Femoral Positioning of the Anterolateral Ligament Graft With and Without Ultrasound Location of the Lateral Epicondyle

Background: In anterior cruciate ligament (ACL) reconstruction with anterolateral ligament (ALL) reconstruction, precise positioning of the ALL graft on the femur and tibia is key to achieve rotational control. The lateral femoral epicondyle is often used as a reference point for positioning of the ALL graft and can be located by palpation or with ultrasound guidance. Purpose: To compare the ALL graft positioning on the femoral side between an ultrasound-guided technique and a palpation technique for the location of the lateral epicondyle. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 120 patients receiving a primary combined ACL and ALL reconstruction between June and December 2019 were included. The location of the lateral epicondyle was determined by palpation in the palpation group (n = 60) and with preoperative ultrasound guidance in the ultrasound group (n = 60). Groups were comparable in age, sex, body mass index (BMI), and operated side. The planned positioning of the femoral ALL graft was proximal and posterior to the lateral epicondyle. The effective positioning of the femoral ALL graft was evaluated on postoperative lateral radiographs. The primary outcome was location of the graft in a 10-mm quadrant posterior and proximal to the lateral epicondyle. Results were analyzed in 2 subgroups according to BMI. Results: All 60 anterolateral grafts (100%) in the ultrasound group were positioned in a 10-mm quadrant posterior and proximal to the lateral epicondyle, as opposed to 52 (87%) in the palpation group ( P = .006). Errors in graft positioning with palpation occurred in overweight patients (BMI >25) as well as nonoverweight patients ( P = .3). Conclusion: Femoral positioning of the ALL graft posterior and proximal to the lateral epicondyle is more reproducible with ultrasound guidance when compared with palpation alone, regardless of BMI.

Download Full-text

Injuries to the anterolateral ligament are observed more frequently compared to lesions to the deep iliotibial tract (Kaplan fibers) in anterior cruciate ligamant deficient knees using magnetic resonance imaging

Knee Surgery Sports Traumatology Arthroscopy ◽

10.1007/s00167-021-06535-6 ◽

2021 ◽

Author(s):

Armin Runer ◽

Dietmar Dammerer ◽

Christoph Kranewitter ◽

Johannes M. Giesinger ◽

Benjamin Henninger ◽

...

Keyword(s):

Pediatric Patients ◽

Cruciate Ligament ◽

Injury Rate ◽

Anterolateral Ligament ◽

Anatomical Reconstruction ◽

Level Of Evidence ◽

Iliotibial Tract ◽

Anterolateral Complex ◽

Anterior Cruciate ◽

Combined Injuries

Abstract Purpose To determine the accuracy of detection, injury rate and inter- and intrarater reproducibility in visualizing lesions to the anterolateral ligament (ALL) and the deep portion of the iliotibial tract (dITT) in anterior cruciate ligament (ACL) deficient knees. Methods Ninety-one consecutive patients, out of those 25 children (age 14.3 ± 3.5 years), with diagnosed ACL tears were included. Two musculoskeletal radiologists retrospectively reviewed MRI data focusing on accuracy of detection and potential injuries to the ALL or dITT. Lesion were diagnosed in case of discontinued fibers in combination with intra- or peri-ligamentous edema and graded as intact, partial or complete tears. Cohen’s Kappa and 95% confidence intervals (95% CI) were determined for inter- and intrarater reliability measures. Results The ALL and dITT were visible in 52 (78.8%) and 56 (84.8%) of adult-and 25 (100%) and 19 (76.0%) of pediatric patients, respectively. The ALL was injured in 45 (58.5%; partial: 36.4%, compleate: 22.1%) patients. Partial and comleate tears, where visualized in 21 (40.4%) and 16 (30.8%) adult- and seven (28.0%) and one (4%) peditric patients. A total of 16 (21.3%; partial: 13.3%, compleate: 8.0%) dITT injuries were identified. Partal and complete lesions were seen in seven (12.5%) and five (8.9%) adult- and three (15.8%) and one (5.3%) pediatric patients. Combined injuries were visualized in nine (12.7%) patients. Inter-observer (0.91–0.95) and intra-observer (0.93–0.95) reproducibility was high. Conclusion In ACL injured knees, tears of the ALL are observed more frequently compared to lesions to the deep iliotibial tract. Combined injuries of both structures are rare. Clinically, the preoperative visualization of potentially injured structures of the anterolateral knee is crucial and is important for a more personalized preoperative planning and tailored anatomical reconstruction. The clinical implication of injuries to the anterolateral complex of the knee needs further investigation. Level of evidence II.

