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Combined Double-Bundle Anterior Cruciate Ligament Reconstruction and Anterior Cruciate Ligament-Mimicking Anterolateral Structure Reconstruction.

ABSTRACT: The outcomes of double-bundle anterior cruciate ligament (ACL) reconstruction leave room for improvement. We hope to augment double-bundle ACL reconstruction with the reconstruction of an ACL-mimicking anterolateral structure (ALS). Thus, we would like to introduce a combined double-bundle ACL reconstruction and ACL-mimicking ALS reconstruction technique. The main indication for this technique is ACL injury with a high degree of pivot shift test, general laxity, or near critical value of the posterior tibial slope. The main steps in this technique include preparation of an isolated graft for the anteromedial bundle of the ACL and a combined graft for the posterolateral bundle of the ACL and ALS, creation of three tibial tunnels and two femoral tunnels, graft placement, and final graft fixation at an adjustable loop. We have obtained promising clinical outcomes with this technique and consider that this report will provide new options in ACL reconstruction.

SUBMITTER: Zhao J

PROVIDER: S-EPMC7451438 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Combined Double Bundle Anterior Cruciate Ligament Reconstruction and Anterolateral Ligament Reconstruction.

Project description:A double-bundle anterior cruciate ligament (ACL) reconstruction associated with an anterolateral ligament (ALL) reconstructions is performed. The semitendinosus and gracilis are harvested. At knee maximum flexion, the anteromedial (AM) femoral tunnel is performed in the AM footprint area. Through the anterolateral portal, the tip of the outside-in femoral guide is placed in the posterolateral footprint area. The guide sleeve is pushed onto the lateral femoral cortex at the ALL attachment. At 110° knee flexion, the posterolateral-ALL tunnel is performed. The tibial ACL tunnel is performed as usual. The tibial guide is placed between the ALL tibial attachment and the tibial ACL tunnel entrance to perform the ALL tibial tunnel. The gracilis graft is introduced from caudal to cranial, achieving fixation with a 6-mm diameter screw (outside-in). The AM femoral fixation is achieved with a suspension device. ACL tibial graft fixation is achieved with a screw. Afterward, the gracilis is passed under the fascia lata to the tibial entry point. A 6-mm diameter screw is placed from the external cortex into the tibial ALL tunnel. The biomechanical advantage of the double-bundle ACL reconstruction with the biomechanical advantage of the ALL anatomic reconstruction is achieved.

| S-EPMC6112256 | biostudies-literature

Combined Anatomic Anterior Cruciate Ligament and Double Bundle Anterolateral Ligament Reconstruction.

Project description:The results of arthroscopic anterior cruciate ligament (ACL) reconstruction are so far satisfactory and improving over time as a result of the improved understanding of the anatomy and biomechanics of the ACL. Rotational instability confirmed by a positive pivot shift is present in more than 15% of cases who underwent successful ACL reconstruction. Persistent rotational instability interferes with performing pivoting sports, and also may lead to meniscal and chondral injuries, or re-rupture of the reconstructed ACL. Surgeons reconsidered the anatomy and biomechanics of the ACL and introduced the double bundle ACL reconstruction technique aiming to achieve a more rotational control by reconstructing the anteromedial and anterolateral bundles of the ACL. To date, the results of double bundle ACL reconstruction are mixed and inconsistent. The improved understanding of the existence, function, and biomechanical role of the anterolateral ligament (ALL) in controlling the rotational instability of the knee has redirected and refocused attention on a supplemental extra-articular reconstruction of the ALL in conjunction with the intra-articular ACL reconstruction so as to restore normal kinematics of the knee. In this Technical Note, we describe a technique that allows for a combined ACL and double bundle ALL reconstruction using autogenous hamstring graft (semitendinosus and gracilis) tendons. This technique is an extension of our previously described technique of a combined anatomic ACL and single bundle ALL reconstruction. The improved understanding of the anatomy of the ALL makes a double bundle ALL reconstruction more anatomic than single bundle ALL reconstruction, as the native ALL is triangular or inverted Y in shape, with a narrow proximal femoral attachment and a broad distal tibial attachment between Gerdy's tubercle and the head of the fibula.

| S-EPMC5621982 | biostudies-literature

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction.

