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Guegan B, Drouineau M, Common H, Robert H. All the menisco-ligamentary structures of the medial plane play a significant role in controlling anterior tibial translation and tibial rotation of the knee. Cadaveric study of 29 knees with the Dyneelax® laximeter. J Exp Orthop 2024; 11:e12038. [PMID: 38807638 PMCID: PMC11131574 DOI: 10.1002/jeo2.12038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/31/2024] [Accepted: 04/19/2024] [Indexed: 05/30/2024] Open
Abstract
Purpose This study aimed to determine the respective roles of the anterior cruciate ligament (ACL) and the different components of the medial plane in the control of anterior tibial translation and internal and external tibial rotation. Methods Twenty-nine fresh lower limbs, disarticulated at the hip, were tested in the anatomy laboratory. The following structures were isolated: the ACL, the anteromedial retinaculum (AMR), the medial collateral ligament (superficial and deep MCL), the posterior medial capsule (PMC) and the posterior horn of the medial meniscus (PHMM). The lower limb was positioned at 30° of flexion on the Dyneelax® laximeter (0.1 mm and 0.1° accuracies) and underwent anterior loads up to 200 N and internal and external tibial rotations sectioned from front to back. and the knee was then retested. The results were presented as relative gains in translation and rotations for each structure. Student's t test and Wilcoxon tests were used. Results The relative gains in translation for the ACL, AMR, superficial MCL, deep MCL, PMC and PHMM, respectively, were 42.9%, 6.7%, 7.4%, 6%, 7.5% and 11.6%. The relative gains in internal rotation for ACL, AMR, superficial MCL, deep MCL, PMC and PHMM, respectively, were 13%, 6.9%, 4.6%, 3.9%, 13% and 8%. The relative gains in external rotation for ACL, AMR, superficial MCL, deep MCL, PMC and medial meniscus, respectively, were 8.9%, 6%, 9.7%, 13.8%,11.2% and 8.5%. All the relative gains in translation, internal and external rotations were significant at each step of transection (p < 0.01). Conclusions The ligamentous structures of the medial plane constitute a functional unit in which each component has a specific passive contribution. This study highlights the importance of recognising the extent of the medial ligament tears and performing a medial side anatomic and individual reconstruction and a suture of a ramp lesion, in addition to an ACL surgery.
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Affiliation(s)
- Baptiste Guegan
- CHU Rennes: Centre Hospitalier Universitaire de RennesRennesFrance
| | - Michel Drouineau
- CHU Rennes: Centre Hospitalier Universitaire de RennesRennesFrance
| | - Harold Common
- CHU Rennes: Centre Hospitalier Universitaire de RennesRennesFrance
| | - Henri Robert
- Centre Hospitalier du Haut AnjouChâteau‐Gontier‐Sur‐MayenneFrance
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Peez C, Hägerich LM, Ruhl F, Klimek M, Briese T, Glasbrenner J, Deichsel A, Raschke MJ, Kittl C, Herbst E. Collateral ligament strain is linearly related to coronal lower limb alignment: A biomechanical study. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38932622 DOI: 10.1002/ksa.12340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/07/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE The purpose of this study was to analyse the influence of coronal lower limb alignment on collateral ligament strain. METHODS Twelve fresh-frozen human cadaveric knees were used. Long-leg standing radiographs were obtained to assess lower limb alignment. Specimens were axially loaded in a custom-made kinematics rig with 200 and 400 N, and dynamic varus/valgus angulation was simulated in 0°, 30°, and 60° of knee flexion. The changes in varus/valgus angulation and strain within different fibre regions of the collateral ligaments were captured using a three-dimensional optical measuring system to examine the axis-dependent strain behaviour of the superficial medial collateral ligament (sMCL) and lateral collateral ligament (LCL) at intervals of 2°. RESULTS The LCL and sMCL were exposed to the highest strain values at full extension (p < 0.001). Regardless of flexion angle and extent of axial loading, the ligament strain showed a strong and linear association with varus (all Pearson's r ≥ 0.98; p < 0.001) and valgus angulation (all Pearson's r ≥ -0.97; p < 0.01). At full extension and 400 N of axial loading, the anterior and posterior LCL fibres exceeded 4% ligament strain at 3.9° and 4.0° of varus, while the sMCL showed corresponding strain values of more than 4% at a valgus angle of 6.8°, 5.4° and 4.9° for its anterior, middle and posterior fibres, respectively. CONCLUSION The strain within the native LCL and sMCL was linearly related to coronal lower limb alignment. Strain levels associated with potential ultrastructural damages to the ligaments of more than 4% were observed at 4° of varus and about 5° of valgus malalignment, respectively. When reconstructing the collateral ligaments, an additional realigning osteotomy should be considered in cases of chronic instability with a coronal malalignment exceeding 4°-5° to protect the graft and potentially reduce failures. LEVEL OF EVIDENCE There is no level of evidence as this study was an experimental laboratory study.
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Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Luise Maria Hägerich
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Felix Ruhl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Matthias Klimek
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Thorben Briese
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Denis-Aubrée P, Barbotte F, Boisrenoult P, Delort M, Labarre C, Pujol N. Anatomic reconstruction of the posteromedial corner of the knee: The Versailles technique. Orthop Traumatol Surg Res 2024; 110:103829. [PMID: 38316269 DOI: 10.1016/j.otsr.2024.103829] [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: 11/24/2022] [Revised: 08/11/2023] [Accepted: 11/13/2023] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Multiligament knee injury with posteromedial laxity is serious and usually requires surgery. Reconstruction is preferable to repair. The main aim of the present study was to report clinical results and laximetry for an original posteromedial corner (PMC) allograft reconstruction technique known as The Versailles Technique. The secondary aim was to determine prognostic factors for surgery. The study hypothesis was that anatomic PMC reconstruction by tendon allograft provides satisfactory medium-term clinical and laximetric results. METHODS A retrospective study assessed postoperative clinical and laximetric results after PMC allograft reconstruction at a minimum 12 months' follow-up. Laxity was assessed on comparative bilateral stress X-rays, and functional results on the International Knee Documentation Committee (IKDC) score, the Lysholm score and the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS Twenty-six patients were included between 2013 and 2019. Mean follow-up was 27.4±9 months. Mean subjective IKDC score was 69.21±17.36, mean Lysholm score 77.78±14.98 and mean KOOS 66.44±18.52. OBJECTIVE IKDC results were 77% grade A, 22% grade B, and 0% grade C or D. Mean medial differential laxity in forced varus was 0.83±1.26mm. Mean subjective IKDC scores were poorer in Schenck KD-III than KD-I (p=0.03). Functional results were comparable with acute and with chronic laxity. Age correlated inversely with median KOOS (p=0.009). There was no correlation between postoperative radiologic laxity in forced varus and functional results. DISCUSSION Versailles anatomic PMC allograft reconstruction for acute or chronic posteromedial knee laxity showed medium-term efficacy in restoring good objective and subjective stability. LEVEL OF EVIDENCE IV; retrospective observational study.
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Affiliation(s)
- Pierre Denis-Aubrée
- Service de chirurgie orthopédique et traumatologique, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - Florian Barbotte
- Service de chirurgie orthopédique et traumatologique, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - Philippe Boisrenoult
- Service de chirurgie orthopédique et traumatologique, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - Marc Delort
- Service de chirurgie orthopédique et traumatologique, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - Chloé Labarre
- Service de chirurgie orthopédique et traumatologique, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - Nicolas Pujol
- Service de chirurgie orthopédique et traumatologique, centre hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France.
