Roberto Freire da Mota e Albuquerque

Combined Intra- and Extra-articular Reconstruction of the Anterior Cruciate Ligament: The Reconstruction of the Knee Anterolateral Ligament

We present a new technique for the combined intra- and extra-articular reconstruction of the anterior cruciate ligament. Intra-articular reconstruction is performed in an outside-in manner according to the precepts of the anatomic femoral tunnel technique. Extra-articular reconstruction is performed with the gracilis tendon while respecting the anatomic parameters of the origin and insertion points and the path described for the knee anterolateral ligament.

Evaluation of the Length and Isometric Pattern of the Anterolateral Ligament With Serial Computer Tomography

Background: Recent anatomical studies have identified the anterolateral ligament (ALL). Injury to this structure may lead to the presence of residual pivot shift in some reconstructions of the anterior cruciate ligament. The behavior of the length of this structure and its tension during range of motion has not been established and is essential when planning reconstruction. Purpose: To establish differences in the ALL length during range of knee motion. Study Design: Descriptive laboratory study. Methods: Ten unpaired cadavers were dissected. The attachments of the ALL were isolated. Its origin and insertion were marked with a 2 mm–diameter metallic sphere. Computed tomography scans were performed on the dissected parts under extension and 30°, 60°, and 90° of flexion; measurements of the distance between the 2 markers were taken at all mentioned degrees of flexion. The distances between the points were compared. Results: The mean ALL length increased with knee flexion. Its mean length at full extension and at 30°, 60°, and 90° of flexion was 37.9 ± 5.3, 39.3 ± 5.4, 40.9 ± 5.4, and 44.1 ± 6.4 mm, respectively. The mean increase in length from 0° to 30° was 3.99% ± 4.7%, from 30° to 60° was 4.20% ± 3.2%, and from 60° to 90° was 7.45% ± 4.8%. From full extension to 90° of flexion, the ligament length increased on average 16.7% ± 12.1%. From 60° to 90° of flexion, there was a significantly higher increase in the mean distance between the points compared with the flexion from 0° to 30° and from 30° to 60°. Conclusion: The ALL shows no isometric behavior during the range of motion of the knee. The ALL increases in length from full extension to 90° of flexion by 16.7%, on average. The increase in length was greater from 60° to 90° than from 0° to 30° and from 30° to 60°. The increase in length at higher degrees of flexion suggests greater tension with increasing flexion. Clinical Relevance: Knowledge of ALL behavior during the range of motion of the knee will allow for fixation (during its reconstruction) to be performed with a higher or lower tension, depending on the chosen degree of flexion.

Simultaneous anterior cruciate ligament reconstruction and computer-assisted open-wedge high tibial osteotomy: a report of eight cases.

Eight patients, aged 37-50 years, with chronic anterior cruciate ligament (ACL) deficiency, medial compartment osteoarthritis and varus deformity underwent simultaneous arthroscopic ACL reconstruction and open-wedge high tibial osteotomy controlled by a computer navigation system. Despite preoperative planning, the surgeon may need to choose a different osteotomy site during the procedure, invalidating the previous plans. The intraoperative wire control for osteotomies is not precise. The navigation system can help obtain precise alignment during high tibial osteotomy. The average preoperative mechanical axis was 7.5 of varum (sd±1.17°), the average postoperative axis was 1.2° of valgus (sd±1.04°) (p<0.01), and the average correction of the mechanical axis was 8.7° (sd±0.76°). The site of the osteotomy was 3.9 cm (3.5-4.8 cm, sd±0.35 mm) from the articular line, with an inclination of 27.9° (24-35, sd±4.8). The simultaneous use of these procedures allowed proper correction of the knee axis during the surgery. The surgery can be performed concomitantly with ACL reconstruction.

Positioning of the femoral tunnel for arthroscopic reconstruction of the anterior cruciate ligament: comparative study of 2 techniques

OBJECTIVE To compare the accuracy of positioning of the femoral tunnel in reconstructing the anterior cruciate ligament by means of 2 techniques: tibial tunnel and anteromedial portal. METHOD Femoral tunnels were drilled in 20 knees from human cadavers by means of arthroscopy. Group I had the femoral tunnel drilled via a trans-tibial tunnel, and Group II via the anteromedial portal. Four variables were measured: A) posterior wall thickness; B) tunnel positioning at the notch; C) tunnel inclination in relation to the femoral axis; and D) distance between the wire guide exit and the lateral epicondyle. RESULTS As above, respectively, A) 2.23 mm for group I and 2.36 mm for group II (P =.54); B) 25.5 degrees for group I and 30.0 degrees for group II (P =.23); C) 23.9 degrees for group I and 32.0 degrees for group II (P =.02); D) 7.8 cm for group I and 3.9 cm for group II (P <.001). CONCLUSIONS Both techniques achieved the desired positioning for the femoral tunnel entrance and satisfactory thickness for the posterior cortex. Drilling via the anteromedial portal may provide greater protection against rupture of the posterior wall.

