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Chellamuthu G, Rathi NK, Ashraf M, Vinodh B. Maximum outcome with minimal resources: report of a multiligamentous knee injury managed with 'modified confluent tunnel technique'. BMJ Case Rep 2024; 17:e256609. [PMID: 38514157 PMCID: PMC10961577 DOI: 10.1136/bcr-2023-256609] [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: 03/23/2024] Open
Abstract
Multiligamentous knee injuries (MLKIs) are rare and challenging to manage in many aspects. The injury requires prompt diagnosis, reconstruction of multiple ligaments, and management of associated neurovascular injuries. Another important aspect that surgeons should consider is resource availability. Successful management of a case of MLKI using the cost-effective 'modified confluent tunnel technique' is described in this case report. We used confluent tunnels for intra- and extra-articular ligament reconstructions at the femoral side. We incorporated the weave technique for medial collateral ligament (MCL) reconstruction, and Larson's technique for posterolateral corner (PLC) reconstruction in this construct, and augmented the anterior cruciate ligament (ACL) and posterior cruciate ligament reconstruction with the remaining PLC and MCL grafts, respectively. This was cost-effective and resulted in good functional outcomes. The technique also helped us to avoid tunnel convergence which is an expected complication in MLKI surgeries.
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Affiliation(s)
- Girinivasan Chellamuthu
- Orthopaedics, Saveetha Institute of Medical and Technical Sciences (Deemed to be University), Chennai, India
| | - Nitesh Kumar Rathi
- Orthopaedics, Saveetha Institute of Medical and Technical Sciences (Deemed to be University), Chennai, India
| | - Munis Ashraf
- Orthopaedics, Saveetha Institute of Medical and Technical Sciences (Deemed to be University), Chennai, India
| | - Benjamin Vinodh
- Orthopaedics, Saveetha Institute of Medical and Technical Sciences (Deemed to be University), Chennai, India
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Yuen WLP, Loh SYJ. Reduction of Collision Risk in Multi-ligament Knee Injury KD-III-M and KD-IV Surgery-Superficial Medial Collateral Ligament Reconstruction with Suture Anchors. Arthrosc Tech 2023; 12:e413-e420. [PMID: 37013006 PMCID: PMC10066433 DOI: 10.1016/j.eats.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/10/2022] [Indexed: 04/05/2023] Open
Abstract
Surgical reconstruction of the medial collateral ligament (MCL) can be challenging during multi-ligament knee injury surgery due to the limited working space. There is risk of collision between the guide pin, pulling sutures, reamer, tunnel, implant, and graft of the different ligament reconstructions. In this Technical Note, we detail our senior author's technique for superficial MCL reconstruction using suture anchors and cruciate ligament reconstruction with all-inside techniques. The technique mitigates the risk of collision by confining the reconstruction process and implants for MCL fixation on the medial femoral condyle and medial proximal tibia.
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Affiliation(s)
- Wen Loong Paul Yuen
- Address correspondence to Wen Loong Paul Yuen, M.B.B.S., M.R.C.S., Department of Orthopaedic Surgery, Changi General Hospital, 2 Simei Street 3, Singapore 5298892.
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Three-dimensional-printed patient-specific instrumentation is an accurate tool to reproduce femoral bone tunnels in multiple-ligament knee injuries. INTERNATIONAL ORTHOPAEDICS 2023; 47:1213-1219. [PMID: 36799973 PMCID: PMC10079717 DOI: 10.1007/s00264-023-05712-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/26/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Multiple-ligament knee reconstruction techniques often involve the creation of several bone tunnels for various reconstruction grafts. A critical step in this procedure is to avoid short tunnels or convergences among them. Currently, no specific template guide to reproduce these angulations has been reported in the literature, and the success of the technique still depends on the experience of the surgeon. The aim of this study is to analyze the accuracy and reliability of 3D-printed patient-specific instrumentation (PSI) for lateral and medial anatomical knee reconstructions. METHODS Ten cadaveric knees were scanned by computed tomography (CT). Using specific computer software, anatomical femoral attachments were identified: (1) on the lateral side the lateral collateral ligament (LCL) and the popliteal tendon (PT) and (2) on the medial side the medial collateral ligament (MCL) and the posterior oblique ligament (POL). Four bone tunnels were planned for each knee, and PSI with different directions were designed as templates to reproduce the planned tunnels during surgery. Twenty 3D-printed PSI were used: ten were tailored to the medial side for reconstructing MCL and POL tunnels, and the other ten were tailored to the lateral side for reconstructing LCL and PT tunnels. Postoperative CT scans were made for each cadaveric knee. The accuracy of the use of 3D-printed PSI was assessed by superimposing post-operative CT images onto pre-operative images and analyzing the deviation of tunnels performed based on the planning, specifically the entry point and the angular deviations. RESULTS The median entry point deviations for the tunnels were as follows: LCL tunnel, 1.88 mm (interquartile range (IQR) 2.2 mm); PT tunnel, 2.93 mm (IQR 1.17 mm); MCL tunnel, 1.93 mm (IQR 4.26 mm); and POL tunnel, 2.16 mm (IQR 2.39). The median angular deviations for the tunnels were as follows: LCL tunnel, 2.42° (IQR 6.49°); PT tunnel, 4.15° (IQR 6.68); MCL tunnel, 4.50° (IQR 6.34°); and POL tunnel, 4.69° (IQR 3.1°). No statistically significant differences were found in either the entry point or the angular deviation among the different bone tunnels. CONCLUSION The use of 3D-printed PSI for lateral and medial anatomical knee reconstructions provides accurate and reproducible results and may be a promising tool for use in clinical practice.
