Isometric Anterolateral Ligament Reconstruction Using the Semitendinosus Tendon With Suspensory Tibial Fixation

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Decreases Passive Anterior Tibial Subluxation Compared With Isolated Anterior Cruciate Ligament Reconstruction Despite Similar Rotational Stability and Clinical Outcomes

PURPOSE

To analyze the effect of augmenting a hamstring autograft anterior cruciate ligament reconstruction (ACLR) with an anterolateral ligament reconstruction (ALLR) on a primary outcome of passive anterior tibial subluxation (PATS) and a secondary outcome of the clinical outcomes.

METHODS

ACL-injured patients who underwent primary ACLR between March 2014 and February 2020 at our center were enrolled. Patients who underwent combined procedures (ACLR + ALLR) were matched in a 1:1 propensity ratio to patients who underwent ACLR only. We evaluated PATS, knee stability (side-to-side laxity difference, pivot-shift test), and patient-reported outcome measures (PROMs) after the procedure and documented complications.

RESULTS

From an initial cohort of 252 patients with a minimum follow-up period of 2 years (48.4 ± 16.6 months), 35 matched pairs were included, and 17 patients (48.6%) in each group underwent second-look arthroscopy. The combined ACLR + ALLR group showed significantly better improvement of PATS in the lateral compartments than the isolated ACLR group (P = .034). There were no significant differences between the groups regarding knee stability (side-to-side laxity difference, pivot-shift test), PROMs, complications, and second-look arthroscopic findings (all P > .05). Moreover, the proportions of patients who achieved the minimal clinically important difference in PROMs were not different between groups.

CONCLUSIONS

The combined ACLR + ALLR procedure was associated with a mean improvement in anterior tibial subluxation for the lateral compartment that was 1.2 mm better than an isolated ACLR procedure, despite its lack of clinical significance.

LEVEL OF EVIDENCE

Level III, cohort study.

Comparison Between Continuous and Separate Grafts for ALL Reconstruction When Combined With ACL Reconstruction: A Retrospective Cohort Study From the SANTI Study Group

BACKGROUND

While various techniques have been described to augment the anterolateral side of the knee, such as lateral extra-articular tenodesis and anterolateral ligament (ALL) reconstruction (ALLR), it is unclear how they affect clinical outcomes. The aim of this study was to compare the results of 2 ALLR techniques for combined anterior cruciate ligament (ACL)/ALL reconstruction.

HYPOTHESIS

The graft rupture rate, complications, and patient-reported outcomes are similar between a reconstruction technique using a continuous gracilis graft (CG) and single femoral tunnel for ACL/ALL reconstruction, and one using a separate gracilis graft (SG) and independent femoral tunnels.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis of data collected prospectively at 2 hospitals was conducted: one in which a CG is preferred when performing combined ACL/ALL reconstruction and the other in which an SG is preferred. The medical records at these 2 hospitals were searched to identify ACL-deficient patients who had undergone ACL/ALL reconstruction between 2015 and 2020. Eligible patients were between 18 and 60 years of age, had the reconstruction surgery done within 24 months of the injury, and had ≥2 years of follow-up. The eligible patients were contacted to gather outcomes, or their outcomes were collected in person during their last follow-up visit. Outcomes evaluated included graft rupture rate, complication rate, and Lysholm and International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) scores. Preoperative and intraoperative data were also evaluated.

RESULTS

A total of 237 patients were available for analysis in the GC group and 178 in the SG group with a mean follow-up of 3 years (CG: SD, 9.6 months; SG: SD, 8.1 months). The authors found a low rate of graft rupture (CG: 3.4%; SG: 2.8%; P = .785) and no difference between techniques. The complication rate was 6% in the CG group, while it was 10% in the SG group (P = .112). The mean value of the IKDC-SKF was similar between techniques (CG: 88.1; SG: 87.9; P = .267), and the mean Lysholm score was excellent in both sets of patients (CG: 90.0; SG: 92.4; P < .001).

CONCLUSION

This study found little to no difference in the graft rupture rate, complication rate, and functional knee scores when using a CG or SG for ALLR during combined ACL/ALL reconstruction. Both techniques are equivalent and can be used for an anterolateral augmentation procedure in combination with ACL reconstruction.

Graft choices for anterolateral ligament knee reconstruction surgery: Current concepts

The anterolateral ligament (ALL) is a primary structure of the anterolateral complex of the knee that contributes to internal rotational stability of the joint. Injury of the ALL is commonly associated with rupture of the anterior cruciate ligament. If left untreated, ALL lesions may lead to residual anterolateral rotational instability of the knee after anterior cruciate ligament reconstruction, which is a common cause of anterior cruciate ligament graft failure. The function of the ALL can be restored by lateral extraarticular tenodesis or anterolateral ligament reconstruction (ALLR). In the lateral extraarticular tenodesis procedure, a strip of the iliotibial band is placed in a non-anatomical position to restrain the internal rotation of the tibia, while in ALLR, a free graft is fixed at the insertion points of the native ALL. Gracilis and semitendinosus grafts have mainly been utilized for ALLR, but other autografts have also been suggested. Furthermore, allografts and synthetic grafts have been applied to minimize donor-site morbidity and maximize the size and strength of the graft. Nevertheless, there has been no strong evidence to fully support one method over another thus far. The present review presents a detailed description of the graft choices for ALLR and the current literature available in regard to the effectiveness and outcomes of published surgical techniques.