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Wierer G, Schroedter R, Hoser C, Milinkovic DD. Trilogy of isolated deep medial collateral ligament injuries of the knee: A set of three cases and overview of the literature. J ISAKOS 2024; 9:100296. [PMID: 39038518 DOI: 10.1016/j.jisako.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 05/21/2024] [Accepted: 07/15/2024] [Indexed: 07/24/2024]
Abstract
The authors present three unique cases of isolated deep medial collateral ligament (dMCL) injuries and comprehensively review the current literature. An isolated dMCL injury is often overlooked in clinical practice, and a consensus on the most adequate treatment is needed. Three male patients were examined at our institution directly following the trauma. The first patient experienced isolated soft-tissue avulsion of the dMCL, the second patient had a bony avulsion from the femoral insertion of the dMCL, and the third patient presented with an isolated "reverse Segond" fracture, which has not previously been described in the literature. All three injuries resulted from a violent external knee joint rotation. The treatment regime included a knee brace for up to 5 weeks and a physical therapy regimen for up to 3 months. All three patients reported satisfactory outcomes regarding restored knee function, absence of symptoms, and early return to activities at the final follow-up. STUDY DESIGN: Case report. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Guido Wierer
- Paracelsus Medical University-Salzburg, Salzburg, Austria; Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | | | - Christian Hoser
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria; GELENKpunkt Sportsclinic, Innsbruck, Austria
| | - Danko Dan Milinkovic
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Germany.
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Borque KA, Han S, Dunbar NJ, Lanfermeijer ND, Sij EW, Gold JE, Ismaily SK, Amis AA, Laughlin MS, Kraeutler MJ, Williams A, Lowe WR, Noble P. Single-Strand "Short Isometric Construct" Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not. Am J Sports Med 2024; 52:968-976. [PMID: 38343203 DOI: 10.1177/03635465231224477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Historical MCL (medial collateral ligament) reconstruction (MCLR) techniques have focused on the superficial MCL (sMCL) to restore valgus stability while frequently ignoring the importance of the deep MCL (dMCL) in controlling tibial external rotation. The recent recognition of the medial ligament complex importance has multiple studies revisiting medial anatomy and questioning contemporary MCLR techniques. PURPOSE To assess whether (1) an isolated sMCL reconstruction (sMCLR), (2) an isolated dMCL reconstruction (dMCLR), or (3) a novel single-strand short isometric construct (SIC) would restore translational and rotational stability to a knee with a dMCL and sMCL injury. STUDY DESIGN Controlled laboratory study. METHODS Biomechanical testing was performed on 14 fresh-frozen cadaveric knee specimens using a custom multiaxial knee activity simulator. The specimens were divided into 2 groups. The first group was tested in 4 states: intact, after sectioning the sMCL and dMCL, isolated sMCLR, and isolated dMCLR. The second group was tested in 3 states: intact, after sectioning the sMCL and dMCL, and after single-strand SIC reconstruction (SICR). In each state, 4 loading conditions were applied at 0°, 20°, 40°, 60°, and 90° of knee flexion: 8-N·m valgus torque, 5-N·m external rotation torque, 90-N anterior drawer, and combined 90-N anterior drawer plus 5-N·m tibial external rotation torque. Anterior translation, valgus rotation, and external rotation of the knee were measured for each state and loading condition using an optical motion capture system. RESULTS sMCL and dMCL transection resulted in increased laxity for all loading conditions at all flexion angles. Isolated dMCLR restored external rotation stability to intact levels throughout all degrees of flexion, yet valgus stability was restored only at 0° of flexion. Isolated sMCLR restored valgus and external rotation stability at 0°, 20°, and 40° of flexion but not at 60° or 90° of flexion. Single-strand SICR restored valgus and external rotation stability at all flexion angles. In the combined anterior drawer plus external rotation test, isolated dMCL and single-strand SICR restored stability to the intact level at all flexion angles, while the isolated sMCL restored stability at 20° and 40° of flexion but not at 60° or 90° of flexion. CONCLUSION In the cadaveric model, single-strand SICR restored valgus and rotational stability throughout the range of motion. dMCLR restored rotational stability to the knee throughout the range of motion but did not restore valgus stability. Isolated sMCLR restored external rotation and valgus stability in early flexion. CLINICAL RELEVANCE In patients with anteromedial rotatory instability in the knee, neither an sMCLR nor a dMCLR is sufficient to restore stability.
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Affiliation(s)
- Kyle A Borque
- Houston Methodist Hospital, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Shuyang Han
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Nicholas J Dunbar
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Nicholas D Lanfermeijer
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Ethan W Sij
- UT McGovern Medical School, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Jonathan E Gold
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Sabir K Ismaily
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Andrew A Amis
- Imperial College London, London, UK
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Mitzi S Laughlin
- Houston Methodist Academic Institute, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Matthew J Kraeutler
- Houston Methodist Hospital, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Andy Williams
- Fortius Clinic, London, UK; FIFA Medical Centre of Excellence, London, UK
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Walter R Lowe
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
| | - Philip Noble
- Department of Orthopedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Investigation performed at the Department of Orthopedic Surgery, UT McGovern Medical School, Houston, Texas, USA
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Cristiani R, van de Bunt F, Kvist J, Stålman A. High Prevalence of Superficial and Deep Medial Collateral Ligament Injuries on Magnetic Resonance Imaging in Patients With Anterior Cruciate Ligament Tears. Arthroscopy 2024; 40:103-110. [PMID: 37353094 DOI: 10.1016/j.arthro.2023.05.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 05/17/2023] [Accepted: 05/26/2023] [Indexed: 06/25/2023]
Abstract
PURPOSE To assess the prevalence of and factors associated with medial collateral ligament (MCL) complex injuries on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) tears. METHODS Data were extracted from the Natural Corollaries and Recovery After ACL Injury (NACOX) multicenter longitudinal cohort study. Between May 2016 and October 2018, patients who presented to 1 of 7 health care clinics across Sweden with an ACL tear sustained no more than 6 weeks earlier and who were aged between 15 and 40 years at the time of injury were invited to participate. All the patients included in this study underwent MRI. The mean time from injury to MRI was 19.6 ± 15.2 days. An orthopaedic surgeon specializing in knee surgery and a musculoskeletal radiologist reviewed all MRI scans. Injuries to the superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament were identified. Stepwise forward multiple binary logistic regression analyses were used to evaluate patient characteristics (age, sex, body mass index, preinjury Tegner activity level, and activity at injury) and injuries on MRI (lateral meniscus [LM] injury, medial meniscus [MM] injury, pivot shift-type bone bruising, medial femoral condyle [MFC] bone bruising, and lateral femoral condyle [LFC] impaction) associated with the presence of MCL complex tears. RESULTS In total, 254 patients (48.4% male patients) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries was 16.5% (42 of 254) and 24.8% (63 of 254), respectively. No isolated sMCL injuries were found. Posterior oblique ligament injuries were found in 12 patients (4.7%) with MCL (sMCL and dMCL) injuries. An LM injury (odds ratio [OR], 3.94; 95% confidence interval [CI], 1.73-8.94; P = .001) and LFC impaction (OR, 2.37; 95% CI, 1.11-5.07; P = .02) increased the odds of having an MCL injury, whereas an MM injury (OR, 0.26; 95% CI, 0.12-0.59; P = .001) reduced the odds. Isolated dMCL injuries were significantly associated with MFC bone bruising (OR, 4.21; 95% CI, 1.92-9.25; P < .001) and LFC impaction (OR, 3.86; 95% CI, 1.99-7.49; P < .001). CONCLUSIONS The overall combined prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries in patients with ACL tears was high (16.5% + 24.8% = 41.3%). The presence of an LM injury and LFC impaction increased the odds of having an MCL injury, whereas the presence of an MM injury reduced the odds. MFC bone bruising and LFC impaction were associated with the presence of isolated dMCL injuries. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Riccardo Cristiani
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden; Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Stockholm, Sweden.
