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Editorial Commentary: Let’s ALL Agree—Anterior Cruciate Ligament Reconstruction Outcomes Need to Be Improved and Extra-Articular Procedures Have an Essential Role

      Abstract

      We are united as an orthopaedic community in trying to improve the outcomes of anterior cruciate ligament (ACL) reconstruction. Graft rupture rates of 10% to 28% are reported in high-risk populations, reoperation for non-graft rupture–related indications are reported in 18% to 26%, and only 50% to 65% of recreational athletes return to their preinjury level of sports. Numerous groups across the world have published studies providing evidence demonstrating significant clinical efficacy of lateral extra-articular tenodesis in improving the outcomes of ACL surgery. Finally, the reductions in ACL graft rupture rates augmented with anterolateral ligament or a modified Lemaire reconstruction appear to be broadly comparable. In our hands, anterolateral ligament may result in fewer adverse events.
      First, we would like to congratulate Getgood, Hewison, Bryant, Litchfiled, Heard, Buchko, Hiemstra, Willits, Firth, MacDonald, and the Stability Group for their prospective randomized controlled trial entitled “No Difference in Functional Outcomes When Lateral Extra-Articular Tenodesis is Added to Anterior Cruciate Ligament Reconstruction in Young Active Patients: The Stability Study.”
      • Getgood A.
      • Hewison C.
      • Bryant D.
      • et al.
      Stability Study Group
      No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability Study.
      The results of this trial have been highly anticipated due to the considerable controversy surrounding this topic. Regular readers of Arthroscopy will be familiar with the heated exchanges that have taken place through letters to the editor regarding whether it is a modified Lemaire, anterolateral ligament (ALL) reconstruction, or another type of procedure that is the most appropriate extra-articular tenodesis.
      • Williams A.
      Editorial Commentary: The anterolateral ligament: the emperor's new clothes?.
      • Sonnery-Cottet B.
      • Claes S.
      • Blakeney W.G.
      • et al.
      Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group.
      • Ferretti A.
      Response to “Editorial Commentary: The anterolateral ligament: The emperor's new clothes?”.
      • Kartus J.T.
      Editorial Commentary: The anterolateral ligament of the knee seems more fact than fiction.
      However, these discussions have been limited due to a lack of published contemporary clinical outcomes for the modified Lemaire procedure and have instead focused on cadaveric biomechanical studies that may not reliably extrapolate to clinical practice.
      • Schon J.M.
      • Moatshe G.
      • Brady A.W.
      • et al.
      Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle.
      • Huser L.E.
      • Noyes F.R.
      • Jurgensmeier D.
      • Levy M.S.
      Anterolateral ligament and iliotibial band control of rotational stability in the anterior cruciate ligament-intact knee: Defined by tibiofemoral compartment translations and rotations.
      • Shimakawa T.
      • Burkhart T.A.
      • Dunning C.E.
      • Degen R.M.
      • Getgood A.M.
      Lateral compartment contact pressures do not increase after lateral extra-articular tenodesis and subsequent subtotal meniscectomy.
      • Inderhaug E.
      • Stephen J.M.
      • Williams A.
      • Amis A.A.
      Anterolateral tenodesis or anterolateral ligament complex reconstruction: Effect of flexion angle at graft fixation when combined with ACL reconstruction.
      • Neri T.
      • Parker D.A.
      • Beach A.
      • Boyer B.
      • Farizon F.
      • Philippot R.
      Anterolateral ligament of the knee: What we know about its anatomy, histology, biomechanical properties and function.
      • Ariel de Lima D.
      • Helito C.P.
      • Lacerda de Lima L.
      • et al.
      Anatomy of the anterolateral ligament of the knee: A systematic review.
      In the meantime, numerous groups across the world have published studies providing evidence demonstrating significant clinical efficacy of anterolateral ligament reconstruction (ALLR) in improving the outcomes of ACL surgery. The Stability study is therefore a welcome addition to the literature and represents a very well-conducted, high-quality study. The main importance of this study, and for that matter any clinical study on this topic, is the fact that we are all united as an orthopaedic community to try and improve the outcomes of ACL reconstruction. Every sports surgeon has a responsibility to look objectively at published contemporary clinical results and ask themselves whether these are acceptable or whether there is a need to improve outcomes: Graft rupture rates of 10% to 28% are reported in high-risk populations,
      • Wiggins A.J.
      • Grandhi R.K.
      • Schneider D.K.
      • Stanfield D.
      • Webster K.E.
      • Myer G.D.
      Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: A systematic review and meta-analysis.
