Comparison of clinical outcomes between isolated ACL reconstruction and combined ACL with anterolateral ligament reconstruction: a systematic review and meta-analysis

Isolated ACL Reconstruction Versus Combined ACL and Anterolateral Ligament Reconstruction: Functional Outcomes, Return to Sport, and Survivorship: An Updated Meta-analysis of Comparative Studies

BACKGROUND

Failure, persistent knee instability, and reinjury rates after anterior cruciate ligament (ACL) reconstruction are still concerns. Biomechanical investigations have highlighted the role of the anterolateral ligament (ALL) as a crucial knee stabilizer, and clinical outcomes after combined ACL and ALL reconstruction appear to indicate the success of the procedure.

PURPOSE

To compare the functional outcomes, return-to-sport (RTS) rate, and complications between combined ACL and ALL reconstruction and isolated ACL reconstruction.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

The PubMed/MEDLINE, Scopus, and Cochrane Central databases were used to search keywords, and a total of 16 studies were included. The data extracted for quantitative analysis included the Tegner activity scale score, Lysholm knee score, International Knee Documentation Committee (IKDC) score, laxity measured using the KT-1000 knee arthrometer, number and types of complications, RTS rate, and survival rate. Random- and fixed-effects models were used for the meta-analysis of pooled mean differences and odds ratios.

RESULTS

A total of 2329 patients were identified, 1116 of whom underwent combined ACL and ALL reconstruction and 1213 of whom underwent isolated ACL reconstruction. The mean ages were 25.4 ± 7.2 years and 26.5 ± 7.8 years for the combined ACL and ALL reconstruction and isolated ACL reconstruction groups, respectively. The mean follow-ups were 40.3 ± 21.4 months and 42.5 ± 21.6 months, respectively. Comparable Tegner activity scale (P = .16), Lysholm knee (P = .13), and IKDC (P = .83) scores were found between groups. Significantly greater postoperative knee laxity was found in the isolated ACL reconstruction group (mean difference, -0.44; 95% CI, -0.85 to -0.04; P = .03). The combined ACL and ALL reconstruction group showed a significantly lower rate of graft failure (odds ratio [OR], 0.37; 95% CI, 0.18-0.77; P = .008), a higher RTS rate (OR, 1.41; 95% CI, 1.11-1.80; P = .005), and a higher survival rate (OR, 2.94; 95% CI, 1.97-4.37; P < .001).

CONCLUSION

Compared with isolated ACL reconstruction, combined ACL and ALL reconstruction yielded comparable functional outcomes but significantly less residual knee laxity and a lower graft failure rate. Patients who underwent combined ACL and ALL reconstruction also had higher RTS and survival rates.

An isolated extra-articular procedure can be indicated for patients with minor instabilities and intact graft after anterior cruciate ligament reconstruction

BACKGROUND

Some patients submitted to isolated ACL reconstruction may have symptomatic postoperative rotational instability. The objective of this study was to evaluate a population with mild rotatory instability after ACL reconstruction, which was submitted to an isolated extra-articular procedure.

METHODS

Patients submitted to an isolated extra-articular procedure after ACL reconstruction were retrospectively evaluated. Only patients presenting anterior knee instability of less than 5 mm, pivot-shift of a maximum of 1+, and ACL graft intact were included. Demographic data, physical examination and subjective functional scales were evaluated.

RESULTS

Twenty patients were included. The mean age was 27.0 ± 7.3 years. The follow up time after the extra-articular procedure was 27.5 ± 6.2 months. The KT-1000 decreased from 3.0 mm ± 0.7 mm to 2 mm ± 0.4 mm (P = 0.00016). The pivot-shift improved from 100% of grade 1 positivity to 30% (6/20 patients) of grade 1 positivity (P < 0.0001). The IKDC showed no difference (74.4 ± 11.8 vs. 87.6 ± 5.8; P = 0.087), but the percentage of patients who passed the PASS IKDC cut-off value increased from 45% (9/20) to 95% (19/20) (P = 0.0012). The Lysholm increased from 81.1 ± 7.3 to 91.2 ± 5.7 (P = 0.0001).

