Hello everyone, it's a great pleasure to be here. I don't have any disclosures relevant to this talk. It's a particular pleasure to be here because our earlier work with much shorter follow-up received the Richard O'Connor Award in 2017. In that study we demonstrated that patients who underwent a combined reconstruction had a significantly reduced graft rupture rate compared to those who had an isolated reconstruction and in multivariate analysis that difference was two to three fold, so very significant. As you all know this has been a very controversial topic but since that initial publication there's been a number of comparative studies from other groups as well as our own demonstrating advantages in specific populations including young patients participating in pivoting sports, those with chronic ACL injuries, hyperlaxity and those undergoing revision ACL reconstruction. Those advantages were with respect to reduced graft rupture rates, improved return to sport, improved patient reported outcome measures. In addition we've also recently demonstrated that patients who have a combined reconstruction and a meniscal repair have a significantly reduced secondary meniscectomy rate and the rationale for these findings is based upon improved knee stability and load sharing with the ACL graft and meniscal repair. We've also just heard that there's advantages seen in elite athletes and we have our own forthcoming comparative series demonstrating significantly reduced graft rupture rates in elite alpine skiers from the French national team. The aim of this study though is to address one of the major deficiencies in the literature which is the lack of any long-term clinical outcomes. We compared patients who underwent isolated reconstruction with combined reconstructions during the period of 2011 to 2012. We matched them using propensity scoring which I'm going to explain in a bit more detail in a moment. The surgical technique for the combined reconstruction is to use a hamstring tendon autograft, a single femoral tunnel for both the ACL and ALL reconstruction. The ACL graft is comprised of a triple semitendinosus and a single strand of gracilis. That additional length of gracilis forms the anterolateral ligament reconstruction. It exits from the lateral cortex proximal and posterior to the lateral epicondyle through a tibial tunnel and back to itself underneath the iliotibial band. It's fixed in full extension and neutral rotation with suture fixation only. In terms of follow-up there was no differences between the groups in terms of rehabilitation. Our follow-up was face-to-face until 24 months and then the final follow-up was through medical notes review and telemedicine. During that telemedicine interview we sought to determine whether they had any symptoms suggestive of graft rupture or re-injury and if they did we recalled them for physical examination and MRI. We also recorded PROMS at final follow-up. The propensity matching is detailed here. On the right hand column you can see the absolute standardized differences. If it's less than 0.25 it means that they're well matched so we analyzed all those seven criteria which I'm not going to go through in detail but we demonstrated good matching of the groups. So we had 86 match pairs that we followed up a mean follow-up of 104 months. There was no differences in knee stability between the groups at the two-year follow-up mark or in PROMS at final follow-up. This is the main slide of interest so when we compare the two groups the graft rupture rate in the isolated group was 17% and in the combined group three and a half percent. When we analyzed that in multivariate analysis the odds ratio was 5.5 in favor of combined reconstructions. The re-operation rate was also significantly higher in the isolated ACL reconstruction group but when we looked at that in detail that was mainly due to the fact that the revision ACL reconstruction rate was higher in the isolated ACL reconstruction group and non graft rupture related re-operations were not significantly different between the two groups. In terms of complications there was also no significant differences between groups but this is likely underpowered because the actual incidence of complications was pretty low in both groups. So in conclusion patients who undergo combined ACL and ALL reconstruction experience significantly better long-term ACL graft survivorship, lower overall rates of re-operation and no increase in complications when compared to those who undergo isolated ACL reconstruction. However patients who underwent an isolated ACL reconstruction have a more than fivefold greater risk of undergoing revision surgery compared to those undergoing combined reconstructions. Thank you.

graft rupture rate

combined reconstruction

patient-reported outcome measures

re-operation rate

long-term graft survivorship