COMBINED ANTERIOR CRUCIATE LIGAMENT & ANTEROLATERAL LIGAMENT RECONSTRUCTION VERSUS ISOLATED ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Abstract

SUMMARY T he rupture of the anterior cruciate ligament (ACL) is one of the most common knee ligament injuries, with an annual incidence of 35 per 100 000 people. This event occurs primarily in active individuals, athletic associated with (contact and non-contact) pivoting mechanism. With females are more likely to ACL injury more than males (2 to 3 times). Consequently, ACL reconstruction is one of the most common preferred orthopedic surgeries. The anterior cruciate ligament (ACL) consists of 2 functional bundles, namely the anteromedial (AM) and posterolateral (PL) bundles, each named for their respective insertion site locations on the tibia. The bundles become evident during development of the fetus and are differentiable throughout life. A septum of connective tissue divides the AM and PL bundles, which provides a blood supply to the ligament and allows the bundles to work synergistically throughout motion. Functionally, the AM bundle attains peak tension between 45° and 60° of flexion but remains tight throughout the knee range of motion. By comparison, the PL bundle is tight in extension and loosens with flexion, thereby allowing rotation to occur. Orthopaedic surgeons generally reported very good results following evolution of the anterior cruciate ligament (ACL) reconstruction arthroscopically from the trans -tibial to double bundle to the final anatomical single bundle which gave a good anteroposterior stability to the knee joint but the research fails to support the reason of still some rotational instability. On average only 60% of patients post operatively returns to the same level of sport otherwise these athletes have a one in four chance of re-injuring an ACL either contralateral or rupturing the graft itself also some have the chance of developing significantly clinical and radiological osteoarthritis (OA) of the knee joint . Residual rotational instability, subjectively measured as a positive pivot shift, is thought to be a cause of recurrent ACL injuries, Persistent problems in rotational laxity control after standard intra-articular ACLR have led knee surgeons to focus on the potential benefits of adding lateral extra articular tenodesis (LET). Theoretically, the addition of LET plays an important role in better constraining the displacement of the lateral tibial compartment and providing a stronger lever arm for controlling the rotational laxity of knee joints. IN 1967; Lemaire described a completely extra-articular procedure to treat chronic ACL deficient knees with the use of iliotibial band , Macintosh described a different anterolateral tenodesis. A 20-cm long, 3-cm wide strip of iliotibial band (ITB) was harvested, preserving the distal insertion. The strip was passed deep to the LCL, and inserted again to the tibia. Recently, new insights into the existence and function of a distinct ligamentous structure on the anterolateral aspect of the knee, the anterolateral ligament (ALL), have refocused attention on primary restraint of the rotational laxity of the knee after ACL injury. The anterolateral ligament (ALL) origin is located on the prominence of the lateral femoral epicondyle proximal and anterior to the LCL and posterior to the popliteus muscle ,the body of the ALL run in an oblique course to the anterolateral side of the proximal tibia and inserted to the area midway between the Gerdy s tubercle and the fibular head and 5 mm from the articular cartilage . The additional of the ALL reconstruction (extra articular) to the (intra articular) ACL reconstruction gave good results in the pivot shift test and also leading to more stability of the joint:  Firstly because the lateral extra articular reconstruction gave a stronger lever arm for controlling the rotational laxity of knee joints.