CONCLUSIONS

Patients submitted to an isolated extra-articular procedure due to residual instability after ACL reconstruction showed improvement in physical examination (KT-1000 and pivot-shift) and subjective functional scales. This procedure can be considered for a specific population with minor instabilities and intact ACL graft, avoiding a complete ACL revision.

Anterior Cruciate Ligament Reconstruction Using Lateral Extra-Articular Procedures: A Systematic Review

Background and Objectives: The present systematic review investigated the efficacy of lateral extra-articular tenodesis (LET) and anterolateral ligament (ALL) as lateral extra-articular procedures (LEAPs) for anterior cruciate ligament (ACL) reconstruction. ACL reconstruction using LEAP may reduce graft rupture and rotatory laxity and allow a quicker return to sports. The outcomes of interest were patient-reported outcome measures (PROMs), return to sport, laxity, failure rate, and safety profile. Materials and Methods: The present systematic review followed the 2020 PRISMA guidelines. In December 2024, PubMed, EMBASE, and Web of Science were accessed without constraints. All clinical investigations evaluating LEAP for ACL reconstruction were considered. Only studies that considered LET and ALL as LEAP were considered. Only studies using a hamstring tendon autograft associated with LET or ALL were considered. Results: Data from 27 clinical studies (3423 patients) were retrieved. The mean length of follow-up was 61.8 ± 39.5 months. ACL reconstruction using LEAP led to a statistically significant improvement in the Lysholm score (p < 0.01) and IKDC (p < 0.01). The mean joint laxity, as measured by the arthrometer, was 1.5 ± 1.8 mm. Finally, 72.3% (623 of 668) of patients returned to their pre-injury level of sport at a mean of 6.3 ± 4.4 months. At the last follow-up, the LET group showed greater IKDC (p = 0.04). On the other hand, there was a statistically significant greater rate of patients positive to the Lachman test (p < 0.01), return to sport (p < 0.01), and reoperation (p = 0.01). No significant differences were found in Lysholm scores (p = 0.6), Tegner scores (p = 0.2), arthrometer measurements (p = 0.2), Pivot shift test results (p = 0.1), time to return to sport (p = 0.3), and failure rates (p = 0.7). Conclusions: LEAP for ACL reconstructions seems to be effective and safe. Most patients returned to their pre-injury level of sport after a mean of 6 months. LET-based ACL reconstruction may be associated with greater clinical outcomes and a higher reoperation rate compared to ALL-based reconstruction.

Combining an Anterolateral Complex Procedure With Anterior Cruciate Ligament Reconstruction Reduces Graft Reinjury Without Increasing the Rate of Complications: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) has been used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR) in recent years. However, there are still concerns that these procedures may lead to complications such as overconstraint of the lateral compartment, stiffness, infections, tunnel convergence, and other intra- and postoperative complications because of increased surgical time and the need for additional procedures.

HYPOTHESIS/PURPOSE

The lateral extra-articular procedure will reduce the failure rate of reconstructed ACLs without increasing the number of complications. The purpose was to compare the complication and graft reinjury rates of 2 main anterolateral complex procedure categories described in the literature-LET and ALLR with isolated ACLR.

STUDY DESIGN

Systematic review and meta-analysis of randomized controlled trials (RTCs); Level of evidence, 2.

METHODS

The methodology followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, Embase, and Cochrane Library databases were searched on March 15, 2024, to identify RTCs comparing isolated ACLR with ACLR + LET or ALLR. The methodological index for nonrandomized studies was employed for the quality evaluation. Complications and graft reinjury rates were recorded and meta-analyzed from all included studies.

RESULTS

The initial search yielded 1411 articles. Seventeen studies that included the complication rates (5 in the ALLR group and 12 in the LET group) were included in the review. No significant differences were found in the incidence of complications between the ACLR and ACLR + ALLR groups (Mantel-Haenszel [M-H], 1.20 [95% CI, 0.05-29.30]; P = .91) or between the ACLR and ACLR + LET groups (M-H, 0.39 [95% CI, 0.05-2.98]; P = .36). Significant differences were observed in the failure rate between the ACLR + ALLR group (M-H, 6.78 [95% CI, 1.98-23.22]; P = .002) and the ACLR + LET group (M-H, 3.14 [95% CI, 1.96- 5.04]; P < .00001).