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Ohliger J, Haus A, Fong R, Lang S, Gilmer BB, Wahl CJ. Modified Bosworth Technique for Medial Collateral Ligament Reconstruction of the Knee Using Semitendinosus Tendon Autograft. Arthrosc Tech 2022; 11:e1903-e1909. [PMID: 36457399 PMCID: PMC9705397 DOI: 10.1016/j.eats.2022.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/08/2022] [Indexed: 02/03/2023] Open
Abstract
The medial collateral ligament (MCL) is a major contributor to knee joint stability and is the most common ligament involved in knee injuries. When conservative management for high-grade MCL injuries fails, operative treatment is indicated. Various reconstruction techniques are described in the literature. The following report describes a reconstruction technique based on the modified Bosworth. We present a step-by-step technique for using autograft semitendinosus tendon as a double limb to reconstruct the MCL and if necessary, the posterior oblique ligament. The technique is versatile with respect to a spectrum of MCL injury patterns, isometric, incorporates techniques that are common to other knee reconstructions, and uses readily available autograft. It has been used extensively by the senior authors as an adjunct/augmentation to the repair of acute MCL injuries as well as in the reconstruction of chronic MCL laxity. The technique restores stability to rotation and valgus stress while maintaining the distal insertion of the semitendinosus intact.
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Affiliation(s)
- James Ohliger
- Barton Center for Orthopedics and Wellness, South Lake Tahoe, California
| | - Andrew Haus
- Barton Center for Orthopedics and Wellness, South Lake Tahoe, California
| | - Rodney Fong
- University of Nevada, Reno School of Medicine, Reno, Nevada
| | - Sarah Lang
- Mammoth Orthopedic Institute, Mammoth Hospital, Mammoth Lakes, California
| | - Brian B. Gilmer
- Mammoth Orthopedic Institute, Mammoth Hospital, Mammoth Lakes, California,Address correspondence to Brian Gilmer, M.D., Mammoth Orthopedic Institute, 85 Sierra Park Rd., Mammoth Lakes, CA 93546.
