Transtibial Femoral Tunnel Technique in ACL Reconstruction and Osteoarthritis Incidence / Técnica do túnel femoral transtibial na reconstrução do LCA e incidência de osteoartrite

Abstract Objective: Evaluate osteoarthritis incidence in patients that undergone ACL reconstruction using the transtibial technique, with a minimum of 5 years of follow up, with isolated ACL injury. Methods: Patients who underwent ACL reconstruction by the same surgeon using the transtibial technique with hamstrings graft and with a minimum of 5 years of follow-up, without other injuries during the surgical procedure, were selected to undergo imaging exams of the operated knee to assess the incidence of osteoarthritis. The obtained data were evaluated by descriptive statistics. Results: Forty-two patients (44 knees) were evaluated, with a mean age of 31 years old (SD: 8), being 23 right knees and 28 male patients. Mean time from surgery to imaging evaluation was 94.1 months (ranging from 60 to 154 months; SD: 28). Of the evaluated knees, 37 did not have osteoarthritis (83.3%) and 7 had (16.7%). Conclusion: ACL reconstruction with femoral tunnel performed through the transtibial technique in patients without other associated injuries in the operated knee, using hamstrings graft, with a minimum of 5 years of follow up, showed an osteoarthritis incidence of 16.7% in a mean follow-up of 94.1 months. Level Of Evidence V; Case Series.

Resumo Objetivo: Avaliar a incidência de osteoartrite em pacientes submetidos à reconstrução do LCA pela técnica transtibial, com seguimento mínimo de 5 anos, com lesão isolada do LCA. Métodos: Pacientes que passaram por reconstrução LCA pelo mesmo cirurgião usando a técnica transtibial com enxerto de tendão dos músculos isquiotibiais e que foram acompanhados por no mínimo 5 anos, sem outras lesões durante o procedimento cirúrgico, foram selecionados para realizar exames de imagem do joelho operado a fim de avaliar a incidência de osteoartrite. Os dados obtidos foram avaliados por meio de estatísticas descritivas.. Resultados: Foram avaliados 42 pacientes (44 joelhos), com idade média de 31 anos (DP: 8), sendo 23 joelhos direitos e 28 pacientes do sexo masculino. O tempo médio entre a cirurgia e a avaliação por imagem foi de 94,1 meses (variando de 60 a 154 meses; DP: 28). Dos joelhos avaliados, 37 não apresentavam osteoartrite (83,3%) e 7 apresentavam (16,7%). Conclusão: A reconstrução do LCA com túnel femoral realizado por meio da técnica transtibial em pacientes sem outras lesões associadas no joelho operado, utilizando enxerto dos tendões isquiotibiais, com um acompanhamento mínimo de 5 anos, apresentou uma incidência de osteoartrite de 16,7% em um acompanhamento médio de 94,1 meses. Level of Evidence V; Case Series. Nível de Evidência V; Série de casos

Difference in bilateral lower limb muscle synergy mode for gait in patients after unilateral anterior cruciate ligament reconstruction / 中国康复理论与实践

ObjectiveTo investigate the difference in bilateral lower limb muscle synergy mode during gait in patients after unilateral anterior cruciate ligament reconstruction. MethodsElectromyography from bilateral lower limb muscles during gait were collected from twelve male and eight female patients after unilateral anterior cruciate ligament reconstruction in Affiliated Hospital of Wuhan Sports University, from April to June, 2023. The data were analyzed using non-negative matrix decomposition algorithm to extract the number of muscle synergies in the affected and unaffected legs, the time to peak activation of muscle synergies and the relative weights of the muscles. ResultsSix types of muscle synergy were identified in the unaffected leg of males during gait, while five types were identified in the affected leg, lacking synergy 2 that mainly from the tibialis anterior muscle. Six types of muscle synergy were identified in both legs in females during gait. There was no significant difference in the time to peak activation of muscle synergies between both legs in males (P > 0.05). However, the time to peak activation of muscle synergies increased in females in the affected leg for synergy 3 and synergy 5 (P < 0.05). The relative weight of the rectus femoris was lower in synergy 1 in the affected leg in males (P < 0.05). For female, the relative weight of the vastus lateralis was higher and the relative weight of the biceps femoris was lower in synergy 2 in the affected leg in females (P < 0.05); while the relative weight of the rectus femoris was lower in synergy 3 (P < 0.05), and the relative weight of the biceps femoris was lower in synergy 6 (P < 0.05). ConclusionMales would freeze the muscle synergy dominating ankle dorsiflexion in affected leg to enhance ankle stability, and reduce the relative weight of rectus femoris during the loading response phase to weaken the knee landing cushioning. However, females would delay the activation of synergies dominating in loading response phase and the mid-stance phase, enhance the relative weight of vastus lateralis during the loading response phase, and reduce the relative weights of rectus femoris in the loading response phase and the relative weight of biceps femoris in the mid-stance phase, to limit knee flexion.

