Initial Graft Tension and ACL Surgery

Anterior Cruciate Ligament Rupture Clinical Trial

Official title:

Effects of Initial Graft Tension on Anterior Cruciate Ligament Reconstruction

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT00434837
• Other study ID #: R01AR047910
• Secondary ID: R01AR047910R01AR
• Status: Completed
• Phase: N/A
• Start date: February 2004
• Est. completion date: February 29, 2024

Study information

• Verified date: April 2024
• Source: Rhode Island Hospital
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The anterior cruciate ligament (ACL) is one of four strong ligaments connecting the bones of the knee joint. If overstretched, the ACL can tear. Reconstruction of a torn ACL is now a common surgical procedure. The amount of tension applied to the ACL during reconstruction may indirectly affect the possible onset of arthritis over time. The purpose of this study is to determine the effect of initial graft tension set during ACL reconstruction surgery on the progression of knee arthritis over at least a 15-year period.

Description:

Damage to the ACL is a common injury that usually requires surgical reconstruction to restore function and prevent progression of post-traumatic osteoarthritis. However, the reconstruction procedure frequently causes degenerative changes to the knee joint over time. The amount of tension applied to the ACL during reconstruction may indirectly affect the possible onset of arthritis over time. High tension would result in less joint motion during the initial healing stages, which may make the onset of arthritis less likely. On the other hand, high tension would result in increased compressive forces between the joint surfaces, which could lead to arthritis. The purpose of this study is to evaluate the effect of initial graft tension set during ACL reconstruction surgery on joint cartilage and the development of knee arthritis over at least a 15-year period.

Participants will include candidates for ACL reconstruction surgery using patellar tendon grafts. Participants will be randomly assigned to one of two treatment groups:

• Low tension (Group 1) participants will receive low-tension treatment with initial graft tension set so that the anterior-posterior (A-P) displacement of the reconstructed knee is equal to that of the uninjured knee.

• High-tension (Group 2) participants will receive high-tension treatment with initial graft tension set to reduce A-P displacement by 2 millimeters relative to that of the uninjured knee.

Participants will enroll in this 15-year study 1 to 6 weeks prior to ACL surgery. There will be two preoperative study visits: one will include magnetic resonance imaging (MRI) and the other will include a knee evaluation, dynamic function testing, and questionnaires. Postoperative visits occurred immediately following surgery and at 6, 12, 36, 60, 84, 120, 144 and 180 months following surgery. Strength testing, functional testing, x-rays, questionnaires, and a knee exam will occur at most postoperative visits. MRIs will occur at some postoperative visits. An additional group of participants with no evidence of knee injury will serve as a control. The control group will attend all study visits except for the 12-month visit. All participants may be followed for up to 15 years.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 168
• Est. completion date: February 29, 2024
• Est. primary completion date: February 29, 2024
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 15 Years to 50 Years

Eligibility

Inclusion Criteria for Groups 1 and 2:

• ACL injury of only one knee (minor meniscal tears involving less than 1/3 of the meniscus are allowed)

• Candidate for ACL reconstruction surgery using a bone-patellar tendon-bone graft or a four-stranded hamstring tendon graft (looped semitendinosus and gracilis muscles)

• Tegner activity score of 5 or greater, indicating participant is at least moderately active

Exclusion Criteria for Groups 1 and 2:

• ACL tear that has occurred more than 12 months prior to surgery

• Moderate-sized fissures or lesions in knee articular cartilage

• Meniscal tears requiring partial removal of meniscus (tears larger than 1/3 of the meniscus)

Inclusion Criteria for the Control Group:

• Tegner activity score of 5 or greater, indicating participant is at least moderately active

Exclusion Criteria for All Participants:

• Previous injury to either knee

• Increased laxity of the medial collateral ligament (MCL), lateral collateral ligament (LCL), or posterior cruciate ligament (PCL), as compared to the uninjured knee

• Radiographic evidence of degenerative arthritis

• Pregnancy

• Any disease that might place a participant at high risk for articular cartilage damage (e.g., rheumatoid arthritis, osteoporosis, metabolic diseases)

Related Conditions & MeSH terms

• Anterior Cruciate Ligament Rupture
• Rupture

Intervention

Procedure:
• Initial graft tension during ACL reconstruction surgery
The amount of tension that is applied to the graft at the time of fixation is being performed with the knee in two different positions. When the knee is at 30 degrees of flexion, the resulting laxity is approximately 2 mm less than the contralateral leg (the "High Tension" treatment). When the tension is performed with the knee in extension (0 degrees of flexion), the the laxity is equal to that of the contralateral leg (the "Low Tension" treatment). Both methods are commonly used in clinical practice. The effect it may have on articular cartilage remains unknown.

