A systematic literature review to investigate if we identify those patients who can cope with anterior cruciate ligament deficiency

doi:10.1016/j.knee.2006.02.010

The Knee

Volume 13, Issue 4, August 2006, Pages 260-265

https://doi.org/10.1016/j.knee.2006.02.010 Get rights and content

Abstract

Rupture of the anterior cruciate ligament (ACL) results in increased tibiofemoral laxity in the knee, thereby ultimately resulting in knee instability and dysfunction. However, ACL rupture does not automatically infer functional impairment and instability as confirmed by the ACL deficient (ACLD) coper, who can resume pre-morbid activity levels. Alternatively, an authentic ACLD non-coper is unable to return to pre-injury levels of activity due to repeated incidents of giving-way. Little is known as to the contributory factors, which allows copers dynamic stability and render non-copers functionally impaired. This systematic literature review aims to examine the evidence presented by relevant trials in order to identify measurement tools, which could differentiate ACLD copers and non-copers.

A literature search found nine trials; four adhered to the inclusion criteria of this review. Consensus was achieved within the studies that laxity measurements and IKDC ratings are incapable of distinguishing the functional status of the ACLD patient. Alternatively, Lysholm, KOS-Sport, KOS-ADL and Global Knee Function Rating Scores were regarded as capable of discriminating between ACLD copers and non-copers. Disagreement existed as to the efficacy of the Quadriceps Index and the single leg hop in categorising the ACLD patient according to function level. It was concluded that no single measurement tool is sufficient in determining the functional status of the ACLD individual. Consequently, a collaboration of tests is recommended, specifically incorporating the KOS-Sport, Global Knee Function Rating, hop tests and Quadriceps Index.

Introduction

Anterior cruciate ligament (ACL) rupture results increased tibiofemoral laxity in the knee that may result in knee instability and dysfunction [1]. Despite 47% of knee ligament injuries involving the ACL, coupled with an estimated incidence of 30 per 100,000 of the population [2], a definitive management strategy for patients with this injury is still far from clear. This is particularly evident when deciding whether to reconstruct the ligament or carry out conservative rehabilitation. The lack of consensus is in part due to the fact that ACL rupture does not automatically infer functional impairment and instability, as confirmed by anterior cruciate ligament deficient (ACLD) copers [1]. The ability to return to pre-morbid levels of sports activity without operative management is characteristic of ACLD copers [3]. Whilst exclusion from activity coupled with the inevitability of reconstructive surgery are factors traditionally associated with the ACLD non-coper population [4].

Two opposing treatment strategies are available to the cruciate deficient individual: conservative management and reconstructive surgery [5]. Controversy exists as to which intervention results in a superior functional outcome for the ACLD patient. Whilst Wittenberg et al. [6] observed unlimited activity levels in 36% of ACL reconstructed individuals, only 14% of conservatively treated patients achieved an identical outcome. Conversely, Buss et al. [7] documented 57.7% of non-operatively managed ACLD patients attained their pre-morbid levels of activity. Despite the findings of Buss et al. [7], a high failure rate of non-operative ACLD rehabilitation programmes nevertheless exists, thereby generating a high percentage of patients automatically opting for reconstructive surgery [8]. Chmielewski et al. [9] inferred that these poor outcomes may reflect deficient methods in identifying suitable rehabilitation candidates (i.e. copers). Theoretically, by selecting ACLD patients with superior knee stability at the start of a rehabilitation programme, non-operative treatment success may be enhanced. Consequently, the necessity to develop a system to differentiate ACL deficient individuals into copers and non-copers is important.

This systematic review aimed to critically appraise the methodological quality of published trials. It aimed to look at clinical-measuring instruments, subjective questionnaires and functional performance testing between ACLD copers and non-copers.

Section snippets

Search strategy

The search strategy of this systematic literature review primarily incorporated electronic databases, specifically Sports Discus, Medline, CINAHL and the Cochrane Database. Additionally, the reference lists of primary articles were scrutinized and hand searching was undertaken; this was in line with the recommendations of Khan and Kleijnen [10]. Numerous key words were utilised for each search engine, including anterior cruciate ligament, coper, non-coper, stability, functional instability and

Description of studies

Following the literature search, a total of nine investigations were found suitable for further analysis, of which four adhered to the strict inclusion criteria. Five investigations were excluded; two failed on population [13], [14], whilst the remaining three utilised inappropriate means of analysing the ACLD population [4], [9], [15].

A study population of 102 anterior cruciate ligament deficient (ACLD) people were identified in the four trials, of which 41 were copers and 61 were non-copers.

