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Anterior cruciate ligament reconstruction and return to sport activity: postural control as the key to success

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Abstract

Purpose

The risk for re-tear following anterior cruciate ligament (ACL) reconstruction is influenced by several hormonal, neuromuscular, biomechanical and anatomic factors. One of the most important negative prognostic factors that markedly increase the risk for ACL re-tear is the presence of high knee-abduction moment (KAM), which can be measured immediately by landing on both feet after a vertical jump. We evaluated the effect in postoperative values for KAM according to the type of graft used for ACL reconstruction (hamstring vs patellar tendon) and a specific rehabilitation protocol focusing on recovery of muscular strength, proprioception and joint stabilisation.

Methods

From November 2010 to September 2012, we enrolled 40 female recreational athletes with clinical and imaging evidence of ACL tear and randomised them in two groups. One group of patients underwent reconstruction with a hamstring-tendon graft and the second with a patellar-tendon graft. A custom rehabilitation programme focusing on proprioception was adopted. Clinical outcomes [International Knee Documentation Committee (IKDC) and Lysholm scores] and performance in functional test for stability (single-leg hop, timed hop, crossover triple hop, KAM test) were assessed preoperatively at three and six months postoperatively.

Results

All patients showed statistically significant clinical improvements postoperatively when compared with preoperative values (P < 0.0001). No significant intergroup difference was observed in all clinical scores and functional tests, with the exception of the value registered for the KAM test (P < 0.0001).

Conclusions

ACL reconstruction using patellar-tendon graft followed by rehabilitation centred on strength, proprioception and stability restoration can produce satisfactory values for KAM within the physiological range. The surgical strategies should be adapted to the patient on the basis of a multidisciplinary approach.

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References

  1. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR (1999) The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med 27(6):699–706

    CAS  PubMed  Google Scholar 

  2. Hewett TE, Myer GD, Ford KR (2006) Anterior cruciate ligament injuries in female athletes: part 1, mechanisms and risk factors. Am J Sports Med 34(2):299–311. doi:10.1177/0363546505284183

    Article  PubMed  Google Scholar 

  3. Hewett TE, Ford KR, Myer GD (2006) Anterior cruciate ligament injuries in female athletes: Part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med 34(3):490–498. doi:10.1177/0363546505282619

    Article  PubMed  Google Scholar 

  4. Wojtys EM, Huston LJ, Lindenfeld TN, Hewett TE, Greenfield ML (1998) Association between the menstrual cycle and anterior cruciate ligament injuries in female athletes. Am J Sports Med 26(5):614–619

    CAS  PubMed  Google Scholar 

  5. Ciuffreda P, Lelario M, Milillo P, Vinci R, Coppolino F, Stoppino L, Genovese E, Macarini L (2013) Mechanism of traumatic knee injuries and MRI findings. Musculoskelet Surg 97(2):127–135

    Article  Google Scholar 

  6. Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG (2009) Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am 91(10):2321–2328. doi:10.2106/JBJS.H.00539

    Article  PubMed  Google Scholar 

  7. Hewett TE, Myer GD, Ford KR (2005) Reducing knee and anterior cruciate ligament injuries among female athletes: a systematic review of neuromuscular training interventions. J Knee Surg 18(1):82–88

    PubMed  Google Scholar 

  8. Myer GD, Ford KR, Khoury J, Hewett TE (2011) Three-dimensional motion analysis validation of a clinic-based nomogram designed to identify high ACL injury risk in female athletes. Phys Sportsmed 39(1):19–28. doi:10.3810/psm.2011.02.1858

    Article  PubMed  Google Scholar 

  9. Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE (2010) Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med 38(10):1968–1978. doi:10.1177/0363546510376053

    Article  PubMed  Google Scholar 

  10. Webster KE, Feller JA (2012) The knee adduction moment in hamstring and patellar tendon anterior cruciate ligament reconstructed knees. Knee Surg Sports Traumatol Arthrosc: Off J ESSKA 20(11):2214–2219. doi:10.1007/s00167-011-1835-z

    Article  Google Scholar 

  11. Pinczewski LA, Deehan DJ, Salmon LJ, Russell VJ, Clingeleffer A (2002) A five-year comparison of patellar tendon versus four-strand hamstring tendon autograft for arthroscopic reconstruction of the anterior cruciate ligament. Am J Sports Med 30(4):523–536

    PubMed  Google Scholar 

  12. Papalia R, Franceschi F, Zampogna B, Tecame A, Maffulli N, Denaro V (2014) Surgical management of partial tears of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc : Off J ESSKA 22(1):154–165. doi:10.1007/s00167-012-2339-1

    Article  Google Scholar 

  13. Schulz KF, Altman DG, Moher D, Group C (2010) CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 340:c332. doi:10.1136/bmj.c332

