Intra-articular Anterior Cruciate Ligament Reconstruction Research Articles

A Cadaveric Study of the Optimal Isometric Region on the Anterolateral Surface of the Knee in Anterolateral Ligament Reconstruction.

Isolated intra-articular anterior cruciate ligament (ACL) reconstruction is not capable of restoring instability in many cases leading some to recommend concomitant anterolateral ligament (ALL) reconstruction. The satisfactory fixation site and graft length change are crucial in ligament reconstruction to restore the ALL function and avoid some unwanted graft behavior. The purpose of this investigation is to determine the optimal isometric region on the anterolateral aspect of the knee for ALL reconstruction using a three-dimensional optical instrument and a suture similar to an intraoperative isometric test. Six freshly frozen cadaveric human knees were used in this study. Data regarding the anterolateral surface were obtained using an optical measurement system to create a three-dimensional model. Nine points were selected on the femur (F1-F9) and tibia (Ta-Ti) respectively. The three-dimensional length change between each pair of tibial and femoral points was measured during passive knee flexion from 0° to 90° in 15° increments. Subsequently, five femoral points (A-E) were selected from the lateral femur, located in different areas relative to the lateral femoral epicondyle, and three tibial reference points (T1-T3) were selected in the isometric test. The changes in the length between each pair of reference points were measured using sutures. The 95% confidence interval for the rate of length change was estimated using the mean and standard deviation of the maximum rate of length change at different flexion angles, and the data were expressed as the mean (95% confidence interval) and compared with the maximum acceptable rate of change (10%). The maximum acceptable change rate for ligament reconstruction is 10%, and the mean maximum rates and the 95% confidence interval (CI) of length change for the point combinations were calculated. Among all the combined points measured using the optical measurement system and the suture, the qualified point combination for reconstruction was F3 (8mm posterior and 8mm proximal to the lateral femoral epicondyle)-Tb (8mm proximal to the midpoint between the center of Gerdy's tubercle and the fibula head), A (posterior and proximal to the lateral femoral epicondyle)-T2 (10mm below the joint line)and A-T3 (15 mm below the joint line). The position of F3-Tb and A-T2 are close to each other. The most isometric area of the femur for ALL reconstruction was posterior and proximal to the lateral femoral epicondyle. We recommend that the initial location of the femoral point be set at 8 mm posterior and 8 mm proximal to the lateral femoral epicondyle and the tibial point at approximately 10 mm below the joint line, midway between Gerdy's tubercle and fibular head, and subsequently adjusted to the most satisfactory position according to the isometric test.

Anterior Cruciate Ligament Reconstruction With Iliotibial Band Autograft in Skeletally Immature Prepubescent Children: A Physeal-Sparing Technique

Background: As there has been an increasing incidence of anterior cruciate ligament (ACL) tears in children and adolescents in the past few decades, nonoperative management is seen to result in less favorable clinical outcomes, resulting in meniscal and cartilage damage, and arthritic changes. Despite the risk of iatrogenic physeal injuries with operative approach, several reconstruction options, such as physeal-sparing techniques for skeletally immature patients, are described to restore joint stability. Indications: We bring a combined extra-articular and intra-articular ACL reconstruction technique using autogenous iliotibial band (ITB), which is indicated for prepubescent patients (Tanner stages 1 or 2) with open physes, significant growth potential (≤11 years for girls and ≤12 years for boys) and smaller knees, where an all-epiphyseal ACL reconstruction would lack epiphyseal space Technique Description: The technique consists of a modified MacIntosh intra-articular and extra-articular ITB reconstruction, described by Micheli and further characterized by Kocher. The central portion of the ITB is harvested proximally (at least 15 cm) and left attached to Gerdy's tubercle distally. The harvested graft is brought from over-the-top posteriorly and passed under the intermeniscal ligament anteriorly through an epiphyseal groove on the tibia. Results: The outcomes shown for the Kocher ITB ACL reconstruction technique are favorable at a mean follow-up of 5.3 years: from 44 patients, 41 returned to sports involving cutting or pivoting, and the revision rate was low at 4.5%. Discussion/Conclusion: The awareness of physeal injury related to the operative treatment of ACL tears in the pediatric population has resulted in several physeal-sparing and physeal-respecting techniques of reconstruction. Some of these have shown to reduce the risk of physeal damage, maintaining stability and providing excellent functional outcomes, with low revision rates in long-term follow-up and minimal risk of growth disturbance. 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.

