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Muccioli GMM, Rinaldi VG, Zappia M, Lullini G, Bignozzi S, Zaffagnini S, Trinchese GF. Minimally invasive anatomic reconstruction of the anterolateral ligament with ipsilateral gracilis tendon: a kinematic in-vitro study. J Exp Orthop 2022; 9:107. [PMID: 36271953 PMCID: PMC9588119 DOI: 10.1186/s40634-022-00543-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022] Open
Abstract
Purpose The anterolateral ligament (ALL) has been defined as a key stabilizer of internal tibial rotation at 35° or more of knee flexion, with a minimal primary or secondary stabilizing role in the AP direction. This study aimed to demonstrate that anatomical reconstruction of the ALL confers rotational stability equal to that of the uninjured knee. Hypothesis: anteroposterior (AP) and rotatory laxity will significantly vary after ALL tenotomy and ALL reconstruction with the author’s previously described technique. Methods After ultrasound (US) ALL identification, different kinematic measurements were performed with an image-less Computer-Assisted Navigation System with dedicated software for Laxity Analysis in 5 knee specimens. Anteroposterior (AP) translations and varus/valgus (VV) and Internal-External (IE) rotations were evaluated by two trained orthopedic surgeons before ALL section, after ALL section, and after ALL anatomical reconstruction with doubled ipsilateral autologous gracilis tendon. Results ALL resection significantly increased laxity in IE rotations with knee 90° flexed (IE90) and AP translation with tibia internally rotated and the knee 30° flexed (APlat) (p < 0.05). ALL reconstruction significantly reduced laxity in IE90 and APlat (p < 0.05) and reduced VV rotations at 30° of flexion (VV30) (p < 0.05). There were no statistically significant elongation differences between native ALL and reconstructed ALL (graft) during laxity tests. The inter-operator repeatability of the tests was excellent for each measurement. Conclusions ALL acted as an important internal tibial rotation restrain at 90° and a significant (secondary) AP stabilizer at 30° of knee flexion. The presented ALL reconstruction technique significantly restored the increase of knee laxity produced by the ALL section. Scientific level Case-Controlled Laboratory Study, Level III.
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Affiliation(s)
- Giulio Maria Marcheggiani Muccioli
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy. .,DIBINEM University of Bologna, via di Barbiano, 1/10 - c/o Lab Biomeccanica ed Innovazione Tecnologica, 40136, Bologna, Italy.
| | - Vito Gaetano Rinaldi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marcello Zappia
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy.,Department of Radiology, Varelli Insitute, Naples, Italy
| | - Giada Lullini
- DIBINEM University of Bologna, via di Barbiano, 1/10 - c/o Lab Biomeccanica ed Innovazione Tecnologica, 40136, Bologna, Italy.,U.O.C. Medicina Riabilitativa e Neuroriabilitazione, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.,DIBINEM University of Bologna, via di Barbiano, 1/10 - c/o Lab Biomeccanica ed Innovazione Tecnologica, 40136, Bologna, Italy
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Abermann E, Herbst E, Herbort M, Smigielski R, Fink C. Instabilität des Kniegelenks – medial oder anteromedial? ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00564-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Zusammenfassung
Hintergrund
Verletzungen des medialen Bandkomplexes gehören zu den häufigsten Knieverletzungen. Sie heilen zwar meist mit konservativer Therapie problemlos aus, persistierende Instabilitäten erhöhen aber die Belastung der Kreuzbänder und benötigen speziell bei deren Beteiligung eine adäquate Therapie.
Anatomie und Biomechanik
Der mediale Seitenbandkomplex besteht im Wesentlichen aus dem oberflächlichen Seitenband (sMCL), welches der primäre Stabilisator gegen Valgus ist, dem tiefen Seitenband (dMCL) mit dessen schräg verlaufendem ventralem Anteil (AML), die nur sekundäre Stabilisatoren gegen Valgus darstellen, aber primär gegen Außenrotation stabilisieren, und dem hinteren Schrägband (POL), das in vollständiger Streckung gegen Valgus sowie gegen Innenrotation stabilisiert.
Therapie
Chronische Instabilitäten bzw. höhergradige Verletzungen mit Dislokation der Bandstümpfe oder multiligamentäre Verletzungen bedürfen einer operativen Versorgung. Im Akutstadium zeigen Avulsionsverletzungen bei anatomischer Refixation gutes Heilungspotenzial, während bei intraligamentären Verletzungen zusätzlich zur Naht der Bandanteile eine Augmentation mit Sehnenmaterial empfohlen wird. Bei chronischen Instabilitäten ist die Differenzierung des Instabilitätsmusters ausschlaggebend für die Wahl der Rekonstruktionstechnik (reine sMCL-Rekonstruktion oder kombinierte Rekonstruktion von sMCL und AML). In beiden Fällen kommt die hier beschriebene Technik mit flachem Transplantat der Anatomie näher als bei konventionellen Verfahren.
Diskussion
Rekonstruktionstechniken unter Verwendung flacher Sehnentransplantate, die alle betroffenen Bandanteile adressieren, haben sich biomechanisch als sehr effektiv erwiesen, komplexe mediale Instabilitäten suffizient zu behandeln. Ob diese auch klinisch überlegen sind, werden zukünftige klinische Studien zeigen müssen.
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53
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Xu J, Ye Z, Han K, Xu C, Zhao J, Dong S. Anterolateral Structure Reconstructions With Different Tibial Attachment Sites Similarly Improve Tibiofemoral Kinematics and Result in Different Graft Force in Treating Knee Anterolateral Instability. Arthroscopy 2022; 38:2684-2696. [PMID: 35337957 DOI: 10.1016/j.arthro.2022.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical effects of anterolateral structure reconstructions (ALSRs) with different tibial attachments on tibiofemoral kinematics and anterolateral structure (ALS) graft forces. METHODS Eight cadaveric knees were tested in a customized knee testing system, using a novel pulley system to simulate more muscle tensions by loading the iliotibial band at 30 N and quadriceps at 10 N in all testing states. Anterior stability during anterior load and anterolateral rotatory stability during 2 simulated pivot-shift tests (PST1 and PST2) were evaluated in 5 states: intact, ALS-deficient (Def), ALSR-Ta (anterior tibial site), ALSR-Tm (middle tibial site), and ALSR-Tp (posterior tibial site). Tibiofemoral kinematics and resulting ALS graft forces against the applied loads were measured and compared in the corresponding states. RESULTS In anterior load, 3 ALSRs mitigated the anterior laxities of the ALS Def state at all degrees, which were close to intact state at 0° and 30° but showed significantly overconstraints at 60° and 90°. In both PSTs, all ALSRs significantly reduced the anterolateral rotatory instability of ALS Def, whereas the significant overconstraints were detected in ALSR-Ta and ALSR-Tm at greater knee flexion angles. All ALS grafts carried forces in resisting anterior and pivot-shift loads. Only ALS graft force in ALSR-Ta increased continuously with knee flexion angles. The ALS graft forces carried by ALSR-Ta were significantly larger than those by ALSR-Tp and ALSR-Tm when resisting anterior load and PSTs at greater knee flexion angles. CONCLUSIONS ALSRs with different tibial attachment sites similarly restored knee laxities close to the native tibiofemoral kinematics in an ALS-deficient knee, whereas the ALSR-Tp showed less propensity for overconstraining the knee at greater flexion angles. The ALS graft in ALSR-Ta carried more forces than those in ALSR-Tp and ALSR-Tm against simulated loads. CLINICAL RELEVANCE Altering the tibial attachment sites of ALSRs may not significantly affect tibiofemoral kinematics at most degrees whereas the posterior may have less overconstraints at greater flexion angles. However, ALS graft positioning at a more anterior tibial attachment site may carry more forces in resisting anterior and pivot-shift loads.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Chalidis B, Pitsilos C, Kitridis D, Givissis P. Graft choices for anterolateral ligament knee reconstruction surgery: Current concepts. World J Clin Cases 2022; 10:8463-8473. [PMID: 36157796 PMCID: PMC9453348 DOI: 10.12998/wjcc.v10.i24.8463] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/26/2022] [Accepted: 07/17/2022] [Indexed: 02/05/2023] Open
Abstract
The anterolateral ligament (ALL) is a primary structure of the anterolateral complex of the knee that contributes to internal rotational stability of the joint. Injury of the ALL is commonly associated with rupture of the anterior cruciate ligament. If left untreated, ALL lesions may lead to residual anterolateral rotational instability of the knee after anterior cruciate ligament reconstruction, which is a common cause of anterior cruciate ligament graft failure. The function of the ALL can be restored by lateral extraarticular tenodesis or anterolateral ligament reconstruction (ALLR). In the lateral extraarticular tenodesis procedure, a strip of the iliotibial band is placed in a non-anatomical position to restrain the internal rotation of the tibia, while in ALLR, a free graft is fixed at the insertion points of the native ALL. Gracilis and semitendinosus grafts have mainly been utilized for ALLR, but other autografts have also been suggested. Furthermore, allografts and synthetic grafts have been applied to minimize donor-site morbidity and maximize the size and strength of the graft. Nevertheless, there has been no strong evidence to fully support one method over another thus far. The present review presents a detailed description of the graft choices for ALLR and the current literature available in regard to the effectiveness and outcomes of published surgical techniques.
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Affiliation(s)
- Byron Chalidis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 57010, Greece
| | - Charalampos Pitsilos
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 54635, Greece
| | - Dimitrios Kitridis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 57010, Greece
| | - Panagiotis Givissis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 57010, Greece
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Sabatini L, Capella M, Vezza D, Barberis L, Camazzola D, Risitano S, Drocco L, Massè A. Anterolateral complex of the knee: State of the art. World J Orthop 2022; 13:679-692. [PMID: 36159618 PMCID: PMC9453282 DOI: 10.5312/wjo.v13.i8.679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/07/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023] Open
Abstract
Rotatory instability of the knee represents the main reason for failure and poor clinical outcomes regarding anterior cruciate ligament (ACL) reconstruction techniques. It is now clear that the anterolateral complex (ALC) of the knee possesses a fundamental role, in association with the ACL, in controlling internal rotation. Over the past decade, ever since the anterolateral ligament has been identified and described as a distinct structure, there has been a renewed interest in the scientific community about the whole ALC: Lateral extra-articular tenodesis have made a comeback in association with ACL reconstructions to improve functional outcomes, reducing the risks of graft failure and associated injuries. Modern ACL reconstruction surgery must therefore investigate residual instability and proceed, when necessary, to extra-articular techniques, whether functional tenodesis or anatomical reconstruction.This review aims to investigate the latest anatomical and histological descriptions, and the role in rotational control and knee biomechanics of the ALC and its components. The diagnostic tools for its identification, different reconstruction techniques, and possible surgical indications are described.. In addition, clinical and functional results available in the literature are reported.
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Affiliation(s)
- Luigi Sabatini
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Marcello Capella
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Daniele Vezza
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Luca Barberis
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Daniele Camazzola
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Salvatore Risitano
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Luca Drocco
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Alessandro Massè
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
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Agarwal N, Monketh J, Volpin A. Clinical and mechanical outcomes in isolated anterior cruciate ligament reconstruction vs additional lateral extra-articular tenodesis or anterolateral ligament reconstruction. World J Orthop 2022; 13:662-675. [PMID: 36051377 PMCID: PMC9302030 DOI: 10.5312/wjo.v13.i7.662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/13/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction has been a successful treatment for ACL rupture. However ongoing rotational instability can be an issue. Several surgical techniques have been recommended to overcome this including lateral extra-articular tenodesis (LET) and more recently anterolateral ligament reconstruction (ALLR).
AIM To compare the clinical outcomes following ACL reconstruction (ACLR) alone or ACLR with either LET or ALLR.
