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Zhang T, Ye Z, Cai J, Chen J, Zheng T, Xu J, Zhao J. Ensemble Algorithm for Risk Prediction of Clinical Failure After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2024; 12:23259671241261695. [PMID: 39165332 PMCID: PMC11334255 DOI: 10.1177/23259671241261695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/10/2024] [Indexed: 08/22/2024] Open
Abstract
Background Patient-specific risk profiles of clinical failure after anterior cruciate ligament reconstruction (ACLR) are meaningful for preoperative surgical planning and postoperative rehabilitation guidance. Purpose To create an ensemble algorithm machine learning (ML) model and ML-based web-based tool that can predict the patient-specific risk of clinical failure after ACLR. Study Design Cohort study; Level of evidence, 3. Methods Included were 432 patients (mean age, 26.8 ± 8.4 years; 74.1% male) who underwent anatomic double-bundle ACLR with hamstring tendon autograft between January 2010 and February 2019. The primary outcome was the probability of clinical failure at a minimum 2-year follow-up. The authors included 24 independent variables for feature selection and model development. The data set was split randomly into training sets (75%) and test sets (25%). Models were built using 4 ML algorithms: extreme gradient boosting, random forest, light gradient boosting machine, and adaptive boosting. In addition, a weighted-average voting (WAV) ensemble model was constructed using the ensemble-voting technique to predict clinical failure after ACLR. Concordance (area under the receiver operating characteristic curve [AUC]), calibration, and decision curve analysis were used to evaluate predictive performances of the 5 models. Results Clinical failure occurred in 73 of the 432 patients (16.9%). The 8 most important predictors for clinical failure were follow-up period, high-grade preoperative knee laxity, time from injury to ACLR, participation in competitive sports, posterior tibial slope, graft diameter, age at surgery, and medial meniscus resection. The WAV ensemble algorithm achieved the best predictive performance based on concordance (AUC, 0.9139), calibration (calibration intercept, -0.1806; calibration slope, 1.2794; Brier score, 0.0888), and decision curve analysis (greatest net benefits) and was used to develop an web-based application to predict a patient's clinical failure risk of ACLR. Conclusion The WAV ensemble algorithm was able to accurately predict patient-specific risk of clinical failure after ACLR. Clinicians and patients can use the web-based application during preoperative consultation to understand individual prediction outcomes.
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Affiliation(s)
- Tianlun Zhang
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiangyu Cai
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Zheng
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Nakamae A, Tsukisaka K, Deie M, Miyamoto A, Eguchi A, Kato T, Nekomoto A, Adachi N. Subjective grade of apprehension during the pivot-shift test reflects patient-reported outcomes more than conventional pivot-shift test grade after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39049502 DOI: 10.1002/ksa.12383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024]
Abstract
PURPOSE To investigate whether the pivot-shift test reflects patient-reported outcomes 1 year after anterior cruciate ligament (ACL) reconstruction based on a multicentre prospective cohort study. METHODS This study included patients who underwent primary ACL reconstruction using the hamstring tendons. The pivot-shift test grades were determined according to the International Knee Documentation Committee (IKDC) form as 0, 1+, 2+ or 3+. In addition, patients' subjective apprehension during the pivot-shift test were classified as 0 (no-apprehension), 1+ (mild-apprehension), 2+ (moderate-apprehension) or 3+ (severe-apprehension). In this study, a positive pivot-shift test was defined as grade 1+ or higher. RESULTS A total of 837 patients were enroled in this study. One year postoperatively, there was no significant difference in the Knee injury and Osteoarthritis Outcome Score (KOOS), IKDC score, Lysholm knee scale and Tegner activity scale between the positive (118 patients) and negative (719 patients) groups of the conventional IKDC grading of the pivot-shift test. However, when divided into two groups based on the apprehension grading of the pivot-shift test after surgery, the postoperative scores were significantly lower in the apprehension-positive group (114 patients) than those in the apprehension-negative group (723 patients) on the Tegner activity scale and KOOS Symptom, Sports/Rec and Quality of Life subscales. CONCLUSIONS Patients' subjective apprehension during the pivot-shift test after ACL reconstruction was significantly associated with the postoperative Tegner activity scale and three subscales of the KOOS. However, there was no association between the conventional IKDC grading of the pivot-shift test and any patient-reported outcomes postoperatively. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Atsuo Nakamae
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | | | - Masataka Deie
- Department of Orhopaedic Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
- Department of Orthopaedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Ayato Miyamoto
- Department of Orthopaedic Surgery, Matsuyama Shimin Hospital, Matsuyama, Japan
| | - Akio Eguchi
- Department of Orthopaedic Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Tomohiro Kato
- Department of Orthopedic Surgery, Chugoku Rosai Hospital, Hiroshima, Japan
| | - Akinori Nekomoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Sonnery-Cottet B, Carrozzo A. Lateral Extra-Articular Tenodesis and Anterolateral Procedures. Clin Sports Med 2024; 43:413-431. [PMID: 38811119 DOI: 10.1016/j.csm.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
The treatment of rotational instability has been an intriguing challenge since the era of modern anterior cruciate ligament (ACL) surgery. Lateral extra-articular procedures (LEAPs) have emerged as a solution to this problem, particularly in high-risk populations. Several studies have shown significant benefits of combining LEAPs with ACL reconstruction, including reduced graft failure rates, improved knee stability, improved rotational stability, and higher return-to-play rates. These findings have led to an in-depth evaluation of LEAPs as lateral extra-articular tenodesis and anterolateral ligament reconstruction and their potential role in improving outcomes after ACL reconstruction.
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Affiliation(s)
- Bertrand Sonnery-Cottet
- Orthopaedic Surgery, Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Alessandro Carrozzo
- Orthopedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy.
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Xing Y, He A, Kang Y, Yang Z, Meng F, Wu P. Loop technique for anterior cruciate ligament reconstruction combined with anterolateral structure reinforcement: technical description and clinical results. BMC Surg 2024; 24:182. [PMID: 38877438 PMCID: PMC11177408 DOI: 10.1186/s12893-024-02439-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 05/06/2024] [Indexed: 06/16/2024] Open
Abstract
PURPOSE We describe a surgical technique for ACL reconstruction combined with anterolateral structure reinforcement and report early clinical follow-up results. METHODS The semitendinosus and gracilis tendons are braided into 5 strands and the ACL femoral tunnel and tibial tunnel are created. The graft is passed through the tunnel with the use of a traction suture and the tibial end is fixed with absorbable interference screws at 30° of knee flexion. The ACL graft traction suture is used as an anterolateral reconstruction structure to pass through the proximal exit of the ACL femoral tunnel and then through the depth of the iliotibial bundle to the anterior to Gerdy's tubercle, a bony tunnel is created from the anterior to Gerdy's tubercle to the goose foot, and the traction suture is passed through this bony tunnel to form a Loop structure at 20° of knee flexion. Between March 2021 and May 2022 IKDC score, Lysholm score, and Tegner score were performed preoperatively and 6-12 months postoperatively in 24 consecutive patients who met the indications for this procedure and underwent surgery. The patient's maximum flexion angle, the circumference of the thigh, and the stress X-ray between the operated and healthy knee were measured. RESULTS Patients showed significant improvement in IKDC score, Lysholm score and Tegner score at a mean follow-up of 7 months postoperatively compared to preoperatively. No significant increase in anterior tibial displacement was found between the patient's operated side and the healthy side. CONCLUSION The Loop technique ACLR combined with ALSA can be used in patients with an ACL tear combined with a high degree of positive pivot shift. The patient's subjective perception was significantly improved from the preoperative period and knee stability was restored. LEVEL OF EVIDENCE IV, therapeutic study.
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Affiliation(s)
- Yang Xing
- Department of Sports Medicine, The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Aishan He
- Department of Sports Medicine, The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Yan Kang
- Department of Sports Medicine, The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Zibo Yang
- Department of Sports Medicine, The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Fangang Meng
- Department of Sports Medicine, The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Second Road, Guangzhou, 510080, China
| | - Peihui Wu
- Department of Sports Medicine, The First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan Second Road, Guangzhou, 510080, China.
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Markström JL, Grinberg Y, Sole G, Häger CK. Strategies for knee stabilising and pivot-shift avoidance in a step-down and cross-over task observed sub-acutely after anterior cruciate ligament reconstruction. Clin Biomech (Bristol, Avon) 2024; 115:106255. [PMID: 38669919 DOI: 10.1016/j.clinbiomech.2024.106255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 04/17/2024] [Accepted: 04/22/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Individuals with a recent anterior cruciate ligament reconstruction may demonstrate an altered movement strategy for protecting the knee and maintaining stability. Altered knee movement might lead to abnormal intra-articular load, potentially contributing to early knee osteoarthritis onset. A protective strategy may be particularly evident during active tasks that induce a pivot-shift manoeuvre, such as a step-down and cross-over task. In this study, we investigated whether knee joint mechanics and muscle activity differed between participants early (∼3 months) following reconstruction (n = 35) to uninjured controls (n = 35) during a step-down and cross-over task with a 45° change-of-direction. METHODS We used motion capture, force plates and surface electromyography to compare time-normalised curves of sagittal and transverse-plane knee mechanics and muscle activity during the cross-over phase between groups using functional t-tests. We also compared knee mechanics between sides within the injured group and compared discrete outcomes describing the cross-over phase between groups. FINDINGS Compared to controls, the injured participants had greater knee flexion angle and moment, lower internal rotation moment, more preparatory foot rotation of the pivoting leg, a smaller cross-over angle, and a longer cross-over phase for both the injured and uninjured sides. The injured leg also had greater biceps femoris and vastus medialis muscle activity compared to controls and different knee mechanics than the uninjured leg. INTERPRETATION Individuals with anterior cruciate ligament reconstruction showed a knee-stabilising and pivot-shift avoidance strategy for both legs early in rehabilitation. These results may reflect an altered motor representation and motivate considerations early in rehabilitation.
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Affiliation(s)
- Jonas L Markström
- Department of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, Sweden; Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Sweden.
| | - Yevgenia Grinberg
- Department of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, Sweden
| | - Gisela Sole
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Charlotte K Häger
- Department of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, Sweden
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Kemler B, Coladonato C, Sonnier JH, Campbell MP, Darius D, Erickson BJ, Tjoumakaris FP, Freedman KB. Evaluation of Failed ACL Reconstruction: An Updated Review. Open Access J Sports Med 2024; 15:29-39. [PMID: 38586217 PMCID: PMC10998505 DOI: 10.2147/oajsm.s427332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/23/2024] [Indexed: 04/09/2024] Open
Abstract
Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.
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Affiliation(s)
- Bryson Kemler
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Michael P Campbell
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Danielle Darius
- Department of Education, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
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Chiba D, Yamamoto Y, Kimura Y, Sasaki E, Sasaki S, Tsuda E, Ishibashi Y. Association Between MRI Signal Intensity of the Repaired Lateral Meniscus and Residual Anterolateral Knee Laxity After ACL Reconstruction. Orthop J Sports Med 2024; 12:23259671241241821. [PMID: 38628462 PMCID: PMC11020732 DOI: 10.1177/23259671241241821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 09/24/2023] [Indexed: 04/19/2024] Open
Abstract
Background Anterolateral knee laxity (ALLx) has been linked to tears of the lateral meniscus (LM) and anterior cruciate ligament (ACL) injury. Purpose To investigate the longitudinal relationship between the signal intensity (SI) of the repaired LM on magnetic resonance imaging (MRI) and residual ALLx after ACL reconstruction (ACLR). Study Design Cohort study; Level of evidence, 3. Methods Included were 87 patients who underwent double-bundle ACLR and lateral meniscal repair (mean age, 23.5 years; body mass index, 23.7 kg/m2; 56 women) at a single institution between 2010 and 2019. Proton density-weighted (PDW) and T2-weighted (T2W) MRI was performed at 3, 6, and 12 months postoperatively, and the SI ratio (SIR) was calculated as (SI of the repaired LM)/(SI of the posterior cruciate ligament). At the 12-month follow-up, ALLx was evaluated using the pivot-shift test; an International Knee Documentation Committee grade ≥1 indicated residual ALLx. Results Overall, 12 patients (13.8%) exhibited ALLx at 12 months postoperatively. At 3 months postoperatively, the SIR on PDW images (SIR-PDW) was significantly higher in patients with ALLx versus those without ALLx (1.98 ± 0.77 vs 1.49 ± 0.52, respectively; P = .007); there was no difference in the SIR on T2W images between the groups. SIR-PDW at 3 months postoperatively was correlated negatively with patient age (r = -0.308, P = .004). When patients were stratified into a younger (≤22 years; n = 53; ALLx = 7 [13.2%]) and an older (>22 years; n = 34; ALLx = 5 [14.7%]) group, the area under the receiver operating characteristic curves (AUCs) for SIR-PDW in the younger group were statistically significant for predicting the prevalence of ALLx at all follow-up times (AUCs, 0.733-0.788) with optimal cutoff values of 2.00 at 3 months, 1.50 at 6 months, and 1.50 at 12 months. Logistic regression analysis revealed that if younger patients consistently had higher SIR-PDW values than the cutoff values, they were more likely to have residual ALLx (odds ratios, 10.24-23.57). Conclusion For younger patients who underwent both ACLR and lateral meniscal repair, higher MRI SI of the repaired LM was associated with a higher prevalence of residual ALLx.
