ObjectiveTo summarize the early postoperative pain management strategies for anterior cruciate ligament reconstruction (ACLR), and to select a reasonable and effective pain management plan to promote functional rehabilitation after ACLR. MethodsThe literature about the early postoperative pain management strategies of ACLR both domestically and internationally in recent years was extensiverly reviewed, and the effects of improving postoperative pain were reviewed. ResultsCurrently, physical therapy and oral medication have advantages such as economy and simplicity, but the effect of improving postoperative pain is not satisfactory, often requires a combination of intravenous injection or intravenous pump, which is also a common way to relieve pain. However, in order to meet the analgesic needs of patients, the amount of analgesic drugs used is often large, which increases the incidence of various adverse reactions. Local infiltration analgesia (LIA), including periarticular or intra-articular injection of drugs, can significantly improve the early postoperative pain of ACLR, and achieve similar postoperative effectiveness as nerve block. LIA can be used as an analgesic technique instead of nerve block, and avoid the corresponding weakness of innervated muscles caused by nerve block, which increases the risk of postoperative falls. Many studies have confirmed that LIA can alleviate postoperative early pain in ACLR, especially the analgesic effects of periarticular injection are more satisfactory. It can also avoid the risk of cartilage damage caused by intra-articular injection. However, the postoperative analgesic effect and timeliness still need to be improved. It is possible to consider combining multimodal mixed drug LIA (combined with intra-articular and periarticular) with other pain intervention methods to exert a synergistic effect, in order to avoid the side effects and risks brought by single drugs or single administration route. LIA is expected to become one of the most common methods for relieving postoperative early pain in ACLR. ConclusionEarly pain after arthroscopic ACLR still affects the further functional activities of patients, and all kinds of analgesic methods can achieve certain effectiveness, but there is no unified standard at present, and the advantages and disadvantages of various analgesic methods need further research.
ObjectiveTo review the current status and progress of sterilization and preservation for allograft in anterior cruciate ligament reconstruction.MethodsThe related literature about the sterilization and preservation of allografts in anterior cruciate ligament reconstruction was extensively reviewed and summarized.ResultsThere are many sterilization methods for allografts, the most commonly used method is γ-ray irradiation, but the optimal irradiation dose is still unclear. Electron beam irradiation is also available, but excessive dose is harmful to graft shaping. A combined sterilization method combining physics and chemistry methods is still being explored. Cryopreservation is the most commonly used method of preservation. In order to reduce the influence of crystals, the principle of " slow cooling and rapid rewarming” should be adhered to as far as possible.ConclusionThe processing methods of allograft can affect the effectiveness of anterior cruciate ligament reconstruction. The clinical doctors should consider the sterilization and preservation methods in practice.
Objective
To explore the clinical significance of systemic rehabilitation training on knee functional recovery after anterior cruciate ligament (ACL) reconstruction.
Methods
Patients who underwent arthroscopic knee ACL reconstruction and met the inclusion criteria were included from January 2015 to October 2016. A 4-phase, 16-week systemic rehabilitation training was given individually according to surgical conditions, sports and other factors. Visual Analogue Scale (VAS), knee range of motion (ROM), knee circumference, and 10-meter walking time were measured before surgery, and 3, 6, and 12 months after surgery. At the same time, the function and stability of the knee joint were graded by Lysholm score, Holden walking score, International Knee Documentation Committee (IKDC) score, and KT-1000 test. The postoperative one-year scores were compared with the other side, and the patient satisfaction was evaluated one year after surgery.
Results
All patients were followed up for at least one year. The VAS pain score, ROM, knee circumference, 10-meter walking time, Lysholm score, Holden score, IKDC score, and KT-1000 of all patients were significantly better than their preoperative levels (P<0.05), and there was no significant difference in joint function from the contralateral side (P>0.05). No serious complications such as infection occurred.
Conclusion
Systemic rehabilitation exercises can help patients with well-restored knee joint function after ACL reconstruction.
ObjectiveTo compare the incidence of chondral injury using Rigidfix femoral fixation device via the anteromedial approach and the tibial tunnel approach during anterior cruciate ligament (ACL) reconstruction.
