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Lou J, Ma Q, Zhao X, Wu S, Gao H, Zhang W, Zhao B, Cai X. Comparison of the biomechanical properties of grafts in three anterior cruciate ligament reconstruction techniques based on three-dimensional finite element analysis. J Orthop Surg Res 2024; 19:322. [PMID: 38812053 PMCID: PMC11137914 DOI: 10.1186/s13018-024-04777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/02/2024] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVE To evaluate the biomechanical characteristics of grafts from three different anterior cruciate ligament (ACL) reconstructive surgeries and to determine which method is better at restoring knee joint stability. METHODS A 31-year-old female volunteer was enrolled in the study. According to the magnetic resonance imaging of her left knee, a three-dimensional model consisting of the distal femur, proximal tibia and fibula, ACL, posterior cruciate ligament, medial collateral ligament and lateral collateral ligament was established. Then, the ACL was removed from the original model to simulate the knee joint after ACL rupture. Based on the knee joint model without the ACL, single-bundle ACL reconstruction, double-bundle ACL reconstruction, and flat-tunnel ACL reconstruction were performed. The cross-sectional diameters of the grafts were equally set as 6 mm in the three groups. The bone tissues had a Young's modulus of 17 GPa and a Poisson's ratio of 0.36. The ligaments and grafts had a Young's modulus of 390 MPa and a Poisson's ratio of 0.4. Six probes were placed in an ACL or a graft to obtain the values of the equivalent stress, maximum principal stress, and maximum shear stress. After pulling the proximal tibia with a forward force of 134 N, the distance that the tibia moved and the stress distribution in the ACL or the graft, reflected by 30 mechanical values, were measured. RESULTS The anterior tibial translation values were similar among the three groups, with the double-bundle ACL reconstruction group performing the best, followed closely by the patellar tendon ACL reconstruction group. In terms of stress distribution, 13 out of 30 mechanical values indicated that the grafts reconstructed by flat bone tunnels had better performance than the grafts in the other groups, while 12 out of 30 showed comparable outcomes, and 5 out of 30 had worse outcomes. CONCLUSION Compared with traditional single-bundle and double-bundle ACL reconstructions, flat-tunnel ACL reconstruction has advantages in terms of stress dispersion. Additionally, flat-tunnel ACL reconstruction falls between traditional double-bundle and single-bundle ACL reconstructions in terms of restoring knee joint stability and is superior to single-bundle ACL reconstruction.
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Affiliation(s)
- Jiawnag Lou
- Hebei North University, 11-South Diamond Road, Gaoxin District, Zhangjiakou City, 075000, China.
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China.
- Beijing MEDERA Medical Group, Beijing, 102200, China.
| | - Qi Ma
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
- Beijing MEDERA Medical Group, Beijing, 102200, China
| | - Xijiu Zhao
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Sha Wu
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
- Beijing MEDERA Medical Group, Beijing, 102200, China
| | - Hong Gao
- Beijing MEDERA Medical Group, Beijing, 102200, China
| | - Wei Zhang
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
- Beijing MEDERA Medical Group, Beijing, 102200, China
| | - Baojing Zhao
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Xu Cai
- Joint Diseases Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
- Beijing MEDERA Medical Group, Beijing, 102200, China
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Chamieh M, Mourad W, Piontek T. Modified Anatomical Anterior Cruciate Ligament Reconstruction with Flat Semitendinosus Graft and C-shaped Tibial Canal. Arthrosc Tech 2024; 13:102835. [PMID: 38312879 PMCID: PMC10838054 DOI: 10.1016/j.eats.2023.09.011] [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: 07/31/2023] [Accepted: 09/07/2023] [Indexed: 02/06/2024] Open
Abstract
Every year, approximately 400,000 patients undergo anterior cruciate ligament (ACL) reconstruction surgery in the United States, accounting for almost 50% of all knee surgeries in the country. Recent studies have demonstrated that the ACL is a ribbon-like structure with a C-shaped tibial insertion and a flat femoral origin. This article introduces a modification of an ACL reconstruction technique. The modification renders the procedure easily reproducible with standard surgical instruments. We will describe a surgical technique modification that goes beyond the standard round bone tunnels and adopts a more anatomical approach using a C-shaped tibial canal and a flat femoral canal using a flat semitendinosus (semi-T) graft. The use of a semi-T graft better reproduces the ribbon-like ACL anatomy. The semi-T graft, a flat femoral canal, and a C-shaped tibial canal provide increased bone-tendon contact surface area and decreased diffusion length, resulting in improved tendon-bone healing. The modification proposed by our team makes the anatomical ribbon-like ACL graft, C-shaped tibial canal, and the flat femoral canal technique feasible in every orthopaedic operating room and mitigates costly specialized instrument.
