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"Back to the future": a historical perspective on the role of extra-articular reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:2989-2992. [PMID: 28871384 DOI: 10.1007/s00167-017-4699-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
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Miller TK. The Role of an Extra-Articular Tenodesis in Revision of Anterior Cruciate Ligament Reconstruction. Clin Sports Med 2017; 37:101-113. [PMID: 29173550 DOI: 10.1016/j.csm.2017.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Patients who present for anterior cruciate ligament (ACL) revision with a high-grade pivot shift at the time of an index ACL revision procedure and subsequent reconstruction failure or a high-grade pivot shift at revision surgery, patients with generalized joint laxity, and those requiring softs tissue grafts should be considered candidates for lateral tenodesis to supplement intraarticular graft revision. Although there is no consensus regarding the optimal lateral tenodesis technique, due to the tibial positioning associated with tensioning and fixation of extra-articular procedures, a lateral tenodesis should not be used in patients with posterolateral corner injuries or lateral compartment articular disease.
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Affiliation(s)
- Thomas K Miller
- Department of Orthopaedic Surgery, Virginia Tech/Carilion School of Medicine, Institute for Orthopaedics and Neurosciences, 2331 Franklin Road, Roanoke, VA 24018, USA.
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Combined Anatomic Anterior Cruciate Ligament and Double Bundle Anterolateral Ligament Reconstruction. Arthrosc Tech 2017; 6:e1229-e1238. [PMID: 29354422 PMCID: PMC5621982 DOI: 10.1016/j.eats.2017.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 04/19/2017] [Indexed: 02/03/2023] Open
Abstract
The results of arthroscopic anterior cruciate ligament (ACL) reconstruction are so far satisfactory and improving over time as a result of the improved understanding of the anatomy and biomechanics of the ACL. Rotational instability confirmed by a positive pivot shift is present in more than 15% of cases who underwent successful ACL reconstruction. Persistent rotational instability interferes with performing pivoting sports, and also may lead to meniscal and chondral injuries, or re-rupture of the reconstructed ACL. Surgeons reconsidered the anatomy and biomechanics of the ACL and introduced the double bundle ACL reconstruction technique aiming to achieve a more rotational control by reconstructing the anteromedial and anterolateral bundles of the ACL. To date, the results of double bundle ACL reconstruction are mixed and inconsistent. The improved understanding of the existence, function, and biomechanical role of the anterolateral ligament (ALL) in controlling the rotational instability of the knee has redirected and refocused attention on a supplemental extra-articular reconstruction of the ALL in conjunction with the intra-articular ACL reconstruction so as to restore normal kinematics of the knee. In this Technical Note, we describe a technique that allows for a combined ACL and double bundle ALL reconstruction using autogenous hamstring graft (semitendinosus and gracilis) tendons. This technique is an extension of our previously described technique of a combined anatomic ACL and single bundle ALL reconstruction. The improved understanding of the anatomy of the ALL makes a double bundle ALL reconstruction more anatomic than single bundle ALL reconstruction, as the native ALL is triangular or inverted Y in shape, with a narrow proximal femoral attachment and a broad distal tibial attachment between Gerdy's tubercle and the head of the fibula.
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Zein A“MN, Ali M, Ali H, Saleh Elsaid AN, Mahmoud AZ, Osman MK, Mohamed Soliman AM. Combined Anatomic Reconstruction of the Anterior Cruciate and Anterolateral Ligaments Using Hamstring Graft Through a Single Femoral Tunnel and With a Single Femoral Fixation. Arthrosc Tech 2017; 6:e567-e577. [PMID: 28706801 PMCID: PMC5495116 DOI: 10.1016/j.eats.2016.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/06/2016] [Indexed: 02/03/2023] Open
Abstract
Patients with complete anterior cruciate ligament (ACL) injury have different degrees of rotational (internal rotation) laxity. A residual pivot shift has been found to be positive in more than 15% of cases after an accurate ACL reconstruction. Improved understanding of the existence, function, and biomechanical role of the anterolateral ligament (ALL) in controlling rotational instability of the knee has redirected and refocused attention on a supplemental extra-articular reconstruction of the ALL in conjunction with the intra-articular ACL reconstruction so as to restore normal kinematics of the knee. This Technical Note describes a technique that allows for a combined ACL and ALL reconstruction using autogenous hamstring graft (semitendinosus and gracilis tendons). One femoral tunnel is used connecting the anatomic femoral attachment of the ALL on the lateral wall of the lateral femoral condyle to the anatomic femoral ACL footprint on the medial wall of the lateral femoral condyle. The remaining part of the graft is fixed to the proximal tibia midway between Gordy's tubercle and the head of the fibula. This Technical Note describes a technique of both ACL and ALL reconstruction with a continuous hamstring graft.
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Affiliation(s)
- Assem “Mohamed Noureldin” Zein
- Address correspondence to Assem “Mohamed Noureldin” Zein, M.D., Orthopedic and Trauma Department, Faculty of Medicine, Minia University, Minia (Kornish el Nile), Egypt.Orthopedic and Trauma DepartmentFaculty of MedicineMinia UniversityMinia (Kornish el Nile)Egypt
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Vap AR, Schon JM, Moatshe G, Cruz RS, Brady AW, Dornan GJ, Turnbull TL, LaPrade RF. The Role of the Peripheral Passive Rotation Stabilizers of the Knee With Intact Collateral and Cruciate Ligaments: A Biomechanical Study. Orthop J Sports Med 2017; 5:2325967117708190. [PMID: 28607939 PMCID: PMC5455885 DOI: 10.1177/2325967117708190] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND A subset of patients have clinical internal and/or external knee rotational instability despite no apparent injury to the cruciate or collateral ligaments. PURPOSE/HYPOTHESIS The purpose of this study was to assess the effect of sequentially cutting the posterolateral, anterolateral, posteromedial, and anteromedial structures of the knee on rotational stability in the setting of intact cruciate and collateral ligaments. It was hypothesized that cutting of the iliotibial band (ITB), anterolateral ligament and lateral capsule (ALL/LC), posterior oblique ligament (POL), and posteromedial capsule (PMC) would significantly increase internal rotation, while sectioning of the anteromedial capsule (AMC) and the popliteus tendon and popliteofibular ligament (PLT/PFL) would lead to a significant increase in external knee rotation. STUDY DESIGN Controlled laboratory study. METHODS Ten pairs (N = 20) of cadaveric knees were assigned to 2 sequential cutting groups (group 1: posterolateral-to-posteromedial [PL → PM] and group 2: posteromedial-to-posterolateral [PM → PL]). Specimens were subjected to applied 5-N·m internal and external rotation torques at knee flexion angles of 0°, 30°, 60°, and 90° while intact and after each cut state. Rotational changes were measured and compared with the intact and previous cut states. RESULTS Sectioning of the ITB significantly increased internal rotation at 60° and 90° by 5.4° and 6.2° in group 1 (PL → PM) and 3.5° and 3.8° in group 2 (PM → PL). PLT/PFL complex sectioning significantly increased external rotation at 60° and 90° by 2.7° and 2.9° in group 1 (PL → PM). At 60° and 90° in group 2 (PM → PL), ALL/LC sectioning produced significant increases in internal rotation of 3.1° and 3.5°, respectively. In group 2 (PM → PL), POL sectioning produced a significant increase in internal rotation of 2.0° at 0°. AMC sectioning significantly increased external rotation at 30° to 90° of flexion with a magnitude of change of <1° in both groups 1 (PL → PM) and 2 (PM → PL). CONCLUSION Collectively, the anterolateral corner structures provided primary internal rotation control of the knee from 60° to 90° of knee flexion in knees with intact cruciate and collateral ligaments. The ITB was the most significant primary stabilizer of internal rotation. The POL had a primary role for internal rotational stability at full extension. The PLT/PFL complex was a primary stabilizer for external rotation of the knee at 60° and 90°. CLINICAL RELEVANCE This study delineates the primary and secondary roles of the ITB, ALL/LC, POL, and PLT/PFL to rotatory stability of the knee and provides new information to understand knee rotational instabilities.
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Affiliation(s)
- Alexander R. Vap
- The Steadman Clinic, Vail, Colorado, USA
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Jason M. Schon
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, USA
- Orthopedic Department, Oslo University Hospital and University of Oslo, Oslo, Norway
- OSTRC, The Norwegian School of Sports Sciences, Oslo, Norway
| | | | - Alex W. Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | - Robert F. LaPrade
- The Steadman Clinic, Vail, Colorado, USA
- Steadman Philippon Research Institute, Vail, Colorado, USA
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Function and strain of the anterolateral ligament part I: biomechanical analysis. Knee Surg Sports Traumatol Arthrosc 2017; 25:1132-1139. [PMID: 28258329 DOI: 10.1007/s00167-017-4472-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/07/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Because reconstruction of the anterior cruciate ligament (ACL) in a double-bundle technique did not solve the problem of persistent rotatory laxity after surgery, new potential answers to this issue are of great interest. One of these is an extraarticular stabilization based on the rediscovery of the anterolateral ligament (ALL). Knowledge about its biomechanical function and benchmark data for an optimal reconstruction remain lacking. Therefore, the purpose of this study was to assess the function of the ALL under passive motion, anterior tibial translation and tibial rotational moments. METHODS Continuous passive motion (0°-120° flexion), ap-translation and static pivot shift tests were performed on eight cadaveric knees. The knees were measured in intact, ACL-resected (ACLres) and ACL + ALL-resected (ALLres) conditions. Ap-translation and static pivot shift under 134 N anterior shear load were determined at 0°, 30°, 60° and 90° flexion. Strain of the ALL was recorded in intact and ACLres conditions. RESULTS During continuous passive motion under unloaded conditions, no significant difference in internal rotation between ACLres and ALLres was observed. With an additional internal tibial torque of 1-4 Nm, internal rotation increased significantly between 60° and 120° after resection of the ALL (p ≤ 0.05). Anterior tibial translation was significantly higher at 30° in ALLres (p = 0.01) and for a simulated pivot shift at 60° and 90° in ACLres (p ≤ 0.01). The ALL was not strained under unloaded passive motion. Adding different internal tibial torques led to strain starting at 60° flexion (1 N m internal torque) and 15° flexion (4 N m internal torque) in intact ligaments. In ACLres, significantly greater ALL strains under lower flexion angles were seen for each condition (p ≤ 0.05). CONCLUSIONS This study demonstrated the ALL to be without function under passive motion and with no influence on tibial rotation. On application of extrinsic loads, the ALL had a low but significant stabilizing effect against anterior tibial shear load at low flexion angles. For this reason, it can be concluded that the ALL is supporting the ACL against internal tibial loads to a minor degree. A relationship between the ALL and the pivot shift cannot be concluded. With these results ALL-reconstruction cannot be recommended at the moment without further biomechanical investigations.
