Excessive tibial rotation during high-demand activities is not restored by anterior cruciate ligament reconstruction

Landing mechanics between noninjured women and women with anterior cruciate ligament reconstruction during 2 jump tasks

BACKGROUND

Women with anterior cruciate ligament reconstruction have different neuromuscular strategies than noninjured women during functional tasks after ligament reconstruction and rehabilitation.

HYPOTHESIS

Landing from a jump creates high loads on the knee creating dynamic instability in women with anterior cruciate ligament reconstruction, whereas noninjured women have stable knee landing mechanics.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fifteen noninjured women and 13 women with anterior cruciate ligament reconstruction performed 5 trials of a single-legged 40-cm drop jump and 2 trials of a 20-cm up-down hop task. Multivariate analyses of variance were used to compare hip and knee joint kinematics, knee joint moments, ground-reaction forces, and electromyographic findings between the dominant leg in noninjured women and reconstructed leg in women with anterior cruciate ligament reconstruction.

RESULTS

No statistically significant differences between groups were found for peak hip and knee joint angles for the drop jump task. Statistically significant differences in neuromuscular activity (P = .001) and anterior-posterior knee shear forces (P < .001) were seen in women with anterior cruciate ligament reconstruction compared with noninjured women in the drop jump task. However, no statistically significant differences (P > .05) between groups were found for either peak hip and knee joint angles, peak joint kinetics, or electromyographic findings during the up-down hop task.

CONCLUSION

Women with anterior cruciate ligament reconstruction have neuromuscular strategies that allow them to land from a jump similar to healthy women, but they exhibit joint moments that could predispose them to future injury if they participate in sports that require jumping and landing.

Strategies to improve anterior cruciate ligament healing and graft placement

Recent improvements in anterior cruciate ligament (ACL) reconstruction have been notable for strategies to improve ACL healing and to improve graft placements. The controversial choice of 1-bundle or 2-bundle grafts requires an advanced knowledge of native ACL insertional anatomy and an appreciation for the kinematic effects of graft placements. Understanding the limitations of surgical techniques to place tunnels is important. Once grafts are placed, new biologic strategies to promote intra-articular and intraosseous healing are evolving. Although these biologic engineering strategies are currently experimental, they are projected for clinical application in the near future.

Femoral tunnel placement in single-bundle anterior cruciate ligament reconstruction: a cadaveric study relating transtibial lateralized femoral tunnel position to the anteromedial and posterolateral bundle femoral origins of the anterior cruciate ligament

BACKGROUND

There is controversy regarding the necessity of reconstructing both the posterolateral and anteromedial bundles of the anterior cruciate ligament.

HYPOTHESIS

A laterally oriented transtibial drilled femoral tunnel replaces portions of the femoral footprints of the anteromedial and posterolateral bundles of the anterior cruciate ligament.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Footprints of the anteromedial and posterolateral bundles of the anterior cruciate ligament were preserved on 7 matched pairs (5 female, 2 male) of fresh-frozen human cadaveric femurs (14 femurs total). Each femur was anatomically oriented and secured in a custom size-appropriate, side-matched replica tibia model to simulate transtibial retrograde drilling of a 10-mm femoral tunnel in each specimen. The relationship of the tunnel relative to footprints of both bundles of the anterior cruciate ligament was recorded using a Microscribe MX digitizer. The angle of the femoral tunnel relative to the vertical 12-o'clock position was recorded for all 14 specimens; only 10 specimens were used for footprint measurements.

RESULTS

On average, the 10-mm femoral tunnel overlapped 50% of the anteromedial bundle (range, 2%-83%) and 51% of the posterolateral bundle (range, 16%-97%). The footprint of the anteromedial bundle occupied 32% (range, 3%-49%) of the area of the tunnel; the footprint of the posterolateral bundle contributed 26% (range, 7%-41%). The remainder of the area of the 10-mm tunnel did not overlap with the anterior cruciate ligament footprint. The mean absolute angle of the femoral tunnel as measured directly on the specimen was 48 degrees (range, 42 degrees-53 degrees) from vertical, corresponding to approximately a 10:30 clock face position on a right knee.

CONCLUSION

Anterior cruciate ligament reconstruction using a laterally oriented transtibial drilled femoral tunnel incorporates portions of the anteromedial and posterolateral bundle origins of the native anterior cruciate ligament.

