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Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET)

Knee Surgery, Sports Traumatology, Arthroscopy volume 28, pages 418–431 (2020)Cite this article

Abstract

Background

Residual rotational instability remains a controversial factor when analysing failure rates of anterior cruciate ligament (ACL) reconstruction. Anatomical and biomechanical studies have demonstrated a very important role of anterolateral structures for rotational control. Revision ACL is considered one of the main indications for a lateral extra-articular tenodesis (LET). Yet, few series evaluating these procedures are published.

Purpose

To perform a systematic review of studies that assessed outcomes in patients treated with revision ACL surgery associated with a lateral extra-articular procedure.

Study design

Systematic review.

Methods

A comprehensive literature search was performed in February 2018 using PubMed, Scopus, Web of Search and Cochrane. Inclusion criteria were series of ACL revision reconstructions associated with lateral extra-articular procedures. Clinical outcomes (Lysholm, subjective IKDC, KOOS, Cincinnati and WOMAC), joint stability measures (Lachman test, pivot-shift, arthrometer assessment and navigation assessment), graft type, reported chondral and meniscal injury, radiographic outcomes, complications and failures were recorded. Articles were assessed for level of evidence and methodology using a modification of the ACL Methodology Score (AMS) system.

Results

Twelve studies met the inclusion criteria out of the 231 abstracts; 9 retrospective evaluations, two prospective cohorts and one combination of two populations (a retrospective and prospective series). A total of 851 patients evaluated with a mean age of 28.8 years (range 16–68 years) and a weighted mean follow-up of 4.9 years (range 1–10 years). The mean time from primary ACL reconstruction to revision was 5.3 years (reported in 7 studies, including 710 patients). The Lysholm, IKDC, and KOOS scores indicated favorable results in studies that reported these outcomes. Objective evaluations reported 86% objective A and B IKDC results, 2.6 mm mean side-to-side arthrometric difference and 80% negative pivot-shift. About 74% of patients returned to their previous sport (evaluated in six studies). Few studies reported radiological evaluation. Fifty-nine complications (8.0%) and 24 failures (3.6%) were reported. The mean modified ACL Methodology Score was 55.5 (range 32–72).

Conclusion

Good mid-term results were obtained for combined revision ACL reconstruction and lateral extra-articular procedures. Despite the fact that in clinical practice LET are a common indication associated with revision ACL, there are no high-level studies supporting this technique.

Level of evidence

IV.

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References

  1. Alessio-Mazzola M, Formica M, Russo A, Sanguineti F, Capello AG, Lovisolo S, Felli L (2018) Outcome after combined lateral extra-articular tenodesis and anterior cruciate ligament revision in professional soccer players. J Knee Surg. https://doi.org/10.1055/s-0038-1672120

    Article  PubMed  Google Scholar 

  2. Botto G, Solessio J, Nogueira M, Alonso CL, Garate F (2016) Revisión de LCA con aumentación extraarticular de Lemaire en deportistas de contacto con alta exigencia. Reporte preliminar de casos y descripción de técnica quirúrgica. Revista Artroscopia 23(2):70–76

    Google Scholar 

  3. Brown CA, McAdams TR, Harris AHS, Maffulli C, Safran MR (2013) ACL reconstruction in patients aged 40 years and older: a systematic review and introduction of a new Methodology Score for ACL studies. Am J Sports Med 41(9):2181–2190

    PubMed  Google Scholar 

  4. Buda R, Ruffilli A, Di Caprio F, Ferruzzi A, Faldini C, Cavallo M, Vannini F, Giannini S (2013) Allograft salvage procedure in multiple-revision anterior cruciate ligament reconstruction. Am J Sports Med 41(2):402–410

    PubMed  Google Scholar 

  5. Burnham JM, Herbst E, Pauyo T, Pfeiffer T, Johnson DL, Fu FH, Musahl V (2017) Technical considerations in revision anterior cruciate ligament reconstruction for operative techniques in orthopaedics. Oper Tech Orthop 27(1):63–69

