC hydrogels, of varying weight percentages, demonstrated tunable swelling and mechanical properties in the absence of cytotoxic degradation products. In vivo, 6wt% MA-MC hydrogels maintained their shape and mechanical integrity while eliciting a minimal inflammatory response; highly desirable properties for soft tissue reconstruction. These cellulose-based photopolymerizable hydrogels can be further optimized for drug delivery and tissue engineering applications to enhance wound repair.

Quadriceps Muscle Function After Rehabilitation With Cryotherapy in Patients With Anterior Cruciate Ligament Reconstruction

PubMed Central

Hart, Joseph M.; Kuenze, Christopher M.; Diduch, David R.; Ingersoll, Christopher D.

2014-01-01

Context: Persistent muscle weakness after anterior cruciate ligament (ACL) reconstruction may be due to underlying activation failure and arthrogenic muscle inhibition (AMI). Knee-joint cryotherapy has been shown to improve quadriceps function transiently in those with AMI, thereby providing an opportunity to improve quadriceps muscle activation and strength in patients with a reconstructed ACL. Objective: To compare quadriceps muscle function in patients with a reconstructed ACL who completed a 2-week intervention including daily cryotherapy (ice bag), daily exercises, or both. Design: Cross-sectional study. Setting: Laboratory. Patients or Other Participants: A total of 30 patients with reconstructed ACLs who were at least 6 months post-index surgery and had measurable quadriceps AMI. Intervention(s): The patients attended 4 supervised visits over a 2-week period. They were randomly assigned to receive 20 minutes of knee-joint cryotherapy, 1 hour of therapeutic rehabilitation exercises, or cryotherapy followed by exercises. Main Outcome Measure(s): We measured quadriceps Hoffmann reflex, normalized maximal voluntary isometric contraction torque, central activation ratio using the superimposed-burst technique, and patient-reported outcomes before and after the intervention period. Results: After the 2-week intervention period, patients who performed rehabilitation exercises immediately after cryotherapy had higher normalized maximal voluntary isometric contraction torques (P = .002, Cohen d effect size = 1.4) compared with those who received cryotherapy alone (P = .16, d = 0.58) or performed exercise alone (P = .16, d = 0.30). Conclusions: After ACL reconstruction, patients with AMI who performed rehabilitation exercises immediately after cryotherapy experienced greater strength gains than those who performed cryotherapy or exercises alone. PMID:25299442

Effect of radial meniscal tear on in situ forces of meniscus and tibiofemoral relationship.

PubMed

Tachibana, Yuta; Mae, Tatsuo; Fujie, Hiromichi; Shino, Konsei; Ohori, Tomoki; Yoshikawa, Hideki; Nakata, Ken

2017-02-01

To clarify the effect of the radial tear of the lateral meniscus on the in situ meniscus force and the tibiofemoral relationship under axial loads and valgus torques. Ten intact porcine knees were settled to a 6-degree of freedom robotic system, while the force and 3-dimensional path of the knees were recorded via Universal Force Sensor (UFS) during 3 cycles of 250-N axial load and 5-Nm valgus torque at 15°, 30°, 45°, and 60° of knee flexion. The same examination was performed on the following 3 meniscal states sequentially; 33, 66, and 100% width of radial tears at the middle segment of the lateral meniscus, while recording the force and path of the knees via UFS. Finally, all paths were reproduced after total lateral meniscectomy and the in situ force of the lateral meniscus were calculated with the principle of superposition. The radial tear of 100% width significantly decreased the in situ force of the lateral meniscus and caused tibial medial shift and valgus rotation at 30°-60° of knee flexion in both testing protocols. Under a 250-N axial load at 60° of knee flexion, the in situ force decreased to 36 ± 29 N with 100% width of radial tear, which was 122 ± 38 N in the intact state. Additionally, the tibia shifted medially by 2.1 ± 0.9 mm and valgusrotated by 2.5 ± 1.9° with the complete radial tear. However, the radial tear of 33 or 66% width had little effect on either the in situ force or the tibial position. A radial tear of 100% width involving the rim significantly decreased the in situ force of the lateral meniscus and caused medial shift and valgus rotation of the tibia, whereas a radial tear of up to 66% width produced only little change. The clinical relevance is that loss of meniscal functions due to complete radial tear can lead to abnormal stress concentration in a focal area of cartilage and can increase the risk of osteoarthritis in the future.

Biomechanical Outcomes After Bio-enhanced Anterior Cruciate Ligament Repair and Anterior Cruciate Ligament Reconstruction Are Equal in a Porcine Model

PubMed Central

Vavken, Patrick; Fleming, Braden C.; Mastrangelo, Ashley N.; Machan, Jason T.; Murray, Martha M.

2011-01-01

Purpose The objective of this study was to compare the biomechanical outcomes of a new method of anterior cruciate ligament (ACL) treatment, bio-enhanced ACL repair, with ACL reconstruction in a large animal model. Methods Twenty-four skeletally immature pigs underwent unilateral ACL transection and were randomly allocated to receive bio-enhanced ACL repair with a collagen-platelet composite, allograft (bone–patellar tendon– bone) reconstruction, or no further treatment (n = 8 for each group). The structural properties and anteroposterior laxity of the experimental and contralateral ACL-intact knees were measured 15 weeks postoperatively. All dependent variables were normalized to those of the contralateral knee and compared by use of generalized linear mixed models. Results After 15 weeks, bio-enhanced ACL repair and ACL reconstruction produced superior biomechanical outcomes to ACL transection. However, there were no significant differences between bio-enhanced ACL repair and ACL reconstruction for maximum load (P = .4745), maximum displacement (P = .4217), or linear stiffness (P = .6327). There were no significant differences between the 2 surgical techniques in anteroposterior laxity at 30° (P = .7947), 60° (P = .6270), or 90° (P = .9008). Conclusions Bio-enhanced ACL repair produced biomechanical results that were not different from ACL reconstruction in a skeletally immature, large animal model, although the variability associated with both procedures was large. Both procedures produced significantly improved results over ACL transection, showing that both were effective in this model. Clinical Relevance Bio-enhanced ACL repair may 1 day provide an alternative treatment option for ACL injury. PMID:22261137

Implant preloading in extension reduces spring length change in dynamic intraligamentary stabilization: a biomechanical study on passive kinematics of the knee.

PubMed

Häberli, Janosch; Voumard, Benjamin; Kösters, Clemens; Delfosse, Daniel; Henle, Philipp; Eggli, Stefan; Zysset, Philippe

2018-06-01

Dynamic intraligamentary stabilization (DIS) is a primary repair technique for acute anterior cruciate ligament (ACL) tears. For internal bracing of the sutured ACL, a metal spring with 8 mm maximum length change is preloaded with 60-80 N and fixed to a high-strength polyethylene braid. The bulky tibial hardware results in bone loss and may cause local discomfort with the necessity of hardware removal. The technique has been previously investigated biomechanically; however, the amount of spring shortening during movement of the knee joint is unknown. Spring shortening is a crucial measure, because it defines the necessary dimensions of the spring and, therefore, the overall size of the implant. Seven Thiel-fixated human cadaveric knee joints were subjected to passive range of motion (flexion/extension, internal/external rotation in 90° flexion, and varus/valgus stress in 0° and 20° flexion) and stability tests (Lachman/KT-1000 testing in 0°, 15°, 30°, 60°, and 90° flexion) in the ACL-intact, ACL-transected, and DIS-repaired state. Kinematic data of femur, tibia, and implant spring were recorded with an optical measurement system (Optotrak) and the positions of the bone tunnels were assessed by computed tomography. Length change of bone tunnel distance as a surrogate for spring shortening was then computed from kinematic data. Tunnel positioning in a circular zone with r = 5 mm was simulated to account for surgical precision and its influence on length change was assessed. Over all range of motion and stability tests, spring shortening was highest (5.0 ± 0.2 mm) during varus stress in 0° knee flexion. During flexion/extension, spring shortening was always highest in full extension (3.8 ± 0.3 mm) for all specimens and all simulations of bone tunnels. Tunnel distance shortening was highest (0.15 mm/°) for posterior femoral and posterior tibial tunnel positioning and lowest (0.03 mm/°) for anterior femoral and anterior tibial tunnel positioning. During passive flexion/extension, the highest spring shortening was consistently measured in full extension with a continuous decrease towards flexion. If preloading of the spring is performed in extension, the spring can be downsized to incorporate a maximum length change of 5 mm resulting in a smaller implant with less bone sacrifice and, therefore, improved conditions in case of revision surgery.

Soft tissue graft interference fit fixation: observations on graft insertion site healing and tunnel remodeling 2 years after ACL reconstruction in sheep.

PubMed

Hunt, Patrick; Rehm, Oliver; Weiler, Andreas

2006-12-01

Using soft tissue grafts for anterior cruciate ligament (ACL) reconstruction, insertion site healing plays a crucial role in the long-term fate of the graft. It has been shown in an experimental animal study that using a soft tissue graft and anatomic graft fixation, a direct ligamentous insertion alike the native ACL developed 24 weeks postoperatively. Yet there are no reports on the long-term insertion site healing of anatomically fixed soft tissue grafts. The objective of this study was to evaluate graft insertion site healing, the intra-tunnel fate of the graft and its osseous replacement 2 years after ACL reconstruction in sheep. The left ACLs of six sheep were replaced by an autologous flexor tendon split graft and anatomically fixed with biodegradable poly-(D, L-lactide) interference screws. Animals received polychromic sequential labeling at different points in time to determine bone apposition per period. For evaluation of the insertion site healing and intra-tunnel changes, MRI scans were taken in vivo. Following sacrifice, radiographic imaging, conventional histology and fluorescence microscopy was undertaken. Most of the specimens showed a wide direct ligamentous insertion. It showed patterns alike the direct ligament insertion seen in intact ACLs. The intra-tunnel part of the graft had completely lost its tendon-like structure and in two cases, it was separated from the graft insertion by a thick bony layer. The biodegradable interference screw was fully degraded in all specimens. Ossification of the former drill tunnels was intense, showing only partial-length tunnel remnants in one femoral and three tibial specimens. As the graft heals to the joint surface and the aperture site is closed with soft tissue, mechanical stress of the intra-tunnel part of the graft is eliminated and the bone tunnel is protected from synovial fluid, resulting in osseous bridging of the tunnel aperture site, accelerated intra-tunnel graft resorption and its osseous replacement.

Comparison of Bioabsorbable Interference Screws Composed of Poly-l-lactic Acid and Hydroxyapatite (PLLA-HA) to WasherLoc Tibial Fixation in Patients After Anterior Cruciate Ligament Reconstruction of the Knee Joint.

PubMed

Patkowski, Mateusz; Królikowska, Aleksandra; Reichert, Paweł

2016-01-01

The reconstruction of the anterior cruciate ligament (ACL) of the knee joint is a standard in ACL complete rupture treatment in athletes. One of the weakest points of this procedure is tibial fixation of grafts. The aim was, firstly, to evaluate patients 3-4 years after primary ACL reconstruction with the use of autologous ipsilateral STGR grafts and with tibial fixation using a bioabsorbable interference screw composed of PLLA-HA or WasherLoc, comparing the postoperative result to the preoperative condition and, secondly, to compare the results between the two groups of patients with different tibial fixation. Group I consisted of 20 patients with a bioabsorbable interference screw composed of PLLA-HA tibial fixation. In Group II, there were 22 patients after ACL reconstruction with the use of WasherLoc tibial fixation. The Lachman test, pivot-shift test, Lysholm Knee Scoring Scale and 2000 International Knee Documentation Committee (2000 IKDC) Subjective Knee Evaluation Form were used to evaluate the results. The intra-group comparison of the results of the 2000 IKDC Subjective Knee Evaluation Form and Lysholm Knee Scoring Scale obtained in the groups studied showed statistically significant differences between the evaluation performed preoperatively and postoperatively. The inter-group comparison of the results of the 2000 IKDC Subjective Knee Evaluation Form and Lysholm Knee Scoring Scale obtained postoperatively showed no statistically significant differences between the two groups. An evaluation 3-4 years after ACL reconstruction with the use of autologous ipsilateral STGR grafts demonstrated significant progress from the preoperative condition to the postoperative result in patients with tibial fixation using a bioabsorbable interference screw composed of PLLA-HA as well as in patients with WasherLoc tibial fixation. There were no differences found between the two groups of patients after ACL reconstruction in terms of manual stability testing or a subjective assessment of knee joint outcomes.

77 FR 7000 - Fisheries of the Northeastern United States; Northeast Multispecies Fishery; Gulf of Maine Winter...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-10

... Biological Catches (ABCs), Annual Catch Limits (ACLs), ACL components, and sector Annual Catch Entitlements (ACEs). The ACL components include sub-ACLs for the common pool and sectors. This action is intended to... through 2012. The catch levels specified by FW 44 included OFLs, ABCs, ACLs, and ACL components, including...

The Direct Insertion of the ACL Carries More Load than the Indirect Insertion

PubMed Central

Nawabi, Danyal H.; Tucker, Scott; Jones, Kristofer J.; Nguyen, Joseph; Wickiewicz, Thomas L.; Imhauser, Carl; Pearle, Andrew

2014-01-01

Objectives: Recent histological studies have shown that the ACL consists of two different structures: the direct and indirect insertions. The direct insertion is located along the lateral intercondylar ridge and the indirect insertion is ‘lower’ in the notch, adjacent to the posterior articular cartilage. The ‘lower’ position has become more popular for locating the femoral tunnel, as surgeons switch to the anteromedial (AM) portal drilling technique in order to place the graft in the region of the native footprint. However, a recent registry-based outcomes study has reported a 1.5 times higher graft failure rate for AM portal versus traditional transtibial techniques. The objective of this study was to investigate the load characteristics of the native ACL in the regions of the direct and indirect insertions. We hypothesized that the direct insertion would carry more load than the indirect insertion. Methods: Twelve cadaveric knees were mounted to a six degree of freedom robot equipped with a universal force-moment sensor. We simulated the Lachman and anterior drawer tests at 30oand 90o of flexion by applying a 134N anterior load, and the pivot shift test at 15o flexion by applying combined valgus (8Nm) and internal (4Nm) rotational moments. The kinematic pathway required to achieve these loading conditions was recorded for each intact knee. Using position control to repeat the loading paths, the robot recorded the loads for the ACL intact, ACL partially sectioned, and ACL completely sectioned states. Sectioning Protocol: The lateral intercondylar ridge and posterior articular margin was identified in each case. The 50% mark between this two areas was used to delineate the regions of the direct and indirect insertions (Fig. 1). Sectioning order was alternated between each cadaver. Footprint Digitization: The borders of the sectioned areas were digitized post-sectioning and mapped onto a computed tomography (CT) scan of each knee. The sectioning method was assessed under a blinded validation by experienced observers (TW, AP) who excluded two specimens that did not conform to the objective definitions of the sectioning method. Statistics: Loads were compared between direct and indirect locations at different flexion angles by conducting two-way repeated measures ANOVA models. Results: Under an anterior tibial load at 30o flexion, the direct insertion carried 83.9% (±7.2%) of the total ACL load compared to 16.1% (±7.2%) in the indirect insertion (p<0.001). The direct insertion also carried more load at 90o flexion (95.2% vs 4.8%; p<0.001). Under a combined rotatory load at 15o flexion, the direct insertion carried 84.2% (±4.2%)of the total ACL load compared to 15.8% (±4.2%) in the indirect insertion (p<0.001). Conclusion: The fibres in the direct insertion of the ACL carry more load than fibres in the indirect insertion. Previous studies have suggested that the direct insertion plays a major role in the mechanical link between the ACL and bone. With the current shift in emphasis towards anatomic ACL reconstruction, it may be beneficial to create the femoral tunnel within the direct insertion rather than ‘lower’ in the notch. Although further work is required in determining graft behaviour at the new insertions sites described in this study, our findings suggest that placing a graft in the region of the direct insertion may be an important consideration when adhering to the principles of anatomic ACL reconstruction.

Effects of electron cyclotron current drive on the evolution of double tearing mode

NASA Astrophysics Data System (ADS)

Sun, Guanglan; Dong, Chunying; Duan, Longfang

2015-09-01

The effects of electron cyclotron current drive (ECCD) on the double tearing mode (DTM) in slab geometry are investigated by using two-dimensional compressible magnetohydrodynamics equations. It is found that, mainly, the double tearing mode is suppressed by the emergence of the secondary island, due to the deposition of driven current on the X-point of magnetic island at one rational surface, which forms a new non-complete symmetric magnetic topology structure (defined as a non-complete symmetric structure, NSS). The effects of driven current with different parameters (magnitude, initial time of deposition, duration time, and location of deposition) on the evolution of DTM are analyzed elaborately. The optimal magnitude or optimal deposition duration of driven current is the one which makes the duration of NSS the longest, which depends on the mutual effect between ECCD and the background plasma. Moreover, driven current introduced at the early Sweet-Parker phase has the best suppression effect; and the optimal moment also exists, depending on the duration of the NSS. Finally, the effects varied by the driven current disposition location are studied. It is verified that the favorable location of driven current is the X-point which is completely different from the result of single tearing mode.

Anatomical versus non-anatomical single bundle anterior cruciate ligament reconstruction: a cadaveric study of comparison of knee stability.

PubMed

Lim, Hong-Chul; Yoon, Yong-Cheol; Wang, Joon-Ho; Bae, Ji-Hoon

2012-12-01

The purpose of this study was to compare the initial stability of anatomical and non-anatomical single bundle anterior cruciate ligament (ACL) reconstruction and to determine which would better restore intact knee kinematics. Our hypothesis was that the initial stability of anatomical single bundle ACL reconstruction would be superior to that of non-anatomical single bundle ACL reconstruction. Anterior tibial translation (ATT) and internal rotation of the tibia were measured with a computer navigation system in seven pairs of fresh-frozen cadaveric knees under two testing conditions (manual maximum anterior force, and a manual maximum anterior force combined with an internal rotational force). Tests were performed at 0, 30, 60, and 90 degrees of flexion with the ACL intact, the ACL transected, and after reconstruction of one side of a pair with either anatomical or non-anatomical single bundle ACL reconstruction. Under manual maximal anterior force, both reconstruction techniques showed no significant difference of ATT when compared to ACL intact knee state at 30° of knee flexion (p > 0.05). Under the combined anterior and internal rotatory force, non-anatomical single-bundle ACL reconstruction showed significant difference of ATT compared to those in ACL intact group (p < 0.05). In contrast, central anatomical single bundle ACL reconstruction showed no significant difference of ATT compared to those in ACL intact group (p > 0.05). Internal rotation of the tibia showed no significant difference in the ACL intact, the ACL transected, non-anatomical reconstructed and anatomical reconstructed knees. Anatomical single bundle ACL reconstruction restored the initial stability closer to the native ACL under combined anterior and internal rotational forces when compared to non-anatomical ACL single bundle reconstruction.

The evaluation of central corneal thickness and intraocular pressure in conjunction with tear IGF-1 levels in patients with acromegaly.

PubMed

Kan, Emrah; Kan, Elif K; Okuyucu, Ali

2017-08-30

To compare the central corneal thickness (CCT), intraocular pressure (IOP), and tear insulin-like growth factor 1 (IGF-1) levels between patients with acromegaly and a control group and to evaluate the possible effect of tear IGF-1 and duration of the disease on CCT and IOP. We included 31 patients with acromegaly (study group) and 40 age- and sex-matched controls in the study. Patients with acromegaly were divided into 2 subgroups based on disease status (active/inactive). All participants underwent complete ophthalmologic evaluation including CCT and IOP values. Basal tear samples were collected from both groups and tear IGF-1 levels were measured. The CCT, IOP, and tear IGF-1 levels were compared between groups and subgroups and the association between tear IGF-I levels and ocular parameters (CCT, IOP) and disease duration were also evaluated. Central corneal thickness, IOP, and tear IGF-1 levels did not show a significant difference between study and control groups. We also did not find a significant difference in terms of CCT, IOP, or tear IGF-1 levels between subgroups of patients. Correlation analysis did not show an association between the duration of disease and tear IGF-1 levels with CCT or IOP. There was no significant difference in tear IGF-1 levels between patients with acromegaly and controls. Additionally, there was no correlation between disease duration and tear IGF-1 levels with CCT or IOP levels. This lack of association may suggest that tear IGF-1 levels might not have an effect on CCT or IOP findings in patients with acromegaly.

Rotator cuff muscle degeneration and tear severity related to myogenic, adipogenic, and atrophy genes in human muscle.

PubMed

Shah, Shivam A; Kormpakis, Ioannis; Cavinatto, Leonardo; Killian, Megan L; Thomopoulos, Stavros; Galatz, Leesa M

2017-12-01

Large rotator cuff tear size and advanced muscle degeneration can affect reparability of tears and compromise tendon healing. Clinicians often rely on direct measures of rotator cuff tear size and muscle degeneration from magnetic resonance imaging (MRI) to determine whether the rotator cuff tear is repairable. The objective of this study was to identify the relationship between gene expression changes in rotator cuff muscle degeneration to standard data available to clinicians. Radiographic assessment of preoperative rotator cuff tear severity was completed for 25 patients with varying magnitudes of rotator cuff tears. Tear width and retraction were measured using MRI, and Goutallier grade, tangent (tan) sign, and Thomazeau grade were determined. Expression of myogenic-, adipogenic-, atrophy-, and metabolism-related genes in biopsied muscles were correlated with tear width, tear retraction, Goutallier grade, tan sign, and Thomazeau grade. Tear width positively correlated with Goutallier grade in both the supraspinatus (r = 0.73) and infraspinatus (r = 0.77), along with tan sign (r = 0.71) and Thomazeau grade (r = 0.68). Decreased myogenesis (Myf5), increased adipogenesis (CEBPα, Lep, Wnt10b), and decreased metabolism (PPARα) correlated with radiographic assessments. Gene expression changes suggest that rotator cuff tears lead to a dramatic molecular response in an attempt to maintain normal muscle tissue, increase adipogenesis, and decrease metabolism. Fat accumulation and muscle atrophy appear to stem from endogenous changes rather than from changes mediated by infiltrating cells. Results suggest that chronic unloading of muscle, induced by rotator cuff tear, disrupts muscle homeostasis. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2808-2814, 2017. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

Predictors for additional anterior cruciate ligament reconstruction: data from the Swedish national ACL register.

PubMed

Fältström, Anne; Hägglund, Martin; Magnusson, Henrik; Forssblad, Magnus; Kvist, Joanna

2016-03-01

To identify predictors for additional anterior cruciate ligament (ACL) reconstruction. Patients from the Swedish national ACL register who underwent ACL reconstruction between January 2005 and February 2013 (follow-up duration 6-104 months) were included. Cox regression analyses included the following independent variables regarding primary injury: age, sex, time between injury and primary ACL reconstruction, activity at primary injury, concomitant injuries, injury side, graft type, and pre-surgery KOOS and EQ-5D scores. Among ACL reconstruction procedures, 93% involved hamstring tendon (HT) autografts. Graft type did not predict additional ACL reconstruction. Final regression models only included patients with HT autograft (n = 20,824). Of these, 702 had revision and 591 contralateral ACL reconstructions. The 5-year post-operative rates of revision and contralateral ACL reconstruction were 4.3 and 3.8%, respectively. Significant predictors for additional ACL reconstruction were age (fourfold increased rate for <16-year-old patients vs. >35-year-old patients), time between injury and primary surgery (two to threefold increased rate for ACL reconstruction within 0-90 days vs. >365 days), and playing football at primary injury. This study identified younger age, having ACL reconstruction early after the primary injury, and incurring the primary injury while playing football as the main predictors for revision and contralateral ACL reconstruction. This suggests that the rate of additional ACL reconstruction is increased in a selected group of young patients aiming to return to strenuous sports after primary surgery and should be taken into consideration when discussing primary ACL reconstruction, return to sports, and during post-surgery rehabilitation. II.

Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises.

PubMed

Lipman, Steven S; Daniels, Kay I; Carvalho, Brendan; Arafeh, Julie; Harney, Kimberly; Puck, Andrea; Cohen, Sheila E; Druzin, Maurice

2010-08-01

Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance. We evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions. Proper compressions were delivered by our teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean +/- SD overall composite score for the tasks was 45 +/- 12% (range, 20-60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Fifty percent of teams did not provide basic information to the neonatal teams as required by neonatal resuscitation provider guidelines. Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision. Copyright (c) 2010 Mosby, Inc. All rights reserved.

Single-legged Hop Tests as Predictors of Self-reported Knee Function After Anterior Cruciate Ligament Reconstruction

PubMed Central

Logerstedt, David; Grindem, Hege; Lynch, Andrew; Eitzen, Ingrid; Engebretsen, Lars; Risberg, May Arna; Axe, Michael J.; Snyder-Mackler, Lynn

2012-01-01

Background Single-legged hop tests are commonly used functional performance measures that can capture limb asymmetries in patients after anterior cruciate ligament (ACL) reconstruction. Hop tests hold potential as predictive factors of self-reported knee function in individuals after ACL reconstruction. Hypothesis Single-legged hop tests conducted preoperatively would not and 6 months after ACL reconstruction would predict self-reported knee function (International Knee Documentation Committee [IKDC] 2000) 1 year after ACL reconstruction. Study Design Cohort study (prognosis); Level of evidence, 2. Methods One hundred twenty patients who were treated with ACL reconstruction performed 4 single-legged hop tests preoperatively and 6 months after ACL reconstruction. Self-reported knee function within normal ranges was defined as IKDC 2000 scores greater than or equal to the age- and sex-specific normative 15th percentile score 1 year after surgery. Logistic regression analyses were performed to identify predictors of self-reported knee function within normal ranges. The area under the curve (AUC) from receiver operating characteristic curves was used as a measure of discriminative accuracy. Results Eighty-five patients completed single-legged hop tests 6 months after surgery and the 1-year follow-up with 68 patients classified as having self-reported knee function within normal ranges 1 year after reconstruction. The crossover hop and 6-m timed hop limb symmetry index (LSI) 6 months after ACL reconstruction were the strongest individual predictors of self-reported knee function (odds ratio, 1.09 and 1.10) and the only 2 tests in which the confidence intervals of the discriminatory accuracy (AUC) were above 0.5 (AUC = 0.68). Patients with knee function below normal ranges were over 5 times more likely of having a 6-m timed hop LSI lower than the 88% cutoff than those with knee function within normal ranges. Patients with knee function within normal ranges were 4 times more likely to have a crossover hop LSI greater than the 95% cutoff than those with knee function below normal ranges. No preoperative single-legged hop test predicted self-reported knee function within normal ranges 1 year after ACL reconstruction (all P > .353). Conclusion Single-legged hop tests conducted 6 months after ACL reconstruction can predict the likelihood of successful and unsuccessful outcome 1 year after ACL reconstruction. Patients demonstrating less than the 88% cutoff score on the 6-m timed hop test at 6 months may benefit from targeted training to improve limb symmetry in an attempt to normalize function. Patients with minimal side-to-side differences on the crossover hop test at 6 months possibly will have good knee function at 1 year if they continue with their current training regimen. Preoperative single-legged hop tests are not able to predict postoperative outcomes. PMID:22926749

Risk Factors for Anthroponotic Cutaneous Leishmaniasis at the Household Level in Kabul, Afghanistan

PubMed Central

Reithinger, Richard; Mohsen, Mohammad; Leslie, Toby

2010-01-01

Background Kabul, Afghanistan, is the largest focus of anthroponotic cutaneous leishmaniasis (ACL) in the world. ACL is a protozoan disease transmitted to humans by the bite of phlebotomine sand flies. Although not fatal, ACL can lead to considerable stigmatization of affected populations. Methods Using data from a standardized survey of 872 households in 4 wards of Kabul, Afghanistan, univariate and multivariate logistic regression analyses tested associations between presence of active ACL and ACL scars with 15 household-level variables. Findings Univariate analyses showed that active ACL was positively associated with household member's age, ACL prevalence, and brick wall type, but negatively associated with household number of rooms, bednet use, and proportion of windows with screens. Multivariate analysis showed a positive association between active ACL and household member's age, ACL prevalence, and brick wall type, and a negative association with household proportion of windows with screens. Conclusion Household-level charateristics were shown to be risk factors for ACL. Monitoring a selected number of household characteristics could assist in rapid assessments of household-level variation in risk of ACL. ACL prevention and control programs should consider improving house construction, including smoothing of walls and screening of windows. PMID:20351787

Intercondylar roof impingement pressure after anterior cruciate ligament reconstruction in a porcine model.

PubMed

Iriuchishima, Takanori; Tajima, Goro; Ingham, Sheila J M; Shen, Wei; Horaguchi, Takashi; Saito, Akiyoshi; Smolinski, Patrick; Fu, Freddie H

2009-06-01

Anterior cruciate ligament (ACL) graft impingement against the intercondylar roof has been postulated, but not thoroughly investigated. The roof impingement pressure changes with different tibial and femoral tunnel positions in ACL reconstruction. Anterior tibial translation is also affected by the tunnel positions of ACL reconstruction. The study design included a controlled laboratory study. In 15 pig knees, the impingement pressure between ACL and intercondylar roof was measured using pressure sensitive film before and after ACL single bundle reconstruction. ACL reconstructions were performed in each knee with two different tibial and femoral tunnel position combinations: (1) tibial antero-medial (AM) tunnel to femoral AM tunnel (AM to AM) and (2) tibial postero-lateral (PL) tunnel to femoral High-AM tunnel (PL to High-AM). Anterior tibial translation (ATT) was evaluated after each ACL reconstruction using robotic/universal force-moment sensor testing system. Neither the AM to AM nor the PL to High-AM ACL reconstruction groups showed significant difference when compared with intact ACL in roof impingement pressure. The AM to AM group had a significantly higher failure load than PL to High-AM group. This study showed how different tunnel placements affect the ACL-roof impingement pressure and anterior-posterior laxity in ACL reconstruction. Anatomical ACL reconstruction does not cause roof impingement and it has a biomechanical advantage in ATT when compared with non-anatomical ACL reconstructions in the pig knee. There is no intercondylar roof impingement after anatomical single bundle ACL reconstruction.

Control of dynamic foot-ground interactions in male and female soccer athletes: females exhibit reduced dexterity and higher limb stiffness during landing.

PubMed

Lyle, Mark A; Valero-Cuevas, Francisco J; Gregor, Robert J; Powers, Christopher M

2014-01-22

Controlling dynamic interactions between the lower limb and ground is important for skilled locomotion and may influence injury risk in athletes. It is well known that female athletes sustain anterior cruciate ligament (ACL) tears at higher rates than male athletes, and exhibit lower extremity biomechanics thought to increase injury risk during sport maneuvers. The purpose of this study was to examine whether lower extremity dexterity (LED)--the ability to dynamically control endpoint force magnitude and direction as quantified by compressing an unstable spring with the lower limb at submaximal forces--is a potential contributing factor to the "at-risk" movement behavior exhibited by female athletes. We tested this hypothesis by comparing LED-test performance and single-limb drop jump biomechanics between 14 female and 14 male high school soccer players. We found that female athletes exhibited reduced LED-test performance (p=0.001) and higher limb stiffness during landing (p=0.008) calculated on average within 51 ms of foot contact. Females also exhibited higher coactivation at the ankle (p=0.001) and knee (p=0.02) before landing. No sex differences in sagittal plane joint angles and center of mass velocity at foot contact were observed. Collectively, our results raise the possibility that the higher leg stiffness observed in females during landing is an anticipatory behavior due in part to reduced lower extremity dexterity. The reduced lower extremity dexterity and compensatory stiffening strategy may contribute to the heightened risk of ACL injury in this population. © 2013 Published by Elsevier Ltd.

Clinical study on the arthroscopic refreshing treatment of anterior cruciate ligament injury combined with stable medial meniscus ramp injury

PubMed Central

Yang, J.; Guan, K.; Wang, J.Z.

2017-01-01

This study sought to investigate the clinical efficacy of arthroscopic refreshing treatment of anterior cruciate ligament (ACL) injury combined with stable medial meniscus ramp injury. Sixty-eight patients treated between January 2010 and January 2014 were included, and their clinical data were retrospectively analyzed. All patients, after being treated using ACL reconstruction, were divided into 2 groups according to meniscus injury treatment method. The observation group (31 cases) was treated by arthroscopic refreshing, which removed the tissue on both sides of the tear edge using a cutting knife, while the control group (37 cases) was treated using Fast-fix sutures. All patients were followed up for at least 24 months. Surgical duration, postoperative function recovery time, and hospital stay for patients in the observation group were significantly shorter than for those of the control group (P<0.05). Both groups showed significant post-operative improvement for Lysholm scores, IKDC scores, and average knee range of motion at 12 and 24 months post-operation (P<0.05), but no significant differences between groups were observed (P>0.05). Regarding the difference in movement range between the healthy and injured sides, both groups showed significant decrease post-operation (P<0.05). Ultimately, there was no significant difference in the recovery of ramp damage and objective symptoms between the two groups (P>0.05). Arthroscopic refreshing treatment of patients with anterior cruciate ligament injury combined with stable ramp lesion can achieve similar clinical curative effects as the Fast-fix suture, thereby providing a simple alternative for patient treatment worth popularizing. PMID:28574418

Control of dynamic foot-ground interactions in male and female soccer athletes: Females exhibit reduced dexterity and higher limb stiffness during landing

PubMed Central

Lyle, Mark A.; Valero-Cuevas, Francisco J.; Gregor, Robert J.; Powers, Christopher M.