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Fusco S, Albano D, Gitto S, Serpi F, Messina C, Sconfienza LM. Posteromedial Corner Injuries of the Knee: Imaging Findings. Semin Musculoskelet Radiol 2024; 28:318-326. [PMID: 38768596 DOI: 10.1055/s-0044-1779718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
The posteromedial corner (PMC) of the knee is an anatomical region formed by ligamentous structures (medial collateral ligament, posterior oblique ligament, oblique popliteal ligament), the semimembranosus tendon and its expansions, the posteromedial joint capsule, and the posterior horn of the medial meniscus. Injuries to the structures of the PMC frequently occur in acute knee trauma in association with other ligamentous or meniscal tears. The correct assessment of PMC injuries is crucial because the deficiency of these supporting structures can lead to anteromedial rotation instability or the failure of cruciate ligaments grafts. This article reviews the anatomy and biomechanics of the PMC to aid radiologists in identifying injuries potentially involving PMC components.
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Affiliation(s)
- Stefano Fusco
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy
| | - Domenico Albano
- Department of Biomedical, Surgical and Dental Sciences, Università Degli Studi di Milano, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Salvatore Gitto
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Francesca Serpi
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy
| | - Carmelo Messina
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Luca Maria Sconfienza
- Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Marcheggiani Muccioli GM, Rinaldi VG, Zaffagnini S. Anterior Cruciate Ligament Over-The-Top Plus Lateral Plasty and Minimally Invasive Double-Bundle Posteromedial Corner Reconstruction. Arthrosc Tech 2024; 13:102957. [PMID: 38835476 PMCID: PMC11144962 DOI: 10.1016/j.eats.2024.102957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/15/2024] [Indexed: 06/06/2024] Open
Abstract
The medial collateral ligament (MCL) and the posteromedial corner (PMC) of the knee are essential structures for maintaining medial knee stability. Chronic MCL instability is infrequent but can necessitate surgical intervention. Various surgical techniques have been described, but they often involve the use of tibial tunnels, which may complicate concurrent ligament reconstructions. This study aims to present a minimally invasive double-bundle PMC reconstruction technique that avoids the use of tibial tunnels. Knee evaluation was performed using standard clinical tests and 1.5-Tesla magnetic resonance imaging. Patients with grade III Hughston MCL injuries were considered for surgery. The technique employs either an autologous semitendinosus graft or a fresh-frozen allograft, usually tibialis anterior, to reconstruct both the superficial MCL and the posterior oblique ligament. The technique described avoids the use of tibial tunnels, preserving tibial bone stock for any future procedures. The graft is secured at the femoral and tibial insertions using bioabsorbable interference screws and titanium staples, respectively. Our minimally invasive double-bundle PMC reconstruction technique offers a feasible and effective solution for patients with chronic medial knee instability. It is particularly beneficial for patients requiring multiple ligament reconstructions, as it avoids tunnel collision and preserves tibial bone stock.
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Affiliation(s)
| | - Vito Gaetano Rinaldi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- DIBINEM, University of Bologna, Bologna, Italy
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Becker R, Nebelung W. [Magnetic resonance imaging of the knee joint : What does the orthopedic surgeon expect from the radiologist?]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:244-253. [PMID: 38206367 DOI: 10.1007/s00117-023-01255-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
Magnet resonance imaging (MRI) offers a precise visualization of structural changes with high sensitivity and specificity. However, not all these soft tissue damages or bony lesions are clinically relevant or require treatment. Therefore, it is important to provide the radiologist with a specific clinical request when asking for an MRI examination of the knee. In this article, all important anatomical structures of the knee joint will be addressed with emphasis on the relevant questions for the radiologist. Based on the clinical examination, the MRI provides information about the damage of anatomical structures. This information is of utmost importance for therapeutic decision-making in order to allow an adequate and personalized treatment of patients.
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Affiliation(s)
- Roland Becker
- Zentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Brandenburg an der Havel, Hochstr. 29, 14770, Brandenburg, Deutschland.
| | - Wolfgang Nebelung
- Orthopädisch Unfallchirurgische Praxisklinik Neuss-Düsseldorf, Plange Mühle 4, 40221, Düsseldorf, Deutschland
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Peez C, Deichsel A, Zderic I, Richards RG, Gueorguiev B, Kittl C, Raschke MJ, Herbst E. Valgus malalignment causes increased forces on a medial collateral ligament reconstruction under dynamic valgus loading: A biomechanical study. Knee Surg Sports Traumatol Arthrosc 2024; 32:864-871. [PMID: 38454816 DOI: 10.1002/ksa.12110] [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: 12/28/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE To investigate the forces on a medial collateral ligament (MCL) reconstruction (MCLR) relative to the valgus alignment of the knee. METHODS Eight fresh-frozen human cadaveric knees were subjected to dynamic valgus loading at 400 N using a custom-made kinematics rig. After resection of the superficial medial collateral ligament, a single-bundle MCLR with a hamstring tendon autograft was performed. A medial opening wedge distal femoral osteotomy was performed and fixed with an external fixator to gradually adjust the alignment in 5° increments from 0° to 10° valgus. For each degree of valgus deformity, the resulting forces acting on the MCLR were measured through a force sensor and captured in 15° increments from 0° to 60° of knee flexion. RESULTS Irrespective of the degree of knee flexion, increasing valgus malalignment resulted in significantly increased forces acting on the MCLR compared to neutral alignment (p < 0.05). Dynamic loading at 5° valgus resulted in increased forces on the MCLR at all flexion angles ranging between 16.2 N and 18.5 N (p < 0.05 from 0° to 30°; p < 0.01 from 45° to 60°). A 10° valgus malalignment further increased the forces on the MCLR at all flexion angles ranging between 29.4 N and 40.0 N (p < 0.01 from 0° to 45°, p < 0.05 at 60°). CONCLUSION Valgus malalignment of the knee caused increased forces acting on the reconstructed MCL. In cases of chronic medial instabilities accompanied by a valgus deformity ≥ 5°, a realigning osteotomy should be considered concomitantly to the MCLR to protect the graft and potentially reduce graft failures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Christian Peez
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
- AO Research Institute Davos, Davos, Switzerland
| | - Adrian Deichsel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | | | | | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Bosco F, Giustra F, Ghirri A, Battaglia DL, Capella M, Massè A. The pie-crust surgical technique for medial collateral ligament release: enhancing visualization of the medial compartment in knee arthroscopy. ANNALS OF JOINT 2024; 9:14. [PMID: 38694812 PMCID: PMC11061655 DOI: 10.21037/aoj-23-54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/05/2023] [Indexed: 05/04/2024]
Abstract
This study presents a comprehensive surgical technique for performing a 'pie-crust' release of the medial collateral ligament (MCL) to enhance visualization of the medial compartment during arthroscopic knee procedures. The primary objective of this research is to improve the precision of diagnosis and treatment for injuries specifically affecting the posterior horn and posterior root of the medial meniscus. Arthroscopic knee procedures have become increasingly common in orthopedic surgery, offering the advantage of minimally invasive techniques for treating a wide range of knee conditions. However, accessing and visualizing the posterior structures within the medial compartment can be challenging. To overcome this limitation, the surgical technique presented in this study offers a systematic approach that includes patient positioning, precise identification of anatomical landmarks, and a detailed, step-by-step procedural description. The process begins with meticulous marking of anatomical landmarks to provide reference points. Precisely identifying the location for the MCL release is of utmost importance. This involves making needle punctures with guidance from arthroscopic visualization and applying valgus strain to the knee as necessary. One of the key advantages of this described surgical technique is its focus on safety and efficacy. Surgeons can work more confidently and precisely by reducing the risk of iatrogenic cartilage damage and facilitating access to the posterior structures within the medial compartment. Clinical outcomes from this approach have demonstrated consistently favorable results, leading to improved patient recovery and reduced complications. Furthermore, it is noteworthy that the postoperative use of a brace is not mandatory, adding to the appeal of this technique for both patients and surgeons. This surgical technique's enhanced visualization and optimized treatment outcomes make it a valuable tool in the arsenal of orthopedic surgeons specializing in knee arthroscopy. In conclusion, this study's surgical technique has the potential to significantly improve the diagnosis and treatment of patients with meniscal injuries in the medial compartment, ultimately leading to better clinical outcomes and patient satisfaction.
