Overconstraint Associated With A Modified Lemaire Lateral Extra-articular Tenodesis Is Decreased By Using An Anterior Femoral Insertion Point In A Cadaveric Model.

PURPOSE: The aim of the present study was to investigate tibiofemoral knee kinematics when shifting the femoral insertion point of the modified Lemaire lateral extra-articular tenodesis (LET) anterior to the lateral epicondyle. METHODS: Six fresh-frozen human knee joints were tested on a test bench in the following states: 1) native, 2) anterolateral insufficient, 3) original Lemaire (oLET; insertion point: 4 mm posterior and 8 mm proximal to the epicondyle), 4) anterior Lemaire (aLET; insertion point: 5 mm anterior and 5 mm proximal to the epicondyle). Internal tibial rotation was statically investigated under an internal tibial torque of 5 Nm in 0°, 30°, 60° and 90° of flexion. Anterior translation was statically investigated during a simulated Lachman test with an anterior translational force of 98 N. Additionally, the range of internal tibial rotation and anterior translation were dynamically investigated by a simulated pivot-shift test. Tibiofemoral kinematics were measured using an optical 3D motion analysis system. RESULTS: The aLET showed an internal tibial rotation comparable to the native state for all tested flexion angles except 90° (0°: P = 0.201; 30°: P = 0.118; 60°: P = 0.126; 90°: P = 0.026 ). The oLET showed an internal tibial rotation below the values of the native state for all tested flexion angles indicating an overconstraint (0°: P = 0.003 ; 30°: P = 0.009; 60°: P = 0.029; 90°: P = 0.029). Direct comparisons between aLET and oLET showed a significantly decreased overconstraint at 0° and 30° of flexion (P = 0.001 and P = 0.003 respectively) when using the aLET. No differences in anterior translation and internal tibial rotation were found between the oLET and aLET during simulated Lachman and pivot-shift test (P > 0.05), approximating the native state. CONCLUSIONS: An anteriorly shifted LET insertion point restored internal tibial rotation after anterolateral insufficiency to the native state while decreasing the overconstraint of internal tibial rotation induced by an LET using the originally described insertion point for small flexion angles ≤ 30°. CLINICAL RELEVANCE: Using an LET insertion point anterior to the epicondyle was recently reported to lower the risk of tunnel interference and has now been shown to effectively restore internal tibial rotation in vitro in the course of the present study. Concerns of overconstraining internal tibial rotation are not diminished by this technique, but using an anterior insertion point helps to decrease overconstraint.

PEEK Interference Screws Show Significant Tunnel Enlargement After ACL Reconstruction and is Comparable to Adjustable-Length Loop Cortical Button Fixation.

Background: It is unclear whether the use of polyetheretherketone (PEEK) interference screws for anterior cruciate ligament (ACL) reconstruction leads to postoperative tunnel enlargement. Femoral tunnel enlargement was further compared with adjustable-length loop cortical fixation. Methods: Eighteen patients with ACL reconstruction using hamstring grafts were retrospectively divided into two groups. Eleven patients were treated with the ACL reconstruction technique using a PEEK interference screw for femoral graft fixation. Seven patients received adjustable-length loop cortical buttons for femoral fixation. Tibial ACL graft fixation was performed using PEEK interference screws. Tunnel volume changes were assessed using computed tomography (CT) scans performed after surgery (100%) and after 1 year. The maximal tunnel diameter was measured. Results: The group with femoral screw fixation showed a mean tunnel volume change of 108.15 ± 13.7% on the tibial side and 124.07 ± 25.38% on the femoral side. The group with femoral button fixation showed a tunnel volume change of 111.12 ± 12.72% on the tibial side and 130.96 ± 21.71% on the femoral side. The differences in femoral tunnel volume changes were not significant (P = 0.562). Femoral tunnels with PEEK screw fixation showed significantly larger diameter after 12 months in comparison with button fixation (13.02 ± 1.43 mm vs. 10.46 ± 1.29 mm, P < 0.001). Conclusions: PEEK interference screws were associated with significant tibial and femoral tunnel enlargement. Femoral tunnel enlargement was comparable between PEEK interference screws and button fixation. Final femoral tunnel diameter was significantly larger with PEEK screw fixation in comparison to button fixation.

Modified Lemaire Tenodesis Forces in Cadaveric Specimens Are Not Affected by Random Small-Scale Variations in the Femoral Insertion Point During Active Knee Joint Flexion-Extension.

