Clinical Outcomes of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis Combined With Primary ACL Reconstruction: A Systematic Review With Meta-analysis

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.

Graft Rupture Rates After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction: A Matched-Pair Analysis From the SANTI Study Group

Background: Clinical studies have demonstrated significant advantages of combined anterior cruciate ligament and anterolateral ligament reconstruction (ACL+ALLR) over isolated ACL reconstruction (ACLR) with respect to reduced graft rupture rates, a lower risk of reoperation for secondary meniscectomy, improved knee stability, and higher rates of return to sports. However, no long-term studies exist. Purpose/Hypothesis: The purpose of this study was to compare the outcomes of isolated ACLR versus ACL+ALLR at long-term follow-up. The hypothesis was that patients who underwent combined procedures would experience significantly lower rates of graft rupture. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing primary ACL+ALLR between January 2011 and March 2012 were propensity matched in a 1:1 ratio to patients who underwent isolated ACLR during the same period. A combination of face-to-face and telemedicine postoperative follow-up was undertaken. At the end of the study period (March 2020), medical notes and a final telemedicine interview were used to determine whether patients had experienced any complications or reoperations. The Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee score, Lysholm score, and Tegner score were collected for all patients. Graft survivorship was assessed using Kaplan-Meier analysis. Logistic regression was performed to account for the potential effect of activity level on graft rupture rates. Results: A total of 86 matched pairs were included in the study. The mean ± SD age was 32.2 ± 8.8 years (range, 22-67 years) in the ACL+ALLR group and 34.7 ± 8.5 years (range, 21-61 years) in the isolated ACLR group. The mean duration of follow-up was 104.33 ± 3.74 months (range, 97-111 months). Patients who underwent combined ACL+ALLR versus isolated ACLR experienced significantly better ACL graft survivorship (96.5% vs 82.6%, respectively; P = .0027), lower overall rates of reoperation (15.3% vs 32.6%; P < .05), and lower rates of revision ACLR (3.5% vs 17.4%; P < .05). Patients undergoing isolated ACLR were at >5-fold greater risk of graft rupture (odds ratio, 5.549; 95% CI, 1.431-21.511; P = .0132), regardless of their preinjury activity level. There were no significant differences between groups with respect to other complications or any clinically important differences in patient-reported outcome measures. Conclusion: Patients who underwent combined ACL+ALLR experienced significantly better long-term ACL graft survivorship, lower overall rates of reoperation, and no increase in complications compared with patients who underwent isolated ACLR. Further, patients who underwent isolated ACLR had a >5-fold increased risk of undergoing revision surgery at a mean follow-up of 104.3 months.

Biomechanical Effects of Combined Anterior Cruciate Ligament Reconstruction and Anterolateral Ligament Reconstruction: A Systematic Review and Meta-analysis

Background: Combined anterior cruciate ligament (ACL) reconstruction (ACLR) and anterolateral ligament reconstruction (ALLR) are performed with the intention to restore native knee kinematics after ACL tears. There continue to be varying results as to the difference in kinematics between combined and isolated procedures, including anterior tibial translation (ATT) and internal tibial rotation (IR). Purpose: To perform a systematic review and meta-analysis to evaluate the kinematic changes of a combined ACLR/ALLR versus isolated ACLR and to assess the effects of different fixation techniques. Study Design: Systematic review. Methods: We conducted a systematic review and meta-analysis of 15 human cadaveric biomechanical studies evaluating combined ACLR/ALLR versus isolated ACLR and their effects on ATT and IR in 149 specimens. The primary outcomes were ATT and IR. Secondary outcomes included graft type and size as well as fixation methods such as type, angle, tension, and position of fixation. Meta-regression was used to examine the effect of various cofactors on the resulting measures. Results: Compared with isolated ACLR, combined ACLR/ALLR decreased ATT and IR by 0.01 mm (95% CI, –0.059 to 0.079 mm; P = .777) and 1.64° (95% CI, 1.30°-1.98°; P < .001), respectively. Regarding ACLR/ALLR, increasing the knee flexion angle and applied IR force led to a significant reduction in IR ( P < .001 and P = .044, respectively). There was also a significant reduction in IR in combined procedures with semitendinosus ALL graft, higher flexion fixation angles, and tension but no change in IR with differing femoral fixation points ( P < .001, P < .001, and P = .268, respectively). Multivariate meta-regression showed that the use of tibial-sided suture anchor fixation significantly reduced IR ( P < .001). Conclusion: These results suggest that a combined ACLR/ALLR procedure significantly decreases IR compared with isolated ACLR, especially at higher knee flexion angles. Semitendinosus ALL graft, fixation at higher knee flexion, increased tensioning, and tibial-sided interference screw fixation in ALLR may help to further reduce IR.

Anterolateral ligament reconstruction associated with hamstring ACL reconstruction reduces the rate of repeat graft ruptures in a population of young athletes at follow-up in 2 years

Objectives: The rate of repeat graft ruptures in young athletes is a major concern after ACL reconstruction. Our objective was to evaluate the association between two reconstruction techniques and repeat ruptures, repeat surgery, return to sports and complications in center playing sportspersons younger than 20 years of age. Methods: A prospective study was conducted in patients under 20 years of age who were center players and who had primary ACL reconstruction with a semitendinosus graft (ST4) by a suspension technique, or a semitendinosus graft with suspension technique combined with independent anterolateral ligament reconstruction (ST4+ALL). Patients were followed up in a minimum of 2 years. Survival data from the Kaplan-Meier analysis were used as well as multivariate logistic regression to identify risk factors for repeat rupture. 203 patients (mean age, 16.3±2 years) with a mean follow-up of 40.6±11 months (24-63 months) were included. There were 101 patients in the ST4 group, and 102 patients in the ST4+ALL group. Results: There was a 9.9% repeat in ruptures in the ST4 group versus 5.8% in the ST4+ALL group (p=0.288). The rate of repeat ruptures in the ST4+ALL group was 5 times lower than in the ST4 group in multivariate analysis (odds ratio [OR], 0.201; 95% CI, 0.044-0.922). There was a 6.9% rate of secondary meniscal procedures in the ST4 group versus 1.9% in the ST4+ALL group (p=0.101). Differential laxity was 1.3±1.3 (-2 - 5) in the ST4 group versus 0.9±1.3 (-6 - 4.8) in the ST4+ALL group (p=0.008). There was a 42.2% return to the same sports level in the ST4 group versus 52% in the ST4+ALL group (p=0.178). The mean postoperative scores at the last follow-up were: IKDC: 83.3±14.3 and 82±14.4; ACL-RSI: 69.8±23.5 and 67.4±22.4; Tegner: 6.6±1.8 and 6.9±1.8 and Lysholm: 86.4±15.2 and 86±16.8; for ST4 and ST4+ALL groups, respectively. Conclusion: Anterolateral ligament reconstruction reduces the rate of repeat ruptures in athletes younger than 20 years of age after a semitendinosus graft. It is also associated with fewer secondary meniscal procedures, better control of laxity and a better rate of return to the same level of sports without further complications.