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Affiliation(s)
- Francesco Bosco
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
- Department of Orthopaedics and Traumatology, G.F. Ingrassia Hospital Unit, ASP 6, Palermo, Italy
| | - Fortunato Giustra
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco—ASL Città di Torino, Turin, Italy
| | - Alessandro Ghirri
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco—ASL Città di Torino, Turin, Italy
| | - Domenico Lewis Battaglia
- Department of Orthopaedics and Traumatology, University of Turin, Turin, Italy
- Department of Orthopaedics and Traumatology, Centro Traumatologico Ortopedico (CTO), Turin, Italy
| | - Marcello Capella
- Department of Orthopaedics and Traumatology, Centro Traumatologico Ortopedico (CTO), Turin, Italy
| | - Alessandro Massè
- Department of Orthopaedics and Traumatology, University of Turin, Turin, Italy
- Department of Orthopaedics and Traumatology, Centro Traumatologico Ortopedico (CTO), Turin, Italy
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Petersen W, Al Mustafa H, Buitenhuis J, Häner M, Braun K. Reconstruction of the Medial Collateral Ligament Complex With a Flat Allograft Semitendinosus Tendon. Arthrosc Tech 2024; 13:102836. [PMID: 38312881 PMCID: PMC10838056 DOI: 10.1016/j.eats.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/07/2023] [Indexed: 02/06/2024] Open
Abstract
The aim of this Technical Note is to reconstruct the medial collateral ligament complex with the superior medial collateral ligament and posterior oblique ligament as anatomically as possible. An allograft or contralateral semitendinosus autograft is used for anatomic reconstruction of the superior medial collateral ligament and posterior oblique ligament. After bony fixation, the tendon bundles are sutured to the remnants of the medial collateral ligament complex. Thus, the tubular grafts are pulled apart to form a flat shape that resembles that of the normal medial ligaments.
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Affiliation(s)
- Wolf Petersen
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Hassan Al Mustafa
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Johannes Buitenhuis
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Martin Häner
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
| | - Karl Braun
- Department for Orthopaedics and Trauma Surgery, Martin Luther Hospital, Berlin, Germany
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Gensior TJ, Mester B, Achtnich A, Winkler PW, Henkelmann R, Hepp P, Glaab R, Krause M, Frosch KH, Zellner J, Schoepp C. Anatomic repair and ligament bracing as an alternative treatment option for acute combined PCL injuries involving the posteromedial or posterolateral corner-results of a multicentre study. Arch Orthop Trauma Surg 2023; 143:7123-7132. [PMID: 37691046 PMCID: PMC10635947 DOI: 10.1007/s00402-023-05015-5] [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: 02/22/2023] [Accepted: 07/24/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Combined PCL injuries involving the posteromedial/-lateral corner (PMC/PLC) usually require surgical management. Literature shows controversy regarding the standards of treatment. Suture-augmented repair leads to excellent results in acute knee dislocations but has not been investigated clinically in combined PCL injuries. The purpose of this multicentre study was to evaluate the clinical outcome of this technique in acute combined PCL injuries. MATERIALS & METHODS N = 33 patients with acute combined PCL injuries involving the PMC/PLC were treated by one-stage suture repair with ligament bracing of the PCL and suture repair of the accompanying PMC/PLC injuries with/without ligament bracing or primary augmentation by semitendinosus autograft. Outcome was assessed by IKDC questionnaire, Lysholm Score, Tegner Activity Scale and KOOS. Additional PCL stress-radiography was performed. RESULTS N = 31 patients with combined PCL injuries (female: male = 7:24; age 39.1 ± 13.8 years) with a follow-up of 16.8 ± 9.6 months were finally evaluated. 18 had PMC injuries, 13 PLC injuries. 32.2% presented with accompanying meniscal tears (70% medial meniscus). 19.4% showed cartilage injuries grade III-IV. Complications included one infection and four knee stiffnesses. Three had symptomatic postoperative instability, all affiliated to the PLC group. The IKDC was 69.8 ± 16.5, Lysholm score 85 ± 14.4 and KOOS 89.7 ± 8.1. Median loss of activity (Tegner) was 0.89 ± 1.31. Comparing PMC and PLC, all scores showed a tendency towards more favourable outcomes in the PMC group (n.s.). Stress-radiography showed an overall side-to-side difference of 3.7 ± 3.8 mm. Subgroup evaluation showed statistically significant better results (p = 0.035) of PMC (2.5 ± 1.5 mm) versus PLC (5.8 ± 5.6 mm). CONCLUSIONS One-stage suture repair with ligament bracing is a viable technique for acute combined PCL injuries and predominantly leads to good and excellent clinical outcomes. Patients with PLC injuries show a tendency towards inferior outcomes and higher instability rates compared to PMC injuries. These results may help in therapy planning and counselling patients with these rare injury pattern. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Tobias J Gensior
- OPND Clinic Neuss-Düsseldorf, Neuss, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Bastian Mester
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany.
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland.
