Ten-Year Survivorship, Patient-Reported Outcome Measures, and Patient Acceptable Symptom State After Over-the-Top Hamstring Anterior Cruciate Ligament Reconstruction With a Lateral Extra-articular Reconstruction: Analysis of 267 Consecutive Cases

Abstract

Background: Long-term patient-reported outcome measures (PROMs) and predictors of success or failure after anterior cruciate ligament (ACL) reconstruction are not fully understood, especially when combined with a lateral extra-articular reconstruction. Purpose: To assess the long-term PROMs, revision rate, and predictors of success or failure after ACL reconstructions using an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular reconstruction. Study Design: Case series; Level of evidence, 4. Methods: The study cohort consisted of 267 consecutive patients (mean age, 30.7 years) who underwent ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring tendon autografts and a lateral extra-articular augmentation between November 2007 and May 2009. The number of subsequent ACL revisions and reoperations were recorded. Subjective clinical status was assessed with PROMs—specifically, the Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm, Tegner, and visual analog scale for pain—at a minimum follow-up of 10 years. Results: Overall, 3% of patients underwent ACL revision, with a 10-year survival rate of 96.3%. High sport activity (hazard ratio, 6.9; P = .285) and concomitant meniscal lesion (hazard ratio, 2.6; P = .0487) were predictors of ACL revision or new meniscectomy. The mean ± SD Lysholm score was 94.1 ± 10.8, while that for the visual analog scale for pain was 0.2 ± 0.9 at rest and 2.1 ± 2.6 during activity. KOOS subscale scores were as follows: 95.7 ± 8.1 for Pain, 92.5 ± 10.5 for Symptoms, 98.4 ± 7.4 for Activities of Daily Living, 90.7 ± 17.2 for Sport, and 91.2 ± 17.1 for Quality of Life; respectively, 88%, 99%, 81%, 89%, and 91% of patients achieved the Patient Acceptable Symptom State. Female sex and chondropathy with Outerbridge grade ≥2 were predictors of worse KOOS subscales. Overall, 82% of patients returned to sport, and 57% were still participating at the 10-year evaluation. Conclusion: ACL reconstruction with an over-the-top surgical technique with single-bundle hamstring autografts and a lateral extra-articular reconstruction provided satisfactory results in terms of function, symptoms, sports, and quality of life in 80% to 90% of patients after 10 years. Long-term survivorship was 96%. Sport participation declined from 82% postoperatively to 57% at long-term follow-up. A concomitant medial meniscal lesion was a predictor of higher risk of ACL failure or new meniscal lesion, while advanced chondropathy and female sex were predictors of higher pain, lower function, and poor quality of life scores.

Clinical Outcomes and Osteoarthritis at Very Long-term Follow-up After ACL Reconstruction: A Systematic Review and Meta-analysis

“…We noted nonoptimal results regarding sports practice, with an average Tegner score of 4, which corresponds to recreational cycling and jogging or moderately heavy work. However, this reduction in sports activity had been reported at 10 years after ACLR 15 and is considered dependent more on changes in patients’ habits due to aging rather than a decline of knee function. Moreover, male athletes after ACLR had a mean career of 10 years, with 5 years at the same level, and among those who decreased their activity level, the reason was not related to knee function in nearly 50% of cases.…”

Equivalent outcomes of ACL revision with over-the-top single and double-bundle reconstruction using hamstring tendon compared to anatomical single and double-bundle reconstruction

“…Revision anterior cruciate ligament reconstruction (ACLR) tends to be more complicated and is more difficult to treat than primary ACLR, because the technique was restricted by the harvested tendon and the location of the bone tunnel in primary surgery [ 3 , 5 , 15 ]. In particular, in cases where the bone tunnel cannot be created in the anatomical position due to postoperative bone tunnel enlargement or malposition of the primary bone tunnel, the choice of the surgical method is often particularly difficult [ 7 , 13 , 17 ].…”

“…The over-the-top route (OTTR) is the method of choice for the femur, when it is difficult to use a primary bone tunnel or to create a new bone tunnel due to the enlargement of the bone tunnel [ 18 ]. The revision of OTTR ACLR has been reported to have comparable results to anatomical reconstruction, and the cadaver study has demonstrated that it is as stable as anatomical single reconstruction, making OTTR a useful method for revision ACLR [ 7 , 8 , 14 , 17 ].…”

Clinical outcomes of contemporary lateral augmentation techniques in primary ACL reconstruction: a systematic review and meta-analysis

“…Even in the face of this biomechanical data, and despite good outcomes of the additional LA procedures being published in small case–control series with long-term follow-up [ 10 , 17 , 44 , 64 ], the evidence to add a LA procedure to primary ACLR in order to improve patient outcomes has remained controversial. Given the more recent publications of high-quality clinical trials suggesting a reduction in anterolateral rotatory laxity and re-rupture rates of primary ACLR when combined with a LA [ 14 , 55 ], we sought to determine whether the addition of a LA to a primary ACLR also ensures better objective knee stability scores and patient reported outcomes compared to an isolated ACLR.…”