Download Full-text

Epidemiological Evaluation of Meniscal Ramp Lesions in 3214 Anterior Cruciate Ligament–Injured Knees From the SANTI Study Group Database: A Risk Factor Analysis and Study of Secondary Meniscectomy Rates Following 769 Ramp Repairs

The American Journal of Sports Medicine ◽

10.1177/0363546518800717 ◽

2018 ◽

Vol 46 (13) ◽

pp. 3189-3197 ◽

Cited By ~ 26

Author(s):

Bertrand Sonnery-Cottet ◽

Cesar Praz ◽

Nikolaus Rosenstiel ◽

William G. Blakeney ◽

Herve Ouanezar ◽

...

Keyword(s):

Risk Factors ◽

Anterior Cruciate Ligament ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Anterolateral Ligament ◽

Partial Meniscectomy ◽

Level Of Evidence ◽

Anterolateral Ligament Reconstruction ◽

Anterior Cruciate

Background: Ramp lesions are characterized by disruption of the peripheral meniscocapsular attachments of the posterior horn of the medial meniscus. Ramp repair performed at the time of anterior cruciate ligament reconstruction (ACLR) has been shown to improve knee biomechanics. Purpose: The primary objectives of this study were to evaluate the incidence of and risk factors for ramp lesions among a large series of patients undergoing ACLR. Secondary objectives were to determine the reoperation rate for failure of ramp repair, defined by subsequent reoperations for partial medial meniscectomy. Study Design: Case-control study; Level of evidence, 3. Case series; Level of evidence, 4. Methods: All patients underwent transnotch posteromedial compartment evaluation of the knee during ACLR. Ramp repair was performed if a lesion was detected. Potentially important risk factors were analyzed for their association with ramp lesions. A secondary analysis of all patients who underwent ramp repair and had a minimum follow-up of 2 years was undertaken to determine the secondary partial meniscectomy rate for failed ramp repair. Results: The overall incidence of ramp lesions in the study population was 23.9% (769 ramp lesions among 3214 patients). Multivariate analysis demonstrated that the presence of ramp lesions was significantly associated with the following risk factors: male sex, patients aged <30 years, revision ACLR, chronic injuries, preoperative side-to-side laxity >6 mm, and concomitant lateral meniscal tears. The secondary meniscectomy rate was 10.8% at a mean follow-up of 45.6 months (range, 24.2-66.2 months). Patients who underwent ACLR + anterolateral ligament reconstruction had a >2-fold reduction in the risk of reoperation for failure of ramp repair as compared with patients who underwent isolated ACLR (hazard ratio, 0.457; 95% CI, 0.226-0.864; P = .021). Conclusion: There is a high incidence of ramp lesions among patients undergoing ACLR. The identification of important risk factors for ramp lesions should help raise an appropriate index of suspicion and prompt posteromedial compartment evaluation. The overall secondary partial meniscectomy rate after ramp repair is 10.8%. Anterolateral ligament reconstruction appears to confer a protective effect on the ramp repair performed at the time of ACLR and results in a significant reduction in secondary meniscectomy rates.

Download Full-text

High Prevalence of Anterolateral Ligament Abnormalities on MRI in Knees With Acute Anterior Cruciate Ligament Injuries: A Case-Control Series From the SANTI Study Group

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119852916 ◽

2019 ◽

Vol 7 (6) ◽

pp. 232596711985291 ◽

Cited By ~ 12

Author(s):

Andrea Ferretti ◽

Edoardo Monaco ◽

Andrea Redler ◽

Giuseppe Argento ◽

Angelo De Carli ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Clinical Decision Making ◽

