Combined ACL reconstruction and Segond fracture fixation fails to abolish anterolateral rotatory instability

The Segond Fracture (SF) is considered pathognomonic of an anterior cruciate ligament (ACL) tear. However, the precise anatomy of the soft tissue attachments responsible for avulsion of SF’s have been a cause of controversy in the literature with some authors suggesting that they occur due to avulsion of the iliotibial band (ITB) and others reporting that it is the anterolateral ligament (ALL). A thirty-one-year-old male patient presented with a work-related injury to his right knee that resulted in ACL tear and a SF. Open SF fixation and arthroscopic ACL reconstruction were performed. The anatomical dissection performed in order to fix the SF demonstrated that the avulsion had occurred as a result of the tibial attachment of the ALL with a completely intact ITB. At one-year postoperative follow-up, the ACL graft had restored anterior tibial translation to within normal limits. However, residual rotational knee laxity was observed in the absence of any other secondary restraint lesions. This is an important finding because it highlights that patients with SF may be at increased risk of persistent instability after ACL reconstruction even in the presence of an anatomically correctly positioned and well-functioning ACL graft. It also demonstrates that anatomical reduction and fixation of SF at the time of ACLR does not necessarily restore normal knee kinematics and consideration should be given to recession of the fixation or augmentation of the ALL when dealing with this injury pattern. A thirty-one-year-old male patient presented with a work-related injury to his right knee that occurred when he was struck by a truck at low speed. The mechanism of injury involved anterior tibial translation, varus stress and internal rotation. Physical examination revealed the following findings: large joint effusion, range of motion 0-100º, no neurological or vascular deficit, positive Lachman’s test with a soft end-point, a side-to-side anteroposterior laxity difference of 7mm measured by the Rolimeter device (Aircast, Europe), and a grade II pivot-shift (clunk). Plain radiographs demonstrated a fracture of the anterolateral border of the tibial plateau (figure 1A) and MRI showed a complete anterior cruciate ligament (ACL) rupture with a concomitant 3x16x18mm fracture of the anterolateral tibial border (figure 1B). MRI did not demonstrate any other intra- or extra-articular injuries. Specifically, there was no evidence of injury to any other ligamentous structure, chondral injury, lateral condyle notch sign, or any type of meniscal tear

Clinical outcomes of extra-articular tenodesis/anterolateral reconstruction in the ACL injured knee

Purpose: The role of concomitant extra-articular procedures in improving the outcome of ACL reconstruction has experienced a recent resurgence in interest. The aim of this article is to highlight the differences in philosophies and outcomes of historical non-anatomic reconstructions and contemporary, anatomical anterolateral reconstruction. Methods: A narrative review was performed using PubMed/MEDLINE using the keywords "lateral extra-articular tenodesis" and "anterolateral ligament reconstruction". Results: Results of search strategy: 37 studies [13 reporting clinical outcomes of isolated lateral extra-articular tenodesis (LET) in ACL deficient knees and 23 comparing isolated anterior cruciate ligament reconstruction (ACLR) with ACLR + LET] and one study on anterolateral ligament (ALL) reconstruction were identified as relevant and included in the review. Results of literature review: Isolated extra-articular reconstructions are rarely performed in contemporary practice. They are associated with a high rate of persistent anterior instability and early degenerative change. Combined ACL reconstruction and lateral extra-articular tenodeses results in a significant reduction in the prevalence of residual pivot shift, but the majority of the studies do not demonstrate any significant difference with respect to patient-reported outcome measures and return to sport. Although several authors report a trend towards decreased graft rupture rates, significant differences were not demonstrated in most studies. In a single clinical study, combined anatomic ACL and anterolateral ligament reconstruction was reported to be associated with a three-fold reduction in graft rupture rates and improved return to sport compared to isolated ACL graft choices. Conclusions: Historically performed, combined ACL reconstruction and lateral extra-articular tenodeses are associated with improved knee kinematics. Although a trend towards decreased graft rupture rates is reported by several authors, the majority did not demonstrate a significant difference, likely as a result of small and underpowered studies using postoperative immobilisation and delayed rehabilitation protocols. More recently, combined ACLR and ALL reconstruction has been shown to be associated with significant improvements in graft failure and return to sport rates when compared to isolated ACLR. However, these results are from a single clinical series with only medium-term follow-up. Level of evidence: IV

Non-operative treatment for partial ruptures of the fibular collateral ligament occurring in combination with complete ruptures of the anterolateral ligament: a common injury pattern in Brazilian Jiu-jitsu athletes presenting with acute knee injury

