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Blanke F, Boljen M, Oehler N, Lutter C, Tischer T, Vogt S. An anteromedial stabilization procedure has the most protective effect on the anterior cruciate ligament in tibial external rotation. A human knee model study. Arch Orthop Trauma Surg 2024; 144:2703-2710. [PMID: 38727813 PMCID: PMC11211157 DOI: 10.1007/s00402-024-05357-8] [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: 12/23/2023] [Accepted: 04/28/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION Anterior cruciate ligament (ACL) reconstruction remains associated with the risk of re-rupture and persisting rotational instability. Additional extraarticular anterolateral stabilization procedures stabilize the tibial internal rotation and lead to lower ACL failure rate and improved knee stability. However, data for additional stabilization of tibial external rotation is lacking and the importance of an anteromedial stabilization procedure is less well evaluated. Aim of this study is to investigate the influence of an extraarticular anteromedial stabilization procedure for the stabilization of the tibial external rotation and protection of the ACL from these rotational forces. METHODS Internal and external rotations of the tibia were applied to a finite element (FE) model with anatomical ACL, posterior cruciate ligament (PCL), lateral collateral ligament (LCL), medial collateral ligament (MCL) and intact medial and lateral meniscus. Five additional anatomic structures (Anteromedial stabilization/anteromedial ligament, AML, augmented superficial medial collateral ligament, sMCL, posterior oblique ligament, POL, anterolateral ligament, ALL, and popliteal tendon, PLT) were added to the FE model separately and then combined. The force histories within all structures were measured and determined for each case. RESULTS The anteromedial stabilization or imaginary AML was the main secondary stabilizer of tibial external rotation (90% of overall ACL force reduction). The AML reduced the load on the ACL by 9% in tibial external rotation which could not be achieved by an augmented sMCL (-1%). The AML had no influence in tibial internal rotation (-1%). In the combined measurements with all additional structures (AML, ALL, PLT, POL) the load on the ACL was reduced by 10% in tibial external rotation. CONCLUSION This study showed that an additional anteromedial stabilization procedure secures the tibial external rotation and has the most protective effect on the ACL during these external rotational forces.
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Affiliation(s)
- Fabian Blanke
- Department of Knee-, Shoulder- and Hip-Surgery and Orthopedic Sports Medicine, Schön Klinik München Harlaching, München, Germany.
- Department of Orthopedic Surgery, University Rostock, Rostock, Germany.
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany.
| | - Matthias Boljen
- Fraunhofer Institute for High-Speed Dynamics, Ernst-Mach-Institut, EMI, Freiburg i, Breisgau, Germany
| | - Nicola Oehler
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany
| | - Christoph Lutter
- Department of Orthopedic Surgery, University Rostock, Rostock, Germany
| | - Thomas Tischer
- Department of Orthopedic Surgery, University Rostock, Rostock, Germany
| | - Stephan Vogt
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany
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van der Wal WA, Meijer DT, Hoogeslag RAG, LaPrade RF. The Iliotibial Band is the Main Secondary Stabilizer for Anterolateral Rotatory Instability and both a Lemaire Tenodesis and Anterolateral Ligament Reconstruction Can Restore Native Knee Kinematics in the Anterior Cruciate Ligament Reconstructed Knee: A Systematic Review of Biomechanical Cadaveric Studies. Arthroscopy 2024; 40:632-647.e1. [PMID: 37207919 DOI: 10.1016/j.arthro.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE To obtain a comprehensive overview of comparative biomechanical cadaveric studies investigating the effect of both the iliotibial band (ITB) and anterolateral ligament (ALL) on anterolateral rotatory instability (ALRI) in anterior cruciate ligament (ACL)-injured knees, and the effect of lateral extra-articular tenodesis (LET) versus ALL reconstruction (ALLR) in ACL-reconstructed knees. METHODS An electronic search was performed in the Embase and MEDLINE databases for the period between January 1, 2010, and October 1, 2022. All sectioning studies comparing the role of both the ITB and ALL on ALRI and all studies comparing the effect of both LET and ALLR were included. Articles were assessed for methodological quality according to the Quality Appraisal for Cadaveric Studies scale. RESULTS Data of 15 studies were included, representing the mean values of biomechanical data collected from 203 cadaveric specimens, with sample sizes ranging from 10 to 20 specimens. All 6 sectioning studies reported that the ITB acts as a secondary stabilizer to the ACL and helps resist internal knee rotation, whereas in only 2 of 6 sectioning studies the ALL contributed significantly to tibial internal rotation (IR). Most reconstruction studies reported that both a modified Lemaire tenodesis and an ALLR could significantly reduce the residual ALRI in isolated ACL-reconstructed knees and were able to restore IR stability/IR stability during the pivot shift. CONCLUSIONS The ITB acts as the main secondary stabilizer to the ACL in resisting IR/IR during pivot shift and an anterolateral corner (ALC) reconstruction with either a modified Lemaire tenodesis and ALLR can improve residual knee rotatory laxity in ACL reconstructed knees. CLINICAL RELEVANCE This systematic review provides insight in the biomechanical function of the ITB and ALL and emphasizes the importance of adding an ALC reconstruction to ACL reconstruction.
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Farinelli L, Meena A, Sonnery-Cottet B, Vieira TD, Pioger C, Tapasvi S, Abermann E, Hoser C, Fink C. Distal Kaplan fibers and anterolateral ligament injuries are associated with greater intra-articular internal tibial rotation in ACL-deficient knees based on magnetic resonance imaging. J Exp Orthop 2023; 10:113. [PMID: 37943352 PMCID: PMC10635991 DOI: 10.1186/s40634-023-00682-0] [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: 08/24/2023] [Accepted: 10/19/2023] [Indexed: 11/10/2023] Open
Abstract
PURPOSE The purpose of the present study was to assess the internal rotation of the tibia on Magnetic Resonance Imaging (MRI) in a series of consecutive athletes with Anterior cruciate Ligament (ACL) tears. METHODS Retrospective analysis of prospectively collected data was performed to include all consecutive patients who had undergone primary ACL reconstruction between January 2022 and June 2022. The angle between surgical epicondylar axes (SEA) of the knee and posterior tibial condyles (PTC) was measured. A negative value was defined as internal torsion. KFs and ALL injuries were reported. Analysis of covariance (ANCOVA) was performed to examine the independent associations between SEA-PTC angle and injuries of KFs and ALL adjusted for physical variables (age, gender and body mass index [BMI]). Statistical significance was set at a p-value of < 0.05. RESULTS A total of 83 eligible patients were included. The result of multiple linear regression analysis showed that internal tibial rotation was associated with KFs and ALL injuries. The estimated average of SEA-PTC angle in relation to ALL injuries controlling the other variables was -5.49 [95%CI -6.79 - (-4.18)] versus -2.99 [95%CI -4.55 - (-1.44)] without ALL injuries. On the other hand, the estimated average of SEA-PTC angle in relation to KFs lesions controlling the other variables was -5.73 [95%CI -7.04 - (-4.43)] versus -2.75 [95%CI -4.31 - (-1.18)] without KFs injuries. CONCLUSIONS KFs and ALL injuries were associated with an increased intra-articular internal tibial rotation in ACL-deficient knees. The measurement of femorotibial rotation on axial MRI could be useful to detect indirect signs of anterolateral complex (ALC) injuries.
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Affiliation(s)
- Luca Farinelli
- Clinical Orthopaedics, Department of Clinical and Molecular Sciences, Università Politecnica Delle Marche, Ancona, Italy
| | - Amit Meena
- Gelenkpunkt - Sports and Joint Surgery, Olympiastraße 39, Innsbruck, 6020, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Bertrand Sonnery-Cottet
- Centre Orthopedique Santy, FIFA Medical Centre of Excellence, Hôpital Mermoz, Groupe Ramsay, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopedique Santy, FIFA Medical Centre of Excellence, Hôpital Mermoz, Groupe Ramsay, Lyon, France
| | - Charles Pioger
- Department of Orthopaedic Surgery, Centre Hospitalier de Versailles, 177, Rue de Versailles, Le Chesnay, 78157, France
| | | | - Elisabeth Abermann
- Gelenkpunkt - Sports and Joint Surgery, Olympiastraße 39, Innsbruck, 6020, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Christian Hoser
- Gelenkpunkt - Sports and Joint Surgery, Olympiastraße 39, Innsbruck, 6020, Austria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
| | - Christian Fink
- Gelenkpunkt - Sports and Joint Surgery, Olympiastraße 39, Innsbruck, 6020, Austria.
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Private University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria.
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Jildeh TR, Bowen E, Bedi A. Revision Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients. J Am Acad Orthop Surg 2023; 31:e920-e929. [PMID: 37364250 DOI: 10.5435/jaaos-d-23-00288] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/27/2023] [Indexed: 06/28/2023] Open
Abstract
Revision anterior cruciate ligament (ACL) reconstruction in the skeletally immature patient is a challenging procedure for pediatric patients with recurrent instability after primary ACL reconstruction. The pediatric population presents unique technical challenges and complications secondary to open physes compared with the adult population. Complications can include growth disturbances, recurrent graft failure, instability, and secondary chondral and/or meniscal injury. Moreover, identifying the etiology of graft failure is critical for a successful revision. Patients should undergo a complete history and physical examination with a focus on patient physiologic age, physeal status, mechanical axis, tibial slope, collagen status, injury mechanism, concomitant injuries, and previous surgical procedures. The surgeon must be adept at reconstruction with various grafts as well as socket or tunnel preparation and fixation, including over-the-top, all-epiphyseal, transphyseal, extra-articular augmentation, and staging approaches. Reported rates of return to sport are lower than those of primary reconstruction, with higher rates of cartilage and meniscal degeneration. Future research should focus on optimizing surgical outcomes and graft survivorship after primary ACL reconstruction with minimized trauma to the physis.
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Affiliation(s)
- Toufic R Jildeh
- From the Department of Orthopaedics, Michigan State University, East Lansing, MI (Jildeh), the Weill Cornell Medical College, New York, NY (Bowen), and the NorthShore Medical Group, Skokie, IL (Bedi)
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Kim YS, Koo S, Kim JH, Tae J, Wang JH, Ahn JH, Jang KM, Jeon J, Lee DK. Greater Knee Rotatory Instability After Posterior Meniscocapsular Injury Versus Anterolateral Ligament Injury: A Proposed Mechanism of High-Grade Pivot Shift. Orthop J Sports Med 2023; 11:23259671231188712. [PMID: 37693803 PMCID: PMC10486219 DOI: 10.1177/23259671231188712] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/24/2023] [Indexed: 09/12/2023] Open
Abstract
Background For anterolateral rotatory instability as a result of secondary soft tissue injuries in anterior cruciate ligament (ACL)-deficient knees, there is increasing interest in secondary stabilizers to prevent internal rotation (IR) of the tibia. Purpose To determine which secondary stabilizer is more important in anterolateral rotatory instability in ACL-deficient knees. Study Design Controlled laboratory study. Methods The lower extremities of 10 fresh-frozen cadavers (20 extremities) without anterior-posterior or rotational instability were included. Matched-pair randomization was performed, with each side per specimen assigned to 1 of 2 groups. In group 1, the ACL was sectioned, followed by the anterolateral ligament (ALL); in group 2, the ACL was sectioned, followed by sequential sectioning of the posterolateral meniscocapsular complex (PLMCC) and posteromedial meniscocapsular complex (PMMCC). The primary outcome was the change in relative tibial IR during a simulated pivot-shift test with 5 N·m of IR torque and 8.9 N of valgus force. The secondary outcomes were the International Knee Documentation Committee grade in the pivot-shift test and the incidence of the grade 3 pivot shift. Results In group 1, compared with baseline, the change in relative tibial IR at 0° of knee flexion was 1.4° (95% CI, -0.1° to 2.9°; P = .052) after ALL release. In group 2, it was 2.5° (95% CI, 0.4° to 4.8°; P = .007) after PLMCC release and 4.1° (95% CI, 0.5° to 7.8°; P = .017) after combined PLMCC and PMMCC release. Combined PLMCC and PMMCC release resulted in greater change of tibial IR with statistical significance at 0°, 15°, and 30° of knee flexion (P = .008, .057, and .004, respectively) compared with ALL release. The incidence of grade 3 pivot shifts was 10% in group 1 and 90% in group 2. Conclusion Posterior meniscocapsular laxity caused an increase in relative tibial IR as much as ALL injury in ACL-deficient knees in our simulated laboratory test, and greater anterolateral rotatory instability occurred with posterior meniscocapsular injury compared with ALL injury. Clinical Relevance Repair of the injured posterior meniscocapsular complex may be an important treatment option for reducing anterolateral rotatory instability in the ACL-deficient knee.
