Extra-articular Reconstruction Research Articles

Anterolateral Knee Extra-articular Stabilizers: A Robotic Sectioning Study of the Anterolateral Ligament and Distal Iliotibial Band Kaplan Fibers

Background: The individual kinematic roles of the anterolateral ligament (ALL) and the distal iliotibial band Kaplan fibers in the setting of anterior cruciate ligament (ACL) deficiency require further clarification. This will improve understanding of their potential contribution to residual anterolateral rotational laxity after ACL reconstruction and may influence selection of an anterolateral extra-articular reconstruction technique, which is currently a matter of debate. Hypothesis/Purpose: To compare the role of the ALL and the Kaplan fibers in stabilizing the knee against tibial internal rotation, anterior tibial translation, and the pivot shift in ACL-deficient knees. We hypothesized that the Kaplan fibers would provide greater tibial internal rotation restraint than the ALL in ACL-deficient knees and that both structures would provide restraint against internal rotation during a simulated pivot-shift test. Study Design: Controlled laboratory study. Methods: Ten paired fresh-frozen cadaveric knees (n = 20) were used to investigate the effect of sectioning the ALL and the Kaplan fibers in ACL-deficient knees with a 6 degrees of freedom robotic testing system. After ACL sectioning, sectioning was randomly performed for the ALL and the Kaplan fibers. An established robotic testing protocol was utilized to assess knee kinematics when the specimens were subjected to a 5-N·m internal rotation torque (0°-90° at 15° increments), a simulated pivot shift with 10-N·m valgus and 5-N·m internal rotation torque (15° and 30°), and an 88-N anterior tibial load (30° and 90°). Results: Sectioning of the ACL led to significantly increased tibial internal rotation (from 0° to 90°) and anterior tibial translation (30° and 90°) as compared with the intact state. Significantly increased internal rotation occurred with further sectioning of the ALL (15°-90°) and Kaplan fibers (15°, 60°-90°). At higher flexion angles (60°-90°), sectioning the Kaplan fibers led to significantly greater internal rotation when compared with ALL sectioning. On simulated pivot-shift testing, ALL sectioning led to significantly increased internal rotation and anterior translation at 15° and 30°; sectioning of the Kaplan fibers led to significantly increased tibial internal rotation at 15° and 30° and anterior translation at 15°. No significant difference was found when anterior tibial translation was compared between the ACL/ALL- and ACL/Kaplan fiber–deficient states on simulated pivot-shift testing or isolated anterior tibial load. Conclusion: The ALL and Kaplan fibers restrain internal rotation in the ACL-deficient knee. Sectioning the Kaplan fibers led to greater tibial internal rotation at higher flexion angles (60°-90°) as compared with ALL sectioning. Additionally, the ALL and Kaplan fibers contribute to restraint of the pivot shift and anterior tibial translation in the ACL-deficient knee. Clinical Relevance: This study reports that the ALL and distal iliotibial band Kaplan fibers restrain anterior tibial translation, internal rotation, and pivot shift in the ACL-deficient knee. Furthermore, sectioning the Kaplan fibers led to significantly greater tibial internal rotation when compared with ALL sectioning at high flexion angles. These results demonstrate increased rotational knee laxity with combined ACL and anterolateral extra-articular knee injuries and may allow surgeons to optimize the care of patients with this injury pattern.

The Role of Extra-Articular Tenodesis in Combined ACL and Anterolateral Capsular Injury.

