Combining Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Procedures in Skeletally Immature Patients Is Safe and Associated With a Low Failure Rate

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.

Hamstring autografts demonstrate either similar or inferior outcomes to quadriceps or bone-patellar tendon-bone autografts in revision anterior cruciate ligament reconstruction: A systematic review of comparative studies

PURPOSE

To evaluate the clinical outcomes in patients undergoing revision anterior cruciate ligament reconstruction (r-ACLR) using hamstring tendon (HT) autografts with those using either quadriceps tendon (QT) or bone-patellar tendon-bone (BPTB) autografts or allografts.

METHODS

Three databases were searched on 8 August 2023. The authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details, patient-reported outcome measures (PROMs), rates of instability, failure and return to sport (RTS) were extracted.

RESULTS

Eleven studies comprising 859 patients were included in this review. Five studies compared HT and QT autografts. One study each reported greater IKDC scores (p = 0.04) and Tegner scores (p = 0.04) in the QT group, while one study each reported higher anterior translation (p = 0.04), rates of positive pivot shift (p = 0.03) and rates of failure (p = 0.03) in the HT group. Six studies compared HT and BPTB autografts with one study each reporting greater Lysholm scores (p = 0.02) and less side-to-side anterior laxity (p < 0.01) in the BPTB group. Two studies compared HT autografts with allografts with only one study reporting a faster time to RTS in the HT group than the allograft group (p < 0.001). All other comparisons were not significant.

CONCLUSIONS

HT autografts result in either similar or inferior outcomes in r-ACLR when compared to QT or BPTB autograft options. Allografts resulted in similar outcomes to HT autografts apart from greater time to RTS for r-ACLR.

LEVEL OF EVIDENCE

Level III.

Substantial Variability Exists in Reporting Clinically Significant Outcome Measure Thresholds for Arthroscopic Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To systematically review the reporting of clinically significant outcome measure (CSO) thresholds and methods for calculating thresholds following anterior cruciate ligament (ACL) reconstruction.

METHODS

A systematic review of PubMed, Embase, and Web of Science databases was conducted to identify articles that met inclusion criteria from January 1, 2015, to July 7, 2024. Inclusion criteria included studies reporting CSO thresholds including minimal clinically important difference (MCID), substantial clinical benefit (SCB), or patient acceptable symptomatic state (PASS) for patients following ACL reconstruction with minimum 12-month follow-up. The MINORS criteria was used to assess study quality. Study demographics, patient-reported outcome measures (PROMs), CSO thresholds, and method of CSO calculation were collected.

RESULTS

A total of 56 studies (n=52,292 patients) met the final inclusion criteria. Reported PROMs included International Knee Documentation Committee (IKDC) (n=35 studies), Knee Injury and Osteoarthritis Outcome score (KOOS) (n=33 studies), Tegner (n=20 studies) and Lysholm (n=19 studies) scores. The PASS was reported in 35 studies, MCID in 30, and SCB in 4. Among the studies that reported PASS, the most used threshold calculation was the ROC-Youden index (71.4%, n=25/35). In the studies reporting MCID, the most used threshold calculation was the 0.5 standard deviation (SD) of mean change method (36.7%, n=11/30). The most reported threshold calculation among the SCB studies was the ROC curve analysis (75%, n=3/4). In studies independently calculating CSOs, the most common methods were 0.5 standard deviations (SD) of mean change for MCID (50%, n=10/20), the ROC-Youden index for PASS (73.3%, n=11/15), and ROC curve analysis (75.0%, n=3/4) for SCB. Descriptions of anchor questions were reported in 22 studies (39.3%).

CONCLUSION

Substantial variability exists in the reporting and calculation of MCID, SCB, and PASS for various PROMs following ACL reconstruction.

Allograft versus autograft ACL reconstruction in skeletally immature patients: a systematic review

INTRODUCTION

Anterior cruciate ligament (ACL) injuries in children and adolescents with open physes are common.

AREAS OF AGREEMENT

Evidence of ACL reconstruction using allografts in children with open physes is limited.

