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Letter to the Editor| Volume 39, ISSUE 4, P908-910, April 2023

A Call for More Studies Evaluating Posttraumatic Knee Osteoarthritis in Patients Undergoing Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Stabilization

DOI:https://doi.org/10.1016/j.arthro.2022.12.031
A Call for More Studies Evaluating Posttraumatic Knee Osteoarthritis in Patients Undergoing Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Stabilization
Previous ArticleEvidence-Based Practice Should Supersede Evidence-Based Medicine Through Consideration of Clinical Experience and Patient Characteristics in Addition to the Published Literature
Next ArticleTreatment of Degenerative Meniscus Tears
      Ever since the “re-discovery” of the anterolateral ligament (ALL) by Vincent et al.
      • Vincent J.P.
      • Magnussen R.A.
      • Gezmez F.
      • et al.
      The anterolateral ligament of the human knee: An anatomic and histologic study.
      Knee Surg Sports Traumatol Arthrosc. 2012; 20: 147-152
      in 2012, a tremendous amount of research has been devoted to determining the anatomy and biomechanics of the ALL as well as its role in rotational stability of the knee joint following an injury to the anterior cruciate ligament (ACL).
      • Kraeutler M.J.
      • Welton K.L.
      • Chahla J.
      • LaPrade R.F.
      • McCarty E.C.
      Current concepts of the anterolateral ligament of the knee: Anatomy, biomechanics, and reconstruction.
      Am J Sports Med. 2018; 46: 1235-1242
      ,
      • Littlefield C.P.
      • Belk J.W.
      • Houck D.A.
      • et al.
      The anterolateral ligament of the knee: An updated systematic review of anatomy, biomechanics, and clinical outcomes.
      Arthroscopy. 2021; 37: 1654-1666
      Biomechanical studies have demonstrated that the ALL plays an important role in resisting internal tibial rotation and preventing the pivot-shift phenomenon.
      • Kittl C.
      • El-Daou H.
      • Athwal K.K.
      • et al.
      The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee.
      Am J Sports Med. 2016; 44: 345-354
      , 
      • Sonnery-Cottet B.
      • Lutz C.
      • Daggett M.
      • et al.
      The involvement of the anterolateral ligament in rotational control of the knee.
      Am J Sports Med. 2016; 44: 1209-1214
      , 
      • Spencer L.
      • Burkhart T.A.
      • Tran M.N.
      • et al.
      Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee.
      Am J Sports Med. 2015; 43: 2189-2197
      Restoration of the function of the ALL in patients undergoing anterior cruciate ligament reconstruction (ACLR) may come in the form of ALL reconstruction or lateral extra-articular tenodesis (LET). Although either of these lateral extra-articular stabilization (LEAS) procedures may reduce residual rotatory instability following ACLR, biomechanical studies also have shown that these procedures may overconstrain the knee joint and increase lateral compartment pressures compared with the native state.
      • Guenther D.
      • Irarrázaval S.
      • Bell K.M.
      • et al.
      The role of extra-articular tenodesis in combined ACL and anterolateral capsular injury.
      J Bone Joint Surg Am. 2017; 99: 1654-1660
      , 
      • Inderhaug E.
      • Stephen J.M.
      • El-Daou H.
      • Williams A.
      • Amis A.A.
      The effects of anterolateral tenodesis on tibiofemoral contact pressures and kinematics.
      Am J Sports Med. 2017; 45: 3081-3088
      , 
      • Marom N.
      • Jahandar H.
      • Fraychineaud T.J.
      • et al.
      Lateral extra-articular tenodesis alters lateral compartment contact mechanics under simulated pivoting maneuvers: An in vitro study.
      Am J Sports Med. 2021; 49: 2898-2907
      , 
      • Schon J.M.
      • Moatshe G.
      • Brady A.W.
      • et al.
      Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle.
      Am J Sports Med. 2016; 44: 2546-2556
      , 
      • Slette E.L.
      • Mikula J.D.
      • Schon J.M.
      • et al.
      Biomechanical results of lateral extra-articular tenodesis procedures of the knee: A systematic review.
      Arthroscopy. 2016; 32: 2592-2611
      Clinically, indications for adding LEAS to patients undergoing ACLR vary by study but may include high-grade pivot shift, chronic ACL tear, revision ACLR, generalized ligamentous laxity, young patients involved in pivoting sports, and elite/professional athletes.
      • Kraeutler M.J.
      • Welton K.L.
      • Chahla J.
      • LaPrade R.F.
      • McCarty E.C.
      Current concepts of the anterolateral ligament of the knee: Anatomy, biomechanics, and reconstruction.
      Am J Sports Med. 2018; 46: 1235-1242
      ,
      • Borque K.A.
      • Jones M.
      • Laughlin M.S.
      • et al.
      Effect of lateral extra-articular tenodesis on the rate of revision anterior cruciate ligament reconstruction in elite athletes.
      Am J Sports Med. 2022; 50: 3487-3492
      ,
      • Getgood A.
      Editorial Commentary: Indications for lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction.
      Arthroscopy. 2022; 38: 125-127
      In randomized controlled trials (RCTs) comparing the results of isolated ACLR versus ACLR with LEAS, the evidence is clear: LEAS procedures significantly reduce the risk of ACL graft rupture/clinical failure in “at-risk” patients.
      • Chen J.
      • Xu C.
      • Cho E.
      • Huangfu X.
      • Zhao J.
      Reconstruction for chronic ACL tears with or without anterolateral structure augmentation in patients at high risk for clinical failure: A randomized clinical trial.
      J Bone Joint Surg Am. 2021; 103: 1482-1490
      , 
      • 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
      , 

