Intra-articular Anterior Cruciate Ligament Reconstruction Research Articles

Clinical Results of Lateral Extra-Articular Tenodesis.

In the anterior cruciate ligament (ACL) deficient knee, excellent outcomes are achieved in many patients with an isolated, intra-articular ACL reconstruction. Some patients, however, have ongoing instability or suffer graft rupture. Failure after ACL reconstruction is multifactorial, but residual anterolateral rotatory laxity is 1 potential contributing factor. Lateral extra-articular procedures are a heterogenous group of operations that were initially described as isolated treatments for the ACL deficient knee, and subsequently used in combination with intra-articular reconstructions. Initial observational studies were encouraging, however, comparative studies were less flattering and lead to a general abandonment of these procedures. With improved understanding of the anatomy and biomechanics of the anterolateral capsuloligamentous complex there has been a renewed interest in these procedures. Recent systematic reviews suggest efficacy of these procedures in improving rotational control, though data showing improved patient reported outcomes or reduced graft rupture rates are lacking. Preliminary results from ongoing clinical trials are supportive for lateral extra-articular tenodesis when used as an augment to modern, intra-articular ACL reconstructions in targeted, high-risk patients.

Role of anterolateral reconstruction in patients undergoing anterior cruciate ligament reconstruction.

There is renewed interest in anterolateral reconstruction (ALR) for patients undergoing anterior cruciate ligament (ACL) reconstruction. This is the result of isolated ACL reconstruction and double-bundle reconstruction providing inadequate control over the pivot shift, and recent anatomical and biomechanical studies on the anterolateral ligament (ALL) and its role in the knee's rotational stability. From a technical point of view, ALR can be performed either as a continuity of the intra-articular ACL reconstruction or an independent procedure. The typical peripheral grafts (gracilis and semitendinosus tendons, iliotibial band) can be used. The femoral tunnel must be posterior and proximal to the lateral epicondyle, and the tibial tunnel on a line joining Gerdy's tubercle with the ALL's tibial insertion. Tensioning and fixation are done with the knee near full extension and the tibia in neutral rotation. The ALR complication rate reported in older studies (pain, hematoma, scar damage) has been reduced. Relative to isolated ACL reconstruction, ALR does not alter the infection or stiffness rate, and it reduces the re-injury rate and secondary meniscal damage rate. Analysis of the literature has not shown an increased rate of osteoarthritis after ALR. The objective and functional outcomes are equal to those after isolated ACL reconstruction. Control over rotation is improved by adding ALR and the return to pivot sports appears to be more successful. While the indications must still be refined, ALR can be proposed to young patients undergoing ACL reconstruction who participate in high-intensity pivot sports, have a high-grade pivot shift or who have a failed ACL reconstruction.

Anterior Cruciate Ligament Injury, Reconstruction, and the Optimization of Outcome.

Anterior cruciate ligament reconstruction (ACLR) provides an established surgical intervention to control pathological tibiofemoral translational and rotational movement. ACLR is a safe and reproducible intervention, but there remains an underlying rate of failure to return to preinjury sporting activity levels. Postoperative pathological laxity and graft reinjury remain concerns. Previously, unrecognized meniscal lesions, disruption of the lateral capsule, and extracapsular structures offer potential avenues to treat and to therefore improve kinematic outcome and functional results, following reconstruction. Addressing laterally based injuries may also improve the durability of intraarticular ACLR. Improving the anterior cruciate ligament (ACL) graft replication of the normal ACL attachment points on the femur and the tibia, using either double bundle or anatomical single bundle techniques, improves kinematics, which may benefit outcome and functionality, following reconstruction.

Short-term complications in intra- and extra-articular anterior cruciate ligament reconstruction. Comparison with the literature on isolated intra-articular reconstruction. A multicenter study by the French Arthroscopy Society

IntroductionLateral tenodesis (LT) is performed to limit the risk of iterative tear following anterior cruciate ligament (ACL) reconstruction in at-risk patients. By adding an extra procedure to isolated ACL graft, LT reconstruction increases operating time and may complicate postoperative course. The objective of the present study was to evaluate the rate of early complications. The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction. Material and methodsA prospective multicenter study included 392 patients: 70% male; mean age, 29.9 years; treated by associated ACL and LT reconstruction. All adverse events were inventoried. ResultsMean hospital stay was 2 days, with 46% day-surgery. Walking was resumed at a mean 27 days, with an advantage for patients treated by the hamstring technique. The early postoperative complications rate was 12%, with 1.7% specifically implicating LT reconstruction: pain, hematoma, stiffness in flexion and extension, and infection. There was a 5% rate of surgical revision during the first year, predominantly comprising arthrolysis for extension deficit. The 1-year recurrence rate was 2.8%. DiscussionThe complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction, with no increase in infection or stiffness rates. The rate of complications specific to ALL reconstruction was low, at 1.7%, and mainly involved fixation error causing lateral soft-tissue impingement. Level of evidenceIV, prospective multicenter study.

