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Purpose: To evaluate the results of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction in patients with chronic ACL injury. It was hypothesized that patients who underwent combined ACL and ALL reconstruction would exhibit less residual laxity and better clinical outcomes., Methods: Two groups of patients were evaluated and compared retrospectively. Both groups consisted only of patients with chronic (more than 12 months) ACL injuries. Patients in group 1 underwent anatomical intra-articular reconstruction of the ACL and patients in group 2 underwent anatomic intra-articular ACL reconstruction combined with ALL reconstruction. The presence of associated meniscal injury, the subjective International Knee Documentation Committee (IKDC) and Lysholm functional outcome scores in the postoperative period, KT-1000 evaluation, the presence of residual pivot shift and graft rupture rate were evaluated., Results: One hundred and one patients who underwent reconstruction of chronic ACL injuries were evaluated. The median follow-up was 26 (24-29) months for group 1 and 25 (24-28) months for group 2. There were no significant differences between groups regarding gender, age, duration of injury until reconstruction, follow-up time or presence of associated meniscal injuries in the preoperative period. Regarding functional outcome scores, patients in group 2 presented better results on both the IKDC (p = 0.0013) and the Lysholm (p < 0.0001) evaluations. In addition, patients in group 2 had better KT-1000 evaluation (p = 0.048) and a lower pivot shift rate at physical examination, presenting only 9.1% positivity versus 35.3% in the isolated ACL reconstruction (p = 0.011). Regarding re-ruptures, group 1 presented 5 (7.3%) cases, and group 2 presented no cases., Conclusion: The combined ACL and ALL reconstruction in patients with chronic ACL injury is an effective and safety solution and leads to good functional outcomes with no increase in complication rate. The clinical relevance of this finding is the possibility to indicate this type of procedure when patients present with more than 12 months after injury for surgery., Level of Evidence: Level III.

Purpose: To determine whether the tibial tuberosity-to-trochlear groove distance (TT-TG) and patellar tendon-to-trochlear groove distance (PT-TG) are equal, whether the bony and cartilaginous points coincide in the trochlea, and whether the insertion of the PT coincides with the most anterior point of the TT in patients with patellar instability., Methods: Fifty-three MRI scans of patients with patellar instability were examined. TT-TG and PT-TG were measured by three examiners in 31 knees. Additionally, the bone-cartilage distance in the trochlea [trochlear cartilage to trochlear bone (TC-TB)] and the distance between the mid-point of the PT insertion and the most anterior point of the TT (PT-TT) were measured by one examiner. The intraclass correlation coefficient was used to evaluate the reliability of the measurements between the three examiners. The relationships between the measurements were determined, the means of the measurements were calculated, and the correlations between PT-TG and TT-TG, PT-TT, and TC-TB were assessed., Results: The ICC was above 0.8. PT-TG was 3.7 mm greater than TT-TG. The TC and TB coincided in 73 % of cases, and the mean TC-TB was 0.3 mm. The PT was lateral to the TT in 94 % of the cases, and the mean PT-TT was 3.4 mm. The Pearson's correlation coefficients between PT-TG and TT-TG, PT-TT, and TC-TB were 0.946, 0.679, and 0.199, respectively., Conclusion: TT-TG underestimated PT-TG, primarily due to the lateralization of the PT insertion relative to the most anterior point of the TT., Clinical Relevance: our study shows that in patients with patellar instability, there are differences in the absolute values of TT-TG and PT-TG, as previously reported for patients without patellar instability. Hence, normal cut-off values based on case-control studies of TT-TG cannot be equivalently used when measuring PT-TG to indicate TT medialization in patients with patellar instability. It is also important to note that the clinical outcomes cannot be directly compared between patients evaluated using TT-TG versus PT-TG measurements., Level of Evidence: III.

Purpose: Medial patellofemoral ligament (MPFL) reconstruction offers good clinical results with a very low rate of instability recurrence. However, its in vivo effect on patellar tracking is not clearly known. The aim of this study is to investigate the effects of MPFL reconstruction on patellar tracking using dynamic 320-detector-row CT., Methods: Ten patients with patellofemoral instability referred to isolated MPFL reconstruction surgery were selected and subjected to dynamic CT before and ≥6 months after surgery. Patellar tilt angles and shift distance were analysed using computer software specifically designed for this purpose. Kujala and Tegner scores were applied, and the radiation of the CTs was recorded. Two protocols for imaging acquisition were compared: a tube potential of 80 kV and 50 mA versus a tube potential of 120 kV and 100 mA, both with a slice thickness of 0.5 mm and an acquisition duration of 10 s., Results: There were no changes in patellar tracking after MPFL reconstruction. There was no instability relapse. Clinical scores improved from a mean of 51.9 (±15.6)-74.2 (±20.9) on the Kujala scale (p = 0.011) and from a median of 2 (range 0-4) to 4 (range 1-6) on the Tegner scale (p = 0.017). The imaging protocols produced a dose-length product (DLP) of 254 versus 1617 mGycm and a radiation effective estimated dose of 0.2 versus 1.3 mSv, respectively. Both protocols allowed the analysis of the studied parameters without loss of precision., Conclusions: Reconstruction of the MPFL produced no improvement in patellar tilt or shift in the population studied. The low-radiation protocol was equally effective in measuring changes in patellar tracking and is recommended. Although the procedure successfully stabilized the patella, knee surgeons should not expect patellar shift and tilt correction when performing isolated patellofemoral ligament reconstruction in patients with recurrent patellar instability., Level of Evidence: IV.

