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Itthipanichpong T, Limskul D, Tanpowpong T, Virulsri C, Tangpornprasert P, Kuptniratsaikul S, Thamrongskulsiri N. Higher contact pressure of the lateral tibiofemoral joint in lateral extra-articular tenodesis with tensioned graft in external rotation than in neutral rotation: A biomechanical study. J ISAKOS 2024; 9:562-567. [PMID: 38636904 DOI: 10.1016/j.jisako.2024.04.009] [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: 02/28/2024] [Revised: 03/29/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To determine the mean contact pressure, peak contact pressure, and mean contact area of the lateral tibiofemoral joint in lateral extra-articular tenodesis (LET) with tension on the graft in tibial neutral and external rotation. METHODS A total of eight Thiel-embalmed cadaveric knees were prepared and divided into two groups (4 knees in each group): the LET-NR group (lateral extra-articular tenodesis tension in neutral rotation) and (2) the LET-ER group (lateral extra-articular tenodesis tension in external rotation). Each knee was prepared according to the corresponding technique. A hydraulic testing system (E10000, Instron) simulates an axial load of 735 N for 10 s in each group. RESULTS The LET-ER group exhibited a statistically significant higher peak contact pressure compared to the LET-NR group. The peak contact pressure values in the LET-NR and LET-ER groups were 702.3 ± 233.9 kPa and 1235.5 ± 171.4 kPa, respectively (p = 0.010, 95% CI, -888.0 to -178.5). The mean contact pressure values in the LET-NR and LET-ER groups were 344.9 ± 69.0 kPa and 355.3 ± 34.9 kPa, respectively (p = 0.796, 95% CI, -105.1-84.2). The mean contact area values in the LET-NR and LET-ER groups were 36.8 ± 3.1 mm2 and 33.3 ± 6.4 mm2, respectively (p = 0.360, 95% CI, -5.2-12.2). CONCLUSIONS The peak contact pressure of the lateral tibiofemoral joint is greater in LET when the graft is tensioned in external rotation than in neutral rotation. However, no statistically significant difference in the mean contact pressure or the mean contact area was observed between the two groups. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Thun Itthipanichpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Danaithep Limskul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Thanathep Tanpowpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Chanyaphan Virulsri
- Center of Excellence for Prosthetic and Orthopedic Implant, Department of Mechanical Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Pairat Tangpornprasert
- Center of Excellence for Prosthetic and Orthopedic Implant, Department of Mechanical Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Somsak Kuptniratsaikul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
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Sasaki R, Niki Y, Kaneda K, Yamada Y, Nagura T, Nakamura M, Jinzaki M. The tibial tubercle-to-trochlear groove distance changes in standing weight-bearing condition: An upright weight-bearing computed tomography analysis. Knee 2024; 48:14-21. [PMID: 38479077 DOI: 10.1016/j.knee.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/20/2024] [Accepted: 02/27/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The tibial tubercle-to-trochlear groove (TT-TG) distance and Insall-Salvati (I/S) ratio are widely used to determine the need for distal realignment in conjunction with medial patellofemoral ligament (MPFL) reconstruction in patients with recurrent patellar dislocation. A TT-TG distance >20 mm and an I/S ratio >1.3 are significant anatomical risk factors for patellar instability. However, these parameters have traditionally been measured using non-weight-bearing (NWB) imaging modalities. As patellar dislocation occurs during weight-bearing actions, these two parameters should be measured under weight-bearing conditions. Thus, this study aimed to measure the TT-TG distance and I/S ratio using upright full-weight-bearing (FWB) computed tomography (CT) scans and compare the data with NWB CT scans. METHODS This study included 49 knee joints of 26 healthy volunteers. CT images were obtained under both FWB and NWB standing conditions using a 320-detector row upright CT scanner. TT-TGs in the axial plane and I/S ratios in the sagittal plane were measured and compared. RESULTS The average FWB TT-TG distance was 20.3 ± 3.9 mm, whereas the average NWB TT-TG distance was 12.3 ± 4.7 mm. The TT-TG level was significantly higher in the FWB condition than that in the NWB condition (P < 0.001). The I/S ratios were comparable between the FWB and NWB conditions (P = 0.29). CONCLUSIONS The TT-TG distance in the standing weight-bearing condition was larger than the conventional TT-TG distance and surpassed the historical cutoff value of TT-TG, which may affect the indication of additional distal realignment in MPFL reconstruction for patellar instability.
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Affiliation(s)
- Ryo Sasaki
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Yasuo Niki
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.
| | - Kazuya Kaneda
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Yoshitake Yamada
- Department of Diagnostic Radiology, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Takeo Nagura
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Masahiro Jinzaki
- Department of Diagnostic Radiology, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
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Alzouhayli K, Schilaty ND, Wei Y, Hooke AW, Sellon JL, Bates NA. Shear wave elastography demonstrates different material properties between the medial collateral ligament and anterolateral ligament. Clin Biomech (Bristol, Avon) 2024; 111:106155. [PMID: 38043170 PMCID: PMC10872362 DOI: 10.1016/j.clinbiomech.2023.106155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Anterolateral ligament and medial collateral ligament injuries could happen concomitantly with anterior cruciate ligament ruptures. The anterolateral ligament is injured more often than the medial collateral ligament during concomitant anterior cruciate ligament ruptures although it offers less restraint to knee movement. Comparing the material properties of the medial collateral ligament and anterolateral ligament helps improve our understanding of their structure-function relationship and injury risk before the onset of injury. METHODS Eight cadaveric lower extremity specimens were prepared and mechanically tested to failure in a laboratory setting using a hydraulic platform. Measurements of surface strains of superficial surface of each medial collateral ligament and anterolateral ligament specimen were found using three-dimensional digital image correlation. Ligament stiffness was found using ultrasound shear-wave elastography. t-tests were used to assess for significant differences in strain, stress, Young's modulus, and stiffness in the two ligaments. FINDINGS The medial collateral ligament exhibited greater ultimate failure strain along its longitudinal axis (p = 0.03) and Young's modulus (p < 0.0018) than the anterolateral ligament. Conversely, the anterolateral ligament exhibited greater ultimate failure stress than the medial collateral ligament (p < 0.0001). Medial collateral ligament failure occurred mostly in the proximal aspect of the ligament, while most anterolateral ligament failure occurred in the distal or midsubstance aspect (P = 0.04). INTERPRETATION Despite both being ligamentous structures, the medial collateral ligament and anterolateral ligament exhibited separate material properties during ultimate failure testing. The weaker material properties of the anterolateral ligament likely contribute to higher rates of concomitant injury with anterior cruciate ligament ruptures.
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Affiliation(s)
- Kenan Alzouhayli
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA; The Ohio State University College of Medicine, Columbus, OH, USA
| | - Nathan D Schilaty
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Yi Wei
- Ohio University Heritage College of Osteopathic Medicine, Dublin, OH, USA
| | | | - Jacob L Sellon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nathaniel A Bates
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Migliorini F, Vecchio G, Eschweiler J, Schneider SM, Hildebrand F, Maffulli N. Reduced knee laxity and failure rate following anterior cruciate ligament reconstruction compared with repair for acute tears: a meta-analysis. J Orthop Traumatol 2023; 24:8. [PMID: 36805839 PMCID: PMC9941413 DOI: 10.1186/s10195-023-00688-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/04/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Following anterior cruciate ligament (ACL) tears, both repair and reconstruction may be performed to restore joint biomechanics and proprioception. The present study compared joint laxity, patient-reported outcome measures (PROMs), and rate of failure following primary repair versus reconstruction for ACL ruptures. METHODS This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pubmed, Google scholar, Embase, and Web of Science were accessed in September 2022. All the clinical investigations comparing repair versus reconstruction for primary ACL tears were accessed. Studies reporting data on multiple ligament injuries settings were not eligible. RESULTS Data from eight articles (708 procedures) were collected. The mean length of the follow-up was 67.3 ± 119.4 months. The mean age of the patients was 27.1 ± 5.7 years. Thirty-six percent (255 of 708 patients) were women. The mean body mass index (BMI) was 24.3 ± 1.1 kg/m2. The mean time span from injury to surgery was 36.2 ± 32.3 months. There was comparability at baseline with regards to instrumental laxity, Lachman test, International Knee Document Committee (IKDC), and Tegner Scale (P > 0.1). Similarity between ACL reconstruction and repair was found in IKDC (P = 0.2) and visual analog scale (VAS) satisfaction (P = 0.7). The repair group demonstrated greater mean laxity (P = 0.0005) and greater rate of failure (P = 0.004). CONCLUSION ACL reconstruction may yield greater joint stability and lower rate of failure compared with surgical repair. Similarity was found in PROMs. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074, Aachen, Germany. .,Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, 52152, Simmerath, Germany.
| | - Gianluca Vecchio
- grid.11780.3f0000 0004 1937 0335Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, SA Italy
| | - Jörg Eschweiler
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074 Aachen, Germany
| | - Sarah-Marie Schneider
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074 Aachen, Germany
| | - Frank Hildebrand
- grid.412301.50000 0000 8653 1507Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074 Aachen, Germany
| | - Nicola Maffulli
- grid.11780.3f0000 0004 1937 0335Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi, SA Italy ,grid.9757.c0000 0004 0415 6205School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Thornburrow Drive, Stoke On Trent, England ,grid.4868.20000 0001 2171 1133Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG England
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5
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Weishorn J, Spielmann J, Kern R, Mayer J, Friedmann-Bette B, Renkawitz T, Bangert Y. [New treatment methods in competitive sports : What can we learn from the medical care of top athletes?]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:897-906. [PMID: 37737887 DOI: 10.1007/s00132-023-04440-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND As elite sport becomes more professional, the medical-psychological care of athletes is an important factor in providing them with the best possible support and thus optimising their performance. Our experience in the fields of prevention, conservative and surgical treatment, and rehabilitation also provides valuable insights for the treatment of our patients in daily practice. PREVENTION Designed to improve static and dynamic muscle strength, kinaesthetic sensitivity, and neuromuscular control, the FIFA 11+ injury prevention programme is a three-part warm-up programme that is widely used in coaching and recreational sports. CONSERVATIVE TREATMENT Platelet-rich plasma (PRP) is probably the most widely used orthobiologic treatment modality for the conservative management of tendon, muscle and cartilage injuries. Its effectiveness depends on the underlying pathology and the affected body region. The best evidence exists for the treatment of patellar tendinitis ("jumper's knee") and epicondylitis humeri radialis ("tennis elbow"). SURGICAL TREATMENT The treatment of ACL injuries in competitive athletes is challenging due to the high physical demands. Prompt surgical intervention, anatomical reconstruction and additional extra-articular stabilisation are associated with improved surgical outcomes. Graft selection must be individualised, adapted to the needs of the athletes and our patients. REHABILITATION Electromyography (EMG) is a diagnostic tool to identify muscular imbalances in rehabilitation and, at the same time, to help reduce them through biofeedback training. COGNITIVE TRAINING Training for the development of basic cognitive skills helps to optimise performance through its potentially positive influence on the executive functions of athletes.