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Effects of different femoral tunnel positions on tension changes in anterolateral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:1272-1278. [PMID: 27225889 DOI: 10.1007/s00167-016-4178-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 05/18/2016] [Indexed: 01/26/2023]
Abstract
PURPOSE Several kinds of anterolateral ligament (ALL) reconstructions to augment intra-articular anterior cruciate ligament reconstruction to better control anterolateral rotational instability (ALRI) have been reported. However, the optimal femoral attachment site for ALL reconstruction is still unclear. The purpose of this study was to investigate the effects of different femoral attachment sites on the tension changes through knee motions in different situations in order to determine a recommended femoral attachment site for ALL reconstruction. METHODS Six fresh-frozen cadaveric knees were included. ALL reconstructions were performed with three different femoral attachment sites (F1: 2 mm anterior and 2 mm distal to the lateral epicondyle, F2: 4 mm posterior and 8 mm proximal to the lateral epicondyle and F3: position for the lateral extra-articular tenodesis). The graft tension changes were measured by a graft tensioning system during knee flexion-extension and manual maximum internal/external tibial rotation in the following situations: (1) intact, (2) ALL cut, (3) ALL and ACL cut and (4) ALL cut and ACL reconstructed. Effects of the different femoral attachment sites, the route superficial or deep to the LCL, and the situations of (1) to (4) were calculated via repeated-measures analysis of variance. RESULTS The tension of F1 was higher in flexion and lower in extension, whereas the tension of F2 and F3 was higher in extension and lower in flexion. F2 showed the smallest tension change. Situations of (1) to (4) did not affect tension changes. The graft tension became higher with internal rotation and lower with external rotation regardless of femoral attachment sites or situations. CONCLUSION With F2-4 mm posterior and 8 mm proximal to the lateral epicondyle-the reconstructed ALL had the least tension change with only a slight increase in tension as the knee extended. This result indicates that F2 is recommended for ALL reconstruction to better control ALRI, which will help determine the optimal femoral tunnel position for ALL reconstruction.
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Branch TP, Stinton SK, Hutton WC, Neyret P. The combination of tibial anterior translation and axial rotation into a single biomechanical factor improves the prediction of patient satisfaction over each factor alone in patients with ACL reconstructed knees. Knee Surg Sports Traumatol Arthrosc 2017; 25:1038-1047. [PMID: 28299388 PMCID: PMC5420376 DOI: 10.1007/s00167-017-4497-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/27/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to identify biomechanical factors, in both reconstructed and healthy knees, that correlate with patient satisfaction after ACL reconstruction. METHODS Seventeen patients who had undergone unilateral ACL reconstruction were reviewed 9 years post-op. Patients completed subjective questionnaires and underwent manual knee laxity testing (Lachman-Trillat, KT-1000, and pivot shift) and automated laxity testing. During automated testing, both legs were rotated into external rotation and then internal rotation until peak rotational torque reached 5.65 Nm. Load-deformation curves were generated from torque and rotation data. Features of the curves were extracted for analysis. Total leg rotation and anterior laxity during KT-1000 testing were combined into a single factor (Joint Play Envelope or JPE). Patients were divided into groups based on patient satisfaction scores (Group 1: Higher Satisfaction, Group 2: Lower Satisfaction, Group 3: Unsatisfied). Load-deformation curve features and manual laxity testing results were compared between groups 1 and 2 to determine which biomechanical factors could distinguish between the groups. Diagnostic screening values were calculated for KT-1000 testing, the pivot shift test, total leg rotation and JPE. RESULTS During manual testing, no significant differences in biomechanical factors were found when comparing reconstructed knees in group 1 and group 2. When comparing the reconstructed and healthy knees within group 2, the reconstructed knees had a significantly higher displacement during the KT-1000 manual maximum test (p < 0.002). When considering the reconstructed knees alone, neither the result of the pivot shift test nor KT-1000 testing could distinguish between group 1 and group 2. During automated testing, there were no significant differences between the groups when comparing the reconstructed lower limbs. The healthy lower limbs in group 2 had more maximum external rotation (p < 0.02) and decreased stiffness at maximum external rotation (p < 0.02) when compared to the healthy lower limbs in group 1. Total leg rotation was unable to distinguish between group 1 and group 2. JPE could distinguish between group 1 and group 2 when considering the reconstructed limb alone (p < 0.02). All four diagnostic screening values for JPE were equal or higher than in the other criteria. JPE also showed the most significant correlation with patient satisfaction. CONCLUSIONS Joint Play Envelope is an objective measure that demonstrated improved predictive value as compared to other tests when used as a measure of satisfaction in patients with ACL reconstructed knees.
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Affiliation(s)
| | - Shaun K Stinton
- ArthroMetrix LLC, 441 Armour Place NE, Atlanta, GA, 30324, USA.
| | - William C Hutton
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA, USA
| | - Philippe Neyret
- Department Orthopedic Surgery, Centre Albert-Trillat, Hôpital de la Croix-Rousse, Lyon, France
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Historical perspective on the "discovery" of the anterolateral ligament of the knee. Knee Surg Sports Traumatol Arthrosc 2017; 25:991-996. [PMID: 27699439 DOI: 10.1007/s00167-016-4349-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/27/2016] [Indexed: 01/01/2023]
Abstract
UNLABELLED There is a lively debate about the existence, origins and discoverer of the anterolateral ligament of the knee. The complex anatomy of the lateral aspect of the knee has made it difficult to differentiate between various structures such as the iliotibial band, capsulo-osseous layer, Kaplan's fibres and the anterolateral capsule. The "discovery" of a new anterolateral structure in 2013 was the culmination of many historical studies. In 1879, Paul Ferdinand Segond described a tibial plateau fracture in which he noted a pearly band reinforcing the joint capsule. Other anatomists had their suspicions about this ligament; it was described by Vallois in 1914 in his thesis and extensively studied by Jost in 1921. References to it can be found in comparative anatomy studies. This historical review serves as a reminder that understanding and treating knee sprains is not something new. LEVEL OF EVIDENCE V.
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Ferretti A, Monaco E, Fabbri M, Mazza D, De Carli A. The Fascia Lata Anterolateral Tenodesis Technique. Arthrosc Tech 2017; 6:e81-e86. [PMID: 28373944 PMCID: PMC5368164 DOI: 10.1016/j.eats.2016.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/09/2016] [Indexed: 02/03/2023] Open
Abstract
A technique for anatomic reconstruction of the anterolateral complex addressing anterolateral rotatory instability both in primary anterior cruciate ligament reconstruction and in revision cases is presented. The extra-articular reconstruction is performed with a pedicle strip of iliotibial tract, fixed on the anatomic origin and insertion points of the anterolateral ligament of the knee in a double-bundle V-shaped fashion.
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Affiliation(s)
| | | | - Mattia Fabbri
- Address correspondence to Mattia Fabbri, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy.Sant'Andrea HospitalVia di Grottarossa 103500189 RomeItaly
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Slette EL, Mikula JD, Schon JM, Marchetti DC, Kheir MM, Turnbull TL, LaPrade RF. Biomechanical Results of Lateral Extra-articular Tenodesis Procedures of the Knee: A Systematic Review. Arthroscopy 2016; 32:2592-2611. [PMID: 27324970 DOI: 10.1016/j.arthro.2016.04.028] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 04/20/2016] [Accepted: 04/22/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review and compare biomechanical results of lateral extra-articular tenodesis (LET) procedures. METHODS A systematic review was performed using the PubMed, Medline, Embase, and Cochrane databases. The search terms included the following: extraarticular, anterolateral, iliotibial, tenodesis, plasty, augmentation, procedure, reconstruction, technique, biomechanics, kinematic, robot, cadaver, knee, lateral tenodesis, ACL, Marcacci, Lemaire, Losee, Macintosh, Ellison, Andrews, Hughston, and Muller. The inclusion criteria were nonanatomic, in vitro biomechanical studies, defined as in vitro investigations of joint motion resulting from controlled, applied forces. RESULTS Of the 10 included studies, 7 analyzed anterior tibial translation and reported that isolated LET procedures did not restore normal anterior stability to the anterior cruciate ligament (ACL)-deficient knee. Seven of the 8 studies analyzing tibial rotation reported a reduction in internal tibial rotation across various flexion angles in the ACL-deficient knee when compared with the native state. Five studies reported a reduction in intra-articular graft force with the addition of an LET. Two studies evaluated length change patterns, graft course, and total strain range and found that reconstruction techniques in which the graft attached proximal to the lateral epicondyle and coursed deep to the fibular collateral ligament were most isometric. CONCLUSIONS In the ACL-deficient knee, LET procedures overconstrained the knee and restricted internal tibial rotation when compared with the native state. In addition, isolated LET procedures did not return normal anterior stability to the ACL-deficient knee but did significantly reduce anterior tibial translation and intra-articular graft forces during anteriorly directed loading. CLINICAL RELEVANCE Combined injury to the ACL and anterolateral structures has been reported to exhibit greater anterolateral rotatory instability when compared with isolated ACL injuries. Despite the reported risk of joint over-constraint, consideration should be given to reconstructing the anterolateral structures and the ACL concurrently to maximally restore both anterior tibial translation and rotatory stability.
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Affiliation(s)
- Erik L Slette
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jacob D Mikula
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jason M Schon
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Matthew M Kheir
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; The Steadman Clinic, Vail, Colorado, U.S.A..
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Wytrykowski K, Swider P, Reina N, Murgier J, Laffosse JM, Chiron P, Cavaignac E. Cadaveric Study Comparing the Biomechanical Properties of Grafts Used for Knee Anterolateral Ligament Reconstruction. Arthroscopy 2016; 32:2288-2294. [PMID: 27161509 DOI: 10.1016/j.arthro.2016.03.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/02/2016] [Accepted: 03/02/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To measure the biomechanical properties (maximum load, stiffness, and elongation) of the anterolateral ligament (ALL), gracilis, and iliotibial band (ITB) within the same subject. METHODS Thirteen unpaired knees were used (7 women, 6 men). The donors had a mean age at death of 54 years (range: 37 to 70 years). The mechanical properties of two types of ALL grafts were evaluated: ITB and two-strand gracilis. The mechanical properties of ALL were also measured. Validated methods were used to perform the tensile tests to failure and to record the results. Student's t-test was used to compare the various samples. RESULTS The maximum load to failure was 141 N (±40.6) for the ALL, 200.7 N (±48.7) for the gracilis, and 161.1 N (±27.1) for the ITB. Only the gracilis had a significantly higher failure load than ITB and ALL (P = .001 and P = .03). The stiffness was 21 N mm-1 (±8.2) for the ALL, 131.7 N mm-1 (±43.7) for the gracilis, and 39.9 N mm-1 (±6) for the ITB. The elongation at failure was 6.2 mm (±3.2) for the ALL, 19.9 mm (±6.5) for the gracilis, and 20.8 mm (±14.7) for the ITB. CONCLUSIONS The gracilis had the highest maximum load to failure. The ITB's mechanical properties most closely resemble those of the ALL. CLINICAL RELEVANCE The biomechanical properties of each potential ALL graft can be factored in when deciding which type of graft to use.
