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Risk of Anterior Cruciate Ligament Rupture With Generalized Joint Laxity Following Trauma

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THE function of the anterior cruciate ligament (ACL) is to …

THE function of the anterior cruciate ligament (ACL) is to
provide stability to the knee and minimize stress across the knee joint. It restrains excessive forward movement of the tibia in relation to the femur. It also limits rotational
movements of the knee. A hard twist or excessive pressure on the ACL can tear or rupture the ligament, resulting in high levels of short-term disability and extensive rehabilitation. The cost of treatment & rehabilitation of an ACL injured person is also phenomenal.

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  • 1. Risk of Anterior Cruciate Ligament Rupture With Generalized Joint Laxity Following Trauma
  • 2. Original Article RISK OF ANTERIOR CRUCIATE LIGAMENT RUPTURE WITH GENERALIZED JOINT LAXITY FOLLOWING TRAUMA Raju Vaishya* and Rohit Hasija** *Senior Consultant, **Registrar, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. Correspondence to: Dr Raju Vaishya, *Senior Consultant, Department of Orthopaedics & Joint Replacement Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. Anterior Cruciate Ligament (ACL) tears are very common sport injuries. Increased joint laxity has been found to be one of the most important contributory factors in causation of ACL tears. Key words: Anterior cruciate ligament, Joint laxity, ACL injury. A detailed clinical history was obtained, with especial emphasis on the mode of injury, prior to clinical examination. All patients presented to us with history of trauma. The mode of injury was mostly due to sports (66.6%), followed by injuries sustained in a Road Traffic Accident (21.8%), domestic falls (11.6%) (Fig.1). The diagnosis was confirmed by MRI and all ACL tears confirmed by arthroscopy prior to reconstruction. We had prospectively assessed the degree of joint laxity in all the patients with a symptomatic ACL injury before they underwent reconstruction. INTRODUCTION THE function of the anterior cruciate ligament (ACL) is to provide stability to the knee and minimize stress across the knee joint. It restrains excessive forward movement of the tibia in relation to the femur. It also limits rotational movements of the knee. A hard twist or excessive pressure on the ACL can tear or rupture the ligament, resulting in high levels of short-term disability and extensive rehabilitation. The cost of treatment & rehabilitation of an ACL injured person is also phenomenal. Chronic ACL insufficiency can cause damage to the articular cartilage & hence these patients are prone to developing early degenerative arthritis, menisci tears [1] and stretching of secondary stabilizers like collateral ligaments etc. All had their laxity scored by Beighton’s criteria. In this method, the following ranges of motion are assessed: (i) passive hyperextension of fifth metacarpophalangeal joint, 1 point for each joint beyond 90º; (ii) thumb apposition to the volar aspect of the forearm, 1 point for each thumb touching the arm, active hyperextension of the elbow, 1 point for each joint beyond 10º; (iii) active hyperextension of the knee, 1 point for each joint beyond 10º; (iv) trunk Many intrinsic & extrinsic causes have been associated as risk factors for ACL tears [2] like excessive athletic demands placed on unconditioned knee, knee flexion angle whilst landing, limb alignment, notch size, hormonal fluctuations, muscle strength & generalized joint laxity. Sports 66% Recently, joint laxity have been implicated as an important contributory factor in the causation of ACL injuries, especially in females [3], those with generalized joint laxity and hyperextension of the knee [4]. MATERIALS AND METHODS We performed 110 ACL reconstructions between 2000 and 2006 in our hospital, using Patella Bone Tendon Bone (PBTB) autografts. There were 65 men and 45 women, whose ages ranged between 20 and 36 years (mean 24.6 years). They presented to us for ACL reconstruction after a mean duration of 11 months (range: 3 to 18 months) after the primary injury. Domestic falls 12% Road traffic accidents Fig.1 Mechanisms of injury. 13 Apollo Medicine, Vol. 6, No. 1, March 2009
  • 3. Original Article have higher rates of ACL injury than men [6]; the reason for this is unknown. After following up 139 professional football players, Nicholas [7] concluded that laxity of the joint predisposes to ligament injuries. Godshall [8] disagreed, in a series of ‘growing’ athletes, and Moretz, Walters and Smith [9] concluded, in a series of 155 football players, that laxity did not predispose to ligament injuries. However, Boden, et al [10] showed a strong correlation between hamstring flexibility and ACL rupture after analyzing data from 100 ruptures. At the Hunt Valley consensus conference for the prevention of non-contact ACL injury, it was judged that the relationship between ACL ruptures and joint laxity remained unresolved [2]. Ramesh [4] and colleagues found that ACL injury was more frequent in those patients with greater overall joint laxity, specifically those with increased knee joint laxity. In our study, the high number of patients with ACL tears had generalized joint laxity (92.7%). It is recognized that the Asian and Oriental population have more lax joints than European and American population [11-13].This might have been the factor responsible, as all of our patients were Indians. flexion with knees straight, 1 point when hand palm flat on floor. The