Lateral Extra-articular Tenodesis Alters Lateral Compartment Contact Mechanics under Simulated Pivoting Maneuvers: An In Vitro Study

Marom, Niv; Jahandar, Hamidreza; Fraychineaud, Thomas; Zayyad, Zaid; Ouanezar, Hervé; Hurwit, Daniel; Wickiewicz, Thomas L.; Pearle, Andrew D.; Imhauser, Carl W.; Nawabi, Danyal H.

doi:10.1177/03635465211028255

Cited by 17 publications

(11 citation statements)

References 62 publications

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“…However, to date, the advantages of combining LET with ACL reconstruction in pediatric patients have been infrequently evaluated. Moreover, there are some unresolved issues that have been raised in recent studies reporting the theoretical risk of knee overconstraint and the increase in lateral compartment pressures, 23,34,48 which can accelerate degenerative joint changes. It remains unclear whether such findings result in alterations in bone growth in patients who are still developing.…”

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confidence: 99%

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

et al. 2022

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Background: The increase in anterior cruciate ligament (ACL) injuries in pediatric patients and the high failure rate reported in the literature in this population are driving surgeons to search for specific techniques to better restore knee stability. Recent literature has reported that the combination of lateral extra-articular tenodesis (LET) and ACL reconstruction improves outcomes in high-risk patients. However, such advantages in pediatric patients have been infrequently evaluated. Purpose: To assess whether adding LET to ACL reconstruction can significantly improve knee stability, clinical outcomes, and failure rates in pediatric patients. Study Design: Cohort study; Level of evidence, 3. Methods: A multicentric study involving 3 orthopaedic teaching centers was conducted to evaluate pediatric patients aged between 12 and 16 years who had undergone primary ACL reconstruction using a physeal-sparing femoral tunnel drilling technique. A minimum 2-year follow-up evaluation was required. Based on the surgical technique performed, the patients were divided into 2 group. The patients in group 1 underwent an isolated arthroscopic ACL reconstruction, while the patients in group 2 had an arthroscopic ACL reconstruction in combination with a modified Lemaire LET procedure. Group 1 was a historical control cohort of patients, whereas group 2 was prospectively enrolled. All the patients included in the present study were clinically evaluated using the Pediatric International Knee Documentation Committee (Pedi-IKDC) subjective score and the Pediatric Functional Activity Brief Scale (Pedi-FABS) score. Anteroposterior knee stability was measured using the KT-1000 knee ligament arthrometer, and the objective pivot-shift evaluation was documented using a triaxial accelerometer (Kinematic Rapid Assessment [KiRA]). The included patients also underwent a standardized radiological protocol to evaluate leg-length discrepancies, axial deviation, and degenerative signs preoperatively and at last follow-up. Results: This study included 66 pediatric patients with an anatomic hybrid ACL reconstruction using an autologous 4-strand hamstring graft. In group 1, there were 34 patients (mean age, 13.5 ± 1.2 years), while 32 patients (mean age, 13.8 ± 1.4 years) were included in group 2. The clinical outcome scores showed no difference between the 2 groups (Pedi-IKDC, P = .072; Pedi-FABS, P = .180). Nevertheless, the patients in group 2 had better anteroposterior stability measured using a KT-1000 arthrometer (1.9 ± 1.1 mm in group 1 vs 0.8 ± 0.8 mm in group 2; P = .031), as well as better rotational stability measured using the KiRA (–0.59 ± 1.05 m/s2 in group 2 vs 0.98 ± 1.12 m/s2 in group 1; P = .012). The patients in group 1 returned to sports at the same competitive level at a rate of 82.4%, while patients included in group 2 returned at the same competitive level in 90.6% of the cases without a significant difference between the 2 groups ( P = .059). No leg-length discrepancies were found between the 2 groups at last follow-up ( P = .881). Two patients displayed an increased valgus deformity of 3° on the operated limb at last follow-up (1 patient in group 1 and 1 patient in group 2). Group 1 had a significatively higher cumulative failure rate (14.7% vs 6.3%; P = .021). No intra- or postoperative complications was observed between the 2 groups. Conclusion: Performing a modified Lemaire LET along with an ACL reconstruction with hamstring graft in pediatric patients reduced the cumulative failure rate and improved objective stability with no increase in intra- or postoperative complications. No significant difference was found between the 2 groups in terms of patient-reported outcomes or in the return-to-sports activity.

