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Autologous Bone Graft Versus Silicate-Substituted Calcium Phosphate in the Treatment of Tunnel Defects in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study With a Minimum Follow-up of 2 Years.
von Recum, J, Gehm, J, Guehring, T, Vetter, SY, von der Linden, P, Grützner, PA, Schnetzke, M
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2020;(1):178-185
Abstract
PURPOSE To compare and evaluate knee laxity and functional outcomes between autologous bone graft and silicate-substituted calcium phosphate (Si-CaP) in the treatment of tunnel defects in 2-stage revision anterior cruciate ligament reconstruction (ACLR). METHODS This prospective, randomized controlled trial was conducted between 2012 and 2015 with a total of 40 patients who underwent 2-stage revision ACLR. The tunnels were filled with autologous iliac crest cancellous bone graft in 20 patients (control group) and with Si-CaP in the other 20 patients (intervention group). After a minimum follow-up period of 2 years, functional outcomes were assessed by KT-1000 arthrometry (side-to-side [STS] difference), the Tegner score, the Lysholm score, and the International Knee Documentation Committee score. RESULTS A total of 37 patients (follow-up rate, 92.5%) with an average age of 31 years were followed up for 3.4 years (range, 2.2-5.5 years). The KT-1000 measurement did not show any STS difference between the bone graft group (0.9 ± 1.5 mm) and the Si-CaP group (0.7 ± 2.0 mm) (P = .731). One patient in the intervention group (5%) had an STS difference greater than 5 mm. Both groups showed significant improvements in the Tegner score, Lysholm score, and International Knee Documentation Committee score from preoperative assessment to final follow-up (P ≤ .002), without any difference between the 2 groups (P ≥ .396). Complications requiring revision occurred in 4 control patients (22%) and in 2 patients in the intervention group (11%) (P = .660). No complications in relation to Si-CaP were observed. CONCLUSIONS Equivalent knee laxity and clinical function outcomes were noted 3 years after surgery in both groups of patients. Si-CaP bone substitute is therefore a safe alternative to autologous bone graft for 2-stage ACLR. LEVEL OF EVIDENCE Level I, prospective, randomized controlled clinical trial.
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Ultrasound-guided adductor canal block after arthroscopic anterior cruciate ligament reconstruction: Effect of adding dexamethasone to bupivacaine, a randomized controlled trial.
Ibrahim, AS, Aly, MG, Farrag, WS, Gad El-Rab, NA, Said, HG, Saad, AH
European journal of pain (London, England). 2019;(1):135-141
Abstract
BACKGROUND Dexamethasone improves the quality and duration of peripheral nerve block when used as an adjuvant to local anaesthetic. We evaluated the effect of adding dexamethasone to bupivacaine on the duration of postoperative analgesia in patients undergoing knee arthroscopy using ultrasound-guided adductor canal block. METHODS The study was a randomized, double-blinded trial. Sixty patients scheduled for arthroscopic anterior cruciate ligament reconstruction were randomly allocated into two groups to receive adductor canal block. The control group received 20 mL bupivacaine 0.5% + 2 mL normal saline, and the dexamethasone group received 20 mL bupivacaine 0.5% + 2 mL dexamethasone (8 mg). Measurements included onset and duration of sensory blockade, visual analog score, time to first analgesic requirement, analgesic consumption, satisfaction score and assessment of quadriceps strength. RESULTS Duration of sensory block was significantly longer in the dexamethasone group (17.42 ± 5.24 h) than the control group (12.52 ± 1.16 h), p < 0.001. The visual analog score was significantly lower (p < 0.05) in the dexamethasone group. Time to first analgesic requirement was significantly longer in the dexamethasone group (13.37 ± 3.68 h) compared with the control group (10.57 ± 0.93 h), p < 0.001. Ketorolac dose as a rescue analgesic was significantly higher in the control group (p < 0.001), whereas patients' satisfaction score was significantly higher in the dexamethasone group (p < 0.001). CONCLUSION The addition of dexamethasone to bupivacaine in adductor canal block provides prolonged postoperative analgesia and less postoperative analgesic consumption than bupivacaine alone in anterior cruciate ligament arthroscopic surgery. SIGNIFICANCE Adding dexamethasone to bupivacaine in adductor canal block significantly increases the duration of sensory block, time to first analgesic requirement and patients' satisfaction score in anterior cruciate ligament arthroscopic surgery.
