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

Addition of anterolateral ligament reconstruction to primary anterior cruciate ligament reconstruction could benefit recovery of functional outcomes

This study aimed to compare functional outcomes sequentially up to 1 year after combined anterior cruciate ligament reconstruction (ACLR) and anterolateral ligament reconstruction (ALLR) and isolated ACLR. Fifty patients who underwent ACLR with versus without ALLR were analyzed at four different time points (preoperatively and 3, 6, and 12 months postoperatively). For the functional outcomes, muscle strength and acceleration time (AT) were measured using an isokinetic dynamometer. Proprioception was evaluated using joint position sense and dynamic postural stability. Patient-reported outcomes were measured using the Tampa Scale for Kinesiophobia (TSK-11) scores. Functional performance was assessed using single-leg hop distance (SLHD) and Limb Symmetry Index. In the operated knees, quadriceps (at 6 months postoperatively, p = 0.003) and hamstring (at 6 and 12 months postoperatively, p < 0.001) strength were significantly higher in the combined ACLR and ALLR group than the isolated ACLR group. The TSK-11 (at 6 and 12 months postoperatively, p < 0.001) was significantly lower in the combined ACLR and ALLR group than the isolated ACLR group. SLHD was significantly higher in the combined ACLR and ALLR group than the isolated ACLR group (at 6 months, p = 0.022 and at 12 months, p = 0.024). The addition of ALLR to primary ACLR yielded better muscle performance, fear of movement, and functional performance than isolated ACLR.

Instrument-based anterolateral rotatory laxity assessment of the knee has a high intra-observer and inter-observer reliability: a systematic review

IMPORTANCE

A reliable evaluation of anterolateral rotatory instability in the anterior cruciate ligament (ACL) deficient knee is important to help surgeons determine which patients might need concurrent anterolateral augmentation procedures.

OBJECTIVE

The purpose of this study was to systematically review studies that assess the intra-observer and inter-observer reliability of instruments used to measure anterolateral rotatory laxity of the knee.

EVIDENCE REVIEW

A comprehensive literature review was conducted according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, using PubMed, Embase, Scopus, and Google Scholar databases for original, English-language studies evaluating the reliability of objective or instrument-based anterolateral rotatory laxity of the knee until October 31, 2022. Reliability data were extracted from text, tables, and figures.

FINDINGS

Twelve studies, with patients between the ages of 14-63 years, were included. The instruments used to measure anterolateral rotatory knee laxity included inertial sensors (n ​= ​9), magnetic resonance imaging (n ​= ​1), and navigation systems (n ​= ​2). The global intra-observer intraclass correlation coefficient for these devices was between 0.63 and 0.97, and the global inter-observer reliability was between 0.63 and 0.99.

CONCLUSION AND RELEVANCE

Instrument-based anterolateral rotatory knee laxity assessment has moderate to good intra- and inter-observer reliability. Evaluating anterolateral instability in ACL-deficient knees with these devices could help in decision-making when considering anterolateral augmentation.

LEVEL OF EVIDENCE

IV.

Impacts of Segond Fractures on Anterior Cruciate Ligament Reconstruction Outcomes

INTRODUCTION

Segond fractures, characterized by avulsion injuries at the lateral tibial condyle's anterolateral structure (ALS) attachment, often coincide with anterior cruciate ligament (ACL) injuries, potentially leading to knee instability. However, the influence of Segond fractures on knee stability after ACL reconstruction remains uncertain. Despite documented ALS reconstructions, there is a lack of consensus regarding the assessment of ALS failure and the criteria for surgical interventions. This study aimed to determine if Segond fracture presence impacts ACL reconstruction outcomes, utilizing patient-reported subjective assessments and healthcare providers' objective evaluations.

MATERIALS AND METHODS

This retrospective study encompassed 639 patients (328 males, 311 females; mean age 26.9 years) who underwent ACL reconstruction, with a follow-up of at least one year. Subjects were divided into two groups: Segond fractures diagnosed through radiographic findings (Group S+, n = 17) and no Segond fractures (Group S-, n = 622). Clinical evaluation included the 36-item Short Form Survey (SF-36), Lysholm score, visual analog scale (VAS) for knee pain, knee injury and osteoarthritis outcome score (KOOS), and knee instability assessment via Telos SE (Telos Japan, Tokyo, Japan). Statistical comparisons were performed between the two groups.

RESULTS

At the final follow-up, all SF-36 subscales improved in all eight subscales compared to before surgery, reaching national standard scores; no significant inter-group differences were evident. Lysholm scores were 93.0 ± 12.1 (Group S+) and 91.7 ± 10.9 (Group S-) (P = 0.62), VAS for knee pain was 10.0 ± 18.0 (Group S+) and 11.9 ± 16.9 (Group S-) (P = 0.62), total KOOS was 89.0 ± 17.4 (Group S+) and 90.7 ± 9.9 (Group S-) (P = 0.39), and anterior tibial translation differences were 2.8 ± 3.0 mm (Group S+) and 2.7 ± 2.9 mm (Group S-) (P = 0.73). All these values represent postoperative measurements. No significant discrepancies existed between groups across evaluation methods.

