Single- vs. double-bundle anterior cruciate ligament reconstruction: a new aspect of knee assessment during activities involving dynamic knee rotation.

SINGLE- VS. DOUBLE-BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A NEW ASPECT OF KNEE ASSESSMENT DURING ACTIVITIES INVOLVING DYNAMIC KNEE ROTATION ANDRZEJ CZAMARA,1,2 ALEKSANDRA KRO´LIKOWSKA,1,2 ŁUKASZ SZUBA,1,2 WOJCIECH WIDUCHOWSKI,1 1 AND MACIEJ KENTEL 1

The Department of Physiotherapy, The College of Physiotherapy in Wroclaw, Wroclaw, Poland; and 2The Department of Physiotherapy, The Center of Rehabilitation and Medical Education, Wroclaw, Poland

ABSTRACT Czamara, A, Kro´likowska, A, Szuba, L, Widuchowski, W, and Kentel, M. Single- vs. double-bundle anterior cruciate ligament reconstruction: A new aspect of knee assessment during activities involving dynamic knee rotation. J Strength Cond Res 29(2): 489–499, 2015—Few studies have compared singlebundle (SB) and double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) in the knee joint during activities involving change-of-direction maneuvers and knee rotation. This study examined whether the type of ACLR contributes to postphysiotherapy outcomes, with an emphasis on knee function assessment during activities involving dynamic knee rotation. Fifteen male patients after SB ACLR and 15 male patients after DB ACLR took part in the same physiotherapy program. Twenty-four weeks after ACLR, both groups underwent anterior laxity measurement, pivot shift tests, range of movement and joint circumference measurements, subjective assessment of pain and stability levels in the knee joint, peak torque measurement of the muscles rotating the tibia toward the femur, and a run test with maximal speed and change-of-direction maneuvers. Comparative analysis did not show any differences between the results of anterior tibial translation, pivot shift test, range of movement and joint circumference, and subjective assessment of pain and knee joint stability levels. No differences were noted between the groups in peak torque values obtained from the muscles responsible for internal and external tibial rotation or results of the run test. The data obtained from this study can be used by research teams to monitor and compare the effectiveness of various study protocols involving surgical and physiotherapy treatment. The data are especially

Address correspondence to Andrzej Czamara, [email protected]. 29(2)/489–499 Journal of Strength and Conditioning Research Ó 2015 National Strength and Conditioning Association

useful when combined with the clinical assessment of patients who would like to return to sport.

KEY WORDS peak torque, shin rotation, functional tests, change-of-direction maneuvers, knee stability, physiotherapy

INTRODUCTION

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n cases of complete tearing of the anterior cruciate ligament (ACL) with full clinical symptoms, singlebundle (SB) anterior cruciate ligament reconstruction (ACLR) is the gold standard technique of ligament repair. Double-bundle (DB) ACLR replicates 2 functional bundles—the anteromedial bundle and the posterolateral bundle—to restore more closely the kinematics and normal stability of the knee (30,39). Proponents of DB ACLR use the functional DB structure of ACL as support for the rationale of the DB method (19). There are studies that have shown that SB ACLR does not fully restore the kinematics of the knee during functional activities; and as far as anterior stability seems to be reconstituted, tibial rotation or transverse motion, compared with native knees, remains abnormal (29,50). Studies conducted to date comparing SB ACLR with DB ACLR approaches were mainly based on measurements of anterior tibial translation in relation to the femur and knee stability in the transverse plane based on measurements using arthrometers, anterior drawer tests, pivot-shift tests, the Lachman test, the Lysholm scale, and the International Knee Documentation Committee assessment (1,2,9,13,20,24,25,36,37,51,53). Other researchers have compared the range of movements in the knee joint and analyzed peak torque values of knee extensors and flexors (9,53). Because the motion and stability of the knee joint are controlled not only by static stabilizers, including ligaments, but also by dynamic stabilizers, such as muscles, it is essential to restore muscle strength after ACLR (3,4,31,34,43,54) not only in the sagittal plane but also in the transverse plane. To the best of the authors’ knowledge, there are no studies examining differences VOLUME 29 | NUMBER 2 | FEBRUARY 2015 |

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Knee Assessment During Dynamic Knee Rotation between SB ACLR and DB ACLR and multiplane function of the knee joint during physical activities such as running, sudden change-of-direction maneuvers, and knee rotation. Because some kinematic studies suggest that rotatory stability in DB reconstructed knees is more similar to that of native knees than SB reconstructed knees (5,21,22,28,30,51), it might be a suggestion that DB technique will provide better stability of the knee during sports that require cutting and pivoting. The authors hypothesize that The results of knee function evaluation during activities involving dynamic knee rotation are better in group of patients after DB ACLR, and thus this technique should be recommended for athletes who perform sports requiring cutting and pivoting. The purpose of this study was to examine whether the different types of ACLR, and the same intensive 4-stage physiotherapy program, contributed to postphysiotherapy outcomes, with an emphasis on assessment of knee function during activities involving dynamic knee rotation.

