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Review
. 2024 Feb 28;12(2):23259671241231254.
doi: 10.1177/23259671241231254. eCollection 2024 Feb.

Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction

David A Kolin  1 , John Apostolakos  2 , Peter D Fabricant  1 , Bridget Jivanelli  1 ; SATURN Study Group; Yi-Meng Yen  3 , Dennis E Kramer  3 , Mininder S Kocher  3 , Andrew Tennant Pennock  4 , Jeffrey J Nepple  5 , Samuel Clifton Willimon  6 , Crystal Ann Perkins  6 , Henry Bone Ellis Jr  7 , Philip L Wilson  7 , Michael McClincy  8 , James Everett Voos  9 , David D Spence  10 , Benton E Heyworth  3
Affiliations
Review

Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction

David A Kolin et al. Orthop J Sports Med. .

Abstract

Background: Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) is being used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR). However, the knee flexion angle at which fixation of ALLR or LET is performed during the procedure is quite variable based on existing technique descriptions.

Purpose/hypothesis: The purpose of this study was to identify whether flexion angle at the time of ALLR/LET fixation affected postoperative outcomes in a clinical population. It was hypothesized that ALLR/LET fixation at low versus high flexion angles would lead to no statistically significant differences in patient-reported outcome measures and graft failure rates.

Study design: Systematic review; Level of evidence, 4.

Methods: The PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify published clinical studies of ACLR with ALLR/LET in which the knee flexion angle at the time of ALLR/LET was reported. A priori, low flexion was defined as 0° to 30°, and high flexion was defined as 60° to 90°. Studies were excluded if the flexion angle was between 31° and 59° because these angles constituted neither low nor high flexion angles and including them in an analysis of high versus low flexion angle at fixation would have biased the study results toward the null. The overall risk of bias was assessed using the Newcastle-Ottawa Scale. The pooled results of the studies were analyzed using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores, along with reported graft failure rates.

Results: A total of 32 clinical studies (5230 patients) met inclusion criteria: 22 studies (1999 patients) in the low-flexion group and 10 studies (3231 patients) in the high-flexion group. The median Newcastle-Ottawa Scale score was 6. Comparisons of patients with a low flexion angle versus a high flexion angle demonstrated no differences in the IKDC (P = .84), Lysholm (P = .67), or Tegner (P = .44) scores or in graft failure (3.4% vs 4.1%, respectively; P = .69).

Conclusion: The results of this review indicated that ACLR performed in conjunction with ALLR/LET provides good to excellent patient-reported outcomes and low graft failure rates when ALLR/LET fixation is performed in either low or high knee flexion.

Keywords: anterior cruciate ligament; anterolateral ligament reconstruction; flexion angle; graft failure; lateral extra-articular tenodesis; patient-reported outcomes.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: P.D.F. has received consulting fees from WishBone Medical and stock options from Osso. B.E.H. has received financial or material support from AlloSource, Springer, and Vericel; education payments from Arthrex; nonconsulting fees from Arthrex; royalties from Springer; and stock options from Imagen Technologies. Y.M.Y. has received consulting fees from Smith & Nephew. D.E.K. has received financial or material support from Arthrex and consulting fees from Johnson & Johnson and Miach. M.S.K. has received financial or material support from Elsevier and Wolters Kluwer Health; consulting fees from Best Doctors, OrthoPediatrics, Ossur, and Smith & Nephew; and royalties from OrthoPediatrics, Ossur, Elsevier, and Wolters Kluwer Health. A.T.P. has received consulting fees from OrthoPediatrics. J.J.N. has received research support from Smith & Nephew and Zimmer Biomet Holdings, consulting fees from Responsive Arthroscopy and Smith & Nephew, nonconsulting fees from Smith & Nephew, and royalties from Responsive Arthroscopy. S.C.W. has received consulting fees from Smith & Nephew. P.L.W. has received research support from AlloSource and Ossur, financial or material support from Elsevier, and royalties from Elsevier. M.M. has received royalties from Elizur. J.E.V. has received consulting fees from Arthrex. D.D.S. has received financial or material support from Elsevier, research support from OrthoPediatrics, and royalties from Elsevier. 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) study selection flow diagram. ALLR, anterolateral ligament reconstruction; LET, lateral extra-articular tenodesis.
Figure 2.
Figure 2.
Forest plots demonstrating the International Knee Documentation Committee (IKDC) scores for (A) low-flexion and (B) high-flexion studies, the Lysholm scores for (C) low-flexion and (D) high-flexion studies, and the Tegner scores for (E) low-flexion and (F) high-flexion studies. RE, random effects.
See this image and copyright information in PMC

References

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