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Anterior Cruciate Ligament Revision Plus Lateral Extra-Articular Procedure Results in Superior Stability and Lower Failure Rates Than Does Isolated Anterior Cruciate Ligament Revision But Shows No Difference in Patient-Reported Outcomes or Return to Sports

Published:December 30, 2022DOI:https://doi.org/10.1016/j.arthro.2022.12.029

      Purpose

      To determine whether comparative clinical studies demonstrate significant advantages of revision anterior cruciate ligament reconstruction (RACLR) combined with a lateral extra-articular procedure (LEAP), with respect to graft rupture rates, knee stability, return to sport rates, and patient-reported outcome measures, compared with isolated RACLR.

      Methods

      A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews & Meta-Analyses Guidelines. A PubMed search was conducted using the key words “revision anterior cruciate ligament reconstruction” combined with any of the following additional terms, “lateral extra-articular tenodesis” OR “anterolateral ligament reconstruction” OR “Lemaire.” All relevant comparative clinical studies were included. Key clinical data were extracted and evaluated.

      Results

      Eight comparative studies (seven Level III studies and a one Level IV study) were identified and included. Most studies reported more favorable outcomes with combined procedures with respect to failure rates (0%-13% following RACLR+LEAP, and 4.4%-21.4% following isolated RACLR), postoperative side-to-side anteroposterior laxity difference (1.3-3.9 mm following RACLR+LEAP and 1.8-5.9 mm following isolated RACLR), and high-grade pivot shift (0%-11.1% following RACLR+LEAP and 10.2%-23.8% in patients following isolated RACLR). There were no consistent differences between isolated and combined procedures with respect to return to sport or patient-reported outcome measures.

      Conclusions

      This systematic review demonstrates that the addition of a LEAP to RACLR was associated with an advantage with respect to ACL graft failure rates and avoidance of high-grade postoperative knee laxity across almost all included studies.

      Level of Evidence

      IV, Systematic review of level III to IV studies.
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      References

      1. Wolfson TS, Mannino B, Owens BD, Waterman BR, Alaia MJ. Tunnel management in revision anterior cruciate ligament reconstruction: Current concepts [published online November 12, 2021]. Am J Sports Med:3635465211045705.

        • Yan X.
        • Yang X.G.
        • Feng J.T.
        • Liu B.
        • Hu Y.C.
        Does revision anterior cruciate ligament (ACL) reconstruction provide similar clinical outcomes to primary ACL reconstruction? A systematic review and meta-analysis.
        Orthop Surg. 2020; 12: 1534-1546
        • Mitchell J.J.
        • Cinque M.E.
        • Dornan G.J.
        • et al.
        Primary versus revision anterior cruciate ligament reconstruction: Patient demographics, radiographic findings, and associated lesions.
        Arthroscopy. 2018; 34: 695-703
        • Pioger C.
        • Claes S.
        • Haidar I.
        • et al.
        Prevalence and incidence of chondral and meniscal lesions in patients undergoing primary and subsequent revision anterior cruciate ligament reconstruction: An analysis of 213 patients from the SANTI Group.
        Am J Sports Med. 2022; 50: 1798-1804
        • Wright R.W.
        • Gill C.S.
        • Chen L.
        • et al.
        Outcome of revision anterior cruciate ligament reconstruction: A systematic review.
        J Bone Joint Surg Am. 2012; 94: 531-536
        • MARS Group, MARS Group
        Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) Cohort.
        Am J Sports Med. 2014; 42: 2301-2310
        • Liechti D.J.
        • Chahla J.
        • Dean C.S.
        • et al.
        Outcomes and risk factors of rerevision anterior cruciate ligament reconstruction: A systematic review.
        Arthroscopy. 2016; 32: 2151-2159
        • ESSKA European ACL Revision Consensus
        Summary of ESSKA European ACL Revision Consensus Project.
        (Accessed October 15, 2022)
        • Sherman S.L.
        • Calcei J.
        • Ray T.
        • et al.
        ACL Study Group presents the global trends in ACL reconstruction: Biennial survey of the ACL Study Group.
        J ISAKOS. 2021; 6: 322-328
        • Eggeling L.
        • Drenck T.C.
        • Frings J.
        • et al.
        Additional lateral extra-articular tenodesis in revision ACL reconstruction does not influence the outcome of patients with low-grade anterior knee laxity.
        Arch Orthop Trauma Surg. 2022; 142: 291-299
        • Cuello-Garcia C.A.
        • Santesso N.
        • Morgan R.L.
        • et al.
        GRADE guidance 24 optimizing the integration of randomized and non-randomized studies of interventions in evidence syntheses and health guidelines.
        J Clin Epidemiol. 2022; 142: 200-208
        • Saithna A.
        • Daggett M.
        • Helito C.P.
        • et al.
        Clinical results of combined ACL and anterolateral ligament reconstruction: A narrative review from the SANTI study group.
        J Knee Surg. 2021; 34: 962-970
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
        • Slim K.
        • Nini E.
        • Forestier D.
        • Kwiatkowski F.
        • Panis Y.
        • Chipponi J.
        Methodological Index for Non-Randomized Studies (MINORS): Development and validation of a new instrument.
        ANZ J Surg. 2003; 73: 712-716
        • Alm L.
        • Drenck T.C.
        • Frosch K.H.
        • Akoto R.
        Lateral extra-articular tenodesis in patients with revision anterior cruciate ligament (ACL) reconstruction and high-grade anterior knee instability.
        Knee. 2020; 27: 1451-1457
      2. Keizer MNJ, Brouwer RW, de Graaff F, Hoogeslag RAG. Higher return to pre-injury type of sports after revision anterior ligament reconstruction with lateral extra-articular tenodesis compared to without lateral extra-articular tenodesis [published June 23, 2022]. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-07018-y.

