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A prospective study evaluating combined arthroscopic anterior cruciate ligament reconstruction and anterolateral extra-articular tenodesis in athletes
⁎Corresponding author: Virender Kumar. drvirender80@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Anterior Cruciate ligament rupture is a common orthopaedic injury that requires singlebundle/double-bundle reconstruction to restore the normal kinematics of the knee joint. However, anterolateral laxity remains a frequently encountered problem in chronic injuries, even with successful ACL reconstruction. This has been attributed to the anterior asymmetrical translation of the lateral tibial plateau. Thus, additional augmentation of the anterolateral structures is necessary to correct the rotator instability along with ACL reconstruction.
This prospective interventional study includes high-risk athletes, patients with 3+ pivot shift in ACL deficient knees, patients with hyperlaxity, and patients requiring revision ACL reconstruction due to clinical instability. A combined procedure of single-bundle ACL reconstruction and Lateral Extra-articular tenodesis using Lemaire's technique was employed. Post-op rehabilitation was started from day one with quadriceps strengthening exercises and gradual progressive knee bending on the couch. Closed chain exercises were started after two weeks and full weight bearing, cycling, light jogging, and squatting were initiated after six weeks. Return to the sport was allowed at six to nine months.
It was observed that this technique resulted in significant improvements in the Lysholm score (p<0.0001), mean subjective IKDC (p<0.0001), and Tegner Activity score progressively increased post-operatively. Further, in subsequent follow-ups, the majority of patients (94.4%) were pivot shift negative, and functional outcomes were excellent to good.
The study concluded that this combined procedure significantly increased the functional outcome scores and substantiated the possibility of a return to sport by providing additional rotational stability.
Keywords
Anterior cruciate ligament
Lateral extra-articular tenodesis
Augmentation
Athletes
Sports injury
1 Introduction
Claudius Galen, a Greek physician (150 AD), was the one who wrote regarding the genesis of “genu cruciate” and emphasized the cruciates as a protective structure of the knee joint, checking atypical motion.1 The anterior cruciate ligament (ACL) is frequently injured in athletes who take part in popular sports activities. In the majority of these injuries, other structures in the knee, such as articular cartilage, meniscus, or other ligaments, are also injured. Providing stability remains the primary function of the ACL against anterior tibial translation and rotatory stability. The basic mechanism of ACL damage includes non-contact deceleration, in particular, abrupt stopping or variation in direction. ACL injury additionally takes place in torsion or blended external rotation with hyperextension, flexion, and valgus. As the knee progresses into hyperextension, the posterolateral bundle of the ACL gets taut, and with further strain, initially, this PL bundle gives way, followed by a compound posterolateral and anteromedial injury.2 Further, it has been observed that even with successful ACL reconstructions, the standard mechanics of the knee joint are not re-established. Moreover, even after a more anatomical, double-bundle restoration of the ACL, the anterolateral rotator instability is not contained, as demonstrated by the pivot-shift test. So, the idea of reinforcement in the form of lateral extra-articular tenodesis of the knee joint has led surgeons to investigate whether adding an anterolateral capsular restraint helps control rotatory laxity more effectively. A significantly better outcome is recognized with a precise interpretation of knee kinematics and specialized intervention techniques for comprehensive intra- and extraarticular restoration.3 (see Figs. 1–4)
2 Material and method
There were 18 clinically and radiologically verified cases of ACL rupture in this prospective interventional study, done at a tertiary care postgraduate institution. The study group included high-risk athlete patients with ACL-deficient knees with 3+ pivot shift, complaining of hyperlaxity (if they continue to experience clinically noticeable subjective instability following the prior intervention). In this strata of athletes, there were no cases of a contemporaneous posterolateral knee injury with associated lateral meniscus tear, mixed ACL and PCL injuries, or combined ACL + MCL tears. The identical orthosurgeon carried out all the interventions. In all the subjects, single-bundle ACL reconstruction was done. The fixation technique for the femur was the endo-button, and for the tibia, we incorporated an interference screw (bioabsorbable). The modified Lemaire technique was employed for anterolateral extra-articular tenodesis,4,5 where graft fixation was done using a Tendon staple over the femur. Preoperative and postoperative clinical evaluation with IKDC scores (International Knee Documentation Committee),6 Tegner activity score,7 Lysholm score,7 and pivot shift test were done. Further, the compiled data was captured in an Excel sheet, coded adequately, and then audited with the Statistical Package for Social Studies.
