Aims. To fully quantify the effect of posterior tibial slope (PTS) angles on joint kinematics and contact mechanics of intact and anterior cruciate ligament-deficient (ACLD) knees during the gait cycle. Methods. In this controlled laboratory study, we developed an original multiscale subject-specific finite element musculoskeletal framework model and integrated it with the tibiofemoral and patellofemoral joints with high-fidelity joint motion representations, to investigate the effects of 2.5° increases in PTS angles on joint dynamics and contact mechanics during the gait cycle. Results. The ACL tensile force in the intact knee was significantly affected with increasing PTS angle. Considerable differences were observed in kinematics and initial posterior femoral translation between the intact and ACLD joints as the PTS angles increased by more than 2.5° (beyond 11.4°). Additionally, a higher contact stress was detected in the peripheral posterior horn areas of the menisci with increasing PTS angle during the gait cycle. The maximum tensile force on the horn of the medial meniscus increased from 73.9 N to 172.4 N in the ACLD joint with increasing PTS angles. Conclusion. Knee joint instability and larger loading on the medial meniscus were found on the ACLD knee even at a 2.5° increase in PTS angle (larger than 11.4°). Our biomechanical findings support recent clinical evidence of a high risk of failure of ACL reconstruction with steeper PTS and the necessity of ACL reconstruction, which would prevent meniscus tear and thus the development or progression of osteoarthritis. Cite this article: Bone Joint Res 2022;11(10):739–750

Introduction. Unicompartmental knee arthroplasty(UKA) has become a popular treatment alternative when one compartment of the knee is affected. Excellent intermediate results have been reported in association with the Miller-Galante unicompartmental implant. These excellent results are based on the development of the implants and the stringent patients selection. The functional cruciate ligaments has been a prerequisite for patients undergoing UKA. However, UKA can be one of the procedures in elderly patiants with deficient anterior cruciate ligaments(ACL) but with no symptoms of instability. The purpose of this report is to determine the clinical results after UKA in patients with ACL-deficient knees and compared those after UKA in ACL-intact knees. Patients and Methods. We identified 332 cases operated from May 2000 to April 2013 whose ACL were evaluated before the operation by MRI., and classified into ACL-deficient group and ACL-intact group. Fixed-bearing Miller-Galante Unicompartmental Knee System or Zimmer Unicompartmental High-Flex Knee Sytem was implanted in all patients. ACL-deficient group included 17 men and 68 women who had an average age of 79 years(range, 70–91 years) at the time of the operation. The underlying diagnosis was osteoarthritis for 77 knees and osteonecrosis for 8 knees. ACL-intact group included 49 men and 198 women who had an average age of 77 years(range, 60–88 years) at the time of the operation. The underlying diagnosis was osteoarthritis for 176 knees and osteonecrosis for 71 knees. Followup for ACL-deficient group was 3.5 years(1–8.8years), and 3.6years (1–13.2years) for ACL-intact group. Results. Japanese Orthopaedic Association score improved from 46.7points preoperatively to 76.5 points at the time of the latest followup in ACL deficient group, and 49.6 points to 81.5 points in ACL-intact group. 7 knees(8.2%) had a partial radiolucent line around the tibial component in ACL-deficient group, and 30 knees(12.6%) had a partial radiolucent line around the tibial component(30knees) or femoral component(one knee) in ACL-intact group, all of these radiolucent lines were <2mm in thickness and remained stable over time. Two knees(2.3%) in ACL-deficient group and five knees(2.0%) in ACL-intact group were revised because of progression of arthritis in the lateral tibiofemoral or patellofemoral components. All of the components in revised knees were well fixed and no polyethylene wear was seen at the time of revision. All of these results between two groups were not significantly different. Conclusion. Controversy exists about whether a functional ACL is necessary to achieve success with UKA. In classical indication, UKA should not be done in patients with symptoms of ACL instability. In elderly active patient with deficient ACL, we should prefer total knee arthroplasty. But UKA should judiciously be done in eldery patients with deficient ACL whose activity is low but with no symptoms of instability

