Lateral Collateral Ligament Reconstruction Research Articles

Arthroscopic lateral collateral ligament imbrication for the treatment of posterolateral rotatory elbow instability

ObjectivesPosterolateral rotatory elbow instability (PLRI) is commonly treated with open lateral collateral ligament (LCL) reconstruction techniques. This cohort study evaluates the efficacy of a less invasive arthroscopic LCL imbrication technique for reducing grade I or II PLRI. MethodsForty-three patients with stage I or II PLRI, unresponsive to conservative therapy, were included. Diagnoses were based on chronic post-traumatic pain (11 patients), chronic atraumatic lateral elbow pain (20), and previous open tennis elbow surgery (12). Following clinical and arthroscopic diagnosis confirmation, the LCL imbrication technique was performed. The Mayo Elbow Performance Score (MEPS) and range of motion (ROM) were assessed preoperatively and postoperatively using the Shapiro-Wilk test and Wilcoxon signed rank test, respectively, with a minimum 12-month follow-up (range 12-48 months). ResultsMEPS increased significantly from a median of 45 points preoperatively to 90 (range 80–100) at three months and 95 (range 80-100) at 12 months follow-up (p < 0.001). Postoperative median flexion reached 140°, and extension was 0°. At 12 months, two patients experienced a 10° extension deficit; 95.3% (41/43) achieved full ROM. Knot irritation occurred in four patients (out of the first ten of this cohort, 9.3%), three of them requiring knot removal. Switching to a PDS 1 suture eliminated this complication. One patient underwent arthroscopic arthrolysis for adhesions after 14 months. ConclusionArthroscopic LCL imbrication offers favorable outcomes for grade I or II PLRI from the third postoperative month, with minimal complications. A slight restriction in ROM and transient knot discomfort were the main issues, the latter resolved by switching to a thinner PDS suture.

Posterior Cruciate Ligament and Posterolateral Corner Reconstruction: Clinical Outcomes Following Popliteal Tendon Tenodesis and Popliteal Tendon Reconstruction.

Injuries to the posterolateral compartment (PLC) of the knee require special attention, as incorrect diagnosis and treatment may lead to considerable morbidity. However, no gold standard treatment has been established for PLC injuries. 38 patients with concomitant (posterior cruciate ligament (PCL) and PLC injuries were divided into two groups according to surgical treatment of the proximal popliteal tendon injury. They were treated with anatomic popliteal tendon, lateral collateral ligament (LCL), and popliteofibular ligament (PFL) reconstruction (group 1; n = 19) and were treated with popliteal tendon tenodesis, LCL, and PFL reconstruction (group 2; n = 19). The Lysholm score, dial test, and lateral compartment opening on varus stress X-ray were used as outcome measurements evaluated before surgery and at 6, 12, and 24months of follow-up. Overall, there was a progressive improvement in the Lysholm score and the lateral opening on varus stress radiography during the evaluated periods for both groups (p < 0.001). Patients from group 2 recorded better Lysholm scores than those from group 1 at 12- and 24-month follow-up (p = 0.02). Dial test was negative in all patients after 6, 12, and 24months. Patients with popliteal tendon tenodesis were found to have better Lysholm scores than patients with reconstruction after 12 and 24months of follow-up. There was no difference in the lateral joint opening evaluated by stress radiography between groups. These results show that tenodesis could be a viable treatment option for lateral femoral condyle popliteal disruptions in the context of PLC and PCL combined injuries, and should be considered in the surgical planning process.

A Novel Fixation Method of the Graft to the Fibular Head in Knee Lateral Collateral Ligament Reconstruction: Technical Note.

The lateral collateral ligament (LCL) is the strongest lateral stabilizer of the knee. It provides support against varus stress and posterolateral rotation of the knee. Lateral collateral ligament injuries mostly occur together with anterior and/or posterior cruciate ligament injuries. While grades 1 and 2 injuries are treated conservatively since they are partial injuries, total ruptures, as in grade 3, require surgical treatment. In conventional LCL reconstruction methods, hamstring grafts are used, and bioscrews are used in bone-tendon fixation. Lateral collateral ligament reconstruction is usually performed as a component of multiple ligament surgery. Therefore, there is a need for a contralateral hamstring tendon or allograft. The present article aims to define a technique that does not require tendon grafts and bioscrews in fibular fixation.

