Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Results in Superior Rotational Stability Compared with Isolated Anterior Cruciate Ligament Reconstruction in High Grade Pivoting Sport Patients: A Prospective Randomized Clinical Trial

Lateral extra-articular procedures combined with ACL reconstructions lead to a higher return to pre-injury level of sport: A systematic review and meta-analysis

Purpose

To compare postoperative activity levels between patients who received an anterior cruciate ligament reconstruction (ACLR) with- and without a lateral extra-articular procedure (LEAP).

Objectives

The primary objective is to examine whether patients treated with an ALCR and LEAP have a greater chance to return to sport (RTS) and return to their pre-injury level of sport (RTPS). The re-rupture rates between the two groups will also be analysed as this is of great influence on the RTS and RTPS.

Methods

A thorough search according to PRISMA guidelines was conducted through the PubMed and Embase databases in May 2024. Randomised controlled trials (RCT) and retrospective cohort studies on patients who underwent primary ACLR with- or without a LEAP were included. Postoperative Tegner score, RTS, RTPS and re-rupture rate were evaluated. All articles were revised according to Cochrane risk of bias tools (RoB 2.0 and ROBINS-I).

Results

Twenty-four studies were included after examining 966 titles, abstracts and manuscripts. A total of 33,527 patients were included in this review with a weighted mean age of 24.9 years. Pooled data demonstrates that the ACLR + LEAP group shows significantly higher postoperative Tegner scores (MD, 0.43 [95% confidence interval, 0.21-0.65]; p < 0.01). 62% of patients who underwent ACLR + LEA returned to their pre-injury level of sport compared to 40% in ACLR group (reported in nine studies).

Conclusion

This meta-analysis demonstrates that patients undergoing a LEAP procedure in addition to ACLR return to higher postoperative activity levels and are more likely to return to their pre-injury level of sport. These results -in addition to further research- may help dictate when to add a LEAP, and whether LEAP in addition to ACLR should become the golden standard.

Level of Evidence

Level III, retrospective cohort studies have been analysed, alongside RCT's, and thus this is the level of evidence.

Outcomes of combined single-bundle anterior cruciate ligament reconstruction and anterolateral structure reconstruction through a modified single femoral tunnel

PURPOSE

To explore the clinical outcomes of combining anterior cruciate ligament (ACL) reconstruction and anterolateral structure (ALS) reconstruction through a modified single femoral tunnel in patients with high risk of clinical failure.

METHODS

From December 2018 to August 2022, a total of 62 patients with ACL injury in our institution were enrolled in this study. All patients were associated with high risk of clinical failure, meeting the indications of ALS reconstruction. All patients accepted arthroscopic single-bundle ACL reconstruction and ALS reconstruction using hamstring autograft through a modified single femoral tunnel. Perioperative clinical outcome measurements consisted of functions, stability and safety evaluation at different time points (preoperative, postoperative three month, six month, one year, two year, three year and more). Functional evaluation included Lysholm score, Tegner activity scale, subjective and objective International Knee Documentation Committee (IKDC) score.

RESULTS

All patients, including 47 males and 15 females, aged 16-52 years with an average age of 29.3 ± 9.2 years, were followed up for 12-58 months. At the last follow-up, the Lysholm, subjective IKDC and Tegner activity scale (93.8 ± 7.0, 88.8 ± 10.7 and 5.8 ± 1.4 respectively) were significantly higher than those before surgery (65.0 ± 20.8, 51.2 ± 21.1 and 2.3 ± 1.3 respectively)(P < 0.05). Postoperative pivot shift and Lachman test were markedly improved (P < 0.05). One patient still had grade II pivot shift, defined as clinical failure. During follow-up, no graft rupture occurred according to magnetic resonance imaging and physical examination, no lateral compartment osteoarthritis were found in all patients.

CONCLUSIONS

Combined single bundle ACL reconstruction and ALS reconstruction through a modified single femoral tunnel could significantly improve knee function and stability with low related risk in patients with high risk of failure in ACL injury.

Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Shows Superior Graft Remodeling, Maturation, and Stability Compared With Isolated Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare graft remodeling, as measured by magnetic resonance imaging (MRI), and clinical outcomes between patients who underwent isolated anterior cruciate ligament reconstruction (ACLR) versus combined anterior cruciate ligament and anterolateral ligament reconstruction (ACLR + ALLR).

METHODS

A retrospective review was conducted on patients who underwent primary ACLR with quadruple hamstring grafts between January 2019 and March 2022, with a minimum follow-up period of 2 years. Patients were categorized into two groups based on the addition of ALLR with tibialis anterior allografts: an isolated ACLR group and an ACLR + ALLR group. Graft ligamentization was assessed using signal-to-noise quotient (SNQ) values obtained from postoperative MRI scans, with lower SNQ values indicating superior graft remodeling. Clinical outcomes were evaluated through knee stability tests (pivot-shift test, side-to-side laxity), functional outcomes, and graft retear rates. The minimal clinically important difference (MCID) for the clinical scores was calculated using the distribution-based method of a half standard deviation of the delta (difference between postoperative and baseline values). Regression analyses identified potential predictive factors for inferior ACL graft remodeling.

