Method for anatomical anterolateral tenodesis of anterolateral ligament of knee joint

Abstract

FIELD: traumatology; orthopedics.SUBSTANCE: used for anatomical anterolateral tenodesis of the anterolateral ligament of the knee joint. The method includes arthroscopic revision of the knee joint with plastic surgery of the anterior cruciate ligament using the semitendinosus tendon using the all-inside technique. From an additional approach along the anteromedial surface of the upper third of the leg, the iliotibial tract is isolated from the Gerdy tubercle of the tibia to the lateral epicondyle of the femur. An autograft is cut out from the proximal part of the iliotibial tract; the proximal part of the autograft from the iliotibial tract is sutured; the diameter of the autograft from the iliotibial tract is determined. The intervention zones are marked with injection needles. The first needle is placed on the Gerdy tubercle of the tibia. The second needle is placed on the head of the fibula and the third needle is placed on the joint space. The first guide wire is installed from the middle of the distance between the head of the fibula and the Gerdy tubercle of the tibia, and the second guide wire is installed in the projection of the Gerdy tubercle of the tibia. Drilling of the opposing bone canals is performed using guide wires with a drill diameter corresponding to the diameter of the autograft from the iliotibial tract. The autograft is inserted from the iliotibial tract through the formed bone channels. With the limb in a straightened position, the position of the lateral femoral epicondyle is determined, from which a guide wire is inserted posteriorly and proximally, and a channel corresponding to the diameter of the iliotibial tract autograft is drilled; the iliotibial tract autograft is inserted and fixed with a bioabsorbable screw. The cavity is washed, the iliotibial tract is sutured, the wound is sutured layer by layer, and an aseptic dressing is applied.EFFECT: increased anterior-rotational stability of the knee joint and eliminating the need for re-intervention by restoring the anterolateral ligament through anatomical extra-articular tenodesis of the iliotibial tract, ensuring contact of the autograft with the autobone.1 cl, 10 dwg, 1 ex

Description

[0001] The invention relates to medicine, namely to traumatology and orthopedics, and can be used in surgery for knee joint instability.

[0002] Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed arthroscopic knee surgeries. Advances in knee reconstructive surgery do not always result in satisfactory outcomes in all cases. Currently, 15% to 25% of patients experience instability and / or pain after knee ligament reconstruction (Wright ML, et al., Combined Anterior Cruciate Ligament and Medial Collateral Ligament Reconstruction Shows High Rates of Return to Activity and Low Rates of Recurrent Valgus Instability: An Updated Systematic Review. Arthrosc Sports Med Rehabil. 2023 May 5; 5(3):e867-e879; Grassi A et al., High Long-term Survivorship From Revision After Physeal-Sparing "Over-the-Top" Anterior Cruciate Ligament Reconstruction and Lateral Tenodesis in Skeletal Immature Patients: 8- to 17-Year Follow-up. Orthop J Sports Med. 2025 Dec 2; 13(12)).Unsatisfactory results can most often be explained by unaccounted rotational or anterolateral instability, which is caused by damage to the anterolateral ligament, which plays an important role in stabilizing the knee joint (Claes S, et al, Anatomy of the anterolateral ligament of the knee. J Anat. 2013 Oct; 223(4):321-8; Na BR et al, Clinical Outcomes of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis Combined With Primary ACL Reconstruction: A Systematic Review With Meta-analysis. Orthop J Sports Med. 2021 Sep 13; 9(9)).