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Affiliation(s)
- Marc Chamieh
- Department of Spine Disorders and Pediatric Orthopedics, Poznan University of Medical Sciences, Poznań, Poland
| | - Wassim Mourad
- Department of Orthopedic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A
| | - Tomasz Piontek
- Department of Spine Disorders and Pediatric Orthopedics, Poznan University of Medical Sciences, Poznań, Poland
- Rehasport Clinic, Poznań, Poland
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Lording TD. Review of Cha et al. (2005) on "Arthroscopic Double Bundle Anterior Cruciate Ligament Reconstruction: An Anatomical Approach". J ISAKOS 2023; 8:140-144. [PMID: 36924827 DOI: 10.1016/j.jisako.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 01/20/2023] [Accepted: 02/16/2023] [Indexed: 03/17/2023]
Abstract
This classic discusses the original publication 'Arthroscopic double-bundle anterior cruciate ligament reconstruction (ACL): An anatomical approach', the first detailed description of the surgical technique popularised by Dr Freddie Fu. The technique, in which the anteromedial and posterolateral bundles of the ACL are reconstructed individually using two grafts with independent bone tunnels, was designed to more closely recreate the function of the native ACL by more closely reproducing the functional anatomy. This reconstruction was biomechanically superior to single-bundle reconstruction, particularly with regards to rotational control, leading to great interest from ACL surgeons around the world. Clinical superiority was more difficult to demonstrate; however, and the technical difficulty of the procedure has limited its use. Nevertheless, the pursuit of improved patient outcomes through attention to functional anatomical detail continues. 'Recreating the functional anatomy of the intact ACL remains the cornerstone of ACL reconstruction'.
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Affiliation(s)
- Timothy D Lording
- Melbourne Orthopaedic Group, Windsor, 3181, Australia; Monash University, Melbourne, 3800, Australia.
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A pilot study on lengthening potentials and biomechanical effects of double and triple hemisection on tendon with slide lengthening. Sci Rep 2023; 13:3922. [PMID: 36894616 PMCID: PMC9998391 DOI: 10.1038/s41598-023-30791-w] [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: 12/29/2021] [Accepted: 03/01/2023] [Indexed: 03/11/2023] Open
Abstract
The current study explored the slide-lengthening potentials of double and triple hemisections and the biomechanical effects of different inter-hemisection distances. Forty-eight porcine flexor digitorum profundus tendons were divided into double- and triple-hemisection groups (Groups A and B) and a control group (Group C). Group A was divided into Group A1 (distance between hemisections were the same as Group B) and Group A2 (distance between hemisections corresponded to the greatest distance between hemisections in Group B). Biomechanical evaluation, motion analysis, and finite element analysis (FEA) were performed. Failure load of intact tendon was significantly highest among groups. When the distance was 4 cm, the failure load of Group A increased significantly. When the distance between the hemisections was 0.5 or 1 cm, the failure load of Group B was significantly lower than Group A. Tendon elongation and failure load of Group B were significantly lower than those in Group A when the greatest distance between hemisections was the same. Consequently, Double hemisections had a similar lengthening ability to that of triple hemisections with the same distance, but better when the distances between extreme hemisections matched. However, the driving force for the initiation of lengthening may be greater.
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Anteromediale Rotationsinstabilität des Kniegelenks: Flache sMCL-Bandplastik kombiniert mit einer anteromedialen Rekonstruktion ist der Einzelstrangrekonstruktion des sMCL überlegen. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00581-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abermann E, Herbst E, Herbort M, Smigielski R, Fink C. Instabilität des Kniegelenks – medial oder anteromedial? ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00564-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Zusammenfassung
Hintergrund
Verletzungen des medialen Bandkomplexes gehören zu den häufigsten Knieverletzungen. Sie heilen zwar meist mit konservativer Therapie problemlos aus, persistierende Instabilitäten erhöhen aber die Belastung der Kreuzbänder und benötigen speziell bei deren Beteiligung eine adäquate Therapie.