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Affiliation(s)
- Yi-Suk Kim
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seungbum Koo
- Department of Mechanical Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Jun Ho Kim
- Department of Orthopedic Surgery, Kyunghee University Hospital at Gangdong, Kyunghee University School of Medicine, Seoul, Republic of Korea
| | - Jungyeun Tae
- Konyang University School of Medicine, Daejeon, Republic of Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Hwan Ahn
- Department of Orthopaedic Surgery, Saeum Hospital, Seoul, Republic of Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jongmin Jeon
- Department of Orthopedic Surgery, Changwon Samsung Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Do Kyung Lee
- Department of Orthopedic Surgery, Changwon Samsung Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
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Lee DH, Kim CH, Kim TH, Kim SG. Sectioning of the Anterolateral Ligaments in Anterior Cruciate Ligament Sectioned Knees Increases Internal Rotation of the Knee Joint: A Systematic Review and Meta-analysis of Cadaveric Studies. Arthroscopy 2023; 39:1692-1701. [PMID: 36708744 DOI: 10.1016/j.arthro.2022.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 12/25/2022] [Accepted: 12/30/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE To investigate whether anterolateral ligament (ALL) sectioning (sALL) in the anterior cruciate ligament (ACL)-sectioned (sACL) knee increases the anterior tibial translation (ATT) or internal rotation (IR) of the knee from previous cadaveric biomechanical studies. METHODS Multiple comprehensive literature databases, including PubMed (MEDLINE), EMBASE, and Cochrane Library, were searched for studies evaluating the in vitro biomechanical function of ALL. This meta-analysis compared the increased ATT and IR between the sACL and sACL + sALL knees at 30°, 60°, and 90° of knee flexion. Thresholds of 2 mm for the difference in ATT and 2° for the difference in IR were considered to be clinically significant. RESULTS Thirteen cadaveric biomechanical studies were included. All 13 studies satisfied the threshold for a satisfactory methodological quality (Quality Appraisal for Cadaveric Studies score >75%). At 30° of knee flexion, the meta-analysis showed a greater increase in ATT in the sACL + sALL knees than in the sACL knees by 1.23 mm (95% confidence interval [CI], 0.62-1.84; P < .0001). However, the mean difference was less than the minimal clinically significant difference (<2 mm). The meta-analysis also showed a greater increase in IR in the sACL + sALL knees than in the sACL knees at 30° (mean difference [MD]: 2.24°; 95% CI: 1.39-3.09; P < .00001), 60° (MD: 2.77°; 95% CI: 1.88-3.67; P < .00001), and 90° (MD: 2.29°; 95% CI: 1.42-3.15; P < .00001) of knee flexion. The differences in IR at 30°, 60°, and 90° of knee flexion were clinically relevant (>2°). CONCLUSIONS Despite the different experimental setups and protocols between studies, the meta-analysis of biomechanical cadaveric studies showed that sectioning of the ALL in sACL knees increased IR at 30°, 60°, and 90° of knee flexion. CLINICAL RELEVANCE The results of this systematic review and meta-analysis suggest that ALL contributes to IR in ACL-deficient knees at 30°, 60°, and 90° of flexion.
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Affiliation(s)
- Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chung-Hyun Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Ho Kim
- Department of Orthopaedic Surgery, National Medical Center, Seoul, Republic of Korea
| | - Sang-Gyun Kim
- Department of Orthopaedic Surgery, National Medical Center, Seoul, Republic of Korea.
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Baker HP, Bowen E, Sheean A, Bedi A. New Considerations in ACL Surgery: When Is Anatomic Reconstruction Not Enough? J Bone Joint Surg Am 2023; Publish Ahead of Print:00004623-990000000-00808. [PMID: 37205735 DOI: 10.2106/jbjs.22.01079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
➤ Clinicians should be careful to assess for associated injuries including anterolateral complex and medial meniscal ramp lesions or lateral meniscal posterior root tears.➤ Consideration of lateral extra-articular augmentation should be given for patients with >12° of posterior tibial slope.➤ Patients with preoperative knee hyperextension (>5°) or other nonmodifiable risk factors, including high-risk osseous geometry, may benefit from a concomitant anterolateral augmentation procedure to improve rotational stability.➤ Meniscal lesions should be addressed at the time of anterior cruciate ligament reconstruction with meniscal root or ramp repair.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, University of Chicago, Chicago, Illinois
| | | | - Andrew Sheean
- San Antonio Military Medical Center, San Antonio, Texas
| | - Asheesh Bedi
- Northshore University Health System, Skokie, Illinois
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Green DW, Hidalgo Perea S, Brusalis CM, Chipman DE, Asaro LA, Cordasco FA. A Modified Lemaire Lateral Extra-articular Tenodesis in High-Risk Adolescents Undergoing Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft: 2-Year Clinical Outcomes. Am J Sports Med 2023; 51:1441-1446. [PMID: 36917840 DOI: 10.1177/03635465231160681] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND The incidence of anterior cruciate ligament (ACL) reconstruction (ACLR) in children and adolescents has increased significantly, and many such patients are at increased risk for ACL retear. Lateral extra-articular tenodesis (LET) may be performed in conjunction with ACLR to reduce the risk of ACL retear. PURPOSE To evaluate the 2-year clinical outcomes of ACLR with soft tissue quadriceps tendon (QUAD) autograft performed with a concomitant LET using a modified Lemaire technique in skeletally immature patients. STUDY DESIGN Case series; Level of evidence, 4. METHODS A consecutive series of adolescent patients who underwent QUAD autograft ACLR and LET with a minimum of 2 years of follow-up data were analyzed retrospectively. ACLR techniques, including all-epiphyseal and complete transphyseal, were indicated based on skeletal age. Outcome measures included return to sports, concomitant or subsequent surgical procedures, and multiple patient-reported outcome measures, including Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC), and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) scores. RESULTS The final cohort included 49 consecutive adolescent patients aged 11 to 16 years (mean, 14.2 ± 1 years) with a minimum follow-up of 2 years. One patient was lost to follow-up. Of the patients included in the study (N = 48; 27 male, 21 female), 98% participated in high-risk competitive sports. Two (4%) patients were undergoing revision ACLR. Thirty-eight (79%) patients underwent complete transphyseal, and 10 (21%) patients underwent all-epiphyseal ACLR. Sixteen (33%) patients had subsequent surgical procedures, including 5 contralateral ACLR, 4 meniscal surgery, 4 QUAD autograft scar revision, 4 irrigation and debridement (2 patients, 2 each), and 3 hardware removal (2 for hemi-epiphysiodesis and 1 tibial socket button removal) procedures. The rate of graft rupture was 0%. At a mean follow-up of 3.4 ± 1.2 years (range, 2-7 range), the mean SANE score was 93, the mean Pedi-IKDC score was 89, and the mean HSS Pedi-FABS score was 23. The return-to-sports rate was 100%. CONCLUSION An LET performed concomitantly with an ACLR is safe and should be considered as a concomitant procedure for adolescent patients with nonmodifiable risk factors who are at high risk of retear.
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Affiliation(s)
- Daniel W Green
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Sofia Hidalgo Perea
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, New York, New York, USA
| | - Christopher M Brusalis
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Danielle E Chipman
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, New York, New York, USA
| | - Lori A Asaro
- Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
| | - Frank A Cordasco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA
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Noyes FR, Clark O, Nolan J, Johnson DJ. Functional Interaction of the Cruciate Ligaments, Posteromedial and Posterolateral Capsule, Oblique Popliteal Ligament, and Other Structures in Preventing Abnormal Knee Hyperextension. Am J Sports Med 2023; 51:1146-1154. [PMID: 36815786 DOI: 10.1177/03635465231155203] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND The ligaments and soft tissue capsular structures of the knee joint that provide a resisting force to prevent abnormal knee hyperextension have not been determined. This knowledge is required for the diagnosis and treatment of knee hyperextension abnormalities. PURPOSE To determine the resisting moment of knee ligament and capsular structures that resist knee hyperextension. HYPOTHESIS The combined posteromedial and posterolateral capsular structures function to provide a major restraint to prevent abnormal knee hyperextension. The anterior and posterior cruciate ligaments resist knee hyperextension but function as secondary restraints. STUDY DESIGN Descriptive laboratory study. METHODS A 6 degrees of freedom robotic system determined intact laxity limits in 24 cadaveric knees from 0° to 100° of knee flexion for anteroposterior limits at ±135 N, abduction-adduction limits at ±7 N·m, and external-internal limits at ±5 N·m. One loading method (n = 14 knees) used a static loading sequence with knee hyperextension to 27-N·m torque while maintaining all other degrees of freedom at zero load during sequential soft tissue cutting. The second method (n = 10 knees) used a cyclic loading sequence to decrease viscoelastic effects with soft tissue cutting at 0° of extension, followed by knee hyperextension to 27-N·m torque and cycled back to 0°. Selective soft tissue cuttings were performed of the following: oblique popliteal ligament, fabellofibular ligament, posterolateral capsule, posteromedial capsule with posterior oblique ligament, cruciate ligaments, lateral collateral ligament, popliteus, anterolateral ligament and iliotibial band, and superficial plus deep medial collateral ligaments. The sequential loss in the restraining moment with sectioning provides the function of that structure in resisting knee hyperextension. RESULTS The median resisting force to knee hyperextension, in descending order, was the posteromedial capsule and posterior oblique ligament (21.7%), posterorolateral ligament and fabellofibular ligament (17.1%), anterior and posterior cruciate ligaments (13% and 12.9%, respectively), superior and deep medial collateral ligament (9.6%), oblique popliteal ligament (7.7%), and lateral collateral ligament (5.4%). The combined posterior capsular structures provided 54.7% and the anterior and posterior cruciate ligaments 25.3% of the total resisting moment to prevent knee hyperextension. CONCLUSION Diagnosis of abnormal knee hyperextension involves a combination of multiple ligament and soft tissue structures without 1 primary restraint. The posteromedial and posterolateral capsular structures provided the major resisting moment to prevent knee hyperextension. The cruciate ligaments produced a lesser resisting moment to knee hyperextension. CLINICAL RELEVANCE This is the first study to comprehensively measure all of the knee ligaments and capsular structures providing a resisting moment to abnormal knee hyperextension. These data are required for diagnostic and treatment strategies on the pathomechanics of abnormal knee hyperextension in patients after injury or developmental cases.
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Affiliation(s)
- Frank R Noyes
- Cincinnati SportsMedicine Research and Education Foundation, Noyes Knee Institute, Mercy Health-Cincinnati SportsMedicine and Orthopaedic Center, Cincinnati, Ohio, USA
| | - Olivia Clark
- Cincinnati SportsMedicine Research and Education Foundation, Noyes Knee Institute, Mercy Health-Cincinnati SportsMedicine and Orthopaedic Center, Cincinnati, Ohio, USA
| | - Joseph Nolan
- Burkardt Consulting Center, Department of Mathematics and Statistics, Northern Kentucky University, Highland Heights, Kentucky, USA
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Devitt BM, Neri T, Fritsch BA. Combined anterolateral complex and anterior cruciate ligament injury: Anatomy, biomechanics, and management-State-of-the-art. J ISAKOS 2023; 8:37-46. [PMID: 36368633 DOI: 10.1016/j.jisako.2022.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/06/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022]
Abstract
Anterior cruciate ligament (ACL) rupture typically occurs because of sudden axial loading of the knee in conjunction with a coupled valgus and rotational moment about the tibia. However, the ACL is not the only structure damaged during this mechanism of injury, and studies have shown that the anterolateral complex (ALC) of the knee is also commonly involved. Biomechanical studies have established that the ALC plays an important role as a secondary stabiliser to control anterolateral rotatory laxity (ALRL). Indeed, it has been suggested that failure to address injury to the ALC at the time of ACL reconstruction (ACLR) may increase the risk of graft failure owing to persistent ALRL. The concept of combining a lateral extra-articular procedure to augment ACLR for the treatment of ACL injury emerged with a view to decrease the failure rate of either procedure in isolation. This state-of-the-art review discusses the history of the anatomy of the ALC, the biomechanics of a variety of lateral extra-articular augmentation procedures, and provides clinical guidelines for their use in primary ACLR.
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Affiliation(s)
- Brian M Devitt
- Dublin City University, School of Health and Human Performance & Sports Surgery Clinic, Dublin, D09 C523, Ireland.
| | - Thomas Neri
- Department of Orthopaedic Surgery, University Hospital of Saint-Etienne, University of Lyon - Jean Monnet, 42000, France
| | - Brett A Fritsch
- Sydney Orthopaedic Research Institute, Level 1, The Gallery, 445 Victoria Avenue, Chatswood, NSW 2067, Australia
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Chevalier A, Van Overmeire A, Vermue H, Pringels L, Herregodts S, Victor J, Loccufier M. Effect of iliotibial band and gastrocnemius activation on knee kinematics. Knee 2023; 40:238-244. [PMID: 36521416 DOI: 10.1016/j.knee.2022.11.025] [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: 06/29/2022] [Revised: 11/10/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND This paper aimed to evaluate the effects of iliotibial band (ITB) activation and gastrocnemius activation on knee kinematics and stability. A quantitative analysis needs to determine the effect of ITB and gastrocnemius activation in each of the six degrees of freedom of the knee joint. METHODS Four cadaveric knee specimens were tested during squat motions with physiological loads. The quadriceps and hamstring muscles were activated in each situation. The ITB was intermittently activated using an actuator and a cable pulley system. The gastrocnemius was activated anatomically as part of the triceps surae complex together with the soleus and the plantaris muscle. During the squat motion, the Achilles tendon has increased tension which induced muscle activation in the calf muscles thus creating the activated situation. RESULTS Introduction of the ITB resulted in a reduced laxity width during extension and an external tibial rotation (2.4°). The femur shifted less posterior in the lateral compartment when the ITB was activated. Activation of gastrocnemius as part of the calf muscles led to an increased laxity width. CONCLUSIONS Knee stability and knee joint kinematics are affected significantly by the activation of the ITB and the gastrocnemius as part of the triceps surae complex. This points to the importance of muscles and stabilizing tissue structures such as the ITB in the evaluation of knee joint kinematics both in vitro and in vivo.