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Affiliation(s)
- Daisuke Chiba
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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Martinez-Cano JP, Familiari F, Vinagre G, Moatshe G, Gomez-Sierra MA, Marín Fermín T. Instrument-based anterolateral rotatory laxity assessment of the knee has a high intra-observer and inter-observer reliability: a systematic review. J ISAKOS 2024; 9:221-226. [PMID: 37495018 DOI: 10.1016/j.jisako.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
IMPORTANCE A reliable evaluation of anterolateral rotatory instability in the anterior cruciate ligament (ACL) deficient knee is important to help surgeons determine which patients might need concurrent anterolateral augmentation procedures. OBJECTIVE The purpose of this study was to systematically review studies that assess the intra-observer and inter-observer reliability of instruments used to measure anterolateral rotatory laxity of the knee. EVIDENCE REVIEW A comprehensive literature review was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, using PubMed, Embase, Scopus, and Google Scholar databases for original, English-language studies evaluating the reliability of objective or instrument-based anterolateral rotatory laxity of the knee until October 31, 2022. Reliability data were extracted from text, tables, and figures. FINDINGS Twelve studies, with patients between the ages of 14-63 years, were included. The instruments used to measure anterolateral rotatory knee laxity included inertial sensors (n = 9), magnetic resonance imaging (n = 1), and navigation systems (n = 2). The global intra-observer intraclass correlation coefficient for these devices was between 0.63 and 0.97, and the global inter-observer reliability was between 0.63 and 0.99. CONCLUSION AND RELEVANCE Instrument-based anterolateral rotatory knee laxity assessment has moderate to good intra- and inter-observer reliability. Evaluating anterolateral instability in ACL-deficient knees with these devices could help in decision-making when considering anterolateral augmentation. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Juan Pablo Martinez-Cano
- Departamento de Ortopedia, Fundación Valle del Lili, Carrera 98 No. 18-49, Cali 760032, Colombia; Universidad Icesi, Calle 18 No. 122-135, Cali 760031, Colombia.
| | - Filippo Familiari
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, 88100 Catanzaro, Italy.
| | - Gustavo Vinagre
- Department of Orthopaedic Surgery and Traumatology, Complexo Hospitalar do Médio Ave, Porto 4761-917, Portugal; Department of Orthopaedic Surgery and Traumatology, Hospital Lusíadas, Porto 4050-115, Portugal.
| | - Gilbert Moatshe
- Oslo Sport Trauma Research Center, Norwegian School of Sports Science, Oslo 0806, Norway; Orthopaedic Clinic, Oslo University Hospital and University of Oslo, Oslo 0369, Norway.
| | - Maria Antonia Gomez-Sierra
- Departamento de Ortopedia, Fundación Valle del Lili, Carrera 98 No. 18-49, Cali 760032, Colombia; Universidad Icesi, Calle 18 No. 122-135, Cali 760031, Colombia
| | - Theodorakys Marín Fermín
- Aspetar Orthopaedic and Sports Medicine Hospital, Sports City Street, Inside Aspire Zone, Al Buwairda St, 29222, Doha, Qatar.
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Tokura T, Nagai K, Hoshino Y, Watanabe S, Kanzaki N, Nishida K, Matsushita T, Kuroda R. Injuries to both anterolateral ligament and Kaplan fiber of the iliotibial band do not increase preoperative pivot-shift phenomenon in ACL injury. Asia Pac J Sports Med Arthrosc Rehabil Technol 2024; 36:40-44. [PMID: 38595931 PMCID: PMC11001600 DOI: 10.1016/j.asmart.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/18/2024] [Indexed: 04/11/2024] Open
Abstract
Background To assess the incidence of anterolateral ligament (ALL) and Kaplan fiber of the iliotibial band (KF) injuries in patients with acute anterior cruciate ligament (ACL) injury on magnetic resonance imaging (MRI), and to investigate the association between these injuries and the magnitude of preoperative pivot-shift test. Method One-hundred and five patients with primary ACL injury were retrospectively reviewed. ALL injury and KF injury were assessed by preoperative MRI, and subjects were allocated into four groups: Group A, neither injury; Group B, only ALL injury; Group C, only KF injury; Group D, simultaneous ALL and KF injuries. Before ACL reconstruction, tibial acceleration during the pivot-shift test was measured by an electromagnetic measurement system, and manual grading was recorded according to the International Knee Documentation Committee (IKDC) guideline. Results In MRI, the ALL was identified in 104 patients (99.1%) and KF in 99 patients (94.3%). ALL and KF injuries were observed in 43 patients (43.9%) and 23 patients (23.5%), respectively. Patient distribution to each group was as follows; Group A: 43 patients (43.9%), Group B: 32 patients (32.7%), Group C: 12 patients (12.2%), Group D: 11 patients (11.2%). No significant differences were observed in tibial acceleration, and manual grading among the four groups. Conclusion Simultaneous injury to both ALL and KF was uncommon, and preoperative pivot-shift phenomenon did not increase even in those patients. The finding suggests that the role of ALL and KF in controlling anterolateral rotatory knee laxity may be less evident in the clinical setting compared to a biomechanical test setting.
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Affiliation(s)
- Takeo Tokura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shu Watanabe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Noriyuki Kanzaki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kyohei Nishida
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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10
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Momaya A, Harris C, Hargreaves M. Why Your Patient May Need an ACL Reconstruction Plus Lateral Extra-Articular Tenodesis Procedure. Int J Sports Phys Ther 2024; 19:251-257. [PMID: 38439781 PMCID: PMC10909304 DOI: 10.26603/001c.94015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Anterior cruciate ligament (ACL) tears are one of the most common knee injuries experienced by active individuals engaging in cutting sports. Despite improved surgical techniques and rehabilitation, the return to sport rate and re-tear rates remain unsatisfactory. Lateral extra-articular tenodesis (LET) is a procedure that has been growing in interest when performed in conjunction with ACL reconstruction. The benefits of adding an LET procedure to an ACL surgery may include greater rotational stability, decreased re-tear rates, and improved return to play. Level of evidence: V.
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11
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Kawanishi Y, Kobayashi M, Yasuma S, Fukushima H, Kato J, Murase A, Takenaga T, Yoshida M, Kuroyanagi G, Kawaguchi Y, Murakami H, Nozaki M. Factors Associated With Residual Pivot Shift After ACL Reconstruction: A Quantitative Evaluation of the Pivot-Shift Test Preoperatively and at Minimum 12-Month Follow-up. Orthop J Sports Med 2024; 12:23259671241230967. [PMID: 38414663 PMCID: PMC10898316 DOI: 10.1177/23259671241230967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/29/2023] [Indexed: 02/29/2024] Open
Abstract
Background Postoperative residual rotatory laxity remains despite improvement in surgical techniques for anterior cruciate ligament (ACL) reconstruction (ACLR). Purpose To evaluate factors associated with residual pivot shift after ACLR by quantitative measurement of the pivot shift before and after surgery. Study Design Case-control study; Level of evidence, 3. Methods A total of 97 patients who underwent primary double-bundle ACLR between June 2016 and March 2021 and underwent surgery to remove staples, with at least 12 months of follow-up evaluation, were enrolled. Quantitative measurements were performed under general anesthesia immediately before ACLR (preoperatively), after temporary fixation of the ACL graft (intraoperatively), and immediately before staple removal (postoperatively). The laxity of pivot shift was assessed using inertial sensors to measure acceleration and external rotational angular velocity (ERAV). Descriptive data were assessed for associations with postoperative acceleration and ERAV in a univariate analysis. A multiple linear regression analysis was performed to identify factors associated with postoperative acceleration and ERAV. Results Anterior tibial translation, acceleration, and ERAV increased from intra- to postoperatively (P < .05). Factors significantly associated with postoperative acceleration were age (β = -0.238; P = .021), lateral posterior tibial slope (PTS) (β = 0.194; P = .048), and preoperative acceleration (β = 0.261; P = .008). Factors significantly affecting postoperative ERAV were age (β = -0.222; P = .029), ramp lesions (β = 0.212; P = .027), and preoperative ERAV (β = 0.323; P = .001). Conclusion Greater preoperative laxity in the pivot shift was the factor having the most significant association with residual pivot shift after ACLR using quantitative measurements under general anesthesia. Younger age, higher lateral PTS, and concomitant ramp lesions were significant predictors of residual pivot shift. These findings can help pre- and intraoperative decision-making regarding whether an anterolateral structure augmentation should be added.
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Affiliation(s)
- Yusuke Kawanishi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Makoto Kobayashi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Sanshiro Yasuma
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Hiroaki Fukushima
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Jiro Kato
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Atsunori Murase
- Kasugai Joint & Sports Orthopedic, Pain Clinic, Kasugai, Japan
| | - Tetsuya Takenaga
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Masahito Yoshida
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Gen Kuroyanagi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Yohei Kawaguchi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Hideki Murakami
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
| | - Masahiro Nozaki
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-Ku, Nagoya, Japan
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12
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Boksh K, Sheikh N, Chong HH, Ghosh A, Aujla R. The Role of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis for Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Clinical Studies. Am J Sports Med 2024; 52:269-285. [PMID: 36960926 DOI: 10.1177/03635465231157377] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND After its success in restoring rotational stability and reducing failure rates in primary anterior cruciate ligament reconstruction (ACLR), lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR) has been endorsed for use in revision ACLR surgery, where failure rates are historically higher. PURPOSE To perform a systematic review and meta-analysis on whether the addition of a LET or ALLR results in superior clinical outcomes and stability compared with isolated revision ACLR (iACLR). STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis of comparative studies using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("extra-articular" OR "tenodesis" OR "anterolateral ligament" OR "iliotibial") AND ("anterior cruciate ligament") AND ("revision" OR "re-operation"). Data pertaining to all patient-reported outcome measures (PROMs), rotational stability, and postoperative complications were extracted from each study. RESULTS After abstract and full-text screening, 10 clinical comparative studies were included. There were 793 patients, of whom 390 had an iACLR while 403 had an ACLR augmented with a LET or an ALLR (augmented ACLR [aACLR]). The mean time for assessment of PROMs was 35 months. The aACLR group had superior International Knee Documentation Committee (IKDC) scores (standardized mean difference [SMD], 0.27; 95% CI, 0.01 to 0.54; P = .04), rotational stability (odds ratio [OR], 2.77; 95% CI, 1.91 to 4.01; P < .00001), and lower side-to-side difference (OR, -0.53; 95% CI, -0.81 to -0.24; P = .0003) than those without the augmentation. Furthermore, they were less likely to fail (OR, 0.44; 95% CI, 0.24 to 0.80; P = .007). Subgroup analysis in the higher-grade laxity cohort (grade ≥2) revealed an even greater IKDC score (SMD, 0.51; 95% CI, 0.16 to 0.86; P = .005) and an improved Lysholm score (SMD, 0.45; 95% CI, 0.24 to 0.67; P < .0001) in the aACLR group. CONCLUSION Revision aACLR with a LET or an ALLR can improve subjective IKDC scores, restore rotational stability, and reduce failure rates compared with iACLR. Although controversy remains on the necessity of augmenting all revision ACLRs, the present meta-analysis advocates adding a lateral procedure, particularly in those with a higher-grade pivot shift.
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Affiliation(s)
- Khalis Boksh
- Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nomaan Sheikh
- Department of Trauma and Orthopaedics, Kettering General Hospital, Kettering, UK
| | - Han Hong Chong
- Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Arijit Ghosh
- Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Randeep Aujla
- Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
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13
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Chiba D, Yamamoto Y, Kimura Y, Sasaki S, Sasaki E, Yamauchi S, Tsuda E, Ishibashi Y. Concomitant Lateral Meniscus Tear is Associated with Residual Rotatory Knee Instability 1 Year after Anterior Cruciate Ligament Reconstruction: Case-cohort Study. J Knee Surg 2023; 36:1341-1348. [PMID: 36564041 DOI: 10.1055/s-0042-1757594] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lateral meniscus tear (LMT) accompanied by anterior cruciate ligament (ACL) injuries has been reported to provoke rotatory instability of the affected knee joint. Unfortunately, these previous papers did not determine whether LMT-derived rotatory knee instability is residual because only preoperative or time zero data exists. This study aimed to longitudinally investigate how the prevalence of comorbid LMT is associated with residual rotatory knee instability (RKI) 1 year after ACL reconstruction (ACLR). A total of 327 patients who underwent double-bundle ACLR (average age: 23.4 years, body mass index: 23.5 kg/m2, 215 females). The patients were divided into three groups based on arthroscopy: 1) intact lateral meniscus (LM); 2) unrepaired LMT; 3) repaired LMT. At the 1-year follow-up, the pivot-shift test was performed. The prevalence of RKI, determined according to IKDC grades (grade ≥1 denoted RKI), was compared with chi-square or Fisher's exact tests. Thirty-eight patients (11.6%) had RKI; 203 subjects (62.1%) showed LMT, and 124 patients were diagnosed with an intact LM. Out of the 203 patients, 79 (38.9%) underwent LM repair. RKI was more prevalent in the LMT group than in the intact group (13.8% versus 8.1%, p = 0.117; Odds ratio: 1.499 [95%CI: 0.864 - 2.600]). In addition, the prevalence of RKI was significantly higher in the LM-repair group than in the intact-LM group (17.7% versus 8.1%, p = 0.038; Odds Ratio: 2.455 [95%CI: 1.032 - 5.842]). Medial meniscus tear (MMT) was detected in 113 patients (34.6%); RKI prevalence was not statistically different between the intact-MM group and the MMT group (12.2% versus 10.6%, p = 0.681). The current cohort study clarified that LMT comorbid with ACL injury was longitudinally associated with increased RKI prevalence 1 year after ACLR. Therefore, patients who underwent both ACLR and LM repair demonstrated a significantly higher prevalence of residual RKI.
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Affiliation(s)
- Daisuke Chiba
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Shohei Yamauchi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
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14
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Borim FM, Jubert NJ, Vinaixa MMR, Portas-Torres I, Bueno JP, Mayayo RS, Peiró JVA, Feliu EC, Monyart JM. Good rates of return-to-sport in athletes after revision anterior cruciate ligament reconstruction using autologous patellar tendon and lateral extra-articular tenodesis: a 2-year follow-up prospective study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3125-3133. [PMID: 37039899 PMCID: PMC10504162 DOI: 10.1007/s00590-023-03544-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/03/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Most athletes who undergo revision of the anterior cruciate ligament reconstruction (ACLR) aim to return to their preinjury sport at a similar level of performance while minimizing the risk for reinjury. Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved outcomes and low complication rate. Yet, there are few series evaluating return-to-sport (RTS) and clinical outcomes after revision ACLR using bone-patellar tendon-bone (BPTB) and LET in athletes. METHODS The study cohort consisted of 19 eligible athletes who had undergone their first revision ACLR using BPTB and LET (modified Lemaire) between January 2019 and 2020. Patients were prospectively followed and interviewed in a sports activity survey during a 2-year follow-up. RESULTS Despite all patients returning to sports after revision ACLR surgery, 52.6% resumed playing at their preinjury level. Furthermore, patient-reported functional outcomes improved significantly following revision surgery, as evidenced by improvements in IKDC [64.4 (± 12) to 87.8 (± 6)], Lysholm [71.27 (± 12) to 84.2 (± 9.7)], and SF-12 scales [Physical: 53.3 (± 3) 57 (± 1.2); Mental: 50.2 (± 3.3) to 52.7 (± 2.4)]. One case (5.3%) experienced persistent pain and underwent reoperation for a partial meniscectomy. CONCLUSION After revision ACLR using autologous BPTB and LET, all active individuals are expected to RTS, similar to primary ACLR. The difference comes down to returning to the preinjury level, where the levels are lower depending on the sport and initial level of play. Good mid-term functional outcomes with a low complication rate can be expected in most cases. STUDY DESIGN Case series; Level of evidence IV. ETHICAL COMMITTEE APPROVAL NUMBER PR(ATR)79/2021 and HCB/2023/0173.