Locations

Country	Name	City	State
United States	Miriam Hospital/Brown University	Providence	Rhode Island
United States	Rhode Island Hospital/Brown University	Providence	Rhode Island

Sponsors (2)

Lead Sponsor	Collaborator
Rhode Island Hospital	National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

Country where clinical trial is conducted

United States, 

References & Publications (27)

Akelman MR, Fadale PD, Hulstyn MJ, Shalvoy RM, Garcia A, Chin KE, Duryea J, Badger GJ, Tung GA, Fleming BC. Effect of Matching or Overconstraining Knee Laxity During Anterior Cruciate Ligament Reconstruction on Knee Osteoarthritis and Clinical Outcomes: A — View Citation

Behnke AL, Parola LR, Karamchedu NP, Badger GJ, Fleming BC, Beveridge JE. Neuromuscular function in anterior cruciate ligament reconstructed patients at long-term follow-up. Clin Biomech (Bristol, Avon). 2021 Jan;81:105231. doi: 10.1016/j.clinbiomech.2020.105231. Epub 2020 Nov 17. — View Citation

Biercevicz AM, Akelman MR, Fadale PD, Hulstyn MJ, Shalvoy RM, Badger GJ, Tung GA, Oksendahl HL, Fleming BC. MRI volume and signal intensity of ACL graft predict clinical, functional, and patient-oriented outcome measures after ACL reconstruction. Am J Spo — View Citation

Bowers ME, Trinh N, Tung GA, Crisco JJ, Kimia BB, Fleming BC. Quantitative MR imaging using "LiveWire" to measure tibiofemoral articular cartilage thickness. Osteoarthritis Cartilage. 2008 Oct;16(10):1167-73. doi: 10.1016/j.joca.2008.03.005. Epub 2008 Apr 14. — View Citation

Bowers ME, Tung GA, Oksendahl HL, Hulstyn MJ, Fadale PD, Machan JT, Fleming BC. Quantitative magnetic resonance imaging detects changes in meniscal volume in vivo after partial meniscectomy. Am J Sports Med. 2010 Aug;38(8):1631-7. doi: 10.1177/0363546510364054. Epub 2010 May 4. — View Citation

Bowers ME, Tung GA, Trinh N, Leventhal E, Crisco JJ, Kimia B, Fleming BC. Effects of ACL interference screws on articular cartilage volume and thickness measurements with 1.5 T and 3 T MRI. Osteoarthritis Cartilage. 2008 May;16(5):572-8. doi: 10.1016/j.joca.2007.09.010. Epub 2007 Oct 22. — View Citation

Brady MF, Bradley MP, Fleming BC, Fadale PD, Hulstyn MJ, Banerjee R. Effects of initial graft tension on the tibiofemoral compressive forces and joint position after anterior cruciate ligament reconstruction. Am J Sports Med. 2007 Mar;35(3):395-403. doi: 10.1177/0363546506294363. Epub 2007 Jan 11. — View Citation

Coats-Thomas MS, Miranda DL, Badger GJ, Fleming BC. Effects of ACL reconstruction surgery on muscle activity of the lower limb during a jump-cut maneuver in males and females. J Orthop Res. 2013 Dec;31(12):1890-6. doi: 10.1002/jor.22470. Epub 2013 Aug 21. — View Citation

Costa MQ, Badger GJ, Chrostek CA, Carvalho OD, Faiola SL, Fadale PD, Hulstyn MJ, Gil HC, Shalvoy RM, Fleming BC. Effects of Initial Graft Tension and Patient Sex on Knee Osteoarthritis Outcomes After ACL Reconstruction: A Randomized Controlled Clinical Tr — View Citation

DeFroda SF, Karamchedu NP, Budacki R, Wiley T, Fadale PD, Hulstyn MJ, Shalvoy RM, Badger GJ, Fleming BC, Owens BD. Evaluation of Graft Tensioning Effects in Anterior Cruciate Ligament Reconstruction between Hamstring and Bone-Patellar Tendon Bone Autograf — View Citation

DeFroda SF, Karamchedu NP, Owens BD, Bokshan SL, Sullivan K, Fadale PD, Hulstyn MJ, Shalvoy RM, Badger GJ, Fleming BC. Tibial tunnel widening following anterior cruciate ligament reconstruction: A retrospective seven-year study evaluating the effects of i — View Citation

