Background:
Limited in vivo kinematic information exists on managing meniscal injury during anterior cruciate ligament reconstruction (ACLR).
Hypothesis:
Isolated anatomic ACLR restores knee ...kinematics, whereas ACLR in the presence of medial meniscal injury is associated with altered long-term knee kinematics.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
From March 2011 to December 2012, 49 of 57 participants in a clinical trial underwent anatomic ACLR with successful kinematic testing at 24 months after ACLR. Twenty-five patients had associated meniscal tears: medial (n = 11), lateral (n = 9), or bilateral (n = 5). With a dynamic stereo radiography system with superimposed high-resolution computed tomography scans of patient knees, kinematics were measured during downhill running. The initial single-support phase of the gait cycle (0%-10%) was analyzed.
Results:
Anterior tibial translation (ATT) was the only kinematic outcome between patients’ ACLR and contralateral knees that had significant interactions among meniscal groups (P = .007). There was significant difference in ATT between patients with intact menisci and medial tears (P = .036) and with medial tears and lateral tears (P = .025). Patients with intact menisci had no difference in ATT, with a negligible effect size between the ACLR and contralateral knees (mean ± SEM: 13.1 ± 0.7 mm vs 12.6 ± 0.5 mm, P = .24, Cohen d = 0.15, n = 24), while patients with medial meniscal tears had an increase in ATT, with a medium effect size between the ACLR and contralateral knees (15.4 ± 1.0 mm vs 13.2 ± 1.0 mm, P = .024, Cohen d = 0.66, n = 11).
Conclusion:
Associated medial meniscal injury in the setting of ACLR leads to increased ATT at 24-month follow-up. Furthermore, isolated anatomic ACLR in the absence of meniscal injury demonstrated no significant difference from native knee kinematics at 24-month follow-up during rigorous “high demand” knee activity with the current sample size. Patients undergoing anatomic ACLR in the presence of medial meniscal injury remained at a higher likelihood of sustaining altered long-term knee kinematics.
The current gold standard for the treatment of an anterior cruciate ligament (ACL) rupture is reconstruction with tendon graft. Recently, two surgical ACL repair techniques have been developed for ...treating an acute ACL rupture: Dynamic Intraligamentary Stabilization (DIS, Ligamys®) and Internal Brace Ligament Augmentation (IBLA, InternalBrace™). We will conduct a single-blind, multi-center, randomized controlled trial which compares DIS, IBLA and reconstruction for relative clinical efficacy and economic benefit.
Subjects, aged 18-50 years, with a proximal, primary and repairable ACL rupture will be included. DIS is preferably performed within 4 weeks post-rupture, IBLA within 12 weeks and reconstruction after 4 weeks post-rupture. Patients are included in study 1 if they present within 0-4 weeks post-rupture and surgery is feasible within 4 weeks post-rupture. Patients of study 1 will be randomized to either DIS or IBLA. Patients are included in study 2 if they present after 4 weeks post-rupture and surgery is feasible between 5 and 12 weeks post-rupture. Patients of study 2 will be randomized to either IBLA or reconstruction. A total of 96 patients will be included, with 48 patients per study and 24 patients per study arm. Patients will be followed-up for 2 years. The primary outcome is change from baseline (pre-rupture) in International Knee Documentation Committee score to 6 months post-operatively. The main secondary outcomes are the EQ-5D-5 L, Tegner score, Lysholm score, Lachman test, isokinetic and proprioceptive measurements, magnetic resonance imaging outcome, return to work and sports, and re-rupture/failure rates. The statistical analysis will be based on the intention-to-treat principle. The economic impact of the surgery techniques will be evaluated by the cost-utility analysis. The LIBRƎ study is to be conducted between 2018 and 2022.
This LIBRƎ study protocol is the first study to compare DIS, IBLA and ACL reconstruction for relative clinical efficacy and economic benefit. The outcomes of this study will provide data which could aid orthopaedic surgeons to choose between the different treatment options for the surgical treatment of an acute ACL rupture.
