Clinical Outcomes of Isolated Revision Anterior Cruciate Ligament Reconstruction or in Combination With Anatomic Anterolateral Ligament Reconstruction

Abstract

Background:

Although the cause of rotational instability after revision anterior cruciate ligament reconstruction (ACLR) is multifactorial, the rationale of adding an extra-articular procedure is based on its ability to restrict rotational instability.

Purpose:

To assess the effect of anterolateral ligament (ALL) reconstruction on revision ACLR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 87 patients who underwent revision ACLR between March 2011 and July 2014 with a follow-up of more than 3 years were included in this retrospective study. Patients were divided into the isolated revision ACLR group (group I, n = 45, from March 2011 to January 2013) or the revision ACLR in combination with ALL reconstruction group (group C, n = 42, from February 2013 to July 2014). Subjective knee assessments including the subjective International Knee Documentation Committee (IKDC) form, Lysholm score, Tegner activity scale, and Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale were used. Clinical and functional tests were performed before surgery and at ≥6 months after surgery. All tests were usually completed at 36 months of follow-up.

Results:

The mean follow-up duration for groups I and C were 41.5 ± 8.2 and 38.2 ± 6.9 months, respectively (P = .451). The subjective IKDC score, Tegner score, and ACL-RSI score were significantly better in group C compared with those in group I at the last follow-up (84.3 ± 18.5 vs 75.9 ± 19.2, 7.0 ± 0.8 vs 6.3 ± 0.7, and 69.5 ± 25.4 vs 51.9 ± 23.1, respectively), although they were not significantly different between the 2 groups at 12 months after surgery (79.2 ± 18.8 vs 76.7 ± 17.2, 6.7 ± 0.7 vs 6.5 ± 0.9, and 50.2 ± 24.6 vs 49.9 ± 25.1, respectively). There were no significant differences in KT-2000 arthrometer, isokinetic extensor strength, single-legged hop for distance, co-contraction test, or carioca test results between the 2 groups at the last follow-up (P = .304, .068, .125, .056, and .066, respectively). Preoperatively, 43 (95.6%) patients in group I and 40 (95.2%) patients in group C had a grade 2 or 3 pivot shift (P = .387). Postoperatively, 23 (53.5%) patients in group I and 38 (90.5%) patients in group C had a negative pivot shift (P < .001). Group C showed a higher rate of return to the same level of sports activity than group I (57.1% vs 25.6%, respectively; P = .008), although there was no significant difference in the rate of return to any sports activity at the last follow-up (88.4% in group I vs 88.1% in group C; P = .713).

Conclusion:

Revision ACLR in combination with ALL reconstruction significantly reduced rotational laxity and showed a higher rate of return to the same level of sports activity than revision ACLR alone, although there were no significant differences in anterior laxity or functional test results between the 2 groups.

Keywords

anterior cruciate ligament anterolateral ligament ACL reconstruction revision ACL reconstruction

Except for new trauma, the most common cause for failure of primary anterior cruciate ligament (ACL) reconstruction (ACLR) is a nonanatomic tunnel position, which produces recurrent rotatory instability and graft reruptures.^2,24 Untreated instability resulting from concomitant injuries to the posterolateral corner or anterolateral ligament (ALL) at the time of primary reconstruction is also a key factor that contributes to failure.² Although acceptable clinical results have been reported after revision ACLR,²⁴ numerous studies have reported that revision ACLR has less favorable results than primary ACLR.^2,32,62 Hence, we need to carefully evaluate the reasons for the failure of primary reconstruction and try to minimize residual rotational instability related to functional outcomes.^3,21

While the reasons for rotatory instability are multifactorial, the effect of the anterolateral complex including the ALL, with the capsule, lateral collateral ligament, and lateral meniscus as secondary restraints to anterior displacement and internal rotation of the tibia, has been receiving interest.^22,44,46 Several biomechanical studies have demonstrated that ALL injuries can affect anterolateral rotatory instability related to the pivot-shift phenomenon.^44,46,60 Recurrent and residual abnormal pivot shifts can result in permanent anterolateral complex injuries.⁶¹ In this regard, extra-articular tenodesis or anatomic ALL reconstruction can be a meaningful attempt in case of revision ACLR to improve rotatory stability.^15,46,48,55

The load-sharing effect of extra-articular procedures can reduce reinjuries on return to sports after revision ACLR, as insufficient biological graft healing is another cause of ACLR failure.² If the ACL graft is not able to share stress with another native structure appropriately, higher tension loads on it would lead to delayed healing and subsequent graft failure.^10-12 Improved control of internal tibial rotation by additional extra-articular tenodesis or ALL reconstruction could protect the ACL graft from excessive stress during the postoperative period and return to sports.^{6,10,41,53,54,58}

A multicenter study has shown that combined revision ACLR and extra-articular lateral tenodesis could reduce the failure rate and increase knee stability, although it could not significantly alter the International Knee Documentation Committee (IKDC) score.⁵⁷ However, the study group or surgical technique was not homogeneous in that study. Recently, another multicenter study has also demonstrated that additional ALL stabilization could improve rotational stability and the rerupture rate compared with previous isolated revision ACLR.³⁴ Unfortunately, there was no control group in that study. Studies that compare isolated revision ACLR versus revision ACLR in combination with an extra-articular procedure are lacking. Therefore, the purpose of the current study was to assess the effect of ALL reconstruction on revision ACLR. We compared subjective and objective outcomes of isolated revision ACLR versus revision ACLR in combination with ALL reconstruction in a single surgeon’s series for a large number of consecutive patients. We hypothesized that revision ACLR combined with ALL reconstruction would be more effective in reducing rotatory instability and result in a more satisfactory rate of return to sports than isolated revision ACLR.

