Clinical Outcome Evaluation of Anatomic Anterior Cruciate Ligament Reconstruction With Tunnel Positioning Using Gold Standard Techniques: A Systematic Review and Meta-analysis

Abstract

Background: There have been conflicting results about the theoretical advantages of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction. Purpose: To evaluate the clinical and functional outcomes comparing anatomic single- versus double-bundle techniques, anatomic versus nonanatomic techniques, and transportal versus outside-in tunnel drilling for ACL reconstruction. Study Design: Systematic review; Level of evidence, 3. Methods: A search was performed in the MEDLINE and EMBASE databases up to August 2018 for clinical trials comparing anatomic ACL reconstruction (with tunnel positioning demonstrated using gold standard radiologic techniques) with another technique, with a minimum functional and biomechanical follow-up of 6 months. A meta-analysis was performed to compare clinical and functional outcomes between anatomic single- versus double-bundle reconstruction and between anatomic versus nonanatomic techniques, using the risk difference or the mean difference. Risk of bias of the included studies was assessed using the Newcastle-Ottawa Scale for cohort and case-control studies and the Cochrane Risk of Bias tool and Jadad Score for randomized controlled trials. Results: Included were 15 studies comprising 1290 patients (follow-up, 12-36 months). No significant differences favoring anatomic double-bundle over anatomic single-bundle reconstruction or outside-in over transportal techniques were found. The meta-analyses showed significant differences in the International Knee Documentation Committee (IKDC) objective score (risk difference, –0.14; 95% confidence interval, –0.27 to –0.01) favoring anatomic over nonanatomic reconstruction. No statistically significant differences were found between anatomic and nonanatomic surgical techniques on other functional scores or clinical examination outcomes, including the IKDC subjective score, Lysholm score, Tegner score, KT-1000 arthrometer test, or pivot-shift test. Conclusion: Double-bundle reconstruction was not superior to the single-bundle technique in clinical and functional outcomes. Anatomic ACL reconstruction shows significantly superior results over nonanatomic ACL reconstruction, reinforcing the anatomic technique as the gold standard choice for clinical practice.

Posteriorly positioned femoral grafts decrease long-term failure in anterior cruciate ligament reconstruction, femoral and tibial graft positions did not affect long-term reported outcome

“…All patients in this study were operated with the trans-tibial technique. Several studies have shown that the anteromedial technique achieves a more anatomic tunnel placement, improved antero-posterior and rotational knee stability [ 10 , 26 , 33 , 38 , 42 , 48 , 51 , 58 ]. However, there is inconsistency between these different studies if the improved graft anatomy of the anteromedial technique leads to better reported and clinical outcome.…”

Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment

“…This concept is supported by a current meta‐analysis that showed that the objective International Knee Documentation Committee (IKDC) score was significantly better for anatomical ACL reconstructions than for nonanatomical reconstructions [17] and by a systematic review which proved that the osteoarthritis rates after anatomical ACL reconstruction were significantly lower than after nonanatomical ACL reconstruction [18]. However, the double‐bundle technique—as a special anatomical reconstruction technique—is not recommended as a standard technique due to the lack of superiority in the long term and the increased risk of complications [19–21].…”

“…Biomechanical studies have shown that rotational stability can be restored better with a central tunnel position than with an anteromedial tunnel position [22,23]. However, research shows that an anteromedial tunnel position is advantageous for competitive athletes in terms of re-rupture rate, return-to-sport rate and performance level [17,24].…”

Excellent short‐term results of dome‐shaped high tibial osteotomy combined with all‐inside anterior cruciate ligament reconstruction

“…With the dependent approach, the femoral tunnel is created in a manner that is dependent on the tibial tunnel [30], or vice versa [31]. Currently, the independent approach is the technique of choice among many surgeons [6,10,23]. In contrast, studies report that modified transtibial approaches by dependent procedures achieve successful outcome [19,36].…”