Lateral Extra‐Articular Tenodesis Procedures and the Anterolateral Ligament


140 Lateral Extra‐Articular Tenodesis Procedures and the Anterolateral Ligament


Felipe Moreira MD, Merce Reverté MD PhD, Enric Castellet MD, and Joan Minguell MD PhD


Vall d’Hebron University Hospital, Barcelona, Spain


Clinical scenario



  • A 15‐year‐old woman comes to your office for pain and effusion in her right knee after sustaining an injury while playing basketball (landing from a jump) four days ago.
  • History and physical reveals a Lachman 2+, grade II/III pivot shift, knee hyperextension, and joint effusion. MRI confirms rupture of the ACL at the level of its femoral insertion. There is no associated meniscal injury.
  • The patient is a passionate basketball player (semiprofessional) and wants to continue practicing this sport.

Top three questions



  1. In patients undergoing anterior cruciate ligament reconstruction (ACLR), does the addition of lateral extra‐articular tenodesis (LET), compared to ACLR alone, improve function, and return to sport results while diminishing failure rate?
  2. In patients undergoing ACLR, does the addition of LET, compared to ACLR alone, reduce rotational laxity, thus preventing osteoarthritis (OA) and meniscal lesions?
  3. In patients undergoing ACLR, is there a surgical technique of LET, as an augmentation to ACLR, that has proven to have superior biomechanical and clinical results compared to other techniques?

Question 1: In patients undergoing anterior cruciate ligament reconstruction (ACLR), does the addition of lateral extra‐articular tenodesis (LET), compared to ACLR alone, improve function, and return to sport results while diminishing failure rate?


Rationale


Intra‐articular reconstruction has become the technique of choice to address ACL deficiency. However, intra‐articular reconstruction does not restore normal knee kinematics and failure rate also remains a factor to consider in many cases, especially in high‐demand young athletes.1,2 In the past two decades, many surgeons have recommended extra‐articular reconstruction in conjunction with an intra‐articular technique in order to address normal kinematics and reduce failure rate.


Clinical comment


It is our impression that the use of additional extra‐articular procedures is increasing in number, especially in challenging primary cases and revisions. By attempting to control rotation laterally, further away from the pivot point of the knee, extra‐articular reconstruction may be better suited to control rotational motion by having a better lever arm.3 A simple intra‐articular procedure combined with an extra‐articular augmentation may achieve better clinical results, while also diminishing failure rates.


Available literature and quality of the evidence


The quality of literature addressing results of lateral extra‐articular procedures associated with ACLR is highly variable, with levels I–IV evidence. Studies lack standardization of protocols and outcomes. The majority of the outcome papers are case series or cohort studies. There are seven randomized controlled trials (RCTs),410 five recent systematic reviews,1115 and one large trial currently underway.16


Findings


Randomized controlled trials


A growing number of RCTs examine the effect of extra‐articular augmentation. The trials differ in the type of LET and intra‐articular reconstruction, outcome measures, and definitions of failure. Drawing firm and reliable conclusions is difficult based on this current highly heterogeneous data set. In total, seven RCTs were found.410 Only one study demonstrated improved patient‐reported outcomes for patients undergoing ACLR associated with LET over controls(6).6 In this study, 75 patients were randomized evenly to three treatment groups. These consisted of: (i) the Marcacci technique (ACLR+LET), (ii) a four‐strand, single‐bundle hamstring ACLR, or (iii) a bone–patella–bone ACLR. At five‐year follow‐up the LET group had higher subjective International Knee Documentation Committee (IKDC) scores and also a quicker return to sport. Later on, some of the same authors in a different study found that, when compared to a double‐bundle group, the Marcacci technique performed worse in terms of IKDC scoring and pivot shift grading.8 Higher return to sport rates were seen in the double‐bundle group, with the Marcacci cohort returning to sport more quickly.


Current trials


The Standard ACL Reconstruction versus ACL and Lateral Extra‐Articular Tenodesis (STAbiLiTY) study is a recently‐completed RCT of 600 divided in two groups (ACLR + modified Lemaire LET vs ACLR), focusing on high‐risk patients, coordinated by the University of Western Ontario.16 The trial includes patients 14 to 25 years old with an ACL deficient knee who play competitive pivoting sports, and have a grade 2 pivot shift or generalized ligamentous laxity. Participants are randomized to hamstring ACLR or ACLR with an iliotibial band‐based LET (modified Lemaire). The primary outcome measure is graft failure at two years, with secondary outcomes being patient‐reported outcome scores, objective functional outcomes, biomechanical assessment, imaging, return to activity, adverse events, and cost outcomes. Preliminary results of the trial have been presente,17 and while the interim results should be interpreted with caution, they appear favorable for LET. Failure rates and the rate of asymmetric pivot shift are significantly lower in favor of the LET procedure. However, this appears to come at the cost of increased early morbidity, with increased pain and reduced lower limb function at three months.17


Resolution of clinical scenario



  • Extra‐articular anterolateral procedures have undergone a renaissance in combination with ACLR in selected cases.
  • Preliminary results from an ongoing clinical trials are supportive for LET when used as an augmented intra‐articular ACL reconstruction in a targeted group of high‐risk patients.
  • Based on these findings, one can only hypothesize some potential indications for high‐risk patients (professional athletes, revision cases, etc.).

Question 2: In patients undergoing ACLR, does the addition of LET, compared to ACLR alone, reduce rotational laxity, thus preventing osteoarthritis (OA) and meniscal lesions?


Rationale


Rotational stability may not be restored by intra‐articular reconstruction alone. Subjectively measured as a positive pivot shift, this instability may be negatively associated with subjective and objective outcomes.18,19 Renewed interest in LET is based on its important role in biomechanical stability. Nevertheless, over‐constraint has also been linked to OA.


Clinical comment


Despite the reported risk of joint over‐constraint, consideration should be given to reconstructing the anterolateral structures and the ACL concurrently to maximally restore both anterior tibial translation and rotatory stability. However, the role of LET in improving rotational knee stability remains a controversial subject.12 To reduce rotational laxity might mean reducing residual pivot shift, and increasing patient satisfaction and functional stability, though it may also risk over‐constraint.


Available literature and quality of the evidence


Most of the studies discussed in Question 1 also report on rotational laxity and OA, with level I–IV evidence. The same seven RCTs are available,410 one meta‐analysis,14 as well as the STAbiLiTY trial.16 Level IV evidence has been found in relation to meniscal lesions.13,20


Findings


Randomized controlled trials

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May 14, 2023 | Posted by in Uncategorized | Comments Off on Lateral Extra‐Articular Tenodesis Procedures and the Anterolateral Ligament

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