Methods

Patients

A total of 108 patients who underwent revision ACLR between March 2011 and July 2014 by an experienced single surgeon (J.G.K.) were enrolled. The inclusion criteria for this study were (1) a rerupture after primary ACLR, (2) revision ACLR using an anatomic outside-in technique, (3) a minimum 36 months of follow-up, and (4) age less than 45 years. Exclusion criteria were (1) multiple ligament injuries including high-grade partial ruptures of the medial collateral ligament and posterolateral complex that could affect the pivot-shift test, (2) contralateral injuries, (3) a subtotal or total meniscectomized state, and (4) cartilage lesions with modified Outerbridge grade ≥3. Revision ACLR usually faces numerous problems such as tunnel widening, tunnel malposition, and preexisting implants. Tunnel widening of more than 16 mm and a well-placed femoral tunnel that could make it difficult to produce a new trajectory were also excluded to render patients as homogeneous as possible. On the basis of these selections, 87 patients were divided into the isolated revision ACLR group (group I, n = 45) and the revision ACLR in combination with ALL reconstruction group (group C, n = 42) (Figure 1). The combination of ALL reconstruction and intra-articular ACLR has been performed since 2013 based on biomechanical backgrounds and clinical suspicion that it could be beneficial for eliminating rotational laxity.^7,8,10,12,57 Isolated revision ACLR was performed for 45 patients (group I) from March 2011 to January 2013, while revision ACLR in combination with ALL reconstruction was performed for 42 patients (group C) since February 2013 in a consecutive manner. The same inclusion and exclusion criteria were used for group C and group I. Retrospective analysis of preoperative demographics revealed that these 2 groups did not differ significantly (Table 1). This retrospective comparative study was performed after obtaining approval from the ethics committee of Konkuk University Medical Center (approval No. KUH1060155). Signed informed consent was obtained from all patients.

Table 1

Preoperative Demographic Data and Clinical Characteristics^a

	Group I (n = 45)	Group C (n = 42)	P Value
Age at revision ACLR, y	27.3 ± 7.6	26.8 ± 6.1	.737
Sex, male/female, n	34/11	33/9	.738
Follow-up duration, mo	41.5 ± 8.2	38.2 ± 6.9	.451
Failure of primary ACLR, n (%)			.197
Traumatic rerupture with tunnel problem	33 (73.3)	35 (83.3)
Traumatic rerupture without tunnel problem	3 (6.7)	2 (4.8)
Tunnel problem without trauma	9 (20.0)	5 (11.9)
Pivot shift, 0/1/2/3, n	0/2/12/31	0/2/15/25	.387
Lysholm score	73.2 ± 15.6	74.4 ± 16.1	.725
Subjective IKDC score	67.1 ± 16.4	68.7 ± 17.3	.659
Preinjury Tegner score	7.4 ± 0.9	7.5 ± 1.0	.697
Preoperative Tegner score	5.2 ± 1.1	5.4 ± 0.8	.573
Side-to-side difference on KT-2000 arthrometer, mm	9.4 ± 1.4	9.8 ± 1.7	.323
IKDC grade of Lachman’s test, A/B/C/D, n	0/1/38/6	0/2/35/5	.295
Meniscus surgery, n			.759
None	21	17
Meniscal repair, medial/lateral	12/8	13/9
Partial meniscectomy, medial/lateral	3/1	1/2

Data are presented as mean ± SD unless otherwise indicated. ACLR, anterior cruciate ligament reconstruction; C, combined revision anterior cruciate ligament reconstruction and anterolateral ligament reconstruction; I, isolated revision anterior cruciate ligament reconstruction; IKDC, International Knee Documentation Committee.

Surgical Techniques

Revision ACLR

After confirmation of an ACL graft rupture by arthroscopic surgery, a tibialis anterior tendon allograft (fresh-frozen) that was irradiated with 50 kGy and controlled by a tissue preservation technique (Clearant Process; Korea Bone Bank) was selected. A graft with a diameter of 9 mm was prepared. The torn graft and residual soft tissue were removed using electrocautery (ArthroCare; Smith & Nephew) to gain better visibility. Through the anteromedial portal, a microfracture awl was placed at a more lateral and posterior position than the previous vertical direction. The FlipCutter (Arthrex) guide tip was located at the center of a new femoral tunnel made using a microfracture awl, and the depth was measured. A stab incision was made at about 3 cm proximal to the lateral epicondyle, and the guide pin was drilled to the intra-articular FlipCutter guide tip using the outside-in method. Following the guide pin, the FlipCutter was engaged into the joint and retrodrilled around 25 to 30 mm to make a femoral socket, the diameter of which was the same as the thickness of the graft (Figure 2). In group C, a new femoral tunnel was made for revision ACLR, followed by another femoral tunnel for ALL reconstruction. The guide pin was drilled 6 mm before reaming for a femoral tunnel for ALL reconstruction. Whether the direction of the guide pin was blended with the femoral tunnel for ACLR was checked. If so, we redirected the guide pin to avoid the overlapping of tunnels (Figure 3).

