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Grassi A, Borque KA, Laughlin MS, Tao MA, Zaffagnini S. Age-specific over-the-top techniques for physeal sparing anterior cruciate ligament (ACL) reconstruction in skeletally immature patients: Current concepts for prepubescents to older adolescents. Knee Surg Sports Traumatol Arthrosc 2025. [PMID: 39901868 DOI: 10.1002/ksa.12607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2024] [Revised: 01/16/2025] [Accepted: 01/16/2025] [Indexed: 02/05/2025]
Abstract
Tailored surgical strategies for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients are presented, emphasizing techniques to minimize growth plate damage and ensure stability. As ACL injuries in youth increase, delaying surgery can lead to joint damage and poor recovery outcomes. Using magnetic resonance imaging-based assessments of skeletal maturity, the authors propose the 'over-the-top (OTT)' approach with lateral tenodesis, adapted for three growth stages: prepubescents, young adolescents and older adolescents. For prepubescents, the extra-physeal approach avoids growth plate drilling; for young adolescents, the supra-physeal technique places tunnels above the growth plate; and for older adolescents, the trans-physeal method mirrors adult techniques, as growth plates are closing. The minimally invasive OTT technique preserves hamstring insertion, ensures isometric graft placement, and allows for combined intra- and extra-articular procedures to improve rotational control and protect the graft. Clinical outcomes highlight high return-to-sport rates, minimal growth disturbances, and low failure rates, although older adolescents show higher graft failures due to activity levels. Various adaptations of the OTT and lateral tenodesis techniques utilizing hamstring tendons provide promising solutions for addressing ACL injuries in skeletally immature patients, ranging from prepubescence to late adolescence. Assessing skeletal age and estimating remaining bone growth are essential for selecting the most appropriate surgical method. The biomechanical principles and positive clinical results observed across different patient groups highlight these techniques as effective, safe and attractive options for managing these challenging cases. LEVEL OF EVIDENCE: Level IV.
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Affiliation(s)
- Alberto Grassi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Kyle A Borque
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | | | - Matthew A Tao
- Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Du H, Li L, Qin Z, Guo J, Zhang X. Over-The-Top Technique for ACL Reconstruction: Advantages, Disadvantages, and Postoperative Complications. Orthop Surg 2025; 17:333-347. [PMID: 39894764 PMCID: PMC11787975 DOI: 10.1111/os.14328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 11/21/2024] [Accepted: 11/29/2024] [Indexed: 01/06/2025] Open
Abstract
Anterior cruciate ligament (ACL) injuries are the most common knee joint injuries related to sports activities in clinical practice. For treating ACL injuries, anatomical reconstruction surgery is often the preferred method. The over-the-top (OTT) technique is a surgical approach that eliminates the need for creating a femoral tunnel. According to the existing literature, the OTT technique offers distinct advantages, particularly for skeletally immature individuals and in revision cases. Currently, femoral tunnel failure is the most common cause of ACL reconstruction failure, which can lead to less than optimal postoperative performance of the ACL and a higher likelihood of needing a revision. Additionally, mistakes in the placement of the femoral tunnel and the subsequent risk of tunnel enlargement can increase the complexity of revision procedures, ultimately reducing the long-term clinical effectiveness for patients. In contrast, the OTT technique has shown excellent biomechanical performance, avoids the need for bone tunnels, is economically practical, and has been proven to provide satisfactory therapeutic outcomes both in the short and long term, especially for skeletally immature individuals and in revision cases. The OTT technique is deemed a safe and effective surgical method for treating ACL injuries. In summary, the OTT technique has unique benefits for skeletally immature individuals and in revision cases, making it a viable option worth considering. Level of evidence V.
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Affiliation(s)
- Haocheng Du
- Department of Sports Medicine and RehabilitationPeking University Shenzhen HospitalShenzhenChina
| | - Lin Li
- Department of Sports Medicine and RehabilitationPeking University Shenzhen HospitalShenzhenChina
| | - Ziwen Qin
- Department of Thoracic SurgeryPeking University Shenzhen HospitalShenzhenChina
| | - Jiang Guo
- Department of Sports Medicine and RehabilitationPeking University Shenzhen HospitalShenzhenChina
| | - Xintao Zhang
- Department of Sports Medicine and RehabilitationPeking University Shenzhen HospitalShenzhenChina
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Maestro A, Rodríguez N, Pipa I, Toyos C, Lanuza L, Machado F, Castaño C, Maestro S. Influence of Extra-Articular Augmentation on Clinical Outcomes and Survival in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Pseudorandomized Study. MEDICINA (KAUNAS, LITHUANIA) 2025; 61:116. [PMID: 39859098 PMCID: PMC11766875 DOI: 10.3390/medicina61010116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Revised: 01/08/2025] [Accepted: 01/10/2025] [Indexed: 01/27/2025]
Abstract
Background and Objectives: Up to 27% of anterior cruciate ligament (ACL) reconstruction cases result in a residual positive pivot shift sign, indicating anteroposterior and rotational instability. This instability can compromise returning to sports and increase the risk of further injuries. The biomechanical role of the anterolateral ligament (ALL) in controlling internal knee rotation is well known. However, there are no clinical trials comparing isolated ACL repairs to those combined with ALL reconstruction. Our objective is to compare the results of these techniques, with a primary focus on assessing knee stability and graft survival, to provide evidence for optimizing surgical approaches, particularly for athletes and physically active individuals. Materials and Methods: An observational study using paired score matching as a method of pseudo-randomization was conducted. Subjects were divided into an ACL group and an ACL+ALL group. Demographic and clinical variables were collected, as well as those related to complications and survival. Results: A total of 236 patients were included, which was reduced to 74 ACL and 37 ACL+ALL after pseudo-randomization, resulting in preoperatively comparable groups. During follow-up, differences in favor of ALL reinforcement were found on the pivot shift test (p = 0.007). No differences were found with regard to the Lachman test (p = 0.201), the International Knee Documentation Committee (IKDC) knee score (p = 0.169), the IKDC subjective score (p = 0.095), intensity of pain (p = 0.928), or complications (p = 0.529). Nor were differences found in the limb symmetry index; the single hop test (p = 0.710); the triple hop test (p = 0.653); the crossover hop test (p = 0.682); the 6 meter timed hop test (p = 0.360); the normalized Y-balance test (YBT) (p = 0.459 anterior; p = 0.898 posterolateral; and p = 0.211 posteromedial directions); or the limb symmetry index of the composite YBT (p = 0.488). There were no differences either with respect to return to sports practice (p = 0.723) or survival (p = 0.798). Conclusions: Patients treated by means of the ACL+ALL technique obtained higher rotational stability, as measured by the pivot shift test, than those subjected to an isolated ACL repair. No differences were found with respect to Lachman test, complications, IKDC, pain, or survival.
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Affiliation(s)
| | | | - Iván Pipa
- Hospital Universitario de Cabueñes, 33394 Gijón, Spain; (I.P.); (L.L.)
| | | | - Lucía Lanuza
- Hospital Universitario de Cabueñes, 33394 Gijón, Spain; (I.P.); (L.L.)
| | - Filipe Machado
- Centro Hospitalar de Setúbal, 2910-446 Setúbal, Portugal;
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Loya D, Kaarre J, Marcaccio SE, Nazzal EM, Como CJ, Herman ZJ, Miller LM, Musahl V. Revision Anterior Cruciate Ligament Reconstruction in Combination With Meniscal and Osteochondral Allograft Transplantation for Complex Knee Injury. Arthrosc Tech 2025; 14:103157. [PMID: 39989698 PMCID: PMC11843324 DOI: 10.1016/j.eats.2024.103157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 06/02/2024] [Indexed: 02/25/2025] Open
Abstract
Revision anterior cruciate ligament reconstruction (ACLR) may present a challenge as a result of several factors, including malpositioned bone tunnels, tunnel osteolysis, and the presence of previous hardware. In addition, concomitant pathology, specifically meniscal and cartilaginous injuries, may be present and should be addressed to minimize the risk of re-rupture. Revision ACLR and treatment of accompanying injuries can be performed either as a 1-stage or 2-stage procedure, yet the latter may increase surgical risk for the patient and extend recovery time. The over-the-top technique serves as a good option for revision ACLR and can be performed with careful consideration of patient-specific anatomy and with proper surgical planning. Therefore, this Technical Note aims to present our 1-stage surgical technique for revision ACLR using over-the-top technique with an Achilles tendon allograft, along with concomitant treatment for meniscal deficiency and a medial femoral condyle chondral defect using meniscal and osteochondral allografts, respectively.
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Affiliation(s)
- Denisse Loya
- Orthopedic Surgery Department, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Janina Kaarre
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pennsylvania, U.S.A
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stephen E. Marcaccio
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pennsylvania, U.S.A
| | - Ehab M. Nazzal
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pennsylvania, U.S.A
| | - Christopher J. Como
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pennsylvania, U.S.A
| | - Zachary J. Herman
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pennsylvania, U.S.A
| | - Liane M. Miller
- University of Pennsylvania Perelman School of Medicine, Orthopaedic Surgery, Philadelphia, Pennsylvania, U.S.A
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pennsylvania, U.S.A
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Agostinone P, Di Paolo S, Lucidi GA, Marchiori G, Bontempi M, Bragonzoni L, Davidoni V, Grassi A, Zaffagnini S. Changes in the Elongation Pattern of the Medial Collateral Ligament During a Single-Leg Squat After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2024; 12:23259671241283795. [PMID: 39507327 PMCID: PMC11539197 DOI: 10.1177/23259671241283795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/05/2024] [Indexed: 11/08/2024] Open
Abstract
Background An anterior cruciate ligament (ACL) tear impairs knee biomechanics in daily activities and potentially breaks the synergy among other knee ligaments. Previous studies have demonstrated that the biomechanics of collateral ligaments is influenced by ACL deficiency. Purpose To investigate changes in the elongation patterns of the medial collateral ligament (MCL), lateral collateral ligament (LCL), and posterior cruciate ligament (PCL) during the execution of a single-leg squat before and after ACL reconstruction. Study Design Descriptive laboratory study. Methods A total of 16 patients (mean age, 24.9 ± 8.5 years) with ACL deficiency were enrolled in the study. Magnetic resonance imaging scans of the affected knees were used to produce 3-dimensional models of the tibia and femur and identify insertion sites of the MCL, LCL, and PCL. Motion capture of a single-leg squat was performed through a biplanar radiographic system. Data were acquired before ACL reconstruction and at a minimum of 18 months (mean, 22.9 ± 4.1 months) postoperatively. The centroids of the ligaments' insertions were used to calculate the length of the investigated structures during the squat task. Absolute length (L), absolute length increase from the orthostatic resting position (ΔL), and relative length increase (ΔL%) were computed for each ligament, and preoperative and postoperative data were compared using the paired Student t test. The intraclass correlation coefficient was used to determine the reliability of the ligament insertion's identification and kinematics between 2 independent observers. Results Significant differences were found for the MCL in absolute length increase (P = .047; Cohen d = 0.60) and relative length increase (P = .043; Cohen d = 0.61) from rest between preoperatively and postoperatively (ΔL pre = 1.0 mm; ΔL post = -1.1 mm; difference = 2.1 mm) at 0° to 30° of knee flexion during the descending phase of the single-leg squat. No differences were seen in the elongation patterns of the LCL or PCL from before to after ACL reconstruction. Conclusion The MCL was significantly longer between 0° and 30° in ACL-deficient knees compared with ACL-reconstructed knees during the descending phase of a single-leg squat. No differences were identified for the LCL or PCL. Clinical Relevance Early ACL reconstruction could have a protective effect on the MCL in combined ACL and MCL lesions.
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Affiliation(s)
- Piero Agostinone
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Di Paolo
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gian Andrea Lucidi
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gregorio Marchiori
- Scienze e Tecnologie Chirurgiche, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Bontempi
- Scienze e Tecnologie Chirurgiche, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Laura Bragonzoni
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | - Vittorio Davidoni
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alberto Grassi
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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Capella M, Rea A, Battaglia DL, Bosco F, Camazzola D, Risitano S, Massè A. Lateral Extra-articular Tenodesis With Cortical Suspensory Femoral Fixation and Suture Tape Augmentation. Arthrosc Tech 2024; 13:103010. [PMID: 39233800 PMCID: PMC11369955 DOI: 10.1016/j.eats.2024.103010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 03/01/2024] [Indexed: 09/06/2024] Open
Abstract
This article aims to provide a new surgical technique for rotational instability in the setting of anterior cruciate ligament rupture. Two main groups of surgical procedures can be identified in the treatment of anterolateral knee instability: lateral extra-articular tenodesis and anterolateral ligament reconstruction. Although the importance of anterior cruciate ligament reconstruction in anterolateral complex injuries is well known, the superiority of lateral extra-articular tenodesis over anterolateral ligament reconstruction or vice versa has not yet been shown. Both techniques show improved outcomes and reduced graft failure rates. The presented procedure can be considered a modification of the technique first described by Lemaire. Better tensioning can be achieved through cortical suspension by identifying the anisometric point on the lateral femur and performing a medial pullout on the femoral side. The advantages of this technique are better fine-tuning and tensioning, less invasiveness, and adjustable cortical fixation, which allows for a precise, incremental tensioning of the graft, ensuring circumferential healing of the graft within the socket and reducing the risk of graft laceration, which may happen with interference screws. Internal bracing provides excellent contact pressure between the femoral button and femoral cortex, ensuring that adequate tensioning is applied to the graft.