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Affiliation(s)
- Karine Wytrykowski
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Pascal Swider
- Laboratoire de Biomécanique, Université Paul Sabatier, Toulouse, France
| | - Nicolas Reina
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Jérôme Murgier
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Jean Michel Laffosse
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France; Laboratoire de Biomécanique, Université Paul Sabatier, Toulouse, France
| | - Philippe Chiron
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Etienne Cavaignac
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France.
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Vundelinckx B, Herman B, Getgood A, Litchfield R. Surgical Indications and Technique for Anterior Cruciate Ligament Reconstruction Combined with Lateral Extra-articular Tenodesis or Anterolateral Ligament Reconstruction. Clin Sports Med 2016; 36:135-153. [PMID: 27871655 DOI: 10.1016/j.csm.2016.08.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
After anterior cruciate ligament (ACL) rupture, anteroposterior and rotational laxity in the knee causes instability, functional symptoms, and damage to other intra-articular structures. Surgical reconstruction aims to restore the stability in the knee, and to improve function and ability to participate in sports. It also protects cartilage and menisci from secondary injuries. Because of persistent rotational instability after ACL reconstruction, combined intra-articular and extra-articular procedures are more commonly performed. In this article, an overview of anatomy, biomechanical studies, current gold standard procedures, techniques, and research topics are summarized.
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Affiliation(s)
- Bart Vundelinckx
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada
| | - Benjamin Herman
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada
| | - Alan Getgood
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada
| | - Robert Litchfield
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada.
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Wascher DC, Lording TD, Neyret P. Extra-articular procedures for the ACL-deficient knee: a state of the art review. J ISAKOS 2016. [DOI: 10.1136/jisakos-2016-000053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Nitri M, Rasmussen MT, Williams BT, Moulton SG, Cruz RS, Dornan GJ, Goldsmith MT, LaPrade RF. An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 2: Anterolateral Ligament Reconstruction Combined With Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2016; 44:593-601. [PMID: 26831632 DOI: 10.1177/0363546515620183] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent biomechanical studies have demonstrated that an extra-articular lateral knee structure, most recently referred to as the anterolateral ligament (ALL), contributes to overall rotational stability of the knee. However, the effect of anatomic ALL reconstruction (ALLR) in the setting of anterior cruciate ligament (ACL) reconstruction (ACLR) has not been biomechanically investigated or validated. PURPOSE/HYPOTHESIS The purpose of this study was to investigate the biomechanical function of anatomic ALLR in the setting of a combined ACL and ALL injury. More specifically, this investigation focused on the effect of ALLR on resultant rotatory stability when performed in combination with concomitant ACLR. It was hypothesized that ALLR would significantly reduce internal rotation and axial plane translation laxity during a simulated pivot-shift test compared with isolated ACLR. STUDY DESIGN Controlled laboratory study. METHODS Ten fresh-frozen cadaveric knees were evaluated with a 6 degrees of freedom robotic system. Knee kinematics were evaluated with simulated clinical examinations including a simulated pivot-shift test consisting of coupled 10-N·m valgus and 5-N·m internal rotation torques, a 5-N·m internal rotation torque, and an 88-N anterior tibial load. Kinematic differences between ACLR with an intact ALL, ACLR with ALLR, and ACLR with a deficient ALL were compared with the intact state. Single-bundle ACLR tunnels and ALLR tunnels were placed anatomically according to previous quantitative anatomic attachment descriptions. RESULTS Combined anatomic ALLR and ACLR significantly improved the rotatory stability of the knee compared with isolated ACLR in the face of a concurrent ALL deficiency. During a simulated pivot-shift test, ALLR significantly reduced internal rotation and axial plane tibial translation when compared with ACLR with an ALL deficiency. Isolated ACLR for the treatment of a combined ACL and ALL injury was not able to restore stability of the knee, resulting in a significant increase in residual internal rotation laxity. ALLR did not affect anterior tibial translation; no significant differences were observed between the varying ALL conditions with ACLR except between ACLR with an intact ALL and ACLR with a deficient ALL at 0° of flexion. CONCLUSION In the face of a combined ACL and ALL deficiency, concurrent ACLR and ALLR significantly improved the rotatory stability of the knee compared with solely reconstructing the ACL. CLINICAL RELEVANCE Significant increases in residual internal rotation and laxity during the pivot-shift test may exist in both acute and chronic settings of an ACL deficiency and in patients treated with isolated ACLR for a combined ACL and ALL deficiency. For this subset of patients, surgical treatment of the ALL, in addition to ACLR, should be considered to restore knee stability.
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Affiliation(s)
- Marco Nitri
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | | | | | - Grant J Dornan
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
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66
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Roessler PP, Schüttler KF, Heyse TJ, Wirtz DC, Efe T. The anterolateral ligament (ALL) and its role in rotational extra-articular stability of the knee joint: a review of anatomy and surgical concepts. Arch Orthop Trauma Surg 2016; 136:305-13. [PMID: 26714471 DOI: 10.1007/s00402-015-2395-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Indexed: 02/09/2023]
Abstract
The anterolateral ligament of the knee (ALL) has caused a lot of rumors in orthopaedics these days. The structure that was first described by Segond back in 1879 has experienced a long history of anatomic descriptions and speculations until its rediscovery by Claes in 2013. Its biomechanical properties and function have been examined recently, but are not yet fully understood. While the structure seems to act as a limiter of internal rotation and lateral meniscal extrusion its possible proprioceptive effect remains questionable. Its contribution to the pivot shift phenomenon has been uncovered in parts, therefore it has been recognized that a concomitant anterolateral stabilization together with ACL reconstruction may aid in prevention of postoperative instability after severe ligamentous knee damages. However, there are a lot of different methods to perform this procedure and the clinical outcome has yet to be examined. This concise review will give an overview on the present literature to outline the long history of the ALL under its different names, its anatomic variances and topography as well as on histologic examinations, imaging modalities, arthroscopic aspects and methods for a possible anterolateral stabilization of the knee joint.
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Affiliation(s)
- Philip P Roessler
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany.
| | - Karl F Schüttler
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
| | - Thomas J Heyse
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
| | - Dieter C Wirtz
- Department of Orthopaedics and Traumatology, University Hospital Bonn, Sigmund-Freud-Straße 25, 53127, Bonn, Germany
| | - Turgay Efe
- Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany.,Orthopaedicum Lich, Lich, Germany
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Kittl C, El-Daou H, Athwal KK, Gupte CM, Weiler A, Williams A, Amis AA. The Role of the Anterolateral Structures and the ACL in Controlling Laxity of the Intact and ACL-Deficient Knee. Am J Sports Med 2016; 44:345-54. [PMID: 26657572 DOI: 10.1177/0363546515614312] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterolateral rotatory instability (ALRI) may result from combined anterior cruciate ligament (ACL) and lateral extra-articular lesions, but the roles of the anterolateral structures remain controversial. PURPOSE To determine the contribution of each anterolateral structure and the ACL in restraining simulated clinical laxity in both the intact and ACL-deficient knee. STUDY DESIGN Controlled laboratory study. METHODS A total of 16 knees were tested using a 6 degrees of freedom robot with a universal force-moment sensor. The system automatically defined the path of unloaded flexion/extension. At different flexion angles, anterior-posterior, internal-external, and internal rotational laxity in response to a simulated pivot shift were tested. Eight ACL-intact and 8 ACL-deficient knees were tested. The kinematics of the intact/deficient knee was replayed after transecting/resecting each structure of interest; therefore, the decrease in force/torque reflected the contribution of the transected/resected structure in restraining laxity. Data were analyzed using repeated-measures analyses of variance and paired t tests. RESULTS For anterior translation, the intact ACL was clearly the primary restraint. The iliotibial tract (ITT) resisted 31% ± 6% of the drawer force with the ACL cut at 30° of flexion; the anterolateral ligament (ALL) and anterolateral capsule resisted 4%. For internal rotation, the superficial layer of the ITT significantly restrained internal rotation at higher flexion angles: 56% ± 20% and 56% ± 16% at 90° for the ACL-intact and ACL-deficient groups, respectively. The deep layer of the ITT restrained internal rotation at lower flexion angles, with 26% ± 9% and 33% ± 12% at 30° for the ACL-intact and ACL-deficient groups, respectively. The other anterolateral structures provided no significant contribution. During the pivot-shift test, the ITT provided 72% ± 14% of the restraint at 45° for the ACL-deficient group. The ACL and other anterolateral structures made only a small contribution in restraining the pivot shift. CONCLUSION The ALL and anterolateral capsule had a minor role in restraining internal rotation; the ITT was the primary restraint at 30° to 90° of flexion. CLINICAL RELEVANCE The ITT showed large contributions in restraining anterior subluxation of the lateral tibial plateau and tibial internal rotation, which constitute pathological laxity in ALRI. In cases with ALRI, an ITT injury should be suspected and kept in mind if an extra-articular procedure is performed.
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Affiliation(s)
- Christoph Kittl
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK Department of Trauma Surgery, Landeskrankenhaus Steyr, Steyr, Austria
| | - Hadi El-Daou
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Kiron K Athwal
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Chinmay M Gupte
- The Musculoskeletal Surgery Group, Department of Surgery and Cancer, Imperial College London, London, UK
| | | | | | - Andrew A Amis
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK The Musculoskeletal Surgery Group, Department of Surgery and Cancer, Imperial College London, London, UK
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68
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Kernkamp WA, van de Velde SK, Bakker EW, van Arkel ER. Anterolateral Extra-articular Soft Tissue Reconstruction in Anterolateral Rotatory Instability of the Knee. Arthrosc Tech 2015; 4:e863-7. [PMID: 27284525 PMCID: PMC4887266 DOI: 10.1016/j.eats.2015.08.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 08/26/2015] [Indexed: 02/03/2023] Open
Abstract
Anterolateral rotatory instability (ALRI) occurs after injury to the anterior cruciate ligament (ACL) and the anterolateral structures of the knee. We present a technique for anterolateral extra-articular soft-tissue (ALES) reconstruction of the knee that can be used in revision ACL reconstruction cases, cases of persistent ALRI after adequate ACL reconstruction, and cases with severe ALRI after primary ACL rupture. The surgeon performs ALES reconstruction with a strip of iliotibial tract autograft while respecting the anatomic origin and insertion of the anterolateral ligament. The purpose of this reconstruction is to restore the normal anterolateral rotatory stability of the knee in ALES-deficient patients.
