ArticlePDF Available

Early active extension after anterior cruciate ligament reconstruction does not result in increased laxity of the knee

Authors:

Abstract and Figures

If permission of full active and passive extension immediately after an anterior cruciate ligament (ACL) reconstruction will increase the post-operative laxity of the knee has been a subject of discussion. We investigated whether a post-operative rehabilitation protocol including active and passive extension without any restrictions in extension immediately after an ACL reconstruction would increase the post-operative anterior-posterior knee laxity (A-P laxity). Our hypothesis was that full active and passive extension immediately after an ACL reconstruction would have no effect on the A-P laxity and clinical results up to 2 years after the operation. Twenty-two consecutive patients (14 men, 8 women, median age 21 years, range 17-41) were included. All the patients had a unilateral ACL rupture and no other ligament injuries or any other history of previous knee injuries. The surgical procedure was identical in all patients and one experienced surgeon operated on all the patients, using the bone-patellar tendon-bone autograft. The post-operative rehabilitation programme was identical in both groups, except for extension training during the first 4 weeks post-operatively. The patients were randomly allocated to post-operative rehabilitation programmes either allowing (Group A, n=11) or not allowing [Group B (30 to -10 degrees ), n=11] full active and passive extension immediately after the operation. They were evaluated pre-operatively and at 6 months and 2 years after the reconstruction. To evaluate the A-P knee laxity, radiostereometric analysis (RSA) and KT-1000 arthrometer (KT-1000) measurements were used, range of motion, Lysholm score, Tegner activity level, the International Knee Documentation Committee (IKDC) evaluation system and one-leg-hop test quotient were used. Pre-operatively, the RSA measurements revealed side-to-side differences in Group A of 8.6 mm (2.3-15.4), median (range) and in Group B of 7.2 mm (2.2-17.4) (n.s.). The corresponding KT-1000 values were for Group A, 2.0 mm (0-8.0) and Group B, 4.0 mm (0-10.0) (n.s.). At 2 years, the differences between the two groups were minimal, regardless of the method that had been used. The RSA measurements in Group A were 2.7 mm (0-10.7) and in Group B 2.8 (-1.8 to 9.5). The KT-1000 values were for Group A, 1.0 mm (-1.5 to 3.5), and for Group B, 0.5 mm (-1.0 to 4.0), without any significant differences between the groups. Nor did the Lysholm score, Tegner activity level, IKDC or one-leg-hop test differ. Early active and passive extension training, without any restrictions in extension, immediately after an ACL reconstruction using bone-patellar tendon-bone graft did not increase post-operative knee laxity up to 2 years after the ACL reconstruction.
Content may be subject to copyright.
Abstract If permission of full active and passive
extension immediately after an anterior cruciate liga-
ment (ACL) reconstruction will increase the post-
operative laxity of the knee has been a subject of dis-
cussion. We investigated whether a post-operative
rehabilitation protocol including active and passive
extension without any restrictions in extension imme-
diately after an ACL reconstruction would increase the
post-operative anterior–posterior knee laxity (A–P
laxity). Our hypothesis was that full active and passive
extension immediately after an ACL reconstruction
would have no effect on the A–P laxity and clinical
results up to 2 years after the operation. Twenty-two
consecutive patients (14 men, 8 women, median age 21
years, range 17–41) were included. All the patients had
a unilateral ACL rupture and no other ligament inju-
ries or any other history of previous knee injuries. The
surgical procedure was identical in all patients and one
experienced surgeon operated on all the patients, using
the bone-patellar tendon-bone autograft. The post-
operative rehabilitation programme was identical in
both groups, except for extension training during the
first 4 weeks post-operatively. The patients were ran-
domly allocated to post-operative rehabilitation pro-
grammes either allowing (Group A, n=11) or not
allowing [Group B (30 to –10°), n=11] full active and
passive extension immediately after the operation.
They were evaluated pre-operatively and at 6 months
and 2 years after the reconstruction. To evaluate the
A–P knee laxity, radiostereometric analysis (RSA) and
KT-1000 arthrometer (KT-1000) measurements were
used, range of motion, Lysholm score, Tegner activity
level, the International Knee Documentation Com-
mittee (IKDC) evaluation system and one-leg-hop test
quotient were used. Pre-operatively, the RSA mea-
surements revealed side-to-side differences in Group A
of 8.6 mm (2.3–15.4), median (range) and in Group B
of 7.2 mm (2.2–17.4) (n.s.). The corresponding KT-
1000 values were for Group A, 2.0 mm (0–8.0) and
Group B, 4.0 mm (0–10.0) (n.s.). At 2 years, the dif-
ferences between the two groups were minimal,
regardless of the method that had been used. The RSA
measurements in Group A were 2.7 mm (0–10.7) and
in Group B 2.8 (–1.8 to 9.5). The KT-1000 values were
for Group A, 1.0 mm (–1.5 to 3.5), and for Group B,
0.5 mm (–1.0 to 4.0), without any significant differences
between the groups. Nor did the Lysholm score, Teg-
ner activity level, IKDC or one-leg-hop test differ.
Early active and passive extension training, without
any restrictions in extension, immediately after an
ACL reconstruction using bone-patellar tendon-bone
graft did not increase post-operative knee laxity up to 2
years after the ACL reconstruction.
Keywords ACL reconstruction Æ Rehabilitation Æ
Extension Æ Radiostereometric analysis
Introduction
Rupture of the anterior cruciate ligament (ACL) is a
common injury during both sports and leisure time
activities [3, 27].
J. Isberg (&) Æ E. Faxe
´
n Æ S. Brandsson Æ B. I. Eriksson Æ
J. Ka
¨
rrholm Æ J. Karlsson
Department of Orthopaedics, Sahlgrenska University
Hospital, 416 85 Goteborg, Sweden
e-mail: Jonas.isberg@vgregion.se
Knee Surg Sports Traumatol Arthrosc (2006) 14:1108–1115
DOI 10.1007/s00167-006-0138-2
123
KNEE
Early active extension after anterior cruciate ligament
reconstruction does not result in increased laxity of the knee
Jonas Isberg
Æ
Eva Faxe´n
Æ
Sveinbjo
¨
rn Brandsson
Æ
Bengt I. Eriksson
Æ
Johan Ka
¨
rrholm
Æ
Jon Karlsson
Received: 4 October 2005 / Accepted: 13 March 2006 / Published online: 6 September 2006
Ó Springer-Verlag 2006
A well-planned post-operative rehabilitation proto-
col is as important for the final outcome after an ACL
reconstruction as the surgery itself. Early joint motion
is also beneficial when it comes to avoiding capsular
contractions and reducing swelling and pain. Post-
operative immobilisation of the knee may contribute to
limited range of motion (ROM), muscular hypotrophy
and inferior knee function [37]. Rehabilitation proto-
cols aim to restore ROM, strength, co-ordination and
full function as soon as possible, without damaging the
graft [18, 35, 36, 38].
To our knowledge, there are no randomised studies
with an adequate follow-up, which have used such an
accurate method as the radiostereometric analysis
(RSA) measuring technique to study the influence of
immediate and active extension on the anterior–pos-
terior knee laxity (A–P laxity) of the knee, after an
ACL reconstruction. Despite this many rehabilitation
programme, include early full active and/or passive
extension after an ACL reconstruction.