Lateral Extra-articular Tenodesis Combined with Intra-articular ACL Reconstruction in Management of Anterolateral Knee Instability

Lateral Extra-articular Tenodesis Combined with Intra-articular ACL Reconstruction in Management of Anterolateral Knee Instability

Adding a Lateral Extraarticular tenodesis to ACL Reconstruction in 2022

Lateral extra-articular tenodesis (LET) is a procedure used to control anterolateral rotatory laxity. It was first described to treat the ACL deficient knee prior to advent of intra-articular reconstruction. The aim was adding a lateral soft tissue restraint away from the central pivot of the knee to improve rotational control. The recent evidence from the STABILITY RCT has shown that the addition of LET to hamstring autograft ACLR in young patients (14-25 years ) results in clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years postoperatively. This has subsequently been verified by various authors that adding a lateral soft tissue restraint to an intraarticular ACL reconstruction reduced both primary and revision ACL graft failures. The current indication for adding an LET to ACL surgery are : in high grade knee laxity in clinic detected on physical examination, patients with joint laxity, chronic ACL injuries, athletes returning to pivot sports after surgery and in revision ACL cases.

Techniques in Pediatric Anterior Cruciate Ligament Reconstruction

In recent years, the frequency of anterior cruciate ligament (ACL) tears and ACL reconstruction (ACLR) in skeletally immature patients has increased. Because distal femoral and proximal tibial physes account for the majority of lower-extremity growth, surgical technique and graft selection are crucial to minimize iatrogenic physeal injury. Combined extra- and intra-articular, all-epiphyseal, and transphyseal with soft-tissue grafts are the most common ACLR techniques used in children. Combined extra- and intra-articular ACLR typically is offered to prepubescent patients with ≥2 years of growth remaining. This technique uses iliotibial band (ITB) autograft passed over the lateral femoral condyle and fixed to the anterior tibial periosteum. All-epiphyseal ACLR is similarly used in patients with ≥2 years of growth remaining, provided sufficient epiphyseal maturity to accommodate an all-epiphyseal socket because both the femoral and tibial tunnels are contained within the epiphyses. In postpubertal patients with <2 years of growth remaining, transphyseal ACLR using a soft-tissue autograft (typically hamstring or quadriceps tendon) and metaphyseal femoral fixation can be performed. This minimizes risk of physeal injury. In borderline patients with approximately 2 years of growth remaining, an additional option includes partial transphyseal ACLR, which uses a soft-tissue graft and a transphyseal tibial tunnel, but an all-epiphyseal or over-the-top femoral graft trajectory. Recently, transphyseal ITB ACLR and hybrid transphyseal hamstring with combined over-the-top ITB ACLR also have been described. Existing clinical studies focused on pediatric and adolescent ACL reconstructions have reported a wide range of graft rupture rates for these techniques (4.3%-25%), with contralateral ACL injury rates of 2.9% to 15.6%. Ongoing multicenter research is underway to directly compare surgical techniques for this demographic and quantify graft rupture rates and other clinical outcomes.

Association between a Concomitant Anterolateral Ligament Tear and Pivot Shift Before and After Single-Bundle Anterior Cruciate Ligament Reconstruction: A Retrospective Cohort Study