METHODS Experimental Approach to the Problem

To assess the impact of the type of ACLR on the activities involving dynamic knee rotation, a run test with maximal speed and change-of-direction maneuvers and peak torque measurements of muscles responsible for tibial rotation were performed. Subjects after SB ACLR and DB ACLR were recruited to this study. All of the participants underwent the same postoperative 24-week long physiotherapeutic procedure. The tests were performed a half-year after the ACLR. Subjects

This study was approved by the local ethics committee, and written informed consent forms were signed by all of the participants before the study. The study was conducted according to the ethical guidelines and principles of the Declaration of Helsinki. The initial sample population comprised 46 male patients after ACLR who presented in

Figure 1. Flow chart of eligibility selection. ACLR = anterior cruciate ligament reconstruction; SB = single-bundle; DB = double-bundle; n = total number of individuals in the population.

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The characteristics of the studied population are preTABLE 1. Characteristics of the study population.* sented in Table 1. The anamnesis revealed that before Age (y) BM (kg) Body height (cm) surgery, the patients performed Mean SD Mean SD Mean SD recreational activity on level 7/8 according to the Tegner SB group (n = 15) 30.40 11.66 82.73 9.26 180.53 7.36 activity scale (46). All patients DB group (n = 15) 28.40 8.10 78.07 10.50 180.13 7.33 were operated on by the same *BM = body mass; SB = single-bundle; n = total number of individuals in the population; experienced surgeon who coDB = double-bundle. operated with physiotherapists from the physiotherapy center who every day supervised patients in the center. The time years 2011–2013 to the physiotherapy center where the between injury and reconstruction was in the range of 3–6 study was conducted (Figure 1). Finally, 30 males were months, which was beyond the researchers’ control. In most divided into 2 groups—group SB (n = 15) after singlecases, the injury was caused by skiing and playing soccer. bundle ACLR and group DB (n = 15) after DB ACLR. The following exclusion criteria were established: damage Surgical Technique to the collateral ligaments (grade II or III), damage to The SB group underwent reconstruction with a semitendinocartilage (grade III or IV according to the Outerbridge sus autograft, and the DB group with a semitendinosusclassification), and additional procedures for cartilage, as gracilis autograft. The semitendinosus and gracilis tendons reported additional injuries to knee joint structures requiring were harvested from the involved leg through a 3-cm oblique changes in physiotherapy protocol, irregular participation in incision over the pes anserinus. For SB ACLR, a single physiotherapy, or withdrawal from the physiotherapy profemoral tunnel was drilled through the anteromedial gram before the fourth stage. portal at 1108 flexion. Each graft was secured with an EndoButton CL (Smith & Nephew, Andover, MA, USA) on the femoral side and with a bioabsorbable interference screw and staple for postfixation on the tibial side (Smith & Nephew fixation). For DB ACLR, the same type of fixation devices was used as for SB reconstruction. For the DB technique, 2 femoral and 2 tibial tunnels were drilled. The semitendinosus tendon graft was doubled to create the anteromedial bundle and the gracilis tendon graft was used for the posterolateral bundle. Postoperative Physiotherapy

Figure 2. The run test with maximal speed and change-of-direction maneuvers.

After the operations, patients from both groups underwent the same 4-stage physiotherapy conducted by the same physiotherapist at the same physiotherapy center (presented in Postoperative Physiotherapy). Four-stage physiotherapy usually takes 6 months (18). Attendance at physiotherapy in the VOLUME 29 | NUMBER 2 | FEBRUARY 2015 |

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Knee Assessment During Dynamic Knee Rotation center averaged 4 days a week, and each session lasted 2 hours. Participants were educated by the physiotherapist on how best to exercise correctly at home and which activities should be avoided.