Graft Selection Between Tendon Autograft and Allograft in Anterior Cruciate Ligament Reconstruction Based on the Histological Perspective: A Meta-Analysis / Seleção de enxerto entre autoenxerto e aloenxerto de tendão na reconstrução do ligamento cruzado anterior com base na perspectiva histológica: uma metanálise

Abstract Objective The purpose of this meta-analysis is to compare ligament healing on autograft and allograft in anterior cruciate ligament (ACL) reconstruction. Methods The selection of appropriate studies was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We made a statistical analysis using a review manager. Electronic reports were searched using the PubMed, Medline, and Cochrane Library databases. The inclusion criteria were animal studies and cellular histology of both grafts as an outcome. Results The initial search revealed 412 potential articles. After duplicates were removed, 246 articles remained. Then, 14 articles were obtained and screened for relevance and eligibility. The relevant articles were searched manually, checking for eligibility and details in order not to miss included reports. Subsequently, 5 studies were included, with a total of 232 samples, reporting the biopsied results with quantitative histology of ligament healing between allograft and autograft. The biopsy samples in those studies were examined under light or electron microscope, to analyze the cellular distribution area and ligamentization stages in each group. Meta-analyses found significant difference between autograft and allograft (Heterogeneity, I2 = 89%; Mean Difference, 95% confidence interval [CI] =-34.92, -54.90, -14.93; p = 0.0006). There is also a significant difference on both graft in cellular count at over 24 weeks (Heterogeneity, I2 = 26%; Mean Difference, 95% CI = -14.59, -16.24, -12.94; p < 0.00001). Conclusion In the current meta-analysis, autograft shows a significant difference when compared to allograft, with more cellular accumulation and faster remodeling response on the ligamentization process being noticed in the former. However, a larger clinical trial will be needed to emphasize this literature's result.

Resumo Objetivo O objetivo desta metanálise comparar a cicatrização de ligamentos no autoenxerto e aloenxerto na reconstrução do ligamento cruzado anterior (LCA). Métodos A seleção dos estudos adequados foi realizada de acordo com as diretrizes de Relatórios Preferenciais para Revisões Sistemáticas e Metanálises (Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA). Uma análise estatística foi feita usando um gerente de revisão. Os relatórios eletrônicos foram pesquisados usando os bancos de dados PubMed, Medline e Cochrane Library. Os critérios de inclusão foram estudos em animais e a histologia celular de ambos os enxertos como desfecho. Resultado A pesquisa inicial revelou 412 artigos potenciais. Após a retirada das duplicatas, restaram 246 artigos. Então, 14 artigos foram obtidos e selecionados pela relevância e elegibilidade. Os artigos relevantes foram pesquisados manualmente, verificando sua elegibilidade e detalhando os estudos para não perder os relatórios incluídos. Posteriormente, foram incluídos 5 estudos, com um total de 232 amostras, relatando os resultados de biópsia com histologia quantitativa de cicatrização de ligamento entre aloenxerto e autoenxerto. As amostras de biópsia nesses estudos foram examinadas sob microscópio leve ou eletrônico, para análise da área de distribuição celular e estágios de ligamentização em cada grupo. As metanálises encontraram diferença significativa entre autoenxerto e aloenxerto (Heterogeneidade, I2 = 89%; Diferença média, 95% intervalo de confiança [IC] =-34,92, -54,90, -14,93; p = 0,0006). Também há uma diferença significativa nosdoisenxertosnacontagem celular de mais de 24 semanas (Heterogeneidade, I2 = 26%; Diferença média, 95% IC = -14,59 , -16,24, -12,94; p < 0,00001). Conclusão Na presente metanálise, o autoenxerto mostra resultados significativos quando comparado ao aloenxerto, com mais acúmulo celular e resposta de remode-lagem mais rápida no processo de ligamentizaçãosendoobservadonoprimeiro.No entanto, será necessário um estudo clínico maior para enfatizar o resultado desta literatura.

Calculation of the Minimal Important Clinical Difference of the Lysholm and IKDC Scores After Anterior Cruciate Ligament Reconstruction / Cálculo da mínima diferença clínica importante dos escores Lysholm e IKDC após reconstrução do ligamento cruzado anterior

Abstract Objective To calculate the minimal important clinical difference (MICD) value for the Lysholm and International Knee Documentation Committee (IKDC) scores in a sample of patients submitted to anterior cruciate ligament reconstruction. Methods Primary, observational, retrospective, analytical study of participants submitted to anterior cruciate ligament reconstruction from March 2019 to December 2020 by the same surgeon, with a minimum follow-up of 6 months, analysis of knee function in the pre- and postoperative period by the Lysholm and IKDC scores, and answer to an anchor question at 6 months postoperatively for the calculation of the MICD of each score. Results A total of 59 patients participated in the study, with a mean age of 27.1 ± 5.7 years old. In the comparison between pre- and postoperative scores of all groups, there was an increase in values with statistical significance after intervention. The MICD was 5.5 for the Lysholm score, and the MICD value for the IKDC score could not be determined. Conclusion For the Lysholm score, the calculation of the MICD value by the anchor question method in the sample evaluated was 5.5. It was not possible to determine the value of the MICD for the IKDC score.

