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Firth AD, Bryant DM, Litchfield R, McCormack RG, Heard M, MacDonald PB, Spalding T, Verdonk PC, Peterson D, Bardana D, Rezansoff A, Getgood AM, Willits K, Birmingham T, Hewison C, Wanlin S, Pinto R, Martindale A, O’Neill L, Jennings M, Daniluk M, Boyer D, Zomar M, Moon K, Moon R, Fan B, Mohan B, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Howells F, Tough M, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Milan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Declerq G, Vuylsteke K, Van Haver M. Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience. Am J Sports Med 2022; 50:384-395. [PMID: 35050817 PMCID: PMC8829733 DOI: 10.1177/03635465211061150] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. PURPOSE/HYPOTHESIS The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. RESULTS Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. CONCLUSION The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.
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Affiliation(s)
| | | | - Robert Litchfield
- London Health Sciences Centre, Western University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | - Tim Spalding
- University Hospitals Coventry Warwickshire NHS Trust, Coventry, UK
| | | | | | | | - Alex Rezansoff
- Sport Medicine Centre, University of Calgary, Calgary, Canada
| | | | - Alan M.J. Getgood
- Alan M.J. Getgood, MD, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, London, ON N6A 3K7, Canada () (Twitter: FKSMC_Getgood)
| | | | | | | | | | | | | | | | | | - Michal Daniluk
- London Health Sciences Centre, Western University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | | | | | - Bindu Mohan
- Fraser Orthopaedic Institute, New Westminster, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michelle Mayer
- Sport Medicine Centre, University of Calgary, Calgary, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mieke Van Haver
- Antwerp Orthopaedic Center, Ghent, Belgium,Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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Combination of anterior tibial and femoral tunnels makes the signal intensity of antero-medial graft higher in double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:783-792. [PMID: 32350577 DOI: 10.1007/s00167-020-06014-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 04/17/2020] [Indexed: 12/27/2022]
Abstract
PURPOSE To elucidate whether sagittal graft tunnel affects the signal intensity in anatomical ACL reconstruction (ACLR) and to clarify the prevalence of intercondylar roof impingement. It was hypothesized that if the tunnel apertures are located within the anatomical footprint of ACL, tunnel position would not affect the signal intensity. METHODS A total of 132 patients who underwent anatomical double-bundle ACLR (DB-ACLR) using hamstring autograft were recruited. Tunnel position was determined by the quadrant method on three-dimensional computed tomography; the femoral tunnel position was defined as "high and low" or "deep and shallow", while that of the tibial side was defined as "anterior and posterior" or "medial and lateral". Subjects were divided into three groups according to the tertile of % deep-shallow. The signal intensity was evaluated by the region of interest value of the antero-medial bundle (AMB) and postero-lateral bundle on magnetic resonance imaging at 12 months after reconstruction. Linear regression analysis was conducted to elucidate the relationship between the percentage position of each tunnel and the graft signal intensity. RESULTS In the shallow tertile group, AMB signal intensity increased in the anterior position of the tibial tunnel (β = - 0.34; P = 0.025). In the intermediate and deep tertile groups, the tunnel position did not correlate with the signal intensity. CONCLUSIONS A more anterior tibial tunnel position increases AMB signal intensity in shallower femoral tunnel. Conversely, this correlation is attenuated for deeper femoral tunnels. Surgeons should pay attention to sagittal femoral tunnel position to create a more anterior tibial tunnel position. LEVEL OF EVIDENCE Level III.
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Hume DR, Navacchia A, Rullkoetter PJ, Shelburne KB. A lower extremity model for muscle-driven simulation of activity using explicit finite element modeling. J Biomech 2019; 84:153-160. [PMID: 30630624 DOI: 10.1016/j.jbiomech.2018.12.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 12/21/2018] [Accepted: 12/22/2018] [Indexed: 10/27/2022]
Abstract
A key strength of computational modeling is that it can provide estimates of muscle, ligament, and joint loads, stresses, and strains through non-invasive means. However, simulations that can predict the forces in the muscles during activity while maintaining sufficient complexity to realistically represent the muscles and joint structures can be computationally challenging. For this reason, the current state of the art is to apply separate rigid-body dynamic and finite-element (FE) analyses in series. However, the use of two or more disconnected models often fails to capture key interactions between the joint-level and whole-body scales. Single framework MSFE models have the potential to overcome the limitations associated with disconnected models in series. The objectives of the current study were to create a multi-scale FE model of the human lower extremity that combines optimization, dynamic muscle modeling, and structural FE analysis in a single framework and to apply this framework to evaluate the mechanics of healthy knee specimens during two activities. Two subject-specific FE models (Model 1, Model 2) of the lower extremity were developed in ABAQUS/Explicit including detailed representations of the muscles. Muscle forces, knee joint loading, and articular contact were calculated for two activities using an inverse dynamics approach and static optimization. Quadriceps muscle forces peaked at the onset of chair rise (2174 N, 1962 N) and in early stance phase (510 N, 525 N), while gait saw peak forces in the hamstrings (851 N, 868 N) in midstance. Joint forces were similar in magnitude to available telemetric patient data. This study demonstrates the feasibility of detailed quasi-static, muscle-driven simulations in an FE framework.
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Affiliation(s)
- Donald R Hume
- University of Denver, Center for Orthopaedic Biomechanics, Denver, CO, United States.
| | - Alessandro Navacchia
- University of Denver, Center for Orthopaedic Biomechanics, Denver, CO, United States
| | - Paul J Rullkoetter
- University of Denver, Center for Orthopaedic Biomechanics, Denver, CO, United States
| | - Kevin B Shelburne
- University of Denver, Center for Orthopaedic Biomechanics, Denver, CO, United States
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Intercondylar Notch Impingement of the Anterior Cruciate Ligament: A Cadaveric In Vitro Study Using Robots. JOURNAL OF HEALTHCARE ENGINEERING 2018; 2018:8698167. [PMID: 30651948 PMCID: PMC6311805 DOI: 10.1155/2018/8698167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/16/2018] [Accepted: 11/06/2018] [Indexed: 01/13/2023]
Abstract
Background Research has indicated that a smaller intercondylar notch could cause contact between the anterior cruciate ligament and the femoral notch, which may predispose individuals to an increased rate of anterior cruciate ligament injury. Hypothesis Contact between the lateral notch wall and the anterior cruciate ligament does increase the strain past the structural integrity of the ligament. Study Design A descriptive laboratory study. Methods A biomechanical study using robotic manipulators was conducted to investigate the occurrence of impingement in human cadaver specimens. Six cadaveric knees from six donors (three male and three female) were instrumented with a thin force sensor, placed on the lateral wall of the femoral condyle, and a differential variable reluctance transducer (DVRT) was attached to the middle section of the anterior medial bundle of the ACL. The knees were then moved through a series of flexion (5° to 90°), valgus (0 to 7.5°), and external rotation (0 to 7.5°) movements using two interacting robots. Results The results revealed that impingement occurred in both male and female specimens with a maximum impingement force of 28 N. Impingement occurred more prominently in female knees and in the combination loading of valgus and external rotation for both genders. The corresponding strain due to impingement was small or compressive, with the male knee maximum strain less than 1.28% and the female knee strain less than 7.1% in the worse case conditions. Conclusion The lack of increased force or strain when impingement occurred indicates that impingement may not affect the healthy function of the knee with a nonstenotic notch. Additionally, the analysis shows that impingement may not be a major contributing factor to anterior cruciate ligament injury, but rather a common occurrence in healthy knees. Clinical Relevance Impingement within the femoral notch does not appear to be a major contributory factor to ACL injury. Other more severe injuries to the knee would occur before ACL impingement with the femoral notch becoming a contributing factor to ACL injury. The small sample size limits the conclusivity of the results presented in this research; thus, additional large sample size studies are warranted.
