Cruciate ligament reconstruction has progressed dramatically in the last 20 years. Anatomic placement of ligament substitutes has fostered rehabilitation efforts that stress immediate and full range of motion, immediate weightbearing, neuromuscular strength and coordination, and early return to athletic competition (3 months). This has placed extreme importance on secure graft fixation at the time of ligament reconstruction. Current ligament substitutes require a bony or soft tissue component to be fixed within a bone tunnel or on the periosteum at a distance from the normal ligament attachment site. Fixation devices have progressed from metal to biodegradable and from far to near-normal native ligament attachment sites. Ideally, the biomechanical properties of the entire graft construct would approach those of the native ligament and facilitate biologic incorporation of the graft. Fixation should be done at the normal anatomic attachment site of the native ligament (aperture fixation) and, over time, allow the biologic return of the histologic transition zone from ligament to fibrocartilage, to calcified fibrocartilage, to bone. The purpose of this article is to review current fixation devices and techniques in cruciate ligament surgery.
Occult osteochondral lesions (bone bruises) have been documented on magnetic resonance images in more than 80% of patients sustaining acute anterior cruciate ligament ruptures. Despite the high prevalence of these lesions, little is known about the histologic changes in the adjacent articular cartilage. Ten patients with acute anterior cruciate ligament ruptures who had a preoperatively documented (by magnetic resonance imaging) geographic bone bruise at the sulcus terminalis on the lateral femoral condyle underwent a 3-mm diameter trephine biopsy of the articular cartilage and subchondral bone overlying the bone bruise at the time of anterior cruciate ligament reconstruction. Biopsy samples of the articular cartilage and subchondral bone were stained with hematoxylin and eosin and toluidine blue. All patients had significant arthroscopic and histologic articular cartilage irregularity in the area overlying the bone bruise. Arthroscopic findings of the articular cartilage included softening (dimpling), fissuring, or overt chondral fracture. Histologic examination revealed degeneration of the chondrocytes and loss of toluidine blue staining in the articular cartilage (loss of proteoglycan). There was necrosis of osteocytes in the subchondral bone, and empty lacuna were visible. This study defines the exact histologic changes of the articular cartilage overlying a geographic bone bruise secondary to an acute anterior cruciate ligament tear. Our findings suggest that a geographic bone bruise found on magnetic resonance imaging indicates substantial damage to normal articular cartilage homeostasis.
The purpose of this study was to determine whether bone mineral density of the host bone, measured using conventional dual photon absorptiometry techniques, and insertion torque can predict part of the ultimate failure strength of interference screw fixation of quadrupled hamstring tendon grafts. The semitendinosus and gracilis tendons were harvested from 10 human cadaveric knees, mean age 66.5 years (range, 53 to 81). The bone tunnel was sized within 0.5 mm of the graft. The graft was fixed with a biodegradable screw (7 x 25 mm for the femur, and 9 x 25 mm for the tibia) directly against the tendon and at the joint surfaces. Tibial fixation and femoral fixation were tested to failure using a materials testing system. Bone mineral density was measured in the metaphyseal region of the tibia and femur. The results of multiple regression analyses showed that both insertion torque and bone mineral density were related to the maximum load the graft withstood. These two variables explained 77.1% of the maximum load observed. We concluded that bone mineral density measurements of the host bone site are an important determinant of postoperative graft strength and thus have an important, but previously unrecognized, clinical role in establishing individual postsurgery rehabilitation protocols. Insertion torque in this study was a useful predictor of graft fixation strength.
Objectives: The purpose of this study was to evaluate the intrarater reliability of selected clinical outcome measures in patients having ACL reconstruction. Background: Several investigations have reported the reliability of isokinetic testing and knee ligament arthrometry. Fewer studies have examined the reliability of lower extremity functional tests, with most of these studies evaluating normal subjects. Methods and Measures: Fifteen physically active males with unilateral ACL-reconstructed knees were evaluated with the KT-1000, Biodex isokinetic dynamometer, and 3 functional hop tests on 5 occasions. Results: lntraclass correlation coefficients (ICCs) revealed good to high intrarater reliability (ICC >0.80) of the functional hop tests and isokinetic peak torque values. KG were higher for the involved limb than the uninvolved limb using the scores from the KT-1000 Manual Maximum Test. Conclusions: The outcome measures examined in this investigation have been shown to be reliable in patients with ACL reconstructions, and support previous investigations in nonimpaired populations. Further research is needed to examine the validity of these postoperative outcome measures in patients with ACL reconstructions. ) . . -Greater demands are being placed on sports physical therapists to improve the measurement and documentation of clinical outcomes following rehabilitation programs of injured athletes. Success is often determined by a return to the same or better level of functional performance than before the injury. The final phase in the management of an injured athlete requires the timely and safe transition from the rehabilitation environment to actual competition. Although physical characteristics such as range of motion, girth, isokinetic strength, and static ligamentous laxity tests provide useful information about an athlete's postinjury or postoperative Isokinetic testing, commonly used by sports medicine clinicians to assess strength and muscle performance, has been determined to be safe17 and reliableS.19.40.P9.S8.~~41~45~~52P58~74~~ with reported intraclass coefficients (ICCs) ranging from 0.72 to 0.99.Many functional tests have been reported to identi-Q, assess, and evaluate knee stability and function following ACL injury or reconstruction. Some of the more commonly used functional tests reported in the literature include the single-leg hop(s), figure 8 run, shuttle run, vertical jump, joint position reproduction, and a crossover cutting maneu~er.~J~v~~.~2. M.75.76 These research investigations provided useful information regarding assessment following ACL injury or reconstruction, but the investigators declined to report on the reliability of the functional tests examined. A recent investigation by Risberg and Ekeland62 examined 6 functional tests performed by patients after ACL reconstruction, but did not report on the tests' reliability. Lephart et a14S.M suggested that the best assessment of functional capacity in athletes with ACL insufficiency is achieved through the use of 3 "functional perfor...
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