The Evaluation Of Tibial Torsion Angle After Anterior Cruciate Ligament Reconstruction

Abstract

The aim of this study is to investigate the effect of anterior cruciate ligament (ACL) reconstruction on tibial torsion angle (TTA) in the operated limb using computed tomography (CT) and physical examination methods and to show the relationship between post-operative muscle strength features and TTA by using isokinetic dynamometer. 21 patients between 18 and 36 years old (25.4±6.8) who underwent ACL reconstruction with hamstring tendon (HT) autograft and then completed the ACL rehabilitation were included in this study. Isokinetic strength measurements were evaluated by Biodex-Multi Joint System-Pro 4 dynamometer. To evaluate TTA; CT, transmalleolar and thigh-foot angle (TFA) measurements were carried out. There was no significant TTA differences between 21 operated and non-operated knees for any method (p> 0.05). At the isokinetic evaluation to the extension direction there were a significant differences 60-180º/sec in peak torque value (p=0,0001, p=0,003) and average power value (p=0,004, p=0,002). As the percentage of losses in peak torque value to the flexion direction at velocity of 180 º/sec increases, the CT diagnosed angle difference between both knees increases. (p<0,01, r=0,548) As the percentage of losses in average power value to the extension direction at the velocity of 60 º/sec increases, the TFA difference between both knees increases. (p<0,01, r=0,563) . The isokinetic evaluation findings show that the strength loss between the knees increases the TTA differences. This finding shows the relationship of post-op rehabilitation with TTA varies and re-injury risk. In the isokinetic evaluation, subjects with high loss of strength in the direction of flexion at 180º/sec velocity had higher TTA differences, so rehabilitation protocols should be also focused on muscle endurance.

Keywords

• Tibial Torsion
• Muscle Strength Dynamometer
• Anterior Cruciate Ligament

References

1. 1. Lai CCH, Ardern CL, Feller JA, Webster KE. Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med. 2018 Jan;52(2):128-38. PubMed PMID: 28223305. Epub 2017/02/21. eng.
2. 2. Todor A, Nistor DV, Caterev S. Clinical outcomes after ACL reconstruction with free quadriceps tendon autograft versus hamstring tendons autograft. A retrospective study with a minimal follow-up two years. Acta Orthop Traumatol Turc. 2019 May;53(3):180-3. PubMed PMID: 30905626. PMCID: PMC6599396. Epub 2019/03/21. eng.
3. 3. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? A Meta-analysis of 47,613 Patients. Clin Orthop Relat Res. 2017 Oct;475(10):2459-68. PubMed PMID: 28205075. PMCID: PMC5599382. eng.
4. 4. Calvo R, Figueroa D, Figueroa F, Vaisman A, Schmidt-Hebbel A, Morales N, et al. Five-Strand Hamstring Autograft Versus Quadruple Hamstring Autograft With Graft Diameters 8.0 Millimeters or More in Anterior Cruciate Ligament Reconstruction: Clinical Outcomes With a Minimum 2-Year Follow-Up. Arthroscopy. 2017 May;33(5):1007-13. PubMed PMID: 28082062. Epub 2017/01/09. eng.
5. 5. Mehl J, Diermeier T, Herbst E, Imhoff AB, Stoffels T, Zantop T, et al. Evidence-based concepts for prevention of knee and ACL injuries. 2017 guidelines of the ligament committee of the German Knee Society (DKG). Arch Orthop Trauma Surg. 2018 Jan;138(1):51-61. PubMed PMID: 28983841. Epub 2017/10/05. eng.
6. 6. Yu B, Garrett WE. Mechanisms of non-contact ACL injuries. Br J Sports Med. 2007 Aug;41 Suppl 1:i47-51. PubMed PMID: 17646249. PMCID: PMC2465243. eng.
7. 7. Grassi A, Signorelli C, Urrizola F, Raggi F, Macchiarola L, Bonanzinga T, et al. Anatomical features of tibia and femur: Influence on laxity in the anterior cruciate ligament deficient knee. Knee. 2018 Aug;25(4):577-87. PubMed PMID: 29802076. Epub 2018/05/24. eng.
8. 8. Meyer EG, Haut RC. Anterior cruciate ligament injury induced by internal tibial torsion or tibiofemoral compression. J Biomech. 2008 Dec;41(16):3377-83. PubMed PMID: 19007932. Epub 2008/11/12. eng.

