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Systematic Review

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Lateral Extra-articular Tenodesis Reduces RotationalLaxity When Combined With Anterior Cruciate

Ligament Reconstruction: A Systematic Review of theLiterature

Christopher E. Hewison, B.Sc.(Kin), Michael N. Tran, M.D., F.R.C.S.C.,Nicole Kaniki, A.T.C., M.Sc., Alliya Remtulla, B.Sc.(Kin), M.Sc., Dianne Bryant, Ph.D.,

and Alan M. Getgood, M.Phil., M.D., F.R.C.S.(Tr&Orth), Dip.S.E.M.

Purpose: To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament (ACL)reconstruction provided greater control of rotational laxity and improved clinical outcomes compared with ACL recon-struction alone. Methods: Two independent reviewers searched 9 databases for randomized and nonrandomized clinicalstudies comparing ACL reconstruction plus LET versus ACL reconstruction alone in a human adult population. All yearsand 5 languages were included. Animal and cadaveric studies, revision or repair surgical techniques, and studies focusedon biomechanical outcomes were excluded. Quality assessment of the included studies was performed with the CochraneCollaboration tool. Outcomes of interest included the pivot-shift test, KT-1000/-2000 measurements (MEDmetric, SanDiego, CA), and International Knee Documentation Committee scores. Results: The literature search yielded 3,612 ar-ticles. After titles and abstracts were reviewed, 106 articles were selected for full-text review, of which 29 studies met theinclusion criteria (8 randomized and 21 nonrandomized studies). Of the 8 randomized studies, 3 concluded that the resultswere nonsignificant between treatment groups, 4 were in favor of the extra-articular tenodesis, and 1 was in favor of theACL reconstruction alone. The Cochrane Collaboration tool showed an unclear to high risk of bias for most articles. Ameta-analysis showed a statistically significant difference for the pivot-shift test (P ¼ .002, I2 ¼ 34%) in favor of ACLreconstruction with LET. No difference was found between the groups for International Knee Documentation Committeescores (P¼ .75, I2 ¼ 19%) and KT-1000/-2000 measurements (P ¼ .84, I2 ¼ 34%). Conclusions: Meta-analysis showed astatistically significant reduction in pivot shift in favor of the combined procedure. Studies lacked sufficientinternal validity, sample size, methodologic consistency, and standardization of protocols and outcomes. Level ofEvidence: Level III, systematic review of Level I, II, and III studies.

ublished patient-reported outcomes after anterior
Pcruciate ligament (ACL) reconstruction have beenshown to be favorable; however, biomechanical
ler Kennedy Sport Medicine Clinic and University of Westerndon, Ontario, Canada.rs report the following potential conflict of interest or source of. receives support from Empower, Canadian Institutes of Healthith & Nephew, and Arthrex. A.M.G. receives support from SBM,tal Transplant Foundation, Canadian Institutes of Healthvatec, and Smith & Nephew.ebruary 4, 2015; accepted April 17, 2015.correspondence to Alan M. Getgood, M.Phil., M.D.,Orth), Dip.S.E.M., Fowler Kennedy Sport Medicine Clinic,iversity - 3M Centre, 1151 Richmond St, London, ON, Canada-mail: [email protected] the Arthroscopy Association of North America/15105/$36.00oi.org/10.1016/j.arthro.2015.04.089

Arthroscopy: The Journal of Arthroscopic and Related

assessment of conventional ACL reconstruction hasshown an inability to restore normal tibial rotation.1-3 Ithas been hypothesized that these abnormal kinematicsmay be to blame for the development of osteoarthritisand the risk of reinjury.4

Recently published anatomic studies of the antero-lateral capsule of the knee have renewed interest inthe anterolateral ligament (ALL), hypothesizing itspotential role in helping the ACL control anterolateralrotatory laxity.5-8 These studies have more accuratelycharacterized the ALL’s anatomic description, as wellas its histology and appearance, on magnetic reso-nance imaging; however, the ALL as a concept is notnew. A number of surgeons, including Segond9 backin 1879 and Hughston et al.10,11 in 1976, havedescribed this structure. Pioneering surgeons such asStrickler, Macintosh, and Lemaire used the concept of

Surgery, Vol -, No - (Month), 2015: pp 1-13 1

mailto:[email protected]://dx.doi.org/10.1016/j.arthro.2015.04.089

Table 1. Inclusion and Exclusion Criteria

Inclusion criteriaHuman adult populationLevel I, II, and III (comparative studies) evidenceComparison of ACL reconstruction with LET v ACL reconstruction

aloneExclusion criteriaAnimal studiesCadaveric studiesLevel III (other), IV, and V evidenceACL revision or repairStudies focused on biomechanical outcomes, rehabilitation, and

imaging

ACL, anterior cruciate ligament; LET, lateral extra-articulartenodesis.

