scholarly journals The Effect of Patient Sex and Graft Type on Postoperative Functional Outcomes After Primary ACL Reconstruction

2020 ◽  
Vol 8 (6) ◽  
pp. 232596712092605
Author(s):  
Milos Lesevic ◽  
Michelle E. Kew ◽  
Stephan G. Bodkin ◽  
David R. Diduch ◽  
Stephen F. Brockmeier ◽  
...  
Keyword(s):  
Patellar Tendon ◽  
Cruciate Ligament ◽  
Return To Sport ◽  
Knee Extensor ◽  
Postoperative Rehabilitation ◽  
Knee Flexor ◽  
Female Patients ◽  
Bptb Graft ◽  
Knee Extensor Strength ◽  
Male Patients

Background: Graft choice in anterior cruciate ligament reconstruction (ACLR) and postoperative rehabilitation may affect strength recovery differently in men than women and therefore affect a timely and successful return to sport. Purpose: To compare knee extensor and flexor strength between men and women who underwent isolated ACLR with either patellar tendon or hamstring tendon (HST) autografts. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 166 patients (87 women, 79 men) with primary unilateral and uncomplicated ACLRs were recruited for participation. A total of 100 patients had bone–patellar tendon–bone (BPTB) autografts and 66 had HST autografts. At 6 months postoperatively, all patients completed the Tegner activity scale and International Knee Documentation Committee Subjective Knee Evaluation as well as underwent bilateral isokinetic (90 deg/s) tests of the knee extensor and flexor groups. Outcomes were recorded in a single session as part of a return-to-sport test battery. Surgical notes were obtained to determine the type of autograft and nerve block used at the time of ACLR. Results: There was a significant sex × graft type interaction for mass-normalized knee flexor torque ( P = .017). Female patients with an HST graft had a significantly lower knee flexor torque compared with female patients with a BPTB graft (0.592 ± 0.49 N·m/kg vs 0.910 ± 0.24 N·m/kg; Cohen d [95% CI] = 0.91 [0.45, 1.36]). They also had a significantly lower knee flexor torque when compared with male patients with an HST graft (0.592 ± 0.49 N·m/kg vs 0.937 ± 0.35 N·m/kg; Cohen d [95% CI]= 0.88 [0.45, 1.31]). There were significant main effects for graft type with knee flexion ( P = .001) and extension ( P = .008) symmetry. Patients with a BPTB graft demonstrated lower knee extensor symmetry (65.7% ± 17.0%) and greater knee flexor symmetry (98.7% ± 18.0%) compared with patients with an HST graft (extension: 77.1% ± 32%, Cohen d [95% CI] = 0.47 [0.16, 0.79]; flexion: 82.9% ± 33.3%, Cohen d [95% CI] = 0.63 [0.31, 0.95]). We also observed a significant main effect for sex ( P = .028) and graft type ( P = .048) for mass-normalized knee extensor strength. Female participants and patients of either sex with BPTB grafts had lower knee extensor strength compared with male participants and patients with HST grafts, respectively. Conclusion: At approximately 6 months after ACLR, female patients reconstructed with HST autografts demonstrated weaker HST strength compared with female patients with a BPTB autograft. There were no differences in HST strength between graft types in male patients. Female patients appear to be recovering HST strength differently than male patients when using an HST autograft. These findings may have implications in surgical planning, postoperative rehabilitation, and return-to-sport decision making.

scholarly journals Hamstring Strength Recovery is Worse in Women than Men following ACL Reconstruction with Hamstring Autografts

2019 ◽  
Vol 7 (7_suppl5) ◽  
pp. 2325967119S0035
Author(s):  
Stephan G. Bodkin ◽  
Aaron Joseph Casp ◽  
Michelle Elizabeth Kew ◽  
Stephen F. Brockmeier ◽  
David R. Diduch ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Patellar Tendon ◽  
Knee Extensor ◽  
Return To Sports ◽  
Knee Flexor ◽  
Cohen’S D ◽  
Strength Recovery ◽  
Bptb Graft ◽  
Graft Choice ◽  
Cohen's D

