Professor Adnan Saithna's presentation at SRATS 2018, Bucharest: Clinical Results of Combined ACL and Anterolateral Ligament Reconstruction

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
Clinical Outcomes of ALL
Reconstruction
Adnan Saithna, MBChB, DipSEM, FRCS,
MSc
Honorary Professor Nottingham Trent University, UK
Consultant Orthopaedic Surgeon
Southport & Ormskirk Hospitals, UK
BOSTAA

2. Widely abandoned after the 1989 AOSSM
Snowmass consensus meeting
1. Lack of significant proven clinical benefit
2. 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

3. • Anterolateral Ligament Reconstruction Is Associated
Significantly Reduced ACL Graft Rupture Rates at a
Minimum Follow-up of 2 Years: A Prospective
Comparative Study of 502 Patients From the SANTI
Group.
ACL Graft Rupture Rates
Winner of AANA 2017 Richard J O’Connor Award
June 2017

4. Indications

5. • 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

6. 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

7. 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).

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

11. Conclusion 1:
 Combined ACL + ALLR is associated with a 2.5 to 3
fold reduction in ACL graft rupture rates when
compared to isolated 4HT or BTB ACLR

12. • 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.
Protecting the repaired medial meniscus
Accepted

13. Surgical
Procedure
MM Repair Failurea
P24 month Follow-up
36 month Follow-
up
Overall mean (95%CI) 7.4 (5.1-10.6) 12.6 (9.4- 16.9) .033
isolated ACLR mean (95%CI) 10.4 (6.8-15.8) 16.2 (11.3-22.9)
ACLR + ALLR mean (95%CI) 4.4 (2.2-8.5) 8.8 (5.2-14.6)

14. Conclusion 2:
 ALLR protects repaired medial meniscus: Two fold reduction
in re-operation for MM repair failure in patients with
ACLR+ALLR compared to patients with isolated ACLR (hazard
ratio, 0.443; 95% CI, 0.218-0.866).

15. AJSM, Sept 2017

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

18. • 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

19. 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%

20. 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%

21. Conclusions
1. Combined ACL + ALLR is associated with a 2.5 to 3 fold
reduction in ACL graft rupture rates when compared to
isolated ACLR
2. ALLR protects repaired medial meniscus: Two fold reduction
in re-operation for MM repair failure
3. ACL+ALLR has a very low rate of specific complications
4. Re-operation rates after ACL+ALLR are broadly comparable
to published rates after isolated ACLR
5. High rates of stiffness and re-operation noted historically
were not observed in this series

22. Thank you