Forty-seven patients with disabling instability due to isolated anterior cruciate deficiency are described. None had responded to conservative measures or to attempted correction of internal derangements. Eighteen patients were treated by extra-articular MacIntosh lateral substitution alone, the other 29 were treated by the same procedure combined with carbon-fibre replacement of the anterior cruciate ligament. No statistically significant difference was found between the two groups at six years. A satisfactory outcome was found in 44% of the extra-articular group and 55% of the carbon-fibre group at last review; however, the latter group had more complications. There was a marked deterioration in the quality of results between three and six years in both groups

The biomechanical function of the anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate ligament (ACL) remains controversial. Some studies report that the AM bundle stabilises the knee joint in anteroposterior (AP) translation and rotational movement (both internal and external) to the same extent as the PL bundle. Others conclude that the PL bundle is more important than the AM in controlling rotational movement. The objective of this randomised cohort study involving 60 patients (39 men and 21 women) with a mean age of 32.9 years (18 to 53) was to evaluate the function of the AM and the PL bundles of the ACL in both AP and rotational movements of the knee joint after single-bundle and double-bundle ACL reconstruction using a computer navigation system. In the double-bundle group the patients were also randomised to have the AM or the PL bundle tensioned first, with knee laxity measured after each stage of reconstruction. All patients had isolated complete ACL tears, and the presence of a meniscal injury was the only supplementary pathology permitted for inclusion in the trial. The KT-1000 arthrometer was used to apply a constant load to evaluate the AP translation and the rolimeter was used to apply a constant rotational force. For the single-bundle group deviation was measured before and after ACL reconstruction. In the double-bundle group deviation was measured for the ACL-deficient, AM- or PL-reconstructed first conditions and for the total reconstruction. We found that the AM bundle in the double-bundle group controlled rotation as much as the single-bundle technique, and to a greater extent than the PL bundle in the double-bundle technique. The double-bundle technique increases AP translation and rotational stability in internal rotation more than the single-bundle technique

Introduction

Anterior tibial translation (ATT) is assessed in the acutely injured knee to investigate for ligamentous injury and rotational laxity. Specifically, there is a growing recognition of the significance of anterior medial rotary laxity (AMRI) as a crucial element in assessing knee stability. Anterior cruciate ligament (ACL) injuries are often accompanied with medial collateral ligament (MCL) damage. It has been suggested that Deep MCL (dMCL) fibres are a primary restraint in rotational displacement. This research aims to quantify the difference in rotational laxity of patients with ACL and MCL injuries to deem if the Feagin-Thomas test can robustly capture metrics of AMRI. 2.

To investigate changes in quadriceps and hamstrings muscle groups during sustained isokinetic knee flexion and extension.

125 paediatric participants (45 males and 80 females, mean age 14.2 years) were divided into two groups: participants with a confirmed ACL tear (ACLi, n = 64), and puberty- and activity-level matched control participants with no prior history of knee injuries (CON, n = 61). Participants completed a series of 44 repetitions of isokinetic knee flexion and extension at 90 deg/ sec using a Biodex dynamometer (Biodex Medical Systems Inc, Shirley, New York). Surface EMG sensors (Delsys Incorporated, Natick, MA) simultaneously recorded the quadriceps and hamstring activations. Muscle function was assessed as the change in quadriceps activation and extension torque were calculated using the percent difference between the mean of the first five trials, and the mean of the last five trials.

ACLi participants had significantly higher percent change in quadriceps activation for both healthy and injured legs, in comparison to CON dominant leg. As such, the healthy leg of the ACLi participants is activating significantly more than their health matched controls, while also demonstrating reduced muscular endurance (less torque in later repetitions). Therefore, we conclude that the non-injured limb of the ACLi participant is not performing as a healthy limb. Since return to activity clearance following ACLi implies return to sport against age- and activity matched opponents, clearing young athletes based on the non-injured contralateral limb may put them at greater risk of reinjury.

