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Berninger MT, Schüttrumpf JP, Barzen S, Domnick C, Eggeling L, Fehske K, Frosch KH, Herbst E, Hoffmann R, Izadpanah K, Kösters C, Neumann-Langen M, Raschke M, Zellner J, Krause M. S2k Guideline for Tibial Plateau Fractures - Classification, Diagnosis, and Treatment. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:510-520. [PMID: 37673084 DOI: 10.1055/a-2121-6538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Tibial plateau fractures are mostly complex and surgically demanding joint fractures, which require a comprehensive understanding of the fracture morphology, ligamentous and neurovascular injuries, as well as the diagnostic and therapeutic options for an optimal clinical outcome. Therefore, a standardised and structured approach is required. The success of the treatment of tibial plateau fractures relies on the interdisciplinary cooperation between surgical and conservative physicians in an outpatient and inpatient setting, physical therapists, patients and service providers (health insurance companies, statutory accident insurance, pension providers). On behalf of the German Society for Orthopaedics and Trauma Surgery (DGOU), the German Trauma Society (DGU) and the Society for Arthroscopy and Joint Surgery (AGA), under the leadership of the Fracture Committee of the German Knee Society (DKG), a guideline for tibial plateau fractures was created, which was developed in several voting rounds as part of a Delphi process. Based on the current literature, this guideline is intended to make clear recommendations and outline the most important treatment steps in diagnostics, therapy and follow-up treatment. Additionally, 25 statements were revised by the authors in several survey rounds using the Likert scale in order to reach a final consensus.
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Affiliation(s)
- Markus Thomas Berninger
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | | | - Stefan Barzen
- Unfallchirurgie und operative Orthopädie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Christoph Domnick
- Klinik für Unfall- und Handchirurgie, Orthopädie, Euregio Klinik, Nordhorn, Deutschland
| | - Lena Eggeling
- Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Kai Fehske
- Klinik und Poliklinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Elmar Herbst
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Munster, Deutschland
| | - Reinhard Hoffmann
- Unfallchirurgie und operative Orthopädie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Deutschland
| | - Kaywan Izadpanah
- Department für Orthopädie und Traumatologie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Clemens Kösters
- Klinik für Orthopädie, Unfall- und Handchirurgie, Maria-Josef-Hospital Greven, Greven, Deutschland
| | - Mirjam Neumann-Langen
- Klinik für Unfallchirurgie, Handchirurgie und Orthopädie, Klinikum Konstanz, Konstanz, Deutschland
| | - Michael Raschke
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Munster, Deutschland
| | - Johannes Zellner
- Orthopädie und Sportmedizin, Sporthopaedicum Regensburg, Regensburg, Deutschland
| | - Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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Sherman SL, Raji Y, Calcei JG, Sherman MF. Anterior Cruciate Ligament Repair-Here to Stay or History Repeating Itself? Clin Sports Med 2024; 43:433-448. [PMID: 38811120 DOI: 10.1016/j.csm.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Anterior cruciate ligament (ACL) injuries continue to be a prevalent concern among athletes and individuals with an active lifestyle. Traditionally, the standard of care for ACL tears has involved surgical reconstruction using autograft or allograft. This article aims to provide an overview of the evolving landscape of primary ACL repair, examining the current evidence, surgical techniques, patient selection criteria, outcomes, and potential future directions in this field.
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Affiliation(s)
- Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway, MC 6342, Pavilion C, Redwood City, CA 94063, USA.
| | - Yazdan Raji
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway, MC 6342, Pavilion C, Redwood City, CA 94063, USA
| | - Jacob G Calcei
- University Hospitals Drusinsky Sports Medicine Institute, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Hanna House 6th Floor, Cleveland, OH 44106, USA
| | - Mark F Sherman
- Richmond University Medical Center, 2052 Richmond Road, Staten Island, NY 10306, USA
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Itthipanichpong T, Kulrat P, Limskul D, Tanpowpong T, Virulsri C, Tangpornprasert P, Kuptniratsaikul S, Thamrongskulsiri N. Traditional suture tape versus multiple high-strength sutures for augmentation of anterior cruciate ligament primary repair: A time-zero biomechanical study. Asia Pac J Sports Med Arthrosc Rehabil Technol 2024; 35:39-42. [PMID: 38162803 PMCID: PMC10755459 DOI: 10.1016/j.asmart.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/20/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
Background/objective During the initial stages of rehabilitation after anterior cruciate ligament (ACL) surgery, a pivotal role is played in ensuring effective recuperation and averting complications. An often-employed strategy to tackle ACL laxity during this period involves the incorporation of synthetic materials for reinforcement. The objective of this study is to compare the effectiveness of conventional suture tape and multiple high-strength sutures as augmentation techniques for ACL repair. Methods Ten preserved cadaveric knees embalmed using the Thiel method were segregated into two groups, each containing five knees. In one group, traditional suture tape was employed for augmentation, while the other group utilized multiple high-strength sutures. Each knee underwent a cyclic load of 1000 sine wave cycles, succeeded by an axial distraction load until failure ensued. The resultant displacement and ultimate load at failure were assessed to contrast the efficacy of the two augmentation techniques. Results The group utilizing multiple high-strength sutures exhibited a significantly higher load to failure at time-zero (1690.7 N) compared to the suture tape group (987.6 N) (P = .003). Furthermore, the multiple high-strength sutures group demonstrated significantly reduced displacement after 1000 cyclic loads (6.6 mm) in comparison to the suture tape group (16.3 mm) (P < .001). Conclusions Multiple high-strength sutures show better biomechanical properties for the augmentation of ACL repair at time-zero. Both suture tape and multiple high-strength sutures had ultimate load-to-failure values higher than the natural ACL loads. Therefore, these substances might serve as augmentation options to prevent the ACL's gradual elongation, a critical concern particularly in the initial stages of rehabilitation.