Lateral Collateral Ligament Reconstruction With Tensionable Loops and Suture Tape Reinforcement

Background: The posterolateral corner (PLC) is an important knee stabilizer that resists varus stress, external tibial rotation, and posterior tibial translation. Untreated PLC injuries have been shown to increase failure rates of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstructions and lead to degenerative changes. Our modified Arciero technique reconstructs the femoral insertion site and functionality of the lateral collateral ligament (LCL) and popliteal fibular ligament, components of the PLC, with an internal brace and tensionable loops. Indications: The primary indication for PLC reconstruction is identified PLC injury. Patients often have a feeling of knee instability and a varus thrust gait. PLC injury should be confirmed with imaging. Technique Description: We employed a modified Arciero technique via LCL reconstruction with tensionable loops and internal brace. We used a semitendinosus allograft truncated at 240-millimeters to avoid the graft bottoming out. A suture augment was incorporated into the graft to reinforce the LCL reconstruction construct during graft tensioning and early rehabilitation. The graft construct was then passed through the transfibular tunnel to femoral sockets at the LCL and popliteus insertions. The graft construct is then affixed to the opposite femoral cortex. The graft was then tensioned with the knee in approximately 30° of flexion, neutral to 10° of internal rotation, and a valgus force applied. This restored excellent valgus stability. Results: Fibular and tibiofibular-based constructs are common procedures for PLC reconstruction. Our LCL reconstruction with tensionable loops technique and the Arciero technique are fibular-based constructs. The fibular-based construct and the tibiofibular-based construct have been found to be biomechanically equivalent at restoring knee stability. However, fibular-based constructs, such as our LCL reconstruction with tensionable loops, were found to be less technically demanding than tibiofibular-based constructs, used fewer grafts, and required a smaller surgical approach. Conclusion: Given similar clinical outcomes, it was concluded that fibular-based constructs, such as our modified Arciero technique, may be more advantageous because of the ability to avoid some of the pitfalls of tibiofibular-based constructs. 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.

Harvesting the Quadriceps Tendon With a Minimally Invasive Approach

Background: This article describes a standardized, minimally invasive approach for harvesting the quadriceps tendon through a 2 to 3 cm transverse skin incision, presenting it as a viable option. Indications: This procedure is indicated for patients undergoing anterior cruciate ligament (ACL), posterior cruciate ligament, medial collateral ligament, or lateral collateral ligament reconstruction surgery using soft tissue quadriceps grafts. Technique Description: A transverse incision is made on the anterior face of the knee, followed by a longitudinal incision of the central third of the rectus femoris. We perform the distal detachment of the patella of the same tendon. Then, the tendon is extracted using a closed stripper. The graft is prepared and folded on itself, resulting in a double graft. Results: Twenty patients, 16 male and 4 female with complete rupture of ACL, were submitted to an ACL reconstruction using the quadriceps soft tissue graft with minimally invasive harvesting technique. The results were satisfactory for all patients. All patients showed good evolution in the immediate and late postoperative period, with no cases of joint stiffness, wound dehiscence, and no infections. Discussion/Conclusion: We can conclude that harvesting the quadriceps tendon with a minimally invasive approach is a valid and reliable option for the treatment of ligament tears of the knee. 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.