Elsaid KA, Fleming BC, Oksendahl HL, Machan JT, Fadale PD, Hulstyn MJ, Shalvoy R, Jay GD. Decreased lubricin concentrations and markers of joint inflammation in the synovial fluid of patients with anterior cruciate ligament injury. Arthritis Rheum. 2008 Jun;58(6):1707-15. doi: 10.1002/art.23495. — View Citation

Fleming BC, Brady MF, Bradley MP, Banerjee R, Hulstyn MJ, Fadale PD. Tibiofemoral compression force differences using laxity- and force-based initial graft tensioning techniques in the anterior cruciate ligament-reconstructed cadaveric knee. Arthroscopy. 2008 Sep;24(9):1052-60. doi: 10.1016/j.arthro.2008.05.013. Epub 2008 Jun 30. — View Citation

Fleming BC, Fadale PD, Hulstyn MJ, Shalvoy RM, Oksendahl HL, Badger GJ, Tung GA. The effect of initial graft tension after anterior cruciate ligament reconstruction: a randomized clinical trial with 36-month follow-up. Am J Sports Med. 2013 Jan;41(1):25-3 — View Citation

Fleming BC, Fadale PD, Hulstyn MJ, Shalvoy RM, Tung GA, Badger GJ. Long-term outcomes of anterior cruciate ligament reconstruction surgery: 2020 OREF clinical research award paper. J Orthop Res. 2021 May;39(5):1041-1051. doi: 10.1002/jor.24794. Epub 2020 — View Citation

Fleming BC, Hulstyn MJ, Oksendahl HL, Fadale PD. Ligament Injury, Reconstruction and Osteoarthritis. Curr Opin Orthop. 2005 Oct;16(5):354-362. doi: 10.1097/01.bco.0000176423.07865.d2. — View Citation

Fleming BC, Oksendahl HL, Mehan WA, Portnoy R, Fadale PD, Hulstyn MJ, Bowers ME, Machan JT, Tung GA. Delayed Gadolinium-Enhanced MR Imaging of Cartilage (dGEMRIC) following ACL injury. Osteoarthritis Cartilage. 2010 May;18(5):662-7. doi: 10.1016/j.joca.2010.01.009. Epub 2010 Feb 11. — View Citation

Kiapour AM, Yang DS, Badger GJ, Karamchedu NP, Murray MM, Fadale PD, Hulstyn MJ, Shalvoy RM, Fleming BC. Anatomic Features of the Tibial Plateau Predict Outcomes of ACL Reconstruction Within 7 Years After Surgery. Am J Sports Med. 2019 Feb;47(2):303-311. — View Citation

Miranda DL, Fadale PD, Hulstyn MJ, Shalvoy RM, Machan JT, Fleming BC. Knee biomechanics during a jump-cut maneuver: effects of sex and ACL surgery. Med Sci Sports Exerc. 2013 May;45(5):942-51. doi: 10.1249/MSS.0b013e31827bf0e4. — View Citation

Miranda DL, Rainbow MJ, Crisco JJ, Fleming BC. Kinematic differences between optical motion capture and biplanar videoradiography during a jump-cut maneuver. J Biomech. 2013 Feb 1;46(3):567-73. doi: 10.1016/j.jbiomech.2012.09.023. Epub 2012 Oct 22. — View Citation

Miranda DL, Schwartz JB, Loomis AC, Brainerd EL, Fleming BC, Crisco JJ. Static and dynamic error of a biplanar videoradiography system using marker-based and markerless tracking techniques. J Biomech Eng. 2011 Dec;133(12):121002. doi: 10.1115/1.4005471. — View Citation

Mulcahey MK, Monchik KO, Yongpravat C, Badger GJ, Fadale PD, Hulstyn MJ, Fleming BC. Effects of single-bundle and double-bundle ACL reconstruction on tibiofemoral compressive stresses and joint kinematics during simulated squatting. Knee. 2012 Aug;19(4):469-76. doi: 10.1016/j.knee.2011.05.004. Epub 2011 Jun 22. — View Citation

Oksendahl HL, Gomez N, Thomas CS, Badger GD, Hulstyn MJ, Fadale PD, Fleming BC. Digital radiographic assessment of tibiofemoral joint space width: a variance component analysis. J Knee Surg. 2009 Jul;22(3):205-12. doi: 10.1055/s-0030-1247750. — View Citation

Rainbow MJ, Miranda DL, Cheung RT, Schwartz JB, Crisco JJ, Davis IS, Fleming BC. Automatic determination of an anatomical coordinate system for a three-dimensional model of the human patella. J Biomech. 2013 Aug 9;46(12):2093-6. doi: 10.1016/j.jbiomech.2013.05.024. Epub 2013 Jun 20. — View Citation