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Affiliation(s)
- Felipe Moreira Borim
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain.
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Nayana Joshi Jubert
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Maria Mercedes Revertè Vinaixa
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - Irene Portas-Torres
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Pijoan Bueno
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - Raquel Sevil Mayayo
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - José Vicente Andrés Peiró
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain
| | - Enric Castellet Feliu
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Minguell Monyart
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellaterra, Barcelona, Spain.
- Orthopaedic Surgery Department; Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, 08017, Barcelona, Spain.
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15
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Haus A, Chand A, Dawson K, Lang S, Gilmer BB, Wahl CJ. Modified Lemaire Lateral Extra-Articular Tenodesis Using an Inlay Technique and All-Suture Knotless Anchor Fixation. Arthrosc Tech 2023; 12:e1607-e1613. [PMID: 37780650 PMCID: PMC10533872 DOI: 10.1016/j.eats.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 05/09/2023] [Indexed: 10/03/2023] Open
Abstract
Appreciation of persistent anterolateral rotatory instability and graft failure after anterior cruciate ligament (ACL) reconstruction procedures has led surgeons to adopt the addition of lateral extra-articular tenodesis (LET) in both the revision and primary setting. Multiple techniques have been shown to eliminate anterolateral rotatory instability and reduce forces on the ACL graft, which has translated to lower re-rupture rates and improved patient outcomes. The risk of ACL/LET tunnel convergence can potentially compromise the fixation of one or both graft reconstructions. This article describes a technique for LET fixation which minimizes the depth of the LET femoral bone socket and utilizes low-profile implants thus mitigating this risk.
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Affiliation(s)
- Andrew Haus
- Barton Center for Orthopedics and Wellness, South Lake Tahoe, California, U.S.A
| | - Avishay Chand
- University of Nevada School of Medicine, Reno, Nevada, U.S.A
| | - Karly Dawson
- Mammoth Orthopedic Institute, Mammoth Hospital, Mammoth Lakes, California, U.S.A
| | - Sarah Lang
- Mammoth Orthopedic Institute, Mammoth Hospital, Mammoth Lakes, California, U.S.A
| | - Brian B. Gilmer
- Mammoth Orthopedic Institute, Mammoth Hospital, Mammoth Lakes, California, U.S.A
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16
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Bormann M, Neidlein C, Neidlein N, Ehrl D, Jörgens M, Berthold DP, Böcker W, Holzapfel BM, Fürmetz J. High Prevalence of Persistent Measurable Postoperative Knee Joint Laxity in Patients with Tibial Plateau Fractures Treated by Open Reduction and Internal Fixation (ORIF). J Clin Med 2023; 12:5580. [PMID: 37685647 PMCID: PMC10488731 DOI: 10.3390/jcm12175580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
The development of post-traumatic osteoarthrosis after tibial plateau fracture (TPF) is multifactorial and can only be partially influenced by surgical treatment. There is no standardized method for assessing pre- and postoperative knee joint laxity. Data on the incidence of postoperative laxity after TPF are limited. The purpose of this study was to quantify postoperative laxity of the knee joint after TPF. Fifty-four patients (mean age 51 ± 11.9 years) were included in this study. There was a significant increase in anterior-posterior translation in 78.0% and internal rotation in 78.9% in the injured knee when compared to the healthy knee. Simple fractures showed no significant difference in laxity compared to complex fractures. When preoperative ligament damage and/or meniscal lesions were present and surgically treated by refixation and/or bracing, patients showed higher instability when compared to patients without preoperative ligament and/or meniscal damage. Patients with surgically treated TPF demonstrate measurable knee joint laxity at a minimum of 1 year postoperatively. Fracture types have no influence on postoperative laxity. This emphasizes the importance of recognizing TPF as a multifaceted injury involving both complex fractures and damage to multiple ligaments and soft tissue structures, which may require further surgical intervention after osteosynthesis.
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Affiliation(s)
- Markus Bormann
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Claas Neidlein
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Niels Neidlein
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Dennis Ehrl
- Department of Hand, Plastic and Aesthetic Surgery, LMU Munich, 81377 Munich, Germany
| | - Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Daniel P. Berthold
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Boris Michael Holzapfel
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Julian Fürmetz
- Department of Trauma Surgery, Trauma Center Murnau, 82418 Murnau am Staffelsee, Germany
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17
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Herbst E, Costello J, Popchak AJ, Tashman S, Irrgang JJ, Fu FH, Musahl V. Untreated Injuries to the Anterolateral Capsular Structures Do Not Affect Outcomes and Kinematics after Anatomic Anterior Cruciate Ligament Reconstruction. J Clin Med 2023; 12:4408. [PMID: 37445441 DOI: 10.3390/jcm12134408] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/11/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Injuries to the anterolateral complex (ALC) may contribute to increased rotatory knee laxity. However, it has not been evaluated whether such injuries affect in vivo kinematics when treated in situ. The purpose of this study was to determine the grade of ALC injury and its effect on kinematic and clinical outcomes of ACL-injured patients 24 months after anatomic ACL reconstruction. It was hypothesized that injury to the ALC would be significantly related to patient-reported outcomes (PROs) and in vivo knee kinematics during downhill running. METHODS Thirty-five subjects (mean age: 22.8 ± 8.5 years) participating in a randomized clinical trial to compare single- and double-bundle ACL reconstruction were included in the study. Subjects were divided into two groups based on the presence or absence of injury to the ALC, as determined on MRI scans performed within 6 weeks of injury. None of the patients underwent treatment for these ALC injuries. At 24 months, PROs, including the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS) and in vivo knee kinematics during downhill running, were obtained. Pivot-shift test results, PROs and in vivo knee kinematics were compared between groups with and without ALC injury using the Pearson's Chi Squared test and Mann-Whitney U test with significance set at p < 0.05. RESULTS The average interval between injury and performing the MRI scans was 9.5 ± 10 days. ALC injury was observed in 17 (49%) study participants. No significant differences were detected in PROs and in vivo kinematics between subjects with and without ALC injury (n.s.). CONCLUSION The findings of this study demonstrate that MRI evidence of an ALC injury does not significantly affect in vivo knee kinematics and PROs even in individuals with a high-grade ALC injury. Injuries to the ALC as observed on MRI might not be a useful indication for an anterolateral procedure.
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Affiliation(s)
- Elmar Herbst
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, 48149 Münster, Germany
| | - Joanna Costello
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Adam J Popchak
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Scott Tashman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
- Steadman Philippon Research Institute, Vail, CO 81657, USA
| | - James J Irrgang
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
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Pellarin M, Youmbi CT, Lotchuang J, Tejpal T, Thangathurai G, Khan A, Cohen D, Simunovic N, Duong A, Ayeni OR. From Protocol to Definitive Study-The State of Randomized Controlled Trial Evidence in Sports Medicine Research: A Systematic Review and Survey Study. Clin J Sport Med 2023; 33:e44-e70. [PMID: 36652662 DOI: 10.1097/jsm.0000000000001117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the progression, quality, and challenges associated with conducting and publishing randomized controlled trials (RCTs) in sports medicine. DESIGN Systematic review and survey. SETTING MEDLINE and Embase were searched for all publications before September 17, 2021. A targeted search of clinicaltrials.gov , BMC Musculoskeletal Disorders, PubMed, and Google Scholar were also conducted. The survey was administered to authors using REDCap. PARTICIPANTS Where the systematic search revealed no corresponding published definitive trial, authors of the published pilots were surveyed. INTERVENTIONS Survey assessing limitations to definitive trials. MAIN OUTCOME MEASURES Protocol/method articles, pilot articles, and relevant clinical trial registry records with corresponding definitive trials were pooled. RESULTS Our literature search yielded 27 006 studies; of which, we included 208 studies (60 (28.8%) pilot RCTs, 84 (40.4%) protocol/method articles, and 64 (30.8%) trial registry records). From these, 44 corresponding definitive RCTs were identified. Pilot study and definitive RCT methodological quality increased on average most significantly during the duration of this review (30.6% and 8.2%). Of the 176 authors surveyed, 59 (33.5%) responded; 24.6% (14/57) stated that they completed an unpublished definitive trial, while 52.6% (30/57) reported having one underway. CONCLUSIONS The quality and number of RCT publications within the field of sports medicine has been increasing since 1999. The number of sports medicine-related protocol and pilot articles preceding a definitive trial publication showed a sharp increase over the past 10 years, although only 5 pilot studies have progressed to a definitive RCT.
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Affiliation(s)
- Mitchell Pellarin
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Cheikh Tchouambou Youmbi
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Joyce Lotchuang
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Tushar Tejpal
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Gowtham Thangathurai
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Abdullah Khan
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; and
| | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; and
| | - Andrew Duong
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; and
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Willinger L, Athwal KK, Holthof S, Imhoff AB, Williams A, Amis AA. Role of the Anterior Cruciate Ligament, Anterolateral Complex, and Lateral Meniscus Posterior Root in Anterolateral Rotatory Knee Instability: A Biomechanical Study. Am J Sports Med 2023; 51:1136-1145. [PMID: 36917838 PMCID: PMC10068405 DOI: 10.1177/03635465231161071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Injuries to the anterior cruciate ligament (ACL), Kaplan fibers (KFs), anterolateral capsule/ligament (C/ALL), and lateral meniscus posterior root (LMPR) have been separately linked to anterolateral instability. PURPOSE To investigate the contributions of the ACL, KFs, C/ALL, and LMPR to knee stability and to measure instabilities resulting from their injury. STUDY DESIGN Controlled laboratory study. METHODS Ten fresh-frozen human knees were tested robotically to determine restraints of knee laxity at 0° to 90° of flexion. An 88-N anterior-posterior force (anterior and posterior tibial translation), 5-N·m internal-external rotation, and 8-N·m valgus-varus torque were imposed and intact kinematics recorded. The kinematics were replayed after sequentially cutting the structures (order varied) to calculate their contributions to stability. Another 10 knees were tested in a kinematics rig with optical tracking to measure instabilities after sequentially cutting the structures across 0° to 100° of flexion. One- and 2-way repeated-measures analyses of variance with Bonferroni correction were used to find significance (P < .05) for the robotic and kinematics tests. RESULTS The ACL was the primary restraint for anterior tibial translation; other structures were insignificant (<10% contribution). The KFs and C/ALL resisted internal rotation, reaching 44% ± 23% (mean ± SD; P < .01) and 14% ± 13% (P < .05) at 90°. The LMPR resisted valgus but not internal rotation. Anterior tibial translation increased after ACL transection (P < .001) and after cutting the lateral structures from 70° to 100° (P < .05). Pivot-shift loading increased anterolateral rotational instability after ACL transection from 0° to 40° (P < .05) and further after cutting the lateral structures from 0° to 100° (P < .01). CONCLUSION The anterolateral complex acts as a functional unit to provide rotatory stability. The ACL is the primary stabilizer for anterior tibial translation. The KFs are the most important internal rotation restraint >30° of flexion. Combined KFs + C/ALL injury substantially increased anterolateral rotational instability while isolated injury of either did not. LMPR deficiency did not cause significant instability with the ACL intact. CLINICAL RELEVANCE This study is a comprehensive biomechanical sectioning investigation of the knee stability contributions of the ACL, anterolateral complex, and LMPR and the instability after their transection. The ACL is significant in controlling internal rotation only in extension. In flexion, the KFs are dominant, synergistic with the C/ALL. LMPR tear has an insignificant effect with the ACL intact.
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Affiliation(s)
- Lukas Willinger
- Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Andreas B Imhoff
- Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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20
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Lai S, Zhang Z, Li J, Fu WL. Comparison of Anterior Cruciate Ligament Reconstruction With Versus Without Anterolateral Augmentation: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Orthop J Sports Med 2023; 11:23259671221149403. [PMID: 37025126 PMCID: PMC10071203 DOI: 10.1177/23259671221149403] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/21/2022] [Indexed: 04/08/2023] Open
Abstract
Background It is clear that the anterolateral ligament has an important role in rotational knee stability. However, whether patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) can benefit from anterolateral augmentation (ALA) is still controversial. Purpose To compare the effects of isolated ACLR versus ACLR combined with ALA (ACLR+ALA) on clinical outcomes and knee stability. Study Design Systematic review; Level of evidence, 1. Methods The methodology followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of the PubMed, Embase, and Cochrane Library Central Register of Controlled Trials databases was undertaken to identify all randomized controlled trials (RCTs) comparing isolated ACLR with ACLR+ALA for the treatment of ACL injuries in the last 15 years. The Cochrane Collaboration risk-of-bias tool and the revised Jadad scale were utilized by 2 independent reviewers to determine the quality of RCTs. Relevant data were extracted and compared between procedures, and heterogeneity across the RCTs was assessed using the I 2 statistic. Results The initial search yielded 849 articles. A total of 14 studies (1850 patients; 941 ACLR and 909 ACLR+ALA) satisfied the eligibility criteria for the meta-analysis. There were no significant differences between the procedures in terms of patient-reported outcomes (International Knee Documentation Committee score, Tegner score, Knee injury and Osteoarthritis Outcome Score) or return-to-sport rates. However, patients who underwent ACLR+ALA had better knee stability based on the pivot-shift test (risk ratio [RR], 1.06 [95% CI, 1.02 to 1.10]; P = .0008), Lachman test (RR, 1.03 [95% CI, 1.00 to 1.07]; P = .04), and side-to-side difference in anterior laxity (standardized mean difference, -0.55 [95% CI, -0.98 to -0.12]; P = .01) as well as a lower incidence of graft failure (RR, 0.30 [95% CI, 0.19 to 0.45]; P < .01) compared with patients who underwent isolated ACLR. Conclusion ALA can be considered as a reinforcement of ACLR to improve anteroposterior and anterolateral rotational stability of the knee and reduce the risk of failure. The patient-reported outcomes of isolated ACLR were similar to those of ACLR+ALA, and both procedures provided improved knee function.
