Improved Knee Stability Research Articles

Strategies for Preventing Tunnel Convergence in Multiligament Knee Injury Reconstructions.

Multiligament knee injuries (MLKIs) are complex and heterogeneous, often associated with concomitant injuries, and necessitates precise treatment strategies. Effective preoperative management in MLKIs requires comprehensive evaluation, starting with a detailed patient history to identify the mechanisms of injury and prior treatments. Physical examination assesses for knee stability, while imaging techniques including magnetic resonance imaging (MRI) and radiographs detail ligament, cartilage, and meniscal injuries to identify all injured structures. Vascular evaluations are critical given the high risk of concomitant neurovascular injuries especially in dislocated knees, bicruciate injuries, and lateral-sided injuries. Anatomic reconstruction of the torn ligaments has been biomechanically and clinically validated to improve knee stability and function. When performing multiple anatomic reconstructions, the risk of tunnel convergence is high. Therefore, surgical intervention aimed at optimizing outcomes necessitates careful planning to avoid tunnel convergence. This involves strategic tunnel placement, orientation, and techniques, such as adjusting tunnel angulation and using intraoperative imaging. These measures are vital for restoring knee functionality and minimizing future complications. Managing tunnel convergence is vital in treating MLKIs. Avoiding convergence on the medial side of the femur and tibia is more challenging due to the number of tunnels. In an MLKI involving all ligaments, 4 femoral tunnels and 4 tibial tunnels are required on the medial side, compared to 3 on the femur and 1 on the tibia for the lateral side, respectively. The successof a multiligament knee reconstruction depends on a precise diagnosis, thorough preoperative management, and strategic tunnel placement. A multidisciplinary approach not only enhances surgical outcomes, but also ensures long-term improvement in knee function, effectively addressing the complexities and risks associated with these injuries.

Comparison of femoral tunnel position and knee function in anterior cruciate ligament reconstruction: a retrospective cohort study using measuring-fluoroscopy method versus bony marker method

BackgroundPrevious studies have shown that surgical technique errors especially the wrong bone tunnel position are the primary reason for the failure of anterior cruciate ligament (ACL) reconstruction. In this study, we aimed to compare the femoral tunnel position and impact on knee function during the ACL reconstruction using measuring combined with fluoroscopy method and bony marker method for femoral tunnel localization.MethodsA retrospective cohort study of patients undergoing ACL reconstruction using the bony marker method or measuring combined with fluoroscopy for femoral tunnel localization was conducted between January 2015 and January 2020. A second arthroscopic exploration was performed more than 1 year after surgery. Data regarding patient demographics, the femoral tunnel position, results of the Lysholm score, the International Knee Documentation Committee (IKDC) score, KT-1000 side-to-side difference, pivot shift grade, and Lachman grade of the knee were collected.ResultsA total of 119 patients were included in the final cohort. Of these, 42 cases were in the traditional method group, and 77 cases were in the measuring method group. The good tunnel position rate was 26.2% in the traditional method group and 81.8% in the measuring method group (p < 0.001). At the final follow-up, the Lysholm and IKDC scores were significantly greater in the measuring method group than the traditional method group (IKDC: 84.9 ± 8.4 vs. 79.6 ± 6.4, p = 0.0005; Lysholm: 88.8 ± 6.4 vs. 81.6 ± 6.4, p < 0.001). Lachman and pivot shift grades were significantly greater in the measuring method group (p = 0.01, p = 0008). The results of KT-1000 side-to-side differences were significantly better in the measuring method group compared with those in the traditional method group (p < 0.001).ConclusionsThe combination of the measuring method and intraoperative fluoroscopy resulted in a concentrated tunnel position on the femoral side, a high rate of functional success, improved knee stability, and a low risk of tunnel deviation. This approach is particularly suitable for surgeons new to ACL reconstructive surgery.

