|Year : 2021 | Volume
| Issue : 3 | Page : 72-79
Efficacy of lateral extra-articular tenodesis on anterior cruciate ligament reconstruction with quadrupled hamstring graft: Magnetic resonance imaging evidence and clinical follow-up
Lalit Pratap Singh1, Shivam Sinha1, Ishan Kumar2, Ashish Kumar Verma2, Shyam Kumar Saraf1, Tej Bali Singh3, Shubhrendu Shekhar Pandey4
1 Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Biostatistics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
4 Department of Orthopaedics, Division of Physiotherapy, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Submission||02-Aug-2021|
|Date of Decision||02-Sep-2021|
|Date of Acceptance||06-Sep-2021|
|Date of Web Publication||20-Dec-2021|
Dr. Shivam Sinha
Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Isolated anterior cruciate ligament (ACL) reconstruction is frequently associated with anterolateral ligament injury (ALL) and results in residual instability at follow-up. It was hypothesized that patients who underwent combined ACL and lateral extra-articular tenodesis (LET) reconstruction would exhibit less residual laxity, better clinical outcomes, and better graft incorporation on follow-up magnetic resonance imaging (MRI) as well. Patient and Methods: Sixty-four patients with concomitant ACL and ALL injuries who were operated over a period of 2 years were enrolled between 2016 and 2018. Two groups of patients were evaluated prospectively. Eighteen patients in control Group B underwent anatomical ACL reconstruction alone, and 20 in test Group A underwent ACL reconstruction combined with LET. Exclusions were multiligament injuries, chondral injury, meniscus tear, and ramp lesion. Follow-up by Lysholm and modified Cincinnati knee rating was done and MRI for status of graft at least 1-year postoperative. Results: After excluding dropout or inadequate follow-up, Group A (n = 20) with ACL + LET was compared with Group B (n = 18), with isolated ACL reconstruction, at final median follow-up of 18 months. There were no significant differences between groups regarding gender, age, and duration of injury. Regarding functional outcome scores, patients in the LET group presented better results on both the clinical scoring (P < 0.0001). In addition, patients in the LET group had better graft uptake on MRI and no pivoting at physical examination. Regarding graft failures, the isolated ACL reconstruction group had 5 and the LET group had 1 failure. Conclusion: The combined ACL and LET reconstruction in patients with ACL injury is an effective and safe solution and leads to good functional outcomes with no increase in complications and aids in early return to preinjury activities with a surviving healthy graft.
Keywords: Anterior cruciate ligament reconstruction, early return to sports, lateral extra-articular tenodesis, Lemaire procedure
|How to cite this article:|
Singh LP, Sinha S, Kumar I, Verma AK, Saraf SK, Singh TB, Pandey SS. Efficacy of lateral extra-articular tenodesis on anterior cruciate ligament reconstruction with quadrupled hamstring graft: Magnetic resonance imaging evidence and clinical follow-up. J Orthop Dis Traumatol 2021;4:72-9
|How to cite this URL:|
Singh LP, Sinha S, Kumar I, Verma AK, Saraf SK, Singh TB, Pandey SS. Efficacy of lateral extra-articular tenodesis on anterior cruciate ligament reconstruction with quadrupled hamstring graft: Magnetic resonance imaging evidence and clinical follow-up. J Orthop Dis Traumatol [serial online] 2021 [cited 2022 Jan 24];4:72-9. Available from: https://www.jodt.org/text.asp?2021/4/3/72/332941
| Introduction|| |
The absence of pivoting, a stable knee and early return to sports or higher activities, defines the success of arthroscopic anterior cruciate ligament (ACL) reconstruction. To improve the results of ACL reconstruction, sports medicine specialists have introduced various innovations, including the technique of footprint placement (transtibial vs. anteromedial), choice of graft between hamstrings, quadriceps or peroneus longus, and single or double-bundle reconstructions, etc. However, despite all permutations or combinations of enriched tips or pearls, the goal remains unfulfilled. The rate of re-injury in patients younger than 20 years may be as high as 20%, whereas recurrent or persistent laxity/pivoting after ACL reconstruction is reported from 11% to 30%.
Rotatory instability remains after reconstruction in some patients, which may cause limitations in regular daily activities and affect the performance of athletes who participate in sports. Residual instability, notch impingement, graft re-tear in ACL-reconstructed knees are commonly associated with failure to return to sports. The residual pivot-shift phenomenon may lead to secondary meniscal injury or osteoarthritis development. Hence, controlling pivot shift is one of the critical factors for improving outcomes after ACL reconstruction.
