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Deichsel A, Peez C, Raschke MJ, Albert A, Herbort M, Kittl C, Fink C, Herbst E. A Flat Reconstruction of the Medial Collateral Ligament and Anteromedial Structures Restores Native Knee Kinematics: A Biomechanical Robotic Investigation. Am J Sports Med 2024:3635465241280984. [PMID: 39360333 DOI: 10.1177/03635465241280984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
BACKGROUND Injuries of the superficial medial collateral ligament (sMCL) and anteromedial structures of the knee result in excess valgus rotation and external tibial rotation (ER) as well as tibial translation. PURPOSE To evaluate a flat reconstruction of the sMCL and anteromedial structures in restoring knee kinematics in the combined MCL- and anteromedial-deficient knee. STUDY DESIGN Controlled laboratory study. METHODS Eight cadaveric knee specimens were tested in a 6 degrees of freedom robotic test setup. Force-controlled clinical laxity tests were performed with 200 N of axial compression in 0°, 30°, 60°, and 90° of flexion: 8 N·m valgus torque, 5 N·m ER torque, 89 N anterior tibial translation (ATT) force, and an anteromedial drawer test consisting of 89 N ATT force under 5 N·m ER torque. After determining the native knee kinematics, we transected the sMCL, followed by the deep medial collateral ligament (dMCL). Subsequently, a flat reconstruction of the sMCL with anteromedial limb, mimicking the function of the anteromedial corner, was performed. Mixed linear models were used for statistical analysis (P < .05). RESULTS Cutting of the sMCL led to statistically significant increases in laxity regarding valgus rotation, ER, and anteromedial translation in all tested flexion angles (P < .05). ATT was significantly increased in all flexion angles but not at 60° after cutting of the sMCL. A combined instability of the sMCL and dMCL led to further increased knee laxity in all tested kinematics and flexion angles (P < .05). After reconstruction, the knee kinematics were not significantly different from those of the native state. CONCLUSION Insufficiency of the sMCL and dMCL led to excess valgus rotation, ER, ATT, and anteromedial tibial translation. A combined flat reconstruction of the sMCL and the anteromedial aspect restored this excess laxity to values not significantly different from those of the native knee. CLINICAL RELEVANCE The presented reconstruction might lead to favorable results for patients with MCL and anteromedial injuries with an anteromedial rotatory knee instability.
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Affiliation(s)
- Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Alina Albert
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | | | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christian Fink
- Gelenkpunkt, Sports and Joint Surgery Innsbruck, Innsbruck, Austria
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Wierer G, Schroedter R, Hoser C, Milinkovic DD. Trilogy of isolated deep medial collateral ligament injuries of the knee: A set of three cases and overview of the literature. J ISAKOS 2024; 9:100296. [PMID: 39038518 DOI: 10.1016/j.jisako.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 05/21/2024] [Accepted: 07/15/2024] [Indexed: 07/24/2024]
Abstract
The authors present three unique cases of isolated deep medial collateral ligament (dMCL) injuries and comprehensively review the current literature. An isolated dMCL injury is often overlooked in clinical practice, and a consensus on the most adequate treatment is needed. Three male patients were examined at our institution directly following the trauma. The first patient experienced isolated soft-tissue avulsion of the dMCL, the second patient had a bony avulsion from the femoral insertion of the dMCL, and the third patient presented with an isolated "reverse Segond" fracture, which has not previously been described in the literature. All three injuries resulted from a violent external knee joint rotation. The treatment regime included a knee brace for up to 5 weeks and a physical therapy regimen for up to 3 months. All three patients reported satisfactory outcomes regarding restored knee function, absence of symptoms, and early return to activities at the final follow-up. STUDY DESIGN: Case report. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Guido Wierer
- Paracelsus Medical University-Salzburg, Salzburg, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | | | - Christian Hoser
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria; GELENKpunkt Sportsclinic, Innsbruck, Austria
| | - Danko Dan Milinkovic
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Germany.
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Petersen W, Mustafa HA, Buitenhuis J, Braun K, Häner M. [Reconstruction of the medial collateral ligament complex with a flat semitendinosus auto- or allograft]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2024:10.1007/s00064-024-00856-8. [PMID: 39172277 DOI: 10.1007/s00064-024-00856-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/27/2023] [Accepted: 08/28/2023] [Indexed: 08/23/2024]
Abstract
OBJECTIVE Replacement of superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with an allograft. INDICATIONS Chronic 3° isolated medial instability and combined anteromedial or posteromedial instability. CONTRAINDICATIONS Infection, open growth plates, restricted range of motion (less than E/F 0-0-90°). SURGICAL TECHNIQUE Longitudinal incision from medial epicondyle to superficial pes anserinus and exposure of the medial collateral ligament complex. Thawing of the allogeneic semitendinosus tendon graft at room temperature, reinforcement of the tendon ends with sutures and preparation of a two-stranded graft. Placement of guidewires in the sMCL and POL insertions and control with image intensifier. Tunnel drilling. Pulling the graft loop into the femoral bone tunnel and fixation with a flip button. Pulling the two graft ends into the tibial tunnels. Tibial fixation by knotting the suture ends in a 20° flexion on the lateral cortex. Suture the tendon bundles to the remaining remnants of the medial collateral ligament complex to adopt the flat structure of the natural medial collateral ligament complex. POSTOPERATIVE MANAGEMENT Six weeks partial weight-bearing, immediately postoperatively splint in the extended position, after 2 weeks movable knee brace for another 4-6 weeks. Mobility: 4 weeks 0-0-60, 5th and 6th weeks 0-0-90. RESULTS From 2015-2021, this surgical procedure was performed in 19 patients (5 women, 14 men, age 34 years). Mean Lysholm score at follow-up after at least 2 years was 89 (76-99) points. In 6 patients, there was restricted range of motion 3 months postoperatively, which resulted in further therapy (3 × systemic cortisone therapy, 3 × arthroscopically supported manipulations under anesthesia).
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Affiliation(s)
- Wolf Petersen
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland.
| | - Hassan Al Mustafa
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
| | - Johannes Buitenhuis
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
| | - Karl Braun
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
| | - Martin Häner
- Klinik für Orthopädie und Unfallchirurgie, Martin-Luther-Krankenhaus Berlin, Caspar Theyss Str. 27-33, Berlin, Deutschland
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Kuder IM, Rock M, Jones GG, Amis AA, Cegla FB, van Arkel RJ. An Optimization Approach for Creating Application-specific Ultrasound Speckle Tracking Algorithms. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:1108-1121. [PMID: 38714465 DOI: 10.1016/j.ultrasmedbio.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 03/04/2024] [Accepted: 03/24/2024] [Indexed: 05/09/2024]
Abstract
OBJECTIVE Ultrasound speckle tracking enables in vivo measurement of soft tissue deformation or strain, providing a non-invasive diagnostic tool to quantify tissue health. However, adoption into new fields is challenging since algorithms need to be tuned with gold-standard reference data that are expensive or impractical to acquire. Here, we present a novel optimization approach that only requires repeated measurements, which can be acquired for new applications where reference data might not be readily available or difficult to get hold of. METHODS Soft tissue motion was captured using ultrasound for the medial collateral ligament (MCL) of three quasi-statically loaded porcine stifle joints, and medial ligamentous structures of a dynamically loaded human cadaveric knee joint. Using a training subset, custom speckle tracking algorithms were created for the porcine and human ligaments using surrogate optimization, which aimed to maximize repeatability by minimizing the normalized standard deviation of calculated strain maps for repeat measurements. An unseen test subset was then used to validate the tuned algorithms by comparing the ultrasound strains to digital image correlation (DIC) surface strains (porcine specimens) and length change values of the optically tracked ligament attachments (human specimens). RESULTS After 1500 iterations, the optimization routine based on the porcine and human training data converged to similar values of normalized standard deviations of repeat strain maps (porcine: 0.19, human: 0.26). Ultrasound strains calculated for the independent test sets using the tuned algorithms closely matched the DIC measurements for the porcine quasi-static measurements (R > 0.99, RMSE < 0.59%) and the length change between the tracked ligament attachments for the dynamic human dataset (RMSE < 6.28%). Furthermore, strains in the medial ligamentous structures of the human specimen during flexion showed a strong correlation with anterior/posterior position on the ligaments (R > 0.91). CONCLUSION Adjusting ultrasound speckle tracking algorithms using an optimization routine based on repeatability led to robust and reliable results with low RMSE for the medial ligamentous structures of the knee. This tool may be equally beneficial in other soft-tissue displacement or strain measurement applications and can assist in the development of novel ultrasonic diagnostic tools to assess soft tissue biomechanics.
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Affiliation(s)
- Isabelle M Kuder
- Imperial College London Department of Mechanical Engineering, London, UK
| | | | - Gareth G Jones
- Imperial College London Department of Surgery and Cancer, London, UK
| | - Andrew A Amis
- Imperial College London Department of Mechanical Engineering, London, UK
| | - Frederic B Cegla
- Imperial College London Department of Mechanical Engineering, London, UK
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Pinheiro VH, Laughlin M, Borque KA, Ngo D, Kent MR, Jones M, Neves N, Fonseca F, Williams A. Career Length After Surgically Treated ACL Plus Collateral Ligament Injury in Elite Athletes. Am J Sports Med 2024; 52:2472-2481. [PMID: 39097768 DOI: 10.1177/03635465241262440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
BACKGROUND Limited data are available regarding career length and competition level after combined anterior cruciate ligament (ACL) and medial- or lateral-sided surgeries in elite athletes. PURPOSE To evaluate career length after surgical treatment of combined ACL plus medial collateral ligament (MCL) and ACL plus posterolateral corner (PLC) injuries in elite athletes and, in a subgroup analysis of male professional soccer players, to compare career length and competition level after combined ACL+MCL or ACL+PLC surgeries with a cohort who underwent isolated ACL reconstruction (ACLR). STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A consecutive cohort of elite athletes undergoing combined ACL+MCL and ACL+PLC surgery was analyzed between February 2001 and October 2019. A subgroup of male elite soccer players from this population was compared with a previously identified cohort having had isolated primary ACLR without other ligament surgery. A minimum 2-year follow-up was required. Outcome measures were career length and competition level. RESULTS A total of 98 elite athletes met the inclusion criteria, comprising 50 ACL+PLC and 48 ACL+MCL surgeries. The mean career length after surgical treatment of combined ACL+MCL and ACL+PLC injuries was 4.5 years. Return-to-play (RTP) time was significantly longer for ACL+PLC injuries (12.8 months; P = .019) than for ACL+MCL injuries (10.9 months). In the subgroup analysis of soccer players, a significantly lower number of players with combined ACL+PLC surgery were able to RTP (88%; P = .003) compared with 100% for ACL+MCL surgery and 97% for isolated ACLR, as well as requiring an almost 3 months longer RTP timeline (12.9 months; P = .002) when compared with the isolated ACL (10.2 months) and combined ACL+MCL (10.0 months) groups. However, career length and competition level were not significantly different between groups. CONCLUSION Among elite athletes, the mean career length after surgical treatment of combined ACL+MCL and ACL+PLC injuries was 4.5 years. Professional soccer players with combined ACL+PLC surgery returned at a lower rate and required a longer RTP time when compared with the players with isolated ACL or combined ACL+MCL injuries. However, those who did RTP had the same career longevity and competition level.
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Affiliation(s)
| | - Mitzi Laughlin
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Kyle A Borque
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Dylan Ngo
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Madison R Kent
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Mary Jones
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Nuno Neves
- Orthopaedic Department, Hospital CUF Porto, Porto, Portugal
- Faculty of Medicine, University of Porto, Portugal
| | | | - Andy Williams
- Fortius Clinic, London, UK
- FIFA Medical Centre of Excellence, London, UK
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van der List JP, Muscott RK, Parikh N, Waterman BR, Trasolini NA. Early Anterior Cruciate Ligament Treatment Might Be Crucial for Acute Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries: A Systematic Review of the Various Treatment Strategies. Arthroscopy 2024; 40:2322-2336. [PMID: 38242254 DOI: 10.1016/j.arthro.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024]
Abstract
PURPOSE To assess the outcomes of acute, combined, complete anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries in the literature. METHODS A literature search using PubMed, Embase, Scopus, and Cochrane Reviews was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria were studies reporting outcomes of complete ACL-MCL injuries at a minimum of 12 months' follow-up. Data were presented as ranges. RESULTS Twenty-seven studies with 821 patients were included (mean age, 29 years; 61% male patients; mean follow-up period, 27 months). There were 4 randomized trials, 10 Level III studies, and 13 Level IV studies. Nine different strategies were noted, of which nonoperative MCL treatment with acute ACL reconstruction and acute MCL repair with acute ACL reconstruction were most commonly performed. Nonoperative MCL-ACL treatment and acute MCL repair with nonoperative ACL treatment led to low rates of valgus stability at 30° of flexion (27%-68% and 36%-77%, respectively) compared with acute ACL reconstruction with either nonoperative MCL treatment (80%-100%), acute MCL repair (65%-100%), or acute MCL reconstruction (81%-100%). Lysholm scores were not different between the strategies. CONCLUSIONS Outcomes in this systematic review suggest that ACL stabilization in the acute setting might result in the lowest rates of residual valgus laxity, whereas there is no clear difference between the different MCL treatments along with acute ACL reconstruction. Nonoperative MCL treatment with either nonoperative or delayed ACL reconstruction, as well as acute MCL repair with either nonoperative or delayed ACL reconstruction, leads to higher rates of valgus laxity. LEVEL OF EVIDENCE Level IV, systematic review of Level I to IV studies.
