Summary

Anterolateral ligament reconstruction combined with ACL revision surgery is a safe and effective option for improving clinical instability in high-risk patients after graft failure

Abstract

INTRODUCTION. Different techniques are used for the reconstruction of primary anterior cruciate ligament (ACL) injury, the success of which is mostly dependent on the surgeon’s preferred choice and familiarity. The estimated failure rate of primary ACL grafts is between 3-10%, with allografts consistently being found to have a higher rate of failure than autografts. Main reasons for graft failure include tunnel malposition, associated instabilities such as tibial rotation, varous malalignment and untreated deficiency of medial, lateral and posterolateral ligaments, and traumatic reinjury. Recently, studies have focused on the anterolateral ligament (ALL) and its role in rotational control of the knee. Since Lemaire, evidence suggests adding an ALL reconstruction (ALLR) procedure to revision ACL reconstruction (RACLR) decreases graft failure rates in high-risk patients.
OBJECTIVES. The objective of this paper is to describe the modified ALLR procedure combined to RACLR surgery performed by a single surgeon at our hospital and assess its short-term clinical and functional results at 2-year follow-up.
Materials and methods. We describe a single surgeon, single procedure technique for ALLR combined with RACLR. Clinical instability was evaluated at 4 weeks, 6 months and 2-year follow-up. Subjective instability and functional results were assessed through patient interview, return to work and sport, and Lysholm and Tegner scores at 2-year follow-up.
RESULTS. After ACL graft failure, twelve patients were selected to undergo revision surgery in a single procedure. A single hamstring tendon allograft of adequate length was selected for both ACL and ALL reconstruction. All patients were at high risk of traumatic reinjury (young, high physical demand and practice of pivoting sports). 16.67% were female; 83.33% male. Ages at time of surgery ranged between 17 and 43 years, with an average age of 30.58 years. Three patients (25%) underwent surgery in the 6 months after traumatic reinjury; nine (75%) over 6 months later. 58.33% were right side ACL injuries; the rest were left side. Diagnostic knee arthroscopy prior con ACLR showed compounding lesions (meniscal tears, cartilage damage, femoropatelar instability) in all patients, which were addressed during the same procedure. At 2-year follow-up, all but two patients (83.33%) had gone back to work and all but four (66.67%) had returned to sporting activities, although none had reached the level prior to surgery. Average Lysholm and Tegner scores were 74.2 and 4, respectively. There were two cases (16.67%) of revision graft failure, one of them due to high energy trauma.
DISCUSSION. RACLR is an increasingly frequent surgery performed on young, active patients with ACL graft failure and clinical instability. Adding an ALLR procedure to RACLR in high-risk patients with high physical demand has proven to improve rotational stability and reduce revision graft failure. Our modified ALLR allograft technique allows for RACLR to be performed in a single, safe, reproducible surgical procedure. Although functional scale results are not easily interpreted due to small sample size and compounding soft-tissue lesions, clinical anterior and lateral instability was improved in all patients, allowing most of them to return to their daily work and sport routine to some degree.