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 aprospective
randomized trialin which a standard
cylinder
cast wascompared
with a mobilecast brace. Both were worn for 4
weeks,
beginning
at 1 weekafter reconstruction of the anterior cruciate
ligament.
Theathletes 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 asignificant atrophy
ofType
I(slow twitch)
muscle fibers in thevastus lateralis. The cast brace
patients
did not show anysignificant changes
in cross-sectional areas ofType
I orType
II(fast twitch)
muscle fibers.The standard cast
patients
had asignificant
reduction ofsuccinate
dehydrogenase (SDH) activity
in the vastus lateraliswhereas the
patients
with the cast brace did not show anysignificant changes.
No difference insurgical
end result was found. A cast brace with a limited range of motion between 20 and 60° of flexion is recommended as the standardpostopera-tive treatment after knee
ligament
surgery.Treatment
of an athlete with a chronic combinedinjury
tohis knee
ligament
involves a number ofproblems
from selection of method ofsurgical repair
to choice ofpostoperative
treat-ment. The final outcomevaries’
and an attainment of agood
functional end result oftenrequires long
and intensivepost-operative
training.
Agreat
number of differentsurgical
tech-niques
to reconstruct the anterior cruciateligament
and restorethe anterior and anteromedial
rotatory
instability
in the kneejoint
have beendescribed.2-11
The widevariety
ofsurgical
techniques points
to thedifficulty
intreating patients
with thistype
ofinjury.
Whatever
surgical
method is used,postoperative
rehabilita-tion is of
great
importance.’)
Numerousexperimental
studiesin animals have shown that immobilization lead to
degenera-tive
changes
in the muscle andcollagen
structures. 13-15
Immo-bilization of theknee
joint
reduces the mechanical stimuli tothe
collagen
structures.&dquo;
Tendons,
ligaments,
andligament
insertionsundergo changes
that reduce theirstrength
andrestrict normal motion. At the same
time,
atrophy
of the muscles involved injoint
function takesplace.
These differentchanges affect joint
function and recoverytime.1’
Several
investigators&dquo;, &dquo;
have shownrapid degenerative
changes
in articularcartilages, ligament
insertions,
andjoint
capsules
after immobilization of ajoint.
Inexperiments
on ratsHa1113
foundgradual changes
of the articularcartilage
withthickening
andflattening
ofthe
joint
line at thosepoints
where the articular surfaces touched each other. He also found adegeneration
of thecartilage
in thoseparts
of thejoint
where the articular surfaces were not in contact and aningrowth
from theperiphery of synovial
membrane.Noyes
eta1.I5
foundthat,
aside from
reducing strength
in theligament-bone
insertion,
immobilization in
monkeys
also resulted inchanges
in thecollagen
substance of theligament
with a reduction of theligament’s strength
and stiffness.Training
in the form ofput-ting weight
on the immobilizedleg
and isometric muscle contractions did not prevent thesedegenerative changes
in theligaments
and their insertions into bone. Anearly postoperative
training
of movement seems to be the best way to counteractthese
disadvantages.
Normal function of the
quadriceps
and thehamstring
mus-cles isimportant
for the function of the kneejoint,
especially
after anteromedial
ligament injuries.
The anteromedialrota-tory
instability
and thestraight
anteriorinstability
can becompensated
for somewhatby good quadriceps
andhamstring
muscles.18
Afterrepair
of the tornligaments,
restoration of normal motion and normal muscular function is therefore animportant
part
of the rehabilitation.muscle after knee
joint
surgery andpostoperative
immobiliza-tion in acast.’9
Atrophy
affectsmostly
theType
Ifibers,
or the so-called &dquo;red fibers&dquo; in thequadriceps
muscle. We also found a decrease in thecapacity
for aerobic metabolism in the form of a reduction in oxidative enzymeactivity,
which mirrors a reducedcapacity
in the muscle for endurancework. 20,21
Im-mobilization of the knee
joint
in an almoststraight position
after knee
ligament
surgery resulted in apronounced
atrophy,
inspite
of the fact that all of thepatients
weregiven
isometric muscletraining by physical therapists.