In 1990, Shelbourne and Nitz [35] presented their
accelerated post-operative rehabilitation protocols
after an ACL reconstruction, in which they allowed
immediate full active extension of the knee and em-
phasised early aggressive rehabilitation. In 1995, Shel-
bourne et al. [34] presented 2–6 years follow-up after
ACL reconstruction with autogenous patellar tendon
graft and participation in accelerated rehabilitation
programme. Three years later Muneta et al. [26] pre-
sented the outcome after an ACL reconstruction, with
multi-strand semitendinosus tendon, in which they
emphasised early aggressive rehabilitation.
Several studies have compared the effect of open
kinetic chain (OKC) and closed kinetic chain (CKC)
[7, 2325, 42] and most of the post-operative rehabili-
tation protocols used today include a combination of
both methods. However, only a few studies have ad-
dressed the question of whether early active and pas-
sive extension immediately after the ACL
reconstruction [35] affects A–P laxity of the knee.
It is also believed that there are two post-operative
periods during which the ACL graft and its fixations
are most vulnerable. The first period starts immedi-
ately after the reconstruction [2426, 30], while the
second begins when the graft becomes weaker due to
graft revitalisation, until it reaches its weakest point,
approximately 12 weeks after the reconstruction [26,
30].
Our aim was to study whether permitting active and
passive extension, without any restrictions in extension,
immediately after ACL reconstruction would increase
the post-operative A–P laxity and subsequently lead to
an inferior clinical outcome.
Our hypothesis was that permitting active and pas-
sive extension, without any restrictions, immediately
after an ACL reconstruction would not have any neg-
ative effect on the A–P laxity, producing similar clini-
cal results up to 2 years after the operation.
Patients and methods
The study was approved by the Human Ethics Com-
mittee at Go
¨
teborg University. All the patients gave
their informed consent.
Patients with a unilateral traumatic ACL rupture
with remaining insufficiency and painful ‘‘giving-way’’
episodes were included. The criteria were that they
should have no history of injury or any other symptoms
on the opposite knee. Presence of meniscal tears from
the index injury which could be treated with a partial
resection at the arthroscopy was accepted.
Exclusion criteria were multiple knee ligament inju-
ries, a history of previous knee injuries or knee surgery
before the index injury, meniscal tears that underwent
repair or knee problems on the opposite side.
Twenty-two consecutive patients (14 men, 8 women)
were included.
Arthroscopy was performed in all patients (injured
knee), confirming the diagnosis. During the same ses-
sion, the tantalum markers (diameter=0.8 mm) were
inserted percutaneously in both the injured and the
intact knee. To ascertain correct positioning, fluoros-
copy was used during insertion. For the RSA mea-
surements, at least three markers in each segment,
located in a 3D triangle are needed. To ensure suffi-
cient marker scatter and stability, four to five tantalum
markers were implanted into the distal femur and
proximal tibia on both the injured and the intact side
(Fig. 1).
The ACL reconstruction procedure was identical in
all patients. The median age at the ACL reconstruction
was 21 (16–41) years. The median time period between
the index injury and the ACL reconstruction was 16
(4–45) weeks.
The operation was performed by one experienced
surgeon, using a patellar tendon autograft. A standard
arthroscopic one-incision technique was used in all
patients. The width of the graft was 8–10 mm,
depending on the size of the patellar tendon. A small
notch plasty was performed to avoid graft impinge-
ment. The graft was placed in approximately the 10.30
(right knee) or 1.30 (left knee) position in the posterior
intercondylar notch.
The fixation was performed using metallic interfer-
ence screws, Cannu-flex silk screws 20 mm from at
Knee Surg Sports Traumatol Arthrosc (2006) 14:1108–1115 1109
123
both ends, 7 mm diameter in femur and 7–9 mm in
tibia (Acufex Ltd, Naples, FL, USA).
Before the operation the patients were randomised
to one of two rehabilitation programmes using sealed,
opaque envelopes. The patients were randomly allo-
cated to post-operative rehabilitation programmes ei-
ther allowing (Group A, n = 11) or not allowing
(Group B, restricted motion between 30 and –10°,
n = 11) active and passive extension, immediately after
the operation.
There were no differences between the two groups
in terms of age, time from injury to surgery and injured
side. The male:female ratio was 5:6 in Group A and 9:2
in Group B (Table 1).
The patients were evaluated pre-operatively, at
6 months and 2 years after the operation. To evaluate
the A–P knee laxity RSA [5, 6, 1315] and KT-1000
measurements were used. Clinical tests included ROM,
Lysholm score, Tegner activity level, the International
Knee Documentation Committee (IKDC) evaluation
system and one-leg-hop test were used. All the patients
were examined at follow-up by independent observers.
Radiographers at the Department of Radiology per-
formed the RSA examinations and dedicated techni-
cians performed measurements of the digital
radiographs. The clinical tests and KT-1000 measure-
ments were done by a physical therapist, who did not
participate in the surgical procedure or the final eval-
uation of data.
Rehabilitation
The rehabilitation programmes, either with or without
restricted active and passive extension between 30 and
–10° was started immediately after the operation. The
patients were supervised by a physiotherapist and
trained three times a week during the first 4 weeks.
Rehabilitation brace
The same model of rehabilitation brace was used in
both groups. This brace allowed 10° of hyperextension
according to a radiographic examination of one of the
author’s knee.
Weeks 0–2
Full weight-bearing was allowed in both groups
immediately post-operatively and crutches were used
for 10 days in both groups. The same model of reha-
bilitation brace was used in both groups, either without
(Group A) or with (Group B) restricted active and
passive extension between 30 and –10°. The training
programme, including active and passive extension
exercises, CKC, was started immediately post-opera-
tively in both groups. One example is an active knee
extension and flexion exercises sitting on the floor and
muscle contraction exercises for both Hamstrings and
Quadriceps.
Weeks 3–4
The two groups still used their rehabilitation brace.
The training programme continued with or without
restricted extension according to the initial protocol.
CKC exercises for Hamstrings and Quadriceps were
continued. Gait, stationary biking, proprioception and
balance training was started. OKC training was started
in both groups.
The brace was removed in the end of week 4 in both
groups.
Weeks 5–6
Active and passive extension without any restrictions
was now allowed in both groups. Isokinetic concentric
and eccentric OKC quadriceps training was initiated in
week 6, and isokinetic hamstrings training as well.
Fig. 1 The tantalum markers can be seen in distal femur and
proximal tibia in this lateral view of stereoradiograph. Cage
markers are visible outside the knee. Two ceiling-mounted
radiographic tubes, one anterior–posterior and one lateral,
connected to two separated generators, were used to obtain
simultaneous exposures, Table 2
Table 1 Demographics in Groups A and B
Group A Group B
Number of patients 11 11
Age, years
a
25 (16–41) 21 (17–38)
Men:women 5:6 9:2
Right:left 5:6 6:5
Time from injury to surgery, weeks
a
18 (9–45) 14 (4–40)
a
Median (range)
1110 Knee Surg Sports Traumatol Arthrosc (2006) 14:1108–1115
123
Weeks 7–12
Functional exercises, for example stair walking and
skip the rope exercises were started. Slideboard exer-
cises were initiated in week 12.