Anterolateral Tenodesis or Anterolateral Ligament Complex Reconstruction: Effect of Flexion Angle at Graft Fixation When Combined With ACL Reconstruction

Background: Despite numerous technical descriptions of anterolateral procedures, knowledge is limited regarding the effect of knee flexion angle during graft fixation. Purpose: To determine the effect of knee flexion angle during graft fixation on tibiofemoral joint kinematics for a modified Lemaire tenodesis or an anterolateral ligament (ALL) complex reconstruction combined with anterior cruciate ligament (ACL) reconstruction. Study Design: Controlled laboratory study. Methods: Twelve cadaveric knees were mounted in a test rig with kinematics recorded from 0° to 90° flexion. Loads applied to the tibia were 90-N anterior translation, 5-N·m internal tibial rotation, and combined 90-N anterior force and 5-N·m internal rotation. Intact, ACL-deficient, and combined ACL plus anterolateral-deficient states were tested, and then ACL reconstruction was performed and testing was repeated. Thereafter, modified Lemaire tenodeses and ALL procedures with graft fixation at 0°, 30°, and 60° of knee flexion and 20-N graft tension were performed combined with the ACL reconstruction, and repeat testing was performed throughout. Repeated-measures analysis of variance and Bonferroni-adjusted t tests were used for statistical analysis. Results: In combined ACL and anterolateral deficiency, isolated ACL reconstruction left residual laxity for both anterior translation and internal rotation. Anterior translation was restored for all combinations of ACL and anterolateral procedures. The combined ACL reconstruction and ALL procedure restored intact knee kinematics when the graft was fixed in full extension, but when the graft was fixed in 30° and 60°, the combined procedure left residual laxity in internal rotation (P = .043). The combined ACL reconstruction and modified Lemaire procedure restored internal rotation regardless of knee flexion angle at graft fixation. When the combined ACL reconstruction and lateral procedure states were compared with the ACL-only reconstructed state, a significant reduction in internal rotation laxity was seen with the modified Lemaire tenodesis but not with the ALL procedure. Conclusion: In a knee with combined ACL and anterolateral ligament injuries, the modified Lemaire tenodesis combined with ACL reconstruction restored normal laxities at all angles of flexion for graft fixation (0°, 30°, or 60°), with 20 N of tension. The combined ACL and ALL procedure restored intact knee kinematics when tensioned in full extension. Clinical Relevance: In combined anterolateral procedure plus intra-articular ACL reconstruction, the knee flexion angle is important when fixing the graft. A modified Lemaire procedure restored intact knee laxities when fixation was performed at 0°, 30°, or 60° of flexion. The ALL procedure restored normal laxities only when fixation occurred in full extension.

Intra-articular Anterior Cruciate Ligament Reconstruction With Extra-articular Lateral Tenodesis of the Iliotibial Band

An increasing concern has been given to the rotation stability of the knee in the setting of an anterior cruciate ligament (ACL) reconstruction. This growing interest stems from a better understanding of the rotational stability of the knee afforded by the identification of the anterolateral ligament. Previously, a residual abnormal pivot-shift test had been found after an anatomic single-band reconstruction of the ACL because of a lack of rotational stability, which may lead to the development of osteoarthritis. Residual instability affects function, especially in high-demand athletes who perform many flexion-rotation movements during sporting activity. The purpose of this Technical Note is to describe our preferred method of intra-articular ACL reconstruction using a hamstring tendon autograft in combination with an extra-articular iliotibial band tenodesis for reinforcement of rotational stability.

The Effects of Anterolateral Tenodesis on Tibiofemoral Contact Pressures and Kinematics

