The Impact of Osseous Malalignment and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence

Abstract

Background:Failure rates of knee ligament surgery may be high, and the impact of osseous alignment on surgical outcome remains controversial. Basic science studies have demonstrated that osseous malalignment can negatively affect ligament strain and that realignment procedures may improve knee joint stability.Hypothesis/Purpose:The purpose of this review was to summarize the clinical evidence concerning the impact of osseous malalignment and realignment procedures in knee ligament surgery. The hypotheses were that lower extremity malalignment would be an important contributor to knee ligament surgery failure and that realignment surgery would contribute to increased knee stability and improved outcome in select cases.Study Design:Systematic review; Level of evidence, 4.Methods:According to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic electronic search of the PubMed database was performed in November 2015 to identify clinical studies investigating (A) the influence of osseous alignment on postoperative stability and/or failure rates after knee ligament surgery and (B) the impact of osseous realignment procedures in unstable knees with or without additional knee ligament surgery on postoperative knee function and stability. Methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and the Coleman Methodological Score (CMS).Results:Of the 1466 potentially relevant articles, 28 studies fulfilled the inclusion and exclusion criteria. Average study quality was poor (CMS, 40). For part A, studies showed increased rerupture rate after anterior cruciate ligament (ACL) replacement in patients with increased tibial slope. Concerning the posterior cruciate ligament (PCL)/posterolateral corner (PLC)/lateral collateral ligament (LCL), varus malalignment was considered a significant risk factor for failure. For part B, studies showed decreased anterior tibial translation after slope-decreasing high tibial osteotomy in ACL-deficient knees. Correcting varus malalignment in PCL/PLC/LCL instability also showed increased stability and better outcomes.Conclusion:In cases of complex knee instability, the 3-dimensional osseous alignment of the knee should be considered (eg, mechanical weightbearing line and tibial slope). In cases of failed ACL reconstruction, the tibial slope should be considered, and slope-reducing osteotomies are often helpful in the patient revised multiple times. In cases of chronic PCL and/or PLC instability, osseous correction of the varus alignment may reduce the failure rate and is often the first step in treatment. Changes in the mechanical axis should be considered in all cases of instability accompanied by early unicompartmental osteoarthritis.

Update on Failure Analysis of Implants in ACL Surgery: Technical Failure or Fate?

“…In HTO with anterior closure, the intra-operative hyperextension of the knee joint should not exceed 5° [34]. At the moment, it is not absolutely clear what are the essential limits for slope correction [41].…”

“…It appears that it is unnecessary to correct a first degree varus malposition in order to achieve adequate knee stability and that this does not bring any increased risk of graft failure [33,41]. However, studies have shown that second or third degree varus malposition may be associated with an increase in tension in the anterior cruciate ligament and that this can then lead to graft failure [41,42]. On the other hand, it is also emphasised that even a minor deviation increases the stress in the anterior cruciate ligament and lateral collateral ligament.…”

Vorderes Kreuzband – Neue Operationstechniken

“…Das betrifft einerseits den Banderhalt durch Refixation oder Augmentation und andererseits die Rekonstruktion der anterolateralen Gelenkecke [1,4,9]. Auch die Bedeutung von Beinachse und Reklination des Tibiaplateaus (posteriorer Slope) für die Stabilisierung des Gelenks findet verstärkt Beachtung [12,13]. Diese Beobachtungen zeigen, dass die operative Therapie der VKB-Ruptur und der anterolateralen Rotationsinstabilität komplex geworden ist.…”

A influência do \"slope\" tibial no risco de falha da reconstrução do ligamento cruzado anterior

“…Vários pesquisadores têm estudado a influência do "slope" tibial no risco de ruptura primária e de falha da reconstrução do LCA (BURNHAM et al, 2017a;DEJOUR et al, 2017;MAROUANE et al, 2014a;SMITH et al, 2012;SONNERY-COTTET et al, 2014b;STIJAK;HERZOG;SCHAI, 2008;TISCHER et al, 2017b), porém ainda não há consenso sobre quando e nem como controlar esse possível fator de risco. O objetivo deste trabalho foi produzir dados, para confrontar as informações da literatura e possibilitar um melhor entendimento da aplicabilidade da medição do ângulo proximal da tíbia no cotidiano ortopédico.…”

“…, há recurvato do joelho, situação também conhecida como "flambagem" do joelho (NOYES; BARBER-WESTIN;HEWETT, 2000). Alguns autores, nos casos de lesão do LCA e degeneração do compartimento medial, também acreditam que esse a osteotomia proximal da tíbia seja necessária (TISCHER et al, 2017a)…”