Anatomie und Biomechanik
Der mediale Seitenbandkomplex besteht im Wesentlichen aus dem oberflächlichen Seitenband (sMCL), welches der primäre Stabilisator gegen Valgus ist, dem tiefen Seitenband (dMCL) mit dessen schräg verlaufendem ventralem Anteil (AML), die nur sekundäre Stabilisatoren gegen Valgus darstellen, aber primär gegen Außenrotation stabilisieren, und dem hinteren Schrägband (POL), das in vollständiger Streckung gegen Valgus sowie gegen Innenrotation stabilisiert.
Therapie
Chronische Instabilitäten bzw. höhergradige Verletzungen mit Dislokation der Bandstümpfe oder multiligamentäre Verletzungen bedürfen einer operativen Versorgung. Im Akutstadium zeigen Avulsionsverletzungen bei anatomischer Refixation gutes Heilungspotenzial, während bei intraligamentären Verletzungen zusätzlich zur Naht der Bandanteile eine Augmentation mit Sehnenmaterial empfohlen wird. Bei chronischen Instabilitäten ist die Differenzierung des Instabilitätsmusters ausschlaggebend für die Wahl der Rekonstruktionstechnik (reine sMCL-Rekonstruktion oder kombinierte Rekonstruktion von sMCL und AML). In beiden Fällen kommt die hier beschriebene Technik mit flachem Transplantat der Anatomie näher als bei konventionellen Verfahren.
Diskussion
Rekonstruktionstechniken unter Verwendung flacher Sehnentransplantate, die alle betroffenen Bandanteile adressieren, haben sich biomechanisch als sehr effektiv erwiesen, komplexe mediale Instabilitäten suffizient zu behandeln. Ob diese auch klinisch überlegen sind, werden zukünftige klinische Studien zeigen müssen.
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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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Behrendt P, Herbst E, Robinson JR, von Negenborn L, Raschke MJ, Wermers J, Glasbrenner J, Fink C, Herbort M, Kittl C. The Control of Anteromedial Rotatory Instability Is Improved With Combined Flat sMCL and Anteromedial Reconstruction. Am J Sports Med 2022; 50:2093-2101. [PMID: 35604117 PMCID: PMC9227970 DOI: 10.1177/03635465221096464] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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 Both the superficial medial collateral ligament (sMCL) and the deep MCL (dMCL) contribute to the restraint of anteromedial (AM) rotatory instability (AMRI). Previous studies have not investigated how MCL reconstructions control AMRI. PURPOSE/HYPOTHESIS The purpose was to establish the optimal medial reconstruction for restoring normal knee kinematics in an sMCL- and dMCL-deficient knee. It was hypothesized that AMRI would be better controlled with the addition of an anatomically shaped (flat) sMCL reconstruction and with the addition of an AM reconstruction replicating the function of the dMCL. STUDY DESIGN Controlled laboratory study. METHODS A 6 degrees of freedom robotic system equipped with a force-torque sensor was used to test 8 unpaired knees in the intact, sMCL/dMCL sectioned, and reconstructed states. Four different reconstructions were assessed. The sMCL was reconstructed with either a single-bundle (SB) or a flattened hamstring graft aimed at better replicating the appearance of the native ligament. These reconstructions were tested with and without an additional AM reconstruction. Simulated laxity tests were performed at 0°, 30°, 60°, and 90° of flexion: 10 N·m valgus rotation, 5 N·m internal and external rotation (ER), and an AM drawer test (combined 134-N anterior tibial drawer in 5 N·m ER). The primary outcome measures of this force-controlled setup were anterior tibial translation (ATT; in mm) and axial tibial rotation (in degrees). RESULTS Sectioning the sMCL/dMCL increased valgus rotation, ER, and ATT with the simulated AM draw test at all flexion angles. SB sMCL reconstruction was unable to restore ATT, valgus rotation, and ER at 30°, 60°, and 90° of flexion to the intact state (P < .05). Flat MCL reconstruction restored valgus rotation at all flexion angles to the intact state (P > .05). ER was restored at all angles except at 90°, but ATT laxity in response to the AM drawer persisted. Addition of an AM reconstruction improved control of ATT relative to the intact state at all flexion angles (P > .05). Combined flat MCL and AM reconstruction restored knee kinematics closest to the intact state. CONCLUSION In a cadaveric model, AMRI resulting from an injured sMCL and dMCL complex could not be restored by an isolated SB sMCL reconstruction. A flat MCL reconstruction or an additional AM procedure, however, better restored medial knee stability. CLINICAL RELEVANCE In patients evaluated with a combined valgus and AM rotatory instability, a flat sMCL and an additional AM reconstruction may be superior to an isolated SB sMCL reconstruction.
