Purpose: We studied early recovery of knee muscles after harvesting the hamstrings for arthroscopic reconstruction of the anterior cruciate ligament (ACL) using an isokinetic testing device (Biodex®).

Material: This prospective consecutive series included 22 athletes (twelve amateur athletes and ten competition level athletes) who presented a full thickness tear of the ACL without associated lesions. Intra-articular and extra-articular ligamentoplasty using the gracilis and semi-tendinous was performed arthroscopically by the same surgeon. The same rehabilitation program was prescribed for all patients.

Method: The flexor and extensor system of both knees was assessed for each patient using the Biodex® device operating in concentric isokinetic mode. Tests were performed at two speeds 90 and 180°/s and at three times: preoperatively, and four and seven months postoperatively. The peak couple and mean power during a series of six flexion-extension movements were retained for this analysis.

Mean values remained unchanged for the three test times for the healthy knees. We therefore chose the preoperative values obtained for the healthy knee as the paired reference value for each patient. The values obtained for the operated knees were compared with these control values using two-way analysis of variance for paired variables.

Results: At four months postop, flexor and extensor muscles exhibited significant (p < 0.05) and equivalent diminution. However, 25% of the patients had already achieved 80% recovery, sufficient for renewed sports activities. At seven months postop, the extensors had totally recovered and the flexors remained significantly diminished (related to hamstring harvesting); 65% of the patients had reached 80% recovery, but 90% of the competition level athletes had recovered more than 80%. The statistical analysis demonstrated a positive correlation between muscle recovery at seven months and preoperative muscle level: the patients with higher preop levels having the higher postop levels.

Discussion: These results suggest the following: preoperative rehabilitation exercises (to start with a higher preop level), more work on the flexors (limiting factor), new recovery objectives (80% at four months, 100% at seven months). Currently, we authorise renewed sports activities on the basis of muscle recovery as assessed by isokinetic tests which are performed at four months for competition level athletes and seven months for amateur athletes.

The purpose of this study was to establish the return of function to an unstable knee following stabilization of the anterior deficient cruciate ligament.

15 consecutive cases of chronic anterior cruciate ligament rupture with instability were studied prior to stabilization by patellar bone-tendon-bone autograph, and again at three months post-operation and at one year post stabilization. There were two women and thirteen men in this study. All operations were performed by one of the authors (John Fleetcroft).

Peak torque, total work and average power were studied at 90°/sec and 120°/sec.

Three patients had unusually low contralateral flexor power at 120°/sec pre-operatively, these measurements were excluded from the 120°/sec results.

Our findings show an initial decrease of strength three months postoperatively; on the extensors more than on the flexors.The flexors recovered faster than the extensors.

Extensor function showed a deficit of 13% at both speeds pre-operatively. Three months following surgery this has increased to an average of 33.7% at 90°/sec and 22.8% at 120°/sec. At one year the deficit had decreased dramatically to 2.2% at 90°/sec and 0.14% at 120°/sec.

Flexor function at 90°/sec showed a deficit of 6.4% pre-operatively, 15% at three months and 1.7% at one year. At 120°/sec, pre-operative flexor deficit was 3.1%, +0.16% at three months and +4.4% at one year.

These tests demonstrate the return of function to unstable cruciate deficient knees, an important observation for those wishing to return to sport.

Defects of the anterior cruciate ligament have been treated surgically with intra- and extra-articular procedures since several decades, either as direct repair or using autografts of the hamstring or patella tendon in open or arthroscopic operations. On the other hand there are studies about successful results of conservative treatment available, too.

Casteleyn et al (1) reported about the follow up of at least five years (mean 8.5 years) of 109 patients which excluded professional and high level athletes. The evaluation of their symptoms with an IKDC score showed 23% in grade A and 50% in grade B out of four possible grades with an incidence of 5.4% secondary ACL surgery.

In an editorial article about anterior cruciate ligament reconstruction Dandy et al (2) reviewed the results of several studies about intra- and extra-articular procedures, which examined pivot-shift and restriction of activity.

Johnson et al (3) found in 87 patients with bone-patellar tendon-bone reconstruction and a mean follow up of 7.9 years 26% positive pivot shift and 25% of the patients had unrestricted activity. Sandberg et al (4) reviewed a similar group of 89 patients after seven years with 11% positive pivot-shift and 24% unrestricted activity.

In comparison to these results extra-articular procedures show a higher incidence of pivot-shift and lower levels of unrestricted activity; Odensten et al (5) report 59% clinical instability four years after Ellison procedure and 39% positive pivot-shift with only 44% unrestricted sport activity at six years after MacIntosh operation.

Over the last years extra-articular procedures were abandoned in favor for intra-articular operations.

