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

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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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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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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Xenograft for anterior cruciate ligament reconstruction was associated with high graft processing infection

Journal of Experimental Orthopaedics ◽

10.1186/s40634-020-00292-0 ◽

2020 ◽

Vol 7 (1) ◽

Author(s):

Willem Van Der Merwe ◽

Martin Lind ◽

Peter Faunø ◽

Kees Van Egmond ◽

Stefano Zaffagnini ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Infection Rate ◽

Pivot Shift ◽

Cruciate Ligament ◽

Pivot Shift Test ◽

Tunnel Widening ◽

Kt 1000 ◽

Anterior Cruciate

Abstract Purpose To evaluate clinical ad radiological outcomes of anterior cruciate ligament (ACL) reconstruction with an immunochemically modified porcine patellar tendon xenograft controlled against human Achilles tendon allograft at 24-month minimum follow-up. Methods 66 patients undergoing arthroscopic ACL reconstruction were randomized into 2 groups: 34 allografts and 32 xenografts treated to attenuate the host immune response. Follow-up was 24-month minimum. Anterior knee stability was measured as KT − 1000 side-to-side laxity difference (respect to the contralateral healthy knee). Functional performance was assessed by one-legged hop test. Objective manual pivot-shift test and subjective (IKDC, Tegner and SF-36) outcomes were collected. MRI and standard X-Ray were performed. Results 61 subjects (32 allograft, 29 xenograft) were evaluated at 12 and 24 months. Six of the subjects in xenograft group (20.6%) got an infection attributed to a water-based pathogen graft contamination in processing. Intention-to-treat analysis (using the last observation carried forward imputation method) revealed higher KT − 1000 laxity in xenograft group at 24-month follow-up (P = .042). Also pivot-shift was higher in xenograft group at 12-month (P = .015) and 24-month follow-up (P = .038). Per-protocol analysis (missing/contaminated subjects excluded) did not revealed clinical differences between groups. Tibial tunnel widening in the allograft group was low, whereas xenograft tunnel widening was within the expected range of 20–35% as reported in the literature. No immunological reactivity was associated to xenograft group. Conclusions High infection rate (20.6%) was reported in xenograft group. Both groups of patients achieved comparable clinical outcomes if missing/contaminated subjects are excluded. Improved harvesting/processing treatments in future studies using xenografts for ACL reconstruction are needed to reduce infection rate, otherwise xenograft should not be used in ACL reconstruction. Level of evidence Multicenter and double-blinded Randomized Controlled Clinical Trial, Level I.

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Effectiveness of early quadriceps exercises after anterior cruciate ligament reconstruction

South African Journal of Sports Medicine ◽

10.17159/2413-3108/2008/v20i1a631 ◽

2016 ◽

Vol 20 (1) ◽

Author(s):

C Pumell

Keyword(s):

Anterior Cruciate Ligament ◽

Range Of Motion ◽

Acl Reconstruction ◽

Methodological Quality ◽

Cruciate Ligament ◽

Meta Analysis ◽

Knee Laxity ◽

Cochrane Library ◽

Anterior Cruciate

Objective. To systematically review the published information regarding the effectiveness and safety of early postoperative quadriceps muscle exercise training on pain, joint laxity, function and range of motion in postoperative anterior cruciate ligament (ACL) reconstruction adult patients. Data sources. Five databases (CINAHL, PEDro, Pubmed, Science Direct and the Cochrane Library) were searched for studies published from January 1990 to May 2007. Study selection. Publications describing research into the effectiveness of early quadriceps exercises after ACL reconstruction were included. A total of three eligible articles met the inclusion criteria. Data extraction. A review of the three eligible studies was undertaken to describe the key study components. The PEDro Scale was used to determine the methodological quality of the selected trials and the level of evidence of all the eligible studies was categorised according to the evidence hierarchy by Lloyd-Smith.24 Relevant data were extracted by the two reviewer groups to reduce bias. Data synthesis. Due to study heterogeneity a meta-analysis could not be conducted. Effect sizes were calculated provided that sufficient data were provided. Outcome measures included range of motion (ROM), functional performance, pain and knee laxity. The methodological quality of the studies did not vary considerably across the studies and the average PEDro score was 66%. Marginal significant differences were noted in knee ROM at 1 month postoperatively, pain day 1 postoperatively, knee laxity and subjective evaluation of function at 6 months postoperatively. Conclusion. Early quadriceps exercises can be performed safely in the first 2 postoperative weeks, but clinically significant gains in ROM, function, pain and knee laxity were not evident. Further research should include standardised interventions, measurement time frames and outcome measurement tools to allow for a meta- analysis to be conducted