| | - Andrea Achtnich
- Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Ligament Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Philipp W Winkler
- Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria
| | - Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Pierre Hepp
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Richard Glaab
- Department of Traumatology, Cantonal Hospital Aarau, Aarau, Switzerland
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Ligament Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Clinic Hamburg, Hamburg, Germany
| | - Johannes Zellner
- Sporthopaedicum Regensburg, Regensburg, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Christian Schoepp
- Clinic for Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Clinic Duisburg, Duisburg, Germany
- Ligament Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
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Pizza N, Di Paolo S, Grassi A, Pagano A, Viotto M, Dal Fabbro G, Agostinone P, Lucidi GA, Monllau JC, Zaffagnini S. Good long-term patients reported outcomes, return-to-work and return-to-sport rate and survivorship after posterior cruciate ligament (PCL)-based multiligament knee injuries (MLKI) with posteromedial corner tears as significant risk factor for failure. Knee Surg Sports Traumatol Arthrosc 2023; 31:5018-5024. [PMID: 37668614 PMCID: PMC10598146 DOI: 10.1007/s00167-023-07547-0] [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: 05/07/2023] [Accepted: 08/09/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE To assess the survival rate and associated risk factors of a wide cohort of patient's underwent surgical treatment for posterior cruciate ligament (PCL)-based multiligament knee injury (MLKI) at long-term follow-up and to investigate the long-term patient's reported outcomes (PROMS) and functional activity. METHODS All cases of PCL-based MLKI performed at one single sport-medicine institution were extracted and patient's with a minimum 2 years of follow-up included. VAS, Lysholm, KOOS, Tegner Activity level scores, the incidence and time of return to sport (RTS) and return to work (RTW) were collected before, after surgery and at final follow-up. A multivariate logistic regression was performed to investigate the outcomes associated with the patient's acceptable symptoms state (PASS) for each sub-score of the KOOS. The Kaplan-Meier method with surgical failure (re-operation to one of the reconstructed ligaments) as endpoint was used to perform the survivorship analysis for the entire cohort. RESULTS Forty-two patients were included and evaluated at an average of 10 years. All PROMS significantly improved from pre- to post-surgery (range ηp2 0.21-0.43, p < 0.05) except for the Tegner score which significantly improved from pre-surgery and to final follow-up (ηp2 = 0.67, p < 0.001). RTW was achieved in the 95.2% after 2.4 ± 1.9 months. RTS was achieved in 78.6% after 6.7 ± 5.0 months. The higher number of surgeries were the significant negative predictors of PASS for the KOOS sub-scales Sport (p = 0.040) and Quality of Life (p = 0.046), while the presence of meniscal lesions was a significant negative predictor of PASS only for the KOOS sub-scale of Sport (p = 0.003). Six patients (14.3%) underwent reoperation and were considered as surgical failures. The global survivorship was 95.2%, 92.6%, 87.1%, and 74.7% at 2, 5, 12, and 15 years, respectively. The survivorship in patient undergoing PMC reconstruction surgery was significantly lower (p = 0.004; HR 7.1) compared to patients without a PMC lesion. CONCLUSION Good-to-excellent PROMS could be obtained and maintained at long-term follow-up after surgery, with the higher number of surgeries and meniscal lesions as significant negative predictors of the PASS. Moreover, the presence of a PMC lesion significantly increases the risk of the PCL reconstruction failure. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Nicola Pizza
- Knee and Arthroscopy Unit, ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Di Paolo
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alberto Grassi
- Dipartimento di Scienze Biomediche e Neuromotorie, DIBINEM, Università di Bologna, Bologna, Italy
| | - Anna Pagano
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marianna Viotto
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giacomo Dal Fabbro
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Piero Agostinone
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gian Andrea Lucidi
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Juan Carlos Monllau
- Knee and Arthroscopy Unit, ICATME, Hospital Universitari Dexeus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, DIBINEM, Università di Bologna, Bologna, Italy
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Herbst E, Muhmann RJ, Raschke MJ, Katthagen JC, Oeckenpöhler S, Wermers J, Glasbrenner J, Robinson JR, Kittl C. The Anterior Fibers of the Superficial MCL and the ACL Restrain Anteromedial Rotatory Instability. Am J Sports Med 2023; 51:2928-2935. [PMID: 37503921 DOI: 10.1177/03635465231187043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
BACKGROUND There is limited knowledge about how the anterior cruciate ligament (ACL) and capsuloligamentous structures on the medial side of the knee act to control anteromedial rotatory knee instability. PURPOSE To investigate the contribution of the medial retinaculum, capsular structures (anteromedial capsule, deep medial collateral ligament [MCL], and posterior oblique ligament), and different fiber regions of the superficial MCL to restraining knee laxity, including anteromedial rotatory instability. STUDY DESIGN Controlled laboratory study. METHODS Eight fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic testing system in a position-controlled mode. Loads of 10 N·m valgus rotation, 5 N·m tibial external rotation, 5 N·m tibial internal rotation, and 134 N anterior tibial translation in 5 N·m external rotation were applied at different flexion angles. The motion of the intact knee at 0° to 120° of flexion was replicated after sequential excision of the sartorial fascia; anteromedial retinaculum; anteromedial capsule; anterior, middle, and posterior fibers of the superficial MCL; the deep MCL; the posterior oblique ligament; and the ACL. The reduction in force/torque indicated the contribution of each resected structure to resisting laxity. A repeated-measures analysis of variance with a post hoc Bonferroni test was used to analyze the relative force and torque changes from the intact state. RESULTS The superficial MCL was the most important restraint to valgus rotation from 0° to 120° and provided the largest contribution to resisting external rotation between 30° and 120° of knee flexion, gradually increasing from 25.2% ± 7.4% at 30° to 36.9% ± 15.4% at 90°. The posterior oblique ligament contributed significantly to resisting valgus rotation only in extension (17.2% ± 12.1%) but was the major restraint to internal rotation at 0° (46.7% ± 13.1%) and 30° (30.4% ± 17.7%) of flexion. The sartorial fascia and anteromedial retinaculum resisted ER at all knee flexion angles (P < .05) and was the single most important restraint in the extended knee (19.5% ± 11%). The capsular structures (anteromedial capsule and deep MCL) had a combined contribution of 20% ± 11.5% at 0° and 23.4% ± 10.5% at 120° of knee flexion but were less important from 30° to 90°. The ACL was the primary restraint to anterior tibial translation in external rotation between 0° and 60° of flexion (50.2% ± 16.9% at 30°), but the superficial MCL was more important at 90° to 120° of knee flexion (36.8% ± 16.4% at 90°). The anterior, middle, and posterior regions of the superficial MCL contributed differently to the simulated laxity tests. The anterior fibers were the most important part of the superficial MCL in resisting external rotation and combined anterior tibial translation in external rotation. CONCLUSION The superficial MCL not only was the primary restraint to valgus rotation throughout the range of knee flexion but also importantly contributed to resisting anterior tibial translation in external rotation, particularly in deeper flexion in the cadaveric model. The anterior fibers of the superficial MCL are the most important superficial MCL fibers in resisting anterior tibial translation in external rotation. This study suggests that a medial reconstruction that reproduces the function of the posterior MCL fibers and posterior oblique ligament may not best control anteromedial rotatory instability. CLINICAL RELEVANCE Based on these data, there is a need for an individualized medial reconstruction to address different types of medial injury patterns and instabilities.
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Affiliation(s)
- Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Raphael J Muhmann
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - J Christoph Katthagen
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Simon Oeckenpöhler
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Jens Wermers
- Faculty of Engineering Physics, FH Muenster, Muenster, Germany
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
| | | | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, University of Muenster, Muenster, Germany
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Guo J, Qi C, Zhang D, Yang G, Wang C, Yang P, Wang B. Safe femoral tunnel drilling angles avoid injury to the medial and posteromedial femoral anatomic structures during single-bundle posterior cruciate ligament reconstruction with the inside-out technique. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07412-0. [PMID: 37039872 DOI: 10.1007/s00167-023-07412-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 04/03/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE To investigate the relationship between the medial and posteromedial femoral anatomic structures and the femoral tunnel exit produced by different tunnel orientations when creating the femoral tunnel for posterior cruciate ligament reconstruction (PCLR) using the inside-out (IO) technique and to estimate safe tunnel orientations to minimize the risk of iatrogenic injury to these structures. METHODS Eleven cadaveric knees were used. The medial and posteromedial aspects of each knee joint were dissected to reveal the "safe zone," which is a bony area that avoids the distribution or attachment of at-risk structures (MCL, PMC structures, and articular cartilage), while remaining 10 mm away from the articular cartilage. The hypothesis of this study was that by creating the femoral tunnel at specific angles using the IO technique, the tunnel outlet would be as close to the safe zone as possible, protecting the at-risk structures from damage. Femoral tunnels were drilled at 20 different angle combinations on each specimen: 0°, 15°, 30°, 45°, and 60° relative to a line parallel to the transepicondylar axis in the axial plane, as well as 15°, 30°, 45°, and 60° relative to a line parallel to the femoral axis in the coronal plane. The positional relationship between each tunnel exit and the safe zone was recorded, and the shortest distance between the exit center and the safe zone boundary was measured. RESULTS The risk of iatrogenic injury differed depending on the drilling orientation (χ2 = 168.880, P < 0.001). Femoral drilling angle combinations of 45/45°, 45/60°, 60/30°, 60/45°, and 60/60° (axial/coronal) were considered relatively safer than other orientations (P < 0.05). The shortest distance between the tunnel exit and the safe zone boundary was negatively correlated with the angle in the axial plane (P < 0.001, r = - 0.810). CONCLUSIONS When creating the IO femoral tunnel for single-bundle PCL reconstruction, angle combinations of 45/45°, 45/60°, 60/30°, 60/45°, and 60/60° (axial/oblique coronal) could be utilized to prevent at-risk structures from being damaged. The drilling angles and the safe zone can be employed to optimize the femoral tunnel in PCLR.