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Affiliation(s)
- Thun Itthipanichpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Puchong Kulrat
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Danaithep Limskul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Thanathep Tanpowpong
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Chanyaphan Virulsri
- Center of Excellence for Prosthetic and Orthopedic Implant, Department of Mechanical Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Pairat Tangpornprasert
- Center of Excellence for Prosthetic and Orthopedic Implant, Department of Mechanical Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Somsak Kuptniratsaikul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
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Gensior TJ, Mester B, Achtnich A, Winkler PW, Henkelmann R, Hepp P, Glaab R, Krause M, Frosch KH, Zellner J, Schoepp C. Anatomic repair and ligament bracing as an alternative treatment option for acute combined PCL injuries involving the posteromedial or posterolateral corner-results of a multicentre study. Arch Orthop Trauma Surg 2023; 143:7123-7132. [PMID: 37691046 PMCID: PMC10635947 DOI: 10.1007/s00402-023-05015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/24/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Combined PCL injuries involving the posteromedial/-lateral corner (PMC/PLC) usually require surgical management. Literature shows controversy regarding the standards of treatment. Suture-augmented repair leads to excellent results in acute knee dislocations but has not been investigated clinically in combined PCL injuries. The purpose of this multicentre study was to evaluate the clinical outcome of this technique in acute combined PCL injuries. MATERIALS & METHODS N = 33 patients with acute combined PCL injuries involving the PMC/PLC were treated by one-stage suture repair with ligament bracing of the PCL and suture repair of the accompanying PMC/PLC injuries with/without ligament bracing or primary augmentation by semitendinosus autograft. Outcome was assessed by IKDC questionnaire, Lysholm Score, Tegner Activity Scale and KOOS. Additional PCL stress-radiography was performed. RESULTS N = 31 patients with combined PCL injuries (female: male = 7:24; age 39.1 ± 13.8 years) with a follow-up of 16.8 ± 9.6 months were finally evaluated. 18 had PMC injuries, 13 PLC injuries. 32.2% presented with accompanying meniscal tears (70% medial meniscus). 19.4% showed cartilage injuries grade III-IV. Complications included one infection and four knee stiffnesses. Three had symptomatic postoperative instability, all affiliated to the PLC group. The IKDC was 69.8 ± 16.5, Lysholm score 85 ± 14.4 and KOOS 89.7 ± 8.1. Median loss of activity (Tegner) was 0.89 ± 1.31. Comparing PMC and PLC, all scores showed a tendency towards more favourable outcomes in the PMC group (n.s.). Stress-radiography showed an overall side-to-side difference of 3.7 ± 3.8 mm. Subgroup evaluation showed statistically significant better results (p = 0.035) of PMC (2.5 ± 1.5 mm) versus PLC (5.8 ± 5.6 mm). CONCLUSIONS One-stage suture repair with ligament bracing is a viable technique for acute combined PCL injuries and predominantly leads to good and excellent clinical outcomes. Patients with PLC injuries show a tendency towards inferior outcomes and higher instability rates compared to PMC injuries. These results may help in therapy planning and counselling patients with these rare injury pattern. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Tobias J Gensior
- OPND Clinic Neuss-Düsseldorf, Neuss, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Bastian Mester
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany.
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland.
| | - Andrea Achtnich
- Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Ligament Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Philipp W Winkler
- Department of Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria
| | - Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Pierre Hepp
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Richard Glaab
- Department of Traumatology, Cantonal Hospital Aarau, Aarau, Switzerland
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Ligament Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Clinic Hamburg, Hamburg, Germany
| | - Johannes Zellner
- Sporthopaedicum Regensburg, Regensburg, Germany
- Trauma Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
| | - Christian Schoepp
- Clinic for Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Clinic Duisburg, Duisburg, Germany
- Ligament Committee of the AGA (Society for Arthroscopy and Joint Surgery), Zurich, Switzerland
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Frings J, Behrendt P, Krause M, Frosch KH. [Multiligament instabilities of the knee in sports injuries : An update of the Hamburg concept]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:882-888. [PMID: 37773214 DOI: 10.1007/s00132-023-04438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Knee dislocation (KD) is a rare but severe injury of the knee joint, with a high rate of concomitant neurovascular injuries. The severity of the ligamentous injury, which is classified according to the Schenck classification, the mechanism of injury, concomitant injuries and individual factors determine the treatment strategy in KD. TREATMENT STRATEGY Furthermore, a clear differentiation between high-velocity (HV) and low-velocity (LV) injuries is necessary. Generally, surgical treatment within 7-10 days should be aspired. Herein, the one-stage hybrid treatment using augmented ligament sutures (ligament bracing) in combination with primary ligament reconstruction (posterolateral and ACL) leads to very good functional results in the mid-term. Ultra-low-velocity (ULV) dislocations and those with concomitant peroneal lesions require a modified approach, due to a limited prognosis. During rehabilitation, the individual progress must be closely monitored and follow an early functional approach. In approximately 20% of all cases, early arthroscopic arthrolysis shows a high success rate.
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Affiliation(s)
- Jannik Frings
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | | | - Matthias Krause
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
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Raja BS, Arora M, Gowda AKS, Maheshwari VK, Regmi A. Augmentation with Fibertape Leads to Biomechanically Superior but Similar Clinical Outcomes in ACL Surgeries: Systematic Review and Meta-analysis. Indian J Orthop 2023; 57:722-747. [PMID: 37128558 PMCID: PMC10147891 DOI: 10.1007/s43465-022-00805-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 12/15/2022] [Indexed: 01/09/2023]
Abstract
Purpose The current generation has witnessed significant progress in the field of knee arthroscopy. Suture tapes have gained immense popularity due to perceived improved biomechanical support to the graft while it heals. The purpose of the present systematic review is to analyze the biomechanical construct of suture tapes in ACL repairs and reconstructions along with clinical outcomes. Methods Cochrane Library, PubMed, and Embase were searched until December 2021. All Biomechanical Studies on animal or cadaver knees that compared construct characteristics of suture tape in ACL repair or reconstruction and clinical studies in English focusing on outcomes following suture tape augmentation in ACL repair or reconstruction were included. The quality of clinical studies using the Modified Coleman Methodology Score (MCMS). Results A total of 16 studies biomechanical and 23 clinical studies were included in qualitative synthesis, leaving nine biomechanical studies for final quantitative analyses. Suture tape revealed biomechanical superiority in terms of ultimate strength, stiffness, cyclic displacement, and elongation of graft, while comparing ACLR with internal brace to standard ACLR. No significant difference in retear rates was seen in clinical studies. Clinical score(IKDC score) was found similar in both augmented and non-augmented construct. Similar results were obtained in biomechanical studies. Conclusion The use of suture tape as a ligament augmentation in both ACL reconstruction and ACL repair offers more strength, less elongation or displacement, and is biomechanically stable and sound. There is a lack of data to comprehensively comment upon the clinical superiority of the use of internal augmentation. However, a meta-analysis of the retear rates and clinical outcome score revealed similar outcomes between suture tape augmented and nonaugmented groups.
