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Lim S, Park KH, Park DY, Kim TH, Koh JH, Chung JY. Rotational stability can be enhanced in revision anterior cruciate ligament reconstruction using the over-the-top augmentation technique compared to single bundle technique. BMC Sports Sci Med Rehabil 2023; 15:111. [PMID: 37715268 PMCID: PMC10504798 DOI: 10.1186/s13102-023-00724-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023]
Abstract
PURPOSE Revision anterior cruciate ligament (ACL) reconstruction is technically challenging due to mispositioned tunnels, bone loss, and tunnel enlargement, which may compromise graft fixation and result in failure. To obtain firm graft fixation and strength in one stage, we utilized an over-the-top augmentation technique using an Achilles tendon allograft in revision ACL reconstruction (OA-ACLR). This study compared OA-ACLR with single-bundle ACL reconstruction (SB-ACLR). We hypothesized that OA-ACLR would enhance the postoperative knee joint rotational stability. METHODS We retrospectively analyzed 47 patients who underwent revisional OA-ACLR and 48 who underwent primary SB-ACLR with minimum follow-up of 6 months. Knee instability was evaluated with the anterior drawer, Lachman, and pivot shift tests preoperatively and at the final follow-up. Side-to-side differences were compared with the non-affected side at the final follow-up. Function was evaluated using the IKDC subjective and Lysholm knee scores preoperatively and at the final follow-up. RESULTS The groups did not differ in terms of sex, age, BMI, and etiology. There were no significant differences in concomitant surgical procedures, such as meniscectomy and meniscus repair, between the two groups (p = 0.335, > 0.99). Both groups significantly improved in the anterior drawer, Lachman, pivot shift tests, and IKDC and Lysholm knee scores after surgery (all p < 0.001). The OA-ACLR group showed significantly higher rotational stability in the pivot shift test than the SB-ACLR group (p = 0.017). The postoperative side-to-side difference, the IKDC and Lysholm scores showed no significant differences between the groups (p = 0.34, 0.301, 0.438). CONCLUSIONS OA-ACLR showed enhanced rotational stability with pivot shift test compared to SB-ACLR. It may be considered a useful alternative for revision ACL reconstruction.
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Affiliation(s)
- Sumin Lim
- Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499, Korea
| | - Ki-Hoon Park
- Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499, Korea
- Daprtment of Orthopedic Surgery, Armed Forces Yangju Medical Center, Yangju-si, Korea
| | - Do Young Park
- Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499, Korea
- Cell Therapy Center, Ajou University Medical Center, Suwon, Korea
| | - Tae Hun Kim
- Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499, Korea
| | - Jeong-Hyun Koh
- Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499, Korea
| | - Jun Young Chung
- Department of Orthopedic Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yongtong-gu, Suwon, 16499, Korea.
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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] [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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Grassi A, Di Paolo S, Fabbro GD, Eroglu ON, Macchiarola L, Lucidi GA, Zaffagnini S. Objective Laxity and Subjective Outcomes are More Influenced by Meniscal Treatment than Anterior Cruciate Ligament Reconstruction Technique at Minimum-Two-Years Follow-Up. J ISAKOS 2022; 7:54-59. [DOI: 10.1016/j.jisako.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/22/2022] [Accepted: 04/21/2022] [Indexed: 11/26/2022]
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A Comprehensive Framework to Evaluate the Effects of Anterior Cruciate Ligament Injury and Reconstruction on Graft and Cartilage Status through the Analysis of MRI T2 Relaxation Time and Knee Laxity: A Pilot Study. Life (Basel) 2021; 11:life11121383. [PMID: 34947914 PMCID: PMC8706566 DOI: 10.3390/life11121383] [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] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Anterior cruciate ligament (ACL) tear represents a common orthopedic traumatic issue that often leads to an early development of osteoarthritis. To improve the diagnostic and prognostic techniques involved in the assessment of the joint after the trauma and during the healing process, the present work proposes a multi-parametric approach that aims to investigate the relationship between joint function and soft tissue status before and after ACL reconstruction. METHODS Thirteen consecutive patients who underwent ACL reconstruction were preliminarily enrolled in this study. Joint laxity assessment as well as magnetic resonance imaging with T2 mapping were performed in the pre-operative stage, at four and 18 months after surgery to acquire objective information to correlate knee function and soft tissue condition. RESULTS Correlations were found between graft and cartilage T2 signal, suggesting an interplay between these tissues within the knee joint. Moreover, graft maturation resulted in being connected to joint laxity, as underlined by the correlation between the graft T2 signal and the temporal evolution of knee function. CONCLUSIONS This preliminary study represents a step forward in assessing the effects of ACL graft maturation on knee biomechanics, and vice versa. The presented integrated framework underlines the possibility to quantitatively assess the impact of ACL reconstruction on trauma recovery and cartilage homeostasis. Moreover, the reported findings-despite the preliminary nature of the clinical impacts-evidence the possibility of monitoring the surgery outcomes using a multi-parametric prognostic investigation tool.
