Reconstruction of Symptomatic Congenital Anterior Cruciate Ligament Insufficiency

Congenital absence of the lateral meniscus: A case report

BACKGROUND

Congenital absence of the menisci is a rare anatomical variation characterized by the absence or underdevelopment of one or both menisci in the knee joint. The menisci are crucial in load distribution, joint stability, and shock absorption. Understanding the clinical presentation, diagnosis, and management of this condition is important for optimal patient care.

CASE SUMMARY

A 27-year-old male with a long-standing history of knee pain underwent diagnostic arthroscopy, revealing a congenital absence of the meniscus. The patient's clinical findings, imaging results, surgical procedures, and pertinent images are detailed. This case presents a unique aspect with the congenital absence of the meniscus, contributing valuable insights to the literature on rare anatomical anomalies.

CONCLUSION

This case of congenital absence of the menisci highlights the diagnostic challenges posed by rare anomalies. The diagnostic arthroscopy played a crucial role in identifying the absence of the meniscus and providing an explanation for the patient's persistent knee pain. The case underscores the importance of individualized treatment approaches, including physical therapy, for optimal management of rare meniscal anomalies. Further research is warranted to explore effective management strategies for the aforementioned cases and to expand our knowledge of these rare conditions.

Imaging the pediatric anterior cruciate ligament: not little adults

An increased incidence of anterior cruciate ligament (ACL) injuries in children over the last few decades has led to a corresponding increase in ACL reconstruction procedures in children. In this review, we will illustrate unique features seen when imaging the ACL in children versus adults. After briefly reviewing relevant normal ACL anatomy, we will review imaging findings of congenital ACL dysplasia. This is followed by a discussion of imaging ACL avulsions. Lastly, we will review the different types of ACL reconstruction procedures performed in skeletally immature children and their post-operative appearances.

Management of Anterior Cruciate Ligament Aplasia for the Arthroscopy Surgeons: A Systematic Review

BACKGROUND

Anterior Cruciate Ligament Aplasia (ACLA) is a rare condition which can sometimes remain asymptomatic into adult life. Although the quoted incidence is 1.7 per 100,000 live births, it is higher due to these silent cases and can be encountered by the arthroscopy surgeon doing reconstructive procedure for the ACL. The aim of this study is to get information on clinical presentation, imaging, arthroscopy findings and management of the knee in patients with ACL aplasia through a systematic review relevant to the arthroscopy surgeon in making a decision when they encounter such a case.

METHODS

We performed a systematic review of the literature to get information on this condition that may be relevant to the arthroscopy surgeon from PubMed, Ovid full text, Embase and Ovid Medline databases. After exclusions and inclusions, we found 31 articles relevant to the search which included 101 knees.

RESULTS

Most of the publications were case reports due to the rarity of this condition. ACLA is commonly associated with Fibular Hemimelia, Congenital Dislocation of the Knee and Proximal Focal Femoral Deficiency (PFFD). Clinical findings, imaging appearances, other associated findings with ACLA have been listed and management options listed and discussed.

CONCLUSIONS

Patients with ACLA are often asymptomatic and arthroscopic reconstruction of the ACL appears to be a viable option in selected symptomatic cases only. The arthroscopic surgeon should be aware of the clinical picture and intraarticular findings of ACLA to recognize the condition and make a decision on the optimal management. Further studies are required to report on long-term outcomes of the condition in terms of secondary osteoarthritis development as well as the procedures performed. We recommend forming a global registry to study and further understand the aspects of this condition.

LEVEL OF EVIDENCE

4.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00651-2.

Iliotibial band autograft is a suitable alternative graft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes

PURPOSE

Despite encouraging clinical, biomechanical and histological results, ACL reconstruction using the ITB was slowly abandoned. The hypothesis was that the current literature supports the use of ITB as the graft of choice for ACL reconstruction because of its good outcomes.

METHODS

A systematic search of the literature was performed in the PubMed, MEDLINE, Cochrane, and Ovid databases to identify published clinical studies relevant to ACL reconstruction with ITB autograft and studies comparing ITB autograft with bone-patellar tendon-bone (BPTB) and hamstring (HT) autografts (none were found). The results of the eligible studies were analyzed in terms of graft failure, instrumented knee laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, Tegner activity score, return to sports rate, return to sports at pre-injury level and complications.

RESULTS

Nineteen clinical studies including 1,210 patients with ACL reconstruction met the inclusion criteria. Graft failure occurred after ITB autograft in 4.2% of patients. Postoperative mean side-to-side laxity was 1.41 mm with 21% of patients having greater than 3 mm side-to-side difference. Lachman test and pivot-shift test were negative (grade 0) in 57% and 85%, respectively, and were grade 0 or 1 in 95% and 97%, respectively. Functional outcomes were satisfactory in 84% of patients with good to excellent results (Lysholm score > 84). Mean postoperative Lysholm score was 93.3 and 84% of patients had an objective IKDC grade of A or B. Mean postoperative Tegner score was 6.8. The return to sports rate was 89% and 61% of patients returned to their pre-injury level. A comparison of 89 ITB versus 80 BPTB autografts revealed no significant differences in graft failure (n.s.), instrumented mean side-to-side knee laxity difference (n.s.) or Tegner score (n.s.).