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Affiliation(s)
- Jia Guo
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Chao Qi
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
| | - Dongfang Zhang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Guodong Yang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Chen Wang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Pu Yang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Bin Wang
- Department of Sports Medicine, the Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
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Daxhelet J, Bouguennec N, Graveleau N. The Mirror Anterolateral Ligament: A Simple Technique to Reconstruct the Deep Medial Collateral Ligament Using the Gracilis Associated With a Four-Strand Semitendinosus for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2022; 11:e1419-e1424. [PMID: 36061457 PMCID: PMC9437466 DOI: 10.1016/j.eats.2022.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/13/2022] [Indexed: 02/03/2023] Open
Abstract
We present a surgical technique to reconstruct the deep portion of the medial collateral ligament (MCL) when associated with an injury of the anterior cruciate ligament (ACL). Patients could benefit from this procedure in cases of ACL reconstruction and persistent laxity at 20° of flexion of the MCL without any laxity in extension. This surgery uses the gracilis to reconstruct the deep portion of the MCL in the same manner described for the anterolateral ligament on the other side of the knee. The procedure is performed percutaneously, graft and tunnels are independent from the ACL, a screw is used on the femoral side, and a cortical device is used on the tibial side.
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Affiliation(s)
| | - Nicolas Bouguennec
- Address correspondence to Nicolas Bouguennec, Clinique du Sport, 2 rue Nègrevergne, 33700 Mérignac, France.
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Wierer G, Kittl C, Fink C, Weiler A. Medial Collateral Ligament Reconstruction: A Gracilis Tenodesis for Anteromedial Knee Instability. Arthrosc Tech 2022; 11:e1409-e1418. [PMID: 36061473 PMCID: PMC9437470 DOI: 10.1016/j.eats.2022.03.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/13/2022] [Indexed: 02/03/2023] Open
Abstract
The main principle of the present medial collateral ligament reconstruction technique is to address anteromedial knee instability. Therefore, we describe a gracilis tenodesis with 2 functional bundles to reconstruct the deep and superficial medial collateral ligament. The proposed technique may be performed as an isolated or combined procedure with anterior cruciate ligament reconstruction. Valgus instability in extension is a contraindication.
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Affiliation(s)
- Guido Wierer
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Hall, Austria,Address correspondence to Guido Wierer, M.D., Department of Orthopedics and Traumatology, Academic Teaching Hospital, Hall in Tirol, Austria.
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Christian Fink
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention, UMIT Hall, Austria,Gelenkpunkt Innsbruck, Austria
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Billières J, Hopper GP, Carrozzo A, Ferreira A, Guy S, Vieira TD, Sonnery-Cottet B. Arthroscopic Medial Compartment Drive-Through Sign for Knee Medial Collateral Ligament Complex Injuries. Arthrosc Tech 2022; 11:e763-e766. [PMID: 35646567 PMCID: PMC9134124 DOI: 10.1016/j.eats.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Acute injuries of the knee medial collateral ligament complex concomitant with anterior cruciate ligament injuries are common. The exact site of the injury may be difficult to diagnose preoperatively on magnetic resonance imaging. This study describes an arthroscopic sign that helps determine the site of the knee medial collateral ligament complex injury. The "medial compartment drive-through sign," visualized during arthroscopy, is described as an excessive opening of the medial compartment. If this excessive opening is above the meniscus, it corresponds to a femoral-sided injury; conversely, if the excessive opening is below the meniscus, then it is a tibial-sided injury. This allows a precise surgical incision to be made, thereby avoiding extensive approaches and possible wound-related complications.
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Affiliation(s)
| | - Graeme P. Hopper
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
| | - Alessandro Carrozzo
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
| | - Alexandre Ferreira
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
| | - Sylvain Guy
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France,Address correspondence to Thais Dutra Vieira, M.D., Centre Orthopedique Santy, 24 Avenue Paul Santy, 69008, Lyon, France.
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hopital Privé Jean Mermoz, Lyon, France
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The treatment of posterolateral knee instability with combined arthroscopic popliteus bypass and PCL reconstruction provides good-to-excellent clinical results in the mid-term follow-up. Knee Surg Sports Traumatol Arthrosc 2022; 30:1414-1422. [PMID: 34059968 DOI: 10.1007/s00167-021-06590-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/21/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical outcomes of patients who were treated with an arthroscopic popliteus bypass (PB) technique, in cases of a posterolateral rotational instability (PLRI) and a concomitant posterior cruciate ligament (PCL) injury of the knee. METHODS This was a retrospective case series in which 23 patients were clinically evaluated after a minimum of 2 years following arthroscopic PB and combined PCL reconstruction. Lysholm, Tegner and Knee Injury and Osteoarthritis Outcome scores as well as visual analog scales (VAS) for joint function and pain were evaluated. Posterior laxity was objectified with stress radiography and a Rolimeter examination. Rotational instability was graded with the dial test. RESULTS 23 patients were available for follow-up, 46.0 ± 13.6 months after surgery. The median time interval from the initial injury to the surgery was 6.0 (3.5;10.5) months. The postoperative Lysholm Score was 95.0 (49-100); the Tegner Score changed from 6.0 (3-10) before the injury to 5.0 (0-10) at the follow-up examination (p = 0.013). The side-to-side difference on stress radiography (SSD) of posterior translation changed from 10.4 (6.6-14.8) mm before the injury to 4.0 (0.2-5.7) mm postoperatively (p < 0.01). Rotational instability was reduced to grade A (82.6%) or B (17.4%) (IKDC). The Rolimeter SSD was 2.0 (0-3) mm at the follow-up examination. VAS Function 0 (0-5), VAS pain 0 (0-6). CONCLUSIONS The arthroscopic PB graft technique provided good-to-excellent clinical results in the mid-term follow-up in patients with type A PLRI and concomitant PCL injury. However, an exact differentiation of lateral, rotational and dorsal instabilities of posterolateral corner (PLC) injuries is crucial, for the correct choice of therapy, as cases with lateral instabilities require more complex reconstruction techniques. Arthroscopic posterolateral corner reconstruction is a safe procedure with a high success rate in the mid-term follow-up. LEVEL OF EVIDENCE IV.
