Anterolateral ligament of the knee: back to the future in anterior cruciate ligament reconstruction

Although the importance of the anterolateral stabilizing structures of the knee in the setting of anterior cruciate ligament (ACL) injuries has been recognized since many years, most of orthopedic surgeons do not take into consideration the anterolateral structures when performing an ACL reconstruction. Anatomic single or double bundle ACL reconstruction will improve knee stability, but a small subset of patients may experience some residual anteroposterior and rotational instability. For this reason, some researchers have turned again towards the anterolateral aspect of the knee and specifically the anterolateral ligament. The goal of this review is to summarize the existing knowledge regarding the anterolateral ligament of the knee, including anatomy, histology, biomechanics and imaging. In addition, the most common anterolateral reconstruction/tenodesis techniques are described together with their respective clinical outcomes.

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Effects of Remnant Tissue Preservation on Tunnel Enlargement After Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Hamstring Tendon

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118811293 ◽

2018 ◽

Vol 6 (12) ◽

pp. 232596711881129 ◽

Cited By ~ 3

Author(s):

Tetsuro Masuda ◽

Eiji Kondo ◽

Jun Onodera ◽

Nobuto Kitamura ◽

Masayuki Inoue ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Double Bundle ◽

Tissue Preservation ◽

Tunnel Enlargement ◽

Level Of Evidence ◽

Anterior Cruciate ◽

Double Bundle Acl Reconstruction ◽

Tunnel Positions

Background: The effects of remnant tissue preservation on tunnel enlargement after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction have not yet been established. Hypothesis: The preservation of ACL remnant tissue may significantly reduce the degree and incidence of tunnel enlargement after anatomic double-bundle ACL reconstruction, while the remnant-preserving procedure may not significantly increase the incidence of tunnel coalition after surgery. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 79 patients underwent anatomic double-bundle ACL reconstruction. Based on the Crain classification of ACL remnant tissue, 40 patients underwent the remnant-preserving procedure (group P), and the remaining 39 patients underwent the remnant-resecting procedure (group R). There were no differences between the 2 groups concerning all background factors, including preoperative knee instability and intraoperative tunnel positions. All patients were examined using computed tomography and a standard physical examination at 2 weeks and 1 year after surgery. Results: During surgery, the femoral and tibial anteromedial (AM) tunnel sizes in both groups averaged 6.6 and 6.5 mm, respectively. The femoral and tibial posterolateral (PL) tunnel sizes in both groups averaged 6 and 6 mm, respectively. There were no differences in the intraoperative tunnel positions and tunnel sizes between groups. Concerning the femoral AM tunnel, the degree of tunnel enlargement in the oblique coronal and oblique axial views in group P was significantly less than that in group R ( P = .0068 and .0323, respectively). Regarding the femoral AM tunnel cross-sectional area, the degree and incidence of tunnel enlargement in group P were significantly less than those in group R ( P = .0086 and .0278, respectively). There were no significant differences in tunnel coalition between groups. In each group, there were no significant relationships between tunnel enlargement and each clinical outcome. Conclusion: Remnant preservation in anatomic double-bundle ACL reconstruction reduced enlargement of the femoral AM tunnel and did not increase the incidence of tunnel coalition. This is one of the advantages of remnant-preserving ACL reconstruction.

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Review Article: Anatomic Double Bundle Anterior Cruciate Ligament Reconstruction

Journal of Orthopaedic Surgery ◽

10.1177/230949900701500219 ◽

2007 ◽

Vol 15 (2) ◽

pp. 216-221 ◽

Cited By ~ 34

Author(s):

W Shen ◽

S Jordan ◽

F Fu

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Clinical Investigation ◽

Cruciate Ligament ◽

Double Bundle ◽

Rotational Stability ◽

Single Bundle ◽

Osteoarthritic Change ◽

Anterior Cruciate ◽

Double Bundle Acl Reconstruction

The anterior cruciate ligament (ACL) consists of 2 bundles: a slightly larger anteromedial bundle and a posterolateral bundle, named according to their relative tibial insertion sites. Both bundles are crucial to knee stability. Although it is more technically demanding, a double bundle ACL reconstruction restores the knee biomechanics better and provides more rotational stability than a single bundle ACL reconstruction. Intermediate and long-term clinical investigation including the measurement of rotational laxity and the evaluation of osteoarthritic change is needed to confirm biomechanical and short-term clinical outcomes.

