Winner of the Richard O'Connor Research Award from the Arthroscopy Association of North America 2017. This study demonstrates major improvement in the outcome of ACL reconstruction when an extra-articular procedure (ALL reconstruction) is also performed. The full manuscript is published in AJSM. Anterolateral Ligament Reconstruction Is Associated With Significantly Reduced ACL Graft Rupture Rates at a Minimum Follow-up of 2 Years: A Prospective Comparative Study of 502 Patients From the SANTI (Scientific ACL NeTwork International) Study Group

1. Anterolateral Ligament Reconstruction
Is Associated With Significantly Reduced
ACL Graft Rupture Rates at a Minimum
Follow-up of 2 Years:
A Prospective Comparative Study of 502 Patients From the SANTI (Scientific
ACL NeTwork International) Study Group
Saithna A, Sonnery-Cottet B, Thaunat M, Helito C,
Daggett M, Temponi EF, Kajatanek C, Cavalier M

2. Disclosures
• AS, BSC and MT are consultants for Arthrex

3. • The rupture rate in a high-risk population = 18%
Lind M et al KSSTA 2009, Kamath GV et al. AJSM 2014, Morgan MD et al. AJSM 2016, Webster KE et al. AJSM
2016
• Persistent Instability = 10-30%
• Return to the pre injury level between 50 to 65%
Brophy RH et al (MOON) group. AJSM 2012, McCullough KA et al. AJSM 2012
Ardern C et al, BJSM 2014.
Contemporary Results Of ACLR Suggest
Considerable Potential For Improvement

4. Rationale for ALL Reconstruction
• Neither double bundle nor AM drilling has resulted in
expected change in outcomes
 Meredick RB et al. Outcome of single-bundle versus double-bundle reconstruction of the ACL: a
meta-analysis. AJSM 2008
 Riboh JC et al. Transtibial vs Independent drilling techniques for ACL. A systematic review, meta-
analysis and meta-regression. AJSM 2013
• LET procedures share load with the ACL graft
 The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion.
Engebretsen L et al. AJSM 1990
• Restore normal kinematics where an isolated ACLR does
not
 Nitri M et al. An in vitro robotic assessment of the ALL: Part 2. AJSM 2016

5. Prospective comparative study of 502 patients
from the SANTI study group

6. Indications

11. Rehabilitation
Same protocol for all 3 graft types:
• brace-free, immediate full weight bearing
• early rehabilitation focused on obtaining full extension
and quadriceps activation
• Gradual return to sport activities allowed
– non-pivoting sports – 4 months
– pivoting non-contact – 6 months
– pivoting contact sports – 8-9 months

12. Prospective Follow up
- Clinical examination weeks 3,6 and months 3,6 and 12
- ROM, Lachman, Side-to-side laxity difference, isokinetic
- IKDC, Tegner, Lysholm
- Final follow up at end of study period by telephone
interview:
- Did you have a new injury to your operated knee?
- If yes, did you have or are you awaiting revision surgery?
- Did you return to the pre-injury level of sport?
- Graft rupture determined by:
- Clinical examination
- Side-to-side laxity greater than 4mm
- MRI

13. Statistical Analyses
Calculations were made with SAS for Windows:
• Baseline characteristics and postoperative outcomes were
compared with the use of ANOVA, Kruskal-Wallis and Chi-square
• Kaplan-Meier used to estimate the cumulative graft failure
• Cox proportional hazards used to perform adjusted analysis of time
to graft failure
• Chi-square used to determine factors associated with increased
likelihood of returning to the pre-injury sport level
•
• Multivariate logistic model used to perform an adjusted analysis of
prognostic factors identified in univariate analyses

14. Results (n=502)
Mean age 22.4 +/-4.0 years (range 16-30 years), 72.5% male (n=364)
Mean follow up 38.4 +/- 8.5 months (range 24-54 months)
No significant differences between each of the groups with respect to:
• mean time between injury and surgery (P = .73)
• preoperative side-to-side laxity (P = .73)
• rate and type/location of meniscal tears (P = .32) (25.4% of the patients had a
medial meniscal tear, 15.4% had a lateral meniscal tear, and 12.8% had tears of
both menisci)
• surgical treatment for meniscal tears (2.8% medial meniscectomy, 35.4% medial
meniscal repair, 4.3% lateral meniscectomy and 23.9% lateral meniscal repair).

16. Quadrupled HT: 10.8%
BPTB: 16.8%
HT+ALL: 4.1%
Graft rupture rates at mean f/up 38 months

18. Return to Sport
• Overall, 93% of patients returned to sport at latest follow up.
• Rate of return to self-described pre-injury level of sport was 64.6%
(272/421).
• In the professional athlete population (n = 39), 5 patients incurred a graft
rupture (3 BPT-B, 1 4HT, 1 HT+ALL), and 6 incurred a contralateral ACL
injury and were excluded from analyses of return to pre-injury levels of
sport. Of the remaining 28 professional athletes, all returned to their pre-
injury level of sport.

20. Re-operation and Complications
128 Patients (25.5%) underwent re-operation after the index procedure:
• Graft failures (n=40), 37 underwent revision ACLR, 3 await revision
• Contralateral ACL rupture (n=40). No difference between groups.
• Re-operation for ipsilateral, non–graft rupture–related causes (n=51). No difference
between the groups with respect to the following causes for reoperation:
• Meniscus (18 meniscectomies, 4 meniscal repairs)
• Arthrolysis for cyclops syndrome (n=22)
• MUA for stiffness (n=2)
• Other complications:
• lavage for septic arthritis (n=1)
• lavage for hemarthrosis (n=1)
• tibial screw removals for cysts (n=3, 1 patient in each group).

21. Discussion
• First clinical series to demonstrate that anatomic ALL reconstruction is associated
with a reduction in the rate of graft ruptures and improved return to pre-injury level
of sport compared with other common graft choices
• High risk population: B-PT-B and HT+ALL groups similar in terms of contact sports
(~83%) and patients aged 25 years (~75%).
• Graft rupture:
• B-PT-B group at 38.4 months 16.77% - similar to previous studies.
• HT+ALL group at same follow up 4.13%
• Similar findings with other types of LET Noyes FR et al. J Bone Joint Surg Am 1991,
Acquitter Y et al. Rev Chir Orthop Reparatrice Appar Mot 2003, Marcacci M et al.
Knee Surg Sports Traumatol Arthrosc 2003, Trojani C et al. Knee Surg Sports
Traumatol Arthrosc 2012, Ferretti A et al. Arthroscopy 2016

22. Discussion
• Concerns with other LET have included additional donor site morbidity,
cosmesis problems, stiffness, loss of motion, patellofemoral crepitation,
poor subjective results, and increased degenerative changes in the lateral
compartment
• Current series reassuring in this regard: Re-operation rates of 8.6% with B-
PT-B grafts, 10.8% with 4HT grafts and 10.4% with HT+ALL grafts.
• No specific complications related to ALL reconstruction

23. Conclusions
• Clinical results demonstrate
 Reduced graft rupture
 Increased return to sport
 Historical concerns regarding high re-operation rates not demonstrated at medium term follow
up
• However,
 Indications expanding and not yet clearly defined
 No RCT’s, single comparative series from SANTI study group only
 No long term data
• Its clear that results of ACLR can be improved and ALL shows
promise but further study is required

24. Thank You