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Affiliation(s)
- Jelle P van der List
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A..
| | - Rachel K Muscott
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Nihir Parikh
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Brian R Waterman
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Nicholas A Trasolini
- Department of Orthopaedic and Sports Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, U.S.A.; Wake Forest University, School of Medicine, Winston-Salem, North Carolina, U.S.A
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Blank JL, Roth JD. An Apparatus for Measuring Combined Shear-Tensile Loading in Fibrous Tissues Ex Vivo. J Biomech Eng 2024; 146:074501. [PMID: 38183226 DOI: 10.1115/1.4064437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/27/2023] [Indexed: 01/07/2024]
Abstract
Soft tissues such as tendon and ligament undergo a combination of shear and tensile loading in vivo due to their boundary conditions at muscle and/or bone. Current experimental protocols are limited to pure tensile loading, biaxial loading, or simple shear, and thus may not fully characterize the mechanics of these tissues under physiological loading scenarios. Our objective was to create an experimental protocol to determine the shear modulus of fibrous tissues at different tensile loads. We assembled a four-actuator experimental system that facilitated shear deformation to be superimposed on a tissue subjected to an axial preload. We measured shear modulus in axially loaded electrospun nanofiber scaffolds with either randomly oriented or aligned fibers. We found that shear modulus in the nanofiber phantoms was shear-strain stiffening and dependent on both the axial load (p < 0.001) and fiber alignment (p < 0.001) of the scaffold. The proposed system can enhance our understanding of microstructure and functional mechanics in soft tissues, while also providing a platform to investigate the behavior of electrospun scaffolds for tissue regeneration. Our experimental protocol for determining loaded shear modulus would be further useful as a method to gauge tissue mechanics under loading conditions that are more representative of physiological loads applied to tendon and ligament.
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Affiliation(s)
- Jonathon L Blank
- Department of Mechanical Engineering, University of Wisconsin-Madison, 1513 University Avenue Room 3046, Madison, WI 53706
| | - Joshua D Roth
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI 53705; Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, 1111 Highland Avenue Room 5037, Madison, WI 53705
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Beel W, Doughty C, Vivacqua T, Getgood A, Willing R. Effect of a Partial Superficial and Deep Medial Collateral Ligament Injury on Knee Joint Laxity. Am J Sports Med 2024; 52:1952-1959. [PMID: 38767158 PMCID: PMC11264541 DOI: 10.1177/03635465241251454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 02/14/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Injuries to the medial collateral ligament (MCL), specifically the deep MCL (dMCL) and superficial MCL (sMCL), are both reported to be factors in anteromedial rotatory instability (AMRI); however, a partial sMCL (psMCL) injury is often present, the effect of which on AMRI is unknown. PURPOSE To investigate the effect of a dMCL injury with or without a psMCL injury on knee joint laxity. STUDY DESIGN Controlled laboratory study. METHODS Sixteen fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator. The anterior cruciate ligament (ACL) was cut first and last in protocols 1 and 2, respectively. The dMCL was cut completely, followed by an intermediary psMCL injury state before the sMCL was completely sectioned. Tibiofemoral kinematics were measured at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 4 N·m of external tibial rotation, 4 N·m of internal tibial rotation, and combined 89 N of anterior tibial translation and 4 N·m of external tibial rotation for both anteromedial rotation (AMR) and anteromedial translation. The differences between subsequent states, as well as differences with respect to the intact state, were analyzed. RESULTS In an ACL-intact or -deficient joint, a combined dMCL and psMCL injury increased external tibial rotation and VR compared with the intact state at all angles. A significant increase in AMR was seen in the ACL-intact knee after this combined injury. Cutting the dMCL alone showed lower mean increases in AMR compared with the psMCL injury, which were significant only when the ACL was intact in knee flexion. Moreover, cutting the dMCL had no effect on VR. The ACL was the most important structure in controlling anteromedial translation, followed by the psMCL or dMCL depending on the knee flexion angle. CONCLUSION A dMCL injury alone may produce a small increase in AMRI but not in VR. A combined dMCL and psMCL injury caused an increase in AMRI and VR. CLINICAL RELEVANCE In clinical practice, if an increase in AMRI at 30° and 90° of knee flexion is seen together with some increase in VR, a combined dMCL and psMCL injury should be suspected.
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Affiliation(s)
- Wouter Beel
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
| | - Callahan Doughty
- School of Biomedical Engineering, Western University, London, Ontario, Canada
| | - Thiago Vivacqua
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Ontario, Canada
- Western’s Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Ryan Willing
- Western’s Bone and Joint Institute, Western University, London, Ontario, Canada
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
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Peez C, Hägerich LM, Ruhl F, Klimek M, Briese T, Glasbrenner J, Deichsel A, Raschke MJ, Kittl C, Herbst E. Collateral ligament strain is linearly related to coronal lower limb alignment: A biomechanical study. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38932622 DOI: 10.1002/ksa.12340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/07/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE The purpose of this study was to analyse the influence of coronal lower limb alignment on collateral ligament strain. METHODS Twelve fresh-frozen human cadaveric knees were used. Long-leg standing radiographs were obtained to assess lower limb alignment. Specimens were axially loaded in a custom-made kinematics rig with 200 and 400 N, and dynamic varus/valgus angulation was simulated in 0°, 30°, and 60° of knee flexion. The changes in varus/valgus angulation and strain within different fibre regions of the collateral ligaments were captured using a three-dimensional optical measuring system to examine the axis-dependent strain behaviour of the superficial medial collateral ligament (sMCL) and lateral collateral ligament (LCL) at intervals of 2°. RESULTS The LCL and sMCL were exposed to the highest strain values at full extension (p < 0.001). Regardless of flexion angle and extent of axial loading, the ligament strain showed a strong and linear association with varus (all Pearson's r ≥ 0.98; p < 0.001) and valgus angulation (all Pearson's r ≥ -0.97; p < 0.01). At full extension and 400 N of axial loading, the anterior and posterior LCL fibres exceeded 4% ligament strain at 3.9° and 4.0° of varus, while the sMCL showed corresponding strain values of more than 4% at a valgus angle of 6.8°, 5.4° and 4.9° for its anterior, middle and posterior fibres, respectively. CONCLUSION The strain within the native LCL and sMCL was linearly related to coronal lower limb alignment. Strain levels associated with potential ultrastructural damages to the ligaments of more than 4% were observed at 4° of varus and about 5° of valgus malalignment, respectively. When reconstructing the collateral ligaments, an additional realigning osteotomy should be considered in cases of chronic instability with a coronal malalignment exceeding 4°-5° to protect the graft and potentially reduce failures. LEVEL OF EVIDENCE There is no level of evidence as this study was an experimental laboratory study.
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Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Luise Maria Hägerich
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Felix Ruhl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Matthias Klimek
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Shatrov J, Bonacic Bartolin P, Holthof SR, Ball S, Williams A, Amis AA. A Comparative Biomechanical Study of Alternative Medial Collateral Ligament Reconstruction Techniques. Am J Sports Med 2024; 52:1505-1513. [PMID: 38551132 PMCID: PMC11064462 DOI: 10.1177/03635465241235858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/03/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND There is little evidence of the biomechanical performance of medial collateral ligament (MCL) reconstructions for restoring stability to the MCL-deficient knee regarding valgus, external rotation (ER), and anteromedial rotatory instability (AMRI). HYPOTHESIS A short isometric reconstruction will better restore stability than a longer superficial MCL (sMCL) reconstruction, and an additional deep MCL (dMCL) graft will better control ER and AMRI than single-strand reconstructions. STUDY DESIGN Controlled laboratory study. METHODS Nine cadaveric human knees were tested in a kinematics rig that allowed tibial loading while the knee was flexed-extended 0° to 100°. Optical markers were placed on the femur and tibia and displacements were measured using a stereo camera system. The knee was tested intact, and then after MCL (sMCL + dMCL) transection, and loaded in anterior tibial translation (ATT), ER, varus-valgus, and combined ATT + ER (AMRI loading). Five different isometric MCL reconstructions were tested: isolated long sMCL, a short construct, each with and without dMCL addition, and isolated dMCL reconstruction, using an 8 mm-wide synthetic graft. RESULTS MCL deficiency caused an increase in ER of 4° at 0° of flexion (P = .271) up to 14° at 100° of flexion (P = .002), and valgus laxity increased by 5° to 8° between 0° and 100° of flexion (P < .024 at 0°-90°). ATT did not increase significantly in isolated MCL deficiency (P > .999). All 5 reconstructions restored native stability across the arc of flexion apart from the isolated long sMCL, which demonstrated residual ER instability (P≤ .047 vs other reconstructions). CONCLUSION All tested techniques apart from the isolated long sMCL graft are satisfactory in the context of restoring the valgus, ER, and AMRI stability to the MCL-deficient knee in a cadaveric model. CLINICAL RELEVANCE Contemporary MCL reconstruction techniques fail to control ER and therefore AMRI as they use a long sMCL graft and do not address the dMCL. This study compares 5 MCL reconstruction techniques. Both long and short isometric constructs other than the long sMCL achieved native stability in valgus and ER/AMRI. Double-strand reconstructions (sMCL + dMCL) tended to provide more stability. This study shows which reconstructions demonstrate the best biomechanical performance, informs surgical reconstruction techniques for AMRI, and questions the efficacy of current popular techniques.
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Affiliation(s)
- Jobe Shatrov
- Imperial College London, London, United Kingdom
- Fortius Clinic, London, United Kingdom
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11
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Behrendt P, Robinson JR, Herbst E, Gellhaus F, Raschke MJ, Seekamp A, Herbort M, Kurz B, Kittl C. Isometry of anteromedial reconstructions mimicking the deep medial collateral ligament depends on the femoral insertion. Knee Surg Sports Traumatol Arthrosc 2024; 32:978-986. [PMID: 38431913 DOI: 10.1002/ksa.12111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE This study aimed to investigate the length change patterns of the native deep medial collateral ligament (dMCL) and potential anteromedial reconstructions (AMs) that might be added to a reconstruction of the superficial MCL (sMCL) to better understand the control of anteromedial rotatory instability (AMRI). METHODS Insertion points of the dMCL and potential AM reconstructions were marked with pins (tibial) and eyelets (femoral) in 11 cadaveric knee specimens. Length changes between the pins and eyelets were then tested using threads in a validated kinematics rig with muscle loading of the quadriceps and iliotibial tract. Between 0° and 100° knee flexion, length change pattern of the anterior, middle and posterior part of the dMCL and simulated AM reconstructions were analysed using a rotary encoder. Isometry was tested using the total strain range (TSR). RESULTS The tibiofemoral distance of the anterior dMCL part lengthened with flexion (+12.7% at 100°), whereas the posterior part slackened with flexion (-12.9% at 100°). The middle part behaved almost isometrically (maximum length: +2.8% at 100°). Depending on the femoral position within the sMCL footprint, AM reconstructions resulted in an increase in length as the knee flexed when a more centred position was used, irrespective of the tibial attachment position. Femoral positioning in the posterior aspect of the sMCL footprint exhibited <4% length change and was slightly less tight in flexion (min TSR = 3.6 ± 1.5%), irrespective of the tibial attachment position. CONCLUSION The length change behaviour of potential AM reconstructions in a functionally intact knee is mainly influenced by the position of the femoral attachment, with different tibial attachments having a minimal effect on length change. Surgeons performing AM reconstructions to control AMRI would be advised to choose a femoral graft position in the posterior part of the native sMCL attachment to optimise graft length change behaviour. Given the high frequency of MCL injuries, sufficient restoration of AMRI is essential in isolated and combined ligamentous knee injuries. LEVEL OF EVIDENCE There is no level of evidence as this study was an experimental laboratory study.
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Affiliation(s)
- Peter Behrendt
- Department of Orthopedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany
- Department of Trauma and Orthopedic Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Florian Gellhaus
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Andreas Seekamp
- Department of Trauma and Orthopedic Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Mirco Herbort
- OCM Orthopedic Surgery Munich Clinic, Munich, Germany
| | - Bodo Kurz
- Department of Anatomy, Christian-Albrechts-University, Kiel, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
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Blank JL, Thelen DG, Roth JD. Regional shear wave speeds track regional axial stress in nonuniformly loaded fibrous soft tissues. J Biomech 2024; 167:112071. [PMID: 38593721 DOI: 10.1016/j.jbiomech.2024.112071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/19/2024] [Accepted: 03/30/2024] [Indexed: 04/11/2024]
Abstract
Ligaments and tendons undergo nonuniform deformation during movement. While deformations can be imaged, it remains challenging to use such information to infer regional tissue loading. Shear wave tensiometry is a promising noninvasive technique to gauge axial stress and is premised on a tensioned beam model. However, it is unknown whether tensiometry can predict regional stress in a nonuniformly loaded structure. The objectives of this study were to (1) determine whether regional shear wave speed tracks regional axial stress in nonuniformly loaded fibrous soft tissues, and (2) determine the sensitivity of regional axial stress and shear wave speed to nonuniform load distribution and fiber alignment. We created a representative set of 12,000 dynamic finite element models of a fibrous soft tissue with probabilistic variations in fiber alignment, stiffness, and aspect ratio. In each model, we applied a randomly selected nonuniform load distribution, and then excited a shear wave and tracked its regional propagation. We found that regional shear wave speed was an excellent predictor of the regional axial stress (RMSE = 0.57 MPa) and that the nature of the regional shear wave speed-stress relationship was consistent with a tensioned beam model (R2 = 0.99). Variations in nonuniform load distribution and fiber alignment did not substantially alter the wave speed-stress relationship, particularly at higher loads. Thus, these findings suggests that shear wave tensiometry could provide a quantitative estimate of regional tissue stress in ligaments and tendons.
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Affiliation(s)
- Jonathon L Blank
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Darryl G Thelen
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA; Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Joshua D Roth
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA; Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI, USA.