Purpose: To directly measure lateral extra-articular tenodesis (LET) forces supporting anterior cruciate ligament reconstruction (ACLR) during dynamic flexion-extension cycles induced by simulated active muscle forces, to investigate the influence of random surgical variation in the femoral LET insertion point around the target insertion position, and to determine potential changes to the extension behavior of the knee joint in a cadaveric model. Methods: After iatrogenic anterior cruciate ligament deficiency and simulated anterolateral rotatory instability, 7 fresh-frozen cadaveric knee joints were treated with isolated ACLR followed by combined ACLR-LET. The specimens were tested on a knee joint test bench during active dynamic flexion-extension with simulated muscle forces. LET forces and the degree of knee joint extension were measured. Random variation in the LET insertion point around the target insertion position was postoperatively quantified by computed tomography. Results: In extension, the median LET force increased to 39 ± 2 N (95% confidence interval [CI], 36 to 40 N). In flexion over 70°, the LET was offloaded (2 ± 1 N; 95% CI, 0 to 2 N). In this study, small-scale surgical variation in the femoral LET insertion point around the target position had a negligible effect on the graft forces measured. We detected no difference in the degree of knee joint extension after combined ACLR-LET (median, 1.0° ± 3.0°; 95% CI, -6.2° to 5.2°) in comparison with isolated ACLR (median, 1.1° ± 3.3°; 95% CI, -6.7° to 6.1°; P = .62). Conclusions: LET forces in combined ACLR-LET increased to a limited extent during active knee joint flexion-extension independent of small-scale variation around 1 specific target insertion point. Combined ACLR-LET did not change knee joint extension in comparison with isolated ACLR under the testing conditions used in this biomechanical study. Clinical Relevance: Low LET forces can be expected during flexion-extension of the knee joint. Small-scale deviations in the femoral LET insertion point around the target insertion position in the modified Lemaire technique might have a minor effect on graft forces during active flexion-extension.

Modified Lemaire tenodesis reduces anterior cruciate ligament graft forces during internal tibial torque loading.

PURPOSE: The aim of the study was to directly measure graft forces of an anterior cruciate ligament reconstruction (ACLR) and a lateral extra-articular tenodesis (LET) using the modified Lemaire technique in combined anterior cruciate ligament (ACL) deficient and anterolateral rotatory instable knees and to analyse the changes in knee joint motion resulting from combined ACLR + LET. METHODS: On a knee joint test bench, six fresh-frozen cadaveric specimens were tested at 0°, 30°, 60°, and 90° of knee flexion in the following states: 1) intact; 2) with resected ACL; 3) with resected ACL combined with anterolateral rotatory instability; 4) with an isolated ACLR; and 5) with combined ACLR + LET. The specimens were examined under various external loads: 1) unloaded; 2) with an anterior tibial translation force (ATF) of 98 N; 3) with an internal tibial torque (IT) of 5 Nm; and 4) with a combined internal tibial torque of 5 Nm and an anterior tibial translation force of 98 N (IT + ATF). The graft forces of the ACLR and LET were recorded by load cells incorporated into custom devices, which were screwed into the femoral tunnels. Motion of the knee joint was analysed using a 3D camera system. RESULTS: During IT and IT + ATF, the addition of a LET reduced the ACLR graft forces up to 61% between 0° and 60° of flexion (P = 0.028). During IT + ATF, the LET graft forces reached 112 N. ACLR alone did not restore native internal tibial rotation after combined ACL deficiency and anterolateral rotatory instability. Combined ACLR + LET was able to restore native internal tibial rotation values for 0°, 60° and 90° of knee flexion with decreased internal tibial rotation at 30° of flexion. CONCLUSION: The study demonstrates that the addition of a LET decreases the forces seen by the ACLR graft and reduces residual rotational laxity after isolated ACLR during internal tibial torque loading. Due to load sharing, a LET could support the ACLR graft and perhaps be the reason for reduced repeat rupture rates seen in clinical studies. Care must be taken not to limit the internal tibial rotation when performing a LET.

ACL reconstruction with adjustable-length loop cortical button fixation results in less tibial tunnel widening compared with interference screw fixation.

PURPOSE: To compare tunnel widening and clinical outcome after anterior cruciate ligament reconstruction (ACLR) with interference screw fixation and all-inside reconstruction using button fixation. METHODS: Tunnel widening was assessed using tunnel volume and diameter measurements on computed tomography (CT) scans after surgery and 6 months and 2 years later, and compared between the two groups. The clinical outcome was assessed after 2 years with instrumented tibial anteroposterior translation measurements, hop testing and International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores. RESULTS: The study population at the final follow-up was 14 patients with screw fixation and 16 patients with button fixation. Tibial tunnels with screw fixation showed significantly larger increase in tunnel volume over time (P = 0.021) and larger tunnel diameters after 2 years in comparison with button fixation (P < 0.001). There were no significant differences in femoral tunnel volume changes over time or in tunnel diameters after 2 years. No significant differences were found in the clinical outcome scores. CONCLUSIONS: All-inside ACLR using button fixation was associated with less tibial tunnel widening and smaller tunnels after 2 years in comparison with ACLR using screw fixation. The need for staged revision ACLRs may be greater with interference screws in comparison with button fixation at the tibial tunnel. The clinical outcomes in the two groups were comparable. LEVEL OF EVIDENCE: II. RCT: Consort NCT01755819.

