Femoral Aperture Fixation Improves Anterior Cruciate Ligament Graft Function When Added to Cortical Suspensory Fixation: An In Vivo Computer Navigation Study

Decreased femur tunnel widening after augmented suspensory fixation compared to suspensory fixation for single bundle hamstring ACL reconstruction

Background

Tunnel widening after Anterior cruciate ligament (ACL) reconstruction using a hamstring graft is known to occur at follow-up. Our study aimed to investigate the effect of suspensory fixation augmentation using an interference screw on tunnel widening in single-bundle hamstring ACL reconstruction.

Methods

48 patients who had single bundle ACL reconstruction with femoral fixed loop fixation technique in 15 knees, and, fixed loop with augmented aperture (bio screw) fixation in 33 knees were analyzed. The width of the tunnel was measured using radiographs immediate post-op and at follow-up within 1 year. Computerized Tomogram (CT) measurements of the tunnels and functional scores were also done with overall follow-up for the fixed loop group being 21.33 months (Standard Deviation (SD)11.14) and the Augmentation group 9.12 months (SD 3.83).

Results

Midpoint femur tunnel widening was reduced in the augmentation group, with measurements of 0.74 (SD 1.05) mm Antero Posterior (AP) and 1.01 (SD 1.04) mm in the Lateral view, compared to 1.54 (SD 1.48) mm AP and 1.79 (SD1.47 mm) in the Lateral for the fixed button group. The radiological widening was considerably less in the augmentation group with a p-value of 0.07. AP aperture widening in the augmentation group was 1.25(SD 1.10 mm), and 1.09(SD0.98) mm in the lateral view. The fixed button-only group measured 1.53 (SD1.30) mm in the AP, and 1.65 (SD 1.29) mm in the lateral view, both of which were not statistically significant. The follow-up Lysholm and International Knee Documentation Committee (IKDC) scores were similar for the 2 groups.

Conclusion

Femoral tunnel midpoint and aperture widening were reduced with the fixed loop with aperture (bio screw) augmentation technique for hamstring grafts in single bundle ACL fixation within 1 year with comparable functional scores.

Level of evidence

4.

The Role of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis for Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Clinical Studies

BACKGROUND

After its success in restoring rotational stability and reducing failure rates in primary anterior cruciate ligament reconstruction (ACLR), lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR) has been endorsed for use in revision ACLR surgery, where failure rates are historically higher.

PURPOSE

To perform a systematic review and meta-analysis on whether the addition of a LET or ALLR results in superior clinical outcomes and stability compared with isolated revision ACLR (iACLR).

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis of comparative studies using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("extra-articular" OR "tenodesis" OR "anterolateral ligament" OR "iliotibial") AND ("anterior cruciate ligament") AND ("revision" OR "re-operation"). Data pertaining to all patient-reported outcome measures (PROMs), rotational stability, and postoperative complications were extracted from each study.

RESULTS

After abstract and full-text screening, 10 clinical comparative studies were included. There were 793 patients, of whom 390 had an iACLR while 403 had an ACLR augmented with a LET or an ALLR (augmented ACLR [aACLR]). The mean time for assessment of PROMs was 35 months. The aACLR group had superior International Knee Documentation Committee (IKDC) scores (standardized mean difference [SMD], 0.27; 95% CI, 0.01 to 0.54; P = .04), rotational stability (odds ratio [OR], 2.77; 95% CI, 1.91 to 4.01; P < .00001), and lower side-to-side difference (OR, -0.53; 95% CI, -0.81 to -0.24; P = .0003) than those without the augmentation. Furthermore, they were less likely to fail (OR, 0.44; 95% CI, 0.24 to 0.80; P = .007). Subgroup analysis in the higher-grade laxity cohort (grade ≥2) revealed an even greater IKDC score (SMD, 0.51; 95% CI, 0.16 to 0.86; P = .005) and an improved Lysholm score (SMD, 0.45; 95% CI, 0.24 to 0.67; P < .0001) in the aACLR group.