METHODS A systematic review was conducted by means of four databases (MEDLINE, EMBASE, Cochrane and Clinical.Trials.Gov), and the Reference Citaion Analysis (https://www.referencecitationanalysis.com/) to identify all studies investigating either or both of LET and ALLR. The Critical Appraisal Skills Programme checklist for cohort studies was employed for critical appraisal and evaluation of all twenty-four studies which met the inclusion criteria.
RESULTS Pooled meta-analyses illustrated that ACLR with additional LET or ALLR results in improved pivot shift test scores, compared to isolated ACLR. There was no statistically significant difference in International Knee Documentation Committee (IKDC) clinical scores with addition of either LET or ALLR. ACL re-rupture rates were compared between LET and ALLR techniques. There was a statistically significant difference between techniques, with a 1.14% rupture rate in ACLR +ALLR, and 4.03% rupture rate in ACLR + LET. Isolated ACLR re-rupture rates were 12.59%, significantly higher than when augmented with either ALLR or LET (P < 0.0001 for both groups). There were no statistical differences in pivot shift test or IKDC scores between LET and ALLR techniques.
CONCLUSION This meta-analysis has found that use of either LET or ALLR in addition to ACLR results in improved mechanical outcomes suggesting surgeons should consider augmenting ACLR with an extra-articular procedure in patients with rotatory instability. Furthermore, both anterolateral extra articular procedures in addition to ACLR lead to reduced ACL re-rupture rates compared to isolated ACLR. Moreover, ALLR results in reduced ACL re-rupture rates, compared to LET. More research is needed to compare the two respective extra-articular procedures.
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Affiliation(s)
- Nikhil Agarwal
- Department of Trauma and Orthopaedics, University of Aberdeen, Aberdeen AB24 3FX, United Kingdom
| | - Jaibaji Monketh
- Health Education England North East, Newcastle Upon Tyne NE15 8NY, United Kingdom
| | - Andrea Volpin
- Department of Trauma and Orthopaedics, NHS Grampian, Elgin IV30 1SN, United Kingdom
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57
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Lee CS, Han SB, Jang KM. Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Using a Single Achilles Tendon Allograft: A Technical Note. Medicina (B Aires) 2022; 58:medicina58070929. [PMID: 35888648 PMCID: PMC9319999 DOI: 10.3390/medicina58070929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Clinical outcomes after anterior cruciate ligament reconstruction (ACLR) have improved remarkably. However, residual rotational instability of the knee joint remains a major concern. The anterolateral ligament (ALL) has recently gained interest as a secondary stabilizer of knee joint rotatory instability, and this has led to the attempt of ALL reconstruction (ALLR) in combination with ACLR to restore rotational stability in patients with anterior cruciate ligament (ACL) injury. Although several techniques for ALLR have recently been introduced, the ideal graft type and surgical technique for combined ACLR and ALLR are yet to be established. This technical note therefore aimed at introducing a novel surgical procedure involving the use of a single Achilles tendon allograft as a relatively simple and minimally invasive procedure for combined ALL and ACL reconstruction.
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Balendra G, Jones M, Borque KA, Willinger L, Pinheiro VH, Williams A. Factors affecting return to play and graft re-rupture after primary ACL reconstruction in professional footballers. Knee Surg Sports Traumatol Arthrosc 2022; 30:2200-2208. [PMID: 34636948 DOI: 10.1007/s00167-021-06765-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/28/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Modern ACL reconstruction (ACL-R) techniques have led to improved outcomes in professional footballers. The aim of this study was to identify and assess patient, surgical and post-operative factors that affected rates and time to return to play (RTP) as well as ACL re-rupture rates. METHODS A retrospective review of consecutive ACL-R undertaken in professional footballers between 2005 and 2018. RESULTS Two-hundred and thirty-two knees in 215 professional footballers (17 bilateral) were included. 205 (88.9%) were male and average age at surgery was 23.3 ± 4.4 years. Two-hundred and twenty-two (96.1%) returned to professional football, with 209 (90.1%) returning to the same or higher Tegner level. Subgroup analysis revealed three factors that independently affected RTP rate: (1) Players under 25 years had a higher rate of RTP (99.3% vs 90.2%. p = 0.001); (2) a subsequent operation prior to RTP decreased RTP rate from 98.2 to 89.7% (p = 0.009).; (3) undergoing meniscal surgery at ACL-R decreased RTP rate (p = 0.002). The mean time to RTP from surgery was 10.5 ± 3.6 months. Factors found to increase RTP time included age under 25 (11.0 vs 9.7 months, p = 0.005), recurrent effusions (11.4 vs 10.2 months, p = 0.035), and medial meniscal repair at ACL-R compared to meniscectomy (12.5 vs 9.6 months, p = 0.022). The surgical technique varied over the study period in relation to graft type, femoral tunnel position and addition of lateral extra-articular tenodesis (LET). Overall, the re-rupture rate was 8.2% at 2 years. Patella tendon autograft in an anteromedial bundle femoral tunnel position with addition of LET has the lowest re-rupture rate (2.0%). CONCLUSION Primary ACL-R in professional footballers yields high rates of RTP (96.1%), with 90.1% at the same level or higher, at a mean 10.5 months. Patients under 25 years not only had a significantly higher RTP rate, but also had a lengthier period of rehabilitation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Mary Jones
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK
| | - Kyle A Borque
- Houston Methodist Orthopedics and Sports Medicine, Houston, USA
| | - Lukas Willinger
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | | | - Andy Williams
- Fortius Clinic, 17 Fitzhardinge Street, London, W1H 6EQ, UK.
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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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60
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Keizer MNJ, Brouwer RW, de Graaff F, Hoogeslag RAG. Higher return to pre-injury type of sports after revision anterior ligament reconstruction with lateral extra-articular tenodesis compared to without lateral extra-articular tenodesis. Knee Surg Sports Traumatol Arthrosc 2022; 31:1699-1703. [PMID: 35739316 PMCID: PMC10090021 DOI: 10.1007/s00167-022-07018-y] [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: 02/02/2022] [Accepted: 05/16/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the rate of return to pre-injury type of sports (RTS type) in patients after revision anterior cruciate ligament reconstruction (ACLR) with lateral extra-articular tenodesis (LET) compared to patients after revision ACLR without LET. METHODS Seventy-eight patients who underwent revision ACLR with an autologous ipsilateral bone-patellar tendon-bone autograft with and without LET were included at least one year after surgery (mean follow-up: 43.9, SD: 29.2 months). All patients filled in a questionnaire about RTS type, the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective form (IKDCsubjective), and the Tegner activity score. RESULTS The RTS type for revision ACLR with LET was 22 of 42 (52%), whereas 11 of 36 (31%) of the patients who underwent revision ACLR without LET returned to the pre-injury type of sport (p = 0.05). No significant differences were found in KOOS subscores, IKDCsubjective, and Tegner activity scores. CONCLUSION An additional LET increases the rate of RTS type after revision ACLR. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michèle N J Keizer
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, UMCG Sector F, FA 23, PO Box 219, 9713 AV, Groningen, The Netherlands.
| | - Reinoud W Brouwer
- Department of Orthopedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Feike de Graaff
- Centre for Orthopaedic Surgery and Sports Medicine OCON, Hengelo, The Netherlands
| | - Roy A G Hoogeslag
- Centre for Orthopaedic Surgery and Sports Medicine OCON, Hengelo, The Netherlands
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61
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Anatomy, Biomechanics, and Reconstruction of the Anterolateral Ligament of the Knee Joint. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060786. [PMID: 35744048 PMCID: PMC9228568 DOI: 10.3390/medicina58060786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022]
Abstract
Despite remarkable advances in the clinical outcomes after anterior cruciate ligament reconstructions (ACLRs), residual rotational instability of the knee joint remains a major concern. Since the anterolateral ligament (ALL) on the knee joint has been “rediscovered”, the role of anterolateral structures, including ALL and deep iliotibial band, as secondary stabilizers of anterolateral rotatory instability has gained interest. This interest has led to the resurgence of anterolateral procedures combined with ACLRs to restore rotational stability in patients with anterior cruciate ligament (ACL) deficiencies. However, the difference in concepts between anterolateral ligament reconstructions (ALLRs) as anatomical reconstruction and lateral extra-articular tenodesis (LETs) as non-anatomical reinforcement has been conflicting in present literature. This study aimed to review the anatomy and biomechanics of anterolateral structures, surgical techniques, and the clinical outcomes of anterolateral procedures, including LET and ALLR, in patients with ACL deficiencies.
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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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Mayr R, Sigloch M, Coppola C, Hoermann R, Iltchev A, Schmoelz W. Modified Lemaire tenodesis reduces anterior cruciate ligament graft forces during internal tibial torque loading. J Exp Orthop 2022; 9:45. [PMID: 35583714 PMCID: PMC9117580 DOI: 10.1186/s40634-022-00484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/06/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The aim of the study was to directly measure graft forces of an anterior cruciate ligament reconstruction (ACLR) and a lateral extra-articular tenodesis (LET) using the modified Lemaire technique in combined anterior cruciate ligament (ACL) deficient and anterolateral rotatory instable knees and to analyse the changes in knee joint motion resulting from combined ACLR + LET. METHODS On a knee joint test bench, six fresh-frozen cadaveric specimens were tested at 0°, 30°, 60°, and 90° of knee flexion in the following states: 1) intact; 2) with resected ACL; 3) with resected ACL combined with anterolateral rotatory instability; 4) with an isolated ACLR; and 5) with combined ACLR + LET. The specimens were examined under various external loads: 1) unloaded; 2) with an anterior tibial translation force (ATF) of 98 N; 3) with an internal tibial torque (IT) of 5 Nm; and 4) with a combined internal tibial torque of 5 Nm and an anterior tibial translation force of 98 N (IT + ATF). The graft forces of the ACLR and LET were recorded by load cells incorporated into custom devices, which were screwed into the femoral tunnels. Motion of the knee joint was analysed using a 3D camera system. RESULTS During IT and IT + ATF, the addition of a LET reduced the ACLR graft forces up to 61% between 0° and 60° of flexion (P = 0.028). During IT + ATF, the LET graft forces reached 112 N. ACLR alone did not restore native internal tibial rotation after combined ACL deficiency and anterolateral rotatory instability. Combined ACLR + LET was able to restore native internal tibial rotation values for 0°, 60° and 90° of knee flexion with decreased internal tibial rotation at 30° of flexion. CONCLUSION The study demonstrates that the addition of a LET decreases the forces seen by the ACLR graft and reduces residual rotational laxity after isolated ACLR during internal tibial torque loading. Due to load sharing, a LET could support the ACLR graft and perhaps be the reason for reduced repeat rupture rates seen in clinical studies. Care must be taken not to limit the internal tibial rotation when performing a LET.
