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OBJECTIVE:Some studies have shown that kinesio taping has positive effects in elevating muscle strength,improving joint stability and reducing pain and oedema in patients after anterior cruciate ligament reconstruction.However,existing studies have divergent results on the clinical efficacy of kinesio taping.In this study,a meta-analysis was conducted to systematically evaluate the effect of kinesio taping in postoperative rehabilitation period following anterior cruciate ligament reconstruction. METHODS:Randomized controlled trials about the effects of kinesio taping on anterior cruciate ligament reconstruction were electronically searched in PubMed,Web of Science,Embase,The Cochrane Library,EBSCO,CNKI,WanFang,and VIP databases,from database inception to December 06,2022.The outcome measures included six continuous variables:quadriceps strength,hamstring strength,knee swelling,knee range of motion,Lysholm knee function score,and Visual Analogue Scale score.EndNote X9.1 was used to screen the literature.The Cochrane Risk Bias Assessment Tool and Jadad Scale were used to evaluate the quality of the included literature.RevMan 5.3 software was used for Meta-analysis. RESULTS:A total of 6 randomized controlled trials involving 252 patients undergoing anterior cruciate ligament reconstruction were finally included.There were 126 cases in control group and 126 in kinesio taping group.The results of Meta-analysis showed that compared with the control group,kinesio taping significantly improved hamstring strength[standardized mean difference(SMD)=0.68,95%confidence interval(CI):0.12 to 1.23,P=0.02)and reduced Visual Analogue Scale score[mean difference(MD)=-0.56,95%CI:-1.04 to-0.08,P=0.02).However,for quadriceps strength,knee swelling,knee range of motion,and Lysholm knee function score,kinesio taping did not show significant difference from the control group(P＞0.05). CONCLUSION:Kinesio taping may help to improve hamstring strength and reduce pain in patients after anterior cruciate ligament reconstruction.However,it cannot significantly improve quadriceps strength,knee swelling,knee range of motion,and functional scores.
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Objective:To compare the short-term effect of the arthroscopic reconstruction of anterior cruciate ligament (ACL) by femoral tunnel positioning through the tendon incision (TI) technique and anteromedial (AM) technique.Methods:Between December 2015 and March 2017, 176 patients with ACL injuries underwent arthroscopic ACL reconstruction at the First Affiliated Hospital of USTC were analyzed. According to the method of localization of femoral tunnel, they were divided into two groups: TI group (localization of femoral tunnel by TI for reconstruction of ACL) and AM group (localization of femoral tunnel by AM for reconstruction of ACL). There were 87 patients in the TI group (63 males and 24 females) with an age of 32.8±9.4 years (range, 19-51 years) and a body mass index (BMI) of 24.8±6.3 kg/m 2 (range, 18.1-31.7 kg/m 2), including 9 obese patients (BMI>28 kg/m 2). There were 89 patients in the AM group (59 males and 30 females) with an age of 36.7±13.0 years (range, 17-56 years) and a BMI of 25.7±5.8 kg/m 2 (range, 18.9-31.6 kg/m 2), including 11 obese patients. To evaluate whether the drill was in contact with the articular surface of the medial condyle of the femur, whether the anterior angle of the medial meniscus was damaged, the sagittal and coronal angles of the femoral tunnel and the total length of the femoral tunnel. The anterior drawer test, Lachmann test, pivot shift test, knee flexion angle (KFA), Lysholm score, International Knee Documentation Committee (IKDC) score and the incidence of postoperative complications were compared between the two groups. At the same time, the time of taking out tendon, operation time, hospital stay and recovery time were compared between two groups of obese people. Results:In the TI group, the guide pin could reach all areas of the medial wall of the lateral femoral condyle from the inferior cartilage edge to the top of the intercondylar fossa, the drill bit had no contact with the medial femoral condyle (MFC), and the anterior angle of the medial meniscus was not damaged. In AM Group, 3 cases of MFC and 1 case of anterior horn of medial meniscus were injured in order to get the best position of femoral tunnel. The angle of femoral tunnel in sagittal plane (50.2°±3.2°) and coronal plane (46.1°±5.8°) in experimental group was notably larger than that in control group (45.6°±5.4°, 38.3°±4.7°), the difference was statistically significant ( P<0.05). However, there was no significant difference in the length of femoral tunnel between the two groups (38.2±3.2 mm and 37.7±2.5 mm, P>0.05). All patients were followed up for an average of 8.3±2.1 (range, 3-12) months. The positive rates of anterior drawer test, Lachmann test and pivot shift test were not significantly different between the two groups at 3, 6, 9 and 12 months after operation ( P>0.05). The KFA, Lysholm and IKDC scores in both groups were significantly increased after operation ( P<0.05), but there was no significant difference of above indexes between the two groups ( P>0.05). The overall complication rate in AM group (14.6%, 13/89) was significantly higher than that in TI group (6.9%, 6/87), the difference was statistically significant ( P<0.05). Additionally, the tendon harvesting (15.0±0.2 min vs. 26.0±0.2 min, P<0.05) and operation time (2.0±0.3 h vs. 3.0±0.4 h, P<0.05) were significantly shortened among obese patients in experimental group compared with those in control group. Conclusion:The TI technique demonstrates comparable effectiveness to the AM technique in ACL reconstruction through femoral tunnel positioning, with the added advantage of safer femoral tunnel localization. This approach minimizes the risk of iatrogenic injuries to the articular cartilage of the medial condyle of the femur and the anterior horn of the medial meniscus. Furthermore, the TI technique reduces tendon removal time, particularly beneficial for obese patients.