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Effect of Blood Flow Restriction Training on Quadriceps Muscle Strength, Morphology, Physiology, and Knee Biomechanics Before and After Anterior Cruciate Ligament Reconstruction: Protocol for a Randomized Clinical Trial.
Erickson, LN, Lucas, KCH, Davis, KA, Jacobs, CA, Thompson, KL, Hardy, PA, Andersen, AH, Fry, CS, Noehren, BW
Physical therapy. 2019;(8):1010-1019
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Abstract
BACKGROUND Despite best practice, quadriceps strength deficits often persist for years after anterior cruciate ligament reconstruction. Blood flow restriction training (BFRT) is a possible new intervention that applies a pressurized cuff to the proximal thigh that partially occludes blood flow as the patient exercises, which enables patients to train at reduced loads. This training is believed to result in the same benefits as if the patients were training under high loads. OBJECTIVE The objective is to evaluate the effect of BFRT on quadriceps strength and knee biomechanics and to identify the potential mechanism(s) of action of BFRT at the cellular and morphological levels of the quadriceps. DESIGN This will be a randomized, double-blind, placebo-controlled clinical trial. SETTING The study will take place at the University of Kentucky and University of Texas Medical Branch. PARTICIPANTS Sixty participants between the ages of 15 to 40 years with an ACL tear will be included. INTERVENTION Participants will be randomly assigned to (1) physical therapy plus active BFRT (BFRT group) or (2) physical therapy plus placebo BFRT (standard of care group). Presurgical BFRT will involve sessions 3 times per week for 4 weeks, and postsurgical BFRT will involve sessions 3 times per week for 4 to 5 months. MEASUREMENTS The primary outcome measure was quadriceps strength (peak quadriceps torque, rate of torque development). Secondary outcome measures included knee biomechanics (knee extensor moment, knee flexion excursion, knee flexion angle), quadriceps muscle morphology (physiological cross-sectional area, fibrosis), and quadriceps muscle physiology (muscle fiber type, muscle fiber size, muscle pennation angle, satellite cell proliferation, fibrogenic/adipogenic progenitor cells, extracellular matrix composition). LIMITATIONS Therapists will not be blinded. CONCLUSIONS The results of this study may contribute to an improved targeted treatment for the protracted quadriceps strength loss associated with anterior cruciate ligament injury and reconstruction.
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A Randomized Controlled Trial of PEEK Versus Titanium Interference Screws for Anterior Cruciate Ligament Reconstruction With 2-Year Follow-up.
Shumborski, S, Heath, E, Salmon, LJ, Roe, JP, Linklater, JP, Facek, M, Pinczewski, LA
The American journal of sports medicine. 2019;(10):2386-2393
Abstract
BACKGROUND Graft fixation with interference screws for anterior cruciate ligament (ACL) reconstruction is a highly successful technique. Polyether ether ketone (PEEK) is a novel thermoplastic polymer with high biocompatibility and mechanical properties that mimic native bone, and it can be imaged on computed tomography or magnetic resonance imaging (MRI) without signal flare. PURPOSE To compare the clinical performance of ACL reconstruction with PEEK and titanium interference screws at 2 years and to evaluate a novel method of measuring tunnel volume. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS A total of 133 patients underwent arthroscopic ACL reconstruction with 4-strand hamstring autografts and were randomized to have titanium or PEEK interference screws for femoral and tibial tunnel fixation. At 2 years, subjective Lysholm and International Knee Documentation Committee scores were assessed and clinical examination performed. At 12 months, MRI was performed to assess graft incorporation and cyst formation, and a novel technique was employed to measure tunnel volumes. RESULTS There were no significant differences in graft rerupture rate, contralateral ACL rupture rate, subjective outcomes, or objective outcomes. In the titanium and PEEK groups, MRI demonstrated high overall rates of graft integration (96%-100% and 90%-93%, respectively) and ligamentization (89% and 84%) and low rates of synovitis (22% and 10%) and cyst formation (0%-18% and 13%-15%). There was a higher proportion of patients with incomplete graft integration within the femoral tunnel in the PEEK group as compared with the titanium group (10% vs 0%, P = .03); however, the authors suggest that metal artifact precluded proper assessment of the graft in the titanium group by MRI. Tunnel volumes also appeared to be equivalent in the 2 groups and were measured with a novel technique that was highly reproducible in the PEEK group secondary to the absence of flare. CONCLUSION Two-year clinical analysis of PEEK interference screws for femoral and tibial fixation of ACL reconstructions showed equivalent clinical performance to titanium interference screws. Given the excellent mechanical characteristics, biological compatibility, and absence of metal artifact on MRI, PEEK has become our material of choice for interference screw fixation in ACL reconstruction.