Objectives: Graft choice in ACL reconstruction (ACLR) and post-operative rehabilitation may influence strength recovery and return to sports differently in men versus women. Persistent muscle weakness, impaired function, and poor patient reported outcomes are a concern for patients early after reconstruction and impact a timely and successful return to unrestricted physical activity without re-injury. However, little is known about the effect of graft choice and sex on short term ACLR recovery and return-to-play assessment. The purpose of this study was to compare knee extensor and flexor strength between male and female patients in isolated ACLR across both patellar tendon and hamstring autografts. Methods: A total of 166 patients with primary, unilateral and uncomplicated ACL reconstructions (22.6±9.9 years, 87 females, 5.94±.46 months post ACLR) were recruited for participation. There were 100 patients with bone patellar tendon bone (BPTB) autografts and 66 hamstring (HS) autografts. All patients completed the Tegner activity Scale and underwent bilateral isokinetic (90°/sec) tests of the knee extensor and flexor groups. Outcomes were recorded in a single session as part of a return-to-sport test battery. Strength was expressed as torque normalized to mass (Nm/kg) and limb-symmetry was expressed as a percentage of (involved/uninvolved)*100. Surgical Notes were obtained to determine the patient’s sex and type of autograft used at the time of ACLR. Strength measures were compared using 2x2 ANCOVAs (Sex by Graft Type) with the patient’s current activity level as a covariate. Post-hoc Cohen’s D effect sizes and 95% CI were calculated and statistical significance was defined as p-values of .05 or less. Results: There was a significant sex*graft type interaction for normalized knee flexor torque (P=.017) (Figure 1). Females with a HS graft (.592±.49 Nm/kg) had significantly less knee flexor torque compared to females with a BPTB graft (.910±.24 Nm/kg, Cohen’s d= .90[.45, 1.36]) and all males (HS: .937±.35, Cohen’s d=.87 [.45, 1.30]). There were significant main effects for graft type for knee flexor (P=.001) and extensor (P=.008) symmetry. Patients with a BPTB graft demonstrated less knee extensor symmetry (65.7±17%) and greater knee flexor symmetry (98.7±18%) compared to patients with a HS graft (Extension: 77.1±32%, Cohen’s d=.47[.16, .79]) (Flexion: 82.9±33%, Cohen’s d=.63[.31,.95]). We also observed a significant main effect for sex (P=.028) and graft type (P=.048) for normalized knee extensor strength. On average, males (1.67±.60 Nm/kg) demonstrated significantly greater normalized extensor torque than females (1.44±.75 Nm/kg, Cohen’s d= .34 [.03, .64]), and patients with a HS graft (1.66±.34 Nm/kg) demonstrated greater normalized extensor strength than those with a BPTB graft (1.45±.42 Nm/kg, Cohen’s d= .54 [.22, .85]). Conclusion: At approximately 6 months following ACLR, female patients reconstructed with hamstring autografts demonstrated weaker hamstring strength compared to females with a BPTB autograft. There were no differences in hamstring strength between graft types in males. Females appear to be recovering hamstring strength differently than males when using a hamstring autograft. These findings may have implications in surgical planning, post-operative rehabilitation and return to sports decision making. [Figure: see text]

scholarly journals Effect of Patient Height and Sex on the Patellar Tendon and Anterior Cruciate Ligament

2021 ◽  
Vol 9 (5) ◽  
pp. 232596712110032
Author(s):  
Abigail L. Campbell ◽  
Jon-Michael E. Caldwell ◽  
Dheeraj Yalamanchili ◽  
Lia Sepanek ◽  
Keon Youssefzadeh ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Regression Analysis ◽  
Linear Regression ◽  
Acl Reconstruction ◽  
Patellar Tendon ◽  
Cruciate Ligament ◽  
Linear Regression Analysis ◽  
Female Patients ◽  
Male Patients ◽  
Anterior Cruciate