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Affiliation(s)
- Marcello Capella
- Center for Orthopedic Trauma Hospital, School of Medicine, University of Turin, Turin, Italy
| | - Antonio Rea
- Center for Orthopedic Trauma Hospital, School of Medicine, University of Turin, Turin, Italy
| | | | - Francesco Bosco
- Department of Orthopedic and Traumatology, University of Palermo, Palermo, Italy
- Department of Orthopaedics and Traumatology, G. F. Ingrassia Hospital Unit, Palermo, Italy
| | - Daniele Camazzola
- Center for Orthopedic Trauma Hospital, School of Medicine, University of Turin, Turin, Italy
| | - Salvatore Risitano
- Center for Orthopedic Trauma Hospital, School of Medicine, University of Turin, Turin, Italy
| | - Alessandro Massè
- Center for Orthopedic Trauma Hospital, School of Medicine, University of Turin, Turin, Italy
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Sonnery-Cottet B, Carrozzo A. Lateral Extra-Articular Tenodesis and Anterolateral Procedures. Clin Sports Med 2024; 43:413-431. [PMID: 38811119 DOI: 10.1016/j.csm.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
The treatment of rotational instability has been an intriguing challenge since the era of modern anterior cruciate ligament (ACL) surgery. Lateral extra-articular procedures (LEAPs) have emerged as a solution to this problem, particularly in high-risk populations. Several studies have shown significant benefits of combining LEAPs with ACL reconstruction, including reduced graft failure rates, improved knee stability, improved rotational stability, and higher return-to-play rates. These findings have led to an in-depth evaluation of LEAPs as lateral extra-articular tenodesis and anterolateral ligament reconstruction and their potential role in improving outcomes after ACL reconstruction.
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Affiliation(s)
- Bertrand Sonnery-Cottet
- Orthopaedic Surgery, Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Alessandro Carrozzo
- Orthopedic Unit, Sant'Andrea University Hospital, La Sapienza University, Rome, Italy.
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Lucidi GA, Agostinone P, Di Paolo S, Grassi A, Pierangeli A, Dal Fabbro G, Zaffagnini S. Loss of chondroprotection of medial collagen meniscus implant (CMI) at 20-year follow-up. J ISAKOS 2024; 9:116-121. [PMID: 37979692 DOI: 10.1016/j.jisako.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/22/2023] [Accepted: 11/13/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE The mid-term results of the collagen meniscus implant (CMI) procedure for the replacement of partial meniscus defects have already been described. However, there is a paucity of long-term comparative studies. This study aimed to compare the clinical outcomes, failures, and osteoarthritis progression of patients who underwent partial medial meniscectomy and medial CMI implantation. METHODS Thirty-six nonconsecutive patients with medial meniscus injuries that underwent medial CMI (MCMI) implantation or partial medial meniscectomy (PMM) between 1997 and 2000 were included in a prospective study with an intermediate 10-year follow-up examination and a final follow-up examination at 20-year follow-up. Outcome measures at the 20-year follow-up included the Lysholm score, visual analogue scale (VAS) for pain, International Knee Documentation Committee (IKDC) knee form , and Tegner activity level. Bilateral weight-bearing radiographs were also performed to evaluate hip-knee-angle (HKA) and the medial joint line height (JL). Data regarding complications and failures were also collected. RESULTS At the 20-year follow-up, 31 patients (83% follow-up rate) with a mean age of 60.7 ± 8.9 years were included in the final analysis (21.1 ± 1.2 years follow-up). Four reoperations and one failure per group were reported. When comparing the clinical results of the two groups, no difference was found considering the Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner, and the IKDC. Moreover, 20 patients underwent radiographic examination (10 MCMI, 10 MM), and no statistically significant difference was reported concerning the JL, HKA, and the presence and incidence of osteoarthritis between the two groups. CONCLUSION The CMI implant for partial medial meniscectomy provided good long-term results and a low failure rate. However, differently from the 10 years follow-up, the clinical and the radiological outcomes were not superior compared to the medial meniscectomy group. The present study's result suggests that using a medial scaffold is not chondroprotective. LEVEL OF EVIDENCE III, Prospective case-control study.
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Affiliation(s)
- Gian Andrea Lucidi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, 40136, Italy; Dipartimento di Scienze Biomediche e Neuromotorie DIBINEM, Università di Bologna, Bologna, 40126, Italy.
| | - Piero Agostinone
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, 40136, Italy
| | - Stefano Di Paolo
- Dipartimento di Scienze per la Qualità della Vita QUVI, Università di Bologna, Bologna, 40136, Italy
| | - Alberto Grassi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, 40136, Italy
| | - Andrea Pierangeli
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, 40136, Italy
| | - Giacomo Dal Fabbro
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, 40136, Italy
| | - Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, 40136, Italy
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Jildeh TR, Bowen E, Bedi A. Revision Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients. J Am Acad Orthop Surg 2023; 31:e920-e929. [PMID: 37364250 DOI: 10.5435/jaaos-d-23-00288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/27/2023] [Indexed: 06/28/2023] Open
Abstract
Revision anterior cruciate ligament (ACL) reconstruction in the skeletally immature patient is a challenging procedure for pediatric patients with recurrent instability after primary ACL reconstruction. The pediatric population presents unique technical challenges and complications secondary to open physes compared with the adult population. Complications can include growth disturbances, recurrent graft failure, instability, and secondary chondral and/or meniscal injury. Moreover, identifying the etiology of graft failure is critical for a successful revision. Patients should undergo a complete history and physical examination with a focus on patient physiologic age, physeal status, mechanical axis, tibial slope, collagen status, injury mechanism, concomitant injuries, and previous surgical procedures. The surgeon must be adept at reconstruction with various grafts as well as socket or tunnel preparation and fixation, including over-the-top, all-epiphyseal, transphyseal, extra-articular augmentation, and staging approaches. Reported rates of return to sport are lower than those of primary reconstruction, with higher rates of cartilage and meniscal degeneration. Future research should focus on optimizing surgical outcomes and graft survivorship after primary ACL reconstruction with minimized trauma to the physis.
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Affiliation(s)
- Toufic R Jildeh
- From the Department of Orthopaedics, Michigan State University, East Lansing, MI (Jildeh), the Weill Cornell Medical College, New York, NY (Bowen), and the NorthShore Medical Group, Skokie, IL (Bedi)
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Agostinone P, Lucidi GA, Dal Fabbro G, Di Paolo S, Pagano A, Viotto M, Neri MP, Grassi A, Zaffagnini S. Satisfactory long-term outcomes for combined anterior cruciate ligament reconstruction and lateral closing wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 2023; 31:4399-4406. [PMID: 37386198 DOI: 10.1007/s00167-023-07496-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/17/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE A combined anterior cruciate ligament (ACL) reconstruction and high tibial osteotomy (HTO) is considered a valuable treatment in young patients affected by symptomatic medial osteoarthritis and ACL deficiency. However, only a few studies have investigated the outcomes of this procedure, especially in the long term. Therefore, the aim of this study is to report clinical and radiographic outcomes of ACL reconstruction and lateral closing wedge HTO at a mean of 14 years of follow-up. METHODS Patients were prospectively evaluated pre-operatively, after 6.5 ± 2.7 years and 14.3 ± 2.2 years. Patient-reported outcome measures (PROMs) were collected, knee laxity was assessed through KT-1000 arthrometer, and limb alignment and knee osteoarthritis were evaluated on long-cassette radiographs. Survivorship of the surgical procedure was calculated through the Kaplan-Meier method. RESULTS 32 patients were initially enrolled and completed the mid-term evaluation (6.5 ± 2.7 years), and 23 patients (72%) were available for the final evaluation at 14.3 ± 2.2 years after surgery. Statistically significant improvement was found for all the clinical scores (VAS, WOMAC, Tegner, subjective IKDC, objective IKDC) between the pre-operative status and the mid-term follow-up (p < .001). VAS, subjective IKDC and objective IKDC showed no statistically significant differences (p > .05) between the mid-term and the final follow-up; a significant decrease of WOMAC (p < .05) and Tegner (p < .001) was found from mid-term to final follow-up. Significant progression of osteoarthritis was found for all the knee compartments. The survivorship was 95.7% at 5 years, 82.6% at 10 years, and 72.8% at 15 years. CONCLUSIONS Combined ACL reconstruction and lateral closing wedge HTO showed satisfactory clinical outcomes and survivorship at a mean of 14 years follow-up. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Piero Agostinone
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Cesare Pupilli 1, 40136, Bologna, BO, Italy.
| | - Gian Andrea Lucidi
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Cesare Pupilli 1, 40136, Bologna, BO, Italy
| | - Giacomo Dal Fabbro
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Cesare Pupilli 1, 40136, Bologna, BO, Italy
| | - Stefano Di Paolo
- Dipartimento di Scienze per la Qualità. della Vita QUVI, Università di Bologna, Bologna, Italy
| | - Anna Pagano
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Cesare Pupilli 1, 40136, Bologna, BO, Italy
| | - Marianna Viotto
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Cesare Pupilli 1, 40136, Bologna, BO, Italy
| | - Maria Pia Neri
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Cesare Pupilli 1, 40136, Bologna, BO, Italy
| | - Alberto Grassi
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Cesare Pupilli 1, 40136, Bologna, BO, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Cesare Pupilli 1, 40136, Bologna, BO, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, DIBINEM, Università di Bologna, Bologna, Italy
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Zaffagnini S, Grassi A, Lucidi GA, Dal Fabbro G, Ambrosini L. Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis: The "Over-the-Top" Technique. VIDEO JOURNAL OF SPORTS MEDICINE 2023; 3:26350254231177378. [PMID: 40308443 PMCID: PMC11962631 DOI: 10.1177/26350254231177378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/29/2023] [Indexed: 05/02/2025]
Abstract
Background The anterior cruciate ligament (ACL) is a primary restraint to anteroposterior as well as rotatory knee laxity. In case of concomitant lesion of menisci or other ligamentous structures, further dynamic instability is encountered. A lateral extra-articular tenodesis (LET) augmentation has been proposed by the Authors to treat or prevent residual laxity. Indications ACL reconstruction is recommended in young athletes involved in pivoting sports, non-contact pivoting injuries, high-grade pivot shift, deep notch sign and double bone bruise, meniscal loss, and revision of previous bone-patellar tendon-bone autograft. Technique Description A 2 to 3 cm oblique incision is made over the pes anserinus. Gracilis and semitendinosus tendons are harvested with their attachment preserved and sutured together. Tibial tunnel is reamed after positioning of a guide pin. A wire-loop passer is directed from the tibial tunnel to the anteromedial portal. A 2 to 3 cm longitudinal incision is made superior-laterally, the ileotibial band is divided and retracted anteriorly. A suture-loop is retrieved from the lateral incision through the anteromedial portal with a curved Kelly clamp. The suture is placed into the wire-loop and retrieved with it from the tibial tunnel. The graft is retrieved from the lateral incision, tensioned with the knee at 70° to 90° of flexion and foot in neutral rotation and secured with 2 staples to the femur. A 1-cm skin incision is performed just below the Gerdy tubercle. The graft is retrieved from this incision below the fascia with a small Kelly clamp, tensioned and secured with a staple. The iliotibial tract defect is closed. Results At long-term follow-up, a revision rate of 3% has been reported, while patient-reported outcome measures (PROMs) were excellent. At very-long-term follow-up, most patients were still involved in sports with a very low rate of positive Lachman and pivot shift tests. No overconstraint and lateral osteoarthritis were encountered. Medial osteoarthritis was related only to medial meniscectomy. Discussion/Conclusion The ACL reconstruction plus LET over-the-top technique is a safe and reliable surgery with a low rate of reoperations and peri-operative complications at very-long-term follow-up. 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.
