Higher return to pre-injury type of sports after revision anterior ligament reconstruction with lateral extra-articular tenodesis compared to without lateral extra-articular tenodesis

One type of graft for reconstruction of the ACL does not suit all patients based on their characteristics and sports: a scoping review

The selection of graft type for anterior cruciate ligament reconstruction remains a topic of debate, taking into consideration patient characteristics, as well as the type and level of sports involvement. The aim of this scoping review was to investigate patient characteristics that might influence the selection of graft type for anterior cruciate ligament reconstruction. PubMed and Scopus were searched to identify articles for inclusion. All included studies focused on one or more patient characteristics involved in the decision-making process regarding anterior cruciate ligament reconstruction autograft, including the hamstrings tendon (HT), patellar tendon (BPTB) and quadriceps tendon (QT). Out of the 1,977 initial studies, 27 studies were included in this review. The BPTB graft seems to be the preferred choice in young patients, females, and athletes-especially those engaged in pivoting sports. The HT graft seems to be the preferred choice in less active and older patients, along with those involved in sports where knee extensors are vital. The HT graft is not preferable in patients with a small body height and graft diameter. Moreover, surgeon preferences were also of importance for graft selection. The success of a specific graft type in anterior cruciate ligament reconstruction is highly dependent on the patient's characteristics and type of sport. Patient characteristics such as age, gender, body height, graft diameter, and the patient's activity level should all be considered when choosing the appropriate graft type.

Lateral extra-articular tenodesis at primary ACL reconstruction increases career length in professional rugby players

PURPOSE

To assess the effect of preoperative and surgical factors on return to play (RTP) rates and career longevity of professional rugby athletes after primary anterior cruciate ligament (ACL) reconstruction (ACL-R).

METHODS

A retrospective review of a consecutive cohort of professional rugby players undergoing primary ACL-R by the senior author between 2005 and 2019 was undertaken. Athletes were included if they were under contract with a professional rugby team at the time of injury and had a minimum of 2-year follow-up. Univariate and multivariate analyses were performed to determine significant predictors of RTP rate, time and career longevity.

RESULTS

One hundred and eighteen rugby players with 125 ACL-Rs were identified. Return to professional rugby was achieved in 115/125 (92%) of cases at an average of 9.6 months and those athletes participated at the professional level for 5.9 ± 3.4 years after ACL-R. Younger age (p = 0.006) and ACL-R with a concomitant lateral extra-articular tenodesis (LET) (p = 0.013) were predictors of a longer career. A Cox proportional hazards model that controlled for age revealed that athletes who underwent ACL-R with an LET had increased career longevity compared to those with an ACL-R without LET (hazard ratio = 2.74, p = 0.021). No factors were significantly associated with RTP rate or RTP time.

CONCLUSION

In professional rugby players undergoing primary ACL-R, those having ACL-R with a concomitant LET and younger age predicted increased career longevity. Rugby players who underwent LET at the time of ACL-R had an 18% greater chance of still playing professionally at 5 years compared to those who underwent ACL-R alone.

LEVEL OF EVIDENCE

Level III.

Lateral Extra-Articular Tenodesis With Iliotibial Band in Anterior Cruciate Ligament Autograft Reconstruction for Female Soccer Athletes With Generalized Ligamentous Laxity Yields Graft Failure and Return-to-Sport Rates Comparable With Athletes Without Generalized Laxity

PURPOSE

To evaluate the effectiveness of adding lateral extra-articular tenodesis (LET) to primary anterior cruciate ligament reconstruction (ACLR) in competitive female soccer athletes with greater preoperative generalized ligamentous laxity.

METHODS

A retrospective review of female high school and collegiate soccer players who underwent primary ACLR from 2013 to 2021, with a minimum of 2 years of follow-up, was conducted. Participants were divided into 2 groups: those who received ACLR alone and those who received ACLR with LET. Generalized ligamentous laxity was defined as a Beighton score ≥4 and was not considered an indication for LET. Anterior cruciate ligament (ACL) autografts included the quadriceps, bone-patellar tendon-bone, and hamstrings in both groups. Patient demographics and physical examination findings, including pivot shift results, were collected. Positive pivot-shift refers to a grade ≥2. Patient outcomes included graft failure (defined as ACL retear), International Knee Documentation Committee score, Lysholm score, return to sport, and complications. Independent t tests, χ2 tests, and Mann-Whitney U tests were conducted to compare outcomes between the 2 groups. Minimally clinical important difference was calculated from preoperative to final follow-up.

