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Restoration of rotational knee laxity for anterior cruciate ligament deficiency: Anterolateral ligament reconstruction versus anterolateral tenodesis
Abstracts / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 9 (2017) 12e58
Significance: The significance of this research lies in the fact that a young athlete who has had multiple recurrent ACL injuries by their mid-20’s will be at significantly increased risk for developing premature knee osteoarthritis which will have a lifetime impact on their ability to remain active. Efforts must be made to reduce recurrent ACL injuries in younger patients with particular attention paid to the danger of returning to high risk sports.
References 1. Kamath GV et al. Anterior Cruciate Ligament Injury, Return to Play, and Reinjury in the Elite Collegiate Athlete: Analysis of an NCAA Division I Cohort. Am J Sports Med. 2014;42(7): 16381643. 2. Morgan MD et al. Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger. Am J Sports Med. 2016;44(2): 384-392. 3. Webster KE et al. Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(3): 641-647. 4. Webster KE and Feller JA. Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016;44(11): 2827-2832. Keywords: Aneterior cruciate ligament, Reconstruction, Graft rupture, Reinjury, Return to sport, Young patients
Knee - Ligament > ACL OP-092 PROXIMAL TIBIAL BONY AND MENISCAL SLOPES ARE HIGHER IN ACL INJURED SUBJECTS THAN CONTROLS. A COMPARATIVE MRI STUDY Timothy Lording 1, Ashraf Elmansori 2, Raphael Dumas 3, Khalifa Elmajri 2, Philippe Neyret 2, Sebastien Lustig 2. 1 Melbourne Orthopaedic e Lyon 1, Group, Australia; 2 Department of Albert Trillat Center, Universit ecanique Et M ecanique Des France; 3 Department of Laboratoire De Biom Chocs, Universit e Lyon 1, France Background: Increased tibial slope is a reported risk factor for non-contact anterior cruciate ligament (ACL) injury as well as failure after ACL reconstruction. The impact of the soft tissues, particularly the menisci, on the functional tibial slope remains unclear. The primary aim of this study was to compare the proximal tibial bony and meniscal slope in patients with and without ACL injury, and to investigate the relationship between the bony slope and meniscal slope. Our hypothesis was that both the bony and meniscal slopes would be increased in ACL injured subjects, and that inclusion of the meniscal horns would reduce the observed slope, correcting the functional slope towards the horizontal. Materials & methods: Using Magnetic Resonance Imaging (MRI), we measured the lateral and medial bony tibial slopes (LBS, MBS), and lateral and medial meniscal slopes (LMS, MMS) in 100 patients with isolated ACL injury, and compared these to a control group of 100 patients with an intact ACL. Inter- and intra- observer reliability were assessed using repeated measures analysis of variance. Slope measurements were compared using independent-samples t-tests. Results: Inter- & intra-observer reliability were good for measurement of both the bony and meniscal slopes (ICC 0.78-0.91 and 0.88-0.93 respectively). The LBS and MBS were greater in the ACL injured group than in the control group (LBS 10.48 ±3.15 vs 7.33 ±3.45, MBS 9.47 ±3.34 vs 7.05 ±3.72, p<0.05). The LMS and MMS were also greater in the ACL injured group than in the control group (LMS 4.76 ±4.74 vs 0.91 ±4.85, MMS 6.06 ±3.49 vs 3.72 ±3.68, p<0.05). In both groups, the lateral bony tibial slope was greater than the medial bony tibial slope (LBS>MBS), but the medial meniscal slope was greater than the lateral meniscal slope (MMS>LMS). The meniscal slopes were less than the bony slopes in both compartments for both groups. Discussion: The most important findings of our study are that the bony and meniscal slopes in both compartments are greater in ACL injured
47
subjects than controls, and that these differences are more pronounced in the lateral compartment. Furthermore, as the LBS was greater than the MBS, but the LMS was less than the MMS, the lateral meniscus has a greater impact on the observed slope than does the medial meniscus. The greatest observed difference was between the LBS and the LMS. These findings support the notion that lateral compartment slope in particular is a significant risk factor for non-contact ACL injury. Under load, the lateral femoral condyle may “slide down” an increased lateral slope, pivoting about the more stable medial femoral condyle. The resultant rotational moment would increase the strain in the ACL, potentially leading to injury. Loss of the posterior horn of the lateral meniscus would