Weeks 13–17
Straight ahead jogging was permitted on an even sur-
face. Eccentric and concentric muscle training was
continued with increased weight and speed.
Weeks 18–24
Sport specific training. Jogging on an uneven surface
and with 90–360° turns were initiated.
Week 25
The patient was allowed to return to sports activities, if
the muscle strength was 90% of the intact leg or more.
Anterior–posterior laxity
Anterior–posterior laxity was measured using RSA
and KT-1000. The difference in A–P laxity between the
injured and the intact knee is presented (side-to-side
difference).
Radiostereometric analysis
Radiostereometric analysis has been used to evaluate
the laxity and kinematics of ACL-injured knees for
more than a decade [6, 10, 1315, 17, 1921, 32]. It has
mainly been used to quantify the effect of an ACL
rupture, and to measure the A–P laxity during the
follow-up after ACL surgery. As a tool for measuring
skeletal and implant motions, RSA is accurate and
precise down to 0.1 mm and 0.1–0.3° [4, 29] and it is
accurate and precise when it comes to measuring A–P
laxity for repeated testing over time [9]. When the ef-
fect of external forces is studied, the repeatability de-
creases due to several factors, such as variations in
muscular tension and inconsistencies in the application
of external forces [5, 6, 14, 20, 21].
RSA examinations
All the patients were examined in a radiographic
laboratory specifically designed to perform RSA
examinations of joints (Fig. 2a). The RSA measure-
ments were made by one experienced examiner from
the radiographic department. Two ceiling-mounted
radiographic tubes, one anterior–posterior and one
lateral, connected to two separated generators, were
used to obtain simultaneous exposures. The patients
were examined in the supine position with the knee in
a Plexiglas calibration cage [32] (Fig. 2b). The distal
femur was fixed with an adjustable frame to minimise
femoral movements. Anterior and posterior loads
were applied approximately 7 cm distal to the joint
line (Fig. 2b). We used the same set-up as that pre-
viously described by Brandsson et al. [6] and Ka
¨
rr-
holm et al. [21].
Fig. 2 a The RSA laboratory with two ceiling-mounted radio-
graphic tubes. b The Plexiglas cage
Knee Surg Sports Traumatol Arthrosc (2006) 14:1108–1115 1111
123
The following positions were tested:
extended knee (0°)
–30° of flexion
–30° of flexion with an anterior traction of 150 N
–30° of flexion with a posterior pushing force of 80 N
The mean intra-articular displacement of the two tips
of the intercondylar eminence along an anterior–pos-
terior axis of the knee represented the A–P laxity. The
femoral markers were used as fixed reference segments.
The median value (range) of the ‘‘mean errors of rigid
body fitting’’ and condition numbers representing mar-
ker stability and scatter were 0.047 mm (0.0–0.236) and
107 (40–318). During the pre-operative examinations,
both the injured and the non-injured side were exam-
ined. At follow-up, the post-operative side-to-side
differences in displacement were based on the pre-
operative measurements of the intact knee, i.e. the
baseline examination. Measurements of digital radio-
graphs and computations of three-dimensional co-
ordinates [28] were performed using a software package
(UMRSA 5.0, RSA Biomedical, Umea
˚
, Sweden).
KT-1000 arthrometer test
A standard KT-1000 (MEDmetric Corp., San Diego,
CA, USA) was used [32]. One experienced observer,
physiotherapist, performed all the measurements [2].
Both legs were placed on the thigh support with the
knee in 30° of flexion. The arms of the patient were
placed along the side of the body and the patient was
instructed to relax. Before each test, the instrument
was calibrated to zero. The intact knee was always
tested first. The median value of three measurements
for each knee was registered, using a force of 139 N.
Range of motion
Range of motion was recorded on both sides pre-
operatively and at each follow-up. A standard hand-
held goniometer was used. Values were rounded off to
the nearest increment of 5°. The extension measure-
ments were performed with the patient in the supine
position and flexion was measured when the patient
slid his/her heel as close to the buttocks as possible
without any help from the arms.
Clinical tests
The ROM, the Lysholm score, Tegner activity level
[41], the IKDC evaluation system [12] and one-leg-hop
test were performed pre-operatively and at each fol-
low-up.
During the one-leg-hop test, the patient jumped and
landed on the same foot with his/her hands behind his/
her back. The longest hop of three attempts was reg-
istered. A quotient (%) was calculated between the
intact and the injured knee [11, 40].
Statistical methods
All the values are presented as the median and range.
The Mann–Whitney U-test was used in the indepen-
dent comparison of the two groups for non-parametric
data and Wilcoxon‘s-signed-rank test was used to
evaluate changes in parameters over time. A P-value
of less than 0.05 was regarded as statistically significant.
Results
All the randomised patients in Group A and Group B
completed their participation in the study.
Anterior–posterior laxity
Pre-operatively, the side-to-side difference using RSA
was 8.6 mm (2.3–15.4) in Group A and 7.2 mm
(2.2–17.4) in Group B, and using the KT-1000 2.0 mm
(0–8.0) in Group A and 4.0 mm (0–10.0) in Group B
(Tables 2 and 3), without any statistical differences
between Groups A and B (n.s.).
At the 6-month follow-up, the side-to-side difference
using RSA was 3.4 mm (–0.6 to 11.5) in Group A and
3.4 mm (–3.3 to 7.8) in Group B, and using the KT-
1000, 0 mm (–3.0 to 1.5) in Group A and 1.5 mm (–0.5
to 4.5) in Group B (Tables 2 and 3), without any sta-
tistical differences between Groups A and B (n.s.).
At the 2-year follow-up, the side-to-side difference
using RSA was 2.7 mm (0–10.7) in Group A and
2.8 mm (–1.8 to 9.5) in Group B, and using the
KT-1000 1.0 mm (–1.5 to 3.5) in Group A, and 0.5 mm
(–1.0 to 4.0) in Group B (Tables 2 and 3), without any
differences between Groups A and B (n.s.).
Table 2 A–P laxity with RSA pre-operatively and at the 2-year
follow-up
RSA Group A
(mm)
Group B
(mm)
Group
A vs. B
Pre-operatively 8.6 (2.3–15.4) 7.2 (2.2–17.4) n.s.
6 months post-op 3.4 (–0.6 to 11.5) 3.4 (–3.3 to 7.8) n.s.
24 months post-op 2.7 (0–10.7) 2.8 (–1.8 to 9.5) n.s.
Pre-op vs.
24 months
P = 0.005 P = 0.005
A–P laxity (side-to-side difference). All measurements are
median (range)
1112 Knee Surg Sports Traumatol Arthrosc (2006) 14:1108–1115
123
Both groups displayed a significant reduction in A–P
laxity between the pre-operative examination and the
2-year follow-up for both the RSA and KT-1000
measurements (Tables 2 and 3), in Group A (RSA
P = 0.005 and KT-1000 P = 0.0096), and in Group B
(RSA P = 0.005 and KT-1000 P = 0.004).
