Rev. bras. ortop. vol.51 número4

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Technical

Note

Reconstruction

of

cruciate

ligament

and

anterolateral

ligament

using

interlinked

hamstrings

–

technical

note

夽

Marcio

de

Castro

Ferreira

a,b,∗

,

Flavio

Ferreira

Zidan

b

,

Francini

Belluci

Miduati

b

,

Caio

Cesar

Fortuna

a,b

,

Bruno

Moreira

Mizutani

b

,

Rene

Jorge

Abdalla

a,c

a_Hospital_do_Corac¸ão,_Departamento_de_Ortopedia_e_{Traumatologia,}_São_Paulo,_SP,_Brazil

b_Hospital_{Renascenc¸a,}_Departamento_de_Cirurgia_de_Joelho,_Osasco,_SP,_Brazil

c_Universidade_Federal_de_São_Paulo,_Escola_Paulista_de_Medicina,_São_Paulo,_SP,_Brazil

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Articlehistory:

Received19August2015 Accepted25August2015 Availableonline4July2016

Keywords:

Anteriorcruciateligament reconstruction

Anterolateralligament Orthopedicprocedures

a

b

s

t

r

a

c

t

Recentanatomicalandbiomechanicalstudiesontheanterolateralligament(ALL)ofthe kneehaveshownthatthisstructurehasanimportantfunctioninrelationtojointstability, especiallywhenassociatedwithanteriorcruciateligament(ACL)injury.However,the crite-riaforitsreconstructionhavenotyetbeenfullyestablishedandthesurgicaltechniques thathavebeendescribedpresentvariationsregardinganatomicalpointsandfixation mate-rials.ThisstudypresentsareproducibletechniqueforALLandACLreconstructionusing hamstringtendons,inwhichthreeinterferencescrewsareusedforfixation.

Reconstruc¸ão

dos

ligamentos

cruzado

e

anterolateral

com

flexores

enlac¸ados

–

Nota

técnica

Palavras-chave:

Reconstruc¸ãodoligamentocruzado anterior

Ligamentoanterolateral Procedimentosortopédicos

r

e

s

u

m

o

Osrecentes estudosanatômicos e biomecânicossobre oligamento anterolateral(LAL) dojoelhoevidenciamqueessaestruturaapresenta funçãorelevanteparaaestabilidade articularprincipalmentequandoassociadaàlesãodoligamentocruzadoanterior(LCA). Noentanto,os critérios parasua reconstrução aindanão estãototalmente estabeleci-dos,assimcomo astécnicascirúrgicasdescritas apresentamvariaçõessobreospontos

夽

StudyconductedattheHospitalRenascenc¸a,DepartamentodeCirurgiadeJoelho,Osasco,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:marciojoelho@gmail.com(M.C.Ferreira).

http://dx.doi.org/10.1016/j.rboe.2015.08.021

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anatômicosemateriaisdefixação.Oestudoapresentaumatécnicareprodutívelparaa reconstruçãodoLALeLCAcomostendõesflexoresqueusatrêsparafusosdeinterferência paraasfixações.

Introduction

Thetreatmentofanteriorkneeinstabilitythrough reconstruc-tion of the anterior cruciate ligament (ACL) presents good clinicalresults. However,the failurerate forthis operation isestimatedtorangefrom1.8%to14%.1,2_The_persistence_of anterolateralinstabilityassessedbythepivot-shifttest post-operativelyisdescribedasoneofthosefactors.2,3

After the anatomical “rediscovery” and biomechanical studies of the anterolateral ligament (ALL) demostrated that this structure is important in anterolateral knee sta-bility, it was observed that insufficiency of this ligament may contribute to the functional failure of isolated ACL reconstructions.4

Thisstudy aimedtopresentareproducibletechniqueof anatomicalACLandALLreconstructionwiththehamstring tendons,usingthreeinterferencescrews.

Surgical

technique

Fifteenadultpatients(19–38years),12menandthreewomen, underwent ACL and ALL reconstruction by the technique describedbelow,withameanfollow-upof10months(6–15 months).Allpatientsreturned,withoutcomplaints,to activi-tiesofdailylivingand/ortosportsandrecreationalactivities thattheypracticedpriortoinjury.

Indication

Afterspinalanesthesia,aclinicalexaminationwasperformed toestimateALLsufficiency.

