Evaluation of the anterolateral ligament of the knee in magnetic resonance mri: case series / Avaliação do ligamento anterolateral do joelho em exames de ressonância magnética: série de casos

ABSTRACT Objective: To evaluate the citation of the ligament in the magnetic resonance imaging (MRI) reports and confirm its presence and injury in the images of exams performed in the acute phase retrospectively. Methods: In total, 103 patients who underwent anterior cruciate ligament (ACL) reconstruction in 2019 were included. The images were reanalyzed by two radiologists. Results: In the first analysis, only one report mentioned the anterolateral ligament (ALL) and its injury (0.97%). On reanalysis, ALL was visualized in almost all cases (95% and 97%). An injury was found in 53 (51.5%) cases by radiologist A and in 56 (54.4%) cases by radiologist B. The injury was diagnosed by both in 39 (37.9%) cases (p < 0.0001). Radiologists disagreed regarding the injury (Kappa = 0.411). Conclusion: The reports failed to describe the ligament and diagnose a significant number of injuries. The analysis of conventional resonance images still presents divergences in the diagnosis of ALL injury associated with the ACL among radiologists. Level of Evidence IV, Case Series.

RESUMO Objetivo: Avaliar, de forma retrospectiva, a citação do ligamento anterolateral (LAL) em laudos de ressonância magnética (RM) e confirmar sua presença e lesão nas imagens de exames feitos na fase aguda. Métodos: Foram incluídos 103 pacientes submetidos à reconstrução do ligamento cruzado anterior (LCA) em 2019, cujas imagens foram reanalisadas por dois radiologistas. Resultados: Em primeira análise, apenas um laudo citava o LAL e sua lesão (0,97%); enquanto na reanálise, o LAL foi visualizado em quase todos os casos (95% pelo radiologista A e 97% pelo radiologista B). Foi encontrada lesão em 53 (51,5%) casos pelo radiologista A e 56 (54,4%) pelo radiologista B. Lesão foi diagnosticada por ambos em 39 (37,9%) casos (p < 0,0001). Houve divergência entre os radiologistas com relação à lesão (KappaL = 0,411). Conclusão: Os laudos deixaram de descrever o ligamento e diagnosticar um número significativo de lesões. A análise das imagens convencionais de ressonância ainda gera divergências no diagnóstico da lesão do LAL associada ao LCA entre os radiologistas. Nível de Evidência IV, Série de Casos.

Combined Reconstruction of the Anterior Cruciate Ligament and Anterolateral Ligament Injury Compared to the Isolated Reconstruction of the Anterior Cruciate Ligament: A Meta-Analysis / Reconstrução combinada do ligamento cruzado Anterior e lesão do ligamento anterolateral comparada àreconstrução isolada do ligamento cruzado anterior: Uma metanálise

Abstract The present research aims to compare the outcomes from the combined reconstruction of the anterior cruciate ligament (ACL) and of the anterolateral ligament (ALL) with the standard isolated ACL reconstruction in patients with chronic ACL injury. To do so, a meta-analysis was carried out to determine whether the combined ACL and ALL reconstruction would lead to a significant improvement in knee function according to the International Knee Documentation Committee (IKDC), the Lysholm test and KT-2000 evaluation scores and lower graft rupture rates in comparison with isolated reconstruction. To identify randomized controlled trials (RCTs) comparing the combined ACL and ALL reconstruction with the isolated ACL reconstruction, papers published between 2010 and 2019 were searched in the MEDLINE, EMBASE, SPORTDiscus, LILACS and Cochrane Central Register of Controlled Trials databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The stability of the knee joint is only marginally improved with the combined reconstruction of ACL and ALL, and both reconstruction techniques show functional results. The main outcomes sought were patient function and graft stability and rupture rates after ACL reconstruction. Out of the 421 studies identified, 6 were included in our meta-analysis. Study quality (internal validity) was assessed using the Cochrane risk-of-bias tool; in general, the studies included presented moderate-quality evidence. The graft rupture rate was higher in patients undergoing isolated ACL reconstruction (relative risk, 0.22; 95% confidence interval, 0.12 to 0.41; p < 0.00001).