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Willinger L, Runer A, Vieider R, Muench LN, Siebenlist S, Winkler PW. Noninvasive and Reliable Quantification of Anteromedial Rotatory Knee Laxity: A Pilot Study on Healthy Individuals. Am J Sports Med 2024; 52:1229-1237. [PMID: 38506950 PMCID: PMC10986148 DOI: 10.1177/03635465241234263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/18/2023] [Indexed: 03/22/2024]
Abstract
BACKGROUND Anteromedial rotatory instability (AMRI) of the knee is a complex and severe condition caused by injury to the anterior cruciate ligament and/or the medial collateral ligament. Clinical studies dealing with AMRI are rare, and objective measurements are nonexistent. PURPOSE/HYPOTHESIS The objectives of this study were, first, to quantify anteromedial rotatory knee laxity in healthy individuals using a noninvasive image analysis software and, second, to assess intra- and interrater reliability and equivalence in measuring anteromedial knee translation (AMT). It was hypothesized that AMT could be reliably quantified using a noninvasive image analysis software. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This prospective proof-of-concept study included healthy individuals aged 16 to 40 years with no history of knee injury or surgery. Three adhesive surface markers were placed on predefined landmarks on the medial side of the knee. Three independent investigators examined anteromedial rotatory knee laxity with an anterior drawer test in different tibial rotations (neutral tibial rotation, 15° of external tibial rotation, and 15° of internal tibial rotation). The entire examination of each knee was recorded, and AMT including the side-to-side difference (SSD) was assessed using a freely available and validated image analysis software (PIVOT iPad application). Group comparisons were performed using a 1-way analysis of variance with Bonferroni-adjusted post hoc analysis. Intraclass correlation coefficients (ICCs) were calculated to assess inter- and intrarater reliability of AMT measurements. Equivalence of measurements was evaluated using the 2 one-sided t-test procedure. RESULTS Anteromedial rotatory knee laxity was assessed in 30 knees of 15 participants (53% male) with a mean age of 26.2 ± 3.5 years. In all 3 raters, the highest AMT was observed in neutral tibial rotation (range of means, 2.2-3.0 mm), followed by external tibial rotation (range of means, 2.0-2.4 mm) and internal tibial rotation (range of means, 1.8-2.2 mm; P < .05). Intrarater reliability of AMT (ICC, 0.88-0.96) and SSD (ICC, 0.61-0.96) measurements was good to excellent and moderate to excellent, respectively. However, interrater reliability was poor to moderate for AMT (ICC, 0.44-0.73) and SSD (ICC, 0.12-0.69) measurements. Statistically significant equivalence of AMT and SSD measurements was observed between and within raters for almost all testing conditions. CONCLUSION Anteromedial rotatory knee laxity could be quantified using a noninvasive image analysis software, with the highest AMT observed during neutral tibial rotation in uninjured individuals. Reliability and equivalence of measurements were good to excellent within raters and moderate between raters.
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Affiliation(s)
- Lukas Willinger
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Armin Runer
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Romed Vieider
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Lukas N. Muench
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
- Department of Trauma and Reconstructive Surgery, Artemed Klinikum München Süd, Munich, Germany
| | - Sebastian Siebenlist
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
| | - Philipp W. Winkler
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria
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Peez C, Deichsel A, Zderic I, Richards RG, Gueorguiev B, Kittl C, Raschke MJ, Herbst E. Valgus malalignment causes increased forces on a medial collateral ligament reconstruction under dynamic valgus loading: A biomechanical study. Knee Surg Sports Traumatol Arthrosc 2024; 32:864-871. [PMID: 38454816 DOI: 10.1002/ksa.12110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE To investigate the forces on a medial collateral ligament (MCL) reconstruction (MCLR) relative to the valgus alignment of the knee. METHODS Eight fresh-frozen human cadaveric knees were subjected to dynamic valgus loading at 400 N using a custom-made kinematics rig. After resection of the superficial medial collateral ligament, a single-bundle MCLR with a hamstring tendon autograft was performed. A medial opening wedge distal femoral osteotomy was performed and fixed with an external fixator to gradually adjust the alignment in 5° increments from 0° to 10° valgus. For each degree of valgus deformity, the resulting forces acting on the MCLR were measured through a force sensor and captured in 15° increments from 0° to 60° of knee flexion. RESULTS Irrespective of the degree of knee flexion, increasing valgus malalignment resulted in significantly increased forces acting on the MCLR compared to neutral alignment (p < 0.05). Dynamic loading at 5° valgus resulted in increased forces on the MCLR at all flexion angles ranging between 16.2 N and 18.5 N (p < 0.05 from 0° to 30°; p < 0.01 from 45° to 60°). A 10° valgus malalignment further increased the forces on the MCLR at all flexion angles ranging between 29.4 N and 40.0 N (p < 0.01 from 0° to 45°, p < 0.05 at 60°). CONCLUSION Valgus malalignment of the knee caused increased forces acting on the reconstructed MCL. In cases of chronic medial instabilities accompanied by a valgus deformity ≥ 5°, a realigning osteotomy should be considered concomitantly to the MCLR to protect the graft and potentially reduce graft failures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
- AO Research Institute Davos, Davos, Switzerland
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | | | | | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Chen W, Zhou Q, Tang J. Material Properties of Fiber Bundles of the Superficial Medial Collateral Ligament of the Knee Joint. J Biomech Eng 2024; 146:031003. [PMID: 38217110 DOI: 10.1115/1.4064476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 12/27/2023] [Indexed: 01/15/2024]
Abstract
The superficial medial collateral ligament (sMCL) of the human knee joint has functionally separate anterior and posterior fiber bundles. The two bundles are alternatively loaded as the knee flexion angle changes during walking. To date, the two bundles are usually not distinguished in knee ligament simulations because there has been little information about their material properties. In this study, we conducted quasi-static tensile tests on the sMCL of matured porcine stifle joints and obtained the material properties of the anterior bundle (AB), posterior bundle (PB), and whole ligament (WL). AB and PB have similar failure stress but different threshold strain, modulus, and failure strain. As a result, we recommend assigning different material properties (i.e., modulus and failure strain) to the two fiber bundles to realize biofidelic ligament responses in human body models. However, it is often inconvenient to perform tensile tests on AB and PB. Hence, we proposed a microstructural model-based approach to predict the material properties of AB and PB from the test results of WL. Such obtained modulus values of AB and PB had an error of 2% and 0.3%, respectively, compared with those measured from the tests. This approach can reduce the experimental cost for acquiring the needed mechanical property data for simulations.
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Affiliation(s)
- Wentao Chen
- State Key Laboratory of Automotive Safety and Energy, School of Vehicle and Mobility, Tsinghua University, Beijing 100084, China
| | - Qing Zhou
- State Key Laboratory of Automotive Safety and Energy, School of Vehicle and Mobility, Tsinghua University, Beijing 100084, China
| | - Jisi Tang
- State Key Laboratory of Automotive Safety and Energy, School of Vehicle and Mobility, Tsinghua University, Beijing 100084, China
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16
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Borque KA, Han S, Dunbar NJ, Lanfermeijer ND, Sij EW, Gold JE, Ismaily SK, Amis AA, Laughlin MS, Kraeutler MJ, Williams A, Lowe WR, Noble P. Single-Strand "Short Isometric Construct" Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not. Am J Sports Med 2024; 52:968-976. [PMID: 38343203 DOI: 10.1177/03635465231224477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Historical MCL (medial collateral ligament) reconstruction (MCLR) techniques have focused on the superficial MCL (sMCL) to restore valgus stability while frequently ignoring the importance of the deep MCL (dMCL) in controlling tibial external rotation. The recent recognition of the medial ligament complex importance has multiple studies revisiting medial anatomy and questioning contemporary MCLR techniques. PURPOSE To assess whether (1) an isolated sMCL reconstruction (sMCLR), (2) an isolated dMCL reconstruction (dMCLR), or (3) a novel single-strand short isometric construct (SIC) would restore translational and rotational stability to a knee with a dMCL and sMCL injury. STUDY DESIGN Controlled laboratory study. METHODS Biomechanical testing was performed on 14 fresh-frozen cadaveric knee specimens using a custom multiaxial knee activity simulator. The specimens were divided into 2 groups. The first group was tested in 4 states: intact, after sectioning the sMCL and dMCL, isolated sMCLR, and isolated dMCLR. The second group was tested in 3 states: intact, after sectioning the sMCL and dMCL, and after single-strand SIC reconstruction (SICR). In each state, 4 loading conditions were applied at 0°, 20°, 40°, 60°, and 90° of knee flexion: 8-N·m valgus torque, 5-N·m external rotation torque, 90-N anterior drawer, and combined 90-N anterior drawer plus 5-N·m tibial external rotation torque. Anterior translation, valgus rotation, and external rotation of the knee were measured for each state and loading condition using an optical motion capture system. RESULTS sMCL and dMCL transection resulted in increased laxity for all loading conditions at all flexion angles. Isolated dMCLR restored external rotation stability to intact levels throughout all degrees of flexion, yet valgus stability was restored only at 0° of flexion. Isolated sMCLR restored valgus and external rotation stability at 0°, 20°, and 40° of flexion but not at 60° or 90° of flexion. Single-strand SICR restored valgus and external rotation stability at all flexion angles. In the combined anterior drawer plus external rotation test, isolated dMCL and single-strand SICR restored stability to the intact level at all flexion angles, while the isolated sMCL restored stability at 20° and 40° of flexion but not at 60° or 90° of flexion. CONCLUSION In the cadaveric model, single-strand SICR restored valgus and rotational stability throughout the range of motion. dMCLR restored rotational stability to the knee throughout the range of motion but did not restore valgus stability. Isolated sMCLR restored external rotation and valgus stability in early flexion. CLINICAL RELEVANCE In patients with anteromedial rotatory instability in the knee, neither an sMCLR nor a dMCLR is sufficient to restore stability.
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Affiliation(s)
- Kyle A Borque
- Houston Methodist Hospital, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Shuyang Han
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Nicholas J Dunbar
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Nicholas D Lanfermeijer
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Ethan W Sij
- UT McGovern Medical School, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Jonathan E Gold
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Sabir K Ismaily
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Andrew A Amis
- Imperial College London, London, UK
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Mitzi S Laughlin
- Houston Methodist Academic Institute, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Matthew J Kraeutler
- Houston Methodist Hospital, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Andy Williams
- Fortius Clinic, London, UK; FIFA Medical Centre of Excellence, London, UK
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Walter R Lowe
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Philip Noble
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
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Petersen W, Al Mustafa H, Buitenhuis J, Häner M, Braun K. Reconstruction of the Medial Collateral Ligament Complex With a Flat Allograft Semitendinosus Tendon. Arthrosc Tech 2024; 13:102836. [PMID: 38312881 PMCID: PMC10838056 DOI: 10.1016/j.eats.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/07/2023] [Indexed: 02/06/2024] Open
Abstract
The aim of this Technical Note is to reconstruct the medial collateral ligament complex with the superior medial collateral ligament and posterior oblique ligament as anatomically as possible. An allograft or contralateral semitendinosus autograft is used for anatomic reconstruction of the superior medial collateral ligament and posterior oblique ligament. After bony fixation, the tendon bundles are sutured to the remnants of the medial collateral ligament complex. Thus, the tubular grafts are pulled apart to form a flat shape that resembles that of the normal medial ligaments.
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Affiliation(s)
- Wolf Petersen
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Hassan Al Mustafa
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Johannes Buitenhuis
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Martin Häner
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Karl Braun
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
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Herbst E, Glasbrenner J, Deichsel A, Briese T, Peez C, Raschke MJ, Kittl C. [Injuries of the medial side of the knee : When and how should they be treated?]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:18-26. [PMID: 37848564 PMCID: PMC10787005 DOI: 10.1007/s00113-023-01368-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 10/19/2023]
Abstract
Different medial structures are responsible for restraining valgus rotation, external rotation, and anteromedial rotation. When injured this can result in various degrees of isolated and combined instabilities. In contrast to earlier speculation, the posterior oblique ligament (POL) is no longer considered to be the main stabilizer of anteromedial rotatory instability (AMRI). Acute proximal medial ruptures are typically managed conservatively with very good clinical results. Conversely, acute distal ruptures usually require a surgical intervention. Chronic instabilities mostly occur in combination with instabilities of the anterior cruciate ligament (ACL). The clinical examination is a particularly important component in these cases to determine the indications for surgery for an additional medial reconstruction. In cases of severe medial and anteromedial instabilities, surgical treatment should be considered. Biomechanically, a combined medial and anteromedial reconstruction appears to be superior to other reconstruction methods; however, there is currently a lack of clinical studies to confirm this biomechanical advantage.
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Affiliation(s)
- Elmar Herbst
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Johannes Glasbrenner
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Adrian Deichsel
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Thorben Briese
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Christian Peez
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Christoph Kittl
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48147, Münster, Deutschland.