Recent magnetic resonance imaging (MRI)-based studies have shown that acutely ACL-injured knees have an 88% prevalence of concomitant anterolateral ligament injury (ALL) abnormalities. At present, the healing potential of the ALL is not known, but biomechanical studies have shown that isolated ACL reconstruction in combined ALL and ACL-injured knees failed to restore normal kinematics. In this situation, normal knee kinematics could only be restored by ACL reconstruction combined with a lateral extra-articular tenodesis (LET) or with ALL reconstruction fixed in extension.
We hypothesize that augmentation of ACL reconstruction with lateral extra-articular tenodesis, henceforth restoring the anterolateral complex, improves clinic-radiological outcomes and facilitates early return to preinjury level of activities by imparting stability to graft.
| Patient and Methods|| |
All patients attending the Outpatient department with ACL injuries were screened with MRI of the injured knee for this prospective cohort study over a period of 2 years from 2016 till 2018.
Magnetic resonance imaging evaluation pre and postoperative
The 3-T MRI films were randomly evaluated by 2 senior radiologists and 1 independent registrar, blinded to patient data for ALL injury in the form of sprain/complete tear. An MRI of the knee was first evaluated for ACL tear which was confirmed if there were
- ACL fiber discontinuity
- high T2 signal intensity in the ligament
- abnormal ACL orientation with decreased angle between ACL and intercondylar line on sagittal images
- fluid signal at the femoral or tibial attachment site of ACL.
Normal ALL was identified on coronal PD-weighted fat-suppressed image as a low-signal sheet such as structure in the lateral aspect of the knee with attachments at lateral femoral condyle, body of lateral meniscus, and proximal tibial plateau. ALL injury is diagnosed if it has a high-signal intensity, indistinct fibers with irregular contours, especially at lateral meniscal and tibial attachment sites, marrow edema at the tibial insertion site or frank avulsion fracture (Segond fracture). Findings were described as increased signal, discontinuity, or complete nonvisualization of its fibers, [Figure 1].
|Figure 1: Anterolateral ligament injury and Segond fracture as seen on magnetic resonance imaging. Avulsion bony edema (black arrow) is noted at the tibial attachment site of the ALL. Otherwise, meniscofemoral (black curved arrow), meniscotibial (white arrow), tibiofemoral (white curved arrow) segments, and femoral attachment site (long white arrow) are intact|
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Postoperative ACL graft was assessed for its orientation, continuity, and signal intensity. If there was a presence of fluid signal in the expected location of the graft or loss of fiber continuity, a complete graft tear was diagnosed. Partial tear of the graft was diagnosed if there was a localized area of increased signal in an otherwise intact graft. Placement of staples, continuity of ALL, if reconstructed was also assessed.
- All patients with clinical and MRI features of ACL + ALL injury
- Failed ACL reconstruction due to traumatic graft tear, residual pivoting, or technical error with unaddressed ALL injury
- All patients operated in the past for ACL reconstruction with quadrupled hamstring graft demonstrating ALL injury in their preoperative MRI
- Patients with ACL reconstruction who have had at least 9–12 months of follow-up are eligible for MRI evaluation of the graft.
- Multiligamentous injury
- Lateral meniscal tear and chondral lesion of lateral femoral condyle (as a possible confounder)
- Medial meniscus tear and ramp lesion
- Pivot shift negative and partial ACL tear
- Graft choice other than hamstrings (to make homogenous groups)
- Tunnel malposition
- Generalized joint laxity
- Patient not consenting to operative or follow-up treatment.
- ACL reconstructed with or without LET who have a follow-up <9 months, not amenable for graft assessment
The study was duly approved by the IRB, and patient recruitment and consent were taken according to the declaration of Helsinki, 1964.
- Group A: (LET group) Patients with ACL and MRI demonstrable ALL injury treated with ACL reconstruction with Hamstring tendon graft and LET
- Group B: (ACL group) Patients with an ACL tear and an MRI showing ALL injury were treated with an isolated ACL reconstruction using a quadrupled hamstring tendon graft.
Recruited patients were assessed with clinical examination including anterior drawer, pivot shift, Lachman's test, varus/valgus stress test, examination under anesthesia before operative procedure.
ACL reconstruction with transportal technique with quadrupled hamstring graft was done and fixed with suspensory fixation endobutton in femur and aperture fixation with Bioscrew (Arthrex®) in tibia. Following the final tensioning of the reconstructed ACL, a modified Lemaire procedure is performed, according to standard indications:
- Graft width was found to be <8 mm
- Revision ACL reconstruction is being undertaken
- Female athlete or high-demand individual
- Residual pivot shift or laxity is present intraoperative.