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Effectiveness of early quadriceps exercises after anterior cruciate ligament reconstruction

South African Journal of Sports Medicine ◽

10.17159/2078-516x/2008/v20i1a631 ◽

2008 ◽

Vol 20 (1) ◽

Author(s):

C Pumell

Keyword(s):

Anterior Cruciate Ligament ◽

Range Of Motion ◽

Acl Reconstruction ◽

Methodological Quality ◽

Cruciate Ligament ◽

Meta Analysis ◽

Knee Laxity ◽

Cochrane Library ◽

Anterior Cruciate

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Accessory Anteromedial Portal may not Provide Clinically Superior Results Compared with the Anteromedial Portal in Anterior Cruciate Ligament Reconstruction

The Journal of Knee Surgery ◽

10.1055/s-0037-1607074 ◽

2017 ◽

Vol 31 (08) ◽

pp. 716-722

Author(s):

Shu-Ming Ye ◽

Jue-Hua Jing ◽

Hao Lv ◽

Ji-Sen Zhang ◽

Xin-Zhong Xu ◽

...

Keyword(s):

Acl Reconstruction ◽

Femoral Tunnel ◽

Pivot Shift ◽

Cruciate Ligament ◽

Tibial Tunnel ◽

Pivot Shift Test ◽

Single Bundle ◽

Anteromedial Portal ◽

Anterior Cruciate

AbstractTechniques using the anteromedial portal (AMP) and accessory anteromedial portal (AAMP) are commonly used in anterior cruciate ligament (ACL) reconstruction. The aim of this study was to investigate the radiological and clinical outcomes of arthroscopic single-bundle ACL reconstruction using the AMP or AAMP technique to drill the femoral tunnel. The records of 157 patients who underwent single-bundle ACL reconstruction using the AMP or AAMP technique between 2011 and 2015 were reviewed. The femoral tunnel clock-face position and femoral tunnel and tibial tunnel anterior–posterior (AP) inclination angles were assessed on axial or AP magnetic resonance images. At last follow-up, the Lachman test and pivot-shift test were used to evaluate AP and rotational stability, respectively. The Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) form were used to evaluate clinical and functional results. No statistically significant differences were found between the groups in patient age, sex, follow-up period, or affected side distribution. The mean femoral tunnel inclination angle was 31.13 ± 8.06 degrees in the AMP group and 30.17 ± 9.02 degrees in the AAMP group (p = 0.513). The tibial tunnel inclination angle in the AMP group (16.28 ± 7.89 degrees) was not different from that in the AAMP group (13.70 ± 6.08 degrees). No significant differences were observed between the two groups in the Lachman test, pivot-shift test, Lysholm knee scoring scale, or IKDC scores. The AAMP technique was not clinically superior to the AMP technique in ACL reconstruction. This is a retrospective comparative study and its level of evidence is III.

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High Rates of Osteoarthritis Develop After Anterior Cruciate Ligament Surgery: An Analysis of 4108 Patients

The American Journal of Sports Medicine ◽

10.1177/0363546517730072 ◽

2017 ◽

Vol 46 (8) ◽

pp. 2011-2019 ◽

Cited By ~ 31

Author(s):