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Herbst E, Muhmann RJ, Raschke MJ, Katthagen JC, Oeckenpöhler S, Wermers J, Glasbrenner J, Robinson JR, Kittl C. The Anterior Fibers of the Superficial MCL and the ACL Restrain Anteromedial Rotatory Instability. Am J Sports Med 2023; 51:2928-2935. [PMID: 37503921 DOI: 10.1177/03635465231187043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
BACKGROUND There is limited knowledge about how the anterior cruciate ligament (ACL) and capsuloligamentous structures on the medial side of the knee act to control anteromedial rotatory knee instability. PURPOSE To investigate the contribution of the medial retinaculum, capsular structures (anteromedial capsule, deep medial collateral ligament [MCL], and posterior oblique ligament), and different fiber regions of the superficial MCL to restraining knee laxity, including anteromedial rotatory instability. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic testing system in a position-controlled mode. Loads of 10 N·m valgus rotation, 5 N·m tibial external rotation, 5 N·m tibial internal rotation, and 134 N anterior tibial translation in 5 N·m external rotation were applied at different flexion angles. The motion of the intact knee at 0° to 120° of flexion was replicated after sequential excision of the sartorial fascia; anteromedial retinaculum; anteromedial capsule; anterior, middle, and posterior fibers of the superficial MCL; the deep MCL; the posterior oblique ligament; and the ACL. The reduction in force/torque indicated the contribution of each resected structure to resisting laxity. A repeated-measures analysis of variance with a post hoc Bonferroni test was used to analyze the relative force and torque changes from the intact state. RESULTS The superficial MCL was the most important restraint to valgus rotation from 0° to 120° and provided the largest contribution to resisting external rotation between 30° and 120° of knee flexion, gradually increasing from 25.2% ± 7.4% at 30° to 36.9% ± 15.4% at 90°. The posterior oblique ligament contributed significantly to resisting valgus rotation only in extension (17.2% ± 12.1%) but was the major restraint to internal rotation at 0° (46.7% ± 13.1%) and 30° (30.4% ± 17.7%) of flexion. The sartorial fascia and anteromedial retinaculum resisted ER at all knee flexion angles (P < .05) and was the single most important restraint in the extended knee (19.5% ± 11%). The capsular structures (anteromedial capsule and deep MCL) had a combined contribution of 20% ± 11.5% at 0° and 23.4% ± 10.5% at 120° of knee flexion but were less important from 30° to 90°. The ACL was the primary restraint to anterior tibial translation in external rotation between 0° and 60° of flexion (50.2% ± 16.9% at 30°), but the superficial MCL was more important at 90° to 120° of knee flexion (36.8% ± 16.4% at 90°). The anterior, middle, and posterior regions of the superficial MCL contributed differently to the simulated laxity tests. The anterior fibers were the most important part of the superficial MCL in resisting external rotation and combined anterior tibial translation in external rotation. CONCLUSION The superficial MCL not only was the primary restraint to valgus rotation throughout the range of knee flexion but also importantly contributed to resisting anterior tibial translation in external rotation, particularly in deeper flexion in the cadaveric model. The anterior fibers of the superficial MCL are the most important superficial MCL fibers in resisting anterior tibial translation in external rotation. This study suggests that a medial reconstruction that reproduces the function of the posterior MCL fibers and posterior oblique ligament may not best control anteromedial rotatory instability. CLINICAL RELEVANCE Based on these data, there is a need for an individualized medial reconstruction to address different types of medial injury patterns and instabilities.
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Affiliation(s)
- Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Raphael J Muhmann
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - J Christoph Katthagen
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Simon Oeckenpöhler
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Jens Wermers
- Faculty of Engineering Physics, FH Muenster, Muenster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | | | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
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Yang Y, Wang Y, Zheng N, Cheng R, Zou D, Zhao J, Tsai TY. Development and Validation of a Novel In Vitro Joint Testing System for Reproduction of In Vivo Dynamic Muscle Force. Bioengineering (Basel) 2023; 10:1006. [PMID: 37760108 PMCID: PMC10525521 DOI: 10.3390/bioengineering10091006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/28/2023] [Accepted: 08/15/2023] [Indexed: 09/29/2023] Open
Abstract
In vitro biomechanical experiments utilizing cadaveric specimens are one of the most effective methods for rehearsing surgical procedures, testing implants, and guiding postoperative rehabilitation. Applying dynamic physiological muscle force to the specimens is a challenge to reconstructing the environment of bionic mechanics in vivo, which is often ignored in the in vitro experiment. The current work aims to establish a hardware platform and numerical computation methods to reproduce dynamic muscle forces that can be applied to mechanical testing on in vitro specimens. Dynamic muscle loading is simulated through numerical computation, and the inputs of the platform will be derived. Then, the accuracy and robustness of the platform will be evaluated through actual muscle loading tests in vitro. The tests were run on three muscles (gastrocnemius lateralis, the rectus femoris, and the semitendinosus) around the knee joint and the results showed that the platform can accurately reproduce the magnitude of muscle strength (errors range from -6.2% to 1.81%) and changing pattern (goodness-of-fit range coefficient ranges from 0.00 to 0.06) of target muscle forces. The robustness of the platform is mainly manifested in that the platform can still accurately reproduce muscle force after changing the hardware combination. Additionally, the standard deviation of repeated test results is very small (standard ranges of hardware combination 1: 0.34 N~2.79 N vs. hardware combination 2: 0.68 N~2.93 N). Thus, the platform can stably and accurately reproduce muscle forces in vitro, and it has great potential to be applied in the future musculoskeletal loading system.
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Affiliation(s)
- Yangyang Yang
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200230, China; (Y.Y.); (Y.W.); (N.Z.); (R.C.); (D.Z.)
- Department of Orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Engineering Research Center for Digital Medicine, Ministry of Education, Shanghai 200230, China
| | - Yufan Wang
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200230, China; (Y.Y.); (Y.W.); (N.Z.); (R.C.); (D.Z.)
- Department of Orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Engineering Research Center for Digital Medicine, Ministry of Education, Shanghai 200230, China
| | - Nan Zheng
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200230, China; (Y.Y.); (Y.W.); (N.Z.); (R.C.); (D.Z.)
- Department of Orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Engineering Research Center for Digital Medicine, Ministry of Education, Shanghai 200230, China
| | - Rongshan Cheng
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200230, China; (Y.Y.); (Y.W.); (N.Z.); (R.C.); (D.Z.)
- Department of Orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Engineering Research Center for Digital Medicine, Ministry of Education, Shanghai 200230, China
| | - Diyang Zou
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200230, China; (Y.Y.); (Y.W.); (N.Z.); (R.C.); (D.Z.)
- Department of Orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Engineering Research Center for Digital Medicine, Ministry of Education, Shanghai 200230, China
| | - Jie Zhao
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200230, China; (Y.Y.); (Y.W.); (N.Z.); (R.C.); (D.Z.)
- Department of Orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Engineering Research Center for Digital Medicine, Ministry of Education, Shanghai 200230, China
- Shanghai Key Laboratory of Orthopaedic Implants & Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200230, China; (Y.Y.); (Y.W.); (N.Z.); (R.C.); (D.Z.)
- Department of Orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Engineering Research Center for Digital Medicine, Ministry of Education, Shanghai 200230, China
- Shanghai Key Laboratory of Orthopaedic Implants & Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
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Tsuda T, Hino K, Kutsuna T, Watamori K, Kinoshita T, Takao M. Difference in implant design affects midflexion rotational laxity in cruciate-retaining total knee arthroplasty: a computer navigation study. J Exp Orthop 2023; 10:85. [PMID: 37605070 PMCID: PMC10441849 DOI: 10.1186/s40634-023-00652-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/04/2023] [Indexed: 08/23/2023] Open
Abstract
PURPOSE This study aimed to compare midflexion rotational laxity between two different design concept models of cruciate-retaining total knee arthroplasty: symmetrical surface design of neutral joint line obliquity and asymmetrical surface design of varus joint line obliquity. METHODS Sixty-three knees that underwent cruciate-retaining total knee arthroplasty were evaluated. Manual maximum passive rotational stress without acceleration was applied to the knees under navigation monitoring. Pre-operative and post-operative internal and external rotational angles were measured at 30°, 45°, 60°, and 90° knee flexion. RESULTS The post-operative internal rotational laxity was significantly increased compared with pre-operative levels at 30°, 45°, 60°, and 90° flexion among all subjects (mean 9.7° vs 11.1°, 10.6° vs 11.6°, 11.2° vs 12.9°, and 13.2° vs 14.9°; p = 0.01, 0.04, 0.001, and 0.008, respectively). The post-operative external rotational laxity was significantly decreased compared to pre-operative levels at 30°, 45°, 60°, and 90° flexion among all subjects (mean 10.8° vs 6.8°, 12.5° vs 9.4°, 12.8° vs 10.0°, and 11.3° vs 9.5°; p < 0.0001, < 0.0001, < 0.0001, and 0.0008, respectively). The post-operative total rotational laxity significantly decreased, compared with pre-operative levels, at 30° and 45° flexion among all subjects (mean 20.4° vs 17.9°, and 23.1° vs 21.1°; p = 0.002 and 0.04, respectively). The post-operative total rotational laxity was significantly smaller in asymmetrically designed total knee arthroplasty than in symmetrically designed total knee arthroplasty at 30°, 45°, and 60° flexion (mean 19.3° vs 15.8°, 22.8° vs 18.7°, and 24.4° vs 20.8°; p = 0.03, 0.03, and 0.02, respectively), whereas no significant difference was observed at 90° flexion. CONCLUSION Compared to symmetrical surface design, asymmetrical surface design resulted in lower rotational laxity at the midflexion range in cruciate-retaining total knee arthroplasty. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Takashi Tsuda
- Department of Bone and Joint Surgery, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
| | - Kazunori Hino
- Department of Joint Reconstruction, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan.
| | - Tatsuhiko Kutsuna
- Department of Bone and Joint Surgery, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
| | - Kunihiko Watamori
- Department of Joint Reconstruction, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
| | - Tomofumi Kinoshita
- Department of Bone and Joint Surgery, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
| | - Masaki Takao
- Department of Bone and Joint Surgery, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
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Von Rehlingen-Prinz F, Leiderer M, Dehoust J, Dust T, Kowald B, Frosch KH, Izadpanah K, Henes FO, Krause M. Association of medial collateral ligament complex injuries with anterior cruciate ligament ruptures based on posterolateral tibial plateau injuries. SPORTS MEDICINE - OPEN 2023; 9:70. [PMID: 37553489 PMCID: PMC10409938 DOI: 10.1186/s40798-023-00611-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/12/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The combined injury of the medial collateral ligament complex and the anterior cruciate ligament (ACL) is the most common two ligament injury of the knee. Additional injuries to the medial capsuloligamentous structures are associated with rotational instability and a high failure rate of ACL reconstruction. The study aimed to analyze the specific pattern of medial injuries and their associated risk factors, with the goal of enabling early diagnosis and initiating appropriate therapeutic interventions, if necessary. RESULTS Between January 2017 and December 2018, 151 patients with acute ACL ruptures with a mean age of 32 ± 12 years were included in this study. The MRIs performed during the acute phase were analyzed by four independent investigators-two radiologists and two orthopedic surgeons. The trauma impact on the posterolateral tibial plateau and associated injuries to the medial complex (POL, dMCL, and sMCL) were examined and revealed an injury to the medial collateral ligament complex in 34.4% of the patients. The dMCL was the most frequently injured structure (92.2%). A dMCL injury was significantly associated with an increase in trauma severity at the posterolateral tibial plateau (p < 0.02) and additional injuries to the sMCL (OR 4.702, 95% CL 1.3-133.3, p = 0.03) and POL (OR 20.818, 95% CL 5.9-84.4, p < 0.0001). Isolated injuries to the sMCL were not observed. Significant risk factors for acquiring an sMCL injury were age (p < 0.01) and injury to the lateral meniscus (p < 0.01). CONCLUSION In about one-third of acute ACL ruptures the medial collateral ligament complex is also injured. This might be associated with an increased knee laxity as well as anteromedial rotational instability. Also, this might be associated with an increased risk for failure of revision ACL reconstruction. In addition, we show risk factors and predictors that point to an injury of medial structures and facilitate their diagnosis. This should help physicians and surgeons to precisely diagnose and to assess its scope in order to initiate proper therapies. With this in mind, we would like to draw attention to a frequently occurring combination injury, the so-called "unlucky triad" (ACL, MCL, and lateral meniscus). Level of evidence Level III Retrospective cohort study.
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Affiliation(s)
- Fidelius Von Rehlingen-Prinz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Miriam Leiderer
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - Julius Dehoust
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Tobias Dust
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Birgitt Kowald
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Kaywan Izadpanah
- Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Frank Oliver Henes
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
- Department of Diagnostic and Interventional Radiology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Kaarre J, Runer A, Benvegnu NA, Dadoo S, Persson F, Nammour M, Musahl V, Samuelsson K. Anatomic Flat Double-Bundle Medial Collateral Ligament Reconstruction. Arthrosc Tech 2023; 12:e1265-e1270. [PMID: 37654890 PMCID: PMC10466096 DOI: 10.1016/j.eats.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/18/2023] [Indexed: 09/02/2023] Open
Abstract
Several surgical techniques have been described to restore the anatomy of the medial collateral ligament, involving suture repair and reconstruction, with the latter having been associated with superior postoperative outcomes. Recently, a growing interest in anatomic isometric medial collateral ligament reconstruction (MCLR) has been developed, involving careful evaluation and finding the most appropriate location for the femoral placement of the allograft. Therefore, the purpose of this article is to describe anatomic MCLR aiming to restore medial knee stability by focusing on isometric positions within the native anatomy of the MCL.
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Affiliation(s)
- Janina Kaarre
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
- Department of Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Neilen A. Benvegnu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Sahil Dadoo
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Fabian Persson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
| | - Michael Nammour
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Kristian Samuelsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Sports Medicine Center, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Tzanetis P, Fluit R, de Souza K, Robertson S, Koopman B, Verdonschot N. Pre-Planning the Surgical Target for Optimal Implant Positioning in Robotic-Assisted Total Knee Arthroplasty. Bioengineering (Basel) 2023; 10:543. [PMID: 37237613 PMCID: PMC10215074 DOI: 10.3390/bioengineering10050543] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/19/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Robotic-assisted total knee arthroplasty can attain highly accurate implantation. However, the target for optimal positioning of the components remains debatable. One of the proposed targets is to recreate the functional status of the pre-diseased knee. The aim of this study was to demonstrate the feasibility of reproducing the pre-diseased kinematics and strains of the ligaments and, subsequently, use that information to optimize the position of the femoral and tibial components. For this purpose, we segmented the pre-operative computed tomography of one patient with knee osteoarthritis using an image-based statistical shape model and built a patient-specific musculoskeletal model of the pre-diseased knee. This model was initially implanted with a cruciate-retaining total knee system according to mechanical alignment principles; and an optimization algorithm was then configured seeking the optimal position of the components that minimized the root-mean-square deviation between the pre-diseased and post-operative kinematics and/or ligament strains. With concurrent optimization for kinematics and ligament strains, we managed to reduce the deviations from 2.4 ± 1.4 mm (translations) and 2.7 ± 0.7° (rotations) with mechanical alignment to 1.1 ± 0.5 mm and 1.1 ± 0.6°, and the strains from 6.5% to lower than 3.2% over all the ligaments. These findings confirm that adjusting the implant position from the initial plan allows for a closer match with the pre-diseased biomechanical situation, which can be utilized to optimize the pre-planning of robotic-assisted surgery.
