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(1)

Cylinder

or

mobile

cast

brace after knee

ligament

surgery

A

clinical

analysis

and

morphologic

and

enzymatic

studies of

changes

in the

quadriceps

muscle

TOM

HÄGGMARK,

M.D.,

AND

EJNAR

ERIKSSON, M.D.,

Stockholm,

Sweden

From the

Section

of

Trauma, Department

of

Surgery,

Karolinska

Sjukhuset,

S-104

01

Stock-holm,

Sweden

ABSTRACT

Sixteen

patients participated

in a

prospective

randomized trial

in which a standard

cylinder

cast was

compared

with a mobile

cast brace. Both were worn for 4

weeks,

beginning

at 1 week

after reconstruction of the anterior cruciate

ligament.

The

athletes that had used a cast brace could return to

sports

activities in about one-half the time it took for the athletes with

a standard cast. The

patients

with a standard cast showed a

significant atrophy

of

Type

I

(slow twitch)

muscle fibers in the

vastus lateralis. The cast brace

patients

did not show any

significant changes

in cross-sectional areas of

Type

I or

Type

II

(fast twitch)

muscle fibers.

The standard cast

patients

had a

significant

reduction of

succinate

dehydrogenase (SDH) activity

in the vastus lateralis

whereas the

patients

with the cast brace did not show any

significant changes.

No difference in

surgical

end result was found. A cast brace with a limited range of motion between 20 and 60° of flexion is recommended as the standard

postopera-tive treatment after knee

ligament

surgery.

Treatment

of an athlete with a chronic combined

injury

to

his knee

ligament

involves a number of

problems

from selection of method of

surgical repair

to choice of

postoperative

treat-ment. The final outcome

varies’

and an attainment of a

good

functional end result often

requires long

and intensive

post-operative

training.

A

great

number of different

surgical

tech-niques

to reconstruct the anterior cruciate

ligament

and restore

the anterior and anteromedial

rotatory

instability

in the knee

joint

have been

described.2-11

The wide

variety

of

surgical

techniques points

to the

difficulty

in

treating patients

with this

type

of

injury.

Whatever

surgical

method is used,

postoperative

rehabilita-tion is of

great

importance.’)

Numerous

experimental

studies

in animals have shown that immobilization lead to

degenera-tive

changes

in the muscle and

collagen

structures. 13-15

Immo-bilization of the

knee

joint

reduces the mechanical stimuli to

the

collagen

structures.&dquo;

Tendons,

ligaments,

and

ligament

insertions

undergo changes

that reduce their

strength

and

restrict normal motion. At the same

time,

atrophy

of the muscles involved in

joint

function takes

place.

These different

changes affect joint

function and recovery

time.1’

Several

investigators&dquo;, &dquo;

have shown

rapid degenerative

changes

in articular

cartilages, ligament

insertions,

and

joint

capsules

after immobilization of a

joint.

In

experiments

on rats

Ha1113

found

gradual changes

of the articular

cartilage

with

thickening

and

flattening

of

the

joint

line at those

points

where the articular surfaces touched each other. He also found a

degeneration

of the

cartilage

in those

parts

of the

joint

where the articular surfaces were not in contact and an

ingrowth

from the

periphery of synovial

membrane.

Noyes

et

a1.I5

found

that,

aside from

reducing strength

in the

ligament-bone

insertion,

immobilization in

monkeys

also resulted in

changes

in the

collagen

substance of the

ligament

with a reduction of the

ligament’s strength

and stiffness.

Training

in the form of

put-ting weight

on the immobilized

leg

and isometric muscle contractions did not prevent these

degenerative changes

in the

ligaments

and their insertions into bone. An

early postoperative

training

of movement seems to be the best way to counteract

these

disadvantages.

Normal function of the

quadriceps

and the

hamstring

mus-cles is

important

for the function of the knee

joint,

especially

after anteromedial

ligament injuries.

