Non-anatomical double-bundle anterior cruciate ligament reconstruction combined with modified lateral extra-articular tenodesis in high-grade pivot shift anterior cruciate ligament injury：A retrospective study

Non-anatomical double-bundle anterior cruciate ligament reconstruction combined with modified lateral extra-articular tenodesis in high-grade pivot shift anterior cruciate ligament injury：A retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Non-anatomical double-bundle anterior cruciate ligament reconstruction combined with modified lateral extra-articular tenodesis in high-grade pivot shift anterior cruciate ligament injury：A retrospective study Xu Liu, Lingzhi Li, Haibo Yang, Zhaojun Wang, Xin Xie, Zhong Li, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2933213/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Both the non-anatomical double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) and lateral extra-articular tenodesis (LET) show superior performance in controlling the rotational stability of the knee. However there are few studies published to investigate the curative effect of non-anatomical DB ACLR combined with LET in high-grade pivot shift anterior cruciate ligament ruptures. This study aims to evaluate the short-term clinical and imaging results of the treatment program and summarize the advantages of the surgical technique. Method: All the 33 patients we reviewed in this study have accepted the non-anatomical DB ACLR with LET surgery from January 2018 to January 2022 in our Department of Orthopedics. Primary demographic data collected include gender (23 males and 10 females), age (16-37 years, average 23.5 years), BMI (21.8-31.2 kg/m 2 , average 25.7 kg/m 2 ), follow-up period (12-18 months, average 15.2 months) and injury mechanism (25 sports Injuries and 8 traffic accidents). The assessment of clinical outcomes included pre- and post-operative physical examination, knee functional scores and imaging data. Result: All patients in this study were followed up with an average 16.8-month (range 12-26 months) follow-up period. 23 patients had a grade 3 pivot shift and 10 had a grade 2 pivot shift. Immediate postoperative pivot shift tests were all negative, and only one case had a grade 1 pivot shift at the final follow-up. All the cases preoperatively had a positive Lachman test and turned negative at the final follow-up. The average ROM improved from 63.2°± 17.9° to 132.8°±3.6 °at the last follow-up (p<0.001); The VAS score decreased from 5.6±1.8 to 0.9±0.7 (p<0.001); the average KT-1000 healthy-side to affected-side difference decreased from 9.3±1.6 mm to 2.2 ± 0.5 mm. The comparison of all the knee functional scores ( IKDC, Tegner scores and Lysholom ) at pre-operative and last follow-up showed a significant difference (p<0.001). None of the cases had operation-related complications except one with slight prepatellar pain. Conclusion: Non-anatomical double-bundle anterior cruciate ligament reconstruction combined with modified lateral extra-articular tenodesis is a reliable and recommended treatment for anterior cruciate ligament rupture with high-grade pivot shift, showing a striking improvement in knee rotational Stability and function in the short-term follow-up. Non-anatomical DB ACLR Modified LET High-grade pivot shift Rotational instability Figures Figure 1 Figure 2 Figure 3 Background Arthroscopic anterior cruciate ligament reconstruction (ACLR) is regarded as the most effective and ideal treatment for anterior cruciate ligament (ACL) rupture and has been proven by massive research [ 1 ]. However, the postoperative residual rotation instability measured by high-grade pivot shift is one of the most significant risk factors leading to the failure of ACL reconstruction and contributes to meniscus and cartilage injury additionally [ 2 – 4 ]. With the development of the anatomy and biomechanics of the knee, ACLR techniques have also significantly progressed [ 5 , 6 ]. It has previously been established that double-bundle (DB) ACLR recovers rotational laxity better than single-bundle (SB) ACLR [ 7 , 8 ]. But the increased number of bone tunnels based on anatomical bundle footprint raised the risk of tunnel enlargement, producing severe clinical outcomes such as graft failure and high-difficulty revision surgery [ 9 ]. Taking this into account, non-anatomical DB ACLR is an appropriate reconstruction technique with fewer bone tunnels and fixation devices but an equivalent effect in restoring rotation stabilization in a shorter operation time [ 10 ]. Nevertheless, the anterior cruciate ligament is the primary structure constraining the anterior movement of the tibia. Its running path forms a very modest angle with the direction of knee joint flexion and extension, which means a limited role in controlling rotation. Rotational instability can occur in up to 25% of patients after isolated ACLR [ 11 ]. The anterolateral complex(ALC) mainly includes the iliotibial band, the anterolateral joint capsule, and the anterolateral ligament [ 12 ]. More recently, the literature has focused on the damage of ALC in ACL injury as it is highly correlated with anterolateral rotation instability of the knee [ 12 ]. Therefore, the augmentation or reconstruction of anterolateral structure combined with ACLR to control rotation has been widely applied. The two main effective techniques comprise lateral extra-articular tenodesis(LET) and anterolateral ligament reconstruction [ 13 – 15 ]. Compared with anterolateral ligament reconstruction, the LET has a more significant restriction on the anteroposterior and internal rotation of the knee [ 15 , 16 ]. Besides that, the LET preserves the insertion of the iliotibial band on the tibial tuberosity without additional tendon grafts harvested [ 15 ]. In summary, non-anatomical double-bundle ACLR with lateral extra-articular tenodesis may be an ideal choice for ACL rupture with high-grade pivot shift. To the best known of our knowledge, only a few studies have observed the clinical results of LET in non-anatomical DB ACLR. Notably, we performed a modified lateral extra-articular tenodesis using loop-lock fixation on the ACL graft, which can promote tendon-bone healing with fewer fixation devices. The purpose of this study was to retrospectively analyze the short-term follow-up results of non-anatomical DB ACLR with LET in high-grade pivot shift ACL rupture. Method patients All the 33 patients we reviewed in this study have accepted the non-anatomical DB ACLR with LET surgery from January 2018 to January 2022 in our Department of Orthopedics. Primary demographic data collected include gender (23 males and 10 females), age (16–37 years, average 23.5 years), BMI (21.8–31.2 kg/m 2 , average 25.7 kg/m2), follow-up period (12–18 months, average 15.2 months) and injury mechanism (25 sports injuries and 8 traffic accidents) (Table. 1). Inclusion criteria were as follows: (1) preoperative MRI and physical examination showed a definite rupture of ACL ; (2) high-grade pivot shift under anesthesia(grade 2 or greater); (3) patients with a least 1-year postoperative follow-up; (4) related case data was available and complete. Exclusion criteria were as follows: (1) patients undergoing knee surgery previously; (2) patients with severe knee degeneration ; (3) ACL rupture combined with severe meniscus injury or ligament injury before operation ; (4) abnormal alignment of the affected limb. According to the detailed preoperative examinations, there are 19 cases with a combined medial or lateral meniscus injury, 10 cases with a mild bone bruise, and 2 cases with slight Segond fracture. Compared with the healthy side under anesthesia, out of 33 cases, 23 cases have a grade 3 pivot shift, others have a grade 2 pivot shift. On arrival at our department, patients were asked to carry out some moderate postoperative rehabilitation to promote the subsidence of swelling. After adequate preoperative preparation, the patients received an operation with informed consent obtained. All the surgeries were performed by the same senior orthopedic surgeon. Surgical technique Non-anatomical DB ACL reconstruction An arthroscopic exploration was performed initially to confirm the ACL rupture and specific condition of the meniscus. If a meniscal injury was found, a partial meniscectomy or suture repair was performed. Then the semitendinosus and gracilis tendons from the ipsilateral limb were harvested to obtain a 2-strand autograft with sufficient strength. According to Zaffagnini et al. [ 7 ], an 8 mm tibial tunnel was drilled from the side of the medial collateral ligament to the Posteromedial side of the original ACL footprint. The entrance of the femoral tunnel was close to the native insertion of the postero-lateral bundle, and the exit on the lateral femoral epicondyle was close to the “over-the-top” location. The ACL autograft was then threaded through the tibial and femoral tunnels, over the top, and back into the tibial tunnel via the lateral soft tissue tunnel. Modified lateral extra-articular tenodesis The iliotibial band was exposed through an arc-shaped incision from the lateral epicondyle of the femur to the anterolateral Gerdy tubercle of the proximal tibia. The tendon was cut about 1 cm wide from the middle and posterior part of