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Affiliation(s)
- Johannes Weishorn
- Orthopädische Universitätsklinik Heidelberg, Ruprecht-Karls-Universität, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | | | - Ralf Kern
- Ethianum, Heidelberg, Deutschland
- TSG 1899 Hoffenheim Fußball-Spielbetriebs GmbH, Zuzenhausen, Deutschland
| | - Jan Mayer
- TSG ResearchLab gGmbH, Zuzenhausen, Deutschland
| | | | - Tobias Renkawitz
- Orthopädische Universitätsklinik Heidelberg, Ruprecht-Karls-Universität, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland
| | - Yannic Bangert
- Orthopädische Universitätsklinik Heidelberg, Ruprecht-Karls-Universität, Schlierbacher Landstraße 200a, 69118, Heidelberg, Deutschland.
- TSG 1899 Hoffenheim Fußball-Spielbetriebs GmbH, Zuzenhausen, Deutschland.
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Kumar A, Raza K, Krishna H, Narayan RK, Jha RK, Kumari C, Asghar A, Kumar T, Agrawal P. Sharing of proximal fibers by the anterolateral and lateral collateral ligaments in the human knee: a cadaveric study. Sci Rep 2023; 13:12317. [PMID: 37516773 PMCID: PMC10387103 DOI: 10.1038/s41598-023-38211-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 07/05/2023] [Indexed: 07/31/2023] Open
Abstract
Literature is highly inconsistent in describing the proximal attachment of the anterolateral ligament (ALL) and its relationship with the lateral collateral ligament (LCL) in human knees. This observational study aims to investigate that lacuna. The gross dissection was performed in the lower limbs (n = 83) from the donated adult-age (> 18 years) embalmed cadavers from medical institutions in the north and east India. The dissected knee specimens were first examined macroscopically. Further routine and special staining and microscopic examinations were performed. The ALL was absent in approximately 20.4% of the studied knee specimens (17/83). In remaining, the sharing of ALL and LCL proximal fibers was observed as a consistent finding (~ 97%) with rare exceptions. The mean length of the tibial and meniscal limbs of ALL was 1.57 ± 0.8 cm [Range (R) 0.5-4 cm] and 0.73 ± 0.47 cm [Range (R) 0.1-1.6 cm], respectively. In addition, multiple variations in its presentation were observed. We propose that the proximal sharing of LCL-ALL fibers is a dominant feature in the studied population. The sharing of the fibers may impact the biomechanics and injury mechanisms for both ligaments. The possibility of ethnic variations in the ALL morphology should be a concern during reconstruction surgery.
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Affiliation(s)
- Ashutosh Kumar
- Department of Anatomy, All India Institute of Medical Sciences, Patna, Bihar, 801507, India.
| | - Khursheed Raza
- Department of Anatomy, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
| | - Hare Krishna
- Department of Anatomy, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ravi K Narayan
- Department of Anatomy, Dr. B.C. Roy Multi Speciality Medical Research Center, Indian Institute of Technology, Kharagpur, West Bengal, India
| | - Rakesh K Jha
- Department of Anatomy, All India Institute of Medical Sciences, Patna, Bihar, 801507, India
| | - Chiman Kumari
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Adil Asghar
- Department of Anatomy, All India Institute of Medical Sciences, Patna, Bihar, 801507, India
| | - Tarun Kumar
- Department of Pathology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Prabhat Agrawal
- Department of Orthopedics, All India Institute of Medical Sciences, Patna, Bihar, India
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Suh DK, Cho IY, Noh S, Yoon DJ, Jang KM. Anatomical and Biomechanical Characteristics of the Anterolateral Ligament: A Descriptive Korean Cadaveric Study Using a Triaxial Accelerometer. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020419. [PMID: 36837620 PMCID: PMC9964873 DOI: 10.3390/medicina59020419] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/11/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023]
Abstract
Background and Objectives: The anterolateral ligament (ALL) could be the potential anatomical structure responsible for rotational instability after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to investigate the anatomical and biomechanical characteristics of the ALL in Korean cadaveric knee joints. Materials and Methods: Twenty fresh-frozen cadaveric knees were dissected and tested. Femoral and tibial footprints of the ALL were recorded. Pivot shift and Lachman tests were measured with KiRA. Results: The prevalence of ALL was 100%. The average distance of the tibial footprint to the tip of the fibular head was 19.85 ± 3.41 mm; from the tibial footprint to Gerdy's tubercle (GT) was 18.3 ± 4.19 mm; from the femoral footprint to the lateral femoral epicondyle was 10.25 ± 2.97 mm. ALL's footprint distance was the longest at 30° of flexion (47.83 ± 8.05 mm, p < 0.01) in a knee with intact ALL-ACL and neutral rotation. During internal rotation, the footprint distance was the longest at 30° of flexion (50.05 ± 8.88 mm, p < 0.01). Internal rotation produced a significant increase at all three angles after ACL-ALL were transected (p = 0.022), where the footprint distance was the longest at 30° of flexion (52.05 ± 7.60 mm). No significant difference was observed in KiRA measurements between intact ALL-ACL and ALL-transected knees for pivot shift and Lachman tests. However, ACL-ALL-transected knees showed significant differences compared to the intact ALL-ACL and ALL-transected knees (p < 0.01). Conclusions: The ALL was identified as a distinct ligament structure with a 100% prevalence in this cadaveric study. The ALL plays a protective role in internal rotational stability. An isolated ALL transection did not significantly affect the ALL footprint distances or functional stability tests. Therefore, the ALL is thought to act as a secondary supportive stabilizer for rotational stability of the knee joint in conjunction with the ACL.
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Affiliation(s)
- Dae Keun Suh
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Il-Yup Cho
- Joint Center, Seoul Barunsesang Hospital, Seoul 08523, Republic of Korea
| | - Sehyun Noh
- College of Medicine, Korea University, Seoul 02841, Republic of Korea
| | - Dong Joo Yoon
- College of Medicine, Korea University, Seoul 02841, Republic of Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
- Correspondence: ; Tel.: +82-920-6406
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8
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Devitt BM, Neri T, Fritsch BA. Combined anterolateral complex and anterior cruciate ligament injury: Anatomy, biomechanics, and management-State-of-the-art. J ISAKOS 2023; 8:37-46. [PMID: 36368633 DOI: 10.1016/j.jisako.2022.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/06/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022]
Abstract
Anterior cruciate ligament (ACL) rupture typically occurs because of sudden axial loading of the knee in conjunction with a coupled valgus and rotational moment about the tibia. However, the ACL is not the only structure damaged during this mechanism of injury, and studies have shown that the anterolateral complex (ALC) of the knee is also commonly involved. Biomechanical studies have established that the ALC plays an important role as a secondary stabiliser to control anterolateral rotatory laxity (ALRL). Indeed, it has been suggested that failure to address injury to the ALC at the time of ACL reconstruction (ACLR) may increase the risk of graft failure owing to persistent ALRL. The concept of combining a lateral extra-articular procedure to augment ACLR for the treatment of ACL injury emerged with a view to decrease the failure rate of either procedure in isolation. This state-of-the-art review discusses the history of the anatomy of the ALC, the biomechanics of a variety of lateral extra-articular augmentation procedures, and provides clinical guidelines for their use in primary ACLR.
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Affiliation(s)
- Brian M Devitt
- Dublin City University, School of Health and Human Performance & Sports Surgery Clinic, Dublin, D09 C523, Ireland.
| | - Thomas Neri
- Department of Orthopaedic Surgery, University Hospital of Saint-Etienne, University of Lyon - Jean Monnet, 42000, France
| | - Brett A Fritsch
- Sydney Orthopaedic Research Institute, Level 1, The Gallery, 445 Victoria Avenue, Chatswood, NSW 2067, Australia
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Muccioli GMM, Rinaldi VG, Zappia M, Lullini G, Bignozzi S, Zaffagnini S, Trinchese GF. Minimally invasive anatomic reconstruction of the anterolateral ligament with ipsilateral gracilis tendon: a kinematic in-vitro study. J Exp Orthop 2022; 9:107. [PMID: 36271953 PMCID: PMC9588119 DOI: 10.1186/s40634-022-00543-2] [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: 07/05/2022] [Accepted: 10/12/2022] [Indexed: 11/15/2022] Open
Abstract
Purpose The anterolateral ligament (ALL) has been defined as a key stabilizer of internal tibial rotation at 35° or more of knee flexion, with a minimal primary or secondary stabilizing role in the AP direction. This study aimed to demonstrate that anatomical reconstruction of the ALL confers rotational stability equal to that of the uninjured knee. Hypothesis: anteroposterior (AP) and rotatory laxity will significantly vary after ALL tenotomy and ALL reconstruction with the author’s previously described technique. Methods After ultrasound (US) ALL identification, different kinematic measurements were performed with an image-less Computer-Assisted Navigation System with dedicated software for Laxity Analysis in 5 knee specimens. Anteroposterior (AP) translations and varus/valgus (VV) and Internal-External (IE) rotations were evaluated by two trained orthopedic surgeons before ALL section, after ALL section, and after ALL anatomical reconstruction with doubled ipsilateral autologous gracilis tendon. Results ALL resection significantly increased laxity in IE rotations with knee 90° flexed (IE90) and AP translation with tibia internally rotated and the knee 30° flexed (APlat) (p < 0.05). ALL reconstruction significantly reduced laxity in IE90 and APlat (p < 0.05) and reduced VV rotations at 30° of flexion (VV30) (p < 0.05). There were no statistically significant elongation differences between native ALL and reconstructed ALL (graft) during laxity tests. The inter-operator repeatability of the tests was excellent for each measurement. Conclusions ALL acted as an important internal tibial rotation restrain at 90° and a significant (secondary) AP stabilizer at 30° of knee flexion. The presented ALL reconstruction technique significantly restored the increase of knee laxity produced by the ALL section. Scientific level Case-Controlled Laboratory Study, Level III.
