A review of Marcel Lemaire's original work on lateral extra-articular tenodesis.

This classic discusses Marcel Lemaire's original publications in the context of modern surgical practice, including a description of his original lateral extra-articular tenodesis. Previously published in French, these translations shed light on his revelations regarding the anterior cruciate ligament's role in knee stability and his detailed insights into the ressaut rotatoire or the pivot shift phenomenon. We track the evolution of Lemaire's procedure since the publication of his original technique in 1967 which used a nylon cord superficial to the lateral collateral ligament followed by cast immobilisation for one month. We report his patient outcomes as he refines his methods through experiential learning. Lemaire's fundamental concepts in relation to anterior cruciate ligament deficiency remain relevant in contemporary clinical practice. Furthermore, the "modified Lemaire technique" has emerged as one of the preferred methods for lateral extra-articular tenodesis. We hope that disseminating his thoughts to a wider audience will help enlighten the ongoing debate regarding the management of rotatory instability. LEVEL OF EVIDENCE: V - Expert Opinion.

The Resolution of Kaplan Fiber Injuries Is Observed in a Majority of Cases at 9 Months After Acute Primary Anterior Cruciate Ligament Reconstruction: A Radiological Study.

BACKGROUND: The natural history of Kaplan fiber (KF) injuries after acute primary anterior cruciate ligament (ACL) reconstruction (ACLR) remains unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the temporal change in the magnetic resonance imaging (MRI) appearance of the KF complex after acute primary ACLR. It was hypothesized that KF injuries would resolve with time. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective MRI analysis was conducted on 89 patients with ACL-injured knees to assess the change in the radiological appearance of KFs after primary ACLR. Patients who had undergone index MRI and ACLR within 90 days of the injury and further MRI at 9 months after surgery were included. Diagnostic criteria to identify radiological evidence of a KF injury and its subsequent resolution were applied, including the presence of high signal intensity on fluid-sensitive sequences, which is indicative of a pathological process radiologically. The proximity of KFs to the femoral cortical suspensory device (CSD) was noted on MRI scans and quantified in millimeters. RESULTS: A KF injury was identified in 30.3% (27/89) of patients, with isolated high signal intensity observed in an additional 18.0% (16/89). At 9 months, MRI evidence of the reconstitution of the KF complex was found in 51.9% (14/27) of patients, with persistent discontinuity in the remaining patients (13/27). All patients (16/16) with isolated high signal intensity had complete resolution on repeat MRI scans. KF thickening was observed in 26.1% (12/46) of patients with previously healthy KFs and in 25.0% (4/16) with isolated high signal intensity. The CSD was positioned in close proximity (≤6 mm) to the center of the KF attachment in 61.8% (55/89) of patients, and this was associated with increased rates of KF thickening. CONCLUSION: The KF injury resolved radiologically in over half of the patients at 9 months after acute primary ACLR. High signal intensity in the region of the KFs on index MRI scans resolved in all cases, with evidence of residual KF thickening in only one-quarter of cases on repeat MRI scans, equivalent to the rate in those with healthy KFs. As such, it is not advisable to use high signal intensity on preoperative MRI scans as the sole criterion for the diagnosis of a KF injury. The position of the CSD after ACLR was intimately related to the KF attachment in the majority of patients, which was associated with KF thickening on postoperative MRI scans.

Impact of Occupation on 12-Month Outcomes After Anterior Cruciate Ligament Reconstruction in Male Patients.

Background: The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown. Purpose/Hypothesis: The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity. Study Design: Cohort study; Level of evidence, 3. Methods: From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test. Results: Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [P = .021]; mean passive, 2.76° vs 5.00°, respectively [P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months. Conclusion: At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.

Combined anterolateral complex and anterior cruciate ligament injury: Anatomy, biomechanics, and management-State-of-the-art.

