Combined Double-Bundle Anterior Cruciate Ligament Reconstruction and Anterior Cruciate Ligament-Mimicking Anterolateral Structure Reconstruction

Double-bundle ACL combined with ALL reconstruction for patients at high risk of ACL failure: clinical and radiological results

BACKGROUND

We investigated whether double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (ACLR) combined with anterolateral ligament reconstruction (ALLR) improved clinical and radiological outcomes in patients at high risk of ACL failure. The primary outcome was graft failure, and secondary outcomes included knee stability and patient-reported outcome measures (PROMs).

PATIENTS AND METHODS

Fifty-two patients who underwent DB ACLR combined with ALLR were included in this retrospective cohort study. Preoperative risk factors, including femorotibial angle (FTA), lateral tibial slope (LTS), medial tibial slope (MTS), and meniscal tears, were assessed using X-ray and magnetic resonance imaging (MRI). The grade of post-operative pivot shift, Lysholm score, and Tegner activity score were used to assess clinical outcomes. The minimum follow up duration was 2 years.

RESULTS

The cohort (mean age, 26.1 ± 9.4 years; 51.9% male) had a mean follow-up duration of 28.9 ± 3.4 months. Preoperatively, 57.8% had lateral meniscus (LM) tears, and 61.0% had a grade 2-3 pivot shift. Postoperatively, no graft failures or revision cases occurred during follow-up. Approximately 90.4% of the patients exhibited a negative pivot shift (p < 0.001), with Lysholm and Tegner activity scores of 92.5 ± 6.1 and 5.1 ± 2.0. The medial meniscus (MM) tear group had a significantly smaller FTA than the intact group (p = 0.043). No significant differences in PROMs were found between the LM tear and intact LM groups or between the high and low MTS or LTS groups (p = n.s.).

CONCLUSION

DB ACLR combined with ALLR had satisfactory clinical outcomes in patients at high risk of ACL failure, with no graft failures observed during a mean follow-up duration of 2.4 years. The technique effectively reduced the postoperative pivot shift, regardless of preoperative risk factors.

STUDY DESIGN

Level IV, retrospective therapeutic case-series.

TRAIL REGISTRATION

ethical approval number, 202300134B0; ethical committee, the Institutional Review Board of Chang Gung Medical Foundation.

Anterolateral Structure Reconstructions With Different Tibial Attachment Sites Similarly Improve Tibiofemoral Kinematics and Result in Different Graft Force in Treating Knee Anterolateral Instability

PURPOSE

To compare the biomechanical effects of anterolateral structure reconstructions (ALSRs) with different tibial attachments on tibiofemoral kinematics and anterolateral structure (ALS) graft forces.

METHODS

Eight cadaveric knees were tested in a customized knee testing system, using a novel pulley system to simulate more muscle tensions by loading the iliotibial band at 30 N and quadriceps at 10 N in all testing states. Anterior stability during anterior load and anterolateral rotatory stability during 2 simulated pivot-shift tests (PST1 and PST2) were evaluated in 5 states: intact, ALS-deficient (Def), ALSR-Ta (anterior tibial site), ALSR-Tm (middle tibial site), and ALSR-Tp (posterior tibial site). Tibiofemoral kinematics and resulting ALS graft forces against the applied loads were measured and compared in the corresponding states.

RESULTS

In anterior load, 3 ALSRs mitigated the anterior laxities of the ALS Def state at all degrees, which were close to intact state at 0° and 30° but showed significantly overconstraints at 60° and 90°. In both PSTs, all ALSRs significantly reduced the anterolateral rotatory instability of ALS Def, whereas the significant overconstraints were detected in ALSR-Ta and ALSR-Tm at greater knee flexion angles. All ALS grafts carried forces in resisting anterior and pivot-shift loads. Only ALS graft force in ALSR-Ta increased continuously with knee flexion angles. The ALS graft forces carried by ALSR-Ta were significantly larger than those by ALSR-Tp and ALSR-Tm when resisting anterior load and PSTs at greater knee flexion angles.

CONCLUSIONS

ALSRs with different tibial attachment sites similarly restored knee laxities close to the native tibiofemoral kinematics in an ALS-deficient knee, whereas the ALSR-Tp showed less propensity for overconstraining the knee at greater flexion angles. The ALS graft in ALSR-Ta carried more forces than those in ALSR-Tp and ALSR-Tm against simulated loads.

CLINICAL RELEVANCE

Altering the tibial attachment sites of ALSRs may not significantly affect tibiofemoral kinematics at most degrees whereas the posterior may have less overconstraints at greater flexion angles. However, ALS graft positioning at a more anterior tibial attachment site may carry more forces in resisting anterior and pivot-shift loads.