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Affiliation(s)
- Raul Mayr
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Maximilian Sigloch
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christian Coppola
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Romed Hoermann
- Institute for Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Alessandra Iltchev
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Werner Schmoelz
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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Ahn JH, Koh IJ, McGarry MH, Patel NA, Lin CC, Lee TQ. Synergistic effect of the anterolateral ligament and capsule injuries on the knee laxity in anterior cruciate ligament injured knees: A cadaveric study. Orthop Traumatol Surg Res 2022; 108:103224. [PMID: 35104628 DOI: 10.1016/j.otsr.2022.103224] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 01/03/2021] [Accepted: 11/29/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION There is much controversy about the practical role of the anterolateral ligament (ALL) and its relation to other anterolateral knee structures including the anterolateral capsule (ALC) and iliotibial band (ITB). The purpose of this cadaveric study was to investigate the effect of the ALL and ALC injuries on knee laxity with the iliotibial band (ITB) preserved in the anterior cruciate ligament (ACL)-injured knee. HYPOTHESIS The ALL and ALC would contribute to knee joint stability during anterior translation and internal rotation of the tibia in an ACL-injured knee. MATERIAL AND METHODS For 10 fresh-frozen cadaveric knees, we measured knee laxity with the following state of knee injuries with ITB preserved: (1) intact knee, (2) ACL-sectioned knee (ACL-), (3) additional sectioning of the ALL (ACL-/ALL-), and (4) additional sectioning of the ALC (ACL-/ALL-/ALC-). We did biomechanical measurements in internal-external rotation, anterior-posterior translation, and varus-valgus angulation for each condition at knee flexion angles of 0°, 30°, 60°, and 90°. RESULTS After we sectioned the ALL (ACL-/ALL-), the mean IR at 0°, 30°, 60°, and 90° of knee flexion were significantly increased, compared to the intact knee (p=<0.001, <0.001, <0.001, and 0.002) and ACL- (p=<0.001, <0.001, <0.001, and 0.002). The additional transection of the ALC (ACL-/ALL-/ALC-) significantly increased IR laxity from the ACL-/ALL- at 30°, 60°, and 90° (p=0.005, 0.003, and 0.047). For anterior laxity, ACL-/ALL- resulted in significantly increased anterior laxity from the ACL- at 30° and 60° (p=0.003 and 0.019), and ACL-/ALL-/ALC- significantly increased anterior laxity even from the ACL-/ALL- at 30° and 60° (p=0.007 and 0.011). For varus laxity, ACL-/ALL- resulted in significantly increased varus laxity from both the intact knee and ACL- at 60° (p=0.004 and 0.007) and 90° (p=<0.001 and<0.001). ACL-/ALL-/ALC- resulted in significantly increased varus from ACL-/ALL- at 60° and 90° (p=<0.001 and 0.003). CONCLUSION The anterolateral ligament and anterolateral capsule injuries in ACL-injured knees even with ITB preserved had a synergistic effect on knee laxity in the aspects of internal rotation, anterior translation, and varus angulation. LEVEL OF EVIDENCE II, Controlled laboratory study.
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Affiliation(s)
- Ji Hyun Ahn
- Department of Orthopaedic Surgery, Dongguk University Ilsan Hospital, 814 Siksadong, Ilsandonggu, Goyangsi, Gyeonggido, 411-773, South Korea.
| | - In Jun Koh
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Nilay A Patel
- Department of Orthopaedic Surgery, University of California, Irvine, CA, USA
| | - Charles C Lin
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
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Guarino A, Farinelli L, Iacono V, Screpis D, Piovan G, Rizzo M, Mariconda M, Zorzi C. Lateral extra-articular tenodesis and anterior cruciate ligament reconstruction in young patients: clinical results and return to sport. Orthop Rev (Pavia) 2022; 14:33696. [PMID: 35774923 PMCID: PMC9239354 DOI: 10.52965/001c.33696] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 12/23/2021] [Indexed: 03/24/2024] Open
Abstract
Lateral extra-articular tenodesis (L.E.T.) have been proposed to reduce the tibia's anterior translation and internal rotation in concomitant to Anterior cruciate ligament (A.C.L.) reconstruction. Recent studies show that the addition of L.E.T. to A.C.L. reconstruction results in a statistically significant reduction in graft failure. The purpose of the present study was to evaluate the clinical outcomes, complications, and rate of return to preinjury sports level in pediatric patients who underwent combined A.C.L. reconstruction with L.E.T. at a minimum 2-year follow-up. The authors retrospectively evaluated 42 pediatric patients at high risk of graft failure who experienced ACLR connected to L.E.T. IKDC and Tegner-Lysholm Knee Scores Scale were used to assess clinical outcomes, and the Tegner Activity Scale to evaluate the return to sport. No graft failure or subsequent surgery related to A.C.L. reconstruction occurred. Furthermore, 88% of patients returned to the sport. Satisfactory clinical results were obtained on a short and medium-term follow-up. These findings help to consider this procedure for active adolescents at a high risk of graft failure to enhance A.C.L. reconstruction.
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Affiliation(s)
- Amedeo Guarino
- Section of Orthopaedics. Department of Public Health, Federico II University, Naples (NA), Italy
| | - Luca Farinelli
- Clinical Orthopaedics Departement of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona(AN), Italy
| | - Venanzio Iacono
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
| | - Daniele Screpis
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
| | - Gianluca Piovan
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
| | - Maria Rizzo
- Section of Orthopaedics. Department of Public Health, Federico II University, Naples (NA), Italy
| | - Massimo Mariconda
- Section of Orthopaedics. Department of Public Health, Federico II University, Naples (NA), Italy
| | - Claudio Zorzi
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
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Onggo JR, Rasaratnam HK, Nambiar M, Onggo JD, Pai V, Damasena I, Riazi A, Babazadeh S. Anterior Cruciate Ligament Reconstruction Alone Versus With Lateral Extra-articular Tenodesis With Minimum 2-Year Follow-up: A Meta-analysis and Systematic Review of Randomized Controlled Trials. Am J Sports Med 2022; 50:1137-1145. [PMID: 33886399 DOI: 10.1177/03635465211004946] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lateral extra-articular tenodesis (LEAT) aims to improve anterolateral stability of the injured knee during anterior cruciate ligament reconstruction (ACLR) surgery. Inconclusive evidence surrounding the efficacy and safety of LEAT has propelled clinical interest and ongoing discussions. PURPOSE To establish level 1 evidence by assessing randomized controlled trials (RCTs) with minimum 2-year follow-up that directly compared ACLR with LEAT (LEAT group) and ACLR alone (non-LEAT group) in terms of clinical outcomes and complications. STUDY DESIGN Meta-analysis and systematic review; Level of evidence, 1. METHODS Meta-analysis was performed with a multidatabase search (Cochrane, EMBASE, OVID Medline, PubMed, and Web of Science) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on September 9, 2020. Data from published RCTs meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model. RESULTS A total of 7 RCTs were included, consisting of 517 LEAT and 589 non-LEAT patients. Only autografts were used for ACLR and LEAT. A variety of LEAT techniques and autograft fixation methods were used. We found improved stability (residual positive pivot shift: risk ratio [RR], 0.59; 95% CI, 0.39-0.88; P = .01) and better clinical outcomes (International Knee Documentation Committee [IKDC] score: mean difference [MD], 2.31; 95% CI, 0.54-4.09; P = .01; and Lysholm score: MD, 2.71; 95% CI, 0.68-4.75; P = .009) in the LEAT than non-LEAT group. Graft rerupture rate was 3 times less likely (RR, 0.31; 95% CI, 0.17-0.58; P < .001) in the LEAT group than the non-LEAT group. CONCLUSION Good-quality evidence is available to support the efficacy of LEAT in improving anterolateral knee stability and reducing graft reruptures in primary ACLR. LEAT should be considered in patients with high risk factors. Although Lysholm and IKDC scores were statistically better in the LEAT group, these are unlikely to be clinically significant. Future studies should aim to identify patient populations that would best benefit from LEAT with ACLR.
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Affiliation(s)
- James Randolph Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | | | - Mithun Nambiar
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Jason Derry Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Vishal Pai
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Iswadi Damasena
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Arash Riazi
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Sina Babazadeh
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
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Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review. Clin J Sport Med 2022; 32:139-144. [PMID: 34173782 DOI: 10.1097/jsm.0000000000000953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We present a review of revision anterior cruciate ligament (ACL) reconstruction in pediatric patients, discussing risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes. DATA SOURCES PubMed, Cochrane, and Embase databases were queried for relevant articles about revision ACL topics. All types of manuscripts, including clinical studies, basic science studies, case series, current concepts reviews, and systematic reviews were analyzed for relevant information. Current concepts on risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes were synthesized. MAIN RESULTS Surgical treatment should be individualized, and the graft type, fixation devices, tunnel placement, and complementary procedures (eg, extra-articular tenodesis) should be tailored to the patient's needs and previous surgeries. Rehabilitation programs should also be centered around eccentric strengthening, isometric quadriceps strengthening, active flexion range of motion of the knee, and an emphasis on closed chain exercises. Despite adherence to strict surgical and postoperative rehabilitation principles, graft refailure rate is high, and return to sports rate is low. CONCLUSION Rerupture of the ACL in the pediatric population is a challenging complication that requires special attention. Diagnostic evaluation of repeat ACL ruptures is similar to primary injuries. Although outcomes after revision ACL reconstruction are expectedly worse than after primary reconstruction, athletes do return to sport after proper rehabilitation. Further research is needed to continue to improve outcomes in this high-risk population, aimed at continued knee stability, graft survivorship, and improved quality of life.
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Shybut TB. Editorial Commentary: Anterior Cruciate Ligament Reconstruction Alone Is Not Sufficient in Anterolateral Complex Injury: Extra-Articular Augmentation (Lateral Extra-Articular Tenodesis [LET] or Anterolateral Ligament [ALL] Reconstruction) Allows Surgeons to Indicate Tight (LET) or Just Right (ALL) on a Case-by-Case Basis. Arthroscopy 2022; 38:925-927. [PMID: 35248237 DOI: 10.1016/j.arthro.2021.08.016] [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: 08/17/2021] [Accepted: 08/17/2021] [Indexed: 02/02/2023]
Abstract
Extra-articular augmentation has become an essential consideration in contemporary anterior cruciate ligament reconstruction (ACL) surgery. The verdict is still out on the extra-articular augmentation procedure of choice to accompany ACL surgery in the treatment of anterolateral rotatory instability. Anterolateral ligament reconstruction and lateral extra-articular tenodesis) are 2 common methods with clinical outcome data to support their use. Both procedures have demonstrated clinical effectiveness in reducing the rate of recurrent ACL tear/recurrent knee instability. Biomechanics studies to date have reached varied conclusions; however, a growing body of research including the study discussed here suggests both procedures enhance stability in the setting of surgical treatment of anterolateral rotatory instability, whereas ACL reconstruction alone is not sufficient in the setting of anterolateral complex injury. I suggest surgeons carefully consider when to augment ACL surgery with an extra-articular procedure and feel there is a place for both procedures. When extra constraint is indicated, I recommend lateral extra-articular tenodesis. When patient athletic demands may be lesser and a less-invasive procedure is indicated, anterolateral ligament augmentation of ACL reconstruction is my preference.
