Anterior Cruciate Ligament Revision Plus Lateral Extra-Articular Procedure Results in Superior Stability and Lower Failure Rates Than Does Isolated Anterior Cruciate Ligament Revision but Shows No Difference in Patient-Reported Outcomes or Return to Sports

Editorial Commentary: Knee Lateral Extra-articular Tenodesis Procedures: Appropriate Study Design Is Essential for Reducing Conflicting Findings and Unnecessary Controversy in the Orthopaedic Literature

Knee lateral extra-articular tenodesis procedures (LEAPs) reduce graft rupture rates when performed at the time of anterior cruciate ligament (ACL) reconstruction. However, in the setting of revision ACL reconstruction, LEAPs are less studied and remain controversial. Many studies support combined procedures (ACL + LEAP), yet others do not. When the literature comprises small patient cohorts and short follow-up periods, conflicting results often arise. The controversy surrounding them may be unnecessarily generated by the publication of low-quality studies. Future studies should focus on adequate power; appropriate design and methodology, including matching or randomization to account for potential confounding factors; proper statistical analyses; and avoidance of spin bias.

Risk for Revision ACLR After Primary All-Inside Quadrupled Semitendinosus Hamstring Tendon Autograft ACLR With Independent Suture Tape Augmentation: A Retrospective Cohort Study

Background

The rate of failed anterior cruciate ligament reconstruction (ACLR) remains high in the younger and more active patient populations. Suture tape augmentation (STA) in addition to ACLR may reduce the risk for revision surgery.

Purpose/Hypothesis

The purpose of this study was to compare patient outcomes between patients who underwent primary all-inside quadrupled semitendinosus hamstring tendon autograft (QST-HTA) ACLR with and without STA. It was hypothesized that the STA cohort would demonstrate a lower incidence of subsequent revision ACLR while maintaining comparable patient-reported outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

All patients ≤40 years of age who received primary all-inside QST-HTA ACLR with and without independent STA augmentation were identified. The following validated patient-reported outcome measures (PROMs) were collected: visual analog scale for pain, Single Assessment Numeric Evaluation, Knee injury and Osteoarthritis Outcome Score subscales, and Tegner activity scale. KT-1000 arthrometer measurements were collected pre- and postoperatively. Cox proportional hazards model and nominal logistic regression analysis were used to assess additional variables associated with revision ACLR.

Results

A total of 104 patients with a mean age of <22 years were included in the final data analysis (STA: 36 patients; control: 68 patients). Significantly fewer patients in the STA group sustained a graft failure necessitating revision surgery at the final follow-up (5.6% vs 24%; relative risk, 0.24 [95% CI, 0.06-0.97]; P = .017). Four-year graft survival was significantly higher in the STA group (97.2% vs 82.4%; P = .031). All PROMs significantly improved postoperatively except for Tegner levels, which decreased in both groups compared with their preinjury levels (P < .001). Return to sports was similar in both groups with >70% of patients returning to their previous level of competition. Regression analysis demonstrated increased risk for revision ACLR in younger patients, high school athletes, and those with higher postoperative activity levels.

Conclusion

QST-HTA ACLR with STA was associated with reduced risk for revision ACLR compared with nonaugmented QST-HTA ACLR in this young patient population. Furthermore, the addition of suture tape did not appear to affect postoperative patient-reported and return-to-sports outcomes.

Less Subsequent Revision Anterior Cruciate Ligament Reconstruction Following Primary Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation-A Retrospective Comparative Therapeutic Trial With 5-Year Follow-Up

PURPOSE

To investigate patient outcomes, including revision rate, following primary bone patellar-tendon bone autograft (BPTB) anterior cruciate ligament reconstruction (ACLR) with and without suture tape augmentation (STA) in a young and active cohort.

METHODS

All eligible patients who received primary BPTB ACLR with a minimum of 2-year follow-up were included in this retrospective cohort study. All patients receiving STA were augmented with the same device. Patients completed the following patient-reported outcome measures (PROMs): the visual analog scale, the Single Assessment Numeric Evaluation, the Knee Injury and Osteoarthritis Outcome Score subscales, and the Tegner activity scale. Anteroposterior knee laxity was assessed using a KT-1000 arthrometer preoperatively and 1-year postoperatively. Posterior tibial slope, femoral tunnel angle, and tibial tunnel placement were calculated for all patients. Subsequent surgical interventions and return to sport (RTS) were obtained from each patient.

RESULTS

One hundred fourteen patients (52 BPTB ACLR with STA, 62 traditional BPTB ACLR) with a mean patient age <19 years and a mean final follow-up of ≥5 years were included. Compared with the control group, the STA group demonstrated significantly less subsequent revision ACLR (0 vs. 5, P = .036). All PROMs and KT-1000 measurements improved at final follow-up (P < .001) and were comparable between groups. There were no differences seen in either posterior tibial slope or graft tunnel placement between groups. More than 85% of the patients were able to return to the sport that led to their injury at full capacity with no differences seen in RTS rate, time to RTS, or level of competition between groups.