Outcome of percutaneous reconstruction of chronic lateral collateral ligament rupture

PurposeMany techniques have been described for the reconstruction of chronic lateral collateral ligament (LCL) rupture with different autograft options. The advantages of percutaneous LCL reconstruction include small incisions, minimal soft tissue disruption, less postoperative pain, and speedy rehabilitation and recovery. The aim of this study was to report the functional outcome of percutaneous LCL reconstruction and overall patient satisfaction in Africans. MethodsThis prospective and interventional study involving 51 patients with chronic LCL rupture who had percutaneous LCL reconstruction using peroneus longus autograft was conducted between January 2021 and December 2022 in National Orthopaedic Hospital, Dala-Kano, Nigeria. The inclusion criteria were patients between the ages of 18 and 45 years with chronic isolated LCL and not more than 1 injury of knee ligament. Exclusion criteria were active infection, and multi-ligament knee injury requiring 2-staged surgery. The knee functions were assessed preoperatively, 3 months, 6 months, and 12 months postoperatively using the Lysholm scoring system. Patient satisfaction with the outcome of the treatment was assessed using a 5-point Likert scale. Relevant information was recorded into Microsoft Excel sheet and data was analyzed using SPSS version 23.0 for windows. The paired samples t-test was used to compare the clinical outcomes as continuous variables. Statistical significance was considered at p < 0.05. ResultsThe mean age of the patients was (30.10 ± 5.90) years. The median time from injury to surgery was 7 months (ranging from 3 to 28 months). The mean follow-up period was (14.07 ± 3.13) months. The mean preoperative and 1-year postoperative Lysholm scores were 44.33 ± 12.97 and 97.96 ± 1.23, respectively. ConclusionPercutaneous LCL reconstruction using peroneus longus autograft significantly improves patient knee function and results in excellent patient satisfaction.

Early mobilization following elective ankle lateral collateral ligament reconstruction in adults.

Emergency departments in the UK are overwhelmed with musculoskeletal trauma, 50 % of which resulting from ligamentous injuries. Of these, ankle sprains are the most prevalent, however with poor rehabilitation in the recovery period, 20 % of patients may develop chronic instability that may necessitate operative reconstruction. At present, there are no national guidelines or protocols to help direct postoperative rehabilitation and determine weightbearing status. Our aim is to review the existing literature that investigated postoperative outcomes following different rehabilitation protocols in patients with Chronic Lateral Collateral Ligament (CLCL) instability. A literature search was performed via Medline, Embase and Pubmed databases using the terms 'ankle', 'lateral ligament', 'repair'. 'reconstruction' and 'early mobilisation'. A total of 19 studies were identified after filtering that they were English language papers. A gray literature search was also performed using the Google search engine. Based on the literature reviewed, patients undergoing early mobilisation and Range Of Movement (ROM) following lateral ligament reconstruction for chronic instability seem to have better functional outcomes and earlier return to work and sports. This is however in the short-term, and there are no medium to long-term studies evaluating the effects of early mobilisation on ankle stability. Furthermore, there may be an increased risk of postoperative complications, mainly wound related, with early mobilization compared to delayed mobilization. Further randomized studies and long-term prospective studies with larger cohorts of patients are required to improve the level of evidence available but based on current literature it would appear that controlled early ROM and weight-bearing is advisable in patients undergoing surgery for CLCL instability.

Preoperative and operative risk factors for failed lateral collateral ligament reconstruction

Repair or reconstruction of the lateral collateral ligament (LCL) using autograft or allograft is a well-accepted treatment of posterolateral rotatory instability. The prevalence and causes for failure of LCL reconstruction are not well documented in the literature. Any approach to the assessment and management of failed LCL reconstruction must begin with understanding the risk factors for failure in the first place. Such understanding would likely make many failures preventable as well. In our experience, there are a number of identifiable preoperative risk factors concerning bony and/or soft tissue constraints for failure of LCL reconstruction. There are also operative factors such as tunnel and graft placement as well as excessive lateral condyle stripping that play a role in risk of failure. This report is an attempt to provide a systematic approach to identifying and managing the preoperative and operative risk factors. Further studies are warranted to determine the indications for, and success rates of surgical intervention in managing these risk factors.