Anterior cruciate ligament (ACL) rupture typically occurs because of sudden axial loading of the knee in conjunction with a coupled valgus and rotational moment about the tibia. However, the ACL is not the only structure damaged during this mechanism of injury, and studies have shown that the anterolateral complex (ALC) of the knee is also commonly involved. Biomechanical studies have established that the ALC plays an important role as a secondary stabiliser to control anterolateral rotatory laxity (ALRL). Indeed, it has been suggested that failure to address injury to the ALC at the time of ACL reconstruction (ACLR) may increase the risk of graft failure owing to persistent ALRL. The concept of combining a lateral extra-articular procedure to augment ACLR for the treatment of ACL injury emerged with a view to decrease the failure rate of either procedure in isolation. This state-of-the-art review discusses the history of the anatomy of the ALC, the biomechanics of a variety of lateral extra-articular augmentation procedures, and provides clinical guidelines for their use in primary ACLR.

Editorial Commentary: Patients With Thin Hip Capsules, Capsular Redundancy, Capsular Defects, Hypermobility, Dysplasia, and Female Patients Are at Increased Risk of Hip Instability.

Patients with thin hip capsules, capsular redundancy, capsular defects, hypermobility, dysplasia, and female patients are at increased risk of hip instability. As our understanding of the factors that contribute to hip instability has increased, so too has our ability to identify "at-risk" patients, in whom we should avoid surgery or perform capsular repair or plication following hip arthroscopy to achieve optimal results. We must tailor our surgical planning accord to gender, bony morphology, capsular volume, and properties of the tissue.

Effect of Radiological Evidence of Kaplan Fiber Injury on the Clinical and Functional Outcomes After Acute Anterior Cruciate Ligament Reconstruction.

BACKGROUND: A paucity of information is available regarding the clinical outcomes of patients with radiological evidence of Kaplan fiber (KF) injury who undergo anterior cruciate ligament (ACL) reconstruction (ACLR). PURPOSE/HYPOTHESIS: The purpose was to compare clinical and functional outcomes in patients undergoing acute primary ACLR with and without magnetic resonance imaging (MRI) evidence of KF injury. The hypothesis was that there would be no difference in clinical or functional outcomes in patients with versus those without radiological evidence of KF injury. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: MRI analysis was conducted on patients in a longitudinal prospective study of ACL injury. Only patients who had an MRI scan and had undergone isolated primary ACLR within 60 days of injury were included. MRI was performed using standard knee protocols, and diagnostic criteria were applied to identify KF injury. A total of 32 patients with KF injury (mean age, 24.2 years; 21 male, 11 female) were identified and matched for sex, age, graft type, and preinjury activity with 90 patients who had intact KF. Patients were followed up at 12 months with KT-1000 arthrometer measurements of side-to-side difference in anterior knee laxity, single- and triple-hop limb symmetry index (LSI), Marx activity and International Knee Documentation Committee (IKDC) scores, and return to sport (RTS) rates at 12 months and 24 months. RESULTS: No differences were found in anterior knee laxity and single- and triple-hop LSI values between the KF-intact and KF-injured cohorts at 12 months. No differences in Marx and IKDC scores were found between the groups at 12 months and 2 years. The overall rate of RTS within 24 months was 75% (92/122), and 5 patients (2 KF-injured; 3 KF-intact) had a subsequent graft rupture. CONCLUSION: We found no difference in clinical or functional outcomes in patients with and without radiological evidence of KF injury who underwent acute primary ACLR. Based on these findings, the radiological presence of KF injury at the time of acute ACL injury should not be regarded as a risk factor for a negative prognosis after ACLR.

Management and outcomes of proximal tibiofibular joint ganglion cysts: A systematic review.

