Lateral augmentation relies on individualized care
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Despite having been around for decades, recent research has ignited a resurgence in the application of lateral-sided extra-articular procedures, such as a lateral extra-articular tenodesis and anterolateral ligament reconstruction.
“Conceptually, lateral extra-articular reconstructions are not new operations, rather they have ben reintroduced in North America recently, while our European colleagues have continued to employ them as a component of the treatment offered to ACL-injured patients since they were first described,” Frank A. Cordasco, MD, MS, professor of orthopedic surgery at Hospital for Special Surgery, told Healio | Orthopedics Today. “Historically, these reconstructions were performed decades before intra-articular ACL reconstruction became the standard of care for ACL injury in North America.”
Source: Kostas J. Economopoulos, MD
Results of recent research and collective international clinical experience have led surgeons in North America to utilize these procedures to diminish the reinjury rate in young, high-risk athletes, according to Cordasco.
In the Stability 1 randomized clinical trial, Alan M. J. Getgood, MD, FRCS (Tr and Orth), Dip SEM, orthopedic surgeon at The Fowler Kennedy Sports Medicine Clinic, and colleagues found the addition of a lateral extra-articular tenodesis (LET) to an ACL reconstruction with a hamstring tendon autograft reduced graft failure by 66% for young, high-risk patients. The study also showed that the addition of LET reduced persistent rotatory laxity in the form of high-grade pivot shifts.
“Certainly, now the studies would suggest that if you are using a hamstring tendon autograft and you are under the age of 25 years, you should have a lateral tenodesis,” Getgood told Healio | Orthopedics Today.
Indications
On the whole, the indications for lateral extra-articular procedures are still unclear, according to Robert F. LaPrade, MD, PhD, complex knee surgeon at Twin Cities Orthopedics.
“We do not have a perfect answer for it because we need more data,” LaPrade told Healio | Orthopedics Today. “The issue is that there are some places, some countries even, that do it for every case. And the jury is still out in terms of whether you need it for every case or whether you need it for selected cases.”
However, Kostas J. Economopoulos, MD, orthopedic surgeon at the Mayo Clinic Arizona, said indications do not necessarily always rely on data alone.
“Data is always good, but in my heart, and this is a subjective decision, there are specific indications that, in my book, everyone gets an LET if they have these certain situations,” Economopoulos said. “That is someone who is ligamentously lax with a Beighton score of four or greater, someone with a pivot shift of two or more preoperatively and a revision ACL.”
Cordasco and his colleague Daniel W. Green, MD, MS, FAAP, FACS, chief of pediatric orthopedic surgery service at Hospital for Special Surgery, published their indications for LET procedures in skeletally immature and young skeletally mature athletes several years ago. These indications can be broken down into patient history and demographics, degree of pathology and nonmodifiable risk factors.
In terms of history and demographics, Cordasco said the indications include high-risk athletes younger than 25 years, patients with chronic ACL insufficiency, patients who have had a contralateral ACL reconstruction and patients who require an ACL revision. In addition, a relative indication exists for 8th- and 9th-grade athletes who bridge middle school and high school. Cordasco said in their experience, these young athletes are at particular risk for recurrent injury.
For degree of pathology, he said the indications include young athletes with anterior-posterior translation (greater than 7 mm), high-grade pivot shift (IKDC 3+), presence of Segond fractures and high velocity transchrondral marrow edema injuries of the lateral tibia plateau and the lateral femoral condyle.
Cordasco said nonmodifiable risk factors include those high-risk athletes with recurvatum, increased lateral tibial slope, a narrow notch and hyperlaxity (Beighton greater than 3).
“If I am taking care of an athlete under the age of 20 years who tears their ACL, I am looking for reasons not to perform a lateral extra-articular reconstruction,” Cordasco said. “That is probably further along the curve than many surgeons in North America, but this opinion is based upon our research and clinical experience in managing young, high-risk athletes under 25 years of age, one quarter of whom are skeletally immature. This is a different demographic than the recreational adult patients many orthopedic surgeons treat in the community.”
LET vs. ALL reconstruction
Two common lateral-sided extra-articular procedures include a LET and anterolateral ligament (ALL) reconstruction. According to Getgood, a LET provides “biomechanical control of the anterolateral rotatory laxity” and reduces the load on an ACL graft. Although Getgood said an ALL reconstruction “has been proposed to be a more anatomic reconstruction of the anterolateral ligament,” that is still up for debate.
