Restoring tibiofemoral alignment during ACL reconstruction results in better knee biomechanics

Chronic ACLD Knees with Early Developmental Cartilage Lesions Exhibited Increased Posterior Tibial Translation during Level Walking

OBJECTIVE

Early articular cartilage lesion (CL) is a vital sign in the onset of posttraumatic knee osteoarthritis (PTOA) in patients with anterior cruciate ligament deficiency (ACLD). Researchers have suggested that altered kinematics could accelerate CLs and, therefore, lead to the onset of PTOA. However, little is known about whether specific knee kinematics exist that lead to early CL in chronic ACLD knees. Level walking is the most frequent and relevant in vivo activity, which greatly impacts knee health. We hypothesized that the knee kinematics during level walking in chronic ACLD knees with early tibiofemoral CL would significantly differ from those of chronic ACLD knees without early tibiofemoral CL.

METHODS

Thirty patients with a chronic ACLD history, including 18 subjects with CLs and 12 subjects without CLs, and 35 healthy control subjects were recruited for the study from July 2020 to August 2022. The knee kinematic data during level walking were collected using a three-dimensional motion analysis system. The kinematic differences between groups were compared using statistical parametric mapping with one dimension for One-Way ANOVA. The cartilage statuses of the ACLD knees were assessed via MRI examination. The CLs distribution of subjects was evaluated using a modified Noyes scale and analyzed by chi-square tests.

RESULTS

ACLD knees with CLs had significantly greater posterior tibial translation (7.7-8.0mm, 12%-18% gait cycle GC, p = 0.014) compared to ACLD knees without CLs during level walking. ACLD knees with CLs had greater posterior tibial translation (4.6-5.5mm, 0%-23% GC, p < 0.001; 5.8-8.0mm, 86%-100% GC, p < 0.001) than healthy controls during level walking. In the group of ACLD knees with CLs, CL is mainly located in the back of the tibia plateau and front of load bearing area of the medial femoral condyle (p < 0.05).

CONCLUSION

Chronic anterior cruciate ligament deficient knees with cartilage lesions have increased posterior tibial translation compared to anterior cruciate ligament deficient knees without cartilage lesions and healthy subjects. The posterior tibial translation may play an important role in knee cartilage degeneration in ACLD knees. The increased posterior tibial translation and cartilage lesion characteristics may improve our understanding of the role of knee kinematics in cartilage degeneration and could be a helpful potential reference for anterior cruciate ligament deficient therapy, such as physical training to improve abnormal kinematic behavior.

Intervention of Refractory Arthrofibrosis After Anterior Cruciate Ligament Reconstruction: A Case Report

OBJECTIVES

Although nonsurgical and surgical management of knee arthrofibrosis has been reported in the literature, there is little information on the effect of procedural treatment modalities of refractory arthrofibrosis on clinical outcomes. The purpose of this case report is to describe the intervention of refractory knee arthrofibrosis after anterior cruciate ligament reconstruction and investigate long-term clinical outcomes after procedural intervention.

METHODS

A 27-year-old male presented with decreased range of motion (ROM), patellar mobility, strength, and knee joint function following anterior cruciate ligament reconstruction of his left knee. After failed conservative management, the patient underwent manipulation under anesthesia (MUA) to release scar tissue. Following MUA, the emphasis of comprehensive physiotherapy was on decreasing inflammation, relieving pain, and maintaining patellar mobility while increasing knee joint ROM and strength. Knee ROM, patellofemoral motion, gait, and quadriceps recruitment were measured 3, 6, 12, and 24 months after MUA.

RESULTS

At 2-year follow-up after MUA, the patient continued to present with decreased ROM and quadriceps strength compared to the contralateral knee, but had returned to a running program and reported knee joint dysfunction no longer interfered with his daily activities.

CONCLUSIONS

This case report demonstrates signs and symptoms that could indicate knee arthrofibrosis and introduces procedural intervention for refractory arthrofibrosis after anterior cruciate ligament reconstruction.

Preoperative excessive lateral anterior tibial subluxation is related to posterior tibial tunnel insertion with worse sagittal alignment after anterior cruciate ligament reconstructions

Objective

To investigate whether preoperative lateral anterior tibial subluxation (LATS) measured from magnetic resonance imaging (MRI) can influence tibial insertion and postoperative sagittal alignment after anterior cruciate ligament reconstructions (ACLRs).