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Xu J, Han K, Lee TQ, Xu C, Su W, Chen J, Yu J, Dong S, Zhao J. Anterolateral Structure Reconstruction Similarly Improves the Stability and Causes Less Overconstraint in Anterior Cruciate Ligament-Reconstructed Knees Compared With Modified Lemaire Lateral Extra-articular Tenodesis: A Biomechanical Study. Arthroscopy 2022; 38:911-924. [PMID: 34358641 DOI: 10.1016/j.arthro.2021.06.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 06/13/2021] [Accepted: 06/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the kinematics of anterolateral structure (ALS) reconstruction (ALSR) and lateral extra-articular tenodesis (LET) in ACL-ALS-deficient knees with anterior cruciate ligament (ACL) reconstruction. METHODS Ten fresh-frozen cadaveric knees with the following conditions were tested: (1) intact, (2) ACL-ALS deficiency, (3) ACL reconstruction (ACLR), (4) ACLR combined with ALSR (ACL-ALSR) or LET (ACLR+LET). Anterior translation and tibial internal rotation were measured with 90-N anterior load and 5 N·m internal torque at 0°, 30°, 60°, and 90°. The anterolateral translation and internal rotation were also measured during a simulated pivot-shift test at 0°, 15°, 30°, and 45°. The knee kinematic changes in all reconstructions were compared with each other, with intact knees as the baseline. RESULTS Isolated ACLR failed to restore native knee kinematics in ACL-ALS-deficient knees. Both ACL-ALSR and ACLR+LET procedures decreased the anterior instability of the ACLR. However, ACLR+LET caused overconstraints in internal rotation at 30° (-3.73° ± 2.60°, P = .023), 60° (-4.96° ± 2.22°, P = .001) and 90° (-6.14° ± 1.60°, P < .001). ACL-ALSR also overconstrained the knee at 60° (-3.65° ± 1.90°, P < .001) and 90° (-3.18° ± 2.53°, P < .001). For a simulated pivot-shift test, both combined procedures significantly reduced the ACLR instability, with anterolateral translation and internal rotation being overconstrained in ACLR+LET at 30° (-3.32 mm ± 3.89 mm, P = .005; -2.58° ± 1.61°, P < .001) and 45° (-3.02 mm ± 3.95 mm, P = .012; -3.44° ± 2.86°, P < .001). However, the ACL-ALSR overconstrained only the anterolateral translation at 30° (-1.51 mm ± 2.39 mm, P = .046) and internal rotation at 45° (-2.09° ± 1.70°, P < .001). There were no significant differences between the two combined procedures at most testing degrees in each testing state, except for the internal rotation at 30° (P = .007) and 90° (P = .032) in internal rotation torque. CONCLUSION ACL reconstruction alone did not restore intact knee kinematics in knees with concurrent ACL tears and severe ALS injury (ACL-ALS-deficient status). Both ACL-ALSR and ACLR+LET procedures restored knee stability at some flexion degrees, with less overconstraints in internal rotation resulting from ACL-ALSR. CLINICAL RELEVANCE For patients with combined ACL tears and severe ALS deficiency, isolated ACLR probably results in residual rotational and pivot-shift instability. Both ACL-ALSR and ACLR+LET show promise for the improvement of knee stability, whereas ACL-ALSR has less propensity for knee overconstraint.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, U.S.A
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiakuo Yu
- Knee Surgery Department of the Institute of Sports Medicine & Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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71
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Devitt BM, Batty LM. High Rate of Initially Overlooked Kaplan Fiber Complex Injuries in Patients With Isolated Anterior Cruciate Ligament Injury: Letter to the Editor. Am J Sports Med 2022; 50:NP1-NP3. [PMID: 34984954 DOI: 10.1177/03635465211049385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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72
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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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Coquard M, Carrozzo A, Saithna A, Vigne G, Le Guen M, Fournier Y, Hager JP, Vieira TD, Sonnery-Cottet B. Anterolateral Ligament Reconstruction Does Not Delay Functional Recovery, Rehabilitation, and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Matched-Pair Analysis From the SANTI (Scientific ACL Network International) Study Group. Arthrosc Sports Med Rehabil 2022; 4:e9-e16. [PMID: 35141532 PMCID: PMC8811495 DOI: 10.1016/j.asmr.2021.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/22/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To determine whether the addition of an anterolateral ligament reconstruction (ALLR) resulted in delayed functional recovery (based on the Knee Santy Athletic Return to Sport [K-STARTS] score) at 6 months after anterior cruciate ligament reconstruction (ACLR). METHODS A retrospective analysis of prospectively collected data from consecutive patients who underwent an ACLR between September 2017 and December 2020 was conducted. Patients who received an isolated hamstring autograft (isolated ACLR group) were propensity matched in a 1:1 ratio to patients who received a hamstring autograft ACLR combined with an ALLR (ACLR-ALLR group). Outcome measures included the Tegner Activity Scale and the K-STARTS test-a validated composite return-to-sports test (including the Anterior Cruciate Ligament-Return to Sport After Injury scale, Qualitative Assessment of Single-Leg Landing tool, limb symmetry index, and ability to change direction using the Modified Illinois Change of Direction Test). RESULTS The study included 111 matched pairs. At 6 months postoperatively, there were no significant differences between groups in the overall K-STARTS score (65.4 for isolated ACLR vs 61.2 for ACLR-ALLR, P = .087) or the Tegner Activity Scale score (3.7 for isolated ACLR vs 3.8 for ACLR-ALLR, P = .45). In addition, an evaluation of the subscales of the K-STARTS score revealed no disadvantage across the domains of neuromuscular control, limb symmetry index, agility, or psychological readiness to return to sport when an ALLR was performed. CONCLUSIONS The addition of ALLR at the time of ACLR does not delay functional recovery. Specifically, at 6 months postoperatively, there was no disadvantage in patients undergoing ALLR-ACLR, when compared with those undergoing isolated ACLR, with respect to neuromuscular control, limb symmetry indices (hop tests), agility, or psychological readiness to return to sport. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Marine Coquard
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Alessandro Carrozzo
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Adnan Saithna
- Arizona Brain, Spine & Sports Injuries Center, Scottsdale, Arizona, U.S.A
| | | | | | - Yann Fournier
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Jean-Philippe Hager
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Lyon, France
- Address correspondence to Thais Dutra Vieira, M.D., Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, 24 Avenue Paul Santy, 69008, Lyon, France.
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Groupe Ramsay-Generale de Santé, Lyon, France
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Lindanger L, Strand T, Mølster AO, Solheim E, Inderhaug E. Effect of Early Residual Laxity After Anterior Cruciate Ligament Reconstruction on Long-term Laxity, Graft Failure, Return to Sports, and Subjective Outcome at 25 Years: Response. Am J Sports Med 2021; 49:NP73-NP74. [PMID: 34855550 DOI: 10.1177/03635465211049370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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75
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Anterior Cruciate Ligament Revision Reconstruction. J Am Acad Orthop Surg 2021; 29:723-731. [PMID: 34096902 DOI: 10.5435/jaaos-d-21-00088] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/03/2021] [Indexed: 02/01/2023] Open
Abstract
Revision anterior cruciate ligament (ACL) reconstruction is used in patients with recurrent instability after primary ACL reconstruction. Identifying the etiology of graft failure is critical to the success of revision reconstruction. The most common etiologies include technical errors, trauma, failure to recognize concomitant injuries, young age, incomplete rehabilitation, and hardware failure. Patients should undergo a complete history and physical examination with a specific focus on previous injury mechanism and surgical procedures. A revision ACL reconstruction is a technically demanding procedure, and the surgeon should be prepared to address bone tunnel osteolysis, concurrent meniscal, ligamentous, or cartilage lesions, and limb malalignment. Surgical techniques described in this article include both single-stage and two-stage reconstruction procedures. Rates of return to sport after a revision reconstruction are lower than after primary reconstruction. Future research should be focused on improving both single-stage and two-stage revision techniques, as well as concomitant procedures to address limb malalignment and associated injuries.
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76
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Chen J, Xu C, Cho E, Huangfu X, Zhao J. Reconstruction for Chronic ACL Tears with or without Anterolateral Structure Augmentation in Patients at High Risk for Clinical Failure: A Randomized Clinical Trial. J Bone Joint Surg Am 2021; 103:1482-1490. [PMID: 34138788 DOI: 10.2106/jbjs.20.01680] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this trial was to determine whether anterior cruciate ligament reconstruction (ACLR) with anterolateral structure augmentation (ALSA) would result in better clinical outcomes in patients with a high risk of clinical failure. METHODS From February 2017 to June 2018, 120 young, active adults with chronic anterior cruciate ligament injury and high risk of clinical failure were randomized. The patients were followed for >2 years, with 5 being lost to follow-up and 1 being withdrawn from the study. Clinical characteristics, operative findings, and postoperative clinical outcomes were analyzed. RESULTS The analysis included data from 114 patients, including 95 men and 19 women with a mean age (and standard deviation) of 30.1 ± 6.7 years in the ACLR group and 30.1 ± 6.4 years in the ALSA group. The rate of clinical failure was 20.4% (11 of 54 patients) and 3.3% (2 of 60 patients) in the ACLR and ALSA groups, respectively (difference, 17.1%; 95% confidence interval [CI], 5.3% to 29.8%; p = 0.007). Significantly higher rates of return to the preinjury level of sports (48.3% versus 27.8%; difference, 20.5%; 95% CI, 2.7% to 36.6%; p = 0.024) and to a competitive level of play (63.3% versus 42.6%; difference, 22.3%; 95% CI, 4.1% to 38.8%; p = 0.027) was found in the ALSA group. CONCLUSIONS Compared with isolated ACLR, combined ACLR and ALSA resulted in a reduction in persistent rotatory laxity and higher rates of return to preinjury and competitive levels of play at 2 years of follow-up in the population studied. Our study suggests that patients with high risk of clinical failure appear to be candidates for the ALSA approach. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
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Combined Anterolateral and Anterior Cruciate Ligament Reconstruction Improves Pivot Shift Compared With Isolated Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arthroscopy 2021; 37:2677-2703. [PMID: 33864833 DOI: 10.1016/j.arthro.2021.03.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis of the literature on anterolateral ligament (ALL) reconstruction as it relates to techniques, biomechanical properties, and clinical outcomes. METHODS PubMed, OVID/Medline, and Embase were queried in July 2020. Data pertaining to (1) techniques, (2) biomechanical properties, and (3) clinical outcomes of ALL reconstruction were recorded. DerSimonian-Laird random-effects meta-analyses were performed for included randomized controlled trials comparing combined ALL/anterior cruciate ligament (ACL) reconstruction and isolated ACL reconstruction. Data from lower levels of evidence were described qualitatively, and when possible, outcomes were reported as ranges to avoid inappropriate pooling of data. RESULTS A total of 46 articles were identified. Sixteen were biomechanical studies, 16 were clinical outcome studies, and 14 were technique studies. Of the 16 biomechanical studies, the majority demonstrated that anterior translation, internal rotation, and pivot shift was restored with combined ACL/ALL reconstruction and superior to ACL reconstruction alone. Ten biomechanical studies reported on constraint: 4 noted overconstraint when the femoral attachment site was proximal and posterior to the lateral femoral condyle, whereas 1 reported laxity. ACL failure rates after combined ACL/ALL reconstruction ranged between 2.7% and 11.1%. The mean postoperative Lysholm score ranged between 58.7 and 98.0; mean postoperative International Knee Documentation Committee score between 57.8 and 96.3; and mean postoperative Tegner score between 4 and 8. Six outcomes were explored through meta-analysis, of which the mean difference in Lysholm scores (2.26, P < .001) and restoration of pivot shift (relative risk 1.1, P = .046) was found to favor combined ACL/ALL reconstruction. CONCLUSIONS Although indications for ALL reconstruction remain heterogeneous, contemporary evidence suggests that ALL reconstruction improves pivot shift and confers comparable clinical and functional outcomes with isolated ACLR. LEVEL OF EVIDENCE IV, systematic review and meta-analysis.
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78
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Yin J, Yang K, Zheng D, Xu N. Anatomic reconstruction of the anterior cruciate ligament of the knee with or without reconstruction of the anterolateral ligament: A meta-analysis. J Orthop Surg (Hong Kong) 2021; 29:2309499020985195. [PMID: 33410381 DOI: 10.1177/2309499020985195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To systematically analyze the effectiveness between combined anterior cruciate ligament and anterolateral ligament reconstruction (ACL+ALLR) and isolated anterior cruciate ligament reconstruction (ACLR) for treatment of patients with injured ACL. METHODS We performed a systematic search in MEDLINE, EMBASE, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, CNKI, and Wanfang Data for all relevant studies. All statistical analysis was performed using Review Manager version 5.3. RESULTS A total of six articles with 460 study subjects were included, with 193 patients in ACL+ALL reconstruction group and 267 patients in ACL reconstruction group. The results of the meta-analysis showed that the ACL+ALL reconstruction group had significantly lower KT measured value (P < 0.00001), Lachman test positive-rate (P = 0.02), Pivot-shift test positive-rate (P < 0.00001) and graft rupture rate (P = 0.02) compared with the ACL reconstruction group. Higher IKDC score (P < 0.00001) and Lysholm score (P < 0.00001) were measured in ACL+ALL reconstruction group, while infection rate (P = 0.86) and other complications rate (P = 0.29) showed no significant differences between the two groups. CONCLUSIONS Anatomic reconstruction of the ACL of the knee with reconstruction of the ALL indicates better postoperative knee function and clinical outcomes compared with isolated ACL reconstruction. The infection rate and other complications rate showed no significant difference between two groups.
