Advertisement

A comparison of the outcomes of anterior curciate ligament reconstruction with large-size graft versus reconstruction with average-size graft combined with extraarticular tenodesis

Published:January 19, 2023DOI:https://doi.org/10.1016/j.injury.2023.01.033

      Abstract

      Introduction

      Many patients who have had anterior cruciate ligament (ACL) reconstruction (R) complain of instability, inability to return to previous levels of sports activity, and possible ACL graft failure. Graft size was discovered to be an important factor in lowering ACL failure rates. Also, extraarticular tenodesis decreases recurrent instability, A comparative study was done to compare the effect of graft size and lateral external tenodesis on the recurrence of instability after ACL-R.

      Patients and methods

      A Prospective Blinded Randomized Controlled study included 100 consecutive patients who underwent ACL-R with hamstring tendon grafts in our Hospital. The patients were allocated into two groups (Group A and B) with randomization; group A received ACL-R with a large-size ACL-graft diameter of 6 strands, and group B received ACL-R of 4 strands combined with lateral extraarticular tenodesis (LET) (Modified Lemaire). Each group had fifty patients. The follow-up time was two years. They were examined for graft failure, anterolateral rotatory instability with the pivot shift test, and clinical outcomes, which were evaluated with the International Knee Documentation Committee score (IKDC) both subjective and objective.

      Results

      In this study; group A, graft failure occurred in three (6.3%) patients, a positive pivot shift test grade I was detected in eight (17.8%) patients, grade II in three (6.7%) patients, and grade III in one (2.2%) patient. The subjective IKDC score was 87.9 (± 7.19) points. The objective IKDC score was normal or nearly normal in 43 (93.4%) patients. In group B, one (2.1%) patient had graft failure, five (10.9%) had a positive pivot shift test grade I, one (2.1%) had a grade II, and no patient had a grade III. The subjective IKDC score was 91.9 (± 8.9) points. The objective IKDC score was normal or nearly normal in 44 (95.6%) patients. As regard the subjective IKDC score, there was a non-significant difference between both groups (p value = 0.465).

      Conclusion

      Both groups showed a low ACL-graft failure rate, low anterolateral rotatory instability, and a good clinical outcome. Although there was no significant difference in subjective IKDC score between both groups, the failure rate and anterolateral rotatory instability were significantly lower in the ACL-R (4 strands) with LET combination group than in the group with the large-diameter (6 strands) graft.