Neither patients in Group A nor Group B had any
motion problems in terms of restricted knee flexion or
extension at 2-year follow-up. The ROM did not differ
between them pre-operatively, after 6 months and
2 years. The ROM data is presented in Tables 4 and 5.
The clinical results in terms of the Lysholm score,
Tegner activity level, one-leg-hop test and IKDC did
not differ between the two groups (Table 5).
Five patients had a partial meniscal tear, two medial
in Group A and one medial and two laterals in Group
B. These tears were addressed with a partial resection
at the time of the index operation.
Discussion
Our hypothesis that permitting active and passive
extension training without any restrictions in extension
immediately after an ACL reconstruction, using bone-
patellar tendon-bone graft, could be done without
jeopardising the A–P laxity of the knee was verified.
Our finding has clinical relevance when it comes to
the choice of post-operative rehabilitation after an
ACL reconstruction, using bone-patellar tendon-bone
graft. According to our findings permission of full ac-
tive and passive extension training immediately after
an ACL reconstruction did not increase the post-
operative A–P laxity.
The current trend in the post-operative management
of ACL reconstruction is early active extension train-
ing after the ACL reconstruction. Our aim was to as
accurately as possible evaluate the A–P laxity in the
knee after an ACL reconstruction.
To our knowledge, there are no randomised studies
with adequate follow-up after an ACL reconstruction,
which have used such an accurate method as RSA to
evaluate the effect of different training protocols on
the A–P laxity of the knee.
In spite of the lack of randomised studies many
rehabilitation programmes already include early full
active and/or passive extension after an ACL recon-
struction.
The principles of accelerated rehabilitation were
described by Shelbourne and Nitz [35] and were fur-
ther modified by Muneta et al. [26]. The results have
been considered as uniformly good, especially in pa-
tients operated on using bone-patellar tendon-bone
autograft. Muneta et al. [26] described less good results
in patients operated on using hamstrings (multi-strand
semitendinosus tendon), especially in terms of in-
creased knee laxity at follow-up. A recent study has
shown that the time to recovery is often longer than
6 months [1].
We choose to use a rehabilitation brace to adapt to
clinical practice. One important problem with such
braces is that they do not guarantee concordance with
the true extension of the patient’s knee [22]. In the
present study we found that the brace used could allow
hyperextension to 10°, provided these conditions were
found in the knee to be tested.
We used the RSA method and the conventional KT-
1000 arthrometer. The first of these methods relies on
skeletal markers and has high resolution and repro-
ducibility. There are some disadvantages using RSA
because it is an invasive method, and each patient and
investigation will take longer time and need more re-
source, for instance a specially designed laboratory, is
needed. Even if the radiation is lower than for an or-
dinary radiographic examination, the examinations add
to the total radiation burden. The advantage with
highly accurate measurements is that they can provide
Table 3 A–P laxity with the KT-1000 pre-operatively and at the
2-year follow-up
KT-1000 Group A
(mm)
Group B
(mm)
Group
A vs. B
Pre-op 2.0 (0–8.0) 4.0 (0–10.0) n.s.
6 months post-op 0 (–3.0 to 1.5) 1.5 (–0.5 to 4.5) n.s.
24 months post-op 1.0 (–1.5 to 3.5) 0.5 (–1.0 to 4.0) n.s.
Pre-op vs.
24 months
P = 0.0096 P = 0.004
A–P laxity (side-to-side difference). All measurements are
median (range)
Table 4 Knee extension in the intact and the injured knee,
2 years after the ACL reconstruction in Group A and Group B
(a) Group A (b) Group B
Intact
knee
Injured
knee
Intact
knee
Injured
knee
Patient 1 0 0 0 0
Patient 2 –10 –10 0 0
Patient 3 –10 –5 –5 –5
Patient 4 0 0 –10 5
Patient 5 0 0 0 0
Patient 6 0 0 –10 0
Patient 7 –5 0 –5 0
Patient 8 –5 –5 0 0
Patient 9 –15 –10 0 0
Patient 10 0 -5 –5 0
Patient 11 –5 –5 –10 –5
Group A allowing full extension; Group B not allowing exten-
sion 30 to –10°
Knee Surg Sports Traumatol Arthrosc (2006) 14:1108–1115 1113
123
important information from a relatively small patient
cohort and after a comparatively short period of time.
This means that the numbers of patients exposed to a
new unproven treatment or implant can be limited to a
minimum.
The present study did not reveal any significant
differences in terms of knee laxity, using either meth-
od. The recorded values differed between the RSA and
the KT-1000. All patients in the study underwent an
arthroscopy where the ACL rupture was verified. Ten
of these 22 patients had a pre-operative side-to-side
difference less than 3 mm using the KT-1000. This
underlines one of the problems using the KT-1000. The
results are similar compared with previous studies [16],
which have shown that KT-1000 underestimates the
side-to-side difference. Despite the fact that the results
of the two methods were not numerically identical,
both indicated that early active and passive extension
training is safe and that it does not jeopardise the A–P
laxity of the knee.
Besides the primary aim we studied some clinical
parameters such as ROM, the Lysholm score, Tegner
activity level, one-leg-hop test and IKDC. The reason
for this was to show that these patients had a clinical
status similar to other ACL studies with a clinical ap-
proach at the follow-up examinations.
We were not able to document any clinical superi-
ority in the knee function using the early extension
training protocol at the 6-month or 2-year follow-up.
Some studies have shown that aggressive extension
immediately after an ACL reconstruction might in-
crease the laxity of the knee [8], and some other studies
have shown that females have more laxity in their
knees than males after an ACL reconstruction [39]. In
the randomising process it so happened that there were
more females, who were allowed early extension. De-
spite this asymmetry, which theoretically could imply
increased risk of graft elongation in the early extension
group, no such effect was observed.
One interesting and potentially important finding
was that more patients regained hyperextension (5–
10°) of the injured knee in the early extension training
group, compared with the traditional group. This
finding is in line with the observation of Shelbourne
and Nitz [35], who found that extension losses was
deleterious in terms of the ability of patients to return
to sports participation. Loss of extension also increased
the risk of further surgical interventions due to symp-
tomatic extension deficit. These researchers also noted
that patients who started the closed- or open kinetic
exercises early after the ACL reconstruction regained
quadriceps strength earlier than those who were trea-
ted with a delayed protocol. The accelerated protocol
was also shown to be beneficial in terms of less anterior
knee pain [35].
We conclude that it appears to be safe, to start early
active and passive extension training without restric-
tion in extension immediately after the ACL recon-
struction with a patellar tendon autograft.
References
1. Augustsson J, Thome
´
e R, Karlsson J (2004) Ability of a new
hop test to determine functional deficits after anterior cru-
ciate ligament reconstruction. Knee Surg Sports Traumatol
Arthrosc 12:350–356
2. Ballantyne BT, French AK, Heimsoth SL, Kachingwe AF,
Lee JB, Soderberg GL (1995) Influence of examiner expe-
rience and gender on interrater reliability of KT-1000 arth-
rometer measurements. Phys Ther 75:898–906
3. Bjordal JM, Arno
¨
y F, Hannestad B, Strand T (1997) Epi-
demiology of anterior cruciate ligament injuries in soccer.