[0003] A known surgical technique for anterolateral ligament (ALL) reconstruction is anatomical ligament reconstruction (ALLR), which requires the collection of additional autograft and the use of additional fixators in the form of anchors or screws. A partially anatomical anterolateral tenodesis (LET) is also known, which does not require the collection of additional autografts and the use of multiple fixators. Numerous scientific studies have not revealed significant advantages of one method over the other in ensuring rotational stability of the knee joint. However, simultaneous reconstruction of the anterior cruciate ligament and anterolateral ligament of the knee joint leads to improved postoperative results. Many researchers report a reduced incidence of instability recurrence, an increased percentage of patients returning to active loads, and an improved quality of life (Ariel de Lima D et al., Clinical outcomes of combined anterior cruciate ligament and anterolateral ligament reconstruction: a systematic review and meta-analysis. Knee Surg Relat Res. 2021 Sep 23; 33(1):33, Helito CP et al, Functional results of multiple revision anterior cruciate ligament with anterolateral tibial tunnel associated with anterolateral ligament reconstruction. Knee Surg Relat Res. 2022 May 8; 34(1):24).

[0004] A known method for treating post-traumatic anterior knee instability (patent RU 2208406, IPC A61B17 / 56, published 20.07.2003) consists of forming a fascial-bone graft from the distal dorsal part of the iliotibial tract and a portion of the bone base on the tibial condyle (Gerdy's tubercle) through an external-lateral incision, separating it from the distal attachment site, and reinserting the graft with tension 8-12 mm distally and anteriorly from the original attachment site. The graft is fixed with transosseous sutures and, if necessary, reinforced with pins. Thus, according to the authors, isometry is created between the lateral epicondyle of the femur and Gerdy's tubercle, which in turn stabilizes the knee joint from excessive rotation.

[0005] The main disadvantages of this method are:

[0006] - the method does not exclude anterior displacement of the tibia in the absence of reconstruction of the anterior cruciate ligament;

[0007] - there is no clear anatomical structure at the fixation points, which leads to greater variability and the risk of excessive or, conversely, insufficient tension of the graft, which is a significant disadvantage;

[0008] - the use of additional fixing pins may be associated with the risk of damage to the underlying tissues and require subsequent removal of the pins.

[0009] The closest technical solution to the claimed one is a method for one-stage plastic surgery of the anterior cruciate and lateral anterolateral ligaments of the knee joint in patients with combined instability of the knee joint (patent RU 2701776, IPC A61B17 / 56, published 01.10.2019), which includes the formation of channels in the tibia and femur, passing an autograft through them, using a free tendon autograft from the tendons of the gracilis and semitendinosus muscles, forming an autograft in the form of a duplication of tendons and using a synthetic polyester augment, freely laid between two folded tendons and fixed to them by stitching over a length of 2.5 cm at a distance of 10 cm from the beginning of the autograft, leaving a free end of the polyester augment, the resulting autograft is inserted as an anterior cruciate ligament through the formed channel in the tibia,The autograft is inserted from the outside to the inside in the channel formed in the femoral condyle up to the previously stitched mark, the autograft is fixed with a biocomposite screw in the channel in the femoral condyle at the point of native attachment of the anterolateral ligament, excess polyester augment is cut off, and the wound is sutured.

[0010] The main disadvantages of this method are:

[0011] - the anterolateral ligament after reconstruction will be represented exclusively by a synthetic augment, which excludes biological remodeling, a higher risk of reactions of surrounding soft tissues to a foreign body, and long-term durability directly depends on the “fatigue” of the synthetic material;

[0012] - the reconstruction is partially anatomical, since the proximal point of the augment coincides with the exit of the anterior cruciate ligament graft from the femoral canal, and not the native point of the ALL, which indicates that the vector of ligament biomechanics directly depends on the femoral canal of the anterior cruciate ligament, and not on its own;

[0013] - High technical complexity of reproduction, multiple tendon harvesting (which may affect the lower leg translation). A large number of fixators were used.

[0014] The objective of the present invention (technical result) is to increase the efficiency of eliminating anterior-rotational instability of the knee joint, eliminating the need for repeated surgical intervention, ensuring contact of the autograft with the autobone, accelerating osseointegration and functional restoration of the knee joint.