RESULTS

A total of 133 female soccer players who underwent ACLR met inclusion criteria, including 43 patients that received an ACLR + LET and 90 patients who underwent isolated ACLR. Average follow-up was 39.0 and 36.1 months in the LET group and the control group, respectively. Patients who underwent LET had a greater generalized ligamentous laxity rate (48.8% vs 18.9%; P < .001) and greater median Beighton score (3.0 vs 1.0; P < .001) than those without LET. There was a similar rate of graft failure in patients who underwent LET compared with the control group (4.7% vs 3.0%; P = .658). On the basis of minimally clinical important difference thresholds, there were no clinically relevant differences in International Knee Documentation Committee or Lysholm scores noted between the 2 groups. Return-to-sport rates also were comparable between the LET and control cohorts (90.7% vs 85.6%; P = .807).

CONCLUSIONS

The addition of LET during ACLR in female soccer players with preoperative generalized ligamentous laxity yields graft retear and return-to-sport rates comparable with those of athletes without ligamentous laxity.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Addition of Modified Lemaire Lateral Extra-Articular Tenodesis in a Single stage Revision Anterior Cruciate Ligament Reconstruction using Peroneus Longus Tendon: A Prospective Study

Introduction

The purpose of this study is to assess the outcomes of patients that underwent single-stage revision ACL reconstruction (ACLR) with peroneus longus tendon (PLT), augmented with lateral extra-articular tenodesis (LET) using the modified Lemaire technique.

Material and Methods

All the 18 patients underwent arthroscopic single-stage revision ACLR using autologous PLT with an additional modified Limier LET procedure. Patients were thoroughly assessed pre- and post-operatively by the Lachman test, the pivot shift test, and the side-to-side difference by the Rolimeter. Functional evaluation was done with the help of the Lysholm score, the IKDC subjective score, Tegner score, VAS score, MARX activity rating scale and The American Orthopaedic Foot and Ankle Society (AOFAS) score. Post-operatively, patient satisfaction, return to sport, and physical activity were also recorded. SPSS ver. 22.0 software was used. Wilcoxon test, paired and unpaired t-tests were used to compare variables. Statistical significance was determined by a two-sided p-value <0.05.

Results

Regarding subjective evaluations; post-operative residual laxity, and return to sport and physical activity, all of the patients demonstrated excellent results. Post-operatively, there was significant improvement in the anterior knee laxity. According to the Marx Activity Rating Scale, the extent of sports engagement was significantly increased at 18 months following surgery (p<0.001). According to the AOFAS score (p=0.38), there were no documented significant donor site morbidities.

Conclusion

Single-stage revision ACLR using PLT with an additional modified Lemaire LET procedure results in a significant reduction in residual knee laxity with good clinical outcomes and a high return to play and physical activity.

Indications for Lateral Extra-articular Tenodesis in Anterior Cruciate Ligament Reconstruction: A Systematic Review

BACKGROUND

The anterior cruciate ligament (ACL) is a major sagittal plane stabilizer of the knee joint. Even if anterior laxity can be brought under control by utilizing modern surgical techniques, internal rotational instability may not always be controlled adequately. Various surgical techniques are used to prevent this coronal or rotational instability, such as lateral extra-articular tenodesis (LET). Despite an abundance of articles in recent decades discussing LET in ACL reconstruction, no definitive indicators for extra-articular tenodesis have been described in the literature.

PURPOSE

Given the scarcity of literature assessing the indications in LET, the purpose of this study was to conduct a systematic review of the described indications for this operation in the context of concurrent ACL reconstruction.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

We searched PubMed, Cochrane Central, ScienceDirect, Web of Science, and Embase using the following key terms with no limits regarding the year of publication: (extraarticular OR extraarticular) AND (tenodesis OR plasty OR augmentation OR procedure or reconstruction OR reconstructive OR surgical OR surgery OR technique) AND (ACL OR anterior cruciate ligament). We included clinical human studies based on levels of evidence 1 to 4 that were written in English. We excluded studies not written in English, case studies, reviews, letters to editors, conference abstracts, or studies containing incomplete or irrelevant data.