    PubMed  PubMed Central  Google Scholar 

  6. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328

    PubMed  PubMed Central  Google Scholar 

  7. Colombet P (2011) Knee laxity control in revision anterior cruciate ligament reconstruction versus anterior cruciate ligament reconstruction and lateral tenodesis: clinical assessment using computer-assisted navigation. Am J Sports Med 39(6):1248–1254

    PubMed  Google Scholar 

  8. Colombet P, Neyret P, Trojani C, Sibihi A, Dijan P, Potel J, Hulet F, Jouve F, Bussiere C, Ehkirch P, Burdin G, Dubrana F, Beaufils P, Franceschi J, Chassaing V, Societe Francaise D’arthroscopie (2007) Revision ACL surgery. Rev Chir Orthop Reparatrice Appart Mot 93(8 suppl):5S54–5S67

    CAS  Google Scholar 

  9. DePhillipo NN, Cinque ME, Chahla J, Geeslin AG, LaPrade RF (2017) Anterolateral ligament reconstruction techniques, biomechanics, and clinical outcomes: a systematic review. Arthroscopy 33(8):1575–1583

    PubMed  Google Scholar 

  10. Devitt BM, Bell SE, Ardern CL, Hartwig T, Porter TJ, Feller JA, Webster KE (2017) The role of lateral extra-articular tenodesis in primary anterior cruciate ligament reconstruction: a systematic review with meta-analysis and best-evidence synthesis. Orthop J Sports Med 5(10):2325967117731767

    PubMed  PubMed Central  Google Scholar 

  11. Ferretti A, Conteduca F, Monaco E, De Carli A, D’Arrigo C (2006) Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction. J Bone Jt Surg Am 88(11):2373–2379

    Google Scholar 

  12. Ferretti A, Conteduca F, Monaco E, De Carli A, D’Arrigo C (2007) Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction. J Bone Jt Surg Am 89(2):196–213

    Google Scholar 

  13. Ferretti A, Monaco E, Fabbri M, Mazza D, De Carli A (2017) The fascia lata anterolateral tenodesis technique. Arthrosc Tech 6(1):e81–e86

    PubMed  PubMed Central  Google Scholar 

  14. Grassi A, Ardern CL, Marcheggiani Muccioli GM, Neri MP, Marcacci M, Zaffagnini S (2016) Does revision ACL reconstruction measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and radiographic results. Br J Sports Med 50:716–724

    PubMed  Google Scholar 

  15. Grassi A, Kim C, Marcheggiani Muccioli GM, Zaffagnini S, Amendola A (2017) What is the mid-term failure rate of revisión ACL reconstruction? A systematic review. Clin Orthop Relat Res 475(10):2484–2499

    PubMed  PubMed Central  Google Scholar 

  16. Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S (2017) Does the type of graft affect the outcome of revisión anterior cruciate ligament reconstruction? A meta-analysis of 32 studies. Bone Jt J 99-B:714–723

    CAS  Google Scholar 

  17. Guenther D, Rahnemai-Azar AA, Bell KM, Irarrázaval S, Fu FH, Musahl V, Debski RE (2017) The anterolateral capsule of the knee behaves like a sheet of fibrous tissue. Am J Sports Med 45(4):849–855

    PubMed  Google Scholar 

  18. Hardy A, Casabianca L, Hardy E, Grimaud O, Meyer A (2017) Combined reconstruction of the anterior cruciate ligament associated with anterolateral tenodesis effectively controls the acceleration of the tibia during the pivot shift. Knee Surg Sports Traumatol Arthrosc 25(4):1117–1124

    PubMed  Google Scholar 

  19. Helito CP, Bonadio MB, Gobbi RG, da Mota E, Albuquerque RF, Pécora JR, Camanho GL, Demange MK (2015) Combined intra- and extra-articular reconstruction of the anterior cruciate ligament: the reconstruction of the knee anterolateral ligament. Arthrosc Tech 4(3):e239–e244

    PubMed  PubMed Central  Google Scholar 

  20. Helito CP, Demange MK, Bonadio MB, Tírico LE, Gobbi RG, Pécora JR, Camanho GL (2013) Anatomy and histology of the knee anterolateral ligament. Orthop J Sports Med 1(7):2325967113513546