After the graft was passed through the tibial tunnel, the ACL TightRope (Arthrex) was used for flipping and compressing the lateral cortex of the femur. Once complete flipping was done, distal pulling was performed for tensioning. A biointerference screw (Matryx; Conmed Linvatec) and additional staple were used for tibial fixation.

ALL Reconstruction

A gracilis tendon allograft (fresh-frozen) irradiated with 50 kGy and controlled by a tissue preservation technique (Clearant Process) with a diameter of 6 mm was prepared. Three bony landmarks (lateral femoral epicondyle, fibular head, and Gerdy tubercle) were identified based on previous ALL anatomy research.^7,44 A curvilinear skin incision was then made in the anterolateral aspect of the knee, extending from the lateral epicondyle to the tibial insertion between the Gerdy tubercle and fibular head (Figure 4A). A guide pin was positioned just proximal and posterior to the lateral femoral epicondyle. The femoral socket was made using a 6 mm–diameter cannulated reamer with a depth of 25 mm. This femoral socket preparation was performed before revision ACLR to avoid femoral tunnel communication. A guide pin was then positioned between the fibular head and Gerdy tubercle at approximately 10 mm below the joint line. The tibial socket was made using a 6 mm–diameter cannulated reamer with a depth of 25 mm. After femoral graft fixation was performed with a 7-mm biointerference screw (Matryx), tibial graft fixation was performed with a 7-mm biointerference screw at 30° of knee flexion and neutral rotation (Figure 4B). The placement of the femoral tunnel (proximal and posterior to the lateral epicondyle) and tibial tunnel (the center between the Gerdy tubercle and fibular head) was checked using 64–detector row 3-dimensional computed tomography scans (LightSpeed VCT XT; GE Medical Systems) that were obtained on the day of surgery (Figure 4C).

Postoperative Rehabilitation

Rehabilitation was performed with the same method for both groups. Patients were permitted to bear weight with an ACL-supporting brace (Legend; DonJoy) locked in full extension as tolerated immediately after surgery. When meniscus repair was performed, partial weightbearing with crutches was allowed for 6 weeks. Range of motion exercise was started with the brace unlocked from 0° to 90° at 3 weeks postoperatively. Progressive range of motion exercise was maintained, aiming for full flexion by week 6. The brace was completely removed at 2 months postoperatively. Open kinetic chain exercises and a perturbation training program were started at 2 months after surgery. After the course of home-based rehabilitation, running was allowed 6 months after surgery according to the recovery of muscle power and knee function. Competitive sports activity was allowed after 9 months postoperatively.

Clinical Assessment

Clinical and functional tests were administered usually before surgery and at 6, 12, 24, and 36 months postoperatively. They were usually completed at 36 months of follow-up. For subjective knee function assessments, the Lysholm score, subjective IKDC form, and Tegner activity scale were used. The mean duration from revision ACLR to return to sports and level of participation in sports were also assessed. The Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale was used to measure psychological readiness for return to sports at 12 months and the last follow-up.^4,26

As objective assessments, anterior laxity, manual pivot shift, isokinetic extensor muscle strength, and functional performance tests were administered. Anterior laxity was evaluated by a side-to-side difference on the KT-2000 arthrometer (MEDmetric) with maximal manual stress. The pivot-shift test was performed by the senior author (J.G.K.), who has more than 20 years of ACLR experience. Results were classified as grade 0 = normal, grade 1 = gliding, grade 2 = clunk, and grade 3 = gross shifting as in previous studies.^{5,16,38,49,50}

Isokinetic extensor muscle strength measurements were performed using the Biodex System 3 dynamometer (Biodex Medical Systems) at an angular velocity of 60 deg/s. Measurements were taken initially on the unaffected side, followed by the affected side. The deficit (%) was then calculated as follows: ([peak muscle torque of the uninvolved side – peak muscle torque of the involved side]/peak muscle torque of the uninvolved side) × 100.

To assess functional performance, the single-legged hop for distance reported by Noyes et al,⁴² co-contraction test, and carioca test were performed.^15,19 For the single-legged hop for distance, patients were asked to hop forward as far as possible, jumping and landing with the same foot. It was performed 3 times, and the longest distances for the involved and uninvolved limbs were measured in centimeters using a ruler on the ground. The limb symmetry index (%) was measured. The co-contraction test was conducted by securing a Velcro belt around the patient’s waist. The belt was attached to a 48-inch length of rubber tubing with a diameter of 1 inch. The tube was anchored to a metal loop that was secured on a wall 60 inches above the floor. A semicircle with a radius of 96 inches from the metal loop was painted on the floor. Patients standing with their toes on the line were asked to run wall to wall along the semicircular line 5 times, and the shortest time was measured. The carioca test was performed by requiring the patient to run laterally 2 lengths of a 12-m distance with a crossover step. The patient ran the course from left to right and then in the reverse direction. The fastest time was recorded.

