Does the posterolateral bundle influence rotational movement more than the anteromedial bundle in anterior cruciate ligament reconstruction?

Comparison of Synovialization and Clinical Outcomes between Anterior Cruciate Ligament Anteromedial Bundle Augmentation and Double-Bundle Anterior Cruciate Ligament Reconstruction

This study aimed to compare clinical outcomes and second-look arthroscopic findings between double-bundle anterior cruciate ligament (ACL) reconstruction for complete ACL rupture and anteromedial (AM) bundle augmentation with preservation of the posterolateral (PL) bundle in isolated AM bundle rupture. Between 2014 and 2021, we retrospectively analyzed 95 ACL reconstructions with at least 2 years of follow-up. Patients undergoing primary ACL reconstruction from January 2014 to June 2021 were included in the study. Double-bundle ACL reconstruction (group 1) was performed in the cases involving male patients, high activity levels, age below 40 years, or when there was a patient preference for double-bundle reconstruction. In contrast, for partial ACL ruptures with an intact PL bundle confirmed on preoperative magnetic resonance imaging, AM augmentation was performed (group 2). Preoperative and final follow-up clinical outcomes, along with synovial coverage during second-look arthroscopy, were compared between group 1 (65 cases) and group 2 (30 cases). Statistical analysis included correlation coefficients between the groups. The Lysholm score, Tegner activity scores, and International Knee Documentation Committee (IKDC) knee evaluation form score at final follow-up were 81.8 (±5.5), 7.2 (±0.9), and 79.4 (±6.7), respectively, in group 1, and they were 88.0 (±6.4, p = 0.038), 7.9 (±0.5, p = 0.042), and 86.2 (±5.4, p = 0.081), respectively, in group 2. For group 1, the Lachman test (p = 0.093) and the pivot shift test (p = 0.176) at the final follow-up showed no laxity in 57 and 59 knees, and there was plus one laxity in 8 and 6 knees. For group 2, there were no laxity in 27 and 28 knees, and plus one laxity in 3 and 2 knees. Synovial coverage area percentages of the grafted tendon were 74.3 (±10.7) and 86.9 (±7.3, p = 0.002) in groups and group 2, respectively, with superior synovial coverage observed in group 2. The AM bundle augmentation with preservation of the PL bundle in ACL injury yielded better synovial coverage and clinical scores compared with double-bundle ACL reconstruction for complete ACL rupture.

Evaluation of the intraoperative kinematics during double-bundle anterior cruciate ligament reconstruction using a navigation system

Background/objective

There is controversy regarding the biomechanical function of the anteromedial (AM) and posterolateral (PL) bundles in isolated tibiofemoral rotation during double-bundle anterior cruciate ligament (ACL) reconstruction. This study aimed to evaluate the biomechanical function of the AM and PL bundles of the ACL using a computer navigation system.

Methods

This study involved 15 patients who underwent double-bundle ACL reconstruction. Anteroposterior and isolated rotational knee laxity were measured with a navigation system. The measurements were performed four times, namely, before fixation, after temporary PL bundle fixation, after AM bundle fixation, and after double-bundle reconstruction. With knee flexion ranging from 20° to 60°, we continuously measured the anterior tibial displacement under an anterior drawer stress (100 N using a spring balance). The total range of tibial rotation was also measured under an external and internal rotational torque of 3 Nm.

Results

Fixation of either the AM or the PL bundle significantly reduced the anteroposterior displacement at all knee flexion angles. Although the anteroposterior displacement after AM bundle fixation was relatively similar throughout the range of motion (2.4–3.2 mm), the anteroposterior displacement after PL bundle fixation increased continuously with knee flexion (2.2–4.6 mm). With respect to the total range of tibial rotation under external and internal rotational torque, there was no significant difference between AM and PL bundle fixation throughout the range of motion. The total range of tibial rotation was significantly reduced only on double-bundle reconstruction at 20° and 25° knee flexion compared to the pre-reconstruction range (P = 0.015 and 0.036, respectively).

Conclusion

The AM and PL bundles function differently for controlling anterior knee laxity throughout the range of motion. The function of the AM and PL bundles was similar for controlling isolated tibiofemoral rotation. Isolated tibiofemoral rotation was significantly controlled only on double-bundle reconstruction at knee flexion angles of 20° and 25°.