    PubMed  PubMed Central  Google Scholar 

  21. Hewison CE, Tran MN, Kaniki N, Remtulla A, Bryant D, Getgood AM (2015) Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: a systematic review of the literature. Arthroscopy 31(10):2022–2034

    PubMed  Google Scholar 

  22. Imbert P, Lustig S, Steltzlen C, Batailler C, Colombet P, Dalmay F, Bertiaux S, D’ingrado P, Ehkirch FP, Louis ML, Pailhé R, Panisset JC, Schlaterrer B, Sonnery-Cottet B, Sigwalt L, Saragaglia D, Lutz C (2017) Midterm results of combined intra- and extra-articular ACL reconstruction compared to historical ACL reconstruction data. Multicenter study of the French Arthroscopy Society. Orthop Traumatol Surg Res 103(8S):S215–S221

    CAS  PubMed  Google Scholar 

  23. Nderhaug E, Stephen JM, El-Daou H, Williams A, Amis AA (2017) The effects of anterolateral tenodesis on tibiofemoral contact pressures and kinematics. Am J Sports Med 45(13):3081–3088

    Google Scholar 

  24. Kemkamp WA, Van de Velde SK, Bakker EW, Van Arkel ER (2015) Anterolateral extra-articular soft tissue reconstruction in anterolateral rotatory instability of the knee. Arthrosc Tech 4(6):e863–e867

    Google Scholar 

  25. Kent RN, Boorman-Padgett JF, Thein R, van der List JP, Nawabi DH, Wickiewicz TL, Imhauser CW, Pearle AD (2017) High interspecimen variability in engagement of the anterolateral ligament—an in vitro cadaveric study. Clin Orthop Relat Res 475(10):2438–2444

    PubMed  PubMed Central  Google Scholar 

  26. Lefavre N, Klouche S, Mirouse G, Herman S, Gerometta A, Bohu Y (2016) Return to sport after primary and revision anterior cruciate ligament reconstruction. A prospective comparative study of 552 patients from the FAST cohort. Am J Sports Med 45(1):34–41

    Google Scholar 

  27. Lording T, Corbo G, Bryant D, Burkhart TA, Getgood A (2017) Rotational laxity control by the anterolateral ligament and the lateral meniscus is dependent on knee flexion angle: a cadaveric biomechanical study. Clin Orthop Relat Res 475(10):2401–2408

    PubMed  PubMed Central  Google Scholar 

  28. Louis ML, D’ingrado P, Ehkirch FP, Bertiaux S, Colombet P, Sonnery-Cottet B, Schlatterer B, Paihé R, Pannisset JC, Stelzlen C, Lustig S, Lutz C, Dalmay F, Imbert P, Saragaglia D (2017) Combined intra- and extra-articular grafting for revision ACL reconstruction: a multicentre study by the French Arthroscopy Society (SFA). Orthop Traumatol Surg Res 103(8S):S223–S229

    PubMed  Google Scholar 

  29. MARS Group (2014) Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) Cohort. Am J Sports Med 42(10):2301–2310

    Google Scholar 

  30. Mascarenhas R, McConkey MO, Forsythe B, Harner CD (2015) Revision anterior cruciate ligament reconstruction with bone-patellar tendon-bone allograft and extra-articular iliotibial band tenodesis. Am J Orthop 44(4):E89–E93

    PubMed  Google Scholar 

  31. Miller TK (2018) The role of an extra-articular tenodesis in revision of anterior cruciate ligament reconstruction. Clin Sports Med 37(1):101–113

    PubMed  Google Scholar 

  32. Mirouse G, Rousseau R, Casabianca L, Ettori MA, Granger B, Pascal-Moussellard H, Khiami F (2016) Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res 102:863–866