TABLE 2. Pain assessment and anterior knee laxity results from the SB and DB groups.* Evaluated features

Stage I (1- to 5-Week Postoperation). Initially, ice packs were used, and after several days they were replaced with local cryotherapy. Continuous passive motion exercises were practiced with gradual increases in the range of motion of the involved joint. Patients underwent mobilization of the patellofemoral joint and soft tissues of the iliotibial tract and the vastus lateralis. The physiotherapist also taught the patients to walk using crutches. Electrostimulation of the vastus medialis and a magnetic field was applied. Patients performed proprioceptive exercises in a closed kinematic chain. At the end of the first stage, patients were taught to walk without crutches on a flat surface. Patients performed isometric tensions of the extensors and flexors of the involved knee and other large muscle groups of the involved leg. They also performed isometric exercises with manually dosed resistance of muscle groups beyond the area of the operated knee joint (the uninvolved lower extremity, upper extremity, and the trunk). Closed kinematic chain exercises with visual feedback and restrictive 2-legged squats on a stable surface were also applied. Stage II (6- to 12-Week Postoperation). March on a treadmill was added to the exercises in this stage. The continuous passive motion device was replaced with a cycloergometer. Proprioceptive exercises were performed on a soft surface. Isometric tensions were replaced with isometric exercises with manually dosed resistance of muscle groups in the area of the operated knee joint. Concentric exercises were performed with gradually increased manually dosed resistance for ischiotibial muscles of the operated leg and for the muscle groups of the lower and upper extremities and the trunk. Exercises on a stepper were added. Concentric and eccentric exercises with gradually increased resistance were performed for hamstring muscles of the operated leg in the sagittal plane and, gradually, in the transverse plane, involving mainly internal tibial rotation. Stage III (13- to 20-Week Postoperation). Exercises performed during the second stage were extended. In the 13th week, a measurement of the maximal isometric torque of knee extensors and flexors was performed on a Biodex 3 system (Biodex Medical Systems, Shirley NY, USA), as the basis for isometric exercises with partial resistance of the involved knee joint extensor muscles, performed on the same dynamometer. Trot was added. Discipline-specific exercises were performed. The first stages of plyometric exercises were implemented. Functional training with movement pattern corrections and core exercises were performed. Once or twice a week, exercises were followed by centrifugal massage. From the 16th week of physiotherapy, strength training was applied in isokinetic conditions. Running with

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Group Mean SD

Everyday pain (mm) Pain during the run test with maximal speed and change-of-direction maneuvers (mm) Pain immediately after the run test with maximal speed and change-of-direction maneuvers (mm) Pain the day after the run test with maximal speed and change-of-direction maneuvers (mm) Pain 3 d after the run test with maximal speed and change-ofdirection maneuvers (mm) Anterior drawer test (mm)

SB DB SB DB

0 0 13 15

0 0 7 5

SB DB

10 10

6 8

SB DB

0 0

0 0

SB DB

0 0

0 0

SB DB

1.8 2 1.6 3

*SB = single-bundle; DB = double-bundle.

gradually increased speed and then with changes of direction and surface inclination angle were added. Patients did exercises with a skipping rope on different surfaces and practiced obstacle jumping and controlled slides. Stage IV (21-Week to 6-Month Postoperation). Exercises performed during the third stage were extended. Proprioception and neuromuscular coordination were stimulated. Concentric and eccentric resistance exercises for lower-limb large muscle groups were performed on devices. Functional training in diagonal patterns with kettle bells and pneumatic resistance was added. Restoration of speed, power, agility, and field orientation, specific for a given discipline or the patient’s job, were the main procedures at this stage. Swimming once a week was recommended. Procedures

Before all testing, patients were required to abstain from unaccustomed strenuous exercise for at least 24 hours. The