Are 7 MM neoprene knee sleeves capable of modifying the knee kinematics and kinetics during box jump and front squat exercises in healthy CrossFit practitioners? An exploratory cross-sectional study

ObjectiveInvestigate whether wearing 7 mm neoprene knee sleeves during the front squat and box jump CrossFit exercises change the biomechanics of the knee joint. Designa cross-sectional exploratory study. SettingLaboratory-based. ParticipantsSeventeen male healthy CrossFit participants completed front squats and box jumps with knee sleeves (KS) and without knee sleeves (WKS). Main outcomes measuresKinematic and kinetic data of the knee in the sagittal, frontal and transverse planes were obtained for the two tasks and under the two experimental situations. The maximum load lifted on 1 MR test was recorded under KS and WKS conditions. The GROC scales were applied after each exercise and condition to assess participants' self-reported perception of stability. ResultsThe KS reduced the knee range of motion in the transverse plane during box jump (p = 0.029) and the peak knee external adduction moment (p = 0.047) during front squat compared to WKS. The 1RM during front squat increased in KS compared to WKS (p < 0.001). Most participants (94%) reported that they felt better stability using KS and all participants (100%) believed that knee sleeves would avoid knee pain. Conclusionneoprene knee sleeves have little impact on the biomechanics of the knee joint during CrossFit. However, participants reported improved knee stability.

Evaluating the Efficacy of Reconstruction: Systematic Review of Six-Strand Hamstring Autografts for Anterior Cruciate Ligament Reconstruction: Biomechanical and Clinical Outcomes

Introduction: Anterior Cruciate Ligament (ACL) injuries are a major concern in orthopedics, particularly affecting active individuals and often necessitating surgery. The incidence of ACL injuries is rising, especially in women, comprising half of knee joint injuries. These injuries, common in sports with pivoting actions, can lead to long-term joint issues like osteoarthritis. Advances in surgical methods and understanding of postoperative recovery are crucial for improving patient outcomes, with considerations for graft size, material, and reconstruction technique critical in the rehabilitation process. Material and Methods: A systematic review was conducted by searching PubMed, MEDLINE, and SCOPUS for studies from 2009 to 10 February 2024, focusing on “six-strand hamstring graft” outcomes in ACL reconstruction. Inclusion criteria were English publications on 6HS autografts’ biomechanical and clinical outcomes. Excluded were non-specific, BTB, or hybrid studies, and non-research articles. Out of 347 records, 9 were analyzed after rigorous screening and quality assessment. This review, emphasizing six-strand hamstring autografts, enriches orthopedic knowledge, particularly for ACL surgery. Results: This review evaluated studies on six-strand hamstring (6HS) autografts for ACL reconstruction, encompassing prospective, retrospective, and cadaveric studies with subjects ranging from 12 to 413. Findings indicate that 6HS autografts enhance knee stability and increase graft diameter, correlating with reduced graft failure rates and improved clinical outcomes, including high patient satisfaction and low re-injury rates. Rehabilitation varied, with recovery times quicker due to larger graft sizes, and most studies reported low complication rates, underscoring 6HS autografts’ efficacy in ACL surgery. Conclusions: Performing 6HS autografts in ACL reconstruction reveals that they offer improved knee stability and graft diameter, leading to better clinical outcomes. These autografts are associated with high patient satisfaction and low re-injury rates, suggesting their effectiveness in mimicking native ACL function and enhancing rehabilitation. However, research limitations highlight the need for further long-term, comprehensive studies.

Management of Medial Femorotibial Knee Osteoarthritis in Conjunction with Anterior Cruciate Ligament Deficiency: Technical Note and Literature Review.

In recent years, there has been increased interest in the management of medial femorotibial knee osteoarthritis (OA) in conjunction with anterior cruciate ligament (ACL) deficiency. Traditional treatment modalities included conservative therapy, high tibial osteotomy with or without ACL reconstruction, and total knee replacement. Since younger patients with higher physical demands are more likely to suffer from this pathological condition, reduced invasiveness, faster recovery time, and improved knee kinematics are preferred to allow for satisfying clinical and functional outcomes. Thus, a new surgical strategy combining medial unicompartmental knee replacement (UKR) and ACL reconstruction has been proposed to allow bone stock preservation, to reduce surgical morbidity and recovery time, and ultimately to improve joint kinematics and clinical outcomes. Based on the data present in the literature, in the setting of unicompartmental OA in association with ACL deficiency, UKR combined with ACL reconstruction provided encouraging early results. Studies evaluating the outcomes of combined ACL reconstruction and UKR demonstrate promising results in select patient populations. Improved knee stability, pain relief, functional recovery, and patient satisfaction improved after surgery. Moreover, the combined approach offered advantages such as reduced surgical trauma, faster rehabilitation, and preservation of native knee anatomy compared with traditional treatment strategies. However, still, high-level studies on this topic are lacking; therefore, more comparative studies reporting long-term outcomes are needed to support the potential of this combined procedure to become mainstream. In this paper, we discuss the relevant features and rationale behind the indications and technique of this combined surgical procedure, to help surgeons choose the correct therapeutic approach for a patient with concomitant medial OA and ACL insufficiency. Continued advancements in surgical techniques, patient selection criteria, and rehabilitation strategies will further enhance the success of this combined approach, offering hope to individuals with concomitant ACL injuries and unicompartmental knee OA.