A cast brace
permitting
limited motion of the kneejoint,
whilepreventing varus-valgus
movements,rotation,
andante-rior and
posterior
drawer,
has beensuggested by
Burri eta1.22
Such a cast brace allows some
movability
of the knee with betterpossibilities
to activate thequadriceps
muscle.&dquo;
This
study
had two mainobjectives.
The first was to compareclinically
the cast brace with its limited range of motion with anordinary cylinder
cast in thepostoperative
treatment after intraarticular reconstruction of the anterior cruciateligament
of the knee. We were interested to know whether or not
partial
mobilization of the knee
joint permitted
earlier restoration of the range ofmotion,
and whether thisearly
mobilization affected thestability
of theknee
joint postoperatively.
The second mainobjective
was tostudy
themorphologic
andenzymatic changes
of thequadriceps
muscle in these different situationsby
means of musclebiopsies.
When anordinary
cylinder
cast isused,
only
isometric contractions of thequad-riceps
muscle arepossible.
In a mobile cast brace a moredynamic training
can beperformed. By determining
thedegree
ofhypotrophy
of the different muscle fibertypes
and thechanges
in the metabolicactivity
of thequadriceps
muscle under theseconditions,
we areattempting
toprovide
a basis forrecommending
the most effectivetype
of treatment toprevent
muscleatrophy.
Our evidence indicates that
patients
with standard casts hadsignificant atrophy
inType
I muscle fibers and reduction of SDHactivity
in the vastuslateralis,
while the other group ofpatients
treated with movable cast braces did not showsignifi-cant
changes
in cross-sectional areas ofType
I orType
II muscle fibers or SDHactivity
in the vastus lateralis.Therefore,
we recommend a cast brace with limited range of flexion as the standard
postoperative
treatment after kneeligament
surgeryto obtain
optimal
rehabilitation.MATERIALS AND METHODS
Sixteen
patients
referred to ourdepartment
for treatment of chronic kneeligament injuries
were studied. Allpatients
hadruptures
of the anterior cruciateligament
and/or
the medial collateralligament,
as well as theposterior capsule
and the medial meniscus. Allpatients
had considerable discomfort. Each hadinjuries
more than 3 months old and two of thepatients
had hadarthrotomies,
at which time the medial me-niscus had been removed. Sincethey
had not been curedby
themeniscectomy,
thepatients
hadsubsequently
been referred for additional treatment of theirligament
injuries. Age
and theclinical data of the
patients
and thetype
of surgery that wasperformed
areprovided
in Table 1. Allpatients
were active insome type of
sport
and had sustained theirinjury
whilepartic-TABLE 1
Descriptive
data for 16patients operated
on for kneeinjuries
&dquo;
ACL, rupture of anterior cruciate
ligament;
MCL, rupture of medial collateralligament;
MM, rupture of medial meniscus; PC,rupture of
posterior
capsule.
ipating
insport.
Allpatients
were studied before surgery and9 to 12 months after surgery. A clinical assessment of the
degree
ofinstability
of the kneejoint
wasperformed.
Theinstability
wasgraded
on the basis of clinical examinationaccording
toO’Donoghue:6
Grade 0: No increased draw-for-wardsign.
No difference between the twoknees;
Grade 0.5:minimal draw-forward
sign;
Grade 1: noticeable draw-forwardsign;
Grade 2: obvious draw-forwardsign.
Slight
instability,
lateral ormedial;
and Grade 3: the tibia could be almostluxated forward and the medial or lateral
instability
wasmarked.
We found this
5-grade
scale of the clinicaljudgment
usefuland different examiners could
give
concordantjudgment.
At the same time clinicaljudgment
of thesubjective
discomfort of thepatient
was madeaccording
to a schemepublished by
Liljedahl
andNordenstrand.24
Thegrades
are as follows: Grade 0: nocomplaints;
Grade 1:complaints
ofslight instability
whenengaged
inheavy physical
exercise;
Grade 2:repeated
attacks ofinstability.
Unable to engage in any form ofcompetitive
or leisuresport;
and Grade 3:repeated
attacks of severeinstability
preventing
them fromcarrying
outordinary
work. Thesepa-tients were on the sick list for
long periods.
Thisjudgement
wasentirely
based on information from thepatients.
