Primary Repair of Tibial-Sided Avulsion of the Anterior Cruciate Ligament

Double Decker anterior cruciate ligament avulsion

Distal anterior cruciate ligament avulsion from tibial side is an unusual injury. It can be either bony avulsion, which is more common, or rarely a soft tissue peeling of tibial spine with no bone injury. This case report represents a very infrequent injury of combined soft tissue peeling of distal anterior cruciate ligament along with bony avulsion of tibial spine in a 12-years-old boy after falling from his bike.

Novel surgical technique for soft tissue distal avulsion of the anterior cruciate ligament: Technical note

The most popular surgical treatment for anterior cruciate ligament (ACL) injuries is reconstruction. However, different native tissue preservation and repair techniques have recently become popular. Among the different types of ACL injuries, the least frequent is the tibial-sided soft-tissue avulsion type. Which can be managed with primary repair as an alternative to reconstruction. However, there aren't many procedures reported for treating these rare injuries. As a result, a repair technique is presented using a suture anchor in the tibial footprint with a double-row construct. We present a prospective intervention cohort of two cases where this procedure was used with adequate clinical evolution and stable fixation at 24 months of follow-up. Likewise, there were no complications or reinterventions performed during follow-up. To our knowledge, this technique had not been reported before in the literature for these lesions and combines the benefits of using a suture anchor with a double-row construct and preserves the native tissue and ACL insertion site. Therefore, in these uncommon lesions, a double-row suture anchor technique can be useful to repair acute distal soft tissue avulsion-type ACL injuries.

Do the Differences in the Epiligament of the Proximal and Distal Parts of the Anterior Cruciate Ligament Explain Their Different Healing Capacities? Quantitative and Immunohistochemical Analysis of CD34 and α-SMA Expression in Relation to the Epiligament Theory

The aim of this study was to assess the epiligament theory by determining the normal epiligament morphology of the proximal and distal parts of the anterior cruciate ligament in humans and analyzing the differences between them and the midportion of the ligament in terms of cell numbers and expression of CD34 and α-SMA. Samples were obtained from the anterior cruciate ligaments of 12 fresh knee joints. Monoclonal antibodies against CD34 and α-SMA were used for immunohistochemistry. Photomicrographs were analyzed using ImageJ software, version 1.53f. The cell density was higher in the epiligament than in the ligament connective tissue. Cell counts were higher in the proximal and distal thirds than in the midsubstance of the epiligament. CD34 was expressed similarly in the proximal and distal thirds, although it seemed slightly more pronounced in the distal third. α-SMA expression was more robust in the proximal than the distal part. The results revealed that CD34 and α-SMA are expressed in the human epiligament. The differences between the numbers of cells in the proximal and distal parts of the epiligament and the expression of CD34 and α-SMA enhance epiligament theory. Future investigations into improving the quality of ligament healing should not overlook the epiligament theory.

Arthroscopic Fixation of Anterior Cruciate Ligament Avulsion Fracture Using FiberWire Suture With Suture Disc

Controversy still exists regarding how to reduce and fix a displaced tibial avulsion fracture. Open reduction and internal fixation may lead to morbidity due to soft-tissue injury and arthrotomy. As a result, arthroscopic techniques are increasing in popularity. In the literature, sutures, K wires, and screws are suggested to be used as the fixation devices. Screws cannot be used in small or comminuted fractures, whereas K wires and sutures may not provide strong stability. Recently, with the advent of ultrahigh molecular weight polyethylene sutures like FiberWire, it has become possible to use it as the fixation device in even comminuted avulsion fractures with acceptable reduction stability. In this paper, we describe a simple arthroscopic technique using a FiberWire to manage the displaced tibial eminence avulsion fracture.