An anteromedial stabilization procedure has the most protective effect on the anterior cruciate ligament in tibial external rotation. A human knee model study

IntroductionAnterior 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.MethodsInternal 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.ResultsThe 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.ConclusionThis 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.

New Anatomic Anterolateral Ligament Reconstruction Used in a Complex Revision ACL Reconstruction

Background: Anterior cruciate ligament reconstructions (ACLRs) are performed to restore knee biomechanics, increase knee stability, and slow the progression of osteoarthritis. After ACLRs, many patients still have residual anterolateral instability which is a risk factor for ACL graft failure. An anterolateral ligament reconstruction (ALLR) attempts to restore the native function of the anterolateral complex to augment the ACL. Performing an ALLR with an ACLR has been reported to reduce symptoms of instability and improve clinical outcomes. Indications: While no definitive indication for an ALLR has been set, current considerations include high posterior tibial slope &gt;12°, revision ACLR, high-grade pivot shift, skeletally immature patients, hyperlaxity, and patients in high-level sports. Technique Description: The preoperative assessment includes a thorough physical examination with special attention paid to rotational laxity assessed via the pivot-shift examination. Imaging should include standard radiographic series (anteroposterior, posteroanterior flexion, lateral, and sunrise views), long-leg mechanical axis views to assess coronal plane alignment and standing lateral ACL stress radiographs to assess sagittal alignment and objective instability. The iliotibial band ALLR graft is harvested first. An 8-cm long by 1-cm wide strip of the inferior iliotibial band is harvested in a standard fashion, leaving the distal aspect attached to Gerdy’s tubercle. An anchor is placed centered upon the native ALL distal tibial insertion. The native ALL femoral origin is identified at 4.7 mm posterior and proximal to the fibular collateral ligament, and a second suture anchor is placed at this point. Final fixation is performed after the final fixation of the ACLR graft. Results: A study by Pioger et al reported that patients with ACLR and ALLR had significantly less reoperation rate than patients with isolated ACLR, 8.9% versus 20.5% respectively. Lee et al found that a revision ACLR in combination with an ALLR was effective in reducing rotational laxity, which was assessed by the pivot-shift test. Discussion: We describe a technique for a new anatomic ALLR using the iliotibial band that attempts to restore the native ALL anatomy. This surgical technique effectively restores rotational laxity and improves knee stability. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Combined Anterior Cruciate Ligament Reconstruction (ACLR) and Lateral Extra-articular Tenodesis through the Modified Lemaire Technique versus Isolated ACLR: A Meta-analysis of Clinical Outcomes.

Objective Lateral extra-articular tenodesis (LET) has been proposed to resolve rotatory instability following anterior cruciate ligament reconstruction (ACLR). The present meta-analysis aimed to compare the clinical outcomes of ACLR and ACLR with LET using the modified Lemaire technique. Materials and Methods We performed a meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) staement. The literature search was performed on the PubMed, EBSCOHost, Scopus, ScienceDirect, and WileyOnline databases. The data extracted from the studies included were the study characteristics, the failure rate (graft or clinical failure) as the primary outcome, and the functional score as the secondary outcome. Comparisons were made between the patients who underwent isolated ACLR (ACLR group) and those submitted to ACLR and LET through the modified Lemaire technique (ACLR + LET group). Results A total of 5 studies including 797 patients were evaluated. The ACLR + LET group presented a lower risk of failure and lower rate of rerupture than the ACLR group (risk ratio [RR] = 0.44; 95% confidence interval [95%CI]: 0.26 to 0.75; I 2 = 9%; p = 0.003). The ACLR + LET group presented higher scores on the Knee Injury and Osteoarthritis Outcome Score (KOOS) regarding the following outcomes: pain, activities of daily living (ADL), sports, and quality of life (QOL), with mean differences of 0.20 (95%CI: 0.10 to 0.30; I 2 = 0%; p < 0.0001), -0.20 (95%CI: -0.26 to -0.13; I 2 = 0%; p < 0.00001), 0.20 (95%CI: 0.02 to 0.38; I 2 = 0%; p = 0.03), and 0.50 (95%CI: 0.29 to 0.71; I 2 = 0%; p < 0.00001) respectively when compared with the ACLR group. Conclusion Adding LET through the modified Lemaire technique to ACLR may improve knee stability because of the lower rate of graft rerupture and the superiority in terms of clinical outcomes. Level of Evidence I.