Background: Combined partial lateral collateral and complete anterolateral ligament (PLCCALL) injuries are a specific injury pattern seen in Brazilian Jiu-jitsu due to the knee varus/flexion mechanism that frequently occurs during grappling. Purpose: The aim of this article was to evaluate the incidence of this injury pattern in a series of Brazilian Jiu-jitsu athletes with an acute knee injury, and also to evaluate clinical and functional outcomes after non-operative management, at a minimum follow up of one year. Hypothesis: Our hypotheses were that partial lateral collateral and complete anterolateral ligament (PLCCALL) injuries are common in BJJ and that non-operative treatment is associated with excellent clinical outcomes and return to the pre-injury level of sport Study Design: Case series – cohort Methods: All Brazilian Jiu-jitsu athletes presenting with an acute knee injury between July 2013 and June 2017 who underwent MRI of the knee were included. A specific emphasis was placed on identifying those whose imaging demonstrated PLCCALL injury. Clinical evaluation included physical examination, Lysholm and International Knee Documentation Committee (IKDC) score. Results: Of the 27 patients analyzed, seven (25.9%) were identified to have MRI proven PLCCALL injuries. The mean follow-up was 41.3 months. The mean IKDC/Lysholm score pre-injury was 94.3/92, at initial assessment after injury was 26/35.6 and this improved to 82.8/78.2 at 12 months post-injury (p<0.00001). All seven patients returned to the pre-injury level of sports after one year of follow-up. The mean time between injury and return to competition level was 4.7 months (range 4-6). Conclusion: Combined partial LCL rupture and complete rupture of the ALL is a specific but infrequent injury pattern in BJJ. The prognosis of this injury following non-operative treatment appears to be excellent. Improved functional scores (IKDC and Lysholm) and MRI demonstrate that the ALL has intrinsic healing potential because the images show complete healing of the previously documented rupture of the anterolateral ligament from its proximal attachment. Clinical Relevance: The present article primarily evaluates the incidence of a specific injury pattern in a large series of Brazilian Jiu-Jitsu athletes with an acute knee injury, and also evaluates clinical and functional outcomes of these patients. The second major finding of this study is that these injuries can heal as proven by improved functional scores (IKDC e Lysholm) and subsequent MRI, how has been debate in the recent literature

Anatomical study and reanalysis of the nomenclature of the anterolateral complex of the knee focusing on the distal iliotibial band: identification and description of the condylar strap

Background: The capsulo-osseous layer, short lateral ligament, mid-third lateral capsular ligament, lateral capsular ligament and anterolateral ligament are terms that have been used interchangeably to describe what is probably the same structure. This has resulted in confusion regarding the anatomy and function of the anterolateral complex of the knee and its relation to the distal iliotibial band. Purpose: To characterize the macroscopic anatomy of the anterolateral complex of the knee, in particular the femoral condylar attachment of the distal iliotibial band (ITB). We identified a specific and consistent anatomical structure that was not accurately described previously, connects the deep surface of the ITB to the condylar area, and is distinct from the anterolateral ligament, the capsulo-osseous layer and the Kaplan fibers. Study Design: Descriptive laboratory study. Methods: Sixteen fresh-frozen human cadaveric knees were used to study the anterolateral complex of the knee. Standardized dissections were performed that included a qualitative and quantitative assessment of the anatomy through both anterior (n=5) and posterior (n=11) approaches. Results: The femoral condylar attachment of the distal ITB was not reliably identified by anterior dissection but was in all posterior dissections. A distinct anatomical structure, hereafter termed condylar strap (CS), was identified between the femur and the lateral gastrocnemius on one side and the deep surface of the ITB on the other, in all posteriorly dissected specimens. The structure had a mean thickness of 0.88 mm, and its femoral insertion was located between the distal Kaplan fibers and the epicondyle. The proximal femoral attachment of the structure had a mean width of 15.82 mm and the width of the distal insertion of the structure on the ITB was 13.27 mm. The mean length of the structure was 26.33 mm on its distal border and 21.88 mm on its proximal border. Qualitative evaluation of behavior in internal rotation revealed that this anatomical structure became tensioned and created a tenodesis effect on the ITB. Conclusions: There is a consistent structure that attaches to the deep ITB and the femoral epicondylar area. The orientation of fibers suggest that it may have a role in anterolateral knee stability. Clinical Relevance: This new anatomical description may help surgeons to optimize technical aspects of lateral extra-articular procedures in cases of anterolateral knee laxity

Anterolateral ligament reconstruction: a possible option in the therapeutic arsenal for persistent rotatory instability after ACL reconstruction

