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KNEEKNEE OBJECTIVE STABILITY OBJECTIVE STABILITY AND ISOKINETIC THIGH AND ISOKINETIC THIGH

MUSCLE STRENGTHMUSCLE STRENGTH AFTER AFTER ANTERIOR CRUCIATE ANTERIOR CRUCIATE

LIGAMENTLIGAMENT (ACL) (ACL) RECONSTRUCTIONRECONSTRUCTION::

A Randomized Six-Month Follow-Up A Randomized Six-Month Follow-Up StudyStudy

M. SajovicM. SajovicDepartment of Orthopedics and Department of Orthopedics and Sports Trauma Surgery, CeljeSports Trauma Surgery, Celje

July 28 - 30, San Francisco 2OMICS - 3rd Int. Conference &

Exhibition on Orthopedics

General Teaching Hospital Celje, General Teaching Hospital Celje, SloveniaSlovenia



Anterior cruciate ligament (ACL) Anterior cruciate ligament (ACL) rupture is the most common rupture is the most common serious injury of the knee. In the serious injury of the knee. In the general population, an estimated 1 general population, an estimated 1 in 3000 individuals sustains an ACL in 3000 individuals sustains an ACL injury per year in the United States, injury per year in the United States, corresponding to an overall injury corresponding to an overall injury rate of approximately 100,000 rate of approximately 100,000 injuries annually.injuries annually.



Several risk factors for tearing Several risk factors for tearing the ACL have been evaluated in the ACL have been evaluated in literature. The highest incidence literature. The highest incidence is in individuals 15 to 25 years is in individuals 15 to 25 years old who participate in pivoting old who participate in pivoting sports. 70 % of ACL injuries sports. 70 % of ACL injuries occur in noncontact situations. occur in noncontact situations. The risk factors for non-contact The risk factors for non-contact ACL injuries fall into four distinct ACL injuries fall into four distinct categories: environmental, categories: environmental, anatomic, hormonal, and anatomic, hormonal, and

biomechanical.biomechanical.



The goals of ACL The goals of ACL reconstructions are to reconstructions are to decrease symptoms, decrease symptoms, improve function, and improve function, and return patients to their return patients to their

preinjury level of activity.preinjury level of activity.



The surgeon has to choose :The surgeon has to choose :

graft

fixation



The most frequently used grafts for The most frequently used grafts for intra-articular anterior cruciate intra-articular anterior cruciate ligament (ACL) reconstruction are the ligament (ACL) reconstruction are the autologous patellar tendon (PT) or autologous patellar tendon (PT) or doubled semitendinosus and gracilis doubled semitendinosus and gracilis tendons (STG) autografts. There are tendons (STG) autografts. There are still controversies about graft selection still controversies about graft selection

for primary ACL reconstructionfor primary ACL reconstruction. .



ACL reconstruction ACL reconstruction

Semitendinosus and gracilis Semitendinosus and gracilis tendon autografttendon autograft

(STG)(STG)

versusversus

Patellar tendon autograft (PT)Patellar tendon autograft (PT)



Operative data Operative data single technique, different single technique, different transplanttransplant

PT PT transplanttransplant

STG STG transplant transplant



RESEARCHRESEARCH

ISOKINETIC EVALUATION AND ISOKINETIC EVALUATION AND OBJECTIVE STABILITY OF THE KNEE OBJECTIVE STABILITY OF THE KNEE

AFTER ANTERIOR CRUCIATE LIGAMENT AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTIONRECONSTRUCTION

The purpose of this study was to analyze The purpose of this study was to analyze objectiveobjective stability and isokinetic strength stability and isokinetic strength of knee extensor and flexor muscles at 6 of knee extensor and flexor muscles at 6 months after ACL reconstruction using months after ACL reconstruction using two different autografts (PT versus STG) two different autografts (PT versus STG) with identical fixation (interference with identical fixation (interference screws) in consecutive patients screws) in consecutive patients undergoing the same accelerated undergoing the same accelerated rehabilitation program. rehabilitation program.



From January 2010 to February From January 2010 to February 2011 57 patients were randomly 2011 57 patients were randomly assigned:assigned:

Group I (Group I ( 29 29 patients patients ))

STGSTG autograft autograft

Group II (Group II ( 28 28 patients patients ))

PPTT autograft autograft



INCLUSION CRITERIAINCLUSION CRITERIA

Time from ACL injury to surgery less than Time from ACL injury to surgery less than 12 months12 months

No previous ligamentous injury and surgery No previous ligamentous injury and surgery of either kneeof either knee

No previous meniscal pathology treated No previous meniscal pathology treated with resection or repairwith resection or repair

No chondral lesions diagnosed by No chondral lesions diagnosed by arthroscopy or MR investigationarthroscopy or MR investigation



SURGICAL TECHNIQUE AND SURGICAL TECHNIQUE AND REHABILITATIONREHABILITATION

Apart from the graft harvesting the surgical Apart from the graft harvesting the surgical technique was identicaltechnique was identical

All procedures were performed by the first author All procedures were performed by the first author (M.S.)(M.S.)

Meniscal surgery were performed in 51% of Meniscal surgery were performed in 51% of patients in STG group and in 62% of patients in PT patients in STG group and in 62% of patients in PT group (group (P P = .408).= .408).