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confidence: 99%

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

et al. 2022

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“…In the same study, a clinically performed PS demonstrated an ATT of -10 mm and an ETR of approximately 15 ◦ . Loading profiles from this study were also adopted by other clinical trials [68]. Other studies reported values of -8 up to -12 mm of ATT and 15 ◦ - 21 ◦ of tibia rotation [72].…”

Section: Resultsmentioning

confidence: 99%

“…We would like to assess the impact of LET in future FE simulations that involve boundary conditions from rigid multibody dynamics resembling such activities. For example, the developed lateral tibiofemoral contact pressures after LET or the impact of ITB debilitation to knee loading due to graft harvesting are debatable topics that we would like to address [57, 68, 84, 85]. Moreover, in the scope of this work we developed a loading profile that seems to trigger the desired PS movement for the given knee model.…”

Section: Discussionmentioning

confidence: 99%

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Can lateral tenodesis improve the rotational stability of the ACL reconstruction? A finite element analysis

Risvas,

Stanev,

Moustakas

2023

Preprint

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One of the most common knee injuries is the Anterior Cruciate Ligament (ACL) rupture with severe implications on knee stability. The usual treatment is the ACL Reconstruction (ACLR) surgery where the surgeon replaces the torn ligament with a graft in an effort to restore knee kinematics. In case of excessive rotatory instability, Lateral Extra - Articular Tenodesis (LET) can be performed in combination with ACLR. Additionally, LET appears to reduce ACLR graft forces reducing graft failure chances. However, there are concerns about overconstraining physiological rotation. To gain insight in this controversial topic, we developed an automatic, open-source tool to create a series of Finite Element (FE) models attempting to investigate the interactions of ACLR and LET through simulation. We started by creating a validated model of the healthy knee joint that served as reference for subsequent FE simulations. Then, we created FE models of standalone ACLR and combined ACLR - LET. Each model was assessed by applying a loading profile that resembles the Pivot - Shift clinical exam. We measured the External Tibia Rotation (ETR), the Anterior Tibia Translation (ATT) of the lateral tibial compartment, and the ACLR graft stress developed around the femoral tunnel insertion site. We observed the following: a) LET reduces ETR and ATT compared to isolated ACLR, b) combined ACLR - LET is more sensitive to LET graft pretension with lower values showcasing performance closer to the healthy joint, c) LET reduces ACLR graft forces for the same pretension values, d) LET exhibits significant overconstraint for higher pretension values. In general, these findings are in agreement with relevant clinical studies and accentuate the potential of the developed framework as a tool that can assist orthopaedists during surgery planning. We provide open access for the FE models of this study to enhance research transparency, reproducibility and extensibility.

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“…Because LET is a non-anatomical reinforcement procedure, the main concern is its potential to over-constrain the lateral compartment, causing stiffness or accelerated development of lateral compartment osteoarthritis (OA). Some biomechanical studies have shown that the addition of LET to ACLR induced the over-restriction of tibial internal rotation compared to the intact knee [16,46]. Specifically, Inderhaug et al, suggested that the constraint on knee kinematics is affected by graft tension and knee flexion angle during fixation.…”

Section: Lateral Extra-articular Tenodesismentioning

confidence: 99%

Anatomy, Biomechanics, and Reconstruction of the Anterolateral Ligament of the Knee Joint

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Despite remarkable advances in the clinical outcomes after anterior cruciate ligament reconstructions (ACLRs), residual rotational instability of the knee joint remains a major concern. Since the anterolateral ligament (ALL) on the knee joint has been “rediscovered”, the role of anterolateral structures, including ALL and deep iliotibial band, as secondary stabilizers of anterolateral rotatory instability has gained interest. This interest has led to the resurgence of anterolateral procedures combined with ACLRs to restore rotational stability in patients with anterior cruciate ligament (ACL) deficiencies. However, the difference in concepts between anterolateral ligament reconstructions (ALLRs) as anatomical reconstruction and lateral extra-articular tenodesis (LETs) as non-anatomical reinforcement has been conflicting in present literature. This study aimed to review the anatomy and biomechanics of anterolateral structures, surgical techniques, and the clinical outcomes of anterolateral procedures, including LET and ALLR, in patients with ACL deficiencies.

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Lateral Extra-articular Tenodesis Alters Lateral Compartment Contact Mechanics under Simulated Pivoting Maneuvers: An In Vitro Study

Cited by 17 publications

References 62 publications

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Can lateral tenodesis improve the rotational stability of the ACL reconstruction? A finite element analysis

Anatomy, Biomechanics, and Reconstruction of the Anterolateral Ligament of the Knee Joint

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