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Review
. 2021 Jan 7;33(1):1.
doi: 10.1186/s43019-020-00086-9.

A systematic review comparing the results of early vs delayed ligament surgeries in single anterior cruciate ligament and multiligament knee injuries

Seong Hwan Kim  1   2 , Sang-Jin Han  1 , Yong-Beom Park  2 , Dong-Hyun Kim  2 , Han-Jun Lee  1 , Nicolas Pujol  3
Affiliations
Review

A systematic review comparing the results of early vs delayed ligament surgeries in single anterior cruciate ligament and multiligament knee injuries

Seong Hwan Kim et al. Knee Surg Relat Res. .

Abstract

Purpose: The purpose of this study was to compare clinical outcomes and incidence of concomitant injuries in patients undergoing early vs delayed surgical treatment of single anterior cruciate ligament (ACL) injury and multiligament knee injury (MLKI).

Methods: A literature search using PubMed, Embase, the Cochrane Library, the Cumulative Index to Nursing and Allied Health, and Scopus from their inception to April 30, 2020 was conducted. Studies with levels I to IV evidence reporting the incidence of meniscus or cartilage injury according to early vs delayed surgery in single ACL injuries and MLKIs were included. In the meta-analysis, data based on the number of meniscus and cartilage injuries were extracted and pooled. Lysholm and Tegner scores were analyzed using two-sample Z-tests to calculate the non-weighted mean difference (NMD). A meta-regression analysis was also performed to determine the effect of single ACL injury and MLKI/study design.

Results: Sixteen studies on single ACL injury and 14 studies on MLKI were included in this analysis. In the analysis, there were significant decreases in Lysholm score (NMD - 5.3 [95% confidence interval (CI) - 7.37 to - 3.23]) and Tegner score (NMD - 0.25 [95% CI - 0.45 to - 0.05]) and increases in risk of meniscus tear (odds ratio [OR] 1.73 [95% CI 1.1-2.73], p = 0.01) and cartilage injury (OR 2.48 [95% CI 1.46-4.2], p = 0.0007) in the delayed surgery group regardless of single ACL injury or MLKI. The result of the meta-regression analysis indicated that single ACL injury and MLKI/study design were not significant moderators of overall heterogeneity (p > 0.05).

Conclusions: Our study suggests that delayed ACL surgery significantly resulted in a higher risk of meniscus tear and cartilage injury and decreased Lysholm and Tegner scores compared to early ACL surgery. The Lysholm scores in the delayed MLKI surgery group were significantly decreased, but the risks of meniscus tear and cartilage injury in the delayed MLKI surgery group remained unclear.

Level of evidence: Level III, meta-analysis.

Keywords: Anterior cruciate ligament injury; Delayed surgery; Early surgery; Meta-analysis; Multiligament knee injury.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow diagram of articles during the selection process
Fig. 2
Fig. 2
Bar plot for risk of bias using ROBINS-I tool
Fig. 3
Fig. 3
Funnel plot for risk of meniscus tear. a Evidence of asymmetry was observed (p = 0.000). b Adjusted funnel plot after the trim-and-fill method indicated the absence of publication bias, and the observed outcome was changed to reinforce direction of the outcome
Fig. 4
Fig. 4
a Forest plot of odds ratio with 95% confidence intervals in meniscus tear. The gray squares represent the results of each study. Ends of the horizontal bars represent 95% confidence intervals. Dark gray diamonds show the overall results of all studies. Random-effects models were used. b Plot of the meta-regression analysis indicated that single ACL injury and MLKI/prospective and retrospective design were not significant moderators of overall heterogeneity (p = 0.255)
Fig. 5
Fig. 5
a Forest plot of odds ratio with 95% confidence intervals in cartilage injury. The gray squares represent the results of each study. Ends of the horizontal bars represent 95% confidence intervals. Dark gray diamonds show the overall results of all studies. Random-effects models were used. b Plot of the meta-regression analysis indicated that prospective and retrospective design were not significant moderators of overall heterogeneity (p = 0.336)
Fig. 6
Fig. 6
Forest plot of mean difference with 95% confidence intervals in Lysholm scores. The gray squares represent the results of each study. Ends of the horizontal bars represent 95% confidence intervals. Due to the heterogeneity, the non-weighted mean differences were used to assess overall results by the best-evidence synthesis; they were not shown in this plot
Fig. 7
Fig. 7
Forest plot of mean difference with 95% confidence intervals in Tegner scores. The gray squares represent the results of each study. Ends of the horizontal bars represent 95% confidence intervals. Due to the heterogeneity, the non-weighted mean differences were used to assess overall results by the best-evidence synthesis; they were not shown in this plot
See this image and copyright information in PMC

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