Resumo Objetivo Calcular o valor da mínima diferença clinicamente importante (MDCI) para os escores de Lysholm e International Knee Documentation Commitee (IKDC) na amostra de pacientes submetidos a reconstrução de ligamento cruzado anterior. Métodos Estudo primário, observacional, retrospectivo, analítico, de participantes submetidos a reconstrução do ligamento cruzado anterior no período de março de 2019 a dezembro de 2020, pelo mesmo cirurgião, com seguimento mínimo de 6 meses, análise da função do joelho no período pré e pós-operatório pelos escores de Lysholm e IKDC, e resposta a uma pergunta âncora aos 6 meses de seguimento pós-operatório, para o MDCI de cada escore. Resultados Participaram do estudo 59 pacientes, com média de idade de 27,1 ± 5,7 anos. Na comparação dos escores pré- e pós-operatórios de todos os grupos, observa-se aumento dos valores com significância estatística após a intervenção. A MDCI foi de 5,5 para o escore de Lysholm, não tendo sido possível determinar o valor para o IKDC. Conclusão O cálculo do valor da MDCI pelo método da pergunta âncora, na amostra avaliada, foi de 5,5 para o escore de Lysholm. Não foi possível determinar o valor da MDCI para o IKDC.

Effect of core stability training on dynamic balance and surface electromyography after anterior cruciate ligament reconstruction / 中国康复理论与实践

ObjectiveTo explore the effect of core stability training on dynamic balance and surface electromyography (sEMG) after anterior cruciate ligament reconstruction (ACLR), and to analyze the correlation between balance index and sEMG. MethodsFrom March to December, 2022, 32 patients with ACLR in Yantai Affiliated Hospital of Binzhou Medical University were randomly divided into control group (n = 16) and experimental group (n = 16). The control group accepted routine rehabilitation treatment, and the experimental group added core stability training, for six weeks. They were evaluated with American Hospital for Special Surgery Knee Score (HSS) and International Knee Documentation Committee Knee Score (IKDC), and the dynamic balance function and sEMG were measured before and after treatment, and the correlation between dynamic balance index and root mean square (RMS) of sEMG was analyzed. ResultsAfter treatment, the scores of HSS and IKDC increased significantly in both groups (|Z| > 3.526, |t| > 63.544, P < 0.001), and were better in the experimental group than in the control group (Z = -2.392, t = 2.650, P < 0.05); the length of gait line and single support line increased significantly, the medial-lateral displacement displacement decreased (|t| > 2.368, Z = -3.516, P < 0.05), and they were better in the experimental group than in the control group (|t| > 2.497, Z = -3.091, P < 0.05); the RMS of gluteus maximus and gluteus medius increased in the experimental group (t = -5.900, Z = -2.741, P < 0.01), and were better than those in the control group (t = 3.930, Z = -3.260, P < 0.01). After treatment, the RMS of gluteus maximus and gluteus medius in both groups were positively correlated with gait line length and single support line length, and were negatively correlated with medial-lateral displacement (|r| > 0.502, P < 0.01). ConclusionCore stability training could significantly improve knee joint function and dynamic balance, and enhance the activation of gluteus maximus and gluteus medius. Dynamic balance is highly correlated with sEMG.

The effects of blood flow restriction on the quadriceps femoris and knee stability after anterior cruciate ligament reconstruction / 中华物理医学与康复杂志

Objective:To explore the effect of blood flow restriction training on the quadriceps femoris and on knee stability after anterior cruciate ligament reconstruction.Methods:Forty patients recovering from anterior cruciate ligament reconstruction were randomly divided into an experimental group and a control group, each of 20. In addition to routine rehabilitation training, the control group was given routine knee flexion and extension strength training, while the experimental group trained for an additional 20 minutes doing knee flexion and extension resistance training with the blood pressure in their groins at 70% of their individual arterial occlusive pressure. (The mean pressure was (123±11.23)mmHg). The training lasted 8 weeks, three times a week. Knee function and hamstring and quadriceps peak torque were assessed before and after the intervention using a Lysholm scale and Humac Norm isokinetic muscle strength tests.Results:There were no significant differences between the two groups in any of the measurements before the training. After the intervention, all of the measurements had improved significantly in both groups, with the average Lysholm score, H/Q% and peak torque of the experimental group significantly better than the control group′s averages.Conclusions:Blood flow restriction training can improve the effectiveness of quadriceps femoris strength, knee stability and knee function training after anterior cruciate ligament reconstruction.

Blood flow restriction can improve knee proprioception and motor coordination after anterior cruciate ligament reconstruction / 中华物理医学与康复杂志

Objective:To explore any effect of blood flow restriction during exercise on knee proprioception and motor coordination after anterior cruciate ligament (ACL) reconstruction.Methods:Thirty patients recovering from ACL reconstruction were randomly divided into an experimental group and a control group, each of 15. Both groups were given routine rehabilitation training, while the experimental group was additionally provided with 45 minutes of training with blood flow restriction, 3 times a week for 8 weeks. The blood flow restriction training involved constant pressure in the groin while the patient performed knee flexion and extension resistance training, squats, alternate knee flexion and extension and ergometer cycling. Before and after the intervention, both groups′ knee function, proprioception and lower limb motor coordination were evaluated using the Lysholm knee scale, the Humac isokinetic measurement system and surface electromyography.Results:Before the experiment there were no significant differences between the two groups in any of the measurements. After the intervention, both groups′ average Lysholm score had improved significantly, and errors in reproducing a knee angle had decreased significantly. Significantly better improvement was observed in the observation group than in the control group. That group′s average coordinated contraction rate on the affected side in extension and flexion was also significantly better than the control group′s ave-rage. Indeed, there were no significant differences in the contraction rates between the healthy and affected sides.Conclusions:Training with restricted blood flow can significantly improve knee function, proprioception and motor coordination after anterior cruciate ligament reconstruction.