Resumo O objetivo da presentepesquisa é comparar, por meio de uma metanálise, os resultados da reconstrução combinada do ligamento cruzado anterior (LCA) e do ligamento anterolateral (LLA), comparado com a reconstrução isolada padrão, em pacientes com lesão crônica do ligamento cruzado anterior. Buscando alcançar o objetivo da pesquisa, foi realizada uma meta-análise para determinar se a combinação da reconstrução combinada LCA e LLA levaria àmelhoria significativa da função do joelho, medida pelos escores de avaliação International Knee Documentation Committee (IKDC), Lysholm, KT-2000 e menor taxa de ruptura do enxerto, em comparação com a reconstrução isolada. Para identificar ensaios clínicos randomizados (ECR) comparando a reconstrução combinada do LCA e LLA com a reconstrução isolada do LCA, foram pesquisados artigos publicados entre 2010 e 2019 nas bases MEDLINE, EMBASE, SPORTDiscus, LILACS e Cochrane Central RegisterofControlledTrials e seguiram os critérios de Itens de Relatórios Preferidos para Revisões Sistemáticas e Metanálises (PRISMA). A estabilidade da articulação do joelho é apenas marginalmente aprimorada com a reconstrução combinada de LCA e LLA, e ambas as técnicas de reconstrução mostram resultados funcionais. Os principais desfechos procurados foram a função do paciente e as taxas de estabilidade e ruptura do enxerto após a reconstrução do LCA. Dos 421 estudos identificados, 6estudos foram incluídos em nossa meta-análise. A qualidade do estudo (validade interna) foi avaliada usando o instrumento Cochrane risco-de-viés; em geral, foi encontrada uma qualidade moderada de evidências dos estudos incluídos. Os pacientes submetidos à reconstrução isolada do LCA mostraram maior taxa de ruptura do enxerto (RR 0,22; índice de confiança [IC]95%: 0,12-0,41; p< 0,00001).

¿Es útil fijar las fracturas de Segond para el manejo de la inestabilidad anterolateral de rodilla? A propósito de un caso / Is it worthwhile fixing Segond fractures for the management of anterolateral knee instability? A case report

Introducción El complejo anterolateral de la rodilla es un estabilizador secundario de la rotación tibial interna, su inserción distal esta localizada en el aspecto anterolateral de la tibia proximal y su avulsión es conocida como fractura de Segond, fue descrita hace mas de un siglo por el cirujano francés que le dio su nombre. Es frecuente la asociación de la lesión del ligamento cruzado anterior (LCA) con este complejo, tanto que en la actualidad se considera la fractura de Segond como un signo patognomónico de ruptura del cruzado anterior. Dada la importancia de brindar estabilidad rotacional desde la periferia de la articulación y las propiedades cada vez mas reconocidas de las estructuras anterolaterales, este artículo reporta un caso de fijación directa de la fractura de Segond, en el cual se buscó restituir la anatomía original de la rodilla. Métodos Revisión de la literatura relevante y reporte retrospectivo del caso de un paciente con lesión de LCA y fractura de Segond que fue llevado a reconstrucción de LCA con autoinjerto de HTH y reducción directa y fijación con sutura de anclaje de fractura de Segond por una incisión mínima, con un seguimiento clínico de 4 años. Se aplicaron escalas de valoración subjetiva previo al procedimiento y en el seguimiento postoperatorio. Resultados La inestabilidad anterior y anterolateral posterior al manejo quirúrgico presentó mejoría clínica pasando de tener Lachman IIB a negativo, y Pivot shift grado II a negativo. Las escalas de valoración subjetivas de Lysholm e IKDC mejoraron notablemente de resultados regulares previo al procedimiento a excelentes en el postoperatorio. No presentó complicaciones durante el procedimiento ni requirió reintervenciones. Discusión Aunque la fractura de Segond está descrita desde hace más de un siglo, y su asociación con lesiones de ligamento cruzado anterior se documentó hace mas de 20 años, aun no hay consenso en el manejo de esta fractura. Desde el punto de vista biomecánico, una estructura localizada en el centro de la rodilla como el LCA, de manera aislada, sería insuficiente para controlar la rotación tibial en relación al fémur. Por lo tanto, sería lógico pensar que una estructura localizada lejos del centro de rotación de la rodilla pueda ser más efectiva en controlar la rotación ya que ejerce un mayor control del torque rotacional. Reportamos resultados funcionales satisfactorios y estabilidad postoperatoria adecuada a 4 años de seguimiento, posterior a la fijación de la fractura de Segond asociada a reconstrucción de LCA; consideramos que puede ser una medida exitosa y segura para el manejo de la inestabilidad anterolateral de la rodilla.