RESULTS

A total of 122 patients in the isolated ACLR group and 54 in the ACLR + ALLR group were evaluated. The mean follow-up periods were similar between the groups (34.1 ± 7.4 months vs 36.4 ± 9.0 months; P = .755). The mean SNQ values were significantly lower in the ACLR + ALLR group compared to the isolated ACLR group (2.8 ± 1.6 vs 4.7 ± 3.5 mm, respectively; P = .001). Inferior ACL graft maturity was associated with an increased posterior tibial slope (P = .016), narrow notch width (P =.018), and concomitant medial meniscal lesion (P = .017). At the final evaluation, the ACLR + ALLR group demonstrated better rotational stability as indicated by the residual pivot-shift test (P = .005). No statistically significant differences were observed between the two groups in side-to-side laxity, functional outcomes, or graft retear rates. There were no differences in the percentage of patients achieving MCID for the International Knee Documentation Committee subjective score between the groups (P = .536).

CONCLUSIONS

Combined ACLR and ALLR resulted in superior graft remodeling, demonstrated by a mean SNQ value that was 1.9 lower than in isolated ACLR, along with improved rotational stability.

LEVEL OF EVIDENCE

Level III, retrospective, nonrandomized, comparative therapeutic study.

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.

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.

Trends of Publications on Single- and Double-Bundle ACL Reconstructions over the Last 20 Years: A Bibliometric Analysis of the PubMed Literature

Purpose

To improve the clinical outcomes of anterior cruciate ligament reconstruction (ACLR), there have been attempts to reproduce anatomic reconstruction by modifying the single-bundle (SB) and double-bundle (DB) techniques. Although DB ACLR restores better rotational control compared to SB ACLR, it is still debatable whether there are higher clinical outcomes in favor of DB ACLR. We aimed to study the trends of publications on SB and DB ACLR techniques over the last 20 years.

Methods

For this bibliometric study, we performed a PubMed search on 31/05/2022 with a well-defined search strategy. The articles were downloaded into Excel software, and citations were determined from the iCite website for PubMed. The analysis was performed using SPSS software version 28.0.1. Data mining was performed using Orange software, Mac version 3.32.0, from the titles of all articles and each group of SB and DB ACLR. The output is presented as word clouds.

Results

A total of 10,530 publications were identified, of which 9699 publications (92.1%) pertained to SB-ACLR and 831 publications (7.9%) to DB-ACLR. There was a steady increase in the publications on SB-ACLR until 2012, followed by a steep increase that peaked in 2021. The highest number of publications on DB-ACLR was in 2012 (n = 76; 9.1%). The mean citations per year for SB-ACLR and DB-ACLR were 2.87 ± 4.31 and 2.74 ± 3.17, respectively. The most prolific journals publishing on this topic were Knee Surgery Sports Traumatology Arthroscopy, American Journal of Sports Medicine, and Arthroscopy. The top three articles that received the maximum number of citations were from Japanese authors.

Conclusion

The number of publications related to SB-ACLR was significantly higher than that related to DB-ACLR in the last 20 years. The publications related to DB-ACLR have decreased in the recent past, after reaching a peak in 2012. The citations per year of SB-ACLR and DB-ACLR were similar.

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.

Superior rotational stability and lower re-ruptures rate after combined anterolateral and anterior cruciate ligament reconstruction compared to isolated anterior cruciate ligament reconstruction: a 2-year prospective randomized clinical trial

PURPOSE

The purpose of the current prospective randomized clinical trial (RCT) was to compare the clinical outcomes of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction with those of isolated ACL reconstruction and evaluate the re-rupture rate between the two study groups.

METHODS

This prospective RCT included 58 patients (43 men and 15 women) who underwent ACL reconstruction, either isolated (Group I: 26 patients) or combined with the ALL reconstruction (Group II: 32 patients). Preoperatively, the two groups differed in age and rate of medial meniscal injuries. The patients were evaluated preoperatively and postoperatively during the time points corresponding to 6 (T₁) weeks, 12 (T₂) weeks, 6 (T₃) months, 12 (T₄) months, and 24 (T₅) months. The evaluation included the clinical examination (comprising Lachman test, Pivot Shift test, Range of Motion, and Rolimeter differential anterior laxity), the objective clinical score (Objective IKDC [The International Knee Documentation Committee] score), and the subjective clinical scores (comprising Subjective IKDC score, Lysholm score, and Tegner activity score). The postoperative complications of all the patients were recorded.

RESULTS

Both the groups reported a significant improvement in clinical scores during the final follow-up as compared to the preoperative value (p < 0.05). The only differences between the two groups were observed with respect to the pivot shift test during each follow-up, wherein more patients from group I reported a pivot shift test grade I as compared to group II (p < 0.05). Three patients from group I reported a re-rupture of the operated knee, whereas no patients from group II reported new ruptures (p = 0.041).

CONCLUSIONS

Combined ACL and ALL reconstruction has proven to be more effective in obtaining a high grade of rotational knee stability during mid-term follow-up as compared to isolated ACL reconstruction along with a significantly lower rate of re-ruptures.

LEVEL OF EVIDENCE

Level I: Randomized Clinical Trial.

REGISTRATION

researchregistry5873: www.researchregistry.com.

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.

Meniscal Tear Management Associated with ACL Reconstruction

Meniscal lesions often occur in association with anterior cruciate ligament (ACL) tears at the moment of the injury or, secondarily, as a consequence of knee instability. Both ACL and meniscus lesions are associated with a higher risk of osteoarthritis. Adequate treatment of these lesions reduces the rate of degenerative changes in the affected knee. Meniscal tears should be addressed concomitantly with ACL reconstruction and the treatment must be oriented towards preserving the meniscal tissue anytime this is possible. Several options for approaching a meniscus tear are available. The meniscal suture should always be considered, and, if possible, meniscectomy should be the last choice. “Masterly neglect” is a valuable option in selected cases.