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Affiliation(s)
- Sike Lai
- Department of Orthopedic Surgery, West China Hospital, Sichuan
University, Chengdu, China
- Orthopedic Research Institute, West China Hospital, Sichuan
University, Chengdu, China
| | - Zhong Zhang
- Department of Orthopedic Surgery, West China Hospital, Sichuan
University, Chengdu, China
- Orthopedic Research Institute, West China Hospital, Sichuan
University, Chengdu, China
| | - Jian Li
- Department of Orthopedic Surgery, West China Hospital, Sichuan
University, Chengdu, China
- Orthopedic Research Institute, West China Hospital, Sichuan
University, Chengdu, China
- Jian Li, MD, or Wei-Li Fu, MD, Department of Orthopedic Surgery,
West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041,
China ( or
, respectively)
| | - Wei-Li Fu
- Department of Orthopedic Surgery, West China Hospital, Sichuan
University, Chengdu, China
- Orthopedic Research Institute, West China Hospital, Sichuan
University, Chengdu, China
- Jian Li, MD, or Wei-Li Fu, MD, Department of Orthopedic Surgery,
West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041,
China ( or
, respectively)
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21
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There Is Substantial Variation in Rehabilitation Protocols Following Anterior Cruciate Ligament Reconstruction: A Survey of 46 American Orthopaedic Surgeons. Arthroscopy 2023; 39:578-589.e20. [PMID: 35988795 DOI: 10.1016/j.arthro.2022.07.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE To identify the clinical practice preferences of orthopaedic surgeons regarding anterior cruciate ligament reconstruction (ACLR) rehabilitation through a survey of members of the Arthroscopy Association of North American (AANA) and the American Orthopaedic Society for Sports Medicine (AOSSM). METHODS An online survey was distributed to members of AANA and AOSSM between November 2020 and September 2021. Participants reported on their clinical preferences for ACLR protocol development and patient selection, use of technology in ACLR recovery and rehabilitation, and preferences for advancing through multiple phases of the rehabilitative process. RESULTS Responses from 46 orthopaedic surgeons were analyzed. Patient-reported outcome measures were not found to be utilized often at various phases of the perioperative period. Thirty-eight (82.6%) participants reported utilization of postoperative bracing. There was no consensus on when participants allow their patients to advance through rehabilitation, but most report waiting 3 to 4 months for advancement to jogging/lateral movement, 6 to 8 months for return to noncontact sport, and 9 months of more for return to unrestricted sport. Many participants utilize functional and strength testing with associated limb symmetry indices to determine patient readiness to return to sport, with 18, 26, and 25 participants reporting use of functional testing and 28, 26, and 27 participants reporting use of strength testing at the return to jogging/lateral movements, noncontact return to sport, and unrestricted return-to-sport phases, respectively. CONCLUSIONS This study provides an insight into the rehabilitative protocols and modalities utilized for ACLR by orthopaedic surgeons in practice across the United States. There is notably substantial variation in rehabilitative patterns and preferences, particularly with regards to what constitutes criteria for progressing patients through the phases of returning to unrestricted sport. Additionally, our findings show that while many surgeons believe that quantitative assessment technology could be beneficial in decision-making for returning patients to sport, there are still many barriers that stand in the way of its implementation into clinical practice. CLINICAL RELEVANCE Postoperative rehabilitative protocols after ACLR vary by surgeon.
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22
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Minguell Monyart J, Moreira Borim F, Revertè Vinaixa MM, Portas-Torres I, Pijoan Bueno J, Castellet Feliu E, Joshi Jubert N. Allografts and lateral extra-articular tenodesis for revision anterior cruciate ligament reconstruction: enhanced rotational stability and improved functional outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03475-4. [PMID: 36708388 PMCID: PMC10368563 DOI: 10.1007/s00590-023-03475-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/18/2023] [Indexed: 01/29/2023]
Abstract
PURPOSE Multiple studies have shown higher failure rate and patient-reported outcomes to be significantly worse following revision anterior cruciate ligament reconstructive (ACLR) surgery, especially using allografts. One of the reasons being rotational instability. Because of this, augmentation with lateral extra-articular tenodesis (LET) is often considered. Good short-term results in regards to functional and perceived scores and low complication rate can be expected in revision ACLR using allografts in combination with LET. METHODS Between 2014 and 2021, 46 patients were registered for revision ACLR using allografts and extra-articular augmentation (modified Lemaire) and included in this prospective study. Patients' demographic and clinical data were collected preoperatively, postoperatively, and during the follow-up period of 12 months. RESULTS Patient-reported functional outcomes were statistically significant for IKDC, Lysholm, and SF-12 physical scale (p < 0.05). Tegner score showed a decreased number of patients who were able to return to sport at their previous level (p = 0.001). Stability examination tests (Lachman and pivot-shift) showed significant improvements. Concomitant lesions were present in 76.1% of patients. Ten patients (21.7%) presented major complications, including six cases of anteroposterior instability, three cases of knee pain and one graft re-rupture. CONCLUSION Revision procedures are inherently challenging with a high number of associated chondral and meniscus lesions. However, good short-term functional outcomes and enhanced rotational stability with an acceptable complication rate can be expected in most cases where revision ACLR using allografts is augmented with LET. STUDY DESIGN Prospective; Case series; Level of evidence IV.
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Affiliation(s)
- Joan Minguell Monyart
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellatera, Barcelona, Spain
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Felipe Moreira Borim
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellatera, Barcelona, Spain.
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Bioengineering, Cell Therapy and Surgery in Congenital Malformations - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Maria Mercedes Revertè Vinaixa
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Irene Portas-Torres
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Pijoan Bueno
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Enric Castellet Feliu
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellatera, Barcelona, Spain
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Nayana Joshi Jubert
- Surgery and Morphological Sciences, Universitat Autónoma de Barcelona (UAB), 08193, Bellatera, Barcelona, Spain.
- Orthopaedic Surgery Department, Knee Surgery Unit, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Reconstructive Surgery of Locomotor System Group - VHIR, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain.
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23
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Moran TE, MacLean IS, Anderson GR, Barras LA, Graf RM, Diduch DR, Miller MD. Lateral Extra-Articular Tenodesis Staple Risks Penetration of Anterior Cruciate Ligament Reconstruction Tunnel. Arthrosc Sports Med Rehabil 2022; 5:e193-e200. [PMID: 36866320 PMCID: PMC9971869 DOI: 10.1016/j.asmr.2022.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 12/25/2022] Open
Abstract
Purpose To identify the risk of anterior cruciate ligament (ACL) femoral tunnel penetration with the use of a staple for lateral extra-articular tenodesis (LET) graft fixation and to determine whether this varied between 2 different techniques for ACL femoral tunnel drilling. Methods Twenty paired, fresh-frozen, cadaver knees underwent ACL reconstruction with a LET. Left and right knees were randomized to ACL reconstruction with femoral tunnel creation by use of either a rigid guide pin and reamer through the accessory anteromedial portal or by the use of a flexible guide pin and reamer through the anteromedial portal. Immediately after tunnel creation, the LET was performed and fixated with a small Richard's staple. Fluoroscopy was used to obtain a lateral view of the knee to determine staple position, and visualization of the ACL femoral tunnel was performed with the arthroscope to investigate penetration of the staple into the femoral tunnel. The Fisher exact test was conducted to determine whether there was any difference in tunnel penetration between tunnel creation techniques. Results The staple was noted to penetrate the ACL femoral tunnel in 8 of 20 (40%) extremities. When stratified by tunnel creation technique, the Richards staple violated 5 of 10 (50%) of the tunnels made via the rigid reaming technique compared with 3 of 10 (30%) of those created with a flexible guide pin and reamer (P = .65). Conclusions A high incidence of femoral tunnel violation is seen with lateral extra-articular tenodesis staple fixation. Level of Evidence Level IV, controlled laboratory study. Clinical Relevance The risk of penetrating the ACL femoral tunnel with a staple for LET graft fixation is not well understood. Yet, the integrity of the femoral tunnel is important for the success of ACL reconstruction. Surgeons can use the information in this study to consider adjustments to operative technique, sequence, or fixation devices used when performing ACL reconstruction with concomitant LET to avoid the potential for disruption of ACL graft fixation.
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Affiliation(s)
- Thomas E. Moran
- Address correspondence to Thomas E. Moran, M.D., Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Rd., Charlottesville, VA 22903.
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Kataoka K, Nagai K, Hoshino Y, Shimabukuro M, Nishida K, Kanzaki N, Matsushita T, Kuroda R. Steeper lateral posterior tibial slope and greater lateral-medial slope asymmetry correlate with greater preoperative pivot-shift in anterior cruciate ligament injury. J Exp Orthop 2022; 9:117. [PMID: 36477926 PMCID: PMC9729454 DOI: 10.1186/s40634-022-00556-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To investigate the association between posterior tibial slope (PTS) and preoperative pivot-shift phenomenon in anterior cruciate ligament (ACL)-injured knees. METHODS Fifty unilateral ACL-injured patients (mean age: 28.0 ± 11.4 years, 29 males) who underwent ACL reconstruction were retrospectively included. Patients with a history of injury to the ipsilateral knee joint, concomitant ligament injuries with ACL injury, and/or more than one year from injury to surgery, were excluded. Pivot-shift tests were performed preoperatively under general anaesthesia using an electromagnetic measurement system, and tibial acceleration (m/s2) during the posterior reduction of the tibia was measured. Medial and lateral PTS (°) were measured respectively using high-resolution CT images taken two weeks after surgery. Lateral-medial slope asymmetry was calculated by subtracting medial PTS from lateral PTS (lateral-medial PTS) and we evaluated the correlation between each PTS parameter (medial PTS, lateral PTS, and lateral-medial slope asymmetry) and tibial acceleration during the pivot-shift test. The level of significance was set at p < 0.05. RESULTS Medial PTS was 4.9 ± 2.0°, and lateral PTS was 5.2 ± 1.9°. The lateral-medial slope asymmetry was 0.3 ± 1.6° (range: -2.9 to 3.8). Tibial acceleration during the pivot-shift test in the ACL-injured knee was 1.6 ± 0.1 m/s2. Preoperative tibial acceleration was positively correlated with lateral PTS (r = 0.436, p < 0.01), and lateral-medial slope asymmetry (r = 0.443, p < 0.01), while no significant correlation was found between preoperative tibial acceleration and medial PTS (r = 0.06, p = 0.70). CONCLUSION Preoperative greater tibial acceleration during the pivot-shift test was associated with steeper lateral PTS and greater lateral-medial slope asymmetry in ACL-injured knees. These findings improve our understanding of anterolateral rotatory knee laxity by linking tibial bony morphology to quantitative measurement of pivot-shift phenomenon. Surgeons should be aware that not only lateral PTS but also lateral-medial slope asymmetry are the factors associated with preoperative pivot-shift. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Kiminari Kataoka
- grid.31432.370000 0001 1092 3077Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017 Japan
| | - Kanto Nagai
- grid.31432.370000 0001 1092 3077Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017 Japan
| | - Yuichi Hoshino
- grid.31432.370000 0001 1092 3077Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017 Japan
| | - Masashi Shimabukuro
- grid.31432.370000 0001 1092 3077Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017 Japan
| | - Kyohei Nishida
- grid.31432.370000 0001 1092 3077Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017 Japan
| | - Noriyuki Kanzaki
- grid.31432.370000 0001 1092 3077Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017 Japan
| | - Takehiko Matsushita
- grid.31432.370000 0001 1092 3077Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017 Japan
| | - Ryosuke Kuroda
- grid.31432.370000 0001 1092 3077Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017 Japan
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25
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Roach RP, Beason DP, Slowik JS, Moore AR, Lall AC, Dugas JR. Biomechanical Evaluation of Anterolateral Ligament Repair Augmented with Internal Brace. J Knee Surg 2022; 35:1484-1490. [PMID: 33853155 DOI: 10.1055/s-0041-1726420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Injuries to the anterolateral ligament (ALL) of the knee are commonly associated with anterior cruciate ligament (ACL) ruptures. Biomechanical studies have demonstrated conflicting results with regard to the role of the ALL in limiting tibial internal rotation. Clinically, residual pivot shift following ACL reconstruction has been reported to occur up to 25% and has been correlated with poor outcomes. As such, surgical techniques have been developed to enhance rotational stability. Recent biomechanical studies have demonstrated restoration of internal rotational control following ALL reconstruction. The purpose of our study was to understand the biomechanical effects of ACL reconstruction with an ALL internal brace augmentation. We hypothesized that (1) sectioning of the ALL while preserving other lateral extra-articular structures would lead to significant internal rotation laxity and gap formation and (2) ALL repair with internal brace augmentation would lead to reduction in internal rotation instability and gap formation. In total, 10 fresh-frozen cadaveric knees were thawed and biomechanically tested in internal rotation for 10 cycles of normal physiologic torque in the intact, ACL-deficient, ACL/ALL-deficient, ACL-reconstructed, and ALL-repaired conditions. Each condition was tested at 30, 60, and 90 degrees of flexion. Following the final ALL-repaired condition, specimens were additionally subjected to a final internal rotation to failure at 1 degree at the last-tested degree of flexion. Kinematic measurements of angle and linear gap between the femur and tibia were calculated in addition to torsional stiffness and failure torque. As hypothesized, ALL repair with internal brace augmentation significantly reduced internal rotation angular motion and gap formation at flexion angles greater than 30 degrees. Additionally, ALL sectioning produced nonsignificant increases in internal rotation laxity and gap formation compared with ACL-deficient and ACL-reconstructed states, which did not support our other hypothesis.
