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Editorial Commentary: Anterior Cruciate Ligament Reconstruction Success Must Be Defined Including Patient-Reported Outcome, Functional and Structural Outcome, Avoidance of Early Adverse Events, and Avoidance of Graft Failure

      Abstract

      Successful anterior cruciate ligament (ACL) reconstruction requires definition. Some focus on return to sport or early return to sport. Others focus on reproduction of normal ACL anatomy or biomechanics. Recent focus includes restoration of secondary stabilizers. However, each new focus can have positive, but also adverse, consequences. In general, positive results in 4 categories are equally important for the success of ACL reconstruction: early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. We are moving the needle to achieve the “best” ACL reconstruction, but we should never change treatment based on one parameter or “fashion.”
      What is a successful anterior cruciate ligament (ACL) reconstruction? I pose a simple and yet unclear question that we have for our field. For the longest time, we have been so proud of how successful we were in getting injured athletes back to activities. We quote patients of high success rate of return to play after injuries. We also pride ourselves in getting patients back to activities faster than others, early rehabilitation, and early return to sports and activities.
      • Shelbourne K.D.
      • Klootwyk T.E.
      • Decarlo
      Update on accelerated rehabilitation after anterior cruciate ligament reconstruction.
      More recently, we have focused on how “anatomic” our reconstruction is. How well we can duplicate the footprint of the native ACL and the biomechanics in the laboratory?
      • Fu F.H.
      • van Eck C.F.
      • Tashman S.
      • Irrgang J.J.
      • Moreland M.S.
      Anatomic anterior cruciate ligament reconstruction: A changing paradigm.
      Most of these changes—or the “fashion,” as I call it—is based on strong feeling and appeal by thought leaders. Unfortunately, most of these changes have fallen out of fashion.
      As we learned more about outcomes of the treatment of ACL injuries, we became less enthused with the high rerupture rate in young athletes and the development of posttraumatic arthritis. A recent fashion adds lateral augmentation to reduce rerupture rate, and large multicenter studies have shown significant differences in outcomes.
      • Getgood A.M.J.
      • Bryant D.M.
      • Litchfield R.
      • et al.
      Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-Year outcomes from the Stability Study randomized clinical trial.
      I read with great interest the article by Qiu, Wang, Kernkamp, Chen, Xu, Tsai, and Zhao, “Augmentation of Anterolateral Structures of Knee Causes Undesirable Tibiofemoral Cartilage Contact in Double-Bundle Anterior Cruciate Ligament Reconstruction: A Randomized In-Vivo Biomechanics Study.”
      • Qiu J.
      • Wang C.
      • Kernkamp W.A.
      • et al.
      Augmentation of anterolateral structures of the knee causes undesirable tibiofemoral cartilage contact in double-bundle anterior cruciate ligament reconstruction: A randomized in-vivo biomechanics study.
      The authors reported that the addition of lateral augmentation can change the contact area significantly and likely cause cartilage degeneration. This is important information as we jump on the bandwagon to perform lateral augmentation without realizing the possible consequences. I do commend the authors of a well-done study. But I do want us to ask ourselves, what is a successful ACL reconstruction?
      At the 2019 Pittsburgh Panther Symposium, a group of international knee surgeons and clinicians tried to answer that question, and a consensus was reached regarding the important clinical outcomes after ACL injury.
      • Svantesson E.
      • Hamrin Senorski E.
      • et al.
      Clinical outcomes after anterior cruciate ligament injury: Panther Symposium ACL Injury Clinical Outcomes Consensus Group.
      In general, outcomes should be considered for 4 categories: early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. Every one of those categories is equally important for the success of ACL reconstruction.
      In the ever-changing world of the treatment of ACL injuries, we have been challenged, but we have been improving our ability to answer the question. I do strongly believe that we are moving the needle to have the “best” ACL reconstruction, but I also caution that we should never change treatment based on one parameter or fashion.

      Supplementary Data

      References

        • Shelbourne K.D.
        • Klootwyk T.E.
        • Decarlo
        Update on accelerated rehabilitation after anterior cruciate ligament reconstruction.
        J Orthop Sports Phys Ther. 1992; 15: 303-308
        • Fu F.H.
        • van Eck C.F.
        • Tashman S.
        • Irrgang J.J.
        • Moreland M.S.
        Anatomic anterior cruciate ligament reconstruction: A changing paradigm.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 640-648
        • Getgood A.M.J.
        • Bryant D.M.
        • Litchfield R.
        • et al.
        Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-Year outcomes from the Stability Study randomized clinical trial.
        Am J Sports Med. 2020; 48: 285-297
        • Qiu J.
        • Wang C.
        • Kernkamp W.A.
        • et al.
        Augmentation of anterolateral structures of the knee causes undesirable tibiofemoral cartilage contact in double-bundle anterior cruciate ligament reconstruction: A randomized in-vivo biomechanics study.
        Arthroscopy. 2022; 38: 1224-1236
        • Svantesson E.
        • Hamrin Senorski E.
        • et al.
        Clinical outcomes after anterior cruciate ligament injury: Panther Symposium ACL Injury Clinical Outcomes Consensus Group.
        Orthop J Sports Med. 2020; 28: 2415-2434