The "gold standard" treatment of anterolateral capsular injuries in anterior cruciate ligament (ACL)-deficient knees has not been determined. The purpose of this study was to determine the effects of ACL reconstruction and extra-articular reconstruction on joint motion in the ACL-deficient knee and in the combined ACL and anterolateral capsule-deficient knee. An anterior tibial load of 134 N and internal tibial torque of 7 Nm were applied to 7 fresh-frozen cadaveric knees using a robotic testing system continuously throughout the range of flexion. The resulting joint motion was recorded for 6 knee states: intact, ACL-deficient, ACL-reconstructed, combined ACL and anterolateral capsule-deficient, ACL-reconstructed + anterolateral capsule-deficient, and ACL-reconstructed + extra-articular tenodesis. Anterior tibial translation of the ACL-reconstructed + anterolateral capsule-deficient knee in response to an anterior tibial load was restored to that of the intact knee at all knee-flexion angles (p > 0.05). However, for this knee state, internal tibial rotation in response to internal tibial torque was not restored to that of the intact knee at 60° or 90° of knee flexion (p < 0.05). For the knee state of ACL-reconstructed + extra-articular tenodesis, internal rotation in response to internal tibial torque was restored to the motion of the intact knee at each of the tested knee-flexion angles (p > 0.05). Compared with the intact knee, 2 of 7 specimens showed decreased internal tibial rotation with ACL reconstruction + extra-articular tenodesis. In this study, an extra-articular tenodesis was necessary to restore rotatory knee stability in response to internal tibial torque in a combined ACL and anterolateral capsule-deficient knee. The amount of rotatory knee instability should be carefully assessed to avoid over-constraint of the knee in these combined ligament-reconstruction procedures. On the basis of our findings, the surgical procedure needs to be personalized depending on the amount of rotatory knee instability in the injured knee and the amount of rotation in the contralateral knee.

Prospective study of arthroscopic reconstruction of anterior cruciate ligament with quadrupled semitendinosus autograft

Background: In contrast to old time in today’s world of competitive sports and vehicular accidents twisting injuries to knee joints causing ligament and meniscal tears are a common occurrence. Being a prime stabilizer of the knee joint anterior cruciate ligament is truly “crucial” for normal functioning and stability of knee. It is responsible for prevention of forward displacement of tibia on the femur as well as prevention of hyperextension and excessive internal rotation of tibia. Additionally it acts as restraint on valgus and varus stress in all degrees of flexion and fine-tunes the screw home motion as the tibia approaches terminal extension. Rupture of ACL, unless properly reconstructed, can have catastrophic consequences for knee stability. The methods of reconstruction of a ruptured ACL include intra-articular reconstruction, extra-articular reconstruction and combined intra-articular and extra-articular reconstruction. With advances in arthroscopy intra-articular reconstruction is fast becoming procedure of choice due to less morbidity and prospect of an early mobilization. Recent studies have shown that four stranded semitendinosus tendon graft have similar strength and stiffness characteristics as that of normal anterior cruciate ligament. We conducted this study to evaluate the result of arthroscopic reconstruction of anterior cruciate ligament with quadrupled semitendinosus autograft and complications associated with this procedure. Materials and Methods: After obtaining approval from institutional ethical committee we conducted a prospective study of 30 patients who had been admitted to our institute with pain, limp and instability due to anterior cruciate ligament rupture. Patients were enrolled on the basis of pre-defined inclusion criteria and any patient having any exclusion criteria was excluded from the study. X-Ray and MRI (if required) were done. Detailed history, thorough clinical examination and baseline investigations were done. All patients underwent ACL reconstruction by semitendinosus autograft. The outcome of arthroscopic reconstruction with quadrupled semitendinosus autograft and complications associated with this procedure were studied. The data was tabulated and analyzed using SPSS 16.0 version software. Results: This study consisted of 30 patients having been diagnosed with anterior cruciate ligament rupture. There were 27 men and 3 women with a M: F ratio of 1: 0.11. The most common age group involved was 31-35 years (30%) followed by 20-25 years (26.67%) and 26-30 years (16.67%). Road traffic accidents (46.67%) and Sports injuries (43.33%) were the predominant causes of ACL rupture. Most patients (26.67%) presented within 6 months of injury. Associated meniscal injuries were seen in 11 (36.67%) patients and medial meniscus (20%) was found to be involved more commonly than lateral meniscus (16.67%). Majority of the patients received 9 mm graft (60%). Most of the patients were discharged from hospital within 1 week (53.33%) while 9 patients (30%) needed to be kept in hospital for up to 2 weeks. Only 5 patients (16.67%) required hospitalization beyond 2 weeks. Pre-operative Tenger- Lysholm score was poor in majority of the patients (73.33%). Post-operatively at the time of 6 months follow up majority of the patients (66.67%) had an excellent Tenger-Lysholm score. No major complications were encountered in any of our patients. Minor complication like wound infection at the graft site (2/30), wound edge necrosis (2/30), foot drop (1/30), chemical burn under the tourniquet (1/30) and synovitis (1/30) were seen in some patients. All these complication resolved with proper management and no residual complications were seen in any of the patients. Conclusion: Arthroscopic reconstruction of ruptured anterior cruciate ligament by quadrupled semitendinosus autograft is associated with good functional results and excellent outcome. Minor complications associated with the procedure can be taken care of by appropriate management.