CLINICAL RELEVANCE

A laterally oriented transtibial drilled femoral tunnel placed at the 10:30 position (1:30 for left knees) reconstructs portions of the anteromedial and posterolateral bundles of the anterior cruciate ligament.

Anterolateral rotational knee instability: role of posterolateral structures. Winner of the AGA-DonJoy Award 2006

INTRODUCTION

The aim of this study was to determine the anterolateral rotational instability (ALRI) of the human knee after rupture of the anterior cruciate ligament (ACL) and after additional injury of the different components of the posterolateral structures (PLS). It was hypothesized that a transsection of the ACL will significantly increase the ALRI of the knee and furthermore that sectioning the PLS [lateral collateral ligament (LCL), popliteus complex (PC)] will additionally significantly increase the ALRI.

MATERIALS AND METHODS

Five human cadaveric knees were used for dissection to study the appearance and behaviour of the structures of the posterolateral corner under anterior tibial load. Ten fresh-frozen human cadaver knees were subjected to anterior tibial load of 134 N and combined rotatory load of 10 Nm valgus and 4 Nm internal tibial torque using a robotic/universal force moment sensor (UFS) testing system and the resulting knee kinematics were determined for intact, ACL-, LCL- and PC-deficient (popliteus tendon and popliteofibular ligament) knee. Statistical analyses were performed using a two-way ANOVA test with the level of significance set at P < 0.05.

RESULTS

Sectioning the ACL significantly increased the anterior tibial translation (ATT) and internal tibial rotation under a combined rotatory load at 0 and 30 degrees flexion (P < 0.05). Sectioning the LCL further increased the ALRI significantly at 0 degrees , 30 degrees and 60 degrees of flexion (P < 0.05). Subsequent cutting of the PC increased the ATT under anterior tibial load (P < 0.05), but did not increase the ALRI (P > 0.05).

CONCLUSION

The results of the current study confirm the concept that the rupture of the ACL is associated with ALRI. Current reconstruction techniques should focus on restoring the anterolateral rotational knee instability to the intact knee. Additional injury to the LCL further increases the anterior rotational instability significantly, while the PC is less important. Cautions should be taken when examining a patient with ACL rupture to diagnose injuries to the primary restraints of tibial rotation such as the LCL. If an additional extraarticular stabilisation technique is needed for severe ALRI, the technique should be able to restore the function of the LCL and not the PC.

Double bundle or single bundle plus extraarticular tenodesis in ACL reconstruction? A CAOS study

Anatomic reconstructions of anterior cruciate ligament (ACL) with double bundle gracilis and semitendonosus tendons graft, reproducing AM and PL bundles, have been introduced to offer a better biomechanical outcome, especially during rotatory loads. On the other hand, many methods of tenodesing the lateral aspect of the tibia to the femur to reduce internal rotation (IR) of the tibia and minimize anterior translation of the tibia relative to the femur as a backup for intra-articular reconstruction, have been also suggested. The goal of this study is to evaluate the effect, on the IR of the tibia, of a lateral reconstruction in addition to a standard single bundle ACL reconstruction as compared with an anatomic double bundle ACL reconstruction. Computer assisted ACL reconstruction has been used because it could be very effective in evaluating the global kinematic performance of the reconstructed knee. We selected 20 consecutive ACL reconstruction procedures to be performed in males in our hospital. Patients were alternately assigned to one of the two groups--group A: standard single bundle ACL reconstruction with doubled gracilis and semitendinosus tendons graft with an arthroscopically assisted two incisions technique and a lateral extraarticular reconstruction; group B: double bundle ACL reconstruction with doubled gracilis and semitendinosus tendons graft with an arthroscopically assisted two incisions technique. In all ACL reconstruction procedures navigation process was performed. Both surgical techniques reduced significantly AP displacement, IR and external rotation (ER) of the tibia respect to pre-operative ACL deficient condition (p<0.05). Comparing the group A after the single bundle reconstruction and the group B after the AM bundle fixation, non differences were found in AP displacement, IR and ER of the tibia (p=0.75, p=0.07 and p=0.07 respectively; power: 0.94). Comparing the group A after the addition of the lateral tenodesis and group B after the PL bundle fixation (AM+PL) no differences in AP tibial displacement and in ER of tibia were found (p=0.9 and 0.15, respectively; power: 0.99); however a significant reduction in IR of the tibia was found in group A after the addition of the lateral tenodesis respect to the group B after the addition of the PL bundle (p=0.0001; power: 0.26). On the basis of our study, the addition of a lateral extraarticular reconstruction to a standard single bundle ACL reconstruction with hamstrings tendons graft in an "in vivo" reconstruction, is more effective in reducing the IR of the tibia at 30 degrees of knee flexion, as compared with a standard single bundle ACL reconstruction and with an anatomic double bundle reconstruction is confirmed.