the iliotibial band, left intact at Gerdy tubercle, and separated about 10 cm to proximal and free the end, which was tightly sutured. Then the iliotibial band graft was passed deep into the lateral collateral ligament (LCL), wrapped around the superficial ACL graft on the lateral epicondyle, and back to the LCL attachment on the femur. An absorbable interference screw was applied to the fixation of the ACL graft at 30°of knee flexion in the tibial tunnel after both the ACL and iliotibial band grafts were tightened. Subsequently, the partial LCL on its femoral attachment, the iliotibial graft band and the superficial ACL graft on the lateral epicondyle were all fixed with high-strength sutures as a unity at 60°flexion. Immediately pivot shift and Lachman tests after surgery are all negative. Surgical procedures are presented in Fig. 1 . Postoperative rehabilitation After recovering from anesthesia completely, the affected limb was allowed to perform isometric quadriceps and ankle pump training to prevent muscle disuse atrophy and venous thrombosis in the lower extremities. Then the patients were required to wear an adjustable brace within the first 2 weeks without any weight-bearing. Gradually bending by 0–90°was allowed in first the 4 weeks after the operation, and the passive range of motion (ROM) reached the level of the healthy side at 6 weeks after surgery. Patients began to partial weight-bearing walk with crutches under the guidance of a rehabilitation physician at 6 weeks after surgery. Strenuous sports exercises were not recommended until an excellent functional assessment 6 months after surgery. Clinical outcome assessment The basic Lachman test, the pivot shift test and the KT-1000 device were used to evaluate knee stability. The Functional evaluation comprised the ROM, visual analogue scale (VAS) score, International Knee Documentation Committee (IKDC) score, tegner activity score and the Lysholm score [ 17 – 19 ]. Complications such as wound infection, prepatellar pain and knee swelling were also recorded. All the data were collected preoperatively and at the last follow-up. Imaging evaluation The radiographic examinations were required to reveal the condition of bone tunnels and internal fixations. In addition, an MRI examination was needed to show the tension and continuity of the graft. Statistical analysis Data management and analysis were carried out using SPSS software (version 25.0, Armonk, NY, USA for SPSS software package, IBM Corp.). The normal data distribution was determined through the Kolmogorov-Smirnov test. The paired t-test was used for the comparison of preoperative and follow-up clinical results. A chi-squared test was performed to compare the results of the pivot shift and Lachman tests. For all tests, a p- value < 0.05 was considered significant. Result All patients in this study were followed up with an average 16.8-month (range 12–26 months) follow-up period. In the preoperative physical examination under anesthesia, 23 patients had a grade 3 pivot shift and 10 had a grade 2 pivot shift. Immediate postoperative pivot shift tests were all negative, while only one case had a grade 1 pivot shift at the final follow-up. All the cases preoperatively had a positive Lachman test and turned negative at the final follow-up (Table. 2). The average ROM improved Significantly from 63.2°± 17.9° preoperatively to 132.8°±3.6 °at the last follow-up (p < 0.001). The pain of patients was significantly relieved with a decreased VAS score from 5.6 ± 1.8 to 0.9 ± 0.7 (p < 0.001). The comparison of all the knee functional scores at pre-operative and last follow-up showed a significant difference (p < 0.001). The average IKDC score improved from 55.0 ± 8.3 to 88.2 ± 3.8; the average Tegner activity score improved from 2.4 ± 0.7 to 6.6 ± 1.3, the average Lysholm score improved from 56.4 ± 7.8 to 91.9 ± 2.8, and the average KT-1000 healthy-side to affected-side difference decreased from 9.3 ± 1.6 mm to 2.2 ± 0.5 mm (Table.3). At the last follow-up, only one patient was reported to have mild prepatellar pain when running, none of the other patients had operation-related complications, including wound infection, nerve injury, limited range of motion and knee swelling. The radiographic and MRI examination at the last follow-up showed that the grafts maintained good tension and continuity with no internal fixation failure. The typical imaging outcomes are shown in Fig. 2 and Fig. 3 . Discussion Thus far, a number of studies confirmed the effectiveness of arthroscopic ACLR in ACL injury with long-term observation. Owing to the rapid development of the knee anatomy, the techniques of ACL reconstruction have also been continuously improved to accomplish a more anatomical reconstruction. Since it was first explicitly reported in 1938 by Palmer et al. [ 20 ] that the ACL can be divided into the anteromedial bundle and posterolateral bundle, the double-bundle reconstructive techniques dedicated to restoring the anatomy of ACL have attracted considerable interest. Prior to the study of Mott in 1983 [ 21 ], the procedure of double-bundle ACLR was largely unknown. In 1999, a subsequent evaluation of clinical efficacy was first reported by Muneta et al. [ 22 ] including 54 cases with at least a 2-year follow-up, showed an excellent clinical result. After nearly two decades of exploration, there are a lot of high-quality original studies comparing single-bundle and double-bundle ACLR. In 2015, Mascarenhas et al. [ 23 ] conducted a systematic review of overlapping meta-analyses comprising 9 literature, and after integrating the results of these studies, the DB ACLR showed better anterior-posterior and rotational stability than SB ACLR. As far as we know, patients with preoperative high-grade pivot shift are more likely to have residual rotation instability after surgery, which contributes to the limitation of activity, degeneration of knee joint and even the failure of grafts [ 3 , 4 ]. Consequently, the double-bundle ACLR might be a suitable approach for high-grade pivot shift patients to eliminate the risks associated with rotational instability. Notably, the DB reconstructive technique in this study was not the traditional 4-tunnel anatomical reconstruction. When first developed by Marcacci [ 24 ], the method was characterized by the combination of double tunnels and the over-the-top passage. Despite not entirely anatomically reconstruction through the footprint of ACL, the non-anatomical DB ACLR can also restore the kinematic effect of the anteromedial and posterolateral bundles to some degree. Moreover, the clinical study have suggested that non-anatomical DB ACLR can achieve the same effective performance in controlling rotation as anatomical DB ACLR with less bone damage and internal fixations [ 10 ]. Nowadays, the ALC has attracted much attention because of its strong correlation with rotational stability. The injury of ALC in ACL ruptures could potentially increase the risk of rotational instability [ 12 ]. Given this, various auxiliary surgical methods have been proposed to improve the stability of the knee joint by the augmentation or reconstruction of the anterolateral structure [ 13 – 15 ]. The lateral extra-articular tenodesis was first presented by KennedyJC et al. [ 25 ] in 1978. It was initially proposed because of the lack of an intra-articular ligament reconstruction technique at that time, so it is suitable for open surgery to restore rotational stability. However, with the development of arthroscopic technique and the concept of minimally invasive, LET was once neglected. However, as more and more patients who have undergone ACL reconstruction in recent years still have residual rotational instability, the surgeons gradually recognized the importance of the LET again. In clinical practice, a variety of tenodesis procedures have been proposed. In accordance with the meta-analyze performed by Hurley et al. [ 26 ], the anatomical reconstruction of anterolateral ligament, the Cocker-Arnold and Lemaire techniques are more effective in reducing the proportion of residual rotational instability and the graft re-ruptures after surgery. Indeed, the LET yields good results in controlling rotational stability in patients with or without ALC injury. A meta-analysis by Onggo et al. [ 27 ] showed that ACL reconstruction combined with LET could significantly reduce the positive rate of pivot shift and improve the subjective function score. Besides, a prospective multicenter randomized controlled trial by Getgood et al. [ 28 ] showed similar outcomes. Up to now, no consensus has been reached on the indications for the clinical application of LET. According to Mahmoud [ 29 ], the application indication of LET is the lateral laxity of the knee, hyperextension, or increased internal rotation angle (more than 5–10°) of the affected knee. While in the research of ArieldeLima et al. [ 30 ], patients with high-grade pivot shift and high exercise demands, and ACL reconstruction or chronic ACL injury patients need to receive LET. In addition, Sonnery-Cottet et al. [ 31 ] added the medial meniscus injury as an indication for LET on the basis of the above. Therefore, the applicable standards of LET needs to be further studied and refined. In our opinion, referring to previous