CONCLUSION

Adding a lateral extra-articular procedure, regardless of the surgical technique, can reduce the failure rate without increasing the number of complications at the mid-term follow-up.

STUDY REGISTRATION

PROSPERO (CRD42023458354).

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Using Suspensory Button Fixation

Despite advancements in surgical techniques for anterior cruciate ligament reconstruction, some patients still experience rotational instability after surgery. Anterior cruciate ligament and anterolateral ligament reconstruction have been described using hamstring tendon autograft while preserving the insertion of the semitendinosus tendon. This article describes a combined anterior cruciate ligament and anterolateral ligament reconstruction using a hamstring tendon autograft with a suspensory button fixation.

Analysis of Changing Practice Trends in Anterior Cruciate Ligament Reconstruction: A Multicenter, Single-Institution Database Analysis

PURPOSE

To identify trends in anterior cruciate ligament reconstruction (ACLR), including graft choice, femoral tunnel drilling techniques, and augmentation techniques, and to assess how various surgeon factors impact these trends.

METHODS

A retrospective review of primary ACLRs performed between 2014 and 2022 was completed using a multicenter institutional database. Patient demographic characteristics, graft type, femoral drilling technique, use of extra-articular tenodesis, and use of suture augmentation were recorded from the medical record. Surgeon fellowship training (sports trained vs non-sports trained), experience (high [minimum of 15 years in practice] vs low), and volume (high [minimum of 15 ACLRs/year] vs low) were used to stratify technique utilization. The z test for proportions was used to compare categorical variables. Pearson correlation analyses identified trends and assessed statistical significance, defined as P < .05.

RESULTS

Our cohort consisted of 2,032 ACLRs performed in 2,006 patients. The average patient age was 28.3 ± 11.6 years, with more procedures performed in male patients (67.3%). The average length of surgeon experience was 19.7 ± 11.4 years, with an average annual procedural volume of 4.0 ± 5.4 ACLRs. Most surgeons were sports trained (n = 55, 64.7%), high experience (n = 44, 57.1%), and low volume (n = 80, 94.1%). There was an increasing annual proportion of ACLRs performed by sports-trained surgeons (R = 0.748, P = .020) and low-experience surgeons (R = 0.940, P < .001). Autograft reconstructions were most often performed by sports-trained (71.2%), low-experience (66.1%), and high-volume (76.9%) surgeons. There was an increasing proportion of autograft ACLRs that used quadriceps tendon among sports-trained (R = 0.739, P = .023), high-experience (R = 0.768, P = .016), and low-volume (R = 0.785, P = .012) surgeons. Independent drilling techniques were used in an increasing proportion of ACLRs performed by non-sports-trained (R = 0.860, P = .003) and high-volume (R = 0.864, P = .003) surgeons. Augmentation of ACLR with concomitant suture augmentation (n = 24, 1.2%) or extra-articular tenodesis (n = 6, 0.3%) was rarely performed.

CONCLUSIONS

In our multicenter institution, the quadriceps tendon autograft has been increasingly used in ACLR by sports-trained, low-volume, and high-experience surgeons. Independent drilling techniques have been increasingly used by non-sports-trained and high-volume surgeons.

CLINICAL RELEVANCE

Surgeons must stay current with the literature that affects their procedures to ensure that evidence-based medicine is being practiced.

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Shows Superior Graft Remodeling, Maturation, and Stability Compared With Isolated Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare graft remodeling, as measured by magnetic resonance imaging (MRI), and clinical outcomes between patients who underwent isolated anterior cruciate ligament reconstruction (ACLR) versus combined anterior cruciate ligament and anterolateral ligament reconstruction (ACLR + ALLR).