BACKGROUND: Regardless of the type of intra-articular anterior cruciate ligament (ACL) reconstruction performed, a certain degree of rotatory instability is often seen after surgery. Recent studies suggest that the anterolateral ligament (ALL) plays a significant role in maintaining stability during internal rotation of the tibia at high knee flexion angles. Unrecognized damage to the ALL may potentially be associated with a positive pivot shift despite a surgically reconstructed ACL being done. AIM: The primary objective of this study was to determine whether a concomitant ALL tear is associated with a high-grade pivot shift before and after ACL reconstruction. METHODS: This study was a retrospective cohort study of patients that underwent single-bundle ACL reconstruction surgery in our institution from October 2014 to March 2017. One hundred and forty-four patients were included in this study. All data were extracted from the department of ACL registry. All knee MRIs were reviewed by the author and coauthor to determine the integrity of the ALL. Subjects were divided into two groups based on the grade of pivot shift before surgery. The prevalence of ALL tear based on MRI was further compared between high-grade and low-grade pivot-shift groups. RESULTS: Overall, the prevalence of a concomitant ALL tear was 70.83%. Comparing the prevalence of concomitant ALL tear between the high-grade pivot-shift group (73.11%) and low-grade pivot-shift group (60%), we had insufficient evidence to demonstrate an association between pre-surgery high-grade pivot shift and concomitant ALL tear. After surgery, none of the patients had a high-grade pivot shift or was positive for Lachman’s test. CONCLUSION: There is a high prevalence of concomitant ALL tear in patients with torn ACL. We have insufficient evidence to demonstrate an association between the presence of a torn ALL and high-grade pivot shift before and after single-bundle ACL reconstruction.

A Comparative Study on Functional Outcomes of Fixed Versus Adjustable Length-Loop Device for Femoral Fixation of Graft in Anterior Cruciate Ligament Reconstruction

A Comparative Study on Functional Outcomes of Fixed Versus Adjustable Length-Loop Device for Femoral Fixation of Graft in Anterior Cruciate Ligament Reconstruction

Clinical assessment and comparison of ACL reconstruction using synthetic graft (Neoligaments versus FiberTape).

Due to the low potential for primary biological healing of the anterior cruciate ligament (ACL), the most popular approach is currently reconstruction using a graft. Recent research indicates that the technique of strengthening a damaged ligament with synthetic tapes (internal bracing) may be an alternative to reconstructive treatment, especially in cases of partial ACL damage. To compare and evaluate the possibility of using a synthetic graft (Neoligaments or FiberTape) to treat partial lesions of the ACL. This was a retrospective cohort study. Selected from a pool of 128 patients undergoing primary unilateral intra-articular ACL reconstruction due to partial lesion of the ACL, group I (Neoligaments) and group II (FiberTape) each included 30 patients. Range of motion (ROM), the Lachman test, the anterior drawer test and the pivot-shift test, the Lysholm Knee Scoring Scale, and International Knee Documentation Committee (IKDC) 2000 scale were used for assessment. Follow-up was carried out after 2 years. The knee joint regained anterior stability in both the subjective and objective assessments in all patients in both groups. The subjective results were respectively: in group I, 97.2 ±3.2 points on the Lysholm scale and 93.9 ±6.1 points on the IKDC 2000 scale; in group II, 96.1 ±4.9 points on the Lysholm scale and 93.2 ±6.8 points on the IKDC 2000 scale. Group comparison of the results of the IKDC 2000 scale, Lysholm Scale and ROM obtained postoperatively showed no statistically significant differences between groups. Reconstruction of partial ACL lesions using a synthetic graft allows regained stability of the knee joint. The results of subjective assessment are comparable with the functional assessment results. The comparison between Neoligaments and FiberTape shows the same functional and objective results, although FiberTape is preferable from an economical perspective.

The deep lateral femoral notch sign: a reliable diagnostic tool in identifying a concomitant anterior cruciate and anterolateral ligament injury.