Statistical Analysis

Statistical analysis was performed using SPSS for Windows version 20.0 (SPSS). An independent t test or Mann-Whitney U test was used to compare parametric or nonparametric variables between the 2 groups. Preoperative and postoperative parametric or nonparametric variables were compared with a paired t test or Wilcoxon signed-rank test in each group. The chi-square test was used to compare categorical data. If more than 20% of expected frequencies were >5, the Fisher exact test was applied. For the chi-square test for trends, linear by linear association was used. Statistical significance was defined at P < .05. To detect a difference of 10 points on the subjective IKDC form between the 2 groups with a level of significance of 5% and a power of 80%, the required sample size was determined to be 36 patients per group. Assuming a dropout rate of 15%, 42 patients per group were required.

Results

The mean follow-up duration for groups I and C were 41.5 ± 8.2 and 38.2 ± 6.9 months (P = .451), respectively. In group I, there were 2 graft ruptures after 12 months. Thus, 43 patients were evaluated at the last follow-up.

Subjective Outcomes

At the last follow-up, both groups showed a significantly improved subjective IKDC score, Lysholm score, and Tegner score compared with preoperative data (all P < .001). However, the subjective IKDC score, Tegner score, and ACL-RSI score were significantly better in group C compared with those in group I at the last follow-up, although they were not significantly different between the 2 groups at 12 months after surgery (Table 2).

Table 2

Subjective Outcomes^a

At 12 Months	Group I (n = 45)	Group C (n = 42)	P Value
Subjective IKDC score	76.7 ± 17.2	79.2 ± 18.8	.519
Lysholm score	85.1 ± 18.4	88.5 ± 16.9	.373
Tegner score	6.5 ± 0.9	6.7 ± 0.7	.253
ACL-RSI score	49.9 ± 25.1	50.2 ± 24.6	.955
At Last Follow-up	Group I (n = 43)	Group C (n = 42)	P Value
Subjective IKDC score	75.9 ± 19.2	84.3 ± 18.5	.041
Lysholm score	87.5 ± 20.4	90.2 ± 19.4	.529
Tegner score	6.3 ± 0.7	7.0 ± 0.8	<.001
ACL-RSI score	51.9 ± 23.1	69.5 ± 25.4	.001

Data are presented as mean ± SD. ACL-RSI, Anterior Cruciate Ligament–Return to Sport after Injury; C, combined revision anterior cruciate ligament reconstruction and anterolateral ligament reconstruction; I, isolated revision anterior cruciate ligament reconstruction; IKDC, International Knee Documentation Committee.

Objective Outcomes

There were no significant differences in KT-2000 arthrometer, isokinetic extensor strength, single-legged hop for distance, co-contraction test, or carioca test results between the 2 groups at the last follow-up (Table 3).

Preoperatively, 43 (95.6%) patients in group I and 40 (95.2%) patients in group C had a grade 2 or 3 pivot shift (P = .387). Postoperatively, 38 (90.5%) patients in group C and 23 (53.5%) patients in group I had a negative pivot shift (P < .001).

Table 3

Objective Outcomes at the Last Follow-up^a

	Group I (n = 43)	Group C (n = 42)	P Value
Side-to-side difference on KT-2000 arthrometer, mm	2.2 ± 1.4	1.9 ± 1.3	.304
IKDC grade of Lachman’s test, A/B/C/D, n	38/3/2/0	39/2/1/0	.102
Pivot shift, 0/1/2/3, n	23/13/7/0	38/4/0/0	<.001
Deficit of isokinetic extensor strength, %	13.2 ± 6.8	10.8 ± 5.1	.068
Limb symmetry index for single-legged hop for distance, cm	88.4 ± 10.3	91.7 ± 9.5	.125
Co-contraction, s	16.7 ± 2.3	15.5 ± 3.4	.056
Carioca, s	11.7 ± 2.0	10.8 ± 2.5	.066

Data are presented as mean ± SD unless otherwise indicated. C, combined revision anterior cruciate ligament reconstruction and anterolateral ligament reconstruction; I, isolated revision anterior cruciate ligament reconstruction; IKDC, International Knee Documentation Committee.

Return to Sports

The mean time to return to running or sports activity for groups I and C were 6.6 ± 2.5 and 6.1 ± 3.2 months (P = .417) or 11.5 ± 3.7 and 9.6 ± 3.4 months (P = .015), respectively. The average score of preinjury Tegner activity scale was 7.4 ± 0.9 in group I and 7.5 ± 1.0 in group C (P = 0.697). At the last follow-up, the mean Tegner score was 7.0 ± 0.8 in group C and 6.3 ± 0.7 in group I (P < .001) (Figure 5). Group C showed a higher rate of return to the same level of sports activity than group I (57.1% vs 25.6%, respectively; P = .008), although there was no significant difference in the rate of return to any sports activity (88.4% in group I vs 88.1% in group C; P = .713) (Figure 6). Reasons for not returning to the same level of sports are described in Table 4.

Table 4

Reasons for Not Returning to the Same Level of Sports at the Last Follow-up^a

	Group I (n = 32)	Group C (n = 18)	P Value
Unclear	2 (6.3)	1 (5.6)	.327
Fear	11 (34.4)	6 (33.3)
Physical limitation	16 (50.0)	8 (44.4)
Pain	4	2
Stiffness	0	0
Weakness	7	5
Rotational laxity during pivoting	5	1
Not related to knee function	3 (9.4)	3 (16.7)

Data are presented as n (%). C, combined revision anterior cruciate ligament reconstruction and anterolateral ligament reconstruction; I, isolated revision anterior cruciate ligament reconstruction.