| | | | - Joanna Kvist
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden; Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of Physiotherapy, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anders Stålman
- Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden; Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Stockholm, Sweden
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Tsuda T, Hino K, Kutsuna T, Watamori K, Kinoshita T, Takao M. Difference in implant design affects midflexion rotational laxity in cruciate-retaining total knee arthroplasty: a computer navigation study. J Exp Orthop 2023; 10:85. [PMID: 37605070 PMCID: PMC10441849 DOI: 10.1186/s40634-023-00652-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/04/2023] [Indexed: 08/23/2023] Open
Abstract
PURPOSE This study aimed to compare midflexion rotational laxity between two different design concept models of cruciate-retaining total knee arthroplasty: symmetrical surface design of neutral joint line obliquity and asymmetrical surface design of varus joint line obliquity. METHODS Sixty-three knees that underwent cruciate-retaining total knee arthroplasty were evaluated. Manual maximum passive rotational stress without acceleration was applied to the knees under navigation monitoring. Pre-operative and post-operative internal and external rotational angles were measured at 30°, 45°, 60°, and 90° knee flexion. RESULTS The post-operative internal rotational laxity was significantly increased compared with pre-operative levels at 30°, 45°, 60°, and 90° flexion among all subjects (mean 9.7° vs 11.1°, 10.6° vs 11.6°, 11.2° vs 12.9°, and 13.2° vs 14.9°; p = 0.01, 0.04, 0.001, and 0.008, respectively). The post-operative external rotational laxity was significantly decreased compared to pre-operative levels at 30°, 45°, 60°, and 90° flexion among all subjects (mean 10.8° vs 6.8°, 12.5° vs 9.4°, 12.8° vs 10.0°, and 11.3° vs 9.5°; p < 0.0001, < 0.0001, < 0.0001, and 0.0008, respectively). The post-operative total rotational laxity significantly decreased, compared with pre-operative levels, at 30° and 45° flexion among all subjects (mean 20.4° vs 17.9°, and 23.1° vs 21.1°; p = 0.002 and 0.04, respectively). The post-operative total rotational laxity was significantly smaller in asymmetrically designed total knee arthroplasty than in symmetrically designed total knee arthroplasty at 30°, 45°, and 60° flexion (mean 19.3° vs 15.8°, 22.8° vs 18.7°, and 24.4° vs 20.8°; p = 0.03, 0.03, and 0.02, respectively), whereas no significant difference was observed at 90° flexion. CONCLUSION Compared to symmetrical surface design, asymmetrical surface design resulted in lower rotational laxity at the midflexion range in cruciate-retaining total knee arthroplasty. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Takashi Tsuda
- Department of Bone and Joint Surgery, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
| | - Kazunori Hino
- Department of Joint Reconstruction, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan.
| | - Tatsuhiko Kutsuna
- Department of Bone and Joint Surgery, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
| | - Kunihiko Watamori
- Department of Joint Reconstruction, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
| | - Tomofumi Kinoshita
- Department of Bone and Joint Surgery, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
| | - Masaki Takao
- Department of Bone and Joint Surgery, Ehime University, Graduate School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan
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Von Rehlingen-Prinz F, Leiderer M, Dehoust J, Dust T, Kowald B, Frosch KH, Izadpanah K, Henes FO, Krause M. Association of medial collateral ligament complex injuries with anterior cruciate ligament ruptures based on posterolateral tibial plateau injuries. SPORTS MEDICINE - OPEN 2023; 9:70. [PMID: 37553489 PMCID: PMC10409938 DOI: 10.1186/s40798-023-00611-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/12/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND The combined injury of the medial collateral ligament complex and the anterior cruciate ligament (ACL) is the most common two ligament injury of the knee. Additional injuries to the medial capsuloligamentous structures are associated with rotational instability and a high failure rate of ACL reconstruction. The study aimed to analyze the specific pattern of medial injuries and their associated risk factors, with the goal of enabling early diagnosis and initiating appropriate therapeutic interventions, if necessary. RESULTS Between January 2017 and December 2018, 151 patients with acute ACL ruptures with a mean age of 32 ± 12 years were included in this study. The MRIs performed during the acute phase were analyzed by four independent investigators-two radiologists and two orthopedic surgeons. The trauma impact on the posterolateral tibial plateau and associated injuries to the medial complex (POL, dMCL, and sMCL) were examined and revealed an injury to the medial collateral ligament complex in 34.4% of the patients. The dMCL was the most frequently injured structure (92.2%). A dMCL injury was significantly associated with an increase in trauma severity at the posterolateral tibial plateau (p < 0.02) and additional injuries to the sMCL (OR 4.702, 95% CL 1.3-133.3, p = 0.03) and POL (OR 20.818, 95% CL 5.9-84.4, p < 0.0001). Isolated injuries to the sMCL were not observed. Significant risk factors for acquiring an sMCL injury were age (p < 0.01) and injury to the lateral meniscus (p < 0.01). CONCLUSION In about one-third of acute ACL ruptures the medial collateral ligament complex is also injured. This might be associated with an increased knee laxity as well as anteromedial rotational instability. Also, this might be associated with an increased risk for failure of revision ACL reconstruction. In addition, we show risk factors and predictors that point to an injury of medial structures and facilitate their diagnosis. This should help physicians and surgeons to precisely diagnose and to assess its scope in order to initiate proper therapies. With this in mind, we would like to draw attention to a frequently occurring combination injury, the so-called "unlucky triad" (ACL, MCL, and lateral meniscus). Level of evidence Level III Retrospective cohort study.
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Affiliation(s)
- Fidelius Von Rehlingen-Prinz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Miriam Leiderer
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
| | - Julius Dehoust
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Tobias Dust
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Birgitt Kowald
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Kaywan Izadpanah
- Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Frank Oliver Henes
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20251, Hamburg, Germany
- Department of Diagnostic and Interventional Radiology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Zhang G, Liu M, Fan S, Liu Z, Nie X, Qi X, Yang C. Comparison of the femoral condylar ellipse line and the surgical epicondylar axis: 3D measurement by MRI scans in healthy Chinese people. Orthop Surg 2023. [PMID: 37317056 PMCID: PMC10350392 DOI: 10.1111/os.13770] [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: 11/29/2022] [Revised: 04/28/2023] [Accepted: 04/30/2023] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE The sagittal shapes of the femoral condyles were thought to consist of circles. However, the line connecting the centers of circles was not consistent with the surgical epicondylar axis (SEA) which was commonly used in surgery. Recently, ellipses have been proposed as an alternative method to represent the sagittal femoral condylar shape. Does the condylar ellipse line (CEL) coincide with the SEA in 3D MRI reconstruction analysis? METHODS From May to August 2021, a total of 80 healthy subjects were scanned by MRI on the right knee in this retrospective study. The ellipses on the most distal slices of the medial and lateral condyles were determined. A line connecting the centers of the medial and lateral ellipses was the CEL. A line connecting the deepest point of the medial sulcus and the most prominent point of the lateral epicondyle was the SEA. Angular measurement of the SEA and the CEL relative to the posterior condylar line (PCL) and the distal condylar line (DCL) was performed on an axial and coronal view of the 3D model, respectively. Measurements were compared between males and females by using the independent-samples t-test. Pearson correlation was used to analyze the relationship between SEA-PCL and CEL-PCL, SEA-DCL, and CEL-DCL. RESULTS On the axial view, the mean SEA-CEL was 0.35° ± 0.96°. SEA-PCL (2.91° ± 1.40°) had a high correlation with CEL-PCL (3.27° ± 1.11°) (r = 0.731, p < 0.001). On the coronal view, the mean coronal SEA-CEL was 1.35° ± 1.13°. SEA-DCL (1.35° ± 1.13°) had a low correlation with CEL-DCL (0.18° ± 0.84°) (r = 0.319, p = 0.007). On the sagittal view, the outlet points of the CEL on the medial and lateral epicondyles were anatomically located in the anteroinferior direction to the SEA. CONCLUSIONS CEL traversed the medial and lateral epicondyles, which has a mean deviation of 0.35° with SEA on axial view and a mean deviation of 0.18° with DCL on coronal view. This study suggested that the ellipse approach is an improved scheme for representing the femoral condylar shape.