The aim of the present study was to investigate the validity and reliability of the deep lateral femoral notch sign (DLFNS) in identifying a concomitant anterior cruciate ligament (ACL)/anterolateral ligament (ALL) rupture and predicting the clinical outcomes following an anatomical single-bundle ACL reconstruction. It was hypothesized that patients with a concomitant ACL/ALL rupture would have an increased DLFNS compared to patients without a concomitant ACL/ALL rupture. The lateral preoperative radiographs and MRI images of 100 patients with an ACL rupture and 100 control subjects were evaluated for the presence of a DLFNS and ACL/ALL rupture, respectively. The patients were evaluated clinically preoperatively and at a minimum 1 year following the ACL reconstruction. A receiver operator curve (ROC) analysis was performed to define the optimal cut-off value of the DLFNS for identifying a concomitant ACL/ALL injury. The relative risk (RR) was also calculated to determine whether the presence of the DLFNS was a risk factor for residual instability or ACL graft rupture following an ACL reconstruction. The prevalence of DLFNS was 52% in the ACL-ruptured patients and 15% in the control group. At a minimum 1-year follow-up, 35% (6/17) of the patients with DLFNS > 1.8mm complained of persistent instability, and an MRI evaluation demonstrated a graft re-rupture rate of 12% (2/17). In patients with a DLFNS < 1.8mm, 8% (7/83) reported a residual instability, and the graft rupture rate was 2.4% (2/83). A DLFNS > 1.8mm demonstrated a sensitivity of 89%, a specificity of 95%, a negative predictive value of 98%, and a positive predictive value of 89% in identifying a concomitant ACL/ALL rupture. Patients with a DLFNS > 1.8mm had 4.2 times increased risk for residual instability and graft rupture compared to patients with a DLFNS ≤ 1.8mm. A DLFNS > 1.8mm could be a clinically relevant diagnostic tool for identifying a concomitant ACL/ALL rupture with high sensitivity and PPV. Patients with a DLFNS > 1.8mm should be carefully evaluated for clinical and radiological signs of a concomitant ACL/ALL rupture and treated when needed with a combined intra-articular ACL reconstruction and extra-articular tenodesis to avoid a residual rotational instability and ACL graft rupture. III.

Clinical and functional evaluation of primary anterior crucial ligament reconstruction by using allograft

The reconstruction of the anterior cruciate ligament (ACL) of the knee joint is the gold standard in complete ACL rupture treatment. One of the central discussion topics is choice of graft. To assess the outcome of treatment after primary ACL reconstruction using allograft. The study was a retrospective cohort study. Out of 372 male patients who had undergone primary unilateral intra-articular ACL reconstruction using strict inclusion and exclusion criteria, 61 patients who qualified for the study took part. Group I was made up of 31 patients with allograft, while Group II consisted of 30 patients involved with autograft. The Lachman test, Pivot-Shift test, Lysholm Knee Scoring scale, and 2000 International Knee Documentation Committee (IKDC) were used to evaluate the results. Follow-up time was 18 months. The knee joint regained anterior stability in subjective and objective assessments in all the patients in both groups. The subjective results were the following: in Group I, 96.6 ±3.08 points on the Lysholm scale and 94.79 ±6.53 points on the IKDC 2000 scale, while in Group II, 98.00 ±1.9 points on the Lysholm scale and 94.81 ±5.6 points on the IKDC 2000 scale. The group comparison of the results of the IKDC 2000 and Lysholm Scale obtained postoperatively showed no statistically significant differences between the 2 groups. Primary ACL reconstruction using an allograft is an effective procedure to counteract instability of the anterior knee joint. Comparative analysis of the results of primary ACL reconstruction in the treatment of anterior knee instability using autograft or allograft gives grounds for the possibility of individual selection of graft depending on what the patient's expectations are.

ACL reconstruction with lateral extra-articular tenodesis using a continuous graft: 10-year outcomes of 50 cases

BackgroundPersistence of pivot shift is the main problem after isolated intra-articular anterior cruciate ligament (ACL) reconstruction. Adding lateral extra-articular tenodesis (LET) to the ACL procedure increases the knee's stability by controlling rotational laxity. The aim of this study was to evaluate the long-term clinical and radiological outcomes of combined ACL reconstruction with LET using a continuous hamstring graft as a first-line procedure. Material and methodsFifty patients were reviewed at 10 years postoperative. Subjective outcome scores –IKDC, Lysholm, KOOS and Tegner– were collected. A clinical and radiological assessment was done. The knees’ anteroposterior laxity was measured with a rollimeter. ResultsThe mean IKDC subjective score was 85.5, the mean Lysholm score was 90.2 and 80% of patients had a score graded as good or very good. No pivot shift was present in 94% of patients and there was a firm endpoint in the Lachman test in 86% of patients. There was a flexion deficit>5° in 5 patients and an extension deficit of 10° in one patient. Most patients (56%) had resumed their physical activities at the same level as before the surgery. Signs of osteoarthritis were found in 26% of patients (16% were Ahlback stage 1 and 10% were stage 2). There was only one graft failure. These good outcomes are consistent with other published studies on combined ACL-LET. There was neither significant stiffness, nor a higher rate of secondary osteoarthritis relative to ACL reconstruction only, particularly in the lateral tibiofemoral compartment. ConclusionAdding primary LET to ACL reconstruction improves control of rotational laxity over time without increasing the complication rate. Level of evidenceIV, retrospective study without control group.