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Glasbrenner J, Deichsel A, Raschke MJ, Briese T, Frank A, Herbort M, Herbst E, Kittl C. Bone Staples Provide Favorable Primary Stability in Cortical Fixation of Tendon Grafts for Medial Collateral Ligament Reconstruction: A Biomechanical Study. Orthop J Sports Med 2021; 9:23259671211017880. [PMID: 34350302 PMCID: PMC8287377 DOI: 10.1177/23259671211017880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/14/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The use of the interference screw (IFS) for the cortical fixation of tendon
grafts in knee ligament reconstruction may lead to converging tunnels in the
multiligament reconstruction setting. It is unknown whether alternative
techniques using modern suture anchor (SA) or bone staple (BS) fixation
provide sufficient primary stability. Purpose: To assess the primary stability of cortical fixation of tendon grafts for
medial collateral ligament (MCL) reconstruction using modern SA and BS
methods in comparison with IFS fixation. Study Design: Controlled laboratory study. Methods: Cortical tendon graft fixation was performed in a porcine knee model at the
tibial insertion area of the MCL using 3 different techniques: IFS (n = 10),
SA (n = 10), and BS (n = 10). Specimens were mounted in a materials testing
machine, and cyclic loading for 1000 cycles at up to 100 N was applied to
the tendon graft, followed by load-to-failure testing. Statistical analysis
was performed using 1-way analysis of variance. Results: There were no statistical differences in elongation during cyclic loading or
peak failure load during load-to-failure testing between BS (mean ± standard
deviation: 3.4 ± 1.0 mm and 376 ± 120 N, respectively) and IFS fixation (3.9
± 1.2 mm and 313 ± 99.5 N, respectively). SA fixation was found to have
significantly more elongation during cyclic loading (6.4 ± 0.9 mm;
P < .0001) compared with BS and IFS fixation and
lower peak failure load during ultimate failure testing (228 ± 49.0 N;
P < .01) compared with BS fixation. Conclusion: BS and IFS fixation provided comparable primary stability in the cortical
fixation of tendon grafts in MCL reconstruction, whereas a single SA
fixation led to increased elongation with physiologic loads. However, load
to failure of all 3 fixation techniques exceeded the loads expected to occur
in the native MCL. Clinical Relevance: The use of BS as a reliable alternative to IFS fixation for peripheral
ligament reconstruction in knee surgery can help to avoid the conflict of
converging tunnels.
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Affiliation(s)
- Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Andre Frank
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Mirco Herbort
- OCM Orthopädische Chirurgie München, München, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Abstract
The multiple ligament knee injury involving the medial collateral ligament, anterior cruciate ligament, and posterior cruciate ligament is typically the result of a high-energy trauma or knee dislocation event. Optimal treatment strategies are debated, specifically in regard to timing of surgery, reconstruction/repair techniques, and postoperative protocols. This review details the stepwise treatment of these complex patients from diagnosis to postoperative rehabilitation and summarizes the current literature.
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Jette C, Pomés J, Sastre S, Gutierrez D, Llusa M, Combalia A. Safe drilling angles avoid femoral tunnel complications during combined anterolateral ligament and anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:3411-3417. [PMID: 30712061 DOI: 10.1007/s00167-019-05388-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 01/30/2019] [Indexed: 01/26/2023]
Abstract
PURPOSE To determine the best angle to drill the femoral tunnels of an anterolateral ligament (ALL) anatomic reconstruction combined with a single-bundle anterior cruciate ligament (ACL) reconstruction to avoid tunnel collisions and cortical disruption. METHODS Ten cadaveric knees were studied. Single-bundle anatomic ACL femoral tunnels were arthroscopically drilled. The starting point of the ALL femoral tunnel was located posterior and superior to the lateral epicondyle. ALL tunnels were drilled at four different angulations: (1) 0° axial/0° coronal, (2) 0° axial/30° coronal superior, (3) 30° axial anterior/0° coronal, and (4) 30° axial anterior 30° coronal superior. Specimens were scanned by computed tomography to measure the relations of each trajectory with the ACL socket and the nearest cortical bone. RESULTS None of the four trajectories studied presented risk of collision with the ACL. The tunnel at 30° anterior/30° proximal presented the safest distance to the ACL socket (P = 0.01) [mean distance 18.6 mm (SD ± 6.7)]. However, both tunnels angled at 0° in the axial plane presented a high risk of posterior femoral cortex disruption (P = 0.01), either by close proximity or direct contact in some specimens (mean distance 3.1 mm (SD ± 2.8) at 0° axial/0° coronal and 3.7 mm (SD ± 2.2) at 0° axial/30° coronal). CONCLUSIONS When performing simultaneous ACL and ALL ligament reconstruction, the ALL femoral tunnel should be drilled with an angle of 30° anterior in the axial plane and 30° proximal in the coronal plane. Tunnels with an angle of 0° in the axial plane showed high risk of contact and disruption of the posterior femoral cortex; thus, these angles should be avoided. The clinical relevance of this work is that an ALL anatomical reconstruction does not represent a risk when performing a simultaneous ACL reconstruction as long as the ALL tunnel is reamed with a proximal and anterior angulation.