Effect of preoperative anterior bony impingement on lateral collateral ankle ligament reconstruction

Objective: To explore whether the combination of anterior bony impingement before surgery will affect the efficacy of the lateral collateral ankle ligament reconstruction surgery in patients with chronic ankle instability (CAI). Methods: A prospective cohort study. Patients with CAI who underwent lateral collateral ankle ligament reconstruction from January 2014 to October 2017 in the Department of Sports Medicine, Huashan Hospital, Fudan University were enrolled in this study. The patients were divided into no bony impingement group (NI group) and bony impingement group (BI group) according to the presence of bone impingement in front of the ankle during the operation. Preoperative American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson ankle functional socre (KAFS), Tegner score, visual analogue scale (VAS) of pain were extracted and were reevaluated at least 2 years after surgery as well as imaging evaluation of ankle. Results: A total of 59 patients were enrolled in this study. There were 29 patients in the NI group, 23 males and 6 females with a mean age of (28.4±7.1) years. And there were 30 cases in the BI group, 28 males and 2 females with a mean age of (31.9±8.6) years. The AOFAS, KAFS and Tegner scores in NI group increased from 65.8±10.6, 65.9±10.1 and 3.0 (3.0, 4.0) before the operation to 97.5±4.3, 97.8±4.7 and 6.0(5.0,6.0) after the operation, respectively; and the VAS decreased from 3.0(3.0, 4.0) to 0(0, 0); there were significant differences in those indexes before and after the operation (all P<0.05). The scores of AOFAS, KAFS and Tegner in BI group increased from 65.2±11.0, 64.2±10.0 and 3.0(3.0, 4.0) before the operation to 97.1±4.3, 97.3±4.3 and 5.0(4.0, 6.0) post the operation, respectively; and the VAS scores decreased from 3.0(3.0, 5.0) to 0(0, 1.0); there were significant differences in up-mentioned indexes before and after the surgery (all P<0.05). There was no significant differences in baseline and preoperative clinical function scores between the two groups (all P>0.05). No significant difference was found in postoperative AOFAS, KAFS and VAS scores between the two groups (all P>0.05), while postoperative Tegner score in the NI group was significantly higher than that in the BI group [6.0(5.0, 6.0) vs 5.0(4.0, 6.0), P=0.026]. Imaging evaluation of all patients showed that the reconstructed ligament was clearly visible, and the intraarticular injuries existing before surgery showed obvious signs of healing. Conclusion: Ankle lateral collateral ligament reconstruction for CAI with or without anterior bony impingement results in similar outcomes in ankle function, stability and pain levels.

Minimally Invasive Knee Lateral Collateral Ligament Reconstruction Using Partial Biceps Femoris Tendon Autograft

Lateral collateral ligament (LCL) is known as an important ligament to restrain varus force of the knee, especially in 30° knee flexion. From the anatomical study, the insertion of LCL at proximal fibula is intimately close to the insertion of biceps femoris (BF) tendon. Since LCL is infrequently injured in isolation, and with limitation in availability of autograft and allograft, this study proposes the partial anterior BF tendon as an alternative autograft source to reconstruct the LCL. This could be performed either by minimally invasive procedure or standard open technique. The core concept is to preserve the posterior part of the BF tendon to protect the peroneal nerve, by which exploration of this nerve and the proximal fibula prior to LCL reconstruction could be exempted. Minimally invasive LCL reconstruction using this autograft would essentially reduce soft tissue injury, shorten the operative time, and enhance recovery of the reconstructed knee.

Arthroscopic lateral collateral ligament imbrication of the elbow: short-term clinical results.

Chronic posterolateral rotatory instability (PLRI) of the elbow results from an insufficient lateral collateral ligament (LCL) complex. Arthroscopic LCL imbrication may prove a minimally invasive alternative to open lateral ulnar collateral ligament (LUCL) reconstruction with a quicker rehabilitation. The purpose of this study is to analyze the validity of a modified arthroscopic imbrication technique. We hypothesized that arthroscopic LUCL imbrication would yield stable elbows in patients with grade 1 or 2 chronic PLRI at a minimum of 2 year of follow-up. We retrospectively assessed data of all PLRI patients who underwent arthroscopic LUCL imbrication from 2010 to 2013 (n=20). Stage 3 PLRIs (frank ulnohumeral dislocations) were excluded from this treatment. After confirmation of PLRI during standard elbow arthroscopy, a doubled absorbable suture is shuttled through as much LCL tissue as possible (from the lateral ulnar border to the area proximal to the lateral epicondyle) and the sutures are tied. This results in a plication of the entire LCL complex. Objective elbow stability was assessed using a combination of the pivot shift, table top, and posterior drawer tests. Of 20 included patients, 18 were stable subjectively and objectively at a minimum of 2 year of follow-up. Mean Mayo Elbow Performance Score improved from 48 preoperatively to 88.9 at final follow-up (P<.001). Mean Quick-Disabilities of the Arm, Shoulder, and Hand score improved from 53 preoperatively to 10.3 at final follow-up (P<.001). One patient developed elbow stiffness. Two patients reported tenderness of the subcutaneous PDS knots. As a less invasive alternative to open LCL reconstruction using a graft, arthroscopic LCL imbrication has demonstrated acceptable rates of perceived elbow stability among patients with stage 1 or 2 PLRI.