METHODS

A retrospective review was conducted on patients who underwent primary ACLR with quadruple hamstring grafts between January 2019 and March 2022, with a minimum follow-up period of 2 years. Patients were categorized into two groups based on the addition of ALLR with tibialis anterior allografts: an isolated ACLR group and an ACLR + ALLR group. Graft ligamentization was assessed using signal-to-noise quotient (SNQ) values obtained from postoperative MRI scans, with lower SNQ values indicating superior graft remodeling. Clinical outcomes were evaluated through knee stability tests (pivot-shift test, side-to-side laxity), functional outcomes, and graft retear rates. The minimal clinically important difference (MCID) for the clinical scores was calculated using the distribution-based method of a half standard deviation of the delta (difference between postoperative and baseline values). Regression analyses identified potential predictive factors for inferior ACL graft remodeling.

RESULTS

A total of 122 patients in the isolated ACLR group and 54 in the ACLR + ALLR group were evaluated. The mean follow-up periods were similar between the groups (34.1 ± 7.4 months vs 36.4 ± 9.0 months; P = .755). The mean SNQ values were significantly lower in the ACLR + ALLR group compared to the isolated ACLR group (2.8 ± 1.6 vs 4.7 ± 3.5 mm, respectively; P = .001). Inferior ACL graft maturity was associated with an increased posterior tibial slope (P = .016), narrow notch width (P =.018), and concomitant medial meniscal lesion (P = .017). At the final evaluation, the ACLR + ALLR group demonstrated better rotational stability as indicated by the residual pivot-shift test (P = .005). No statistically significant differences were observed between the two groups in side-to-side laxity, functional outcomes, or graft retear rates. There were no differences in the percentage of patients achieving MCID for the International Knee Documentation Committee subjective score between the groups (P = .536).

CONCLUSIONS

Combined ACLR and ALLR resulted in superior graft remodeling, demonstrated by a mean SNQ value that was 1.9 lower than in isolated ACLR, along with improved rotational stability.

LEVEL OF EVIDENCE

Level III, retrospective, nonrandomized, comparative therapeutic study.

The Role of Artificial Intelligence in Anterior Cruciate Ligament Injuries: Current Concepts and Future Perspectives

The remarkable progress in data aggregation and deep learning algorithms has positioned artificial intelligence (AI) and machine learning (ML) to revolutionize the field of medicine. AI is becoming more and more prevalent in the healthcare sector, and its impact on orthopedic surgery is already evident in several fields. This review aims to examine the literature that explores the comprehensive clinical relevance of AI-based tools utilized before, during, and after anterior cruciate ligament (ACL) reconstruction. The review focuses on current clinical applications and future prospects in preoperative management, encompassing risk prediction and diagnostics; intraoperative tools, specifically navigation, identifying complex anatomic landmarks during surgery; and postoperative applications in terms of postoperative care and rehabilitation. Additionally, AI tools in educational and training settings are presented. Orthopedic surgeons are showing a growing interest in AI, as evidenced by the applications discussed in this review, particularly those related to ACL injury. The exponential increase in studies on AI tools applicable to the management of ACL tears promises a significant future impact in its clinical application, with growing attention from orthopedic surgeons.

Anterolateral augmentation procedures during anterior cruciate ligament reconstructions in skeletally immature patients: Scoping review of surgical techniques and outcomes

Purpose

Graft failure rates after anterior cruciate ligament reconstruction (ACLR) in children and adolescents are higher compared to adults. Anterolateral augmentation procedures have recently generated increased focus regarding their ability to reduce graft failure rates. Concerns in skeletally immatures are potential growth disturbances and overconstraint after anterolateral augmentation. The aim of this scoping review is to provide an overview of all current anterolateral augmentation procedures in skeletally immature patients and to discuss surgical techniques, clinical and biomechanical outcomes.

Methods

This scoping review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement extension for scoping reviews. On 22 December 2022, an information specialist performed a systematic literature search in Cochrane, PubMed (Medline) and EMBASE databases. Inclusion criteria were anterolateral augmentation procedures, including lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in combination with ACLR in skeletally immatures.

Results

Twenty studies were included after screening 1.485 abstracts. Seventeen studies describe LET techniques, four studies ALLR techniques and one study both techniques. Biomechanical data is scarce and shows conflicting results. Two studies compared ACLR with LET to ACLR in skeletally immatures with promising results in favour of the combined procedure. There were no differences in outcomes between LET and ALLR.