The anteromedial

rota-tory

instability

and the

straight

anterior

instability

can be

compensated

for somewhat

by good quadriceps

and

hamstring

muscles.18

After

repair

of the torn

ligaments,

restoration of normal motion and normal muscular function is therefore an

important

part

of the rehabilitation.
(2)

muscle after knee

joint

surgery and

postoperative

immobiliza-tion in a

cast.’9

Atrophy

affects

mostly

the

Type

I

fibers,

or the so-called &dquo;red fibers&dquo; in the

quadriceps

muscle. We also found a decrease in the

capacity

for aerobic metabolism in the form of a reduction in oxidative enzyme

activity,

which mirrors a reduced

capacity

in the muscle for endurance

work. 20,21

Im-mobilization of the knee

joint

in an almost

straight position

after knee

ligament

surgery resulted in a

pronounced

atrophy,

in

spite

of the fact that all of the

patients

were

given

isometric muscle

training by physical therapists.

A cast brace

permitting

limited motion of the knee

joint,

while

preventing varus-valgus

movements,

rotation,

and

ante-rior and

posterior

drawer,

has been

suggested by

Burri et

a1.22

Such a cast brace allows some

movability

of the knee with better

possibilities

to activate the

quadriceps

muscle.&dquo;

This

study

had two main

objectives.

The first was to compare

clinically

the cast brace with its limited range of motion with an

ordinary cylinder

cast in the

postoperative

treatment after intraarticular reconstruction of the anterior cruciate

ligament

of the knee. We were interested to know whether or not

partial

mobilization of the knee

joint permitted

earlier restoration of the range of

motion,

and whether this

early

mobilization affected the

stability

of the

knee

joint postoperatively.

The second main

objective

was to

study

the

morphologic

and

enzymatic changes

of the

quadriceps

muscle in these different situations

by

means of muscle

biopsies.

When an

ordinary

cylinder

cast is

used,

only

isometric contractions of the

quad-riceps

muscle are

possible.

In a mobile cast brace a more

dynamic training

can be

performed. By determining

the

degree

of

hypotrophy

of the different muscle fiber

types

and the

changes

in the metabolic

activity

of the

quadriceps

muscle under these

conditions,

we are

attempting

to

provide

a basis for

recommending

the most effective

type

of treatment to

prevent

muscle

atrophy.

Our evidence indicates that

patients

with standard casts had

significant atrophy

in

Type

I muscle fibers and reduction of SDH

activity

in the vastus

lateralis,

while the other group of

patients

treated with movable cast braces did not show

signifi-cant

changes

in cross-sectional areas of

Type

I or

Type

II muscle fibers or SDH

activity

in the vastus lateralis.

Therefore,

we recommend a cast brace with limited range of flexion as the standard

postoperative

treatment after knee

ligament

surgery

to obtain

optimal

rehabilitation.

MATERIALS AND METHODS

Sixteen

patients

referred to our

department

for treatment of chronic knee

ligament injuries

were studied. All

patients

had

ruptures

of the anterior cruciate

ligament

and/or

the medial collateral

ligament,

as well as the

posterior capsule

and the medial meniscus. All

patients

had considerable discomfort. Each had

injuries

more than 3 months old and two of the

patients

had had

arthrotomies,

at which time the medial me-niscus had been removed. Since

they

had not been cured

by

the

meniscectomy,

the

patients

had

subsequently

been referred for additional treatment of their

ligament

injuries. Age

and the

clinical data of the

patients

and the

type

of surgery that was

performed

are

provided

in Table 1. All

patients

were active in

some type of

sport

and had sustained their

injury

while

partic-TABLE 1

Descriptive

data for 16

patients operated

on for knee

injuries

&dquo;

ACL, rupture of anterior cruciate

ligament;

MCL, rupture of medial collateral

ligament;

MM, rupture of medial meniscus; PC,

rupture of

posterior

capsule.

ipating

in

sport.

All

patients

were studied before surgery and

9 to 12 months after surgery. A clinical assessment of the

degree

of

instability

of the knee

joint

was

performed.