Complications

A graft rerupture that needed re-revision surgery was found in 2 (4.4%) patients in group I, while no patient in group C showed a rerupture. The mean time from return to sports to a rerupture was 15.1 ± 3.9 months in the 2 patients. In the current study, 7 patients with a grade 2 pivot shift in group I did not have subjective knee instability. Therefore, they were not recommended to undergo another operative procedure. A complication related to the extra-articular procedure (n = 1) was only femoral interference screw protrusion that required removal. There was no stiffness in either group.

Discussion

The main finding of the present study was that the addition of anatomic ALL reconstruction to revision ACLR was effective in reducing rotational laxity assessed by the pivot-shift test. Anatomic ALL reconstruction plus revision ACLR showed significantly more reduction in residual pivot shift with a higher rate of return to the same level of sports activity compared with isolated revision ACLR. The subjective IKDC score, Tegner score, and ACL-RSI score were significantly better in group C compared with those in group I at the last follow-up, although there were no significant differences in the Lysholm score, anterior laxity, or functional test results between the 2 groups. There is concern that the ceiling effect of the Lysholm score is greater than that of the subjective IKDC score. It should be addressed when assessing knee function postoperatively.⁴⁵ However, the subjective IKDC form has merits, such as its point-based calculation system, which means that scoring is not affected by patient factors such as age or sex because it takes various knee-related problems into account.^37,43,45 To date, few studies have compared the results of revision ACLR versus a combination of anatomic ALL reconstruction with revision ACLR. There are no such comparative studies in a single surgeon’s series. Moreover, research about revision ACLR has difficulty in selecting a homogeneous group of patients. We tried to carefully decide the reasons for primary reconstruction failure and the inclusion criteria with an aim to have homogeneous patients.

A recent multicenter cohort study by the Multicenter Arthroscopic Knee Surgery (MAKS) group has reported that 4.2% (2/48) in the positive residual pivot-shift group and 13% (42/320) in the negative residual pivot-shift group had a grade ≤2 preoperative pivot shift (grade 1 is subtle gliding and grade 2 is gliding according to their classification).⁵⁸ It also investigated risk factors for residual pivot shift after primary ACLR based on a prospective cohort study. Melugin et al³⁸ revealed that 90.0% (18/20) of patients who had a combined ACL tear with Segond fracture and 82.5% (33/40) of patients who had an ACL tear without Segond fracture showed a grade ≥2 (clunk) preoperative pivot shift, respectively. Similarly, Lee et al²⁷ showed that 64% (176/275) of patients with acute ACL ruptures had ALL injuries and that 84% of 275 patients had a high-grade pivot shift. Another multicenter study by the French Arthroscopy Society reported that 77% (268/349) showed a grade ≥2 preoperative pivot shift.³⁴ It also evaluated outcomes of combined intra- and extra-articular grafting during revision surgery after previous ACLR. Several studies have investigated the risk factors for a high-grade pivot shift after an ACL injury and concluded that anterolateral structure disruptions are associated with increased knee rotatory laxity.^40,50 We hypothesized that a rerupture after primary ACLR would result in more frequent anterolateral structure injuries and a positive pivot shift. Although most ACLR failures were secondary to technical errors, a subset of patients could also have residual rotatory laxity, despite a well-positioned graft.³⁹ Such an abnormal pivot shift could result in permanent anterolateral complex injuries.⁶¹ In the current study, 95.4% showed a high-grade (grade ≥2) pivot shift.

Sonnery-Cottet et al⁵¹ have suggested that ACLR failures are caused by persistent rotational instability during sports activity. Hence, in patients with objective excessive rotatory laxity after ACLR, additional tenodesis or reconstruction of anterolateral structures could be considered when performing revision ACLR. Trojani et al⁵⁷ have reported that the proportion of negative pivot shifts was 80% with lateral tenodesis plus revision ACLR (n = 84) and 63% with isolated revision ACLR (P = .03), although additional lateral tenodesis did not influence the IKDC score in a multicenter study of 163 revision ACLRs. Louis et al³⁴ have demonstrated that 99% of 349 patients who underwent combined ALL stabilization and revision ACLR showed a negative pivot shift. Their negative pivot-shift prevalence was lower compared with about 10% in previous reports.^24,29,57 In addition, the rerupture rate was 1.2% in their multicenter study. In our study, 90.5% in group C showed a negative pivot shift, while 53.5% in group I had a negative pivot shift (P < .001). There was no rerupture after ALL stabilization in the present study. One prospective study, which was the first clinical series to show that anatomic ALL reconstruction was associated with a reduction in the graft rerupture rate, reported that the rate of graft failure with a combination of ALL reconstruction and ACLR was more than 2 times less than that with isolated ACLR.⁵⁴ Therefore, in revision ACLR, an additional extra-articular procedure could be considered as a strategy to improve rotational stability and reduce the rerupture rate. This is in accordance with the concept of “belt and suspenders” and “backup for ACL graft” in biomechanical studies.^{12,14,17,35,36,53}

Few studies have evaluated the rate of return to sports after a combined extra-articular procedure and revision ACLR. Our results showed a higher rate of return to the same sports level compared with 43% of 1167 patients who underwent revision ACLR in a meta-analysis.¹ Lefevre et al²⁸ reported that 23.7% of 497 patients in the primary ACLR group returned to the same or better sports level at 1 year compared with 12.7% of 55 patients in the revision ACLR group (P = .04). The involved knee was the main reason for changing or stopping the preinjury sports level. In the current study, 57.1% of patients in group C returned to the same level of sports activity at the last follow-up compared with 25.6% of patients in group I (P = .008), although there was no significant difference in the rate of return to a lower level of sports activity (groups I and C: 88.4% vs 88.1%, respectively; P = .713). One multicenter study reported that the mean time to return to sports was less than 8 months in 86% of 349 patients after ALL stabilization plus revision ACLR.³⁴ Sonnery-Cottet et al⁵⁴ showed that the addition of anatomic ALL reconstruction was associated with a greater odds of returning to the preinjury sports level compared with isolated ACLR.