research and combined with the actual situation, young patients with high-grade rotation instability and demands of high-intensity exercise should receive LET, and the cases in our study met the standards. Noteworthy, we used a modified lateral extra-articular tenodesis similar to the modified Lemaire technique [ 32 ] in this study. The iliotibial band graft was passed deep into not only the LCL but also the superficial ACL graft on the lateral epicondyle, then wrapped around back to the LCL femoral attachment, forming a stable loop-lock structure. Furthermore, for the fixation of the iliotibial band graft, high-strength sutures were used to sew it with the ACL graft on the lateral epicondyle and partial LCL on its femoral attachment to obtain a sheet-shaped whole, which can increase the contact surface to promote tendon-bone healing with no other fixation devices. Although both the non-anatomical DB ACLR and LET show superior performance in controlling the rotational stability of the knee, there are few studies published to investigate the curative effect of non-anatomical DB ACLR combined with LET in high-grade pivot shift anterior cruciate ligament injury. In our research, integrating the two surgical techniques yields inspiring outcomes in rotational stability and function of the knee. However, the generalisability of the results is subject to certain limitations. For instance, there is a missing control group of other surgical, and the detailed situations of ALC in all cases need to be collected, for further research on this surgical technique, larger cohorts and more extended follow-up periods are required. Conclusion Non-anatomical double-bundle anterior cruciate ligament reconstruction combined with modified lateral extra-articular tenodesis is a reliable and recommended treatment for anterior cruciate ligament rupture with high-grade pivot shift, showing a striking improvement in knee rotational Stability and function in the short-term follow-up. Abbreviations DB double-bundle ACLR arthroscopic anterior cruciate ligament reconstruction LET lateral extra-articular tenodesis ACL anterior cruciate ligament SB single-bundle ALC anterolateral complex LCL lateral collateral ligament ROM range of motion VAS visual analogue scale IKDC International Knee Documentation Committee MRI Magnetic resonance imaging CT Computed tomography. Declarations Ethics approval and consent to participate The Ethics Committee of the Affiliated Hospital of Southwest Medical University approved all experimental procedures in conformity with the Declaration of Helsinki. Informed consent was obtained from all patients included in the study. Consent for publication I nformed consent for the article publication was obtained from all the patients in this study Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to limitations of ethical approval involving the patient data and anonymity but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' contributions ZL and JCL designed the study. XL drafted the article. ZL and JCL performed the surgery. LZL and HBY revised the manuscript. ZJW and XX collected the data. The author(s) read and approved the final manuscript. We would like to thank all the staff in our Department of Orthopedics References Hensler D, Illingworth KD, Fu FH. Principle considerations in anatomic ACL reconstruction. Arthroscopy. 2010;26(11):1414–5. Kawanishi Y, Kobayashi M, Yasuma S, Fukushima H, Kato J, Murase A, et al. Anterolateral ligament reconstruction in addition to primary double-bundle anterior cruciate ligament reconstruction for grade 3 pivot shift improves residual knee instability during surgery. J Exp Orthop. 2021;19(1):51. Galway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res. 1980;(147):45–50. Stergiou N, Ristanis S, Moraiti C, Georgoulis AD. Tibial rotation in anterior cruciate ligament (ACL)-deficient and ACL-reconstructed knees: a theoretical proposition for the development of osteoarthritis. Sports Med. 2007;37(7):601–13. Zampeli F, Ntoulia A, Giotis D, Tsiaras VA, Argyropoulou M, Pappas E, et al. Correlation between anterior cruciate ligament graft obliquity and tibial rotation during dynamic pivoting activities in patients with anatomic anterior cruciate ligament reconstruction: an in vivo examination. Arthroscopy. 2012;28(2):234–46. Hwang MD, Piefer JW, Lubowitz JH. Anterior cruciate ligament tibial footprint anatomy: systematic review of the 21st century literature. Arthroscopy. 2012;28(5):728–34. Zaffagnini S, Bruni D, Marcheggiani Muccioli GM, Bonanzinga T, Lopomo N, Bignozzi S, et al. Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings ACL reconstruction: a prospective randomized study at 8-year minimum follow-up. Knee Surg Sports Traumatol Arthrosc. 2011;19(3):390–7. Maeyama A, Hoshino Y, Kato Y, Debandi A, Lertwanich P, Wang JH, et al. Anatomic double bundle ACL reconstruction outperforms any types of single bundle ACL reconstructions in controlling dynamic rotational laxity. Knee Surg Sports Traumatol Arthrosc. 2018;26(5):1414–9. Sastre S, Popescu D, Núñez M, Pomes J, Tomas X, Peidro L. Double-bundle versus single-bundle ACL reconstruction using the horizontal femoral position: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc. 2010;18(1):32–6. Zaffagnini S, Marcheggiani Muccioli GM, Signorelli C, Lopomo N, Grassi A, Bonanzinga T, et al. Anatomic and nonanatomic double-bundle anterior cruciate ligament reconstruction: an in vivo kinematic analysis. Am J Sports Med. 2014;42(3):708–15. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543–52. Getgood A, Brown C, Lording T, Amis A, Claes S, Geeslin A, et al. The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):166–76. 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):3089–97. Delaloye JR, Hartog C, Blatter S, Schläppi M, Müller D, Denzler D, et al. Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-Articular Tenodesis Similarly Improve Knee Stability After Anterior Cruciate Ligament Reconstruction: A Biomechanical Study. Arthroscopy. 2020;36(7):1942–50. Geeslin AG, Moatshe G, Chahla J, Kruckeberg BM, Muckenhirn KJ, Dornan GJ, et al. Anterolateral Knee Extra-articular Stabilizers: A Robotic Study Comparing Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis. Am J Sports Med. 2018;46(3):607–16. Inderhaug E, Stephen JM, Williams A, Amis AA. Biomechanical Comparison of Anterolateral Procedures Combined With Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017;45(2):347–54. Rossi MJ, Lubowitz JH, Guttmann D. Development and validation of the International Knee Documentation Committee Subjective Knee Form. Am J Sports Med. 2002;30(1):152. Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Reliability, validity, and responsiveness of the Lysholm knee scale for various chondral disorders of the knee. J Bone Joint Surg Am. 2004;86(6):1139–45. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43–9. Palmer I. On the injuries to the ligaments of the knee joint: a clinical study. 1938. Clin Orthop Relat Res. 2007;454:17–22. Mott HW. Semitendinosus anatomic reconstruction for cruciate ligament insufficiency. Clin Orthop Relat Res. 1983;(172):90–2. Muneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto H, Shinomiya K. Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with endobuttons: operative technique and preliminary results. Arthroscopy. 1999;15(6):618–24. Mascarenhas R, Cvetanovich GL, Sayegh ET, Verma NN, Cole BJ, Bush-Joseph C, 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(6):1185–96. Marcacci M, Molgora AP, Zaffagnini S, Vascellari A, Iacono F, Presti ML. Anatomic double-bundle anterior cruciate ligament reconstruction with hamstrings. Arthroscopy. 2003;19(5):540–6. Kennedy JC, Stewart R, Walker DM. Anterolateral rotatory instability of the knee joint. An early analysis of the Ellison procedure. J Bone Joint Surg Am. 1978;60(8):1031–9. Hurley ET, Bloom DA, Hoberman A, Anil U, Gonzalez-Lomas G, Strauss EJ, et al. There are differences in knee stability based on lateral extra-articular augmentation technique alongside anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2021;29(11):3854–63. Onggo JR, Rasaratnam HK, Nambiar M, Onggo JD, Pai V, Damasena I, et al. Anterior Cruciate Ligament Reconstruction Alone Versus With Lateral Extra-articular Tenodesis With Minimum 2-Year Follow-up: A Meta-analysis and Systematic Review of Randomized Controlled Trials. Am J Sports Med. 2022;50(4):1137–45. Getgood AMJ, Bryant DM, Litchfield R, Heard M, McCormack RG, Rezansoff A, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020;48(2):285–97. Mahmoud A, Torbey S, Honeywill C, Myers P. Lateral Extra-Articular Tenodesis Combined With Anterior Cruciate Ligament Reconstruction Is Effective in Knees With Additional Features of Lateral, Hyperextension, or Increased Rotational Laxity: A Matched Cohort Study. Arthroscopy. 2022;38(1):119–24. Ariel de Lima D, Helito CP, Lima FRA, Leite JAD. Surgical indications for anterior cruciate ligament reconstruction combined with extra-articular lateral tenodesis or anterolateral ligament reconstruction. Rev Bras Ortop. 2018;53(6):661–7. Sonnery-Cottet B, Vieira TD, Ouanezar H. Anterolateral Ligament of the Knee: Diagnosis, Indications, Technique. Outcomes Arthrosc. 