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Sigloch M, Coppola C, Hoermann R, Alt P, Schmoelz W, Mayr R. Overconstraint Associated With a Modified Lemaire Lateral Extra-Articular Tenodesis Is Decreased by Using an Anterior Femoral Insertion Point in a Cadaveric Model. Arthroscopy 2024:S0749-8063(24)00573-5. [PMID: 39173687 DOI: 10.1016/j.arthro.2024.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 07/29/2024] [Accepted: 07/29/2024] [Indexed: 08/24/2024]
Abstract
PURPOSE To investigate tibiofemoral knee kinematics when shifting the femoral insertion point of the modified Lemaire lateral extra-articular tenodesis (LET) anterior to the lateral epicondyle. METHODS Six fresh-frozen human knee joints were tested on a test bench in the following states: (1) native, (2) anterolateral insufficient, (3) original Lemaire (oLET; insertion point: 4 mm posterior and 8 mm proximal to the epicondyle), (4) anterior Lemaire (aLET; insertion point: 5 mm anterior and 5 mm proximal to the epicondyle). Internal tibial rotation was statically investigated under an internal tibial torque of 5 Nm in 0°, 30°, 60°, and 90° of flexion. Anterior translation was statically investigated during a simulated Lachman test with an anterior translational force of 98 N. Additionally, the range of internal tibial rotation and anterior translation were dynamically investigated by a simulated pivot-shift test. Tibiofemoral kinematics were measured using an optical 3D motion analysis system. RESULTS The aLET showed an internal tibial rotation comparable to the native state for all tested flexion angles except 90° (0°: P = .201; 30°: P = .118; 60°: P = .126; 90°: P = .026). The oLET showed an internal tibial rotation below the values of the native state for all tested flexion angles indicating an overconstraint (0°: P = .003; 30°: P = .009; 60°: P = .029; 90°: P = .029). Direct comparisons between aLET and oLET showed a significantly decreased overconstraint at 0° and 30° of flexion (P = .001 and P = .003, respectively) when using the aLET. No differences in anterior translation and internal tibial rotation were found between the oLET and aLET during simulated Lachman and pivot-shift test (P > .05), approximating the native state. CONCLUSIONS An anteriorly shifted LET insertion point restored internal tibial rotation after anterolateral insufficiency to the native state while decreasing the overconstraint of internal tibial rotation induced by an LET using the originally described insertion point for small flexion angles ≤30°. CLINICAL RELEVANCE Using an LET insertion point anterior to the epicondyle was recently reported to lower the risk of tunnel interference and has now been shown to restore internal tibial rotation effectively in vitro in the course of the present study. Concerns of overconstraining internal tibial rotation are not diminished by this technique, but using an anterior insertion point helps to decrease overconstraint.
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Affiliation(s)
- Maximilian Sigloch
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Coppola
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Romed Hoermann
- Institute for Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Prisca Alt
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Schmoelz
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Raul Mayr
- Department for Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
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Suh DK, Kang MW, Kim TJ, Kim SY, Wang JH. Incidence of Convergence Between Distally and Anteriorly Oriented ALL Femoral Tunnels and ACL Femoral Tunnels in Combined ACL and ALL Reconstruction: 3-Dimensional Computed Tomography Analysis of 227 Patients. Am J Sports Med 2024; 52:902-908. [PMID: 38353108 DOI: 10.1177/03635465241227223] [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: 03/17/2024]
Abstract
