Anterior cruciate ligament reconstruction with synthetic grafts. A review of literature

Anterior cruciate ligament (ACL) rupture, one of the most common knee injuries in sports, results in anteroposterior laxity, which often leads to an unstable knee. Traditional ACL reconstruction is performed with autograft; disadvantages of this technique are donor site morbidity and a long rehabilitation period. In the 1980s, artificial ligaments became an attractive alternative to biological grafts. The initial enthusiasm surrounding their introduction stemmed from their lack of donor morbidity, their abundant supply and significant strength, immediate loading and reduced postoperative rehabilitation. Synthetic grafts made of different materials such as carbon fibers, polypropylene, Dacron and polyester have been utilised either as a prosthesis or as an augmentation for a biological ACL graft substitute. Nevertheless, every material presented serious drawbacks: cross-infections, immunological responses, breakage, debris dispersion leading to synovitis, chronic effusions, recurrent instability and knee osteoarthritis. Recently, a resurgence of interest in the use of synthetic prostheses has occurred and studies regarding new artificial grafts have been reported. Although many experimental studies have been made and much effort has been put forth, currently no ideal prosthesis mimicking natural human tissue has been found.     

Isolierte und kombinierte Kniebandverletzungen

Complex knee ligament injuries are characterized by simultaneous rupture of the anterior cruciate ligament (ACL) and/or the posterior cruciate ligament (PCL) and at least one collateral ligament. Isolated injury to the medial collateral ligament (MCL) and PCL have a high healing capacity and can be treated conservatively in many cases. Ruptures of the MCL can also be treated conservatively in complex injuries if the cruciate ligaments are reconstructed. Ruptures of the lateral structures usually need surgical reconstruction. Indications for acute surgical repair include meniscus dislocation, entrapment of collateral ligament portions in the joint, knee dislocation with severe knee instability, and displaced bony avulsions. The anatomy of the knee ligaments must be carefully respected in surgical reconstruction. Acute repair of collateral ligament injuries is possible only in the first 2 weeks after trauma. Acute arthroscopy is indicated only in combination with reconstructive surgery.     

Review of evolution of tunnel position in anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) rupture is one of the commonest knee sport injuries. The annual incidence of the ACL injury is between 100000-200000 in the United States. Worldwide around 400000 ACL reconstructions are performed in a year. The goal of ACL reconstruction is to restore the normal knee anatomy and kinesiology. The tibial and femoral tunnel placements are of primordial importance in achieving this outcome. Other factors that influence successful reconstruction are types of grafts, surgical techniques and rehabilitation programmes. A comprehensive understanding of ACL anatomy has led to the development of newer techniques supplemented by more robust biological and mechanical concepts. In this review we are mainly focussing on the evolution of tunnel placement in ACL reconstruction, focusing on three main categories, i.e., anatomical, biological and clinical outcomes. The importance of tunnel placement in the success of ACL reconstruction is well researched. Definite clinical and functional data is lacking to establish the superiority of the single or double bundle reconstruction technique. While there is a trend towards the use of anteromedial portals for femoral tunnel placement, their clinical superiority over trans-tibial tunnels is yet to be established.     

Peroneus longus tendon graft for anterior cruciate ligament reconstruction: A case report and review of literature

IntroductionThe anterior cruciate ligament (ACL) is one of the most frequently injured structures of the knee joint. Anterior cruciate ligament reconstruction (ACLR) provides surgical restoration of the injured ACL using the placement of graft material. The choice of graft is principal in providing optimal knee stability after surgery. Peroneus longus tendon (PLT) is an autograft modality that offers unique benefits for ACL reconstruction cases.Presentation of caseWe present a case of ACL reconstruction surgery using PLT graft in a patient with a confirmed ACL rupture. Assessment of post-surgical pain, knee stability, and ankle function were performed to determine functional outcome and donor site morbidity. The follow-up results revealed favorable recovery and improvement in all objective parameters.DiscussionPost-operative biomechanical outcomes were evaluated using the International Knee Documentation Committee (IKDC) and the American Orthopedic Foot and Ankle Score (AOFAS) score. The use of PLT in ACL reconstruction established an excellent potential for its satisfactory result and comparable to other graft modalities in widely used evidence-based findings.ConclusionPeroneus longus tendon may be considered the first-option graft in ACL reconstruction as it indicated the absence of significant post-operative morbidity.     

