Restoring rotational stability following anterior cruciate ligament surgery: single-bundle reconstruction combined with lateral extra-articular tenodesis versus double-bundle reconstruction
Publication: Journal of Comparative Effectiveness Research
Abstract
Aim: To compare the outcomes of patients who underwent single-bundle (SB) anterior cruciate ligament (ACL) reconstruction combined with lateral extra-articular tenodesis (LET) with the outcomes of those who underwent double-bundle (DB) ACL reconstruction. Methods: 16 patients who underwent ACL hamstring SB reconstruction combined with LET (Coker–Arnold modification of the MacIntosh procedure) were retrospectively compared with 20 patients who underwent hamstring DB reconstruction at an average follow-up of 6.2 years. Assessment included Lysholm and International Knee Documentation Committee scores, objective examination and instrumented laxity test. Results: No complications were reported. Mean Lysholm and International Knee Documentation Committee scores significantly increased from preoperatively (p < 0.05). No differences were reported between the two groups with regard to point scales, anterior tibial translation and pivot-shift test (p = not significant). Conclusions: Both DB ACL reconstruction and combined LET and autologous hamstring SB ACL reconstruction are effective at providing satisfying functional outcomes and restoring rotational stability.
Traditional single-bundle (SB) anterior cruciate ligament (ACL) reconstruction has been shown to produce good to excellent results in most cases [1]. However, many studies have outlined poor rates in terms of return to sport and a significant percentage of re-tear, especially in young patients practicing high-risk sports [2–4]. Furthermore, although adequate anteroposterior stability can be achieved with this technique, studies have shown that many patients continue to exhibit persistent anterolateral rotatory laxity following ACL reconstruction, with a residual pivot-shift rate ranging from 10% to 20% [5,6]. Therefore, in an attempt to increase return to sport rate, improve rotational control and reduce the incidence of re-tear, other surgical strategies have been proposed as viable options to address these issues.
In the past years, double-bundle (DB) ACL reconstruction, which aims to reconstruct both the anteromedial (AM) and posterolateral (PL) bundles of the ACL, has been proposed to better restore the anatomy and biomechanics of the native ligament, improve rotational control and ultimately reduce failure compared with SB reconstruction. However, outcomes between the two procedures are controversial, and there is still a lack of objective data documenting a difference between the two reconstructive methods [7–12]. In fact, although reduced occurrence of rotational instability and tunnel widening has been reported compared with SB reconstruction [7–10], clinical results of DB reconstruction did not show any significant improvement over the conventional procedure, and the disadvantages of increased technical complexity, surgical time and cost may not be justified [11,12].
Recently, studies on the role of the knee anterolateral complex of the knee have led to the development of new reconstruction techniques of the anterolateral ligament (ALL) and a resurgence of interest in lateral extra-articular tenodesis (LET) procedures, which are currently recommended as adjuvant procedures to existing ACL reconstructive strategies. Previous studies demonstrated that both additional ALL reconstruction and LET improve patient-related outcomes and reduce the risks of graft failures, especially in high-demanding patients or to improve revision surgery outcomes [13–23].
The aim of this study is to compare the clinical outcome of patients who underwent DB ACL reconstruction with that of those who underwent SB ACL reconstruction combined with LET, with regard to patient satisfaction, return to preinjury activity level and functional outcomes, specifically investigating rotational knee stability. The authors hypothesized that the rotational stability acquired following DB ACL reconstruction was comparable to the one acquired following ACL SB reconstruction combined with LET in the setting of primary ACL surgery.
Materials & methods
Patient recruitment
This retrospective comparative case series examined 36 patients who underwent ACL reconstruction surgery between 2011 and 2018. Average follow-up was 6.2 years (range: 2–9 years). All were competitive or recreational athletes. All patients met the following inclusion criteria: aged 18–45 years; primary ACL reconstruction; absence of concomitant cartilage, ligament or meniscal pathology requiring surgery; and pivot-shift test greater than or equal to grade 2. All the operations were performed by the same well-experienced senior surgeon. 16 patients who underwent ACL SB reconstruction combined with LET were matched for age and BMI to a control group of 20 consecutive patients who underwent autologous hamstring DB reconstruction taken from the senior author's database. The surgical technique was chosen depending on the surgeon's preference. Table 1 shows complete demographic and anthropometric data. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical approval was not required for the retrospective follow-up of this cohort, as the patient-reported outcomes used are part of routine follow-up at the authors' institution (observational analytic study with a retrospective design on well-established surgical procedures). Informed consent was obtained from all individual participants included in the study.