BACKGROUND: Proximal tibiofibular joint (PTFJ) ganglion cysts are rare; however, their optimal management remains unclear. This study aimed to systematically review the surgical treatment options with a focus on recurrence rates and complications. METHODS: A systematic review of the literature was performed, searching three electronic databases, according to the PRISMA guidelines. The presentation, treatment, and outcomes of PTFJ ganglion cysts of minimum 1-year follow-up was collected. Study quality was assessed using the Modified Downs and Blacks checklist. Surgical interventions were considered ordinally from simple to more extensive as follows; cyst aspiration, cyst excision, cyst excision with an intervention to the PTFJ, either a hemi-resection or arthrodesis. RESULTS: Twenty-two studies comprising 100 patients (101 knees) met inclusion criteria. Among all patients, pain was present in 59.7%, a lateral fullness in 71.6% and symptoms of the common peroneal nerve in 57.4%. The overall rate of recurrence after primary treatment was 28.9%. Recurrence rates for aspiration, cyst excision, PTFJ hemi-resection and PTFJ arthrodesis were 81.8%, 27.4%, 8.3% and 0%, respectively. Revision excision for recurrence failed in all cases. Outcomes beyond recurrence were poorly reported. CONCLUSION: Addressing the PTFJ at the time of cyst excision reduces recurrence rates, however, the morbidity from PTFJ hemi-resection and arthrodesis are poorly reported. Whilst primary excision offers resolution in most cases (73%), revision cyst excision in isolation for the treatment of recurrent cysts is an inadequate treatment option. Cyst aspiration is ineffective. Data pertaining to patient reported outcomes for all treatment types are lacking.

Is There an Association in Young Patients Between Quadriceps or Hamstring Strength After ACL Reconstruction and Graft Rupture?

Background: Younger patients who sustain anterior cruciate ligament (ACL) ruptures are at high risk for reinjury after ACL reconstruction. Restoring muscle strength before return to sports (RTS) is regarded as an important factor in reducing the reinjury risk, and quadriceps and hamstring strength assessment is commonly included in RTS testing. However, it is not clear whether reduced strength is a risk factor for subsequent graft rupture in this patient population. Purpose: To investigate the association between quadriceps and hamstring strength at 12 months after primary ACL reconstruction and ACL graft rupture in young patients. Study Design: Case-control study; Level of evidence, 3. Methods: The cohort consisted of 210 patients (100 men and 110 women) who were younger than 20 years at the time of primary ACL reconstruction with a hamstring tendon autograft and who had no previous contralateral ACL injury. Isokinetic strength testing (60 and 180 deg/s) of knee flexors and extensors was performed at 12 months postoperatively, and the limb symmetry index (LSI) for each strength outcome was calculated. RTS rates and the incidence of further ACL graft ruptures were recorded. Results: Measures of central tendency (mean and median) of LSI values ranged from 88 to 98. The percentage of patients with LSI ≥90 was 57% to 69% for quadriceps strength and 45% to 47% for hamstring strength. Overall, 19 patients (9%) sustained an ACL graft rupture. No significant differences were found between the patients who sustained an ACL graft rupture and those who did not in terms of quadriceps and hamstring strength at 12 months. No significant associations were found between achieving LSI ≥90 for quadriceps peak torque and subsequent ACL graft rupture. Conclusion: In young patients who underwent an ACL reconstruction, no association was noted between quadriceps and hamstring strength at 12 months postoperatively and subsequent graft ruptures. The role of strength testing as part of the RTS criteria after ACL reconstruction, and specifically the use of limb symmetry thresholds, warrants further investigation and clarification.

The Modified Ellison Technique: A Distally Fixed Iliotibial Band Transfer for Lateral Extra-articular Augmentation of the Knee.

Lateral extra-articular augmentation (LEA) of anterior cruciate ligament reconstructions significantly reduces graft failure rates. Currently, proximally fixed LEA procedures are popular techniques. However, there are concerns about these techniques regarding anterior cruciate ligament tunnel collision, kinematic overconstraint, and increasing lateral-compartment contact forces. These issues are potentially avoided by the modified Ellison procedure, which is a distally fixed LEA technique. This article describes the surgical details of this easily reproducible technique.

