Does Revision Anterior Cruciate Ligament (ACL) Reconstruction Provide Similar Clinical Outcomes to Primary ACL Reconstruction? A Systematic Review and Meta‐Analysis

Context: Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures, with more than 200,000 ACL tears occurring annually. Although primary ACL reconstruction is a successful operation, success rates still range from 75% to 97%. Consequently, several thousand revision ACL reconstructions are performed annually and are unfortunately associated with inferior clinical outcomes when compared with primary reconstructions. Evidence Acquisition: Data were obtained from peer-reviewed literature through a search of the PubMed database (1988-2013) as well as from textbook chapters and surgical technique papers. Study Design: Clinical review. Level of Evidence: Level 4. Results: The clinical outcomes after revision ACL reconstruction are largely based on level IV case series. Much of the existing literature is heterogenous with regard to patient populations, primary and revision surgical techniques, concomitant ligamentous injuries, and additional procedures performed at the time of the revision, which limits generalizability. Nevertheless, there is a general consensus that the outcomes for revision ACL reconstruction are inferior to primary reconstruction. Conclusion: Excellent results can be achieved with regard to graft stability, return to play, and functional knee instability but are generally inferior to primary ACL reconstruction. A staged approach with autograft reconstruction is recommended in any circumstance in which a single-stage approach results in suboptimal graft selection, tunnel position, graft fixation, or biological milieu for tendon-bone healing. Strength-of-Recommendation Taxonomy (SORT): Good results may still be achieved with regard to graft stability, return to play, and functional knee instability, but results are generally inferior to primary ACL reconstruction: Level B.

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Clinical outcomes of combined anterior cruciate ligament and anterolateral ligament reconstruction: a systematic review and meta-analysis

Knee Surgery and Related Research ◽

10.1186/s43019-021-00115-1 ◽

2021 ◽

Vol 33 (1) ◽

Author(s):

Diego Ariel de Lima ◽

Lana Lacerda de Lima ◽

Nayara Gomes Reis de Souza ◽

Rodrigo Amorim de Moraes Perez ◽

Marcel Faraco Sobrado ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Clinical Outcomes ◽

Acl Reconstruction ◽

Pivot Shift ◽

Cruciate Ligament ◽

Meta Analysis ◽

Anterolateral Ligament ◽

Cochrane Library ◽

Anterior Cruciate

Abstract Objectives To compare the clinical outcomes of isolated anterior cruciate ligament (ACL) reconstruction with combined reconstruction of the ACL and anterolateral ligament (ALL) of the knee. Methods A search was conducted on the PubMed, Medline, Google Scholar, EMBASE, and Cochrane library databases, in line with the PRISMA protocol. The indexation terms used were “anterior cruciate ligament” OR “acl” AND “anterolateral ligament” AND “reconstruction.” Articles that compared patients submitted to combined ACL and ALL reconstruction with those submitted to isolated reconstruction of the ACL, with levels of evidence I, II, and III, were included. Studies with follow-up of less than 2 years and articles that did not use “anatomical” techniques for ALL reconstruction, such as extraarticular tenodesis, were excluded. A meta-analysis with R software was conducted, with a random effects model, presented as risk ratio (RR) or mean difference (MD), with a 95% confidence level (CI) and statistically significant at p < 0.05. Results Ten articles were selected, with a total of 1495 patients, most of whom were men, of whom 674 submitted to ACL and ALL reconstruction and 821 to isolated ACL reconstruction. Combined ACL and ALL reconstruction exhibited a statistically significant advantage in residual pivot shift (RR 0.34, 95% CI 0.24–0.47, I2 = 0%, p < 0.01), rerupture rate (RR 0.34, 95% CI 0.19–0.62, I2 = 0%, p < 0.01), Lachman test (RR 0.59, 95% CI 0.40–0.86, I2 = 21%, p < 0.01), and postoperative Lysholm score (MD 2.28, CI 95% 0.75–3.81, I2 = 73%, p < 0.01). Conclusions Combined ACL and ALL reconstruction obtained better postoperative clinical outcomes when compared with isolated ACL reconstruction, especially in reducing residual pivot shift and rerupture rate.