RESULTS

The analysis evaluated 29 articles published between 1999 and 2023. We evaluated mostly level 3 (n = 13) and level 4 (n = 12) evidence; however, there were 4 articles with level 1 evidence. The majority of the studies were retrospective (n = 21), although there were prospective studies (n = 8). The mean age of the participants was 24.4 years. The most prevalent indications for LET were high-risk sports (16 articles), medial meniscal repair/excision (11 articles), and pivot-shift test grades 2 and 3 (11 articles).

CONCLUSION

The reviewed articles showed reduced pivoting and laxity, improved clinical outcomes, and decreased revision rates after primary ACL reconstruction. The main frequent and repeated indications for using LET in ACL reconstruction are meniscal surgery, sports activity, and grade 2 and 3 pivoting.

Anterolateral corner of knee: Current concepts

The anatomy of the antero-lateral corner (ALC) has been the topic of recent interest, as evidenced by the increasing number of publications. Knowledge needs to be improved amongst clinicians regarding the anatomy and biomechanical function of this vital structure and its implications on the rotational stability of the knee. There has yet to be a consensus on the role of surgical procedures and their indications for addressing the instability associated with the injury to these structures. Through this article, the authors have tried to outline the existing literature regarding Anterolateral knee instability, the associated structures, and the management of its injuries, emphasising the role of the anterolateral capsule and reconstructive procedures in combined ligamentous knee injuries.

Lateral Extraarticular Tenodesis in Revision Anterior Cruciate Ligament Reconstruction: An Analysis of Clinical Outcomes and Failure Rates

Background/Objectives: Lateral extraarticular tenodesis (LET) has been advocated in revision anterior cruciate ligament reconstruction (ACLR) to improve knee stability and furthermore, decrease failure rates. The aim of this study was to compare clinical outcomes, knee laxity, and failure rates after revision ACLR with LET (ACLR + LET) versus without LET. It was hypothesized that ACLR + LET improves clinical outcomes and reduces the failure rate. Methods: A retrospective analysis of prospectively collected data was conducted to examine patients who underwent revision ACLR with and without LET between 2017 and 2021 with a minimum follow-up of 24 months. Patients with coronal malalignment (>5°), posterior tibial slope >12°, and concomitant injuries to collateral ligaments were excluded. Patient reported outcome measures (PROMs) included the International Knee Documentation Committee (IKDC) subjective knee score, the Lysholm score, and the Tegner activity scale (TAS). Anterior knee laxity was measured with a Rolimeter and side-to-side difference (SSD) was determined. Revision ACLR failure was defined as ACL revision surgery and SSD > 5 mm. Group comparisons were performed using chi-square-, independent-samples students t-test or Mann-Whitney-U tests. Results: Of 56 eligible patients, 45 (80%, follow up, 23 isolated rACLR vs. 22 rACLR + LET) were included with a mean follow-up of 45.6 ± 15.8 months. Postoperative PROMs were not statistically different between rACLR and rACLR + LET groups (IKDC: 73.0 ± 18.9 vs. 68.7 ± 16.6, n.s.; Lysholm: 84.8 ± 12.3 vs. 77.7 ± 16.2, n.s.). Both groups showed similar TAS (rACLR vs. rACLR +LET (5; range 4-6 vs. 4; range 3-5; n.s.). Anterior knee laxity SSD was 2.4 ± 1.3 mm in the rACLR group and 1.8 ± 1.8 mm in the rACLR + LET group (n.s.). The failure rate was 13% in the rACLR group compared to 4.5% in the rACLR + LET group (n.s.). Conclusions: Isolated revision ACLR showed comparable postoperative patient-reported outcome measures and anterior knee laxity compared to ACLR + LET at mid-term follow up. The addition of a LET demonstrated a lower, though non-significant, failure rate after revision surgery. However, future studies with a prospective, randomized design and an increased number of patients are needed to clearly identify the exact indication for the use of additional LET.

The role of anterolateral complex surgery and slope-reducing osteotomies in revision ACL reconstructions: a narrative review

Background and Objective

Anterior cruciate ligament reconstruction (ACLR) failures occur for various reasons including residual laxity, untreated concomitant injuries, poor graft quality, and high tibial slope. Various additional procedures can help to decrease revision ACLR failures including anterolateral complex (ALC) procedures and slope-reducing osteotomies for patients with high tibial slopes. This narrative review aims to review the literature on the roles of ALC augmentation procedures and slope-reducing osteotomies in the setting of patients undergoing revision ACLRs.