Anatomic double bundle ACL reconstruction: a literature review

With the abundance of anatomic double bundle ACL reconstruction techniques that currently exist and limited patient outcome data, one has to ask whether or not they should be used and if so, which one, and what is the learning curve for the average knee surgeon to become competent with the technique that they select? The purpose of this literature review is to summarize existing anatomic double bundle ACL reconstruction surgical and rehabilitation techniques and the clinical and biomechanical study evidence that currently exists. In choosing to perform anatomic double bundle ACL reconstruction we suggest that the knee surgeon should look for evidence of: (1) control of the pivot shift phenomenon, (2) improved transverse plane rotatory knee control during the performance of sports type movements, (3) a decreased likelihood of revision procedures either for ACL reconstruction or for treatment of associated primary or recurrent meniscal injuries, (4) improved patient self-reports of perceived function, satisfaction, and quality of life, and (5) radiographic evidence of a lower incidence and/or magnitude of osteoarthritic changes compared to conventional single bundle ACL reconstruction.

Vertical femoral tunnel placement results in rotational knee laxity after anterior cruciate ligament reconstruction

PURPOSE

This retrospective study was performed to relate tunnel position as measured by plain radiographs and magnetic resonance imaging (MRI) to residual pivot shift and to determine its clinical relevance after anterior cruciate ligament reconstruction via central quadriceps tendon autograft.

METHODS

We reviewed 137 arthroscopic anterior cruciate ligament reconstructions via quadriceps tendon autograft with a minimum of 2 years' follow-up. Clinical results were evaluated by use of the Lachman test, pivot-shift test, Lysholm score, and Cybex dynamometer (Lumex, Ronkonkoma, NY). Anterior tibial translation was measured with the KT-1000 arthrometer (MEDmetric, San Diego, CA). Patients were classified into 3 groups based on postoperative pivot-shift and Lachman test findings: group I, both negative; group II, negative Lachman test and positive pivot shift; and group III, both positive. The radiographic analysis was performed via the angle between the tibial and femoral tunnels on plain anteroposterior radiographs, the angle between the tibial tunnel and anterior tibial cortex on the lateral view, and the femoral and tibial tunnel location by use of the ratio method. Postoperative knee MRI was performed, and the angle between the intercondylar anteroposterior axis and femoral tunnel on the axial view and the angle between the joint line and the graft on the oblique coronal and sagittal views were measured.

RESULTS

There were 100 patients in group I, 13 in group II, and 24 in group III. Patients in group I showed the greatest improvement in Lysholm score among the groups, and patients in group III had the greatest side-to-side difference by KT-1000 arthrometer. Tunnel obliquity as measured by the angle between the anteroposterior axis of the femur and the femoral tunnel in the axial view on MRI was greater (P < .05) and the angle between the joint line and the graft on the oblique coronal view was less in group I.

CONCLUSIONS

This study showed a significantly lower Lysholm score and more vertical orientation of the femoral tunnel in the group with residual pivot shift than in the group without pivot shift. Vertical orientation of the femoral tunnel in the axial plane is closely related to residual pivot shift without definite anteroposterior laxity. More oblique positioning of the graft may have advantages in rotational stability, which in turn increase subjective patient satisfaction.

LEVEL OF EVIDENCE

Level III, diagnostic study of nonconsecutive patients without consistently applied reference gold standard.