Background: Graft-tunnel mismatch is an avoidable complication in anterior cruciate ligament (ACL) reconstruction. Patient height and sex may be predictors of patellar tendon length (PTL) and intra-articular ACL length (IAL). Understanding these relationships may assist in reducing graft-tunnel mismatch during ACL reconstruction with bone–patellar tendon–bone (BTB) autograft. Purpose: To determine the association of patient height and sex with PTL and IAL. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Magnetic resonance imaging (MRI) studies were obtained on the healthy knees of 100 male and 100 female patients. Patients with prior surgery, open physes, significant degenerative changes, ACL rupture, or extensor mechanism injury were excluded. Three independent readers measured PTL, IAL, and Caton-Deschamps Index (CDI) on MRI. Bivariate and linear regression analysis was performed to detect the association of anthropometric data with anatomic parameters measured on MRI studies. Results: The mean age and body mass index were not significantly different between the male and female patients; however, male patients were significantly taller than female patients (1.75 vs 1.72 m, respectively; P < .001). There was a substantial agreement between the 3 readers for all parameters (κ > 0.75). Overall, female patients had significantly longer PTL (47.38 vs 43.92 mm), higher CDI (1.146 vs 1.071), and shorter IAL (33.05 vs 34.39 mm) ( P < .001 for all). Results of the linear regression analysis demonstrated that both height and female sex were predictive of longer PTL. Further, height was independently predictive of IAL but sex was not. Conclusion: PTL was correlated more with patient sex than height. IAL was also correlated with patient sex. Longer BTB grafts are expected to be harvested in female patients compared with male patients of the same height despite shorter IAL. These associations should be considered during BTB ACL reconstruction to minimize graft-tunnel mismatch.

Current Perspectives of the Australian Knee Society on Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

2020 ◽  
Vol 29 (7) ◽  
pp. 970-975 ◽  
Author(s):  
Jay R. Ebert ◽  
Kate E. Webster ◽  
Peter K. Edwards ◽  
Brendan K. Joss ◽  
Peter D’Alessandro ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Anterior Cruciate Ligament Reconstruction ◽  
Ligament Reconstruction ◽  
Cruciate Ligament ◽  
Return To Sport ◽  
Postoperative Rehabilitation ◽  
Cruciate Ligament Reconstruction ◽  
Orthopedic Surgeons ◽  
Anterior Cruciate ◽  
Retear Rate

Context: The importance of rehabilitation and evaluation prior to return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction has been reported. Objective: This study sought to investigate current perspectives of Australian orthopedic surgeons on rehabilitation and RTS evaluation. Design: Survey. Participants: Members of the Australian Knee Society. Main Outcome Measures: A 14-question survey was disseminated to Australian Knee Society members (orthopedic surgeons) to investigate (1) preferred graft choice, (2) estimated retear rate, (3) importance of preoperative and postoperative rehabilitation, and (4) preferred timing of RTS and evaluation prior to RTS discharge. Results: Of all 85 Australian Knee Society members contacted, 86% (n = 73) responded. Overall, 66 respondents (90.4%) preferentially used hamstring tendon autografts. All surgeons estimated their retear rate to be ≤15%, with 31 (42.5%) <5%. Twenty-eight surgeons (38.4%) reported no benefit in preoperative rehabilitation. The majority of surgeons (82.2%–94.5%) reported that postoperative rehabilitation was important within various periods throughout the postoperative timeline. Most surgeons did not permit RTS until ≥9 months (n = 56, 76.7%), with 17 (23.3%) allowing RTS between 6 and 9 months. The most highly reported considerations for RTS clearance were time (90.4%), functional capacity (90.4%), and strength (78.1%). Most commonly, knee strength and/or function was assessed via referral to a preferred rehabilitation specialist (50.7%) or with the surgeon at their practice (11.0%). Conclusions: This survey revealed variation in beliefs and practices surrounding rehabilitation and RTS evaluation. This is despite the current evidence demonstrating the benefit of preoperative and postoperative rehabilitation, as well as the emerging potential of RTS assessments consisting of strength and functional measures to reduce reinjury rates.

scholarly journals Conditioning Brain Responses to Improve Quadriceps Function in an Individual With Anterior Cruciate Ligament Reconstruction

2019 ◽  
Vol 11 (4) ◽  
pp. 306-315 ◽  
Author(s):  
Chandramouli Krishnan ◽  
Edward P. Washabaugh ◽  
Aviroop Dutt-Mazumder ◽  
Scott R. Brown ◽  
Edward M. Wojtys ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Operant Conditioning ◽  
Muscle Activation ◽  
Cruciate Ligament ◽  
Knee Extensor ◽  
Quadriceps Muscle ◽  
Corticospinal Excitability ◽  
Knee Extensor Strength ◽  
Anterior Cruciate ◽  
Quadriceps Function