2014-01-01

Controlling dynamic interactions between the lower limb and ground is important for skilled locomotion and may influence injury risk in athletes. It is well known that female athletes sustain anterior cruciate ligament (ACL) tears at higher rates than male athletes, and exhibit lower extremity biomechanics thought to increase injury risk during sport maneuvers. The purpose of this study was to examine whether lower extremity dexterity (LED) – the ability to dynamically control endpoint force magnitude and direction as quantified by compressing an unstable spring with the lower limb at submaximal forces – is a potential contributing factor to the “at-risk” movement behavior exhibited by female athletes. We tested this hypothesis by comparing LED-test performance and single-limb drop jump biomechanics between 14 female and 14 male high school soccer players. We found that female athletes exhibited reduced LED-test performance (p=0.001) and higher limb stiffness during landing (p=0.008) calculated on average within 51 ms of foot contact. Females also exhibited higher coactivation at the ankle (p=0.001) and knee (p=0.02) before landing. No sex differences in sagittal plane joint angles and center of mass velocity at foot contact were observed. Collectively, our results raise the possibility that the higher leg stiffness observed in females during landing is an anticipatory behavior due in part to reduced lower extremity dexterity. The reduced lower extremity dexterity and compensatory stiffening strategy may contribute to the heightened risk of ACL injury in this population. PMID:24275440

Adolescents and female patients are at increased risk for contralateral anterior cruciate ligament reconstruction: a cohort study from the Swedish National Knee Ligament Register based on 17,682 patients.

PubMed

Snaebjörnsson, Thorkell; Hamrin Senorski, Eric; Sundemo, David; Svantesson, Eleonor; Westin, Olof; Musahl, Volker; Alentorn-Geli, Eduard; Samuelsson, Kristian

2017-12-01

The impact of different surgical techniques in index ACL reconstruction for patients undergoing contralateral ACL reconstruction was investigated. The study was based on data from the Swedish National Knee Ligament Register. Patients undergoing index ACL reconstruction and subsequent contralateral ACL reconstruction using hamstring graft under the study period were included. The following variables were evaluated: age at index surgery, gender, concomitant meniscal or cartilage injury registered at index injury, transportal femoral bone tunnel drilling and transtibial femoral bone tunnel drilling. The end-point of primary contralateral ACL surgery was analysed as well as the time-to-event outcomes using survivorship methods including Kaplan-Meier estimation and Cox proportional hazards regression models. A total of 17,682 patients [n = 10,013 males (56.6%) and 7669 females (43.4%)] undergoing primary ACL reconstruction from 1 January 2005 through 31 December 2014 were included in the study. A total of 526 (3.0%) patients [n = 260 males (49.4%) and 266 females (50.6%)] underwent primary contralateral ACL reconstruction after index ACL reconstruction during the study period. Females had a 33.7% greater risk of contralateral ACL surgery [HR 1.337 (95% CI 1.127-1.586); (P = 0 0.001)]. The youngest age group (13-15 years) showed an increased risk of contralateral ACL surgery compared with the reference (36-49) age group [HR 2.771 (95% CI 1.456-5.272); (P = 0.002)]. Decreased risk of contralateral ACL surgery was seen amongst patients with concomitant cartilage injury at index surgery [HR 0.765 (95% CI 0.623-0.939); (P = 0.010)]. No differences in terms of the risk of contralateral ACL surgery were found between anatomic and non-anatomic techniques of primary single-bundle ACL reconstruction, comparing transportal anatomic technique to transtibial non-anatomic, anatomic and partial-anatomic. Age and gender were identified as risk factors for contralateral ACL reconstruction; hence young individuals and females were more prone to undergo contralateral ACL reconstruction. Patients with concomitant cartilage injury at index ACL reconstruction had lower risk for contralateral ACL reconstruction. No significant differences between various ACL reconstruction techniques could be related to increased risk of contralateral ACL reconstruction. Retrospective Cohort Study, Level III.

Generation of stem cell-based bioartificial anterior cruciate ligament (ACL) grafts for effective ACL rupture repair.

PubMed

Kouroupis, Dimitrios; Kyrkou, Athena; Triantafyllidi, Eleni; Katsimpoulas, Michalis; Chalepakis, George; Goussia, Anna; Georgoulis, Anastasios; Murphy, Carol; Fotsis, Theodore

2016-09-01

In the present study, we combined stem cell technology with a non-absorbable biomaterial for the reconstruction of the ruptured ACL. Towards this purpose, multipotential stromal cells derived either from subcutaneous human adipose tissue (hAT-MSCs) or from induced pluripotent stem cells (iPSCs) generated from human foreskin fibroblasts (hiPSC-MSCs) were cultured on the biomaterial for 21days in vitro to generate a 3D bioartifical ACL graft. Stem cell differentiation towards bone and ligament at the ends and central part of the biomaterial was selectively induced using either BMP-2/FGF-2 or TGF-β/FGF-2 combinations, respectively. The bioartificial ACL graft was subsequently implanted in a swine ACL rupture model in place of the surgically removed normal ACL. Four months post-implantation, the tissue engineered ACL graft generated an ACL-like tissue exhibiting morphological and biochemical characteristics resembling those of normal ACL. Copyright © 2016 Helmholtz Zentrum München. Published by Elsevier B.V. All rights reserved.

In vitro comparison of human fibroblasts from intact and ruptured ACL for use in tissue engineering.

PubMed

Brune, T; Borel, A; Gilbert, T W; Franceschi, J P; Badylak, S F; Sommer, P

2007-12-17

The present study compares fibroblasts extracted from intact and ruptured human anterior cruciate ligaments (ACL) for creation of a tissue engineered ACL-construct, made of porcine small intestinal submucosal extracellular matrix (SIS-ECM) seeded with these ACL cells. The comparison is based on histological, immunohistochemical and RT-PCR analyses. Differences were observed between cells in a ruptured ACL (rACL) and cells in an intact ACL (iACL), particularly with regard to the expression of integrin subunits and smooth muscle actin (SMA). Despite these differences in the cell source, both cell populations behaved similarly when seeded on an SIS-ECM scaffold, with similar cell morphology, connective tissue organization and composition, SMA and integrin expression. This study shows the usefulness of naturally occurring scaffolds such as SIS-ECM for the study of cell behaviour in vitro, and illustrates the possibility to use autologous cells extracted from ruptured ACL biopsies as a source for tissue engineered ACL constructs.

Dynamics and function of the tear film in relation to the blink cycle.

PubMed

Braun, R J; King-Smith, P E; Begley, C G; Li, Longfei; Gewecke, N R

2015-03-01

Great strides have recently been made in quantitative measurements of tear film thickness and thinning, mathematical modeling thereof and linking these to sensory perception. This paper summarizes recent progress in these areas and reports on new results. The complete blink cycle is used as a framework that attempts to unify the results that are currently available. Understanding of tear film dynamics is aided by combining information from different imaging methods, including fluorescence, retroillumination and a new high-speed stroboscopic imaging system developed for studying the tear film during the blink cycle. During the downstroke of the blink, lipid is compressed as a thick layer just under the upper lid which is often released as a narrow thick band of lipid at the beginning of the upstroke. "Rippling" of the tear film/air interface due to motion of the tear film over the corneal surface, somewhat like the flow of water in a shallow stream over a rocky streambed, was observed during lid motion and treated theoretically here. New mathematical predictions of tear film osmolarity over the exposed ocular surface and in tear breakup are presented; the latter is closely linked to new in vivo observations. Models include the effects of evaporation, osmotic flow through the cornea and conjunctiva, quenching of fluorescence, tangential flow of aqueous tears and diffusion of tear solutes and fluorescein. These and other combinations of experiment and theory increase our understanding of the fluid dynamics of the tear film and its potential impact on the ocular surface. Copyright © 2014 Elsevier Ltd. All rights reserved.

Dynamics and function of the tear film in relation to the blink cycle

PubMed Central

Braun, R.J.; King-Smith, P.E.; Begley, C.G.; Li, Longfei; Gewecke, N.R.

2014-01-01

Great strides have recently been made in quantitative measurements of tear film thickness and thinning, mathematical modeling thereof and linking these to sensory perception. This paper summarizes recent progress in these areas and reports on new results. The complete blink cycle is used as a framework that attempts to unify the results that are currently available. Understanding of tear film dynamics is aided by combining information from different imaging methods, including fluorescence, retroillumination and a new high-speed stroboscopic imaging system developed for studying the tear film during the blink cycle. During the downstroke of the blink, lipid is compressed as a thick layer just under the upper lid which is often released as a narrow thick band of lipid at the beginning of the upstroke. “Rippling” of the tear film/air interface due to motion of the tear film over the corneal surface, somewhat like the flow of water in a shallow stream over a rocky streambed, was observed during lid motion and treated theoretically here. New mathematical predictions of tear film osmolarity over the exposed ocular surface and in tear breakup are presented; the latter is closely linked to new in vivo observations. Models include the effects of evaporation, osmotic flow through the cornea and conjunctiva, quenching of fluorescence, tangential flow of aqueous tears and diffusion of tear solutes and fluorescein. These and other combinations of experiment and theory increase our understanding of the fluid dynamics of the tear film and its potential impact on the ocular surface. PMID:25479602

Arthroscopic direct repair for a complete radial tear of the posterior root of the medial meniscus.

PubMed

Wang, Kook Hyun; Hwang, Dae Hee; Cho, Jin Ho; Changale, Sachin D; Woo, Sung Jong; Nha, Kyung Wook

2011-12-01

We report here on a new arthroscopic direct repair technique for a radial tear of the posterior root of the medial meniscus (PRMM) using a posterior trans-septal portal. Radial tears of the PRMM are commonly observed in the elderly population of Korea and Japan, and the life style of these people requires squatting and kneeling down in daily life. A radial tear of the PRMM results in the loss of hoop tension and this accelerates degenerative changes in the knee joint and causes early osteoarthritis. Several reports in the medical literature have focused on various repair techniques for these tears by using pull out sutures. These techniques result in nonanatomic fixation of the meniscus, which may lead to disturbed meniscal excursion and failure to restore hoop tension. Arthroscopic direct repair may contribute to restoring hoop tension and preventing accelerated degenerative changes in the knee joint of these patients.

Arthroscopic Direct Repair for a Complete Radial Tear of the Posterior Root of the Medial Meniscus

PubMed Central

Wang, Kook Hyun; Hwang, Dae Hee; Cho, Jin Ho; Changale, Sachin D.; Woo, Sung Jong

2011-01-01

We report here on a new arthroscopic direct repair technique for a radial tear of the posterior root of the medial meniscus (PRMM) using a posterior trans-septal portal. Radial tears of the PRMM are commonly observed in the elderly population of Korea and Japan, and the life style of these people requires squatting and kneeling down in daily life. A radial tear of the PRMM results in the loss of hoop tension and this accelerates degenerative changes in the knee joint and causes early osteoarthritis. Several reports in the medical literature have focused on various repair techniques for these tears by using pull out sutures. These techniques result in nonanatomic fixation of the meniscus, which may lead to disturbed meniscal excursion and failure to restore hoop tension. Arthroscopic direct repair may contribute to restoring hoop tension and preventing accelerated degenerative changes in the knee joint of these patients. PMID:22162797

Anterior cruciate ligament (ACL) loading in a collegiate athlete during sidestep cutting after ACL reconstruction: A case study.

PubMed

Samaan, Michael A; Ringleb, Stacie I; Bawab, Sebastian Y; Greska, Eric K; Weinhandl, Joshua T

2016-08-01

Athletes with anterior cruciate ligament (ACL) injuries usually undergo ACL-reconstruction (ACLR) in order to restore joint stability, so that dynamic maneuvers such as the sidestep cut can be performed. Despite restoration of joint stability after ACLR, many athletes do not return to pre-injury levels and may be at a high risk of a second ACL injury. The purpose of this study was to determine whether or not ACL loading, would increase after ACLR. One female Division I collegiate athlete performed bilateral unanticipated sidestep cuts both before ACL injury and 27months after ACLR. Musculoskeletal simulations were used to calculate ACL loading during the deceleration phase of the sidestep cuts. Twenty-seven months after ACLR, the athlete demonstrated higher total ACL loading in the ipsilateral limb as well as altered joint kinematics, moments, and quadriceps muscle force production. In the contralateral limb, there were no increases in total ACL loading or muscle force production yet altered lower extremity joint kinematics and moments were present after ACLR. Higher total ACL loading in the ipsilateral limb of this athlete may suggest an increased risk of second ACL injury. The results of this study provide an initial step in understanding the effects of ACLR on the risk of second ACL injury in an elite athlete and suggest that it is important to develop a better understanding of this surgical intervention on knee joint loading, in order to reduce the risk of second ACL injury while performing dynamic maneuvers. Copyright © 2016 Elsevier B.V. All rights reserved.

Identification and Comparison of the Polar Phospholipids in Normal and Dry Eye Rabbit Tears by MALDI-TOF Mass Spectrometry

PubMed Central

Ham, Bryan M.; Cole, Richard B.; Jacob, Jean T.

2008-01-01

Purpose To identify and compare the phosphorylated lipids in normal and dry eye rabbit tears using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). Methods MALDI-TOF MS studies were performed on tear samples from normal and dry eyes of female New Zealand White rabbits. Experimental dry eye was induced by complete removal of the main and accessory lacrimal glands and nictitating membranes. A solid ionic crystal MALDI matrix of paranitroaniline and butyric acid was used to enhance the mass spectral responses of the phospholipids. In addition, a novel lipid isolation, preconcentration, and clean-up method using pipettes containing immobilized metal ion affinity chromatography (IMAC) medium was used. Results The polar phospholipids present in the normal and dry eye rabbit tears showed both similarities and differences. Species related to platelet-activating factor (PAF) and/or lysophosphatidylcholine (lyso-PC), phosphatidylcholine (PC), and sphingomyelin (SM) were found in both the normal and dry eye rabbit tears. However, the number of types and the concentrations of SM molecules were markedly greater in the dry eye tears than in the normal tears. In addition, phosphatidylserine (PS) species that were readily detectable in dry eye tears were not found in normal tears. Conclusions The combination of immobilized metal ion affinity chromatography and the solid ionic crystal matrix for MALDI enabled the detection and study of phosphorylated lipids in the tears. Specific differences between phospholipid levels in normal and dry eye tears were observable with this methodology. The appearance of various SM species only in the dry eye tears may provide markers for this disease state in the future. PMID:16877399

Extension of knee immobilization delays recovery of histological damages in the anterior cruciate ligament insertion and articular cartilage in rabbits.

PubMed

Mutsuzaki, Hirotaka; Nakajima, Hiromi; Sakane, Masataka

2018-01-01

[Purpose] To investigate the influence of knee immobilization period on recovery of histological damages in the anterior cruciate ligament (ACL) insertion and articular cartilage in rabbits. This knowledge is important for determining the appropriate rehabilitation approach for patients with ligament injuries, fracture, disuse atrophy, and degenerative joint disease. [Materials and Methods] Forty-eight male Japanese white rabbits were divided equally into the remobilization and control groups. The remobilization group had the right knee surgically immobilized, and was divided equally into four subgroups according to the duration of immobilization (1, 2, 4 and 8 weeks). After the immobilization was removed, the rabbits moved freely for 8 weeks. The control group underwent sham operation and followed the same time course as the remobilization group. The chondrocyte apoptosis rate and chondrocyte proliferation rate in the ACL insertion and articular cartilage were analyzed after remobilization. [Results] In the ACL insertion, the remobilization group had a higher chondrocyte apoptosis rate than the control group after 8 weeks of immobilization, and a lower chondrocyte proliferation rate than the control group after 4 and 8 weeks of immobilization. In the articular cartilage, the remobilization group had a lower chondrocyte proliferation rate than the control group after 8 weeks of immobilization. After 8 weeks of remobilization, the ACL insertion and articular cartilage are not completely recovered after 4 and 8 weeks of immobilization, respectively. [Conclusion] Our results suggest that 8 weeks of remobilization will result in recovery of the ACL insertion after 2 weeks of knee immobilization, and recovery of the articular cartilage after 4 weeks of knee immobilization. If 8 weeks of immobilization occurs, a remobilization duration of more than 8 weeks may be necessary.

Phlebotomines (Diptera: Psychodidae) in a Hydroelectric System Affected Area from Northern Amazonian Brazil: Further Insights into the Effects of Environmental Changes on Vector Ecology

PubMed Central

Furtado, Nercy Virginia Rabelo; Galardo, Allan Kardec Ribeiro; Galardo, Clicia Denis; Firmino, Viviane Caetano

2016-01-01

During 2012–2015, an entomological survey was conducted as part of a phlebotomine (Diptera: Psychodidae) monitoring program in an area influenced by the Santo Antônio do Jari hydroelectric system (Amapá State, Brazil). The purpose was to study aspects of Amazon/Guianan American cutaneous leishmaniasis (ACL) vectors subjected to stresses by anthropogenic environmental changes. For sampling, CDC light traps were positioned 0.5, 1, and 20 m above ground at five capture locations along the Jari River Basin. Fluctuations in phlebotomine numbers were analyzed to determine any correlation with rainfall, dam waterlogging, and/or ACL cases, from May 2012 to March 2015. We captured 2,800 individuals, and among 45 species identified, Bichromomyia flaviscutellata, Nyssomyia umbratilis, and Psychodopygus squamiventris s.l. were determined to be the main putative vectors, based on current knowledge of the Amazon/Guianan ACL scenario. Rainfall, but not complete flooding, was relatively correlated with phlebotomine fluctuation, mainly observed for Ps. squamiventris s.l., as were ACL cases with Ny. umbratilis. Behavioral changes were observed in the unexpected high frequency of Bi. flaviscutellata among CDC captures and the noncanopy dominance of Ny. umbratilis, possibly attributable to environmental stress in the sampled ecotopes. Continuous entomological surveillance is necessary to monitor the outcomes of these findings. PMID:28042300

Manual Khalifa Therapy Improves Functional and Morphological Outcome of Patients with Anterior Cruciate Ligament Rupture in the Knee: A Randomized Controlled Trial

PubMed Central

Kastner, Andreas; Wallenboeck, Engelbert; Pehn, Robert; Schneider, Frank; Groell, Reinhard; Szolar, Dieter; Walach, Harald; Sandner-Kiesling, Andreas

2014-01-01

Rupture of the anterior cruciate ligament (ACL) is a high incidence injury usually treated surgically. According to common knowledge, it does not heal spontaneously, although some claim the opposite. Regeneration therapy by Khalifa was developed for injuries of the musculoskeletal system by using specific pressure to the skin. This randomized, controlled, observer-blinded, multicentre study was performed to validate this assumption. Thirty patients with complete ACL rupture, magnetic resonance imaging (MRI) verified, were included. Study examinations (e.g., international knee documentation committee (IKDC) score) were performed at inclusion (t 0). Patients were randomized to receive either standardised physiotherapy (ST) or additionally 1 hour of Khalifa therapy at the first session (STK). Twenty-four hours later, study examinations were performed again (t 1). Three months later control MRI and follow-up examinations were performed (t 2). Initial status was comparable between both groups. There was a highly significant difference of mean IKDC score results at t 1 and t 2. After 3 months, 47% of the STK patients, but no ST patient, demonstrated an end-to-end homogeneous ACL in MRI. Clinical and physical examinations were significantly different in t 1 and t 2. ACL healing can be improved with manual therapy. Physical activity can be performed without pain and nearly normal range of motion after one treatment of specific pressure. PMID:24600477

In vivo measurement of ACL length and relative strain during walking

PubMed Central

Taylor, K A; Cutcliffe, H C; Queen, R M; Utturkar, G M; Spritzer, C E; Garrett, W E; DeFrate, L E

2012-01-01

Although numerous studies have addressed the effects of ACL injury and reconstruction on knee joint motion, there is currently little data available describing in vivo ACL strain during activities of daily living. Data describing in vivo ACL strain during activities such as gait is critical to understanding the biomechanical function of the ligament, and ultimately, to improving the surgical treatment of patients with ACL rupture. Thus, our objective was to characterize the relative strain in the ACL during both the stance and swing phases of normal level walking. Eight normal subjects were recruited for this study. Through a combination of magnetic resonance imaging, biplanar fluoroscopy, and motion capture, we created in vivo models of each subject’s normal walking movements to measure knee flexion, ACL length, and relative ACL strain during gait. Regression analysis demonstrated an inverse relationship between knee flexion and ACL length (R2=0.61, p<0.001). Furthermore, relative strain in the ACL peaked at 13±2% (mean± 95%CI) during mid-stance when the knee was near full extension. Additionally, there was a second local maximum of 10±7% near the end of swing phase, just prior to heel strike. These data are a vital step in further comprehending the normal in vivo biomechanics experienced by the ACL. In the future, this information could prove critical to improving ACL reconstruction and provide useful validation to future computational models investigating ACL function. PMID:23178040

Anatomic double-bundle anterior cruciate ligament reconstruction restores patellofemoral contact areas and pressures more closely than nonanatomic single-bundle reconstruction.

PubMed

Tajima, Goro; Iriuchishima, Takanori; Ingham, Sheila J M; Shen, Wei; van Houten, Albert H; Aerts, Maarten M; Shimamura, Tadashi; Smolinski, Patrick; Fu, Freddie H

2010-10-01

To investigate the effects of anterior cruciate ligament (ACL) deficiency and nonanatomic single-bundle (SB) and anatomic double-bundle (DB) ACL reconstruction on the contact characteristics of the patellofemoral (PF) joint. By use of a materials testing system, 7 fresh-frozen human cadaveric knees were tested. The following states were tested: ACL-intact knee, nonanatomic SB ACL reconstruction, anatomic DB ACL reconstruction, and ACL-deficient knee. Hamstring autografts were used. PF contact pressures and areas were measured with pressure-sensitive film at 30°, 60°, and 90° of knee flexion with a constant 100-N load on the quadriceps tendon. The total contact area of ACL-deficient and nonanatomic SB ACL-reconstructed knees (123.8 ± 63.9 and 149.6 ± 79.3 mm(2), respectively) significantly decreased when compared with those of the intact knee (206.1 ± 83.6 mm(2)) at 30° of knee flexion. The lateral-facet peak pressure of ACL-deficient and nonanatomic SB ACL-reconstructed knees (1.12 ± 0.52 and 1.22 ± 0.54 MPa, respectively) significantly decreased when compared with those of the intact knee (0.68 ± 0.38 MPa) at 90° of knee flexion. Anatomic DB ACL reconstruction restored the contact pressures and areas to values similar to those of the intact knee (no significant difference). ACL deficiency resulted in a significant decrease in the total and medial PF contact areas and in an increase in the lateral PF contact pressure. Anatomic DB ACL reconstruction more closely restored normal PF contact area and pressure than did nonanatomic SB ACL reconstruction. Our findings suggest that the changes in the PF contact area and pressures in ACL deficiency and after nonanatomic SB ACL reconstruction may be one of the causes of PF osteoarthritis or other related PF problems found at long-term follow-up. Anatomic DB ACL reconstruction may reduce the incidence of PF problems by closely restoring the contact area and pressure. Copyright © 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Unicondylar arthroplasty in knees with deficient anterior cruciate ligaments.

PubMed

Engh, Gerard A; Ammeen, Deborah J

2014-01-01

Historically, a functional ACL has been a prerequisite for patients undergoing unicondylar knee arthroplasty (UKA). However, this premise has not been rigorously tested. We compared (1) the survivorship free from revision and (2) the failure mechanisms of UKAs in ACL-deficient knees and UKAs in ACL-intact knees performed over the same time interval. Between November 2000 and July 2008, a fixed bearing UKA was performed in 72 patients (81 knees) with intraoperatively confirmed ACL deficiency. Five patients (five knees) with preoperative instability underwent ACL reconstruction and were excluded from analysis. Of the remaining 67 patients (76 knees) without preoperative instability, implant status was known for 68 UKAs in 60 patients. Survivorship and failure mechanisms for these knees were compared to those of 706 UKAs in ACL-intact knees performed during the same time interval by the same surgeon using the same implant system. Minimum followup for the ACL-deficient group was 2.9 years (mean, 6 years; range, 2.9-10 years). Revision rates between UKAs with and without intact ACLs were similar in the absence of clinical instability (p = 0.58). Six-year UKA survivorship was 94% (95% CI: 88%-100%) in ACL-deficient knees and 93% (95% CI: 91%-96%) in ACL-intact knees (p = 0.89). Five knees (7%) in the ACL-deficient group were revised: disease progression (two), loose tibia (one), persistent pain (one), and revised elsewhere/reason unknown (one). Thirty-six knees in the ACL-intact group underwent revision (5%): aseptic loosening (13), revised elsewhere/reason unknown (11), disease progression (three), tibial subsidence/fracture (four), infection (three), pain (one), and lateral compartment overload (one). At 6 years, deficiency of the ACL in patients without clinical knee instability did not impact the survivorship of UKAs compared to UKAs performed in knees with intact ACLs.

Factors predicting rotator cuff retears: an analysis of 1000 consecutive rotator cuff repairs.

PubMed

Le, Brian T N; Wu, Xiao L; Lam, Patrick H; Murrell, George A C

2014-05-01

The rate of retears after rotator cuff repair varies from 11% to 94%. A retear is associated with poorer subjective and objective clinical outcomes than intact repair. This study was designed to determine which preoperative and/or intraoperative factors held the greatest association with retears after arthroscopic rotator cuff repair. Cohort study; Level of evidence, 3. This study retrospectively evaluated 1000 consecutive patients who had undergone a primary rotator cuff repair by a single surgeon using an arthroscopic inverted-mattress knotless technique and who had undergone an ultrasound evaluation 6 months after surgery to assess repair integrity. Exclusion criteria included previous rotator cuff repair on the same shoulder, incomplete repair, and repair using a synthetic polytetrafluoroethylene patch. All patients had completed the modified L'Insalata Questionnaire and underwent a clinical examination before surgery. Measurements of tear size, tear thickness, associated shoulder injury, tissue quality, and tendon mobility were recorded intraoperatively. The overall retear rate at 6 months after surgery was 17%. Retears occurred in 27% of full-thickness tears and 5% of partial-thickness tears (P < .0001). The best independent predictors of retears were anteroposterior tear length (correlation coefficient r = 0.41, P < .0001), tear size area (r = 0.40, P < .0001), mediolateral tear length (r = 0.34, P < .0001), tear thickness (r = 0.29, P < .0001), age at surgery (r = 0.27, P < .0001), and operative time (r = 0.18, P < .0001). These factors produced a predictive model for retears: logit P = (0.039 × age at surgery in years) + (0.027 × tear thickness in %) + (1 × anteroposterior tear length in cm) + (0.76 × mediolateral tear length in cm) - (0.17 × tear size area in cm(2)) + (0.018 × operative time in minutes) -9.7. Logit P can be transformed into P, which is the chance of retears at 6 months after surgery. A rotator cuff retear is a multifactorial process with no single preoperative or intraoperative factor being overwhelmingly predictive of it. Nevertheless, rotator cuff tear size (tear dimensions, tear size area, and tear thickness) showed stronger associations with retears at 6 months after surgery than did measures of tissue quality and concomitant shoulder injuries.

50 CFR 648.323 - Accountability measures.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Administrative Procedure Act. (b) ACL overages-(1) If the ACL is determined to have been exceeded in any given... between ACL and ACT, initially specified at 25 percent, shall be increased by 1 percent for each 1-percent ACL overage in the second fishing year following the fishing year in which the ACL overage occurred...

50 CFR 648.96 - FMP review, specification, and framework adjustment process.

Code of Federal Regulations, 2012 CFR

2012-10-01

... and ACLs. (1) The Councils or the PDT may develop options for setting ABC, ACL, and OFL for each.... The Councils or the PDT may recommend to the SSC that ABC, ACL, and OFL are specified for each.... (ii) ACL recommendations. The Councils shall establish ACLs for each management area that are...

50 CFR 648.323 - Accountability measures.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Administrative Procedure Act. (b) ACL overages-(1) If the ACL is determined to have been exceeded in any given... between ACL and ACT, initially specified at 25 percent, shall be increased by 1 percent for each 1-percent ACL overage in the second fishing year following the fishing year in which the ACL overage occurred...

50 CFR 648.96 - FMP review, specification, and framework adjustment process.

Code of Federal Regulations, 2013 CFR

2013-10-01

... and ACLs. (1) The Councils or the PDT may develop options for setting ABC, ACL, and OFL for each.... The Councils or the PDT may recommend to the SSC that ABC, ACL, and OFL are specified for each.... (ii) ACL recommendations. The Councils shall establish ACLs for each management area that are...

50 CFR 648.323 - Accountability measures.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Administrative Procedure Act. (b) ACL overages-(1) If the ACL is determined to have been exceeded in any given... between ACL and ACT, initially specified at 25 percent, shall be increased by 1 percent for each 1-percent ACL overage in the second fishing year following the fishing year in which the ACL overage occurred...

50 CFR 648.96 - FMP review, specification, and framework adjustment process.

Code of Federal Regulations, 2014 CFR

2014-10-01

... and ACLs. (1) The Councils or the PDT may develop options for setting ABC, ACL, and OFL for each.... The Councils or the PDT may recommend to the SSC that ABC, ACL, and OFL are specified for each.... (ii) ACL recommendations. The Councils shall establish ACLs for each management area that are...

50 CFR 648.323 - Accountability measures.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Administrative Procedure Act. (b) ACL overages-(1) If the ACL is determined to have been exceeded in any given... between ACL and ACT, initially specified at 25 percent, shall be increased by 1 percent for each 1-percent ACL overage in the second fishing year following the fishing year in which the ACL overage occurred...

50 CFR 648.323 - Accountability measures.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Administrative Procedure Act. (b) ACL overages-(1) If the ACL is determined to have been exceeded in any given... between ACL and ACT, initially specified at 25 percent, shall be increased by 1 percent for each 1-percent ACL overage in the second fishing year following the fishing year in which the ACL overage occurred...

No difference between mechanical perturbation training with compliant surface and manual perturbation training on knee functional performance after ACL rupture.

PubMed

Nawasreh, Zakariya; Logerstedt, David; Failla, Mathew; Snyder-Mackler, Lynn

2017-10-27

Manual perturbation training improves dynamic knee stability and functional performance after anterior cruciate ligament rupture (ACL-rupture). However, it is limited to static standing position and does not allow time-specific perturbations at different phase of functional activities. The purpose of this study was to investigate whether administering mechanical perturbation training including compliant surface provides effects similar to manual perturbation training on knee functional measures after an acute ACL-rupture. Sixteen level I/II athletes with ACL-ruptures participated in this preliminary study. Eight patients received mechanical (Mechanical) and eight subjects received manual perturbation training (Manual). All patients completed a functional testing (isometric quadriceps strength, single-legged hop tests) and patient-reported measures (Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS), Global Rating Score (GRS), International Knee Documentation Committee 2000 (IKDC 2000) at pre- and post-training. 2 × 2 ANOVA was used for data analysis. No significant group-by-time interactions were found for all measures (p > 0.18). Main effects of time were found for single hop (Pre-testing: 85.14% ± 21.07; Post-testing: 92.49% ± 17.55), triple hop (Pre-testing: 84.64% ± 14.17; Post-testing: 96.64% ± 11.14), KOS-ADLS (Pre-testing: 81.13% ± 11.12; Post-testing: 88.63% ± 12.63), GRS (Pre-testing: 68.63% ± 15.73; Post-testing: 78.81% ± 13.85), and IKDC 2000 (Pre-testing: 66.66% ± 9.85; Post-testing: 76.05% ± 14.62) (p < 0.032). Administering mechanical perturbation training using compliant surfaces induce effects similar to manual perturbation training on knee functional performance after acute ACL-rupture. The clinical significance is both modes of training improve patients' functional-performance and limb-to-limb movement symmetry, and enhancing the patients' self-reported of knee functional measures after ACL rupture. Mechanical perturbation that provides a compliant surface might be utilized as part of the ACL rehabilitation training. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

Knee-Extension Torque Variability and Subjective Knee Function in Patients with a History of Anterior Cruciate Ligament Reconstruction.