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Affiliation(s)
- Ryan P Roach
- American Sports Medicine Institute, Birmingham, Alabama
| | | | | | - A Ryves Moore
- American Sports Medicine Institute, Birmingham, Alabama
| | - Ajay C Lall
- American Hip Institute Research Foundation, Des Plaines, Illinois.,American Hip Institute, Des Plaines, Illinois
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26
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Devitt BM, Klemm HJ, Kirby J, Batty LM, Webster KE, Whitehead TS, Feller JA. Effect of Radiological Evidence of Kaplan Fiber Injury on the Clinical and Functional Outcomes After Acute Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2022; 50:3557-3564. [PMID: 36178144 DOI: 10.1177/03635465221124249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A paucity of information is available regarding the clinical outcomes of patients with radiological evidence of Kaplan fiber (KF) injury who undergo anterior cruciate ligament (ACL) reconstruction (ACLR). PURPOSE/HYPOTHESIS The purpose was to compare clinical and functional outcomes in patients undergoing acute primary ACLR with and without magnetic resonance imaging (MRI) evidence of KF injury. The hypothesis was that there would be no difference in clinical or functional outcomes in patients with versus those without radiological evidence of KF injury. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS MRI analysis was conducted on patients in a longitudinal prospective study of ACL injury. Only patients who had an MRI scan and had undergone isolated primary ACLR within 60 days of injury were included. MRI was performed using standard knee protocols, and diagnostic criteria were applied to identify KF injury. A total of 32 patients with KF injury (mean age, 24.2 years; 21 male, 11 female) were identified and matched for sex, age, graft type, and preinjury activity with 90 patients who had intact KF. Patients were followed up at 12 months with KT-1000 arthrometer measurements of side-to-side difference in anterior knee laxity, single- and triple-hop limb symmetry index (LSI), Marx activity and International Knee Documentation Committee (IKDC) scores, and return to sport (RTS) rates at 12 months and 24 months. RESULTS No differences were found in anterior knee laxity and single- and triple-hop LSI values between the KF-intact and KF-injured cohorts at 12 months. No differences in Marx and IKDC scores were found between the groups at 12 months and 2 years. The overall rate of RTS within 24 months was 75% (92/122), and 5 patients (2 KF-injured; 3 KF-intact) had a subsequent graft rupture. CONCLUSION We found no difference in clinical or functional outcomes in patients with and without radiological evidence of KF injury who underwent acute primary ACLR. Based on these findings, the radiological presence of KF injury at the time of acute ACL injury should not be regarded as a risk factor for a negative prognosis after ACLR.
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Affiliation(s)
- Brian M Devitt
- OrthoSport Victoria Research Unit, Richmond, Melbourne, Victoria, Australia.,School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - Haydn J Klemm
- OrthoSport Victoria Research Unit, Richmond, Melbourne, Victoria, Australia
| | - Julia Kirby
- OrthoSport Victoria Research Unit, Richmond, Melbourne, Victoria, Australia
| | - Lachlan M Batty
- OrthoSport Victoria Research Unit, Richmond, Melbourne, Victoria, Australia.,School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - Kate E Webster
- School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | | | - Julian A Feller
- OrthoSport Victoria Research Unit, Richmond, Melbourne, Victoria, Australia.,School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
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27
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Watanabe S, Nagai K, Hoshino Y, Kataoka K, Nakanishi Y, Araki D, Kanzaki N, Matsushita T, Kuroda R. Influence of Injury to the Kaplan Fibers of the Iliotibial Band on Anterolateral Rotatory Knee Laxity in Anterior Cruciate Ligament Injury: A Retrospective Cohort Study. Am J Sports Med 2022; 50:3265-3272. [PMID: 35993529 DOI: 10.1177/03635465221116097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Biomechanical cadaveric studies have shown that Kaplan fibers (KFs) of the iliotibial band play a role in controlling anterolateral rotatory knee laxity in anterior cruciate ligament (ACL) injury. However, in the clinical setting, the contribution of injury to KFs on anterolateral rotatory laxity remains unclear. PURPOSE To use magnetic resonance imaging (MRI) scans to detect concomitant KF injury in ACL-injured knees and to then examine the effect of KF injury on anterolateral rotatory laxity as measured by the pivot-shift test in a clinical setting. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS The study enrolled 91 patients with primary ACL tears (mean age 25 ± 11 years; 46 male and 45 female) whose MRI was conducted within 90 days after injury. KF injury was assessed by MRI according to previously reported criteria, and the patients were allocated to a KF injury group and a no-KF injury group. At the time of ACL reconstruction, the pivot-shift test was performed with the patient under anesthesia and quantitatively evaluated by tibial acceleration using an electromagnetic measurement system. Manual grading of the pivot-shift test was assessed according to guidelines of the International Knee Documentation Committee. The data were statistically compared between the 2 groups using Mann-Whitney U test and Fisher exact test (P < .05). RESULTS KFs were identified in 85 patients (93.4%), and KF injury was detected in 20 of the 85 patients (23.5%). No significant differences were observed between the KF injury group (n = 20) and the no-KF injury group (n = 65) in demographic characteristics, the period from injury to MRI (8.0 ± 14.0 days vs 8.9 ± 12.1 days, respectively), the rate of meniscal injury (50.0% vs 53.8%), or the rate of anterolateral ligament injury (45.0% vs 44.6%). Regarding the pivot-shift test, no significant differences were observed in tibial acceleration (1.2 m/s2 [interquartile range, 0.5-2.1 m/s2] vs 1.0 m/s2 [interquartile range, 0.6-1.7 m/s2], respectively) or manual grading between the 2 groups. CONCLUSION Concomitant KF injury did not significantly affect the pivot-shift phenomenon in acute ACL-injured knees. The findings suggest that the contribution of KF injury to anterolateral rotatory knee laxity may be limited in the clinical setting.
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Affiliation(s)
- Shu Watanabe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kiminari Kataoka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuta Nakanishi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Araki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Noriyuki Kanzaki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Raghavan S, Teo SH, Mohamed Al-Fayyadh MZ, Mohamed Ali MR, Ng WM. Variation in Kaplan fiber insertion to the distal femur and surgical implications: A cadaveric anatomical study comparing Asian and Caucasian knees. Knee 2022; 38:56-61. [PMID: 35930893 DOI: 10.1016/j.knee.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 06/07/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The iliotibial band together with its attachment to the distal femur, known eponymously as the Kaplan fibers, has been shown to contribute to anterolateral rotatory stability of the knee. However, there remains paucity of data regarding the detailed anatomy of the Kaplan fibers to aid us in anatomical-based surgical reconstruction of these structures. The aim of our study was to identify and compare the presence and quantitative anatomy of the Kaplan fibers in Caucasian and Asian cadavers. METHODS Twenty paired fresh-frozen Asian and 20 unpaired embalmed Caucasian cadaveric knees were dissected using a standard outside-in technique. The presence, qualitative and quantitative measurements of any distal femoral attachments of the iliotibial band were recorded. Mean values of its dimensions were calculated and compared between the Caucasian and Asian groups. RESULTS A consistent supracondylar attachment of the iliotibial band was found in all Caucasian knees and in 19 of 20 Asian knees. The fibers were noted to have two variations with regard to their insertion to the distal femur, either as a single limb or as a double limb attachment, averaging between 30 mm and 40 mm from the lateral femoral epicondyle. No statistically significant difference was noted in dimensions of the fibers between the Caucasian and Asian groups. CONCLUSIONS The Kaplan fibers are a consistent attachment of the iliotibial band at the distal femur in both Caucasian and Asian knees with two different patterns of insertion. Surgical reconstructions should aim to recreate these attachments to be as anatomically based as possible.
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Affiliation(s)
- Sugesh Raghavan
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Seow Hui Teo
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohamed Zubair Mohamed Al-Fayyadh
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohamed Razif Mohamed Ali
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wuey Min Ng
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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The coronal lateral collateral ligament sign in the anterior cruciate ligament-injured knees was observed regardless of the knee laxity based on the quantitative measurements. Knee Surg Sports Traumatol Arthrosc 2022; 30:3508-3514. [PMID: 35412065 DOI: 10.1007/s00167-022-06970-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The coronal lateral collateral ligament (LCL) sign has been reported to be associated with deviated position of the tibia on MRI due to anterior cruciate ligament (ACL) injuries. However, the relationships between LCL sign and clinical knee laxity evaluations are still unclear. The purpose of the study was to investigate the relationship between the coronal LCL sign and knee laxity measurements. METHODS A retrospective review of unilateral ACL injured patients who underwent ACL reconstruction was performed. The coronal LCL sign was determined using magnetic resonance imaging (MRI). Clinical grading of the pivot-shift test, KT-1000 measurements, and quantitative measurements of the Lachman test and the pivot-shift test using an electromagnetic system, were compared between patients with positive and negative coronal LCL sign. A subgroup analysis of different age groups was then performed, dividing patients to adolescent (age ≤ 18 years) and adult (age > 18 years) groups. RESULTS A total of 85 patients were enrolled, of which 45 patients had coronal LCL signs. The coronal LCL sign was not associated with the pivot-shift test clinical grading (n.s), KT-1000 measurement (n.s), the tibial translation during the Lachman test (n.s), or with tibia acceleration (n.s) and translation (n.s) during the pivot-shift test. The subgroup analysis also showed that the aforementioned parameters were not associated with the coronal LCL sign in either adolescent or adult subgroups. CONCLUSION The occurrence of coronal LCL sign in MRI did not imply greater clinical knee laxity evaluations in patients with ACL tears. The knee laxity should routinely be evaluated regardless the coronal LCL sign. LEVEL OF EVIDENCE Level III.
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Nie S, Zhou S, Huang W. Femoral fixation methods for hamstring graft in anterior cruciate ligament reconstruction: A network meta-analysis of controlled clinical trials. PLoS One 2022; 17:e0275097. [PMID: 36137116 PMCID: PMC9499312 DOI: 10.1371/journal.pone.0275097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 09/11/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To compare the clinical effectiveness of cortical button (CB), cross-pin (CP) and compression with interference screws (IS) fixation techniques in anterior cruciate ligament (ACL) reconstruction using hamstring graft. Methods Studies were systematically retrieved from PubMed, Embase, Cochrane Library and Web of Science up to May 20, 2021. Primary outcomes were KT-1000 assessment, International Knee Documentation Committee (IKDC) score A or B, Lachman’s test, pivot-shift test, visual analogue scale (VAS) score, Lysholm score, Tegner score, and Cincinnati Knee Score. Secondary outcomes included reconstruction failures and synovitis. League tables, rank probabilities and forest plots were drawn for efficacy comparison. Results Twenty-six controlled clinical trials (CCTs) with 1,824 patients undergoing ACL reconstruction with hamstring graft were included. No significant differences were found among CB, CP and IS fixation methods regarding the 10 outcomes. For KT-1000 assessment, IKDC score A or B, Lachman’s test, VAS score and pivot-shift test, CP had the greatest probability of becoming the best method, and IS may be the suboptimal method in 4 out of these 5 outcomes except pivot-shift test. Conclusions CP, CB and IS fixations have comparable clinical performance, while CP fixation is most likely to be the optimum fixation technique for hamstring graft in ACL reconstruction. Future larger-sample studies of high quality comparing these techniques in more clinical outcomes are required.
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Affiliation(s)
- Shixin Nie
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
| | - Shuqing Zhou
- Department of Orthopedics, The Centre Hospital of Jiangjin, Chongqing, China
| | - Wei Huang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Orthopedic Laboratory of Chongqing Medical University, Chongqing, China
- * E-mail:
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Berthold DP, Achtnich A, Mehl J. Anterolaterale Instabilität – Grenzgebiete der Indikation. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00565-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Agarwal N, Monketh J, Volpin A. Clinical and mechanical outcomes in isolated anterior cruciate ligament reconstruction vs additional lateral extra-articular tenodesis or anterolateral ligament reconstruction. World J Orthop 2022; 13:662-675. [PMID: 36051377 PMCID: PMC9302030 DOI: 10.5312/wjo.v13.i7.662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/13/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction has been a successful treatment for ACL rupture. However ongoing rotational instability can be an issue. Several surgical techniques have been recommended to overcome this including lateral extra-articular tenodesis (LET) and more recently anterolateral ligament reconstruction (ALLR).
AIM To compare the clinical outcomes following ACL reconstruction (ACLR) alone or ACLR with either LET or ALLR.
METHODS A systematic review was conducted by means of four databases (MEDLINE, EMBASE, Cochrane and Clinical.Trials.Gov), and the Reference Citaion Analysis (https://www.referencecitationanalysis.com/) to identify all studies investigating either or both of LET and ALLR. The Critical Appraisal Skills Programme checklist for cohort studies was employed for critical appraisal and evaluation of all twenty-four studies which met the inclusion criteria.
RESULTS Pooled meta-analyses illustrated that ACLR with additional LET or ALLR results in improved pivot shift test scores, compared to isolated ACLR. There was no statistically significant difference in International Knee Documentation Committee (IKDC) clinical scores with addition of either LET or ALLR. ACL re-rupture rates were compared between LET and ALLR techniques. There was a statistically significant difference between techniques, with a 1.14% rupture rate in ACLR +ALLR, and 4.03% rupture rate in ACLR + LET. Isolated ACLR re-rupture rates were 12.59%, significantly higher than when augmented with either ALLR or LET (P < 0.0001 for both groups). There were no statistical differences in pivot shift test or IKDC scores between LET and ALLR techniques.
CONCLUSION This meta-analysis has found that use of either LET or ALLR in addition to ACLR results in improved mechanical outcomes suggesting surgeons should consider augmenting ACLR with an extra-articular procedure in patients with rotatory instability. Furthermore, both anterolateral extra articular procedures in addition to ACLR lead to reduced ACL re-rupture rates compared to isolated ACLR. Moreover, ALLR results in reduced ACL re-rupture rates, compared to LET. More research is needed to compare the two respective extra-articular procedures.