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ObjectiveTo investigate the difference in bilateral lower limb muscle synergy mode during gait in patients after unilateral anterior cruciate ligament reconstruction. MethodsElectromyography from bilateral lower limb muscles during gait were collected from twelve male and eight female patients after unilateral anterior cruciate ligament reconstruction in Affiliated Hospital of Wuhan Sports University, from April to June, 2023. The data were analyzed using non-negative matrix decomposition algorithm to extract the number of muscle synergies in the affected and unaffected legs, the time to peak activation of muscle synergies and the relative weights of the muscles. ResultsSix types of muscle synergy were identified in the unaffected leg of males during gait, while five types were identified in the affected leg, lacking synergy 2 that mainly from the tibialis anterior muscle. Six types of muscle synergy were identified in both legs in females during gait. There was no significant difference in the time to peak activation of muscle synergies between both legs in males (P > 0.05). However, the time to peak activation of muscle synergies increased in females in the affected leg for synergy 3 and synergy 5 (P < 0.05). The relative weight of the rectus femoris was lower in synergy 1 in the affected leg in males (P < 0.05). For female, the relative weight of the vastus lateralis was higher and the relative weight of the biceps femoris was lower in synergy 2 in the affected leg in females (P < 0.05); while the relative weight of the rectus femoris was lower in synergy 3 (P < 0.05), and the relative weight of the biceps femoris was lower in synergy 6 (P < 0.05). ConclusionMales would freeze the muscle synergy dominating ankle dorsiflexion in affected leg to enhance ankle stability, and reduce the relative weight of rectus femoris during the loading response phase to weaken the knee landing cushioning. However, females would delay the activation of synergies dominating in loading response phase and the mid-stance phase, enhance the relative weight of vastus lateralis during the loading response phase, and reduce the relative weights of rectus femoris in the loading response phase and the relative weight of biceps femoris in the mid-stance phase, to limit knee flexion.
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BACKGROUND:In recent years,the treatment of anterior cruciate ligament injury has become more and more mature.However,there are still disputes about the timing of surgery,the choice of surgical methods,the choice of grafts,and the methods to promote graft healing after anterior cruciate ligament injury. OBJECTIVE:To summarize the latest research progress of surgical timing,surgical methods,graft selection and methods to promote graft healing after anterior cruciate ligament injury,and to find new treatment directions for anterior cruciate ligament injury. METHODS:Relevant articles concerning anterior cruciate ligament injury were retrieved from PubMed,CNKI,WanFang Date,VIP,SinoMed,ScienceDirect,Springer and Cochrane Library.After the screening,72 related articles were finally included. RESULTS AND CONCLUSION:(1)Surgical timing:Compared with delayed anterior cruciate ligament reconstruction,early reconstruction can reduce meniscus injury,elevate quality of life,and improve functional recovery.However,it is still uncertain whether the different operation timing will accelerate cartilage injury.(2)Surgical methods:Arthroscopic anterior cruciate ligament reconstruction is a common surgical method for anterior cruciate ligament injury.Dynamic internal stabilization repair of anterior cruciate ligament can bring similar results to traditional anterior cruciate ligament reconstruction in short-term and long-term effects.(3)Graft selection:Autogenous hamstring tendon is the first choice of anterior cruciate ligament graft,while bone-patellar tendon-bone grafts and allografts are the secondary choices.(4)Among the methods to promote graft healing,suture band strengthening can increase knee joint stability and ensure graft healing.Stem cells promote the tendon-bone healing of grafts through anti-inflammatory action,angiogenesis,inhibition of osteolysis and promotion of chondrocyte differentiation.Preserving the residual end of the anterior cruciate ligament can maintain the stability of the knee joint,promote the recovery of proprioception,and provide a prerequisite for the healing of the graft.The effectiveness of platelet-rich plasma in promoting graft healing remains to be discussed.However,biomaterials,gene therapy,stem cell application and other methods to promote tendon healing remain in the stage of molecular and animal researches.Clinical transformation is also needed in the future.
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OBJECTIVE:To systematically review the clinical effect of blood flow restriction training on rehabilitation after anterior cruciate ligament reconstruction to provide a reference for clinical practice. METHODS:Databases including CNKI,WanFang,PubMed,Web of Science and EBSCO were searched to collect randomized controlled trials of blood flow restriction training in the intervention of anterior cruciate ligament reconstruction from inception to August 10,2022.Outcomes included knee muscle strength,knee muscle mass,and knee function evaluation,all of which were continuous variables.Two reviewers independently screened the literature and extracted data.Cochrane bias risk assessment tool and Physiotherapy Evidence Database Scale were used to evaluate the bias risk of the included articles.Meta-analysis was then performed using RevMan 5.4 software. RESULTS:A total of 9 publications were included,including 226 subjects,114 in the trial group and 112 in the control group.Meta-analysis results showed that compared with conventional resistance training,the blood flow restriction training group could significantly improve knee muscle strength[SMD=0.54,95%CI(0.29,0.79),P＜0.01],muscle mass[SMD=0.26,95%CI(0.06,0.46),P=0.01]and knee joint function[SMD=1.17,95%CI(0.53,1.80),P＜0.01].Subgroup analysis showed that only when the intervention time was more than 4 weeks,there were significant improvements in knee joint muscle strength[SMD=0.68,95%CI(0.38,0.97),P＜0.01]and muscle mass[SMD=0.38,95%CI(0.09,0.68),P=0.01]. CONCLUSION:Current evidence shows that blood flow restriction training can improve muscle strength and knee function in patients with anterior cruciate ligament reconstruction and reduce muscle atrophy.It is recommended that the postoperative intervention time should be more than 4 weeks to achieve better muscle strength and muscle mass improvement.
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BACKGROUND:At present,postoperative timing or subjective criteria by clinicians are commonly employed to determine the return-to-sport timing for patients undergoing anterior cruciate ligament reconstruction.Unfortunately,these criteria do not adequately consider the biomechanical deficits in patients following anterior cruciate ligament reconstruction. OBJECTIVE:To explore the lower extremity kinematic and kinetic characteristics of athletes after anterior cruciate ligament reconstruction during bilateral vertical jumping. METHODS:Twenty athletes undergoing anterior cruciate ligament reconstruction and twenty healthy athletes,aged 20-24 years,were recruited in Wuhan Sports University from December 2021 to December 2022.All the 40 subjects underwent a bilateral vertical jumping test.The kinematic and dynamic characteristics of the lower limbs at propulsion phase,initial landing time and peak vertical ground reaction force moment. RESULTS AND CONCLUSION:At the initial landing time,the athletes undergoing anterior cruciate ligament reconstruction showed higher hip flexion angle(P=0.031)and lower ankle plantar flexion angle(P=0.018)on the operated side compared with the healthy athletes.At the peak vertical ground reaction force moment,the athletes undergoing anterior cruciate ligament reconstruction had higher hip flexion angle(P=0.016),lower hip abduction angle(P=0.019),lower knee flexion angle(P=0.025),higher knee external rotation angle(P=0.030),and higher ankle external rotation angle(P=0.042)on the operated side compared with the healthy athletes.At the peak vertical ground reaction force moment,the athletes undergoing anterior cruciate ligament reconstruction showed lower knee extension moment(P=0.036),lower knee internal rotation moment(P=0.016),lower hip abduction moment(P=0.004),higher hip extension moment(P=0.040),and higher hip external rotation moment(P=0.005)on the operated side compared with the healthy athletes.To conclude,the athletes undergoing anterior cruciate ligament reconstruction exhibit a stiff landing pattern,in which the knee load on the operated side tends to shift to the hip joint,and show inadequate control of lower limb rotational stability.Therefore,detection and correction of abnormal biomechanical characteristics should be part of the rehabilitation after anterior cruciate ligament reconstruction.