PubMed

Goetschius, John; Hart, Joseph M

2016-01-01

When returning to physical activity, patients with a history of anterior cruciate ligament reconstruction (ACL-R) often experience limitations in knee-joint function that may be due to chronic impairments in quadriceps motor control. Assessment of knee-extension torque variability may demonstrate underlying impairments in quadriceps motor control in patients with a history of ACL-R. To identify differences in maximal isometric knee-extension torque variability between knees that have undergone ACL-R and healthy knees and to determine the relationship between knee-extension torque variability and self-reported knee function in patients with a history of ACL-R. Descriptive laboratory study. Laboratory. A total of 53 individuals with primary, unilateral ACL-R (age = 23.4 ± 4.9 years, height = 1.7 ± 0.1 m, mass = 74.6 ± 14.8 kg) and 50 individuals with no history of substantial lower extremity injury or surgery who served as controls (age = 23.3 ± 4.4 years, height = 1.7 ± 0.1 m, mass = 67.4 ± 13.2 kg). Torque variability, strength, and central activation ratio (CAR) were calculated from 3-second maximal knee-extension contraction trials (90° of flexion) with a superimposed electrical stimulus. All participants completed the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and we determined the number of months after surgery. Group differences were assessed using independent-samples t tests. Correlation coefficients were calculated among torque variability, strength, CAR, months after surgery, and IKDC scores. Torque variability, strength, CAR, and months after surgery were regressed on IKDC scores using stepwise, multiple linear regression. Torque variability was greater and strength, CAR, and IKDC scores were lower in the ACL-R group than in the control group (P < .05). Torque variability and strength were correlated with IKDC scores (P < .05). Torque variability, strength, and CAR were correlated with each other (P < .05). Torque variability alone accounted for 14.3% of the variance in IKDC scores. The combination of torque variability and number of months after surgery accounted for 21% of the variance in IKDC scores. Strength and CAR were excluded from the regression model. Knee-extension torque variability was moderately associated with IKDC scores in patients with a history of ACL-R. Torque variability combined with months after surgery predicted 21% of the variance in IKDC scores in these patients.

Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction.

PubMed

Webster, Kate E; Feller, Julian A; Leigh, Warren B; Richmond, Anneka K

2014-03-01

Graft rupture of the same knee or injury to the anterior cruciate ligament (ACL) in the contralateral knee is a devastating outcome after ACL reconstruction surgery. While a number of factors have been identified as potentially increasing the risk of subsequent ACL injury, the literature is far from definitive. To determine the rates of graft rupture and contralateral ACL injury in a large cohort and to investigate patient characteristics that may be associated with these. Case-control study; Level of evidence, 3. A consecutive cohort of 750 patients who had undergone primary ACL reconstruction surgery with a minimum 3-year follow-up were questioned about the incidence of ACL graft rupture, contralateral ACL injury, family history of ACL injury, and current activity level. Patient databases provided details for age, sex, original injury mechanism, meniscus or articular surface injury, and graft diameter. Responses were received from 561 patients (75%) at a mean ± SD follow-up time of 4.8 ± 1.1 years. Anterior cruciate ligament graft ruptures occurred in 25 patients (4.5%), and contralateral ACL injuries occurred in 42 patients (7.5%). The highest incidence of further ACL injury occurred in patients younger than 20 years at the time of surgery. In this group, 29% sustained a subsequent ACL injury to either knee. The odds for sustaining an ACL graft rupture or contralateral injury increased 6- and 3-fold, respectively, for patients younger than 20 years. Returning to cutting/pivoting sports increased the odds of graft rupture by a factor of 3.9 and contralateral rupture by a factor of 5. A positive family history doubled the odds for both graft rupture and contralateral ACL injury. Patients younger than 20 years who undergo ACL reconstruction are at significantly increased risk for both graft rupture and contralateral ACL injury. Whether age per se is a risk factor or age represents a proxy for other factors remains to be determined.

Initial treatment of complete rotator cuff tear and transition to surgical treatment: systematic review of the evidence

PubMed Central

Abdul-Wahab, Taiceer A.; Betancourt, Jean P.; Hassan, Fadi; Thani, Saeed Al.; Choueiri, Hened; Jain, Nitin B.; Malanga, Gerard A.; Murrell, William D.; Prasad, Anil; Verborgt, Olivier

2016-01-01

Summary Background rotator cuff tear affects many people. Natural history, and evidence for non-operative treatment remains limited. Our objective is to assess evidence available for the efficacy and morbidity of commonly used systemic medications, physiotherapy, and injections alongside evaluating any negative long-term effects. Methods a systematic search was performed of PubMed, Cochrane, EMBASE and CINAHL dates (1 January 1960 – 1 December 2014), search terms: ‘rotator cuff tear’, ‘natural history’, ‘atraumatic’, ‘injection’, ‘physiotherapy’ or ‘physical therapy’, ‘injection’, ‘corticosteroid’, ‘PRP‘, ‘MSC’, risk of conservative treatment’, and ‘surgical indication’. Results eleven studies were included. The mean Coleman Methodology Score modified for conservative therapy is 69.21 (range 88–44) (SD 12.31). This included 2 RCTs, 7 prospective, and 2 retrospective studies. Evidence suggests it is safe to monitor symptomatic rotator cuff tears, as tear size and symptoms are not correlated with pain, function, and/or ultimate outcome. Conclusions complete rotator cuff tears may be effectively treated with injections, exercise in the short and intermediate terms respectively. Negative effect of corticosteroids on rotator cuff tissue has not been demonstrated. Timing to end conservative treatment is unknown, but likely indicated when a patient demonstrates increased weakness and loss of function not recoverable by physiotherapy. PMID:27331030

Perceived personal importance of exercise and fears of re-injury: a longitudinal study of psychological factors related to activity after anterior cruciate ligament reconstruction.

PubMed

Gignac, Monique Am; Cao, Xingshan; Ramanathan, Subha; White, Lawrence M; Hurtig, Mark; Kunz, Monica; Marks, Paul H

2015-01-01

Psychological perceptions are increasingly being recognized as important to recovery and rehabilitation post-surgery. This research longitudinally examined perceptions of the personal importance of exercise and fears of re-injury over a three-year period post anterior cruciate ligament (ACL) reconstruction. Stability and change in psychological perceptions was examined, as well as the association of perceptions with time spent in different types of physical activity, including walking, household activities, and lower and higher risk for knee injury activities. Participants were athletes, 18-40 years old, who underwent ACL reconstruction for first-time ACL injuries. They were recruited from a tertiary care centre in Toronto, Canada. Participants completed interviewer-administered questionnaires pre-surgery and at years one, two and three, postoperatively. Questions assessed demographics, pain, functional limitations, perceived personal importance of exercise, fear of re-injury and physical activities (i.e., walking; household activities; lower risk for knee injury activities; higher risk for knee injury activities). Analyses included fixed-effect longitudinal modeling to examine the association of a fear of re-injury and perceived personal importance of exercise and changes in these perceptions with the total hours spent in the different categories of physical activities, controlling for other factors. Baseline participants were 77 men and 44 women (mean age = 27.6 years; SD = 6.2). At year three, 78.5% of participants remained in the study with complete data. Fears of re-injury decreased over time while personal importance of exercise remained relatively stable. Time spent in walking and household activities did not significantly change with ACL injury or surgery. Time spent in lower and higher risk of knee injury physical activity did not return to pre-injury levels at three years, post-surgery. Greater time spent in higher risk of knee injury activities was predicted by decreases in fears of re-injury and by greater personal importance of exercise. This study highlights not only fears of re-injury, which has been documented in previous studies, but also the perceived personal importance of exercise in predicting activity levels following ACL reconstructive surgery. The findings can help in developing interventions to aid individuals make decisions about physical activities post knee injury and surgery.

Rotator cuff tear following long-standing axillary neuropathy in a female motocross racer.

PubMed

Skedros, John G; Henrie, Tanner R; Peterson, Mitchell D

2018-06-15

A 'terrible triad' of anterior shoulder dislocation, axillary nerve damage and rotator cuff tear has been previously described. However, we are unaware of any report of anterior shoulder dislocation, humeral fracture, axillary neuropathy and subsequent rotator cuff tear requiring surgery when the axillary neuropathy was deemed permanent. We report the case of a 20-year-old woman who fell in a motocross accident and had an anterior shoulder dislocation, humeral fracture and axillary neuropathy. The fracture was treated surgically with open reduction and internal fixation. The axillary nerve injury was ultimately permanent. Thirteen months after the motocross accident, the patient sustained a rotator cuff tear from seemingly minor trauma. However, several months of aggressive physical therapy preceded the rotator cuff tear. The tear was repaired and the patient was followed for 5 years after the initial injury. She returned to competing in motocross, even though the axillary neuropathy remained complete and permanent. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Abnormal tibiofemoral contact stress and its association with altered kinematics following center-center ACL reconstruction: an in vitro study

PubMed Central

Imhauser, Carl; Mauro, Craig; Choi, Daniel; Rosenberg, Eric; Mathew, Stephen; Nguyen, Joseph; Ma, Yan; Wickiewicz, Thomas

2014-01-01

Background Abnormal tibiofemoral contact stress and aberrant kinematics may influence the progression of osteoarthritis in the ACL-deficient and the ACL-reconstructed knee. However, relationships between contact stress and kinematics following ACL reconstruction are poorly understood. Therefore, we posed the following research questions: (1) How do ACL deficiency and reconstruction affect kinematics of and contact stress in the tibiofemoral joint? (2) What kinematic differences are associated with abnormal contact stress following ACL reconstruction? Hypothesis/Purpose Center-center ACL reconstruction will not restore knee kinematics and contact stress. Correlations will exist between abnormal contact stress and aberrant kinematics following ACL reconstruction will exist. Study Design Controlled laboratory study Methods Clinical tests of anterior and rotational stability were simulated on eleven cadaveric knees using an industrial robot. Tests were conducted with the ACL intact, sectioned, and after single bundle ACL reconstruction using a quadrupled hamstring autograft with tunnels drilled through the center of the native footprints. Kinematics were recorded during the tests. Contact stress was continuously recorded from a stress transducer fixed to the tibial plateau and mean contact stress was calculated regionally. Results ACL deficiency resulted in increased mean contact stress in the posterior sectors of the medial and lateral compartments under anterior and rotational loads, respectively. Reconstruction reduced stress in these locations; however contact stress abnormalities remained. On average, kinematics were overconstrained following ACL reconstruction (≤1.8mm and ≤2.6° in all directions). However, combinations of overconstrained and underconstrained motions in ab/adduction and medial-lateral translation in response to combined moments, and axial rotation, anterior-posterior and medial-lateral translation in response to an anterior load were associated with abnormal mean contact stress. Conclusions ACL reconstruction reduces high stresses generated in the posterior compartment of the ACL-deficient knee. Abnormal contact stress following ACL reconstruction is related to multiplanar variations in knee kinematics. Clinical Relevance Clinical measures of multiplanar kinematics may help to better characterize the quality of ACL reconstruction. Such measures may help identify those at increased risk of long-term joint degeneration following this surgery. PMID:23470858

50 CFR 648.70 - Surfclam and ocean quahog Annual Catch Limit (ACL).

Code of Federal Regulations, 2013 CFR

2013-10-01

... Limit (ACL). 648.70 Section 648.70 Wildlife and Fisheries FISHERY CONSERVATION AND MANAGEMENT, NATIONAL... Annual Catch Limit (ACL). (a) The MAFMC staff shall recommend to the MAFMC ACLs for the surfclam and... Surfclam and Ocean Quahog FMP. The ACL for ocean quahog will then be allocated to the Maine and non-Maine...

50 CFR 648.233 - Spiny dogfish Accountability Measures (AMs).

Code of Federal Regulations, 2012 CFR

2012-10-01

... vessels issued a spiny dogfish permit under this part. (b) ACL overage evaluation. The ACL will be... determine if the ACL has been exceeded. (c) Overage repayment. In the event that the ACL has been exceeded in a given fishing year, the exact amount in pounds by which the ACL was exceeded shall be deducted...

50 CFR 648.70 - Surfclam and ocean quahog Annual Catch Limit (ACL).

Code of Federal Regulations, 2014 CFR

2014-10-01

... Limit (ACL). 648.70 Section 648.70 Wildlife and Fisheries FISHERY CONSERVATION AND MANAGEMENT, NATIONAL... Annual Catch Limit (ACL). (a) The MAFMC staff shall recommend to the MAFMC ACLs for the surfclam and... Surfclam and Ocean Quahog FMP. The ACL for ocean quahog will then be allocated to the Maine and non-Maine...

50 CFR 648.233 - Spiny dogfish Accountability Measures (AMs).

Code of Federal Regulations, 2013 CFR

2013-10-01

... vessels issued a spiny dogfish permit under this part. (b) ACL overage evaluation. The ACL will be... determine if the ACL has been exceeded. (c) Overage repayment. In the event that the ACL has been exceeded in a given fishing year, the exact amount in pounds by which the ACL was exceeded shall be deducted...

50 CFR 648.70 - Surfclam and ocean quahog Annual Catch Limit (ACL).

Code of Federal Regulations, 2012 CFR

2012-10-01

... Limit (ACL). 648.70 Section 648.70 Wildlife and Fisheries FISHERY CONSERVATION AND MANAGEMENT, NATIONAL... Annual Catch Limit (ACL). (a) The MAFMC staff shall recommend to the MAFMC ACLs for the surfclam and... Surfclam and Ocean Quahog FMP. The ACL for ocean quahog will then be allocated to the Maine and non-Maine...

50 CFR 622.49 - Annual catch limits (ACLs) and accountability measures (AMs).

Code of Federal Regulations, 2012 CFR

2012-10-01

... limit (ACL), the AA will file a notification with the Office of the Federal Register, at or near the...-year ACL was exceeded. The commercial ACL for 2010 and subsequent fishing years is 138,000 lb (62,596 kg). (ii) Recreational sector. If recreational landings, as estimated by the SRD, exceed the ACL, the...

50 CFR 648.53 - Acceptable biological catch (ABC), annual catch limits (ACL), annual catch targets (ACT), DAS...

Code of Federal Regulations, 2013 CFR

2013-10-01

... catch limits (ACL), annual catch targets (ACT), DAS allocations, and individual fishing quotas (IFQ... limits (ACL), annual catch targets (ACT), DAS allocations, and individual fishing quotas (IFQ). (a... process specified in § 648.55 and is equal to the overall scallop fishery ACL. The ABC/ACL shall be...

50 CFR 648.233 - Spiny dogfish Accountability Measures (AMs).

Code of Federal Regulations, 2011 CFR

2011-10-01

... vessels issued a spiny dogfish permit under this part. (b) ACL overage evaluation. The ACL will be... determine if the ACL has been exceeded. (c) Overage repayment. In the event that the ACL has been exceeded in a given fishing year, the exact amount in pounds by which the ACL was exceeded shall be deducted...

50 CFR 648.290 - Individual fishing quota program and other restrictions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Limit (ACL). (a) The Tilefish Monitoring Committee shall recommend to the MAFMC an ACL for the...) Periodicity. The tilefish commercial ACL may be established on an annual basis for up to 3 years at a time... the sector ACLs at least every 5 years. (1) If the ACL is exceeded with a frequency greater than 25...

50 CFR 648.53 - Acceptable biological catch (ABC), annual catch limits (ACL), annual catch targets (ACT), DAS...

Code of Federal Regulations, 2014 CFR

2014-10-01

... catch limits (ACL), annual catch targets (ACT), DAS allocations, and individual fishing quotas (IFQ... limits (ACL), annual catch targets (ACT), DAS allocations, and individual fishing quotas (IFQ). (a... process specified in § 648.55 and is equal to the overall scallop fishery ACL. The ABC/ACL shall be...

Hyperosmolar Tears Induce Functional and Structural Alterations of Corneal Nerves: Electrophysiological and Anatomical Evidence Toward Neurotoxicity

PubMed Central

Hirata, Harumitsu; Mizerska, Kamila; Marfurt, Carl F.; Rosenblatt, Mark I.

2015-01-01

Purpose In an effort to elucidate possible neural mechanisms underlying diminished tearing in dry eye disease, this study sought to determine if hyperosmolar tears, a ubiquitous sign of dry eye disease, produce functional changes in corneal nerve responses to drying of the cornea and if these changes correlate with alterations in corneal nerve morphology. Methods In vivo extracellular electrophysiological recordings were performed in rat trigeminal ganglion neurons that innervated the cornea before, and up to 3 hours after, the ocular application of continuous hyperosmolar tears or artificial tears. In corollary experiments, immunohistochemical staining was performed to compare corneal nerve morphology in control and in eyes treated with hyperosmolar solutions. Results Our previous studies identified a population of corneal afferents, dry-sensitive neurons that are strongly excited by corneal dessication (“dry response”), a response thought to trigger the lacrimation reflex. In the present study, we found that the dry responses of corneal dry-sensitive neurons were depressed or even completely abolished by hyperosmolar tears in a time- (30 minutes to 3 hours) and dose (450- to 1000-mOsm solutions)-dependent manner. Furthermore, eyes treated with hyperosmolar tears for 3 hours contained large numbers of morphologically abnormal (granular, fragmented, or prominently beaded) subbasal nerves that appeared to be undergoing degeneration. Conclusions These results demonstrate that tear hyperosmolarity, considered to be a “core” mechanism of dry eye disease, significantly decreases physiological sensitivity and morphologic integrity of the corneal nerves important in tear production. These alterations might contribute to the diminished tearing seen clinically in dry eye patients. PMID:26720465

Hyperosmolar Tears Induce Functional and Structural Alterations of Corneal Nerves: Electrophysiological and Anatomical Evidence Toward Neurotoxicity.

PubMed

Hirata, Harumitsu; Mizerska, Kamila; Marfurt, Carl F; Rosenblatt, Mark I

2015-12-01

In an effort to elucidate possible neural mechanisms underlying diminished tearing in dry eye disease, this study sought to determine if hyperosmolar tears, a ubiquitous sign of dry eye disease, produce functional changes in corneal nerve responses to drying of the cornea and if these changes correlate with alterations in corneal nerve morphology. In vivo extracellular electrophysiological recordings were performed in rat trigeminal ganglion neurons that innervated the cornea before, and up to 3 hours after, the ocular application of continuous hyperosmolar tears or artificial tears. In corollary experiments, immunohistochemical staining was performed to compare corneal nerve morphology in control and in eyes treated with hyperosmolar solutions. Our previous studies identified a population of corneal afferents, dry-sensitive neurons that are strongly excited by corneal dessication ("dry response"), a response thought to trigger the lacrimation reflex. In the present study, we found that the dry responses of corneal dry-sensitive neurons were depressed or even completely abolished by hyperosmolar tears in a time- (30 minutes to 3 hours) and dose (450- to 1000-mOsm solutions)-dependent manner. Furthermore, eyes treated with hyperosmolar tears for 3 hours contained large numbers of morphologically abnormal (granular, fragmented, or prominently beaded) subbasal nerves that appeared to be undergoing degeneration. These results demonstrate that tear hyperosmolarity, considered to be a "core" mechanism of dry eye disease, significantly decreases physiological sensitivity and morphologic integrity of the corneal nerves important in tear production. These alterations might contribute to the diminished tearing seen clinically in dry eye patients.

Posterior Root Meniscal Tears: Preoperative, Intraoperative, and Postoperative Imaging for Transtibial Pullout Repair.

PubMed

Palisch, Andrew R; Winters, Ronald R; Willis, Marc H; Bray, Collin D; Shybut, Theodore B

2016-10-01

The menisci play an important biomechanical role in axial load distribution of the knees by means of hoop strength, which is contingent on intact circumferentially oriented collagen fibers and meniscal root attachments. Disruption of the meniscal root attachments leads to altered biomechanics, resulting in progressive cartilage loss, osteoarthritis, and subchondral edema, with the potential for development of a subchondral insufficiency fracture. Identification of meniscal root tears at magnetic resonance (MR) imaging is crucial because new arthroscopic surgical techniques (transtibial pullout repair) have been developed to repair meniscal root tears and preserve the tibiofemoral cartilage of the knee. An MR imaging classification of posterior medial meniscal root ligament lesions has been recently described that is dedicated to the posterior root of the medial meniscus. An arthroscopic classification of meniscal root tears has been described that can be applied to the anterior and posterior roots of both the medial meniscus and the lateral meniscus. This arthroscopic classification includes type 1, partial stable root tears; type 2, complete radial root tears; type 3, vertical longitudinal bucket-handle tears; type 4, complex oblique tears; and type 5, bone avulsion fractures of the root attachments. Knowledge of these classifications and the potential contraindications to meniscal root repair can aid the radiologist in the preoperative reporting of meniscal root tear types and the evaluation of the tibiofemoral cartilage. As more patients undergo arthroscopic repair of meniscal root tears, familiarity with the surgical technique and the postoperative radiographic and MR imaging appearance is important to adequately report the imaging findings. © RSNA, 2016.

Do Magnetic Resonance Imaging Characteristics of Full-Thickness Rotator Cuff Tears Correlate With Sleep Disturbance?

PubMed

Reyes, Bryan A; Hull, Brandon R; Kurth, Alexander B; Kukowski, Nathan R; Mulligan, Edward P; Khazzam, Michael S

2017-11-01

Many patients with rotator cuff tears suffer from nocturnal shoulder pain, resulting in sleep disturbance. To determine whether rotator cuff tear size correlated with sleep disturbance in patients with full-thickness rotator cuff tears. Cross-sectional study; Level of evidence, 3. Patients with a diagnosis of unilateral full-thickness rotator cuff tears (diagnosed via magnetic resonance imaging [MRI]) completed the Pittsburgh Sleep Quality Index (PSQI), a visual analog scale (VAS) quantifying their shoulder pain, and the American Shoulder and Elbow Surgeons (ASES) questionnaire. Shoulder MRI scans were analyzed for anterior-posterior tear size (mm), tendon retraction (mm), Goutallier grade (0-4), number of tendons involved (1-4), muscle atrophy (none, mild, moderate, or severe), and humeral head rise (present or absent). Bivariate correlations were calculated between the MRI characteristics and baseline survey results. A total of 209 patients with unilateral full-thickness rotator cuff tears were included in this study: 112 (54%) female and 97 (46%) male (mean age, 64.1 years). On average, shoulder pain had been present for 24 months. The mean PSQI score was 9.8, and the mean VAS score was 5.0. No significant correlations were found between any of the rotator cuff tear characteristics and sleep quality. Only tendon retraction had a significant correlation with pain. Although rotator cuff tears are frequently associated with nocturnal pain and sleep disruption, this study demonstrated that morphological characteristics of full-thickness rotator cuff tears, such as size and tendon retraction, do not correlate with sleep disturbance and have little to no correlation with pain levels.

Basic science of anterior cruciate ligament injury and repair

PubMed Central

Kiapour, A. M.; Murray, M. M.

2014-01-01

Injury to the anterior cruciate ligament (ACL) is one of the most devastating and frequent injuries of the knee. Surgical reconstruction is the current standard of care for treatment of ACL injuries in active patients. The widespread adoption of ACL reconstruction over primary repair was based on early perception of the limited healing capacity of the ACL. Although the majority of ACL reconstruction surgeries successfully restore gross joint stability, post-traumatic osteoarthritis is commonplace following these injuries, even with ACL reconstruction. The development of new techniques to limit the long-term clinical sequelae associated with ACL reconstruction has been the main focus of research over the past decades. The improved knowledge of healing, along with recent advances in tissue engineering and regenerative medicine, has resulted in the discovery of novel biologically augmented ACL-repair techniques that have satisfactory outcomes in preclinical studies. This instructional review provides a summary of the latest advances made in ACL repair. Cite this article: Bone Joint Res 2014;3:20–31. PMID:24497504

Posterior Cruciate Ligament Injuries Associated With Military Survival Swim Training.

PubMed

Crowell, Michael S; Mason, John S; Posner, Matthew A; Haley, Chad A

2017-07-01

Posterior cruciate ligament (PCL) injuries are relatively common injuries associated with athletic activities and high-energy trauma. Posterolateral corner (PLC) injuries frequently accompany injury to the PCL. Diagnosis can be challenging and requires a comprehensive history and physical examination. Patients frequently report vague, nonspecific symptoms and the mechanism of injury is often useful in localizing injured structures. Two of the more common mechanisms for PCL injury include a direct blow to the proximal anterior tibia with the knee flexed, as well as a significant knee hyperextension injury. With a PCL tear, patients rarely describe an audible "pop" that is commonly reported in ACL injuries. On physical exam, a frequent finding in PCL tears is a loss of 10 to 20° of knee flexion. Although the most common clinical tests for PCL tears include the posterior drawer test, the posterior sag sign, and the quadriceps active test, there is a lack of high-quality diagnostic accuracy studies. Two cases of U.S. Military Academy Cadets who sustained PCL injuries while removing combat boots during military survival swim training are presented. The results of the clinical examination are accompanied by magnetic resonance imaging results and intraoperative arthroscopic images to highlight key findings. Both patients were evaluated and diagnosed with PCL injures within 10 days of their injuries. Each reported feeling/hearing a "pop," which is atypical in PCL tears. Both patients demonstrated a lack of active and passive knee flexion, which is a commonly reported impairment. One patient was managed nonsurgically with physical therapy and eventually returned to full duty without limitations 9 months after his injury. The other patient, who sustained a combined PCL-PLC injury, underwent a PCL reconstruction and PLC repair and reconstruction 8 weeks after his injury. He returned all training, with the exception of contact/collision sports, 9 months after surgery. Both patient's rehabilitation programs consisted of a progression of exercises to improve range of motion, muscle strength/endurance, motor control, and muscular power. Military and sports medicine professionals should be aware of the potential for PCL injury with this unusual, and previously unreported, mechanism of injury during survival swim training. Prompt diagnosis and appropriate treatment is essential to prevent long-term disability. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

50 CFR 622.12 - Annual catch limits (ACLs) and accountability measures (AMs) for Caribbean island management...

Code of Federal Regulations, 2013 CFR

2013-10-01

... ACL, as specified in paragraph (a)(1) of this section for Puerto Rico management area species or... ensure landings do not exceed the applicable ACL. If NMFS determines the ACL for a particular species or... relative to the applicable ACL based on a moving multi-year average of landings, as described in the FMP...

77 FR 10668 - Fisheries of the Northeastern United States; Atlantic Herring Fishery; Sub-ACL (Annual Catch...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-23

...-ACL (Annual Catch Limit) Harvested for Management Area 2 AGENCY: National Marine Fisheries Service... biological catch, annual catch limit (ACL), optimum yield, domestic harvest and processing, U.S. at-sea...,200 metric tons (mt); the 2012 sub-ACL allocated to Area 2 is 22,146 mt, and 0 mt of the sub-ACL is...

77 FR 32914 - Snapper-Grouper Fishery of the South Atlantic; 2012 Recreational Accountability Measure and...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-04

... landings from 2010 and 2011 exceeded the recreational annual catch limit (ACL) for golden tilefish. To... mitigate overages of the ACL if they occur. The final rule for Amendment 17B established ACLs for eight... implemented if these ACLs are reached or exceeded (75 FR 82280, December 30, 2010). The recreational ACL for...

50 CFR 648.22 - Closure of the fishery.

Code of Federal Regulations, 2011 CFR

2011-10-01

... specified for a period of up to 3 years; (2) ACL; ACT including RSA, DAH, DAP; bycatch level of the TALFF... review, may be specified for a period of up to 3 years; (3) ACL; commercial ACT, including RSA, DAH, DAP... less than or equal to the OFL. (ii) ACL. The ACL or Domestic ABC is calculated using the formula ACL...

78 FR 21071 - Fisheries of the Northeastern United States; Atlantic Herring Fishery; Sub-ACL (Annual Catch...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-09

...-ACL (Annual Catch Limit) Harvested for Management Area 2 AGENCY: National Marine Fisheries Service... limit (ACL), optimum yield, domestic harvest and processing, U.S. at-sea processing, border transfer...); the 2013 sub-ACL allocated to Area 2 is 22,146 mt, and 0 mt of the sub-ACL is set aside for research...

50 CFR 622.41 - Annual catch limits (ACLs), annual catch targets (ACTs), and accountability measures (AMs).

Code of Federal Regulations, 2014 CFR

2014-10-01

..., exceed the commercial ACL, as specified in (a)(1)(iii) of this section, the AA will file a notification... reduce the commercial ACT (commercial quota) and the commercial ACL for that following year by the amount of any commercial ACL overage in the prior fishing year. (iii) The commercial ACL for greater...

50 CFR 622.12 - Annual catch limits (ACLs) and accountability measures (AMs) for Caribbean island management...

Code of Federal Regulations, 2014 CFR

2014-10-01

... ACL, as specified in paragraph (a)(1) of this section for Puerto Rico management area species or... ensure landings do not exceed the applicable ACL. If NMFS determines the ACL for a particular species or... relative to the applicable ACL based on a moving multi-year average of landings, as described in the FMP...

76 FR 14367 - Fisheries in the Western Pacific; Mechanism for Specifying Annual Catch Limits and Accountability...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-16

... have statutory exceptions to the ACL and AM requirements. The intent of the amendment is end and... being exceeded, and to correct or mitigate any overages of the ACL. The ACL and AM mechanism would be... prevent ACLs from being exceeded or to mitigate overages of an ACL, including use of annual catch targets...

50 CFR 622.41 - Annual catch limits (ACLs), annual catch targets (ACTs), and accountability measures (AMs).

Code of Federal Regulations, 2013 CFR

2013-10-01

..., exceed the commercial ACL, as specified in (a)(1)(iii) of this section, the AA will file a notification... reduce the commercial ACT (commercial quota) and the commercial ACL for that following year by the amount of any commercial ACL overage in the prior fishing year. (iii) The commercial ACL for greater...

Histological analysis of the tibial anterior cruciate ligament insertion.

PubMed

Oka, Shinya; Schuhmacher, Peter; Brehmer, Axel; Traut, Ulrike; Kirsch, Joachim; Siebold, Rainer

2016-03-01

This study was performed to investigate the morphology of the tibial anterior cruciate ligament (ACL) by histological assessment. The native (undissected) tibial ACL insertion of six fresh-frozen cadaveric knees was cut into four sagittal sections parallel to the long axis of the medial tibial spine. For histological evaluation, the slices were stained with haematoxylin and eosin, Safranin O and Russell-Movat pentachrome. All slices were digitalized and analysed at a magnification of 20×. The anterior tibial ACL insertion was bordered by a bony anterior ridge. The most medial ACL fibres inserted from the medial tibial spine and were adjacent to the articular cartilage of the medial tibial plateau. Parts of the bony insertions of the anterior and posterior horns of the lateral meniscus were in close contact with the lateral part of the tibial ACL insertion. A small fat pad was located just posterior to the functional ACL fibres. The anterior-posterior length of the medial ACL insertion was an average of 10.8 ± 1.1 mm compared with the lateral, which was only 6.2 ± 1.1 mm (p < 0.001). There were no central or posterolateral inserting ACL fibres. The shape of the bony tibial ACL insertion was 'duck-foot-like'. In contrast to previous findings, the functional mid-substance fibres arose from the most posterior part of the 'duck-foot' in a flat and 'c-shaped' way. The most anterior part of the tibial ACL insertion was bordered by a bony anterior ridge and the most medial by the medial tibial spine. No posterolateral fibres nor ACL bundles have been found histologically. This histological investigation may improve our understanding of the tibial ACL insertion and may provide important information for anatomical ACL reconstruction.

The Influence of Knee Flexion Angle for Graft Fixation on Rotational Knee Stability During Anterior Cruciate Ligament Reconstruction: A Biomechanical Study.

PubMed

Debandi, Aníbal; Maeyama, Akira; Hoshino, Yuichi; Asai, Shigehiro; Goto, Bunsei; Smolinski, Patrick; Fu, Freddie H

2016-11-01

To evaluate the effect of knee flexion angle for hamstring graft fixation, full extension (FE), or 30°, on acceleration of the knee motion during pivot-shift testing after either anatomic or nonanatomic anterior cruciate ligament (ACL) reconstruction using triaxial accelerometry. Two types of ACL reconstructions (anatomic and nonanatomic) using 2 different angles of knee flexion during graft fixation (FE and 30°) were performed on 12 fresh-frozen human knees making 4 groups: anatomic-FE, anatomic-30°, nonanatomic-FE, and nonanatomic-30°. Manual pivot-shift testing was performed at ACL-intact, ACL-deficient, and ACL-reconstructed conditions. Three-dimensional acceleration of knee motion was recorded using a triaxial accelerometer. The anatomic-30° group showed the smallest overall magnitude of acceleration among the ACL-reconstructed groups (P = .0039). There were no significant differences among the anatomic-FE group, the nonanatomic-FE group, and the nonantomic-30° group (anatomic-FE vs nonanatomic-FE, P = .1093; anatomic-FE vs nonanatomic-30°, P = .8728; and nonanatomic-FE vs nonanatomic-30°, P = .1093). After ACL transection, acceleration was reduced by ACL reconstruction with the exception of the nonanatomic-FE group that did not show a significant difference when compared with the ACL-deficient (P = .4537). The anatomic ACL reconstruction with the graft fixed at 30° of knee flexion better restored rotational knee stability compared with FE. An ACL graft fixed with the knee at FE in anatomic position did not show a significant difference compared with the nonanatomic ACL reconstructions. Knee flexion angle at the time of graft fixation for ACL reconstruction can be considered to maximize the rotational knee stability. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Contact Stress and Kinematic Analysis of All-Epiphyseal and Over-the-Top Pediatric Reconstruction Techniques for the Anterior Cruciate Ligament

PubMed Central

McCarthy, Moira M.; Tucker, Scott; Nguyen, Joseph T.; Green, Daniel W.; Imhauser, Carl W.; Cordasco, Frank A.

