Discussion
anterior laxity, ALL-R., ALL
PATHOLOGY
The most important finding of this study was that supplementary ALL-R in combination with ACL-revision did not result in improved subjective patient-reported outcomes or better clinical laxity and rotational knee stability compared to ACL-revision without ALL-R. Theoretically, the ALL-R should support internal rotational stability of the knee, but this could not be confirmed in the current study, in which there was actually a higher proportion of patients with a positive pivot shift in the + ALL group, although not statistically significant.Although not statistically significant, the proportion of female male patients in the + ALL group was lower than in the − ALL group. Reported outcome after ACL revision based on gender is sparse in the literature but some evidence exists after primary ACL-R with studies reporting worse patient reported outcome in female patient compared to male patient after ACL reconstruction [Clinical studies regarding the effects of combined ACL revision and ALL-R are sparse. Lee et al. [Clinical outcomes after ACL revision combined with a LET procedure have been described in several studies. A review [Eggeling et al. [The effect of ALL-R in combination with ACL surgery has been investigated in several biomechanical studies with diverging results. A positive effect on both anterior laxity and internal rotation has been reported [ALL-R reconstruction and LET in combination with ACL surgery have been compared in a number of biomechanical studies. Inderhaug et al. [ACL revision patients show a high grade of diversity in knee pathology, and ALL-R or a LET procedure might be just one of several possible supplemental procedures that can address abnormal soft tissue and bony anatomy [Getgood et al. [Due to the loss of patients to follow-up, this study did not meet the necessary number of patients defined in the a priori sample size calculation. This carries a risk of type 2 errors. However, the actual standard deviation (SD) of the KNEES-ACL score was lower than expected, and a post hoc sample size calculation showed that only approximately 30 patients were needed in each group.The ALL-R resulted in two extra incisions on the lateral side, which means that the patients were not blinded regarding the procedure. The objective measurements were performed by an independent investigator with no influence on patient enrollment, randomization, or surgical procedures, but the investigator was not blinded in relation to which group each patient belonged to. The lack of blinding normally leads to a positive effect for the intervention group. However, in this study, the intervention group was not superior at any endpoint. The pivot shift assessment is based on the skills of the examiner, which could bias the results of rotational instability in this study. Regional differences of the physiotherapist guided rehabilitation period were possible as described in the method section. Hopefully, the differences were divided equally between groups because of the randomized study design but the decentralized rehabilitation of patients could carry a potential bias.