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Affiliation(s)
- Jianjian Yin
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Kaiyuan Yang
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Dong Zheng
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Nanwei Xu
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
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79
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Saithna A, Helito CP, Vieira TD, Sonnery-Cottet B, Muramatsu K. The Anterolateral Ligament Has Limited Intrinsic Healing Potential: A Serial, 3-Dimensional-Magnetic Resonance Imaging Study of Anterior Cruciate Ligament-Injured Knees From the SANTI Study Group. Am J Sports Med 2021; 49:2125-2135. [PMID: 34015246 DOI: 10.1177/03635465211013015] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent imaging studies demonstrate that the anterolateral ligament (ALL) is frequently injured at the time of anterior cruciate ligament (ACL) rupture. The intrinsic healing potential of these injuries after ACL reconstruction (ACLR) has not been defined. PURPOSE/HYPOTHESIS The primary objective was to evaluate the rate and duration of the healing process of injured ALLs after ACLR using serial 3-dimensional magnetic resonance imaging (3D-MRI). The secondary objective was to investigate whether any patient, injury, or surgical factors influenced the healing rate. The hypothesis was that serial imaging would demonstrate that the ALL has limited healing potential. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients enrolled in the study underwent 3D-MRI (slice thickness 0.5 mm) preoperatively and at 1, 6, 12, and 24 months after ACLR. Three observers determined the grade of ALL injury according to the Muramatsu classification. Inter- and intraobserver reliabilities were calculated. The rates of injury and time points for healing were determined. Full healing was defined as a change from a preoperative Muramatsu grade of B or C (indicating partial or complete injury) to grade A (normal). Multivariate analysis was used to investigate the association of aforementioned factors with the risk of incomplete healing. RESULTS A total of 44 patients were enrolled in the study. Of them, 71.2% had an ALL injury on preoperative imaging. Overall, full healing of ALL injuries occurred at a rate of 3.2%, 15.2%, and 30.3% at 1, 6, and 12 months, respectively. There were no changes in the Muramatsu grade in any patient beyond 12 months postoperatively. None of the complete lesions demonstrated full healing, but the proportion of patients with a grade C injury decreased from 13.6% preoperatively to 4.5% at 12 months due to an improvement to grade B in 4 of 6 patients (66%). Inter- and intraobserver reliabilities of the classification system were almost perfect at 0.81-0.94 and 0.95-1.00, respectively. None of the potential risk factors investigated were predictive of an increased risk of nonhealing. CONCLUSION ALL injuries occurred in the majority of ACL-injured knees. They had limited intrinsic healing potential, with only 30.3% healing by 12 months after ACLR. The process of healing took >6 months in half of the patients in whom it occurred. No new cases of full healing occurred beyond 12 months postoperatively. No significant risk factors for failure of full healing to occur were identified, but it is likely that this aspect of the study was underpowered.
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Affiliation(s)
- Adnan Saithna
- AZBSC Orthopedics, Scottsdale, Arizona, USA.,School of Science & Technology, Nottingham Trent University, Clifton Campus, Nottingham, UK
| | - Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Thais Dutra Vieira
- Centre Orthopedique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Generale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopedique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Generale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
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80
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Ahn JH, Koh IJ, McGarry MH, Patel NA, Lin CC, Lee TQ. Double-Bundle Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Tenodesis Is Effective in Restoring Knee Stability in a Chronic, Complex Anterior Cruciate Ligament-Injured Knee Model: A Cadaveric Biomechanical Study. Arthroscopy 2021; 37:2220-2234. [PMID: 33705893 DOI: 10.1016/j.arthro.2021.02.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 02/17/2021] [Accepted: 02/25/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare knee stability after intra-articular isolated double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) and single-bundle (SB) and DB ACLR combined with lateral extra-articular tenodesis (LET) in a chronic, complex anterior cruciate ligament (ACL)-injured knee model. METHODS In 10 fresh-frozen cadaveric knees, we measured knee laxity in the following order: (1) intact knee; (2) ACL-sectioned knee; (3) complex ACL-injured knee model with additional sectioning of the anterolateral complex and the posterior horns of the medial and lateral menisci; (4) SB ACLR plus LET; (5) DB ACLR; and (6) DB ACLR plus LET. RESULTS In comparison with the intact knee, significantly increased internal rotation (IR) laxity persisted at 60° and 90° after DB ACLR (P = .002 and P = .003, respectively). SB ACLR plus LET and DB ACLR plus LET resulted in significant reductions in IR laxity at 90° (P = .003 and P = .037, respectively), representing overconstraint in IR. SB ACLR plus LET resulted in persistently increased external rotation (ER) laxity at 30°, 60°, and 90° (P = .001, P < .001, and P < .001, respectively). The DB ACLR condition persistently showed significant increases in anterior tibial translation laxity at 60° and 90° (P = .037 and P = .024, respectively). A greater increase in ER laxity was seen after SB ACLR plus LET versus DB ACLR plus LET at 30°, 60°, and 90° (P < .001, P < .001, and P < .001, respectively). CONCLUSIONS DB ACLR plus LET restored intact knee stability in IR, ER, and anterior tibial translation laxity at 0°, 30°, 60°, and 90° of knee flexion except for overconstraint in IR at 90° in a chronic, complex ACL-injured knee model. CLINICAL RELEVANCE This cadaveric study provides some biomechanical evidence to support performing DB ACLR combined with LET to restore knee stability after a complex, chronic knee injury involving an ACL tear combined with anterolateral complex injury and irreparable tears of the posterior horns of the medial and lateral menisci.
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Affiliation(s)
- Ji Hyun Ahn
- Department of Orthopaedic Surgery, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea.
| | - In Jun Koh
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, U.S.A
| | - Nilay A Patel
- Department of Orthopaedic Surgery, University of California, Irvine, California, U.S.A
| | - Charles C Lin
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, U.S.A
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, U.S.A
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81
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Willinger L, Athwal KK, Williams A, Amis AA. An Anterior Cruciate Ligament In Vitro Rupture Model Based on Clinical Imaging. Am J Sports Med 2021; 49:2387-2395. [PMID: 34115540 PMCID: PMC8283191 DOI: 10.1177/03635465211017145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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 Biomechanical studies on anterior cruciate ligament (ACL) injuries and reconstructions are based on ACL transection instead of realistic injury trauma. PURPOSE To replicate an ACL injury in vitro and compare the laxity that occurs with that after an isolated ACL transection injury before and after ACL reconstruction. STUDY DESIGN Controlled laboratory study. METHODS Nine paired knees were ACL injured or ACL transected. For ACL injury, knees were mounted in a rig that imposed tibial anterior translation at 1000 mm/min to rupture the ACL at 22.5° of flexion, 5° of internal rotation, and 710 N of joint compressive force, replicating data published on clinical bone bruise locations. In contralateral knees, the ACL was transected arthroscopically at midsubstance. Both groups had ACL reconstruction with bone-patellar tendon-bone graft. Native, ACL-deficient, and reconstructed knee laxities were measured in a kinematics rig from 0° to 100° of flexion with optical tracking: anterior tibial translation (ATT), internal rotation (IR), anterolateral (ATT + IR), and pivot shift (IR + valgus). RESULTS The ACL ruptured at 26 ± 5 mm of ATT and 1550 ± 620 N of force (mean ± SD) with an audible spring-back tibiofemoral impact with 5o of valgus. ACL injury and transection increased ATT (P < .001). ACL injury caused greater ATT than ACL transection by 1.4 mm (range, 0.4-2.2 mm; P = .033). IR increased significantly in ACL-injured knees between 0° and 30° of flexion and in ACL transection knees from 0° to 20° of flexion. ATT during the ATT + IR maneuver was increased by ACL injury between 0° and 80° and after ACL transection between 0° and 60°. Residual laxity persisted after ACL reconstruction from 0° to 40° after ACL injury and from 0° to 20° in the ACL transection knees. ACL deficiency increased ATT and IR in the pivot-shift test (P < .001). The ATT in the pivot-shift increased significantly at 0° to 20° after ACL transection and 0° to 50° after ACL injury, and this persisted across 0° to 20° and 0° to 40° after ACL reconstruction. CONCLUSION This study developed an ACL injury model in vitro that replicated clinical ACL injury as evidenced by bone bruise patterns. ACL injury caused larger increases of laxity than ACL transection, likely because of damage to adjacent tissues; these differences often persisted after ACL reconstruction. CLINICAL RELEVANCE This in vitro model created more realistic ACL injuries than surgical transection, facilitating future evaluation of ACL reconstruction techniques.
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Affiliation(s)
- Lukas Willinger
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK,Orthopaedic Surgery Department, Technical University of Munich, Munich, Germany
| | - Kiron K. Athwal
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
| | - 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), Mechanical Engineering Department, Imperial College London, London, SW7 2AZ, UK ()
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82
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Kelly SR, Cutter BM, Huish EG. Biomechanical Effects of Combined Anterior Cruciate Ligament Reconstruction and Anterolateral Ligament Reconstruction: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9:23259671211009879. [PMID: 34250171 PMCID: PMC8237218 DOI: 10.1177/23259671211009879] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/16/2020] [Indexed: 01/26/2023] Open
Abstract
Background: Combined anterior cruciate ligament (ACL) reconstruction (ACLR) and
anterolateral ligament reconstruction (ALLR) are performed with the
intention to restore native knee kinematics after ACL tears. There continue
to be varying results as to the difference in kinematics between combined
and isolated procedures, including anterior tibial translation (ATT) and
internal tibial rotation (IR). Purpose: To perform a systematic review and meta-analysis to evaluate the kinematic
changes of a combined ACLR/ALLR versus isolated ACLR and to assess the
effects of different fixation techniques. Study Design: Systematic review. Methods: We conducted a systematic review and meta-analysis of 15 human cadaveric
biomechanical studies evaluating combined ACLR/ALLR versus isolated ACLR and
their effects on ATT and IR in 149 specimens. The primary outcomes were ATT
and IR. Secondary outcomes included graft type and size as well as fixation
methods such as type, angle, tension, and position of fixation.
Meta-regression was used to examine the effect of various cofactors on the
resulting measures. Results: Compared with isolated ACLR, combined ACLR/ALLR decreased ATT and IR by 0.01
mm (95% CI, –0.059 to 0.079 mm; P = .777) and 1.64° (95%
CI, 1.30°-1.98°; P < .001), respectively. Regarding
ACLR/ALLR, increasing the knee flexion angle and applied IR force led to a
significant reduction in IR (P < .001 and
P = .044, respectively). There was also a significant
reduction in IR in combined procedures with semitendinosus ALL graft, higher
flexion fixation angles, and tension but no change in IR with differing
femoral fixation points (P < .001, P
< .001, and P = .268, respectively). Multivariate
meta-regression showed that the use of tibial-sided suture anchor fixation
significantly reduced IR (P < .001). Conclusion: These results suggest that a combined ACLR/ALLR procedure significantly
decreases IR compared with isolated ACLR, especially at higher knee flexion
angles. Semitendinosus ALL graft, fixation at higher knee flexion, increased
tensioning, and tibial-sided interference screw fixation in ALLR may help to
further reduce IR.
