scholarly journals Diagnosis and treatment of rotatory knee instability

2019 ◽  
Vol 6 (1) ◽  
Author(s):  
Jonathan D. Hughes ◽  
Thomas Rauer ◽  
Christopher M. Gibbs ◽  
Volker Musahl
Keyword(s):  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Three Dimensional ◽  
Knee Instability ◽  
Rotational Stability ◽  
Main Body ◽  
Anatomic Acl Reconstruction ◽  
Select Group ◽  
Wide Range ◽  
Rotation Motion

Abstract Background Rotatory knee instability is an abnormal, complex three-dimensional motion that can involve pathology of the anteromedial, anterolateral, posteromedial, and posterolateral ligaments, bony alignment, and menisci. To understand the abnormal joint kinematics in rotatory knee instability, a review of the anatomical structures and their graded role in maintaining rotational stability, the importance of concomitant pathologies, as well as the different components of the knee rotation motion will be presented. Main Body The most common instability pattern, anterolateral rotatory knee instability in an anterior cruciate ligament (ACL)-deficient patient, will be discussed in detail. Although intra-articular ACL reconstruction is the gold standard treatment for ACL injury in physically active patients, in some cases current techniques may fail to restore native knee rotatory stability. The wide range of diagnostic options for rotatory knee instability including manual testing, different imaging modalities, static and dynamic measurement, and navigation is outlined. As numerous techniques of extra-articular tenodesis procedures have been described, performed in conjunction with ACL reconstruction, to restore anterolateral knee rotatory stability, a few of these techniques will be described in detail, and discuss the literature concerning their outcome. Conclusion In summary, the essence of reducing anterolateral rotatory knee instability begins and ends with a well-done, anatomic ACL reconstruction, which may be performed with consideration of extra-articular tenodesis in a select group of patients.

Biomechanical Evaluation of Anterolateral Ligament Repair augmented with Internal Brace

2021 ◽  
Author(s):  
Ryan P. Roach ◽  
David P. Beason ◽  
Jonathan S. Slowik ◽  
A. Ryves Moore ◽  
Ajay C. Lall ◽  
...  
Keyword(s):  
Internal Rotation ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Surgical Techniques ◽  
Anterolateral Ligament ◽  
Torsional Stiffness ◽  
Rotational Stability ◽  
Gap Formation ◽  
Internal Brace ◽  
Acl Deficient

AbstractInjuries to the anterolateral ligament (ALL) of the knee are commonly associated with anterior cruciate ligament (ACL) ruptures. Biomechanical studies have demonstrated conflicting results with regard to the role of the ALL in limiting tibial internal rotation. Clinically, residual pivot shift following ACL reconstruction has been reported to occur up to 25% and has been correlated with poor outcomes. As such, surgical techniques have been developed to enhance rotational stability. Recent biomechanical studies have demonstrated restoration of internal rotational control following ALL reconstruction. The purpose of our study was to understand the biomechanical effects of ACL reconstruction with an ALL internal brace augmentation. We hypothesized that (1) sectioning of the ALL while preserving other lateral extra-articular structures would lead to significant internal rotation laxity and gap formation and (2) ALL repair with internal brace augmentation would lead to reduction in internal rotation instability and gap formation. In total, 10 fresh-frozen cadaveric knees were thawed and biomechanically tested in internal rotation for 10 cycles of normal physiologic torque in the intact, ACL-deficient, ACL/ALL-deficient, ACL-reconstructed, and ALL-repaired conditions. Each condition was tested at 30, 60, and 90 degrees of flexion. Following the final ALL-repaired condition, specimens were additionally subjected to a final internal rotation to failure at 1 degree at the last-tested degree of flexion. Kinematic measurements of angle and linear gap between the femur and tibia were calculated in addition to torsional stiffness and failure torque. As hypothesized, ALL repair with internal brace augmentation significantly reduced internal rotation angular motion and gap formation at flexion angles greater than 30 degrees. Additionally, ALL sectioning produced nonsignificant increases in internal rotation laxity and gap formation compared with ACL-deficient and ACL-reconstructed states, which did not support our other hypothesis.

scholarly journals Percutaneous MCL reconstruction technique in acute anterior medial knee instability using cadaveric grafts

2014 ◽  
Vol 2 (12_suppl4) ◽  
pp. 2325967114S0025
Author(s):  
Jorge Batista ◽  
Rodrigo Maestu ◽  
Sebastián Teper ◽  
Manuel Ocampo ◽  
German Antúnez ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Functional Results ◽  
Lysholm Score ◽  
High Rate ◽  
Knee Instability ◽  
Reconstruction Technique ◽  
Medial Knee ◽  
Acute Injuries ◽  
Anterior Cruciate