    Article  PubMed Central  PubMed  Google Scholar 

  14. Franceschi F, Papalia R, Rizzello G, Del Buono A, Maffulli N, Denaro V (2013) Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: any clinical relevance? A retrospective comparative study. Arthroscopy: J Arthrosc Relat Surg : Off Publ Arthroscopy Assoc N Am Int Arthroscopy Assoc 29(8):1330–1337. doi:10.1016/j.arthro.2013.05.020

    Article  Google Scholar 

  15. Prins M (2006) The Lachman test is the most sensitive and the pivot shift the most specific test for the diagnosis of ACL rupture. Aust J Physiother 52(1):66

    Article  PubMed  Google Scholar 

  16. Hefti F, Muller W, Jakob RP, Staubli HU (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc : Off J ESSKA 1(3–4):226–234

    Article  CAS  Google Scholar 

  17. Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR (2009) The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med 37(5):890–897. doi:10.1177/0363546508330143

    Article  PubMed  Google Scholar 

  18. Barrios JA, Higginson JS, Royer TD, Davis IS (2009) Static and dynamic correlates of the knee adduction moment in healthy knees ranging from normal to varus-aligned. Clin Biomech 24(10):850–854. doi:10.1016/j.clinbiomech.2009.07.016

    Article  Google Scholar 

  19. Barber FA, Click SD (1997) Meniscus repair rehabilitation with concurrent anterior cruciate reconstruction. Arthroscopy: J Arthrosc Relat Surg : Off Publ Arthroscopy Assoc of N Am Int Arthroscopy Assoc 13(4):433–437

    Article  CAS  Google Scholar 

  20. Clatworthy M, Amendola A (1999) The anterior cruciate ligament and arthritis. Clin Sports Med 18(1):173–198, vii

    Article  CAS  PubMed  Google Scholar 

  21. Maffulli N, Osti L (2013) ACL stability, function, and arthritis: what have we been missing? Orthopedics 36(2):90–92. doi:10.3928/01477447-20130122-02

    Article  PubMed  Google Scholar 

  22. Hara K, Niga S, Ikeda H, Cho S, Muneta T (2008) Isolated anterior cruciate ligament reconstruction in patients with chronic anterior cruciate ligament insufficiency combined with grade II valgus laxity. Am J Sports Med 36(2):333–339. doi:10.1177/0363546507307501

    Article  PubMed  Google Scholar 

  23. Jacobsen K (1977) Osteoarthrosis following insufficiency of the cruciate ligaments in man. A clinical study. Acta Orthop Scand 48(5):520–526

    Article  CAS  PubMed  Google Scholar 

  24. van der Hart CP, van den Bekerom MP, Patt TW (2008) The occurrence of osteoarthritis at a minimum of ten years after reconstruction of the anterior cruciate ligament. J Orthop Surg Res 3:24

    Article  PubMed Central  PubMed  Google Scholar 

  25. Cebesoy O (2006) What are the risk factors in the development of osteoarthritis following ACL reconstruction? Int Orthop 30(5):431–431

    Article  PubMed Central  PubMed  Google Scholar 

  26. Krishnan SR, Randle R (2009) ACL reconstruction with unicondylar replacement in knee with functional instability and osteoarthritis. J Orthop Surg Res 4:43

    Article  PubMed Central  PubMed  Google Scholar 

  27. Madhusudhan T, Kumar T, Bastawrous S, Sinha A (2008) Clinical examination, MRI and arthroscopy and meniscal and ligamentous knee Injuries – a prospective study. J Orthop Surg Res 3:19

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  28. Papalia R, Zampogna B, Torre G, Lanotte A, Vasta S, Albo E, Tecame A, Denaro V (2014) Sarcopenia and its relationship with osteoarthritis: risk factor or direct consequence? Musculoskeletal surgery:1–6

  29. Maffulli N, Binfield PM, King JB (2003) Articular cartilage lesions in the symptomatic anterior cruciate ligament-deficient knee. Arthroscopy:J Arthrosc Relat Surg 19(7):685–690

    Article  Google Scholar 

  30. Osti L, Papalia R, Del Buono A, Leonardi F, Denaro V, Maffulli N (2011) Surgery for ACL deficiency in patients over 50. Knee Surg Sports Traumatol Arthrosc 19(3):412–417

    Article  PubMed  Google Scholar 

  31. Osti L, Papalia R, Del Buono A, Leonardi F, Denaro V, Maffulli N (2011) Surgery for ACL deficiency in patients over 50. Knee Surg Sports Traumatol Arthrosc : Off J ESSKA 19(3):412–417. doi:10.1007/s00167-010-1242-x