According to Volker Musahl, MD, professor of orthopedic surgery and bioengineering and chief of sports medicine at the University of Pittsburgh Medical Center, both a LET and ALL reconstruction are nonanatomic procedures.
“We accept that fact that [extra-articular procedures are] not anatomic, but rather it is serving a purpose of a secondary restraint,” Musahl said. “We all understand, at least in early data, it does reduce the failure rate of the ACL by putting a rotational stabilizer on the lateral side.”
Although research has shown LET and ALL reconstructions have similar biomechanics and functional outcomes, Economopoulos said LETs are more feasible than ALL reconstructions due to cost.
“The number one reason that I went away from ALL reconstructions was cost,” Economopoulos said. “More implants are necessary to do a reconstruction as compared to an LET.”
He added there is also the concern of tibial fracture with ALL reconstruction.
“When we are putting the anchors of the tunnels into the tibia, we are close to that articular margin, and there is always that possibility of fracturing through,” Economopoulos said. “By using the native attachment of the [iliotibial] IT band and not having to put anything down there [in an LET], it diminishes the chance for a fracture or some type of complication. That is why I have gone with [LET] and have tried to avoid the reconstructions.”
LaPrade said the difference between the procedures is more so a matter of surgeon preference.
“The LET procedure is probably just a little bit better, but not statistically significant, so there is not any clinical difference you would see,” LaPrade said. “What we could say is that it probably does not matter which one you use. You want to make sure the surgeon does the one that is best in their hands for your particular situation.”
Risks
As with any surgery, Musahl said there are risks associated with lateral extra-articular procedures.
“With any lateral procedure, with any additional procedure really, there are downsides and risks,” Musahl said. “You are making an extra incision, there is additional pain whether it is ALL reconstruction or LET. We are violating the musculature of the lateral side, and so there is evidence that it causes some weakness in the early postoperative phase. Some additional pain, some slight motion restrictions.”
LaPrade added that overloading the lateral compartment may cause arthritis and damage to the cartilage.
However, Getgood said the concern of overloading the lateral compartment has not been borne out in the literature.
“In our trials where we have looked at quantitative MRI and radiographs and we are still ongoing follow-up with patients after 7 years, we are not seeing any evidence of lateral arthritis,” Getgood said. “But it still is a theoretical concern and something we keep an eye on.”
In addition, Economopoulos said hematoma formation has been a concern with lateral extra-articular procedures.
“There is a lot of good blood supply between the femur and the IT band, and when we are doing our LETs, it is not always easy to see it all,” Economopoulos said. “I have run into some situations where our athletes get a bit of a hematoma out there.”
Psychological impact
Despite the potential risks associated with lateral extra-articular procedures, Cordasco said he is “more concerned with the risk of reinjury and revision ACL surgery in the highest-risk young athletic population.”
“This has been supported by our published work, which has demonstrated a lower risk of reinjury, a higher return to sport and greater patient satisfaction when an LET is combined with an ACL reconstruction,” Cordasco said.
The psychodynamic and psychosocial experience of middle school and high school athletes may be impacted by losing 7 months to 1 year following a primary ACL surgery as “these athletes lose a component of the collegiality and comradery they experience with their teammates as well as their identity within the cohort during a significant developmental period in their lives,” according to Cordasco.
“A second surgery (with the additional loss of 7 to 12 months of rehabilitation) is difficult to recover from physically, psychologically and as it relates to return to sport. Additional injury and surgery will likely increase the potential for posttraumatic arthritis as well,” Cordasco said. “It is clear that the best outcomes occur with primary ACL reconstruction when compared to revision ACL reconstruction. Anything we can do to prevent a reinjury following ACL surgery, which to date has not been shown to be harmful to the patient, should be strongly considered in this population of young athletes. Additional research in this area will help define and confirm the indications.”
In addition, Economopoulos said an LET or ALL reconstruction can give young, high-risk athletes the confidence they need on the playing field to return from injury without fears of reinjury.