Effect of COVID-19 Social Isolation Policies on Rehabilitation After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The coronavirus 2019 (COVID-19) pandemic has had a profound impact on health care in Australia. To contain the spread of the virus, strict physical distancing and social isolation policies were implemented from late March 2020. This presented a situation in which patients recovering from anterior cruciate ligament (ACL) reconstruction had limited access to face-to-face supervised rehabilitation and rehabilitation facilities. PURPOSE: To explore the impact of social distancing and isolation policies on postoperative rehabilitation in patients after ACL reconstruction. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients who had ACL reconstruction from October 2019 until the end of March 2020 (6 months before the implementation of COVID-19 restrictions) completed an online self-report questionnaire containing 5 sections: utilization of health care professionals for rehabilitation, frequency of rehabilitation, patient concerns and attitude, perceived impact on recovery, and changes to employment status. We compared the responses of patients who had surgery in 2019 with those who had surgery in 2020. Statistical analysis was performed using frequency statistics and central tendency measures. RESULTS: A total of 185 patients (97 men, 88 women) completed the survey, for a 73% response rate. Patients had a mean age of 28 years (range, 13-57 years) and had undergone surgery a mean 4.5 months prior (range, 1.5-8 months). Most patients (80%) maintained face-to-face rehabilitation, predominantly with a physical therapist, regardless of whether their surgery took place in 2019 or 2020; rehabilitation with active, supervised exercises was most common. Almost all patients were performing strengthening exercises (164/185), and most were performing range-of-motion (139/185) and aerobic (123/185) activities at their homes. Patients were minimally concerned about access to supervised rehabilitation and knee reinjury, but they were concerned about access to equipment. Because of COVID-19, 30% were working from home; 17% were on reduced hours and 8% on increased hours; 15% were on leave or unemployed; and 30% reported no change in employment status. CONCLUSION: Patients who had undergone ACL reconstruction just before or during the first few months of the COVID-19 pandemic were able to maintain in-person contact with their health professionals during rehabilitation, and they had a positive outlook and managed well despite the restrictions.

Effect of Time on MRI Appearance of Graft After ACL Reconstruction: A Comparison of Autologous Hamstring and Quadriceps Tendon Grafts.

BACKGROUND: After anterior cruciate ligament (ACL) reconstruction (ACLR), changes in the appearance of the ACL graft can be monitored using magnetic resonance imaging (MRI). PURPOSE: The purpose of this study was to evaluate and compare the MRI signal intensity (SI) of hamstring and quadriceps tendon grafts during the first postoperative year after ACLR. As a secondary aim, the relationship of SI to clinical and anatomic measurements was analyzed. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 78 patients who underwent ACLR with an autologous graft were reviewed; 55 received hamstring grafts and 23 received quadriceps tendon grafts. At 3 and 9 months postoperatively, 3-T MRI was performed using a dedicated knee coil, and the median SI of the intra-articular ACL graft was measured on sagittal-plane images. Postoperative lateral radiographs were analyzed to determine medial and lateral posterior tibial slope (PTS). Side-to-side difference in anterior knee laxity between injured and uninjured limbs was measured at 6 and 12 months postoperatively. RESULTS: The median SI of quadriceps grafts was significantly greater than hamstring grafts at 3 months after ACLR (P = .02). Between 3 and 9 months, the median SI of quadriceps grafts decreased (P < .001), while that of hamstring grafts did not significantly change (P = .55). The lateral PTS was significantly correlated with median SI measurements at 3 and 9 months such that greater lateral PTS values were associated with greater median SI. The side-to-side difference in anterior knee laxity decreased for the quadriceps group (P = .04) between 6 and 12 months but did not change for the hamstring group (P = .88). CONCLUSION: The median SI of quadriceps grafts significantly decreased on MRI between 3 and 9 months after ACLR, while the median SI of hamstring grafts did not significantly change. The change in MRI appearance of the quadriceps grafts was paralleled by a reduction in anterior knee laxity between 6 and 12 months after surgery. In the absence of standardized imaging techniques and imaging analysis methods, the role of MRI in determining graft maturation, and the implications for progression through rehabilitation to return to sport, remain uncertain.

Augmentation of Primary ACL Reconstruction With a Modified Ellison Lateral Extra-articular Tenodesis in High-Risk Patients: A Pilot Study.