2.1 Surgical technique
Following the reconstruction of the ACL using a harvested semitendinosus graft, otherwise BPTB (bone-patellar-ligament-bone) graft, an incision was made on the anterolateral aspect of the Gerdy's tubercle, beginning 1 cm posterior to it and extending proximally up to the femoral lateral epicondylar eminence. The incision was made in a curvilinear manner. The skin flaps were raised on both sides. At the same time, the knee was kept in 90° flexion. The tensor fascia lata strip was elevated with a 15-mm blade, maintaining its insertion at the Gerdy's tubercle. The strip's measurements were a width of 1–1.5 cm and a length of 10–15 cm. Using a scale, the proximal portion was amputated to check that it measured at least 10–15 cm.
Thus, the strip taken from the tensor fascia lata was left free proximally and anchored distally at Gerdy's tubercle. The fibular collateral ligament, which extends from the lateral epicondylar eminence to the fibular head, was then exposed by dissection. The anterior and posterior borders of the middle part of the fibular collateral ligament were primarily dissected. No. 2 ethibond sutures were used to whipstitch the graft's loose perimeter. These sutures move the fascia lata graft from anterior to posterior over the dissected fibular collateral ligament. After that, it was curled around it and secured to the bone on the posterior aspect of the lateral femoral epicondyle, marginally proximal, and at the isometric point. Using an osteotome and bone nibbler, this region was debrided and denuded to reveal a bed of raw, bleeding bone. A follow-up examination was conducted to ensure that the tendon staple used to secure the tensor fascia lata graft was isometric and did not move at full knee joint flexion and extension. A tendon staple was used to secure the tensor fascia lata graft to the raw, leaking bone after a number of places were examined and the optimal isometric point was determined. Maintaining the knee in a 30° flexion and modest external rotation helped to secure the graft in tension. Isometricity is confirmed by looping the threads of whip stitches of the free end of the Fascia lata strip around a beath pin passed 3 mm posterior and proximal to lateral femoral epicondyle and minor adjustments made while taking the knee through cycles of flexion and extension.
In revision cases, if the new tunnel happened to be not in the exact location of the previous tunnel, for the femoral tunnel, the endobutton, the reconstructed ACL, and the remnant of the previously reconstructed ACL were debrided and removed. A fresh femoral tunnel was reconstructed, and the newly reconstructed ACL graft was secured using a fresh endobutton, leaving the previous tunnel undisturbed. For the tibial tunnel, if the fresh tunnel happened to be not in the exact location of the previous tunnel, then in such a situation, the previous tunnel and bioscrew were left undisturbed, and the previously reconstructed ACL remnants were debrided, followed by the drilling of a fresh tibial tunnel at the determined site, and the newly harvested ACL graft was secured with the help of a fresh bioscrew. After the incision site was closed with vicryl and silk sutures or skin staplers, tension in the varus and valgus was evaluated, and the Lachman and pivot shift tests were demonstrated postoperatively. After performing an aseptic dressing, a full-extension knee immobilizer was applied. We never employed any DVT protocol for such revision cases, and no DVT cases were identified during the study interval.