Arthroscopic anatomical reconstruction of lateral collateral ligaments with ligament advanced reinforcement system artificial ligament for chronic ankle instability.

BACKGROUNDRecently, the use of ligament advanced reinforcement system (LARS) artificial ligament, a new graft which has several unique advantages such as no donor-site morbidity, early recovery and no risk of disease transmission which has been a significant breakthrough for anatomical ligament reconstruction. Growing studies suggested that the special design of the LARS ligament with open fibers in its intra-articular part was believed to be more resistant to torsional fatigue and wearing. However, the safety and efficacy of LARS artificial ligament for ankle joint lateral collateral ankle ligament reconstruction has not been defined to date.AIMTo evaluate the clinical results of all-arthroscopic anatomical reconstruction of ankle joint lateral collateral ligaments with the LARS artificial ligament for chronic ankle instability.METHODSTwenty-two patients with chronic lateral instability underwent anatomical reconstruction of the lateral collateral ligaments of ankle with LARS artificial ligament. The visual analogue score (VAS), American Orthopaedic Foot and Ankle Society score (AOFAS score) and Karlsson score were used to evaluate the clinical results before and after surgery.RESULTSA total of 22 patients (22 ankles) were followed up for a mean of 12 mo. All patients reported significant improvement compared to their preoperative status. The mean AOFAS score improved from 42.3 ± 4.9 preoperatively to 90.4 ± 6.7 postoperatively. The mean Karlsson score improved from 38.5 ± 3.2 preoperatively to 90.1 ± 7.8 postoperatively. The mean VAS score improved from 1.9 ± 2.5 preoperatively to 0.8 ± 1.7 postoperatively.CONCLUSIONAll-arthroscopic anatomical reconstruction of the lateral collateral ligaments with LARS artificial ligament achieved a satisfactory surgical outcome for chronic ankle instability.

Posterolateral Corner Reconstruction of the Knee Using Gracilis Autograft and Biceps Femoris

We introduce our technique for posterolateral corner reconstruction, which is based on the principle described in Arciero’s technique for anatomic reconstruction of lateral collateral ligament (LCL) and popliteofibular ligament (PFL) to gain static stability in varus strain and external rotation. This technique uses a doubled gracilis autograft to reconstruct the PFL and a split biceps tendon transfer to reconstruct the LCL. Using this technique an anatomical LCL and PFL reconstruction can be performed in combination with anterior cruciate ligament or posterior cruciate ligament reconstruction without contralateral graft harvest or allograft. The technique also enables an isolated reconstruction of LCL or PFL when required and can be performed to augment an acute repair.

Lateral Collateral Ligament and Biceps Femoris Tendon Fixation with a Suture Anchor to the Tibial Metaphysis after Proximal Fibula En Bloc Resections Preserve Lateral Knee Stability.