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BACKGROUND:Internal tension-reduction technique is to reconstruct the anterior cruciate ligament through high-strength suture system combined with tendon.It can effectively reduce graft relaxation and frets by sharing the internal load of the knee joint,and has achieved good biomechanical results and clinical efficacy.However,whether it can reduce cartilage degeneration after anterior cruciate ligament reconstruction through stress sharing reduction has not been studied. OBJECTIVE:To investigate the effect of internal tension-reduction technique on articular cartilage degeneration in southern Yunnan small-ear pigs undergoing anterior cruciate ligament reconstruction. METHODS:Ten adult female Yunnan small-ear pigs were selected,and the ipsilateral knee Achilles tendon was taken from the left knee joint for anterior cruciate ligament reconstruction(normal group,n=10),and the ipsilateral knee Achilles tendon from the right knee joint combined with internal tension-reduction and augmentation system for anterior cruciate ligament reconstruction(tension-reduction group,n=10).One year after surgery,the experimental pigs were sacrificed,and the left and right knee cartilage was taken for hematoxylin-eosin staining,Safranin O-fast green staining,Osteoarthritis Research Society International scoring,and immunohistochemistry staining of type Ⅱ collagen,interleukin-1β,and tumor necrosis factor-alpha in the cartilage. RESULTS AND CONCLUSION:Hematoxylin-eosin staining showed that in the tension-reduction group,there were mild pathologic changes of osteoarthritis,with a low number of empty bone lacunae and no obvious pathological changes such as fibrosis or cell layer breakage;in the normal group,more severe cartilage damage,with an increased number of empty bone lacunae,loss of chondrocytes near the bone and even the formation of fissures.Safranin O-fast green staining indicated that the tension-reduction group had normal cartilage tissue thickness,flat cartilage surface,a neat cell arrangement in a polar pattern,and no swelling or apoptosis,while in the normal group,the thickness of cartilage tissue was obviously thinner,the cell arrangement was disordered with no polarity,the number of cells was reduced,obvious cartilage fractures and cartilage vacuoles formed,and the absence of cells near the central bone was obvious.The Osteoarthritis Research Society International score was significantly lower in the tension-reduction group than in the normal group(P＜0.05).Immunohistochemical findings showed that the protein expression of type Ⅱ collagen in cartilage tissue of the tension-reducing group was higher than that of the normal group(P＜0.05),and the protein expression of interleukin 1β and tumor necrosis factor ɑ in cartilage tissue was lower than that of normal group(P＜0.05).To conclude,internal tension-reduction technique can delay the degeneration of articular cartilage in Yunnan small-eared pigs following anterior cruciate ligament reconstruction.
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BACKGROUND:The type of graft selected during anterior cruciate ligament revision is considered one of the main factors affecting the postoperative outcome,but there are few reports on the comparison between different graft materials. OBJECTIVE:To explore the medium-to-long-term clinical efficacy after anterior cruciate ligament revision with autologous ligament,allogeneic ligament,and LARS artificial ligament. METHODS:A total of 67 patients with the first anterior cruciate ligament revision admitted to the Department of Joint and Sports Medicine,The Second Hospital of Tangshan from May 2011 to May 2020 were selected,including 41 males and 26 females,with a mean age of(45.83±7.39)years.They were divided into three groups according to different grafts used:autologous ligament group(n=24),allogeneic ligament group(n=22),and LARS artificial ligament group(n=21).Follow-up for more than 36 months after revision was performed to evaluate the effect of revision. RESULTS AND CONCLUSION:(1)International Knee Documentation Committee(IKDC)score,Lysholm knee score,and Tegner motor score 1 year after surgery and at the last follow-up in the three groups were higher than those before surgery(P<0.05).There were no significant differences in IKDC score,Lysholm knee score,and Tegner motor score among the three groups 1 year after surgery and the last follow-up(P>0.05).(2)The lateral differences of KT-1000 at 1 year after surgery and the last follow-up among the three groups were lower than those before surgery(P<0.05).The lateral difference of KT-1000 and the positive rate of the axial shift test in the last follow-up of the LARS artificial ligament group were higher than those in the autologous ligament group and allogeneic ligament group(P<0.05).(3)At the last follow-up,X-ray films showed no obvious enlargement of the reconstructed bone tunnel and no obvious failure of the graft fixation device.There was no obvious aggravation of osteoarthritis,but bone density decreased significantly in some elderly patients.(4)These findings suggest that anterior cruciate ligament revision with LARS artificial ligaments can obtain good initial stability,but with the extension of time,the stability of partial cases tends to decrease,even with reconstructed ligament failure.Both allogeneic and autogenous ligaments can obtain good clinical efficacy in anterior cruciate ligament revision.
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BACKGROUND:Grafts are often used to reconstruct the anterior cruciate ligament in clinical practice,while different types of grafts affect postoperative knee function and the development of rehabilitation programs. OBJECTIVE:To retrospectively analyze the effects of different graft types on muscle strength,joint stability,functional activities,and return to sports in patients after anterior cruciate ligament reconstruction. METHODS:Related studies were searched through PubMed,Web of Science,Cochrane,CNKI,and WANFANG databases.The Chinese and English key words were"anterior cruciate ligament reconstruction,autografts,allografts,artificial ligaments,bone-patellatendon-bone,quadriceps tendon autograft,hamstring tendon autograft,peroneus longus tendon autograft,rehabilitation,exercise,protocol,return to sport". RESULTS AND CONCLUSION:Patients with bone-patellar tendon-bone grafts should strengthen centrifugal contraction exercises of quadriceps muscle,and pay attention to the recovery of quadriceps muscle endurance and explosive power in the later stage of rehabilitation.Compared with bone-patellar tendon-bone grafts and hamstring tendon grafts,significantly fewer patients with quadriceps tendon grafts met regression criteria within 5-8 months,and a longer training plan should be developed,with the training cycle lasting as long as possible to more than 3 years.The selection of hamstring tendon grafts should strengthen the hamstring muscle strength training under multiple angles,especially the cycle of bending the knee above 60° until at least 18 weeks after surgery.Patients who choose peroneus longus tendon graft should strengthen the muscle strength around the ankle,mainly the plantar muscle strength.In the selection of allograft,attention should be paid to the reduction of tension resistance of 20%after the graft is disinfected by low-dose radiation,so attention should be paid to knee stability training.Patients who choose artificial ligament grafts can gradually enhance quadriceps and hamstring muscle strength training within 3-6 weeks,pay attention to early proprioceptive exercises,and conduct targeted training on balance,jumping,and flexibility.