        • 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.
        Am J Sports Med. 2019; 47: 324-333
        • Trojani C.
        • Beaufils P.
        • Burdin G.
        • et al.
        Revision ACL reconstruction: Influence of a lateral tenodesis.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1565-1570
        • Ventura A.
        • Legnani C.
        • Boisio F.
        • Borgo E.
        • Peretti G.M.
        The association of extra-articular tenodesis restores rotational stability more effectively compared to contralateral hamstring tendon autografts ACL reconstruction alone in patients undergoing ACL revision surgery.
        Orthop Traumatol Surg Res. 2021; 107102739
        • Yoon K.H.
        • Hwang I.U.
        • Kim E.J.
        • Kwon Y.B.
        • Kim S.G.
        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
      3. Helito CP, Sobrado MF, Moreira da Silva AG, et al. The addition of either an anterolateral ligament reconstruction or an iliotibial band tenodesis is associated with a lower failure rate after revision anterior cruciate ligament reconstruction: A retrospective comparative trial [published online July 15, 2022]. Arthroscopy. https://doi.org/10.1016/j.arthro.2022.06.039.

        • Pioger C.
        • Gousopoulos L.
        • Hopper G.P.
        • et al.
        Clinical outcomes after combined ACL and anterolateral ligament reconstruction versus isolated ACL reconstruction with bone-patellar tendon-bone grafts: A matched-pair analysis of 2018 patients from the SANTI Study Group.
        Am J Sports Med. 2022; 50: 3493-3501
        • Hurley E.T.
        • Bloom D.A.
        • Hoberman A.
        • et al.
        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
        • 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
        • 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.
        Am J Sports Med. 2017; 45: 1547-1557
        • 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.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 3652-3659
        • 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.
        Arthroscopy. 2019; 35: 2648-2654
        • Guy S.
        • Fayard J.M.
        • Saithna A.
        • et al.
        Risk of graft rupture after adding a lateral extra-articular procedure at the time of ACL reconstruction: A retrospective comparative study of elite Alpine skiers from the French National Team.
        Am J Sports Med. 2022; 50: 1609-1617
        • Sonnery-Cottet B.
        • Haidar I.
        • Rayes J.
        • et al.
        Long-term graft rupture rates after combined ACL and anterolateral ligament reconstruction versus isolated ACL reconstruction: A matched-pair analysis from the SANTI Study Group.
        Am J Sports Med. 2021; 49: 2889-2897
        • Ziegler C.G.
        • DePhillipo N.N.
        • Kennedy M.I.
        • Dekker T.J.
        • Dornan G.J.
        • LaPrade R.F.
        Beighton score, tibial slope, tibial subluxation, quadriceps circumference difference, and family history are risk factors for anterior cruciate ligament graft failure: A retrospective comparison of primary and revision anterior cruciate ligament reconstructions.
        Arthroscopy. 2021; 37: 195-205
        • 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.
        Am J Sports Med. 2017; 45: 3089-3097
        • Monaco E.
        • Helito C.P.
        • Redler A.
        • et al.
        Correlation between magnetic resonance imaging and surgical exploration of the anterolateral structures of the acute anterior cruciate ligament-injured knee.
        Am J Sports Med. 2019; 47: 1186-1193
        • Saithna A.
        • Helito C.P.
        • Vieira T.D.
        • Sonnery-Cottet B.
        • Muramatsu K.
        The anterolateral ligament has limited intrinsic healing potential: A serial, 3-dimensional-magnetic resonance imaging study of anterior cruciate ligament-injured knees from the SANTI Study Group.
        Am J Sports Med. 2021; 49: 2125-2135
        • Ferretti A.
        • Monaco E.
        • Redler A.
        • et al.