Meta-Analysis of Knee Joint Function Recovery after Anterior Cruciate Ligament Reconstruction by Accelerated Rehabilitation Surgery

Objective. This investigation was undertaken to systematically assess the impact of increasingly rapid recovery treatment on the functional status of the knee following anterior cruciate ligament restructuring. Methods. Computer search from the establishment of the database to March 2022 in China Knowledge Network Database (CNKI), PubMed, EMBASE, ScienceDirect, CochraneLibrary, China VIP Database, Wanfang Database, and China Biomedical Literature Database (CBM). The control group was given only traditional rehabilitation training, and the observation group was treated with perioperative accelerated rehabilitation surgery intervention randomized controlled trial (RCT). Data for all included studies were extracted by two independent researchers, and the risk of bias for the quality of each included study was assessed by the Cochrane Handbook 5.1.0 criteria. Meta-analysis of the collected data by using RevMan5.4 statistical software. Results. A total of 593 articles were retrieved from the computer database and 8 RCT articles with a total of 636 samples were finally included for meta-analysis. According to the Jadad scale, the RCT score of 8 articles was ≥4 points. Meta-analysis was performed on the postoperative VAS scores of the ERAS group and the traditional rehabilitation group, and the heterogeneity test showed Chi2 = 288.60, df = 5, $P<0.00001$ , and I2 = 99%. There was a statistically significant difference in the postoperative VAS scale between the intervention and the traditional rehabilitation model $\left(P<0.05\right)$ . Eight articles reported the effect of accelerated rehabilitation surgery on the recovery of knee joint motion after ACL rehabilitation. After meta-analysis, the heterogeneity test showed Chi2 = 314.98, df = 7, $P<0.00001$ , and I2 = 98%, and it can be concluded from the analysis that, compared with the traditional rehabilitation model, the enhanced rehabilitation surgery has an effect on the joint function after anterior cruciate ligament reconstruction. The improvement effect was more significant, and the difference was statistically significant $\left(P<0.05\right)$ . Four articles reported the effect of enhanced recovery after surgery intervention on the range of motion of the knee joint of patients, the heterogeneity test showed Chi2 = 117.52, df = 2, $P<0.00001$ , and I2 = 98%, through analysis, and compared with the traditional rehabilitation model and the enhanced recovery. The effect of surgery on the range of motion of the knee joint after ACL reconstruction was more significant, and the difference was statistically significant $\left(P<0.05\right)$ . The effect of enhanced recovery after surgery and traditional rehabilitation mode on the incidence of postoperative adverse reactions in patients undergoing ACL reoperation was analyzed. The results of heterogeneity test showed that Chi2 = 1.59, df = 2, $P=0.66>0.05$ , and I2 = 98%, and the analysis showed that, compared with the traditional rehabilitation mode, enhanced rehabilitation surgery can significantly reduce the risk of adverse reactions after anterior cruciate ligament reconstruction $\left(P<0.05\right)$ . An inverted funnel plot was used to analyze publication bias in studies with quality of life as an outcome measure. The results showed that Egger’s test $P=0.0005<0.001$ suggesting that there may be a certain degree of publication bias. Conclusion. The existing research evidence shows that accelerating the reconstruction of anterior cruciate ligament can effectively promote the recovery of knee joint function, reduce the pain of patients, and reduce postoperative complications. However, more research is needed to further verify this.

Effect of Anterolateral Structure Augmentation on Graft Maturity After Anterior Cruciate Ligament Reconstruction: A Clinical and MRI Follow-up of 2 Years

BACKGROUND

Anterolateral structure augmentation (ALSA) has been applied to prevent residual rotatory instability and lower clinical failure rates after anterior cruciate ligament (ACL) reconstruction (ACLR); however, the effect of combined ALSA on the maturity of ACL grafts remains unknown.

PURPOSE

To evaluate the graft maturity and patient-reported outcomes in patients who underwent double-bundle ACLR with or without ALSA.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 92 patients who underwent double-bundle ACLR between January 2016 and July 2019 were included in the present study-44 patients with isolated ACLR (ACLR group) and 48 patients with combined ACLR and ALSA (ALSA group). Demographic characteristics, intraoperative findings, and patient-reported outcomes were prospectively collected. On postoperative magnetic resonance imaging at the 2-year follow-up, the signal-to-noise quotient (SNQ) values were separately calculated for 6 sections of the ACL graft, including the femoral intratunnel graft (FTG), intra-articular graft (IAG), and tibial intratunnel graft (TTG) of the anteromedial bundle (AMB) and the posterolateral bundle (PLB). Superior graft maturity was usually indicated by lower SNQ values.