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BACKGROUND:Anterior cruciate ligament rupture is one of the injuries that seriously affect life and sports performance,and the anterior cruciate ligament as a stabilizing structure is irreplaceable in maintaining sports performance.In view of its severe injury manifestations,the current treatment for anterior cruciate ligament rupture is a surgery for anterior cruciate ligament reconstruction.Since an anterior cruciate ligament injury can cause loss of mechanoreceptors,which in turn causes a reduction in proprioception,it is a great problem for patients to recover their motor performance. OBJECTIVE:To summarize the effects of proprioceptive training on clinical outcomes after anterior cruciate ligament reconstruction and to explore the underlying mechanisms,thereby providing more references for clinical prevention and treatment. METHODS:A computerized search of PubMed,CNKI,WanFang Data,and VIP databases was conducted for literature(from January 2013 to March 2023)related to proprioceptive training after anterior cruciate ligament reconstruction that improves joint stability and motor balance ability.A total of 108 articles were finally included for review. RESULTS AND CONCLUSION:Proprioceptive training can effectively improve the proprioceptive functions of patients,such as positional sense and kinesthetic sense after anterior cruciate ligament reconstruction,and improve joint stability,postural control and motor ability.The proprioceptive training improves the proprioceptive function through three mechanisms:stimulation of periprosthetic receptors around the knee joint,activation of spinal reflex stimulation,reinforcement of motor control in the brain,and enhancement of cognitive processing.The proprioceptive training may improve proprioceptive functions by activating the potential mechanisms of growth associated protein-43 activity,Piezo2 mechanotransducer,and NT-3/TrkC signaling pathway.Hydrotherapy is the mainstay in the early stages,while neuromuscular training,individual strength training and visual feedback training are prioritized in the middle and late stages.There exists an as-yet-unsegmented reconstructive surgery graft,sex,and a lack of devices or proprioceptive training methods based on the idea of combining multiple sensory stimuli.
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BACKGROUND:The maximum muscle strength is typically used for evaluating the recovery of muscle function after anterior cruciate ligament reconstruction.Recent studies have suggested that neuromuscular function should also be considered,such as rate of force development,which measures the slope of the force time curve at different time intervals under conditions of isometric muscle contraction. OBJECTIVE:To elaborate on the current research status and shortcomings of muscle isometric rate of force development in patients undergoing anterior cruciate ligament reconstruction surgery,and analyze the degree of defects in quadriceps femoris and hamstring isometric rate of force development at different times after surgery;to analyze the effect of isometric rate of force development on postoperative functional performance,thereby providing important information for optimizing postoperative rehabilitation following anterior cruciate ligament reconstruction,reducing secondary injury to patients,and reducing the incidence of knee osteoarthritis. METHODS:Literature retrieval of CNKI,VIP,WanFang and PubMed was performed using"anterior cruciate ligament,rate of force development"as Chinese search terms and"anterior cruciate ligament,rate of force development,rate of torque development"as English search terms.Finally,69 articles were included according to inclusion and exclusion criteria. RESULTS AND CONCLUSION:Most studies have found defects in bilateral muscle isometric rate of force development in patients undergoing anterior cruciate ligament reconstruction within 6 months.Early isometric rate of force development of the bilateral hamstring muscles(i.e.the slope of the force time curve at any time interval during muscle contraction of 100 ms)showed significant improvement after 6 months.However,long-term defects in early isometric rate of force development of the bilateral quadriceps indicate long-term damage to the neuromuscular function of the quadriceps after surgery.There is limited research on late isometric rate of force development(the slope of the force time curve at any time interval after 100 ms of muscle contraction),and conclusions cannot be drawn.Regarding landing exercises(jumping to the ground,lateral cutting,etc.)and daily activities(walking,running),early isometric rate of force development of the quadriceps is more correlated with isometric peak torque.Abnormal biomechanical changes during exercise are considered an important risk factor for secondary injury and traumatic knee osteoarthritis in patients.Actively improving early isometric rate of force development of the quadriceps may reduce the incidence of secondary injury and traumatic knee osteoarthritis.Currently,there is limited evidence to suggest that whole-body vibration training can improve early isometric rate of force development of the quadriceps femoris in patients undergoing anterior cruciate ligament reconstruction.It is recommended to use neuromuscular electrical stimulation to intervene in the quadriceps and hamstring in the early postoperative stage and implement explosive force and high resistance training in the late postoperative stage,which may improve the isometric rate of force development in patients.Generating sufficient muscle strength in a short period of time is necessary to effectively protect the anterior cruciate ligament,while the relationship between isometric rate of force development in the hamstring muscle and functional performance is still unclear,which may provide information on preventing secondary injury in patients.It is recommended to use the isometric rate of force development as one of the evaluation indicators for guiding rehabilitation and restoring movement.In addition to focusing on improving symmetry and differences from normal individuals,the hamstring to quadriceps strength ratio should also be considered.An appropriate range of ratios can ensure the balance of muscles during rapid muscle exertion,which may reduce the occurrence of secondary injuries.However,the normal range of ratios is not yet clear.Future research should consider the effects of graft type and knee flexion angle on isometric rate of force development,in order to identify neuromuscular dysfunction in patients as much as possible and help them recover better.