Comparative Study of Arthroscopic ACL Reconstruction with Peroneus Longus Autograft vs Hamstring Autograft

Introduction The ACL is 1 of 4 main ligaments in the knee. Ligaments are rope-like structures that connect and hold the bones together to keep the knee stable. There are two components of the ACL, the anteromedial bundle (AMB) and the posterolateral bundle (PLB). The ACL has a microstructure of collagen bundles of multiple types (mostly type I) and a matrix made of a network of proteins, glycoproteins, elastic systems, and glycosaminoglycans. The ACL is innervated by posterior articular branches of the tibial nerve and is vascularized by branches of the middle genicular artery. Anterior cruciate ligament (ACL) reconstruction improves knee stability and function. Phatama et al. reported that there was no significant difference between the peroneus longus and hamstring tendon in terms of tensile strength. Peroneus longus tendon autografts are commonly used in some orthopedic procedures, including spring ligament reconstruction, deltoid ligament reconstruction and medial patellofemoral ligament reconstruction. This is possible, due to the synergistic function of the peroneus longus and peroneus brevis. Some studies have even found that the peroneus brevis is a more effective evertor of the ankle, justifying the harvest of the peroneus longus tendon.

Evaluation of biomechanical properties and biocompatibility: are partially absorbable cords eligible for anterior cruciate ligament reconstruction?

Introduction: Independent augmentation technology based on reinforcing devices has been reported to signifi-cantly reduce the elongation behavior of graft and improve knee stability after anterior cruciate ligament reconstruction (ACLR). Using biodegradable devices could reduce the risk of severe inflammatory reactions due to particle accumulation from foreign bodies. Given the limitations of the mechanical properties of biodegradable materials, partially biodegradable composite devices may offer a compromise strategy. Methods: Three types of partially absorbable core-sheath sutures, including low-absorbable cord (LA-C), medium-absorbable cord (MA-C) and high-absorbable cord (HA-C), were braided using unabsorbable ultra-high molecular weight polyethylene (UHMWPE) yarn and absorbable polydioxanone (PDO) monofil-ament bundle based on the desired configuration. The feasibility of these partially absorbable cords were verified by biomechanical testing, material degradation testing, and cell experiments, all performed in vitro. Results: Reinforcement of an 8mm graft with the cords decreased dynamic elongation by 24%-76%, was positively related to dynamic stiffness, and increased the failure load by 44%-105%, during which LA-C showed maximum enhancement. Human ligament-derived fibroblasts showed good proliferation and vitality on each cord over 2weeks and aligned themselves in the direction of the fibers, especially the UHMWPE portion. Discussion: This study supports the potential of partially degradable UHMWPE/PDO cords, particularly LA-C, for graft protection. Nervertheless, a higher proportion of biodegradable material results in lower stiffness, which may impair the protective and lead to mechanical instability during degradation.

ALL Repair and Reconstruction: Techniques From the SANTI Study Group

Background: Combining an anterior cruciate ligament (ACL) reconstruction with an anterolateral ligament (ALL) reconstruction results in significant advantages including reduced graft rupture rates, a lower risk of reoperation for secondary meniscectomy, improved knee stability, and higher rates of return to preinjury levels of sport. Indications: The previously reported indications for combined ACL and ALL reconstruction are as follows: ACL reconstruction revision; high-grade pivot shift test; long-term ACL rupture; young patients; pivoting activities; concomitant medial meniscus repair, and, specifically, regarding the ALL repair, it must be an acute surgery (within 15 days from injury). Technique Description: Several modern techniques have been described to repair and reconstruct the ALL. This technical note details a number of these techniques performed by the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group. Results: First, we describe a combined ACL reconstruction and double-bundle ALL reconstruction using hamstring autograft. Secondly, we describe a single-bundle ALL reconstruction using gracilis autograft. Thirdly, we describe an ALL reconstruction technique using a knotless soft anchor, which provides shallow fixation and prevents tunnel convergence. Finally, we describe a technique for ALL repair. Conclusion: Several techniques have been described to repair and reconstruct the ALL, all offering significant advantages over an isolated ACL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Double-Bundle PCL Reconstruction in the Multiple-Ligament Injured Knee

