Iliotibial band autograft is a suitable alternative graft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes

PurposeThere remains a lack of consensus around autograft selection in anterior cruciate ligament reconstruction (ACLR), though there is a large body of overlapping systematic reviews and meta‐analyses. Systematic reviews and their methodological quality were aimed to be further assessed, using a validated tool known as assessing the methodological quality of systematic reviews (AMSTAR‐2).MethodsMEDLINE, Embase and CENTRAL were searched from inception to 23 April 2023 for systematic reviews (with/without meta‐analysis) comparing primary ACLR autografts. A final quality rating from AMSTAR‐2 was provided for each study (‘critically low’, ‘low’, ‘moderate’ or ‘high’ quality). Correlational analyses were conducted for ratings in relation to study characteristics.ResultsTwo thousand five hundred and ninety‐eight studies were screened, and 50 studies were ultimately included. Twenty‐four studies (48%) were rated as ‘critically low’, 17 (34%) as ‘low’, seven (14%) as ‘moderate’ and two (4%) as ‘high’ quality. The least followed domains were reporting on sources of funding (1/50 studies), the impact of risk of bias on results of meta‐analyses (11/36 studies) and publication bias (17/36 studies). There was a significant increase in the frequency of studies graded as ‘moderate’ compared to ‘low’ or ‘critically low’ quality over time (p = 0.020).ConclusionThe methodological quality of systematic reviews comparing autografts in ACLR is low, with many studies being rated lower due to commonly absent aspects of systematic review methodology such as investigating sources of funding and publication bias. More recent studies were generally more likely to be of higher quality. Authors are advised to consult AMSTAR‐2 prior to conducting systematic reviews in ACLR.Level of Evidence: Level IV.

Section: Resultsmentioning

confidence: 99%

Section: Study Characteristicsmentioning

confidence: 99%

Evaluating the quality of systematic reviews of comparative studies in autograft‐based anterior cruciate ligament reconstruction using the AMSTAR‐2 tool: A systematic umbrella review

Sritharan,

Milantoni,

Abdel Khalik

et al. 2024

“…All ACLR techniques were analysed in association with LEAP. This decision was made because of the growing evidence supporting its use for reducing graft failure [13,14,16,18]. Additionally, ITBG, which inherently involves LEAPs, is commonly used in France and in our institution, and is recommended for cases requiring additional stabilisation for rotatory instability, such as athletes and individuals with high-risk knees [13,14,16,18].…”

Section: Discussionmentioning

confidence: 99%

“…This decision was made because of the growing evidence supporting its use for reducing graft failure [13,14,16,18]. Additionally, ITBG, which inherently involves LEAPs, is commonly used in France and in our institution, and is recommended for cases requiring additional stabilisation for rotatory instability, such as athletes and individuals with high-risk knees [13,14,16,18]. Although the choice of fixation for the same graft type varies, this study shows that the least amount of fixation clearly acts as the differentiating factor in terms of global impact.…”

Section: Discussionmentioning

confidence: 99%

“…This encompasses quadruple-bundle semitendinosus graft (ST4), bone-patellar tendonbone (BPTB) graft, iliotibial band augmented with gracilis tendon graft (ITBG) [16,17], doubled semitendinosus and doubled gracilis graft (HG), and quadriceps tendon graft (QTG). The ITBG technique is a modification of the traditional MacIntosh procedure which involved passing a flap of the iliotibial band over the top of the lateral condyle of the knee, and is widely used several French institutions as a first line or for revision ACLR and which has been reported to have good results following a recent meta-analysis [16,18].…”

Section: Inclusion and Exclusionmentioning

confidence: 99%

See 1 more Smart Citation

Sustainability studies in orthopaedic surgery: The carbon footprint of anterior cruciate ligament reconstruction depends on graft choice