High incidence of tunnel collision in combined ACL reconstruction and LET

Aims and Objectives:Lateral extra-articular tenodesis (LET) procedures are being increasingly performed as concomitant procedures to both primary and revision intra-articular ACL reconstructions with the purpose of controlling excessive anterolateral rotatory instability and to reduce tension on the ACL graft.There is, however, a lack of evidence on benefits and pitfalls of different femoral LET attachment positions.The purpose of this study was to assess the risk of tunnel convergence in combined ACL and LET procedures comparing two different femoral attachment sites (Lemaire and MacIntosh).Materials and Methods:10 fresh-frozen cadaver knees were examined. In each specimen an anatomic ACL femoral tunnel and two LET tunnels were drilled applying the Lemaire and MacIntosh position. Following knee dissection, minimal distances between ACL and LET tunnels were directly measured on the lateral femoral cortex. Furthermore, computed tomography (CT) scans were obtained to measure inter-tunnel convergence and lateral femoral condyle (LFC) width. Based on the average LFC width, knees were divided into large and small knees to determine a relationship between knee size and tunnel convergence.Results:Convergence of ACL and LET tunnels occurred in 7 of 10 cases (70%) using the Lemaire attachment position. All tunnel collisions occurred directly on the lateral femoral cortex, while inter-tunnel conflicts were not observed. Collisions emerged in both, small (n=4) and large (n=3) knees. Critical tunnel convergence did not occur using the MacIntosh position. The mean minimal distance between the LET and ACL tunnel using the Lemaire and MacIntosh position was 3.1±4.6 mm and 9.8±5.4 mm, respectively.Conclusion:A high risk of tunnel convergence was observed in combined ACL and LET reconstruction using the Lemaire technique, independent of the knee size. LET femoral tunnel positioning according to the MacIntosh reconstruction can significantly reduce the risk of tunnel collision. These findings help to intraoperatively raise the awareness for the risk of tunnel convergence in combined ACL and LET procedures.Adjustments on ACL reconstruction techniques and especially on the femoral fixation have to be considered when applying an additional Lemaire reconstruction.

Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: systematic review and meta-analysis.

Anterolateral augmentation procedures can be divided into traditional lateral extra-articular tenodesis (LET) and modern anterolateral ligament (ALL) reconstruction. Nevertheless, no studies have compared the clinical results between LET and ALL reconstruction, when combined with intra-articular ACL reconstruction. This study was therefore designed to compare the clinical results, including the anterior translation, rotational laxity, and patient-reported outcomes, in a group of patients who underwent ACL reconstruction combined with LET or ALL reconstruction. All studies systematically searched until March 2018 without any language restriction that reported the results of a lateral extra-articular stabilization procedure using either LET or ALL reconstruction methods combined with ACL reconstruction were evaluated. Two reviewers independently recorded data from each study, including the sample size, improvement in Lysholm score, and the number of patients with each grade of knee laxity using Lachman and pivot shift tests. The pooled results of ten studies showed that the postoperative proportion of knees with grade 2 or 3 on the Lachman test was significantly higher following LET compared with ALL reconstruction in combination with ACL reconstruction (10.8%, 95% confidence interval [CI]: 6.6-17.1% vs. 1.5%, 95% CI 0.5-4.5%; p = 0.001). However, the pooled results of 12 studies showed that the proportion of knees that belonged to grade 2 or 3 on the pivot shift test, indicating poor rotational stability, was similar between these two techniques (4.9%, 95% CI 2.0-11.5% vs. 2.3%, 95% CI 1.1-4.5%; p = 0.101). The pooled improvements in Lysholm scores in these two groups were also similar (32.3, 95% CI 26.8-37.9 vs. 25.7, 95% CI 16.7-34.7, p = 0.218). LET could lead to worse anterior instability than with ALL reconstruction when these two approaches were combined with single-bundle ACL reconstruction. However, rotational stability and patient-reported outcomes were similar between the techniques.

