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Giusto JD, Cohen D, Dadoo S, Grandberg C, Lott A, Hughes JD, Ayeni OR, Musahl V. Lateral extra-articular tenodesis may be more cost-effective than independent anterolateral ligament reconstruction: A systematic review and economic analysis. J ISAKOS 2024; 9:689-698. [PMID: 38604570 DOI: 10.1016/j.jisako.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024]
Abstract
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.
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Affiliation(s)
- Joseph D Giusto
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Dan Cohen
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Sahil Dadoo
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Camila Grandberg
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ariana Lott
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Volker Musahl
- Department of Orthopaedic Surgery, Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
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Kolin DA, Jones RH, Heyworth BE, Jivanelli B, Fabricant PD. No difference in stability among various knee flexion angles during fixation of anterolateral ligament reconstruction or lateral extra-articular tenodesis: A systematic review and meta-analysis of biomechanical studies. J Exp Orthop 2024; 11:e12079. [PMID: 39015341 PMCID: PMC11250156 DOI: 10.1002/jeo2.12079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/18/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024] Open
Abstract
Purpose The purpose of this study was to investigate the effect of anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) fixation at low versus high flexion angles during anterior cruciate ligament reconstruction (ACLR) on rotation or translational knee stability. Methods The inclusion criteria for this study were (1) cadaveric study, (2) cadaveric specimens underwent ACLR, (3) cadaveric specimen underwent ALLR or LET and (4) specimen preparation technique described the knee flexion angle at the time of ALLR or LET tensioning and fixation. A priori, 'low flexion' was defined as 0-30° and 'high flexion' was defined as 60-90° at graft fixation. Main outcomes of interest included internal rotation and anterior translation. Results Data from 92 cadaveric knees (from 9 studies) were extracted and included in the meta-analysis. The mean pooled value for internal rotation was 10.1° (95% confidence interval [CI], 5.7-14.5°) for the low flexion group and 11.5° (95% CI, 7.4-15.7°) for the high flexion group (n.s.). The mean pooled value for anterior translation was 4.3 mm (95% CI, 0.5-8.1 mm) for the low flexion group and 3.0 mm (95% CI, 1.1-5.0 mm) for the high flexion group (n.s.). Conclusion This meta-analysis of existing biomechanical research found that the rotational and translational stability of the knee were not significantly different between scenarios in which ALLR or LET fixation was performed at low knee flexion angles (0-30°) versus high knee flexion angles (60-90°). Level of Evidence Level IV.
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Affiliation(s)
| | - Ruth H. Jones
- Pediatric Orthopedic Surgery ServiceNew YorkNew YorkUSA
| | - Benton E. Heyworth
- Orthopedics and Sports Medicine DepartmentBoston Children's HospitalBostonMassachusettsUSA
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Bosco F, Giustra F, Masoni V, Capella M, Sciannameo V, Camarda L, Massè A, LaPrade RF. Combining an Anterolateral Complex Procedure With Anterior Cruciate Ligament Reconstruction Reduces the Graft Reinjury Rate and Improves Clinical Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2024; 52:2129-2147. [PMID: 38353002 DOI: 10.1177/03635465231198494] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established surgical procedure, but it may not always restore complete rotational knee stability. Interest is increasing in anterolateral complex (ALC) procedures, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in association with ACLR to overcome this problem. The better ALC procedure, LET or ALLR, remains controversial to date. PURPOSE To analyze the patient-reported outcome measures and ACL reinjury rate after ACLR with an ALC procedure compared with after isolated ACLR, as well as to analyze the clinical results and graft failure rate of the LET group versus the ALLR group. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 2. METHODS A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart was used to conduct a comprehensive search of 5 databases: Scopus, MEDLINE, Embase, PubMed, and the Cochrane Database of Systematic Reviews. Only randomized controlled trials were included. Eligible articles were classified according to the levels of evidence of the Oxford Centre for Evidence-Based Medicine. A methodological quality assessment of randomized controlled trials was performed using the Risk of Bias 2 tool. The present systematic review and meta-analysis was registered on PROSPERO. RESULTS A total of 14 clinical trials were included in the final analysis, with 1830 patients. Isolated ACLR or a combined procedure with LET or ALLR was performed, with several characteristics described, including the surgical technique, additional torn knee structures and their management, graft failure, complications, clinical outcomes, clinical and instrumental examinations to assess knee stability, and postoperative protocols. Regarding clinical outcomes, pivot-shift tests and reduced graft failure, a significant difference was found in the superiority of the combined ACLR associated with the ALC procedure compared with an isolated ACLR (P < .05). No statistically significant difference was found between the 2 ALC procedures. CONCLUSION This systematic review and meta-analysis reported on the importance of combined ACLR and ALC procedures in patients with a high-grade rotational laxity, as both procedures, LET or ALLR, without superiority of one over the other, are associated with improved pivot-shift tests, patient-reported outcome measures, and reduced graft failure rates.
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Affiliation(s)
- Francesco Bosco
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco di Torino-ASL Città di Torino, Turin, Italy
| | - Fortunato Giustra
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco di Torino-ASL Città di Torino, Turin, Italy
| | - Virginia Masoni
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Marcello Capella
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Veronica Sciannameo
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Lawrence Camarda
- Department of Orthopaedics and Traumatology (DiChirOnS), University of Palermo, Palermo, Italy
| | - Alessandro Massè
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
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Vind TD, Petersen ET, Sørensen OG, Lindgren L, Stilling M. Dynamic radiostereometry can objectively quantify the kinematic laxity patterns and rotation instability of the knee during a pivot-shift test. Knee Surg Sports Traumatol Arthrosc 2024; 32:1492-1506. [PMID: 38643397 DOI: 10.1002/ksa.12181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE The pivot-shift test is used to clinically assess knee instability in patients with anterior cruciate ligament (ACL) lesions; however, it has low interobserver reliability. Dynamic radiostereometry (dRSA) is a highly precise and noninvasive method for the objective evaluation of joint kinematics. The purpose of this study was to quantify precise knee kinematics during a pivot-shift test using dRSA imaging. METHOD Eight human donor legs, including hemipelvises, were evaluated. Arthroscopic intervention was performed inducing ligament lesions in the ACL, and anterolateral ligament (ALL) section was performed as a capsular incision. The pivot-shift test was recorded with dRSA on knees with intact ligaments, ACL-deficient and ACL + ALL-deficient knees. RESULTS A pivot-shift pattern was identifiable after ligament lesion, as a change in tibial posterior drawer velocity from 7.8 mm/s (95% CI: 3.7; 11.9) in ligament intact knees to 30.4 mm/s (95% CI 23.0; 38.8) after ACL lesion to 35.1 mm/s (95% CI 23.4; 46.7) after combined ACL-ALL lesion. The anterior-posterior drawer excursion increased from 2.8 mm (95% CI 2.1; 3.4) in ligament intact knees to 7.2 mm (95% CI 5.5; 8.9) after ACL lesion to 7.6 mm (95% CI 5.5; 9.8) after combined lesion. A statistically significant increase in tibial external rotation towards the end of the pivot-shift motion was observed when progressing from intact to ACL + ALL-deficient knees (p < 0.023). CONCLUSION This experimental study demonstrates the feasibility of dRSA to objectively quantify the kinematic laxity patterns of the knee during the pivot-shift test. The dynamic parameters obtained through dRSA revealed the kinematic changes from ACL to combined ACL-ALL ligament lesion. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Tobias Dahl Vind
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Emil Toft Petersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Ole Gade Sørensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Division of Sports Trauma, Orthopaedic Department, Aarhus University Hospital, Aarhus N, Denmark
| | - Lars Lindgren
- Department of Radiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Maiken Stilling
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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Leao RV, Helito PVP, Saithna A, de Paula Correa MF, Helito CP. Anterolateral Ligament and Kaplan Fiber Injury Both Occur Frequently in Acute Anterior Cruciate Ligament-Injured Knees. J Clin Med 2024; 13:946. [PMID: 38398260 PMCID: PMC10889686 DOI: 10.3390/jcm13040946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The association of ALL and KF injuries in anterior cruciate ligament (ACL)-deficient knees remain topics of conflicting research despite improved magnetic resonance imaging (MRI). We aimed to evaluate the rate of the anterolateral ligament (ALL) and Kaplan fibers (KF) injuries in adults with acute ACL injuries using MRI. METHODS We retrospectively reviewed 64 patients with clinical and MRI diagnoses of acute ACL tears. Two radiologists analyzed and categorized the status of the ALL and KF in all patients as intact, partially injured, or completely injured. Interobserver agreement was assessed. Injuries to the collateral ligaments, ITB and posterior cruciate ligament (PCL) were also evaluated. RESULTS The mean age of the patients was 33 years. ALL injuries were observed in 46 (71%) patients, among whom 33 (71%) had partial and 13 (28%) had complete injuries. KF injuries were identified in 32 (50%) patients, with 28 (87.5%) of them having partial and 4 (12.5%) having complete injuries. Combined injuries of both ALL and KF were found in 25 (32.4%) patients (p-value of 0.266). The agreement between the examiners ranged from moderate to substantial (Kappa between 0.55 and 0.75), with the highest agreement observed in cases of KF injuries (Kappa = 0.75). CONCLUSIONS ALL and KF injuries were prevalent in acute ACL-injured knees with rates of injury of 71% and 50%, respectively. ALL injuries were more frequent and more frequently severe compared to KF injuries.
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Affiliation(s)
- Renata Vidal Leao
- Institute of Radiology, Hospital Sírio-Libanês, R. Ovidio Pires de Campos, São Paulo 05403-911, Brazil;
| | | | - Adnan Saithna
- AZBSC Orthopedics, 7649 E Pinnacle Peak Rd, Scottsdale, AZ 85255, USA;
- Orthopaedics Department, Arizona State University, Tempe, AZ 85287, USA
| | | | - Camilo Partezani Helito
- Institute of Orthopaedics and Traumatology, Faculty of Medicine, University of São Paulo, São Paulo 05508-220, Brazil;
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Gonnachon A, Labattut L, Abdoul Carime N, Orta C, Baulot E, Martz P. Does combined anterior cruciate ligament and anterolateral ligament reconstruction improve return to sport? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:981-987. [PMID: 37803219 DOI: 10.1007/s00590-023-03744-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE Only 50-65% of patients return to their previous sporting level after ACL rupture. The literature reports a reduced rate of graft rupture when an anterolateral ligament reconstruction (ALLR) is associated with ACL reconstruction. ACL reconstruction combined with ALL allows a higher return to sport at pre-injury level than isolated reconstruction in patients playing pivot-contact sports. METHODS A retrospective, single-centre study between 2012 and 2020 comparing reconstruction by hamstring tendon technique, isolated ACLR vs ACL with ALLR. An isokinetic test was performed at 6 months post-operatively and patients were re-contacted at a minimum 2-year follow-up to assess their level and delay to return to sport, graft rupture rate and functional evaluation. RESULTS 83 patients were included, 42 in ACLR group and 41 in ACL + ALLR group. Four patients were lost to follow-up and 79 patients were analysed. No significant difference was found on the level of return to sport (28.2% vs. 42.5%; p = 0.18), return to competition (43% vs. 60%; p = 0.18), delay to sports return, isokinetic assessment, functional scores, but a significant difference was found on graft rupture rate in favour of ALLR (12.8% vs. 0%; p = 0.02). CONCLUSION In our study, the addition of an ALL to ACL reconstruction did not improve pre-injury sports recovery or return to competition. STUDY DESIGN Cohort study, level of evidence 4.
