Ultrasound guidance may reproduce femoral positioning of anterolateral graft
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Use of ultrasound guidance may provide reproducible femoral positioning of the anterolateral graft posterior and proximal to the lateral epicondyle compared with the use of palpation alone, according to published results.
Researchers separated 120 patients undergoing combined ACL and anterolateral ligament (ALL) reconstruction into groups based on whether the location of the lateral epicondyle was determined by palpation (n=60) or with preoperative ultrasound guidance (n=60). Researchers evaluated the effective positioning of the femoral ALL graft on postoperative lateral radiographs. Researchers considered location of the graft in a 10-mm quadrant posterior and proximal to the lateral epicondyle as the primary outcome. Researchers also analyzed results in two subgroups according to BMI.
Results showed the ultrasound group had 100% of anterolateral grafts positioned in a 10- mm quadrant posterior and proximal to the lateral epicondyle vs. 87% of patients in the palpation group. Researchers found the palpation group had 12% of grafts positions anterior to the lateral epicondyle compared with 0% in the ultrasound group. Both patients with a BMI of less than 25 kg/m2 and of 25 kg/m2 or greater had errors in graft positioning with palpation, according to results.
Researchers noted excellent intraobserver reliability of the distance measurements on postoperative radiographs at a 1-month interval in both the palpation and ultrasound groups for overall distance. Results showed excellent interobserver reliability of the distance measurements on postoperative radiographs in the palpation group, while the ultrasound group had good interobserver reliability.
“The results of this study encourage the routine use of the ultrasound-guided technique for lateral epicondyle location when performing ALL reconstruction,” the authors wrote.
Perspective
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The study by Marie Castoldi, MD, and colleagues provides important data for surgeons performing anterolateral ligament graft reconstructions in locating the most advantageous femoral graft placement posterior and proximal to the lateral femoral epicondyle. Ultrasound lateral femoral epicondyle identification provided a 100% accurate graft location on postoperative radiographs. Local palpation of the lateral femoral epicondyle resulted in eight of 60 grafts misplaced, commonly anterior to the lateral femoral epicondyle, resulting in excessive graft elongation with knee flexion. The recommendation for lateral femoral epicondyle ultrasound identification, when percutaneous 10-mm incisions are used, is soundly based and other studies are credited that reported the inaccuracy of lateral femoral epicondyle palpation techniques.
I have a preference to perform a lateral extra-articular tenodesis using a posterior strip of iliotibial band and a relatively small lateral incision to directly visualize the attachment of the lateral collateral ligament just posterior to the lateral femoral epicondyle, with the graft attached just proximal and posterior to the lateral collateral ligament (surgeon preference for graft passed beneath the lateral collateral ligament attachment). The lateral soft tissue structures and boney anatomy are complex with anatomic variations, providing an argument for direct visualization. Two added points: Internal and external tibial rotation produces major anterolateral ligament graft elongation and shortening, respectively, and may be visualized at surgery to select a neutral tibial rotation. Graft tensioning loads and the ideal knee flexion position are still an open debate. We published a robotic cadaveric study selecting a low-load graft tension (2 pounds, 8.9N) at 60° knee flexion.
The authors are to be congratulated for showing their inaccurate anterolateral ligament graft placement cases and the correction with ultrasound for subcutaneous graft techniques.
References:
Jaecker V, et al. Arch Orthop Trauma Surg. 2020;doi:10.1007/s00402-020-03331-8.
Noyes FR, et al. Am J Sports Med. 2017;doi:10.1177/0363546516682233.
Pfeiffer TR, et al. Arthroscopy. 2018;doi:10.1016/j.arthro.2018.03.035.
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