Conclusions

Several LET and ALLR techniques have been described for skeletally immature patients and the first clinical data on LET and ALLR is available, which showed promising results. Further research is necessary to evaluate the risk of growth disturbances and overconstraint in skeletally immatures.

Level of Evidence

Level IV.

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.

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Decreases Passive Anterior Tibial Subluxation Compared With Isolated Anterior Cruciate Ligament Reconstruction Despite Similar Rotational Stability and Clinical Outcomes

PURPOSE

To analyze the effect of augmenting a hamstring autograft anterior cruciate ligament reconstruction (ACLR) with an anterolateral ligament reconstruction (ALLR) on a primary outcome of passive anterior tibial subluxation (PATS) and a secondary outcome of the clinical outcomes.

METHODS

ACL-injured patients who underwent primary ACLR between March 2014 and February 2020 at our center were enrolled. Patients who underwent combined procedures (ACLR + ALLR) were matched in a 1:1 propensity ratio to patients who underwent ACLR only. We evaluated PATS, knee stability (side-to-side laxity difference, pivot-shift test), and patient-reported outcome measures (PROMs) after the procedure and documented complications.

RESULTS

From an initial cohort of 252 patients with a minimum follow-up period of 2 years (48.4 ± 16.6 months), 35 matched pairs were included, and 17 patients (48.6%) in each group underwent second-look arthroscopy. The combined ACLR + ALLR group showed significantly better improvement of PATS in the lateral compartments than the isolated ACLR group (P = .034). There were no significant differences between the groups regarding knee stability (side-to-side laxity difference, pivot-shift test), PROMs, complications, and second-look arthroscopic findings (all P > .05). Moreover, the proportions of patients who achieved the minimal clinically important difference in PROMs were not different between groups.

CONCLUSIONS

The combined ACLR + ALLR procedure was associated with a mean improvement in anterior tibial subluxation for the lateral compartment that was 1.2 mm better than an isolated ACLR procedure, despite its lack of clinical significance.

LEVEL OF EVIDENCE

Level III, cohort study.

Single Bundle Anterior Cruciate Ligament With Anterolateral Ligament Reconstruction Yields Similar Clinical and Radiographic Results at Minimum 2-Year Follow-Up Versus Double Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Controlled Trial

PURPOSE

To compare the clinical, radiographic, and second-look arthroscopic outcomes between double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (DB group) and combined single-bundle (SB) ACL and anterolateral ligament (ALL) reconstruction (SB + ALL group) by a prospective randomized controlled trial.

METHODS

From May 2019 to June 2020, 84 patients were enrolled in this study. Among them, 10 were lost to follow-up. Thirty-six and 38 patients were successfully allocated to the DB (mean follow up 27.3 ± 4.2 months) and SB + ALL groups (27.2 ± 4.5 months), respectively. The preoperative and postoperative Lachman test, pivot shift test, anterior translation on stress radiographs, KT-2000 arthrometer, Lysholm score, International Knee Documentation Committee score, and Tegner activity score were evaluated and compared. Graft continuity was evaluated using postoperative magnetic resonance imaging (MRI) (32 and 36 patients underwent MRI in the DB and SB + ALL groups at 7.4 ± 3.2 and 7.5 ± 2.9 months after surgery, respectively), and second-look examinations (second-look examination and tibial screw removal were performed concomitantly when patients (1) had tibial screw-related irritation or (2) needed the screws removed, 28 and 23 patients underwent examinations in the DB and SB + ALL groups at 24.0 ± 6.8 and 24.9 ± 8.1 months after surgery, respectively). All measurements were compared between the groups.

RESULTS

Postoperative clinical outcomes significantly improved in both groups. (All variables showed P < .001) No statistically different outcomes were found between the 2 groups. Additionally, postoperative graft continuity on MRI and second-look examinations were not different between the 2 groups.

CONCLUSIONS

The DB and SB + ALL groups showed similar postoperative clinical, radiographic, and second-look arthroscopic outcomes. Both groups showed excellent postoperative stability and clinical outcomes compared with the preoperative measurements.