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Ueki H, Nakagawa Y, Ohara T, Watanabe T, Horie M, Katagiri H, Otabe K, Katagiri K, Hiyama K, Katakura M, Hoshino T, Inomata K, Araya N, Sekiya I, Muneta T, Koga H. Risk factors for residual pivot shift after anterior cruciate ligament reconstruction: data from the MAKS group. Knee Surg Sports Traumatol Arthrosc 2018; 26:3724-3730. [PMID: 29947841 DOI: 10.1007/s00167-018-5005-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/30/2018] [Indexed: 01/03/2023]
Abstract
PURPOSE To investigate the risk factors for residual pivot shift test after anterior cruciate ligament (ACL) reconstruction based on a multicenter prospective cohort study. METHODS This study included patients who were registered in the Multicenter Arthroscopic Knee Surgery Study, a prospective longitudinal multicenter cohort study, and who underwent primary ACL reconstruction using autologous hamstring tendon graft between 2013 and 2016. The exclusion criteria included prior injuries or surgeries in the contralateral knee, prior ligamentous injuries in the involved knee, grade 2 or 3 concomitant ligament injuries, and inflammatory or other forms of osteoarthritis. Data from the preoperative period and at 1-year follow-up were used for further analysis, and patients with incomplete data, re-injury and loss to follow-up were also excluded. Logistic regression analysis was conducted with age, gender, Lachman test, pivot shift test, KT measurement, hyperextension, single-bundle vs. double-bundle, meniscus injury sites, and meniscus treatments as the independent variables, and postoperative pivot shift test was used as the dependent variable. RESULTS Three hundred and sixty-eight patients were included in the study. Hyperextension knee (P = 0.025) and a preoperative pivot shift test under anesthesia (P = 0.040) were identified as risk factors for a postoperative pivot shift via logistic regression analysis. There were no statistically significant differences in the other variables. CONCLUSIONS The results from a multicenter cohort study indicated that knee hyperextension and greater preoperative pivot shift under anesthesia were risk factors for residual pivot shift at 1 year after ACL reconstruction. In cases with a preoperative high-grade pivot shift and knee hyperextension, additional anterolateral structure augmentation might be considered in order to eliminate pivot shift and eventually obtain better outcomes after ACL reconstruction. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Hiroko Ueki
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshiyuki Ohara
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshifumi Watanabe
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masafumi Horie
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroki Katagiri
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Koji Otabe
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kenta Katagiri
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kanehiro Hiyama
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Mai Katakura
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takashi Hoshino
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kei Inomata
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Naoko Araya
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takeshi Muneta
- National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo, 190-0014, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Bone-patellar tendon-bone autograft could be recommended as a superior graft to hamstring autograft for ACL reconstruction in patients with generalized joint laxity: 2- and 5-year follow-up study. Knee Surg Sports Traumatol Arthrosc 2018; 26:2568-2579. [PMID: 29502168 DOI: 10.1007/s00167-018-4881-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/28/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE The present study aimed to compare 2- and 5-year outcomes of ACL reconstruction between patients with and without generalized joint laxity and to perform comparative evaluation between two types of grafts used for ACL reconstruction in patients with generalized joint laxity. METHODS Two hundred and thirty-seven patients who underwent ACL reconstruction from 2001 to 2008 were included. Patients were classified into two groups according to the presence or the absence of generalized joint laxity, and further subdivided into two subgroups based on the type of graft used: bone-patellar tendon-bone (BPTB) or hamstring. Generalized joint laxity was assessed with the Beighton and Horan criteria using a point scoring system. Stability reflected by the Lachman test, pivot-shift test, and anterior translation measured with KT-2000, and functional outcomes reflected by Lysholm knee score, and International Knee Documentation Committee (IKDC) subjective score were investigated. IKDC objective grade and radiographic grade were also assessed. Clinical assessments were conducted preoperatively and at 2 and 5 years after operation. RESULTS Two-year follow-up results showed that patients with generalized joint laxity receiving hamstring grafts had poorer outcomes than those without generalized joint laxity. Five-year follow-up results showed that patients with generalized joint laxity experienced poorer outcomes than patients without generalized joint laxity, irrespective of the type of graft. Comparison of grafts used showed that, in patients with generalized joint laxity, BPTB graft provided significantly better stability and functional outcomes than hamstring graft at both 2- and 5-year follow-ups. Comparisons between serial outcomes measured at 2 and 5 years demonstrated that stability and functional outcomes deteriorated over time in patients with generalized joint laxity. CONCLUSIONS Less satisfactory stability and functional outcomes were noted in patients with generalized joint laxity, compared to patients without generalized joint laxity. Comparisons of stability and functional outcomes after ACL reconstruction in patients with generalized joint laxity between two different grafts demonstrated that BPTB graft achieves better results than hamstring graft. LEVEL OF EVIDENCE III, a retrospective cohort study.
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Hume DR, Navacchia A, Ali AA, Shelburne KB. The interaction of muscle moment arm, knee laxity, and torque in a multi-scale musculoskeletal model of the lower limb. J Biomech 2018; 76:173-180. [PMID: 29941208 DOI: 10.1016/j.jbiomech.2018.05.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 05/11/2018] [Accepted: 05/30/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Musculoskeletal modeling allows insight into the interaction of muscle force and knee joint kinematics that cannot be measured in the laboratory. However, musculoskeletal models of the lower extremity commonly use simplified representations of the knee that may limit analyses of the interaction between muscle forces and joint kinematics. The goal of this research was to demonstrate how muscle forces alter knee kinematics and consequently muscle moment arms and joint torque in a musculoskeletal model of the lower limb that includes a deformable representation of the knee. METHODS Two musculoskeletal models of the lower limb including specimen-specific articular geometries and ligament deformability at the knee were built in a finite element framework and calibrated to match mean isometric torque data collected from 12 healthy subjects. Muscle moment arms were compared between simulations of passive knee flexion and maximum isometric knee extension and flexion. In addition, isometric torque results were compared with predictions using simplified knee models in which the deformability of the knee was removed and the kinematics at the joint were prescribed for all degrees of freedom. RESULTS Peak isometric torque estimated with a deformable knee representation occurred between 45° and 60° in extension, and 45° in flexion. The maximum isometric flexion torques generated by the models with deformable ligaments were 14.6% and 17.9% larger than those generated by the models with prescribed kinematics; by contrast, the maximum isometric extension torques generated by the models were similar. The change in hamstrings moment arms during isometric flexion was greater than that of the quadriceps during isometric extension (a mean RMS difference of 9.8 mm compared to 2.9 mm, respectively). DISCUSSION The large changes in the moment arms of the hamstrings, when activated in a model with deformable ligaments, resulted in changes to flexion torque. When simulating human motion, the inclusion of a deformable joint in a multi-scale musculoskeletal finite element model of the lower limb may preserve the realistic interaction of muscle force with knee kinematics and torque.
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Affiliation(s)
- Donald R Hume
- University of Denver, Center for Orthopaedic Biomechanics, Denver, CO, United States
| | - Alessandro Navacchia
- University of Denver, Center for Orthopaedic Biomechanics, Denver, CO, United States
| | - Azhar A Ali
- University of Denver, Center for Orthopaedic Biomechanics, Denver, CO, United States
| | - Kevin B Shelburne
- University of Denver, Center for Orthopaedic Biomechanics, Denver, CO, United States.
