Evaluation of the Stability, Revision Rate, and Complication Profile of Combined Anterior Cruciate Ligament Reconstruction with Lateral Extra-Articular Tenodesis and Hughston Procedure in Anterior Cruciate Ligament and Medial Collateral Ligament Injury: An 8-Year Cohort Study.

Abstract

Background: Anterior cruciate ligament (ACL) tears combined with medial collateral ligament (MCL) injury has been associated with an increased rate of ACL reconstruction (ACLR) failure, high-grade pivot shift (PS), and lower return to sports rate. On the other hand, medial-sided procedures in the setting of ACLR are associated with knee stiffness and arthrofibrosis.

Purpose/hypothesis: This study aimed to compare clinical scores, objective knee laxity, failure, and complication rates in 2 different patient groups. The combination of ACL reconstruction with LET and the Hughston procedure yields comparable failure rates, complication rates, and clinical outcomes to ACL reconstruction with LET in patients without medial instability.

Study design: Cohort study; Level of evidence, 3.

Methods: A group of patients had a combined ACL and MCL injury grade 2 with chronic instability and underwent ACLR associated with lateral extra-articular tenodesis (LET) and the Hughston procedure (Hughston group). The control group included matched patients with isolated ACL lesion without medial instability who underwent ACL reconstruction with LET (control group). Patient-reported outcome measures, complications, and reoperations were collected for both groups. A clinical evaluation was performed including objective anteroposterior laxity measurement (KT-1000 arthrometer) and PS quantification. The primary outcomes were ACL revision and ACL-clinical failure, a composite parameter of anteroposterior and rotatory laxity. A test for 2-way analysis of variance for repeated measures was performed to assess the between-group differences (P < .05). Surgical and clinical failure were assessed via Kaplan-Meier method.

Results: A total of 70 patients (35 per group) were enrolled in the present study at a follow-up of 8.1 ± 2.7 years. All the patient-reported outcome measures significantly improved at the final follow-up with no difference between the 2 groups (P > .05). ACL revision was performed in 2 of 35 (5.7%) patients in both groups (P = .79). A total of 10 patients (4 in the Hughston group and 6 in the control group) were excluded from the analysis of the clinical failures due to contralateral-side injury. Clinical failure was identified in 7 of 28 (25.0%) patients in the Hughston group and 5 of 29 (17.2%) in the control group (P = .59). Reoperation due to knee stiffness was required only in 1 of 35 patients (2.9%) of the Hughston group.

Conclusion: Due to its simplicity and cost-effectiveness, the Hughston technique should be included in the orthopaedic surgeon's armamentarium for the treatment of moderate anteromedial instability in combined ACL and MCL injury. Moreover, the outcomes and failure rate of the Hughston technique combined with an ACLR + LET are similar to that of an ACLR + LET used to treat an isolated ACL injury.