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Affiliation(s)
- Peter Behrendt
- Department of Orthopedic and Trauma Surgery, Asklepios St. Georg, Hamburg, Germany,Department of Anatomy, Christian-Albrechts-University, Kiel, Germany,Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | | | | | - Michael J. Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Jens Wermers
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Christian Fink
- Gelenkpunkt-Sports and Joint Surgery, Innsbruck, Austria
| | - Mirco Herbort
- OCM Orthopedic Surgery Munich Clinic, Munich, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany,Christoph Kittl, Dr med MD(res), Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany ()
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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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Senftl M, Petek D, Jacobi M, Schallberger A, Spycher J, Stock A, Hess R, Tannast M. Occurrence of inadequate ACL healing after Dynamic Intraligamentary Stabilization and functional outcome-a multicentre case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1265-1274. [PMID: 34430988 PMCID: PMC9433353 DOI: 10.1007/s00590-021-03096-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/12/2021] [Indexed: 11/24/2022]
Abstract
Introduction Dynamic Intraligamentary Stabilization (DIS) is a technique for preservation, anatomical repair and stabilization of a freshly injured anterior cruciate ligament (ACL). The main purpose of this study was to evaluate the short-term re-operation rate when compared to traditional autograft reconstruction. Methods Four, from the developer independent, centres enrolled patients that underwent ACL repair by DIS, according to the specific indications given by MRI imaging at a minimum follow-up of 12 months. The re-operation rate was recorded as primary outcome. Secondary outcome measures were the postoperative antero-posterior knee laxity (using a portable Rolimeter®), as well as the Tegner, Lysholm and IKDC Scores. Results A total of 105 patients were investigated with a median follow-up of 21 months. Thirteen patients were lost to follow-up. Of the remaining 92 patients 15 (16.3%) had insufficient functional stability and required subsequent ACL reconstruction. These patients were excluded from further analysis, leaving 77 consecutive patients for a 12 months follow-up. The median age at time of surgery was 30 years for that group. At time of follow-up a median antero-posterior translation difference of 2 mm was measured. None of these patients reported subjective insufficiency (giving way), but in 14 patients (18.2%), the difference of antero-posterior translation was more than 3 mm. We found a median Tegner Score of 5.5, a median Lysholm Score of 95.0 and a median IKDC Score of 89.4. Conclusion The main finding of this multicentre study is a relevant re-operation rate of 16.3%. Another 18.2% showed objective antero-posterior laxity (≥ 3 mm) during testing raising the suspicion of postoperative non-healing. The failure rate of DIS in this study is higher than for reconstruction with an autologous tendon graft. However, our successfully treated patients had a good clinical and functional outcome based on antero-posterior knee laxity and clinical scores, comparable to patients treated by autograft reconstruction.
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Affiliation(s)
- Monika Senftl
- Department of Orthopaedic Surgery, Fribourg Hospital, Villars-sur-Glâne, Switzerland
| | - Daniel Petek
- Department of Orthopaedic Surgery, Fribourg Hospital, Villars-sur-Glâne, Switzerland. .,University of Fribourg (UNIFR), HFR Cantonal Hospital, Ch. des Pensionnats 2-6, 1700, Fribourg, Switzerland.