BACKGROUND Adjusting the direction of the anterolateral ligament (ALL) femoral tunnel is suggested to avoid tunnel convergence during anterior cruciate ligament (ACL) reconstruction. Yet, there has been no in vivo clinical study reporting the effect of changing the direction of the ALL tunnel on the incidence of convergence with the ACL tunnel. PURPOSE To report the incidence of convergence between the ACL femoral tunnel and a distally and anteriorly directed ALL femoral tunnel and to determine a safe distal angle and anterior angle. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 227 patients undergoing concomitant ALL and anatomic single-bundle ACL reconstruction between January 2020 and December 2022 were retrospectively reviewed. The tunnel convergence rate, angular orientation of the tunnels, and distance between tunnels were obtained using postoperative computed tomography. The patients were grouped based on the direction of the ALL tunnel (transverse vs distal anterior) and the presence of tunnel convergence (convergence vs no convergence). RESULTS The overall tunnel convergence rate was 53.3% (121/227 patients). Tunnel convergence was observed less frequently in the distal anterior group (33.7%) than in the transverse group (65.2%) (P < .001). The no convergence group showed an ALL tunnel oriented more distally (20.2°± 11.1°) and anteriorly (19.5°± 10.2°) compared with the convergence group (8.7°± 6.5° and 6.9°± 5.3°, respectively) (P = .005 and P = .008, respectively). There were no cases of tunnel convergence for ALL tunnels >24.3° distally and >25.5° anteriorly. There was no difference in the angle of the ACL femoral tunnel between all groups. CONCLUSION A distally and anteriorly directed ALL femoral tunnel reduced the incidence of convergence with the ACL femoral tunnel. A distal angle >24.3° and an anterior angle >25.5° of an ALL tunnel are suggested to safely avoid convergence with the ACL tunnel.
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Affiliation(s)
- Dae Keun Suh
- Department of Orthopaedic Surgery, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Min Wook Kang
- Department of Orthopaedic Surgery, Incheon Himchan General Hospital, Incheon, Republic of Korea
| | - Tae Jin Kim
- Department of Orthopaedic Surgery, Incheon Himchan General Hospital, Incheon, Republic of Korea
| | - Si Yeon Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Health Sciences and Technology and Department of Medical Device Management and Research, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Republic of Korea
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Behrendt P, Fahlbusch H, Akoto R, Thürig G, Frings J, Herbst E, Raschke MJ, Frosch KH, Kittl C, Krause M. Comparison of Onlay Anchor Fixation Versus Transosseous Fixation for Lateral Extra-articular Tenodesis During Revision ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671231166380. [PMID: 37213658 PMCID: PMC10196542 DOI: 10.1177/23259671231166380] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/30/2023] [Indexed: 05/23/2023] Open
Abstract
Background There is evidence on the clinical effectiveness of the Lemaire technique for lateral extra-articular tenodesis (LET) in patients undergoing revision anterior cruciate ligament reconstruction (ACLR), but the best fixation technique is unknown. Purpose To compare the clinical outcomes of 2 fixation techniques after revision ACLR: (1) onlay anchor fixation, which would avoid tunnel conflict and physis injury, and (2) transosseous tightening and interference screw fixation. Pain at the area of LET fixation was also assessed. Study Design Cohort study; Level of evidence, 3. Methods This was a retrospective 2-center study of patients with first-time revision ACLR and either LET with anchor fixation (aLET) with a 2.4-mm suture anchor or LET with transosseous fixation (tLET). Outcomes at minimum 12-month follow-up were assessed with the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, visual analog scale for pain at the LET fixation area, Tegner score, and anterior tibial translation (ATT). A subgroup analysis within the aLET group investigated passing the graft over or under the lateral collateral ligament (LCL). Results In total, 52 patients were included (26 patients in each group); the mean ± SD follow-up was 13.7 ± 3.4 months. No statistically significant differences were detected between the groups with respect to patient-reported outcome scores, clinical examination, or instrumented testing (side-to-side difference in ATT at 30° of flexion; aLET, 1.5 ± 2.5 mm; tLET, 1.6 ± 1.7 mm). Clinical failure was detected in 1 patient with aLET and none with tLET. Subgroup analysis revealed a small, nonsignificant flexion deficit in knees in which the iliotibial band strand was passed under (n = 42) or over (n = 10) the LCL. No clinically relevant tenderness was detected at the area of LET fixation in any group (aLET, 0.6 ± 1.3; tLET, 0.9 ± 1.7; over the LCL, 0.2 ± 0.6; under the LCL, 0.9 ± 1.6). Conclusion Onlay anchor fixation and transosseous fixation of the LET were equivalent with respect to outcome scores and instrumented ATT testing. Clinically, there were minor differences in passage of the LET graft over or under the LCL.
