Functional, Radiological, and Neuromuscular Outcomes Following Reverse-Passing Anterior Cruciate Ligament Reconstruction With Anterolateral Ligament Reconstruction Using Hamstring Autograft

Abstract

Introduction: Combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction has gained increasing attention for improving rotational stability and reducing graft failure rates, but early outcomes following novel techniques such as the reverse-passing reconstruction technique remain poorly characterized. Materials and methods: Sixty-four consecutive patients underwent primary ACL reconstruction using a single-surgeon reverse-passing hamstring autograft technique with simultaneous ALL reconstruction. Functional outcomes (Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), and Lysholm Knee Scoring Scale), MRI-based graft maturation (signal-to-noise quotient (SNQ)), and quadriceps and hamstring limb symmetry indices (LSI) were assessed at six months. Activity level (Tegner) and return-to-sport status were assessed at 12 months. Correlation and multivariable regression analyses examined relationships between SNQ and functional and strength outcomes. Results: At six months, mean KOOS was 88.9 ± 8.7, IKDC 86.8 ± 6.7, and Lysholm 88.6 ± 6.6. The mean SNQ was 4.86 ± 1.55 and correlated strongly with quadriceps LSI (r = −0.87, P < 0.001) and hamstring LSI (r = −0.95, P < 0.001), but not with patient-reported outcomes. Multivariable regression confirmed SNQ as an independent predictor of quadriceps strength recovery but not subjective function. Tegner scores returned to pre-injury levels by 12 months (P = 0.544), and all patients (100%) had returned to sport by 12 months. No graft failures, infections, or neurovascular complications occurred; one patient (1.6%) required surgical revision for hardware-related wound dehiscence overlying Gerdy's tubercle. Conclusions: In this single-arm preliminary series, reverse-passing ACL and ALL reconstruction were associated with excellent six-month functional recovery, a strong correlation between graft maturation and neuromuscular but not subjective recovery, a high rate of return to sport by 12 months, and a low complication rate. Comparative studies with a control group are needed to determine whether these outcomes are attributable to the reverse-passing technique itself.