Am J Sports Med 25:341–345
4. Bragdon CR, Malchau H, Yuan X, Perinchief R, Ka
¨
rrholm J,
Borlin N, Estok DM, Harris WH (2002) Experimental
assessment of precision and accuracy of radiostereometric
analysis for the determination of polyethylene wear in a total
hip replacement model. J Orthop Res 20:688–695
5. Brandsson S, Karlsson J, Eriksson BI, Ka
¨
rrholm J (2001)
Kinematics after tear in the anterior cruciate ligament. Dy-
namic bilateral radiostereometric studies in 11 patients. Acta
Orthop Scand 72:372–378
Table 5 The functional and objective results pre-operatively and at the 2-year follow-up
Group A (n = 11) Group B (n = 12) Group A:Group B
Pre-op 2 year Pre-op 2 year Pre-op 2 year
Tegner 3 (2–6) 7 (4–10) 3 (2–9) 6.5 (4–9) n.s. n.s.
Lysholm 76 (25–99) 95 (80–100) 70 (47–99) 97 (79–100) n.s. n.s.
One-leg-hop 82 (0–96) 97 (86–100) 80 (0–96) 96 (85–100) n.s. n.s.
IKDC A 0 4 0 4 n.s. n.s.
IKDC B 0 6 0 6 n.s. n.s.
IKDC C 5 1 5 1 n.s. n.s.
IKDC D 6 0 6 0 n.s. n.s.
Differences between Groups A and B (right)
1114 Knee Surg Sports Traumatol Arthrosc (2006) 14:1108–1115
123
6. Brandsson S, Karlsson J, Swa
¨
rd L, Kartus J, Eriksson BI,
Ka
¨
rrholm J (2002) Kinematics and laxity of the knee joint
after anterior cruciate ligament reconstruction. Am J Sports
Med 3:361–367
7. Bynum EB, Barrack RL, Alexander AH (1995) Open versus
closed chain kinetic exercises after anterior cruciate ligament
reconstruction—a prospective randomized study. Am J
Sports Med 23:401–406
8. DeVita P, Hortobagyi T, Barrier J (1998) Gait biomechanics
are not normal after anterior cruciate ligament reconstruc-
tion and accelerated rehabilitation. Med Sci Sports Exerc
30:1481–1488
9. Fleming BC, Peura GD, Abate JA, Beynnon BD (2001)
Accuracy and repeatability of Roentgen stereophotogram-
metric analysis (RSA) for measuring knee laxity in longitu-
dinal studies. J Biomech 34:1355–1359
10. Fride
´
n T, Ryd L, Lindstrand A (1992) Laxity and graft fix-
ation after reconstruction of the anterior cruciate ligament.
A roentgen stereophotogrammetric analysis of 11 patients.
Acta Orthop Scand 63:80–84
11. Gauffin H, Tropp H, Odenrick P (1988) Effect of ankle disk
training on postural control in patients with functional
instability of the ankle joint. Int J Sports Med 9:141–144
12. Hefti F, Muller W, Jakob RP, Staubli HU (1993) Evaluation
of knee ligament injuries with the IKDC form. Knee Surg
Sports Traumatol Arthrosc 1:226–234
13. Jonsson H, Elmqvist L-G, Ka
¨
rrholm J, Fugl-Meyer A (1992)
Graft lengthening after surgery of anterior cruciate ligament.
Roentgen stereophotogrammetry of 32 cases. Acta Orthop
Scand 63:587–592
14. Jonsson H, Ka
¨
rrholm J (1994) Three-dimensional knee joint
movements during a step-up: evaluation after anterior cru-
ciate ligament rupture. J Orthop Res 12:769–779
15. Jonsson H, Ka
¨
rrholm J, Elmqvist LG (1989) Kinematics of
active knee extension after tear of the anterior cruciate lig-
ament. Am J Sports Med 17:792–802
16. Jonsson H, Ka
¨
rrholm J, Elmqvist LG (1993) Knee laxity
after cruciate ligament injury. The KT-1000 arthrometer
versus roentgen stereophotogrammetry in 86 patients. Acta
Orthop Scand 64:567–570
17. Jorn LP, Fride
´
n T, Ryd L (1998) Simultaneous measure-
ments of sagittal knee laxity with an external device and
radiostereometric analysis. J Bone Joint Surg Br 80:169–172
18. Ja
¨
rvinen M, Natri A, Lehto M, Kannus P (1995) Recon-
struction of chronic anterior cruciate ligament insufficiency
in athletes using a bone-patellar tendon-bone autograft. A
two-year follow up study. Int Orthop 19:1–6
19. Ka
¨
rrholm J (1989) Roentgen stereophotogrammetry. Review
of orthopaedic applications. Acta Orthop Scand 60:491–503
20. Ka
¨
rrholm J, Brandsson S, Freeman MAR (2000) Changes of
axial tibial rotation at the weight-bearing knee studied by
RSA. J Bone Joint Surg Br 82:1201–1203
21. Ka
¨
rrholm J, Selvik G, Elmqvist LG, Hansson LI, Jonsson H
(1988) Three-dimensional instability of the anterior cruciate
deficient knee. J Bone Joint Surg Br 70:777–783
22. Mikkelsen C, Cerulli G, Lorenzini M, Bergstrand G, Werner
S (2003) Can a post-operative brace in slight hyperextension
prevent extension deficit after anterior cruciate ligament
reconstruction? A prospective randomized study. Knee Surg
Sports Traumatol Arthrosc 11:318–321
23. Mikkelsen C, Werner S, Eriksson E (2000) Closed kinetic
chain alone compared to combined open and closed kinetic
chain exercises for quadriceps strengthening after anterior
cruciate ligament reconstruction with respect to return to
sports: a prospective matched follow-up study. Knee Surg
Sports Traumatol Arthrosc 8:337–342
24. Morrisey MC, Drechsler WI, Morrisey D, Knight PR,
Armstrong P, McAuliffe T (2002) Effects of distally fixated
versus nondistally fixated leg extensor resistance training on
knee pain in the early period after anterior cruciate ligament
reconstruction. Phys Ther 82:35–43
25. Morrisey MC, Hudson ZL, Drechsler WI, Coutts FJ, Knight
PR, Ki JB (2000) Effects of open versus closed kinetic chain
training on knee laxity in the early period after anterior
cruciate ligament reconstruction. Knee Surg Sports Trau-
matol Arthrosc 8:343–348
26. Muneta T, Sekiya I, Ogiuchi T, Yagishita K, Yamamoto H,
Shinomiy K (1998) Effects of aggressive early rehabilitation on
the outcome of anterior cruciate ligament reconstruction with
multi-strand semitendinosus tendon. Int Orthop 22:352–356
27. Nielsen AB, Yde J (1989) Epidemiology and traumatology
of injuries in soccer. Am J Sports Med 17:803–807
28. Noyes FR, Mangine RE, Barber S (1987) Early knee motion
after open and arthroscopic anterior cruciate ligament
reconstruction. Am J Sports Med 15:149–160
29. Onsten I, Berzins A, Shott S, Sumner DR (2001) Accuracy
and precision of radiostereometric analysis in the measure-
ment of THR femoral component translations: human and
canine in vitro models. J Orthop Res 19:1162–1167
30. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF
(1993) Tendon healing in a bone tunnel. A biomechanical
and histological study in the dog. J Bone Joint Surg Am
75:1795–1803
31. Roos H, Karlsson J (1998) Anterior cruciate ligament
instability and reconstruction. Review of current trends in
treatment. Scand J Med Sci Sports 8:426–431
32. Selvik G (1974, 1989) Roentgen stereophotogrammetry. A
method for the study of the kinematics of the skeletal system.