2014-01-01

Background Anterior cruciate ligament (ACL) injuries are an increasingly recognized problem in the pediatric population. Unfortunately, outcomes with conservative treatment are extremely poor. Furthermore, adult reconstruction techniques may be inappropriate to treat skeletally immature patients due to the risk of physeal complications. “Physeal-sparing” reconstruction techniques exist but their ability to restore knee stability and contact mechanics is not well understood. Purpose (1) To assess the ability of the all-epiphyseal (AE) and over-the-top (OT) reconstructions to restore knee kinematics; (2) to assess whether these reconstructions decrease the high posterior contact stresses seen with ACL deficiency; (3) to determine whether the AE or OT produce abnormal tibiofemoral contact stresses. Hypothesis The AE reconstruction will restore contact mechanics and kinematics similarly to that of the ACL intact knee. Methods Ten fresh-frozen human cadaveric knees were tested using a robotic manipulator. Tibiofemoral motions were recorded with the ACL intact, after sectioning the ACL, and after both reconstructions in each of the 10 specimens. The AE utilized an all-inside technique with tunnels exclusively within the epiphysis and fixed with suspensory cortical fixation devices. The OT had a central and vertical tibial tunnel with an over-the-top femur position and was fixed with staples and posts on both ends. Anterior stability was assessed with 134N anterior force at 0, 15, 30, 60, and 90° of knee flexion. Rotational stability was assessed with combined 8 Nm and 4 Nm of abduction and internal rotation, respectively, at 5, 15, and 30° of knee flexion. Results Both reconstruction techniques offloaded the posterior aspect of the tibial plateau compared to the ACL deficient knee in response to both anterior loads and combined moments as demonstrated by reduced contact stresses in this region at all flexion angles. Compared to the ACL intact condition, both the AE and OT had increased posteromedial contact stresses in response to anterior load at some flexion angles and the OT had increased peripheral posterolateral contact stresses at 15° in response to combined moments. Neither reconstruction completely restored the mid-joint contact stresses. Both reconstruction techniques restored anterior stability at flexion angles less than or equal to 30°. In contrast, neither reconstruction restored anterior stability at 60 and 90° flexion. Both reconstructions restored coupled anterior translation under combined moments. Additionally, the AE over-constrained internal rotation in response to the combined moments by 12% at 15° flexion. Conclusions Both reconstructions provide anterior and rotational stability, and decrease posterior joint contact stresses compared to the ACL deficient knee. However, neither reconstruction restored the contact mechanics and kinematics of the ACL intact knee. Clinical Relevance Since the AE reconstruction has clinical advantages over the OT, our results support the hypothesis that the new AE technique is a potential candidate for use in the skeletally immature athlete. PMID:23613444

Analysis of change in gait in the ovine stifle: normal, injured, and anterior cruciate ligament reconstructed.

PubMed

Heard, B J; Beveridge, J E; Atarod, M; O'Brien, E J; Rolian, C; Frank, C B; Hart, D A; Shrive, N G

2017-05-23

Many patients who undergo anterior cruciate ligament (ACL) reconstructive surgery develop post-traumatic osteoarthritis (PTOA). ACL reconstructive surgery may not fully restore pre-injury joint biomechanics, thereby resulting in further joint damage and contributing to the development of PTOA. In an ovine model of idealized ACL reconstruction (ACL-R), it has been shown that signs of PTOA develop within surgical joints by 20 weeks post-surgery. The aim of the present study was to investigate whether altered kinematics contribute to early PTOA development within ACL-R joints of the ovine injury model by comparing the gait of these surgical animals to the gait of a stable normal control group, and an unstable injury group in which the ACL and medial collateral ligament (MCL) had been transected. Fifteen skeletally mature female sheep were allocated evenly into 3 treatment groups: normal control, ACL-R, and ACL/MCL Tx (each group n = 5). Each animal's gait was recorded at baseline, 4 weeks post injury, and 20 weeks post injury. Principal component analysis (PCA) was used to identify the kinematic patterns that may be discriminant between treatment groups. Results from previous studies were referenced to present the amount of gross PTOA-like changes that occurred in the joints. ACL-R and ACL/MCL transected (Tx) animals developed a similar amount of early PTOA-like changes within the surgical joints, but differed significantly in the amount of kinematic change present at 20 weeks post-surgery. We showed that the stifle joint kinematics of ACL/MCL Tx differed significantly from those of CTRL and the majority of ACL-R animals, while no significant differences in joint kinematic changes were found between ACL-R and CTRL animals. These results suggest that the early PTOA-like changes reported in the ACL-R model cannot be attributed exclusively to post-surgical kinematic changes, and therefore biologic components in the post-injury environment must be contributing significantly to PTOA development.

Jump-Landing Biomechanics and Knee-Laxity Change Across the Menstrual Cycle in Women With Anterior Cruciate Ligament Reconstruction

PubMed Central

Bell, David R.; Blackburn, J. Troy; Hackney, Anthony C.; Marshall, Stephen W.; Beutler, Anthony I.; Padua, Darin A.

2014-01-01

Context: Of the individuals able to return to sport participation after an anterior cruciate ligament(ACL) injury, up to 25% will experience a second ACL injury. This population may be more sensitive to hormonal fluctuations, which may explain this high rate of second injury. Objective: To examine changes in 3-dimensional hip and knee kinematics and kinetics during a jump landing and to examine knee laxity across the menstrual cycle in women with histories of unilateral noncontact ACL injury. Design  Controlled laboratory study. Setting: Laboratory. Patients or Other Participants: A total of 20 women (age = 19.6 ± 1.3 years, height = 168.6 ± 5.3 cm, mass = 66.2 ± 9.1 kg) with unilateral, noncontact ACL injuries. Intervention(s) Participants completed a jump-landing task and knee-laxity assessment 3 to 5 days after the onset of menses and within 3 days of a positive ovulation test. Main Outcome Measure(s): Kinematics in the uninjured limb at initial contact with the ground during a jump landing, peak kinematics and kinetics during the loading phase of landing, anterior knee laxity via the KT-1000, peak vertical ground reaction force, and blood hormone concentrations (estradiol-β-17, progesterone, free testosterone). Results: At ovulation, estradiol-β-17 (t = −2.9, P = .009), progesterone (t = −3.4, P = .003), and anterior knee laxity (t = −2.3, P = .03) increased, and participants presented with greater knee-valgus moment (Z = −2.6, P = .01) and femoral internal rotation (t = −2.1, P = .047). However, during the menses test session, participants landed harder (greater peak vertical ground reaction force; t = 2.2, P = .04), with the tibia internally rotated at initial contact (t = 2.8, P = .01) and greater hip internal-rotation moment (Z = −2.4, P = .02). No other changes were observed across the menstrual cycle. Conclusions Knee and hip mechanics in both phases of the menstrual cycle represented a greater potential risk of ACL loading. Observed changes in landing mechanics may explain why the risk of second ACL injury is elevated in this population. PMID:24568229

Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury.

PubMed

Wellsandt, Elizabeth; Failla, Mathew J; Snyder-Mackler, Lynn

2017-05-01

Study Design Prospective cohort. Background The high risk of second anterior cruciate ligament (ACL) injuries after return to sport highlights the importance of return-to-sport decision making. Objective return-to-sport criteria frequently use limb symmetry indexes (LSIs) to quantify quadriceps strength and hop scores. Whether using the uninvolved limb in LSIs is optimal is unknown. Objectives To evaluate the uninvolved limb as a reference standard for LSIs utilized in return-to-sport testing and its relationship with second ACL injury rates. Methods Seventy athletes completed quadriceps strength and 4 single-leg hop tests before anterior cruciate ligament reconstruction (ACLR) and 6 months after ACLR. Limb symmetry indexes for each test compared involved-limb measures at 6 months to uninvolved-limb measures at 6 months. Estimated preinjury capacity (EPIC) levels for each test compared involved-limb measures at 6 months to uninvolved-limb measures before ACLR. Second ACL injuries were tracked for a minimum follow-up of 2 years after ACLR. Results Forty (57.1%) patients achieved 90% LSIs for quadriceps strength and all hop tests. Only 20 (28.6%) patients met 90% EPIC levels (comparing the involved limb at 6 months after ACLR to the uninvolved limb before ACLR) for quadriceps strength and all hop tests. Twenty-four (34.3%) patients who achieved 90% LSIs for all measures 6 months after ACLR did not achieve 90% EPIC levels for all measures. Estimated preinjury capacity levels were more sensitive than LSIs in predicting second ACL injuries (LSIs, 0.273; 95% confidence interval [CI]: 0.010, 0.566 and EPIC, 0.818; 95% CI: 0.523, 0.949). Conclusion Limb symmetry indexes frequently overestimate knee function after ACLR and may be related to second ACL injury risk. These findings raise concern about whether the variable ACL return-to-sport criteria utilized in current clinical practice are stringent enough to achieve safe and successful return to sport. Level of Evidence Prognosis, 2b. J Orthop Sports Phys Ther 2017;47(5):334-338. Epub 29 Mar 2017. doi:10.2519/jospt.2017.7285.

Pre-Service Teachers' Perceptions of Middle School Students

ERIC Educational Resources Information Center

O'Connor, Kevin J.; D'Angelo, Christina M.

2013-01-01

This report shares a study that explored the perceptions pre-service teachers have of middle school students. Participants were asked to complete the "Adjective Checklist" ("ACL") by endorsing the words they considered most characteristic of a typical middle school student. Items most frequently endorsed indicated a…

76 FR 66654 - Fisheries of the Northeastern United States; Atlantic Herring Fishery; Sub-ACL (Annual Catch...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-27

...; Sub-ACL (Annual Catch Limit) Harvested for Management Area 1A AGENCY: National Marine Fisheries... biological catch, annual catch limit (ACL), optimum yield, domestic harvest and processing, U.S. at-sea...,200 metric tons (mt); the 2011 sub-ACL allocated to Area 1A is 26,546 mt, and 0 mt of the sub-ACL is...

Abnormal tibiofemoral contact stress and its association with altered kinematics after center-center anterior cruciate ligament reconstruction: an in vitro study.

PubMed

Imhauser, Carl; Mauro, Craig; Choi, Daniel; Rosenberg, Eric; Mathew, Stephen; Nguyen, Joseph; Ma, Yan; Wickiewicz, Thomas

2013-04-01

Abnormal tibiofemoral contact stress and aberrant kinematics may influence the progression of osteoarthritis in the anterior cruciate ligament (ACL)-deficient and the ACL-reconstructed knee. However, relationships between contact stress and kinematics after ACL reconstruction are poorly understood. Therefore, we posed the following research questions: (1) How do ACL deficiency and reconstruction affect the kinematics of and contact stress in the tibiofemoral joint? (2) What kinematic differences are associated with abnormal contact stress after ACL reconstruction? Center-center ACL reconstruction will not restore knee kinematics and contact stress. Correlations will exist between abnormal contact stress and aberrant kinematics after ACL reconstruction. Controlled laboratory study. Clinical tests of anterior and rotational stability were simulated on 11 cadaveric knees using an industrial robot. Tests were conducted with the ACL intact, sectioned, and after single-bundle ACL reconstruction using a quadrupled hamstring autograft with tunnels drilled through the center of the native footprints. Kinematics were recorded during the tests. Contact stress was continuously recorded from a stress transducer fixed to the tibial plateau, and mean contact stress was calculated regionally. ACL deficiency resulted in increased mean contact stress in the posterior sectors of the medial and lateral compartments under anterior and rotational loads, respectively. Reconstruction reduced stress in these locations; however, contact stress abnormalities remained. On average, kinematics were overconstrained after ACL reconstruction (≤1.8 mm and ≤2.6° in all directions). However, combinations of overconstrained and underconstrained motions in abduction/adduction and medial-lateral translation in response to combined moments, and anterior-posterior translation, medial-lateral translation, and axial rotation in response to an anterior load were associated with abnormal mean contact stress. ACL reconstruction reduces high stresses generated in the posterior compartment of the ACL-deficient knee. Abnormal contact stress after ACL reconstruction is related to multiplanar variations in knee kinematics. Clinical measures of multiplanar kinematics may help to better characterize the quality of ACL reconstruction. Such measures may help identify patients at increased risk of long-term joint degeneration following this surgery.

Relationships Between Tibiofemoral Contact Forces and Cartilage Morphology at 2 to 3 Years After Single-Bundle Hamstring Anterior Cruciate Ligament Reconstruction and in Healthy Knees.

PubMed

Saxby, David John; Bryant, Adam L; Wang, Xinyang; Modenese, Luca; Gerus, Pauline; Konrath, Jason M; Bennell, Kim L; Fortin, Karine; Wrigley, Tim; Cicuttini, Flavia M; Vertullo, Christopher J; Feller, Julian A; Whitehead, Tim; Gallie, Price; Lloyd, David G

2017-08-01

Prevention of knee osteoarthritis (OA) following anterior cruciate ligament (ACL) rupture and reconstruction is vital. Risk of postreconstruction knee OA is markedly increased by concurrent meniscal injury. It is unclear whether reconstruction results in normal relationships between tibiofemoral contact forces and cartilage morphology and whether meniscal injury modulates these relationships. Since patients with isolated reconstructions (ie, without meniscal injury) are at lower risk for knee OA, we predicted that relationships between tibiofemoral contact forces and cartilage morphology would be similar to those of normal, healthy knees 2 to 3 years postreconstruction. In knees with meniscal injuries, these relationships would be similar to those reported in patients with knee OA, reflecting early degenerative changes. Cross-sectional study; Level of evidence, 3. Three groups were examined: (1) 62 patients who received single-bundle hamstring reconstruction with an intact, uninjured meniscus (mean age, 29.8 ± 6.4 years; mean weight, 74.9 ± 13.3 kg); (2) 38 patients with similar reconstruction with additional meniscal injury (ie, tear, repair) or partial resection (mean age, 30.6 ± 6.6 years; mean weight, 83.3 ± 14.3 kg); and (3) 30 ligament-normal, healthy individuals (mean age, 28.3 ± 5.2 years; mean weight, 74.9 ± 14.9 kg) serving as controls. All patients underwent magnetic resonance imaging to measure the medial and lateral tibial articular cartilage morphology (volumes and thicknesses). An electromyography-driven neuromusculoskeletal model determined medial and lateral tibiofemoral contact forces during walking. General linear models were used to assess relationships between tibiofemoral contact forces and cartilage morphology. In control knees, cartilage was thicker compared with that of isolated and meniscal-injured ACL-reconstructed knees, while greater contact forces were related to both greater tibial cartilage volumes (medial: R 2 = 0.43, β = 0.62, P = .000; lateral: R 2 = 0.19, β = 0.46, P = .03) and medial thicknesses ( R 2 = 0.24, β = 0.48, P = .01). In the overall group of ACL-reconstructed knees, greater contact forces were related to greater lateral cartilage volumes ( R 2 = 0.08, β = 0.28, P = .01). In ACL-reconstructed knees with lateral meniscal injury, greater lateral contact forces were related to greater lateral cartilage volumes ( R 2 = 0.41, β = 0.64, P = .001) and thicknesses ( R 2 = 0.20, β = 0.46, P = .04). At 2 to 3 years postsurgery, ACL-reconstructed knees had thinner cartilage compared with healthy knees, and there were no positive relationships between medial contact forces and cartilage morphology. In lateral meniscal-injured reconstructed knees, greater contact forces were related to greater lateral cartilage volumes and thicknesses, although it was unclear whether this was an adaptive response or associated with degeneration. Future clinical studies may seek to establish whether cartilage morphology can be modified through rehabilitation programs targeting contact forces directly in addition to the current rehabilitation foci of restoring passive and dynamic knee range of motion, knee strength, and functional performance.

Relationships Between Tibiofemoral Contact Forces and Cartilage Morphology at 2 to 3 Years After Single-Bundle Hamstring Anterior Cruciate Ligament Reconstruction and in Healthy Knees

PubMed Central

Saxby, David John; Bryant, Adam L.; Wang, Xinyang; Modenese, Luca; Gerus, Pauline; Konrath, Jason M.; Bennell, Kim L.; Fortin, Karine; Wrigley, Tim; Cicuttini, Flavia M.; Vertullo, Christopher J.; Feller, Julian A.; Whitehead, Tim; Gallie, Price; Lloyd, David G.

2017-01-01

Background: Prevention of knee osteoarthritis (OA) following anterior cruciate ligament (ACL) rupture and reconstruction is vital. Risk of postreconstruction knee OA is markedly increased by concurrent meniscal injury. It is unclear whether reconstruction results in normal relationships between tibiofemoral contact forces and cartilage morphology and whether meniscal injury modulates these relationships. Hypotheses: Since patients with isolated reconstructions (ie, without meniscal injury) are at lower risk for knee OA, we predicted that relationships between tibiofemoral contact forces and cartilage morphology would be similar to those of normal, healthy knees 2 to 3 years postreconstruction. In knees with meniscal injuries, these relationships would be similar to those reported in patients with knee OA, reflecting early degenerative changes. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Three groups were examined: (1) 62 patients who received single-bundle hamstring reconstruction with an intact, uninjured meniscus (mean age, 29.8 ± 6.4 years; mean weight, 74.9 ± 13.3 kg); (2) 38 patients with similar reconstruction with additional meniscal injury (ie, tear, repair) or partial resection (mean age, 30.6 ± 6.6 years; mean weight, 83.3 ± 14.3 kg); and (3) 30 ligament-normal, healthy individuals (mean age, 28.3 ± 5.2 years; mean weight, 74.9 ± 14.9 kg) serving as controls. All patients underwent magnetic resonance imaging to measure the medial and lateral tibial articular cartilage morphology (volumes and thicknesses). An electromyography-driven neuromusculoskeletal model determined medial and lateral tibiofemoral contact forces during walking. General linear models were used to assess relationships between tibiofemoral contact forces and cartilage morphology. Results: In control knees, cartilage was thicker compared with that of isolated and meniscal-injured ACL-reconstructed knees, while greater contact forces were related to both greater tibial cartilage volumes (medial: R 2 = 0.43, β = 0.62, P = .000; lateral: R 2 = 0.19, β = 0.46, P = .03) and medial thicknesses (R 2 = 0.24, β = 0.48, P = .01). In the overall group of ACL-reconstructed knees, greater contact forces were related to greater lateral cartilage volumes (R 2 = 0.08, β = 0.28, P = .01). In ACL-reconstructed knees with lateral meniscal injury, greater lateral contact forces were related to greater lateral cartilage volumes (R 2 = 0.41, β = 0.64, P = .001) and thicknesses (R 2 = 0.20, β = 0.46, P = .04). Conclusion: At 2 to 3 years postsurgery, ACL-reconstructed knees had thinner cartilage compared with healthy knees, and there were no positive relationships between medial contact forces and cartilage morphology. In lateral meniscal-injured reconstructed knees, greater contact forces were related to greater lateral cartilage volumes and thicknesses, although it was unclear whether this was an adaptive response or associated with degeneration. Future clinical studies may seek to establish whether cartilage morphology can be modified through rehabilitation programs targeting contact forces directly in addition to the current rehabilitation foci of restoring passive and dynamic knee range of motion, knee strength, and functional performance. PMID:28894756

Ipsilateral Medial and Lateral Discoid Meniscus with Medial Meniscus Tear

PubMed Central

Shimozaki, Kengo; Nakase, Junsuke; Ohashi, Yoshinori; Numata, Hitoaki; Oshima, Takeshi; Takata, Yasushi; Tsuchiya, Hiroyuki

2016-01-01

Introduction: Discoid meniscus is a well-documented knee pathology, and there are many cases of medial or lateral discoid meniscus reported in the literature. However, ipsilateral concurrent medial and lateral discoid meniscus is very rare, and only a few cases have been reported. Herein, we report a case of concurrent medial and lateral discoid meniscus. Case Report: A 27-year-old Japanese man complained of pain on medial joint space in his right knee that was diagnosed as a complete medial and lateral discoid meniscus. In magnetic resonance imaging, although the lateral discoid meniscus had no tear, the medial discoid meniscus had a horizontal tear. Arthroscopic examination of his right knee similarly revealed that the medial discoid meniscus had a horizontal tear. In addition, the discoid medial meniscus also had an anomalous insertion to the anterior cruciate ligament, and there was also mild fibrillation of the medial tibial cartilage surface. We performed arthroscopic partial meniscectomy for the torn medial discoid meniscus but not for the asymptomatic lateral discoid meniscus. The latest follow-up at 18 months indicated satisfactory results. Conclusion: We report a rare case of ipsilateral medial and lateral discoid meniscus with medial meniscus tear. The medial discoid meniscus with tear was treated with partial meniscectomy, whereas the lateral discoid meniscus without tear was only followed up. PMID:28164045

ACL-reconstructed and ACL-deficient individuals show differentiated trunk, hip, and knee kinematics during vertical hops more than 20 years post-injury.

PubMed

Markström, Jonas L; Tengman, Eva; Häger, Charlotte K

2018-02-01

Little is known regarding movement strategies in the long term following injury of the anterior cruciate ligament (ACL), and even less about comparisons of reconstructed and deficient knees in relation to healthy controls. The present purpose was to compare trunk, hip, and knee kinematics during a one-leg vertical hop (VH) ~20 years post-ACL injury between persons treated with surgery and physiotherapy (ACL R ), solely physiotherapy (ACL PT ), and controls (CTRL). Between-leg kinematic differences within groups were also investigated. Sixty-six persons who suffered unilateral ACL injury on average 23 ± 2 years ago (32 ACL R , 34 ACL PT ) and 33 controls performed the VH. Peak trunk, hip, and knee angles during Take-off and Landing phases recorded with a 3D motion capture system were analysed with multivariate statistics. Significant group effects during both Take-off and Landing were found, with ACL PT differing from CTRL in Take-off with a combination of less knee flexion and knee internal rotation, and from both ACL R and CTRL in Landing with less hip and knee flexion, knee internal rotation, and greater hip adduction. ACL R also presented different kinematics to ACL PT and CTRL in Take-off with a combination of greater trunk flexion, hip flexion, hip internal rotation, and less knee abduction, and in Landing with greater trunk flexion and hip internal rotation. Further, different kinematics and hop height were found between legs within groups in both Take-off and Landing for both ACL groups, but not for CTRL. Different kinematics for the injured leg for both ACL groups compared to CTRL and between treatment groups, as well as between legs within treatment groups, indicate long-term consequences of injury. Compensatory mechanisms for knee protection seem to prevail over time irrespective of initial treatment, possibly increasing the risk of re-injury and triggering the development of osteoarthritis. Detailed investigation of movement strategies during the VH provides important information and a more comprehensive evaluation of knee function than merely hop height. More attention should also be given to the trunk and hip in clinics when evaluating movement strategies after ACL injury. Prospective cohort study, Level II.

Report of the Clinical and Functional Primary Outcomes in Men of the ACL-SPORTS Trial: Similar Outcomes in Men Receiving Secondary Prevention With and Without Perturbation Training 1 and 2 Years After ACL Reconstruction.

PubMed

Arundale, Amelia J H; Cummer, Kathleen; Capin, Jacob J; Zarzycki, Ryan; Snyder-Mackler, Lynn

2017-10-01

Athletes often are cleared to return to activities 6 months after anterior cruciate ligament (ACL) reconstruction; however, knee function measures continue to improve up to 2 years after surgery. Interventions beyond standard care may facilitate successful return to preinjury activities and improve functional outcomes. Perturbation training has been used in nonoperative ACL injury and preoperative ACL reconstruction rehabilitation, but has not been examined in postoperative ACL reconstruction rehabilitation, specifically return to sport rehabilitation. The purpose of this study was to determine whether there were differences at 1 and 2 years after ACL reconstruction between the male SAP (strengthening, agility, and secondary prevention) and SAP+PERT (SAP protocol with the addition of perturbation training) groups with respect to (1) quadriceps strength and single-legged hop limb symmetry; (2) patient-reported knee outcome scores; (3) the proportion who achieve self-reported normal knee function; and (4) the time from surgery to passing return to sport criteria. Forty men who had completed ACL reconstruction rehabilitation and met enrollment criteria (3-9 months after ACL reconstruction, > 80% quadriceps strength limb symmetry, no pain, full ROM, minimal effusion) were randomized into the SAP or SAP+PERT groups of the Anterior Cruciate Ligament-Specialised Post-Operative Return to Sports trial (ACL-SPORTS), a single-blind randomized clinical study of secondary prevention and return to sport. Quadriceps strength, single-legged hopping, the International Knee Documentation Committee (IKDC) 2000 subjective knee form, Knee Injury and Osteoarthritis Outcome Score (KOOS)-sports and recreation, and KOOS-quality-of-life subscales were collected 1 and 2 years after surgery by investigators blind to group. Athletes were categorized as having normal or abnormal knee function at each time point based on IKDC score, and the time until athletes passed strict return-to-sport criteria was also recorded. T-tests, chi square tests, and analyses of variance were used to identify differences between the treatment groups over time. There were no differences between groups for quadriceps symmetry (1 year: SAP = 101% ± 14%, SAP+PERT = 101% ± 14%; 2 years: SAP = 103% ± 11%, SAP+PERT = 98% ± 14%; mean differences between groups at 1 year: 0.4 [-9.0 to 9.8], 2 years = 4.5 [-4.3 to 13.1]; mean difference between 1 and 2 years: SAP = -1.0 [-8.6 to 6.6], SAP+PERT = 3.0 [-4.3 to 10.3], p = 0.45) or single-legged hop test limb symmetry. There were no clinically meaningful differences for any patient-reported outcome measures. There was no difference in the proportion of athletes in each group who achieved normal knee function at 1 year (SAP 14 of 19, SAP+PERT 18 of 20, odds ratio 0.31 [0.5-19.0]; p = 0.18); however, the SAP+PERT group had fewer athletes with normal knee function at 2 years (SAP 17 of 17, SAP+PERT 14 of 19, p = 0.03). There were no differences between groups in the time to pass return to sport criteria (SAP = 325 ± 199 days, SAP+PERT = 233 ± 77 days; mean difference 92 [-9 to 192], p = 0.09). This randomized trial found few differences between an ACL rehabilitation program consisting of strengthening, agility, and secondary prevention and one consisting of those elements as well as perturbation training. In the absence of clinically meaningful differences between groups in knee function and self-reported outcomes measures, the results indicate that perturbation training may not contribute additional benefit to the strengthening, agility, and secondary prevention base of the ACL-SPORTS training program. Level II, therapeutic study.

Comparison of hamstring muscle behavior for anterior cruciate ligament (ACL) patient and normal subject during local marching

NASA Astrophysics Data System (ADS)

Amineldin@Aminudin, Nurul Izzaty Bt.; Rambely, A. S.

2014-09-01

This study aims to investigate the hamstring muscle activity after the surgery by carrying out an electromyography experiment on the hamstring and to compare the behavior of the ACL muscle activity between ACL patient and control subject. Electromyography (EMG) is used to study the behavior of muscles during walking activity. Two hamstring muscles involved which are semitendinosus and bicep femoris. The EMG data for both muscles were recorded while the subject did maximum voluntary contraction (MVC) and marching. The study concluded that there were similarities between bicep femoris of the ACL and control subjects. The analysis showed that the biceps femoris muscle of the ACL subject had no abnormality and the pattern is as normal as the control subject. However, ACL patient has poor semitendinosus muscle strength compared to that of control subject because the differences of the forces produced. The force of semitendinosus value for control subject was two times greater than that of the ACL subject as the right semitendinosus muscle of ACL subject was used to replace the anterior cruciate ligament (ACL) that was injured.

Hamstring graft bacterial contamination during anterior cruciate ligament reconstruction: clinical and microbiological study.

PubMed

Badran, Mohamad Aboelnour; Moemen, Dalia Mohamed

2016-09-01

Autograft preparation for anterior cruciate ligament (ACL) reconstruction has a potential for graft contamination. The purpose of this study was to evaluate the possibility of bacterial contamination of hamstring autograft during preparation and when dropped onto the operating room floor and methods of graft decontamination. Sixty hamstring tendon autograft specimens were used as the test group. Excess tendon not used in the ACL procedure was divided into five segments. One segment, at the completion of preparation, was sent for culture as a control; the remaining four segments were dropped onto the floor adjacent to the surgical field for 15 seconds. One segment was cultured without undergoing any further treatment. Cultures were taken from each segment after immersion in 10 % povidone-iodine solution, 4 % chlorhexidine and bacitracin, respectively, for three minutes. Cultures of a skin swab and floor swab were taken at the same time and place that the ACL was dropped. Cultures of control graft tissue from ten patients (16.7 %) were positive for bacteria. No patient developed post-operative infection. Ninety organisms were identified, with Staphylococcus epidermidis being the most common isolate. Grafts rinsed in either bacitracin or 4 % chlorhexidine solutions were less likely to be culture positive. A high rate of contamination can be expected during autograft preparation for ACL reconstruction. Soaking the hamstring autograft in either bacitracin or 4 % chlorhexidine solution is effective for decontamination, particulary if graft is dropped on the floor.

Association Between Contact Lens Discomfort and Pre-lens Tear Film Kinetics.

PubMed

Guillon, Michel; Dumbleton, Kathryn A; Theodoratos, Panagiotis; Wong, Stephanie; Patel, Kishan; Banks, Gaidig; Patel, Trisha

2016-08-01

The relationship between contact lens wettability and comfort has been extensively evaluated; however, a direct correlation between the characteristics of the pre-lens tear film and the symptoms associated with contact lens discomfort has yet to be established. In addition, there is relatively limited knowledge relating to the entire tear film kinetics during the inter-blink period in contact lens wearers. The purpose of this analysis was to identify the characteristics of the pre-lens tear film kinetics that may be associated with the symptoms of contact lens discomfort. The study population comprised 202 soft (hydrogel and silicone hydrogel) contact lens wearers attending pre-screening visits at the OTG-i research clinic. All participants completed the Ocular Surface Disease Index (OSDI) questionnaire and the tear film was quantified via post hoc, masked analysis of high definition digital Tearscope videos recorded at the visit. The tear film kinetics of the least symptomatic wearers (OSDI lowest quintile scores, n = 45) were compared to the tear film kinetics of the most symptomatic wearers (OSDI highest quintile scores, n = 43). The hypothesis tested was that the tear film kinetics of asymptomatic wearers were better than tear film kinetics of symptomatic wearers. The distribution of lens types worn was as follows: Daily Disposable 46.5%, 1-Month Replacement 39.6%, and 2-Week Replacement 13.6%. 48.2% of lenses were silicone hydrogel and 51.8% hydrogel. Symptomatic wearers had a shorter break-up time (4.7 s vs. 6.0 s; p = 0.003), lesser surface coverage by the tear film during the interblink period (95.1% vs. 98.5%; p < 0.001) and greater surface exposure at the time of the blink (9.4% vs. 3.9%; p = 0.001). The current study demonstrated that the tear film kinetics of asymptomatic and symptomatic contact lens wearers were different, the findings supporting the hypothesis of poorer tear film kinetics for symptomatic than asymptomatic wearers in a general contact lens wearing population.

A prospective multipractice investigation of patients with full-thickness rotator cuff tears: the importance of comorbidities, practice, and other covariables on self-assessed shoulder function and health status.