MethodsEighteen adult cadaver knees were divided randomly into 2 groups, 9 knees in each group. Femoral tunnel drilling and cross-pin guide insertions were performed using the Rigidfix femoral fixation device through the anteromedial approach (group A) and the tibial tunnel approach (group B). ACL reconstruction simulation was performed at 0, 10, 20, 30, 45, 60, 70, 80, and 90°in the horizontal position. The correlation between incidence of chondral injury and slope angles was analyzed, and then the incidence was compared between the 2 groups.
ResultsThe correlation analysis indicated that the chondral injury incidence increased with the increasing of the slope angle (r=0.611, P=0.000; r=0.852, P=0.000). The incidence of chondral injury was 69.1% (56/81) and 48.1% (39/81) in groups A and B respectively, showing significant difference (χ2=7.356, P=0.007). The sublevel analysis showed that the chondral injury incidence of group A (36.1%, 13/36) was significantly higher than that of group B (0) at 0-30°(χ2=15.864, P=0.000), but no significant difference was found between group A (95.6%, 43/45) and group B (86.7%, 39/45) at 45-90°(P=0.267).
ConclusionIt has more risk of chondral injury to use Rigidfix femoral fixation device via the anteromedial approach than the tibial tunnel approach to reconstruct ACL.
ObjectiveTo observe the effect of preserving tibial residual fibers on the expressions of ligament remodeling related genes in rabbit anterior cruciate ligament (ACL) reconstruction model.
MethodsSixty healthy adult New Zealand white rabbits were randomly divided into 4 groups:normal control group (group A, n=6) , sham-operation group (group B, n=18) , non tibial remnant preserved group (group C, n=18) , and tibial remnant preserved group (group D, n=18) . At 2, 6, and 12 weeks after operation, the ligament tissue was harvested to detect the mRNA expressions of collagen type 1A1(COL1A1) , collagen type 3A1(COL3A1) , transforming growth factor β1(TGF-β1), vascular endothelial growth factor (VEGF), growth-associated protein 43(GAP-43) , and neurotrophin 3(NT-3) by real-time fluorescent quantitative PCR.
ResultsAt each time point, there was no significant difference in the mRNA expressions of COL1A1, COL3A1, VEGF, and NT-3 between group A and group B (P>0.05) . In group D, the mRNA expressions of COL1A1, COL3A1, TGF-β1, and GAP-43 significantly increased when compared with those of group C at 6 weeks after operation (P＜0.05) ; an increased level of VEGF mRNA was also detected in the group D at 12 weeks after operation (P＜0.05) ; and an increased level of NT-3 mRNA was also observed in group D at 2 and 12 weeks after operation (P＜0.05) .
ConclusionThere is a time-dependent manner of angiogenesis-promoting, repair-related, and nerve-related gene expressions after ACL reconstruction with preserving tibial residual fibers during the process of ligamentization. Furthermore, the remnant preservation in ACL reconstruction can promote the expressions of related genes in some time points.
ObjectiveTo clarify the intervention guidance of return to sports WeChat applet and evaluate the rehabilitation effectiveness after anterior cruciate ligament (ACL) reconstruction. MethodsBetween September 2020 and September 2022, 80 patients who met the selection criteria and underwent ACL anatomical single bundle reconstruction were selected as the research objects. According to the double-blind random method, they were divided into the applet group and the regular group, with 40 cases in each group. Patients in the applet group were rehabilitated under the guidance of the return to sports WeChat applet, and the patients were asked to perform the test once a month after operation, including patients’ subjective scores [Tegner score, knee injury and osteoarthritis outcome score (KOOS), International Knee Documentation Committee (IKDC) score, American Hospital for Special Surgery (HSS) score], psychological assessment [ACL recovery sports injury scale (ACL-RSI) score], jumping test, balance test, bending angle test. Patients in the regular group were followed up by doctors and nurses regularly by telephone every month. All the patients were reexamined at 3, 6, 9, and 12 months after operation, and the range of motion of the knee joint with 6 degrees of freedom (flexion and extension angle, varus and valgus angle, internal and external rotation angle, anteroposterior displacement, superior and inferior displacement, and internal and external displacement) recorded by Opti_Knee three-dimensional knee joint motion measurement gait analysis system was observed. The anterior tibial translation difference (ATTD) was measured by Ligs knee measuring instrument when a forward thrust of 120 N was applied to the posterior part of the proximal tibia. Tegner score, IKDC score, KOOS score (including KOOS-Pain score, KOOS-Symptoms score, KOOS-Activities of daily living score, KOOS-Sport score, and KOOS-Quality of life score), HSS score, ACL-RSI score, jumping