The clinical diagnosis of a partial tear of the anterior cruciate ligament (ACL) is still subject to debate. Little is known about the contribution of each ACL bundle during the Lachman test. We investigated this using six fresh-frozen cadaveric lower limbs. Screws were placed in the femora and tibiae as fixed landmarks for digitisation of the bone positions. The femur was secured horizontally in a clamp. A metal hook was screwed to the tibial tubercle and used to apply a load of 150 N directed anteroposteriorly to the tibia to simulate the Lachman test. The knees then received constant axial compression and 3D knee kinematic data were collected by digitising the screw head positions in 30° flexion under each test condition. Measurements of tibial translation and rotation were made, first with the ACL intact, then after sequential cutting of the ACL bundles, and finally after complete division of the ACL. Two-way analysis of variance analysis was performed.

During the Lachman test, in all knees and in all test conditions, lateral tibial translation exceeded that on the medial side. With an intact ACL, both anterior and lateral tibial landmarks translated significantly more than those on the medial side (p < 0.001). With sequential division of the ACL bundles, selective cutting of the posterolateral bundle (PLB) did not increase translation of any landmark compared with when the ACL remained intact. Cutting the anteromedial bundle (AMB) resulted in an increased anterior translation of all landmarks. Compared to the intact ACL, when the ACL was fully transected a significant increase in anterior translation of all landmarks occurred (p < 0.001). However, anterior tibial translation was almost identical after AMB or complete ACL division.

We found that the AMB confers its most significant contribution to tibial translation during the Lachman test, whereas the PLB has a negligible effect on anterior translation. Section of the PLB had a greater effect on increasing the internal rotation of the tibia than the AMB. However, its contribution of a mean of 2.8° amplitude remains low. The clinical relevance of our investigation suggests that, based on anterior tibial translation only, one cannot distinguish between a full ACL and an isolated AMB tear. Isolated PLB tears cannot be detected solely by the Lachman test, as this bundle probably contributes more resistance to the pivot shift.

To investigate differences in the drop vertical jump height in female adolescents with an ACL injury and healthy controls and the contribution of each limb in this task. Forty female adolescents with an ACL injury (ACLi, 15.2 ± 1.4 yrs, 164.6 ± 6.0 cm, 63.1 ± 10.0 kg) and thirty-nine uninjured (CON, 13.2 ± 1.7 yrs, 161.7 ± 8.0 cm, 50.6 ± 11.0 kg) were included in this study. A 10-camera infrared motion analysis system (Vicon, Nexus, Oxford, UK) tracked pelvis, thigh, shank, and foot kinematics at 200Hz, while the participants performed 3 trials of double-legged drop vertical jumps (DVJ) on two force plates (Bertec Corp., Columbus, USA) sampled at 2000Hz.The maximum jump height normalised by dominant leg length was compared between groups using independent samples t-test. The maximum vertical ground reaction force (GRFz) and sagittal ankle, knee and hip velocities before take-off were compared between limbs in both groups, using paired samples t-test. The normalised jump height was 11% lower in the ACLi than in the CON (MD=0.04 cm, p=0.020). In the ACLi, the maximum GRFz (MD=46.17N) and the maximum velocities of ankle plantar flexion (MD=79.83°/s), knee extension (MD=85.80°/s), and hip extension (MD=36.08°/s) were greater in the non-injured limb, compared to the injured limb. No differences between limbs were found in the CON.

ACL injured female adolescents jump lower than the healthy controls and have greater contribution of their non-injured limb, compared to their injured limb, in the DVJ task. Clinicians should investigate differences in the contribution between limbs during double-legged drop vertical jump when assessing patients with an ACL injury, as this could help identify asymmetries, and potentially improve treatment, criteria used to clear athletes to sport, and re-injury prevention.

To investigate if the countermovement jump height differs between ACL injured and uninjured female adolescents and to explore kinematic differences between limbs. Additionally, the association between isometric knee extension strength and jump height was investigated.