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Affiliation(s)
- Arnaud Gonnachon
- Orthopedics Department, CHU F.Mitterrand Dijon-Bourgogne, 12 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France.
| | - Ludovic Labattut
- Orthopedics Department, CHU F.Mitterrand Dijon-Bourgogne, 12 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France
| | - Nafiz Abdoul Carime
- Public Health Department, CHU F.Mitterrand Dijon-Bourgogne, 12 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France
| | - Cyril Orta
- Convalescence and Rehabilitation Centre, CHU F.Mitterrand Dijon-Bourgogne, 23a Chem. de Cromois, 21000, Dijon, France
| | - Emmanuel Baulot
- Orthopedics Department, CHU F.Mitterrand Dijon-Bourgogne, 12 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France
- INSERM CAPS 1093, Faculty of Sports Sciences (UFR Staps), University of Burgundy, 3 Allée Des Stades Universitaires, BP 27877, Dijon, France
| | - Pierre Martz
- Orthopedics Department, CHU F.Mitterrand Dijon-Bourgogne, 12 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France
- INSERM CAPS 1093, Faculty of Sports Sciences (UFR Staps), University of Burgundy, 3 Allée Des Stades Universitaires, BP 27877, Dijon, France
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Kolin DA, Apostolakos J, Fabricant PD, Jivanelli B, Yen YM, Kramer DE, Kocher MS, Pennock AT, Nepple JJ, Willimon SC, Perkins CA, Ellis HB, Wilson PL, McClincy M, Everett Voos J, Spence DD, Heyworth BE. Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction. Orthop J Sports Med 2024; 12:23259671241231254. [PMID: 38425364 PMCID: PMC10903213 DOI: 10.1177/23259671241231254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 03/02/2024] Open
Abstract
Background Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) is being used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR). However, the knee flexion angle at which fixation of ALLR or LET is performed during the procedure is quite variable based on existing technique descriptions. Purpose/Hypothesis The purpose of this study was to identify whether flexion angle at the time of ALLR/LET fixation affected postoperative outcomes in a clinical population. It was hypothesized that ALLR/LET fixation at low versus high flexion angles would lead to no statistically significant differences in patient-reported outcome measures and graft failure rates. Study Design Systematic review; Level of evidence, 4. Methods The PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify published clinical studies of ACLR with ALLR/LET in which the knee flexion angle at the time of ALLR/LET was reported. A priori, low flexion was defined as 0° to 30°, and high flexion was defined as 60° to 90°. Studies were excluded if the flexion angle was between 31° and 59° because these angles constituted neither low nor high flexion angles and including them in an analysis of high versus low flexion angle at fixation would have biased the study results toward the null. The overall risk of bias was assessed using the Newcastle-Ottawa Scale. The pooled results of the studies were analyzed using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores, along with reported graft failure rates. Results A total of 32 clinical studies (5230 patients) met inclusion criteria: 22 studies (1999 patients) in the low-flexion group and 10 studies (3231 patients) in the high-flexion group. The median Newcastle-Ottawa Scale score was 6. Comparisons of patients with a low flexion angle versus a high flexion angle demonstrated no differences in the IKDC (P = .84), Lysholm (P = .67), or Tegner (P = .44) scores or in graft failure (3.4% vs 4.1%, respectively; P = .69). Conclusion The results of this review indicated that ACLR performed in conjunction with ALLR/LET provides good to excellent patient-reported outcomes and low graft failure rates when ALLR/LET fixation is performed in either low or high knee flexion.
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Affiliation(s)
| | | | - Peter D. Fabricant
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | | | | | - Yi-Meng Yen
- Boston Children’s Hospital, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | | - Michael McClincy
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Yau W, Lin W. Evaluation of Graft Maturation by MRI in Anterior Cruciate Ligament Reconstruction With and Without Concomitant Anterolateral Ligament Reconstruction. Orthop J Sports Med 2024; 12:23259671231223976. [PMID: 38304056 PMCID: PMC10832426 DOI: 10.1177/23259671231223976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 08/10/2023] [Indexed: 02/03/2024] Open
Abstract
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.
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Affiliation(s)
- W.P. Yau
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong Special Administrative Region, The People's Republic of China
| | - Wei Lin
- Department of Orthopaedics and Traumatology, The Duchess of Kent Children's Hospital at Sandy Bay, Hong Kong Special Administrative Region, The People's Republic of China
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Ng MK, Vasireddi N, Emara AK, Lam A, Voyvodic L, Rodriguez AN, Pan X, Razi AE, Erez O. Anterolateral knee complex considerations in contemporary anterior cruciate ligament reconstruction and total knee arthroplasty: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:319-330. [PMID: 37490068 DOI: 10.1007/s00590-023-03647-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023]
Abstract
The anterolateral ligament (ALL) was first described in 1879 in the context of Segond fractures, which correlate with a 75-100% chance of an anterior cruciate ligament (ACL) tear or a 66-75% chance of a meniscal tear. The purpose of this paper is to provide an updated comprehensive review on the anterolateral ligament complex of the knee focusing on the: (1) anatomy of the ALL/ALC; (2) associated biomechanics/function; and (3) important surgical considerations in contemporary anterior cruciate ligament (ACL) reconstruction and total knee arthroplasty (TKA). A systematic review of studies on ALL was conducted on Pubmed/MEDLINE and Cochrane databases (May 7th, 2020 to February 1st, 2022), with 20 studies meeting inclusion/exclusion criteria. Studies meeting inclusion criteria were anatomical/biomechanical studies assessing ALL function, cadaveric and computer simulations, and comparative studies on surgical outcomes of ALLR (concomitant with ACL reconstruction). Eight studies were included and graded by MINOR and Newcastle-Ottawa scale to identify potential biases. The anatomy of the ALL is part of the anterolateral ligament complex (ALC), which includes the superficial/deep iliotibial band (including the Kaplan fiber system), iliopatellar band, ALL, and anterolateral capsule. Multiple biomechanical studies have characterized the ALC as a secondary passive stabilizer in resisting tibial internal rotation. Given the role of the ALC in resisting internal tibial rotation, lateral extra-articular procedures including ALL augmentation may be considered for chronic ACL tears, ACL revisions, and a high-grade pivot shift test. In the context of TKA, in the event of injury to the ALC, a more constrained implant or soft-tissue reconstruction may be necessary to restore appropriate knee stability.
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Affiliation(s)
- Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
| | - Nikhil Vasireddi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Aaron Lam
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
| | - Lucas Voyvodic
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
| | - Ariel N Rodriguez
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA.
| | - Xuankang Pan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Afshin E Razi
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
| | - Orry Erez
- Department of Orthopaedic Surgery, Maimonides Medical Center, 927 49th St., Brooklyn, NY, 11219, USA
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Suzuki N, Watanabe A, Ninomiya T, Nakajima H, Horii M, Watanabe S, Shiko Y, Sasho T. Lateral meniscal injury without medial meniscal injury indicates the existence of the Segond fracture in ACL-deficient knees. Asia Pac J Sports Med Arthrosc Rehabil Technol 2024; 35:59-64. [PMID: 38236496 PMCID: PMC10792093 DOI: 10.1016/j.asmart.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/13/2023] [Accepted: 11/27/2023] [Indexed: 01/19/2024] Open
Abstract
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.
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Affiliation(s)
- Nobutada Suzuki
- Department of Radiology, Eastern Chiba Medical Center, 3-6-1 Okayamadai, Togane, Chiba, 283-8686, Japan
- Center for Preventive Medicine, Musculoskeletal Disease and Pain, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Atsuya Watanabe
- Department of Orthopedic Surgery, Eastern Chiba Medical Center, 3-6-1 Okayamadai, Togane, Chiba, 283-8686, Japan
| | - Taishi Ninomiya
- Center for Preventive Medicine, Musculoskeletal Disease and Pain, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
- Department of Orthopedic Surgery, Funabashi Orthopedic Hospital, 1-833 Hasamacho, Funabashi, Chiba, 274-0822, Japan
| | - Hirofumi Nakajima
- Center for Preventive Medicine, Musculoskeletal Disease and Pain, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
- Department of Orthopedic Surgery, Funabashi Orthopedic Hospital, 1-833 Hasamacho, Funabashi, Chiba, 274-0822, Japan
| | - Manato Horii
- Department of Orthopedic Surgery, Eastern Chiba Medical Center, 3-6-1 Okayamadai, Togane, Chiba, 283-8686, Japan
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Shotaro Watanabe
- Center for Preventive Medicine, Musculoskeletal Disease and Pain, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-0856, Japan
| | - Takahisa Sasho
- Center for Preventive Medicine, Musculoskeletal Disease and Pain, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
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11
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Lee SS, Kwon KB, Lee J, Ryu DJ, Jang S, Wang JH. 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. Arthroscopy 2023; 39:2502-2512. [PMID: 37207917 DOI: 10.1016/j.arthro.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 05/21/2023]
Abstract
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.
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Affiliation(s)
- Sung-Sahn Lee
- Department of Orthopaedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, Goyangsi, Gyeonggido, Korea
| | - Kyeu Baek Kwon
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeounghun Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Jin Ryu
- Department of Orthopaedic Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Seungpil Jang
- Department of Orthopaedic Surgery, Bupyeong Himchan Hospital, Incheon, Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Health Sciences and Technology and Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea.
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12
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Ripoll T, Moreira da Silva AG, Saoudi S, Noguero A, Nicolle R, Maris V, Helito C, Cavaignac E. Comparison Between Continuous and Separate Grafts for ALL Reconstruction When Combined With ACL Reconstruction: A Retrospective Cohort Study From the SANTI Study Group. Am J Sports Med 2023; 51:3163-3170. [PMID: 37700466 DOI: 10.1177/03635465231197353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
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.
