Does an ACL injury require additional peripheral stabilization? The rise of individualized ACL reconstruction
By: Daniel Günther, MD, PD, MHBA
Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine,
Cologne Merheim Medical Center, Witten/Herdecke University, Germany
Reconstruction of the anterior cruciate ligament (ACL) is among the most frequent surgeries in orthopedics. After ACL rupture, it is important to treat anterior tibial translation instability and antero-lateral rotatory instability of the knee. Despite improved clinical and kinematic outcomes after anatomic ACL reconstruction, a subset of patients continues to exhibit persistent rotatory knee instability, as demonstrated by a positive pivot-shift phenomenon, or experiences a rerupture of the ACL1,2.
Maybe such patients would have profited from an additional anterolateral extraarticular stabilization at the time of ACL reconstruction?
The indications and techniques of anterolateral stabilization have been a hot topic over the last decade. Initially, the discussion was inspired mainly by personal opinions rather than clear indications. The anatomy was rediscovered3, and a consensus statement4 conceptualized the experiences of the orthopedic community, giving rise to multiple biomechanical and clinical studies5-9.
To date, it is known that many different factors contribute to rotatory instability of the knee, such as injuries to the menisci10, injuries to the periphery, or malaligned bone morphology11 including an increased posterior tibial slope12, a tomahawk-formed lateral femoral condyle13, and valgus or varus malalignment14.
It is important to address those risk factors surgically whenever possible. A meniscal root tear, a symptomatic medial meniscus ramp lesion, or a common meniscus tear should be fixed at the time of ACL reconstruction. An increased posterior tibial slope and/or a valgus or varus malalignment can be addressed with an osteotomy. There is ongoing debate about whether such osteotomies should be performed exclusively in revision ACL surgery or even in primary cases. Clear indications, such as the threshold of malalignment to perform an osteotomy in ACL surgery, must be further defined.
The indications for an antero-lateral stabilization must be further defined: The ACL graft choice might lead to persistent knee laxity. A prospective clinical trial showed that an anterolateral stabilization leads to clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after ACL reconstruction using a hamstring tendon graft9. It will be interesting to see the results of an ongoing trial using the quadriceps tendon for ACL reconstruction, since the quadriceps tendon is biomechanically stiffer than the hamstring tendon.
It is important to mention that an anterolateral stabilization should not be a substitute for nonanatomic ACL tunnel placement. A high femoral ACL tunnel, like created in the past using a transtibial approach, may lead to sufficient anterior tibial translation stability, but not to sufficient rotatory stability of the knee.
In summary, ACL surgery has become increasingly more individualized, including different ACL graft options like the quadriceps, hamstring, patella, or peroneus longus tendons, osteotomies to address bony malalignment, specific techniques to address meniscus injuries like meniscus root or ramp repair, and the stabilization of the periphery including antero-lateral stabilization techniques.
A proficient sports surgeon aiming for optimized patient outcomes must include all these techniques in his or her “construction kit.” ACL surgery has improved tremendously during the last decade, but it has also become much more complex.
In the past, teaching younger surgeons the skills required to perform complex operations was mainly performed in the operating room by the senior surgeon assisting with parts of the operation. However, it is beneficial to increase the skill level of younger surgeons before entering the operation room to perform complex individualized surgeries. Like a pilot proving his or her skills in a flight simulator, a surgeon should perform well in a simulated setting before treating real patients. For this reason, cadaver courses to practice such techniques in a calm and professional atmosphere are crucial. AO Sports creates such a learning experience, and all ambitious sports surgeons can profit from experienced instructors and incredible course formats. I highly recommend the AO Sports courses to learn and improve techniques in individualized ACL reconstruction.
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The indications for an antero-lateral stabilization must be further defined: The ACL graft choice might lead to persistent knee laxity. A prospective clinical trial showed that an anterolateral stabilization leads to clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after ACL reconstruction using a hamstring tendon graft9. It will be interesting to see the results of an ongoing trial using the quadriceps tendon for ACL reconstruction, since the quadriceps tendon is biomechanically stiffer than the hamstring tendon.
It is important to mention that an anterolateral stabilization should not be a substitute for nonanatomic ACL tunnel placement. A high femoral ACL tunnel, like created in the past using a transtibial approach, may lead to sufficient anterior tibial translation stability, but not to sufficient rotatory stability of the knee.
In summary, ACL surgery has become increasingly more individualized, including different ACL graft options like the quadriceps, hamstring, patella, or peroneus longus tendons, osteotomies to address bony malalignment, specific techniques to address meniscus injuries like meniscus root or ramp repair, and the stabilization of the periphery including antero-lateral stabilization techniques.