This study aims to analyze the functional outcomes and lateral knee stability of patients who underwent lateral collateral ligament (LCL) and biceps femoris tendon reconstruction with suture anchors after proximal fibula en bloc resection for bone tumors. Patients who underwent proximal fibular en bloc resection between 2007 and 2018 were retrospectively viewed. Patients were invited to visit the clinic, and their functional scores were evaluated using the Musculoskeletal Tumor Society Scoring (MSTS) system. Lateral knee stability was evaluated by varus stress radiographs obtained at 20 degrees of flexion, and the range of motion (ROM) of the bilateral knee was assessed. Side-to-side differences were graded according to the International Knee Documentation Committee (IKDC) criteria and compared between types I and II resections. A total of 17 patients (4 males and 13 females) with a mean age of 31.1 ± 17.1 (range: 13-65) years at the time of surgery were available for radiological and clinical examination at a mean follow-up of 68.6 ± 36.4 (range: 22-124) months after surgery. In terms of ROM measurements, IKDC grades and side-to-side differences in both flexion and extension were not significantly different between the groups. On varus stress radiographs, lateral knee gapping was measured to be 0.93 ± 0.91 mm in type-I resections and 1.83 ± 0.45 mm in type-II resections, and statistically significant differences were detected among the groups (p = 0.039). When the values were graded according to IKDC criteria, none of the knees were classified as abnormal, and no difference was observed between the groups. Mean MSTS score of patients with type-I resections was significantly higher than those of patients with type-II resections (92.7 vs. 84.4%, p = 0.021). In the subscale analysis, a significant difference was observed in the support scores (type I = 94.5%, type II = 70%; p = 0.001). The reattachment of LCL and biceps femoris tendon to the tibial metaphysis with a suture anchor is a simple and effective method to prevent lateral knee instability after proximal fibula resections.

Valgus Deformity and Posterolateral Instability after Elbow Dislocation in a Pediatric Patient- Case Report

Introduction: The aim of this paper is to report a rare case of a child who suffered a simple elbow dislocation (SED) that developed a post-traumatic valgus deformity and a subsequent posterolateral elbow instability. Case Report: We report a case of a female patient who suffered a posterolateral SED of her elbow at the age of 12. She was treated with closed reduction and over the years, she developed an asymptomatic valgus deformity. At the age of 16, she suffered a fall trauma while playing field hockey with a re-dislocation of the elbow. Since then, she presented multiple episodes of subluxation. A supracondylar subtractive wedge osteotomy of 20° and double plate osteosynthesis was performed with reconstruction of the ulnar lateral collateral ligament. Conclusion: The focus of this article must be on the unusual occurrence of this sequence of conditions. SED is rare in children and generally associated with medial epicondyle fractures. The occurrence of a valgus deformity resulting from an injury to the periosteum can be present and must be taken into account. Posterolateral instability is rare in the context of a valgus elbow. Angular correction osteotomy and ligament reconstruction can be associated with good functional and aesthetic results.

The Cinch Knot Technique of Anatomical Fibular Collateral Ligament Reconstruction

Reconstructing the lateral collateral ligament (LCL) has started gaining importance with better appreciation of the knee anatomy and biomechanics. Over the years, a multitude of reconstructive techniques have been described. Among these, the anatomical reconstructions closely reproduce the native anatomy with better functional outcomes. In this technical note, we have described the cinch knot technique of anatomical LCL reconstruction, an implant free technique at the fibular end which satisfactorily recreates the native footprint of the LCL.

Arthroscopic Lateral Collateral Ligament Complex Reconstruction for Posterolateral Rotatory Instability of the Elbow, the Operative Technique

Posterolateral rotatory instability is concerning pathology in patients with recalcitrant lateral elbow pain. An arthroscopic technique can be used to perform reconstruction of lateral collateral ligament for eradicating the instability and also to manage concomitant lesions in a simultaneous operation. Similar to the modified Brostrӧm procedure using an inferior extensor retinaculum to augment the lateral collateral ligament for lateral ankle instability, in our Technical Note, we use anconeus muscles and annular ligament to augment the lateral collateral ligament for elbow instability during the reconstruction, allowing all tissue to heal with the bone by using a knotless technique.

Is There a Disadvantage to Early Physical Therapy After Multiligament Surgery for Knee Dislocation? A Pilot Randomized Clinical Trial.