All-inside versus full-tibial tunnel techniques of anterior cruciate ligament reconstruction: a systematic review and meta-analysis / 中华骨科杂志

Objective:To compare the clinical efficacy of arthroscopic all-inside technique versus full-tibial tunnel technique for anterior cruciate ligament (ACL) reconstruction.Methods:Literature on all-inside versus full-tibial tunnel for ACL reconstruction was retrieved from databases including China National Knowledge Infrastructure (CNKI), Wanfang Data, Full-text Database of Chinese Medical Journals, PubMed, Web of Science, and Cochrane Library from their establishment to February 2023. Meta-analysis was performed on the included studies. Random effects model was used if heterogeneity was large, while fixed effects model was used if heterogeneity was small.Results:A total of 13 studies with 511 cases in the all-inside group and 465 cases in the full-tibial tunnel group were included in the meta-analysis, with a mean follow-up of 6-25.8 months. Meta-analysis showed that the graft diameter [ MD=0.42, 95% CI (0.11, 0.73), P=0.007] and International Knee Documentation Committee (IKDC) subjective score [ MD=1.11, 95% CI (0.36, 1.86), P=0.004] of the all-inside group was larger than full-tibial tunnel group, and the tibial tunnel widening of the all-inside group was less than full-tibial tunnel group [ MD=-1.70, 95% CI (-2.38, -1.01), P<0.001]. There were no significant differences in IKDC objective score [ OR=1.09, 95% CI (0.67, 1.78), P=0.730], Lysholm score [ MD=0.99, 95% CI (-0.08, 2.05), P=0.070], Tegner activity score [ MD=-0.01, 95% CI (-0.48, 0.45), P=0.950], bilateral knee anterior laxity difference [ MD=0.32, 95% CI (-0.22, 0.86), P=0.250], negative rate of pivot shift test [ OR=0.80, 95% CI (0.33, 1.91), P=0.610], graft re-rupture rate [ OR=0.76, 95% CI (0.34, 1.74), P=0.524] and return to sport rate [ OR=1.56, 95% CI (0.85, 2.86), P=0.150]. Conclusion:All-inside ACL reconstruction provides satisfactory efficacy. Compared with full-tibial tunnel technique, it has the advantages of larger graft diameter and less tibial tunnel widening, with no difference in joint function within 2 years postoperatively.

Methods of reducing the "killer turn" effect in the posterior cruciate ligament reconstruction / 中华骨科杂志

The reconstruction of the posterior cruciate ligament (PCL) through the tibial tunnel is the most commonly used reconstruction technique after ligament injury.However, when the graft passes through the tibial tunnel back to the medial condyle of the femur, a sharp angle is formed at the proximal end of the tibia, called the "killer turn". The existence of the "killer turn" can lead to graft wear and expansion of adjacent tibial tunnel after PCL reconstruction, affecting the stability of the posterior knee joint after operation and even leading to the failure of operation. There are several techniques, such as modifified tibial tunnel technique which the proximal exit of tibial tunnel is located in the inferior and lateral aspect of the PCL tibial anatomic insertion site, increasing the angle between the tibial tunnel and the tibial plateau, creating a tibial tunnel from the anterior lateral side of the tibia, remnant preserving as soft tissue cushion, and inlay and onlay techniques for reconstructing PCL without using tibial tunnel reconstruction, can reduce the "killer turn" effect. The above 6 techniques, theoretically, can effectively reduce or eliminate the "killer turn" effect and improve the posterior stability of the knee joint after PCL reconstruction, so as to improve the clinical efficacy of PCL reconstruction. But, the number of cases using these techniques is relatively small, and their effectiveness, reliability, and advantages and disadvantages for patients still need more clinical practice to further explore and verify.

Causes analysis and coping strategies of posterior laxity after posterior cruciate ligament reconstruction / 中华骨科杂志

It is difficult to maintain the initial posterior stability of the knee after posterior cruciate ligament reconstruction. Residual posterior knee laxity after operation is a problem of PCL reconstruction. It not only results in abnormal kinematics of the knee, but also leads to secondary meniscus injury and cartilage degeneration of the affected knee, and eventually leads to knee osteoarthritis, which may especially happen with persistent and severe posterior laxity. The main reasons of residual posterior knee laxity after PCL reconstruction are: improper treatment of the posterolateral corner injury, poor positioning of the femoral tunnel, small tibial slope, and unreasonable postoperative rehabilitation. There are some concepts and technologies, such as using artificial ligaments, tibial tunnel fixation with suspensory device or suspensory device combined with interference screws, enlargement of graft diameter, all-inside reconstruction combined suture augmentation, slow and gradual postoperative rehabilitation, which can eliminate or reduce the postoperative residual laxity, in order to improve clinical outcomes after PCL reconstruction. For the patients with flat tibial slopes, double-bundle PCL reconstruction and concurrent slope-increasing tibial osteotomy is suggested. It can reduce the risk of posterior laxity and improve the stability of the knee after operation.