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Influence of Bundle Diameter and Attachment Point on Kinematic Behavior in Double Bundle Anterior Cruciate Ligament Reconstruction Using Computational Model

Computational and Mathematical Methods in Medicine ◽

10.1155/2014/948292 ◽

2014 ◽

Vol 2014 ◽

pp. 1-8 ◽

Cited By ~ 4

Author(s):

Oh Soo Kwon ◽

Tserenchimed Purevsuren ◽

Kyungsoo Kim ◽

Won Man Park ◽

Tae-Kyu Kwon ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Knee Joint ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Double Bundle ◽

Pivot Shift Test ◽

Tibial Rotation ◽

Attachment Point ◽

Anterior Cruciate ◽

Double Bundle Acl Reconstruction

A protocol to choose the graft diameter attachment point of each bundle has not yet been determined since they are usually dependent on a surgeon’s preference. Therefore, the influence of bundle diameters and attachment points on the kinematics of the knee joint needs to be quantitatively analyzed. A three-dimensional knee model was reconstructed with computed tomography images of a 26-year-old man. Based on the model, models of double bundle anterior cruciate ligament (ACL) reconstruction were developed. The anterior tibial translations for the anterior drawer test and the internal tibial rotation for the pivot shift test were investigated according to variation of bundle diameters and attachment points. For the model in this study, the knee kinematics after the double bundle ACL reconstruction were dependent on the attachment point and not much influenced by the bundle diameter although larger sized anterior-medial bundles provided increased stability in the knee joint. Therefore, in the clinical setting, the bundle attachment point needs to be considered prior to the bundle diameter, and the current selection method of graft diameters for both bundles appears justified.

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Anterolateral ligament reconstruction in addition to primary double-bundle anterior cruciate ligament reconstruction for grade 3 pivot shift improves residual knee instability during surgery

Journal of Experimental Orthopaedics ◽

10.1186/s40634-021-00369-4 ◽

2021 ◽

Vol 8 (1) ◽

Author(s):

Yusuke Kawanishi ◽

Makoto Kobayashi ◽

Sanshiro Yasuma ◽

Hiroaki Fukushima ◽

Jiro Kato ◽

...

Keyword(s):

Acl Reconstruction ◽

Ligament Reconstruction ◽

Pivot Shift ◽

Cruciate Ligament ◽

Double Bundle ◽

Acl Injuries ◽

Significant Difference ◽

Anterior Cruciate ◽

Grade 3 ◽

Double Bundle Acl Reconstruction

Abstract Purpose High-grade pivot shift in the anterior cruciate ligament (ACL) injured knee is a risk factor for postoperative residual pivot shift. Procedures in addition to ACL reconstruction such as anterolateral ligament (ALL) reconstruction have been performed for patients with a high-risk of residual pivot shift. The aim of this study was to investigate the effect of the addition of ALL reconstruction to primary double-bundle ACL reconstruction in patients with preoperative high-grade pivot shift to improve stability as evaluated by quantitative measurement. Methods Patients with ACL injuries who showed preoperative grade 3 subjective pivot shift and who underwent primary double-bundle ACL reconstruction combined with ALL reconstructions were retrospectively enrolled. Anterior tibial translation (ATT) in the Lachman test, and acceleration and external rotational angular velocity (ERAV) in the pivot shift were measured as quantitative values. Quantitative values before surgical intervention for ACL-injured knees (ACLD) and uninjured contralateral knees (intact), after temporary fixation of the isolated ACL grafts (ACLR), and subsequently after temporary fixation of both ACL and ALL grafts (ACLR + ALLR) were measured with the patient under general anaesthesia. Results In total, 18 patients were included. The ATT was lower in ACLR and ACLR + ALLR than in intact (P = .008 and .005), while there was no significant difference between ACLR and ACLR + ALLR (P > .05). The acceleration of ACLR + ALLR was lower than that for ACLR (P = .008), while there was no significant difference between intact and ACLR or ACLR + ALLR (P > .05). The ERAV of ACLR was higher than that of intact (P < .001), while that of ACLR + ALLR was lower than that of ACLR (P < 0.001), and there was no significant difference in ERAV between intact and ACLR + ALLR (P > 0.05). Conclusion According to quantitative assessment of the pivot shift, the addition of ALL reconstruction to primary double-bundle ACL reconstruction improved residual knee instability and restored knee stability during surgery. Combination of ALL reconstruction with primary double-bundle ACL reconstruction was effective for patients with ACL injuries exhibiting a preoperative grade 3 subjective pivot shift. Level of evidence IV