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Affiliation(s)
- Balgovind S. Raja
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Manit Arora
- Department of Orthopaedics, Fortis Hospital, Mohali, Punjab India
| | - Aditya K. S. Gowda
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Vikas K. Maheshwari
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Anil Regmi
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India
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Cruz CA, Mannino BJ, Venrick CB, Miles RN, Peterson DR, Zhou L, Min KS, Bottoni CR. Failure Rates After Anterior Cruciate Ligament Repair With Suture Tape Augmentation in an Active-Duty Military Population. Orthop J Sports Med 2023; 11:23259671221142315. [PMID: 36814764 PMCID: PMC9940188 DOI: 10.1177/23259671221142315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 09/26/2022] [Indexed: 02/24/2023] Open
Abstract
Background Anterior cruciate ligament (ACL) repair had previously been considered the standard of care for a ruptured ACL; however, ACL reconstruction has became the standard of care because of poor midterm outcomes after ACL repair. Recently, studies have suggested that the treatment paradigm should shift back to ACL repair. Purpose/Hypothesis The purpose of this study was to evaluate the outcomes of ACL repair augmented with suture tape in a high-demand military population. We hypothesized that for proximal ACL avulsions, ACL repair with suture tape augmentation would lead to acceptable failure rates, satisfactory knee stability, excellent functional outcomes, and high rates of return to preinjury activity levels. Study Design Case series; Level of evidence, 2. Methods Patients who were treated with ACL repair by a single surgeon between March 2017 and June 2019 and who had a minimum of 2 years of follow-up were included. Intraoperatively, all patients first underwent an arthroscopic examination. If an ACL avulsion of the proximal insertion with adequate remaining tissue was visualized, then ACL repair was performed. The primary outcome assessed was ACL repair failure, defined as reruptures or clinical instability requiring revision to ACL reconstruction. Analysis of the risk factors for ACL repair failure was conducted, with age at surgery, sex, body mass index, level of competition, and tobacco use evaluated. Results Included were 46 patients (32 male and 14 female; mean age, 28.3 ± 8.4 years) who underwent ACL repair with suture tape augmentation. There were 12 cases of failure (26.1%; 8 male and 4 female). The mean time from injury to surgery in the failure group was 164.1 ± 59.4 days compared to 107.3 ± 98.0 days in the nonfailure group (P = .02). According to multivariate regression analysis, patients aged ≤17 and ≥35 years, elite/competitive/operational patients, and current smokers had a higher chance of ACL repair failure. The mean time to pass a military physical fitness test was 5.0 months. There were no complications other than ACL repair failure. Conclusion Primary arthroscopic ACL repair with suture tape augmentation resulted in unacceptably high failure rates at a minimum of 2 years of follow-up in a highly active military population. Age ≤17 and ≥35 years, elite level of competition, time from injury to surgery, and active tobacco use were independent risk factors for ACL repair failure.
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Affiliation(s)
- Christian A. Cruz
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA.,Christian A. Cruz, MD, Department of Orthopaedic Surgery, Tripler Army Medical Center, 1 Jarret White Road, Honolulu, HI 96859, USA ()
| | - Brian J. Mannino
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Connor B. Venrick
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Rebecca N. Miles
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - David R. Peterson
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Liang Zhou
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Kyong S. Min
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Craig R. Bottoni
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
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Watrinet J, von Rüden C, Regenbogen S, Brand A, Bormann M, Stuby FM, Fürmetz J. Mid-Term Results following Traumatic Knee Joint Dislocation. J Clin Med 2022; 12:jcm12010266. [PMID: 36615066 PMCID: PMC9821045 DOI: 10.3390/jcm12010266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Although treatment strategies of knee joint dislocations have evolved, there is still no consensus on the best method and timing. New therapeutic concepts suggest that early one-stage treatment, including suturing and bracing of the cruciate ligaments in acute knee joint dislocation, are leading to improved functional results. This study aimed to evaluate the midterm functional outcome following traumatic knee joint dislocation and to determine whether the outcome is influenced by the surgical management, patient habitus or concomitant injuries. METHODS In this retrospective single center study, 38 patients with acute Schenck type II to IV knee dislocations were treated over an eight-year period in a level I trauma center. At follow-up, various clinical scores, such as the International Knee Documentation Committee (IKDC) Score, Lysholm Score, and Tegner Activity Scale (TAS), and individual questions about rehabilitation and activity levels of 38 patients were evaluated. RESULTS Mean follow-up was 5.5 ± 2.7 years. The mean IKDC Score was 65.6 ± 15.7 points, the average Lysholm Score was 70.5 ± 16.4 points and the median TAS was 4 (0-7), resulting in a loss of activity of 2 (range 0-6) points. There was no significant difference between a one-stage treatment compared to a two-stage approach. Ligament reconstruction of the ACL in a two-stage approach was required in only 33.3%. Further operations (early and late) were performed in 37% of cases. Being overweight was associated with more complications and worse outcomes, and external fixation with arthrofibrosis. CONCLUSIONS Knee dislocation is a severe trauma that often leads to a prolonged loss of function and increased knee pain over years, affecting the patient's activity. Clinical outcome is influenced significantly by concomitant injuries. Severe cases with initial external fixation are associated with a higher risk of knee stiffness and should be considered during rehabilitation. Obese patients present a challenge due to higher complication rates and lower postoperative knee function. LEVEL OF EVIDENCE Retrospective single center study, level III.