Background: Anterolateral tenodeses are increasingly popular in combination with intra-articular anterior cruciate ligament reconstructions. Despite the perception of risk of overconstraint and lateral osteoarthritis, evidence is lacking regarding the effect of graft tensioning on knee kinematics and intra-articular compartmental joint pressures. Purpose: To investigate tibiofemoral joint contact pressures and kinematics related to an anterolateral lesion and the effectiveness of a MacIntosh tenodesis in restoring these when varying (1) graft tension and (2) tibial rotation during graft fixation. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric knees were tested in a customized rig with femur fixed and tibia free to move from 0° to 90° of flexion. The quadriceps and iliotibial band were loaded by means of a weighted pulley system. At 30° intervals of knee flexion, tibiofemoral contact pressures were measured with a Tekscan sensor and tibiofemoral kinematics were recorded by use of an optical tracking system. The knee was tested intact and then with an anterolateral soft tissue transection. MacIntosh tenodeses were then tested in a randomized order with 20 N or 80 N of graft tension, each with the tibia held in neutral intact alignment or free to rotate. Results: Tibial anterior translation and internal rotation were significantly increased and lateral contact pressures significantly reduced compared with the intact knee following anterolateral soft tissue cutting (P < .05). Contact pressures were restored with fixed neutral tibial rotation combined with 20 N or 80 N of graft tension or by a free-hanging tibia with 20 N of graft tension (all P values > .5). Grafts tensioned with 80 N caused significant overconstraint both when the tibia was fixed and free hanging (all P values < .05). Increases in the lateral tibiofemoral contact pressures were also seen when the tibia was free hanging and 80 N was used for graft tension (P < .05). Conclusion: Anterolateral soft tissue injury caused reduced lateral tibiofemoral contact pressures and altered tibiofemoral kinematics; these were restored with a MacIntosh procedure performed with 20 N of graft tension. If 80 N of graft tension was used, increased lateral contact pressures and overconstraint in internal rotation were seen. With the tibia free hanging, intact contact biomechanics were restored when 20 N of graft tension was applied, but 80 N of graft tension significantly increased lateral tibiofemoral pressures and overconstrained internal rotation. The kinematic and contact pressure effects were significantly correlated: Changes in tibial rotation caused by increased graft tension correlated with elevated lateral articular contact pressure. Clinical Relevance: Controlling tibial position appears important when tensioning anterolateral tenodeses. However, the identified changes were subtle and may not be clinically significant in a fully loaded knee.

Combined Anatomic Reconstruction of the Anterior Cruciate and Anterolateral Ligaments Using Hamstring Graft Through a Single Femoral Tunnel and With a Single Femoral Fixation

Patients with complete anterior cruciate ligament (ACL) injury have different degrees of rotational (internal rotation) laxity. A residual pivot shift has been found to be positive in more than 15% of cases after an accurate ACL reconstruction. Improved understanding of the existence, function, and biomechanical role of the anterolateral ligament (ALL) in controlling rotational instability of the knee has redirected and refocused attention on a supplemental extra-articular reconstruction of the ALL in conjunction with the intra-articular ACL reconstruction so as to restore normal kinematics of the knee. This Technical Note describes a technique that allows for a combined ACL and ALL reconstruction using autogenous hamstring graft (semitendinosus and gracilis tendons). One femoral tunnel is used connecting the anatomic femoral attachment of the ALL on the lateral wall of the lateral femoral condyle to the anatomic femoral ACL footprint on the medial wall of the lateral femoral condyle. The remaining part of the graft is fixed to the proximal tibia midway between Gordy's tubercle and the head of the fibula. This Technical Note describes a technique of both ACL and ALL reconstruction with a continuous hamstring graft.

Postoperative Knee Joint Stability Following Anterior Cruciate Ligament Reconstruction Using the Ligament Advanced Reinforcement System.

One of the goals of the synthetic materials used in knee joint reconstruction of the anterior cruciate ligament (ACL) is to improve the strength and stability of the graft immediately after the reconstruction. One of the synthetic grafts is a non-absorbable synthetic ligament device made of terephthalic polyethylene polyester fibers, the Ligament Advanced Reinforcement System (LARS). The aim of the study was to assess postoperative knee joint stability in patients who had undergone ACL reconstruction using the LARS graft. The study group was comprised of 20 males who had undergone primary unilateral intraarticular ACL reconstruction using LARS. The patients were evaluated one day before the reconstruction and an average of six weeks postoperatively. Knee stability was evaluated manually using the Lachman test, anterior drawer test and pivot-shift test. Knee active range of motion (ROM) was measured. Preoperatively, the Lachman test indicated abnormal/2+ results in the vast majority of the patients. The postoperative results in most of the patients were normal/0. The anterior drawer test results were also abnormal/2+ preoperatively and normal/0 postoperatively. The pivot-shift test was positive in all of the patients before the ACL reconstruction and negative after the surgery. In general, no differences were found in the ROM between the involved and uninvolved limbs and in the between-measurement comparison. The evaluation demonstrated significant progress from the preoperative to postoperative results in reducing anterior translation and anterolateral rotational instability of the tibia in patients who had undergone ACL reconstruction using the synthetic LARS graft. In the short-term follow-up assessments, restoration of anterior and anterolateral rotational stability of the operated knee joints was observed.

Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: a systematic review and best evidence synthesis.