BACKGROUND: Lateral extra-articular tenodesis (LET) has been used to augment primary anterior cruciate ligament (ACL) reconstruction to reduce the risk of reinjury. Most LET procedures result in a construct that is fixed to both the femur and the tibia. In a modified Ellison procedure, the construct is only fixed distally, reducing the risk of inadvertently overconstraining the lateral compartment. PURPOSE: To evaluate the use of the modified Ellison procedure in a cohort of patients deemed to be at a high risk of further ACL injury after primary ACL reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included were 25 consecutive patients with at least 2 of the following risk factors: age <20 years at the time of surgery, previous contralateral ACL reconstruction, positive family history of ACL rupture (parent or sibling), generalized ligamentous laxity (Beighton ≥4), grade 3 pivot shift in the consulting room, a desire to return to a pivoting sport, and an elite or professional status. All patients underwent primary ACL reconstruction with an additional modified Ellison procedure. Postoperatively, patients completed the IKDC subjective knee evaluation form (International Knee Documentation Committee), KOOS Quality of Life subscale (Knee injury and Osteoarthritis Outcome Score), ACL-Return to Sport After Injury Scale, Marx Activity Rating Scale, and SANE score (Single Assessment Numeric Evaluation). RESULTS: At 12-month follow-up, the mean outcome scores were as follows: SANE, 94/100; IKDC, 92/100; Marx, 13/16; ACL-Return to Sport, 85/100; and KOOS, 77/100. At 24 months, return-to-sport data were available for 23 of 25 patients; 17 (74%) were playing at the same level or higher than preinjury and 2 at a lower level. One patient (4%) sustained a contact mechanism graft rupture at 12 months. There were 2 (9%) contralateral ACL injuries, including 1 ACL graft rupture, at 11 and 22 months postoperatively. There was a further contralateral ACL graft rupture at 26 months. CONCLUSION: The use of the modified Ellison procedure as a LET augmentation of a primary ACL reconstruction to produce a low graft rupture rate appeared to be safe in a cohort considered to be at a high risk of reinjury. The procedure showed promise in terms of reducing further graft injuries.

Risk assessment and management of primary patellar dislocation is complex and multifactorial: a survey of Australian knee surgeons.

OBJECTIVES: Recurrent patellar instability following first-time lateral patellar dislocation is associated with a variety of bony, soft tissue and patient-related risk factors. The specific management of recurrent dislocation may vary depending on the presence and combination of these factors as well as the treating physician's interpretation of these. Therefore, this study aimed to determine which factors Australian knee surgeons regard as increasing the risk of recurrence following first-time patellar dislocation and to characterise the surgical decision-making process of these surgeons in the management of lateral patellar instability. METHODS: An online survey was sent to all active members of the Australian Knee Society (AKS). The survey addressed (i) risk factors for recurrence following first-time patellar dislocation and (ii) the surgical decision-making process in treating patellar instability. RESULTS: Seventy-seven per cent (53 of 69) Australian Knee Society members responded. Factors identified by respondents as significantly increasing the risk of recurrence were a history of contralateral recurrent patellar dislocation (74% respondents), an atraumatic injury mechanism (57%), trochlear dysplasia (49%) younger age (45%), patella alta (43%) and generalised ligamentous laxity (42%). Forty-four per cent replied that there may be an indication for surgical intervention following first-time patellar dislocation with no apparent loose body present. All respondents would recommend operative management of recurrent patellar dislocation after a third episode, with 45% of surgeons recommending surgery after a second episode. The most common surgical procedures performed by respondents were medial patellofemoral ligament (MPFL) reconstruction (94%), tibial tuberosity medialisation (91%) and tibial tuberosity distalisation (85%). Only 23% of respondents consider trochleoplasty for primary surgical intervention. CONCLUSION: Surgeons identified a large number of factors that they use to assess risk of recurrence following first-time patellar dislocation, many of which are not supported by the literature. The two highest ranked factors (history of contralateral recurrent patellar dislocation and an atraumatic injury mechanism) are without a significant evidence base. There was considerable variation in the criteria used to make the decision to perform a patellar stabilisation procedure. MPFL reconstruction was the most commonly used procedure, either in isolation or combined with another procedure. LEVEL OF EVIDENCE: Cross-sectional study; expert opinion (Level V).

Preservation of the Tibial Stump During Anterior Cruciate Ligament Reconstruction Surgery Did Not Increase the Rate of Surgery for Symptomatic Cyclops Lesions.