Methods

84 patients who underwent single-bundle ACLRs were retrospectively investigated. Among them, 39 patients (LATS of <6 mm) 23 patients (LATS of ≥6 mm and <10 mm) and 22 patients (excessive LATS of ≥10 mm) were defined as group 1, 2 and 3, respectively. LATS, the position of graft insertion into tibia as ratio of anterior-posterior width (AP ratio) and the sagittal graft angle (SGA) were postoperatively assessed from MRI at 2-year follow-up. Following linear regression analyses were employed.

Results

The group 3 exhibited the largest preoperative LATS and remained the most postoperative LATS. Moreover, the group 3 possessed the most posteriorly located tunnel insertion with the largest AP ratio and the most vertical graft orientation. Of all included patients, a moderate correlation was demonstrated between pre- and postoperative LATS (r = 0.635). A low correlation was observed between preoperative LATS and AP ratio (r = 0.300) and a moderate correlation was displayed between AP ratio and SGA (r = 0.656).

Conclusion

For ACL injuries with excessive LATS (≥10 mm), most posteriorly located tibial insertion was found out, and worse sagittal alignment containing high residual LATS was associated with more vertical graft orientation following ACLRs.

ACLD patients exhibit additional knee kinematic asymmetries at the speed level of healthy subjects

Anterior cruciate ligament deficiency (ACLD) patients tend to walk slowly but try to catch up with the speed level of healthy subjects daily. Exploring the effects of the walking speed level of healthy subjects on the ACLD patients’ knee kinematics is important to improving non-operative treatments and delaying the progression of posttraumatic knee osteoarthritis. This study aimed to explore whether healthy controls’ walking speed level leads to additional knee kinematic asymmetries in patients with ACLD. 27 ACLD patients and 29 healthy controls were recruited for the study. The ACLD patients walked at two levels of walking speed, including self-selected and healthy controls’ walking speed levels. A three-dimensional gait analysis system was used to collect their knee kinematic data. ACLD patients exhibited more kinematic asymmetries when walking at healthy controls’ walking speed level than at their self-selected speeds. The kinematic asymmetries included increased posterior tibial translation (4.6 mm) and anteroposterior tibial ROM (3.9 mm), abduction angle (1.5°), and distal tibial translation (3.2 mm) asymmetries (p < 0.05). Our findings are meaningful for developing non-operative treatment strategies for patients with ACLD. To get fewer knee kinematic asymmetries, self-selected walking speed could be suggested for patients with ACLD daily rather than the speed levels of healthy subjects.

Development of new cartilage lesions after ACL reconstruction is associated with abnormal knee rotation

PURPOSE

The purpose of this study is to examine the association between the development of articular cartilage pathology and knee rotation after single-bundle anterior cruciate ligament (ACL) reconstruction.

METHODS

Seventeen patients that underwent single-bundle ACL reconstruction and did not have any cartilage lesions at the time of surgery based on the Outerbridge classification or meniscal injury that required meniscectomy > 20% were examined by MRI and in the biomechanics laboratory at a 6-year minimum follow-up. Cartilage lesions that occurred after reconstruction were graded on MRI according to a modified Noyes scale. For cartilage evaluation, the lateral and medial femoral condyles were divided into 9 segments each (lateral, central, and medial third and each third was divided into anterior, central, and posterior segment). Tibial rotation during a pivoting task was measured with optoelectronic motion analysis system and side-to-side differences of tibial rotation between the reconstructed and contralateral intact knees were calculated. The association between the total modified Noyes scale score (outcome variable) and side-to-side differences of tibial rotation after controlling for meniscectomy and meniscal repair was investigated with hierarchical regression models.

RESULTS

Side-to-side difference of tibial rotation was associated with total modified Noyes scale score (p = 0.015, β = 0.667, adjusted R² = 42.1%). All patients developed new cartilage lesions in MRI located mainly at the central region of the lateral femoral condyle and less frequently in the central and anterior regions of the medial femoral condyle.

CONCLUSION

Abnormally increased tibial rotation that persists after ACL-R is significantly associated with the development of new articular cartilage lesions at mean 8.4 years after reconstruction which were located mainly at the central region of the LFC and secondarily in the central and anterior regions of the MFC (more superficial lesions). These findings suggest that there is emerging evidence that abnormal rotational kinematics is a potential risk factor for the pathogenesis and onset of posttraumatic articular cartilage degeneration after ACLR.

