Anterior cruciate ligament surgeons frequently modify their approach when treating patients with knee hyperextension or ligamentous hyperlaxity: Results from an international survey of ISAKOS members.

Abstract

Patients with ligamentous hyperlaxity or knee hyperextension seem to be at a higher risk of failure following anterior cruciate ligament (ACL) reconstruction. The objective of this study was to better understand global practices for the treatment of ACL injuries in patients with knee hyperextension and ligamentous hyperlaxity among knee and sports medicine surgeons worldwide. A survey invitation was sent to members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) who were identified as knee and sports surgeons. The survey consisted of a total of 25 questions, covering topics related to preoperative assessment, surgical technique, and postoperative management of patients with knee hyperextension. Survey responses were tabulated and reported using descriptive statistics. In total, 427 responses to the survey were obtained from ISAKOS members. All continents participated, with the largest number of responses coming from Latin America (36.8 ​%). 75.4 ​% of respondents believe that patients with knee hyperextension tend to have more ACL tears, and 90.4 ​% believe that those who undergo ACL reconstruction have higher rates of reconstruction failure. Regarding surgical technique and graft type, 66.7 ​% of respondents modify their approach when treating patients with knee hyperextension. 82.7 ​% of respondents do not change the position of the bone tunnels, while 12.9 ​% reported placing the tibial tunnel more posteriorly. The most used grafts are hamstrings (38.4 ​%) and bone-patellar tendon-bone (BTB) (37.2 ​%). Allografts are preferred by only 5.9 ​% of respondents, and 75.9 ​% of surgeons are not concerned about using autografts, even in cases of suspected collagen disorders. 89.5 ​% of respondents believe adding an extra-articular procedure could minimize failure risk. The most used extra-articular procedure is lateral extra-articular tenodesis (LET) (63.9 ​%). ACL surgeons across diverse regions, demographics, experience levels, and surgical volumes tend to modify their approach for patients with knee hyperextension or ligamentous hyperlaxity. Hamstring and BTB grafts are most commonly used, with the vast majority not changing tunnel positioning. Most fix the graft at 20-30° of knee flexion and believe that lateral augmentations reduce failure rates in this population, with LET being the preferred technique. Level V, expert opinion study.