The

instability

was

graded

on the basis of clinical examination

according

to

O’Donoghue:6

Grade 0: No increased draw-for-ward

sign.

No difference between the two

knees;

Grade 0.5:

minimal draw-forward

sign;

Grade 1: noticeable draw-forward

sign;

Grade 2: obvious draw-forward

sign.

Slight

instability,

lateral or

medial;

and Grade 3: the tibia could be almost

luxated forward and the medial or lateral

instability

was

marked.

We found this

5-grade

scale of the clinical

judgment

useful

and different examiners could

give

concordant

judgment.

At the same time clinical

judgment

of the

subjective

discomfort of the

patient

was made

according

to a scheme

published by

Liljedahl

and

Nordenstrand.24

The

grades

are as follows: Grade 0: no

complaints;

Grade 1:

complaints

of

slight instability

when

engaged

in

heavy physical

exercise;

Grade 2:

repeated

attacks of

instability.

Unable to engage in any form of

competitive

or leisure

sport;

and Grade 3:

repeated

attacks of severe

instability

preventing

them from

carrying

out

ordinary

work. These

pa-tients were on the sick list for

long periods.

This

judgement

was

entirely

based on information from the

patients.

Surgical

treatment

In order to reconstruct the anterior cruciate

ligament,

we have

used a modification of Jones’

patellar

tendon

transfer.’

The medial collateral

ligament

was also reefed and a

plasty

of the

posterior capsule

was

performed.

A detailed

description

of the

surgical technique

we used has been

given

by

Eriksson. 23

The

principle

of this

technique

is evident from

Figure

1.

Postoperative

treatment

The

patients

were

given

a dorsal

plaster splint

at the time of

operation

and were treated with the

leg

in an elevated

position

(3)

50

Fig.

1.

Principle of

the

operative

technique.

patients

were thereafter randomized into two groups. One

group of

eight patients

was fitted with a movable cast brace

(Fig.

2),

which is a modification of the cast brace

suggested by

Burri et

a1.22

The other group of

eight patients

was

given

ordinary cylinder

casts from the ankle up to the upper

part

of

the

thigh.

Both groups wore the casts for 4 weeks. Movable cast brace

The

type

of cast brace that has been used in this

study

consists of two

cylinder

casts connected

by

two

hinges

that allow a range of motion of 40

degrees.

The center of motion is

posi-tioned so that it

corresponds

to the center of motion of the knee

joint.

In order to

prevent

the cast brace from

sliding

up or

down and the center of motion from

changing,

the cast brace was

originally

fixed to the skin with an elastic adhesive

plaster.

Presently,

we are

using

a

simple

set of

plastic

ankle

hinges

and

a

plastic

heel which is included in the cast, so that a limited range of motion of the knee between 20 and 60° of flexion and full range of motion of the ankle are

permitted.

The

plastic

heel

prevents

the cast brace from

sliding

up or down. The cast

brace prevents any

valgus-varus

motion and it also prevents rotation in the knee

joint

(Fig.

3).

The cast is

applied

to the

thigh relatively loosely

to

prevent

the

incongruity

between the

center of motion in the cast

brace,

which is a

simple

hinge

joint,

and the knee

joint

with its more

complicated

flexion-rotation motion. Anatomical studies conducted

by

Burri et

a1.22

have shown that this limited range of motion does not affect the tension in either the two cruciates or the two collateral

ligaments.

This means that one could allow this range of

motion without

endangering

the result of the

ligament

repair.

Postoperative training

All

patients

were

supervised by

a

physical

therapist

in their

postoperative training.

The

physical therapist

instructed them three times a week

during

the 4 weeks that

they

wore casts.

The

patients

with an

ordinary cylinder

cast

performed

isometric contraction

training.