      Mogos S, Antonescu D, Stoica I-C, D’Ambrosi R. Superior rotational stability and lower re-ruptures rate after combined anterolateral and anterior cruciate ligament reconstruction compared to isolated anterior cruciate ligament reconstruction: A 2-year prospective randomized clinical trial [published online August 18, 2022]. Phys Sportsmed. doi: 10.1080/00913847.2022.2112914.

      , 
      • Onggo J.R.
      • Rasartnam H.K.
      • Nambiar M.
      • et al.
      Anterior cruciate ligament reconstruction alone versus with lateral extra-articular tenodesis with minimum 2-year follow-up: A meta-analysis and systematic review of randomized controlled trials.
      Am J Sports Med. 2022; 50: 1137-1145
      Several retrospective comparative studies have also found lower failure rates with combined ACLR and LEAS versus isolated ACLR.
      • Helito C.P.
      • Sobrado M.F.
      • Moreira da Silva A.G.
      • 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.
      Arthroscopy. 2023; 39: 308-319
      , 
      • Hopper G.P.
      • Pioger C.
      • Philippe C.
      • et al.
      Risk factors for anterior cruciate ligament graft failure in professional athletes: An analysis of 342 patients with a mean follow-up of 100 months from the SANTI Study Group.
      Am J Sports Med. 2022; 50: 3218-3227
      , 
      • Monaco E.
      • Carrozzo A.
      • Saithna A.
      • et al.
      Isolated ACL reconstruction versus ACL reconstruction combined with lateral extra-articular tenodesis: A comparative study of clinical outcomes in adolescent patients.
      Am J Sports Med. 2022; 50: 3244-3255
      , 
      • Perelli S.
      • Gianluca Costa G.
      • Montiel Terron V.
      • et al.
      Combined anterior cruciate ligament reconstruction and modified Lemaire lateral extra-articular tenodesis better restores knee stability and reduces failure rates than isolated anterior cruciate ligament reconstruction in skeletally immature patients.
      Am J Sports Med. 2022; 50: 3778-3785
      In some retrospective studies, addition of LEAS also has been shown to reduce the risk of other reoperations, such as subsequent meniscectomy following ACLR.
      • 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
      ,
      • 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
      But what about the biomechanical studies showing increased lateral compartment pressures with LEAS? Might this increase the risk for posttraumatic osteoarthritis (PTOA) in the future? PTOA after ACL injury is high, with reported rates of knee osteoarthritis in approximately 50% of patients who undergo ACLR at 10 to 20 years’ postoperatively.
      • Belk J.W.
      • Kraeutler M.J.
      • Carver T.J.
      • McCarty E.C.
      Knee osteoarthritis after anterior cruciate ligament reconstruction with bone-patellar tendon-bone versus hamstring tendon autograft: A systematic review of randomized controlled trials.
      Arthroscopy. 2018; 34: 1358-1365
      ,
      • Lohmander L.S.
      • Englund P.M.
      • Dahl L.L.
      • Roos E.M.
      The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis.
      Am J Sports Med. 2007; 35: 1756-1769
      As far as we can find, there is only 1 RCT with long-term (>10 years) follow-up comparing rates of PTOA in patients undergoing isolated ACLR versus ACLR with LEAS. At a minimum 19-year follow-up, Castoldi et al.
      • Castoldi M.
      • Magnussen R.A.
      • Gunst S.
      • et al.
      A randomized controlled trial of bone-patellar tendon–bone anterior cruciate ligament reconstruction with and without lateral extra-articular tenodesis: 19-year clinical and radiological follow-up.
      Am J Sports Med. 2020; 48: 1665-1672
      found that patients who underwent ACLR with LET demonstrated a significantly greater rate of lateral-compartment osteoarthritis compared with patients who underwent isolated ACLR (59% vs 22%, P = .02). This is a dramatic difference and certainly should be evaluated in other RCTs as long-term follow-up becomes available.
      LET is nothing new. In fact, in the 1970s and 1980s, extra-articular reconstructions were the procedure of choice for treating the resultant rotatory instability that occurred with injury to the ACL, without addressing the ACL itself.
      • McCulloch P.C.
      • Lattermann C.
      • Boland A.L.
      • Bach Jr., B.R.
      An illustrated history of anterior cruciate ligament surgery.
      J Knee Surg. 2007; 20: 95-104
      ACL reconstruction with an “over-the-top” approach combined with LET was widely used in the 1980s but often resulted in arthrofibrosis.
      • McCulloch P.C.
      • Lattermann C.
      • Boland A.L.
      • Bach Jr., B.R.
      An illustrated history of anterior cruciate ligament surgery.
      J Knee Surg. 2007; 20: 95-104
      ,
      • Nogalski M.P.
      • Bach Jr., B.R.
      A review of early anterior cruciate ligament surgical repair or reconstruction. Results and caveats.
      Orthop Rev. 1993; 22: 1213-1223
      It is unclear whether stiffness was caused by joint overconstraint and/or significant dissection resulting in scar tissue formation. As indications for LEAS continue to expand, we fear that history may be repeating itself.
      If it is revealed that LEAS procedures significantly increase the risk for PTOA, it does not necessarily mean that these procedures should be abandoned. They certainly hold advantages in terms of reduced risk of graft rupture, and so refinement of the indications for LEAS and a discussion with each patient would be justified to explain the risks and benefits and come to a decision on an individual basis. The benefits of LEAS are clear, but we think it is necessary to learn more about the possible detriments of the procedure before LEAS can be adopted as standard practice in “at-risk” patients undergoing ACL reconstruction.