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Affiliation(s)
- Shayne R Kelly
- San Joaquin General Hospital, French Camp, California, USA.,Valley Orthopedic Surgery Residency, Modesto, California, USA
| | - Brendan M Cutter
- San Joaquin General Hospital, French Camp, California, USA.,Valley Orthopedic Surgery Residency, Modesto, California, USA
| | - Eric G Huish
- San Joaquin General Hospital, French Camp, California, USA.,Valley Orthopedic Surgery Residency, Modesto, California, USA
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Hecker A, Egli RJ, Liechti EF, Leibold CS, Klenke FM. Multiplanar reformation improves identification of the anterolateral ligament with MRI of the knee. Sci Rep 2021; 11:13216. [PMID: 34168252 PMCID: PMC8225870 DOI: 10.1038/s41598-021-92707-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/14/2021] [Indexed: 11/09/2022] Open
Abstract
The anterolateral ligament (ALL) is subject of the current debate concerning rotational stability in case of anterior cruciate ligament (ACL) injuries. Today, reliable anatomical and biomechanical evidence for its existence and course is available. Some radiologic studies claim to be able to identify the ALL on standard coronal plane MRI sections. In the experience of the authors, however, ALL identification on standard MRI sequences frequently fails and is prone to errors. The reason for this mainly lies in the fact, that the entire ALL often cannot be identified on a single MRI image. This study aimed to establish an MRI evaluation protocol improving the visualization of the ALL, using multiplanar reformation (MPR) with the goal to be able to evaluate the ALL on one MRI image. A total of 47 knee MRIs performed due to atraumatic knee pain between 2018 and 2019 without any pathology were analyzed. Identification of the ALL was performed twice by an orthopedic surgeon and a radiologist on standard coronal plane and after MPR. For the latter axial and coronal alignment was obtained with the femoral condyles as a reference. Then the coronal plane was adjusted to the course of the ALL with the lateral epicondyle as proximal reference. Visualization of the ALL was rated as “complete” (continuous ligamentous structure with a tibial and femoral insertion visible on one coronal image), “partial” (only parts of the ALL like the tibial insertion were visible) and “not visible”. The distances of its tibial insertion to the bony joint line, Gerdy’s tubercle and the tip of the fibular head were measured. On standard coronal images the ALL was fully visible in 17/47, partially visible in 27/47, and not visible in 3/47 cases. With MPR the ALL was fully visible in 44/47 and not visible in 3/47 cases. The median distance of its tibial insertion to the bony joint line, Gerdy’s tubercle and the tip of the fibular head were 9, 21 and 25 mm, respectively. The inter- (ICC: 0.612; 0.645; 0.757) and intraobserver (ICC: 0.632; 0.823; 0.857) reliability was good to excellent. Complete visualization of the ALL on a single MRI image is critical for its identification and evaluation. Applying multiplanar reformation achieved reliable full-length visualization of the ALL in 94% of cases. The described MPR technique can be applied easily and fast in clinical routine. It is a reliable tool to improve the assessment of the ALL.
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Affiliation(s)
- Andreas Hecker
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Rainer J Egli
- Department of Diagnostic, Interventional and Pediatric Radiology (DIPR), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emanuel F Liechti
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christiane S Leibold
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Frank M Klenke
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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84
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Chiba D, Gale T, Nishida K, Suntaxi F, Lesniak BP, Fu FH, Anderst W, Musahl V. Lateral Extra-articular Tenodesis Contributes Little to Change In Vivo Kinematics After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial. Am J Sports Med 2021; 49:1803-1812. [PMID: 33872056 DOI: 10.1177/03635465211003298] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lateral extra-articular tenodesis (LET) in combination with anterior cruciate ligament (ACL) reconstruction (ACLR) has been proposed to improve residual rotatory knee instability in patients having ACL deficiency. PURPOSE/HYPOTHESIS The purpose was to compare the effects of isolated ACLR (iACLR) versus LET in combination with ACLR (ACLR+LET) on in vivo kinematics during downhill running. It was hypothesized that ACLR+LET would reduce the internal rotation of the reconstructed knee in comparison with iACLR. STUDY DESIGN Controlled laboratory study. METHODS A total of 18 patients with ACL deficiency were included. All participants were randomly assigned to receive ACLR+ LET or iACLR during surgery. Six months and 12 months after surgery, knee joint motion during downhill running was measured using dynamic biplane radiography and a validated registration process that matched patient-specific 3-dimensional bone models to synchronized biplane radiographs. Anterior tibial translation (ATT; positive value means "anterior translation") and tibial rotation (TR) relative to the femur were calculated for both knees. The side-to-side differences (SSDs) in kinematics were also calculated (operated knee-contralateral healthy knee). The SSD value was compared between ACLR+LET and iACLR groups using a Mann-Whitney U test. RESULTS At 6 months after surgery, the SSD of ATT in patients who had undergone ACLR+LET (-1.9 ± 2.0 mm) was significantly greater than that in patients who had undergone iACLR (0.9 ± 2.3 mm) at 0% of the gait cycle (foot strike) (P = .031). There was no difference in ATT 12 months after surgery. Regarding TR, there were no differences between ACLR+LET and iACLR at either 6 months (P value range, .161-.605) or 12 months (P value range, .083-.279) after surgery. CONCLUSION LET in combination with ACLR significantly reduced ATT at the instant of foot strike during downhill running at 6 months after surgery. However, this effect was not significant at 12 months after surgery. The addition of LET to ACLR had no effect on TR at both 6 and 12 months after surgery. CLINICAL RELEVANCE LET in combination with ACLR may stabilize sagittal knee motion during downhill running in the early postoperation phase, but according to this study, it has no effect on 12-month in vivo kinematics. REGISTRATION NCT02913404 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Daisuke Chiba
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan.,Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tom Gale
- Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kyohei Nishida
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Felipe Suntaxi
- Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bryson P Lesniak
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William Anderst
- Biodynamics Laboratory, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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85
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Anterolateral Rotatory Laxity: What is it, When to Address it, and How? OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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86
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Marmura H, Getgood AMJ, Spindler KP, Kattan MW, Briskin I, Bryant DM. Validation of a Risk Calculator to Personalize Graft Choice and Reduce Rupture Rates for Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2021; 49:1777-1785. [PMID: 33945339 DOI: 10.1177/03635465211010798] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstructions (ACLRs) fail at an alarmingly high rate in young active individuals. The Multicenter Orthopaedic Outcomes Network (MOON) knee group has developed an autograft risk calculator that uses patient characteristics and lifestyle to predict the probability of graft rupture if the surgeon uses a hamstring tendon (HT) or a bone-patellar tendon-bone (BPTB) graft to reconstruct the ligament. If validated, this risk calculator can be used during the shared decision-making process to make optimal ACLR autograft choices and reduce rupture rates. The STABILITY 1 randomized clinical trial offers a large, rigorously collected data set of similar young active patients who received HT autograft with or without lateral extra-articular tenodesis (LET) for ACLR. PURPOSE/HYPOTHESIS The purpose was to validate the ACLR graft rupture risk calculator in a large external data set and to investigate the utility of BPTB and LET for ACLR. We hypothesized that the risk calculator would maintain adequate discriminative ability and calibration in the external STABILITY 1 data set when compared with the initial MOON development data set. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 1. METHODS The model predictors for the risk calculator include age, sex, body mass index, sport played at the time of injury, Marx Activity Score, preoperative knee laxity, and graft type. The STABILITY 1 trial data set was used for external validation. Discriminative ability, calibration, and diagnostic test validity of the model were assessed. Finally, predictor strength in the initial and validation samples was compared. RESULTS The model showed acceptable discriminative ability (area under the curve = 0.73), calibration (Brier score = 0.07), and specificity (85.3%) to detect patients who will experience a graft rupture. Age, high-grade preoperative knee laxity, and graft type were significant predictors of graft rupture in young active patients. BPTB and the addition of LET to HT were protective against graft rupture versus HT autograft alone. CONCLUSION The MOON risk calculator is a valid predictor of ACLR graft rupture and is appropriate for clinical practice. This study provides evidence supporting the idea that isolated HT autografts should be avoided for young active patients undergoing ACLR. REGISTRATION NCT00463099 (MOON); NCT02018354 (STABILITY 1) (ClinicalTrials.gov identifiers).
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Affiliation(s)
- Hana Marmura
- Faculty of Health Sciences, Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada.,Lawson Research, London Health Sciences Centre, London, Ontario, Canada
| | - Alan M J Getgood
- Faculty of Health Sciences, Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada.,Lawson Research, London Health Sciences Centre, London, Ontario, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Kurt P Spindler
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Isaac Briskin
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dianne M Bryant
- Faculty of Health Sciences, Western University, London, Ontario, Canada.,Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.,Bone and Joint Institute, Western University, London, Ontario, Canada.,Lawson Research, London Health Sciences Centre, London, Ontario, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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87
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Pioger C, Saithna A, Rayes J, Haidar IM, Fradin T, Ngbilo C, Vieira TD, Cavaignac E, Sonnery-Cottet B. Influence of Preoperative Tunnel Widening On the Outcomes of a Single Stage-Only Approach to Every Revision Anterior Cruciate Ligament Reconstruction: An Analysis of 409 Consecutive Patients From the SANTI Study Group. Am J Sports Med 2021; 49:1431-1440. [PMID: 33689510 DOI: 10.1177/0363546521996389] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative tunnel widening is a frequently reported indication for performing a 2-stage revision anterior cruciate ligament reconstruction (ACLR) instead of a single-stage procedure. However, the strength of the available evidence to support a 2-stage strategy is low. PURPOSE/HYPOTHESIS The purpose was to evaluate the clinical outcomes of a single stage-only approach to revision ACLR. It was hypothesized that this approach would be associated with significant improvements from baseline in patient-reported outcome measures (PROMs) and knee stability and that there would be no significant differences in any postoperative outcomes between patients with and without preoperative tunnel widening. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective analysis was conducted of a large series of consecutive patients undergoing revision ACLR with a minimum follow-up of 2 years. Preoperative tunnel widening was assessed using digital radiographs. All patients underwent single-stage surgery with an outside-in technique, regardless of the degree of tunnel widening. Clinical outcomes were compared according to whether tunnel widening was present (either tunnel ≥12 mm) or not (both tunnels <12 mm). RESULTS The study included 409 patients with a mean ± SD follow-up of 69.6 ± 29.0 months. After revision ACLR, there was a significant reduction in the side-to-side anteroposterior laxity difference, from 7.7 ± 2.2 mm preoperatively to 1.2 ± 1.1 mm at 2 years (P < .001). The mean International Knee Documentation Committee (IKDC) and all subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS) exceeded the thresholds for the Patient Acceptable Symptom State defined for primary ACLR. An overall 358 patients had retrievable preoperative radiographs. According to the tunnel diameter measurements, 111 patients were allocated to group A (both tunnels <12 mm) and 247 patients to group B (either/both tunnels ≥12 mm). There were no significant differences between groups with respect to anteroposterior side-to-side laxity difference, graft rupture rates, non-graft rupture related reoperations, or contralateral anterior cruciate ligament injury rates. There was also no significant difference between groups that exceeded minimal detectable change thresholds for any of the PROMs recorded (ACL-RSI [Anterior Cruciate Ligament-Return to Sports After Injury], Lysholm, Tegner, IKDC, KOOS). CONCLUSION A single-stage approach to revision ACLR is associated with excellent clinical results when an outside-in drilling technique is utilized. The presence of preoperative tunnel widening does not significantly influence PROMs, knee stability, graft rupture rates, or non-graft rupture related reoperation rates.
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Affiliation(s)
- Charles Pioger
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Adnan Saithna
- Arizona Brain, Spine and Sports Injuries Center, Scottsdale, Arizona, USA
| | - Johnny Rayes
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Ibrahim M Haidar
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thomas Fradin
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Cedric Ngbilo
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Lyon, France; Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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88
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Littlefield CP, Belk JW, Houck DA, Kraeutler MJ, LaPrade RF, Chahla J, McCarty EC. The Anterolateral Ligament of the Knee: An Updated Systematic Review of Anatomy, Biomechanics, and Clinical Outcomes. Arthroscopy 2021; 37:1654-1666. [PMID: 33340678 DOI: 10.1016/j.arthro.2020.12.190] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/29/2020] [Accepted: 12/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform an updated systematic review of the anatomy, biomechanics, function of the anterolateral ligament (ALL), and the clinical outcomes of anterolateral ligament reconstruction (ALLR) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR). METHODS A systematic search of the literature was performed by searching PubMed, the Cochrane Library, and Embase with the search phrase anterolateral ligament for articles published from February 2017 to May 2020. Inclusion criteria included studies that evaluated the anatomy, function, or biomechanics of the ALL; surgical technique articles on ALLR; clinical articles reporting outcomes of ALLR; studies published in English; and full-text articles. Exclusion criteria included studies published before February 2017. A subjective synthesis was performed, in which ranges were reported, and individual study data were presented in forest plots. RESULTS Overall, 40 articles were included in this systematic review, with 11 articles describing ALL anatomy, 14 articles analyzing ALL function and biomechanics, 7 articles discussing the surgical technique of combined ACLR and ALLR (ACLR/ALLR), and 8 articles describing the clinical outcomes of ACLR/ALLR. The addition of ALLR in combination with ACLR (ACLR+) results in lower graft failure rates for ACLR/ALLR (0.0%-15.7%) when compared with isolated ACLR (I-ACLR) patients (7.4%-21.7%). Three of 5 studies using the Subjective International Knee Documentation Committee score, 2 of 5 studies using the Lysholm score, and 1 of 2 studies using the Tegner score reported significantly better scores at latest follow-up among ACLR+ patients compared with I-ACLR (P < .05). CONCLUSIONS The ALL acts as a secondary stabilizer to the anterior cruciate ligament and helps resist internal knee rotation and anterior tibial translation. Based on the current literature, combined ACLR with ALLR may result in lower graft failure rates and improved patient-reported outcomes when compared with I-ACLR in patients with specific indications, although several studies have shown equivalent outcomes between these 2 cohorts. CLINICAL RELEVANCE The contents of this review provide great insight for orthopaedic surgeons who are performing ACLR and considering additional procedures to increase overall knee stability and decrease likeliness for re-rupture. The postoperative functional and clinical outcomes shown in patients undergoing ACLR+ compared with I-ACLR should be given proper consideration when evaluating available treatment courses.
