Comparison of Primary Repair of the Anterior Cruciate Ligament and Anterolateral Structures to Reconstruction and Lateral Extra-articular Tenodesis at 2-Year Follow-up

Abstract

Background: Lateral extra-articular procedures have been effective in reducing graft rupture rates after anterior cruciate ligament (ACL) reconstruction (ACLR), but the evidence supporting their role in ACL repair is sparse. Purpose/Hypothesis: The purpose was to compare clinical and radiological outcomes of ACLR and lateral extra-articular tenodesis (LET) (ACLR+LET) against combined repair of the ACL and anterolateral (AL) structures (ACL+AL Repair). It was hypothesized that patients undergoing ACL+AL Repair would have noninferior clinical and radiological outcomes with respect to International Knee Documentation Committee (IKDC) scores, knee laxity parameters, and magnetic resonance imaging (MRI) characteristics. Furthermore, it was hypothesized that patients undergoing repair would have significantly better Forgotten Joint Score–12 (FJS-12) values and shorter times to return to the preinjury level of sport, without any increase in the rate of ipsilateral second ACL injury. Study Design: Cohort study; Level of evidence, 2. Methods: Consecutive patients evaluated with an acute ACL tear were considered for study eligibility. ACLR+LET was only performed when intraoperative tear characteristics contraindicated ACL repair. Patient-reported outcome measures such as the IKDC score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS); reinjury rates; anteroposterior side-to-side laxity difference; and MRI characteristics were reported at a minimum follow-up of 2 years. The noninferiority study was based on the IKDC subjective score; side-to-side anteroposterior laxity difference; and signal-to-noise quotient (SNQ). The noninferiority margins were defined using the existing literature. An a priori sample size calculation was performed using the IKDC subjective score as the primary outcome measure. Results: A total of 100 patients (47 ACLR+LET, 53 ACL+AL Repair) with a mean follow-up of 25.2 months (range, 24-31 months) were enrolled and underwent surgery within 15 days of injury. At the final follow-up, the differences between groups with respect to the IKDC score, anteroposterior side-to-side laxity difference, and SNQ did not exceed noninferiority thresholds. ACL+AL Repair was associated with a shorter time to return to the preinjury level of sport (ACL+AL Repair: mean, 6.4 months; ACLR+LET: mean, 9.5 months; P < .01), better FJS-12 values (ACL+AL Repair: mean, 91.4; ACLR+LET: mean, 97.4; P = .04), and a higher proportion of patients achieving the Patient Acceptable Symptom State (PASS) for the KOOS subdomains studied (Symptoms: 90.2% vs 67.4%, P = .005; Sport and Recreation: 94.1% vs 67.4%, P < .001; Quality of Life: 92.2% vs 73.9%, P = .01). There were no significant differences between groups with respect to ipsilateral second ACL injury rates (ACL+AL Repair group, 3.8% and ACLR+LET group, 2.1% [n = 1]; P = .63). Conclusion: ACL+AL Repair yielded clinical outcomes that were noninferior to (or not significantly different from) ACLR+LET with respect to IKDC subjective, Tegner activity level, and Lysholm scores; knee laxity parameters; graft maturity; and rates of failure and reoperation. However, there were significant advantages of ACL+AL Repair, including a shorter duration of time to return to the preinjury level of sport, better FJS-12 values, and a higher proportion of patients achieving PASS for KOOS subdomains studied (Symptoms, Sport and Recreation, Quality of Life).

Surgical Treatment of an Unusual Ski Injury: Combined Tibial Fracture With Anterior Cruciate Ligament Avulsion and Segond Lesion

“…With regard to the clinical results of ACL repair, Ferreira et al 5 showed that the results of patients undergoing ACL primary repair with a pull-out technique were noninferior to those of standard reconstruction at 2-year follow-up. The same results were later confirmed in a more recent study by Ferretti et al 6…”

“…With regard to the clinical results of ACL repair, Ferreira et al 5 showed that the results of patients undergoing ACL primary repair with a pull-out technique were noninferior to those of standard reconstruction at 2-year followup. The same results were later confirmed in a more recent study by Ferretti et al 6 Ferretti et al 7 showed that the appearance of an acutely repaired ACL gets normal within 6 months and demonstrated good functional outcomes, restoration of knee ROM, and rotational stability.…”

Advancements in Anterior Cruciate Ligament Repair—Current State of the Art

“…Recent research by Ferretti et al has provided valuable insights into the comparative effectiveness of ACL repair combined with ALL repair versus ACL reconstruction combined with LET. Their findings suggest non-inferior clinical outcomes with ACL + ALL repair compared to ACL-R + LET, highlighting the potential of laterally based procedures in achieving satisfactory functional outcomes and patient satisfaction [52].…”

“…These studies [46,50,52] underscore the evolving landscape of ACL repair surgery, wherein a nuanced understanding of knee biomechanics and ligamentous anatomy informs the development of tailored treatment algorithms. By integrating laterally based procedures into ACL repair protocols, surgeons can comprehensively address the complex nature of knee instability, ultimately optimizing patient outcomes and reducing the risk of postoperative complications.…”

“…However, as reported by Duong et al [14] and by Robertson et al [1], without graft harvest comorbidity, a faster and less painful recovery is expected, with quicker patient confidence in mobility. Ferretti et al demonstrated that combined ACL + ALL repair resulted in a faster return to the pre-injury sport level than ACLR + LET [52].…”