TABLE 3. Pivot shift test results from the SB and DB groups.* Pivot shift test

Group SB DB

Negative, n 13 14

Positive, n 2 1


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patients were instructed to not make any changes in their to the right one over a 5-m distance, passing beyond it, and diet and were encouraged to consume water leading up to then ran along a straight line passing the block of the envetesting. The clinical examination, peak torque measurements lope on the left side. The running direction was then changed of muscles responsible for tibial rotation in the knee joint, by 908, and the patient ran at maximal speed in a straight line, and the run test with maximal speed and change-ofreached the right block of the envelope, and passed beyond direction maneuvers had been always performed around it and headed left. Patients then ran laterally to the left over noon. Patients were instructed to avoid eating a heavy a 5-m distance, passing the next block externally. Next, breakfast in the morning before the test and to avoid eating patients ran backward to the middle block, passing it exterwithin 2 hours of the test. nally and, still running backward, changed the direction of Clinical assessment of the patient and measurements were movement by 908, running toward the block where they carried out in the 24th week after ACLR. Clinical examinastarted the test. The time it took for each patient to cover tion of the knee joint started with scrutinizing the patient the distance was measured to an accuracy of 0.1 second. while standing. Both knees were inspected from the front, Apart from questions about pain, patients were also asked lateral, and medial sides and posteriorly. The general whether they experienced the knee “giving way” or anxiety alignment of the lower limb was assessed. The Q angle before and during the test. The run test was performed in all was assessed. Patients were then evaluated while walking cases by the same physiotherapist. Before the study, there and in a supine position. The examination was followed by was performed the test-retest reliability of the run test with ligament testing (posterior drawer test, abduction and maximal speed, and change-of-direction maneuvers was adduction test, grinding test) (6). Clinical tests, measurement evaluated to validate the use of the test in clinical research of joint stability, knee circumference, and range of move(Appendix 1). The test-retest values for the run test indicated ment measurements were carried out for the involved and excellent reliability (intraclass coefficient [ICC] = 0.96) (15). uninvolved leg. For pain assessment, the 100-mm visual anaPeak torque measurements of the muscles responsible for log scale (VAS) was used (11). Patients assessed their everytibial rotation under isokinetic conditions were performed day pain and also pain during and after a run test that using the Humac Norm Testing and Rehabilitation System included running at maximal speed and change-of(CSMI Computer Sports Medicine, Stoughton, MA, USA) direction maneuvers (see Figure 2) on the next day and 3 with the patient in the supine position, according to a previous days after the test. The anterior laxity of the knee was meatesting method (17). Measurements were performed 24 weeks sured. Results were expressed in millimeters. The pivot shift after the ACLR. They were preceded by a warm-up on a cycle test was also carried out (14). Knee joint circumference was ergometer. The knee joint was stabilized in the sagittal plane measured at the knee joint line level. Results are expressed in in tibial flexion at an angle of 808 relative to the femur. The centimeters (6). Goniometric measurements of active range foot was placed at 908 relative to the tibia and the angle of hip of movements in knee joint extension and flexion were carflexion was 808. The patient performed 2 series of concentric ried out with an accuracy of 18. During measurement, the exercises under isokinetic conditions. Each series was prepatient assumed a reclining position (6,10). The patients ceded by a trial repetition. The first series, performed with were asked about their subjective feelings on their knee an angular velocity of 608$s21, was 5 repetitions of alternate “giving way” during various everyday activities. The clinical assessment was performed in all cases by the same clinician. TABLE 4. Comparison between the SB and DB groups for knee joint A run test with maximal circumference measurements and knee range of movement results.* speed and change-of-direction Involved leg Uninvolved leg maneuvers was performed to check whether patients were Group Mean SD Mean SD able to run with sudden Knee joint SB 37.8 1.5 37.4 1.7 change-of-direction and knee circumference (cm) DB 36.6 2.7 35.8 2.2 rotations (dynamic pivots) p 0.228 0.131 (Figure 2). It was performed Knee extension (8) SB 0 1 0 0 24 weeks after the ACLR. DB 0 1 0 1 After the warm-up, patients p 0.655 0.336 Knee flexion (8) SB 124 7 130 5 ran at maximal speed on DB 123 8 129 5 a 5 3 5 m square, covering p 0.908 0.367 the envelope distance twice without breaking. On the *SB = single-bundle; DB = double-bundle. “start” command, the patient ran from the left starting block VOLUME 29 | NUMBER 2 | FEBRUARY 2015 |

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TABLE 5. Comparison between the SB and DB groups for run test with maximal speed and change-of-direction maneuvers.* Time (s) Group Mean SD Run test with maximal speed and change-of-direction maneuvers

SB 22:20 0.98 DB 21:67 4.67 p 0.322


internal and external tibial rotation toward the femur. The second series, performed with an angular velocity of 1808$s21, was 8 repetitions of alternate internal and external tibial rotation relative to the femur. There was a 90-second interval between exercise sets. The patients from the SB and DB groups were tested bilaterally, starting with the uninvolved leg (17). The peak torque measurement was performed in all cases by the same physiotherapist. The test-retest reliability of PT measurements of the muscles responsible for tibial rotation using the Humac Norm Testing and Rehabilitation System dynamometer was evaluated to validate the use of the dynamometer in clinical research. The test-retest indicated excellent reliability values (ICC = 0.95–0.99) of PT measurement of the muscles responsible for internal tibial rotation and excellent reliability values of PT measurement of the muscles responsible for external tibial rotation (ICC = 0.95–0.97) (15). Statistical Analyses

