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.