Background: Multi-ligament knee injuries and knee dislocations are potentially devastating injuries that typically result in injury to both cruciate ligaments and variable injury to collateral ligament complexes. Indications: Surgical intervention typically leads to better patient outcomes than nonoperative management. We describe our preferred technique for bicruciate ligament reconstruction with a focus on double-bundle posterior cruciate ligament (PCL) reconstruction. Technique Description: A transtibial approach is used to drill the PCL tibial tunnel. A safety incision on the proximal medial tibia, which may incorporate the distal aspect of a medial-sided incision for medial collateral ligament (MCL) reconstruction, allows palpation of the PCL fovea for anatomic tunnel placement, protection of the posterior neurovascular structures, and egress of arthroscopic fluid during the case. This technique uses an inside-out approach for creation of the 2 femoral sockets to recreate the 2 PCL bundles. The grafts are passed in antegrade fashion, with passage and femoral fixation of the posteromedial (PM) bundle followed by the anterolateral (AL) bundle. After passage of the anterior cruciate ligament (ACL) graft and fixation on the femur in standard fashion, attention is turned to PCL tibia-sided fixation. We use a screw and spiked washer to fix the AL bundle at 90° of flexion with an anterior drawer maneuver. The PM bundle is then fixed with a polyetheretherketone (PEEK) interference screw in near full extension. Fixation of the ACL on the tibia in standard fashion completes the bicruciate ligament reconstruction. Results: In biomechanical cadaveric studies, double-bundle PCL reconstruction has been shown to more closely approximate native knee kinematics, with more restraint to posterior translation at all knee flexion angles and less internal rotation laxity at higher knee flexion angles. In clinical results, both single-bundle and double-bundle reconstructions improve knee stability and patient-reported outcomes. Double-bundle PCL reconstruction may provide improved objective posterior tibial stability and objective International Knee Documentation Committee (IKDC) scores. Discussion: Double-bundle PCL reconstruction can be performed efficiently with good outcomes and potentially less residual posterior translation or internal rotation laxity than single-bundle PCL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Diagnostic Accuracy of Fine Needle Aspiration Cytology for Evaluation of Breast Lump Compared to Trucut Biopsy

Background: The primary issue after isolated intra-articular anterior cruciate ligament (ACL) surgery is the continuation of pivot shift. By limiting rotational laxity, the lateral extra-articular tenodesis (LET) treatment added to the ACL surgery improves knee stability. This study's objective was to assess the long-term clinical and radiological results of ACL restoration coupled with LET utilizing a continuous hamstring graft as the first operation. Method and Analysis: Four years postoperatively, 20 patients were examined. Collecting subjective outcome ratings (IKDC, Lysholm, KOOS, and Tegner). A clinical and radiological evaluation was conducted. The anteroposterior laxity of the knees was assessed using a rollimeter. Using SPSS version 23, the statistical analysis was conducted. The mean and standard deviation of quantitative data were used to summarize the data. Fischer's exact test was used to compare qualitative characteristics, whereas Student's t-test was used to compare mean values. A p value of 0.05 or less was regarded as significant. Result: The mean IKDC subjective score was 83.1, the mean Lysholm score was 89.02 and 75% of patients had exceptional or excellent scores. In 85% of patients, there was no pivot shift, and 60% of patients had a definitive endpoint on the Lachman test. Conclusion: The addition of primary LET to ACL restoration enhances rotational laxity control over time without raising the risk of complications.