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Objective:The pain-relieving effect and safety of compound aminopyrine phenacetin tab-lets,tramcontin(tramadol hydrochloride sustained-release tablets)and dolantin in the early stage of au-tologous tendon reconstruction of the anterior cruciate ligament(ACL)of the knee joint were compared.Methods:Retrospective analysis of postoperative pain and drug analgesia in 45 patients performed by the same group from November 2018 to February 2019.The random area group design was divided into two groups according to whether ACL rupture was combined with meniscal injury,group A was 24 patients with ACL reconstruction of knee joint and group B was 21 patients with ACL fracture combined with me-niscus injury.The two groups were divided into three subgroups respectively according to the actual treat-ment of postoperative analgesic drugs received by the patients,including 4 cases of compound aminopy-rine phenacetin tablets,11 cases of oral tramcontin,9 cases of intramuscular dolantin combined with phenergan in group A;3 cases of compound aminopyrine phenacetin tablets,10 cases of oral tramcontin,and 8 cases of intramuscular dolantin combined with phenergan in group B.When the early postoperative patients complain about pain and actively ask for analgesia.When the patients complained about pain af-ter the operation and actively asked for analgesia,they were randomly given painkillers,tramcontin or do-lantin combined with phenergan to relieve pain.Pain visual analogue scale(VAS)was used to evaluate pain relief and observe the occurrence of adverse reactions.Results:There were no significant dif-ferences in gender,age,body mass index,and time of hospital stay between the two groups of patients(P＞0.05).In the patients who used tramcontin and dolantin combined with phenergan to relieve pain judging by VAS score before and 1 h after taking the drug,it was found that the pain situation of the pa-tient was significantly relieved,and the difference before and after taking the drug had statistical signifi-cance(P＜0.05).Pairwise comparisons of the three drugs applied in the two groups showed significantly greater pain relief in the dolantin combined with phenergan group than in the remaining two drugs.There was no significant difference(P＞0.05).Dolantin was prone to nausea and vomiting,but the application of phenergan was also used to reduce side effects.In terms of adverse reactions,only 1 case of nausea oc-curred in the tramcontin group for simple ACL reconstruction,and none of the patients in the other groups showed serious complications and allergic reactions.Conclusion:Whether in cruciate ligament recon-struction alone or combined with meniscus molding or suture,compound aminopyrine phenacetin tablets,tramcontin,dolantin combined with phenergan can effectively relieve pain.Among the three drugs,do-lantin caused the largest pain relief.At the same time,the combination of phenergan effectively reduced the adverse reactions,such as vomiting and nausea,and increased the drug safety.
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Objective To investigate the impact of not using drainage on clinical outcomes after arthroscopic autologous semitendinosus tendon reconstruction with anterior cruciate ligament reconstruction.Methods From March 2022 to June 2023,59 patients undergoing arthroscopic autologous semitendinosus tendon reconstruction with anterior cruciate ligament reconstruction in Lincang People's Hospital were collected and randomly divided into the non-drainage group consisting of 29 cases(observation group)and the 24-hour drainage group consisting of 30 cases(control group).The pain levels of the two groups of patients were recorded on the 1st,3rd,7th,14th,and 30th day after the surgery by using a visual analog scale.Additionally,the knee joint range of motion,length of hospital stay,and occurrence of postoperative complications were monitored.The circumference of the thigh was measured before and after the surgery,and the difference was calculated.Results Repeated measures analysis of variance revealed that there were statistically significant within-subject differences in pain ratings,thigh circumference,and knee joint range of motion(P<0.05),but no statistically significant between-subject differences(P>0.05).Independent samples t-tests showed that on the first day after the surgery,the observation group had lower pain ratings(P<0.001),and higher thigh circumference and knee joint range of motion compared to the control group(P<0.05).There were no statistically significant differences in pain ratings,knee joint range of motion,and thigh circumference between the two groups at the remaining follow-up times(P>0.05);The observation group had a shorter hospital stay than the control group(P<0.001);Both groups of patients had no complications such as lower limb nerve damage,deep vein thrombosis,knee joint infection,or hematomas requiring puncture and aspiration.Conclusion In the early postoperative period following arthroscopic autologous hamstring tendon reconstruction of the anterior cruciate ligament,the omission of drainage does not affect the clinical outcomes in terms of pain,knee joint mobility,and thigh circumference.Moreover,omitting drainage reduces the level of pain experienced by patients on the first day after the surgery,improves the knee joint mobility,and decreases the length of hospital stay.Therefore,in arthroscopic autologous hamstring tendon reconstruction of the anterior cruciate ligament,it is not recommended to routinely use drainage for preventive purposes.
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Abstract Objective: Evaluate osteoarthritis incidence in patients that undergone ACL reconstruction using the transtibial technique, with a minimum of 5 years of follow up, with isolated ACL injury. Methods: Patients who underwent ACL reconstruction by the same surgeon using the transtibial technique with hamstrings graft and with a minimum of 5 years of follow-up, without other injuries during the surgical procedure, were selected to undergo imaging exams of the operated knee to assess the incidence of osteoarthritis. The obtained data were evaluated by descriptive statistics. Results: Forty-two patients (44 knees) were evaluated, with a mean age of 31 years old (SD: 8), being 23 right knees and 28 male patients. Mean time from surgery to imaging evaluation was 94.1 months (ranging from 60 to 154 months; SD: 28). Of the evaluated knees, 37 did not have osteoarthritis (83.3%) and 7 had (16.7%). Conclusion: ACL reconstruction with femoral tunnel performed through the transtibial technique in patients without other associated injuries in the operated knee, using hamstrings graft, with a minimum of 5 years of follow up, showed an osteoarthritis incidence of 16.7% in a mean follow-up of 94.1 months. Level Of Evidence V; Case Series.
