Clinical Outcomes After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction With Bone–Patellar Tendon–Bone Grafts: A Matched-Pair Analysis of 2018 Patients From the SANTI Study Group

Abstract

Background: Bone–patellar tendon–bone (BPTB) autografts are widely considered the standard for anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis: The aims of this study were to compare the clinical outcomes after ACLR with gold standard BPTB autografts versus combined ACLR + anterolateral ligament reconstruction (ALLR) with hamstring tendon (HT) autografts at medium-term follow-up in a large series of propensity-matched patients. The hypothesis was that combined ACLR + ALLR with HT autografts would result in lower graft rupture rates and non–graft rupture-related reoperation rates. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing combined ACLR + ALLR using HT autografts between January 2003 and December 2019 were propensity matched in a 1:1 ratio to patients undergoing isolated ACLR using BPTB autografts. At the end of the study period, graft ruptures, contralateral knee injuries, and any other reoperations or complications after the index procedure were identified by a search of a prospective database and a review of medical records. Results: A total of 1009 matched pairs were included. The mean duration of follow-up was 101.3 ± 59.9 months. Patients in the isolated group were >3-fold more likely to have graft failure than those in the combined group (hazard ratio, 3.554 [95% CI, 1.744-7.243]; P = .0005). Patients aged <20 years were at a particularly high risk of graft ruptures compared with patients aged >30 years (hazard ratio, 5.650 [95% CI, 1.834-17.241]; P = .0002). Additionally, there was a significantly higher reoperation rate after isolated ACLR than after combined ACLR + ALLR (20.5% vs 8.9%, respectively; P < .0001). The overall rate of subsequent contralateral ruptures was 9.1% after index surgery (isolated: 10.2%; combined: 8.0%; P = .0934), indicating that the risk profiles for both groups were similar. Conclusion: Patients who underwent isolated ACLR with BPTB autografts experienced significantly worse graft survivorship and overall reoperation-free survivorship compared with those who underwent combined ACLR + ALLR with HT autografts. The risk of graft ruptures was >3-fold higher in patients who underwent isolated ACLR using BPTB autografts.

Comparison Between Continuous and Separate Grafts for ALL Reconstruction When Combined With ACL Reconstruction: A Retrospective Cohort Study From the SANTI Study Group

“…This indicates that both surgeons were highly aware of the benefits of combined reconstruction and extended the indications to patients at high risk of failure for isolated ACL reconstruction. Importantly, the outcomes at a mean follow-up of 3 years (CG: SD, 9.6 months; SG: SD, 8.1 months) after combined ACL/ALL reconstruction when using either technique are comparable with the previously published outcomes, 29,31,39,44 which is further evidence that our findings are valid. The graft rupture rate was around 3% in our study, which is similar to the 2.6% rate reported by Thaunat et al, 44 2.3% rate reported by Helito et al, 19 and 1.3% rate reported by Pioger et al 29 after a minimum follow-up of 2 years.…”

“…This indicates that both surgeons were highly aware of the benefits of combined reconstruction and extended the indications to patients at high risk of failure for isolated ACL reconstruction. Importantly, the outcomes at a mean follow-up of 3 years (CG: SD, 9.6 months; SG: SD, 8.1 months) after combined ACL/ALL reconstruction when using either technique are comparable with the previously published outcomes, 29,31,39,44 which is further evidence that our findings are valid.…”

Return to Sports After ACL Augmentation With Anterolateral Reconstruction (ALR) Harvesting Gracilis Only Compared With ACL Reconstruction With ALR Harvesting Both Hamstring Tendons

“…43 In the evaluation of covariates, a threshold of absolute standardized mean differences <0.25 was defined a priori to reach enough similarity between groups to allow for comparisons to be drawn. 17,51 Inclusion criteria for the ACL-Rc with ALR group were all patients operated on by the same surgeons with this technique during the same inclusion period (pool of 306 patients). The indications for ALR surgery in addition to ACL-Rc were based on published indications 20 : young age (<20 years old), participation in pivoting sports or a high-demand athlete, evidence of a high-grade pivot shift on examination, evidence of a lateral femoral notch sign on preoperative imaging, a Segond fracture, or chronic (>12 months) ACL injury.…”

ALL Repair and Reconstruction: Techniques From the SANTI Study Group

“…Firstly, we describe a combined ACL reconstruction and double-bundle ALL reconstruction. 4,7,9,11 Appropriate landmarks are identified and marked including the joint line, Gerdy tubercle, fibular head, and lateral epicondyle. Three stab incisions are made in preparation for the ALL reconstruction.…”