PubMed

Harryman, Douglas T; Hettrich, Carolyn M; Smith, Kevin L; Campbell, Barry; Sidles, John A; Matsen, Frederick A

2003-04-01

Rotator cuff tears are among the most common conditions of the shoulder. One of the major difficulties in studying patients with rotator cuff tears is that the clinical expression of these tears varies widely and different practices may have substantially different patient populations. The goals of the present prospective multipractice study were to use patient self-assessment questionnaires (1) to identify some of the characteristics of patients with rotator cuff tears, other than the size of the cuff tear, that are correlated with shoulder function, and (2) to determine whether there are significant differences in these characteristics among patients from the practices of different surgeons. Ten surgeons enrolled a total of 333 patients with a full-thickness tear of the supraspinatus tendon into this prospective study. Each patient completed self-assessment questionnaires that included items regarding demographic characteristics, prior treatment, medical and social comorbidities, general health status, and shoulder function. As expected, patients who had an infraspinatus tendon tear as well as a supraspinatus tendon tear had significantly worse ability to use the arm overhead compared with those who had a supraspinatus tear alone (p < 0.005). However, shoulder function and health status were correlated with patient characteristics other than the size of the rotator cuff tear. The number of shoulder functions that were performable was correlated with the subscales of the Short Form-36 and was inversely associated with medical and social comorbidities. The patients from the ten different surgeon practices showed significant differences in almost every parameter, including age, gender, method of tear documentation, tear size, prior treatment, medical and social comorbidities, general health status, and shoulder function. Clinical studies on the natural history of rotator cuff tears and the effectiveness of treatment must control for a wide range of variables, many of which do not pertain directly to the shoulder. Patients from the practices of different surgeons cannot be assumed to be similar with respect to these variables. Patient self-assessment questionnaires appear to offer a practical method of uniform assessment across different practices.

Self-reported Knee Function Can Identify Athletes Who Fail Return to Activity Criteria up to 1 Year after Anterior Cruciate Ligament Reconstruction. A Delaware-Oslo ACL Cohort Study

PubMed Central

Logerstedt, David; Stasi, Stephanie Di; Grindem, Hege; Lynch, Andrew; Eitzen, Ingrid; Engebretsen, Lars; Risberg, May Arna; Axe, Michael J; Snyder-Mackler, Lynn

2014-01-01

STUDY DESIGN Cohort study, cross-sectional. OBJECTIVES To determine if self-reported knee function assessed with the International Knee Documentation Committee 2000 Subjective Knee Form (IKDC2000) could discriminate between successful and non-successful performance on return to activity criteria (RTAC) tests after anterior cruciate ligament (ACL) reconstruction. BACKGROUND Rehabilitation specialists are challenged in selecting appropriate performance-based and patient-reported tests that can detect side-to-side asymmetries, assess global knee function, and determine a participant's readiness to return to activity after ACL reconstruction. A simple tool or questionnaire that could identify athletes with neuromuscular impairments or activity limitations could provide rehabilitation specialists crucial data pertinent to their current knee function and their readiness to return to higher level activities. METHODS One hundred fifty-eight Level I/II athletes 6 months after ACL reconstruction and 141 athletes 12 months after ACL reconstruction completed a functional test battery to determine readiness to return to activity and the IKDC2000 to determine self-reported knee function. For each athlete, status on return to activity tests criteria was dichotomized as “Passed” or ”Failed” and status on the IKDC2000 scores was dichotomized as being “within” or “below age- and sex-matched normal ranges”. Comparisons were made between status on RTAC and IKDC2000 using Chi-square tests. Accuracy statistics were also calculated. RESULTS Six months after ACL reconstruction, 112 athletes (70.9%) failed RTAC and 76 (48.1%) were classified as having self-reported knee function below normal ranges. Among the 76 participants with IKDC2000 scores below normal ranges, 69 (90.8%) failed RTAC test battery (P<.001). However, among the 82 participants whose IKDC2000 scores were within normal limits at 6 months, only 39 (47.6%) passed RTAC test battery (P=.74). Twelve months after ACL reconstruction, 67 athletes (47.5%) failed RTAC and 31 (78.0%) had knee function below normal ranges. Among the 31 participants with IKDC2000 scores below normal ranges, 25 (80.6%) failed RTAC test battery (P<.001). However, among the 110 participants whose IKDC2000 scores were within normal limits at 12 months, only 68 (61.8%) passed RTAC test battery (P=.017). CONCLUSION The IKDC2000 may be a clinically relevant tool to determine the timeliness or necessity of RTAC testing. For scores obtained 6 and 12 months after ACL reconstruction, low IKDC2000 scores were reasonably indicative of failure on RTAC test battery, whereas normal IKDC2000 scores were not predictive of passing scores on the RTAC test battery. PMID:25347228

Anterior cruciate ligament injury in female and male athletes: the relationship between foot structure and injury.

PubMed

Jenkins, Walter L; Killian, Clyde B; Williams, D S; Loudon, Janice; Raedeke, Suzanne G

2007-01-01

It has been shown that anterior cruciate ligament (ACL) injuries are more prevalent in female athletes than in male athletes. Soccer and basketball are considered high-risk sports for ACL injury in female athletes. Several studies have reported a relationship between ACL injury and measures of foot structure. This study was conducted to investigate the relationship between foot structure and ACL injury rates in female and male soccer and basketball players. One hundred five soccer and basketball players (53 women and 52 men) were recruited and divided into an ACL-normal group (n=89) and an ACL-injured group (n=16). Two measures of foot structure (subtalar joint neutral position and navicular drop test values) were recorded for each subject. An independent t test and a paired t test were used to analyze differences in ACL status, foot structure, and sex. A chi2 analysis determined whether the prevalence of ACL injury was independent of sport. No statistically significant differences were found in the foot structure measures between women and men. Female soccer and basketball players had an ACL injury rate seven times that of male players. Values derived from subtalar joint neutral position measurement and the navicular drop test were not associated with ACL injury in collegiate female and male soccer and basketball players.

Fatigue injury risk in anterior cruciate ligament of target side knee during golf swing.

PubMed

Purevsuren, Tserenchimed; Kwon, Moon Seok; Park, Won Man; Kim, Kyungsoo; Jang, Seung Ho; Lim, Young-Tae; Kim, Yoon Hyuk

2017-02-28

A golf-related ACL injury can be linked with excessive golf play or practice because such over-use by repetitive golf swing motions can increase damage accumulation to the ACL bundles. In this study, joint angular rotations, forces, and moments, as well as the forces and strains on the ACL of the target-side knee joint, were investigated for ten professional golfers using the multi-body lower extremity model. The fatigue life of the ACL was also predicted by assuming the estimated ACL force as a cyclic load. The ACL force and strain reached their maximum values within a short time just after ball-impact in the follow-through phase. The smaller knee flexion, higher internal tibial rotation, increase of the joint compressive force and knee abduction moment in the follow-through phase were shown as to lead an increased ACL loading. The number of cycles to fatigue failure (fatigue life) in the ACL might be several thousands. It is suggested that the excessive training or practice of swing motion without enough rest may be one of factors to lead to damage or injury in the ACL by the fatigue failure. The present technology can provide fundamental information to understand and prevent the ACL injury for golf players. Copyright © 2017. Published by Elsevier Ltd.

Simultaneous acute rotator cuff tear and distal biceps rupture in a strongman competitor.

PubMed

George, Michael S

2010-04-01

Acute rotator cuff tear is commonly associated with tearing of the proximal biceps tendon, but has never been reported to occur simultaneously with a distal biceps tendon rupture. A 38-year-old right-hand-dominant strongman competitor attempted a 300-pound overhead axle press and experienced immediate pain in the right shoulder and elbow. He had no known systemic risk factors for tendon ruptures including hyperparathyroidism, hemodialysis, alcoholism, rheumatoid arthritis, statin medications, fluoroquinolones, and steroid use.Right shoulder magnetic resonance imaging (MRI) showed a full-thickness supraspinatus tear with 3 cm of retraction. There was minimal fatty infiltration of the supraspinatus on the sagittal cuts consistent with acute rupture. The subscapularis was intact. The long head of the biceps tendon had mild medial subluxation but was completely within the bicipital groove. Right elbow MRI showed a complete distal biceps tendon rupture. Thirteen days after his injury, the patient underwent arthroscopic supraspinatus repair and proximal biceps tenodesis. Distal biceps tendon repair was performed using the modified 2-incision muscle-splitting technique. At 24-month follow-up, the patient was pain free and had returned to full activity including weightlifting but had not returned to strongman competition.This is the first report of simultaneous acute full thickness ruptures of the rotator cuff and distal biceps tendon. This case report underscores the importance of a complete physical examination and a high index of suspicion for additional concomitant injuries, particularly in athletes with unusually high stresses to the body. Copyright 2010, SLACK Incorporated.

Value of ultrasonography for detecting chronic injury of the lateral ligaments of the ankle joint compared with ultrasonography findings.

PubMed

Cheng, Y; Cai, Y; Wang, Y

2014-01-01

The aim of this study was to assess the accuracy of ultrasonography in the diagnosis of chronic lateral ankle ligament injury. A total of 120 ankles in 120 patients with a clinical suspicion of chronic ankle ligament injury were examined by ultrasonography by using a 5- to 17-MHz linear array transducer before surgery. The results of ultrasonography were compared with the operative findings. There were 18 sprains and 24 partial and 52 complete tears of the anterior talofibular ligament (ATFL); 26 sprains, 27 partial and 12 complete tears of the calcaneofibular ligament (CFL); and 1 complete tear of the posterior talofibular ligament (PTFL) at arthroscopy and operation. Compared with operative findings, the sensitivity, specificity and accuracy of ultrasonography were 98.9%, 96.2% and 84.2%, respectively, for injury of the ATFL and 93.8%, 90.9% and 83.3%, respectively, for injury of the CFL. The PTFL tear was identified by ultrasonography. The accuracy of identification between acute-on-chronic and subacute-chronic patients did not differ. The accuracies of diagnosing three grades of ATFL injuries were almost the same as those of diagnosing CFL injuries. Ultrasonography provides useful information for the evaluation of patients presenting with chronic pain after ankle sprain. Intraoperative findings are the reference standard. We demonstrated that ultrasonography was highly sensitive and specific in detecting chronic lateral ligments injury of the ankle joint.

Value of ultrasonography for detecting chronic injury of the lateral ligaments of the ankle joint compared with ultrasonography findings

PubMed Central

Cheng, Y; Cai, Y

2014-01-01

Objective: The aim of this study was to assess the accuracy of ultrasonography in the diagnosis of chronic lateral ankle ligament injury. Methods: A total of 120 ankles in 120 patients with a clinical suspicion of chronic ankle ligament injury were examined by ultrasonography by using a 5- to 17-MHz linear array transducer before surgery. The results of ultrasonography were compared with the operative findings. Results: There were 18 sprains and 24 partial and 52 complete tears of the anterior talofibular ligament (ATFL); 26 sprains, 27 partial and 12 complete tears of the calcaneofibular ligament (CFL); and 1 complete tear of the posterior talofibular ligament (PTFL) at arthroscopy and operation. Compared with operative findings, the sensitivity, specificity and accuracy of ultrasonography were 98.9%, 96.2% and 84.2%, respectively, for injury of the ATFL and 93.8%, 90.9% and 83.3%, respectively, for injury of the CFL. The PTFL tear was identified by ultrasonography. The accuracy of identification between acute-on-chronic and subacute–chronic patients did not differ. The accuracies of diagnosing three grades of ATFL injuries were almost the same as those of diagnosing CFL injuries. Conclusion: Ultrasonography provides useful information for the evaluation of patients presenting with chronic pain after ankle sprain. Advances in knowledge: Intraoperative findings are the reference standard. We demonstrated that ultrasonography was highly sensitive and specific in detecting chronic lateral ligments injury of the ankle joint. PMID:24352708

The Natural History and Tailored Treatment of ACL Injury.

ERIC Educational Resources Information Center

Evans, Nick A.; Chew, Hall F.; Stanish, William D.

2001-01-01

Bodily responses to an anterior cruciate ligament injury can range from minor to very significant. Understanding factors influencing the course can help physicians determine effective treatment strategies. Certain patterns, such as complete disruption and participation in high-demand sports, highlight the need for an aggressive approach.…

Interferometer for measuring dynamic corneal topography

NASA Astrophysics Data System (ADS)

Micali, Jason Daniel

The cornea is the anterior most surface of the eye and plays a critical role in vision. A thin fluid layer, the tear film, coats the outer surface of the cornea and serves to protect, nourish, and lubricate the cornea. At the same time, the tear film is responsible for creating a smooth continuous surface where the majority of refraction takes place in the eye. A significant component of vision quality is determined by the shape of the cornea and stability of the tear film. It is desirable to possess an instrument that can measure the corneal shape and tear film surface with the same accuracy and resolution that is currently performed on common optical elements. A dual interferometer system for measuring the dynamic corneal topography is designed, built, and verified. The completed system is validated by testing on human subjects. The system consists of two co-aligned polarization splitting Twyman-Green interferometers designed to measure phase instantaneously. The primary interferometer measures the surface of the tear film while the secondary interferometer simultaneously tracks the absolute position of the cornea. Eye motion, ocular variation, and a dynamic tear film surface will result in a non-null configuration of the surface with respect to the interferometer system. A non-null test results in significant interferometer induced errors that add to the measured phase. New algorithms are developed to recover the absolute surface topography of the tear film and corneal surface from the simultaneous interferometer measurements. The results are high-resolution and high-accuracy surface topography measurements of the in vivo cornea that are captured at standard camera frame rates. This dissertation will cover the development and construction of an interferometer system for measuring the dynamic corneal topography of the human eye. The discussion starts with the completion of an interferometer for measuring the tear film. The tear film interferometer is part of an ongoing research project that has spanned multiple dissertations. For this research, the instrument was tested on human subjects and resulted in refinements to the interferometer design. The final configuration of the tear film interferometer and results from human subjects testing are presented. Feedback from this instrument was used to support the development and construction of the interferometric corneal topographer system. A calibration is performed on the instrument, and then verified against simulated eye surfaces. Finally, the instrument is validated by testing on human subjects. The result is an interferometer system that can non-invasively measure the dynamic corneal topography with greater accuracy and resolution than existing technologies.

Sports-specific differences in postsurgical infections after arthroscopically assisted anterior cruciate ligament reconstruction.

PubMed

Krutsch, Werner; Zellner, Johannes; Zeman, Florian; Nerlich, Michael; Koch, Matthias; Pfeifer, Christian; Angele, Peter

2017-12-01

Post-operative infection after arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a rare but severe complication, particularly for young and active patients. It is unclear whether the prevalence of knee infection is correlated with the type of sports or the level of performance. From 2008 to 2012, the internal single-centre ACL registry of the FIFA Medical Centre of Excellence Regensburg was retrospectively screened for sex, age, time between isolated primary ACL rupture and surgery, surgical technique, rate of infection after ACL reconstruction and the type of sports practised. In total, 4801 ACL reconstructions had been conducted over 5 years, 4579 in amateur and 221 in professional athletes. After application of the exclusion criteria, 1809 athletes with ACL reconstruction were analysed regarding postsurgical infection and the type of sports practised. Professionals and amateurs did not significantly differ with regard to infection rates (n.s.) but in the timing of ACL repair (p < 0.001). Eleven of 1130 football players had developed postsurgical infection after ACL reconstruction (1.0%) in contrast to 557 skiers and snowboarders without infection (p = 0.02). The timing of ACL repair did not differ between the different types of sports (n.s.). Staphylococcus aureus and epidermidis were the predominant detected bacteria. All patients were hospitalised and successfully treated with arthroscopic lavage and antibiotic medication. ACL infections showed sports-related differences. Athletes practising summer outdoor sports such as football had a significantly higher risk of infection after ACL reconstruction than winter sports athletes. No difference was found between professional and amateur athletes. Relevant prevention strategies for postsurgical ACL infections should consider influencing patient factors such as the type of sports activity and attendant circumstances. III.

Isolation and Characterization of Human Anterior Cruciate Ligament-Derived Vascular Stem Cells

PubMed Central

Matsumoto, Tomoyuki; Ingham, Sheila M.; Mifune, Yutaka; Osawa, Aki; Logar, Alison; Usas, Arvydas; Kuroda, Ryosuke; Kurosaka, Masahiro; Fu, Freddie H.

2012-01-01

The anterior cruciate ligament (ACL) usually fails to heal after rupture mainly due to the inability of the cells within the ACL tissue to establish an adequate healing process, making graft reconstruction surgery a necessity. However, some reports have shown that there is a healing potential of ACL with primary suture repair. Although some reports showed the existence of mesenchymal stem cell-like cells in human ACL tissues, their origin still remains unclear. Recently, blood vessels have been reported to represent a rich supply of stem/progenitor cells with a characteristic expression of CD34 and CD146. In this study, we attempted to validate the hypothesis that CD34- and CD146-expressing vascular cells exist in hACL tissues, have a potential for multi-lineage differentiation, and are recruited to the rupture site to participate in the intrinsic healing of injured ACL. Immunohistochemistry and flow cytometry analysis of hACL tissues demonstrated that it contains significantly more CD34 and CD146-positive cells in the ACL ruptured site compared with the noninjured midsubstance. CD34+CD45− cells isolated from ACL ruptured site showed higher expansionary potentials than CD146+CD45− and CD34−CD146−CD45− cells, and displayed higher differentiation potentials into osteogenic, adipogenic, and angiogenic lineages than the other cell populations. Immunohistochemistry of fetal and adult hACL tissues demonstrated a higher number of CD34 and CD146-positive cells in the ACL septum region compared with the midsubstance. In conclusion, our findings suggest that the ACL septum region contains a population of vascular-derived stem cells that may contribute to ligament regeneration and repair at the site of rupture. PMID:21732814

Dynamic augmentation restores anterior tibial translation in ACL suture repair: a biomechanical comparison of non-, static and dynamic augmentation techniques.

PubMed

Hoogeslag, Roy A G; Brouwer, Reinoud W; Huis In 't Veld, Rianne; Stephen, Joanna M; Amis, Andrew A

2018-02-03

There is a lack of objective evidence investigating how previous non-augmented ACL suture repair techniques and contemporary augmentation techniques in ACL suture repair restrain anterior tibial translation (ATT) across the arc of flexion, and after cyclic loading of the knee. The purpose of this work was to test the null hypotheses that there would be no statistically significant difference in ATT after non-, static- and dynamic-augmented ACL suture repair, and they will not restore ATT to normal values across the arc of flexion of the knee after cyclic loading. Eleven human cadaveric knees were mounted in a test rig, and knee kinematics from 0° to 90° of flexion were recorded by use of an optical tracking system. Measurements were recorded without load and with 89-N tibial anterior force. The knees were tested in the following states: ACL-intact, ACL-deficient, non-augmented suture repair, static tape augmentation and dynamic augmentation after 10 and 300 loading cycles. Only static tape augmentation and dynamic augmentation restored ATT to values similar to the ACL-intact state directly postoperation, and maintained this after cyclic loading. However, contrary to dynamic augmentation, the ATT after static tape augmentation failed to remain statistically less than for the ACL-deficient state after cyclic loading. Moreover, after cyclic loading, ATT was significantly less with dynamic augmentation when compared to static tape augmentation. In contrast to non-augmented ACL suture repair and static tape augmentation, only dynamic augmentation resulted in restoration of ATT values similar to the ACL-intact knee and decreased ATT values when compared to the ACL-deficient knee immediately post-operation and also after cyclic loading, across the arc of flexion, thus allowing the null hypotheses to be rejected. This may assist healing of the ruptured ACL. Therefore, this study would support further clinical evaluation of dynamic augmentation of ACL repair.

Morphologic Characteristics Help Explain the Gender Difference in Peak Anterior Cruciate Ligament Strain During a Simulated Pivot Landing

PubMed Central

Lipps, David B.; Oh, Youkeun K.; Ashton-Miller, James A.; Wojtys, Edward M.

2015-01-01

Background Gender differences exist in anterior cruciate ligament (ACL) cross-sectional area and lateral tibial slope. Biomechanical principles suggest that the direction of these gender differences should induce larger peak ACL strains in females under dynamic loading. Hypothesis Peak ACL relative strain during a simulated pivot landing is significantly greater in female ACLs than male ACLs. Study Design Controlled laboratory study. Methods Twenty cadaveric knees from height- and weight-matched male and female cadavers were subjected to impulsive 3-dimensional test loads of 2 times body weight in compression, flexion, and internal tibial torque starting at 15° of flexion. Load cells measured the 3-dimensional forces and moments applied to the knee, and forces in the pretensioned quadriceps, hamstring, and gastrocnemius muscle equivalents. A novel, gender-specific, nonlinear spring simulated short-range and longer range quadriceps muscle tensile stiffness. Peak relative strain in the anteromedial bundle of the ACL (AM-ACL) was measured using a differential variable reluctance transducer, while ACL cross-sectional area and lateral tibial slope were measured using magnetic resonance imaging. A repeated-measures Mann-Whitney signed-rank test was used to test the hypothesis. Results Female knees exhibited 95% greater peak AM-ACL relative strain than male knees (6.37% [22.53%] vs 3.26% [11.89%]; P = .004). Anterior cruciate ligament cross-sectional area and lateral tibial slope were significant predictors of peak AM-ACL relative strain (R2 = .59; P = .001). Conclusion Peak AM-ACL relative strain was significantly greater in female than male knees from donors of the same height and weight. This gender difference is attributed to a smaller female ACL cross-sectional area and a greater lateral tibial slope. Clinical Relevance Since female ACLs are systematically exposed to greater strain than their male counterparts, training and injury prevention programs should take this fact into consideration. PMID:21917612

Biomechanical consequences of a nonanatomic posterior medial meniscal root repair.

PubMed

LaPrade, Christopher M; Foad, Abdullah; Smith, Sean D; Turnbull, Travis Lee; Dornan, Grant J; Engebretsen, Lars; Wijdicks, Coen A; LaPrade, Robert F

2015-04-01

Posterior medial meniscal root tears have been reported to extrude with the meniscus becoming adhered posteromedially along the posterior capsule. While anatomic repair has been reported to restore tibiofemoral contact mechanics, it is unknown whether nonanatomic positioning of a meniscal root repair to a posteromedial location would restore the loading profile of the knee joint. The purpose of this study was to compare the tibiofemoral contact mechanics of a nonanatomic posterior medial meniscal tear with that of the intact knee or anatomic repair. It was hypothesized that a nonanatomic root repair would not restore the tibiofemoral contact pressures and areas to that of the intact or anatomic repair state. Controlled laboratory study. Tibiofemoral contact mechanics were recorded in 6 male human cadaveric knee specimens (average age, 45.8 years) using pressure sensors. Each knee underwent 5 testing conditions for the posterior medial meniscal root: (1) intact knee; (2) root tear; (3) anatomic transtibial pull-out repair; (4) nonanatomic transtibial pull-out repair, placed 5 mm posteromedially along the edge of the articular cartilage; and (5) root tear concomitant with an ACL tear. Knees were loaded with a 1000-N axial compressive force at 4 flexion angles (0°, 30°, 60°, 90°), and contact area, mean contact pressure, and peak contact pressure were calculated. Contact area was significantly lower after nonanatomic repair than for the intact knee at all flexion angles (mean = 44% reduction) and significantly higher for anatomic versus nonanatomic repair at all flexion angles (mean = 27% increase). At 0° and 90°, and when averaged across flexion angles, the nonanatomic repair significantly increased mean contact pressures in comparison to the intact knee or anatomic repair. When averaged across flexion angles, the peak contact pressures after nonanatomic repair were significantly higher than the intact knee but not the anatomic repair. In contrast, when averaged across all flexion angles, the anatomic repair resulted in a 17% reduction in contact area and corresponding increases in mean and peak contact pressures of 13% and 26%, respectively, compared with the intact knee. For most testing conditions, the nonanatomic repair did not restore the contact area or mean contact pressures to that of the intact knee or anatomic repair. However, the anatomic repair produced near-intact contact area and resulted in relatively minimal increases in mean and peak contact pressures compared with the intact knee. Results emphasize the importance of ensuring an anatomic posterior medial meniscal root repair by releasing the extruded menisci from adhesions and the posteromedial capsule. Similar caution toward preventing displacement of the meniscal root repair construct should be emphasized. © 2015 The Author(s).

Return to Play and Clinical Outcomes after All-Inside, Anterior Cruciate Ligament Reconstruction in Skeletally Immature Athletes

PubMed Central

Nawabi, Danyal H.; McCarthy, Moira; Graziano, Jessica; deMille, Polly; Chiaia, Theresa; Green, Daniel W.; Cordasco, Frank A.

2014-01-01

Objectives: Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are on the rise because of increased participation and level of competition within sports, sports specialization and societal factors. Conservative treatment of these injuries has a poor natural history due to recurrent instability with meniscal and articular cartilage damage. The purpose of this study was to evaluate the results of an all-inside, physeal-sparing ACL reconstruction in skeletally immature athletes, with a focus on return to play. Methods: Forty-two skeletally immature athletes (mean chronologic age 12.7 yrs, [range 10-15]) were prospectively evaluated following an all-inside ACL reconstruction utilizing hamstring autograft. The mean bone age (Greulich and Pyle method) was 13.5 years. There were 10 females and 32 males. Twenty-six patients had an all-epiphyseal (AE) ACL reconstruction and 16 patients had a partial transphyseal (PTP) ACL reconstruction, which spared the femoral physis but crossed the tibial physis. The PTP option was reserved for patients with minimal proximal tibial growth remaining. Fourteen athletes were involved in recreational sport and 28 participated competitively. Lacrosse (36%) and Soccer (32%) were the two most common sports associated with ACL injury in our cohort. All athletes were evaluated with a physical examination, KT-1000 arthrometry, isokinetic testing, validated outcome scores including the International Knee Documentation Committee score (IKDC), the Lysholm score and Marx activity rating scale. Standing radiographs and SPGR MRI analysis was performed at 6, 12 and 24 months post-op depending upon skeletal age. A ‘Return to Play’ performance analysis was also performed where symmetry, alignment control and the ability to decelerate were assessed during progressively challenging movement patterns encountered in sport. Results: At a mean follow-up of 16.7 months (range 12-24), the mean IKDC score was 92.9 ± 7.2, the mean Lysholm score was 97.7 ± 4.6 and the mean Marx activity rating scale score was 12.4 ± 3.5. Lachman and pivot shift testing was negative in all patients. The mean side-to-side difference in the KT-1000 arthrometry was 0.9 ± 0.7 mm, with the maximum difference in the cohort being 2 mm. Isokinetic testing showed a mean deficit of 4.1% in extension torque and 9.2% in flexion torque at a repetition speed of 180 degrees per second. No angular deformities, significant leg length discrepancy or physeal disturbances were observed on postoperative radiographs or MRI. One athlete had a traumatic graft disruption at 12 months and underwent revision ACL reconstruction and one athlete sustained a contralateral ACL rupture at 11 months. The mean time for return to unrestricted competitive activity after successful completion of the ‘Return to Play’ analysis was 12.5 +/- 1.3 months from the time of surgery. Conclusion: An all-inside, physeal-sparing ACL reconstruction technique using hamstring autograft demonstrates excellent subjective and objective clinical outcomes in skeletally immature athletes without growth disturbance. ‘Return to Play’ assessment is an important tool to guide the young athlete and her or his family regarding resumption of competitive sports. In our experience, athletes were on average released for full return to sport after 1 year from ACL reconstruction.

Anterior cruciate ligament rupture: differences between males and females.

PubMed

Sutton, Karen M; Bullock, James Montgomery

2013-01-01

The rate of anterior cruciate ligament (ACL) rupture is three times higher in female athletes than in male athletes. Intrinsic factors such as increased quadriceps angle and increased posterior tibial slope may predispose girls and women to ACL injury. Compared with males, females have smaller notch widths and smaller ACL cross-sectional area; however, no conclusive correlation between ACL size and notch dimension exists, especially in relation to risk of ACL injury. Female athletes who land with the knees in inadequate flexion and in greater-than-normal valgus and external rotation are at increased risk of ACL injury. No conclusive link has been made between ACL injury and the menstrual cycle. Neuromuscular intervention protocols have been shown to reduce the rate of injury in girls and women. Females are more likely than males to have a narrow A-shaped intercondylar notch, and special surgical considerations are required in such cases. Following ACL reconstruction, female athletes are more likely than male athletes to rupture the contralateral ACL; however, males and females are equally likely to rupture the reconstructed knee. Although self-reported outcomes in the first 2 years following reconstruction are worse for females than for males, longer-term studies demonstrate no difference between males and females.

Structural and Anatomic Restoration of the Anterior Cruciate Ligament Is Associated With Less Cartilage Damage 1 Year After Surgery: Healing Ligament Properties Affect Cartilage Damage

PubMed Central

Kiapour, Ata M.; Fleming, Braden C.; Murray, Martha M.

2017-01-01

Background: Abnormal joint motion has been linked to joint arthrosis after anterior cruciate ligament (ACL) reconstruction. However, the relationships between the graft properties (ie, structural and anatomic) and extent of posttraumatic osteoarthritis are not well defined. Hypotheses: (1) The structural (tensile) and anatomic (area and alignment) properties of the reconstructed graft or repaired ACL correlate with the total cartilage lesion area 1 year after ACL surgery, and (2) side-to-side differences in anterior-posterior (AP) knee laxity correlate with the total cartilage lesion area 1 year postoperatively. Study Design: Controlled laboratory study. Methods: Sixteen minipigs underwent unilateral ACL transection and were randomly treated with ACL reconstruction or bridge-enhanced ACL repair. The tensile properties, cross-sectional area, and multiplanar alignment of the healing ACL or graft, AP knee laxity, and cartilage lesion areas were assessed 1 year after surgery. Results: In the reconstructed group, the normalized graft yield and maximum failure loads, cross-sectional area, sagittal and coronal elevation angles, and side-to-side differences in AP knee laxity at 60° of flexion were associated with the total cartilage lesion area 1 year after surgery (R 2 > 0.5, P < .04). In the repaired group, normalized ACL yield load, linear stiffness, cross-sectional area, and the sagittal and coronal elevation angles were associated with the total cartilage lesion area (R 2 > 0.5, P < .05). Smaller cartilage lesion areas were observed in the surgically treated knees when the structural and anatomic properties of the ligament or graft and AP laxity values were closer to those of the contralateral ACL-intact knee. Reconstructed grafts had a significantly larger normalized cross-sectional area and sagittal elevation angle (more vertical) when compared with repaired ACLs (P < .02). Conclusion: The tensile properties, cross-sectional area, and multiplanar alignment of the healing ACLs or grafts and AP knee laxity in reconstructed knees were associated with the extent of tibiofemoral cartilage damage after ACL surgery. Clinical Relevance: These data highlight the need for novel ACL injury treatments that can restore the structural and anatomic properties of the torn ACL to those of the native ACL in an effort to minimize the risk of early-onset posttraumatic osteoarthritis. PMID:28875154

Quantitative In Situ Analysis of the Anterior Cruciate Ligament: Length, Midsubstance Cross-sectional Area, and Insertion Site Areas.

PubMed

Fujimaki, Yoshimasa; Thorhauer, Eric; Sasaki, Yusuke; Smolinski, Patrick; Tashman, Scott; Fu, Freddie H

2016-01-01

Quantification of the cross-sectional area (CSA) of the anterior cruciate ligament (ACL) in different loading conditions is important for understanding the native anatomy and thus achieving anatomic reconstruction. The ACL insertion sites are larger than the ACL midsubstance, and the isthmus (region of the smallest CSA) location may vary with the load or flexion angle. To (1) quantify the CSA along the entire ACL, (2) describe the location of the ACL isthmus, (3) explore the relationship between ACL length and CSA, and (4) validate magnetic resonance imaging (MRI) for assessing the CSA of the midsubstance ACL. Descriptive laboratory study. Eight cadaveric knees were dissected to expose the ACL and its attachments. Knees were positioned using a robotic loading system through a range of flexion angles in 3 loading states: (1) unloaded, (2) anterior tibial translation, and (3) combined rotational load of valgus and internal torque. Laser scanning quantified the shape of the ACL and its insertion site boundaries. The CSA of the ACL was measured, and the location of the isthmus was determined; the CSA of the ACL was also estimated from MRI and compared with the laser-scanned data. The CSA of the ACL varied along the ligament, and the isthmus existed at an average (±SD) of 53.8% ± 5.5% of the distance from the tibial insertion center to the femoral insertion center. The average CSA at the isthmus was smallest in extension (39.9 ± 13.7 mm(2)) and increased with flexion (43.9 ± 12.1 mm(2) at 90°). The ACL length was shortest at 90° of flexion and increased by 18.8% ± 10.1% in unloaded extension. Application of an anterior load increased the ACL length by 5.0% ± 3.3% in extension, and application of a combined rotational load increased its length by 4.1% ± 3.0% in extension. The ACL isthmus is located almost half of the distance between the insertion sites. The CSA of the ACL at the isthmus is largest with the knee unloaded and at 90° of flexion, and the area decreases with extension and applied loads. The CSA at the isthmus represents less than half the area of the insertion sites. These results may aid surgical planning, specifically for choosing a graft size and fixation angle that most closely matches the native anatomy and function across the entire range of knee motion. © 2015 The Author(s).

Quantification of bone marrow water and lipid composition in anterior cruciate ligament-injured and osteoarthritic knees using three-dimensional magnetic resonance spectroscopic imaging.