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Affiliation(s)
- Amélie Chevalier
- Department of Electromechanical, Systems and Metals Engineering, Ghent University, Ghent, Belgium; Department of Electromechanics, CoSysLab, University of Antwerp, Belgium; AnSyMo/Cosys, Flanders Make, the strategic research centre for the manufacturing industry.
| | - Arent Van Overmeire
- Department of Electromechanical, Systems and Metals Engineering, Ghent University, Ghent, Belgium
| | - Hannes Vermue
- Department of Human Structure and Repair, Ghent University Hospital, Belgium
| | - Lauren Pringels
- Department of Human Structure and Repair, Ghent University Hospital, Belgium
| | - Stijn Herregodts
- Department of Human Structure and Repair, Ghent University Hospital, Belgium
| | - Jan Victor
- Department of Human Structure and Repair, Ghent University Hospital, Belgium
| | - Mia Loccufier
- Department of Electromechanical, Systems and Metals Engineering, Ghent University, Ghent, Belgium
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12
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Randhawa S, Stavinoha TJ, Trivedi S, Ganley TJ, Tompkins M, Ellis H, Wilson P, Green DW, Fabricant PD, Musahl V, Shea KG. Paediatric reference anatomy for ACL reconstruction and secondary anterolateral ligament or lateral extra-articular tenodesis procedures. J ISAKOS 2022; 7:206-213. [PMID: 35589081 DOI: 10.1016/j.jisako.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/04/2022] [Accepted: 04/30/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES For iliotibial band (ITB) lateral extra-articular tenodesis or anterolateral ligamentous/capsular reconstruction with anterior cruciate ligament reconstruction, a clear understanding of the referenced anterolateral knee anatomy is critical-especially given the risk of injury to the physis or key anterolateral structures in the paediatric population, which is at high-risk for primary and secondary anterior cruciate ligament injury. The purpose of this study was to quantitatively assess the anatomy of the knee physes, paediatric lateral collateral ligament (LCL) origin, popliteus origin and ITB tibial insertion. METHODS Nine paediatric cadaveric knee specimens with average age 4.2 years (range 2 months-10 years) underwent dissection to identify the LCL's and popliteus' femoral origins and the ITB's tibial insertion. Metallic marking pins demarcated precise anatomic attachment sites, and subsequent computerised tomography scans enabled quantified measurements among them. RESULTS LCL & Popliteus: On the femur, the popliteus origin lay consistently deep to the LCL and inserted both distally and anteriorly to the LCL, a mean distance of 4.6 mm (range 1.9-7.6; standard deviation 2.0). From the joint line, the LCL lay a mean distance of 12.5 mm proximally while the popliteus measured a mean of 8.2 mm. Both were consistently distal to the physis. The LCL was a mean distance of 4.4 mm (range 1.0-9.5) and the popliteus was a mean distance of 8.2 (range 1.7-12.5) from the physis. ITB insertion: The ITB insertion at Gerdy's tubercle had an average footprint measuring 28.2 mm2 (range 10.3-58.4) and the ITB centre lay proximal to the physis in 6 specimens (mean age 4.2 years, median 2.5 years) and distal in 3 specimens (mean age 1.5 years, median 4 months). Mean distance from the footprint centre to the physis was 1.6 mm proximal (range 7.1 proximal - 2.2 distal). CONCLUSION This study describes relative and quantitative positions of the femoral LCL and popliteus origins and tibial ITB attachment and their respective physeal relationships. Knowledge of paediatric anterolateral knee anatomy will help guide essential future research and procedures providing extra-articular anterolateral rotatory stabilisation and may help reduce iatrogenic physeal injury risk. LEVEL OF EVIDENCE N/A (descriptive anatomic study).
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Affiliation(s)
- Sahej Randhawa
- Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Road, Palo Alto, CA 94304, USA; UC San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA 92092, USA
| | - Tyler J Stavinoha
- Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Road, Palo Alto, CA 94304, USA
| | - Sunny Trivedi
- Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Road, Palo Alto, CA 94304, USA; University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Theodore J Ganley
- The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Marc Tompkins
- University of Minnesota, 2450 Riverside Ave., Minneapolis, MN 55455, USA
| | - Henry Ellis
- Texas Scottish Rite Hospital for Children, 2222 Welborn St, Dallas, TX 75219, USA
| | - Phil Wilson
- Texas Scottish Rite Hospital for Children, 2222 Welborn St, Dallas, TX 75219, USA
| | - Daniel W Green
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Peter D Fabricant
- Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA
| | - Volker Musahl
- University of Pittsburgh, UPMC Freddie Fu Sports Medicine Center, Dept of Orthopedics, 3200 S. Water St, PA 15203, USA
| | - Kevin G Shea
- Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Road, Palo Alto, CA 94304, USA.
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13
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Roach RP, Beason DP, Slowik JS, Moore AR, Lall AC, Dugas JR. Biomechanical Evaluation of Anterolateral Ligament Repair Augmented with Internal Brace. J Knee Surg 2022; 35:1484-1490. [PMID: 33853155 DOI: 10.1055/s-0041-1726420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Injuries to the anterolateral ligament (ALL) of the knee are commonly associated with anterior cruciate ligament (ACL) ruptures. Biomechanical studies have demonstrated conflicting results with regard to the role of the ALL in limiting tibial internal rotation. Clinically, residual pivot shift following ACL reconstruction has been reported to occur up to 25% and has been correlated with poor outcomes. As such, surgical techniques have been developed to enhance rotational stability. Recent biomechanical studies have demonstrated restoration of internal rotational control following ALL reconstruction. The purpose of our study was to understand the biomechanical effects of ACL reconstruction with an ALL internal brace augmentation. We hypothesized that (1) sectioning of the ALL while preserving other lateral extra-articular structures would lead to significant internal rotation laxity and gap formation and (2) ALL repair with internal brace augmentation would lead to reduction in internal rotation instability and gap formation. In total, 10 fresh-frozen cadaveric knees were thawed and biomechanically tested in internal rotation for 10 cycles of normal physiologic torque in the intact, ACL-deficient, ACL/ALL-deficient, ACL-reconstructed, and ALL-repaired conditions. Each condition was tested at 30, 60, and 90 degrees of flexion. Following the final ALL-repaired condition, specimens were additionally subjected to a final internal rotation to failure at 1 degree at the last-tested degree of flexion. Kinematic measurements of angle and linear gap between the femur and tibia were calculated in addition to torsional stiffness and failure torque. As hypothesized, ALL repair with internal brace augmentation significantly reduced internal rotation angular motion and gap formation at flexion angles greater than 30 degrees. Additionally, ALL sectioning produced nonsignificant increases in internal rotation laxity and gap formation compared with ACL-deficient and ACL-reconstructed states, which did not support our other hypothesis.
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Affiliation(s)
- Ryan P Roach
- American Sports Medicine Institute, Birmingham, Alabama
| | | | | | - A Ryves Moore
- American Sports Medicine Institute, Birmingham, Alabama
| | - Ajay C Lall
- American Hip Institute Research Foundation, Des Plaines, Illinois.,American Hip Institute, Des Plaines, Illinois
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14
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Berthold DP, Achtnich A, Mehl J. Anterolaterale Instabilität – Grenzgebiete der Indikation. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00565-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Xu J, Ye Z, Han K, Xu C, Zhao J, Dong S. Anterolateral Structure Reconstructions With Different Tibial Attachment Sites Similarly Improve Tibiofemoral Kinematics and Result in Different Graft Force in Treating Knee Anterolateral Instability. Arthroscopy 2022; 38:2684-2696. [PMID: 35337957 DOI: 10.1016/j.arthro.2022.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical effects of anterolateral structure reconstructions (ALSRs) with different tibial attachments on tibiofemoral kinematics and anterolateral structure (ALS) graft forces. METHODS Eight cadaveric knees were tested in a customized knee testing system, using a novel pulley system to simulate more muscle tensions by loading the iliotibial band at 30 N and quadriceps at 10 N in all testing states. Anterior stability during anterior load and anterolateral rotatory stability during 2 simulated pivot-shift tests (PST1 and PST2) were evaluated in 5 states: intact, ALS-deficient (Def), ALSR-Ta (anterior tibial site), ALSR-Tm (middle tibial site), and ALSR-Tp (posterior tibial site). Tibiofemoral kinematics and resulting ALS graft forces against the applied loads were measured and compared in the corresponding states. RESULTS In anterior load, 3 ALSRs mitigated the anterior laxities of the ALS Def state at all degrees, which were close to intact state at 0° and 30° but showed significantly overconstraints at 60° and 90°. In both PSTs, all ALSRs significantly reduced the anterolateral rotatory instability of ALS Def, whereas the significant overconstraints were detected in ALSR-Ta and ALSR-Tm at greater knee flexion angles. All ALS grafts carried forces in resisting anterior and pivot-shift loads. Only ALS graft force in ALSR-Ta increased continuously with knee flexion angles. The ALS graft forces carried by ALSR-Ta were significantly larger than those by ALSR-Tp and ALSR-Tm when resisting anterior load and PSTs at greater knee flexion angles. CONCLUSIONS ALSRs with different tibial attachment sites similarly restored knee laxities close to the native tibiofemoral kinematics in an ALS-deficient knee, whereas the ALSR-Tp showed less propensity for overconstraining the knee at greater flexion angles. The ALS graft in ALSR-Ta carried more forces than those in ALSR-Tp and ALSR-Tm against simulated loads. CLINICAL RELEVANCE Altering the tibial attachment sites of ALSRs may not significantly affect tibiofemoral kinematics at most degrees whereas the posterior may have less overconstraints at greater flexion angles. However, ALS graft positioning at a more anterior tibial attachment site may carry more forces in resisting anterior and pivot-shift loads.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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16
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Garcia-Mansilla I, Zicaro JP, Martinez EF, Astoul J, Yacuzzi C, Costa-Paz M. Overview of the anterolateral complex of the knee. World J Clin Cases 2022; 10:8474-8481. [PMID: 36157829 PMCID: PMC9453364 DOI: 10.12998/wjcc.v10.i24.8474] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/08/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
In the last few years, much more information on the anterolateral complex of the knee has become available. It has now been demonstrated how it works in conjunction with the anterior cruciate ligament (ACL) controlling anterolateral rotatory laxity. Biomechanical studies have shown that the anterolateral complex (ALC) has a role as a secondary stabilizer to the ACL in opposing anterior tibial translation and internal tibial rotation. It is of utmost importance that surgeons comprehend the intricate anatomy of the entire anterolateral aspect of the knee. Although most studies have only focused on the anterolateral ligament (ALL), the ALC of the knee consists of a functional unit formed by the layers of the iliotibial band combined with the anterolateral joint capsule. Considerable interest has also been given to imaging evaluation using magnetic resonance and several studies have targeted the evaluation of the ALC in the setting of ACL injury. Results are inconsistent with a lack of association between magnetic resonance imaging evidence of injury and clinical findings. Isolated ACL reconstruction may not always reestablish knee rotatory stability in patients with associated ALC injury. In such cases, additional procedures, such as anterolateral reconstruction or lateral tenodesis, may be indicated. There are several techniques available for ALL reconstruction. Graft options include the iliotibial band, gracilis or semitendinosus tendon autograft, or allograft.
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Affiliation(s)
| | - Juan Pablo Zicaro
- Knee Surgery, Hospital Italiano de Buenos Aires, Buenos Aires 1199, Argentina
| | | | - Juan Astoul
- Knee Surgery, Hospital Italiano de Buenos Aires, Buenos Aires 1199, Argentina
| | - Carlos Yacuzzi
- Knee Surgery, Hospital Italiano de Buenos Aires, Buenos Aires 1199, Argentina
| | - Matias Costa-Paz
- Knee Surgery, Hospital Italiano de Buenos Aires, Buenos Aires 1199, Argentina
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17
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Moreno Mateo F, Perea SH, Green DW. Lateral-extra articular tenodesis vs. anterolateral ligament reconstruction in skeletally immature patients undergoing anterior cruciate ligament reconstruction. Curr Opin Pediatr 2022; 34:71-75. [PMID: 34845153 DOI: 10.1097/mop.0000000000001084] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the most recent available evidence about lateral-extra articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction in young patients treated for anterior cruciate ligament (ACL) injury. RECENT FINDINGS The ALL of the knee acts as a secondary stabilizer of the knee preventing anterior translation and internal rotation. In vitro and in vivo biomechanical studies as well as prospective clinical trials have shown the importance of the ALL in knee biomechanics. The ALL injury has a synergetic impact on the knee stability in patients with acute ACL injury. ALL augmentation of ACL provides reduction of knee instability and graft failure and higher return to sport rates in high-risk patients. It has not been demonstrated that extra-articular procedures increase the risk of knee osteoarthritis secondary to knee over-constriction. Both Iliotibial band (ITB) ALL reconstruction and modified Lemaire LET have been shown safe and effective. Minimal biomechanical or clinical differences have been found between the two reconstruction methods. SUMMARY Young patients with ACL tears and risk factors such as laxity or pivot shift willing to return to sports may benefit from ALL augmentation. Therefore, it is essential to identify these high-risk patients to individualize treatment.
