Lars Good

Long-term results after primary repair or non-surgical treatment of anterior cruciate ligament rupture : A randomized study with a 15-year follow-up

We investigated the long‐term outcome of 100 patients 15 years after having been randomly allocated to primary repair (augmented or non‐augmented) or non‐surgical treatment of an anterior cruciate ligament (ACL) rupture. The subjective outcome was similar between the groups, with no difference regarding activity level and knee‐injury and osteoarthritis outcome score but with a slightly lower Lysholm score for the non‐surgically treated group. This difference was attributed to more instability symptoms. The radiological osteoarthritis (OA) frequency did not differ between surgically or non‐surgically treated patients, but if a meniscectomy was performed, two‐thirds of the patients showed OA changes regardless of initial treatment of the ACL. There were significantly more meniscus injuries in patients initially treated non‐surgically. One‐third of the patients in the non‐surgically treated group underwent secondary ACL reconstruction due to instability problems. In this study, ACL repair itself could not reduce the risk of OA nor increase the subjective outcome scores. However, one‐third of the non‐surgical treated patients were later ACL reconstructed due to instability. The status of the menisci was found to be the most important predictor of developing OA. Early ACL repair and also ACL reconstruction can reduce the risk of secondary meniscus tears. Indirectly this supports the hypothesis that early stabilization of the knee after ACL injury is advantageous for the long‐term outcome.

Postural Control after Anterior Cruciate Ligament Reconstruction and Functional Rehabilitation

Total sagittal knee laxity and postural control in the sagittal and frontal planes were measured in 25 patients at a mean of 36 months (range, 27 to 44) after anterior cruciate ligament reconstruction and in a control group consisting of 20 uninjured age- and activity-matched subjects. Body sway was measured in the sagittal plane on a stable and on a sway-referenced force plate in single-legged stance, double-legged stance, or both, with the eyes open and closed. Postural reactions to perturbations in the sagittal and frontal planes were recorded in the single-legged stance with the eyes open. Total sagittal plane laxity was significantly greater in the anterior cruciate ligament-reconstructed knee (11.2 mm; range, 6 to 15) than in the uninjured knee (8.9 mm; range, 6 to 12) or in the control group (6.0 mm; range, 5 to 8). In spite of this, the patients, in comparison with the controls, exhibited normal postural control except in two variables—the reaction time and the latency between the start of force movement to maximal sway in the sagittal plane perturbations. This supports the hypothesis that rehabilitation, with proprioceptive and agility training, is an important component in restoring the functional stability in the anterior cruciate ligament-reconstructed knee.

INTERCONDYLAR NOTCH MEASUREMENTS WITH SPECIAL REFERENCE TO ANTERIOR CRUCIATE LIGAMENT SURGERY

The femoral intercondylar notch width was measured in 93 patients with chronic anterior cruciate ligament (ACL) insufficiency (Group 1), in 62 patients with an acute tear of the ACL (Group 2), and in 38 fresh anatomic specimen knees (Group 3). In six of the specimen knees, further anatomic studies of the intercondylar notch were performed after tissue removal. The average intercondylar distance was 16.1 mm in Group 1, 18.1 mm in Group 2, and 20.4 mm in Group 3. All differences were highly significant. The intercondylar notch was wider in the posterior part and had no crossing bony ridges but had generally concave walls, which provided a functional shelf for the ACL to insert on the lateral side. Significant osteophyte formation and stenosis of the anterior outlet of the intercondylar notch occur early in the ACL-deficient knee. A narrow anterior outlet of the intercondylar notch without osteophytes was also found in knees with an acute ACL rupture. At reconstruction of the ACL, notchplasty should be performed concomitantly.

Postural control — a comparison between patients with chronic anterior cruciate ligament insufficiency and healthy individuals

Postural control in the sagittal plane was evaluated in 22 patients with chronic anterior cruciate ligament (ACL) deficiency and the result was compared to that of a control group of 20 uninjured subjects. Measurement of the body sway was done on a fixed and sway‐referenced force plate in both single‐limb and two‐limb stance, with the eyes open and closed, respectively. Further, an analysis of the postural reactions to perturbations backwards and forwards, respectively, was made in single‐limb stance.

