ACL Reconstruction Combined With the Arnold-Coker Modification of the MacIntosh Lateral Extra-articular Tenodesis: Long-term Clinical and Radiological Outcomes

Abstract

Background: Interest in the role of lateral extra-articular tenodesis (LET) in preventing rotatory instability and the pivot-shift phenomenon after anterior cruciate ligament reconstruction (ACLR) has been recently renewed. Nevertheless, there is still concern about overconstraint of the lateral compartment of the knee and the risk of subsequent osteoarthritis (OA). Purpose: The purpose of this retrospective study was to compare long-term subjective and objective outcomes and the rate of OA development between patients undergoing isolated ACLR (iACLR) with a hamstring tendon autograft and those with a combined Arnold-Coker modification of the McIntosh extra-articular procedure. Risk factors for long-term OA were evaluated. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 165 consecutive patients treated at a single center by ACLR. A total of 86 patients underwent iACLR (iACLR group) and 79 received combined intra- and extra-articular reconstruction (ACLR+LET). The International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity scores were administered. Knee stability was tested through the Lachman test, the pivot-shift test, and the KT-1000 knee arthrometer test. A positive pivot-shift test (++/+++), laxity on the KT-1000, and referred giving-way episodes or revision ACLR were considered failures. Radiographic results were assessed according to the Fairbank, IKDC, and Kellgren-Lawrence scales. Radiographic evaluation included both the overall tibiofemoral joint and the medial and lateral compartment separately. A univariate and a multivariate logistic regression with penalized maximum likelihood was used to identify risks factors associated with long-term OA. Results: The mean follow-up was 15.7 years. There were no statistically significant differences in subjective scores between the 2 groups. A side-to-side difference >5 mm on the KT-1000 arthrometer evaluation was found in 8 patients in the iACLR group and in 1 patient in the ACLR+LET group ( P = .01). Nine cases of failure were found in the iACLR group and only 1 case was found in the ACLR+LET group ( P = .0093). Patients in the iACLR group had a significantly higher OA grades than those in the ACLR+LET group for the overall tibiofemoral joint and the lateral compartment of the knee. No differences were found in the medial compartment. A higher level of lateral compartment OA was found in patients who received partial lateral meniscectomy in the iACLR group compared with those in the ACLR+LET group. Univariate and multivariate analysis results demonstrated that meniscectomy was the most significant factor for long-term OA development. Conclusion: A significantly higher risk of long-term OA was found with iACLR than with ACLR combined with the Arnold-Coker modification of the McIntosh extra-articular procedure. Knees with combined ACLR also had a significantly lower OA grade after partial lateral meniscectomy. Additionally, those undergoing combined ACLR had better knee stability and lower graft rupture rates at the long-term follow-up. Partial meniscectomy was the main risk factor negatively associated with OA changes.

Can lateral tenodesis improve the rotational stability of the ACL reconstruction? A finite element analysis

“…On the other hand, large pretension values lead to an overconstrained knee behavior regarding ETR [ 28 ]. However, while knee overconstraint has been reported in similar clinical studies, its effect on knee range of motion and early OA onset is still a debatable topic [ 48 – 51 ].…”

Lateral Extra-Articular Tenodesis with Indirect Femoral Fixation Using an Anterior Cruciate Ligament Reconstruction Suspensory Device

“…Several studies with long-term follow-ups ranging from 20 to 25 years demonstrate high patient-satisfaction rates [49,50]. Moreover, combining a lateral extra-articular tenodesis with anterior cruciate ligament reconstruction has shown long-term protective effects in reducing the risk of arthritis compared to isolated ACL reconstruction [51].…”

Quantitative MRI Analysis of Patellofemoral Joint Cartilage Health 2 Years After Anterior Cruciate Ligament Reconstruction and Lateral Extra-Articular Tenodesis

“…15,16 Multiple studies have shown that performing a lateral extra-articular tenodesis (LET) in combination with ACLR is effective in reducing persistent anterolateral rotatory laxity, as measured by the pivot shift, and graft failure. 3,19,22,32,33,51 The STABILITY 1 multicenter randomized controlled trial demonstrated that patients who underwent primary ACLR…”

“…15,16 Multiple studies have shown that performing a lateral extra-articular tenodesis (LET) in combination with ACLR is effective in reducing persistent anterolateral rotatory laxity, as measured by the pivot shift, and graft failure. 3,19,22,32,33,51 The STABILITY 1 multicenter randomized controlled trial demonstrated that patients who underwent primary ACLR with hamstring tendon autograft had an 11% graft failure rate, whereas the addition of an iliotibial band (ITB)–based LET resulted in a significantly reduced graft rupture rate (4%) in patients who were deemed to be at high risk of reinjury after ACLR. 19 However, there remains a concern as to whether an ITB-based LET may cause overconstraint of the tibiofemoral joint, leading to cartilage damage.…”