Na Bo-Ram, Kwak Woo-Kyoung, Seo Hyoung-Yeon, Seon Jong-Keun
Department of Orthopedic Surgery, Chonnam National University Hospital, Gwangju, Republic of Korea.
Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, Chonnam, Republic of Korea.
Orthop J Sports Med. 2021 Sep 13;9(9):23259671211023099. doi: 10.1177/23259671211023099. eCollection 2021 Sep.
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.
To conduct a systematic review and meta-analysis of the literature regarding the efficacy of AEAP in primary ACLR.
Systematic review; Level of evidence, 3.
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.
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.
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.
多年来，单纯前交叉韧带重建术（ACLR）后残留的旋转不稳定一直是个难题。包括前外侧韧带重建术（ALLR）或外侧关节外肌腱固定术（LET）在内的前外侧关节外手术（AEAPs）作为增强旋转稳定性的一种手术选择，但缺乏其有效性的确切证据。
对关于AEAP在初次ACLR中疗效的文献进行系统评价和荟萃分析。
系统评价；证据等级，3级。
由2名独立的评价者进行文献检索、数据提取和质量评估。按照PRISMA（系统评价和荟萃分析的首选报告项目）指南，于2020年4月检索了MEDLINE、EMBASE和Cochrane图书馆。共筛选了3444项研究，评估了20项研究（11项随机对照试验和9项非随机研究）。比较了接受初次ACLR联合AEAP的患者与接受单纯初次ACLR的患者的功能结果、稳定性和并发症。对于亚组分析，根据AEAP技术（ALLR与LET）以及受伤至手术的时间（≤12个月与>12个月）比较结果。使用Cochrane偏倚风险工具、Jadad量表和纽卡斯尔-渥太华量表评估纳入研究的方法学质量。
与单纯ACLR相比，ACLR联合AEAP可改善轴移分级和移植物失败率，无论AEAP技术或受伤至手术的时间如何。接受AEAP联合ACLR的患者主观功能评分有有限的、轻微的改善。与ALLR相反，接受LET联合ACLR的患者膝关节僵硬和不良事件的风险增加。
我们的评价表明，当需要改善旋转稳定性和主观功能时，无论受伤时间如何，均可考虑AEAP联合初次ACLR。与LET相比，ALLR似乎是改善旋转稳定性的更好选择。