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Affiliation(s)
- Guanpeng Zhang
- Department of Orthopaedic Surgery Center, The First Hospital of Jilin University, Changchun, China
- Department of Orthopaedic Surgery 3nd, Xuchang Central Hospital, Xuchang, China
| | - Mingyang Liu
- Department of Orthopaedic Surgery Center, The First Hospital of Jilin University, Changchun, China
- Henan Province Intelligent Orthopedic Technology Innovation and Transformation International Joint Laboratory, Henan Key Laboratory for Intelligent Precision Orthopedics, Department of Surgery of Spine and Spinal Cord, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou, China
| | - Shenghu Fan
- Department of Orthopaedic Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Zhaoliang Liu
- Department of Orthopaedic Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Xinlin Nie
- Department of Orthopaedic Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Xin Qi
- Department of Orthopaedic Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Chen Yang
- Department of Orthopaedic Surgery Center, The First Hospital of Jilin University, Changchun, China
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Tzanetis P, Fluit R, de Souza K, Robertson S, Koopman B, Verdonschot N. Pre-Planning the Surgical Target for Optimal Implant Positioning in Robotic-Assisted Total Knee Arthroplasty. Bioengineering (Basel) 2023; 10:543. [PMID: 37237613 PMCID: PMC10215074 DOI: 10.3390/bioengineering10050543] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/19/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Robotic-assisted total knee arthroplasty can attain highly accurate implantation. However, the target for optimal positioning of the components remains debatable. One of the proposed targets is to recreate the functional status of the pre-diseased knee. The aim of this study was to demonstrate the feasibility of reproducing the pre-diseased kinematics and strains of the ligaments and, subsequently, use that information to optimize the position of the femoral and tibial components. For this purpose, we segmented the pre-operative computed tomography of one patient with knee osteoarthritis using an image-based statistical shape model and built a patient-specific musculoskeletal model of the pre-diseased knee. This model was initially implanted with a cruciate-retaining total knee system according to mechanical alignment principles; and an optimization algorithm was then configured seeking the optimal position of the components that minimized the root-mean-square deviation between the pre-diseased and post-operative kinematics and/or ligament strains. With concurrent optimization for kinematics and ligament strains, we managed to reduce the deviations from 2.4 ± 1.4 mm (translations) and 2.7 ± 0.7° (rotations) with mechanical alignment to 1.1 ± 0.5 mm and 1.1 ± 0.6°, and the strains from 6.5% to lower than 3.2% over all the ligaments. These findings confirm that adjusting the implant position from the initial plan allows for a closer match with the pre-diseased biomechanical situation, which can be utilized to optimize the pre-planning of robotic-assisted surgery.
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Affiliation(s)
- Periklis Tzanetis
- Department of Biomechanical Engineering, University of Twente, 7522 LW Enschede, The Netherlands
| | - René Fluit
- Faculty of Science and Engineering, University of Groningen, 9747 AG Groningen, The Netherlands
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | | | | | - Bart Koopman
- Department of Biomechanical Engineering, University of Twente, 7522 LW Enschede, The Netherlands
| | - Nico Verdonschot
- Department of Biomechanical Engineering, University of Twente, 7522 LW Enschede, The Netherlands
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
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Daxhelet J, Bouguennec N, Graveleau N. The Mirror Anterolateral Ligament: A Simple Technique to Reconstruct the Deep Medial Collateral Ligament Using the Gracilis Associated With a Four-Strand Semitendinosus for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2022; 11:e1419-e1424. [PMID: 36061457 PMCID: PMC9437466 DOI: 10.1016/j.eats.2022.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/13/2022] [Indexed: 02/03/2023] Open
Abstract
We present a surgical technique to reconstruct the deep portion of the medial collateral ligament (MCL) when associated with an injury of the anterior cruciate ligament (ACL). Patients could benefit from this procedure in cases of ACL reconstruction and persistent laxity at 20° of flexion of the MCL without any laxity in extension. This surgery uses the gracilis to reconstruct the deep portion of the MCL in the same manner described for the anterolateral ligament on the other side of the knee. The procedure is performed percutaneously, graft and tunnels are independent from the ACL, a screw is used on the femoral side, and a cortical device is used on the tibial side.
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Affiliation(s)
| | - Nicolas Bouguennec
- Address correspondence to Nicolas Bouguennec, Clinique du Sport, 2 rue Nègrevergne, 33700 Mérignac, France.
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Wierer G, Kittl C, Fink C, Weiler A. Medial Collateral Ligament Reconstruction: A Gracilis Tenodesis for Anteromedial Knee Instability. Arthrosc Tech 2022; 11:e1409-e1418. [PMID: 36061473 PMCID: PMC9437470 DOI: 10.1016/j.eats.2022.03.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/13/2022] [Indexed: 02/03/2023] Open
Abstract
The main principle of the present medial collateral ligament reconstruction technique is to address anteromedial knee instability. Therefore, we describe a gracilis tenodesis with 2 functional bundles to reconstruct the deep and superficial medial collateral ligament. The proposed technique may be performed as an isolated or combined procedure with anterior cruciate ligament reconstruction. Valgus instability in extension is a contraindication.
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Affiliation(s)
- Guido Wierer
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Hall, Austria,Address correspondence to Guido Wierer, M.D., Department of Orthopedics and Traumatology, Academic Teaching Hospital, Hall in Tirol, Austria.
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Christian Fink
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Hall, Austria,Gelenkpunkt Innsbruck, Austria
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10
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Helal A, Marie A, El-Forse ES. The "Figure of Four" Reconstruction of the Medial Collateral Ligaments in the Setting of Anteromedial Rotatory Knee Instability Using a Single Autograft. Arthrosc Tech 2022; 11:e1239-e1245. [PMID: 35936844 PMCID: PMC9353192 DOI: 10.1016/j.eats.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/03/2022] [Indexed: 02/03/2023] Open
Abstract
The deep medial collateral ligament plays an important role in controlling tibial external rotation and restrain anterior translation of the medial tibial plateau. Despite being the basic lesion of anteromedial knee instability as proposed by many authors, the majority of the medial side reconstructions do not restore the anatomy and the function of the deep medial collateral ligament. In this Technical Note, we describe a technique to reconstruct both the superficial and deep medial collateral ligament in the setting of anteromedial knee instability using a single peroneus longus autograft.
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Affiliation(s)
- Ahmed Helal
- Address correspondence to Ahmed Helal, M.D., Ph.D., Faculty of Medicine, Tanta University, El-Gash St. Medical Campus-The Faculty of Medicine, Tanta, El-Gharbia Govenorate, Egypt.
