Anterolateral ligament reconstruction with autologous grafting: A biomechanical study

Accepted Manuscript Anterolateral ligament reconstruction with autologous grafting: A biomechanical study

E. Monaco, R.M. Lanzetti, M. Fabbri, A. Redler, A. De Carli, A. Ferretti PII: DOI: Reference:

S0268-0033(17)30081-5 doi: 10.1016/j.clinbiomech.2017.03.013 JCLB 4309

To appear in:

Clinical Biomechanics

Received date: Accepted date:

20 September 2016 30 March 2017

Please cite this article as: E. Monaco, R.M. Lanzetti, M. Fabbri, A. Redler, A. De Carli, A. Ferretti , Anterolateral ligament reconstruction with autologous grafting: A biomechanical study. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Jclb(2017), doi: 10.1016/j.clinbiomech.2017.03.013

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ACCEPTED MANUSCRIPT Anterolateral ligament reconstruction with autologous grafting: a biomechanical study

Monaco E, Lanzetti RM, Fabbri M, Redler A, De Carli A, Ferretti A

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University of Rome “La Sapienza” II School of Medicine, Sant’Andrea Hospital

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Kirk Kilgour Sports Injury Center

Edoardo Monaco, MD: Sant’Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy

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Riccardo Maria Lanzetti, MD: Sant’Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy

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Mattia Fabbri, MD: Sant’Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy Andrea Redler, MD: Sant’Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy

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Angelo De Carli, MD: Sant’Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy

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Andrea Ferretti, MD: Sant’Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy

Corresponding Author:

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Riccardo Maria Lanzetti

Address: Di grottarossa 1035 00189, Rome (Italy)

E-mail: [email protected] Word count: Abstract: 203 Main text: 2041

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ACCEPTED MANUSCRIPT ABSTRACT Background To evaluate the reliability of the Iliotibial band compared to gracilis tendon as a graft to be used in anterolateral ligament reconstruction. Methods

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Gracilis tendon and a strip of Iliotibial band compared were harvested from 8 fresh human

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cadaveric knees. The gracilis tendon was prepared to obtain a graft of 10 cm in length (Group 1). Iliotibial band compared was prepared to obtain a graft of 10 cm in length and 0.5 cm in width from

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the middle portion (Group 2). All the specimens were fixed on a servo hydraulic tensile machine

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with dedicated cryo-clamp. The loading protocol, used to compare the previously published results of ultimate failure load and Stiffness of the anterolateral ligament (Group 3), included a cyclic

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preconditioning between 10 and 25 N at 0.1 Hz for 10 cycles and then a load to failure test at 20 mm/min.

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Findings

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Gracilis tendon showed higher Ultimante Failure Load and stiffness when compared to a strip of Iliotibial band.

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Gracilis tendon and a strip of Iliotibial band compared showed higher Ultimante Failure Load and

Interpretation

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stiffness when compared with native anterolateral ligament as reported by Kennedy.

Both grafts tested in the present studies are suitable for an anatomical anterolateral ligament reconstruction.

Key words Anterolateral ligament; gracilis tendon; ileotibial band; biomechanics

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ACCEPTED MANUSCRIPT 1. INTRODUCTION Anterolateral rotatory knee instability results from a combined injury of anterior cruciate ligament (ACL) and secondary restraints of lateral compartment (Hugson et al., 1976). Despite arthroscopic ACL reconstruction yields good results in most cases, many authors have reported a persistent

shift test (Aglietti et al., 1997; Eriksson, 1997; Kocher et al., 2002).

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instability of the knee at follow-up, especially under rotatory load as revealed by a positive pivot-

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Historically, non-anatomic lateral extra-articular tenodesis (LET) have been used in addition to

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intra-articular reconstruction and various techniques have been described to improve the results of ACL reconstruction (Colombet, 2011; Marcacci et al., 2009; Lemaire and Combelles, 1980).

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Hewison et al. (2015) recently showed through a meta-analysis that the rate of positive pivot shift was significantly reduced after combined ACL reconstruction and LET. The LET procedure is most

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often performed with iliotibial band (ITB) or gracilis grafts.