      References

        • Vincent J.P.
        • Magnussen R.A.
        • Gezmez F.
        • et al.
        The anterolateral ligament of the human knee: An anatomic and histologic study.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 147-152
        View in Article
        • Kraeutler M.J.
        • Welton K.L.
        • Chahla J.
        • LaPrade R.F.
        • McCarty E.C.
        Current concepts of the anterolateral ligament of the knee: Anatomy, biomechanics, and reconstruction.
        Am J Sports Med. 2018; 46: 1235-1242
        View in Article
        • Littlefield C.P.
        • Belk J.W.
        • Houck D.A.
        • et al.
        The anterolateral ligament of the knee: An updated systematic review of anatomy, biomechanics, and clinical outcomes.
        Arthroscopy. 2021; 37: 1654-1666
        View in Article
        • Kittl C.
        • El-Daou H.
        • Athwal K.K.
        • et al.
        The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee.
        Am J Sports Med. 2016; 44: 345-354
        View in Article
        • Sonnery-Cottet B.
        • Lutz C.
        • Daggett M.
        • et al.
        The involvement of the anterolateral ligament in rotational control of the knee.
        Am J Sports Med. 2016; 44: 1209-1214
        View in Article
        • Spencer L.
        • Burkhart T.A.
        • Tran M.N.
        • et al.
        Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee.
        Am J Sports Med. 2015; 43: 2189-2197
        View in Article
        • Guenther D.
        • Irarrázaval S.
        • Bell K.M.
        • et al.
        The role of extra-articular tenodesis in combined ACL and anterolateral capsular injury.
        J Bone Joint Surg Am. 2017; 99: 1654-1660
        View in Article
        • Inderhaug E.
        • Stephen J.M.
        • El-Daou H.
        • Williams A.
        • Amis A.A.
        The effects of anterolateral tenodesis on tibiofemoral contact pressures and kinematics.
        Am J Sports Med. 2017; 45: 3081-3088
        View in Article
        • Marom N.
        • Jahandar H.
        • Fraychineaud T.J.
        • et al.
        Lateral extra-articular tenodesis alters lateral compartment contact mechanics under simulated pivoting maneuvers: An in vitro study.
        Am J Sports Med. 2021; 49: 2898-2907
        View in Article
        • Schon J.M.
        • Moatshe G.
        • Brady A.W.
        • et al.
        Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle.
        Am J Sports Med. 2016; 44: 2546-2556
        View in Article
        • Slette E.L.
        • Mikula J.D.
        • Schon J.M.
        • et al.
        Biomechanical results of lateral extra-articular tenodesis procedures of the knee: A systematic review.
        Arthroscopy. 2016; 32: 2592-2611
        View in Article
        • Borque K.A.
        • Jones M.
        • Laughlin M.S.
        • et al.
        Effect of lateral extra-articular tenodesis on the rate of revision anterior cruciate ligament reconstruction in elite athletes.
        Am J Sports Med. 2022; 50: 3487-3492
        View in Article
        • Getgood A.
        Editorial Commentary: Indications for lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction.
        Arthroscopy. 2022; 38: 125-127
        View in Article
        • Chen J.
        • Xu C.
        • Cho E.
        • Huangfu X.
        • Zhao J.
        Reconstruction for chronic ACL tears with or without anterolateral structure augmentation in patients at high risk for clinical failure: A randomized clinical trial.
        J Bone Joint Surg Am. 2021; 103: 1482-1490
        View in Article
        • 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
        View in Article