| DB ACL reconstruction | SB ACL reconstruction combined with LET | p-value | |
|---|---|---|---|
| n of patients | 20 | 16 | |
| Gender Male Female | 11 9 | 11 5 | |
| BMI (SD) | 23.5 (1.9) | 22.9 (1.7) | ns |
| Time from injury to surgery (SD) (months) | 6.5 (0.9) | 5.8 (1.1) | ns |
| Age at surgery (SD) (years) | 28.3 (9.2) | 26.8 (8.7) | ns |
ACL: Anterior cruciate ligament; DB: Double-bundle; LET: Lateral extra-articular tenodesis; ns: Not significant; SB: Single-bundle; SD: Standard deviation.
Surgical technique of autologous hamstring DB reconstruction
Patients in this group underwent an arthroscopically assisted reconstruction using harvested doubled semitendinosus tendon for the AM bundle and doubled gracilis tendon for the PL bundle. A 50° guide (Acufex; Smith & Nephew, MD, USA) placed in the native PL bundle footprint was used to drill the tibial tunnel for the PL, while the AM tunnel was drilled using a 55° angle, leaving a bone bridge of at least 5 mm between the guidewires. The femoral half-tunnels were drilled using either a transtibial or an anteromedial technique. In case satisfactory graft positioning could not be achieved with the transtibial approach, an anteromedial technique was preferred. Then, after passing the grafts through the tibial tunnels, fixation was achieved using a supension fixation device (Tightrope; Arthrex, FL, USA). Two bioabsorbable interference screws (Arthrex), each 1 mm larger than the graft, fixed the graft distally by putting the knee fully extended for the PL bundle and flexed at 20° for the AM bundle under maximal manual tension.
Surgical technique of autologous hamstring SB reconstruction combined with LET
SB ACL reconstruction was performed with a traditional technique, using a transtibial or an anteromedial approach and drilling the tunnels similarly to way described for the AM bundle in the DB technique. In addition to ACL reconstruction, a Coker–Arnold modification of the MacIntosh procedure was performed: a strip of the central portion of the iliotibial band was detached proximally, looped deeply under the lateral collateral ligament (LCL) and sutured distally on itself while keeping the knee mid-flexed in a neutral position.
Rehabilitation protocol
For patients who underwent DB ACL reconstruction, a brace-free routinary rehabilitation protocol was adopted, while a knee brace for 7 days was used during walking for pain control for patients who underwent SB reconstruction combined with LET. Walking with crutches with partial weight bearing was allowed for the first 4 weeks, together with swelling control, regaining of complete knee range of motion quadriceps activation and muscle strength recovery; after this period, proprioception exercises were started. Swimming and indoor cycling were allowed after 12 weeks, jogging after 5 months. Return to sport was allowed at 6 months for non-pivoting sports, at 7 months for pivoting sports.
Follow-up assessment
Patients were evaluated preoperatively and after an average follow-up of 6.2 years (range: 2–9 years). Assessment included Lysholm score [24], International Knee Documentation Committee (IKDC) score [25], objective examination including manual laxity testing (anterior drawer sign [26], Lachman test [27], pivot-shift test [28]) and instrumented laxity test with KT-1000 arthrometer (MEDmetric Corporation, CA, USA) under a 134-N anterior tibial load [29].
Statistical analysis
Data extracted were analyzed using the program IBM SPSS Statistics for Windows©, version 21.0 (IBM Corp, NY, USA). Wilcoxon signed-rank test for related samples was utilized to compare the preoperative and follow-up status, while the Mann–Whitney test for independent samples was used to compare the differences between the two groups. Differences with p < 0.05 were considered statistically significant.