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Affiliation(s)
- Thomas Ripoll
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Andre Giardino Moreira da Silva
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil
| | - Samy Saoudi
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Antoine Noguero
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Romain Nicolle
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Victor Maris
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
| | - Camillo Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil
| | - Etienne Cavaignac
- Department of Orthopedic Surgery and Trauma, Pierre-Paul Riquet Hospital, Toulouse, France
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Brophy RH, Lowry KJ. American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary: Management of Anterior Cruciate Ligament Injuries. J Am Acad Orthop Surg 2023; 31:531-537. [PMID: 36727995 PMCID: PMC10168113 DOI: 10.5435/jaaos-d-22-01020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 11/04/2022] [Indexed: 02/03/2023] Open
Abstract
Management of Anterior Cruciate Ligament Injuries : Evidence-based Clinical Practice Guideline is based on a systematic review of published studies for the treatment of anterior cruciate ligament injurie in both skeletally mature and immature patients. This guideline contains eight recommendations and seven options to assist orthopaedic surgeons and all qualified physicians managing patients with ACL injuries based on the best current available evidence. It is also intended to serve as an information resource for professional healthcare practitioners and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development.
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Affiliation(s)
- Robert H. Brophy
- From Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO (Brophy) and Aspirus Rhinelander Hospital, Aspirus Northland Orthopedics & Sports Medicine, Rhinelander, WI (Lowry)
| | - Kent Jason Lowry
- From Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO (Brophy) and Aspirus Rhinelander Hospital, Aspirus Northland Orthopedics & Sports Medicine, Rhinelander, WI (Lowry)
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14
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Goes RA, Pereira R, Oliveira FLD, Castelhanito P, Serra Cruz R, Rocha de Faria JL. Single Femoral Tunnel for Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Graft and Lemaire's Extra-Articular Tenodesis as a Good Alternative for Combined Anterior Cruciate Ligament and Anterolateral Ligament Revision Surgeries. Arthrosc Tech 2023; 12:e903-e914. [PMID: 37424656 PMCID: PMC10323833 DOI: 10.1016/j.eats.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 02/12/2023] [Indexed: 07/11/2023] Open
Abstract
The literature has shown a significant decrease in failure rates when the anterior cruciate ligament (ACL) reconstruction was associated with an extra-articular reinforcement technique such as the anterolateral ligament (ALL) or the iliotibial band tenodesis (ITBT) using the modified Lemaire technique. As much as there is a progressive decrease in the failure rates of ACL reconstructions when the ALL reconstruction technique is associated, there are still and will be cases that will result in graft rupture. These cases will require more alternatives for revision, which are always challenging for the surgeon, where the lateral approaches represent complicating factors, especially because of the distortion of the lateral anatomy (by the previous approach for ALL reconstruction), previous reconstruction tunnels, and the presence of fixation materials. We present here a safe technique that offers great stability to the fixation of the graft and is easy to perform, using a single tunnel for the passage of the ACL and ITBT grafts, allowing a single fixation for both. In this way, we performed a lower-cost surgery, with a lower risk of lateral condyle fracture and tunnel confluence. This technique is indicated to be used in cases of revision after failure of combined ACL reconstruction with ALL.
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Affiliation(s)
- Rodrigo Araújo Goes
- North Lisbon University Hospital Centre (CHULN) - Santa Maria Hospital, Lisbon, Portugal
- The Division of Traumatology and Ortopedics (DITRO) of National Institute of Traumatology and Orthopedics of Brazil (INTO), Rio de Janeiro, Brazil
- Free Assistant of the Chair of Orthopedics at the Faculty of Medicine of Lisbon - FMUL, Lisbon, Portugal
| | - Rafael Pereira
- North Lisbon University Hospital Centre (CHULN) - Santa Maria Hospital, Lisbon, Portugal
| | | | - Pedro Castelhanito
- North Lisbon University Hospital Centre (CHULN) - Santa Maria Hospital, Lisbon, Portugal
| | - Raphael Serra Cruz
- The Division of Traumatology and Ortopedics (DITRO) of National Institute of Traumatology and Orthopedics of Brazil (INTO), Rio de Janeiro, Brazil
| | - José Leonardo Rocha de Faria
- The Division of Traumatology and Ortopedics (DITRO) of National Institute of Traumatology and Orthopedics of Brazil (INTO), Rio de Janeiro, Brazil
- School of Medicine from University of São Paulo, USP Riberão Preto, SP, Brazil
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15
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Anterolateral ligament of the knee-Cadaver study in a Caucasian population. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T134-T138. [PMID: 36528296 DOI: 10.1016/j.recot.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/01/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Despite the recognized importance of the anterolateral ligament (ALL) in rotational stability of the knee, some studies still deny its role and even its existence. We studied the prevalence of the ALL in a Caucasian population, as well as its characteristics and anatomical relationships. MATERIALS AND METHODS The study was performed on 20 knees from 10 embalmed cadavers. A lateral approach, as described by Steven Claes, was used and the relations of the ALL with the lateral epicondyle, lateral inferior genicular artery, lateral meniscus, Gerdy's tubercle and fibular head were recorded. Its length and its width were also measured. RESULTS The ALL was identified in 16 knees. Its origin was at a distance inferior to 1mm posterior and proximal to the lateral femoral epicondyle and insertion within a mean distance of 2.1±0.6mm from the tibial articular surface, 20.6±1.3mm from the Gerdy's tubercle and 20.3±1.2mm from the fibular head. In all cases ALL presented mutual fibers with the lateral meniscus. The length was 35.8±4.6mm and the width was 4.2±1.3/4.9±1.0/6.5±1.5mm at its proximal, middle and distal third, respectively. No difference was found between gender and the dimensions of the ligament. CONCLUSIONS The ALL was found in 80% of the knees. Its origin is closely related to the lateral collateral ligament and its insertion is halfway between the fibular head and the Gerdy's tubercle. In all cases, we verified the connection between ALL and the lateral meniscus.
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16
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Lai S, Zhang Z, Li J, Fu WL. Comparison of Anterior Cruciate Ligament Reconstruction With Versus Without Anterolateral Augmentation: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Orthop J Sports Med 2023; 11:23259671221149403. [PMID: 37025126 PMCID: PMC10071203 DOI: 10.1177/23259671221149403] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/21/2022] [Indexed: 04/08/2023] Open
Abstract
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.
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Affiliation(s)
- Sike Lai
- Department of Orthopedic Surgery, West China Hospital, Sichuan
University, Chengdu, China
- Orthopedic Research Institute, West China Hospital, Sichuan
University, Chengdu, China
| | - Zhong Zhang
- Department of Orthopedic Surgery, West China Hospital, Sichuan
University, Chengdu, China
- Orthopedic Research Institute, West China Hospital, Sichuan
University, Chengdu, China
| | - Jian Li
- Department of Orthopedic Surgery, West China Hospital, Sichuan
University, Chengdu, China
- Orthopedic Research Institute, West China Hospital, Sichuan
University, Chengdu, China
- Jian Li, MD, or Wei-Li Fu, MD, Department of Orthopedic Surgery,
West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041,
China ( or
, respectively)
| | - Wei-Li Fu
- Department of Orthopedic Surgery, West China Hospital, Sichuan
University, Chengdu, China
- Orthopedic Research Institute, West China Hospital, Sichuan
University, Chengdu, China
- Jian Li, MD, or Wei-Li Fu, MD, Department of Orthopedic Surgery,
West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu 610041,
China ( or
, respectively)
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17
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Fernandes JC, Pinho AR, Pereira PA, Madeira MD, Raposo FA, Sousa AN, Lobo JM. Anterolateral ligament of the knee-Cadaver study in a Caucasian population. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:134-138. [PMID: 35691577 DOI: 10.1016/j.recot.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/18/2022] [Accepted: 06/01/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Despite the recognized importance of the anterolateral ligament (ALL) in rotational stability of the knee, some studies still deny its role and even its existence. We studied the prevalence of the ALL in a Caucasian population, as well as its characteristics and anatomical relationships. MATERIALS AND METHODS The study was performed on 20 knees from 10 embalmed cadavers. A lateral approach, as described by Steven Claes, was used and the relations of the ALL with the lateral epicondyle, lateral inferior genicular artery, lateral meniscus, Gerdy's tubercle and fibular head were recorded. Its length and its width were also measured. RESULTS The ALL was identified in 16 knees. Its origin was at a distance inferior to 1mm posterior and proximal to the lateral femoral epicondyle and insertion within a mean distance of 2.1±0.6mm from de tibial articular surface, 20.6±1.3mm from the Gerdy's tubercle and 20.3±1.2mm from the fibular head. In all cases ALL presented mutual fibers with the lateral meniscus. The length was 35.8±4.6mm and the width was 4.2±1.3/4.9±1.0/6.5±1.5mm at its proximal, middle and distal third, respectively. No difference was found between gender and the dimensions of the ligament. CONCLUSIONS The ALL was found in 80% of the knees. Its origin is closely related to the lateral collateral ligament and its insertion is halfway between the fibular head and the Gerdy's tubercle. In all cases, we verified the connection between ALL and the lateral meniscus.
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Affiliation(s)
- J C Fernandes
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Portugal.
| | - A R Pinho
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - P A Pereira
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Portugal
| | - M D Madeira
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Portugal
| | - F A Raposo
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - A N Sousa
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - J M Lobo
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
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18
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Park YB, Lee HJ, Cho HC, Pujol N, Kim SH. 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. Arthroscopy 2023; 39:758-776.e10. [PMID: 36567183 DOI: 10.1016/j.arthro.2022.11.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 11/16/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Yong-Beom Park
- Departments of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Han-Jun Lee
- Departments of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Hyung-Chul Cho
- Departments of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Nicolas Pujol
- Department of Orthopedic Surgery, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Seong Hwan Kim
- Departments of Orthopedic Surgery, Chung-Ang University Hospital, Seoul, Republic of Korea.
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Cheng YH, Chiu CH, Chen ACY, Chan YS, Hsu KY. Outcomes of Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction According to GNRB Arthrometer Measurement. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020366. [PMID: 36837568 PMCID: PMC9966521 DOI: 10.3390/medicina59020366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/02/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023]
Abstract
Background and Objectives: To investigate the prognosis of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction, we used a GNRB (Genourob, Laval, France) arthrometer to measure surgical outcomes. Materials and Methods: This retrospective study reviewed patients who underwent combined ACL and ALL reconstruction and had a minimum follow-up of 2 years. Subjective outcomes, namely the International Knee Documentation Committee (IKDC) evaluation form scale scores and Lysholm scores, were evaluated preoperatively and postoperatively. We used a GNRB arthrometer to test the side-to-side laxity under pressures of 134 and 200 N, and we calculated the differential of the slope of the curves. We also recorded complications. Results: Our study examined 18 patients (mean age: 30.56 ± 8.9 years, range: 19-53) with a mean follow-up of 27.37 ± 3.4 months (range: 24-36). Both Lysholm and IKDC scores were significantly improved following the operation. The GNRB arthrometer measured mean anteroposterior laxity side-to-side as 0.76 ± 0.78 mm and 0.82 ± 0.8 mm under pressures of 134 and 200 N, respectively. The mean side-to-side differential slope under 200 N was 3.52 ± 2.17 μm/N. These values indicated that patients displayed no graft tear or low functional knee instability. All patients had a grade 3 pivot shift preoperatively; only two patients had a grade 1 pivot shift postoperatively, with the rest having a negative pivot shift. Conclusions: Our study revealed that combined ACL and ALL reconstruction has an excellent prognosis. GNRB measurement demonstrated excellent stability, and most patients had no residual pivot shift.