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Affiliation(s)
- Willem A. Kernkamp
- Department of Orthopedic Surgery, Medical Center Haaglanden, The Hague, The Netherlands,Address correspondence to Willem Alexander Kernkamp, M.D., Department of Orthopedic Surgery, Medical Center Haaglanden, 2512 VA, The Hague, Lijnbaan 32, The Netherlands.
| | | | - Eric W.P. Bakker
- Kennis- en Behandelcentrum Fysiothearpie en Manuele Therapie, The Hague, The Netherlands
| | - Ewoud R.A. van Arkel
- Department of Orthopedic Surgery, Medical Center Haaglanden, The Hague, The Netherlands
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69
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Zein A“MNE. Step-by-Step Arthroscopic Assessment of the Anterolateral Ligament of the Knee Using Anatomic Landmarks. Arthrosc Tech 2015; 4:e825-31. [PMID: 27284519 PMCID: PMC4886523 DOI: 10.1016/j.eats.2015.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/04/2015] [Indexed: 02/03/2023] Open
Abstract
New insights into the existence and function of the anterolateral ligament (ALL) of the knee have redirected and refocused attention on the secondary restraints of rotational stability of the knee. The importance of assessing the ALL is increasing, especially in anterior cruciate ligament reconstruction surgery, to decide on the need for an adjunctive extra-articular reconstruction of the ALL to control rotational instability of the knee. However, preoperative assessment of this ligament is difficult. Clinical assessment of rotatory instability has poor reproducibility. Moreover, it is difficult to assess by current imaging techniques. We describe an easy, simple, practical, safe, and reproducible arthroscopic technique to fully assess the ALL of the knee.
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Affiliation(s)
- Assem “Mohamed Nour Eldin” Zein
- Address correspondence to Assem “Mohamed Nour Eldin” Zein, M.D., Department of Orthopedic Surgery, Faculty of Medicine, Minia University, 39 Shalaby, Minia, Egypt.
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LaPrade RF, Moulton SG, Nitri M, Mueller W, Engebretsen L. Clinically relevant anatomy and what anatomic reconstruction means. Knee Surg Sports Traumatol Arthrosc 2015; 23:2950-9. [PMID: 25957611 DOI: 10.1007/s00167-015-3629-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/29/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Within the past 20 years, knee ligament injuries have been increasingly reported in the literature to be treated with anatomic reconstructions over soft tissue advancements or sling-type procedures to recreate the native anatomy and restore knee function. Historically, early clinician scientists published on the qualitative anatomy of the knee, which provided a foundation for the initial knee biomechanical studies in the nineteenth and twentieth centuries. Similarly, the work of early sports medicine orthopaedic clinician scientists in the late twentieth century formed the basis for the quantitative anatomic and functional robotic biomechanical studies found currently in the sports medicine orthopaedic literature. The development of an anatomic reconstruction first requires an appreciation of the quantitative anatomy and function of each major stabilizing component of the knee. PURPOSE This paper provides an overview of the initial qualitative anatomic studies from which the initial knee ligament surgeries were based and expands to recent detailed quantitative studies of the major knee ligaments and the renewed recent focus on anatomic surgical reconstructions. CONCLUSIONS Anatomic repairs and reconstructions of the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament and posterolateral corner attempt to restore knee function by rebuilding or restoring the native anatomy. The basis of anatomic reconstruction techniques is a detailed understanding of quantitative knee anatomy. Additionally, an appreciation of the function of each component is necessary to ensure surgical success. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Robert F LaPrade
- The Steadman Clinic, 181 W. Meadow Drive, Suite 400, Vail, CO, 81657, USA. .,Steadman Philippon Research Institute, Vail, CO, USA.
| | | | - Marco Nitri
- 2nd Orthopaedics and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Bologna, Italy
| | | | - Lars Engebretsen
- University of Oslo, Oslo, Norway.,Oslo Sports Trauma Research Center, Oslo, Norway
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71
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Hewison CE, Tran MN, Kaniki N, Remtulla A, Bryant D, Getgood AM. Lateral Extra-articular Tenodesis Reduces Rotational Laxity When Combined With Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Literature. Arthroscopy 2015; 31:2022-34. [PMID: 26116497 DOI: 10.1016/j.arthro.2015.04.089] [Citation(s) in RCA: 161] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 03/25/2015] [Accepted: 04/17/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction would provide greater control of rotational laxity and improved clinical outcomes compared with ACL reconstruction alone. METHODS Two independent reviewers searched 9 databases for randomized and nonrandomized clinical studies comparing ACL reconstruction plus LET versus ACL reconstruction alone in a human adult population. All years and 5 languages were included. Animal and cadaveric studies, revision or repair surgical techniques, and studies focused on biomechanical outcomes were excluded. Quality assessment of the included studies was performed with the Cochrane Collaboration tool. Outcomes of interest included the pivot-shift test, KT-1000/-2000 measurements (MEDmetric, San Diego, CA), and International Knee Documentation Committee scores. RESULTS The literature search yielded 3,612 articles. After titles and abstracts were reviewed, 106 articles were selected for full-text review, of which 29 studies met the inclusion criteria (8 randomized and 21 nonrandomized studies). Of the 8 randomized studies, 3 concluded that the results were nonsignificant between treatment groups, 4 were in favor of the extra-articular tenodesis, and 1 was in favor of the ACL reconstruction alone. The Cochrane Collaboration tool showed an unclear to high risk of bias for most articles. A meta-analysis showed a statistically significant difference for the pivot-shift test (P = .002, I2 = 34%) in favor of ACL reconstruction with LET. No difference was found between the groups for International Knee Documentation Committee scores (P = .75, I2 = 19%) and KT-1000/-2000 measurements (P = .84, I2 = 34%). CONCLUSIONS Meta-analysis showed a statistically significant reduction in pivot shift in favor of the combined procedure. Studies lacked sufficient internal validity, sample size, methodologic consistency, and standardization of protocols and outcomes. LEVEL OF EVIDENCE Level III, systematic review of Level I, II, and III studies.
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Affiliation(s)
- Christopher E Hewison
- Fowler Kennedy Sport Medicine Clinic and University of Western Ontario, London, Ontario, Canada
| | - Michael N Tran
- Fowler Kennedy Sport Medicine Clinic and University of Western Ontario, London, Ontario, Canada
| | - Nicole Kaniki
- Fowler Kennedy Sport Medicine Clinic and University of Western Ontario, London, Ontario, Canada
| | - Alliya Remtulla
- Fowler Kennedy Sport Medicine Clinic and University of Western Ontario, London, Ontario, Canada
| | - Dianne Bryant
- Fowler Kennedy Sport Medicine Clinic and University of Western Ontario, London, Ontario, Canada
| | - Alan M Getgood
- Fowler Kennedy Sport Medicine Clinic and University of Western Ontario, London, Ontario, Canada.
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72
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Spencer L, Burkhart TA, Tran MN, Rezansoff AJ, Deo S, Caterine S, Getgood AM. Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee. Am J Sports Med 2015; 43:2189-97. [PMID: 26093007 DOI: 10.1177/0363546515589166] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic anterolateral ligament (ALL) reconstruction has been proposed to assist anterior cruciate ligament (ACL) reconstruction in controlling anterolateral rotational laxity of the knee. However, the biomechanical effects have not been reported. PURPOSE (1) To investigate the effect of ALL transection on rotational knee kinematics and (2) to determine the effect on knee biomechanics of ALL reconstruction procedures compared with lateral extra-articular tenodesis (LET). STUDY DESIGN Controlled laboratory study. METHODS A total of 12 cadaveric knee specimens were tested in the following sequence: (1) ACLintact, (2) anteromedial bundle of ACL sectioned (ACLamb), (3) complete ACL sectioned (ACLfull), (4) ALL sectioned (ALLsec), (5) anatomic ALL reconstruction (ALLanat), and (6) LET. Biomechanical anterior drawer and Lachman tests were performed in which a 90-N load was applied to the posterior tibia, and anterior translation was measured. A combined load to simulate the early phase of the pivot-shift test was executed in which a 5-N·m internal rotation moment was applied to a fully extended knee; anterior translation and internal rotation were measured. RESULTS Anterior translation increased across conditions for the biomechanical tests. Internal rotation during the simulated early-phase pivot-shift test was significantly different between ACLfull and ALLsec. Anatomic ALL reconstruction did not significantly reduce internal rotation or anterior translation during the simulated early-phase pivot-shift test. After LET, a significant decrease in anterior translation was found. There was no evidence of overconstraint of the knee with either anatomic ALL reconstruction or LET. CONCLUSION The ALL demonstrated a role in controlling anterolateral laxity. LET had a composite effect in governing both anterior and rotational laxity. Anatomic ALL reconstruction did not reduce anterolateral rotational laxity. CLINICAL RELEVANCE Profiling the biomechanical characteristics of anterolateral reconstruction is integral to understanding the implications and potential benefit of such an additional procedure to ACL reconstruction.
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Affiliation(s)
- Luke Spencer
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | - Timothy A Burkhart
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Michael N Tran
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | | | - Shaneel Deo
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | - Scott Caterine
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada. Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alan M Getgood
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.
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Rezende FC, de Moraes VY, Martimbianco ALC, Luzo MV, da Silveira Franciozi CE, Belloti JC. Does Combined Intra- and Extraarticular ACL Reconstruction Improve Function and Stability? A Meta-analysis. Clin Orthop Relat Res 2015; 473:2609-18. [PMID: 25845949 PMCID: PMC4488196 DOI: 10.1007/s11999-015-4285-y] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 03/25/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND ACL reconstruction aims to restore knee function and stability; however, rotational stability may not be completely restored by use of standard intraarticular reconstruction alone. Although individual studies have not shown the superiority of combined ACL reconstruction compared with isolated intraarticular reconstruction in terms of function and stability, biomechanical principles suggest a combined approach may be helpful, therefore pooling (meta-analyzing) the available randomized clinical studies may be enlightening. QUESTIONS/PURPOSES We performed a meta-analysis to determine whether combining extraarticular with intraarticular ACL reconstruction would lead to: (1) similar knee function measured by the IKDC evaluation, return-to-activity, and Tegner Lysholm scores, compared with isolated intraarticular reconstruction; (2) increased stability measured by pivot shift and instrumented Lachman examination; and (3) any differences in complications and adverse events? METHODS To identify randomized controlled trials (RCTs) comparing combined intra- and extrarticular ACL reconstruction (combined reconstruction) with intraarticular ACL reconstruction only, we searched MEDLINE, EMBASE, SPORTDiscus, Latin American and Caribbean Health Sciences (LILACS), and the Cochrane Central Register of Controlled Trials, and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The main outcomes we sought were patient function and stability and complications after ACL reconstruction. Of 386 identified studies, eight RCTs were included (n=682 participants; followup, 12-84 months; men to women ratio, 2.17:1) in our meta-analysis. Study quality (internal validity) was assessed using the Cochrane risk-of-bias tool; in general, we found a moderate quality of evidence of the included studies. RESULTS When functional outcomes were compared, we found no difference between patients who underwent intraarticular ACL reconstruction only and those who underwent combined reconstruction (IKDC, return-to-activity, and Tegner Lysholm scores). However, patients who underwent combined reconstruction were more likely to show improved stability based on the pivot shift test (risk ratio [RR], 0.95; 95% CI, 0.91-0.99; p=0.02) and Lachman test (RR, 0.93; 95% CI, 0.88-0.98; p=0.01). In addition, our meta-analysis found no difference between the two treatments in terms of general complications or adverse events (RR, 1.31; 95% CI, 0.70-2.34; p=0.40) and the proportion of patients whose reconstructions failed (RR, 2.88; 95% CI, 0.73-11.47; p=0.13). CONCLUSION Combined intra- and extraarticular ACL reconstruction provided marginally improved knee stability and comparable failure rates but no difference in patient-reported functional outcomes scores. Complications and adverse events such as knee stiffness may be underreported and technical factors such as graft placement were difficult to evaluate. Future studies are needed to determine whether the small differences in additional stability warrant the potential morbidity of the additional extraarticular procedure and to determine long-term failure rates.