Trojani et al⁵⁷ showed that there was no difference in the objective IKDC score between isolated revision ACLR and lateral tenodesis plus revision ACLR at a minimum 2-year follow-up. Vadala et al⁵⁹ reported that clinical outcomes other than the pivot shift did not show significant differences between patients with an extra-articular procedure and those without an extra-articular procedure. Similarly, there were no significant differences in KT-2000 arthrometer, isokinetic extensor strength, single-legged hop for distance, co-contraction test, or carioca test results between the 2 groups at the last follow-up in our study. However, ALL reconstruction showed a trend to have better results on the co-contraction and carioca tests in the current study. Lephart et al³¹ suggested that the co-contraction, carioca, and shuttle run tests were quantitative measurements of functional capabilities after ACLR. They provide a basis for determining patients’ readiness to return to sports. The co-contraction and carioca tests were designed to reproduce rotational forces, necessitating the control of tibial translation and the pivot-shift phenomenon.^30,31 Jang et al¹⁸ reported that the co-contraction and carioca tests, mainly for assessing rotational stability, showed statistically significant differences between return to sports and non–return to sports at a minimum 2-year follow-up.

Numerous recent studies about ALL anatomy and biomechanics have led to a better understanding of them. Subsequently, various anatomic ALL reconstruction techniques have emerged.^9,19,23,60 However, regarding extra-articular procedures, no consensus is available on the graft type, location of fixation, or fixation angle. In particular, there have been various fixation angles from full extension to 90°.²³ Schon et al⁴⁷ have reported that anatomic ALL reconstruction in conjunction with ACLR can significantly reduce rotatory laxity beyond 30° of flexion. However, it resulted in mild overconstraining, regardless of the fixation angle. However, Thaunat et al⁵⁶ demonstrated that the high rates of stiffness and reoperation reported in historical series of nonanatomic extra-articular lateral tenodesis were not found in anatomic ALL reconstruction with a cohort of 548 patients. Our suggestion is that ALL is less isometric structure, therefore, anatomic ligament reconstruction to restore anatomy as close as possible is important.^13,20 Furthermore, combined ACLR and anatomic ALL reconstruction using 1 femoral tunnel in revision cases could be a simple and safe strategy to avoid the overlapping of 2 new femoral tunnels.⁵² Further research is necessary to fully understand the biomechanics and clinical effects of anterolateral structures.

The present study has some limitations. First, this study was a retrospective comparative study. However, there has been no prospective randomized study about ALL reconstruction and revision ACLR. Second, there was no equipment to evaluate pivot shift quantitatively.^25,33 Fixation angle and tension of the graft should be individually adapted according to the amount of rotatory laxity. Hence, equipment that can assess pivot shift needs to be developed. Third, we could not evaluate the evidence of osteoarthritis related to lateral overconstraint at the last follow-up. A 3-year follow-up period is not long enough to identify the progression of osteoarthritis. Thus, a larger sample size and longer follow-up period are required. Finally, the quality of return to sports or psychological readiness of patients to return to sports needs to be more specific. Additional psychological and performance measurements are needed to complement patient-reported outcome scores.

Conclusion

Revision ACLR with ALL reconstruction significantly reduced rotational laxity and showed a higher rate of return to the same level of sports activity than isolated revision ACLR, although there were no significant differences in anterior laxity or functional test results between the 2 groups.

Footnotes

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

References

Andriolo

Filardo

Kon

et al . Revision anterior cruciate ligament reconstruction: clinical outcome and evidence for return to sport. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2825-2845.

Ansari

Claes

Wascher

Neyret

Stuart

Krych

AJ.

International perspective on revision anterior cruciate ligament reconstruction: what have we been missing?

Instr Course Lect. 2017;66:543-556.

Ayeni

Chahal

Tran

Sprague

Pivot shift as an outcome measure for ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2012;20(4):767-777.

Bohu

Klouche

Lefevre

Webster

Herman

Translation, cross-cultural adaptation and validation of the French version of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale. Knee Surg Sports Traumatol Arthrosc. 2015;23(4):1192-1196.

Cavaignac

Faruch

Wytrykowski

et al . Ultrasonographic evaluation of anterolateral ligament injuries: correlation with magnetic resonance imaging and pivot-shift testing. Arthroscopy. 2017;33(7):1384-1390.

Cerciello

Batailler

Darwich

Neyret

Extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: an overview. Clin Sports Med. 2018;37(1):87-100.

Claes

Vereecke

Maes

Victor

Verdonk

Bellemans

Anatomy of the anterolateral ligament of the knee. J Anat. 2013; 223(4):321-328.