Results
No major complications or graft failures were reported at follow-up. The mean overall Lysholm score increased from a preoperative mean of 64.5 (standard deviation [SD]: 7.9) to 86.1 (SD: 8.5), showing a statistically significant difference (p < 0.001). IKDC score improved from 43.2 (SD: 8.8) to 83.5 (SD: 8.6) (p < 0.001). The outcomes of clinical assessment regarding the Lachman test and pivot-shift sign were clearly improved when compared with preoperative status (p < 0.001). A detailed overview of the results of the clinical assessment of the two groups is shown in Tables 2 & 3.
| Preoperative | Postoperative | p-value | |
|---|---|---|---|
| Lysholm score (mean, SD) | 65.2 (SD: 8.1) | 85.4 (SD: 7.8) | p < 0.001 |
| IKDC score (mean, SD) | 44.8 (SD: 9.6) | 82.2 (SD: 8.6) | p < 0.001 |
| Lachman sign (positivity) | 20/20 (100%) | 1/20 (5%) | p < 0.001 |
| Pivot-shift sign (positivity) | 20/20 (100%) | 2/20 (10%) | p < 0.001 |
| Mean side-to-side anterior laxity in mm (mean, SD) | 6.2 (SD: 1.1) | 1.8 (SD: 0.9) | p < 0.001 |
IKDC: International Knee Documentation Committee; SD: Standard deviation.
| Preoperative | Postoperative | p-value | |
|---|---|---|---|
| Lysholm score (mean, SD) | 63.8 (SD: 7.7) | 86.9 (SD: 9.1) | p < 0.001 |
| IKDC subjective score (mean, SD) | 41.7 (SD: 8.2) | 84.8 (SD: 8.5) | p < 0.001 |
| Lachman sign (positivity) | 16/16 (100%) | 1/16 (6%) | p < 0.001 |
| Pivot-shift sign (positivity) | 16/16 (100%) | 1/16 (6%) | p < 0.001 |
| Mean side-to-side anterior laxity in mm (mean, SD) | 6.9 (SD: 1.2) | 1.6 (SD: 0.6) | p < 0.001 |
IKDC: International Knee Documentation Committee; SD: Standard deviation.
The differences in the outcomes between the two groups are reported in Table 4. No statistically significant differences were reported between the two groups with regard to point scales (p = not significant [ns]) and anterior tibial translation according to the Lachman test and as measured with KT-1000 arthrometer (p = ns). With regard to rotational instability, the results of the pivot-shift test were slightly in favor of patients who had undergone LET, with a lower percentage of subjects (6%) positive to the pivot-shift test postoperatively compared with the DB group (10%); however, the result was not statistically significant. No subjective or objective loss of motion was reported, neither postoperative stiffness nor donor-site morbidity.
| DB ACL reconstruction | SB ACL reconstruction combined with LET | p-value | |
|---|---|---|---|
| Lysholm score (mean, SD) | 85.4 (SD: 7.8) | 86.9 (SD: 9.1) | ns |
| IKDC subjective score (mean, SD) | 82.2 (SD: 8.6) | 84.8 (SD: 8.5) | ns |
| Lachman sign (positivity) | 1/20 (5%) | 1/16 (6%) | ns |
| Pivot-shift sign (positivity) | 2/20 (10%) | 1/16 (6%) | ns |
| Mean side-to-side anterior laxity in mm (mean, SD) | 1.8 (SD: 0.9) | 1.6 (SD: 0.6) | ns |
ACL: Anterior cruciate ligament; DB: Double-bundle; IKDC: International Knee Documentation Committee; LET: Lateral extra-articular tenodesis; ns: Not significant; SB: Single-bundle; SD: Standard deviation.
Discussion
The findings demonstrate that both DB ACL reconstruction and combined LET and autologous contralateral hamstring SB ACL reconstruction are effective surgical methods, providing satisfying functional outcomes and conferring additional rotational stability control in selected patients in the setting of primary ACL reconstruction.
Residual rotational laxity has been reported in a significant percentage of patients following SB ACL reconstruction. To overcome this problem, DB reconstruction and more recently ALL reconstructive techniques, as well as LET procedures, have been proposed in order to improve knee stability, especially with regard to rotatory loads [7–19]. Their influence on rotational stability of the tibia is supposed to represent a protective element against the occurrence of new knee injuries and ACL rerupture, thus allowing a safer early rehabilitation phase and a more predictable return to sport [20]. Long-term follow-up studies have shown that the addition of a LET to intra-articular ACL reconstruction does not increase the rate of osteoarthritis in the presence of intact menisci [30].