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Affiliation(s)
- Fernando Cury Rezende
- Department of Orthopedics and Traumatology, Federal University of São Paulo, Borges Lagoa Street 783, Sao Paulo, SP 04038-032 Brazil
| | - Vinicius Ynoe de Moraes
- Department of Orthopedics and Traumatology, Federal University of São Paulo, Borges Lagoa Street 783, Sao Paulo, SP 04038-032 Brazil
| | - Ana Luiza Cabrera Martimbianco
- Department of Orthopedics and Traumatology, Federal University of São Paulo, Borges Lagoa Street 783, Sao Paulo, SP 04038-032 Brazil
| | - Marcus Vinícius Luzo
- Department of Orthopedics and Traumatology, Federal University of São Paulo, Borges Lagoa Street 783, Sao Paulo, SP 04038-032 Brazil
| | | | - João Carlos Belloti
- Department of Orthopedics and Traumatology, Federal University of São Paulo, Borges Lagoa Street 783, Sao Paulo, SP 04038-032 Brazil
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Clinical outcome of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction for medial compartment osteoarthritis in young patients with anterior cruciate ligament-deficient knees: a systematic review. Arthroscopy 2015; 31:507-19. [PMID: 25239170 DOI: 10.1016/j.arthro.2014.07.026] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 07/22/2014] [Accepted: 07/25/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE High tibial osteotomy (HTO) has been a well-established procedure addressing tibiofemoral osteoarthritis in young patients. However, for physically active patients with concomitant anterior cruciate ligament (ACL) injury, simultaneous HTO and ACL reconstruction is considered a salvage procedure. Controversy exists regarding the subjective and objective evaluations and the prevalence of complications. METHODS A search in the Medline database and of major orthopaedic journals was performed. Articles were included if they met the specific inclusion and exclusion criteria. Anterior knee laxity, osteoarthritis, subjective outcomes, sagittal and coronal alignment, and complications were analyzed. RESULTS A total of 721 articles were retrieved from the search, and 11 eligible studies (218 knees) were included for evaluation. Postoperatively, the mean side-to-side difference measured by KT-1000 (MEDmetric, San Diego, CA) was 2.4 mm, and 85.7% of patients gained grade A or B stability according to International Knee Documentation Committee evaluation. Medial compartment osteoarthritis showed a tendency of alleviation. Regardless of the scoring system, all subjective evaluations showed improvement and most of the participants returned to recreational sports. All cases of varus malalignment were corrected, with a mean value of 7.13°. The most prevalent complication was deep venous thrombosis (7.7%). CONCLUSIONS Simultaneous HTO and ACL reconstruction was a salvage procedure for physically active young patients because it provided satisfactory restoration of anterior stability, alleviation of medial compartment osteoarthritis, improvement of subjective evaluations, and a predictable return to recreational sports. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.
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Parsons EM, Gee AO, Spiekerman C, Cavanagh PR. The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med 2015; 43:669-74. [PMID: 25556221 PMCID: PMC4708263 DOI: 10.1177/0363546514562751] [Citation(s) in RCA: 232] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent anatomic investigations of the lateral structures of the knee have identified a new ligament, called the anterolateral ligament (ALL). To date, the anterolateral ligament has not been biomechanically tested to determine its function. HYPOTHESIS The ALL of the knee will resist internal rotation at high angles of flexion but will not resist anterior drawer forces. STUDY DESIGN Controlled laboratory study. METHODS Eleven cadaveric knees were subjected to 134 N of anterior drawer at flexion angles between 0° and 90° and separately to 5 N·m of internal rotation at the same flexion angles. The in situ forces of the ALL, anterior cruciate ligament (ACL), and lateral collateral ligament (LCL) were determined by the principle of superposition. RESULTS The contribution of the ALL during internal rotation increased significantly with increasing flexion, whereas that of the ACL decreased significantly. At knee flexion angles greater than 30°, the contribution of the ALL exceeded that of the ACL. During anterior drawer, the forces in the ALL were significantly less than the forces in the ACL at all flexion angles (P < .001). The forces in the LCL were significantly less than those in either the ACL or the ALL at all flexion angles for both anterior drawer and internal rotation (P < .001). CONCLUSION The ALL is an important stabilizer of internal rotation at flexion angles greater than 35°; however, it is minimally loaded during anterior drawer at all flexion angles. The ACL is the primary resister during anterior drawer at all flexion angles and during internal rotation at flexion angles less than 35°. CLINICAL RELEVANCE Damage to the ALL of the knee could result in knee instability at high angles of flexion. It is possible that a positive pivot-shift sign may be observed in some patients with an intact ACL but with damage to the ALL. This work may have implications for extra-articular reconstruction in patients with chronic anterolateral instability.
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Affiliation(s)
- Erin M. Parsons
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Albert O. Gee
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Charles Spiekerman
- Department of Oral Health Sciences, University of Washington, Seattle, Washington, USA
| | - Peter R. Cavanagh
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA,Address correspondence to Peter R. Cavanagh, Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Box 356500, 1959 NE Pacific Street, Seattle, WA 98195, USA ()
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Kittl C, Halewood C, Stephen JM, Gupte CM, Weiler A, Williams A, Amis AA. Length change patterns in the lateral extra-articular structures of the knee and related reconstructions. Am J Sports Med 2015; 43:354-62. [PMID: 25540293 DOI: 10.1177/0363546514560993] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [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 soft tissue reconstructions in the knee may be used as a combined procedure in revision anterior cruciate ligament surgery as well as in primary treatment for patients who demonstrate excessive anterolateral rotatory instability. Only a few studies examining length change patterns and isometry in lateral extra-articular reconstructions have been published. PURPOSE To determine a recommended femoral insertion area and graft path for lateral extra-articular reconstructions by measuring length change patterns through a range of knee flexion angles of several combinations of tibial and femoral insertion points on the lateral side of the knee. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen cadaveric knees were freed of skin and subcutaneous fat. The knee was then mounted in a kinematics rig that loaded the quadriceps muscles and simulated open-chain knee flexion. The length changes of several combinations of tibiofemoral points were measured at knee flexion angles between 0° and 90° by use of linear variable displacement transducers. The changes in length relative to the 0° measurement were recorded. RESULTS The anterior fiber region of the iliotibial tract displayed a significantly different (P < .001) length change pattern compared with the posterior fiber region. The reconstructions that had a femoral insertion site located proximal to the lateral epicondyle and with the grafts passed deep to the lateral collateral ligament displayed similar length change patterns to each other, with small length increases during knee extension. These reconstructions also showed a significantly lower total strain range compared with the reconstruction located anterior to the epicondyle (P < .001). CONCLUSION These findings show that the selection of graft attachment points and graft course affects length change pattern during knee flexion. A graft attached proximal to the lateral femoral epicondyle and running deep to the lateral collateral ligament will provide desirable graft behavior, such that it will not suffer excessive tightening or slackening during knee motion. CLINICAL RELEVANCE These results provide a surgical rationale for lateral extra-articular soft tissue reconstruction in terms of femoral graft fixation site and graft route.
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Affiliation(s)
- Cristoph Kittl
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK Department of Trauma Surgery, Landeskrankenhaus Steyr, Steyr, Austria
| | - Camilla Halewood
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
| | - Joanna M Stephen
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK
| | - Chinmay M Gupte
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | | | | | - Andrew A Amis
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, UK The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
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Araujo PH, Kfuri Junior M, Ohashi B, Hoshino Y, Zaffagnini S, Samuelsson K, Karlsson J, Fu F, Musahl V. Individualized ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22:1966-75. [PMID: 24623186 DOI: 10.1007/s00167-014-2928-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 02/25/2014] [Indexed: 01/13/2023]
Abstract
UNLABELLED The pivot shift test is the only physical examination test capable of predicting knee function and osteoarthritis development after an ACL injury. However, because interpretation and performance of the pivot shift are subjective in nature, the validity of the pivot shift is criticized for not providing objective information for a complete surgical planning for the treatment of rotatory knee laxity. The aim of ACL reconstruction was eliminating the pivot shift sign. Many structures and anatomical characteristics can influence the grading of the pivot shift test and are involved in the genesis and magnitude of rotatory instability after an ACL injury. The objective quantification of the pivot shift may be able to categorize knee laxity and provide adequate information on which structures are affected besides the ACL. A new algorithm for rotational instability treatment is presented, accounting for patients' unique anatomical characteristics and objective measurement of the pivot shift sign allowing for an individualized surgical treatment. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Paulo H Araujo
- Department of Biomechanics, Medicine and Rehabilitation of Locomotor System - Ribeirao Preto Medical School, São Paulo University, Av. Bandeirantes, 3900 - Monte Alegre, Ribeirão Prêto, CEP 14049-900, SP, Brazil,
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78
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van Eck CF, van den Bekerom MPJ, Fu FH, Poolman RW, Kerkhoffs GMMJ. Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surg Sports Traumatol Arthrosc 2013; 21:1895-903. [PMID: 23085822 DOI: 10.1007/s00167-012-2250-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 10/12/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE The aims of this meta-analysis were to determine the sensitivity and specificity of the Lachman, pivot shift and anterior drawer test for acute complete ACL rupture in the office setting and under anaesthesia. It was hypothesized that the Lachman test is the most sensitive and the pivot shift test the most specific. Secondly, it was hypothesized that the sensitivity and specificity of all three exams increases when the examination is performed under anaesthesia. METHODS An electronic database search was performed using MEDLINE and EMBASE. All cross-sectional and cohort studies comparing one or more physical examination tests for diagnosing acute complete ACL rupture to an accepted reference standard such as arthroscopy, arthrotomy and MRI were included. RESULTS Twenty studies were identified and included. The overall sensitivity of the Lachman test was 0.81 and the specificity 0.81; with anaesthesia, the sensitivity was 0.91 and the specificity 0.78. For the anterior drawer test, the sensitivity was 0.38 and the specificity 0.81; with anaesthesia, the sensitivity was 0.63 and the specificity 0.91. The sensitivity of the pivot shift test was 0.28 and the specificity 0.81; with anaesthesia, the sensitivity was 0.73 and the specificity 0.98. CONCLUSION In the office setting, the Lachman test has the highest sensitivity for diagnosing an acute, complete ACL rupture, while all three tests had comparable specificity. When the examination was performed under anaesthesia, the Lachman test still obtained the highest sensitivity, but the pivot shift test was the most specific. LEVEL OF EVIDENCE Meta-analysis of diagnostic test accuracy, Level II.