Theanteriorasymmetryofthelateralplateauwith inter-nalrotationofthetibiainflexionof30–60◦5 _relative_to_the

contralateralknee,andincreasedpositivityofthepivot-shift maneuvercanbeaclinicalsignoffailureoftheALL.4

Thestudyusedtheclassificationforthepivot-shift maneu-ver determined by the International Knee Documentation Committee6_(IKDC)_2000,_which_describes_four_grades:₀_– nor-mal,1–glide,2–clunk,3–grossshift.

ThecriteriausedforALLreconstructionassociatedwith ACLinjurieswere:

1. InjuryintheALLsubstanceidentifiedatamagnetic reso-nanceimaging(MRI),termedSegond-likeinjury;

2. Segondfracture7_;

3. Pivot-shiftclassifiedasgradeII_/III_;

4. ACL reconstruction reviewin which patients had resid-ualpivot-shiftduringthepostoperativeperiodandevolved withgraftinjury;

5. Asymmetrical anterior lateral plateau visible with knee internalrotationinflexionbetween30◦_and₆₀◦_.

6. Lateralfemoralnotchsign.8

Graftpreparationandsurgicaltechnique

Theexcisionofthesemitendinosustendon(ST)andgracilis tendon(GR)ismadethrougha4-cmanteromedialincisionin

thetibiaoverthepesanserinus.

During the arthroscopic procedure forthe anteromedial and anterolateral portals, the joint is assessed and the intercondyle is cleaned, whiletendons are handled at the instrumentationtable.AllgraftsarepreparedwithEthibondR n◦₂_(Ethicon,_Somerville,_NJ).

TheGRusedtorebuildtheALLispreparedtoformadouble graft.EachendissuturedwithKrackowstitches.

One end ofthe GR is passed as a “handle” during the preparationofthetripleSTgraft,whichwillbeusedforACL reconstruction, so that the double GR graft has the same sizeinits twoparts and thetriple STgraft hasaKrackow sutureinoneendandtheotherendisanchoredinthe GR (Fig.1A–C).

After preparation and measurement of graft diameters (usually8mmforthetripleSTgraftand5mmforthedouble GR),thefemoralandtibialtunnelsareprepared.

Thefemoraltunnel,commontotheACLandALL,ismade usingtheoutside-intechnique.AtibialACLguideisplacedso thatitsjointpositionoverlapsthefootprintoftheanatomical insertionoftheACLintheintercondylarwall.A65◦_opening

isappliedtominimizethe“killerturn”ofthegraft.

AftertheACLguideispositionedandthesitewherethe guide wirewill beintroducedis assessed,the guidewireis removed,and a4-cmlongitudinal incisionin theskin and iliotibialtractisperformedonthelateralsideoftheknee.

The lateral epicondyle is identified by palpation; the guidewire is introduced 8mm (about one digital tip) posterosuperiorly9,10_in_the_lateral_femoral_cortex_to_mark_the entrysite.

The ACL guide is then reattached and coupled to the guidewire,followedbythedrillingofthepathfortheACL foot-print.Sequentially,onedrillofthesamediameterasthegraft isusedtomakethetunnel,whichisgenerally35-mmlong.

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Fig.1–(A)Tensionedtriplesemitendinosusgraftand doublegracilisgraft;intertwined,readyforsuturing.(B) Triplesemitendinosusgraft(LCA)anddoublegracilisgraft (LAL),startedsuturing.(C)Finishedgrafts.

AftercreatingthetunnelsfortheACL,asutureispassed withtheguidewirethroughfouroutside-inholesthroughthe femoraltunneland withdrawnwithagraspertoolthrough thetibialtunnel,soastopassoverthejointandallowforthe passageofthegraft.

SuturesattheloosenedgeoftheSTgraft(ACL)arelooped inthetransacetabularwireandthegraft ispassed outside-infromthefemurtothetibia,remaininginitsfinalposition (Fig.2AandB).Aninterferencescrewofthesamediameteras thedrilledtunnel,with30–35mmlength,isusedforfemoral fixation.

ForthereconstructionandattachmentoftheALLinthe tibia,theACLguideispositionedat65◦_,_so_that_the_guidewire

canbeinserted2cmdistaltothetibialtunnelthroughthe sameincision madeforACLgraft removal.Itexitshalfway betweenGerdy’stubercleandtheheadofthefibula,9–13mm distaltothesurfaceofthelateraltibialplateau,theanatomical ALLpoint.9

A 3-cmanterolateral skin and iliotibial tract incision is made(Fig.2C)andthetunnelisdrilledwitha6-mmbit.