In this case series after an average time of 6 years from surgery, overall mean Lysholm score improved to 86.1, while the IKDC score was 83.5. None of the patients reported knee instability. Subjective results are in line with those reported by other authors [13–18]. Dejour et al. reported increased stability in patients following SB patellar tendon ACL reconstruction combined with LET compared with SB patellar tendon ACL reconstruction and DB hamstring reconstruction as measured by Telos stress radiography at a mean follow-up of 25 months, and they suggested its use in patients involved in highly demanding sports [31]. The present authors reported satisfying outcomes in a cohort of active patients who had a preoperative grade 2 or 3+ pivot shift, supporting the concept of adding either a PL bundle or a LET as an augmentation in selected patients requiring increased stability.
In a comparative study on 35 patients with an isolated ACL injury (average age: 34.0 ± 8.7 years), Zaffagnini et al. reported superior results in terms of constraining the displacement of the lateral tibial compartment in patients who underwent LET, while DB reconstruction was more effective in controlling the pivot-shift stress test [32]. Grassi et al. reported improvement in internal-external tibial rotation following SB ACL reconstruction with associated LET compared with isolated SB or DB reconstruction [33]. Similarly, Branch et al. observed a reduction in internal tibial rotation in 18 patients aged 26–48 years who underwent SB ACL reconstruction with associated LET compared with intra-articular reconstruction alone, 9 years after surgery [34]. Ahn et al. retrospectively compared the results of 48 patients who underwent DB ACL reconstruction and 47 patients who underwent SB ACL reconstruction combined with LET after an average follow-up of 49.7 months. The second group reported significantly better results in pivot-shift grade, although no statistically significant difference could be seen regarding anterior tibial translation, subjective functional IKDC score or revision rate between the two groups [35].
With regard to subjective outcomes, in the authors' case series the two procedures did not show statistically significant differences. Anterior stability evaluated through manual test and with the KT-1000 arthrometer did not demonstrate a significant difference between the two groups. The results of the pivot-shift test were slightly in favor of LET, with a lower percentage of subjects positive to the pivot-shift test postoperatively compared with the DB group. However, the limited study population may not have allowed for the detection of small differences between groups.
The DB procedure, by anatomically reconstructing both the AM and the PL bundles of the ACL, is advocated to mimic native ACL configuration more closely and therefore to restore knee biomechanics more accurately. However, limited evidence exists that DB ACL reconstruction may lead to improved clinical outcomes; in addition, its technical difficulty and increased costs led to its falling out of favor [11,12]. On the other hand, although LET may attract surgeons for its cost–effectiveness and its relatively easy reproducibility, it carries the disadvantages of being an open and non-anatomical procedure with risks of postoperative pain and increased stiffness [36].
Several clinical studies showed the benefits of ALL reconstruction. Laboudie et al. reported reduced failure rates and less secondary meniscal lesions in young athletes who underwent combined ALL and ACL reconstruction compared with those who underwent ACL reconstruction alone [37]. Helito et al. compared the results of combined ACL and ALL reconstruction with hamstring grafts between acute and chronic cases and reported no differences in terms of knee stability, functional scores and failure rates after a minimum follow-up of 2 years [38]. Similarly, according to Rayes et al., adding ALL reconstruction in the setting of revision ACL surgery was safe and effective [39].
Theoretically, it would appear reasonable that the most reliable reconstructive procedure able to restore knee anatomy and biomechanics as closely as possible to normal would be to address each injured structure, as demonstrated by a recent cadaveric study by Yasuma et al., in which concomitant ALL and DB ACL reconstruction appeared to better control rotational instability [40]. However, before such an approach can be widely adopted in clinical practice, clinical trials are needed to substantiate if additional surgical time, morbidity and costs are justified by improvement in patient outcomes.
The limitations of the present study include its retrospective nature, the relatively small sample size and the fact that no power analysis was performed. A greater number of patients in each group could have enhanced the power of the results obtained. The findings suggest that these techniques have potential for improving rotational stability to add potential benefit to young, active patients involved in highly demanding sports. Studies with larger cohorts and longer-term outcomes as well as economic analyses are needed to better investigate the differences in the two surgical techniques, thus guiding surgeons and healthcare systems to the most appropriate treatment strategy.