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Y-reconstruction could be better for ACL reconstruction in knee hyperextension versus double-bundle double-tunnel technique: a retrospective comparative study of 56 patients. Arch Orthop Trauma Surg 2018; 138:827-834. [PMID: 29504034 DOI: 10.1007/s00402-018-2909-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE To compare the clinical outcomes of double-bundle (DB) single-tibial tunnel technique and double-tunnel technique for ACL reconstruction in patients with knee hyperextension. METHODS Defined as having constitutional hyperextension of greater than 10°, 56 patients with knee hyperextension who underwent ACL reconstruction were included in this study. To exclude concomitant lesions, preoperative magnetic resonance imaging (MRI) was performed in all knees. 24 patients (Group A) were treated with the anatomic DB/single-tibial tunnel ACL reconstruction and 32 patients (Group B) were treated with DB/double-tibial tunnel ACL reconstruction, all the included patients had knee hyperextension. Clinical results were evaluated by the extension angle, ROM, IKDC 2000 subjective score, rotational stability, pivot-shift test and anterior-posterior translation test before the operation and at the end of follow-up. MRI scan of the knee positioned in full extension was performed after 6 months post-operation. Location of tibial tunnels and graft signal intensity were assessed according to the MRI. RESULTS Postoperative extension deficit was detected in Group B, ROM of the injured knee in Group A was from extension angle 8.91 ± 3.16° to flexion angle 115.58 ± 10.53°. ROM of the injured knee in Group B was from extension angle - 2.13 ± 5.88° to flexion angle 119.25 ± 12.63°. Flexion angles of two groups did not show any significant difference (p = 0.24), while extension angles were quite different (p < 0.0001). Group A was slightly higher than Group B in IKDC subjective scores, but without significant difference (Group A 45.1 ± 6.5, Group B 42.4 ± 4.8, p = 0.09). There was no significant difference between two groups in pivot-shift test. Post-operational MRI showed more anterior located tibial tunnel and higher graft signal intensity in Group B when compared with Group A. One patient in the Group B had ligament retear, and required revision surgery. CONCLUSION DB/single-tibial tunnel technique restored the knee stability and overcame the shortcomings (such as knee extension deficit and graft impingement) of DB/double tibial tunnel, which might be more suitable for ACL reconstruction in knees with hyperextension. LEVEL OF EVIDENCE Level II to III.
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Kim SJ, Choi CH, Lee SK, Lee W, An H, Jung M. Minimum Two-Year Follow-up of Anterior Cruciate Ligament Reconstruction in Patients with Generalized Joint Laxity. J Bone Joint Surg Am 2018; 100:278-287. [PMID: 29462031 DOI: 10.2106/jbjs.17.00767] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purposes of this investigation were to compare outcomes of anterior cruciate ligament (ACL) reconstruction between patients with generalized joint laxity and those without it and to investigate the effect of generalized joint laxity on outcomes of ACL reconstruction from 2 to 8 years postoperatively. METHODS We retrospectively reviewed 163 patients who had undergone unilateral ACL reconstruction from January 2001 to December 2008. Patients were divided into 2 groups according to presence or absence of generalized joint laxity. The proportions of patients with meniscectomy, graft rupture, and contralateral ACL rupture were compared. Rupture rates were compared with Kaplan-Meier analysis. The Lachman test, pivot-shift test, and anterior translation measured with the KT-2000 arthrometer were evaluated. The Lysholm knee score and International Knee Documentation Committee (IKDC) subjective score were compared. The IKDC objective grade and radiographic grade were also evaluated. Follow-up assessments were performed at 2, 5, and 8 years postoperatively. RESULTS The proportions of meniscectomy, graft rupture, and contralateral ACL rupture in patients with generalized joint laxity were higher than in patients without generalized joint laxity during the whole evaluation period. However, differences in proportions and cumulative rupture rates did not reach significance (p > 0.05). Patients with generalized joint laxity had less stability and poorer functional outcomes at the 8-year follow-up compared with patients without generalized joint laxity. With regard to the Lachman test and anterior translation, poorer results were shown in patients with generalized joint laxity than in patients without generalized joint laxity during the whole evaluation period. The results of pivot-shift testing differed significantly at 5 years (p = 0.002) and 8 years (p = 0.007). Patients with generalized joint laxity also had worse Lysholm knee scores and IKDC subjective scores during the whole evaluation period; these differences may not be clinically important. Comparisons between serial outcomes measured at 2, 5, and 8-year follow-ups within each patient group showed that anterior translation (p = 0.002), Lysholm knee score (p = 0.014), and IKDC subjective score (p = 0.002) deteriorated over time, although the values at 8 years were similar to those at 5 years, in patients with generalized joint laxity. CONCLUSIONS Generalized joint laxity as an inherent physiologic characteristic of patients was related to a significant adverse effect on stability and functional outcomes of ACL reconstruction for patients followed for 2 to 8 years. Generalized joint laxity should be considered a risk factor for poor outcomes after ACL reconstruction. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sung-Jae Kim
- Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, South Korea
| | - Chong Hyuk Choi
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Su-Keon Lee
- Department of Orthopaedic Surgery, Gwangmyung Sungae Hospital, Gyeonggi, South Korea
| | - Wonyong Lee
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Haemosu An
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Jung
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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Sundemo D, Mikkelsen C, Cristiani R, Forssblad M, Senorski EH, Svantesson E, Samuelsson K, Stålman A. Contralateral knee hyperextension is associated with increased anterior tibial translation and fewer meniscal injuries in the anterior cruciate ligament-injured knee. Knee Surg Sports Traumatol Arthrosc 2018; 26:3020-3028. [PMID: 29974175 PMCID: PMC6154035 DOI: 10.1007/s00167-018-5047-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/27/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate the influence of hyperextension of the contralateral healthy knee on anterior tibial translation (ATT) and the presence of associated injuries in the anterior cruciate ligament (ACL)-injured knee. METHODS A local patient data register containing the surgical and clinical data of patients undergoing ACL reconstruction was analyzed. Patients were divided into groups according to the degree of hyperextension of the contralateral knee: normal (Group A ≤ 0°), mild (Group B 1°-5°), moderate (Group C 6°-10°), and severe (Group D > 10°). The ATT was measured in both knees preoperatively and 6 months postoperatively using the KT-1000 arthrometer. The presence of associated meniscal and cartilage injuries was noted. Using multivariate analysis, Groups B, C, and D were compared with Group A, using this group as a reference. RESULTS A total of 10,957 patients were available in the register and 8502 (Group A n = 4335, Group B n = 3331, Group C n = 771, Group D n = 65) were included in the final analysis. Groups B (10.3 mm; 95% CI 0.06-0.042, p < 0.0001) and C (10.6 mm; 95% CI 0.23-0.89, p = 0.006) showed significantly greater preoperative ATT in the injured knee compared with the control group (10.1 mm). Moreover, at the 6-month follow-up, greater ATT was observed for Groups B (8.5 mm; 95% CI 0.13-0.45, p < 0.0001), C (8.5 mm; 95% CI 0.02-0.60, p = 0.035), and D (9.1 mm; 95% CI - 0.08-1.77, p = 0.082) compared with Group A (8.2 mm). Meniscal injuries were less frequent in patients with contralateral hyperextension [Group B 903 (27.1%) p < 0.0001, Group C 208 (27.0%) p = 0.0003, and Group D 12 (18.5%), 0.012] compared with the control group [Group A 1479 (34.1%)]. CONCLUSION Contralateral knee hyperextension is associated with greater pre- and postoperative ATT in the ACL-injured knee. In patients with contralateral knee hyperextension, concomitant injuries to the menisci are less frequent. Surgeons should consider grafts with superior properties regarding postoperative anteroposterior laxity to patients with contralateral knee hyperextension. LEVEL OF EVIDENCE Retrospective cohort study, Level IV.