Mark E. Cinque ◽

Grant J. Dornan ◽

Jorge Chahla ◽

Gilbert Moatshe ◽

Robert F. LaPrade

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Meta Analysis ◽

Patient Age ◽

Time Of Surgery ◽

Patient Âgé ◽

Anterior Cruciate ◽

Time From Injury

Background: Posttraumatic osteoarthritis (PTOA) after anterior cruciate ligament (ACL) reconstruction ultimately translates into a large economic effect on the health care system owing to the young ages of this population. Purpose/Hypothesis: The purposes were to perform a meta-analysis to determine the prevalence of osteoarthritis after an ACL reconstruction, examining the effects of length of time after surgery, preoperative time interval from injury to surgery, and patient age at the time of surgery. It was hypothesized that the prevalence of PTOA increased with time from surgery and that increased time from injury to surgery and age were also risk factors for the development of PTOA. Study Design: Meta-analysis. Methods: A meta-analysis of the prevalence of radiographic PTOA after ACL reconstruction was performed of studies with a minimum of 5 years’ follow-up, with a level of evidence of 1, 2, or 3. The presence of osteoarthritis was defined according to knee radiographs evaluated with classification based on Kellgren and Lawrence, Ahlbäck, International Knee Documentation Committee, or the Osteoarthritis Research Society International. Metaregression models quantified the relationship between radiographic PTOA prevalence and the mean time from injury to surgery, mean patient age at time of surgery, and mean postoperative follow-up time. Results: Thirty-eight studies (4108 patients) were included. Longer postsurgical follow-up time was significantly positively associated with a higher proportion of PTOA development. The model-estimated proportion of PTOA (95% CI) at 5, 10, and 20 years after surgery was 11.3% (6.4%-19.1%), 20.6% (14.9%-27.7%), and 51.6% (29.1%-73.5%), respectively. Increased chronicity of the ACL tear before surgery and increased patient age were also associated with a higher likelihood of PTOA development. Conclusion: The prevalence of osteoarthritis after an ACL reconstruction significantly increased with time. Longer chronicity of ACL tear and older age at the time of surgery were significantly positively correlated with the development of osteoarthritis. A timely referral and treatment of symptomatic patients are vital to diminish the occurrence of PTOA.

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Revision Anterior Cruciate Ligament Reconstruction with Contralateral Hamstring Tendon Grafts: 6 Years Follow-Up

Joints ◽

10.1055/s-0037-1601410 ◽

2017 ◽

Vol 05 (01) ◽

pp. 017-020 ◽

Cited By ~ 5

Author(s):

Claudio Legnani ◽

Stefania Zini ◽

Enrico Borgo ◽

Alberto Ventura

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Hamstring Tendon ◽

Activity Level ◽

Wilcoxon Test ◽

Pivot Shift Test ◽

Tendon Grafts ◽

Anterior Cruciate

Purpose The purpose of this study was to retrospectively evaluate the clinical outcome of revision anterior cruciate ligament (ACL) reconstruction with contralateral hamstring tendon autografts, specifically with regard to patient satisfaction, return to preinjury activity level, and postoperative functional outcomes. Methods Between 2004 and 2011, 23 patients underwent revision ACL reconstruction with contralateral autogenous hamstring tendon grafts and were retrospectively reviewed at an average follow-up of 6.3 years. Subjective and functional evaluations were performed. The Tegner score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) Subjective Knee Form were used. Objective evaluation included range of motion, Lachman test, pivot-shift test, and KT-1000 instrumented laxity testing. Wilcoxon test was used to compare the preoperative and follow-up status. Differences with a p-value of <0.05 were considered statistically significant. Results No major complications were reported. The mean KOOS significantly increased from a preoperative mean of 62.8 ± 8.3 to 85.8 ± 6.9 (p < 0.001). IKDC subjective score significantly improved from 29.2 ± 10.4 to 72.8 ± 5.2 (p < 0.001). The median Tegner activity score significantly improved from a preoperative mean of 6.5 (range: 4–10) to 7.5 (range: 7–10) (p < 0.001). Most of the patients increased or returned to the same activity level, with 61% of the patients returning to cutting and pivoting sports. Conclusion The use of contralateral hamstring tendon autografts for ACL revision surgery represents a valid option following a failed primary ACL reconstruction and confirms subjective and objective clinical improvement 6 years after surgery. Level of Evidence Level IV, therapeutic case series.