The recent literature has shifted its attention to the structures of the lateral aspect of the knee, acting

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as secondary restraints in the ACL deficient knee (Ferretti et al., 2014). As a matter of fact, Spencer

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et al. (2015) explained: “These findings have led researchers to re-examine the peripheral structures of the knee, with the emergence of the anterolateral ligament (ALL) as a key structure for further

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investigation.” Particularly, the "revisited" anterolateral ligament (ALL) has been well anatomically and biomechanically described as an effective lateral knee structure that provides rotatory stability

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to the knee, specifically controlling the pivot-shift phenomenon (Claes et al., 2013; Kennedy et al., 2015; Rasmussen et al. 2016, guenther et al. 2015). Moreover, the recent knowledge of anatomy of the anterolateral complex led surgeons to develop more anatomic extra-articular reconstruction aiming to reproduce femoral and tibial insertion point of the ALL using a gracilis tendon or a strip of Ileotibial band (ITB) as a graft (Helito et al., 2015; Sonnery-Cottet et al., 2015; Smith et al., 2015; Kernkamp et al., 2015; Ferretti et al, 2017). Concerns exist on the choice of the best graft to be used in anatomical anterolateral ligament reconstruction. 3

ACCEPTED MANUSCRIPT Therefore, the goal of this study was to describe the biomechanical properties (ultimate failure load and stiffness) of the two most used grafts for ALL reconstruction (a strip of ITB and gracilis tendon). The secondary outcome was to compare properties of the two graft tested with those of the native ALL as reported by Kennedy et al. (2015).

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We hypothesized that gracilis and ileotibial band would have a higher maximum load and stiffness

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than the anterolateral ligament being biomechanically suitable for ALL anatomical reconstruction.

2.1 METHODS

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After obtaining ethical approval, 8 fresh human cadaveric knees from 4 cadavers (3 men and 1 woman; mean age 68.6± years) were dissected as allowed to harvest gracilis tendon and a strip of

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ITB.

The lateral compartment was approached with a hockey-stick incision. After dissection of

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subcutaneous tissue, the ITB was identified and harvested from its distal insertion on Gerdy's

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tubercle to a length of 10 cm in a proximal direction. ITB dissection was carefully carried out to obtain its middle and posterior portion, which is commonly used for extra-articular tenodesis

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(Marcacci et al., 2009; Lemaire and Combelles, 1980, Ireland and Trickey, 1980). A second incision was performed after identification of pes anserinus and the gracilis tendon was harvested as

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usual with a stripper, carefully removing soft tissues. The Gracilis was prepared to obtain a single bundle a graft of 10 cm in length with its original width (Group 1). The mean original gracilis diameter was 4mm (+/-0.7) ITB was prepared to obtain a grafts of 10 cm in length and 0.5 cm in width from the middle portion, (Group 2).The mean original thickness of the ITB was 2 mm(0+/-.4). Throughout the experimental protocol, specimens were soaked with physiologic saline solution to prevent dehydration. All the specimens were mounted on a servo hydraulic tensile machine (model Z010, Zwick-Ruell, Ulm, Germany) and fixed with dedicated cryo-clamp. Dry ice was used to 4

ACCEPTED MANUSCRIPT better fix the graft in the dedicated cryo-clamp obtaining a final length of the graft free for test of approximately 4 cm, actually corresponding to the length of the ALL (Fig.1-2) (Claes et al., 2013; Kennedy et al., 2015). The loading protocol was adapted from previously published pull to failure testing protocols and included a cyclic preconditioning between 10 and 25 N at 0.1 Hz for 10 cycles and then a load to

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failure test at 20 mm/min (Kennedy et al., 2015). This testing protocol was chosen because it was

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previously used in a paper evaluating biomechanical properties of the native ALL (Kennedy et al.,

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2015). Thus, we could use data reported by Kennedy as control group., (Group 3). Ultimate failure load (UFL) was determined as the ultimate load reached by the specimen before failure. Stiffness

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was calculated between 10 N and 75% of individual specimen maximum load. Moreover, the mode of failure of each specimen was registered (Fig.3).

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2.2 STATISTICAL ANALYSIS

All the data were analysed by a single researcher. We used parametric tests if data were normally

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distributed and homogeneous and/or non-parametric tests if these two conditions were not satisfied.

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To assess if data were normally distributed and homogeneous we used Kolmogorov-Smirnov’s test and Levene’s test, respectively.