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Affiliation(s)
- Giulio Maria Marcheggiani Muccioli
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy. .,DIBINEM University of Bologna, via di Barbiano, 1/10 - c/o Lab Biomeccanica ed Innovazione Tecnologica, 40136, Bologna, Italy.
| | - Vito Gaetano Rinaldi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marcello Zappia
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy.,Department of Radiology, Varelli Insitute, Naples, Italy
| | - Giada Lullini
- DIBINEM University of Bologna, via di Barbiano, 1/10 - c/o Lab Biomeccanica ed Innovazione Tecnologica, 40136, Bologna, Italy.,U.O.C. Medicina Riabilitativa e Neuroriabilitazione, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.,DIBINEM University of Bologna, via di Barbiano, 1/10 - c/o Lab Biomeccanica ed Innovazione Tecnologica, 40136, Bologna, Italy
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10
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Xu J, Ye Z, Han K, Xu C, Zhao J, Dong S. Anterolateral Structure Reconstructions With Different Tibial Attachment Sites Similarly Improve Tibiofemoral Kinematics and Result in Different Graft Force in Treating Knee Anterolateral Instability. Arthroscopy 2022; 38:2684-2696. [PMID: 35337957 DOI: 10.1016/j.arthro.2022.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical effects of anterolateral structure reconstructions (ALSRs) with different tibial attachments on tibiofemoral kinematics and anterolateral structure (ALS) graft forces. METHODS Eight cadaveric knees were tested in a customized knee testing system, using a novel pulley system to simulate more muscle tensions by loading the iliotibial band at 30 N and quadriceps at 10 N in all testing states. Anterior stability during anterior load and anterolateral rotatory stability during 2 simulated pivot-shift tests (PST1 and PST2) were evaluated in 5 states: intact, ALS-deficient (Def), ALSR-Ta (anterior tibial site), ALSR-Tm (middle tibial site), and ALSR-Tp (posterior tibial site). Tibiofemoral kinematics and resulting ALS graft forces against the applied loads were measured and compared in the corresponding states. RESULTS In anterior load, 3 ALSRs mitigated the anterior laxities of the ALS Def state at all degrees, which were close to intact state at 0° and 30° but showed significantly overconstraints at 60° and 90°. In both PSTs, all ALSRs significantly reduced the anterolateral rotatory instability of ALS Def, whereas the significant overconstraints were detected in ALSR-Ta and ALSR-Tm at greater knee flexion angles. All ALS grafts carried forces in resisting anterior and pivot-shift loads. Only ALS graft force in ALSR-Ta increased continuously with knee flexion angles. The ALS graft forces carried by ALSR-Ta were significantly larger than those by ALSR-Tp and ALSR-Tm when resisting anterior load and PSTs at greater knee flexion angles. CONCLUSIONS ALSRs with different tibial attachment sites similarly restored knee laxities close to the native tibiofemoral kinematics in an ALS-deficient knee, whereas the ALSR-Tp showed less propensity for overconstraining the knee at greater flexion angles. The ALS graft in ALSR-Ta carried more forces than those in ALSR-Tp and ALSR-Tm against simulated loads. CLINICAL RELEVANCE Altering the tibial attachment sites of ALSRs may not significantly affect tibiofemoral kinematics at most degrees whereas the posterior may have less overconstraints at greater flexion angles. However, ALS graft positioning at a more anterior tibial attachment site may carry more forces in resisting anterior and pivot-shift loads.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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11
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Sabatini L, Capella M, Vezza D, Barberis L, Camazzola D, Risitano S, Drocco L, Massè A. Anterolateral complex of the knee: State of the art. World J Orthop 2022; 13:679-692. [PMID: 36159618 PMCID: PMC9453282 DOI: 10.5312/wjo.v13.i8.679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/07/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023] Open
Abstract
Rotatory instability of the knee represents the main reason for failure and poor clinical outcomes regarding anterior cruciate ligament (ACL) reconstruction techniques. It is now clear that the anterolateral complex (ALC) of the knee possesses a fundamental role, in association with the ACL, in controlling internal rotation. Over the past decade, ever since the anterolateral ligament has been identified and described as a distinct structure, there has been a renewed interest in the scientific community about the whole ALC: Lateral extra-articular tenodesis have made a comeback in association with ACL reconstructions to improve functional outcomes, reducing the risks of graft failure and associated injuries. Modern ACL reconstruction surgery must therefore investigate residual instability and proceed, when necessary, to extra-articular techniques, whether functional tenodesis or anatomical reconstruction.This review aims to investigate the latest anatomical and histological descriptions, and the role in rotational control and knee biomechanics of the ALC and its components. The diagnostic tools for its identification, different reconstruction techniques, and possible surgical indications are described.. In addition, clinical and functional results available in the literature are reported.
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Affiliation(s)
- Luigi Sabatini
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Marcello Capella
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Daniele Vezza
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Luca Barberis
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Daniele Camazzola
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Salvatore Risitano
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Luca Drocco
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Alessandro Massè
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
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12
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Sasaki R, Niki Y, Kaneda K, Yamada Y, Nagura T, Nakamura M, Jinzaki M. A novel anteroposterior axis of the tibia for total knee arthroplasty: An upright weight-bearing computed tomography analysis. Knee 2022; 36:80-86. [PMID: 35561561 DOI: 10.1016/j.knee.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 03/13/2022] [Accepted: 04/18/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The traditional anteroposterior (AP) axis (i.e., Akagi's line) has been widely used as the tibial component AP axis during total knee arthroplasty (TKA). However, this AP axis has been defined based on computed tomography (CT) in a non-weight-bearing supine position. In this study, AP axes of the tibial plateau from upright CT in weight-bearing and non-weight-bearing positions were determined and compared. METHODS This study included 43 knees from 23 healthy volunteers. CT images were obtained in weight-bearing and non-weight-bearing standing positions using a 320-detector row upright CT scanner. The line perpendicular to surgical transepicondylar axis projected onto the tibia plateau was determined as the AP axis in upright weight-bearing and non-weight-bearing conditions. Angular differences between these two conditions were measured. RESULTS The upright weight-bearing AP axis was positioned in a mean of 7.4 ± 4.3° of internal rotation relative to the traditional AP axis. Distance between the traditional and upright weight-bearing AP axis was 2.9 ± 1.6 mm at the edge of the tibial plateau. The upright non-weight-bearing AP axis was positioned in a mean of 3.5 ± 4.1° of internal rotation relative to the traditional AP axis. Mean angular difference between weight-bearing and non-weight-bearing conditions was 3.9 ± 4.1°. CONCLUSIONS The upright weight-bearing AP axis was positioned in 7.4° of internal rotation relative to the traditional AP axis, showing one-seventh of the tibial tuberosity away from the medial border of the tibial tubercle, which represents a practical landmark for the tibial component AP axis during TKA.
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Affiliation(s)
- Ryo Sasaki
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Yasuo Niki
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.
| | - Kazuya Kaneda
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Yoshitake Yamada
- Department of Diagnostic Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Takeo Nagura
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
| | - Masahiro Jinzaki
- Department of Diagnostic Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
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13
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Fortier LM, Stylli JA, Civilette M, Duran NS, Hanukaai S, Wilder H, Sherman WF, Kaye AD. An Evidence-Based Approach to Multi-Ligamentous Knee Injuries. Orthop Rev (Pavia) 2022; 14:35825. [PMID: 35769647 PMCID: PMC9235428 DOI: 10.52965/001c.35825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/12/2022] [Indexed: 01/19/2024] Open
Abstract
Multi ligament knee injuries (MLKIs) are highly complex injuries with associated complications and often present with difficult management strategies. MLKIs may affect the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (or posteromedial corner (PMC)), and lateral collateral ligament (or posterolateral corner (PLC)) in addition to other structures including the menisci, common peroneal nerve, and popliteal artery. MLKIs are highly associated with the male sex and are commonly seen in high-velocity motor vehicle accidents and low-velocity sports injuries. Given the multiple planes of movement in the knee and various primary and secondary stabilizers throughout those planes, there is great heterogeneity in an injury pattern and most involve the ACL and PCL. Initial evaluation of this injury includes assessment of lower extremity sensation, distal pulses, and ankle-brachial index (ABI). If vascular compromise is suspected, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) are indicated to evaluate the vasculature. As opposed to CTA, MRA offers visualization of the soft-tissue structures that are commonly damaged in MLKIs. Initial management typically includes closed reduction of the knee with subsequent external fixation. Classification systems guide initial assessments; however, further management is unclear and leads the surgical team to decide the best, individualized management option for each patient. As a result, optimal surgical and postoperative treatment options remain complicated, and clinical outcomes remain difficult to predict. The purpose of this review is to consolidate the most up-to-date practices of the diagnostic workup, management, and treatment of MLKIs.
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Affiliation(s)
| | | | | | | | | | - Heath Wilder
- Department of Orthopaedic Surgery, Tulane University
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport
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14
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Qiu J, Wang C, Kernkamp WA, Chen J, Xu C, Tsai TY, Zhao J. Author Reply to "Regarding 'Augmentation of Anterolateral Structures of the Knee Causes Undesirable Tibiofemoral Cartilage Contact in Double-Bundle Anterior Cruciate Ligament Reconstruction-A Randomized In-Vivo Biomechanics Study'". Arthroscopy 2022; 38:1392-1394. [PMID: 35501006 DOI: 10.1016/j.arthro.2021.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/17/2021] [Indexed: 02/02/2023]
Affiliation(s)
- Jiayu Qiu
- Department of Sports Medicine, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Cong Wang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Willem A Kernkamp
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Tsung-Yuan Tsai
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
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15
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Hodel S, Torrez C, Flury A, Fritz B, Steinwachs MR, Vlachopoulos L, Fucentese SF. Tibial internal rotation in combined anterior cruciate ligament and high-grade anterolateral ligament injury and its influence on ACL length. BMC Musculoskelet Disord 2022; 23:262. [PMID: 35303847 PMCID: PMC8932291 DOI: 10.1186/s12891-022-05218-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 03/14/2022] [Indexed: 01/11/2023] Open
Abstract
Background Assessment of combined anterolateral ligament (ALL) and anterior cruciate ligament (ACL) injury remains challenging but of high importance as the ALL is a contributing stabilizer of tibial internal rotation. The effect of preoperative static tibial internal rotation on ACL -length remains unknown. The aim of the study was analyze the effect of tibial internal rotation on ACL length in single-bundle ACL reconstructions and to quantify tibial internal rotation in combined ACL and ALL injuries. Methods The effect of tibial internal rotation on ACL length was computed in a three-dimensional (3D) model of 10 healthy knees with 5° increments of tibial internal rotation from 0 to 30° resulting in 70 simulations. For each step ACL length was measured. ALL injury severity was graded by a blinded musculoskeletal radiologist in a retrospective analysis of 61 patients who underwent single-bundle ACL reconstruction. Preoperative tibial internal rotation was measured in magnetic resonance imaging (MRI) and its diagnostic performance was analyzed. Results ACL length linearly increased 0.7 ± 0.1 mm (2.1 ± 0.5% of initial length) per 5° of tibial internal rotation from 0 to 30° in each patient. Seventeen patients (27.9%) had an intact ALL (grade 0), 10 (16.4%) a grade 1, 21 (34.4%) a grade 2 and 13 (21.3%) a grade 3 injury of the ALL. Patients with a combined ACL and ALL injury grade 3 had a median static tibial internal rotation of 8.8° (interquartile range (IQR): 8.3) compared to 5.6° (IQR: 6.6) in patients with an ALL injury (grade 0–2) (p = 0.03). A cut-off > 13.3° of tibial internal rotation predicted a high-grade ALL injury with a specificity of 92%, a sensitivity of 30%; area under the curve (AUC) 0.70 (95% CI: 0.54–0.85) (p = 0.03) and an accuracy of 79%. Conclusion ACL length linearly increases with tibial internal rotation from 0 to 30°. A combined ACL and high-grade ALL injury was associated with greater preoperative tibial internal rotation. This potentially contributes to unintentional graft laxity in ACL reconstructed patients, in particular with concomitant high-grade ALL tears. Study design Cohort study; Level of evidence, 3. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05218-8.