Biomechanical Effects of Additional Anterolateral Structure Reconstruction With Different Femoral Attachment Sites on Anterior Cruciate Ligament Reconstruction

Background: Recently reported anterolateral structure reconstructions (ALSRs) to augment intra-articular anterior cruciate ligament reconstruction (ACLR) use various femoral attachment sites, and their biomechanical effects are still unknown. Hypothesis: ALSR concomitant with ACLR would control anterolateral rotational instability better than ACLR alone, and if ALSR had different femoral attachment sites, there would be different effects on its control of anterolateral rotational instability. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen hemipelvis lower limbs were included. Anterior tibial translation during the Lachman test and tibial acceleration during the pivot-shift test were measured with a 3-dimensional electromagnetic measurement system in situations with the (1) ACL and ALS intact, (2) ACL and ALS cut, (3) ALSR without ACLR (ALSR alone), (4) ACLR without ALSR (ACLR alone), and (5) ALSR with ACLR. Three femoral attachment sites were used for ALSR: F1, 2 mm anterior and 2 mm distal to the lateral epicondyle; F2, 4 mm posterior and 8 mm proximal to the lateral epicondyle; and F3, over-the-top position for the lateral extra-articular tenodesis. The Steel test and Wilcoxon signed rank test were used for statistical analysis. Results: Anterior tibial translation during the Lachman test in the ACL and ALS–cut state was significantly larger than it was in the ACL and ALS–intact state, while its difference disappeared after ACLR. As for the pivot-shift test, additional ALSR with F2 to ACLR significantly decreased the acceleration (P = .046), although additional ALSR with F1 and F3 showed no significant effect. Conclusion: ALSR with the femoral attachment site 4 mm posterior and 8 mm proximal to the lateral epicondyle in addition to ACLR played a role in reducing anterolateral rotational instability the most effectively among the measured attachment sites. Clinical Relevance: The present data will contribute to determine the appropriate femoral attachment site for ALSR to better control anterolateral rotational instability after ACL reconstruction.

DOES A COMBINED INTRA-ARTICULAR AND EXTRA-ARTICULAR ACL RECONSTRUCTION EFFECT EXTERNAL KNEE VALGUS MOMENT ASYMMETRY?

Introduction: Peak external knee valgus moment can predict future ACL injury and is, often times, asymmetric following anatomic intra-articular ACL reconstruction. The purpose of this study is to evaluate the external knee valgus moment during a drop landing and a single limb squat 2 years following an iliotibial band (ITB) intra-articular and extra-articular physeal-sparing ACL reconstruction. Methods: Fourteen study subjects (mean age: 14.3 ± 2.6 yrs) who had previously undergone a physeal-sparing ACL reconstruction, as originally described by McIntosh using an ITB autograft, were enrolled in this IRB-approved study. All subjects were seen at a minimum of 24 months after surgery (mean follow-up: 55.0 ± 28.9 mos) and clinical, radiographic, and patient reported outcomes were collected. During functional testing, subjects underwent drop landing (DL) and unilateral squat (US) tasks. Isokinetic muscle strength of the hip and knee was collected using an isokinetic dynamometer at 60°/s. Paired student’s t-tests evaluated differences between affected (AFF) and unaffected (UNAFF) limbs. Results: During a drop landing, the AFF limb, compared to the UNAFF limb, did not demonstrate a difference in external knee valgus moment (0.50° vs. 0.51°, p=0.736). However, in the AFF limb, the mean knee peak knee valgus angle was 2.8 degrees less than the UNAFF limb during a drop landing (p=0.039). This difference was not considered within the range of a minimal clinical difference (MCD) of 5.1 degrees. Similar trends were found during a single limb squat with no significant difference seen in peak knee valgus moment between AFF and UNAFF (0.14° vs. 0.07°, p=0.150) with a statistical, yet not minimal clinical difference, in knee valgus angle at 45° squat position (-2.4° vs. 0.7°, p=0.033; MCD = 5.2). Thus, no asymmetry in peak knee valgus moment during a drop landing or a single limb squat following an ITB intra- and extra-articular ACL reconstruction was observed. In this series at 2 years’ post-op, the Pedi-IKDC and HSS Pedi-FABS were 96.54 ± 5 and 22.6 ± 5, respectively. Subjects demonstrated return to pre-operative Tegner Activity scores (8.42 vs. 8.17, p=0.33). Normalized hip abduction strength was significantly stronger in AFF (1.05 Nm/kg) vs. UNAFF (0.93 Nm/kg, p=0.02). Conclusion: Overall, there were no clinically significant differences, or asymmetry, in functional knee valgus in subjects following combined intra- and extra-articular iliotibial band ACL reconstruction during a drop landing or single leg squat. Young athletes can be expected to return to pre-operative activity levels and demonstrate appropriate knee valgus control following this physeal-sparing ACL reconstruction.

