Modified Iliotibial Band Tenodesis Is Indicated to Correct Intraoperative Residual Pivot Shift After Anterior Cruciate Ligament Reconstruction Using an Autologous Hamstring Tendon Graft: A Prospective Randomized Controlled Trial

Lateral extra-articular tenodesis may be more cost-effective than independent anterolateral ligament reconstruction: A systematic review and economic analysis

IMPORTANCE

Anterolateral augmentation during primary anterior cruciate ligament (ACL) reconstruction (ACLR) may lower rates of ACL graft failure. However, differences in costs between two techniques, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), are unclear.

OBJECTIVE

To perform a systematic review and subsequent cost-effectiveness analysis comparing LET versus ALLR in the setting of primary ACLR. The hypothesis was that LET is more cost-effective than ALLR.

EVIDENCE REVIEW

A systematic review was conducted on studies in which patients underwent primary ACLR with a concomitant LET or ALLR with minimum 24 months follow-up published between January 2013 and July 2023. Primary outcomes included ACL graft failure rates and Knee Injury and Osteoarthritis Outcome Survey-Quality of Life (KOOS-QoL) subscale scores, which were used to determine health utilities measured by quality-adjusted life years (QALYs) gained. A decision tree model with one-way and two-way sensitivity analyses compared the cost of primary ACLR with a concomitant LET, independent autograft ALLR, or independent allograft ALLR. Costs were estimated using a combination of QALYs, institution prices, literature references, and a survey sent to 49 internationally recognized high-volume knee surgeons.

FINDINGS

A total of 2505 knees undergoing primary ACLR with concomitant LET (n=1162) or ALLR (n=1343) were identified from 22 studies. There were 77 total ACL graft failures with comparable failure rates between patients receiving LET versus ALLR (2.9% vs. 3.2%, P=0.690). The average QALYs gained was slightly higher for those who received LET (0.77) compared to ALLR (0.75). Survey results revealed a 5 minute longer median self-reported operative time for ALLR (20 ​min) than LET (15 ​min). The estimated costs for LET, autograft ALLR, and allograft ALLR were $1,015, $1,295, and $3,068, respectively.

CONCLUSIONS AND RELEVANCE

Anterolateral augmentation during primary ACLR with LET is more cost-effective than independent autograft and allograft ALLR given the lower costs and comparable clinical outcomes. Surgeons may utilize this information when determining the optimal approach to anterolateral augmentation during primary ACLR, although differences in preferred technique and health care systems may influence operative efficiency and material costs.

LEVEL OF EVIDENCE

Systematic review; Level of evidence, IV.

Lateral Extra-Articular Tenodesis with Indirect Femoral Fixation Using an Anterior Cruciate Ligament Reconstruction Suspensory Device

BACKGROUND

The lateral extra-articular tenodesis (LET) procedure associated with anterior cruciate ligament (ACL) reconstruction can be considered in selected patients to diminish the risk of persistent rotatory instability and achieve a protective effect on the graft. Several techniques have been described in the literature to treat rotatory instability. Usually, a strip of the iliotibial band (ITB) is harvested from its middle while leaving the distal insertion, then passed underneath the lateral collateral ligament and fixed on the lateral aspect of the distal femur with various fixation methods such as staples, screws, anchors or extracortical suspensory devices. Despite their effectiveness, these fixation methods may be associated with complications such as lateral pain, over-constraint and tunnel convergence.

METHODS

This study presents a detailed surgical description of a new technique to perform an LET during ACL reconstruction with any type of graft fixing the ITB strip with the sutures of the ACL femoral button, comparing its pros and cons in relation to similar techniques found in the literature.

CONCLUSIONS

This technique represents a reproducible, easy to learn and inexpensive solution to perform a lateral extra-articular tenodesis associated with an ACL reconstruction using the high-resistance sutures of the femoral button.

Evaluation of Graft Maturation by MRI in Anterior Cruciate Ligament Reconstruction With and Without Concomitant Anterolateral Ligament Reconstruction

Background

Single-bundle anterior cruciate ligament reconstruction (SB-ACLR) with concomitant anterolateral ligament reconstruction (ALLR) has been associated with better clinical results when compared with isolated SB-ACLR. However, it is not known whether the improved outcomes are the result of the influence of concomitant ALLR on ACL graft healing.

Purpose/Hypothesis

The purpose of this study was to determine whether concomitant ALLR is associated with improved graft ligamentization after SB-ACLR. It was hypothesized that ALLR would not affect graft healing.

Study Design

Cohort study; Level of evidence, 3.