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Affiliation(s)
- Nikhil Agarwal
- Department of Trauma and Orthopaedics, University of Aberdeen, Aberdeen AB24 3FX, United Kingdom
| | - Jaibaji Monketh
- Health Education England North East, Newcastle Upon Tyne NE15 8NY, United Kingdom
| | - Andrea Volpin
- Department of Trauma and Orthopaedics, NHS Grampian, Elgin IV30 1SN, United Kingdom
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Perelli S, Morales-Avalos R, Formagnana M, Rojas-Castillo G, Serrancolí G, Monllau JC. Lateral extraarticular tenodesis improves stability in non-anatomic ACL reconstructed knees: in vivo kinematic analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:1958-1966. [PMID: 35091787 DOI: 10.1007/s00167-021-06854-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To carry out an in vivo kinematic analysis to determine whether adding a lateral extraarticular tenodesis (LET) for those patients with subjective instability and objective residual laxity after a transtibial (TT) anterior cruciate ligament reconstruction (ACLR) reduces anteroposterior and rotational laxity and to evaluate the 2-year follow-up clinical outcomes to analyze whether biomechanical changes determine clinical improvement or not. METHODS A total of 19 patients with residual knee instability after TT ACLR who underwent a modified Lemaire LET were prospectively evaluated for at least 2-year follow-up. Preoperative, intraoperative, and 6 and 24-month postoperative kinematic analyses were carried out using the KiRA accelerometer and KT1000 arthrometer to look for residual anterolateral rotational instability and residual anteroposterior instability. Functional outcomes were measured with the single-leg vertical jump test and the single-leg hop test. Clinical outcomes were evaluated using the IKDC 2000, Lysholm, and Tegner scores. RESULTS A significant reduction in anterolateral rotational instability was detected with the patient under anesthesia (from 3 ± 1.2 to 1.1 ± 1.1 m/s2; p < 0.05) as well as with the patient awake (from 2.1 ± 0.8 to 0.7 ± 1.4 m/s2; p < 0.05). A significant reduction in anteroposterior instability was only present under anesthesia (from 3.4 ± 1.9 to 2.1 ± 1.1 mm; p < 0.05), while no difference was present without anesthesia (from 2.3 ± 1.1 to 1.6 ± 1 mm; n.s.). Postoperative analysis of knee laxity did not show any significant variation from the first to the last follow-up. Both the single-leg vertical jump test and single-leg hop test improved significantly at the last follow-up (both p < 0.05). The mean values of both the IKDC and Tegner scores showed an improvement (p < 0.05 and p < 0.05, respectively), whereas that was not the case with the Lysholm score (n.s.). CONCLUSIONS The modified Lemaire LET can improve the kinematics of a non-anatomic ACL reconstructed knee with residual subjective and objective instability. These kinematic changes were able to lead to an improvement in subjective stability as well as the function of the knee in a small cohort of recreationally active patients. At 2-year follow-up, the kinematic changes as well as the level of activity of the patients and the IKDC score show their improvement sustained. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Simone Perelli
- Institut Català de Traumatologia I Medicina de L'Esport (ICATME), Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Rodolfo Morales-Avalos
- Institut Català de Traumatologia I Medicina de L'Esport (ICATME), Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain. .,Department of Orthopedic Surgery and Traumatology, School of Medicine, University Hospital "Dr, José Eleuterio González", Universidad Autonoma de Nuevo León, Monterrey, Mexico. .,Knee Unit, Department of Orthopedic Surgery and Traumatology, School of Medicine, University Hospital "Dr, José Eleuterio González", Universidad Autonoma de Nuevo León (U.A.N.L.), 4th Floor, Central Building of the University Hospital, Av. Francisco I. Madero and Av. Dr. Eduardo Aguirre Pequeño, s/n, Col. Mitras Centro, C.P. 64460, Monterrey, Nuevo León, Mexico.
| | - Mario Formagnana
- Department of Orthopaedic Surgery and Traumatology, Nuovo Ospedale Degli Infermi, Biella, Italy
| | - Gonzalo Rojas-Castillo
- Department of Orthopaedic Surgery and Traumatology, Talca Regional Hospital, Universidad Catolica del Maule, Talca, Chile
| | - Gil Serrancolí
- Department of Mechanical Engineering, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Juan Carlos Monllau
- Institut Català de Traumatologia I Medicina de L'Esport (ICATME), Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Surgery and Morphologic Science, Orthopaedic Surgery Service, Universitat Autònoma de Barcelona, Hospital del Mar, Barcelona, Spain
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Magosch A, Jacquet C, Nührenbörger C, Mouton C, Seil R. Grade III pivot shift as an early sign of knee decompensation in chronic ACL-injured knees with bimeniscal tears. Knee Surg Sports Traumatol Arthrosc 2022; 30:1611-1619. [PMID: 34302192 DOI: 10.1007/s00167-021-06673-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/16/2021] [Indexed: 01/26/2023]
Abstract
PURPOSE To analyse possible associations between the preoperative pivot shift (PS) test and both patient and injury characteristics in anterior cruciate ligament (ACL)-injured knees, considering previously neglected meniscal injuries such as ramp and root tears. The hypothesis was that a preoperative grade III PS was associated with the amount of intra-articular soft-tissue damage and chronicity of the injury. METHODS The cohort involved 376 patients who underwent primary ACL reconstruction (239 males/137 females; median age 26). Patients were examined under anesthesia before surgery, using the PS test. During arthroscopy, intra-articular soft-tissue damage of the injured knee was classified as: (1) partial ACL tear; (2) complete isolated ACL tear; (3) complete ACL tear with one meniscus tear; and (4) complete ACL and bimeniscal tears. Chi-square and Mann-Whitney U tests were used to evaluate whether sex, age, body mass index, sport at injury, mechanism of injury, time from injury and intra-articular damage (structural damage of ACL and menisci) were associated with a grade III PS. Intra-articular damage was further analyzed for two sub-cohorts: acute (time from injury ≤ 6 months) and chronic injuries (> 6 months). RESULTS A grade III PS test was observed in 26% of patients. A significant association with PS grading was shown for age, time from injury and intra-articular soft-tissue damage (p < 0.05). Further analyses showed that grade III PS was associated with intra-articular damage in chronic injuries only (p < 0.01). In complete ACL and bimeniscal tears, grade III PS was more frequent in chronic (53%) than in acute knee injuries (26%; p < 0.01). Patients with chronic complete ACL and bimeniscal tears had a grade III PS 3.3 [1.3-8.2] times more often than patients in the acute sub-cohort. CONCLUSION In ACL-injured patients, a preoperative grade III PS was mainly associated with a higher amount of intra-articular soft-tissue damage and chronicity of the injury. Patients with complete chronic ACL injuries and bimeniscal tears were more likely to have a preoperative grade III PS than their acute counterparts. This suggests that grade III PS may be an early sign of knee decompensation of dynamic rotational knee laxity in chronic ACL-injured knees with bimeniscal lesions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Amanda Magosch
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78 Rue d'Eich, 1460, Luxembourg, Luxembourg
| | - Christophe Jacquet
- Institute for Movement and Locomotion (IML), Department of Orthopedic Surgery and Traumatology, St. Marguerite Hospital, Marseille, France
| | - Christian Nührenbörger
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78 Rue d'Eich, 1460, Luxembourg, Luxembourg.,Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg
| | - Caroline Mouton
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78 Rue d'Eich, 1460, Luxembourg, Luxembourg.,Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg
| | - Romain Seil
- Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d'Eich, 78 Rue d'Eich, 1460, Luxembourg, Luxembourg. .,Luxembourg Institute of Research in Orthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg. .,Human Motion, Orthopaedics, Sports Medicine and Digital Methods, Luxembourg Institute of Health, Strassen, Luxembourg.
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Lynch TB, Bernot JM, Oettel DJ, Byerly D, Musahl V, Chasteen J, Antosh IJ, Patzkowski JC, Sheean AJ. Magnetic resonance imaging does not reliably detect Kaplan fiber injury in the setting of anterior cruciate ligament tear. Knee Surg Sports Traumatol Arthrosc 2022; 30:1769-1775. [PMID: 34522987 DOI: 10.1007/s00167-021-06730-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/30/2021] [Indexed: 01/24/2023]
Abstract
PURPOSE There has been a continued effort to better understand the role Kaplan fiber injury plays in persistent instability following ACL tears. However, the prevalence of these injuries remains poorly understood. Therefore, the purpose of this study was to define the prevalence of Kaplan fiber injury in the setting of complete anterior cruciate ligament tear using a commonly used grading system for assessing ligament injuries. The inter-rater reliability of this commonly used grading system and the relationship between Kaplan fiber injury and injury to other structures commonly found in conjunction with ACL tears was also evaluated. METHODS All isolated, complete anterior cruciate ligament tears confirmed on magnetic resonance imaging within 90 days of injury between 2014 and 2020 at a single institution were included for analysis. Each scan was read by two, fellowship-trained musculoskeletal radiologists. Kaplan fiber injury was evaluated using a previously described grading scheme. Kappa, [Formula: see text], of inter-rater agreement was determined for all magnetic resonance image scans. Kruskal Wallis test was performed to assess for associations between Kaplan fiber injury and magnet strength (1.5 T vs. 3.0 T), patient gender, the presence of medial and/or lateral meniscal tears, and/or posterolateral tibial bone bruise. RESULTS Between 2014 and 2020, 131 patients (94 males, 37 females) with a complete anterior cruciate ligament tear were included in the final analysis. The mean age of the cohort was 27.8 ± 6.8 years. Kaplan fiber injuries were identified in 51 of 131 (38.9%, CI 31.0-47.5%) scans with complete anterior cruciate ligament injuries (Grade 1: 28, Grade 2: 18, and Grade 3: 5). Inter-rater agreement for Kaplan fiber injury was fair ([Formula: see text] with 43 (32.8%) scans requiring third reviewer adjudication. There were no significant associations between Kaplan fiber injury and gender, magnet strength, meniscal tears, or posterolateral tibial bone bruise. CONCLUSION The prevalence of Kaplan fiber injuries was comparable to previously described rates; however, the classification system used to report Kaplan fiber injury was associated with low inter-rater reliability. The presence of Kaplan fiber injury was not associated with other injuries commonly observed in conjunction with ACL tear. The previously proposed Kaplan fiber injury classification system is not reproducible nor is it likely to aid surgeons in distinguishing higher grades of rotatory knee instability. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Thomas B Lynch
- San Antonio Military Medical Center, 3551 Roger Brooke Road, San Antonio, TX, 78234, USA.
| | - Jeremy M Bernot
- San Antonio Military Medical Center, 3551 Roger Brooke Road, San Antonio, TX, 78234, USA
| | - David J Oettel
- San Antonio Military Medical Center, 3551 Roger Brooke Road, San Antonio, TX, 78234, USA
| | - Douglas Byerly
- San Antonio Military Medical Center, 3551 Roger Brooke Road, San Antonio, TX, 78234, USA
| | | | | | - Ivan J Antosh
- San Antonio Military Medical Center, 3551 Roger Brooke Road, San Antonio, TX, 78234, USA
| | - Jeanne C Patzkowski
- San Antonio Military Medical Center, 3551 Roger Brooke Road, San Antonio, TX, 78234, USA
| | - Andrew J Sheean
- San Antonio Military Medical Center, 3551 Roger Brooke Road, San Antonio, TX, 78234, USA
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Nakamae A, Sumen Y, Tsukisaka K, Deie M, Fujimoto E, Ishikawa M, Omoto T, Adachi N. A larger side-to-side difference in anterior knee laxity increases the prevalence of medial and lateral meniscal injuries in patients with ACL injuries. Knee Surg Sports Traumatol Arthrosc 2022; 30:1560-1567. [PMID: 33970292 DOI: 10.1007/s00167-021-06601-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/30/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The objective of this study was to investigate factors that influence the prevalence of medial and lateral meniscal injuries at the time of anterior cruciate ligament (ACL) reconstruction in patients with ACL injuries. METHODS Patients with ACL injuries at 9 institutions were enrolled in this multicentre study. Age, sex, duration between injury and surgery, pivot shift test grade, anterior knee laxity determined using the Kneelax 3 arthrometer, and other variables were assessed by logistic regression analysis. Meniscal conditions were evaluated via arthroscopy. RESULTS In all, 830 patients were enrolled. The prevalence of medial and lateral meniscal tears was 32.0% (266 knees) and 26.5% (220 knees), respectively. Significant factors that influenced the prevalence of medial meniscal injuries were age [odds ratio (OR) 1.03; P = 0.000], side-to-side differences in instrumented anterior knee laxity before surgery (OR 1.12; P = 0.002), duration between injury and surgery (≥ 12 months) (OR 1.86; P = 0.023), and pivot shift test grade (OR 1.36; P = 0.014). Significant factors of lateral meniscal injury were side-to-side differences in anterior knee laxity before surgery (OR 1.12; P = 0.003) and the male sex (OR 1.50; P = 0.027). CONCLUSION Greater anterior knee laxity, age, a longer duration between injury and surgery, and a higher pivot shift test grade predicted medial meniscal injury. Greater anterior knee laxity and the male sex predicted lateral meniscal injury. In patients with ACL injuries, the importance of side-to-side differences in anterior knee laxity should be rediscovered from the viewpoint of meniscal conditions. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Atsuo Nakamae
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Yoshio Sumen
- Department of Orthopaedic Surgery, JA Onomichi General Hospital, 1-10-23, Hirahara, Onomichi, Hiroshima, 722-8508, Japan
| | - Kazuhiro Tsukisaka
- Department of Orthopaedic Surgery, Mazda Hospital, 2-15, Aosakiminami, Huchu-cho, Aki-gun, Hiroshima, 735-8585, Japan
| | - Masataka Deie
- Department of Orthopedic Surgery, Aichi Medical University, 21 Karimata, Yazako, Nagakute, Aichi, 480-1195, Japan
| | - Eisaku Fujimoto
- Department of Orthopedic Surgery, Chugoku Rosai Hospital, 1-5-1, Hiro-Tagaya, Kure, Hiroshima, 737-0193, Japan
| | - Masakazu Ishikawa
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takenori Omoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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37
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Guarino A, Farinelli L, Iacono V, Screpis D, Piovan G, Rizzo M, Mariconda M, Zorzi C. Lateral extra-articular tenodesis and anterior cruciate ligament reconstruction in young patients: clinical results and return to sport. Orthop Rev (Pavia) 2022; 14:33696. [PMID: 35774923 PMCID: PMC9239354 DOI: 10.52965/001c.33696] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 12/23/2021] [Indexed: 03/24/2024] Open
Abstract
Lateral extra-articular tenodesis (L.E.T.) have been proposed to reduce the tibia's anterior translation and internal rotation in concomitant to Anterior cruciate ligament (A.C.L.) reconstruction. Recent studies show that the addition of L.E.T. to A.C.L. reconstruction results in a statistically significant reduction in graft failure. The purpose of the present study was to evaluate the clinical outcomes, complications, and rate of return to preinjury sports level in pediatric patients who underwent combined A.C.L. reconstruction with L.E.T. at a minimum 2-year follow-up. The authors retrospectively evaluated 42 pediatric patients at high risk of graft failure who experienced ACLR connected to L.E.T. IKDC and Tegner-Lysholm Knee Scores Scale were used to assess clinical outcomes, and the Tegner Activity Scale to evaluate the return to sport. No graft failure or subsequent surgery related to A.C.L. reconstruction occurred. Furthermore, 88% of patients returned to the sport. Satisfactory clinical results were obtained on a short and medium-term follow-up. These findings help to consider this procedure for active adolescents at a high risk of graft failure to enhance A.C.L. reconstruction.