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Affiliation(s)
- Periklis Tzanetis
- Department of Biomechanical Engineering, University of Twente, 7522 LW Enschede, The Netherlands
| | - René Fluit
- Faculty of Science and Engineering, University of Groningen, 9747 AG Groningen, The Netherlands
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | | | | | - Bart Koopman
- Department of Biomechanical Engineering, University of Twente, 7522 LW Enschede, The Netherlands
| | - Nico Verdonschot
- Department of Biomechanical Engineering, University of Twente, 7522 LW Enschede, The Netherlands
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
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Blomquist MB, Blank JL, Schmitz DG, Thelen DG, Roth JD. Shear wave tensiometry tracks reductions in collateral ligament tension due to incremental releases. J Orthop Res 2023; 41:524-533. [PMID: 35716160 PMCID: PMC9759618 DOI: 10.1002/jor.25400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 05/31/2022] [Accepted: 06/15/2022] [Indexed: 02/04/2023]
Abstract
Surgeons routinely perform incremental releases on overly tight ligaments during total knee arthroplasty (TKA) to reduce ligament tension and achieve their desired implant alignment. However, current methods to assess whether the surgeon achieved their desired reduction in the tension of a released ligament are subjective and/or do not provide a quantitative metric of tension in an individual ligament. Accordingly, the purpose of this study was to determine whether shear wave tensiometry, a novel method to assess tension in individual ligaments based on the speed of shear wave propagation, can detect changes in ligament tension following incremental releases. In seven medial and eight lateral collateral porcine ligaments (MCL and LCL, respectively), we measured shear wave speeds and ligament tensions before and after incremental releases consisting of punctures with an 18-gauge needle. We found that shear wave speed squared decreased linearly with decreasing tension in both the MCL (average coefficient of determination (R2 avg ) = 0.76) and LCL (R2 avg = 0.94). We determined that errors in predicting tension following incremental releases were 26.2 and 14.2 N in the MCL and LCL, respectively, using ligament-specific calibrations. These results suggest shear wave tensiometry is a promising method to objectively measure the tension reduction in released structures. Clinical Significance: Direct, objective measurements of the tension changes in individual ligaments following release could enhance surgical precision during soft tissue balancing in total knee arthroplasty. Thus, shear wave tensiometry could help surgeons reduce the risk of poor outcomes associated with overly tight ligaments, including residual knee pain and stiffness.
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Affiliation(s)
- Matthew B. Blomquist
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jonathon L. Blank
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Dylan G. Schmitz
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Darryl G. Thelen
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Joshua D. Roth
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin
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王 勇, 余 泽, 李 箭, 李 棋. [Diagnosis and treatment progress in the femoral insertion injury of medial collateral ligament of knee]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2023; 37:215-220. [PMID: 36796819 PMCID: PMC9970769 DOI: 10.7507/1002-1892.202211057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/16/2023] [Indexed: 02/18/2023]
Abstract
Objective To summarize the diagnosis and treatment progress in the femoral insertion injury of the medial collateral ligament (MCL) of knee, and to provide a clinical reference for diagnosis and treatment. Methods The literature on the femoral insertion injury of the MCL of knee was widely reviewed. The incidence, mechanisms of injury and anatomy, the diagnosis and classification, and status of treatment were summarized. Results The mechanism of the femoral insertion injury of the MCL of knee is related to its anatomical and histological characteristics, as well as the abnormal valgus of the knee joint, excessive external rotation of the tibial platform and it is classified according to the injury characteristics to guide the refined and individualized clinical treatment. Conclusion Due to different understanding of femoral insertion injury of MCL of knee, the treatment methods are different, and thus is the healing effect. Additional studies are still needed to promote the healing of insertion injuries.
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Affiliation(s)
- 勇 王
- 四川大学华西医院骨科 骨科研究所(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - 泽平 余
- 四川大学华西医院骨科 骨科研究所(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - 箭 李
- 四川大学华西医院骨科 骨科研究所(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
| | - 棋 李
- 四川大学华西医院骨科 骨科研究所(成都 610041)Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China
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Borque KA, Ball S, Sij E, Amis AA, Laughlin MS, Jones M, Williams A. A "Short Isometric Construct" Reconstruction Technique for the Medial Collateral Ligament of the Knee. Arthrosc Tech 2023; 12:e167-e171. [PMID: 36879857 PMCID: PMC9984723 DOI: 10.1016/j.eats.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/12/2022] [Indexed: 01/20/2023] Open
Abstract
Recently there has been increased focus on the medial collateral ligament (MCL) and the role the medial ligament complex plays in preventing valgus and external rotation, especially in the setting of a combined ligament injury. Multiple surgical techniques purport to reproduce "normal anatomy"; however, only one technique addresses the deep MCL fibers and the prevention of external rotation. Thus we describe the "short isometric construct" MCL reconstruction which is stiffer than the anatomic reconstructions. The "short isometric construct" technique resists valgus throughout range of motion whereas its obliquity resists tibial external rotation, helping to reduce the risk of anterior cruciate ligament graft re-rupture.
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Affiliation(s)
| | - Simon Ball
- the Fortius Clinic, FIFA Medical Centre of Excellence, London, United Kingdom
| | - Ethan Sij
- McGovern Medical School, UT Health, Houston, Texas, U.S.A
| | | | | | - Mary Jones
- the Fortius Clinic, FIFA Medical Centre of Excellence, London, United Kingdom
| | - Andy Williams
- the Fortius Clinic, FIFA Medical Centre of Excellence, London, United Kingdom
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Meyer P, Reiter A, Akoto R, Steadman J, Pagenstert G, Frosch KH, Krause M. Imaging of the medial collateral ligament of the knee: a systematic review. Arch Orthop Trauma Surg 2022; 142:3721-3736. [PMID: 34628563 PMCID: PMC9596543 DOI: 10.1007/s00402-021-04200-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/28/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The primary aim of this investigation was to systematically review relevant literature of various imaging modalities (magnetic resonance imaging (MRI), stress radiography and ultrasonography) in the assessment of patients with a medial collateral ligament (MCL) injury. MATERIALS AND METHODS A systematic literature review of articles indexed in PubMed and Cochrane library was performed. Original research reporting data associated with medial gapping, surgical, and clinical findings associated with MCL injuries were considered for inclusion. The methodological quality of each inclusion was also assessed using a verified tool. RESULTS Twenty-three imaging studies (magnetic resonance imaging (MRI) n = 14; ultrasonography n = 6; radiography n = 3) were ultimately included into the review. A total of 808 injured, and 294 control, knees were assessed. Interobserver reliabilities were reported in radiographic and ultrasonographic investigations with almost perfect agreement. MRI studies demonstrated agreement ranging between substantial to almost perfect. Intraobserver reliability was only reported in radiographic studies pertinent to medial gapping and was found to be almost perfect. Correlation of MRI with clinical findings was moderate to strong (65-92%). Additionally, MRI imaging was more sensitive in the detection of MCL lesions when compared to clinical examination. However, when compared to surgical findings, MRI underestimated the grade of instability in up to 21% of cases. Furthermore, MRI showed relatively inferior performance in the identification of the exact MCL-lesion location when compared to surgical findings. Interestingly, preoperative clinical examination was slightly inferior to stress radiography in the detection of MCL lesions. However, clinical testing under general anaesthesia performed similar to stress radiography. The methodological quality analysis showed a low risk of bias regarding patient selection and index testing in each imaging modality. CONCLUSION MRI can reliably diagnose an MCL lesion but demonstrates limitations in its ability to predict the specific lesion location or grade of MCL instability. Ultrasonography is a widely available, radiation free modality, but is rarely used in clinical practice for detecting MCL lesions and clinical or surgical correlates are scarce. Stress radiography findings correlate with surgical findings but clinical correlations are missing in the literature. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- P Meyer
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - A Reiter
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - R Akoto
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - J Steadman
- Department of Orthopaedics, University of Utah, Salt Lake City, USA
| | - G Pagenstert
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Clarahof Clinic of Orthopaedic Surgery, Merian-Iselin-Hospital Swiss Olympic Medical Center, Basel, Switzerland
- Knee Institute Basel, Basel, Switzerland
| | - K H Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - M Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Anteromediale Rotationsinstabilität des Kniegelenks: Flache sMCL-Bandplastik kombiniert mit einer anteromedialen Rekonstruktion ist der Einzelstrangrekonstruktion des sMCL überlegen. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00581-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Winkler PW, Chan CK, Lucidi GA, Polamalu SK, Wagala NN, Hughes JD, Debski RE, Musahl V. Increasing the posterior tibial slope lowers in situ forces in the native ACL primarily at deep flexion angles. J Orthop Res 2022. [PMID: 36370132 DOI: 10.1002/jor.25484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/03/2022] [Accepted: 11/07/2022] [Indexed: 11/15/2022]
Abstract
High tibial osteotomy is becoming increasingly popular but can be associated with unintentional posterior tibial slope (PTS) increase and subsequent anterior cruciate ligament (ACL) degeneration. This study quantified the effect of increasing PTS on knee kinematics and in situ forces in the native ACL. A robotic testing system was used to apply external loads from full extension to 90° flexion to seven human cadaveric knees: (1) 200 N axial compressive load, (2) 5 Nm internal tibial + 10 Nm valgus torque, and (3) 5 Nm external tibial + 10 Nm varus torque. Kinematics and in situ forces in the ACL were acquired for the native and increased PTS state. Increasing PTS resulted in increased anterior tibial translation at 30° (1.8 mm), 60° (1.7 mm), and 90° (0.9 mm) flexion and reduced in situ force in the ACL at 30° (57.6%), 60° (69.8%), and 90° (75.0%) flexion in response to 200 N axial compressive load. In response to 5 Nm internal tibial + 10 Nm valgus torque, there was significantly less (39.0%) in situ force in the ACL at 90° flexion in the increased compared with the native PTS state. Significantly less in situ force in the ACL at 60° (62.8%) and 90° (67.0%) flexion was observed in the increased compared with the native PTS state in response to 5 Nm external tibial + 10 Nm varus torque. Increasing PTS affects knee kinematics and results in a reduction of in situ forces in the native ACL during compressive and rotatory loads at flexion angles exceeding 30°. In a controlled laboratory setting PTS increase unloads the ACL, affecting its natural function.
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Affiliation(s)
- Philipp W Winkler
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Calvin K Chan
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gian Andrea Lucidi
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sene K Polamalu
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nyaluma N Wagala
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan D Hughes
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedics, University of Gothenburg, Gothenburg, Sweden
| | - Richard E Debski
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Orthopaedic Robotics Laboratory, Departments of Orthopaedic Surgery and Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Peez C, Wermers J, Glasbrenner J, Briese T, Raschke MJ, Herbst E, Kittl C. Qualitative and Quantitative Assessment of the Medial Patellar Retinaculum Anatomy: the Anteromedial Side of the Knee Revisited. Orthop J Sports Med 2022; 10:23259671221134818. [PMID: 36419479 PMCID: PMC9676305 DOI: 10.1177/23259671221134818] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/12/2022] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND In the current literature, studies on the anatomy of the anteromedial region of the knee are scarce. However, the anteromedial structures, especially the longitudinal medial patellar retinaculum (MPR), may play an important role in restraining external tibial rotation. PURPOSE To conduct a layer-by-layer dissection of the anteromedial side of the knee and describe qualitatively and quantitatively the MPR anatomy pertaining to surgically relevant landmarks. STUDY DESIGN Descriptive laboratory study. METHODS A total of 10 fresh-frozen human cadaveric knees (mean age 81 ± 16.3 years) without history of previous ligament injury were used in this study. A layer-by-layer dissection was performed, and measurements were obtained using a tactile 3-dimensional (3-D) measuring arm to define the anatomy of the MPR in relation to surgically relevant landmarks, such as the superficial medial collateral ligament (sMCL) and medial patellofemoral ligament (MPFL). The 3-D datasets were used for multiplanar reconstruction. RESULTS The tibial and femoral attachment of the MPR were identified in 100% of cases. Layer-by-layer dissection confirmed its close topography to the sMCL. The mean length of the MPR was 84.9 ± 9.1 mm. The average width of the tibial and femoral attachment was 23.8 ± 3.1 mm and 69.2 ± 8.2 mm, respectively. The distance from the midpoint of the MPR tibial attachment to the midpoint of the distal tibial attachment of the sMCL was 27.2 ± 5.8 mm. Femorally, the MPR attached at the anterior border of the MPFL over a mean distance of 52.3 ± 9.4 mm. CONCLUSION The MPR is a distinct tibiofemoral structure with well-defined tibial and femoral attachments, which could be consistently identified. Layer-by-layer dissection confirmed its close topography to the sMCL and MPFL. CLINICAL RELEVANCE As injuries to the anteromedial side of the knee may contribute to anteromedial rotational rotatory instability (AMRI), precise knowledge of the underlying anatomy of the MPR may be necessary to perform an anatomic reconstruction of the anteromedial side of the knee.