Arthroscopic evaluation of ACL grafts reconstructed with the anatomical two-bundle technique using hamstring tendon autograft

This article describes second-look arthroscopic evaluation of the transplanted grafts after anatomical two-bundle ACL reconstruction, which had been performed between December 2000 and March 2004. Using two double-looped semitendinosus tendon grafts via separate femoral and tibial tunnels in the anatomical ACL footprints, 65 patients (mean age of 24 years) underwent anatomical two-bundle ACL reconstruction. The evaluation was performed for those who had undergone the procedure 5-29 months (mean 16.5) previously, with emphasis on graft tension and the presence of graft damage by meticulous probing. None of the anteromedial (AM) grafts showed rupture, while 11% of the posterolateral (PL) grafts showed substantial damage around the femoral tunnel aperture. Both the AM and PL grafts were evaluated as lax without apparent graft rupture in 9% of the knees. These results suggest that the currently performed anatomical two-bundle ACL reconstruction and postoperative regimen still remain to be improved to achieve better postoperative graft morphology.

Effectiveness of reconstruction of the anterior cruciate ligament with quadrupled hamstrings and bone-patellar tendon-bone autografts: an in vivo study comparing tibial internal-external rotation

BACKGROUND

The 2 most frequently used autografts for anterior cruciate ligament reconstruction are the bone-patellar tendon-bone and the quadrupled hamstrings tendon.

HYPOTHESIS

Hamstring tendon graft is superior to patellar tendon graft in restoring tibial rotation during highly demanding activities because of its superiority in strength and linear stiffness and because it is closer morphologically to the anatomy of the natural anterior cruciate ligament.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Eleven patients with patellar tendon graft anterior cruciate ligament reconstruction, 11 patients with hamstring tendon graft anterior cruciate ligament reconstruction, and 11 controls were assessed. Kinematic data were collected (50 Hz) with a 6-camera optoelectronic system while the subjects descended stairs and, immediately after, pivoted on their landing leg. The dependent variable examined was the tibial internal-external rotation during pivoting. All patients in both groups were also assessed clinically and with the use of a KT-1000 arthrometer to evaluate anterior tibial translation.

RESULTS

The results demonstrated that reconstructions with either graft successfully restored anterior tibial translation. However, both anterior cruciate ligament reconstruction groups had significantly increased tibial rotation when compared with the controls, whereas no differences were found between the 2 reconstructed groups.

CONCLUSION

The 2 most frequently used autografts for anterior cruciate ligament reconstruction cannot restore tibial rotation to normal levels.

CLINICAL RELEVANCE

New surgical techniques are needed that can better approximate the actual anatomy and function of the anterior cruciate ligament.

Tibial rotation is not restored after ACL reconstruction with a hamstring graft

Recent research suggests ACL reconstruction does not restore tibial rotation to normal levels during high demand activities when a bone-patellar tendon-bone graft is used. We asked if an alternative graft, the semitendinosus-gracilis (ST/G) tendon graft, could restore tibial rotation during a high demand activity. Owing to its anatomic similarity with the normal ACL we hypothesized the ST/G graft could restore excessive tibial rotation to normal healthy levels along with a successful reinstatement of the clinical stability of the knee. We assessed tibial rotation in vivo, using gait analysis. We compared the knees of ACL reconstructed patients with an ST/G graft to their intact contralateral and healthy controls during a pivoting task that followed a stair descent. We also evaluated knee stability after ACL reconstruction with standard clinical tests. ACL reconstruction with the ST/G graft and with current techniques did not restore tibial rotation to previous physiological levels during an activity with increased rotational loading at the knee, although abnormal anteroposterior (AP) tibial translation was restored.

Tibial Rotation in Anterior Cruciate Ligament (ACL)-Deficient and ACL-Reconstructed Knees

Excessive tibial rotation has been documented in anterior cruciate ligament (ACL) deficiency during walking. ACL reconstruction has been unable to correct this abnormality in activities that are more demanding than walking and involve both anterior and rotational loading of the knee. These findings persist regardless of graft selection for the ACL reconstruction (bone-patellar tendon-bone or semitendinosus gracilis). Based on this research work, we propose a theoretical perspective for the development of osteoarthritis in both the ACL-deficient and the ACL-reconstructed knee. We propose that excessive tibial rotation will lead to abnormal loading of the cartilage areas that are not commonly loaded in the healthy knee. Over time, this abnormal loading will lead to osteoarthritis. We hypothesise that the development of new surgical procedures and grafts, such as a more horizontally oriented femoral tunnel or a double-bundle ACL reconstruction, could possibly restore tibial rotation to normal levels and prevent future knee pathology. However, in vivo gait analysis studies are needed to examine the effects of these surgical procedures on tibial rotation. Prospective in vivo and in vitro studies are also necessary to verify or refute our theoretical proposition for the development of osteoarthritis.