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Comparison between functional outcome of arthroscopic anterior cruciate ligament reconstruction using single bundle six fold and four fold semitendinosus and gracilis graft

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20180441 ◽

2018 ◽

Vol 4 (2) ◽

pp. 220

Author(s):

Rahul G. Jaju ◽

Jeevan B. Tonde

Keyword(s):

Anterior Cruciate Ligament ◽

Functional Outcome ◽

Acl Reconstruction ◽

Pivot Shift ◽

Cruciate Ligament ◽

Pivot Shift Test ◽

Single Bundle ◽

Lachman Test ◽

Anterior Drawer Test ◽

Anterior Cruciate

Background: With increase participation in sports activities, anterior cruciate ligament (ACL) tear is a common and functionally disabling injury. Hamstring tendon as autografts for arthroscopic ACL reconstructions have shown good clinical and functional outcome in patients. The purpose of present study was to compare the functional outcome of arthroscopic Anterior Cruciate ligament (ACL) reconstruction using single bundle six fold and four fold ST and G graft.Methods: This was a prospective study conducted between period June 2008 to December 2010.181 patients undergoing ACL reconstruction were screened and 113 patients fulfilling the inclusion exclusion criteria were selected for the study.Results: All patients completed a minimum of 1 years follow up. In 4 fold group 27.50% were having grade 1 anterior drawer test 22.50% were having grade 1 Lachman test and 17.50% had grade 1 pivot shift test as compared to 6 fold group 6.66% had grade 1 anterior drawer test, 11.66% had grade 1 Lachman test, and 3.33% had grade 1 pivot shift test respectively which was statistically significant (p<0.05). Conclusions: Arthroscopic ACL reconstruction using six fold graft is effective modality of treatment in patient with ACL deficient knee. Six fold graft is thicker in diameter and cross sectional area as compared to four fold graft which occupies more surface area of normal ACL foot print and gives better stability of knee joint in both AP and rotational plane.

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Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes

British Journal of Sports Medicine ◽

10.1136/bjsports-2016-096836 ◽

2017 ◽

Vol 52 (2) ◽

pp. 128-138 ◽

Cited By ~ 99

Author(s):

Courtney C H Lai ◽

Clare L Ardern ◽

Julian A Feller ◽

Kate E Webster

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Athletic Performance ◽

Elite Athletes ◽

Cruciate Ligament ◽

Meta Analysis ◽

Return To Sport ◽

Cochrane Library ◽

Graft Rupture ◽

Anterior Cruciate

ObjectivesThe primary objective was to calculate the rate of return to sport (RTS) following anterior cruciate ligament (ACL) reconstruction in elite athletes. Secondary objectives were to estimate the time taken to RTS, calculate rates of ACL graft rupture, evaluate postsurgical athletic performance and identify determinants of RTS.DesignPooled RTS and graft rupture rates were calculated using random effects proportion meta-analysis. Time to RTS, performance data and determinants of RTS were synthesised descriptively.Data sourcesMEDLINE, EMBASE, AMED, CINAHL, AMI, PEDro, SPORTDiscus and The Cochrane Library were searched from inception to 19 January 2016. Hand searching of 10 sports medicine journals and reference checking were also performed.Eligibility criteria for selecting studiesStudies were included if they reported the ratio of elite athletes who returned to their preinjury level of sport following ACL reconstruction. Twenty-four studies were included.ResultsThe pooled RTS rate was 83% (95% CI 77% to 88%). The mean time to RTS ranged from 6 to 13 months. The pooled graft rupture rate was 5.2% (95% CI 2.8% to 8.3%). Six out of nine studies that included a noninjured control group found no significant deterioration in athletic performance following ACL reconstruction. Indicators of greater athletic skill or value to the team were associated with RTS.Summary and conclusionsEighty-three per cent of elite athletes returned to sport following ACL reconstruction, while 5.2% sustained a graft rupture. Most athletes who returned to sport performed comparably with matched, uninjured controls. This information may assist in guiding expectations of athletes and clinicians following ACL reconstruction.

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