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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: 2] [Impact Index Per Article: 0.7] [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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Buerba RA, Zaffagnini S, Kuroda R, Musahl V. ACL reconstruction in the professional or elite athlete: state of the art. J ISAKOS 2021; 6:226-236. [PMID: 34272299 DOI: 10.1136/jisakos-2020-000456] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/27/2020] [Accepted: 11/07/2020] [Indexed: 01/26/2023]
Abstract
Anterior cruciate ligament (ACL) injuries are on the rise at all levels of sport, including elite athletics. ACL injury can have implications on the athlete's sport longevity, as well as other long-term consequences, such as the development of future knee osteoarthritis. In the elite athlete, ACL injury can also have ramifications in terms of contract/scholastic obligations, sponsorships and revenue-generating potential. Although the goal of anterior cruciate ligament reconstruction (ACLR) is to return any athlete to the same preinjury level of sport, management of ACL injuries in the elite athlete come with the additional challenge of returning him or her to an extremely high level of physical performance. Despite outcome studies after ACLR in elite athletes showing a high return-to-sport rate, these studies also show that very few athletes are able to return to sport at the same level of performance. They also show that those athletes who undergo ACLR have careers that are more short-lived in comparison to those without injury. Thus, returning an elite athlete to 'near peak' performance may not be good enough for the athletic demands of elite-level sports. A possible explanation for the variability in outcomes is the great diversity seen in the management of ACL injuries in the elite athlete in terms of rehabilitation, graft choices, portal drilling and reconstruction techniques. Recently, the advent of anatomical, individualised ACLR has shown improved results in ACLR outcomes. However, larger-scale studies with long-term follow-ups are needed to better understand the outcomes of modern ACLR techniques-particularly with the rise of quadriceps tendon as an autograft choice and the addition of lateral extra-articular tenodesis procedures. The purpose of this article was thus to provide an up-to-date state-of-the-art review in the management of ACL injuries in the elite athlete.
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Affiliation(s)
| | - Stefano Zaffagnini
- 2nd Orthopaedic Surgery and Traumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Ryosuke Kuroda
- Orthopaedic, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Volker Musahl
- Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Agostinone P, Di Paolo S, Grassi A, Pinelli E, Bontempi M, Bragonzoni L, Zaffagnini S. ACL deficiency influences medio-lateral tibial alignment and knee varus-valgus during in vivo activities. Knee Surg Sports Traumatol Arthrosc 2021; 29:389-397. [PMID: 32253481 DOI: 10.1007/s00167-020-05979-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/30/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE The role of the anterior cruciate ligament (ACL) in knee biomechanics in vivo and under weight-bearing is still unclear. The purpose of this study was to compare the tibiofemoral kinematics of ACL-deficient knees to healthy contralateral ones during the execution of weight-bearing activities. METHODS Eight patients with isolated ACL injury and healthy contralateral knees were included in the study. Patients were asked to perform a single step forward and a single leg squat first with the injured knee and then with the contralateral one. Knee motion was determined using a validated model-based tracking process that matched subject-specific MRI bone models to dynamic biplane radiographic images, under the principles of Roentgen stereophotogrammetric analysis (RSA). Data processing was performed in a specific software developed in Matlab. RESULTS Statistically significant differences (p < 0.05) were found for single leg squat along the frontal plane: ACL-deficient knees showed a more varus angle, especially at the highest knee flexion angles (40°-50° on average), compared to the contralateral knees. Furthermore, ACL-deficient knees showed tibial medialization along the entire task, while contralateral knees were always laterally aligned. This difference became statistically relevant (p < 0.05) for knee flexion angles included between 0° and about 30°. CONCLUSION ACL-deficient knees showed an abnormal tibial medialization and increased varus angle during single leg squat when compared to the contralateral knees. These biomechanical anomalies could cause a different force distribution on tibial plateau, explaining the higher risk of early osteoarthritis in ACL deficiency. The clinical relevance of this study is that also safe activities used in ACL rehabilitation protocols are significantly altered in ACL deficiency. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Piero Agostinone
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Di Paolo
- Dipartimento di Scienze Biomediche e Neuromotorie DIBINEM, Università di Bologna, Via Giulio Cesare Pupilli, 1, 40136, Bologna, BO, Italy.