Introduction The anterolateral complex of the knee is a secondary stabiliser of the internal tibial rotation. Its distal insertion is located in the anterolateral aspect of the proximal tibia, and its avulsion is known as Segond fracture. This was described more than a century ago by the French surgeon who gave it his name. The combination of anterior cruciate ligament injury (ACL) with the anterolateral complex is so common in as much that Segond fracture is currently considered as a pathognomonic sign of rupture of the anterior cruciate. Given the importance of providing rotational stability from the periphery of the joint and the increasingly recognised properties of the anterolateral structures, this article reports a case of direct fixation of the Segond fracture, in which it was sought to restore the original anatomy of the knee. Methods Review of relevant literature and retrospective case report of a patient with ACL injury and Segond fracture who underwent ACL reconstruction with a host-to-host (HTH) autograft and direct reduction and fixation with Segond fracture anchor suture through a minimal incision. There was a clinical follow-up of 4 years. Subjective assessment scales were applied prior to the procedure and in the postoperative follow-up. Results Anterior and anterolateral instability after surgical management showed a clinical improvement, going from having Lachman IIB to negative, and from Pivot shift grade II to negative. The subjective rating scales of Lysholm and International Knee Documentation Committee (IKDC) improved markedly from regular results prior to the procedure to excellent in the postoperative period. There were no complications during the procedure and no reoperations were required Discussion Although the Segond fracture has been described for more than a century, and its association with anterior cruciate ligament injuries was documented more than 20 years ago, there is still no consensus on the management of this fracture. From the biomechanical point of view, a structure located in the centre of the knee like the ACL, in isolation, would be insufficient to control the tibial rotation in relation to the femur. Therefore, it would be logical to think that a structure located far from the centre of rotation of the knee can be more effective in controlling rotation, since it exerts a greater control of rotational torque. Satisfactory functional results are reported, together with an adequate postoperative stability at 4 years of follow-up, after the fixation of the Segond fracture associated with ACL reconstruction. It is considered that this can be a successful and safe measure for the management of anterolateral instability of the knee.

Tubérculo de Gerdy: una estructura olvidada en la terminología anatómica internacional / Gerdy's tubercle: a forgotten structure in the international anatomical terminology

