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Reconstruction of the anterior cruciate- and anterolateral ligament deficient knee with a modified iliotibial graft reduces instability more than with an intra-articular hamstring graft

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To compare knee kinematics before and after anterior cruciate ligament ACL reconstruction (ACL-R) using hamstring graft (HG) and a double-stranded iliotibial tract graft attached to Gerdy’s tubercle (providing an extra-articular anterolateral tenodesis) (named the modified iliotibial tract graft = MIT).

Method

Eighteen cadaveric knees were tested in a 6 degree of freedom kinematics rig. An optical tracking system recorded kinematics of the knee from 0 to 80 degrees of flexion applying no load, internal/external rotation (IR/ER), valgus/varus rotation (VGR/VRR), simulated pivot shift (SPS), anterior translation (AT) and posterior translation loads. The knee was tested before and after resection of the ACL and the anterolateral ligament (ALL), respectively; then after HG-ACL-R and MIT-ACL-R. Grafts were fixed at 20° of flexion. Results were compared to the intact knee.

Results

ACL resection resulted in a significant increase in AT (p < 0.05) over the entire range of motion, peaking at 20° of flexion, mean difference 6.6 ± 2.25 mm (p = 0.0007). ACL-R with HG-ACL and MIT-ACL restored AT. Resection of the ALL increased IR in the fully extended knee, mean difference 2.4 ± 2.1° (p = 0.024). When compared to the intact knee and the knee after HG-ACL-R, MIT-ACL-R knee reduced IR/SPS significantly (p < 0.05) in deep flexion angles (60°–80°), peaking at 80° of flexion. The MIT-ACL-R caused significantly less VRR at 80° flexion (p = 0.02).

Conclusion

MIT-ACL-R restored AT equally to the HG-ACL-R. The MIT-ACL-R reduced IR and SPS in deep flexion, resulting in overconstraint. MIT-ACL-R can be used as an alternative to standard reconstruction methods.

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Abbreviations

ACL:

Anterior cruciate ligament

ALL:

Anterolateral ligament

AT:

Anterior translation

ER:

External rotation

LCL:

Lateral collateral ligament

HG:

Hamstrings graft

IR:

Internal rotation

ITB:

Iliotibial band

MIT:

Modified iliotibial tract

PCL:

Posterior cruciate ligament

PT:

Posterior translation

R:

Reconstruction

ROM:

Range of motion

VGR:

Valgus rotation

VRR:

Varus rotation

SD:

Standard deviation

SPS:

Simulated pivot shift

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Acknowledgements

Our grateful thanks to the research group at Imperial College London, especially Dr. Joanna Stephen, Dr. Hadi El-Daou, for their help in acquiring the specimens, the setup of the lab and interpretation of the results. We also extend our gratitude to The Sports Fund of the Danish Ministry of Culture, Aase & Ejner Danielsen Fonden, Gangsted Fonden and the IOC Research Fund for funding this work.

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Authors and Affiliations

  1. University of Copenhagen, Copenhagen, Denmark

    Salameh Belal Eljaja & Michael Rindom Krogsgaard

  2. Department of Arthroscopy and Sport Traumatology, Part of the IOC Reseach Center, Bispebjerg Hospital, Bispebjerg Bakke 23, Entrance 5, 2. Floor, Copenhagen, Denmark

    Salameh Belal Eljaja, Lars Konradsen & Michael Rindom Krogsgaard

  3. Slagelse, Denmark

    Salameh Belal Eljaja

  4. Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014, Copenhagen K, Denmark

    Volkert Dirk Siersma

  5. Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK

    Kiron Athwal & Andrew Arthur Amis

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  1. Salameh Belal Eljaja
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Correspondence to Salameh Belal Eljaja.

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Conflict of interest

Co-author Kiron Athwal, Ph.D., disclosed his salary funded by a research fund at Imperial College London, as a potential COI. All other authors did not disclose any COIs.

Funding

This study was funded by The Sports Fund of the Danish Ministry of Culture (Grant no. TAKT2017-377), Aase & Ejner Danielsen Fonden (Grant no. 10-001673), Gangsted Fonden (Grant no. 29886) and the IOC Research Fund.

Ethical approval

Cadaveric knees were used with consent of Imperial College Healthcare Tissue Bank, License 12275, Projecyt R15090, REC Wales approval: 12/WA/0196.

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Eljaja, S.B., Konradsen, L., Siersma, V.D. et al. Reconstruction of the anterior cruciate- and anterolateral ligament deficient knee with a modified iliotibial graft reduces instability more than with an intra-articular hamstring graft. Knee Surg Sports Traumatol Arthrosc 28, 2526–2534 (2020). https://doi.org/10.1007/s00167-020-05850-8

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