Purpose: Lesions of the medial collateral ligament (MCL) are the most common knee ligament injuries, and lesions associated with the anterior cruciate ligament or the posterior cruciate ligament (PCL) in knee dislocations should be reconstructed to prevent failure of the central pivot reconstruction. The purpose of this study was to evaluate the outcomes of combined PCL/MCL reconstruction using a single femoral tunnel with a minimum 2-year follow-up., Method: A retrospective study of thirteen patients with combined PCL/MCL injuries was conducted. The patients underwent PCL and MCL reconstruction using an Achilles tendon allograft with a single tunnel in the medial femoral condyle, thereby avoiding tunnel conversion., Results: All patients achieved a range of motion of at least 100°. The mean loss of extension and flexion values compared to the contralateral side was 1° ± 2° and 9° ± 10°, respectively. Our results included 26 reconstructions with three (11.5 %) failures, two in the PCL (15.3 %) and one in the MCL (7.6 %), in three different patients. In the final evaluation, the mean IKDC subjective score was 71.63 ± 16.23, the mean Lysholm score was 80.08 ± 13.87, and the median Tegner score was 6 (range = 2-7)., Conclusion: The PCL/MCL reconstruction technique using a single femoral tunnel and an Achilles tendon allograft is safe, avoids the convergence of tunnels in the medial femoral condyle, has excellent results, and is reproducible., Level of Evidence: IV.

Purpose: The aim of this study is to characterize in detail the meniscal insertion of the anterolateral ligament (ALL) of the knee, establishing parameters regarding the circumference of the lateral meniscus and the popliteal muscle tendon (PMT) groove in addition to its histological analysis., Methods: A total of 33 knees of cadavers were dissected. The ALL and the lateral meniscus were removed en bloc. After removal of the anatomical specimen, the meniscus circumference, the ALL insertion points on the external surface of the lateral meniscus, and the PMT groove were measured. Eight menisci were subjected to histological analysis., Results: The ALL was found in all dissections performed. The ALL insertion occurred macroscopically in the transition between the anterior horn and the lateral meniscus body, specifically beginning at 36.0% and ending at 41.9% of the meniscal circumference, occupying a mean area of 5.6 mm. The distance between the end of the ALL meniscal insertion and the beginning of the PMT groove averaged 12.9 mm. In the histological evaluation, in longitudinal sections, we observed dense collagen fibers of the ligament inserting on the external surface of the meniscus. It is possible to observe a spreading of collagen fibers at the moment of meniscal insertion., Conclusions: The ALL meniscal insertion was found in all dissected specimens, beginning with approximately 36% of the meniscal outer diameter, 12.9 mm anterior to the beginning of the PMT groove. The histological analysis confirmed the presence of true ligamentous tissue in the dissected specimens.

Purpose: To assess whether the use of an articulated external fixator provides improvements in the mobility, stability and subjective function of patients undergoing ligament reconstruction., Methods: Thirty-three patients with sub-acute and chronic knee dislocation were subjected to multi-ligament reconstruction surgery. These patients were randomly allocated to two groups for immobilization after reconstruction: group 0-control (18 patients), with rigid knee bracing, and group 1-articulated external fixator (15 patients). The stability of the reconstructed ligaments was assessed after at least 14 months (26.6-month average) postoperatively by physical examination. Deficit of extension and flexion was measured in relation to the unaffected contralateral knee, and the Lysholm knee scoring scale questionnaire was applied., Results: There was no difference in the assessment of joint stability between the groups. In group 1, patients showed less flexion deficit (4.8° ± 5.4° vs. 18.2° ± 14.8°, p < 0.05), and the percentage of patients with a flexion deficit of 5° or less were higher compared with group 0 (64 vs. 18 %, p < 0.05). There was no difference between groups in relation to extension loss. Group 1 also presented better Lysholm scores, with 73 % of patients rated as excellent or good compared with 35 % in group 0 (p < 0.05)., Conclusions: Compared with the control rehabilitation protocol with rigid knee bracing in extension, the use of an articulated external fixator in the treatment of chronic multi-ligament-injured knees provided the same ligament stability, better final range of motion and improved Lysholm score. Patients presenting with chronic multi-ligament instability should be considered for articulated external fixation to supplement reconstruction procedures., Level of Evidence: Randomized controlled trial, Level I.