Dynamische intraligamentäre Stabilisierung frischer Rupturen des vorderen Kreuzbandes (Ligamys)

Anterior cruciate ligament (ACL) reconstruction with the use of autologous tendon grafts is the gold standard in the treatment of ACL instability; however, many different techniques have been proposed to suture freshly ruptured ACLs. Unfortunately, the rate of recurrent instability is high. A new technique, dynamic intraligamentary stabilization (DIS), was developed to restore biomechanical stability after primary ACL repair and therefore to allow stable healing. In order to compensate for the anisometry of the ACL, in contrast to simple augmentation a spring mechanism is used in DIS that helps to maintain the tibia in a posterior drawer position during all degrees of flexion. Initial results of biomechanical and clinical studies are promising, indicating that reconstruction of knee joint kinematics after ACL repair with DIS is possible; however, further clinical studies are required to determine its usefulness in the clinical setting.     

Complex instability of the anterior knee

Complex knee instability involves the anterior cruciate ligament (ACL) and one or more major stabilizers of the knee [medial collateral ligament (MCL), lateral collateral ligament (LCL), posterior cruciate ligament (PCL)]. The medial side has a high healing potential and does not need operative treatment in most cases if ACL reconstruction is performed. Reconstruction of the medial ligament complex is indicated in gross instability of the medial meniscus fixation, dislocation of the MCL into the joint, and large dislocated bony avulsions. Injuries on the lateral side do not heal spontaneously and require acute operative treatment (first 2 weeks). Frank knee dislocations and gross multiligament injuries should be reduced acutely, and the integrity of the vascular structures must be examined closely. In a European multicenter study, operative treatment with reconstruction of both cruciate ligaments and functional rehabilitation gave better results than conservative treatment with immobilization of the joint.     

How to treat knee ligament injuries?

Indications for conservative treatment of knee ligament injuries can be established for all grade I or II sprains (partial tears), as well as isolated grade III sprains (complete tears) of the posterior cruciate ligament (PCL) and medial collateral ligament (MCL). These injuries should be treated with immediate mobilization. Only in isolated partial anterior cruciate ligament (ACL) tears without a positive pivot shift phenomenon is conservative treatment justified. However, many of these injuries may require operative reconstruction later. In complete ACL tears the surgical treatment consists of primary reconstruction or augmented primary repair. Today, the middle third of the patella tendon with the bone blocks is regarded as the "gold standard" for augmented repairs and late reconstructions. For the present, there is no place for synthetic prostheses in the treatment of an acute ACL rupture. Allograft replacement of the ACL must now be considered an experimental procedure. In the reconstruction of the PCL the above mentioned patella tendon graft is also preferable. Lateral collateral ligament (LCL) tears, especially if they are combined with ruptures of posterolateral ligament complex, should be repaired immediately after the injury. In these injuries late reconstructions are difficult and the results are poor. Conservative treatment of partial tears and postoperative treatment of reconstructed ligaments is twofold: on the one hand, the healing tissue should be protected and on the other hand, atrophy and wasting of uninjured tissue should be avoided. Overload and stretching of the injured ligaments should be eliminated with the aid of a suitable knee brace, but early range of motion exercises of the knee are allowed immediately.(ABSTRACT TRUNCATED AT 250 WORDS)     

急性完全性前交叉韧带损伤的膝关节镜下早期重建治疗

目的　探讨膝关节镜下对急性完全性前交叉韧带 (ACL)断裂的早期重建治疗 ,以尽早恢复膝关节稳定性。　方法　ACL急性断裂早期在关节镜下应用挤压螺钉固定骨 髌腱 (中 1/ 3) 骨复合体自体移植重建ACL ,止点重建或缝合修复治疗内侧副韧带断裂。　结果　 1998年 2月～ 1999年 3月共治疗急性完全性ACL断裂合并内侧副韧带断列患者 10例 ,术后平均随访 10个月 ,近期效果良好。　结论　急性ACL损伤早期可以在关节镜下完成重建 ,手术创伤小 ,治疗及时 ,可同时处理合并损伤 ,能早期恢复膝关节稳定性和运动功能。     

Anterior cruciate ligament integrity in osteoarthritis of the knee in patients undergoing total knee replacement

Background  

Anterior cruciate ligament (ACL) rupture has been implicated in the development of knee osteoarthritis (OA). This study aimed at determining the incidence of prior ACL deficiency in patients undergoing total knee replacement (TKR), the effect of prior ACL deficiency on function and the macroscopic and microscopic appearance of the ligament.     