Thesis, Lund: University of Lund Sweden, Reprint: Acta
Orthop Scand (Suppl. 232)
33. Sernert N, Kartus J, Ko
¨
hler K, Ejerhed L, Karlsson J (2001)
Evaluation of the reproducibility of the KT-1000 arthrome-
ter. Scand J Med Sci Sports 11:120–125
34. Shelbourne KD, Klootwyk M, Wilckens J, Decarlo M (1995)
Ligament stability two to six years after anterior cruciate
ligament reconstruction with autogenous patellar tendon
graft and participation in accelerated program. Am J Sports
Med 23:575–579
35. Shelbourne KD, Nitz P (1990) Accelerated rehabilitation
after anterior cruciate ligament reconstruction. Am J Sports
Med 18:292–299
36. Shelbourne KD, Patel DV (1996) Rehabilitation after
autogenous bone-patellar tendon-bone ACL reconstruction.
Instr Course Lect 45:263–273
37. Shelbourne KD, Patel DV (1999) Treatment of limited
motion after anterior cruciate ligament reconstruction. Knee
Surg Sports Traumatol Arthrosc 7:85–92
38. Shelbourne KD, Rowdon GA (1994) Anterior cruciate lig-
ament injury. The competitive athlete. Sports Med 17:132–
140
39. Shino K, Inoue M, Horibe S, Nakamura H, Ono K (1987)
Measurement of anterior instability of the knee. A new
apparatus for clinical testing. J Bone Joint Surg Br 69:608–613
40. Stark J (1850) Two cases of ruptured crucial ligaments of the
knee joint. Edinb Med Surg 74:267–271
41. Tegner Y, Lysholm J, Lysholm M, Gillquist J (1986) A
performance test to monitor rehabilitation and evaluate
anterior cruciate ligament injuries. Am J Sports Med 14:156–
159
42. Yack HJ, Collins CE, Whieldon TJ (1993) Comparison of
closed and open kinetic chain exercise in the anterior cru-
ciate ligament-deficient knee. Am J Sports Med 21:49–54
Knee Surg Sports Traumatol Arthrosc (2006) 14:1108–1115 1115
123
... Compared with an uninjured leg, individuals with ACLR spent less time in double-limb support during late adaptation. However, the ACLR group was capable of adjusting this parameter in such a way that the PG leg spent an increased amount of time in double support during the de-adaptation period [59][60][61][62]. ...
Article
Full-text available
Gait analysis is recognized as a method used in quantifying gait disorders and in clinical evaluations of patients. However, the current guidelines for the evaluation of post anterior cruciate ligament reconstruction (ACLR) patient outcomes are primarily based on qualitative assessments. This study aims to apply gait analyses and mathematical, index-based health management, using the Mahalanobis Taguchi System (MTS) and the Kanri Distance Calculator (KDC) to diagnose the level of the gait abnormality and to identify its contributing factors following ACLR. It is hypothesized that (1) the method is able to discriminate the gait patterns between a healthy group (HG) and patients with ACLR (PG), and (2) several contributing factors may affect ACLR patients’ rehabilitation performance. This study compared the gait of 10 subjects in the PG group with 15 subjects in the HG. The analysis was based on 11 spatiotemporal parameters. Gait data of all subjects were collected in a motion analysis laboratory. The data were then analyzed using MTS and KDC. In this study, two significant groups were recognized: the HG, who achieved results which were within the Mahalanobis space (MS), and (ii) the PG who achieved results above the MS. The results may be seen as being on-target and off-target, respectively. Based on the analysis, three variables (i.e., step width, single support time, and double support time) affected patient performance and resulted in an average mark of above 1.5 Mahalanobis distance (MD). The results indicated that by focusing on the contributing factors that affect the rehabilitation performance of the patients, it is possible to provide individualized and need-based treatment.
... En cuanto a los ejercicios isométricos, se recomienda comenzarlos inmediatamente tras la cirugía (34) . ...
... Early joint motion is beneficial when it comes to avoiding capsular contractions, reducing swelling and pain, and gaining early full passive and active extension appears to have no adverse effect on joint laxity. 16 Unsatisfactory recovery of joint range of motion appears to adversely affect subjective and objective outcome markers in late-stage rehabilitation. 17 Use of aquatic therapy can support the improvement in both joint swelling and passive and active range of motion. ...
Article
Full-text available
Outcomes after long-term injuries such as anterior cruciate ligament reconstruction (ACLR) need improving. One area which has received limited research attention is the use of aquatic therapy to optimize the functional recovery process after injury. There is still limited understanding of what the benefits of the pool can bring for rehabilitation and particularly what and when can be done in the pool after injury. This clinical commentary describes how the application of the properties of water can support the functional recovery process after ACLR. Here it is proposed that the main properties (density, hydrostatic pressure, buoyancy and viscosity) of aquatic therapy, if applied correctly to rehabilitation practices, can be used to achieve six primary goals after ACLR : 1) assist in the reduction of pain and swelling; 2) support the recovery of gait; 3) support the maintenance and/ or development of cardiovascular fitness; 4) help accelerate and optimize motor pattern retraining; 5) allow for earlier introduction of plyometrics and power training and 6) support the between session recovery and optimal load management, particularly in the later phases of rehabilitation. If implemented correctly, the presented phased protocol can support practitioners in implementing or delivering aquatic therapy rehabilitation services to their injured athletes. To support implementation, the authors have provided a specific protocol and supplementary videos for the use of aquatic therapy after ACLR. Level of evidence: 5.
... Current guidelines for evaluating an ACLR patient's results are primarily based on clinicians' decisions and experience. These guidelines usually consist of qualitative assessment of early intervention plans that emphasizes restoring flexibility, muscular strength, and ligament stability by using closed kinetic chain exercises [71][72][73]. However, a major problem with this kind of qualitative assessment is the clinician's capacity to provide safe, high-quality care can be reliant on their ability to reason, think, and judge, which can be restricted by absence of experience [74,75]. ...
