Combined ACL and ALL reconstruction reduces the rate of reoperation for graft failure or secondary meniscal lesions in young athletes

Abstract

Purpose Graft failure and secondary meniscal tears are major concerns after anterior cruciate ligament (ACL) reconstruction in young athletes. The aim was to evaluate the link between ACL reconstruction with and without anterolateral ligament (ALL) reconstruction and outcomes in young patients participating in pivoting sports. Methods This was a retrospective study of data collected prospectively. Patients less than 20 years, involved in pivoting sports and undergoing primary ACL reconstruction with a quadruple hamstring tendon (4HT) graft or 4HT graft combined with anterolateral ligament reconstruction (4HT + ALL) were included. Survival analysis was performed to identify the prognostic indicators for reoperation due to graft failure or secondary meniscal lesions. Knee laxity was assessed and patient reported outcome measures (PROMs) were collected. Results A total of 203 patients (mean (± SD) age: 16.3 ± 2 years) with a mean follow-up of 4.8 ± 0.9 (range: 3.3-6.8) years were included. There were 101 4HT and 102 4HT + ALL grafts. Graft rupture rates were 11.9% for 4HT grafts and 5.8% for 4HT + ALL grafts (n.s.). There were 9.9% secondary meniscal procedures for 4HT grafts vs. 1.9% for 4HT + ALL grafts (p = 0.02). With reoperation for graft failure or secondary meniscal lesions at inal follow-up as the endpoint, survival was better in the 4HT + ALL group (91.4% vs. 77.8%, respectively; p = 0.03). Absence of ALL reconstruction (HR = 4.9 [95%CI: 1.4-17.9]; p = 0.01) and preoperative side-to-side laxity > 3 mm (HR = 3.1 [95%CI: 1.03-9.1]; p = 0.04) were independently associated with an increased rate of reoperations. Mean (± SD) side-to-side laxity was 1.3 ± 1.3 mm (range: − 2 to 5) for 4HT grafts vs. 0.9 ± 1.3 mm (range: − 6 to 4.8) for 4HT + ALL grafts (n.s.) 6 months post-surgery. The rate of return to the same sport at the same level was 42.2% for 4HT grafts vs. 52% for 4HT + ALL grafts (n.s.). There was no signiicant diference in subjective outcomes including PROMs between the two groups. Conclusion Combined ALL + ACL reconstruction reduced the rate of graft failure and secondary meniscal injury in young athletes when compared to ACL reconstruction alone. Subjective results were comparable, with a similar rate of complications. Combined reconstruction should be preferred in this young population. Level of evidence Level IV.

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

“…These findings are consistent with numerous previous comparative studies demonstrating significant advantages of combined ACLR 1 lateral extra-articular procedures with respect to graft rupture rates compared with isolated ACLR. 6,14,18,22,45 It was also an important finding that there were significant differences between groups with respect to the occurrence of non-graft rupture-related reoperations. The rate of reoperations for symptomatic cyclops lesions in the isolated group was more than double that in the combined group (4.3% [n = 43] vs 1.7% [n = 17], respectively; P = .0094).…”

“…These findings are consistent with numerous previous comparative studies demonstrating significant advantages of combined ACLR + lateral extra-articular procedures with respect to graft rupture rates compared with isolated ACLR. 6,14,18,22,45…”

“…These findings are consistent with numerous comparative studies of other high-risk populations demonstrating the advantages of combined reconstruction. 22…”

“…However, this has not been evidenced by meta-analyses, and any statistically significant differences are likely to be small. In contrast, significantly reduced graft rupture rates have been reported in young patients 22 participating in pivoting sports with combined ACLR 1 anterolateral ligament (ALL) reconstruction (ALLR) using HT autografts to create a single graft construct for both reconstruction procedures. This suggests that the former might be a better graft choice than the established standard.…”

Anatomy, Biomechanics, and Reconstruction of the Anterolateral Ligament of the Knee Joint

“…Recently, the clinical advantages of ALLR combined with ACLR compared to isolated ACLR have been demonstrated in multiple studies: reduced re-tear rate, a lower reoperation rate for secondary meniscectomy, and a higher rate of return to sports [21][22][23]. However, the proper indications and optimal surgical techniques are still controversial, owing to conflicting indications and surgical techniques across studies.…”