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Affiliation(s)
- Carola F van Eck
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufman building suite 1011, Pittsburgh, PA 15213, USA.
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79
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Salvi M, Caputo F, Piu G, Sanna M, Sanna C, Marongiu G. The loss of extension test (LOE test): a new clinical sign for the anterior cruciate ligament insufficient knee. J Orthop Traumatol 2013; 14:185-91. [PMID: 23558793 PMCID: PMC3751350 DOI: 10.1007/s10195-013-0238-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 03/11/2013] [Indexed: 12/03/2022] Open
Abstract
Background This prospective study was created to evaluate the reliability of a new clinical test, which we termed the “loss of extension test” (LOE test). The LOE test investigates the loss of normal maximum passive extension (MPE) of the knee due to an anterior cruciate ligament tear in comparison to the normal MPE of the healthy knee. Materials and methods The study was divided into two consecutive parts. Part 1 was designed to assess the side-to-side difference in normal MPE in a healthy population. In part 1, 100 healthy adults were enrolled. Part 2 was designed to evaluate the LOE test reliability in injured knees. In part 2, we included 196 selected patients. Results In part 1, the average side-to-side difference in MPE in the healthy population was not statistically significant. In part 2, the overall average side-to-side difference in MPE of the injured group was 10.1 mm ± 14.1 (min −20; max 60), which was not statistically significant (p = 0.52). An anterior cruciate ligament (ACL) tear was found in 121 knees among 196 patients. The average side-to-side difference in MPE in the ACL-insufficient group was 16.9 mm ± 13.4 (min −20; max 60), which was statistically significant (p < 0.0001). The accuracy of the loss of extension test was 83.7 %, its specificity was 93.3 %, its sensitivity was 77.7 %, its positive predictive value was 95 %, and its negative predictive value was 72.2 %. Conclusions The reliability of the LOE test is comparable to those reported in the literature for the Lachman test and dynamic tests, so the LOE test could represent a useful tool for the diagnosis of the anterior cruciate ligament insufficient knee.
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Affiliation(s)
- Massimiliano Salvi
- Department of Prosthetic and Sports Surgery, Casa di Cura Lay, Via S. Ignazio da Laconi, 34, 09123, Cagliari, Sardinia, Italy.
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80
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Abstract
Evaluation of injured-knee laxity is essential for treatment selection, clinical follow-up, and research. Interest in rotatory knee laxity increased with implementation of anatomic anterior cruciate ligament reconstruction. The pivot shift test represents a link between static testing with 1° of freedom and dynamic testing during functional activity. Difficulties lie in standardizing the performance of the pivot shift test and extracting measurable and relevant kinematic data. Noninvasive methodologies based on electromagnetic or acceleration sensors can evaluate the pivot shift in a quantitative and reliable manner. Further validation and reliability testing of devices for examination of rotatory laxity is warranted.
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Affiliation(s)
- Mattias Ahldén
- Department of Orthopaedics, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Mölndal, Sweden.
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81
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Chalmers PN, Mall NA, Yanke AB, Bach BR. Contemporary Anterior Cruciate Ligament Outcomes: Does Technique Really Matter? OPER TECHN SPORT MED 2013. [DOI: 10.1053/j.otsm.2012.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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82
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Debandi A, Maeyama A, Hoshino Y, Asai S, Goto B, Smolinski P, Fu FH. The effect of tunnel placement on rotational stability after ACL reconstruction: evaluation with use of triaxial accelerometry in a porcine model. Knee Surg Sports Traumatol Arthrosc 2013; 21:589-95. [PMID: 22437660 DOI: 10.1007/s00167-012-1961-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 03/06/2012] [Indexed: 12/17/2022]
Abstract
PURPOSE Conventional transtibial technique fails to restore the rotational knee stability in spite of successful anterior laxity, while anatomic anterior cruciate ligament reconstruction using the anteromedial portal technique has been developed expecting better rotational kinematics because of closer reproduction of the native anterior cruciate ligament anatomy. However, the rotational instability after those two procedures has not been fully examined especially in terms of dynamic component of the rotational stability. The purpose was to assess the effect of anatomic versus non-anatomic tunnel placement on rotational knee stability after anterior cruciate ligament reconstruction using triaxial accelerometry. METHODS Sixteen porcine knees underwent a manual pivot-shift test at four different conditions: (1) anterior cruciate ligament intact, (2) anterior cruciate ligament deficient, (3) non-anatomic transtibial reconstruction, and (4) anatomic anteromedial portal reconstruction. The three-dimensional acceleration of knee motion during the pivot-shift test was recorded using a triaxial accelerometer. RESULTS Both anterior cruciate ligament reconstructions decreased significantly the acceleration of the pivot-shift test from the increased level in the anterior cruciate ligament-deficient condition. However, the transtibial technique fails to reach the intact level of acceleration, while the anteromedial portal technique reduced the acceleration to even less than the intact level. CONCLUSION The transtibial anterior cruciate ligament reconstruction could not restore the dynamic rotational stability of the intact knee, whereas the anteromedial portal technique restored the dynamic rotational stability closer to the intact level. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Aníbal Debandi
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, 1010 Kaufmann Building, Pittsburgh, PA 15213, USA
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83
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Chambat P, Guier C, Sonnery-Cottet B, Fayard JM, Thaunat M. The evolution of ACL reconstruction over the last fifty years. INTERNATIONAL ORTHOPAEDICS 2013; 37:181-6. [PMID: 23322063 PMCID: PMC3560904 DOI: 10.1007/s00264-012-1759-3] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 12/13/2012] [Indexed: 01/13/2023]
Abstract
Anterior cruciate ligament (ACL) reconstruction has evolved considerably over the past 30 years. This has largely been due to a better understanding of ACL anatomy and in particular a precise description of the femoral and tibial insertions of its two bundles. In the 1980s, the gold standard was anteromedial bundle reconstruction using the middle third of the patellar ligament. Insufficient control of rotational laxity led to the development of double bundle ACL reconstruction. This concept, combined with a growing interest in preservation of the ACL remnant, led in turn to selective reconstruction in partial tears, and more recently to biological reconstruction with ACL remnant conservation. Current ACL reconstruction techniques are not uniform, depending on precise analysis of the type of lesion and the aspect of the ACL remnant in the intercondylar notch.
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Affiliation(s)
- Pierre Chambat
- />Centre Orthopédique Santy, Unité Genou – 1er Etage, 24 Avenue Paul Santy, 69008 Lyon, France
| | | | - Bertrand Sonnery-Cottet
- />Centre Orthopédique Santy, Unité Genou – 1er Etage, 24 Avenue Paul Santy, 69008 Lyon, France
| | - Jean-Marie Fayard
- />Centre Orthopédique Santy, Unité Genou – 1er Etage, 24 Avenue Paul Santy, 69008 Lyon, France
| | - Mathieu Thaunat
- />Centre Orthopédique Santy, Unité Genou – 1er Etage, 24 Avenue Paul Santy, 69008 Lyon, France
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84
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Sharma G, Naik VA, Pankaj A. Displaced osteochondral fracture of the lateral femoral condyle associated with an acute anterior cruciate ligament avulsion fracture: a corollary of "the lateral femoral notch sign". Knee Surg Sports Traumatol Arthrosc 2012; 20:1599-602. [PMID: 22113226 DOI: 10.1007/s00167-011-1795-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 11/14/2011] [Indexed: 12/11/2022]
Abstract
Anterior cruciate ligament (ACL) rupture is usually accompanied by bone contusions resulting from impact of tibia on femur. The injury sometimes becomes manifest as a depression on the lateral femoral condyle giving rise to "lateral femoral notch" sign. The authors describe a rare case of impaction of the tibia and femur resulting in an osteochondral fracture rather than the usual bone contusion, which frequently occurs with ACL rupture. Open reduction and internal fixation of both the ACL avulsion fracture and the osteochondral fracture from the lateral femoral condyle were done, and the patient had a good outcome at 1-year follow-up. Level of evidence V.
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Affiliation(s)
- Gaurav Sharma
- Department of Orthopedics, University College of Medical Sciences and GTB Hospital, Delhi, 110095, India.
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85
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Optimal measurement of clinical rotational test for evaluating anterior cruciate ligament insufficiency. Knee Surg Sports Traumatol Arthrosc 2012; 20:1323-30. [PMID: 21850429 DOI: 10.1007/s00167-011-1643-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 07/29/2011] [Indexed: 01/24/2023]
Abstract
PURPOSE Rotational instability in ACL insufficient knee addresses the symptom or the abnormal motion which can be reproduced and subjectively evaluated in the clinical exam. Clinically available quantitative measurement for this instability has not been established due to mixed testing maneuvers and complex kinematics. The purpose was to measure knee kinematics during three manually performed rotational tests and to determine the optimal method to detect the abnormality in ACL deficient knees. METHOD Thirteen unilateral ACL deficient patients were tested by internal and external pure rotational stress tests and pivot shift test under anesthesia before scheduled ACL reconstructions. Rotation and coupled motion, i.e., tibial anteroposterior translation, were measured using an electromagnetic measurement system. Additionally, the acceleration of the tibial posterior translation during pivot shift test was calculated. The differences of these parameters between ACL intact and deficient knees were tested. RESULTS Knee rotation is not different between ACL intact and deficient during both pure rotational stress test and pivot shift test. The coupled anterior tibial translation during pivot shift test was significantly different between ACL intact, 13.5 ± 4.1 mm, and deficient knees, 23.1 ± 4.4 mm, (P < 0.01) as well as the acceleration of the tibial posterior translation (1.1 ± 0.4 m/sec(2) in intact knees, 3.2 ± 1.5 m/sec(2) in deficient knees; P < 0.01). The coupled motion during pure rotational stress tests was similar regardless of ACL condition. CONCLUSION The rotational instability of the ACL deficiency was reproduced only by the pivot shift test and detected only by measuring the tibial anteroposterior translation and acceleration of the tibial posterior reduction. Level of evidence Diagnostic study, Level III.