Background: Persistent quadriceps weakness and activation failure are common in individuals with anterior cruciate ligament (ACL) reconstruction. A growing body of evidence indicates that this chronic quadriceps dysfunction could be partly mediated due to reduced corticospinal excitability. However, current rehabilitation approaches do not directly target corticospinal deficits, which may be critical for restoring optimal clinical outcomes after the surgery. This case study tested the feasibility of operant conditioning of torque responses evoked by transcranial magnetic stimulation (TMS) to improve quadriceps function after ACL reconstruction. Hypothesis: Operant conditioning of motor evoked torque responses would improve quadriceps strength, voluntary activation, and corticospinal excitability. Study Design: Case study and research report. Level of Evidence: Level 5. Methods: A 24-year-old male with an ACL reconstruction (6 months postsurgery) trained for 20 sessions (2-3 times per week for 8 weeks) to increase his TMS-induced motor evoked torque response (MEP torque) of the quadriceps muscles using operant conditioning principles. Knee extensor strength, voluntary quadriceps muscle activation, and quadriceps corticospinal excitability were evaluated at 3 time points: preintervention (pre), 4 weeks (mid), and immediately after the intervention (post). Results: The participant was able to successfully condition (ie, increase) the quadriceps MEP torque after 1 training session, and the conditioned MEP torque gradually increased over the course of 20 training sessions to reach about 500% of the initial value at the end of training. The participant’s control MEP torque values and corticospinal excitability, which were measured outside of the conditioning paradigm, also increased with training. These changes were paralleled by improvements in knee extensor strength and voluntary quadriceps muscle activation. Conclusion: This study shows that operant conditioning of MEP torque is a feasible approach to improving quadriceps corticospinal excitability and quadriceps function after ACL reconstruction and encourages further testing in a larger cohort of ACL-reconstructed individuals. Clinical Relevance: Operant conditioning may serve as a potential therapeutic adjuvant for ACL rehabilitation.

The Influence of Perioperative Nerve Block on Strength and Functional Return to Sports After Anterior Cruciate Ligament Reconstruction

2020 ◽  
Vol 48 (7) ◽  
pp. 1689-1695
Author(s):  
Michelle E. Kew ◽  
Stephan G. Bodkin ◽  
David R. Diduch ◽  
Marvin K. Smith ◽  
Anthony Wiggins ◽  
...  
Keyword(s):  
Nerve Block ◽  
Cruciate Ligament ◽  
Knee Extensor ◽  
Block Type ◽  
Return To Sports ◽  
Nerve Blocks ◽  
Knee Flexor ◽  
Significant Difference ◽  
Ikdc Score ◽  
Anterior Cruciate

Background: Patients often have quadriceps or hamstring weakness after anterior cruciate ligament reconstruction (ACLR), despite postoperative physical therapy regimens; however, little evidence exists connecting nerve blocks and ACLR outcomes. Purpose: To compare muscle strength at return to play in patients who received a nerve block with ACLR and determine whether a specific block type affected subjective knee function. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were recruited 5 to 7 months after primary, isolated ACLR and completed bilateral isokinetic strength tests of the knee extensor/flexor groups as a single-session return-to-sport test. Subjective outcomes were assessed with the International Knee Documentation Committee (IKDC) score. Strength was expressed as torque normalized to mass (N·m/kg) and limb symmetry index as involved/uninvolved torque. Chart review was used to determine the type of nerve block and graft used. Nerve block types were classified as knee extensor motor (femoral nerve), knee flexor motor (sciatic nerve), or isolated sensory (adductor canal block/saphenous nerve). A 1-way analysis of covariance controlling for graft type was used. Results: A total of 169 patients were included. Graft type distribution consisted of 102 (60.4%) ipsilateral bone–patellar tendon–bone (BTB) and 67 (39.6%) ipsilateral hamstring tendon. Nerve block type distribution consisted of 38 (22.5%) femoral, 25 (14.8%) saphenous, 45 (26.6%) femoral and sciatic, and 61 (36.1%) saphenous and sciatic. No significant difference was found in knee extensor strength ( P = .113) or symmetry ( P = .860) between patients with knee extensor motor blocks (1.57 ± 0.45 N·m/kg; 70.1% ± 15.3%) and those without (1.47 ± 0.47 N·m/kg; 69.6% ± 18.8%). A significant difference was found between patients with knee flexor motor blocks (0.83 ± 0.26 N·m/kg) and those without (0.92 ± 0.27 N·m/kg) for normalized knee flexor strength ( P = .21) but not knee flexor symmetry ( P = .592). Controlling for graft type, there were no differences in subjective knee function (IKDC score) between all nerve block groups ( P = .57). Conclusion: Our data showed that use of a sciatic nerve block with ACLR in patients with hamstring and BTB grafts influences persistent knee flexor strength deficits at time of return to sports. Although the cause of postoperative muscular weakness is multifactorial, this study adds to the growing body of evidence suggesting that perioperative nerve blocks affect muscle strength and functional rehabilitation after ACLR.