CONCLUSIONS

Compared with traditional BPTB ACLR, additional STA appeared to safely and effectively lead to less subsequent revision ACLR while maintaining acceptable PROMs and objective joint laxity measurements in a young and active patient population.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Editorial Commentary: Anterior Cruciate Ligament Repair or Reconstruction With Internal Bracing, for Properly Indicated Patients, Is Safe, Biocompatible, and Biomimetic

Anterior cruciate ligament (ACL) reconstruction with internal bracing (IB)-and ACL repair with IB when indicated-reduces graft or repair failure. IB is safe and protects ligament reconstructions and repairs. The IB construct should not be misunderstood as a synthetic ligament. To be effective, suture tape must be independently secured with the knee in full extension, reflecting the terminal length of the ACL. Regardless of graft type, the graft must be cyclically tensioned independent of the IB to allow for creep, and when properly performed, this significantly increases the ultimate tensile strength of the construct and reduces graft elongation, without stress shielding. Thus, the generic term "suture augmentation" may be misleading because the successful results reported apply to the IB technique. In our experience, the failure rate after ACL reconstruction with IB is 1% at the 5-year follow-up period. Notably, these results were achieved without an additional lateral extra-articular procedure.

Lateral Extra-Articular Tenodesis and Anterolateral Procedures

The treatment of rotational instability has been an intriguing challenge since the era of modern anterior cruciate ligament (ACL) surgery. Lateral extra-articular procedures (LEAPs) have emerged as a solution to this problem, particularly in high-risk populations. Several studies have shown significant benefits of combining LEAPs with ACL reconstruction, including reduced graft failure rates, improved knee stability, improved rotational stability, and higher return-to-play rates. These findings have led to an in-depth evaluation of LEAPs as lateral extra-articular tenodesis and anterolateral ligament reconstruction and their potential role in improving outcomes after ACL reconstruction.

Revision Anterior Cruciate Ligament Reconstruction and Associated Procedures

Failure of anterior cruciate ligament reconstruction (ACLR) is a common yet devastating complication due to inferior clinical outcomes associated with revision ACLR. Identifying the cause and associated risk factors for failure is the most important consideration during preoperative planning. Special attention to tunnel quality, concomitant injuries, and modifiable risk factors will help determine the optimal approach and staging for revision ACLR. Additional procedures including lateral extra-articular tenodesis and osteotomy may be considered for at-risk populations. The purpose of this review is to explore causes of ACLR failure, clinical indications and appropriate patient evaluation, and technical considerations when performing revision ACLR.

Evaluation of Anterior Tibial Translation Under Physiological Axial Load After ACL Reconstruction With Lateral Extra-articular Tenodesis

Background

Postoperative laxity correlates with negative clinical outcomes after anterior cruciate ligament reconstruction (ACLR). The influence of lateral extra-articular tenodesis (LET) on anteroposterior translation is unclear.

Purpose/Hypothesis

This study aimed to evaluate the reduction in radiographic static anterior tibial translation (SATT) and dynamic anterior tibial translation (DATT) after LET as an adjunctive procedure to ACLR. It was hypothesized that adding a LET procedure would have no effect on postoperative SATT and DATT.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent primary ACLR with hamstring tendon autografts between 2020 and 2022 were reviewed, and those who underwent ACLR and LET as an anterolateral associate procedure were paired 1 to 1 with those who underwent isolated ACLR (control) based on age, sex, preoperative SATT, and posterior tibial slope (PTS). The indications for LET were age <18 years and anterolateral rotary instability (grade ≥2 pivot shift). A previously validated technique was used to measure SATT, DATT, and PTS on lateral weightbearing and lateral stress knee radiographs. Preoperative and 9-month postoperative radiographs were compared between the 2 groups.

Results

A total of 72 patients were included in the analysis (n = 36 patients in each group). The inter- and intraobserver reliability of the SATT, DATT, and PTS measurements was excellent (intraclass correlation coefficients, 0.88-0.99). The mean pre- and postoperative SATT in the ACLR+LET group was 2.44 ± 2.90 mm and 2.44 ± 2.38 mm, respectively, compared with 2.60 ± 2.99 mm and 2.12 ± 2.74 mm, respectively, in the control group. The mean pre- and postoperative reduction in side-to-side DATT in the ACLR+LET group was 5.44 ± 4.65 mm and 1.13 ± 2.95 mm, respectively, compared with 5.03 ± 3.66 mm and 2 ± 3.12 mm, respectively, in the control group. There was no pre- to postoperative difference in SATT (P = .51). However, the side-to-side DATT was reduced by 3.66 ± 3.37 mm postoperatively (P < .001), without significant differences between groups (P = .24).