The results of anterior cruciate ligament reconstruction (ACLR) are widely recognized to be satisfactory on the basis of outcome measures such as the International Knee Documentation Committee (IKDC) and Lysholm scores. However, there is moderate variation among several series of different techniques. For example, Hussein et al showed a range of residual pivot, from 7% to 33%, depending on the technique used. Furthermore, up to 30% of patients in contemporary series can still experience persistent instability, and only 65% to 83% can return to the preinjury level of sport

Arthrogenic muscle inhibition after ACL reconstruction: a scoping review of the efficacy of interventions

Objective: To determine whether reported therapeutic interventions for arthrogenic muscle inhibition (AMI) in patients with ACL injuries, following ACL reconstruction, or in laboratory studies of AMI, are effective in improving quadriceps activation failure when compared with standard therapy in control groups. Design: A scoping review of the efficacy of interventions was conducted in accordance with the methodological framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search terms included 'arthrogenic muscle inhibition', 'quadriceps activation following knee injuries', 'anterior cruciate' or 'knee’ combined with 'quadriceps activation', 'quadriceps inhibition', 'corticomotor', 'arthrogenic', 'brain activation' and 'neuroplasticity'. Articles were evaluated for risk of bias using the PEDro (Physiotherapy Evidence Database) criteria. The overall quality of evidence for each intervention was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Data sources: PubMed, EMBASE and Cumulative Index to Nursing and Allied Health Literature databases. Eligibility criteria for selecting studies: Isolated case reports and articles reporting outcomes in patients with chronic disease or major trauma were excluded. All other original research articles were included. Results: 780 potential articles were identified. 20 met the inclusion criteria. These studies provided a moderate quality of evidence to support the efficacy of cryotherapy and physical exercises in the management of AMI. There was low-quality evidence for efficacy of neuromuscular electrical stimulation and transcutaneous electrical nerve stimulation, and very low-quality evidence for efficacy of ultrasound and vibration. Conclusions: This scoping review demonstrated moderate-quality evidence for the efficacy of cryotherapy and physical exercises in improving quadriceps activation failure after ACL injury and reconstruction. These therapeutic modalities are therefore recommended in the management of AMI

High lateral portal for sparing the infrapatellar fat-pad during ACL reconstruction

SummaryDuring arthroscopic ACL reconstruction, intra-articular visualization can be compromised by the interposition of the infrapatellar fat pad (IPFP) between the scope and the notch. In this technical note, we describe our technique of using lateral higher arthroscopic portal, starting arthroscopy with the resection of the ligamentum mucosum and performing the tibial tunnel in 40° of knee flexion to optimise the intra-articular view without IPFP debridement. This technique was performed in 112 consecutive arthroscopic ACL reconstructions and compared to that in the previous 112 cases in which a conventional method was used. The use of this technique was associated with a shorter operative time and no increase in the difficulty in performing associated meniscal procedures

Osteochondritis dissecans of the knee. Pearls and pitfalls of anatomical reduction and secure fixation

Osteochondritis dissecans of the knee is characterized by sterile necrosis of the subchondral bone and typically affects skeletally immature patients. When left untreated, osteochondritis dissecans can lead to early-onset osteoarthritis, resulting in pain and disability. This study shows the pearls and pitfalls of an arthroscopic technique of fixation performed successfully using a bioabsorbable nail for unstable osteochondritis dissecans lesions located in the medial femoral condyle of the knee

Isolated meniscotibial ligament rupture. The medial meniscus “belt lesion”

Ramp lesions play a major role in both anteroposterior and rotational instability following anterior cruciate ligament rupture. The meniscotibial ligament (MTL) is the most important structure to repair and is the primary stabilizer of the posterior horn of the medial meniscus. The posteroinferior insertion of the MTL on the posterior horn of the medial has been described, forming a posterior “belt.” Isolated MTL lesion diagnosis can be challenging, as the absence of a meniscocapsular ligament lesion prevents its correct visualization through transnotch vision. This article details a tech- nique to diagnose and repair the “belt lesion” of the medial meniscus

How to rapidly abolish knee extension deficit after injury or surgery: a practice-changing video pearl from the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group

Knee extension deficit is frequently observed after anterior cruciate ligament reconstruction or rupture and other acute knee injuries. Loss of terminal extension often occurs because of hamstring contracture and quadriceps inactivation rather than mechanical intra-articular pathology. Failure to regain full extension in the first few weeks after anterior cruciate ligament reconstruction is a recognized risk factor for adverse long-term outcomes, and therefore, it is important to try to address it. In this technical note, a simple, rapid, and effective technique to help regain full knee extension and abolish quadriceps activation failure is described