Methods

A narrative review of relevant literature was performed in July 2024. Studies about anterolateral complex reconstructions and slope-reducing osteotomies in revision ACLRs were included.

Key Content and Findings

The literature reported that lateral extra-articular tenodesis (LET) and anterolateral ligament reconstructions (ALLR) can be used in revision ACLR cases to significantly reduce clinical knee laxity and the risk of repeated graft failure. There is not currently a strong opinion on which ALC procedure is superior. There are reported slight differences in lateral knee pain and knee stiffness, but both similarly significantly improve clinical and functional outcomes. In revision ACLR cases that also have a high posterior tibial slope (PTS), a slope-reducing tibial osteotomy is warranted. An anterior closing wedge proximal tibial osteotomy (ACW-PTO) significantly reduces anterior tibial translation and graft failure. There is concern about the changes to patellar height, but the literature has found that such changes are either slight or absent by 6 months postoperatively.

Conclusions

The risk of ACLR failure is increased by risk factors like high tibial slope, preoperative knee laxity, and prior ACLR rupture. Anterolateral complex procedures and slope-reducing osteotomies may be used to address these specific concerns and reduce the risk of graft rupture. For revision ACLR cases with lower PTS, augmentation with a LET or an ALLR to reduce the risk of graft failure and improve rotational stability may be warranted. In the setting of a revision ACLR in patients with a high PTS of ≥12°, a concomitant ACW-PTO and ALC procedure should be considered to decrease the risk of an ACLR graft failure.

Editorial Commentary: Knee Lateral Extra-articular Tenodesis Procedures: Appropriate Study Design Is Essential for Reducing Conflicting Findings and Unnecessary Controversy in the Orthopaedic Literature

Knee lateral extra-articular tenodesis procedures (LEAPs) reduce graft rupture rates when performed at the time of anterior cruciate ligament (ACL) reconstruction. However, in the setting of revision ACL reconstruction, LEAPs are less studied and remain controversial. Many studies support combined procedures (ACL + LEAP), yet others do not. When the literature comprises small patient cohorts and short follow-up periods, conflicting results often arise. The controversy surrounding them may be unnecessarily generated by the publication of low-quality studies. Future studies should focus on adequate power; appropriate design and methodology, including matching or randomization to account for potential confounding factors; proper statistical analyses; and avoidance of spin bias.

Why Your Patient May Need an ACL Reconstruction Plus Lateral Extra-Articular Tenodesis Procedure

Anterior cruciate ligament (ACL) tears are one of the most common knee injuries experienced by active individuals engaging in cutting sports. Despite improved surgical techniques and rehabilitation, the return to sport rate and re-tear rates remain unsatisfactory. Lateral extra-articular tenodesis (LET) is a procedure that has been growing in interest when performed in conjunction with ACL reconstruction. The benefits of adding an LET procedure to an ACL surgery may include greater rotational stability, decreased re-tear rates, and improved return to play. Level of evidence: V.

Impact of Lateral Extra-Articular Procedure Augmentation on Rerupture Risk and Tegner Activity Scale Outcomes in Adolescent Anterior Cruciate Ligament: A Matched Comparative Study With a Minimum 2-Year Follow-up

BACKGROUND

Despite the well-established role of lateral extra-articular procedures (LEAPs) in reducing failure rates after anterior cruciate ligament (ACL) reconstruction (ACLR) in the adult population, similar in-depth research for the adolescent and pediatric population remains lacking.

PURPOSE

To examine the effect of the LEAP augmentation on the rerupture rate after ACLR in patients aged <18 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This was a retrospective analysis of prospectively collected data from October 2012 to June 2020, involving adolescents <18 years old undergoing primary ACLR with a minimum follow-up of 2 years. Two groups, matched for age, sex, Tegner activity scale, and presence of meniscal injury, were established: ACLR alone and ACLR+LEAP augmentation. The primary outcome measure was the rate of rerupture after ACLR. The secondary outcome measures were the rate of non-graft rupture related reoperation after ACLR; rate of return to sport (RTS) rate, timing, and level compared with preinjury status; and functional scores including the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) (Pain, Symptoms, Activities of Daily Living, Sport and Recreation, and Quality of Life), Tegner activity scale score, ACL Return to Sport after Injury (ACL-RSI) score, and Lysholm score.