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11
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Miyaji N, Holthof SR, Ball SV, Williams A, Amis AA. Medial Collateral Ligament Reconstruction for Anteromedial Instability of the Knee: A Biomechanical Study In Vitro. Am J Sports Med 2022; 50:1823-1831. [PMID: 35511430 PMCID: PMC9160947 DOI: 10.1177/03635465221092118] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/24/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although a medial collateral ligament (MCL) injury is associated with anteromedial rotatory instability (AMRI) and often with an anterior cruciate ligament (ACL) injury, there has been little work to develop anteromedial (AM) reconstruction to address this laxity. PURPOSE To measure the ability of a novel "anatomic" AM reconstruction technique to restore native knee laxity for isolated AM insufficiency and combined AM plus posteromedial insufficiency. STUDY DESIGN Controlled laboratory study. METHODS A total of 12 cadaveric knees were mounted in a kinematic testing rig that allowed the tibia to be loaded while the knee flexed-extended 0° to 100° with 88-N anteroposterior translation, 5-N·m internal rotation-external rotation (ER), 8-N·m valgus, and combined anterior translation plus ER to simulate AMRI. Joint motion was measured using optical trackers with the knee intact, after superficial MCL (sMCL) and deep MCL (dMCL) transection, and after AM reconstruction of the sMCL and dMCL with semitendinosus autografts. The posteromedial capsule (PMC)/posterior oblique ligament (POL) was then transected to induce a grade 3 medial injury, and kinematic measurements were repeated afterward and again after removing the grafts. Laxity changes were examined using repeated-measures analysis of variance and post-testing. RESULTS sMCL and dMCL deficiency increased valgus, ER, and AMRI laxities. These laxities did not differ from native values after AM reconstruction. Additional PMC/POL deficiency did not increase these laxities significantly but did increase internal rotation laxity near knee extension; this was not controlled by AM reconstruction. CONCLUSION AM reconstruction eliminated AMRI after transection of the dMCL and sMCL, and also eliminated AMRI after additional PMC/POL transection. CLINICAL RELEVANCE Many MCL injuries occur in combination with ACL injuries, causing AMRI. These injuries may rupture the AM capsule and dMCL. Unaddressed MCL deficiency leads to an increased ACL reconstruction failure rate. A dMCL construct oriented anterodistally across the medial joint line, along with an sMCL graft, can restore native knee ER laxity. PMC/POL lesions did not contribute to AMRI.
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Affiliation(s)
- Nobuaki Miyaji
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sander R. Holthof
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | | | - Andy Williams
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
- Fortius Clinic, London, UK
| | - Andrew A. Amis
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
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12
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Miyaji N, Holthof SR, Bastos RP, Ball SV, Espregueira-Mendes J, Williams A, Amis AA. A Triple-Strand Anatomic Medial Collateral Ligament Reconstruction Restores Knee Stability More Completely Than a Double-Strand Reconstruction: A Biomechanical Study In Vitro. Am J Sports Med 2022; 50:1832-1842. [PMID: 35503457 PMCID: PMC9160957 DOI: 10.1177/03635465221090612] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are many descriptions of medial collateral ligament (MCL) reconstruction, but they may not reproduce the anatomic structures and there is little evidence of their biomechanical performance. PURPOSE To investigate the ability of "anatomic" MCL reconstruction to restore native stability after grade III MCL plus posteromedial capsule/posterior oblique ligament injuries in vitro. STUDY DESIGN Controlled laboratory study. METHODS Twelve cadaveric knees were mounted in a kinematic testing rig to impose tibial displacing loads while the knee was flexed-extended: 88-N anteroposterior translation, 5-N·m internal-external rotation, 8-N·m valgus-varus, and combined anterior translation plus external rotation (anteromedial rotatory instability). Joint motion was measured via optical trackers with the knee intact; after superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament transection; and then after MCL double- and triple-strand reconstructions. Double strands reproduced the sMCL and posterior oblique ligament and triple-strands the sMCL, dMCL, and posterior oblique ligament. The sMCL was placed 5 mm posterior to the epicondyle in the double-strand technique and at the epicondyle in the triple-strand technique. Kinematic changes were examined by repeated measures 2-way analysis of variance with posttesting. RESULTS Transection of the sMCL, dMCL, and posterior oblique ligament increased valgus rotation (5° mean) and external rotation (9° mean). The double-strand reconstruction controlled valgus in extension but allowed 5° excess valgus in flexion and did not restore external rotation (7° excess). The triple-strand reconstruction restored both external rotation and valgus throughout flexion. CONCLUSION In a cadaveric model, a triple-strand reconstruction including a dMCL graft restored native external rotation, while a double-strand reconstruction without a dMCL graft did not. A reconstruction with the sMCL graft placed isometrically on the medial epicondyle restored valgus rotation across the arc of knee flexion, whereas a reconstruction with a more posteriorly placed sMCL graft slackened with knee flexion. CLINICAL RELEVANCE An MCL injury may rupture the anteromedial capsule and dMCL, causing anteromedial rotatory instability. Persistent MCL instability increases the likelihood of ACL graft failure after combined injury. A reconstruction with an anteromedial dMCL graft restored native external rotation, which may help to unload/protect an ACL graft. It is important to locate the sMCL graft isometrically at the femoral epicondyle to restore valgus across flexion.
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Affiliation(s)
- Nobuaki Miyaji
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK,Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Sander R. Holthof
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
| | - Ricardo P.S. Bastos
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK,Clínica do Dragão–Espregueira-Mendes Sports Centre, Porto, Portugal
| | | | | | - Andy Williams
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK,Fortius Clinic, London, UK
| | - Andrew A. Amis
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK,Andrew A. Amis, FREng, DSc(Eng), Biomechanics Group, Mechanical Engineering Department, Imperial College London, London SW7 2AZ, UK ()
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The post-traumatic meniscal extrusion, sign of meniscotibial ligament injury. A case series. Orthop Traumatol Surg Res 2022; 108:103226. [PMID: 35123034 DOI: 10.1016/j.otsr.2022.103226] [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: 04/29/2021] [Revised: 11/03/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Medial meniscal extrusion (ME) has been found to be associated to anterior cruciate ligament (ACL) injury. Post-traumatic extrusion is mainly attributed to meniscotibial ligament (MTL) tear. The aim of this retrospective study was to assess the incidence of MTL tear associated with meniscal extrusion, evaluate arthroscopic findings and the associated clinical findings. HYPOTHESIS The medial meniscal extrusion, when associated to ACL injury, is related to a tear of the MTL. PATIENTS AND METHODS Patients who underwent to primary or revision ACL reconstruction with associated medial meniscal rise and/or meniscotibial tear or insufficiency were retrospectively identified over a 5-year period (from 2015 to 2019). Twenty-four patients were included in this study with preoperative magnetic resonance imaging (MRI) carried out at our institution Each MRI was evaluated by the senior author for the presence of meniscal extrusion and also for the additional pathology of meniscotibial ligament. Patient medical records were reviewed to obtain demographic information, including age, gender, and arthrometric evaluation of anteroposterior laxity. RESULTS All included patients underwent arthroscopic ACL reconstruction using autograft tissue, (19 primary and in 5 revision ACL reconstruction). The mean age was 31.2 years (range: 15-57; SD: 12.3 years) at the time of surgery. ME was identified at MRI in all cases preoperatively and confirmed arthroscopically. No correlation was found between meniscal extrusion and anteroposterior translation (ρ=-0.270; p=0.202). Neither between having more than 3mm of extrusion and gender (χ2=0.80; p=0.371), acute/chronic lesion (χ2=0.91; p=0.341) and primary/revision reconstructions (χ2=0.83; p=0.364). In the last three patients, arthroscopic treatment of meniscal extrusion was carried out through outside-in repair of medial meniscus at its capsular junction. Reduction of meniscal extrusion has been verified by MRI, performed at 3-month follow-up. DISCUSSION A high prevalence of ME was found at MRI in patients with ACL injury and MTL tear. Therefore, ME may be associated to acute or chronic ligamentous injury involving the MTL, and its tear can be considered as the main determinant of extrusion. Further research is needed to increase evidence concerning MTL incidence and surgical outcomes. LEVEL OF EVIDENCE IV, retrospective case series.