2019;35(2):302–3. Porter MD, Shadbolt B, Pomroy S. The Augmentation of Revision Anterior Cruciate Ligament Reconstruction With Modified Iliotibial Band Tenodesis to Correct the Pivot Shift: A Computer Navigation Study. Am J Sports Med. 2018;46(4):839–45. Tables Table 1 Demographics and preoperative features in this study Demographics and preoperative features Value Number of patients 33 Sex, male/female 23/10 Age, years (range) 22.1 (16–37) Side, left/right 12/21 BMI, kg/m 2 (range) 25.2 ± 3.0 (16–37) Follow-up period, months (range) 16.8 (12–26) Injury mechanism, sports Injury/traffic accident 25/8 Values are presented as mean ± standard deviation; BMI body mass index Table 2 The pivot shift and Lachman tests at pre-operative and last follow-up Item Pre-operative N (%) Last follow-up N (%) Pivot-shift test Negative 0 (0%) 32 (97%) Grade 1 0 (0%) 1 (3%) Grade 2 10 (30%) 0 (0%) Grade 3 23 (70%) 0 (0%) Lachman test Negative 33 (100%) 0 (0%) Positive 0 (0%) 33 (100%) Table 3 Comparison of clinical outcomes at pre-operative and last follow-up Outcome Pre-operative Last follow-up p -value ROM (°) 63.2 ± 17.9 132.8 ± 3.6 < 0.001* VAS pain 5.6 ± 1.8 0.9 ± 0.7 < 0.001* IKDC score 55.0 ± 8.3 88.2 ± 3.8 < 0.001* Tegner activity score 2.4 ± 0.7 6.6 ± 1.3 < 0.001* Lysholm score 56.4 ± 7.8 91.9 ± 2.8 < 0.001* KT-1000 side-to-side difference (mm) 9.3 ± 1.6 2.2 ± 0.5 < 0.001* Values are presented as mean ± standard deviation; ROM range of motion,; VAS visual analog scale; IKDC International Knee Documentation Committee *Signifcant diference compared to preoperatively Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2933213","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":200268992,"identity":"90094770-ca66-4818-b882-5bfa32959830","order_by":0,"name":"Xu Liu","email":"","orcid":"","institution":"Department of Orthopaedics, the Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Liu","suffix":""},{"id":200268993,"identity":"e458898d-cabb-4ec1-b235-7160e5a38be6","order_by":1,"name":"Lingzhi Li","email":"","orcid":"","institution":"Department of Orthopaedics, the Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lingzhi","middleName":"","lastName":"Li","suffix":""},{"id":200268994,"identity":"ce07c75b-ecee-4a9a-9561-a8f979a7f652","order_by":2,"name":"Haibo Yang","email":"","orcid":"","institution":"Department of Orthopaedics, the Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Haibo","middleName":"","lastName":"Yang","suffix":""},{"id":200268995,"identity":"833b290e-6398-457a-bd76-900099bc0309","order_by":3,"name":"Zhaojun Wang","email":"","orcid":"","institution":"Department of Orthopaedics, the Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhaojun","middleName":"","lastName":"Wang","suffix":""},{"id":200268996,"identity":"2f2fa513-10aa-498d-b1ba-384268bac457","order_by":4,"name":"Xin Xie","email":"","orcid":"","institution":"Department of Clinical Medicine, the Southwest Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Xie","suffix":""},{"id":200268997,"identity":"1c520ce1-e316-44fa-88b7-51ac3222f80a","order_by":5,"name":"Zhong Li","email":"","orcid":"","institution":"Department of Orthopaedics, the Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhong","middleName":"","lastName":"Li","suffix":""},{"id":200268998,"identity":"ade9b0ec-b9e3-4c9c-9bf4-bc72b125c3b0","order_by":6,"name":"Juncai Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIie3QsYoCMRCA4cjIVKPbzqLcMywIi4Lgq2wQ7ATLFCKCsluIvb6FpaWykCpiK9hoY62dpdHqKpPy4PIXgcB8DIkQodAfrC529kyYIoD9JVNjN8EPUe1mXGA/uRjtQ94Z1U2OlMbXOXiQSnlr1HImUeJAySmKqFhkji06jdeWVGagT3LbFGwOGwcxyA9LAHBwkgbtVww9iLQEgdKRzMGT3A0TWSI8iW51VoqJAfucGU3Ot0RcXs+UTHq9Y7l/PNX4JyqW34ngXZV/3+n7+GfNFO7uqVAoFPrXvQBnikIm5pQNngAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Orthopaedics, the Affiliated Hospital of Southwest Medical University, Sichuan Provincial Laboratory of Orthopaedic Engineering","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Juncai","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2023-05-14 09:59:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2933213/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2933213/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":37154905,"identity":"93bb3b71-6f41-4eb0-b543-c118f9f04381","added_by":"auto","created_at":"2023-05-17 19:40:48","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":303841,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-operative images. \u003cstrong\u003ea\u003c/strong\u003e Brief technical presentation in frontal and anterolateral views of the knee. \u003cstrong\u003eb \u003c/strong\u003eThe ACL was confirmed ruptured by arthroscopy. \u003cstrong\u003ec \u003c/strong\u003eThe femoral bone and soft tissue tunnels. \u003cstrong\u003e\u0026nbsp;d \u003c/strong\u003eFemoral tunnel (red arrow) and tibial tunnel (white arrow) were drilled under the C-arm monitoring. \u003cstrong\u003ee-f\u003c/strong\u003e Arthroscopic non-anatomical DB ACLR. \u003cstrong\u003eg\u003c/strong\u003eThe 10-cm-long by 1-cm-wide iliotibial band strip was extracted from the posterior half of the iliotibial band and left intact at Gerdy's tubercle.\u003cstrong\u003eh\u003c/strong\u003e The soft tissue tunnel in over-the-top position. \u003cstrong\u003ei\u003c/strong\u003e The ACL graft was passed through the femoral bone tunnel and back in the soft tissue tunnel. \u003cstrong\u003ej\u003c/strong\u003eThe modified lateral extra-articular tenodesis. \u003cstrong\u003ek \u003c/strong\u003eThe ACL graft was 26 cm in length and 6 mm in diameter, and the DB ACL graft was 8 mm in diameter.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2933213/v1/a77d9092a2936456d2dfcc68.jpg"},{"id":37154903,"identity":"ed85046c-ed14-41b3-8724-397a99492bdc","added_by":"auto","created_at":"2023-05-17 19:40:48","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":204834,"visible":true,"origin":"","legend":"\u003cp\u003eA 16-year-old male sprained his right knee in a basketball competition (case 1). \u003cstrong\u003ea-b \u003c/strong\u003e\u0026nbsp;Preoperative MRI examination showed the ACL rupture. \u003cstrong\u003ec-d\u003c/strong\u003e Immediately MRI images after surgery showed good tension and continuity of the ACL graft. \u003cstrong\u003ee–f \u003c/strong\u003ePostoperative X-ray examination showed no metal internal fixations. \u003cstrong\u003eg-h \u003c/strong\u003eMRI examination at the last follow-up showed that the ACL graft maintained good appearance and tension.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2933213/v1/858747d5336dd8236debb14f.jpg"},{"id":37155578,"identity":"c79bba86-5f22-412f-9d92-fbe33e23c8b4","added_by":"auto","created_at":"2023-05-17 19:48:48","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":198730,"visible":true,"origin":"","legend":"\u003cp\u003eA 22-year-old female hyperextended the right knee while running (case 2). \u003cstrong\u003ea-b \u003c/strong\u003ePreoperative MRI examination showed the ACL rupture. \u003cstrong\u003ec-d\u003c/strong\u003e Immediately MRI images after surgery showed good tension and continuity of the ACL graft. \u003cstrong\u003ee–f \u003c/strong\u003ePostoperative X-ray examination showed no metal internal fixations. \u003cstrong\u003eg-h \u003c/strong\u003eMRI examination at the last follow-up showed that the ACL graft maintained good appearance and tension.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2933213/v1/e9ebbfcb99b49c841e7e8b07.jpg"},{"id":40862008,"identity":"e33d12d0-e801-49e0-9b60-051cd3d0b986","added_by":"auto","created_at":"2023-08-01 06:22:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":749420,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2933213/v1/e185cd92-8878-45b4-a0cb-84cfdf92d1b0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Non-anatomical double-bundle anterior cruciate ligament reconstruction combined with modified lateral extra-articular tenodesis in high-grade pivot shift anterior cruciate ligament injury：A retrospective study","fulltext":[{"header":"Background","content":"\u003cp\u003eArthroscopic anterior cruciate ligament reconstruction (ACLR) is regarded as the most effective and ideal treatment for anterior cruciate ligament (ACL) rupture and has been proven by massive research [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, the postoperative residual rotation instability measured by high-grade pivot shift is one of the most significant risk factors leading to the failure of ACL reconstruction and contributes to meniscus and cartilage injury additionally [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. With the development of the anatomy and biomechanics of the knee, ACLR techniques have also significantly progressed [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It has previously been established that double-bundle (DB) ACLR recovers rotational laxity better than single-bundle (SB) ACLR [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. But the increased number of bone tunnels based on anatomical bundle footprint raised the risk of tunnel enlargement, producing severe clinical outcomes such as graft failure and high-difficulty revision surgery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Taking this into account, non-anatomical DB ACLR is an appropriate reconstruction technique with fewer bone tunnels and fixation devices but an equivalent effect in restoring rotation