RESULTS

After accounting for follow-up losses, we analyzed 132 patients who underwent ACLR alone and 121 patients who underwent ACLR+LEAP from the initial 147 per group. The mean age of the patients in both groups was 16.1 years (SD, 1.1 and 1.0 years, respectively), with similar patient and injury characteristics across both groups (P > .05). Both groups also showed comparable preoperative functional scores. A significantly lower preoperative ACL-RSI score was observed in the ACLR-alone group compared with the ACLR+LEAP group (P = .0044). Graft rupture was significantly less common in the ACLR+LEAP group (2.5%) than in the ACLR-alone group (13.6%) (P = .002). The attributable risk reduction for ACLR+LEAP was 11.1%, and the calculated number needed to treat was 9. Kaplan-Meier analysis showed significantly better rerupture-free survival at 5 years for the ACLR+LEAP group (P = .001). Cox regression confirmed a 6-fold increased rerupture risk in the ACLR-alone group (P = .004). At the final follow-up, despite similar IKDC, KOOS, Lysholm, and ACL-RSI values across both groups, the ACLR+LEAP group had a significantly higher Tegner score (7.2 vs 6.3; P = .0042). No significant differences were observed in RTS rates or sport level compared with preinjury states between the groups.

CONCLUSION

ACLR+LEAP augmentation significantly reduced rerupture risk and facilitated higher postoperative activity levels in adolescents.

REGISTRATION

NCT02511158 (ClinicalTrials.gov identifier).

The Role of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis for Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Clinical Studies

BACKGROUND

After its success in restoring rotational stability and reducing failure rates in primary anterior cruciate ligament reconstruction (ACLR), lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR) has been endorsed for use in revision ACLR surgery, where failure rates are historically higher.

PURPOSE

To perform a systematic review and meta-analysis on whether the addition of a LET or ALLR results in superior clinical outcomes and stability compared with isolated revision ACLR (iACLR).

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis of comparative studies using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("extra-articular" OR "tenodesis" OR "anterolateral ligament" OR "iliotibial") AND ("anterior cruciate ligament") AND ("revision" OR "re-operation"). Data pertaining to all patient-reported outcome measures (PROMs), rotational stability, and postoperative complications were extracted from each study.

RESULTS

After abstract and full-text screening, 10 clinical comparative studies were included. There were 793 patients, of whom 390 had an iACLR while 403 had an ACLR augmented with a LET or an ALLR (augmented ACLR [aACLR]). The mean time for assessment of PROMs was 35 months. The aACLR group had superior International Knee Documentation Committee (IKDC) scores (standardized mean difference [SMD], 0.27; 95% CI, 0.01 to 0.54; P = .04), rotational stability (odds ratio [OR], 2.77; 95% CI, 1.91 to 4.01; P < .00001), and lower side-to-side difference (OR, -0.53; 95% CI, -0.81 to -0.24; P = .0003) than those without the augmentation. Furthermore, they were less likely to fail (OR, 0.44; 95% CI, 0.24 to 0.80; P = .007). Subgroup analysis in the higher-grade laxity cohort (grade ≥2) revealed an even greater IKDC score (SMD, 0.51; 95% CI, 0.16 to 0.86; P = .005) and an improved Lysholm score (SMD, 0.45; 95% CI, 0.24 to 0.67; P < .0001) in the aACLR group.

CONCLUSION

Revision aACLR with a LET or an ALLR can improve subjective IKDC scores, restore rotational stability, and reduce failure rates compared with iACLR. Although controversy remains on the necessity of augmenting all revision ACLRs, the present meta-analysis advocates adding a lateral procedure, particularly in those with a higher-grade pivot shift.

One-stage anterior cruciate ligament revision surgery after primary failed double-bundle reconstruction: a systematic review

INTRODUCTION

Anterior cruciate ligament (ACL) revision surgery after failed double-bundle (DB) reconstruction is a challenging procedure. This study aimed to systematically review the research on ACL revision surgery following failed DB reconstruction, providing an overview on indications, surgical techniques, clinical outcomes and potential pitfalls occurring while performing this therapeutic approach.

