IV.

Background:The role of lateral extra-articular tenodesis (LEAT) to augment primary anterior cruciate ligament reconstruction (ACLR) remains controversial.Purpose:To determine whether the addition of LEAT to primary ACLR provides greater control of rotational laxity and improves clinical outcomes compared with ACLR alone and to assess the impact of early versus delayed ACLR.Study Design:Systematic review; Level of evidence, 3.Methods:Two reviewers independently searched 7 databases for randomized and nonrandomized clinical studies comparing ACLR plus LEAT versus ACLR alone. Animal, cadaveric, and biomechanical studies; revision or repair procedures; and studies using synthetic ligaments and multiligamentous-injured knees were excluded. Risk of bias was assessed with a modified Downs and Black checklist. The primary outcome was postoperative pivot shift. These data were pooled by use of a fixed-effects meta-analysis model. The studies were divided into delayed (>12 months) and early (≤12 months) reconstruction groups for meta-analysis. A best-evidence synthesis was performed on the remaining outcome measures.Results:Of 387 titles identified, 11 articles were included (5 of high quality). Meta-analysis of postoperative pivot shift in 3 studies of delayed primary ACLR showed a statistically significant difference for the pivot-shift test in favor of ACLR with LEAT (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.81; P = .008; I 2 = 0). Meta-analysis of 5 studies of early primary ACLR found no statistically significant difference with the addition of LEAT (OR, 0.60; 95% CI, 0.33-1.09; P = .10; I 2 = 33%). Insufficient evidence was available to determine whether the addition of LEAT had any effect on clinical, objective, subjective, and functional outcomes.Conclusion:In primary ACLR, no evidence is available showing additional benefit of LEAT in reducing the postoperative pivot shift in early reconstructions (≤12 months); however, LEAT may have a role in delayed ACLR. Strong evidence exists that a combined ACLR and LEAT reduces lateral femoral translation, but there is insufficient evidence to identify any benefit for other clinical outcomes.

Case-control study, Level III.

PurposeThe Ligament Augmentation and Reconstruction System (LARS®) is a synthetic ligament consisting of fibres made of polyethylene terephthalate. Despite the LARS being used as an anterior cruciate ligament (ACL) device for nearly 30 years and the well‐documented complications from earlier synthetic ligament designs, there is a paucity of published medium‐ to long‐term results. The aim of this study is to report the clinical and functional outcomes after ACL reconstruction using the LARS at a minimum follow‐up of 6 years. MethodsResults of a single surgeon’s entire cohort of 55 patients who underwent primary LARS ACL surgery were reviewed at a median of 7.8 years (6.0–9.4). Patient‐reported outcome measures including the International Knee Documentation Committee (IKDC) score and 36‐Item Short Form Health Survey (SF‐36) were collected and clinical assessment consisted of range of motion (ROM) and the KT‐1000 arthrometer to assess the side–side difference in the operative and non‐operative knee. Mechanical failures of the graft were confirmed at revision surgery and a survivorship analysis was performed using the Kaplan–Meier method. ResultsThe overall mechanical failure rate was 17/51 (33.3%) with ruptures occurring at a median 3.9 years (0.6–8.8 years) following primary LARS ACL surgery. Secondary operative procedures were performed in 39.2% of patients. For intact grafts, there was no statistically significant difference is side‐to‐side ROM or anterior knee laxity and subjective scores revealed a median IKDC subjective score of 85.1 (26.4–100) and SF‐36 physical component score of 94.1. ConclusionThe rates of LARS ACL construct failure (33.3%) in this cohort are high and based on these results the LARS should not be considered as a graft option for primary ACL reconstruction. Level of evidenceIII, cohort study.

Background:Although isolated posterior cruciate ligament reconstruction (PCLR) has become a more frequently performed procedure, reports of functional outcomes and return-to-sport (RTS) rates to support its use are still limited.Purpose:To systematically review the literature to determine the rates of RTS and the functional outcomes of patients after isolated PCLR.Study Design:Systematic review: Level of evidence, 4.Methods:Two reviewers independently searched 5 databases for patient-based clinical studies with a minimum 2-year follow-up that analyzed functional outcome and RTS following isolated PCLR. Studies with multiligament knee reconstruction were excluded. Risk of bias was performed with a modified Downs and Black checklist. The primary outcomes were Tegner and Lysholm scores, rates of RTS, and International Knee Documentation Committee (IKDC) subjective scores. Secondary outcomes were IKDC objective scores, instrumented knee laxity assessment, and Telos radiographic analysis. Where feasible, these data were pooled via a random effects meta-analysis model.Results:Of the 240 titles identified, 14 studies were included. The median time from injury to surgery was 10.6 months (range, 6 weeks–21 years). The pooled mean postoperative Tegner and Lysholm scores were 5.7 (95% CI, 5.4-6.0) and 87.8 (95% CI, 85.6-90.0), respectively, following isolated PCLR; the pooled effect size between pre- and postoperative values was 2.8 (95% CI, 1.6-4.0) and 3.7 (95% CI, 2.6-4.9), respectively. An RTS rate of 44% (95% CI, 23%-66%) was identified. IKDC subjective scores improved to a pooled mean of 73.5 (95% CI, 62.8-84.1), with an effect size of 3.0 (95% CI, 0.4-5.6). The proportion of patients with postoperative IKDC objective scores of grade A/B was 82%. The pooled postoperative KT-1000/KT-2000 side-to-side difference was 3.4 mm (95% CI, 2.5-4.3 mm), with an effect size of 2.8 (95% CI, 1.1-4.5). The pooled postoperative Telos side-to-side difference measurement was 3.5 mm (95% CI, 2.8-4.3 mm), with an effect size of 3.9 (95% CI, 3.3-4.5).Conclusion:The results of this review demonstrate that while isolated PCLR results in a significant improvement in functional outcome scores and improved knee laxity, there is a low rate of return to preinjury level of sport. The prolonged period from injury to surgery might reduce functional improvement and RTS following reconstruction. Therefore, comparison of the outcomes of isolated PCLR and nonoperative treatment is impracticable owing to the potential for selection bias.