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Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Jens Wermers
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J. Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Borque KA, Jones M, Balendra G, Willinger L, Pinheiro VH, Anand BS, Williams A. High return to play rate following treatment of multiple-ligament knee injuries in 136 elite athletes. Knee Surg Sports Traumatol Arthrosc 2022; 30:3393-3401. [PMID: 35279739 DOI: 10.1007/s00167-022-06926-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/21/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of the study is to assess return to play rate and timing of elite athletes treated for multi-ligament knee injuries with modern surgical techniques. METHODS A retrospective review was performed of all professional or national/international level athletes treated for a multi-ligament knee injury by the senior author in the period from February 2001 to October 2019, with a minimum of 2-year follow-up. The study cohort consisted of 136 elite athletes who underwent surgery of two or more knee ligaments. Outcomes measures were return to play (RTP), defined as return to elite level sport, return to play time, and further surgical procedures. RESULTS One hundred and twenty (88.2%) athletes returned to elite level sport at an average of 12.8 months from operation. In unicruciate injuries, ACL and PCL-based injuries had similar return to play rates (89.1% vs. 87.5% respectfully, n.s.) although mean RTP time was longer in those with PCL-based injuries (15.2 vs. 11.9 months, p < 0.01). Bicruciate injuries had longer RTP times compared to unicruciate injuries (mean RTP 16.0vs. 12.4 months, p < 0.05) but were able to return at a similar rate (83.3% vs. 88.9%, n.s.). Medial and lateral sided injuries had similar RTP rates (89.3% vs. 87.9%, n.s.) though lateral sided injuries took longer before returning to play (13.4 vs. 11.6 months, p < 0.05). Further surgery was required in 54 (39.9%) patients including 25 (18.4%) manipulations under anaesthesia. Four (2.9%) of the athletes underwent revision ligament surgery. CONCLUSION Modern surgical techniques used in the treatment of multi-ligament knee injuries can lead to high return to play rates in elite athletes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kyle A Borque
- Houston Methodist Orthopedics and Sports Medicine, Houston, USA
| | - Mary Jones
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Ganesh Balendra
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Lukas Willinger
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Vitor Hugo Pinheiro
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Bobby Singh Anand
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK
- FIFA Medical Centre of Excellence, London, UK
| | - Andy Williams
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK.
- FIFA Medical Centre of Excellence, London, UK.
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33
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Wierer G, Kittl C, Fink C, Weiler A. Medial Collateral Ligament Reconstruction: A Gracilis Tenodesis for Anteromedial Knee Instability. Arthrosc Tech 2022; 11:e1409-e1418. [PMID: 36061473 PMCID: PMC9437470 DOI: 10.1016/j.eats.2022.03.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/13/2022] [Indexed: 02/03/2023] Open
Abstract
The main principle of the present medial collateral ligament reconstruction technique is to address anteromedial knee instability. Therefore, we describe a gracilis tenodesis with 2 functional bundles to reconstruct the deep and superficial medial collateral ligament. The proposed technique may be performed as an isolated or combined procedure with anterior cruciate ligament reconstruction. Valgus instability in extension is a contraindication.
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Affiliation(s)
- Guido Wierer
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Hall, Austria,Address correspondence to Guido Wierer, M.D., Department of Orthopedics and Traumatology, Academic Teaching Hospital, Hall in Tirol, Austria.
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Christian Fink
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Hall, Austria,Gelenkpunkt Innsbruck, Austria
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Behrendt P, Herbst E, Robinson JR, von Negenborn L, Raschke MJ, Wermers J, Glasbrenner J, Fink C, Herbort M, Kittl C. The Control of Anteromedial Rotatory Instability Is Improved With Combined Flat sMCL and Anteromedial Reconstruction. Am J Sports Med 2022; 50:2093-2101. [PMID: 35604117 PMCID: PMC9227970 DOI: 10.1177/03635465221096464] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Both the superficial medial collateral ligament (sMCL) and the deep MCL (dMCL) contribute to the restraint of anteromedial (AM) rotatory instability (AMRI). Previous studies have not investigated how MCL reconstructions control AMRI. PURPOSE/HYPOTHESIS The purpose was to establish the optimal medial reconstruction for restoring normal knee kinematics in an sMCL- and dMCL-deficient knee. It was hypothesized that AMRI would be better controlled with the addition of an anatomically shaped (flat) sMCL reconstruction and with the addition of an AM reconstruction replicating the function of the dMCL. STUDY DESIGN Controlled laboratory study. METHODS A 6 degrees of freedom robotic system equipped with a force-torque sensor was used to test 8 unpaired knees in the intact, sMCL/dMCL sectioned, and reconstructed states. Four different reconstructions were assessed. The sMCL was reconstructed with either a single-bundle (SB) or a flattened hamstring graft aimed at better replicating the appearance of the native ligament. These reconstructions were tested with and without an additional AM reconstruction. Simulated laxity tests were performed at 0°, 30°, 60°, and 90° of flexion: 10 N·m valgus rotation, 5 N·m internal and external rotation (ER), and an AM drawer test (combined 134-N anterior tibial drawer in 5 N·m ER). The primary outcome measures of this force-controlled setup were anterior tibial translation (ATT; in mm) and axial tibial rotation (in degrees). RESULTS Sectioning the sMCL/dMCL increased valgus rotation, ER, and ATT with the simulated AM draw test at all flexion angles. SB sMCL reconstruction was unable to restore ATT, valgus rotation, and ER at 30°, 60°, and 90° of flexion to the intact state (P < .05). Flat MCL reconstruction restored valgus rotation at all flexion angles to the intact state (P > .05). ER was restored at all angles except at 90°, but ATT laxity in response to the AM drawer persisted. Addition of an AM reconstruction improved control of ATT relative to the intact state at all flexion angles (P > .05). Combined flat MCL and AM reconstruction restored knee kinematics closest to the intact state. CONCLUSION In a cadaveric model, AMRI resulting from an injured sMCL and dMCL complex could not be restored by an isolated SB sMCL reconstruction. A flat MCL reconstruction or an additional AM procedure, however, better restored medial knee stability. CLINICAL RELEVANCE In patients evaluated with a combined valgus and AM rotatory instability, a flat sMCL and an additional AM reconstruction may be superior to an isolated SB sMCL reconstruction.
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Affiliation(s)
- Peter Behrendt
- Department of Orthopedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany,Department of Anatomy, Christian-Albrechts-University, Kiel, Germany,Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | | | | | - Michael J. Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Jens Wermers
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria
| | - Mirco Herbort
- OCM Orthopedic Surgery Munich Clinic, Munich, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany,Christoph Kittl, Dr med MD(res), Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany ()
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Chen W, Zhou Q. Opposite Effect of Cyclic Loading on the Material Properties of Medial Collateral Ligament at Different Temperatures: An Animal Study. Front Bioeng Biotechnol 2022; 10:925033. [PMID: 35774057 PMCID: PMC9237215 DOI: 10.3389/fbioe.2022.925033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
In traffic accidents, the medial collateral ligament (MCL) injury of the knee joint of pedestrians is common. Biofidelic material is important to realize MCL's native biomechanics in simulations to clarify the injury mechanisms of pedestrians. Pedestrians' MCLs usually experience cyclic loading at the intra-articular temperature of the knee joint before accidents. Temperature influences the material behaviors of ligaments. However, the mechanical properties of ligaments under cyclic loading have been widely evaluated only at room temperature rather than physiological temperature. Therefore, this study aimed to determine whether the difference between room and intra-articular temperatures influences the effect of cyclic loading on the mechanical properties of MCL. We measured the tensile properties of 34 porcine MCLs at room temperature (21-23°C) and intra-articular temperature (35-37°C), with either 10 cycles or 240 cycles of cyclic loading, a total of four different conditions. The structural responses and geometric data were recorded. After 240 cycles of cyclic loading, stiffness increased by 29.0% (p < 0.01) at room temperature and decreased by 11.5% (p = 0.106) at intra-articular temperature. Material properties were further compared because the geometric differences between samples were inevitable. At room temperature, after 240 cycles of cyclic loading, elastic modulus increased by 29.6% (p < 0.001), and failure strain decreased by 20.4% (p < 0.05). By contrast, at intra-articular temperature, after 240 cycles of cyclic loading, modulus decreased by 27.4% (p < 0.001), and failure strain increased by 17.5% (p = 0.193), insignificant though. In addition, there were no significant differences between the four groups in other structural or material properties. The results showed that temperature reversed the effect of cyclic loading on the mechanical properties of MCL, which may be caused by the high strength and thermally stable crosslinks of MCL. Therefore, for improving the fidelity of knee joint simulations and elucidating the injury mechanism of pedestrians, it is better to measure the mechanical properties of MCL at intra-articular temperature rather than room temperature.
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Affiliation(s)
| | - Qing Zhou
- State Key Laboratory of Automotive Safety and Energy, School of Vehicle and Mobility, Tsinghua University, Beijing, China
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Helal A, Marie A, El-Forse ES. The "Figure of Four" Reconstruction of the Medial Collateral Ligaments in the Setting of Anteromedial Rotatory Knee Instability Using a Single Autograft. Arthrosc Tech 2022; 11:e1239-e1245. [PMID: 35936844 PMCID: PMC9353192 DOI: 10.1016/j.eats.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/03/2022] [Indexed: 02/03/2023] Open
Abstract
The deep medial collateral ligament plays an important role in controlling tibial external rotation and restrain anterior translation of the medial tibial plateau. Despite being the basic lesion of anteromedial knee instability as proposed by many authors, the majority of the medial side reconstructions do not restore the anatomy and the function of the deep medial collateral ligament. In this Technical Note, we describe a technique to reconstruct both the superficial and deep medial collateral ligament in the setting of anteromedial knee instability using a single peroneus longus autograft.
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Affiliation(s)
- Ahmed Helal
- Address correspondence to Ahmed Helal, M.D., Ph.D., Faculty of Medicine, Tanta University, El-Gash St. Medical Campus-The Faculty of Medicine, Tanta, El-Gharbia Govenorate, Egypt.
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Yamagami R, Inui H, Taketomi S, Kono K, Kawaguchi K, Sameshima S, Kage T, Tanaka S. Proximal tibial morphology is associated with risk of trauma to the posteromedial structures during tibial bone resection reproducing the anatomical posterior tibial slope in bicruciate-retaining total knee arthroplasty. Knee 2022; 36:1-8. [PMID: 35381571 DOI: 10.1016/j.knee.2022.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 07/23/2021] [Accepted: 03/21/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND A tibial cut with the native posterior tibial slope (PTS) is a theoretical prerequisite in bicruciate-retaining total knee arthroplasty (BCRTKA) to regain physiological knee kinematics. The present study reveals tibial morphological risk factors of trauma to the posteromedial structures of the knee during tibial bone resection in BCRTKA. METHODS Fifty patients undergoing BCRTKA for varus knee osteoarthritis were analyzed. A three-dimensional tibial bone model was reconstructed using a computed tomography-based preoperative planning system, and the coronal tibial slope (CTS) and medial PTS (MPTS) were measured. Then, we set the simulated tibial cutting plane neutral on the coronal plane, posteriorly inclined in accordance with the MPTS on the sagittal plane, and 9 mm below the surface of the subchondral cortical bone (i.e., 11 mm below the surface of the cartilage) of the lateral tibial plateau. The association between the tibial morphology and the distance from the simulated cutting plane to the semimembranosus (SM) insertion (Dsm) was analyzed. RESULTS Of the 50 patients, 19 (38%) had negative Dsm values, indicating a cut into the SM (namely, below the posterior oblique ligament) insertion. The MPTS was negatively correlated with Dsm (r = -0.396, p = 0.004), whereas the CTS was positively correlated with Dsm (r = 0.619, p < 0.001). On multivariate linear regression analysis, the MPTS and CTS were independent predictors of Dsm. CONCLUSION In the setting of tibial cuts reproducing the native MPTS in BCRTKA, patients with larger PTS and smaller CTS had more risk of trauma to the posteromedial structures.
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Affiliation(s)
- Ryota Yamagami
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Inui
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Shuji Taketomi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenichi Kono
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kohei Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shin Sameshima
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomofumi Kage
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Miyaji N, Holthof SR, Ball SV, Williams A, Amis AA. Medial Collateral Ligament Reconstruction for Anteromedial Instability of the Knee: A Biomechanical Study In Vitro. Am J Sports Med 2022; 50:1823-1831. [PMID: 35511430 PMCID: PMC9160947 DOI: 10.1177/03635465221092118] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/24/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although a medial collateral ligament (MCL) injury is associated with anteromedial rotatory instability (AMRI) and often with an anterior cruciate ligament (ACL) injury, there has been little work to develop anteromedial (AM) reconstruction to address this laxity. PURPOSE To measure the ability of a novel "anatomic" AM reconstruction technique to restore native knee laxity for isolated AM insufficiency and combined AM plus posteromedial insufficiency. STUDY DESIGN Controlled laboratory study. METHODS A total of 12 cadaveric knees were mounted in a kinematic testing rig that allowed the tibia to be loaded while the knee flexed-extended 0° to 100° with 88-N anteroposterior translation, 5-N·m internal rotation-external rotation (ER), 8-N·m valgus, and combined anterior translation plus ER to simulate AMRI. Joint motion was measured using optical trackers with the knee intact, after superficial MCL (sMCL) and deep MCL (dMCL) transection, and after AM reconstruction of the sMCL and dMCL with semitendinosus autografts. The posteromedial capsule (PMC)/posterior oblique ligament (POL) was then transected to induce a grade 3 medial injury, and kinematic measurements were repeated afterward and again after removing the grafts. Laxity changes were examined using repeated-measures analysis of variance and post-testing. RESULTS sMCL and dMCL deficiency increased valgus, ER, and AMRI laxities. These laxities did not differ from native values after AM reconstruction. Additional PMC/POL deficiency did not increase these laxities significantly but did increase internal rotation laxity near knee extension; this was not controlled by AM reconstruction. CONCLUSION AM reconstruction eliminated AMRI after transection of the dMCL and sMCL, and also eliminated AMRI after additional PMC/POL transection. CLINICAL RELEVANCE Many MCL injuries occur in combination with ACL injuries, causing AMRI. These injuries may rupture the AM capsule and dMCL. Unaddressed MCL deficiency leads to an increased ACL reconstruction failure rate. A dMCL construct oriented anterodistally across the medial joint line, along with an sMCL graft, can restore native knee ER laxity. PMC/POL lesions did not contribute to AMRI.