Isolated Lateral Extra-articular Tenodesis (LEAT) for Chronic Rotational Instability following Primary Anterior Cruciate Ligament (ACL) Reconstruction has Low Surgical Morbidity and Improves Knee Stability

Isolated Lateral Extra-articular Tenodesis (LEAT) for Chronic Rotational Instability following Primary Anterior Cruciate Ligament (ACL) Reconstruction has Low Surgical Morbidity and Improves Knee Stability

COMPARATIVE STUDY OF FUNCTIONAL OUTCOME OF ACL RECONSTRUCTION BY HAMSTRING VS PERONEUS LONGUS AUTOGRAFT

Introduction: Anterior cruciate ligament (ACL) reconstruction improves knee stability and function with many graft types, either autografts or allografts, which have already been studied extensively. Among these grafts, bone–patellar tendon–bone (BPTB) and four-strand hamstring autografts are the two most common autografts used for ACL reconstruction and each has its advantages and disadvantages. Orthopaedic surgeons are attempting to use peroneus longus tendon as a graft. Peroneus longus tendon autografts are commonly used in some orthopaedic procedures, including spring ligament reconstruction, deltoid ligament reconstruction and medial patellofemoral ligament reconstruction. The purpose of this study is to compare the functional outcome between the peroneus longus tendon and hamstring tendon in ACL Reconstruction. Material And Methods: In our study we took 40 cases of ACL tear fulfilling inclusion and exclusion criteria. Patient selection was randomised, half of the patients were operated by Diagnostic Arthroscopy with ACL reconstruction using hamstring autograft and the other half by using peroneus longus autograft. Patients were in the age group of 19 to 54 years. The male/female ratio is 32 males and 8 females. Results: Patient was followed at 6 weeks, 3 and 6-months post operatively for clinical and radiological evaluation and results at end of 6 months were calculated by using IKDC and Lysholm knee score. The functional and radiological outcome is similar in both groups Conclusion: Anterior cruciate ligament reconstruction with peroneus longus autografts produces a functional score (IKDC, Lysholm) comparable to that of hamstring autografts at a 6-month follow-up.

Prediction of Semitendinosus Graft Length and Girth using Anthropometric Parameters: A Prospective Study in North Kerala Population

Introduction: Semitendinosus, Gracilis and Bone-Patellar Tendon-Bone (BPTB) graft are the most popular grafts for Anterior Cruciate Ligament (ACL) reconstruction. Although bone-to-bone patellar tendon grafting improves knee stability and healing rates, there are drawbacks, including donor site morbidity, patellar tendinopathy, anterior knee pain, flexion contracture, and patellar fracture. The advantages of semitendinosus graft include preservation of bone stock, the ability to triple graft length when needed, and the ability to take Gracilis graft through the same incision if graft diameter is too small. Aim: To predict the semitendinosus graft length and diameter using anthropometric parameters (height, weight, Body Mass Index (BMI), waist circumference, thigh circumference and thigh length). Materials and Methods: This prospective descriptive study was conducted in the Department of Orthopaedics, Malabar Medical College, Calicut, Kerala, India for a period of one year (from October 2021 to October 2022). A total of 50 patients in the age group 15-60 years with ACL insufficiency planned for hamstring autograft reconstruction were examined. A number of preoperative factors, including age, gender, height, weight, BMI, thigh length, thigh circumference and waist circumference were assessed. A 2-tailed test and Pearson correlation was used to identify relationships between outcome variables (semitendinosus graft length and quadrupled tendon diameter) and predictor variables (age, gender, height, weight, BMI, thigh length, thigh circumference and waist circumference). Results: A total of 68% of patients had a semitendinosus graft diameter ≥8 mm, while 32% percent were &lt;8 mm. Compared to males, females had a lower body weight and height and their hamstring grafts were shorter with smaller diameter. Correlation analysis indicated that there was a significant positive relation between height and weight on graft length and diameter (p&lt;0.005). Conclusion: The study concluded that both hamstring diameter and length was related to height and weight of the person. Patients who were taller and heavier might be anticipated to have grafts with longer length and larger diameter. Also, thigh and waist parameters had no impact on hamstring tendon size.