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Affiliation(s)
- Sandro Hodel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Carlos Torrez
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Andreas Flury
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Benjamin Fritz
- Department of Radiology, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Matthias R Steinwachs
- SportClinic Zurich Hirslanden Clinic, Witellikerstrasse, 40, 8032, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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16
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Xu J, Han K, Lee TQ, Xu C, Su W, Chen J, Yu J, Dong S, Zhao J. Anterolateral Structure Reconstruction Similarly Improves the Stability and Causes Less Overconstraint in Anterior Cruciate Ligament-Reconstructed Knees Compared With Modified Lemaire Lateral Extra-articular Tenodesis: A Biomechanical Study. Arthroscopy 2022; 38:911-924. [PMID: 34358641 DOI: 10.1016/j.arthro.2021.06.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 06/13/2021] [Accepted: 06/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the kinematics of anterolateral structure (ALS) reconstruction (ALSR) and lateral extra-articular tenodesis (LET) in ACL-ALS-deficient knees with anterior cruciate ligament (ACL) reconstruction. METHODS Ten fresh-frozen cadaveric knees with the following conditions were tested: (1) intact, (2) ACL-ALS deficiency, (3) ACL reconstruction (ACLR), (4) ACLR combined with ALSR (ACL-ALSR) or LET (ACLR+LET). Anterior translation and tibial internal rotation were measured with 90-N anterior load and 5 N·m internal torque at 0°, 30°, 60°, and 90°. The anterolateral translation and internal rotation were also measured during a simulated pivot-shift test at 0°, 15°, 30°, and 45°. The knee kinematic changes in all reconstructions were compared with each other, with intact knees as the baseline. RESULTS Isolated ACLR failed to restore native knee kinematics in ACL-ALS-deficient knees. Both ACL-ALSR and ACLR+LET procedures decreased the anterior instability of the ACLR. However, ACLR+LET caused overconstraints in internal rotation at 30° (-3.73° ± 2.60°, P = .023), 60° (-4.96° ± 2.22°, P = .001) and 90° (-6.14° ± 1.60°, P < .001). ACL-ALSR also overconstrained the knee at 60° (-3.65° ± 1.90°, P < .001) and 90° (-3.18° ± 2.53°, P < .001). For a simulated pivot-shift test, both combined procedures significantly reduced the ACLR instability, with anterolateral translation and internal rotation being overconstrained in ACLR+LET at 30° (-3.32 mm ± 3.89 mm, P = .005; -2.58° ± 1.61°, P < .001) and 45° (-3.02 mm ± 3.95 mm, P = .012; -3.44° ± 2.86°, P < .001). However, the ACL-ALSR overconstrained only the anterolateral translation at 30° (-1.51 mm ± 2.39 mm, P = .046) and internal rotation at 45° (-2.09° ± 1.70°, P < .001). There were no significant differences between the two combined procedures at most testing degrees in each testing state, except for the internal rotation at 30° (P = .007) and 90° (P = .032) in internal rotation torque. CONCLUSION ACL reconstruction alone did not restore intact knee kinematics in knees with concurrent ACL tears and severe ALS injury (ACL-ALS-deficient status). Both ACL-ALSR and ACLR+LET procedures restored knee stability at some flexion degrees, with less overconstraints in internal rotation resulting from ACL-ALSR. CLINICAL RELEVANCE For patients with combined ACL tears and severe ALS deficiency, isolated ACLR probably results in residual rotational and pivot-shift instability. Both ACL-ALSR and ACLR+LET show promise for the improvement of knee stability, whereas ACL-ALSR has less propensity for knee overconstraint.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, U.S.A
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiakuo Yu
- Knee Surgery Department of the Institute of Sports Medicine & Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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17
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Moreno Mateo F, Perea SH, Green DW. Lateral-extra articular tenodesis vs. anterolateral ligament reconstruction in skeletally immature patients undergoing anterior cruciate ligament reconstruction. Curr Opin Pediatr 2022; 34:71-75. [PMID: 34845153 DOI: 10.1097/mop.0000000000001084] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the most recent available evidence about lateral-extra articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction in young patients treated for anterior cruciate ligament (ACL) injury. RECENT FINDINGS The ALL of the knee acts as a secondary stabilizer of the knee preventing anterior translation and internal rotation. In vitro and in vivo biomechanical studies as well as prospective clinical trials have shown the importance of the ALL in knee biomechanics. The ALL injury has a synergetic impact on the knee stability in patients with acute ACL injury. ALL augmentation of ACL provides reduction of knee instability and graft failure and higher return to sport rates in high-risk patients. It has not been demonstrated that extra-articular procedures increase the risk of knee osteoarthritis secondary to knee over-constriction. Both Iliotibial band (ITB) ALL reconstruction and modified Lemaire LET have been shown safe and effective. Minimal biomechanical or clinical differences have been found between the two reconstruction methods. SUMMARY Young patients with ACL tears and risk factors such as laxity or pivot shift willing to return to sports may benefit from ALL augmentation. Therefore, it is essential to identify these high-risk patients to individualize treatment.
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Affiliation(s)
- Fernando Moreno Mateo
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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18
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Badawy CR, Jan K, Beck EC, Fleet N, Taylor J, Ford K, Waterman BR. Contemporary Principles for Postoperative Rehabilitation and Return to Sport for Athletes Undergoing Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2022; 4:e103-e113. [PMID: 35141542 PMCID: PMC8811493 DOI: 10.1016/j.asmr.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/09/2021] [Indexed: 12/16/2022] Open
Abstract
Despite advancements in our understanding of anterior cruciate ligament (ACL) injury prevention and nonsurgical management, ACL reconstruction continues to occur at an alarming rate. Among athletic patients, individuals participating in basketball, soccer, and football have the highest incidence of ACL injury, often requiring surgical intervention. To ensure the optimal treatment strategy for return to sport and prevention of secondary graft re-tear, it is important to tailor to the specific demands of the injured athlete and apply evidence-based best practices and rehabilitation principles. The purpose of this review is to provide readers with a brief background regarding ACL injuries, a focused review of clinical outcome studies after ACL reconstruction, and an updated framework with expert-guided recommendations for postoperative rehabilitation and return to sporting activity. Currently, there is no gold standard for rehabilitation after ACL reconstruction, highlighting the need for robust studies evaluating the best modalities for athlete rehabilitation, as well as determining the efficacy of new tools for improving therapy including blood flow restriction therapy and neuromuscular electrical stimulation. Based on clinical experience, a renewed focus on objective, criteria-based milestones may maximize the ability of return to preinjury levels of athletic function.
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Affiliation(s)
- Charles R Badawy
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Kyleen Jan
- University of Illinois College of Medicine, Chicago, Illinois, U.S.A
| | - Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Niles Fleet
- Department of Athletics, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - Jeffrey Taylor
- Department of Physical Therapy, High Point University, High Point, North Carolina, U.S.A
| | - Kevin Ford
- Department of Physical Therapy, High Point University, High Point, North Carolina, U.S.A
| | - Brian R Waterman
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
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19
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Zhang ZY, Wang C, Maimaitimin M, Huang HJ, Pan XY, Maimaitijiang P, He ZY, Wang XW, Zhang X, Wang JQ. Anterior and rotational tibial subluxation in the setting of anterior cruciate ligament injuries: An MRI analysis. Knee 2021; 33:365-373. [PMID: 34753026 DOI: 10.1016/j.knee.2021.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/10/2021] [Accepted: 10/11/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The relationship between preoperative tibiofemoral position and failure of anterior cruciate ligament (ACL) reconstruction has been widely discussed. Most established methods for measuring tibiofemoral position on magnetic resonance imaging (MRI) mainly focus on anterior tibial subluxation (ATS), while a quantitative measuring method for rotational tibial subluxation (RTS) is still undetermined. Moreover, there are still controversies about the related factors for ATS. The aim of this study was to quantitatively describe preoperative ATS and RTS in ACL-injured and ACL-intact knees and identify the related factors for ATS and RTS based on MRI images. METHODS Demographic data and preoperative MRIs of 104 ACL-injured patients were retrospectively analyzed. ACL-intact knees were 1:1 matched as control group. ATS was measured using longitudinal tibial axis, and RTS was determined by the difference between lateral and medial ATS. Related factors for ATS and RTS were examined. RESULTS Increased lateral ATS (P < 0.0001), medial ATS (P < 0.0001) and RTS (P = 0.0479) were observed in ACL-injured knees compared with the control group. Increased posterior tibial slope (PTS), Beighton Score ≥ 4, presence of meniscal injury and long injury-to-MRI time were identified as being correlated with the increase of ATS. Factors for the increase of RTS were increased lateral PTS, Beighton score ≥ 4, presence of lateral meniscal injury, and left side. CONCLUSIONS In ACL-injured knees, tibia not only subluxated anteriorly in both lateral and medial compartments, but also rotated internally. During preoperative planning, attentions should be paid to the factors that are correlated with altered tibiofemoral position.
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Affiliation(s)
- Zhi-Yu Zhang
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Peking University Health Science Center, Beijing, China
| | - Cheng Wang
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Peking University Health Science Center, Beijing, China
| | - Maihemuti Maimaitimin
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Peking University Health Science Center, Beijing, China
| | - Hong-Jie Huang
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Peking University Health Science Center, Beijing, China
| | - Xiao-Yu Pan
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Peking University Health Science Center, Beijing, China
| | - Pakezhati Maimaitijiang
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Department of Sports Medicine, Peking University Third Hospital, Beijing, China
| | - Zi-Yi He
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Peking University Health Science Center, Beijing, China
| | - Xue-Wen Wang
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Peking University Health Science Center, Beijing, China
| | - Xin Zhang
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Peking University Health Science Center, Beijing, China.
| | - Jian-Quan Wang
- Department of Sports Medicine, Peking University Third Hospital, Beijing, China; Institute of Sports Medicine of Peking University, Beijing, China; Beijing Key Laboratory of Sports Injuries, Beijing, China; Peking University Health Science Center, Beijing, China.