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Affiliation(s)
- Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Alberto Grassi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Gian Andrea Lucidi
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Giacomo Dal Fabbro
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
| | - Luca Ambrosini
- II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italia
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Grassi A, Agostinone P, Paolo SD, Lucidi GA, Pinelli E, Marchiori G, Bontempi M, Bragonzoni L, Zaffagnini S. Medial Meniscal Posterior Horn Suturing Influences Tibial Internal-External Rotation in ACL-Reconstructed Knees. Orthop J Sports Med 2023; 11:23259671231177596. [PMID: 37529533 PMCID: PMC10387796 DOI: 10.1177/23259671231177596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/09/2023] [Indexed: 08/03/2023] Open
Abstract
Background The role of meniscal lesions and repair in combination with anterior cruciate ligament (ACL) injury and reconstruction has not been extensively investigated in vivo and under weightbearing conditions. Purpose The purposes of this study were to (1) compare the in vivo knee kinematics between patients with ACL tear and those with combined ACL and medial meniscal tears and (2) investigate kinematic differences between isolated ACL reconstruction and ACL reconstruction plus medial meniscal repair (MR). It was hypothesized that concomitant posterior horn medial meniscal tear and ACL deficiency would affect knee internal-external rotation and anterior-posterior translation but MR would restore these parameters. Study Design Controlled laboratory study. Methods Nineteen patients who underwent ACL reconstruction were included: 10 had intact menisci (IM group) and 9 had a medial meniscal injury that was repaired during ACL reconstruction using an all-inside technique (MR group). Preoperatively and 18 months postoperatively, active knee kinematics under weightbearing conditions was evaluated during a single-leg squat using a dynamic biplane x-ray imaging system. The general linear model was used to investigate the differences between group (IM vs MR) and time (preoperative vs follow-up) and their interactions. Results Tibial internal rotation was higher in the MR group than the IM group both before and after surgery (P = .007). Knee valgus rotation was higher in the MR group preoperatively (P < .001), while no differences were found postoperatively because of an increase of valgus rotation in the IM group, which was significant in the descendant phase (P < .001). Preoperatively, the IM group showed a more medial tibial translation compared with the MR group in the descendant phase (P = .006). Conclusion When performing a single-leg squat, patients with ACL-deficient knees and a medial meniscal tear demonstrated a more valgus rotation, tibial internal rotation, and lateral tibial translation versus those with intact menisci. After ACL reconstruction and MR, these patients demonstrated significantly higher tibial internal rotation when compared with patients who underwent isolated ACL reconstruction. Clinical Relevance Surgeons should be aware that MR does not fully restore knee kinematics in vivo and under weightbearing conditions in the context of ACL reconstruction.
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Affiliation(s)
- Alberto Grassi
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Piero Agostinone
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Di Paolo
- Dipartimento di Scienze per la Qualità della Vita QuVi, University of Bologna, Rimini, Italy
| | - Gian Andrea Lucidi
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Erika Pinelli
- Dipartimento di Scienze per la Qualità della Vita QuVi, University of Bologna, Rimini, Italy
| | - Gregorio Marchiori
- Scienze e Tecnologie Chirurgiche, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Bontempi
- Scienze e Tecnologie Chirurgiche, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Laura Bragonzoni
- Dipartimento di Scienze per la Qualità della Vita QuVi, University of Bologna, Rimini, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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13
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Nazzal EM, Keeling LE, Ryan PM, Herman ZJ, Hughes JD. The Role of Lateral Extra-articular Tenodesis in Anterior Cruciate Ligament Reconstruction and Treatment of Rotatory Knee Instability: a Scoping Review. Curr Rev Musculoskelet Med 2023; 16:235-245. [PMID: 36995532 PMCID: PMC10234940 DOI: 10.1007/s12178-023-09832-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE OF REVIEW The addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL) reconstruction (ACLR) has become increasingly popular to address residual rotatory knee instability. The purpose of this article is to review the anatomy and biomechanics of the anterolateral complex (ALC) of the knee, outline different LET techniques, and provide biomechanical and clinical evidence for its use as an augmentation procedure with ACLR. RECENT FINDINGS Rotatory knee instability has been identified as a common contributor to ACL rupture in both the primary and revision settings. Several biomechanical studies have shown that LET reduces strain on the ACL by decreasing excess tibial translation and rotation. Additionally, in vivo studies have demonstrated restoration of side-to-side differences in anterior-posterior knee translation, higher rates of return to play, and overall increased patient satisfaction following combined ACLR and LET. As a result, various LET techniques have been developed to help offload the ACL graft and lateral compartment of the knee. However, conclusions are limited by a lack of concrete indications and contraindications for use of LET in the clinical setting. Recent studies have shown that rotatory knee instability contributes to native ACL and ACL graft rupture and LET may provide further stability to reduce rates of failure. Further investigation is needed to establish concrete indications and contraindications to determine which patients would most benefit from added stability of the ALC.
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Affiliation(s)
- Ehab M. Nazzal
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Laura E. Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Patrick M. Ryan
- Department of Orthopedic Surgery, Baylor Scott & White Medical Center, Temple, TX USA
| | - Zachary J. Herman
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Jonathan D. Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203 USA
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Zaffagnini S, Lucidi GA, Macchiarola L, Agostinone P, Neri MP, Marcacci M, Grassi A. The 25-year experience of over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: the story so far. J Exp Orthop 2023; 10:36. [PMID: 37005946 PMCID: PMC10067780 DOI: 10.1186/s40634-023-00599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/16/2023] [Indexed: 04/04/2023] Open
Abstract
This article presents with an evidence based approach, the kinematical rationale, biological evidence and the long term results of the "Over-The-Top" anterior cruciate ligament reconstruction with lateral plasty technique. This surgery was developed more than 25 years ago at the Rizzoli Institute by professor Marcacci and Zaffagnini and it is still widely performed in many orthopedic center worldwide.
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Affiliation(s)
- Stefano Zaffagnini
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
| | - Gian Andrea Lucidi
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
| | - Luca Macchiarola
- Ortopedia E Traumatologia, IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Piero Agostinone
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy.
| | - Maria Pia Neri
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
| | - Maurilio Marcacci
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Clinical and Research Center, Milan, Italy
| | - Alberto Grassi
- Clinica Ortopedica E Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, Bologna, Italy
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15
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Gómez Cáceres A, Mariño IT, Martínez Malo FJ, Vieitez Riestra I, Idiart RP. "Over-the-Top" Anterior Cruciate Ligament Reconstruction Associated With a Lateral Extra-Articular Tenodesis in Children. Arthrosc Tech 2023; 12:e441-e448. [PMID: 37138689 PMCID: PMC10149820 DOI: 10.1016/j.eats.2022.11.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/10/2022] [Indexed: 05/05/2023] Open
Abstract
Anterior cruciate ligament (ACL) tears are one of the most frequent injuries in growing children, and they are often associated with other injuries such as meniscal and chondral injuries. In the past, treatment of ACL tears in growing patients relied on activity modification and bracing. However, surgical treatment has prevailed over conservative treatment in recent years. A surgical technique is presented for ACL reconstruction using an "over-the-top" technique associated with a lateral extra-articular tenodesis procedure in children. An extra-articular lateral tenodesis is done first. The gracilis and semitendinous tendons are then extracted using a tenotome without releasing their distal desinsertions. The tibial guide is then centered over the ACL tibial footprint under arthroscopic vision and an image intensifier, proximal to the physis. Then, a Kocher-type forceps is used to pass a suture "over the top" from the posterolateral window to the tibial tunnel. The double-bundle graft and iliotibial tract graft are fixed within the tunnel in full extension and neutral rotation with an interference screw.
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Affiliation(s)
- Abel Gómez Cáceres
- Hospital HM Málaga, Málaga, Spain
- Málaga Football Club, Málaga, Spain
- Address correspondence to Abel Gómez Cáceres, M.D., Avenida Carlos Haya 121, 29010, Málaga, Spain.
| | - Iskandar Tamimi Mariño
- Hospital HM Málaga, Málaga, Spain
- Hospital Regional Universitario de Málaga, Málaga, Spain
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16
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McKeithan LJ, Lameire DL, Tagliero AJ, Chahal J, Gwathmey FW, Lee CA. What's New in Sports Medicine. J Bone Joint Surg Am 2023; 105:582-590. [PMID: 36853964 DOI: 10.2106/jbjs.22.01385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- Lydia J McKeithan
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento, California
| | - Darius L Lameire
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Adam J Tagliero
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Jaskarndip Chahal
- University of Toronto Orthopaedic Sports Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Cassandra A Lee
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento, California
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Helito CP, da Silva AGM, Sobrado MF, Guimarães TM, Gobbi RG, Pécora JR. Small Hamstring Tendon Graft for Anterior Cruciate Ligament Reconstruction Combined With Anterolateral Ligament Reconstruction Results in the Same Failure Rate as Larger Hamstring Tendon Graft Reconstruction Alone. Arthroscopy 2023:S0749-8063(23)00160-3. [PMID: 36774971 DOI: 10.1016/j.arthro.2023.01.101] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/30/2022] [Accepted: 01/24/2023] [Indexed: 02/14/2023]
Abstract
PURPOSE To compare patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring grafts 7 mm or less in diameter combined with anterolateral ligament (ALL) reconstruction versus isolated ACL reconstruction with grafts greater than 7 mm in diameter. METHODS We retrospectively evaluated the descriptive data and clinical outcomes of patients who underwent primary ACL reconstruction with hamstring grafts from June 2013 to January 2020 and had a minimum follow-up period of 2 years. Patients with quadrupled or quintupled semitendinosus and gracilis autograft 7 mm or less in diameter combined with single-strand ALL reconstruction (ACL-ALL group) were matched in a 1:2 propensity ratio to patients who underwent isolated single-bundle ACL reconstruction with hamstring grafts greater than 7 mm (ACL group). RESULTS We identified 30 patients in our database who met the criteria for the ACL-ALL group. The patients in this group were matched to 60 patients comprising the ACL group. Both groups were similar regarding all preoperative matched and unmatched variables. The mean ACL graft diameter was 6.8 ± 0.4 mm in the ACL-ALL group and 8.6 ± 0.6 mm in the ACL group (P < .001). The ACL-ALL group presented 1 failure (3.3%), and the ACL group presented 3 failures (5%) (P = .717). Postoperative KT-1000 measurements were similar between the groups (2.1 ± 1.1 mm vs 1.9 ± 1.2 mm, P = .114), as were postoperative pivot-shift grades (P = .652). Subjective International Knee Documentation Committee scores and Lysholm scores did not present any differences between the groups (P = .058 and P = .280, respectively). CONCLUSIONS Patients who undergo combined ACL-ALL reconstruction with an ACL graft diameter of 7 mm or less can achieve similar results to patients who undergo isolated ACL reconstruction with a graft diameter greater than 7 mm. An associated ALL reconstruction can be performed to increase knee stability in patients with small-diameter hamstring grafts. LEVEL OF EVIDENCE Level III, retrospective, comparative therapeutic trial.
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Affiliation(s)
- Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil
| | - Andre Giardino Moreira da Silva
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil
| | - Tales Mollica Guimarães
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Screpis D, Baldini M, Magnanelli S, Amarossi A, Piovan G, Natali S, Zorzi C. Anatomic Combined Anterior Cruciate Ligament and Antero-Lateral Ligament Reconstruction Using Autologous Gracilis and Semitendinosus Graft With Single Tibial and Femoral Tunnel. Arthrosc Tech 2023; 12:e255-e259. [PMID: 36879871 PMCID: PMC9984781 DOI: 10.1016/j.eats.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/31/2022] [Indexed: 01/21/2023] Open
Abstract
Anterior cruciate ligament (ACL) injuries are among the most common lesions in orthopaedics practice, but still today, rates up to 24% of unsatisfactory results are reported. Unaddressed anterolateral complex (ALC) injuries have been claimed to be responsible for residual anterolateral rotatory instability (ALRI) after isolate ACL reconstruction and have demonstrated to increase graft failure. In this article, we present our technique for reconstruction of the ACL and anterolateral (ALL) ligament combining the advantages of the anatomical position and the intraosseous femoral fixation to ensure anteroposterior and anterolateral rotational stability.
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Affiliation(s)
- Daniele Screpis
- IRCCS Ospedale Sacro Cuore - Don Calabria, Negrar di Valpolicella, Italia
| | - Marco Baldini
- Clinica Ortopedica dell’Adulto e Pediatrica, Università Politecnica delle Marche, Ancona, Italia
| | - Stefano Magnanelli
- IRCCS Ospedale Sacro Cuore - Don Calabria, Negrar di Valpolicella, Italia
| | - Andrea Amarossi
- Department of Orthopedics and Trauma Surgery, University of Verona, Verona, Italy
| | - Gianluca Piovan
- IRCCS Ospedale Sacro Cuore - Don Calabria, Negrar di Valpolicella, Italia
| | - Simone Natali
- IRCCS Ospedale Sacro Cuore - Don Calabria, Negrar di Valpolicella, Italia
- Address correspondence to Simone Natali, M.D., IRCCS Ospedale Sacro Cuore - Don Calabria, Viale Luigi Rizzardi 4, Negrar di Valpolicella (VR), Italia.
| | - Claudio Zorzi
- IRCCS Ospedale Sacro Cuore - Don Calabria, Negrar di Valpolicella, Italia
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Grassi A, Di Paolo S, Coco V, Romandini I, Filardo G, Lucidi GA, Marcacci M, Zaffagnini S. Survivorship and Reoperation of 324 Consecutive Isolated or Combined Arthroscopic Meniscal Allograft Transplants Using Soft Tissue Fixation. Am J Sports Med 2023; 51:119-128. [PMID: 36349951 PMCID: PMC9810826 DOI: 10.1177/03635465221131522] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Meniscal allograft transplant (MAT) is an effective treatment for relieving symptoms and improving knee function in patients who experience symptomatic unicompartmental knee pain after a previous meniscectomy. However, the literature contains a paucity of studies assessing the survival rate and prognostic factors of soft tissue MAT. PURPOSE To report the survivorship of a large, single-center cohort of consecutive patients treated with arthroscopic MAT using soft tissue technique and to investigate variables that could potentially influence failures and outcomes. STUDY DESIGN Case series; Level of evidence, 4. METHODS Consecutive MAT procedures totaling 364 performed in a single institution between June 2004 and April 2019 were screened and assessed for eligibility. Subjective clinical scores (Lysholm score, Tegner activity scale, and visual analog score) were collected preoperatively and at 2, 5, 7, and 10 years of follow-up. Two survival analyses were performed using Kaplan-Meier curves, with surgical failure (defined as any graft revision) and clinical failure (defined as a Lysholm score <65 points) used as endpoints. Univariate analyses were performed using reoperations, surgical failure, clinical failure, and different demographic and surgical characteristics as endpoints. RESULTS A total of 324 consecutive patients were evaluated at a mean follow-up 5.7 ± 3.0 years. Of these, 189 (58%) underwent an associated surgical procedure. A total of 22 patients (6.8%) were considered to have experienced surgical failure, and no predictors of surgical failure were identified based on the relevant variables. When all patients were considered, a significant improvement in all of the patient-reported outcome measures was present between the preoperative assessment and the last follow-up (P < .001), with no significant decrease over time. Moreover, 70 (21.6%) patients were considered to have experienced clinical failure; the need for concurrent cartilage procedures (odds ratio, 0.16; P = .001) and anterior cruciate ligament (ACL) reconstruction (odds ratio, 0.40; P = .059) were predictors of failure. Finally, a lower survival rate was reported in female patients compared with male patients (49% vs 69%, respectively; P = .007) and in patients who required cartilage surgery (P = .014). In particular, patients who required cartilage surgery showed nearly half the survival rate compared with those with required no cartilage procedures at 10-year follow-up (36.4% vs 71%, respectively; P = .029). CONCLUSION Female sex and the need to combine MAT with a cartilage procedure or ACL reconstruction could result in an increased rate of clinical failure at midterm follow-up.