CONCLUSIONS

This study's results suggest that Segond fractures have minimal impact on clinical ACL reconstruction outcomes, as assessed through both patient-reported subjective evaluations and objective healthcare provider evaluations. Segond fractures' significance in postoperative outcomes questions the necessity of ALS reconstruction.

Lateral meniscal injury without medial meniscal injury indicates the existence of the Segond fracture in ACL-deficient knees

Background/Objective

The purpose of this study was to find factors indicating the occurrence of the Segond fracture, a specific type of anterolateral ligament injury.

Methods

From January 2015 to December 2017, we retrospectively reviewed the medical records of patients diagnosed with acute anterior cruciate ligament (ACL) injury who underwent reconstruction within 90 days of injury. Diagnosis of the Segond fracture was determined either by magnetic resonance imaging or plain radiographs. Factors examined were: age at surgery, sex, body mass index (kg/m2), status of menisci, and activities led to ACL injury. After univariate screening, multivariate logistic regression analyses were performed. Patients were divided into four groups based on the presence of lateral meniscal (LM) and/or medial meniscal (MM) injuries and compared with respect to the occurrence of Segond fractures.

Results

A total of 375 patients were included (163 males, 212 females), with mean age 25.8 years old. Among them, 22 of 375 (5.9 %) had a Segond fracture. We identified injured lateral menisci (adjusted odds ratio (aOR), 3.029; 95 % Confidence Interval (CI), 1.206-7.609; P = 0.018), intact medial menisci (aOR, 0.229; 95 % CI, 0.065-0.810; P = 0.022), and higher body mass index (aOR, 1.102; 95 % CI, 1.008-1.205; P = 0.034) as factors indicative of the occurrence of Segond fracture. LM injury without MM injury suggested the existence of a Segond fracture.

Conclusion

LM injury without a MM injury indicated the occurrence of a Segond fracture. Higher body mass index also increased the risk for Segond fracture occurrence.

Is antero-lateral complex of knee joint of critical importance in restoring rotational instability in patients with anterior cruciate ligament tear?

Antero-lateral ligament complex (ALC) is a vital structure for maintaining rotational stability of the knee. Evaluation of ALC radiologically (MRI) is still unpopular in setting of anterior cruciate ligament injury. A dire necessity exists for the orthopedic surgeons in outdoor patient department settings to rule out involvement of ALC. So, that it can be addressed during operating for Anterior Cruciate Ligament injury. The authors have formulated an algorithm on a personal level and have implemented this screening program and initiated screening of young to middle aged patients reporting with rotational knee instability for ALC involvement before recommending final operative plan. This screening program which uses specifically devised physical tests have significantly reduced the number of underdiagnosed Antero Lateral Ligament tear.

Reconstruction of the anterior cruciate ligament: a historical view

Management of anterior cruciate ligament (ACL) tears has continuously evolved since its first description in approximately 170 A.D. by Claudius Galenus of Pergamum and Rome. The initial immobilization using casts was replaced by a variety of surgical and conservative approaches over the past centuries. The first successful case of ACL repair was conducted by Mayo Robson in 1885, suturing cruciate at the femoral site. In the nineteenth century, surgical techniques were focused on restoring knee kinematics and published the first ACL repair. The use of grafts for ACL reconstruction was introduced in 1917 but gained popularity in the late 1900s. The introduction of arthroscopy in the 1980s represented the greatest milestones in the development of ACL surgery, along with the refinements of indications, development of modern strategies, and improvement in rehabilitation methods. Despite the rapid development and multitude of new treatment approaches for ACL injuries in the last 20 years, autografting has remained the treatment of choice. Compared to the initial methods, arthroscopic procedures are mainly performed, and more resistant and safer fixation devices are available. This results in significantly less trauma from the surgery and more satisfactory long-term results. The most commonly used procedures are still patellar tendon or hamstring autograft. Additionally, popular, but less common, is the use of quadriceps tendon (QT) grafts and allografts. In parallel with surgical developments, biological reconstruction focusing on the preservation of ACL remnants through the use of cell culture techniques, partial reconstruction, tissue engineering, and gene therapy has gained popularity. In 2013, Claes reported the discovery of a new ligament [anterolateral ligament (ALL)] in the knee that could completely change the treatment of knee injuries. The intent of these modifications is to significantly improve the primary restriction of rotational laxity of the knee after ACL injury. Kinematic studies have demonstrated that anatomic ACL reconstruction and anterolateral reconstruction are synergistic in controlling pivot displacement. Recently, there has been an increased focus on the application of artificial intelligence and machine learning to improve predictive capability within numerous sectors of medicine, including orthopedic surgery.