Colombet

PD.

Navigated intra-articular ACL reconstruction with additional extra-articular tenodesis using the same hamstring graft. Knee Surg Sports Traumatol Arthrosc. 2011;19(3):384-389.

DePhillipo

Cinque

Chahla

Geeslin

LaPrade

RF.

Anterolateral ligament reconstruction techniques, biomechanics, and clinical outcomes: a systematic review. Arthroscopy. 2017;33(8):1575-1583.

10.

Draganich

Reider

Ling

Samuelson

An in vitro study of an intraarticular and extraarticular reconstruction in the anterior cruciate ligament deficient knee. Am J Sports Med. 1990;18(3):262-266.

11.

Duthon

Magnussen

Servien

Neyret

ACL reconstruction and extra-articular tenodesis. Clin Sports Med. 2013;32(1):141-153.

12.

Engebretsen

Lew

Lewis

Hunter

RE.

The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med. 1990;18(2):169-176.

13.

Feagin

Hirschmann

Muller

Understand, respect and restore anatomy as close as possible!

Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2771-2772.

14.

Guenther

Irarrazaval

Bell

et al . The role of extra-articular tenodesis in combined ACL and anterolateral capsular injury. J Bone Joint Surg Am. 2017;99(19):1654-1660.

15.

Helito

Bonadio

Gobbi

et al . Combined intra- and extra-articular reconstruction of the anterior cruciate ligament: the reconstruction of the knee anterolateral ligament. Arthrosc Tech. 2015;4(3):e239-e244.

16.

Helito

Camargo

Sobrado

et al . Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction [published online April 2, 2018]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-018-4934-2

17.

Imbert

Lutz

Daggett

et al . Isometric characteristics of the anterolateral ligament of the knee: a cadaveric navigation study. Arthroscopy. 2016;32(10):2017-2024.

18.

Jang

Kim

Wang

Yang

SJ.

Functional performance tests as indicators of returning to sports after anterior cruciate ligament reconstruction. Knee. 2014;21(1):95-101.

19.

Kennedy

Claes

Fuso

et al . The anterolateral ligament: an anatomic, radiographic, and biomechanical analysis. Am J Sports Med. 2015;43(7):1606-1615.

20.

Kittl

Halewood

Stephen

et al . Length change patterns in the lateral extra-articular structures of the knee and related reconstructions. Am J Sports Med. 2015;43(2):354-362.

21.

Kocher

Steadman

Briggs

Sterett

Hawkins

RJ.

Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32(3):629-634.

22.

Kosy

Mandalia

VI.

Revisiting the anterolateral ligament of the knee. J Knee Surg. 2016;29(7):571-579.

23.

Kraeutler

Welton

Chahla

LaPrade

McCarty

EC.

Current concepts of the anterolateral ligament of the knee: anatomy, biomechanics, and reconstruction. Am J Sports Med. 2018;46(5):1235-1242.

24.

Kraeutler

Welton

McCarty

Bravman

JT.

Revision anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2017; 99(19):1689-1696.

25.

Kuroda

Hoshino

Araki

et al . Quantitative measurement of the pivot shift, reliability, and clinical applications. Knee Surg Sports Traumatol Arthrosc. 2012;20(4):686-691.

26.

Kvist

Osterberg

Gauffin

Tagesson

Webster

Ardern

Translation and measurement properties of the Swedish version of ACL-Return to Sports after Injury questionnaire. Scand J Med Sci Sports. 2013;23(5):568-575.

27.

Lee

Kim

et al . Evaluation of anterolateral ligament injuries and concomitant lesions on magnetic resonance imaging after acute anterior cruciate ligament rupture. Arthroscopy. 2018; 34(8):2398-2406.

28.

Lefevre

Klouche

Mirouse

Herman

Gerometta

Bohu

Return to sport after primary and revision anterior cruciate ligament reconstruction: a prospective comparative study of 552 patients from the FAST cohort. Am J Sports Med. 2017;45(1):34-41.

29.

Legnani

Peretti

Borgo

Zini

Ventura

Revision anterior cruciate ligament reconstruction with ipsi- or contralateral hamstring tendon grafts. Eur J Orthop Surg Traumatol. 2017;27(4):533-537.

30.

Lephart

Kocher

Harner

FH.

Quadriceps strength and functional capacity after anterior cruciate ligament reconstruction: patellar tendon autograft versus allograft. Am J Sports Med. 1993;21(5):738-743.

31.

Lephart

Perrin

Gieck

McCue

Irrgang

JJ.

Relationship between selected physical characteristics and functional capacity in the anterior cruciate ligament-insufficient athlete. J Orthop Sports Phys Ther. 1992;16(4):174-181.

32.

Lind

Menhert

Pedersen

AB.

Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med. 2012;40(7):1551-1557.

33.

Lopomo

Zaffagnini

Amis

AA.

Quantifying the pivot shift test: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):767-783.

34.

Louis

D’Ingrado

Ehkirch

et al . Combined intra- and extra-articular grafting for revision ACL reconstruction: a multicentre study by the French Arthroscopy Society (SFA). Orthop Traumatol Surg Res. 2017;103(8)(suppl):S223-S229.

35.

Lutz

Role of anterolateral reconstruction in patients undergoing anterior cruciate ligament reconstruction. Orthop Traumatol Surg Res. 2018;104(1)(suppl):S47-S53.

