title: Biomechanical Comparison of Anterolateral Procedures Combined With Anterior Cruciate Ligament Reconstruction.
abstract: BACKGROUND
  Anterolateral soft tissue structures of the knee have a role in controlling anterolateral rotational laxity, and they may be damaged at the time of anterior cruciate ligament (ACL) ruptures.
  
  
  OBJECTIVE
  To compare the kinematic effects of anterolateral operative procedures in combination with intra-articular ACL reconstruction for combined ACL plus anterolateral-injured knees.
  
  
  METHODS
  Controlled laboratory study.
  
  
  METHODS
  Twelve cadaveric knees were tested in a 6 degrees of freedom rig using an optical tracking system to record the kinematics through 0° to 90° of knee flexion with no load, anterior drawer, internal rotation, and combined loading. Testing was first performed in ACL-intact, ACL-deficient, and combined ACL plus anterolateral-injured (distal deep insertions of the iliotibial band and the anterolateral ligament [ALL] and capsule cut) states. Thereafter, ACL reconstruction was performed alone and in combination with the following: modified MacIntosh tenodesis, modified Lemaire tenodesis passed both superficial and deep to the lateral collateral ligament, and ALL reconstruction. Anterolateral grafts were fixed at 30° of knee flexion with both 20 and 40 N of tension. Statistical analysis used repeated-measures analyses of variance and paired t tests with Bonferroni adjustments.
  
  
  RESULTS
  ACL reconstruction alone failed to restore native knee kinematics in combined ACL plus anterolateral-injured knees ( P < .05 for all). All combined reconstructions with 20 N of tension, except for ALL reconstruction ( P = .002-.01), restored anterior translation. With 40 N of tension, the superficial Lemaire and MacIntosh procedures overconstrained the anterior laxity in deep flexion. Only the deep Lemaire and MacIntosh procedures-with 20 N of tension-restored rotational kinematics to the intact state ( P > .05 for all), while the ALL underconstrained and the superficial Lemaire overconstrained internal rotation. The same procedures with 40 N of tension led to similar findings.
  
  
  CONCLUSIONS
  In a combined ACL plus anterolateral-injured knee, ACL reconstruction alone failed to restore intact knee kinematics. The addition of either the deep Lemaire or MacIntosh tenodesis tensioned with 20 N, however, restored native knee kinematics.
  
  
  CONCLUSIONS
  The current study indicates that unaddressed anterolateral injuries, in the presence of an ACL deficiency, result in abnormal knee kinematics that is not restored if only treated with intra-articular ACL reconstruction. Both the modified MacIntosh and modified deep Lemaire tenodeses (with 20 N of tension) restored native knee kinematics at time zero.
authors.affiliation: Biomechanics Group, Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, UK.|Department of Orthopaedic Surgery, Haraldsplass Deaconess Hospital, Bergen, Norway.
authors.forename: Eivind
authors.initials: E
authors.lastname: Inderhaug
authors.affiliation: Biomechanics Group, Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, UK.|Fortius Clinic, London, UK.
authors.forename: Joanna M
authors.initials: JM
authors.lastname: Stephen
authors.affiliation: Fortius Clinic, London, UK.
authors.forename: Andy
authors.initials: A
authors.lastname: Williams
authors.affiliation: Biomechanics Group, Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, UK.|Musculoskeletal Surgery Group, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Amis
mesh_terms: D000328:Adult; D000070598:Anterior Cruciate Ligament Injuries / Q000601:surgery*; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D001696:Biomechanical Phenomena; D002102:Cadaver; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000601:surgery*; D007717:Knee / Q000502:physiology; D007719:Knee Joint / Q000502:physiology*; D008297:Male; D008875:Middle Aged; D011897:Random Allocation; D016059:Range of Motion, Articular; D053656:Tenodesis / Q000379:methods*
keywords: Lemaire; MacIntosh; anterior cruciate ligament reconstruction; anterolateral ligament