| | | | - Alex Schallberger
- Department of Orthopaedic Surgery, Interlaken Hospital, Unterseen, Switzerland
| | - Jonathan Spycher
- Department of Orthopaedic Surgery, Interlaken Hospital, Unterseen, Switzerland
| | - Anna Stock
- Department of Orthopaedic Surgery, Thun Hospital, Thun, Switzerland
| | - Rolf Hess
- Department of Orthopaedic Surgery, Thun Hospital, Thun, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic Surgery, Fribourg Hospital, Villars-sur-Glâne, Switzerland.,University of Fribourg (UNIFR), HFR Cantonal Hospital, Ch. des Pensionnats 2-6, 1700, Fribourg, Switzerland
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11
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Funchal LFZ, Astur DC, Pizzolatti ALA, Grimaldi AP, Jimenez AE, Moré ADO, de Mello Roesler CR, Cohen M. Tendon grafts with preserved muscle demonstrate similar biomechanical properties to tendon grafts stripped of muscular attachments: a biomechanical evaluation in a porcine model. J Exp Orthop 2021; 8:57. [PMID: 34341872 PMCID: PMC8329107 DOI: 10.1186/s40634-021-00375-6] [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: 04/23/2021] [Accepted: 07/23/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose (1) To evaluate the biomechanical properties of a porcine flexor digitorum superficialis tendon graft with preserved muscle fibers and (2) to compare these results with the biomechanical properties of a porcine tendon graft after removal of associated muscle. Methods Eighty-two porcine forelegs were dissected and the flexor digitorum superficialis muscle tendons were harvested. The study comprised of two groups: Group 1 (G1), harvested tendon with preserved muscle tissue; and Group 2 (G2), harvested contralateral tendon with removal of all muscle tissue. Tests in both groups were conducted using an electro-mechanical material testing machine (Instron, model 23-5S, Instron Corp., Canton, MA, USA) with a 500 N force transducer. Yield load, stiffness, and maximum load were evaluated and compared between groups. Results The behavior of the autografts during the tests followed the same stretching, deformation, and failure patterns as those observed in human autografts subjected to axial strain. There were no significant differences in the comparison between groups for ultimate load to failure (p = 0.105), stiffness (p = 0.097), and energy (p = 0.761). Conclusion In this porcine model biomechanical study, using autograft tendon with preserved muscle showed no statistically significant differences for yield load, stiffness, or maximum load compared to autograft tendon without preserved muscle. The preservation of muscle on the autograft tendon did not compromise the mechanical properties of the autograft. Level of evidence Level III Controlled laboratory study
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Affiliation(s)
| | - Diego Costa Astur
- Universidade Federal de São Paulo, Hospital Samaritano and Instituto Astur, Av Pacaembu 1024, São Paulo, SP, 01234-000, Brazil.
| | | | - Arthur Paiva Grimaldi
- Biomechanical Laboratory From Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | | | | | | | - Moises Cohen
- Orthoapedic Surgeon From Universidade Federal de São Paulo, São Paulo, Brazil
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12
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Milinkovic DD, Fink C, Kittl C, Sillanpää P, Herbst E, Raschke MJ, Herbort M. Anatomic and Biomechanical Properties of Flat Medial Patellofemoral Ligament Reconstruction Using an Adductor Magnus Tendon Graft: A Human Cadaveric Study. Am J Sports Med 2021; 49:1827-1838. [PMID: 33960859 DOI: 10.1177/03635465211009540] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In contrast to the majority of existing techniques for reconstruction of the medial patellofemoral ligament (MPFL), the technique described in this article uses the adductor magnus muscle tendon to gain a flat, broad graft, leaving its distal femoral insertion intact, and does not require drilling within or near the femoral physis. It also allows for soft tissue patellar fixation and could facilitate anatomic MPFL reconstruction in skeletally immature patients. PURPOSE To evaluate the anatomic and structural properties of the native MPFL and the adductor tendon (AT), followed by biomechanical evaluation of the proposed reconstruction. STUDY DESIGN Descriptive laboratory study. METHODS The morphological and topographical features of the AT and MPFL were evaluated in 12 fresh-frozen cadaveric knees. The distance between the distal insertion of the AT on the adductor tubercle and the adductor hiatus, as well as the desired length of the graft, was measured to evaluate this graft's application potential. Load-to-failure tests were performed to determine the biomechanical properties of the proposed reconstruction construct. The construct was placed in a uniaxial testing machine and cyclically loaded 500 times between 5 and 50 N, followed by load to failure, to measure the maximum elongation, stiffness, and maximum load. RESULTS The mean ± SD length of the AT was 12.6 ± 1.5 cm, and the mean distance between the insertion on the adductor tubercle and adductor hiatus was 10.8 ± 1.3 cm, exceeding the mean desired length of the graft (7.5 ± 0.5 cm) by 3.3 ± 0.7 cm. The distal insertion of the AT was slightly proximal and posterior to the insertion of the MPFL. The maximum elongation after cyclical loading was 1.9 ± 0.4 mm. Ultimately, the mean stiffness and load to failure were 26.2 ± 7.6 N/mm and 169.7 ± 19.2 N, respectively. The AT graft failed at patellar fixation in 2 of the initially tested specimens and at the femoral insertion in the remaining 10. CONCLUSION The described reconstruction using the AT has potential for MPFL reconstruction. The AT graft presents a graft of significant volume, beneficial anatomic topography, and adequate tensile properties in comparison with the native MPFL following the data from previously published studies. CLINICAL RELEVANCE Given its advantageous anatomic relationship as an application that avoids femoral drilling and osseous patellar fixation, the AT may be considered a graft for MPFL reconstruction in skeletally immature patients.