| | - Alberto Grassi
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Erika Pinelli
- Dipartimento di Scienze per la Qualità della Vita QuVi, Università di Bologna, Bologna, Italy
| | - Marco Bontempi
- Laboratorio di Biomeccanica ed Innovazione Tecnologica, IRCSS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Laura Bragonzoni
- Dipartimento di Scienze per la Qualità della Vita QuVi, Università di Bologna, Bologna, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie DIBINEM, Università di Bologna, Via Giulio Cesare Pupilli, 1, 40136, Bologna, BO, Italy
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Grassi A, Macchiarola L, Lucidi GA, Silvestri A, Dal Fabbro G, Marcacci M, Zaffagnini S. Ten-Year Survivorship, Patient-Reported Outcome Measures, and Patient Acceptable Symptom State After Over-the-Top Hamstring Anterior Cruciate Ligament Reconstruction With a Lateral Extra-articular Reconstruction: Analysis of 267 Consecutive Cases. Am J Sports Med 2021; 49:374-383. [PMID: 33523751 DOI: 10.1177/0363546520986875] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Long-term patient-reported outcome measures (PROMs) and predictors of success or failure after anterior cruciate ligament (ACL) reconstruction are not fully understood, especially when combined with a lateral extra-articular reconstruction. PURPOSE To assess the long-term PROMs, revision rate, and predictors of success or failure after ACL reconstructions using an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular reconstruction. STUDY DESIGN Case series; Level of evidence, 4. METHODS The study cohort consisted of 267 consecutive patients (mean age, 30.7 years) who underwent ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular augmentation between November 2007 and May 2009. The number of subsequent ACL revisions and reoperations were recorded. Subjective clinical status was assessed with PROMs-specifically, the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and visual analog scale for pain-at a minimum follow-up of 10 years. RESULTS Overall, 3% of patients underwent ACL revision, with a 10-year survival rate of 96.3%. High sport activity (hazard ratio, 6.9; P = .285) and concomitant meniscal lesion (hazard ratio, 2.6; P = .0487) were predictors of ACL revision or new meniscectomy. The mean ± SD Lysholm score was 94.1 ± 10.8, while that for the visual analog scale for pain was 0.2 ± 0.9 at rest and 2.1 ± 2.6 during activity. KOOS subscale scores were as follows: 95.7 ± 8.1 for Pain, 92.5 ± 10.5 for Symptoms, 98.4 ± 7.4 for Activities of Daily Living, 90.7 ± 17.2 for Sport, and 91.2 ± 17.1 for Quality of Life; respectively, 88%, 99%, 81%, 89%, and 91% of patients achieved the Patient Acceptable Symptom State. Female sex and chondropathy with Outerbridge grade ≥2 were predictors of worse KOOS subscales. Overall, 82% of patients returned to sport, and 57% were still participating at the 10-year evaluation. CONCLUSION ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring autografts and a lateral extra-articular reconstruction provided satisfactory results in terms of function, symptoms, sports, and quality of life in 80% to 90% of patients after 10 years. Long-term survivorship was 96%. Sport participation declined from 82% postoperatively to 57% at long-term follow-up. A concomitant medial meniscal lesion was a predictor of higher risk of ACL failure or new meniscal lesion, while advanced chondropathy and female sex were predictors of higher pain, lower function, and poor quality of life scores.
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Affiliation(s)
- Alberto Grassi
- IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica II, Bologna, Italy
| | - Luca Macchiarola
- IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica II, Bologna, Italy
| | - Gian Andrea Lucidi
- IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica II, Bologna, Italy
| | - Annamaria Silvestri
- IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica II, Bologna, Italy
| | - Giacomo Dal Fabbro
- IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica II, Bologna, Italy
| | | | - Stefano Zaffagnini
- IRCCS Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica II, 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: 1.7] [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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