Patellar tendon versus artificial grafts in anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Abstract Background The aim of anterior cruciate ligament reconstruction (ACLR) is to restore the function of the knee joint, protect the cartilage, and reduce the occurrence of osteoarthritis. However, due to the structural limitations of the human body, it is not possible to perform ACLR with conventional sutures. To restore normal functioning of the anterior cruciate ligament (ACL), a new ligament must be reconstructed in the position of the previous ACL. Objective To compare autografts and synthetic grafts in terms of postoperative knee stability and function Search methods The protocol for this study was registered with PROSPERO (CRD42021243451). Two reviewers independently searched the PubMed, Embase, and the Cochrane Library databases from database inception though February 10, 2021. The following search method was used: ((Autograft) OR (Autologous) OR (Autotransplant)) OR Artificial Ligament AND (Anterior Cruciate Ligament Injury [MeSH Terms]) AND (Randomized controlled trial [MeSH Terms]). Methodological quality was assessed by the Cochrane risk of bias tool. Selection criteria We only included randomized controlled trials (level I) that compared autograft and synthetic graft interventions in participants with ACL injury. We included trials that evaluated ACLR using at least one outcome (Lachman test, pivot shift test, IKDC grades, or complications). Results A total of 748 studies were identified in the initial literature search, and seven studies that examined only bone-patellar tendon-bone (BPTB) grafts compared with artificial grafts met the predetermined inclusion criteria. The results showed that BPTB grafts were associated with significantly better pivot shift test and Lachman test results and better IKDC grades and lower complication rates than synthetic grafts. Conclusions This review indicates that for adults, BPTB grafts perform more favorably than synthetic grafts in ACLR in terms of knee stability, function, and complication. More research is needed to compare autologous tendons and allogeneic tendons with artificial ligaments, especially in elderly individuals. Level of evidence Level I, systematic review and meta-analysis

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Anatomical anterior cruciate ligament reconstruction (ACLR) results in fewer rates of atraumatic graft rupture, and higher rates of rotatory knee stability: a meta-analysis

Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine ◽

10.1136/jisakos-2020-000476 ◽

2020 ◽

Vol 5 (6) ◽

pp. 359-370

Author(s):

Yousif Eliya ◽

Khaled Nawar ◽

Benjamin B Rothrauff ◽

Bryson P Lesniak ◽

Volker Musahl ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Anterior Cruciate Ligament Reconstruction ◽

Failure Rate ◽

Ligament Reconstruction ◽

Pivot Shift ◽

Cruciate Ligament ◽

Meta Analysis ◽

Knee Stability ◽

Cruciate Ligament Reconstruction ◽

Anterior Cruciate

ImportanceThis review highlights the differences in outcomes between anatomical and non-anatomical anterior cruciate ligament reconstruction (ACLR) techniques.ObjectiveTo compare clinical and functional outcomes between anatomical and non-anatomical ACLR techniques.Evidence reviewA search of MEDLINE, Embase and PubMed from 1 January 2000 to 24 October 2019 was conducted. Randomised and prospective primary ACLR studies using autograft and a minimum of 2 years of follow-up were included. The Anatomic Anterior Cruciate Ligament Reconstruction Checklist (AARSC) was used to categorise studies as anatomical. Outcomes analysed included failure rate, knee stability and functional outcomes. A meta-analysis using risk ratio and mean differences was conducted using a random effects model.FindingsThirty-six studies were included, representing 3710 patients with a follow-up range of 24–300 months. The overall failure rate was 96/1470 (6.5%) and 131/1952 (6.7%) in the anatomical group and non-anatomical group, respectively. The pooled results of the overall failure rate showed that there was no statistically significant difference between the anatomical and the non-anatomical groups (p=0.96). There were 37/60 (61.7%) and 29/67 (43.3%) traumatic failures in the anatomical and non-anatomical groups, respectively. The number of patients with the negative postoperative pivot-shift test was 995/1252 (79.5%) and 1140/1589 (71.1%) in the anatomical and non-anatomical groups, respectively. The pooled results indicated a statistically significant higher number of patients with a positive pivot shift in the non-anatomical group compared with the anatomical group (p=0.03).Conclusions and relevanceThis study demonstrated that the overall failure rate was similar between the anatomical and non-anatomical approaches. However, the anatomical ACLR demonstrated a significantly superior restoration of rotatory stability, as evidenced by a higher percentage with a negative postoperative pivot-shift test. Non-anatomical ACLR resulted in higher rates of atraumatic graft ruptures and persistent rotatory knee instability. Surgeons should consider anatomical ACLR when treating rotatory knee stability in patients.Level of evidenceII, systematic review and meta-analysis of level I and II studies.