Purpose: There are several alternatives described for the treatment of acute injuries of the anterior cruciate ligament (ACL ) and the medial collateral ligament (MCL) of the knee. We present the result of the combined ACL reconstruction and MCL in the same surgical procedure using only percutaneous cadaveric graft in the reconstruction of the MCL ligament. Methods: We retrospectively analyzed 30 patients with acute anterior and medial knee instability surgically treated between August 2007 and September 2013. 27 men and 3 women , mean age 30.53 years (range 18-46 ) The level of pre and post surgical activity was determined by the Tegner score , while the function was evaluated using the Lysholm score and IKDC grade Results: The average follow-up was 43 months (range 12-84 months). The mean Lysholm score was 91 (R, 61-100 ) . Only 19 of 30 (63.3 %) patients returned and kept the pre -injury level sports ; 26 patients IKDC : A (normal knee ), 3 patients IKDC : B (slightly abnormal knee ) and 1 patient IKDC C ( Knee abnormal) with limitation of 15 degrees of extension that had to be reoperated. Conclusion: The use of cadaveric tendons for reconstruction of MCL in combination with ACL reconstruction surgeries resulted in less postoperative pain, good functional results, and a high rate of return to competitive sport. The result of this study shows that the percutaneous reconstruction of LCM cadaveric graft is a viable option.

The Contribution of Partial Meniscectomy to Preoperative Laxity and Laxity After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction: In Vivo Kinematics With Navigation

2019 ◽  
Vol 47 (13) ◽  
pp. 3203-3211
Author(s):  
Alberto Grassi ◽  
Stefano Di Paolo ◽  
Gian Andrea Lucidi ◽  
Luca Macchiarola ◽  
Federico Raggi ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Knee Flexion ◽  
Cruciate Ligament ◽  
Single Bundle ◽  
Anatomic Acl Reconstruction ◽  
Medial Meniscectomy ◽  
Lateral Meniscectomy ◽  
Anterior Cruciate

Background: Limited in vivo kinematic information exists on the effect of clinical-based partial medial and lateral meniscectomy in the context of anterior cruciate ligament (ACL) reconstruction. Hypothesis: In patients with ACL deficiency, partial medial meniscus removal increases the anteroposterior (AP) laxity with compared with those with intact menisci, while partial lateral meniscus removal increases dynamic laxity. In addition, greater postoperative laxity would be identified in patients with partial medial meniscectomy. Study design: Cross-sectional study; Level of evidence, 3. Methods: A total of 164 patients with ACL tears were included in the present study and divided into 4 groups according to the meniscus treatment they underwent: patients with partial lateral meniscectomy (LM group), patients with partial medial meniscectomy (MM group), patients with partial medial and lateral meniscectomy (MLM group), and patients with intact menisci who did not undergo any meniscus treatment (IM group). A further division in 2 new homogeneous groups was made based on the surgical technique: 46 had an isolated single-bundle anatomic ACL reconstruction (ACL group), while 13 underwent a combined single-bundle anatomic ACL reconstruction and partial medial meniscectomy (MM-ACL group). Standard clinical laxities (AP translation at 30° of knee flexion, AP translation at 90° of knee flexion) and pivot-shift (PS) tests were quantified before and after surgery by means of a surgical navigation system dedicated to kinematic assessment. The PS test was quantified through 3 different parameters: the anterior displacement of the lateral tibial compartment (lateral AP); the posterior acceleration of the lateral AP during tibial reduction (posterior acceleration); and finally, the area included by the lateral AP translation with respect to the flexion/extension angle (area). Results: In the ACL-deficient status, the MM group showed a significantly greater tibial translation compared with the IM group ( P < .0001 for AP displacement at 30° [AP30] and 90° [AP90] of flexion) and the LM group ( P = .002 for AP30 and P < .0001 for AP90). In the PS test, the area of LM group was significantly larger (57%; P = .0175) than the one of the IM group. After ACL reconstruction, AP translation at 30° was restored, while the AP90 remained significantly greater at 1.3 mm ( P = .0262) in the MM-ACL group compared with those with intact menisci. Conclusion: Before ACL reconstruction, partial medial meniscectomy increased AP laxity at 30° and 90° and lateral meniscectomy increased dynamic PS laxity with respect to intact menisci. Anatomic single-bundle ACL reconstruction decreased laxities, but a residual anterior translation of 1.3 mm at 90° remained in patients with partial medial meniscectomy, with respect to those with intact menisci.

scholarly journals TECHNICAL VARIATION IN AFFIXING HAMSTRING GRAFTS TO THE TIBIA IN ACL RECONSTRUCTION

2018 ◽  
Vol 26 (2) ◽  
pp. 94-97
Author(s):  
MARCUS VINICIUS DANIELI ◽  
JOÃO PAULO FERNANDES GUERREIRO ◽  
ALEXANDRE OLIVEIRA QUEIROZ ◽  
CARLOS ROBERTO PADOVANI
Keyword(s):  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Tibial Tunnel ◽  
Case Series ◽  
International Knee Documentation Committee ◽  
Interference Screw ◽  
Anatomic Reconstruction ◽  
Anatomic Acl Reconstruction ◽  
Level Of Evidence ◽  
Hamstring Grafts

