Anteroposterior stability of the knee during the stance phase of gait after anterior cruciate ligament deficiency
Highlights
► Combined DFIS and MR image based technique was used to investigate treadmill gait of the knee. ► Higher flexion angles and anterior tibial translations were found in ACL deficient knees during stance phase of gait. ► Higher flexion gait strategy of ACL injured knees could not compensate the anterior tibial translation effectively.
Introduction
Numerous studies have demonstrated that ACL deficiency could lead to further meniscus tear and cartilage degeneration [1], [2]. The post-injury joint degeneration has been mainly attributed to altered joint kinematics caused by ACL deficiency [3], [4]. Therefore, understanding the effect of ACL injuries on knee joint motion is critical for development of conservative treatment or surgical reconstruction of the ACL injured knees. Historically, in vitro cadaveric studies have reported on the anterior tibial translation when the knee was subjected to an anterior tibial load or a rotational torque [5], [6]. Few studies have reported on the knee joint motion in response to simulated muscle loads [7], [8]. Recently, advanced imaging techniques have been used to examine the bony motion of the knee after ACL injuries during down-hill running [9] and single leg lunge [10], [11], [12]. Few data, however, have been reported on the influence of ACL deficiency on knee joint motion during gait [13], [14], [15], [16], [17], [18], [19], [20] – the most commonly performed daily activity.
In literature, the effect of ACL deficiency on knee joint motion during gait has been assumed to be a quadriceps avoidance gait strategy [15], where the patients with ACL injuries adapt to a reduced quadriceps contraction or extension joint moment during the midstance phase of the gait cycle. A reduced quadriceps function was thought to reduce the anterior shear force applied to the tibia at low flexion angles of the knee so that to avoid the increased anterior tibial translation due to the rupture of the ACL [13], [15], [18]. However, many studies have reported other adaptation strategies for ACL deficient patients, showing an increased flexion angle during stance phase of gait in ACL deficient knees [14], [16], [17], [20]. This higher knee flexion with the increased activity of the hamstring muscles suggested a mechanism exists which may improve sagittal joint stability during locomotion for ACL deficient knees. Although there are some studies that reported the tibiofemoral translation during gait [13], [17], the soft tissue artifacts were thought to be a limitation of the skin-marker-based motion capture system, especially in knee joint translation [21], [22]. In addition, it is still unclear that either the quadriceps avoidance gait or higher flexion strategy can effectively avoid the excessive anterior tibial translation caused by ACL deficiency.
Recently, we validated a combined dual fluoroscopic imaging system (DFIS) and MR image technique [23] in determination of the kinematics of the knee during stance phase of gait on a treadmill [19], [24]. The objective of this study was to determine the flexion angles and anteroposterior tibial translation of the knee after ACL injuries during gait on a treadmill and to compare these data to those measured from the intact contralateral side. We hypothesized that while the ACL deficient knees may adapt to higher flexion gait strategy under low demand activities such as walking, the anterior tibial translation could not be reduced due to the increased flexion angles.
Section snippets
Patient recruitment
10 subjects who suffered from unilateral ACL tear were recruited for this study (five females and five males with an average age of 35.5 ± 8.5 years, body weight of 77.1 ± 9.1 kg, body height of 1.76 ± 0.07 m and body mass index (BMI) of 24.9 ± 2.8 kg/m2). The ACL deficiency of the injured knee was verified through physical examination by an orthopaedic surgeon as well as MRI examination performed as part of this study. Additionally, the status of each injured ACL was confirmed during arthroscopy performed
Flexion
Both the ACL deficient and normal knees demonstrated a similar flexion pattern along the stance phase of the gait cycle (Fig. 3). More specifically, both groups extended similarly at heel strike (2.2 ± 9.2° in normal group and −0.5 ± 9.3° in ACL deficient group) and flexed from 0% to 20%. The flexion reached the first peak with 8.3 ± 5.9° and 5.3 ± 5.1° in the ACL deficient and normal knees, respectively, at 20% of the stance phase. Thereafter, the ACL deficient knees kept to rotate in higher flexion
Discussion
This study investigated the flexion angle and the anterior–posterior translation of the ACL-deficient and intact contralateral knees during the stance phase of gait on a treadmill. In general, the ACL-deficient knees tended to flex more and have more anterior tibial translation compared to the intact contralateral side. The results confirmed our hypothesis on the effect of ACL deficiency on the motion of the knee during gait on a treadmill.
The gait is the mostly performed activity of daily
Conflict of interest statement
No potential conflict of interest declared.
Acknowledgements
The authors would like to gratefully acknowledge the financial support of the National Institute of Health (R01 AR055612) and the Department of Orthopaedic Surgery at Massachusetts General Hospital.
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