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Affiliation(s)
| | - Christian Fink
- Gelenkpunk-Sports and Joint Surgery, Innsbruck, 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
| | | | - Petri Sillanpää
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University of Muenster, Muenster, Germany
| | - Elmar Herbst
- Pihlajalinna Koskisairaala Hospital, Tampere, Finland
| | | | - Mirco Herbort
- 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.,OCM Orthopedic Surgery Munich Clinic, Munich, Germany
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Glasbrenner J, Herbst E, Raschke MJ, Peez C, Briese T, Kittl C. Anteromedial Rotatory Laxity: What is it, When to Address, and How? OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Tanaka MJ. Femoral Origin Anatomy of the Medial Patellofemoral Complex: Implications for Reconstruction. Arthroscopy 2020; 36:3010-3015. [PMID: 32569722 DOI: 10.1016/j.arthro.2020.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the shape and orientation of the medial patellofemoral complex (MPFC) footprint on the medial femur and describe the difference between the proximal (medial quadriceps tendon femoral ligament, MQTFL) and distal (medial patellofemoral ligament, MPFL) fibers. METHODS In 20 cadaveric knees, the MPFC footprint on the medial femur was exposed. Images of the medial femur were analyzed using ImageJ software. The length and width of the MPFC footprint were described to the nearest 0.1 mm; the angle of its long axis was described relative to the axis of the femoral shaft (0.1°). The footprint's most proximal and distal margins were described in relation to the adductor tubercle and medial epicondyle. The differences between each were compared using paired t tests. RESULTS 17 knees from 10 cadavers were included in this study. The MPFC footprint had a length of 11.7 ± 1.8 mm and a width of 1.7 ± 0.4 mm. The long axis of the footprint was at an angle 14.6° ± 16.6° anterior to the axis of the femoral shaft. The most proximal (MQTFL) fibers originated 7.4 ± 3.8 mm anterior and 1.8 ± 4.7 mm distal to the adductor tubercle and 4.1 ± 2.9 mm posterior and 8.4 ± 5.6 mm proximal to the medial epicondyle. The most distal (MPFL) fibers originated 4.9 ± 4.2 mm anterior and 12.7 ± 4.3 mm distal to the adductor tubercle, as well as 7.1 ± 2.4 mm posterior and 0.5 ± 5.6 mm distal to the medial epicondyle. The distal margin of the femoral MPFC footprint was 10.9 ± 1.7 mm distal (p < .001) and 2.6 ± 3.2 mm more posterior (p = .005) than the proximal margin. CONCLUSIONS The femoral footprint of the MPFC has a length almost 7 times greater than its width, with the distal margin being 10.9 mm distal and 2.6 mm posterior to the proximal margin. CLINICAL RELEVANCE This differential anatomy within the femoral origin suggests that MPFL and MQTFL reconstruction may require separate positions of femoral fixation to recreate the anatomy of these fibers.
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Affiliation(s)
- Miho J Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A..
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15
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Fink C, Smigielski R, Siebold R, Abermann E, Herbort M. Anterior Cruciate Ligament Reconstruction Using a Ribbon-Like Graft With a C-Shaped Tibial Bone Tunnel. Arthrosc Tech 2020; 9:e247-e262. [PMID: 32099779 PMCID: PMC7029192 DOI: 10.1016/j.eats.2019.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/07/2019] [Indexed: 02/03/2023] Open
Abstract
According to recent anatomic studies, the anterior cruciate ligament (ACL) appears to be a flat, "ribbon-like" structure, with a thin, oval-shaped insertion on the femur and a C-shaped tibial insertion. According to this anatomy, we describe an ACL-reconstruction technique that aims to approximate this natural anatomy. The basic principle of this technique is not to use conventional round tunnels but create tunnel shapes that resemble more closely the original ACL insertion sites. Using either a rectangular quadriceps tendon graft or a "flat" hamstring graft may not only provide a biomechanical advantage with increased rotational stability but also improve bone-tendon healing due to increased bone-tendon contact and decreased diffusion length. Creating a C-shaped tibial tunnel also avoids laceration of the anterior horn of the lateral meniscus, which is frequently harmed during conventional tibial tunnel drilling.