[0015] The problem is solved using the method of anatomical anterolateral tenodesis of the anterolateral ligament of the knee joint, including arthroscopic revision of the knee joint with plastic surgery of the anterior cruciate ligament with the tendon of the semitendinosus muscle using the all-inside technique; through an additional approach along the anteromedial surface of the upper third of the leg, the iliotibial tract is isolated from the Gerdy tubercle of the tibia to the lateral epicondyle of the femur; an autograft is cut out from the proximal part of the iliotibial tract; the proximal part of the autograft from the iliotibial tract is sutured; the diameter of the autograft from the iliotibial tract is determined; The intervention zones are marked with injection needles: the first needle is placed on the Gerdy tubercle of the tibia, the second needle is placed on the head of the fibula, and the third needle is placed on the joint space;The first guide wire is inserted from the midpoint of the fibular head and Gerdy's tubercle of the tibia, and the second guide wire is inserted in the projection of Gerdy's tubercle of the tibia; counter bone channels are drilled along the guide wires with a drill diameter corresponding to the diameter of the autograft from the iliotibial tract; the autograft from the iliotibial tract is inserted through the formed bone channels; in the straightened position of the limb, the position of the lateral epicondyle of the femur is determined, from which, moving backward and proximally, a guide wire is inserted and a channel is drilled corresponding to the diameter of the autograft from the iliotibial tract; the autograft from the iliotibial tract is inserted and fixed with a biodegradable screw. perform cavity lavage, suturing of the iliotibial tract, layer-by-layer suturing of the wound and application of an aseptic dressing;

[0016] The method of anatomical anterolateral tenodesis of the anterolateral ligament of the knee joint includes collecting an autograft from the iliotibial tract, marking anatomical points with subsequent formation of bone canals and inserting the autograft from the iliotibial tract into the formed bone canals and its subsequent fixation at the native point of the lateral epicondyle of the femur with a biodegradable screw.

[0017] The invention is explained by the following images.

[0018] Figure 1 shows a schematic representation of the anatomical anterolateral tenodesis, where 1 is the iliotibial tract, 2 is the lateral collateral ligament, 3 is the converging bone canal, Figure 2 shows the approach to the iliotibial tract, Figure 3 shows the marking of the head of the fibula and the Gerdy tubercle of the tibia, Figure 4 shows the isolated autograft from the iliotibial tract, Figure 5 shows the sutured autograft from the iliotibial tract, Figure 6 shows the formed converging bone canal of the tibia, Figure 7 shows the measurement of the diameter of the autograft from the iliotibial tract, Figure 8 shows the passed autograft from the iliotibial tract through the bone canal, Figure 9 shows the formation of the bone canal on the outer epicondyle of the femur, Fig. 10 shows the fixation of an autograft from the iliotibial tract with a biodegradable screw.

[0019] To obtain the technical result, the invention can be implemented in the following preferred manner, which does not exclude other methods of implementation within the framework of the stated invention formula.

[0020] The method involves arthroscopic revision of the knee joint with grafting of the anterior cruciate ligament using the semitendinosus tendon using the all-inside technique on self-tightening buttons. An incision from the lateral femoral epicondyle to the Gerdy tubercle of the tibia is made to isolate the iliotibial tract and extract the autograft from it. Bone canals are formed midway between the head of the fibula (the first bone canal) and the points of native fixation of the iliotibial tract on the tibia, which corresponds to the Gerdy tubercle of the tibia (the second bone canal). The autograft from the iliotibial tract is then passed through the formed bone canals and fixed to the femur with a bioabsorbable screw. The autograft from the iliotibial tract contacts the autogenous bone within the bone canal, improving osseointegration. Reconstruction is performed in a single procedure.

[0021] The method of anatomical anterolateral tenodesis of the anterolateral ligament of the knee joint is carried out as follows.

[0022] The surgery is performed under spinal anesthesia. The patient is placed supine with the knee flexed. A pneumatic tourniquet is applied to the thigh at 300 mmHg. The surgical site is cleaned with an antiseptic. Through two standard anterior arthroscopic ports, an examination is performed to assess the condition of all segments of the knee joint, including the menisci, cartilaginous surfaces, and cruciate ligaments.