Consideration of lateral augmentation in anatomic anterior cruciate ligament reconstruction

Anatomic intra-articular anterior cruciate ligament reconstruction (ACLR) techniques have been shown to reliably correct anteroposterior (translational) stability; however, they have failed to restore normal tibial rotational kinematics. Re-establishing rotational stability correlates with return to sport, functional scores, overall knee function and patient satisfaction. Several structures in addition to the ACL have been identified as important contributors to rotational knee stability. Recent interest in the anatomical and biomechanical properties of the anterolateral soft tissue structures has led to a resurgence in surgical techniques, specifically anterolateral ligament (ALL) reconstruction and lateral extra-articular tenodesis (LET), to address rotational stability at the time of ACL reconstruction. In the accompanying review we outline the relevant anatomy, biomechanics and clinical results for lateral augmentation procedures; discuss the indications and describe our preferred LET technique for lateral augmentation.

EXTRA-ARTICULAR RECONSTRUCTION ASSOCIATED WITH THE ANTERIOR CRUCIATE LIGAMENT IN BRAZIL.

ABSTRACTObjective:To assess the knowledge and technical preferences of Brazilian knee surgeons in relation to the treatment of Anterior Cruciate Ligament (ACL) injuries using intra-articular reconstruction in combination with extra-articular reconstruction.Methods:A questionnaire consisting of 16 questions about intra-articular ACL reconstruction in combination with extra-articular procedures and about the Anterolateral Ligament (ALL) was applied at the 48th Brazilian Congress of Orthopedics.Results:One hundred thirty-seven surgeons answered the questionnaire. Most surgeons perform 10-30 ACL reconstructions per year, with the transtibial technique appearing as the most common. Most surgeons find some percentage of residual pivot-shift after reconstructions, but the minority performs extra-articular procedures on a routine basis. The main indications for extra-articular reconstruction are revision and profuse pivot-shift cases. Most surgeons consider the ALL a true ligament, but 46.7% with less biomechanical importance and 32.3% with greater importance in knee stability. However, 91.4% had a positive perception of the reconstruction of this structure.Conclusion:Although the preferred technique is still the transtibial procedure, combined anatomical reconstructions already make up more than 50% of cases. Extra-articular reconstructions associated with the ACL are still performed by the minority of Brazilian surgeons, but 91.4% of them report having had a positive perception with their reconstruction. Level of Evidence III, Descriptive Study.

Anatomic anterior cruciate ligament (ACL) reconstruction vs. non-anatomic ACL reconstruction with lateral tenodesis

Anterior cruciate ligament (ACL) reconstruction is one of the most common knee surgical procedure. The overall outcome of the ACL-reconstruction is very satisfactory, however, some patients continue to experience dynamic instability and therefore reduced clinical outcome and lower return to sports rate even after a technically correct surgery. Different approaches have been proposed to address the rotatory instability: an anatomical ACL reconstruction or an intra-articular ACL reconstruction with an extra-articular augmentation or tenodesis (EAT). This review is focused on the historical and contemporary rationale of the combined procedure (EAT).