A proficient sports surgeon aiming for optimized patient outcomes must include all these techniques in his or her “construction kit.” ACL surgery has improved tremendously during the last decade, but it has also become much more complex.
In the past, teaching younger surgeons the skills required to perform complex operations was mainly performed in the operating room by the senior surgeon assisting with parts of the operation. However, it is beneficial to increase the skill level of younger surgeons before entering the operation room to perform complex individualized surgeries. Like a pilot proving his or her skills in a flight simulator, a surgeon should perform well in a simulated setting before treating real patients. For this reason, cadaver courses to practice such techniques in a calm and professional atmosphere are crucial. AO Sports creates such a learning experience, and all ambitious sports surgeons can profit from experienced instructors and incredible course formats. I highly recommend the AO Sports courses to learn and improve techniques in individualized ACL reconstruction.
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References:
- Ayeni OR, Chahal M, Tran MN, Sprague S. Pivot shift as an outcome measure for ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2012;20(4):767-77.
- Sonnery-Cottet B, Thaunat M, Freychet B, et al. Outcome of a Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Technique With a Minimum 2-Year Follow-up. Am J Sports Med. 2015;43(7):1598-605.
- Herbst E, Albers M, Burnham JM, et al. The anterolateral complex of the knee: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2017;25(4):1009-14.
- Getgood A, Brown C, Lording T, et al. The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):166-76.
- Guenther D, Sexton SL, Bell KM, et al. Non-uniform strain distribution in anterolateral capsule of knee: Implications for surgical repair. J Orthop Res. 2019;37(5):1025-32.
- Guenther D, Irarrazaval S, Bell KM, et al. The Role of Extra-Articular Tenodesis in Combined ACL and Anterolateral Capsular Injury. J Bone Joint Surg Am. 2017;99(19):1654-60.
- Kittl C, Halewood C, Stephen JM, et al. Length change patterns in the lateral extra-articular structures of the knee and related reconstructions. Am J Sports Med. 2015;43(2):354-62.
- Rahnemai-Azar AA, Miller RM, Guenther D, et al. Structural Properties of the Anterolateral Capsule and Iliotibial Band of the Knee. Am J Sports Med. 2016;44(4):892-7.
- Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020;48(2):285-97.
- Musahl V, Rahnemai-Azar AA, Costello J, et al. The Influence of Meniscal and Anterolateral Capsular Injury on Knee Laxity in Patients With Anterior Cruciate Ligament Injuries. Am J Sports Med. 2016;44(12):3126-31.
- Musahl V, Ayeni OR, Citak M, et al. The influence of bony morphology on the magnitude of the pivot shift. Knee Surg Sports Traumatol Arthrosc. 2010;18(9):1232-8.
- Rahnemai-Azar AA, Abebe ES, Johnson P, et al. Increased lateral tibial slope predicts high-grade rotatory knee laxity pre-operatively in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2017;25(4):1170-6.
- Pfeiffer TR, Burnham JM, Hughes JD, et al. An Increased Lateral Femoral Condyle Ratio Is a Risk Factor for Anterior Cruciate Ligament Injury. J Bone Joint Surg Am. 2018;100(10):857-64.
- van de Pol GJ, Arnold MP, Verdonschot N, et al. Varus alignment leads to increased forces in the anterior cruciate ligament. Am J Sports Med. 2009;37(3):481-7.
- Magnussen RA, Reinke EK, Huston LJ, et al Factors Associated With High-Grade Lachman, Pivot Shift, and Anterior Drawer at the Time of Anterior Cruciate Ligament Reconstruction. Arthroscopy. 2016;32(6):1080-5.
- Guenther D, Rahnemai-Azar AA, Bell KM, et al. The Anterolateral Capsule of the Knee Behaves Like a Sheet of Fibrous Tissue. Am J Sports Med. 2017;45(4):849-55.
- Lemaire M, Combelles F. [Plastic repair with fascia lata for old tears of the anterior cruciate ligament (author's transl)]. Rev Chir Orthop Reparatrice Appar Mot. 1980;66(8):523-5.
- Claes S, Vereecke E, Maes M, et al. Anatomy of the anterolateral ligament of the knee. J Anat. 2013;223(4):321-8.
- Amirault JD, Cameron JC, MacIntosh DL, et al. Chronic anterior cruciate ligament deficiency. Long-term results of MacIntosh's lateral substitution reconstruction. J Bone Joint Surg Br. 1988;70(4):622-4.