Suturing the Anterior Cruciate Ligament Using a No. 16 Intravenous Catheter Needle in Avulsion Anterior Cruciate Ligament Injury

Avulsion anterior cruciate ligament injuries are more common in pediatric patients. There are several methods of fixation available for these injuries (tibial intercondylar eminence fractures), such as the pullout suture technique, screw fixation, and suture anchor fixation. Currently, a pullout technique is widely used for fixation. We purpose a pullout technique method using a modified No. 16 intravenous catheter needle to suture the anterior cruciate ligament fiber instead of a suture hook or suture passer. We also use one anterior tibial tunnel for this arthroscopic pullout fixation technique to decrease the incidence of physeal injury in pediatric patients by using many tibial tunnels.

Central patellar portal placement frequently provokes anterior knee compartment radiological abnormalities in anterior cruciate ligament reconstruction

PURPOSE

A central patellar (CP) portal can be used to view the native femoral insertion site of the anterior cruciate ligament (ACL). It aids in the drilling of an anatomical tunnel; however, its impact on the patellar tendon and the infrapatellar fat pad remains a concern. The aim of this study was to investigate complications associated with the CP portal use in arthroscopic ACL reconstruction (ACLR).

METHODS

A total of 105 patients (107 knees, 60 females) who underwent ACLR with a CP portal from 2012 to 2017 were included in this study. The mean age was 28.3 ± 12.4 years. All surgeries were single-bundle reconstructions using the trans-tibial technique via the CP and anteromedial portals. Post-operative events, magnetic resonance imaging (MRI), and arthroscopic findings associated with CP portal creation were evaluated.

RESULTS

Five patients (4.7%) had symptomatic postoperative complications, which included two patients with patellar tendonitis and three patients with fibrosis in the anterior knee compartment. Abnormal signal intensity of the patellar tendon on MRI and increased thickness at the CP portal area were found in 18 of 25 knees (72%). Three of 56 knees (5.4%) that underwent second-look arthroscopy showed fibrosis of the infrapatellar fat pad. Seven patients (12.5%) showed hypertrophy of the ligamentum mucosum.

CONCLUSIONS

The rate of symptomatic complications associated with CP portal placement was 4.7%; however, abnormal MRI or follow-up arthroscopy findings were much higher than clinically symptomatic patients. This study suggests that CP portal placement could provoke anterior knee compartment fibrosis or hypertrophy.

LEVEL OF EVIDENCE

IV.

Anterior cruciate ligament repair - past, present and future

Background

This article provides a detailed narrative review on the history and current concepts surrounding ligamentous repair techniques in athletic patients. In particular, we will focus on the anterior cruciate ligament (ACL) as a case study in ligament injury and ligamentous repair techniques. PubMed (MEDLINE), EMBASE and Cochrane Library databases for papers relating to primary anterior cruciate ligament reconstruction were searched by all participating authors. All relevant historical papers were included for analysis. Additional searches of the same databases were made for papers relating to biological enhancement of ligament healing.

Current standard

The poor capacity of the ACL to heal is one of the main reasons why the current gold standard surgical treatment for an ACL injury in an athletic patient is ACL reconstruction with autograft from either the hamstrings or patella tendon. It is hypothesised that by preserving and repairing native tissues and negating the need for autograft that primary ACL repair may represent a key step change in the treatment of ACL injuries.

History of primary ACL repair

The history of primary ACL repair will be discussed and the circumstances that led to the near-abandonment of primary ACL repair techniques will be reviewed.

New primary repair techniques

There has been a recent resurgence in interest with regards to primary ACL repair. Improvements in imaging now allow for identification of tear location, with femoral-sided injuries, being more suitable for repair. We will discuss in details strategies for improving the mechanical and biological environment in order to allow primary healing to occur.

In particular, we will explain mechanical supplementation such as Internal Brace Ligament Augmentation and Dynamic Intraligamentary Stabilisation techniques. These are novel techniques that aim to protect the primary repair by providing a stabilising construct that connects the femur and the tibia, thus bridging the repair.