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Non-anatomic tunnel position increases the risk of revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 30:1388-1395. [PMID: 33983487 DOI: 10.1007/s00167-021-06607-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/05/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE Anterior cruciate ligament (ACL) graft failure is a complication that may require revision ACL reconstruction (ACL-R). Non-anatomic placement of the femoral tunnel is thought to be a frequent cause of graft failure; however, there is a lack of evidence to support this belief. The purpose of this study was to determine if non-anatomic femoral tunnel placement is associated with increased risk of revision ACL-R. METHODS After screening all 315 consecutive patients who underwent primary single-bundle ACL-R by a single senior orthopedic surgeon between January 2012 and January 2017, 58 patients were found to have both strict lateral radiographs and a minimum of 24 months follow-up without revision. From a group of 456 consecutive revision ACL-R, patients were screened for strictly lateral radiographs and 59 patients were included in the revision group. Femoral tunnel placement for each patient was determined using a strict lateral radiograph taken after the primary ACL-R using the quadrant method. The center of the femoral tunnel was measured in both the posterior-anterior (PA) and proximal-distal (PD) dimensions and represented as a percentage of the total distance (normal center of anatomic footprint: PA 25% and PD 29%). RESULTS In the PA dimension, the revision group had significantly more anterior femoral tunnel placement compared with the primary group (38% ± 11% vs. 28% ± 6%, p < 0.01). Among patients who underwent revision; those with non-traumatic chronic failure had statistically significant more anterior femoral tunnel placement than those who experienced traumatic failure (41% ± 13% vs. 35% ± 8%, p < 0.03). In the PD dimension, the revision group had significantly more proximal femoral tunnel placement compared with the primary group (30% ± 9% vs 38% ± 9%, p < 0.01). CONCLUSION In this retrospective study of 58 patients with successful primary ACL-R compared with 59 patients with failed ACL-R, anterior and proximal (high) femoral tunnels for ACL-R were shown to be independent risk factors for ACL revision surgery. As revision ACL-R is associated with patient- and economic burden, particular attention should be given to achieving an individualized, anatomic primary ACL-R. Surgeons may reduce the risk of revision ACL-R by placing the center of the femoral tunnel within the anatomic ACL footprint. LEVEL OF EVIDENCE Level III.
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MR Imaging of the Knee Posterolateral and Posteromedial Corner Injuries. Magn Reson Imaging Clin N Am 2022; 30:215-226. [DOI: 10.1016/j.mric.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Surgical Principles for Medial and Posteromedial Knee Injuries. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Rodriguez AN, Shleck K, LaPrade RF. Complications of Medial and Lateral Knee Surgery and How to Best Avoid Them. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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22
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Madi S, Acharya K, Pandey V. Current concepts on management of medial and posteromedial knee injuries. J Clin Orthop Trauma 2022; 27:101807. [PMID: 35242534 PMCID: PMC8873958 DOI: 10.1016/j.jcot.2022.101807] [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: 01/27/2022] [Revised: 02/06/2022] [Accepted: 02/16/2022] [Indexed: 11/25/2022] Open
Abstract
Traditionally, while managing ligament injuries around the knee, medial side injuries are frequently overlooked or considered 'benign' with very little influence on overall knee stability outcomes. However, much has changed in the recent past, and like the lateral side of the knee, it is gaining considerable attention. It is now well known that the Medial collateral ligament and Posteromedial corner are fundamentally two distinct structures that differ in anatomy and biomechanics. When it comes to decision making between conservative versus operative approach for medial side injuries, treating orthopaedic surgeons are subjected to walking on a thin line trying to balance between potential residual laxity and joint stiffness. This review will delve into some of the recent works focusing on the medial side injuries and discuss the evolving concepts.
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Affiliation(s)
| | | | - Vivek Pandey
- Corresponding author. Sports injury and arthroscopy division, Orthopaedics, Kasturba medical college, Manipal, Manipal academy of Higher education, Manipal, 576104, India.,
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[Experience in diagnosis and treatment of KD- ⅢM dislocation of knee joint]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:33-40. [PMID: 35038797 PMCID: PMC8844627 DOI: 10.7507/1002-1892.202105117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To explore the effectiveness of one-stage posterior medial corner (PMC) repair or reconstruction combined with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction in treating KD-ⅢM dislocation. METHODS The clinical data of 15 patients with knee KD-ⅢM dislocation who met the selection criteria between January 2016 and July 2019 were retrospectively analyzed. There were 9 males and 6 females, aged 22-61 years (mean, 40.3 years). Injuries were caused by violence of flexion, valgus, and external rotation, including 10 cases of traffic accident injuries, 3 cases of crush injuries, 1 case of winch injury, and 1 case of explosion injury. The time from injury to operation ranged from 3 days to 6 months, with an average of 18.5 days. PMC repair combined with PCL+ACL reconstruction was performed in 10 cases in acute stage (within 3 weeks after injury), including 3 cases of irreducible dislocation. PMC+PCL+ACL reconstruction was performed in 5 cases with chronic dislocation. Before operation and at last follow-up, the knee joint function was evaluated by Lysholm score and International Knee Documentation Committee (IKDC) 2000 score. KT-3000 was used to evaluate the forward stability of the knee (calculated the difference of tibial anterior displacement of both knees), the X-ray films of the stress position of the knee joint was used to evaluate the valgus of the knee (calculated the difference of medial joint space width of both knees) and the backward stability (calculated the difference of tibial posterior displacement of both knees), and the internal and external rotation stability was evaluated by knee flexion 30° tibial external rotation and knee flexion 90° tibial internal rotation tests (calculated the difference of tibial internal rotation and the difference of tibial external rotation of both knees). RESULTS The operation time was 120-240 minutes, with an average of 186.5 minutes. Patients were followed up 24-48 months, with an average of 27.4 months. There was no complication such as infection, deep vein thrombosis, vascular injury, or heterotopic ossification. At last follow-up, the Lysholm score, IKDC2000 score, the difference of tibial anterior displacement of both knees, the difference of medial joint space width of both knees, the difference of tibial posterior displacement of both knees, the difference of tibial internal rotation and the difference of tibial external rotation of both knees significantly improved when compared with preoperative ones ( P<0.05). According to the IKDC2000 valgus stability grading standard, there were 3 cases of grade C and 12 cases of grade D before operation, and 10 cases of grade A and 5 cases of grade B at last follow-up, which was significantly improved when compared with that before operation ( Z=-4.930, P=0.000). At last follow-up, the pivot shift tests of 15 patients were negative. The anterior and posterior drawer tests of 10 patients were negative, 5 patients had mild instability, both the anterior and posterior drawer tests were positive. CONCLUSION KD-ⅢM dislocation of the knee joint can lead to the posterior medial and anterior instability. Acute dislocation combined with "dimple sign" requires surgical reduction as soon as possible to repair PMC and reconstruct PCL and ACL. In chronic patients, PMC is difficult to repair, it is recommended to reconstruct PMC, PCL, and ACL at one stage to improve knee joint stability. The early and middle effectiveness are satisfactory.
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Easwaran R, Khan M, Sancheti P, Shyam A, Bhandari M, Ranawat AS, Thakkar S, Parikh S, Musahl V, Joglekar S, J Deshmukh A, Plancher K, Verma N, McAllister D, Verdonk P, Lustig S, Chandrateya A, Smigleiski R, Solayar G, Chernchujit B, Yung P, Budhiparama N, Hoshino Y, White N, Parker D, Clatworthy M, Brown C, Manzary M, Rajan D, Narvekar A, Tapasvi S, Pardiwala D, Panigrahi R, Arumugam S, Kapoor V, Mody B, Maheshwari J, Dahiya V, Joseph C, Laddha M, Rajgopal A. Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts. Knee Surg Sports Traumatol Arthrosc 2022; 30:3634-3643. [PMID: 35435469 PMCID: PMC9013735 DOI: 10.1007/s00167-022-06973-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/29/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic. METHODS The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus. RESULTS Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis. CONCLUSION It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.