All-inside anterior cruciate ligament reconstruction: a review of development, evolution and clinical significance / 中华骨科杂志

Rupture of anterior cruciate ligament (ACL) is one of the most common sports injuries of the knee, which may cause limitation of motor function and degeneration of the knee, seriously affecting patients' living quality. Currently, arthroscopic ACL reconstruction (ACLR) has been identified as the gold standard for ACL rupture. In an effort to further increase surgical accuracy and decrease surgical trauma so as to promotes quick recovery, all-inside ACLR has gained increasing attention in recent years. All-inside ACLR is as effective as traditional reconstruction, but it has benefits such as the preservation of tendons, preservation of bone mass, reduction of postoperative pain, prevention of synovial fluid leakage, expansion of the tendon-bone healing area, avoidance of complications related to extrusion screws, and suitability for children and adolescents. However, applying of numerous novel techniques for all-inside ACLR increases the learning curve, operating time, and cost. Besides, improper bone tunnel fabrication and graft fixation may lead to the widening of the bone tunnel, affecting the surgical effect. Therefore, in order to provide a theoretical foundation for further promoting the clinical application of this technique, this article reviews the development, evolution, and clinical outcomes of this technique as well as its advantages and disadvantages.

Advances in anterolateral ligament reconstruction: clinical practice and controversy / 中华骨科杂志

Rupture of the anterior cruciate ligament (ACL) is one of the most frequent forms of knee sports injuries. Nowadays, ACL reconstruction is commonly performed to help patients restore their rotational stability. However, in patients with high risk factors, the risk of ACL reconstruction failure remains high, primarily because of continuous postoperative anterolateral rotational instability. This rotational instability after ACL reconstruction has prompted researchers to focus on the anterolateral complex of the knee, such as iliotibial tract and anterolateral ligament (ALL). Among them, ALL has remained largely unappreciated for more than a century since its discovery in 1879. Even though it is still controversial, most studies in recent years have supported the anterolateral ligament as an independent ligament and a crucial anatomical component for preserving the rotational stability of the knee joint. Although augmentation of the anterolateral complex has experienced twists and turns, the anatomic ALL reconstruction, which can be performed minimally invasively and has a low risk of complications and minimal injury, is reappearing as a key strategy to address this problem. Currently, the majority of scholars believe that the need for combined ALL reconstruction during ACL reconstruction should be taken into account when there is severe rotational instability present, such as high-grade pivot shift test preoperatively, ACL revision surgery, and high requirements for rotational stability, such as age less than 25 years and the need to participate in pivoting sports. The corresponding suggested criteria are also put forth in the authoritative consensus of both domestic and foreign sources. However, the surgical indications chosen by different experts based on their individual experiences are not all consistent. Due to conflicting reports on the actual impact of ALL reconstruction on improving rotational stability and whether it will excessively restrict knee's internal rotation function, there is still much debate among researchers regarding whether ALL reconstruction and ACL reconstruction should be combined. Currently, there are two main reconstruction techniques: ALL single bundle reconstruction and Y-construct ALL double bundle reconstruction. Y-construct ALL double bundle reconstruction has a better ability to restore the original anatomy and is recommended in the consensus, but there is still a lack of randomized controlled trials between the two techniques. Therefore, the combination of ALL reconstruction at the time of ACL reconstruction has been clinically started in recent years for patients who are susceptible to failure after ACL reconstruction, which also raises many controversies.

Postoperative infection after anterior cruciate ligament reconstruction caused by Finegoldia magna: a case report / 中华骨科杂志

One case of knee infection after anterior cruciate ligament reconstruction caused by the gram-positive anaerobic bacterium Finegoldia magna was reported. The patient was admitted to hospital due to fever and knee joint swelling and pain after anterior cruciate ligament reconstruction. Through medical history, physical examination, imaging examination and next-generation sequencing, it was confirmed that the infection was caused by Finegoldia magna. Through literature review, 37 literatures on infectious diseases caused by Finegoldia magna was retrieved and analyzed, and the identification points of anaerobic bacteria, the application of second-generation sequencing technology and the treatment status of infection after anterior cruciate ligament reconstruction were reviewed. The incidence of infection after arthroscopic anterior cruciate ligament reconstruction is low, while anaerobic infection is even more rare and difficult to culture. The next-generation sequencing can be used to assist the diagnosis. On the basis of giving priority to the preservation of the reconstructed ligament, the combined use of arthroscopic debridement, irrigation and sensitive antibiotics is the main treatment method.

Clinical application of LARS artificial ligament in anterior cruciate ligament reconstruction: an update / 中华创伤杂志

The anterior cruciate ligament (ACL) is one of the most crucial components to maintain knee joint stability and also the most vulnerable structure during knee-related sports activities. ACL injuries often cause knee instability, difficulty in returning to sports, and secondary degenerative knee disease. Although using autograft to reconstruct the ACL is currently a popular choice in clinical settings, it has drawbacks such as limited autograft source, donor site morbidity and delayed return to sports. Ligament advanced reinforcement system (LARS) artificial ligament possesses unique advantages such as wide availability, no donor-site morbidity, and early recovery, avoiding the problems associated with autograft reconstruction of ACL, and it has drawn increasing attention in recent years. In this paper, the authors reviewed the characteristics of LARS artificial ligament and its application in ACL reconstruction, so as to provide reference for clinical treatment of ACL injuries.