The ligament augmentation device: an historical perspective.

Anterior cruciate ligament (ACL) injury is the most common ligament injury in the knee, and a significant number of patients may develop progressive instability and disability despite aggressive rehabilitation. Various materials have been used for its reconstruction. These include autografts, allografts, prosthetic ligaments, and synthetic augmentation of the biological tissue. The concept of ligament augmentation device (LAD) arose from the observation that biological grafts undergo a phase of degeneration and loss of strength before being incorporated. The LAD is meant to protect the biological graft during this vulnerable phase. However, it provokes an inflammatory reaction in the knee, and has been found to delay maturation of autogenous graft in humans. In experimental situations, the LAD has been found to share loads in a composite graft. It has also been found to be substantially stronger than the biological graft. However, in clinical situations no significant advantages have been observed with the use of LAD to augment patellar tendon or hamstring reconstruction of the chronic ACL-deficient knee or in the acute setting to augment repair of the torn ACL. There are very few reports of the use of LAD in reconstruction of the posterior cruciate ligament, and again these do not suggest any advantage in its use. Insertion of the LAD implies the introduction of a foreign material into the knee, has been associated with complications such as reactive synovitis and effusions, and may also be associated with an increased risk of infection. At present, there is no evidence that its routine use should be advocated in uncomplicated reconstructions of the ACL using biological grafts.     

The ACL-deficient knee: natural history and treatment options

Injury to the anterior cruciate ligament removes the major stabilizing structure to anterior tibial translation. The initial trauma may lead to meniscal and cartilage damage, predisposing the knee to early degenerative changes. Moreover, a knee with an isolated ACL rupture may have recurrent episodes of instability that can lead to a similar degenerative course. At this time, one cannot accurately predict which patients will tolerate ACL deficiency, and which patients will not. Current long-term studies support a progressive worsening condition in the ACL and meniscal deficient knees. Physical therapy together with lifestyle modifications may be necessary. Those unwilling to make these types of changes or those with associated injuries may benefit from ACL reconstruction.     

Chronic instability after posterior cruciate ligament injury. Tactics, techniques, and results

Summary This article reviews the surgical treatment of chronic posterior knee instability. The treatment rationale includes exact definition of the instability pattern (“envelope-of-motion” of the tibia) by clinical examination, arthrometry and stress radiography. Exact evaluation of the osseous anatomy is mandatory to identify an eventual varus morphotype. This osseous variant in combination with posterior/posterolateral instability should be treated by an osteotomy in every case. The technique of additive osteotomy to correct varus and increase the sagittal tilt of the proximal tibia is described. Ligament reconstruction in chronic posterior knee instability must address the posterior cruciate ligament and the lateral/posterolateral structures in many cases. Patellar tendon grafts, quadriceps tendon grafts or hamstrings can be used for posterior cruciate ligament replacement. Arthroscopic or mini-open techniques may be used for graft placement, direct posterior fixation of the graft via a posterior incision is an option for patellar tendon grafts. Bousquet's biceps plasty or Clancy's biceps tenodesis may be used for posterolateral stabilization; a biceps tendon strip can also be used for lateral collateral ligament reconstruction. Results of surgery are still moderate. In the author's series of chronic posterior/posterolateral instability, 26 cases were treated with posterior cruciate ligament reconstruction and biceps tenodesis. Follow-up at 18 months demonstrated increased stability (mean residual posterior drawer 8 mm at 70 ° and 20 lb force) and improved knee function (33 % IKDC B, 67 % IKDC C). Presently, surgical treatment of chronic posterior knee instability should be restricted to centers devoted to this problem.      

