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Treatment of Anterior Cruciate Ligament Injuries

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (25 August 2023) | Viewed by 21644

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Dr. Elmar Herbst

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Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, 48149 Muenster, Germany
Interests: knee; ACL; rotatory instability; osteotomy; ligament; meniscus; biomechanics
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Dear Colleagues,

Injuries to the anterior cruciate ligament (ACL) are among the most frequent ligament injuries requiring surgical treatment. While surgical techniques have improved significantly, persistent (rotatory) instability and a high rate of ACL re-tears as well as early onset osteoarthritis are still prevalent following ACL reconstruction.

There are also still several open questions in the field of ACL reconstruction despite the extensive scientific work on the subject. The authors of one paper carried out an early repair of a torn ACL despite negative reports on this technique. New insights into the biologics of healing and techniques to repair the torn ligament have re-popularized ACL repair. Nevertheless, high-quality scientific data proving the superiority of ACL repair over conservative treatment or ACL reconstruction are lacking to date. Another topic requiring attention is persistent anterolateral and anteromedial instability following ACL injury and reconstruction. It has been shown clinically that an anterolateral reconstruction/tenodesis reduces the ACL graft failure rate in the short term. However, long-term data on cartilage degradation due to a tenodesis are pending.

Lastly, managing complex or multiple ACL revisions is a topic of increasing interest. Recently, several studies investigated the effect of the posterior tibial slope as well as other bony factors on an increased ACL graft failure risk.

This Special Issue addresses the aforementioned challenges in the treatment of patients with ACL injuries based on a combination of original research and review papers.

Dr. Elmar Herbst
Guest Editor

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Keywords

ACL
tibial slope
revision
rotatory knee instability
anterolateral
anteromedial

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Published Papers (9 papers)

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13 pages, 1090 KiB

Open AccessArticle

What Are the Criteria for an Acute Form of Anterior Cruciate Ligament Tear for the Severity of the Process by Gait Analysis Data?

by Dmitry Skvortsov, Alyona Altukhova, Sergey Kaurkin and Alexander Akhpashev

J. Clin. Med. 2023, 12(14), 4803; https://doi.org/10.3390/jcm12144803 - 20 Jul 2023

Viewed by 1073

Abstract

Purpose: There is still controversy over the criteria for acute ACL tear. In this paper, knee joint function and walking were considered possible ones. Method: The study included 21 subjects with acute ACL tear and 20 healthy volunteers as a control group. Biomechanical gait analysis was performed using the inertial sensor system including EMG recording. All subjects (but for controls) were divided into two groups: Group 1—“up to 4 weeks” and Group 2—“from 4 weeks to 3 months”. Results: Temporal gait parameters in subjects from Group 1 demonstrate the asymmetry of 4% and more in terms of the gait cycle with a decrease in the affected limb, and are within normal range in Group 2. The amplitudes at the hip and knee joints in the affected limb are reduced which is especially pronounced in Group 1 (2–4 and 6–10 degrees, respectively). The affected knee joint shows a decrease in the range of motion by up to 5 degrees in the first half of the stance phase and flexion by less than 40 degrees in the swing phase. The tibialis anterior and quadriceps femoris muscle function is decreased in the affected limb only in Group 1 (72% and 78% from normal, respectively). Conclusions: The severity of the condition after an ACL tear is largely determined by functional changes. The time factor is of secondary importance. Full article

(This article belongs to the Special Issue Treatment of Anterior Cruciate Ligament Injuries)

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10 pages, 255 KiB

Open AccessArticle

Recurrent Instability Rate and Subjective Knee Function following Accelerated Rehabilitation after ACL Reconstruction in Comparison to a Conservative Rehabilitation Protocol

by Adrian Deichsel, Simon Oeckenpöhler, Michael J. Raschke, Ole Grunenberg, Christian Peez, Thorben Briese, Elmar Herbst, Christoph Kittl and Johannes Glasbrenner