“I do believe that the LET can give someone more of a psychological advantage by having a stable knee that is not giving out on them,” Economopoulos said. “The feeling of residual instability, even a small change like 10° of internal rotation, is going to affect them, and they are going to sense it and they are going to lose that confidence. And if you do not have the confidence to make that cut, that pivot, you are not going to be able to get back to your same high level.”
Tips and pearls
Good surgical technique can reduce the risk of failure in both LETs and ALL reconstructions, according to LaPrade.
“The biggest thing is just making sure your surgical incision is big enough so you can see surgical landmarks and put the grafts in the right spot, whether you are doing an LET or an anterolateral ligament reconstruction,” LaPrade said. “I have seen some that are put in very nonanatomic positions that are not achieving good function because the incisions were so small that people did not quite recognize where the grafts needed to be placed.”
He added, “There is always a striving, especially in the western part of our country, to make tiny incisions. But tiny incisions sometimes lead to big complications and nonanatomic positions.”
A pearl specific to LETs, according to Musahl, is to feel the lateral collateral ligament (LCL).
“We pass this IT band graft deep to the LCL,” Musahl said. “I recommend putting the leg in the figure-four position so that the LCL picks up tension, so you can clearly feel it, mark it with a little pen and then make a wide incision proximal and distal to it.”
He added finding the fixation point is the next step, and the more proximal a surgeon goes, the more isometric the construct will be.
“Isometry is what we will be shooting for,” Musahl said.
Individualized care
The future of lateral extra-articular procedures and ACL reconstruction management will rely on individualized care, according to Getgood.
“We have gone beyond the days of just saying my graft of choice for every single patient is hamstring or is patellar tendon. It is more about a risk assessment of individual patients, and we can assess different risk factors such as their laxity profile, their age, their activity level [and] their tibial slope,” Getgood said. “More and more of the surgical community need to understand that and need to start looking at their patients on an individualized manner, and then counseling the patients appropriately as per graft choice.”
He added there are more predictive tools that orthopedic surgeons can use to help choose between grafts based on risk stratification.
“In time, we will start to see more information to help both surgeons and patients determine what the best surgical intervention is to try and reduce their risk of failure, and also increase their chance of having a good outcome,” Getgood said.
Musahl said the Stability 2 trial will answer some of the questions that are still unanswered when it comes to lateral extra-articular procedures.
“If you use hamstrings, it is quite clear that if it is a young, active person, an LET is probably a good addition to do,” Musahl said. “But we do not know that for patellar tendon. We do not know that for quadriceps tendon. Stability 2, which will probably come out in 2027 or so, will shed some light on this.”
- References:
- Claes S, et al. J Anat. 2013;doi:10.1111/joa.12087.
- Cordasco FA, et al. Am J Sports Med. 2019;doi:10.1177/0363546518819217.
- Firth AD, et al. Am J Sports Med. 2022;doi:10.1177/03635465211061150.
- Geeslin AG, et al. Am J Sports Med. 2018;doi:10.1177/0363546517745268.
- Getgood AMJ, et al. Am J Sports Med. 2020;doi:10.1177/0363546519896333.
- Green DW, et al. Am J Sports Med. 2023;doi:10.1177/0365465231160681.
- Musahl V, et al. N Engl J Med. 2019;doi:10.1056/NEJMcp1805931.
- Price MJ, et al. Curr Opin Pediatr. 2017;doi:10.1097/MOP.0000000000000444.
- Satyen J, et al. JBJS Essent Surg Tech. 2019;doi:10.2106/JBJS.ST.19.00017.
- Sonnery-Cottet B, et al. J Arthrosc Tech. 2019;doi:10.1016/j.eats.2016.08.003.
- For more information:
- Frank A. Cordasco, MD, MS, of Hospital for Special Surgery, can be reached at rennichr@hss.edu.
- Kostas J. Economopoulos, MD, of the Mayo Clinic Arizona, can be reached at economopoulos.kostas@mayo.edu.
- Alan M. J. Getgood, MD, FRCS (Tr and Orth), Dip SEM, of the Fowler Kennedy Sports Medicine Clinic, can be reached at agetgoo@uwo.ca.
- Robert F. LaPrade MD, PhD, of Twin Cities Orthopedics, can be reached at robertlaprade@tcomn.com.
- Volker Musahl, MD, of the University of Pittsburgh Medical Center, can be reached at musahlv@upmc.edu.
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