stabilization in a shorter operation time [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, the anterior cruciate ligament is the primary structure constraining the anterior movement of the tibia. Its running path forms a very modest angle with the direction of knee joint flexion and extension, which means a limited role in controlling rotation. Rotational instability can occur in up to 25% of patients after isolated ACLR [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The anterolateral complex(ALC) mainly includes the iliotibial band, the anterolateral joint capsule, and the anterolateral ligament [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. More recently, the literature has focused on the damage of ALC in ACL injury as it is highly correlated with anterolateral rotation instability of the knee [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, the augmentation or reconstruction of anterolateral structure combined with ACLR to control rotation has been widely applied. The two main effective techniques comprise lateral extra-articular tenodesis(LET) and anterolateral ligament reconstruction [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Compared with anterolateral ligament reconstruction, the LET has a more significant restriction on the anteroposterior and internal rotation of the knee [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Besides that, the LET preserves the insertion of the iliotibial band on the tibial tuberosity without additional tendon grafts harvested [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn summary, non-anatomical double-bundle ACLR with lateral extra-articular tenodesis may be an ideal choice for ACL rupture with high-grade pivot shift. To the best known of our knowledge, only a few studies have observed the clinical results of LET in non-anatomical DB ACLR. Notably, we performed a modified lateral extra-articular tenodesis using loop-lock fixation on the ACL graft, which can promote tendon-bone healing with fewer fixation devices. The purpose of this study was to retrospectively analyze the short-term follow-up results of non-anatomical DB ACLR with LET in high-grade pivot shift ACL rupture.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003epatients\u003c/h2\u003e \u003cp\u003eAll the 33 patients we reviewed in this study have accepted the non-anatomical DB ACLR with LET surgery from January 2018 to January 2022 in our Department of Orthopedics. Primary demographic data collected include gender (23 males and 10 females), age (16\u0026ndash;37 years, average 23.5 years), BMI (21.8\u0026ndash;31.2 kg/m\u003csup\u003e2\u003c/sup\u003e, average 25.7 kg/m2), follow-up period (12\u0026ndash;18 months, average 15.2 months) and injury mechanism (25 sports injuries and 8 traffic accidents) (Table. 1).\u003c/p\u003e \u003cp\u003eInclusion criteria were as follows: (1) preoperative MRI and physical examination showed a definite rupture of ACL ; (2) high-grade pivot shift under anesthesia(grade 2 or greater); (3) patients with a least 1-year postoperative follow-up; (4) related case data was available and complete.\u003c/p\u003e \u003cp\u003eExclusion criteria were as follows: (1) patients undergoing knee surgery previously; (2) patients with severe knee degeneration ; (3) ACL rupture combined with severe meniscus injury or ligament injury before operation ; (4) abnormal alignment of the affected limb.\u003c/p\u003e \u003cp\u003eAccording to the detailed preoperative examinations, there are 19 cases with a combined medial or lateral meniscus injury, 10 cases with a mild bone bruise, and 2 cases with slight Segond fracture. Compared with the healthy side under anesthesia, out of 33 cases, 23 cases have a grade 3 pivot shift, others have a grade 2 pivot shift. On arrival at our department, patients were asked to carry out some moderate postoperative rehabilitation to promote the subsidence of swelling. After adequate preoperative preparation, the patients received an operation with informed consent obtained. All the surgeries were performed by the same senior orthopedic surgeon.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eNon-anatomical DB ACL reconstruction\u003c/h2\u003e \u003cp\u003eAn arthroscopic exploration was performed initially to confirm the ACL rupture and specific condition of the meniscus. If a meniscal injury was found, a partial meniscectomy or suture repair was performed. Then the semitendinosus and gracilis tendons from the ipsilateral limb were harvested to obtain a 2-strand autograft with sufficient strength. According to Zaffagnini et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], an 8 mm tibial tunnel was drilled from the side of the medial collateral ligament to the Posteromedial side of the original ACL footprint. The entrance of the femoral tunnel was close to the native insertion of the postero-lateral bundle, and the exit on the lateral femoral epicondyle was close to the \u0026ldquo;over-the-top\u0026rdquo; location. The ACL autograft was then threaded through the tibial and femoral tunnels, over the top, and back into the tibial tunnel via the lateral soft tissue tunnel.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eModified lateral extra-articular tenodesis\u003c/h2\u003e \u003cp\u003eThe iliotibial band was exposed through an arc-shaped incision from the lateral epicondyle of the femur to the anterolateral Gerdy tubercle of the proximal tibia. The tendon was cut about 1 cm wide from the middle and posterior part of the iliotibial band, left intact at Gerdy tubercle, and separated about 10 cm to proximal and free the end, which was tightly sutured. Then the iliotibial band graft was passed deep into the lateral collateral ligament (LCL), wrapped around the superficial ACL graft on the lateral epicondyle, and back to the LCL attachment on the femur. An absorbable interference screw was applied to the fixation of the ACL graft at 30\u0026deg;of knee flexion in the tibial tunnel after both the ACL and iliotibial band grafts were tightened. Subsequently, the partial LCL on its femoral attachment, the iliotibial graft band and the superficial ACL graft on the lateral epicondyle were all fixed with high-strength sutures as a unity at 60\u0026deg;flexion. Immediately pivot shift and Lachman tests after surgery are all negative. Surgical procedures are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative rehabilitation\u003c/h2\u003e \u003cp\u003eAfter recovering from anesthesia completely, the affected limb was allowed to perform isometric quadriceps and ankle pump training to prevent muscle disuse atrophy and venous thrombosis in the lower extremities. Then the patients were required to wear an adjustable brace within the first 2 weeks without any weight-bearing. Gradually bending by 0\u0026ndash;90\u0026deg;was allowed in first the 4 weeks after the operation, and the passive range of motion (ROM) reached the level of the healthy side at 6 weeks after surgery. Patients began to partial weight-bearing walk with crutches under the guidance of a rehabilitation physician at 6 weeks after surgery. Strenuous sports exercises were not recommended until an excellent functional assessment 6 months after surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical outcome assessment\u003c/h2\u003e \u003cp\u003eThe basic Lachman test, the pivot shift test and the KT-1000 device were used to evaluate knee stability. The Functional evaluation comprised the ROM, visual analogue scale (VAS) score, International Knee Documentation Committee (IKDC) score, tegner activity score and the Lysholm score [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Complications such as wound infection, prepatellar pain and knee swelling were also recorded. All the data were collected preoperatively and at the last follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eImaging evaluation\u003c/h2\u003e \u003cp\u003eThe radiographic examinations were required to reveal the condition of bone tunnels and internal fixations. In addition, an MRI examination was needed to show the tension and continuity of the graft.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData management and analysis were carried out using SPSS software (version 25.0, Armonk, NY, USA for SPSS software package, IBM Corp.). The normal data distribution was determined through the Kolmogorov-Smirnov test. The paired t-test was used for the comparison of preoperative and follow-up clinical results. A chi-squared test was performed to compare the results of the pivot shift and Lachman tests. For all tests, a \u003cem\u003ep-\u003c/em\u003evalue\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eAll patients in this study were followed up with an average 16.8-month (range 12\u0026ndash;26 months) follow-up period. In the preoperative physical examination under anesthesia, 23 patients had a grade 3 pivot shift and 10 had a grade 2 pivot shift. Immediate postoperative pivot shift tests were all negative, while only one case had a grade 1 pivot shift at the final follow-up. All the cases preoperatively had a positive Lachman test and turned negative at the final follow-up (Table. 