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Affiliation(s)
- David Sundemo
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Christina Mikkelsen
- Capio Artro Clinic, Sophiahemmet, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Riccardo Cristiani
- Capio Artro Clinic, Sophiahemmet, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Forssblad
- 0000 0004 1937 0626grid.4714.6Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Eric Hamrin Senorski
- 0000 0000 9919 9582grid.8761.8Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eleonor Svantesson
- 0000 0000 9919 9582grid.8761.8Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Samuelsson
- 0000 0000 9919 9582grid.8761.8Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ,000000009445082Xgrid.1649.aDepartment of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Anders Stålman
- Capio Artro Clinic, Sophiahemmet, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
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Tashiro Y, Sundaram V, Thorhauer E, Gale T, Anderst W, Irrgang JJ, Fu FH, Tashman S. In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament-Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique. Arthroscopy 2017; 33:1393-1402. [PMID: 28343809 PMCID: PMC5495610 DOI: 10.1016/j.arthro.2017.01.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/25/2017] [Accepted: 01/26/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the in vivo dynamic graft bending angle (GBA) in anterior cruciate ligament (ACL)-reconstructed knees, correlate the angle to tunnel positions and tunnel widening, and evaluate the effects of 2 femoral tunnel drilling techniques on GBA. METHODS Patients with an isolated ACL injury undergoing reconstruction from 2011 to 2012 were included. Transportal techniques were used to create femoral tunnels. Tunnel locations were determined by 3-dimensional computed tomography. Tibiofemoral kinematics during treadmill walking and running were assessed by dynamic stereo x-ray analysis 6 months and 2 years postoperatively. The GBA was calculated from the 3-dimensional angle between the graft and femoral tunnel vectors on each motion frame. The cross-sectional areas of femoral tunnels were measured at 6 months and compared with the initial size to assess tunnel widening. RESULTS A total of 54 patients were included. Use of flexible drills resulted in significantly higher GBAs during walking (80.6° ± 7.8°, P < .001) and running (80.5° ± 9.0°, P = .025) than rigid drills (walking, 67.5° ± 9.3°; running, 74.1° ± 9.6°). Their use led to greater tunnel widening of 113.9% ± 17.6%, as compared with 97.7% ± 17.5% for rigid drills (P = .003). The femoral and tibial apertures were located in similar anatomic positions in both groups, but the femoral tunnel exits were located more anteriorly (P < .001) in the flexible drill group. A higher GBA was highly correlated with anterior location of femoral exits (r = 0.63, P < .001) and moderately correlated with greater tunnel widening (r = 0.48, P < .001). CONCLUSIONS High GBAs were identified during dynamic activities after anatomic ACL reconstruction with a transportal femoral tunnel drilling technique. The GBA was greater when flexible drills were used. The high bending angle resulted from the more anterior location of the femoral tunnel exits, and it correlated with early bone tunnel widening at 6 months. These results suggest that a high GBA may increase stress at the bone-graft interface and contribute to greater tunnel widening after anatomic ACL reconstruction, although the clinical impact should be further investigated. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ysutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA, Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Vani Sundaram
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Eric Thorhauer
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Tom Gale
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - William Anderst
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - James J. Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Freddie H. Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
| | - Scott Tashman
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue Pittsburgh, PA 15213, USA
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Tashiro Y, Irarrázaval S, Osaki K, Iwamoto Y, Fu FH. Comparison of graft bending angle during knee motion after outside-in, trans-portal and trans-tibial anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:129-137. [PMID: 27277192 DOI: 10.1007/s00167-016-4191-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 05/31/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE To determine graft bending angle (GBA) during knee motion after anatomic anterior cruciate ligament (ACL) reconstruction and to clarify whether surgical techniques affect GBA. Our hypotheses were that the graft bending angle would be highest at knee extension and the difference of surgical techniques would affect the bending steepness. METHODS Eight healthy volunteers with a mean age of 29.3 ± 3.0 years were recruited and 3D MRI knee models were created at three flexion angles (0°, 90° and 130°). Surgical simulation of the tunnel drilling was performed with anatomic tunnel position using each outside-in (OI), trans-portal (TP) and trans-tibial (TT) techniques on the identical cases. The models were matched to other knee positions and the GBA in 3D was measured using computational software. Double-bundle ACL reconstruction was analysed first, and single-bundle reconstruction was also analysed to evaluate its effect to reduce GBA. A repeated-measures ANOVA was used to compare GBA difference at three flexion angles, by three techniques or of three bundles. RESULTS GBA changed substantially with knee motion, and it was highest at full extension (p < 0.001) in each surgical technique. OI technique exhibited highest GBA for anteromedial bundle (94.3° ± 5.2°) at extension, followed by TP (83.1° ± 6.5°) and TT (70.0° ± 5.2°) techniques (p < 0.01). GBA for posterolateral bundle at extension were also high in OI (84.6° ± 7.4°), TP (83.0° ± 6.3°) and TT (77.2° ± 7.0°) techniques (n.s.). Single-bundle grafts did not decrease GBA compared with double-bundle grafts. In OI technique, a more proximal location of the femoral exit reduced GBA of each bundle at extension and 90° flexion. CONCLUSION A significant GBA change with knee motion and considerably steep bending at full extension, especially with OI and TP techniques, were simulated. Although single-bundle technique did not reduce GBA as seen in double-bundle technique, proximal location of femoral exits by OI technique, with tunnels kept in anatomic position, was effective in decreasing GBA at knee extension and flexion. For clinical relevance, high stress on graft and bone interface has been suggested by steep GBA at full extension after anatomic ACL reconstruction. LEVEL OF EVIDENCE Therapeutic study (prospective comparative study), Level II.
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Affiliation(s)
- Yasutaka Tashiro
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA. .,Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Sebastián Irarrázaval
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Kanji Osaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
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Thein R, Spitzer E, Doyle J, Khamaisy S, Nawabi DH, Chawla H, Lipman JD, Pearle AD. The ACL Graft Has Different Cross-sectional Dimensions Compared With the Native ACL: Implications for Graft Impingement. Am J Sports Med 2016; 44:2097-105. [PMID: 27179055 DOI: 10.1177/0363546516645531] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Impingement of anterior cruciate ligament (ACL) grafts against the femoral notch and the posterior cruciate ligament (PCL) is thought to be influenced primarily by tunnel position and graft orientation. Recent data have implied that the native ACL is ribbon-shaped. PURPOSE To evaluate the 3-dimensional shape and cross-sectional area of the native ACL versus the ACL graft and to compare the degree of impingement against the femoral notch and PCL. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Bilateral knee magnetic resonance images were analyzed for 27 patients with unilateral bone-patellar tendon-bone (BPTB) ACL reconstruction performed via transtibial or anteromedial portal femoral tunneling techniques. Three-dimensional models of the ACL, PCL, femur, and tibia were digitally rendered. The cross-sectional area and dimensions of the native ACL and the reconstructed graft were determined at 3 equally spaced locations and compared via Wilcoxon-Mann-Whitney and Kruskal-Wallis tests. In addition, impingement of the ACL on the PCL and femoral notch was graded in 3 groups. Chi-square or Fisher exact tests were used to compare the proportional differences of impingement of the native and reconstructed ACL on the PCL and femoral notch, respectively. All analyses were performed using 2-sided hypothesis testing, with statistical significance at P < .05. RESULTS Cross-sectional areas at all 3 points on the ACL graft were significantly greater than those of the native ACL (P < .001). The long- to short-axis ratio for the native ACL was significantly greater at each location compared with the corresponding locations along the ACL graft (P < .001), implying that the native ACL is "flatter" than is an ACL graft. There were 19 operated knees (70%) with contact or impingement between the ACL graft and the femoral notch compared with zero knees with a native ACL (P < .001). In addition, 22 operated knees (81%) showed contact or impingement between the ACL graft and the PCL, compared with 7 knees (26%) with a native ACL (P < .001). No significant differences in impingement frequency were noted between the transtibial and anteromedial tunneling techniques for ACL graft specimens (P > .05). CONCLUSION Native ACLs have a smaller cross-sectional area, are "flatter," and experience less incidence of impingement compared with anatomically placed BPTB ACL grafts.