      16. Mogos S, Antonescu D, Stoica I-C, D’Ambrosi R. Superior rotational stability and lower re-ruptures rate after combined anterolateral and anterior cruciate ligament reconstruction compared to isolated anterior cruciate ligament reconstruction: A 2-year prospective randomized clinical trial [published online August 18, 2022]. Phys Sportsmed. doi: 10.1080/00913847.2022.2112914.

        View in Article
        • Onggo J.R.
        • Rasartnam H.K.
        • Nambiar M.
        • et al.
        Anterior cruciate ligament reconstruction alone versus with lateral extra-articular tenodesis with minimum 2-year follow-up: A meta-analysis and systematic review of randomized controlled trials.
        Am J Sports Med. 2022; 50: 1137-1145
        View in Article
        • Helito C.P.
        • Sobrado M.F.
        • Moreira da Silva A.G.
        • 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.
        Arthroscopy. 2023; 39: 308-319
        View in Article
        • Hopper G.P.
        • Pioger C.
        • Philippe C.
        • et al.
        Risk factors for anterior cruciate ligament graft failure in professional athletes: An analysis of 342 patients with a mean follow-up of 100 months from the SANTI Study Group.
        Am J Sports Med. 2022; 50: 3218-3227
        View in Article
        • Monaco E.
        • Carrozzo A.
        • Saithna A.
        • et al.
        Isolated ACL reconstruction versus ACL reconstruction combined with lateral extra-articular tenodesis: A comparative study of clinical outcomes in adolescent patients.
        Am J Sports Med. 2022; 50: 3244-3255
        View in Article
        • Perelli S.
        • Gianluca Costa G.
        • Montiel Terron V.
        • et al.
        Combined anterior cruciate ligament reconstruction and modified Lemaire lateral extra-articular tenodesis better restores knee stability and reduces failure rates than isolated anterior cruciate ligament reconstruction in skeletally immature patients.
        Am J Sports Med. 2022; 50: 3778-3785
        View in Article
        • 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
        View in Article
        • 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
        View in Article
        • Belk J.W.
        • Kraeutler M.J.
        • Carver T.J.
        • McCarty E.C.
        Knee osteoarthritis after anterior cruciate ligament reconstruction with bone-patellar tendon-bone versus hamstring tendon autograft: A systematic review of randomized controlled trials.
        Arthroscopy. 2018; 34: 1358-1365
        View in Article
        • Lohmander L.S.
        • Englund P.M.
        • Dahl L.L.
        • Roos E.M.
        The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis.
        Am J Sports Med. 2007; 35: 1756-1769
        View in Article
        • Castoldi M.
        • Magnussen R.A.
        • Gunst S.
        • et al.
        A randomized controlled trial of bone-patellar tendon–bone anterior cruciate ligament reconstruction with and without lateral extra-articular tenodesis: 19-year clinical and radiological follow-up.
        Am J Sports Med. 2020; 48: 1665-1672
        View in Article
        • McCulloch P.C.
        • Lattermann C.
        • Boland A.L.
        • Bach Jr., B.R.
        An illustrated history of anterior cruciate ligament surgery.
        J Knee Surg. 2007; 20: 95-104
        View in Article
        • Nogalski M.P.
        • Bach Jr., B.R.
        A review of early anterior cruciate ligament surgical repair or reconstruction. Results and caveats.
        Orthop Rev. 1993; 22: 1213-1223
        View in Article

      Article info

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      DOI: https://doi.org/10.1016/j.arthro.2022.12.031

      Copyright

      © 2023 by the Arthroscopy Association of North America

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