J. Clin. Med. 2023, 12(14), 4567; https://doi.org/10.3390/jcm12144567 - 9 Jul 2023

Cited by 1 | Viewed by 1728

Abstract

Introduction: The Purpose of the present study was to assess the outcome of anterior cruciate ligament reconstruction (ACLR) with an accelerated rehabilitation protocol and to compare it to a conservative rehabilitation protocol. It was hypothesized that an accelerated rehabilitation protocol, including brace-free early weight bearing, would result in a higher rate of recurrent instability and revision surgery compared to a conservative rehabilitation protocol. Methods: From 2016 to 2017, two different rehabilitation protocols for isolated ACLR were used at a high-volume knee surgery center. A total of 65 consecutive patients with isolated hamstring ACLR, of whom n = 33 had been treated with an accelerated (AccRehab) and n = 32 with a conservative rehabilitation protocol (ConRehab), were retrospectively included in the study. Patients were evaluated for recurrent instability, revision surgery, and other complications at a mean follow-up period of 64 ± 7.4 months. In addition, Tegner Activity Scale, Lysholm Score, and IKDC-subjective Score were evaluated. Statistical comparison between the two groups was performed utilizing Fisher’s exact test and Student’s t-test. Results: Mean age (29.3 vs. 26.6 years) and preoperative Tegner Score (6.4 vs. 5.9) were comparable between both groups. At 64 ± 7.4 months after ACLR, six cases of recurrent instability were reported in the AccRehab group (18%) in comparison to three cases (9%) in the ConRehab group (p = n.s.). There was no significant difference regarding revision surgery and further complications. Furthermore, no significant difference was found between both groups regarding Tegner (5.5 ± 1.9 vs. 5.5 ± 1.2), Lysholm (93.6 ± 6.3 vs. 89.3 ± 10.7), and IKDC score (89.7 ± 7.9 vs. 86.7 ± 12.1). Conclusion: No significant disadvantage of an accelerated rehabilitation protocol following ACLR was found in terms of recurrent instability rate, revision surgery, or patient-reported outcome. However, a trend towards a higher reinstability rate was found for an accelerated rehabilitation protocol. Future level one trials evaluating brace-free early weight bearing following ACLR are desirable. Full article

(This article belongs to the Special Issue Treatment of Anterior Cruciate Ligament Injuries)

11 pages, 885 KiB

Open AccessArticle

Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Using a Calcium Phosphate-Hybridized Tendon Graft with More than an Average of 5 Years of Follow-Up: A Follow-Up Study of a Randomized Controlled Trial

by Hirotaka Mutsuzaki and Tomonori Kinugasa

J. Clin. Med. 2023, 12(13), 4437; https://doi.org/10.3390/jcm12134437 - 30 Jun 2023

Viewed by 1384

Abstract

Calcium phosphate (CaP)-hybridized tendon grafting using an alternate soaking process improves tendon-to-bone healing in anterior cruciate ligament (ACL) reconstructions. This study aimed to compare bone tunnel enlargement, knee osteoarthritis, and clinical results between CaP-hybridized tendon grafting and conventional grafting in anatomical single-bundle ACL reconstruction. This study was a follow-up of a randomized controlled trial. Between July 2011 and December 2015, 90 patients underwent unilateral anatomical single-bundle ACL reconstructions and were randomly assigned to the CaP-hybridized tendon grafting (CaP group, n = 45; age, 27.1 [14–54] years; sex, 21 males and 24 females) or conventional grafting (control group, n = 45; age, 22.9 [13–58] years; sex, 26 males and 19 females). The randomization was performed according to the days of the week when the patients first visited the outpatient. The CaP-hybridized tendon grafting was created intraoperatively. The tendon grafts were soaked in a calcium solution for 30 s. After that, the tendon grafts were soaked in a NaHPO4 solution for 30 s. This soaking cycle between the calcium solution and the NaHPO4 solution was repeated 10 times. The bone tunnel enlargement, osteoarthritis grade, clinical score, and sports level were evaluated in patients who could be followed up for >3 years (CaP group, n = 20, average follow-up period 6.0 [5.1–6.9] years; control group, n = 15, average follow-up period 5.6 [4.3–6.9] years). Clinical scores, sports levels, and osteoarthritis grades were analyzed using a generalized linear mixed model (GLMM) based on repeated measurement data from preoperative and final observations, with time, group, sex, age, and BMI as fixed effects and the effect of individual differences as variable effects. In addition, bone-tunnel enlargements were analyzed using generalized linear models (GLM) with group, sex, age, and BMI as the main effects. Compared with the control group, the CaP group exhibited significantly reduced bone-tunnel enlargement on the femoral side (anteroposterior diameter; CaP group, 7.9% [−1.1–16.8] vs. control group, 29.2% [17.9–40.5], p = 0.004, MCID 16.05, proximal-distal diameter; CaP group, 7.9% [−1.9–17.8] vs. control group, 22.8% [10.9–34.7], p = 0.062, MCID 15.00). The osteoarthritis grades progressed in both groups (p < 0.001). The clinical scores and sports levels were not significantly different between the groups. This study suggests that the calcium phosphate-hybridized tendon graft reduces femoral bone-tunnel enlargement after anatomical single-bundle anterior cruciate ligament reconstruction in an average >5-year follow-up period. A longer follow-up period is necessary to reveal the clinical effects of the calcium phosphate-hybridized tendon grafts in anterior cruciate ligament reconstruction. Full article