2 C. E. HEWISON ET AL.

anterolateral capsule reconstruction to address theACL-deficient knee by using lateral extra-articulartenodesis (LET).12 LET is thought to be analogous tothe ALL in function, in terms of controlling antero-lateral rotational laxity; however, the 2 differanatomically. The proximal fibers of the ALL are in-tegrated with the origin and the fibular collateral lig-ament (FCL), run superficial to the FCL, and insert onthe tibia between the Gerdy tubercle and the insertionpoint of the FCL.8 Many LET techniques incorporate aproximal fixation point close to the femoral epicondyleand are fixed distally at or around the Gerdy tubercle,often running deep to the FCL.12 Initially, ACL defi-ciency was addressed by solely using LET withoutperforming an ACL reconstruction, unlike the stan-dard treatment of today.12 The benefits of the proce-dure were short-lived, however, because the repairwould frequently stretch out and fail.13-16

Because of these concerns, as well as technologicdevelopments and a greater understanding of theanatomic characteristics of the ACL, combined intra-and extra-articular reconstructions were developed,with good results reported.17 With the advent ofarthroscopy, the intra-articular reconstruction tookcenter stage, and it was believed that the extra-articularcomponent was surplus to requirements and thus fellout of favor. Many surgeons still believed in its benefit,however, particularly in Europe, where surgeonscontinued to perform the procedure in combinationwith ACL reconstruction.Recent clinical publications have shown that current

ACL reconstructions do not restore the normal kine-matics of the knee. Importantly, anterolateral rotatoryinstability, as subjectively measured by the pivot-shifttest, is not controlled, even with the advent ofdouble-bundle and, later, anatomic ACL reconstructiontechniques.18 Although reported results are still good interms of patient-reported outcomes, reduced rates ofreturn to sport, a high prevalence of postoperativeosteoarthritis,19 and a reinjury rate of greater than 20%in the age group younger than 20 years continue.18,20

It is hypothesized that a residual pivot shift may beassociated with these issues and that obliteratinganterior laxity may not significantly improve subjectiveand objective outcomes. This was shown by studiesreporting that a residual pivot shift led to a decrease inpatient satisfaction and an increase in functionalinstability.21-23

The renewed interest in the ALL has led investigatorsto revisit the question of whether the addition of ananterolateral capsular restraint to help control the pivotshift would control rotatory laxity more effectively. Thepurpose of our systematic review and meta-analysiswas to determine whether the addition of LET to ACLreconstruction would provide greater functional stabil-ity and improved clinical outcomes compared with ACL

reconstruction alone. The hypothesis was that an ACLreconstruction with LET would result in (1) increasedrotational stability as measured by the pivot shift, (2)decreased anterior laxity using the KT-1000/-2000arthrometer (MEDmetric, San Diego, CA), and (3)improved clinical outcomes as measured by the Inter-national Knee Documentation Committee (IKDC)objective score.

MethodsThis study was conducted according to the methods of

the Cochrane Handbook for Systematic Reviews of In-terventions.24 The findings are reported according to thePreferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) statement.25

Literature Search and Study SelectionA systematic literature search of 9 databases was

conducted, which included PubMed, Medline Ovid,Embase, CINAHL (Cumulative Index to Nursing andAllied Health Literature), Scopus, SPORTSDiscus, Webof Science, Cochrane Library, and Proquest Disserta-tions and Theses, from inception through March 13,2014. Two independent authors (A.R., C.E.H.) sepa-rately completed the search, which was directed withthe help of a librarian at our institution. The base termused in each search was “anterior cruciate ligament”; itwas used in combination with subject terms from eachdatabase and the following keywords: “extraarticular,”“extra articular,” “extra-articular,” “lateral plasty,”“lateral-plasty,” “tenodesis,” “procedure,” “augment,”“technique,” “reconstruction,” “Lemaire,” “Losee,”“MacIntosh,” “Ellison,” “Andrews,” and “Hughston.”Five languages were included (English, French, Span-ish, German, and Italian).After the removal of duplicates, 2 independent au-

thors (N.K., C.E.H.) assessed titles and abstracts foreligibility (Table 1). Any disagreement between authorsat this stage resulted in the article being includedfor full-text review. Two independent authors (N.K.,C.E.H.) reviewed full-text articles, and disagreements