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Affiliation(s)
- Nobuaki Miyaji
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sander R. Holthof
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | | | - Andy Williams
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
- Fortius Clinic, London, UK
| | - Andrew A. Amis
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
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Miyaji N, Holthof SR, Bastos RP, Ball SV, Espregueira-Mendes J, Williams A, Amis AA. A Triple-Strand Anatomic Medial Collateral Ligament Reconstruction Restores Knee Stability More Completely Than a Double-Strand Reconstruction: A Biomechanical Study In Vitro. Am J Sports Med 2022; 50:1832-1842. [PMID: 35503457 PMCID: PMC9160957 DOI: 10.1177/03635465221090612] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are many descriptions of medial collateral ligament (MCL) reconstruction, but they may not reproduce the anatomic structures and there is little evidence of their biomechanical performance. PURPOSE To investigate the ability of "anatomic" MCL reconstruction to restore native stability after grade III MCL plus posteromedial capsule/posterior oblique ligament injuries in vitro. STUDY DESIGN Controlled laboratory study. METHODS Twelve cadaveric knees were mounted in a kinematic testing rig to impose tibial displacing loads while the knee was flexed-extended: 88-N anteroposterior translation, 5-N·m internal-external rotation, 8-N·m valgus-varus, and combined anterior translation plus external rotation (anteromedial rotatory instability). Joint motion was measured via optical trackers with the knee intact; after superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament transection; and then after MCL double- and triple-strand reconstructions. Double strands reproduced the sMCL and posterior oblique ligament and triple-strands the sMCL, dMCL, and posterior oblique ligament. The sMCL was placed 5 mm posterior to the epicondyle in the double-strand technique and at the epicondyle in the triple-strand technique. Kinematic changes were examined by repeated measures 2-way analysis of variance with posttesting. RESULTS Transection of the sMCL, dMCL, and posterior oblique ligament increased valgus rotation (5° mean) and external rotation (9° mean). The double-strand reconstruction controlled valgus in extension but allowed 5° excess valgus in flexion and did not restore external rotation (7° excess). The triple-strand reconstruction restored both external rotation and valgus throughout flexion. CONCLUSION In a cadaveric model, a triple-strand reconstruction including a dMCL graft restored native external rotation, while a double-strand reconstruction without a dMCL graft did not. A reconstruction with the sMCL graft placed isometrically on the medial epicondyle restored valgus rotation across the arc of knee flexion, whereas a reconstruction with a more posteriorly placed sMCL graft slackened with knee flexion. CLINICAL RELEVANCE An MCL injury may rupture the anteromedial capsule and dMCL, causing anteromedial rotatory instability. Persistent MCL instability increases the likelihood of ACL graft failure after combined injury. A reconstruction with an anteromedial dMCL graft restored native external rotation, which may help to unload/protect an ACL graft. It is important to locate the sMCL graft isometrically at the femoral epicondyle to restore valgus across flexion.
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Affiliation(s)
- Nobuaki Miyaji
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK,Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Sander R. Holthof
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
| | - Ricardo P.S. Bastos
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK,Clínica do Dragão–Espregueira-Mendes Sports Centre, Porto, Portugal
| | | | | | - Andy Williams
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK,Fortius Clinic, London, UK
| | - Andrew A. Amis
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK,Andrew A. Amis, FREng, DSc(Eng), Biomechanics Group, Mechanical Engineering Department, Imperial College London, London SW7 2AZ, UK ()
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Hodel S, Hasler J, Fürnstahl P, Fucentese SF, Vlachopoulos L. Elongation Patterns of the Superficial Medial Collateral Ligament and the Posterior Oblique Ligament: A 3-Dimensional, Weightbearing Computed Tomography Simulation. Orthop J Sports Med 2022; 10:23259671221091264. [PMID: 35547613 PMCID: PMC9083062 DOI: 10.1177/23259671221091264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Although length change patterns of the medial knee structures have been reported, either the weightbearing state was not considered or quantitative radiographic landmarks that allow the identification of the insertion sites were not reported. Purpose: To (1) analyze the length changes of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) under weightbearing conditions and (2) to identify the femoral sMCL insertion site that demonstrates the smallest length changes during knee flexion and report quantitative radiographic landmarks. Study Design: Descriptive laboratory study. Methods: The authors performed a 3-dimensional (3D) analysis of 10 healthy knees from 0° to 120° of knee flexion using weightbearing computed tomography (CT) scans. Ligament length changes of the sMCL and POL during knee flexion were analyzed using an automatic string generation algorithm. The most isometric femoral insertion of the sMCL that demonstrated the smallest length changes throughout the full range of motion (ROM) was identified. Radiographic landmarks were reported on an isometric grid defined by a true lateral view of the 3D CT model and transferred to a digitally reconstructed radiograph. Results: The sMCL demonstrated small ligament length changes, and the POL demonstrated substantial shortening during knee flexion ( P = .005). Shortening of the POL started from 30° of flexion. The most isometric femoral sMCL insertion was located 0.6 ± 1.7 mm posterior and 0.8 ± 1.2 mm inferior to the center of the sMCL insertion and prevented ligament length changes >5% during knee flexion in all participants. The insertion was located 47.8% ± 2.7% from the anterior femoral cortex and 46.3% ± 1.9% from the joint line on a true lateral 3D CT view. Conclusion: The POL demonstrated substantial shortening starting from 30° of knee flexion and requires tightening near full extension to avoid overconstraint. Femoral sMCL graft placement directly posteroinferior to the center of the anatomical insertion of the sMCL demonstrated the most isometric behavior during knee flexion. Clinical Relevance: The described elongation patterns of the sMCL and POL aid in guiding surgical medial knee reconstruction and preventing graft lengthening and overconstraint of the medial compartment. Repetitive graft lengthening is associated with graft failure, and overconstraint leads to increased compartment pressure, cartilage degeneration, and restricted ROM.
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Affiliation(s)
- Sandro Hodel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Julian Hasler
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Sandro F. Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Monson JK, Schoenecker J, Matheson JW, O'Keefe J, Schwery N, Hickmann A. Modern Principles for Rehabilitation for Medial and Lateral Knee Ligament Surgery: How to Optimize Outcomes. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abermann E, Wierer G, Herbort M, Smigielski R, Fink C. MCL Reconstruction Using a Flat Tendon Graft for Anteromedial and Posteromedial Instability. Arthrosc Tech 2022; 11:e291-e300. [PMID: 35256966 PMCID: PMC8897492 DOI: 10.1016/j.eats.2021.10.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/26/2021] [Indexed: 02/03/2023] Open
Abstract
The main principles of the present medial collateral ligament (MCL) reconstruction techniques are (1) to approximate the natural anatomy and (2) to restore the main passive restraining structures in anteromedial and posteromedial knee instability. Therefore, we describe a technique using a flat tendon graft instead of tubular grafts with point-to-point bone fixation. Moreover, we address the deep MCL, a relevant restraint to anteromedial instability.
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Affiliation(s)
- Elisabeth Abermann
- Gelenkpunkt Innsbruck, Austria,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria
| | - Guido Wierer
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria,LKH Hall in Tirol, Hall, Austria
| | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria,OCM Clinic, Munich, Germany
| | | | - Christian Fink
- Gelenkpunkt Innsbruck, Austria,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria,Address correspondence to Christian Fink, M.D., Gelenkpunkt – Sports and Joint Surgery Innsbruck, Olympiastraße 39, 6020 Innsbruck, Austria.
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Arant LR, Roth JD. Development and evaluation of ligament phantoms targeted for shear wave tensiometry. J Mech Behav Biomed Mater 2022; 126:104984. [PMID: 34857491 PMCID: PMC8792233 DOI: 10.1016/j.jmbbm.2021.104984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/03/2021] [Accepted: 11/17/2021] [Indexed: 02/03/2023]
Abstract
Developing a shear wave tensiometer capable of non-invasively measuring ligament tension holds promise for enhancing research and clinical assessments of ligament function. Such development would benefit from tunable test specimens fabricated from well-characterized and consistent materials. Although previous work found that yarn can replicate the mechanical behavior of collateral ligaments, it is not obvious whether yarn-based phantoms would be suitable for development of a shear wave tensiometer for measuring ligament tension. Accordingly, the primary objective of this study was to characterize the mechanical properties and shear wave speed - stress relationships of ligament phantoms fabricated from yarn and silicone, and compare these results to published data from biological ligaments. We measured the mechanical properties and shear wave speeds during axial loading in nine phantoms with systematically varied material properties. We performed a simple linear regression between shear wave speed squared and axial stress to determine the shear wave speed - stress relationship for each phantom. We found comparable elastic moduli, hysteresis, and shear wave speed squared - stress regression parameters between the phantoms and collateral ligaments. For example, the ranges of the coefficients of determination (R2) and slopes across the nine phantoms were 0.84-0.95, and 0.78-1.27 kPa/m2/s2, respectively, which overlapped with the ranges found in a prior study in porcine collateral ligaments (0.84-0.996 and 0.34-1.18 kPa/m2/s2, respectively). Additionally, the shear wave speed squared - stress regression parameters varied predictably with the density of the phantom and the shear modulus of the silicone. In summary, we found that yarn-based phantoms serve as mechanical analogs for ligaments (i.e., are ligament mimicking), and thus, should prove beneficial for investigations into ligament structure-function relationships and in the development of a shear wave tensiometer for measuring ligament tension.
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Affiliation(s)
- Lesley R. Arant
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Joshua D. Roth
- Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI, USA,Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA
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Willinger L, Balendra G, Pai V, Lee J, Mitchell A, Jones M, Williams A. High incidence of superficial and deep medial collateral ligament injuries in 'isolated' anterior cruciate ligament ruptures: a long overlooked injury. Knee Surg Sports Traumatol Arthrosc 2022; 30:167-175. [PMID: 33661325 PMCID: PMC8800884 DOI: 10.1007/s00167-021-06514-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/19/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE In anterior cruciate ligament (ACL) injuries, concomitant damage to peripheral soft tissues is associated with increased rotatory instability of the knee. The purpose of this study was to investigate the incidence and patterns of medial collateral ligament complex injuries in patients with clinically 'isolated' ACL ruptures. METHODS Patients who underwent ACL reconstruction for complete 'presumed isolated' ACL rupture between 2015 and 2019 were retrospectively included in this study. Patient's characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the grade and location of injuries to the superficial MCL (sMCL), dMCL and the posterior oblique ligament (POL) recorded. All patients were clinically assessed under anaesthesia with standard ligament laxity tests. RESULTS Hundred patients with a mean age of 22.3 ± 4.9 years were included. The incidence of concomitant MCL complex injuries was 67%. sMCL injuries occurred in 62%, dMCL in 31% and POL in 11% with various injury patterns. A dMCL injury was significantly associated with MRI grade II sMCL injuries, medial meniscus 'ramp' lesions seen at surgery and bone oedema at the medial femoral condyle (MFC) adjacent to the dMCL attachment site (p < 0.01). Logistic regression analysis identified younger age (OR 1.2, p < 0.05), simultaneous sMCL injury (OR 6.75, p < 0.01) and the presence of bone oedema at the MFC adjacent to the dMCL attachment site (OR 5.54, p < 0.01) as predictive factors for a dMCL injury. CONCLUSION The incidence of combined ACL and medial ligament complex injuries is high. Lesions of the dMCL were associated with ramp lesions, MFC bone oedema close to the dMCL attachment, and sMCL injury. Missed AMRI is a risk factor for ACL graft failure from overload and, hence, oedema in the MCL (especially dMCL) demands careful assessment for AMRI, even in the knee lacking excess valgus laxity. This study provides information about specific MCL injury patterns including the dMCL in ACL ruptures and will allow surgeons to initiate individualised treatment. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lukas Willinger
- Department of Trauma and Orthopaedics, Chelsea and Westminster Hospital, Chelsea and Westminster NHS Foundation Trust, London, UK ,Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | | | - Vishal Pai
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Justin Lee
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Adam Mitchell
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Mary Jones
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Andy Williams
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.