Laxity

Three studies showed that laxity measurements have little predictive value in differentiating ACLD copers and non-copers [1], [3], [12]. Interpretation of these findings infers that ACLD copers and non-copers should therefore have the same probability of instability; a factor refuted by the characteristic superior dynamic stability evident in copers [11], [12]. With 75% of the included studies in this review reporting no significant difference in passive knee joint laxity between ACLD copers

Conclusion

No single knee-measuring tool is sufficient in determining the functional status of the ACLD individual. Consequently, KOS-Sport, Global Knee Function Rating, hop tests and Quadriceps Index should all be included when assessing these patients.

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There are more references available in the full text version of this article.

Cited by (63)

Anteromedial Portal Technique, but Not Outside-in Technique, Is Superior to Standard Transtibial Technique in Knee Stability and Functional Recovery After Anterior Cruciate Ligament Reconstruction: A Network Meta-analysis
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
To compare the postoperative outcomes of 4 different femoral drilling techniques in anterior cruciate ligament reconstruction.
Three databases were searched for randomized controlled trials comparing any 2 or more of the following femoral drilling techniques in anterior cruciate ligament reconstruction: standard transtibial (sTT), anteromedial portal (AMP), outside-in (OI), or modified transtibial (mTT) technique. A Bayesian network meta-analysis was performed to assess postoperative stability and functional recovery in terms of the side-to-side difference (measured by arthrometry), Lachman test, pivot-shift test, International Knee Documentation Committee subjective and objective scores, Lysholm score, and Tegner score. The Fisher exact probability test and χ² test were used to compare the incidences of infection and graft rupture, respectively.
We included 20 randomized controlled trials involving 1,515 patients. The AMP technique showed a lower side-to-side difference (standardized mean difference, –0.33; 95% credible interval [CrI], –0.53 to –0.12), higher negative rate on the pivot-shift test (odds ratio, 2.19; 95% CrI, 1.38 to 3.44), and higher International Knee Documentation Committee objective score (odds ratio, 3.13; 95% CrI, 1.42 to 7.82) than the sTT technique. However, knee stability and functional outcomes did not differ significantly between the OI and sTT techniques. Safety outcomes of the mTT technique were unavailable. The incidence of graft rupture was 5.20% for the OI technique, 2.27% for the AMP technique, and 1.51% for the sTT technique. The OI technique had a significantly higher incidence of graft rupture than the sTT technique (χ² = 4.421, P = .035). No significant difference in the incidence of infection was found between the sTT, AMP, and OI techniques (P = .281).
The AMP technique, but not the OI technique, was superior to the sTT technique in knee stability and functional recovery. The OI technique had a higher incidence of graft rupture than the sTT technique. There was no significant difference between the AMP and OI techniques or between the mTT technique and any other femoral drilling technique.
Level II, meta-analysis of Level I and II studies.
Knee flexion angle and muscle activations control the stability of an anterior cruciate ligament deficient joint in gait
2021, Journal of Biomechanics
Citation Excerpt :
It is also to be noted that, constrained by the external moments reported in gait, quadriceps (in the first half of stance) and gastrocnemii (in the second half of stance) activations, though variable with changes in KFAs, could not be diminished further below their optimum values computed here (Fig. 6). In the absence of differences in the passive laxity tests of copers versus noncopers (Eastlack et al., 1999; Herrington and Fowler, 2006) and in search of contributory parameters affecting their distinct responses, two parameters were identified in this work as the primary compensatory controllers of an ACLD joint stability; KFA as well as the activity index defined as the ratio of ACL antagonist muscle (i.e., quads and gastrocnemii) to ACL agonist (i.e, hamstrings) forces. Stability of an ACLD joint is influenced and maintained by an interplay between these two crucial parameters; smaller activity indices needed at smaller KFA whereas larger ones can be tolerated but require greater KFA.