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Affiliation(s)
- Cristian Jette
- Department of Orthopaedic Surgery and Traumatology, Hospital Clinic, 170 Villarroel Street, 08036, Barcelona, Spain.
| | - Jaume Pomés
- Division of Musculoskeletal Radiology, Department of Radiology, Hospital Clinic, Barcelona, Spain
| | - Sergi Sastre
- Department of Orthopaedic Surgery and Traumatology, Hospital Clinic, 170 Villarroel Street, 08036, Barcelona, Spain
| | - David Gutierrez
- Department of Orthopaedic Surgery and Traumatology, Hospital Clinic, 170 Villarroel Street, 08036, Barcelona, Spain
| | - Manuel Llusa
- Department of Orthopaedic Surgery and Traumatology, Hospital Clinic, 170 Villarroel Street, 08036, Barcelona, Spain.,Department of Human Anatomy, University of Barcelona Medical School, Barcelona, Spain
| | - Andrés Combalia
- Department of Orthopaedic Surgery and Traumatology, Hospital Clinic, 170 Villarroel Street, 08036, Barcelona, Spain.,Department of Human Anatomy, University of Barcelona Medical School, Barcelona, Spain
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Crawford MD, Kennedy MI, Bernholt DL, DePhillipo NN, LaPrade RF. Combined Posterior Cruciate Ligament and Superficial Medial Collateral Ligament Knee Reconstruction: Avoiding Tunnel Convergence. Arthrosc Tech 2019; 8:e929-e933. [PMID: 31700789 PMCID: PMC6823869 DOI: 10.1016/j.eats.2019.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/01/2019] [Indexed: 02/03/2023] Open
Abstract
Combined posterior cruciate ligament (PCL) and medial collateral ligament (MCL) injuries represent a complex pathology that requires a thorough clinical and radiographic examination to diagnose and identify all injured structures. Anatomic reconstruction of the injured ligaments is recommended, including double-bundle PCL reconstruction and superficial MCL augmentation. In the setting of this complex reconstruction, several technical aspects require consideration and preoperative planning, including the risk of femoral tunnel convergence on the medial aspect of the femoral condyle. This article details our technique for combined anatomic double-bundle PCL reconstruction and superficial MCL augmentation to avoid tunnel convergence. Level I (knee); level II (PCL).
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Affiliation(s)
| | | | | | | | - Robert F. LaPrade
- Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Robert F. LaPrade, M.D., Ph.D., The Steadman Clinic, 181 West Meadow Dr, Suite 400, Vail, CO 81657, U.S.A.
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Bonadio MB, Helito CP, Foni NO, da Mota E Albuquerque RF, Pécora JR, Camanho GL, Demange MK, Angelini FJ. Combined reconstruction of the posterior cruciate ligament and medial collateral ligament using a single femoral tunnel. Knee Surg Sports Traumatol Arthrosc 2017; 25:3024-3030. [PMID: 27000395 DOI: 10.1007/s00167-016-4071-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 02/24/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Lesions of the medial collateral ligament (MCL) are the most common knee ligament injuries, and lesions associated with the anterior cruciate ligament or the posterior cruciate ligament (PCL) in knee dislocations should be reconstructed to prevent failure of the central pivot reconstruction. The purpose of this study was to evaluate the outcomes of combined PCL/MCL reconstruction using a single femoral tunnel with a minimum 2-year follow-up. METHOD A retrospective study of thirteen patients with combined PCL/MCL injuries was conducted. The patients underwent PCL and MCL reconstruction using an Achilles tendon allograft with a single tunnel in the medial femoral condyle, thereby avoiding tunnel conversion. RESULTS All patients achieved a range of motion of at least 100°. The mean loss of extension and flexion values compared to the contralateral side was 1° ± 2° and 9° ± 10°, respectively. Our results included 26 reconstructions with three (11.5 %) failures, two in the PCL (15.3 %) and one in the MCL (7.6 %), in three different patients. In the final evaluation, the mean IKDC subjective score was 71.63 ± 16.23, the mean Lysholm score was 80.08 ± 13.87, and the median Tegner score was 6 (range = 2-7). CONCLUSION The PCL/MCL reconstruction technique using a single femoral tunnel and an Achilles tendon allograft is safe, avoids the convergence of tunnels in the medial femoral condyle, has excellent results, and is reproducible. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Marcelo Batista Bonadio
- Knee Surgery Division, Institute of Orthopedics and Traumatology, University of São Paulo, Rua Ovídio Pires de Campos 333, São Paulo, SP, 05403-010, Brazil.