AREAS OF CONTROVERSY

Whether the outcomes of ACL allograft reconstruction in children and adolescents with open physes are superior to autograft ACL reconstruction is unclear, with contrasting evidence.

SOURCE OF DATA

In October 2024, the Web of Science, PubMed, and Embase were accessed with no additional filters. Only clinical investigations evaluating ACL reconstruction in children or adolescents with open physes were eligible. Only studies reporting a minimum length of 24 months of follow-up were included.

AREAS TIMELY FOR DEVELOPING RESEARCH

Children who undergo allograft ACL reconstruction demonstrate similar functional outcomes to those who undergo autograft ACL reconstruction. Although allografts allow a faster return to sport, the greater laxity, the reduced activity level, and the higher failure and reoperation rates make their use dubious as a first-choice option for ACL reconstruction in skeletally immature patients.

A lateral extra-articular tenodesis without additional hardware: Surgical technique and biomechanical comparison with an anatomic anterolateral ligament reconstruction in the augmentation of anterior cruciate ligament reconstruction

BACKGROUND

The aims of this study were to describe a lateral extra-articular tenodesis (LET) using no additional hardware and compare the tibiofemoral kinematics of anterior cruciate ligament (ACL) reconstruction augmented with either the LET or a standard anatomic anterolateral ligament (ALL) reconstruction using intra-tunnel fixation.

METHODS

Ten cadaveric knees were mounted on a robotic testing system and underwent a kinematic assessment of anterior tibial translation and internal tibial rotation under a simulated pivot-shift in the following states: ACL-intact, ACL-sectioned, ACL-sectioned/anterolateral complex (ALC)-sectioned, ACL-reconstructed/ALC-sectioned, ACL-reconstructed/ALL-reconstructed, and ACL-reconstructed/LET. For the LET, an iliotibial autograft was passed under the fibular collateral ligament and secured to the femur with the pull sutures of the ACL reconstruction femoral cortical suspensory fixation device, positioned at the distal ridge of Kaplan's fibers.

RESULTS

Anterior tibial translation was restored to normal by ACL reconstruction without meaningful benefit of augmentation with LET or ALL. ACL reconstruction restored internal tibial rotation close to normal between 0° and 30°, but increased internal tibial rotation persisted between 45° and 90°. Augmentation of ACL reconstruction with the LET reduced internal rotation close to normal between 45° and 90°, whereas increased internal rotation persisted after ALL reconstruction.

CONCLUSION

ACL reconstruction and LET are complementary in controlling tibiofemoral kinematics of knees with a combined ACL and ALC injury: ACL reconstruction restored native tibiofemoral kinematics except for internal rotation at flexion greater than 30°. The increased internal rotation at flexion greater than 30° was restored to normal with an LET, but not with an ALL reconstruction.

All-epiphyseal anterior cruciate ligament reconstruction yields superior sports performances than the trans-epiphyseal technique in skeletally immature patients: a systematic review

BACKGROUND

Anterior cruciate ligament (ACL) tears in skeletally immature patients are increasingly common. Evidence comparing the outcomes of all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients is limited, and the current literature could benefit from a comprehensive systematic review. The present study compared all-epiphyseal versus trans-epiphyseal ACL reconstruction in skeletally immature patients. The outcomes of interest were to compare joint laxity, patient-reported outcome measures (PROMs), return to sport, and complications.

METHODS

This study was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. No additional filters were used in the database search. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles that clearly stated the surgical technique (all- or trans-epiphyseal) were eligible. Only articles with a minimum of 6 months of follow-up were included. Only articles that clearly stated that surgeries were conducted in children with open physis were eligible.