PubMed

Tufts, Lauren S; Shet, Keerthi; Liang, Fei; Majumdar, Sharmila; Li, Xiaojuan

2016-06-01

To quantitatively evaluate longitudinal changes in water and lipid in knee bone marrow with and without bone marrow edema-like lesions (BMELs) in subjects with acutely ruptured anterior cruciate ligaments (ACLs) or osteoarthritis (OA) using three-dimensional magnetic resonance spectroscopic imaging (3D MRSI). Ten ACL and 10 OA subjects who presented with BMEL and seven BMEL-free controls were scanned at 3T. All ACL and OA subjects had one-year follow-up scans. 3D MRSI was acquired in BMEL and adjacent bone marrow, and water content (WC) and unsaturated lipid index (UI) were calculated in each region of interest. At baseline, ACL BMEL WC was significantly higher than ACL non-BMEL, OA BMEL, and control WC; ACL non-BMEL WC, ACL BMEL UI, and OA BMEL WC were significantly higher than control. ACL BMEL WC decreased significantly one year post-reconstruction; UI decreased non-significantly (p=0.09). No significant changes in OA BMEL or ACL and OA non-BMEL WC and UI were observed. 3D MRSI is a powerful method of quantitatively assessing the biochemical composition of bone marrow in OA and ACL-injured knees, which may serve as imaging markers to improve comprehension of primary and secondary OA pathology. Copyright © 2016 Elsevier Inc. All rights reserved.

Vertical stiffness is not related to anterior cruciate ligament elongation in professional rugby union players.

PubMed

Serpell, Benjamin G; Scarvell, Jennie M; Pickering, Mark R; Ball, Nick B; Perriman, Diana; Warmenhoven, John; Smith, Paul N

2016-01-01

Novel research surrounding anterior cruciate ligament (ACL) injury is necessary because ACL injury rates have remained unchanged for several decades. An area of ACL risk mitigation which has not been well researched relates to vertical stiffness. The relationship between increased vertical stiffness and increased ground reaction force suggests that vertical stiffness may be related to ACL injury risk. However, given that increased dynamic knee joint stability has been shown to be associated with vertical stiffness, it is possible that modification of vertical stiffness could help to protect against injury. We aimed to determine whether vertical stiffness is related to measures known to load, or which represent loading of, the ACL. This was a cross-sectional observational study of 11 professional Australian rugby players. Knee kinematics and ACL elongation were measured from a 4-dimensional model of a hopping task which simulated the change of direction manoeuvre typically observed when non-contact ACL injury occurs. The model was generated from a CT scan of the participant's knee registered frame by frame to fluoroscopy images of the hopping task. Vertical stiffness was calculated from force plate data. There was no association found between vertical stiffness and anterior tibial translation (ATT) or ACL elongation (r=-0.05; p=0.89, and r=-0.07; p=0.83, respectively). ATT was related to ACL elongation (r=0.93; p=0.0001). Vertical stiffness was not associated with ACL loading in this cohort of elite rugby players but a novel method for measuring ACL elongation in vivo was found to have good construct validity.

Bone-to-bone Fixation Enhances Functional Healing of the Porcine Anterior Cruciate Ligament Using a Collagen-Platelet Composite

PubMed Central

Murray, Martha M.; Magarian, Elise; Zurakowski, David; Fleming, Braden C.

2010-01-01

Purpose The purpose of this study was to determine if providing bony stabilization between the tibia and femur would improve the structural properties of an “enhanced” ACL repair using a collagen-platelet composite when compared to the traditional (Marshall) suture technique. Methods Twelve pigs underwent unilateral ACL transection and were treated with sutures connecting the bony femoral ACL attachment site to the distal ACL stump (LIGAMENT group), or to the tibia via a bone tunnel (TIBIA group). A collagen-platelet composite was placed around the sutures to enhance the biologic repair in both groups. Anteroposterior (AP) knee laxity and the graft structural properties were measured after 15 weeks of healing in both the ACL-repaired and contralateral ACL-intact joints. Results Enhanced ACL repair with bone-to-bone fixation significantly improved yield load and linear stiffness of the ACL repairs (p<0.05) after 15 weeks of healing. However, laxity values of the knees were similar in both groups of repaired knees (p>0.10). Conclusions Using an enhanced ACL suture repair technique that includes bone-to-bone fixation to protect the repair in the initial healing stages resulted in an ACL with improved structural properties after 15 weeks in the porcine model. Clinical Relevance The healing response of an ACL suture repair using a collagen-platelet composite can be enhanced by providing bony stabilization between the tibia and femur to protect the graft during the initial healing process in a translational model. PMID:20810092

The Influence of Meniscal and Anterolateral Capsular Injury on Knee Laxity in Patients With Anterior Cruciate Ligament Injuries.

PubMed

Musahl, Volker; Rahnemai-Azar, Ata A; Costello, Joanna; Arner, Justin W; Fu, Freddie H; Hoshino, Yuichi; Lopomo, Nicola; Samuelsson, Kristian; Irrgang, James J

2016-12-01

The role of the anterolateral capsule (ALC) as a secondary restraint to quantitative rotatory laxity of patients with an anterior cruciate ligament (ACL) injury is currently debated. The purpose was to determine the influence of concomitant ALC injuries as well as injuries to other soft tissue structures on rotatory knee laxity in patients with an ACL injury. It was hypothesized that a concomitant ALC injury would be associated with increased rotatory knee laxity as measured during a quantitative pivot-shift test. Cross-sectional study; Level of evidence, 3. Forty-one patients with an ACL injury (average age, 23 ± 6.9 years) were enrolled. Two blinded musculoskeletal radiologists reviewed magnetic resonance imaging (MRI) scans for the presence of ACL injuries and concomitant soft tissue injuries including the ALC, medial collateral ligament, lateral collateral ligament, posterolateral corner, medial meniscus, and lateral meniscus. A standardized pivot-shift test was performed under anesthesia, and rotatory laxity was quantified according to anterior translation of the lateral tibial compartment during the pivot-shift maneuver. The Student t test was used to analyze the data. Statistical significance was set at P < .05. A complete ACL rupture was confirmed in all of the patients. MRI evidence of an ALC injury was observed in 21 (51%) of the patients. Patients with MRI evidence of an ALC injury had significantly higher rotatory knee laxity (3.6 ± 1.5 mm) compared with those without an ALC injury (2.7 ± 1.5 mm; P = .04). Lateral and medial meniscus injuries were detected in 17 (41%) and 19 (46%) patients, respectively. Patients with MRI evidence of either a medial meniscus injury or lateral meniscus injury had significantly higher rotatory knee laxity compared with patients without these injuries (medial meniscus: 3.7 ± 1.4 mm vs 2.7 ± 1.6 mm, respectively; lateral meniscus: 3.7 ± 1.7 mm vs 2.7 ± 1.3 mm, respectively) (P = .03 for both). MRI evidence of a concomitant injury to the ALC, medial meniscus, or lateral meniscus is associated with increased knee rotatory laxity in patients with an ACL injury. These structures may function as important secondary stabilizers in an ACL-injured knee. Careful assessment and proper treatment of injuries to these secondary stabilizers should be considered, especially in knees with a high level of the pivot shift. © 2016 The Author(s).

50 CFR 648.123 - Scup accountability measures.

Code of Federal Regulations, 2013 CFR

2013-10-01

... remainder of the period. (1) Commercial ACL overage evaluation. The commercial sector ACL will be evaluated... discards will be evaluated in determining if the commercial sector ACL has been exceeded. (2) Commercial... the commercial sector ACL is exceeded. Any current year landings in excess of the commercial quota in...

50 CFR 648.123 - Scup accountability measures.

Code of Federal Regulations, 2012 CFR

2012-10-01

... remainder of the period. (1) Commercial ACL overage evaluation. The commercial sector ACL will be evaluated... discards will be evaluated in determining if the commercial sector ACL has been exceeded. (2) Commercial... the commercial sector ACL is exceeded. Any current year landings in excess of the commercial quota in...

50 CFR 648.103 - Summer flounder accountability measures.

Code of Federal Regulations, 2012 CFR

2012-10-01

... sector ACL to be exceeded, or if the commercial fisheries in all states have been closed. The Regional... commercial fisheries in one or more states have been reopened without causing the sector ACL to be exceeded... in that state. (1) Commercial ACL overage evaluation. The commercial sector ACL will be evaluated...

50 CFR 648.103 - Minimum fish sizes.

Code of Federal Regulations, 2011 CFR

2011-10-01

... determines that the inaction of one or more states will cause the commercial sector ACL to be exceeded, or if... more states have been reopened without causing the sector ACL to be exceeded. (b) State commercial...) Commercial ACL overage evaluation. The commercial sector ACL will be evaluated based on a single-year...

50 CFR 648.55 - Framework adjustments to management measures.

Code of Federal Regulations, 2014 CFR

2014-10-01

... establish OFL, ABC, ACL, ACT, DAS allocations, rotational area management programs, percentage allocations... measures will be adjusted. (c) OFL, ABC, ACL, ACT, and AMs. The Council shall specify OFL, ABC, ACL, ACT... derive specifications for ABC, ACL, and ACT, as specified in paragraphs (c)(2) through (c)(5) of this...

50 CFR 648.82 - Effort-control program for NE multispecies limited access vessels.

Code of Federal Regulations, 2013 CFR

2013-10-01

... ACL for a particular stock to be exceeded. If such catch resulted in the overall ACL for a particular... amount of the overage of the overall ACL for that stock multiplied by the common pool's share of the overall ACL for that stock calculated...

50 CFR 648.123 - Scup accountability measures.

Code of Federal Regulations, 2014 CFR

2014-10-01

... remainder of the period. (1) Commercial ACL overage evaluation. The commercial sector ACL will be evaluated... discards will be evaluated in determining if the commercial sector ACL has been exceeded. (2) Commercial... the commercial sector ACL is exceeded. Any current year landings in excess of the commercial quota in...

50 CFR 648.55 - Framework adjustments to management measures.

Code of Federal Regulations, 2013 CFR

2013-10-01

... establish OFL, ABC, ACL, ACT, DAS allocations, rotational area management programs, percentage allocations... measures will be adjusted. (c) OFL, ABC, ACL, ACT, and AMs. The Council shall specify OFL, ABC, ACL, ACT... derive specifications for ABC, ACL, and ACT, as specified in paragraphs (c)(2) through (c)(5) of this...

50 CFR 648.103 - Summer flounder accountability measures.

Code of Federal Regulations, 2013 CFR

2013-10-01

... sector ACL to be exceeded, or if the commercial fisheries in all states have been closed. The Regional... commercial fisheries in one or more states have been reopened without causing the sector ACL to be exceeded... in that state. (1) Commercial ACL overage evaluation. The commercial sector ACL will be evaluated...

50 CFR 648.55 - Framework adjustments to management measures.

Code of Federal Regulations, 2012 CFR

2012-10-01

... establish OFL, ABC, ACL, ACT, DAS allocations, rotational area management programs, percentage allocations... measures will be adjusted. (c) OFL, ABC, ACL, ACT, and AMs. The Council shall specify OFL, ABC, ACL, ACT... derive specifications for ABC, ACL, and ACT, as specified in paragraphs (c)(2) through (c)(5) of this...

50 CFR 648.55 - Framework adjustments to management measures.

Code of Federal Regulations, 2011 CFR

2011-10-01

... establish OFL, ABC, ACL, ACT, DAS allocations, rotational area management programs, percentage allocations... measures will be adjusted. (c) OFL, ABC, ACL, ACT, and AMs. The Council shall specify OFL, ABC, ACL, ACT... derive specifications for ABC, ACL, and ACT, as specified in paragraphs (a)(2) through (5) of this...

50 CFR 648.103 - Summer flounder accountability measures.

Code of Federal Regulations, 2014 CFR

2014-10-01

... sector ACL to be exceeded, or if the commercial fisheries in all states have been closed. The Regional... commercial fisheries in one or more states have been reopened without causing the sector ACL to be exceeded... in that state. (1) Commercial ACL overage evaluation. The commercial sector ACL will be evaluated...

ACL deficient potential copers and non-copers reveal different isokinetic quadriceps strength profiles in the early stage after injury

PubMed Central

Eitzen, I; Eitzen, TJ; Holm, I; Snyder-Mackler, L; Risberg, MA

2011-01-01

Background Isokinetic muscle strength tests using the peak torque value is the most frequently included quadriceps muscle strength measurement for anterior cruciate ligament (ACL) injured subjects. Aims The purpose of this study was to investigate quadriceps muscle performance during the whole isokinetic curve in ACL deficient subjects classified as potential copers or non-copers, and investigate whether these curve profiles were associated with single-leg hop performance. We hypothesized that quadriceps muscle torque at other knee flexion angles than peak torque would give more information about quadriceps muscle strength deficits. Furthermore, we hypothesized that there would be significant torque differences between potential copers and non-copers, and a significant relationship between angle specific torque values and single-leg hop performance. Study Design Cross-sectional study; Level of evidence, 2 Methods Seventy-six individuals with a complete unilateral ACL rupture within the last 3 months were included. The subjects were classified into potential copers and non-copers according to the criteria from Fitzgerald et al12. Isokinetic quadriceps muscle tests were performed at 60°/sec (Biodex 6000). Mean torque values were calculated for peak torque as well as for specific knee flexion angles. The one-leg hop and the 6 meter timed hop tests were included and symmetry indices were used. Results The peak torque value did not identify the largest quadriceps muscle strength deficit. Rather, these were established at knee flexion angles of less than 40°. There were significant differences in angle specific torque values between potential copers and non-copers (p<0.05). Moderate to strong associations were disclosed between angle specific torque values and single-leg hop performance, but only for non-copers (r≥0.32– 0.58). Conclusions Angle specific quadriceps muscle torque values of less than 40° of knee flexion provide more information on the quadriceps strength deficits after ACL injury compared to the commonly used peak torque values. PMID:20110458

Satisfaction With Knee Function After Primary Anterior Cruciate Ligament Reconstruction Is Associated With Self-Efficacy, Quality of Life, and Returning to the Preinjury Physical Activity.

PubMed

Ardern, Clare L; Österberg, Annika; Sonesson, Sofi; Gauffin, Håkan; Webster, Kate E; Kvist, Joanna

2016-08-01

To assess whether patient-reported outcomes (psychological factors, appraisals of knee function, and physical activity participation) were associated with satisfaction with knee function after anterior cruciate ligament (ACL) reconstruction. Participants who were aged 18 to 45 years and a minimum 12 months post primary ACL reconstruction completed a questionnaire battery evaluating knee self-efficacy, knee-related quality of life, self-reported function, and physical activity participation. Participants' responses to the question "If you were to spend the rest of your life with your knee just the way it has been in the last week, would you feel . . . (7-point ordinal scale; 1 = happy, 7 = unhappy)" were categorized as satisfied, mostly satisfied, or dissatisfied and used as the primary outcome. Ordinal regression was used to examine associations between independent variables and the primary outcome. A total of 177 participants were included at an average of 3 years after primary ACL reconstruction. At follow-up, 44% reported they would be satisfied, 28% mostly satisfied, and 28% dissatisfied with the outcome of ACL reconstruction. There were significant differences in psychological responses and appraisal of knee function between the 3 groups (P = .001), and significantly more people in the satisfied group had returned to their preinjury activity (58%) than in the mostly satisfied (28%) and dissatisfied (26%) groups (P = .001). Multivariable analysis demonstrated that the odds of being satisfied increased by a factor of 3 with higher self-efficacy, greater knee-related quality of life, and returning to the preinjury activity. People who had returned to their preinjury physical activity and who reported higher knee-related self-efficacy and quality of life were more likely to be satisfied with the outcome of ACL reconstruction. Level IV, prognostic case series. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Next-Generation Evaporative Cooling Systems for the Advanced Extravehicular Mobility Unit Portable Life Support System

NASA Technical Reports Server (NTRS)

Makinen, Janice V.; Anchondo, Ian; Bue, Grant C.; Campbell, Colin; Colunga, Aaron

2012-01-01

The development of the Advanced Extravehicular Mobility Unit (AEMU) Portable Life Support System (PLSS) is currently underway at NASA Johnson Space Center. The AEMU PLSS features two new evaporative cooling systems, the Reduced Volume Prototype Spacesuit Water Membrane Evaporator (RVP SWME), and the Auxiliary Cooling Loop (ACL). The RVP SWME is the third generation of hollow fiber SWME hardware, and like its predecessors, RVP SWME provides nominal crewmember and electronics cooling by flowing water through porous hollow fibers. Water vapor escapes through the hollow fiber pores, thereby cooling the liquid water that remains inside of the fibers. This cooled water is then recirculated to remove heat from the crewmember and PLSS electronics. Major design improvements, including a 36% reduction in volume, reduced weight, and more flight like back-pressure valve, facilitate the packaging of RVP SWME in the AEMU PLSS envelope. In addition to the RVP SWME, the Auxiliary Cooling Loop (ACL), was developed for contingency crewmember cooling. The ACL is a completely redundant, independent cooling system that consists of a small evaporative cooler--the Mini Membrane Evaporator (Mini-ME), independent pump, independent feed-water assembly and independent Liquid Cooling Garment (LCG). The Mini-ME utilizes the same hollow fiber technology featured in the RVP SWME, but is only 25% of the size of RVP SWME, providing only the necessary crewmember cooling in a contingency situation. The ACL provides a number of benefits when compared with the current EMU PLSS contingency cooling technology; contingency crewmember cooling can be provided for a longer period of time, more contingency situations can be accounted for, no reliance on a Secondary Oxygen Vessel (SOV) for contingency cooling--thereby allowing a SOV reduction in size and pressure, and the ACL can be recharged-allowing the AEMU PLSS to be reused, even after a contingency event. The development of these evaporative cooling systems will contribute to a more robust and comprehensive AEMU PLSS.

Sidestep and crossover lower limb kinematics during a prolonged sport-like agility test.

PubMed

Potter, Danielle; Reidinger, Kellie; Szymialowicz, Rebecca; Martin, Thomas; Dione, Donald; Feinn, Richard; Wallace, David; Garbalosa, Juan C

2014-10-01

Non-contact anterior cruciate ligament (ACL) injuries in athletes occur more often towards the end of athletic competitions. However, the exact mechanisms of how prolonged activity increases the risk for ACL injuries are not clear. To determine the effect of prolonged activity on the hip and knee kinematics observed during self-selected cutting maneuvers performed in a timed agility test. Nineteen female Division I collegiate soccer players completed a self-selected cutting agility test until they were unable to meet a set performance time (one standard deviation of the average baseline trial). Using the 3D dimensional coordinate data the cut type was identified by the principle investigators. The 3D hip and knee angles at 32ms post heel strike were analyzed using a two-factor, linear mixed model to assess the effect of prolonged activity and cut type on the recorded mean hip and knee angles. Athletes performed either sidestep or crossover cuts. An effect of cut type and prolonged activity was seen at the hip and knee. During the prolonged activity trials, the knee was relatively more adducted and both the hip and knee were less flexed than during the baseline trials regardless of cut type. Regardless of activity status, during sidestep cuts, the hip was more internally rotated and abducted, and less flexed than during crossover cuts while the knee was more abducted and less flexed during the sidestep than crossover cuts. During a sport-like agility test, prolonged activity appears to predispose the athlete to position their knee in a more extended and abducted posture and their hip in a more extended posture. This position has been suggested to place stress on the ACL and potentially increase the risk for injury. Clinicians may want to consider the effects of prolonged activity on biomechanical risk factors for sustaining ACL injuries in the design of intervention strategies to prevent ACL injuries. Level 4.

Cross-cultural translation of the Lysholm knee score in Chinese and its validation in patients with anterior cruciate ligament injury.

PubMed

Wang, W; Liu, L; Chang, X; Jia, Z Y; Zhao, J Z; Xu, W D

2016-10-19

The Lysholm Knee Score (LKS) is widely used and is one of the most effective questionnaires employed to assess knee injuries. Although LKS has been translated into multiple languages, there is no Chinese version even though China has the largest population of patients with knee-joint injuries. The objective of our study was to develop the Chinese version of LKS (C-LKS) and assess its reliability, validity and responsiveness in Chinese patients with anterior cruciate ligament (ACL) injuries. Study participants were mainly recruited among patients with ACL injuries scheduled for arthroscopic ACL reconstruction at our hospital. First, we developed the C-LKS in a five-step translation and cross-cultural adaptation procedure. Next, we calculated the Cronbach's alpha, intraclass correlation coefficient (ICC), Pearson's correlation coefficient (r), effect size (ES), and standardized response mean (SRM) to evaluate the reliability, validity, and responsiveness of C-LKS respectively. Overall, 126 patients with ACL injuries successfully completed the questionnaires. Acceptable internal consistency (Cronbach's alpha = 0.726) as well as excellent test-retest reliability (ICC = 0.935) was found for C-LKS. Good or moderate correlation (r = 0.514-0.837) was determined among C-LKS and International Knee Documentation Committee Subjective Knee Form (IKDC), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), physical subscales of SF-36; C-LKS also had fair or moderate correlation (r = 0.207-0.462) with the other subscales of SF-36, which adequately illustrated that good validity was included in C-LKS. In addition, good responsiveness was also observed in C-LKS (ES = 1.36,SRM = 1.26). We have shown that our developed C-LKS questionnaire is reliable, valid and responsible for the evaluation of Chinese-speaking patients with ACL injuries and it would be an effective instrument.

[MRI of the rotator cuff: evaluation of a new symptomatologic classification].

PubMed

Tavernier, T; Walch, G; Noël, E; Lapra, C; Bochu, M

1995-05-01

The different classifications use for the rotator cuff pathology seem to be incomplete. We propose a new classification with many advantages: 1) Differentiate the tendinopathy between less serious (grade 2A) and serious (grade 2B). 2) Recognize the intra-tendinous cleavage of the infra-spinatus associated with complete tear of the supra-spinatus. 3) Differentiate partial and complete tears of the supra-spinatus. We established this classification after a retrospective study of 42 patients operated on for a rotator cuff pathology. Every case had had a preoperative MRI. This classification is simple, reliable, especially for the associated intra tendinous cleavage.

Rehabilitation after anterior cruciate ligament reconstruction: a systematic review.

PubMed

Kruse, L M; Gray, B; Wright, R W

2012-10-03

Rigorous rehabilitation after anterior cruciate ligament (ACL) reconstruction is necessary for a successful surgical outcome. A large number of clinical trials continue to assess aspects of this rehabilitation process. Prior systematic reviews evaluated fifty-four Level-I and II clinical trials published through 2005. Eighty-five articles from 2006 to 2010 were identified utilizing multiple search engines. Twenty-nine Level-I or II studies met inclusion criteria and were evaluated with use of the CONSORT (Consolidated Standards of Reporting Trials) criteria. Topics included in this review are postoperative bracing, accelerated strengthening, home-based rehabilitation, proprioception and neuromuscular training, and six miscellaneous topics investigated in single trials. Bracing following ACL reconstruction remains neither necessary nor beneficial and adds to the cost of the procedure. Early return to sports needs further research. Home-based rehabilitation can be successful. Although neuromuscular interventions are not likely to be harmful to patients, they are also not likely to yield large improvements in outcomes or help patients return to sports faster. Thus, they should not be performed to the exclusion of strengthening and range-of-motion exercises. Vibration training may lead to faster and more complete proprioceptive recovery but further evidence is needed. Several new modalities for rehabilitation after ACL reconstruction may be helpful but should not be performed to the exclusion of range-of-motion, strengthening, and functional exercises. Accelerated rehabilitation does not appear to be harmful but further investigation of rehabilitation timing is warranted. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

ACL reconstruction - discharge

MedlinePlus

Anterior cruciate ligament reconstruction - discharge; ACL reconstruction - discharge ... had surgery to reconstruct your anterior cruciate ligament (ACL). The surgeon drilled holes in the bones of ...

Posterior medial meniscus root ligament lesions: MRI classification and associated findings.

PubMed

Choi, Ja-Young; Chang, Eric Y; Cunha, Guilherme M; Tafur, Monica; Statum, Sheronda; Chung, Christine B

2014-12-01

The purposes of this study were to determine the prevalence of altered MRI appearances of "posterior medial meniscus root ligament (PMMRL)" lesions, introduce a classification of lesion types, and report associated findings. We retrospectively reviewed 419 knee MRI studies to identify the presence of PMMRL lesions. Classification was established on the basis of lesions encountered. The medial compartment was assessed for medial meniscal tears in the meniscus proper, medial meniscal extrusion, insertional PMMRL osseous changes, regional synovitis, osteoarthritis, insufficiency fracture, and cruciate ligament abnormality. PMMRL abnormalities occurred in 28.6% (120/419) of the studies: degeneration, 14.3% (60/419) and tear, 14.3% (60/419). Our classification system included degeneration and tearing. Tearing was categorized as partial or complete with delineation of the point of failure as entheseal, midsubstance, or junction to meniscus. Of all tears, 93.3% (56/60) occurred at the meniscal junction. Univariate analysis revealed significant differences between the knees with and without PMMRL lesions in age, medial meniscal tear, medial meniscal extrusion, insertional PMMRL osseous change, regional synovitis, osteoarthritis, insufficiency fracture (p=0.017), and cruciate ligament degeneration (p<0.001). PMMRL lesions are commonly detected in symptomatic patients. We have introduced an MRI classification system. PMMRL lesions are significantly associated with age, medial meniscal tears, medial meniscal extrusion, insertional PMMRL osseous change, regional synovitis, osteoarthritis, insufficiency fracture, and cruciate ligament degeneration.

Acute torn meniscus combined with acute cruciate ligament injury. Second look arthroscopy after 3-month conservative treatment.

PubMed

Ihara, H; Miwa, M; Takayanagi, K; Nakayama, A

1994-10-01

The purpose of this study was to evaluate arthroscopically the natural healing of an acute torn meniscus combined with an acute cruciate ligament injury treated nonoperatively. There were 30 lateral and 10 medial meniscus tears associated with 25 acute anterior cruciate ligament and 7 posterior cruciate ligament injuries in 32 patients. There was more than 1 tear on some menisci for a total of 51 tear sites. Injuries to the menisci and ligaments were allowed to heal without surgery, but were given protective mobilization immediately in order to stimulate stress oriented healing of injured collagen fibers and promote circulation of synovial fluid to the meniscus and ligament. A Kyuro knee brace with a coil spring traction system was used to add adequate but not excessive stress to the associated injured cruciate ligament. All knees were examined and arthroscoped before and after a 3-month treatment period. Results indicated that 69% of the lateral menisci healed completely and 18% healed partially, whereas 58% of the medial menisci healed completely and none healed partially. Twenty of 25 anterior cruciate ligaments and 3 of 7 posterior cruciate ligaments healed satisfactorily. This study indicated that acute tears of the meniscus, even when they occur in association with a cruciate ligament injury, can heal morphologically with nonsurgical treatment.

Bio-enhanced repair of the anterior cruciate ligament

PubMed Central

Proffen, Benedikt L.; Sieker, Jakob T.; Murray, Martha

2015-01-01

Suture repair of the ACL has been widely abandoned in favor of ACL reconstruction, largely due to the high rates of failure and unreliability of the outcomes following suture repair. However, there have been recent basic science studies which suggest that combining a suture repair with a biologic adjunct may improve the results of suture repair of the ACL, with several studies in large animal models showing equivalent strength of an ACL treated with bio-enhanced repaired with that of an ACL graft at 3, 6 and 12 months after surgery. In addition, the groups treated with bio-enhanced repair had significantly less osteoarthritis when compared with the animals undergoing ACL reconstruction. These findings have led to a renewed interest in bio-enhanced primary repair as a way to make repair of the ACL a viable option for a select group of patients in the future. PMID:25595694

Three-Dimensional Engineered Bone–Ligament–Bone Constructs for Anterior Cruciate Ligament Replacement

PubMed Central

Ma, Jinjin; Smietana, Michael J.; Kostrominova, Tatiana Y.; Wojtys, Edward M.; Larkin, Lisa M.

2012-01-01

The anterior cruciate ligament (ACL), a major stabilizer of the knee, is commonly injured. Because of its intrinsic poor healing ability, a torn ACL is usually reconstructed by a graft. We developed a multi-phasic, or bone–ligament–bone, tissue-engineered construct for ACL grafts using bone marrow stromal cells and sheep as a model system. After 6 months in vivo, the constructs increased in cross section and exhibited a well-organized microstructure, native bone integration, a functional enthesis, vascularization, innervation, increased collagen content, and structural alignment. The constructs increased in stiffness to 52% of the tangent modulus and 95% of the geometric stiffness of native ACL. The viscoelastic response of the explants was virtually indistinguishable from that of adult ACL. These results suggest that our constructs after implantation can obtain physiologically relevant structural and functional characteristics comparable to those of adult ACL. They present a viable option for ACL replacement. PMID:21902608

A Novel Repair Method for Radial Tears of the Medial Meniscus: Biomechanical Comparison of Transtibial 2-Tunnel and Double Horizontal Mattress Suture Techniques Under Cyclic Loading.

PubMed

Bhatia, Sanjeev; Civitarese, David M; Turnbull, Travis Lee; LaPrade, Christopher M; Nitri, Marco; Wijdicks, Coen A; LaPrade, Robert F

2016-03-01

Complete radial tears of the medial meniscus have been reported to be functionally similar to a total meniscectomy. At present, there is no consensus on an ideal technique for repair of radial midbody tears of the medial meniscus. Prior attempts at repair with double horizontal mattress suture techniques have led to a reportedly high rate of incomplete healing or healing in a nonanatomic (gapped) position, which compromises the ability of the meniscus to withstand hoop stresses. A newly proposed 2-tunnel radial meniscal repair method will result in decreased gapping and increased ultimate failure loads compared with the double horizontal mattress suture repair technique under cyclic loading. Controlled laboratory study. Ten matched pairs of male human cadaveric knees (average age, 58.6 years; range, 48-66 years) were used. A complete radial medial meniscal tear was made at the junction of the posterior one-third and middle third of the meniscus. One knee underwent a horizontal mattress inside-out repair, while the contralateral knee underwent a radial meniscal repair entailing the same technique with a concurrent novel 2-tunnel repair. Specimens were potted and mounted on a universal testing machine. Each specimen was cyclically loaded 1000 times with loads between 5 and 20 N before experiencing a load to failure. Gap distances at the tear site and failure load were measured. The 2-tunnel repairs exhibited a significantly stronger ultimate failure load (median, 196 N; range, 163-212 N) than did the double horizontal mattress suture repairs (median, 106 N; range, 63-229 N) (P = .004). In addition, the 2-tunnel repairs demonstrated decreased gapping at all testing states (P < .05) with a final measured gapping of 1.7 mm and 4.1 mm after 1000 cycles for the 2-tunnel and double horizontal mattress suture repairs, respectively. The 2-tunnel repairs displayed significantly less gapping distance after cyclic loading and had significantly stronger ultimate failure loads compared with the double horizontal mattress suture repairs. Complete radial tears of the medial meniscus significantly decrease the ability of the meniscus to dissipate tibiofemoral loads, predisposing patients to early osteoarthritis. Improving the ability to repair medial meniscal radial tears in a way that withstands cyclic loads and heals in an anatomic position could significantly improve patient healing rates and result in improved preservation of the articular cartilage of the medial compartment of the knee. The 2-tunnel repair may be a more reliable and stronger repair option for midbody radial tears of the medial meniscus. Clinical studies are warranted to further evaluate these repairs. © 2015 The Author(s).

50 CFR 648.163 - Bluefish Accountability Measures (AMs).

Code of Federal Regulations, 2014 CFR

2014-10-01

...) ACL overage evaluation. The ACL will be evaluated based on a single-year examination of total catch (landings and dead discards). Both landings and dead discards will be evaluated in determining if the ACL... cause the ACL specified in § 648.160(a) to be exceeded, or if the commercial fisheries in all states...

50 CFR 648.163 - Bluefish Accountability Measures (AMs).

Code of Federal Regulations, 2012 CFR

2012-10-01

...) ACL overage evaluation. The ACL will be evaluated based on a single-year examination of total catch (landings and dead discards). Both landings and dead discards will be evaluated in determining if the ACL... cause the ACL specified in § 648.160(a) to be exceeded, or if the commercial fisheries in all states...

50 CFR 622.49 - Accountability measures.

Code of Federal Regulations, 2010 CFR

2010-10-01

... exceed the applicable annual catch limit (ACL), the AA will file a notification with the Office of the... following year by the amount the prior-year ACL was exceeded. The applicable ACLs are 105,000 lb (47,627 kg... applicable ACL, the AA will file a notification with the Office of the Federal Register reducing the length...

50 CFR 648.100 - Summer flounder Annual Catch Limit (ACL).

Code of Federal Regulations, 2014 CFR

2014-10-01

... 50 Wildlife and Fisheries 12 2014-10-01 2014-10-01 false Summer flounder Annual Catch Limit (ACL... Management Measures for the Summer Flounder Fisheries § 648.100 Summer flounder Annual Catch Limit (ACL). (a... frequent or more specific ACL performance review criteria as part of a stock rebuilding plan following a...