Conclusion

Including a LET procedure for patients undergoing ACLR did not reduce SATT; that is, it did not decrease the amount of tibial translation due to physiological axial load.

Clinical Outcomes of Different Management Techniques for Medial Meniscal Type 3 Ramp Lesions in Anterior Cruciate Ligament Reconstruction: A Comparative Analysis Between All-inside Repair, Suture Hook Repair, and Lesions Left In Situ

BACKGROUND

There is ongoing debate about the best way to manage ramp lesions at the time of anterior cruciate ligament (ACL) reconstruction (ACLR). Type 3 lesions are not visible by the transnotch approach without superior debridement, making the management debate even more problematic.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the rate of secondary surgical interventions according to the management method of a type 3 ramp lesion concomitant with primary ACLR. The hypothesis was that the rate of secondary ACL or meniscal interventions would be higher in patients who underwent all-inside repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis of all patients who underwent primary ACLR with a type 3 ramp lesion between January 2012 and May 2020, regardless of the treatment method, was performed. The main criterion analyzed in this cohort was a secondary surgical intervention, defined as revision ACLR or a reintervention of the repaired meniscus. A survivorship analysis was performed to evaluate secondary surgical interventions in 3 groups: all-inside repair, suture hook repair, and left in situ. The following data were collected preoperatively and at the last follow-up: patient characteristics, time to surgery, side-to-side difference in laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner score, and meniscal repair failure rate.

RESULTS

A total of 113 patients who underwent type 3 ramp lesion repair concomitant with ACLR were included: 52 (46.0%) in the all-inside repair group, 23 (20.4%) in the suture hook repair group, and 38 (33.6%) in the lesion left in situ group. There were 17 patients (15.0%) who underwent a secondary intervention because of ACL graft failure (n = 6) or meniscal repair failure (n = 15 [4 of whom underwent a concomitant ACL reintervention]). Overall, 62 patients (54.9%) underwent combined ACLR and anterolateral ligament reconstruction, while 51 patients (45.1%) underwent isolated ACLR. In the adjusted Cox model, the type of meniscal repair was not statistically significantly associated with secondary surgical interventions. The only risk factor for secondary surgical interventions in this cohort was isolated ACLR (hazard ratio, 8.077; P = .007).

CONCLUSION

The rates of secondary surgical interventions after medial meniscal type 3 ramp lesion repair concomitant with ACLR were similar regardless of the management method of the meniscal lesion. Despite not being associated with meniscal treatment, this rate was 8 times higher for patients who underwent isolated ACLR in this cohort; this is probably because of the protection that lateral extra-articular procedures provide to the ACL graft.

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.

Single Bundle Anterior Cruciate Ligament With Anterolateral Ligament Reconstruction Yields Similar Clinical and Radiographic Results at Minimum 2-Year Follow-Up Versus Double Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Controlled Trial

PURPOSE

To compare the clinical, radiographic, and second-look arthroscopic outcomes between double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (DB group) and combined single-bundle (SB) ACL and anterolateral ligament (ALL) reconstruction (SB + ALL group) by a prospective randomized controlled trial.

METHODS

From May 2019 to June 2020, 84 patients were enrolled in this study. Among them, 10 were lost to follow-up. Thirty-six and 38 patients were successfully allocated to the DB (mean follow up 27.3 ± 4.2 months) and SB + ALL groups (27.2 ± 4.5 months), respectively. The preoperative and postoperative Lachman test, pivot shift test, anterior translation on stress radiographs, KT-2000 arthrometer, Lysholm score, International Knee Documentation Committee score, and Tegner activity score were evaluated and compared. Graft continuity was evaluated using postoperative magnetic resonance imaging (MRI) (32 and 36 patients underwent MRI in the DB and SB + ALL groups at 7.4 ± 3.2 and 7.5 ± 2.9 months after surgery, respectively), and second-look examinations (second-look examination and tibial screw removal were performed concomitantly when patients (1) had tibial screw-related irritation or (2) needed the screws removed, 28 and 23 patients underwent examinations in the DB and SB + ALL groups at 24.0 ± 6.8 and 24.9 ± 8.1 months after surgery, respectively). All measurements were compared between the groups.

RESULTS

Postoperative clinical outcomes significantly improved in both groups. (All variables showed P < .001) No statistically different outcomes were found between the 2 groups. Additionally, postoperative graft continuity on MRI and second-look examinations were not different between the 2 groups.

CONCLUSIONS

The DB and SB + ALL groups showed similar postoperative clinical, radiographic, and second-look arthroscopic outcomes. Both groups showed excellent postoperative stability and clinical outcomes compared with the preoperative measurements.

LEVEL OF EVIDENCE

Level II, randomized controlled trial.