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86
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Ng AWH, Griffith JF, Hung EHY, Law KY, Ho EPY, Yung PSH. Can MRI predict the clinical instability and loss of the screw home phenomenon following ACL tear? Clin Imaging 2012. [PMID: 23206617 DOI: 10.1016/j.clinimag.2012.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our purpose was to determine the relationship between tibiofemoral translation on magnetic resonance imaging and clinical instability of the knee following anterior cruciate ligament (ACL) injury. Within 66 patients (43 males, 23 females, mean age 30.25 years), 15 of 19 patients (80%) with an intact ACL had a demonstrable normal screw home movement, while 24 of 47 patients (51%) with an ACL tear had absence of the screw home movement. Patients with clinical instability had greater tibial translation and excursion at the lateral compartment (P=.0001). Following ACL injury, there is demonstrable absence of the normal screw-home movement with anterior tibial translation and excursion related to presence of clinical instability.
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Affiliation(s)
- Alex Wing Hung Ng
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong.
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87
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Standardized pivot shift test improves measurement accuracy. Knee Surg Sports Traumatol Arthrosc 2012; 20:732-6. [PMID: 22205096 DOI: 10.1007/s00167-011-1850-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/16/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE The variability of the pivot shift test techniques greatly interferes with achieving a quantitative and generally comparable measurement. The purpose of this study was to compare the variation of the quantitative pivot shift measurements with different surgeons' preferred techniques to a standardized technique. The hypothesis was that standardizing the pivot shift test would improve consistency in the quantitative evaluation when compared with surgeon-specific techniques. METHODS A whole lower body cadaveric specimen was prepared to have a low-grade pivot shift on one side and high-grade pivot shift on the other side. Twelve expert surgeons performed the pivot shift test using (1) their preferred technique and (2) a standardized technique. Electromagnetic tracking was utilized to measure anterior tibial translation and acceleration of the reduction during the pivot shift test. The variation of the measurement was compared between the surgeons' preferred technique and the standardized technique. RESULTS The anterior tibial translation during pivot shift test was similar between using surgeons' preferred technique (left 24.0 ± 4.3 mm; right 15.5 ± 3.8 mm) and using standardized technique (left 25.1 ± 3.2 mm; right 15.6 ± 4.0 mm; n.s.). However, the variation in acceleration was significantly smaller with the standardized technique (left 3.0 ± 1.3 mm/s(2); right 2.5 ± 0.7 mm/s(2)) compared with the surgeons' preferred technique (left 4.3 ± 3.3 mm/s(2); right 3.4 ± 2.3 mm/s(2); both P < 0.01). CONCLUSION Standardizing the pivot shift test maneuver provides a more consistent quantitative evaluation and may be helpful in designing future multicenter clinical outcome trials. LEVEL OF EVIDENCE Diagnostic study, Level I.
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Engebretsen L, Wijdicks CA, Anderson CJ, Westerhaus B, LaPrade RF. Evaluation of a simulated pivot shift test: a biomechanical study. Knee Surg Sports Traumatol Arthrosc 2012; 20:698-702. [PMID: 22057355 DOI: 10.1007/s00167-011-1744-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 10/21/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE Double-bundle anterior cruciate reconstructions have led to an increased interest in quantifying anterolateral rotatory stability. The application of combined internal rotation and valgus torques to the knee can more nearly recreate the anterolateral subluxation that occurs in the pivot shift test in vitro compared to coupled internal rotation torque and anterior tibial loads. METHODS Twelve non-paired cadaveric knees were biomechanically tested with the ACL intact and sectioned. For each test state, six-degree-of-freedom positional data were collected for two simulated pivot shift loads consisting of a 5-Nm internal rotation torque coupled with either a 10-Nm valgus torque or an 88 N anterior tibial load at 0°, 20°, 30°, 60°, and 90° of knee flexion. RESULTS The coupled internal rotation and valgus torques produced a significant increase in anterolateral subluxation between the ACL intact and sectioned states at all tested angles except 90º (5.9 ± 0.4 mm at 0°, 4.3 ± 0.6 mm at 20°, 3.5 ± 0.6 mm at 30°, 2.1 ± 0.6 mm at 60°). The coupled internal rotation and an anterior tibial load produced significant increases between the ACL intact and sectioned states at all tested angles except 30º (5.4 ± 0.5 mm at 0°, 3.7 ± 0.5 mm at 20°, 2.1 ± 0.8 mm at 60°, 1.4 ± 0.3 mm at 90°). CONCLUSIONS We found that the coupled internal rotation and valgus torques best recreated the anterolateral subluxation that occurs in the pivot shift in vitro. This study describes an anterolateral subluxation test for ACL integrity in the laboratory setting.
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Affiliation(s)
- Lars Engebretsen
- Department of Orthopaedic Surgery, Oslo University Hospital and Faculty of Medicine, Kirkeveien 166, 0407 Oslo, Norway.
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Zaffagnini S, Marcheggiani Muccioli GM, Lopomo N, Signorelli C, Bonanzinga T, Musiani C, Vassilis P, Nitri M, Marcacci M. Can the pivot-shift be eliminated by anatomic double-bundle anterior cruciate ligament reconstruction? Knee Surg Sports Traumatol Arthrosc 2012; 20:743-51. [PMID: 22270673 DOI: 10.1007/s00167-012-1897-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 01/10/2012] [Indexed: 01/31/2023]
Abstract
PURPOSE To assess the ability of anatomic double-bundle anterior cruciate ligament reconstruction in eliminating the pivot-shift phenomenon when identified by a quantitative measuring system (computer navigation or magnetic resonance imaging). METHODS Literature review. Medline, Google Scholar and Cochrane Reviews computerized databases research using the keywords "pivot-shift," "anterior cruciate ligament reconstruction" and "double bundle." Twelve (7 in vitro and 5 in vivo) studies met the inclusion criteria. RESULTS There was a wide variation in the absolute value of translation and rotation measured after anatomic double-bundle anterior cruciate ligament reconstruction. There were also differences in fixation methods, pivot-shift execution conditions, applied stresses during the pivot-shift, calculation methods and reference systems utilized by measurement systems. CONCLUSIONS The double-bundle reconstruction was shown to over-constrain the knee with respect to the intact value, especially closer to knee extension. This review demonstrated that anatomic double-bundle anterior cruciate ligament reconstruction is able to eliminate pathological translations and rotations during the pivot-shift phenomenon, as identified by quantitative measurement systems. LEVEL OF EVIDENCE Review of Level III studies, Level III.
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Affiliation(s)
- Stefano Zaffagnini
- 3rd Orthopaedic and Traumatology Clinic and Biomechanics Laboratory, Codivilla-Putti Research Center, Istituto Ortopedico Rizzoli-University of Bologna, via di Barbiano, 1/10, 40100 Bologna, Italy.
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Tanaka M, Vyas D, Moloney G, Bedi A, Pearle AD, Musahl V. What does it take to have a high-grade pivot shift? Knee Surg Sports Traumatol Arthrosc 2012; 20:737-42. [PMID: 22222616 DOI: 10.1007/s00167-011-1866-5] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 12/23/2011] [Indexed: 01/13/2023]
Abstract
UNLABELLED The pivot shift is the most specific clinical test to assess pathological knee joint rotatory laxity following ACL injury. This article attempts to describe the anatomic structures responsible for creating a high-grade pivot shift and their potential role in customizing ACL reconstruction. A review of the literature demonstrates that disruption of the secondary stabilizers of anterior translation of the lateral compartment including the lateral meniscus, anterolateral capsule, and IT band contributes to a high-grade pivot shift in the ACL-deficient knee. The morphology of the lateral tibial plateau, including increased posteroinferior tibial slope and small size, can also contribute to high-grade pivot shift. Factors that may decrease the grade of the pivot shift include medial compartment injury, MCL injury, patient guarding, and osteoarthritis. In conclusion, a high-grade pivot shift in the ACL-deficient knee is often associated with incompetence of the lateral soft tissue envelope. Rotatory laxity as assessed by the pivot shift may also be falsely underestimated by concomitant injuries. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- M Tanaka
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
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91
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Kuroda R, Hoshino Y, Araki D, Nishizawa Y, Nagamune K, Matsumoto T, Kubo S, Matsushita T, Kurosaka M. Quantitative measurement of the pivot shift, reliability, and clinical applications. Knee Surg Sports Traumatol Arthrosc 2012; 20:686-91. [PMID: 22210517 DOI: 10.1007/s00167-011-1849-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/16/2011] [Indexed: 02/07/2023]
Abstract
Static load-displacement measurement is unrelated to the dynamic knee function of anterior cruciate ligament (ACL) insufficiency. Performing an accurate, dynamic functional evaluation is necessary not only for the primary ACL injury, but also as an outcome measurement in ACL reconstruction. The pivot shift test is commonly used for assessing dynamic rotatory knee laxity in ACL-insufficient knees and is related to subjective knee function. Residual pivot shift after ACL reconstruction is a crucial factor related to poor clinical outcome. However, the pivot shift test is subjectively determined by the examiners' hands. Not only 3-dimensional (3D) position displacement but also its 3D acceleration should be measured for quantitative evaluation of the pivot shift test and is currently feasible by using recent advanced technology, i.e., electromagnetic devices. We summarize the basic knowledge and current concepts of quantitative exploration of the dynamic knee movement during the pivot shift test.
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Affiliation(s)
- Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan.
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Dodds AL, Gupte CM, Neyret P, Williams AM, Amis AA. Extra-articular techniques in anterior cruciate ligament reconstruction: a literature review. ACTA ACUST UNITED AC 2012; 93:1440-8. [PMID: 22058292 DOI: 10.1302/0301-620x.93b11.27632] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique. The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.
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Affiliation(s)
- A L Dodds
- Imperial College NHS Trust/St Mary's and Charing Cross Hospitals, Praed Street, London W2 1NY, UK
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93
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Kuroda R, Hoshino Y, Kubo S, Araki D, Oka S, Nagamune K, Kurosaka M. Similarities and differences of diagnostic manual tests for anterior cruciate ligament insufficiency: a global survey and kinematics assessment. Am J Sports Med 2012; 40:91-9. [PMID: 21989128 DOI: 10.1177/0363546511423634] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Lachman and pivot-shift tests are 2 standard manual tests to diagnose anterior cruciate ligament (ACL) insufficiency. However, the global variation of these testing procedures is not known. PURPOSE To survey currently used testing techniques and to measure the knee movement during manual tests among various expert surgeons from across the globe. STUDY DESIGN Controlled laboratory study. METHODS Part 1: descriptive survey. A questionnaire asking about testing procedures of Lachman and pivot-shift tests was conducted among 33 ACL surgeons. Part 2: knee kinematics comparison. Lachman and pivot-shift tests were performed on a unilateral ACL-injured patient by 5 surgeons, while knee kinematics was recorded by an electromagnetic system. Tibial translation was measured during the Lachman test, while tibial translation, rotation, and pivot-shift acceleration were calculated during the pivot-shift test. RESULTS Part 1: Tibial anterior drawer by a medially placed hand was widely advocated for the Lachman test. Flexion type of the pivot-shift test maneuver was supported by two thirds, while extension type was supported by one third. However, the "feeling" of subluxation or reduction during the pivot shift was the primary evaluation method used by the vast majority of surgeons. Part 2: Increased tibial translation during the Lachman test was observed in the ACL-injured knee with significant variation between examiners (P < .01). Tibial translation and pivot-shift acceleration during the pivot-shift test increased in the ACL-injured side (P < .01), but tibial rotation was too diverse to find any trend (P = .31). Tibial translation and acceleration of the pivot shift in the ACL-injured knee showed no significant difference between examiners (P > .05). CONCLUSION The Lachman test can display a wide variation of actual movement despite maneuver similarity, while the pivot-shift test could possibly be measurable by tibial translation and/or acceleration beyond their procedural variation. CLINICAL RELEVANCE We should recognize the limitations of these manual tests and the possibilities of their objective measurement.