Clinical outcome of arthroscopic anatomic single bundle reconstruction of posterior cruciate ligament assisted by internal tension relieving technique combined with rapid rehabilitation in the treatment of posterior cruciate ligament rupture / 中华创伤杂志

Objective:To compare the clinical efficacies between arthroscopic anatomic single bundle reconstruction of posterior cruciate ligament (PCL) assisted by internal tension relieving technique combined with rapid rehabilitation and anatomic single bundle reconstruction combined with conventional rehabilitation in the treatment of PCL rupture.Methods:A retrospective cohort study was used to analyze the clinical data of 88 patients with PCL rupture admitted to First Affiliated Hospital of Kunming Medical University from September 2016 to September 2020. The patients included 65 males and 23 females, aged 18-55 years [(39.3±10.8)years]. Forty-four patients underwent arthroscopic anatomic single bundle reconstruction of PCL assisted by internal tension relieving technique combined with rapid rehabilitation therapy (tension-relieving group), and 44 patients underwent arthroscopic routine anatomic single bundle reconstruction of PCL combined with conventional rehabilitation (traditional group). The two groups were compared before and at 3, 12, and 24 months after surgery regarding the following items: International Knee Literature Committee (IKDC) score, Hospital for Special Surgery (HSS) score, Lysholm score, knee motion cycle (maximum stride length, minimum stride length, and stride frequency) and 6 kinematic indicators (angle of forward and back extension, angle of internal and external rotation, angle of internal and external rotation, up and down displacement, internal and external displacement, and forward and back displacement). The Marburger arthroscopy score (MAS) and Professor Ao Yingfang′s improved score by secondary arthroscopy were compared between the two groups at 12 months after surgery. The perioperative complications were observed.Results:All patients were followed for 24-36 months [(25.5±6.3)months]. In tension-relieving group and the traditional group, the values of IKDC score were (71.8±9.8)points and (68.5±6.5)points at 3 months after surgery, (87.6±6.0)points and (87.6±5.5)points at 12 months after surgery, and (95.5±3.1)points and (92.8±11.6)points at 24 months after surgery, respectively. The values were gradually increased, significantly higher than those before surgery [(48.1±16.9)points and (47.1±15.0)points] (all P<0.05). There were no significant differences between the two groups at each time point (all P>0.05). In tension-relieving group and the traditional group, the values of HSS score were (74.2±6.2)points and (68.4±9.5)points at 3 months after surgery, (91.9±5.4)points and (88.4±4.7)points at 12 months after surgery, and (97.1±2.0)points and (96.2±2.8)points at 24 months after surgery, respectively. The values of HSS score gradually increased, significantly higher than those before surgery [(57.5±17.7)points and (56.8±14.3)points] (all P<0.05). At 3 and 12 months after surgery, the values of HSS score in the tension-relieving group were significantly higher than those in the traditional group (all P<0.05), but others were not significantly different between the two groups (all P>0.05). In tension-relieving group and the traditional group, the values of Lysholm score were (74.2±14.9)points and (70.3±7.5)points at 3 months after surgery, (90.9±6.1)points and (88.7±4.7)points at 12 months after surgery, and (96.9±3.0)points and (96.3±2.8)points at 24 months after surgery, respectively. The values of Lysholm score were gradually increased, significantly higher than those before operation [(48.7±20.7)points and (48.2±19.9)points] (all P<0.05). There were no significant differences between the two groups at any time points (all P>0.05). At 3, 12, and 24 months after surgery, the motion cycle (maximum stride length, minimum stride length and stride frequency) and 6 kinematic indicators (angle of forward bending and backward extension, angle of internal and external rotation, angle of internal and external rotation, internal and external displacement, up and down displacement, and forward and backward displacement) of knee joint were significantly improved in both groups compared with those before surgery (all P<0.05). At 3, 12, and 24 months after surgery, the forward and backward displacement in the tension-relieving group was significantly decreased than that in the traditional group (all P<0.05), but others were not significantly different between the two groups (all P>0.05). The MAS was rated as excellent to good in 14 patients and fair to poor in 2, with the excellent and good rate of 87.5% (14/16) in the tension-relieving group, while the score was rated as excellent to good in 11 patients and fair to poor in 3, with the excellent and good rate of 78.6% (11/14) in the traditional group ( P>0.05). The Professor Ao Yingfang′s improved score was (10.6±1.5)points in the tension-relieving group, markedly higher than that in the traditional group [(9.6±2.3)points] ( P<0.05). No perioperative complications were observed. Conclusion:Compared with anatomic single bundle reconstruction combined with conventional rehabilitation, arthroscopic anatomic single bundle reconstruction of PCL assisted by internal tension relieving technique combined with rapid rehabilitation have higher subjective function score, better anteroposteric stability during knee movement, and better results of secondary microscopy.