Project description:Despite technologic advances in the surgical technique for anterior cruciate ligament (ACL) reconstruction, some patients continue to have rotational instability postoperatively. Recently, authors have reported the anatomic and functional characteristics of the anterolateral ligament (ALL), a structure that originates near the lateral epicondyle on the femur and inserts on the tibia between the Gerdy tubercle and the fibular head. Recent biomechanical studies have shown the ALL is an important stabilizer against anterolateral tibial rotation, and its reconstruction has shown excellent initial clinical results. Several techniques have been developed to try to anatomically address this structure in the setting of an ACL reconstruction. This article details a simple anatomic technique to reconstruct the ACL and the ALL of the knee using hamstring tendon autograft and maintaining the semitendinosus insertion.

| S-EPMC5263705 | biostudies-literature

Combined Revision Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction.

Project description:There has been a substantial increase in the number of revision anterior cruciate ligament (ACL) reconstructions performed in the past decade. This Technical Note describes combined revision ACL and anterolateral ligament reconstruction using outside-in drilling, which avoids the need for 2-stage revision ACL reconstruction because it allows unconstrained anatomic placement.

| S-EPMC9353271 | biostudies-literature

Combined Anterior Cruciate Ligament Repair and Anterolateral Ligament Reconstruction.

Project description:There has been a renewed interest in anterior cruciate ligament (ACL) repairs over the last decade with some early promising results in the right patient population. Additionally, the anterolateral ligament has been extensively studied and has recently been shown to have a protective effect on standard ACL reconstructions in a clinical trial. Given its protective effect on ACL reconstructions, we believe this phenomenon is also relevant to ACL repairs and can decrease rerupture rates. In this publication, we demonstrate a surgical technique for ACL repair using an internal brace combined with an anterolateral ligament reconstruction using a gracilis autograft.

| S-EPMC6408622 | biostudies-literature

"Y" Graft Double Bundle Anterior Cruciate Ligament Reconstruction.

Project description:Single-bundle (SB) anterior cruciate ligament (ACL) reconstruction has been a standard procedure. However, residual rotary instability in approximately 20% of the cases (irrespective of the graft choice and the surgical technique) forces the surgeon to improve the biomechanical quality of the reconstruction. In parallel, adjustable suspensory fixation (ASF) devices have arisen. Biomechanics has defined (both anatomical and functional) the anteromedial (AM) and posterolateral (PL) bundles that work synergistically. In the unsymmetrical "anatomic" SB ACL reconstruction, the distribution of the ACL graft fibers (for AM or PL behavior) is not under the control of the surgeon. Furthermore, different sizes of the original footprints (depending on height) suggest the need to customize the graft footprint. This customization is only possible if distances are measured during surgical procedures. We present an inside-out technique for DB ACL reconstruction ("all-inside" also possible). Semitendinosus is folded to obtain a Y-shaped trifurcate configuration graft, distributing their bundles in two different areas. Used as measuring instruments, we used the "offset" guides as measuring instruments, allowing the surgeon to know the distance between the centers of the AM and PL tunnels. It may be carried out by means of common "offset" guides and any marketed ASF devices, while generating customized footprints.ClassificationI: knee; II: ACL.

| S-EPMC8417341 | biostudies-literature

Anatomic Double-Bundle Transtibial Anterior Cruciate Ligament Reconstruction.