This

training

consisted of

repeated

maxi-mal contractions of the

quadriceps

muscle. The

patients

sat

with a

support

underneath the

leg

and contracted the muscle

maximally

for 6 sec followed

by

a rest of 3 to 5 sec. The number

of contractions was

gradually

increased. The other group of

patients

with movable cast braces

got

dynamic training

in

which the range of motion in the cast was used. The

patients

lay

on their backs with a firm

pillow

below the knee and stretched and bent the knee.

During

the 1 st

week,

no

weight

was

put

on the

leg

except

for the cast itself, but

during

the last weeks most of the

patients

in this group could train with an
(4)

groups were allowed to walk and to

put

full

weight

on the

leg

during

the time

they

wore the casts.

Determination of range of motion

When

recording

the range of motion of the knee

joint,

a

two-armed

goniometer

with arms 20 cm

long

was used. The axes of the

thigh

and the lower

leg

were marked, and the ranges of

motion of the

operated

and control

leg

were recorded first in extension and then in flexion.

During

flexion the

patient

was asked to bend his knee as much as

possible

in a

sitting position.

The

recording

of the range of motion was conducted

by

two

different examiners. In order to determine the

methodologic

error, these examiners

performed

12

paired recordings

in

dif-ferent

patients.

The error of the method in

paired

examinations

expressed

as coefficient of variation was 5.7%. Muscle studies

The muscle chosen for

study

was vastus lateralis of the

quad-riceps

muscle. Muscle

biopsies

were obtained with a

Bergstrom

needle.25

The

biopsies

were taken 15 cm above the upper

part

of

patella

and at a

depth

of about 5 cm. All

biopsies

were taken

in the same area of the muscle.

Biopsies

were obtained from both

thighs

on the

day

before

operation,

1 week after surgery,

Fig.

2.

Partially

movable cast brace used in this

study.

Fig.

3.

Modification of

cast brace.

and on removal of the cast after 5 weeks. The

biopsies

were divided into two

portions.

One

portion

was frozen in

liquid

nitrogen

within a

couple

of seconds for later biochemical

analyses

of oxidative and

glycolytic enzymatic

activities. The other

part

was mounted in an

embedding

medium frozen in

isopenthane

cooled with

liquid nitrogen

and stored at -80 C

before

analysis.

Serial transverse sections

(10

jut)

were cut with a microtome at -20 C and stained

histochemically

for

myofi-brillar adenosine

triphosphate

(ATPase)

after

preincubation

at

both

pH

10.3 and

4.3. 26

Stainings

were also

performed

for

DPNH-diaphorase

and

a-glycerophosphate

dehydrogenase

in

order to

study

the oxidative and

glycolytic

activity

histochem-ically.

Classification of fibers

The fibers were classified

according

to their

stainability

for ATPase at

pH

10.3. With this histochemical

technique,

two

main fiber

types

can be

separated.21, 27, 28

Fibers that stained dark for

myofibrillar

ATPase at

preincubation

at an alkaline

pH

are called

Type

II or fast twitch fibers. The other main

type

of

fibers,

Type

I

fibers,

show no stain at this

preincuba-tion .2’

At an acid

preincubation

reversed stain is obtained as a result of the

varying

sensitivity

for

pH

shown

by

the ATPase

enzymes of the muscle cells. At an acid

preincubation

a dark stain of

Type

I fibers is obtained while the

Type

II fibers

remain unstained and

light (Fig.

4).

NADH and

(5)

Fig.

4. Muscle section

stained for

myofibrillar

A TPase at an acid

preincubation.

Dark-stained

Type

I fibers

and

light-stained

Type

II fibers.

and

glycolytic

activities of the muscle fibers. Fibers with a

high

oxidative

activity

stain more

intensively

for

a-glycerophosphate

dehydrogenase.

Fiber area

The areas of the

transversely

cut fibers were measured

accord-ing

to the method described

by

Edstrom and

Torlegård.30

The

measurements were

performed

on the ATPase-stained sections. The area of

Types

I and II fibers was measured. The

quotient

of the area of

Type

II to

Type

I fibers was recorded for each section. The area of 30 to 40 fibers was determined on each section.

