Presentation at American Academy of Orthopaedic Surgeons, New Orleans 2018. This study demonstrates that re-operation rates after this procedure are broadly comparable to those seen after isolated ACLR. The high rates of stiffness and complications seen with non-anatomical ITB based procedures was not observed in this series

1.  Contributors from
SANTI Study Group
 Bertrand Sonnery-Cottet, France
 Adnan Saithna, UK
 Camilo Helito, Brazil
 Matt Daggett, USA
 Mathieu Thaunat, France
 Eduardo Frois Temponi, Brazil
 Charles Kajetanek, France
 Maxime Cavalier, France
 Herve Ounazer, France
 Eric Choudja, Switzerland
 Gilles Clowez, France
 Jean-Marie Fayard, France
 Thais Dutra Viera, Brazil
Re-operation Rates After
Combined ACL and
Anterolateral Ligament
Reconstruction:
Clinical Outcomes from the
SANTI Study Group
Adnan Saithna, MBChB, DipSEM, FRCS,
MSc
Honorary Professor Nottingham Trent University, UK
Consultant Orthopaedic Surgeon
Southport & Ormskirk Hospitals, UK

3. Widely abandoned after the 1989 AOSSM
Snowmass consensus meeting
• Lack of significant proven clinical benefit
• Concerns regarding poor outcomes and high complication rates
– donor site morbidity
– overconstraint
– cosmetic problems
– stiffness
– increased risk of septic arthritis
– long-term chronic pain and swelling
– poor long-term functional outcomes with lower subjective and objective results
History of lateral extra-articular
procedures

4. • 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 Study Group.
– 2.5-3 fold reduction in ACL graft rupture rates when compared to isolated ACLR in a high
population (young patients, pivoting sports)
– ACL+ALL graft associated with significantly higher odds of return to pre-injury level of
sport than 4HT [Odds ratio, 1.938; 95% CI 1.174-3.224]
• Anterolateral Ligament Reconstruction Protects The Repaired Medial Meniscus: A
Comparative Study of 383 ACL Reconstructions from the SANTI Study Group with a
Minimum Follow Up of Two Years.
– Protects repaired medial meniscus: Two fold reduction in re-operation for MM repair
patients with ACLR+ALLR compared to patients with isolated ACLR (hazard ratio, 0.443;
CI, 0.218-0.866).
Clinical Effectiveness of ACL+ALLR
Winner of AANA 2017 Richard J O’Connor Award
June 2017
Accepted

5. AJSM, Sept 2017

6. Rationale for improved results compared to historically poor
outcomes:
Less Invasive & More Anatomic

7. Retrospective analysis of prospectively collected data from the multi-surgeon SANTI
(Scientific ACL NeTwork International) Study Group
All patients undergoing combined ACL+ALLR between 2012-14 included
Indications for combined procedure:
• Failure to resume pre-injury activity due to instability AND 1 or more of the following criteria:
• Grade III pivot shift
• High levels of sporting activity
• Participation in pivoting sports (eg, soccer, rugby, handball, basketball)
• Lateral femoral notch sign on plain radiographs
• Revision ACL reconstruction
• Segond fracture
• Chronic ACL rupture
Study Design

8. • Saithna A, Thaunat M, Delaloye JR, Ouanezar H, Fayard JM, Sonnery-Cottet, B.
Combined ACL and Anterolateral Ligament Reconstruction JBJS Essential
Surgical Techniques. 8(1):e2, January-March 2018.
• Sonnery-Cottet B, Daggett M, Helito CP, Fayard JM, Thaunat M. Combined
anterior cruciate ligament and anterolateral ligament reconstruction. Arthrosc
Tech Arthrosc Tech. 2016:31;5(6):e1253-e1259.
Surgical Technique

9. • Physical evaluation pre-operatively and at weeks 3 & 6, and months 3,6,and12
• All patients contacted by telephone interview at final follow up (minimum 2
years) and asked the following standardised questions:
– Did you have a second operation after your ACL reconstruction?
– Did you have a contralateral ACL rupture or contralateral ACL reconstruction after the index
procedure?
• Operative records were obtained for all patients undergoing re-operation
Follow up

10. Retrospective analysis of prospectively collected data from the multi-surgeon SANTI
(Scientific ACL NeTwork International) Study Group
Patient Flow
Final population 548 ACLR+ALLR
Mean follow up 35.5 months
(Range 24-54 months)

11. • Mean Age 24.3 years
• No meniscal tear, n=222 (40.5%)
• Medial meniscal tear, n=217 (39.6%)
– Repair, 170
– Meniscectomy, 45
– Not operated, 2
• Lateral meniscal tear n=183 (33.4%)
– Repair, 154
– Meniscectomy, 28
– Not operated, 1
• Contralateral ACLR before index surgery, n=65 (11.9%)
Population Characteristics (n=548)

13. • 3/548 (0.5%) of patients had a complication specific to ACL+ALLR
and all involved femoral hardware
- Patient 1: femoral screw too long
- Patient 2: persistent pain
- Patient 3: posterior wall blow-out
- All patients made a full recovery after screw removal
- No re-operations to cut a tight graft
Specific Complications

14. Comparison to studies reporting re-
operation after isolated ACLR
• Kartus et al, (n=604)
• follow up ranging from 2-5 years
• re-operation rate 26.7%
• Hettrich et al, MOON study group
(n=980)
• follow up 6 years
• re-operation rate 18.9%

15. KARTUS HETTRICH CURRENT
Re-operation rate 26.7% 18.9% 13.1%
Meniscus 8.6% 5% 5.5%
Arthrofibrosis 10.7% 4.1% 4.0%
Deep Infection 0.9% 0.5% 0.5%

16. Conclusions
1. ACL+ALLR has a very low rate of specific complications
2. Re-operation rates after ACL+ALLR are broadly
comparable to published rates after isolated ACLR
3. High rates of stiffness and re-operation noted
historically were not observed in this series

17. Thank you
www.centre-orthopedique-santy.com