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Affiliation(s)
- Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University, Kobe, Hyogo, Japan.
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Schindler OS. Surgery for anterior cruciate ligament deficiency: a historical perspective. Knee Surg Sports Traumatol Arthrosc 2012; 20:5-47. [PMID: 22105976 DOI: 10.1007/s00167-011-1756-x] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 10/26/2011] [Indexed: 12/13/2022]
Abstract
The anterior cruciate ligament (ACL) has entertained scientific minds since the Weber brothers provided biomechanical insight into the importance of the ACL in maintaining normal knee kinematics. Robert Adams described the first clinical case of ACL rupture in 1837 some 175 years to date, followed by Mayo-Robson of Leeds who performed the first ACL repair in 1895. At that time, most patients presented late and clinicians started to appreciate signs and symptoms and disabilities associated with such injuries. Hey Groves of Bristol provided the initial description of an ACL reconstruction with autologous tissue graft in 1917, almost as we know it today. His knowledge and achievements were, however, not uniformly appreciated during his life time. What followed was a period of startling ingenuity which created an amazing variety of different surgical procedures often based more on surgical fashion and the absence of a satisfactory alternative than any indication that continued refinements were leading to improved results. It is hence not surprising that real inventors were forgotten, good ideas discarded and untried surgical methods adopted with uncritical enthusiasm only to be set aside without further explanation. Over the past 100 years, surgeons have experimented with a variety of different graft sources including xenograft, and allografts, whilst autologous tissue has remained the most popular choice. Synthetic graft materials enjoyed temporary popularity in the 1980 and 1990s, in the misguided belief that artificial ligaments may be more durable and better equipped to withstand stresses and strains. Until the 1970s, ACL reconstructions were considered formidable procedures, often so complex and fraught with peril that they remained reserved for a chosen few, never gaining the level of popularity they are enjoying today. The increasing familiarity with arthroscopy, popularised through Jackson and Dandy, and enhancements in surgical technology firmly established ACL reconstruction as a common procedure within the realm of most surgeons' ability. More recently, the principle of anatomic ACL reconstruction, aiming at the functional restoration of native ACL dimensions and insertion sites, has been introduced, superseding the somewhat ill-advised concept of isometric graft placement. Double-bundle reconstruction is gaining in popularity, and combined extra- and intra-articular procedures are seeing a revival, but more accurate and reliable pre- and post-operative assessment tools are required to provide customised treatment options and appropriate evaluation and comparability of long-term results. Modern ACL surgery is united in the common goal of re-establishing joint homoeostasis with normal knee kinematics and function which may ultimately assist in reducing the prevalence of post-operative joint degeneration. This review hopes to provide an insight into the historical developments of ACL surgery and the various controversies surrounding its progress. Level of evidence V.
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Milewski MD, Beck NA, Lawrence JT, Ganley TJ. Anterior Cruciate Ligament Reconstruction in the Young Athlete: A Treatment Algorithm for the Skeletally Immature. Clin Sports Med 2011; 30:801-10. [DOI: 10.1016/j.csm.2011.08.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Araki D, Kuroda R, Kubo S, Nagamune K, Hoshino Y, Nishimoto K, Takayama K, Matsushita T, Tei K, Yamaguchi M, Kurosaka M. The use of an electromagnetic measurement system for anterior tibial displacement during the Lachman test. Arthroscopy 2011; 27:792-802. [PMID: 21497045 DOI: 10.1016/j.arthro.2011.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 01/09/2011] [Accepted: 01/11/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to assess quantitative anterior/posterior values during the Lachman test by an electromagnetic measurement system and to compare data with KT-1000 arthrometric measurements (MEDmetric, San Diego, CA), as well as the measurement of radiologic laxity by dynamic radiographs. METHODS We used an electromagnetic device to quantitatively evaluate anterior knee displacements. We tested 82 knees in 41 patients (30 isolated anterior cruciate ligament [ACL]-deficient, 11 ACL-reconstructed, and 41 contralateral ACL-intact knees). Anterior displacements during the Lachman test were calculated by the electromagnetic measurement system and fluoroscopic measurement, and anterior displacements were also measured by the KT-1000 arthrometer. Anterior/posterior displacements measured by these methods were compared, and correlations were assessed. RESULTS In ACL-deficient knees, mean anterior/posterior displacement (±SE) was 22.4 ± 0.8 mm in electromagnetic measurements, 22.0 ± 0.7 mm in fluoroscopic measurements, and 15.0 ± 0.6 mm in KT-1000 measurements. In contralateral ACL-intact knees, it was 15.7 ± 0.6 mm, 15.6 ± 0.5 mm, and 9.9 ± 0.4 mm, respectively. In ACL-reconstructed knees, it was 15.7 ± 0.7 mm, 16.2 ± 0.8 mm, and 11.2 ± 0.6 mm, respectively. In all knee conditions, significant differences between fluoroscopic measurements and KT-1000 measurements were detected (P < .01). Significant differences were also detected between electromagnetic measurements and KT-1000 measurements (P < .01). No significant differences were detected between fluoroscopic measurements and electromagnetic measurements. A strong correlation was obtained between KT-1000 measurements and fluoroscopic measurements (r = 0.62, P < .01) and between electromagnetic measurements and KT-1000 measurements (r = 0.64, P < .01). However, the strongest correlation was observed between electromagnetic measurements and fluoroscopic measurements (r = 0.96, P < .01). CONCLUSIONS An electromagnetic measurement system to test anterior/posterior tibial translation determined that quantification of the Lachman test could be performed as accurately as fluoroscopic measurements. LEVEL OF EVIDENCE Level II, development of diagnostic criteria on basis of consecutive patients with universally applied reference gold standard.
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Affiliation(s)
- Daisuke Araki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
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Sakai H, Hiraoka H, Yashiki M. Gravity-assisted pivot-shift test can predict the function of the reconstructed anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2011; 19:572-8. [PMID: 20890695 DOI: 10.1007/s00167-010-1279-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 09/15/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE The gravity-assisted pivot-shift (GAPS) test is a newly advocated test for anterior cruciate ligament (ACL) injury. We retrospectively investigated the relationships between the result of preoperative GAPS test and the function of the reconstructed ACL using autogenous hamstring tendon grafts. METHODS Seventy-eight patients with unilateral ACL injury and a minimum of 1-year follow-up were enrolled in this study. According to the result of preoperative GAPS test, they were divided into two groups, i.e., positive test group (Group P) and negative test group (Group N). At the time of follow-up, the operated knee was examined manually and using KT-1000 arthrometer. According to these results, the function of the reconstructed ACL was classified. RESULTS The proportion of the knees with a negative abnormal laxity test was less in Group P than Group N with the significant difference in Lachman test (P = 0.0029) and N-test (P = 0.0081). The proportion of the cases having greater than 3 mm of the side-to-side difference in anterior knee laxity using KT-1000 arthrometer was greater in Group P, in spite of no statistically significant difference. Regarding the classification of the function of the reconstructed ACL, Group P was worse than Group N (P = 0.0187), and all 4 knees classified as failed belonged to Group P. CONCLUSION The knees with a preoperative positive GAPS test showed worse postoperative function of the reconstructed ACL than those with a negative test. Preoperative positive GAPS test is considered to be a predisposing factor to poor functional outcome after ACL reconstruction. It is possible that the use of hamstring tendons as a graft source should be avoided for the ACL-injured patients with a positive GAPS test.
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Affiliation(s)
- Hiroya Sakai
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University, 1981, Kamoda, Kawagoe, Saitama, 350-8550, Japan.
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Arciero RA. Pearls and Pitfalls in the Management of the Chronic Multiple Ligament-Injured Knee. OPER TECHN SPORT MED 2010. [DOI: 10.1053/j.otsm.2010.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Chan DB, Temple HT, Latta LL, Mahure S, Dennis J, Kaplan LD. A biomechanical comparison of fan-folded, single-looped fascia lata with other graft tissues as a suitable substitute for anterior cruciate ligament reconstruction. Arthroscopy 2010; 26:1641-7. [PMID: 20875723 DOI: 10.1016/j.arthro.2010.03.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 03/21/2010] [Accepted: 03/25/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the initial biomechanical properties of a fan-folded, single-loop construct of fan-folded fascia lata allograft in comparison to other graft tissues currently being used for anterior cruciate ligament (ACL) reconstruction. METHODS Eighteen fascia lata specimens were harvested from 11 donors and fan folded through a proprietary process. Bone-patellar tendon-bone (BPTB), tibialis anterior, tibialis posterior, and peroneus longus tendons were harvested from 4 additional donors. All soft-tissue grafts were tested to failure in an MTS machine (MTS Systems, Eden Prairie, MN) in a single-looped fashion. BPTB grafts were similarly clamped in freeze grips. The ultimate load to failure and stiffness were calculated for each graft type tested. RESULTS The mean ultimate load to failure was 3,266 N and stiffness was 414 N/mm for the single-looped fascia lata grafts (n = 18). There was no significant difference for ultimate load to failure and stiffness between the fascia lata and tibialis anterior (3,012 N and 342 N/mm, respectively), tibialis posterior (3,666 N and 392 N/mm, respectively), and peroneus longus (3,050 N and 346 N/mm, respectively) tendons. The fascia lata grafts performed significantly better (P < .001) than BPTB (1,404 N and 224 N/mm, respectively). CONCLUSIONS A single-loop construct of fan-folded fascia lata allograft has, on biomechanical testing, initial ultimate tensile strength (3,266 N) and stiffness values equivalent to or better than several other graft tissues currently used in ACL reconstruction, including BPTB (1,403 N), tibialis anterior (3,012 N), tibialis posterior (3,666 N), and peroneus longus (3,050 N). CLINICAL RELEVANCE In the face of potential allograft tissue shortages and increasing constraints on health care expenditures, the use of fascia lata has the potential to be a readily available graft for ACL reconstruction that performs as well as other grafts and at a comparable or lower cost.
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Affiliation(s)
- Daniel B Chan
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Florida 33136, USA.
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