Today bone-patellar tendon-bone grafts are widely used for these repairs.

Clancy et al (6) and Butler et al (7) have shown in animal studies a decrease of strength and mechanical properties postoperatively during an initial period of revascularisation and remodelling.

Grontvedt et al (8) look at these properties in their study about the effects of the use of a ligament augmentation device by isokinetic testing on a Biodex™ system. They measured peak torque and total work and found a deficit in the quadriceps strength in comparison to the uninjured knee of 25% at six months, 15% at one year and 10% at two years. The hamstrings improved to equal levels already after six months.

The aim of our study was to assess the mechanical properties torque, total work and average power of the hamstrings and quadriceps in order to evaluate the progress of the patients postoperatively including the above mentioned initial decrease in strength. The testing was performed with a Cybex™ machine preoperatively as well as three and twelve months postoperatively.

We tested patients who had a bone-tendon-bone anterior cruciate ligament reconstruction performed between March 1998 and January 1999. It was only a limited time window available for this study and therefore we could conduct the tests only on 15 consecutive patients. We tested two women and 13 men. Their mean age was 38.4 years (21 to 50). Injuries of the anterior cruciate ligament were confirmed by both clinical and arthroscopic examination. Indications were clinical instability, pain and / or swelling during sport or other physical activity and / or other relevant history (knee gives way). All the operations were arthroscopic assisted procedures. They were performed by only one surgeon (J P Fleetcroft). The graft was obtained from the middle third of the patellar tendon and fixed with Acufex™ interference screws.

The isokinetic tests were performed preoperatively, then three months postoperatively and one year postoperatively. The following parameter were obtained for both flexors and extensors at two speeds (90°/sec and 120°/sec): peak torque, total work and average power. At the preoperative test both injured and contralateral knees were tested, at three months and one year only the involved knee. The figures of the uninvolved knee were used as references to calculate mean deficit / progress percentages for the operated side during the course of the study.

Three patients (number 2, 6 and 14) showed at the preoperative measurements unusually low strength at the 120°/sec tests of the flexors of their uninjured knees. The figures of the uninjured knees had to be used as references in the evaluation of progress / deficits of the injured and operated knees. Therefore all calculated results of those three patients became unrealistically high and did not represent true values. As the mechanical properties of the uninjured knees were otherwise of no interest for this study we decided to exclude these patients from the 120°/sec flexor tests.

Preoperatively the extensors showed a deficit of strength (average of peak torque, total work and average power) at both speeds of 13%. This deficit worsened at three months to 33.7% at 90°/sec and 22.8% at 120°/sec. After one year strength had improved nearly to the preoperative level with a deficit of 2.2% at 90°/sec and 0.14% at 120°/sec.

Flexors: The flexors showed smaller deficits than the extensors. Preoperative figures show deficits of 6.4% at 90°/sec and 3.1% at 120°/sec. At three months the deficit at 90°/sec worsened to 15% but at 120°/sec it improved to the level of the unoperated leg (+0.16%). After one year the strength was at both speeds better than at the unoperated leg (+1.7% at 90°/sec and +4.4% at 120°/sec). The detailed deficit / progress figures for all the measured properties of our study are shown in the tables below.

Table 1 Mean deficit / progress [%]; PT = peak torque, TW = total work, Pow = average power

Table 2 Deficit / progress [%] of strength (average of peak torque, total work, average power)

The strength deficits which resulted from the anterior cruciate ligament defect improved significantly. In both muscle groups and at both test speeds the average strength of the operated knee was after 12 months at about the same level as the uninjured leg. As the flexors are to a lesser extent effected by the operation than the extensors they recovered faster; similar to the findings of Grontvedt et al (8).

The flexors showed at both speeds slightly better results than the uninvolved knee and only the extensors had still a small deficit of 0.147% (120°/sec) and 2.21% (90°/sec) in comparison to the uninjured knee after 12 months.

Further could be shown that apart from flexors at 120°/sec an initial decrease in strength occurred at the three months measurements (as also reported in [6] and [7]).

Grontvedt et al ( 8) still report about 25% weakness of the extensors after six months. In our study already at three months all groups apart from the extensors at 90°/sec (−33.7%) have results better than this (−22.8%, −15.04%, +0.17%). Grontvedt’s study shows 15% deficit after one year and 10% after two years. In comparison to this we could demonstrate nearly normal results (−2.2%, −0.14%, +1.7%, +4.4%) after 12 months. As the test speed influences the results especially during the initial period of decreased strength and Grontvedts study tested at 60 and 240°/sec this might be one reason for the different results.

The overall figures for the patients’ progress are satisfactory. They demonstrate the return of function to an initially unstable cruciate deficient knee.