Statistical analysis was performed using IBM SPSS Statistics 20. Mean (x) and SD values were calculated for the results of examined features: the pain assessment with the use of the

VAS, the measurement of the anterior drawer test, knee joint circumferences measurement, knee active extension and flexion measurements, run test with maximal speed and changeof-direction maneuvers, and peak torque measurement of the muscles responsible for internal and external tibial rotation. In the SB group and DB group, peak torque values were normalized to body mass (BM) and expressed in N$m$kg21 BM. The normalization of peak torque values to measures of BM was used to eliminate the BM dependence in SB and DB groups. According to Royston (42) the Shapiro-Wilk test was performed to study the distribution in each group, because the total number of individuals (n) in each group was 3 # n # 5000. Because in all cases, the p in the ShapiroWilk test was .0.05 (p . 0.005) for comparisons between the SB and DB groups (independent samples), and the parametric t-test for independent samples was applied. A p value of #0.05 was considered statistically significant. Levene’s test to assess the equality of variances for a variable calculated for 2 groups was used.

RESULTS Results of the measurement of the anterior knee laxity in the SB and DB groups did not exceed 2 mm. The difference in mean values between the studied groups amounted to 0.2 mm and was statistically insignificant (Table 2). No patient in the study population reported pain when performing everyday activities (Table 2). Results of the pivot shift test in the SB group were negative in 13 patients and positive in 2 patients. Results of this test in the DB group were negative in 14 patients and positive in 1 patient (Table 3). No statistically significant differences were noted between the studied groups in the range of movement and knee circumference measurements (Table 4). No statistically significant differences were noted in the time (s) of the run test with maximal speed and change-of-direction

TABLE 6. Comparison between the SB and DB groups for normalized peak torque values of the muscles responsible for internal and external tibial rotation.* Normalized peak torque (N$m$kg21) Muscles responsible for IR Involved leg

Muscles responsible for ER

Uninvolved leg

Involved leg

Uninvolved leg

Angular velocity

Group

SB

DB

p

SB

DB

p

SB

DB

p

SB

DB

p

608$s21

Mean SD Mean SD

0.48 0.09 0.38 0.08

0.51 0.11 0.41 0.09

0.553

0.51 0.08 0.41 0.06

0.55 0.12 0.45 0.10

0.400

0.46 0.08 0.38 0.06

0.48 0.11 0.39 0.07

0.650

0.50 0.07 0.40 0.07

0.50 0.09 0.41 0.08

0.971

1808$s21

0.382

0.176

0.677

0.626

*IR = internal tibial rotation; ER = external tibial rotation; SB = single-bundle; DB = double-bundle.

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Journal of Strength and Conditioning Research maneuvers between the studied groups (Table 5). No patient reported pain either the day after the test or 3 days after it (Table 2). No patient reported anxiety before the test or experienced “their knee giving way.” The statistical peak torque values (mean and SD) of the muscles responsible for internal and external tibial rotation obtained from the SB group were similar to those obtained from the DB group. No statistically significant differences between the 2 groups were found for peak torque (Table 6).

DISCUSSION The results of this study suggest that (1) comparative analysis carried out 24-weeks postoperation did not show any significant differences in anterior tibial translation measurements, range of movement, and joint circumference measurements, and subjective assessment of pain and knee joint stability between the SB group and the DB group; (2) generally, no significant differences between groups were found in peak torque values obtained from the muscles responsible for internal and external tibial rotation; and (3) the results of the pivot shift tests were better in the DB group compared with the SB group; however, this finding is not reflected in the result of the run test with maximal speed and change-of-direction maneuvers. The ACLR is aimed at the restoration of the anatomical structure, stability, and function of the ligament. The aim of physiotherapy after ACLR is to restore the symmetry of both knee joints in terms of circumference, range of movement, and joint function (the so-called “Knee symmetry model”) (10). Another goal of physiotherapy is the return of the patient to previous occupational and physical activity and prevention of subsequent injuries (40). However, despite ACLR, approximately one-third of the patients fail to restore their baseline physical activity (47), and some patients experience instability sensations in the involved knee joint despite having normal results with the Lachman test and normal anthropometric measurement results (27). Hoping that restoration of 2 separate ACL bundles would help the patient obtain better clinical results, orthopedists introduced DB reconstruction (35,38,41,55). The difficulty in restoring stability of the knee joint, both in the sagittal and transverse planes, results from the connections for internal rotation with the mechanism in noncontact ACL injuries (49). Noncontact ACL injuries most often result from sudden acceleration and stopping. ACL is most loaded during excessive tibial rotation combined with valgus torque of the knee joint (44), which is also the most frequent underlying mechanism of injury. The present in vitro study suggests that DB ACLR restores anteroposterior and rotational stability better than SB ACLR (33,52); however, clinical studies have not unequivocally indicated which ACLR technique is more beneficial for the patient (12,25,32,45,51). The results of this study indicated that, generally, during the 24th week of physiotherapy, no significant differences in clinical assessment were noted between patients after DB ACLR and

