Extra-articular ACL Reconstruction and Pivot Shift

Abstract

Background: The pivot-shift test is considered a reliable examination to evaluate the results of anterior cruciate ligament (ACL) reconstruction, as it strongly correlates with patient satisfaction, giving-way episodes, and activity level. The addition of lateral tenodesis (LT) to current techniques of intra-articular reconstruction with a hamstring graft could potentially improve knee laxity in cases of severe rotational instability. Purpose: To biomechanically investigate the effect of intra- and extra-articular ACL reconstructions on knee laxity and the pivot-shift phenomenon. Study Design: Controlled laboratory study. Methods: Twenty patients underwent anatomic single-bundle ACL reconstruction with doubled semitendinosus and gracilis tendons with the addition of extra-articular reconstruction. In patients in group A, intra-articular reconstruction was performed first and LT thereafter; in patients in group B, LT was performed first and intra-articular reconstruction thereafter. A navigator equipped with software designed for both static and dynamic evaluations was used to measure maximum anterior tibial translation (ATT) and axial tibial rotation (ATR) at 30° of flexion (static evaluation) and during the pivot-shift test (dynamic evaluation). Measurements were performed before reconstruction, after the first procedure, and after the second procedure. Results: For the static evaluation, in group A, the mean ATT significantly decreased from 14.1 ± 3.7 mm in the preoperative (ACL-deficient) condition to 6.0 ± 1.9 mm after ACL reconstruction and to 5.3 ± 1.6 mm after LT. The mean ATR at 30° of knee flexion significantly decreased from 35.7° ± 4.8° to 28.9° ± 4.1° and to 20.9° ± 4.8°, respectively. In group B, the mean ATT significantly decreased from 13.5 ± 6.5 mm in the preoperative (ACL-deficient) condition to 10.2 ± 3.2 mm after LT and to 4.0 ± 1.6 mm after ACL reconstruction. The mean ATR at 30° of knee flexion significantly decreased from 36.7° ± 4.8° to 26.2° ± 6.2° and to 23.5° ± 4.9°, respectively. For the dynamic evaluation (pivot-shift test), in group A, the mean ATT significantly decreased from 15.0 ± 6.8 mm in the preoperative (ACL-deficient) condition to 9.4 ± 6.4 mm after ACL reconstruction and to 8.5 ± 5.4 mm after LT. The mean ATR significantly decreased from 16.9° ± 4.7° to 11.6° ± 4.1° and to 6.1° ± 2.2°, respectively. In group B, the mean ATT significantly decreased from 12.5 ± 3.3 mm in the preoperative (ACL-deficient) condition to 9.1 ± 5.9 mm after LT and to 8.1 ± 5.4 mm after ACL reconstruction. The mean ATR significantly decreased from 16.0° ± 4.5° to 9.2° ± 4.3° and to 7.5° ± 4.0°, respectively. Conclusion/Clinical Relevance: Extra-articular reconstruction had little effect in reducing the anterior displacement of the tibia at 30° of flexion, but it was more effective than intra-articular reconstruction in reducing ATR. Anatomic ACL reconstruction and LT were synergic in controlling the pivot-shift phenomenon.