Application of continuous nursing based on hybrid electronic platform and fragmented time concept in out-of-hospital rehabilitation of patients with anterior cruciate ligament reconstruction / 中国实用护理杂志

Objective:To explore the application effect of continuous nursing based on hybrid electronic platform and fragmentation time in the out-of-hospital rehabilitation of patients with anterior cruciate ligament reconstruction.Methods:This was a randomized controlled study. From April 2020 to October 2021, a total of 90 patients undergoing anterior cruciate ligament reconstruction in Weifang People′s Hospital were selected as the research objects by convenience sampling. Forty patients from April to December 2020 were selected as control group, and 45 patients from January to October 2021 were selected as intervention group. The control group implemented routine discharge guidance and follow-up, while the intervention group was given continuous nursing plan based on the concept of hybrid electronic platform and fragmented time. Before operation and 1, 3 and 6 months after operation, the knee range of motion and Lysholm score of patients in the two groups were analyzed. At 1, 3 and 6 months after operation, the rehabilitation exercise compliance score, self-efficacy score and knee stability examination of the two groups were analyzed.Results:A total of 41 patients in each group completed the study. At 1 month after operation, the knee range of motion, Lysholm score, rehabilitation exercise compliance score and self-efficacy score of intervention group were (96.46 ±3.58) ° and (53.54 ± 6.57), (69.17 ± 6.27), (4.01 ± 0.38) points, respectively. In the control group, they were (89.02 ± 4.22)° and (45.02 ± 7.61), (56.78 ± 8.45), (3.61 ± 0.42) points. At 3 months after operation, they were (136.83 ± 4.30)° and (72.76 ± 4.96), (60.71 ± 5.87), (4.97 ± 0.32) points in the intervention group, (133.54 ± 3.58)° and (69.83 ± 6.65), (56.73 ± 8.57), (4.83 ± 0.45) points in the control group, respectively. At 6 months after operation, they were (139.39 ± 1.99)° and (85.61 ± 6.11), (57.71 ± 7.41), (6.58 ± 0.96) points in the intervention group, (138.29 ± 2.65)° and (81.80 ± 6.38), (47.90 ± 6.02), (6.35 ± 1.23) points in the control group, respectively. The knee range of motion, Lysholm score and rehabilitation exercise compliance score of the intervention group were better than those of the control group at 1, 3 and 6 months after operation, and the differences were statistically significant ( t values were 2.12-8.61, all P<0.05). The self-efficacy score of the intervention group was higher than that of the control group at 1 month after operation, and the difference was statistically significant ( t=4.57, P<0.05). Conclusions:The continuous nursing program based on hybrid electronic platform and fragmented time can improve the knee function of patients with anterior cruciate ligament reconstruction in the early postoperative period, improve the compliance of rehabilitation exercise and the level of early self-efficacy.

Clinical observation of virtual reality technology combined with isokinetic strength training for patients after anterior cruciate ligament reconstruction / 中国骨伤

OBJECTIVE@#To explore application value and effectiveness of virtual reality technology combined with isokinetic muscle strength training in the rehabilitation of patients after anterior cruciate ligament (ACL) reconstruction surgery.@*METHODS@#Forty patients who underwent ACL reconstruction surgery from December 2021 to January 2023 were selected and divided into control group and observation group according to treatment methods, 20 patients in each group. Control group was received routine rehabilitation training combined with isokinetic muscle strength training, including 15 males and 5 females, aged from 17 to 44 years old, with an average of (29.10±8.60) years old. Observation group was performed virtual reality technology combined with isokinetic muscle strength training, including 16 males and 4 females, aged from 17 to 45 years old with an average of (30.95±9.11) years old. Lysholm knee joint score, knee extension peak torque, and knee flexion peak torque between two groups at 12 (before training) and 16 weeks (after training) after surgery were compared.@*RESULTS@#All patients were followed up for 1 to 6 months with an average of (3.30±1.42) months. There were no statistically significant difference in Lysholm knee joint score, peak knee extension peak torque, and peak knee flexion peak torque between two groups (P>0.05) before training. After training, Lysholm knee joint score, knee extension peak torque, and knee flexion peak torque of both groups were improved compared to before training (P<0.05);there were significant difference in Lysholm knee joint score, knee extension peak torque, and knee flexion peak torque between two groups(P<0.05).@*CONCLUSION@#The application of virtual reality technology combined with isokinetic muscle strength training could promote recovery of knee joint function and enhance muscle strength in patients after ACL reconstruction surgery in further.

Correlation between preoperative MRI measurement of cross-sectional area of hamstring tendon and graft in anterior cruciate ligament reconstruction / 中国骨伤

OBJECTIVE@#To study the corretation between the cross-sectional area of hamstring tenden measured by MRI and gragt in anterior cruciate ligament rexonstruction.@*METHODS@#MRI data of 50 patients who planned to undergo anterior cruciate ligament reconstruction from November 2021 to March 2022 were collected, including 32 males and 18 females, aged from 19 to 48 years old with an average of(31.1±8.7) years. Before the operation, the semitendinosus and gracilis tendons were measured and recorded by MRI, and then the anterior cruciate ligament was reconstructed under arthroscope. During the operation, gracilis and semitendinosus tendons were taken to prepare the final tendon to be transplanted, and the diameter of the prepared final graft was measured during the operation. Finally, the data were analyzed by statistical software.@*RESULTS@#The cross sectional areas of semitendinosus tendon, gracilis tendon, semitendinosus tendon and gracilis tendon measured by MRI were significantly and positively correlated with the diameter of grafts required in anterior cruciate ligament surgery, the r values were 0.858, 0.728, 0.842(P<0.001), respectively. The area under curre (AUC), sensitivity, and specificity of the sum of the cross sectional areas of semitendinosus tendon and gracilis tendon were 0.925, 90.48%, and 85.71%, respectively.@*CONCLUSION@#In patients undergoing anterior cruciate ligament reconstruction, preoperative MRI measurement has a strong statistical correlation with the diameter of hamstring muscle transplantation during operation. The sum of the cross sectional areas of semitendinosus tendon and gracilis tendon has a high predictive value for the diameter of grafts during anterior cruciate ligament reconstruction, and can predict the size of grafts during operation.