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Varying femoral-sided fixation techniques in anterior cruciate ligament reconstruction have similar clinical outcomes: a network meta-analysis

Journal of ISAKOS Joint Disorders & Orthopaedic Sports Medicine ◽

10.1136/jisakos-2018-000206 ◽

2018 ◽

Vol 3 (4) ◽

pp. 220-228

Author(s):

Ajay Shah ◽

Daniel Joshua Hoppe ◽

David M Burns ◽

Joseph Menna ◽

Daniel Whelan ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Soft Tissue ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Meta Analysis ◽

Optimal Method ◽

Femoral Fixation ◽

Kt 1000 ◽

Level I ◽

Anterior Cruciate

ImportanceThere is significant controversy regarding the optimal femoral fixation method in anterior cruciate ligament (ACL) reconstruction. Given the importance of ACL reconstruction in patient return to sport and quality of life, it is imperative to identify the optimal method of femoral fixation.ObjectiveThe primary objective of this study is to identify the optimal method of femoral fixation in ACL reconstruction with soft tissue grafts. There are three main techniques for femoral-sided fixation in ACL reconstruction: suspensory extracortical buttons (EC), interference screws (IS) and transfemoral crosspins (TF). Previous primary studies have provided conflicting results regarding the superior method, and prior systematic reviews have failed to identify a difference; however, these analyses were only able to make comparisons between two of the treatments directly. This study employed a network meta-analysis technique to maximise sample size and statistical power, increasing the validity of its findings.Evidence reviewA network meta-analysis was conducted using results from 19 randomised controlled trials. Only studies with level I or II evidence, directly comparing two interventions in ACL soft tissue graft reconstruction, were included. Graft failure rates, International Knee Documentation Committee scores and KT-1000 knee arthrometer scores were the primary outcomes measured. Secondary outcomes included Lysholm, Tegner, Lachman and Pivot Shift scores.FindingsAn overall sample of 1372 patients was analysed. No statistically significant differences were detected among outcomes, except for the KT-1000 analysis which slightly favoured EC over IS and TF fixation (mean difference (MD)=−0.53 mm; 95% CI −0.07 to –0.98), and TF over IS fixation (MD=−0.41 mm; 95% CI −0.05 to –0.76). The clinical consequences of this difference are likely minimal.ConclusionsBased on the results of this network meta-analysis, there is no clear statistically superior method of femoral fixation in soft tissue ACL reconstruction.Level of evidenceLevel II (systematic review of level I and II studies).

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Non-anatomical Anterior Cruciate Ligament Remnants Do Not Contribute Dynamic Knee Stability ˜Quantitative Measurement Of The Pivot Shift Test˜

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967114s00107 ◽

2014 ◽

Vol 2 (7_suppl2) ◽

pp. 2325967114S0010

Author(s):

Kanto Nagai ◽

Ryosuke Kuroda ◽

Daisuke Araki ◽

Yuichiro Nishizawa ◽

Takehiko Matsushita ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Quantitative Measurement ◽

Pivot Shift ◽

Cruciate Ligament ◽

Pivot Shift Test ◽

Knee Stability ◽

Anterior Cruciate

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Anterior Cruciate Ligament Graft Choices: A Review of Current Concepts