A 10-cm curvilinear incision is placed just posterior to the lateral femoral epicondyle up to Gerdy's tubercle. A 10-cm long and 1-cm wide strip of ITB is harvested from the posterior half of the ITB, ensuring that the most posterior fibers of the capsulo-osseous layer remain intact. It is left attached distally to the Gerdy's tubercle, freed of any deep attachments to vastus lateralis, released proximally, and a Vicryl whipstitch is placed in the free end of the graft [Figure 2]. The fibular collateral ligament is then identified. Small capsular incisions are made anterior and posterior to the proximal portion of the ligament, and Metzenbaum scissors are placed deep into the FCL to bluntly dissect out a tract for graft passage. The ITB graft is then passed beneath the FCL from distal to proximal. The lateral femoral supracondylar area is then cleared of the small fat pad found proximal to the lateral head of gastrocnemius using electrocautery. The attachment site is identified just anterior and proximal to the lateral gastrocnemius tendon. The periosteum is cleared using a cob on the metaphyseal flare of the lateral femoral condyle. Care is taken not to damage the ACL graft femoral fixation as the suspensory loop button is often found close to this location. The graft is then held taught but not overtensioned, with the knee at 60° of flexion and the foot in neutral rotation to avoid lateral compartment overconstraint. A small Richard's staple is used to secure the graft, which is then folded back distally and sutured to itself with a Vicryl whipstitch [Figure 3] and [Figure 4]. The wound is irrigated, hemostasis is confirmed, and closure is performed in layers.,
|Figure 2: Harvest about 9 cm long and 1 cm wide strip of ITB, attached distally to Gerdy's tubercle|
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|Figure 3: Rerouting of graft under FCL and fixation at metaphyseal flare, at insertion of Kaplan's fibers with staple|
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|Figure 4: Postoperative X-rays of ACL with LET, positioning of staple and femoral tunnel/endobutton|
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The two groups were rehabilitated with the same postoperative protocol. They were allowed full weight-bearing walking in immediate postoperative, knee bending up to 90° in a dial knee brace. Bicycle and hamstring strengthening along with proprioception started from 6 weeks onward. Brace is discontinued, usually after 6 weeks. Closed chain exercises and squats were allowed afterward.
Clinical scoring and follow-up
Initial clinical scoring and follow-up of the patients of each group at a definite interval of 3, 6, and 12 weeks was done and then continued for every 3 months till 2 years. Lysholm and modified Cincinnati knee scoring was done from atleast 1 year to assess return to sports and higher activities. Follow up MRI was obtained from every patient at a minimum interval of 9 months to 1 year for the evaluation of graft status. Cut off was established with the patients in both the groups completing a minimum follow-up of 1 year, availability for MRI and final clinical scoring.
All statistical analyses were performed using SPSS v21.0, (IBM corp,Armonk, NY) for windows. Qualitative data was expressed as either mean and standard deviation or numbers and percentages. The monitored and normally distributed variables were analyzed by a paired t-test for comparison between 2 groups. P value (α error) <0.05 was considered statistically significant, within a confidence interval of 95%. The power of study was kept at 80%. For small categorical variables, Fisher's exact test/Chi-squared test was employed.
| Results|| |
Of the 104 patients/records who attended the OPD for ACL injuries, 64 patients were found to have some sort of ALL injury. Thirty-two patients were randomly allocated to either group. According to the indications listed for LET, postsurgery 10 patients were relocated from Group B to A. This implies that LET was done in 10 patients initially allocated to Group B, based on intraoperative findings or due to poor graft harvest or residual laxity/pivoting postadjacent channel leakage ratio (ACLR). Thus, the final study sample had 42 patients with ACL + LET (Group A) and 22 patients in isolated ACL reconstruction (Group B).
Only 20 patients from Group A and 18 from Group B were available for follow-up evaluation for MRI at 1-year postoperative. Results and statistical analysis were performed on this study sample of a total of 38 patients in either group. The demographics of the two groups are mentioned in [Table 1].
The average age ranged from 18 to 45 years with a mean age of 27 ± 10 years. The male-to-female ratio was 5.3:1. A maximum follow-up of 42 months could be obtained in Group B, which was statistically significant. Longer follow-up could be obtained for Group B, as eight of them were operated on before the study commenced and retrospectively, their preoperative MRI retrieved from hospital records, revealed concomitant ALL injury.