Anatomical and morphological features associated with high grade pivot shift

The pivot shift test is the most specific physical examination to assess the rotatory laxity of knee joint following anterior cruciate ligament injury. It is also one of the most important physical examinations to assess the stability and recovery of the knee joint after anterior cruciate ligament reconstruction. The following anterior lateral structures of knee joint contribute to the grade of the pivot shift, including the lateral meniscus, anterolateral capsule, iliotibial band and the morphology of tibial plateau. Lateral meniscus is a secondary stabilizer to rotatory loads in the anterior cruciate ligament deficient knee. Anterolateral capsule controls anterior tibial translation and internal rotation. Iliotibial band is an important secondary restraint to anterior tibial translation and internal rotation at high flexion angles. Posteroinferior slope of the tibial plateau results in increased anterior tibial translation during pivot shift. The size of the lateral tibial plateau is also associated with the grade of poivt shift. The integrity destruction of the anterolateral soft tissue in the anterior cruciate ligament deficient knee leads to higher grade of poivt shift. The morphological features of the tibial plateau can also affect the stability of the knee joint. However, there is still a paucity of knowledge about the anatomical and morphological features responsible for a high grade pivot shift. Higher grade pivot shift indicates the injury of anterolateral structures and the abnormality of tibial plateau. In order to restore the integrity of anterolateral soft tissue, the injury of lateral meniscus and iliotibial band should be repaired via anterior cruciate ligament reconstruction surgery with an addition of a lateral extraarticular reconstruction when the anterior cruciate ligament deficiency combined with injuries to anterolateral capsule.

Short-term complications in intra- and extra-articular anterior cruciate ligament reconstruction. Comparison with the literature on isolated intra-articular reconstruction. A multicenter study by the French Arthroscopy Society

IntroductionLateral tenodesis (LT) is performed to limit the risk of iterative tear following anterior cruciate ligament (ACL) reconstruction in at-risk patients. By adding an extra procedure to isolated ACL graft, LT reconstruction increases operating time and may complicate postoperative course. The objective of the present study was to evaluate the rate of early complications. The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction. Material and methodsA prospective multicenter study included 392 patients: 70% male; mean age, 29.9 years; treated by associated ACL and LT reconstruction. All adverse events were inventoried. ResultsMean hospital stay was 2 days, with 46% day-surgery. Walking was resumed at a mean 27 days, with an advantage for patients treated by the hamstring technique. The early postoperative complications rate was 12%, with 1.7% specifically implicating LT reconstruction: pain, hematoma, stiffness in flexion and extension, and infection. There was a 5% rate of surgical revision during the first year, predominantly comprising arthrolysis for extension deficit. The 1-year recurrence rate was 2.8%. DiscussionThe complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction, with no increase in infection or stiffness rates. The rate of complications specific to ALL reconstruction was low, at 1.7%, and mainly involved fixation error causing lateral soft-tissue impingement. Level of evidenceIV, prospective multicenter study.