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Affiliation(s)
- Christian Fink
- Gelenkpunkt–Sports and Joint Surgery, Innsbruck, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria
| | | | | | - Elisabeth Abermann
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria
- Tauernklinikum Zell am See/Mittersill GmbH, Austria
| | - Mirco Herbort
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT, Hall, Austria
- OCM Clinic, Munich, Germany
- Address correspondence to Mirco Herbort, M.D., Prof., OCM Clinic, Steinerstrasse 6, 81477 Munich, Germany.
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16
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The Ribbon-shaped Femoral Footprint of the Medial Patellofemoral Ligament: Implications for Reconstruction. Sports Med Arthrosc Rev 2019; 27:150-153. [PMID: 31688533 DOI: 10.1097/jsa.0000000000000238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The medial patellofemoral ligament (MPFL) is the primary static stabilizer to lateral translation of the patella and serves as part of the medial patellar soft tissue restraints. Because of the sensitivity of MPFL graft function after reconstruction to the position of the femoral tunnel, many studies have aimed to identify the exact point of the femoral origin, as well as defining techniques to confirm this position intraoperatively. We describe the ribbon-shaped footprint of the MPFL on the medial femur and the associated difficulty in identifying the origin as a single "point." Varying isometry and biomechanical functions have been shown to exist within the most proximal and most distal fibers, suggesting the function of the MPFL may not be fully recreated with a tubular graft in a round tunnel. We review the anatomical descriptions of the elongated femoral footprint of the MPFL and describe our surgical technique to recreate this.
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18
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Perez JR, Letter M, Klein J, Kaplan LD. Simplifying Anterior Cruciate Ligament Graft Bone Plug Reconstructions: The "U" Trough Technique. Arthrosc Tech 2017; 6:e1271-e1274. [PMID: 29354427 PMCID: PMC5622206 DOI: 10.1016/j.eats.2017.05.003] [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: 02/03/2017] [Accepted: 05/02/2017] [Indexed: 02/03/2023] Open
Abstract
This Technical Note discusses an anterior cruciate ligament graft preparation technique to simplify and ease graft visualization, insertion, and fixation. Our technique incorporates a 2-mm central trough in the bone plug of the graft to improve one's ability to efficiently identify and orient the anterior cruciate ligament graft during insertion, and ensure correct screw placement and fixation.
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Affiliation(s)
- Jose R. Perez
- Address correspondence to Jose R. Perez, B.S., Miller School of Medicine, University of Miami, 801 Navarre Avenue, Coral Gables, Miami, FL 33134, U.S.A.Miller School of MedicineUniversity of Miami801 Navarre AvenueCoral Gables, MiamiFL33134U.S.A.
| | - Michael Letter
- Michael Letter, Ph.D-S., P.A-C., Department of Kinesiology and Sport Sciences, 5202 University Drive, Coral Gables, FL 33124, U.S.A.Department of Kinesiology and Sport Sciences5202 University DriveCoral GablesFL33124U.S.A.
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19
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Herbst E, Albers M, Burnham JM, Shaikh HS, Naendrup JH, Fu FH, Musahl V. The anterolateral complex of the knee: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 2017; 25:1009-1014. [PMID: 28233023 DOI: 10.1007/s00167-017-4449-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/20/2017] [Indexed: 01/26/2023]
Abstract
Injuries to the anterolateral complex of the knee can result in increased rotatory knee instability. However, to diagnose and treat patients with persistent instability properly, surgeons need to understand the multifactorial genesis as well as the complex anatomy of the anterolateral aspect of the knee in its entirety. While recent research focused primarily on one structure (anterolateral ligament-ALL), the purpose of this pictorial essay is to provide a detailed layer-by-layer description of the anterolateral complex of the knee, consisting of the iliotibial band with its superficial, middle, deep, and capsulo-osseous layer as well as the anterolateral joint capsule. This may help surgeons to not only understand the anatomy of this particular part of the knee, but may also provide guidance when performing extra-articular procedures in patients with rotatory knee instability. Level of evidence V.