    CAS  PubMed  Google Scholar 

  33. Musahl V, Getgood A, Neyret P, Claes S, Burnham JM, Batailler C, Sonnery-Cottet B, Williams A, Amis A, Zaffagnini S, Karlsson J (2017) Contributions of the anterolateral complex and the anterolateral ligament to rotatory knee stability in the setting of ACL injury: a roundtable discussion. Knee Surg Sports Traumatol Arthrosc 25(4):997–1008

    PubMed  Google Scholar 

  34. Noyes FR, Huser LE, Jurgensmeier D, Walsh J, Levy MS (2017) Is an anterolateral ligament Reconstruction required in ACL-reconstructed knees with associated injury to the anterolateral structures? A robotic analysis of rotational knee stability. Am J Sports Med 45(5):1018–1027

    PubMed  Google Scholar 

  35. Ntagiopoulos P, Dejour D (2018) Extra-articular plasty for revision anterior cruciate ligament reconstruction. Clin Sports Med 37(1):115–125

    PubMed  Google Scholar 

  36. Panisset JC, Pailhé R, Schlatterer B, Sigwalt L, Sonnery-Cottet B, Lutz C, Lustig S, Batailler C, Bertiaux S, Ehkirch FP, Colombet P, Steltzlen C, Louis ML, D’ingrado P, Dalmay F, Imbert P, Saragaglia D (2017) Short-term complications in intra- and extra-articular anterior cruciate ligament reconstruction. Comparison with the literature on isolated intra-articular reconstruction. A multicenter study by the French Arthroscopy Society. Orthop Traumatol Surg Res 103(8S):S231–S236

    CAS  PubMed  Google Scholar 

  37. Parsons EM, Gee AO, Spiekerman C, Cavanagh PR (2015) The biomechanical function of the anterolateral ligament of the knee. Am J Sports Med 43(3):669–674

    PubMed  PubMed Central  Google Scholar 

  38. Porter MD, Shadbolt B, Pomroy S (2018) Anterior cruciate ligament reconstruction with modified iliotibial band tenodesis to correct the pivot shift. A computer navigation study. Am J Sports Med 46(4):839–845

    PubMed  Google Scholar 

  39. Redler A, Iorio R, Monaco E, Puglia F, Wolf M, Mazza D, Ferretti A (2018) Revision anterior cruciate ligament reconstruction with hamstrings and extra-articular tenodesis: a mid- to long-term clinical and radiological study. Arthrosc 34(12):3204–3213

    Google Scholar 

  40. Shea KG, Milewski MD, Cannamela PC, Ganley TJ, Fabricant PD, Terhune EB, Styhl AC, Anderson AF, Polousky JD (2016) Anterolateral ligament of the knee shows variable anatomy in pediatric specimens. Clin Orthop Relat Res 475(6):1583–1591

    PubMed Central  Google Scholar 

  41. Trojani C, Beaufils P, Burdin G, Bussiere C, Chassaing V, Djian P, Dubrana F, Ehkirch FP, Franceschi JP, Hulet C, Jouve F, Potel JF, Sbihi A, Neyret P, Colombet P (2012) Revision ACL Reconstruction: influence of a lateral tenodesis. Knee Surg Sports Traumatol Arthrosc 20:1565–1570

    PubMed  Google Scholar 

  42. Vincent JP, Magnussen RA, Gezmez F, Uguen A, Jacobi M, Weppe F, Al-Saati MF, Lustig S, Demey G, Servien E, Neyret P (2012) The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surg Sports Traumatol Arthrosc 20:147–152

    PubMed  Google Scholar 

  43. Weber AE, Zuke W, Mayer EN, Forsythe B, Getgood A, Verma NN, Bach BR, Bedi A, Cole BJ (2018) Lateral augmentation procedures in anterior cruciate ligament reconstruction. Am J Sports Med. https://doi.org/10.1177/0363546517751140

    Article  PubMed  Google Scholar 

  44. Wright RW, Gill CS, Chen L, Brophy RH, Matava MJ, Smith MV, Mall NA (2012) Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Jt Surg Am 94(6):531–536