maximum score is 9 points. It wasaccepted that an individual is considered “hypermobile” when at least 4 maneuvers exceed the predetermined range. Our control group comprised 55 individuals matched for age and gender with no known ACL-related problems or those attending our OPD but who had no knee symptoms. The laxity scores were determined in these individuals. RESULTS In our prospective cohort study it was found that more than 92.7 % (102 out of 110) of our patients, with ACL injuries, have significant joint laxity i.e., score of more than 4/9, compared to only 16.4% in the control group. There was no significant sex predominance found in this study. This difference was statistically significant (p<0.05). Hyper-extension of the affected knee was present in all patients with significant joint laxity. A non-contact mechanism of injury was more common in patients of both groups with ACL injury (Table 1). DISCUSSION Nothing can be done to change ligament laxity, but certain training techniques may help reduce athletes’ risk of ACL tears – something that might be especially important for those with greater laxity in the knee joint. There is enough evidence that neuromuscular training programmes are effective in increasing performance and preventing injuries in atheletes [14,15]. For example, learning how to land from a jump with proper alignment, and not in a “knock-kneed” position, may help prevent ACL injuries. In addition, strengthening the hamstring muscles, which help stabilize the knee joint, appears particularly important. ACL injury is common amongst young athletic individuals. Some are more predisposed to have it compared to others. Various instrinsic & extrinsic factors have been suggested to contribute to these injuries. Amongst all the extrinsic factors, joint laxity is now being recognized as one of the most important risk factors in the causation of ACL injuries. Ramesh [4] in his study did highlight hyperextension of knee and physiological joint laxity as contributing factor to ACL injuries. However no validated method for the screening and identification of athletes at greater risk of ACL injury based on joint laxity has previously been available. We used a simple clinical method of Beighton [5] to check & quantifiy the joint laxity. Beighton’s method is quick to perform and has been well established in the literature. In our study, we have been able to provide statistically significant evidence to support the association between generalized joint laxity and ACL rupture. We suggest that all the athletes should be screened for generalized joint laxity based on Beighton’s criteria. If the score >4/9, they should undergo proper counseling to prevent these injuries and supportive orthosis, muscle and joint proprioception training to prevent ACL tear. Further research into the proposed theory relating to this musculoskeletal problem is warranted for intervention and possible prevention of ACL injuries in athletes which can help in decreasing the number and thus the cost associated with treatment and rehabilitation of patients with ACL injuries. Previously published data indicate that women who participate in sports or who are otherwise physically active REFERENCES Table 1: Clinical profile of patients 1. George AC, Sirish Maddali, Lois Horovitz. The effects of time course after anterior cruciate ligament injury in correlation with meniscal and cartilage Loss. Am J Sports Med. 2001; 29(1):9-14. Study group Control group Total number of patients Male:Female Patients with Generalised Ligament Laxity Score >4/9 110 55 65:45 34:21 102 9 Apollo Medicine, Vol. 6, No. 1, March 2009 2. Griffin LY, Agel J, Albohm MJ, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg 2000; 8:141-150. 14
  • 4. Original Article knee injuries in college football players. Phys Sportsmed 1982; 10: 93-97. 3. Gregory D Myer, Kevin R Ford, Mark V Paterno. The effects of generalized joint laxity on risk of anterior cruciate ligament injury in young female athletes. The American Journal of Sports Medicine 2008;36:1073-1080. 10. Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopaedics 2000; 23: 573-578. 4. Ramesh R, Von Arx O, Azzopardi T, Schranz PJ. The risk of anterior cruciate ligament rupture with generalized joint laxity. J Bone Joint Surg Br. 2005; 87:800-803. 11. Everman DB, Robin NH. Hypermobility syndrome. Pediatr Rev. 1998; 19:111-117. 5. Beighton P, Solomon L, Soskilne C. Articular mobility in an African population. Ann Rheum Dis 1973; 32:413-418. 12. Finsterbush A, Pogrund H. The hypermobility syndrome. Clin Orthop Relat Res. May 1982: 124-127. 6. Toth AP, Cordasco FA. Anterior cruciate ligament injuries in the female athlete. The Journal of Gender-Specific Medicine 2001; 4(4): 25-34. 13. Larsson LG, Baum J, Mudholkar GS, Kollia GD. Benefits and disadvantages of joint hypermobility among musicians. N Engl J Med. 1993; 329:1079-1082. 7. Nicholas JA. Injuries to knee ligaments: relationship to looseness and tightness in football players. JAMA 1970; 212: 2236-2239. 14. Hall MG, Ferrell WR, Sturrock RD, Hamblen DL, Baxendale RH. The effect of hypermobility syndrome on knee joint proprioception. Br J Rheumatol. 1995; 34: 121 125. 8. Godshall RW. The predictability of athletic injuries: an eight year study. J Sports Med 1975; 3: 50-54. 15. Perlau R, Frank C, Fick G. The effect of elastic bandages on human knee proprioception in the uninjured population. Am J Sports Med. 1995; 23: 251-255. 9. Moretz JA, Walters R, Smith L. Flexibility as a predictor of 15 Apollo Medicine, Vol. 6, No. 1, March 2009
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