increase the functional slope and potentially magnify this effect. As a risk factor for failure after ACL reconstruction, tibial slope is potentially modifiable by osteotomy. Such intervention may be considered in cases of excessive slope, especially after the loss of the meniscus, however the precise indications for this significant intervention are unclear. Limitations of this study include the use of recumbent MRI scanning, and a control group with MRI performed for patello-femoral pain, who may have different slope characteristics to a true normal population. Conclusion: Increased tibial slope is a risk factor for ACL injury and can be reliably measured using an MRI based method. The meniscus corrects the observed slope towards the horizontal, particularly in the lateral compartment. As such, loss of the posterior meniscus may potentiate the risk of injury, or failure of ACL reconstruction, by increasing the functional tibial slope. Keywords: ACL, Tibial slope, Meniscal slope
Knee - Ligament > Anterolateral ligament OP-093 AN ANATOMICAL AND MRI ASSESSMENT OF THE OF ANTEROLATERAL LIGAMENT Ming Li 1, Haile Pan 2. 1 Department of Sports Injuries And Arthroscopy, Zhengzhou Orthopaedic Hospital, China; 2 Department of Sports Medicine, The Second Affiliated Hospital of Harbin Medical University, China Objectives: Characterize the anatomy of the ALL in fresh cadaver knees and as viewed using MRI imaging within cadaver knees and those of healthy volunteers. Methods: The anterolateral ligament (ALL) was dissected from the knees of 8 fresh cadavers. Both dissections of fresh cadaver knees and MRI imaging of cadavers and healthy volunteers were used to provide a description of the anatomical features and projections of the ALL as well as the conditions for optimal imaging of this structure. Results: The ALL was identified in all but one of the 8 (87.5%) fresh cadaver knees. It originates from the fibular condyle of the femur and courses anterolaterally to the tibial plateau. The ALL width within the tibial plateau was 7.42±0.80mm, 8.56±0.59mm and 10.53±0.51mm within the different in footprints of the ALL in the femur and tibia. The thickness within the tibial plateau was 1.29±0.03mm. With the knee flexed at 60 , the length of the ALL was 33.93±1.81mm. When using 3.0T MRI, the ALL could be clearly identified within coronal and anteroposterior positions of the 7 fresh cadaver knees and the 3 healthy volunteers. Conclusion: With the use of 3.0 MRI, the ALL could be identified in the anterolateral region of the knees in cadavers and healthy volunteers. It appears that a 0 flexion of the knee may provide an optimal orientation for viewing the ALL with MRI. Keywords: anterolateral ligament, MRI, anatomy
Knee - Ligament > Anterolateral ligament OP-094 RESTORATION OF ROTATIONAL KNEE LAXITY FOR ANTERIOR CRUCIATE LIGAMENT DEFICIENCY: ANTEROLATERAL LIGAMENT RECONSTRUCTION VERSUS ANTEROLATERAL TENODESIS Xin Liu, Hua Feng. Department of Sports Medicine Service, Beijing Jishuitan Hospital, China
48
Abstracts / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 9 (2017) 12e58
Background: The extra-articular procedures have received increased interest in recent years after wide dissemination of the anatomy and function of the anterolateral ligament of the knee. This study was designed to compare the early clinical outcomes of anterior cruciate ligament (ACL) reconstruction combined with anterolateral ligament reconstruction (ALLR) and anterolateral tenodesis procedures in patients with high grade pivot-shift after ACL injuries. Material: Between March 2015 and December 2015, 371 patients received surgery treatments because of ACL injuries. Among them, 85 patients underwent a combined ACL and anterolateral augmentation procedure. Indications for a combined procedure were associated high grade pivotshift (2+ or 3+). 41 patients received ALLR while another 44 received anterolateral tenodesis procedure with ACL reconstruction contemporarily. Methods: Iliotibial band (ITB) was used in both ALLR and anterolateral tenodesis procedures. The posterior band of ITB was cut with a width of 10 mm and length of 10cm. In ALLR group, the anatomic ALLR technique was used. In tenodesis group, the distal attachment of anterolateral ITB band at the Gerdy tubercle was preserved. The proximal end of the band was fixed proximally and posteriorly to the femoral insertion of the lateral collateral ligament. For ACL reconstruction, single-bundle technique was performed using hamstring autograft. Patients were assessed pre- and postoperatively with Lachman test and pivot-shift test. Lysholm score was used to evaluate the clinical function. Instrumented knee testing was performed with the KT-1000 arthrometer. The Complications including pain, stiffness or graft failure were also recorded. Results: The mean follow-up period was 12.7±2.4 months. 