Methods

A 1 to 1 matching study was conducted on a consecutive series of 732 patients who underwent ACLR using a hamstring tendon autograft between 2007 and 2019. Patients were excluded if they had skeletal immaturity, inflammatory joint disease, multiple ligament reconstruction (other than ALLR), or a graft rupture. Patients with concomitant SB-ACLR and ALLR (SB-ACLR/ALLR) and isolated SB-ACLR were matched 1 to 1 based on age, sex, examination under anesthesia (EUA) grade 3 pivot shift, EUA grade 3 anterior drawer test, presence of graft impingement, sagittal graft angle, skeletal maturity, lack of generalized ligamentous laxity, and multiple ligamentous injury. A total of 40 matched pairs underwent postoperative magnetic resonance imaging (MRI) within the second year after surgery to assess graft ligamentization, which was measured by the signal-to-noise quotient (SNQ) of the ACL graft.

Results

The mean follow-up period was 41 months, with a 2-year follow-up rate of 80% in the SB-ACLR/ALLR group and 98% in the isolated SB-ACLR group. The mean duration between the index operation and MRI was 16.4 ± 3.4 months. No significant difference was observed in the SNQ of the ACL graft between the SB-ACLR/ALLR and SB-ACLR groups (6.9 ± 4.6 vs 5.2 ± 4.8, respectively; P = .066).

Conclusion

Study findings indicated that a concomitant ALLR at the time of hamstring tendon autograft ACLR did not affect graft healing as assessed by the SNQ of the ACL graft.

Determinants of Performance in Professional Soccer Players at 2 and 5 Years After ACL Reconstruction

BACKGROUND

A number of studies have investigated return to play after anterior cruciate ligament reconstruction (ACLR) in professional soccer players, but it is unclear which factors are associated with a return to the preinjury performance and ability to play over time.

PURPOSE

To identify factors that contribute to a professional soccer player's return to preinjury performance after ACLR, as well as to report their playing performance at 2 and 5 years after ACLR compared with their preinjury performance.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A consecutive cohort of professional soccer players undergoing primary ACLR were analyzed between 2005 and 2019. A minimum 2-year follow-up was required. The effect of patient, surgical, and postoperative factors on performance rates, defined as a combination of league level and playing time, was evaluated with univariate and multivariate logistic regression models.

RESULTS

A total of 200 male professional soccer players were included. When combining league level and playing time, 30% of athletes returned to their preinjury performance at 2 years and 22% at 5 years. However, 53% of athletes returned to their preinjury performance for at least 1 season by year 5. At 2 years, a chondral lesion of grade 3 or 4 decreased the odds of return to preinjury performance (odds ratio [OR], 0.37; P = .010). Athletes receiving an ACLR with the addition of a lateral extra-articular tenodesis procedure were 2.42 times more likely to return to preinjury performance at 2 years than athletes with ACLR alone (P = .004). By 5 years after ACLR, athletes aged ≥25 years at the time of reconstruction were 3 times less likely to be performing at their preinjury performance (OR, 0.32; P < .001), and those with a grade ≥3 chondral lesion were >2 times less likely to be performing at their preinjury performance (OR, 0.43; P = .033).

CONCLUSION

The presence of >50% thickness chondral pathology, ACLR without lateral extra-articular tenodesis, and age >25 years at the time of surgery were all significant risk factors of worse performance rates after ACLR. Significant decreases in performance rates were noted at 2 and 5 years postoperatively.

Concomitant Lateral Meniscus Tear is Associated with Residual Rotatory Knee Instability 1 Year after Anterior Cruciate Ligament Reconstruction: Case-cohort Study

Lateral meniscus tear (LMT) accompanied by anterior cruciate ligament (ACL) injuries has been reported to provoke rotatory instability of the affected knee joint. Unfortunately, these previous papers did not determine whether LMT-derived rotatory knee instability is residual because only preoperative or time zero data exists. This study aimed to longitudinally investigate how the prevalence of comorbid LMT is associated with residual rotatory knee instability (RKI) 1 year after ACL reconstruction (ACLR). A total of 327 patients who underwent double-bundle ACLR (average age: 23.4 years, body mass index: 23.5 kg/m2, 215 females). The patients were divided into three groups based on arthroscopy: 1) intact lateral meniscus (LM); 2) unrepaired LMT; 3) repaired LMT. At the 1-year follow-up, the pivot-shift test was performed. The prevalence of RKI, determined according to IKDC grades (grade ≥1 denoted RKI), was compared with chi-square or Fisher's exact tests. Thirty-eight patients (11.6%) had RKI; 203 subjects (62.1%) showed LMT, and 124 patients were diagnosed with an intact LM. Out of the 203 patients, 79 (38.9%) underwent LM repair. RKI was more prevalent in the LMT group than in the intact group (13.8% versus 8.1%, p = 0.117; Odds ratio: 1.499 [95%CI: 0.864 - 2.600]). In addition, the prevalence of RKI was significantly higher in the LM-repair group than in the intact-LM group (17.7% versus 8.1%, p = 0.038; Odds Ratio: 2.455 [95%CI: 1.032 - 5.842]). Medial meniscus tear (MMT) was detected in 113 patients (34.6%); RKI prevalence was not statistically different between the intact-MM group and the MMT group (12.2% versus 10.6%, p = 0.681). The current cohort study clarified that LMT comorbid with ACL injury was longitudinally associated with increased RKI prevalence 1 year after ACLR. Therefore, patients who underwent both ACLR and LM repair demonstrated a significantly higher prevalence of residual RKI.