LEVEL OF EVIDENCE

Level II, randomized controlled trial.

Comparison of ACL and Anterolateral Ligament Reconstruction With Isolated ACL Reconstruction Using Hamstring Autograft: Outcomes in Young Female Patients With High-Grade Pivot Shift

Background

Inferior return to sports (RTS) and functional outcomes have been reported in women after anterior cruciate ligament reconstruction (ACLR).

Purpose/Hypothesis

The purpose was to evaluate the results of combined ACLR and anterolateral ligament reconstruction (ALLR) in young women with a high-grade pivot shift (grade ≥2). It was hypothesized that combined ACLR and ALLR would result in better RTS and rotational stability than isolated ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Two groups were retrospectively evaluated and compared. Group I (n = 39; mean age, 31.1 ± 5.7 years) underwent isolated ACLR using hamstring autografts; group C (n = 39; mean age, 30.4 ± 6.1 years) underwent combined ACLR and ALLR. Subjective outcome measures included the International Knee Documentation Committee subjective form, Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI). Objective tests included a KT-2000 arthrometer stress test, a pivot-shift test, an isokinetic strength test, a Y-balance test, and a single-leg hop test. A postoperative questionnaire was administered to determine the rates and types of RTS, quality of sports performance, and reinjury and satisfaction rates. Subjective scores and clinical tests were performed at 2 years. Magnetic resonance imaging and second-look arthroscopy were conducted during the 1- and 2-year follow-ups, respectively.

Results

The mean follow-up for groups I and C were 30.4 ± 3.9 and 29.3 ± 3.5 months, respectively (P = .194). Patients in group C had better anteroposterior (P = .001) and rotational (P = .005) stability and higher ACL-RSI scores (P = .025) than those in group I. Group C had higher composite and posteromedial reach scores on the Y-balance test than group I (P = .014 and P = .010, respectively). A total of 26 (66.7%) patients in group C and 17 (43.6%) in group I returned to their prior level of sports (P = .040). Rerupture of the ACL graft and contralateral ACL rupture occurred in 2 (5.1%) and 2 (5.1%) patients in group I, respectively, compared with no rerupture or contralateral ACL rupture in group C.

Conclusion

Combined ACLR and ALLR in young women with a high-grade pivot shift was associated with better knee stability parameters, dynamic postural stability, and psychological readiness to RTS than isolated ACLR.

A Review of Current Concepts of the Anterolateral Complex of the Knee

The anterolateral complex (ALC) of the knee has gained increased interest over the last decades due to the high revision rates of anterior cruciate ligament reconstruction (ACLR). Furthermore, in patients with an ACL tear, the injury of at least one of the ALC's anatomic structures has been shown to be significantly higher, thus affecting its secondary stabilizing role at the knee joint. As such, ACLR augmentation techniques, that embrace the ALC, have been proposed recently, and indications for these procedures are still evolving. This review aims to present and discuss the most current anatomical, biomechanical, and imaging data, current reconstruction techniques, and the clinical results of ALC reconstruction.

Combined ACL and ALL reconstruction reduces the rate of reoperation for graft failure or secondary meniscal lesions in young athletes

PURPOSE

Graft failure and secondary meniscal tears are major concerns after anterior cruciate ligament (ACL) reconstruction in young athletes. The aim was to evaluate the link between ACL reconstruction with and without anterolateral ligament (ALL) reconstruction and outcomes in young patients participating in pivoting sports.

METHODS

This was a retrospective study of data collected prospectively. Patients less than 20 years, involved in pivoting sports and undergoing primary ACL reconstruction with a quadruple hamstring tendon (4HT) graft or 4HT graft combined with anterolateral ligament reconstruction (4HT + ALL) were included. Survival analysis was performed to identify the prognostic indicators for reoperation due to graft failure or secondary meniscal lesions. Knee laxity was assessed and patient reported outcome measures (PROMs) were collected.