The Open Orthopaedics Journal ◽

10.2174/1874325001206010281 ◽

2012 ◽

Vol 6 (1) ◽

pp. 281-286 ◽

Cited By ~ 22

Author(s):

Sujay K Dheerendra ◽

Wasim S Khan ◽

Rohit Singhal ◽

Deepak G Shivarathre ◽

Ravi Pydisetty ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Meta Analysis ◽

Hamstring Tendon ◽

Anterior Cruciate Ligament Graft ◽

Graft Choice ◽

Anterior Cruciate ◽

Synthetic Grafts ◽

Comparative Trials

The graft choice for anterior cruciate ligament (ACL) reconstruction continues to be controversial. There are several options available for the treating surgeon, including Bone Patellar Tendon Bone (BPTB) grafts, Hamstring tendon (HT) grafts, allografts and synthetic grafts. Within the last decade there have been several comparative trials and meta-analysis, which have failed to provide an answer with regards to the best graft available. The aim of this review is to understand the current concepts in graft choices for ACL reconstruction.

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Independent Versus Transtibial Drilling in Anterior Cruciate Ligament Reconstruction: A Meta-analysis With Meta-regression

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211015616 ◽

2021 ◽

Vol 9 (7) ◽

pp. 232596712110156

Author(s):

Marco Cuzzolin ◽

Davide Previtali ◽

Marco Delcogliano ◽

Giuseppe Filardo ◽

Christian Candrian ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Meta Analysis ◽

Cochrane Library ◽

Pivot Shift Test ◽

Clinically Significant ◽

Anterior Cruciate ◽

Femoral Tunnel Drilling ◽

Tibial Translation

Background: Anterior cruciate ligament (ACL) reconstruction can be performed with different techniques for independent and transtibial (TT) drilling of femoral tunnels, but there is still no consensus on which approach leads to the best outcome. Purpose: To assess whether the independent or TT drilling approach for ACL reconstruction leads to the best functional outcomes. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic literature search was conducted on July 1, 2020, using the PubMed, Web of Science, Cochrane Library, and Scopus databases. The influence of different femoral drilling techniques was analyzed through a meta-analysis in terms of patient-reported outcome measure scores, risk of complications, range of motion limitations, graft failure, and differential laxity. Subanalyses were performed to compare the different independent drilling techniques considered. Linear metaregression was performed to evaluate if the year of study publication influenced the results. The risk of bias and quality of evidence were assessed following the Cochrane guidelines. Results: A total of 22 randomized controlled trials including 1658 patients were included in the meta-analysis. Both International Knee Documentation Committee (IKDC) subjective score and Lysholm score were higher with the independent drilling approach (mean difference [MD], 1.24 [ P = .02] and 0.55 [ P = .005], respectively). No difference was documented in terms of the risk of reinjury, but independent drilling led to reduced KT-1000 arthrometer–assessed anterior tibial translation (MD, 0.23; P = .01) and a higher probability of a negative postoperative pivot-shift test finding (risk ratio, 1.13; P = .04). There were no significant differences in IKDC objective or Tegner scores. A P value of .07 was found for the association between the year of the study and IKDC objective scores. Conclusion: Independent femoral tunnel drilling provided better results than the TT approach, although the difference was not clinically significant. No difference was observed in the risk of reinjury. Increasingly better results were seen among surgical procedures performed in more recent years. Among the independent drilling options, the anteromedial portal technique seemed to provide the most favorable outcomes. The lack of clinically significant differences and the promising outcomes reported with new modified TT techniques suggest the importance of correct placement, rather than the tunnel drilling approach, to optimize the results of ACL reconstruction.