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Physical prognostic factors predicting outcome following anterior cruciate ligament reconstruction: protocol for a systematic review

BMJ Open ◽

10.1136/bmjopen-2019-033429 ◽

2020 ◽

Vol 10 (3) ◽

pp. e033429

Author(s):

Andrew Middlebrook ◽

Sheree Bekker ◽

Nicola Middlebrook ◽

Alison B Rushton

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Prognostic Factors ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Meta Analysis ◽

Risk Of Bias ◽

Predicting Outcome ◽

Anterior Cruciate

IntroductionInjuries of the anterior cruciate ligament (ACL) are a common musculoskeletal complication and can cause significant reduction in patient function and quality of life. Many undergo ACL reconstruction, with high-quality rehabilitation key to successful outcome. Knowledge of physical prognostic factors, such as quadriceps strength, is crucial to inform rehabilitation and has important implications for outcome following ACL reconstruction. However, these factors predicting outcome are poorly defined. Therefore, the aim of this systematic review is to establish physical prognostic factors predictive of outcome in adults following ACL reconstruction. Outcome will be subdivided into two groups of outcome measures, patient-reported and performance-based. Physical prognostic factors of interest will reflect a range of domains and may be modifiable/non-modifiable. Results will help decide most appropriate management and assist in planning and tailoring preoperative and postoperative rehabilitation.Methods and analysisThis systematic review protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. MEDLINE, CINAHL and EMBASE databases, key journals and grey literature will be searched from inception to July 2019. Prospective cohort studies including participants aged ≥16 years who have undergone ACL reconstruction will be included, with articles focusing on multi-ligament reconstructions and ACL repair surgery, or not published in English excluded. Two independent reviewers will conduct searches, assess study eligibility, extract data, assess risk of bias (Quality in Prognostic Studies tool) and quantify overall quality of evidence (modified Grading of Recommendations, Assessment, Development and Evaluation guidelines). If possible, a meta-analysis will be conducted, otherwise a narrative synthesis will ensue focusing on prognostic factors, risk of bias of included studies and strength of association with outcomes.Ethics and disseminationFindings will be published in a peer-reviewed journal, presented at conferences and locally to physiotherapy departments. Ethical approval is not required for this systematic review.PROSPERO registration numberCRD42019127732.

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Vancomycin Presoaking of the Graft Appears to Prevent Infection After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

HSS Journal ® ◽

10.1177/15563316211011682 ◽

2021 ◽

pp. 155633162110116

Author(s):

Francisco Figueroa ◽

David Figueroa ◽

Rafael Calvo ◽

Alex Vaisman ◽

Marilaura Nuñez ◽

...

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Meta Analysis ◽

Case Series ◽

Control Group ◽

Infection Rates ◽

Reconstruction Methods ◽

Anterior Cruciate

Background: Vancomycin presoaking of the graft has been shown to decrease infection rates in some case series of anterior cruciate ligament (ACL) reconstruction. Purpose: We sought to substantiate the efficacy of vancomycin presoaked grafts for the prevention of infection after ACL reconstruction. Methods: We performed a systematic review of Medline and OVID to assess the incidence of postoperative infection in studies comparing patients undergoing ACL reconstruction with the use of vancomycin presoaked ACL grafts and a control group of patients undergoing ACL reconstruction without the use of presoaked grafts. The efficacy of vancomycin presoaking was calculated using the Agresti-Coull confidence interval. Relative risk (RR) was calculated for every study and the total sample. Results: The 11 studies that met inclusion criteria comprised 24,298 patients. In patients with vancomycin presoaking of the graft, 1 infection was reported in 8764 cases (0.01% rate). In the studies with control groups that did not have vancomycin presoaked grafts, there were 125 infections in 15,534 ACL reconstructions (0.8% rate). The efficacy of vancomycin presoaking in preventing infection after ACL reconstruction was 99.9% (0.999%–1.000% CI). The overall RR obtained was 0.07 (0.03–0.16 CI). All included studies were retrospective cohort studies (level III). Conclusions: Vancomycin presoaking of the graft has been shown to decrease infection rates after ACL reconstruction in studies of low evidence level. This suggests the need for prospective randomized controlled trials addressing this issue so that recommendations on the routine use of vancomycin presoaking of ACL grafts can be made with confidence.