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A prospective comparison of double- and single-bundle anterior cruciate ligament reconstructions

Medicina ◽

10.3390/medicina44020014 ◽

2008 ◽

Vol 44 (2) ◽

pp. 110 ◽

Cited By ~ 6

Author(s):

Rimtautas Gudas ◽

Alfredas Smailys ◽

Kristina Vostrugina ◽

Ramûnas Tamoðiûnas ◽

Donatas Simonaitis ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Double Bundle ◽

Activity Level ◽

Single Bundle ◽

Prospective Comparison ◽

Significant Difference ◽

Anterior Cruciate ◽

Double Bundle Acl Reconstruction

Objective. A nonrandomized clinical study was performed to compare the clinical and radiological outcome between double-bundle and single-bundle anterior cruciate ligament (ACL) reconstructions with semitendinosus tendon in athletes. Material and methods. We examined 70 patients with unilateral anterior cruciate ligament injury. They were followed up for a mean of 24 months. Each group of 35 patients underwent either double- or singlebundle ACL reconstruction. The mean age of the patients was 24.7 years (range, 18–35 years). There were no differences between two groups regarding age at surgery, sex, follow-up period, period before surgery, combined meniscus injuries, athletic activity level, and International Knee Documentation Committee (IKDC) and Tegner scores. All patients followed the same postoperative program. They were evaluated using manual knee laxity tests, knee extension and flexion strength testing. General knee condition was evaluated by the IKDC and Tegner scores. Results. The results were excellent and good in 32 (91.4%) patients after double-bundle ACL reconstruction and in 30 (85.7%) patients after single-bundle ACL reconstruction, evaluating by IKDC system. However, statistical analysis showed no significant difference between the two groups regarding all IKDC-categorized data (P=0.87). The average scores of Tegner activity in double-bundle and single-bundle groups were 8.0 and 8.1, respectively. Conclusions. This trial showed no significant difference between the double and single-bundle ACL repairs.

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Comparing post-operative pain between single bundle and double bundle anterior cruciate ligament reconstruction: a retrospective study

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04635-5 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Chaiwat Chuaychoosakoon ◽

Wachiraphan Parinyakhup ◽

Arnan Wiwatboworn ◽

Peeranut Purngpiputtrakul ◽

Pawin Wanasitchaiwat ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Retrospective Study ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Double Bundle ◽

Single Bundle ◽

Pain Scores ◽

Post Operative Pain ◽

Anterior Cruciate ◽

Double Bundle Acl Reconstruction

Abstract Background In anterior cruciate ligament (ACL) reconstruction, the clinical outcome and level of post-operative pain are important factors. To date there have been no studies evaluating differences in post-operative pain between single bundle and double bundle ACL reconstruction with a hamstring graft. Hypothesis/purpose We hypothesized that post-operative pain in single bundle ACL reconstruction would be less than in double bundle ACL reconstruction. This study was to compare post-operative pain between patients undergoing single bundle versus double bundle ACL reconstruction. Study design Cohort study. Methods This was a retrospective study comparing post-operative pain scores between single bundle and double bundle ACL reconstruction. Each patient was given our standard regimen of oral diclofenac (25 mg/tab) three times per day and paracetamol (500 mg/tab) six times per day for 1 day post-operatively. If the patient complained of moderate to severe pain (pain numeric rating scale (PNRS) > 3), 3 mg of morphine was injected intravenously every 3 h for 24 h and 1 mg of morphine as a rescue medication every 1 h for 24 h. PNRS and morphine consumption were recorded at 4-h intervals for 24 h. Results 209 patients were included in this study of whom 102 and 107 patients received single bundle and double bundle ACL reconstruction, respectively. The average post-operative pain scores of the single bundle group were lower at all time points. Linear mixed effect regression analyses showed that the single bungle group had lower post-operative pain than the double bundle group after adjusting for confounders (beta = − 0.45; 95% CI = − 0.838, − 0.062) but there was no statistically significant difference between numbers of bundle ACL reconstruction with regard to morphine consumption. Conclusion Single bundle ACL reconstruction had significantly lower post-operative pain scores than double bundle ACL reconstruction. Clinical relevance Double bundle ACL reconstruction results in higher post-operative pain, which may slow the start of rehabilitation and reduce patient satisfaction. In middle-aged adult patients with low-demand activities, we suggest performing a single bundle ACL reconstruction.