Midterm results of combined intra- and extra-articular ACL reconstruction compared to historical ACL reconstruction data. Multicenter study of the French Arthroscopy Society

IntroductionDuring anterior cruciate ligament (ACL) reconstruction procedures, anterolateral reconstruction (ALR) can also be performed to improve the knee's rotational stability. However, the effectiveness of this supplemental technique and its impact on the risk of retears and on the onset of secondary degenerative changesare controversial. HypothesisALR improves control over the pivot shift, reduces the retear risk and delays the appearance of secondary degenerative lesions. Material and methodsClinical examination, knee laxity measurements and X-ray evaluations were done in 478 patients with more than 3years’ follow-up after combined ACL and ALR from 11 participating hospitals. The mean patient age at the time of surgery was 28years. Eighty-eight percent of the patients participated in pivot sports and 45% were competitive athletes. The findings of this study were compared to historical isolated ACL reconstruction data. ResultsThe average follow-up was 6.8years. No detectable pivot shift was found in 83% of patients, while 12.8% of patient had a smooth glide. The side-to-side difference in anteroposterior knee laxity with maximum manual force was less than 3mm in 66% of patients and less than 5mm in 95%. The retear rate was 5.4%, with half of these patients undergoing revision ACL surgery. Secondary meniscus damage requiring surgery occurred in 6.3% of patients; the radiological osteoarthritis rate was 17.5%. DiscussionWhen compared to historical ACL reconstruction data, combined intra- and extra-articular reconstruction does not increase the complication rate. At a mean follow-up of 6.8years, it provides better control over the pivot shift along with a low retear rate and low occurrence of secondary meniscus injuries. Level of evidenceIV, multicenter study.

Combined Anatomic Anterior Cruciate Ligament and Double Bundle Anterolateral Ligament Reconstruction

The results of arthroscopic anterior cruciate ligament (ACL) reconstruction are so far satisfactory and improving over time as a result of the improved understanding of the anatomy and biomechanics of the ACL. Rotational instability confirmed by a positive pivot shift is present in more than 15% of cases who underwent successful ACL reconstruction. Persistent rotational instability interferes with performing pivoting sports, and also may lead to meniscal and chondral injuries, or re-rupture of the reconstructed ACL. Surgeons reconsidered the anatomy and biomechanics of the ACL and introduced the double bundle ACL reconstruction technique aiming to achieve a more rotational control by reconstructing the anteromedial and anterolateral bundles of the ACL. To date, the results of double bundle ACL reconstruction are mixed and inconsistent. The improved understanding of the existence, function, and biomechanical role of the anterolateral ligament (ALL) in controlling the rotational instability of the knee has redirected and refocused attention on a supplemental extra-articular reconstruction of the ALL in conjunction with the intra-articular ACL reconstruction so as to restore normal kinematics of the knee. In this Technical Note, we describe a technique that allows for a combined ACL and double bundle ALL reconstruction using autogenous hamstring graft (semitendinosus and gracilis) tendons. This technique is an extension of our previously described technique of a combined anatomic ACL and single bundle ALL reconstruction. The improved understanding of the anatomy of the ALL makes a double bundle ALL reconstruction more anatomic than single bundle ALL reconstruction, as the native ALL is triangular or inverted Y in shape, with a narrow proximal femoral attachment and a broad distal tibial attachment between Gerdy's tubercle and the head of the fibula.

An in Vivo Simulation of Isometry of the Anterolateral Aspect of the Healthy Knee.