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Affiliation(s)
- Raju Easwaran
- Shree Meenakshi Orthopedics and Sports Medicine Clinic, B H 41 East, Shalimar Bagh, New Delhi, 110088, India.
- Department of Arthroscopy and Sports Injuries, Max Super-Speciality Hospital Shalimar Bagh, New Delhi, India.
| | - Moin Khan
- Sports Medicine and Shoulder Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Parag Sancheti
- Sancheti Institute for Orthopaedics and Rehabilitation and PG College, Pune, India
| | - Ashok Shyam
- Sancheti Institute for Orthopedics and Rehabilitation, Pune, India
| | - Mohit Bhandari
- Chair, Department of Surgery, McMaster University, Hamilton, Canada
| | - Anil S Ranawat
- Knee Division of SMI, Hospital for Special Surgery, New York, USA
| | - Savyasachi Thakkar
- Johns Hopkins Orthopaedics, Hip and Knee Reconstruction Surgery, Columbia, USA
| | - Shital Parikh
- Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Volker Musahl
- UPMC Freddie Fu Sports Medicine Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, USA
| | - Siddharth Joglekar
- Orthopedic Service, VA Central California Health Care System, Fresno, CA, USA
- UCSF Fresno Orthopedic Residency Program, Fresno, USA
| | | | - Kevin Plancher
- Albert Einstein College of Medicine/Montefiore Medical Center, New York, NY, USA
- Weill Cornell Medical College, New York, USA
- Orthopaedic Foundation, Stamford, CT, USA
- Plancher Orthopaedics and Sports Medicine, New York, USA
| | - Nikhil Verma
- Division of Sports Medicine, Sports Medicine Fellowship, Rush University Medical Center, Midwest Orthopedics at Rush, Chicago, USA
| | - David McAllister
- Sports Medicine Service, Vice Chair of Academic Affairs, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, USA
- UCLA Department of Athletics, David Geffen School of Medicine at UCLA, Los Angeles, USA
| | - Peter Verdonk
- Orthopaedic Center Antwerp, Antwerp, Belgium
- Department of Orthopaedic Surgery, Antwerp University, Antwerp, Belgium
| | - Sebastien Lustig
- Department of Orthopedic Surgery and Sport Medicine, Croix-Rousse Hospital, Lyon, France
| | - Amit Chandrateya
- Princess of Wales Hospital Bridgend, Cwm Taf Morgannwg University Health Board, Bridgend, UK
| | - Robert Smigleiski
- Orthopaedics and Sports Medicine, Department at LIFE Institute, LIFE Institute Biological Treatment Centre, Warsaw, Poland
| | - Gandhi Solayar
- Orthopaedic Specialist Centre, Subang Jaya, Selangor, Malaysia
| | - Bancha Chernchujit
- Department of Orthopedics, Thammasat University Hospital, Khlong Nueng, Thailand
| | - Patrick Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong (CUHK), Hong Kong, China
| | - Nicolaas Budhiparama
- School of Vocational Studies and Department of Orthopaedics and Traumatology, School of Medicine, University of Airlangga, Jl. Mayjend. Prof. Dr. Moestopo, Jawa Timur, Indonesia
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
- Nicolaas Institute of Constructive Orthopaedic Research and Education Foundation for Arthroplasty and Sports Medicine, Medistra Hospital, Jakarta, Indonesia
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, School of Medicine, Kobe University, Kobe, Japan
| | | | - David Parker
- Sydney Orthopaedic Research Institute, Chatswood, Australia
| | | | - Charlie Brown
- International Knee and Joint Centre, Abu Dhabi, United Arab Emirates
| | - Mojieb Manzary
- Orthopedic Services, Johns Hopkins Aramco Health Care Center, Dhahran, Saudi Arabia
- Department of Orthopedics, Johns Hopkins University School of Medicine, Dhahran, Saudi Arabia
| | - David Rajan
- Ortho One-Orthopaedic Speciality Centre, Coimbatore, India
| | - Abhay Narvekar
- P D Hinduja Hospitals Mumbai, Global Hospital Parel, Mumbai, India
| | | | - Dinshaw Pardiwala
- Arthroscopy Service, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
| | - Ranjit Panigrahi
- PG Dept of Orthopaedics, Hitech Medical College and Hospital, Bhubaneswar, Odisha, India
- Kalinga Super Speciality Hospital, Bhubaneswar, Odisha, India
| | - S Arumugam
- Centre for Sports Science, Sri Ramachandra Institute of Higher Education and Research (Deemed University), Chennai, India
| | - Vikash Kapoor
- Medica Superspeciality Hospital, Medica Hospitals, Kolkata, India
| | - Bharat Mody
- Welcare Hospital, Atladra-Vadsar Ring Road, Atladra, Vadodara, Gujarat, India
| | - Jitender Maheshwari
- Knee and Shoulder Service, Department of Orthopaedics, Sitaram Bharatiya Hospital, New Delhi, India
| | - Vivek Dahiya
- Adult Reconstruction Lower Limb, Institute of Musculoskeletal Disorders and Orthopaedics, Medanta, Gurugram, India
| | - Clement Joseph
- Arthroscopy and Sports Medicine, Asian Joint Reconstruction Institute, SIMS, Chennai, India
| | | | - Ashok Rajgopal
- Institute of Musculoskeletal Diseases and Orthopaedics, Medanta Medicity, Gurugram, Haryana, India
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Li Y, Feng H, Li X, Song G, Zhang Z, Zheng T, Cao Y, Zhang H. The clinical outcome of minimally invasive popliteal tendon recess procedure is comparable to arthroscopic popliteal tendon reconstruction in patients with type A posterolateral rotational instability. Knee Surg Sports Traumatol Arthrosc 2022; 30:200-207. [PMID: 33544158 DOI: 10.1007/s00167-021-06444-8] [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: 06/20/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To compare the objective and subjective clinical outcome of minimally invasive popliteal tendon (PT) recess procedure versus arthroscopic PT reconstruction, combined with posterior cruciate ligament reconstruction in patients with Type A posterolateral rotational instability (PLRI). The hypothesis was that the two techniques had comparable clinical outcomes. METHODS Between 2012 and 2017, patients who were eligible for inclusion in this study if they (1) had Type A PLRI according to Fanelli's classification with posterior tibial translation > 12 mm on stress radiography and side-to-side difference of dial test external rotation > 10°, (2) PT peel-off lesion or laxity with structural integrity (3) were followed for a minimum of 2 years with examination under anesthesia (EUA) and stress radiograph results. Evaluation included subjective scoring, knee stability examinations and second-look arthroscopic lateral gutter drive-through (LGDT) test. Patients who underwent PT recess procedure were designated as Group A, while patients who underwent arthroscopic PT reconstruction were labelled as Group B. The differences between the two groups were analyzed. RESULTS A total of 61 eligible patients with a minimum follow-up time of 2 years were evaluated in the present study. At the final follow-up, there were no significant inter-group differences in Lysholm scores (Group A: 69.0 ± 16.5, Group B: 75.8 ± 14.6, ns), Tegner scores [Group A: 2 (1-4), Group B: 3 (1-5), ns], or IKDC subjective scores (Group A: 70.5 ± 13.5, Group B: 71.1 ± 9.1, ns). No significant difference in side-to-side difference on posterior stress radiography (Group A: 4.3 ± 3.8 mm, Group B: 4.7 ± 4.6 mm, P = 0.701), dial test result (Group A: 0.9 ± 4.4°, Group B: 1.6 ± 4.9°, ns) or LGDT test positive rate (Group A: 2/34, 5.9%, Group B: 2/27, 7.7%, ns) was observed. CONCLUSION Both minimally invasive PT recess procedure and arthroscopic PT reconstruction significantly improved the knee stability and subjective outcome comparing with preoperative value. In a comparison with arthroscopic PT reconstruction, the recess procedure demonstrated comparable subjective and objective clinical outcome. When both PT reconstruction and PT recess procedure are indicated, the minimally invasive and graft-free recess procedure can be a viable option. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yue Li
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hua Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Xu Li
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Guanyang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Zhijun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Tong Zheng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Yanwei Cao
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hui Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China.