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Periarticular Injection Versus Femoral Nerve Block for Pain Relief After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial.
Kurosaka, K, Tsukada, S, Nakayama, H, Iseki, T, Kanto, R, Sugama, R, Yoshiya, S
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2018;(1):182-188
Abstract
PURPOSE To compare the effectiveness and safety of periarticular injection (PI) with those of femoral nerve block (FNB) after anterior cruciate ligament (ACL) reconstruction. METHODS A total of 129 patients scheduled for ACL reconstruction were randomly assigned to receive PI or FNB. Other perioperative interventions were identical for all patients. The primary outcome was the postoperative pain score 24 hours after surgery, which was measured using a 100-mm visual analog scale (VAS). The pain scores were also assessed to determine whether the VAS score would reach the threshold values reported for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS). RESULTS The PI group had significantly lower VAS scores 24 hours after ACL reconstruction than the FNB group (21 mm vs 39 mm; P < .0001). Consequently, the primary outcome reached the level of clinical significance as indicated by the threshold values of an MCID of 9.9 and a PASS of 33. The PI group also had a significantly lower VAS score at rest at 4 hours, 8 hours, and 2 days after surgery (30 mm vs 39 mm [P = .025], 25 mm vs 33 mm [P = .022], and 22 mm vs 32 mm [P = .0022], respectively). The opioid consumption during the initial 24 hours was significantly lower in the PI group (354 μg vs 503 μg; P = .0003). The complication rate, including opioid-related complications, was not significantly different between groups. CONCLUSION The patients treated with PI had significantly better pain scores and lower opioid consumption than those treated with FNB without elevating the complication rate. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Effect of Whole-Body Vibration on Sagittal Plane Running Mechanics in Individuals With Anterior Cruciate Ligament Reconstruction: A Randomized Crossover Trial.
Pamukoff, DN, Montgomery, MM, Choe, KH, Moffit, TJ, Vakula, MN
Archives of physical medicine and rehabilitation. 2018;(5):973-980
Abstract
OBJECTIVE To examine the effect of whole-body vibration (WBV) on running biomechanics in individuals with anterior cruciate ligament reconstruction (ACLR). DESIGN Single-blind randomized crossover trial. SETTING Research laboratory. PARTICIPANTS Individuals (N=20) with unilateral ACLR (age [± SD]=22.3 [±3.3] years; mass=71.8 [±15.3] kg; time since ACLR=44.9 [±22.8] months; 15 females, 10 patellar tendon autograft, 7 hamstrings autograft, 3 allograft; International Knee Documentation Committee Score=83.5 [±9.3]). MAIN OUTCOME MEASURE Participants performed isometric squats while being exposed to WBV or no vibration (control). WBV and control conditions were delivered in a randomized order during separate visits separated by 1-week washout periods. Running biomechanics of the injured and uninjured limbs were evaluated before and immediately after each intervention. Dependent variables included peak vertical ground reaction force (GRF) and loading rate (LR), peak knee flexion angle and external moment, and knee flexion excursion during the stance phase of running. RESULTS There was an increase in knee flexion excursion (+4.1°, 95% confidence interval [CI]: 0.65, 7.5°) and a trend toward a reduction in instantaneous LR after WBV in the injured limb (-4.03 BW/sec-1, 95% CI -0.38, -7.69). No effect was observed on peak GRF, peak knee flexion angle, or peak external knee flexion moment, and no effect was observed in the uninjured limb. CONCLUSIONS Our findings indicate that a single session of WBV acutely increases knee flexion excursion. WBV could be useful to improve running characteristics in individuals with knee pathology.