En la enseñanza de la anatomía, el uso de los epónimos es cada vez más escaso, sin embargo su uso aún es evidente incluso en la literatura actualizada, en este caso el uso del epónimo se acompaña generalmente del término correcto según la Terminología Anatómica Internacional (TAI). El denominado "Tubérculo de Gerdy" (TG) es un epónimo ampliamente usado en la literatura y la comunidad científica para denominar un reparo óseo ubicado en el cóndilo lateral de la tibia, corresponde a un referente anatómico y clínico importante para inserción de músculos, ligamentos y procedimientos medicoquirúrgicos de la rodilla. A pesar de esta amplia denominación, y en comparación con otros epónimos, la TAI no la incluye y no relaciona algún término oficial con esta estructura anatómica. El objetivo del trabajo fue revisar libros usados en la enseñanza de la anatomía y artículos científicos actualizados para ver la presencia y descripción de esta estructura a fin de proponer un término que se ajuste a los principios básicos de la Terminología Anatómica Internacional en concordancia con la tarea del Programa Federativo Internacional de Terminología Anatómica (FIPAT), organismo de la Federación Internacional de Asociaciones de Anatomistas (IFAA). El TG se describe como una estructura ubicada entre la tuberosidad de la tibia y la cabeza de la fíbula, refiriéndose a él con sinónimos como tubérculo del músculo tibial anterior, tubérculo del músculo tensor de la fascia lata, tubérculo del tracto iliotibial y tubérculo anterolateral de la tibia. En revistas morfológicas aparece en artículos actuales relacionados al ligamento anterolateral. Según la descripción de la literatura proponemos como término anatómico para esta estructura "Tuberculum anterolateralis tibiae", cuya traducción es usada como sinónimo por otros autores, ajustándose así a los principios básicos de la TAI. Pretendemos que estos antecedentes sean discutidos por los expertos que conforman el FIPAT.

In teaching anatomy, the use of eponyms is increasingly scarce. Nonetheless, eponyms remain evident in updated literature, in this case the use of the eponym is accompanied by the correct term according to the International Anatomical terminology (TAI) Gerdy´s tubercle (GT) is an eponym widely used in the literature and scientific community to name a lateral tubercle of the tibia. It is an insertion site of muscles and ligaments and an important anatomical reference in knee surgical procedures. Despite its importance, it is not included in the International Anatomical Terminology (IAT) and an official name for this structure is lacking. The aim of this work was to review classic books used in the anatomy teaching and recent scientific papers, and further, to propose an anatomical term for the Gerdy tubercle that fit IAT basic principles, in agreement with the International Federal Program of Anatomical Terminology (IFPAT), and organism that is part of the International Federation of Anatomist Associations (IFAA). The TG is described as a structure located between the tuberosity of the tibia and the head of the fibula, referring to it with synonyms such as tubercle of the anterior tibia, tubercle of the tensor fascia lata, tubercle of iliotibial tract and anterolateral tibial tubercle. In morphological journals it appears in current articles related to the anterolateral ligament. We propose as an anatomical term for the Gerdy´s tubercle the name of "Tuberculum anterolteralis tibiae" its translation is used as a synonym by other authors and fits the basic principles of TAI. We hope that this information be considered by the experts that make up the FIPAT.

Extra-articular reconstruction associated with the anterior cruciate ligament in brazil / Reconstrução extra-articular associada ao ligamento cruzado anterior no brasil

ABSTRACT Objective: To assess the knowledge and technical preferences of Brazilian knee surgeons in relation to the treatment of Anterior Cruciate Ligament (ACL) injuries using intra-articular reconstruction in combination with extra-articular reconstruction. Methods: A questionnaire consisting of 16 questions about intra-articular ACL reconstruction in combination with extra-articular procedures and about the Anterolateral Ligament (ALL) was applied at the 48th Brazilian Congress of Orthopedics. Results: One hundred thirty-seven surgeons answered the questionnaire. Most surgeons perform 10-30 ACL reconstructions per year, with the transtibial technique appearing as the most common. Most surgeons find some percentage of residual pivot-shift after reconstructions, but the minority performs extra-articular procedures on a routine basis. The main indications for extra-articular reconstruction are revision and profuse pivot-shift cases. Most surgeons consider the ALL a true ligament, but 46.7% with less biomechanical importance and 32.3% with greater importance in knee stability. However, 91.4% had a positive perception of the reconstruction of this structure. Conclusion: Although the preferred technique is still the transtibial procedure, combined anatomical reconstructions already make up more than 50% of cases. Extra-articular reconstructions associated with the ACL are still performed by the minority of Brazilian surgeons, but 91.4% of them report having had a positive perception with their reconstruction. Level of Evidence III, Descriptive Study.