Surgical
treatmentIn order to reconstruct the anterior cruciate
ligament,
we haveused a modification of Jones’
patellar
tendontransfer.’
The medial collateralligament
was also reefed and aplasty
of theposterior capsule
wasperformed.
A detaileddescription
of thesurgical technique
we used has beengiven
by
Eriksson. 23
Theprinciple
of thistechnique
is evident fromFigure
1.Postoperative
treatmentThe
patients
weregiven
a dorsalplaster splint
at the time ofoperation
and were treated with theleg
in an elevatedposition
50
Fig.
1.Principle of
theoperative
technique.
patients
were thereafter randomized into two groups. Onegroup of
eight patients
was fitted with a movable cast brace(Fig.
2),
which is a modification of the cast bracesuggested by
Burri eta1.22
The other group ofeight patients
wasgiven
ordinary cylinder
casts from the ankle up to the upperpart
ofthe
thigh.
Both groups wore the casts for 4 weeks. Movable cast braceThe
type
of cast brace that has been used in thisstudy
consists of twocylinder
casts connectedby
twohinges
that allow a range of motion of 40degrees.
The center of motion isposi-tioned so that it
corresponds
to the center of motion of the kneejoint.
In order toprevent
the cast brace fromsliding
up ordown and the center of motion from
changing,
the cast brace wasoriginally
fixed to the skin with an elastic adhesiveplaster.
Presently,
we areusing
asimple
set ofplastic
anklehinges
anda
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 arepermitted.
Theplastic
heel
prevents
the cast brace fromsliding
up or down. The castbrace prevents any
valgus-varus
motion and it also prevents rotation in the kneejoint
(Fig.
3).
The cast isapplied
to thethigh relatively loosely
toprevent
theincongruity
between thecenter of motion in the cast
brace,
which is asimple
hinge
joint,
and the kneejoint
with its morecomplicated
flexion-rotation motion. Anatomical studies conductedby
Burri eta1.22
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 ofmotion without
endangering
the result of theligament
repair.
Postoperative training
All
patients
weresupervised by
aphysical
therapist
in theirpostoperative training.
Thephysical therapist
instructed them three times a weekduring
the 4 weeks thatthey
wore casts.The
patients
with anordinary cylinder
castperformed
isometric contractiontraining.
Thistraining
consisted ofrepeated
maxi-mal contractions of thequadriceps
muscle. Thepatients
satwith a
support
underneath theleg
and contracted the musclemaximally
for 6 sec followedby
a rest of 3 to 5 sec. The numberof contractions was
gradually
increased. The other group ofpatients
with movable cast bracesgot
dynamic training
inwhich the range of motion in the cast was used. The
patients
lay
on their backs with a firmpillow
below the knee and stretched and bent the knee.During
the 1 stweek,
noweight
was
put
on theleg
except
for the cast itself, butduring
the last weeks most of thepatients
in this group could train with angroups were allowed to walk and to
put
fullweight
on theleg
during
the timethey
wore the casts.Determination of range of motion
When
recording
the range of motion of the kneejoint,
atwo-armed
goniometer
with arms 20 cmlong
was used. The axes of thethigh
and the lowerleg
were marked, and the ranges ofmotion of the
operated
and controlleg
were recorded first in extension and then in flexion.During
flexion thepatient
was asked to bend his knee as much aspossible
in asitting position.
Therecording
of the range of motion was conductedby
twodifferent examiners. In order to determine the
methodologic
error, these examiners
performed
12paired recordings
indif-ferent
patients.
The error of the method inpaired
examinationsexpressed
as coefficient of variation was 5.7%. Muscle studiesThe muscle chosen for
study
was vastus lateralis of thequad-riceps
muscle. Musclebiopsies
were obtained with aBergstrom
needle.25
Thebiopsies
were taken 15 cm above the upperpart
ofpatella
and at adepth
of about 5 cm. Allbiopsies
were takenin the same area of the muscle.
Biopsies
were obtained from boththighs
on theday
beforeoperation,
1 week after surgery,Fig.
2.Partially
movable cast brace used in thisstudy.
Fig.
3.Modification of
cast brace.and on removal of the cast after 5 weeks. The
biopsies
were divided into twoportions.
