Contribution of Additional Anterolateral Structure Augmentation to Controlling Pivot Shift in Anterior Cruciate Ligament Reconstruction

Abstract

Background: Several types of anterolateral structure (ALS) augmentation procedures in anterior cruciate ligament (ACL) reconstruction have been reported. However, information is limited regarding the effect of additional ALS augmentation on rotatory stability in a clinical setting. Purpose/Hypothesis: This study aimed to investigate the contribution of additional ALS augmentation in ACL reconstruction in cases with a high risk of residual pivot shift. The 2 hypotheses were as follows. First, additional ALS augmentation would improve rotatory stability as compared with solely reconstructing the ACL. Second, graft tension changes would be different between the ACL and ALS during knee range of motion and against anterior or rotatory loads. Study Design: Controlled laboratory study. Methods: Fifteen patients who met at least 1 of the following criteria were included: (1) revision ACL reconstruction, (2) preoperative high-grade pivot shift, or (3) hyperextended knee. The pivot-shift test was performed preoperatively and during surgery after ACL reconstruction and after additional ALS augmentation with acceleration measurements from a triaxial accelerometer. The tension changes of the ACL and ALS grafts were also measured during knee range of motion and against manual maximum anterior tibial translation, internal rotation, and external rotation. Results: After ACL reconstruction, the pivot-shift acceleration was still greater than that of the uninjured knee. However, additional ALS augmentation further reduced acceleration when compared with ACL reconstruction alone in both primary and revision cases ( P < .05 vs preoperative, P < .05 vs ACL). During knee flexion-extension, the tension of the ACL increased as the knee was extended, whereas that of the ALS did not change. Graft tension of the ACL and ALS became higher with internal rotation and lower with external rotation as compared with the neutral position. Tension of the ACL was significantly increased against anterior tibial translational loads, whereas that of the ALS was not. Conclusion: Additional ALS augmentation further improved the rotatory stability during ACL reconstruction in patients with a high risk of residual pivot shift at the time of surgery. Significant differences in graft tension changes were also observed between the ACL and ALS against different loads. Additional ALS augmentation may be considered to eliminate the pivot shift in patients with a high risk of residual pivot shift.

Preoperative Knee Instability Affects Residual Instability as Evaluated by Quantitative Pivot-Shift Measurements During Double-Bundle ACL Reconstruction

“…The results of the present study can contribute to the evaluation of the optimal indications for additional procedures to ACLR (eg, anterolateral ligament reconstruction, 28 , 29 anterolateral tenodesis, 8 , 33 and anterolateral structure augmentation 30 ), and greater preoperative instability on pivot-shift testing may be a factor. Furthermore, it may be desirable to use the cutoff value calculated by quantitative measurements as per this study because these quantitative values enable surgeons to evaluate indications more objectively.…”

Surgical Treatment for Avulsion Fractures of the Anterolateral Ligament Associated with Periarticular Fractures of the Knee

“…Ferretti et al [15] reported that the incidence of ALL injuries associated with ACL tears is about 90%. For these reasons, several clinical studies of combined ACLR and ALLR have been performed and have reported improved rotatory stability of the knee [27,29,42,43,48]. Studies have shown that the pivot-shift test is a reliable examination in evaluating functional instability [4,25].…”

“…After the associated fracture had been xed, the pivot-shift test was performed by the senior attending surgeon prior to xing the ALL tibial avulsion fracture [27,28,48,43]. The patients were routinely followed up at 1, 3, 6, 12, and 24 months postoperatively.…”

Correlation Between the Thickness of Anterolateral Ligament and Lateral Collateral Ligament of the Knee

“…There has been a renewed worldwide interest in defining the anterolateral corner of the knee following the publication of the precise anatomic details of the anterolateral ligament (ALL) [7][8][9]. Cadaveric as well as clinical studies have reported on the benefits of supplementing ALL reconstruction with ACL reconstruction in cases with concomitant injuries [10][11][12]. However, there are studies that claim that ALL reconstruction may be detrimental to knee function and produce early joint degeneration and lateral extra-articular reinforcement may be the preferred reconstruction option [13,14].…”