title: Combined Intra-articular and Extra-articular Reconstruction in Anterior Cruciate Ligament-Deficient Knee: 25 Years Later.
abstract: To determine whether an anterior cruciate ligament (ACL)-reconstructed knee with hamstring autograft has a greater incidence of degenerative changes when an extra-articular reconstruction is added and to determine the effect of the combined reconstruction on knee stability and function at long-term follow-up.
  
  
  
  For this retrospective study, patients who underwent ACL reconstruction between January 2002 and December 2003 were selected and classified into 2 groups, I and II. Group I consisted of patients operated by a standard ACL reconstruction, and group II consisted of patients in whom, owing to the presence of risk factors (severe pivot shift graded +++ or high-risk sports), an extra-articular reconstruction performed with ileo-tibial tract according to McIntosh as modified by Cocker Arnold technique, was used in conjunction with intra-articular ACL reconstruction. At final follow-up, Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores were used. An arthrometric KT-1000 evaluation was done. Comparative weight-bearing radiographs were taken, including a skyline view for the patellofemoral joint and analyzed according to Fairbank, Kellgren, and IKDC classification.
  
  
  
  Seventy-two of the 75 (96%) patients in group I and 68 of the 75 patients in group II were available at the final follow-up (minimum 10 years). Subjective scores improved significantly in both groups, with no significant difference. Objectively, the number of patients receiving C and D IKDC objective activity scores in group I (7/56; 12.5%) was significantly higher than in group II (0/60) (P = .01). Considering as a failure a side-to-side arthrometric difference more than 5 mm or a pivot shift test graded as ++ or +++, or any giving way episode occurring postoperatively, we found 8 cases in group I and no cases in group II (P = .01) despite the presence of risk factors that group I did not include. Radiologic evaluation showed less arthritic changes in group II in both tibiofemoral and patellofemoral joints.
  
  
  
  On the basis of the results of this study, adding an extra-articular reconstruction to an anatomically placed intra-articular ACL reconstruction, followed by a modern rehabilitation protocol, does not increase the risk of osteoarthritis and may be able to reduce the rate of failure.
  
  
  
  Level III, retrospective comparative study.
authors.affiliation: "La Sapienza" University, Sant'Andrea Hospital, Traumatology Sports Center "Kilk Kilgour", Rome, Italy. Electronic address: aferretti51@virgilio.it.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ferretti
authors.affiliation: "La Sapienza" University, Sant'Andrea Hospital, Traumatology Sports Center "Kilk Kilgour", Rome, Italy.
authors.forename: Edoardo
authors.initials: E
authors.lastname: Monaco
authors.affiliation: "La Sapienza" University, Sant'Andrea Hospital, Traumatology Sports Center "Kilk Kilgour", Rome, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Ponzo
authors.affiliation: "La Sapienza" University, Sant'Andrea Hospital, Traumatology Sports Center "Kilk Kilgour", Rome, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Basiglini
authors.affiliation: "La Sapienza" University, Sant'Andrea Hospital, Traumatology Sports Center "Kilk Kilgour", Rome, Italy.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Iorio
authors.affiliation: "La Sapienza" University, Sant'Andrea Hospital, Traumatology Sports Center "Kilk Kilgour", Rome, Italy.
authors.forename: Ludovico
authors.initials: L
authors.lastname: Caperna
authors.affiliation: "La Sapienza" University, Sant'Andrea Hospital, Traumatology Sports Center "Kilk Kilgour", Rome, Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: Conteduca
mesh_terms: D000293:Adolescent; D000328:Adult; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D053587:Arthrometry, Articular; D064592:Autografts; D005260:Female; D005500:Follow-Up Studies; D000070633:Hamstring Muscles / Q000637:transplantation*; D006801:Humans; D007719:Knee Joint / Q000601:surgery*; D065466:Lysholm Knee Score; D008297:Male; D008875:Middle Aged; D020370:Osteoarthritis, Knee / Q000000981:diagnostic imaging; D063868:Patient Outcome Assessment; D026741:Physical Therapy Modalities; D011182:Postoperative Care; D012189:Retrospective Studies; D055815:Young Adult