Biochemical

analysis

The

activity

of

SDH,

one of the oxidative enzymes in the citric

cycle,

was recorded with a fluorometric

technique

modified

according

to

Lowry

and

Passonneau .3’

A detailed

description

of this method is

presented by Haggmark

et

al. 19

The sE of the method was 6.5% in 12

paired

determinations. The

activity

of

phosphofructokinase

was also determined

fluorometrically

ac-cording

to

Lowry

and

Passonneau.3I

This enzyme is one of the

regulating

enzymes in

glycolysis.

The SE of this method in 14

paired

measurements was 7.0%.

Muscle

biopsies

All

patients

were

carefully

informed about the aim of the

study

and about the

biopsy technique

and its

possible complications.

An informed consent was obtained from all of them and

they

were told that

they

could leave the

study

at any time. Four

patients actually

left the

study

because the muscle

biopsies

were

slightly painful.

One of the

patients

originally

scheduled

for the

study

obtained a

superficial

wound infection with an

impaired

wound

healing

that

prevented

normal

training.

This

patient

was therefore excluded. The 16

patients reported

in this

study

showed no

postoperative complications.

RESULTS

Range

of motion

Patients with a movable cast brace

regained

full range of motion of the knee

joint

faster than did the group with a

cylinder

cast

(Fig.

5).

When the cast was

removed,

the group with a cast brace had an average range of motion of 74°

(range,

50 to

90°).

After 4

weeks,

six of these

eight patients

had a range of 0 to 110°.

Eight

weeks after removal of the cast, all of the

patients

in the movable cast brace group had extension and flexion that was the same as or not

greater

than 10° less than the control

leg.

The group with a

cylinder

cast

regained

full range of motion at a slower pace. On an average, it took 16 weeks for this group to achieve the same range of motion as the group with a cast brace had obtained within 8 weeks

(Fig.

5).

One of the

patients

(Case 2)

had an extension defect of 5 °

for 6 months

postoperatively.

Clinical assessment of

ligament repair

During

clinical determinations of the

stability

of the knee

joint

9 to 12 months after surgery, no difference between the two

groups was found

(Table 2).

Patients

preoperatively

classified

in

Group

3, i.e.,

very

unstable,

were somewhat less stable after surgery than those who had been classified as

Group

2 in the clinical examination. We found no

signs

of

rupture

of the reconstructed anterior cruciate

ligament

during

the first 9 to 12

months in any of the groups. The

patients’ subjective

com-plaints

were recorded after 12 months.

(Table 3).

All

patients

were

improved.

Four of the

patients

had not been able to

return to the

sports

activity

they

had been

engaged

in before
(6)

Fig.

5.

Graph illustrating

the range

of motion

of

the knees

for

those

patients

treated with the cast brace and those treated with the

standard cast.

TABLE 2

Clinical

judgment

of

stability&dquo;

(O’Donoghue~)

&dquo;

Grades 0,

0.5,

1, 2, 3 = a

range from no increased drawer

sign

to

marked

instability

where the tibia could be (almost) luxated forward. TABLE 3

Patient’s

judgment

of symptoms before and 9 to 12 months after

surgery

(according

to

Liljedahl

and

Nordenstrandz4)

Fiber area

The

patients

who had a

cylinder

cast for 5 weeks showed a

marked reduction in the size of

Type

I fibers

compared

with

their

Type

II fibers. The

quotient

Type

II fiber

area-Type

I

fiber area, thus increased

significantly during

the 5 weeks. The

mean area

quotient

at surgery was 1.04 and after 5 weeks in a

cylinder

cast was 1.43

(Table 4).

The muscle fibers of the

control

leg

in our series showed no

significant changes.

The

patients

with a movable cast brace showed a less marked

atrophy

in the

operated leg

than the

patients

with a

cylinder

cast. Both muscle fiber

types

showed some reduction of area but these differences were not

significant,

nor were any

differ-ences seen in the cross-sectional area between

Types

I and II

fibers. The

quotient Type II-Type

I was

unchanged

( 1.12

vs.