50 CFR 648.120 - Scup Annual Catch Limit (ACL).

Code of Federal Regulations, 2013 CFR

2013-10-01

... 50 Wildlife and Fisheries 12 2013-10-01 2013-10-01 false Scup Annual Catch Limit (ACL). 648.120... Measures for the Scup Fishery § 648.120 Scup Annual Catch Limit (ACL). (a) The Scup Monitoring Committee... more specific ACL performance review criteria as part of a stock rebuilding plan following a...

50 CFR 648.163 - Gear restrictions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Bluefish Accountability Measures (AMs). (a) ACL overage evaluation. The ACL will be evaluated based on a... be evaluated in determining if the ACL has been exceeded. (b) Commercial sector EEZ closure. NMFS... inaction of one or more states will cause the ACL specified in § 648.160(a) to be exceeded, or if the...

50 CFR 648.120 - Scup Annual Catch Limit (ACL).

Code of Federal Regulations, 2014 CFR

2014-10-01

... 50 Wildlife and Fisheries 12 2014-10-01 2014-10-01 false Scup Annual Catch Limit (ACL). 648.120... Measures for the Scup Fishery § 648.120 Scup Annual Catch Limit (ACL). (a) The Scup Monitoring Committee... more specific ACL performance review criteria as part of a stock rebuilding plan following a...

50 CFR 648.96 - FMP review, specification, and framework adjustment process.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Councils or the PDT may develop options for setting ABC, ACL, and OFL for each monkfish stock, as necessary... recommend to the SSC that ABC, ACL, and OFL are specified for each monkfish stock for multiple years as... not limited to, OFLs, ACLs, and management uncertainty. (ii) ACL recommendations. The Councils shall...

50 CFR 648.160 - Catch quotas and other restrictions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Limit (ACL). (a) The Bluefish Monitoring Committee shall recommend to the MAFMC an ACL for the bluefish fishery, which shall be equal to the ABC recommended by the SSC. (1) Periodicity. The bluefish fishery ACL... Monitoring Committee shall conduct a detailed review of fishery performance relative to the ACL at least...

50 CFR 648.120 - Scup Annual Catch Limit (ACL).

Code of Federal Regulations, 2012 CFR

2012-10-01

... 50 Wildlife and Fisheries 12 2012-10-01 2012-10-01 false Scup Annual Catch Limit (ACL). 648.120... Measures for the Scup Fishery § 648.120 Scup Annual Catch Limit (ACL). (a) The Scup Monitoring Committee... more specific ACL performance review criteria as part of a stock rebuilding plan following a...

50 CFR 648.290 - Tilefish Annual Catch Limit (ACL).

Code of Federal Regulations, 2013 CFR

2013-10-01

... 50 Wildlife and Fisheries 12 2013-10-01 2013-10-01 false Tilefish Annual Catch Limit (ACL). 648... Measures for the Tilefish Fishery § 648.290 Tilefish Annual Catch Limit (ACL). (a) The Tilefish Monitoring Committee shall recommend to the MAFMC an ACL for the commercial tilefish fishery, which shall be equal to...

50 CFR 648.100 - Summer flounder Annual Catch Limit (ACL).

Code of Federal Regulations, 2013 CFR

2013-10-01

... 50 Wildlife and Fisheries 12 2013-10-01 2013-10-01 false Summer flounder Annual Catch Limit (ACL... Management Measures for the Summer Flounder Fisheries § 648.100 Summer flounder Annual Catch Limit (ACL). (a... frequent or more specific ACL performance review criteria as part of a stock rebuilding plan following a...

50 CFR 648.160 - Bluefish Annual Catch Limit (ACL).

Code of Federal Regulations, 2012 CFR

2012-10-01

... 50 Wildlife and Fisheries 12 2012-10-01 2012-10-01 false Bluefish Annual Catch Limit (ACL). 648... Measures for the Atlantic Bluefish Fishery § 648.160 Bluefish Annual Catch Limit (ACL). (a) The Bluefish Monitoring Committee shall recommend to the MAFMC an ACL for the bluefish fishery, which shall be equal to...

50 CFR 648.160 - Bluefish Annual Catch Limit (ACL).

Code of Federal Regulations, 2013 CFR

2013-10-01

... 50 Wildlife and Fisheries 12 2013-10-01 2013-10-01 false Bluefish Annual Catch Limit (ACL). 648... Measures for the Atlantic Bluefish Fishery § 648.160 Bluefish Annual Catch Limit (ACL). (a) The Bluefish Monitoring Committee shall recommend to the MAFMC an ACL for the bluefish fishery, which shall be equal to...

50 CFR 648.160 - Bluefish Annual Catch Limit (ACL).

Code of Federal Regulations, 2014 CFR

2014-10-01

... 50 Wildlife and Fisheries 12 2014-10-01 2014-10-01 false Bluefish Annual Catch Limit (ACL). 648... Measures for the Atlantic Bluefish Fishery § 648.160 Bluefish Annual Catch Limit (ACL). (a) The Bluefish Monitoring Committee shall recommend to the MAFMC an ACL for the bluefish fishery, which shall be equal to...

50 CFR 648.163 - Bluefish Accountability Measures (AMs).

Code of Federal Regulations, 2013 CFR

2013-10-01

...) ACL overage evaluation. The ACL will be evaluated based on a single-year examination of total catch (landings and dead discards). Both landings and dead discards will be evaluated in determining if the ACL... cause the ACL specified in § 648.160(a) to be exceeded, or if the commercial fisheries in all states...

50 CFR 648.290 - Tilefish Annual Catch Limit (ACL).

Code of Federal Regulations, 2012 CFR

2012-10-01

... 50 Wildlife and Fisheries 12 2012-10-01 2012-10-01 false Tilefish Annual Catch Limit (ACL). 648... Measures for the Tilefish Fishery § 648.290 Tilefish Annual Catch Limit (ACL). (a) The Tilefish Monitoring Committee shall recommend to the MAFMC an ACL for the commercial tilefish fishery, which shall be equal to...

50 CFR 648.290 - Tilefish Annual Catch Limit (ACL).

Code of Federal Regulations, 2014 CFR

2014-10-01

... 50 Wildlife and Fisheries 12 2014-10-01 2014-10-01 false Tilefish Annual Catch Limit (ACL). 648... Measures for the Tilefish Fishery § 648.290 Tilefish Annual Catch Limit (ACL). (a) The Tilefish Monitoring Committee shall recommend to the MAFMC an ACL for the commercial tilefish fishery, which shall be equal to...

50 CFR 648.100 - Summer flounder Annual Catch Limit (ACL).

Code of Federal Regulations, 2012 CFR

2012-10-01

... 50 Wildlife and Fisheries 12 2012-10-01 2012-10-01 false Summer flounder Annual Catch Limit (ACL... Management Measures for the Summer Flounder Fisheries § 648.100 Summer flounder Annual Catch Limit (ACL). (a... frequent or more specific ACL performance review criteria as part of a stock rebuilding plan following a...

50 CFR 648.233 - Spiny dogfish Accountability Measures (AMs).

Code of Federal Regulations, 2014 CFR

2014-10-01

... dogfish permit under this part. (b) ACL overage evaluation. The ACL will be evaluated based on a single-year examination of total catch (including both landings and dead discards) to determine if the ACL has been exceeded. (c) Overage repayment. In the event that the ACL has been exceeded in a given fishing...

50 CFR 648.70 - Annual individual allocations.

Code of Federal Regulations, 2011 CFR

2011-10-01

... text is set forth as follows: § 648.70 Surfclam and ocean quahog Annual Catch Limit (ACL). (a) The... established consistent with the guidelines contained in the Atlantic Surfclam and Ocean Quahog FMP. The ACL... ACLs at least every 5 years. (1) If the surfclam or the ocean quahog ACL is exceeded with a frequency...

Anticardiolipin antibodies in patients from Malaysia with systemic lupus erythematosus.

PubMed

Jones, H W; Ireland, R; Senaldi, G; Wang, F; Khamashta, M; Bellingham, A J; Veerapan, K; Hughes, G R; Vergani, D

1991-03-01

Systemic lupus erythematosus (SLE) is highly prevalent in Malaysia, which has a mixed population of Malays, Chinese, and Indians. A quantitative enzyme linked immunosorbent assay (ELISA) was used to determine anticardiolipin antibody (aCL) levels (total immunoglobulin, IgG, and IgM) in 200 patients with SLE (164 Chinese, 26 Malay, and 10 Indian) attending the University Hospital of Kuala Lumpur, Malaysia, and 103 matched controls. Only 33 (16.5%) of the patients had raised aCL levels; 26 had raised IgG aCL, five IgM aCL, and two both IgG and IgM aCL. There was a low prevalence of raised levels of aCL in the population studied, which was seen in conjunction with a rare occurrence of thrombosis. The classical association of high aCL levels with thrombocytopenia and recurrent abortions was noted, though not with cerebral disease. The low prevalence of aCL in this study population of mixed racial origin contrasts with findings in European patients with SLE and lends support to the influence of local factors, be they genetic or environmental, on the clinical manifestations of this disease.

Athymic Rat Model for Evaluation of Engineered Anterior Cruciate Ligament Grafts

PubMed Central

Leong, Natalie L.; Kabir, Nima; Arshi, Armin; Nazemi, Azadeh; Wu, Ben M.; McAllister, David R.; Petrigliano, Frank A.

2015-01-01

Anterior cruciate ligament (ACL) rupture is a common ligamentous injury that often requires surgery because the ACL does not heal well without intervention. Current treatment strategies include ligament reconstruction with either autograft or allograft, which each have their associated limitations. Thus, there is interest in designing a tissue-engineered graft for use in ACL reconstruction. We describe the fabrication of an electrospun polymer graft for use in ACL tissue engineering. This polycaprolactone graft is biocompatible, biodegradable, porous, and is comprised of aligned fibers. Because an animal model is necessary to evaluate such a graft, this paper describes an intra-articular athymic rat model of ACL reconstruction that can be used to evaluate engineered grafts, including those seeded with xenogeneic cells. Representative histology and biomechanical testing results at 16 weeks postoperatively are presented, with grafts tested immediately post-implantation and contralateral native ACLs serving as controls. The present study provides a reproducible animal model with which to evaluate tissue engineered ACL grafts, and demonstrates the potential of a regenerative medicine approach to treatment of ACL rupture. PMID:25867958

The common mechanisms of anterior cruciate ligament injuries in judo: a retrospective analysis.

PubMed

Koshida, S; Deguchi, T; Miyashita, K; Iwai, K; Urabe, Y

2010-09-01

Although high prevalence of anterior cruciate ligament injuries (ACL) in judokas has been reported, there has been very little research concerning events preceding the injury. To determine the common situations and mechanisms of ACL injury in judo. A total of 43 cases of ACL injuries that had occurred during judo competition or practice were investigated, using questionnaires with interviews conducted by a single certified athletic trainer who has 20 years of judo experience to obtain information regarding the situation and mechanism in which the ACL injury occurred. The number of ACL injuries when the participant's grip style was different from the style of the opponent (ie, kenka-yotsu style) (28 cases) was significantly greater than when the participant's grip style was the same as that of the opponent (ie, ai-yotsu style) (15 cases; p<0.001). The number of ACL injuries was significantly higher when the participant was attacked by the opponent than when counterattacked or when attempting the attack (p<0.001). In addition, being attacked with osoto-gari was revealed as the leading cause of ACL injury incidence among the participants (16.8%). Grip style may be associated with ACL injury occurrence in judo. In addition, direct contact due to the opponent's attack may be a common mechanism for ACL injuries in judo.

Anterior cruciate ligament injury about 20 years post-treatment: A kinematic analysis of one-leg hop.

PubMed

Tengman, E; Grip, H; Stensdotter, Ak; Häger, C K

2015-12-01

Reduced dynamic knee stability, often evaluated with one-leg hops (OLHs), is reported after anterior cruciate ligament (ACL) injury. This may lead to long-standing altered movement patterns, which are less investigated. 3D kinematics during OLH were explored in 70 persons 23 ± 2 years after ACL injury; 33 were treated with physiotherapy in combination with ACL reconstruction (ACL(R)) and 37 with physiotherapy alone (ACL(PT)). Comparisons were made to 33 matched controls. We analyzed (a) maximal knee joint angles and range of motion (flexion, abduction, rotation); (b) medio-lateral position of the center of mass (COM) in relation to knee and ankle joint centers, during take-off and landing phases. Unlike controls, ACL-injured displayed leg asymmetries: less knee flexion and less internal rotation at take-off and landing and more lateral COM related to knee and ankle joint of the injured leg at landing. Compared to controls, ACL(R) had larger external rotation of the injured leg at landing. ACL(PT) showed less knee flexion and larger external rotation at take-off and landing, and larger knee abduction at Landing. COM was more medial in relation to the knee at take-off and less laterally placed relative to the ankle at landing. ACL injury results in long-term kinematic alterations during OLH, which are less evident for ACL(R). © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Histological Analysis of the Tibial Anterior Cruciate Ligament Insertion

PubMed Central

Siebold, Rainer; Oka, Shinya; Traut, Ulrike; Schuhmacher, Peter; Kirsch, Joachim

2017-01-01

Objective: To describe the morphology of the tibial ACL insertion by histological assessment in the sagittal plane. Methods: For histology the native (undissected) tibial ACL insertion of 6 fresh-frozen cadaveric knees was cut into 4 sagittal sections parallel to the long axis of the medial tibial spine. The slices were stained with hematoxylin and eosin, Safranin O and Russell-Movat pentachrome. All slices were digitalized and analyzed at a magnification of ×20. Results: From medial to lateral the anterior-posterior lengths of the ACL insertion were an average of 10.2, 9.3, 7.6 and 5.8 mm. The anterior margin of the tibial ACL insertion raised from an anterior ridge. The most medial ACL fibers rose along with a peak of the anterior part of the medial tibial spine in which the direct insertion was adjacent to the articular cartilage. Parts of the bony insertions of the anterior and posterior horns of the lateral meniscus were in close contact to the lateral ACL insertion. A small fat pad was located just posterior to the tibial ACL insertion. There were no central or posterolateral inserting ACL fibers in the area intercondylaris anterior. Conclusion: The functional intraligamentous midsubstance ACL fibers arose from the most posterior part of its bony tibial insertion in a flat and “C-shape” way. The anterior border of this functional ACL started from a bony ‘anterior ridge’ and the medial border was along with a peak of the medial tibial spine.

[Contribution of MRI to the preoperative evaluation of rotator cuff tears].

PubMed

Gagey, N; Desmoineaux, P; Gagey, O; Idy-Peretti, I; Mazas, F

1991-01-01

The authors report a series of 38 patients who had been examined by MRI and then operated for a rotator cuff syndrome. The correlation between the description of the cuff lesions after MRI and the surgical observations were excellent for 37 patients. In one case MRI showed a false image of tear of the supra spinatus m. on its anterior edge. This was due to a bad knowledge of the anatomy of the muscle and tendon and to a poor orientation of the frontal cut plane. This study was completed with MRI and anatomic study of 12 non embalmed cadaveric shoulders. The results showed that MRI was very sensitive (0.93) and specific (0.94) for the diagnosis of rotator cuff tears. MRI allowed also to show partial tears of the tendons of the rotator cuff. The authors propose a MRI classification of cuff lesions which permits to establish a good surgical planning.

A study for health hazard evaluation of methylene chloride evaporated from the tear gas mixture.

PubMed

Park, Seung-Hyun; Chung, Eun-Kyo; Yi, Gwang-Yong; Chung, Kwang-Jae; Shin, Jung-Ah; Lee, In-Seop

2010-09-01

This study explored the health hazard of those exposed to methylene chloride by assessing its atmospheric concentration when a tear gas mixture was aerially dispersed. The concentration of methylene chloride ranged from 311.1-980.3 ppm (geometric mean, 555.8 ppm), 30 seconds after the dispersion started. However, the concentration fell rapidly to below 10 ppm after dispersion was completed. The concentration during the dispersion did not surpass the National Institute for Occupational Safety and Health 'immediately dangerous to life or health' value of 2,300 ppm, but did exceed the American Conference of Governmental Industrial Hygienists excursion limit of 250 ppm. Since methylene chloride is highly volatile (vapor pressure, 349 mmHg at 20℃), the postdispersion atmospheric concentration can rise instantaneously. Moreover, the o-chlorobenzylidenemalononitrile formulation of tear gas (CS gas) is an acute upper respiratory tract irritant. Therefore, tear gas mixtures should be handled with delicate care.

Second-look arthroscopic findings after repairs of posterior root tears of the medial meniscus.

PubMed

Seo, Hee-Soo; Lee, Su-Chan; Jung, Kwang-Am

2011-01-01

A posterior root tear of the medial meniscus disrupts hoop tension and causes extrusion of the meniscus, which results in progressive cartilage degeneration. To identify the structural integrity of healing after arthroscopic repair of a posterior root tear of the medial meniscus by second-look arthroscopy and to determine the clinical relevance of the findings. Case series; Level of evidence, 4. From December 2006 to August 2008, 21 consecutive patients underwent arthroscopic pullout suture repair for a posterior root tear of the medial meniscus. Eleven were available for second-look arthroscopy evaluation (mean, 13.4 months; range, 10 to 22 months). The healing status of the repaired meniscus was classified as complete healing, lax healing, scar tissue healing, and failed healing. Chondral lesions were reviewed using arthroscopic photographs, and clinical evaluation was based on the Lysholm knee scores and the Hospital for Special Surgery scores. There was no case with complete healing. Five knees had lax healing (symptomatic in 2 and asymptomatic in 3); 4, scar tissue healing (asymptomatic in all 4); and 2, failed healing (symptomatic in 1 and asymptomatic in 1). Progression of the chondral lesion was found in 1 case. Mean Lysholm scores improved from 56.1 preoperatively (range, 41 to 71) to 83.0 at follow-up (range, 69 to 91; P = .003); mean Hospital for Special Surgery score also significantly increased, from 64.1 (range, 50 to 76) to 87.4 (range, 77 to 95; P = .003). Complete healing was not observed in this retrospective case series of posterior horn meniscus repairs performed by 2 surgeons using a single technique. Further research is needed to clarify why all patients showed clinical improvement despite findings of incomplete or failed healing on second-look arthroscopy. Treatment modalities for managing posterior root tears of the medial meniscus require further investigation to determine their efficacy.

Anterior Cruciate Ligament Reconstruction with Tibial Attachment Preserving Hamstring Graft without Implant on Tibial Side

PubMed Central

Sinha, Skand; Naik, Ananta Kumar; Maheshwari, Mridul; Sandanshiv, Sumedh; Meena, Durgashankar; Arya, Rajendra K

2018-01-01

Background: Tibial attachment preserving hamstring graft could prevent potential problems of free graft in anterior cruciate ligament (ACL) reconstruction such as pull out before graft-tunnel healing or rupture before ligamentization. Different implants have been reportedly used for tibial side fixation with this technique. We investigated short-term outcome of ACL reconstruction (ACLR) with tibial attachment sparing hamstring graft without implant on the tibial side by outside in technique. Materials and Methods: Seventy nine consecutive cases of ACL tear having age of 25.7 ± 6.8 years were included after Institutional Board Approval. All subjects were male. The mean time interval from injury to surgery was of 7.5 ± 6.4 months. Hamstring tendons were harvested with open tendon stripper leaving the tibial insertion intact. The free ends of the tendons were whip stitched, quadrupled, and whip stitched again over the insertion site of hamstring with fiber wire (Arthrex). Single bundle ACLR was done by outside in technique and the femoral tunnel was created with cannulated reamer. The graft was pulled up to the external aperture of femoral tunnel and fixed with interference screw (Arthrex). The scoring was done by Lysholm, Tegner, and KT 1000 by independent observers. All cases were followed up for 2 years. Results: The mean length of quadrupled graft attached to tibia was 127.65 ± 7.5 mm, and the mean width was 7.52 ± 0.78 mm. The mean preoperative Lysholm score of 47.15 ± 9.6, improved to 96.8 ± 2.4 at 1 year. All cases except two returned to the previous level of activity after ACLR. There was no significant difference statistically between preinjury (5.89 ± 0.68) and postoperative (5.87 ± 0.67) Tegner score. The anterior tibial translation (ATT) (KT 1000) improved from 11.44 ± 1.93 mm to 3.59 ± 0.89 mm. The ATT of operated knee returned to nearly the similar value as of the opposite knee (3.47 ± 1.16 mm). The Pivot shift test was negative in all cases. None had a failure of graft till final followup. Conclusion: Attachment sparing hamstring graft without a tibial implant is a simple, cost-effective technique that provides a consistently satisfactory outcome. PMID:29576645

Risk Factors for Anterior Cruciate Ligament Injury in Competitive Adolescent Alpine Skiers

PubMed Central

Westin, Maria; Harringe, Marita L.; Engström, Björn; Alricsson, Marie; Werner, Suzanne

2018-01-01

Background: There is a high risk for anterior cruciate ligament (ACL) injuries in alpine skiers. To reduce or try to prevent these injuries, intrinsic and extrinsic risk factors need to be identified. Purpose: To identify possible intrinsic and extrinsic ACL injury risk factors among competitive adolescent alpine skiers. Study Design: Case-control study; Level of evidence, 3. Methods: Between 2006 and 2009, a cohort of 339 alpine ski students (176 male, 163 female) from Swedish ski high schools were prospectively observed in terms of ACL injuries. First-time ACL injuries were recorded. In September, prior to each ski season, the skiers were clinically examined according to a specific knee protocol. Results: Overall, 11 male and 14 female skiers sustained a total of 25 first-episode ACL injuries. The majority of injuries occurred in the left knee (P < .05). Skiers who had participated in alpine skiing for >13 years (hazard ratio, 0.83; 95% CI, 0.68-1.00; P < .05) had a reduced risk of sustaining an ACL injury. Eighteen ACL injuries occurred during training, 12 in the technical discipline of giant slalom, and 8 in slalom. Fourteen skiers reported not to be fatigued at all at the time of injury, and 8 skiers reported that they were somewhat fatigued. Conclusion: ACL injuries occurred more often in the left knee than the right. This should be taken into consideration in the design of ACL injury prevention programs. Those who reported a higher number of active years in alpine skiing showed a reduced risk of sustaining an ACL injury. No other factor among those studied could be identified as an independent risk factor for ACL injury. PMID:29780835

Vertical stiffness is not related to anterior cruciate ligament elongation in professional rugby union players

PubMed Central

Serpell, Benjamin G; Scarvell, Jennie M; Pickering, Mark R; Ball, Nick B; Perriman, Diana; Warmenhoven, John; Smith, Paul N

2016-01-01

Background Novel research surrounding anterior cruciate ligament (ACL) injury is necessary because ACL injury rates have remained unchanged for several decades. An area of ACL risk mitigation which has not been well researched relates to vertical stiffness. The relationship between increased vertical stiffness and increased ground reaction force suggests that vertical stiffness may be related to ACL injury risk. However, given that increased dynamic knee joint stability has been shown to be associated with vertical stiffness, it is possible that modification of vertical stiffness could help to protect against injury. We aimed to determine whether vertical stiffness is related to measures known to load, or which represent loading of, the ACL. Methods This was a cross-sectional observational study of 11 professional Australian rugby players. Knee kinematics and ACL elongation were measured from a 4-dimensional model of a hopping task which simulated the change of direction manoeuvre typically observed when non-contact ACL injury occurs. The model was generated from a CT scan of the participant's knee registered frame by frame to fluoroscopy images of the hopping task. Vertical stiffness was calculated from force plate data. Results There was no association found between vertical stiffness and anterior tibial translation (ATT) or ACL elongation (r=−0.05; p=0.89, and r=−0.07; p=0.83, respectively). ATT was related to ACL elongation (r=0.93; p=0.0001). Conclusions Vertical stiffness was not associated with ACL loading in this cohort of elite rugby players but a novel method for measuring ACL elongation in vivo was found to have good construct validity. PMID:27900192

Quantitative comparison of the pivot shift test results before and after anterior cruciate ligament reconstruction by using the three-dimensional electromagnetic measurement system.

PubMed

Nagai, Kanto; Hoshino, Yuichi; Nishizawa, Yuichiro; Araki, Daisuke; Matsushita, Takehiko; Matsumoto, Tomoyuki; Takayama, Koji; Nagamune, Kouki; Kurosaka, Masahiro; Kuroda, Ryosuke

2015-10-01

Tibial acceleration during the pivot shift test is a potential quantitative parameter to evaluate rotational laxity of anterior cruciate ligament (ACL) insufficiency. However, clinical application of this measurement has not been fully examined. This study aimed to measure and compare tibial acceleration before and after ACL reconstruction (ACLR) in ACL-injured patients. We hypothesized tibial acceleration would be reduced by ACLR and tibial acceleration would be consistent in the same knee at different time points. Seventy ACL-injured patients who underwent ACLR were enrolled. Tibial acceleration during the pivot shift test was measured using an electromagnetic measurement system before ALCR and at the second-look arthroscopy 1 year post-operatively. Tibial acceleration was compared to clinical grading and between ACL-injured/ACL-reconstructed and contralateral knees. Pre-operative tibial acceleration was increased stepwise with the increase in clinical grading (P < 0.01). Tibial acceleration in ACL-injured knee (1.9 ± 1.2 m/s(2)) was larger than that in the contralateral knee (0.8 ± 0.3 m/s(2), P < 0.01), and reduced to 0.9 ± 0.3 m/s(2) post-operatively (P < 0.01). There was no difference between ACL-reconstructed and contralateral knee (n.s.). Tibial acceleration in contralateral knees was consistent pre- and post-operatively (n.s.). Tibial acceleration measurement demonstrated increased rotational laxity in ACL-injured knees and its reduction by ALCR. Additionally, consistent measurements were obtained in ACL-intact knees at different time points. Therefore, tibial acceleration during the pivot shift test could provide quantitative evaluation of rotational stability before and after ACL reconstruction. III.

Tibiofemoral joint contact area and pressure after single- and double-bundle anterior cruciate ligament reconstruction.

PubMed

Morimoto, Yusuke; Ferretti, Mario; Ekdahl, Max; Smolinski, Patrick; Fu, Freddie H

2009-01-01

The purpose of this study was to compare the tibiofemoral contact area and pressure after single-bundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) reconstruction by use of 2 femoral and 2 tibial tunnels in intact cadaveric knees. Tibiofemoral contact area and mean and maximum pressures were measured by pressure-sensitive film (Fujifilm, Valhalla, NY) inserted between the tibia and femur. The knee was subjected to a 1,000-N axial load by use of a uniaxial testing machine at 0 degrees , 15 degrees , 30 degrees , and 45 degrees of flexion. Three conditions were evaluated: (1) intact ACL, (2) SB ACL reconstruction (n = 10 knees), and (3) DB ACL reconstruction (n = 9 knees). When compared with the intact knee, DB ACL reconstruction showed no significant difference in tibiofemoral contact area and mean and maximum pressures. SB ACL reconstruction had a significantly smaller contact area on the lateral and medial tibiofemoral joints at 30 degrees and 15 degrees of flexion. SB ACL reconstruction also had significantly higher mean pressures at 15 degrees of flexion on the medial tibiofemoral joint and at 0 degrees and 15 degrees of flexion on the lateral tibiofemoral joint, as well as significantly higher maximum pressures at 15 degrees of flexion on the lateral tibiofemoral joint. SB ACL reconstruction resulted in a significantly smaller tibiofemoral contact area and higher pressures. DB ACL more closely restores the normal contact area and pressure mainly at low flexion angles. Our findings suggest that the changes in the contact area and pressures after SB ACL reconstruction may be one of the causes of osteoarthritis on long-term follow-up. DB ACL reconstruction may reduce the incidence of osteoarthritis by closely restoring contact area and pressure.

Increased Platelet Concentration does not Improve Functional Graft Healing in Bio-Enhanced ACL Reconstruction

PubMed Central

Fleming, Braden C.; Proffen, Benedikt L.; Vavken, Patrick; Shalvoy, Matthew R.; Machan, Jason T.; Murray, Martha M.

2014-01-01

Purpose The use of an extra-cellular matrix scaffold (ECM) combined with platelets to enhance healing of an ACL graft (“bio-enhanced ACL reconstruction”) has shown promise in animal models. However, the effects of platelet concentration on graft healing remains unknown. The objectives of this study were to determine if increasing the platelet concentration in the ECM scaffold would; 1) improve the graft biomechanical properties, and 2) decrease cartilage damage after surgery. Methods Fifty-five adolescent minipigs were randomized to 5 treatment groups; untreated ACL transection (n=10), conventional ACL reconstruction (n=15), and bio-enhanced ACL reconstruction using 1X (n=10), 3X (n=10) or 5X (n=10) platelet-rich plasma. The graft biomechanical properties, anteroposterior (AP) knee laxity, graft histology and macroscopic cartilage integrity were measured at 15 weeks. Results The mean linear stiffness of the bio-enhanced ACL reconstruction procedure using the 1X preparation was significantly greater than traditional reconstruction while the 3X and 5X preparations were not. The failure loads of all the ACL reconstructed groups were equivalent but significantly greater than untreated ACL transection. There were no significant differences in the ligament maturity index or AP laxity between reconstructed knees. Macroscopic cartilage damage was relatively minor, though significantly less when the ECM-platelet composite was used. Conclusions Only the 1X platelet concentration improved healing over traditional ACL reconstruction. Increasing the platelet concentration from 1X to 5X in the ECM scaffold did not further improve the graft mechanical properties. The use of an ECM-platelet composite decreased the amount of cartilage damage seen after ACL surgery. PMID:24633008

Increased platelet concentration does not improve functional graft healing in bio-enhanced ACL reconstruction.

PubMed

Fleming, Braden C; Proffen, Benedikt L; Vavken, Patrick; Shalvoy, Matthew R; Machan, Jason T; Murray, Martha M

2015-04-01

The use of an extracellular matrix scaffold (ECM) combined with platelets to enhance healing of an anterior cruciate ligament (ACL) graft ("bio-enhanced ACL reconstruction") has shown promise in animal models. However, the effects of platelet concentration on graft healing remain unknown. The objectives of this study were to determine whether increasing the platelet concentration in the ECM scaffold would (1) improve the graft biomechanical properties and (2) decrease cartilage damage after surgery. Fifty-five adolescent minipigs were randomized to five treatment groups: untreated ACL transection (n = 10), conventional ACL reconstruction (n = 15) and bio-enhanced ACL reconstruction using 1× (n = 10), 3× (n = 10) or 5× (n = 10) platelet-rich plasma. The graft biomechanical properties, anteroposterior (AP) knee laxity, graft histology and macroscopic cartilage integrity were measured at 15 weeks. The mean linear stiffness of the bio-enhanced ACL reconstruction procedure using the 1× preparation was significantly greater than traditional reconstruction, while the 3× and 5× preparations were not. The failure loads of all the ACL-reconstructed groups were equivalent but significantly greater than untreated ACL transection. There were no significant differences in the Ligament Maturity Index or AP laxity between reconstructed knees. Macroscopic cartilage damage was relatively minor, though significantly less when the ECM-platelet composite was used. Only the 1× platelet concentration improved healing over traditional ACL reconstruction. Increasing the platelet concentration from 1× to 5× in the ECM scaffold did not further improve the graft mechanical properties. The use of an ECM-platelet composite decreased the amount of cartilage damage seen after ACL surgery.

Differences in kinematics of single leg squatting between anterior cruciate ligament-injured patients and healthy controls.

PubMed

Yamazaki, J; Muneta, T; Ju, Y J; Sekiya, I

2010-01-01

Seventy to eighty percent of all anterior cruciate ligament (ACL) injuries are due to non-contact injury mechanisms. It has been reported that the majority of injuries due to single leg landing come from valgus positioning of the lower leg. Preventing valgus positioning during single leg landing is expected to help reduce the number of ACL injuries. We found that many ACL-deficient patients cannot perform stable single leg squatting. Therefore, we performed 3D motion analysis of the single-legged half squat for ACL-injured patients to evaluate its significance as a risk factor for ACL injuries. We evaluated the relative angles between the body, thigh, and lower leg using an electromagnetic device during single leg half squatting performed by 63 ACL-injured patients (32 males, 31 females) the day before ACL reconstruction and by 26 healthy control subjects with no knee problems. The uninjured leg of ACL-injured male subjects demonstrated significantly less external knee rotation than that of the dominant leg of the male control. The uninjured leg of ACL-injured female subjects demonstrated significantly more external hip rotation and knee flexion and less hip flexion than that of the dominant leg of the female control. Comparing injured and uninjured legs, the injured leg of male subjects demonstrated significantly less external knee and hip rotation, less knee flexion, and more knee varus than that of the uninjured leg of male subjects. The injured leg of female subjects demonstrated more knee varus than that of the uninjured leg of female subjects. Regarding gender differences, female subjects demonstrated significantly more external hip rotation and knee valgus than male subjects did in both the injured and uninjured legs (P < 0.05). The current kinematic study exhibited biomechanical characteristics of female ACL-injured subjects compared with that of control groups. Kinematic correction during single leg half squat would reduce ACL reinjury in female ACL-injured subjects.