THE EFFECT OF INTRA-ARTICULAR APPLICATION OF ALLOGENIC MESENCHYMAL STEM CELL COMBINE WITH VEGF TO GRAFT TUNNEL HEALING AND AUTOGRAFT TENDON INTEGRATION IN ACL RECONSTRUCTION; A BIOMECHANICAL STUDY

Graft-tunnel healing is the most determination factors in successful of Anterior Cruciate Ligament (ACL) reconstruction. The application of bone marrow derived mesenchymal stem cell (MSC) and vascular endothelial growth factor (VEGF) are one of integration biological augmentation method that often used in ACL reconstruction. Combination intra-articular post ACL reconstruction is expected to accelerate healing time and integration strength of tendon graft that used in bone tunnel. This method is experimental laboratory using animal model. The research is randomized post test only controlled group design. Five New Zealand white rabbit knee are used for ACL reconstruction with harmstring tendon graft and treated with combination allograft MSC and VEGF intra-articular, while five other rabbit knee as control without treatment. The evaluation is tensile test in third and six weeks post operation. Data was analyzed statistically and comparatively to compare the influence of MSC and VEGF to integration strength of graft tunnel healing. All the samples from treatment and control group found no complication after surgery. On third weeks evaluation, found a difference in failure tension load in both groups but not statistically significant (p&gt;0,05), while on six weeks evaluation, found a statistically significant difference. Treatment group has a failure tension load higher than control group. While failure type of ACL tendon graft on 3 weeks evaluation, only 2 of 5 graft have pullout failure in treatment group. However, at three weeks in control group, the failure type of the tendon graft was a midsubtance rupture in intra-articular part during biomechanical tension test. The use of BM-MSC and VEGF intra-articular can increase tension failure load. It is expected that combination of BM-MSC and VEGF can increase integration process between bone graft and healing post ACL reconstruction, so that rehabilitation and mobilisation can be done earlier.Keywords: Graft-tunnel healing, ACL reconstruction, Vascular Endothelial Growth Factor (VEGF), Bone Marrow Derived Mesenchymal Stem Cell (BMMSC)

An In Vivo Prediction of Anisometry and Strain in Anterior Cruciate Ligament Reconstruction – A Combined Magnetic Resonance and Dual Fluoroscopic Imaging Analysis

To evaluate the invivo anisometry and strain of theoretical anterior cruciate ligament (ACL) grafts in the healthy knee using various socket locations on both the femur and tibia. Eighteen healthy knees were imaged using magnetic resonance imaging and dual fluoroscopic imaging techniques during a step-up and sit-to-stand motion. The anisometry of the medial aspect of the lateral femoral condyle was mapped using 144 theoretical socket positions connected to an anteromedial, central, and posterolateral attachment site on the tibia. The 3-dimensional wrapping paths of each theoretical graft were measured. Comparisons were made between the anatomic, over the top (OTT), and most-isometric (isometric) femoral socket locations, as well as between tibial insertions. The area of least anisometry was found in the proximal-distal direction just posterior to the intercondylar notch. The most isometric attachment site was found midway on the Blumensaat line with approximately 2% and 6% strain during the step-up and sit-to-stand motion, respectively. Posterior femoral attachments resulted in decreased graft lengths with increasing flexion angles, whereas anterodistal attachments yielded increased lengths with increasing flexion angles. The anisometry of the anatomic, OTT and isometric grafts varied between tibial insertions (P < .001). The anatomic graft was significantly more anisometric than the OTT and isometric graft at deeper flexion angles (P < .001). An area of least anisometry was found in the proximal-distal direction just posterior to the intercondylar notch. ACL reconstruction at the isometric and OTT location resulted in nonanatomic graft behavior, which could overconstrain the knee at deeper flexion angles. Tibial location significantly affected graft strains for the anatomic, OTT, and isometric socket location. CLINICALRELEVANCE: This study improves the knowledge on ACL anisometry and strain and helps surgeons to better understand the consequences of socket positioning during intra-articular ACL reconstruction.