Risk Factors for Symptomatic Cyclops Lesion Formation after Anterior Cruciate Ligament Reconstruction

Objective  To evaluate the incidence of symptomatic cyclops lesions requiring surgical treatment after anterior cruciate ligament (ACL) reconstruction and to establish possible intraoperative risk factors related to it. Methods  Three hundred and eighty-nine patients aged between 18 and 50 years who underwent primary ACL reconstruction were retrospectively evaluated. Patients were divided into groups according to the presence or absence of symptomatic cyclops lesions, and their characteristics were compared. Patients with associated lesions that required additional surgical procedures (except anterolateral extra-articular procedures) were not included. The rate of symptomatic cyclops lesions was recorded and the following parameters were evaluated: age, gender, time from injury to surgery, graft type and diameter, femoral tunnel perforation technique, fixation type, presence of knee hyperextension, preservation of the ACL remnant, associated anterolateral extra-articular procedure, associated meniscal injury and participation in sports. Results  389 patients were evaluated and 26 (6.7%) patients developed cyclops. The patients with and without cyclops lesions did not differ in age, time from injury to surgery, graft type or diameter, surgical technique, femoral fixation method, presence of knee hyperextension, remnant preservation and associated meniscal injury. The group with cyclops lesion had a higher proportion of females (10 (38.4%) vs 68 (18.7%); OR = 2.7; p  = 0.015), higher proportion of extra-articular reconstruction (18 (11.8%) vs 8 (3.4%); OR = 3.8; p  = 0.001) and higher proportion of sports practice (23 (8.6%) vs 3 (2.5%); OR = 3.6; p  = 0.026). Conclusion  In our series, 6.7% of the patients required arthroscopic removal of cyclops lesions. Female gender, associated extra-articular reconstruction and sports practice were factors related to this lesion. Remnant preservation had no relationship with cyclops lesion formation.

Modified Lemaire Lateral Extra-Articular Tenodesis Using an Inlay Technique and All-Suture Knotless Anchor Fixation

Appreciation of persistent anterolateral rotatory instability and graft failure after anterior cruciate ligament (ACL) reconstruction procedures has led surgeons to adopt the addition of lateral extra-articular tenodesis (LET) in both the revision and primary setting. Multiple techniques have been shown to eliminate anterolateral rotatory instability and reduce forces on the ACL graft, which has translated to lower re-rupture rates and improved patient outcomes. The risk of ACL/LET tunnel convergence can potentially compromise the fixation of one or both graft reconstructions. This article describes a technique for LET fixation which minimizes the depth of the LET femoral bone socket and utilizes low-profile implants thus mitigating this risk.

Comparison of Anterior Cruciate Ligament Reconstruction With Versus Without Anterolateral Augmentation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

It is clear that the anterolateral ligament has an important role in rotational knee stability. However, whether patients undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) can benefit from anterolateral augmentation (ALA) is still controversial.

Purpose

To compare the effects of isolated ACLR versus ACLR combined with ALA (ACLR+ALA) on clinical outcomes and knee stability.

Study Design

Systematic review; Level of evidence, 1.

Methods

The methodology followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of the PubMed, Embase, and Cochrane Library Central Register of Controlled Trials databases was undertaken to identify all randomized controlled trials (RCTs) comparing isolated ACLR with ACLR+ALA for the treatment of ACL injuries in the last 15 years. The Cochrane Collaboration risk-of-bias tool and the revised Jadad scale were utilized by 2 independent reviewers to determine the quality of RCTs. Relevant data were extracted and compared between procedures, and heterogeneity across the RCTs was assessed using the I ² statistic.

Results

The initial search yielded 849 articles. A total of 14 studies (1850 patients; 941 ACLR and 909 ACLR+ALA) satisfied the eligibility criteria for the meta-analysis. There were no significant differences between the procedures in terms of patient-reported outcomes (International Knee Documentation Committee score, Tegner score, Knee injury and Osteoarthritis Outcome Score) or return-to-sport rates. However, patients who underwent ACLR+ALA had better knee stability based on the pivot-shift test (risk ratio [RR], 1.06 [95% CI, 1.02 to 1.10]; P = .0008), Lachman test (RR, 1.03 [95% CI, 1.00 to 1.07]; P = .04), and side-to-side difference in anterior laxity (standardized mean difference, -0.55 [95% CI, -0.98 to -0.12]; P = .01) as well as a lower incidence of graft failure (RR, 0.30 [95% CI, 0.19 to 0.45]; P < .01) compared with patients who underwent isolated ACLR.

