Anterior cruciate ligament - updating article

Luzo, Marcus Vinicius Malheiros; Franciozi, Carlos Eduardo da Silveira; Rezende, Fernando Cury; Gracitelli, Guilherme Conforto; Debieux, Pedro; Cohen, Moisés

doi:10.1016/j.rboe.2016.05.001

Marcus Vinicius Malheiros Luzo

Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Grupo do Joelho, São Paulo, SP, Brazil

Carlos Eduardo da Silveira Franciozi ^** Corresponding author. E-mail: cacarlos66@hotmail.com (C.E.d.S. Franciozi).

Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Grupo do Joelho, São Paulo, SP, Brazil

Fernando Cury Rezende

Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Grupo do Joelho, São Paulo, SP, Brazil

Guilherme Conforto Gracitelli

Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Grupo do Joelho, São Paulo, SP, Brazil

Pedro Debieux

Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Grupo do Joelho, São Paulo, SP, Brazil

Moisés Cohen

Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Grupo do Joelho, São Paulo, SP, Brazil

* Corresponding author. E-mail: cacarlos66@hotmail.com (C.E.d.S. Franciozi).

Conflicts of interest

The authors declare no conflicts of interest.

Figures (3)
Tables (1)

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Fig. 1
Arthroscopic classification of the ACL remnant.

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Fig. 2
Recommended ACLR type that preserves the remnant.

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Fig. 3
ACLR involving current concepts of remnant tissue preservation and extra-articular reinforcement with iliotibial tract band (monoloop) and reconstruction of the anterolateral ligament. (A) ACL injury with presence of remnant tissue. Morphological type: scarring at the intercondylar roof (III). Remnant functionality (assessed with probe): functional. No. 5 Ethbond wire passed from the femoral tunnel to the tibial tunnel, showing tissue preservation with tibial tunnel made in the periphery of the footprint and preserving the remnant. The graft will be passed alongside it, thus maintaining the remnant functional fibers and its tibial and femoral inserts. (B) AG ACLR that preserves the remnant. AG-augmentation: ACLR in a partial lesion involving one or both bundles with functional remnant tissue. Estimated percentage of graft coverage by the remnant tissue: 30%. The line separates the graft in the inferior region and the remainder in the superior portion. (C) ACL injury with presence of remnant tissue. Morphological type: unidentifiable pattern, scarred at the lateral femoral condyle (IV). Remnant functionality (assessed with probe): nonfunctional. A path was created within the remnant shell with the shaver, which opens it proximally (the tip of the shaver can be seen protruding through the remainder of the enclosure). All tissue in the periphery is maintained, and only a central path is created, to pass the graft. (D) ACL Remnant-preserving reconstruction type NFRP. NFRP - nonfunctional remnant preservation: ACLR in a complete lesion involving both bundles with non-functional remnant tissue. The graft was passed through the center of the tibial footprint and encased by the remnant tissue, which will act as a biological sleeve, whether by the remnant synovial sheath, remnant ligament tissue, or both. Estimated percentage of graft coverage by the remnant tissue: 60%. Arrow shows graft exit within the remnant. (E) Extra-articular ACL reinforcement with isolated iliotibial band (derivative monoloop, similar to the extra-articular techniques by MacIntosh and Lemaire). The central one-third of the iliotibial tract is dissected with 1-1.5 cm thicknesses, maintaining its distal insertion and releasing its proximal insertion. This is prepared with Krackow suture with No. 5 Ethbond wire. A Kelly clamp is passed deeply into the lateral collateral ligament (arrow) to allow for central iliotibial tract band passage after proximal release and preparation. The central third of the iliotibial tract with 1-1.5 cm thicknesses is already made. (F) Center band of the iliotibial tract already deeply passed by the lateral collateral ligament (arrowhead) and inserted into the distal insertion of the lateral intermuscular septum of the femur, as shown by the arrow (one of the recommended points for insertion of extra-articular reinforcements in ACLR) after satisfactory isometric test. The reinforcement is fixed with an interference screw or anchor with knee at 90° flexion and neutral rotation after ACLR and fixation. In this case it was made with quintuple flexor grafts, outside-in femoral tunnel (aiming to avoid conflict with the femoral tunnel for the fixation of extra-articular reinforcement) and fixation with absorbable interference screw in the femur and tibia. This case demonstrates primary ACLR and extra-articular reinforcement was indicated due to the presence of explosive pivot. (G) Open reconstruction of the anterolateral ligament with gracilis graft combined with ACLR with triple semitendinosus graft. The arrow shows the femoral insertion of the anterolateral ligament. (H) Percutaneous reconstruction of the anterolateral ligament with gracilis graft combined with ACLR with triple semitendinosus graft. The arrow shows the femoral origin and the wire demonstrates the bone tunnels used for tibial insertion of the anterolateral ligament. In this type of reconstruction, the graft is passed superficially to the lateral collateral ligament.

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Table 1
Advantages and disadvantages of each femoral tunnel construction technique.