The role of lateral extra-articular tenodesis (LEAT) as an augment to primary anterior cruciate ligament reconstruction (ACLR) remains controversial. However, concerns exist regarding the risk of development of osteoarthritis due to over constraint of the knee. To systematically review the literature to analyse the long-term incidence of osteoarthritis in patients who had an LEAT performed in isolation or in combination with intra-articular ACLR for the treatment of ACL deficiency. Two reviewers independently searched five databases for randomized controlled trials (RCTs), non-randomized comparative, and retrospective cohort studies (CS) with long-term radiological follow-up of patients with ACL deficiency treated with ACLR combined with LEAT or LEAT in isolation. Risk of bias was performed using a modified Downs & Black's checklist. The primary outcome was the development of osteoarthritis. The studies were divided into those with moderate/severe osteoarthritis at between 5 to 10 years and >10-year follow-up. The rate of meniscal pathology at the time of the index surgery was recorded. A best evidence synthesis was performed. Eight studies reported on 421 patients in which an LEAT procedure was carried out. There were two high-quality RCTs and six low-quality CS. The follow-up was between 5- and 10-years in 5 studies and >10-years in 3. The presence of moderate/severe osteoarthritis was not detected in three studies and was found in 4/44 (9%) and 13/70 (18.6%) patients in the other two. At 11year follow-up, one study demonstrated no osteoarthritis, while the other two studies reported rates of 54/100 (54%) and 17/24 (71%) respectively at >24 years. In the latter two cases, the rate of meniscal pathology was >50%. A best evidence synthesis revealed that there was insufficient evidence that the addition of a LEAT to an ACLR resulted in an increased rate of osteoarthritis. The best available evidence would suggest that the addition of a LEAT to ACLR does not result in an increase rate of osteoarthritis of the knee. In knees that have undergone a combined ACLR and LEAT, the incidence of osteoarthritis was low up to 11 years but increased thereafter. The presence of meniscal injury at the index surgery was reported to be greater predictor of the development of osteoarthritis. IV.

Historical Overview of Lateral Tenodeses Procedures and State of the Art in 2016

Since the original descriptions of the lateral capsuloligamentous complex of the knee, this structure (also known as the anterolateral ligament [ALL]) has been known to be commonly injured at the time of anterior cruciate ligament (ACL) injury. Surgeons have sought to reconstruct the ALL in ACL-deficient knees with the goal of restoring normal kinematics. Numerous surgical procedures have been developed over the last 50 years to correct the pathologic anterior and rotatory laxity seen with ACL tears. Initially, isolated lateral extra-articular tenodesis procedures were used. These procedures corrected the pathologic internal rotation laxity but their inability to adequately control anterior tibial translation led to a high rate of failure. Therefore, isolated lateral tenodesis procedures have fallen out of favor. With the advent of arthroscopy, isolated intra-articular ACL reconstructions became more popular. Some surgeons performed an additional lateral tenodesis procedure in conjunction with an intra-articular ACL reconstruction. Although these combined procedures have been abandoned by many surgeons, long-term results of these reconstructions have been encouraging. Because of the persistence of a pivot shift in some patients after isolated intra-articular ACL reconstruction, there has been a renewed interest in the anatomy and biomechanics of the ALL. Most recently, several authors have described an anatomic ALL reconstruction. Although early clinical results of these ALL reconstructions are encouraging, ongoing studies are still needed to better understand the biomechanical effects of these procedures on knee kinematics and on the intra-articular graft. The specific indications for lateral tenodeses and the ideal technique have yet to be determined.

Repair of the Anterolateral Structures in the Acutely Injured Anterior Cruciate Ligament

Repair of the acutely injured anterolateral complex is a surgical procedure justified by biomechanical studies, surgical findings, and clinical results. In a lack of specific radiological protocols able to reliably detect such injuries, indications are still related to the degree of pivot test, as evaluated preoperatively under anesthesia (explosive pivot shift). Repair techniques, to be always performed along with an anterior cruciate ligament reconstruction, are simple procedures strictly related to the type of injury. In type I and II tears, when a clear stretching is encountered (limited to the anterolateral capsule and ligament or extended toward the posterolateral capsule), repair consists of retensioning the capsule by means of plicating it with simple stitches. In type III tears, when a complete rupture of the capsule is found, an end-to-end suture is performed, possibly reproducing native tension. In type IV tears (bony avulsion, Segond fracture), repair is performed using periosteal stitches, suture anchors, or cancellous bone screws, according to the size of the fragment. In selected cases of generalized hyperlaxity or when a severely damaged tissue is found, augmentation with fascia lata or other autologous or allogenic grafts could be considered. Old prejudices about the possible complications of extra-articular procedures associated with intra-articular anterior cruciate ligament reconstructions for overconstraint, reduced range of motion, and higher rate of degenerative osteoarthritis seem to be overtaken, when modern surgical and rehabilitative procedure are used.