Conclusion

ALA can be considered as a reinforcement of ACLR to improve anteroposterior and anterolateral rotational stability of the knee and reduce the risk of failure. The patient-reported outcomes of isolated ACLR were similar to those of ACLR+ALA, and both procedures provided improved knee function.

Combined Lateral Extra-Articular Tenodesis or Combined Anterolateral Ligament Reconstruction and Anterior Cruciate Ligament Reconstruction Improves Outcomes Compared to Isolated Reconstruction for Anterior Cruciate Ligament Tear: A Network Meta-analysis of Randomized Controlled Trials

PURPOSE

To conduct a network meta-analysis (NMA) comparing the results of randomized controlled trials (RCTs) among patients who underwent either isolated anterior cruciate ligament (ACL) reconstruction or combined lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR).

METHODS

RCTs that compared isolated ACL reconstruction and combined LET or ALLR were included with minimum 12 months follow-up. Studies that used the double-bundle technique were excluded. Outcome assessment included the number of positive pivot shifts, amount of anterior tibial translation, and International Knee Documentation Committee (IKDC) subjective, Tegner, and Lysholm scores. Bayesian NMA and the surface under the cumulative ranking area (SUCRA) were evaluated.

RESULTS

A total of 1,077 patients from 11 RCTs were enrolled in this study. In NMA, the odds ratios (ORs) of positive pivot shift were significantly lower in ACL + ALLR (OR: 0.17; 95% CI: 0.027-0.67) than isolated ACL reconstruction, but no difference between ACL + ALLR and ACL + LET. There were no significant differences in anterior tibial translation among the techniques, but the IKDC subjective and Lysholm scores of ACL + ALLR and ACL + LET were significantly higher than isolated ACL reconstruction. ACL + ALLR were the most preferred in terms of residual pivot shift, anterior tibial translation, and IKDC subjective scores (SUCRA = 88.2%, 86.4%, and 93.1%, respectively). Additional lateral procedures resulted in significantly lower risk of graft failure (OR: 0.27; 95% CI: 0.1-0.71) than isolated ACL reconstruction.

CONCLUSIONS

ACL + ALLR were found to have significantly better outcomes in terms of knee rotational stability and graft failure rate than isolated ACL reconstructions, but the clinical outcomes were uncertain after a minimum 12 months follow-up. Considering the greatest probability of obtaining better knee rotational stability in this NMA, ACL + ALLR was found to be the most preferred technique for patients with ACL injury.

LEVEL OF EVIDENCE

Level II, network meta-analysis and systematic review of Level I and II studies.

Effect of Lateral Extra-articular Tenodesis on the Rate of Revision Anterior Cruciate Ligament Reconstruction in Elite Athletes

BACKGROUND

There is growing evidence that anterolateral procedures can reduce the risk of rerupture in high-risk recreational athletes undergoing primary anterior cruciate ligament (ACL) reconstruction (ACLR). However, this effectiveness has never been evaluated in elite athletes.

PURPOSE

The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis (LET) in reducing revision rates in primary ACLR in elite athletes. Additionally, this study evaluated whether LET had a greater effect when combined with ACLR utilizing a hamstring or patellar tendon graft.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A consecutive cohort of elite athletes with an isolated ACL tear undergoing autograft patellar or hamstring tendon reconstruction with or without Lemaire LET were analyzed between 2005 and 2018. A minimum 2-year follow-up was required. The association between the use of LET and ACL graft failure as defined by revision ACLR was evaluated with univariate and multivariate logistic regression models.

RESULTS

A total of 455 elite athletes (83% men and overall age 22.5 ± 4.7 years) underwent primary ACLR with (n = 117) or without (n = 338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure, including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACLR reduced the risk of graft failure by 2.8 times, with 16.5 athletes needing LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (relative risk = 0.325; P = .029) as compared with ACLR alone after controlling for sex and age at ACLR. Including graft type in the model did not significantly change the risk profile, and although a patellar tendon graft had a slightly lower risk of failure, this was not statistically significant (P = .466).

CONCLUSION

The addition of LET reduced the risk of undergoing revision by 2.8 times in elite athletes undergoing primary ACLR. This risk reduction did not differ significantly between the patellar tendon and hamstring tendon autografts. With these results, status as an elite athlete should be included in the indications for a LET, as they are at increased risk for ACL graft failure.

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.

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.

Clinical and mechanical outcomes in isolated anterior cruciate ligament reconstruction vs additional lateral extra-articular tenodesis or anterolateral ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction has been a successful treatment for ACL rupture. However ongoing rotational instability can be an issue. Several surgical techniques have been recommended to overcome this including lateral extra-articular tenodesis (LET) and more recently anterolateral ligament reconstruction (ALLR).