Verletzungen des vorderen Kreuzbandes bei Sportlern

Anterior cruciate ligament ruptures represent serious injuries for athletes which are often associated with accompanying injuries and lead to relevant kinematic alterations in the femorotibial roll-glide mechanism of the knee joint. Instability resulting in recurrent giving way events, as well as instability-related meniscal and cartilage lesions can cause functional long-term impairment that may limit the athlete’s career. Anterior cruciate ligament replacement is therefore considered to be the gold standard for recovery of physical performance and to prevent secondary meniscal and cartilage damage. Continuous changes in the reconstruction of the anterior cruciate ligament have led to a variety of different methods, including graft choice, fixation devices and surgical techniques, which support the consideration of individual requirements of the athlete as well as sport-specific aspects. One of the main factors for restoring stability and the physiological kinematic roll-glide mechanism of the knee is an anatomical tunnel placement as well as a stable graft fixation in the tibia and femur. By achieving of these fundamental technical requirements an early functional rehabilitation and accelerated recovery of neuromuscular skills, strength and coordination can be achieved, so that an early return to sport activities is possible.     

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

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.     

膝关节前交叉韧带损伤的MRI诊断研究进展

前交叉韧带(anterior cruciate ligament,ACL)损伤较常见,多见于运动性损伤并关系到膝关节的稳定性。临床稳定性检查、影像学检查及关节镜检查是目前临床上常用的诊断方法。近年来磁共振成像因其具有无创、多方位、多序列成像及良好的软组织分辨率和较高的空间分辨率,已成为临床上诊断ACL损伤常用的重要影像学检查手段,其检查结果是进行关节镜检查的重要依据,同时可指导ACL重建并评估其效果。     

Anterior cruciate ligament injury in professional dancers

Background?Anterior cruciate ligament injury (ACL) is a common sport injury; however, there are no data concerning dance and ACL injury. We report the incidence, injury mechanism, and clinical follow‐up of ACL injury in professional dancers.

Patients and methods?In a retrospective cohort study involving the three major dance companies in the Netherlands, by interviewing all 253 dancers who had had a full‐time contract during 1991–2002, dancers with symptomatic ACL injury or past ACL reconstruction were identified and examined.

Results?6 dancers (2 of whom were women) had had a symptomatic ACL rupture and reconstruction. Interestingly, all had been on the left side and had had a similar trauma mechanism: while dancing a classical variation they landed, after a jump, on their left leg, in the turned out position with a valgus force on their knee. There was a higher risk of ACL injury in the classical company than in the two contemporary companies. The risk of dancers having a rupture of the left ACL during a 10‐year career in this classical company was 7%.

Interpretation?ACL injuries are not an infrequently seen type of injury in professional classical dancers, with a very specific mechanism of injury—a landing on the left leg in exorotation. More attention and prophylactic measures should be given to this specific injury mechanism.     

Kindliche Kniebinnenverletzungen

Patella dislocations are the most common knee injuries causing hemarthrosis in children. Flake fractures represent the main complication of these injuries and require fixation. First time dislocations are treated conservatively. Recurrent dislocations are managed operatively. Precise analysis of the underlying dispositional and pathological factors is important to determine the appropriate operative procedure. To protect the growth plate, special techniques are required. Tibial spine fractures are bony avulsions of the anterior cruciate ligament (ACL). Management includes closed reduction in hyperextension and immobilization in a knee cast. Tibial spine fractures which cannot be reduced require operative treatment using either arthroscopic or open reduction and stabilization without injuring the growth plate. Intraligamentous ACL injuries are increasingly observed in children and adolescents. The risk of meniscus tears or chondral damage is high in these injuries. In case of persistent ACL instability, early reconstruction is recommended. Various techniques have been described; however, there is no consensus regarding the most favorable technique. The attending physician must be familiar with different ACL reconstruction techniques and with the anatomy of the growth plate. Meniscus tears require early suturing. Healing rates are good in children.     