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Double-bundle anterior cruciate ligament recontruction by Hamstring tendon autograft: the ALL - INSIDE technique

Vietnam Journal of Endolaparoscopic Surgery ◽

10.51199/vjsel.2019.2.4 ◽

2019 ◽

Vol 9 (2) ◽

Author(s):

Ngọc Trưởng Phạm ◽

Hải Nam Vũ

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Hamstring Tendon ◽

Double Bundle ◽

Rotational Stability ◽

Hamstring Tendon Autograft ◽

Anterior Cruciate ◽

Double Bundle Acl Reconstruction ◽

Tendon Autograft

Tóm tắt Đặt vấn đề: Đánh giá kết quả đạt được trong việc tái tạo 2 bó dây chằng chéo trước All-inside, gân cơ Hamstring. (DCCT) với kỹ thuật “all-inside” bó sau ngoài sử dụng mảnh ghép gân cơ thon, gân cơ bán gân tự thân. Từ kết quả đạt được đưa ra một số nhận xét về kỹ thuật. Phương pháp nghiên cứu: Tiến cứu, mô tả cắt ngang 43 bệnh nhân tổn thương DCCT được lựa chọn chỉ định phẫu thuật nội soi tái tạo DCCT 2 bó bằng gân cơ bán gân và gân cơ thon tự thân với kỹ thuật “all-inside” bó sau ngoài tại Bệnh viện 198 Bộ Công an. Kết quả: 43 bệnh nhân trong lứa tuổi 19-35, thời gian theo dõi trung bình là 13,5 tháng. Kết quả bước đầu, bệnh nhân cải thiện rất tốt sự ổn định và chức năng của khớp gối nhất là ổn định xoay. Điểm Lysholm ở mức độ tốt và rất tốt đạt 95,4%. Tỷ lệ quay lại tập luyện thi đấu thể thao là 93,0% và chưa phát hiện bệnh nhân đứt lại DCCT sau tái tạo. Kết luận: Phẫu thuật tái tạo 2 bó DCCT với kỹ thuật “all-inside” bó sau ngoài có ưu điểm cố định được mảnh ghép ngắn, sử dụng được nguồn gân ghép tự thân, cho kết quả phục hồi chức năng tốt. Phẫu thuật góp phần nâng cao hiệu quả điều trị tái tạo DCCT, làm giảm nguy cơ phải sử dụng mảnh ghép đồng loại. Abstract Introduction: To evaluate the results obtained in the Double-Bundle Anterior Cruciate Ligament (ACL) Reconstruction of the hamstring tendon autograft with the "all-inside" technique Material and Methods: A prospective, cross-sectional study of 43 patients with indication for Double-Bundle Anterior Cruciate Ligament Reconstruction with hamstring tendon autograft Results: 43 patients between the ages of 19-35 years, with a mean follow-up of 13.5 months, 95,4% good and excellent Lysholm score and were shown to significantly improve rotational stability. The return to sport rate following ACL reconstruction was 93,0% and the graft failure rate was 0%. Conclusion: The hamstring tendon autograft can be used for the Double-Bundle ACL reconstruction with the "all-inside" technique. This technique can use short graft, resulting in good rehabilitation Keywords: ACL double-bundle reconstruction, “all-inside” technique, minimally invasive, hamstring tendon.

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