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ACL deficiency influences medio-lateral tibial alignment and knee varus–valgus during in vivo activities

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The role of the anterior cruciate ligament (ACL) in knee biomechanics in vivo and under weight-bearing is still unclear. The purpose of this study was to compare the tibiofemoral kinematics of ACL-deficient knees to healthy contralateral ones during the execution of weight-bearing activities.

Methods

Eight patients with isolated ACL injury and healthy contralateral knees were included in the study. Patients were asked to perform a single step forward and a single leg squat first with the injured knee and then with the contralateral one. Knee motion was determined using a validated model-based tracking process that matched subject-specific MRI bone models to dynamic biplane radiographic images, under the principles of Roentgen stereophotogrammetric analysis (RSA). Data processing was performed in a specific software developed in Matlab.

Results

Statistically significant differences (p < 0.05) were found for single leg squat along the frontal plane: ACL-deficient knees showed a more varus angle, especially at the highest knee flexion angles (40°–50° on average), compared to the contralateral knees. Furthermore, ACL-deficient knees showed tibial medialization along the entire task, while contralateral knees were always laterally aligned. This difference became statistically relevant (p < 0.05) for knee flexion angles included between 0° and about 30°.

Conclusion

ACL-deficient knees showed an abnormal tibial medialization and increased varus angle during single leg squat when compared to the contralateral knees. These biomechanical anomalies could cause a different force distribution on tibial plateau, explaining the higher risk of early osteoarthritis in ACL deficiency. The clinical relevance of this study is that also safe activities used in ACL rehabilitation protocols are significantly altered in ACL deficiency.

Level of evidence

III.

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Abbreviations

ACL:

Anterior cruciate ligament

ACLD:

Anterior cruciate ligament deficient

RSA:

Roentgen stereophotogrammetric analysis

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Funding

This work was supported by Italian Ministry of Health, Progetto RF Ministero della Salute (Grant number 2010-2312173).

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Authors and Affiliations

Authors

Contributions

PA analyzed patients’ kinematics data, participated in study design and drafted the manuscript, SDP contributed in methods development, helped to draft the manuscript and performed statistical analysis, AG took care of clinical part of the study and helped to draft the manuscript, EP participated in kinematics data analysis, MB developed the software used to extrapolate data of present study, LB and SZ participated in study design, coordinated activities and helped to draft the manuscript. All the authors read the final manuscript and approved it.

Corresponding author

Correspondence to Stefano Di Paolo.

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Conflict of interest

Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

Ethical approval

This study obtained the approval from Institutional Review Board (IRB) of Rizzoli Orthopaedic Institute (ID: 40/CE/US/ml—Clinical Trial Gov ID: NCT02323386.

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Agostinone, P., Di Paolo, S., Grassi, A. et al. ACL deficiency influences medio-lateral tibial alignment and knee varus–valgus during in vivo activities. Knee Surg Sports Traumatol Arthrosc 29, 389–397 (2021). https://doi.org/10.1007/s00167-020-05979-6

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