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Affiliation(s)
- Julius Watrinet
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian von Rüden
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Stephan Regenbogen
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Andreas Brand
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute of Biomechanics, BG Trauma Center Murnau, 82418 Murnau, Germany
| | - Markus Bormann
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany
| | - Fabian M. Stuby
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Julian Fürmetz
- Department Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munich, Germany
- Correspondence:
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Herbst E, Raschke MJ, Peez C, Briese T, Oeckenpöhler S. [Ligament injuries in tibial plateau fractures]. Unfallchirurg 2022; 125:535-541. [PMID: 35394156 DOI: 10.1007/s00113-022-01177-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
Abstract
Fracture dislocations of the proximal tibia are associated with a markedly high incidence of ligament ruptures. Despite knowledge on the frequency of accompanying ligament injuries, even now neither adequate diagnostics nor targeted treatment of associated ligament injuries are the gold standard in the treatment algorithm for tibial plateau fractures. To be able to assess the risk and the type of accompanying ligament injuries in tibial plateau fractures, it is recommended to decidedly analyze the fracture morphology. For example, flexion varus fractures are very frequently associated with injuries to the anterior cruciate ligament, whereas valgus fractures are prone to ruptures of the medial collateral ligament and (hyper)extension fractures facilitate ruptures of the posterior cruciate ligament and the posterolateral corner. In order not to overlook high-grade instability, magnetic resonance imaging or intraoperative dynamic fluoroscopy can be carried out after completing osteosynthesis. Bony avulsions should either be addressed directly during osteosynthesis or indirectly retained via interfragmentary compression. In cases of direct visualization or relevant instability, intraligamentous tears should at least be intraoperatively reduced. If patients suffer from persistent instability a secondary ligament reconstruction with autologous tendons can be carried out following bony consolidation of the tibial plateau fracture.
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Affiliation(s)
- Elmar Herbst
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert, Schweitzer-Campus 1, 48147, Münster, Deutschland.
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert, Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Christian Peez
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert, Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Thorben Briese
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert, Schweitzer-Campus 1, 48147, Münster, Deutschland
| | - Simon Oeckenpöhler
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert, Schweitzer-Campus 1, 48147, Münster, Deutschland
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Drenck TC, Preiss A, Domnick C, Herbort M, Frings J, Akoto R, Krause M, Frosch KH. The Popliteus Bypass provides superior biomechanical properties compared to the Larson technique in the reconstruction of combined posterolateral corner and posterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc 2021; 29:732-741. [PMID: 32372281 DOI: 10.1007/s00167-020-05987-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/07/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aimed to compare the biomechanical properties of the popliteus bypass against the Larson technique for the reconstruction of a combined posterolateral corner and posterior cruciate ligament injury. METHODS In 18 human cadaver knees, the kinematics for 134 N posterior loads, 10 Nm varus loads, and 5 Nm external rotational loads in 0°, 20°, 30°, 60,° and 90° of knee flexion were measured using a robotic and optical tracking system. The (1) posterior cruciate ligament, (2) meniscofibular/-tibial fibers, (3) popliteofibular ligament (PFL), (4) popliteotibial fascicle, (5) popliteus tendon, and (6) lateral collateral ligament were cut, and the measurements were repeated. The knees underwent posterior cruciate ligament reconstruction, and were randomized into two groups. Group PB (Popliteus Bypass; n = 9) underwent a lateral collateral ligament and popliteus bypass reconstruction and was compared to Group FS (Fibular Sling; n = 9) which underwent the Larson technique. RESULTS Varus angulation, posterior translation, and external rotation increased after dissection (p < 0.01). The varus angulation was effectively reduced in both groups and did not significantly differ from the intact knee. No significant differences were found between the groups. Posterior translation was reduced by both techniques (p < 0.01), but none of the groups had restored stability to the intact state (p < 0.02), with the exception of group PB at 0°. No significant differences were found between the two groups. The two techniques revealed major differences in their abilities to reduce external rotational instability. Group PB had less external rotational instability compared to Group FS (p < 0.03). Only Group PB had restored rotational instability compared to the state of the intact knee (p < 0.04) at all degrees of flexion. CONCLUSION The popliteus bypass for posterolateral reconstruction has superior biomechanical properties related to external rotational stability compared to the Larson technique. Therefore, the popliteus bypass may have a positive influence on the clinical outcome. This needs to be proven through clinical trials.
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Affiliation(s)
- Tobias C Drenck
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Achim Preiss
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Christoph Domnick
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Mirco Herbort
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Jannik Frings
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Ralph Akoto
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Matthias Krause
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center, Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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ACL Repair: A Game Changer or Will History Repeat Itself? A Critical Appraisal. J Clin Med 2021; 10:jcm10050912. [PMID: 33652689 PMCID: PMC7956607 DOI: 10.3390/jcm10050912] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/05/2021] [Accepted: 02/22/2021] [Indexed: 01/13/2023] Open
Abstract
Until the past decade the common thought was that the anterior cruciate ligament (ACL) was not able to heal and restore knee stability. In this manuscript a brief review of studies of the developers and the early adaptors of four different modern ACL repair techniques are presented. The present status and considerations for the future of ACL repair and its research are shared. After promising short- to midterm ACL healing results by the developers, the results of the early adaptors show more variety in terms of rerupture and reintervention for other reasons. Risk factors for failure are a young age, high preinjury sports activity level, midsubstance ruptures and impaired integrity of the ACL bundles and the synovial sheath. There is a call for more clinical data and randomized clinical trials. Conclusion: an important finding of the past decade is that the ACL is able to heal and subsequently restabilize the knee. Patient selection is emphasized: the ideal patient is a non-high athlete older than 25 and has an acute proximal one bundle ACL rupture. Further research will have to show if ACL repair could be a game changer or if history will repeat itself.