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Affiliation(s)
- Ran Thein
- Department of Orthopedic Surgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - Elad Spitzer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - John Doyle
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Saker Khamaisy
- Department of Orthopedic Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Danyal H Nawabi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Harshvardhan Chawla
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Joseph D Lipman
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Andrew D Pearle
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Benner RW, Shelbourne KD, Gray T. The Degree of Knee Extension Does Not Affect Postoperative Stability or Subsequent Graft Tear Rate After Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft. Am J Sports Med 2016; 44:844-9. [PMID: 26801922 DOI: 10.1177/0363546515623507] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is concern that high degrees of hyperextension may lead to an increase in graft laxity or graft failure after anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS Patients with a high degree of hyperextension will have a higher rate of graft tear/failure and lower subjective scores after surgery compared with patients with less knee extension. STUDY DESIGN Cohort study, Level of evidence, 2. METHODS Of 2329 patients who underwent ACL reconstruction with patellar tendon autograft between 1998 and 2008, there were 625 patients who met the inclusion criteria of having primary ACL surgery, no bilateral ACL injuries, no existing osteoarthritis, and having either ≥6° of knee hyperextension before and after surgery (group A: n = 318; mean hyperextension, 8° ± 2° [range, 6°-15°]) or ≤3° of knee hyperextension before and after surgery (group B: n = 307; mean hyperextension, 0° ± 3° [range, 3° hyperextension to -4° short of 0° neutral]). KT-1000 arthrometer manual maximum difference between knees, range of motion measurements, and subjective follow-up with International Knee Documentation Committee (IKDC) and Cincinnati Knee Ratings Scale (CKRS) surveys were used to evaluate results. Subsequent graft tear related to specific injury within 5 years of surgery was recorded. Graft failure was defined as a KT-1000 manual maximum difference of >5 mm. RESULTS Follow-up was obtained from 278 (87%) in group A and 275 (90%) in group B at a mean of 4.1 ± 1.1 years after surgery. The KT-1000 arthrometer manual maximum difference between knees was 2.0 ± 1.4 in group A and 2.1 ± 1.6 in group B (P = .701). Subsequent ACL graft tear/failure occurred in 22 patients (6.9%) in group A and 30 patients (9.8%) in group B (P = .246). Further subanalysis showed that the graft tear/failure rate was 6 of 81 (7.4%) for patients with ≥10° of hyperextension versus 16 of 237 (6.8%) for patients with 6° to 9° of hyperextension. There was no difference in IKDC or CKRS scores between groups after surgery (P = .933 and .155, respectively). CONCLUSION Obtaining full hyperextension that is anatomically normal for most patients does not affect objective stability, ACL graft tear/failure rates, or subjective scores after ACL reconstruction with patellar tendon autograft.
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Affiliation(s)
| | | | - Tinker Gray
- Shelbourne Knee Center, Indianapolis, Indiana, USA
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15
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Matsubara H, Okazaki K, Tashiro Y, Toyoda K, Uemura M, Hashizume M, Iwamoto Y. Intercondylar roof impingement after anatomic double-bundle anterior cruciate ligament reconstruction in patients with knee hyperextension. Am J Sports Med 2013; 41:2819-27. [PMID: 24099713 DOI: 10.1177/0363546513505073] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although an anatomically placed graft in anterior cruciate ligament (ACL) reconstruction is reported to have a low risk of roof impingement, which may cause deterioration of the graft or an extension deficit, the incidence of roof impingement by these grafts has not been evaluated in hyperextensible knees. PURPOSE To evaluate the incidence of roof impingement by the native ACL in hyperextensible knees and to examine the risk of roof impingement by anatomic placement of the ACL graft in hyperextensible knees. STUDY DESIGN Controlled laboratory study. METHODS Twelve patients were selected for a hyperextensible knee group (group A), defined as having hyperextension of the knee of greater than 10°. Twelve patients were recruited to a normal extension knee group (group B) with normal extension of the knee of less than 5° of hyperextension. Magnetic resonance imaging (MRI) scans of the knee positioned in 30° of flexion and full extension were acquired from all patients. The shape of the native ACL at full extension was compared between the groups. A 3-dimensional (3D) bone model was created from the acquired 2D MRI scans. A virtual anatomic double-bundle ACL reconstruction in each patient and a virtual anatomic single-bundle reconstruction in the patients in group A were performed using the 3D MRI bone models. The volume of the overlap between the graft and roof was calculated to evaluate graft impingement in each instance. RESULTS The MRI scans showed posterior bowing of the native ACL in the group A knees. The simulated double-bundle ACL reconstruction showed that the overlapped volume was significantly greater in patients in group A than in patients in group B (P < .05). However, the overlap of the simulated single-bundle ACL reconstruction was significantly less than for the double-bundle ACL reconstruction (P < .05). CONCLUSION To reduce the risk of roof impingement by the graft, single-bundle ACL reconstruction with the graft placed at the center of the footprint might be the better method for patients with a hyperextensible knee than an anatomic double-bundle ACL reconstruction. CLINICAL RELEVANCE It is recommended that surgeons cautiously consider roof impingement after anatomic double-bundle ACL reconstruction in patients with a hyperextensible knee.
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Affiliation(s)
- Hirokazu Matsubara
- Ken Okazaki, Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 8128582, Japan.
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Pujol N, Queinnec S, Boisrenoult P, Maqdes A, Beaufils P. Anatomy of the anterior cruciate ligament related to hamstring tendon grafts. A cadaveric study. Knee 2013; 20:511-4. [PMID: 23157968 DOI: 10.1016/j.knee.2012.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 10/09/2012] [Accepted: 10/11/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of modern techniques for anatomic reconstruction of the ACL is to reproduce ACL footprints, in order to restore anatomy and therefore normal biomechanics. Is there an oversizing of the hamstring grafts related to ACL dimensions? METHODS Twenty-two paired cadaver knees were dissected. ACL dimensions at mid-portion and ACL footprints were measured after removing the synovial membrane. Hamstrings were harvested and prepared in a quadruple strand graft in order to measure the mean circumference. RESULTS The average ACL tibial and femoral insertion site areas of the ACL were 117.9mm(2) (range, 90 to 130mm) and 96.8mm(2) (range, 80 to 121mm), respectively. The average diameter and cross sectional area of the ACL tendon at mid-portion were 6.1mm (range, 5 to 7mm) and 29.2mm(2) (range, 20 to 38.9), respectively. The average diameter and cross-sectional area of the 4-stranded hamstring tendons were 6.7 (range, 5 to 8) and 35.3mm(2) (range, 20 to 50), respectively. There was a correlation between the 4-stranded hamstring grafts and ACL dimensions (footprints, ligament at mid substance, p<0.01). The cross sectional area of hamstring tendon was significantly larger than the ACL area at mid-portion (mean 20.9%, p<0.05). CONCLUSION With current ACL reconstruction techniques, the graft is oversized at a mean of 21%, despite a good correlation between the ACL and the hamstring tendon, especially among small subjects and women. The question arises whether the anatomic reconstruction of the ACL should fill ACL footprints or mimic the ligament itself. CLINICAL RELEVANCE Hamstrings grafts are significantly larger than native ACL.
