J Knee Surg 2021; 34(06): 672-678
DOI: 10.1055/s-0039-1700575
Original Article

Long-Term Results of ACL Reconstruction Using a Nonanatomic Double-Bundle Technique with Extra-Articular Reinforcement

J. Dalla-Rosa
1   Department of Orthopaedic Surgery and Traumatology, Hospital Vithas Parque San Antonio, Málaga, España, Spain
A. Espejo-Reina
2   Department of Orthopaedic Surgery, Hospital Clínico Universitario Virgen de la Victoria, Málaga, España, Spain
I. Tamimi
3   Department of Orthopaedic Surgery, Hospital Regional Universitario de Málaga, Málaga, España, Spain
M. J. Espejo-Reina
4   Department of Orthopaedic Surgery, Hospital de Antequera, Antequera, España, Spain
M. Lombardo-Torre
1   Department of Orthopaedic Surgery and Traumatology, Hospital Vithas Parque San Antonio, Málaga, España, Spain
A. Espejo-Baena
1   Department of Orthopaedic Surgery and Traumatology, Hospital Vithas Parque San Antonio, Málaga, España, Spain
› Author Affiliations


Extra-articular procedures for the improvement in rotational stability after anterior cruciate ligament (ACL) reconstruction have gained popularity in the last decade. This surgical gesture hoped to improve resistance to the high tensional forces affecting the ACL graft during cutting and pivoting movements of the lower extremity and eventually prevent ACL reconstruction failure. We performed this study to analyze the long-term results of patients undergoing ACL reconstruction using a nonanatomic double-bundle technique with an additional extra-articular augmentation. All the cases that underwent an ACL reconstruction using a nonanatomic double-bundle technique with an extra-articular reinforcement during the period between 1992 and 1997 were reviewed. The inclusion criteria for this study included a minimum follow-up of 10 years and age between 14 and 45 years at the time of the surgery. Forty patients were included in this series (34 males and 6 females). The mean Lysholm score after a minimum follow-up period of 10 years was 92.3 (standard deviation [SD], 9.4). The average preoperative Tegner score of the participants was 7.0 (SD, 1.1). This score decreased to 5.7 (SD, 1.2) at the end of follow-up. Follow-up X-rays were reviewed to assess the degenerative changes in the three knee compartments. Degenerative changes ≥ Kellgren–Lawrence grade 2 were observed in our six (15%) patients, all of them in the medial knee compartment. With these results, we conclude that double-bundle nonanatomic ACL reconstruction combined with an extra-articular reinforcement resembling the anterolateral ligament offers good overall long-term results, with relatively low rates of osteoarthritis.

