Anterior cruciate ligament (ACL) rupture leads to weakened quadriceps muscle strength and a decline in proprioception, impairing the neuromuscular control of the lower extremities. ACL reconstruction, aimed at addressing such structural and functional instability, has become a primary treatment method for young and active patients. Consequently, there have been significant advancements in surgical techniques, resulting in improved clinical outcomes. However, achieving successful outcomes after ACL reconstruction is not solely dependent on the surgery itself; pre- and postoperative rehabilitation and management are equally crucial. A well-designed functional recovery program based on medical evidence before and after ACL reconstruction plays a vital role in restoring function to preinjury levels. The process of the functional recovery program, from presurgery to sports return, should adhere to certain principles. These principles involve prompt and accurate clinical diagnosis and patient classification after injury, systematic programs addressing joint swelling and inflammation control, reduction of arthrogenic muscle inhibition, restoration of range of motion, muscle strength recovery, and proprioception restoration. Postoperatively, it is essential to go beyond traditional methods (such as range of motion restoration and muscle strengthening) by implementing a functional recovery program that includes enhancement of proprioception and neuromuscular control system from the early stages, considering the biological healing response of the graft. This comprehensive approach is vital for achieving optimal outcomes in the recovery of function after ACL reconstruction.

n patients who have undergone knee joint surgery or suffer from osteoarthritis, weakened quadriceps muscle strength is often observed. This can lead to various pathological issues in the long term, such as abnormal gait and persistent knee pain. Due to the need to protect against pain or surgical site complications, high-intensity exercise is often restricted for most patients with muscle atrophy in the knee joint due to surgery or osteoarthritis or surgery. To overcome this challenge, various methods are being attempted, including exercise combined with neuromuscular electrical stimulation, blood flow restriction (BFR) exercise, and biofeedback exercise. Recently, BFR exercise has garnered attention in line with these strategic trends. Applying low-intensity BFR exercise to patients who have undergone anterior cruciate ligament reconstruction surgery or suffer from knee joint osteoarthritis, most studies report improvements in strength, muscle mass, and functional enhancement of the knee joint. Compared to non-BFR high-intensity exercise, it has been reported that increases in maximal strength and muscle mass are similar, but pain reduction is superior with BFR exercise. Engaging in low-intensity BFR exercise for a sufficient duration can minimize the risk of injury associated with high-intensity exercise while maximizing the exercise’s effectiveness, leading to symptom improvement and enhancement of knee joint function. Furthermore, when conducted according to specified manuals, the likelihood of cardiovascular imbalance, muscle damage, thrombosis, and embolism due to BFR is low, making it a safe rehabilitation method.

Background: Criteria for return to sports (RTS) following anterior cruciate ligament (ACL) reconstruction have been extensively studied. But there is no consensus among investigators regarding which factors are most important in determining a safe RTS. Methods: Sixty-one patients who underwent ACL reconstruction were included. Subjective knee scoring systems (International Knee Documentation Committee [IKDC] score and Lysholm score), functional performance tests (carioca test and single-leg hop for distance [SLHD] test), and isokinetic knee strength test were used for assessment and analyzed for association with the limb symmetry index (LSI) of the Y-balance test for lower quarter (YBT-LQ). Results: The LSI of the YBT-LQ was significantly correlated with Lysholm score, IKDC score, Carioca, LSI for the SLHD, and extensor strength deficit at 6 months after ACL reconstruction. At 12 months, Lysholm score, IKDC score, LSI for the SLHD, and extensor strength deficit were significantly correlated with the LSI of the YBT-LQ. Conclusions The YBT-LQ test could be used conveniently as an additional tool to assess the patient’s functional performance results after ACL reconstruction in outpatient clinics.

As the number of anterior cruciate ligament (ACL) reconstructions has increased significantly, surgical techniques have also made a lot of progress, and clinical outcomes are improving accordingly. However, the authors still have different opinions on ACL anatomy, femoral tunnel position, how to make a femoral tunnel, and graft selection, and many parts are controversial. Major factors contributing to the failure of ACL reconstruction, such as technical errors and biological healing failures. To reduce technical errors, a comprehensive understanding of ACL anatomy and the ability to create a well-positioned femoral tunnel are crucial. This involves recognizing the advantages and disadvantages of three surgical techniques: modified transtibial, transanteromedial portal, and outside-in. To improve biological healing, the four principles of tissue engineering (cells, growth factors, scaffolds, and mechanical stimuli) have been increasingly explored in various methods of bioaugmentation. Residual rotational instability of the knee joint remains a significant concern. Since the rediscovery of the anterolateral ligament (ALL) in the knee joint, the role of anterolateral complex, including the ALL and the deep iliotibial band, as secondary stabilizers of anterolateral rotatory instability, has gained attention. In the quest to reinforce the anterolateral complex, there are two approaches: ALL reconstruction as anatomical reconstruction concept and lateral extraarticular tenodesis as a nonanatomical reinforcement concept.