ABSTRACT Purpose: To present a technical variation in tibial fixation of quadruple hamstring grafts during anatomic reconstruction of the anterior cruciate ligament (ACL). The secondary purpose was to decrease the costs associated with this procedure. Methods: Twenty patients who underwent ACL reconstruction were selected. A tibial tunnel was constructed using standard techniques, and a femoral tunnel was anatomically created using the outside-in technique. The hamstring autograft was passed (with its bend) into the tibial tunnel and affixed to the tibia using the suspensory technique and a simple staple. Femoral fixation was performed using a titanium interference screw. The patients underwent postoperative evaluations at 0, 3, 6 and 12 months using the subjective International Knee Documentation Committee (IKDC) form and Lysholm knee scores. Results: The IKDC and Lysholm score results improved over time (p<0.001) without major complications. The cost of the procedure could be reduced by using lower-cost hardware (staples). Conclusion: The proposed technique for anatomic ACL reconstruction using inverted hamstring grafts with their bend in the tibial tunnel, suspension-type fixation using a staple demonstrated good to excellent results after 1 year of follow up, with lower aggregate costs. Level of Evidence IV; Case series.

scholarly journals Clinical Outcome Evaluation of Anatomic Anterior Cruciate Ligament Reconstruction With Tunnel Positioning Using Gold Standard Techniques: A Systematic Review and Meta-analysis

2021 ◽  
Vol 9 (6) ◽  
pp. 232596712110133
Author(s):  
Tiago Lazzaretti Fernandes ◽  
Hugo Henrique Moreira ◽  
Renato Andrade ◽  
Sandra Umeda Sasaki ◽  
Wanderley Marques Bernardo ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Gold Standard ◽  
Functional Outcomes ◽  
Cruciate Ligament ◽  
Meta Analysis ◽  
Double Bundle ◽  
Risk Difference ◽  
Single Bundle ◽  
Anatomic Acl Reconstruction ◽  
Anterior Cruciate

Background: There have been conflicting results about the theoretical advantages of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction. Purpose: To evaluate the clinical and functional outcomes comparing anatomic single- versus double-bundle techniques, anatomic versus nonanatomic techniques, and transportal versus outside-in tunnel drilling for ACL reconstruction. Study Design: Systematic review; Level of evidence, 3. Methods: A search was performed in the MEDLINE and EMBASE databases up to August 2018 for clinical trials comparing anatomic ACL reconstruction (with tunnel positioning demonstrated using gold standard radiologic techniques) with another technique, with a minimum functional and biomechanical follow-up of 6 months. A meta-analysis was performed to compare clinical and functional outcomes between anatomic single- versus double-bundle reconstruction and between anatomic versus nonanatomic techniques, using the risk difference or the mean difference. Risk of bias of the included studies was assessed using the Newcastle-Ottawa Scale for cohort and case-control studies and the Cochrane Risk of Bias tool and Jadad Score for randomized controlled trials. Results: Included were 15 studies comprising 1290 patients (follow-up, 12-36 months). No significant differences favoring anatomic double-bundle over anatomic single-bundle reconstruction or outside-in over transportal techniques were found. The meta-analyses showed significant differences in the International Knee Documentation Committee (IKDC) objective score (risk difference, –0.14; 95% confidence interval, –0.27 to –0.01) favoring anatomic over nonanatomic reconstruction. No statistically significant differences were found between anatomic and nonanatomic surgical techniques on other functional scores or clinical examination outcomes, including the IKDC subjective score, Lysholm score, Tegner score, KT-1000 arthrometer test, or pivot-shift test. Conclusion: Double-bundle reconstruction was not superior to the single-bundle technique in clinical and functional outcomes. Anatomic ACL reconstruction shows significantly superior results over nonanatomic ACL reconstruction, reinforcing the anatomic technique as the gold standard choice for clinical practice.

scholarly journals Revision Anterior Cruciate Ligament Reconstruction

2013 ◽  
Vol 6 (6) ◽  
pp. 504-518 ◽  
Author(s):  
Jeffrey Wilde ◽  
Asheesh Bedi ◽  
David W. Altchek
Keyword(s):  
Anterior Cruciate Ligament ◽  
Clinical Outcomes ◽  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Knee Instability ◽  
Return To Play ◽  
Revision Acl Reconstruction ◽  
Pubmed Database ◽  
Anterior Cruciate ◽  
Primary Acl Reconstruction