(This article belongs to the Special Issue Treatment of Anterior Cruciate Ligament Injuries)

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10 pages, 1041 KiB

Open AccessArticle

Untreated Injuries to the Anterolateral Capsular Structures Do Not Affect Outcomes and Kinematics after Anatomic Anterior Cruciate Ligament Reconstruction

by Elmar Herbst, Joanna Costello, Adam J. Popchak, Scott Tashman, James J. Irrgang, Freddie H. Fu and Volker Musahl

J. Clin. Med. 2023, 12(13), 4408; https://doi.org/10.3390/jcm12134408 - 30 Jun 2023

Cited by 1 | Viewed by 1135

Abstract

Background: Injuries to the anterolateral complex (ALC) may contribute to increased rotatory knee laxity. However, it has not been evaluated whether such injuries affect in vivo kinematics when treated in situ. The purpose of this study was to determine the grade of ALC injury and its effect on kinematic and clinical outcomes of ACL-injured patients 24 months after anatomic ACL reconstruction. It was hypothesized that injury to the ALC would be significantly related to patient-reported outcomes (PROs) and in vivo knee kinematics during downhill running. Methods: Thirty-five subjects (mean age: 22.8 ± 8.5 years) participating in a randomized clinical trial to compare single- and double-bundle ACL reconstruction were included in the study. Subjects were divided into two groups based on the presence or absence of injury to the ALC, as determined on MRI scans performed within 6 weeks of injury. None of the patients underwent treatment for these ALC injuries. At 24 months, PROs, including the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS) and in vivo knee kinematics during downhill running, were obtained. Pivot-shift test results, PROs and in vivo knee kinematics were compared between groups with and without ALC injury using the Pearson’s Chi Squared test and Mann–Whitney U test with significance set at p < 0.05. Results: The average interval between injury and performing the MRI scans was 9.5 ± 10 days. ALC injury was observed in 17 (49%) study participants. No significant differences were detected in PROs and in vivo kinematics between subjects with and without ALC injury (n.s.). Conclusion: The findings of this study demonstrate that MRI evidence of an ALC injury does not significantly affect in vivo knee kinematics and PROs even in individuals with a high-grade ALC injury. Injuries to the ALC as observed on MRI might not be a useful indication for an anterolateral procedure. Full article

(This article belongs to the Special Issue Treatment of Anterior Cruciate Ligament Injuries)

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9 pages, 2125 KiB

Open AccessArticle

Extracorporeal Shockwave Therapy Improves Outcome after Primary Anterior Cruciate Ligament Reconstruction with Hamstring Tendons

by Patrick Weninger, Christoph Thallinger, Manuel Chytilek, Yannis Hanel, Caterina Steffel, Ramin Karimi and Xaver Feichtinger