This study is registered at ClinicalTrials.gov; NCT03441295. Date registered 13.02.2018.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Rupturing the anterior cruciate ligament is an orthopedic injury that results in neuromuscular impairments affecting sensory input to the central nervous system. Traditional physical therapy after ...anterior cruciate ligament reconstruction aims to rehabilitate orthopedic impairments but fails to address asymmetric gait mechanics that are present post-operatively and are linked to the development of post-traumatic osteoarthritis. A first step towards developing gait interventions is understanding if individuals after anterior cruciate ligament reconstruction have the capacity to learn new walking mechanics.
The split-belt treadmill offers a task-specific approach to examine neuromuscular adaptations in patients after injury. The potential for changing spatiotemporal gait mechanics via split-belt treadmill adaptation has not been tested early after anterior cruciate ligament reconstruction; nor has the ability to retain and transfer newly learned gait mechanics. Therefore, we used a split-belt treadmill paradigm to compare gait adaptation, retention, and transfer to overground walking between 15 individuals 3–9 months after anterior cruciate ligament reconstruction and 15 matched control individuals.
Results suggested individuals after anterior cruciate ligament reconstruction were able to adapt and retain step length symmetry changes as well as controls. There was also evidence of partial transfer to overground walking, similar to controls.
Despite disruption in afferent feedback from the joint, individuals early after anterior cruciate ligament reconstruction can learn a new gait pattern using sensorimotor adaptation, retain, and partially transfer the learned gait pattern. This may be a critical time to intervene with gait-specific interventions targeting post-operative gait asymmetries.
•Individuals after anterior cruciate ligament reconstruction can learn new walking patterns.•They do not learn a new step length symmetry pattern differently than controls.•The newly learned step length symmetry pattern is retained over the short-term.•The newly learned step length symmetry pattern partially transfers to overground.
Background
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.
Questions/purposes
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.
Methods
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.
Results
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).
Conclusions
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 of Evidence
Level I, therapeutic study.
Background:
Static anterior tibial translation (SATT) is radiographically measured to show the amount of tibial translation during the single-leg stance, and thus it is representative of the ...physiological axial load subjected to the anterior cruciate ligament (ACL) during the stance. Increased SATT has been associated with increased posterior tibial slope (PTS) and is also associated with increased graft failure.
Purpose:
To compare the SATT value in a control population with that in a population with an isolated ACL injury, as well as to compare the effect of tibial slope on SATT between the 2 groups.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
A consecutive series of patients without ligamentous or meniscal injuries between 2019 and 2022 was reviewed. A matched consecutive cohort of patients with nonacute ACL injuries (surgery between 6 and 12 weeks after injury) without concomitant pathology was reviewed. Preoperative SATT and PTS were measured with a previously validated technique on lateral weightbearing knee radiographs. The SATT value was determined, and regression analysis was performed to investigate the relationship between SATT and PTS.
Results:
In total, 101 controls and 115 patients with an ACL injury were included in this study. The mean SATT was 1.31 mm (SD, 2.44 mm) and the mean PTS was 10.61° (SD, 3.28°) in the control cohort. The SATT was larger (mean, 2.27 mm; SD, 3.36 mm) in the ACL-injured cohort despite the tibial slope measurement being less in the ACL-injured cohort (mean, 9.46°; SD, 2.85°; P = .016). Linear regression analysis showed that for every 1° of increase in PTS, there was a 0.34-mm increase in SATT in the control cohort; however, there was a greater increase of 0.5 mm for every 1° of increase in PTS in the ACL-injured cohort. We found no significant differences in SATT when the cohorts were compared by age (P = .26) or sex (P = .10).
Conclusion:
The present study reports a reference SATT value of 1.31 mm (SD, 2.44 mm) in a non–ACL-injured cohort, which was lower than in the ACL-injured cohort (mean, 2.27 mm; SD, 3.36 mm). The effect of slope on weightbearing anterior tibial translation was greater in the ACL-injured population than in the control cohort.