Resumo Objetivo: Avaliar a incidência de osteoartrite em pacientes submetidos à reconstrução do LCA pela técnica transtibial, com seguimento mínimo de 5 anos, com lesão isolada do LCA. Métodos: Pacientes que passaram por reconstrução LCA pelo mesmo cirurgião usando a técnica transtibial com enxerto de tendão dos músculos isquiotibiais e que foram acompanhados por no mínimo 5 anos, sem outras lesões durante o procedimento cirúrgico, foram selecionados para realizar exames de imagem do joelho operado a fim de avaliar a incidência de osteoartrite. Os dados obtidos foram avaliados por meio de estatísticas descritivas.. Resultados: Foram avaliados 42 pacientes (44 joelhos), com idade média de 31 anos (DP: 8), sendo 23 joelhos direitos e 28 pacientes do sexo masculino. O tempo médio entre a cirurgia e a avaliação por imagem foi de 94,1 meses (variando de 60 a 154 meses; DP: 28). Dos joelhos avaliados, 37 não apresentavam osteoartrite (83,3%) e 7 apresentavam (16,7%). Conclusão: A reconstrução do LCA com túnel femoral realizado por meio da técnica transtibial em pacientes sem outras lesões associadas no joelho operado, utilizando enxerto dos tendões isquiotibiais, com um acompanhamento mínimo de 5 anos, apresentou uma incidência de osteoartrite de 16,7% em um acompanhamento médio de 94,1 meses. Level of Evidence V; Case Series. Nível de Evidência V; Série de casos
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Humans , Osteoarthritis , Diagnostic Imaging , Anterior Cruciate Ligament ReconstructionABSTRACT
Abstract Objective The aim of this study is to analyse the needs for pre-operative rehabilitation in patients undergoing ACL reconstruction. Methods The database reports were searched within 2018 to 2023, using PubMed, Cochrane library database, Medline, and other published trials. A statistical analysis was made from Review Manager. Results Pre-operative rehabilitation group shows significantly higher 2 years post-operative KOOS score in all subscore and the total mean of the score, pain (p < 0. 0001), symptoms (p < 0. 0001), ADL (p < 0. 0001), sports and recreations (p < 0. 0001), QoL (p < 0. 0001), and the total mean of the KOOS score (p < 0.0001). In contrary, pre-operative rehabilitation group shows insignificantly higher score on 3 months post-operative Lysholm score (p = 0.12). Conclusion This meta-analysis conclude pre-operative rehabilitation may provide better long-term post-operative outcome, however it may not provide much of a short-term outcome. It is recommended to add pre-operative rehabilitation as a guideline for ACL injury management to improve long-term outcome of patients with ACL injury undergoing ACL reconstruction procedure.
Resumo Objetivo O objetivo deste estudo é analisar as necessidades de pré-habilitação cirúrgica em pacientes submetidos à reconstrução do LCA. Métodos Os relatórios das bases de dados foram pesquisados entre 2018 e 2023, utilizando PubMed, base de dados da biblioteca Cochrane, Medline e outros artigos publicados. Uma análise estatística foi feita utilizando-se o Review Manager. Resultados O grupo de pré-habilitação cirúrgica apresenta pontuação KOOS pós-operatória de 2 anos significativamente maior em todos os subescores e na média total da pontuação, dor (p < 0,0001), sintomas (p < 0,0001), AVD (p < 0,0001). 0,0001), esportes e recreação (p < 0,0001), QV (p < 0,0001) e média total do escore KOOS (p < 0,0001). Em contrapartida, o grupo de habilitação pré-operatória apresenta pontuação insignificantemente maior no escore de Lysholm pós-operatório de 3 meses (p = 0,12). Conclusão Esta metanálise conclui que a pré-habilitação cirúrgica pode proporcionar melhores resultados pós-operatórios a longo prazo, no entanto, pode não proporcionar um resultado significativo a curto prazo. Recomenda-se adicionar a pré-habilitação cirúrgica como uma diretriz para o manejo da lesão do LCA para melhorar o resultado a longo prazo dos pacientes com lesão do LCA submetidos ao procedimento de reconstrução do LCA.
Subject(s)
Humans , Anterior Cruciate Ligament Reconstruction , Anterior Cruciate Ligament Injuries/surgery , Preoperative ExerciseABSTRACT
Abstract The anterior cruciate ligament (ACL) injury causes anteroposterior and rotational instability in the knee. Intra-articular reconstructions often fail to achieve satisfactory rotational control, leading to persistent complaints of instability and subjecting the neo-ligament to increased stress. Young patients with high athletic demands and grade 2 or 3 pivot-shift often have a higher risk of re-rupture after isolated ACL reconstruction. Over the years, various techniques have been developed to address such situations. Among the described techniques, one of the most commonly used is the modified or "mini-Lemaire" lateral extra-articular tenodesis. Biomechanical studies demonstrate the versatility of the technique due to its relatively isometric behavior in flexion angles of 0-60° when the graft is introduced deeply to the lateral collateral ligament. It offers the possibility of fixation at different anatomical positions on the lateral femoral condyle and at different degrees of flexion. The objective of this study is to describe an accessible, reproducible technique that relies on materials widely available in our environment.
Resumo A lesão do ligamento cruzado anterior (LCA) causa instabilidade anteroposterior e rotatória do joelho. Reconstruções isoladas intra-articulares muitas vezes não obtêm controle rotacional satisfatório, mantendo queixa de instabilidade e impondo ao neoligamento um maior estresse. Pacientes jovens, com alta demanda atlética e com pivot-shift grau 2 ou 3 apresentam um maior risco de rerrotura após reconstrução isolada do LCA. Ao longo dos anos diversas técnicas foram desenvolvidas na tentativa de mitigar tais situações. Dentre as técnicas descritas, uma das mais utilizadas é a Tenodese extra-articular Lateral tipo Lemaire modificada ou "mini-Lemaire". Estudos biomecânicos demonstram versatilidade da técnica devido a seu comportamento relativamente isométrico em graus de flexão de 0-60° quando a fita é introduzida profundamente ao ligamento colateral lateral, com possibilidade de fixação em diferentes posições anatômicas no côndilo femoral lateral e em diferentes graus de flexão. O objetivo do estudo é descrever uma técnica acessível, reprodutível e dependente de material amplamente disponível em nosso meio.
Subject(s)
Humans , Tenodesis , Anterior Cruciate Ligament Reconstruction , Anterior Cruciate Ligament InjuriesABSTRACT
Abstract The lateral collateral ligament (LCL) is the strongest lateral stabilizer of the knee. It provides support against varus stress and posterolateral rotation of the knee. Lateral collateral ligament injuries mostly occur together with anterior and/or posterior cruciate ligament injuries. While grades 1 and 2 injuries are treated conservatively since they are partial injuries, total ruptures, as in grade 3, require surgical treatment. In conventional LCL reconstruction methods, hamstring grafts are used, and bioscrews are used in bone-tendon fixation. Lateral collateral ligament reconstruction is usually performed as a component of multiple ligament surgery. Therefore, there is a need for a contralateral hamstring tendon or allograft. The present article aims to define a technique that does not require tendon grafts and bioscrews in fibular fixation.