2). The average ROM improved Significantly from 63.2\u0026deg;\u0026plusmn; 17.9\u0026deg; preoperatively to 132.8\u0026deg;\u0026plusmn;3.6 \u0026deg;at the last follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The pain of patients was significantly relieved with a decreased VAS score from 5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 to 0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The comparison of all the knee functional scores at pre-operative and last follow-up showed a significant difference (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The average IKDC score improved from 55.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3 to 88.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8; the average Tegner activity score improved from 2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 to 6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3, the average Lysholm score improved from 56.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8 to 91.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8, and the average KT-1000 healthy-side to affected-side difference decreased from 9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 mm to 2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 mm (Table.3). At the last follow-up, only one patient was reported to have mild prepatellar pain when running, none of the other patients had operation-related complications, including wound infection, nerve injury, limited range of motion and knee swelling. The radiographic and MRI examination at the last follow-up showed that the grafts maintained good tension and continuity with no internal fixation failure. The typical imaging outcomes are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThus far, a number of studies confirmed the effectiveness of arthroscopic ACLR in ACL injury with long-term observation. Owing to the rapid development of the knee anatomy, the techniques of ACL reconstruction have also been continuously improved to accomplish a more anatomical reconstruction. Since it was first explicitly reported in 1938 by Palmer et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] that the ACL can be divided into the anteromedial bundle and posterolateral bundle, the double-bundle reconstructive techniques dedicated to restoring the anatomy of ACL have attracted considerable interest. Prior to the study of Mott in 1983 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], the procedure of double-bundle ACLR was largely unknown. In 1999, a subsequent evaluation of clinical efficacy was first reported by Muneta et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] including 54 cases with at least a 2-year follow-up, showed an excellent clinical result. After nearly two decades of exploration, there are a lot of high-quality original studies comparing single-bundle and double-bundle ACLR. In 2015, Mascarenhas et al. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] conducted a systematic review of overlapping meta-analyses comprising 9 literature, and after integrating the results of these studies, the DB ACLR showed better anterior-posterior and rotational stability than SB ACLR. As far as we know, patients with preoperative high-grade pivot shift are more likely to have residual rotation instability after surgery, which contributes to the limitation of activity, degeneration of knee joint and even the failure of grafts [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, the double-bundle ACLR might be a suitable approach for high-grade pivot shift patients to eliminate the risks associated with rotational instability. Notably, the DB reconstructive technique in this study was not the traditional 4-tunnel anatomical reconstruction. When first developed by Marcacci [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], the method was characterized by the combination of double tunnels and the over-the-top passage. Despite not entirely anatomically reconstruction through the footprint of ACL, the non-anatomical DB ACLR can also restore the kinematic effect of the anteromedial and posterolateral bundles to some degree. Moreover, the clinical study have suggested that non-anatomical DB ACLR can achieve the same effective performance in controlling rotation as anatomical DB ACLR with less bone damage and internal fixations [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNowadays, the ALC has attracted much attention because of its strong correlation with rotational stability. The injury of ALC in ACL ruptures could potentially increase the risk of rotational instability [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Given this, various auxiliary surgical methods have been proposed to improve the stability of the knee joint by the augmentation or reconstruction of the anterolateral structure [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The lateral extra-articular tenodesis was first presented by KennedyJC et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] in 1978. It was initially proposed because of the lack of an intra-articular ligament reconstruction technique at that time, so it is suitable for open surgery to restore rotational stability. However, with the development of arthroscopic technique and the concept of minimally invasive, LET was once neglected. However, as more and more patients who have undergone ACL reconstruction in recent years still have residual rotational instability, the surgeons gradually recognized the importance of the LET again. In clinical practice, a variety of tenodesis procedures have been proposed. In accordance with the meta-analyze performed by Hurley et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], the anatomical reconstruction of anterolateral ligament, the Cocker-Arnold and Lemaire techniques are more effective in reducing the proportion of residual rotational instability and the graft re-ruptures after surgery. Indeed, the LET yields good results in controlling rotational stability in patients with or without ALC injury. A meta-analysis by Onggo et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] showed that ACL reconstruction combined with LET could significantly reduce the positive rate of pivot shift and improve the subjective function score. Besides, a prospective multicenter randomized controlled trial by Getgood et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] showed similar outcomes.\u003c/p\u003e \u003cp\u003eUp to now, no consensus has been reached on the indications for the clinical application of LET. According to Mahmoud [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], the application indication of LET is the lateral laxity of the knee, hyperextension, or increased internal rotation angle (more than 5\u0026ndash;10\u0026deg;) of the affected knee. While in the research of ArieldeLima et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], patients with high-grade pivot shift and high exercise demands, and ACL reconstruction or chronic ACL injury patients need to receive LET. In addition, Sonnery-Cottet et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] added the medial meniscus injury as an indication for LET on the basis of the above. Therefore, the applicable standards of LET needs to be further studied and refined. In our opinion, referring to previous research and combined with the actual situation, young patients with high-grade rotation instability and demands of high-intensity exercise should receive LET, and the cases in our study met the standards.\u003c/p\u003e \u003cp\u003eNoteworthy, we used a modified lateral extra-articular tenodesis similar to the modified Lemaire technique [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] in this study. The iliotibial band graft was passed deep into not only the LCL but also the superficial ACL graft on the lateral epicondyle, then wrapped around back to the LCL femoral attachment, forming a stable loop-lock structure. Furthermore, for the fixation of the iliotibial band graft, high-strength sutures were used to sew it with the ACL graft on the lateral epicondyle and partial LCL on its femoral attachment to obtain a sheet-shaped whole, which can increase the contact surface to promote tendon-bone healing with no other fixation devices.\u003c/p\u003e \u003cp\u003eAlthough both the non-anatomical DB ACLR and LET show superior performance in controlling the rotational stability of the knee, there are few studies published to investigate the curative effect of non-anatomical DB ACLR combined with LET in high-grade pivot shift anterior cruciate ligament injury. In our research, integrating the two surgical techniques yields inspiring outcomes in rotational stability and function of the knee. However, the generalisability of the results is subject to certain limitations. For instance, there is a missing control group of other surgical, and the detailed situations of ALC in all cases need to be collected, for further research on this surgical technique, larger cohorts and more extended follow-up periods are required.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNon-anatomical double-bundle anterior cruciate ligament reconstruction combined with modified lateral extra-articular tenodesis is a reliable and recommended treatment for anterior cruciate ligament rupture with high-grade pivot shift, showing a striking improvement in knee rotational Stability and function in the short-term follow-up.