[Table 2] reveals significant differences in Tegner-Lysholm scoring between the cohorts. Both the groups show improvement in pre- and postoperative scoring at the final follow-up. There were no poor results in either group, but the percentage of excellent to good results was higher in the LET group (P > 0.05). Return to sports or preinjury level, based on modified Cincinnati scores at a final follow-up, was significant in the LET group. This evaluation was made after completion of the postoperative rehabilitation program of the institute, after a minimum of 9 months to 1-year postoperative.
|Table 2: Patient reported outcome measures, Lysholm score and return to sports/higher activities based Cincinnati knee scoring at least 1 year|
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[Table 3] shows parameters for MRI evaluation for graft signal changes, perigraft edema, partial thinning, impingement of graft, technical failure if any. It revealed a statistically significant difference in signal changes and perigraft edema with the LET group, pointing to a protective action of tenodesis on graft health.
Complications specific to the LET group were terminal knee stiffness (n = 5), staple pull out (n = 2), pain at staple site, 1 case had penetration/proximity of staple in femoral tunnel, staple malposition (n = 2), and infection (n = 1). However, both groups were comparable and there was no statistically significant difference regarding complications such as loss of terminal flexion, graft impingement, re-tear, and residual pivoting.
| Discussion|| |
Our results reveal that LET improves functional outcomes and early return to sports or preinjury activities by conferring protective effect on ACL graft, as demonstrated on MRI at a minimum of 1-year follow-up. Recent evidence supports our findings. Rowan et al. reported better outcomes in the 55 LET patients, after applying narrow inclusion criteria and evaluating return to multidirectional sports in a cohort of 263 patients. Thirteen patients with ACL reconstruction had graft re-tear in their study as compared to the LET group.
LET or anterolateral complex restoration has been debated for certain issues. First, few studies claim that LET increases lateral compartment pressure and risk of degenerative arthritis.,,, Until recently, Shimakawa et al., based on cadaveric model and software sensors, on various degrees of flexion with or without subtotal lateral meniscectomy found that it is safe to perform LET in conjunction with ACL without altering lateral compartment pressures, despite meniscectomy. Our results support that the findings as alteration in lateral compartment pressures did not clinically manifest as lateral compartment pain or cartilage and meniscal degeneration on imaging. Likewise, significant pivoting was not encountered in the LET group in the follow-up.
Encouraging results were obtained by SANTI study in ACL and ALL reconstruction in 221 patients out of 502 patients with 2-year follow-up in terms of lower graft failure rates of 8%, with approximately 53% of patients returning to competitive sports. Nevertheless, it was a retrospective study, not free from selection bias and graft selection was not uniform (either BTB or hamstring graft). In comparison, the present study, despite having a smaller cohort, is prospective and about 75% of patients with LET return to sports and higher activities. Moreover, patients were prospectively evaluated with postoperative MRI as a helping documentary tool for internal validity of results. Furthermore, considering uniformity in graft selection and similar technique of reconstruction, our results may overcome random error or confounding.
To obtain indications for ALL reconstruction, Helito et al. in 2018 conducted a retrospective study on 101 patients with chronic ACL injuries (>12 months), with a median follow-up of 24 months, by KT 1000 arthrometer, Lysholm's scoring, rate of pivoting, and graft rupture. The graft failure rate was lower in the ALL group (7.3%), comparable to the present study. However, results in female athletes or high-risk groups could not be elicited due to smaller samples of these subsets, as in our study.
Extended indications were sought by the same group in another retrospective study comprising 90 patients with generalized joint laxity and a Beighton score >5. Significant lower graft rupture rates were identified in 30 patients of the ALL group (3.3% vs. 21.7%). Thus, imparting that ALL reconstruction improves graft longevity, even where joint laxity or collagen disorder prevails. Even though we excluded the patients of GJL, this finding strengthens our hypothesis of the protective effect of LET on the graft.
Second, ALC may be restored either by nonanatomic LET by modified Lemaire, Losee, or McIntosh procedure or by anatomical anterolateral ligament reconstruction (ALL) as described by Sonnery-Cottet et al. in SANTI study and others.,,,,,,,
Despite the fact that most of the research applied to ALL reconstruction, we employed nonanatomical LET of Lemaire procedure. Recently, Geeslin et al. could demonstrate in either procedures, using robotic model in controlled cadaveric laboratory study, significant reduction of anterior tibial translation, and tibial internal rotation at most degrees of knee flexion. Moreover, LET has the advantage of over anatomical ALL reconstruction as it is cheaper, easier to perform, cost effective and offers minimal lateral compartment constraint.