Reliability and usefulness of a new in vivo measurement system of the pivot shift

Residual pivot shift after ACL reconstruction is a crucial factor related to poor clinical outcome. However, no method exists that is able to evaluate pivot shift quantitatively and noninvasively. We propose a new measurement system for the pivot shift test using an electromagnetic device and have evaluated its reliability and clinical usefulness. Posterior translation, lateral translation and maximum velocity during the reduction phase of pivot shift were calculated and used as parameters for evaluation. In measurement system analysis, discrepancies of motion between the bones and the sensors were minimal, while reproducibility in repeated measurement was acceptable. Next, clinical usefulness was evaluated by correlating the values obtained by kinematic measurement with the clinical grade. We found differences in each of the measured parameters among clinical grades. These data suggest the system is a valuable measurement tool for clinical evaluation of the pivot shift test.

Influence d’une ligamentoplastie extra-articulaire latérale sur les résultats de la reconstruction du ligament croisé antérieur avec le ligament patellaire avec 7 ans de recul

PURPOSE OF THE STUDY

Reconstruction of the anterior cruciate ligament (ACL) is a common procedure, but use of lateral reinforcement is still a subject of debate. The purpose of this study was to compare two randomized series of ACL reconstructions, one using an intra-articular method (patellar tendon autograft) and the other an intra- and extra-articular method (Mac-InJones).

MATERIAL AND METHODS

From January 1995 to March 1998, 63 knees underwent surgery for ACL reconstruction. Inclusion criteria was significant medial differential laxity measured between 7 and 12 mm on passive dynamic x-rays as 20 degrees flexion. Group 1 (patellar tendon intra-articular reconstruction) included 34 patients (27.1+/-7.5 years) and group 2 (intra-articular reconstruction plus extra-articular quadircipital tendon plasty) included 29 patients (28.5+/-12 years). The IKDC score was determined for 72% of the knees in group 1 and 68% in group 2 at seven years follow-up on average (102 and 93 months respectively). Anterior laxity was measured radiographically and with KT-1000. The position of the tunnels was controlled using the Aglietti method.

RESULTS

The subjective functional score was 83.6+/-3.5 in group 1 and 83.5+/-3.5 in group 2. The overall IKDC knee score classes for group 1 were 0% A, 52.4% B, 28.6% C, and 19% D and for group 2 were 5.5% group A, 50% group B, 33.3% group C, and 11.1% group D. In group 1, the pivot test was negative in 61.9% and noted stage 1 in 28.6% and stage 2 in 9.5%. In group 2, the pivot test was negative in 78.9% and noted stage 1 in 15.8% and stage 2 in 5.3%. The KT-1000 showed no difference in gain in laxity: 31% for group 1 and 27% for group 2. Similarly, radiographically there was no difference with a 43.9% gain in differential laxity for the medial compartment and 45.3% for the lateral compartment in group 1. In group 2 the corresponding values were 51.9% and 41.8%. The position of the tunnels was the same in the two groups.

DISCUSSION

In a preliminary study with two years follow-up, the results in these two series were not significantly different. It was concluded that there was not clear advantage to adding the extra-articular lateral plasty. At the present 7-year follow-up, pivoting appears to be better controlled in the lateral plasty group (p=0.23), but with no significant difference for laxity for both knee compartments. The inclusion criteria would be different today and would be based on the laxity of the lateral compartment.

Anatomic double-bundle anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures performed by orthopaedic surgeons. The procedure has improved significantly since its inception in 1900 and continues to be intensively studied with outcomes receiving considerable attention. Traditional ACL reconstruction techniques have focused on one portion of the ACL--the anteromedial bundle. Single-bundle ACL reconstruction is the criterion standard and has provided good to excellent results, with many athletes being able to return to sports; however, recently, some authors have noted persistent instability with functional testing and degenerative radiographic changes after single-bundle ACL reconstruction. As a result, several centers have attempted to improve upon the single-bundle technique by reconstructing both the anteromedial and posterolateral bundles of the ACL. This article will present the embryologic, anatomic, and biomechanical rationale for double-bundle ACL reconstruction. In addition, the latest outcomes of double-bundle ACL reconstruction will be presented.