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Suspension button constructs restore posterior knee laxity in solid tibial avulsion of the posterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2021; 29:4163-4171. [PMID: 33675369 PMCID: PMC8595177 DOI: 10.1007/s00167-021-06510-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/17/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Dislocated tibial avulsions of the posterior cruciate ligament (PCL) require surgical intervention. Several arthroscopic strategies are options to fix the fragment and restore posterior laxity, including two types of suspension button devices: adjustable (self-locking) and rigid knotted systems. Our hypothesis was that a rigid knotted button construct has superior biomechanical properties regarding laxity restoration compared with an adjustable system. Both techniques were compared with standard screw fixation and the native PCL. METHODS Sixty porcine knees were dissected. The constructs were tested for elongation, stiffness, yield force, load to failure force, and failure mode in a material testing machine. Group N (native, intact PCL) was used as a control group. In group DB (Dogbone™), TR (Tightrope™), and S (screw), a standardized block osteotomy with the osteotomized fragment attached to the PCL was set. The DB and TR groups simulated using a suspension button system with either a rigid knotted (DB) or adjustable system (TR). These groups were compared to a screw technique (S) simulating antegrade screw fixation from posterior. RESULTS Comparing the different techniques (DB, TR, S), no significant elongation was detected; all techniques achieved a sufficient posterior laxity restoration. Significant elongation in the DB and TR group was detected compared with the native PCL (N). In contrast, screw fixation did not lead to significant elongation. The stiffness, yield load, and load to failure force did not differ significantly between the techniques. None of the techniques reached the same level of yield load and load to failure force as the intact state. CONCLUSION Arthroscopic suspension button techniques sufficiently restore the posterior laxity and gain a comparable construct strength as an open antegrade screw fixation.
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Management of acute knee dislocations: anatomic repair and ligament bracing as a new treatment option-results of a multicentre study. Knee Surg Sports Traumatol Arthrosc 2019; 27:2710-2718. [PMID: 30631909 DOI: 10.1007/s00167-018-5317-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 12/04/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE The literature shows no consensus regarding the best method and timing for the treatment of acute knee dislocations. Studies indicate that a one-stage procedure performed in the early stages of injury can lead to superior results. The aim of this study was to evaluate the results after performing early surgical repair with additional suture augmentation (ligament bracing) of all torn ligaments in acute knee dislocations. METHODS In this prospective multicentre study, 73 patients with an acute type III or IV knee dislocation were treated with one-stage ligament bracing within 10 days. Twenty-six patients sustained a type III medial dislocation, thirty-nine patients sustained a type III lateral dislocation, and eight patients presented a type IV dislocation. Four patients were lost to follow-up. Within the follow-up evaluation, various scores were collected (International Knee Documentation Committee IKDC Score, Tegner Score and Lysholm Score). Additional stress radiography was performed (Telos™) postoperatively. RESULTS Sixty-nine knee dislocations (Schenck III and IV) with a follow-up at a mean of 14 ± 1.6 months were evaluated. The average IKDC score was 75.5 ± 14.5, the average Lysholm score was 81.0 ± 15.5, and the median loss of activity in the Tegner score was 1 (range 0-3) point. Stress radiographs showed side-to-side differences at a mean of 3.2 ± 1.3 mm for the anterior cruciate ligament (ACL) and of 2.9 ± 2.1 mm for the posterior cruciate ligament (PCL). The operative revision rate (early and late) was 17.4%. In the early stage, one wound infection and one case of transient common peroneal nerve (CPN) paresis were successfully revised. In the later stage, four patients with knee stiffness and six cases with symptomatic knee instability needed reoperation. Patients without ultra-low velocity (ULV) dislocations or CPN showed good or excellent results in 87.5% according to the Lysholm score. CONCLUSION In cases of acute knee dislocation, primary ACL and PCL transosseous sutures with additional suture augmentation predominantly lead to good and excellent clinical results. Obese patients sustaining ultra-low velocity (ULV) dislocations and patients following injury to the CPN show inferior outcomes. In patients without ULV and CPN intraoperative and postoperative complications occurred in 10.1%. The obtained results and revision rates show that early primary suture repair is a promising option. LEVEL OF EVIDENCE Prospective multicentre study, II.
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14
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Leister I, Kulnik ST, Kindermann H, Ortmaier R, Barthofer J, Vasvary I, Katzensteiner K, Mattiassich G. Functional performance testing and return to sport criteria in patients after anterior cruciate ligament injury 12–18 months after index surgery: A cross-sectional observational study. Phys Ther Sport 2019; 37:1-9. [DOI: 10.1016/j.ptsp.2019.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 01/16/2023]
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Arthroscopic primary repair of proximal anterior cruciate ligament tears: outcomes of the first 56 consecutive patients and the role of additional internal bracing. Knee Surg Sports Traumatol Arthrosc 2019; 27:21-28. [PMID: 30612165 DOI: 10.1007/s00167-018-5338-z] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/07/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Recent outcomes of arthroscopic primary repair of proximal anterior cruciate ligament (ACL) tears have been promising in small cohort studies. The purpose of this study was to assess outcomes of arthroscopic ACL repair in a larger cohort and to assess the role of additional augmentation. METHODS The first 56 consecutive patients that underwent arthroscopic ACL repair were examined at minimum 2-year follow-up. The latter 27 patients [48.2% (27/56)] received additional internal bracing with ACL repair. All 56 patients were included (100% follow-up). Mean age at surgery was 33.5 ± 11.3 years (59% male) and mean follow-up 3.2 ± 1.7 years. Clinical examination was performed using the objective International Knee Documentation Committee (IKDC) form. Subjective outcomes were obtained using the Lysholm, modified Cincinnati, Single Assessment Numeric Evaluation (SANE), and subjective IKDC scores. RESULTS Six repairs (10.7%) failed and four additional patients underwent reoperation (7.1%): two for meniscus tears and two for suture anchor irritation. Objective IKDC scores were A in 38 (73%), B in 8 (15%) and C/D in 6 (12%) patients. Mean Lysholm score was 94 ± 7.6, modified Cincinnati 94 ± 8.9, SANE 90 ± 12.5, pre-injury Tegner 6.7 ± 1.5, current Tegner 6.2 ± 1.5, and subjective IKDC 90 ± 10.9. Failures rates were 7.4% with and 13.8% without internal bracing (P = 0.672). There were no statistically significant or clinically relevant differences in subjective outcomes. CONCLUSION Arthroscopic primary repair has resulted in good objective and subjective outcomes at 3.2-year follow-up in a carefully selected population. The role of additional internal bracing is possibly beneficial, but larger groups are needed to assess this. LEVEL OF EVIDENCE III.
