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Anterior Cruciate Ligament Anterolateral Ligament: Let’s Stick to the Facts!

Anterior Cruciate Ligament ‐ Anterolateral Ligament: Let's Stick to the Facts!

- Discussion:
    - anatomy of ACL
    - biomechanics of ACL
    - epidemiology_of_ACL_injuries
    - mechanism: ACL Tear
    - natural history of the ACL-deficient knee
    - partial ACL injury
    - pediatric ACL injuries

- Evaluation of ACL Injuries:
    - examination

- Surgical Management: 
    - timing:
            - early surgery may be associated with arthrofibrosis
            - references:
                   - Acute anterior cruciate ligament repair.
                   - Acute anterior cruciate ligament reconstruction. Analysis of complications
                   - Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries

    - graft placement theory:
            - femoral tunnel
            - tibial tunnel
    - surgical techniques:
            - bone patellar bone reconstruction
                      - main disadvtange of BPB reconstruction is that it does not allow for anteromedial (AM)
                                femoral tunnel positioning and does not allow for differential graft tensioning (posterior
                                graft in 10 deg flexion and anterior graft in 45 deg flexion)
            - hamstring reconstruction
                      - double bundle reconstruction
                      - allograft reconstruction
                      - extra-articular reconstruction (historical discussion)
    - graft fixation techniques
    - post operative care and complications:
            - arthrofibrosis:
            - hyperlaxity:
                   - Minimum Two-Year Follow-up of Anterior Cruciate Ligament Reconstruction in Patients with Generalized Joint Laxity.

- Adjunctive Techniques:
    - management of concomitant meniscal tears
    - chondral injuries 
    - anteromedial instabilility
           - Acute MCL and ACL injuries: first results of minimal-invasive MCL ligament bracing with combined ACL single-bundle reconstruction.
    - anterolateral instability:
           - lateral collateral ligament 
           - references:
                  - Imaging Diagnosis of Injury to the Anterolateral Ligament in Patients With Anterior Cruciate Ligaments: Association of Anterolateral Ligament Injury With Other Types of Knee Pathology and Grade of Pivot-Shift Examination: A Systematic Review.
                          Anterolateral Ligament Injury With Other Types of Knee Pathology and Grade of Pivot-Shift Examination:
                  - Anterolateral Ligament: Let's Stick to the Facts!

    - posterolateral instability
           - references:
                  - The influence of the integrity of posterolateral structures on tibiofemoral orientation when an anterior cruciate ligament graft is tensioned. 
                  - Anterolateral rotational knee instability: role of posterolateral structures. Winner of the AGA-DonJoy Award 2006. 
                  - The influence of posterolateral rotatory instability on ACL reconstruction: comparison between isolated ACL reconstruction and ACL reconstruction combined with posterolateral corner reconstruction.
    - posterior cruciate ligament
    - high tibial osteotmy
          - indicated w/ concomitant varus alignment;
          - varus classification:
                 - primary varus:
                         - varus alignment due to the underlying tibiofemoral alignment;
                         - there is no associated posterolateral ligament deficiency or abnormal lateral joint opening;
                 - double varus:
                         - there is an associated deficiency of the lateral collateral ligament;
                         - varus alignment is increased as a result of both tibiofemoral osseous alignment and abnormal lateral joint opening;
                 - triple varus:
                         - there is deficiency of all of the posterolateral structures;
                         - varus alignment increases on standing, and a varus recurvatum position is present;
          - generally HTO is performed months prior to performing ACL reconstruction;
          - in the report by Noyes FR et al (2000), the authors followed 41 young patients who had ACL deficiency, genu varus
                 angulation, and varying amounts of posterolateral ligament deficiency;
                 - all patients were treated with HTO and, in the majority (N = 34), ACL reconstruction a mean of 8 months later;
                 - posterolateral reconstructions were also required in 18 knees;
                 - patient rating of the knee condition was normal or very good in 37% (15 knees) and good in 34% (14 knees);
          - references:
                 - High Tibial Osteotomy and Ligament Reconstruction for Varus Angulated Anterior Cruciate Ligament-Deficient Knees.
                 - High tibial osteotomy and ligament reconstruction in varus angulated, anterior cruciate ligament-deficient knees. A two- to seven-year follow-up study.
                 - Is Correctional Osteotomy Crucial in Primary Varus Knees Undergoing Anterior Cruciate Ligament Reconstruction?
                 - Clinical outcome of simultaneous high tibial osteotomy and anterior cruciate ligament reconstruction for medial compartment osteoarthritis in young patients with anterior cruciate ligament-deficient knees: a systematic review.

- Misc. Articles:
  Suture of the torn anterior cruciate ligament. 5-year follow-up of 60 cases using an instrumental stability test
  Ganglion cysts of the anterior cruciate ligament: a series of 15 cases
  Ganglion cysts of the anterior cruciate ligament: a case report and review of the literature