CONCLUSION

Revision aACLR with a LET or an ALLR can improve subjective IKDC scores, restore rotational stability, and reduce failure rates compared with iACLR. Although controversy remains on the necessity of augmenting all revision ACLRs, the present meta-analysis advocates adding a lateral procedure, particularly in those with a higher-grade pivot shift.

Effects of Platelet-Rich Osteoconductive-Osteoinductive Allograft Compound on Tunnel Widening of ACL Reconstruction: A Randomized Blind Analysis Study

The anterior cruciate ligament (ACL) is a commonly injured ligament in the knee. Bone tunnel widening is a known phenomenon after soft-tissue ACL reconstruction and etiology and the clinical relevance has not been fully elucidated. Osteoconductive compounds are biomaterials providing an appropriate scaffold for bone formation such as a demineralized bone matrix. Osteoinductive materials contain growth factors stimulating bone lineage cells and bone growth. A possible application of osteoinductive/osteoconductive (OIC) material is in ACL surgery. We hypothesized that OIC placed in ACL bone tunnels: (1) reduces tunnel widening, (2) improves graft maturation, and (3) reduces tunnel ganglion cyst formation. To test this hypothesis, this study evaluated the osteogenic effects of demineralized bone matrix (DBM) and platelet-rich plasma (PRP) on tunnel widening, graft maturation, and ganglion cyst formation. This was a randomized controlled clinical trial pilot study. A total of 26 patients that elected to have ACL reconstruction surgery were randomized between the OIC and control group. Measurements of tunnel expansion and graft-tunnel incorporation were conducted via the quantitative image analysis of MRI scans performed at six months after surgery for both groups. No patients had adverse post-operative reactions or infections. The use of OIC significantly reduced tunnel widening (p < 0.05) and improved graft maturation (p < 0.05). Patients treated with OIC had a significantly lower prevalence of ganglion cyst compared to the control group (p < 0.05). The use of OIC has measurable effects on the reduction of tunnel widening, improved graft maturation, and decreased size of ganglion cyst after ACL reconstruction. This study explored the utilization of biologics to minimize bone tunnel widening in ACL reconstruction surgery.

Modified iliotibial band tenodesis versus lateral extracapsular tenodesis, to augment anterior cruciate ligament reconstruction: a 2-year randomized controlled trial

BACKGROUND

Residual instability following anterior cruciate ligament (ACL) reconstruction is associated with disruption of the anterolateral complex (ALC). Our goal was to conduct a randomized controlled trial comparing the effectiveness of modified Iliotibial tenodesis (MITBT) versus lateral extracapsular tenodesis (LET) to correct this residual instability.

METHODS

Group 1 underwent MITBT, Group 2 LET, added to the ACL reconstruction. Outcomes of interest were Tegner activity Scores (TAS), international knee documentation committee score (IKDC), knee osteoarthritis outcome score (KOOS), ACL related quality of life (ACL QoL), recurrent ACL rupture and meniscal tears. Follow-up was 2 years. Statistical analysis used chi-squared tests, frequency statistics and generalized linear models. We have followed the guidelines outlined in the CONSORT statement.

RESULTS

A total of 164 patients were randomized, 84 to Group 1, 80 to Group 2. Group 1 had higher TAS than Group 2, at 2 years (median 8, range 7-10 vs. median 7, range 5-9, P<0.001). Group 1 had higher ACL QoL scores at 1 and 2 years post-surgery (82.1, SD2.7 vs. 67.9, SD 4.0, P< 0.001 and 82.5, SD 2.6 vs. 68.8, SD 3.8, P<0.001, respectively), and higher KOOS Sport/recreation subscale at both 1 and 2 years (91.5, SD4.3 vs. 78.3, SD7.9, P<0.001 and 91.8, SD4.8 vs. 80.4, SD 9.5, P<0.001). Risk of recurrent ACL rupture (0% vs. 5%, P = 0.040-0.05) and medial meniscal tear (2.4% vs. 14%, P = 0.007-0.02) were lower in Group 1.

CONCLUSION

Augmentation of ACL reconstruction with the MITBT, rather than the LET, was associated with improved outcomes, and lower risks of recurrent ACL rupture and medial meniscal tears.