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Surgical intra- and extra-articular anterior cruciate ligament reconstruction: a meta-analysis

10.21203/rs.2.20069/v1 ◽

2020 ◽

Author(s):

Xiangyun Cheng ◽

Fanxiao Liu ◽

Dongsheng Zhou ◽

Alexander C. Paulus

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Pivot Shift ◽

Cruciate Ligament ◽

Meta Analysis ◽

Cochrane Library ◽

Pivot Shift Test ◽

Reconstruction Technique ◽

Anterior Cruciate

Abstract Background: It is still controversial whether the combination of anterior cruciate ligament (ACL) reconstruction and extra-articular reconstruction (EAR) have good clinical efficacy. This meta-analysis aims to compare the clinical effectiveness of ACL reconstruction and combined reconstruction. Methods: Electronic databases, including Medline/PubMed, Embase and the Cochrane Library, were systematically searched to identify targeted studies. A meta-analysis aims to pool the outcome estimates of interest, such as the Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores and the results from the KT-1000/2000 arthrometer test, the Lachman test and the pivot shift test. Results : Twelve studies involving 1146 knees were identified. Compared with single ACL reconstruction, combined reconstruction had better results for a pivot shift of grade 1 (relative ratio [RR] = 0.88, 95% CI: 0.83-0.94) and grade 2 (RR = 0.95, 95% CI: 0.91-0.99) rather than grade 3 (RR = 0.98, 95% CI: 0.90-1.06) and no statistically significant difference for both Lachman grade 1 (RR = 0.96, 95% CI: 0.89-1.05) and grade 2 (RR = 0.96, 95% CI: 0.90-1.03). Combined reconstruction resulted in significant improvements on the instrumented joint laxity test when considering a failure standard of more than 5 mm (a side-to-side arthrometric difference) (RR = 0.94, 95% CI: 0.89-0.98) rather than 3 mm (RR = 0.94, 95% CI: 0.86-1.03). Moreover, combined reconstruction increased the IKDC score at the 12-month (weighted mean difference [WMD] = -6.38, 95% CI: -9.66 to -3.10), 24-month (WMD = -5.60, 95% CI: -8.54 to -2.66) and 36-month follow-ups (WMD = -4.71, 95% CI: -7.59 to -1.83) and the Tegner score at the 36-month follow-up (WMD = -0.53, 95% CI: -0.97 to -0.09), but it did not increase the Lysholm score at the 36-month follow-up (WMD = -0.84, 95% CI: -2.02 to 0.34). Conclusion : With the advances in reconstruction techniques, combined reconstructions were found to be effective in improving rotational stability and to lead to good functional scores. However, obviously, the combined reconstruction technique is more time-consuming and requires an additional incision, which is not suitable for all ACL-deficient patients. Therefore, programs should be personalized and customized for the specific situation of each patient.

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724 Quadriceps Tendon Autograft Versus Hamstring Tendon Autograft in Anterior Cruciate Ligament Repair: A Systematic Review and Meta-Analysis

British Journal of Surgery ◽

10.1093/bjs/znab259.934 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

T K Tan ◽

A G Subramaniam ◽

R Radic

Keyword(s):