Oneportion
was frozen inliquid
nitrogen
within acouple
of seconds for later biochemicalanalyses
of oxidative andglycolytic enzymatic
activities. The otherpart
was mounted in anembedding
medium frozen inisopenthane
cooled withliquid nitrogen
and stored at -80 Cbefore
analysis.
Serial transverse sections(10
jut)
were cut with a microtome at -20 C and stainedhistochemically
formyofi-brillar adenosine
triphosphate
(ATPase)
afterpreincubation
atboth
pH
10.3 and4.3. 26
Stainings
were alsoperformed
forDPNH-diaphorase
anda-glycerophosphate
dehydrogenase
inorder to
study
the oxidative andglycolytic
activity
histochem-ically.
Classification of fibers
The fibers were classified
according
to theirstainability
for ATPase atpH
10.3. With this histochemicaltechnique,
twomain fiber
types
can beseparated.21, 27, 28
Fibers that stained dark formyofibrillar
ATPase atpreincubation
at an alkalinepH
are calledType
II or fast twitch fibers. The other maintype
offibers,
Type
Ifibers,
show no stain at thispreincuba-tion .2’
At an acidpreincubation
reversed stain is obtained as a result of thevarying
sensitivity
forpH
shownby
the ATPaseenzymes of the muscle cells. At an acid
preincubation
a dark stain ofType
I fibers is obtained while theType
II fibersremain unstained and
light (Fig.
4).
NADH andFig.
4. Muscle sectionstained for
myofibrillar
A TPase at an acidpreincubation.
Dark-stainedType
I fibers
andlight-stained
Type
II fibers.
and
glycolytic
activities of the muscle fibers. Fibers with ahigh
oxidativeactivity
stain moreintensively
fora-glycerophosphate
dehydrogenase.
Fiber area
The areas of the
transversely
cut fibers were measuredaccord-ing
to the method describedby
Edstrom andTorlegård.30
Themeasurements were
performed
on the ATPase-stained sections. The area ofTypes
I and II fibers was measured. Thequotient
of the area of
Type
II toType
I fibers was recorded for each section. The area of 30 to 40 fibers was determined on each section.Biochemical
analysis
The
activity
ofSDH,
one of the oxidative enzymes in the citriccycle,
was recorded with a fluorometrictechnique
modifiedaccording
toLowry
andPassonneau .3’
A detaileddescription
of this method is
presented by Haggmark
etal. 19
The sE of the method was 6.5% in 12paired
determinations. Theactivity
ofphosphofructokinase
was also determinedfluorometrically
ac-cording
toLowry
andPassonneau.3I
This enzyme is one of theregulating
enzymes inglycolysis.
The SE of this method in 14paired
measurements was 7.0%.Muscle
biopsies
All
patients
werecarefully
informed about the aim of thestudy
and about thebiopsy technique
and itspossible complications.
An informed consent was obtained from all of them and
they
were told that
they
could leave thestudy
at any time. Fourpatients actually
left thestudy
because the musclebiopsies
wereslightly painful.
One of thepatients
originally
scheduledfor the
study
obtained asuperficial
wound infection with animpaired
woundhealing
thatprevented
normaltraining.
Thispatient
was therefore excluded. The 16patients reported
in thisstudy
showed nopostoperative complications.
RESULTS
Range
of motionPatients with a movable cast brace
regained
full range of motion of the kneejoint
faster than did the group with acylinder
cast(Fig.
5).
When the cast wasremoved,
the group with a cast brace had an average range of motion of 74°(range,
50 to
90°).
After 4weeks,
six of theseeight patients
had a range of 0 to 110°.Eight
weeks after removal of the cast, all of thepatients
in the movable cast brace group had extension and flexion that was the same as or notgreater
than 10° less than the controlleg.
The group with acylinder
castregained
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 thepatients
(Case 2)
had an extension defect of 5 °for 6 months
postoperatively.
Clinical assessment of
ligament repair
During
clinical determinations of thestability
of the kneejoint
9 to 12 months after surgery, no difference between the two
groups was found
(Table 2).