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Heusdens CHW, Hopper GP, Dossche L, Roelant E, Mackay GM. Anterior cruciate ligament repair with Independent Suture Tape Reinforcement: a case series with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 2019; 27:60-67. [PMID: 30382289 DOI: 10.1007/s00167-018-5239-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 10/17/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE The treatment of acute anterior cruciate ligament (ACL) ruptures with a repair technique has recently regained interest. A novel ACL repair technique was described using Independent Suture Tape Reinforcement with 2-year follow-up results. METHODS Forty-two consecutive patients with an acute ACL rupture undergoing repair using this technique were followed up for a minimum of 2 years. Patients with mid-substance, distal ACL ruptures, poor ACL tissue quality or retracted ACL remnants as well as patients with multi-ligament injuries were excluded. Knee Injury and Osteoarthritis Outcome Score (KOOS), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12 Item Health Survey (VR-12) and the Marx Activity scale were collected by online questionnaires. Two-year postoperative patients were asked by telephone if they had experienced a rerupture. RESULTS All the KOOS subscales improved significantly in comparison to the preoperative score. The largest improvement of all scores was seen at 3 months postoperatively which is significant in all cases. The KOOS sport and recreation showed a meaningful change and the largest improvement of the KOOS subscales at 3 months postoperatively, as well as the highest total improvement at 1 year postoperatively compared to preoperatively. The VAS-pain and VR-12 physical score improved significantly, however the Marx activity scale decreased significantly in comparison to preoperative scores. Two patients reported a rerupture (4.8%, CI 1.7-11.2%). CONCLUSIONS This is the first case series that described the 2-year follow-up results of patients with an acute, proximal ACL rupture, treated with the Independent Suture Tape Reinforcement repair technique. A meaningful KOOS sport and recreation change and significant improvements in the KOOS, VAS-pain and VR-12 physical scores as well as a significant decrease of the Marx activity scale in comparison to preoperative scores are demonstrated. Two of the 42 patients (4.8%) reported an ACL rerupture. Repair with this technique could be clinically relevant as a treatment option for patients with an acute, proximal ACL rupture which is not retracted and of good tissue quality. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Graeme P Hopper
- Speciality Registrar (T&O), Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, Scotland
| | - Lieven Dossche
- Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Ella Roelant
- Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
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Achtnich A, Schmitt A, Forkel P, Imhoff AB, Beitzel K. [Acute injury of the posterior cruciate ligament with femoral avulsion : Arthroscopic ligament repair and bracing]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 31:12-19. [PMID: 30478635 DOI: 10.1007/s00064-018-0578-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/04/2018] [Accepted: 09/28/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim of arthroscopic bracing of the posterior cruciate ligament (PCL) is to restore anatomic and biomechanic function in acute PCL tears. Therefore, primary augmentation of the PCL by using a stable suturing system is used. INDICATIONS Acute tears of the PCL, femoral avulsions, isolated or combined in cases of multiligament injuries (knee dislocations of Schenk types II-IV). CONTRAINDICATIONS Chronic instabilities of the PCL, infection of the knee joint. SURGICAL TECHNIQUE Arthroscopic preparation of the femoral PCL footprint. Suturing of the PCL stump with non-resorbable sutures. Placement of the femoral and tibial tunnel with a specific arthroscopic PCL guide. Femoral fixation of the bracing system and the PCL augmenting sutures extracortical via a button or intraarticular with a suture anchor. Tibial fixation via a button has to be performed in a minimum of 80° of flexion and under permanent anterior drawer tension. POSTOPERATIVE MANAGEMENT Brace in full extension with posterior support 24 h/day, range of motion (ROM) restricted up to 90° of flexion and limited weight bearing with 20 kg for the first 6 weeks postoperatively. After 6 weeks, weight bearing and ROM can be increased and a solid frame brace with posterior support is recommended for the next 6 weeks.
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Affiliation(s)
- A Achtnich
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - A Schmitt
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P Forkel
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - A B Imhoff
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - K Beitzel
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
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Dynamic augmentation restores anterior tibial translation in ACL suture repair: a biomechanical comparison of non-, static and dynamic augmentation techniques. Knee Surg Sports Traumatol Arthrosc 2018; 26:2986-2996. [PMID: 29396585 DOI: 10.1007/s00167-018-4848-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/24/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE There is a lack of objective evidence investigating how previous non-augmented ACL suture repair techniques and contemporary augmentation techniques in ACL suture repair restrain anterior tibial translation (ATT) across the arc of flexion, and after cyclic loading of the knee. The purpose of this work was to test the null hypotheses that there would be no statistically significant difference in ATT after non-, static- and dynamic-augmented ACL suture repair, and they will not restore ATT to normal values across the arc of flexion of the knee after cyclic loading. METHODS Eleven human cadaveric knees were mounted in a test rig, and knee kinematics from 0° to 90° of flexion were recorded by use of an optical tracking system. Measurements were recorded without load and with 89-N tibial anterior force. The knees were tested in the following states: ACL-intact, ACL-deficient, non-augmented suture repair, static tape augmentation and dynamic augmentation after 10 and 300 loading cycles. RESULTS Only static tape augmentation and dynamic augmentation restored ATT to values similar to the ACL-intact state directly postoperation, and maintained this after cyclic loading. However, contrary to dynamic augmentation, the ATT after static tape augmentation failed to remain statistically less than for the ACL-deficient state after cyclic loading. Moreover, after cyclic loading, ATT was significantly less with dynamic augmentation when compared to static tape augmentation. CONCLUSION In contrast to non-augmented ACL suture repair and static tape augmentation, only dynamic augmentation resulted in restoration of ATT values similar to the ACL-intact knee and decreased ATT values when compared to the ACL-deficient knee immediately post-operation and also after cyclic loading, across the arc of flexion, thus allowing the null hypotheses to be rejected. This may assist healing of the ruptured ACL. Therefore, this study would support further clinical evaluation of dynamic augmentation of ACL repair.
