Technical notesFunctional recovery following primary ACL repair with dynamic intraligamentary stabilization
Introduction
Return to high-level sporting activities outcomes, following anterior cruciate ligament (ACL) reconstruction are widely varied [1], [2], [3], [4]. A high rerupture rate following ACL reconstruction has been reported for young active adults returning back to sports [5], [6]. In the study of Ardem et al. on athletes undergoing ACL reconstruction, only 1/3 of patients returned to preinjury level of competitive sport by 12 months after surgery and less than 50% by two to seven years following ACL reconstruction [7], [8]. Additionally, of the patients successfully returning to preoperative activity status following ACL reconstruction, 10 to 30% will go on to a second knee injury [9], [10], [11], [12].
Deficits in neuromuscular control and significant side-to-side differences in lower extremity biomechanics are considered as the principal reasons for rerupture following ACL reconstruction [13], [14], [15], [16]. Muscle strength is also considered as a crucial factor for returning to sports following ACL reconstruction [17], [18], [19], [20]. Literature data support that an ACL-reconstructed patient should be able to achieve isokinetic quadriceps peak torque of up to 85% of the uninvolved lower extremity in order to progress to plyometric activities [21].
Hop tests have been used as a measure of functional performance in the lower extremity and are believed to effectively test a patient's strength and neuromuscular control [22], [23], [24], [25], [26]. Additionally, they have been shown to be a reliable and valid outcome in patients who have undergone an ACL reconstruction [22]. The patient's test performance on the hop test is described as the leg symmetry index (LSI) and is measured by comparing the involved limb to the uninvolved limb and is expressed as a percentage [22]. A score of 85% or less on the hop tests is considered to be abnormal [27].
Nowadays, ligament reconstruction with autologous graft represents the “gold standard” on ACL treatment [28], [29]. Based on the philosophy of the healing potential of the ACL, a new technique for primary ACL stabilization, dynamic intraligamentary stabilization (DIS) was developed at the authors' institution (University Hospital, Level A Trauma centre) [30], [31]. It consists of a threaded sleeve (10 × 30 mm) housing a preloaded spring and a mechanism for securing the spring in the tibia. A braided wire (1.8 mm) traverses the knee joint through the middle of the torn ACL, exiting through the lateral aspect of the femur where it is anchored with a button to the bone [32], [33], [34], [35], [36].
The aim of the present study is to evaluate the time to return to sports, for patients with ACL ruptures treated with DIS acute repair. We hypothesized that the hop test would prove to be a reliable tool when used in the assessment of a patient's readiness to return to sports following ACL surgery.
Section snippets
Materials & methods
Between February 2012 and October 2013, after receiving appropriate Institutional Review Board approval, 45 patients (13 females, 32 males) presenting with acute rupture of the ACL with a Median age of 26 ± 10 years (range, 18 to 54 years) composed the study group (Table 1). Inclusion criteria were: clinical and radiological confirmation of a complete isolated ACL rupture, an acute injury within a three week post-injury timeframe, active patients with a Tegner score of at least four. Exclusion
Results
Mean rehabilitation time was 22 ± 6 weeks. Compared to the contralateral healthy limb, two (4.4%) patients demonstrated a flexion deficit of five degrees to 10° while one (2.2%) of 15° (Table 2).
No patients demonstrated an extension deficit of more than five. Most patient experienced no pain (VAS (0 to 10): 0 range one to three). Median strength of the operative limb (leg press) was 123 ± 37.8 kg while median strength in relation to the non-operative limb was 91.4 ± 12.6%. Median difference in
Discussion
The data of this study demonstrate good functional recovery following DIS repair with median LSI of 91.6% ± 8.3 at a median rehabilitation time of 22 ± 6 weeks.
Functional recovery represents the ultimate challenge following ACL repair/reconstruction techniques. Single leg hop tests are commonly used as physical performance measures of function following ACL injury or surgical reconstruction. Since the test can simulate various motion sequences (i.e. velocity, change of direction, braking, rebound,
Conclusion
This study supports that ACL repair using DIS technique with proper rehabilitation following acute ACL rupture provides successful functional recovery and low rerupture rate at one-year follow-up.
Conflict of interest statement
“Conflicts of interest: none”.
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