To assess the isometry of theoretical lateral extra-articular reconstruction (LER), we evaluated theoretical grafts attached to various points on the lateral femoral condylar area and to either Gerdy's tubercle or the anatomic attachment site of the anterolateral ligament to the tibia. In 18 subjects, healthy knees with no history of either injury or surgery involving the lower extremity were studied. The subjects performed a sit-to-stand motion (from approximately 90° of flexion to full extension), and each knee was studied using magnetic resonance and dual fluoroscopic imaging techniques. The 3-dimensional wrapping paths of each theoretical LER graft were measured. Grafts showing the least change in length during the sit-to-stand motion were considered to be the most isometric. The most isometric attachment site on the lateral femoral epicondyle to either of the studied tibial attachment sites was posterior-distal to the femoral attachment site of the fibular collateral ligament. The LER graft had a mean change in length of approximately 3%. Moving the femoral attachment site anteriorly resulted in increased length of the graft with increasing flexion; more posterior attachment sites resulted in decreased length with increasing flexion. Moving the attachment site in the proximal-distal direction had a less profound effect. Moving the tibial attachment site from Gerdy's tubercle to the tibial attachment site of the anterolateral ligament affected the overall isometric distribution on the lateral femoral epicondyle. The most isometric attachment site on the femur for an LER would be posterior-distal to the femoral attachment site of the fibular collateral ligament. Different length changes for LER grafts were identified with respect to different femoral attachment sites. Desirable graft fixation locations for treating anterolateral rotatory instability were found posterior-proximal to the femoral fibular collateral ligament attachment. The present data could be used both in biomechanical studies and in clinical studies as guidelines for planning LER surgical procedures.

Role of the anterolateral complex in rotatory instability of the anterior cruciate ligament deficient knee

The anterolateral complex (ALC) of the knee plays an important role in rotatory knee stability, especially in anterior cruciate ligament (ACL)-deficient patients. There is considerable awareness of anterolateral rotatory instability secondary to reported high failure rates after ACL reconstruction. As such, there has been a renewed interest in lateral extra-articular reconstruction procedures to stabilize the ALC. The concept of lateral extra-articular tenodesis (EAT) as the sole treatment of ACL injuries was popular in the 1970s, but fell out of favor due to unacceptably poor long-term outcomes. However, as greater understanding of rotatory knee instability has evolved, lateral stabilization procedures similar to those described in the 1970s have emerged to augment ACL reconstruction. These additional soft tissue techniques are not without risk, as many studies have demonstrated knee over-constraint after these procedures. Therefore, it is prudent to take an individualized approach to ACL reconstruction and to assess the value of additional soft tissue procedures in the face of persistent rotatory laxity. This review will address the role of the ALC in rotatory knee injury, the difficulty in diagnosing these injuries, and provide an objective review of additional stabilizing procedures after ACL reconstruction.

Clinical outcomes of extra-articular tenodesis/anterolateral reconstruction in the ACL injured knee.

The role of concomitant extra-articular procedures in improving the outcome of ACL reconstruction has experienced a recent resurgence in interest. The aim of this article is to highlight the differences in philosophies and outcomes of historical lateral extra-articular tenodesis (LET) and contemporary, anterolateral reconstruction. A narrative review was performed using PubMed/MEDLINE using the keywords "lateral extra-articular tenodesis" and "anterolateral ligament reconstruction". Results of search strategy: Thirty-seven studies [13 reporting clinical outcomes of isolated LET in ACL deficient knees and 24 comparing isolated anterior cruciate ligament reconstruction (ACLR) with ACLR+LET] and 1 study on anterolateral ligament (ALL) reconstruction were identified as relevant and included in the review. Results of literature review: Isolated extra-articular reconstructions are rarely performed in contemporary practice. They are associated with a high rate of persistent anterior instability and early degenerative change. Combined ACL reconstruction and lateral extra-articular tenodeses results in a significant reduction in the prevalence of residual pivot shift, but the majority of the studies do not demonstrate any significant difference with respect to patient-reported outcome measures and return to sport. Although several authors report a trend towards decreased graft rupture rates, significant differences were not demonstrated in most studies. In a single clinical study, combined anatomic ACL and anterolateral ligament reconstruction was reported to be associated with a threefold reduction in graft rupture rates and improved return to sport compared to isolated ACL graft choices. Historically performed, combined ACL reconstruction and lateral extra-articular tenodeses are associated with improved knee kinematics. Although trends towards decreased graft rupture rates are reported by several authors, the majority did not demonstrate a significant difference, likely as a result of small and underpowered studies using post-operative immobilisation and delayed rehabilitation protocols. More recently, combined ACLR and ALL reconstruction has been shown to be associated with significant improvements in graft failure and return to sport rates when compared to isolated ACLR. However, these results are from a single clinical series with only medium-term follow-up. IV.