Cruciate Ligament ◽

Anterolateral Ligament ◽

Iliotibial Band ◽

Level Of Evidence ◽

Control Series ◽

Anterior Cruciate ◽

Injured Knee ◽

Mri Evaluation

Background: Broad variation in the reported rate of magnetic resonance imaging (MRI)–detected abnormalities of the anterolateral structures of the anterior cruciate ligament (ACL)–injured knee suggests a lack of reliability that has limited the use of MRI in clinical decision making. Purpose/Hypothesis: The aim of this study was to use MRI to determine the prevalence and spectrum of abnormalities of the anterolateral structures in acute ACL-injured knees, using the contralateral uninjured knee as a reference. We hypothesized that MRI evaluation of the acutely injured knee (using the uninjured knee as a reference) would allow reliable identification of abnormalities of the anterolateral structures. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Patients with acute ACL injury underwent MRI scan of both knees. Images were evaluated by 3 observers. Inter- and intraobserver reliabilities were determined for MRI parameters of anterolateral ligament (ALL) injury by use of the kappa (κ) test. Univariate and multivariate analyses were conducted to test associations between ALL abnormality and associated injuries. Results: A total of 34 patients were evaluated. Of these, 30 patients (88.2%) had at least 1 ALL abnormality in the ACL-injured knee (increased signal: n = 27[79.4%]; increased thickness: n = 15[44.1%]; tapering: n = 7[20.6%]; irregularities in the path of the ALL fibers: n = 21[61.7%]). Asymmetries of the genicular vessels were observed in 21 patients (61.7%). ALL abnormality was significantly associated with lateral joint capsular tears ( P < .001). No correlation was found between ALL lesions and iliotibial band lesions ( P = .49). Inter- and intraobserver reliabilities were very good concerning ALL signal changes and femoral and tibial bone bruises (κ coefficient, 0.81-1). Conclusion: MRI evaluation of the ALL was associated with good and very good inter- and intraobserver reliabilities, and it demonstrated abnormalities of the ALL in the majority of acutely ACL-injured knees. The index of suspicion for ALL injury should be elevated by the presence of lesions of the lateral capsule. This suggests that the ALL is part of a wider area of the lateral capsule that is often injured simultaneously in an acute ACL tear.

Download Full-text

Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Reconstruction With a Single-Strand Gracilis Graft

Arthroscopy Techniques ◽

10.1016/j.eats.2021.01.041 ◽

2021 ◽

Author(s):

Jean-Marie Fayard ◽

Alexandre Penet ◽

Paul-Henri Bauwens ◽

Mathieu Thaunat

Keyword(s):

Anterior Cruciate Ligament ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Anterolateral Ligament ◽

Single Strand ◽

Ligament Repair ◽

Anterolateral Ligament Reconstruction ◽

Anterior Cruciate Ligament Repair ◽

Anterior Cruciate

Download Full-text

Graft Preparation for Combined ACL and ALL Reconstruction With a Single Femoral Tunnel

Video Journal of Sports Medicine ◽

10.1177/26350254211004597 ◽

2021 ◽

Vol 1 (3) ◽

pp. 263502542110045

Author(s):

Camilo Partezani Helito ◽

Tales Mollica Guimarães ◽

Marcel Faraco Sobrado

Keyword(s):

Anterior Cruciate Ligament ◽

High Risk ◽

Cruciate Ligament ◽

Anterolateral Ligament ◽

Anatomical Landmarks ◽

High Risk Patients ◽

Risk Patients ◽

Anterior Cruciate ◽

Semitendinosus Graft ◽

Lemaire Procedure

Background: Combined reconstruction of the anterolateral ligament (ALL) and anterior cruciate ligament (ACL) has shown excellent results. It could potentially reduce graft failure and improve outcomes in high-risk patients. There are several surgical techniques described. Hamstrings are the most frequently used graft for ALL reconstruction. The distal portion of the iliotibial band is used for the modified Lemaire procedure. Indications: Anterior cruciate ligament reconstructions associated with the following risk factors: pivoting sports, high-demand athletes, high-grade pivot-shift, chronic ACL injury, lateral femoral condyle notch, Segond fractures, young patients (<20 years), ACL revision, generalized hyperlaxity, and Lachman >7 mm. Technique Description: Semitendinosus and gracilis tendons are harvested and their extremities are prepared with continuous suture. The semitendinosus graft is folded in 3 parts leaving the ends of the graft internalized. The triple semitendinosus will be the main component of the ACL and the single gracilis will be used for both ACL and ALL. Anterolateral ligament anatomical landmarks are proximal and posterior to the lateral epicondyle in the femur, and in the mid distance from the fibular head and the Gerdy tubercle in the tibia. The ALL is fixed in knee extension with interference screws. This video also includes a brief demonstration of graft preparation for the modified Lemaire procedure. Results: Results from our group using this technique have shown excellent clinical outcomes, minimal complications, and low failure rates in high-risk populations. This graft preparation shows excellent diameter and length for combined ACL and ALL reconstruction. Conclusion: This technique is easy to perform, with minimal complications, and should be considered in high-risk patients undergoing ACL reconstruction.

Download Full-text