J. Clin. Med. 2023, 12(10), 3350; https://doi.org/10.3390/jcm12103350 - 9 May 2023

Cited by 2 | Viewed by 6487

Abstract

Purpose: The decision regarding the timepoint of a return to sports after anterior cruciate ligament (ACL) reconstruction is complex and depends on many factors, including objectively tested physical and psychological readiness as well as biological healing. The aim of this study was to investigate the influence of repetitive extracorporeal shockwave therapy (ESWT) on return-to-sports duration, clinical results and MRI results after ACL reconstruction with hamstring tendons (HT). Material and Methods: In this prospective controlled study, all patients with acute ACL ruptures were treated by ACL reconstruction with HT. Patients were randomized into two groups (Group A: ESWT group; Group B: control group). Patients in the ESWT group received focused shockwave therapy 4, 5 and 6 weeks after ACL surgery. Follow-up investigations including IKDC score, Lysholm score, VAS and evaluation regarding return-to-sports timepoints that were conducted 3-, 6-, 9- and 12-months post-operation. An MRI investigation was performed 12-months post-operation and graft maturation (signal intensity ratio (SIR)) as well as femoral and tibial tunnel characteristics (bone marrow oedema, tunnel fluid effusion) were assessed. Results: In total, 65 patients (27.65 ± 7.07 years; 35 male/30 female) were included in this study. The mean timepoint for “return-to-pivoting-sports” was 27.92 weeks (±2.99) in the ESWT group as well as 42.64 weeks (±5.18) in the control group (p < 0.001). In the ESWT group 31 patients (vs. control group: n = 6) attained the “pre-injury activity level”, whereas 6 patients (vs. control group: n = 22) did not reach this level within 12 months post-operation. The IKDC score, Lysholm score, and VAS showed significant improvement in the ESWT group compared with the control group for all time-points (p < 0.001). The mean SIR in the ESWT group revealed 1.81 (±0.88), whereas the control group showed a mean SIR of 2.68 (±1.04) (p < 0.01). Discussion: In conclusion, this is the first study investigating the effect of repetitive ESWT on ACL reconstruction with clinical outcome measurements, including the duration of return-to-sports activity and an MRI follow-up examination. Return-to-sports parameters, clinical scores and graft maturation were significantly improved in the ESWT group. This study may support an earlier return-to-sports timepoint by ESWT and is of high clinical relevance as ESWT is a cost-effective treatment option with no relevant side effects. Full article

(This article belongs to the Special Issue Treatment of Anterior Cruciate Ligament Injuries)

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11 pages, 1422 KiB

Open AccessArticle

Primary Proximal ACL Repair: A Biomechanical Evaluation of Different Arthroscopic Suture Configurations

by Steffen B. Rosslenbroich, Andrea Achtnich, Cathrin Brodkorb, Clemens Kösters, Carolin Kreis, Sebastian Metzlaff, Benedikt Schliemann and Wolf Petersen