| | - Camilo Partezani Helito
- Knee Surgery Division, Institute of Orthopedics and Traumatology, University of São Paulo, Rua Ovídio Pires de Campos 333, São Paulo, SP, 05403-010, Brazil
| | - Noel Oizerovici Foni
- Knee Surgery Division, Institute of Orthopedics and Traumatology, University of São Paulo, Rua Ovídio Pires de Campos 333, São Paulo, SP, 05403-010, Brazil
| | - Roberto Freire da Mota E Albuquerque
- Knee Surgery Division, Institute of Orthopedics and Traumatology, University of São Paulo, Rua Ovídio Pires de Campos 333, São Paulo, SP, 05403-010, Brazil
| | - José Ricardo Pécora
- Knee Surgery Division, Institute of Orthopedics and Traumatology, University of São Paulo, Rua Ovídio Pires de Campos 333, São Paulo, SP, 05403-010, Brazil
| | - Gilberto Luis Camanho
- Knee Surgery Division, Institute of Orthopedics and Traumatology, University of São Paulo, Rua Ovídio Pires de Campos 333, São Paulo, SP, 05403-010, Brazil
| | - Marco Kawamura Demange
- Knee Surgery Division, Institute of Orthopedics and Traumatology, University of São Paulo, Rua Ovídio Pires de Campos 333, São Paulo, SP, 05403-010, Brazil
| | - Fábio Janson Angelini
- Knee Surgery Division, Institute of Orthopedics and Traumatology, University of São Paulo, Rua Ovídio Pires de Campos 333, São Paulo, SP, 05403-010, Brazil
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Ferrari MB, Chahla J, Mitchell JJ, Moatshe G, Mikula JD, Marchetti DC, LaPrade RF. Multiligament Reconstruction of the Knee in the Setting of Knee Dislocation With a Medial-Sided Injury. Arthrosc Tech 2017; 6:e341-e350. [PMID: 28580251 PMCID: PMC5442403 DOI: 10.1016/j.eats.2016.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/04/2016] [Indexed: 02/07/2023] Open
Abstract
Multiple ligament knee injuries are complex pathologies that often result from traumatic knee dislocations. Both a high level of suspicion and a thorough clinical and radiographic examination are mandatory to diagnose and identify all injured structures. Reconstruction of all injured ligaments is recommended to aid in early mobilization and to avoid joint stiffness or graft failure. For knee dislocations involving injury to the anterior cruciate ligament, posterior cruciate ligament, and medial-sided structures, a repair and augmentation of the medial collateral ligament, together with an anatomic reconstruction of the anterior cruciate ligament and double-bundle posterior cruciate ligament, is recommended. In the setting of these complex reconstructions, there are several technical aspects that require consideration to ensure concise and efficient treatment of these injuries. Graft choice, sequence of reconstruction, tunnel position and orientation, and graft tensioning all pose surgical challenges, and require dedicated preoperative preparation and planning. The purpose of this Technical Note is to report a safe, effective, and reproducible surgical technique for treatment of multiligament injuries in the setting of a knee dislocation with a medial-sided component (classified as KD-III-M in the Schenck classification system).
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Affiliation(s)
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,Oslo University Hospital, Oslo, Norway,OSTRC, The Norwegian School of Sports Sciences, Oslo, Norway
| | - Jacob D. Mikula
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Robert F. LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Robert F. LaPrade, M.D., Ph.D., Steadman Philippon Research Institute, The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO 81657, U.S.A.Steadman Philippon Research InstituteThe Steadman Clinic181 West Meadow DriveSuite 400VailCO81657U.S.A.