3 patients in ALLR group and 7 in tenodesis group were lost follow-up because of lost of contact. Leaving 75 patients for final evaluation. None of the patients complaint about pain or loss of range of motion at the final follow-up. There was no graft failure in both groups. The mean side-to-side difference of anteroposterior knee laxity assessed by KT-1000 was 2.3±0.7mm in ALLR group and 1.9±1.1mm in tenodesis group, which was significantly improved compared with preoperative assessment (ALLR, 9.2±2.6mm. Tenodesis, 10.1±4.3mm)(P<0.01). There was no statistical difference between the two groups in anteroposterior laxity (P¼0.865>0.05). At the final follow-up, 3 patients in ALLR group and 2 in tenodesis group had 1+ rotational laxity. The pivot-shift assessment was not significantly different comparing the two groups (P¼0.696>0.05). The postoperative Lysholm score was not significantly different comparing the two groups (P¼0.815>0.05). Discussion: The most important finding of this study was that the rotational laxity of the knee joints assessed by pivot shift test with ACL deficiency could be well restored using ALLR as well as anterolateral tenodesis procedures. There was no significant difference concerning about the results of pivot shift test between these two anterolateral augmentation techniques. And the combined ACL and ALLR or anterolateral tenodesis procedure allowed good anteroposterior control without specific complications such stiffness or limited range of motion. Under the consideration that isolated ACL reconstructions do not restore normal kinematics and biomechanics of the knee. And double-bundle ACL reconstruction has not provided an obvious benefit in rotational control. The lateral tenodesis has been considered am option to restore the rotational laxity. Many published articles indicated that the addition of a lateral extra-articular reconstruction to a standard single-bundle ACL reconstruction was more effective in reducing the internal rotation of the tibia at 30 of knee flexion than both a standard single-bundle ACL reconstruction and an anatomic doublebundle reconstruction. Moreover, the anatomic and biomechanical study of ALL became an attractive controversy in recent years. Although the existence of ALL was suspected as early as 1879 by Segond, an identifiable ALL has only recently been described by several authors. It has been indicated that a combined ACL and ALLR can be an effective procedure without specific complications at a minimum follow-up of 2 years. The results of our study were similar as the previous studies. However, there was no statistically significant difference between ALLR and anterolateral tenodesis in controlling of rotational laxity of the knee. Further anatomic and biomechanical studies of the anterolateral structures and in particular the ALL, demonstrating its role in the rotational control of the knee, are needed to improve clinical results. Conclusion: The rotational laxity for ACL deficiency of high grade pivotshift could be effectively restored using ACL reconstruction combined with
ALLR as well as anterolateral tenodesis procedure. The early stage clinical outcomes did not prove significant difference comparing the two procedures. Keywords: anterior cruciate ligament injury, pivot-shift test, anterolateral ligament reconstruction, tenodesis
Knee - Ligament > PCL/PLRI OP-095 A MODIFIED ARTHROSCOPIC TECHNIQUE FOR FIXING ACUTE TIBIAL AVULSION FRACTURE OF THE POSTERIOR CRUCIATE LIGAMENT Chen Yu-xian, Li Zhi-yong. Department of Joint And Orthopedic Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, China Background: Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament from the tibia has been well demonstrated. However, almost these type surgical procedures need establish posteromedial and posterolateral approaches. Simultaneously, two tibial tunnels were set up during the course to fix the stitches or the endobutten plat. The purpose of this study was to introduce a novel arthroscopic method to reduced and fix the avulsion fracture fragments of the PCL. Material and Method: Twelve patients between Feb.2013 to Jan. 2016 who had an avulsion fracture of the posterior cruciate ligament from the tibia were analyzed retrospectively. Twelve patients were male, age 21~53(36±7.2)Y. All patients were undergone by arthroscopy. Merely avulsion fractures of the posterior cruciate ligament and one