Biomechanical Comparison of Anterolateral Procedures Combined With Anterior Cruciate Ligament Reconstruction

Background: Anterolateral soft tissue structures of the knee have a role in controlling anterolateral rotational laxity, and they may be damaged at the time of anterior cruciate ligament (ACL) ruptures. Purpose: To compare the kinematic effects of anterolateral operative procedures in combination with intra-articular ACL reconstruction for combined ACL plus anterolateral–injured knees. Study Design: Controlled laboratory study. Methods: Twelve cadaveric knees were tested in a 6 degrees of freedom rig using an optical tracking system to record the kinematics through 0° to 90° of knee flexion with no load, anterior drawer, internal rotation, and combined loading. Testing was first performed in ACL-intact, ACL-deficient, and combined ACL plus anterolateral–injured (distal deep insertions of the iliotibial band and the anterolateral ligament [ALL] and capsule cut) states. Thereafter, ACL reconstruction was performed alone and in combination with the following: modified MacIntosh tenodesis, modified Lemaire tenodesis passed both superficial and deep to the lateral collateral ligament, and ALL reconstruction. Anterolateral grafts were fixed at 30° of knee flexion with both 20 and 40 N of tension. Statistical analysis used repeated-measures analyses of variance and paired t tests with Bonferroni adjustments. Results: ACL reconstruction alone failed to restore native knee kinematics in combined ACL plus anterolateral–injured knees (P < .05 for all). All combined reconstructions with 20 N of tension, except for ALL reconstruction (P = .002-.01), restored anterior translation. With 40 N of tension, the superficial Lemaire and MacIntosh procedures overconstrained the anterior laxity in deep flexion. Only the deep Lemaire and MacIntosh procedures—with 20 N of tension—restored rotational kinematics to the intact state (P > .05 for all), while the ALL underconstrained and the superficial Lemaire overconstrained internal rotation. The same procedures with 40 N of tension led to similar findings. Conclusion: In a combined ACL plus anterolateral–injured knee, ACL reconstruction alone failed to restore intact knee kinematics. The addition of either the deep Lemaire or MacIntosh tenodesis tensioned with 20 N, however, restored native knee kinematics. Clinical Relevance: The current study indicates that unaddressed anterolateral injuries, in the presence of an ACL deficiency, result in abnormal knee kinematics that is not restored if only treated with intra-articular ACL reconstruction. Both the modified MacIntosh and modified deep Lemaire tenodeses (with 20 N of tension) restored native knee kinematics at time zero.

Effects of different femoral tunnel positions on tension changes in anterolateral ligament reconstruction

Several kinds of anterolateral ligament (ALL) reconstructions to augment intra-articular anterior cruciate ligament reconstruction to better control anterolateral rotational instability (ALRI) have been reported. However, the optimal femoral attachment site for ALL reconstruction is still unclear. The purpose of this study was to investigate the effects of different femoral attachment sites on the tension changes through knee motions in different situations in order to determine a recommended femoral attachment site for ALL reconstruction. Six fresh-frozen cadaveric knees were included. ALL reconstructions were performed with three different femoral attachment sites (F1: 2mm anterior and 2mm distal to the lateral epicondyle, F2: 4mm posterior and 8mm proximal to the lateral epicondyle and F3: position for the lateral extra-articular tenodesis). The graft tension changes were measured by a graft tensioning system during knee flexion-extension and manual maximum internal/external tibial rotation in the following situations: (1) intact, (2) ALL cut, (3) ALL and ACL cut and (4) ALL cut and ACL reconstructed. Effects of the different femoral attachment sites, the route superficial or deep to the LCL, and the situations of (1) to (4) were calculated via repeated-measures analysis of variance. The tension of F1 was higher in flexion and lower in extension, whereas the tension of F2 and F3 was higher in extension and lower in flexion. F2 showed the smallest tension change. Situations of (1) to (4) did not affect tension changes. The graft tension became higher with internal rotation and lower with external rotation regardless of femoral attachment sites or situations. With F2-4mm posterior and 8mm proximal to the lateral epicondyle-the reconstructed ALL had the least tension change with only a slight increase in tension as the knee extended. This result indicates that F2 is recommended for ALL reconstruction to better control ALRI, which will help determine the optimal femoral tunnel position for ALL reconstruction.