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Affiliation(s)
- Alberto Grassi
- IIa Clinica, IRCCS, Istituto Ortopedico
Rizzoli, Bologna, Italy
| | - Stefano Di Paolo
- Dipartimento di Scienze per la Qualità
della Vita QuVi, Università di Bologna, Bologna, Italy
| | - Vito Coco
- IIa Clinica, IRCCS, Istituto Ortopedico
Rizzoli, Bologna, Italy
| | | | - Giuseppe Filardo
- Applied and Translational Research
(ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gian Andrea Lucidi
- IIa Clinica, IRCCS, Istituto Ortopedico
Rizzoli, Bologna, Italy,Gian Andrea Lucidi, MD, IIa Clinica, IRCCS, Istituto Ortopedico
Rizzoli, Via Cesare Pupilli 1, Bologna, 40136, Italy (
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20
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High return to sport rate and few re-ruptures at long term in professional footballers after anterior cruciate ligament reconstruction with hamstrings. Knee Surg Sports Traumatol Arthrosc 2022; 30:3681-3688. [PMID: 35451640 DOI: 10.1007/s00167-022-06944-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Anterior cruciate ligament (ACL) ruptures are considered high burden injuries in sports with high pivotal activity, especially for professional footballers. A lack of evidence exists about long-term follow up of professional elite athletes who underwent ACL reconstruction. The purpose of the study is to analyze the return to play and the career of professional footballers who underwent ACL reconstruction with hamstrings, to evaluate re-rupture and reoperation at either indexed and contralateral knee, and to assess the long-term clinical subjective outcomes and satisfaction. METHODS Twenty-eight professional footballers that underwent 33 ACL reconstructions were retrospectively included in the study. All surgical interventions were performed using hamstring tendons graft and an over the top technique. Inclusion criteria were: inability to compete due to joint instability caused by total or subtotal ACL lesion, patients contracted to a professional football team at time of surgery. Exclusion criteria were: multi-ligament reconstruction or concomitant meniscal allograft transplantation. Patients were contacted by phone and a brief questionnaire about surgery was administered. Subsequently, a Lysholm knee scoring scale was obtained. After that, an online research was performed on publicly available websites in order to retrieve information of the patients included after surgery. RESULTS In all cases, ACL Reconstruction was performed with hamstring tendons using a non-anatomic Double-Bundle technique in 16 cases (49%), an Over-The-Top Single-Bundle technique in 9 cases (27%), and an Over-The-Top Single-Bundle plus Lateral Plasty technique in 8 cases (24%); moreover, a meniscal lesion was present in 20 cases (61%). Three (9%) of the 33 ACL reconstruction failed (2/16 Double-Bundle, 1/9 Single- Bundle, 0/8 Single-Bundle + Lateral Plasty; p = n.s.), with two of them within 12 months from surgery. Other procedures, mainly arthroscopic meniscectomies, were performed in 10 cases (30%). The first official match was played after an average of 8.0 ± 3.6 (4.6-18.2) months in 31 cases (94%). Patients were evaluated after 12.6 ± 3.3 years (6.7-17.5) from the indexed ACL reconstruction. The average Lysholm score was 94.2 ± 8.3. CONCLUSIONS In our small case-series, professional soccer players were able to return to play at a competitive level with a hamstrings over the top technique. Patients with long careers had a high percentage of reoperation on the contralateral knee. LEVEL OF EVIDENCE IV.
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21
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Slope-Reducing High Tibial Osteotomy and Over-The-Top Anterior Cruciate Ligament Reconstruction With Achilles Tendon Allograft in Multiple Failed Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2022; 11:e2021-e2028. [PMID: 36457378 PMCID: PMC9705769 DOI: 10.1016/j.eats.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/31/2022] [Indexed: 11/05/2022] Open
Abstract
Graft failure is a challenging complication following anterior cruciate ligament reconstruction (ACL-R). Among the multiple anatomic and nonanatomic risk factors contributing to ACL-R failure, there is accumulating evidence that a posterior tibial slope of 12° or greater may predispose patients to graft failure of primary and revision ACL-R. In addition, previously malpositioned or widened tunnels, as well as limited autograft options, pose challenges in the setting of revision ACL-R. This Technical Note describes a technique to correct an increased posterior tibial slope using slope-reducing high tibial osteotomy, and single stage revision ACL-R with Achilles tendon allograft using the over-the-top route, in a single-stage procedure. The surgical technique involves an anterior approach to the proximal tibia, followed by tibial tubercle osteotomy and anterior closing-wedge osteotomy. The posterior cortical osteotomy hinge is left intact below the insertion of the posterior cruciate ligament. Over-the-top revision ACL-R is then performed using an Achilles tendon allograft passed around the posterior aspect of the lateral femoral condyle and fixed onto the lateral femur.
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22
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Rosso F, Rossi R, Faletti R, Cantivalli A, Blonna D, Bonasia DE. Transepicondylar distance measured on MRI can predict the length of the graft required for different anterior cruciate ligament reconstruction (ACLR) techniques useful for revision surgery. J Orthop Traumatol 2022; 23:50. [PMID: 36242704 PMCID: PMC9569264 DOI: 10.1186/s10195-022-00670-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 09/24/2022] [Indexed: 12/04/2022] Open
Abstract
Background The aim of this study is to find a correlation between linear measurements and the graft length required for different anterior cruciate ligament (ACL) revision techniques, to extract formulas to predict required graft length during the preoperative planning. Methods At time 0 and 30 days later, two observers measured eight linear distances on standard 2D knee magnetic resonance imaging (MRI), and nine curved distances on 3D MRI sequences, corresponding to different techniques for ACL revision, anatomic anterolateral ligament (ALL) reconstruction, and lateral extrarticular tenodesis (LET). Intra- and interobserver reliability was tested for 2D and 3D measurements. The correlation between 2D and 3D measurements was tested. The 2D measurements with highest repeatability and reproducibility, and with strongest correlation with 3D measurements were used to extract formulas to calculate the graft length from 2D values. Results Fifty MRIs acquired with both 2D and 3D sequences were used. The intra- and interobserver reliability of linear 2D measurement was high, with the transepicondylar distance (TD) showing the highest reproducibility and repeatability. The intra- and interobserver reliability of 3D measurements was lower than 2D, but acceptable for all measurements except for ALL reconstruction. The TD showed the strongest correlation with 3D measurements. The formulas extracted to calculate the graft length from the TD proved to be accurate. Conclusion Accurate formulas were created to calculate the graft length needed for different ACL revision techniques and ALL reconstruction/LET techniques from TD. These formulas can be used during preoperative planning of ACL revision cases.
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Affiliation(s)
- Federica Rosso
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, 10128, Turin, Italy
| | - Roberto Rossi
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, 10128, Turin, Italy. .,Università Degli Studi Di Torino, Via Po 8, 10100, Turin, Italy.
| | - Riccardo Faletti
- Department of Radiology, AOU "Città Della Salute e Della Scienza" Hospital, University of Torino, Via Genova 3, 10126, Turin, Italy
| | - Antonino Cantivalli
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, 10128, Turin, Italy
| | - Davide Blonna
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, 10128, Turin, Italy
| | - Davide Edoardo Bonasia
- Department of Orthopaedics and Traumatology, AO Ordine Mauriziano Hospital, University of Torino, Largo Turati 62, 10128, Turin, Italy
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Zsidai B, Engler ID, Pujol O, Lucidi GA, Curley AJ, Zaffagnini S, Musahl V. Over-The-Top Technique for Revision ACL Reconstruction with Achilles Allograft and Associated Lateral Extra-articular Tenodesis. Arthrosc Tech 2022; 11:e1633-e1640. [PMID: 36185109 PMCID: PMC9520075 DOI: 10.1016/j.eats.2022.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/20/2022] [Indexed: 02/03/2023] Open
Abstract
Revision anterior cruciate ligament reconstruction (ACL-R) is made challenging by the frequent presence of rotatory instability, tunnel malpositioning and widening, and limited autograft options. Lateral extra-articular tenodesis (LET), alternative tunnel routing, and the use of allograft tissue can be used to manage these challenges. This Technical Note describes revision ACL-R using the over-the-top (OTT) technique with Achilles tendon allograft with concomitant LET. The surgical approach involves routing the graft around the posterior aspect of the lateral femoral condyle, and then deep to the iliotibial band to a site just medial to Gerdy's tubercle, with staple fixation on the lateral femur for the ACL-R and anterolateral tibia for the LET. The OTT technique with LET provides a versatile approach for the management of failed ACL-R by circumventing challenges in revision ACL-R and addressing rotatory instability, a contributing factor to prior graft failure.
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Affiliation(s)
- Bálint Zsidai
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, U.S.A.,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,Address correspondence to Bálint Zsidai, M.D., Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Ian D. Engler
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, U.S.A
| | - Oriol Pujol
- Knee Surgery Unit, Orthopedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Gian Andrea Lucidi
- Clinica II, Istituto Ortopedico Rizzoli, IRCCS Via Pupilli, Bologna, Italy
| | - Andrew J. Curley
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, U.S.A
| | - Stefano Zaffagnini
- Clinica II, Istituto Ortopedico Rizzoli, IRCCS Via Pupilli, Bologna, Italy
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, U.S.A.,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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24
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Sabatini L, Capella M, Vezza D, Barberis L, Camazzola D, Risitano S, Drocco L, Massè A. Anterolateral complex of the knee: State of the art. World J Orthop 2022; 13:679-692. [PMID: 36159618 PMCID: PMC9453282 DOI: 10.5312/wjo.v13.i8.679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/07/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023] Open
Abstract
Rotatory instability of the knee represents the main reason for failure and poor clinical outcomes regarding anterior cruciate ligament (ACL) reconstruction techniques. It is now clear that the anterolateral complex (ALC) of the knee possesses a fundamental role, in association with the ACL, in controlling internal rotation. Over the past decade, ever since the anterolateral ligament has been identified and described as a distinct structure, there has been a renewed interest in the scientific community about the whole ALC: Lateral extra-articular tenodesis have made a comeback in association with ACL reconstructions to improve functional outcomes, reducing the risks of graft failure and associated injuries. Modern ACL reconstruction surgery must therefore investigate residual instability and proceed, when necessary, to extra-articular techniques, whether functional tenodesis or anatomical reconstruction.This review aims to investigate the latest anatomical and histological descriptions, and the role in rotational control and knee biomechanics of the ALC and its components. The diagnostic tools for its identification, different reconstruction techniques, and possible surgical indications are described.. In addition, clinical and functional results available in the literature are reported.
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Affiliation(s)
- Luigi Sabatini
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Marcello Capella
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Daniele Vezza
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Luca Barberis
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Daniele Camazzola
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Salvatore Risitano
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Luca Drocco
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
| | - Alessandro Massè
- Department of Orthopaedics and Traumatology, Università degli Studi di Torino, Torino 10126, Italy
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25
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Will the Kaplan Fiber Complex Be the ‘‘New Anterolateral Ligament’’? Insights from Direct Surgical Exploration in the Context of ACL Injury and Reconstruction. J Clin Med 2022; 11:jcm11164842. [PMID: 36013077 PMCID: PMC9410125 DOI: 10.3390/jcm11164842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
According to the most popular scientific literature database in 2022, nearly 20 papers mentioning the “Kaplan Fiber” complex have been published in the last 2 years, highlighting the role of this anatomical structure in the context of anterior cruciate ligament tear [...]