Application of femoral I.D.E.A.L localization in anterior cruciate ligament reconstruction with single bundle anterior cruciate ligament / 中国骨伤

OBJECTIVE@#To evaluate the effect of femoral I.D.E.A.L localization in single bundle anterior cruciate ligament reconstruction (ACLR).@*METHODS@#From January 2019 to October 2022, 122 patients with anterior cruciate ligament injury were treated with ACLR, including 83 males and 39 females. The age ranged from 23 to 43 years old, with an average of (32.19 ±8.55) years old. The course of disease ranged from 1 week to 6 months. According to the different surgical schemes, the patients were divided into two groups, namely the traditional group, which adopted the over-the-top femoral lateral positioning scheme, including 64 patients. The I.D.E.A.L group adopted the I.D.E.A.L femoral lateral positioning scheme, including 58 patients. The patient has pain and dysfunction of knee joint before operation. MRI of knee joint indicates anterior cruciate ligament injury. The visual analogue scale(VAS), International Knee Documentation Committee(IKDC) scoring system and Lysholm scoring system were used to evaluate the knee joint function of the patient. KT-2000 was used to detect the recovery of knee joint after operation and to count the postoperative complications.@*RESULTS@#The wounds healed well after operation. One hundred and twenty-tow patients were followed up for 15 to 46 months, with an average of (25.45±9.22) months. The knee joint stability of patients after operation was significantly increased. The VAS at 1 day and 1 week after operation of patients in the I.D.E.A.L group was significantly lower than that in the traditional group(P<0.05). The IKDC score and Lysholm score of patients in the I.D.E.A.L group were significantly higher than those in the traditional group(P<0.05). In the traditional group, there were 6 cases of short-term (<1 month) complications and 19 cases of long-term (≥1 month)complicatios. In the I.D.E.A.L group, there were 3 cases of short-term complications and 7cases of long-term complications(P<0.05).@*CONCLUSION@#The single bundle anterior cruciate ligament reconstruction and femoral I.D.E.A.L positioning can achieve better early postoperative effect and reduce early postoperative pain.

Modified application of interface screw in femoral side during anterior cruciate ligament reconstruction / 中国骨伤

OBJECTIVE@#To compare clinical effects of the improved interface screw fixation of femoral end of anterior cruciate ligament with classic femoral lateral loop plate fixation.@*METHODS@#A retrospective analysis of 65 patients who underwent arthroscopic anterior cruciate ligament reconstruction from January 2019 to September 2021 were performed. According to the different fixation methods of the femoral side, 35 patients were divided into loop plate fixation(loop plate group), including 27 males and 8 females, aged from 18 to 50 years old with an average of (35.00±7.60) years old;30 patients in interface screw fixation(interface screw group), including 20 males and 10 females, aged from 18 to 50 years old with an average of (32.00±8.50) years old. Hospital stay, hospital expenses, operation time, complications, C-reactive protein at 1, 3, 6 days after operation, and postoperative Lysholm score and International Knee Documentation Committee(IKDC) score at 18 months were compared between two groups.@*RESULTS@#All patients were successfully operated, and obtained follow-up from 18 to 36 months with an average of (25.16±4.50) months. Anterior drawer test and Lachman test of all patients turned to negative. There were no statistical differences in hospital stay, hospital expenses and complications between two groups(P>0.05);operation time in loop plate group was (74.00±6.84) min, and (91.67±6.34) min in interface screw group, and had difference between two groups(P<0.05). C-reactive protein on the 1st and 3rd day after operation was (40.00±10.10), (20.00±8.23) mg·L-1 in loop plate group, and (60.00±8.93), (30.00±8.66) mg·L-1 in interface nail group, had statistical difference between two groups (P<0.05);while there was no difference in C-reactive protein on the 6th day after operation(P>0.05). At 18 months after operation, Lysholm and IKDC scores showed no significant difference between two groups (P>0.05). In loop plate group, medullary enlargement on coronal and sagittal views were (2.75±0.19) mm, (1.55±0.25) mm, and (2.81±0.22) mm, (1.61±0.20) mm in interface screw group, and had statistical difference between two groups(P<0.05).@*CONCLUSION@#In the reconstruction of anterior cruciate ligament, the common interface screw on the femoral side is changed to the sheath interface screw, and intramedullary screw is changed to the compression and fixation of tendon from outside to inside of joint. Although the operation procedure is relatively complicated and operation time is slightly longer, it has advantages of no residual metal foreign body after operation, and clinical effect is no different from classical loop plate suspension fixation, which is still a good choice.