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Surgical reconstruction of ruptured anterior cruciate ligament prolongs trauma-induced increase of inflammatory cytokines in synovial fluid: an exploratory analysis in the KANON trial.
Larsson, S, Struglics, A, Lohmander, LS, Frobell, R
Osteoarthritis and cartilage. 2017;(9):1443-1451
Abstract
OBJECTIVE Prospectively monitor how treatment of acutely ruptured anterior cruciate ligament (ACL) affects biomarkers of inflammation and proteolytic degradation over 5 years. DESIGN We studied 119 subjects with acute ACL injury from the randomized controlled knee anterior cruciate ligament, non-surgical versus surgical treatment (KANON)-trial (Clinical trial ISRCTN 84752559) who had synovial fluid, serum and urine samples available from at least two out of six visits over 5 years after acute ACL rupture. All subjects followed a similar rehabilitation protocol where, according to randomization, 60 also had early ACL reconstruction and 59 had the option to undergo a delayed ACL reconstruction if needed. Interleukin (IL)-6, IL-8, IL-10, interferon-gamma (IFNγ), tumor necrosis factor (TNF), amino acids alanine, arginine, glycine, serine (ARGS)-aggrecan, C-terminal crosslinking telopeptide type II collagen (CTX-II) and N-terminal crosslinking telopeptide type I collagen (NTX-I) were quantified by enzyme-linked immunosorbent assays (ELISA). RESULTS Subjects randomized to early ACL reconstruction had higher cytokine concentrations in index knee synovial fluid at 4 months (IL-6, IL-8, IL-10, TNF), 8 months (IL-6 and TNF) and at 5 years (IFNγ) compared to those randomized to optional delayed reconstruction. Those that underwent delayed ACL reconstruction within 5 years (30 subjects), had higher synovial fluid concentrations of IL-6 at 5 years compared to those treated with rehabilitation alone. No differences between groups were noted for ARGS-aggrecan in synovial fluid and serum or CTX-II and NTX-I in urine over 5 years, neither as randomized nor as treated. CONCLUSIONS Surgical ACL reconstruction constitutes a second trauma to the acutely injured joint resulting in a prolonged elevation of already high synovial fluid levels of inflammatory cytokines.
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Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study.
von Recum, J, Schwaab, J, Guehring, T, Grützner, PA, Schnetzke, M
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2017;(4):819-827
Abstract
PURPOSE To evaluate the histologic and radiographic outcomes of using silicate-substituted calcium phosphate (Si-CaP) as bone graft substitute for the augmentation of tunnel defects in 2-stage revision anterior cruciate ligament (ACL) reconstruction. METHODS Forty patients undergoing 2-stage revision ACL reconstruction were included in a prospective, randomized controlled clinical trial between 2012 and 2015. The inclusion criteria were tunnel diameter of the tibial and/or femoral tunnel of 10 mm or greater after failed ACL reconstruction. Twenty patients received autologous bone from the iliac crest and 20 patients received Si-CaP as a bone graft substitute for tunnel grafting at the first-stage procedure. Punch biopsy specimens of the augmented tunnels were taken at the second-stage procedure, and histologic examination included quantitative analysis of the area of immature bone formation, lamellar bone, and bone marrow. Radiographic analysis included determination of the filling rates of the tunnels on postoperative computed tomography scans. RESULTS Forty patients with a mean age of 32 years (standard deviation [SD], 11.0 years) were analyzed. Histologic examination of the tunnels filled with Si-CaP showed that 15% (SD, 14%) of the area was covered with immature bone formation, 41% (SD, 10%) with well-organized lamellar bone, and 44% (SD, 8%) with bone marrow. In the control group (autologous bone), 58% (SD, 3%) of the area was covered with well-organized lamellar bone and 42% (SD, 3%) with bone marrow. Quantitative evaluation of the postoperative computed tomography scans showed a trend of better filling rates in patients with Si-CaP for the tibial tunnel (86% [SD, 17%] vs 78% [SD, 14%]; P = .131). Intraoperatively, Si-CaP was completely integrated into the original bone tunnel providing good stability for tunnel placement and tendon graft fixation comparable to autologous bone. CONCLUSIONS Si-CaP as bone graft substitute for tunnel augmentation in 2-stage revision ACL reconstruction shows good histologic, radiographic, and intraoperative integration comparable to autologous bone. LEVEL OF EVIDENCE Level I, prospective randomized controlled trial.