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003edouble-bundle\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACLR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003earthroscopic anterior cruciate ligament reconstruction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLET\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elateral extra-articular tenodesis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eanterior cruciate ligament\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esingle-bundle\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eanterolateral complex\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLCL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elateral collateral ligament\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003erange of motion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evisual analogue scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIKDC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Knee Documentation Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe Ethics Committee of the Affiliated Hospital of Southwest Medical University approved all experimental procedures in conformity with the Declaration of Helsinki. Informed consent was obtained from all patients included in the study.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eI\u003cem\u003enformed\u003c/em\u003e \u003cem\u003econsent\u003c/em\u003e for the article\u0026nbsp;publication\u0026nbsp;was obtained from all the patients\u0026nbsp;in this study\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to limitations of ethical approval involving the patient data and anonymity but are available from the corresponding author on reasonable request.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eZL and JCL designed the study. XL drafted the article. \u0026nbsp; ZL and JCL performed the surgery. LZL and HBY revised the manuscript. ZJW and XX collected the data. The author(s) read and approved the final manuscript.\u003c/p\u003e\u003cp\u003eWe would like to thank all the staff in our Department of Orthopedics\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHensler D, Illingworth KD, Fu FH. Principle considerations in anatomic ACL reconstruction. Arthroscopy. 2010;26(11):1414\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKawanishi Y, Kobayashi M, Yasuma S, Fukushima H, Kato J, Murase A, et al. Anterolateral ligament reconstruction in addition to primary double-bundle anterior cruciate ligament reconstruction for grade 3 pivot shift improves residual knee instability during surgery. J Exp Orthop. 2021;19(1):51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop Relat Res. 1980;(147):45\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStergiou N, Ristanis S, Moraiti C, Georgoulis AD. Tibial rotation in anterior cruciate ligament (ACL)-deficient and ACL-reconstructed knees: a theoretical proposition for the development of osteoarthritis. Sports Med. 2007;37(7):601\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZampeli F, Ntoulia A, Giotis D, Tsiaras VA, Argyropoulou M, Pappas E, et al. Correlation between anterior cruciate ligament graft obliquity and tibial rotation during dynamic pivoting activities in patients with anatomic anterior cruciate ligament reconstruction: an in vivo examination. Arthroscopy. 2012;28(2):234\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHwang MD, Piefer JW, Lubowitz JH. Anterior cruciate ligament tibial footprint anatomy: systematic review of the 21st century literature. Arthroscopy. 2012;28(5):728\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaffagnini S, Bruni D, Marcheggiani Muccioli GM, Bonanzinga T, Lopomo N, Bignozzi S, et al. Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings ACL reconstruction: a prospective randomized study at 8-year minimum follow-up. Knee Surg Sports Traumatol Arthrosc. 2011;19(3):390\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaeyama A, Hoshino Y, Kato Y, Debandi A, Lertwanich P, Wang JH, et al. Anatomic double bundle ACL reconstruction outperforms any types of single bundle ACL reconstructions in controlling dynamic rotational laxity. Knee Surg Sports Traumatol Arthrosc. 2018;26(5):1414\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSastre S, Popescu D, N\u0026uacute;\u0026ntilde;ez M, Pomes J, Tomas X, Peidro L. Double-bundle versus single-bundle ACL reconstruction using the horizontal femoral position: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc. 2010;18(1):32\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaffagnini S, Marcheggiani Muccioli GM, Signorelli C, Lopomo N, Grassi A, Bonanzinga T, et al. Anatomic and nonanatomic double-bundle anterior cruciate ligament reconstruction: an in vivo kinematic analysis. Am J Sports Med. 2014;42(3):708\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArdern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGetgood A, Brown C, Lording T, Amis A, Claes S, Geeslin A, et al. The anterolateral complex of the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):166\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInderhaug 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\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelaloye JR, Hartog C, Blatter S, Schl\u0026auml;ppi M, M\u0026uuml;ller D, Denzler D, et al. Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-Articular Tenodesis Similarly Improve Knee Stability After Anterior Cruciate Ligament Reconstruction: A Biomechanical Study. Arthroscopy. 2020;36(7):1942\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeeslin AG, Moatshe G, Chahla J, Kruckeberg BM, Muckenhirn KJ, Dornan GJ, et al. Anterolateral Knee Extra-articular Stabilizers: A Robotic Study Comparing Anterolateral Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis. Am J Sports Med. 2018;46(3):607\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInderhaug E, Stephen JM, Williams A, Amis AA. Biomechanical Comparison of Anterolateral Procedures Combined With Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017;45(2):347\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRossi MJ, Lubowitz JH, Guttmann D. Development and validation of the International Knee Documentation Committee Subjective Knee Form. Am J Sports Med. 2002;30(1):152.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Reliability, validity, and responsiveness of the Lysholm knee scale for various chondral disorders of the knee. J Bone Joint Surg Am. 2004;86(6):1139\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalmer I. On the injuries to the ligaments of the knee joint: a clinical study. 1938. Clin Orthop Relat Res. 2007;454:17\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMott HW. Semitendinosus anatomic reconstruction for cruciate ligament insufficiency. Clin Orthop Relat Res. 1983;(172):90\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto H, Shinomiya K. Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with endobuttons: operative technique and preliminary results. Arthroscopy. 1999;15(6):618\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMascarenhas R, Cvetanovich GL, Sayegh ET, Verma NN, Cole BJ, Bush-Joseph C, 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(6):1185\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarcacci M, Molgora AP, Zaffagnini S, Vascellari A, Iacono F, Presti ML. Anatomic double-bundle anterior cruciate ligament reconstruction with hamstrings. Arthroscopy. 2003;19(5):540\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKennedy JC, Stewart R, Walker DM. Anterolateral rotatory instability of the knee joint. An early analysis of the Ellison procedure. J Bone Joint Surg Am. 1978;60(8):1031\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHurley ET, Bloom DA, Hoberman A, Anil U, Gonzalez-Lomas G, Strauss EJ, et al. There are differences in knee stability based on lateral extra-articular augmentation technique alongside anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2021;29(11):3854\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnggo JR, Rasaratnam HK, Nambiar M, Onggo JD, Pai V, Damasena I, et al. Anterior Cruciate Ligament Reconstruction Alone Versus With Lateral Extra-articular Tenodesis With Minimum 2-Year Follow-up: A Meta-analysis and Systematic Review of Randomized Controlled Trials. Am J Sports Med. 2022;50(4):1137\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGetgood AMJ, Bryant DM, Litchfield R, Heard M, McCormack RG, Rezansoff A, et al. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med. 2020;48(2):285\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmoud A, Torbey S, Honeywill C, Myers P. Lateral Extra-Articular Tenodesis Combined With Anterior Cruciate Ligament Reconstruction Is Effective in Knees With Additional Features of Lateral, Hyperextension, or Increased Rotational Laxity: A Matched Cohort Study. Arthroscopy. 2022;38(1):119\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAriel de Lima D, Helito CP, Lima FRA, Leite JAD. Surgical indications for anterior cruciate ligament reconstruction combined with extra-articular lateral tenodesis or anterolateral ligament reconstruction. Rev Bras Ortop. 2018;53(6):661\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSonnery-Cottet B, Vieira TD, Ouanezar H. Anterolateral Ligament of the Knee: Diagnosis, Indications, Technique. Outcomes Arthrosc. 