    Google Scholar 

  45. Zaffagnini S, Tommaso Bonanzinga, Grassi A, Marcheggiani Muccioli GM, Musiani C, Raggi F, Iacono F, Vaccari V, Marcacci M (2013) Combined ACL reconstruction and closing-wedge HTO for varus angulated ACL-deficient knees. Knee Surg Sports Traumatol Arthrosc 21:934–941

    PubMed  Google Scholar 

  46. Zaffagnini S, Grassi A, Marcheggiani Muccioli GM, Raggi F, Romagnoli M, Bondi A, Calderone S, Signorelli C (2018) The anterolateral ligament does exist: an anatomic description. Clin Sports Med 37(1):9–19

    PubMed  Google Scholar 

  47. Zaffagnini S, Marcheggiani Muccioli GM, Grassi A, Roberti di Sarsina T, Raggi F, Signorelli C, Urrizola F, Spinnato P, Rimondi E, Marcacci M (2017) Over-the-top ACL reconstruction plus extra-articular lateral tenodesis with hamstring tendon grafts: prospective evaluation with 20-year minimum follow-up. Am J Sports Med 45(14):3233–3242

    PubMed  Google Scholar 

  48. Zaffagnini S, Signorelli C, Bonanzinga T, Di Sarsina TR, Grassi A, Budeyri A, Marcheggiani Muccioli GM, Raggi F, Bragonzoni L, Lopomo N, Marcacci M (2016) Technical variables of ACL surgical reconstruction: effect on post-operative static laxity and clinical implication. Knee Surg Sports Traumatol Arthrosc 24(11):3496–3506

    CAS  PubMed  Google Scholar 

  49. Zanovello J, Rosso F, Bistolfi A, Rossi R, Castoldi F (2017) Combined intra- and extra-articular technique in revisión anterior cruciate ligament reconstruction. Joints 5(3):156–163

    PubMed  PubMed Central  Google Scholar 

  50. Zein AMN, Elshafie M, Elsaid ANS, Elrefai MAE (2017) Combined anatomic anterior cruciate ligament and double bundle anterolateral ligament reconstruction. Arthrosc Tech 6(4):e1229–e1238

    PubMed  PubMed Central  Google Scholar 

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Acknowledgements

Members of the ESSKA Arthroscopy Committee; Vincenzo Condello, Alberto Grassi, Kristian Samuelsson, Adrian Wilson, Corrado Bait, Marco Bonomo, Marc Strauss, Sven Scheffler, Christian Hoser, Karl Eriksson, Martin Wyman Rathcke.

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No funding were used for the present paper.

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Authors and Affiliations

  1. IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1/10, 40136, Bologna, Italy

    Alberto Grassi & Stefano Zaffagnini

  2. Dipartimento di Scienze Biomediche e Neuromotorie DIBINEM, Università di Bologna, Bologna, Italy

    Stefano Zaffagnini

  3. Department of Knee Arthroscopy, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

    Juan Pablo Zicaro & Matias Costa-Paz

  4. Joint Preservation and Reconstructive Surgery and Sports Medicine Unit, Humanitas Castelli Clinic, Bergamo, Italy

    Vincenzo Condello

  5. Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    Kristian Samuelsson

  6. Department of Orthopaedic Surgery, Basingstoke and North Hampshire Hospitals, NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire, RG24 9NA, UK

    Adrian Wilson

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  1. Alberto Grassi
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The ESSKA Arthroscopy Committee

  • Vincenzo Condello
  • , Alberto Grassi
  • , Kristian Samuelsson
  • , Adrian Wilson
  • , Corrado Bait
  • , Marco Bonomo
  • , Marc Strauss
  • , Sven Scheffler
  • , Christian Hoser
  • , Karl Eriksson
  •  & Martin Wyman Rathcke

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Correspondence to Alberto Grassi.

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Grassi, A., Zicaro, J.P., Costa-Paz, M. et al. Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET). Knee Surg Sports Traumatol Arthrosc 28, 418–431 (2020). https://doi.org/10.1007/s00167-019-05625-w

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Keywords

  • Revision anterior cruciate ligament
  • Anterior cruciate ligament re-rupture
  • Lateral extra-articular plasty
  • Lateral tenodesis
  • Anterolateral ligament