In vivo knee rotational stability 2 years after double-bundle and anatomic single-bundle ACL reconstruction

PURPOSE

The objective of this study was to evaluate knee rotational stability at least 2 years after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction (SB) and double-bundle ACL reconstruction (DB) in comparison with the contralateral healthy knee joint. The Cincinnati, Lysholm and IKDC scores were analysed too.

METHODS

There were 40 patients in both groups, the mean follow-up was 27 months. For all measurements, the navigation system OrthoPilot was used. Measurement started with the patient in the standing position in neutral rotation. Then, the patient achieved in 30° knee flexion under weight-bearing maximal external trunk rotation and returned to the neutral position. The same measurement was done for the internal trunk rotation. For the anterior-posterior stability, KT-1000 arthrometer was used. All measurements were repeated three times for each knee joint.

RESULTS

After the DB reconstruction, the mean external rotation of the tibia (ER) was 8.2° and the internal rotation (IR) was 10.2°. In the contralateral healthy knee joint, ER was 8.5° (p = 0.597) and IR was 12.1° (p = 0.064). After the SB reconstruction, ER was 9.4° and IR was 13.1°. In the contralateral healthy knee joint, ER was 7.7° (p = 0.066) and IR was 9.8° (p = 0.005). Anterior-posterior translation was to the same extent for both groups.

CONCLUSIONS

The DB reconstruction of the ACL restores the rotational stability of the knee joint without any significant difference in comparison to the contralateral healthy knee (p > 0.05). The main finding of this study is that the internal rotational stability of the knee joint after the anatomic SB technique is not sufficient.

Current use of navigation system in ACL surgery: a historical review

PURPOSE

The present review aims to analyse the available literature regarding the use of navigation systems in ACL reconstructive surgery underling the evolution during the years.

METHODS

A research of indexed scientific papers was performed on PubMed and Cochrane Library database. The research was performed in December 2015 with no publication year restriction. Only English-written papers and related to the terms ACL, NAVIGATION, CAOS and CAS were considered. Two reviewers independently selected only those manuscripts that presented at least the application of navigation system for ACL reconstructive surgery.

RESULTS

One hundred and forty-six of 394 articles were finally selected. In this analysis, it was possible to review the main uses of navigation system in ACL surgery including tunnel positioning for primary and revision surgery and kinematic assessment of knee laxity before and after different surgical procedures. In the early years, until 2006, navigation system was mainly used to improve tunnel positioning, but since the last decade, this tool has been principally used for kinematics evaluation. Increased accuracy of tunnel placement was observed using navigation surgery, especially, regarding femoral, 42 of 146 articles used navigation to guide tunnel positioning. During the following years, 82 of 146 articles have used navigation system to evaluate intraoperative knee kinematic. In particular, the importance of controlling rotatory laxity to achieve better surgical outcomes has been underlined.

CONLUSIONS

Several applications have been described and despite the contribution of navigation systems, its potential uses and theoretical advantages, there are still controversies about its clinical benefit. The present papers summarize the most relevant studies that have used navigation system in ACL reconstruction. In particular, the analysis identified four main applications of the navigation systems during ACL reconstructive surgery have been identified: (1) technical assistance for tunnel placement; (2) improvement in knowledge of the kinematic behaviour of ACL and other structures; (3) comparison of effectiveness of different surgical techniques in controlling laxities; (4) navigation system performance to improve the outcomes of ACL reconstruction and cost-effectiveness.

LEVEL OF EVIDENCE

IV.

A new technique in double-bundle anterior cruciate ligament reconstruction with implant-free tibial fixation

PURPOSE

This case-series outcome study presents a surgical technique for anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with 4-tunnel using two interference screws. There was a 2-year minimum follow-up.

METHODS

From January to December 2009, an ACL 4-tunnel, anatomic, double-bundle reconstruction was performed on 27 patients. Double-strand hamstring tendon grafts were used in each femoral tunnel as well as two interference screws. Tibial fixation was insured through manual tension, by tying non-absorbable sutures on the bone bridge between the two tunnels at 20° of knee flexion. Clinical assessments included the International Knee Documentation Committee (IKDC) and Lysholm knee scores, range of motion (ROM), pivot-shift test, single-leg hop, and quadriceps-hamstrings strength tests using a hand-held dynamometer. Anterior knee laxity was also assessed using a rolimeter. A single examiner performed all testing pre-operatively at 6 months and during the 2-year follow-up.