Thirty-one ACL injured female adolescents (ACLi, 15.3 ± 1.4yrs, 163.9 ± 6.6cm, 63.0 ± 9.3kg) and thirty-eight uninjured (CON, 13.2±1.7yrs, 161.7 ± 8.1cm, 50.6 ± 11.1kg) participated in this study. All participants performed a countermovement jump task, with 3D kinematics collected using a motion analysis system (Vicon, Nexus, Oxford, UK) at 200Hz, and a maximum isometric knee extension task on an isokinetic dynamometer (Biodex Medical Systems, New York, USA) for three trials. The peak torque was extracted from the isometric trials. Independent samples t-test compared the maximum jump height normalised by the dominant leg length between groups, paired samples t-test compared the maximum hip and knee extension and ankle plantar flexion velocities before take-off between limbs in both groups, and a Pearson's correlation test investigated the association between the isometric knee extension strength and jump height.

The ACLi jumped 13% lower compared to the CON (p=0.022). In the ACLi, the maximum hip and knee extension and ankle plantar flexion velocities were greater in the non-injured limb, compared to the injured limb; however, no differences between limbs were found in the CON. The isometric knee extension strength of both limbs was positively correlated with jump height (limb 1: r=0.329; p=0.006, and limb 2: r=0.386; p=0.001; whereas limb 1 corresponds to the ACLi injured limb and CON non-dominant limb, and limb 2 to the ACLi non-injured limb and CON dominant limb).

ACL injured female adolescents present lower jump height than controls and greater contribution of their non-injured limb, compared to their injured limb, during a countermovement jump task. Also, current results indicate that jump height is positively related to isometric knee extension strength measure.

Aims

To test the hypothesis that reseeded anterior cruciate ligament (ACL)-derived cells have a better ability to survive and integrate into tendon extracellular matrix (ECM) and accelerate the ligamentization process, compared to adipose-derived mesenchymal stem cells (ADMSCs).

Anterior cruciate ligament (ACL) reconstruction is commonly performed and has been for many years. Despite this, the technical details related to ACL anatomy, such as tunnel placement, are still a topic for debate. In this paper, we introduce the flat ribbon concept of the anatomy of the ACL, and its relevance to clinical practice.

Cite this article: Bone Joint J 2016;98-B:1020–6.

INTRODUCION

Appropriate soft tissue balance is an important factor for postoperative function and long survival of total knee arthroplasty(TKA). Soft tissue balance is affected by ligament release, osteophyte removal, order of soft tissue release, cutting angle of tibial surface and rotational alignment of femoral components. The purpose of this study is to know the characteristics of soft tissue balance in ACL deficient osteoarthritis(OA) knee and warning points during procedures for TKA.

Purpose:- to examine changing demographics in ACL Injury

Methods:- the data from a cohort of 117 consecutive patients with ACL injury from a study performed in 1994 was compared with the data from a cohort of 103 consecutive patients with ACL injury collected in 1994/95.

Results:- In 1994, 12% of the patients were female, in 2004 25%.

In 1994, 62% of the injuries were sustained during soccer and rugby, in 2004 58%. In 1994, 9% of injuries were sustained during skiing, in 2004 28% – a 300% increase.

In 1994 the average age was 26.5, in 2004 33. When this increase was examined in detail the average age of the skiers was 41, the soccer players 31 and the rugby players 27.

Clearly there has been a change in the demographics of ACL injury which may have a significant impact in providing NHS services for the ACL injured patient in the UK.