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Femoral Nerve Block versus Intra-Articular Infiltration: A Preliminary Study of Analgesic Effects and Quadriceps Strength in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction.
Iamaroon, A, Tamrongchote, S, Sirivanasandha, B, Halilamien, P, Lertwanich, P, Surachetpong, S, Rungwattanakit, P
Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 2016;(5):578-83
Abstract
BACKGROUND Adequate analgesia and early rehabilitation is necessary for arthroscopic anterior cruciate ligament reconstruction (A CLR) surgery. OBJECTIVE To compare analgesia and quadriceps strength after femoral nerve block (FNB) with intra-articular infiltration (IA) using 0.25% bupivacaine for ACLR with patella tendon graft. MATERIAL AND METHOD Forty patients were randomized to receive FNB under ultrasound guidance with 20 mL of bupivacaine or IA with 15 mL of bupivacaine into the knee joint and 5 mL infiltrated along the incision sites including portal sites at the end of surgery. All patients received intravenous ketorolac at wound closure. Data regarding demographic, time to first pain, time to first morphine requirement, morphine usage, pain scores and quadriceps strength were recorded. RESULTS Significant difference in quadriceps strength was shown. Ninety percent of patients in Group IA and fifty-five percent of patients in Group FNB had good ability to extend knee at 24 hours after surgery (p = 0.013). No differences were found in demographic data, time to first pain, time to first morphine requirement, post operative pain scores and morphine consumption, CONCLUSION The preliminary results demonstrated that IA has an effect on quadriceps strength less than FNB while provide comparable postoperative analgesia after patellar tendon graft ACLR.
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The effect of gentamicin in irrigating solutions on articular infection prophylaxis during arthroscopic ACL reconstruction.
Yazdi, H, Moradi, A, Herbort, M
Archives of orthopaedic and trauma surgery. 2014;(2):257-61
Abstract
PURPOSE The purpose of this study was to investigate whether gentamicin irrigation solutions provide a potential new tool to prevent joint infection after arthroscopic ACL reconstruction. METHODS In this prospective randomized study, 360 consecutive ACL recondition patients were randomized in two groups alternately from Feb 2008 to March 2012. In the first group, 180 patients underwent ACL reconstruction with a hamstring autograft, preoperative IV antibiotics, and normal saline (0.9% sodium chloride) solution. In the second group 180 patients underwent ACL reconstruction with a hamstring autograft, preoperative IV antibiotics, and normal saline (0.9% sodium chloride solution) with added gentamicin (80 mg/L) (group 2). Three patients from group 1 and six patients from group 2 were excluded from the study due to loss of follow-up. The patients were followed for 6 months and assessed for signs of deep infection. RESULTS In group 1, a total of 4 (2.2%) postoperative septic arthritis cases were documented. In group 2, just one postoperative deep infection (septic arthritis) was documented (0.57%). Although the rate of septic arthritis in group 1 was higher than in group 2, statistical analysis showed that the difference between using the gentamicin irrigation solution (80 mg/L) and the saline solution alone was not significant. CONCLUSIONS Using gentamicin in irrigating solutions during arthroscopic ACL reconstruction surgery does not statistically decrease post operation septic arthritis. LEVEL OF EVIDENCE Therapeutic Level II.