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Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: systematic review and meta-analysis

Archives of Orthopaedic and Trauma Surgery ◽

10.1007/s00402-020-03393-8 ◽

2020 ◽

Vol 140 (7) ◽

pp. 923-931 ◽

Cited By ~ 4

Author(s):

Ho Jong Ra ◽

Jun-Ho Kim ◽

Dae-Hee Lee

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Anterior Cruciate Ligament Reconstruction ◽

Clinical Outcomes ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Meta Analysis ◽

Anterolateral Ligament ◽

Cruciate Ligament Reconstruction ◽

Anterior Cruciate

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Anterior Cruciate Ligament Reconstruction in Patients Older Than 50 Years: A Systematic Review and Meta-analysis

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120915698 ◽

2020 ◽

Vol 8 (4) ◽

pp. 232596712091569

Author(s):

Chong-Wei Tan ◽

Wei-Hsiu Hsu ◽

Pei-An Yu ◽

Chi-Lung Chen ◽

Liang-Tseng Kuo ◽

...

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Cohort Studies ◽

Clinical Outcomes ◽

Cruciate Ligament ◽

Meta Analysis ◽

Middle Aged ◽

Aged Patients ◽

Younger Patients ◽

Anterior Cruciate

Background: There is no consensus regarding the best treatment approach for middle-aged patients with anterior cruciate ligament (ACL) injuries. Chronic ACL-deficient knees are often associated with instability as well as secondary meniscal and cartilage lesions. ACL reconstruction (ACLR) has achieved satisfactory outcomes in younger patients; however, the effectiveness and safety of ACLR in middle-aged patients remain uncertain. Purpose: To compare the patient-reported functional scores, arthrometric outcomes, and complications of primary ACLR between older (≥50 years) and younger (<50 years) patients. Study Design: Systematic review; Level of evidence, 3. Methods: We conducted a systematic review of cohort studies that compared the clinical outcomes of ACLR between patients aged ≥50 years and those aged <50 years. The Cochrane Central Register of Controlled Trials, Embase, and MEDLINE databases were searched for relevant studies. The Methodological Index for Non-randomized Studies (MINORS) criteria was used to assess the risk of bias and conducted a random-effects meta-analysis to combine the data, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the overall quality of the body of retrieved evidence. The primary outcome was knee functional outcomes, and secondary outcomes were arthrometric outcomes of ACLR and complications. Results: This study included 4 retrospective cohort studies with a total of 287 participants (129 in the older group and 158 in the younger group). All included studies reported significant improvements in clinical outcomes in both groups after ACLR. No significant differences were noted in the improvement of International Knee Documentation Committee (IKDC) scores (mean difference [MD], 0.20 [95% CI, −2.65 to 3.05]; P = .89) and Lysholm scores (MD, −1.98 [95% CI, −6.93 to 2.98]; P = .43) between the 2 groups. No significant differences were observed in anteroposterior stability or risk of complications between the groups. Conclusion: ACLR may be performed in middle-aged patients (≥50 years) without concern for inferior clinical and arthrometric results compared with younger patients (<50 years).

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Meta-analysis of the Risk of Infections After Anterior Cruciate Ligament Reconstruction by Graft Type

The American Journal of Sports Medicine ◽

10.1177/0363546517714450 ◽

2017 ◽

Vol 46 (6) ◽

pp. 1500-1508 ◽

Cited By ~ 31

Author(s):