Conclusion
Both DB ACL reconstruction and combined LET and autologous hamstring SB ACL reconstruction are effective surgical methods providing satisfying functional outcomes and restoring rotational stability control in selected patients in the setting of primary ACL reconstruction. Studies with larger cohorts are needed; given the small sample size, the present research might be underpowered to answer the study question.
•
Residual rotational laxity has been reported in a significant percentage of patients following single-bundle (SB) anterior cruciate ligament (ACL) reconstruction.
•
To overcome this problem, double-bundle (DB) reconstruction and more recently lateral extra-articular tenodesis (LET) have been proposed in order to improve knee stability, especially with regard to rotatory loads.
•
16 patients who underwent SB ACL reconstruction combined with LET were compared with 20 patients who underwent hamstring DB reconstruction at an average follow-up of 6.2 years (range: 2–9 years).
•
Assessments included Lysholm score, International Knee Documentation Committee score, manual laxity testing (Lachman test, pivot-shift test) and instrumented laxity test with KT-1000 arthrometer.
•
No major complications were reported. The mean overall Lysholm score and International Knee Documentation Committee score increased from preoperatively, showing a statistically significant difference (p < 0.05).
•
The outcomes of clinical assessment regarding the Lachman test and pivot-shift sign were clearly improved when compared with preoperative status (p < 0.05).
•
With regard to rotational instability, the results of the pivot-shift test were slightly in favor of patients who underwent LET, with a lower percentage of subjects (6%) positive to the pivot-shift test postoperatively compared with the DB group (10%); however, the result was not statistically significant.
•
The findings demonstrate that both DB ACL reconstruction and combined LET and autologous hamstring SB ACL reconstruction are effective surgical methods providing satisfying functional outcomes and conferring additional rotational stability control in selected patients in the setting of primary ACL reconstruction.
•
These techniques could improve rotational stability to add potential benefit to young, active patients involved in highly demanding sports.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.
No writing assistance was utilized in the production of this manuscript.
Ethical conduct of research
The authors state that they have obtained appropriate institutional review board approval or have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.
References
Papers of special note have been highlighted as: • of interest; •• of considerable interest
1.
Volpi P, Cervellin M, Denti M et al. ACL reconstruction in sports active people: transtibial DB technique with ST/G vs. transtibial SB technique with BPTB: preliminary results. Injury 41(11), 1168–1171 (2010).
2.
Webster KE, Feller J. Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am. J. Sports Med. 44(11), 2827–2832 (2016).
3.
Legnani C, Peretti GM, Del Re M, Borgo E, Ventura A. Return to sports and re-rupture rate following anterior cruciate ligament reconstruction in amateur sportsmen: long-term outcomes. J. Sports Med. Phys. Fitness 59(11), 1902–1907 (2019).
4.
Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br. J. Sports Med. 48(21), 1543–1552 (2014).
5.
Björnsson H, Samuelsson K, Sundemo D et al. A randomized controlled trial with mean 16-year follow-up comparing hamstring and patellar tendon autografts in anterior cruciate ligament reconstruction. Am. J. Sports Med. 44(9), 2304–2313 (2016).
6.
Karikis I, Desai N, Sernert N, Rostgard-Christensen L, Kartus J. Comparison ofanatomic double- and single-bundle techniques for anterior cruciate ligament reconstruction using hamstring tendon autografts: a prospective randomized study with 5-year clinical and radiographic follow-up. Am. J. Sports Med. 44(5), 1225–1236 (2016).
7.
Ventura A, Iori S, Legnani C, Terzaghi C, Borgo E, Albisetti W. Single bundle vs. double bundle ACL reconstruction: assessment with vertical jump test. Arthroscopy 29(7), 1201–1210 (2013).
8.
Volpi P, Quaglia A, Carimati G, Galli M, Papalia R, Petrillo S. Double bundle anterior cruciate ligament reconstruction: failure rate and patients-reported outcomes at 4–11 years of follow up. J. Orthop. 16(3), 224–229 (2019).
9.
Ventura A, Legnani C, Terzaghi C, Borgo E. Single- and double-bundle anterior cruciate ligament reconstruction in patients aged over 50 years. Arthroscopy 28(11), 1702–1709 (2012).
10.