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A Kruskal-Wallis H test was conducted to determine if there were differences in UFL and stiffness scores between groups. Where significant differences were identified, a Conover–Inman multiple

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comparison test was used (Conover WJ, 1999). Version 3 was used for calculations. Computed P values were 2-sided, and p<0.05 was used to determine statistical significance. 3. RESULTS Baseline characteristics of the three different grafts are shown in Table 1. UFL (N): According to ultimate failure load, the median scores were statistically significantly different between groups, χ2 = 23.54, P<0.001 (Fig.4). The gracilis tendon graft showed a higher ultimate failure load than both the ileotibial band graft (P=0.003) and the anterolateral ligament 5

ACCEPTED MANUSCRIPT (P<0.001). Moreover, the ileotibial band graft had a higher UFL than the anterolateral ligament (P<0.001). Stiffness (N/mm): According to stiffness, median scores were statistically significantly different between groups, χ2 = 24.26, P<0.001 (Fig.5). The gracilis tendon graft had a higher stiffness than both the ileotibial band graft (P=0.002) and the anterolateral ligament (P<0.001). Furthermore, the

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ileotibial band graft had a higher stiffness than the anterolateral ligament (P<0.001).

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Mode of faiulure: in all the specimens the mode of failure registered was a mid-substance tear.

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4. DISCUSSION

The most important finding of the present study is that the null hypothesis is confirmed.

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Both the two graft tested were showed biomechanical properties adequate for ALL anatomical reconstruction in term of UFL and stiffness and should be considered eligible for these new

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techniques.

Biomechanical properties of the ALL and capsule, as compared with others ligament of the knee,

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are 4 to 5 times lower, concerning UFL and stiffness (Kennedy et al., 1976; LaPrade et al., 2005;

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Scheffler et al., 2001; Woo et al., 1991). Nevertheless, such ligamentous structure has been well anatomically identified and described (Claes et al., 2013; Vincent et al., 2012). Moreover, its role as

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a secondary restrain of the ACL deficient knee as well as its effectiveness in controlling rotational stability of the knee has been demonstrated in several biomechanical and navigation studies

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(Kennedy et al., 2015; Rasmussen et al., 2016; Monaco et al. 2012). Finally, lesions of anterolateral ligament and capsule are often associated to ACL acute tear in about 90% of cases and are strongly correlated to an explosive pivot-shift (Ferretti et al., 2016). For this reason, anatomical reconstruction of the ALL have been proposed with the aim to better control rotational stability of the knee and improve clinical results and specially concerning to pivot-shift. Historically, extra-articular procedures associated with ACL reconstruction have been described and widely used in the past, basically acting as lateral tenodesis taking advantage from their long lever arm (Colombet, 2011; Marcacci et al., 2009; Lemaire and Combelles, 1980, Ireland and 6

ACCEPTED MANUSCRIPT Trickey, 1980). However, concerns still exist on long-term follow up of these procedures and possible overconstraining of the lateral aspect of the knee (Rahnemai-Azar et al., 2016). In actual fact, the role of reconstructive surgery should be to replicate a torn secondary restrain with a constraining graft, always considering that if an anatomic structure is torn, the goal should be to reconstruct its anatomy to as close to native as possible (Musahl V et al., 2016). For this reason, the

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recent knowledge on anatomy of anterolateral complex, stimulated surgeons to develop new

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techniques for its anatomical reconstruction, aiming to control rotational stability of the knee.

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However, understanding of the native structural properties of the ALL and graft is essential to optimize reconstructive procedure, especially concerning graft selection. Different graft have been

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recently proposed to reconstruct the ALL, in particular gracilis tendon and a strip of ITB (Helito et

2017).

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al., 2015; Sonnery-Cottet et al, 2015; Smith et al., 2015; Kernkamp et al., 2015, (Ferretti et al,

The primary goal of this study was to test biomechanically these two grafts and compare their

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properties with those the native ALL.

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The most important finding of the present study is that the null hypothesis is confirmed: Both the two graft tested showed biomechanical properties adequate for ALL anatomical

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reconstruction in term of UFL and stiffness. On the basis of these results, we could speculate that both graft are eligible for ALL anatomical

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reconstruction.