scholarly journals Increased fascicle length but not patellar tendon stiffness after accentuated eccentric-load strength training in already-trained men

2020 ◽  
Vol 120 (11) ◽  
pp. 2371-2382 ◽  
Author(s):  
Simon Walker ◽  
Joanne Trezise ◽  
Guy Gregory Haff ◽  
Robert U. Newton ◽  
Keijo Häkkinen ◽  
...  
Keyword(s):  
Strength Training ◽  
Patellar Tendon ◽  
External Load ◽  
Vastus Lateralis ◽  
Knee Extensor ◽  
Fascicle Length ◽  
Tendon Stiffness ◽  
Knee Extensor Strength ◽  
Tendon Properties ◽  
Fascicle Angle

Abstract Purpose This study examined whether additional external load during the eccentric phase of lower limb strength training exercises led to greater adaptations in knee extensor strength, muscle architecture, and patellar tendon properties than traditional concentric–eccentric training in already-trained men. Methods Twenty-eight men accustomed to strength training were randomized to undertake 10 weeks of supervised traditional (TRAD) or accentuated eccentric loading (AEL) or continue their habitual unsupervised (CON) strength training. TRAD and AEL trained 2∙week−1 with a six-repetition maximum (RM) session and a ten-RM session. TRAD used the same external load in both concentric and eccentric phases, while AEL used 40% greater load during the eccentric than concentric phase. Tests were performed at pre- and post-training, including: maximum unilateral isokinetic (30°·s−1) concentric, eccentric and isometric torques by isokinetic dynamometry, unilateral isometric ramp contractions with muscle–tendon ultrasound imaging to measure tendon stiffness and hysteresis, and resting vastus lateralis and medialis fascicle angle and length measured by extended-field-of-view ultrasound. Results After training, both TRAD and AEL significantly increased maximum concentric and isometric torque (p < 0.05), but only AEL increased eccentric torque (AEL: + 10 ± 9%, TRAD: + 4 ± 9%) and vastus lateralis (AEL: + 14 ± 14%, TRAD: + 1 ± 10%) and medialis (AEL: + 19 ± 8%, TRAD: + 5 ± 11%) fascicle length. Conclusion Both TRAD and AEL increased maximum knee extensor strength but only AEL increased VL and VM fascicle length. Neither training program promoted changes in fascicle angle or changes in patellar tendon properties in our already-trained men.

Effects of Continuous Passive Motion on Anterior Laxity Following ACL Reconstruction with Autogenous Patellar Tendon Grafts

1993 ◽  
Vol 2 (3) ◽  
pp. 171-178 ◽  
Author(s):  
Michael R. McCarthy ◽  
Barton P. Buxton ◽  
Carlan K. Yates
Keyword(s):  
Acl Reconstruction ◽  
Patellar Tendon ◽  
Cruciate Ligament ◽  
Continuous Passive Motion ◽  
Anterior Tibial Translation ◽  
Postoperative Rehabilitation ◽  
Passive Motion ◽  
Early Motion ◽  
Anterior Laxity ◽  
Tibial Translation

Continuous passive motion (CPM) is a modality used in the treatment, management, and rehabilitation of a variety of orthopedic problems. Recently, CPM devices have been therapeutically employed immediately after autogenous patellar tendon reconstruction of the anterior cruciate ligament (ACL). Whereas the concept of early motion is indicated, there is a concomitant concern that the implementation of immediate passive motion may stretch or rupture the graft. Twenty subjects scheduled to undergo ACL reconstruction were randomized into two groups (10 CPM and 10 non-CPM). All subjects performed the same postoperative rehabilitation with the exception of the CPM. Objective anterior tibial translation measurements were recorded with a KT-1000 for a 30-1b (133.5-N) Lachman test at 1 year postreconstruction. The results of this study indicated that the implementation of immediate continuous passive motion did not have any deleterious effects on the stability of the ligament reconstruction.

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