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Review
. 2021 Sep 13;9(9):23259671211023099.
doi: 10.1177/23259671211023099. eCollection 2021 Sep.

Clinical Outcomes of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis Combined With Primary ACL Reconstruction: A Systematic Review With Meta-analysis

Bo-Ram Na  1 , Woo-Kyoung Kwak  1 , Hyoung-Yeon Seo  1   2 , Jong-Keun Seon  1   2
Affiliations
Review

Clinical Outcomes of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis Combined With Primary ACL Reconstruction: A Systematic Review With Meta-analysis

Bo-Ram Na et al. Orthop J Sports Med. .

Abstract

Background: Residual rotational instability after isolated anterior cruciate ligament reconstruction (ACLR) has been a challenge for many years. Anterolateral extra-articular procedures (AEAPs), including anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET), are performed as a surgical option for additional rotational stability, but clear evidence for their usefulness is lacking.

Purpose: To conduct a systematic review and meta-analysis of the literature regarding the efficacy of AEAP in primary ACLR.

Study design: Systematic review; Level of evidence, 3.

Methods: A literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. MEDLINE, EMBASE, and the Cochrane Library were searched in April 2020, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 3444 studies were screened, and 20 studies (11 randomized controlled trials and 9 nonrandomized studies) were evaluated. Functional outcomes, stability, and complications were compared between patients who underwent primary ACLR with AEAP and those who underwent isolated primary ACLR. For subgroup analysis, outcomes were compared according to AEAP technique (ALLR vs LET) and time from injury to surgery (≤12 vs >12 months). The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool, Jadad scale, and Newcastle-Ottawa Scale.

Results: Compared with isolated ACLR, combined ACLR with AEAP led to improved pivot-shift grades and graft failure rates, regardless of the AEAP technique or of time from injury to surgery. A limited, marginal improvement in subjective function score was observed in patients who underwent AEAP combined with ACLR. In contrast to ALLR, patients who underwent LET combined with ACLR had an increased risk of knee stiffness and adverse events.

Conclusion: Our review suggests that when there is a need to improve rotational stability and subjective function, AEAP combined with primary ACLR can be considered regardless of time from injury. ALLR appeared to be a better option for improving rotational stability compared with LET.

Keywords: anterolateral ligament reconstruction; graft failure; lateral extra-articular tenodesis; pivot shift; primary anterior cruciate ligament reconstruction.

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Conflict of interest statement

The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of the identification and selection of the studies included in the meta-analysis.
Figure 2.
Figure 2.
Risk-of-bias assessment of the included randomized controlled trials (Cochrane risk-of-bias tool). +, low risk of bias; −, high risk of bias; ?, unclear risk of bias.
Figure 3.
Figure 3.
Comparison of pivot-shift test results. The forest plot shows that a significantly lower proportion of patients who underwent an additional extra-articular procedure combined with ACLR had grade 2 or 3 pivot shift compared with those who underwent isolated ACLR. ACLR, anterior cruciate ligament reconstruction; ALLR, anterolateral ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.
Figure 4.
Figure 4.
Comparison of graft failure rates. The forest plot shows a significantly lower rate of graft failure in patients who underwent an additional extra-articular procedure combined with ACLR than in those who underwent isolated ACLR. ACLR, anterior cruciate ligament reconstruction; ALLR, anterolateral ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.
Figure 5.
Figure 5.
Comparison of pivot-shift results after ACLR according to additional procedure. The forest plot shows that compared with isolated ACLR, a significantly lower proportion of   ACLR+ALLR and ACLR+LET patients had grade 2 or 3 pivot shift. ACLR, anterior cruciate ligament reconstruction; ALLR, anterolateral ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.
Figure 6.
Figure 6.
Comparison of adverse event rates after ACLR according to additional procedure. The forest plot shows that compared with isolated ACLR, the ACLR+ALLR group had a significantly lower rate of adverse events and the ACLR+LET group had a significantly higher rate of adverse events. ACLR, anterior cruciate ligament reconstruction; ALLR, anterolateral ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.
Figure 7.
Figure 7.
Comparison of knee stiffness rates after ACLR according to additional procedure. The forest plot shows a significantly higher rate of knee stiffness in the ACLR+LET group than in the isolated ACLR group. In contrast, the rate of knee stiffness was not significantly different between the ACLR+ALLR and isolated ACLR groups. ACLR, anterior cruciate ligament reconstruction; ALLR, anterolateral ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.
Figure 8.
Figure 8.
Comparison of pivot shift after ACLR according to time from injury to surgery. The forest plot shows that regardless of whether the procedure was early (≤12 months) or delayed (>12 months), a significantly lower proportion of patients with grade 2 or 3 pivot shift was seen after additional extra-articular procedure combined with ACLR versus isolated ACLR. ACLR, anterior cruciate ligament reconstruction; ALLR, anterolateral ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.
Figure 9.
Figure 9.
Comparison of graft failure rate after ACLR according to time from injury to surgery. The forest plot shows that regardless of whether the procedure was early (≤12 months) or delayed (>12 months), a significantly lower graft failure rate was seen in patients after additional extra-articular procedure combined with ACLR versus isolated ACLR. ACLR, anterior cruciate ligament reconstruction; ALLR, anterolateral ligament reconstruction; LET, lateral extra-articular tenodesis; M-H, Mantel-Haenszel.
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