Clinical Outcomes of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis Combined With Primary ACL Reconstruction: A Systematic Review With Meta-analysis

Abstract

Background: Residual rotational instability after isolated anterior cruciate ligament reconstruction (ACLR) has been a challenge for many years. Anterolateral extra-articular procedures (AEAPs), including anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET), are performed as a surgical option for additional rotational stability, but clear evidence for their usefulness is lacking. Purpose: To conduct a systematic review and meta-analysis of the literature regarding the efficacy of AEAP in primary ACLR. Study Design: Systematic review; Level of evidence, 3. Methods: A literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. MEDLINE, EMBASE, and the Cochrane Library were searched in April 2020, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 3444 studies were screened, and 20 studies (11 randomized controlled trials and 9 nonrandomized studies) were evaluated. Functional outcomes, stability, and complications were compared between patients who underwent primary ACLR with AEAP and those who underwent isolated primary ACLR. For subgroup analysis, outcomes were compared according to AEAP technique (ALLR vs LET) and time from injury to surgery (≤12 vs >12 months). The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool, Jadad scale, and Newcastle-Ottawa Scale. Results: Compared with isolated ACLR, combined ACLR with AEAP led to improved pivot-shift grades and graft failure rates, regardless of the AEAP technique or of time from injury to surgery. A limited, marginal improvement in subjective function score was observed in patients who underwent AEAP combined with ACLR. In contrast to ALLR, patients who underwent LET combined with ACLR had an increased risk of knee stiffness and adverse events. Conclusion: Our review suggests that when there is a need to improve rotational stability and subjective function, AEAP combined with primary ACLR can be considered regardless of time from injury. ALLR appeared to be a better option for improving rotational stability compared with LET.

Isolated ACL Reconstruction Versus ACL Reconstruction Combined With Lateral Extra-articular Tenodesis: A Comparative Study of Clinical Outcomes in Adolescent Patients

“…Specifically, Rezende et al 41 demonstrated in a systematic review that combined reconstruction is associated with significantly better knee stability based on not only the pivot-shift test (risk ratio, 0.95 [95% CI, 0.91-0.99]; P = .02) but also the Lachman test (risk ratio, 0.93 [95% CI, 0.88-0.98]; P = .01). Similarly, Na et al, 37 in a more recent systematic review and meta-analysis, demonstrated that the proportion of patients with Lachman grade 2 or 3 was significantly lower in the combined reconstruction group than in the isolated ACLR group (odds ratio, 0.42 [95% CI, 0.20-0.89]; P = .02; I 2 = 0%).…”

Modified iliotibial band tenodesis versus lateral extracapsular tenodesis, to augment anterior cruciate ligament reconstruction: a 2‐year randomized controlled trial

“…Na et al performed a systematic literature review and concluded that 'the general control of rotation and the protective effect on the graft' is more important than the specific procedure used to augment the ACL reconstruction. 22 Procedures reconstructing other components of the ALC, such as the ALL of the knee, have also been shown to be effective in improving control of the pivot shift. 23 This may be the case even if the anterolateral procedure is added as second procedure in patients who present with persistent rotatory instability following previous ACL reconstruction whether perform anatomically, 24 or a non-anatomically.…”

“…Na et al . performed a systematic literature review and concluded that ‘the general control of rotation and the protective effect on the graft’ is more important than the specific procedure used to augment the ACL reconstruction 22 . Procedures reconstructing other components of the ALC, such as the ALL of the knee, have also been shown to be effective in improving control of the pivot shift 23 .…”

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts

“…Concerns regarding addition of this procedure include the risk of over-constraint and later degenerative joint disease, the lack of definitive diagnostics methods to guide decision-making and a few anatomical studies examining the anterolateral pediatric knee. 73 , 74 One recent cadaveric study has demonstrated that the anterolateral complex is inconsistent, ill-defined, and underdeveloped in children highlighting the need for further research. 75 …”