BACKGROUND: This study aimed to determine the effects of single semitendinosus tendon (ST) harvesting for anterior cruciate ligament (ACL) reconstruction by comparing outcomes of single ST and semitendinosus-gracilis tendon (ST-G) harvesting. METHODS: ACL reconstruction with ST-G harvesting (D group, n = 60) or single ST harvesting (S group, n = 60) were included according to inclusion criteria. Subjective assessments included subjective International Knee Documentation Committee score, Lysholm score, and Tegner activity scale score. Objective assessments included isokinetic strength and functional tests. These tests were completed at 36 months of follow-up. Magnetic resonance imaging (MRI) and second-look arthroscopy findings were evaluated. In the S group, regeneration properties were assessed by serial ultrasonography (US). RESULTS: The S group showed significantly less deep flexor strength deficit than the D group (p < 0.001). Deep flexor power deficits showed significant correlation with the shift of musculotendinous junction of the ST. There was significant difference in the cocontraction test between the groups (p = 0.012), and the S group tended to show better results in other functional tests at the last follow-up. There were no significant differences in graft tension and synovial coverage on second-look arthroscopy between the groups. In the S group, the regeneration rates assessed by US at the joint line and distal insertion were 81.7% and 80%, respectively at 6 months of follow-up. CONCLUSIONS: The S group showed significantly less deficit in deep flexor strength and tended to show better clinical results at the last follow-up than the D group. In the S group, more than 80% showed good regeneration at the 6-month follow-up. Hence, single ST harvesting is effective in minimizing flexor weakness and functional deficits and shows great potential for regeneration.
Anterior Cruciate Ligament Reconstruction ; Anterior Cruciate Ligament ; Arthroscopy ; Follow-Up Studies ; Joints ; Knee ; Lysholm Knee Score ; Magnetic Resonance Imaging ; Regeneration ; Tendons ; Transplants ; Ultrasonography

Functional knee braces are commonly prescribed to support anterior cruciate ligament (ACL) reconstruction. The aim of this study was to evaluate the current literature on the use of functional knee braces of ACL with respect to biomechanical, clinical and functional outcomes. A literature search was conducted (2000 to 2017) by two independent reviewers using PubMed MEDLINE database. Articles were retrieved by an electronic search using keywords (anterior cruciate ligament, brace, and bracing) and their combinations. Current functional braces used to treat ACL injury were identified. Studies that met inclusion criteria were assessed for pertinent data. Fourteen studies met the inclusion criteria. Functional knee brace reportedly did not improve long-term clinical and functional outcomes following ACL reconstruction, but some studies suggest that functional brace may have some benefit with regard to biomechanics, proprioception, and subsequent injury rates. Functional knee brace after ACL reconstruction was found no significant difference in clinical and functional outcomes. But Further large-scale recent studies will be required to determine long-term outcomes of the brace.
Anterior Cruciate Ligament Reconstruction ; Anterior Cruciate Ligament* ; Braces* ; Knee ; Ligaments ; Proprioception

BACKGROUND: The present study aimed to evaluate the prevalence of patellofemoral osteoarthritis (PFOA) and identify the factors that affect PFOA development after single-bundle anterior cruciate ligament (ACL) reconstruction with hamstring autograft. We hypothesized that detecting these factors could be helpful in establishment of a rehabilitation strategy to focus on the modifiable factors. METHODS: Of the 324 patients who underwent primary ACL reconstruction between January 2010 and June 2013, 92 patients who were available for follow-up for a minimum of 36 months after the surgery and underwent second-look arthroscopy were enrolled. Subjective assessments and clinical outcome evaluation were conducted. Arthroscopic cartilage evaluation was done using the Outerbridge classification. Univariable and multivariable logistic regression analyses were used. RESULTS: Ninety-two patients were evaluated at an average of 38.9 ± 5.4 months of follow-up. PFOA above grade 2 was observed in 19 patients (20.7%) at the second-look arthroscopy. Of them, three patients with pre-existing PFOA (3.3%) showed progression of the Outerbridge grade, and 16 (17.4%) had newly developed PFOA. According to the multivariable logistic regression analysis, isokinetic extensor deficit at 60°/sec at the last follow-up (odds ratio [OR], 2.193; 95% confidence interval [CI], 1.081 to 12.439; p = 0.031), age at primary surgery (OR, 1.118; 95% CI, 1.019 to 1.227; p = 0.018), and concurrent meniscectomy at primary surgery (OR, 0.091; 95% CI, 1.012 to 1.177; p = 0.023) were the significant predictors of PFOA development. CONCLUSIONS: Significant predictors of PFOA after ACL reconstruction with hamstring autograft were decreased quadriceps strength at last follow-up, increased age, and concurrent meniscectomy at primary surgery. Quadriceps weakness as a modifiable factor should be considered in the establishment of a rehabilitation strategy to prevent PFOA after ACL reconstruction, especially in older age.
Anterior Cruciate Ligament Reconstruction* ; Anterior Cruciate Ligament* ; Arthroscopy ; Autografts* ; Cartilage ; Classification ; Follow-Up Studies ; Humans ; Logistic Models ; Osteoarthritis* ; Prevalence* ; Rehabilitation ; Risk Factors ; Tendons*