A Comprehensive Rehabilitation Program With Quadriceps Strengthening in Closed Versus Open Kinetic Chain Exercise in Patients With Anterior Cruciate Ligament Deficiency A Randomized Clinical Trial Evaluating Dynamic Tibial Translation and Muscle Function

Background There is no consensus regarding the optimal rehabilitation regimen for increasing quadriceps strength after anterior cruciate ligament (ACL) injury. Hypothesis A comprehensive rehabilitation program supplemented with quadriceps strengthening in open kinetic chain (OKC) exercise will increase quadriceps strength and improve knee function without increasing static or dynamic sagittal tibial translation, compared with the same comprehensive rehabilitation program supplemented with quadriceps strengthening in closed kinetic chain (CKC) exercise, in patients with acute ACL deficiency. Study Design Randomized controlled trial; Level of evidence, 1. Methods Forty-two patients were tested a mean of 43 days (range, 20–96 days) after an ACL injury. Patients were randomized to rehabilitation with CKC quadriceps strengthening (11 men and 9 women) or OKC quadriceps strengthening (13 men and 9 women). Aside from these quadriceps exercises, the 2 rehabilitation programs were identical. Patients were assessed after 4 months of rehabilitation. Sagittal static translation and dynamic tibial translation were evaluated with a CA-4000 electrogoniometer. Muscle strength, jump performance, and muscle activation were also assessed. Functional outcome was evaluated by determining the Lysholm score and the Knee Injury and Osteoarthritis Outcome Score. Results There were no group differences in static or dynamic translation after rehabilitation. The OKC group had significantly greater isokinetic quadriceps strength after rehabilitation (P = .009). The hamstring strength, performance on the 1-repetition-maximum squat test, muscle activation, jump performance, and functional outcome did not differ between groups. Conclusions Rehabilitation with OKC quadriceps exercise led to significantly greater quadriceps strength compared with rehabilitation with CKC quadriceps exercise. Hamstring strength, static and dynamic translation, and functional outcome were similar between groups. Patients with ACL deficiency may need OKC quadriceps strengthening to regain good muscle torque.

Sagittal Knee Stability After Anterior Cruciate Ligament Reconstruction with a Patellar Tendon Strip A Two-year Follow-up Study

Tibial anteroposterior displacement after anterior cru ciate ligament reconstruction with a patellartendon graft was followed prospectively for 2 years in 24 patients with an arthrometer. The femoral ligament insertion lo cation, in a lateral projection, and the change in intra articular fixation distance, measured with an isometer, were documented intraoperatively. Two years after sur gery, the overall mean injured-noninjured difference in anteroposterior displacement was 2.0 ± 2.3 mm. All grafts were fixed during surgery at 20° of knee flexion. Patients for whom this angle coincided with the angle of minimum intraarticular fixation distance (Group I), and patients who had a femoral ligament insertion location >2 mm anterior to the center of the normal anterior cru ciate ligament attachment (Group A) showed larger tibial displacement than the other patients. An injured- noninjured difference in tibial anteroposterior displace ment ≥3 mm was classified as failure. Groups I and A failure rates were higher than for the other patients. No correlation was found between anteroposterior dis placement and magnitude of the change in intraarticular fixation distance. We conclude that anterior femoral lo cations lead to larger sagittal play after 2 years than central or posterior locations and that the magnitude of the fixation distance is less important than the pattern.

Tourniquet use in total knee replacement does not improve fixation, but appears to reduce final range of motion: A randomized RSA study involving 50 patients