Combined Intra-articular and Extra-articular Reconstruction in Anterior Cruciate Ligament–Deficient Knee: 25 Years Later

To determine whether an anterior cruciate ligament (ACL)-reconstructed knee with hamstring autograft has a greater incidence of degenerative changes when an extra-articular reconstruction is added and to determine the effect of the combined reconstruction on knee stability and function at long-term follow-up. For this retrospective study, patients who underwent ACL reconstruction between January 2002 and December 2003 were selected and classified into 2 groups, I and II. Group I consisted of patients operated by a standard ACL reconstruction, and group II consisted of patients in whom, owing to the presence of risk factors (severe pivot shift graded+++ or high-risk sports), an extra-articular reconstruction performed with ileo-tibial tract according to McIntosh as modified by Cocker Arnold technique, was used in conjunction with intra-articular ACL reconstruction. At final follow-up, Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores were used. An arthrometric KT-1000 evaluation was done. Comparative weight-bearing radiographs were taken, including a skyline view for the patellofemoral joint and analyzed according to Fairbank, Kellgren, and IKDC classification. Seventy-two of the 75 (96%) patients in group I and 68 of the 75 patients in group II were available at the final follow-up (minimum 10years). Subjective scores improved significantly in both groups, with no significant difference. Objectively, the number of patients receiving C and D IKDC objective activity scores in group I (7/56; 12.5%) was significantly higher than in group II (0/60) (P= .01). Considering as a failure a side-to-side arthrometric difference more than 5mm or a pivot shift test graded as++ or+++, or any giving way episode occurring postoperatively, we found 8 cases in group I and no cases in group II (P= .01) despite the presence of risk factors that group I did not include. Radiologic evaluation showed less arthritic changes in group II in both tibiofemoral and patellofemoral joints. On the basis of the results of this study, adding an extra-articular reconstruction to an anatomically placed intra-articular ACL reconstruction, followed by a modern rehabilitation protocol, does not increase the risk of osteoarthritis and may be able to reduce the rate of failure. Level III, retrospective comparative study.

Extra-articular procedures for the ACL-deficient knee: a state of the art review

Some patients have continued rotatory instability following intra-articular anterior cruciate ligament (ACL) reconstruction, which limits their functional abilities. Advanced surgical techniques, such as double-bundle reconstruction and anteromedial portal drilling, have not solved this problem. This has led many surgeons to revisit the use of extra-articular procedures to control rotatory laxity. Multiple anatomic studies have confirmed the presence of an anterolateral ligament (ALL) that attaches to the tibia at the site of the Segond fracture. The biomechanical importance of this ligament is still being debated. Extra-articular reconstructions decrease the forces produced by intra-articular ACL grafts. Patients likely to benefit from additional extra-articular reconstruction are: (1) those with high-grade pivot shifts; (2) patients with previous failed ACL reconstructions without an obvious cause; (3) participants in contact sports and (4) patients in subgroups that have a high risk of failure (eg, generalised laxity). A variety of extra-articular reconstructions have been developed. Those techniques that have long-term follow-up data were described before most current orthopaedic surgeons were in practice. The available evidence suggests that performing an additional extra-articular reconstruction can improve rotational stability in patients undergoing intra-articular ACL reconstructions. Newer ‘anatomic’ reconstructions of the ALL have recently been proposed but there are limited data on their effectiveness. Currently, there are no studies comparing different extra-articular procedures.

Anterior cruciate ligament reconstruction in adolescents (Tanner stages 2 and 3).

Management of anterior cruciate ligament injuries in skeletally immature patients (in Tanner stages 2 and 3) is controversial. Conventional reconstruction used in adults can cause iatrogenic growth disturbance due to physeal damage, and studies that report long-term results using a specific technique are scarce. The aim of this study is to evaluate in a large series the mid- and long-term results of a partial transphyseal technique and define the safe percentage of lesions of the femoral growth plate. Between 1989 and 2012, 42 adolescents at risk of growth disturbances (growth prediction of lower limbs >5 cm-Tanner 2, 3) underwent reconstruction of the anterior cruciate ligament using the semitendinosus and gracilis tendons. Growth characteristics of all the patients were assessed preoperatively, and the percentage of damage that would be produced in the femoral physis by the drilling of a 6-mm-diameter tunnel was determined. The technique used achieved graft fixation at both insertion sites, drilling the femoral physis and avoiding the tibial physis. We distinguished two groups: (a) long-term follow-up (mean 13 years 7 months, min 10.9, max 16.2) and (b) medium follow-up (mean 6 years 3 months, min 3.7, max 9.9). All knees were evaluated subjectively by history and objectively by KT2000 testing, and X-rays of both knees were compared for osteoarthritis using the Kellgren-Lawrence classification. In group A (12 patients) one osteoarthritis grade 2, one instability, and ten good stability and function were observed. The mean KT2000 arthrometer values at 30 lb showed a difference of +2.4 mm (range 1-4 mm) between the operated and non-operated sides (p < 0.05). In group B (21 patients) no growth disturbance of the lower limbs, two failures (reinjury while participating in pivoting sports), and 19 good stability and function were observed. The mean KT2000 arthrometer values at 30 lb showed a difference of +1.9 mm (range 1-5 mm) between the operated and non-operated sides (p < 0.05). The average IKDC score of all the patients was 90 (min: 68, max: 97). None of the adolescents had consequences on growth after an eccentric damage passing tendons less than 7% on the frontal plane and of 1% on cross-sectional area of the femoral physis, and after an oblique tunnel passing 6-mm-diameter tendons of the tibial epiphyseal nucleus. This study defines the possibility to perform a partial transphyseal intra-articular ACL reconstruction in patients in Tanner stages 2 and 3 that avoids tibial physis, involves the distal femoral physis, and produces good results at mid- and long-term follow-up without causing growth disturbances. IV.