RESUMO Objetivo: Avaliar o conhecimento e as preferências técnicas entre os cirurgiões de joelho brasileiros no tratamento das lesões do ligamento cruzado anterior, com reconstrução intra-articular associada à reconstrução extra-articular. Métodos: Foi aplicado questionário de 16 perguntas no 48° Congresso Brasileiro de Ortopedia acerca de reconstrução intra-articular do ligamento cruzado anterior associada a procedimentos extra-articulares e sobre o ligamento anterolateral. Resultados: Responderam o questionário 137 cirurgiões. A maioria faz entre 10 e 30 reconstruções de ligamento cruzado anterior por ano, sendo a técnica transtibial a mais realizada. A maioria encontrou alguma porcentagem de pivot-shift residual após as reconstruções, mas a minoria realizou procedimento extra-articular de rotina. As indicações principais de reconstrução extra-articular foram casos de revisão e pivot-shift exuberante. A maioria considera o ligamento anterolateral um ligamento verdadeiro, porém 46,7% o caraterizou com importância biomecânica menor e 32,3% com importância maior na estabilidade do joelho, mas 91,4% tiveram percepção positiva em relação à reconstrução dessa estrutura. Conclusão: Apesar da técnica de preferência ainda ser a transtibial, as reconstruções anatômicas combinadas já são mais de 50% dos casos. As reconstruções extra-articulares associadas ao ligamento cruzado anterior ainda são feitas pela minoria dos cirurgiões brasileiros, mas 91,4% deles referem ter tido uma percepção positiva com sua reconstrução. Nível de Evidência III, Estudo Descritivo.

Actualización en las inserciones anatómicas del ligamento anterolateral: revisión sistemática de la literatura / Update in the Anatomical Insertions of the Anterolateral Ligament: Systematic Review of Literature

Introducción Aunque las indicaciones para su reconstrucción aún son motivo de debate, desde su descripción, la anatomía del ligamento anterolateral ha sido estudiada extensivamente. Sus puntos de inserción se han modificado en los estudios más recientes y esto es importante en el momento de hacer una reconstrucción anatómica. Este estudio busca hacer una revisión sistemática de la literatura para establecer sus puntos de inserción en fémur y tibia. Materiales y métodos Revisión sistemática desde enero de 2012 hasta junio de 2017. Se buscaron publicaciones en Pubmed, Embase, Google Scholar y Cochrane. Se incluyeron estudios cadavéricos que evaluaran la anatomía del ligamento anterolateral y describieran sus puntos de inserción. Resultados Se encontraron 334 estudios con los términos de interés, que tras su evaluación llevó a incluir 13 artículos. El ligamento no estaba presente en el 100% de los especímenes evaluados en los diferentes artículos. Su inserción tibial se ha mantenido sin cambios desde la descripción inicial, en un punto intermedio entre la cabeza del peroné y el tubérculo de Gerdy, mientras que la femoral ha cambiado. Esta se ha modificado a un punto posterior y proximal al epicóndilo lateral del fémur y al origen del colateral externo, contrario a la ubicación inicial anterior y distal a estos. Discusión Actualmente se considera que la inserción del ligamento anterolateral es posterior y proximal al origen del ligamento colateral externo. Esto tiene importancia para su reconstrucción quirúrgica: el ligamento debería ser fijado cuando tiene su máxima longitud, entre 20-30° de flexión de la rodilla.