分期修复重建膝关节多发韧带损伤的临床疗效

目的 :探讨关节镜下分期治疗膝关节多发韧带损伤的临床疗效。方法 :2006年3月至2012年6月,关节镜下分期治疗膝关节多发韧带损伤14例(14膝)。男8例,女6例;年龄20~49岁,平均(31.8±8.1)岁。患者均行X线、MR检查,提示10例前交叉韧带、后交叉韧带及内侧副韧带损伤,4例前交叉韧带、后交叉韧带及后外侧角损伤。合并内侧半月板损伤4例,外侧半月板损伤2例。Ⅰ期手术治疗内侧副韧带损伤、后交叉韧带及半月板,术后固定3周后开始主被动功能锻炼,3~6个月后膝关节活动范围正常且存在明显松弛时Ⅱ期重建前交叉韧带和(或)后交叉韧带。结果:术后切口均Ⅰ期愈合,无感染等手术相关并发症发生。患者均获随访,时间24~80个月,平均48.9个月。末次随访时膝关节Lysholm评分达87.1±2.8,优于术前19.6±0.9(t=12.3,P0.01)。国际膝关节评分委员会(International Knee Documentation Committee,IKDC)评级:9例接近正常,5例异常。结论 :关节镜下分期治疗膝关节多发韧带损伤能有效恢复膝关节稳定性和功能。     

Chronic instability after posterior cruciate ligament injury. Tactics, techniques, and results Taktik, Technik und Ergebnisse

This article reviews the surgical treatment of chronic posterior knee instability. The treatment rationale includes exact definition of the instability pattern (“envelope-of-motion” of the tibia) by clinical examination, arthrometry and stress radiography. Exact evaluation of the osseous anatomy is mandatory to identify an eventual varus morphotype. This osseous variant in combination with posterior/posterolateral instability should be treated by an osteotomy in every case. The technique of additive osteotomy to correct varus and increase the sagittal tilt of the proximal tibia is described. Ligament reconstruction in chronic posterior knee instability must address the posterior cruciate ligament and the lateral/posterolateral structures in many cases. Patellar tendon grafts, quadriceps tendon grafts or hamstrings can be used for posterior cruciate ligament replacement. Arthroscopic or mini-open techniques may be used for graft placement, direct posterior fixation of the graft via a posterior incision is an option for patellar tendon grafts. Bousquet's biceps plasty or Clancy's biceps tenodesis may be used for posterolateral stabilization; a biceps tendon strip can also be used for lateral collateral ligament reconstruction. Results of surgery are still moderate. In the author's series of chronic posterior/posterolateral instability, 26 cases were treated with posterior cruciate ligament reconstruction and biceps tenodesis. Follow-up at 18 months demonstrated increased stability (mean residual posterior drawer 8 mm at 70 ° and 20 lb force) and improved knee function (33 % IKDC B, 67 % IKDC C). Presently, surgical treatment of chronic posterior knee instability should be restricted to centers devoted to this problem.     

Isolated lateral extra-articular tenodesis enhance better rotatory knee joint stability post-primary ACL repair: Four cases report and literature review

Introduction and importanceResidual rotatory instability has been reported to occur after primary anterior cruciate ligament reconstruction. The anterolateral ligament complex of the knee has gained attention for its role in rotational instability of the knee, especially in association with anterior cruciate ligament injuries. The role of an isolated lateral extra-articular tenodesis procedure among those patients presenting with residual rotatory instability after primary anterior cruciate ligament reconstruction has not been reported on.Case presentationFour patients (Tegner level 4) presenting with residual rotatory instability after primary anterior cruciate ligament reconstruction without signs of graft failure, underwent an isolated lateral extra-articular tenodesis with modified Lemaire procedure. Pre- and postoperative outcome scores were assessed. At one-year follow-up, all patients reported functional knee stability. Pivot shift tests were negative and postoperative Lysholm scores were increased with a mean of 19.75 points. Tegner scores equaled the preinjury level.Clinical discussionThis case report showed that our four patients where successfully treated with an isolated secondary modified Lemaire procedure for residual anterolateral rotatory instability after primary anterior cruciate ligament reconstruction.ConclusionAn isolated secondary lateral extra-articular tenodesis procedure can be a valuable treatment option for moderate active patients with residual rotatory instability after a primary anterior cruciate ligament reconstruction without signs of graft failure.