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Jonkergouw A, van der List JP, DiFelice GS. Multiligament Repair With Suture Augmentation in a Knee Dislocation With Medial-Sided Injury. Arthrosc Tech 2018; 7:e839-e843. [PMID: 30167362 PMCID: PMC6112193 DOI: 10.1016/j.eats.2018.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/12/2018] [Indexed: 02/03/2023] Open
Abstract
Knee dislocations often result in a severe multiligament injured knee (MLIK) with complex instability. Multiligament reconstruction can successfully restore knee stability and is commonly recommended, although surgical morbidity is induced by graft harvesting and tunnel drilling, and convergence of multiple tunnels can complicate the surgery. Therefore, as an alternative, primary repair of knee ligaments is currently reconsidered. The main advantages of primary repair consist of tissue preservation and decrease of surgical morbidity, which might improve knee functionality. Techniques in which avulsed ligaments are reapproximated to their anatomic origin have resulted in good clinical outcomes in selected patients over the past decade. More recently, repaired ligaments have been augmented with suture tape, to protect them from excessive stretch, which can improve healing and allows early rehabilitation. The surgical technique of primary repair in the multiligament injured knee has not yet been described. The purpose of this Technical Note is to explain suture augmented primary repair in KDIII-M injury, including the anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament.
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Affiliation(s)
- Anne Jonkergouw
- Address correspondence to Anne Jonkergouw, M.D., Hospital for Special Surgery, Orthopedic Surgery, 525 East 68th Street, Starr 2 Room K-215, New York, NY 10021, U.S.A.
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Schliemann B, Glasbrenner J, Rosenbaum D, Lammers K, Herbort M, Domnick C, Raschke MJ, Kösters C. Changes in gait pattern and early functional results after ACL repair are comparable to those of ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:374-380. [PMID: 28674740 DOI: 10.1007/s00167-017-4618-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/19/2017] [Indexed: 01/12/2023]
Abstract
PURPOSE Dynamic intraligamentary stabilization (DIS) has been introduced as a new technique to repair the torn anterior cruciate ligament (ACL) and to restore knee joint kinematics after an acute ACL tear. Aim of the present study was to compare the early post-operative activity, restoration of gait pattern and functional results after DIS in comparison with primary ACL reconstruction (ACLR) for acute ACL tears. It was hypothesized that functional results, post-operative activity and changes in gait pattern after DIS are comparable to those after ACLR. METHODS Sixty patients with acute ACL tears were included in this study and underwent either DIS or ACLR with an anatomic semitendinosus autograft in a randomized manner. Patients were equipped with an accelerometric step counter for the first 6 weeks after surgery in order to monitor their early post-operative activity. 3D gait analysis was performed at 6 weeks and 6 months after surgery. Temporal-spatial, kinematic and kinetic parameters were extracted and averaged for each subject. Functional results were recorded at 6 weeks, 6 months and 12 months after surgery using the Tegner activity scale, International Knee Documentation Committee score and Lysholm score. RESULTS Patients who underwent DIS showed an increased early post-operative activity with significant differences at week 2 and 3 (p = 0.0241 and 0.0220). No significant differences between groups were found for knee kinematic and kinetic parameters or the functional scores at any time of the follow-up. Furthermore, the difference in anterior tibial translation was not significantly different between the two groups (n.s.). CONCLUSION Early functional results and changes in gait pattern after DIS are comparable to those of primary ACLR. Therefore, ACL repair may be an alternative to ACLR in this cohort of patients. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Benedikt Schliemann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, 48149, Münster, Germany.
| | - Johannes Glasbrenner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, 48149, Münster, Germany
| | - Dieter Rosenbaum
- Movement Analysis Lab, Institute for Experimental Musculoskeletal Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building D3, 48149, Münster, Germany
| | - Katharina Lammers
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, 48149, Münster, Germany
| | - Mirco Herbort
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, 48149, Münster, Germany
| | - Christoph Domnick
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, 48149, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, 48149, Münster, Germany
| | - Clemens Kösters
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building W1, 48149, Münster, Germany
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Regauer M, Mackay G, Lange M, Kammerlander C, Böcker W. Syndesmotic InternalBrace TM for anatomic distal tibiofibular ligament augmentation. World J Orthop 2017; 8:301-309. [PMID: 28473957 PMCID: PMC5396014 DOI: 10.5312/wjo.v8.i4.301] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/22/2016] [Accepted: 02/13/2017] [Indexed: 02/06/2023] Open
Abstract
Reconstruction of unstable syndesmotic injuries is not trivial, and there is no generally accepted treatment guidelines. Thus, there still remain considerable controversies regarding diagnosis, classification and treatment of syndesmotic injuries. Syndesmotic malreduction is the most common indication for early re-operation after ankle fracture surgery, and widening of the ankle mortise by only 1 mm decreases the contact area of the tibiotalar joint by 42%. Outcome of ankle fractures with syndesmosis injury is worse than without, even after surgical syndesmotic stabilization. This may be due to a high incidence of syndesmotic malreduction revealed by increasing postoperative computed tomography controls. Therefore, even open visualization of the syndesmosis during the reduction maneuver has been recommended. Thus, the most important clinical predictor of outcome is consistently reported as accuracy of anatomic reduction of the injured syndesmosis. In this context the TightRope® system is reported to have advantages compared to classical syndesmotic screws. However, rotational instability of the distal fibula cannot be safely limited by use of 1 or even 2 TightRopes®. Therefore, we developed a new syndesmotic InternalBraceTM technique for improved anatomic distal tibiofibular ligament augmentation to protect healing of the injured native ligaments. The InternalBraceTM technique was developed by Gordon Mackay from Scotland in 2012 using SwiveLocks® for knotless aperture fixation of a FiberTape® at the anatomic footprints of the augmented ligaments, and augmentation of the anterior talofibular ligament, the deltoid ligament, the spring ligament and the medial collateral ligaments of the knee have been published so far. According to the individual injury pattern, patients can either be treated by the new syndesmotic InternalBraceTM technique alone as a single anterior stabilization, or in combination with one posteriorly directed TightRope® as a double stabilization, or in combination with one TightRope® and a posterolateral malleolar screw fixation as a triple stabilization. Moreover, the syndesmotic InternalBraceTM technique is suitable for anatomic refixation of displaced bony avulsion fragments too small for screw fixation and for indirect reduction of small posterolateral tibial avulsion fragments by anatomic reduction of the anterior syndesmosis with an InternalBraceTM after osteosynthesis of the distal fibula. In this paper, comprehensively illustrated clinical examples show that anatomic reconstruction with rotational stabilization of the syndesmosis can be realized by use of our new syndesmotic InternalBraceTM technique. A clinical trial for evaluation of the functional outcomes has been started at our hospital.