      Level of evidence

      Level 1; Randomized Comparative Study.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Anderson A.F.
        • Snyder R.B.
        • Lipscomb Jr A.B.
        Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods.
        Am J Sports Med. 2001; 29 (eng) (May-Jun): 272-279https://doi.org/10.1177/03635465010290030201
        • Ardern C.L.
        • Taylor N.F.
        • Feller J.A.
        • Webster K.E.
        Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery.
        Am J Sports Med. 2012; 40 (eng) (Jan): 41-48https://doi.org/10.1177/0363546511422999
        • Kuroda R.
        • et al.
        Quantitative measurement of the pivot shift, reliability, and clinical applications.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20 (eng) (Apr): 686-691https://doi.org/10.1007/s00167-011-1849-6
        • Getgood A.
        • Bryant D.
        • Firth A.
        The stability study: a protocol for a multicenter randomized clinical trial comparing anterior cruciate ligament reconstruction with and without Lateral Extra-articular Tenodesis in individuals who are at high risk of graft failure.
        BMC Musculoskelet Disord. 2019; 20 (eng) (May 15): 216https://doi.org/10.1186/s12891-019-2589-x
        • Hughes J.D.
        • Rauer T.
        • Gibbs C.M.
        • Musahl V.
        Diagnosis and treatment of rotatory knee instability.
        J Exp Orthop. 2019; 6: 019-0217
        • Ahldén M.
        • et al.
        Clinical grading of the pivot shift test correlates best with tibial acceleration.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 708-712
        • Jakob R.P.
        • Stäubli H.U.
        • Deland J.T.
        Grading the pivot shift. Objective tests with implications for treatment.
        J Bone Jt Surg Br. 1987; 69 (eng) (Mar): 294-299https://doi.org/10.1302/0301-620x.69b2.3818763
        • Getgood A.M.J.
        • et al.
        Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial.
        Am J Sports Med. 2020; 48 (eng) (Feb): 285-297https://doi.org/10.1177/0363546519896333
        • Sundemo D.
        • et al.
        Correlation between quantitative pivot shift and generalized joint laxity: a prospective multicenter study of ACL ruptures.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 2362-2370
        • Ishibashi Y.
        • Tsuda E.
        • Yamamoto Y.
        • Tsukada H.
        • Toh S.
        Navigation evaluation of the pivot-shift phenomenon during double-bundle anterior cruciate ligament reconstruction: is the posterolateral bundle more important?.
        Arthroscopy. 2009; 25 (eng) (May): 488-495https://doi.org/10.1016/j.arthro.2008.10.008
        • Labbé D.R.
        • Li D.
        • Grimard G.
        • de Guise J.A.
        • Hagemeister N.
        Quantitative pivot shift assessment using combined inertial and magnetic sensing.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23 (eng) (Aug): 2330-2338https://doi.org/10.1007/s00167-014-3056-8
        • Hoshino Y.
        • et al.
        Quantitative evaluation of the pivot shift by image analysis using the iPad.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21 (eng) (Apr): 975-980https://doi.org/10.1007/s00167-013-2396-0
        • Izawa T.
        • et al.
        Comparison of rotatory stability after anterior cruciate ligament reconstruction between single-bundle and double-bundle techniques.
        Am J Sports Med. 2011; 39 (eng) (Jul): 1470-1477https://doi.org/10.1177/0363546510397172
        • Zaffagnini S.
        • et al.
        Can the pivot-shift be eliminated by anatomic double-bundle anterior cruciate ligament reconstruction?.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 743-751
        • Tang S.P.
        • Wan K.H.
        • Lee R.H.
        • Wong K.K.
        • Wong K.K.
        Influence of hamstring autograft diameter on graft failure rate in Chinese population after anterior cruciate ligament reconstruction.
        Asia Pac J Sports Med Arthrosc Rehabil Technol. 2020; 22 (eng) (Oct): 45-48https://doi.org/10.1016/j.asmart.2020.07.005
        • Snaebjörnsson T.
        • et al.
        Graft diameter as a predictor for revision anterior cruciate ligament reconstruction and KOOS and EQ-5D values: A cohort study from the Swedish national knee ligament register based on 2240 patients.
        Am J Sports Med. 2017; 45 (eng) (Jul): 2092-2097https://doi.org/10.1177/0363546517704177
        • Figueroa F.
        • Figueroa D.
        • Espregueira-Mendes J.
        Hamstring autograft size importance in anterior cruciate ligament repair surgery.
        EFORT Open Rev. 2018; 3 (eng) (Mar): 93-97https://doi.org/10.1302/2058-5241.3.170038
        • Alkhalaf F.N.A.
        • Hanna S.
        • Alkhaldi M.S.H.
        • Alenezi F.
        • Khaja A.
        Autograft diameter in ACL reconstruction: size does matter.
        SICOT J. 2021; 7 (eng)https://doi.org/10.1051/sicotj/2021018
        • Batty L.
        • Lording T.
        Clinical results of lateral extra-articular tenodesis.
        Tech Orthop. 2018; 33 (eng) (Dec): 232-238https://doi.org/10.1097/bto.0000000000000309
        • Meynard P.
        • et al.
        ACL reconstruction with lateral extra-articular tenodesis using a continuous graft: 10-year outcomes of 50 cases.
        Orthop Traumatol Surg Res. 2020; 106 (eng) (Sep): 929-935https://doi.org/10.1016/j.otsr.2020.04.007
        • Na B.R.
        • Kwak W.K.
        • Seo H.Y.
        • Seon J.K.
        Clinical outcomes of anterolateral ligament reconstruction or lateral extra-articular tenodesis combined with primary ACL reconstruction: a systematic review with meta-analysis.
        Orthop J Sports Med. 2021; 9 (eng) (Sep)23259671211023099https://doi.org/10.1177/23259671211023099
        • Zaffagnini S.
        • et al.