BACKGROUND: The purpose of this study was to compare the clinical and radiological results of 2 different tibial fixations performed using bioabsorbable screws with added hydroxyapatite (HA) and pure poly-L-lactic acid (PLLA) screws in anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 394 patients who underwent arthroscopic ACL reconstruction between March 2009 and June 2012 were retrospectively reviewed. Of those, 172 patients who took the radiological and clinical evaluations at more than 2 years after surgery were enrolled and divided into 2 groups: PLLA group (n = 86) and PLLA-HA group (n = 86). Both groups were assessed by means of the Lysholm score, International Knee Documentation Committee (IKDC) subjective knee score, and Tegner activity score. Stability was evaluated using the KT-2000 arthrometer. Magnetic resonance imaging was performed to evaluate tibial tunnel widening, screw resorption, osteoingeration, and foreign body reactions. RESULTS: The PLLA-HA group showed significant reduction in the extent of tibial tunnel widening and foreign body reactions and significant increase in screw resorption compared to the pure PLLA group (p < 0.001 for both). In contrast, postoperative Lysholm score, Tegner activity score, IKDC score, and side-to-side difference on the KT-2000 arthrometer showed no significant differences between groups (p = 0.478, p = 0.906, p = 0.362, and p = 0.078, respectively). The PLLA group showed more significant widening in the proximal tibial tunnel than the PLLA-HA group (p = 0.001). In the correlation analysis, proximal tibial tunnel widening revealed a positive correlation with knee laxity (r = 0.866) and a negative correlation with Lysholm score (r = −0.753) (p < 0.01 for both). CONCLUSIONS: The HA added PLLA screws would be advantageous for tibial graft fixation by reducing tibial tunnel widening, improving osteointegration, and lowering foreign body reactions. Even though no clinically significant differences were noted between the pure PLLA group and PLLA-HA group, widening of the proximal area of the tibial tunnel showed a tendency to increase knee laxity measured using the KT-2000 arthrometer.
Anterior Cruciate Ligament ; Durapatite ; Foreign Bodies ; Humans ; Knee ; Lysholm Knee Score ; Magnetic Resonance Imaging* ; Retrospective Studies ; Transplants

PURPOSE: The purpose of this study is to present the effective design of N-plasty of the iliotibial band and surgical results of its use as a treatment for refractory external snapping hip. MATERIALS AND METHODS: We evaluated 17 patients (24 cases) with external snapping hip who underwent N-plasty between October 2013 and May 2016 and who were followed up for at least 12 months. All patients were male and the mean age was 20.8 years. The mean duration of symptoms prior to surgical intervention was 28.5 months with an average follow up of 24.5 months. Surgery was defined as being successful when patients could carry out their daily activities and exercise without a clicking sensation or pain 6 months after surgery until their last follow-up. Failure was defined when either a clicking sensation or pain was present. The visual analog scale (VAS) and modified Harris hip score (mHHS) were measured and compared preoperatively and at last follow-up. RESULTS: All patients had complete resolution of pain and snapping. The VAS decreased from 6.77 preoperatively to 0.09 postoperatively and mHHS improved from 69.5 to 97.8 after surgery. CONCLUSION: Modified designed N-plasty is considered to be an excellent treatment method facilitating operation reproducibility with maximum elongation effect of the iliotibial band.
Follow-Up Studies ; Hip* ; Humans ; Male ; Methods ; Sensation ; Visual Analog Scale

PURPOSE: The purpose of this study is to present the effective design of N-plasty of the iliotibial band and surgical results of its use as a treatment for refractory external snapping hip. MATERIALS AND METHODS: We evaluated 17 patients (24 cases) with external snapping hip who underwent N-plasty between October 2013 and May 2016 and who were followed up for at least 12 months. All patients were male and the mean age was 20.8 years. The mean duration of symptoms prior to surgical intervention was 28.5 months with an average follow up of 24.5 months. Surgery was defined as being successful when patients could carry out their daily activities and exercise without a clicking sensation or pain 6 months after surgery until their last follow-up. Failure was defined when either a clicking sensation or pain was present. The visual analog scale (VAS) and modified Harris hip score (mHHS) were measured and compared preoperatively and at last follow-up. RESULTS: All patients had complete resolution of pain and snapping. The VAS decreased from 6.77 preoperatively to 0.09 postoperatively and mHHS improved from 69.5 to 97.8 after surgery. CONCLUSION: Modified designed N-plasty is considered to be an excellent treatment method facilitating operation reproducibility with maximum elongation effect of the iliotibial band.
Follow-Up Studies ; Hip* ; Humans ; Male ; Methods ; Sensation ; Visual Analog Scale