ability, balance ability, patients’ satisfaction with the rehabilitation process, and ACL healing grading according to ACL continuity and signal intensity shown by MRI. Results There were significant differences in various indicators between different time points after operation in the two groups (P<0.05). At 3 months after operation, except that the ACL-RSI score of the applet group was significantly higher than that of the regular group (P<0.05), there was no significant difference in the other indicators between the two groups (P>0.05). At 6 months after operation, the ACL-RSI score, IKDC score, Tegner score, KOOS scores of different items, HSS score, balance and jumping ability of the applet group were significantly higher than those of the regular group (P<0.05), and there was no significant difference in the other indicators between the two groups (P>0.05). At 9 months after operation, there was no significant difference in all indicators between the two groups (P>0.05). At 12 months after operation, 27 cases (67.5%) in the applet group and 21 cases (52.5%) in the regular group returned to sport, with a significant difference of the return to sports incidence between the two groups [RR(95%CI)=1.50 (1.00, 2.25), P=0.049]. In the applet group, 27 cases were very satisfied with the rehabilitation process, 10 cases were satisfied, 2 cases were basically satisfied, and 1 case was not satisfied, while 19, 13, 5, and 3 cases in the regular group, respectively. The satisfaction degree of the applet group was significantly better than that of the regular group (P=0.049). MRI examination of the two groups showed that the ACL was continuous without secondary rupture or necrosis. The ACL healing grade of the applet group was 31 cases of grade 1 and 9 cases of grade 2, and that of the regular group was 28 cases of grade 1 and 12 cases of grade 2, there was no significant difference in ACL healing grade between the two groups (P=0.449). ConclusionThe application of return to sports WeChat applet in the rehabilitation of patients after ACL reconstruction can significantly reduce the fear of return to sports and improve the rate of return to sports. The return to sports WeChat applet is convenient to operate, with high utilization rate and high patient compliance, which significantly improves the satisfaction.
ObjectiveTo evaluate the correlation between the Mohawk (MKX) expression level and the collagen fiber diameter of autologous hamstring tendon graft during the stable graft remodeling phase after anterior cruciate ligament (ACL) reconstruction.MethodsBetween January 2018 and August 2018, patients who underwent arth-roscopic single-bundle anatomical ACL reconstruction with autologous hamstring tendons for at least 48 months and also underwent second-look arthroscopy were enrolled in study. During the second-look arthroscopic procedures, ACL graft biopsies were performed from the surface of central part of the ligament. MKX expressions of ACL grafts were analysed by real-time fluorescent quantitative PCR (qRT-PCR). The ultrastructure of collagen fibers of grafts were evaluated by transmission electron microscopy, which included average diameter of collagen fibers (Dc), average diameter of large-diameter collagen fibers (DL), average diameter of small-diameter collagen fibers (DS), and large-small collagen fibers ratio (RL/S). The correlation between MKX expression level and graft collagen fiber diameter was calculated.ResultsTwenty-six patients met the selection criteria and their ACL graft specimens were enrolled in the study. The interval between ACL reconstruction and second-look arthroscopy was 52-128 months, with an average of 78.6 months. Arthroscopic graft remodeling score was 3-6 (mean, 4.8). There were 17 cases of excellent remodeling and 9 cases of fair remodeling. All ACL grafts showed typical bimodal distributions of both large-diameter collagen fibers and small-diameter collagen fibers, but the ultrastructural characteristics of the graft collagen fibers were different according to different remodeling status under arthroscopy. The DC, DL, DS, and RL/S of the graft specimens were (65.2±9.3) nm, (91.6±10.5) nm, (45.7±8.6) nm, and 0.73±0.12, respectively. The relative expression level of MKX was 1.42±0.11, which was positively linearly correlated with DC, DL, and RL/S, and the correlation coefficient was statistically significant (r=0.809, P=0.000; r=0.861, P=0.000; r=0.942, P=0.000), while there was no significant correlation between DS and relative expression level of MKX (r=0.147, P=0.238). Regression analysis showed that the relative expression level of MKX could predict the DC, DL, and RL/S results of the ACL graft specimens (P<0.05).ConclusionAfter autologous hamstring tendon grafts stepped into stabilized remodeling phase, MKX expression level could predict the diameter measurement results of collagen fibers and be used as an important evaluation basis for graft collagen anabolic metabolism.
