Extraaarticular Reconstruction In ACL Deficient Knee: 25 Years Later

OBJECTIVES: Extraarticular Reconstructions (ERs), isolated or in association with Intraarticular ACL Reconstructions (IRs) were popular in the eighties. However they were almost completely given up as a result of a consensus conference organized by AOSSM in 1989 in Snowmass (Co) where the experts concluded that ERs, even if biomechanically justified, were unable to provide any improvement in clinical results with greater morbidity, higher risk of complications and increased rate of degenerative osteoarthritis (DOA). However, as since then the surgical techniques and postoperative rehabilitation have radically changed, it could be helpful to reconsider ERs and their long term effect on knee stability and on DOA. METHODS: One hundred consecutive patients who underwent an anatomic single bundle ACL reconstruction with hamstrings were re-evaluated at a minimum follow up of eleven years. In 23 cases (group B), due to the presence of a Pivot Shift test graded as +++ or in cases of athletes involved in high risk sports, a lateral tenodesis (Coker/Arnold) was associated. The other 77 patients, where an isolated IR was performed with the same technique (group A), served as control. All patients followed the same, standard postoperative rehabilitation program. At follow up Lysholm, IKDC and Tegner activity scores were used. A side to side maximum manual (S/S MM) KT1000 measurement was done. Comparative weight bearing antero-posterior and lateral radiograms were performed and analyzed according to Fairbank, Kellgren and IKDC classification. Tibio-femoral and patella-femoral joints were analyzed separately. Statistical analysis was performed using Student t-test, Pearson chi-square test with SPPS 9.0 software. RESULTS: Group A and B were homogeneous for sex and age. At final follow up seven patients were lost. Subjectively Lysholm score, IKDC and Tegner Activity score improved significantly in both groups with no significant difference. Objectively the number of patient categorized as A and B according to the IKDC was significantly higher in group B than in group A ( P=0.05). Considering as a failure a S/S M/M difference > 5mm or a Pivot Shift test graded as ++ or +++ or a recurrence of any giving way episode, we found 7 cases in group A and no cases in group B (P=0.006). Radiogical evaluation showed no statistically significant difference between the two groups in all scales in both femoro-tibial and patello-femoral joints. CONCLUSION: The main limitation of the study is that the two groups were not homogeneous in term of preoperative conditions. However as highest grades of activity level and Pivot Shift correlate with an increased risk of DOA, this limitation appears to strengthen the value of the study. Adding a lateral tenodesis to an ACL IR with hamstrings, followed by a standard rehabilitative protocol, seems not to increase the risk of development of DOA, improving rotatory knee stability and reducing risk of recurrence. The meeting in Snowmass has been a milestone event in the evaluation of role of ERs in ACL deficent knee, giving an outstanding contribution to their definition, their biomechanical effect and their role in rotatory instability. However, on the basis of the results of this study, we could speculate that the conclusions of the meeting were somewhat misleading or at least misinterpreted, as they were based on surgical techniques and rehabilitation procedures no more in use in the modern ACL surgery.