Fig. 3 ACLR involving current concepts of remnant tissue preservation and extra-articular reinforcement with iliotibial tract band (monoloop) and reconstruction of the anterolateral ligament. (A) ACL injury with presence of remnant tissue. Morphological type: scarring at the intercondylar roof (III). Remnant functionality (assessed with probe): functional. No. 5 Ethbond wire passed from the femoral tunnel to the tibial tunnel, showing tissue preservation with tibial tunnel made in the periphery of the footprint and preserving the remnant. The graft will be passed alongside it, thus maintaining the remnant functional fibers and its tibial and femoral inserts. (B) AG ACLR that preserves the remnant. AG-augmentation: ACLR in a partial lesion involving one or both bundles with functional remnant tissue. Estimated percentage of graft coverage by the remnant tissue: 30%. The line separates the graft in the inferior region and the remainder in the superior portion. (C) ACL injury with presence of remnant tissue. Morphological type: unidentifiable pattern, scarred at the lateral femoral condyle (IV). Remnant functionality (assessed with probe): nonfunctional. A path was created within the remnant shell with the shaver, which opens it proximally (the tip of the shaver can be seen protruding through the remainder of the enclosure). All tissue in the periphery is maintained, and only a central path is created, to pass the graft. (D) ACL Remnant-preserving reconstruction type NFRP. NFRP - nonfunctional remnant preservation: ACLR in a complete lesion involving both bundles with non-functional remnant tissue. The graft was passed through the center of the tibial footprint and encased by the remnant tissue, which will act as a biological sleeve, whether by the remnant synovial sheath, remnant ligament tissue, or both. Estimated percentage of graft coverage by the remnant tissue: 60%. Arrow shows graft exit within the remnant. (E) Extra-articular ACL reinforcement with isolated iliotibial band (derivative monoloop, similar to the extra-articular techniques by MacIntosh and Lemaire). The central one-third of the iliotibial tract is dissected with 1-1.5 cm thicknesses, maintaining its distal insertion and releasing its proximal insertion. This is prepared with Krackow suture with No. 5 Ethbond wire. A Kelly clamp is passed deeply into the lateral collateral ligament (arrow) to allow for central iliotibial tract band passage after proximal release and preparation. The central third of the iliotibial tract with 1-1.5 cm thicknesses is already made. (F) Center band of the iliotibial tract already deeply passed by the lateral collateral ligament (arrowhead) and inserted into the distal insertion of the lateral intermuscular septum of the femur, as shown by the arrow (one of the recommended points for insertion of extra-articular reinforcements in ACLR) after satisfactory isometric test. The reinforcement is fixed with an interference screw or anchor with knee at 90° flexion and neutral rotation after ACLR and fixation. In this case it was made with quintuple flexor grafts, outside-in femoral tunnel (aiming to avoid conflict with the femoral tunnel for the fixation of extra-articular reinforcement) and fixation with absorbable interference screw in the femur and tibia. This case demonstrates primary ACLR and extra-articular reinforcement was indicated due to the presence of explosive pivot. (G) Open reconstruction of the anterolateral ligament with gracilis graft combined with ACLR with triple semitendinosus graft. The arrow shows the femoral insertion of the anterolateral ligament. (H) Percutaneous reconstruction of the anterolateral ligament with gracilis graft combined with ACLR with triple semitendinosus graft. The arrow shows the femoral origin and the wire demonstrates the bone tunnels used for tibial insertion of the anterolateral ligament. In this type of reconstruction, the graft is passed superficially to the lateral collateral ligament.

Surgical technique	Transtibial	Transportal	Outside-in	Outside-in retrograde
Advantages	Single incision; less invasive than double incision	Allows access to the footprint of the anteromedial and posterolateral bundles	More predictable and anatomical femoral positioning	More predictable and anatomical femoral positioning
	More isometric graft function along the ADM	Independent tunnels	No need for knee hyperflexion	No need for knee hyperflexion
	Most patients with stable Lachman score	Interference screw placed in parallel	Useful for epiphyseal techniques in skeletally immature patients	Useful for epiphyseal techniques in skeletally immature patients
	Axis of the femoral tunnels similar to the ACL, leading to a lower chance of graft-tunnel and graft-intercondyle impact.	Re-establishes the natural rotational forces during the stance and balance gait phases.	Lower risk of blow-out of the posterior wall	Lower risk of blow-out of the posterior wall
	Low risk of collision of the associated posterolateral reconstruction tunnels	Allows preservation of intact bundles and selective reconstructions	Lower bone resorption at the bone-graft interface due to a more even distribution of contact pressure in the anterior and lateral walls	Smaller lateral incision when compared with the classic outside-in
	Large tunnel length	All-inside techniques can be used
		It can be used without special guides
		Intermediate length of the tunnel
Disadvantages	The tibial tunnel is dependent on the femoral tunnel	Harder to visualize and alter the superior, inferior, superficial, and deep references with the knee in hyperflexion	Need for two incisions and increased surgical morbidity	Increased surgical time
	The femoral tunnel is more anterior and vertical than the anatomical positioning, which can generate rotational instability	Increased risk of iatrogenic chondral lesions	Short tunnel length	Increased costs due to the special instruments
	Verticalized graft generates excessive femoral rotation in the stance phase of gait	Greater chance of rupture of the posterior wall of the lateral condyle	Risk of iatrogenic injury originated at the lateral collateral ligament	A very horizontalized tunnel can further wear out the graft
	Sulcoplasty is sometimes necessary to visualize the femoral origin of the ACL	Technically harder	High risk of collision of the associated posterolateral reconstruction tunnels
		Higher revision index
		Increased risk of peroneal nerve injury
		Need for an assistant to hold the hyperflexion of the knee during drilling
		Intermediate risk of collision of the associated posterolateral reconstruction tunnels

[1] * Corresponding author. E-mail: cacarlos66@hotmail.com (C.E.d.S. Franciozi).

Brasil

Brasil

Anterior cruciate ligament - updating article^{^☆} ☆ Study conducted at the Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Grupo do Joelho, São Paulo, SP, Brazil.

ABSTRACT

Brasil

Brasil

Anterior cruciate ligament - updating article☆ ☆ Study conducted at the Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Grupo do Joelho, São Paulo, SP, Brazil.

ABSTRACT

Anterior cruciate ligament - updating article^{^☆} ☆ Study conducted at the Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, Grupo do Joelho, São Paulo, SP, Brazil.