Ligament fibroblasts must be mechanosensitive and possess sufficient adaptability to a novel mechanomilieu ensuring the permanent load capacity of the tissue. Once mechanoreceptors are activated, the fibroblasts react with a specific signal transmission (mechanotransduction), which ultimately leads to an adaption of their cytoskeletal organization and protein synthesis. However, the cellular response of anterior cruciate ligament (ACL) fibroblasts to cyclic mechanical stretching is still unclear. Hence, this study should allow a deeper understanding of the reaction profile of mechanically stretched ACL cells in two- (2D) and three-dimensional (3D) biomaterial-free and biomaterial cultures with respect to cell survival, size, orientation, migration and distribution. For the 2D approach consisting of monolayers with 6000 lapine (L) ACL cells per cm2 and for the 3D cultures using preformed LACL cell spheroids (2.5–4/cm2) with 25.000 cells per spheroid, silicone chambers were coated with geltrex and statically colonized with the LACL cells for 24 h before cyclically stretched for 48 h (14 percent uniaxial stretch). A second approach using 3D scaffold cultures was performed which were seeded dynamically for 24 h with LACL cells before cyclically stretched in a novel custom-made mechanostimulator. The scaffolds [polylactic acid (PLA) and polycaprolactone (PCL)] were functionalized with 10 percent gas fluorination and a collagen foam. Scaffolds (120 mm2) were precolonized dynamically with an LACL cell suspension (1 mio cells/mL) for 24 h before stretched for 72 h (4 percent uniaxial stretch). Cell vitality and numbers were monitored. The cytoskeleton orientation was shown by cytochemistry (F-actin) and evaluated (ImageJ). Cell proliferation, based on the DNA content was measured. Cell viability in stretched samples (2D, 3D and scaffold) remained above 90 percent. Stretching on the silicone chambers led to increased cell counts, length and significantly higher colonized areas than in unstretched controls. Higher numbers of LACL cells migrated out of the 3D spheroids under stretching conditions. In response to intermittent stretching, cells oriented in a 70 degrees' angle against the stretch direction in silicone chambers, whereas cell arrangement was more compact on the threads of the scaffolds than in unstretched cultures. In summary, stretching induced a rapid (48 h) cell and cytoskeletal alignment in 2D as well as in 3D cultures. The natural ACL is characterized by a strongly uniaxial cell and extracellular matrix organization which might be achieved in tissue engineered constructs by a suitable cyclic stretching protocol in future.

Cultured primary cells have a limited life span and undergo dedifferentiation. Tissue engineering (TE) approaches require high cell numbers, but availability of human derived cells is limited and animal cells show inter-species differences. The advantages of immortalized cells are delayed senescence and phenotypic stability. The present study was undertaken to validate key properties of immortalized human anterior cruciate ligament (ACL) fibroblasts in direct comparison with non-immortalized cells from the same donor to assess their applicability as TE model. Human ACL ligamentocytes (40 years old female donor) were either immortalized using repeated transient transfection with a simian virus SV40 plasmid or remained untreated. Both cell populations were analyzed for cell survival, DNA content, tendon marker, extracellular matrix (ECM) and cytoskeletal protein expression. Cell spheroids of both populations were seeded on scaffolds embroidered either from polylactic acid (PLA) threads alone or combined PLA- and PLA-co-caprolacton-(P(LA-CL)) threads, functionalized with fluor treatment and collagen foams. Cell survival on the scaffolds was monitored for up to 5 weeks. In contrast to non-immortalized ligamentocytes, immortalized cells reflected some chaotic and incomplete cell divisions, higher DNA content, numbers of dying cells and nucleoli, reduced vimentin and vinculin-associated focal adhesions. Analysed markers, other cytoskeletal and ECM components were similarly expressed. Compared to the non-immortalized ligamentocytes immortalized formed instable spheroids and died on the scaffolds after 21 d. Both cell populations reflected superior growth on the PLA-P(LA-CL) compared with PLA scaffolds. Immortalized cells share crucial properties with their non-immortalized counterparts, but TE is only possible for limited culturing periods.