Patientspreoperatively
classifiedin
Group
3, i.e.,
veryunstable,
were somewhat less stable after surgery than those who had been classified asGroup
2 in the clinical examination. We found nosigns
ofrupture
of the reconstructed anterior cruciateligament
during
the first 9 to 12months in any of the groups. The
patients’ subjective
com-plaints
were recorded after 12 months.(Table 3).
Allpatients
were
improved.
Four of thepatients
had not been able toreturn to the
sports
activity
they
had beenengaged
in beforeFig.
5.Graph illustrating
the rangeof motion
of
the kneesfor
thosepatients
treated with the cast brace and those treated with thestandard cast.
TABLE 2
Clinical
judgment
ofstability&dquo;
(O’Donoghue~)
&dquo;
Grades 0,
0.5,
1, 2, 3 = arange from no increased drawer
sign
tomarked
instability
where the tibia could be (almost) luxated forward. TABLE 3Patient’s
judgment
of symptoms before and 9 to 12 months aftersurgery
(according
toLiljedahl
andNordenstrandz4)
Fiber area
The
patients
who had acylinder
cast for 5 weeks showed amarked reduction in the size of
Type
I fiberscompared
withtheir
Type
II fibers. Thequotient
Type
II fiberarea-Type
Ifiber area, thus increased
significantly during
the 5 weeks. Themean area
quotient
at surgery was 1.04 and after 5 weeks in acylinder
cast was 1.43(Table 4).
The muscle fibers of thecontrol
leg
in our series showed nosignificant changes.
Thepatients
with a movable cast brace showed a less markedatrophy
in theoperated leg
than thepatients
with acylinder
cast. Both muscle fiber
types
showed some reduction of area but these differences were notsignificant,
nor were anydiffer-ences seen in the cross-sectional area between
Types
I and IIfibers. The
quotient Type II-Type
I wasunchanged
( 1.12
vs.0.99) (Table 5).
Enzyme activity
The SDH
activity
in bothlegs
of eachpatient
decreasedduring
the 1stpostoperative
week when thepatients
wererecumbent;
in the
operated leg
from 7.34 to 6.0 J-LM Xg-’
xmin-1
and in the controlleg
from 7.3 to 6.2 ftm Xg-’
xmin-1
(Table 6).
When the casts were removed after 5
weeks,
the group that hadcylinder
casts showed asignificantly
loweractivity
in theoperated leg
than in the controlleg
(5.9
vs. 7.1 ttm Xg-’
Xmin-’, respectively).
The group ofpatients
that had movablecast braces had no difference in
activity
betweenoperated
and controllegs
(5.52
and 5.14 ftm Xg-’
Xmin’B respectively)
upon removal of the casts. The
phosphofructokinase activity
wasunchanged
in theoperated
and in the controllegs
of bothgroups
during
this time(Table
7).
DISCUSSION
Injuries
to the anterior cruciateligament
and/or
the medialcollateral
ligament
and the medial meniscus oftengive
rise toa chronic
instability
of the kneejoint.
Thisinstability
leads toearly
arthriticchanges
of thejoint.&dquo;,’
These
patients
alsorap-idly develop atrophy
of thethigh
muscles
A number of intra- and extra-articular
procedures
have beensuggested
to overcome thesagittal
and rotationalinstability
secondary
to theseinjuries.
We have used a modification of Jones’procedure’
in
order to reconstruct the anterior cruciateTABLE 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
andEriksson.2.3
Alm andGillquist’3~
have followed up a series of 164 cases in which this method was used.They
showed that 66% of theirpatients
could return to athletic activities.They
also stressed the benefits of muscletraining
andtraining
of themovability
of the kneejoint
in thepostoperative period.
Liljedahl
andNordenstrand24
alsoemphasized
theimportance
of not
immobilizing
the kneejoint
forlong periods
postopera-tively,
and showed thatelderly patients receiving operations
forknee
joint injuries
hadgreat
difficulties inregaining
mo-bility
and musclestrength.
Ourpatients
alsodeveloped
a considerable muscleatrophy
after kneeligament
surgery and restoration of muscle function is affectedconsiderably
afteroperation
and immobilization in a standardcast.’9
The purpose of
postoperative
immobilization in a cast, after theligament
reconstruction of the kneejoint,
is toprotect
the suturedligaments
andprevent
them frombeing pulled
apart
during
thehealing period.
