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Lateral extra-articular tenodesis may reduce graft failure after ACL reconstruction
BOSTON — Young active patients undergoing hamstring autograft ACL reconstruction with lateral extra-articular tenodesis experienced reduced graft failure and anterolateral rotatory laxity compared to patients who had ACL reconstruction alone, according to results presented at the American Orthopaedic Society for Sports Medicine.
Alan M. Getgood, MD, FRCS(Tr&Orth), and colleagues in the Stability Study Group randomly assigned 618 patients who were younger than 25 years old with an ACL-deficient knee to undergo standard hamstring tendon ACL reconstruction either with or without lateral extra-articular tenodesis. To be included in the study, patients had to have specific characteristics “that would potentially put them at a higher risk of reinjury,” according to Getgood.
“Those included two of the following three criteria: returning to contact pivoting sport; a high grade rotatory laxity, which is a pivot shift of grade 2 or greater; or they had to have generalized ligamentous laxity,” Getgood, consultant orthopedic surgeon at Fowler Kennedy Sports Medicine Clinic, told Healio.com/Orthopedics.
Patients were followed up at 3, 6, 12 and 24 months, with the primary outcome of clinical failure defined as persistent rotatory laxity including a positive pivot shift and graft failure, according to Getgood. He added secondary outcomes included graft failure on its own, the four-item pain intensity measure, KOOS and IKDC scores.
Getgood noted patients in the ACL reconstruction with lateral extra-articular tenodesis group had a reduction in clinical failure from 40% to 25% that equates to a relative risk reduction of 40%.
“The graft ruptures were reduced from 11% down to 4%, again a statistically significant [result] with a relative risk reduction of 66%,” Getgood said.
He also noted no clinically significant differences in patient-reported outcomes between the two groups.
“There were slight differences at 3 months and 6 months in favor of the ACL only group, but that was most likely associated with a slight delay in recovery,” Getgood said. – by Casey Tingle
Reference:
Getgood AM, et al. Abstract 34. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 11-14, 2019; Boston.
Disclosure: Getgood reports he has no relevant financial disclosures.
Perspective
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I would start by congratulating these authors on this award-winning presentation. This work has the potential to change practice in the care of ACL-injured athletes. This is a multicenter, North American and European randomized controlled trial of hamstring autograft ACL reconstruction with or with the addition of a lateral tenodesis performed by expert surgeons.
With more than 83% 2-year follow-up of 624 patients, they found a significant increase in graft re-rupture in the ACL reconstruction only group (11%) compared with the ACL reconstruction and lateral extra-articular tenodesis group (4%). They also found a similar significantly higher “failure” defined by asymmetric pivot shift, revision or symptomatic instability in the ACL reconstruction alone group (41% vs 25%). Despite this, they found no 1- or 2-year differences in KOOS or IKDC.
I am interested to see how their activity measures compared at 2 years. It would also be interesting to evaluate lateral extra-articular tenodesis as an adjunct to ACL reconstruction with patella tendon autograft. These minor comments aside, this work is applauded and helps support the adjunctive use of lateral extra-articular tenodesis in a primary ACL reconstruction situation and is poised to become a landmark study.
Brown University Alpert Medical School
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