RESULTS

Data from 1489 patients (1493 procedures) were collected, of which 32% (490 of 1489 patients) were female. The mean length of follow-up was 46.6 months. The mean age of the patients was 12.7 years. No difference was found in joint laxity (Table 3): positive pivot shift (P = 0.4), positive Lachman test (P = 0.3), and mean arthrometer laxity (P = 0.1). No difference was found in PROMs (Table 4): International Knee Documentation Committee (IKDC) (P = 0.3), Lysholm (P = 0.4), and Tegner (P = 0.7). The trans-epiphyseal technique was associated with a greater rate of patients unable to return to sports (1% versus 7%, P = 0.0001) and with a longer time to return to sports (7.7 versus 8.6 months, P = 0.01). Though the trans-epiphyseal technique was associated with a lower rate of return to sport, this difference was not statistically significant (P = 0.8). No difference was evidenced in the rate of patients who had reduced their league or level of sports activity (P = 0.6) or in the rate of patients who had returned to their previous league or level of sports activity (P = 0.7). No difference was found in the rate of complication: re-tear (P = 0.8), reoperation (P = 0.7), increased laxity (P = 0.9), and persistent instability sensation (P = 0.3).

CONCLUSION

Trans-epiphyseal ACL reconstruction was associated with a greater rate of patients unable to return to sport and with a longer time to return to sport compared with the all-epiphyseal technique in skeletally immature patients. Level of evidence Level III, systematic review.

Anterior cruciate ligament reconstruction in skeletally immature patients is effective: A systematic review

PURPOSE

The present study evaluated the outcomes of anterior cruciate ligament (ACL) reconstruction in children with open physes. The outcomes of interest were to compare the increase in joint laxity and PROMs from baseline to the last follow-up, the rate and features of the return to sport and the rate of complications.

METHODS

This study was conducted according to the 2020 PRISMA guidelines. In October 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. All the clinical studies investigating ACL reconstruction in skeletally immature patients were accessed. Only articles which clearly stated that surgeries were conducted in children with open physis were eligible.

RESULTS

Data from 53 studies (1691 procedures) were collected. 35% (597 out of 1691 patients) were women. The mean length of the follow-up was 44.7 ± 31.3 months. The mean age of the patients was 12.7 ± 1.1 years old. All PROMs significantly improved from the baseline values to those at the last follow-up. The mean time to return to sport was 8.3 ± 1.9 months. 89% (690 out of 771 patients) returned to sports, 15% (109 out of 721 patients) reduced their level of sports activity or league, and 84% (651 out of 771 patients) returned to their previous level of sport. 9% (112 out of 1213) of patients experienced re-tear of the reconstructed ACL, and 11% (75 out of 660) of patients underwent a further ACL reoperation. No patients (0 out of 83) demonstrated increased laxity at the last follow-up, and persistent sensation of instability was reported by 5% (11 out of 235) of patients.

CONCLUSION

ACL reconstruction in skeletally immature patients is effective and safe, and is associated with fast recovery and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Physeal Sparing Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis With Semitendinosus and Gracilis Tendons

Anterior cruciate ligament (ACL) injuries among young patients have increased in recent years. The purpose of this study was to present a physeal-sparing intra- and extra-articular reconstruction using semitendinosus and gracilis tendons autograft. In recent years, the management of these injuries in the pediatric population has become increasingly surgical to restore knee function and reduce the risk of meniscal and chondral injury due to persistent knee instability. However, this is a population at high risk for ACL graft rupture, but it can be lowered by an addition of lateral extra-articular tenodesis (LET). This study shows the pearls and pitfalls of an arthroscopic physeal-sparing ACL reconstruction combined with a concomitant LET using hamstrings autograft.

Association of Lateral Extra-Articular Tenodesis With Improved Graft Maturity on MRI 2 Years After ACL Reconstruction With Quadriceps Tendon Autograft in Skeletally Immature Athletes

Background

Quadriceps tendon autograft (QTA) has recently gained popularity in the treatment of anterior cruciate ligament (ACL) ruptures in pediatric patients. The addition of lateral extra-articular tenodesis (LET) to an ACL reconstruction (ACLR) has been found to reduce the risk of ACL retear in high-risk patients.

Purpose

To (1) compare ACL graft maturity using signal intensity ratios (SIRs) on magnetic resonance imaging (MRI) scans in skeletally immature patients undergoing ACLR with QTA either with or without concomitant LET and (2) evaluate LET safety by calculating the physeal disturbance-related reoperation rate in the ACLR+LET group.

Study Design

Cohort study; Level of evidence, 3.