Micheli Anterior Cruciate Ligament Reconstruction in Skeletally Immature Youths

Background: The management of anterior cruciate ligament (ACL) tears in the skeletally immature patient remains controversial. Outcomes on a physeal-sparing technique using the iliotibial band for combined intra-articular and extra-articular ACL reconstruction, called the Micheli technique, have been described and reported by the original authors. Purpose: To evaluate the clinical outcomes of a physeal-sparing technique using the iliotibial band for combined intra-articular and extra-articular ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Between 2005 and 2011, all patients who underwent Micheli ACL reconstruction performed by a single surgeon were identified. A minimum of 3 years’ growth remaining was a prerequisite for Micheli reconstruction. Patients were excluded if postoperative follow-up was less than 1 year. Patients were evaluated for functional outcomes, satisfaction, graft survival, radiographic and clinical evidence of growth disturbance, and the need for additional procedures. Results: Twenty-one patients (22 knees) met the inclusion criteria for this study. The mean age at the time of surgery was 11.8 years (range, 9.9-14.0 years). All patients were male. There were 4 concomitant meniscal repairs and 5 partial meniscectomies performed. All patients (100%) completed follow-up at a mean duration of 3.0 years (range, 1.0-6.9 years). Overall, 6 knees (27%) underwent reoperation. Of these, 3 knees (14%) underwent revision ACL surgery: 2 revision reconstructions at 2.8 and 4.0 years postoperatively and 1 graft shrinkage at 4.7 months postoperatively. Three knees (14%) underwent subsequent meniscal procedures, including 2 partial meniscectomies and 1 meniscal repair. Of the 19 knees that did not require revision ACL surgery, the median patient satisfaction score was 10 (range, 9-10). The mean Pediatric International Knee Documentation Committee score was 96.5 ± 2.9, and the mean Lysholm score was 95.0 ± 6.1. The median preinjury Tegner activity level was 8 (range, 6-10), and the median postoperative Tegner activity level was 8 (range, 6-10). Of the 19 knees that did not require revision ACL surgery, all had a normal Lachman test result, with a firm endpoint and normal pivot shift. At follow-up, 53% of knees had closed physes. There were no angular deformities or limb-length discrepancies. Conclusion: At a mean 3-year follow-up, the study findings confirmed excellent functional outcomes, a low ACL revision rate, and no growth disturbances. Patients returned to their preoperative activity level after reconstruction. This procedure offers a safe and effective ACL reconstruction option in children with several years of growth remaining.

Single-bundle ACL reconstruction with and without extra-articular reconstruction: evaluation with robotic lower leg rotation testing and patient satisfaction scores.

