Evidence too weak to guide surgical treatment decisions for anterior cruciate ligament injury: a systematic review of the risk of new meniscal tears after anterior cruciate ligament injury

Abstract

ObjectiveTo investigate the risk of new meniscal tears after treatment for anterior cruciate ligament (ACL) injury, in children and adults with and without ACL reconstruction.DesignPrognosis systematic review (PROSPERO registration number CRD42016036788).MethodsWe searched Embase, Ovid Medline, Cochrane, CINAHL, SPORTDiscus, PEDro and Google Scholar from inception to 3rd May 2018. Eligible articles included patients with ACL injury (diagnosis confirmed by MRI and/or diagnostic arthroscopy), reported the number of meniscal tears at the time of ACL injury diagnosis/start of treatment and reported the number of new meniscal tears that subsequently occurred. Articles with fewer than 20 patients at follow-up, and articles limited to ACL revision surgery or multi-ligament knee injuries were excluded. Two independent reviewers screened articles, assessed eligibility, assessed risk of bias and extracted data. We judged the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group methodology.ResultsOf 75 studies included in the systematic review, 54 studies with 9624 patients and 501 new meniscal tears were appropriate for quantitative analysis. Heterogeneity precluded data pooling. The risk of new meniscal tears was 0%–21% when follow-up was <2 years, 0%–29% when follow-up was 2 to 5 years, 5%–52% when follow-up was 5 to 10 years and 4%–31% when follow-up was longer than 10 years. The proportion of studies with high risk of selection, misclassification and detection bias was 84%, 69% and 68%, respectively. Certainty of evidence was very low.ConclusionNew meniscal tears occurred in 0%–52% of patients between 4 months and 20 years (mean 4.9±4.4 years) following treatment for ACL injury. The certainty of evidence was too low to guide surgical treatment decisions. This review cannot conclude that the incidence of new meniscal tears is lower if ACL injury is treated with surgery compared with treatment with rehabilitation only.

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Why, When, and in Which Patients Nonoperative Treatment of Anterior Cruciate Ligament Injury Fails: An Exploratory Analysis of the COMPARE Trial

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Effect of menstrual cycle phase, menstrual irregularities and hormonal contraceptive use on anterior knee laxity and non-contact anterior cruciate ligament injury occurrence in women: a protocol for a systematic review and meta-analysis

“… 24 The Newcastle Ottawa Quality Assessment Scale is a domain-based risk of bias tool that comprises eight items within three categories to assess the key bias domains: (i) selection; (ii) comparability and (iii) outcome/exposure. We have developed coding systems, that are very similar to formerly published work in our research area, 25 according to our outcomes (ie, anterior knee laxity and ACL injury occurrence) and ensured that the assessment is specific to each outcome. We have opted for using the Newcastle Ottawa Quality Assessment Scale without the star-rating system, as the PRISMA explanation and elaboration 26 states that presenting assessments for each domain in the tool is preferable to reporting an overall ‘quality score’ because it enables users to understand the specific domains that are at risk of bias in each study.…”