Loss of proprioception following an anterior cruciate ligament (ACL) injury has been well documented. We evaluated proprioception in both the injured and the uninjured limb in 25 patients with ACL injury and in 25 healthy controls, as assessed by joint position sense (JPS), the threshold for the detection of passive movement (TDPM) and postural sway during single-limb stance on a force plate. There were significant proprioceptive deficits in both ACL-deficient and uninjured knees compared with control knees, as assessed by the angle reproduction test (on JPS) and postural sway on single limb stance. The degree of loss of proprioception in the ACL-deficient knee and the unaffected contralateral knee joint in the same patient was similar. The TDPM in the injured knee was significantly higher than that of controls at 30° and 70° of flexion. The TDPM of the contralateral knee joint was not significantly different from that in controls.

Based on these findings, the effect of proprioceptive training of the contralateral uninjured knee should be explored.

Cite this article: Bone Joint J 2013;95-B:188–91.

Introduction

There is a challenge to detect partial tear of the ACL, the number of bundle injured and the proportion of fibers torn. The MRI was shown efficient to individualize the two anteromedial (AM) and posterolateral (PL) bundles of the ACL. The purpose of this study was to assess the ability of the MRI to detect partial tears of the ACL on axial views to display the AM and PL bundles.

Purpose: Arthroscopic reconstruction of the anterior cruciate ligament (ACL) with a free patellar tendon graft is a classical method for the treatment of anterior knee laxity. The purpose of this study was to analyse clinical and radiological outcome in 218 cases at five years and to search for prognostic factors.

Material and methods: Between 1993 and 1994, arthroscopic repair of the ACL was performed in 218 knees with two independent tunnels using a free patellar graft. This prospective study included 177 knees reviewed at a mean 67±7 months follow-up using the IKDC criteria and instrumental manual KT-1000 laxity measurements. The series included 67.4% men and 32.6% women, mean age 26.7 years (14–59). Delay from the accident to surgery was a mean 22.3 months (1–228 months). Two medial, 15 lateral and five medial and lateral meniscectomies had been performed before the operation studied. The position of the tunnels was studied using the Aglietti method. Differences were considered significant at p < 0.05.

Results: Sports activities could be resumed in 87% of the cases at the same level for 62% with a mean delay of 12 months. Subjectively, the patients were satisfied or very satisfied in 86% of the cases. Symptom score was A in 50%, B in 38%, C in 8.3% and D in 3.7%. Maximal manual residual differential measured with KT-100 was 0.75 ± 2.3 mm with an abolished click in 82% of the cases and a glide in 12%. Sceondary medial meniscectomy was performed in 19 cases. At last follow-up the meniscal material was intact in 127 cases (60%). Overall IKDC score for the 177 cases reviewed was: A 57%, B 24%, C 9%, D 9%. Radiographically, the knee was normal in 66.6% of the cases, remodelled in 29.6%, and exhibited joint space narrowing less than 50% in 13.4% and overall osteoarthritis in 0.6%. The Aglietti lateral score as 25.5±7% for the tibia and 66.3±7.2% for the femur. During follow-up, there were 13 cases of recurrent tears related to repeated sports trauma or poor femoral position. During this same period, there were 20 tears of the contralateral ACL. Functional outcome was correlated with the presence of a medial meniscus, the length of delay from accident to surgery, and the presence of radiological evidence of residual laxity.

Conclusion: This study demonstrated that chronic anterior laxity of the knee, treated with a free patellar tendon graft implanted arthroscopically provides good restoration of the knee in 82% of the cases with little residual laxity. Joint space narrowing was found in 1% of the cases and was strongly correlated with the status of the medial meniscus that should be preserved. The number of recurrent tears was equivalent to the number of contralateral tears observed during the same period.

We studied arthroscopically the meniscal pathology in 100 patients with functional instability of the knee from isolated rupture of the anterior cruciate ligament at an average time of three years after injury. Meniscal tears were observed in 86 patients and multiple lesions of both menisci were common. An incomplete longitudinal cleavage, visible on both surfaces of the posterior horn, was seen in more than half the knees and seemed to indicate progressive meniscal deterioration. Clinical examination was unreliable and we suggest that arthroscopic assessment is necessary for accurate diagnosis and staging.