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Affiliation(s)
- Fernando Moreno Mateo
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
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18
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Runer A, Dammerer D, Kranewitter C, Giesinger JM, Henninger B, Hirschmann MT, Liebensteiner MC. Injuries to the anterolateral ligament are observed more frequently compared to lesions to the deep iliotibial tract (Kaplan fibers) in anterior cruciate ligamant deficient knees using magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc 2022; 30:309-318. [PMID: 33770221 PMCID: PMC8800892 DOI: 10.1007/s00167-021-06535-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/09/2021] [Indexed: 01/26/2023]
Abstract
PURPOSE To determine the accuracy of detection, injury rate and inter- and intrarater reproducibility in visualizing lesions to the anterolateral ligament (ALL) and the deep portion of the iliotibial tract (dITT) in anterior cruciate ligament (ACL) deficient knees. METHODS Ninety-one consecutive patients, out of those 25 children (age 14.3 ± 3.5 years), with diagnosed ACL tears were included. Two musculoskeletal radiologists retrospectively reviewed MRI data focusing on accuracy of detection and potential injuries to the ALL or dITT. Lesion were diagnosed in case of discontinued fibers in combination with intra- or peri-ligamentous edema and graded as intact, partial or complete tears. Cohen's Kappa and 95% confidence intervals (95% CI) were determined for inter- and intrarater reliability measures. RESULTS The ALL and dITT were visible in 52 (78.8%) and 56 (84.8%) of adult-and 25 (100%) and 19 (76.0%) of pediatric patients, respectively. The ALL was injured in 45 (58.5%; partial: 36.4%, compleate: 22.1%) patients. Partial and comleate tears, where visualized in 21 (40.4%) and 16 (30.8%) adult- and seven (28.0%) and one (4%) peditric patients. A total of 16 (21.3%; partial: 13.3%, compleate: 8.0%) dITT injuries were identified. Partal and complete lesions were seen in seven (12.5%) and five (8.9%) adult- and three (15.8%) and one (5.3%) pediatric patients. Combined injuries were visualized in nine (12.7%) patients. Inter-observer (0.91-0.95) and intra-observer (0.93-0.95) reproducibility was high. CONCLUSION In ACL injured knees, tears of the ALL are observed more frequently compared to lesions to the deep iliotibial tract. Combined injuries of both structures are rare. Clinically, the preoperative visualization of potentially injured structures of the anterolateral knee is crucial and is important for a more personalized preoperative planning and tailored anatomical reconstruction. The clinical implication of injuries to the anterolateral complex of the knee needs further investigation. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Dietmar Dammerer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | | | - Johannes M. Giesinger
- Innsbruck Institute of Patient-Centered Outcome Research (IIPCOR), Innsbruck, Austria
| | - Benjamin Henninger
- Department of Orthopaedic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Michael T. Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
| | - Michael C. Liebensteiner
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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19
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Anterolateral complex injuries occur in the majority of 'isolated' anterior cruciate ligament ruptures. Knee Surg Sports Traumatol Arthrosc 2022; 30:176-183. [PMID: 33796903 DOI: 10.1007/s00167-021-06543-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/18/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE The anterolateral soft tissue envelope of the knee is frequently injured at the time of ACL rupture. This study aims to investigate the MRI injury patterns to the Anterolateral complex and their associations in patients with acute 'isolated ligament' ACL ruptures. METHODS Professional athletes who underwent ACL reconstruction for complete ACL rupture between 2015 and 2019 were included in this study. Patients' characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the injuries to respective structures of the Anterolateral complex and their associations were recorded. RESULTS Anterolateral complex injuries were noted in 63% of cases. The majority of injuries were to Kaplan Fibre (39% isolated injury and 19% combined with Anterolateral ligament injury). There was a very low incidence of isolated Anterolateral ligament injuries (2%). Kaplan Fibre injuries are associated with the presence of lateral femoral condyle bone oedema, and injuries to the superficial MCL, deep MCL, and ramp lesions. High grade pivot shift test was not associated with the presence of Kaplan Fibre or Anterolateral ligament injuries. Patients with an intact Anterolateral complex sustained injury to other knee structures (13% to medial ligament complex, 14% to medial meniscus, and 16% to lateral meniscus). CONCLUSION There is a high incidence of concomitant Anterolateral complex injuries in combination with ACL ruptures, with Kaplan Fibre (and therefore the deep capsulo-osseous layer of the iliotibial band) being the most commonly injured structure. Anterolateral ligament injuries occur much less frequently. These findings reinforce the importance of considering the presence of, and if necessary, treating injuries to structures other than the ACL, as a truly isolated ACL injury is rare.
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20
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Musahl V, Nazzal EM, Lucidi GA, Serrano R, Hughes JD, Margheritini F, Zaffagnini S, Fu FH, Karlsson J. Current trends in the anterior cruciate ligament part 1: biology and biomechanics. Knee Surg Sports Traumatol Arthrosc 2022; 30:20-33. [PMID: 34927221 DOI: 10.1007/s00167-021-06826-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022]
Abstract
A trend within the orthopedic community is rejection of the belief that "one size fits all." Freddie Fu, among others, strived to individualize the treatment of anterior cruciate ligament (ACL) injuries based on the patient's anatomy. Further, during the last two decades, greater emphasis has been placed on improving the outcomes of ACL reconstruction (ACL-R). Accordingly, anatomic tunnel placement is paramount in preventing graft impingement and restoring knee kinematics. Additionally, identification and management of concomitant knee injuries help to re-establish knee kinematics and prevent lower outcomes and registry studies continue to determine which graft yields the best outcomes. The utilization of registry studies has provided several large-scale epidemiologic studies that have bolstered outcomes data, such as avoiding allografts in pediatric populations and incorporating extra-articular stabilizing procedures in younger athletes to prevent re-rupture. In describing the anatomic and biomechanical understanding of the ACL and the resulting improvements in terms of surgical reconstruction, the purpose of this article is to illustrate how basic science advancements have directly led to improvements in clinical outcomes for ACL-injured patients.Level of evidenceV.
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Affiliation(s)
- Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Ehab M Nazzal
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA.
| | - Gian Andrea Lucidi
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA.,IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Rafael Serrano
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3471 Fifth Ave, Suite 1010, Pittsburgh, PA, USA
| | - Jon Karlsson
- The Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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21
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Berthold DP, Willinger L, LeVasseur MR, Marrero DE, Bell R, Muench LN, Zenon K, Imhoff AB, Herbst E, Cote MP, Arciero RA, Edgar CM. High Rate of Initially Overlooked Kaplan Fiber Complex Injuries in Patients With Isolated Anterior Cruciate Ligament Injury: Response. Am J Sports Med 2022; 50:NP3-NP5. [PMID: 34984957 DOI: 10.1177/03635465211049388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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22
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Caracciolo G, Yáñez R, Silvestre R, De la Fuente C, Zamorano H, Ossio A, Strömbäck L, Abusleme S, P Carpes F. Intraoperative pivot-shift accelerometry combined with anesthesia improves the measure of rotatory knee instability in anterior cruciate ligament injury. J Exp Orthop 2021; 8:80. [PMID: 34561730 PMCID: PMC8463650 DOI: 10.1186/s40634-021-00396-1] [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] [Received: 05/12/2021] [Accepted: 08/27/2021] [Indexed: 01/11/2023] Open
Abstract
Purpose The knee stiffness acquired following an Anterior Cruciate Ligament (ACL) injury might affect clinical knee tests, i.e., the pivot-shift maneuver. In contrast, the motor effects of spinal anesthesia could favor the identification of rotatory knee deficiencies prior to ACL reconstruction. Hence, we hypothesized that the intra-operative pivot-shift maneuver under spinal anesthesia generates more acceleration in the lateral tibial plateau of patients with an injured ACL than without. Methods Seventy patients with unilateral and acute ACL rupture (62 men and 8 women, IKDC of 55.1 ± 13.8 pts) were assessed using the pivot-shift maneuver before and after receiving spinal anesthesia. A triaxial accelerometer was attached to the skin between Gerdys’ tubercle and the anterior tuberosity to measure the subluxation and reduction phases. Mixed ANOVA and multiple comparisons were performed considering the anesthesia and leg as factors (alpha = 5%). Results We found a higher acceleration in the injured leg measured under anesthesia compared to without anesthesia (5.12 ± 1.56 m.s− 2 vs. 2.73 ± 1.19 m.s− 2, p < 0.001), and compared to the non-injured leg (5.12 ± 1.56 m.s− 2 vs. 3.45 ± 1.35 m.s− 2, p < 0.001). There was a presence of significant interaction between leg and anesthesia conditions (p < 0.001). Conclusions The pivot-shift maneuver performed under anesthesia identifies better rotatory instability than without anesthesia because testing the pivot-shift without anesthesia underestimates the rotatory subluxation of the knee by an increased knee stiffness. Thus, testing under anesthesia provides a unique opportunity to determine the rotational instability prior to ACL reconstruction.
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Affiliation(s)
- Gastón Caracciolo
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Roberto Yáñez
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Rony Silvestre
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Carlos De la Fuente
- Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile.,Applied Neuromechanics Research Group, Laboratory of Neuromechanics, Federal University of Pampa, Uruguaiana, RS, 97500-970, Brazil.,Carrera de Kinesiología, Departamento de Cs. de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, RM, 7820436, Chile
| | - Héctor Zamorano
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Alejandra Ossio
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Lars Strömbäck
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Sebastian Abusleme
- Clínica MEDS, Santiago, RM, 7691236, Chile.,Centro de investigación en Medicina, Ejercicio, Deporte y Salud, Clínica MEDS, Santiago, RM, 7691236, Chile
| | - Felipe P Carpes
- Applied Neuromechanics Research Group, Laboratory of Neuromechanics, Federal University of Pampa, Uruguaiana, RS, 97500-970, Brazil.
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23
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Akmese R, Ovali SA, Celebi MM, Malatyali B, Kocaoglu H. A Surgical Algorithm According to Pivot-Shift Grade in Patients With ACL Injury: A Prospective Clinical and Radiological Evaluation. Orthop J Sports Med 2021; 9:23259671211025494. [PMID: 34435069 PMCID: PMC8381438 DOI: 10.1177/23259671211025494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/28/2021] [Indexed: 01/26/2023] Open
Abstract
Background: Some patients have a positive pivot-shift finding and rotational instability
after anterior cruciate ligament (ACL) reconstruction (ACLR). Three major
pathologies known to affect the pivot-shift examination include ACL tear,
anterolateral ligament injury, and loss of posterior lateral meniscus root
function. Purpose: To describe a surgical algorithm determining indications for lateral
extra-articular tenodesis (LET) based on intraoperative pivot-shift
examination to prevent postoperative pivot shift and rotational instability
and to evaluate the 2-year clinical and functional outcomes. Study Design: Case series; Level of evidence, 4. Methods: The study included 47 consecutive patients (39 men and 8 women) who underwent
operative treatment for ACL injury between 2016 and 2017. Pivot-shift
examination was performed under anesthesia, and the pivot shift was graded
as grade 1 (glide), grade 2 (clunk), or grade 3 (gross). According to the
surgical algorithm, single-bundle ACLR was performed in patients with grade
1 pivot shift. In patients with grade 2 with loss of posterior lateral
meniscus root function, concurrent lateral meniscal repair was performed,
and in patients with grade 2 with an intact lateral meniscus posterior root,
concurrent extra-articular iliotibial band tenodesis was performed. Patients
with grade 3 underwent ACLR, lateral meniscal repair, and LET. Clinical and
radiographic evaluations were performed. Results: The mean age was 27.2 years (range, 16-56 years). In total, 26 (55.3%)
patients were evaluated as having pivot-shift grade 1; 16 (34%) patients,
grade 2; and 5 (10.6%) patients, grade 3. A total of 7 (14.9%) patients
underwent LET in addition to ACLR. Two of these patients had pivot-shift
grade 2, and LET was performed since the lateral meniscus posterior root was
intact. In 14 of 16 patients with grade 2, lateral meniscus root disruption
was detected, and lateral meniscal repair was performed. One patient was
excluded from the further follow-up because of graft failure. At a mean
postoperative follow-up of 29 months in 46 patients, the pivot-shift
examination was negative in all patients. The mean Lysholm and International
Knee Documentation Committee subjective scores were 95.35 ± 4.40 and 82.87 ±
9.36, respectively. Radiographic evidence of osteoarthritis was not
detected. Conclusion: Only 14.9% of patients needed LET. With proper ACL, lateral meniscal, and
anterolateral ligament surgery, it was possible to prevent positive
pivot-shift findings postoperatively.
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Affiliation(s)
- Ramazan Akmese
- Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Mehmet Mesut Celebi
- Department of Sports Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Batu Malatyali
- Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hakan Kocaoglu
- Department of Orthopedics and Traumatology, Ankara University Faculty of Medicine, Ankara, Turkey
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24
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Combined Anterolateral and Anterior Cruciate Ligament Reconstruction Improves Pivot Shift Compared With Isolated Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arthroscopy 2021; 37:2677-2703. [PMID: 33864833 DOI: 10.1016/j.arthro.2021.03.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis of the literature on anterolateral ligament (ALL) reconstruction as it relates to techniques, biomechanical properties, and clinical outcomes. METHODS PubMed, OVID/Medline, and Embase were queried in July 2020. Data pertaining to (1) techniques, (2) biomechanical properties, and (3) clinical outcomes of ALL reconstruction were recorded. DerSimonian-Laird random-effects meta-analyses were performed for included randomized controlled trials comparing combined ALL/anterior cruciate ligament (ACL) reconstruction and isolated ACL reconstruction. Data from lower levels of evidence were described qualitatively, and when possible, outcomes were reported as ranges to avoid inappropriate pooling of data. RESULTS A total of 46 articles were identified. Sixteen were biomechanical studies, 16 were clinical outcome studies, and 14 were technique studies. Of the 16 biomechanical studies, the majority demonstrated that anterior translation, internal rotation, and pivot shift was restored with combined ACL/ALL reconstruction and superior to ACL reconstruction alone. Ten biomechanical studies reported on constraint: 4 noted overconstraint when the femoral attachment site was proximal and posterior to the lateral femoral condyle, whereas 1 reported laxity. ACL failure rates after combined ACL/ALL reconstruction ranged between 2.7% and 11.1%. The mean postoperative Lysholm score ranged between 58.7 and 98.0; mean postoperative International Knee Documentation Committee score between 57.8 and 96.3; and mean postoperative Tegner score between 4 and 8. Six outcomes were explored through meta-analysis, of which the mean difference in Lysholm scores (2.26, P < .001) and restoration of pivot shift (relative risk 1.1, P = .046) was found to favor combined ACL/ALL reconstruction. CONCLUSIONS Although indications for ALL reconstruction remain heterogeneous, contemporary evidence suggests that ALL reconstruction improves pivot shift and confers comparable clinical and functional outcomes with isolated ACLR. LEVEL OF EVIDENCE IV, systematic review and meta-analysis.
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25
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Yin J, Yang K, Zheng D, Xu N. Anatomic reconstruction of the anterior cruciate ligament of the knee with or without reconstruction of the anterolateral ligament: A meta-analysis. J Orthop Surg (Hong Kong) 2021; 29:2309499020985195. [PMID: 33410381 DOI: 10.1177/2309499020985195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To systematically analyze the effectiveness between combined anterior cruciate ligament and anterolateral ligament reconstruction (ACL+ALLR) and isolated anterior cruciate ligament reconstruction (ACLR) for treatment of patients with injured ACL. METHODS We performed a systematic search in MEDLINE, EMBASE, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, CNKI, and Wanfang Data for all relevant studies. All statistical analysis was performed using Review Manager version 5.3. RESULTS A total of six articles with 460 study subjects were included, with 193 patients in ACL+ALL reconstruction group and 267 patients in ACL reconstruction group. The results of the meta-analysis showed that the ACL+ALL reconstruction group had significantly lower KT measured value (P < 0.00001), Lachman test positive-rate (P = 0.02), Pivot-shift test positive-rate (P < 0.00001) and graft rupture rate (P = 0.02) compared with the ACL reconstruction group. Higher IKDC score (P < 0.00001) and Lysholm score (P < 0.00001) were measured in ACL+ALL reconstruction group, while infection rate (P = 0.86) and other complications rate (P = 0.29) showed no significant differences between the two groups. CONCLUSIONS Anatomic reconstruction of the ACL of the knee with reconstruction of the ALL indicates better postoperative knee function and clinical outcomes compared with isolated ACL reconstruction. The infection rate and other complications rate showed no significant difference between two groups.