      ,
      • Webster K.E.
      • Feller J.A.
      Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction.
      reoperation rates for non-graft rupture–related indications are reported between 18% and 26% of patients,
      • Hettrich C.M.
      • Dunn W.R.
      • Reinke E.K.
      • Spindler K.P.
      MOON Group
      The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: Two- and 6-year follow-up results from a multicenter cohort.
      and only 50% to 65% of recreational athletes return to their preinjury level of sport.
      • McCullough K.A.
      • Phelps K.D.
      • Spindler K.P.
      • Matava M.J.
      • Dunn W.R.
      • Parker R.D.
      • MOON Group
      • et al.
      Return to high school- and college-level football after anterior cruciate ligament reconstruction: A multicenter orthopaedic outcomes network (MOON) cohort study.
      Such poor outcomes would not be accepted in any other subspecialty in orthopaedics, and there is clearly a need to improve. The Stability study adds to the wealth of clinical data supporting extra-articular tenodesis (EAT) procedures and allows us to speak with a united voice that EAT procedures have an essential role.
      • Getgood A.
      • Hewison C.
      • Bryant D.
      • et al.
      Stability Study Group
      No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability Study.
      ,
      • Getgood A.M.J.
      • Bryant D.M.
      • Litchfield R.
      • et al.
      STABILITY Study Group. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the stability study randomized clinical trial.
      The rationale for adding an EAT includes the following:
      • numerous clinical studies demonstrating a reduction in ACL graft rupture rates with an EAT
        • Noyes F.R.
        • Barber S.D.
        The effect of an extra-articular procedure on allograft reconstructions for chronic ruptures of the anterior cruciate ligament.
        • Imbert P.
        • Lustig S.
        • Steltzlen C.
        • et al.
        French Arthroscopy Society. Midterm results of combined intra- and extra-articular ACL reconstruction compared to historical ACL reconstruction data. Multicenter study of the French Arthroscopy Society.
        • Sonnery-Cottet B.
        • Saithna A.
        • Cavalier M.
        • et al.
        Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI Study Group.
        • Helito C.P.
        • Sobrado M.F.
        • Giglio P.N.
        • et al.
        Combined reconstruction of the anterolateral ligament in patients with anterior cruciate ligament injury and ligamentous hyperlaxity leads to better clinical stability and a lower failure rate than isolated anterior cruciate ligament reconstruction.
        ;
      • all clinical series of combined anterior cruciate ligament reconstruction (ACLR) + EAT since 2015 have reported good clinical outcomes in adults
        • Sonnery-Cottet B.
        • Thaunat M.
        • Freychet B.
        • Pupim B.H.
        • Murphy C.G.
        • Claes S.
        Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up.
        • Ferretti A.
        • Monaco E.
        • Ponzo A.
        • et al.
        Combined intra-articular and extra-articular reconstruction in anterior cruciate ligament-deficient knee: 25 years later.
        • Zaffagnini S.
        • Marcheggiani Muccioli G.M.
        • Grassi A.
        • et al.
        Over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: prospective evaluation with 20-year minimum follow-up.
        • Helito C.P.
        • Camargo D.B.
        • Sobrado M.F.
        • et al.
        Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction.
        • Ponzo A.
        • Monaco E.
        • Basiglini L.
        • et al.
        Long-term results of anterior cruciate ligament reconstruction using hamstring grafts and the outside-in technique: A comparison between 5- and 15-year follow-up.
        • Sonnery-Cottet B.
        • Saithna A.
        • Blakeney W.G.
        • et al.
        Anterolateral ligament reconstruction protects the repaired medial meniscus: A comparative study of 383 anterior cruciate ligament reconstructions from the Santi study group with a minimum follow-up of 2 years.
        • Ueki H.
        • Katagiri H.
        • Otabe K.
        • et al.
        Contribution of additional anterolateral structure augmentation to controlling pivot shift in anterior cruciate ligament reconstruction.
        • Rosenstiel N.
        • Praz C.
        • Ouanezar H.
        • et al.
        Combined anterior cruciate and anterolateral ligament reconstruction in the professional athlete: Clinical outcomes from the scientific anterior cruciate ligament network international study group in a series of 70 patients with a minimum follow-up of 2 years.
        • Lee D.W.
        • Kim J.G.
        • Cho S.I.
        • Kim D.H.
        Clinical outcomes of isolated revision anterior cruciate ligament reconstruction or in combination with anatomic anterolateral ligament reconstruction.