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Affiliation(s)
- Nicolas Pujol
- Orthopedic Department, Centre Hospitalier de Versailles, Versailles-Saint Quentin University, 177, rue de Versailles, 78157 Le Chesnay, France.
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Anatomic double-bundle ACL reconstruction restricts knee extension in knees with hyperextension. Knee Surg Sports Traumatol Arthrosc 2013; 21:2057-62. [PMID: 22945469 DOI: 10.1007/s00167-012-2190-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 08/21/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Double-bundle ACL reconstruction has been demonstrated to be at least as effective as single-bundle reconstruction in terms of restoring knee rotational and translational stability. Until now, the influence on knees with hyperextension has not been evaluated. It was the purpose of this study to evaluate whether double-bundle ACL reconstruction restricts extension in hyperextendable knees. METHODS Hamstring tendon reconstructions of 10 human cadaveric knees with the ability of hyperextension (age: 48 ± 14 years) were performed as single bundle (SB) on one side and double bundle (DB) on the other side. A surgical navigation system (BrainLab, Germany) was used to assess the kinematics of each knee at the intact and reconstructed state. A difference with regard to the anterior-to-posterior translation (AP) and rotational stability at 30° of knee flexion, 90° of flexion and the hyperextension capability of each specimen was analysed. RESULTS The difference in AP translation before and after the reconstruction was not significantly different in 30° and 90° of flexion (n.s). Both single- and double-bundle reconstructions restored the preoperative kinematics at 30° and 90° of knee flexion (n.s). The knee extension was 4° ± 1.8° with the intact ACL and 4° ± 1.7° after reconstruction in the SB group (n.s). The knee extension was 5° of hyperextension ± 1.1° with the intact ACL and 0° ± 0.4° after reconstruction in the DB group; the limitation of the extension was significantly larger in this group (p = 0.013). CONCLUSION Both single- and double-bundle ACL reconstruction techniques are capable of restoring knee anteroposterior and rotational stability. Double-bundle reconstructions significantly reduce knee extension in knees with hyperextension capability. Care must be taken when using double-bundle techniques in patients with knee hyperextension as this procedure may limit the knee extension after double-bundle ACL reconstruction.
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Iriuchishima T, Shirakura K, Fu FH. Graft impingement in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2013; 21:664-70. [PMID: 22527419 DOI: 10.1007/s00167-012-2014-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 04/12/2012] [Indexed: 01/25/2023]
Abstract
Anterior cruciate ligament (ACL) graft impingement is one of the most troubling complications in ACL reconstruction. In the previous strategy of isometric "non-anatomical" ACL reconstruction, posterior tibial tunnel placement and notchplasty were recommended to avoid graft impingement. Recently, the strategy of ACL reconstruction is shifting towards "anatomical" reconstruction. In anatomical ACL reconstruction, the potential risk of graft impingement is higher than in non-anatomical reconstruction because the tibial tunnel is placed at a more anterior portion on the tibia. However, there have been few studies reporting on graft impingement in anatomical ACL reconstruction. This study will provide a review of graft impingement status in both non-anatomical and the more recent anatomical ACL reconstruction techniques. In conclusion, with the accurate creation of bone tunnels within ACL native footprint, the graft impingement might not happen in anatomical ACL reconstruction. For the clinical relevance, to prevent graft impingement, surgeons should pay attention of creating correct anatomical tunnels when they perform ACL reconstruction. Level of evidence IV.
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Affiliation(s)
- Takanori Iriuchishima
- Division of Rehabilitation Medicine, Gunma University Hospital, Maebashi City, Showa-machi, Gunma, 3-39-15, Japan.
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Scheffel PT, Henninger HB, Burks RT. Relationship of the intercondylar roof and the tibial footprint of the ACL: implications for ACL reconstruction. Am J Sports Med 2013; 41:396-401. [PMID: 23221829 DOI: 10.1177/0363546512467955] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Debate exists on the proper relation of the anterior cruciate ligament (ACL) footprint with the intercondylar notch in anatomic ACL reconstructions. Patient-specific graft placement based on the inclination of the intercondylar roof has been proposed. The relationship between the intercondylar roof and native ACL footprint on the tibia has not previously been quantified. HYPOTHESIS No statistical relationship exists between the intercondylar roof angle and the location of the native footprint of the ACL on the tibia. STUDY DESIGN Case series; Level of evidence, 4. METHODS Knees from 138 patients with both lateral radiographs and MRI, without a history of ligamentous injury or fracture, were reviewed to measure the intercondylar roof angle of the femur. Roof angles were measured on lateral radiographs. The MRI data of the same knees were analyzed to measure the position of the central tibial footprint of the ACL (cACL). The roof angle and tibial footprint were evaluated to determine if statistical relationships existed. RESULTS Patients had a mean ± SD age of 40 ± 16 years. Average roof angle was 34.7° ± 5.2° (range, 23°-48°; 95% CI, 33.9°-35.5°), and it differed by sex but not by side (right/left). The cACL was 44.1% ± 3.4% (range, 36.1%-51.9%; 95% CI, 43.2%-45.0%) of the anteroposterior length of the tibia. There was only a weak correlation between the intercondylar roof angle and the cACL (R = 0.106). No significant differences arose between subpopulations of sex or side. CONCLUSION The tibial footprint of the ACL is located in a position on the tibia that is consistent and does not vary according to intercondylar roof angle. The cACL is consistently located between 43.2% and 45.0% of the anteroposterior length of the tibia. Intercondylar roof-based guidance may not predictably place a tibial tunnel in the native ACL footprint. Use of a generic ACL footprint to place a tibial tunnel during ACL reconstruction may be reliable in up to 95% of patients.
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Affiliation(s)
- Peter T Scheffel
- Department of Orthopaedics, University of Utah, 1326 South 1000 East, Salt Lake City, UT 84105, USA.
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Iriuchishima T, Tajima G, Ingham SJM, Shirakura K, Fu FH. PCL to graft impingement pressure after anatomical or non-anatomical single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2012; 20:964-9. [PMID: 21935616 DOI: 10.1007/s00167-011-1680-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 09/12/2011] [Indexed: 01/01/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) graft impingement against the posterior cruciate ligament (PCL) has been postulated, but not thoroughly investigated. PURPOSE To evaluate PCL impingement pressure and biomechanical stability with different tibial and femoral tunnel positions in ACL reconstruction. METHODS In 15 porcine knees, the impingement pressure between ACL and PCL was measured using pressure sensitive film before and after ACL single-bundle reconstruction. ACL reconstructions were performed in each knee with three different tibial and femoral tunnel position combinations: (1) tibial antero-medial (AM) tunnel to femoral AM tunnel (AM-AM), (2) tibial postero-lateral (PL) tunnel to femoral High-AM tunnel (PL-High-AM) and (3) tibial AM tunnel to femoral High-AM tunnel (AM-High-AM). Anterior tibial translation (ATT) was evaluated after each ACL reconstruction using robotic/universal force-moment sensor testing system. RESULTS There was no significant difference of the impingement pressure between AM and AM, PL-High-AM reconstructed groups and intact ACL. Only AM-High-AM ACL reconstruction group showed significantly higher impingement pressure compared with intact ACL. With regard to ATT, AM-AM group had significantly higher stiffness than PL-High-AM group. CONCLUSION Anatomical ACL reconstruction does not cause PCL impingement and it has biomechanical advantage in ATT when compared with non-anatomical ACL reconstructions in porcine knee. For the clinical relevance, in the anatomical ACL reconstruction, no ACL-PCL impingement is found.