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14
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The association of bone bruising and grade of MCL injury in patients sustaining isolated MCL injuries. Skeletal Radiol 2022; 51:1073-1080. [PMID: 34628510 DOI: 10.1007/s00256-021-03932-3] [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: 07/20/2021] [Revised: 09/15/2021] [Accepted: 10/03/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate the incidence of bone bruising with isolated medial collateral ligament injury and to assess whether the presence of bone bruising is related to the injury grade. MATERIALS AND METHODS Patients who sustained an acute isolated medial collateral ligament injury demonstrated on knee MRI between 2016 and 2020 were included in this study. Patient's characteristics and injury classification (clinical and radiological) were reviewed from clinical notes and imaging. The patients were divided into two groups, based on the presence of bone bruising. Fisher's exact test was used for dichotomous variables and odds ratios were computed in areas of clinical significance. RESULTS Sixty patients with a median age of 37.6 ± 13.8 were included. Twenty-eight (46.7%) had bone bruising demonstrated on MRI scan. The bone bruising group were 7 times (95% CI [1.4;36.5]) more likely to have a complete disruption of the superficial medial collateral ligament and MRI grade III injury. Injury to the deep medial collateral ligament was more often observed in this group (p < 0.05). The most common location of bone bruising was the lateral femoral condyle (57.1%, 16/28) and/or the medial femoral condyle (57.1%, 16/28). CONCLUSIONS The incidence of bone bruising with isolated medial collateral ligament injury is significant and is more common with radiologically higher grade injuries. There was no statistically significant difference between the anatomical location of bone bruise and the grade of MCL injury. Bone bruising patterns can help determine the mechanism of injury, with a valgus impact or avulsion type injury most commonly seen.
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15
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Abermann E, Wierer G, Herbort M, Smigielski R, Fink C. MCL Reconstruction Using a Flat Tendon Graft for Anteromedial and Posteromedial Instability. Arthrosc Tech 2022; 11:e291-e300. [PMID: 35256966 PMCID: PMC8897492 DOI: 10.1016/j.eats.2021.10.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/26/2021] [Indexed: 02/03/2023] Open
Abstract
The main principles of the present medial collateral ligament (MCL) reconstruction techniques are (1) to approximate the natural anatomy and (2) to restore the main passive restraining structures in anteromedial and posteromedial knee instability. Therefore, we describe a technique using a flat tendon graft instead of tubular grafts with point-to-point bone fixation. Moreover, we address the deep MCL, a relevant restraint to anteromedial instability.
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Affiliation(s)
- Elisabeth Abermann
- Gelenkpunkt Innsbruck, Austria,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria
| | - Guido Wierer
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria,LKH Hall in Tirol, Hall, Austria
| | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria,OCM Clinic, Munich, Germany
| | | | - Christian Fink
- Gelenkpunkt Innsbruck, Austria,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria,Address correspondence to Christian Fink, M.D., Gelenkpunkt – Sports and Joint Surgery Innsbruck, Olympiastraße 39, 6020 Innsbruck, Austria.
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16
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Willinger L, Balendra G, Pai V, Lee J, Mitchell A, Jones M, Williams A. High incidence of superficial and deep medial collateral ligament injuries in 'isolated' anterior cruciate ligament ruptures: a long overlooked injury. Knee Surg Sports Traumatol Arthrosc 2022; 30:167-175. [PMID: 33661325 PMCID: PMC8800884 DOI: 10.1007/s00167-021-06514-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/19/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE In anterior cruciate ligament (ACL) injuries, concomitant damage to peripheral soft tissues is associated with increased rotatory instability of the knee. The purpose of this study was to investigate the incidence and patterns of medial collateral ligament complex injuries in patients with clinically 'isolated' ACL ruptures. METHODS Patients who underwent ACL reconstruction for complete 'presumed isolated' ACL rupture between 2015 and 2019 were retrospectively included in this study. Patient's characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the grade and location of injuries to the superficial MCL (sMCL), dMCL and the posterior oblique ligament (POL) recorded. All patients were clinically assessed under anaesthesia with standard ligament laxity tests. RESULTS Hundred patients with a mean age of 22.3 ± 4.9 years were included. The incidence of concomitant MCL complex injuries was 67%. sMCL injuries occurred in 62%, dMCL in 31% and POL in 11% with various injury patterns. A dMCL injury was significantly associated with MRI grade II sMCL injuries, medial meniscus 'ramp' lesions seen at surgery and bone oedema at the medial femoral condyle (MFC) adjacent to the dMCL attachment site (p < 0.01). Logistic regression analysis identified younger age (OR 1.2, p < 0.05), simultaneous sMCL injury (OR 6.75, p < 0.01) and the presence of bone oedema at the MFC adjacent to the dMCL attachment site (OR 5.54, p < 0.01) as predictive factors for a dMCL injury. CONCLUSION The incidence of combined ACL and medial ligament complex injuries is high. Lesions of the dMCL were associated with ramp lesions, MFC bone oedema close to the dMCL attachment, and sMCL injury. Missed AMRI is a risk factor for ACL graft failure from overload and, hence, oedema in the MCL (especially dMCL) demands careful assessment for AMRI, even in the knee lacking excess valgus laxity. This study provides information about specific MCL injury patterns including the dMCL in ACL ruptures and will allow surgeons to initiate individualised treatment. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lukas Willinger
- Department of Trauma and Orthopaedics, Chelsea and Westminster Hospital, Chelsea and Westminster NHS Foundation Trust, London, UK ,Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | | | - Vishal Pai
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Justin Lee
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Adam Mitchell
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Mary Jones
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ UK
| | - Andy Williams
- Fortius Clinic, 17 Fitzhardinge St, London, W1H 6EQ, UK.
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17
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Semimembranosus Tendon Advancement for the Anteromedial Knee Rotatory Instability Treatment. Arthrosc Tech 2021; 10:e2789-e2795. [PMID: 35004162 PMCID: PMC8719225 DOI: 10.1016/j.eats.2021.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/14/2021] [Indexed: 02/03/2023] Open
Abstract
Injury to the medial compartment of the knee is the most common ligament injury to this joint. The medial approach must consider the presence of associated anteromedial instability. Untreated injury of these instabilities can result in failure of the other reconstructed ligaments. As treatment is usually associated with other ligaments, it is relevant that the technique could save grafts and synthetic material. This article aims to describe a technique for the treatment of anteromedial instabilities through semimembranosus tendon tenodesis in a more anterior and distal position, promoting the tensioning of the posteromedial structures.
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18
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Hinz M, Imhoff AB, Schmitt A. [Update on the Operative Treatment of Cartilage Defects]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021; 159:459-475. [PMID: 33975378 DOI: 10.1055/a-1302-8636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Focal cartilage defects lead to swelling, significant pain and loss of function of the affected joint. Additionally, they are linked to early onset of osteoarthritis. Often young and active patients are especially susceptible due to the high stress placed on their joints. A vast amount of treatment options is available to orthopaedic surgeons to cure cartilage defects of the knee, hip, shoulder, elbow and ankle joints. This article serves to give an overview of these available treatment options and to explain the expected outcomes.
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19
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Isolierte Verletzung des tiefen Innenbands am Kniegelenk. ARTHROSKOPIE 2021. [DOI: 10.1007/s00142-020-00430-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ZusammenfassungIsolierte Rupturen des tiefen Innenbands am Kniegelenk (dMCL) werden meist im chronischen Stadium bzw. in Zusammenhang mit einer Verletzung des oberflächlichen Innenbands beschrieben. In diesem Beitrag wird über den Fall eines 15-jährigen Patienten berichtet, welcher sich nach einem Außenrotationstrauma des Kniegelenks in der Notaufnahme vorstellte. Die weiterführende Diagnostik zeigte eine isolierte Läsion des tiefen Innenbands. Erstmaßnahmen erfolgten mit Schonung, Hochlagerung, Salbenverbänden, oraler Schmerztherapie und einer Knieorthese. Fünf Wochen nach dem initialen Trauma war der Patient beschwerdefrei. Anhand der aktuellen Literatur wird ein Therapieschema der akuten bis chronischen Läsion des dMCL diskutiert.