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Affiliation(s)
- You-Hung Cheng
- Department of Orthopedic Surgery, New Taipei Municipal Tu-Cheng Hospital, Chang Gung Memorial Hospital, New Taipei City 236, Taiwan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Chih-Hao Chiu
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Alvin Chao-Yu Chen
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Yi-Sheng Chan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Kuo-Yao Hsu
- Department of Orthopedic Surgery, New Taipei Municipal Tu-Cheng Hospital, Chang Gung Memorial Hospital, New Taipei City 236, Taiwan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Department of Orthopedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
- Correspondence: ; Tel.: +886-3-328-1200 (ext. 2163); Fax: +886-3-327-8113
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20
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Function and strain of the anterolateral ligament part II: reconstruction. Knee Surg Sports Traumatol Arthrosc 2023; 31:390-398. [PMID: 32712685 DOI: 10.1007/s00167-020-06137-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/26/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Anterolateral rotatory instability (ALRI) may result from isolated ruptures of the anterior cruciate ligament (ACL) or combined lesions with the anterolateral ligament (ALL). Biomechanical studies have demonstrated that the ALL contributes to the overall rotational stability of the knee. The purpose of this study was to investigate the biomechanical function of anatomic ALL reconstruction (ALLrec) in the setting of a combined ACL and ALL injury and reconstruction. The hypothesis was that combined ACL reconstruction (ACLrec) and ALLrec (ACL/ALLrec) significantly reduces internal rotation and shows load sharing between both reconstructions compared with isolated ACLrec. METHODS Eight fresh-frozen cadaveric knees were evaluated using a six degrees of freedom knee simulator. Continuous passive motion and external loads were tested. Kinematic differences between ACLrec and combined ACL/ALLrec were compared. Additionally, ACL graft tension and ALL graft strain were measured continuously throughout the testing protocol. RESULTS Combined anatomic ACL/ALLrec significantly improved the internal rotatory stability compared with isolated ACLrec at 30°-90° under an internal rotation moment. During a static pivot-shift test, additional ALLrec showed no significant reduction of ap-translation. ALLrec resulted in an increase in ACL graft tension during continuous passive motion and with additional internal rotation moment. CONCLUSION In the case of a combined ACL and ALL deficiency, concurrent ACLrec and ALLrec significantly improved the rotatory stability of the knee compared with solely reconstructing the ACL at flexion angles ≥ 30°. Nevertheless, additional ALLrec with fixation at 60° and with low tension could not restore extension-near rotatory stability. For that reason, ALLrec with fixation at 60° flexion cannot be recommended in clinical application.
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21
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Mogoş Ş, D'Ambrosi R, Antonescu D, Stoica IC. 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. J Knee Surg 2023; 36:54-61. [PMID: 33932949 DOI: 10.1055/s-0041-1729621] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of the current randomized clinical trial (RCT) was to evaluate the clinical outcomes of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction and to compare them with those of isolated ACL reconstruction. The hypothesis was that combined ACL and ALL reconstruction will result in superior clinical outcomes in terms of the rotational stability of the knee. This prospective RCT included 57 patients (44 men and 13 women, mean age = 31 ± 7.1 years) who underwent ACL reconstruction either isolated (Group I: 25 patients) or combined with ALL reconstruction (Group II: 32 patients). The evaluation of the patients was done preoperatively and postoperatively at 6 weeks, 12 weeks, 6 months, and 12 months including a clinical examination (Lachman's test, Pivot shift's test, and Rolimeter differential anterior laxity), an objective clinical scores (objective: the International Knee Documentation Committee [IKDC] score) and a subjective clinical scores (subjective: IKDC's score, Lysholm's score, and Tegner's activity score). Postoperative complications of all the patients were recorded. There was a significant difference between the study groups at all follow-up intervals when evaluating the postoperative pivot shift test (p < 0.05) with a superior rotational stability in the group of combined ACL and ALL reconstruction. At the final follow-up evaluation, 36% of the patients from Group I and 6.2% in Group II had a grade I positive pivot shift test (p < 0.05). There was a statistically significant difference between the two groups regarding the number of patients with a grade A IKDC objective score (p < 0.05) at the 6- and 12-month follow-up intervals (p = 0.007). There was a significant difference concerning the IKDC subjective score between the two study groups in favor of the combined ACL and ALL reconstruction group at 12 months postoperatively (p = 0.048). Combined ACL and ALL reconstruction technique was demonstrated to be effective in obtaining a superior control of the rotational knee instability and to improve the clinical objective and subjective outcomes when compared with isolated ACL reconstruction in sports patients with high-grade pivoting shifts.
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Affiliation(s)
- Ştefan Mogoş
- Foişor Orthopaedics Hospital, Bucharest, Romania
| | | | - Dinu Antonescu
- University of Medicine and Pharmacy, Carol Davila Bucharest, Romania
| | - Ioan-Cristian Stoica
- Foişor Orthopaedics Hospital, Bucharest, Romania.,University of Medicine and Pharmacy, Carol Davila Bucharest, Romania
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22
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Moon HS, Choi CH, Seo YJ, Lee Y, Jung M, Park JH, Kim SH. The orientation of the ALL femoral tunnel to minimize collision with the ACL tunnel depends on the need or not of far-cortex drilling. Knee Surg Sports Traumatol Arthrosc 2022; 30:3805-3817. [PMID: 35643937 DOI: 10.1007/s00167-022-07007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To (1) evaluate the optimal drill orientation of the anterolateral ligament (ALL) femoral tunnel to minimize collision with the anterior cruciate ligament (ACL) femoral tunnel during anatomical ACL reconstruction according to the need for far-cortex drilling and (2) investigate the geometric factors that affect tunnel collision secondary to drill orientation of the ALL femoral tunnel. METHODS A three-dimensional femoral model of patients who underwent anatomical single-bundle ACL reconstruction between 2015 and 2016 was constructed, and the geometric factors were evaluated. Virtual ALL femoral tunnels were created to simulate 45 drilling conditions. For each condition, whether the virtual ALL femoral tunnel and its trajectory violated the femoral cortex and the minimum distance between tunnels was investigated. RESULTS Thirty-nine subjects were included. Overall violation rates of the femoral cortex by the ALL tunnels and its trajectories were 11.1% (195 of 1755 conditions) and 40.7% (714 of 1755 conditions), respectively. A drilling angle of axial 0° and coronal - 40° showed the longest minimum distance between tunnels without femoral cortex violation by the ALL tunnel (6.3 ± 4.0 mm; collision rate 2.6% [1 of 39 subjects]). With simultaneous consideration of the ALL tunnel's trajectory representing far-cortex drilling, a drill angle of axial 40° and coronal 10° showed the longest minimum distance between tunnels without femoral cortex violation (0.6 ± 3.9 mm; collision rate 38.5% [15 of 39 subjects]). For surgical techniques requiring far-cortex drilling, regression analyses were performed on geometric factors that could affect tunnel collision, which revealed that the sagittal inclination angle of the ACL and the distance between the ACL femoral tunnel's outlet and ALL's femoral attachment were associated with tunnel collision. CONCLUSION The optimal drill orientations of the ALL femoral tunnel to minimize collision with the ACL femoral tunnel were axial 0° and coronal - 40° for surgical techniques not requiring far-cortex drilling and axial 40° and coronal 10° for techniques requiring far-cortex drilling. For techniques requiring far-cortex drilling, additional adjustment for orientation of the ACL femoral tunnel is required to reduce the risk of tunnel collision. Therefore, an individualized surgical strategy should be applied according to the graft fixation method of the ALL femoral tunnel.
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Affiliation(s)
- Hyun-Soo Moon
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Chong-Hyuk Choi
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Jin Seo
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Younghan Lee
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Jung
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hun Park
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Sung-Hwan Kim
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 20 Eonju-ro 63-gil, Gangnam-gu, Seoul, 06229, Republic of Korea.
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23
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Athanasiou V, Panagopoulos A, Kouzelis A, Kokkalis ZT, Lakoumentas J, Katsanos K, Gliatis J. A Review of Current Concepts of the Anterolateral Complex of the Knee. Orthop Rev (Pavia) 2022; 14:38651. [PMID: 36213619 PMCID: PMC9536860 DOI: 10.52965/001c.38651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - John Lakoumentas
- Medical Physics Department, Medical School, University of Patras, Patras, Greece
| | | | - John Gliatis
- Orthopaedic Department, Patras University Hospital, Greece
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24
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Barahona M, Mosquera M, De Padua V, Galan H, Del Castillo J, Mejias S, Bacarreza F, Araya O, Kuhn A, Vaisman A, Graieb A, Almazan A, Helito C, Fuentes C, Collazo C, Esquivel D, Gigante F, Motta F, Ochoa G, Arteaga G, Ferrer G, Zvietcovich G, Cardona J, Hurtado J, Erlund L, Costa-Paz M, Roby M, Ponzo N, Sarmiento P, Yáñez R, Urbieta S, Marques de Olivera V, Álvaro Zamorano, Radice F, Nardin L, Gelink A, Hernandez R, Rosa ADL, Irarrazaval S, Cordivani F, Canuto S, Gravini G. Latin American formal consensus on the appropriate indications of extra-articular lateral procedures in primary anterior cruciate ligament reconstruction. J ISAKOS 2022:S2059-7754(22)00082-7. [PMID: 36087904 DOI: 10.1016/j.jisako.2022.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/09/2022] [Accepted: 08/29/2022] [Indexed: 10/14/2022]
Abstract
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.