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Affiliation(s)
- Takanori Iriuchishima
- Division of Rehabilitation Medicine, Gunma University Hospital, Showa-Machi 3-39-15, Maebashi City, Gunma, 371-8511, Japan.
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Iriuchishima T, Shirakura K, Horaguchi T, Morimoto Y, Fu FH. Full knee extension magnetic resonance imaging for the evaluation of intercondylar roof impingement after anatomical double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2011; 19 Suppl 1:S22-8. [PMID: 21468612 DOI: 10.1007/s00167-011-1504-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 03/21/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to reveal the relationship between anatomically placed anterior cruciate ligament (ACL) graft and the intercondylar roof using magnetic resonance imaging (MRI). METHODS Twenty patients undergoing anatomical double-bundle ACL reconstruction were included in this study. Anatomical double-bundle ACL reconstruction was performed with two femoral tunnels (antero-medial; AM and postero-lateral; PL) and two tibial tunnels. Hamstring autograft was used in all cases. More than 6 months after operation, MRI was performed with full knee extension. The relationship between the graft and the intercondylar roof was evaluated using an axial view of the T2 image at the most distal slice of the intercondylar roof. Qualitative evaluation of the ACL graft was performed with a sagittal view of the T2 image. Tunnel placement was evaluated with three-dimensional computed tomography (3D-CT) and radiographs. The extension angle of the knee was also evaluated with 3D-CT. RESULTS In 12 subjects, the ACL graft touched the roof (Touch group) but no graft deformation was observed. In 8 subjects, no roof-graft contact was observed (Non-touch group). In 1 case, the ACL graft was bowed posteriorly. Signal intensity alteration of the graft was observed in 3 cases. No significant difference in femoral and tibial tunnel placement was observed between the Touch and Non-touch groups. All subjects attained full knee extension. CONCLUSION Although graft-roof impingement after anatomical double-bundle ACL reconstruction was suspected in some cases after the MRI evaluation, no extension loss in the knee was observed. In these suspected cases of impingement, long-term follow-up will be needed to determine the connection between any potential pathological effects. For the clinical relevance, MRI is an effective tool to determine the status of roof impingement in anatomical double-bundle ACL reconstruction.
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Affiliation(s)
- Takanori Iriuchishima
- Division of Rehabilitation Medicine, Gunma University Hospital, Showa-machi, Maebashi, 3-39-15, Gunma, Japan.
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Maak TG, Bedi A, Raphael BS, Citak M, Suero EM, Wickiewicz T, Pearle AD. Effect of femoral socket position on graft impingement after anterior cruciate ligament reconstruction. Am J Sports Med 2011; 39:1018-23. [PMID: 21335349 DOI: 10.1177/0363546510395477] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite improved biomechanical stability and kinematics with anatomic anterior cruciate ligament (ACL) reconstruction, concerns regarding notch impingement of the graft have persisted, particularly with increasingly anterior tibial tunnel position. The potentially mitigating effect of anatomic femoral socket position, however, has not been evaluated. HYPOTHESIS Placement of the femoral socket in the central or posterolateral bundle footprint reduces the risk and magnitude of graft impingement after ACL reconstruction compared with placement in the anteromedial bundle footprint. STUDY DESIGN Controlled laboratory study. METHODS This study employed computer-assisted navigation in a cadaveric model to evaluate the effect of tibial and femoral tunnel position on ACL graft impingement. Sixteen cadaveric knees were tested using the Praxim ACL Surgetics Navigation System, with the tibial tunnel positioned in the footprint of the anteromedial bundle and the femoral socket placed in the (1) anteromedial bundle footprint, (2) center of footprint, or (3) posterolateral bundle footprint. The amount of maximum impingement, angle of initial impingement, and location of graft impingement were documented through a full arc of knee motion. RESULTS Impingement occurred with all 3 femoral socket positions, but the mean angle of impingement with the anteromedial femoral position (42.8° ± 26.4°) was significantly greater (P < .003) than the mean angles of impingement with the central femoral position (19.4° ± 19.2°) and the posterolateral bundle femoral position (16.7° ± 13.3°). CONCLUSION Although notch impingement was seen in all femoral socket locations with an anteromedial tibial socket position, femoral socket position in a central or posterolateral bundle location may reduce the risk and magnitude of graft impingement after ACL reconstruction. Additional studies are necessary to determine the influence of these different constructs on graft isometry and knee kinematics. CLINICAL RELEVANCE Anatomic femoral socket position in the center of the native ACL footprint may reduce the risk and magnitude of notch impingement compared with an anteromedial bundle position with ACL reconstruction.
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Affiliation(s)
- Travis G Maak
- Hospital for Special Surgery, New York, New York, USA
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Evaluation of the intercondylar roof impingement after anatomical double-bundle anterior cruciate ligament reconstruction using 3D-CT. Knee Surg Sports Traumatol Arthrosc 2011; 19:674-9. [PMID: 21127838 DOI: 10.1007/s00167-010-1331-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 11/08/2010] [Indexed: 12/28/2022]
Abstract
PURPOSE To reveal the relationship between anatomically placed anterior cruciate ligament (ACL) graft and the intercondylar roof using three-dimensional computed tomography (3D-CT). METHODS Twenty-four patients undergoing anatomical double-bundle ACL reconstruction were included in this study. Anatomical double-bundle ACL reconstruction was performed with two femoral tunnels (antero-medial; AM and postero-lateral; PL) and two tibial tunnels. Hamstring autograft was used in all cases. Six to eight weeks after operation and when the subjects had obtained full extension of the knee, 3D-CT was performed with full knee extension. In the 3D-CT, the ACL graft was also reconstructed and visualized three dimensionally. Tunnel placement was evaluated with 3D-CT and intra-operative radiographs. The extension angle of the knee was also evaluated with 3D-CT. RESULTS No intercondylar roof impingement was observed. In 12 subjects, the ACL graft touched the roof (Touch group) but no graft deformation was observed. In 12 subjects, no roof-graft contact was observed (Non-touch group). No significant difference in femoral and tibial tunnel placement was observed between the Touch and Non-touch groups. All subjects attained full knee extension. CONCLUSION We believe that 3D-CT is an effective means of evaluating impingement after ACL reconstruction. For the clinical relevance, when the grafts are positioned in an anatomical fashion, there is no risk of impingement, and surgeons can perform anatomical double-bundle ACL as an impingement-free reconstruction. LEVEL OF EVIDENCE III (Case control study).
