Summary
This single-surgeon retrospective cohort series is the first to compare the clinical results of two different lateral extra-articular procedure (LEAP) techniques, demonstrating that both an anatomic ALL-reconstruction utilizing a free gracilis graft as well as a mini-ITB-tenodesis produce equally positive clinical outcomes in the case of primary ACL reconstruction.
Abstract
Background
The anterolateral ligament has been shown to perform as a secondary restraint in the ACL-deficient knee. Additional lateral extra-articular procedures (LEAP) such as anatomical ALL-reconstruction (ALL-R) and ITB-tenodesis (ITB-T) have recently been demonstrated to lower ACL graft rupture rates by almost 50%. Nonetheless, comparative studies focusing on clinical outcomes between these different reported techniques are limited. This study compared two ACL reconstruction patient cohorts treated by either anatomic ALL reconstruction (aALL-R) or mini-ITB tenodesis (mITB-T), with the hypothesis that they would perform equally effective.
Methods
This single-surgeon retrospective cohort study study examined 2 groups of patients undergoing ACL reconstruction and a concomitant LEAP procedure. Inclusion criteria were patients aged 16-50 years with confirmed primary ACL ruptures plus a high-risk for ACL graft rupture given their age, sex, type of sport, etc. In the a-ALL-R group, anatomical ALL-reconstruction was performed using a free autologous gracilis graft, fixed at the reported anatomical origin and insertion site of the ALL on both femur and tibia respectively. Patients in the ITB-T group were treated by a technique utilizing a strip of the ITB left attached at Gerdy’s tubercle, subsequently tunneled under the LCL and fixated with an anchor at the femoral origin of the ALL. Clinical outcomes were measured using IKDC score, Lysholm Knee Score, Tegner score, and NRS pain scale at baseline, 12 months, and 24 months. Complications including graft re-rupture, as well as re-operation rates were recorded. Statistics involved a linear mixed-effect model for repeated measures, with non-inferiority being assessed based on 95%- confidence intervals with significance set at a = 0.05.
Results
A total of 108 patients were included, of whom 66 underwent aALL-R and 42 received the ITB-T. No statistically significant differences were observed in IKDC, Lysholm, Tegner, and NRS scores at any of the time points between the two groups. At the 24-month follow-up, the aALL-R group experienced 3 graft ruptures (4,5%), while for the ITB-T group, 2 re-ruptures (4,7%) occurred, with no statistical difference between both groups. Non-inferiority at 95% confidence interval was demonstrated for IKDC (µ= 2.64, CI: -0.83; 7.98), NRSact (µ = 2.29, CI: -8.89 ; 6.12), NRSrest (µ= 2.64, CI: -2.25; 8.82) and Lysholm (µ= 1, CI: -4.49; 6.51).
Conclusion
This study found no significant differences or inferiority between the aALL-R group and the mITB-T group regarding functional outcomes, complications, revision rates, and failure rates. These results demonstrate that both an anatomic ALL-reconstruction utilizing a free gracilis graft as well as a mini-ITB-tenodesis generate equally positive clinical outcomes as so-called lateral extra-articular procedures (LEAPs) in the case of primary ACL reconstruction.