Comparative study on anterior cruciate ligament reconstruction: determination of isometric points with and without navigation

OBJECTIVES: To compare the accuracy of tunnel placement and graft isometry for anterior cruciate ligament reconstruction performed using a computer-assisted navigation system (Orthopilot) and using traditional instruments. METHODS: The anterior cruciate ligament was removed intact from 36 pairs of human cadaver knees. From each pair, one knee was randomized to Group 1 (conventional) and the other to Group 2 (Orthopilot). An inelastic suture was then passed through the central points of the tibial and femoral tunnels. Neither of the tunnels was drilled. All knees were then dissected, and six parameters were obtained: distances from the tibial tunnel center to the 1) posterior cruciate ligament, 2) anterior horn of the lateral meniscus and 3) medial tibial spine; 4) distance from the femoral tunnel center to the posterior femoral cortex; 5) femoral tunnel coronal angle; and 6) variation of the distance from the femoral to the tibial tunnel with the knee extended and at 90 degrees of flexion. RESULTS: The variation of the distance from the femoral to the tibial tunnel during flexion and extension was smaller in the Orthopilot group (better isometry) compared to the conventional group. There were no statistical differences in any other parameters between the groups, and all tunnels were considered to be in satisfactory positions. DISCUSSION: The results obtained for anterior cruciate ligament reconstruction depend on precise isometric point positioning, and a navigation system is a precision tool that can assist surgeons in tunnel positioning. CONCLUSION: No differences in tunnel position were observed between the groups. Nonetheless, better isometry was achieved in the Orthopilot group than with conventional instruments.

Importance of the different posterolateral knee static stabilizers: biomechanical study

PURPOSE The purpose of this study was to evaluate the relative importance of the different static stabilizers of the posterolateral corner of the knee in cadavers. METHODS Tests were performed with the application of a varus and external rotation force to the knee in extension at 30 and 60 degrees of flexion using 10 cadaver knees. The forces were applied initially to an intact knee and then repeated after a selective sectioning of the ligaments into the following: section of the lateral collateral ligament; section of the lateral collateral ligament and the popliteofibular complex; and section of the lateral collateral ligament, the popliteofibular complex and the posterolateral capsule. The parameters studied were the angular deformity and stiffness when the knees were submitted to a 15 Newton-meter varus torque and a 6 Newton-meter external tibial torque. Statistical analysis was performed using the ANOVA (Analysis of Variance) and Tukey’s tests. RESULTS AND CONCLUSION Our findings showed that the lateral collateral ligament was important in varus stability at 0, 30 and 60 degrees. The popliteofibular complex was the most important structure for external rotation stability at all angles of flexion and was also important for varus stability at 30 and 60 degrees. The posterolateral capsule was important for varus stability at 0 and 30 degrees and for external rotation stability in extension. Level of evidence: Level IV (cadaver study).

An in vitro biomechanical comparison of anterior cruciate ligament reconstruction: single bundle versus anatomical double bundle techniques

INTRODUCTION Anterior cruciate ligament ruptures are frequent, especially in sports. Surgical reconstruction with autologous grafts is widely employed in the international literature. Controversies remain with respect to technique variations as continuous research for improvement takes place. One of these variations is the anatomical double bundle technique, which is performed instead of the conventional single bundle technique. More recently, there has been a tendency towards positioning the two bundles through double bone tunnels in the femur and tibia (anatomical reconstruction). OBJECTIVES To compare, through biomechanical tests, the practice of anatomical double bundle anterior cruciate ligament reconstruction with a patellar graft to conventional single bundle reconstruction with the same amount of patellar graft in a paired experimental cadaver study. METHODS Nine pairs of male cadaver knees ranging in age from 44 to 63 years were randomized into two groups: group A (single bundle) and group B (anatomical reconstruction). Each knee was biomechanically tested under three conditions: intact anterior cruciate ligament, reconstructed anterior cruciate ligament, and injured anterior cruciate ligament. Maximum anterior dislocation, rigidity, and passive internal tibia rotation were recorded with knees submitted to a 100 N horizontal anterior dislocation force applied to the tibia with the knees at 30, 60 and 90 degrees of flexion. RESULTS There were no differences between the two techniques for any of the measurements by ANOVA tests. CONCLUSION The technique of anatomical double bundle reconstruction of the anterior cruciate ligament with bone-patellar tendon-bone graft has a similar biomechanical behavior with regard to anterior tibial dislocation, rigidity, and passive internal tibial rotation.