        Saithna A, Daggett M, Helito CP, et al. Clinical results of combined ACL and anterolateral ligament reconstruction: A narrative review from the Santi study group [published online February 5, 2020]. J Knee Surg. https://doi.org/10.1055/s-0040-1701220.

        • Grassi A.
        • Zicaro J.P.
        • Costa-Paz M.
        • et al.
        ESSKA Arthroscopy Committee. Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET).

        Ra HJ, Kim JH, Lee DH. Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: Systematic review and meta-analysis [published online March 5, 2020]. Arch Orthop Trauma Surg. doi: 10.1007/s00402-020-03393-8.

        and skeletally immature patients
        • Kocher M.S.
        • Heyworth B.E.
        • Fabricant P.D.
        • Tepolt F.A.
        • Micheli L.J.
        Outcomes of physeal-sparing ACL reconstruction with iliotibial band autograft in skeletally immature prepubescent children.
        ,
        • Wilson P.L.
        • Wyatt C.W.
        • Wagner 3rd, K.J.
        • Boes N.
        • Sabatino M.J.
        • Ellis Jr., H.B.
        Combined transphyseal and lateral extra-articular pediatric anterior cruciate ligament reconstruction: A novel technique to reduce ACL reinjury while allowing for growth.
        ;
      • numerous clinical studies demonstrating a high proportion (up to 90% in acute ACL-injured knees) of injuries to anterolateral structures, both on imaging and at open lateral exploration
        • Helito C.P.
        • Helito P.V.P.
        • Leão R.V.
        • Demange M.K.
        • Bordalo-Rodrigues M.
        Anterolateral ligament abnormalities are associated with peripheral ligament and osseous injuries in acute ruptures of the anterior cruciate ligament.
        • Cavaignac E.
        • Faruch M.
        • Wytrykowski K.
        • Constant O.
        • Murgier J.
        • Berard E.
        • Chiron P.
        Ultrasonographic evaluation of anterolateral ligament injuries: Correlation with magnetic resonance imaging and pivot-shift testing.
        • Muramatsu K.
        • Saithna A.
        • Watanabe H.
        • et al.
        Three-dimensional magnetic resonance imaging of the anterolateral ligament of the knee: An evaluation of intact and anterior cruciate ligament-deficient knees from the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group.
        • Ferretti A.
        • Monaco E.
        • Fabbri M.
        • Maestri B.
        • De Carli A.
        Prevalence and classification of injuries of anterolateral complex in acute anterior cruciate ligament tears.
        ; and finally
      • the fact that the theoretical early degenerative change has never been clinically demonstrated.
        • Devitt B.M.
        • Bouguennec N.
        • Barfod K.W.
        • Porter T.
        • Webster K.E.
        • Feller J.A.
        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.
      So, as Rossi said in his brilliant editorial commentary, “Anterolateral Ligament Augmentation for the Anterior Cruciate Ligament-Deficient Knee Debate—The Proof Is in the Pudding,”
      • Rossi M.J.
      Editorial Commentary: Anterolateral ligament augmentation for the anterior cruciate ligament-deficient knee debate—the proof is in the pudding.
      “The story is not anymore “if” augmentation should be considered but “when” and, maybe more important, “how” to augment.”
      Of course, the debate regarding which EAT is best can only be answered through future comparative clinical studies.
      • Reider B.
      ACL or ACL.
      However, some observations can be drawn in the interim. The Stability Group studied a modified Lemaire, whereas the SANTI Study Group has extensively studied reconstruction of the ALL. Biomechanically, there are some differences between the procedures since the ALL demonstrates nonisometric behavior, being tight in extension and slack in flexion, thus allowing physiological internal rotation of the tibia at 90° of flexion.
      • Imbert P.
      • Lutz C.
      • Daggett M.
      • et al.
      Isometric characteristics of the anterolateral ligament of the knee: A cadaveric navigation study.
      In contrast, the modified Lemaire is isometric, with a tendency to limit physiological internal rotation of the tibia at 90° of flexion, without knowing whether it is clinically important or not.
      • Kittl C.
      • Halewood C.
      • Stephen J.M.
      • et al.
      Length change patterns in the lateral extra-articular structures of the knee and related reconstructions.
      Despite these differences, the reductions in graft rupture rates with each procedure appear to be broadly comparable. The Stability Group reported an 11% graft rupture rate after isolated hamstring ACLR versus 4% following ACLR with a concomitant modified Lemaire, therefore confirming the effectiveness of this type of EAT.
      • Getgood A.M.J.
      • Bryant D.M.
      • Litchfield R.
      • et al.
      STABILITY Study Group. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the stability study randomized clinical trial.
      Similarly, in our prospective, nonrandomized study of more than 500 patients, we also reported broadly comparable, and significantly lower graft rupture rates with a concomitant ALLR.
      • Sonnery-Cottet B.
      • Saithna A.
      • Cavalier M.
      • et al.
      Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI Study Group.
      However, it is also important to highlight some potentially important differences in clinical outcomes, particularly with respect to rates of adverse events. In 2017, Thaunat et al.
      • Thaunat M.
      • Clowez G.
      • Saithna A.
      • et al.
      Reoperation rates after combined anterior cruciate ligament and anterolateral ligament reconstruction: A series of 548 patients from The SANTI Study Group with a minimum follow-up of 2 years.
      showed a low rate of reoperation after combined ACLR + ALLR in 548 patients, with less than 1% of patients experiencing ALLR-related complications. Moreover, in an interim analysis of results from our randomized controlled trial (ClinicalTrials.gov: NCT03740022) we found no evidence of an increased risk of short-term adverse events after combined ACLR + ALLR when compared with isolated ACLR.