Background and purpose Although a tourniquet may reduce bleeding during total knee replacement (TKA), and thereby possibly improve fixation, it might also cause complications. Migration as measured by radiostereometric analysis (RSA) can predict future loosening. We investigated whether the use of a tourniquet influences prosthesis fixation measured with RSA. This has not been investigated previously to our knowledge. Methods 50 patients with osteoarthritis of the knee were randomized to cemented TKA with or without tourniquet. RSA was performed postoperatively and at 6 months, 1 year, and 2 years. Pain during hospital stay was registered with a visual analog scale (VAS) and morphine consumption was measured. Overt bleeding and blood transfusions were registered, and total bleeding was estimated by the hemoglobin dilution method. Range of motion was measured up to 2 years. Results RSA maximal total point motion (MTPM) differed by 0.01 mm (95% CI –0.13 to 0.15). Patients in the tourniquet group had less overt bleeding (317 mL vs. 615 mL), but the total bleeding estimated by hemoglobin dilution at day 4 was only slightly less (1,184 mL vs. 1,236 mL) with a mean difference of –54 mL (95% CI –256 to 152). Pain VAS measurements were lower in the non-tourniquet group (p = 0.01). There was no significant difference in morphine consumption. Range of motion was 11° more in the non-tourniquet group (p = 0.001 at 2 years). Interpretation Tourniquet use did not improve fixation but it may cause more postoperative pain and less range of motion.

Precision in reconstruction of the anterior cruciate ligament: A new positioning device compared with hand drilling

To evaluate the precision of a drill guide for use in anterior cruciate ligament reconstruction and the reproducibility of the results, the device was tested in 30 operations (Group 1); 17 operations were done freehand (Group 2); 10 cadaver knees served as anatomic controls. The internal orifices of the bony channels in Groups 1 and 2 and the central point of the anterior cruciate ligament attachments in the cadaver group were identified on lateral radiographic views. The position of the tibial ligament attachments in the cadaver group did not differ from the orifices of the drilled channels in Groups 1 and 2. The position of the femoral attachments in the cadaver group did not differ from the orifices of the drilled channels in Group 1, but between the cadaver group and Group 2, and Groups 1 and 2, the positions of the femoral attachments differed. The hand-drilled channels were generally located too far anteriorly, and the scatter of the attachments was 1.8 times greater. The drill guide enables reproducible anatomic positioning of an anterior cruciate ligament graft.

Joint position sense is not changed after acute disruption of the anterior cruciate ligament

We evaluated the impact of acute, isolated ACL disruption on knee joint proprioception by means of passive-active and active-active joint position sense (JPS) measurement techniques. 18 subjects with acute, isolated and unilateral ACL disruption were tested for JPS in a standing position. The test protocol included 6 trials for each leg. In each trial, the lower leg was passively positioned to an index angle approximating either 30 degrees or 70 degrees, followed by 5 active repetitions of the index angle where the subjects attempted to reproduce the index angle to the best of their ability. The errors from the exact index angle reproduction were calculated as both real (showing both magnitude and direction) and absolute values (only magnitude). All subjects had a tendency to reproduce the index angle with both the injured and normal knees in a more flexed position (overestimation). Only the absolute error produced by the active-active test at flexion angles greater than 45 degrees produced a significant difference with a larger error for the normal knee. In all other comparisons between the injured and the normal knee no differences were found. We conclude that the afferent signals which are compromised by an acute tear of the ACL are insignificant compared to afferent signals from the other joint and muscle receptors.

Effects of celecoxib on blood loss, pain, and recovery of function after total knee replacement: A randomized placebo-controlled trial

Background Pain management after surgery has been used as a sales argument for the use of COX-2 inhibitors, but their potential positive and negative effects have not been fully investigated. We thus conducted a controlled evaluation of the effect of celecoxib on perioperative blood loss, pain relief and consumption of analgesics, range of motion, and subjective outcome in conjunction with total knee replacement (TKR). Method 50 patients were randomized to either placebo or celecoxib (200 mg) preoperatively and then twice daily. Total blood loss was calculated by the Hb balance method, taking the patients pre- and postoperative hemoglobin and blood volume into account. Pain scores (VAS), range of motion, and subjective outcome (KOOS) were monitored postoperatively and during the first year after surgery. Results No differences in total, hidden, or drainage blood loss were found between the groups. There were 30% lower pain scores during the first 4 weeks after surgery and lower morphine consumption after surgery in the celecoxib group, while no effect was seen on pain, range of motion, and subjective outcome at the 1 year follow-up. Interpretation Celecoxib does not increase perioperative blood loss but reduces pain during the postoperative period after TKR. It is not necessary to discontinue celecoxib before surgery. The postoperative use of celecoxib did not increase range of motion or subjective outcome 1 year after TKR.