Anterior cruciate ligament (ACL) is a primary structure and a commonly injured ligament of the knee joint. Some patients with ACL deficiency (ACLD) experience joint instability and require a reconstructive surgery to return to daily routines, some can adapt by limiting their activities while others, called copers, can return to high-level activities with no instability. We investigated the effects of alterations in the knee flexion angle (KFA) and muscle force activations on the stability and biomechanics of ACLD joints at 25, 50, and 75% periods of gait stance. ACLD joint stability is controlled by variations in both KFA and knee muscle forces. For the latter, a parameter called activity index is defined as the ratio of forces in ACL antagonists (quadriceps and gastrocnemii) to those in ACL agonists (hamstrings). Under a greater KFA (2–6° beyond the mean of reported values in healthy subjects), an ACLD joint regains its pre-injury stability levels. The ACLD joint stability also markedly improves at smaller quadriceps and larger hamstrings forces (activity indices of 2.0–3.6 at 25%) at the first half of stance and smaller gastrocnemii and larger hamstrings forces (activity indices of 0.1–1.1 at 50% and 0.1–1.2 at 75%) at the second half of stance. Activity index and KFA are both crucial when assessing the dynamic stability of an ACLD joint. These results are helpful in our understanding of the biomechanics and stability of ACLD joints towards improved prevention and treatment strategies.
Low correlation between functional performance and patient reported outcome measures in individuals with non-surgically treated ACL injury
2021, Physical Therapy in Sport
Describe a consecutive cohort of people with a non-surgically treated ACL injury and evaluate correlations between functional performance and patient reported outcome measures (PROMs).
Cross-sectional.
Sixty-eight individuals (38 males, 18–45 years old) 2–5 years after ACL injury.
Tegner Activity Scale, International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Anterior Cruciate Ligament Return to Sport after Injury scale (ACL-RSI) and ACL-Quality of Life (ACL-QoL) were completed. Functional performance was assessed using 4 hop tests and a squat test.
Mean IKDC-SKF score was 72 ± 17 and mean LSI on performance tests were above 90%. Tegner Activity Scale was reduced from median 8 pre-injury to 5 at follow up. Satisfaction with activity level was median 7 on a 10-point ordinal scale. Correlations were moderate to strong (r = 0.552–0.856) between PROMs, negligible to weak (r = 0.003–0.403) between performance tests and PROMs and negligible to moderate (r = 0.142–0.683) between performance tests.
Functional performance had negligible or weak correlation to PROMs, which indicates the need for multi-modal assessment strategies. Activity level was reduced 2–5 years after a non-surgically treated ACL injury, but most patients were able to resume physical activity at a sufficient level to maintain health and displayed symmetrical functional performance.
Retrospective cohort study, Level III.
Analysis of partial bundle anterior cruciate ligament tears- diagnosis and management with ACL augmentation
2020, Journal of Clinical Orthopaedics and Trauma
Partial ACL tears are increasingly recognized in young active patients. They can evolve into complete tears. Controversy exists regarding the need to spare intact ACL bundle as it has its advantages considering biomechanical strength, blood supply and proprioception. The current study determined the challenges in partial ACL tear management and assessed the functional outcomes.
Twenty consecutive patients with partial ACL tears were studied. Inclusion criteria were: age 16–45yrs and patients operated for partial ACL tear. Exclusion criteria were: combined ACL-PCL injuries, associated collateral injuries, complete ACL tear, chondral defect or bony malalignment and patients with radiographic signs of arthritis. ‘Partial’ tear was defined as continuous fibers from native tibial ACL footprint to native femoral ACL footprint in arthroscopy. Clinical and radiological assessment was done to evaluate anteromedial(AM) or posterolateral(PL) bundle tears. We used the term “ACL-augmentation” without disturbing the intact bundle or preserving the intact fibers as much as possible. Functional scoring was done using Lysholm score. Standard post-operative protocols were followed. Statistical analysis was done using SPSS software.
Mean age of patients was 31.2 years. Physically active age group (<30yrs) included 62.5% patients. Males were 87.5%. Pain and instability were the presenting complaints in 75% and 70% respectively. Average duration of presentation since injury was 4.2 months. Sports activities were the most common mode of injury (45%) followed by road traffic accidents (37.5%). Anterior drawer test was positive in 40%, pivot shift in 35% and Lachman test was positive in 65%. On arthroscopy, 65% had AM bundle tears and 35% had PL bundle tears. The intact bundle was found lax in 13% cases. Associated meniscal tear was present in 28% patients. Stiff knee was the most common post-operative complaint. Preoperative Lysholm knee score of 74.5 improved to 87.7 at 12months (p < 0.001). Around 97.5% of the patients reported outcomes as good and fair.
The treatment strategy needs to be individualized. The ACL augmentation needs more systematic and accurate placement of portals while sparing the intact ACL fibers. For AM bundle, tibial tunnel entry point is about 1–2 cm medial to tibial tuberosity. For PL bundle, it is about 3–4 cm medial to tibial tuberosity to protect the AM bundle. Long term studies with greater number of subjects are required.
Anterior Cruciate Ligament Reconstruction with Platelet-Rich Plasma: A Systematic Review of Randomized Control Trials
2020, Arthroscopy - Journal of Arthroscopic and Related Surgery
