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Regarding “Editorial Commentary: Ultrasound Barely Beats Magnetic Resonance Imaging in Knee Anterolateral Ligament Evaluation … But Does This Change the Treatment of the Anterior Cruciate Ligament-Deficient Knee?”
Letter to the Editor
Regarding “Editorial Commentary: Ultrasound Barely Beats Magnetic Resonance Imaging in Knee Anterolateral Ligament Evaluation . But Does This Change the Treatment of the Anterior Cruciate Ligament-Deficient Knee?”
We read with great interest the editorial commentary by Rossi titled “Ultrasound Barely Beats Magnetic Resonance Imaging in Knee Anterolateral Ligament Evaluation . But Does This Change the Treatment of the Anterior Cruciate Ligament-Deficient Knee?” We would like to provide additional information on the role of ultrasound in our treatment algorithm and on the methods used in our article1 that the commentary relates to. The pivot shift test seems to provide a good view of the knee’s rotational stability2,3; however, the concept of knee rotational stability is multifactorial.4-6 Should we use only one multifactorial sign to propose a single treatmentdlateral extra-articular tenodesis? More generally, the root of the problem is defining the indications for lateral extra-articular tenodesis. The indications in various published studies are extreme pivot shift instabilities, revision cases with disruption of secondary restraints, and athletes returning to high-risk sports.7-10 (1)
The pivot shift, as mentioned above, is a multifactorial phenomenon that some authors want to treat with a single procedure. (2) Why wait for a revision procedure when disruption of the secondary restraints can be detected right away? (3) Because the goal is always to provide patients with the best treatment possible, we do not agree with different types of athletes being offered different treatments. We incorporate ultrasound imaging into our treatment algorithm to determine all the potential causes of rotational instability. In our study,1 we excluded typical secondary lesions (meniscus injury and ligament tears other than the anterior cruciate ligament), because the goal was to analyze the in vivo link between anterolateral ligament injury and a high-grade pivot shift. The correlation between the two was strong. However, because other potential causes of rotational instability were excluded from the analysis, we could not conclude that all high-grade pivot shifts are due to an anterolateral ligament tear. When a patient has a
1918
high-grade pivot shift, the anterolateral structures must be evaluated. We feel that ultrasound imaging is an appropriate tool for this. The identification and reproducibility rate in our study were very high because our team is highly aware of the anatomy of the anterolateral ligament.1,11-13 Other teams14 did not have such high rates with their protocol, but they started the analysis at the femur. The key feature, as mentioned by Rossi, is the analysis of the tibial portion of the ligament. Ultrasound is a dynamic imaging modality with very good spatial resolution. Paraclinical examinations are only a supplement to a rigorous clinical examination. Both are essential for deciding on the treatment because they analyze a wide span of potential injuries. This will help us better define the indications for lateral extra-articular tenodesis. Etienne Cavaignac, M.D. Karine Wytrykowski, M.D. Jérôme Murgier, M.D. Nicolas Reina, M.D. Philippe Chiron, M.D., Ph.D. Department of Orthopedic Surgery and Trauma Hôpital Pierre Paul Riquet, Toulouse, France Marie Faruch, M.D., Ph.D. Department of Radiology CHU Toulouse, Toulouse, France Note: The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2017 by the Arthroscopy Association of North America https://doi.org/10.1016/j.arthro.2017.08.278
References 1. Cavaignac E, Faruch M, Wytrykowski K, et al. Ultrasonographic evaluation of anterolateral ligament injuries: Correlation with magnetic resonance imaging and pivotshift testing. Arthroscopy 2017;33:1384-1390.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 11 (November), 2017: pp 1918-1919
LETTER TO THE EDITOR 2. Galway HR, MacIntosh DL. The lateral pivot shift: A symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res 1980;147:45-50. 3. Musahl V, Kopf S, Rabuck S, et al. Rotatory knee laxity tests and the pivot shift as tools for ACL treatment algorithm. Knee Surg Sports Traumatol Arthrosc 2012;20: 793-800. 4. Song GY, Hong L, Zhang H, Zhang J, Li Y, Feng H. Clinical outcomes of combined lateral extra-articular tenodesis and intra-articular anterior cruciate ligament reconstruction in addressing high-grade pivot-shift phenomenon. Arthroscopy 2016;32:898-905. 5. Monaco E, Ferretti A, Labianca L, et al. Navigated knee kinematics after cutting of the ACL and its secondary restraint. Knee Surg Sports Traumatol Arthrosc 2012;20:870-877. 6. Tanaka M, Vyas D, Moloney G, Bedi A, Pearle AD, Musahl V. What does it take to have a high-grade pivot shift? Knee Surg Sports Traumatol Arthrosc 2012;20:737-742. 7. Noyes FR, Huser LE, Jurgensmeier D, Walsh J, Levy MS. Is an anterolateral ligament reconstruction required in ACL-reconstructed knees with associated injury to the anterolateral structures? A robotic analysis of rotational knee stability. Am J Sports Med 2017;45:1018-1027. 8. Noyes FR. Editorial commentary: Lateral extra-articular reconstructions with anterior cruciate ligament surgery:
9.