week suffered injuryed met the inclusion criteria by X-ray and CT scans. Contrarily, combine another lesions were excluded. The conventional anterior approaches were established. Intercondylar portal was established for observing the PCL ending points and surrounding the PCL. The posteromedial approach was set up to pass stitches. A 4.5mm tibial tunnel was ready to pass the No. 5 Ethibond sutures. Last, a simple straddle nail was used to fix the threads. Outcome of the fracture reduction was checked arthroscopically and radiographically. All patients were protected with brace for 6 weeks postoperatively. Result: Patients were followed up from 6 to 12 months(mean 7.3±3.3 months). The osseous union was observed in approximately 6 months Xray. No posterior tibial sag was seen, and the range of motion was normal after 6 months after surgery. No complications were existed. Conclusion: Tibial PCL avulsion fractures were entirely treated by arthroscopic suture fixation. It is a sophisticated technique to restore tibial avulsion fracture. The method mentioned was more simply, less traumatic, and less costly. Keywords: Tibial Avulsion Fracture, The Posterior Cruciate Ligament, Modified Arthroscopic Technique, Reduce and Fixation
Knee - Ligament > PCL/PLRI OP-096 ALL-INSIDE ARTHROSCOPIC TREATMENT OF POSTERIOR CRUCIATE LIGAMENT TIBIAL AVULSION FRACTURES WITH TIGHTROPE Lei Mingming. Department of Orthopaedic Sports Medicine And Arthroscope, The Sports Hospital Affiliated To Chengdu Sport University, China Background: The posterior cruciate ligament (PCL) avulsion fracture from its tibial insertion is not a rare condition in west China. Despite the further technical advent in refixation of avulsion fractures, the reported failure rate of current approaches remains high and the optimal surgical technique has not been elucidated yet. Material: The purpose of this study is to introduce an all-inside arthroscopic operation technique for bony tibial avulsion fractures of the PCL and its initial clinical outcomes. Methods: A retrospective analysis of 12 cases (12 knees) of acute PCL avulsion fracture on the clinical date between February 2014 and January 2016. 9 males and 3 females, aged (37.96±5.47) years on average(range, 2952 years). Two conventional arthroscopic approaches were used to observe the avulsion fracture and place the PCL tibial locator. A proximal medial tibial mini incision was used to drill bone tunnel (Arthrex, USA) through
Significance: The significance of this research lies in the fact that a young athlete who has had multiple recurrent ACL injuries by their mid-20’s will be at significantly increased risk for developing premature knee osteoarthritis which will have a lifetime impact on their ability to remain active. Efforts must be made to reduce recurrent ACL injuries in younger patients with particular attention paid to the danger of returning to high risk sports.
References 1. Kamath GV et al. Anterior Cruciate Ligament Injury, Return to Play, and Reinjury in the Elite Collegiate Athlete: Analysis of an NCAA Division I Cohort. Am J Sports Med. 2014;42(7): 16381643. 2. Morgan MD et al. Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger. Am J Sports Med. 2016;44(2): 384-392. 3. Webster KE et al. Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(3): 641-647. 4. Webster KE and Feller JA. Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016;44(11): 2827-2832. Keywords: Aneterior cruciate ligament, Reconstruction, Graft rupture, Reinjury, Return to sport, Young patients
Knee - Ligament > ACL OP-092 PROXIMAL TIBIAL BONY AND MENISCAL SLOPES ARE HIGHER IN ACL INJURED SUBJECTS THAN CONTROLS. A COMPARATIVE MRI STUDY Timothy Lording 1, Ashraf Elmansori 2, Raphael Dumas 3, Khalifa Elmajri 2, Philippe Neyret 2, Sebastien Lustig 2. 1 Melbourne Orthopaedic e Lyon 1, Group, Australia; 2 Department of Albert Trillat Center, Universit ecanique Et M ecanique Des France; 3 Department of Laboratoire De Biom Chocs, Universit e Lyon 1, France Background: Increased tibial slope is a reported risk factor for non-contact anterior cruciate ligament (ACL) injury as well as failure after ACL reconstruction. The impact of the soft tissues, particularly the menisci, on the functional tibial slope remains unclear. The primary aim of this study was to compare the proximal tibial bony and meniscal slope in patients with and without ACL injury, and to investigate the relationship between the bony slope and meniscal slope. Our hypothesis was that both the bony and meniscal slopes would be increased in ACL injured subjects, and that inclusion of the meniscal horns would reduce the observed