Summary
Description and evaluation of the impact of a score indicating lateral extra-articular procedures in ACL reconstruction.
Abstract
Background
The addition of a lateral extra-articular procedure (LEAP) to anterior cruciate ligament reconstruction (ACLR) has been associated with a lower risk of graft failure. However, there is currently no validated decision-making tool to guide surgeons on when to perform LEAP alongside ACLR.
Hypothesis/purpose: The purpose of this study was to develop and validate a clinically applicable predictive score to identify patients at higher risk of ACL graft rupture who would gain the greatest benefit from adding LEAP to their ACLR.
Study design: Retrospective cohort study, level of evidence 3.
Methods
This retrospective cohort study analyzed patients who underwent primary ACLR, with or without LEAP, between 2018 and 2022 at a specialized sports surgery center. The primary outcome of the study was the rate of re-rupture post ACLR. Through multivariate logistic regression, key risk factors associated with graft rupture were identified. A predictive scoring system was developed using odds ratios of these factors. The predictive performance of the score was assessed using receiver operating characteristic (ROC) analysis, with sensitivity and specificity determined for optimal cut-off values. Within the group identified as high-risk using this cut-off, the clinical utility of LEAP was assessed by calculating the absolute risk reduction (ARR) and the number needed to treat (NNT).
Results
A total of 2,782 patients were analyzed (64% male, mean age 26.8 ± 8.4 years). Multivariate analysis identified younger age at surgery (<20 years, OR = 2.48 [1.57–3.92]), competitive-level sports participation (OR = 1.59 [1.08–2.33]), and high preoperative Tegner activity score (=7, OR = 1.77 [1.02–3.06]) as significant predictors of graft rupture. The non-inclusion of LEAP significantly increased the risk of graft failure (OR = 2.12 [1.48–3.03], p < 0.0001). A clinical predictive scoring system was created with a cut-off value =4 points to identify patients at increased risk of rupture (AUC = 0.6537; sensitivity = 82.8%, specificity = 39.5%). In patients scoring =4 points, performing LEAP reduced the rupture rate from 10.1% to 6.0%, resulting in an ARR of 4.17% and an NNT of 24 patients to prevent one additional graft rupture.
Conclusion
This study presents a novel decision-making score to guide the indication for LEAP in ACLR. Based solely on simple demographic and clinical variables (age, sports level, and preoperative activity score), the tool can be readily applied by general practitioners, orthopedic surgeons, sports physicians, and sports surgeons.