Comparative Efficacy of Graft Options in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Network Meta-Analysis

Abstract

Purpose To evaluate the effectiveness of various graft options for anterior cruciate ligament reconstruction using network meta-analysis. Methods A medical literature search was conducted of PubMed, the Cochrane Library, Embase, SCOPUS, and Web of Science from their inception through March 1, 2019. The outcomes, including International Knee Documentation Committee (IKDC) form, Lachman test, Lysholm score, Pivot shift test, and Tegner score, were evaluated among graft options. Data extraction was carried out according to inclusion and exclusion criteria, and a network meta-analysis was performed using STATA 14.0. Results A total of 45 trials with 3992 patients were included. The forest plots revealed no significant differences in IKDC, Lysholm, or Tegner score among the grafts. In Lachman score, a significant difference was found in the comparisons of hamstring tendon allograft (HT-AL) versus patellar tendon autograft (PT-AU) and HT-AL versus hamstring tendon autograft (HT-AU). In pivot shift test, PT-AU was superior to all the other grafts, and quadriceps tendon autograft (QT-AU) was superior to HT-AL and artificial ligament (Art-L) in the number of cases with negative results. According to surface under the cumulative ranking area (SUCRA), PT-AU had the highest probability to be the best intervention in Lachman test and Tegner score; tibialis anterior tendon allograft (TA-AL) in IKDC and Lysholm score; and QT-AU in pivot shift test. Based on the cluster analysis of SUCRA, PT-AU was considered the most appropriate intervention by IKDC and Lachman test. Conclusion This study suggests that PT-AU may be the most appropriate graft for ACL reconstruction according to IKDC and Lachman test results. Level of Evidence Level I, network meta-analysis of randomized controlled trials.

A Systematic Review of Randomized Controlled Trials in Anterior Cruciate Ligament Reconstruction: Standard Techniques Are Comparable (299 Trials With 25,816 Patients)

“…In recent years, a number of systematic reviews and meta-analyses have evaluated different aspects of ACLR surgery as well as instructional reviews 72 and practice guidelines. 73 In their review of graft options, Mo et al 74 evaluated 45 RCTs and found that patellar tendon autograft was most appropriate in terms of IKDC and Lachman test results. Wang et al 75 evaluated 11 RCTs comparing clinical outcomes and adverse events associated with irradiated and nonirradiated allografts in ACLR and found no significant differences between autograft and nonirradiated allograft, although autograft offered greater advantages in functional outcomes and adverse events.…”

“… 73 In their review of graft options, Mo et al . 74 evaluated 45 RCTs and found that patellar tendon autograft was most appropriate in terms of IKDC and Lachman test results. Wang et al .…”

Our Preferred Technique for Bone–Patellar Tendon–Bone Allograft Preparation

“…7,10 A multitude of studies have evaluated advantages and disadvantages of each graft, but generally there is higher donor site morbidity, larger incisions, possible violation of the extensor mechanism, and increased surgical times with autografts, whereas there is a higher failure rate in patients <25 years old; an increased risk of infection, disease transmission, and cost; and reduced graft strength with allograft selections. [7][8][9]11 BTB autograft is preferred in the senior author's clinical practice of >35 years, especially for patients involved in high-level athletic competition; however, the role of BTB autograft versus allograft in older, less high-demand individuals is less clearly defined. The senior author experienced allograft BTB usage increasing at 5-year increments since 1986 of 1%, 3%, 13%, 24%, and >50%.…”

“…Although BTB autograft is considered the gold standard for primary ACL reconstruction 7 , 8 , 9 among high-volume ligament surgeons, particularly those who take care of intercollegiate, professional, and elite-level athletes, many factors should be considered before definitive selection. These include age, desired activity level, quality of host tissue, gender, concurrent injuries, risk of donor site morbidity, cosmesis, and desired type of graft fixation.…”

“… 7 , 10 A multitude of studies have evaluated advantages and disadvantages of each graft, but generally there is higher donor site morbidity, larger incisions, possible violation of the extensor mechanism, and increased surgical times with autografts, whereas there is a higher failure rate in patients <25 years old; an increased risk of infection, disease transmission, and cost; and reduced graft strength with allograft selections. 7 , 8 , 9 , 11 …”