Modified Iliotibial Band Tenodesis Is Indicated to Correct Intraoperative Residual Pivot Shift After Anterior Cruciate Ligament Reconstruction Using an Autologous Hamstring Tendon Graft: A Prospective Randomized Controlled Trial

BACKGROUND

The indications for the addition of anterolateral soft tissue augmentation to anterior cruciate ligament (ACL) reconstruction and its effectiveness remain uncertain.

PURPOSE

To determine if modified iliotibial band tenodesis (MITBT) can improve clinical outcomes and reduce the recurrence of ACL ruptures when added to ACL reconstruction in patients with a residual pivot shift.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Patients with a primary ACL rupture satisfying the following inclusion criteria were enrolled: first ACL rupture, involved in pivoting sports, skeletally mature, no meniscal repair performed, and residual pivot shift relative to the contralateral uninjured knee immediately after ACL reconstruction. Patients were randomized to group A (no further surgery) or group B (MITBT added) and were followed up for 2 years. The patient-reported outcome (PRO) measures used were the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) subscale of sport/recreation (Sport/Rec), KOOS subscale of quality of life (QoL), Lysholm knee score (LKS), Tegner activity scale (TAS), recurrent ACL ruptures, or need for further surgery in either knee. Analysis of variance was used to compare PROs; the Wilcoxon test was used for the TAS; and the chi-square test was used for recurrence of ACL ruptures, meniscal injuries, and contralateral ACL ruptures (P < .05).

RESULTS

A total of 55 patients were randomized: 27 to group A (female:male ratio = 15:12; mean age, 22.3 ± 3.7 years) and 28 to group B (female:male ratio = 17:11; mean age, 21.8 ± 4.1 years). At 2-year follow-up, group A had a similar IKDC score (90.9 ± 10.7 vs 94.2 ± 11.2; respectively; P = .21), lower KOOS Sport/Rec score (91.5 ± 6.4 vs 95.3 ± 4.4, respectively; P = .02), similar KOOS QoL score (92.0 ± 4.8 vs 95.1 ± 4.3, respectively; P = .14), lower LKS score (92.5 ± 4.8 vs 96.8 ± 8.0, respectively; P = .004), lower TAS score (median, 7 [range, 7-9] vs 8 [range, 8-10], respectively; P = .03), higher rate of recurrence (14.8% vs 0.0%, respectively; P < .001), similar rate of meniscal tears (14.8% vs 3.6%, respectively; P = .14), and similar rate of contralateral ACL ruptures (3.7% vs 3.6%, respectively; P = .99) relative to group B.

CONCLUSION

The augmentation of ACL reconstruction with MITBT reduced the risk of recurrent ACL ruptures in knees with a residual pivot shift after ACL reconstruction and improved KOOS Sport/Rec, LKS, and TAS scores.

REGISTRATION

ACTRN12618001043224 (Australian New Zealand Clinical Trials Registry).

Editorial Commentary: Rehabilitation and Return-to-Sports Readiness, the "Black Box" of Anterior Cruciate Ligament Reconstruction Patient Recovery

When progressing patients who have undergone anterior cruciate ligament reconstruction through rehabilitation and deciding whether they are ready to safely return to sports, the health care team needs to consider what they know and what they do not know about each patient. Although increased postsurgical time without related functional improvement is of limited value, greater time postsurgery that leads to enhanced neuromuscular control and dynamic knee stability restoration may be of considerable value, particularly when soft tissue grafts are combined with extracortical suspensory devices or other forms of indirect fixation.

