Project description:BackgroundAn anterior cruciate ligament (ACL) tear is a common knee injury, particularly among young and active individuals. Little is known, however, about the societal impacts of ACL tears, which could be large given the typical patient age and increased lifetime risk of knee osteoarthritis. This study evaluates the cost-effectiveness of ACL reconstruction compared with structured rehabilitation only.MethodsA cost-utility analysis of ACL reconstruction compared with structured rehabilitation only was conducted with use of a Markov decision model over two time horizons: the short to intermediate term (six years), on the basis of Level-I evidence derived from the KANON Study and the Multicenter Orthopaedic Outcomes Network (MOON) database; and the lifetime, on the basis of a comprehensive literature review. Utilities were assessed with use of the SF-6D. Costs (in 2012 U.S. dollars) were estimated from the societal perspective and included the effects of the ACL tear on work status, earnings, and disability. Effectiveness was expressed as quality-adjusted life years (QALYs) gained.ResultsIn the short to intermediate term, ACL reconstruction was both less costly (a cost reduction of $4503) and more effective (a QALY gain of 0.18) compared with rehabilitation. In the long term, the mean lifetime cost to society for a typical patient undergoing ACL reconstruction was $38,121 compared with $88,538 for rehabilitation. ACL reconstruction resulted in a mean incremental cost savings of $50,417 while providing an incremental QALY gain of 0.72 compared with rehabilitation. Effectiveness gains were driven by the higher probability of an unstable knee and associated lower utility in the rehabilitation group. Results were most sensitive to the rate of knee instability after initial rehabilitation.ConclusionsACL reconstruction is the preferred cost-effective treatment strategy for ACL tears and yields reduced societal costs relative to rehabilitation once indirect cost factors, such as work status and earnings, are considered. The cost of an ACL tear over the lifetime of a patient is substantial, and resources should be directed to developing innovations for injury prevention and for altering the natural history of an ACL injury.

Project description:The anterior cruciate ligament (ACL) is an essential stabilizer of the tibiofemoral articulation. ACL tears often lead to functional instability and are associated with an increased risk for osteoarthritis. The healing potential of the injured ACL is poorly understood and is considered to be limited. Transcriptome-wide expression profiles of 24 human ACL remnants recovered at the time of surgical reconstruction were analyzed utilizing the Agilent human 8x60K microarray platform. Gene ontology was performed on differentially expressed transcripts based on time-from-injury (acute, <3 months; intermediate, 3-12 months; chronic, >12 months). A subset of transcripts was validated via microfluidic digital polymerase-chain-reaction. Expression of periostin, a highly differentially expressed transcript, was tested by immunohistochemistry. Numerous transcripts covering important functional classifications were differentially expressed by time-from-injury. In acute tears, processes representing angiogenesis were repressed while those representing stem-cell differentiation were elevated. In intermediate tears, processes representing stem-cell proliferation concomitant with cellular component organization/cellular localization were elevated. In chronic tears, processes denoting myosin filament organization were elevated while those representing cellular component organization/cell localization and extracellular matrix organization were repressed. Expression levels of periostin were down-regulated in chronic tears compared to acute (42-fold) and intermediate (29-fold) tears. Immunohistochemistry confirmed a decline in periostin expression in tissues from chronic tears. These findings suggest an initial attempt of the injured ACL to repair, which declines with time-from-injury. These findings have implications for efforts to repair the ACL and may be relevant for reconstruction of the ACL. The functional role of periostin in ACL injuries, and the potential implication for surgical treatment, warrants further investigation.

Project description:The anterior cruciate ligament (ACL) is an essential stabilizer of the tibiofemoral articulation. ACL tears often lead to functional instability and are associated with an increased risk for osteoarthritis. The healing potential of the injured ACL is poorly understood and is considered to be limited. Transcriptome-wide expression profiles of 24 human ACL remnants recovered at the time of surgical reconstruction were analyzed utilizing the Agilent human 8x60K microarray platform. Gene ontology was performed on differentially expressed transcripts based on time-from-injury (acute, <3 months; intermediate, 3-12 months; chronic, >12 months). A subset of transcripts was validated via microfluidic digital polymerase-chain-reaction. Expression of periostin, a highly differentially expressed transcript, was tested by immunohistochemistry. Numerous transcripts covering important functional classifications were differentially expressed by time-from-injury. In acute tears, processes representing angiogenesis were repressed while those representing stem-cell differentiation were elevated. In intermediate tears, processes representing stem-cell proliferation concomitant with cellular component organization/cellular localization were elevated. In chronic tears, processes denoting myosin filament organization were elevated while those representing cellular component organization/cell localization and extracellular matrix organization were repressed. Expression levels of periostin were down-regulated in chronic tears compared to acute (42-fold) and intermediate (29-fold) tears. Immunohistochemistry confirmed a decline in periostin expression in tissues from chronic tears. These findings suggest an initial attempt of the injured ACL to repair, which declines with time-from-injury. These findings have implications for efforts to repair the ACL and may be relevant for reconstruction of the ACL. The functional role of periostin in ACL injuries, and the potential implication for surgical treatment, warrants further investigation. Total RNA obtained frominjured anterior cruciate ligament (ACL) tissues from pateints undergoing ACL surgery.

Project description:Posterior cruciate ligament (PCL) reconstruction for patients with PCL insufficiency has been associated with postoperative improvements in proprioceptive function due to mechanoreceptor regeneration. However, it is unclear whether reconstructed PCL or contralateral normal knees have better proprioceptive function outcomes. This meta-analysis was designed to compare the proprioceptive function of reconstructed PCL or contralateral normal knees in patients with PCL insufficiency. All studies that compared proprioceptive function, as assessed with threshold to detect passive movement (TTDPM) or joint position sense (JPS) in PCL reconstructed or contralateral normal knees were included. JPS was calculated by reproducing passive positioning (RPP). Five studies met the inclusion/exclusion criteria for the meta-analysis. The proprioceptive function, defined as TTDPM (95% CI: 0.25 to 0.51°; P<0.00001) and RPP (95% CI: 0.19 to 0.45°; P<0.00001), was significantly different between the reconstructed PCL and contralateral normal knees. The mean difference in angle of error between the reconstructed PCL and contralateral normal knees was 0.06° greater in TTDPM than by RPP. In addition, results from subgroup analyses, based on the starting angles and the moving directions of the knee, that evaluated TTDPM at 15° flexion to 45° extension, TTDPM at 45° flexion to 110° flexion, RPP in flexion, and RPP in extension demonstrated that mean angles of error were significantly greater, by 0.38° (P = 0.0001), 0.36° (P = 0.02), 0.36° (P<0.00001), and 0.23° (P = 0.04), respectively, in reconstructed PCL than in contralateral normal knees. The proprioceptive function of PCL reconstructed knees was decreased, compared with contralateral normal knees, as determined by both TTDPM and RPP. In addition, the amount of loss of proprioception was greater in TTDPM than in RPP, even with minute differences. Results from subgroup analysis, that evaluated the mean angles of error in moving directions through RPP, suggested that the moving direction of flexion has a significantly greater mean for angles of error than the moving direction of extension. Although the level of differences between various parameters were statistically significant, further studies are needed to determine whether the small differences (>1°) of the loss of proprioception are clinically relevant.

Project description:ObjectivesPartial 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.MethodsTwenty 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.ResultsMean 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.ConclusionThe 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.

Dataset Information

Effect of Time after Anterior Cruciate Ligament Tears on Proprioception and Postural Stability.

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Effect of Time after Anterior Cruciate Ligament Tears on Proprioception and Postural Stability.

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