Alongforcepsisintroduced throughtheALLtibial inci-siondeepintotheiliotibialtractuntilitsoutputinthefemoral ACLtunnelincision,wheretheGRgraftispulledandpassed throughthetibialALLtunnel(Fig.2D–F).

Thekneeisthenplacedat30◦_flexion_for_ACL_fixation_and

at45–60◦ _for_ALL_fixation5_with_interference_screws_that_are

2mmlargerthanthedrilledtunnels,boththroughthesame anteromedialincision.Thesuturegraftscanbetiedto rein-forcethefixation.

Postoperative rehabilitationfollowsthe protocol forACL reconstructionwithhamstrings.

Discussion

The“rediscovery”oftheALLanditsroleinanterolateralknee stabilityiscurrentlypresentedasoneofthetrendsinknee ligamentreconstructions.11

ThefactsthattheALLisnotastructureroutinelydescribed inMRIreportsandthatthereconstructioncriteriaarenotfully establishedcontributetothemissdiagnosisand undertreat-mentofthisinjury.

Helito etal.12 _showed_that _the_ALL_is_fully _visualized_in 71.7%oftheMRIs.Inturn,Tanejaetal.13_have_identified_the fullALLviewin11%.

Spenceretal.4_showed_that_the_{anterolateral}_knee insta-bility is accentuated when the ACL and the ALL are torn, emphasizingthepivot-shiftmaneuver.

Sonnery-Cottetetal.11_recommend_ALL_{reconstruction}_in Segondfractures,chronicACLinjuries, gradeIII_pivot-shift,

high-levelathletesorthosewhopracticesportsthatrequire rotationoftheknee,andinthepresenceoflateralfemoral notch sign.8 _However, _the _present_authors _do_not _consider chronicityand thepatient’sactivitiesascriteriafor empiri-calALLreconstructionifthephysicalexaminationshowsno evidenceofitsfailure.

RegardingthedescribedtechniquesforACLandALL recon-struction,Helitoetal.14_used_a_quadruple_graft_(triple_ST_and oneGR)forACLandoneGRforALL;tibialfixationwas con-ducted withanchors.Sonnery-Cottet etal.11 _used_triple _ST graftforACLanddoubleGRgraftforALL,withtwotibialholes torebuildtheALL.

Inthepresenttechnique,themethodusedforgraft prepa-rationcreatesasuspensioneffectsimilartotheEndobutton, added to the suture to reinforce this union, which also includesaninterferencescrew.ThisallowstheendoftheST grafttoremainclosetothearticularfemoralpoint,andthereis noneedtooccupytheentiretunnel,whichwillbecompleted bytheGRgraft,thusfacilitatingtheprocedureincaseofshort grafts.

StudieshaveshowndifferencesintheALLfemoral anatom-icalpoint.Caterineetal.10_and_Kennedy_et_al.9_demonstrated thatitsoriginisonaverage3mmposteriorandproximalto the lateral epicondyle; this point was used in the present technique.Inturn,Helitoetal.15 _and_Claes_et_al.16 demon-strated that the origin ofthe ALLis anteriorto the lateral epicondyle.

Theoptionadoptedinthepresenttechniquewastomake thetunnelposterosuperiortothelateralepicondyle,inorder toreducetheintraarticular“killerturn”ofthegraft;thispoint approachestheisometricsdescribedbyKurosawaetal.17_for lateraltenodesisoftheiliotibialtract.

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Fig.2–(A)ACLgraftpositionedinthefemoralandtibialtunnelsandALLgraftfixedinthefemoralpoint;(B)doubleGRgraft lengthtorebuildtheALLonthepathitmustfollow;(C)positioningoftheACLguideat65◦_and_exit_point_halfway_between

Gerdy’stubercleandthefibularhead,13mmfromthesurfaceofthelateraltibialplateau;(D)clamppasseddeepintothe iliotibialtracttodrivetheALLgraftintothetibialtunnel;(E)passageoftheALLgraftthroughthetibialtunnel;(F)ACLand ALLgraftsreadytobefixedwithinterferencescrewthroughthesameincision.

Conclusion

ACLand ALL reconstructionusing the techniquedescribed fortheanterolateralinstabilityofthekneewassatisfactory inthesepatients;itusesmaterials,guides,andincisionsthat arefamiliartoanysurgeon,whichfacilitatesitsreproduction.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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