Combined Anatomic Reconstruction of the Anterior Cruciate and Anterolateral Ligaments Using Hamstring Graft Through a Single Femoral Tunnel and With a Single Femoral Fixation

Patients with complete anterior cruciate ligament (ACL) injury have different degrees of rotational (internal rotation) laxity. A residual pivot shift has been found to be positive in more than 15% of cases after an accurate ACL reconstruction. Improved understanding of the existence, function, and biomechanical role of the anterolateral ligament (ALL) in controlling rotational instability of the knee has redirected and refocused attention on a supplemental extra-articular reconstruction of the ALL in conjunction with the intra-articular ACL reconstruction so as to restore normal kinematics of the knee. This Technical Note describes a technique that allows for a combined ACL and ALL reconstruction using autogenous hamstring graft (semitendinosus and gracilis tendons). One femoral tunnel is used connecting the anatomic femoral attachment of the ALL on the lateral wall of the lateral femoral condyle to the anatomic femoral ACL footprint on the medial wall of the lateral femoral condyle. The remaining part of the graft is fixed to the proximal tibia midway between Gordy's tubercle and the head of the fibula. This Technical Note describes a technique of both ACL and ALL reconstruction with a continuous hamstring graft.

Minimally Invasive Combined Anterior and Anterolateral Stabilization of the Knee Using Hamstring Tendons and Adjustable-Loop Suspensory Fixation Device: Surgical Technique

Despite the numerous techniques described regarding isolated anterior cruciate ligament (ACL) reconstruction, many authors have reported that residual knee rotational instability is not always eliminated. The combination of lateral extra-articular knee tenodesis and ACL reconstruction is an alternative surgical approach with very promising clinical results. The purpose of this article is to describe a reliable and reproducible technique of combined ACL reconstruction and lateral extra-articular knee tenodesis using a continuous looped hamstring tendon autograft. A 4-strand graft inside the joint and a 2-strand graft for the tenodesis are attached to 2 adjustable-loop button suspensory fixation devices.

The Fascia Lata Anterolateral Tenodesis Technique

A technique for anatomic reconstruction of the anterolateral complex addressing anterolateral rotatory instability both in primary anterior cruciate ligament reconstruction and in revision cases is presented. The extra-articular reconstruction is performed with a pedicle strip of iliotibial tract, fixed on the anatomic origin and insertion points of the anterolateral ligament of the knee in a double-bundle V-shaped fashion.

Salvage of dislocated hip and knee during limb lengthening for congenital femoral deficiency

Background The articular and soft tissue deficiencies associated with congenital femoral deficiency are reported to predispose to joint dislocation during limb lengthening, which would negate the value of limb lengthening. Patients and methods The cases of 17 children who suffered hip and/or knee dislocation as a result of femoral lengthening for congenital femoral deficiency of Paley’s classification type 1 and 2a were included. Their ages ranged from 4.5 to 13 years (average: 6.8 years). The average lengthening achieved at the time of diagnosis of the dislocation was 5.7±1.048 cm (range: 4.5–8 cm). Hip dislocation only was present in seven (41%) cases, knee dislocation only in six (35%) cases, and combined dislocation in four (24%) cases. Results A center-edge angle of Wiberg less than 22° had a highly significant effect on hip dislocation (P=0.001), and all knee dislocations were associated with a hypoplastic lateral femoral condyle. Both joint dislocations were common when the child had a center-edge angle of 15–20° together with a hypoplastic lateral femoral condyle. Discussion and conclusion Hip dislocations were managed with soft tissue release and pericapsular acetabuloplasty with satisfactory Mckay’s hip scores in all cases. Knee dislocations were reduced and stabilized by means of extra-articular ligament reconstruction with satisfactory Judet’s knee criteria in 82% of cases.

