Augmentation of Anatomic Anterior Cruciate Ligament Reconstruction With Lateral Extra-articular Tenodesis Does Not Significantly Affect Rotatory Knee Laxity: A Time Zero, In Vivo Kinematic Analysis

Abstract

Background: The pivot-shift test is used to assess for rotatory knee laxity in the anterior cruciate ligament (ACL)-deficient knee and ACL-reconstructed knee; however, the pivot shift uses a subjective grading system that is limited by variability between examiners. Consequently, quantified pivot shift (QPS) test software (PIVOT iPad application) has been developed and validated to measure the magnitude of rotatory knee laxity during the positive pivot-shift test. Purpose: To employ intraoperative QPS (iQPS) to assess for differences in residual rotatory knee laxity after ACL reconstruction (ACLR) versus ACLR augmented with lateral extra-articular tenodesis (ACLR + LET), and to employ iQPS to determine if ACLR and/or ACLR + LET result in overconstrained knee kinematics when compared with the contralateral knee. Study Design: Cohort study; Level of evidence, 2. Methods: iQPS was performed in 20 patients by a single surgeon on both the operative and contralateral knees before ACLR. ACLR was augmented with a LET if the lateral compartment tibial translation measured during QPS was greater than or equal to double the amount of lateral tibial compartment translation measured for the contralateral knee. After each reconstruction (ACLR or ACLR + LET), iQPS measurements were performed. iQPS data were compared with the preoperative QPS measurements of the operative and contralateral knees. Postoperative iQPS data were compared with both the preoperative QPS measurements of the operative and contralateral knees with paired samples t tests. Categorical variables were compared using the Fisher exact test. Results: The mean age in the cohort was 17.3 years (range, 15-24 years). There were no significant differences between the groups in terms of the proportion of male patients (ACLR: 5 male, 5 female vs ACLR + LET: 4 male, 6 female) or age (ACLR: 17.7 ± 3.3 years; 95% CI, 15.4-24.0 vs ACLR + LET: 16.8 ± 2.8 years, 95% CI, 14.8-22.0; P = .999). There were no significant differences between the groups with respect to preoperative QPS performed during examination under anesthesia (ACLR: 4.7 ± 2.0 mm; 95% CI, 3.3-6.1 vs ACLR + LET: 3.6 ± 1.8 mm; 95% CI, 2.3-4.9; P = .2). Both ACLR and ACLR + LET resulted in significant decreases in rotatory knee laxity when compared with preoperative QPS measurements (ACLR: –3.4 ± 1.7 mm; 95% CI, −4.6 to −2.2; P < .001: ACLR + LET: –2.6 ± 1.9 mm; 95% CI, −3.9 to −1.3; P < .002). Moreover, when compared with isolated ACLR, ACLR + LET did not result in a significantly smaller magnitude of change in iQPS between the pre- and postoperative states ( P = .3). Conclusion: Both ACLR and ACLR + LET resulted in significant decreases in rotatory knee laxity. The augmentation of ACLR with LET did not change the constraint of the knee with respect to lateral compartment translation as measured during iQPS.

Augmentation of Anterolateral Structures of the Knee Causes Undesirable Tibiofemoral Cartilage Contact in Double-Bundle Anterior Cruciate Ligament Reconstruction—A Randomized In-Vivo Biomechanics Study

“…7 Recent systematic reviews and meta-analyses have shown that anterolateral surgical interventions are generally effective in rotatory constraint and reduce graft failure. 2,23 For the current study, after ACLR, all grade 3 positive pivot shift signs detected before surgery had turned negative at the 1-year follow-up with or without ALSA, agreeing with the study of Sheean et al 10 Similarly, no significant difference in medialelateral compartmental sliding distances were found (Table 3). Therefore, these data demonstrated that the isolated DB-ACLR can be a good solution for those patients with a high-grade pivot-shift.…”

“…7 Some researchers reported promising clinical outcomes, as decreased ACL-graft ruptures 8 and better survival of meniscal repair 9 were observed in the combined ACLR with ALSA knees. However, others found no benefit on the rotatory control 10 or even overconstrained knee motion 11 after the procedure.…”

Isolated lateral extra-articular tenodesis in ACL-deficient knees: in vivo knee kinematics and clinical outcomes

“…Biomechanical, cadaveric, and clinical studies have investigated the advantages, disadvantages, and clinical results of these combined procedures [27, 31, 40, 47]. Some studies have analyzed the kinematic effect of lateral extra‐articular tenodesis (LET) in vivo [6, 34, 42, 49]. All those investigations were carried out with a focus on the effects of the combined LET and ACL procedures and described contrary results.…”

Clinical Outcomes After Anterior Cruciate Ligament Reconstruction in Patients With a Concomitant Segond Fracture: A Systematic Review

“…17 A time-zero, in vivo kinematic analysis using quantified pivot-shift test software showed that both ACL reconstruction and ACL reconstruction augmented with LET resulted in significant decreases in rotatory knee laxity and that the augmentation of ACL reconstruction with LET did not change the constraint of the knee with respect to lateral compartment translation, suggesting that the utility of combining LET with ACL reconstruction remains unclear and future research is necessary to refine the indications for LET in patients determined to be at risk for residual rotatory knee instability and/or variations in injury pattern. 41…”

“…17 A time-zero, in vivo kinematic analysis using quantified pivot-shift test software showed that both ACL reconstruction and ACL reconstruction augmented with LET resulted in significant decreases in rotatory knee laxity and that the augmentation of ACL reconstruction with LET did not change the constraint of the knee with respect to lateral compartment translation, suggesting that the utility of combining LET with ACL reconstruction remains unclear and future research is necessary to refine the indications for LET in patients determined to be at risk for residual rotatory knee instability and/or variations in injury pattern. 41 Among 5 studies included in the current review, 4 studies directly compared outcomes between a group with unrepaired Segond fracture and a group with no Segond fracture. Interestingly, the current meta-analysis of those 4 studies (292 patients with Segond fracture and 2114 without Segond fracture) showed no statistically significant difference in the risk of graft failure or revision surgery between the group with unrepaired Segond fracture and the group with no Segond fracture.…”