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Affiliation(s)
- Elmar Herbst
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Marcio Albers
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Jeremy M Burnham
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Humza S Shaikh
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Jan-Hendrik Naendrup
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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Domnick C, Wieskötter B, Raschke MJ, Schulze M, Kronenberg D, Wefelmeier M, Langer MF, Herbort M. Evaluation of biomechanical properties: are porcine flexor tendons and bovine extensor tendons eligible surrogates for human tendons in in vitro studies? Arch Orthop Trauma Surg 2016; 136:1465-71. [PMID: 27475640 DOI: 10.1007/s00402-016-2529-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Porcine flexor tendons, bovine extensor tendons, and human (semitendinosus) tendons are frequently used as substitutes for human ACL grafts in biomechanical in vitro studies. This study compares the biomechanical properties and structural differences of these tendons. MATERIALS AND METHODS In this biomechanical study, fresh-frozen porcine flexor tendons, bovine extensor tendons, and human semitendinosus tendons were used (n = 36). The tendons were mounted in a uniaxial testing machine (Zwick/Roell) with cryo-clamps, leaving a 60 mm tendon part free between the two clamps. Specimens have been loaded to failure to evaluate the biomechanical parameters stiffness, yield load, and maximum load. A Total Collagen Assay Kit was used to detect differences in the total collagen type I concentration (n = 30). A one-way ANOVA was performed to detect differences in the means. The significance level was set at p < 0.05. RESULTS There were no significant differences in the stiffness between the groups (bovine 194 ± 43 N/mm, porcine 211 ± 63 N/mm, and human cadaveric 208 ± 58 N/mm). The yield and maximum loads were high (>1000 N) in all groups, but they were significantly increased in both animal specimens (means of 1681-1795 N) compared with human cadaveric specimen (means of 1289-1406 N; p < 0.01). No difference in the collagen type I concentration was detected (N.S.). CONCLUSION Porcine flexor and bovine extensor tendons are eligible substitutes with similar stiffness and high failure loads compared with human cadaveric semitendinosus tendons in in vitro studies.
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Affiliation(s)
- C Domnick
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Waldeyer Strasse 1, 48149, Muenster, Germany.
| | - B Wieskötter
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Waldeyer Strasse 1, 48149, Muenster, Germany
| | - M J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Waldeyer Strasse 1, 48149, Muenster, Germany
| | - M Schulze
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Waldeyer Strasse 1, 48149, Muenster, Germany
| | - D Kronenberg
- Institute of Experimental Musculoskeletal Medicine, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - M Wefelmeier
- Department of Operative Dentistry, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - M F Langer
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Waldeyer Strasse 1, 48149, Muenster, Germany
| | - M Herbort
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Waldeyer Strasse 1, 48149, Muenster, Germany
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Wierer G, Runer A, Hoser C, Gföller P, Fink C. Anatomical MCL reconstruction following TKA. Knee 2016; 23:911-4. [PMID: 27396812 DOI: 10.1016/j.knee.2016.06.006] [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] [Received: 04/15/2016] [Revised: 05/22/2016] [Accepted: 06/15/2016] [Indexed: 02/02/2023]
Abstract
Adequate ligament balancing has a tremendous impact on successful total knee arthroplasty. In case of instability, severely disabling symptoms require revision surgery. Here we present a case of early total knee arthroplasty failure due to secondary valgus laxity, which was successfully treated with medial collateral ligament (MCL) reconstruction. For anatomical MCL reconstruction, a flattened semitendinosus autograft was used to reconstruct the superficial medial collateral and the posterior oblique ligament.
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Affiliation(s)
- Guido Wierer
- Department of Traumatology and Sports Injuries, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
| | - Armin Runer
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria.
| | - Christian Hoser
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria.
| | - Peter Gföller
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria.
| | - Christian Fink
- Gelenkpunkt - Center for Sports and Joint Surgery, Olympiastraße 39, 6020 Innsbruck, Austria; Research Unit for OSMI, UMIT/ISAG, Eduard-Wallnöfer-Zentrum 1, 6060 Hall in Tirol, Austria.
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