Clinical Results of Combined ACL and Anterolateral Ligament Reconstruction: A Narrative Review from the SANTI Study Group

Abstract

Lateral extraarticular procedures (LEAPs) in the anterior cruciate ligament (ACL)-injured knee were widely abandoned in the 1990s but have seen a recent resurgence. The aim of this review was to demonstrate that anterolateral ligament reconstruction (ALLR) is associated with evidence of significant advantages and no evidence of historical concerns. A narrative review of the literature was performed. Combined ACL + ALLR is associated with improved outcomes when compared against isolated ACL reconstruction, including a significantly lower risk of ACL graft rupture (hazard ratio [HR]: 0.327, 95% CI: 0.130–0.758), a significantly lower risk of reoperation for secondary meniscectomy following medial meniscal repair at the time of ACL reconstruction (HR: 0.443, 95% CI: 0.218–0.866), significantly increased likelihood of return to the preinjury level of sport following primary (odds ratio [OR]: 1.938, 95% CI: 1.174–3.224) and revision ACL reconstruction (57.1 vs. 25.6%, respectively; p = 0.008), and in chronic ACL injuries, less residual pivot shift (9.1 vs. 35.3%, p = 0.011), and better IKDC (92.7 ± 5.9 vs. 87.1 ± 9.0, p = 0.0013) and Lysholm (95.4 ± 5.3 vs. 90.0 ± 7.1, p < 0.0001) scores, and no evidence of historical concerns. Combined ACLR + ALLR is associated with excellent clinical outcomes with no evidence of the adverse events that led to the historical widespread abandonment of other types of LEAP. Specifically, comparative series have demonstrated significant advantages of ALLR when compared against isolated ACLR with respect to reduced rates of ACL graft rupture, secondary meniscectomy, persistent instability, and significantly improved functional outcomes and improved return to sport metrics.

Outcomes After Isolated Acute Anterior Cruciate Ligament Reconstruction Are Inferior in Patients With an Associated Anterolateral Ligament Injury

“…Currently, indications for combined ALL and ACL reconstruction in primary cases consist of patients who practice high-demand sports activities associated with frequent rotational knee movements, young patients, ligamentous hyperlaxity/genu recurvatum, or cases of chronic injury. 10,17,31,33 The findings of the present study indicate that an observed ALL injury on MRI examination is a factor related to a higher incidence of reconstruction failure and possible worse clinical outcomes. ALL reconstruction has been shown to be effective in decreasing the number of reinjuries in other scenarios, and we believe that its application should be considered in patients with this finding on imaging.…”

“…This nonhealing scenario is important because biomechanical studies have suggested that in cases of an acute combined injury of the ACL and the anterolateral structures, isolated reconstruction of the ACL does not reestablish normal knee biomechanics. 20,29 Although numerous clinical studies have proven significant advantages of ALL reconstruction, 31 the influence of an associated ALL injury on postoperative outcomes of patients undergoing isolated ACL reconstruction has not been well-studied. In addition, research on the prognostic value of an ALL injury is limited to case series with a short follow-up and for chronic injuries to the ACL.…”

“…Although numerous clinical studies have proven significant advantages of ALL reconstruction, 31 the influence of an associated ALL injury on postoperative outcomes of patients undergoing isolated ACL reconstruction has not been well-studied. In addition, research on the prognostic value of an ALL injury is limited to case series with a short follow-up and for chronic injuries to the ACL.…”

Author Reply to “Regarding ‘The Effect of Combined Anterolateral and Anterior Cruciate Ligament Reconstruction on Reducing Pivot Shift Rate and Clinical Outcomes: A Meta-analysis’”

“…[7][8][9] The purpose of the meta-analysis is to provide highlevel evidence for clinical practice. Although several well-performed level III studies [10][11][12] included in the narrative review from the SANTI group 13 support the advantage of ALLR regarding reduced ACL graft rupture rates, the nonrandomization and retrospective study design prevented the studies from inclusion in our meta-analysis. Whether the risk of bias from the inclusion of comparable studies with lower-level evidence is outweighed by the benefits requires further investigation.…”

Editorial Commentary: Let’s ALL Agree—Anterior Cruciate Ligament Reconstruction Outcomes Need to Be Improved and Extra-Articular Procedures Have an Essential Role

“…numerous clinical studies demonstrating a reduction in ACL graft rupture rates with an EAT [17][18][19][20] ; all clinical series of combined anterior cruciate ligament reconstruction (ACLR) þ EAT since 2015 have reported good clinical outcomes in adults [21][22][23][24][25][26][27][28][29][30][31][32] and skeletally immature patients 33,34 ; numerous clinical studies demonstrating a high proportion (up to 90% in acute ACL-injured knees) of injuries to anterolateral structures, both on imaging and at open lateral exploration [35][36][37][38] ; and finally the fact that the theoretical early degenerative change has never been clinically demonstrated. 39 So, as Rossi said in his brilliant editorial commentary, "Anterolateral Ligament Augmentation for the Anterior Cruciate Ligament-Deficient Knee DebatedThe Proof Is in the Pudding," 40 "The story is not anymore "if" augmentation should be considered but "when" and, maybe more important, "how" to augment.…”