slope, correcting the functional slope towards the horizontal. Materials & methods: Using Magnetic Resonance Imaging (MRI), we measured the lateral and medial bony tibial slopes (LBS, MBS), and lateral and medial meniscal slopes (LMS, MMS) in 100 patients with isolated ACL injury, and compared these to a control group of 100 patients with an intact ACL. Inter- and intra- observer reliability were assessed using repeated measures analysis of variance. Slope measurements were compared using independent-samples t-tests. Results: Inter- & intra-observer reliability were good for measurement of both the bony and meniscal slopes (ICC 0.78-0.91 and 0.88-0.93 respectively). The LBS and MBS were greater in the ACL injured group than in the control group (LBS 10.48 ±3.15 vs 7.33 ±3.45, MBS 9.47 ±3.34 vs 7.05 ±3.72, p<0.05). The LMS and MMS were also greater in the ACL injured group than in the control group (LMS 4.76 ±4.74 vs 0.91 ±4.85, MMS 6.06 ±3.49 vs 3.72 ±3.68, p<0.05). In both groups, the lateral bony tibial slope was greater than the medial bony tibial slope (LBS>MBS), but the medial meniscal slope was greater than the lateral meniscal slope (MMS>LMS). The meniscal slopes were less than the bony slopes in both compartments for both groups. Discussion: The most important findings of our study are that the bony and meniscal slopes in both compartments are greater in ACL injured
47
subjects than controls, and that these differences are more pronounced in the lateral compartment. Furthermore, as the LBS was greater than the MBS, but the LMS was less than the MMS, the lateral meniscus has a greater impact on the observed slope than does the medial meniscus. The greatest observed difference was between the LBS and the LMS. These findings support the notion that lateral compartment slope in particular is a significant risk factor for non-contact ACL injury. Under load, the lateral femoral condyle may “slide down” an increased lateral slope, pivoting about the more stable medial femoral condyle. The resultant rotational moment would increase the strain in the ACL, potentially leading to injury. Loss of the posterior horn of the lateral meniscus would increase the functional slope and potentially magnify this effect. As a risk factor for failure after ACL reconstruction, tibial slope is potentially modifiable by osteotomy. Such intervention may be considered in cases of excessive slope, especially after the loss of the meniscus, however the precise indications for this significant intervention are unclear. Limitations of this study include the use of recumbent MRI scanning, and a control group with MRI performed for patello-femoral pain, who may have different slope characteristics to a true normal population. Conclusion: Increased tibial slope is a risk factor for ACL injury and can be reliably measured using an MRI based method. The meniscus corrects the observed slope towards the horizontal, particularly in the lateral compartment. As such, loss of the posterior meniscus may potentiate the risk of injury, or failure of ACL reconstruction, by increasing the functional tibial slope. Keywords: ACL, Tibial slope, Meniscal slope
Knee - Ligament > Anterolateral ligament OP-093 AN ANATOMICAL AND MRI ASSESSMENT OF THE OF ANTEROLATERAL LIGAMENT Ming Li 1, Haile Pan 2. 1 Department of Sports Injuries And Arthroscopy, Zhengzhou Orthopaedic Hospital, China; 2 Department of Sports Medicine, The Second Affiliated Hospital of Harbin Medical University, China Objectives: Characterize the anatomy of the ALL in fresh cadaver knees and as viewed using MRI imaging within cadaver knees and those of healthy volunteers. Methods: The anterolateral ligament (ALL) was dissected from the knees of 8 fresh cadavers. Both dissections of fresh cadaver knees and MRI imaging of cadavers and healthy volunteers were used to provide a description of the anatomical features and projections of the ALL as well as the conditions for optimal imaging of this structure. Results: The ALL was identified in all but one of the 8 (87.5%) fresh cadaver knees. It originates from the fibular condyle of the femur and courses anterolaterally to the tibial plateau. The ALL width within the tibial plateau was 7.42±0.80mm, 8.56±0.59mm and 10.53±0.51mm within the different in footprints of the ALL in the femur and tibia. The thickness within the tibial plateau was 1.29±0.03mm. With the knee flexed at 60 , the length of the ALL was 33.93±1.81mm. When using 3.0T MRI, the ALL could be clearly identified within coronal and anteroposterior positions of the 7 fresh cadaver knees and the 3 healthy volunteers. Conclusion: With the use of 3.0 MRI, the ALL could be identified in the anterolateral region of the knees in cadavers and healthy volunteers. It appears that a 0 flexion of the knee may provide an optimal orientation for viewing the ALL with MRI. Keywords: anterolateral ligament, MRI, anatomy