        High prevalence of anterolateral ligament abnormalities on MRI in knees with acute anterior cruciate ligament injuries: A case-control series from the SANTI Study Group.
        Orthop J Sports Med. 2019; 72325967119852916
        • 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.
        Arthroscopy. 2018; 34: 2207-2217
        • Suh D.
        • Chang M.J.
        • Park H.J.
        • Chang C.B.
        • Kang S.B.
        Assessment of anterolateral ligament of the knee after primary versus revision anterior cruciate ligament reconstruction.
        Orthop J Sports Med. 2021; 923259671211026236
        • Sobrado M.F.
        • Giglio P.N.
        • Bonadio M.B.
        • et al.
        Outcomes after isolated acute anterior cruciate ligament reconstruction are inferior in patients with an associated anterolateral ligament injury.
        Am J Sports Med. 2020; 48: 3177-3182
        • Engebretsen L.
        • Lew W.D.
        • Lewis J.L.
        • Hunter R.E.
        The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion.
        Am J Sports Med. 1990; 18: 169-176
        • Mayr R.
        • Sigloch M.
        • Coppola C.
        • Hoermann R.
        • Iltchev A.
        • Schmoelz W.
        Modified Lemaire tenodesis reduces anterior cruciate ligament graft forces during internal tibial torque loading.
        J Exp Orthop. 2022; 9: 45
        • Marom N.
        • Ouanezar H.
        • Jahandar H.
        • et al.
        Lateral extra-articular tenodesis reduces anterior cruciate ligament graft force and anterior tibial translation in response to applied pivoting and anterior drawer loads.
        Am J Sports Med. 2020; 48: 3183-3193
        • Novaretti J.V.
        • Arner J.W.
        • Chan C.K.
        • et al.
        Does lateral extra-articular tenodesis of the knee affect anterior cruciate ligament graft in situ forces and tibiofemoral contact pressures?.
        Arthroscopy. 2020; 36: 1365-1373
        • 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.
        Am J Sports Med. 2018; 46: 1819-1826
        • Sonnery-Cottet B.
        • Praz C.
        • Rosenstiel N.
        • et al.
        Epidemiological evaluation of meniscal ramp lesions in 3214 anterior cruciate ligament-injured knees from the SANTI Study Group database: A risk factor analysis and study of secondary meniscectomy rates following 769 ramp repairs.
        Am J Sports Med. 2018; 46: 3189-3197
        • Nwachukwu B.U.
        • Sullivan S.W.
        • Rauck R.C.
        • et al.
        Patient-reported outcomes and factors associated with achieving the minimal clinically important difference after ACL reconstruction.
        JBJS Open Access. 2021; 6 (e21.00056)
        • Weng C.J.
        • Yeh W.L.
        • Hsu K.Y.
        • et al.
        Clinical and functional outcomes of anterior cruciate ligament reconstruction with autologous hamstring tendon in patients aged 50 years or older.
        Arthroscopy. 2020; 36: 558-562
        • Roos E.M.
        • Lohmander L.S.
        The Knee injury and Osteoarthritis Outcome Score (KOOS): From joint injury to osteoarthritis.
        Health Qual Life Outcomes. 2003; 1: 64
        • Rayes J.
        • Ouanezar H.
        • Haidar I.M.
        • et al.
        Revision anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft combined with modified Lemaire technique versus hamstring graft combined with anterolateral ligament reconstruction: A clinical comparative matched study with a mean follow-up of 5 years from the SANTI Study Group.
        Am J Sports Med. 2022; 50: 395-403
        • Jaecker V.
        • Ibe P.
        • Endler C.H.
        • Pfeiffer T.R.
        • Herbort M.
        • Shafizadeh S.
        High risk of tunnel convergence in combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis.
        Am J Sports Med. 2019; 47: 2110-2115
        • Sonnery-Cottet B.
        • Ouanezar H.
        • Vieira T.D.
        • et al.
        High risk of tunnel convergence in combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis: Letter to the editor.
        Am J Sports Med. 2019; 47: NP67-NP68