RESULTS

A total of 203 patients (mean (± SD) age: 16.3 ± 2 years) with a mean follow-up of 4.8 ± 0.9 (range: 3.3‒6.8) years were included. There were 101 4HT and 102 4HT + ALL grafts. Graft rupture rates were 11.9% for 4HT grafts and 5.8% for 4HT + ALL grafts (n.s.). There were 9.9% secondary meniscal procedures for 4HT grafts vs. 1.9% for 4HT + ALL grafts (p = 0.02). With reoperation for graft failure or secondary meniscal lesions at final follow-up as the endpoint, survival was better in the 4HT + ALL group (91.4% vs. 77.8%, respectively; p = 0.03). Absence of ALL reconstruction (HR = 4.9 [95%CI: 1.4-17.9]; p = 0.01) and preoperative side-to-side laxity > 3 mm (HR = 3.1 [95%CI: 1.03-9.1]; p = 0.04) were independently associated with an increased rate of reoperations. Mean (± SD) side-to-side laxity was 1.3 ± 1.3 mm (range: - 2 to 5) for 4HT grafts vs. 0.9 ± 1.3 mm (range: - 6 to 4.8) for 4HT + ALL grafts (n.s.) 6 months post-surgery. The rate of return to the same sport at the same level was 42.2% for 4HT grafts vs. 52% for 4HT + ALL grafts (n.s.). There was no significant difference in subjective outcomes including PROMs between the two groups.

CONCLUSION

Combined ALL + ACL reconstruction reduced the rate of graft failure and secondary meniscal injury in young athletes when compared to ACL reconstruction alone. Subjective results were comparable, with a similar rate of complications. Combined reconstruction should be preferred in this young population.

LEVEL OF EVIDENCE

Level IV.

Latin American formal consensus on the appropriate indications of extra-articular lateral procedures in primary anterior cruciate ligament reconstruction

OBJECTIVES

To create a practice guideline for the appropriate indications of an extra-articular procedure in primary anterior cruciate ligament reconstruction (ACLR).

METHODS

The formal consensus method described by the Haute Autorité de Santé was used. The Latin American Society of Arthroscopy, Articular Replacement, and Sports Injuries (SLARD) recruited three groups of experts on ACLR. Initially, the steering group, consisting of eight surgeons, performed a systematic review of the literature and elaborated on 192 scenarios for primary ACLR. The rating group, composed of 23 surgeons, rated each scenario in two rounds, with an in-between in-person meeting for discussion. Median scores and agreement levels were estimated to classify each scenario as inappropriate, uncertain or appropriate for adding anterolateral reconstruction. Finally, the lecture group, consisting of 10 surgeons, revised each stage of the method, results and interpretation.

RESULTS

Of the scenarios, 11.97% were rated as appropriate for adding an extra-articular lateral procedure, 7.81% as inappropriate and 80.21% as uncertain. The key recommendations for the addition of extra-articular lateral techniques were as follows: it is appropriate when the patient is under 25 years of age, has high-grade physical examination findings, practises a pivoting sport and has hyperlaxity; meanwhile, it is inappropriate when the patient has low-grade physical examination findings, has normal laxity and does not practise a pivoting sport.

CONCLUSIONS

The appropriate indications of extra-articular lateral procedures in primary ACLR were determined on the basis of the best available evidence and expert opinion following a formal consensus method.

LEVEL OF EVIDENCE

V.

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

PURPOSE

To evaluate the rate of return to pre-injury type of sports (RTS type) in patients after revision anterior cruciate ligament reconstruction (ACLR) with lateral extra-articular tenodesis (LET) compared to patients after revision ACLR without LET.

METHODS

Seventy-eight patients who underwent revision ACLR with an autologous ipsilateral bone-patellar tendon-bone autograft with and without LET were included at least one year after surgery (mean follow-up: 43.9, SD: 29.2 months). All patients filled in a questionnaire about RTS type, the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective form (IKDC_subjective), and the Tegner activity score.

RESULTS

The RTS type for revision ACLR with LET was 22 of 42 (52%), whereas 11 of 36 (31%) of the patients who underwent revision ACLR without LET returned to the pre-injury type of sport (p = 0.05). No significant differences were found in KOOS subscores, IKDC_subjective, and Tegner activity scores.

CONCLUSION

An additional LET increases the rate of RTS type after revision ACLR.

LEVEL OF EVIDENCE

III.