We would suggest further research into the details of the initial weakness during the first postoperative months as this might have implications for physiotherapy and rehabilitation as well as surgical technique and devices.

In 11 paediatric patients (seven girls and four boys, from 12 to 15 years old) with unilateral obligatory patellar dislocation and ligamentous laxity vastus medialis advancement, lateral release, partial patellar ligament transposition and Galeazzi semitendinosus tenodesis was undertaken to stabilise the patella. The diagnostic criterion for ligamentous laxity was based on the Beighton scale. Outcomes were evaluated radiologically and functionally by measurement of the range of knee movement and isokinetic testing. The evaluation also included the Lysholm knee scale. Follow-up studies took place at a mean of 8.1 years (5 to 15) post-operatively.

Normal patellar tracking without any recurrence of dislocation was obtained in ten out of 11 patients. Pain related to vigorous activity was reported by nine patients. Compared with the opposite normal side, the isokinetic tests revealed a statistically significant decrease in the maximal torque values for the affected quadriceps muscle (p = 0.003 and p = 0.004), but no difference between the knee flexors (for angular velocities of 60°/s and 180°/s) (p = 0.858 and p = 0.79).

The applied surgical technique generally prevents the recurrence of the disorder in children with habitual patellar dislocation and ligamentous laxity. Quadriceps muscle weakness can be expected to occur post-operatively,

Cite this article: Bone Joint J 2015;96-B:129–33.

Introduction. Patients with neglected rupture of the Achilles tendon typically present with weakness and reduced function rather than pain. Shortening of the musculotendinous unit and atrophy of the muscle belly in chronic rupture potentially leads to poorer recovery following tendon transfer. Few papers have looked at the outcomes of FHL reconstruction specifically in neglected TA rupture. Of those that have none report functional outcomes following a transtendinous repair. Methods. Twenty patients with irreparable unilateral tendoachilles ruptures treated with transtendinous FHL reconstruction between 2003 and 2011 were reviewed. Achilles Tendon Rupture Score (ATRS), AOFAS hindfoot score, Tegner score and SF12 were recorded. Standard isokinetic assessment of ankle plantarflexion was performed with a Cybex dynamometer. Great toe flexion strength was tested clinically. Results. The mean age at surgery was 53 years (22–83 years). Mean time from rupture to surgery was 7 months (1–36 months). Follow up ranged from 29–120 months (mean 73 months). Sixteen patients were completely satisfied and four moderately satisfied. The mean ATRS was 80 (range 25–100) and AOFAS 94 (range 82–100). Postoperative Tegner score showed a reduction by one level from pre-injury (mean 5.1 pre injury to 4.3 post surgery). No cases of re-rupture were encountered. Six patients had wound issues. The mean maximal strength of ankle plantar flexion on the operated leg 95Nm (41–163) was less than the non-operated leg 123 Nm (50–190Nm). The average difference in strength was 24%. The operated hallux had only 40% of strength in flexion of the contralateral toe. There were no floating toes. Conclusion. Transtendinous FHL transfer for late presenting Achilles tendon ruptures provides reliable long term function and reasonable ankle plantar flexion strength. Long FHL harvest has little morbidity and lack of a distal tenodesis did not result in any notable functional loss or alignment issues to the great toe

Purpose of the study: A systematic isokinetic assessment of both shoulders was performed in 103 men with shoulder instability subsequent to several anterior or antero-inferior trauma-induced dislocations. The assessment was part of the preoperative workup which included a clinical examination and an imaging protocol (standard x-rays + tomographies as needed). The purpose of the present study was to evaluate the force of the rotator muscles of the injured shoulder and to compare the findings with those obtained for the healthy shoulder. The objective was to determine the impact of instability on muscle balance in the injured shoulder. Material and methods: This study concerned 103 men, mean age 24.8 years. The injured shoulder was dominant for 65 and non-dominant for 38. Time from the first episode of instability and the test was at least 2 months. One operator performed all tests using a unique dynamometer: Cybex Norm operating in concentric mode at 60 to 180/s. Results: Overall, the results for 103 subjects at 60/s did not reveal any difference between the injured and the healthy side for internal rotators. There was a 2% deficit for the external rotators. At 180/s, the deficit was 5% for the internal rotators and 3% for the external rotators. For the injured dominant shoulders (n=65 subjects): at 60/s, there was no deficit; at 180/s, the deficit was 2% for internal rotators and 1% for internal rotators. For the injured non-dominant shoulders (n=38 subjects: the deficit was less than 10% compared with the healthy side for both 60/s and 180/s. Conclusion: No significant deficit in internal or external rotation power was observed in the injured shoulder. Inclusion of an isokinetic test as a systematic part of the preoperative work-up for post-trauma instability in male subjects would not be warranted. The present findings can be used as control data for research involving non-trauma-induced uni- or multidirectional shoulder instability

