Complications and revision surgeries in two extra-articular tenodesis techniques associated to anterior cruciate ligament reconstruction. A case-control study

Various Definitions of Failure Are Used in Studies of Patients Who Underwent Anterior Cruciate Ligament Reconstruction

Purpose

To conduct a literature review to assess the definitions of anterior cruciate ligament reconstruction (ACLR) failure used throughout the orthopaedic literature.

Methods

A systematic search of Embase, Ovid Medline, SPORTDiscus, and Web of Science was conducted by a university librarian to identity level I-IV clinical studies on ACLR failure. Inclusion criteria consisted of patients who underwent ACLR and included a definition of failure of ACLR. Patients who underwent anterior cruciate ligament (ACL) repairs, animal/cadaver studies, review studies, non-English language articles, and non-full text articles were excluded. Failure data were extracted from each study and categorized. Other data that were extracted included follow-up time after ACLR, failure reoperation rate, and failure reoperation procedure. Descriptive statistics was used to analyze the data.

Results

Out of 2,775 studies, 104 (3.75%) met inclusion criteria and were analyzed in this review. The most common definition of ACLR failure included the use of a physical examination, specifically Lachman's test (21/104 [20.2%]), anterior laxity assessment, or a Pivot-Shift test (24/104 [35.2%]) or undergoing or requiring revision ACLR (39/104 [37.5%]). Although some studies used quantitative tests or imaging to help define "failure," others simply defined it as graft rerupture that was otherwise not defined (22/104 [22.5%]). Other common definitions included: the use of imaging (magnetic resonance imaging/radiographs) to confirm graft re-rupture (37/104 [35.6%]), patient-reported outcomes (recurrent instability)/patient reported outcomes measures (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner) (18/104 [17.3%]), and the use of an arthrometer (KT-1000/2000, Rollimeter, or Kneelax) (17/104 [16.3%]). The least common definitions included graft failure or rerupture confirmed by arthroscopy (13/104 [12.5%]) and nonrevision surgery (2/104 [1.0%]). The failure rate of this procedure ranged from 0% to 100% depending on the definition of "failure."

Conclusion

In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. The most common criteria for failure of ACLR were the results of physical examination tests (35%), the need for undergoing a revision ACLR (36%), and the use of imaging to diagnose the failure (34%). About 17% of studies included in this review used patient-reported outcomes, specifically recurrent instability, or PROMs (IKDC, KOOS, Tegner) in their assessment of failure of ACLR. The least used definitions of "failure" of ACLR included nonrevision ACLR surgery (2%). Although some studies used similar tests or categories in their definition of failure, there were a variety of score and grade cutoff points between them.

Level of Evidence

Level IV, systematic review of Level II-IV studies.

Single Femoral Tunnel for Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Graft and Lemaire's Extra-Articular Tenodesis as a Good Alternative for Combined Anterior Cruciate Ligament and Anterolateral Ligament Revision Surgeries

The literature has shown a significant decrease in failure rates when the anterior cruciate ligament (ACL) reconstruction was associated with an extra-articular reinforcement technique such as the anterolateral ligament (ALL) or the iliotibial band tenodesis (ITBT) using the modified Lemaire technique. As much as there is a progressive decrease in the failure rates of ACL reconstructions when the ALL reconstruction technique is associated, there are still and will be cases that will result in graft rupture. These cases will require more alternatives for revision, which are always challenging for the surgeon, where the lateral approaches represent complicating factors, especially because of the distortion of the lateral anatomy (by the previous approach for ALL reconstruction), previous reconstruction tunnels, and the presence of fixation materials. We present here a safe technique that offers great stability to the fixation of the graft and is easy to perform, using a single tunnel for the passage of the ACL and ITBT grafts, allowing a single fixation for both. In this way, we performed a lower-cost surgery, with a lower risk of lateral condyle fracture and tunnel confluence. This technique is indicated to be used in cases of revision after failure of combined ACL reconstruction with ALL.