LEVEL OF EVIDENCE

IV.

In Vivo Knee Kinematics in Patients With Arthrofibrosis After Anterior Cruciate Ligament Reconstruction

Context: Arthrofibrosis after anterior cruciate ligament (ACL) reconstruction can be detrimental to the knee joint function and patient outcomes. However, the effects of arthrofibrosis on the in vivo tibiofemoral and patellofemoral joint kinematics after ACL reconstruction remain unclear. Objective: The objective of this study was to quantify the in vivo knee kinematics during a dynamic lunge task in the knee with arthrofibrosis after ACL reconstruction. Methods: Eleven patients with arthrofibrosis in one knee after ACL reconstruction participated in this study. Computed tomography and dual fluoroscopic imaging were used to evaluate in vivo kinematics of affected and contralateral knees during a lunge task. Differences in 6 degrees of freedom tibiofemoral kinematics and patellar tracking between limbs were assessed via repeated-measures analysis of variance. Results: Internal tibial rotation (5.2° vs 7.5°, respectively; P < .001) and inferior patellar shift (24.6 mm vs 28.9 mm, respectively; P < .001) were significantly lower in the arthrofibrotic knee compared with the contralateral knee from 15° to 75° of knee flexion. The patella in the arthrofibrotic knee significantly less flexed by 9.1° (P = .009) throughout the measured ROM and less laterally tilted by 3° (P = .017) compared with the contralateral knee from 30° to 75° of knee flexion. Conclusions: A significant superior shift and medial tilt of the patella were found in the affected knee compared with those in the contralateral knee during the dynamic lunge. Decreased internal tibial rotation and patellar flexion were found in knees with arthrofibrosis following ACL reconstruction; whether these kinematic changes are caused by arthrofibrosis need further investigation.

Systematic Review of Surgical Technique and Tunnel Target Points and Placement in Anatomical Single-Bundle ACL Reconstruction

The purpose of this systematic review was to reveal the trend in surgical technique and tunnel targets points and placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, data collection was performed. PubMed, EMBASE, and Cochran Review were searched using the terms "anterior cruciate ligament reconstruction," "anatomic or anatomical," and "single bundle." Studies were included when they reported clinical results, surgical technique, and/or tunnel placement evaluation. Laboratory studies, technical reports, case reports, and reviews were excluded from this study. From these full article reviews, graft selection, method of creating the femoral tunnel, and femoral and tibial tunnel target points and placement were evaluated. In the 79 studies included for data evaluation, the selected grafts were: bone patella tendon bone autograft (12%), and hamstring autograft (83%). The reported methods of creating the femoral tunnel were: transportal technique (54%), outside-in technique (15%), and transtibial technique (19%). In the 60 studies reporting tunnel target points, the target point was the center of the femoral footprint (60%), and the center of the anteromedial bundle footprint (22%). In the 23 studies evaluating tunnel placement, the femoral tunnel was placed in a shallow-deep direction (32.3%) and in a high-low direction (30.2%), and the tibial tunnel was placed from the anterior margin of the tibia (38.1%). The results of this systematic review revealed a trend in anatomical single-bundle ACL reconstruction favoring a hamstring tendon with a transportal technique, and a tunnel target point mainly at the center of the ACL footprint. The level of evidence stated is Systematic review of level-III studies.

Coronal subluxation of the tibiofemoral joint before and after anterior cruciate ligament reconstruction

Background

Studies have shown that medial subluxation of the tibia occurs after anterior cruciate ligament (ACL) rupture. However, it is unclear whether anterior cruciate ligament reconstruction (ACLR) can correct tibial coronal subluxation.

Purpose

To determine whether the tibia is medially subluxated after ACL rupture, and whether ACLR can correct medial subluxation of the tibia.

Study design

Case series; Level of evidence, 4, Retrospective clinical study.

Methods

The distance of tibial coronal subluxation before and after ACLR surgery was measured in 48 patients with ACL rupture and meniscus injury. Tibiofemoral subluxation was defined as the perpendicular distance between the long axis of the tibia and a second parallel line originating at the most proximal aspect of the femoral intercondylar notch. To determine the long axis of the tibia, two circles separated by 5 cm were centered on the proximal tibia. The proximal circle is 5 cm from the tibial plateau, and the distal circle is 5 cm from the proximal circle. The line passing through the center of the two circles was considered the long axis of the proximal tibia. Care was taken to ensure that each patient lied on the back with their patellae facing upward, to minimize rotational variation among the radiographs. At the same time, 30 patients with simple meniscus injury who underwent arthroscopy during the same period were selected to determine the degree of tibiofemoral coronal subluxation as the baseline value. The changes before and after operation were compared, as well as the differences with the baseline data.