Article
Full-text available
In this paper, a gait patterns classification system is proposed, which is based on Mahalanobis–Taguchi System (MTS). The classification of gait patterns is necessary in order to ascertain the rehab outcome among anterior cruciate ligament reconstruction (ACLR) patients. (1) Background: One of the most critical discussion about when ACLR patients should return to work (RTW). The objective was to use Mahalanobis distance (MD) to classify between the gait patterns of the control and ACLR groups, while the Taguchi Method (TM) was employed to choose the useful features. Moreover, MD was also utilised to ascertain whether the ACLR group approaching RTW. The combination of these two methods is called as Mahalanobis-Taguchi System (MTS). (2) Methods: This study compared the gait of 15 control subjects to a group of 10 subjects with laboratory. Later, the data were analysed using MTS. The analysis was based on 11 spatiotemporal parameters. (3) Results: The results showed that gait deviations can be identified successfully, while the ACLR can be classified with higher precision by MTS. The MDs of the healthy group ranged from 0.560 to 1.180, while the MDs of the ACLR group ranged from 2.308 to 1509.811. Out of the 11 spatiotemporal parameters analysed, only eight parameters were considered as useful features. (4) Conclusions: These results indicate that MTS can effectively detect the ACLR recovery progress with reduced number of useful features. MTS enabled doctors or physiotherapists to provide a clinical assessment of their patients with more objective way.
... This study enabled us to ask about and analyze a small number of important rehabilitation-related issues in the revision ACL reconstruction setting, including early versus delayed active and passive range of motion, immediate versus delayed weightbearing, and rehabilitative and functional bracing. Range of motion has been analyzed in previous studies of primary ACL reconstructions 7,40 . Early initiation of extension and flexion has not been noted to be deleterious for the graft and may aid in obtaining a full range of motion. ...
Article
Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes than primary ACL reconstruction. The reasons remain varied and not completely understood. Methods: Patients undergoing revision ACL reconstruction were prospectively enrolled. Data collected included baseline demographics, surgical technique and pathological condition, prescribed rehabilitation instructions, and a series of validated patient-reported outcome instruments. Patients were followed for 2 years and asked to complete a set of outcome instruments identical to those completed at baseline. Subsequent surgical procedures on the ipsilateral knee were recorded. Regression analysis was used to control for age, sex, activity level, baseline outcome scores, and the above-mentioned rehabilitation-related variables in order to assess the factors affecting clinical outcomes 2 years after revision ACL reconstruction. Results: A total of 843 patients met the inclusion criteria and were successfully enrolled, and 82% (695) were followed for 2 years. Two rehabilitation-related factors were found to influence outcome. First, patients who were prescribed an ACL brace for their return to sports had a significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) for sports and recreational activities at 2 years (odds ratio [OR] =1.50, 95% confidence interval [CI] = 1.07 to 2.11; p = 0.019). Second, patients prescribed an ACL brace for the postoperative rehabilitation period were 2.3 times more likely to have subsequent surgery by 2 years (OR = 2.26, 95% CI = 1.11 to 4.60; p = 0.024). The odds of a graft rerupture were not affected by any type of brace wear. Conclusions: Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years. Weight-bearing and motion can be initiated immediately postoperatively. Bracing during the early postoperative period is not helpful. Use of a functional brace early in the postoperative period was associated with an increased risk of a reoperation. Use of a functional brace for a return to sports improved the KOOS on the sports/recreation subscale. Level of evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Chapter
This chapter summarizes data in the current literature regarding return to sports (RTS) after patellofemoral realignment surgery from 52 studies encompassing 1892 patients. There were 1408 patients in 36 studies that underwent medial patellofemoral ligament (MPFL) reconstruction or repair and 484 patients in 16 studies that underwent a variety of patellar proximal and/or distal realignment procedures that did not involve MPFL reconstruction or repair (such as Fulkerson and Elmslie-Trillat). Following MPFL reconstruction, a mean of 70% of patients returned to preinjury sports activity levels, a mean of 83% returned to any sport, and the approximate mean postoperative Tegner score was 5.2 points. After other proximal/distal procedures, the mean values for return to preinjury sports (provided in only 5 studies) ranged from 22% to 97% and the mean postoperative Tegner score was 4.1 points. The mean time patients were usually allowed to RTS was provided in 28 studies and varied from 3 to 9 months postoperatively. Almost no objective criteria were provided to determine when patients could be safely released to either sports-specific training or unrestricted athletic activities. The failure rates were <10% in the majority of studies. The Cincinnati Sports Medicine and Orthopedic Center postoperative rehabilitation program and return to sport criteria are provided.
Chapter
This chapter presents a comprehensive rehabilitation program that should be performed before ACL reconstruction and documents data from multiple studies that demonstrate the advantages of formal preoperative therapy in terms of restoration of knee motion, muscle strength, and neuromuscular function. Major issues to treat and resolve before surgery are discussed, including hemarthrosis and knee joint effusion, pain, muscle weakness and inhibition, and abnormal gait mechanics.
Chapter
This chapter reviews the running, agility, basic plyometric, and advanced Sportsmetrics neuromuscular training programs for anterior cruciate ligament reconstruction postoperative rehabilitation. The exercises are detailed, with the criteria provided to advance the patient through training in a manner that is safe and responsive to the patient’s final activity-level goals. Our comprehensive objective assessment of muscle strength, neuromuscular function, balance, range of knee motion, and ligament stability required for release to unrestricted athletics is provided.
Chapter
This chapter reviews the scientific principles and concepts for anterior cruciate ligament reconstruction postoperative rehabilitation programs. The scientific concepts and basis for immediate knee motion and weight-bearing, as well as early restoration of muscle strength and neuromuscular function, are presented. Potential major complications are discussed, including infection, deep venous thrombosis, arthrofibrosis, complex regional pain syndrome, and patella infera, to enable early detection and treatment. The exercises and modalities used for programs are presented. Criteria are provided to advance the patient in a manner that is safe to the healing graft and responsive to the patient’s final activity level goals.
Article
Full-text available
The hypothesis proposed in this study was that the initiation of active and passive knee motion within 48 hours of major intraarticular knee ligament surgery would not have the deleterious effects of increasing knee effusion, hemarthrosis, periarticular soft tissue edema, and swelling. We conducted a prospective study with randomized assignment of 18 patients into two groups: 9 patients in the "motion" group began 10 hours of daily continu ous passive motion (CPM) on the 2nd postoperative day, while the remaining 9 in the "delayed motion" group used a soft hinged knee brace with knee hinges locked at 10° of flexion and entered into the motion program on the 7th postoperative day. All knees were allowed full 0° to 90° of motion except for a total of seven knees with concomitant mensicus repairs and extraar ticular reconstructions where 20° to 90° of motion was allowed, limiting the last 20° of knee extension for the first 4 postoperative weeks to protect the repair. In all other respects, the rehabilitation program after surgery was the same for the two groups, including postoper ative compression dressings, exercises, and weight- bearing status. Ten of the eighteen patients had acute ACL disrup tions and 8 had chronic ACL insufficiencies. There was an even distribution of acute and chronic knee cases and of open and arthroscopic ligament procedures in the early and delayed motion groups. Associated sur gery included four meniscus repairs, three medial col lateral ligament repairs, and one lateral collateral liga ment repair. Special suturing and fixation techniques were used at surgery to maintain the integrity of liga ment and meniscus structures, allowing the surgeon to feel safe in subjecting the joint to early postoperative motion. The objective parameters measured were KT- 1000 arthrometer measurements, Cybex isokinetic testing, girth measurements at four lower limb loca tions, range of motion goniometer measurements, post operative pain medications, and days of hospitalization. Starting intermittent passive motion on the 2nd post operative day did not increase joint effusion, hemar throsis, or soft tissue swelling. In both motion groups, postoperative joint effusions were absent after the 14th postoperative day. There was no statistically significant difference in knee extension or flexion limits, pain med ication used, or hospital stay in comparing the two knee motion programs. An important finding of this study was the significant decreases in thigh circumference that occurred within the first few weeks of surgery, which progressed de spite a closely supervised inpatient and outpatient re habilitation program. The decreased thigh girth was related to the type of operative procedure. Arthroscopic reconstructions had only 25% to 38% of the loss of thigh girth found in open operative procedures. By the 7th postoperative day, the average circumference loss for the open reconstruction group (motion at 7th post operative day) was nearly 4 cm, compared with the arthroscopic group's average of 1 cm. By the 21 st postoperative day, all patients who underwent open procedures sustained an average of 6.5 cm thigh cir cumference decrease compared with a 2 to 3.5 cm loss in the arthroscopic group. We concluded that traditional rehabilitation protocols are often ineffective in prevent ing the significant quadriceps muscle atrophy that may occur within the first few days of surgery. Of importance was the finding that initiating early knee motion did not stretch out ligamentous recon structions. We strongly recommend an early motion program to decrease the morbidity of major intraarti cular ligamentous procedures. The program is initiated within the hospital setting immediately after knee sur gery.