RESULTS

All patients were assessed during the 2-year follow-up. At that time, 92 % of the patients presented normal anterior laxity (average, 1.3 ± 0.5 mm) and rotational knee stability. No statistical side-to-side difference was found for ROM, muscle strength, single-leg hop, and function (n.s.). All patients presented a normal knee function according to the IKDC and the Lysholm score. In addition, no infection, graft failure, or pain were observed at the harvesting site.

CONCLUSION

The study shows that satisfactory results in relation to knee laxity, function, and strength can be achieved with the implant-free tibial fixation in the ACL double-bundle reconstruction with two interference screws.

LEVEL OF EVIDENCE

Therapeutic case series, Level IV.

Stability Outcomes following Computer-Assisted ACL Reconstruction

Purpose. The purpose of this study was to determine whether intraoperative prereconstruction stability measurements and/or patient characteristics were associated with final knee stability after computer-assisted ACL reconstruction. Methods. This was a retrospective review of all patients who underwent computer-assisted single-bundle ACL reconstruction by a single surgeon. Prereconstruction intraoperative stability measurements were correlated with patient characteristics and postreconstruction stability measurements. 143 patients were included (87 male and 56 female). Average age was 29.8 years (SD ± 11.8). Results. Females were found to have significantly more pre- and postreconstruction internal rotation than males (P < 0.001 and P = 0.001, resp.). Patients with additional intra-articular injuries demonstrated more prereconstruction anterior instability than patients with isolated ACL tears (P < 0.001). After reconstruction, these patients also had higher residual anterior translation (P = 0.01). Among all patients with ACL reconstructions, the percent of correction of anterior translation was found to be significantly higher than the percent of correction for internal or external rotation (P < 0.001). Conclusion. Anterior translation was corrected the most using a single-bundle ACL reconstruction. Females had higher pre- and postoperative internal rotation. Patients with additional injuries had greater original anterior translation and less operative correction of anterior translation compared to patients with isolated ACL tears.

Clinical outcomes of second-look arthroscopic evaluation after anterior cruciate ligament augmentation

We report the clinical outcome and findings at second-look arthroscopy of 216 patients (mean age 25 years (11 to 58)) who underwent anterior cruciate ligament (ACL) reconstruction or augmentation. There were 73 single-bundle ACL augmentations (44 female, 29 male), 82 double-bundle ACL reconstructions (35 female, 47 male), and 61 single-bundle ACL reconstructions (34 female, 27 male).

In 94 of the 216 patients, proprioceptive function of the knee was evaluated before and 12 months after surgery using the threshold to detect passive motion test.

Second-look arthroscopy showed significantly better synovial coverage of the graft in the augmentation group (good: 60 (82%), fair: 10 (14%), poor: 3 (4%)) than in the other groups (p = 0.039). The mean side-to-side difference measured with a KT-2000 arthrometer was 0.4 mm (-3.3 to 2.9) in the augmentation group, 0.9 mm (-3.2 to 3.5) in the double-bundle group, and 1.3 mm (-2.7 to 3.9) in the single-bundle group: the result differed significantly between the augmentation and single-bundle groups (p = 0 .013). No significant difference in the Lysholm score or pivot-shift test was seen between the three groups (p = 0.09 and 0.65, respectively). In patients with good synovial coverage, three of the four measurements used revealed significant improvement in proprioceptive function (p = 0.177, 0.020, 0.034, and 0.026).

We conclude that ACL augmentation is a reasonable treatment option for patients with favourable ACL remnants.

Cite this article: Bone Joint J 2014;96-B:1325–32

Applications of computer navigation in sports medicine knee surgery: an evidence-based review

Computer-assisted surgery (CAS) has been investigated in a number of sports medicine procedures in the knee. Current barriers to its widespread introduction include increased costs, duration, and invasiveness of surgery. Randomized trials on the use of CAS in anterior cruciate ligament reconstruction have failed to demonstrate a clinical benefit. Data on CAS use in high tibial osteotomy are more promising; however, long-term studies are lacking. CAS has a number of research applications in knee ligament surgery, and studies continue to explore its use in the treatment of osteochondral lesions. This article reviews the applications of CAS in sports medicine knee surgery and summarizes current literature on clinical outcomes.