Table 2. Randomized Controlled Trials Included in Systematic Review

Study Year Country Control ExperimentalMean

Follow-up, yr Outcomes Conclusions LOE

Acquitter et al.26 2003 France Patellar tendon (n ¼ 50) Patellar tendon plusquadriceps tendon LET(n ¼ 50)

4.8 IKDC, KT-1000 No statistically significantdifference

I

Anderson et al.27 2001 UnitedStates

Patellar tendon (n ¼ 35)and hamstring (n ¼ 33)

Hamstring plus Losee LET(n ¼ 34)

3 Physical examination, KT-1000,strength, radiographs, HSS kneescore, IKDC

No statistically significantdifference

I

Giraud et al.28 2006 France Patellar tendon (n ¼ 34) Patellar tendon plusquadriceps tendon LET(n ¼ 29)

7 IKDC, KT-1000, radiographs No statistically significantdifference

II

Kerschbaumer et al.29 1987 Austria Patellar tendon (n ¼ 13) Patellar tendon plus EllisonLET (n ¼ 37)

2.9 Physical examination, pivot shift,pain, return to sport, ROM,effusion

Favors LET I

Trichine et al.30 2014 Algeria Patellar tendon (n ¼ 60) Patellar tendon plus ITBLET (n ¼ 60)

2 IKDC, pivot shift, physicalexamination, radiographs

No statistically significantdifference

I

Vadalà et al.31 2013 Italy Hamstring (n ¼ 32) Hamstring plus Cocker-Arnold LET (n ¼ 28)

3.7 Physical examination, pivot shift,KT-1000, Lysholm, Tegner,VAS, IKDC

Favors LET I

Zaffagnini et al.32 2006 Italy Patellar tendon (n ¼ 25)and hamstring (n ¼ 25)

Marcacci hamstring pluslateral sling (n ¼ 25)

5 IKDC, Tegner score, thighcircumference, pivot shift,Lachman, KT-2000, ROM,return to sports

Favors LET I

Zaffagnini et al.33 2008 Italy Hamstring (n ¼ 37) Marcacci hamstring pluslateral sling (n ¼ 35)

3 IKDC, Tegner score, KT-2000,Marx Activity Rating Scale,psychovitality questionnaire,radiographs

Favors control II

HSS, Hospital for Special Surgery; IKDC, International Knee Documentation Committee; ITB, iliotibial band; LET, lateral extra-articular tenodesis; LOE, level of evidence; ROM, range ofmotion; VAS, visual analog scale.

LATERALEXTRA-ARTICULARTENODESIS

3

Table 3. Nonrandomized Trials Included in Systematic Review

Authors Year Country Control ExperimentalMean


Barber-Westinand Noyes34

1993 UnitedStates

Patellar tendon(n ¼ 52)

Patellar tendon plus Losee LET(n ¼ 32)

3.1 KT-1000, Sports Activity Scale Favors LET II

Barrett andRichardson35

1995 UnitedStates

Patellar tendon(n ¼ 38)

Patellar tendon plus ITB LET(n ¼ 32)

2.8 (control) and2.9(experimental)

Subjective VAS, thighcircumference, ROM, KT-1000,Lachman, pivot shift

No statisticallysignificantdifference

III

Dejour et al.36 2013 France andBrazil

Hamstring (n ¼ 25)and patellartendon (n ¼ 25)

Patellar tendon plus Lemaire LET(n ¼ 25)

2.1 Radiographs, IKDC, pivot shift,pain, sensory deficits,subsequent surgical procedures,return to sports, ability to kneelor squat on affected knee

Favors LET II

Ferkel et al.37 1988 UnitedStates

Meniscus (n ¼ 71) Meniscus plus Ellison or modifiedEllison LET (n ¼ 20), Ellisonwith popliteal advancement(n ¼ 1), or Ellison withadvancement of ITB andpopliteus (n ¼ 8)

4.3 Standard questionnaire;instrumented clinical-testingapparatus; Zarins and Rowesubjective, objective, andfunctional rating


II

Goertzen andSchulitz38

1993 Germany Hamstring (n ¼ 24) Hamstring plus Jäger-Wirth LET(n ¼ 32)

1 year Lysholm score, clinicalassessment, radiographs,Lachman, pivot shift, KT-1000,isokinetic tests, Tegner

Favors LET II

Hefti et al.39 1982 Switzerland Quadriceps tendonplus patellartendon (n ¼ 27)and patellartendon (n ¼ 25)

Carbon fiber combined with intra-and extra-articular over-the-topreconstruction (n ¼ 23)