Article
Full-text available
32 patients with old anterior cruciate ligament injuries were operated on with patellar tendon-prepatellar tissue-quadriceps tendon graft over the top without and with augmentation (Kennedy-LAD). The anteroposterior (AP) laxity was assessed preoperatively, and at 6, 12, and 24 months after the operation with roentgen stereophotogrammetry. 6 months postoperatively the instability had decreased 5.4 mm in the nonaugmented and 1.9 mm in the augmented group, but not to normal values. During the following 18 months the AP laxity increased and returned to the preoperative level. At 2 years, 28 of the 32 patients were considered good or excellent, according to the Lysholm score. There was a lack of correlation between AP laxity and functional tests.
Article
We obtained simultaneous measurements of sagittal knee laxity in 12 consecutive patients after reconstruction of the anterior cruciate ligament (ACL), using the Stryker laxity tester and radiostereometric analysis (RSA). The mean anteroposterior (AP) displacement when a 90 N load was applied in both directions was 5.3 ± 2.7 mm with RSA and 9.8 ± 1.6 mm with the external device (p < 0.001). The corresponding measurements at a load of 180 N were 5.7 ± 2.4 mm and 13.8 ± 3.7 mm, respectively (p < 0.001). More than 50% of the sagittal knee movement, as measured by the external device at a load of 180 N, was not true femorotibial displacement of the joint but was due to soft-tissue deformation.
Article
To overcome many of the complications after ACL reconstruction (prolonged knee stiffness, limitation of complete extension, delay in strength recovery, anterior knee pain), yet still maintain knee stability, we developed a rehabilitation protocol that emphasizes full knee extension on the first postoperative day and immediate weightbearing according to the patient's tolerance. Of 800 patients who underwent intraarticular ACL patellar tendon-bone graft reconstruction, performed by the same surgeon, the last 450 patients have followed the accelerated rehabilitation schedule as outlined in the protocol. A longer than 2 year followup is recorded for 73 of the patients in the accelerated rehabilitation group. On the 1st postoperative day, we encouraged these patients to walk with full weightbearing and full knee extension. By the 2nd postoperative week, the patients with a 100 degree range of motion participated in a guided exercise and strengthening program. By the 4th week, patients were permitted unlimited activities of daily living and were allowed to return to light sports activities as early as the 8th week if the Cybex strength scores of the involved extremity exceeded 70% of the scores of the noninvolved extremity and the patient had completed a sport-specific functional/agility program. The patient database was compiled from frequent clinical examinations, periodic knee questionnaires, and objective information, such as range of motion measurements, KT-1000 values, and Cybex strength scores. A series of graft biopsies obtained at various times have revealed no adverse histologic reaction.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
The sagittal laxity of the knee was measured in 11 consecutive patients with chronic anterior cruciate ligament deficiency before and 1 year after ligament reconstruction with a free bone-tendon-bone graft from the patellar tendon (modified Clancy technique). Tantalum markers were implanted in the femur, in the tibia, and in the graft for roentgen stereophotogrammetric analysis (RSA) of the sagittal laxity and the migration of the bony ends of the graft. The precision in measurements of total anterior-posterior displacement (± 2 SD of the differences between repeated measurements) was 2.2 mm. A decrease in total anterior-posterior displacement from 12 mm before reconstruction to 5 mm 1 year postoperatively using a stress load of 150 N was found. The bony ends of the free graft migrated maximally 0.7 mm, implying adequate fixation.
Article
Thirty athletes (18 men and 12 women) were followed up for an average of 2.2 years after operative reconstruction for chronic anterior cruciate injuries with a mini-arthrotomy technique using a bone-patellar ligament-bone autograft. All the patients were active in sports, and the injuries in 40% occurred while playing soccer. The average delay between injury and reconstruction was 4.7 years; before this 26 knee operations had been carried out in 22 of the patients. At follow up, 20 patients were satisfied subjectively and 22 were classified objectively as excellent or good. Anteroposterior stability was good in 29 knees, and the Lachman and pivot shift tests were strongly positive in only one patient. Wasting of the thigh was more prominent in 9 patients who had a flexion deficit of 10° or more, than in the other 21. Of the 15 competitive athletes, who had all given up their sport after injury, 8 were able to return to sport. Reconstruction using a bone-patellar ligament-bone autograft is recommended for symptomatic chronic anterior cruciate ligament insufficiency in athletes.
Article
To overcome many of the complications after ACL reconstruction (prolonged knee stiffness, limitation of complete extension, delay in strength recovery, anterior knee pain), yet still maintain knee stability, we developed a rehabilitation protocol that emphasizes full knee extension on the first postoperative day and immediate weightbearing according to the patient's tolerance. Of 800 patients who underwent intraarticular ACL patellar tendon-bone graft reconstruction, performed by the same surgeon, the last 450 patients have followed the accelerated rehabilitation schedule as outlined in the protocol. A longer than 2 year followup is recorded for 73 of the patients in the accelerated rehabilitation group. On the 1st postoperative day, we encouraged these patients to walk with full weightbearing and full knee extension. By the 2nd postoperative week, the patients with a 100° range of motion participated in a guided exercise and strengthening program. By the 4th week, patients were permitted unlimited activities of daily living and were allowed to return to light sports activities as early as the 8th week if the Cybex strength scores of the involved extremity exceeded 70% of the scores of the noninvolved extremity and the patient had completed a sport-specific functional/agility program. The patient database was compiled from frequent clinical examinations, periodic knee questionnaires, and objective information, such as range of motion measurements, KT-1000 values, and Cybex strength scores. A series of graft biopsies obtained at various times have revealed no adverse histologic reaction. The evidence indicates that in this population, the accelerated rehabilitation program has been more effective than our initial program in reducing limitations of motion (particularly knee extension) and loss of strength while maintaining stability and preventing anterior knee pain.