Resumo O ligamento colateral lateral (LCL) é o estabilizador lateral mais forte do joelho. Ele fornece suporte contra o estresse varus e a rotação de posterolateral do joelho. As lesões de LCL ocorrem principalmente com lesões do ligamento cruzado anterior e/ou posterior. Enquanto as lesões grau 1 e 2 são tratadas de forma conservadora, uma vez que são lesões parciais, rupturas totais, como no grau 3, requerem tratamento cirúrgico. Utilizam-se enxertos isquiotibiais nos métodos convencionais de reconstrução da LCL e bioscrews na fixação do tendão ósseo. A reconstrução do LCL é geralmente realizada como um componente de cirurgia de ligamento múltiplo. Portanto, há necessidade de um tendão contralateral ou aloenxerto. O presente artigo tem como objetivo definir uma técnica que não exija enxertos tendíneos e bioscrews na fixação fibular.
Subject(s)
Humans , Athletic Injuries , Collateral Ligaments , Anterior Cruciate Ligament Reconstruction , Joint Instability , Knee InjuriesABSTRACT
Abstract Objective Lateral extra-articular tenodesis (LET) has been proposed to resolve rotatory instability following anterior cruciate ligament reconstruction (ACLR). The present meta-analysis aimed to compare the clinical outcomes of ACLR and ACLR with LET using the modified Lemaire technique. Materials and Methods We performed a meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) staement. The literature search was performed on the PubMed, EBSCOHost, Scopus, ScienceDirect, and WileyOnline databases. The data extracted from the studies included were the study characteristics, the failure rate (graft or clinical failure) as the primary outcome, and the functional score as the secondary outcome. Comparisons were made between the patients who underwent isolated ACLR (ACLR group) and those submitted to ACLR and LET through the modified Lemaire technique (ACLR + LET group). Results A total of 5 studies including 797 patients were evaluated. The ACLR + LET group presented a lower risk of failure and lower rate of rerupture than the ACLR group (risk ratio [RR] = 0.44; 95% confidence interval [95%CI]: 0.26 to 0.75; I2 = 9%; p = 0.003). The ACLR + LET group presented higher scores on the Knee Injury and Osteoarthritis Outcome Score (KOOS) regarding the following outcomes: pain, activities of daily living (ADL), sports, and quality of life (QOL), with mean differences of 0.20 (95%CI: 0.10 to 0.30; I2 = 0%; p < 0.0001), -0.20 (95%CI: -0.26 to -0.13; I2 = 0%; p < 0.00001), 0.20 (95%CI: 0.02 to 0.38; I2 = 0%; p = 0.03), and 0.50 (95%CI: 0.29 to 0.71; I2 = 0%; p < 0.00001) respectively when compared with the ACLR group. Conclusion Adding LET through the modified Lemaire technique to ACLR may improve knee stability because of the lower rate of graft rerupture and the superiority in terms of clinical outcomes. Level of Evidence I.
Resumo Objetivo A tenodese extra-articular lateral (TEL) foi proposta para resolver a instabilidade rotatória após a reconstrução do ligamento cruzado anterior (RLCA). Esta metanálise teve como objetivo comparar os resultados clínicos da RLCA e da RLCA com TEL por meio da técnica de Lemaire modificada. Materiais e Métodos Esta metanálise foi feita de acordo com a declaração dos Itens Principais para Relatar Revisões Sistemáticas e Metanálises (Preferred Reporting Items for Systematic Reviews and Meta-Analysis, PRISMA, em inglês). A pesquisa bibliográfica foi realizada nos bancos de dados PubMed, EBSCOHost, Scopus, ScienceDirect e WileyOnline. Dos estudos incluídos foram extraídas informações sobre as características do estudo, a taxa de falha (falha clínica ou do enxerto) como resultado primário, e o escore funcional como resultado secundário. Foram feitas comparações entre os pacientes submetidos apenas à RLCA (grupo RLCA) e à RLCA e TEL pela técnica de Lemaire modificada (grupo RLCA + TEL). Resultados Foram avaliados 5 estudos que incluíam 797 pacientes. O grupo RLCA + TEL apresentou um risco menor de falha e menor taxa de rerruptura do que o grupo RLCA (razão de risco [RR] = 0,44; intervalo de confiança de 95% [IC95%] 0,26 a 0,75; I2 = 9%; p = 0,003). O grupo RLCA + TEL obteve pontuações maiores no Escore de Desfechos de Osteoartrite e Lesão no Joelho (Knee Injury and Osteoarthritis Outcome Score, KOOS, em inglês) com relação aos seguintes desfechos: dor, atividades cotidianas (AC), esportes, e qualidade de vida (QV), com diferenças médias de 0,20 (IC95%: 0,10 a 0,30; I2 = 0%; p < 0,0001), -0.20 (IC95%: -0,26 a-0,13; I2 =0%; p < 0,00001), 0,20 (IC95%: 0,02 a 0,38; I2 = 0%; p = 0,03) e 0,50 (IC95%: 0,29 a 0,71; I2 = 0%; p < 0,00001), respectivamente, quando comparado com o grupo RLCA. Conclusão O acréscimo de TEL pela técnica de Lemaire modificada à RLCA pode melhorar a estabilidade do joelho devido à menor taxa de rerruptura do enxerto e à superioridade dos resultados clínicos. Nível de evidência I.
Subject(s)
Humans , Treatment Outcome , Tenodesis , Anterior Cruciate Ligament Reconstruction , Joint Instability , Knee JointABSTRACT
Abstract Objective To study the influence of various tunnel parameters and graft inclination angle (GIA) on the clinical and radiological outcome after anterior cruciate ligament reconstruction (ACLR) at long-term follow-up. Methods In this retrospective study, 80 patients with isolated anterior cruciate ligament (ACL) injury treated by single bundle ACLR using bone patellar tendon bone (BPTB) and hamstring (HT) autografts were evaluated clinically and radiologically at their long-term follow-up. The study population were divided into two groups based on ideal and nonideal tunnel parameters as well as ideal and nonideal GIA. The various tunnel parameters and GIA were interpreted with clinical and radiological outcome at long-term follow-up. Results Eighty patients, 36 (45%) using BPTB and 44 (55%) using HT autografts, were available to complete the study. Patients with ideal coronal tibial tunnel angle (CTTA) and coronal femoral tunnel angle (CFTA) show superior clinical outcome (pivot shift test) than nonideal CTTA and CFTA, which was found to be statistically significant (p-value < 0.038 and 0.024, respectively). Similarly, patients with ideal coronal tibial tunnel position (CTTP) show superior clinical outcome (International Knee Documentation Committee - IKDC objective) over nonideal CTTP (p-value < 0.017). All other tunnel parameters and GIA were not found to have influence on clinical outcome. None of the tunnel parameters have influenced osteoarthritis (OA) change. There was no progression of OA change in the study population at long-term follow-up after ACLR. Conclusion Ideal coronal tunnel parameters produced a better clinical outcome at long-term follow-up after ACLR. There was no progression of OA change at long-term follow-up after isolated ACLR.