      Sonnery-Cottet, B, Pioger, C, Vieira, TD, et al. Combined ACL and anterolateral reconstruction is not associated with a higher risk of adverse outcomes: Preliminary results from the SANTI randomized controlled trial [published online May 1, 2020]. Orthop J Sports Med. doi:10.1177/2325967120918490.

      In contrast, the Stability group reported greater rates of adverse events (n = 23 LET-related complications in 151 patients) with their technique for modified Lemaire, including overconstraint of the lateral compartment, iatrogenic injury to the lateral collateral ligament, unspecified difficulties with the EAT graft, hardware irritation requiring removal, pain or sensitivity over the lateral extra-articular tenodesis staple, hematoma at the lateral extra-articular tenodesis site, iliotibial band snapping, and increased early pain and delayed functional recovery (including delayed return to sport).
      • Getgood A.
      • Hewison C.
      • Bryant D.
      • et al.
      Stability Study Group
      No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability Study.
      ,
      • Getgood A.M.J.
      • Bryant D.M.
      • Litchfield R.
      • et al.
      STABILITY Study Group. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the stability study randomized clinical trial.
      It is for these reasons that we prefer an ALLR and reserve the modified Lemaire for revision of ACL reconstructions. However, it is only with additional well-designed comparative clinical trials that we will be able to know which EAT is the most suitable and particularly for which types of patients.
      • Reider B.
      ACL or ACL.
      As a final thought, it is important to highlight that the main purpose of the current study was to assess functional outcomes.
      • Getgood A.
      • Hewison C.
      • Bryant D.
      • et al.
      Stability Study Group
      No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability Study.
      For patients, this simply means being able to return to their chosen sport at the preinjury level, and unfortunately this was not reported. Instead, the authors chose the Limb Symmetry Index based upon 4 hop tests as the primary outcome measure. It is recognized that Limb Symmetry Index may underestimate performance deficits (due to bilateral deficits following ACLR) and should be interpreted with caution.
      • Gokeler A.
      • Welling W.
      • Benjaminse A.
      • Lemmink K.
      • Seil R.
      • Zaffagnini S.
      A critical analysis of limb symmetry indices of hop tests in athletes after anterior cruciate ligament reconstruction: A case control study.
      However, their finding that there was no difference between groups remains an important one.
      • Getgood A.
      • Hewison C.
      • Bryant D.
      • et al.
      Stability Study Group
      No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability Study.
      Once again, we congratulate the Stability Group for their excellent work. It is only with clinical articles of this quality that we can improve outcomes for our patients.

      Supplementary Data

      References

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        No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: The Stability Study.
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        Editorial Commentary: The anterolateral ligament: the emperor's new clothes?.
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        Response to “Editorial Commentary: The anterolateral ligament: The emperor's new clothes?”.
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        Editorial Commentary: The anterolateral ligament of the knee seems more fact than fiction.
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        Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle.
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        Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI Study Group.
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        Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction.
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        Long-term results of anterior cruciate ligament reconstruction using hamstring grafts and the outside-in technique: A comparison between 5- and 15-year follow-up.
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        • Saithna A.
        • Blakeney W.G.
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        Anterolateral ligament reconstruction protects the repaired medial meniscus: A comparative study of 383 anterior cruciate ligament reconstructions from the Santi study group with a minimum follow-up of 2 years.
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      1. Saithna A, Daggett M, Helito CP, et al. Clinical results of combined ACL and anterolateral ligament reconstruction: A narrative review from the Santi study group [published online February 5, 2020]. J Knee Surg. https://doi.org/10.1055/s-0040-1701220.

        • Grassi A.
        • Zicaro J.P.
        • Costa-Paz M.
        • et al.
        ESSKA Arthroscopy Committee. Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET).
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 418-431
      2. Ra HJ, Kim JH, Lee DH. Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: Systematic review and meta-analysis [published online March 5, 2020]. Arch Orthop Trauma Surg. doi: 10.1007/s00402-020-03393-8.

        • Kocher M.S.
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