Anterior Cruciate Ligament ◽

Observational Studies ◽

Cruciate Ligament ◽

Meta Analysis ◽

Quadriceps Tendon ◽

Peak Torque ◽

Hamstring Tendon ◽

Pivot Shift Test ◽

Anterior Cruciate ◽

Tendon Autograft

Abstract Aim Quadriceps tendon (QT) autograft has recently become the popular choice of autograft in anterior cruciate ligament reconstruction (ACLR) and slowly replacing hamstring tendon (HT) autograft. QT autograft has traditionally served as the alternative of HT autograft, but recent studies revealed that QT autografts are not inferior to HT autografts. The purpose of this study was to provide an in-depth review the clinical and functional outcomes between QT and HT autografts in ACLR. Method Databases of Pubmed, EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until November 2020. All observational studies comparing QT and HT autografts in the ACRL surgery were included. Results Twenty-two observational studies (3 randomized controlled trials and 19 comparative studies) comprising of 16952 patients (QT = 1407, HT = 15545) were included in quantitative meta-analysis. In comparison to HT autograft, patients who received QT autograft had similar postoperative Lysholm Score (MD:1.05, p = 0.44), Tegner Score (MD:0.11, p = 0.06), IKDC score (MD:0.48, p = 0.48), side to side laxity(MD:-0.08, p = 0.77), limb symmetry index (MD:1.87, p = 0.61), Pivot shift test grade 0 (OR:1.13, p = 0.74), Lachman test grade 0 (OR:2.38, p = 0.32), hamstring to quadriceps ratio (MD:-1.10, p = 0.82), incidence of graft failure (OR:0.68, p = 0.43), contralateral knee injury (OR:1.22, p = 0.61), peak torque muscle strength flexion (MD:-0.20, ρ = 0.10) and Cincinnati score (MD:-0.85, p = 0.66). Conclusions In this meta-analysis, the usage of QT autograft is not inferior to HT autograft in ACLR. Our study demonstrated comparable morbidity, clinical and functional outcome in QT and HT autografts, indicating that QT autograft is equally safe as HT autograft.

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Passive Knee Stability After Anterior Cruciate Ligament Reconstruction Using the Endobutton or ToggleLoc With ZipLoop as a Femoral Fixation Device: A Comparison of 1654 Patients From the Danish Knee Ligament Reconstruction Registry

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118778507 ◽

2018 ◽

Vol 6 (6) ◽

pp. 232596711877850 ◽

Cited By ~ 1

Author(s):

Christian Asmus Peter Asmussen ◽

Mikkel Lindegaard Attrup ◽

Kristian Thorborg ◽

Per Hölmich

Keyword(s):

Anterior Cruciate Ligament ◽

Ligament Reconstruction ◽

Pivot Shift ◽

Cruciate Ligament ◽

Pivot Shift Test ◽

Knee Stability ◽

Knee Ligament ◽

Knee Ligament Reconstruction ◽

Anterior Cruciate ◽

Tibial Translation

Background: Biomechanical studies show varying results regarding the elongation of adjustable fixation devices. This has led to growing concern over the stability of the ToggleLoc with ZipLoop used in anterior cruciate ligament (ACL) reconstruction (ACLR) in vivo. Purpose/Hypothesis: The purpose of this study was to compare passive knee stability 1 year after ACLR in patients in whom the Endobutton or ToggleLoc with ZipLoop was used for femoral graft fixation. The hypothesis was that the ToggleLoc with ZipLoop would be inferior in knee stability to the Endobutton 1 year after primary ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: Data from 3175 patients (Endobutton: n = 2807; ToggleLoc with ZipLoop: n = 368) were included from the Danish Knee Ligament Reconstruction Registry (DKRR) between June 2010 and September 2013. Data were retrieved from standardized ACL forms filled out by the operating surgeon preoperatively, during surgery, and at a clinical examination 1 year after surgery. Passive knee stability was evaluated using 1 of 2 arthrometers (Rolimeter or KT-1000 arthrometer) and the pivot-shift test. Using the same database, the number of reoperations performed up to 4 years after primary surgery was examined. Results: Full data were available for 1654 patients (Endobutton: n = 1538; ToggleLoc with ZipLoop: n = 116). ACLR with both devices resulted in increased passive knee stability ( P < .001). Patients who received the ToggleLoc with ZipLoop were found to have a better preoperative ( P = .005 ) and postoperative ( P < .001) pivot-shift test result. No statistically significant difference regarding the number of reoperations ( P = .086) or the time to reoperation ( P = .295) was found. Conclusion: Patients who underwent fixation with the ToggleLoc with ZipLoop had improved passive knee stability 1 year after surgery, measured by anterior tibial translation and pivot-shift test results, similar to patients who underwent fixation with the Endobutton. No difference was seen in knee stability or reoperation rates between the 2 devices.

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