9. 9. Donnell-Fink LA, Klara K, Collins JE, Yang HY, Goczalk MG, Katz JN, et al. Effectiveness of Knee Injury and Anterior Cruciate Ligament Tear Prevention Programs: A Meta-Analysis. PLoS One. 2015;10(12):e0144063. PubMed PMID: 26637173. PMCID: PMC4670212. Epub 2015/12/04. eng.
10. 10. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990 1990 May-Jun;18(3):292-9. PubMed PMID: 2372081. eng.
11. 11. Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985 Jan;67(1):39-47. PubMed PMID: 3968103. eng.
12. 12. ROSEN H, SANDICK H. The measurement of tibiofibular torsion. J Bone Joint Surg Am. 1955 Jul;37-A(4):847-55. PubMed PMID: 13242614. eng.
13. 13. Staheli LT, Engel GM. Tibial torsion: a method of assessment and a survey of normal children. Clin Orthop Relat Res. 1972 1972 Jul-Aug;86:183-6. PubMed PMID: 5047787. eng.
14. 14. Rosskopf AB, Ramseier LE, Sutter R, Pfirrmann CW, Buck FM. Femoral and tibial torsion measurement in children and adolescents: comparison of 3D models based on low-dose biplanar radiography and low-dose CT. AJR Am J Roentgenol. 2014 Mar;202(3):W285-91. PubMed PMID: 24555627. eng.
15. 15. Yang PF, Kriechbaumer A, Albracht K, Sanno M, Ganse B, Koy T, et al. On the relationship between tibia torsional deformation and regional muscle contractions in habitual human exercises in vivo. J Biomech. 2015 Feb;48(3):456-64. PubMed PMID: 25543279. Epub 2014/12/16. eng.
16. 16. Guler O, Isyar M, Karataş D, Ormeci T, Cerci H, Mahirogulları M. Investigating the relationship between internal tibial torsion and medial collateral ligament injury in patients undergoing knee arthroscopy due to tears in the posterior one third of the medial meniscus. Knee. 2016 Aug;23(4):655-8. PubMed PMID: 26751979. Epub 2015/12/29. eng.
17. 17. Liu X, Kim W, Drerup B, Mahadev A. Tibial torsion measurement by surface curvature. Clin Biomech (Bristol, Avon). 2005 May;20(4):443-50. PubMed PMID: 15737453. eng.
18. 18. Bayrak A. KGB, Yargic M. P., Tuncer I. Comparison of Tibial Torsion Angles Between Elite Athletes and Sedentary People. The Turkish Journal of Sport and Exercise. 2018;20(3):137-9. Epub 3 January 2018.
19. 19. le Damany PG. Technique of tibial tropometry. 1903. Clin Orthop Relat Res. 1994 May(302):4-10; discussion 2-3. PubMed PMID: 8168319. eng.
20. 20. Ritter MA, DeRosa GP, Babcock JL. Tibial torsion? Clin Orthop Relat Res. 1976 Oct(120):159-63. PubMed PMID: 975652. eng.
21. 21. Malekafzali S, Wood MB. Tibial torsion--a simple clinical apparatus for its measurement and its application to a normal adult population. Clin Orthop Relat Res. 1979 1979 Nov-Dec(145):154-7. PubMed PMID: 535266. eng.
22. 22. Turner MS, Smillie IS. The effect of tibial torsion of the pathology of the knee. J Bone Joint Surg Br. 1981;63-B(3):396-8. PubMed PMID: 7263753. eng.
23. 23. Hazlewood ME, Simmons AN, Johnson WT, Richardson AM, van der Linden ML, Hillman SJ, et al. The Footprint method to assess transmalleolar axis. Gait Posture. 2007 Apr;25(4):597-603. PubMed PMID: 16904892. Epub 2006/08/14. eng.
24. 24. Jakob RP, Haertel M, Stüssi E. Tibial torsion calculated by computerised tomography and compared to other methods of measurement. J Bone Joint Surg Br. 1980 May;62-B(2):238-42. PubMed PMID: 7364840. eng.
25. 25. Joseph B, Carver RA, Bell MJ, Sharrard WJ, Levick RK, Aithal V, et al. Measurement of tibial torsion by ultrasound. J Pediatr Orthop. 1987 1987 May-Jun;7(3):317-23. PubMed PMID: 3294897. eng.
26. 26. Schneider B, Laubenberger J, Jemlich S, Groene K, Weber HM, Langer M. Measurement of femoral antetorsion and tibial torsion by magnetic resonance imaging. Br J Radiol. 1997 Jun;70(834):575-9. PubMed PMID: 9227249. eng.
27. 27. Liodakis E, Doxastaki I, Chu K, Krettek C, Gaulke R, Citak M, et al. Reliability of the assessment of lower limb torsion using computed tomography: analysis of five different techniques. Skeletal Radiol. 2012 Mar;41(3):305-11. PubMed PMID: 21560009. Epub 2011/05/11. eng.
28. 28. Asaeda M, Deie M, Kono Y, Mikami Y, Kimura H, Adachi N. The relationship between knee muscle strength and knee biomechanics during running at 6 and 12 months after anterior cruciate ligament reconstruction. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2019 Apr;16:14-8. PubMed PMID: 30984558. PMCID: PMC6445434. Epub 2018/12/14. eng.
29. 29. Güven M, Akman B, Unay K, Ozturan EK, Cakici H, Eren A. A new radiographic measurement method for evaluation of tibial torsion: a pilot study in adults. Clin Orthop Relat Res. 2009 Jul;467(7):1807-12. PubMed PMID: 19052824. PMCID: PMC2690742. Epub 2008/12/04. eng.
30. 30. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011 Jun;45(7):596-606. PubMed PMID: 21398310. Epub 2011/03/11. eng.
31. 31. Culvenor AG, Patterson BE, Guermazi A, Morris HG, Whitehead TS, Crossley KM. Accelerated Return to Sport After Anterior Cruciate Ligament Reconstruction and Early Knee Osteoarthritis Features at 1 Year: An Exploratory Study. PM R. 2018 04;10(4):349-56. PubMed PMID: 28919498. Epub 2017/09/14. eng.
32. 32. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016 Jul;50(13):804-8. PubMed PMID: 27162233. PMCID: PMC4912389. Epub 2016/05/09. eng.
33. 33. Ardern CL, Bizzini M, Bahr R. It is time for consensus on return to play after injury: five key questions. Br J Sports Med. 2016 May;50(9):506-8. PubMed PMID: 26590181. Epub 2015/11/20. eng.