Minimally Invasive Anterolateral Ligament Reconstruction of the Knee

Anterior cruciate ligament (ACL) tears are among the most common knee injuries, and multiple reconstructive techniques have been described. However, studies frequently report an inability to duplicate native, dynamic knee function, particularly rotationally. This residual joint laxity that occasionally follows an ACL reconstruction can cause further problems post surgical intervention, including meniscal tears and especially late osteoarthritic change. Additionally, ACL graft retears are a concern, particularly in young patients. Although these undesired sequelae of ACL reconstruction could be a by-product of insufficient ACL reconstruction methods related to either graft placement or problems with graft healing and biology, it is also possible that failure to additionally address lateral extra-articular structures after ACL injury could play a role in the residual knee laxity of the affected knee. The purpose of this article is to show a minimally invasive technique for extra-articular anterolateral ligament reconstruction.

In Vivo Length Changes of the Anterolateral Ligament and Related Extra-articular Reconstructions

Background: Both anatomic anterolateral ligament (ALL) and nonanatomic anterolateral reconstructions are performed to improve the stability of anterior cruciate ligament (ACL)–deficient patients. However, the in vivo length change patterns and isometry of these anterolateral reconstructions are unknown. Purpose: To measure the theoretical length change patterns of the ALL and various anterolateral extra-articular reconstructions in healthy and ACL-deficient knees during in vivo weightbearing flexion. Study Design: Controlled laboratory study. Methods: Ten patients with an ACL injury in 1 knee and the contralateral side intact were included. By use of magnetic resonance and dual fluoroscopic imaging techniques, the changes in length of the ALL, modeled with its femoral attachment either anterior or posterior-proximal to the fibular collateral ligament (FCL) attachment, and nonanatomic extra-articular reconstructions were measured as a function of knee flexion and were compared between the intact and ACL-deficient knees. Results: The ALL, with its femoral attachment anterior to the FCL attachment, showed a consistent length increase of approximately 50% from 0° to 90° of knee flexion. The length change of the ALL was 20% ± 6% when its femoral attachment was placed posterior-proximal to the FCL. ACL deficiency did not affect ALL length. Even minor shifts in position around the rotational axis of the femur resulted in contrary ligament kinematic patterns. An extra-articular reconstruction with the femoral attachment proximal to the lateral epicondyle and the tibial attachment on the Gerdy tubercle increased 15% ± 4% in length from 0° to 60° and shortened at 90° of flexion. When the tibial fixation of the anatomic ALL with its femoral attachment posterior to the FCL was moved to the Gerdy tubercle, a 30% ± 4% length increase over 90° occurred, without the decrease in length at 90°. A significant length increase of both theoretical reconstruction grafts was seen at 0° in ACL-deficient knees. Conclusion: An anatomic ALL reconstruction as modeled based on recent anatomic studies was not isometric during in vivo knee flexion and was not affected by ACL deficiency. The nonanatomic extra-articular reconstructions demonstrated more biomechanically favorable length change patterns with the smallest percentage increase in elongation during knee flexion. Clinical Relevance: This study presents the first in vivo biomechanical data on the ALL, in both healthy and ACL-deficient knees, and provides surgical information that may be valuable for restoring normal anterolateral stability.

Anterior cruciate ligament – updating article

This updating article on the anterior cruciate ligament (ACL) has the aim of addressing some of the most interesting current topics in this field. Within this stratified approach, it contains the following sections: ACL remnant; anterolateral ligament and combined intra and extra-articular reconstruction; fixation devices; and ACL femoral tunnel creation techniques.

Combined Intra-articular and Extra-articular Reconstruction in Anterior Cruciate Ligament–Deficient Knee: 25 Years Later