PurposeThe purpose of this study was to compare the biomechanical characteristics and patient outcomes after either isolated intraarticular ACL reconstruction or intraarticular reconstruction with lateral extra-articular tenodesis. In addition, we aimed to evaluate biomechanical parameters of the entire uninjured, contralateral knee as a baseline during the analysis.MethodsEighteen patients were evaluated at an average of 9.3 years after ACL reconstruction. Twelve patients had an intraarticular reconstruction (BTB), and six had an additional lateral extraarticular procedure (BTB/EAR). Patients were selected for the additional procedure by the operating surgeon based on clinical and radiological criteria. At the time of review, each patient was assessed using subjective patient questionnaires, manual laxity testing, and instrumented laxity testing. Each knee was also evaluated using a robotic lower leg axial rotation testing system. This system measured maximum internal and external rotations at 5.65 Nm of applied torque and generated load deformation curves and compliance data. Pointwise statistical comparisons within each group and between groups were performed using the appropriate paired or unpaired t test. Features were extracted from each load deformation curve for comparative analysis.ResultsThere were no significant differences between the two groups with respect to the patient satisfaction scores or to laxity testing (manual or instrumented). Robotic testing results for within-group comparisons demonstrated a significant reduction in maximum external rotation (8.77°) in the reconstructed leg when compared to the healthy leg (p < 0.05) in the BTB/EAR group, with a non-significant change in internal rotation. The slope of the curve at maximum internal rotation was also significantly greater in the reconstructed legs for the BTB/EAR group (p < 0.05), indicating reduced endpoint compliance or a harder endpoint. Finally, the leg that received the extra-articular tenodesis had a trend towards a reduced total leg axial rotation. Conversely, patients in the BTB group demonstrated no significant differences between their legs. For between-group comparisons, there was a significant increase in maximum internal rotation in the healthy legs in the BTB/EAR group compared with the healthy legs in the BTB group (p < 0.05). If the injured/reconstructed legs were compared, the significant difference at maximum internal rotation disappeared (p < 0.10). Similarly, the healthy legs in patients in the BTB/EAR group had a significantly more compliant or softer endpoint in internal rotation, greater maximum internal rotation, and more internal rotation at torque 0 in their healthy legs compared with the healthy legs in the BTB group (p < 0.05). These same differences were not noted in the reconstructed knees. The only identifiable significant difference between the injured/reconstructed legs was rotation at 0 torque (p < 0.05).ConclusionsIn this group of patients who were at an average of 9 years from surgery, the addition of a lateral extra-articular reconstruction to a standard bone–tendon–bone intraarticular ACL reconstruction does reduces internal rotation of the tibia with respect to the femur when compared to intraarticular reconstruction alone. It appears that the selection process for inclusion into the BTB/EAR group included an increase in total axial rotation of the healthy knee during the examination along with a decrease in endpoint stiffness at maximum internal rotation.Level of evidenceII.

Does Combined Intra- and Extraarticular ACL Reconstruction Improve Function and Stability? A Meta-analysis.

ACL reconstruction aims to restore knee function and stability; however, rotational stability may not be completely restored by use of standard intraarticular reconstruction alone. Although individual studies have not shown the superiority of combined ACL reconstruction compared with isolated intraarticular reconstruction in terms of function and stability, biomechanical principles suggest a combined approach may be helpful, therefore pooling (meta-analyzing) the available randomized clinical studies may be enlightening. We performed a meta-analysis to determine whether combining extraarticular with intraarticular ACL reconstruction would lead to: (1) similar knee function measured by the IKDC evaluation, return-to-activity, and Tegner Lysholm scores, compared with isolated intraarticular reconstruction; (2) increased stability measured by pivot shift and instrumented Lachman examination; and (3) any differences in complications and adverse events? To identify randomized controlled trials (RCTs) comparing combined intra- and extrarticular ACL reconstruction (combined reconstruction) with intraarticular ACL reconstruction only, we searched MEDLINE, EMBASE, SPORTDiscus, Latin American and Caribbean Health Sciences (LILACS), and the Cochrane Central Register of Controlled Trials, and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The main outcomes we sought were patient function and stability and complications after ACL reconstruction. Of 386 identified studies, eight RCTs were included (n=682 participants; followup, 12-84 months; men to women ratio, 2.17:1) in our meta-analysis. Study quality (internal validity) was assessed using the Cochrane risk-of-bias tool; in general, we found a moderate quality of evidence of the included studies. When functional outcomes were compared, we found no difference between patients who underwent intraarticular ACL reconstruction only and those who underwent combined reconstruction (IKDC, return-to-activity, and Tegner Lysholm scores). However, patients who underwent combined reconstruction were more likely to show improved stability based on the pivot shift test (risk ratio [RR], 0.95; 95% CI, 0.91-0.99; p=0.02) and Lachman test (RR, 0.93; 95% CI, 0.88-0.98; p=0.01). In addition, our meta-analysis found no difference between the two treatments in terms of general complications or adverse events (RR, 1.31; 95% CI, 0.70-2.34; p=0.40) and the proportion of patients whose reconstructions failed (RR, 2.88; 95% CI, 0.73-11.47; p=0.13). Combined intra- and extraarticular ACL reconstruction provided marginally improved knee stability and comparable failure rates but no difference in patient-reported functional outcomes scores. Complications and adverse events such as knee stiffness may be underreported and technical factors such as graft placement were difficult to evaluate. Future studies are needed to determine whether the small differences in additional stability warrant the potential morbidity of the additional extraarticular procedure and to determine long-term failure rates.