Tunnel widening after ACL reconstruction with aperture screw fixation or all-inside reconstruction with suspensory cortical button fixation: Volumetric measurements on CT and MRI scans.

BACKGROUND: Tunnel widening after anterior cruciate ligament reconstruction (ACLR) is influenced by the surgical and fixation techniques used. Computed tomography (CT) is the most accurate image modality for assessing tunnel widening, but magnetic resonance imaging (MRI) might also be reliable for tunnel volume measurements. In the present study tunnel widening after ACLR using biodegradable interference screw fixation was compared with all-inside ACLR using button fixation, with tunnel volume changes being measured on CT and MRI scans. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Thirty-three patients were randomly assigned to hamstring ACLR using a biodegradable interference screw or all-inside cortical button fixation. CT and MRI scanning were done at the time of surgery and six months after. Tunnel volume changes were calculated and compared. RESULTS: On CT, femoral tunnel volumes changed from the postoperative state (100%) to 119.8% with screw fixation and 143.2% with button fixation (P=0.023). The changes in tibial tunnel volumes were not significant (113.9% vs. 117.7%). The changes in bone tunnel volume measured on MRI were comparable with those on CT only for tunnels with interference screws. Tibial tunnels with button fixation were significantly underestimated on MRI scanning (P=0.018). CONCLUSIONS: All-inside ACLR using cortical button fixation results in increased femoral tunnel widening in comparison with ACLR with biodegradable interference screw fixation. MRI represents a reliable imaging modality for future studies investigating tunnel widening with interference screw fixation.

Biomechanical comparison of 2 anterior cruciate ligament graft preparation techniques for tibial fixation: adjustable-length loop cortical button or interference screw.

BACKGROUND: Cortical button fixation at the femoral side and interference screws within the tibial bone tunnel are widely used for anterior cruciate ligament graft fixation. Using a bone socket instead of a full tunnel allows cortical button fixation on the tibial side as well. If adjustable-length loop cortical button devices are used for femoral and tibial fixation, the tendon graft has to be secured with sutures in a closed tendon loop. The increased distance of fixation points and potential slippage of the tendon strands at the securing sutures might lead to greater risk of postoperative graft elongation when compared with conventional graft preparation with tibial interference screw fixation. HYPOTHESIS: Compared with an anterior cruciate ligament graft with tibial adjustable-length loop cortical button fixation, a graft with tibial interference screw fixation will show less graft elongation during cyclic loading and lower ultimate failure loads. STUDY DESIGN: Controlled laboratory study. METHODS: Grafts with tibial adjustable-length loop cortical button fixation and grafts with tibial interference screw fixation were biomechanically tested in calf tibiae (n = 10 per group). Femoral fixation was equivalent for both groups, using an adjustable-length loop cortical button. Specimens underwent cyclic loading followed by a load-to-failure test. RESULTS: Grafts with screw fixation showed significantly less initial elongation (cycles 1-5: 1.46 ± 0.26 mm), secondary elongation (cycles 6-1000: 1.87 ± 0.67 mm), and total elongation (cycles 1-1000: 3.33 ± 0.83 mm) in comparison with grafts with button fixation (2.47 ± 0.26, 3.56 ± 0.39, and 6.03 ± 0.61 mm, respectively) (P < .001). While pull-out stiffness was significantly higher for grafts with screw fixation (309.5 ± 33.2 vs 185.6 ± 16.4 N/mm) (P < .001), grafts with button fixation were able to withstand significantly higher ultimate failure loads (908 ± 74 vs 693 ± 119 N) (P < .001). CONCLUSION: Grafts with tibial adjustable-length loop cortical button fixation resulted in higher graft elongation during cyclic loading and showed higher ultimate failure loads in comparison with conventional graft preparation with tibial interference screw fixation at time zero. CLINICAL RELEVANCE: The results of this biomechanical study suggest that grafts with tibial interference screw fixation provide better knee stability at time zero because of reduced graft elongation and greater stiffness in comparison with grafts with tibial adjustable-length loop cortical button fixation.