Third, residual pivot shift was an outcome measure in the aforementioned studies. Ueki et al. identified certain risk factors apart from graft choice and ALL reconstruction in the multicenter arthroscopic knee surgery study. According to them, a hyperextension deformity of the knee and a preoperative pivot shift of higher grade is an independent risk factor for postoperative residual pivoting at 1 year. As a possible confounder, we tried to eliminate its effect by assessing the intraoperative pivot shift in Group B, post-ACL reconstruction. If the pivot shift was positive after ACL reconstruction in Group B, LET was performed and patients were relocated to Group A.
In our study, one patient in the LET Group (1 of 20, 5%) had a graft rupture, most likely due to infection. Isolated ACL reconstruction did not report graft rupture but definitely, a perigraft edema, graft attrition, poor uptake on postoperative MRI, amounting to graft failure (n = 5). Clinically, such patients had a significantly lower rate of return to preinjury level with poor clinical scoring. The relatively protective action of LET on ACL graft is due to the fact that combined ACL reconstruction associated with anterolateral tenodesis suppresses acute pathologic tibial acceleration in the pivot shift, proven by KiRA (triaxial accelerometer) and under various loads in internal rotation and flexion and extension in recent studies.,
In contrast to our findings, the most recent randomized control trial by Getgood and Jesani in their “stability study” found no differences in functional outcomes in 352 young active patients randomized in the two groups at 1 year. In contrast, they reported a temporary higher pain scores, reduction in quadriceps strength, and lower (lower extremity functional scoring) by 6-month postoperative. By 1 year, these differences disappeared and did not affect the hop test for (limb symmetry index, used as criteria for return to sports by the authors.
Adding to this, the “stability trial,” over 2-year follow-up, reported findings similar to our study, employing primary outcome as ACLR clinical failure. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, KOOS, IKDC, and ACL quality of life questionnaire, which were remarkable in the LET group. This randomized trial was multicentric and did not record the MRI findings but applied pragmatic and stringent criteria in randomization and evaluation.
A highlighting feature of the present study is the postoperative follow-up radiological evaluation by MRI of both groups. In both groups, femoral and tibial tunnel, graft angle, graft signal, status of meniscus, and status of cartilage were noted, and hence, graft healing and technical flaws as other reasons for failed reconstruction could be ruled out. In the LET group, ACL graft signal is noted as normal whereas, in the isolated ACL group, graft signal is noted as intermediate to high suggestive of sprain or tear in graft [Figure 5] and [Figure 6].
|Figure 5: A 18-month follow-up of magnetic resonance imaging of 24/M army recruit in Group A, graft uptake has near-normal signal without buckling of PCL, or perigraft edema, normal tunnel position|
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|Figure 6: A 24-month follow-up magnetic resonance imaging of young footballer, in Group B, shows graft attrition, edema, inadequate ligamentization. However, the patient has excellent Lysholm score|
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Another unique feature of the present study is documentation and quantification of anterolateral complex injury in preoperative MRI. ALL injuries are more rampantly reported, as high as 76.25% in recent literature. To avoid unnecessary lateral compartment constraint, we believe that ALC should not be reconstructed in cases where it is not damaged.
The strength of the study is that a novel hypothesis is being evaluated in a prospective follow-up. Patient-related outcome measurements were closely monitored and documented by follow-up MRI, near the stage of ligamentization. Clinical results in terms of patient-related outcomes were correlated by clinical examination and clinical scoring. Evaluation tools used have been standardized and thus add to the internal validity and precision of the present study. Temporal assessment of MRI makes the results more generalizable.
However, limitations include shorter follow-up with a relatively small sample size. Another limitation is the age group, which is quite wide (16–45 years), for a physiologically active population. We specifically did not focus on the high-demand athletes, but our patient population included army recruits, high-demand individuals, motorcycle commuters, professional dancers. Hence, we focused mainly on individuals whose daily activities include pivoting activities and are representative of the general population.
Other weaknesses include failure to obtain subgroups of high-risk individuals, such as female gender, generalized ligament laxity, chronic ACL injuries, and other graft types such as bone-patellar tendon–bone graft or peroneus longus. Long follow-up studies are required in the future to know long-term outcomes of this procedure in these subgroups. Age, gender, return to sports, and other important parameters need to be correlated separately.
| Conclusion|| |
The combined ACL and LET reconstruction in patients with ACL injury is an effective and safe solution and leads to good functional outcomes with no increase in complications and aids in early return to preinjury activities with a surviving healthy graft. We recommend its application in indicated cases, especially when MRI documents ALL injury.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]