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26
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Marshall DC, Silva FD, Goldenberg BT, Quintero D, Baraga MG, Jose J. Imaging Findings of Complications After Lateral Extra-Articular Tenodesis of the Knee: A Current Concepts Review. Orthop J Sports Med 2022; 10:23259671221114820. [PMID: 36062159 PMCID: PMC9434692 DOI: 10.1177/23259671221114820] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Despite successful anterior cruciate ligament (ACL) reconstruction, many patients continue to experience persistent anterolateral rotatory instability. Lateral extra-articular tenodesis (LET) is used to address this instability by harvesting a portion of the iliotibial band, passing it underneath the fibular collateral ligament, and attaching it just proximal and posterior to the lateral femoral epicondyle. Based on the most recent clinical evidence, the addition of LET to ACL reconstruction improves clinical outcomes, which has led to an increase in the use of this technique. Purpose To provide an overview of the postoperative complications of the LET procedure and their associated imaging findings, with a focus on magnetic resonance imaging (MRI). Study Design Narrative review. Methods In this scoping review, the authors reviewed available radiographic, computed tomography, and MRI scans of patients who experienced postoperative complications after ACL reconstruction with LET, in which the complication was determined to be from the LET procedure. Images were reviewed and subsequently described by an on-staff musculoskeletal radiologist. Results The authors found 9 different complications associated with LET: graft failure, hematoma, infection, chronic pain, tunnel convergence, fixation device migration, muscular hernia, peroneal nerve palsy, and knee stiffness. They supplemented these findings with radiographic evidence from 6 patients. Conclusion As extra-articular reconstruction techniques including LET become more popular among orthopaedic surgeons, it is important that radiologists and surgeons be adept at recognizing the normal imaging findings of LET and associated complications.
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Affiliation(s)
- Danielle C. Marshall
- Department of Orthopaedics, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
| | - Flavio D. Silva
- Department of Radiology, Grupo Osteomuscular, Fleury Medicine e
Saúde, São Paulo, Brazil
| | - Brandon T. Goldenberg
- Department of Orthopaedics, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
| | - Daniel Quintero
- Department of Orthopaedics, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
- Department of Radiology, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
| | - Michael G. Baraga
- Department of Orthopaedics, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
| | - Jean Jose
- Department of Radiology, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
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27
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Onggo JR, Rasaratnam HK, Nambiar M, Onggo JD, Pai V, Damasena I, Riazi A, Babazadeh S. Anterior Cruciate Ligament Reconstruction Alone Versus With Lateral Extra-articular Tenodesis With Minimum 2-Year Follow-up: A Meta-analysis and Systematic Review of Randomized Controlled Trials. Am J Sports Med 2022; 50:1137-1145. [PMID: 33886399 DOI: 10.1177/03635465211004946] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lateral extra-articular tenodesis (LEAT) aims to improve anterolateral stability of the injured knee during anterior cruciate ligament reconstruction (ACLR) surgery. Inconclusive evidence surrounding the efficacy and safety of LEAT has propelled clinical interest and ongoing discussions. PURPOSE To establish level 1 evidence by assessing randomized controlled trials (RCTs) with minimum 2-year follow-up that directly compared ACLR with LEAT (LEAT group) and ACLR alone (non-LEAT group) in terms of clinical outcomes and complications. STUDY DESIGN Meta-analysis and systematic review; Level of evidence, 1. METHODS Meta-analysis was performed with a multidatabase search (Cochrane, EMBASE, OVID Medline, PubMed, and Web of Science) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on September 9, 2020. Data from published RCTs meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model. RESULTS A total of 7 RCTs were included, consisting of 517 LEAT and 589 non-LEAT patients. Only autografts were used for ACLR and LEAT. A variety of LEAT techniques and autograft fixation methods were used. We found improved stability (residual positive pivot shift: risk ratio [RR], 0.59; 95% CI, 0.39-0.88; P = .01) and better clinical outcomes (International Knee Documentation Committee [IKDC] score: mean difference [MD], 2.31; 95% CI, 0.54-4.09; P = .01; and Lysholm score: MD, 2.71; 95% CI, 0.68-4.75; P = .009) in the LEAT than non-LEAT group. Graft rerupture rate was 3 times less likely (RR, 0.31; 95% CI, 0.17-0.58; P < .001) in the LEAT group than the non-LEAT group. CONCLUSION Good-quality evidence is available to support the efficacy of LEAT in improving anterolateral knee stability and reducing graft reruptures in primary ACLR. LEAT should be considered in patients with high risk factors. Although Lysholm and IKDC scores were statistically better in the LEAT group, these are unlikely to be clinically significant. Future studies should aim to identify patient populations that would best benefit from LEAT with ACLR.
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Affiliation(s)
- James Randolph Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | | | - Mithun Nambiar
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Jason Derry Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Vishal Pai
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Iswadi Damasena
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Arash Riazi
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Sina Babazadeh
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
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28
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Min BH, Song HK, Park KH, Kim TH, Park DY, Chung JY. Biomechanical Evaluation of Modified ACL Reconstruction with Over-the-Top Augmentation Technique. Indian J Orthop 2022; 56:812-820. [PMID: 35547346 PMCID: PMC9043071 DOI: 10.1007/s43465-021-00597-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/20/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Modified ACL reconstruction with over-the-top augmentation technique (OA-ACLR) was designed to allow one-stage revision regardless of tunnel conditions as well as to offer firm stability by hybrid double-fixation. Thus, the purpose of the study is to biomechanically evaluate its effect on knee stability by comparing it with single-bundle ACL reconstruction (SB-ACLR). METHODS Ten porcine knees were sequentially tested using a custom testing system for intact ACL, ACL deficiency, SB-ACLR and OA-ACLR. First, 134-N anterior tibial load was applied, and anterior tibial translation was measured at 30°, 60°, and 90°. Then, anterior tibial translation and relative tibial rotation were measured in a combined rotatory load of 5-Nm of internal tibial torque and 10-Nm of valgus torque. RESULTS Under anterior tibial load or combined anterior and rotatory loads, SB-ACLR and OA-ACLR resulted in no significant increase in anterior tibial translation at all flexion angles compared with an intact ACL group, and no significant difference was noted in anterior tibial translation between the two ACL reconstruction groups. In combined rotatory load, OA-ACLR resulted in enhanced rotational stability compared with SB-ACLR, and it more closely restored relative tibial internal rotation to the intact ACL group. CONCLUSIONS Our study showed that modified ACL reconstruction with over-the-top augmentation technique resulted in enhanced rotational stability compared to the conventional single-bundle ACL reconstruction, especially at lower flexion angle in a porcine model. Therefore, with several potential advantages as well as biomechanical superiority, our new technique could be clinically applicable in primary and revision ACL reconstruction. LEVEL OF EVIDENCE Experimental.
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Affiliation(s)
- Byoung-Hyun Min
- grid.251916.80000 0004 0532 3933Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499 Korea
| | - Hyung Keun Song
- grid.251916.80000 0004 0532 3933Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499 Korea
| | - Ki Hoon Park
- grid.251916.80000 0004 0532 3933Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499 Korea
| | - Tae Hun Kim
- grid.251916.80000 0004 0532 3933Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499 Korea
| | - Do Young Park
- grid.251916.80000 0004 0532 3933Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499 Korea
| | - Jun Young Chung
- grid.251916.80000 0004 0532 3933Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499 Korea
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29
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Di Paolo S, Agostinone P, Grassi A, Lucidi GA, Pinelli E, Bontempi M, Marchiori G, Bragonzoni L, Zaffagnini S. Dynamic Radiostereometry Evaluation of 2 Different Anterior Cruciate Ligament Reconstruction Techniques During a Single-Leg Squat. Orthop J Sports Med 2021; 9:23259671211011940. [PMID: 34350300 PMCID: PMC8287361 DOI: 10.1177/23259671211011940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/19/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Lateral extra-articular tenodesis in the context of anterior cruciate
ligament (ACL) reconstruction (ACLR) is performed to better control
anterolateral knee instability in patients with high-grade preoperative
pivot shift. However, some authors believe these procedures may cause
lateral compartment overconstraint, affecting knee motion in daily life. Purpose/Hypothesis: The primary aim of the present study was to identify kinematic differences
during the execution of an activity under weightbearing conditions between
knees having undergone ACLR using anatomic single-bundle (SB) versus
single-bundle plus lateral plasty (SBLP) techniques. The secondary aim was
to compare the postoperative kinematic data with those from the same knees
before ACLR and from the healthy contralateral knees in order to investigate
if ACLR was able to restore physiologic knee biomechanics during squat
execution. The hypotheses were that (1) the SBLP technique would allow a
better restoration of internal-external (IE) knee rotation than would SB and
(2) regardless of the technique, ACLR would not fully restore physiologic
knee biomechanics. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: In total, 32 patients (42 knees) were included in the study. Patients were
asked to perform a single-leg squat before surgery (ACL-injured group, n =
32; healthy contralateral group, n = 10) and at minimum 18-month follow-up
after ACLR (SB group, n = 9; SBLP group, n = 18). Knee motion was determined
using a validated model-based tracking process that matched patient-specific
magnetic resonance imaging bone models to dynamic biplane radiographic
images under the principles of roentgen stereophotogrammetric analysis. Data
processing was performed using specific software. The authors compared IE
and varus-valgus rotations and anterior-posterior and medial-lateral
translations among the groups. Results: The mean follow-up period was 21.7 ± 4.5 months. No kinematic differences
were found between the SB and SBLP groups (P > .05). A
more medial tibial position (P < .05) of the ACL-injured
group was reported during the entire motor task and persisted after ACLR in
both the SB and the SBLP groups. Differences in IE and varus-valgus
rotations were found between the ACL-injured and healthy groups. Conclusion: There were no relevant kinematic differences between SBLP and anatomic SB
ACLR during the execution of a single-leg squat. Regardless of the surgical
technique, ACLR failed in restoring knee biomechanics. Registration: NCT02323386 (ClinicalTrials.gov
identifier).
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Affiliation(s)
- Stefano Di Paolo
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | - Piero Agostinone
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | - Alberto Grassi
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gian Andrea Lucidi
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Erika Pinelli
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | - Marco Bontempi
- Scienze e Tecnologie chirurgiche, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gregorio Marchiori
- Scienze e Tecnologie chirurgiche, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Laura Bragonzoni
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | - Stefano Zaffagnini
- 2nd Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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30
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Zaffagnini S, Roberti di Sarsina T. Editorial Commentary: Chronic Anterior Cruciate Ligament Injury Requires Reconstruction Plus Lateral Tenodesis to Control Rotational Instability: Additional Technical Complexity May Result in Complications Without Improved Outcomes. Arthroscopy 2021; 37:2235-2236. [PMID: 34226011 DOI: 10.1016/j.arthro.2021.04.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 02/02/2023]
Abstract
How to restore native knee kinematics following complex knee injuries is still debated and under investigation. To better reproduce the native anterior cruciate ligament (ACL), surgeons have a host of different options, including graft choice, technique, fixation method, and single-, double-, and triple-bundle techniques, etc. Isolated ACL reconstruction alone is not effective in controlling complex instability patterns, especially regarding internal and external rotations. Several techniques have been described to address such instabilities, like single- or double- bundle ACL reconstruction plus lateral extra-articular tenodesis. In truth, chronic ACL injury requires reconstruction plus lateral tenodesis to control rotational instability. Additional technical complexity may result in complications without improved outcomes. Neither single-bundle nor double-bundle techniques are "truly" anatomic. Keep it simple; keep it safe.
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31
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Grassi A, Macchiarola L, Lucidi GA, Dal Fabbro G, Mosca M, Caravelli S, Zaffagnini S. Anterior Cruciate Ligament Reconstruction and Lateral Plasty in High-Risk Young Adolescents: Revisions, Subjective Evaluation, and the Role of Surgical Timing on Meniscal Preservation. Sports Health 2021; 14:188-196. [PMID: 34034569 DOI: 10.1177/19417381211014487] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In adolescents, the rate of meniscal injury at the time of anterior cruciate ligament (ACL) reconstruction, the rate of ACL graft revision, and clinical outcomes has not yet been investigated. HYPOTHESIS In patients younger than 16 years, the rate of meniscal injuries at the time of ACL reconstruction increases with time from injury. The mid-term revision rate and reoperation rate after ACL reconstruction with hamstrings and lateral tenodesis are lower than those reported in literature for isolate ACL reconstruction. STUDY DESIGN Case series. LEVEL OF EVIDENCE Level 4. METHODS Patients younger than 16 years who underwent ACL reconstruction with hamstring and lateral tenodesis, with a follow-up ≥2 years were included. The number of meniscal lesions was stratified according to the delay between injury-to-surgery (<3, 3-12, >12 months). All reoperations, Lysholm score, Knee Injury and Osteoarthritis Outcome Score subscales for pain (at rest and during activity), and return to sport were collected. RESULTS A total of 151 patients (mean age 14.8 ± 1.2 years) were included. Patients undergoing surgery at <3 months after injury had a lower meniscal injury rate (36%) than those treated at 3 to 12 months (55%) and >12 months (63%) after injury (P = 0.04). Medial meniscal lesions were more likely to be repaired when surgery was performed <3 months after injury (91%). Subjective follow-up data were available for 132 patients, and 19 were lost to follow-up. At 6.0 ± 2.6 years, 6% of patients underwent ACL revision; 1 of 20 (5%) patients with posterior tibial slope ≥12° and 4 of 45 (9%) patients with Tegner level ≥8. Nine new meniscal procedures were performed; 19% of repaired menisci underwent meniscectomy. Good or excellent Lysholm score was reported by 88% of patients; 56% of patients with concurrent lateral meniscectomy had pain during activity, 91% returned to sport, and 79% were still participating at final follow-up. CONCLUSION Patients younger than 16 years undergoing ACL reconstruction within 3 months from injury had the lowest rate of meniscal injuries. ACL reconstruction with lateral tenodesis had low revision rate (6%) and good or excellent clinical outcomes in 88% of young adolescents. CLINICAL RELEVANCE Sport physicians should be aware that adolescent patients undergoing ACL reconstruction within 3 months after injury have the lowest rate of meniscal injuries; the mid-term revision rate of ACL reconstruction with lateral plasty is lower than 10% and the patients' perceived outcomes are good with almost all patients returning to sport activity.