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Background: The increase in anterior cruciate ligament (ACL) injuries in pediatric patients and the high failure rate reported in the literature in this population are driving surgeons to search for specific techniques to better restore knee stability. Recent literature has reported that the combination of lateral extra-articular tenodesis (LET) and ACL reconstruction improves outcomes in high-risk patients. However, such advantages in pediatric patients have been infrequently evaluated. Purpose: To assess whether adding LET to ACL reconstruction can significantly improve knee stability, clinical outcomes, and failure rates in pediatric patients. Study Design: Cohort study; Level of evidence, 3. Methods: A multicentric study involving 3 orthopaedic teaching centers was conducted to evaluate pediatric patients aged between 12 and 16 years who had undergone primary ACL reconstruction using a physeal-sparing femoral tunnel drilling technique. A minimum 2-year follow-up evaluation was required. Based on the surgical technique performed, the patients were divided into 2 group. The patients in group 1 underwent an isolated arthroscopic ACL reconstruction, while the patients in group 2 had an arthroscopic ACL reconstruction in combination with a modified Lemaire LET procedure. Group 1 was a historical control cohort of patients, whereas group 2 was prospectively enrolled. All the patients included in the present study were clinically evaluated using the Pediatric International Knee Documentation Committee (Pedi-IKDC) subjective score and the Pediatric Functional Activity Brief Scale (Pedi-FABS) score. Anteroposterior knee stability was measured using the KT-1000 knee ligament arthrometer, and the objective pivot-shift evaluation was documented using a triaxial accelerometer (Kinematic Rapid Assessment [KiRA]). The included patients also underwent a standardized radiological protocol to evaluate leg-length discrepancies, axial deviation, and degenerative signs preoperatively and at last follow-up. Results: This study included 66 pediatric patients with an anatomic hybrid ACL reconstruction using an autologous 4-strand hamstring graft. In group 1, there were 34 patients (mean age, 13.5 ± 1.2 years), while 32 patients (mean age, 13.8 ± 1.4 years) were included in group 2. The clinical outcome scores showed no difference between the 2 groups (Pedi-IKDC, P = .072; Pedi-FABS, P = .180). Nevertheless, the patients in group 2 had better anteroposterior stability measured using a KT-1000 arthrometer (1.9 ± 1.1 mm in group 1 vs 0.8 ± 0.8 mm in group 2; P = .031), as well as better rotational stability measured using the KiRA (–0.59 ± 1.05 m/s2 in group 2 vs 0.98 ± 1.12 m/s2 in group 1; P = .012). The patients in group 1 returned to sports at the same competitive level at a rate of 82.4%, while patients included in group 2 returned at the same competitive level in 90.6% of the cases without a significant difference between the 2 groups (P = .059). No leg-length discrepancies were found between the 2 groups at last follow-up (P = .881). Two patients displayed an increased valgus deformity of 3° on the operated limb at last follow-up (1 patient in group 1 and 1 patient in group 2). Group 1 had a significatively higher cumulative failure rate (14.7% vs 6.3%; P = .021). No intra- or postoperative complications was observed between the 2 groups. Conclusion: Performing a modified Lemaire LET along with an ACL reconstruction with hamstring graft in pediatric patients reduced the cumulative failure rate and improved objective stability with no increase in intra- or postoperative complications. No significant difference was found between the 2 groups in terms of patient-reported outcomes or in the return-to-sports activity.

Association Between Anteromedial Portal Versus Tibial Tunnel Drilling and Meniscal Reoperation Risk Following Anterior Cruciate Ligament Reconstruction: A Cohort Study

Background: Anterior cruciate ligament reconstruction (ACLR) provides functional stability to an injured knee. While multiple techniques can be used to drill the femoral tunnel during ACLR, a single technique has yet to be proven as clinically superior. One marker of postoperative functional stability is subsequent meniscal tears; a lower risk of subsequent meniscal surgery could be expected with improved knee stability. Purpose: To determine if there is a meniscal protective effect when using an anteromedial portal (AMP) femoral tunnel drilling technique versus transtibial (TT) drilling. Study Design: Cohort study; Level of evidence, 2. Methods: Data from Kaiser Permanente’s ACLR registry were used to identify patients who had a primary isolated ACLR between 2009 and 2018; those with previous surgery in the index knee and meniscal pathology at the time of ACLR were excluded. The exposure of interest was TT (n = 2711) versus AMP (n = 5172) drilling. Multivariable Cox proportional hazard regression was used to evaluate the risk of a subsequent ipsilateral meniscal reoperation with adjustment for age, sex, femoral fixation, and graft choice. We observed a shift in surgeon practice from the TT to AMP over the study time frame; therefore, the relationship between technique and surgeon experience on meniscal reoperation was evaluated using an interaction term in the model. Results: At the 9-year follow-up, the crude cumulative meniscal reoperation probability for AMP procedures was 7.76%, while for TT it was 5.88%. After adjustment for covariates, we observed a higher risk for meniscal reoperation with AMP compared with TT (hazard ratio [HR], 1.53; 95% CI, 1.05-2.23). When stratifying by surgeon experience, this adverse association was observed for patients who had their procedure performed by surgeons with less AMP experience (no previous AMP ACLR: HR, 1.26; 95% CI, 0.84-1.91) while a protective association was observed for patients who had their procedure with more experienced surgeons (40 previous AMP ACLRs: HR, 0.34; 95% CI, 0.13-0.92). Conclusion: Drilling the femoral tunnel via the AMP was associated with a higher risk of subsequent meniscal surgery compared with TT drilling. However, when AMP drilling was used by surgeons experienced with the technique, a meniscal protective effect was observed.