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D'Ambrosi R, Corona K, Guerra G, Cerciello S, Ursino N, Cavaignac E, Vieira TD, Sonnery-Cottet B. Midterm Outcomes, Complications, and Return to Sports After Medial Collateral Ligament and Posterior Oblique Ligament Reconstruction for Medial Knee Instability: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211056070. [PMID: 34888393 PMCID: PMC8649099 DOI: 10.1177/23259671211056070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/24/2021] [Indexed: 11/17/2022] Open
Abstract
Background In cases of multiple ligaments or medial collateral ligament (MCL) reconstruction, restoring the native anatomy of the posterior oblique ligament (POL) to address chronic valgus instability has been attracting increased attention. Purpose To review the current literature on postoperative outcomes, complications, and return to sports after superficial MCL-POL (sMCL-POL) reconstruction to restore medial knee integrity. Study Design Systematic review; Level of evidence, 4. Methods A systematic review was conducted based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two independent reviewers searched the PubMed, Scopus, Embase, and Cochrane Library databases using the terms "posterior oblique ligament," "posteromedial corner of the knee," and "reconstruction." Included were studies that reported postoperative clinical and functional outcomes in patients who had undergone a combined sMCL-POL reconstruction for medial knee instability. The authors evaluated surgical technique, rehabilitation protocol, postoperative outcomes (Lysholm, International Knee Documentation Committee [IKDC], and Tegner scores and valgus stress radiograph), and return to sports and complication rates across the included studies. Results A total of 6 studies were reviewed. The cohort consisted of 199 patients (121 men and 78 women), with a mean age of 32.7 ± 3.9 years (range, 27.4-36.6 years). The Lysholm and IKDC scores improved from pre- to postoperatively (Lysholm, from 67.2 ± 20.4 to 89.4 ± 3; IKDC, from 45.8 ± 2.1 to 84.8 ± 7.5). The Tegner score produced satisfactory results, from a preoperative mean of 3.3 ± 2.4 to 6.3 ± 0.9 postoperatively. The medial joint opening on valgus stress radiographs ranged from 7.5 ± 1.1 mm preoperatively to 3 ± 3.1 mm postoperatively. After passing activity-specific functional and clinical tests, 88% to 91.3% of the patients were reported to have returned to recreational sports within 6 to 12 months postoperatively, whereas 10% of the patients developed postoperative complications. Conclusion Satisfactory clinical and functional outcomes, a high rate of return to recreational sports, and a low rate of postoperative complications were reported after an sMCL-POL reconstruction to restore medial knee integrity.
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Affiliation(s)
| | - Katia Corona
- Department of Medicine, Health Sciences "Vincenzo Tiberio," University of Molise, Campobasso, Italy
| | - Germano Guerra
- Department of Medicine, Health Sciences "Vincenzo Tiberio," University of Molise, Campobasso, Italy
| | - Simone Cerciello
- Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy.,Casa di Cura Villa Betania, Rome, Italy.,Marrelli Hospital, Crotone, Italy
| | | | - Etienne Cavaignac
- Department of Orthopaedic Surgery and Trauma, Hôpital Pierre Paul Riquet, Toulouse, France
| | - Thais D Vieira
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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Requicha F, Comley A. Medial soft-tissue complex of the knee: Current concepts, controversies, and future directions of the forgotten unit. Orthop Rev (Pavia) 2021; 13:24463. [PMID: 34745468 DOI: 10.52965/001c.24463] [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: 05/01/2021] [Accepted: 05/30/2021] [Indexed: 11/06/2022] Open
Abstract
The medial side of the knee is comprised of ligaments, myotendinous and meniscal structures that work as a unit to stabilize the joint. The superficial medial collateral ligament is its core structure. Still, all elements of the medial side have load-sharing relationships, leading to a cascade of events in the scenario of insufficiency of any of them. Understanding the medial soft tissue structures as part of a unit is of utmost importance because the most common ligaments damaged in knee injuries belong to it. Surprisingly, there is a lack of high-level evidence published around the issue, and most studies focus on the superficial medial collateral ligament, overlooking the complexity of these injuries. Acknowledging the consequences for joint biomechanics and treatment outcomes, interest in this area is growing between researchers. Emerging evidence may become a game-changer in the future management of these injuries. Based on a thorough research of published literature, this review provides a current biomechanical concepts and clinical guidance to treat these injuries.
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D'Ambrosi R, Corona K, Guerra G, Cerciello S, Ursino C, Ursino N, Hantes M. Posterior oblique ligament of the knee: state of the art. EFORT Open Rev 2021; 6:364-371. [PMID: 34150330 PMCID: PMC8183151 DOI: 10.1302/2058-5241.6.200127] [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] [Indexed: 01/15/2023] Open
Abstract
The posterior oblique ligament (POL) is the predominant ligamentous structure on the posterior medial corner of the knee joint. A thorough understanding of the anatomy, biomechanics, diagnosis, treatment and rehabilitation of POL injuries will aid orthopaedic surgeons in the management of these injuries. The resulting rotational instability, in addition to valgus laxity, may not be tolerated by athletes participating in pivoting sports. The most common mechanism of injury – accounting for 72% of cases – is related to sports activity, particularly football, basketball and skiing. Moreover, three different injury patterns have been reported: those associated with injury to the capsular arm of the semimembranosus (SM), those involving a complete peripheral meniscal detachment and those involving disruption of the SM and peripheral meniscal detachment. The hallmark of an injury related to POL lesions is the presence of anteromedial rotatory instability (AMRI), which is defined as ‘external rotation with anterior subluxation of the medial tibial plateau relative to the distal femur’. In acute settings, POL lesions can be easily identified using coronal and axial magnetic resonance imaging (MRI) where the medial collateral ligament (MCL) and POL appear as separate structures. However, MRI is not sensitive in chronic cases. Surgical treatment of the medial side leads to satisfactory clinical results in a multi-ligamentous reconstruction scenario, but it is known to be associated with secondary stiffness. In young patients with high functional demands, return to sports is allowed no earlier than 9–12 months after they have undergone a thorough rehabilitation programme.
Cite this article: EFORT Open Rev 2021;6:364-371. DOI: 10.1302/2058-5241.6.200127
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Affiliation(s)
| | - Katia Corona
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Germano Guerra
- Department of Medicine and Health Sciences "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Simone Cerciello
- Department of Orthopaedics, A. Gemelli University Hospital Foundation IRCCS, Catholic University, Rome, Italy.,Casa di Cura Villa Betania, Rome, Italy.,Marrelli Hospital, Crotone, Italy
| | | | | | - Michael Hantes
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Thessalia, University Hospital of Larissa, Larissa, Greece
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