Isokinetic assessment of the flexor-extensor balance of the knee in athletes with total rupture of the anterior cruciate ligament

The purpose of this study was to assess the flexor-extensor group of muscles of the knee in young athletes diagnosed with a total rupture of the anterior cruciate ligament (ACL). Eighteen knees of 18 athletes (14 men and 4 women) with an average age of 21.6 years (range 16-32 years) were assessed with a Cybex 6000 model isokinetic apparatus. The average internal between occurrence of the injury and assessment was 10.2 months (range 2-48 months). There was an associated meniscal injury in eight of the knees. Athletes with any other kind of associated injury, limitation, or blockage of the movement of the joint, significant pain during the exam, or interval between injury and exam of less than two months were excluded from the study. The parameters studied were the peak torque-velocity and flexor-extensor relationships at the constant angular velocities of 60 degrees/sec and 240 degrees/sec. Previous warming-up was done by means of an ergometric bicycle and adaptation with 3 submaximal repetitions. The contra-lateral side, which presented no injury, was used as control. Peak torque (PT) at the constant velocity of 60 degrees/sec was greater than that at 240 degrees/sec for knees with and without injuries. However, there was no significant difference between the injured and uninjured sides at 60 degrees/sec or at 240 degrees/sec. The average value for the flexor-extensor relationship at 60 degrees/sec on the injured was 60% ((6), compared to 57% ((10) on the contra-lateral side. At 240 degrees/sec, the average value was 75% ((10) on the injured side, and 65% ((12) on the contra-lateral side. In conclusion, despite the complete rupture of the ACL of one knee, the average values for the flexor-extensor relationship were similar on the injured and uninjured sides at the velocity of 60 degrees/sec. As the velocity increased, an increase in the values for the flexor-extensor relationship of the knee also occurred, indicating a tendency of the performance of the flexor muscle group to approach that of the extensor muscle group, and this tendency was more pronounced on the side of the injury.

Description of the Posterolateral Rotatory Drawer Maneuver for the Identification of Posterolateral Corner Injury

Injury to the posterolateral corner (PLC) is difficult to diagnose; most lesions of this type are included within the context of complex knee injuries. Study of the posterolateral complex is growing in importance because of the complex instability generated by these injuries. Although various physical examination tests are described for the diagnosis of PLC lesions, in 72% of cases these lesions are not identified at their initial presentation, which shows the difficulty in both performing these tests and interpreting the results. The maneuver described in this report is performed by executing external rotation of the leg. With the thumb of the proximally positioned hand, the examiner evaluates the positioning of the lateral tibial plateau in relation to the femoral condyle. With this maneuver, in lesions of the PLC and particularly lesions of its external rotation-restricting structures, we observe external rotation of the tibia and posterior subluxation of the lateral tibial plateau that cause the anterior edge of the tibial plateau to be posteriorized in relation to the anterior edge of the lateral femoral condyle. The idea behind this maneuver is not to eliminate the use of other tests but, rather, to add it to a diagnostic arsenal that still has interpretation flaws.

Screw loosening and iliotibial band friction after posterolateral corner reconstruction.

BACKGROUND Many reconstruction techniques have already been developed for treating posterolateral corner (PLC) injuries, with still no consensus regarding what would be the best option. Some techniques use non-bone tunnel fixation, attaching the graft to the femur using a cortical screw with toothed washer. The main objective of the present study is to evaluate complications related to fixation performed by a screw and toothed washer technique. METHODS A prospective study with surgical reconstruction of the PLC structures of the knee between January 2008 and December 2009 was performed. PLC reconstruction included reconstruction of the lateral collateral ligament, popliteofibular ligament and popliteal muscle tendon. Fixation of the grafts in the femur was achieved by means of a 4.5mm screw with a toothed washer. The assessments were done using the following methods: objective IKDC, subjective IKDC, Lysholm and Tegner. Radiographic evaluations were performed immediately after the operation, at 3, 6 and 12months after surgery, and yearly thereafter. Complications were documented. RESULTS The mean subjective IKDC score after the operation was 69.2; Lysholm scale was 80.7. Two patients presented failure of reconstructions of the PLC. In the radiographic evaluations, signs of loosening of the screw with toothed washer in the femur were observed in eight cases (66.6%). Six patients (50%) complained of lateral pain after the operation. CONCLUSION The technique of femoral fixation was shown to be efficient in restoration of stability. However there was a high rate of complications secondary to implant, such as loosening of the screws and iliotibial tract friction. LEVEL OF EVIDENCE Case series, leve IV.