A cast brace which allows limitedmovement of the knee
joint
in flexion and extension, butprevents
valgus-varus
movement and rotation in addition toany
sagittal
movement between femur and tibia, would there-fore fill the same function as a standard cast inpreventing
thesutured or reconstructed
ligaments
frombeing pulled
apart.
However, this type of cast brace would also allow
early
training
of movements. It
might
of course beargued
that one shouldrefrain from
using
any castduring
thepostoperative
period
after
ligament
reconstruction in theknee
joint.
Alm andGillquist32
and Alm andStromberg33
studied this inreconstruc-tion of the anterior cruciate
ligament
indogs, using
a similartechnique
to the one used in thisstudy. They
found anunac-ceptably high frequency
of failures related toruptures
of thereconstructed
ligaments
in the group in which the kneejoint
was not immobilized.
The cast brace
originally suggested
for kneejoint
surgeryby
Burri et
al. 22
provided
a limited range of movement in the kneejoint
but had thedisadvantage
ofimmobilizing
theankle 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 anklejust
above the malleoli with thehelp
of elastictape.
In a latermodification,
we used a softplastic
heel with softplastic hinges
that allows full movement of the anklejoint
butprevents
thecast brace from
slipping
downward. This cast brace functionedextremely
well in ourdaily
work. As a matter offact,
several athletes have even taken up some activetraining
before re-moval of the cast brace.In this
prospective
randomizedstudy,
one of our mainobjectives
was to determine whetherearly movability
of theknee
joint
would interfere with the end result of ourligament
reconstructions. At
follow-up
examinations 1 year later, wecould not notice any difference in the end results between those
our results are well in
agreement
with thosepresented by
Alm andGillquist.,)2
However, when wecompared
the range of motion of the kneejoints
a considerable difference was noted between thosepatients
who had been treated with a cast braceand those who had a standard cast. All
patients
treated with acast brace
regained
a full range of motion 8 weeks after removal of the cast. The group treated with a standardcylinder
cast didnot
regain
full range of motion until 16 weeks after removal of the cast. Aside from itspractical
value,
thisfinding
hasgreat
psychologic importance
for ourpatients,
themajority
of whom were active athletes.The
morphological
studies of thebiopsies
from the vastuslateralis muscles of the two groups of
patients
showedvarying
degrees
of muscleatrophy.
Inspite
of theirpostoperative
training,
thepatients
that had been immobilized in a closedcast showed an
atrophy
of theType
I(slow twitch)
fibers,
which are the ones used
primarily
in activities ofdaily living.
The cross-sectional area of theType
II(fast twitch)
fibers didnot
change appreciably
and thus thequotient Type II-Type
Iarea increased.
The
postoperative training
which could begiven
in the closed cast,i.e.,
isometriccontractions,
probably
activated theType
II fibers. In the group ofpatients
who used a movableTABLE 6
Succinate
dehydrogenase
(SDH)activity
&dquo;
Enzyme
activity,
ttm Xg-’
X min -’.b
Number of
patients.
TABLE 7
Phosphofructokinase activity
in the vastus lateralis muscle before and after surgery and immobilization in a different castcast brace and was therefore able to receive a more
dynamic
training,
the cross-sectional areas of theTypes
I and II fibers did not show anysignificant changes.
Thequotient
Type
II-Type
I area wasunchanged.
The difference between the closedcast and the cast brace group
suggests
a difference inrecruit-ment
pattern
of muscle fibers. Thepatients
that wore a castbrace
evidently
could also activate theirType
I fibersduring
the
period
in the cast.Goldberg
etal..34
have studied different stimuli which causeatrophy
andhypertrophy
of different muscle fibers.They
found that a mostimportant
factor was the tensiondevelopment
in thefibers;
i.e., muscle fibers withregular
tensiondevelopment
showedhypertrophy
while a lackof tension
development
lead toatrophy
of the muscle fibers.Changes
in the metaboliccapacity
of the muscles can be reflectedby changes
in theenzymatic activity
of themuscles.&dquo;’
The oxidative
enzymatic activity
showed differentpatterns
ofchange
in the two groups ofpatients
in ourstudy.
