Risk of Anterior Cruciate Ligament Rupture With Generalized Joint Laxity Following Trauma

Original Article

RISK OF ANTERIOR CRUCIATE LIGAMENT RUPTURE WITH GENERALIZEDJOINT LAXITY FOLLOWING TRAUMA

Raju Vaishya* and Rohit Hasija***Senior Consultant, **Registrar, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo

Hospitals, Sarita Vihar, New Delhi 110 076, India.

Correspondence to: Dr Raju Vaishya, *Senior Consultant, Department of Orthopaedics & Joint ReplacementSurgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.

Anterior Cruciate Ligament (ACL) tears are very common sport injuries. Increased joint laxity has been foundto be one of the most important contributory factors in causation of ACL tears.

Key words: Anterior cruciate ligament, Joint laxity, ACL injury.

INTRODUCTION

THE function of the anterior cruciate ligament (ACL) is toprovide stability to the knee and minimize stress across theknee joint. It restrains excessive forward movement of thetibia in relation to the femur. It also limits rotationalmovements of the knee. A hard twist or excessive pressureon the ACL can tear or rupture the ligament, resulting in highlevels of short-term disability and extensive rehabilitation.The cost of treatment & rehabilitation of an ACL injuredperson is also phenomenal.

Chronic ACL insufficiency can cause damage to the arti-cular cartilage & hence these patients are prone to developingearly degenerative arthritis, menisci tears [1] and stretchingof secondary stabilizers like collateral ligaments etc.

Many intrinsic & extrinsic causes have been associatedas risk factors for ACL tears [2] like excessive athleticdemands placed on unconditioned knee, knee flexion anglewhilst landing, limb alignment, notch size, hormonalfluctuations, muscle strength & generalized joint laxity.

Recently, joint laxity have been implicated as animportant contributory factor in the causation of ACLinjuries, especially in females [3], those with generalizedjoint laxity and hyperextension of the knee [4].

MATERIALS AND METHODS

We performed 110 ACL reconstructions between 2000and 2006 in our hospital, using Patella Bone Tendon Bone(PBTB) autografts. There were 65 men and 45 women,whose ages ranged between 20 and 36 years (mean 24.6years). They presented to us for ACL reconstruction after amean duration of 11 months (range: 3 to 18 months) after theprimary injury.

A detailed clinical history was obtained, with especialemphasis on the mode of injury, prior to clinicalexamination. All patients presented to us with history oftrauma. The mode of injury was mostly due to sports(66.6%), followed by injuries sustained in a Road TrafficAccident (21.8%), domestic falls (11.6%) (Fig.1). Thediagnosis was confirmed by MRI and all ACL tearsconfirmed by arthroscopy prior to reconstruction. We hadprospectively assessed the degree of joint laxity in all thepatients with a symptomatic ACL injury before theyunderwent reconstruction.

All had their laxity scored by Beighton’s criteria. In thismethod, the following ranges of motion are assessed: (i)passive hyperextensionof fifth metacarpophalangeal joint,1 point for each joint beyond 90º; (ii) thumb apposition tothe volar aspect of the forearm, 1 point for each thumbtouching the arm, active hyperextension of the elbow, 1point for each joint beyond 10º; (iii) active hyperextensionof the knee, 1 point for each joint beyond 10º; (iv) trunk

13 Apollo Medicine, Vol. 6, No. 1, March 2009

Fig.1 Mechanisms of injury.

Sports 66%

Road traffic accidentsDomestic falls 12%

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Original Article

flexion with knees straight, 1 point when hand palm flat onfloor. The maximum score is 9 points. It wasaccepted that anindividual is considered “hypermobile” when at least 4maneuvers exceed the predetermined range.

Our control group comprised 55 individuals matchedfor age and gender with no known ACL-related problems orthose attending our OPD but who had no knee symptoms.The laxity scores were determined in these individuals.

RESULTS

In our prospective cohort study it was found that morethan 92.7 % (102 out of 110) of our patients, with ACLinjuries, have significant joint laxity i.e., score of more than4/9, compared to only 16.4% in the control group. Therewas no significant sex predominance found in this study.This difference was statistically significant (p<0.05).Hyper-extension of the affected knee was present in allpatients with significant joint laxity. A non-contactmechanism of injury was more common in patients of bothgroups with ACL injury (Table 1).