Resumo Objetivo O objetivo deste estudo foi analisar a influência de vários parâmetros do túnel e do ângulo de inclinação do enxerto (GIA, do inglês graft inclination angle) nos desfechos clínicos e radiológicos da reconstrução do ligamento cruzado anterior (RLCA) no acompanhamento de longo prazo. Métodos Neste estudo retrospectivo, 80 pacientes com lesão isolada do ligamento cruzado anterior (LCA) submetidos à RLCA de feixe único com autoenxertos de tendão patelar ósseo (TPO) e isquiotibiais (IT) foram avaliados clínica e radiologicamente durante o acompanhamento em longo prazo. A população do estudo foi dividida em dois grupos com base nos parâmetros ideais ou não ideais do túnel, bem como no GIA ideal e não ideal. Os vários parâmetros do túnel e o GIA foram interpretados com os desfechos clínicos e radiológicos no acompanhamento em longo prazo. Resultados Oitenta pacientes, sendo 36 (45%) submetidos ao procedimento com autoenxertos de TPO e 44 (55%) com autoenxertos IT, puderam completar o estudo. Pacientes com ângulo do túnel tibial coronal (ATTC) e ângulo do túnel femoral coronal (ATFC) ideais apresentam resultados clínicos superiores (teste de pivot shift) do que aqueles com ATTC e ATFC não ideais, sendo a diferença estatisticamente significativa (valor de p < 0,038 e 0,024, respectivamente). Da mesma forma, pacientes com posição do túnel tibial coronal (PTTC) ideal apresentam resultado clínico superior (International Knee Documentation Committee [IKDC] objetivo) em relação àqueles com PTTC não ideal (valor de p < 0,017). Os demais parâmetros do túnel e o GIA não influenciaram o desfecho clínico. Nenhum dos parâmetros do túnel influenciou a alteração associada à osteoartrite (OA). Não houve progressão da alteração da OA na população do estudo no acompanhamento em longo prazo após a RLCA. Conclusão Os parâmetros ideais do túnel coronal produziram um melhor desfecho clínico no acompanhamento de longo prazo após a RLCA. Não houve progressão da alteração da OA no acompanhamento em longo prazo após a RLCA isolada.
Subject(s)
Humans , Osteoarthritis , Anterior Cruciate Ligament Reconstruction , Knee Joint/surgeryABSTRACT
Abstract Objective The purpose of this meta-analysis is to compare ligament healing on autograft and allograft in anterior cruciate ligament (ACL) reconstruction. Methods The selection of appropriate studies was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We made a statistical analysis using a review manager. Electronic reports were searched using the PubMed, Medline, and Cochrane Library databases. The inclusion criteria were animal studies and cellular histology of both grafts as an outcome. Results The initial search revealed 412 potential articles. After duplicates were removed, 246 articles remained. Then, 14 articles were obtained and screened for relevance and eligibility. The relevant articles were searched manually, checking for eligibility and details in order not to miss included reports. Subsequently, 5 studies were included, with a total of 232 samples, reporting the biopsied results with quantitative histology of ligament healing between allograft and autograft. The biopsy samples in those studies were examined under light or electron microscope, to analyze the cellular distribution area and ligamentization stages in each group. Meta-analyses found significant difference between autograft and allograft (Heterogeneity, I2 = 89%; Mean Difference, 95% confidence interval [CI] =-34.92, -54.90, -14.93; p = 0.0006). There is also a significant difference on both graft in cellular count at over 24 weeks (Heterogeneity, I2 = 26%; Mean Difference, 95% CI = -14.59, -16.24, -12.94; p < 0.00001). Conclusion In the current meta-analysis, autograft shows a significant difference when compared to allograft, with more cellular accumulation and faster remodeling response on the ligamentization process being noticed in the former. However, a larger clinical trial will be needed to emphasize this literature's result.
Resumo Objetivo O objetivo desta metanálise comparar a cicatrização de ligamentos no autoenxerto e aloenxerto na reconstrução do ligamento cruzado anterior (LCA). Métodos A seleção dos estudos adequados foi realizada de acordo com as diretrizes de Relatórios Preferenciais para Revisões Sistemáticas e Metanálises (Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA). Uma análise estatística foi feita usando um gerente de revisão. Os relatórios eletrônicos foram pesquisados usando os bancos de dados PubMed, Medline e Cochrane Library. Os critérios de inclusão foram estudos em animais e a histologia celular de ambos os enxertos como desfecho. Resultado A pesquisa inicial revelou 412 artigos potenciais. Após a retirada das duplicatas, restaram 246 artigos. Então, 14 artigos foram obtidos e selecionados pela relevância e elegibilidade. Os artigos relevantes foram pesquisados manualmente, verificando sua elegibilidade e detalhando os estudos para não perder os relatórios incluídos. Posteriormente, foram incluídos 5 estudos, com um total de 232 amostras, relatando os resultados de biópsia com histologia quantitativa de cicatrização de ligamento entre aloenxerto e autoenxerto. As amostras de biópsia nesses estudos foram examinadas sob microscópio leve ou eletrônico, para análise da área de distribuição celular e estágios de ligamentização em cada grupo. As metanálises encontraram diferença significativa entre autoenxerto e aloenxerto (Heterogeneidade, I2 = 89%; Diferença média, 95% intervalo de confiança [IC] =-34,92, -54,90, -14,93; p = 0,0006). Também há uma diferença significativa nosdoisenxertosnacontagem celular de mais de 24 semanas (Heterogeneidade, I2 = 26%; Diferença média, 95% IC = -14,59 , -16,24, -12,94; p < 0,00001). Conclusão Na presente metanálise, o autoenxerto mostra resultados significativos quando comparado ao aloenxerto, com mais acúmulo celular e resposta de remode-lagem mais rápida no processo de ligamentizaçãosendoobservadonoprimeiro.No entanto, será necessário um estudo clínico maior para enfatizar o resultado desta literatura.