Project description:Double-bundle anterior cruciate ligament (ACL) reconstruction (DBACLR) is a reasonable transition from single-bundle ACL reconstruction to obtain better clinical outcomes, and most authors believe that it can only be performed through a medial portal. However, in our clinical practice, we have found that anatomic DBACLR can be performed easily and exactly through transtibial tunnels just by positioning the tibial tunnels appropriately. Thus, we would like to introduce this anatomic double-bundle transtibial ACL reconstruction technique, in which the most critical step is to create a shallow tibial tunnel for the anteromedial bundle with a proximal projection to the anatomic location of the corresponding femoral tunnel. We believe this Technical Note will give an interesting view of anatomic DBACLR.

| S-EPMC7953165 | biostudies-literature

Condyle-Pinching Double-Bundle Anterior Cruciate Ligament Reconstruction.

Project description:The outcomes of anterior cruciate ligament (ACL) reconstruction are still unsatisfactory. Anterolateral ligament (ALL) reconstruction has been applied to augment ACL reconstruction, with better but still nonoptimal results. An anatomical analysis revealed that the route of ALL is quite different from that of ACL on the lateral view of the knee. Thus, we hope to augment ACL reconstruction with the reconstruction of an ACL-mimicking anterolateral structure, in which the route is similar to that of ACL. Thus, we aimed to introduce a combined ACL and ACL-mimicking anterolateral structure reconstruction technique, which we named condyle-pinching double-bundle ACL reconstruction. The main indication of this technique is ACL injury with a high degree of pivot shift or general laxity. The main steps of this technique include preparation of a combined graft, creation of a common femoral tunnel and 2 tibial tunnels, graft placement, and final graft fixation to an adjustable loop. We have been obtaining obvious outcome improvement clinically with this technique and consider that this report will provide special option in ACL reconstruction.

| S-EPMC7451757 | biostudies-literature

TriLink: Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction.

Project description:Cadaveric and clinical biomechanical studies show improved kinematic restoration using double-bundle anterior cruciate ligament (ACL) reconstruction techniques. These have been criticized in the past for being technically challenging. We present a novel 3-socket approach for anatomic "all-inside" double-bundle reconstruction using a single hamstring tendon fashioned to create a trifurcate graft: the TriLink technique. The semitendinosus alone is harvested, quadrupled, and attached to 3 suspensory fixation devices in a Y-shaped configuration, creating a 4-stranded tibial limb and 2 double-stranded femoral limbs. A medial viewing/lateral working arthroscopic approach is adopted using specifically designed instrumentation. Anatomic placement of the 2 femoral tunnels is performed by a validated direct measurement technique. A single mid-bundle position is used on the tibia. Both femoral and tibial sockets are created in a retrograde manner using outside-to-in drilling. This is a simplified operative technique for anatomic double-bundle ACL reconstruction that maximizes bone preservation. The TriLink construct replicates the 2 bundles of the ACL, conferring native functional anisometry and improving femoral footprint coverage while avoiding the complexities and pitfalls of double-tibial tunnel techniques. Preservation of the gracilis reduces the morbidity of hamstring harvest and allows greater flexibility in graft choice in cases requiring multiligament reconstruction.

| S-EPMC3986474 | biostudies-literature

Modified Technique for Combined Reconstruction of Anterior Cruciate Ligament and Anterolateral Ligament.

Project description:During the past few decades, surgical techniques for anterior cruciate ligament (ACL) reconstruction have been developing significantly. To date, studies have shown that after ACL reconstruction, rotational stability has a greater impact on the patient's satisfaction, functional scores, and return to sports than translational stability. Although challenged by many authors in the literature, biomechanical studies on the anterolateral ligament (ALL) of the knee and clinical studies regarding ALL reconstruction have been revealing promising results. Thus, the potentially significant role of the ALL in biomechanical load sharing and improving rotational control of the knee has led to the development of various reconstruction techniques whose goal is to achieve simplicity and yield the best results possible. Guided by this idea, we have developed a modified ACL-ALL reconstruction surgical technique. In this article, our simple, bone-saving, anatomic technique to reconstruct both the ACL and ALL using hamstring tendon autograft is described.

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