Ware JK, Owens BD, Akelman MR, Karamchedu NP, Fadale PD, Hulstyn MJ, Shalvoy RM, Badger GJ, Fleming BC. Preoperative KOOS and SF-36 Scores Are Associated With the Development of Symptomatic Knee Osteoarthritis at 7 Years After Anterior Cruciate Ligament R — View Citation

Zandiyeh P, Parola LR, Costa MQ, Hague MJ, Molino J, Fleming BC, Beveridge JE. Long-Term Bilateral Neuromuscular Function and Knee Osteoarthritis after Anterior Cruciate Ligament Reconstruction. Bioengineering (Basel). 2023 Jul 6;10(7):812. doi: 10.3390/bioengineering10070812. — View Citation

Zandiyeh P, Parola LR, Fleming BC, Beveridge JE. Wavelet analysis reveals differential lower limb muscle activity patterns long after anterior cruciate ligament reconstruction. J Biomech. 2022 Mar;133:110957. doi: 10.1016/j.jbiomech.2022.110957. Epub 2022 Jan 20. — View Citation

* Note: There are 27 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Radiographic joint space narrowing	Medial joint space width measurements were obtained from radiographs preoperatively and postoperatively using the semiflexed metatarsophalangeal view. Radiographs were taken of each knee, and the medial compartment joint space width was measured at the midline of the compartment in the coronal plane using a validated computer algorithm.; (Duryea et al., Trainable rule-based algorithm for the measurement of joint space width in digital radiographic images of the knee, Medical Physics 27, 580 (2000); doi: 10.1118/1.598897). Subjects are identified as having radiographic signs of OA if they exhibit a change in the medial or lateral compartments greater that 0.30mm over the study period	15 years
Secondary	Knee injury and osteoarthritis outcome score (KOOS)	The five dimensions of Knee Osteoarthritis Outcome Score were scored separately: pain , symptoms ,activities of daily life function, sport and recreation function, and knee-related quality of life . Each sub score has a 0-100 scale. 0- extreme knee problems and 100- no knee problems.	15 years
Secondary	Knee joint laxity	Difference in Anterior-Posterior (A-P) knee laxity value; A-P laxity is defined as the amount of A-P directed translation of the tibia (relative to the femur) between the shear load limits of -90 N (posterior) and 133 N (anterior).	15 years
Secondary	Limb strength international knee documentation committee (IKDC) score	Clinical outcome was assessed using the 2000 IKDC Knee Examination Score (http://www.sportsmed.org). The IKDC scores evaluate 4 categories: function, symptoms, range of knee motion, and clinical examination.The IKDC score rates knees as normal (A), nearly normal (B), abnormal (C), and severely abnormal (D), with the final IKDC rating based on the score of the worst category.	15 years
Secondary	Short Form-36 (SF-36) health survey	The SF-36 evaluates general health related to physical function, role limitations, bodily pain, vitality, social functioning, mental health, and health transition. Each sub score is on a 0-100 scale. 100 indicates no problems and 0 indicates severe problems.	15 years
Secondary	Muscle atrophy	Thigh circumference 6 cm above the joint line for injured and contralateral knees	15 years
Secondary	Whole Organ Magnetic Resonance Image Score (WORMS)	The OA status of the knee was assessed using the semiquantitative Whole Organ Magnetic Resonance Imaging Score (WORMS).The score uses magnetic resonance imaging (MRI) sequences to grade 14 independent features: cartilage signal and morphological characteristics, subarticular bone marrow abnormality, subarticular cysts, subarticular bone attrition, and marginal osteophytes evaluated in 15 regions. The condition of the menisci, cruciate and collateral ligaments, synovitis, loose bodies, and periarticular cysts was also included for a total possible score of 332 points.; 0-indicates no damage in anatomical landmarks assessed. 332-severe damage to the anatomical landmarks assessed.	15 years
Secondary	One-legged hop test	Ratio of hop distance on the injured knee to the hop distance on the contralateral uninjured knee.	15 years
Secondary	Modified OsteoArthritis Research Society International (OARSI) score	OARSI-The overall condition of the knee joints of both surgical and contralateral limbs were graded on radiographs by a radiologist. (0-83). 83-severe damage.0- no damage. The difference of the score between surgical and contralateral limbs is also presented.	15 years
Secondary	Isokinetic Strength	Strength of quadriceps muscles was quantified by averaging the peak torques of 3 repetitions and normalizing these values with respect to body weight.Percent torque of surgical compared to contralateral is presented. If the quadriceps muscle of the surgical limb had the same peak torque as the contralateral, it would be 100%.	7 years