Multiligament knee injuries, though rare, can be profoundly disabling. Surgeons disagree about when to initiate rehabilitation after surgical reconstruction due to the conflicting priorities of postoperative stability and motion. (1) Does early or late initiation of physical therapy after multiligament knee surgery result in fewer postoperative manipulations? (2) Does early versus late physical therapy compromise stability postoperatively? (3) Does early initiation of physical therapy result in improved patient-reported outcomes, as measured by the Multi-ligament Quality of Life (ML-QOL) score? Between 2011 and 2016, 36 adults undergoing multiligament repair or reconstruction were prospectively enrolled in a randomized controlled trial and randomized 1:1 to either early rehabilitation or late rehabilitation after surgery. Eligibility included those with an injury to the posterior cruciate ligament (PCL) and at least one other ligament, as well as the ability to participate in early rehabilitation. Patients who were obtunded or unable to adhere to the protocols for other reasons were excluded. Early rehabilitation consisted of initiating a standardized physical therapy protocol on postoperative day 1 involving removal of the extension splint for quadriceps activation and ROM exercises. Late rehabilitation consisted of full-time immobilization in an extension splint for 3 weeks. Following this 3-week period, both groups engaged in the same standardized physical therapy protocol. All surgical reconstructions were performed at a single center by one of two fellowship-trained sports orthopaedic surgeons, and all involved allograft Achilles tendon PCL reconstruction. When possible, hamstring autograft was used for ACL and medial collateral ligament reconstructions, whereas lateral collateral ligament and posterolateral reconstruction was performed primarily with allograft. The primary outcome was the number of patients undergoing manipulation during the first 6 months. Additional outcomes added after trial registration were patient-reported quality of life scores (ML-QOL) at 1 year and an objective assessment of laxity through a physical examination and stress radiographs at 1 year. One patient from each group was not assessed for laxity or ROM at 1 year, and one patient from each group did not complete the ML-QOL questionnaires. No patient crossover was observed. With the numbers available, there was no difference in the use of knee manipulation during the first 6 months between the rehabilitation groups: 1 of 18 patients in the early group and 4 of 18 patients in the late group (p = 0.34). Similarly, there were no differences in knee ROM, stability, or patient-reported quality of life (ML-QOL) between the groups at 1 year. With the numbers available in this study, we were unable to demonstrate a difference between early and late knee rehabilitation with regard to knee stiffness, laxity, or patient-reported quality of life outcomes. The results of this small, randomized pilot study suggest a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies. Level II, therapeutic study.

A case of PLRI of the elbow with lateral collateral ligament reconstruction by triceps fascia

A case of PLRI of the elbow with lateral collateral ligament reconstruction by triceps fascia

Biomechanical comparison of lateral collateral ligament reconstruction with and without additional internal bracing using a three-dimensional elbow simulator

BackgroundAlthough an additional internal bracing significantly increases stability in a repair of the lateral ulnar collateral ligament, it remains unclear whether it also does in reconstruction. Aim of this study was to implement a three-dimensional elbow simulator for testing posterolateral rotatory instability. We hypothesized that (1) reconstruction with and without internal bracing is comparable in biomechanical properties, and (2) there would be higher load-to-failure with internal bracing. MethodsPosterolateral rotatory instability was tested by imitating the lateral pivot shift test in 16 elbows. Valgus and supination torques were simultaneously increased stepwise up to 1.2 Nm. Specimens were tested at 30°, 60°, 90°, and 120° elbow flexion with an intact lateral collateral ligament complex, dissected complex, and after reconstruction with or without internal bracing. Outcome measures included joint gapping, laxity, and load to failure. FindingsWith the implemented elbow simulator no significant difference was observed for gapping or laxity between both treatment groups. Comparing treatment and native ligament, gapping was reduced, especially with increased elbow flexion. Laxity was also reduced at some flexion angles. The mean load-to-failure was 8.1 ± 2.7 Nm without and 9.6 ± 3.6 Nm with internal bracing (P = 0.645). InterpretationBoth treatments were comparable in biomechanical properties but did not fully restore the native state. Although the additional augmentation of the LUCL reconstruction tends to increase the maximum load to failure, this difference was not statistically significant. Still, reconstruction with internal bracing seems to be a reasonable option in selected primary reconstructions. It could also be useful in revision reconstruction.