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Concomitant ALL reconstruction yielded significantly reduced ACL graft rupture rate
The rate of ACL graft failure did not differ for isolated quadrupled hamstring tendon grafts and bone-patellar tendon-bone grafts.
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Patients who underwent ACL reconstruction with a hamstring tendon graft combined with anterolateral ligament reconstruction experienced a lower rate of graft failure and had greater odds of returning to their preinjury levels of sport, according to results of a prospective study.
“The main message of this study is that performing anterolateral ligament (ALL) reconstruction at the same time as ACL reconstruction is associated with significantly lower graft rupture rates than with isolated ACL reconstruction using either one of the two most frequently used graft choices in contemporary practice,” Bertrand Sonnery-Cottet, MD, of Centre Orthopédique Santy, FIFA Medical Center of Excellence in Lyon, France, told Orthopedics Today.
Lower graft failure rate
Sonnery-Cottet and his colleagues conducted a prospective study of 502 patients (72.5% were men) who underwent primary ACL reconstruction with either a bone-patellar tendon-bone (BPTB) graft, a quadrupled hamstring (HS) tendon graft or a HS tendon graft combined with ALL reconstruction. To identify prognosticators of graft rupture and return to sport, researchers analyzed survivorship data from the Kaplan-Meier analysis using multivariate Cox regression models.
The mean preoperative and postoperative subjective IKDC scores, side-to-side laxity and postoperative Lysholm and Tegner scores were not significantly different between the groups, investigators noted. At a mean follow-up of 38.4 months, the graft rupture rates were 10.77%, 16.77% and 4.13%, respectively, for quadrupled HS tendon grafts, BPTB grafts and HS tendon grafts combined with ALL reconstruction.
The researchers found no significant difference in graft failure rates between isolated quadrupled HS tendon grafts and BPTB grafts. However, in multivariate analysis, HS tendon grafts combined with ALL reconstruction had a rate of graft failure that was 2.5-times less than BPTB grafts and 3.1-times less than quadrupled HS tendon grafts.
Independent variables and failure
Independent variables associated with increased risk of graft failure included patient age of 25 years or younger and preoperative side-to-side laxity greater than 7 mm.
Hamstring tendon grafts combined with ALL reconstruction were associated with greater odds of returning to the pre-injury level of sports when compared with quadrupled HS tendon grafts, but not when compared with BPTB grafts, the researchers noted.
Sonnery-Cottet said the results of this study have shown that not only does the current, anatomic ALL reconstruction have a low reoperation rate due to graft rupture-related and non-graft rupture-related indications, it also does not have the excessively high reoperation rate that has been shown to be associated with non-anatomical lateral extra-articular tenodeses.
“The lack of specific complications of anatomic ALL reconstruction coupled with excellent results leads us to question whether concomitant ALL reconstruction should be considered for all patients undergoing ACL reconstruction,” Sonnery-Cottet said.
However, he and his colleagues have begun a prospective randomized study to address the limitations of this latest study. Another goal of this next study, is to “confirm the significant improvement of graft rupture rates and return to sport with an additional ALL reconstruction compared to an isolated ACL reconstruction,” Sonnery-Cottet said. – by Casey Tingle
- Reference:
- Sonnery-Cottet B, et al. Am J Sports Med. 2017;doi:10.1177/0363546516686057.
- For more information:
- Bertrand Sonnery-Cottet, MD, can be reached at Centre Orthopédique Santy, 24 Avenue Paul Santy, Lyon 69008, France; email: sonnerycottet@aol.com.
Disclosure: Sonnery-Cottet reports he receives royalties from, is a paid consultant for, receives research support from and has made presentations for Arthrex.
Perspective
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Freddie H. Fu, MD, DSc(Hon), DPs(Hon)
Sonnery-Cottet and colleagues reported a combined ACL and ALL reconstruction significantly reduces the ACL re-rupture rate. We commend them for this large retrospective study of young, active patients, which had a 92.8% follow-up rate.
However, it should be noted the reported re-rupture rate in this study is higher when compared to randomized controlled trials on anatomic ACL reconstructions. Those level 1 studies by independent groups worldwide found the ACL re-rupture rate was no higher than 5.7% after a minimum 2-year follow-up. In contrast, Sonnery-Cottet and colleagues found an overall ACL failure rate of 8% (10.77% and 16.77% for the HS tendon and BPTB groups, respectively, and 4.13% for the combined ACL and ALL reconstruction cohort). Furthermore, the 25.4% reported reoperation rate is higher than previously reported.
The key to optimal outcomes following ACL reconstruction is not to perform a one-size-fits all surgery, but to individualize the approach according to patient-specific factors, such as activity level, knee morphology (ie, intercondylar notch size) and recreation of the native ACL anatomy and insertion site. In our own ongoing, randomized-controlled trial, the ACL re-rupture rate is less than 5% at greater than 3-years follow-up.
I agree a subset of patients has persistent rotatory knee instability following ACL reconstruction and in some of these cases, a lateral extra-articular procedure may be beneficial. However, the evidence is still lacking regarding appropriate indications to perform such surgery. In light of recent biomechanical studies which demonstrated the role of the ALL in knee mechanics was negligible, and other studies that raised concerns about over-constraint of the lateral compartment, surgeons should exercise caution before performing lateral extra-articular reconstructions on patients with ACL injuries.
We look forward to seeing the long-term outcomes of these patients.
References:
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Steven Claes, MD, PhD
Keeping in mind that only athletes with a high risk for having an ACL graft rupture were included in this study, the finding is, frankly, fascinating to me that a combined ACL plus ALL reconstruction reduces the risk for ACL graft rupture by 2.5 and 3.1 times compared to a traditional ACL reconstruction using a BPTB and HS graft, respectively. The scientific value of solid clinical series like this one can hardly be overestimated because they do inject the present ALL debate with much-needed clinical data about what happens in our patients.
With the current ALL controversy being fueled by laboratory reports that utilize different nomenclature and anatomy, I am convinced this landmark paper will generate an interesting mindset change in the ongoing discussion of this topic.
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