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Moatshe G, Brady AW, Slette EL, Chahla J, Turnbull TL, Engebretsen L, LaPrade RF. Multiple Ligament Reconstruction Femoral Tunnels: Intertunnel Relationships and Guidelines to Avoid Convergence. Am J Sports Med 2017; 45:563-569. [PMID: 27872126 DOI: 10.1177/0363546516673616] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Knee dislocations often require multiple concurrent ligament reconstructions, which involve creating several tunnels in the distal femur. Therefore, the risk of tunnel convergence is increased because of the limited bone volume within the distal aspect of the femur. PURPOSE To assess the risk of tunnel convergence and determine the optimal reconstruction tunnel orientations for multiple ligament reconstructions in the femur. STUDY DESIGN Descriptive laboratory study. METHODS Three-dimensional knee models were developed from computed tomography scans of 21 patients. Medical image processing software was used to create tunnels for each of the primary ligamentous structures, replicating a surgical approach that would be used in multiple ligament reconstructions. Thereafter, the tunnel orientation was varied in surgically relevant directions to determine orientations that minimized the risk of tunnel convergence. The orientation of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tunnels was held constant throughout the study, while the orientation of the fibular collateral ligament (FCL), popliteus tendon (PLT), superficial medial collateral ligament (sMCL), and posterior oblique ligament (POL) tunnels was varied to avoid convergence. RESULTS A high risk of tunnel convergence was observed between the FCL and ACL tunnels when the FCL tunnel was aimed at 0° in the axial and coronal planes. Aiming the FCL tunnel 35° anteriorly minimized convergence with the ACL tunnel. No tunnel convergence was observed for the PLT tunnel aimed 35° anteriorly and parallel to the FCL tunnel. To avoid convergence between the sMCL and PCL tunnels, the sMCL tunnels should be aimed 40° proximally in the coronal plane and 20° to 40° anteriorly. During concomitant POL reconstruction, the sMCL should be aimed 40° proximally and anteriorly and the POL 20° proximally and anteriorly. The PLT and POL tunnels aimed at 0° in both the coronal and axial planes had an increased risk of violating the intercondylar notch. CONCLUSION Femoral tunnel orientations during multiple ligament reconstructions need to be adjusted to avoid tunnel convergence. On the lateral side, aiming the FCL and PLT tunnels 35° anteriorly eliminated convergence with the ACL tunnel. On the medial side, tunnel convergence was avoided by orienting the sMCL tunnel 40° proximally and anteriorly and the POL tunnel 20° proximally and anteriorly. The POL and PLT tunnels aimed at 0° in the axial plane had an increased risk of violating the intercondylar notch. CLINICAL RELEVANCE The risk of tunnel convergence with the ACL and PCL femoral tunnels can be reduced by adjusting the orientation of the FCL and PLT tunnels and the sMCL and POL tunnels, respectively.
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Affiliation(s)
- Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, USA.,Oslo University Hospital, Oslo, Norway.,Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Alex W Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Erik L Slette
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Lars Engebretsen
- Oslo University Hospital, Oslo, Norway.,Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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Zheng X, Li T, Wang J, Dong J, Gao S. Medial collateral ligament reconstruction using bone-patellar tendon-bone allograft for chronic medial knee instability combined with multi-ligament injuries: a new technique. J Orthop Surg Res 2016; 11:85. [PMID: 27443560 PMCID: PMC4957390 DOI: 10.1186/s13018-016-0416-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 07/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The medial collateral ligament (MCL) is the main static stabilizer of the medial knee. The surgical treatment was recommended in cases with serious medial collateral ligament insufficiency combined with multi-ligament injuries and chronic symptomatic medial instability. Several surgical techniques have been described for the MCL reconstruction, while potential problems including donor site morbidity, complicated procedure, and high risk of femoral tunnel collision were reported. In order to minimize such potential limitations, we describe a new medial reconstruction technique for MCL injury using bone-patellar tendon-bone (BPTB) allograft. METHODS A longitudinal incision at the medial knee was made. The centers of femoral and tibial attachments were gained through repeated isometricity test. Then, the bone grooves were made around the femoral and tibial centers. The appropriate BPTB allograft was selected, and both ends were trimmed. The prepared bone blocks were embedded into the grooves and fixed with cancellous screws. The programmed rehabilitation exercises were performed after the operation. RESULTS A strong graft and bone-to-bone healing on both femoral and tibial attachment sites were obtained, and femoral tunnel collision during multi-ligament reconstruction was avoided. Satisfactory valgus and rotatory stability were gained. CONCLUSIONS This novel MCL reconstruction technique using BPTB allograft can be safely performed, and the clinical outcome was favorable with satisfactory valgus and rotatory stability. More cases and additional follow-up results are needed to verify the overall effect of this technique.
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Affiliation(s)
- Xiaozuo Zheng
- Department of Orthopedics, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China. .,Orthopaedic Biomechanics Laboratory of Hebei Province, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
| | - Tong Li
- Department of Orthopedics, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Orthopaedic Biomechanics Laboratory of Hebei Province, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Juan Wang
- Department of Orthopedics, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Orthopaedic Biomechanics Laboratory of Hebei Province, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Jiangtao Dong
- Department of Orthopedics, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.,Orthopaedic Biomechanics Laboratory of Hebei Province, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Shijun Gao
- Department of Orthopedics, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China. .,Orthopaedic Biomechanics Laboratory of Hebei Province, 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
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