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20
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Caracciolo G, Yáñez R, Silvestre R, De la Fuente C, Zamorano H, Ossio A, Strömbäck L, Abusleme S, P Carpes F. Intraoperative pivot-shift accelerometry combined with anesthesia improves the measure of rotatory knee instability in anterior cruciate ligament injury. J Exp Orthop 2021; 8:80. [PMID: 34561730 PMCID: PMC8463650 DOI: 10.1186/s40634-021-00396-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/27/2021] [Indexed: 01/11/2023] Open
Abstract
Purpose The knee stiffness acquired following an Anterior Cruciate Ligament (ACL) injury might affect clinical knee tests, i.e., the pivot-shift maneuver. In contrast, the motor effects of spinal anesthesia could favor the identification of rotatory knee deficiencies prior to ACL reconstruction. Hence, we hypothesized that the intra-operative pivot-shift maneuver under spinal anesthesia generates more acceleration in the lateral tibial plateau of patients with an injured ACL than without. Methods Seventy patients with unilateral and acute ACL rupture (62 men and 8 women, IKDC of 55.1 ± 13.8 pts) were assessed using the pivot-shift maneuver before and after receiving spinal anesthesia. A triaxial accelerometer was attached to the skin between Gerdys’ tubercle and the anterior tuberosity to measure the subluxation and reduction phases. Mixed ANOVA and multiple comparisons were performed considering the anesthesia and leg as factors (alpha = 5%). Results We found a higher acceleration in the injured leg measured under anesthesia compared to without anesthesia (5.12 ± 1.56 m.s− 2 vs. 2.73 ± 1.19 m.s− 2, p < 0.001), and compared to the non-injured leg (5.12 ± 1.56 m.s− 2 vs. 3.45 ± 1.35 m.s− 2, p < 0.001). There was a presence of significant interaction between leg and anesthesia conditions (p < 0.001). Conclusions The pivot-shift maneuver performed under anesthesia identifies better rotatory instability than without anesthesia because testing the pivot-shift without anesthesia underestimates the rotatory subluxation of the knee by an increased knee stiffness. Thus, testing under anesthesia provides a unique opportunity to determine the rotational instability prior to ACL reconstruction.
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Affiliation(s)
- Gastón Caracciolo
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Roberto Yáñez
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Rony Silvestre
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Carlos De la Fuente
- Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile.,Applied Neuromechanics Research Group, Laboratory of Neuromechanics, Federal University of Pampa, Uruguaiana, RS, 97500-970, Brazil.,Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, RM, 7820436, Chile
| | - Héctor Zamorano
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Alejandra Ossio
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Lars Strömbäck
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Sebastian Abusleme
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Felipe P Carpes
- Applied Neuromechanics Research Group, Laboratory of Neuromechanics, Federal University of Pampa, Uruguaiana, RS, 97500-970, Brazil.
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21
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Littlefield CP, Belk JW, Houck DA, Kraeutler MJ, LaPrade RF, Chahla J, McCarty EC. The Anterolateral Ligament of the Knee: An Updated Systematic Review of Anatomy, Biomechanics, and Clinical Outcomes. Arthroscopy 2021; 37:1654-1666. [PMID: 33340678 DOI: 10.1016/j.arthro.2020.12.190] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/29/2020] [Accepted: 12/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform an updated systematic review of the anatomy, biomechanics, function of the anterolateral ligament (ALL), and the clinical outcomes of anterolateral ligament reconstruction (ALLR) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR). METHODS A systematic search of the literature was performed by searching PubMed, the Cochrane Library, and Embase with the search phrase anterolateral ligament for articles published from February 2017 to May 2020. Inclusion criteria included studies that evaluated the anatomy, function, or biomechanics of the ALL; surgical technique articles on ALLR; clinical articles reporting outcomes of ALLR; studies published in English; and full-text articles. Exclusion criteria included studies published before February 2017. A subjective synthesis was performed, in which ranges were reported, and individual study data were presented in forest plots. RESULTS Overall, 40 articles were included in this systematic review, with 11 articles describing ALL anatomy, 14 articles analyzing ALL function and biomechanics, 7 articles discussing the surgical technique of combined ACLR and ALLR (ACLR/ALLR), and 8 articles describing the clinical outcomes of ACLR/ALLR. The addition of ALLR in combination with ACLR (ACLR+) results in lower graft failure rates for ACLR/ALLR (0.0%-15.7%) when compared with isolated ACLR (I-ACLR) patients (7.4%-21.7%). Three of 5 studies using the Subjective International Knee Documentation Committee score, 2 of 5 studies using the Lysholm score, and 1 of 2 studies using the Tegner score reported significantly better scores at latest follow-up among ACLR+ patients compared with I-ACLR (P < .05). CONCLUSIONS The ALL acts as a secondary stabilizer to the anterior cruciate ligament and helps resist internal knee rotation and anterior tibial translation. Based on the current literature, combined ACLR with ALLR may result in lower graft failure rates and improved patient-reported outcomes when compared with I-ACLR in patients with specific indications, although several studies have shown equivalent outcomes between these 2 cohorts. CLINICAL RELEVANCE The contents of this review provide great insight for orthopaedic surgeons who are performing ACLR and considering additional procedures to increase overall knee stability and decrease likeliness for re-rupture. The postoperative functional and clinical outcomes shown in patients undergoing ACLR+ compared with I-ACLR should be given proper consideration when evaluating available treatment courses.
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Affiliation(s)
- Connor P Littlefield
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - John W Belk
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A..
| | - Darby A Houck
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
| | - Matthew J Kraeutler
- St. Joseph's University Medical Center, Department of Orthopaedic Surgery, Paterson, New Jersey, U.S.A
| | | | - Jorge Chahla
- Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Eric C McCarty
- University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A
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22
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Xu J, Han K, Su W, Jiang J, Yan X, Yu J, Dong S, Zhao J. A Secondary Injury of the Anterolateral Structure Plays a Minor Role in Anterior and Anterolateral Instability of Anterior Cruciate Ligament-Deficient Knees in the Case of Functional Iliotibial Band. Arthroscopy 2021; 37:1182-1191. [PMID: 33227322 DOI: 10.1016/j.arthro.2020.10.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 10/24/2020] [Accepted: 10/24/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the contribution of a secondary anterolateral structure (ALS) deficiency to knee instability based on anterior cruciate ligament (ACL) deficiency, in the condition of a functional iliotibial band (ITB). METHODS Nine freshly-frozen cadaveric knees were sectioned sequentially to create ACL deficiency and ACL-ALS deficiency, using intact knees before sectioning as controls. When ITB was tensioned with 30 N, 4 separate aspects of knee instability were tested as follows: anterior translation in 90 N anterior load, isolated internal rotation in 5 N·m internal rotational torque from 0° to 90° in 15° increments, and anterolateral translation and internal rotation during a simulated pivot-shift test at 0°, 15°, 30°, and 45°. The contribution of ACL deficiency alone and additional ALS deficiency to knee instability were evaluated. RESULTS The addition of an ALS lesion produced no significant exacerbation of either anterior translational or pivot shift instability in ACL-deficient knees. Additional ALS deficiency in an ACL-deficient knee resulted in a significant increase in isolated internal rotation from 45° to 90° (P = .001 at 45° and P < .001 in other cases). After sequentially sectioning, the contribution to instability of additional ALS deficiency to the entire instability in ACL-ALS-deficient knees was significantly smaller than that of ACL deficiency alone during anterior load and pivot-shift test (P < .001 in all cases), but significantly contributed more to isolated internal rotational instability at 60° (P = .011) and 90° (P = .015). CONCLUSIONS When ITB was tensioned, ALS played a minor role in controlling both anterior or pivot shift stability in ACL-deficient knees but a major role in restraining isolated internal rotation from 45° to 90°. CLINICAL RELEVANCE In the condition of functional ITB, concomitant ALS injury might not exacerbate anterior and pivot-shift instability after ACL rupture, while affecting isolated internal rotation stability at higher flexion.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaoyu Yan
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiakuo Yu
- Knee Surgery Department of the Institute of Sports Medicine & Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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23
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Blanke F, Boljen M, Lutter C, Oehler N, Tischer T, Vogt S. Does the anterolateral ligament protect the anterior cruciate ligament in the most common injury mechanisms? A human knee model study. Knee 2021; 29:381-389. [PMID: 33711673 DOI: 10.1016/j.knee.2021.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/01/2020] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction still has a risk of re-rupture and persisting rotational instability. Thus, extra-articular structures such as the anterolateral ligament (ALL) are increasingly treated. The ALL however prevents the internal rotation of the tibia and it must be doubted that the ALL protects the ACL in other common injury mechanisms which primarily include tibial external rotation. In this study we aimed to evaluate which extra-articular structures support the ACL in excessive tibial internal and external rotation using a knee finite element (FE) model. METHODS Internal and external rotations of the tibia were applied to an FE model with anatomical ACL, posterior cruciate ligament (PCL), lateral collateral ligament (LCL), medial collateral ligament (MCL) and intact medial and lateral meniscus. Three additional anatomic structures (anterolateral ligament, popliteal tendon and posterior oblique ligament) were added to the FE model separately and then all together. The force histories within all structures were measured and determined for each case. RESULTS The ACL was the most loaded ligament both in tibial internal and external rotation. The ALL was the main stabilizer of the tibial internal rotation (46%) and prevented the tibial external rotation by only 3%. High forces were only observed in the LCL with tibial external rotation. The ALL reduced the load on the ACL in tibial internal rotation by 21%, in tibial external rotation only by 2%. The POL reduced the load on the ACL by 8%, the PLT by 6% in tibial internal rotation. In tibial external rotation the POL and PLT did not reduce the load on the ACL by more than 1%. CONCLUSION The ALL protects the ACL in injury mechanisms with tibial internal rotation but not in mechanisms with tibial external rotation. In injury mechanisms with tibial external rotation other structures that support the ACL need to be considered.
