Summary

ACL augmentation with LET or ALL improves IKDC score, rotational stability and reduced failure compared to without in revision surgery. The current meta-analysis advocates adding a lateral procedure, particularly in those with a higher-grade pivot shift.

Abstract

Background

Following its success in restoring rotational stability and reducing failure rates in primary anterior cruciate ligament restoration (ACLR), authors have endorsed the use of lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR) for use in revision ACLR surgery, where failure rates are historically higher.

Purpose

To perform a systematic review and meta-analysis on whether the addition of a LET or ALLR had superior clinical outcomes and stability compared to isolated revision ACLR (iACLR).

Study Design: Meta-Analysis

Methods

The Cochrane Controlled Register of Trials, PubMed, Medline and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: (‘extra-articular’ OR ‘tenodesis’ OR ‘anterolateral ligament’ OR ‘iliotibial’) AND (‘anterior cruciate ligament’) AND (‘revision’ OR ‘re-operation). Data pertaining to all patient reported outcome measures (PROMs), rotational stability and post-operative complications were extracted from each study.

Results

After abstract and full-text screening, 10 clinical comparative studies were included. There were 793 patients of which 390 patients had an iACLR whilst 403 had ACLR augmented with a LET or ALLR (aACLR). The mean time for assessment of PROMs was 35 months. The aACLR group had superior IKDC scores (SMD, 0.27; 95% CI, 0.01-0.54, p = 0.04), rotational stability (Odds Ratio [OR], 2.77; 95% CI, 1.91-4.01, p < 0.00001) and lower side-to-side difference (OR, -0.53; 95% CI, -0.81 to -0.24, p = 0.0003) than those without the augmentation. Furthermore, they were less likely to fail (OR, 0.44; 95% CI, 0.24-0.80, p = 0.007). Subgroup analysis in the higher-grade laxity cohort (Grade = 2) revealed an even greater IKDC score (SMD, 0.51; 95% CI, 0.16-0.86, p = 0.005) and an improved Lysholm score (SMD, 0.45; 95%CI, 0.24-0.67, p < 0.0001) in the aACLR group.

Conclusion

Revision aACLR with a LET or ALLR can improve subjective IKDC scores, restore rotational stability and reduce failure rates by 56% compared to isolated revision ACLR. Although controversy remains on the necessity of augmenting all revision ACLRs, the current meta-analysis advocates adding a lateral procedure, particularly in those with a higher-grade pivot shift.