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Affiliation(s)
- Jianjian Yin
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Kaiyuan Yang
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Dong Zheng
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Nanwei Xu
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
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26
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Berthold DP, Willinger L, LeVasseur MR, Marrero DE, Bell R, Muench LN, Kane Z, Imhoff AB, Herbst E, Cote MP, Arciero RA, Edgar CM. High Rate of Initially Overlooked Kaplan Fiber Complex Injuries in Patients With Isolated Anterior Cruciate Ligament Injury. Am J Sports Med 2021; 49:2117-2124. [PMID: 34086492 PMCID: PMC8246408 DOI: 10.1177/03635465211015682] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injuries to the Kaplan fiber complex (KFC) are not routinely assessed for in the anterior cruciate ligament (ACL)-deficient knee during preoperative magnetic resonance imaging (MRI). As injuries to the KFC lead to anterolateral rotatory instability (ALRI) in the ACL-deficient knee, preoperative detection of these injuries on MRI scans may help surgeons to individualize treatment and improve outcomes, as well as to reduce failure rates. PURPOSE To retrospectively determine the rate of initially overlooked KFC injuries on routine MRI in knees with isolated primary ACL deficiency. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent isolated ACL reconstruction between August 2013 and December 2019 were identified. No patient had had Kaplan fiber (KF) injury identified on the initial reading of the MRI scan or at the time of surgery. Preoperative knee MRI scans (minimum 1.5 T) were reviewed and injuries to the proximal and distal KFs were recorded by 3 independent reviewers. KF length and distance to nearby anatomic landmarks (the lateral joint line and the lateral femoral epicondyle) were measured. Additional radiological findings, including bleeding, lateral femoral notch sign, and bone marrow edema (BME), were identified to detect correlations with KFC injury. RESULTS The intact KFC could reliably be identified by all 3 reviewers (85.9% agreement; Kappa, 0.716). Also, 53% to 56% of the patients with initially diagnosed isolated ACL ruptures showed initially overlooked injuries to the KFC. Injuries to the distal KFs were more frequent (48.1%, 53.8%, and 43.3% by the first, second, and third reviewers, respectively) than injuries to the proximal KFs (35.6%, 47.1%, and 45.2% by the first, second, and third reviewers, respectively). Bleeding in the lateral supracondylar region was associated with KFC injuries (P = .023). Additionally, there was a positive correlation between distal KF injuries and lateral tibial plateau BME (P = .035), but no associations were found with the lateral femoral notch sign or other patterns of BME, including pivot-shift BME. CONCLUSION KF integrity and injury can be reliably detected on routine knee MRI scans. Also, 53% to 56% of the patients presenting with initially diagnosed isolated ACL ruptures had concomitant injuries to the KFC. This is of clinical relevance, as ACL injuries diagnosed by current routine MRI examination protocols may come with a high number of occult or hidden KFC injuries. As injuries to the KFC contribute to persistent ALRI, which may influence ACL graft failure or reoperation rates, significant improvements in preoperative diagnostic imaging are required to determine the exact injury pattern and to assist in surgical decision making.
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Affiliation(s)
- Daniel P. Berthold
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany,Daniel P. Berthold, MD, Ismaninger Str. 22, 81675 Munich, Germany ()
| | - Lukas Willinger
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Matthew R. LeVasseur
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Daniel E. Marrero
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Ryan Bell
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Lukas N. Muench
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Zenon Kane
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Andreas B. Imhoff
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery University Hospital, Münster, Germany
| | - Mark P. Cote
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Robert A. Arciero
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Cory M. Edgar
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
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27
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Anterolateral Rotatory Laxity: What is it, When to Address it, and How? OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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28
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Besler BA, Schadow JE, Durongbhan P, Steiner TH, Choo RJ, Zulliger MA, Wilke M, Atal K, Firminger C, Quintin A, Koller B, Müller R, Nesic D, Stok KS. Quantitative measures of bone shape, cartilage morphometry and joint alignment are associated with disease in an ACLT and MMx rat model of osteoarthritis. Bone 2021; 146:115903. [PMID: 33652170 DOI: 10.1016/j.bone.2021.115903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 12/16/2022]
Abstract
Multi-scale, subject-specific quantitative methods to characterize and monitor osteoarthritis in animal models and therapeutic treatments could help reveal causal relationships in disease development and distinguish treatment strategies. In this work, we demonstrate a reproducible and sensitive quantitative image analysis to characterize bone, cartilage and joint measures describing a rat model of post-traumatic osteoarthritis. Eleven 3-month-old male Wistar rats underwent medial anterior cruciate ligament (ACL) transection and medial meniscectomy on the right knee to destabilise the right tibiofemoral joint. They were sacrificed 6 weeks post-surgery and a silicon-based micro-bead contrast agent was injected in the joint space, before scanning with micro-computed tomography (microCT). Subsequently, 3D quantitative morphometric analysis (QMA), previously developed for rabbit joints, was performed. This included cartilage, subchondral cortical and epiphyseal bone measures, as well as novel tibiofemoral joint metrics. Semi-quantitative evaluation was performed on matching two-dimensional (2D) histology and microCT images. Reproducibility of the QMA was tested on eleven age-matched additional joints. The results indicate the QMA method is accurate and reproducible and that microCT-derived cartilage measurements are valid for the analysis of rat joints. The pathologic changes caused by transection of the ACL and medial meniscectomy were reflected in measurements of bone shape, cartilage morphology, and joint alignment. Furthermore, we were able to identify model-specific predictive parameters based on morphometric parameters measured with the QMA.
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Affiliation(s)
- Bryce A Besler
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland; University of Calgary, Calgary, Canada.
| | - Jemima E Schadow
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland; Department of Biomedical Engineering, The University of Melbourne, Parkville, Australia.
| | - Pholpat Durongbhan
- Department of Biomedical Engineering, The University of Melbourne, Parkville, Australia.
| | | | - Ryan J Choo
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland.
| | | | | | - Kailash Atal
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Colin Firminger
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland.
| | - Aurelie Quintin
- Department of BioMedical Research, University of Bern, Bern, Switzerland.
| | | | - Ralph Müller
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland.
| | - Dobrila Nesic
- Department of BioMedical Research, University of Bern, Bern, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Kathryn S Stok
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland; SCANCO Medical AG, Brüttisellen, Switzerland; Department of Biomedical Engineering, The University of Melbourne, Parkville, Australia.
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29
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Xu J, Han K, Su W, Jiang J, Yan X, Yu J, Dong S, Zhao J. A Secondary Injury of the Anterolateral Structure Plays a Minor Role in Anterior and Anterolateral Instability of Anterior Cruciate Ligament-Deficient Knees in the Case of Functional Iliotibial Band. Arthroscopy 2021; 37:1182-1191. [PMID: 33227322 DOI: 10.1016/j.arthro.2020.10.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 10/24/2020] [Accepted: 10/24/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the contribution of a secondary anterolateral structure (ALS) deficiency to knee instability based on anterior cruciate ligament (ACL) deficiency, in the condition of a functional iliotibial band (ITB). METHODS Nine freshly-frozen cadaveric knees were sectioned sequentially to create ACL deficiency and ACL-ALS deficiency, using intact knees before sectioning as controls. When ITB was tensioned with 30 N, 4 separate aspects of knee instability were tested as follows: anterior translation in 90 N anterior load, isolated internal rotation in 5 N·m internal rotational torque from 0° to 90° in 15° increments, and anterolateral translation and internal rotation during a simulated pivot-shift test at 0°, 15°, 30°, and 45°. The contribution of ACL deficiency alone and additional ALS deficiency to knee instability were evaluated. RESULTS The addition of an ALS lesion produced no significant exacerbation of either anterior translational or pivot shift instability in ACL-deficient knees. Additional ALS deficiency in an ACL-deficient knee resulted in a significant increase in isolated internal rotation from 45° to 90° (P = .001 at 45° and P < .001 in other cases). After sequentially sectioning, the contribution to instability of additional ALS deficiency to the entire instability in ACL-ALS-deficient knees was significantly smaller than that of ACL deficiency alone during anterior load and pivot-shift test (P < .001 in all cases), but significantly contributed more to isolated internal rotational instability at 60° (P = .011) and 90° (P = .015). CONCLUSIONS When ITB was tensioned, ALS played a minor role in controlling both anterior or pivot shift stability in ACL-deficient knees but a major role in restraining isolated internal rotation from 45° to 90°. CLINICAL RELEVANCE In the condition of functional ITB, concomitant ALS injury might not exacerbate anterior and pivot-shift instability after ACL rupture, while affecting isolated internal rotation stability at higher flexion.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaoyu Yan
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiakuo Yu
- Knee Surgery Department of the Institute of Sports Medicine & Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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30
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Ahn JH, Kim J, Mun JW. A Retrospective Comparison of Single-Bundle Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Tenodesis With Double-Bundle Anterior Cruciate Ligament Reconstruction. Arthroscopy 2021; 37:976-984. [PMID: 33188853 DOI: 10.1016/j.arthro.2020.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/31/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare postoperative objective knee stability and clinical outcomes between double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) and single-bundle (SB) ACLR combined with lateral extra-articular tenodesis (LET). METHODS ACL-injured patients with grade 3 pivot-shift who underwent either DB ACLR (DB ACLR group) or SB ACLR with LET (SB ACLR+LET group) were enrolled. All patients who met inclusion and exclusion criteria were retrospectively evaluated for knee laxity (the anterior translation and pivot-shift grade), clinical outcomes using the International Knee Documentation Committee (IKDC) examination form, Kellgren-Lawrence grade, graft maturation score on second-look arthroscopy, and revision rates at the last follow-up. RESULTS From an initial cohort of 171 consecutive patients over a 3-year period, 95 (56%) met inclusion and exclusion criteria. The SB ACLR+LET group (n = 47) showed significantly better results in pivot-shift grade at the last follow-up as compared with the DB ACLR group (n = 48) (P = .021). In the SB ACLR+LET group, 93.6% (44/47) were grade 0, whereas 72.9% (35/48) in the DB ACLR group were grade 0. The SB ACLR+LET group (grade A: 42, grade B: 4 and grade C: 1) showed significantly superior results in IKDC objective grade compared with the DB ACLR group (grade A: 32; grade B: 8; and grade C: 8) (P = .017). However, no statistically significant difference could be shown in anterior translation, subjective functional IKDC score, or revision rate between the 2 groups. The mean follow-up duration was 49.7 ± 5.7 months. CONCLUSIONS SB ACLR + LET demonstrated fewer pivot-shifts (P = .021) and superior IKDC objective grades (P = .017) than a DB ACLR at a mean follow-up of almost 50 months. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ji Hyun Ahn
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggido, Republic of Korea.
| | - Jaehyun Kim
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggido, Republic of Korea
| | - Ji Weon Mun
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggido, Republic of Korea
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31
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Blanke F, Boljen M, Lutter C, Oehler N, Tischer T, Vogt S. Does the anterolateral ligament protect the anterior cruciate ligament in the most common injury mechanisms? A human knee model study. Knee 2021; 29:381-389. [PMID: 33711673 DOI: 10.1016/j.knee.2021.02.026] [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: 08/28/2020] [Revised: 12/01/2020] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction still has a risk of re-rupture and persisting rotational instability. Thus, extra-articular structures such as the anterolateral ligament (ALL) are increasingly treated. The ALL however prevents the internal rotation of the tibia and it must be doubted that the ALL protects the ACL in other common injury mechanisms which primarily include tibial external rotation. In this study we aimed to evaluate which extra-articular structures support the ACL in excessive tibial internal and external rotation using a knee finite element (FE) model. METHODS Internal and external rotations of the tibia were applied to an FE model with anatomical ACL, posterior cruciate ligament (PCL), lateral collateral ligament (LCL), medial collateral ligament (MCL) and intact medial and lateral meniscus. Three additional anatomic structures (anterolateral ligament, popliteal tendon and posterior oblique ligament) were added to the FE model separately and then all together. The force histories within all structures were measured and determined for each case. RESULTS The ACL was the most loaded ligament both in tibial internal and external rotation. The ALL was the main stabilizer of the tibial internal rotation (46%) and prevented the tibial external rotation by only 3%. High forces were only observed in the LCL with tibial external rotation. The ALL reduced the load on the ACL in tibial internal rotation by 21%, in tibial external rotation only by 2%. The POL reduced the load on the ACL by 8%, the PLT by 6% in tibial internal rotation. In tibial external rotation the POL and PLT did not reduce the load on the ACL by more than 1%. CONCLUSION The ALL protects the ACL in injury mechanisms with tibial internal rotation but not in mechanisms with tibial external rotation. In injury mechanisms with tibial external rotation other structures that support the ACL need to be considered.