BACKGROUND: Preservation of the tibial stump during anterior cruciate ligament reconstruction (ACLR) is controversial. While proposed benefits include enhanced graft revascularization, improved proprioception, and decreased graft rupture rates, a potential complication is the development of a symptomatic cyclops lesion. It is therefore important to determine whether any benefits outweigh potential complications. PURPOSE: To determine whether greater preservation of the tibial stump remnant would be associated with a decreased graft rupture rate without a concomitant increase in the rate of surgery for symptomatic cyclops lesions at 2 years after ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A cohort of 658 patients in whom the amount of tibial stump preserved was classified as no stump (n = 228), <50% (n = 342), or >50% (n = 88) was followed up for 2 years, with graft ruptures and surgical treatment for cyclops lesions recorded. Contingency and Kaplan-Meier survival analyses were used to determine trends among the 3 remnant preservation groups in terms of graft rupture rates and surgery for cyclops lesions. Subgroup analysis was also conducted to examine sex-based differences. RESULTS: There was no significant association between graft rupture rates and remnant preservation. There was a significant trend for fewer operations for symptomatic cyclops lesions with greater remnant preservation when the entire cohort was analyzed (P = .04) and also when only female patients were analyzed (P = .04). CONCLUSION: Although preservation of the tibial stump remnant was not associated with a reduced graft rupture rate, it was also not associated with increased rates of surgery for symptomatic cyclops lesions.

Lateral tenodesis procedures increase lateral compartment pressures more than anterolateral ligament reconstruction, when performed in combination with ACL reconstruction: a pilot biomechanical study.

OBJECTIVES: Given the common occurrence of residual laxity and re-injury post anterior cruciate ligament reconstruction (ACLR), additional anterolateral procedures are increasingly used in combination with an ACLR. Despite the perception that there is a risk of over-constraining the lateral tibiofemoral (LTF) compartment, potentially leading to osteoarthritis, assessment on their effect on intra-articular compartment pressures is still lacking. Our objective was therefore, through a pilot biomechanical study, to compare LTF contact pressures after the most commonly used anterolateral procedures. METHODS: A controlled laboratory pilot study was performed using 4 fresh-frozen cadaveric whole lower limbs. Through 0° to 90° of flexion, LTF contact pressures were measured with a Tekscan sensor, located under the lateral meniscus. Knee kinematics were obtained in 3 conditions of rotation (NR: neutral, ER: external and IR: internal rotation) to record the position of the knees for each loading condition. A Motion Analysis system with a coordinate system based on CT scans 3D bone modelling was used. After an ACLR, defined as the reference baseline, 5 anterolateral procedures were compared: anterolateral ligament reconstruction (ALLR), modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh procedures. The last 3 procedures were randomised. For each procedure, the graft was fixed in NR at 30° of flexion and with a tension of 20 N. RESULTS: Compared with isolated ACLR, addition of either ALLR or modified Ellison procedure did not increased the overall LTF contact pressure (all p>0.05) through the full range of flexion for the IR condition. Conversely, deep Lemaire, superficial Lemaire and modified MacIntosh procedure (all p<0.05) did increase the overall LTF contact pressure compared with ACLR in IR. No significant difference was observed in ER and NR conditions. CONCLUSION: This pilot study, comparing the main anterolateral procedures, revealed that addition of either ALLR or modified Ellison procedure did not change the overall contact pressure in the LTF compartment through 0° to 90° of knee flexion. In contrast, the deep and superficial Lemaire, and modified MacIntosh procedures significantly increased overall LTF contact pressures when the knee was internally rotated.

Different anterolateral procedures have variable impact on knee kinematics and stability when performed in combination with anterior cruciate ligament reconstruction.