In allpatients
there was a decrease in the oxidative enzymeactivity
(SDH)
invastus lateralis
during
the 1 stpostoperative
week when thepatients
were bedridden(Table 3).
When their casts wereremoved,
thosepatients
who had used a cast brace showed nosignificant change
in SDHactivity
between the twolegs.
Thepatient~
that used a standard cast showed asignificantly
lower SDHactivity
in the immobilizedleg.
This means that their muscles had a reducedcapacity
for oxidative metabolism and therefore endurance work. The isometric muscle contractionsevidently
could notprevent
the reduction in SDHactivity.
Grimby
etal..36
studied isometrictraining
inhealthy
volunteersfor a
period
of 6 weeks.During
thisperiod
thesubjects
per-formed 30 maximal isometric contractions
daily,
5days
a week. These authors were able to demonstrate in these volunteers asignificant
increase in SDHactivity
as well as an increased force of contraction in the trained skeletal muscle.During
thepostoperative period
aftermajor
kneeligament
surgery,pain
andswelling
reduce the effectiveness of isometrictraining.
The
glycolytic
metabolicactivity
asexpressed by
phospho-fructokinaseactivity
did notchange during
thepostoperative
period
in either of these twopatients
groups.This
study
has demonstrated a number of differencesbe-tween the
patient
group with a standard cast and that with acast brace after reconstruction of the anterior cruciate
ligament
of the kneejoint.
Theadvantages
of the cast brace can be summarized:(1)
theearly
mobilization of theknee
joint
re-sulted in arapid
restoration of full range ofmotion;
and(2)
the
early
mobility
gave no selectiveatrophy
of theType
I fibers and facilitated anearly
return tosports
training
andsports
activities.Although
there appears to be no difference in the end result of thesurgical
procedure,
we areusing
the cast braceroutinely
for alltypes
of kneeligament
surgery in ourdepart-ment because of the
advantages
it offers thepatient
ascom-pared
with the standardcylinder
cast.REFERENCES
1.
O’Donoghue
DH: Treatmentof Injuries
to Athletes. Second edition.Philadelphia,
WB Saunders Co, 1970, pp 517-5192.
Hey-Groves
EW:Operation
for therepair
of the crucialligaments.
The cruciateligaments
of the kneejoints.
Br JSurg
7: 505-515,56
3. Palmer I: On the
injuries
to theligaments
of the kneejoint.
Acta Chir Scand Vol 1 53: 665-667, 19384. Helfet AJ: Function of the cruciate
ligaments
of the kneejoints.
Lancet 1: 665, 1948
5. Smillie IS: Injuries to the Knee Joint. Second edition.
Edinburgh,
E and S
Livingstone
Ltd, 19766.
O’Donoghue
DH: A method forreplacement
of the anteriorcru-ciate
ligament
of the knee. J Bone JointSurg
45A: 905-924, 1963 7. Jones KG: Reconstruction of the anterior cruciateligament.
Atechnique using
the central one-third of thepatellar ligament.
J Bone JointSurg
45A: 925-932, 19638. Brostrom L,
Gillquist
J,Liljedahl
S-O, et al:Behandling
av invet-erad ruptur av framre korsbandet.Lakartidningen
64: 447, 1968 9. Slocum DB, Larson RL: Pes anserinustransplantation.
Asurgical
procedure
for control of rotatoryinstability
of the knee. J Bone JointSurg
50A: 211-225, 196810. Nicholas JA: The five-one reconstruction for anteromedial
insta-bility
of the knee. Indications,technique
and the results infifty-two
patients.
J Bone JointSurg
55A: 899-922, 197311.
Hughston
JC, Eilers AF: The role of theposterior oblique ligament
inrepairs
of acute medial (collateral)ligament
tears of the knee. J Bone JointSurg
55A: 923-940, 197312. Watson-Jones R: Fracture and Joint
Injuries.
Fifth edition.Edin-burgh,
E and SLivingstone
Ltd, 1976,p 1012
13. Hall MC:
Cartilage changes
afterexperimental
immobilization of the kneejoint
of the young rat. J Bone JointSurg
45A: 36-44,1963
14.