MATERIALS AND METHODS

Literature published from exception to February 2023 was searched in the Pubmed/MEDLINE, Embase and CINAHL databases. Studies in English reporting on patients who underwent ACL revision surgery after prior failed DB reconstruction were considered. Review articles and expert opinion or editorial pieces were excluded. Outcomes of interest included indications and pre-operative planning, surgical technique and associated procedures, type of revision surgery (either one- or two-stage), graft choice, clinical and functional outcomes, rate of complications, failure rate.

RESULTS

Overall, 4 studies met all the inclusion criteria for this review. All were published between 2007 and 2020. The search resulted in two retrospective comparative studies, one case series, and one case report. Average follow-up periods ranged from 24 to 45 months. From these studies, 66 patients (66 knees) were identified. One-stage revision surgery was performed in 64 on 66 patients (97%) with pathologic laxity following DB ACL reconstruction. Most frequently reported outcome was Lysholm score in five studies: average postoperative Lysholm score ranged from 90.5 to 91.0 while Tegner activity level ranged from 5.6 to 7.0. In 4 patients (6%) re-revision surgery was performed due to graft re-rupture.

CONCLUSIONS

One-stage ACL revision surgery following DB ACL reconstruction appears feasible providing satisfying outcomes and limited complications. The literature on this subject is limited and further comparative studies reporting long-term outcomes are needed, as high-level studies on this topic are still lacking.

Satisfactory outcomes after one-stage revision anterior cruciate ligament reconstruction using rectangular tunnel technique

PURPOSE

One-stage revision anterior cruciate ligament reconstruction (ACLR) with the anatomic rectangular tunnel (RT) technique using bone-patellar tendon-bone (BTB) grafts results in anatomically precise tunnel placement and secure graft fixation. This study evaluated knee joint laxity and clinical outcomes in terms of femoral tunnel overlap. It was hypothesised that there would be no significant differences in knee joint laxity or clinical outcomes regardless of femoral tunnel overlap.

METHODS

Between 2012 and 2021, a single surgeon conducted 196 one-stage revision ACLRs with the RT technique using BTB grafts. Patients were divided based on the presence of femoral tunnel overlap. Knee joint laxity was evaluated using the Lachman test, pivot shift test, and side-to-side difference measured with a KT-1000 arthrometer. Clinical outcomes were assessed using the Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) Knee Examination Form 2000. Knee joint laxity and clinical outcomes were compared between groups after a median follow-up of 2.5 years (range 2.0-8.0).

RESULTS

The study included 30 and 73 patients in the overlap and non-overlap groups, respectively. No significant differences were observed in the results of the Lachman test, pivot shift test, or KT-1000 arthrometer as well as in the Lysholm, KOOS, or IKDC scores between the two groups. Based on the IKDC scores, all patients were graded as normal or nearly normal.

CONCLUSION

One-stage revision ACLR with the RT technique using BTB grafts improved knee joint laxity and had favourable clinical outcomes regardless of femoral tunnel overlap. To achieve optimal results in one-stage revision ACLR, it is crucial to create a tunnel within the anatomical attachment area and ensure proper graft fixation and tensioning.

LEVEL OF EVIDENCE

III.

Combined anterior cruciate ligament revision with reconstruction of the antero-lateral ligament does not improve outcome at 2-year follow-up compared to isolated acl revision; a randomized controlled trial

PURPOSE

It is essential to obtain rotational stability of the knee after anterior cruciate ligament reconstruction (ACL-R) and it is suggested that a supplementary reconstruction of the antero-lateral ligament (ALL-R) may supports this. Theoretically, ALL-R may be particularly advantageous to support revision of failed ACL-Rs. It was hypothesized that ACL revision combined with ALL-R will result in superior outcome compared to isolated ACL revision.

METHODS

The study was designed as a randomized controlled trial. Patients eligible for first time ACL revision were randomized to either isolated ACL revision (- ALL group) or ACL revision combined with a single-stranded allograft ALL-reconstruction (+ ALL group). Patient reported outcomes and function were evaluated at two-year follow-up by KNEES-ACL, KOOS, and Tegner activity scale. Objective knee laxity was evaluated at one-year follow-up using an instrumented Rolimeter test, the pivot shift test, and a manual Lachman test.