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Affiliation(s)
- Alberto Grassi
- IRCCS Istituto Ortopedico Rizzoli, II Clinica Ortopedica e Traumatologica, Bologna, Italy
| | - Luca Macchiarola
- IRCCS Istituto Ortopedico Rizzoli, II Clinica Ortopedica e Traumatologica, Bologna, Italy
| | - Gian Andrea Lucidi
- IRCCS Istituto Ortopedico Rizzoli, II Clinica Ortopedica e Traumatologica, Bologna, Italy
| | - Giacomo Dal Fabbro
- IRCCS Istituto Ortopedico Rizzoli, II Clinica Ortopedica e Traumatologica, Bologna, Italy
| | - Massimilano Mosca
- IRCCS Istituto Ortopedico Rizzoli, II Clinica Ortopedica e Traumatologica, Bologna, Italy
| | - Silvio Caravelli
- IRCCS Istituto Ortopedico Rizzoli, II Clinica Ortopedica e Traumatologica, Bologna, Italy
| | - Stefano Zaffagnini
- IRCCS Istituto Ortopedico Rizzoli, II Clinica Ortopedica e Traumatologica, Bologna, Italy
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Hamstring grafts for anterior cruciate ligament reconstruction show better magnetic resonance features when tibial insertion is preserved. Knee Surg Sports Traumatol Arthrosc 2021; 29:507-518. [PMID: 32266415 DOI: 10.1007/s00167-020-05948-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Comparing the MRI features of the grafts between a group of patients treated with an over-the-top anterior cruciate ligament reconstruction technique that preserves the hamstring attachment and a control group with a classical reconstruction technique. METHODS Patients were assigned to a standard reconstruction technique or an Over-the-top plus lateral plasty technique. All patients underwent preoperative, 4-months and 18-months MRI; together with a clinical evaluation with KOOS and KT1000 laxity assessment. MRI study involved different parameters: the "Graft" was evaluated with the continuity, Howell Grading system, presence of liquid and signal noise quotient. The "Tibial Tunnel" was evaluated with the signal noise quotient, presence of edema or liquid and tunnel widening. All points assigned to each parameter formed a composite score ranging from 0-10. Tunnel and graft positioning were evaluated. RESULTS At 18-month 20 MRIs (10 each group) were available, demographics were not significantly different between groups. The non-detached group showed significantly less liquid within the graft at 4-months (p = 0.008) and 18-months (p = 0.028), the tunnel was significantly smaller (p < 0.05) and less enlarged at both follow-ups (p < 0.05), signal noise quotient of the intra-tunnel graft was lower at 18-months (p < 0.05). The total score of the non-detached group saw a significant improvement at 4-months (p = 0.006) that remained stable at 18-months (n.s.). CONCLUSIONS Hamstring grafts, which tibial insertions were preserved, showed better MRI features at 4-and 18-months follow-up, especially in terms of liquid effusion, tunnel enlargement and signal noise quotient. LEVEL OF EVIDENCE IV.
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Fones L, Kostyun RO, Cohen AD, Pace JL. Patient-Reported Outcomes, Return-to-Sport Status, and Reinjury Rates After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes: Minimum 2-Year Follow-up. Orthop J Sports Med 2020; 8:2325967120964471. [PMID: 33283005 PMCID: PMC7686622 DOI: 10.1177/2325967120964471] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/08/2020] [Indexed: 12/16/2022] Open
Abstract
Background Significant variation exists in the published rates of return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR). Functional outcomes and psychological response to injury have been implicated as factors that influence return to sport. Most studies focus on patients aged in the mid-20s, and less is known about this topic in adolescents. Purpose To report midterm ACLR results for adolescent patients with regard to return to primary sport, patient-reported outcomes, and reinjury rate. Study Design Case-control study; Level of evidence, 3. Methods Adolescent athletes were contacted at a minimum of 2 years after ACLR. Patients completed 2 patient-reported outcome measures, the ACL--Return to Sport After Injury (ACL-RSI) and the International Knee Documentation Committee (IKDC) subjective form, and responded to questions regarding preinjury primary sport and level of competition, post-ACLR return to primary sport status, and reinjury. Results A total of 74 patients (mean ± SD surgical age, 15.9 ± 1.5 years; follow-up age, 19.9 ± 2.0 years; response rate, 24.5%) completed the surveys at a mean of 4.0 ± 2.0 years after primary ACLR. Outcome scores averaged 90.3 ± 12.3 for IKDC and 81.6 ± 20.4 for ACL-RSI. Questionnaire responses indicated that 27.0% of patients did not return to or sustain primary sport participation after ACLR; the principal reasons were poor knee function, team/training change, and fear of another injury. Both IKDC and ACL-RSI scores were statistically lower in patients who did not successfully return to their primary sport in contrast to patients who successfully resumed their primary sport (IKDC, P = .026; ACL-RSI, P < .001). IKDC and ACL-RSI scores were moderately positively correlated with one another (r Spearman = 0.60). There were 18 patients (reinjury rate, 24.3%) who suffered another ACL injury; 8 of these injuries included ipsilateral ACL graft tear (retear rate, 10.8%). Conclusion In our cohort, 73% of adolescent patients successfully returned to their primary preinjury sport at a minimum of 2 years after ACLR. Both knee function and psychological responses to injury were important in determining an adolescent athlete's return to sport. The findings support the use of the IKDC and ACL-RSI at midterm follow-up, with higher scores associated with a greater likelihood of adolescent patients returning to sport after ACLR.
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Affiliation(s)
- Lilah Fones
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Regina O Kostyun
- Hartford Healthcare Bone & Joint Institute, Hartford, Connecticut, USA
| | - Andrew D Cohen
- Elite Sports Medicine, Connecticut Children's Medical Center, Farmington, Connecticut, USA
| | - J Lee Pace
- Elite Sports Medicine, Connecticut Children's Medical Center, Farmington, Connecticut, USA.,Department of Orthopedic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, USA
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Lanzetti RM, Pace V, Ciompi A, Perugia D, Spoliti M, Falez F, Auro C. Over the top anterior cruciate ligament reconstruction in patients with open physes: a long-term follow-up study. INTERNATIONAL ORTHOPAEDICS 2020; 44:771-778. [PMID: 31993711 DOI: 10.1007/s00264-020-04490-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/20/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Anterior cruciate ligament (ACL) rupture in skeletally immature athletes is becoming an injury with increasing incidence. Choices of treatment are still debated, including conservative management vs. various surgical techniques. The lack of long-term reports has been highlighted in the literature. AIM To evaluate long-term results of ACL reconstructions performed in skeletally immature patients using the Over the Top technique with lateral extra-articular tenodesis. METHODS Retrospective study. All surgeries performed by same surgeon. A total of 42 patients included. All patients had pre-operative radiological studies. SUBJECTS 30 males and 12 females. Average age: 12.5 years (range 11-14 years). Average follow-up: 96.1 months. Clinical evaluation: Pedi-IKDC, Tegner-Lysholm, KT-1000 and plain radiographs. Standardized rehabilitation protocol. RESULTS No instability or leg length discrepancy was recorded. Average pre-operative Tegner-Lysholm and Pedi-IKDC scores were 55 and 40, respectively, with a score of 94.8 (p < 0.05) and 94.78, respectively, at final follow-up (p < 0.05). Average post-operative (1 month) Tegner-Lysholm score: 75 (range: 62-79). Median post-operative Tegner activity: 8. Mean side-to-side (KT-1000): 1.2 mm. A total of 22 patients could go back to pre-injury sport activity, with an average rehabilitation of 7.3 months. DISCUSSION A significant number of cases were included in our structured standardized study and follow-up. Functional scores were excellent overall. Excellent results are testified by a final achievement of 22 patients going back to pre-injury sport activity, which is in keeping with the literature. Our experience exhibited a low complication rate and no metalwork failure. We correlate our results to the use of the Over the Top technique with lateral extra-articular tenodesis. CONCLUSION The studied procedure seems to be an excellent option and an effective, feasible and safe technique when treating ruptured ACLs in skeletally immature patients.
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Affiliation(s)
- Riccardo Maria Lanzetti
- Orthopaedics and Traumatology Unit, Department Emergency and Acceptance, San Camillo - Forlanini Hospital Rome,Italy, Cir.ne Gianicolense 87, 00152, Rome, Italy.
| | - Valerio Pace
- Università degli studi di Perugia- Perugia- Italy, Piazzale Gambuli, 06100, Perugia, Italy
| | | | - Dario Perugia
- "La Sapienza" University, Via Elio Chianesi, 00128, Rome, Italy
| | - Marco Spoliti
- Orthopaedics and Traumatology Unit, Department Emergency and Acceptance, San Camillo - Forlanini Hospital Rome,Italy, Cir.ne Gianicolense 87, 00152, Rome, Italy
| | - Francesco Falez
- Santo Spirito Hospital, Lungotevere in Sassia 1, 00193, Rome, Italy
| | - Caraffa Auro
- Università degli studi di Perugia- Perugia- Italy, Piazzale Gambuli, 06100, Perugia, Italy
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Anterolateral ligament reconstruction as an augmented procedure for double-bundle anterior cruciate ligament reconstruction restores rotational stability: Quantitative evaluation of the pivot shift test using an inertial sensor. Knee 2020; 27:397-405. [PMID: 32178972 DOI: 10.1016/j.knee.2020.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/01/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate the biomechanical function of the anterolateral structures (ALS) of the knee regarding rotational stability, and to attempt to verify the effectiveness of anterolateral ligament (ALL) reconstruction concomitant with double-bundle anterior cruciate ligament (ACL) reconstruction by quantifying the pivot shift test (PST) using an inertial sensor. METHODS Six knees of the fresh-frozen cadavers were evaluated during the following phases: (1) [Intact]; (2) ACL-deficient [ACL-D]; (3) ACL-reconstructed [ACL-R]; (4) ACL-reconstructed + ALS-deficient [ACL-R + ALS-D]; and (5) combined ACL and ALL reconstructed [ACL-R + ALL-R]. We evaluated knee rotational instability during each phase using the PST. We used an inertial sensor to calculate tibial external rotational angular velocity (ERAV) and tibial acceleration. Data were analyzed using repeated-measures analysis of variance; statistical significance was accepted as P < 0.05. RESULTS Relative to [Intact], [ACL-D] caused a significant increase in ERAV and acceleration. However, there was no difference in these parameters between [ACL-R] and [Intact]. [ACL-R + ALS-D] increased ERAV significantly compared with [ACL-R], and there was a significant difference between ERAV during [ACL-R + ALS-D] and [Intact]. However, ERAV was significantly reduced during [ACL-R + ALL-R] compared with [ACL-R + ALS-D], and there was no significant difference in ERAV or acceleration between [ACL-R + ALL-R] and [Intact]. CONCLUSIONS ALS controlled rotational instability in cooperation with the ACL in a cadaveric model. In cases of combined injury of ACL and ALS, concomitant ACL and ALL reconstruction may restore knee stability comparable with the intact state.