Anchal Bansal ◽

Joseph D. Lamplot ◽

James VandenBerg ◽

Robert H. Brophy

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Lower Incidence ◽

Cruciate Ligament ◽

Meta Analysis ◽

Significant Difference ◽

Anterior Cruciate ◽

Meta Analyses ◽

Primary Acl Reconstruction ◽

Bone Patellar Tendon

Background: An infection after anterior cruciate ligament (ACL) reconstruction is a relatively rare but challenging complication. There are no meta-analyses comparing the incidence of infections after ACL reconstruction with the various available graft choices. Purpose: To compare the incidence of infections after ACL reconstruction with bone–patellar tendon–bone (BPTB) autografts compared with hamstring autografts, with a secondary aim of comparing the incidence of infections after reconstruction with autografts compared with allografts. Study Design: Meta-analysis. Methods: A systematic review was performed to identify level 1 and 2 studies that reported the incidence of infections by graft type after ACL reconstruction. Studies that evaluated patients undergoing primary ACL reconstruction with an autograft, allograft, or combination of autograft and allograft and reported the number of postoperative infections by graft type utilized were considered for inclusion. Studies were excluded if they included revision ACL reconstruction or did not specify the number of infections by graft type. Study findings were reviewed, and meta-analysis was performed when data were sufficiently homogeneous. Results: Twenty-one studies meeting criteria were identified from the literature review. Meta-analysis revealed a significant difference in the incidence of deep infections between BPTB autografts and hamstring autografts, with the BPTB group displaying a 77% lower incidence of infections compared with the hamstring group (relative risk [RR], 0.23; 95% CI, 0.097-0.54). The incidence of infections was 66% lower with BPTB autografts compared with all other graft types, with a pooled RR of 0.33 (95% CI, 0.15-0.71). There was no significant difference in the incidence of infections after ACL reconstruction with autografts compared with allografts (RR, 1.035; 95% CI, 0.589-1.819). Conclusion: The findings of this meta-analysis demonstrate a significantly lower incidence of deep infections after ACL reconstruction with BPTB autografts compared with hamstring autografts but not compared with allografts. Clinical Relevance: Although the overall infection rate after ACL reconstruction is relatively low, the significantly higher rate of infections with hamstring autografts compared with BPTB autografts should be a consideration when discussing graft choices for ACL reconstruction.

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Relationship Between Timing of Anterior Cruciate Ligament Reconstruction and Chondral Injuries: A Systematic Review and Meta-analysis

The American Journal of Sports Medicine ◽

10.1177/03635465211036141 ◽

2021 ◽

pp. 036354652110361

Author(s):

Apostolos D. Prodromidis ◽

Chrysoula Drosatou ◽

Anastasios Mourikis ◽

Paul M. Sutton ◽

Charalambos P. Charalambous

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Cohort Studies ◽

Acl Reconstruction ◽

Odds Ratio ◽

Cruciate Ligament ◽

Meta Analysis ◽

Reconstruction Surgery ◽

Chondral Injury ◽

Anterior Cruciate

Background: After anterior cruciate ligament (ACL) injury, the optimal timing of ACL reconstruction and the influence of this timing on chondral damage remain unclear. Purpose: To assess the effect of timing of ACL reconstruction on the presence of chondral injuries via a systematic review and meta-analysis. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: Two reviewers independently performed systematic literature searches of 5 online databases using the Cochrane methodology for systematic reviews. Eligibility criteria were any comparative study of patients aged >16 years that assessed the relationship between timing of primary ACL reconstruction surgery and rates of chondral injuries. Meta-analysis was conducted using a random-effects model. Results: After screening, 14 studies (n = 3559 patients) out of 2363 titles met the inclusion criteria: 3 randomized controlled trials (n = 272), 3 prospective cohort studies (n = 398), and 8 retrospective cohort studies (n = 2889). In analysis of the studies, chondral injury rates were compared between ACL reconstructions performed before and after 3 time points: 3, 6, and 12 months after injury (eg, ≤3 vs >3 months). The rates of chondral injury increased with each time point. The increase was mostly due to low-grade injuries at 3 months (estimated odds ratio, 1.914; 95% CI, 1.242-2.949; P = .003), with the increase in high-grade injuries becoming predominant after 12 months (estimated odds ratio, 3.057; 95% CI, 1.460-6.40; P = .003). Conclusion: Our findings suggest that delaying ACL reconstruction surgery results in a higher rate of chondral injuries and the severity of these lesions worsens with time. These findings are comparable with those of our previously published study, which demonstrated a higher risk of meniscal tears associated with delayed ACL surgery. When ACL reconstruction is indicated, surgery ≤3 months after injury is associated with a lower risk of intra-articular damage. Registration: CRD42016032846 (PROSPERO).

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