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Affiliation(s)
- F Blanke
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany; Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany.
| | - M Boljen
- Fraunhofer Institute for High-Speed Dynamics, Ernst-Mach-Institut, EMI, Freiburg i. Breisgau, Germany
| | - C Lutter
- Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany
| | - N Oehler
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany
| | - T Tischer
- Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany
| | - S Vogt
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany
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24
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Gali JC, Gali Filho JC, Marques MF, Almeida TA, Cintra da Silva PA, LaPrade RF. Capsulo-osseous Layer Retensioning and Distal Kaplan Fiber Surgical Reconstruction: A Proposed Anatomical Lateral Extra-articular Tenodesis Approach. Arthrosc Tech 2021; 10:e159-e164. [PMID: 33532223 PMCID: PMC7823100 DOI: 10.1016/j.eats.2020.09.021] [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: 07/20/2020] [Accepted: 09/20/2020] [Indexed: 02/03/2023] Open
Abstract
Anterior cruciate ligament intra-articular reconstruction may require extra-articular reinforcement in certain situations. As knee lateral region anatomical and biomechanical knowledge has increased with new research, it has been reported that the iliotibial band is important in the anterolateral stabilization of the knee. Possible indications for a "more anatomical" extra-articular tenodesis focusing on capsulo-osseous layer tensioning and distal Kaplan fibers reconstruction are reported, surgical approach details are described, and scientific data that gives support for this procedure are discussed.
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Affiliation(s)
- Julio Cesar Gali
- Faculty of Medical Science and Health, Catholic University of São Paulo, Sorocaba
- Address correspondence to Julio Cesar Gali, M.D., Ph.D., Faculty of Medical Science and Health, Catholic University of São Paulo, R. Jouberte Wey 290, Sorocaba-SP, Brazil. 18030070.
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25
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Chaware P, Santoshi JA, Chaurasia A, Parija M, Singh U, Rathinam BA. Correlation Between the Thickness of Anterolateral Ligament and Lateral Collateral Ligament of the Knee. Cureus 2021; 13:e12668. [PMID: 33598371 PMCID: PMC7878636 DOI: 10.7759/cureus.12668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Persistent anterolateral rotatory instability (ALRI) following the anterior cruciate ligament (ACL) reconstruction has led to a renewed interest in defining the role of anterolateral complex (ALC) of the knee. Methods We explored the anterolateral corner of 34 cadaveric knees to define the anterolateral ligament (ALL) in all its dimensions and measured the thickness of lateral collateral ligament (LCL) at the lateral meniscus level (tLCL) in ALL-intact and ALL-deficient knees. Results ALL was present in 27/34 (79%) of the knees. We found complete ALL in 13 cadavers bilaterally. ALL was absent bilaterally in three cadavers; it was present on one side and absent contralaterally in one cadaver. In ALL-intact knees, the average tLCL was 2.05 mm, whereas, in ALL-deficient knees, it was 2.57 mm. This difference in tLCL was statistically significant. Conclusions Our study adds new data to the recent voluminous research on ALL. We have examined the correlation between the thickness of ALL and LCL and documented alterations in the thickness of LCL in ALL-intact knees. These findings would help in designing reconstructive procedures for the combined ACL injury with ALRI.
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Affiliation(s)
| | - John A Santoshi
- Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Aditi Chaurasia
- Radiology, All India Institute of Medical Sciences, Bhopal, IND
| | | | - Urvashi Singh
- Anatomy, All India Institute of Medical Sciences, Bhopal, IND
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26
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Neri T, Dabirrahmani D, Beach A, Grasso S, Putnis S, Oshima T, Cadman J, Devitt B, Coolican M, Fritsch B, Appleyard R, Parker D. Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction. J ISAKOS 2020; 6:74-81. [PMID: 33832980 DOI: 10.1136/jisakos-2019-000360] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The optimal anterolateral procedure to control anterolateral rotational laxity of the knee is still unknown. The objective was to compare the ability of five anterolateral procedures performed in combination with anterior cruciate ligament reconstruction (ACLR) to restore native knee kinematics in the setting of a deficient anterior cruciate ligament (ACL) and anterolateral structures. METHODS A controlled laboratory study was performed using 10 fresh-frozen cadaveric whole lower limbs with intact iliotibial band. Kinematics from 0° to 90° of flexion were recorded using a motion analysis three-dimensional (3D) optoelectronic system, allowing assessment of internal rotation (IR) and anteroposterior (AP) tibial translation at 30° and 90° of flexion. Joint centres and bony landmarks were calculated from 3D bone models obtained from CT scans. Intact knee kinematics were assessed initially, followed by sequential section of the ACL and anterolateral structures (anterolateral ligament, anterolateral capsule and Kaplan fibres). After ACLR, five anterolateral procedures were performed consecutively on the same knee: ALLR, modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh. The last three procedures were randomised. For each procedure, the graft was fixed in neutral rotation at 30° of flexion and with a tension of 20 N. RESULTS Isolated ACLR did not restore normal overall knee kinematics in a combined ACL plus anterolateral-deficient knee, leaving a residual tibial rotational laxity (p=0.034). Only the ALLR (p=0.661) and modified Ellison procedure (p=0.641) restored overall IR kinematics to the normal intact state. Superficial and deep Lemaire and modified MacIntosh tenodeses overconstrained IR, leading to shifted and different kinematics compared with the intact condition (p=0.004, p=0.001 and p=0.045, respectively). Compared with ACLR state, addition of an anterolateral procedure did not induce any additional control on AP translation at 30° and 90° of flexion (all p>0.05), except for the superficial Lemaire procedure at 90° (p=0.032). CONCLUSION In biomechanical in vitro setting, a comparison of five anterolateral procedures revealed that addition of either ALLR or modified Ellison procedure restored overall native knee kinematics in a combined ACL plus anterolateral-deficient knee. Superficial and deep Lemaire and modified MacIntosh tenodeses achieved excellent rotational control but overconstrained IR, leading to a change from intact knee kinematics. LEVEL OF EVIDENCE The level-of-evidence statement does not apply for this laboratory experiments study.
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Affiliation(s)
- Thomas Neri
- Sydney Orthopaedic Research Institute Ltd, Chatswood, New South Wales, Australia .,Laboratory of Human Movement Biology (LIBM EA 7424), University of Lyon-Jean Monnet, Saint Etienne, France
| | - Danè Dabirrahmani
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Aaron Beach
- Sydney Orthopaedic Research Institute Ltd, Chatswood, New South Wales, Australia
| | - Samuel Grasso
- Sydney Orthopaedic Research Institute Ltd, Chatswood, New South Wales, Australia
| | - Sven Putnis
- Sydney Orthopaedic Research Institute Ltd, Chatswood, New South Wales, Australia
| | - Takeshi Oshima
- Sydney Orthopaedic Research Institute Ltd, Chatswood, New South Wales, Australia
| | - Joseph Cadman
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Brian Devitt
- OrthoSport Victoria, Richmond, Victoria, Australia
| | - Myles Coolican
- Sydney Orthopaedic Research Institute Ltd, Chatswood, New South Wales, Australia
| | - Brett Fritsch
- Sydney Orthopaedic Research Institute Ltd, Chatswood, New South Wales, Australia
| | - Richard Appleyard
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - David Parker
- Sydney Orthopaedic Research Institute Ltd, Chatswood, New South Wales, Australia
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27
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Alsiri NF, Alhadhoud MA, Al-Mukaimi A, Palmer S. The effect of Mulligan's mobilization with movement following total knee arthroplasty: Protocol of a single-blind randomized controlled trial. Musculoskeletal Care 2020; 19:20-27. [PMID: 33045126 DOI: 10.1002/msc.1503] [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: 08/06/2020] [Revised: 08/12/2020] [Accepted: 08/15/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Mulligan's mobilization with movement (MWM) aims to enhance the kinematics of the joint. Kinematic impairment of the knee joint is significant following total knee arthroplasty (TKA), which could be managed with Mulligan's MWM. This article describes the study protocol for a single-blind randomized controlled trial investigating the effectiveness of Mulligan's MWM following TKA. METHODS A single-blind randomized controlled trial design will be employed to compare two groups: an intervention and control group. Each group will attend a standard post-operative rehabilitation program. The intervention group will additionally receive articular mobilization using a Mulligan's MWM approach. A blinded examiner will assess participants at four points: pre-operation, 3 weeks post-operation (when the intervention starts), 6 weeks post-operation (when the intervention ends), and at 6 months as a long-term follow-up. The two groups will be compared on the basis of knee range of motion (standard goniometry), knee joint pain (Visual Analogue Scales), walking speed using (15-metre walk test), functional mobility (timed up and go test) and participation (Western Ontario and McMaster Universities Osteoarthritis Index questionnaire). A blinded examiner will measure knee joint alignment using a computed tomography scanogram pre-operatively and at 3 months post operation. Mixed model ANOVA will be used to identify any group differences. Ethical approval has been secured from the ethical committee of Kuwait Ministry of Health, and the trial is registered in the ISRCTN registry (ref:13028992). DISCUSSION The study findings could inform the optimization of post-operative rehabilitation of patients following TKA.
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Affiliation(s)
- Najla F Alsiri
- Rehabilitation Department, Al-Razi Orthopaedics and Rehabilitation Hospital, Shuwaikh, Kuwait
| | | | - Ali Al-Mukaimi
- Rehabilitation Department, Al-Razi Orthopaedics and Rehabilitation Hospital, Shuwaikh, Kuwait
| | - Shea Palmer
- Department of Allied Health Professions, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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28
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Mechanical Properties and Characteristics of the Anterolateral and Collateral Ligaments of the Knee. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10186266] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Biomechanical studies assessing the major knee ligaments, such as the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament (MCL), and lateral collateral ligament (LCL), have been conducted using various methodologies. However, despite the anterolateral ligament (ALL) being regarded as the important ligament for the stability of the knee, a lack of biomechanical research focusing on the ALL exists to date. Moreover, studies assessing the relative mechanical properties of each ligament of the knee are insufficient. Therefore, this study examined the mechanical properties of the ALL, MCL, and LCL and considered the relative differences between these ligaments. Twenty-one fresh cadaver knees were chosen to investigate the mechanical properties. The width, thickness, and length were measured. The stiffness, ultimate load, and elastic modulus were also tested. The MCL showed the greatest ultimate load (498.5 N) and the highest stiffness (71.97 N/mm), and the ALL presented the smallest ultimate load (146.64 N) and lowest stiffness (42.62 N/mm). Meanwhile, the LCL was second concerning the ultimate load (263.22 N) and stiffness (69.70 N/mm). The elastic modulus of the LCL (493.86 MPa) was greater than those of both the MCL and ALL (326.75 MPa and 345.27 MPa, respectively). There was no difference between the sides according to the different properties of all the ligaments. A sex difference was apparent only concerning the ultimate load for all the ligaments. Each ligament showed similar stiffness irrespective of its size; for this reason, stiffness should be considered initially and while conducting biomechanical simulations of these ligaments.