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those after SB ACLR. In both groups, anterior tibial translation was below 2 mm, and similar range of movement and circumference of the knee joint measurements were noted. No patient complained of everyday pain. In the evaluation of patients after ACL reconstruction, various strength tests are commonly used (23,26). Yip et al. (54) compared peak torque values obtained from extensor and flexor muscles in patients after SB ACLR with values obtained from DB ACLR patients. They considered the theory that suggests that because DB ACLR was found to restore the rotational stability of the knee joint more effectively, it would provide better neuromuscular control and better results of knee joint extensor and flexor training as part of postoperative physiotherapy (54). However, comparative analysis of peak torque in extensor and flexor muscles of the knee joint did not show any statistically significant differences between the results of the 2 reconstruction methods (54). Studies have compared peak torque values of the muscles responsible for internal and external tibial rotation in relation to the femur after ACLR between the involved and the uninvolved leg (8,17,48), and the effects of physiotherapy on postoperative recovery of strength have been assessed (17). However, to the best of the authors’ knowledge, no study has compared peak torque values of muscles responsible for rotation of the knee joint in SB ACLR and DB ACLR patients. The results of this study did not show any differences in peak torque values of the muscles responsible for internal and external tibial rotation in relation to the femur in the knee joint between SB ACLR and DB ACLR patients, despite the fact that DB reconstruction involved additional graft harvesting from the gracilis muscle. More patients in the SB group obtained positive results with the pivot shift test, which indicates that the results of the DB group are better. Nevertheless, assessment of knee joint stability in the transverse plane is based on the pivot shift test, which, like all manual tests, depends on the examiner’s subjective assessment. Therefore, rotation assessment is more often based on 3-dimensional kinematic assessments of pivot shift test results or optoelectronic and electromagnetic systems of navigation (3,7,47). Interestingly, regardless of the better results of pivot shift tests in the DB group, no between-group differences were noted in the results of the performed run test. In addition, no patient reported having the sensation of their knee “giving way,” nor did any patient report apprehension or pain during the performed run test. There are few studies comparing SB ACLR and DB ACLR techniques, and assessing at the same time knee joint rotation during high-demand activities (34). During such dynamic forms of physical activity, the knee joint, including the articular surface, ligaments, and the articular capsule, is exposed to combined external and internal forces, including muscle forces (31). Therefore, studies assessing only passive stability of the knee joint with exposure to static loading are not sufficient to asses ACLR techniques in the evaluation of VOLUME 29 | NUMBER 2 | FEBRUARY 2015 |

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Knee Assessment During Dynamic Knee Rotation the patient’s ability to return to physical activities of highmotion dynamics, such as running at maximal speed, change-of-direction maneuvers, pivots, rotation in lowerlimb joints, and sudden stopping after ACLR. The results of this study provide new and important information on the behavior of dynamic functional rotational stability of the knee joint when comparing results of clinical tests assessing knee joint stability with the patient’s subjective assessment. Peak torque measurements of the muscles responsible for tibial rotation in relation to the femur under isokinetic conditions and times recorded for running at maximal speed and with change-of-direction maneuvers carried out at the end of 6 months after ACLR did not show any significant differences between SB ACLR and DB ACLR groups. Times recorded for the run test were similar in ACLR patients and healthy control participants with high levels of physical fitness, as noted in another study (16). This article presents a simple functional test that is easy to carry out, does not require any specialist equipment, enables assessment of a patient’s ability to return to sport, and is based on a series of dynamic pivots in the knee joints performed by the patient under conditions of natural motion. In future, such studies can be used for distant complex assessment of results obtained from ACLR patients. The need to complement clinical assessment of ACL injury treatment with a 3-dimensional record of tibial movements relative to the femur and assessment of strength and strength-speed characteristics of muscles affecting the knee joint, both in the sagittal and transverse plane, will challenge further research.