Publication History

Received: 24 April 2019

Accepted: 18 September 2019

Article published online:
09 December 2019

© 2019. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Lemaire M. [Chronic knee instability. Technics and results of ligament plasty in sports injuries]. J Chir (Paris) 1975; 110 (04) 281-294
  • 2 MacIntosh DL, Darby JA. Lateral substitution reconstruction. Proceedings of the Canadian Orthopaedic Association. J Bone Joint Surg Br 1976; 58: 142
  • 3 Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat 2013; 223 (04) 321-328
  • 4 DePhillipo NN, Cinque ME, Chahla J, Geeslin AG, LaPrade RF. Anterolateral ligament reconstruction techniques, biomechanics, and clinical outcomes: a systematic review. Arthroscopy 2017; 33 (08) 1575-1583
  • 5 Ménétrey J, Duthon VB, Laumonier T, Fritschy D. “Biological failure” of the anterior cruciate ligament graft. Knee Surg Sports Traumatol Arthrosc 2008; 16 (03) 224-231
  • 6 Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL-Y. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 2002; 30 (05) 660-666
  • 7 Crawford SN, Waterman BR, Lubowitz JH. Long-term failure of anterior cruciate ligament reconstruction. Arthroscopy 2013; 29 (09) 1566-1571
  • 8 Mascarenhas R, Cvetanovich GL, Sayegh ET. et al. Does double-bundle anterior cruciate ligament reconstruction improve postoperative knee stability compared with single-bundle techniques? A systematic review of overlapping meta-analyses. Arthroscopy 2015; 31 (06) 1185-1196
  • 9 Colombet P. Knee laxity control in revision anterior cruciate ligament reconstruction versus anterior cruciate ligament reconstruction and lateral tenodesis: clinical assessment using computer-assisted navigation. Am J Sports Med 2011; 39 (06) 1248-1254
  • 10 Monaco E, Labianca L, Conteduca F, De Carli A, Ferretti A. Double bundle or single bundle plus extraarticular tenodesis in ACL reconstruction? A CAOS study. Knee Surg Sports Traumatol Arthrosc 2007; 15 (10) 1168-1174
  • 11 Sonnery-Cottet B, Saithna A, Cavalier M. et al. 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. Am J Sports Med 2017; 45 (07) 1547-1557
  • 12 Schlatterer B, Jund S, Delépine F, Razafindratsiva C, Peretti FD. Reconstruction précoce intra et extra-articulaire du ligament croisé antérieur utilisant le tractus iliotibial selon la technique de MacIntosh modifiée [Early intra and extraarticular reconstruction of the anterior cruciate ligament using iliotibial band according to modified MacIntosh technique]. Rev Chir Orthop Repar Appar Mot 2006; 92 (08) 778-787
  • 13 Lording TD, Lustig S, Servien E, Neyret P. Lateral reinforcement in anterior cruciate ligament reconstruction. AP-SMART 2014; 1 (01) 3-10
  • 14 Hughston JC. Anterior cruciate deficient knee. Am J Sports Med 1983; 11 (01) 1-2
  • 15 Espejo A, Moro JA, Montañez E, de la Varga V, Urbano V, Queipo de Llano A. Ligamentoplastia trifascicular del ligamento cruzado anterior con tendones de la pata de ganso [Triple bundle anterior cruciate ligament reconstruction using hamstrings tendons]. Cuadernos Artroscopia 1995; 2: 35-41
  • 16 Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982; 10 (03) 150-154
  • 17 Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985; (198) 43-49
  • 18 Hefti F, Müller W, Jakob RP, Stäubli H-U. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993; 1 (3-4): 226-234
  • 19 Petersson IF, Boegård T, Saxne T, Silman AJ, Svensson B. Radiographic osteoarthritis of the knee classified by the Ahlbäck and Kellgren & Lawrence systems for the tibiofemoral joint in people aged 35-54 years with chronic knee pain. Ann Rheum Dis 1997; 56 (08) 493-496
  • 20 Inderhaug E, Stephen JM, Williams A, Amis AA. Anterolateral tenodesis or anterolateral ligament complex reconstruction: effect of flexion angle at graft fixation when combined with ACL reconstruction. Am J Sports Med 2017; 45 (13) 3089-3097
  • 21 Herbst E, Albers M, Burnham JM, Fu FH, Musahl V. The anterolateral complex of the knee. Orthop J Sports Med 2017; 5 (10) 2325967117730805
  • 22 Zaffagnini S, Signorelli C, Lopomo N. et al. Anatomic double-bundle and over-the-top single-bundle with additional extra-articular tenodesis: an in vivo quantitative assessment of knee laxity in two different ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 2012; 20 (01) 153-159
  • 23 Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med 2007; 35 (04) 564-574
  • 24 Hui C, Salmon LJ, Kok A, Maeno S, Linklater J, Pinczewski LA. Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for “isolated” anterior cruciate ligament tear. Am J Sports Med 2011; 39 (01) 89-98
  • 25 Thompson S, Salmon L, Waller A, Linklater J, Roe J, Pinczewski L. Twenty-year outcomes of a longitudinal prospective evaluation of isolated endoscopic anterior cruciate ligament reconstruction with patellar tendon autografts. Am J Sports Med 2015; 43 (09) 2164-2174
  • 26 Funk Jr FJ. Osteoarthritis of the knee following ligamentous injury. Clin Orthop Relat Res 1983; (172) 154-157
  • 27 Kannus P, Järvinen M. Conservatively treated tears of the anterior cruciate ligament. Long-term results. J Bone Joint Surg Am 1987; 69 (07) 1007-1012
  • 28 McDaniel Jr WJ, Dameron Jr TB. Untreated ruptures of the anterior cruciate ligament. A follow-up study. J Bone Joint Surg Am 1980; 62 (05) 696-705
  • 29 Yasuda K, Kondo E, Ichiyama H. et al. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 2004; 20 (10) 1015-1025
  • 30 Ibrahim SA-R, Al-Kussary IM, Al-Misfer AR, Al-Mutairi HQ, Ghafar SA, El Noor TA. Clinical evaluation of arthroscopically assisted anterior cruciate ligament reconstruction: patellar tendon versus gracilis and semitendinosus autograft. Arthroscopy 2005; 21 (04) 412-417
  • 31 Li RT, Lorenz S, Xu Y, Harner CD, Fu FH, Irrgang JJ. Predictors of radiographic knee osteoarthritis after anterior cruciate ligament reconstruction. Am J Sports Med 2011; 39 (12) 2595-2603
  • 32 Grassi A, Zaffagnini S, Muccioli GMM, Sarsina TRD, Barrientos FU, Marcacci M. Revision anterior cruciate ligament reconstruction does not prevent progression in one out of five patients of osteoarthritis: a meta-analysis of prevalence and progression of osteoarthritis. J ISAKOS 2016; 1 (01) 16-24
  • 33 Neuman P, Englund M, Kostogiannis I, Fridén T, Roos H, Dahlberg LE. Prevalence of tibiofemoral osteoarthritis 15 years after nonoperative treatment of anterior cruciate ligament injury: a prospective cohort study. Am J Sports Med 2008; 36 (09) 1717-1725
  • 34 Richmond JC, Lubowitz JH, Poehling GG. Prompt operative intervention reduces long-term osteoarthritis after knee anterior cruciate ligament tear. Arthroscopy 2011; 27 (02) 149-152
  • 35 Mehl J, Otto A, Baldino JB. et al. The ACL-deficient knee and the prevalence of meniscus and cartilage lesions: a systematic review and meta-analysis (CRD42017076897). Arch Orthop Trauma Surg 2019; 139 (06) 819-841
  • 36 Barenius B, Forssblad M, Engström B, Eriksson K. Functional recovery after anterior cruciate ligament reconstruction, a study of health-related quality of life based on the Swedish National Knee Ligament Register. Knee Surg Sports Traumatol Arthrosc 2013; 21 (04) 914-927
  • 37 Cox C, Huston L, Dunn W. et al. Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and MARX activity level outcomes after ACL reconstruction? A 6-year Moon cohort study. Osteoarthritis Cartilage 2013; 21 DOI: 10.1016/j.joca.2013.02.457.
  • 38 Ferretti A, Monaco E, Ponzo A. et al. Combined intra-articular and extra-articular reconstruction in anterior cruciate ligament-deficient knee: 25 years later. Arthroscopy 2016; 32 (10) 2039-2047
  • 39 Schon JM, Moatshe G, Brady AW. et al. Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle. Am J Sports Med 2016; 44 (10) 2546-2556
  • 40 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; 26 (08) 960-966
  • 41 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; 43 (07) 1598-1605
  • 42 Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med 1994; 22 (05) 632-644
  • 43 Kempen JH. Appropriate use and reporting of uncontrolled case series in the medical literature. Am J Ophthalmol 2011; 151 (01) 7-10.e1