Result

The average follow-up period was 21.2 ± 5.8 months. The average distance of tibial coronal subluxation before ACLR was 5.5 ± 2.1 mm, which was significantly different from that of baseline group (7.3 ± 2.1 mm) (P < 0.001). The tibial subluxation after ACLR was 7.7 ± 2.6 mm, which was significantly different from that before operation (P < 0.001). There was no significant difference in the distance between postoperative tibial subluxation and baseline group (P = 0.472).

Conclusion

The tibia was coronally medially subluxated after ACL rupture. ACLR can correct the medial subluxation of tibia. This finding is helpful in the diagnosis of ACL rupture, and can be used to assess the imaging status of the tibiofemoral joint on the coronal plane during or after ACLR.

Reporte de caso de postcirugía de ligamento cruzado anterior

El ligamento cruzado anterior (LCA) es la lesión de la rodilla con mayor prevalencia en los atletas. Los avances en la técnica quirúrgica y la fijación de injertos han permitido a los pacientes participar en una rehabilitación funcional postoperatoria temprana. Este tratamiento está dirigido a lograr un mayor rango de movimiento, progresando hacia la movilización, fortalecimiento y control neuromuscular propioceptivo de la articulación. Existen varios protocolos de rehabilitación con variaciones en ejercicios específicos, progresión a través de fases y componentes claves que permiten la recuperación funcional. El objetivo final de la fisioterapia es devolver al paciente al nivel de rendimiento anterior a la lesión, incluidos el movimiento y la fuerza, sin dañar ni alargar el injerto. Presentamos el reporte de un caso con una lesión de LCA compleja, que recupero la funcionalidad de la articulación por aplicación de plan de tratamiento fisioterapéutico de forma inmediata a su intervención quirúrgica.

Dynamic Radiostereometry Evaluation of 2 Different Anterior Cruciate Ligament Reconstruction Techniques During a Single-Leg Squat

Background:

Lateral extra-articular tenodesis in the context of anterior cruciate ligament (ACL) reconstruction (ACLR) is performed to better control anterolateral knee instability in patients with high-grade preoperative pivot shift. However, some authors believe these procedures may cause lateral compartment overconstraint, affecting knee motion in daily life.

Purpose/Hypothesis:

The primary aim of the present study was to identify kinematic differences during the execution of an activity under weightbearing conditions between knees having undergone ACLR using anatomic single-bundle (SB) versus single-bundle plus lateral plasty (SBLP) techniques. The secondary aim was to compare the postoperative kinematic data with those from the same knees before ACLR and from the healthy contralateral knees in order to investigate if ACLR was able to restore physiologic knee biomechanics during squat execution. The hypotheses were that (1) the SBLP technique would allow a better restoration of internal-external (IE) knee rotation than would SB and (2) regardless of the technique, ACLR would not fully restore physiologic knee biomechanics.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

In total, 32 patients (42 knees) were included in the study. Patients were asked to perform a single-leg squat before surgery (ACL-injured group, n = 32; healthy contralateral group, n = 10) and at minimum 18-month follow-up after ACLR (SB group, n = 9; SBLP group, n = 18). Knee motion was determined using a validated model-based tracking process that matched patient-specific magnetic resonance imaging bone models to dynamic biplane radiographic images under the principles of roentgen stereophotogrammetric analysis. Data processing was performed using specific software. The authors compared IE and varus-valgus rotations and anterior-posterior and medial-lateral translations among the groups.

Results:

The mean follow-up period was 21.7 ± 4.5 months. No kinematic differences were found between the SB and SBLP groups (P > .05). A more medial tibial position (P < .05) of the ACL-injured group was reported during the entire motor task and persisted after ACLR in both the SB and the SBLP groups. Differences in IE and varus-valgus rotations were found between the ACL-injured and healthy groups.

Conclusion:

There were no relevant kinematic differences between SBLP and anatomic SB ACLR during the execution of a single-leg squat. Regardless of the surgical technique, ACLR failed in restoring knee biomechanics.

Registration:

NCT02323386 (ClinicalTrials.gov identifier).