36.

Lutz

Sonnery-Cottet

Niglis

Freychet

Clavert

Imbert

Behavior of the anterolateral structures of the knee during internal rotation. Orthop Traumatol Surg Res. 2015;101(5):523-528.

37.

Lynch

Logerstedt

Grindem

et al . Consensus criteria for defining “successful outcome” after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. Br J Sports Med. 2015;49(5):335-342.

38.

Melugin

Johnson

Levy

Stuart

Krych

AJ.

Is treatment of Segond fracture necessary with combined anterior cruciate ligament reconstruction?

Am J Sports Med. 2018;46(4):832-838.

39.

Miller

TK.

The role of an extra-articular tenodesis in revision of anterior cruciate ligament reconstruction. Clin Sports Med. 2018;37(1):101-113.

40.

Musahl

Rahnemai-Azar

Costello

et al . The influence of meniscal and anterolateral capsular injury on knee laxity in patients with anterior cruciate ligament injuries. Am J Sports Med. 2016; 44(12):3126-3131.

41.

Nitri

Rasmussen

Williams

et al . An in vitro robotic assessment of the anterolateral ligament, part 2: anterolateral ligament reconstruction combined with anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44(3):593-601.

42.

Noyes

Barber

Mangine

RE.

Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19(5):513-518.

43.

Piontek

Ciemniewska-Gorzela

Naczk

Cichy

Szulc

Linguistic and cultural adaptation into Polish of the IKDC 2000 subjective knee evaluation form and the Lysholm scale. Pol Orthop Traumatol. 2012;77:115-119.

44.

Pomajzl

Maerz

Shams

Guettler

Bicos

A review of the anterolateral ligament of the knee: current knowledge regarding its incidence, anatomy, biomechanics, and surgical dissection. Arthroscopy. 2015;31(3):583-591.

45.

Kim

Choi

Kim

JG.

Comparison of the ceiling effect in the Lysholm score and the IKDC subjective score for assessing functional outcome after ACL reconstruction. Knee. 2014;21(5):906-910.

46.

Roessler

Schuttler

Heyse

Wirtz

Efe

The anterolateral ligament (ALL) and its role in rotational extra-articular stability of the knee joint: a review of anatomy and surgical concepts. Arch Orthop Trauma Surg. 2016;136(3):305-313.

47.

Schon

Moatshe

Brady

et al . Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle. Am J Sports Med. 2016;44(10):2546-2556.

48.

Smith

Yasen

Lord

Wilson

AJ.

Combined anterolateral ligament and anatomic anterior cruciate ligament reconstruction of the knee. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3151-3156.

49.

Song

Zhang

Wang

Zhang

Feng

Bone contusions after acute noncontact anterior cruciate ligament injury are associated with knee joint laxity, concomitant meniscal lesions, and anterolateral ligament abnormality. Arthroscopy. 2016;32(11):2331-2341.

50.

Song

Zhang

Wang

Zhang

Feng

Risk factors associated with grade 3 pivot shift after acute anterior cruciate ligament injuries. Am J Sports Med. 2016;44(2):362-369.

51.

Sonnery-Cottet

Daggett

Fayard

et al . Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament-deficient knee. J Orthop Traumatol. 2017;18(2):91-106.

52.

Sonnery-Cottet

Daggett

Helito

Fayard

Thaunat

Combined anterior cruciate ligament and anterolateral ligament reconstruction. Arthrosc Tech. 2016;5(6):e1253-e1259.

53.

Sonnery-Cottet

Lutz

Daggett

et al . The involvement of the anterolateral ligament in rotational control of the knee. Am J Sports Med. 2016;44(5):1209-1214.

54.

Sonnery-Cottet

Saithna

Cavalier

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(7):1547-1557.

55.

Sonnery-Cottet

Thaunat

Freychet

Pupim

Murphy

Claes

Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med. 2015;43(7):1598-1605.

56.

Thaunat

Clowez

Saithna

et al . Reoperation rates after combined anterior cruciate ligament and anterolateral ligament reconstruction: a series of 548 patients from the SANTI study group with a minimum follow-up of 2 years. Am J Sports Med. 2017;45(11):2569-2577.

57.

Trojani

Beaufils

Burdin

et al . Revision ACL reconstruction: influence of a lateral tenodesis. Knee Surg Sports Traumatol Arthrosc. 2012;20(8):1565-1570

58.

Ueki

Nakagawa

Ohara

et al . Risk factors for residual pivot shift after anterior cruciate ligament reconstruction: data from the MAKS group [published online June 8, 2018]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-018-5005-4

59.

Vadala

Iorio

De Carli

et al . An extra-articular procedure improves the clinical outcome in anterior cruciate ligament reconstruction with hamstrings in female athletes. Int Orthop. 2013;37(2):187-192.

60.

Van der Watt

Khan

Rothrauff

et al . The structure and function of the anterolateral ligament of the knee: a systematic review. Arthroscopy. 2015;31(3):569-582.e3.

61.

Vundelinckx

Herman

Getgood

Litchfield

Surgical indications and technique for anterior cruciate ligament reconstruction combined with lateral extra-articular tenodesis or anterolateral ligament reconstruction. Clin Sports Med. 2017;36(1):135-153.

62.

Wright

Gill

Chen

et al . Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am. 2012;94(6):531-536.