Purpose of the study: The objective was to compare the results of ligamentoplasties with two commonly used grafts, hamstring and patellar tendon. This was a prospective randomized study. Material and methods: Between January 2001 and June 2004, 98 patients with an acute or chronic anterior cruciate ligament (ACL) tear with joint instability were included in this randomized study for arthroscopic repair. Patients were randomized to the patellar or hamstring arm. Clinical assessment was based on laxity, IKDC score, Lyscholm score, pain visual analog scale (VAS), midthigh thickness and isokinetic assessment at three months. Measurements were recorded preoperatively and at 1, 3, 6 weeks and 3, 6, and 12 months. Results: The two groups were comparable regarding gender, morphotype, associated lesions, and activity level. There was no difference in operative time or in recovery of complete extension. Anterior laxity was the same in the two groups. The isokinetic deficit appeared to be greater in the bone-tendon-bone group at three months. The IKDC and Lysholm scores were not significantly different at six and twelve months. Harvesting site morbidity was more pronounced in the bone-tendon-bone group. Conclusion: The two techniques provide good results. The bone-tendon-bone technique appears to cause greater harvesting site morbidity. While the isokinetic results appear to be better in the hamstring group, the measurements of laxity and recovery of stability did not show any difference

To review the medium term results of acute repair of rupture of the biceps brachii insertion using a single incision bone anchor anatomical repair. Three patients with acute biceps brachii tendon insertion ruptures and treated surgically using a single incision bone anchor anatomical repair underwent dynamometer strength assessment of both arms using a KinCom isokinetic dynamometer. This was performed shortly after completion of rehabilitation (7–12 months after surgery) and again at 3.3 years after surgery. All patients were male (mean age 40.3 years, range 34 to 53). Surgery was performed less than 7 days post injury using the same technique. Isokinetic assessment was performed at a mean of 8.7 months post surgery (range 7 to 12 months) and again at assessment (maintained at medium term assessment). All patients had returned to their full premorbid occupation and level of sporting activity. Dynamometer results of a repaired dominant limb equated to approximately the strength of a normal non dominant limb, a repaired non dominant side equated to two thirds the strength of a normal dominant limb at early assessment. This relationship was maintained at the medium term assessment, however there was a substantial increase in strength in both affected and unaffected arms. The one incision approach, using bone anchors, is recommended as the method of choice providing an optimal surgical repair with a reduction in the risk factors theoretically associated with anatomical surgical repair. Our short-term results are comparable with other quantitative results published (for both bone anchor and non-bone anchor procedure). The medium term results how a measurable increase in strength of the repaired limb although the strength relative to the uninjured side remains the same as at early assessment

Background:. The aim of this study was to investigate the outcome after ACL reconstruction between a group of patients receiving a standardized supervised physiotherapy guided rehabilitation program and a group of patients who followed an un-supervised, home-based rehabilitation program. Methods:. 40 patients with isolated anterior cruciate ligament injuries were allocated to either a supervised physiotherapy intervention group or home-based exercise group. Patients were investigated by an independent examiner pre-operative, 3, 6, 9 and 12 months post-surgery using the following outcome measures: Lysholm Score and Tegner Activity Scale, functional hopping tests, isometric and isokinetic strength assessments. Results:. Both groups improved significantly (p=0.01–0.04) following 12 months after surgery. The median Lysholm score increased from 57 (34–90) to 94 (90–100) in the supervised group and 60 (41–87) to 97 (95–100) in the unsupervised group. The median Tegner Activity Scale increased from 3 (2–8) to 6 (3–8) in the supervised group and 4 (2–8) to 5 (3–10) in the unsupervised group. The combined mean symmetry indices for the hopping tests improved from 77.3+ 18.7 to 86.8+11.1 (supervised) and from 78.1+30.5 to 88.3+10.9 (unsupervised). Isometric and isokinetic strength symmetry indices for knee extension improved from 68.9+23.5 to 82.8+11.9 resp. 63.7+22.8 to 82.7+15.1 in the supervised group and from 73.6+20.5 to 76.5+17.9 resp. 69.5+24.3 to 76.9+16.9 in the unsupervised group. Eccentric strength symmetry indices for knee extension improved from 67.9+27.7 to 87.8+6.8 in the supervised group and from 71.3+17.8 to 82.6+15.6 in the unsupervised group. Conclusion:. This study could not demonstrate a benefit in a rehabilitation program supervised by a physiotherapist in our population compared to an unsupervised cohort

Aims

Flexor hallucis longus (FHL) tendon transfer is a well-recognized technique in the treatment of the neglected tendo Achillis (TA) rupture.