DISCUSSION

ACL injury is common amongst young athleticindividuals. Some are more predisposed to have itcompared to others. Various instrinsic & extrinsic factorshave been suggested to contribute to these injuries.Amongst all the extrinsic factors, joint laxity is now beingrecognized as one of the most important risk factors in thecausation of ACL injuries. Ramesh [4] in his study didhighlight hyperextension of knee and physiological jointlaxity as contributing factor to ACL injuries. However novalidated method for the screening and identification ofathletes at greater risk of ACL injury based on joint laxityhas previously been available. We used a simple clinicalmethod of Beighton [5] to check & quantifiy the joint laxity.Beighton’s method is quick to perform and has been wellestablished in the literature. In our study, we have been ableto provide statistically significant evidence to support theassociation between generalized joint laxity and ACLrupture.

Previously published data indicate that women whoparticipate in sports or who are otherwise physically active

have higher rates of ACL injury than men [6]; the reason forthis is unknown. After following up 139 professionalfootball players, Nicholas [7] concluded that laxity of thejoint predisposes to ligament injuries. Godshall [8]disagreed, in a series of ‘growing’ athletes, and Moretz,Walters and Smith [9] concluded, in a series of 155 footballplayers, that laxity did not predispose to ligament injuries.However, Boden, et al [10] showed a strong correlationbetween hamstring flexibility and ACL rupture afteranalyzing data from 100 ruptures. At the Hunt Valleyconsensus conference for the prevention of non-contactACL injury, it was judged that the relationship between ACLruptures and joint laxity remained unresolved [2]. Ramesh[4] andcolleagues found that ACL injury was more frequentin those patients with greater overall joint laxity, specificallythose with increased knee joint laxity. In our study, the highnumber of patients with ACL tears had generalized jointlaxity (92.7%). It is recognized that the Asian and Orientalpopulation have more lax joints than European andAmerican population [11-13].This might have been thefactor responsible, as all of our patients were Indians.

Nothing can be done to change ligament laxity, butcertain training techniques may help reduce athletes’ risk ofACL tears – something that might be especially importantfor those with greater laxity in the knee joint. There isenough evidence that neuromuscular training programmesare effective in increasing performance and preventinginjuries in atheletes [14,15]. For example, learning how toland from a jump with proper alignment, and not in a“knock-kneed” position, may help prevent ACL injuries. Inaddition, strengthening the hamstring muscles, which helpstabilize the knee joint, appears particularly important.

We suggest that all the athletes should be screened forgeneralized joint laxity based on Beighton’s criteria. If thescore >4/9, they should undergo proper counseling toprevent these injuries and supportive orthosis, muscle andjoint proprioception training to prevent ACL tear. Furtherresearch into the proposed theory relating to thismusculoskeletal problem is warranted for intervention andpossible prevention of ACL injuries in athletes which canhelp in decreasing the number and thus the cost associatedwith treatment and rehabilitation of patients with ACLinjuries.

REFERENCES

1. George AC, Sirish Maddali, Lois Horovitz. The effects oftime course after anterior cruciate ligament injury incorrelation with meniscal and cartilage Loss. Am J SportsMed. 2001; 29(1):9-14.

2. Griffin LY, Agel J, Albohm MJ, et al. Noncontact anteriorcruciate ligament injuries: risk factors and preventionstrategies. J Am Acad Orthop Surg 2000; 8:141-150.

Table 1: Clinical profile of patients

Study group Control group

Total number of patients 110 55

Male:Female 65:45 34:21

Patients with GeneralisedLigament Laxity Score >4/9 102 9

Original Article

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3. Gregory D Myer, Kevin R Ford, Mark V Paterno. The effectsof generalized joint laxity on risk of anterior cruciateligament injury in young female athletes. The AmericanJournal of Sports Medicine 2008;36:1073-1080.

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7. Nicholas JA. Injuries to knee ligaments: relationship tolooseness and tightness in football players. JAMA 1970;212: 2236-2239.

8. Godshall RW. The predictability of athletic injuries: an eightyear study. J Sports Med 1975; 3: 50-54.

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10. Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr.Mechanisms of anterior cruciate ligament injury.Orthopaedics 2000; 23: 573-578.

11. Everman DB, Robin NH. Hypermobility syndrome. PediatrRev. 1998; 19:111-117.

12. Finsterbush A, Pogrund H. The hypermobility syndrome.Clin Orthop Relat Res. May 1982: 124-127.

13. Larsson LG, Baum J, Mudholkar GS, Kollia GD. Benefitsand disadvantages of joint hypermobility amongmusicians. N Engl J Med. 1993; 329:1079-1082.

14. Hall MG, Ferrell WR, Sturrock RD, Hamblen DL,Baxendale RH. The effect of hypermobility syndrome onknee joint proprioception. Br J Rheumatol. 1995; 34: 121 -125.

15. Perlau R, Frank C, Fick G. The effect of elastic bandageson human knee proprioception in the uninjured population.Am J Sports Med. 1995; 23: 251-255.

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