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29
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Mullins W, Jarvis GE, Oluboyede D, Skingle L, Poole K, Turmezei T, Brassett C. The Segond fracture occurs at the site of lowest sub-entheseal trabecular bone volume fraction on the tibial plateau. J Anat 2020; 237:1040-1048. [PMID: 32770847 PMCID: PMC7704226 DOI: 10.1111/joa.13282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/26/2023] Open
Abstract
In a series of human cadaveric experiments, Dr. Paul Segond first described the avulsion injury occurring at the anterolateral tibial plateau that later took his name. The fracture is thought to arise as a consequence of excessive tibia internal rotation which often also elicits damage to other connective tissue of the knee. The exact mechanism behind the avulsion is, however, unclear. A number of ligamentous structures have been proposed in separate studies to insert into the Segond fragment. Suggestions include the iliotibial band (ITB), biceps femoris and the controversial ‘anterolateral ligament’ (ALL). Despite increasing knowledge of tibial plateau bony microarchitecture in both healthy and disease states, no studies have yet, to our knowledge, considered the role of tibial sub‐entheseal bone structure in pathogenesis of the Segond fracture. The goal of this study was thus to elucidate the differences in trabecular properties at regions across the tibial plateau in order to provide an explanation for the susceptibility of the anterolateral region to avulsion injury. Twenty human tibial plateaus from cadaveric donors were dissected and imaged using a Nikon‐XTH225‐μCT scanner with <80 μm isotropic voxel size. Scans were reconstructed using MicroView 3D Image Viewer and Analysis Tool. Subsequent virtual biopsy at ten anatomically defined regions of interest (ROI) generated estimates of bone volume fraction (‘bone volume divided by total volume’ (BV/TV)). The overall mean BV/TV value across all 20 tibiae and all 10 ROIs was 0.271. Univariate repeated‐measurements ANOVA demonstrated that BV/TV values differed between ROIs. BV/TV values at the Segond site (Sα, Sβ or Sγ) were lower than all other ROIs at 0.195, 0.192 and 0.193, respectively. This suggests that, notwithstanding inter‐ and intra‐specimen variation, the Segond site tends to have a lower trabecular bone volume fraction than entheseal sites elsewhere on the tibia. Since BV/TV correlates with tensile and torsional strength, the lower BV/TV at the Segond site could equate to a region of local weakness in certain individuals which predisposes them to an avulsion injury following the application of force from excessive internal rotation. The low BV/TV recorded at the Segond site also challenges the idea that the fracture occurs due to pull from a discrete ‘anterolateral ligament’, as the tension exerted focally would be expected to elicit a hypertrophic response in line with Frost's Mechanostat hypothesis. Our data would instead agree with the aforementioned reports of the fibrous band at the Segond site being part of a broader insertion of an ‘anterolateral complex’.
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Affiliation(s)
- William Mullins
- Human Anatomy Centre, Anatomy Building, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Gavin E Jarvis
- Human Anatomy Centre, Anatomy Building, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Daniel Oluboyede
- Human Anatomy Centre, Anatomy Building, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Linda Skingle
- Department of Medicine, Cambridge NIHR Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Ken Poole
- Department of Medicine, Cambridge NIHR Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Tom Turmezei
- Norfolk and Norwich University Hospitals NHS Trust, Norwich, UK
| | - Cecilia Brassett
- Human Anatomy Centre, Anatomy Building, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
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Abstract
A subset of patients have residual rotational laxity following anterior cruciate ligament reconstruction (ACLR) despite the evolution of ACLR techniques. In recent years, there has been increased interest in addressing residual laxity because it is associated with poor outcomes after ACLR. There is an expanding body of knowledge on the anatomy and biomechanics of the anterolateral soft tissue restraints in regard to their rotational control of the knee and this has reignited an interest in extra-articular reconstruction techniques for augmenting ACLR. Reconstruction techniques currently used can be broadly categorized as either lateral extra-articular tenodesis or anterolateral ligament reconstruction. In this review, we discuss the relevant anatomy, biomechanics, and rationale behind the indications and technique of our current extra-articular augmentation procedure.
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Lagae KC, Robberecht J, Athwal KK, Verdonk PCM, Amis AA. ACL reconstruction combined with lateral monoloop tenodesis can restore intact knee laxity. Knee Surg Sports Traumatol Arthrosc 2020; 28:1159-1168. [PMID: 31980844 PMCID: PMC7148266 DOI: 10.1007/s00167-019-05839-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/16/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE An anterior cruciate ligament (ACL) injury is often combined with injury to the lateral extra-articular structures, which may cause a combined anterior and rotational laxity. It was hypothesised that addition of a 'monoloop' lateral extra-articular tenodesis (mLET) to an ACL reconstruction would restore anteroposterior, internal rotation and pivot-shift laxities better than isolated ACL reconstruction in combined injuries. METHOD Twelve cadaveric knees were tested, using an optical tracking system to record the kinematics through 0°-100° of knee flexion with no load, anterior and posterior translational forces (90 N), internal and external rotational torques (5 Nm), and a combination of an anterior translational (90 N) plus internal rotational load (5 Nm). They were tested intact, after sectioning the ACL, sectioning anterolateral ligament (ALL), iliotibial band (ITB) graft harvest, releasing deep ITB fibres, hamstrings tendon ACL reconstruction, mLET combined with ACL reconstruction, and isolated mLET. Two-way repeated-measures ANOVA compared laxity data across knee states and flexion angles. When differences were found, paired t tests with Bonferroni correction were performed. RESULTS In the ACL-deficient knee, cutting the ALL significantly increased anterior laxity only at 20°-30°, and only significantly increased internal rotation at 50°. Additional deep ITB release significantly increased anterior laxity at 40°-90° and caused a large increase of internal rotation at 20°-100°. Isolated ACL reconstruction restored anterior drawer, but significant differences remained in internal rotation at 30°-100°. After adding an mLET there were no remaining differences with anterior translation or internal rotation compared to the intact knee. With the combined injury, isolated mLET allowed abnormal anterior translation and rotation to persist. CONCLUSIONS Cutting the deep fibres of the ITB caused large increases in tibial internal rotation laxity across the range of knee flexion, while cutting the ALL alone did not. With ACL deficiency combined with anterolateral deficiency, ACL reconstruction alone was insufficient to restore native knee rotational laxity. However, combining a 'monoloop' lateral extra-articular tenodesis with ACL reconstruction did restore native knee laxity.
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Affiliation(s)
- Koen C. Lagae
- Antwerp Orthopaedic Centre Monica Hospitals, Antwerp, Belgium ,Galeazzi Orthopaedic Institute, Milan, Italy
| | - Joris Robberecht
- Department of Orthopaedic Surgery, Antwerp University Hospital (UZA), Antwerp, Belgium
| | - Kiron K. Athwal
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, SW7 2AZ UK
| | - Peter C. M. Verdonk
- Antwerp Orthopaedic Centre Monica Hospitals, Antwerp, Belgium ,Department of Orthopaedic Surgery, Antwerp University Hospital (UZA), Antwerp, Belgium
| | - Andrew A. Amis
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, SW7 2AZ UK ,Musculoskeletal Surgery Group, Imperial College London School of Medicine, Charing Cross Hospital, London, W6 8RF UK
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Helito CP. Editorial Commentary: Extension of Knowledge-and the Knee! New Biomechanical Study Suggests the Clinical Practice of Anterolateral Ligament Fixation Near Extension. Arthroscopy 2019; 35:2160-2163. [PMID: 31272637 DOI: 10.1016/j.arthro.2019.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 02/02/2023]
Abstract
The knee anterolateral ligament (ALL) is one of the most hotly debated topics in sports medicine in the last decade. Once one aspect of discussion regarding the ALL reaches a consensus, attention immediately turns to the next one. This has already happened with the existence of the ALL itself, its anatomic features, the ability to visualize the ALL with magnetic resonance imaging, and many other topics. In the end, the most important aspect must be clinical outcomes, and existing studies are trying to find the optimum surgical technique to best restore knee stability and reduce failure rates. It appears that, when doing an anatomic ALL reconstruction, fixation must be performed in full extension. The literature regarding ALL reconstruction shows promising results, with a strong tendency to present better knee stability, improved functional scores, and lower failure rates.
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Khanna M, Gupte C, Dodds A, Williams A, Walker M. Magnetic resonance imaging appearances of the capsulo-osseous layer of the iliotibial band and femoral attachments of the iliotibial band in the normal and pivot-shift ACL injured knee. Skeletal Radiol 2019; 48:729-740. [PMID: 30593591 PMCID: PMC6456473 DOI: 10.1007/s00256-018-3128-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 11/28/2018] [Accepted: 12/03/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Biomechanical evidence suggests that the anterolateral structures of the knee may be important restraints against anterolateral rotatory instability (ALRI) in the setting of anterior cruciate ligament (ACL) injury. OBJECTIVE To describe the anatomy and presence of injury of the capsule-osseous layer of the iliotibial band (CITB), the iliotibial band, and its deep distal femoral attachments in patients with a 'normal' knee (no pivot-shift bone marrow edema (BME) pattern) and patients with a pivot-shift BME pattern indicative of a pivot-shift injury associated with ACL tears. METHODS Group 1: 20 consecutive patients with no MRI evidence of pivot-shift injury and group 2: 20 consecutive patients with a pivot-shift BME pattern on MRI were identified. Retrospective consensus analysis of the anatomy and appearances of the CITB and the 'proximal' and 'epicondylar' distal femoral attachments of the ITB was performed for each MRI by two experienced musculoskeletal radiologists. RESULTS The positive predictive value (PPV) of CITB injury for pivot-shift ACL injury was 74%, negative predicted Value (NPV) was 80%. The PPV for injury of the 'proximal' ITB femoral attachment with pivot-shift ACL injury was 93%, NPV was 84%. The PPV for 'epicondylar' iliotibial femoral attachment injury was 62%, NPV was 45%. CONCLUSIONS Injury of the CITB and 'proximal' deep femoral attachments of the ITB are good markers for ACL injury even in the absence of a Segond fracture and should be evaluated on all MRIs as they may prove important in the further management of ALRI.
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Affiliation(s)
- Monica Khanna
- Department of Clinical Imaging, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY UK
| | - Chimnay Gupte
- Department of Clinical Imaging, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY UK
| | | | - Andy Williams
- Fortius Clinic, Fitzhardinghe Street, London, W1H 6EQ UK
| | - Miny Walker
- Department of Clinical Imaging, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY UK
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Abstract
BACKGROUND The mechanisms of anterior cruciate ligament (ACR) rupture may include a pivoting mechanism, which is responsible for concomitant lesions of the anterolateral structures. This anterolateral complex is the main stabilizer of tibial internal rotation and therefore accountable for a persisting pivot shift despite technical improvement of ACR reconstruction. For this reason, knee surgeons' interest in addressing anterolateral stabilization in addition to ACR reconstruction has been renewed. STUDIES Biomechanical and clinical studies have shown promising results so far. The modified, lateral, extra-articular stabilization according to Lemaire as a non-anatomical reconstruction of the anterolateral ligament (ALL) shines with a low morbidity, since no additional tendon harvesting is needed. Besides the potential benefits there are several risks and disadvantages. For example, complete control of the pivot-shift phenomenon is not possible in nearly 8% of cases. In addition, too tight tensioning of the ALL may result in an increase of pressure in the lateral knee compartment. Overall, ALL reconstruction is a hot topic and is heavily discussed in literature. This article provides an overview and brings the modified technique of Lemaire into focus.