ObjectiveTo investigate the best knee flexion angle by analyzing the length and orientation of the femoral tunnel through anteromedial portal (AM) at different flexion angles during anterior cruciate ligament (ACL) reconstruction.
MethodsTwelve fresh cadaveric knees were selected to locate the center of ACL femoral footprint through AM using the improved hook slot vernier caliper, and to locate the posterior bone cortex using a diameter 3 mm ball at flexion of 90, 100, 110, 120, and 130°. The femoral tunnel length, standard coronal and sagittal plane angles, and the position relation between exit point and the lateral epicondyle were measured; the tunnel orientation on the anteroposterior and lateral X-ray films was also measured.
ResultsWith increasing flexion of the knee, the femoral tunnel length showed a first increasing and then stable tendency; significant difference was found between at flexion of 90°and at flexions of 100, 110, 120, and 130°, and between flexions of 100°and 120°(P<0.05). The femoral tunnel showed a trend of decreasing with coronal angle, whereas gradually increasing with sagittal angle. The knee flexion angle had significant difference either among flexions of 90, 110, and 130°or between flexions of 100°and 120°(P<0.05). The exit point of the femoral tunnel located at the lateral epicondyle of the femur proximal to posterior region at flexion of 90°in all knees, and at flexion of 100°in 7 knees, but it located at the lateral epicondyle of the femur proximal to anterior region at flexion of 110, 120, and 130°in all knees. As the knee flexion angle increasing, the angle between femoral tunnel with the tangent of internal-external femoral condyle on anteroposterior X-ray films showed a trend of decreasing gradually, but a trend of increasing gradually on lateral X-ray films. On the anteroposterior X-ray films, significant differences were found in the angle either among flexions of 90, 110, and 130°or between flexions of 100°and 120°(P<0.05). On the lateral X-ray films, there were significant differences in the angle among flexions of 90, 100, 110, 120, and 130°(P<0.05).
ConclusionDuring ACL reconstruction by AM, 110°is the best flexion angle, which can get the ideal femoral tunnel.
Objective To explore the early effectiveness and influence on cartilage of local injection of multimodal drug cocktail (MDC) during anterior cruciate ligament reconstruction (ACLR). Methods Between February 2022 and August 2023, patients undergone arthroscopic ACLR using autologous hamstring tendons were selected as the study subjects. Among them, 90 patients met the selection criteria and were randomly divided into 3 groups (n=30) according to the different injection drugs after ligament reconstruction. There was no significant difference in baseline data such as gender, age, body mass index, surgical side, disease duration, preoperative thigh circumference, and preoperative levels of tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), IL-1, matrix metalloproteinase 3 (MMP-3), MMP-13, and aggrecan (ACAN) in synovial fluid between groups (P>0.05). After the ligament reconstruction during operation, corresponding MDC (consisting of ropivacaine, tranexamic acid, and betamethasone in group A, and ropivacaine, betamethasone, and saline in group B) or saline (group C) were injected into the joint and tendon site, respectively. The length of hospital stay, postoperative tramadol injection volume, incidence of complications, degree of knee joint swelling and range of motion, visual analogue scale (VAS) score, International Knee Documentation Committee (IKDC) score, Lyshlom score, and Hospital for Special Surgery (HSS) score were recorded and compared between groups. The T2* values in different cartilage regions were detected by MRI examination and the levels of TNF-α, IL-6, IL-1, MMP-3, MMP-13, and ACAN in synovial fluid were detected by ELISA method. Results The patients in group A, B, and C were followed up (12.53±3.24), (13.14±2.87), and (12.82±3.32) months, respectively. All incisions healed by first intention. Compared with group C, group A and group B had shorter length of hospital stay, less tramadol injection volume, and lower incidence of complications, showing significant differences (P<0.05); there was no significant difference between group A and group B (P>0.05). The degree of knee swelling in group