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Affiliation(s)
- F Blanke
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany; Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany.
| | - M Boljen
- Fraunhofer Institute for High-Speed Dynamics, Ernst-Mach-Institut, EMI, Freiburg i. Breisgau, Germany
| | - C Lutter
- Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany
| | - N Oehler
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany
| | - T Tischer
- Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany
| | - S Vogt
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany
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32
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Noyes FR, Huser LE, Palmer M. A Biomechanical Study of Pivot-Shift and Lachman Translations in Anterior Cruciate Ligament-Sectioned Knees, Anterior Cruciate Ligament-Reconstructed Knees, and Knees With Partial Anterior Cruciate Ligament Graft Slackening: Instrumented Lachman Tests Statistically Correlate and Supplement Subjective Pivot-Shift Tests. Arthroscopy 2021; 37:672-681. [PMID: 33065214 DOI: 10.1016/j.arthro.2020.09.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the statistical and predictive correlation between instrumented Lachman and pivot-shift tests with progressive loss of anterior cruciate ligament (ACL) function. METHODS The kinematic correlations between pivot-shift and Lachman anterior tibial translations (ATTs) in ACL-deficient and ACL-reconstructed states and in partially lax ACL grafts were determined with precise robotic testing in cadaveric knees. The Lachman test (100-N anteroposterior) and 2 pivot-shift loadings were conducted: anterior tibial loading (100 N), valgus rotation (7 Nm), and internal rotation (5 Nm and 1 Nm). The tibia was digitized to study the resulting medial, central, and lateral tibiofemoral compartment translations. In group 1 knees, 15 bone-patellar tendon-bone reconstructions were first tested, followed by ACL graft loosening with 3- and 5-mm increases in Lachman ATT. In group 2, 43 knees underwent robotic testing before and after ACL sectioning and underwent analysis of the effect of 3- and 5-mm increases in Lachman ATT and complete ACL sectioning on pivot-shift compartment translations. RESULTS In group 1 knees, ACL graft loosening allowing a 3-mm increase in Lachman ATT resulted in increases in pivot-shift lateral compartment translation (lateral compartment ATT) of only 1.6 ± 0.3 mm and 2.2 ± 1.0 mm (internal rotation of 5 Nm and 1 Nm, respectively) that were one-half of those required for a positive pivot-shift test finding. In group 2, for a 3-mm increased Lachman test, there were no positive pivot-shift values. In both groups, a Lachman test with an increase in ATT of 3 mm or less (100 N) had a 100% predictive value for a negative pivot-shift test finding. With ACL graft loosening and a 5-mm increase in the Lachman ATT, group 1 still had no positive pivot-shift values, and in group 2, a positive pivot-shift test finding occurred in 3 of 43 knees (7%, pivot shift 1-Nm internal rotation). After ACL sectioning, a highly predictive correlation was found between abnormal increases in Lachman and pivot-shift translations (P < .001). CONCLUSIONS ACL graft slackening and an instrumented Lachman test with an increase in ATT of 3 mm or less were 100% predictive of a negative pivot-shift subluxation finding and retained ACL stability. Further graft slackening and a 5-mm increase in the Lachman ATT produced pivot-shift lateral compartment ATT increases still less than the values in the ACL-deficient state; however, 7% of the knees (3 of 43) were converted to a positive pivot-shift test finding indicative of ACL graft failure. CLINICAL RELEVANCE Instrumented Lachman tests provide objective data on ACL function and graft failure to supplement subjective pivot-shift tests and are highly recommended for single-center and multicenter ACL studies. In the past decade, a near majority of published ACL studies no longer reported on instrumented Lachman tests, relying solely on highly subjective pivot-shift grading by multiple examiners.
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Affiliation(s)
- Frank R Noyes
- Cincinnati Sportsmedicine and Orthopaedic Center-Mercy Health, Cincinnati, Ohio, U.S.A.; The Noyes Knee Institute, Cincinnati, Ohio, U.S.A..
| | - Lauren E Huser
- Cincinnati Sportsmedicine and Orthopaedic Center-Mercy Health, Cincinnati, Ohio, U.S.A.; The Noyes Knee Institute, Cincinnati, Ohio, U.S.A
| | - Michael Palmer
- Cincinnati Sportsmedicine and Orthopaedic Center-Mercy Health, Cincinnati, Ohio, U.S.A.; The Noyes Knee Institute, Cincinnati, Ohio, U.S.A
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Patel RM, Castile RM, Jenkins MJ, Lake SP, Brophy RH. Microstructural and Mechanical Properties of the Anterolateral Ligament of the Knee. Am J Sports Med 2021; 49:172-182. [PMID: 33381993 DOI: 10.1177/0363546520974381] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The variable anatomy and controversy of the anterolateral ligament (ALL) reflect the complex relationship among the anterolateral knee structures. PURPOSE/HYPOTHESIS The purpose was to quantify the microstructural and mechanical properties of the ALL as compared with the anterolateral capsule (ALC) and lateral collateral ligament (LCL). The primary hypotheses were that (1) there is no difference in these properties between the ALL and ALC and (2) the LCL has significantly different properties from the ALL and ALC. STUDY DESIGN Descriptive laboratory study. METHODS The LCL, ALL, and ALC were harvested from 25 cadaveric knees. Mechanical testing and microstructural analyses were performed using quantitative polarized light imaging. The average degree of linear polarization (AVG DoLP; mean strength of collagen alignment) and standard deviation of the angle of polarization (STD AoP; degree of variation in collagen angle orientation) were calculated. RESULTS Linear region moduli were not different between the ALC and ALL (3.75 vs 3.66 MPa, respectively; P > .99). AVG DoLP values were not different between the ALC and ALL in the linear region (0.10 vs 0.10; P > .99). Similarly, STD AoP values were not different between the ALC and ALL (24.2 vs 21.7; P > .99). The LCL had larger modulus, larger AVG DoLP, and smaller STD AoP values than the ALL and ALC. Of 25 knee specimens, 3 were observed to have a distinct ALL, which exhibited larger modulus, larger AVG DoLP, and smaller STD AoP values as compared with nondistinct ALL samples. CONCLUSION There were no differences in the mechanical and microstructural properties between the ALL and ALC. The ALC and ALL exhibited comparably weak and disperse collagen alignment. However, when a distinct ALL was present, the properties were suggestive of a ligamentous structure. CLINICAL RELEVANCE The properties of the ALL are similar to those of a ligament only when a distinct ALL is present, but otherwise, for the majority of specimens, ALL properties are closer to those of the capsule. Variability in the ligamentous structure of the ALL suggests that it may be more important in some patients than others and reconstruction may be considered in selective patients. Further study is needed to better understand its selective role and optimal indications for reconstruction.
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Affiliation(s)
- Ronak M Patel
- Washington University in St Louis, St Louis, Missouri, USA
| | - Ryan M Castile
- Washington University in St Louis, St Louis, Missouri, USA
| | | | - Spencer P Lake
- Washington University in St Louis, St Louis, Missouri, USA
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Abstract
Increasing emphasis in the literature is recently being put on controlling rotational stability in patients with an anterior cruciate ligament rupture by addressing the anterolateral complex during anterior cruciate ligament reconstruction. Many different techniques for lateral extra-articular tenodesis have been described, with the (modified) Lemaire technique being widely favored. Recent literature does report that lateral extra-articular tenodesis leads to a reduction in persistent rotatory laxity and graft rupture rate, but also may be associated with increased pain, reduced quadriceps strength, reduced subjective functional recovery, and cosmetic complaints. Thus this article aims to describe our minimally invasive technique for a modified Lemaire tenodesis.
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de Alencar Neto JB, de Souza CJD, Lopes MBG, Cavalcante MLC, Neto LHP. Bilateral Avulsion Fracture of the Fibula Head of the Knee Associated with Avulsion Fracture of the Iliotibial Band: A Rare Case of Fracture Segond Associated with Arcuate Fracture. Case Rep Orthop 2020; 2020:8825638. [PMID: 32733728 PMCID: PMC7378631 DOI: 10.1155/2020/8825638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/22/2020] [Accepted: 07/03/2020] [Indexed: 01/26/2023] Open
Abstract
Fibular head avulsion fractures are rare and are so-called the arcuate signal. Avulsion fracture of the iliotibial band and anterolateral ligament is known as a Segond fracture, and it is another rare entity. We describe the case of a 27-year-old woman who was hit by a car and suffered polytrauma, mainly suffering injuries to both knees. Radiographs of the knees showed a Segond fracture associated with the arched signal bilaterally. The aim of this study is to present a rare case report and literature review of a bilateral fibular head avulsion fracture associated with an anterolateral tibial avulsion fracture.
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Affiliation(s)
- Jonatas Brito de Alencar Neto
- Orthopedic Surgeon of the Dr. José Frota Institute, 1816 Barão do Rio Branco St., Fortaleza, Ceará, Brazil
- Orthopedic Surgeon in Articular Clinic Medical Center, 2340 Pontes Vieira Ave., Fortaleza, Ceará, Brazil
| | | | - Márcio Bezerra Gadelha Lopes
- Orthopedic Surgeon of the Dr. José Frota Institute, 1816 Barão do Rio Branco St., Fortaleza, Ceará, Brazil
- Orthopedic Surgeon in Articular Clinic Medical Center, 2340 Pontes Vieira Ave., Fortaleza, Ceará, Brazil
| | - Maria Luzete Costa Cavalcante
- Department of Orthopedics in Walter Cantídio Hospital University Federal of Ceará, 1290 Pastor Samuel Munguba St., Fortaleza, CE, Brazil
| | - Luiz Holanda Pinto Neto
- Orthopedic Surgeon of the Dr. José Frota Institute, 1816 Barão do Rio Branco St., Fortaleza, Ceará, Brazil
- Orthopedic Surgeon in Articular Clinic Medical Center, 2340 Pontes Vieira Ave., Fortaleza, Ceará, Brazil
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Delaloye JR, Hartog C, Blatter S, Schläppi M, Müller D, Denzler D, Murar J, Koch PP. Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-Articular Tenodesis Similarly Improve Knee Stability After Anterior Cruciate Ligament Reconstruction: A Biomechanical Study. Arthroscopy 2020; 36:1942-1950. [PMID: 32251683 DOI: 10.1016/j.arthro.2020.03.027] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/11/2020] [Accepted: 03/15/2020] [Indexed: 02/09/2023]
Abstract
PURPOSE To determine the stabilizing role of anterolateral ligament reconstruction (ALLR) and modified Lemaire lateral extra-articular tenodesis (LET) performed in combination with anterior cruciate ligament reconstruction (ACLR) and to determine whether either procedure was superior to the other. METHODS Six nonpaired, human, fresh-frozen cadaveric knees were tested with a 6-df robotic system. Internal rotation and anterior translation of the knee were recorded from 0° to 90° of flexion after application of a 5-Nm internal rotation torque and a 134-N anterior load, respectively. A full kinematic assessment was performed in each of the following conditions: (1) intact knee, (2) after sectioning of the anterior cruciate ligament (ACL), (3) after sectioning of the ACL and anterolateral ligament, (4) after isolated ACLR, and (5) after combined ACLR and Lemaire LET and combined ACLR and ALLR. ALLR was performed using the gracilis tendon, whereas the modified Lemaire procedure was performed using the central strip of the iliotibial band. The different states were compared using a Tukey paired comparison test. RESULTS In knees with combined deficiency of the ACL and anterolateral structures, anterior translation and internal rotation remained significantly increased after isolated ACLR compared with the intact knee (+2.33 ± 1.44 mm and +1.98° ± 1.06°, respectively; P < .01). On the other hand, the addition of ALLR or modified Lemaire LET to ACLR restored anterior translation and internal rotation to values similar to those in the intact knee. The 2 anterolateral procedures did not show statistically significantly different values for both tests. This difference was 0.67 ± 1.46 mm for anterior translation (P = .79) and 0.11° ± 1.11° for internal rotation (P = .99). CONCLUSIONS In knees with ACL and anterolateral deficiency, combined ACLR and anterolateral reconstruction restored the native knee stability in anterior translation and internal rotation contrary to isolated ACLR. In addition, both types of extra-articular reconstruction-ALLR and modified Lemaire LET-were similar in terms of restoring knee kinematics, and neither overconstrained the knee. CLINICAL RELEVANCE In knees with deficiency of the ACL and anterolateral structures, combined ACLR and anterolateral reconstruction increased knee stability at time zero after surgery. This biomechanical improvement could be responsible for the protective effect on ACL graft and meniscal repair reported in the literature after the combined procedure.
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Affiliation(s)
- Jean-Romain Delaloye
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland.
| | - Christoph Hartog
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland
| | - Samuel Blatter
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland
| | - Michel Schläppi
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland
| | - Dominic Müller
- School of Engineering, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Dario Denzler
- School of Engineering, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Jozef Murar
- Twin Cities Orthopedics, Edina, Minnesota, U.S.A
| | - Peter Philipp Koch
- Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland
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Berthold DP, Willinger L, Muench LN, Forkel P, Schmitt A, Woertler K, Imhoff AB, Herbst E. Visualization of Proximal and Distal Kaplan Fibers Using 3-Dimensional Magnetic Resonance Imaging and Anatomic Dissection. Am J Sports Med 2020; 48:1929-1936. [PMID: 32407130 DOI: 10.1177/0363546520919986] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In current magnetic resonance imaging (MRI) of the knee, injuries to the anterolateral ligament complex (ALC) and the Kaplan fibers (KFs) are not routinely assessed. As ruptures of the KFs contribute to anterolateral rotatory instability in the anterior cruciate ligament-deficient knee, detecting these injuries on MRI may help surgeons to individualize treatment. PURPOSE To visualize the KFs on 3-T MRI and to conduct a layer-by-layer dissection of the ALC. STUDY DESIGN Descriptive laboratory study. METHODS Ten fresh-frozen human cadaveric knees (mean ± SD age, 72 ± 8.5 years) without history of ligament injury were used in this study. Before layer-by-layer dissection of the ALC, MRI was performed to define the radiologic anatomy of the KFs. A coronal T1-weighted 3-dimensional turbo spin echo sequence and a transverse T2-weighted turbo spin echo sequence were obtained. Three-dimensional data sets were used for multiplanar reconstructions. RESULTS KFs were identified in 100% of cases on MRI and in anatomic dissection. The mean length of the proximal and distal KFs was 17.9 ± 3.6 mm and 12.4 ± 6.5 mm, respectively. On MRI, the distance from the lateral femoral epicondyle to the proximal KFs was 35.9 ± 6.9 mm and to the distal KFs, 16.6 ± 4.1 mm; in anatomic dissection, the distances were 41.4 ± 8.1 mm for proximal KFs and 28.2 ± 8.1 mm for distal KFs. The distance from the lateral joint line to the proximal KFs was 63.5 ± 7.6 mm and to the distal KFs, 45.3 ± 3.7 mm. Interobserver reliability for image analysis was excellent for all measurements. CONCLUSION KFs can be consistently identified on MRI with use of 3-dimensional sequences. Subsequent anatomic dissection confirmed their close topography to the superior lateral genicular artery. For clinical implications, the integrity of the KFs should be routinely reviewed on MRI scans. CLINICAL RELEVANCE As ruptures of the KFs contribute to anterolateral rotatory instability, accurate visualization of the KFs on MRI may facilitate surgical decision making for additional anterolateral procedures in the anterior cruciate ligament-deficient knee.