RESULTS

The rates of return to preinjury sports were 47.9% and 27.3% in the ALSA and ACLR groups, respectively (difference, 20.6% [95% CI, 1.3%-40%]; P = .042). The AMB demonstrated significantly lower SNQ values in the ALSA group than in the ACLR group (FTG, 7.04 ± 3.65 vs 9.44 ± 4.51 [P = .006]; IAG, 6.62 ± 4.19 vs 8.77 ± 5.92 [P = .046]; TTG, 6.93 ± 3.82 vs 8.75 ± 4.55 [P = .040]). The SNQ values were significantly lower in the ALSA group for 2 of the 3 sections of the PLB (IAG, 7.73 ± 4.61 vs 9.88 ± 5.61 [P = .047]; TTG, 5.88 ± 3.10 vs 8.57 ± 4.32 [P = .001]). Partial lateral meniscectomy was correlated with higher SNQ values of the TTG in the AMB (β = 0.27; P = .009) and the PLB (β = 0.25; P = .008), with both groups pooled. Higher body mass index, smaller ACL graft-Blumensaat line angles, larger AMB graft diameters, and lower postoperative Tegner scores were also associated with inferior maturity in specific regions of the ACL graft.

CONCLUSION

A combination of ACLR and ALSA is a desirable option to improve the maturity of ACL grafts for patients who are young or expected to return to pivoting sports. Meanwhile, further investigations with higher levels of evidence and longer periods of follow-up are warranted.

Augmentation of Anterolateral Structures of the Knee Causes Undesirable Tibiofemoral Cartilage Contact in Double-Bundle Anterior Cruciate Ligament Reconstruction-A Randomized In-Vivo Biomechanics Study

PURPOSE

To analyze the in vivo tibiofemoral cartilage contact patterns in knees undergoing double-bundle anterior cruciate ligament reconstruction(DB-ACLR) with or without anterolateral structure augmentation (ALSA).

METHODS

Twenty patients with an ACL-ruptured knee and a healthy contralateral side were included. Nine patients received an isolated DB-ACLR (DB-ACLR group), and 11 patients had a DB-ACLR with ALSA (DB+ALSA group). At 1-year follow-up, a combined computed tomography, magnetic resonance imaging, and dual fluoroscopy imaging system analysis was used to capture a single-legged lunge of both the operated and healthy contralateral side. Tibiofemoral contact points (CPs) of the medial and lateral compartments were compared. CP locations were expressed as anteroposterior (AP, +/-) and medial-lateral (ML, -/+) values according to the tibia.

RESULTS

In the DB-ACLR knees, no significant differences were found in CPs when compared with the healthy contralateral knees (P ≥ .31). However, in the DB+ALSA knees, the CPs in the lateral compartment had a significantly more anterior (mean AP: operative, -2.8 mm, 95% confidence interval [CI] -5.0 to-0.7 vs healthy, -5.0 mm, 95% CI -6.7 to -3.2; P = .006) and lateral (mean ML: operative, 23.2 mm, 95% CI 21.9-24.5 vs healthy, 21.8 mm, 95% CI 20.2-23.3; P = .013) location. The CPs in the medial compartment were located significantly more posterior (mean AP: operative, -3.4, 95% CI -5.0 to -1.9 vs healthy, -1.3, 95% CI -2.6 to -0.1; P = .006) and lateral (mean ML: operative, -21.3, 95% CI -22.6 to -20.0 vs healthy, -22.6, 95% CI -24.2 to -21.0; P = .021).

CONCLUSIONS

DB-ACLR restored the tibiofemoral cartilage contact mechanics to near-normal values at 1-year follow-up. Adding the ALSA to the DB-ACLR resulted in significantly altered tibiofemoral cartilage contact locations in both the medial and lateral compartments.

CLINICAL RELEVANCE

In DB-ACLR knees, the addition of an ALSA may be unfavorable as it caused significantly changed arthrokinematics.

Three-in-One Procedure for Revision ACL Reconstruction

Revision anterior cruciate ligament (ACL) reconstruction is a challenge due to the unfavorable condition of the knee and the lack of autogenous graft tissue. Anterolateral structure (ALS) reconstruction of the knee has been proved effective to address the unfavorable condition in revision cases, and lateral extra-articular tenodesis (LET) is a special technique that can enhance anterolateral stability of the knee without graft tissue. We introduce a procedure that combines ACL and ALS reconstruction, as well as LET for failed ACL reconstruction. The critical point of this technique is using the anterior half of the iliotibial band to realize LET and to partially reconstruct the ACL. Our clinical experience indicates this technique is extremely useful in revision ACL reconstruction without enough free graft tissue. This technique will provide a reasonable choice in revision ACL reconstruction.