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Anatomic medial knee reconstruction restores stability and function at minimum 2 years follow-up. Knee Surg Sports Traumatol Arthrosc 2022; 30:280-287. [PMID: 33616694 DOI: 10.1007/s00167-021-06502-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 02/10/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Chronic grade 3 tears of the medial collateral ligament and posterior oblique ligament may result in valgus laxity and anteromedial rotational instability after an isolated or multiligament injury. The purpose of this study was to prospectively analyze the restoration of physiologic medial laxity as assessed on stress radiography and patient reported subjective functional outcomes in patients who undergo an anatomic medial knee reconstruction. METHODS This was a prospective study which included patients with chronic (> 6 weeks old) posteromedial corner injury with or without other ligament and meniscus lesions. Pre- and post-operative valgus stress radiographs were performed in 20° knee flexion and functional outcome was recorded as per the International Knee Documentation Committee (IKDC) and Lysholm scores. All patients underwent anatomic medial reconstruction with two femoral and two tibial sockets using ipsilateral hamstring tendon autograft. Simultaneous ligament and meniscus surgery was performed as per the associated injury pattern. All patients were followed up for a minimum of 24 months post-surgery. RESULTS Thirty-four patients (23 males, 11 females) were enrolled in the study and all were available till final follow-up of mean 49.7 ± 14.9 months. The mean age was 30.6 ± 7.9 (18-52 years). Two patients had isolated medial sided lesions and 23 had associated ligament injuries. The mean follow up was 49.7 (24-72) months. The mean IKDC score improved from 58 ± 8.3 to 78.2 ± 9.5 (p < 0.001). Post-operatively there were 15 excellent, 11 good and 8 fair outcomes on Lysholm score. The mean pre-operative valgus side-to-side opening improved from 7.5 ± 2.5 mm to 1.2 ± 0.7 mm on stress radiography (p < 0.001). CONCLUSION Anatomic reconstruction of the superficial medial collateral and posterior oblique ligaments restore stability in a consistent manner cases of chronic grade 3 instability. The objective functional results, subjective outcomes and measures of static medial stability are satisfactory in the short term. LEVEL OF EVIDENCE IV.
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Anterolateral complex injuries occur in the majority of 'isolated' anterior cruciate ligament ruptures. Knee Surg Sports Traumatol Arthrosc 2022; 30:176-183. [PMID: 33796903 DOI: 10.1007/s00167-021-06543-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/18/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE The anterolateral soft tissue envelope of the knee is frequently injured at the time of ACL rupture. This study aims to investigate the MRI injury patterns to the Anterolateral complex and their associations in patients with acute 'isolated ligament' ACL ruptures. METHODS Professional athletes who underwent ACL reconstruction for complete ACL rupture between 2015 and 2019 were included in this study. Patients' characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the injuries to respective structures of the Anterolateral complex and their associations were recorded. RESULTS Anterolateral complex injuries were noted in 63% of cases. The majority of injuries were to Kaplan Fibre (39% isolated injury and 19% combined with Anterolateral ligament injury). There was a very low incidence of isolated Anterolateral ligament injuries (2%). Kaplan Fibre injuries are associated with the presence of lateral femoral condyle bone oedema, and injuries to the superficial MCL, deep MCL, and ramp lesions. High grade pivot shift test was not associated with the presence of Kaplan Fibre or Anterolateral ligament injuries. Patients with an intact Anterolateral complex sustained injury to other knee structures (13% to medial ligament complex, 14% to medial meniscus, and 16% to lateral meniscus). CONCLUSION There is a high incidence of concomitant Anterolateral complex injuries in combination with ACL ruptures, with Kaplan Fibre (and therefore the deep capsulo-osseous layer of the iliotibial band) being the most commonly injured structure. Anterolateral ligament injuries occur much less frequently. These findings reinforce the importance of considering the presence of, and if necessary, treating injuries to structures other than the ACL, as a truly isolated ACL injury is rare.
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Willinger L, Balendra G, Pai V, Lee J, Mitchell A, Jones M, Williams A. Medial meniscal ramp lesions in ACL-injured elite athletes are strongly associated with medial collateral ligament injuries and medial tibial bone bruising on MRI. Knee Surg Sports Traumatol Arthrosc 2022; 30:1502-1510. [PMID: 34341846 PMCID: PMC9033723 DOI: 10.1007/s00167-021-06671-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/16/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE Medial menisco-capsular separations (ramp lesions) are typically found in association with anterior cruciate ligament (ACL) deficiency. They are frequently missed preoperatively due to low MRI sensitivity. The purpose of this article was to describe demographic and anatomical risk factors for ramp lesions, and to identify concomitant lesions and define their characteristics to improve diagnosis of ramp lesions on MRI. METHODS Patients who underwent anterior cruciate ligament (ACL) reconstruction between September 2015 and April 2019 were included in this study. The presence/absence of ramp lesions was recorded in preoperative MRIs and at surgery. Patients' characteristics and clinical findings, concomitant injuries on MRI and the posterior tibial slope were evaluated. RESULTS One hundred patients (80 male, 20 female) with a mean age of 22.3 ± 4.9 years met the inclusion criteria. The incidence of ramp lesions diagnosed at surgery was 16%. Ramp lesions were strongly associated with injuries to the deep MCL (dMCL, p < 0.01), the superficial medial collateral ligament (sMCL, p < 0.01), and a small medial-lateral tibial slope asymmetry (p < 0.05). There was also good correlation between ramp lesions and bone oedema in the posterior medial tibia plateau (MTP, p < 0.05) and medial femoral condyle (MFC, p < 0.05). A dMCL injury, a smaller differential medial-lateral tibial slope than usual, and the identification of a ramp lesion on MRI increases the likelihood of finding a ramp lesion at surgery. MRI sensitivity was 62.5% and the specificity was 84.5%. CONCLUSION The presence on MRI of sMCL and/or dMCL lesions, bone oedema in the posterior MTP and MFC, and a smaller differential medial-lateral tibial slope than usual are highly associated with ramp lesions visible on MRI. Additionally, a dMCL injury, a flatter lateral tibial slope than usual, and the identification of a ramp lesion on MRI increases the likelihood of finding a ramp lesion at surgery. Knowledge of the risk factors and secondary injury signs associated with ramp lesions facilitate the diagnosis of a ramp lesion preoperatively and should raise surgeons' suspicion of this important lesion. LEVEL OF EVIDENCE Diagnostic study, Level III.
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Affiliation(s)
- Lukas Willinger
- grid.6936.a0000000123222966Department of Trauma Surgery, Technical University of Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - Ganesh Balendra
- grid.490147.fFortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Vishal Pai
- grid.490147.fFortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Justin Lee
- grid.490147.fFortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Adam Mitchell
- grid.490147.fFortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Mary Jones
- grid.490147.fFortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Andy Williams
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.
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Guenther D, Pfeiffer T, Petersen W, Imhoff A, Herbort M, Achtnich A, Stein T, Kittl C, Schoepp C, Akoto R, Höher J, Scheffler S, Stöhr A, Stoffels T, Mehl J, Jung T, Ellermann A, Eberle C, Vernacchia C, Lutz P, Krause M, Mengis N, Müller PE, Patt T, Best R. Treatment of Combined Injuries to the ACL and the MCL Complex: A Consensus Statement of the Ligament Injury Committee of the German Knee Society (DKG). Orthop J Sports Med 2021; 9:23259671211050929. [PMID: 34888389 PMCID: PMC8649102 DOI: 10.1177/23259671211050929] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/26/2021] [Indexed: 01/13/2023] Open
Abstract
Background: Different indications and treatment options for combined injuries to the anterior cruciate ligament (ACL) and medial collateral ligament complex (MCL) are not clearly defined. Purpose: To perform a modified Delphi process with the Committee for Ligament Injuries of the German Knee Society (DKG) in order to structure and optimize the process of treating a combined injury to the ACL and MCL. Study Design: Consensus statement. Methods: Scientific questions and answers were created based on a comprehensive literature review using the central registers for controlled studies of Medline, Scopus, and Cochrane including the terms medial collateral ligament, anterior cruciate ligament, MCL, ACL, and outcome used in various combinations. The obtained statements passed 3 cycles of a modified Delphi process during which each was readjusted and rated according to the available evidence (grades A-E) by the members of the DKG Ligament Injuries Committee and its registered guests. Results: The majority of answers, including several questions with >1 graded answer, were evaluated as grade E (n = 16) or C (n = 10), indicating that a low level of scientific evidence was available for most of the answers. Only 5 answers were graded better than C: 3 answers with a grade of A and 2 answers with a grade of B. Only 1 answer was evaluated as grade D. An agreement of >80% (range, 83%-100%) among committee members was achieved for all statements. Conclusion: The results of this modified Delphi process offer a guideline for standardized patient care in cases of combined injuries to the ACL and MCL.
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Affiliation(s)
- Daniel Guenther
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Thomas Pfeiffer
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Wolf Petersen
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Andreas Imhoff
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Mirco Herbort
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Andrea Achtnich
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Thomas Stein
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Christoph Kittl
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Christian Schoepp
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Ralph Akoto
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Jürgen Höher
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Sven Scheffler
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Amelie Stöhr
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Thomas Stoffels
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Julian Mehl
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Tobias Jung
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Andree Ellermann
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Christian Eberle
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Cara Vernacchia
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Patricia Lutz
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Matthias Krause
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Natalie Mengis
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Peter E Müller
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Thomas Patt
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Raymond Best
- Investigation performed at Cologne Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
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Garner AJ, Dandridge OW, Amis AA, Cobb JP, van Arkel RJ. Partial and Combined Partial Knee Arthroplasty: Greater Anterior-Posterior Stability Than Posterior Cruciate-Retaining Total Knee Arthroplasty. J Arthroplasty 2021; 36:3765-3772.e4. [PMID: 34330602 DOI: 10.1016/j.arth.2021.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/15/2021] [Accepted: 06/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Little is known regarding anterior-posterior stability after anterior cruciate ligament-preserving partial (PKA) and combined partial knee arthroplasty (CPKA) compared to standard posterior cruciate-retaining total knee arthroplasty (TKA). METHODS The anterior-posterior tibial translation of twenty-four cadaveric knees was measured, with optical tracking, while under 90N drawer with the knee flexed 0-90°. Knees were tested before and after PKA, CPKA (medial and lateral bicompartmental and bi-unicondylar), and then posterior cruciate-retaining TKA. The anterior-posterior tibial translations of the arthroplasty states, at each flexion angle, were compared to the native knee and each other with repeated measures analyses of variance and post-hoc t-tests. RESULTS Unicompartmental and bicompartmental arthroplasty states had similar laxities to the native knee and to each other, with ≤1-mm differences throughout the flexion range (P ≥ .199). Bi-unicondylar arthroplasty resulted in 6- to 8-mm increase of anterior tibial translation at high flexion angles compared to the native knee (P ≤ .023 at 80-90°). Meanwhile, TKA exhibited increased laxity across all flexion angles, with increased anterior tibial translation of up to 18 ± 6 mm (P < .001) and increased posterior translation of up to 4 ± 2 mm (P < .001). CONCLUSIONS In a cadaveric study, anterior-posterior tibial translation did not differ from native laxity after PKA and CPKA. Posterior cruciate ligament-preserving TKA demonstrated increased laxity, particularly in anterior tibial translation.
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Affiliation(s)
- Amy J Garner
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, White City Campus, London, UK; Mechanical Engineering Department, Biomechanics Group, Imperial College London, London, UK; Royal College of Surgeons of England and Dunhill Medical Trust Clinical Research Fellowship, Royal College of Surgeons of England, London, UK; Health Education Kent, Surrey and Sussex, London, UK
| | - Oliver W Dandridge
- Mechanical Engineering Department, Biomechanics Group, Imperial College London, London, UK
| | - Andrew A Amis
- Mechanical Engineering Department, Biomechanics Group, Imperial College London, London, UK
| | - Justin P Cobb
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, White City Campus, London, UK
| | - Richard J van Arkel
- Mechanical Engineering Department, Biomechanics Group, Imperial College London, London, UK
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50
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Kittl C, Robinson J, Raschke MJ, Olbrich A, Frank A, Glasbrenner J, Herbst E, Domnick C, Herbort M. Medial collateral ligament reconstruction graft isometry is effected by femoral position more than tibial position. Knee Surg Sports Traumatol Arthrosc 2021; 29:3800-3808. [PMID: 33454831 PMCID: PMC8514388 DOI: 10.1007/s00167-020-06420-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/14/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE The purpose of this study was to examine the length change patterns of the native medial structures of the knee and determine the effect on graft length change patterns for different tibial and femoral attachment points for previously described medial reconstructions. METHODS Eight cadaveric knee specimens were prepared by removing the skin and subcutaneous fat. The sartorius fascia was divided to allow clear identification of the medial ligamentous structures. Knees were then mounted in a custom-made rig and the quadriceps muscle and the iliotibial tract were loaded, using cables and hanging weights. Threads were mounted between tibial and femoral pins positioned in the anterior, middle, and posterior parts of the attachment sites of the native superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL). Pins were also placed at the attachment sites relating to two commonly used medial reconstructions (Bosworth/Lind and LaPrade). Length changes between the tibiofemoral pin combinations were measured using a rotary encoder as the knee was flexed through an arc of 0-120°. RESULTS With knee flexion, the anterior fibres of the sMCL tightened (increased in length 7.4% ± 2.9%) whilst the posterior fibres slackened (decreased in length 8.3% ± 3.1%). All fibre regions of the POL displayed a uniform lengthening of approximately 25% between 0 and 120° knee flexion. The most isometric tibiofemoral combination was between pins placed representing the middle fibres of the sMCL (Length change = 5.4% ± 2.1% with knee flexion). The simulated sMCL reconstruction that produced the least length change was the Lind/Bosworth reconstruction with the tibial attachment at the insertion of the semitendinosus and the femoral attachment in the posterior part of the native sMCL attachment side (5.4 ± 2.2%). This appeared more isometric than using the attachment positions described for the LaPrade reconstruction (10.0 ± 4.8%). CONCLUSION The complex behaviour of the native MCL could not be imitated by a single point-to-point combination and surgeons should be aware that small changes in the femoral MCL graft attachment position will significantly effect graft length change patterns. Reconstructing the sMCL with a semitendinosus autograft, left attached distally to its tibial insertion, would appear to have a minimal effect on length change compared to detaching it and using the native tibial attachment site. A POL graft must always be tensioned near extension to avoid capturing the knee or graft failure.
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Affiliation(s)
- Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany.
| | | | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Arne Olbrich
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Andre Frank
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Christoph Domnick
- Department of Trauma and Hand Surgery, Euregio Klinik Nordhorn, Nordhorn, Deutschland
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