PRACTICAL APPLICATIONS First, the results of the study showed that the knee function during activities involving dynamic knee rotation in a group of patients after DB ACLR was not better than in patients after SB ACLR who underwent the same physiotherapy procedure. Thus, for athletes who perform sports requiring cutting and pivoting both types of surgical technique may be recommended as long as the physiotherapy program will be focused on the athlete’s return to high-demand physical activity. The data obtained from this study can be used by research teams to monitor and compare the effectiveness of various study protocols involving surgical and physiotherapy treatment. The data are especially useful when combined with the clinical assessment of patients who would like to return to sport. This article presents a simple functional test that is easy to carry out, does not require any specialist equipment, enables assessment of a patient’s ability to return to sport, and is based on a series of dynamic pivots in the knee joints performed by the patient under conditions of natural motion.

conduct, interpret, and publish research is not compromised by any controlling sponsor as a condition of review and publication. The authors have no financial interest or benefit arising from the direct applications of their research. The study was conducted in the Center of Rehabilitation and Medical Education in Wroclaw (Poland) for the College of Physiotherapy in Wroclaw (Poland). A conflict of interest cannot occur because all of the expenses were covered by The College of Physiotherapy in Wroclaw (Poland) and Andrzej Czamara.

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ACKNOWLEDGMENTS

14. Buckup, K. Clinical Tests for the Musculoskeletal System. Stuttgart, Germany: Georg Thieme Verlag, 2004.

All authors declare that they have no actual or potential competing financial interest. The authors’ freedom to design,

15. Cicchetti, DV and Sparrow, SA. Developing criteria for establishing interrater reliability of specific items: Applications to assessment of adaptive behavior. Am J Ment Defic 86: 127–137, 1981.

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period and not to take part in any vigorous physical activity for 2 days before the day of the measurement.

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Methods

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APPENDIX 1: The Test-Retest of the Peak Torque Measurements of Muscle Responsible for Tibial Rotation in the Knee Joint and the Test-Retest of the Run Test With Maximal Speed and Change-of-Direction Maneuvers Studied Material

Twenty-four male recreational athletes (group T-R I) were recruited to participate in the test-retest reliability of the peak torque (PT) measurements of muscle responsible for tibial rotation in the knee joint using the Humac Norm Testing and Rehabilitation System dynamometer. Ten male recreational athletes (group T-R II) were recruited to participate in the test-retest reliability of the run test with maximal speed and change-of-direction maneuvers. All of the participants were without known cardiovascular or orthopedic problems. They were recruited to participate in the validation of the peak torque measurements and the run test from the student population of the college where the study was conducted. Their physical characteristics are presented in Table A1. They were instructed to maintain their regular training regimens throughout the experimental

The Test-Retest of the Peak Torque Measurements of Muscle Responsible for Tibial Rotation in the Knee Joint The test-retest reliability of PT measurements using the Humac Norm Testing and Rehabilitation System dynamometer was evaluated to validate the use of the dynamometer in clinical research. Testing was conducted in 2 identical sessions held 3 days apart at the same time of the day. All measurements were performed by the same researcher. During both sessions, torque measurements of the muscles responsible for internal and external tibial rotation in the knee joint were performed under isokinetic conditions according to the procedure of Czamara et al. (2). Both knees of the group T-R I participants were tested, starting with the dominant leg. The Test-Retest of the Run Test With Maximal Speed and Changeof-Direction Maneuvers The test-retest reliability of the run test with maximal speed and change-of-direction maneuvers was evaluated to validate the use of the test in clinical research. Testing was conducted in 2 identical sessions held 3 days apart at the same time of the day. All measurements were performed by the same researcher. During both sessions, participants performed the run test with maximal speed and change-of-direction maneuvers. Statistical Analyses Intraclass correlation coefficients (ICC; Shrout and Fleiss model 2) were calculated to compare the data between sessions in the test-retest assessment (3). The following guidelines, described by Cicchetti and Sparrow (1), were used to assess reliability coefficients: ,0.40 was considered poor, 0.40–0.59 was considered fair, 0.60–0.74 was considered good, and $0.75 was considered excellent. Results

Excellent reliability values were obtained in the test-retest analysis (ICC = 0.95–0.99) of PT measurement of the muscles responsible for IR (Table A2). There was also excellent agreement between the values obtained in each session for measurement of PT of the muscles responsible for ER (ICC = 0.95–0.97; Table A2).

TABLE A1. Characteristics of the study population.* Age (y)

Group T-R I (n = 24) Group T-R II (n = 10)

BM (kg)

Body height (cm)

Mean

SD

Mean

SD

Mean

SD

25.20 25.02

3.67 1.61

75.80 78.79

6.87 11.29

179.60 182.92

4.16 8.80

*BM = body mass; group T-R I = males who participated in the test-retest of the peak torque measurement; group T-R II = males who participated in the test-retest of the run test; n = total number of individuals in the population.