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Affiliation(s)
- Connor P Littlefield
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - John W Belk
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A..
| | - Darby A Houck
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - Matthew J Kraeutler
- St. Joseph's University Medical Center, Department of Orthopaedic Surgery, Paterson, New Jersey, U.S.A
| | | | - Jorge Chahla
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Eric C McCarty
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
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89
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Espregueira-Mendes J. Is the anterolateral ligament the smoking gun to explain rotational knee laxity or just vaporware? J ISAKOS 2021; 6:63-65. [PMID: 33832978 DOI: 10.1136/jisakos-2020-000529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- João Espregueira-Mendes
- Clínica do Dragão, Espregueira-Mendes Sports Centre - FIFA Medical Centre of Excellence, Porto, Portugal .,Dom Henrique Research Centre, Porto, Portugal.,School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal.,3B's Research Group-Biomaterials, Biodegradablesand Biomimetics, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, University of Minho, AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra, Barco, Guimarães, Portugal
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90
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Hamstrings substitution via anteromedial portal with optional anterolateral ligament reconstruction is the preferred surgical technique for anterior cruciate ligament reconstruction: a survey among ESSKA members. Knee Surg Sports Traumatol Arthrosc 2021; 29:1120-1127. [PMID: 32591846 DOI: 10.1007/s00167-020-06107-0] [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: 03/11/2020] [Accepted: 06/11/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE The objective of this study was to report on a worldwide web-based survey among the ESSKA community developed to investigate current recommendations regarding ACL reconstruction surgical procedures. METHODS All contacts in the official mailing list of the ESSKA were contacted to investigate preferences regarding graft type, anterolateral ligament reconstruction, femoral tunnel drilling technique, single-bundle vs double-bundle technique, femoral and tibial fixation methods. RESULTS Eight-hundred and twenty responses were analyzed. Hamstrings autograft was the graft of choice in male patients for 634 (79%) and in female patients for 674 (84%) responders, while its preference for ACL reconstruction in professional athletes was for 401 (50%). 480 (63%) surgeons surveyed would include anterolateral ligament reconstruction only if diagnosed and remaining instability after ACL surgery or revision. 598 (75%) respondents were in favor of anteromedial portal for femoral tunnel drilling. The most popular femoral fixation technique was found to be cortical suspension (500-66%), while a compression system was preferred on the tibial side by 537 (71% of the sample). CONCLUSIONS This survey study found that HT autograft, single-bundle reconstruction, anteromedial portal for femoral tunnel drilling, cortical suspension systems for femoral fixation and compression systems for tibial fixation represent the current standard of ACLR in a large community of orthopedic surgeons. The present study performed with surgeons who are members of the ESSKA community will help to comprehend the actual ACLR worldwide practice patterns. Due to low response rate, these results should be interpreted with caution and not to be intended to represent the state of the art of ESSKA community. LEVEL OF EVIDENCE III.
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91
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Ventura A, Legnani C, Boisio F, Borgo E, Peretti GM. The association of extra-articular tenodesis restores rotational stability more effectively compared to contralateral hamstring tendon autografts ACL reconstruction alone in patients undergoing ACL revision surgery. Orthop Traumatol Surg Res 2021; 107:102739. [PMID: 33390331 DOI: 10.1016/j.otsr.2020.06.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/27/2020] [Accepted: 06/22/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recent years have seen a resurgence of interest about lateral extra-articular procedures performed in association with anterior cruciate ligament (ACL) surgery, as they can reduce the positivity to pivot shift test by acting on rotational instability. The purpose of the present study is to compare the postoperative functional outcomes of ACL revision surgery using contralateral hamstring tendon autografts with or without extra-articular tenodesis. HYPOTHESIS The hypothesis is that combined extra-articular tenodesis gives better rotational stability following revision ACL surgery. PATIENTS AND METHODS Twenty-four patients who underwent ACL revision surgery were retrospectively reviewed at an average follow-up of 4.5 years; 12 underwent contralateral hamstring tendon autografts reconstruction (group A) while in 12 extra-articular tenodesis was associated (group B). Assessment included Lysholm score, International Knee Documentation Committee (IKDC) Subjective Knee Form, Tegner activity level and objective evaluation (range of motion, Lachman test, pivot-shift test and KT-1000 instrumented laxity testing). RESULTS Follow-up examination showed that there were no statistically significant differences in Lysholm, IKDC and Tegner scores between the groups (p=n.s.). Similarly, no differences concerning anterior tibial translation as measured with KT-1000 arthrometer were reported between the groups (p=n.s.); the percentage of positivity to pivot shift test was significantly higher in patients in group A (p<0.05). CONCLUSIONS The association of extra-articular tenodesis restores rotational stability more effectively compared to contralateral hamstring tendon autografts ACL revision surgery alone. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alberto Ventura
- IRCCS Istituto Ortopedico Galeazzi, Sports Traumatology and Minimally Invasive Articular Surgery Center, Milan, Italy
| | - Claudio Legnani
- IRCCS Istituto Ortopedico Galeazzi, Sports Traumatology and Minimally Invasive Articular Surgery Center, Milan, Italy.
| | | | - Enrico Borgo
- IRCCS Istituto Ortopedico Galeazzi, Sports Traumatology and Minimally Invasive Articular Surgery Center, Milan, Italy
| | - Giuseppe M Peretti
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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92
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Devitt BM, Al'khafaji I, Blucher N, Batty LM, Murgier J, Webster KE, Feller JA. Association Between Radiological Evidence of Kaplan Fiber Injury, Intraoperative Findings, and Pivot-Shift Grade in the Setting of Acute Anterior Cruciate Ligament Injury. Am J Sports Med 2021; 49:1262-1269. [PMID: 33719594 DOI: 10.1177/0363546521994467] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Biomechanical studies have suggested that the Kaplan fibers (KFs) of the iliotibial band play a role in controlling anterolateral rotation of the knee. There is a paucity of clinical information on whether injury to the KF in the setting of anterior cruciate ligament (ACL) rupture contributes to increased rotatory laxity of the knee. PURPOSE/HYPOTHESIS The purpose was to evaluate the association among radiological evidence of KF injury, intraoperative arthroscopic findings, and grade of pivot shift at the time of ACL reconstruction (ACLR). It was hypothesized that KF injury would be associated with increased injury to the lateral compartment of the knee and a higher grade of pivot shift. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective magnetic resonance imaging (MRI) analysis was conducted on 267 patients with ACL-injured knees who underwent primary ACLR. Patients who had MRI and surgery within 60 days of injury were included (mean age, 23.6 years); there were 158 (59.2%) male patients. MRI was performed using standard knee protocols, and diagnostic criteria were applied to identify KF injury. Associations were made among MRI findings, intraoperative findings, and grade of pivot shift with the patient examined under anesthesia at the time of ACLR. A comparison was made between patients with and without radiological evidence of KF injury. RESULTS The prevalence of KF injury was 17.6% (47/267 patients). Arthroscopic evidence of lateral meniscal injury was associated with KF injury (KF intact, 31%; KF injured, 55%; P = .010). The majority of patients in the intact and injured KF groups had a grade 2 pivot shift (75% and 70%, respectively). A minority had grade 3 pivot shift: 5% in the intact group versus 6.4% in the injured group. There was no association between radiological evidence of KF injury and pivot-shift grade (P = .600). CONCLUSION In acute ACL injury, KF injuries were not very common (17.6%), and the rate of grade 3 pivot shift was low (5.2%). When present, KF injuries were not associated with a higher-grade pivot shift. However, there was an association between KF injury and lateral meniscal tears identified at the time of ACLR. The role of KFS in controlling anterolateral rotatory laxity in the acute ACL injury in the clinical setting may be less evident when compared with the biomechanical setting.
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Affiliation(s)
- Brian M Devitt
- OrthoSport Victoria, Richmond, Australia.,School of Allied Health, Human Services and Sport, LaTrobe University, Melbourne, Australia
| | | | | | | | | | - Kate E Webster
- School of Allied Health, Human Services and Sport, LaTrobe University, Melbourne, Australia
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93
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Gassner C. [25/m-Knee distortion during basketball : Preparation for the medical specialist examination: part 62]. Unfallchirurg 2021; 124:171-178. [PMID: 33755762 DOI: 10.1007/s00113-021-00978-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Christoph Gassner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland.
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Mao Y, Sun W, Fu W, Li J. [Effectiveness of double-bundle anterior cruciate ligament reconstruction combined with anterolateral ligament reconstruction for revision]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:330-336. [PMID: 33719242 DOI: 10.7507/1002-1892.202010044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To investigate the effectiveness of double-bundle anterior cruciate ligament (ACL) reconstruction combined with anterolateral ligament (ALL) reconstruction in the treatment of revision patients with ACL graft failure. Methods Between January 2018 and June 2019, 15 patients underwent ACL revision with double-bundle ACL reconstruction combined with ALL reconstruction. There were 12 males and 3 females with an average age of 30.1 years (range, 17-49 years). The technique of primary ACL reconstruction included single-bundle reconstruction in 13 cases and double-bundle reconstruction in 2 cases. These reconstructions applied autografts in 14 cases and allograft in 1 case. The causes of ACL reconstruction failure were identified as traumatic rupture in 9 cases and non-traumatic failure in 6 cases, including 2 cases of graft absorption and 3 cases of graft laxity. The average time from the primary ACL reconstruction to revision was 28.5 months (range, 8-60 months). The subjective and objective indicators of knee joint function were compared before operation and at last follow-up to evaluate the effectiveness. The subjective indicators included International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score. The objective indicators included anterior tibial translation (dynamic and static) and side-to-side difference (SSD), pivot-shift test, Lachman test, the difference of single-legged hop test, and the loss ratio of extensor muscle strength on the affected side. Results All incisions healed by first intetion, and no complications such as infection, venous thrombosis of lower extremity, or neurovascular injury occurred. All patients were followed up for an average of 19.1 months (range, 12-30 months). At last follow-up, all patients had returned to pre-injury sports level. The IKDC score, Lysholm score, and Tegner score were significantly improved ( P<0.05); anterior tibial translations (dynamic and static) significantly decreased when compared with preoperative one ( P<0.05) and returned to the physiological range. The SSD, Lachman test, pivot-shift test, the difference of single-legged hop test, and the loss ratio of extensor muscle strength on the affected side were significantly better than those before operation ( P<0.05).During the follow-up, there was no re-rupture of the graft, no stiffness of the knee joint and limitation of mobility; 1 case had a protruding femoral end compression screw, which was removed through the original incision under local anesthesia. Conclusion Double-bundle ACL reconstruction combined with ALL reconstruction can significantly improve the knee function in revision patients with ACL graft failure. It can reduce the anterior translation of tibia, and effectively prevent postoperative rotational instability of the knee.