To perform a systematic review of the randomized controlled trials (RCTs) evaluating the efficacy of platelet-rich plasma (PRP) to augment anterior cruciate ligament (ACL) reconstruction.
Two independent reviewers screened the MEDLINE, The Cochrane Library, and EMBASE databases using Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines for applicable RCTs evaluating the efficacy of PRP in ACL reconstruction. A meta-analysis was performed on the papers involving bone–patellar tendon–bone (BPTB) grafting.
Thirteen RCTs fulfilled the inclusion criteria involving 765 patients. There was no clinical improvement (Tegner, Lysholm, Knee Injury and Osteoarthritis Outcome Score, or International Knee Documentation Committee scores) in any of the 7 studies evaluating PRP alongside the hamstring tendon autograft ACL reconstructions versus the control. Two studies evaluating PRP for hamstring tendon autograft demonstrated significantly improved magnetic resonance imaging findings. Two studies analyzed the use of PRP with allograft ACL reconstruction showed no clinical, biochemical, or radiologic improvements in postoperative follow-up. No functional improvements were found when PRP was used alongside BPTB in 4 studies. There was no significant difference in visual analog scale score in the BPTB group (1.1 vs 1.5, P = .18), or tibial filling defects (P = .30).
This study found that the current level I evidence does not support the use of PRP to improve graft healing, improve donor-site morbidity, reduce postoperative pain levels, or improve functional outcomes following ACL reconstruction.
Level I; systematic review of level I evidence
Computation of the role of kinetics, kinematics, posterior tibial slope and muscle cocontraction on the stability of ACL-deficient knee joint at heel strike – Towards identification of copers from non-copers
2018, Journal of Biomechanics
Citation Excerpt :
In contrast, lower flexion rotations (Lewek et al., 2002) and no differences in hamstrings activity (Hurd and Snyder-Mackler, 2007) have also been noted in ACL-D subjects. Post-injury passive anterior laxity tests are not able to differentiate copers from non-copers (Eastlack et al., 1999; Herrington and Fowler, 2006). Higher cocontraction of hamstrings (Alkjær et al., 2002; Courtney and Rine, 2006) and of both hamstrings and quads (Alkjaer et al., 2003) have been reported in copers versus non copers.
Rupture of anterior cruciate ligament (ACL) undermines normal activity and function of the knee joint and places it at higher risk of re-injury and degeneration. ACL reconstruction surgery neither necessarily ensures return to pre-injury activities nor alleviates risk of long-term degeneration. Here in this computational investigation of a lower-extremity hybrid model at heel strike (HS) of gait, we search for factors that influence the stability of the joint and hence the distinct performances between post-ACL injury copers and non-copers. Due to the very unstable state of the joint under the mean gait input data, joint rotations-moments, posterior tibial slope (PTS), and cocontraction were altered within the reported data in the literature and the effects on the joint stability (anterior tibial translation (ATT) and critical muscle stiffness coefficient (q_cr)) were investigated. Results indicate that, in presence of both a small extension moment (0.1 or 0.2 Nm/kg) and a flexion rotation (∼5–8°), ACL-deficient (ACL-D) knee joint stability substantially improves to levels computed in the pre-injury intact joint. In addition, low cocontraction levels of 1–3% (in hamstrings and quads only and not in gastrocnemii) and reduced PTS (by 5°) further improve ACL-D joint stability. Therefore for a stable joint with ATT < 3 mm and q_cr < 25 similar to those in the intact knee at HS, higher flexion angles (>5°) and a small extension moment (∼0.1–0.2 Nm/kg) (i.e., higher activity in hamstrings than quads) are required. A lower posterior tibial slope (by 5°) and a small minimum cocontraction level (1–3%) in hamstrings and quads (but not in gastrocnemii) are also beneficial. These results identify mechanisms likely in play at HS in gait of copers when compared to non-copers.

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A systematic literature review to investigate if we identify those patients who can cope with anterior cruciate ligament deficiency

Abstract

Introduction

Section snippets

Search strategy

Description of studies

Laxity

Conclusion

Clin Biomech

J Electromyogr Kinesiol

Laxity, instability and functional outcome after ACL injury: coper versus noncopers

Med Sci Sports Exerc

The incidence of knee ligament injuries in the general population

Am J Knee Surg

The relationship between passive joint laxity and functional outcome after ACL injury

Am J Sports Med

What is the optimal treatment of the anterior cruciate ligament injury?

Critical evaluation of different scoring systems of the knee

Sports Med Arthrosc Rev

Nonoperative treatment of acute anterior cruciate ligament injuries in a selected group of patients

Am J Sports Med

Early season anterior cruciate ligament tears: a treatment dilemma

Am J Sports Med

Dynamic knee stability: current theory and implications for clinicians and scientists

J Orthop Sports Phys Ther