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Helito CP, Camargo DB, Sobrado MF, Bonadio MB, Giglio PN, Pécora JR, Camanho GL, Demange MK. Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:3652-3659. [PMID: 29610972 DOI: 10.1007/s00167-018-4934-2] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/26/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the results of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction in patients with chronic ACL injury. It was hypothesized that patients who underwent combined ACL and ALL reconstruction would exhibit less residual laxity and better clinical outcomes. METHODS Two groups of patients were evaluated and compared retrospectively. Both groups consisted only of patients with chronic (more than 12 months) ACL injuries. Patients in group 1 underwent anatomical intra-articular reconstruction of the ACL and patients in group 2 underwent anatomic intra-articular ACL reconstruction combined with ALL reconstruction. The presence of associated meniscal injury, the subjective International Knee Documentation Committee (IKDC) and Lysholm functional outcome scores in the postoperative period, KT-1000 evaluation, the presence of residual pivot shift and graft rupture rate were evaluated. RESULTS One hundred and one patients who underwent reconstruction of chronic ACL injuries were evaluated. The median follow-up was 26 (24-29) months for group 1 and 25 (24-28) months for group 2. There were no significant differences between groups regarding gender, age, duration of injury until reconstruction, follow-up time or presence of associated meniscal injuries in the preoperative period. Regarding functional outcome scores, patients in group 2 presented better results on both the IKDC (p = 0.0013) and the Lysholm (p < 0.0001) evaluations. In addition, patients in group 2 had better KT-1000 evaluation (p = 0.048) and a lower pivot shift rate at physical examination, presenting only 9.1% positivity versus 35.3% in the isolated ACL reconstruction (p = 0.011). Regarding re-ruptures, group 1 presented 5 (7.3%) cases, and group 2 presented no cases. CONCLUSION The combined ACL and ALL reconstruction in patients with chronic ACL injury is an effective and safety solution and leads to good functional outcomes with no increase in complication rate. The clinical relevance of this finding is the possibility to indicate this type of procedure when patients present with more than 12 months after injury for surgery. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Danilo Bordini Camargo
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Batista Bonadio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Pedro Nogueira Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gilberto Luis Camanho
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marco Kawamura Demange
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Neri T, Dalcol P, Palpacuer F, Bergandi F, Prades JM, Farizon F, Philippot R, Peoc'h M. The anterolateral ligament is a distinct ligamentous structure: A histological explanation. Knee 2018; 25:360-366. [PMID: 29655900 DOI: 10.1016/j.knee.2018.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/29/2018] [Accepted: 03/21/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim was to determine whether the anterolateral ligament (ALL) had a histological structure that defined it as a real ligament. METHODS Histological examination of 30 ALL samples taken from fresh-frozen knees were performed. The ALL femoral insertion and its relationship with the lateral collateral ligament (LCL) were studied and the tibial insertion and its relationship with articular cartilage of the tibial joint surface were analyzed. For the ligamentous part, its histological structure and its differences with the articular capsule were studied. RESULTS This connective tissue is composed of a dense fibrous core constituted by a network of oriented collagenous fibers. The periphery of this dense connective center is made up of loose fibrocollagenous tissue with vascular structures and focal deposits of adipose tissue. This part was in contact but different to the joint capsule. With a perpendicular orientation of the collagen fibers relative to the bone, a fibrocartilaginous zone with an unmineralized hyalinized aspect, a mineralization front, its bone insertions presented a typical ligamentous insertion. With a cleavage plane between ALL and LCL femoral insertion, the ALL appeared to have a femoral insertion distinct from the LCL. ALL tibial insertion was less characteristic with less organized connective tissue and was at a distance from the articular cartilage. CONCLUSION From its bony insertion to its tissue composition and organization, the ALL has all the histological characteristics of a ligamentous structure. Our study confirms that ALL can be considered a real and distinct ligament.
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Affiliation(s)
- Thomas Neri
- University of Lyon - UJM-Saint-Etienne, Inter-university Laboratory of Human Movement Science, EA 7424, F-42023 Saint-Etienne, France; Department of Orthopedic Surgery, University Hospital of Saint Etienne, Saint Etienne, France.
| | - Pierre Dalcol
- Department of Pathology, University Hospital of Saint Etienne, Saint Etienne, France
| | - Fabien Palpacuer
- Department of Orthopedic Surgery, University Hospital of Saint Etienne, Saint Etienne, France
| | - Florian Bergandi
- Laboratory of Human Anatomy, Faculty of Medicine, University of Saint-Etienne, France
| | - Jean Michel Prades
- Laboratory of Human Anatomy, Faculty of Medicine, University of Saint-Etienne, France
| | - Frederic Farizon
- University of Lyon - UJM-Saint-Etienne, Inter-university Laboratory of Human Movement Science, EA 7424, F-42023 Saint-Etienne, France; Department of Orthopedic Surgery, University Hospital of Saint Etienne, Saint Etienne, France
| | - Remi Philippot
- University of Lyon - UJM-Saint-Etienne, Inter-university Laboratory of Human Movement Science, EA 7424, F-42023 Saint-Etienne, France; Department of Orthopedic Surgery, University Hospital of Saint Etienne, Saint Etienne, France
| | - Michel Peoc'h
- Department of Pathology, University Hospital of Saint Etienne, Saint Etienne, France
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Helito CP, Saithna A, Bonadio MB, Daggett M, Monaco E, Demange MK, Sonnery-Cottet B. Anterolateral Ligament Reconstruction: A Possible Option in the Therapeutic Arsenal for Persistent Rotatory Instability After ACL Reconstruction. Orthop J Sports Med 2018; 6:2325967117751348. [PMID: 29376085 PMCID: PMC5777553 DOI: 10.1177/2325967117751348] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Adnan Saithna
- Medical Technologies and Advanced Materials, Clifton Campus, Nottingham Trent University, Nottingham, UK.,Renacres Hospital, Lancashire, UK
| | - Marcelo B Bonadio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Matt Daggett
- Kansas City University, Kansas City, Missouri, USA
| | | | - Marco K Demange
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Generale de Sante, Hospital Privé Jean Mermoz, Lyon, France
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Inderhaug E, Stephen JM, Williams A, Amis AA. Anterolateral Tenodesis or Anterolateral Ligament Complex Reconstruction: Effect of Flexion Angle at Graft Fixation When Combined With ACL Reconstruction. Am J Sports Med 2017; 45:3089-3097. [PMID: 28898106 DOI: 10.1177/0363546517724422] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite numerous technical descriptions of anterolateral procedures, knowledge is limited regarding the effect of knee flexion angle during graft fixation. PURPOSE To determine the effect of knee flexion angle during graft fixation on tibiofemoral joint kinematics for a modified Lemaire tenodesis or an anterolateral ligament (ALL) complex reconstruction combined with anterior cruciate ligament (ACL) reconstruction. STUDY DESIGN Controlled laboratory study. METHODS Twelve cadaveric knees were mounted in a test rig with kinematics recorded from 0° to 90° flexion. Loads applied to the tibia were 90-N anterior translation, 5-N·m internal tibial rotation, and combined 90-N anterior force and 5-N·m internal rotation. Intact, ACL-deficient, and combined ACL plus anterolateral-deficient states were tested, and then ACL reconstruction was performed and testing was repeated. Thereafter, modified Lemaire tenodeses and ALL procedures with graft fixation at 0°, 30°, and 60° of knee flexion and 20-N graft tension were performed combined with the ACL reconstruction, and repeat testing was performed throughout. Repeated-measures analysis of variance and Bonferroni-adjusted t tests were used for statistical analysis. RESULTS In combined ACL and anterolateral deficiency, isolated ACL reconstruction left residual laxity for both anterior translation and internal rotation. Anterior translation was restored for all combinations of ACL and anterolateral procedures. The combined ACL reconstruction and ALL procedure restored intact knee kinematics when the graft was fixed in full extension, but when the graft was fixed in 30° and 60°, the combined procedure left residual laxity in internal rotation ( P = .043). The combined ACL reconstruction and modified Lemaire procedure restored internal rotation regardless of knee flexion angle at graft fixation. When the combined ACL reconstruction and lateral procedure states were compared with the ACL-only reconstructed state, a significant reduction in internal rotation laxity was seen with the modified Lemaire tenodesis but not with the ALL procedure. CONCLUSION In a knee with combined ACL and anterolateral ligament injuries, the modified Lemaire tenodesis combined with ACL reconstruction restored normal laxities at all angles of flexion for graft fixation (0°, 30°, or 60°), with 20 N of tension. The combined ACL and ALL procedure restored intact knee kinematics when tensioned in full extension. CLINICAL RELEVANCE In combined anterolateral procedure plus intra-articular ACL reconstruction, the knee flexion angle is important when fixing the graft. A modified Lemaire procedure restored intact knee laxities when fixation was performed at 0°, 30°, or 60° of flexion. The ALL procedure restored normal laxities only when fixation occurred in full extension.
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Affiliation(s)
| | - Joanna M Stephen
- Fortius Clinic, London, UK.,Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
| | | | - Andrew A Amis
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK.,Musculoskeletal Surgery Group, Department of Surgery & Cancer, Imperial College London School of Medicine, London, UK
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39
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Lansdown D, Ma CB. The Influence of Tibial and Femoral Bone Morphology on Knee Kinematics in the Anterior Cruciate Ligament Injured Knee. Clin Sports Med 2017; 37:127-136. [PMID: 29173552 DOI: 10.1016/j.csm.2017.07.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Bone morphology is one feature that contributes to knee kinematics. The geometry of the tibia and femur vary across individuals, and these differences can influence the risk of anterior cruciate ligament (ACL) injury and of failure after isolated ACL reconstruction. There has been renewed interest in lateral extra-articular stabilization procedures to supplement an ACL reconstruction, although which patients benefit most from these procedures remains unclear. This article reviews the impact of bone morphology on knee kinematics, including tibial slope, depth of the medial tibial plateau, intercondylar notch shape, tibial eminence volume, and sphericity of the femoral condyles.
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Affiliation(s)
- Drew Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco, 1500 Owens Street, Suite 186, San Francisco, CA 94158, USA
| | - Chunbong Benjamin Ma
- Department of Orthopaedic Surgery, University of California, San Francisco, 1500 Owens Street, Suite 186, San Francisco, CA 94158, USA.
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