To determine whether an anterior cruciate ligament (ACL)-reconstructed knee with hamstring autograft has a greater incidence of degenerative changes when an extra-articular reconstruction is added and to determine the effect of the combined reconstruction on knee stability and function at long-term follow-up. For this retrospective study, patients who underwent ACL reconstruction between January 2002 and December 2003 were selected and classified into 2 groups, I and II. Group I consisted of patients operated by a standard ACL reconstruction, and group II consisted of patients in whom, owing to the presence of risk factors (severe pivot shift graded+++ or high-risk sports), an extra-articular reconstruction performed with ileo-tibial tract according to McIntosh as modified by Cocker Arnold technique, was used in conjunction with intra-articular ACL reconstruction. At final follow-up, Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores were used. An arthrometric KT-1000 evaluation was done. Comparative weight-bearing radiographs were taken, including a skyline view for the patellofemoral joint and analyzed according to Fairbank, Kellgren, and IKDC classification. Seventy-two of the 75 (96%) patients in group I and 68 of the 75 patients in group II were available at the final follow-up (minimum 10years). Subjective scores improved significantly in both groups, with no significant difference. Objectively, the number of patients receiving C and D IKDC objective activity scores in group I (7/56; 12.5%) was significantly higher than in group II (0/60) (P= .01). Considering as a failure a side-to-side arthrometric difference more than 5mm or a pivot shift test graded as++ or+++, or any giving way episode occurring postoperatively, we found 8 cases in group I and no cases in group II (P= .01) despite the presence of risk factors that group I did not include. Radiologic evaluation showed less arthritic changes in group II in both tibiofemoral and patellofemoral joints. On the basis of the results of this study, adding an extra-articular reconstruction to an anatomically placed intra-articular ACL reconstruction, followed by a modern rehabilitation protocol, does not increase the risk of osteoarthritis and may be able to reduce the rate of failure. Level III, retrospective comparative study.

Extra-articular procedures for the ACL-deficient knee: a state of the art review

Some patients have continued rotatory instability following intra-articular anterior cruciate ligament (ACL) reconstruction, which limits their functional abilities. Advanced surgical techniques, such as double-bundle reconstruction and anteromedial portal drilling, have not solved this problem. This has led many surgeons to revisit the use of extra-articular procedures to control rotatory laxity. Multiple anatomic studies have confirmed the presence of an anterolateral ligament (ALL) that attaches to the tibia at the site of the Segond fracture. The biomechanical importance of this ligament is still being debated. Extra-articular reconstructions decrease the forces produced by intra-articular ACL grafts. Patients likely to benefit from additional extra-articular reconstruction are: (1) those with high-grade pivot shifts; (2) patients with previous failed ACL reconstructions without an obvious cause; (3) participants in contact sports and (4) patients in subgroups that have a high risk of failure (eg, generalised laxity). A variety of extra-articular reconstructions have been developed. Those techniques that have long-term follow-up data were described before most current orthopaedic surgeons were in practice. The available evidence suggests that performing an additional extra-articular reconstruction can improve rotational stability in patients undergoing intra-articular ACL reconstructions. Newer ‘anatomic’ reconstructions of the ALL have recently been proposed but there are limited data on their effectiveness. Currently, there are no studies comparing different extra-articular procedures.

Reconstrucción mínimamente invasiva del ligamento anterolateral

IntroductionAnteroposterior instability and rotatory laxity demonstrated by severe pivot-shift test may be caused by combined lesions of the anterior cruciate ligament (ACL) and lateral structures of the knee, particularly the anterolateral ligament (ALL). This ligament acts as a secondary stabiliser that restrains internal rotation and supplements the primary stabilising role of the ACL. Materials and methodsTo describe a minimally invasive ALL reconstruction technique following anterior cruciate ligament revision surgery. Brief description of surgical indications, outcomes, and complications. DiscussionPersistent rotatory instability after ACL reconstruction suggests that intra-articular reconstruction may not be sufficient to restore rotational stability in a subgroup of patients. Numerous extra-articular reconstruction techniques have been described with long incisions and cosmetic issues. A description is presented of a simple, minimally invasive ALL reconstruction technique performed after anatomical ACL revision in a single procedure. This technique is indicated in patients with acute ACL injuries and revision ACL associated with a severe pivot-shift, chronic ACL injuries, and joint hyper-laxity. Although this technique has not proven to be superior to any other extra-articular anterolateral ligament reconstructions, it uses simple, reliable and cosmetic surgery, with good early results in a small series of patients.