Context: Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures, with more than 200,000 ACL tears occurring annually. Although primary ACL reconstruction is a successful operation, success rates still range from 75% to 97%. Consequently, several thousand revision ACL reconstructions are performed annually and are unfortunately associated with inferior clinical outcomes when compared with primary reconstructions. Evidence Acquisition: Data were obtained from peer-reviewed literature through a search of the PubMed database (1988-2013) as well as from textbook chapters and surgical technique papers. Study Design: Clinical review. Level of Evidence: Level 4. Results: The clinical outcomes after revision ACL reconstruction are largely based on level IV case series. Much of the existing literature is heterogenous with regard to patient populations, primary and revision surgical techniques, concomitant ligamentous injuries, and additional procedures performed at the time of the revision, which limits generalizability. Nevertheless, there is a general consensus that the outcomes for revision ACL reconstruction are inferior to primary reconstruction. Conclusion: Excellent results can be achieved with regard to graft stability, return to play, and functional knee instability but are generally inferior to primary ACL reconstruction. A staged approach with autograft reconstruction is recommended in any circumstance in which a single-stage approach results in suboptimal graft selection, tunnel position, graft fixation, or biological milieu for tendon-bone healing. Strength-of-Recommendation Taxonomy (SORT): Good results may still be achieved with regard to graft stability, return to play, and functional knee instability, but results are generally inferior to primary ACL reconstruction: Level B.

Long-Term Results of ACL Reconstruction Using a Nonanatomic Double-Bundle Technique with Extra-Articular Reinforcement

2019 ◽  
Author(s):  
J. Dalla-Rosa ◽  
A. Espejo-Reina ◽  
I. Tamimi ◽  
M. J. Espejo-Reina ◽  
M. Lombardo-Torre ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Cruciate Ligament ◽  
Double Bundle ◽  
Degenerative Changes ◽  
Long Term Results ◽  
Rotational Stability ◽  
X Rays ◽  
Double Bundle Technique

AbstractExtra-articular procedures for the improvement in rotational stability after anterior cruciate ligament (ACL) reconstruction have gained popularity in the last decade. This surgical gesture hoped to improve resistance to the high tensional forces affecting the ACL graft during cutting and pivoting movements of the lower extremity and eventually prevent ACL reconstruction failure. We performed this study to analyze the long-term results of patients undergoing ACL reconstruction using a nonanatomic double-bundle technique with an additional extra-articular augmentation. All the cases that underwent an ACL reconstruction using a nonanatomic double-bundle technique with an extra-articular reinforcement during the period between 1992 and 1997 were reviewed. The inclusion criteria for this study included a minimum follow-up of 10 years and age between 14 and 45 years at the time of the surgery. Forty patients were included in this series (34 males and 6 females). The mean Lysholm score after a minimum follow-up period of 10 years was 92.3 (standard deviation [SD], 9.4). The average preoperative Tegner score of the participants was 7.0 (SD, 1.1). This score decreased to 5.7 (SD, 1.2) at the end of follow-up. Follow-up X-rays were reviewed to assess the degenerative changes in the three knee compartments. Degenerative changes ≥ Kellgren–Lawrence grade 2 were observed in our six (15%) patients, all of them in the medial knee compartment. With these results, we conclude that double-bundle nonanatomic ACL reconstruction combined with an extra-articular reinforcement resembling the anterolateral ligament offers good overall long-term results, with relatively low rates of osteoarthritis.

scholarly journals Primary ACL Repair Revisited: Back to the Future?

2019 ◽  
Vol 7 (11_suppl6) ◽  
pp. 2325967119S0044
Author(s):  
Bruce Reider
Keyword(s):  
Acl Reconstruction ◽  
Primary Repair ◽  
Cruciate Ligament ◽  
The United States ◽  
Current Recommendation ◽  
Acl Repair ◽  
Early Results ◽  
Select Group ◽  
Anterior Cruciate

Primary repair of the Anterior Cruciate Ligament (ACL) had some popularity among a select group of surgeons in the mid 20th century. Techniques described by Ivar Palmer of Sweden were adopted in the United States by surgeons such as O’Donoghue, Marshall, and Feagin. However, promising early results were followed by disappointing failure rates at 5-year follow-up, and ACL reconstruction became the norm. Recently there has been a renewed interest in ACL repair. One use has been in conjunction with ACL reconstruction as remnant preservation. Isolated repair has been reported using a variety of techniques, including bridge-enhanced repair (BEAR) with a sheath, meticulous suturing with or without suture tape reinforcement, and repair to a dynamic intraligamentary stabilization (DIS) device. Early reports have been encouraging. However, in the case of the BEAR, the series is so far small and short-term; the two other techniques have more results reported but they include some studies with a concerning level of failure, especially in younger or more active patients. My current recommendation is to await more clinical documentation before adopting these technique in lieu of ACL reconstruction.

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