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Anterolateral Structure Reconstruction Unnecessary with Anatomic ACL Reconstruction for Knee Stability

Commentary on an article by Frank R. Noyes, MD, et al.: “The Effect of an ACL Reconstruction in Controlling Rotational Knee Stability in Knees with Intact and Physiologic Laxity of Secondary Restraints as Defined by Tibiofemoral Compartment Translations and Graft Forces”

Fu, Freddie H., MD

doi: 10.2106/JBJS.17.01311
Commentary and Perspective
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Department of Orthopaedic Surgery at the University of Pittsburgh School of Medicine and UPMC, Pittsburgh, Pennsylvania

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Commentary

The article “The Effect of an ACL Reconstruction in Controlling Rotational Knee Stability in Knees with Intact and Physiologic Laxity of Secondary Restraints as Defined by Tibiofemoral Compartment Translations and Graft Forces,” by Frank R. Noyes, MD, et al., utilized a robotic testing system on 21 fresh cadaveric knees and evaluated the kinematics before and after ACL (anterior cruciate ligament) reconstruction, in order to clarify whether anatomic ACL reconstruction can stabilize ACL-sectioned knees with severely abnormal anterior subluxations. The pivot-shift, Lachman, and internal tibial rotation loading tests were simulated, and tibiofemoral translations and rotations were determined. The authors showed that, even in knees with physiologically lax secondary restraints, an ACL graft placed in the central two-thirds of the native ACL femoral and tibial footprints restored the stabilizing function of the ACL, without any excessive graft force.

Recently, a concurrent reconstruction of the anterolateral structure, especially in unstable knees, was recommended by several authors1-5. However, an anterolateral structure reconstruction has shown little effect in limiting abnormal pivot-shift subluxations6,7. The results shown by Noyes et al. add to the evidence that anatomic ACL reconstruction, which reproduces the central two-thirds of the native ACL footprint, can restore knee stability, even in knees with a grossly positive Lachman test or Grade-3 pivot-shift test. Anatomic ACL reconstruction, which covers the native ACL footprint sufficiently, is the key to success in restoring normal knee kinematics8,9.

Disclosure: The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/E585).

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References

1. Branch T, Lavoie F, Guier C, Branch E, Lording T, Stinton S, Neyret P. 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. 2015 Oct;23(10):2882-91. Epub 2015 Sep 4.
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4. Tavlo M, Eljaja S, Jensen JT, Siersma VD, Krogsgaard MR. The role of the anterolateral ligament in ACL insufficient and reconstructed knees on rotatory stability: a biomechanical study on human cadavers. Scand J Med Sci Sports. 2016 Aug;26(8):960-6. Epub 2015 Aug 6.
5. Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BH, Murphy CG, Claes S. Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med. 2015 Jul;43(7):1598-605. Epub 2015 Mar 4.
6. Spencer L, Burkhart TA, Tran MN, Rezansoff AJ, Deo S, Caterine S, Getgood AM. Biomechanical analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee. Am J Sports Med. 2015 Sep;43(9):2189-97. Epub 2015 Jun 19.
7. Thein R, Boorman-Padgett J, Stone K, Wickiewicz TL, Imhauser CW, Pearle AD. Biomechanical assessment of the anterolateral ligament of the knee: a secondary restraint in simulated tests of the pivot shift and of anterior stability. J Bone Joint Surg Am. 2016 Jun 1;98(11):937-43.
8. Araujo PH, Asai S, Pinto M, Protta T, Middleton K, Linde-Rosen M, Irrgang J, Smolinski P, Fu FH. ACL graft position affects in situ graft force following ACL reconstruction. J Bone Joint Surg Am. 2015 Nov 4;97(21):1767-73.
9. van Eck CF, Schreiber VM, Mejia HA, Samuelsson K, van Dijk CN, Karlsson J, Fu FH. “Anatomic” anterior cruciate ligament reconstruction: a systematic review of surgical techniques and reporting of surgical data. Arthroscopy. 2010 Sep;26(9)(Suppl):S2-12.

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