J. Clin. Med. 2023, 12(6), 2340; https://doi.org/10.3390/jcm12062340 - 17 Mar 2023

Cited by 3 | Viewed by 1684

Abstract

Purpose: Several suture techniques have been described in the past for direct ACL repair with poor healing capacity and a high re-rupture rate. Therefore, we investigated a refixation technique for acute primary proximal ACL repair. The purpose of this study is to compare the biomechanical properties of different suture configurations using a knotless anchor. Methods: In this study, 35 fresh-frozen porcine knees underwent proximal ACL refixation. First, in 10 porcine femora, the biomechanical properties of the knotless anchor, without the ligament attached, were tested. Then, three different suture configurations were evaluated to reattach the remaining ACL. Using a material testing machine, the structural properties were evaluated for cyclic loading followed by loading to failure. Results: The ultimate failure load of the knotless anchor was 198, 76 N ± 23, 4 N significantly higher than all of the tested ACL suture configurations. Comparing the different configurations, the modified Kessler–Bunnell suture showed significant superior ultimate failure load, with 81, 2 N ± 15, 6 N compared to the twofold and single sutures (50, 5 N ± 14 N and 37, 5 ± 3, 8 N). In cyclic loading, there was no significant difference noted for the different configurations in terms of stiffness and elongation. Conclusions: The results of this in vitro study show that when performing ACL suture using a knotless anchor, a modified Kessler–Bunnell suture provides superior biomechanical properties than a single and a twofold suture. Within this construct, no failure at the bone–anchor interface was seen. Clinical relevance: Since primary suture repair techniques of ACL tears have been abandoned because of inconsistent results, ACL reconstruction remains the gold standard of treating ACL tears. However, with the latest improvements in surgical techniques, instrumentation, hardware and imaging, primary ACL suture repair might be a treatment option for a select group of patients. By establishing an arthroscopic technique in which proximal ACL avulsion can be reattached, the original ACL can be preserved by using a knotless anchor and a threefold suture configuration. Nevertheless, this technique provides an inferior ultimate failure load compared to graft techniques, so a careful rehabilitation program must be followed if using this technique in vivo. Full article

(This article belongs to the Special Issue Treatment of Anterior Cruciate Ligament Injuries)

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18 pages, 2761 KiB

Open AccessArticle

Brace-Free Rehabilitation after Isolated Anterior Cruciate Ligament Reconstruction with Hamstring Tendon Autograft Is Not Inferior to Brace-Based Rehabilitation—A Randomised Controlled Trial

by Christian Schoepp, Tobias Ohmann, Wolfgang Martin, Arthur Praetorius, Christine Seelmann, Marcel Dudda, Dirk Stengel and Jakob Hax

J. Clin. Med. 2023, 12(5), 2074; https://doi.org/10.3390/jcm12052074 - 6 Mar 2023

Cited by 3 | Viewed by 3425

Abstract

Purpose: The postoperative use of a rehabilitative knee brace after isolated primary anterior cruciate ligament (ACL) reconstruction (ACLR) using a hamstring tendon (HT) autograft is controversial. A knee brace may provide subjective safety but can cause damage if applied incorrectly. The aim of this study is to evaluate the effect of a knee brace on clinical outcomes following isolated ACLR using HT autograft. Methods: In this prospective randomised trial, 114 adults (32.4 ± 11.5 years, 35.1% women) underwent isolated ACLR using HT autograft after primary ACL rupture. Patients were randomly assigned to wear either a knee brace (n = 58) or no brace (n = 56) for 6 weeks postoperatively. An initial examination was performed preoperatively, and at 6 weeks and 4, 6, and 12 months. The primary endpoint was the subjective International Knee Documentation Committee (IKDC) score to measure participants’ subjective perceptions. Secondary endpoints included objective knee function assessed by IKDC, instrumented knee laxity measurements, isokinetic strength tests of the knee extensors and flexors, Lysholm Knee Score, Tegner Activity Score, Anterior Cruciate Ligament—Return to Sport after Injury Score, and quality of life determined by Short Form-36 (SF36). Results: There were no statistically significant or clinically meaningful differences in IKDC scores between the two study groups (3.29, 95% confidence interval (CI) −1.39 to 7.97, p = 0.03 for evidence of non-inferiority of brace-free compared with brace-based rehabilitation). The difference in Lysholm score was 3.20 (95% CI −2.47 to 8.87); the difference in SF36 physical component score 0.09 (95% CI −1.93 to 3.03). In addition, isokinetic testing did not reveal any clinically relevant differences between the groups (n.s.). Conclusions: Brace-free rehabilitation is non-inferior to a brace-based protocol regarding physical recovery 1 year after isolated ACLR using HT autograft. Consequently, the use of a knee brace might be avoided after such a procedure. Level of Evidence: Level I, therapeutic study. Full article

(This article belongs to the Special Issue Treatment of Anterior Cruciate Ligament Injuries)