To investigate the changes in landing biomechanics over a 3-year period and their correlation with cartilage degenerative changes in the medial tibiofemoral joint of the knee after anterior cruciate ...ligament reconstruction (ACLR) using magnetic resonance T1ρ mapping.
Thirty-one anterior cruciate ligament–injured patients underwent magnetic resonance imaging of the injured knee before ACLR and 3 years after ACLR, as well as biomechanical analysis of a drop-landing task at 6 months and 3 years after ACLR. Sixteen healthy individuals were recruited and underwent knee magnetic resonance imaging and biomechanical assessment during a drop-landing task. T1ρ cartilage relaxation times were calculated for the medial femur and tibia.
ACLR patients exhibited increased peak vertical ground reaction force (VGRF), VGRF impulse, peak knee flexion moment (KFM), and KFM impulse from 6 months to 3 years (P < .001 for each). Although the ACLR knees showed significantly lower peak VGRF and KFM at 6 months (P < .001 for both) when compared with the controls, there were no significant differences at 3 years. At 3 years, ACLR patients showed higher T1ρ values over the medial femur (P < .001) and tibia (P = .012) when compared with their preoperative values and with healthy control values. Within the ACLR group, side-to-side differences in peak VGRF and sagittal knee biomechanics at 6 months were associated with increased T1ρ values from baseline to 3 years.
The results of this longitudinal study show that landing biomechanics are altered after ACLR but biomechanical abnormalities tend to recover at 3 years after ACLR. Differences in lower-extremity mechanics during a landing task at 6 months may be associated with cartilage degeneration at 3 years after anterior cruciate ligament injury and reconstruction.
Level II, prospective trial.
Anterior Cruciate Ligament Tear Musahl, Volker; Karlsson, Jon
The New England journal of medicine,
06/2019, Letnik:
380, Številka:
24
Journal Article
Recenzirano
In recreational athletes with an ACL tear, initial treatment can be nonoperative (including physical therapy) or operative (followed by physical therapy). Reconstruction is recommended in cases of ...increased or persistent laxity after nonoperative treatment and in elite athletes.
Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery ...and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.
We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.
Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.
Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management.
The UK National Institute for Health Research Health Technology Assessment Programme.
Purpose
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.
Methods
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.
Results
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).
Conclusion
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.
Level of evidence
Retrospective Review with Control, Level III.
Purpose
To determine the prevalence of a deep lateral femoral notch sign (LFNS) in magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) and concomitant posterior root ...tears of the lateral meniscus (PLRT).
Methods
A retrospective chart review was conducted to identify all patients undergoing ACL reconstruction between 2016 and 2018. Based on the arthroscopic appearance of the lateral meniscus, patients were assorted to one of three groups: isolated ACL tear (ACL-Group), ACL tear with concomitant lateral meniscus tear not involving the posterolateral root (Meniscus-Group), and ACL tear with concomitant PLRT (PLRT-Group). Incidence and depth of a LFNS on preoperative MRI was compared between the three cohorts.
Results
115 patients (mean age: 29.5 ± 11.3 years) were included in the study, with 58 patients (50.4%) assorted to the ACL-Group, 24 patients (20.9%) to the Meniscus-Group, and 33 patients (28.7%) to the PLRT-Group. The prevalence of a LFNS was significantly higher in the PLRT-Group (39.4%), when compared to the ACL- (5.2%) or Meniscus-Groups (25.0%;
p
< 0.001, respectively). Additionally, logistic regression analysis demonstrated that patients with PLRT were 5.3 times more likely to have a LFNS as compared to those without a lateral root tear (
p
< 0.001).
Conclusion
In patients with ACL tears, the presence of a LFNS on preoperative MRI may be predictive for a PLRT. As the LFNS occurs in almost 40% of the patients with combined ACL tears and PLRT, the LFNS may be a useful secondary diagnostic finding in early MRI diagnostic. Identifying PLRT on MRI is clinically relevant, as it prevents misdiagnosis and facilitates surgical decision-making, thus avoiding subsequent delayed treatment.
Level of evidence
Level IV.
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