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25
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Mogos Ș, Antonescu D, Stoica IC, D'Ambrosi R. 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. PHYSICIAN SPORTSMED 2022:1-8. [PMID: 35968574 DOI: 10.1080/00913847.2022.2112914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
| | - Dinu Antonescu
- University of Medicine and Pharmacy Carol Davila Bucharest, Bucuresti, Romania
| | - Ioan-Cristian Stoica
- Foișor Orthopaedics Hospital Bucharest, Romania.,University of Medicine and Pharmacy Carol Davila Bucharest, Bucuresti, Romania
| | - Riccardo D'Ambrosi
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.,Dipartimento di Scienze Biomediche per la Salute, Universit' degli Studi di Milano, Milan, Italy
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26
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Agarwal N, Monketh J, Volpin A. Clinical and mechanical outcomes in isolated anterior cruciate ligament reconstruction vs additional lateral extra-articular tenodesis or anterolateral ligament reconstruction. World J Orthop 2022; 13:662-675. [PMID: 36051377 PMCID: PMC9302030 DOI: 10.5312/wjo.v13.i7.662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/13/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Nikhil Agarwal
- Department of Trauma and Orthopaedics, University of Aberdeen, Aberdeen AB24 3FX, United Kingdom
| | - Jaibaji Monketh
- Health Education England North East, Newcastle Upon Tyne NE15 8NY, United Kingdom
| | - Andrea Volpin
- Department of Trauma and Orthopaedics, NHS Grampian, Elgin IV30 1SN, United Kingdom
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27
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Comparison of clinical outcomes between isolated ACL reconstruction and combined ACL with anterolateral ligament reconstruction: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:685-694. [PMID: 35044518 DOI: 10.1007/s00590-021-03194-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/29/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND To compare the clinical outcomes between isolated cruciate ligament reconstruction (ACLR) and combined ACL with anterolateral ligament reconstruction in chronic ACL injury especially with rotary instability problem. METHODS Systematic searches were conducted of literature published up to July 2021 on PubMed, Google Search, and Cochrane databases for studies comparing isolated ACLR and ACL with anterolateral reconstruction. Two reviewers independently determined eligibility, extracted outcome data, and assessed the risk of bias of eligible studies. Pooled clinical outcomes used random effects with mean differences and risk ratio for continuous and dichotomous variables, respectively. RESULTS After excluding 49 articles based on full-text screening, six studies were identified which met the inclusion criteria in the meta-analysis. Clinical outcomes such as residual laxity, rotatory instability, and graft failure were compared between isolated ACLR and combined ACL and anterolateral stability reconstruction. Overall, both clinical outcomes of isolated ACL and combined ACL with anterolateral reconstruction show improvement results in pivot shift test, the absence of residual laxity and incidence of graft failure. Compared to isolated ACLR, the prominent postoperative result was by combined ACL with anterolateral reconstruction which had significant differences in laxity outcome based on (I2 = 89%, p < 0.00001) and (MD = 0.71, 95%CI: 0.33-1.08, p = 0.00002). CONCLUSIONS The combined ACL with anterolateral reconstruction tended to have superior clinical outcomes, especially in the absence of residual laxity, compared to the isolated ACLR, but the other results were not significantly different statistically. Combined ACL and anterolateral reconstruction were not performed routinely for patients undergoing ACL reconstruction, but more suitable for chronic rotatory instability problem.
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Runer A, Dammerer D, Kranewitter C, Giesinger JM, Henninger B, Hirschmann MT, Liebensteiner MC. Injuries to the anterolateral ligament are observed more frequently compared to lesions to the deep iliotibial tract (Kaplan fibers) in anterior cruciate ligamant deficient knees using magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc 2022; 30:309-318. [PMID: 33770221 PMCID: PMC8800892 DOI: 10.1007/s00167-021-06535-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/09/2021] [Indexed: 01/26/2023]
Abstract
PURPOSE To determine the accuracy of detection, injury rate and inter- and intrarater reproducibility in visualizing lesions to the anterolateral ligament (ALL) and the deep portion of the iliotibial tract (dITT) in anterior cruciate ligament (ACL) deficient knees. METHODS Ninety-one consecutive patients, out of those 25 children (age 14.3 ± 3.5 years), with diagnosed ACL tears were included. Two musculoskeletal radiologists retrospectively reviewed MRI data focusing on accuracy of detection and potential injuries to the ALL or dITT. Lesion were diagnosed in case of discontinued fibers in combination with intra- or peri-ligamentous edema and graded as intact, partial or complete tears. Cohen's Kappa and 95% confidence intervals (95% CI) were determined for inter- and intrarater reliability measures. RESULTS The ALL and dITT were visible in 52 (78.8%) and 56 (84.8%) of adult-and 25 (100%) and 19 (76.0%) of pediatric patients, respectively. The ALL was injured in 45 (58.5%; partial: 36.4%, compleate: 22.1%) patients. Partial and comleate tears, where visualized in 21 (40.4%) and 16 (30.8%) adult- and seven (28.0%) and one (4%) peditric patients. A total of 16 (21.3%; partial: 13.3%, compleate: 8.0%) dITT injuries were identified. Partal and complete lesions were seen in seven (12.5%) and five (8.9%) adult- and three (15.8%) and one (5.3%) pediatric patients. Combined injuries were visualized in nine (12.7%) patients. Inter-observer (0.91-0.95) and intra-observer (0.93-0.95) reproducibility was high. CONCLUSION In ACL injured knees, tears of the ALL are observed more frequently compared to lesions to the deep iliotibial tract. Combined injuries of both structures are rare. Clinically, the preoperative visualization of potentially injured structures of the anterolateral knee is crucial and is important for a more personalized preoperative planning and tailored anatomical reconstruction. The clinical implication of injuries to the anterolateral complex of the knee needs further investigation. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Dietmar Dammerer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | | | - Johannes M. Giesinger
- Innsbruck Institute of Patient-Centered Outcome Research (IIPCOR), Innsbruck, Austria
| | - Benjamin Henninger
- Department of Orthopaedic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Michael T. Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
| | - Michael C. Liebensteiner
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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There are differences in knee stability based on lateral extra-articular augmentation technique alongside anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:3854-3863. [PMID: 33483768 DOI: 10.1007/s00167-020-06416-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/10/2020] [Indexed: 12/23/2022]
Abstract
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.
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Interlinked Hamstrings for Combined Anterolateral and Anterior Cruciate Ligament Reconstruction: A Novel Technique for ALL. Indian J Orthop 2021; 56:621-627. [PMID: 35342523 PMCID: PMC8921427 DOI: 10.1007/s43465-021-00551-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/15/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anterolateral ligament (ALL) reconstruction provides rotational stability in patients undergoing anterior cruciate ligament (ACL) reconstruction. The aim of this study was to assess the outcome of patients who underwent combined ACL and ALL reconstruction with a novel anatomic technique using hamstring tendon autograft and fixed loop suspensory device. METHODS From 2016 to 2018, 25 patients who underwent combined reconstruction of ACL and ALL in our Institution were evaluated retrospectively. International Knee Documentation Committee (IKDC) Score, Tegner Lysholm Knee Score, grade of pivot shift was assessed at a final follow-up. RESULTS Mean follow-up was 31.5 months (28-42). Mean IKDC (81.5) and Tegner Lysholm (82.8) Knee Scores improved significantly at a final follow-up, with all knees demonstrating negative pivot shift. All patients had good outcomes at 2 years follow-up with no graft failure and with no residual instability. CONCLUSION ACL and ALL reconstruction using this technique described for the anterolateral instability of the knee was satisfactory in our patients. This technique is simple, easily reproducible and avoids additional implants for ALL in the tibia. LEVEL OF EVIDENCE IV.
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Yoon KH, Hwang IU, Kim EJ, Kwon YB, Kim SG. Anterolateral Ligament Reconstruction Improves Anteroposterior Stability As Well As Rotational Stability in Revision Anterior Cruciate Ligament Reconstruction with High-Grade Pivot Shift. J Knee Surg 2021; 34:1310-1317. [PMID: 32369841 DOI: 10.1055/s-0040-1708055] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This study aimed to investigate the effect of anterolateral ligament reconstruction (ALLR) in revision anterior cruciate ligament reconstruction (ACLR) with high-grade pivot shift. The hypothesis was that revision ACLR combined with ALLR (RACLR with ALLR group) would show superior clinical outcomes to those of isolated revision ACLR. We retrospectively evaluated consecutive patients who underwent revision ACLR (RACLR) combined with ALLR between October 2015 and January 2017. The indication for combination of ALLR with revision ACLR was failed ACLR with ≥G2 pivot-shift instability. The control group included patients who underwent isolated revision ACLR (isolated RACLR group) for the same indication between July 2013 and September 2015. Exclusion criteria were ≤G1 pivot-shift instability, multiple ligament reconstruction, bilateral ligament injury, double-bundle reconstruction, insufficient medical records, postoperative infection, and follow-up loss at postoperative 2 years. Clinical scores, stability tests, and failure rates were compared between groups at the 2-year follow-up. The RACLR with ALLR group had 18 patients (mean age, 32.9 ± 10.8 years) and the RACLR group had 21 patients (mean age, 29.6 ± 10.2 years). Clinical scores at the 2-year follow-up showed no significant differences between groups. However, the RACLR with ALLR group showed better stability in the Lachman test (p = 0.005), pivot-shift test (p = 0.030), and side-to-side difference in stress radiographs (3.9 ± 3.0 mm vs. 5.9 ± 2.8 mm, p = 0.018) than the isolated RACLR group. The RACLR with ALLR group had two failures (11.1%), and the RACLR group had three failures (14.3%). In conclusion, ALLR in revision ACLR with high-grade pivot shift improves anteroposterior stability as well as rotational stability at 2-year follow-up. Therefore, ALLR is recommended with revision ACLR, especially in patients with high-grade pivot shift. This is a Level III, retrospective cohort review.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Korea
| | - In Uk Hwang
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Korea
| | - Eung Ju Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Korea
| | - Yoo Beom Kwon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Korea
| | - Sang-Gyun Kim
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, Gyeongki-do, Korea
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Ariel de Lima D, de Lima LL, de Souza NGR, de Moraes Perez RA, Sobrado MF, Guimarães TM, Helito CP. Clinical outcomes of combined anterior cruciate ligament and anterolateral ligament reconstruction: a systematic review and meta-analysis. Knee Surg Relat Res 2021; 33:33. [PMID: 34556187 PMCID: PMC8461945 DOI: 10.1186/s43019-021-00115-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/08/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES To compare the clinical outcomes of isolated anterior cruciate ligament (ACL) reconstruction with combined reconstruction of the ACL and anterolateral ligament (ALL) of the knee. METHODS A search was conducted on the PubMed, Medline, Google Scholar, EMBASE, and Cochrane library databases, in line with the PRISMA protocol. The indexation terms used were "anterior cruciate ligament" OR "acl" AND "anterolateral ligament" AND "reconstruction." Articles that compared patients submitted to combined ACL and ALL reconstruction with those submitted to isolated reconstruction of the ACL, with levels of evidence I, II, and III, were included. Studies with follow-up of less than 2 years and articles that did not use "anatomical" techniques for ALL reconstruction, such as extraarticular tenodesis, were excluded. A meta-analysis with R software was conducted, with a random effects model, presented as risk ratio (RR) or mean difference (MD), with a 95% confidence level (CI) and statistically significant at p < 0.05. RESULTS Ten articles were selected, with a total of 1495 patients, most of whom were men, of whom 674 submitted to ACL and ALL reconstruction and 821 to isolated ACL reconstruction. Combined ACL and ALL reconstruction exhibited a statistically significant advantage in residual pivot shift (RR 0.34, 95% CI 0.24-0.47, I2 = 0%, p < 0.01), rerupture rate (RR 0.34, 95% CI 0.19-0.62, I2 = 0%, p < 0.01), Lachman test (RR 0.59, 95% CI 0.40-0.86, I2 = 21%, p < 0.01), and postoperative Lysholm score (MD 2.28, CI 95% 0.75-3.81, I2 = 73%, p < 0.01). CONCLUSIONS Combined ACL and ALL reconstruction obtained better postoperative clinical outcomes when compared with isolated ACL reconstruction, especially in reducing residual pivot shift and rerupture rate.