[0023] From an additional access along the anteromedial surface of the upper third of the leg, the tendon of the semitendinosus muscle is harvested, followed by processing and plastic surgery of the anterior cruciate ligament using the all-inside technique.

[0024] Using an additional access from the Gerdy tubercle of the tibia to the lateral epicondyle of the femur (approximately 10-12 cm), the iliotibial tract is isolated using blunt and sharp dissection. An iliotibial tract autograft is dissected from the proximal portion of the iliotibial tract, measuring 1 cm in width and approximately 10 cm in length (depending on the patient's constitutional characteristics). The proximal portion of the iliotibial tract autograft is sutured, and its diameter is determined. The intervention zones are marked with injection needles: the first needle is placed on the Gerdy tubercle of the tibia, the second on the head of the fibula, and the third on the joint space. The guide wires are installed, the first guide wire is installed from the middle of the distance between the head of the fibula and the Gerdy tubercle of the tibia, the second opposite guide wire is installed in the projection of the Gerdy tubercle of the tibia.The guide wires are used to drill counter-tunnels using a drill diameter corresponding to the diameter of the iliotibial tract autograft. The iliotibial tract autograft is inserted through the created bone channel. The limb is then positioned in an extended position, the lateral femoral epicondyle is identified posteriorly and proximally, a guide wire is inserted, and a channel is drilled to match the diameter of the iliotibial tract autograft, followed by insertion and fixation with a bioabsorbable screw. After checking the tension and fixation strength of the iliotibial tract autograft, the cavity is irrigated, the iliotibial tract is sutured, the wound is closed layer by layer, and an aseptic dressing, Class 2 compression stockings, and immobilization with a splint are applied.

[0025] Clinical example.

[0026] Patient M., born in 1986, presented with persistent complaints of residual instability of her right knee joint. She sustained an injury in 2012 and underwent surgery in 2015, including debridement and resection of the damaged portion of the meniscus. In 2017, a repeat arthroscopic debridement of the knee joint was performed. In 2019, arthroscopic reconstruction of the anterior cruciate ligament was performed, with persistent complaints of residual instability of the operated knee joint.

[0027] According to the MRI results, damage to the anterolateral ligament was noted at the distal portion of the fixation, with the anterior cruciate ligament autograft visible under sufficient tension. The surgery was performed according to the stated method. Arthroscopy was performed for debridement and ablative treatment of the anterior cruciate ligament autograft. The iliotibial tract was isolated through an incision along the lateral surface of the femur and tibia, its length and width were marked, and the iliotibial tract was sutured and dissected, followed by the isolation of the autograft down to the Gerdy tubercle of the tibia. Opposing bone canals were created along a guide wire. The autograft from the iliotibial tract was passed through the bone canal. A bone tunnel was created over the lateral femoral epicondyle using a guide wire. An autograft from the iliotibial tract was inserted into the tunnel and secured with a bioabsorbable screw. Range of motion was verified and found to be full.The tension of the iliotibial band autograft was satisfactory. No knee instability was detected, and knee instability tests (Lachman, pivot-shift, and anterior drawer tests) were negative. The iliotibial band was sutured and the wounds were closed layer by layer. An aseptic dressing was applied. The knee was immobilized with a splint. There was moderate swelling postoperatively.

[0028] Thus, the proposed method of anatomical anterolateral tenodesis of the anterolateral ligament of the knee joint allows to increase the anterior-rotational stability of the knee joint by restoring the anterolateral ligament through anatomical extra-articular tenodesis of the iliotibial tract, eliminate the need for repeated intervention by ensuring contact of the autograft with the autobone, accelerate osseointegration and functional restoration of the knee joint.

[0029] The proposed method of anatomical anterolateral tenodesis of the anterolateral ligament of the knee joint can be used in surgery for knee joint instability.

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