10.
11.
12.
13.
14.
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Are these operative procedures supported by in vitro biomechanical studies? Arthroscopy 2016;32:2612-2615. LaPrade RF. Editorial commentary: Defining the anatomy of the anterolateral aspect of the knee among experts is clearly needed. Arthroscopy 2016;32:842-843. Rossi MJ. Editorial commentary: Addressing the anterolateral side of an anterior cruciate ligament-deficient knee: The controversy is getting even more interesting. Arthroscopy 2016;32:2048-2049. Wytrykowski K, Swider P, Reina N, et al. Cadaveric study comparing the biomechanical properties of grafts used for knee anterolateral ligament reconstruction. Arthroscopy 2016;32:2288-2294. Cavaignac E, Wytrykowski K, Reina N, et al. Ultrasonographic identification of the anterolateral ligament of the knee. Arthroscopy 2016;32:120-126. Faruch M, Cavaignac E, Wytrykowski K, et al. Anterolateral ligament injuries in knees with an anterior cruciate ligament tear: Contribution of ultrasonography and MRI [published online July 12, 2017]. Eur Radiol. doi:10.1007/ s00330-017-4955-0. Capo J, Kaplan DJ, Fralinger DJ, et al. Ultrasonographic visualization and assessment of the anterolateral ligament. Knee Surg Sports Traumatol Arthrosc. June 25, 2016. [Epub ahead of print.]
Regarding “Editorial Commentary: Ultrasound Barely Beats Magnetic Resonance Imaging in Knee Anterolateral Ligament Evaluation . But Does This Change the Treatment of the Anterior Cruciate Ligament-Deficient Knee?”
We read with great interest the editorial commentary by Rossi titled “Ultrasound Barely Beats Magnetic Resonance Imaging in Knee Anterolateral Ligament Evaluation . But Does This Change the Treatment of the Anterior Cruciate Ligament-Deficient Knee?” We would like to provide additional information on the role of ultrasound in our treatment algorithm and on the methods used in our article1 that the commentary relates to. The pivot shift test seems to provide a good view of the knee’s rotational stability2,3; however, the concept of knee rotational stability is multifactorial.4-6 Should we use only one multifactorial sign to propose a single treatmentdlateral extra-articular tenodesis? More generally, the root of the problem is defining the indications for lateral extra-articular tenodesis. The indications in various published studies are extreme pivot shift instabilities, revision cases with disruption of secondary restraints, and athletes returning to high-risk sports.7-10 (1)
The pivot shift, as mentioned above, is a multifactorial phenomenon that some authors want to treat with a single procedure. (2) Why wait for a revision procedure when disruption of the secondary restraints can be detected right away? (3) Because the goal is always to provide patients with the best treatment possible, we do not agree with different types of athletes being offered different treatments. We incorporate ultrasound imaging into our treatment algorithm to determine all the potential causes of rotational instability. In our study,1 we excluded typical secondary lesions (meniscus injury and ligament tears other than the anterior cruciate ligament), because the goal was to analyze the in vivo link between anterolateral ligament injury and a high-grade pivot shift. The correlation between the two was strong. However, because other potential causes of rotational instability were excluded from the analysis, we could not conclude that all high-grade pivot shifts are due to an anterolateral ligament tear. When a patient has a
1918