Restoring rotational stability following anterior cruciate ligament surgery: single-bundle reconstruction combined with lateral extra-articular tenodesis versus double-bundle reconstruction

Aim: To compare the outcomes of patients who underwent single-bundle (SB) anterior cruciate ligament (ACL) reconstruction combined with lateral extra-articular tenodesis (LET) with the outcomes of those who underwent double-bundle (DB) ACL reconstruction. Methods: 16 patients who underwent ACL hamstring SB reconstruction combined with LET (Coker-Arnold modification of the MacIntosh procedure) were retrospectively compared with 20 patients who underwent hamstring DB reconstruction at an average follow-up of 6.2 years. Assessment included Lysholm and International Knee Documentation Committee scores, objective examination and instrumented laxity test. Results: No complications were reported. Mean Lysholm and International Knee Documentation Committee scores significantly increased from preoperatively (p < 0.05). No differences were reported between the two groups with regard to point scales, anterior tibial translation and pivot-shift test (p = not significant). Conclusions: Both DB ACL reconstruction and combined LET and autologous hamstring SB ACL reconstruction are effective at providing satisfying functional outcomes and restoring rotational stability.

Postoperative thromboprophylaxis does not reduce the incidence of thromboembolic events after ACL reconstruction

INTRODUCTION

Anterior cruciate ligament (ACL) reconstructive surgery is one of the most common ligament-related surgeries performed in France. The French Society of Anesthesia & Intensive Care Medicine (SFAR) recommends the systematic use of low-molecular weight heparin postoperatively to prevent venous thromboembolisms (VTE). However, these recommendations differ from one country to another; several national societies do not recommend them. To specify the benefits of such a treatment, we did a retrospective case-control study to evaluate the incidence of symptomatic VTE after ACL reconstruction. Hypothesis We hypothesized that the rate of symptomatic VTE would be the same, whether a course of postoperative anticoagulants is prescribed or not.

METHODS

This was a retrospective, multicenter, multi-surgeon study. Of the four participating surgeons, two never prescribed thromboprophylaxis after surgery while the other two always prescribed a 10-day course of low-molecular weight heparin. All patients who underwent primary ACL reconstruction using an autologous graft between the 1st of January 2019 and the 15th of February 2020 were included. The 535 patients who had undergone ACL reconstruction were divided into two groups: (Group 1) 279 patients in the group without anticoagulants; 96% received a four-strand semi-tendinosus graft (ST4) and 4% received a quadriceps tendon (QT) graft; the mean age of these patients was 30 years (14-58); 41% of them were women and 22% of them were smokers; the mean body mass index was 24.4 (18-37); the mean tourniquet time was 37minutes. (Group 2) 256 patients in the group with anticoagulants; 81% received a semi-tendinosus/gracilis graft, 15% received a ST4 and 4% a QT; the mean age of these patients was 29 years (14-60); 38% of them were women and 21% of them were smokers; the mean body mass index was 25.0 (18-38); the mean tourniquet time was 34minutes. The two groups were comparable in all respects except for the type of graft used. All patients were contacted at a minimum interval of 3 months after their surgery, by telephone. Doppler ultrasonography was done solely when a VTE was suspected.

RESULTS

In the group without anticoagulants, 249 of 279 patients were contacted, while in the group with anticoagulants, 221 of 256 were contacted. The two groups were comparable in terms of age, gender ratio, tourniquet time, body mass index and proportion of smokers. Two cases of deep vein thrombosis (all in the calf region) were found in each group with no associated pulmonary embolism. There was no difference between groups in the VTE rate.

DISCUSSION

Our hypothesis was confirmed since the incidence of symptomatic VTE was the same whether postoperative anticoagulants were prescribed or not. The incidence of symptomatic VTE after ACL reconstruction was identical whether thromboprophylaxis was used or not. This casts doubt on the need for postoperative thromboprophylaxis, especially in younger patients who do not have risk factors, and brings into question whether the recommendations in France should be changed.

LEVEL OF EVIDENCE

III (retrospective case-control study).

Modified Lemaire Lateral Extra-articular Tenodesis in the Pediatric Patient: An Adjunct to Anterior Cruciate Ligament Reconstruction

Recent literature has identified a population of active adolescents aged 13 to 15 years who are at high risk for anterior cruciate ligament graft rupture. Addressing the anterolateral complex during primary anterior cruciate ligament reconstruction has recently re-emerged in the literature, with various techniques available. This paper aims to describe a lateral extra-articular tenodesis procedure using the iliotibial band with a modified Lemaire technique. This procedure is recommended for active adolescents at a high risk of graft re-tear as an enhancement to primary anterior cruciate ligament reconstruction with soft-tissue graft.