AIM

To compare the clinical outcomes following ACL reconstruction (ACLR) alone or ACLR with either LET or ALLR.

METHODS

A systematic review was conducted by means of four databases (MEDLINE, EMBASE, Cochrane and Clinical.Trials.Gov), and the Reference Citaion Analysis (https://www.referencecitationanalysis.com/) to identify all studies investigating either or both of LET and ALLR. The Critical Appraisal Skills Programme checklist for cohort studies was employed for critical appraisal and evaluation of all twenty-four studies which met the inclusion criteria.

RESULTS

Pooled meta-analyses illustrated that ACLR with additional LET or ALLR results in improved pivot shift test scores, compared to isolated ACLR. There was no statistically significant difference in International Knee Documentation Committee (IKDC) clinical scores with addition of either LET or ALLR. ACL re-rupture rates were compared between LET and ALLR techniques. There was a statistically significant difference between techniques, with a 1.14% rupture rate in ACLR +ALLR, and 4.03% rupture rate in ACLR + LET. Isolated ACLR re-rupture rates were 12.59%, significantly higher than when augmented with either ALLR or LET (P < 0.0001 for both groups). There were no statistical differences in pivot shift test or IKDC scores between LET and ALLR techniques.

CONCLUSION

This meta-analysis has found that use of either LET or ALLR in addition to ACLR results in improved mechanical outcomes suggesting surgeons should consider augmenting ACLR with an extra-articular procedure in patients with rotatory instability. Furthermore, both anterolateral extra articular procedures in addition to ACLR lead to reduced ACL re-rupture rates compared to isolated ACLR. Moreover, ALLR results in reduced ACL re-rupture rates, compared to LET. More research is needed to compare the two respective extra-articular procedures.

Modified iliotibial band tenodesis versus lateral extracapsular tenodesis, to augment anterior cruciate ligament reconstruction: a 2-year randomized controlled trial

BACKGROUND

Residual instability following anterior cruciate ligament (ACL) reconstruction is associated with disruption of the anterolateral complex (ALC). Our goal was to conduct a randomized controlled trial comparing the effectiveness of modified Iliotibial tenodesis (MITBT) versus lateral extracapsular tenodesis (LET) to correct this residual instability.

METHODS

Group 1 underwent MITBT, Group 2 LET, added to the ACL reconstruction. Outcomes of interest were Tegner activity Scores (TAS), international knee documentation committee score (IKDC), knee osteoarthritis outcome score (KOOS), ACL related quality of life (ACL QoL), recurrent ACL rupture and meniscal tears. Follow-up was 2 years. Statistical analysis used chi-squared tests, frequency statistics and generalized linear models. We have followed the guidelines outlined in the CONSORT statement.

RESULTS

A total of 164 patients were randomized, 84 to Group 1, 80 to Group 2. Group 1 had higher TAS than Group 2, at 2 years (median 8, range 7-10 vs. median 7, range 5-9, P<0.001). Group 1 had higher ACL QoL scores at 1 and 2 years post-surgery (82.1, SD2.7 vs. 67.9, SD 4.0, P< 0.001 and 82.5, SD 2.6 vs. 68.8, SD 3.8, P<0.001, respectively), and higher KOOS Sport/recreation subscale at both 1 and 2 years (91.5, SD4.3 vs. 78.3, SD7.9, P<0.001 and 91.8, SD4.8 vs. 80.4, SD 9.5, P<0.001). Risk of recurrent ACL rupture (0% vs. 5%, P = 0.040-0.05) and medial meniscal tear (2.4% vs. 14%, P = 0.007-0.02) were lower in Group 1.

CONCLUSION

Augmentation of ACL reconstruction with the MITBT, rather than the LET, was associated with improved outcomes, and lower risks of recurrent ACL rupture and medial meniscal tears.

Anterior cruciate ligament reconstruction with lateral extra-articular tenodesis reduces knee rotation laxity and graft failure rate: A systematic review and meta-analysis

PURPOSE

To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) reduces rotational laxity of the knee, and to compare the clinical results of this treatment with those of ACLR alone.

METHODS

PubMed, Embase, and Cochrane Library were searched by two researchers for clinical studies comparing ACLR with and without LET. Studies with only evidence levels I and II and studies in which anterior lateral ligament reconstruction was performed with grafts were excluded. The risk of bias of the studies was assessed using the Cochrane risk-of-bias and modified Downs & Black tools. The outcomes included (1) functional outcomes; (2) knee laxity measures; (3) knee injury osteoarthritis and outcome score; and (4) complications. The outcomes of the two groups were extracted, summarized and compared.

RESULTS

A total of 234 studies were retrieved and 223 were excluded. Eleven clinical studies with 1745 patients were included in our meta-analysis. Compared to the patients who underwent ACLR alone, the patients who underwent ACLR with LET had reduced pivot-shift (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.31 to 0.74, p = 0.0009), and lower graft failure rate (OR 0.34, 95% CI 0.20 to 0.55, p < 0.0001).