0.99) (Table 5).

Enzyme activity

The SDH

activity

in both

legs

of each

patient

decreased

during

the 1st

postoperative

week when the

patients

were

recumbent;

in the

operated leg

from 7.34 to 6.0 J-LM X

g-’

x

min-1

and in the control

leg

from 7.3 to 6.2 ftm X

g-’

x

min-1

(Table 6).

When the casts were removed after 5

weeks,

the group that had

cylinder

casts showed a

significantly

lower

activity

in the

operated leg

than in the control

leg

(5.9

vs. 7.1 ttm X

g-’

X

min-’, respectively).

The group of

patients

that had movable

cast braces had no difference in

activity

between

operated

and control

legs

(5.52

and 5.14 ftm X

g-’

X

min’B respectively)

upon removal of the casts. The

phosphofructokinase activity

was

unchanged

in the

operated

and in the control

legs

of both

groups

during

this time

(Table

7).

DISCUSSION

Injuries

to the anterior cruciate

ligament

and/or

the medial

collateral

ligament

and the medial meniscus often

give

rise to

a chronic

instability

of the knee

joint.

This

instability

leads to

early

arthritic

changes

of the

joint.&dquo;,’

These

patients

also

rap-idly develop atrophy

of the

thigh

muscles

A number of intra- and extra-articular

procedures

have been

suggested

to overcome the

sagittal

and rotational

instability

secondary

to these

injuries.

We have used a modification of Jones’

procedure’

in

order to reconstruct the anterior cruciate
(7)

TABLE 4

Fiber area in the vastus lateralis muscle before and after 5 weeks in

cylinder

cast

&dquo;

Mean + SD.

TABLE 5

Fiber area in the vastus lateralis muscle before and after 5 weeks in a movable cast&dquo;

&dquo;

Values are means of 20 to 50 measured fibers.

b Mean :t SD.

NS, not

significant.

al.s

and

Eriksson.2.3

Alm and

Gillquist’3~

have followed up a series of 164 cases in which this method was used.

They

showed that 66% of their

patients

could return to athletic activities.

They

also stressed the benefits of muscle

training

and

training

of the

movability

of the knee

joint

in the

postoperative period.

Liljedahl

and

Nordenstrand24

also

emphasized

the

importance

of not

immobilizing

the knee

joint

for

long periods

postopera-tively,

and showed that

elderly patients receiving operations

for

knee

joint injuries

had

great

difficulties in

regaining

mo-bility

and muscle

strength.

Our

patients

also

developed

a considerable muscle

atrophy

after knee

ligament

surgery and restoration of muscle function is affected

considerably

after

operation

and immobilization in a standard

cast.’9

The purpose of

postoperative

immobilization in a cast, after the

ligament

reconstruction of the knee

joint,

is to

protect

the sutured

ligaments

and

prevent

them from

being pulled

apart

during

the

healing period.

A cast brace which allows limited

movement of the knee

joint

in flexion and extension, but

prevents

valgus-varus

movement and rotation in addition to

any

sagittal

movement between femur and tibia, would there-fore fill the same function as a standard cast in

preventing

the

sutured or reconstructed

ligaments

from

being pulled

apart.

However, this type of cast brace would also allow

early

training

of movements. It

might

of course be

argued

that one should

refrain from

using

any cast

during

the

postoperative

period

after

ligament

reconstruction in the

knee

joint.

Alm and

Gillquist32

and Alm and

Stromberg33

studied this in

reconstruc-tion of the anterior cruciate

ligament

in

dogs, using

a similar

technique

to the one used in this

study. They

found an

unac-ceptably high frequency

of failures related to

ruptures

of the

reconstructed

ligaments

in the group in which the knee

joint

was not immobilized.

The cast brace

originally suggested

for knee

joint

surgery

by

Burri et

al. 22

provided

a limited range of movement in the knee

joint

but had the

disadvantage

of

immobilizing

the

ankle joint.