high-grade pivot shift, the anterolateral structures must be evaluated. We feel that ultrasound imaging is an appropriate tool for this. The identification and reproducibility rate in our study were very high because our team is highly aware of the anatomy of the anterolateral ligament.1,11-13 Other teams14 did not have such high rates with their protocol, but they started the analysis at the femur. The key feature, as mentioned by Rossi, is the analysis of the tibial portion of the ligament. Ultrasound is a dynamic imaging modality with very good spatial resolution. Paraclinical examinations are only a supplement to a rigorous clinical examination. Both are essential for deciding on the treatment because they analyze a wide span of potential injuries. This will help us better define the indications for lateral extra-articular tenodesis. Etienne Cavaignac, M.D. Karine Wytrykowski, M.D. Jérôme Murgier, M.D. Nicolas Reina, M.D. Philippe Chiron, M.D., Ph.D. Department of Orthopedic Surgery and Trauma Hôpital Pierre Paul Riquet, Toulouse, France Marie Faruch, M.D., Ph.D. Department of Radiology CHU Toulouse, Toulouse, France Note: The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2017 by the Arthroscopy Association of North America https://doi.org/10.1016/j.arthro.2017.08.278
References 1. Cavaignac E, Faruch M, Wytrykowski K, et al. Ultrasonographic evaluation of anterolateral ligament injuries: Correlation with magnetic resonance imaging and pivotshift testing. Arthroscopy 2017;33:1384-1390.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 11 (November), 2017: pp 1918-1919
LETTER TO THE EDITOR 2. Galway HR, MacIntosh DL. The lateral pivot shift: A symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res 1980;147:45-50. 3. Musahl V, Kopf S, Rabuck S, et al. Rotatory knee laxity tests and the pivot shift as tools for ACL treatment algorithm. Knee Surg Sports Traumatol Arthrosc 2012;20: 793-800. 4. Song GY, Hong L, Zhang H, Zhang J, Li Y, Feng H. Clinical outcomes of combined lateral extra-articular tenodesis and intra-articular anterior cruciate ligament reconstruction in addressing high-grade pivot-shift phenomenon. Arthroscopy 2016;32:898-905. 5. Monaco E, Ferretti A, Labianca L, et al. Navigated knee kinematics after cutting of the ACL and its secondary restraint. Knee Surg Sports Traumatol Arthrosc 2012;20:870-877. 6. Tanaka M, Vyas D, Moloney G, Bedi A, Pearle AD, Musahl V. What does it take to have a high-grade pivot shift? Knee Surg Sports Traumatol Arthrosc 2012;20:737-742. 7. Noyes FR, Huser LE, Jurgensmeier D, Walsh J, Levy MS. Is an anterolateral ligament reconstruction required in ACL-reconstructed knees with associated injury to the anterolateral structures? A robotic analysis of rotational knee stability. Am J Sports Med 2017;45:1018-1027. 8. Noyes FR. Editorial commentary: Lateral extra-articular reconstructions with anterior cruciate ligament surgery:
9.
10.
11.
12.
13.
14.
1919
Are these operative procedures supported by in vitro biomechanical studies? Arthroscopy 2016;32:2612-2615. LaPrade RF. Editorial commentary: Defining the anatomy of the anterolateral aspect of the knee among experts is clearly needed. Arthroscopy 2016;32:842-843. Rossi MJ. Editorial commentary: Addressing the anterolateral side of an anterior cruciate ligament-deficient knee: The controversy is getting even more interesting. Arthroscopy 2016;32:2048-2049. Wytrykowski K, Swider P, Reina N, et al. Cadaveric study comparing the biomechanical properties of grafts used for knee anterolateral ligament reconstruction. Arthroscopy 2016;32:2288-2294. Cavaignac E, Wytrykowski K, Reina N, et al. Ultrasonographic identification of the anterolateral ligament of the knee. Arthroscopy 2016;32:120-126. Faruch M, Cavaignac E, Wytrykowski K, et al. Anterolateral ligament injuries in knees with an anterior cruciate ligament tear: Contribution of ultrasonography and MRI [published online July 12, 2017]. Eur Radiol. doi:10.1007/ s00330-017-4955-0. Capo J, Kaplan DJ, Fralinger DJ, et al. Ultrasonographic visualization and assessment of the anterolateral ligament. Knee Surg Sports Traumatol Arthrosc. June 25, 2016. [Epub ahead of print.]