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TABLE A2. Comparison of peak torque of the muscles responsible for IR and ER obtained from the dominant and nondominant legs during 2 separate measurements (the test-retest) in the group T-R I.* Peak torque (N$m) IR muscles Dominant leg Measurement AV 608$s21 Mean SD 1808$s21 Mean SD

ER muscles

Nondominant leg

Dominant leg

Nondominant leg

First

Second

ICC

First

Second

ICC

First

Second

ICC

First

Second

ICC

40.62 8.46

39.62 8.71

0.97

38.95 8.46

39.54 8.95

0.99

38.04 6.22

39.62 8.71

0.95

38.41 7.78

39.42 7.14

0.97

33.83 7.19

34.12 7.42

0.97

32.41 7.35

32.04 6.69

0.95

32.75 5.82

31.87 6.54

0.97

31.87 6.54

31.04 7.03

0.96

*IR = internal tibial rotation; ER = external tibial rotation; ICC = intraclass correlation coefficient; AV = angular velocity.

TABLE A3. Comparison of the results of the run test with maximal speed and change-ofdirection maneuvers during 2 separate tests (the test-retest) in the group T-R II.* Time (s) Run test with maximal speed and change-of-direction maneuvers

Measurement First Second ICC

*ICC = intraclass correlation coefficient.

Mean SD 20.41 1.01 20.53 0.98 0.96

The test-retest values for the run test with maximal speed and change-of-direction maneuvers also indicated excellent reliability (ICC = 0.96; Table A3).

REFERENCES 1. Cicchetti, DV and Sparrow, SA. Developing criteria for establishing interrater reliability of specific items: Applications to assessment of adaptive behavior. Am J Ment Defic 86: 127–137, 1981. 2. Czamara, A, Szuba, L, Krzeminska, A, Tomaszewski, W, and Wilk-Franczuk, M. Effect of physiotherapy on the strength of tibial internal rotator muscles in males after anterior cruciate ligament reconstruction (ACLR). Med Sci Monit 17: CR523– CR531, 2011. 3. Shrout, PE and Fleiss, JL. Intraclass correlations: Uses in assessing rater reliability. Psychol Bull 86: 420–428, 1979.

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Dynamic knee joint mechanics after anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction and knee osteoarthritis.

[Knee laxity in anterior cruciate ligament reconstruction : The influence of graft rotation using interference screw fixation].

Risk factors for knee instability after anterior cruciate ligament reconstruction.

ANATOMICAL RECONSTRUCTION OF ANTERIOR CRUCIATE LIGAMENT OF THE KNEE: DOUBLE BAND OR SINGLE BAND?

Differences in hip-knee joint coupling during gait after anterior cruciate ligament reconstruction.

Medio-lateral knee fluency in anterior cruciate ligament-injured athletes during dynamic movement trials.

Combined unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction in knees with osteoarthritis and deficient anterior cruciate ligament.

Association of Anterior Cruciate Ligament Width With Anterior Knee Laxity.

Osteonecrosis of the Knee After Anterior Cruciate Ligament Reconstruction: A Report of 5 Cases.

A modified repair for the anterior cruciate ligament deficient knee.

Knee joint kinematics with dynamic augmentation of primary anterior cruciate ligament repair - a biomechanical study.

Periprosthetic total knee fracture after remote reconstruction of the anterior cruciate ligament: a case report.

Knee-Extension Torque Variability and Subjective Knee Function in Patients with a History of Anterior Cruciate Ligament Reconstruction.

Hybrid Graft Anterior Cruciate Ligament Reconstruction: A Predictable Graft for Knee Stabilization.

Extra-articular reconstruction in the anterior cruciate ligament deficient knee: a commentary.

The O'Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears.

Assessment of functional impairment after knee anterior cruciate ligament reconstruction using cardiorespiratory parameters: a cross-sectional study.

Impact biomechanics of lateral knee bracing. The anterior cruciate ligament.

Results of knee manipulations after anterior cruciate ligament reconstructions.

A quantitative assessment of orthoses for stabilization of the anterior cruciate ligament deficient knee.

Combined anterior cruciate ligament and posterolateral reconstruction of the knee using allograft tissue in chronic knee injuries.

Isokinetic Identification of Knee Joint Torques before and after Anterior Cruciate Ligament Reconstruction.

Effect of knee angle on quadriceps strength and activation after anterior cruciate ligament reconstruction.