Introduction Although its anatomy has been extensively studied, there is still controversy in the medical literature as regards when the anterolateral ligament should be reconstructed. Its insertion points have been modified in the most recent studies and this might play an important role in its anatomical reconstruction. This study aims to conduct a systematic review of literature in order to establish insertion points of the anterolateral ligament in the femur and tibia. Materials and methods A systematic review of literature was conducted between January 2012 and June 2017. It included post-mortem studies of dissection of the anterolateral ligament in adult knees that reported its anatomical insertions. The following databases were searched: PubMed, Embase, Google Scholar and Cochrane. Results A total of 334 studies were found in the systematic review using the key words. After evaluating them, 13 papers fulfilled the eligibility criteria and were included in the study. The anterolateral ligament was not found in the 100% of the post-mortem knees. Its tibial insertion continued to be similar to the original description: between the fibula head and Gerdy's tubercle. The femoral insertion has changed, now being posterior and proximal to the lateral epicondyle and the insertion of the lateral collateral ligament, as opposed to its initial location of anterior and distal to these structures. Discussion The femoral insertion of the anterolateral ligament is currently considered to be proximal and posterior to the origin of the lateral collateral ligament. This is important for an anatomical surgical reconstruction, when the ligament should be fixed in its maximal length, between 20-30° of knee flexion.

Reconstrucción mínimamente invasiva del ligamento anterolateral / Minimally invasive anterolateral ligament reconstruction following anterior cruciate ligament revision surgery: technical note

INTRODUCCIÓN: La inestabilidad anteroposterior y la laxitud rotatoria demostrada mediante test de pivot-shift severo podría estar causada por la combinación de lesión de ligamento cruzado anterior (LCA) y de estructuras laterales de la rodilla, particularmente del ligamento anterolateral (LAL). Este último actúa como estabilizador secundario, restringiendo la rotación interna y complementando el rol primario de estabilización del LCA. MATERIAL Y MÉTODOS: Describir la técnica de reconstrucción mínimamente invasiva del LAL tras realizar una cirugía de revisión del LCA. Además, se ofrece una breve descripción de las indicaciones quirúrgicas, resultados y complicaciones. DISCUSIÓN: La inestabilidad rotatoria persistente tras la reconstrucción de LCA indica que la reconstrucción intraarticular podría no ser suficiente para restaurar la estabilidad rotacional en un subgrupo específico de pacientes. Se han descrito numerosas técnicas de reconstrucción extraarticulares (mencionadas previamente), algunas de ellas con incisiones de gran tamaño, con los consiguientes problemas estéticos. Esta nota describe una técnica simple y mínimamente invasiva de reconstrucción de LAL, realizada tras una revisión del LCA con técnica anatómica, todo en el mismo procedimiento quirúrgico. Esta técnica está indicada en roturas agudas o exploraciones/revisiones del LCA que presenten pivot-shift severo, así como también en pacientes con roturas crónicas del LCA o en pacientes que sean hiperlaxos. A pesar de que esta técnica no ha demostrado ser superior a otras reconstrucciones extraarticulares del LAL, se presenta como una cirugía simple, confiable y rápida, con buenos resultados estéticos.

INTRODUCTION: Anteroposterior instability and rotatory laxity demonstrated by severe pivot-shift test may be caused by combined lesions of the anterior cruciate ligament (ACL) and lateral structures of the knee, particularly the anterolateral ligament (ALL). This ligament acts as a secondary stabiliser that restrains internal rotation and supplements the primary stabilising role of the ACL. MATERIAL AND METHODS: To describe a minimally invasive ALL reconstruction technique following anterior cruciate ligament revision surgery. Brief description of surgical indications, outcomes, and complications. DISCUSSION: Persistent rotatory instability after ACL reconstruction suggests that intra-articular reconstruction may not be sufficient to restore rotational stability in a subgroup of patients. Numerous extra-articular reconstruction techniques have been described with long incisions and cosmetic issues. A description is presented of a simple, minimally invasive ALL reconstruction technique performed after anatomical ACL revision in a single procedure. This technique is indicated in patients with acute ACL injuries and revision ACL associated with a severe pivot-shift, chronic ACL injuries, and joint hyper-laxity. Although this technique has not proven to be superior to any other extra-articular anterolateral ligament reconstructions, it uses simple, reliable and cosmetic surgery, with good early results in a small series of patients.