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Affiliation(s)
- Daniel P Berthold
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Lukas Willinger
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Lukas N Muench
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Philipp Forkel
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Andreas Schmitt
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Klaus Woertler
- Department of Radiology, Technical University of Munich, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
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Nishida K, Matsushita T, Hoshino Y, Araki D, Matsumoto T, Niikura T, Kuroda R. The Influences of Chronicity and Meniscal Injuries on Pivot Shift in Anterior Cruciate Ligament-Deficient Knees: Quantitative Evaluation Using an Electromagnetic Measurement System. Arthroscopy 2020; 36:1398-1406. [PMID: 32001277 DOI: 10.1016/j.arthro.2020.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 12/31/2019] [Accepted: 01/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the influences of time from injury to surgery and meniscal injuries on knee rotational laxity in anterior cruciate ligament (ACL)-deficient knees using the electromagnetic system retrospectively. METHODS Ninety-four unilateral ACL-injured patients (44 male and 50 female, mean age: 27.3 ± 11.8 years) were included. The pivot-shift test was performed before ACL reconstruction, as was a quantitative evaluation using the electromagnetic system to determine tibial acceleration. Patients were divided into 4 groups according to the chronicity: group 1, within 3 months (22 patients); group 2, between 3 and 6 months (29 patients); group 3, between 6 and 12 months (23 patients); and group 4, more than 12 months (20 patients). The presence of meniscal injuries was examined arthroscopically. RESULTS The tibial acceleration was significantly greater in group 4. There was a positive correlation between tibial acceleration and the time from injury to surgery (r = 0.47, P = .02). In groups 1, 2 and 3, the tibial acceleration in patients with a lateral meniscal injury was significantly greater than in patients with a medial meniscal injury and without meniscal injury. When patients with lateral meniscal injury were excluded (leaving those with medial meniscus injury or without meniscal injury), group 4 had significantly greater accelerations than other groups. CONCLUSIONS In ACL-deficient knees, rotational laxity increased with time and the increased rotational laxity was evident more than 1 year after injury whereas it increased with concomitant lateral meniscal injuries within 1 year after injury. LEVEL OF EVIDENCE Ⅳ, diagnostic study of nonconsecutive patients.
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Affiliation(s)
- Kyohei Nishida
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Araki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Lee JK, Seo YJ, Jeong SY, Yang JH. Biomechanical function of the anterolateral ligament of the knee: a systematic review. Knee Surg Relat Res 2020; 32:6. [PMID: 32660580 PMCID: PMC7219217 DOI: 10.1186/s43019-019-0021-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/21/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND It has been suggested that the anterolateral ligament (ALL) is an important anterolateral stabilizer of the knee joint which functions to prevent anterolateral subluxation and anterior subluxation at certain flexion angles in the knee. PURPOSE To analyze and systematically interpret the biomechanical function of the ALL. METHODS An online search was conducted for human cadaveric biomechanical studies that tested function of the ALL in resisting anterolateral subluxation and anterior subluxation of the knee. Two reviewers independently searched Medline, Embase, and the Cochrane Database of Systematic Reviews for studies up to 25 September 2018. Biomechanical studies not reporting the magnitude of anterior tibial translation or tibial internal rotation in relation to the function of the ALL were excluded. RESULTS Twelve biomechanical studies using human cadavers evaluating parameters including anterior tibial translation and/or internal tibial rotation in anterior cruciate ligament (ACL)-sectioned and ALL-sectioned knees were included in the review. Five studies reported a minor increase or no significant increase in anterior tibial translation and internal tibial rotation with further sectioning of the ALL in ACL-deficient knees. Five studies reported a significant increase in knee laxity in tibial internal rotation or pivot shift with addition of sectioning the ALL in ACL-deficient knees. Two studies reported a significant increase in both anterior tibial translation and internal tibial rotation during application of the anterior-drawer and pivot-shift tests after ALL sectioning. CONCLUSION There was inconsistency in the biomechanical characteristics of the ALL of the knee in resisting anterolateral and anterior subluxation of the tibia.
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Affiliation(s)
- Jin Kyu Lee
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, South Korea
| | - Young Jin Seo
- Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Dongtan, Gyeonggi-do, South Korea
| | - Soo-Young Jeong
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, South Korea
| | - Jae-Hyuk Yang
- Department of Orthopedic Surgery, Guri Hospital, Hanyang University Medical Center, 153, Gyeongchunro, Guri, Gyeonggi-Do, 11923, South Korea.
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Hughes JD, Rauer T, Gibbs CM, Musahl V. Diagnosis and treatment of rotatory knee instability. J Exp Orthop 2019; 6:48. [PMID: 31865518 PMCID: PMC6925612 DOI: 10.1186/s40634-019-0217-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/13/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Rotatory knee instability is an abnormal, complex three-dimensional motion that can involve pathology of the anteromedial, anterolateral, posteromedial, and posterolateral ligaments, bony alignment, and menisci. To understand the abnormal joint kinematics in rotatory knee instability, a review of the anatomical structures and their graded role in maintaining rotational stability, the importance of concomitant pathologies, as well as the different components of the knee rotation motion will be presented. MAIN BODY The most common instability pattern, anterolateral rotatory knee instability in an anterior cruciate ligament (ACL)-deficient patient, will be discussed in detail. Although intra-articular ACL reconstruction is the gold standard treatment for ACL injury in physically active patients, in some cases current techniques may fail to restore native knee rotatory stability. The wide range of diagnostic options for rotatory knee instability including manual testing, different imaging modalities, static and dynamic measurement, and navigation is outlined. As numerous techniques of extra-articular tenodesis procedures have been described, performed in conjunction with ACL reconstruction, to restore anterolateral knee rotatory stability, a few of these techniques will be described in detail, and discuss the literature concerning their outcome. CONCLUSION In summary, the essence of reducing anterolateral rotatory knee instability begins and ends with a well-done, anatomic ACL reconstruction, which may be performed with consideration of extra-articular tenodesis in a select group of patients.
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Affiliation(s)
- Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Thomas Rauer
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christopher M Gibbs
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA.
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Correlation between ACL injury and involvement of the anterolateral ligament: A retrospective study. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Modified Lemaire Lateral Extra-articular Tenodesis in the Pediatric Patient: An Adjunct to Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2019; 9:e111-e116. [PMID: 32021783 PMCID: PMC6993266 DOI: 10.1016/j.eats.2019.09.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/11/2019] [Indexed: 02/03/2023] Open
Abstract
Recent literature has identified a population of active adolescents aged 13 to 15 years who are at high risk for anterior cruciate ligament graft rupture. Addressing the anterolateral complex during primary anterior cruciate ligament reconstruction has recently re-emerged in the literature, with various techniques available. This paper aims to describe a lateral extra-articular tenodesis procedure using the iliotibial band with a modified Lemaire technique. This procedure is recommended for active adolescents at a high risk of graft re-tear as an enhancement to primary anterior cruciate ligament reconstruction with soft-tissue graft.
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Golan EJ, Tisherman R, Byrne K, Diermeier T, Vaswani R, Musahl V. Anterior Cruciate Ligament Injury and the Anterolateral Complex of the Knee-Importance in Rotatory Knee Instability? Curr Rev Musculoskelet Med 2019; 12:472-478. [PMID: 31773476 PMCID: PMC6942070 DOI: 10.1007/s12178-019-09587-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW In the setting of rotatory knee instability following anterior cruciate ligament (ACL) reconstruction, there has been a resurgence of interest in knee's anterolateral complex (ALC). Reconstruction or augmentation of the ALC with procedures such as a lateral extra-articular tenodesis (LET) has been proposed to reduce rotatory knee instability in conjunction with ACL reconstruction. The current review investigates the recent literature surrounding the role of the ALC in preventing rotatory knee instability. RECENT FINDINGS The knee's anterolateral complex (ALC) is a complex structure composed of the superficial and deep portions of the iliotibial band, the capsulo-osseous layer, and the anterolateral capsule. Distally, these various layers merge to form a single functional unit which imparts stability to the lateral knee. While the iliotibial band and the capsule-osseous layer have been shown to be primary restraints to rotatory motion after ACL injury, the biomechanical role of the anterolateral capsule remains unclear. Biomechanical studies have shown that the anterolateral capsule and the anterolateral thickening of this capsule act as a sheet of fibrous tissue which does not resist motion around the knee as other longitudinally oriented ligaments do. Augmentation of the ALC, with LET, has been performed globally for over 30 years. This procedure can decrease rotatory knee instability, but long-term studies have found little difference in patient-reported outcomes, osteoarthritis, or ACL reconstruction failure with the addition of LET. Further research is needed to clarify indications for the clinical use of ALC-based procedures.
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Affiliation(s)
- Elan J Golan
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Robert Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
- Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, PA USA
| | - Kevin Byrne
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Theresa Diermeier
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
- Orthopaedic Sport Medicine, Technical University Munich, Munich, Germany
| | - Ravi Vaswani
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
- Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, PA USA
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Araki D, Matsushita T, Hoshino Y, Nagai K, Nishida K, Koga H, Nakamura T, Katakura M, Muneta T, Kuroda R. The Anterolateral Structure of the Knee Does Not Affect Anterior and Dynamic Rotatory Stability in Anterior Cruciate Ligament Injury: Quantitative Evaluation With the Electromagnetic Measurement System. Am J Sports Med 2019; 47:3381-3388. [PMID: 31657944 DOI: 10.1177/0363546519879692] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The biomechanical function of the anterolateral structure (ALS), which includes the anterolateral joint capsule and anterolateral ligament (ALL), remains a topic of debate. HYPOTHESIS The ALS contributes to knee joint stability during the Lachman test and the pivot-shift test in anterior cruciate ligament (ACL)-deficient knees. STUDY DESIGN Controlled laboratory study. METHODS Fourteen fresh-frozen hemipelvis lower limbs were used. For 7 specimens, the anterior one-third of the ALS and the residual ALS were cut intra-articularly with a radiofrequency device. Subsequently, the ACL was cut arthroscopically. For the other 7 specimens, the ACL was cut first, followed by the anterior one-third of the ALS and the residual ALS intra-articularly. During the procedures, the iliotibial band (ITB) was kept intact. At each condition, the anterior tibial translation (ATT) during the manual Lachman test and the acceleration of posterior tibial translation (APT) and the posterior tibial translation (PTT) during the manual pivot-shift test were measured quantitatively with an electromagnetic measurement system. The mean values of those parameters were compared among 6 groups (ACL intact, one-third ALS cut, all ALS cut, ACL cut, ACL/one-third ALS cut, and ACL/all ALS cut). RESULTS The mean ATTs during the Lachman test and the mean APTs and PTTs in the ACL-cut conditions (ACL cut, ACL/one-third ALS cut, and ACL/all ALS cut) were significantly larger than those under the ACL-intact conditions (ACL intact, one-third ALS cut, all ALS cut) (P < .01). However, no statistically significant differences were observed among the intact, one-third ALS-cut, and all ALS-cut conditions, within the ACL-intact or ACL-cut conditions. CONCLUSION Intra-articular dissection of the ALS did not increase the ATT during the Lachman test or the APT and PTT during the pivot-shift test under the intact condition of the ITB, regardless of the integrity of the ACL. When the ITB is intact, the ALS does not have a significant role in either anterior or dynamic rotatory knee stability, while the ACL does. CLINICAL RELEVANCE Recent growing interest about ALL reconstruction or ALS augmentation may not have a large role in controlling either anterior or dynamic rotatory knee instability in isolated ACL-deficient knees.
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Affiliation(s)
- Daisuke Araki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Kyohei Nishida
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mai Katakura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Takeshi Muneta
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
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Park YB, Lee HJ, Ro DH, Lee GY, Kim S, Kim SH. Anterolateral ligament injury has a synergic impact on the anterolateral rotatory laxity in acute anterior cruciate ligament-injured knees. Knee Surg Sports Traumatol Arthrosc 2019; 27:3334-3344. [PMID: 30631908 DOI: 10.1007/s00167-019-05347-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 01/04/2019] [Indexed: 01/24/2023]
Abstract
PURPOSE To investigate the prevalence of the anterolateral ligament (ALL) injuries and its role in rotatory laxity in acute anterior cruciate ligament (ACL)-injured knees. METHODS Two-hundred and ninety-six consecutive patients with acute ACL injuries were evaluated retrospectively, excluding those with other ligament injury and undetectable path of ALL in MRI. Patients were divided into two groups based on the degree of ACL injury in arthroscopy (complete versus partial group). Logistic regression and discriminant analysis were performed to assess the risk of pivot shift test. RESULTS A total of 169 patients were included (128 with complete and 41 with partial ACL rupture). Overall, 106/169 (62.7%) of ALL injuries were characterized, 87/128 (67.9%) in complete group, and 19/41 (46.3%) in partial group. The incidence of pivot shift was 120/128 (93.8%) and 14/41 (34.1%) in the complete and partial groups, respectively. The odds ratio in the pivot shift of combined ALL injury was found as 3.8 (95% CI 1.8-8.4) with the overall ACL injury, but higher as 17.1 (95% CI 3.1-96.4) with partial group. Higher grade of pivot shift showed a greater incidence of injury of ALL. Degree of ACL injury and ALL injury allowed 87.0% of correct classification of subsequent anterolateral rotatory laxity. CONCLUSION Injury to the ALL could have a synergetic effect on anterolateral rotatory laxity in acute ACL-injured knee, however, its effect might be minor in case of complete tear. Careful assessment about combined ALL injury should be considered, especially in knees with high-grade pivot shift in acute ACL-injured knees. LEVEL OF EVIDENCE Retrospective prognostic study, Level IV.
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Affiliation(s)
- Yong-Beom Park
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Han-Jun Lee
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Du-Hyun Ro
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-Gu, Seoul, 03080, South Korea
| | - Geun Young Lee
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Sujin Kim
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea
| | - Seong Hwan Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul, 06973, South Korea. .,Orthopedic Department, Centre Hospitalier de Versailles, Le Chesnay, France.