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Affiliation(s)
- Diego Ariel de Lima
- UFERSA, Universidade Federal Rural do Semi-Árido, R. Francisco Mota, 572, Pres. Costa e Silva, Mossoró, RN, CEP: 59625-900, Brazil. .,Hospital Tarcísio Maia, Mossoró, Brazil.
| | - Lana Lacerda de Lima
- UFERSA, Universidade Federal Rural do Semi-Árido, R. Francisco Mota, 572, Pres. Costa e Silva, Mossoró, RN, CEP: 59625-900, Brazil.,Hospital Tarcísio Maia, Mossoró, Brazil
| | | | | | - Marcel Faraco Sobrado
- USP, Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Tales Mollica Guimarães
- USP, Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Camilo Partezani Helito
- USP, Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
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Na BR, Kwak WK, Seo HY, Seon JK. Clinical Outcomes of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis Combined With Primary ACL Reconstruction: A Systematic Review With Meta-analysis. Orthop J Sports Med 2021; 9:23259671211023099. [PMID: 34541008 PMCID: PMC8442508 DOI: 10.1177/23259671211023099] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/24/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Residual rotational instability after isolated anterior cruciate ligament reconstruction (ACLR) has been a challenge for many years. Anterolateral extra-articular procedures (AEAPs), including anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET), are performed as a surgical option for additional rotational stability, but clear evidence for their usefulness is lacking. PURPOSE To conduct a systematic review and meta-analysis of the literature regarding the efficacy of AEAP in primary ACLR. STUDY DESIGN Systematic review; Level of evidence, 3. METHODS A literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. MEDLINE, EMBASE, and the Cochrane Library were searched in April 2020, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 3444 studies were screened, and 20 studies (11 randomized controlled trials and 9 nonrandomized studies) were evaluated. Functional outcomes, stability, and complications were compared between patients who underwent primary ACLR with AEAP and those who underwent isolated primary ACLR. For subgroup analysis, outcomes were compared according to AEAP technique (ALLR vs LET) and time from injury to surgery (≤12 vs >12 months). The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool, Jadad scale, and Newcastle-Ottawa Scale. RESULTS Compared with isolated ACLR, combined ACLR with AEAP led to improved pivot-shift grades and graft failure rates, regardless of the AEAP technique or of time from injury to surgery. A limited, marginal improvement in subjective function score was observed in patients who underwent AEAP combined with ACLR. In contrast to ALLR, patients who underwent LET combined with ACLR had an increased risk of knee stiffness and adverse events. CONCLUSION Our review suggests that when there is a need to improve rotational stability and subjective function, AEAP combined with primary ACLR can be considered regardless of time from injury. ALLR appeared to be a better option for improving rotational stability compared with LET.
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Affiliation(s)
- Bo-Ram Na
- Department of Orthopedic Surgery, Chonnam National University
Hospital, Gwangju, Republic of Korea
| | - Woo-Kyoung Kwak
- Department of Orthopedic Surgery, Chonnam National University
Hospital, Gwangju, Republic of Korea
| | - Hyoung-Yeon Seo
- Department of Orthopedic Surgery, Chonnam National University
Hospital, Gwangju, Republic of Korea
- Department of Orthopedic Surgery, Chonnam National University
Medical School and Hospital, Chonnam, Republic of Korea
| | - Jong-Keun Seon
- Department of Orthopedic Surgery, Chonnam National University
Hospital, Gwangju, Republic of Korea
- Department of Orthopedic Surgery, Chonnam National University
Medical School and Hospital, Chonnam, Republic of Korea
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Chen J, Xu C, Cho E, Huangfu X, Zhao J. Reconstruction for Chronic ACL Tears with or without Anterolateral Structure Augmentation in Patients at High Risk for Clinical Failure: A Randomized Clinical Trial. J Bone Joint Surg Am 2021; 103:1482-1490. [PMID: 34138788 DOI: 10.2106/jbjs.20.01680] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this trial was to determine whether anterior cruciate ligament reconstruction (ACLR) with anterolateral structure augmentation (ALSA) would result in better clinical outcomes in patients with a high risk of clinical failure. METHODS From February 2017 to June 2018, 120 young, active adults with chronic anterior cruciate ligament injury and high risk of clinical failure were randomized. The patients were followed for >2 years, with 5 being lost to follow-up and 1 being withdrawn from the study. Clinical characteristics, operative findings, and postoperative clinical outcomes were analyzed. RESULTS The analysis included data from 114 patients, including 95 men and 19 women with a mean age (and standard deviation) of 30.1 ± 6.7 years in the ACLR group and 30.1 ± 6.4 years in the ALSA group. The rate of clinical failure was 20.4% (11 of 54 patients) and 3.3% (2 of 60 patients) in the ACLR and ALSA groups, respectively (difference, 17.1%; 95% confidence interval [CI], 5.3% to 29.8%; p = 0.007). Significantly higher rates of return to the preinjury level of sports (48.3% versus 27.8%; difference, 20.5%; 95% CI, 2.7% to 36.6%; p = 0.024) and to a competitive level of play (63.3% versus 42.6%; difference, 22.3%; 95% CI, 4.1% to 38.8%; p = 0.027) was found in the ALSA group. CONCLUSIONS Compared with isolated ACLR, combined ACLR and ALSA resulted in a reduction in persistent rotatory laxity and higher rates of return to preinjury and competitive levels of play at 2 years of follow-up in the population studied. Our study suggests that patients with high risk of clinical failure appear to be candidates for the ALSA approach. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
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Beckers L, Vivacqua T, Firth AD, Getgood AMJ. Clinical outcomes of contemporary lateral augmentation techniques in primary ACL reconstruction: a systematic review and meta-analysis. J Exp Orthop 2021; 8:59. [PMID: 34383156 PMCID: PMC8360253 DOI: 10.1186/s40634-021-00368-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/24/2021] [Indexed: 12/19/2022] Open
Abstract
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 6th, 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.
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Affiliation(s)
- Lucas Beckers
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Thiago Vivacqua
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Andrew D Firth
- Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Alan M J Getgood
- Department of Orthopedic Surgery, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
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Combined Anterolateral and Anterior Cruciate Ligament Reconstruction Improves Pivot Shift Compared With Isolated Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arthroscopy 2021; 37:2677-2703. [PMID: 33864833 DOI: 10.1016/j.arthro.2021.03.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis of the literature on anterolateral ligament (ALL) reconstruction as it relates to techniques, biomechanical properties, and clinical outcomes. METHODS PubMed, OVID/Medline, and Embase were queried in July 2020. Data pertaining to (1) techniques, (2) biomechanical properties, and (3) clinical outcomes of ALL reconstruction were recorded. DerSimonian-Laird random-effects meta-analyses were performed for included randomized controlled trials comparing combined ALL/anterior cruciate ligament (ACL) reconstruction and isolated ACL reconstruction. Data from lower levels of evidence were described qualitatively, and when possible, outcomes were reported as ranges to avoid inappropriate pooling of data. RESULTS A total of 46 articles were identified. Sixteen were biomechanical studies, 16 were clinical outcome studies, and 14 were technique studies. Of the 16 biomechanical studies, the majority demonstrated that anterior translation, internal rotation, and pivot shift was restored with combined ACL/ALL reconstruction and superior to ACL reconstruction alone. Ten biomechanical studies reported on constraint: 4 noted overconstraint when the femoral attachment site was proximal and posterior to the lateral femoral condyle, whereas 1 reported laxity. ACL failure rates after combined ACL/ALL reconstruction ranged between 2.7% and 11.1%. The mean postoperative Lysholm score ranged between 58.7 and 98.0; mean postoperative International Knee Documentation Committee score between 57.8 and 96.3; and mean postoperative Tegner score between 4 and 8. Six outcomes were explored through meta-analysis, of which the mean difference in Lysholm scores (2.26, P < .001) and restoration of pivot shift (relative risk 1.1, P = .046) was found to favor combined ACL/ALL reconstruction. CONCLUSIONS Although indications for ALL reconstruction remain heterogeneous, contemporary evidence suggests that ALL reconstruction improves pivot shift and confers comparable clinical and functional outcomes with isolated ACLR. LEVEL OF EVIDENCE IV, systematic review and meta-analysis.
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Feller JA, Devitt BM, Webster KE, Klemm HJ. Augmentation of Primary ACL Reconstruction With a Modified Ellison Lateral Extra-articular Tenodesis in High-Risk Patients: A Pilot Study. Orthop J Sports Med 2021; 9:23259671211021351. [PMID: 34409112 PMCID: PMC8366134 DOI: 10.1177/23259671211021351] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/18/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Lateral extra-articular tenodesis (LET) has been used to augment primary anterior cruciate ligament (ACL) reconstruction to reduce the risk of reinjury. Most LET procedures result in a construct that is fixed to both the femur and the tibia. In a modified Ellison procedure, the construct is only fixed distally, reducing the risk of inadvertently overconstraining the lateral compartment. PURPOSE To evaluate the use of the modified Ellison procedure in a cohort of patients deemed to be at a high risk of further ACL injury after primary ACL reconstruction. STUDY DESIGN Case series; Level of evidence, 4. METHODS Included were 25 consecutive patients with at least 2 of the following risk factors: age <20 years at the time of surgery, previous contralateral ACL reconstruction, positive family history of ACL rupture (parent or sibling), generalized ligamentous laxity (Beighton ≥4), grade 3 pivot shift in the consulting room, a desire to return to a pivoting sport, and an elite or professional status. All patients underwent primary ACL reconstruction with an additional modified Ellison procedure. Postoperatively, patients completed the IKDC subjective knee evaluation form (International Knee Documentation Committee), KOOS Quality of Life subscale (Knee injury and Osteoarthritis Outcome Score), ACL-Return to Sport After Injury Scale, Marx Activity Rating Scale, and SANE score (Single Assessment Numeric Evaluation). RESULTS At 12-month follow-up, the mean outcome scores were as follows: SANE, 94/100; IKDC, 92/100; Marx, 13/16; ACL-Return to Sport, 85/100; and KOOS, 77/100. At 24 months, return-to-sport data were available for 23 of 25 patients; 17 (74%) were playing at the same level or higher than preinjury and 2 at a lower level. One patient (4%) sustained a contact mechanism graft rupture at 12 months. There were 2 (9%) contralateral ACL injuries, including 1 ACL graft rupture, at 11 and 22 months postoperatively. There was a further contralateral ACL graft rupture at 26 months. CONCLUSION The use of the modified Ellison procedure as a LET augmentation of a primary ACL reconstruction to produce a low graft rupture rate appeared to be safe in a cohort considered to be at a high risk of reinjury. The procedure showed promise in terms of reducing further graft injuries.