One of the major concerns in ALL reconstruction is possible overconstraing of the knee. For this reason we should consider that another important finding of the study is that both grafts tested showed a higher UFL and stiffness when compared to the native ALL. Even if different studies clearly demonstrated that overconstraing of the knee after ALL reconstruction is strongly related to insertion size of the graft and flexion angle of fixation, a possible further overconstraing effect when using a gracilis graft or an ITB graft due to its biomechanical properties can not be excluded. However, when considering only the two grafts tested in the present study, gracilis showed an 7

ACCEPTED MANUSCRIPT higher UFL and stiffness when compared to the ITB. Moreover, in a recently paper Helito et al.(Helito et al., 2016) testes ALL biomechanical properties using the same Kennedy protocol (Kennedy et al., 2015): they reported a mean of UFL of 204.8 (SD 114.9) N and a stiffness of 41.9 (SD 25.7) N/mm. These results are similar with the results of ITB reported in the present study, suggesting that ITB should be a more suitable graft for ALL reconstruction.

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This study has several limitations. The first limitation is the lack of a control group consisting in the

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ALL. This was due to disapproval of the ethical committee for harvest bone tissue necessary to test

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ALL as described by other authors. For this reason as control group we used results reported by Kennedy et al.(2015) on biomechanical properties of ALL. However to make results more

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comparable, we used the same testing protocol. Second, The age of the specimens in this study was clearly higher than the age of patients who typically undergo ACL reconstruction procedures. The

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effect of age was evaluated on 82 patellar tendons taken from donors between 17 and 54 years of age (Blevins et al., 1994). These tendons were tested at strain rates of either 10%/s or 100%/s. The

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modulus of elasticity was lower only in the older tendons tested at 100%/s. The other biomechanical

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properties were not altered by age. Finally, this is a biomechanical study, only evaluating structural properties at time 0 of two different graft proposed for anatomical ALL reconstruction, not

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evaluating remodeling and healing of the graft. For this reason no sure clinical consideration can be extrapolated.

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However, only few techniques have been proposed for ALL reconstruction, always using gracilis or ITB as graft. To our knowledge, there is the first paper reporting on biomechanical properties of ITB used as a graft for ALL reconstruction. However, further clinical studies at long term follow up are needed to better clarify the real role of these new surgical techniques to improve clinical outcome of ACL recon ruction in term of rotational stability. 5. CONCLUSION

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ACCEPTED MANUSCRIPT Structural properties of a strip of ITB and gacilis are higher than those of the native ALL. Both grafts can be taken into consideration as a graft when performing an anatomical ALL

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reconstruction.

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ACCEPTED MANUSCRIPT Conflict Of Interest The authors declare that they have no conflict of interest Acknowledgements All the authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the

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subject of this article.

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Formatting of funding sources

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Ethical approval

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The study was approved by the Institutional Review Board.

Figures Legend

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Fig.1 Gracilis tendon graft is fixed with dedicated cryo-clamp on a servo hydraulic tensile machine

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Fig.2 The ITB graft is fixed with dedicated cryo-clamp on a servo hydraulic tensile machine Fig.3 The mode of failure of the specimen is registered: midsubstance tear

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Fig.4 Ultimate failure load median distribution of the gracilis tendon graft (A), the ileotibial band graft (B) and the anterolateral ligament (C)

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Fig.5 Stiffness median distribution of the gracilis tendon graft (A), the ileotibial band graft (B) and the anterolateral ligament (C)

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Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S. 1991. Tensile properties of the human femu anterior cruciate ligament-tibia complex: the effects of specimen age and orientation. The American

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25TH 503.35 109.49 260.28 53.75 144.00 14.00

PERCENTILES MEDIAN 531.43 113.00 267.29 57.45 183.00 17.00

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STD. DEVIATION 53.37 9.66 32.43 5.91 64.54 8.17

75TH 591.12 118.98 293.00 67.47 193.00 27.00

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TABLE.1 DESCRIPTIVE ANALYSIS OUTCOME GROUPS MEAN MEASURES 525.45 UFL 1 (N=8) 114.18 STIFFNESS 279.46 UFL 2 (N=8) 58.03 STIFFNESS 174.87 UFL 3 (N=15) 20.20 STIFFNESS

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ACCEPTED MANUSCRIPT Highlights. 1) Gracilis and Iliotibial-band are the most used graft for the ALL reconstruction 2)Gracilis and Iliotibial-band showed higher UFl than native ALL 3) Gracilis and Iliotibial-band showed higher stiffness than native ALL

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4) Gracilis and Iliotibial-band are suitable graft for ALL reconstruction

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