Aga C, Wilson KJ, Johansen S, Dornan G, La Prade RF, Engebretsen L. Tunnel widening in single- versus double-bundle anterior cruciate ligament reconstructed knees. Knee Surg. Sports Traumatol. Arthrosc. 25(4), 1316–1327 (2017).
11.
Fernandes TL, Moreira HH, Andrade R et al. Clinical outcome evaluation of anatomic anterior cruciate ligament reconstruction with tunnel positioning using gold standard techniques: a systematic review and meta-analysis. Orthop. J. Sports Med. 9(6), 23259671211013327 (2021).
12.
Matar HE, Platt SR, Bloch BV, James PJ, Cameron HU. A systematic review of randomized controlled trials in anterior cruciate ligament reconstruction: standard techniques are comparable (299 trials with 25,816 patients). Arthrosc. Sports Med. Rehabil. 3(4), e1211–e1226 (2021).
13.
Lagae KC, Robberecht J, Athwal KK, Verdonk PCM, Amis AA. ACL reconstruction combined with lateral monoloop tenodesis can restore intact knee laxity. Knee Surg. Sports Traumatol. Arthrosc. 28(4), 1159–1168 (2020).
14.
Legnani C, Peretti GM, Boisio F, Borgo E, Ventura A. Functional outcomes following contralateral hamstring tendon autografts with extra-articular tenodesis for ACL revision surgery. J. Sports Med. Phys. Fitness 59(11), 1897–1901 (2019).
15.
Ntagiopoulos P, Dejour D. Extra-articular plasty for revision anterior cruciate ligament reconstruction. Clin. Sports Med. 37(1), 115–125 (2018).
16.
Getgood A, Bryant D, Firth A. Stability Group. The Stability study: a protocol for a multicenter randomized clinical trial comparing anterior cruciate ligament reconstruction with and without lateral extra-articular tenodesis in individuals who are at high risk of graft failure. BMC Musculoskelet. Disord. 20(1), 216 (2019).
17.
Rowan FE, Huq SS, Haddad FS. Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up. Arch. Orthop. Trauma Surg. 139(10), 1425–1433 (2019).
18.
Batailler C, Lustig S, Reynaud O, Neyret P, Servien E. Complications and revision surgeries in two extra-articular tenodesis techniques associated to anterior cruciate ligament reconstruction. A case-control study. Orthop. Traumatol. Surg. Res. 104(2), 197–201 (2018).
19.
Ventura A, Legnani C, Boisio F, Borgo E, Peretti GM. The association of extra-articular tenodesis restores rotational stability more effectively compared to contralateral hamstring tendon autografts ACL reconstruction alone in patients undergoing ACL revision surgery. Orthop. Traumatol. Surg. Res. 107(2), 102739 (2021).
20.
Ra HJ, Kim JH, Lee DH. Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: systematic review and meta-analysis. Arch. Orthop. Trauma Surg. 140(7), 923–931 (2020).
•• Meta-analysis showing non-clinically significant differences in rotational stability and patient-reported outcomes between lateral extra-articular tenodesis and anterolateral ligament reconstruction in combination with single-bundle anterior cruciate ligament reconstruction.
21.
Sonnery-Cottet B, Daggett M, Helito CP, Fayard JM, Thaunat M. Combined anterior cruciate ligament and anterolateral ligament reconstruction. Arthrosc. Tech. 5(6), e1253–e1259 (2016).
22.
Ariel de Lima D, de Lima LL, de Souza NGR et al. Clinical outcomes of combined anterior cruciate ligament and anterolateral ligament reconstruction: a systematic review and meta-analysis. Knee Surg. Relat. Res. 33(1), 33 (2021).
23.
Hurley ET, Fried JW, Kingery MT, Strauss EJ, Alaia MJ. Anterolateral ligament reconstruction improves knee stability alongside anterior cruciate ligament reconstruction. Knee Surg. Sports Traumatol. Arthrosc. 29(3), 764–771 (2021).
24.
Cerciello S, Corona K, Morris BJ et al. Cross-cultural adaptation and validation of the Italian versions of the Kujala, Larsen, Lysholm and Fulkerson scores in patients with patellofemoral disorders. J. Orthop. Traumatol. 19(1), 18 (2018).
25.
Padua R, Bondi R, Ceccarelli E et al. Italian version of the International Knee Documentation Committee Subjective Knee Form: cross-cultural adaptation and validation. Arthroscopy 20(8), 819–823 (2004).