Karam,

Moussa,

Valentin

et al. 2024

PurposeEnvironmental sustainability in medicine is a growing concern. Determining the carbon footprint of medical procedures may aid in selecting a less impactful technique moving forward. The purpose of this study was to understand the environmental impact of different anterior cruciate ligament reconstruction techniques, for which there is no consensus in terms of optimal graft.MethodsA life cycle analysis of different anterior cruciate ligament reconstruction techniques was performed. These included quadrupled semitendinosus graft, bone‐patellar tendon‐bone graft, iliotibial band augmented with gracilis graft, doubled semitendinosus and doubled gracilis graft, and quadriceps tendon graft. All procedures were systematically paired with a lateral extra‐articular procedure. The study was conducted in a specialised centre using surgeon preference cards, with the help of a dedicated organisation for calculation according to the ISO 14044 standard. The primary outcome measure was the carbon footprint of each of the five techniques. Secondary outcomes included other environmental impact indicators, including human carcinogenic toxicity and mineral resource scarcity, among others, based on the ReCiPe 2016 midpoint guideline. The analysis had three scopes, each encompassing varying numbers of processes: graft implantation, full procedure, and entire environmental impact, from medical prescription to patient discharge. Results were reported as percentage increases compared to the graft technique with the lowest environmental impact.ResultsIt was demonstrated that the surgical procedure itself accounted for <40% of the life cycle, with arthroscopy being 88% of surgery's GHG emissions, and scrubbing and draping contributing 39% to the carbon footprint. The iliotibial band augmented with gracilis tendon technique had the lowest carbon footprint (0.199 Kg Co2 eq), and the least impact in most categories at all scopes of the life cycle analysis. Using this technique as a reference, in terms of graft implantation, it was determined that extensor mechanism grafts had the highest carbon footprint (300% higher than the reference). Greater scopes showed a similar trend, with percentage differences decreasing significantly, reaching 1–3% when considering the entire environmental impact for most categories. Nevertheless, among the aforementioned factors of the ReCiPe 2016 guidelines, the semitendinosus graft paried with a lateral extra‐articular procedure displayed greater difference in human carcinogenic toxicity and mineral resource scarcity (6% and 10% respectively) compared to the reference. The individual processes with the highest impact were also highlighted.ConclusionsIn the institution where the study was conducted, the studied iliotibial band graft option was found to have the lowest environmental impact. Such analyses of standardised procedures can be replicated in individual institutions in order to determine their environmental impact. Identification of procedures with comparable results and differing environmental consequences may influence the future decision‐making process.Level of EvidenceLevel II, prospective cohort study.

Identifying iliotibial band graft length and incision site may minimise the potential risk of harming adjacent structures: A novel approach for surgeon guidance

Gonera,

Balcerzak,

Ruzik

et al. 2024

PurposeThe Iliotibial band (ITB) is a fibrous thickening of the fascia lata originating at the iliac crest and inserting at Gerdy's tubercle on the lateral tibia. The ITB significantly contributes to lateral knee stabilisation. Due to its size, tensile strength and easy access, it is widely used in orthopaedic surgery as an autograft during reconstruction procedures. Although ITB harvesting may result in complications, such as reduced knee extension or hip flexion, no safety margins or guidelines have been proposed for the procedure. Our aim was to determine the maximal safe length of an ITB graft, that is, that does not harm the lateral collateral ligament (LCL), tensor fasciae latae (TFL), gluteus maximus (GM) or adjacent structures, and reduce the complication rate.MethodsThe study included 50 lower limbs of 25 human cadavers, previously fixed in 10% formalin solution. The inclusion criterion was the lack of visible signs of surgical interventions in the study region. Forty lower limbs were included in the study: 16 female (mean age 83.1 ± 3.4 years) and 24 male (mean age 84.2 ± 6.8 years). Dissection was performed with a previously established protocol. Morphometric measurements were then obtained twice by two researchers.ResultsThe mean femur length was 404.8 mm [female (F) = 397.3 mm, male (M) = 409.9 mm, standard deviation (SD): F = 23.8 mm, M = 24.1 mm]. The mean ITB length was 318.9 mm (F = 309.4 mm, M = 325.2 mm, SD: F = 25.7 mm, M = 33.7 mm). Longer femurs were associated with longer ITB (p < 0.05). The mean distance from the insertion of the GM to the myofascial junction of TFL and ITB was 34.6 mm (F = 34.5 mm, M = 34.6 mm, SD: F = 3.2 mm, M = 3.3 mm). The longer femurs or ITBs demonstrated a greater distance from GM insertion to the myofascial junction of the TFL and ITB (p < 0.05).ConclusionITB grafts longer than 21 cm may contribute to the greater risk of TFL rupture. Based on simple measurements of the femur length, the surgeon may assess approximate ITB length, and thus assess the length of the maximal graft length. Moreover, to avoid harming the LCL, the incision should be performed 5 cm proximal to the articular surface of the lateral femoral condyle or 13 mm proximal to the lateral femoral epicondyle. Such preparation and preoperative planning may greatly reduce the risk of complications during ITB harvesting, while performing, for instance, the over‐the‐top technique for anterior cruciate ligament reconstruction in skeletally immature patients.Level of the StudyBasic I.