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Schliemann B, Lenschow S, Domnick C, Herbort M, Häberli J, Schulze M, Wähnert D, Raschke MJ, Kösters C. Knee joint kinematics after dynamic intraligamentary stabilization: cadaveric study on a novel anterior cruciate ligament repair technique. Knee Surg Sports Traumatol Arthrosc 2017; 25:1184-1190. [PMID: 26239862 DOI: 10.1007/s00167-015-3735-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 07/22/2015] [Indexed: 01/12/2023]
Abstract
PURPOSE Dynamic intraligamentary stabilization (DIS) has been introduced for the repair of acute anterior cruciate ligament (ACL) tears as an alternative to delayed reconstruction. The aim of the present study was to compare knee joint kinematics after DIS to those of the ACL-intact and ACL-deficient knee under simulated Lachman/KT-1000 and pivot-shift tests. We hypothesized that DIS provides knee joint kinematics equivalent to an intact ACL. METHODS With the use of a robotic knee simulator, knee kinematics were determined in simulated Lachman/KT-1000 and pivot-shift tests at 0°, 15°, 30°, 60°, and 90° of flexion in eight cadaveric knees under the following conditions: (1) intact ACL, (2) ACL deficiency, (3) DIS with a preload of 60 N, and (4) DIS with a preload of 80 N. Statistical analyses were performed using two-factor repeated-measures analysis of variance. The significance level was set at a p value of <0.05. RESULTS After DIS with a preload of either 60 N or 80 N, the anterior translation was significantly reduced in the simulated Lachman/KT-1000 and pivot-shift tests when compared to the ACL-deficient knee (p < 0.05). No significant differences were observed between the DIS reconstruction with a preload of 80 N and the intact ACL with regard to anterior laxity in either test. However, DIS with a preload of only 60 N was not able to restore knee joint kinematics to that of an intact knee in all degrees of flexion. CONCLUSION DIS with a preload of 80 N restores knee joint kinematics comparable to that of an ACL-intact knee and is therefore capable of providing knee joint stability during ACL healing. DIS therefore provides a new technique for primary ACL repair with superior biomechanical properties in comparison with other techniques that have been described previously, although further clinical studies are required to determine its usefulness in clinical settings.
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Affiliation(s)
- Benedikt Schliemann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building Waldeyerstraße 1, 48149, Münster, Germany.
| | - Simon Lenschow
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building Waldeyerstraße 1, 48149, Münster, Germany
| | - Christoph Domnick
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building Waldeyerstraße 1, 48149, Münster, Germany
| | - Mirco Herbort
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building Waldeyerstraße 1, 48149, Münster, Germany
| | | | - Martin Schulze
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building Waldeyerstraße 1, 48149, Münster, Germany
| | - Dirk Wähnert
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building Waldeyerstraße 1, 48149, Münster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building Waldeyerstraße 1, 48149, Münster, Germany
| | - Clemens Kösters
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Albert-Schweitzer-Campus, Building Waldeyerstraße 1, 48149, Münster, Germany
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Häberli J, Henle P, Acklin YP, Zderic I, Gueorguiev B. Knee joint kinematics with dynamic augmentation of primary anterior cruciate ligament repair - a biomechanical study. J Exp Orthop 2016; 3:29. [PMID: 27783350 PMCID: PMC5080274 DOI: 10.1186/s40634-016-0064-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 10/04/2016] [Indexed: 01/28/2023] Open
Abstract
Background Dynamic augmentation of anterior cruciate ligament tears seems to reduce anteroposterior knee translation close to the pre-injury level. The aim of the present study is to biomechanically investigate the course of translation during a simulated early post-operative phase. It is hypothesized that anteroposterior translation is maintained at the immediate post-operative level over a simulated rehabilitation period of 50’000 gait cycles. Methods Eight fresh-frozen human cadaveric knee joints from donors with a mean age of 35.5 (range 25–40) years were subjected to 50’000 cycles of 0°-70°-0° flexion-extension movements in a custom-made test setup. Anteroposterior translation was assessed with simulated Lachman/KT-1000 testing in 0°, 15°, 30°, 60° and 90° of flexion in knee joints treated with the novel technique initially and after 50’000 cycles testing. Statistical analysis was performed using the Wilcoxon Signed-Rank Test. The level of significance was set at p = 0.05. Results Anteroposterior translation changed non-significantly for all flexion angles between cycle 0 and 50’000 (p = 0.39 to p = 0.89), except for 30° flexion, where a significant increase by 1.4 mm was found (p = 0.03). Conclusion Increase in anteroposterior translation of knees treated with this dynamic augmentation procedure is low. The procedure maintains translation close to the immediate post-operative level over a simulated rehabilitation period of 50’000 gait cycles and therefore supports anterior cruciate ligament repair during biological healing.
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Affiliation(s)
- Janosch Häberli
- Sonnenhof Orthopaedic Centre, Buchserstrasse 30, 3006, Bern, Switzerland.
| | - Philipp Henle
- Sonnenhof Orthopaedic Centre, Buchserstrasse 30, 3006, Bern, Switzerland
| | - Yves P Acklin
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland
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