RESULTS

A total of 103 patients were enrolled with 49 patients randomized to the + ALL group and 54 patients in the - ALL group. There were no differences at baseline between groups regarding age, gender, body mass index, preoperative patient reported outcome scores and concomitant meniscus or cartilage injury. The ACL revision was performed with an allograft in 10 patients (20%) in the + ALL group and 8 patients (15%) in the -ALL group. At follow-up there was no significant difference between the groups in patient reported outcome scores and clinical knee laxity.

CONCLUSION

Supplementary ALL-R does not improve subjective outcome of first time ACL revision at two-years and clinical knee stability at one-year follow-up compared to isolated ACL revision.

LEVEL OF EVIDENCE

Level I.

Good rates of return-to-sport in athletes after revision anterior cruciate ligament reconstruction using autologous patellar tendon and lateral extra-articular tenodesis: a 2-year follow-up prospective study

BACKGROUND

Most athletes who undergo revision of the anterior cruciate ligament reconstruction (ACLR) aim to return to their preinjury sport at a similar level of performance while minimizing the risk for reinjury. Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved outcomes and low complication rate. Yet, there are few series evaluating return-to-sport (RTS) and clinical outcomes after revision ACLR using bone-patellar tendon-bone (BPTB) and LET in athletes.

METHODS

The study cohort consisted of 19 eligible athletes who had undergone their first revision ACLR using BPTB and LET (modified Lemaire) between January 2019 and 2020. Patients were prospectively followed and interviewed in a sports activity survey during a 2-year follow-up.

RESULTS

Despite all patients returning to sports after revision ACLR surgery, 52.6% resumed playing at their preinjury level. Furthermore, patient-reported functional outcomes improved significantly following revision surgery, as evidenced by improvements in IKDC [64.4 (± 12) to 87.8 (± 6)], Lysholm [71.27 (± 12) to 84.2 (± 9.7)], and SF-12 scales [Physical: 53.3 (± 3) 57 (± 1.2); Mental: 50.2 (± 3.3) to 52.7 (± 2.4)]. One case (5.3%) experienced persistent pain and underwent reoperation for a partial meniscectomy.

CONCLUSION

After revision ACLR using autologous BPTB and LET, all active individuals are expected to RTS, similar to primary ACLR. The difference comes down to returning to the preinjury level, where the levels are lower depending on the sport and initial level of play. Good mid-term functional outcomes with a low complication rate can be expected in most cases.

STUDY DESIGN

Case series; Level of evidence IV.

ETHICAL COMMITTEE APPROVAL NUMBER

PR(ATR)79/2021 and HCB/2023/0173.

Anterior Cruciate Ligament Revision Plus Lateral Extra-Articular Procedure Results in Superior Stability and Lower Failure Rates Than Does Isolated Anterior Cruciate Ligament Revision but Shows No Difference in Patient-Reported Outcomes or Return to Sports

PURPOSE

To determine whether comparative clinical studies demonstrate significant advantages of revision anterior cruciate ligament reconstruction (RACLR) combined with a lateral extra-articular procedure (LEAP), with respect to graft rupture rates, knee stability, return to sport rates, and patient-reported outcome measures, compared with isolated RACLR.

METHODS

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews & Meta-Analyses Guidelines. A PubMed search was conducted using the key words "revision anterior cruciate ligament reconstruction" combined with any of the following additional terms, "lateral extra-articular tenodesis" OR "anterolateral ligament reconstruction" OR "Lemaire." All relevant comparative clinical studies were included. Key clinical data were extracted and evaluated.

RESULTS

Eight comparative studies (seven Level III studies and a one Level IV study) were identified and included. Most studies reported more favorable outcomes with combined procedures with respect to failure rates (0%-13% following RACLR+LEAP, and 4.4%-21.4% following isolated RACLR), postoperative side-to-side anteroposterior laxity difference (1.3-3.9 mm following RACLR+LEAP and 1.8-5.9 mm following isolated RACLR), and high-grade pivot shift (0%-11.1% following RACLR+LEAP and 10.2%-23.8% in patients following isolated RACLR). There were no consistent differences between isolated and combined procedures with respect to return to sport or patient-reported outcome measures.

CONCLUSIONS

This systematic review demonstrates that the addition of a LEAP to RACLR was associated with an advantage with respect to ACL graft failure rates and avoidance of high-grade postoperative knee laxity across almost all included studies.

LEVEL OF EVIDENCE

IV, Systematic review of level III to IV studies.