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Nagai K, Rothrauff BB, Li RT, Fu FH. Over-the-top ACL reconstruction restores anterior and rotatory knee laxity in skeletally immature individuals and revision settings. Knee Surg Sports Traumatol Arthrosc 2020; 28:538-543. [PMID: 31549207 DOI: 10.1007/s00167-019-05719-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/11/2019] [Indexed: 01/26/2023]
Abstract
PURPOSE To investigate the objective outcomes following anterior cruciate ligament reconstruction (ACLR) with the over-the-top (OTT) technique. METHODS Thirty-five ACL-deficient patients with mean follow-up of 2.2 years were retrospectively reviewed. This included 14 skeletally immature individuals (age: 14 ± 1 years) who underwent primary OTT ACLR (adolescent group) and 21 skeletally mature individuals (age: 25 ± 8 years) who underwent OTT revision ACLR (revision group). The tibial tunnel was created at the anatomic position for all cases. No lateral extra-articular tenodesis was performed. Before and after surgery, the side-to-side difference (SSD) in anterior laxity was measured using KT-1000 arthrometer. Lachman and pivot-shift tests were assessed according to IKDC grade. The graft failure rate was assessed. RESULTS The post-operative SSD in anterior laxity was significantly reduced in the adolescent (pre-op, 3.9 ± 1.8 mm; post-op, 1.2 ± 0.8 mm; p = 0.040) and revision groups (pre-op, 4.2 ± 1.7 mm; post-op, 1.2 ± 1.4 mm; p < 0.001). Postoperative knee laxity measured by Lachman and pivot-shift tests were also significantly improved in both groups. Graft rupture occurred in two patients in the adolescent group (14.3%), and one patient in the revision group (4.8%). CONCLUSION ACLR with the OTT technique restored anterior and rotatory knee laxity in skeletally immature individuals and in revision settings. This one-step procedure may be a good option for skeletally immature individuals and revision settings. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kanto Nagai
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.,Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Benjamin B Rothrauff
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Ryan T Li
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, University of Pittsburgh, Kaufmann Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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Hughes JD, Rauer T, Gibbs CM, Musahl V. Diagnosis and treatment of rotatory knee instability. J Exp Orthop 2019; 6:48. [PMID: 31865518 PMCID: PMC6925612 DOI: 10.1186/s40634-019-0217-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/13/2019] [Indexed: 01/15/2023] Open
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.
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Affiliation(s)
- Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Thomas Rauer
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christopher M Gibbs
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA, 15203, USA.
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Golan EJ, Tisherman R, Byrne K, Diermeier T, Vaswani R, Musahl V. Anterior Cruciate Ligament Injury and the Anterolateral Complex of the Knee-Importance in Rotatory Knee Instability? Curr Rev Musculoskelet Med 2019; 12:472-478. [PMID: 31773476 PMCID: PMC6942070 DOI: 10.1007/s12178-019-09587-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW In the setting of rotatory knee instability following anterior cruciate ligament (ACL) reconstruction, there has been a resurgence of interest in knee's anterolateral complex (ALC). Reconstruction or augmentation of the ALC with procedures such as a lateral extra-articular tenodesis (LET) has been proposed to reduce rotatory knee instability in conjunction with ACL reconstruction. The current review investigates the recent literature surrounding the role of the ALC in preventing rotatory knee instability. RECENT FINDINGS The knee's anterolateral complex (ALC) is a complex structure composed of the superficial and deep portions of the iliotibial band, the capsulo-osseous layer, and the anterolateral capsule. Distally, these various layers merge to form a single functional unit which imparts stability to the lateral knee. While the iliotibial band and the capsule-osseous layer have been shown to be primary restraints to rotatory motion after ACL injury, the biomechanical role of the anterolateral capsule remains unclear. Biomechanical studies have shown that the anterolateral capsule and the anterolateral thickening of this capsule act as a sheet of fibrous tissue which does not resist motion around the knee as other longitudinally oriented ligaments do. Augmentation of the ALC, with LET, has been performed globally for over 30 years. This procedure can decrease rotatory knee instability, but long-term studies have found little difference in patient-reported outcomes, osteoarthritis, or ACL reconstruction failure with the addition of LET. Further research is needed to clarify indications for the clinical use of ALC-based procedures.
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Affiliation(s)
- Elan J Golan
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Robert Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
- Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, PA USA
| | - Kevin Byrne
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Theresa Diermeier
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
- Orthopaedic Sport Medicine, Technical University Munich, Munich, Germany
| | - Ravi Vaswani
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Freddie Fu Sports Medicine Building, 3200 South Water Street, Pittsburgh, PA 15203 USA
- Orthopaedic Robotics Laboratory, University of Pittsburgh, Pittsburgh, PA USA
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Grassi A, Signorelli C, Lucidi GA, Raggi F, Macchiarola L, Roberti Di Sarsina T, Marcheggiani Muccioli GM, Filardo G, Zaffagnini S. ACL reconstruction with lateral plasty reduces translational and rotatory laxity compared to anatomical single bundle and non-anatomical double bundle surgery: An in vivo kinematic evaluation with navigation system. Clin Biomech (Bristol, Avon) 2019; 69:1-8. [PMID: 31260843 DOI: 10.1016/j.clinbiomech.2019.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/24/2019] [Accepted: 06/13/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Significantly better stability may be achieved with a Single Bundle Lateral Plasty (SBLP) reconstruction compared with the Single Bundle (SB) and Double Bundle (DB) procedures. METHODS The study included 42 patients who underwent ACL reconstruction. Patients were randomly selected for one of the following surgical procedure defining three study groups: Single-Bundle-Lateral-Plasty, Single-Bundle and Double-Bundle procedures. Laxity evaluation was performed with an intraoperative navigation system. Lachman test (AP30), Drawer test (AP90), Varus-Valgus stress test at 0° and 30° knee flexion (VV0, VV30), Internal-External rotation (IE30, IE90), and pivot shift (PS) test are the clinical test executed for the laxity evaluation. Laxity reduction was defined as the difference between laxity before the fixation of the graft used for the reconstruction and the laxity just after its fixation. FINDINGS For all the analyzed surgical techniques, the pre-reconstruction laxity values were statistically higher (P < 0.05) than the post-reconstruction values for all the analyzed tests. The analysis of the Drawer test and Internal-External rotation at 30° and 90° of knee flexion, highlighted a significant difference at time zero after surgery among the three study groups. The results showed that the SBLP technique had the highest reduction values compared to SB (PIE90 = 0.001) and DB (PAP90 = 0.012; PIE30 = 0.021; PIE90 = 0.003) techniques. INTERPRETATION SBLP technique showed significantly superior results in terms of antero-posterior and internal-external laxity reduction at time-zero after ACL reconstruction.
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Affiliation(s)
- Alberto Grassi
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Via Di Barbiano 1/10, 40136 Bologna, BO, Italy; IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica I, Via Pupilli 1, 40136 Bologna, BO, Italy; Università di Bologna, Dipartimento di Scienze Biomediche e NeuroMotorie (DIBINEM), Via Foscolo 7, 40123 Bologna, BO, Italy.
| | - Cecilia Signorelli
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Via Di Barbiano 1/10, 40136 Bologna, BO, Italy.
| | - Gian Andrea Lucidi
- IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica I, Via Pupilli 1, 40136 Bologna, BO, Italy.
| | - Federico Raggi
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Via Di Barbiano 1/10, 40136 Bologna, BO, Italy; IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica I, Via Pupilli 1, 40136 Bologna, BO, Italy; Università di Bologna, Dipartimento di Scienze Biomediche e NeuroMotorie (DIBINEM), Via Foscolo 7, 40123 Bologna, BO, Italy
| | - Luca Macchiarola
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Via Di Barbiano 1/10, 40136 Bologna, BO, Italy; IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica I, Via Pupilli 1, 40136 Bologna, BO, Italy; Università di Bologna, Dipartimento di Scienze Biomediche e NeuroMotorie (DIBINEM), Via Foscolo 7, 40123 Bologna, BO, Italy
| | - Tommaso Roberti Di Sarsina
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Via Di Barbiano 1/10, 40136 Bologna, BO, Italy; IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica I, Via Pupilli 1, 40136 Bologna, BO, Italy; Università di Bologna, Dipartimento di Scienze Biomediche e NeuroMotorie (DIBINEM), Via Foscolo 7, 40123 Bologna, BO, Italy
| | - Giulio Maria Marcheggiani Muccioli
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Via Di Barbiano 1/10, 40136 Bologna, BO, Italy; IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica I, Via Pupilli 1, 40136 Bologna, BO, Italy; Università di Bologna, Dipartimento di Scienze Biomediche e NeuroMotorie (DIBINEM), Via Foscolo 7, 40123 Bologna, BO, Italy
| | - Giuseppe Filardo
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di NanoBiotecnologie (NaBi), Via Di Barbiano 1/10, 40136 Bologna, BO, Italy.
| | - Stefano Zaffagnini
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Via Di Barbiano 1/10, 40136 Bologna, BO, Italy; IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica I, Via Pupilli 1, 40136 Bologna, BO, Italy; Università di Bologna, Dipartimento di Scienze Biomediche e NeuroMotorie (DIBINEM), Via Foscolo 7, 40123 Bologna, BO, Italy.
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Raggi F, Roberti di Sarsina T, Signorelli C, Marcheggiani Muccioli GM, Macchiarola L, Cucurnia I, Romagnoli M, Grassi A, Zaffagnini S. Triaxial accelerometer can quantify the Lachman test similarly to standard arthrometers. Knee Surg Sports Traumatol Arthrosc 2019; 27:2698-2703. [PMID: 30474693 DOI: 10.1007/s00167-018-5306-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 11/15/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess the relationship between the KiRA triaxial accelerometer and the KT-1000 measurements in the intact, anterior cruciate ligament (ACL) deficient, and ACL reconstructed knee joint for the quantification of the Lachman test. Moreover, the intra- and inter-examiner repeatability of the KiRA device will be determined. It was hypothesized that the side-to-side difference of the anterior tibial translation as measured by the KiRA device would be equivalent to the one measured by the KT-1000 during the Lachman test. METHODS Sixty patients were divided into three groups and have been prospectively included in the present study. Group_A composed of 20 patients with a diagnosis of an isolated ACL tear. Group_B composed of 20 patients who underwent ACL reconstruction with a Single-Bundle Lateral Plasty (SBLP) technique with at least 20 years of follow-up. Group_C was the control group and included 20 patients with no history of ACL lesion. Lachman test has been performed at manual-maximum load on both sides, the involved and the contralateral and analyzed with the two different devices. RESULTS The KiRA device in terms of side-to-side difference resulted not statistically different from the measurement of the KT-1000 arthrometer for the three study groups (n.s): Group_A: (4 ± 2 mm KiRA, 4 ± 2 mm KT1000), Group_B: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), Group_C: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), an excellent intra- (ICC = 0.88-0.89) and inter-examiner (ICC = 0.79) agreement was found for KiRA measurements. CONCLUSION The KiRA (I+, Italy) device offers a valid method to quantify the Lacham test. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Federico Raggi
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Tommaso Roberti di Sarsina
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Cecilia Signorelli
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, BO, Italy. .,Laboratorio di Biomeccanica e Innovazione Tecnologica, Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.
| | - Giulio Maria Marcheggiani Muccioli
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Luca Macchiarola
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Ilaria Cucurnia
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Matteo Romagnoli
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy
| | - Alberto Grassi
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
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Zaffagnini S, Di Paolo S, Stefanelli F, Dal Fabbro G, Macchiarola L, Lucidi GA, Grassi A. The biomechanical role of meniscal allograft transplantation and preliminary in-vivo kinematic evaluation. J Exp Orthop 2019; 6:27. [PMID: 31240420 PMCID: PMC6593038 DOI: 10.1186/s40634-019-0196-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/04/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Meniscus allograft transplantation (MAT) is a surgical procedure performed in patients complaining post-meniscectomy syndrome. Although the effectiveness of MAT on knee stability has been already demonstrated in cadaveric studies, its biomechanical role has been poorly evaluated in-vivo. METHODS A narrative review of the biomechanical effect of meniscectomy and MAT was performed. Furthermore, two cases were presented, of one patient who underwent Medial MAT and Anterior Cruciate Ligament (ACL) reconstruction, and one who underwent Lateral MAT. During the surgery, knee laxity was evaluated using a surgical navigation system. RESULTS AP laxity and IE rotation were reduced of 25% to 50% at both 30° and 90° of knee flexion after MAT transplantation. DISCUSSION In both cases, almost all the tests performed showed a reduction of knee laxity after meniscus transplant, when compared with pre-operative knee laxity. This assessment confirms the insights of previous in-vitro studies and underline a crucial role of MAT in knee biomechanics.
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Affiliation(s)
- Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Di Paolo
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Federico Stefanelli
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Giacomo Dal Fabbro
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Macchiarola
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gian Andrea Lucidi
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alberto Grassi
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie DIBINEM, Università di Bologna, Bologna, Italy
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Meniscal allograft transplantation combined with anterior cruciate ligament reconstruction provides good mid-term clinical outcome. Knee Surg Sports Traumatol Arthrosc 2019; 27:1914-1923. [PMID: 30083970 DOI: 10.1007/s00167-018-5078-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 07/23/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE Aim of this study is to document if combined meniscal allograft transplantation (MAT) and ACL reconstruction can improve knee function, reduce pain and allow patients with meniscal defect and ACL lesion to resume sport activities. METHODS Fifty MAT, arthroscopically performed without bone plugs and combined with one-stage primary or revision ACL reconstruction, with or without high tibial osteotomy (HTO), were included. Patients (aged 38.2 ± 10.6 years, 87% males) were evaluated at a mean follow-up of 5 years with Lysholm, Tegner and VAS scores. Patient satisfaction was also recorded, together with complications and failures. RESULTS VAS and Lysholm scores improved significantly (from 63.7 to 24.5 and from 60.6 to 82.7, respectively, p < 0.001), while the Tegner score did not reach pre-injury values (p < 0.001), but it improved significantly compared to pre-surgery values (from 2.8 to 4.6, p < 0.001). Medial MAT reported significantly better results compared to lateral MAT. Patients undergoing concomitant HTO reported a significantly higher decrease of VAS. Younger patients with higher pre-operative pain and lower activity level presented higher satisfaction. Eight patients needed a reoperation. Three patients were considered surgical failures while four were considered clinical failures, for a total of 15% failures. CONCLUSIONS Meniscal allograft transplantation combined with ACL reconstruction represents a safe and suitable treatment, which should be considered as a suitable option in the clinical practice. All evaluated patient profiles, ACL injury in a patient with post-meniscectomy syndrome, failed ACL reconstruction in patients with a meniscus defect, and ACL reconstruction in patients with malalignment due to meniscal defect, benefited from the combined MAT procedure at medium-term follow-up. LEVEL OF EVIDENCE IV.