Cooper
RR: Alterationsduring
immobilization andregeneration
of skeletal muscle in cats. J Bone JointSurg
54A: 919-953, 1972 15.Noyes
FR, DeLucas JL, Torvik PJ: Biomechanics of anterior cruciateligament
failure: Ananalysis
of strain-ratesensitivity
andmechanisms of failure in
primates.
J Bone JointSurg
56A: 236-253,1974
16. Laros GS,
Tipton
CM,Cooper
RR: Influence ofphysical activity
on
ligament
insertions in the knee ofdogs.
J Bone JointSurg
53A:275-286, 1971
17.
Tipton
CM: Lesions and connective tissue.Proceedings
of The First Scandinavian Conference inSports
Medicine, Strömmen,Norway.
Synthex
Ther 2: 67-80, 197718. White AA,
Raphael IG:
The effects ofquadriceps
loads and kneeposition
on strain movements on the tibial collateralligament.
ActaOrthop
Scand 43: 176, 197219.
Haggmark
T, Eriksson E, Jansson E: Fiber type and metabolicpotential
of thethigh
muscle in man after knee surgery and immobilization. Scand J Clin Lab Invest (inpress)
20.
Holloszy
JO:Adaptation
of skeletal muscle to endurance exercise. Med SciSports
7: 155-164, 197521. Saltin B, Henriksson J,
Nygaard
E, et al: Fiber types and metabolicpotentials
of skeletal muscles insedentary
man and endurance runners. Ann NY A cad Sci 301: 3-29, 197722. Burri C,
Henkemeyer
H, Passler HH: FunktionelleBehandlung
nach Bandnaht und Plastik amKniegelent.
Langenbecks
Arch ChirSuppl
112: 197123. Eriksson E:
Sports
injuries
of the kneeligaments:
Theirdiagnosis,
treatment, rehabilitation andprevention.
Med SciSports
8:133-144, 1976
24.
Liljedahl
S-O, Nordenstrand S-O:Injuries
to theligaments
of theknee.
Injury
1: 17-24, 196925.
Bergstrom
J: Muscleelectrolytes
in man. Scand J Clin Lab Invest(Suppl)
68: 11-12 196226.
Padykula
HA, Herman E: Thespecificity
of the histochemical method for adenosinetriphosphatase.
J HistochemCytochem
3:170-195, 1955
27.
Engel
WK: Theessentiality
of histo- andcytochemical
studies ofskeletal muscle in the
investigation
of neuromuscular disease.Neurology
12: 778-784, 196228. Gollnick PD,
Armstrong
RB, Saubert CW, et al:Enzyme
activity
and fibercomposition
in skeletal muscle of untrained and trainedmen.
J Appl
Physiol 33:
312-319, 197229.
Engel
WK:Fiber-type
nomenclature of human skeletal muscle for histochemical purposes.Neurology
24: 344-348, 197430. Edstrom L,
Torlegård
K: Area estimation oftransversely
sectioned muscle fibers. Z Wiss Mikrosk Mikrosk Tech 69: 166-178, 1968/6931.
Lowry
OH Passonneau JV: A FlexibleSystem
of
Enzymatic
Anal-ysis.
New York, Academic Press, Inc, 197232. Alm A,
Gillquist
J: Reconstruction of the anterior cruciateligament
by using
the medial third of thepatellar ligament.
Acta Chir Scand140: 289-296, 1974
33. Alm A,
Strömberg
B:Transposed
medial third ofpatellar
ligament
in reconstruction of the anterior cruciateligament.
Acta Chir Scand(Suppl)
445: 197434.
Goldberg
AL,Etlinger
JD,Goldspink
DF, et al: Mechanism of work-inducedhypertrophy
of skeletal muscle. Med SciSports
7:185-198, 1975
35. Henriksson J, Reitman JS: Time course of
changes
in humanskeletal muscle succinate
dehydrogenase
andcytochrome
oxidase activities and maximal oxygenuptake
withphysical activity
andinactivity.
ActaPhysiol
Scand 99: 91-97, 197736.
Grimby
G,Bjorntorp
P, Fahlén M, et al: Metabolic effects of isometric