A Lateral Extra-articular Procedure Reduces the Failure Rate of Revision Anterior Cruciate Ligament Reconstruction Surgery Without Increasing Complications: A Systematic Review and Meta-analysis

Author:

Grassi Alberto1,Olivieri Huerta Rodrigo A.2,Lucidi Gian Andrea1,Agostinone Piero1,Dal Fabbro Giacomo1,Pagano Anna1,Tischer Thomas34ORCID,Zaffagnini Stefano1

Affiliation:

1. IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

2. Knee Unit, Orthopaedic Department, Hospital del Trabajador, Santiago, Chile

3. Department of Orthopaedic and Trauma Surgery, Klinik Für Orthopädie und Unfallchirurgie, Malteser Waldkrankenhaus St Marien, Erlangen, Germany

4. Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany

Abstract

Background: Lateral extra-articular procedures are becoming increasingly popular in association with anterior cruciate ligament (ACL) reconstruction, especially in patients with persistent rotatory instability and in a high-risk population. However, few studies have investigated the outcomes of the lateral extra-articular procedure as an associated procedure in an ACL revision (R-ACLR) setting and its benefit with respect to isolated intra-articular reconstruction. Hypothesis: Lateral extra-articular procedures reduce the failure rate of revision ACL reconstruction (R-ACLR). Purpose: To compare subjective outcomes, knee stability, and failure and complication rates between patients who underwent ACL revision with and without an associated lateral extra-articular procedure. Study Design: Systematic review and meta-analysis; Level of evidence, 3. Methods: A systematic search of the PubMed, Cochrane, and OVID databases was performed on September 2022 in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies were trials directly comparing patients who had isolated ACL revision with patients who had ACL revision associated with lateral extra-articular procedures at a minimum follow-up of 2 years. A meta-analysis was performed, and bias and the quality of the evidence were rated according to the Newcastle-Ottawa Scale. The meta-analysis was conducted according to the PRISMA guidelines. Results: Eight studies were included: a total of 334 patients were treated with isolated revision (isolated (R-ACLR)) and 342 treated with combined revision and a lateral extra-articular procedure (combined (R-ACLR)). For the failure rate, the meta-analysis showed a significantly decreased relative risk reduction of 54% ( P = .004) in patients with combined (R-ACLR) with respect to isolated R-ACL, whereas no difference in complication rate was observed. The combined (R-ACLR) group demonstrated a decreased risk ratio of 50% ( P = .002) for having a positive pivot-shift test result and a relative risk reduction of 68% ( P = .003) for having a grade 2-3 pivot shift when compared with the isolated (R-ACLR) group. Finally, no significant differences were observed among the lateral extra-articular procedures. Conclusion: The addition of a lateral extra-articular procedure to revision ACL significantly reduced the failure rate and postoperative pivot shift without increasing the complication rate. Anterolateral ligament reconstruction and a lateral extra-articular procedure with iliotibial band were effective in improving the outcomes of revision ACL reconstruction. Further high-level studies could help to clarify which subgroup of patients could particularly benefit from an anterolateral procedure in the context of ACL revision.

Publisher

SAGE Publications

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