26.
Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part I. History, physical examination, radiographs, and laboratory tests. Am. Fam. Physician 68, 907–912 (2003).
27.
Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J. Orthop. Sports Phys. Ther. 36, 267–288 (2006).
28.
Galway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin. Orthop. Relat. Res. 147, 45–50 (1980).
29.
Daniel DM, Stone ML, Sachs R, Malcom L. Instrumented measurement of anterior knee laxity in patients with acute anterior cruciate ligament disruption. Am. J. Sports Med. 13, 401–407 (1985).
30.
Devitt BM, Bouguennec N, Barfod KW, Porter T, Webster KE, Feller JA. Combined anterior cruciate ligament reconstruction and lateral extra-articular tenodesis does not result in an increased rate of osteoarthritis: a systematic review and best evidence synthesis. Knee Surg. Sports Traumatol. Arthrosc. 25(4), 1149–1160 (2017).
31.
Dejour D, Vanconcelos W, Bonin N, Saggin PR. Comparative study between mono-bundle bone-patellar tendon-bone, double-bundle hamstring and mono-bundle bone-patellar tendon-bone combined with a modified Lemaire extra-articular procedure in anterior cruciate ligament reconstruction. Int. Orthop. 37(2), 193–199 (2013).
32.
Zaffagnini S, Signorelli C, Lopomo N et al. Anatomic double-bundle and over-the-top single-bundle with additional extra-articular tenodesis: an in vivo quantitative assessment of knee laxity in two different ACL reconstructions. Knee Surg. Sports Traumatol. Arthrosc. 20(1), 153–159 (2012).
• Comparative study reporting that lateral extra-articular tenodesis played an important role in better constraining the displacement of the lateral tibial compartment compared with anatomic double-bundle reconstruction.
33.
Grassi A, Signorelli C, Lucidi GA et al. ACL reconstruction with lateral plasty reduces translational and rotatory laxity compared to anatomical single bundle and non-anatomical double bundle surgery: an in vivo kinematic evaluation with navigation system. Clin. Biomech. (Bristol, Avon) 72, 211 (2020).
• Randomized clinical trial reporting that single-bundle reconstruction combined with lateral extra-articular tenodesis showed significantly superior results in terms of anteroposterior and internal-external laxity reduction at time-zero after anterior cruciate ligament reconstruction compared with single-bundle and double-bundle procedures.
34.
Branch T, Lavoie F, Guier C et al. Single-bundle ACL reconstruction with and without extra-articular reconstruction: evaluation with robotic lower leg rotation testing and patient satisfaction scores. Knee Surg. Sports Traumatol. Arthrosc. 23(10), 2882–2891 (2015).
35.
Ahn JH, Kim J, Mun JW. A retrospective comparison of single-bundle anterior cruciate ligament reconstruction with lateral extra-articular tenodesis with double-bundle anterior cruciate ligament reconstruction. Arthroscopy 37(3), 976–984 (2021).
•• Retrospective comparative study showing significantly better results in pivot-shift grade in patients who underwent single-bundle anterior cruciate ligament reconstruction combined with lateral extra-articular tenodesis compared with patients who underwent double-bundle anterior cruciate ligament reconstruction.
36.
Lording T, Dejour D, Neyret P, Getgood A. Extra-articular plasty with ACL reconstruction: long-term results of associated procedure. In: Controversies in the Technical Aspects of ACL Reconstruction: An Evidence-Based Medicine Approach. Nakamura N, Zaffagnini S, Marx RG, Musahl V (Eds). Springer Berlin Heidelberg, Berlin, Heidelberg, 355–370 (2017).
37.
Laboudie P, Douiri A, Bouguennec N, Biset A, Graveleau N. Combined ACL and ALL reconstruction reduces the rate of reoperation for graft failure or secondary meniscal lesions in young athletes. Knee Surg. Sports Traumatol. Arthrosc. (2022) (Epub ahead of print).
38.
Helito CP, Sobrado MF, Giglio PN et al. Surgical timing does not interfere on clinical outcomes in combined reconstruction of the anterior cruciate ligament and anterolateral ligament: a comparative study with minimum 2-year follow-up. Arthroscopy 37(6), 1909–1917 (2021).
39.