We have modified that cast brace so as to allow full movement

of the ankle

joint. Initially,

we fixed the cast brace to the ankle

just

above the malleoli with the

help

of elastic

tape.

In a later

modification,

we used a soft

plastic

heel with soft

plastic hinges

that allows full movement of the ankle

joint

but

prevents

the

cast brace from

slipping

downward. This cast brace functioned

extremely

well in our

daily

work. As a matter of

fact,

several athletes have even taken up some active

training

before re-moval of the cast brace.

In this

prospective

randomized

study,

one of our main

objectives

was to determine whether

early movability

of the

knee

joint

would interfere with the end result of our

ligament

reconstructions. At

follow-up

examinations 1 year later, we

could not notice any difference in the end results between those

(8)

our results are well in

agreement

with those

presented by

Alm and

Gillquist.,)2

However, when we

compared

the range of motion of the knee

joints

a considerable difference was noted between those

patients

who had been treated with a cast brace

and those who had a standard cast. All

patients

treated with a

cast brace

regained

a full range of motion 8 weeks after removal of the cast. The group treated with a standard

cylinder

cast did

not

regain

full range of motion until 16 weeks after removal of the cast. Aside from its

practical

value,

this

finding

has

great

psychologic importance

for our

patients,

the

majority

of whom were active athletes.

The

morphological

studies of the

biopsies

from the vastus

lateralis muscles of the two groups of

patients

showed

varying

degrees

of muscle

atrophy.

In

spite

of their

postoperative

training,

the

patients

that had been immobilized in a closed

cast showed an

atrophy

of the

Type

I

(slow twitch)

fibers,

which are the ones used

primarily

in activities of

daily living.

The cross-sectional area of the

Type

II

(fast twitch)

fibers did

not

change appreciably

and thus the

quotient Type II-Type

I

area increased.

The

postoperative training

which could be

given

in the closed cast,

i.e.,

isometric

contractions,

probably

activated the

Type

II fibers. In the group of

patients

who used a movable

TABLE 6

Succinate

dehydrogenase

(SDH)

activity

&dquo;

Enzyme

activity,

ttm X

g-’

X min -’.

b

Number of

patients.

TABLE 7

Phosphofructokinase activity

in the vastus lateralis muscle before and after surgery and immobilization in a different cast

cast brace and was therefore able to receive a more

dynamic

training,

the cross-sectional areas of the

Types

I and II fibers did not show any

significant changes.

The

quotient

Type

II-Type

I area was

unchanged.

The difference between the closed

cast and the cast brace group

suggests

a difference in

recruit-ment

pattern

of muscle fibers. The

patients

that wore a cast

brace

evidently

could also activate their

Type

I fibers

during

the

period

in the cast.

Goldberg

et

al..34

have studied different stimuli which cause

atrophy

and

hypertrophy

of different muscle fibers.

They

found that a most

important

factor was the tension

development

in the

fibers;

i.e., muscle fibers with

regular

tension

development

showed

hypertrophy

while a lack

of tension

development

lead to

atrophy

of the muscle fibers.

Changes

in the metabolic

capacity

of the muscles can be reflected

by changes

in the

enzymatic activity

of the

muscles.&dquo;’

The oxidative

enzymatic activity

showed different

patterns

of

change

in the two groups of

patients

in our

study.

In all

patients

there was a decrease in the oxidative enzyme

activity

(SDH)

in

vastus lateralis

during

the 1 st

postoperative

week when the

patients

were bedridden

(Table 3).

When their casts were

removed,

those

patients

who had used a cast brace showed no

significant change

in SDH

activity

between the two

legs.

The

patient~

that used a standard cast showed a

significantly

lower SDH

activity

in the immobilized

leg.

This means that their muscles had a reduced

capacity

for oxidative metabolism and therefore endurance work. The isometric muscle contractions

evidently

could not

prevent

the reduction in SDH

activity.

Grimby

et

al..36

studied isometric

training

in

healthy

volunteers

for a

period

of 6 weeks.

