Evaluation of Anterolateral Ligament Healing After Anatomic Anterior Cruciate Ligament Reconstruction

Abstract

Background: Few studies have reported the healing process of anterolateral ligament (ALL) injuries. Purpose/Hypothesis: This study investigated the healing status of ALL injuries after primary anterior cruciate ligament (ACL) reconstruction (ACLR). Additionally, we investigated the association between the healing status of ALL injuries and associated lesions such as osseous lesions and meniscal tears occurring at the time of an ACL rupture. We hypothesized that acute ALL injuries show a high rate (more than two-thirds) of healing at the 1-year follow-up after ACLR and that concomitant lesions observed at the time of an ACL rupture affect the healing status of the ALL. Study Design: Case-control study; Level of evidence, 3. Methods: We retrospectively investigated patients with ALL injuries who underwent primary ACLR between March 2015 and February 2017. Using magnetic resonance imaging (MRI), we evaluated the features of ALL injuries and concomitant lesions, and MRI was performed at the 1-year follow-up to assess the healing status of the ALL. We investigated the association between the healing status of the ALL and concomitant lesions observed at the time of an ACL rupture. A subjective assessment was performed using the Lysholm score, International Knee Documentation Committee subjective score, and Tegner activity scale. Objective tests included an isokinetic strength assessment and functional performance testing. Results: With respect to the severity of ALL injuries, of 54 patients, a complete rupture occurred in 16 (29.6%) of the 54 patients and a partial rupture in 38 (70%). A significant association was observed between the severity of ALL injuries and bone contusions (lateral tibial plateau and medial tibial plateau [MTP]) and meniscus ramp lesions (Fisher exact test: P = .023, .012, and .023, respectively). Good and partial healing of the ALL occurred in 16 (29.6%) and 23 (42.6%) of 54 patients, respectively. Scar formation occurred in 12 (22.2%), and nonvisualization of the ALL was observed in 3 (5.6%) of 54 patients. Poor healing of the ALL was associated with preoperative MTP bone contusions and a high-grade pivot shift. Multivariate analysis showed that an MTP bone contusion was an independent risk factor associated with poor healing of the ALL. Among the functional tests performed, significant differences were observed between the good and poor healing groups with respect to the carioca test ( P = .039). The good healing group (n = 16) showed a negative pivot shift at the last follow-up, whereas 5 (13.2%) of the patients from the poor healing group (n = 38) showed a positive pivot shift, including 2 (5.3%) with a high-grade pivot shift. Conclusion: Approximately 70% of acute ALL injuries showed poor healing at the 1-year follow-up. Poor healing of ALL injuries was significantly associated with preoperative MTP bone contusions and a high-grade pivot shift. Therefore, a careful assessment of posteromedial bone contusions at the time of an ACL rupture is warranted, particularly in patients with a high-grade pivot shift.

The Anterolateral Ligament Has Limited Intrinsic Healing Potential: A Serial, 3-Dimensional–Magnetic Resonance Imaging Study of Anterior Cruciate Ligament–Injured Knees From the SANTI Study Group

“…Although direct comparison between studies is precluded by important methodological differences (imaging protocols, classification systems, and the inclusion of chronic as well as acute injuries in the current study), the overall healing rates are broadly similar across studies (current study, 30.3%; Lee et al, 23 30%). It is also of interest to note similar findings with regard to the limited ability of complete injuries to fully heal (current study, 6 complete injuries, full healing rate 0%; Lee et al, 23 16 complete injuries, 12 remained discontinuous, 3 nonvisualized [assumed complete injuries], full healing rate 1/16; 6.25%). Although the multivariate analysis in the current study did not demonstrate a difference in the rate of full healing between grade B and grade C injuries at 12 months (37% vs 0%; OR, 0.132; 95% CI, 0.01-3.22; P = .2141), the trend across both studies of a lower healing rate in complete injuries warrants additional future investigation with a larger sample size.…”

“…To our knowledge, no previous prospective serial MRI study has evaluated the rate and duration of the healing process of ALL injuries. However, in a recent retrospective study, Lee et al 23 reported that approximately 30% of patients demonstrated good healing (defined as taut, linear, and low signal intensity) of the ALL based on MRI at 12 months after acute (within 1 month of injury) ACLR.…”

Outcomes After Isolated Acute Anterior Cruciate Ligament Reconstruction Are Inferior in Patients With an Associated Anterolateral Ligament Injury

“…8,15,27,28,32,35 The healing potential of the ALL is not well-known. Lee et al 23 evaluated this parameter and found poor healing in approximately 70% of the patients after 1 year. This nonhealing scenario is important because biomechanical studies have suggested that in cases of an acute combined injury of the ACL and the anterolateral structures, isolated reconstruction of the ACL does not reestablish normal knee biomechanics.…”

Tibial internal rotation in combined anterior cruciate ligament and high-grade anterolateral ligament injury and its influence on ACL length

“…As previous literature demonstrated improved clinical outcome after ALL reconstruction [ 9 , 10 , 13 ], the clinical relevance of partial ALL ruptures or strains is of high interest to define more detailed criteria for a simultaneous ALL reconstruction in the future. Moreover, the healing potential of the ALL is low and a rotatory laxity most likely will persist if treated non-operatively [ 38 , 39 ].…”