A biomechanical comparison of the main anterolateral procedures used in combination with anterior cruciate ligament reconstruction

Abstract

Background: None of the anterolateral procedures used in combination with ACL reconstruction (ACLR) to control rotational laxity have demonstrated superiority. The objective was to compare the capacity of the main anterolateral procedures associated with ACLR to restore intact knee kinematics in case of combined ACL and anterolateral structure injury. Methods: The complete kinematics of 10 cadaveric knees, previously modelled by TDM, were recorded using a 3D Motion Analysis® system. Intact knee kinematics, including internal rotation (IR) of the tibial and anterior-posterior (AP) laxity at 30 and 90° flexion were initially assessed, followed by a sequential section of the ACL and anterolateral complex (ALC) (anterolateral ligament (ALL), ALL capsule and Kaplan fibers). After the ACLR, 5 anterolateral procedures were performed consecutively on the same knee: ALLR; Ellison; Deep Lemaire; Superficial Lemaire; and MacIntosh. The last three procedures were randomized. For each procedure, the graft was fixed in neutral rotation at 30° flexion with a tension of 20 N. Results: ACLR alone did not restore overall knee kinematics when there was an ACL+ALC injury, and resulted in residual rotational laxity of the tibia (p > 0.001). Only the ALLR (p=0.262) and modified Ellison (p=0.081) procedures restored normal global IR kinematics. Superficial/deep Lemaire and MacIntosh procedures resulted in over-constrained kinematic profiles (respectively: p=0.013, p=0.018 and p=0.030). In terms of ACLR, the addition of an anterolateral procedure did not provide additional control over AP translation at 30 and 90° (p > 0.05), exception for the surficial Lemaire procedure at 90° (p = 0.032). Discussion: ACLR alone was not sufficient to restore normal kinematics in ACL and ALC-deficient knees. ALLR and Ellison procedures restored physiological kinematics, unlike the MacIntosh procedure which caused additional control of IR and thereby induced over-constraint. Conclusion: The addition of ALLR or the modified Ellison procedure, which restore intrinsic kinematics, might be useful during primary ACL reconstruction to avoid repeated injury without a risk of over-constraint. The superficial/deep Lemaire and MacIntosh procedures resulted in over-constrained kinetics but provided additional rotation control that could be useful in revision surgery.

The effect of modelling parameters in the development and validation of knee joint models on ligament mechanics: A systematic review

“…Several studies have already used this idea (e.g. Blankevoort et al [ 82 ] and Neri et al [ 83 ]). A standard joint coordinate system (JCS), such as the Grood and Suntay [ 84 , 85 ], should also be adopted in combination with these activities.…”

Editorial Commentary: Nonanatomic Lateral Extra-Articular Procedures Performed at the Time of Anterior Cruciate Ligament Reconstruction Risk Overconstraint: Anatomic Anterolateral Ligament Reconstruction Does Not

“…20 Regardless, it is not confirmed that these issues have been fully resolved in contemporary practice. Although it is clear that combined reconstruction with either an ALL reconstruction or modified Lemaire procedure can restore normal knee kinematics without overconstraining the knee, 21 it is my opinion that overconstraint is perhaps more likely with a modified Lemaire procedure (because it is nonanatomic and the knee is fixed in flexion) when compared with an ALL reconstruction (anatomic, with the knee fixed in extension, replicating the normal biomechanics and anisometry of the ALL); this is supported by several biomechanical studies 17,[22][23][24][25][26] and a clinical report of overconstraint from the STAbiLiTY (Standard ACL Reconstruction vs ACL þ Lateral Extra-Articular Tenodesis) study. 27 However, the issue is clouded by the fact that we do not have a clear consensus on the definition of "overconstraint" and what degree of overconstraint is clinically important.…”

Towards a validated musculoskeletal knee model to estimate tibiofemoral kinematics and ligament strains: comparison of different anterolateral augmentation procedures combined with isolated ACL reconstructions

“…Neri et al [ 25 , 26 ] in a recent cadaveric study compared several of these anterolateral techniques. They found that adding either anterolateral ligament reconstruction or modified Ellison procedures returned the reconstructed knee closest to the native knee kinematics.…”

“…A return to natural knee kinematics is thought to provide an ideal mechanical environment for the ACL graft during its integration [ 27 ]. However, they also reported that some anterolateral procedures, while improving overall kinematics, also appear to cause increased lateral tibiofemoral compartment pressures [ 25 , 26 ]. Evidence suggests that this may accelerate knee osteoarthritis [ 28 ].…”

“…This study aimed to complement the cadaveric studies [ 25 , 26 ] by developing a subject-specific musculoskeletal computational model based on one of the cadaveric specimens. Kinematic data for the intact and ACL-sectioned cadaveric knee were used for validation.…”