Epidemiology of Combined Injuries of the Secondary Stabilizers in ACL-Deficient Knees: Medial Meniscal Ramp Lesion, Lateral Meniscus Root Tear, and ALL Tear: A Prospective Case Series of 602 Patients With ACL Tears From the SANTI Study Group

Abstract

Background: Medial meniscal ramp lesion (MMRL), lateral meniscus root tear (LMRT), and anterolateral ligament (ALL) tear are individual injuries that have been described in patients who have an anterior cruciate ligament (ACL) tear. However, the prevalence of these lesions and their combination has not been defined. Purposes: To define the individual and combined prevalence of MMRL, LMRT, and ALL tears in a case series of patients undergoing ACL reconstruction and to identify the risk factors for combined injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients aged >15 years undergoing primary ACL reconstruction between January 2019 and June 2021 were enrolled in the study. A preoperative ultrasound scan was performed to look for an ALL tear. The presence of MMRL and LMRT was determined during a standardized arthroscopy exploration. A multivariate logistic regression model was used to determine the individual effect of patient variables on the risk of associated single, dual, triad, or tetrad injuries (MMRL, LMRT, ALL, ACL), represented by an adjusted odds ratio. Results: The case series consisted of 602 patients who underwent primary ACL reconstruction. An isolated ACL injury was present in 147 patients (24%). A dual injury was detected in 34 patients (6%) who had ACL-MMRL, 16 (2.65%) who had ACL-LMRT, and 265 (44%) who had ACL-ALL. A triad injury was detected in 80 patients (13.28%) who had ACL-ALL-MMRL, 36 (6%) who had ACL-ALL-LMRT, and 3 (0.5%) who had ACL-MMRL-LMRT. A tetrad injury pattern was detected in 21 patients (3.5%). Multivariate analysis showed that the occurrence of tetrad injury was significantly lower in older patients (adjusted odds ratio by year, 0.93 [95% CI, 0.88-0.99]; P = .028). Identifying LMRT increased the likelihood of finding MMRL-ALL injuries by 2.11 times (95% CI, 1.09-3.12; P = .031). Conclusion: Isolated ACL tear is less common than combined injuries, which are quite frequent. Younger age is a risk factor for combined injuries. The search for damaged secondary stabilizers of the knee must be meticulous and systematic, especially when 1 injured structure has already been diagnosed.

Risk Factors for Anterior Cruciate Ligament Graft Failure in Professional Athletes: An Analysis of 342 Patients With a Mean Follow-up of 100 Months From the SANTI Study Group

“…Undeniably, there has been an increased incidence of ACLR combined with a LEAP, supported by the growing body of literature on the prevalence of injuries to the ALL and its role in rotational control of the knee. 12,16,18,25,41,52 LEAPs are able to load share with the ACL graft and reliably restore knee kinematics, in contrast to isolated ACLRs. Indeed, Marom et al 40 demonstrated that a lateral extra-articular tenodesis decreased ACL graft force up to 80%.…”

Preserving the Semitendinosus Distal Attachment Is Associated With Improved Graft Remodeling After ACL Reconstruction

“…If indicated (anterolateral ligament tear, pivot shift >1, or high sports level), lateral tenodesis was performed using the gracilis tendon. 5,6,15,19,37 An anterolateral ligament tear was diagnosed using preoperative ultrasound analysis. If the anterolateral ligament was not continuous over its entire length or if it was avulsed from the tibial insertion, it was considered torn.…”

New Considerations in ACL Surgery

“…Concomitant meniscal injury is common among patients with ACL tears. Approximately 23% to 24% of patients with ACL tears have concomitant MMRL 30,32 , whereas 8% to 16% have LMPRT 30,33 . Meniscal injury results in increased anterior tibial translation 34 , rotational instability, altered kinematics, and increased contact pressures within the affected compartment 33 .…”

“…Concomitant ALC injuries are common, occurring in 46% to 79% of patients with an ACL injury 29,30,49 . These injury patterns are frequently missed or left untreated.…”