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Affiliation(s)
- Julian A. Feller
- OrthoSport Victoria Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Brian M. Devitt
- OrthoSport Victoria Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Kate E. Webster
- School of Allied Health, La Trobe University, Melbourne, Australia
| | - Haydn J. Klemm
- OrthoSport Victoria Research Unit, Epworth HealthCare, Melbourne, Australia
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Yin J, Yang K, Zheng D, Xu N. Anatomic reconstruction of the anterior cruciate ligament of the knee with or without reconstruction of the anterolateral ligament: A meta-analysis. J Orthop Surg (Hong Kong) 2021; 29:2309499020985195. [PMID: 33410381 DOI: 10.1177/2309499020985195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To systematically analyze the effectiveness between combined anterior cruciate ligament and anterolateral ligament reconstruction (ACL+ALLR) and isolated anterior cruciate ligament reconstruction (ACLR) for treatment of patients with injured ACL. METHODS We performed a systematic search in MEDLINE, EMBASE, PubMed, Web of Science, Cochrane databases, Chinese Biomedical Literature Database, CNKI, and Wanfang Data for all relevant studies. All statistical analysis was performed using Review Manager version 5.3. RESULTS A total of six articles with 460 study subjects were included, with 193 patients in ACL+ALL reconstruction group and 267 patients in ACL reconstruction group. The results of the meta-analysis showed that the ACL+ALL reconstruction group had significantly lower KT measured value (P < 0.00001), Lachman test positive-rate (P = 0.02), Pivot-shift test positive-rate (P < 0.00001) and graft rupture rate (P = 0.02) compared with the ACL reconstruction group. Higher IKDC score (P < 0.00001) and Lysholm score (P < 0.00001) were measured in ACL+ALL reconstruction group, while infection rate (P = 0.86) and other complications rate (P = 0.29) showed no significant differences between the two groups. CONCLUSIONS Anatomic reconstruction of the ACL of the knee with reconstruction of the ALL indicates better postoperative knee function and clinical outcomes compared with isolated ACL reconstruction. The infection rate and other complications rate showed no significant difference between two groups.
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Affiliation(s)
- Jianjian Yin
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Kaiyuan Yang
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Dong Zheng
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
| | - Nanwei Xu
- Department of Orthopedics, The Affiliated Changzhou No.2 People's Hospital with Nanjing Medical University, Changzhou, China
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Chen J, Wang C, Xu C, Qiu J, Xu J, Tsai TY, Zhao J. Effects of Anterolateral Structure Augmentation on the In Vivo Kinematics of ACL-Reconstructed Knees: Response. Am J Sports Med 2021; 49:NP43-NP44. [PMID: 34259605 DOI: 10.1177/03635465211023749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Ahn JH, Koh IJ, McGarry MH, Patel NA, Lin CC, Lee TQ. Double-Bundle Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Tenodesis Is Effective in Restoring Knee Stability in a Chronic, Complex Anterior Cruciate Ligament-Injured Knee Model: A Cadaveric Biomechanical Study. Arthroscopy 2021; 37:2220-2234. [PMID: 33705893 DOI: 10.1016/j.arthro.2021.02.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 02/17/2021] [Accepted: 02/25/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare knee stability after intra-articular isolated double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) and single-bundle (SB) and DB ACLR combined with lateral extra-articular tenodesis (LET) in a chronic, complex anterior cruciate ligament (ACL)-injured knee model. METHODS In 10 fresh-frozen cadaveric knees, we measured knee laxity in the following order: (1) intact knee; (2) ACL-sectioned knee; (3) complex ACL-injured knee model with additional sectioning of the anterolateral complex and the posterior horns of the medial and lateral menisci; (4) SB ACLR plus LET; (5) DB ACLR; and (6) DB ACLR plus LET. RESULTS In comparison with the intact knee, significantly increased internal rotation (IR) laxity persisted at 60° and 90° after DB ACLR (P = .002 and P = .003, respectively). SB ACLR plus LET and DB ACLR plus LET resulted in significant reductions in IR laxity at 90° (P = .003 and P = .037, respectively), representing overconstraint in IR. SB ACLR plus LET resulted in persistently increased external rotation (ER) laxity at 30°, 60°, and 90° (P = .001, P < .001, and P < .001, respectively). The DB ACLR condition persistently showed significant increases in anterior tibial translation laxity at 60° and 90° (P = .037 and P = .024, respectively). A greater increase in ER laxity was seen after SB ACLR plus LET versus DB ACLR plus LET at 30°, 60°, and 90° (P < .001, P < .001, and P < .001, respectively). CONCLUSIONS DB ACLR plus LET restored intact knee stability in IR, ER, and anterior tibial translation laxity at 0°, 30°, 60°, and 90° of knee flexion except for overconstraint in IR at 90° in a chronic, complex ACL-injured knee model. CLINICAL RELEVANCE This cadaveric study provides some biomechanical evidence to support performing DB ACLR combined with LET to restore knee stability after a complex, chronic knee injury involving an ACL tear combined with anterolateral complex injury and irreparable tears of the posterior horns of the medial and lateral menisci.
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Affiliation(s)
- Ji Hyun Ahn
- Department of Orthopaedic Surgery, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea.
| | - In Jun Koh
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, U.S.A
| | - Nilay A Patel
- Department of Orthopaedic Surgery, University of California, Irvine, California, U.S.A
| | - Charles C Lin
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, U.S.A
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, U.S.A
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Espregueira-Mendes J. Is the anterolateral ligament the smoking gun to explain rotational knee laxity or just vaporware? J ISAKOS 2021; 6:63-65. [PMID: 33832978 DOI: 10.1136/jisakos-2020-000529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- João Espregueira-Mendes
- Clínica do Dragão, Espregueira-Mendes Sports Centre - FIFA Medical Centre of Excellence, Porto, Portugal .,Dom Henrique Research Centre, Porto, Portugal.,School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal.,3B's Research Group-Biomaterials, Biodegradablesand Biomimetics, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, University of Minho, AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra, Barco, Guimarães, Portugal
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Anterolateral ligament reconstruction improves the clinical and functional outcomes of anterior cruciate ligament reconstruction in athletes. Knee Surg Sports Traumatol Arthrosc 2021; 29:1173-1180. [PMID: 32617609 DOI: 10.1007/s00167-020-06119-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 06/24/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE To compare the outcomes of anterior cruciate ligament (ACL) reconstruction with those of combined ACL and anterolateral ligament (ALL) reconstruction in ACL-deficient knees. The objective of this study was to improve knowledge regarding the treatment of ACL-deficient knees with combined ACL and ALL reconstruction. Combined ACL and ALL reconstruction has been hypothesized to result in better clinical and functional outcomes than isolated ACL reconstruction (ACLR). METHODS One-hundred and seven adult male athletes with ACL tears and high-grade pivot shifts were randomized into two groups. Those in group A (n = 54) underwent ACLR, while those in group B (n = 53) underwent combined ACL and ALL reconstruction. The median age was 26 (18-40) and 24 (18-33) years in groups A and B, respectively, and the median follow-up was 60 (55-65) months. Physical examination findings, instrumented knee laxity tested using a KT-1000 arthrometer, and International Knee Documentation Committee Scale (IKDC) scores were used to evaluate the outcomes. RESULTS One-hundred and two patients were available for follow-up: 52 in group A and 50 in group B. Postoperatively, the pivot shift was normal in 43 (82.7%) and 48 (96%) patients in groups A and B, respectively (p < 0.001). The median instrumented knee laxity was 2.5 ± 0.7 (1.2-6.1) mm in patients in group A and 1.2 ± 0.7 (1.2-3.2) mm in patients in group B (p < 0.001). Additionally, 44 (84.6%) patients in group A had normal IKDC scores and 3 (5.8%) had nearly normal scores, while 48 (96.0%) patients in group B had normal IKDC scores and 2 (4%) had nearly normal scores (p < 0.001). CONCLUSION Combined ACL and ALL reconstruction, compared with isolated ACLR resulted in favourable clinical and functional outcomes, as demonstrated by decreased rotational instability and instrumented knee laxity, a lower graft rupture rate and better postoperative IKDC scores. LEVEL OF EVIDENCE 1.
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Saithna A, Helito CP, Carrozzo A, Kim JG, Sonnery-Cottet B. Regarding "The Effect of Combined Anterolateral and Anterior Cruciate Ligament Reconstruction on Reducing Pivot Shift Rate and Clinical Outcomes: A Meta-analysis". Arthroscopy 2021; 37:787-789. [PMID: 33673961 DOI: 10.1016/j.arthro.2020.12.200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 12/15/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Adnan Saithna
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri, U.S.A
| | - Camilo P Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Jin Goo Kim
- Konkuk University Medical Center, Seoul, Republic of Korea
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Xu C, Chen J, Cho E, Zhao J. Author Reply to "Regarding 'The Effect of Combined Anterolateral and Anterior Cruciate Ligament Reconstruction on Reducing Pivot Shift Rate and Clinical Outcomes: A Meta-analysis'". Arthroscopy 2021; 37:789-791. [PMID: 33673962 DOI: 10.1016/j.arthro.2020.12.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/15/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Eunshinae Cho
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Hurley ET, Fried JW, Kingery MT, Strauss EJ, Alaia MJ. Antero-lateral ligament reconstruction improves knee stability alongside anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:764-771. [PMID: 32322949 DOI: 10.1007/s00167-020-06002-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/16/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE Recent evidence has found the antero-lateral ligament (ALL) may play a role in stabilizing the knee, but its role in anterior cruciate ligament (ACL) reconstruction is controversial. The purpose of the current study is to systematically review and meta-analyze the current evidence in the literature to ascertain whether ACL reconstruction combined with ALL reconstruction affects knee stability, re-rupture rates and patient-reported outcomes compared to ACL reconstructions performed alone. METHODS A literature search was performed based on the PRISMA guidelines. Cohort studies comparing ACL + ALL reconstruction and ACL reconstruction alone were included. RESULTS Six clinical trials (LOE I: I, LOE II: 2, LOE III: 3) with 729 patients were included, with a mean follow-up time of 34.2 (24-54.9) months. There was a significant difference in favor of combined ACL + ALL reconstruction for reduced re-rupture rate (2.4% vs 7.3%, p < 0.01), residual positive pivot shift rate (33.3% vs 11.4%, p < 0.01), and reduced KT-arthrometer evaluation (1.6 vs 2.6, p < 0.01). Combined ACL + ALL reconstruction resulted in improved IKDC scores (92.5 vs 87.8, p < 0.01), Lysholm scores (95.7 vs 91.2, p < 0.01) and Tegner scores (6.7 vs 5.7, p < 0.01). There was no significant difference in rate of return to play at the same level (54.3% vs 46.0%, n.s.). CONCLUSION The current evidence suggests alongside soft tissue graft ACL reconstruction that concomitant ALL reconstruction improves clinical outcomes, with improved knee stability and lower re-rupture rates. LEVEL OF EVIDENCE III.