OBJECTIVE: The optimal anterolateral procedure to control anterolateral rotational laxity of the knee is still unknown. The objective was to compare the ability of five anterolateral procedures performed in combination with anterior cruciate ligament reconstruction (ACLR) to restore native knee kinematics in the setting of a deficient anterior cruciate ligament (ACL) and anterolateral structures. METHODS: A controlled laboratory study was performed using 10 fresh-frozen cadaveric whole lower limbs with intact iliotibial band. Kinematics from 0° to 90° of flexion were recorded using a motion analysis three-dimensional (3D) optoelectronic system, allowing assessment of internal rotation (IR) and anteroposterior (AP) tibial translation at 30° and 90° of flexion. Joint centres and bony landmarks were calculated from 3D bone models obtained from CT scans. Intact knee kinematics were assessed initially, followed by sequential section of the ACL and anterolateral structures (anterolateral ligament, anterolateral capsule and Kaplan fibres). After ACLR, five anterolateral procedures were performed consecutively on the same knee: ALLR, modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh. The last three procedures were randomised. For each procedure, the graft was fixed in neutral rotation at 30° of flexion and with a tension of 20 N. RESULTS: Isolated ACLR did not restore normal overall knee kinematics in a combined ACL plus anterolateral-deficient knee, leaving a residual tibial rotational laxity (p=0.034). Only the ALLR (p=0.661) and modified Ellison procedure (p=0.641) restored overall IR kinematics to the normal intact state. Superficial and deep Lemaire and modified MacIntosh tenodeses overconstrained IR, leading to shifted and different kinematics compared with the intact condition (p=0.004, p=0.001 and p=0.045, respectively). Compared with ACLR state, addition of an anterolateral procedure did not induce any additional control on AP translation at 30° and 90° of flexion (all p>0.05), except for the superficial Lemaire procedure at 90° (p=0.032). CONCLUSION: In biomechanical in vitro setting, a comparison of five anterolateral procedures revealed that addition of either ALLR or modified Ellison procedure restored overall native knee kinematics in a combined ACL plus anterolateral-deficient knee. Superficial and deep Lemaire and modified MacIntosh tenodeses achieved excellent rotational control but overconstrained IR, leading to a change from intact knee kinematics. LEVEL OF EVIDENCE: The level-of-evidence statement does not apply for this laboratory experiments study.

Association Between Radiological Evidence of Kaplan Fiber Injury, Intraoperative Findings, and Pivot-Shift Grade in the Setting of Acute Anterior Cruciate Ligament Injury.

BACKGROUND: Biomechanical studies have suggested that the Kaplan fibers (KFs) of the iliotibial band play a role in controlling anterolateral rotation of the knee. There is a paucity of clinical information on whether injury to the KF in the setting of anterior cruciate ligament (ACL) rupture contributes to increased rotatory laxity of the knee. PURPOSE/HYPOTHESIS: The purpose was to evaluate the association among radiological evidence of KF injury, intraoperative arthroscopic findings, and grade of pivot shift at the time of ACL reconstruction (ACLR). It was hypothesized that KF injury would be associated with increased injury to the lateral compartment of the knee and a higher grade of pivot shift. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective magnetic resonance imaging (MRI) analysis was conducted on 267 patients with ACL-injured knees who underwent primary ACLR. Patients who had MRI and surgery within 60 days of injury were included (mean age, 23.6 years); there were 158 (59.2%) male patients. MRI was performed using standard knee protocols, and diagnostic criteria were applied to identify KF injury. Associations were made among MRI findings, intraoperative findings, and grade of pivot shift with the patient examined under anesthesia at the time of ACLR. A comparison was made between patients with and without radiological evidence of KF injury. RESULTS: The prevalence of KF injury was 17.6% (47/267 patients). Arthroscopic evidence of lateral meniscal injury was associated with KF injury (KF intact, 31%; KF injured, 55%; P = .010). The majority of patients in the intact and injured KF groups had a grade 2 pivot shift (75% and 70%, respectively). A minority had grade 3 pivot shift: 5% in the intact group versus 6.4% in the injured group. There was no association between radiological evidence of KF injury and pivot-shift grade (P = .600). CONCLUSION: In acute ACL injury, KF injuries were not very common (17.6%), and the rate of grade 3 pivot shift was low (5.2%). When present, KF injuries were not associated with a higher-grade pivot shift. However, there was an association between KF injury and lateral meniscal tears identified at the time of ACLR. The role of KFS in controlling anterolateral rotatory laxity in the acute ACL injury in the clinical setting may be less evident when compared with the biomechanical setting.

Is the KiRA Device Useful in Quantifying the Pivot Shift in Anterior Cruciate Ligament-Deficient Knees?