Knee - Ligament > Anterolateral ligament OP-094 RESTORATION OF ROTATIONAL KNEE LAXITY FOR ANTERIOR CRUCIATE LIGAMENT DEFICIENCY: ANTEROLATERAL LIGAMENT RECONSTRUCTION VERSUS ANTEROLATERAL TENODESIS Xin Liu, Hua Feng. Department of Sports Medicine Service, Beijing Jishuitan Hospital, China
48
Abstracts / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 9 (2017) 12e58
Background: The extra-articular procedures have received increased interest in recent years after wide dissemination of the anatomy and function of the anterolateral ligament of the knee. This study was designed to compare the early clinical outcomes of anterior cruciate ligament (ACL) reconstruction combined with anterolateral ligament reconstruction (ALLR) and anterolateral tenodesis procedures in patients with high grade pivot-shift after ACL injuries. Material: Between March 2015 and December 2015, 371 patients received surgery treatments because of ACL injuries. Among them, 85 patients underwent a combined ACL and anterolateral augmentation procedure. Indications for a combined procedure were associated high grade pivotshift (2+ or 3+). 41 patients received ALLR while another 44 received anterolateral tenodesis procedure with ACL reconstruction contemporarily. Methods: Iliotibial band (ITB) was used in both ALLR and anterolateral tenodesis procedures. The posterior band of ITB was cut with a width of 10 mm and length of 10cm. In ALLR group, the anatomic ALLR technique was used. In tenodesis group, the distal attachment of anterolateral ITB band at the Gerdy tubercle was preserved. The proximal end of the band was fixed proximally and posteriorly to the femoral insertion of the lateral collateral ligament. For ACL reconstruction, single-bundle technique was performed using hamstring autograft. Patients were assessed pre- and postoperatively with Lachman test and pivot-shift test. Lysholm score was used to evaluate the clinical function. Instrumented knee testing was performed with the KT-1000 arthrometer. The Complications including pain, stiffness or graft failure were also recorded. Results: The mean follow-up period was 12.7±2.4 months. 3 patients in ALLR group and 7 in tenodesis group were lost follow-up because of lost of contact. Leaving 75 patients for final evaluation. None of the patients complaint about pain or loss of range of motion at the final follow-up. There was no graft failure in both groups. The mean side-to-side difference of anteroposterior knee laxity assessed by KT-1000 was 2.3±0.7mm in ALLR group and 1.9±1.1mm in tenodesis group, which was significantly improved compared with preoperative assessment (ALLR, 9.2±2.6mm. Tenodesis, 10.1±4.3mm)(P<0.01). There was no statistical difference between the two groups in anteroposterior laxity (P¼0.865>0.05). At the final follow-up, 3 patients in ALLR group and 2 in tenodesis group had 1+ rotational laxity. The pivot-shift assessment was not significantly different comparing the two groups (P¼0.696>0.05). The postoperative Lysholm score was not significantly different comparing the two groups (P¼0.815>0.05). Discussion: The most important finding of this study was that the rotational laxity of the knee joints assessed by pivot shift test with ACL deficiency could be well restored using ALLR as well as anterolateral tenodesis procedures. There was no significant difference concerning about the results of pivot shift test between these two anterolateral augmentation techniques. And the combined ACL and ALLR or anterolateral tenodesis procedure allowed good anteroposterior control without specific complications such stiffness or limited range of motion. Under the consideration that isolated ACL reconstructions do not restore normal kinematics and biomechanics of the knee. And double-bundle ACL reconstruction has not provided an obvious benefit in rotational control. The lateral tenodesis has been considered am option to restore the rotational laxity. Many published articles indicated that the addition of a lateral extra-articular reconstruction to a standard single-bundle ACL reconstruction was more effective in reducing the internal rotation of the tibia at 30 of knee flexion than both a standard single-bundle ACL reconstruction and an anatomic doublebundle reconstruction. Moreover, the anatomic and biomechanical study of ALL became an attractive controversy in recent