Methods

The records of patients aged ≤18 years who underwent ACLR between 2015 and 2021 were reviewed retrospectively. Patients undergoing ACLR with QTA who had open distal femoral and proximal tibial physes on MRI scans and a minimum 2-year follow-up data were included. SIR values were measured on sagittal MRI scans by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the posterior cruciate ligament at its insertion. Statistical analysis was performed to evaluate differences in SIR values at 6 months, 1 year, and 2 years postoperatively in patients who underwent ACLR alone versus ACLR+LET.

Results

Overall, 29 patients were included in the study: 16 patients in the ACLR+LET group and 13 patients in the ACLR-only group. There were no significant differences in SIR values between groups at the 6-month or 1-year postoperative timepoints. At 2 years postoperatively, the median SIR of the ACLR+LET group was significantly lower than that of the ACLR-only group on both univariate (1.33 vs 1.86, respectively, P = .0012) and multivariate regression analyses adjusting for both sex and surgical technique (β = -0.49 [95% CI, -0.91 to -0.05]; P = .029). There were no cases of reoperation for physeal disturbance in patients who underwent ACLR+LET.

Conclusion

The addition of LET to an ACLR with QTA was associated with lower average SIR values and thus improved graft maturity at 2 years postoperatively compared with ACLR alone in skeletally immature patients. The addition of LET to an ACLR was found to be safe in skeletally immature patients.

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.

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Using a Single Peroneus Longus Tendon Graft

The peroneus longus tendon seems a viable graft option for knee ligament reconstructions, with adequate biomechanical properties and low morbidity after harvesting. The objective of this article is to describe a combined anterior cruciate ligament and anterolateral ligament reconstruction technique using a single peroneus longus tendon graft harvested from the infra malleolar region to ensure sufficient length.

Though five-strand hamstring autografts demonstrate greater graft diameter, postoperative outcomes are equivocal to four-strand hamstring autograft preparations: a systematic review and meta-analysis of level I and II studies

PURPOSE

To compare graft dimensions, functional outcomes, and failure rates following anterior cruciate ligament reconstruction (ACLR) with either five-strand or four-strand hamstring autograft options.

METHODS

Three databases (MEDLINE, PubMed, and EMBASE) were searched from inception to 22 April 2023 for level I and II studies comparing five- and four-strand hamstring autografts in ACLR. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details and rehabilitation, graft diameter, patient-reported outcome measures (PROMs), and rates of positive Lachman test, positive pivot shift test, and graft rupture were extracted. PROMs included Knee Osteoarthritis and Outcome Score (KOOS) subscales, Lysholm, and International Knee Documentation Committee (IKDC).

RESULTS

One randomized controlled trial (RCT) and four prospective cohort studies with 572 patients were included. Graft diameters were larger in the five-strand group with a mean difference of 0.93 mm (95% CI 0.61 to 1.25, p < 0.001, I2 = 66%). The five-strand group reported statistically higher KOOS ADL subscale and Lysholm scores with a mean difference of 4.85 (95% CI 0.14 to 9.56, p = 0.04, I2 = 19%) and 3.01 (95% CI 0.48 to 5.53, p = 0.02, I2 = 0%), respectively. There were no differences in KOOS symptoms, pain, quality of life, or sports subscales, or IKDC scores. There were no differences in rates of positive Lachman test, positive pivot shift test, or graft rupture with pooled odds ratios of 0.62 (95% CI 0.13 to 2.91, n.s., I2 = 80%), 0.94 (95% CI 0.51 to 1.75, n.s., I2 = 31%), and 2.13 (95% CI 0.38 to 12.06, n.s., I2 = 0%), respectively.

CONCLUSIONS

Although five-stranded hamstring autografts had significantly larger graft diameters compared to four-stranded grafts with a mean difference of 0.93 mm, similar graft rupture rates and clinical laxity assessments were identified following ACLR. While some PROMs were statistically superior in the five-stranded hamstring groups, the threshold for the minimal clinical important difference was not reached indicating similar clinical outcomes overall.

LEVEL OF EVIDENCE

Level II.