2.2 Postoperative rehabilitation protocol
Postoperatively, patients were kept on intravenous antibiotics for two to three days, and ice fomentation was done for 24 hours. The limb was kept elevated using three to four pillows. Patients were discharged following 48–72 hours of surgery. Following surgery, the cases were monitored for two weeks following the removal of sutures. For a month, patients were reviewed every two weeks, and after that, every month for six months. After that, at three-month intervals, For the initial two weeks, the patients were non-weight-bearing until the suture was removed postoperatively, followed by partial weight-bearing with the help of crutches or a walker.
Exercises to strengthen the quadriceps were initiated on the first day and included increasing passive knee bending with the heel resting on the couch. After two weeks, closed-chain exercises were gradually introduced in order to achieve the target range of motion in four to six weeks. After the full range of motion was established, patients were allowed to walk with their entire weight. However, during the first six weeks, they were not allowed to walk with their entire weight without a knee immobilizer. After four to six weeks, depending on the progress, cycling, mild running, and squatting were added. After three to four months, specific sports-related activities were started, and athletes returned to competition no earlier than 6–9 months later, with the timing of this being further determined by the development and recovery of the quadriceps strength.
Patients' pre-operative, at 6-month follow-up, and subsequently at 12-month follow-up, knee isokinetic quadriceps strengths were recorded using an isokinetic dynamometer with the BIODEX SYSTEM at two distinct angular velocities (60°/s and 180°/s). An isokinetic dynamometer was used to test the flexion and extension strengths of the knee. The dynamometer was adjusted by the fixed protocol (seat, dynamometer and adapter) set for knee extension and flexion strengths. Isokinetic measurements of the patients were conducted for concentric contraction at two angular velocities (60°/s and 180°/s). The pad on which the lower leg attachment was fixed was placed proximal to the lateral malleus. In addition, the ankle was placed on the leg stabilizer under the dynamometer seat to prevent movement in the contralateral limb. The range of motion (ROM) of the dynamometer was set between 0° (knee extension) and 90° (knee flexion). The knee joint rotation axis was identified through the lateral femoral condyle and aligned with the motor axis. Gravity correction was applied (at 90° full extension) to eliminate the antigravity effect of the limbs. The test protocol on the dynamometer included a warm-up set for each angular velocity at the same pace followed in the test set. In the warm-up set, patients performed sub-maximal 4-repeat flexion/extension movements. Isokinetic knee Extension and Flexion strength tests for both Healthy knee and ACLR groups were performed with concentric/concentric (Con/Con) contractions aligned at 60°/s and 180°/s. Participants were given 1-min rest intervals between test sessions (i.e., between angular velocity changes) to minimize fatigue. Once the testing of one side was completed, there was a 5-min interval, during which the dynamometer setting was changed to adjust to the contralateral lower extremity. Measurements were first conducted on the ACLR knee. To ensure maximum effort, all participants were given standard verbal encouragement and were asked to apply maximum force. All tests were performed in the same order by the same researcher. The duration of the test protocol was approximately 15–20 min for each patient. The values obtained from the measurements were recorded as force-based torque values (Newton meters). In addition, Hamstring/Quadriceps ratios were recorded as percentages (%). The dynamometer was calibrated before each laboratory visit.
For the management of Grade 1 laxity in the follow-up phase, the final goal was the Strengthening of joint muscles primarily focusing on the Quadriceps, Hamstrings and calf muscles and exercises include Isometric exercises, Resistance exercises, and balance exercises.
3 Observations and results
Patients in this study ranged in age from 18 to 50, with a mean age of 28.61 and a standard deviation of 9.38 years. The majority of the cases, i.e., 88.9%, were sports injuries, while 11.1% were non-sports injuries. In our study, nine (50%) patients were high-risk athletes, followed by five (27.8%) patients who were already operated on in the past for ACL tear; now, revision surgery has been done. Three (16.7%) patients with 3+ pivot shifts were chosen. Only one (5.6%) patient with hyperlaxity was present. The recurrent surgery was done using a bone-patellar ligament-bone graft, anchored using an interference screw at the tibial and femoral sites. The original tunnels were re-reamed and used in all cases, as they were in the correct place and orientation. Re-trauma was the cause of graft failure in all recurrent cases. The Tegner activity score, IKDC score, and Lysholm score were recorded both preoperatively and postoperatively and subsequently evaluated, and the difference was highly significant in Lysholm and IKDC scores.