Rayes J, Ouanezar H, Haidar IM et al. Revision anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft combined with modified Lemaire technique versus hamstring graft combined with anterolateral ligament reconstruction: a clinical comparative matched study with a mean follow-up of 5 years from the SANTI study group. Am. J. Sports Med. 50(2), 395–403 (2022).
40.
Yasuma S, Nozaki M, Murase A et al. Anterolateral ligament reconstruction as an augmented procedure for double-bundle anterior cruciate ligament reconstruction restores rotational stability: quantitative evaluation of the pivot shift test using an inertial sensor. Knee 27(2), 397–405 (2020).
Information & Authors
Information
Published In
Pages: 729 - 736
PubMed: 35642491
Copyright
© 2022 Future Medicine Ltd.
History
Received: 14 October 2021
Accepted: 18 May 2022
Published online: 1 June 2022
Keywords:
Topics
Authors
Metrics & Citations
Metrics
Article Usage
Article usage data only available from February 2023. Historical article usage data, showing the number of article downloads, is available upon request.
Citations
How to Cite
Restoring rotational stability following anterior cruciate ligament surgery: single-bundle reconstruction combined with lateral extra-articular tenodesis versus double-bundle reconstruction. (2022) Journal of Comparative Effectiveness Research. DOI: 10.2217/cer-2021-0248
Export citation
Select the citation format you wish to export for this article or chapter.
Citing Literature
- W. P. Yau, No difference found in the magnetic resonance imaging signal intensity of the anterior cruciate ligament reconstruction graft between single‐bundle anterior cruciate ligament reconstruction with concomitant anterolateral ligament surgery and double‐bundle anterior cruciate ligament reconstruction, Journal of Experimental Orthopaedics, 10.1002/jeo2.70542, 12, 4, (2025).
- Jan Zabrzyński, Bartosz Turoń, Adam Kwapisz, Achilles Boutsiadis, Maria Zabrzyńska, Maciej Sokołowski, Bartosz Majchrzak, Michalina Adamczyk, Katie Kellett, Gazi Huri, Technical Variations in Lateral Extra-Articular Tenodesis for Anterior Cruciate Ligament Reconstruction: A Systematic Review, Journal of Clinical Medicine, 10.3390/jcm14186510, 14, 18, (6510), (2025).
- Claudio Legnani, Martina Faraldi, Matteo Del Re, Giuseppe Peretti, Alberto Ventura, Side-hop test can detect deficits in knee functional ability in male athletes following anterior cruciate ligament reconstruction compared to a control group during a battery test performance, Frontiers in Sports and Active Living, 10.3389/fspor.2025.1545226, 7, (2025).
- Yi Zhang, Sharon Si Heng Tan, Andrew Kean Seng Lim, James Hoi Po Hui, Comparative outcomes of anterior cruciate ligament reconstruction with and without lateral extra‐articular tenodesis: A meta‐analysis, Knee Surgery, Sports Traumatology, Arthroscopy, 10.1002/ksa.12726, (2025).
- Filippo Migliorini, Ludovico Lucenti, Ying Ren Mok, Tommaso Bardazzi, Riccardo D’Ambrosi, Angelo De Carli, Domenico Paolicelli, Nicola Maffulli, Anterior Cruciate Ligament Reconstruction Using Lateral Extra-Articular Procedures: A Systematic Review, Medicina, 10.3390/medicina61020294, 61, 2, (294), (2025).
- Lorenz Fritsch, Luca Bausch, Armin Runer, Philipp W. Winkler, Romed P. Vieider, Sebastian Siebenlist, Julian Mehl, Lukas Willinger, Lateral Extraarticular Tenodesis in Revision Anterior Cruciate Ligament Reconstruction: An Analysis of Clinical Outcomes and Failure Rates, Journal of Clinical Medicine, 10.3390/jcm13237201, 13, 23, (7201), (2024).
- Cheng-Pang Yang, Mu-Ze Chen, Chih-Li Wang, Alvin Chao-Yu Chen, Kuo-Yao Hsu, Yi-Sheng Chan, Joe Chih-Hao Chiu, Double-bundle ACL combined with ALL reconstruction for patients at high risk of ACL failure: clinical and radiological results, BMC Musculoskeletal Disorders, 10.1186/s12891-024-07703-8, 25, 1, (2024).