Passive anterior tibia translation in anterior cruciate ligament-injured, anterior cruciate ligament-reconstructed and healthy knees: a systematic review

Abstract

Anterior tibia translation (ATT) is mainly prevented by the anterior cruciate ligament. Passive ATT tests are commonly used to diagnose an anterior cruciate ligament (ACL) injury, to select patients for an ACL reconstruction (ACLR), and as an outcome measure after an ACLR. The aim of this review was to present an overview of possible factors determining ATT. A second purpose was to give a summary of the ATT measured in the literature in healthy, ACL-injured and ACLR knees and a comparison between those groups. A literature search was conducted with PubMed. Inclusion criteria were full-text primary studies published in English between January 2006 and October 2016. Studies included reported ATT in explicit data in healthy as well as ACL-injured or ACLR knees or in ACL-injured as well as ACLR knees. Sixty-one articles met inclusion criteria. Two articles measured the ATT in healthy as well as ACL-injured knees, 51 in ACL-injured as well as in ACLR knees, three in ACLR as well as in healthy knees and three in healthy, ACL-injured and ACLR knees. A difference in ATT is found between healthy, contralateral, ACLR and ACL-injured knees and between chronic and acute ACL injury. Graft choices and intra-articular injuries are factors which could affect the ATT. The mean ATT was lowest to highest in ACLR knees using a bone–patella tendon–bone autograft, ACLR knees using a hamstring autograft, contralateral healthy knees, healthy knees, ACLR knees with an allograft and ACL-injured knees. Factors which could affect the ATT are graft choice, ACL injury or reconstruction, intra-articular injuries and whether an ACL injury is chronic or acute. Comparison of ATT between studies should be taken with caution as a high number of different measurement methods are used. To be able to compare studies, more consistency in measuring devices used should be introduced to measuring ATT. The clinical relevance is that an autograft ACLR might give better results than an allograft ACLR as knee laxity is greater when using an allograft tendon.

Level of evidence

III.

The Augmentation of Revision Anterior Cruciate Ligament Reconstruction With Modified Iliotibial Band Tenodesis to Correct the Pivot Shift: A Computer Navigation Study

BACKGROUND

Iliotibial band (ITB) tenodesis improves stability and functional outcomes when added to anterior cruciate ligament (ACL) reconstruction. Its precise indications are unknown. Persistence of the pivot shift after revision ACL reconstruction may be one indication.

HYPOTHESIS

The addition of ITB tenodesis for a persistent pivot shift after revision ACL reconstruction will improve stability and activity levels.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Adults with recurrent ACL ruptures underwent revision ACL reconstruction, followed by a pivot-shift test before the surgery ended. If the pivot shift was grade 0 or 1, no further surgery was performed (group 1). If it was grade 2 or 3, ITB tenodesis was performed (group 2). The pivot-shift test was performed, graded, and measured using computer navigation before revision ACL reconstruction and after revision ACL reconstruction with and without ITB tenodesis. Tegner activity scores were obtained 2 years after surgery. Groups were compared with regard to anterior translation and internal rotation during the pivot shift as well as Tegner activity scores ( P < .05).

RESULTS

There were 20 patients in group 1 and 18 in group 2. The mean anterior translation improved in group 1, from 17.7 ± 3.5 mm to 6.6 ± 1.9 mm, and group 2, from 18.5 ± 3.3 mm to 6.1 ± 1.2 mm, after revision ACL reconstruction ( P < .001), with no difference between the groups ( P = .15). After ITB tenodesis, the reduction in anterior translation in group 2 (5.3 ± 1.5 mm) became greater than that in group 1 (6.6 ± 1.9 mm) ( P = .03). In both groups after revision ACL reconstruction, there was a reduction in internal rotation (group 1: 24.2° ± 4.0° to 10.3° ± 1.1°; group 2: 25.4° ± 3.7° to 14.6° ± 2.8°; P < .001), but this change was less in group 2 ( P = .02). After ITB tenodesis, internal rotation in group 2 (8.3° ± 2.6°) became less than that in group 1 (10.3° ± 1.1°) ( P = .02). The mean Tegner activity scores in group 1 were 8.1 ± 1.1 before surgery and 7.4 ± 0.9 after surgery, while in group 2 they were 7.0 ± 1.3 and 7.2 ± 0.4, respectively, and not significantly different ( P = .29).

CONCLUSION

ITB tenodesis improved laxity, although it did not affect activity levels, when there was a persistent pivot shift after revision ACL reconstruction.

CLINICAL RELEVANCE

An indication to perform ITB tenodesis is the persistence of a grade ≥2 pivot shift after revision ACL reconstruction.