CONCLUSION

Compared with ACLR only, ACLR combined with LET can effectively reduce rotation laxity of the knee joint, and reduce the graft failure rate in high-risk patients. However, the effects on the function and activity level of patients cannot be confirmed.

Anterior Cruciate Ligament Reconstruction Alone Versus With Lateral Extra-articular Tenodesis With Minimum 2-Year Follow-up: A Meta-analysis and Systematic Review of Randomized Controlled Trials

BACKGROUND

Lateral extra-articular tenodesis (LEAT) aims to improve anterolateral stability of the injured knee during anterior cruciate ligament reconstruction (ACLR) surgery. Inconclusive evidence surrounding the efficacy and safety of LEAT has propelled clinical interest and ongoing discussions.

PURPOSE

To establish level 1 evidence by assessing randomized controlled trials (RCTs) with minimum 2-year follow-up that directly compared ACLR with LEAT (LEAT group) and ACLR alone (non-LEAT group) in terms of clinical outcomes and complications.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 1.

METHODS

Meta-analysis was performed with a multidatabase search (Cochrane, EMBASE, OVID Medline, PubMed, and Web of Science) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on September 9, 2020. Data from published RCTs meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model.

RESULTS

A total of 7 RCTs were included, consisting of 517 LEAT and 589 non-LEAT patients. Only autografts were used for ACLR and LEAT. A variety of LEAT techniques and autograft fixation methods were used. We found improved stability (residual positive pivot shift: risk ratio [RR], 0.59; 95% CI, 0.39-0.88; P = .01) and better clinical outcomes (International Knee Documentation Committee [IKDC] score: mean difference [MD], 2.31; 95% CI, 0.54-4.09; P = .01; and Lysholm score: MD, 2.71; 95% CI, 0.68-4.75; P = .009) in the LEAT than non-LEAT group. Graft rerupture rate was 3 times less likely (RR, 0.31; 95% CI, 0.17-0.58; P < .001) in the LEAT group than the non-LEAT group.

CONCLUSION

Good-quality evidence is available to support the efficacy of LEAT in improving anterolateral knee stability and reducing graft reruptures in primary ACLR. LEAT should be considered in patients with high risk factors. Although Lysholm and IKDC scores were statistically better in the LEAT group, these are unlikely to be clinically significant. Future studies should aim to identify patient populations that would best benefit from LEAT with ACLR.

There are differences in knee stability based on lateral extra-articular augmentation technique alongside anterior cruciate ligament reconstruction

PURPOSE

The purpose of the current study is to systematically review and network meta-analyze the current evidence in the literature to ascertain if there is a superior lateral extra-articular augmentation technique in conjunction with anterior cruciate ligament (ACL) reconstruction (ACL.R) with respect to knee stability, re-rupture rates and functional outcomes.

METHODS

The literature search was performed based on the PRISMA guidelines. Cohort studies comparing ACL.R to ACL.R + lateral extra-articular augmentation were included. Lateral extra-articular techniques included were anterolateral ligament reconstruction (ALL.R), Cocker-Arnold, Lemaire, Losee, Maraccaci, and McIntosh. Clinical outcomes were compared between ACL.R alone and the different lateral extra-articular augmentation techniques using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-Score.

RESULTS

Twenty-eight studies with a total of 2990 patients were included. ACL.R + Cocker-Arnold technique had the highest P-Score for ACL re-ruptures and residual pivot-shift. ACL.R + Cocker-Arnold, Lemaire, and ALL.R all significantly reduced the rate of ACL re-rupture, and residual pivot-shift, compared to ACL.R alone. There was no significant difference between any of the lateral extra-articular augmentation techniques and ACL.R alone. ALL.R had the highest P-Score for return to play, and return to play at pre-injury level.

CONCLUSION

This study established that ACL.R + Cocker-Arnold, Lemaire and ALL.R resulted in significantly lower ipsilateral ACL re-ruptures, as well as reduced pivot-shift, compared to ACL.R alone. Whereas, the other lateral extra-articular augmentation techniques did not reduce pivot-shift and re-rupture. Additionally, functional outcomes and return to play were comparable between those who underwent ACL.R and lateral extra-articular augmentation and ACL.R alone.

LEVEL OF EVIDENCE

III.

A Systematic Review of Randomized Controlled Trials in Anterior Cruciate Ligament Reconstruction: Standard Techniques Are Comparable (299 Trials With 25,816 Patients)

Purpose

To provide an overview of all published randomized controlled trials (RCTs) in anterior cruciate ligament reconstruction (ACLR) summarizing the available evidence.

Methods

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane FIGCentral Register of Controlled Trials, Ovid MEDLINE, and Embase for RCTs of ACLR from their inception to August 26, 2020. Outcome measure was whether RCTs reported statistically significant findings. RCTs were then classified according to their intervention groups in a narrative synthesis of the evidence.