During

this

period

the

subjects

per-formed 30 maximal isometric contractions

daily,

5

days

a week. These authors were able to demonstrate in these volunteers a

significant

increase in SDH

activity

as well as an increased force of contraction in the trained skeletal muscle.

During

the

postoperative period

after

major

knee

ligament

surgery,

pain

and

swelling

reduce the effectiveness of isometric

training.

The

glycolytic

metabolic

activity

as

expressed by

phospho-fructokinase

activity

did not

change during

the

postoperative

period

in either of these two

patients

groups.

This

study

has demonstrated a number of differences

be-tween the

patient

group with a standard cast and that with a

cast brace after reconstruction of the anterior cruciate

ligament

of the knee

joint.

The

advantages

of the cast brace can be summarized:

(1)

the

early

mobilization of the

knee

joint

re-sulted in a

rapid

restoration of full range of

motion;

and

(2)

the

early

mobility

gave no selective

atrophy

of the

Type

I fibers and facilitated an

early

return to

sports

training

and

sports

activities.

Although

there appears to be no difference in the end result of the

surgical

procedure,

we are

using

the cast brace

routinely

for all

types

of knee

ligament

surgery in our

depart-ment because of the

advantages

it offers the

patient

as

com-pared

with the standard

cylinder

cast.

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1.

O’Donoghue

DH: Treatment

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to Athletes. Second edition.

Philadelphia,

WB Saunders Co, 1970, pp 517-519

2.

Hey-Groves

EW:

Operation

for the

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7: 505-515,
(9)

56

3. Palmer I: On the

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Acta Chir Scand Vol 1 53: 665-667, 1938

4. Helfet AJ: Function of the cruciate

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Lancet 1: 665, 1948

5. Smillie IS: Injuries to the Knee Joint. Second edition.

Edinburgh,

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O’Donoghue

DH: A method for

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8. Brostrom L,

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Liljedahl

S-O, et al:

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transplantation.

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J Bone Joint

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11.

Hughston

JC, Eilers AF: The role of the

posterior oblique ligament

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55A: 923-940, 1973

12. Watson-Jones R: Fracture and Joint

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18. White AA,

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19.

Haggmark

T, Eriksson E, Jansson E: Fiber type and metabolic

potential

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thigh

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press)

20.

Holloszy

JO:

Adaptation

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21. Saltin B, Henriksson J,

Nygaard

E, et al: Fiber types and metabolic

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22. Burri C,

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H, Passler HH: Funktionelle

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23. Eriksson E:

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24.

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Padykula

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28. Gollnick PD,

Armstrong

RB, Saubert CW, et al:

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activity

and fiber

composition

in skeletal muscle of untrained and trained

men.

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312-319, 1972

29.

Engel

WK:

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Neurology

24: 344-348, 1974

30. Edstrom L,

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31.

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32. Alm A,

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J: Reconstruction of the anterior cruciate

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patellar ligament.

Acta Chir Scand

140: 289-296, 1974

33. Alm A,

Strömberg

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Acta Chir Scand

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34.

Goldberg

AL,

Etlinger

JD,

Goldspink

DF, et al: Mechanism of work-induced

hypertrophy

of skeletal muscle. Med Sci

Sports

7:

185-198, 1975

35. Henriksson J, Reitman JS: Time course of

changes

in human

skeletal muscle succinate

dehydrogenase

and

cytochrome

oxidase activities and maximal oxygen

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P, Fahlén M, et al: Metabolic effects of isometric

training.

Scand J Clin Lab Invest 31: 301-305, 1973

Figure

Fig.  1.  Principle of  the  operative  technique.
Fig.  2.  Partially  movable  cast  brace used  in  this  study.
Fig.  4.  Muscle  section  stained for  myofibrillar  A  TPase  at  an  acid  preincubation
Fig.  5.  Graph illustrating  the  range  of motion  of  the knees  for  those  patients  treated with the  cast  brace and  those treated  with the standard  cast.

References

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