Addition of autologous mesenchymal stem cells to whole blood for bioenhanced ACL repair has no benefit in the porcine model.

PubMed

Proffen, Benedikt L; Vavken, Patrick; Haslauer, Carla M; Fleming, Braden C; Harris, Chad E; Machan, Jason T; Murray, Martha M

2015-02-01

Coculture of mesenchymal stem cells (MSCs) from the retropatellar fat pad and peripheral blood has been shown to stimulate anterior cruciate ligament (ACL) fibroblast proliferation and collagen production in vitro. Current techniques of bioenhanced ACL repair in animal studies involve adding a biologic scaffold, in this case an extracellular matrix-based scaffold saturated with autologous whole blood, to a simple suture repair of the ligament. Whether the enrichment of whole blood with MSCs would further improve the in vivo results of bioenhanced ACL repair was investigated. The addition of MSCs derived from adipose tissue or peripheral blood to the blood-extracellular matrix composite, which is used in bioenhanced ACL repair to stimulate healing, would improve the biomechanical properties of a bioenhanced ACL repair after 15 weeks of healing. Controlled laboratory study. Twenty-four adolescent Yucatan mini-pigs underwent ACL transection followed by (1) bioenhanced ACL repair, (2) bioenhanced ACL repair with the addition of autologous adipose-derived MSCs, and (3) bioenhanced ACL repair with the addition of autologous peripheral blood derived MSCs. After 15 weeks of healing, the structural properties of the ACL (yield load, failure load, and linear stiffness) were measured. Cell and vascular density were measured in the repaired ACL via histology, and its tissue structure was qualitatively evaluated using the advanced Ligament Maturity Index. After 15 weeks of healing, there were no significant improvements in the biomechanical or histological properties with the addition of adipose-derived MSCs. The only significant change with the addition of peripheral blood MSCs was an increase in knee anteroposterior laxity when measured at 30° of flexion. These findings suggest that the addition of adipose or peripheral blood MSCs to whole blood before saturation of an extracellular matrix carrier with the blood did not improve the functional results of bioenhanced ACL repair after 15 weeks of healing in the pig model. Whole blood represents a practical biologic additive to ligament repair, and any other additive (including stem cells) should be demonstrated to be superior to this baseline before clinical use is considered. © 2014 The Author(s).

Strain Response of the Anterior Cruciate Ligament to Uniplanar and Multiplanar Loads During Simulated Landings: Implications for Injury Mechanism.

PubMed

Kiapour, Ata M; Demetropoulos, Constantine K; Kiapour, Ali; Quatman, Carmen E; Wordeman, Samuel C; Goel, Vijay K; Hewett, Timothy E

2016-08-01

Despite basic characterization of the loading factors that strain the anterior cruciate ligament (ACL), the interrelationship(s) and additive nature of these loads that occur during noncontact ACL injuries remain incompletely characterized. In the presence of an impulsive axial compression, simulating vertical ground-reaction force during landing (1) both knee abduction and internal tibial rotation moments would result in increased peak ACL strain, and (2) a combined multiplanar loading condition, including both knee abduction and internal tibial rotation moments, would increase the peak ACL strain to levels greater than those under uniplanar loading modes alone. Controlled laboratory study. A cadaveric model of landing was used to simulate dynamic landings during a jump in 17 cadaveric lower extremities (age, 45 ± 7 years; 9 female and 8 male). Peak ACL strain was measured in situ and characterized under impulsive axial compression and simulated muscle forces (baseline) followed by addition of anterior tibial shear, knee abduction, and internal tibial rotation loads in both uni- and multiplanar modes, simulating a broad range of landing conditions. The associations between knee rotational kinematics and peak ACL strain levels were further investigated to determine the potential noncontact injury mechanism. Externally applied loads, under both uni- and multiplanar conditions, resulted in consistent increases in peak ACL strain compared with the baseline during simulated landings (by up to 3.5-fold; P ≤ .032). Combined multiplanar loading resulted in the greatest increases in peak ACL strain (P < .001). Degrees of knee abduction rotation (R(2) = 0.45; β = 0.42) and internal tibial rotation (R(2) = 0.32; β = 0.23) were both significantly correlated with peak ACL strain (P < .001). However, changes in knee abduction rotation had a significantly greater effect size on peak ACL strain levels than did internal tibial rotation (by ~2-fold; P < .001). In the presence of impulsive axial compression, the combination of anterior tibial shear force, knee abduction, and internal tibial rotation moments significantly increases ACL strain, which could result in ACL failure. These findings support multiplanar knee valgus collapse as one the primary mechanisms of noncontact ACL injuries during landing. Intervention programs that address multiple planes of loading may decrease the risk of ACL injury and the devastating consequences of posttraumatic knee osteoarthritis. © 2016 The Author(s).

Posteromedial Meniscocapsular Lesions Increase Tibiofemoral Joint Laxity With Anterior Cruciate Ligament Deficiency, and Their Repair Reduces Laxity.

PubMed

Stephen, Joanna M; Halewood, Camilla; Kittl, Christoph; Bollen, Steve R; Williams, Andy; Amis, Andrew A

2016-02-01

Injury to the posteromedial meniscocapsular junction has been identified after anterior cruciate ligament (ACL) rupture; however, there is a lack of objective evidence investigating how this affects knee kinematics or whether increased laxity can be restored by repair. Such injury is often overlooked at surgery, with possible compromise to results. (1) Sectioning the posteromedial meniscocapsular junction in an ACL-deficient knee will result in increased anterior tibial translation and rotation. (2) Isolated ACL reconstruction in the presence of a posteromedial meniscocapsular junction lesion will not restore intact knee laxity. (3) Repair of the posteromedial capsule at the time of ACL reconstruction will reduce tibial translation and rotation to normal. (4) These changes will be clinically detectable. Controlled laboratory study. Nine cadaveric knees were mounted in a test rig where knee kinematics were recorded from 0° to 100° of flexion by use of an optical tracking system. Measurements were recorded with the following loads: 90-N anterior-posterior tibial forces, 5-N·m internal-external tibial rotation torques, and combined 90-N anterior force and 5-N·m external rotation torque. Manual Rolimeter readings of anterior translation were taken at 30° and 90°. The knees were tested in the following conditions: intact, ACL deficient, ACL deficient and posteromedial meniscocapsular junction sectioned, ACL deficient and posteromedial meniscocapsular junction repaired, ACL patellar tendon reconstruction with posteromedial meniscocapsular junction repair, and ACL reconstructed and capsular lesion re-created. Statistical analysis used repeated-measures analysis of variance and post hoc paired t tests with Bonferroni correction. Tibial anterior translation and external rotation were both significantly increased compared with the ACL-deficient knee after posterior meniscocapsular sectioning (P < .05). These parameters were restored after ACL reconstruction and meniscocapsular lesion repair (P > .05). Anterior and external rotational laxities were significantly increased after sectioning of the posteromedial meniscocapsular junction in an ACL-deficient knee. These were not restored after ACL reconstruction alone but were restored with ACL reconstruction combined with posterior meniscocapsular repair. Tibial anterior translation changes were clinically detectable by use of the Rolimeter. This study suggests that unrepaired posteromedial meniscocapsular lesions will allow abnormal meniscal and tibiofemoral laxity to persist postoperatively, predisposing the knee to meniscal and articular damage. © 2015 The Author(s).

Validity of the Strong Interest Inventory: Gender and Personal Styles.

ERIC Educational Resources Information Center

Lindley, Lori D.; Borgen, Fred H.

The gender validity of the Strong Interest Inventory's Personal Style Scales (Work Style, Learning Environment, Leadership Style, and Risk Taking/Adventure) was examined through a study of 458 female and 282 male college students at Iowa State University. The students completed the Personal Style Scales and the Adjective Check List (ACL), which is…

Non-operative management of a complete anterior cruciate ligament injury in an English Premier League football player with return to play in less than 8 weeks: applying common sense in the absence of evidence

PubMed Central

Weiler, Richard; Monte-Colombo, Mathew; Mitchell, Adam; Haddad, Fares

2015-01-01

This case report illustrates and discusses the non-operative management of a complete anterior cruciate ligament (ACL) injury in an English Premier League football player, his return to play within 8 weeks and problem-free follow-up at 18 months post injury. When non-operative verses surgical ACL reconstruction is considered there are many fundamental gaps in our knowledge and currently, at elite level, there are no cases in cutting sports within the literature to guide these decisions. When the norm is for all professional footballers to be recommended surgery, it will be very challenging when circumstances and patient autonomy dictate a conservative approach, where prognosis, end points and risk are unclear and assumed to be high. This case challenges current dogma and provides a starting point for much needed debate about best practice, treatment options, research direction and not just at the elite level of sport. PMID:25917066

Postural stability does not differ among female sports with high risk of anterior cruciate ligament injury.

PubMed

Cortes, Nelson; Porter, Larissa D; Ambegaonkar, Jatin P; Caswell, Shane V

2014-12-01

Dancers have a lower incidence of anterior cruciate ligament (ACL) injury compared to athletes in sports that involve cutting and landing motions. Balance can impact ACL injury risk and is related to neuromuscular control during movement. The purpose of this study was to investigate whether balance differences exist among female dancers and female soccer and basketball athletes. Fifty-eight female dancers, soccer, and basketball athletes (16.5 ± 1.6 yrs, 1.6 ± 0.2 m, 60.2 ± 14.1 kg) completed the Stability Evaluation Test (SET) on the NeuroCom VSR Sport (NeuroCom International, Clackamas, OR) to measure sway velocity. Video records of the SET test were used for Balance Error Scoring System (BESS) test scoring. A oneway ANCOVA compared composite sway velocity and BESS scores among sports. There was no statistically significant difference for sway velocity or BESS among sports (sway velocity soccer 2.3 ± 0.4, dance 2.2 ± 0.4, and basketball 2.4 ± 0.4; BESS soccer 13.6 ± 5.0, dance 11.9 ± 5.5, and basketball 14.9 ± 5.1, p>0.05). Balance was similar among athletes participating in different sports (dance, basketball, and soccer). Quasi-static balance may not play a significant role in neuromuscular control during movement and not be a significant risk factor to explain the disparity in ACL injury incidence among sports. Future research should examine the effects of dynamic balance and limb asymmetries among sports to elucidate on the existing differences on ACL injury incidence rates.

Diagnostic Value of Knee Arthrometry in the Prediction of Anterior Cruciate Ligament Strain During Landing

PubMed Central

Kiapour, Ata M.; Wordeman, Samuel C.; Paterno, Mark V.; Quatman, Carmen E.; Levine, Jason W.; Goel, Vijay K.; Demetropoulos, Constantine K.; Hewett, Timothy E.

2014-01-01

Background Previous studies have indicated that higher knee joint laxity may be indicative of an increased risk of anterior cruciate ligament (ACL) injuries. Despite the frequent clinical use of knee arthrometry in the evaluation of knee laxity, little data exist to correlate instrumented laxity measures and ACL strain during dynamic high-risk activities. Purpose/Hypotheses The purpose of this study was to evaluate the relationships between ACL strain and anterior knee laxity measurements using arthrometry during both a drawer test and simulated bipedal landing (as an identified high-risk injurious task). We hypothesized that a high correlation exists between dynamic ACL strain and passive arthrometry displacement. The secondary hypothesis was that anterior knee laxity quantified by knee arthrometry is a valid predictor of injury risk such that specimens with greater anterior knee laxity would demonstrate increased levels of peak ACL strain during landing. Study Design Controlled laboratory study. Methods Twenty cadaveric lower limbs (mean age, 46 ± 6 years; 10 female and 10 male) were tested using a CompuKT knee arthrometer to measure knee joint laxity. Each specimen was tested under 4 continuous cycles of anterior-posterior shear force (±134 N) applied to the tibial tubercle. To quantify ACL strain, a differential variable reluctance transducer (DVRT) was arthroscopically placed on the ACL (anteromedial bundle), and specimens were retested. Subsequently, bipedal landing from 30 cm was simulated in a subset of 14 specimens (mean age, 45 ± 6 years; 6 female and 8 male) using a novel custom-designed drop stand. Changes in joint laxity and ACL strain under applied anterior shear force were statistically analyzed using paired sample t tests and analysis of variance. Multiple linear regression analyses were conducted to determine the relationship between anterior shear force, anterior tibial translation, and ACL strain. Results During simulated drawer tests, 134 N of applied anterior shear load produced a mean peak anterior tibial translation of 3.1 ± 1.1 mm and a mean peak ACL strain of 4.9% ± 4.3%. Anterior shear load was a significant determinant of anterior tibial translation (P <.0005) and peak ACL strain (P = .04). A significant correlation (r = 0.52, P <.0005) was observed between anterior tibial translation and ACL strain. Cadaveric simulations of landing produced a mean axial impact load of 4070 ± 732 N. Simulated landing significantly increased the mean peak anterior tibial translation to 10.4 ± 3.5 mm and the mean peak ACL strain to 6.8% ± 2.8% (P <.0005) compared with the prelanding condition. Significant correlations were observed between peak ACL strain during simulated landing and anterior tibial translation quantified by knee arthrometry. Conclusion Our first hypothesis is supported by a significant correlation between arthrometry displacement collected during laxity tests and concurrent ACL strain calculated from DVRT measurements. Experimental findings also support our second hypothesis that instrumented measures of anterior knee laxity predict peak ACL strain during landing, while specimens with greater knee laxity demonstrated higher levels of peak ACL strain during landing. Clinical Relevance The current findings highlight the importance of instrumented anterior knee laxity assessments as a potential indicator of the risk of ACL injuries in addition to its clinical utility in the evaluation of ACL integrity. PMID:24275863

How does a cadaver model work for testing ultrasound diagnostic capability for rheumatic-like tendon damage?

PubMed

Janta, Iustina; Morán, Julio; Naredo, Esperanza; Nieto, Juan Carlos; Uson, Jacqueline; Möller, Ingrid; Bong, David; Bruyn, George A W; D Agostino, Maria Antonietta; Filippucci, Emilio; Hammer, Hilde Berner; Iagnocco, Annamaria; Terslev, Lene; González, Jorge Murillo; Mérida, José Ramón; Carreño, Luis

2016-06-01

To establish whether a cadaver model can serve as an effective surrogate for the detection of tendon damage characteristic of rheumatoid arthritis (RA). In addition, we evaluated intraobserver and interobserver agreement in the grading of RA-like tendon tears shown by US, as well as the concordance between the US findings and the surgically induced lesions in the cadaver model. RA-like tendon damage was surgically induced in the tibialis anterior tendon (TAT) and tibialis posterior tendon (TPT) of ten ankle/foot fresh-frozen cadaveric specimens. Of the 20 tendons examined, six were randomly assigned a surgically induced partial tear; six a complete tear; and eight left undamaged. Three rheumatologists, experts in musculoskeletal US, assessed from 1 to 5 the quality of US imaging of the cadaveric models on a Likert scale. Tendons were then categorized as having either no damage, (0); partial tear, (1); or complete tear (2). All 20 tendons were blindly and independently evaluated twice, over two rounds, by each of the three observers. Overall, technical performance was satisfactory for all items in the two rounds (all values over 2.9 in a Likert scale 1-5). Intraobserver and interobserver agreement for US grading of tendon damage was good (mean κ values 0.62 and 0.71, respectively), with greater reliability found in the TAT than the TPT. Concordance between US findings and experimental tendon lesions was acceptable (70-100 %), again greater for the TAT than for the TPT. A cadaver model with surgically created tendon damage can be useful in evaluating US metric properties of RA tendon lesions.

50 CFR 648.140 - Black sea bass Annual Catch Limit (ACL).

Code of Federal Regulations, 2014 CFR

2014-10-01

... 50 Wildlife and Fisheries 12 2014-10-01 2014-10-01 false Black sea bass Annual Catch Limit (ACL... Management Measures for the Black Sea Bass Fishery § 648.140 Black sea bass Annual Catch Limit (ACL). (a) The Black Sea Bass Monitoring Committee shall recommend to the MAFMC separate ACLs for the commercial and...

50 CFR 648.140 - Black sea bass Annual Catch Limit (ACL).

Code of Federal Regulations, 2013 CFR

2013-10-01

... 50 Wildlife and Fisheries 12 2013-10-01 2013-10-01 false Black sea bass Annual Catch Limit (ACL... Management Measures for the Black Sea Bass Fishery § 648.140 Black sea bass Annual Catch Limit (ACL). (a) The Black Sea Bass Monitoring Committee shall recommend to the MAFMC separate ACLs for the commercial and...

50 CFR 648.140 - Black sea bass Annual Catch Limit (ACL).

Code of Federal Regulations, 2012 CFR

2012-10-01

... 50 Wildlife and Fisheries 12 2012-10-01 2012-10-01 false Black sea bass Annual Catch Limit (ACL... Management Measures for the Black Sea Bass Fishery § 648.140 Black sea bass Annual Catch Limit (ACL). (a) The Black Sea Bass Monitoring Committee shall recommend to the MAFMC separate ACLs for the commercial and...

Reducing the Risk of ACL Injury in Female Athletes

ERIC Educational Resources Information Center

McDaniel, Larry W.; Rasche, Adrienna; Gaudet, Laura; Jackson, Allen

2010-01-01

The Anterior Cruciate Ligament (ACL) is located behind the kneecap (patella) and connects the thigh bone (femur) to the shin bone (tibia). Stabilizing the knee joint is the primary responsibility of the ACL. Injuries that affect the ACL are three to five times more common in females than males. This is a result of anatomical, biomechanical,…

78 FR 26782 - Agency Information Collection Activities; Submission for OMB Review; Comment Request; State...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-08

...: Administration for Community Living, HHS. ACTION: Notice. SUMMARY: The Administration for Community Living (ACL....eop.gov , Attn: OMB Desk Officer for ACL. FOR FURTHER INFORMATION CONTACT: Elena Fazio at 202-357-3583 or email: [email protected]acl.hhs.gov . SUPPLEMENTARY INFORMATION: In compliance with 44 U.S.C. 3507, ACL...

50 CFR 648.230 - Spiny dogfish Annual Catch Limits (ACLs).

Code of Federal Regulations, 2014 CFR

2014-10-01

... Spiny Dogfish Monitoring Committee shall recommend to the Joint Spiny Dogfish Committee, an ACL for the...) recommended by the SSC as specified in § 648.20. (1) Periodicity. The spiny dogfish ACL may be established on... shall conduct a detailed review of fishery performance relative to the ACL at least every 5 years. (1...

50 CFR 648.230 - Spiny dogfish Annual Catch Limits (ACLs).

Code of Federal Regulations, 2013 CFR

2013-10-01

... Spiny Dogfish Monitoring Committee shall recommend to the Joint Spiny Dogfish Committee, an ACL for the...) recommended by the SSC as specified in § 648.20. (1) Periodicity. The spiny dogfish ACL may be established on... shall conduct a detailed review of fishery performance relative to the ACL at least every 5 years. (1...

77 FR 66746 - Fisheries of the Northeastern United States; Atlantic Herring Fishery; Sub-ACL (Annual Catch...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-07

...-ACL (Annual Catch Limit) Harvested for Management Area 1A AGENCY: National Marine Fisheries Service... catch, annual catch limit (ACL), optimum yield, domestic harvest and processing, U.S. at-sea processing, border transfer, and the sub-ACL for each management area. The 2012 Domestic Annual Harvest was set as 91...

50 CFR 648.64 - Yellowtail flounder sub-ACLs and AMs for the scallop fishery.

Code of Federal Regulations, 2012 CFR

2012-10-01

... framework adjustment process specified in § 648.90, the scallop fishery shall be allocated a sub-ACL for the... flounder sub-ACL for the scallop fishery is exceeded, the area defined by the following coordinates shall... the corresponding percent overage of the Georges Bank yellowtail flounder sub-ACL, as follows: (i) For...

78 FR 32995 - Snapper-Grouper Fishery of the South Atlantic; 2013 Recreational Accountability Measure and...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-03

... catch limit (ACL) for golden tilefish. Furthermore, information from 2013 recreational landings indicate that landings are projected to reach the recreational ACL on June 3, 2013. To account for the 2012 ACL overage and to prevent an ACL overage in 2013, NMFS closes the recreational sector for golden tilefish on...

50 CFR 648.230 - Catch quotas and other restrictions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... the Joint Spiny Dogfish Committee, an ACL for the commercial spiny dogfish fishery, which shall equal....20. (1) Periodicity. The spiny dogfish ACL may be established on an annual basis for up to 5 years at... fishery performance relative to the ACL at least every 5 years. (1) If an ACL is exceeded with a frequency...

77 FR 41704 - Fisheries of the Northeastern United States; Northeast Multispecies Fishery; Adjustment of...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-16

... catch of GB yellowtail flounder by the scallop fishery and is consistent with a request for the ACL... multispecies, scallop, and other fisheries. The allocation to the scallop fishery, known as the sub-ACL, is..., to maximize scallop catch. The groundfish sub-ACL is determined after deducting the sub-ACL allocated...

50 CFR 648.230 - Spiny dogfish Annual Catch Limits (ACLs).

Code of Federal Regulations, 2012 CFR

2012-10-01

... Spiny Dogfish Monitoring Committee shall recommend to the Joint Spiny Dogfish Committee, an ACL for the...) recommended by the SSC as specified in § 648.20. (1) Periodicity. The spiny dogfish ACL may be established on... shall conduct a detailed review of fishery performance relative to the ACL at least every 5 years. (1...

76 FR 61061 - Fisheries of the Northeastern United States; Atlantic Herring Fishery; Sub-ACL (Annual Catch...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-03

...-ACL (Annual Catch Limit) Harvested for Management Area 3 AGENCY: National Marine Fisheries Service...-ACL (annual catch limit) for Area 3 becomes available, except when transiting as described in this notice. This action is based on the determination that 95 percent of the herring sub-ACL allocated to...

50 CFR 622.58 - Annual catch limits (ACLs), annual catch targets (ACTs), and accountability measures (AMs).

Code of Federal Regulations, 2014 CFR

2014-10-01

... commercial ACL, then during the following fishing year, if commercial landings reach or are projected to reach the commercial ACL, the AA will file a notification with the Office of the Federal Register to close the commercial sector for the remainder of that fishing year. The commercial ACL for royal red...

50 CFR 622.58 - Annual catch limits (ACLs), annual catch targets (ACTs), and accountability measures (AMs).

Code of Federal Regulations, 2013 CFR

2013-10-01

... commercial ACL, then during the following fishing year, if commercial landings reach or are projected to reach the commercial ACL, the AA will file a notification with the Office of the Federal Register to close the commercial sector for the remainder of that fishing year. The commercial ACL for royal red...

77 FR 61299 - Fisheries of the Northeastern United States; Atlantic Herring Fishery; Sub-ACL (Annual Catch...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-09

...-ACL (Annual Catch Limit) Harvested for Management Area 3 AGENCY: National Marine Fisheries Service..., annual catch limit (ACL), optimum yield, domestic harvest and processing, U.S. at-sea processing, border transfer, and the sub-ACL for each management area. The 2012 Domestic Annual Harvest was set as 91,200...

76 FR 34903 - Revisions to Framework Adjustment 45 to the Northeast Multispecies Fishery Management Plan and...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-15

... Management Plan and Sector Annual Catch Entitlements; Updated Annual Catch Limits for Sectors and the Common... (ACLs) for common pool vessels (common pool sub-ACLs), ACLs for sector vessels (sector sub-ACLs), and... number of participants electing to fish in either sectors or the common pool fishery in FY 2011. DATES...

Prevention of anterior cruciate ligament injury in the female athlete

PubMed Central

Silvers, Holly Jacinda; Mandelbaum, Bert R

2007-01-01

The relationships of gender, age and training to the incidence of anterior cruciate ligament (ACL) injury are pivotal to developing a comprehensive neuromuscular and proprioceptive training programme to decrease ACL injuries in female athletes. A prophylactic neuromuscular and proprioceptive training programme may have direct benefit in decreasing the number of ACL injuries in female athletes. This research foundation endorses further epidemiological and biomechanical studies to determine the exact mechanism of ACL injury and the most effective intervention for decreasing ACL injuries in this high‐risk population. PMID:17609222

Comparing the effects of mechanical perturbation training with a compliant surface and manual perturbation training on joints kinematics after ACL-rupture.

PubMed

Nawasreh, Zakariya; Failla, Mathew; Marmon, Adam; Logerstedt, David; Snyder-Mackler, Lynn

2018-05-23

Performing physical activities on a compliant surface alters joint kinematics and increases joints stiffness. However, the effect of compliant surface on joint kinematics after ACL-rupture is yet unknown. To compare the effects of mechanical perturbation training with a compliant surface to manual perturbation training on joint kinematics after ACL-rupture. Sixteen level I/II athletes with ACL-rupture participated in this preliminary study. Eight patients received mechanical perturbation with compliant surface (Mechanical) and 8 patients received manual perturbation training (Manual). Patients completed standard gait analysis before (Pre) and after (Post) training. Significant group-by-time interactions were found for knee flexion angle at initial contact (IC) and peak knee flexion (PKF) (p<0.004), with manual group significantly increased knee flexion angle at IC and PKF (p<0.03). Main effects of group were found for hip flexion angle at IC (Manual:34.34+3.51°, Mechanical:27.68+4.08°, p = 0.011), hip rotation angle at PKE (Manual:-3.40+4.78°, Mechanical:5.43+4.78°, p < 0.0001), and knee adduction angle at PKE (Manual:-2.00+2.23°, Mechanical:0.55+2.23°, p = 0.039). Main effects of time were found for hip adduction angle at PKE (Pre:6.98+4.48°, Post:8.41+4.91°, p = 0.04), knee adduction angle at IC (Pre:-2.90+3.50°, Post:-0.62+2.58°, p = 0.03), ankle adduction angle at IC (Pre:2.16+3.54, Post:3.8+3.68, p = 0.008), and ankle flexion angle at PKF (Pre:-4.55+2.77°, Post:-2.39+3.48°, p = 0.01). Training on a compliant surface induces different effects on joint kinematics compared to manual perturbation training after ACL-rupture. Manual perturbation improved hip alignment and increased knee flexion angles, while mechanical training decreased knee flexion angles throughout the stance phase. Administering training on a compliant surface after ACL-rupture may help improving dynamic knee stability, however, long-term effects on knee health needs to be determined. Copyright © 2018 Elsevier B.V. All rights reserved.

Comparison of CT and MRI in patients with tibial plateau fracture: can CT findings predict ligament tear or meniscal injury?

PubMed

Mui, Leonora W; Engelsohn, Eliyahu; Umans, Hilary

2007-02-01

(1) To determine the accuracy of computed tomography (CT) in the evaluation of ligament tear and avulsion in patients with tibial plateau fracture. (2) To evaluate whether the presence or severity of fracture gap and articular depression can predict meniscal injury. A fellowship-trained musculoskeletal radiologist retrospectively reviewed knee CT and MRI examinations of 41 consecutive patients presenting to a level 1 trauma center with tibial plateau fractures. Fracture gap, articular depression, ligament tear and footprint avulsions were assessed on CT examinations. The MRI studies were examined for osseous and soft tissue injuries, including meniscal tear, meniscal displacement, ligament tear, and ligament avulsion. CT demonstrated torn ligaments with 80% sensitivity and 98% specificity. Only 2% of ligaments deemed intact on careful CT evaluation had partial or complete tears on MRI. Although the degree of fracture gap and articular depression was significantly greater in patients with meniscal injury compared with those without meniscal injury, ROC analysis demonstrated no clear threshold for gap or depression that yielded a combination of high sensitivity and specificity. In the acute setting, CT offers high sensitivity and specificity for depicting osseous avulsions, as well as high negative predictive value for excluding ligament injury. However, MRI remains necessary for the preoperative detection of meniscal injury.

Mechanisms, Prediction, and Prevention of ACL Injuries: Cut Risk With Three Sharpened and Validated Tools

PubMed Central

Hewett, Timothy E.; Myer, Gregory D.; Ford, Kevin R.; Paterno, Mark V.; Quatman, Carmen E.

2017-01-01

Economic and societal pressures influence modern medical practice to develop and implement prevention strategies. Anterior cruciate ligament (ACL) injury devastates the knee joint leading to short term disability and long term sequelae. Due to the high risk of long term osteoarthritis in all treatment populations following ACL injury, prevention is the only effective intervention for this life-altering disruption in knee health. The “Sequence of Prevention” Model provides a framework to monitor progress towards the ultimate goal of preventing ACL injuries. Utilizing this model, our multidisciplinary collaborative research team has spent the last decade working to delineate injury mechanisms, identify injury risk factors, predict which athletes are at-risk for injury, and develop ACL injury prevention programs. Within this model of injury prevention, modifiable factors (biomechanical and neuromuscular) related to injury mechanisms likely provide the best opportunity for intervention strategies aimed to decrease the risk of ACL injury, particularly in female athletes. Knowledge advancements have led to the development of potential solutions that allow athletes to compete with lowered risk of ACL injury. Design and integration of personalized clinical assessment tools and targeted prevention strategies for athletes at high risk for ACL injury may transform current prevention practices and ultimately significantly reduce ACL injury incidence. This 2016 OREF Clinical Research Award focuses on the authors' work and contributions to the field. The author's acknowledge the many research groups who have contributed to the current state of knowledge in the fields of ACL injury mechanisms, injury risk screening and injury prevention strategies. PMID:27612195

Anterior cruciate ligament- and hamstring tendon-derived cells: in vitro differential properties of cells involved in ACL reconstruction.

PubMed

Ghebes, Corina Adriana; Kelder, Cindy; Schot, Thomas; Renard, Auke J; Pakvis, Dean F M; Fernandes, Hugo; Saris, Daniel B

2017-04-01

Anterior cruciate ligament (ACL) reconstruction involves the replacement of the torn ligament with a new graft, often a hamstring tendon (HT). Described as similar, the ACL and HT have intrinsic differences related to their distinct anatomical locations. From a cellular perspective, identifying these differences represents a step forward in the search for new cues that enhance recovery after the reconstruction. The purpose of this study was to characterize the phenotype and multilineage potential of ACL- and HT-derived cells. ACL- and HT-derived cells were isolated from tissue harvest from patients undergoing total knee arthroplasty (TKA) or ACL reconstruction. In total, three ACL and three HT donors were investigated. Cell morphology, self-renewal potential (CFU-F), surface marker profiling, expression of tendon/ligament-related markers (PCR) and multilineage potential were analysed for both cell types; both had fibroblast-like morphology and low self-renewal potential. No differences in the expression of tendon/ligament-related genes or a selected set of surface markers were observed between the two cell types. However, differences in their multilineage potential were observed: while ACL-derived cells showed a high potential to differentiate into chondrocytes and adipocytes, but not osteoblasts, HT-derived cells showed poor potential to form adipocytes, chondrocytes and osteoblasts. Our results demonstrated that HT-derived cells have low multilineage potential compared to ACL-derived cells, further highlighting the need for extrinsic signals to fully restore the function of the ACL upon reconstruction. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Lateral Intercondylar Ridge: Is it a reliable landmark for femoral ACL insertion?: An anatomical study.

PubMed

Bhattacharyya, Rahul; Ker, Andrew; Fogg, Quentin; Spencer, Simon J; Joseph, Jibu

2018-02-01

Incorrect femoral tunnel placement is the most common cause of graft failure during Anterior Cruciate Ligament (ACL) Reconstruction. A reliable landmark can minimize errors. To identify whether the Lateral Intercondylar Ridge (LIR) is a consistent anatomical structure and define its relationship with the femoral ACL insertion. Phase 1: we studied 23 femoral dry bone specimens macroscopically. Using a digital microscribe, the medial surface of the lateral femoral condyle was reconstructed (3D) to evaluate whether there was an identifiable bony ridge. Phase 2: 7 cadaveric specimens with intact soft tissues were dissected to identify the femoral ACL insertion. A 3D reconstruction of the femoral ACL insertion and the surface allowed us to define the relationship between the LIR and the ACL insertion. All specimens had a defined LIR on the medial surface of the lateral femoral condyle. The ridge was consistently located just anterior to the femoral ACL insertion. The ACL footprint was present in the depression between the ridge and the Inferior Articular Cartilage Margin (IACM). The mean distance from the midpoint of the IACM to the LIR was 10.1 mm. This is the first study to use the microscribe to digitally reconstruct the medial surface of the lateral femoral condyle. It shows that the LIR is a consistent anatomical structure that defines the anterior margin of the femoral ACL insertion, which guides femoral tunnel placement. Our findings support the ruler technique, which is a commonly used method for anatomic single bundle ACL reconstruction. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.