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Affiliation(s)
- Yunhe Mao
- Department of Orthopaedics, Orthopaedics Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Weihao Sun
- Department of Orthopaedics, Orthopaedics Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Weili Fu
- Department of Orthopaedics, Orthopaedics Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jian Li
- Department of Orthopaedics, Orthopaedics Institute, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Femoral and tibial bone bruise volume is not correlated with ALL injury or rotational instability in patients with ACL-deficient knee. Knee Surg Sports Traumatol Arthrosc 2021; 29:900-906. [PMID: 32385558 DOI: 10.1007/s00167-020-06045-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 04/28/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Some researchers have suggested that bone bruises are evidence of rotational instability. The hypothesis was that the extent of lateral bone edema is correlated with the presence of an anterolateral ligament (ALL) injury. The main objective was to determine whether there was a correlation between the presence of an ALL injury the extent of bone bruises. METHODS A prospective diagnostic study enrolled all the patients who suffered an acute anterior cruciate ligament (ACL) who were operated on within 8 weeks. The extent of bone bruising according to the ICRS classification was measured on preoperative MRIs by two independent blinded raters twice with an interval of 4 weeks. Dynamic ultrasonography (US) to look for ALL injury and the pivot shift test were performed before the ACL surgery. The correlation between ALL injury and bone bruises, and the correlation between an ALL injury and a high-grade pivot shift test were determined. RESULTS Sixty-one patients were included; 52% of patients had an ALL injury on US. The extent of lateral bone bruise was not related to the presence of an ALL injury, nor related to the presence of a high-grade pivot shift. A grade 2 or 3 pivot shift was significantly correlated with an ALL injury (p < 0.0001). Inter- and intra-rater reliability for the bone bruise rating was excellent. CONCLUSION The extent of lateral bone bruise is not correlated with ALL injury or a high-grade pivot shift; thus, it is not correlated with rotational instability of the knee. LEVEL OF EVIDENCE II.
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96
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Ahn JH, Kim J, Mun JW. A Retrospective Comparison of Single-Bundle Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Tenodesis With Double-Bundle Anterior Cruciate Ligament Reconstruction. Arthroscopy 2021; 37:976-984. [PMID: 33188853 DOI: 10.1016/j.arthro.2020.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/31/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare postoperative objective knee stability and clinical outcomes between double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) and single-bundle (SB) ACLR combined with lateral extra-articular tenodesis (LET). METHODS ACL-injured patients with grade 3 pivot-shift who underwent either DB ACLR (DB ACLR group) or SB ACLR with LET (SB ACLR+LET group) were enrolled. All patients who met inclusion and exclusion criteria were retrospectively evaluated for knee laxity (the anterior translation and pivot-shift grade), clinical outcomes using the International Knee Documentation Committee (IKDC) examination form, Kellgren-Lawrence grade, graft maturation score on second-look arthroscopy, and revision rates at the last follow-up. RESULTS From an initial cohort of 171 consecutive patients over a 3-year period, 95 (56%) met inclusion and exclusion criteria. The SB ACLR+LET group (n = 47) showed significantly better results in pivot-shift grade at the last follow-up as compared with the DB ACLR group (n = 48) (P = .021). In the SB ACLR+LET group, 93.6% (44/47) were grade 0, whereas 72.9% (35/48) in the DB ACLR group were grade 0. The SB ACLR+LET group (grade A: 42, grade B: 4 and grade C: 1) showed significantly superior results in IKDC objective grade compared with the DB ACLR group (grade A: 32; grade B: 8; and grade C: 8) (P = .017). However, no statistically significant difference could be shown in anterior translation, subjective functional IKDC score, or revision rate between the 2 groups. The mean follow-up duration was 49.7 ± 5.7 months. CONCLUSIONS SB ACLR + LET demonstrated fewer pivot-shifts (P = .021) and superior IKDC objective grades (P = .017) than a DB ACLR at a mean follow-up of almost 50 months. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ji Hyun Ahn
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggido, Republic of Korea.
| | - Jaehyun Kim
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggido, Republic of Korea
| | - Ji Weon Mun
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggido, Republic of Korea
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97
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Xu C, Chen J, Cho E, Zhao J. The Effect of Combined Anterolateral and Anterior Cruciate Ligament Reconstruction on Reducing Pivot Shift Rate and Clinical Outcomes: A Meta-analysis. Arthroscopy 2021; 37:694-705. [PMID: 33098948 DOI: 10.1016/j.arthro.2020.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/01/2020] [Accepted: 10/10/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether combined anterior cruciate ligament reconstruction (ACLR) and anterolateral ligament reconstruction (ALLR) result in better knee rotatory stability and postoperative clinical outcomes than ACLR alone. METHODS A computer literature search was conducted of Medline (1982 to April 2020), Embase (1982 to April 2020), OVID (1982 to April 2020), and the Cochrane Library (1982 to April 2020) to screen all therapeutic trials on combined ACLR and ALLR versus isolated ACLR. Only level of evidence I and II clinical studies were included. The outcome measures included (1) objective knee stability examination such as anterior drawer test, Lachman test, KT-arthrometer measurement, and pivot shift test; (2) patient-reported outcomes such as International Knee Documentation Committee (IKDC), Tegner activity score, and Lysholm score; (3) return to play; and (4) graft rupture rate. Data were extracted, pooled, and analyzed to compare the 2 groups. RESULTS A total of 890 studies were screened, and 884 were excluded. Six clinical trials with 828 subjects were included in the final meta-analysis. In comparison to patients received combined ACLR and ALLR, patients who received isolated ACLR had a significantly lower negative pivot shift test rate (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.23 to 0.92, I2 = 0%, P = .03, 95% prediction interval [PrI] 1.00 to 2.26), Lysholm score (mean difference -2.79, 95 % CI -4.68 to -0.91, I2 = 77 %, P = .004, 95% PrI -10.81 to 5.42), Tegner score (mean difference -0.57, 95% CI -1.12 to -0.02, I2 = 90 %, P = .04, 95% PrI -3.12 to 1.93). CONCLUSIONS Combined ALLR and ACLR could effectively augment knee rotatory stability by reducing pivot shift rate and moderately improve patients' clinical outcomes. However, the effect of ALLR on overall graft rupture rate cannot be confirmed. LEVEL OF EVIDENCE II, meta-analysis of level I and II studies.
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Affiliation(s)
- Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Eunshinae Cho
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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98
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Zhu M, Han Lee DY, Williams A. Safe Femoral Fixation Depth and Orientation for Lateral Extra-Articular Tenodesis in Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:2325967120976591. [PMID: 33614797 PMCID: PMC7869183 DOI: 10.1177/2325967120976591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/27/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Patients who undergo anterior cruciate ligament (ACL) reconstruction (ACLR)
can have a persistent postoperative pivot shift. Performing lateral
extra-articular tenodesis (LET) concurrently has been proposed to address
this; however, LET femoral fixation may interfere with the ACLR femoral
tunnel, which could damage the ACL graft or its fixation. Purpose: To evaluate the safe maximum implant or tunnel depth for a modified Lemaire
LET when combined with ACLR anteromedial portal femoral tunnel drilling and
to validate the safe LET drilling angles to avoid conflict with the ACLR
femoral tunnel. Study Design: Descriptive laboratory study. Methods: Twelve fresh-frozen cadaveric knees were used. With each knee at 120° of
flexion, an ACLR femoral tunnel in the anteromedial bundle position was
created arthroscopically via the anteromedial portal using a 5-mm offset
guide, a guide wire, and an 8-mm reamer, which was left in situ. A modified
Lemaire LET was performed using a 1 cm-wide iliotibial band strip harvested
with the distal attachment intact, to be fixed in the femur. The desired LET
fixation point was identified with an external aperture 10 mm proximal and 5
mm posterior to the fibular collateral ligament’s femoral attachment, and a
2.4-mm guide wire was drilled, aiming at 0°, 10°, 20°, or 30° anteriorly in
the axial plane and at 0°, 10°, or 20° proximally in the coronal plane (12
different drilling angle combinations). The relationship between the LET
drilling guide wire and the ACLR femoral tunnel reamer was recorded for each
combination. When a collision with the femoral tunnel was recorded, the LET
wire depth was measured. Results: Collision with the ACLR femoral tunnel occurred at a mean LET wire depth of
23.6 mm (range, 15-33 mm). No correlation existed between LET wire depth and
LET drilling orientation (r = 0.066; P =
.67). Drilling angle in the axial plane was significantly associated with
the occurrence of tunnel conflict (P < .001). However,
no such association was detected when comparing the drilling angle in the
coronal plane (P = .267). Conclusion: Conflict of LET femoral fixation with the ACLR femoral tunnel using
anteromedial portal drilling occurred at a mean depth of 23.6 mm but also at
a depth as little as 15 mm, which is shorter than most implants. When longer
implants or tunnels are used, the orientation should be directed at least
30° anteriorly in the axial plane to minimize the risk of tunnel conflict,
bearing in mind the risk of joint violation. Clinical Relevance: This study provides important information for surgeons performing LET in
combination with ACLR anteromedial portal femoral tunnel drilling regarding
safe femoral implant or tunnel length and orientation.
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Affiliation(s)
- Meng Zhu
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore
| | - Dave Yee Han Lee
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore
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Lateral Extra-articular Tenodesis: A Technique With an Iliotibial Band Strand Without Implants. Arthrosc Tech 2021; 10:e85-e89. [PMID: 33532213 PMCID: PMC7823113 DOI: 10.1016/j.eats.2020.09.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/15/2020] [Indexed: 02/03/2023] Open
Abstract
The main goal in anterior cruciate ligament reconstruction (ACLR) should be to restore normal knee biomechanics so the chances of failure decrease. The persistence of knee instability after ACLR goes from 0.7% to 20%. Several factors have been identified and studied, but there are some selected cases in which it seems that without adding lateral extra-articular tenodesis (LET) it is not possible to control rotational instability. Data exist supporting that LET could reduce pivot shift (PS), without losing flexion/extension range of motion nor adding risk of osteoarthritis. Recently, LET has been used in addition to ACLR to add restriction to internal tibial rotation forces, and different authors have shown their techniques to achieve this task. Also, biomechanical studies have compared different techniques for LET procedures. This article aims to describe our technique performing a modified Macintosh LET as an addition to ACLR in selected patients who require extra internal tibial rotation control. This is a reproducible, easy to learn, and inexpensive procedure in terms that only a high resistance suture is needed and not any other implant, such as a stapler, anchors, or screws, reducing the risk of tunnel coalition.
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100
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Robert H, Vincent JP. Combined Anterior and Anterolateral Stabilization of the Knee With the Hamstring Tendons. Arthrosc Tech 2021; 10:e275-e282. [PMID: 33680756 PMCID: PMC7917012 DOI: 10.1016/j.eats.2020.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/04/2020] [Indexed: 02/03/2023] Open
Abstract
Anterior cruciate ligament reconstruction allows good control of sagittal laxity but insufficient rotary laxity control. Our objective is to describe an original lateral extra-articular tenodesis using gracilis in addition to an intra-articular reconstruction using the semitendinosus in a short 4-strand graft. The principles are as follows: The femoral tunnel for intra-articular and extra-articular reconstruction is unique, the femoral attachment is posterior and proximal to the lateral epicondyle, the graft is under the lateral collateral ligament, and the tibial insertion is isometric from 0° to 60° between the Gerdy tubercle and the fibular head.
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Affiliation(s)
- Henri Robert
- Orthopedic Surgery Unit, Haut-Anjou Hospital, Château-Gontier, France,Address correspondence to Henri Robert, M.D., Orthopedic Surgery Unit, Haut-Anjou Hospital, 1 quai Dr. Lefevre, 53200, Château-Gontier, France.
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