A was significantly less than that in group B and group C (P<0.05), but there was no significant difference between group B and group C (P>0.05). At 3, 6, 12, 24, and 48 hours after operation, VAS scores of group A and group B were significantly lower than those of group C (P<0.05); at 72 hours after operation, there was no significant difference among the three groups (P>0.05). At 3 days, 14 days, and 1 month after operation, the range of motion of knee joint in group A were significantly better than those in group C (P<0.05), and there was no significant difference between the other groups (P>0.05). At 1 month after operation, the IKDC score of group A and group B was significantly higher than that of group C (P<0.05); there was no significant difference among the three groups at other time points (P>0.05). There was no significant difference in Lyshlom score and HSS score among the three groups at each time point (P>0.05). At 14 days after operation, the levels of IL-1 and IL-6 in the synovial fluid in groups A and B were significantly lower than those in group C (P<0.05). There was no significant difference in the levels of TNF-α, MMP-3, MMP-13, and ACAN between groups A and B (P>0.05). At 1 month after operation, there was no significant difference in the above indicators among the three groups (P>0.05). At 3, 6, and 12 months after operation, there was no significant difference in the T2* values of different cartilage regions among the three groups (P>0.05). ConclusionInjecting MDC (ropivacaine, tranexamic acid, betamethasone) into the joint and tendon site during ACLR can achieve good early effectiveness without significant impact on cartilage.
Objective?To evaluate the tendon regeneration after anterior cruciate ligament (ACL) reconstruction with semitendinosus tendon and gracilis tendon autografts by MRI.?Methods?Between September 2007 and September 2009, 52 patients undergoing ACL reconstructions with semitendinosus tendon and gracilis tendon autografts were enrolled. There were 29 males and 23 females with an average age of 31.6 years (range, 19-42 years). The left knees were involved in 34 cases and the right knees in 18 cases. The injury was caused by traffic accident in 11 cases, by sports in 38 cases, by heavy pound injury in 2 cases, and by other in 1 case. The time between injury and operation was 6 days to 31 months (median, 11.4 months). Joint pain occurred in 19 cases, joint instability in 28 cases, and joint swelling in 5 cases. The physical examination on admission showed thigh amyotrophy in 7 cases (thigh circumference side-to-side difference gt; 1 cm) and limitation of joint motion in 2 cases. The results of floating patella test, Lachman test, pivot shift test, and anterior drawer test were positive in 5, 51, 49, and 52 cases, respectively. The range of motion of knee was (127.77 ± 5.73)°, International Knee Documentation Committee (IKDC) score was 49.50 ± 4.08, and Lysholm score was 52.40 ± 3.45. Of the patients, 23 were accompanied with medial meniscus tear, 6 with lateral meniscus tear, 2 with plica synovialis, and 1 with loose body.?Results?All incisions healed by first intention. All the patients were followed up 12-18 months (mean, 14.9 months). At 12 months postoperatively, the results of Lachman test and pivot shift test were positive in 1 case, respectively; the results of anterior drawer test were negative in 52 cases. The range of motion of knee was (131.91 ± 1.81)°, Lysholm score was 94.98 ± 2.77, IKDC score was 93.65 ± 2.42; and there were significant differences when compared with the preoperative ones (P lt; 0.05). At 12 months postoperatively, at 90° resisted flexion of the knee, a very distinct fibrous band could be identified on the posteromedial aspect of the knee in 39 cases. MRI showed that both semitendinosus tendon and gracilis tendon regeneration in 10 cases, only semitendinosus tendon regeneration in 29 cases, only gracilis tendon regeneration in 2 cases, and no tendon regeneration in 11 cases. The regeneration rate of the semitendinosus tendon was 75.0% (39/52); the regeneration rate of the gracilis tendon was 23.1% (12/52); and the regeneration rate of the semitendinosus tendon and gracilis tendon was 78.8% (41/52).?Conclusion?MRI results suggest that some of the semitendinosus tendon and gracilis tendon could regenerate after harvested for ACL reconstruction.