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Sabatini L, Risitano S, Atzori F, Volante M, Aprato A, Indelli PF, Massè A. Histological analysis of the anterolateral ligament of the knee. J Orthop 2019; 16:368-372. [PMID: 31011250 DOI: 10.1016/j.jor.2019.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 03/31/2019] [Indexed: 12/15/2022] Open
Abstract
Anterolateral ligament (ALL) was recently described as an important structure to control the pivot-shift phenomenon in the knee. Doubts remain regarding its origin and histological properties. The purpose of this study was to identify the ALL histological structure comparing its characteristics with those of the anterior cruciate ligament (ACL) and joint capsule. ALL was harvested in 25 knees during a total knee arthroplasty (TKA) and histologically evaluated investigating for orientation of fibers, adipose tissue, presence of proprioceptors and synovial like coating. Analysis showed significant differences in several aspects between capsule and ALL; analogies were found comparing the ALL with ACL.
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Affiliation(s)
- Luigi Sabatini
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy
| | - Salvatore Risitano
- Department of Orthopaedic Surgery and Traumatology, "Maggiore" Hospital of Chieri. Chieri, Turin, ITA, Italy
| | - Francesco Atzori
- Department of Orthopaedic Surgery, Cottolengo Hospital, Turin, Italy
| | - Marco Volante
- Pathologist Department, "San Luigi Gonzaga" Hospital Orbassano, Turin, ITA, Italy
| | - Alessandro Aprato
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy
| | - Pier Francesco Indelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine and the Palo Alto Veterans Affairs Health Care System(PAVAHCS), Palo Alto, CA, USA
| | - Alessandro Massè
- Department of Orthopaedic Surgery and Traumatology, University of Turin, "Città della salute e della scienza"-CTO Hospital of Turin, Turin, ITA, Italy
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Roberti di Sarsina T, Macchiarola L, Signorelli C, Grassi A, Raggi F, Marcheggiani Muccioli GM, Zaffagnini S. Anterior cruciate ligament reconstruction with an all-epiphyseal "over-the-top" technique is safe and shows low rate of failure in skeletally immature athletes. Knee Surg Sports Traumatol Arthrosc 2019; 27:498-506. [PMID: 30209520 DOI: 10.1007/s00167-018-5132-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 09/06/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE The aim of this study was to follow up, clinically and radiographically, skeletally immature patients who underwent ACL reconstruction with an all-epiphyseal "over-the-top" technique. METHODS Twenty athletes aged between 8 and 13 years were enrolled and retrospectively evaluated. The subjects underwent surgical ACL reconstruction between 2009 and 2013. The surgical technique consisted of a single-bundle all-epiphyseal ACL reconstruction with an extra-articular lateral tenodesis. The mean follow-up was 54 months [34-123] after surgery. Clinically, the patients were evaluated pre- and post-operatively with Lysholm and KOOS scores; sport activity level was evaluated using the pre-injury, pre-operative and post-operative Tegner scores. Objective IKDC was calculated post-operatively. The joint laxity was evaluated by KT1000 and Rolimeter arthrometers. Panoramic AP standing radiographs of the lower limbs and lateral knee radiographs were also taken at the follow-up to evaluate limb length discrepancies (LLD) and axial malalignment. Normally distributed parameters were presented as mean ± standard deviation, while the non-normally distributed parameters were presented as median [25° percentile, 75° percentile]. RESULTS Clinical scores showed significant (P < 0.01) improvement: Lysholm and KOOS scores improved from 40 [22; 65] and 59 [42, 73], respectively, to 100 [95; 100] and 99 [97;100] after surgery. Tegner score improved from 2 [2; 2] pre-operatively to 7 [3; 9] at follow-up (P < 0.01). At follow-up, IKDC score was A for 19 patients and one who scored B. All patients returned to sport activity and had good stability at follow-up: the KT1000 showed a median side-to-side difference of 0.0 mm [- 0.4; 1.0] for the standard force evaluation and 0.0 mm [- 1.0; 0.8] for manual-maximum test. The Rolimeter showed median side-to-site difference of 0.0 mm [- 1.0; 0.8]. Three minor leg length discrepancies and axial deviations were observed at the radiograph: one patient had 0.6 cm lengthening and 4° of varus, one had 1 cm lengthening, and one had 3° of varus (in comparison with the non-operated limb). No re-injury was observed. CONCLUSION This study demonstrates that the modified all-epiphyseal single-bundle "over-the-top" technique is a viable and safe option for ACL reconstruction in pediatric subjects. These results support once more that not only ACL reconstruction is a safe procedure in skeletally immature patients, but also it is highly recommended for those who want to pursue an active and sportive life. LEVEL OF EVIDENCE Case series, IV.
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Affiliation(s)
- Tommaso Roberti di Sarsina
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via C. Pupilli 1, 40136, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e NeuroMotorie DIBINEM, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Luca Macchiarola
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via C. Pupilli 1, 40136, Bologna, BO, Italy. .,Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy. .,Dipartimento di Scienze Biomediche e NeuroMotorie DIBINEM, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy.
| | - Cecilia Signorelli
- Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy
| | - Alberto Grassi
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via C. Pupilli 1, 40136, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e NeuroMotorie DIBINEM, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Federico Raggi
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via C. Pupilli 1, 40136, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e NeuroMotorie DIBINEM, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Giulio Maria Marcheggiani Muccioli
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via C. Pupilli 1, 40136, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e NeuroMotorie DIBINEM, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, Istituto Ortopedico Rizzoli, Via C. Pupilli 1, 40136, Bologna, BO, Italy.,Laboratorio di Biomeccanica e Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, Bologna, BO, Italy.,Dipartimento di Scienze Biomediche e NeuroMotorie DIBINEM, Università di Bologna, Via U. Foscolo 7, Bologna, BO, Italy
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Over-the-top ACL reconstruction yields comparable outcomes to traditional ACL reconstruction in primary and revision settings: a systematic review. Knee Surg Sports Traumatol Arthrosc 2019; 27:427-444. [PMID: 30078121 DOI: 10.1007/s00167-018-5084-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/27/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE To assess clinical outcomes of over-the-top (OTT) ACL reconstruction (ACLR) in skeletally mature patients, where physeal sparing is not a consideration. The hypothesis is that OTT will produce successful yet inferior outcomes compared to anatomic ACL approaches in both primary and revision settings. METHODS Two reviewers searched two online databases (EMBASE and MEDLINE) from inception to October 2017 for literature on OTT ACLR in skeletally mature patients. The systematic screening process was completed in duplicate, independently, and based on predetermined criteria. An expert in the field was consulted to resolve disagreements for full-text screening. Quality assessment of included papers was performed independently and in duplicate. RESULTS From 3148 initial studies, 16 eligible studies (three RCTs and 13 case series) satisfied inclusion criteria. Three focused on the revision setting. The mean age of patients undergoing primary reconstruction was 26.9 ± 3.6, with 21.3% female patients and 31.4 ± 1.2 (26.1% female) in revision settings. Of primary studies reporting return to sport (n = 151), 69% of patients returned to pre-injury sports participation, with a total 94% returning to any sports activity. In revision settings (n = 48), 52.1% of patients returned to pre-injury sports participation, 25.2% returned to a lower level and 12.5% ceased sporting activity. Primary reconstruction studies reported a mean post-operative Tegner score of 6.5 ± 0.5 (n = 181) and mean KOOS of 82.8 ± 8.1 (n = 96). Primary studies reported a total 13 graft failures (3.7%), seven of which were re-ruptures (2.0%). The revision failure rate was 8.4% (four patients). CONCLUSION Clinically important outcomes for OTT ACLR are comparable to literature figures for traditional all-inside, transtibial and/or anteromedial portal drilling techniques. This holds true in revision settings. LEVEL OF EVIDENCE IV.
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Abstract
In the anterior cruciate ligament (ACL) deficient knee, excellent outcomes are achieved in many patients with an isolated, intra-articular ACL reconstruction. Some patients, however, have ongoing instability or suffer graft rupture. Failure after ACL reconstruction is multifactorial, but residual anterolateral rotatory laxity is 1 potential contributing factor. Lateral extra-articular procedures are a heterogenous group of operations that were initially described as isolated treatments for the ACL deficient knee, and subsequently used in combination with intra-articular reconstructions. Initial observational studies were encouraging, however, comparative studies were less flattering and lead to a general abandonment of these procedures. With improved understanding of the anatomy and biomechanics of the anterolateral capsuloligamentous complex there has been a renewed interest in these procedures. Recent systematic reviews suggest efficacy of these procedures in improving rotational control, though data showing improved patient reported outcomes or reduced graft rupture rates are lacking. Preliminary results from ongoing clinical trials are supportive for lateral extra-articular tenodesis when used as an augment to modern, intra-articular ACL reconstructions in targeted, high-risk patients.
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Zhong S, Wu B, Wang M, Wang X, Yan Q, Fan X, Hu Y, Han Y, Li Y. The anatomical and imaging study of pes anserinus and its clinical application. Medicine (Baltimore) 2018; 97:e0352. [PMID: 29642176 PMCID: PMC5908566 DOI: 10.1097/md.0000000000010352] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The pes anserinus was an important graft choice for anterior cruciate ligament (ACL) reconstruction. The infrapatellar branch of the saphenous nerve (IPBSN) might be damaged in this surgery. This study aimed to provide anatomic and ultrasonic measurement data of pes anserinus and superficial nerves. METHODS Eighty lower limb specimens of forty adult cadavers were dissected. The length, width, thickness, and the position of the tibial attachment of pes anserinus tendons were anthropometric measured, as well as the distance between the infrapatellar branch of the saphenous nerve and the pes anserinus. Sixty healthy adult participants were enrolled for ultrasonic research. The length, width, thickness of pes anserinus was also measured and the saphenous nerve was also assessed. RESULTS Anatomic results showed that there were 3 types of pes anserinus, the infrapatellar branch of the saphenous nerve (IPBSN) was almost paralleled to the upper edge of the pes anserinus tendon, and the average of distance between them was about 0.95 cm. The length of semitendinosus and gracilis tendons were 146.49 ± 12.83 mm and 124.62 ± 8.86 mm, the width of sartorius tendon was 25.58 ± 4.65 mm, wider than other tendons. The classification of pes anserinus tendons and the saphenous nerves could be identified in ultrasonic image. The length of semitendinosus and gracilis tendons were 151.35 ± 9.65 mm and 120.86 ± 8.99 mm, the width of sartorius tendon was 22.84 ± 3.83 mm. And there was no significance difference between anatomic and ultrasonic measurement (P > .05). CONCLUSION The morphology of pes anserinus and its peripheral structures could be identified and measured precisely by ultrasound device, a presurgical ultrasonic examination was recommended. The arrangement of pes anserinus tendons was classified into 3 types according to our results. The incision should be performed medial to tibial eminence 1.5 cm and under the tibial tubercle level 2 to 3 cm, an oblique incision formed an angle of 50° with tibial transection was recommend, which was parallel to the direction of pes anserinus tendon.
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Affiliation(s)
- Sheng Zhong
- Department of Neurosurgery, the First Hospital of Jilin University
- Clinical College, Jilin University
| | - Bo Wu
- Clinical College, Jilin University
- Department of Orthopedics, the First Hospital of Jilin University, Changchun
| | - Miao Wang
- Team of Student Brigade, Second Military Medical University, Shanghai
| | - Xiaohong Wang
- Department of Respiratory Medicine, Jilin University First Hospital, Changchun
| | - Qi Yan
- Basic Medical College, Qiqihar Medical University, Qiqihar
| | | | | | - Yingying Han
- Department of Neurology, China-Japan Union Hospital of Jilin University
| | - Youqiong Li
- Department of Human Anatomy, Norman Bethune Medical College, Jilin University, Changchun, China
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48
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Ntagiopoulos P, Dejour D. Extra-Articular Plasty for Revision Anterior Cruciate Ligament Reconstruction. Clin Sports Med 2018; 37:115-125. [DOI: 10.1016/j.csm.2017.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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49
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Cerciello S, Batailler C, Darwich N, Neyret P. Extra-Articular Tenodesis in Combination with Anterior Cruciate Ligament Reconstruction. Clin Sports Med 2018; 37:87-100. [DOI: 10.1016/j.csm.2017.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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50
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Ferrer GA, Guenther D, Pauyo T, Herbst E, Nagai K, Debski RE, Musahl V. Structural Properties of the Anterolateral Complex and Their Clinical Implications. Clin Sports Med 2018; 37:41-47. [DOI: 10.1016/j.csm.2017.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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