Combined ACL and anterolateral ligament reconstruction: time to pivot and shift the focus?

综述

PART

The incidence of anterior cruciate ligament (ACL) injuries among adolescent athletes has been steadily increasing, with females peaking at age 16 years and males at age 17 years, with rates of 392 ACL tears and 422 ACL tears per 100 000 person-years, respectively^[1].

In 2015, Smigielski et al. reported that native ACL morphology was “ribbon-like”, becoming more strand or bundle-like as it rotated upon itself^[26].

General anatomic ACL reconstruction principles, such as better appreciation of native anatomy, individualizing surgery to patient-specifc anatomical variability and functional needs, graft positioning within the native footprint centers, and physiologic tension restoration^[12], has led to better transverse plane knee movement control during stressful running–cutting directional change and single leg jump landing movements.

Despite these surgical technique advances, alarming failure rates and re-injury rates after ACL reconstruction have been reported, especially in younger people who participate in pivoting sports^[28,29].

PART

A plethora of ACL reconstruction methods and/or supplemental pe-ripheral capsuloligamentous surgical methods have been developed to prevent the excessive internal or external transverse plane tibial rotation that leads to graft failure^[7,17,19,22].

This evolution has followed an interesting progression with re-commendations shifting from the general need for more medial , to more lateral extra-articular capsuloligamentous reinforcement procedures^[17].

As anatomic and biomechanical understanding has improved, peripheral capsuloligamentous and intra-articular knee reconstruction procedures have similarly evolved^[5,12,17,26].

In 1983, Losee^[15] suggested that transverse plane rotational k-nee control might best be achieved from the periphery, such as stopping a rotating wagon wheel by grabbing the rim rather than the axle.

Over time, however, isolated lateral extra-articular procedures were found to be inefective at restoring knee kinematics^[7^], possessing high failure rates^[19], and were suspected to increase the risk of lateral tibiofemoral compartment ote-oarthritis^[22].

In 2013, Claes et al.^[5]provided a com-prehensive description of anterolateral ligament (ALL) knee anatomy.

A consensus paper by Sonnery-Cottet et al.^[27] in 2017 suggested that ALL repair or reconstruction may improve the transverse plane rotational stability control provided by ACL reconstruction.

The consensus group agreed that since secondary restraint injury often occurs concurrently with acute ACL tear cases, their recognition and repair should be considered to augment the transverse plane rotational knee kinematic control provided by ACL reconstruction^[27].

PART

Recently the perceived indications for combined ACL and lateral extra-articular procedures have expanded, particularly regarding what might be considered to be a high re-injury risk patient^[2,11,16,27].

This term is often subjective, varying between studies and ultimately, in our opinion, matching a high percentage of young and active patients who seek ACL injury treatment.

It is concerning if concomitant lateral extra-articular reconstruction or repair procedures becomes the new standard augmentation for most ACL reconstruction cases^[25].

Indications for the inclusion of a lateral extraarticular procedure remains a contentious debate in the research community^[10], particularly regarding how much its addition truly adds to the restoration of normal knee kinematics and which patient population benefts from it.

Several studies have suggested that appropriate fxation of anatomically placed, and biomechanically com-petent ACL grafts in most cases restores knee stability, negating the need for any supplemental lateral extra-articular procedures to control rotational instability^[4,8,20].

Although concomitant lateral extra-articular procedures and ACL reconstruction increase ACL graft survival rates at midterm^[2,11], it has not beenfound to improve long term patient perceived function, even among high risk patients^[16].

These questions, in addition to surgical decision-making com-plexities, make it very diffcult for the low volume surgeon to efectively navigate who should, and who should not be ofered the com-bined procedures, particularly among adolescent athletes.

PART

Perhaps we should slow down and refect about this.

For decades, an almost singular surgical focus has been placed on eliminating multi-planar knee laxity as indicated by a positive pivot shift test.

While this is essential for safely returning patients back to sports and improving outcomes, greater indi-vidualized attention may need to be placed on the plethora of factors that infuence a safe return to sports, including psychological factors and the volume of training/competition tissue loading that induces accumulative microtrauma^[3].

Although is it essential to restore normal knee kinematics, greater appreciation for and mitigation of other factors that may increase knee re-injury risk should occur.

The current focus seems to be placed more on short-term surgical outcome metrics rather than on more global and highly individualized patient-centered health outcome factors including, but not limited to kinesiophobia, fear avoidance, self-efcacy, self-identity, health locus of control and quality of life, in addition to perceived functional limitations, disabilities, and envi-ronmental or personal factors^[13].

Given that adolescent athletes are training at greater intensities and frequencies than ever before, there is concern that many will be deemed “high risk” thereby ftting the combined procedure selection criteria, even in the absence of a high grade pivot shift test^[27].

Associated with this is the growing professionalism of how many adolescent athletes are currently being trained.

At frst mention of a Premier or Champions League soccer player undergoing the combined procedure, many parents will likely be demanding the same for their child.

PART

In 1974, the elbow surgeon Dr. Jobe introduced the ulnar collateral ligament reconstruction procedure that is now referred to as the “Tommy John surgery”^[14].

Since its inception, use of this procedure has increased to the point, where today almost 25% of all major league baseball pitchers have had the surgery ^[9].

It was not until 2006 that youth baseball pitch count and frequency limitations were implemented that signifcantly decreased shoulder and elbow injury rates and severity^[23].

Why have similar rules not been considered to monitor adolescent athlete lower extremity joint loading?

The goal of surgery is to improve ACL injured patient outcomes and safe return to activities^[27].

Of considerable challenge in treating adolescent athletes are the complexities associated with concurrent multi-body system growth, and obsessive sports passion^[13,21].

The intersection of physical, mental and emotional health factors at this highly developmental life phase makes healthcare decisions that might infuence long-term quality of life very challenging.

As primary prevention interventions have shown at the shoulders and elbows of adolescent overhead throwing athletes^[23], greater focus may need to be placed on primary and secondary knee injury prevention programs.

By altering training intervals^[18,24] in a manner that better addresses the recovery time needed for lower metabolic rate non-contractile tissues we may better facilitate knee capsuloligamentous tissue mic-rotrauma healing and recovery, particularly among developing athletes^[6].

Reference

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