CONCLUSION

The graft survival rate and clinical and functional outcomes for ITB autograft are satisfactory. By allowing ACL reconstruction and lateral tenodesis to be done with a single, continuous, pedicled graft through an outside-in femoral tunnel, this technique may become the preferred alternative for primary or secondary ACL surgery.

LEVEL OF EVIDENCE

Level IV.

Bilateral Recurrent, Atraumatic Anterior Knee Dislocations in a Pediatric Patient With Congenital Absence of the Anterior Cruciate Ligament

An 8 yo 15 kg male child with an undiagnosed congenital syndrome presented with painful, recurrent atraumatic bilateral knee dislocations. Recurrent dislocations were reduced in the emergency department and were never associated with neurovascular compromise. Magnetic resonance imaging identified congenital agenesis of the anterior cruciate ligament (ACL) bilaterally. He underwent staged bilateral physeal-sparing ACL reconstructions with autograft iliotibial band and had no subsequent dislocations during 14 month follow-up. To our knowledge, this is the only reported case of atraumatic spontaneous bilateral knee dislocations in a patient with bilateral congenital absence of the ACL. This case describes a novel indication for physeal-sparing ACL reconstruction in a rare clinical entity.

Extra-articular Tenodesis Using Autogenous Iliotibial Band for Symptomatic Congenital Absence of Anterior Cruciate Ligament: A Report of 2 Cases

CASE

We report 2 cases of congenital absence of anterior cruciate ligament with symptomatic knee instability in young children. This report describes the surgical technique and outcomes of extra-articular tenodesis using autogenous iliotibial band (ITB) without drilling across the open physis. Excellent results were observed at a short-term follow-up.

CONCLUSION

Severe symptoms of knee instability even in young children may warrant surgical approach. Extra-articular tenodesis using autogenous ITB in young children is a good option with positive improvements in knee stability and symptomatic relief.

Iliotibial band autograft: what size is the graft? A mathematical and cadaveric model : ITB single and double strand size

BACKGROUND

The iliotibial band (ITB) is used in anterior cruciate ligament (ACL) reconstruction in skeletally immature patients as well as several other orthopedic reconstructions. The purpose of this study is to determine the size of the ITB as an autograft option in ACL reconstruction surgery or other orthopedic soft tissue reconstructions.

METHODS

Five adult cadavers resulting in nine ITB were used. Thickness and width of the ITB were determined. Using ITB width of 15-60 mm, single and doubled graft sizes were determined using standard surgical graft size technique. Geometric calculations based on average graft thickness were used to mathematically confirm the graft size of the ITB.

RESULTS

The ITB is less than 1 mm in thickness in males and females. Cadaveric measurements were less than 1 mm larger than mathematical measurements, in majority of measurements. ITB autograft can be harvested to a maximum 9 mm single-stranded graft or > 12 mm doubled graft. A minimum of 50 mm of ITB width is required to make a 8 mm graft.

CONCLUSIONS

ITB is a versatile graft that can be used for a graft size up to 9 mm single strand and over 12 mm double strand. A minimum of 50 mm width of ITB is required to obtain a 8 mm-diameter autograft. To ensure appropriate graft size, surgeons should consider harvesting the maximum amount of ITB when performing ACL reconstructions in skeletally immature patients.

CLINICAL RELEVANCE

Surgeons have a quick reference for the width of ITB they should harvest based on the size of graft they require for a successful surgery.

How should congenital absence of cruciate ligaments be treated? A case report and literature review

BACKGROUND

Hypoplasia of bilateral cruciate ligaments is a rare congenital malformation. The diagnosis of such diseases and indications for the various treatment options require further analysis and discussion.

CASE SUMMARY

The patient is a 26-year-old Chinese woman who has been suffering from knee pain since the age of 8 years, 2-3 episodes a year. Three years ago, due to the practice of advanced yoga poses, the frequency of left knee pain increased, requiring prompt medical treatment. Magnetic resonance imaging demonstrated an absence of both anterior and posterior cruciate ligaments of both knees with abnormal posterior tilting of the tibial plateau. Bilateral subluxation of the knee joint was also found, therefore tibial osteotomy was performed. The patient reported at the 24 mo follow-up that the frequency of pain and instability had been reduced and function restored.

CONCLUSION

Osteotomy may be an effective method to treat patients with congenital cruciate ligament deficiency with posterior tibial plateau tilting. The diagnosis of congenital cruciate ligament deficiency shall be based on the combination of patient’s medical history, clinical manifestations, and findings from imaging to avoid possible misdiagnosis. Based on the symptoms, frequency of attacks, and intent of the individual, appropriate treatment options shall be identified.

Bilateral absence of the cruciate ligaments with meniscal dysplasia: Unexpected diagnosis in a child with juvenile idiopathic arthritis

Bilateral agenesis of the cruciate ligaments is a rare congenital anomaly. We report a unique case of a young girl who had congenital short femur and diagnosed with polyarticular juvenile idiopathic arthritis (JIA) and later discovered to have congenital absence of both anterior and posterior cruciate ligaments and meniscal dysplasia in both the knees when MRI was performed at 11 years of age. The MRI was performed to evaluate knee laxity and persistent symptoms despite medical management and multiple steroid injections for arthritis treatment. This patient is one of the youngest with congenital absence of both the cruciate ligaments to be treated with ACL reconstruction. We highlight the unique radiographic imaging manifestations of congenital cruciate ligament agenesis and emphasize the role of MRI to confirm and depict additional intraarticular abnormalities.