When patients with ACL tears were evaluated preoperatively by pivot shift testing, ten (55.6%) cases were in grade 1+ pivot shift positive. Three (16.7%) patients had a grade 3+ pivot shift positive, which was also an inclusion criterion for our study. Five (27.8%) cases demonstrated a grade 2+ pivot shift test, whereas none exhibited a negative test. Postoperatively, seventeen (94.4%) subjects showed a negative pivot shift, except one (5.6%) case had a 1+ pivot grade positive following surgery. None of the cases demonstrated a grade 2+ or 3+ pivot shift postoperatively.
Preoperative and postoperative scores were also calculated, showing minor differences by conventional criteria for Tegner activity scores.
There were no postoperative (nor intraoperatively) complications related to the surgery, including vascular injury, graft mal-positioning, or graft failure. Two (11.1%) cases complained of knee pain in our study. Two patients (11.1%) had a sensory deficit at the proximal medial tibia because of the saphenous nerve infrapatellar branch implication. One (5.6%) case developed a superficial stitch infection, which subsequently responded to intravenous antibiotics and daily dressing. A clicking sensation, over the upper lateral aspect was complained by three (16.7%) patients.
4 Discussion
An ACL injury is a frequent event in orthopaedics and sports medicine and mandates a single-bundle or double-bundle repair to restore normal kinematics. A double-bundle ACL reconstruction technique came later after an absolute anatomical and biomechanical understanding of two diverse bundles of ACL, namely the PL and AM bundles. In various comparative analyses, the double-bundle ACL restoration, despite exhibiting better intraoperative dynamics, failed to provide a significantly better clinical and functional outcome in the long-term follow-up.8,9 Also, this technique has a few added disadvantages, including prolonged surgical time, inflated cost, and increased procedural complexity. It also ends up with bigger bony voids in the femoral condyles to restore in a subsequent surgery.10 So, in our study, we considered only the single-bundle reconstruction technique.
Chronic ACL injuries differ from acute injuries as they demonstrate a high level of anterolateral laxity because of disproportionate anterior translation in the lateral tibial plateau.11 Either acute damage to the anterior cruciate ligament not healing satisfactorily or a therapeutic intervention not improving effectively ensures the inadequacy of anterolateral structures. Hence, a lone ACL reconstruction in these injuries does not restore normal knee kinematics, thus mandating a supplementary augmentation for better chances of returning to sports.12 In a group of 60 cases of acute ACL injury, Ferretti et al. concluded that 90% of injuries were related to these structures.13 The recovery prospects of anterolateral structures are uncertain, but given the share of residual pivot shift among various modalities used for ACL reconstruction, a vast majority of such cases in all likelihood mandate surgery.14
It was also inferred that lateral extra-articular tenodesis gives significantly better outcomes than ALL reconstruction, as demonstrated by Mathew et al.15 and further supported by Vundelinckx et al.16 The evidence from their research indicated that the lateral compartment was over-constrained following an ALL reconstruction, which could be further attributed to the alignment of the reconstruction, which is oriented perpendicular to the joint and further loads the knee during stress. In the literature, more and more attention is given to improvising various techniques for lateral extra-articular tenodesis. Strickler17 explained the lateral extra-articular tenodesis procedure the earliest. Lemaire 4, Ellison,18 Macintosh,19 and Andrews20 procedures are the most common techniques. So, we proposed this study to evaluate the combined ACL reconstruction with anterolateral extra-articular tenodesis. In our study, the mean age was 28.6, which is similar to other studies conducted by Zaffagnini et al. (2006),21 where the mean age was 26.7 years; Yamaguchi et al. (2006),22 who concluded the mean age was 23.9 years; and Trichine et al. (2014),23 where the mean age was observed to be 28.6 years.
