Residual rotational instability after ACL reconstruction: is leat the answer for grade 3 pivot shift

Introduction: Persistent residual rotational instability has been reported in about 15-35% of cases after ACL reconstruction, demonstrated by a positive pivot-shift test. Therefore, it has been proposed that reconstructive techniques for ACL injuries do not completely restore the normal rotational stability of the knee, despite recent advancements in surgical procedures and knowledge of the architecture and biomechanics of the ACL. Considering the reported variation in combined ACL and Lateral extra-articular tenodesis outcomes, this study assessed the improvement in rotational instability after combined ACL and LEAT. Methods: The current study analysed 54 patients who had been treated for ACL injuries in the Sports Injury Centre, VMMC&SJH, New Delhi. The clinical evaluation for residual laxity or rotational instability was conducted 12 months post-surgery using the pivot shift test, anterior drawer test, and Lachman test. Results: The study included 54 patients, out of which 8.78% were female and 92.22% were male. The mean age of the operated patients was 29.14 years (16- 53 years). Of the 54 patients, 16 reported positive for high-grade pivot shift test with positive anterior drawer and Lachman test pre-operatively. The 16 patients operated on for ACL reconstruction and LEAT did not report any 'giving way' complaints and were found negative for pivot shift test post-operatively at follow-up after 12 months. On the other hand, out of 38 patients who underwent isolated ACL reconstruction, 6 patients (15.8%) were found to be positive for pivot shift test post-operatively after 12 months. One of these patients reported graft failure with the complaint of not being able to return to normal activity completely at a follow-up of 12 months. Conclusion: The data supporting the combined ACL and ALL reconstruction surgeries are limited, low-evidence, and controversial. Such procedures should be customized according to clinical imaging and arthroscopic assessment. This audit may add to the data pool for generating high-quality clinical evidence to opt for combined surgeries over isolated ACL reconstruction.