Supplementary Lateral Extra-articular Tenodesis for Residual Anterolateral Rotatory Instability in Patients Undergoing Single-Bundle Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Randomized Controlled Trials

Abstract

Background: The combination of lateral extra-articular tenodesis (LET) with primary single-bundle anterior cruciate ligament (ACL) reconstruction (ACLR) remains controversial.

Purpose: To determine whether the combination of LET with single-bundle ACLR provides greater control of anterolateral rotatory instability and improved clinical outcomes compared with ACLR alone.

Study design: Systematic review; Level of evidence, 2.

Methods: PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases were searched between inception and July 1, 2020. Level 1 or 2 randomized controlled trials that compared isolated single-bundle ACLR with combined LET with ACLR were included. Data were meta-analyzed for the primary outcome measure of knee stability and the secondary outcome measures of patient-reported outcome scores, return to sports, and graft failure. Dichotomous variables were presented as relative risks (RRs), and continuous variables were presented as mean differences (MDs) and standardized MDs (SMDs).

Results: A total of 6 studies involving 1010 patients were included. Pooled data showed that the ACLR+LET group had a lower incidence of the pivot shift (RR, 0.56 [95% CI, 0.45 to 0.69]; P < .00001), a higher postoperative activity level (MD, 0.47 [95% CI, 0.15 to 0.78]; P = .004), and a lower risk of graft failure (RR, 0.35 [95% CI, 0.21 to 0.59]; P < .00001) than did the ACLR group. However, there were no statistically significant differences in primary outcomes including positive Lachman test findings (RR, 0.76 [95% CI, 0.48 to 1.21]; P = .26) or side-to-side differences (SMD, -0.43 [95% CI, -0.95 to 0.09]; P = .11) or in secondary outcomes including International Knee Documentation Committee scores (SMD, 0.25 [95% CI, -0.06 to 0.56]; P = .11) or Lysholm scores (SMD, 0.28 [95% CI, -0.06 to 0.62]; P = .11). Although the overall rate of return to sports was not significantly different between the groups (RR, 0.97 [95% CI, 0.90 to 1.03]; P = .33), the activity level was higher in the ACLR+LET group.

Conclusion: The addition of LET to primary single-bundle ACLR produced greater knee stability, a higher activity level, and a lower incidence of graft failure than did ACLR alone. There may be a role for adding LET to ACLR for the treatment of ACL injuries.

Keywords: Knee; anterior cruciate ligament reconstruction; anterolateral rotatory instability; lateral extra-articular tenodesis; pivot shift.

Figure 1.

Flowchart of study search and selection. ACLR, anterior cruciate ligament reconstruction; RCT, randomized controlled trial.

Figure 2.

Forest plot comparing the rates of patients with concomitant partial meniscectomy between the ACLR and ACLR+LET groups. ACLR, anterior cruciate ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.

Figure 3.

Quality assessment of the included studies. (A) Graph of the risk of different types of bias. (B) Summary of bias risk. + = low risk of bias; − = high risk of bias; ? = unclear or unknown risk of bias.

Figure 4.

Forest plot of the incidence of positive knee anterolateral rotatory instability in the ACLR and ACLR+LET groups. ACLR, anterior cruciate ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.

Figure 5.

Forest plot of the incidence of positive anterior laxity in the ACLR and ACLR+LET groups. ACLR, anterior cruciate ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.

Figure 6.

Forest plot of the side-to-side difference between the ACLR and ACLR+LET groups. ACLR, anterior cruciate ligament reconstruction; IV, inverse variance; LET, lateral extra-articular tenodesis; Std, standardized.

Figure 7.

Forest plot of the overall rate of return to sports in the ACLR and ACLR+LET groups. ACLR, anterior cruciate ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.

Figure 8.

Forest plot comparing activity levels at last follow-up between the ACLR and ACLR+LET groups. ACLR, anterior cruciate ligament reconstruction; IV, inverse variance; LET, lateral extra-articular tenodesis.

Figure 9.

Forest plot comparing postoperative International Knee Documentation Committee scores (based on the 2000 subjective evaluation form) between the ACLR and ACLR+LET groups. ACLR, anterior cruciate ligament reconstruction; IV, inverse variance; LET, lateral extra-articular tenodesis; Std, standardized.

Figure 10.

Forest plot comparing postoperative Lysholm scores between the ACLR and ACLR+LET groups. ACLR, anterior cruciate ligament reconstruction; IV, inverse variance; LET, lateral extra-articular tenodesis; Std, standardized.

Figure 11.

Forest plot of graft failure between the ACLR and ACLR+LET groups. ACLR, anterior cruciate ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.