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Affiliation(s)
- Amedeo Guarino
- Section of Orthopaedics. Department of Public Health, Federico II University, Naples (NA), Italy
| | - Luca Farinelli
- Clinical Orthopaedics Departement of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona(AN), Italy
| | - Venanzio Iacono
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
| | - Daniele Screpis
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
| | - Gianluca Piovan
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
| | - Maria Rizzo
- Section of Orthopaedics. Department of Public Health, Federico II University, Naples (NA), Italy
| | - Massimo Mariconda
- Section of Orthopaedics. Department of Public Health, Federico II University, Naples (NA), Italy
| | - Claudio Zorzi
- Department of Orthopaedic Surgery, IRCCS Sacro Cuore - Don Calabria in Negrar (VE), Italy
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38
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Onggo JR, Rasaratnam HK, Nambiar M, Onggo JD, Pai V, Damasena I, Riazi A, Babazadeh S. Anterior Cruciate Ligament Reconstruction Alone Versus With Lateral Extra-articular Tenodesis With Minimum 2-Year Follow-up: A Meta-analysis and Systematic Review of Randomized Controlled Trials. Am J Sports Med 2022; 50:1137-1145. [PMID: 33886399 DOI: 10.1177/03635465211004946] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lateral extra-articular tenodesis (LEAT) aims to improve anterolateral stability of the injured knee during anterior cruciate ligament reconstruction (ACLR) surgery. Inconclusive evidence surrounding the efficacy and safety of LEAT has propelled clinical interest and ongoing discussions. PURPOSE To establish level 1 evidence by assessing randomized controlled trials (RCTs) with minimum 2-year follow-up that directly compared ACLR with LEAT (LEAT group) and ACLR alone (non-LEAT group) in terms of clinical outcomes and complications. STUDY DESIGN Meta-analysis and systematic review; Level of evidence, 1. METHODS Meta-analysis was performed with a multidatabase search (Cochrane, EMBASE, OVID Medline, PubMed, and Web of Science) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on September 9, 2020. Data from published RCTs meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model. RESULTS A total of 7 RCTs were included, consisting of 517 LEAT and 589 non-LEAT patients. Only autografts were used for ACLR and LEAT. A variety of LEAT techniques and autograft fixation methods were used. We found improved stability (residual positive pivot shift: risk ratio [RR], 0.59; 95% CI, 0.39-0.88; P = .01) and better clinical outcomes (International Knee Documentation Committee [IKDC] score: mean difference [MD], 2.31; 95% CI, 0.54-4.09; P = .01; and Lysholm score: MD, 2.71; 95% CI, 0.68-4.75; P = .009) in the LEAT than non-LEAT group. Graft rerupture rate was 3 times less likely (RR, 0.31; 95% CI, 0.17-0.58; P < .001) in the LEAT group than the non-LEAT group. CONCLUSION Good-quality evidence is available to support the efficacy of LEAT in improving anterolateral knee stability and reducing graft reruptures in primary ACLR. LEAT should be considered in patients with high risk factors. Although Lysholm and IKDC scores were statistically better in the LEAT group, these are unlikely to be clinically significant. Future studies should aim to identify patient populations that would best benefit from LEAT with ACLR.
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Affiliation(s)
- James Randolph Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | | | - Mithun Nambiar
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Jason Derry Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Vishal Pai
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Iswadi Damasena
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Arash Riazi
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Sina Babazadeh
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
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Xu J, Han K, Lee TQ, Xu C, Su W, Chen J, Yu J, Dong S, Zhao J. Anterolateral Structure Reconstruction Similarly Improves the Stability and Causes Less Overconstraint in Anterior Cruciate Ligament-Reconstructed Knees Compared With Modified Lemaire Lateral Extra-articular Tenodesis: A Biomechanical Study. Arthroscopy 2022; 38:911-924. [PMID: 34358641 DOI: 10.1016/j.arthro.2021.06.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 06/13/2021] [Accepted: 06/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the kinematics of anterolateral structure (ALS) reconstruction (ALSR) and lateral extra-articular tenodesis (LET) in ACL-ALS-deficient knees with anterior cruciate ligament (ACL) reconstruction. METHODS Ten fresh-frozen cadaveric knees with the following conditions were tested: (1) intact, (2) ACL-ALS deficiency, (3) ACL reconstruction (ACLR), (4) ACLR combined with ALSR (ACL-ALSR) or LET (ACLR+LET). Anterior translation and tibial internal rotation were measured with 90-N anterior load and 5 N·m internal torque at 0°, 30°, 60°, and 90°. The anterolateral translation and internal rotation were also measured during a simulated pivot-shift test at 0°, 15°, 30°, and 45°. The knee kinematic changes in all reconstructions were compared with each other, with intact knees as the baseline. RESULTS Isolated ACLR failed to restore native knee kinematics in ACL-ALS-deficient knees. Both ACL-ALSR and ACLR+LET procedures decreased the anterior instability of the ACLR. However, ACLR+LET caused overconstraints in internal rotation at 30° (-3.73° ± 2.60°, P = .023), 60° (-4.96° ± 2.22°, P = .001) and 90° (-6.14° ± 1.60°, P < .001). ACL-ALSR also overconstrained the knee at 60° (-3.65° ± 1.90°, P < .001) and 90° (-3.18° ± 2.53°, P < .001). For a simulated pivot-shift test, both combined procedures significantly reduced the ACLR instability, with anterolateral translation and internal rotation being overconstrained in ACLR+LET at 30° (-3.32 mm ± 3.89 mm, P = .005; -2.58° ± 1.61°, P < .001) and 45° (-3.02 mm ± 3.95 mm, P = .012; -3.44° ± 2.86°, P < .001). However, the ACL-ALSR overconstrained only the anterolateral translation at 30° (-1.51 mm ± 2.39 mm, P = .046) and internal rotation at 45° (-2.09° ± 1.70°, P < .001). There were no significant differences between the two combined procedures at most testing degrees in each testing state, except for the internal rotation at 30° (P = .007) and 90° (P = .032) in internal rotation torque. CONCLUSION ACL reconstruction alone did not restore intact knee kinematics in knees with concurrent ACL tears and severe ALS injury (ACL-ALS-deficient status). Both ACL-ALSR and ACLR+LET procedures restored knee stability at some flexion degrees, with less overconstraints in internal rotation resulting from ACL-ALSR. CLINICAL RELEVANCE For patients with combined ACL tears and severe ALS deficiency, isolated ACLR probably results in residual rotational and pivot-shift instability. Both ACL-ALSR and ACLR+LET show promise for the improvement of knee stability, whereas ACL-ALSR has less propensity for knee overconstraint.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, U.S.A
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiakuo Yu
- Knee Surgery Department of the Institute of Sports Medicine & Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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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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41
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Moreno Mateo F, Perea SH, Green DW. Lateral-extra articular tenodesis vs. anterolateral ligament reconstruction in skeletally immature patients undergoing anterior cruciate ligament reconstruction. Curr Opin Pediatr 2022; 34:71-75. [PMID: 34845153 DOI: 10.1097/mop.0000000000001084] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the most recent available evidence about lateral-extra articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction in young patients treated for anterior cruciate ligament (ACL) injury. RECENT FINDINGS The ALL of the knee acts as a secondary stabilizer of the knee preventing anterior translation and internal rotation. In vitro and in vivo biomechanical studies as well as prospective clinical trials have shown the importance of the ALL in knee biomechanics. The ALL injury has a synergetic impact on the knee stability in patients with acute ACL injury. ALL augmentation of ACL provides reduction of knee instability and graft failure and higher return to sport rates in high-risk patients. It has not been demonstrated that extra-articular procedures increase the risk of knee osteoarthritis secondary to knee over-constriction. Both Iliotibial band (ITB) ALL reconstruction and modified Lemaire LET have been shown safe and effective. Minimal biomechanical or clinical differences have been found between the two reconstruction methods. SUMMARY Young patients with ACL tears and risk factors such as laxity or pivot shift willing to return to sports may benefit from ALL augmentation. Therefore, it is essential to identify these high-risk patients to individualize treatment.
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Affiliation(s)
- Fernando Moreno Mateo
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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Nishida K, Gale T, Chiba D, Suntaxi F, Lesniak B, Fu F, Anderst W, Musahl V. The effect of lateral extra-articular tenodesis on in vivo cartilage contact in combined anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:61-70. [PMID: 33580345 DOI: 10.1007/s00167-021-06480-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/25/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE Lateral extra-articular tenodesis (LET) may confer improved rotational stability after anterior cruciate ligament reconstruction (ACLR). Little is known about how LET affects in vivo cartilage contact after ACLR. The aim of this study was to investigate the effect of LET in combination with ACLR (ACLR + LET) on in vivo cartilage contact kinematics compared to isolated ACLR (ACLR) during downhill running. It was hypothesised that cartilage contact area in the lateral compartment would be larger in ACLR + LET compared with ACLR, and that the anterior-posterior (A-P) position of the contact center on the lateral tibia would be more anterior after ACLR + LET than after ACLR. METHODS Twenty patients were randomly assigned into ACLR + LET or ACLR during surgery (ClinicalTrials.gov:NCT02913404). At 6 months and 12 months after surgery, participants were imaged during downhill running using biplane radiography. Tibiofemoral motion was tracked using a validated registration process. Patient-specific cartilage models, obtained from 3 T MRI, were registered to track bone models and used to calculate the dynamic cartilage contact area and center of cartilage contact in both the medial and lateral tibiofemoral compartments, respectively. The side-to-side differences (SSD) were compared between groups using a Mann-Whitney U test. RESULTS At 6 months after surgery, the SSD in A-P cartilage contact center in ACLR + LET (3.9 ± 2.6 mm, 4.4 ± 3.1 mm) was larger than in ACLR (1.2 ± 1.6 mm, 1.5 ± 2.0 mm) at 10% and 20% of the gait cycle, respectively (p < 0.01, p < 0.05). There was no difference in the SSD in cartilage contact center at 12 months after surgery. There was no difference in SSD of cartilage contact area in the medial and lateral compartments at both 6 and 12 months after surgery. There were no adverse events during the trial. CONCLUSION LET in combination with ACLR may affect the cartilage contact center during downhill running in the early post-operation phase, but this effect is lost in the longer term. This suggests that healing and neuromuscular adaptation occur over time and may also indicate a dampening of the effect of LET over time. (337 /350 words) LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Kyohei Nishida
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.,Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA
| | - Tom Gale
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA
| | - Daisuke Chiba
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.,Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA.,Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Felipe Suntaxi
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA
| | - Bryson Lesniak
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Freddie Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - William Anderst
- Biodynamics Laboratory, University of Pittsburgh, Rivertech Building Complex, 3820 South Water Street, Pittsburgh, PA, 15203, USA.
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
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An older age, a longer duration between injury and surgery, and positive pivot shift test results increase the prevalence of articular cartilage injury during ACL reconstruction in all three compartments of the knee in patients with ACL injuries. Knee Surg Sports Traumatol Arthrosc 2022; 30:219-230. [PMID: 33543356 DOI: 10.1007/s00167-021-06461-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To investigate factors that influence the prevalence of articular cartilage injury in patients with anterior cruciate ligament (ACL) injury. METHODS This multicentre study included patients with ACL injury. Logistic regression analysis was conducted to identify factors that influence the prevalence of cartilage injury during ACL reconstruction. RESULTS A total of 811 patients were enrolled. The factors that significantly influenced the prevalence of cartilage injury were age (odds ratio [OR], 1.04; P = 0.000), a positive pivot shift test result (OR, 1.43; P = 0.021), medial meniscal injury (OR, 2.55; P = 0.000), and delayed surgery (≥ 12 months) (OR, 2.52; P = 0.028) in the medial compartment of the knee; age (OR, 1.05; P = 0.000), subjective grades of apprehension during the pivot shift test (OR, 1.46; P = 0.010), lateral meniscal injury (OR, 1.98; P = 0.003), femoro-tibial angle (FTA) (OR, 0.92; P = 0.006), and delayed surgery (≥ 12 months) (OR, 2.63; P = 0.001) in the lateral compartment; and age (OR, 1.06; P = 0.000), body mass index (OR, 1.07; P = 0.028), a positive pivot shift test result (OR, 1.60; P = 0.018), FTA (OR, 0.90; P = 0.006), and delayed surgery (≥ 12 months) (OR, 3.17; P = 0.008) in the patellofemoral compartment. CONCLUSION An older age, a longer duration between injury and surgery, and a positive pivot shift test result were positively associated with the prevalence of cartilage injury in three compartments in patients with ACL injuries. Early ACL reconstruction is recommended to prevent cartilage injury. LEVEL OF EVIDENCE Level III.
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Laxity measurement of internal knee rotation after primary anterior cruciate ligament rupture versus rerupture. Arch Orthop Trauma Surg 2022; 142:2839-2847. [PMID: 34870728 PMCID: PMC9474331 DOI: 10.1007/s00402-021-04269-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/16/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of the current study was to objectify the rotational laxity after primary anterior cruciate ligament (ACL) rupture and rerupture after ACL reconstruction by instrumented measurement. It was hypothesized that knees with recurrent instability feature a higher internal rotation laxity as compared to knees with a primary rupture of the native ACL. STUDY DESIGN Cross-sectional study, Level of evidence III. METHODS In a clinical cross-sectional study successive patients with primary ACL rupture and rerupture after ACL reconstruction were evaluated clinically and by instrumented measurement of the rotational and antero-posterior laxity with a validated instrument and the KT1000®, respectively. Clinical examination comprised IKDC 2000 forms, Lysholm Score, and Tegner Activity Scale. Power calculation and statistical analysis were performed (p value < 0.05). RESULTS 24 patients with primary ACL rupture and 23 patients with ACL rerupture were included. There was no significant side-to-side difference in anterior translation. A side-to side difference of internal rotational laxity ≥ 10° was found significantly more frequent in reruptures (53.6%) compared to primary ruptures (19.4%; p < 0.001). A highly significant relationship between the extent of the pivot-shift phenomenon and side-to-side difference of internal rotation laxity could be demonstrated (p < 0.001). IKDC 2000 subjective revealed significantly better scores in patients with primary ACL tear compared to patients with ACL rerupture (56.4 ± 7.8 vs. 50.8 ± 6.2; p = 0.01). Patients with primary ACL tears scored significantly better on the Tegner Activity Scale (p = 0.02). No significant differences were seen in the Lysholm Score (p = 0.78). CONCLUSION Patients with ACL rerupture feature significantly higher internal rotation laxity of the knee compared to primary ACL rupture. The extend of rotational laxity can be quantified by instrumented measurements. This can be valuable data for the indication of an anterolateral ligament reconstruction in ACL revision surgery.