Bio enhanced repair

In addition, biological supplementation is being investigated as an adjunct and we will review the current literature with regards to bio-enhancement in the form platelet rich plasma, bio-scaffolds and stem cells. On the basis of current evidence, there appears to be a role for bio-enhancement, however, this is not yet translated into clinical practice.

Conclusions

Several promising avenues of further research now exist in the form of mechanical and biological augmentation techniques. Further work is clearly needed but there is renewed interest and focus for primary ACL repair that may yet prove the new frontier in ligament repair.

Mechanism of Activating the Proprioceptive NT-3/TrkC Signalling Pathway by Reverse Intervention for the Anterior Cruciate Ligament-Hamstring Reflex Arc with Electroacupuncture

The anterior cruciate ligament (ACL) is an important structure maintaining stability of the knee joints. Deficits in physical stability and the proprioceptive capabilities of the knee joints are observed, when the ACL is damaged. Additionally, a unilateral ACL injury can affect bilateral knee proprioception; therefore, proprioception of the ACL may play a key role in stability. Electroacupuncture therapy has a definite effect nerve regeneration. In this study, cynomolgus monkeys were randomly divided into 4 groups: the model control group, intervention of the injured knee with electroacupuncture (IIKE) group, intervention of the bilateral knees with electroacupuncture (IBKE) group, and the blank control group. The unilateral ACL injury model was developed in IIKE and IBKE groups; acupuncture points around the knees underwent intervention similarly in the IIKE and IBKE groups. Then, mRNA and protein expressions of NT-3 and TrkC in the dorsal root ganglion and of growth-associated protein-43 in the ACL increased according to reverse-transcription quantitative polymerase chain reaction and Western blotting results. Decreased incubations and increased amplitudes were found for somatosensory-evoked potentials and motor nerve conduction velocity. The finding indicates that electroacupuncture may play an important role in the recovery of proprioception in the ACL by activating the NT-3/TrkC signalling pathway.

The Location of Anterior Cruciate Ligament Tears: A Prevalence Study Using Magnetic Resonance Imaging

Background:

Over the past decade, there has been a resurgence of interest in anterior cruciate ligament (ACL) preservation. Proximal and distal avulsion tears have been treated with arthroscopic primary repair, while augmented repair, remnant tensioning, primary repair with biological scaffold, and remnant preservation have been proposed for different types of midsubstance tears. Currently, the incidence of these different tear types is unknown.

Purpose:

To propose a magnetic resonance imaging (MRI) classification system for different tear types based on clinical relevance and to assess the distribution of these different ACL tear types.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective search in an institutional radiographic database was performed for patients who underwent knee MRI at our institution between June 2014 and June 2016. Patients younger than 18 years and those with reports of chronic tears, partial tears, multiligamentous injuries, were excluded. Tear types were graded as proximal avulsion (distal remnant length >90% of total ligament length, type I), proximal (75%-90%, type II), midsubstance (25%-75%, type III), distal (10%-25%, type IV), and distal avulsion (<10%, type V). An orthopaedic surgeon, a radiologist, and a research fellow graded the tear type on 30 MRIs to determine reliability, and the research fellow graded all MRIs. Inter- and intraobserver reliability were measured using kappa statistics.

Results:

A total of 353 patients (57% male; mean age, 37.1 years; range, 18.1-81.2 years) were included. Interobserver reliability was 0.670 (95% confidence interval, 0.505-0.836), and intraobserver reliability ranged from 0.741 to 0.934. Incidence of type I tears was 16%, type II tears 27%, type III tears 52%, type IV tears 1%, and type V tears 3% (2.5% with bony avulsion). Type I tears were more common in patients older than 35 years compared with those younger than 35 years (23% vs 8%; P < .001).

Conclusion:

This classification system was reliable in assessing tear location in acute ACL injuries. Type I tears were seen in 16%, type II in 27%, and type III in 52% of patients in our cohort. These data suggest that there may be greater potential application for ACL preservation techniques.