        ST/G ACL reconstruction: double strand plus extra-articular sling vs double bundle, randomized study at 3-year follow-up.
        Scand J Med Sci Sports. 2008; 18 (eng) (Oct): 573-581https://doi.org/10.1111/j.1600-0838.2007.00697.x
        • Bernholt D.L.
        • Kennedy M.I.
        • Crawford M.D.
        • DePhillipo N.N.
        • LaPrade R.F.
        Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis.
        Arthrosc Tech. 2019; 8 (eng) (Aug): e855-e859https://doi.org/10.1016/j.eats.2019.03.027
        • Hefti F.
        • Müller W.
        • Jakob R.P.
        • Stäubli H.U.
        Evaluation of knee ligament injuries with the IKDC form.
        Knee Surg Sports Traumatol Arthrosc. 1993; 1 (eng): 226-234https://doi.org/10.1007/bf01560215
        • Ahmed K.M.
        • Said H.G.
        • Ramadan E.K.A.
        • Abd El-Radi M.
        • El-Assal M.A.
        Arabic translation and validation of three knee scores, Lysholm Knee Score (LKS), Oxford Knee Score (OKS), and International Knee Documentation Committee Subjective Knee Form (IKDC).
        SICOT J. 2019; 5 (eng)https://doi.org/10.1051/sicotj/2018054
        • Boniello M.R.
        • Schwingler P.M.
        • Bonner J.M.
        • Robinson S.P.
        • Cotter A.
        • Bonner K.F.
        Impact of hamstring graft diameter on tendon strength: a biomechanical study.
        Arthroscopy. 2015; 31 (eng) (Jun): 1084-1090https://doi.org/10.1016/j.arthro.2014.12.023
        • Grassi A.
        • Kim C.
        • Marcheggiani Muccioli G.M.
        • Zaffagnini S.
        • Amendola A.
        What is the mid-term failure rate of revision ACL reconstruction? A systematic review.
        Clin Orthop Relat Res. 2017; 475 (eng) (Oct): 2484-2499https://doi.org/10.1007/s11999-017-5379-5
        • Zaffagnini S.
        • et al.
        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. 2017; 45 (eng) (Dec): 3233-3242https://doi.org/10.1177/0363546517723013
        • Gudas R.
        • Jurkonis R.
        • Smailys A.
        Comparison of return to pre-injury sport after 10 mm size Bone-Patellar Tendon-Bone (BPTB) versus 8 mm hamstring anterior cruciate ligament reconstruction: a retrospective study with a two-year follow-up.
        Med Sci Monit. 2018; 24 (eng) (Feb 17): 987-996https://doi.org/10.12659/msm.904709
        • Guzzini M.
        • et al.
        Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players.
        Int Orthop. 2016; 40 (eng) (Oct): 2091-2096https://doi.org/10.1007/s00264-016-3261-9
        • Dodds A.L.
        • Gupte C.M.
        • Neyret P.
        • Williams A.M.
        • Amis A.A.
        Extra-articular techniques in anterior cruciate ligament reconstruction: a literature review.
        J Bone Jt Surg Br. 2011; 93 (eng) (Nov): 1440-1448https://doi.org/10.1302/0301-620x.93b11.27632
        • Jette C.
        • Gutierrez D.
        • Sastre S.
        • Llusa M.
        • Combalia A.
        Biomechanical comparison of anterolateral ligament anatomical reconstruction with a semi-anatomical lateral extra-articular tenodesis. A cadaveric study.
        Knee. 2019; 26 (eng) (Oct): 1003-1009https://doi.org/10.1016/j.knee.2019.07.005
        • Herbst E.
        • et al.
        Lateral extra-articular tenodesis has no effect in knees with isolated anterior cruciate ligament injury.
        Arthroscopy. 2018; 34 (eng) (Jan): 251-260https://doi.org/10.1016/j.arthro.2017.08.258
        • Devitt B.M.
        • Bouguennec N.
        • Barfod K.W.
        • Porter T.
        • Webster K.E.
        • Feller J.A.
        Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: a systematic review and best evidence synthesis.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25 (eng) (Apr): 1149-1160https://doi.org/10.1007/s00167-017-4510-1
        • Rhatomy S.
        • Widjaya M.
        • Ghazali S.
        • Setyawan R.
        • Budhiparama N.
        The influence of hamstring autograft diameter on patient-reported functional scoresfollowing anterior cruciate ligament (ACL) reconstruction.
        J Med Sci. 2019; 51 (Journal Article2019): 309-315
        • Crawford K.
        • Briggs K.K.
        • Rodkey W.G.
        • Steadman J.R.
        Reliability, validity, and responsiveness of the IKDC score for meniscus injuries of the knee.
        Arthroscopy. 2007; 23 (eng) (Aug): 839-844https://doi.org/10.1016/j.arthro.2007.02.005
        • Cheecharern S.
        Return to sport and knee functional scores after anterior cruciate ligament reconstruction: 2 to 10 years' follow-up.
        Asia Pac J Sports Med Arthrosc Rehabil Technol. 2018; 12 (eng) (Apr): 22-29https://doi.org/10.1016/j.asmart.2018.01.003
        • Ferretti A.
        • et al.
        Combined intra-articular and extra-articular reconstruction in anterior cruciate ligament-deficient knee: 25 years later.
        Arthroscopy. 2016; 32 (eng) (Oct): 2039-2047https://doi.org/10.1016/j.arthro.2016.02.006
        • Magnitskaya N.
        • Mouton C.
        • Gokeler A.
        • Nuehrenboerger C.
        • Pape D.
        • Seil R.
        Younger age and hamstring tendon graft are associated with higher IKDC 2000 and KOOS scores during the first year after ACL reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28 (eng) (Mar): 823-832https://doi.org/10.1007/s00167-019-05516-0
        • Kowalchuk D.A.
        • Harner C.D.
        • Fu F.H.
        • Irrgang J.J.
        Prediction of patient-reported outcome after single-bundle anterior cruciate ligament reconstruction.
        Arthroscopy. 2009; 25 (eng) (May): 457-463https://doi.org/10.1016/j.arthro.2009.02.014
        • Tan S.H.
        • Lau B.P.
        • Khin L.W.
        • Lingaraj K.
        The importance of patient sex in the outcomes of anterior cruciate ligament reconstructions: a systematic review and meta-analysis.
        Am J Sports Med. 2016; 44 (eng) (Jan): 242-254