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Iriuchishima T, Tajima G, Ingham SJM, Shen W, Smolinski P, Fu FH. Impingement pressure in the anatomical and nonanatomical anterior cruciate ligament reconstruction: a cadaver study. Am J Sports Med 2010; 38:1611-7. [PMID: 20410375 DOI: 10.1177/0363546510363461] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although the literature has extensively discussed impingement after anterior cruciate ligament (ACL) reconstruction, the definition of impingement is vague, and impingement pressure has not been well investigated as a function of tunnel position. PURPOSE To determine the amount of impingement pressure between the ACL and posterior cruciate ligament (PCL) and between the ACL and notch roof in the native ACL, the single-bundle ACL reconstruction with different tunnel placements, and the anatomical double-bundle ACL reconstruction. STUDY DESIGN Controlled laboratory study. METHODS Fifteen fresh-frozen nonpaired human cadaver knees were used. In each knee, different femoral and tibial tunnels were created, which allowed different graft placements. A single graft was placed in 3 positions: tibial anteromedial (AM) to femoral AM (anatomical), tibial posterolateral (PL) to femoral high AM (nonanatomical/mismatch), and tibial AM to femoral high AM. Double grafts were placed in an anatomical fashion (AM to AM and PL to PL). In each case, pressure-measuring films were inserted between the ACL and roof, the ACL and PCL, and the AM and PL bundles (for double-bundle group only). Knees were then moved with 40 N of force and from full flexion to full extension, and the pressure pattern on the film was analyzed. RESULTS Compared with other groups, only the AM-high AM group showed significantly higher roof impingement pressure (P < .05). There was no significant difference in PCL impingement pressure between the intact ACL group and any of the reconstructed groups. No impingement pressure was observed between the grafts in the anatomical double-bundle ACL reconstruction. CONCLUSION This study evaluated the effect of different tunnel placements on the impingement pressure after ACL reconstruction. Anatomical single- or double-bundle ACL reconstruction and nonanatomical tibial PL-femoral high AM ACL reconstruction do not cause roof, PCL, and interbundle impingement. CLINICAL RELEVANCE Surgeons can perform the anatomical double-bundle ACL, anatomical single-bundle, and nonanatomical tibial PL-femoral high AM reconstructions as impingement-free reconstructions.
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Affiliation(s)
- Takanori Iriuchishima
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
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Kim SJ, Moon HK, Kim SG, Chun YM, Oh KS. Does severity or specific joint laxity influence clinical outcomes of anterior cruciate ligament reconstruction? Clin Orthop Relat Res 2010; 468:1136-41. [PMID: 19582525 PMCID: PMC2835583 DOI: 10.1007/s11999-009-0961-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 06/15/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED It generally is believed generalized joint laxity is one of the risk factors for failure of anterior cruciate ligament (ACL) reconstruction. However, no consensus exists regarding whether adverse effects on ACL reconstruction are attributable to joint-specific laxity or are related to the severity of generalized joint laxity. We therefore asked whether knee stability and functional outcomes would be related to joint-specific laxity and would differ according to the severity of generalized joint laxity. The Beighton and Horan criteria were used to assess joint laxity in 272 subjects. All elements are added to give an overall joint laxity score ranging from 0 to 5. Knee translation did not increase in proportion to the severity of the generalized joint laxity. Patients with scores less than 4 showed similar knee stability. When all variables, including the severity of generalized joint laxity, were considered, only hyperextension of the knee independently predicted knee stability and function. In patients with knee hyperextension, a bone-patellar tendon-bone autograft provided superior stability and function compared with a hamstring tendon autograft. Our data suggest knee hyperextension predicts postoperative stability and function regardless whether patients have severe generalized joint laxity. LEVEL OF EVIDENCE Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sung-Jae Kim
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Arthroscopy & Joint Research Institute, CPO Box 8044, 134, Shinchon-Dong, Seodaemun-Ku, 120-752 Seoul, Korea
| | - Hong-Kyo Moon
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Arthroscopy & Joint Research Institute, CPO Box 8044, 134, Shinchon-Dong, Seodaemun-Ku, 120-752 Seoul, Korea
| | - Sul-Gee Kim
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Arthroscopy & Joint Research Institute, CPO Box 8044, 134, Shinchon-Dong, Seodaemun-Ku, 120-752 Seoul, Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Arthroscopy & Joint Research Institute, CPO Box 8044, 134, Shinchon-Dong, Seodaemun-Ku, 120-752 Seoul, Korea
| | - Kyung-Soo Oh
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Arthroscopy & Joint Research Institute, CPO Box 8044, 134, Shinchon-Dong, Seodaemun-Ku, 120-752 Seoul, Korea
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Intercondylar roof impingement pressure after anterior cruciate ligament reconstruction in a porcine model. Knee Surg Sports Traumatol Arthrosc 2009; 17:590-4. [PMID: 19089408 DOI: 10.1007/s00167-008-0691-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2008] [Accepted: 11/13/2008] [Indexed: 10/21/2022]
Abstract
Anterior cruciate ligament (ACL) graft impingement against the intercondylar roof has been postulated, but not thoroughly investigated. The roof impingement pressure changes with different tibial and femoral tunnel positions in ACL reconstruction. Anterior tibial translation is also affected by the tunnel positions of ACL reconstruction. The study design included a controlled laboratory study. In 15 pig knees, the impingement pressure between ACL and intercondylar roof was measured using pressure sensitive film before and after ACL single bundle reconstruction. ACL reconstructions were performed in each knee with two different tibial and femoral tunnel position combinations: (1) tibial antero-medial (AM) tunnel to femoral AM tunnel (AM to AM) and (2) tibial postero-lateral (PL) tunnel to femoral High-AM tunnel (PL to High-AM). Anterior tibial translation (ATT) was evaluated after each ACL reconstruction using robotic/universal force-moment sensor testing system. Neither the AM to AM nor the PL to High-AM ACL reconstruction groups showed significant difference when compared with intact ACL in roof impingement pressure. The AM to AM group had a significantly higher failure load than PL to High-AM group. This study showed how different tunnel placements affect the ACL-roof impingement pressure and anterior-posterior laxity in ACL reconstruction. Anatomical ACL reconstruction does not cause roof impingement and it has a biomechanical advantage in ATT when compared with non-anatomical ACL reconstructions in the pig knee. There is no intercondylar roof impingement after anatomical single bundle ACL reconstruction.
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Abstract
PURPOSE To present a classification of intercondylar notch stenosis (IS) adjacent to the anterior cruciate ligament (ACL) in degenerative knee arthritis, to raise awareness of this disorder, to describe the arthroscopic findings, and to promote an organized approach to its treatment with favorable results. TYPE OF STUDY Case series. METHODS Of 362 arthroscopies in patients with gonarthrosis, we identified 122 knees in 96 patients (34%) with central knee pain and subjective instability without ACL laxity to determine the notch changes adjacent to the ACL. We followed a cohort of 69 knees in 64 patients, 47 female (73%) and 17 male (27%), excluding 53 knees in 32 patients for other symptomatic lesions, noncompliance with protocol, or loss to follow-up. The average patient age was 66 years (range, 53 to 78 years). Stenosis was classified as: type I, anterior; type II, lateral; type III, mixed; and type IV, massive. Diagnosis was determined by manipulation during arthroscopy to visualize impingement and was followed by notchplasty. Average follow-up was 26 months (range, 12 to 36 months). RESULTS Type III was most common, appearing in 48% of knees. Type I was found in 29%, type II in 20%, and type IV in 3% of knees. Preoperatively, central pain occurred in all patients, being moderate in 40 knees (58%) and severe in 26 knees (38%), with diminished strength and subjective instability in all cases; only 42 (61%) had knee extension loss. Flexion contracture resolved in 81% of cases; 90% had good to excellent pain relief and 74% excellent relief of subjective instability, without significant complications. CONCLUSIONS Intercondylar notch stenosis in the arthritic knee may be a cause of ACL damage, symptomatic instability, and loss of extension. A structured approach to diagnosis and treatment was beneficial in restoring more normal function for our patients and may prevent disease progression. LEVEL OF EVIDENCE Level IV.
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