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Ahn JH, Kim J, Mun JW. A Retrospective Comparison of Single-Bundle Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Tenodesis With Double-Bundle Anterior Cruciate Ligament Reconstruction. Arthroscopy 2021; 37:976-984. [PMID: 33188853 DOI: 10.1016/j.arthro.2020.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/31/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Ji Hyun Ahn
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggido, Republic of Korea.
| | - Jaehyun Kim
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggido, Republic of Korea
| | - Ji Weon Mun
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggido, Republic of Korea
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Chen J, Wang C, Xu C, Qiu J, Xu J, Tsai TY, Zhao J. Effects of Anterolateral Structure Augmentation on the In Vivo Kinematics of Anterior Cruciate Ligament-Reconstructed Knees. Am J Sports Med 2021; 49:656-666. [PMID: 33464924 DOI: 10.1177/0363546520981743] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Double-bundle anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-known treatment that restores the stability of ACL-deficient knees. However, some isolated ACL-reconstructed knees ultimately show rotatory laxity and develop osteoarthritis. Whether combined ACLR with anterolateral structure (ALS) augmentation (ALSA) can provide better improvement in the in vivo knee rotational kinematics remains unknown. HYPOTHESIS When compared with isolated double-bundle ACLR, combined double-bundle ACLR with ALSA can improve knee in vivo rotational kinematics and provide better restoration of knee kinematics. STUDY DESIGN Controlled laboratory study. METHODS Sixteen patients with unilateral ACL injury were randomly divided into 2 groups to receive either combined double-bundle ACLR and ALSA (ALSA group) or isolated double-bundle ACLR (ACLR group). All patients performed a single-leg lunge using the operative and nonoperative/contralateral legs under dual-fluoroscopic imaging system surveillance during a hospital visit at a minimum 1 year (12-13 months) of follow-up to assess the 6 degrees of freedom knee kinematics. Functional evaluation using the Lysholm and Marx rating scales and clinical examinations were also performed. RESULTS From full extension to approximately 90° of knee flexion at 5° intervals, the mean ± SD internal rotation of the reconstructed knees in the ALSA group (1.5°± 0.9°) was significantly smaller than that of the contralateral knees (8.2°± 1.9°; P = .008). The ALSA group knees also showed significantly (P = .045) more medial translation than the contralateral knees. In the ACLR group, the mean internal rotation of the reconstructed knee (6.0°± 2.1°) was significantly smaller than that of the contralateral knees (8.9°± 0.6°; P < .001). At full extension, the tibia was significantly more externally rotated than that of the contralateral legs (0.5°± 7.4° vs 7.6°± 3.4°, P = .049). CONCLUSION When compared with isolated double-bundle ACLR, double-bundle ACLR augmented with ALS reconstruction resulted in anterolateral rotatory overconstraint during the lunge motion. CLINICAL RELEVANCE Additional ALSA of double-bundle ACL-reconstructed knees overconstrained rotatory stability. Therefore, the use of ALSA for ACL-reconstructed knees should be considered with caution for patients with ACL deficiency and anterolateral rotatory instability. Longer-term follow-up to evaluate long-term outcomes and altered kinematics over time is recommended.
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Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cong Wang
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China.,Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiayu Qiu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering and Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China.,Engineering Research Center of Digital Medicine and Clinical Translation, Ministry of Education, Shanghai, China.,Shanghai Key Laboratory of Orthopaedic Implants and Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Blanke F, Boljen M, Lutter C, Oehler N, Tischer T, Vogt S. Does the anterolateral ligament protect the anterior cruciate ligament in the most common injury mechanisms? A human knee model study. Knee 2021; 29:381-389. [PMID: 33711673 DOI: 10.1016/j.knee.2021.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/01/2020] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction still has a risk of re-rupture and persisting rotational instability. Thus, extra-articular structures such as the anterolateral ligament (ALL) are increasingly treated. The ALL however prevents the internal rotation of the tibia and it must be doubted that the ALL protects the ACL in other common injury mechanisms which primarily include tibial external rotation. In this study we aimed to evaluate which extra-articular structures support the ACL in excessive tibial internal and external rotation using a knee finite element (FE) model. METHODS Internal and external rotations of the tibia were applied to an FE model with anatomical ACL, posterior cruciate ligament (PCL), lateral collateral ligament (LCL), medial collateral ligament (MCL) and intact medial and lateral meniscus. Three additional anatomic structures (anterolateral ligament, popliteal tendon and posterior oblique ligament) were added to the FE model separately and then all together. The force histories within all structures were measured and determined for each case. RESULTS The ACL was the most loaded ligament both in tibial internal and external rotation. The ALL was the main stabilizer of the tibial internal rotation (46%) and prevented the tibial external rotation by only 3%. High forces were only observed in the LCL with tibial external rotation. The ALL reduced the load on the ACL in tibial internal rotation by 21%, in tibial external rotation only by 2%. The POL reduced the load on the ACL by 8%, the PLT by 6% in tibial internal rotation. In tibial external rotation the POL and PLT did not reduce the load on the ACL by more than 1%. CONCLUSION The ALL protects the ACL in injury mechanisms with tibial internal rotation but not in mechanisms with tibial external rotation. In injury mechanisms with tibial external rotation other structures that support the ACL need to be considered.
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Affiliation(s)
- F Blanke
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany; Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany.
| | - M Boljen
- Fraunhofer Institute for High-Speed Dynamics, Ernst-Mach-Institut, EMI, Freiburg i. Breisgau, Germany
| | - C Lutter
- Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany
| | - N Oehler
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany
| | - T Tischer
- Department of Orthopedic Surgery, University Hospital Rostock, Rostock, Germany
| | - S Vogt
- Department of Orthopedic Sports Medicine and Arthroscopic Surgery, Hessing Stiftung Augsburg, Augsburg, Germany
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Bucar AL, Pires RNDA, Silva RDC, Araujo EACD, da Silva MF, de Araujo PHN. Combined Reconstruction of the Anterior Cruciate Ligament and Anterolateral Ligament Injury Compared to the Isolated Reconstruction of the Anterior Cruciate Ligament: A Meta-Analysis. Rev Bras Ortop 2021; 56:24-30. [PMID: 33627895 PMCID: PMC7895624 DOI: 10.1055/s-0040-1709990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/02/2020] [Indexed: 01/26/2023] Open
Abstract
The present research aims to compare the outcomes from the combined reconstruction of the anterior cruciate ligament (ACL) and of the anterolateral ligament (ALL) with the standard isolated ACL reconstruction in patients with chronic ACL injury. To do so, a meta-analysis was carried out to determine whether the combined ACL and ALL reconstruction would lead to a significant improvement in knee function according to the International Knee Documentation Committee (IKDC), the Lysholm test and KT-2000 evaluation scores and lower graft rupture rates in comparison with isolated reconstruction. To identify randomized controlled trials (RCTs) comparing the combined ACL and ALL reconstruction with the isolated ACL reconstruction, papers published between 2010 and 2019 were searched in the MEDLINE, EMBASE, SPORTDiscus, LILACS and Cochrane Central Register of Controlled Trials databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The stability of the knee joint is only marginally improved with the combined reconstruction of ACL and ALL, and both reconstruction techniques show functional results. The main outcomes sought were patient function and graft stability and rupture rates after ACL reconstruction. Out of the 421 studies identified, 6 were included in our meta-analysis. Study quality (internal validity) was assessed using the Cochrane risk-of-bias tool; in general, the studies included presented moderate-quality evidence. The graft rupture rate was higher in patients undergoing isolated ACL reconstruction (relative risk, 0.22; 95% confidence interval, 0.12 to 0.41; p < 0.00001).
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Affiliation(s)
- Augusto Leão Bucar
- Departamento de Ortopedia, Hospital das Forças Armadas, Brasília, DF, Brasil
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Xu C, Chen J, Cho E, Zhao J. The Effect of Combined Anterolateral and Anterior Cruciate Ligament Reconstruction on Reducing Pivot Shift Rate and Clinical Outcomes: A Meta-analysis. Arthroscopy 2021; 37:694-705. [PMID: 33098948 DOI: 10.1016/j.arthro.2020.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/01/2020] [Accepted: 10/10/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether combined anterior cruciate ligament reconstruction (ACLR) and anterolateral ligament reconstruction (ALLR) result in better knee rotatory stability and postoperative clinical outcomes than ACLR alone. METHODS A computer literature search was conducted of Medline (1982 to April 2020), Embase (1982 to April 2020), OVID (1982 to April 2020), and the Cochrane Library (1982 to April 2020) to screen all therapeutic trials on combined ACLR and ALLR versus isolated ACLR. Only level of evidence I and II clinical studies were included. The outcome measures included (1) objective knee stability examination such as anterior drawer test, Lachman test, KT-arthrometer measurement, and pivot shift test; (2) patient-reported outcomes such as International Knee Documentation Committee (IKDC), Tegner activity score, and Lysholm score; (3) return to play; and (4) graft rupture rate. Data were extracted, pooled, and analyzed to compare the 2 groups. RESULTS A total of 890 studies were screened, and 884 were excluded. Six clinical trials with 828 subjects were included in the final meta-analysis. In comparison to patients received combined ACLR and ALLR, patients who received isolated ACLR had a significantly lower negative pivot shift test rate (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.23 to 0.92, I2 = 0%, P = .03, 95% prediction interval [PrI] 1.00 to 2.26), Lysholm score (mean difference -2.79, 95 % CI -4.68 to -0.91, I2 = 77 %, P = .004, 95% PrI -10.81 to 5.42), Tegner score (mean difference -0.57, 95% CI -1.12 to -0.02, I2 = 90 %, P = .04, 95% PrI -3.12 to 1.93). CONCLUSIONS Combined ALLR and ACLR could effectively augment knee rotatory stability by reducing pivot shift rate and moderately improve patients' clinical outcomes. However, the effect of ALLR on overall graft rupture rate cannot be confirmed. LEVEL OF EVIDENCE II, meta-analysis of level I and II studies.
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Affiliation(s)
- Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Eunshinae Cho
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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