Results

In total, 299 RCTs met the inclusion criteria and were included with a total number of 25,186 patients. Only 30 RCTs (10%) reported significant differences between the intervention and the control groups. These included 101 RCTs on grafts, 20 RCTs on tunnel placements, 48 RCTs on graft fixation, 42 RCTs on single-bundle compared with double-bundle reconstructions, 11 RCTs on additional procedures, 11 RCTs on graft tensioning, 5 RCTs on timing of surgery, 25 RCTs on technical variations from standard techniques, 6 RCTs on ACL repair, 5 RCTs on navigation, 16 RCTs on perioperative management, and 9 RCTs on other aspects of ACLR. Only 14 RCTs (4.7%) reported outcomes beyond 10 years with greater allograft failures compared with autografts, high incidence of osteoarthritic changes in reconstructed knees (22%-100%), with no significant differences in outcomes between bioabsorbable or metal screws for graft fixation, patellar versus hamstrings or single- versus double-bundle reconstructions.

Conclusions

The evidence indicates that a standard arthroscopic single- or double-bundle ACLR with hamstrings/patella autografts, transportal technique, and fixation techniques familiar to the surgeon leads to comparable results. This evidence offers surgeons the flexibility to use standard and cost-effective techniques and achieve comparable outcomes.

Level of Evidence

Level II; systematic review of Level I-II randomized controlled trials.

Clinical outcomes of contemporary lateral augmentation techniques in primary ACL reconstruction: a systematic review and meta-analysis

PURPOSE

The purpose of this investigation was to systematically review the contemporary literature to determine if a lateral augmentation (LA) added to an Anterior Cruciate Ligament Reconstruction (ACLR) provides better clinical and patient reported outcomes compared to an isolated ACLR.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) criteria. Two authors independently conducted an electronic search using MEDLINE® and Embase® on February 6^th, 2021 for level I-III randomized controlled trials (RCT) and prospective cohort studies without randomization, published after 2012 and with a minimum of two year follow-up. Publications were included when they reported on the objective knee stability examination, patient reported outcome scores, return to sports or graft rupture rate of any type of primary, isolated ACLR compared to ACLR combined with any type of LA.

RESULTS

A total of 11 studies that reported on a combined total of 1892 unique patients were eligible for data extraction, including five RCTs and six prospective cohort studies. In 6 studies, an Anterolateral Ligament reconstruction (ALLR) was the LA of choice, while the 5 other publications used different types of Lateral Extra-articular Tenodesis (LET). A significant reduction in graft ruptures was found in patients treated with ACLR + LA (3%) compared to isolated ACLR (12%). Rotational laxity was significantly higher in isolated ACLR (14%) compared to ACLR + LA (6%). Addition of a LA reduced anterior translation when assessed via instrumented laxity testing. No significant difference was found in the patient reported outcome scores (IKDC and Tegner) between both patient groups, except for the Lysholm Score which was significant in favour of the ACLR + LA group.

CONCLUSION

Combination of a primary ACLR with a LA can significantly reduce the risk of graft rupture and provide better rotatory stability, without jeopardizing patient reported outcomes.

LEVEL OF EVIDENCE

Level III, Systematic Review of Level I, II and III studies.

Lateral Extra-articular Tenodesis Contributes Little to Change In Vivo Kinematics After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

BACKGROUND

Lateral extra-articular tenodesis (LET) in combination with anterior cruciate ligament (ACL) reconstruction (ACLR) has been proposed to improve residual rotatory knee instability in patients having ACL deficiency.

PURPOSE/HYPOTHESIS

The purpose was to compare the effects of isolated ACLR (iACLR) versus LET in combination with ACLR (ACLR+LET) on in vivo kinematics during downhill running. It was hypothesized that ACLR+LET would reduce the internal rotation of the reconstructed knee in comparison with iACLR.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 18 patients with ACL deficiency were included. All participants were randomly assigned to receive ACLR+ LET or iACLR during surgery. Six months and 12 months after surgery, knee joint motion during downhill running was measured using dynamic biplane radiography and a validated registration process that matched patient-specific 3-dimensional bone models to synchronized biplane radiographs. Anterior tibial translation (ATT; positive value means "anterior translation") and tibial rotation (TR) relative to the femur were calculated for both knees. The side-to-side differences (SSDs) in kinematics were also calculated (operated knee-contralateral healthy knee). The SSD value was compared between ACLR+LET and iACLR groups using a Mann-Whitney U test.

RESULTS

At 6 months after surgery, the SSD of ATT in patients who had undergone ACLR+LET (-1.9 ± 2.0 mm) was significantly greater than that in patients who had undergone iACLR (0.9 ± 2.3 mm) at 0% of the gait cycle (foot strike) (P = .031). There was no difference in ATT 12 months after surgery. Regarding TR, there were no differences between ACLR+LET and iACLR at either 6 months (P value range, .161-.605) or 12 months (P value range, .083-.279) after surgery.