years. Although the existence of ALL was suspected as early as 1879 by Segond, an identifiable ALL has only recently been described by several authors. It has been indicated that a combined ACL and ALLR can be an effective procedure without specific complications at a minimum follow-up of 2 years. The results of our study were similar as the previous studies. However, there was no statistically significant difference between ALLR and anterolateral tenodesis in controlling of rotational laxity of the knee. Further anatomic and biomechanical studies of the anterolateral structures and in particular the ALL, demonstrating its role in the rotational control of the knee, are needed to improve clinical results. Conclusion: The rotational laxity for ACL deficiency of high grade pivotshift could be effectively restored using ACL reconstruction combined with
ALLR as well as anterolateral tenodesis procedure. The early stage clinical outcomes did not prove significant difference comparing the two procedures. Keywords: anterior cruciate ligament injury, pivot-shift test, anterolateral ligament reconstruction, tenodesis
Knee - Ligament > PCL/PLRI OP-095 A MODIFIED ARTHROSCOPIC TECHNIQUE FOR FIXING ACUTE TIBIAL AVULSION FRACTURE OF THE POSTERIOR CRUCIATE LIGAMENT Chen Yu-xian, Li Zhi-yong. Department of Joint And Orthopedic Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, China Background: Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament from the tibia has been well demonstrated. However, almost these type surgical procedures need establish posteromedial and posterolateral approaches. Simultaneously, two tibial tunnels were set up during the course to fix the stitches or the endobutten plat. The purpose of this study was to introduce a novel arthroscopic method to reduced and fix the avulsion fracture fragments of the PCL. Material and Method: Twelve patients between Feb.2013 to Jan. 2016 who had an avulsion fracture of the posterior cruciate ligament from the tibia were analyzed retrospectively. Twelve patients were male, age 21~53(36±7.2)Y. All patients were undergone by arthroscopy. Merely avulsion fractures of the posterior cruciate ligament and one week suffered injuryed met the inclusion criteria by X-ray and CT scans. Contrarily, combine another lesions were excluded. The conventional anterior approaches were established. Intercondylar portal was established for observing the PCL ending points and surrounding the PCL. The posteromedial approach was set up to pass stitches. A 4.5mm tibial tunnel was ready to pass the No. 5 Ethibond sutures. Last, a simple straddle nail was used to fix the threads. Outcome of the fracture reduction was checked arthroscopically and radiographically. All patients were protected with brace for 6 weeks postoperatively. Result: Patients were followed up from 6 to 12 months(mean 7.3±3.3 months). The osseous union was observed in approximately 6 months Xray. No posterior tibial sag was seen, and the range of motion was normal after 6 months after surgery. No complications were existed. Conclusion: Tibial PCL avulsion fractures were entirely treated by arthroscopic suture fixation. It is a sophisticated technique to restore tibial avulsion fracture. The method mentioned was more simply, less traumatic, and less costly. Keywords: Tibial Avulsion Fracture, The Posterior Cruciate Ligament, Modified Arthroscopic Technique, Reduce and Fixation
Knee - Ligament > PCL/PLRI OP-096 ALL-INSIDE ARTHROSCOPIC TREATMENT OF POSTERIOR CRUCIATE LIGAMENT TIBIAL AVULSION FRACTURES WITH TIGHTROPE Lei Mingming. Department of Orthopaedic Sports Medicine And Arthroscope, The Sports Hospital Affiliated To Chengdu Sport University, China Background: The posterior cruciate ligament (PCL) avulsion fracture from its tibial insertion is not a rare condition in west China. Despite the further technical advent in refixation of avulsion fractures, the reported failure rate of current approaches remains high and the optimal surgical technique has not been elucidated yet. Material: The purpose of this study is to introduce an all-inside arthroscopic operation technique for bony tibial avulsion fractures of the PCL and its initial clinical outcomes. Methods: A retrospective analysis of 12 cases (12 knees) of acute PCL avulsion fracture on the clinical date between February 2014 and January 2016. 9 males and 3 females, aged (37.96±5.47) years on average(range, 2952 years). Two conventional arthroscopic approaches were used to observe the avulsion fracture and place the PCL tibial locator. A proximal medial tibial mini incision was used to drill bone tunnel (Arthrex, USA) through