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20
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Wierer G, Milinkovic D, Robinson JR, Raschke MJ, Weiler A, Fink C, Herbort M, Kittl C. The superficial medial collateral ligament is the major restraint to anteromedial instability of the knee. Knee Surg Sports Traumatol Arthrosc 2021; 29:405-416. [PMID: 32277264 DOI: 10.1007/s00167-020-05947-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 03/19/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE The purpose of the present study was to determine how the medial structures and ACL contribute to restraining anteromedial instability of the knee. METHODS Twenty-eight paired, fresh-frozen human cadaveric knees were tested in a six-degree of freedom robotic setup. After sequentially cutting the dMCL, sMCL, POL and ACL in four different cutting orders, the following simulated clinical laxity tests were applied at 0°, 30°, 60° and 90° of knee flexion: 4 Nm external tibial rotation (ER), 4 Nm internal tibial rotation (IR), 8 Nm valgus rotation (VR) and anteromedial rotation (AMR)-combined 89 N anterior tibial translation and 4 Nm ER. Knee kinematics were recorded in the intact state and after each cut using an optical tracking system. Differences in medial compartment translation (AMT) and tibial rotation (AMR, ER, IR, VR) from the intact state were then analyzed. RESULTS The sMCL was the most important restraint to AMR, ER and VR at all flexion angles. Release of the proximal tibial attachment of the sMCL caused no significant increase in laxity if the distal sMCL attachment remained intact. The dMCL was a minor restraint to AMT and ER. The POL controlled IR and was a minor restraint to AMT and ER near extension. The ACL contributed with the sMCL in restraining AMT and was a secondary restraint to ER and VR in the MCL deficient knee. CONCLUSION The sMCL appears to be the most important restraint to anteromedial instability; the dMCL and POL play more minor roles. Based on the present data a new classification of anteromedial instability is proposed, which may support clinical examination and treatment decision. In higher grades of anteromedial instability an injury to the sMCL should be suspected and addressed if treated surgically.
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Affiliation(s)
- Guido Wierer
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria. .,Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), ISAG, UMIT Hall, Hall in Tirol, Austria.
| | - Danko Milinkovic
- Department of Orthopedic and Trauma surgery, Arcus Sportclinic, Pforzheim, Germany
| | | | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | | | - Christian Fink
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), ISAG, UMIT Hall, Hall in Tirol, Austria.,Gelenkpunkt - Sports and Joint Surgery, Innsbruck, Austria
| | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), ISAG, UMIT Hall, Hall in Tirol, Austria.,OCM Clinic, Munich, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
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21
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Athwal KK, Willinger L, Manning W, Deehan D, Amis AA. A constrained-condylar fixed-bearing total knee arthroplasty is stabilised by the medial soft tissues. Knee Surg Sports Traumatol Arthrosc 2021; 29:659-667. [PMID: 32322947 PMCID: PMC7892729 DOI: 10.1007/s00167-020-05995-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/10/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE Revision constrained-condylar total knee arthroplasty (CCK-TKA) is often used to provide additional mechanical constraint after failure of a primary TKA. However, it is unknown how much this translates to a reliance on soft-tissue support. The aim of this study was therefore to compare the laxity of a native knee to the CCK-TKA implanted state and quantify how medial soft-tissues stabilise the knee following CCK-TKA. METHODS Ten intact cadaveric knees were tested in a robotic system at 0°, 30°, 60° and 90° flexion with ± 90 N anterior-posterior force, ± 8 Nm varus-valgus and ± 5 Nm internal-external torques. A fixed-bearing CCK-TKA was implanted and the laxity tests were repeated with the soft tissues intact and after sequential cutting. The deep and superficial medial collateral ligaments (dMCL, sMCL) and posteromedial capsule (PMC) were sequentially transected and the percentage contributions of each structure to restraining the applied loads were calculated. RESULTS Implanting a CCK-TKA did not alter anterior-posterior laxity from that of the original native knee, but it significantly decreased internal-external and varus-valgus rotational laxity (p < 0.05). Post CCK-TKA, the sMCL restrained 34% of the tibial displacing load in anterior drawer, 16% in internal rotation, 17% in external rotation and 53% in valgus, across the flexion angles tested. The dMCL restrained 11% of the valgus rotation moment. CONCLUSIONS With a fully-competent sMCL in-vitro, a fixed-bearing CCK-TKA knee provided more rotational constraint than the native knee. The robotic test data showed that both the soft-tissues and the semi-constrained implant restrained rotational knee laxity. Therefore, in clinical practice, a fixed-bearing CCK-TKA knee could be indicated for use in a knee with lax, less-competent medial soft tissues. LEVEL OF EVIDENCE Controlled laboratory study.
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Affiliation(s)
- Kiron K Athwal
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK
| | - Lukas Willinger
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK
| | - William Manning
- Department of Orthopaedic Surgery, Newcastle Freeman University Hospital, Newcastle, UK
| | - David Deehan
- Department of Orthopaedic Surgery, Newcastle Freeman University Hospital, Newcastle, UK
| | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK.
- Musculoskeletal Surgery Group, Department of Surgery and Cancer, Imperial College London School of Medicine, London, UK.
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22
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Inagawa M, Sanada T, Iwaso H. Deep MCL injury cases with arthroscopic findings of hypermobile medial meniscus: A report of six cases of arthroscopic meniscal suture repair. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2020; 22:1-4. [PMID: 32551231 PMCID: PMC7289751 DOI: 10.1016/j.asmart.2020.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/13/2020] [Accepted: 05/25/2020] [Indexed: 10/31/2022]
Abstract
MRI did not detect any abnormality in the medial meniscus besides high-intensity changes at the meniscofemoral portion of the deep medial collateral ligament. Although pure valgus stress test proved no medial joint widening at 0° and 30°, when an examiner applied knee valgus and tibial external rotation force, the patient experienced pain in the anteromedial knee joint that coincided with their refractory symptoms in individual specific activity. Arthroscopy investigation confirmed that the anterior to middle segment of the medial meniscus had excessively slid into the central direction by a probe-drawing manoeuvre; synchronous meniscal movement in the valgus and external rotation test was also observed. After arthroscopic meniscal suture to the lesion had suppressed the abnormal meniscal movement, the patients' refractory anteromedial symptoms disappeared immediately. From their common history of medial collateral injury and the high intensity at the deep medial collateral ligament, we assumed that chronic deep medial collateral ligament impairment sustained the hypermobility of the medial meniscus. Arthroscopic confirmation of hypermobility led to definitive treatment of a simple meniscal suture. Painful deep MCL injuries with hypermobile medial arthroscopic findings are not a rare phenomenon as previously assumed; however, surgeons often fail to recognize its latent clinical features.
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Affiliation(s)
- Miyu Inagawa
- Corresponding author. 1-1Kizuki Sumiyoshi-cho, Nakahara-ku, Kawasaki city, Kanagawa-pref, Japan. TEL:+81-044-411-3131; FAX:+81-044-433-3150
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Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery. Knee Surg Sports Traumatol Arthrosc 2020; 28:3720-3732. [PMID: 32483671 PMCID: PMC7669796 DOI: 10.1007/s00167-020-06050-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/30/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE To define the length-change patterns of the superficial medial collateral ligament (sMCL), deep MCL (dMCL), and posterior oblique ligament (POL) across knee flexion and with applied anterior and rotational loads, and to relate these findings to their functions in knee stability and to surgical repair or reconstruction. METHODS Ten cadaveric knees were mounted in a kinematics rig with loaded quadriceps, ITB, and hamstrings. Length changes of the anterior and posterior fibres of the sMCL, dMCL, and POL were recorded from 0° to 100° flexion by use of a linear displacement transducer and normalised to lengths at 0° flexion. Measurements were repeated with no external load, 90 N anterior draw force, and 5 Nm internal and 5 Nm external rotation torque applied. RESULTS The anterior sMCL lengthened with flexion (p < 0.01) and further lengthened by external rotation (p < 0.001). The posterior sMCL slackened with flexion (p < 0.001), but was lengthened by internal rotation (p < 0.05). External rotation lengthened the anterior dMCL fibres by 10% throughout flexion (p < 0.001). sMCL release allowed the dMCL to become taut with valgus rotation (p < 0.001). The anterior and posterior POL fibres slackened with flexion (p < 0.001), but were elongated by internal rotation (p < 0.001). CONCLUSION The structures of the medial ligament complex react differently to knee flexion and applied loads. Structures attaching posterior to the medial epicondyle are taut in extension, whereas the anterior sMCL, attaching anterior to the epicondyle, is tensioned during flexion. The anterior dMCL is elongated by external rotation. These data offer the basis for MCL repair and reconstruction techniques regarding graft positioning and tensioning.