2019;35(2):302\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePorter MD, Shadbolt B, Pomroy S. The Augmentation of Revision Anterior Cruciate Ligament Reconstruction With Modified Iliotibial Band Tenodesis to Correct the Pivot Shift: A Computer Navigation Study. Am J Sports Med. 2018;46(4):839\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDemographics and preoperative features in this study\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDemographics and preoperative features\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eValue\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eNumber of patients\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSex, male/female\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e23/10\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eAge, years (range)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e22.1 (16\u0026ndash;37)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSide, left/right\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e12/21\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e (range)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 (16\u0026ndash;37)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFollow-up period, months (range)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e16.8 (12\u0026ndash;26)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eInjury mechanism, sports Injury/traffic accident\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e25/8\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\"\u003eValues are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation;\u003cspan class=\"Bold\"\u003eBMI\u003c/span\u003e body mass index\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eThe pivot shift and Lachman tests at pre-operative and last follow-up\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eItem\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePre-operative\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003eN (%)\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLast follow-up\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003eN (%)\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePivot-shift test\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eNegative\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0 (0%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e32 (97%)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGrade 1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0 (0%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1 (3%)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGrade 2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e10 (30%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0 (0%)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGrade 3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e23 (70%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0 (0%)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLachman test\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eNegative\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33 (100%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0 (0%)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePositive\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0 (0%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33 (100%)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eComparison of clinical outcomes at pre-operative and last follow-up\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eOutcome\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePre-operative\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLast follow-up\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003ep\u003c/span\u003e-value\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eROM (\u0026deg;)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e63.2\u0026thinsp;\u0026plusmn;\u0026thinsp;17.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e132.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001*\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eVAS pain\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001*\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eIKDC score\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e55.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e88.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001*\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eTegner activity score\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001*\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLysholm score\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e56.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e91.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001*\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eKT-1000 side-to-side difference\u0026nbsp;(mm)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001*\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003eValues are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation; \u003cspan class=\"Bold\"\u003eROM\u003c/span\u003e range of motion,;\u003cspan class=\"Bold\"\u003eVAS\u003c/span\u003e visual analog scale; \u003cspan class=\"Bold\"\u003eIKDC\u003c/span\u003e International Knee Documentation Committee\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003e*Signifcant diference compared to preoperatively\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Non-anatomical DB ACLR, Modified LET, High-grade pivot shift, Rotational instability","lastPublishedDoi":"10.21203/rs.3.rs-2933213/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2933213/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eBoth the non-anatomical double-bundle (DB) anterior cruciate ligament reconstruction (ACLR) and lateral extra-articular tenodesis (LET) show superior performance in controlling the rotational stability of the knee. However there are few studies published to investigate the curative effect of non-anatomical DB ACLR combined with LET in high-grade pivot shift anterior cruciate ligament ruptures. This study aims to evaluate the short-term clinical and imaging results of the treatment program and summarize the advantages of the surgical technique.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eAll the 33 patients we reviewed in this study have accepted the non-anatomical DB ACLR with LET surgery from January 2018 to January 2022 in our Department of Orthopedics. Primary demographic data collected include gender (23 males and 10 females), age (16-37 years, average 23.5 years), BMI (21.8-31.2 kg/m\u003csup\u003e2\u003c/sup\u003e, average 25.7 kg/m\u003csup\u003e2\u003c/sup\u003e), follow-up period (12-18\u0026nbsp;months, average 15.2 months) and injury mechanism (25 sports Injuries and 8 traffic accidents). The assessment of clinical outcomes included pre- and post-operative physical examination, knee functional scores and imaging data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult: \u003c/strong\u003eAll patients in this study were followed up with an average 16.8-month (range 12-26 months) follow-up period. 23 patients had a grade 3 pivot shift and 10 had a grade 2 pivot shift. Immediate postoperative pivot shift tests were all negative, and only one case had a grade 1 pivot shift at the final follow-up. All the cases preoperatively had a positive Lachman test and turned negative at the final follow-up. The average ROM improved from 63.2°± 17.9° to 132.8°±3.6 °at the last follow-up (p\u0026lt;0.001); The VAS score decreased from 5.6±1.8 to 0.9±0.7 (p\u0026lt;0.001); the average KT-1000 healthy-side to affected-side difference decreased from 9.3±1.6 mm to 2.2 ± 0.5 mm. The comparison of all the knee functional scores ( IKDC, Tegner scores and Lysholom ) at pre-operative and last follow-up showed a significant difference (p\u0026lt;0.001). None of the cases had operation-related complications except one with slight prepatellar pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eNon-anatomical double-bundle anterior cruciate ligament reconstruction combined with modified lateral extra-articular tenodesis is a reliable and recommended treatment for anterior\u003c/p\u003e\n\u003cp\u003ecruciate ligament rupture with high-grade pivot shift, showing a striking improvement in knee rotational Stability and function in the short-term follow-up.\u003c/p\u003e","manuscriptTitle":"Non-anatomical double-bundle anterior cruciate ligament reconstruction combined with modified lateral extra-articular tenodesis in high-grade pivot shift anterior cruciate ligament injury：A retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-17 19:40:43","doi":"10.21203/rs.3.rs-2933213/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ec631508-dfce-445d-8213-c22b7b0e1b32","owner":[],"postedDate":"May 17th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-08-02T06:44:25+00:00","versionOfRecord":[],"versionCreatedAt":"2023-05-17 19:40:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2933213","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2933213","identity":"rs-2933213","version":["v1"]},"buildId":"ehx78VzkSd0WSzXnipQa-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}