CONCLUSION

LET in combination with ACLR significantly reduced ATT at the instant of foot strike during downhill running at 6 months after surgery. However, this effect was not significant at 12 months after surgery. The addition of LET to ACLR had no effect on TR at both 6 and 12 months after surgery.

CLINICAL RELEVANCE

LET in combination with ACLR may stabilize sagittal knee motion during downhill running in the early postoperation phase, but according to this study, it has no effect on 12-month in vivo kinematics.

REGISTRATION

NCT02913404 (ClinicalTrials.gov identifier).

Age, activity level and meniscus injury, but not tear location, tibial slope or anterolateral ligament injury predict coping with anterior cruciate ligament injury

INTRODUCTION

Early recognition of potential predictors on the success of conservative treatment of anterior cruciate ligament (ACL) is important, as appropriate treatment can be applied to each individual patient. The goal of this study is to assess the patient demographic and radiological parameters that predict coping with ACL injuries.

METHODS

All patients presenting with a complete ACL injury between 2014 and 2018 at our clinic were included. The role of patient demographics (age, gender, activity level, meniscus injury and time from injury to clinic), and ACL tear location, bone bruises, tibial slope, and anterolateral ligament (ALL) injury were assessed on the success of conservative treatment using univariate and multivariate analyses.

RESULTS

Sixty-five patients (32%) were copers and 141 (68%) were non-copers. Univariate analysis showed that copers were significantly older (40 vs. 27 years, P < 0.001), had lower preinjury activity level (Tegner 5.7 vs. 6.5, P < 0.001) and less often lateral meniscus tears (16% vs. 5%, P = 0.019) but not medial meniscus tears (17% vs. 14%, P = 0.609) than non-copers. Multivariate analysis revealed that increasing age (P < 0.001), Tegner level ≤ 6 (P = 0.003) and no meniscus injury (P = 0.045) were independent predictors of coping with ACL deficiency.

CONCLUSIONS

Older age, participation in lower activity sports levels and absence of meniscus injury were predictive of coping with ACL deficiency, whereas there was no such role for tear location, tibial slope, lateral bone bruise presence, ALL injury or gender. These findings might help to identify potential copers and guide surgeons early in the optimal treatment for patients with ACL injury.

A Retrospective Comparison of Single-Bundle Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Tenodesis With Double-Bundle Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare postoperative objective knee stability and clinical outcomes between double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) and single-bundle (SB) ACLR combined with lateral extra-articular tenodesis (LET).

METHODS

ACL-injured patients with grade 3 pivot-shift who underwent either DB ACLR (DB ACLR group) or SB ACLR with LET (SB ACLR+LET group) were enrolled. All patients who met inclusion and exclusion criteria were retrospectively evaluated for knee laxity (the anterior translation and pivot-shift grade), clinical outcomes using the International Knee Documentation Committee (IKDC) examination form, Kellgren-Lawrence grade, graft maturation score on second-look arthroscopy, and revision rates at the last follow-up.

RESULTS

From an initial cohort of 171 consecutive patients over a 3-year period, 95 (56%) met inclusion and exclusion criteria. The SB ACLR+LET group (n = 47) showed significantly better results in pivot-shift grade at the last follow-up as compared with the DB ACLR group (n = 48) (P = .021). In the SB ACLR+LET group, 93.6% (44/47) were grade 0, whereas 72.9% (35/48) in the DB ACLR group were grade 0. The SB ACLR+LET group (grade A: 42, grade B: 4 and grade C: 1) showed significantly superior results in IKDC objective grade compared with the DB ACLR group (grade A: 32; grade B: 8; and grade C: 8) (P = .017). However, no statistically significant difference could be shown in anterior translation, subjective functional IKDC score, or revision rate between the 2 groups. The mean follow-up duration was 49.7 ± 5.7 months.

CONCLUSIONS

SB ACLR + LET demonstrated fewer pivot-shifts (P = .021) and superior IKDC objective grades (P = .017) than a DB ACLR at a mean follow-up of almost 50 months.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Editorial Commentary: Anterolateral Reconstruction Versus Lateral Extra-Articular Tenodesis-Six of One and Half a Dozen of the Other?

Over the past several years, there has been a resurgence of interest in the anterolateral side of the anterior cruciate ligament-injured knee. The 2 most commonly techniques on the anterolateral side for surgically controlling residual rotational instability are anterolateral ligament reconstruction and modified Lemaire lateral extra-articular tenodesis. Several biomechanical studies have shown no or only subtle differences between the 2 procedures. It is time to advance from the biomechanical analyses and direct future work to clinical studies focusing on improving patient selection, surgical morbidity, and longer-term outcomes.