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The bone attachments of the medial collateral and posterior oblique ligaments are defined anatomically and radiographically. Knee Surg Sports Traumatol Arthrosc 2020; 28:3709-3719. [PMID: 32737529 PMCID: PMC7669814 DOI: 10.1007/s00167-020-06139-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/26/2020] [Indexed: 10/31/2022]
Abstract
PURPOSE To define the bony attachments of the medial ligaments relative to anatomical and radiographic bony landmarks, providing information for medial collateral ligament (MCL) surgery. METHOD The femoral and tibial attachments of the superficial MCL (sMCL), deep MCL (dMCL) and posterior oblique ligament (POL), plus the medial epicondyle (ME) were defined by radiopaque staples in 22 knees. These were measured radiographically and optically; the precision was calculated and data normalised to the sizes of the condyles. Femoral locations were referenced to the ME and to Blumensaat's line and the posterior cortex. RESULTS The femoral sMCL attachment enveloped the ME, centred 1 mm proximal to it, at 37 ± 2 mm (normalised at 53 ± 2%) posterior to the most-anterior condyle border. The femoral dMCL attachment was 6 mm (8%) distal and 5 mm (7%) posterior to the ME. The femoral POL attachment was 4 mm (5%) proximal and 11 mm (15%) posterior to the ME. The tibial sMCL attachment spread from 42 to 71 mm (81-137% of A-P plateau width) below the tibial plateau. The dMCL fanned out anterodistally to a wide tibial attachment 8 mm below the plateau and between 17 and 39 mm (33-76%) A-P. The POL attached 5 mm below the plateau, posterior to the dMCL. The 95% CI intra-observer was ± 0.6 mm, inter-observer ± 1.3 mm for digitisation. The inter-observer ICC for radiographs was 0.922. CONCLUSION The bone attachments of the medial knee ligaments are located in relation to knee dimensions and osseous landmarks. These data facilitate repairs and reconstructions that can restore physiological laxity and stability patterns across the arc of knee flexion.
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Kim MS, Koh IJ, In Y. Superficial and Deep Medial Collateral Ligament Reconstruction for Chronic Medial Instability of the Knee. Arthrosc Tech 2019; 8:e549-e554. [PMID: 31334009 PMCID: PMC6620564 DOI: 10.1016/j.eats.2019.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/28/2019] [Indexed: 02/03/2023] Open
Abstract
There are several surgical techniques for medial collateral ligament reconstruction, including anatomic or nonanatomic medial knee reconstruction. Although the medial collateral ligament consists of the superficial medial collateral ligament (sMCL) and deep medial collateral ligament (dMCL), surgical procedures have only been described for reconstruction of the sMCL alone or reconstruction of the sMCL and posterior oblique ligament. The dMCL assists the knee in rotational stability, primarily in extension, moving into early flexion. We describe sMCL and dMCL reconstruction with semitendinosus and gracilis autografts using adjustable-length loop suspensory fixation devices for tibial fixation. By use of our technique, it is possible to provide good stability and satisfactory results for medial instability of the knee.
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Affiliation(s)
- Man Soo Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Jun Koh
- Department of Orthopaedic Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong In
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea,Address correspondence to Yong In, M.D., Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, Seocho-Gu, Seoul 06591, Republic of Korea.
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Knorpel-Knochen-Defekte als Symptom. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-0278-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sirisena D, Papi E, Tillett E. Clinical assessment of antero-medial rotational knee laxity: a systematic review. Knee Surg Sports Traumatol Arthrosc 2017; 25:1068-1077. [PMID: 27787588 DOI: 10.1007/s00167-016-4362-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 10/13/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE To inventory the examination methods available to assess antero-medial rotational laxity (AMRL) of the knee following medial collateral ligament injury. METHODS Searches were conducted in accordance with the PRISMA guidelines and using four online databases: WEB OF SCIENCE, MEDLINE, EMBASE, and AMED. The Critical Appraisal Skills Programme guidelines for Diagnostic Test Studies were used for the quality assessment of the articles. RESULTS A total of 2241 articles were identified from the database searches. From this, four articles were included in the final review. All were case-control studies, considered a combined ACL/MCL injury and had small study populations. Specialised equipment was required in all studies, and one needed additional imaging support before measurements could be taken. Two employed commercially available measuring equipment as part of the assessment process. CONCLUSION Clinical assessment of AMRL in relation to a MCL injury remains challenging. Although methods have been developed to support clinical examination, they are limited by a number of factors, including the need for additional time in the clinical environment when setting up equipment, the need for specific equipment to produce and measure rotational movement and imaging support. In addition, there are patient safety concerns from the repeated imaging. A reliable and valid clinical examination remains to be found to truly assess antero-medial rotational laxity of the knee. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Dinesh Sirisena
- Institute for Sport, Exercise and Health, University College London, London, UK. .,Khoo Teck Puat Hospital, 90 Yishun Central, Yishun, 768828, Singapore.
| | - Enrica Papi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Eleanor Tillett
- Institute for Sport, Exercise and Health, University College London, London, UK
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Guess TM, Razu S. Loading of the medial meniscus in the ACL deficient knee: A multibody computational study. Med Eng Phys 2017; 41:26-34. [PMID: 28089224 PMCID: PMC5316296 DOI: 10.1016/j.medengphy.2016.12.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 08/25/2016] [Accepted: 12/21/2016] [Indexed: 11/26/2022]
Abstract
The menisci of the knee reduce tibiofemoral contact pressures and aid in knee lubrication and nourishment. Meniscal injury occurs in half of knees sustaining anterior cruciate ligament injury and the vast majority of tears in the medial meniscus transpire in the posterior horn region. In this study, computational multibody models of the knee were derived from medical images and passive leg motion for two female subjects. The models were validated against experimental measures available in the literature and then used to evaluate medial meniscus contact force and internal hoop tension. The models predicted that the loss of anterior cruciate ligament (ACL) constraint increased contact and hoop forces in the medial menisci by a factor of 4 when a 100N anterior tibial force was applied. Contact forces were concentrated in the posterior horn and hoop forces were also greater in this region. No differences were found in contact or hoop tension between the intact and ACL deficient (ACLd) knees when only a 5Nm external tibial torque was applied about the long axis of the tibia. Combining a 100N anterior tibial force and a 5Nm external tibial torque increased posterior horn contact and hoop forces, even in the intact knee. The results of this study show that the posterior horn region of the medial meniscus experiences higher contact forces and hoop tension, making this region more susceptible to injury, especially with the loss of anterior tibia motion constraint provided by the ACL. The contribution of the dMCL in constraining posterior medial meniscus motion, at the cost of higher posterior horn hoop tension, is also demonstrated.