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11 pages, 1055 KiB

Open AccessArticle

Intraoperative Administration of Adipose Stromal Vascular Fraction Does Not Improve Functional Outcomes in Young Patients with Anterior Cruciate Ligament Reconstruction

by Wen-Chin Su, Ho-Yi Tuan-Mu, Hung-Maan Lee, Ting-Yu Hung and Kuan-Lin Liu

J. Clin. Med. 2022, 11(21), 6240; https://doi.org/10.3390/jcm11216240 - 22 Oct 2022

Cited by 1 | Viewed by 1469

Abstract

Adipose stromal vascular fraction (SVF) has a versatile cellular system for biologically augmented therapies. However, there have been no clinical studies investigating the benefits of the augmentation of anterior cruciate ligament reconstruction (ACLR) with SVF. We conducted a retrospective study in assessing the effects of intraoperative SVF administration on the functional outcomes in young patients with ACLR. The enrolled patients were divided into the control group (ACLR only) and the SVF group (ACLR with SVF). The functional outcomes in both groups were assessed by the Lysholm knee scoring system, the Tegner activity scale, and the International Knee Documentation Committee (IKDC) subjective evaluation form, and compared at several time points during a 12-month follow-up. We found that the sex distribution and pre-surgery scores were similar in the two groups, whereas the mean age of the SVF group was higher than that of the control group (p = 0.046). The between-group analysis and generalized estimating equation model analysis revealed that, while patients in the SVF group significantly improved all their functional outcomes at 12 months after surgery, this improvement was not significantly different from the results of patients in the control group (Lysholm, p = 0.553; Tegner, p = 0.197; IKDC, p = 0.486). No side effects were observed in either group. We concluded that the intraoperative administration of SVF does not improve or accelerate functional recovery after ACLR in young patients. Full article

(This article belongs to the Special Issue Treatment of Anterior Cruciate Ligament Injuries)

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15 pages, 2419 KiB

Open AccessSystematic Review

Ultrasound Imaging in Predicting the Autograft Size in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis

by Tsung-Min Lee, Wei-Ting Wu, Yi-Hsiang Chiu, Ke-Vin Chang and Levent Özçakar

J. Clin. Med. 2022, 11(13), 3876; https://doi.org/10.3390/jcm11133876 - 4 Jul 2022

Cited by 3 | Viewed by 2010

Abstract

Anterior cruciate ligament (ACL) reconstruction is widely used to restore knee stability after injury, but the risk of revision surgery increases when the autograft size is inadequate. Ultrasound (US) measurements of preoperative target tendons have been applied to predict the intraoperative autograft size, with various outcomes across different studies. This systematic review and meta-analysis aimed to summarize the evidence and investigate the usefulness of US in predicting autograft size. Electronic databases were searched for relevant studies from inception to 19 January 2022. The primary outcome was the correlation between the preoperative US measurements of donor tendons and intraoperative autograft size. The secondary outcomes encompassed the predictive performance of US for autograft size and the comparison between US and magnetic resonance imaging (MRI) for preoperative tendon measurements. Nine studies, comprising 249 patients, were enrolled. The preoperative US measurements of the donor tendons demonstrated a significant positive correlation with their intraoperative autograft diameter, with a pooled correlation coefficient of 0.443 (95% confidence interval [CI], 0.266–0.591, p < 0.001) for the gracilis and semitendinosus autograft, 0.525 (95% CI, 0.114–0.783, p = 0.015) for the semitendinosus autograft, and 0.475 (95% CI, 0.187–0.687, p = 0.002) for the gracilis autograft. The pooled sensitivity and specificity of US imaging in predicting the autograft diameter were 0.83 (95% CI 0.57–0.95) and 0.70 (95% CI, 0.36–0.91), respectively. Moreover, no significant differences were observed between US and MRI measurements in predicting the sizes of the gracilis and semitendinosus autografts. Preoperative US measurements of the target tendons were moderately correlated with the intraoperative autograft size. US imaging has a discriminative performance similar to that of MRI in predicting the autograft size. A standardized US scanning protocol is needed for future studies to minimize the variations in tendon measurements across different investigators and increase the comparability of US imaging with intraoperative findings. Full article

(This article belongs to the Special Issue Treatment of Anterior Cruciate Ligament Injuries)

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