All the patients were rehabilitated according to the All the patients were rehabilitated according to the same accelerated protocol with immediate full same accelerated protocol with immediate full weight-bearing and full range of motion without use weight-bearing and full range of motion without use of rehabilitation brace. of rehabilitation brace.

The rehabilitation program has been completed in The rehabilitation program has been completed in the Unitur Spa and Rehabilitation Center the Unitur Spa and Rehabilitation Center Zreče Zreče





METHODSMETHODS

All postoperative measurements were All postoperative measurements were performed in the Unitur Spa and performed in the Unitur Spa and Rehabilitation Center Rehabilitation Center ZrečeZreče by the same by the same senior physical therapistsenior physical therapist

Isokinetic strength and endurance of the Isokinetic strength and endurance of the extensor and flexor muscle groups was extensor and flexor muscle groups was measured with the isokinetic measured with the isokinetic dynamometer En – Knee (Enraf – dynamometer En – Knee (Enraf – Nonius).Nonius).

Objective AP knee laxity measurements Objective AP knee laxity measurements were performed by using the KT-1000 were performed by using the KT-1000 arthrometer (MEDmetric, San Diego, CA)arthrometer (MEDmetric, San Diego, CA)



ISOKINETIC TESTING OF THE ISOKINETIC TESTING OF THE KNEEKNEE

Isokinetic Isokinetic measurements of measurements of extensor and flexor extensor and flexor knee muscles is knee muscles is performed in an performed in an open kinetic chainopen kinetic chain

Testing is always Testing is always performed on both performed on both sides (first healthy sides (first healthy then the injured then the injured extremity)extremity)

Measurements are Measurements are safe and have a high safe and have a high repeatabilityrepeatability



KT-KT-22000 arthrometer 000 arthrometer (MEDmetric, San Diego, (MEDmetric, San Diego,

CA)CA)



METHODSMETHODSISOKINETIC AND KNEE LAXITY ISOKINETIC AND KNEE LAXITY

EVALUATIONSEVALUATIONS

EENDURANCE TESTNDURANCE TEST PPOWER TESTOWER TEST KT-1000 AP LAXITYKT-1000 AP LAXITY

3 months 3 months

postoperativelypostoperatively6 months 6 months

postoperativelypostoperatively6 months 6 months

postoperativelypostoperatively

angular velocity of angular velocity of

180°/s180°/sangular velocity of 60°/sangular velocity of 60°/s KT- 1000 arthrometer KT- 1000 arthrometer

ROM 20°- 90° ROM 20°- 90° ROM 10°- 90° ROM 10°- 90° •134 N134 N•manual maximum forcemanual maximum force

25 repetitions25 repetitions 6 repetitions6 repetitions average of three average of three

measurementsmeasurements



ISOKINETIC RESULTSISOKINETIC RESULTSGroup STG Group PTGroup PT PP

(STG/PT)(STG/PT)Average deficit (%)

SD Average Average

deficit deficit

(%)(%)

SDSD

EnduranEnduran

ce testce test

18018000/s/s

Extensor Extensor

musclesmuscles18.8 14.6 21.21.55 1177..66 ..527527

Flexor Flexor

musclesmuscles5.2 13.2 3.3.99 88..66 ..666677

Power Power

testtest

606000/s/s

Extensor Extensor

musclesmuscles14.0 9.7 2266..77 1100.3.3 .00015.00015

Flexor Flexor

musclesmuscles3.9 16.8 1.1.44 1100..11 .49.4977



KT-1000 measurements at 6 months KT-1000 measurements at 6 months

postoperativelypostoperatively

Group STGGroup STG Group PTGroup PT PP

(STG/PT)(STG/PT)

Average Average

(mm)(mm)SDSD Average Average

(mm)(mm)SDSD

134 N134 N 1.1.66 1.5 1.5 11..44 1.6 1.6 . 509. 509

Manual Manual

maximummaximum

1.1.99 1.1.66 11..77 1.1.77 . . 555588



DISCUSSIONDISCUSSION

Average deficit in flexor muscle strength Average deficit in flexor muscle strength between the involved and the uninvolved leg between the involved and the uninvolved leg was less than 6 % in both groups. This is a very was less than 6 % in both groups. This is a very good result, particularly in the STG group, good result, particularly in the STG group, because previous research has found that the because previous research has found that the hamstring tendons harvest significantly hamstring tendons harvest significantly reduces the flexor strength for approximately 1 reduces the flexor strength for approximately 1 to 2 years after surgeryto 2 years after surgery

Excellent results resulted from good surgery Excellent results resulted from good surgery technique of an experienced surgeon as well as technique of an experienced surgeon as well as rehabilitation program focusing on due and rehabilitation program focusing on due and proper stretching and strengthening of flexor proper stretching and strengthening of flexor musclesmuscles



CONCLUSIONCONCLUSION

At 6 months after surgery, we found significantly At 6 months after surgery, we found significantly lower isokinetic quadriceps peak torque in the PT lower isokinetic quadriceps peak torque in the PT group compared with the STG group at angular group compared with the STG group at angular velocity of 60°/svelocity of 60°/s

WWe did not find significant difference in flexor e did not find significant difference in flexor muscle power comparing both groupsmuscle power comparing both groups

We did not find significant differences in knee We did not find significant differences in knee laxity measurements between the two study laxity measurements between the two study groupsgroups

No significant correlation was found between the No significant correlation was found between the knee objective stability and the isokinetic thigh knee objective stability and the isokinetic thigh muscle strength.muscle strength.



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