A Biomechanical Comparison of the LaPrade Technique Versus a Novel Technique for Reconstruction of Medial-Sided Knee Injuries

Background: Medial-sided knee injuries can lead to symptomatic valgus laxity or anteromedial rotatory instability and may require surgery, particularly in the setting of cruciate tears and tibial-sided medial collateral ligament (MCL) avulsions. The LaPrade (LP) technique utilizes 2 free grafts to reconstruct the superficial MCL (sMCL) and the posterior oblique ligament (POL). An alternative MCL reconstruction devised by the senior author comprises an anatomic single-bundle reconstruction using a free graft to reconstruct the sMCL with advancement and imbrication of the posteromedial capsule/POL (MCL anatomic reconstruction with capsular imbrication [MARCI] technique). These techniques have not been biomechanically compared with one another. Purpose: To identify if one of these reconstruction techniques better restores valgus and rotational medial knee stability throughout the range of motion. Study Design: Controlled laboratory study. Methods: A total of 20 fresh-frozen, male (mean age, 43.7 years [range, 20-63 years]), midfemur-to-toe-matched cadaveric knees were utilized. All reconstructions were performed by a single fellowship-trained sports medicine surgeon. Left and right specimens within matched pairs were randomized to 1 of the 2 treatment groups: LP or MARCI. Each specimen was tested in 3 phases: (1) intact knee, (2) destabilized (MCL and POL completely severed), and (3) reconstructed (post-LP or post-MARCI reconstruction). We quantified valgus angulation defined by medial joint line opening, as well as internal and external tibial rotation at 0°, 20°, 30°, 60°, and 90° of knee flexion under applied external moments/torques at each phase. Results: There were significant differences between the MARCI and LP reconstruction groups in valgus stability compared with the intact state (P = .021), with the MARCI reconstruction more closely approximating the intact knee. There was no overall difference between the MARCI and LP reconstruction techniques for internal rotation (P = .163), with both closely resembling the intact state. For external rotation, the effect of the reconstruction technique was dependent on the knee flexion angle (P < .001). At the highest angles, there were no differences between reconstructions; however, for lower knee flexion angles, the MARCI technique more closely resembled the intact state. Conclusion: Although both techniques improved knee stability compared with destabilized conditions, the MARCI technique better approximated intact stability during valgus at knee flexion angles from 0° to 90° and external rotation loads at knee flexion angles ≤30° in a cadaveric model. Clinical Relevance: The MARCI technique provides an alternative option to improve valgus stability throughout the range of motion. It utilizes a POL advancement without the potential limitations seen in the LP technique, such as multiple tunnel complexity and collision, particularly in the multiple ligament–injured knee.

Influence of Whole Body Vibration on Drop Jump Landings and Knee Loading Mechanics

Plyometric training is one commonly used method of improving jump performance through improving explosive power generation. Research has also demonstrated that whole body vibration (WBV) can improve jumping and enhance explosive strength especially when supplementing resistance and plyometric training programs. With the drop jump being a common training skill, proper lower extremity landing mechanics are important to consider. Limited evidence suggests that WBV may reduce ground reaction forces and improve knee stability however, its influence on knee loading have not been reported. This study sought to examine the effects of WBV on ground reaction forces and knee valgus during a drop jump. 19 participants (10 female) completed drop jumps pre, immediately post, 10 &amp; 20 minutes post WBV. Results were analyzed by repeated measures ANOVA. Main findings indicated that valgus knee angle increased significantly (p=0.011) post vibration and remained elevated across the 10 &amp; 20 minute post vibration time intervals. Significant differences between sexes revealed that females demonstrated greater internal knee abduction moments (p=0.038). Findings that WBV increases knee valgus angle, a position linked to anterior cruciate ligament injury, suggest further investigation understand the effects of WBV on neuromuscular control and eccentric loading. Strength and conditioning professionals should exercise caution when incorporating WBV into plyometric protocols.