BACKGROUND: Various technologies have been developed to quantify the pivot shift, as it is regarded as a key indicator of anterolateral rotatory laxity of the knee. PURPOSE: To determine the usefulness of a commercially available triaxial accelerometer (Kinematic Rapid Assessment [KiRA]) in numerically quantifying the pivot shift in patients under anesthesia with an anterior cruciate ligament (ACL)-deficient knee. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Both knees of 50 patients (26 male [mean age, 30.4 years], 24 female [mean age, 26.6 years]) under anesthesia were assessed immediately before unilateral ACL reconstruction by an orthopaedic fellow and 1 of 3 experienced knee surgeons. The pivot-shift grade and 2 KiRA outputs (range of acceleration and slope of acceleration change) were compared. RESULTS: The surgeon and fellow recorded the same pivot-shift grade for 45 of 50 patients (90%). Data from the 5 patients with no agreement and 1 patient with extreme outlying data were excluded from subsequent analysis. Using the KiRA range and slope data, the surgeon identified the injured knee in 74% and 76% of patients, respectively, while the fellow's rate of injured knee identification was 74% and 80%, respectively. A correlation could be found only between pivot-shift grade and surgeon-derived range data (ρ = 0.40; P < .01) but not slope data or any fellow-derived outputs. Using the surgeon-derived range data, there was a significant difference between a grade 3 pivot (>5 m/s2) and a grade 1 or 2 pivot (<5 m/s2) (P = .01). CONCLUSION: Although a correlation between KiRA output data and pivot-shift grade was found when the device was used by an experienced surgeon, there was no correlation when used by a well-trained but less experienced orthopaedic fellow. Furthermore, the KiRA output data identified the ACL-deficient knee correctly in only 74% of patients. Although a threshold acceleration range value could be identified, above which the value was associated with a grade 3 pivot shift, this was dependent on the examiner, and distinction between other grades could not be made.

Long-term results after thoracoscopic anterior spondylodesis with or without posterior stabilization of unstable incomplete burst fractures of the thoracolumbar junction: a prospective cohort study.

BACKGROUND: Minimally invasive, thoracoscopic anterior spondylodesis (MIAS) is an established treatment for burst fractures of the thoracolumbar spine. Good restoration of the local sagittal alignment and good functional results have been reported. The aim of this study was to evaluate long-term results of MIAS in patients with incomplete burst fractures and to analyze the influence on global sagittal alignment, clinical outcomes, and adjacent segment degeneration. METHODS: From 2002 to 2003, 18 patients were treated with MIAS for incomplete thoracolumbar burst fractures. Mono-segmental spondylodesis was performed with an iliac crest bone graft and bisegmental spondylodesis with a titanium cage. In this single-center prospective cohort study, 15 patients were available for follow-up (FU) after an average of 12.9 years (12.1-14.4). Seven patients were treated with a combined anterior and posterior instrumentation and eight patients with anterior spondylodesis only. The primary clinical outcome parameter was the Oswestry Disability Index (ODI); secondary parameters were the Short Form 36 (SF36) and the visual analog scale (VAS spine). Full spine radiographs were assessed for bisegmental Cobb angle, alignment parameters, and signs of adjacent segment degeneration (ASD). RESULTS: ODI evaluation showed a mean impairment of 11.7% with minimal limitations in 13 patients. Neither a significant deterioration over time nor significant differences between both therapy strategies were found in the clinical scores at the latest follow-up. The mean bisegmental increase of regional malalignment of reduction was 8.8° (± 7.3°) with no significant correlation to any clinical outcome scores. The majority of patients had no signs of adjacent segment degeneration. Two patients showed minor radiologic changes. All patients had a balanced sagittal spine profile. CONCLUSIONS: In conclusion, MIAS leads to good clinical results with-in majority-minimal spine-related impairment at the latest follow-up. No significant deterioration at 12-year FU was detectable compared to the 6-year results for the SF36 and VAS spine scores. There was no association between sagittal alignment, clinical outcome scores, and ASD. TRIAL REGISTRATION: The study was retrospectively registered in the German Clinical Trials Register ( Nr.00015656 ).