In the present study group of athletes managed with a combined ACL reconstruction and lateral extra-articular tenodesis, we have observed marked improvement in the Lysholm score postoperatively (p-value <0.0001). The improved Lysholm score seen in studies by Ferreti et al.25 (96.2) and Vadala et al.26 (95.8) is also found in this study. The mean Lysholm score of 94.9 is obtained, all pointing to a positive functional outcome. The study found that the mean subjective IKDC improved statistically significantly (p-value <0.0001) after surgery, rising from 51.52 to 94.43. Ferreti et al.25 (96.2), Marcacci et al.27 (93.5), Saragaglia et al.28 (89.0), and Zaffagnini et al.21 (89.0) are comparable to this; they have also demonstrated statistically significant improvements in subjective IKDC after surgery.
The Tegner activity score in our study showed an upward trend after surgery. A longer follow-up period is required to observe additional improvement, as the eleven-month mean follow-up revealed improvement but was not equivalent to the pre-injury levels. The study by Zaffagnini et al.,21 Marcacci et al.,27 Vadala et al.,26 and Yagamuchi et al.22 likewise showed a correlation with the significance between pre-injury and postoperative Tegner scores at the final follow-up. But after surgery, Ferreti et al.25 showed a highly substantial improvement in the Tegner score, which was almost back to its pre-injury level. This may be explained by the various follow-up schedules, the unique characteristics of the patient, and increased adherence to postoperative therapy.
The highest percentage of patients in this study (94.4%) had pivot shift negativity. Additionally, according to Zaffagnini et al.24 (94.3%) and other studies like Trichine et al.25 (93.2%), Zaffagnini et al.21 (92%), and Dejour et al.23 (92%), none of the patients showed a gross pivot shift. These findings can be attributed to lateral extra-articular tenodesis augmentation rather than isolated ACL reconstruction in these studies. One limitation of the study is the intuitive capacity to interpret the pivot-shift test; however, our superior choice was to have an impartial expert examiner observe every case because there were no systematized, unbiased tests accessing rotatory instability.
In this study, three cases (16.7%) had a clicking sensation on the lateral aspect of the knee, which resolved spontaneously in further follow-ups. At the same time, two cases (11.1%) complained of knee pain. The pain was managed by painkillers and local site warm fomentation; one patient (5.6%) suffered a superficial stitch line infection further managed by antibiotics and regular dressing. Hypoesthesia is a frequent complication following hamstring ACL surgery 30. Around the site of the hamstring graft harvesting incision, two patients (11.1%) had hypoesthesia. Iatrogenic trauma of the saphenous nerve branch (infrapatellar) is a documented reason for regional hypoesthesia of the distal leg following an ACL reconstruction surgery. A well-planned oblique incision, staying parallel to the nerve fibers, in contrast to a vertically placed incision, would further minimize the incidence of this avertable complication following an ACL reconstruction.
5 Conclusion
The study emphasizes that in revision ACL reconstruction with concomitant high-grade pivot-shift positive patients and cases with generalized hyperlaxity, particularly in high-demand athletes, anterior cruciate ligament reconstruction augmented with anterolateral extra-articular tenodesis of the knee joint using the modified Lemaire technique gives excellent to good functional outcomes. This procedure increases the possibility of returning to sports activities as professional athletes by providing additional rotation stability.
Authors contribution
All authors contributed equally to the progress, analysis and outcome of the study.
Funding/sponsorship
This study is not funded or sponsored by any individual, group or society/institution.
Patient consent
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients to be included in the study.
Ethical statement
The institutional Ethics Committee reviewed the application to conduct the research study entitled above and approved the same via letter No. IEC/Th/18/Ortho/04, Dated: January 20, 2018. All procedures followed were by the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients to be included in the study.
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