    Article  Google Scholar 

  32. Feller J, Webster KE (2013) Return to sport following anterior cruciate ligament reconstruction. Int Orthop 37(2):285–290

    Article  PubMed Central  PubMed  Google Scholar 

  33. Chaves SF, Marques NP, Silva RL, Rebouças NS, de Freitas LM, de Paula Lima PO, de Oliveira RR (2012) Neuromuscular efficiency of the vastus medialis obliquus and postural balance in professional soccer athletes after anterior cruciate ligament reconstruction. MLTJ 2(2):121

    PubMed Central  PubMed  Google Scholar 

  34. Joseph C, Pathak SS, Aravinda M, Rajan D (2008) Is ACL reconstruction only for athletes? Int Orthop 32(1):57–61

    Article  PubMed Central  PubMed  Google Scholar 

  35. Li R, Maffulli N, Hsu YC, Chan KM (1996) Isokinetic strength of the quadriceps and hamstrings and functional ability of anterior cruciate deficient knees in recreational athletes. Br J Sports Med 30(2):161–164

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  36. Yuan T, Zhang C-Q, Wang JH (2013) Augmenting tendon and ligament repair with platelet-rich plasma (PRP). MLTJ 3(3):139

    PubMed Central  PubMed  Google Scholar 

  37. Kanazawa T, Soejima T, Noguchi K, Tabuchi K, Noyama M, Nakamura K, Shiba N Tendon-to-bone healing using autologous bone marrow-derived mesenchymal stem cells in ACL reconstruction without a tibial bone tunnel-A histological study. Muscle, Ligaments and Tendons Journal 4 (2):201–206

  38. Filomeno P, Dayan V, Touriño C (2012) Stem cell research and clinical development in tendon repair. MLTJ 2(3):204

    PubMed Central  PubMed  Google Scholar 

  39. Chambat P, Guier C, Sonnery-Cottet B, Fayard J-M, Thaunat M (2013) The evolution of ACL reconstruction over the last fifty years. Int Orthop 37(2):181–186

    Article  PubMed Central  PubMed  Google Scholar 

  40. Samuelsson K, Andersson D, Ahlden M, Fu FH, Musahl V, Karlsson J (2013) Trends in surgeon preferences on anterior cruciate ligament reconstructive techniques. Clin Sports Med 32(1):111–126. doi:10.1016/j.csm.2012.08.011

    Article  PubMed  Google Scholar 

  41. Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K (2005) Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy: J Arthrosc Relat Surg : Off Publ Arthroscopy Assoc of N Am Int Arthroscopy Assoc 21(8):948–957. doi:10.1016/j.arthro.2005.04.110

    Article  Google Scholar 

  42. Myer GD, Ford KR, Khoury J, Succop P, Hewett TE (2010) Development and validation of a clinic-based prediction tool to identify female athletes at high risk for anterior cruciate ligament injury. Am J Sports Med 38(10):2025–2033. doi:10.1177/0363546510370933

    Article  PubMed Central  PubMed  Google Scholar 

  43. Lui P, Zhang P, Chan K, Qin L (2010) Biology and augmentation of tendon-bone insertion repair. J Orthop Surg Res 5(1):1–14

    Article  Google Scholar 

  44. Aglietti P, Buzzi R, D’Andria S, Zaccherotti G (1992) Arthroscopic anterior cruciate ligament reconstruction with patellar tendon. Arthroscopy: J Arthrosc Relat Surg : Off Publ Arthroscopy Assoc of N Am Int Arthroscopy Assoc 8(4):510–516

    Article  CAS  Google Scholar 

  45. Aglietti P, Zaccherotti G, Menchetti PP, De Biase P (1995) A comparison of clinical and radiological parameters with two arthroscopic techniques for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc : Off J ESSKA 3(1):2–8

    Article  CAS  Google Scholar 

  46. Aglietti P, Buzzi R, Giron F, Simeone AJ, Zaccherotti G (1997) Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon. A 5-8-year follow-up. Knee Surg Sports Traumatol Arthrosc : Off J ESSKA 5(3):138–144

    Article  CAS  Google Scholar 

  47. Aglietti P, Buzzi R, Menchetti PM, Giron F (1996) Arthroscopically assisted semitendinosus and gracilis tendon graft in reconstruction for acute anterior cruciate ligament injuries in athletes. Am J Sports Med 24(6):726–731

    Article  CAS  PubMed  Google Scholar 

  48. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr (2003) Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 31(1):2–11

    PubMed  Google Scholar 

  49. Meighan AA, Keating JF, Will E (2003) Outcome after reconstruction of the anterior cruciate ligament in athletic patients. A comparison of early versus delayed surgery. J Bone Joint Surg Br Vol 85(4):521–524

