Sydney Orthopaedic Research Institute Ltd, Chatswood, New South Wales, Australia
Laboratory of Human Movement Biology (LIBM EA 7424), University of Lyon-Jean Monnet, Saint Etienne, France.
J ISAKOS. 2021 Mar;6(2):74-81. doi: 10.1136/jisakos-2019-000360. Epub 2020 Nov 24.
The optimal anterolateral procedure to control anterolateral rotational laxity of the knee is still unknown. The objective was to compare the ability of five anterolateral procedures performed in combination with anterior cruciate ligament reconstruction (ACLR) to restore native knee kinematics in the setting of a deficient anterior cruciate ligament (ACL) and anterolateral structures.
A controlled laboratory study was performed using 10 fresh-frozen cadaveric whole lower limbs with intact iliotibial band. Kinematics from 0° to 90° of flexion were recorded using a motion analysis three-dimensional (3D) optoelectronic system, allowing assessment of internal rotation (IR) and anteroposterior (AP) tibial translation at 30° and 90° of flexion. Joint centres and bony landmarks were calculated from 3D bone models obtained from CT scans. Intact knee kinematics were assessed initially, followed by sequential section of the ACL and anterolateral structures (anterolateral ligament, anterolateral capsule and Kaplan fibres). After ACLR, five anterolateral procedures were performed consecutively on the same knee: ALLR, modified Ellison, deep Lemaire, superficial Lemaire and modified MacIntosh. The last three procedures were randomised. For each procedure, the graft was fixed in neutral rotation at 30° of flexion and with a tension of 20 N.
Isolated ACLR did not restore normal overall knee kinematics in a combined ACL plus anterolateral-deficient knee, leaving a residual tibial rotational laxity (p=0.034). Only the ALLR (p=0.661) and modified Ellison procedure (p=0.641) restored overall IR kinematics to the normal intact state. Superficial and deep Lemaire and modified MacIntosh tenodeses overconstrained IR, leading to shifted and different kinematics compared with the intact condition (p=0.004, p=0.001 and p=0.045, respectively). Compared with ACLR state, addition of an anterolateral procedure did not induce any additional control on AP translation at 30° and 90° of flexion (all p>0.05), except for the superficial Lemaire procedure at 90° (p=0.032).
In biomechanical in vitro setting, a comparison of five anterolateral procedures revealed that addition of either ALLR or modified Ellison procedure restored overall native knee kinematics in a combined ACL plus anterolateral-deficient knee. Superficial and deep Lemaire and modified MacIntosh tenodeses achieved excellent rotational control but overconstrained IR, leading to a change from intact knee kinematics.
The level-of-evidence statement does not apply for this laboratory experiments study.
控制膝关节前外侧旋转松弛的最佳前外侧入路仍不清楚。本研究的目的是比较 5 种在前交叉韧带重建（ACL）时联合应用的前外侧入路在 ACL 和前外侧结构缺失的情况下恢复正常膝关节运动学的能力。
本研究采用 10 个新鲜冷冻的完整下肢尸体标本进行对照实验室研究，包括完整的髂胫束。使用运动分析三维（3D）光电系统记录 0°至 90°的屈曲运动学，允许在 30°和 90°的屈曲时评估内旋（IR）和前后（AP）胫骨平移。关节中心和骨标志从 CT 扫描获得的 3D 骨模型中计算得出。最初评估完整膝关节运动学，然后依次切除 ACL 和前外侧结构（前外侧韧带、前外侧囊和 Kaplan 纤维）。在 ACLR 后，在同一条膝关节上连续进行 5 种前外侧手术：ALLR、改良 Ellison、深 Lemaire、浅 Lemaire 和改良 MacIntosh。后三种手术是随机进行的。对于每个手术，移植物在 30°的屈曲时固定在中立旋转位置，并施加 20 N 的张力。
ACL 单独重建不能恢复 ACL 联合前外侧缺失膝关节的正常整体膝关节运动学，导致残留胫骨旋转松弛（p=0.034）。只有 ALLR（p=0.661）和改良 Ellison 手术（p=0.641）将整体 IR 运动学恢复到正常完整状态。浅层和深层 Lemaire 以及改良 MacIntosh 肌腱过度限制了 IR，导致与完整状态相比出现移位和不同的运动学（p=0.004，p=0.001 和 p=0.045，分别）。与 ACLR 状态相比，在前外侧手术的基础上，在 30°和 90°的屈曲时，AP 平移没有任何额外的控制（均 p>0.05），除了浅层 Lemaire 手术在 90°时（p=0.032）。
在生物力学的体外环境中，对 5 种前外侧手术的比较显示，无论是 ALLR 还是改良 Ellison 手术的附加手术都可以恢复 ACL 联合前外侧缺失膝关节的整体正常膝关节运动学。浅层和深层 Lemaire 以及改良 MacIntosh 肌腱能够实现出色的旋转控制，但过度限制了 IR，导致与正常膝关节运动学不同。
本实验室实验研究的证据水平不适用。