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Affiliation(s)
- Peter Behrendt
- Department of Trauma Surgery,
Orthopedics and Sportsorthopedics, Asklepios St Georg, Hamburg, Germany
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Anatomy,
Christian-Albrechts-University, Kiel, Germany
| | - Hendrik Fahlbusch
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralph Akoto
- Department of Trauma Surgery,
Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Grégoire Thürig
- Department of Orthopedics and
Traumatology, Cantonal Hospital Fribourg, Fribourg, Switzerland
| | - Jannik Frings
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elmar Herbst
- 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
| | - 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 Hospital Hamburg, Hamburg, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and
Reconstructive Surgery, University of Muenster, Muenster, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Matthias Krause, Priv-Doz,
Dr med, Department of Trauma and Orthopaedic Surgery, University Medical Center
Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, 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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Moon HS, Choi CH, Seo YJ, Lee Y, Jung M, Park JH, Kim SH. The orientation of the ALL femoral tunnel to minimize collision with the ACL tunnel depends on the need or not of far-cortex drilling. Knee Surg Sports Traumatol Arthrosc 2022; 30:3805-3817. [PMID: 35643937 DOI: 10.1007/s00167-022-07007-1] [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: 01/08/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To (1) evaluate the optimal drill orientation of the anterolateral ligament (ALL) femoral tunnel to minimize collision with the anterior cruciate ligament (ACL) femoral tunnel during anatomical ACL reconstruction according to the need for far-cortex drilling and (2) investigate the geometric factors that affect tunnel collision secondary to drill orientation of the ALL femoral tunnel. METHODS A three-dimensional femoral model of patients who underwent anatomical single-bundle ACL reconstruction between 2015 and 2016 was constructed, and the geometric factors were evaluated. Virtual ALL femoral tunnels were created to simulate 45 drilling conditions. For each condition, whether the virtual ALL femoral tunnel and its trajectory violated the femoral cortex and the minimum distance between tunnels was investigated. RESULTS Thirty-nine subjects were included. Overall violation rates of the femoral cortex by the ALL tunnels and its trajectories were 11.1% (195 of 1755 conditions) and 40.7% (714 of 1755 conditions), respectively. A drilling angle of axial 0° and coronal - 40° showed the longest minimum distance between tunnels without femoral cortex violation by the ALL tunnel (6.3 ± 4.0 mm; collision rate 2.6% [1 of 39 subjects]). With simultaneous consideration of the ALL tunnel's trajectory representing far-cortex drilling, a drill angle of axial 40° and coronal 10° showed the longest minimum distance between tunnels without femoral cortex violation (0.6 ± 3.9 mm; collision rate 38.5% [15 of 39 subjects]). For surgical techniques requiring far-cortex drilling, regression analyses were performed on geometric factors that could affect tunnel collision, which revealed that the sagittal inclination angle of the ACL and the distance between the ACL femoral tunnel's outlet and ALL's femoral attachment were associated with tunnel collision. CONCLUSION The optimal drill orientations of the ALL femoral tunnel to minimize collision with the ACL femoral tunnel were axial 0° and coronal - 40° for surgical techniques not requiring far-cortex drilling and axial 40° and coronal 10° for techniques requiring far-cortex drilling. For techniques requiring far-cortex drilling, additional adjustment for orientation of the ACL femoral tunnel is required to reduce the risk of tunnel collision. Therefore, an individualized surgical strategy should be applied according to the graft fixation method of the ALL femoral tunnel.
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Affiliation(s)
- Hyun-Soo Moon
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Chong-Hyuk Choi
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Jin Seo
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Younghan Lee
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Jung
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hun Park
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Sung-Hwan Kim
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 20 Eonju-ro 63-gil, Gangnam-gu, Seoul, 06229, Republic of Korea.
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