    Article  CAS  Google Scholar 

  50. Mohammadi F, Salavati M, Akhbari B, Mazaheri M, Mohsen Mir S, Etemadi Y (2013) Comparison of functional outcome measures after ACL reconstruction in competitive soccer players: a randomized trial. J Bone Joint Surg Am 95(14):1271–1277. doi:10.2106/JBJS.L.00724

    Article  PubMed  Google Scholar 

  51. Streich NA, Zimmermann D, Bode G, Schmitt H (2011) Reconstructive versus non-reconstructive treatment of anterior cruciate ligament insufficiency. A retrospective matched-pair long-term follow-up. Int Orthop 35(4):607–613

    Article  PubMed Central  PubMed  Google Scholar 

  52. Katayama M, Higuchi H, Kimura M, Kobayashi A, Hatayama K, Terauchi M, Takagishi K (2004) Proprioception and performance after anterior cruciate ligament rupture. Int Orthop 28(5):278–281

    Article  PubMed Central  PubMed  Google Scholar 

  53. Haus J, Halata Z (1990) Innervation of the anterior cruciate ligament. Int Orthop 14(3):293–296

    Article  CAS  PubMed  Google Scholar 

  54. Fonseca ST, Ocarino JM, Silva PL, Guimaraes RB, Oliveira MC, Lage CA (2005) Proprioception in individuals with ACL-deficient knee and good muscular and functional performance. Res Sports Med 13(1):47–61. doi:10.1080/15438620590922095

    Article  PubMed  Google Scholar 

  55. Jensen TO, Fischer-Rasmussen T, Kjaer M, Magnusson SP (2002) Proprioception in poor- and well-functioning anterior cruciate ligament deficient patients. J Rehabil Med : Off J UEMS (EBPRM) 34(3):141–149

    Article  CAS  Google Scholar 

  56. Schultz RA, Miller DC, Kerr CS, Micheli L (1984) Mechanoreceptors in human cruciate ligaments. A histological study. J Bone Joint Surg Am 66(7):1072–1076

    CAS  PubMed  Google Scholar 

  57. Woo SL-Y, Wu C, Dede O, Vercillo F, Noorani S (2006) Biomechanics and anterior cruciate ligament reconstruction. J Orthop Surg Res 1 (2)

  58. Dhillon MS, Bali K, Prabhakar S (2012) Differences among mechanoreceptors in healthy and injured anterior cruciate ligaments and their clinical importance. MLTJ 2(1):38

    PubMed Central  PubMed  Google Scholar 

  59. Papalia R, Franceschi F, Vasta S, Di Martino A, Maffulli N, Denaro V (2012) Sparing the anterior cruciate ligament remnant: is it worth the hassle? Br Med Bull 104(1):91–111

    Article  PubMed  Google Scholar 

  60. Mohammadi F, Salavati M, Akhbari B, Mazaheri M, Khorrami M, Negahban H (2012) Static and dynamic postural control in competitive athletes after anterior cruciate ligament reconstruction and controls. Knee Surg Sports Traumatol Arthrosc : Off J ESSKA 20(8):1603–1610. doi:10.1007/s00167-011-1806-4

    Article  Google Scholar 

  61. Gobbi A, Domzalski M, Pascual J (2004) Comparison of anterior cruciate ligament reconstruction in male and female athletes using the patellar tendon and hamstring autografts. Knee Surg Sports Traumatol Arthrosc: Off J ESSKA 12(6):534–539. doi:10.1007/s00167-003-0486-0

    Article  Google Scholar 

  62. Barenius B, Webster WK, McClelland J, Feller J (2013) Hamstring tendon anterior cruciate ligament reconstruction: does gracilis tendon harvest matter? Int Orthop 37(2):207–212

    Article  PubMed Central  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Via Alvaro del Portillo 200, Rome, Italy

    Rocco Papalia, Francesco Franceschi, Andrea Tecame, Stefano D’Adamio & Vincenzo Denaro

  2. Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84081, Baronissi, Salerno, Italy

    Nicola Maffulli

  3. Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, UK

    Nicola Maffulli

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  1. Rocco Papalia
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  2. Francesco Franceschi
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  3. Andrea Tecame
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  4. Stefano D’Adamio
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  5. Nicola Maffulli
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  6. Vincenzo Denaro
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Correspondence to Nicola Maffulli.

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Papalia, R., Franceschi, F., Tecame, A. et al. Anterior cruciate ligament reconstruction and return to sport activity: postural control as the key to success. International Orthopaedics (SICOT) 39, 527–534 (2015). https://doi.org/10.1007/s00264-014-2513-9

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  • DOI: https://doi.org/10.1007/s00264-014-2513-9

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