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45
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Agostinone P, Di Paolo S, Lucidi GA, Dal Fabbro G, Grassi A, Zaffagnini S. Severe bicompartmental bone bruise is associated with rotatory instability in anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc 2022; 30:1725-1732. [PMID: 34491380 PMCID: PMC9033705 DOI: 10.1007/s00167-021-06735-0] [Citation(s) in RCA: 4] [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] [Received: 06/09/2021] [Accepted: 08/30/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The presence and severity of bone bruise is more and more investigated in the non-contact anterior cruciate ligament (ACL) injury context. Recent studies have advocated a correlation between bone bruise and preoperative knee laxity. The aim of the present study was to investigate the correlation between bone bruise and preoperative rotatory knee laxity. METHODS Twenty-nine patients (29.1 ± 9.8 years) with MRI images at a maximum of 3 months after ACL injury (1.6 ± 0.8 months) were included. The bone bruise severity was evaluated according to the International Cartilage Repair Society (ICRS) scale for lateral femoral condyle, lateral tibial plateau, medial femoral condyle, and medial tibial plateau. The intraoperative rotational knee laxity was evaluated through a surgical navigation system in terms of internal-external rotation at 30° and 90° of knee flexion (IE30, IE90) and internal-external rotation and acceleration during pivot-shift test (PS IE, PS ACC). The KOOS score was also collected. The association between ICRS grade of bone bruise and rotational laxity or KOOS was investigated. RESULTS Significant correlation (p < 0.05) was found between the bone bruise severity on the medial tibial plateau and rotational laxity (IE90, PS IE, and PS ACC) and between the severity of bone bruise on femoral lateral condyle and KOOS-Symptoms sub-score. The presence of bone bruise on the medial tibial plateau was significantly associated with a lateral femoral notch sign > 2 mm (very strong odds ratio). No kinematical differences were found between none-to-deep and extensive-generalized lateral bone bruise, while higher IE30 and IE90 were found in extensive-generalized bicompartmental bone bruise than isolated extensive-generalized lateral bone bruise. CONCLUSION A severe bicompartmental bone bruise was related to higher rotatory instability in the intraoperative evaluation of ACL deficient knees. The severity of edema on the medial tibial plateau was directly correlated with higher intraoperative pivot shift, and the size of edema on the lateral femoral condyle was associated with lower preoperative clinical scores. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Piero Agostinone
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | - Stefano Di Paolo
- Dipartimento di Scienze per la Qualità della Vita QUVI, Università Di Bologna, Corso D'Augusto 237, 47921, Rimini, RN, Italy.
| | - Gian Andrea Lucidi
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | - Giacomo Dal Fabbro
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | - Alberto Grassi
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
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Berthold DP, Willinger L, LeVasseur MR, Marrero DE, Bell R, Muench LN, Zenon K, Imhoff AB, Herbst E, Cote MP, Arciero RA, Edgar CM. High Rate of Initially Overlooked Kaplan Fiber Complex Injuries in Patients With Isolated Anterior Cruciate Ligament Injury: Response. Am J Sports Med 2022; 50:NP3-NP5. [PMID: 34984957 DOI: 10.1177/03635465211049388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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47
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Nakamura T, Marshall BD, Price TM, Mao Y, Linde MA, Koga H, Smolinski P, Fu FH. Arthroscopic Centralization for Lateral Meniscal Injuries Reduces Laxity in the Anterior Cruciate Ligament-Reconstructed Knee. Am J Sports Med 2021; 49:3528-3533. [PMID: 34524037 DOI: 10.1177/03635465211041747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A lateral meniscal (LM) disorder is one factor that causes rotational laxity after anterior cruciate ligament (ACL) reconstruction (ACLR). There are different types of irreparable meniscal disorders, one of which is a massive meniscal defect. HYPOTHESIS/PURPOSE The purpose of this study was to evaluate the kinematic effects of arthroscopic centralization on an irreparable LM defect. The hypothesis was that arthroscopic centralization for an irreparable LM defect with concomitant ACLR would improve knee rotational stability. STUDY DESIGN Controlled laboratory study. METHODS A total of 14 fresh-frozen human cadaveric knees were tested in 4 states: (1) intact ACL and intact lateral meniscus, (2) reconstructed ACL and intact lateral meniscus, (3) reconstructed ACL and lateral meniscus defect, and (4) reconstructed ACL and centralized lateral meniscus. Anatomic ACLR was performed using an 8 mm-diameter hamstring tendon graft. An LM defect (20% of the anteroposterior length) was created arthroscopically, and arthroscopic centralization was performed. Kinematics were analyzed using a 6 degrees of freedom robotic system under 4 knee loads: (1) an 89.0-N anterior tibial load, (2) a 5.0-N·m external rotation tibial torque, (3) a 5.0-N·m internal rotation tibial torque, and (4) a simulated pivot-shift load with a combined 7.0-N·m valgus and 5.0-N·m internal rotation tibial torque. RESULTS LM centralization reduced anterior tibial translation similar to that of the ACLR intact LM state under anterior tibial loading (~2 mm at 30° of flexion) and showed 40% to 100% of tibial displacement in the 4 knee states under simulated pivot-shift loading. The procedure overconstrained the knee under internal rotation tibial torque and simulated pivot-shift loading. CONCLUSION Arthroscopic centralization reduced knee laxity after ACLR for a massive LM defect in a cadaveric model. CLINICAL RELEVANCE In cases involving irreparable LM injuries during ACLR, consideration should be given to arthroscopic centralization for reducing knee laxity. However, the procedure may overconstrain the knee in certain motions.
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Affiliation(s)
- Tomomasa Nakamura
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Brandon D Marshall
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Taylor M Price
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yongtao Mao
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Monica A Linde
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Patrick Smolinski
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ariel de Lima D, de Lima LL, de Souza NGR, de Moraes Perez RA, Sobrado MF, Guimarães TM, Helito CP. Clinical outcomes of combined anterior cruciate ligament and anterolateral ligament reconstruction: a systematic review and meta-analysis. Knee Surg Relat Res 2021; 33:33. [PMID: 34556187 PMCID: PMC8461945 DOI: 10.1186/s43019-021-00115-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/08/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES To compare the clinical outcomes of isolated anterior cruciate ligament (ACL) reconstruction with combined reconstruction of the ACL and anterolateral ligament (ALL) of the knee. METHODS A search was conducted on the PubMed, Medline, Google Scholar, EMBASE, and Cochrane library databases, in line with the PRISMA protocol. The indexation terms used were "anterior cruciate ligament" OR "acl" AND "anterolateral ligament" AND "reconstruction." Articles that compared patients submitted to combined ACL and ALL reconstruction with those submitted to isolated reconstruction of the ACL, with levels of evidence I, II, and III, were included. Studies with follow-up of less than 2 years and articles that did not use "anatomical" techniques for ALL reconstruction, such as extraarticular tenodesis, were excluded. A meta-analysis with R software was conducted, with a random effects model, presented as risk ratio (RR) or mean difference (MD), with a 95% confidence level (CI) and statistically significant at p < 0.05. RESULTS Ten articles were selected, with a total of 1495 patients, most of whom were men, of whom 674 submitted to ACL and ALL reconstruction and 821 to isolated ACL reconstruction. Combined ACL and ALL reconstruction exhibited a statistically significant advantage in residual pivot shift (RR 0.34, 95% CI 0.24-0.47, I2 = 0%, p < 0.01), rerupture rate (RR 0.34, 95% CI 0.19-0.62, I2 = 0%, p < 0.01), Lachman test (RR 0.59, 95% CI 0.40-0.86, I2 = 21%, p < 0.01), and postoperative Lysholm score (MD 2.28, CI 95% 0.75-3.81, I2 = 73%, p < 0.01). CONCLUSIONS Combined ACL and ALL reconstruction obtained better postoperative clinical outcomes when compared with isolated ACL reconstruction, especially in reducing residual pivot shift and rerupture rate.
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Affiliation(s)
- Diego Ariel de Lima
- UFERSA, Universidade Federal Rural do Semi-Árido, R. Francisco Mota, 572, Pres. Costa e Silva, Mossoró, RN, CEP: 59625-900, Brazil. .,Hospital Tarcísio Maia, Mossoró, Brazil.
| | - Lana Lacerda de Lima
- UFERSA, Universidade Federal Rural do Semi-Árido, R. Francisco Mota, 572, Pres. Costa e Silva, Mossoró, RN, CEP: 59625-900, Brazil.,Hospital Tarcísio Maia, Mossoró, Brazil
| | | | | | - Marcel Faraco Sobrado
- USP, Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Tales Mollica Guimarães
- USP, Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Camilo Partezani Helito
- USP, Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
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49
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Marom N, Jahandar H, Fraychineaud TJ, Zayyad ZA, Ouanezar H, Hurwit D, Zhu A, Wickiewicz TL, Pearle AD, Imhauser CW, Nawabi DH. Lateral Extra-articular Tenodesis Alters Lateral Compartment Contact Mechanics under Simulated Pivoting Maneuvers: An In Vitro Study. Am J Sports Med 2021; 49:2898-2907. [PMID: 34314283 DOI: 10.1177/03635465211028255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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 utilization of lateral extra-articular tenodesis (LET) in conjunction with anterior cruciate ligament (ACL) reconstruction (ACLR) may disturb lateral compartment contact mechanics and contribute to joint degeneration. HYPOTHESIS ACLR augmented with LET will alter lateral compartment contact mechanics in response to simulated pivoting maneuvers. STUDY DESIGN Controlled laboratory study. METHODS Loads simulating a pivot shift were applied to 7 cadaveric knees (4 male; mean age, 39 ± 12 years; range, 28-54 years) using a robotic manipulator. Each knee was tested with the ACL intact, sectioned, reconstructed (via patellar tendon autograft), and, finally, after augmenting ACLR with LET (using a modified Lemaire technique) in the presence of a sectioned anterolateral ligament and Kaplan fibers. Lateral compartment contact mechanics were measured using a contact stress transducer. Outcome measures were anteroposterior location of the center of contact stress (CCS), contact force from anterior to posterior, and peak and mean contact stress. RESULTS On average, augmenting ACLR with LET shifted the lateral compartment CCS anteriorly compared with the intact knee and compared with ACLR in isolation by a maximum of 5.4 ± 2.3 mm (P < .001) and 6.0 ± 2.6 mm (P < .001), respectively. ACLR augmented with LET also increased contact force anteriorly on the lateral tibial plateau compared with the intact knee and compared with isolated ACLR by a maximum of 12 ± 6 N (P = .001) and 17 ± 10 N (P = .002), respectively. Compared with ACLR in isolation, ACLR augmented with LET increased peak and mean lateral compartment contact stress by 0.7 ± 0.5 MPa (P = .005) and by 0.17 ± 0.12 (P = .006), respectively, at 15° of flexion. CONCLUSION Under simulated pivoting loads, adding LET to ACLR anteriorized the CCS on the lateral tibial plateau, thereby increasing contact force anteriorly. Compared with ACLR in isolation, ACLR augmented with LET increased peak and mean lateral compartment contact stress at 15° of flexion. CLINICAL RELEVANCE The clinical and biological effect of increased anterior loading of the lateral compartment after LET merits further investigation. The ability of LET to anteriorize contact stress on the lateral compartment may be useful in knees with passive anterior subluxation of the lateral tibia.
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Affiliation(s)
- Niv Marom
- Department of Orthopaedic Surgery, Meir Medical Center, Kfar Saba, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hamidreza Jahandar
- Biomechanics Department, Hospital for Special Surgery, New York, New York, USA
| | | | - Zaid A Zayyad
- Biomechanics Department, Hospital for Special Surgery, New York, New York, USA
| | | | - Daniel Hurwit
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Andrew Zhu
- Biomechanics Department, Hospital for Special Surgery, New York, New York, USA
| | - Thomas L Wickiewicz
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Andrew D Pearle
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Carl W Imhauser
- Biomechanics Department, Hospital for Special Surgery, New York, New York, USA
| | - Danyal H Nawabi
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
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Akmese R, Ovali SA, Celebi MM, Malatyali B, Kocaoglu H. A Surgical Algorithm According to Pivot-Shift Grade in Patients With ACL Injury: A Prospective Clinical and Radiological Evaluation. Orthop J Sports Med 2021; 9:23259671211025494. [PMID: 34435069 PMCID: PMC8381438 DOI: 10.1177/23259671211025494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/28/2021] [Indexed: 01/26/2023] Open
Abstract
Background: Some patients have a positive pivot-shift finding and rotational instability
after anterior cruciate ligament (ACL) reconstruction (ACLR). Three major
pathologies known to affect the pivot-shift examination include ACL tear,
anterolateral ligament injury, and loss of posterior lateral meniscus root
function. Purpose: To describe a surgical algorithm determining indications for lateral
extra-articular tenodesis (LET) based on intraoperative pivot-shift
examination to prevent postoperative pivot shift and rotational instability
and to evaluate the 2-year clinical and functional outcomes. Study Design: Case series; Level of evidence, 4. Methods: The study included 47 consecutive patients (39 men and 8 women) who underwent
operative treatment for ACL injury between 2016 and 2017. Pivot-shift
examination was performed under anesthesia, and the pivot shift was graded
as grade 1 (glide), grade 2 (clunk), or grade 3 (gross). According to the
surgical algorithm, single-bundle ACLR was performed in patients with grade
1 pivot shift. In patients with grade 2 with loss of posterior lateral
meniscus root function, concurrent lateral meniscal repair was performed,
and in patients with grade 2 with an intact lateral meniscus posterior root,
concurrent extra-articular iliotibial band tenodesis was performed. Patients
with grade 3 underwent ACLR, lateral meniscal repair, and LET. Clinical and
radiographic evaluations were performed. Results: The mean age was 27.2 years (range, 16-56 years). In total, 26 (55.3%)
patients were evaluated as having pivot-shift grade 1; 16 (34%) patients,
grade 2; and 5 (10.6%) patients, grade 3. A total of 7 (14.9%) patients
underwent LET in addition to ACLR. Two of these patients had pivot-shift
grade 2, and LET was performed since the lateral meniscus posterior root was
intact. In 14 of 16 patients with grade 2, lateral meniscus root disruption
was detected, and lateral meniscal repair was performed. One patient was
excluded from the further follow-up because of graft failure. At a mean
postoperative follow-up of 29 months in 46 patients, the pivot-shift
examination was negative in all patients. The mean Lysholm and International
Knee Documentation Committee subjective scores were 95.35 ± 4.40 and 82.87 ±
9.36, respectively. Radiographic evidence of osteoarthritis was not
detected. Conclusion: Only 14.9% of patients needed LET. With proper ACL, lateral meniscal, and
anterolateral ligament surgery, it was possible to prevent positive
pivot-shift findings postoperatively.
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Affiliation(s)
- Ramazan Akmese
- Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Mehmet Mesut Celebi
- Department of Sports Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Batu Malatyali
- Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hakan Kocaoglu
- Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey
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