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46
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Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up. Arch Orthop Trauma Surg 2019; 139:1425-1433. [PMID: 31297583 DOI: 10.1007/s00402-019-03218-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Indexed: 02/09/2023]
Abstract
PURPOSE The role for extra-articular procedures in addition to ACL reconstruction to restore rotational stability is debated. We use lateral extra-articular tenodesis (LEAT) for patients that meet criteria. Our null hypothesis was that there would be no difference between two groups of patients that were treated with ACL reconstruction alone or ACL reconstruction with LEAT according to criteria. METHODS A prospectively collected database of patients that were treated primarily according to the presence of a high-grade pivot shift with LEAT at the time of ACL reconstruction was propensity-matched with a group of patients that underwent ACL reconstruction alone. Minimum follow-up was 2 years. Stratified variable analysis of the groups was also performed. RESULTS There were 218 and 55 patients in the ACL reconstruction group and ACL reconstruction with LEAT group, respectively. There were 125 patients and 46 patients after propensity matching with a median follow-up of 52 months and 27 months, respectively. Post-operative Lysholm score (P = 0.005), Tegner activity index (P = 0.003) and time to return to sport (P < 0.001) favoured ACL reconstruction with LEAT compared to ACL reconstruction alone. Sports with frequent change of direction maneuvers and higher rates of ACL injury (rugby, soccer, skiing) favoured ACL reconstruction with LEAT versus ACL reconstruction alone (P = 0.001). No significant difference in re-operation rate or type of surgery was found between the two surgical groups after propensity matching but 13 patients in the ACL reconstruction-only group re-injured their ACL, 8 of whom required supplementary LEAT at the time of revision surgery. CONCLUSION Patient-reported outcomes and return to multi-directional sports after ACL reconstruction favour LEAT at the time of ACL reconstruction when narrow inclusion criteria are applied.
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47
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Smith PA, Thomas DM, Pomajzl RJ, Bley JA, Pfeiffer FM, Cook JL. A Biomechanical Study of the Role of the Anterolateral Ligament and the Deep Iliotibial Band for Control of a Simulated Pivot Shift With Comparison of Minimally Invasive Extra-articular Anterolateral Tendon Graft Reconstruction Versus Modified Lemaire Reconstruction After Anterior Cruciate Ligament Reconstruction. Arthroscopy 2019; 35:1473-1483. [PMID: 30926192 DOI: 10.1016/j.arthro.2018.11.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether the deep fibers of the iliotibial band (dITB) or the anterolateral ligament (ALL) provides more control of a simulated pivot shift and whether a minimally invasive anterolateral reconstruction (ALR) designed to functionally restore the ALL and dITB is mechanically equivalent to a modified Lemaire reconstruction (MLR). METHODS Six matched pairs of cadaveric knees (N = 12) were subjected to a simulated pivot shift to evaluate anteroposterior translation; internal rotation; and valgus laxity at 0°, 30°, and 90° of flexion. The anterior cruciate ligament (ACL) was sectioned in all specimens, and retesting was performed. Within each pair, sequential sectioning of the ALL and dITB was performed, followed by testing; the contralateral knee was sectioned in reverse order. Knees underwent ACL reconstruction (ACLR) and repeat testing. Then, MLR (n = 6) or ALR (n = 6) was performed on matched pairs for final testing. RESULTS Sectioning of the dITB versus ALL (after ACL sectioning) produced significantly more anterior translation at all flexion angles (P = .004, P = .012, and P = .011 for 0°, 30°, and 90°, respectively). The ACL-plus-dITB sectioned state had significantly more internal rotation at 0° versus ACL plus ALL (P = .03). ACLR plus ALR restored native anterior translation at all flexion angles. ACLR plus MLR restored anterior translation to native values only at 0° (P = .34). We found no statistically significant differences between ACLR plus ALR and ACLR plus MLR at any flexion angle for internal rotation or valgus laxity compared with the native state. CONCLUSIONS ALR of the knee in conjunction with ACLR can return the knee to its native biomechanical state without causing overconstraint. The dITB plays a more critical role in controlling anterior translation and internal rotation at 0° than the ALL. The minimally invasive ALR was functionally equivalent to MLR for restoration of knee kinematics after ACLR. CLINICAL RELEVANCE The dITB is more important than the ALL for control of the pivot shift. A minimally invasive extra-articular tendon allograft reconstruction was biomechanically equivalent to a modified Lemaire procedure for control of a simulated pivot shift.
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Affiliation(s)
- Patrick A Smith
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A.; Columbia Orthopaedic Group, Columbia, Missouri, U.S.A..
| | - Dimitri M Thomas
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Ryan J Pomajzl
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A.; SSM Health Medical Group, Bridgeton, Missouri, U.S.A
| | - Jordan A Bley
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A
| | - Ferris M Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A.; Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
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48
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Noyes FR, Huser LE, Ashman B, Palmer M. Anterior Cruciate Ligament Graft Conditioning Required to Prevent an Abnormal Lachman and Pivot Shift After ACL Reconstruction: A Robotic Study of 3 ACL Graft Constructs. Am J Sports Med 2019; 47:1376-1384. [PMID: 30986093 DOI: 10.1177/0363546519835796] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) graft conditioning protocols to decrease postoperative increases in anterior tibial translation and pivot-shift instability have not been established. PURPOSE To determine what ACL graft conditioning protocols should be performed at surgery to decrease postoperative graft elongation after ACL reconstruction. STUDY DESIGN Controlled laboratory study. METHODS A 6 degrees of freedom robotic simulator evaluated 3 ACL graft constructs in 7 cadaver knees for a total of 19 graft specimens. Knees were tested before and after ACL sectioning and after ACL graft conditioning protocols before reconstruction. The ACL grafts consisted of a 6-strand semitendinosus-gracilis TightRope, bone-patellar tendon-bone TightRope, and bone-patellar tendon-bone with interference screws. Two graft conditioning protocols were used: (1) graft board tensioning (20 minutes, 80 N) and (2) cyclic conditioning (5°-120° of flexion, 90-N anterior tibial load) after graft reconstruction to determine the number of cycles needed to obtain a steady state with no graft elongation. After conditioning, the grafts were cycled a second time under anterior-posterior loading (100 N, 25° of flexion) and under pivot-shift loading (100 N anterior, 5-N·m internal rotation, 7 N·m valgus) to verify that the ACL flexion-extension conditioning protocol was effective. RESULTS Graft board tensioning did not produce a steady-state graft. Major increases in anterior tibial translation occurred in the flexion-extension graft-loading protocol at 25° of flexion (mean ± SD: semitendinosus-gracilis TightRope, 3.4 ± 1.1 mm; bone-patellar tendon-bone TightRope, 3.2 ± 1.0 mm; bone-patellar tendon-bone with interference screws, 2.4 ± 1.5 mm). The second method of graft conditioning (40 cycles, 5°-120° of flexion, 90-N anterior load) produced a stable conditioned state for all grafts, as the anterior translations of the anterior-posterior and pivot-shift cycles were statistically equivalent ( P < .05, 1-20 cycles). CONCLUSION ACL graft board conditioning protocols are not effective, leading to deleterious ACL graft elongations after reconstruction. A secondary ACL graft conditioning protocol of 40 flexion-extension cycles under 90-N graft loading was required for a well-conditioned graft, preventing further elongation and restoring normal anterior-posterior and pivot-shift translations. CLINICAL RELEVANCE There is a combined need for graft board tensioning and robust cyclic ACL graft loading before final graft fixation to restore knee stability.
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Affiliation(s)
- Frank R Noyes
- The Jewish Hospital-Mercy Health and The Noyes Knee Institute, Cincinnati, Ohio, USA
| | - Lauren E Huser
- The Jewish Hospital-Mercy Health and The Noyes Knee Institute, Cincinnati, Ohio, USA
| | - Brad Ashman
- The Jewish Hospital-Mercy Health and The Noyes Knee Institute, Cincinnati, Ohio, USA
| | - Michael Palmer
- The Jewish Hospital-Mercy Health and The Noyes Knee Institute, Cincinnati, Ohio, USA
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49
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Lian J, Novaretti JV, Sheean AJ, Patel NK, Whaley S, Popchak A, Musahl V. Static Lateral Tibial Plateau Subluxation Predicts High-Grade Rotatory Knee Laxity in Anterior Cruciate Ligament-Deficient Knees. Am J Sports Med 2019; 47:277-284. [PMID: 30525899 DOI: 10.1177/0363546518812435] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In anterior cruciate ligament-deficient (ACL-D) knees, injury pattern and bony morphologic features have been shown to influence both static anterior tibial subluxation relative to the femur and dynamic rotatory knee laxity. Therefore, the relationship between static anterior tibial subluxation and dynamic rotatory knee laxity was investigated. PURPOSE To determine whether static tibial subluxation as measured on magnetic resonance imaging (MRI) is associated with the grade of rotatory knee laxity in ACL-D knees. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS Two-hundred fifty-eight knees underwent preoperative, image-guided assessment of lateral knee compartment translation during quantitative pivot shift (QPS). Subluxations of the medial and lateral tibial plateaus were measured on preoperative MRI in a subset of primary ACL-D knees meeting criteria for high-grade (QPS > 5.2 mm) and low-grade (QPS < 2.4 mm) rotatory laxity. Tibial subluxations on MRI were compared between patients with high- and low-grade rotatory laxity through use of pairwise t test and were analyzed via univariate and multivariate logistic regression. Significance was set at P < .05. RESULTS On MRI, greater anterior subluxation of the lateral tibial plateau was observed in patients with high-grade compared with low-grade rotatory knee laxity (4.5 mm vs 2.3 mm; P < .05). No similar relationship was observed for the medial tibial plateau (-0.9 mm vs -0.4 mm; P > .05). Univariate logistic regression demonstrated that static subluxation of the lateral tibial plateau was associated with high-grade rotatory knee laxity (odds ratio [OR], 1.2; P < .05). An optimal cutoff of 2.95 mm of static lateral tibial subluxation was associated with high-grade rotatory knee laxity (sensitivity, 75%; specificity, 63%). Lateral meniscal injury was the first variable entered into a multivariate regression analysis and proved to be most associated with high-grade rotatory knee laxity (OR, 6.8; P < .05). When lateral meniscal injury was excluded from multivariate regression analysis, static anterior subluxation of the lateral tibial plateau alone was associated with high-grade rotatory knee laxity (OR, 1.2; P < .05). CONCLUSION Data from this MRI study of two distinct rotatory knee laxity groups showed that static anterior subluxation of the lateral tibial plateau of 2.95 mm or greater was associated with high-grade rotatory knee laxity, and each millimeter increase of lateral tibial plateau subluxation was associated with a 1.2-fold odds of high-grade rotatory knee laxity. Anterior subluxation of the lateral tibial plateau on MRI was not independently associated with high-grade rotatory knee laxity in the presence of concomitant lateral meniscal injury. Static measurements made preoperatively may aid in predicting high-grade rotatory knee laxity and refining the indications for individualized knee surgery.
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Affiliation(s)
- Jayson Lian
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Albert Einstein College of Medicine, Bronx, New York, USA
| | - João V Novaretti
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Orthopaedics and Traumatology Sports Center (CETE), Department of Orthopaedics and Traumatology, Paulista School of Medicine (EPM), Federal University of São Paulo, São Paulo, Brazil
| | - Andrew J Sheean
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Neel K Patel
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sean Whaley
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam Popchak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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50
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Hoshino Y, Miyaji N, Nishida K, Nishizawa Y, Araki D, Kanzaki N, Kakutani K, Matsushita T, Kuroda R. The concomitant lateral meniscus injury increased the pivot shift in the anterior cruciate ligament-injured knee. Knee Surg Sports Traumatol Arthrosc 2019; 27:646-651. [PMID: 30310925 DOI: 10.1007/s00167-018-5209-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/04/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE Concomitant meniscus injuries in the anterior cruciate ligament (ACL) have been suggested to exacerbate rotational laxity. However, the effect is supposed to be so small, if any, that some quantitative pivot-shift measurement is needed. The purpose of this prospective study was to determine the effect of meniscus tear on rotational laxity in ACL-deficient knees by an quantitative measurement. It was hypothesized that a concomitant meniscus tear, especially a lateral one, would induce greater pivot shift. METHODS Fifty-seven unilateral ACL-injured patients (26 men and 31 women, mean age: 24 ± 10 years) were included. The pivot-shift test was performed prior to ACL reconstruction, while a quantitative evaluation using an electromagnetic system to determine tibial acceleration and a clinical grading according to the IKDC were performed. Meniscus injuries were diagnosed arthroscopically, and concomitant meniscus tear was confirmed in 32 knees. RESULTS The clinical grade was not different between the ACL-injured knees of patients with and without meniscus tear (n.s.). Tibial acceleration did not show a statistical significant difference (meniscus-injured knees: 1.6 ± 1.1 m/s2 versus meniscus-intact knees: 1.2 ± 0.7 m/s2, n.s.). However, the subgroup analysis demonstrated that there was increased tibial acceleration in ACL-deficient knees with lateral meniscus tear (2.1 ± 1.1 m/s2, n = 13) compared with meniscus-intact knees (p < 0.05), whereas rotational laxity did not increase in the medial meniscus-injured and bilateral-injured knees (1.2 ± 0.9 m/s2, n = 12, n.s. and 1.4 ± 1.1 m/s2, n = 7, n.s., respectively). CONCLUSION A concomitant meniscus tear, especially a lateral meniscus tear, has a significant impact on rotational laxity in ACL-injured knees. When a large pivot shift is observed in the ACL-injured knee, a concomitant meniscus tear should be suspected and an aggressive treatment would be considered. Meniscus injuries should be inspected carefully when substantial pivot shift is encountered in ACL-injured knees. LEVEL OF EVIDENCE Diagnostic study, Level III.
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Affiliation(s)
- Yuichi Hoshino
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Nobuaki Miyaji
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kyohei Nishida
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | | | - Daisuke Araki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Noriyuki Kanzaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kenichiro Kakutani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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