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Affiliation(s)
- Trent M Guess
- University of Missouri, Department of Physical Therapy, Department of Orthopaedic Surgery, 801 Clark Hall, Columbia, MO 65211-4250, United States .
| | - Swithin Razu
- University of Missouri, Department of Physical Therapy, Department of Orthopaedic Surgery, 801 Clark Hall, Columbia, MO 65211-4250, United States
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Wytrykowski K, Swider P, Reina N, Murgier J, Laffosse JM, Chiron P, Cavaignac E. Cadaveric Study Comparing the Biomechanical Properties of Grafts Used for Knee Anterolateral Ligament Reconstruction. Arthroscopy 2016; 32:2288-2294. [PMID: 27161509 DOI: 10.1016/j.arthro.2016.03.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/02/2016] [Accepted: 03/02/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To measure the biomechanical properties (maximum load, stiffness, and elongation) of the anterolateral ligament (ALL), gracilis, and iliotibial band (ITB) within the same subject. METHODS Thirteen unpaired knees were used (7 women, 6 men). The donors had a mean age at death of 54 years (range: 37 to 70 years). The mechanical properties of two types of ALL grafts were evaluated: ITB and two-strand gracilis. The mechanical properties of ALL were also measured. Validated methods were used to perform the tensile tests to failure and to record the results. Student's t-test was used to compare the various samples. RESULTS The maximum load to failure was 141 N (±40.6) for the ALL, 200.7 N (±48.7) for the gracilis, and 161.1 N (±27.1) for the ITB. Only the gracilis had a significantly higher failure load than ITB and ALL (P = .001 and P = .03). The stiffness was 21 N mm-1 (±8.2) for the ALL, 131.7 N mm-1 (±43.7) for the gracilis, and 39.9 N mm-1 (±6) for the ITB. The elongation at failure was 6.2 mm (±3.2) for the ALL, 19.9 mm (±6.5) for the gracilis, and 20.8 mm (±14.7) for the ITB. CONCLUSIONS The gracilis had the highest maximum load to failure. The ITB's mechanical properties most closely resemble those of the ALL. CLINICAL RELEVANCE The biomechanical properties of each potential ALL graft can be factored in when deciding which type of graft to use.
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Affiliation(s)
- Karine Wytrykowski
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Pascal Swider
- Laboratoire de Biomécanique, Université Paul Sabatier, Toulouse, France
| | - Nicolas Reina
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Jérôme Murgier
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Jean Michel Laffosse
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France; Laboratoire de Biomécanique, Université Paul Sabatier, Toulouse, France
| | - Philippe Chiron
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France
| | - Etienne Cavaignac
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital P.P.R., Toulouse, France.
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Herbst E, Naendrup JH, Pfeiffer T, Debski RE, Musahl V. Neue App zur Quantifizierung des Pivot-shift-Tests. ARTHROSKOPIE 2016. [DOI: 10.1007/s00142-016-0096-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rahnemai-Azar AA, Naendrup JH, Soni A, Olsen A, Zlotnicki J, Musahl V. Knee instability scores for ACL reconstruction. Curr Rev Musculoskelet Med 2016; 9:170-7. [PMID: 26980119 PMCID: PMC4896882 DOI: 10.1007/s12178-016-9339-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Despite abundant biological, biomechanical, and clinical research, return to sport after anterior cruciate ligament (ACL) injury remains a significant challenge. Residual rotatory knee laxity has been identified as one of the factors responsible for poor functional outcome. To improve and standardize the assessment of knee instability, a variety of instability scoring systems is available. Recently, devices to objectively quantify static and dynamic clinical exams have been developed to complement traditional subjective grading systems. These devices enable an improved evaluation of knee instability and possible associated injuries. This additional information may promote the development of new treatment algorithms and allow for individualized treatment. In this review, the different subjective laxity scores as well as complementary objective measuring systems are discussed, along with an introduction of injury to an individualized treatment algorithm.
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Affiliation(s)
- Ata A Rahnemai-Azar
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Orthopaedic Robotics Laboratory, Center for Bioengineering, University of Pittsburgh, 300 Technology Drive, Pittsburgh, PA, 15219, USA
| | - Jan-Hendrik Naendrup
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Orthopaedic Robotics Laboratory, Center for Bioengineering, University of Pittsburgh, 300 Technology Drive, Pittsburgh, PA, 15219, USA
| | - Ashish Soni
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Adam Olsen
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Jason Zlotnicki
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Orthopaedic Robotics Laboratory, Center for Bioengineering, University of Pittsburgh, 300 Technology Drive, Pittsburgh, PA, 15219, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
- Orthopaedic Robotics Laboratory, Center for Bioengineering, University of Pittsburgh, 300 Technology Drive, Pittsburgh, PA, 15219, USA.
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Residual rotatory laxity after anterior cruciate ligament reconstruction: how do we diagnose it and prevent it? CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000373] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Navigation-based femorotibial rotation pattern correlated with flexion angle after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2016; 24:89-95. [PMID: 25261225 DOI: 10.1007/s00167-014-3340-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 09/17/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate whether intraoperative kinematics obtained by navigation systems can be divided into several kinematic patterns and to assess the correlation between the intraoperative kinematics with maximum flexion angles before and after total knee arthroplasty (TKA). METHOD Fifty-four posterior-stabilised (PS) TKA implanted using an image-free navigation system were evaluated. At registration and after implantation, tibial internal rotation angles at maximum extension, 30°, 45°, 60°, 90°, and maximum flexion were collected. The rotational patterns were divided into four groups and were examined the correlation with maximum flexion before and after operation. RESULTS Tibial internal rotation from 90° of flexion to maximum flexion at registration was correlated with maximum flexion angles pre- and postoperatively. The four groups showed statistically different kinematic patterns. The group with tibial external rotation up to 90° of flexion, following tibial internal rotation at registration, achieved better flexion angles, compared to those of another groups (126.7° ± 12.0°, p < 0.05). The group with tibial external rotation showed the worst flexion angles (80.0° ± 40.4°, p < 0.05). Furthermore, the group with limited extension showed worse flexion angles (111.6° ± 8.9°, p < 0.05). CONCLUSION Navigation-based kinematic patterns found at registration predict postoperative maximum flexion angle in PS TKA. Navigation-based kinematics can be useful information during TKA surgery. LEVEL OF EVIDENCE Diagnostic studies, development of diagnostic criteria in a consecutive series of patients and a universally applied "gold" standard, Level II.
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Factors affecting intraoperative kinematic patterns and flexion angles in navigated total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015; 23:1741-7. [PMID: 25763851 DOI: 10.1007/s00167-015-3572-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To investigate the factors affecting intraoperative kinematics, as measured with a navigation system, and their effect on maximum flexion angles during total knee arthroplasty (TKA). METHOD One hundred posterior stabilised (PS) TKAs performed using an image-free navigation system were evaluated. Tibial internal rotation angles at maximum extension, 30°, 45°, 60°, 90°, and maximum flexion were collected at registration and after implantation. The varus angles from the coronal mechanical axis were also collected. The rotational patterns were divided into four groups to investigate whether flexion contracture and varus deformity affected the kinematic patterns, and correlated with the maximum pre- and post-operative flexion angles. RESULTS At registration, the flexion angles at maximum extension differed significantly between the kinematic groups; the flexion angle at maximum extension at registration was negatively correlated with the pre-operative maximum flexion angle (R(2) = 0.226, p < 0.0001) and the post-operative maximum flexion angle (R(2) = 0.059, p = 0.0167). Varus deformity at registration also differed significantly between the kinematic groups; varus deformity at registration was negatively correlated with the pre-operative maximum flexion angle (R(2) = 0.087, p = 0.0036) and post-operative maximum flexion angle (R(2) = 0.101, p = 0.0027). CONCLUSION Navigation-based measurements in patients undergoing PS TKA indicated that pre-operative flexion contracture and varus deformity are negatively correlated with both pre- and post-operative maximum flexion angles. The results may improve the ease with which surgeons can interpret intraoperative kinematics, by providing a multi-dimensional perspective. With further knowledge regarding intraoperative kinematics, it might be possible to improve surgical approach, prosthesis design, and clinical outcomes. LEVEL OF EVIDENCE II.
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