2 Clinical examination, pivot shift,Lachman, HSS knee score

Favors control II

Hernández-Hermosoet al.40

2002 Spain Patellar tendon(n ¼ 30)



Level and frequency of athleticactivity, IKDC, radiographicLachman, hop test


III

Kanisawa et al.41 2003 Japan Hamstring (n ¼ 6) Hamstring plus ITB LET (n ¼ 5) 1.6 Step up/down activity usinglateral fluoroscopy, IKDC, KT-1000


II

Laffargue et al.42 1997 France Patellar tendon(n ¼ 36)


2.5 ARPEGE CLAS, IKDC, pivot shift,radiographic Lachman,radiographs

Favors control II

Lerat et al.43 1997 France Patellar tendon(n ¼ 50)

Patellar tendon plus quadricepstendon LET (n ¼ 60)

4 ARPEGE, dynamic radiographs,KT-1000

Favors LET II

Monaco et al.44 2007 Italy Hamstring (n ¼ 10) Hamstring plus Cocker-ArnoldLET (n ¼ 10)

NA Manual maximum AP tibialtranslation, manual maximuminternal rotation of tibia,manual maximum externalrotation at 30� of knee flexion

Favors LET II

(continued)

4C.E.HEWISO

NETAL.

Table 3. Continued

Authors Year Country Control ExperimentalMean


Noyes andBarber45

1991 UnitedStates

Patellar tendonallograft (n ¼ 64)

Patellar tendon allograft plus ITBLET (n ¼ 40)

2.9 KT-1000, isokinetic testing, pivotshift, subjective assessment(symptoms, functionallimitations during sportactivities and activities of dailyliving, level of sports activity,changes in level of activity)

Favors LET II

O’Brien et al.46 1991 UnitedStates

Patellar tendonallograft (n ¼ 32)

Patellar tendon allograft pluslateral sling of ITB (n ¼ 48)

4 Physical examination, KT-1000arthrometer, HSS ligamentrating scale

Favors control III

Paterson andTrickey47

1986 England Patellar tendon(n ¼ 23)

Patellar tendon plus ITB LET(n ¼ 17)

2.9 Ireland and Trickey symptoms ofinstability, Lachman, jerk test,patient views on operation


III

Riel et al.48 1991 Germany Patellar tendon(n ¼ 31)

Modified Marshall-MacIntoshquadriceps and patellar tendonwith polypropylene band(n ¼ 50)

3.8 KT-1000, return to sport,strength, Lysholm

Favors LET II

Roth et al.49 1987 Canada Quadriceps tendonplus patellartendon withpolypropylenebraid (n ¼ 50)

Quadriceps tendon, patellartendon, and polypropylenebraid plus biceps femoristendon advancement (n ¼ 43)


Questionnaire, physicalexamination, objectivefunctional testing (KT-1000,isotonic strength, horizontalhopping on 1 leg for distance),radiographs


III

Savalli et al.50 2008 France Hamstring(n ¼ 436)

Hamstring plus Lemaire LET(n ¼ 84)

1.2 Return to sport, IKDC No statisticallysignificantdifference

II

Sgaglione et al.51 1990 UnitedStates

Repair plushamstring(n ¼ 21)

Repair plus hamstring plus ITBLET (n ¼ 51)

3.2 Questionnaire, physicalexamination, pivot shift,generalized ligamentous laxity,KT-1000, HSS knee ligamentrating score, radiographs


III

Sonnery-Cottetet al.52

2011 France Patellar tendon,hamstring, orquadricepstendon(n ¼ 1,769)

Patellar tendon, hamstring, orquadriceps tendon plus ITB LET(n ¼ 188)

NA Septic arthritis Favors control III

Strum et al.53 1989 UnitedStates

Meniscus (n ¼ 75)or patellar tendon(n ¼ 9)

Meniscus (n ¼ 31), patellar tendon(n ¼ 3), or BPTB (n ¼ 9) plusEllison LET (n ¼ 25), Galwayand MacIntosh LET (n ¼ 11), orLemaire LET (n ¼ 7)

3.8 Questionnaire, physicalexamination, radiographs,instrumented knee ligamenttesting


II

Verdano et al.54 2012 Italy Hamstring (n ¼ 20) Hamstring over-the-top techniquestapled at Gerdy tubercle(n ¼ 20)

4 Clinical evaluation, IKDC,Lysholm score, Tegner activitylevel


II

ARPEGE, Association de Recherche pour l’étude du Genou; AP, anteroposterior; BPTB, boneepatellar tendonebone; CLAS, compétition, loisir, actif, sédentaire; HSS, Hospital for SpecialSurgery; IKDC, International Knee Documentation Committee; ITB, iliotibial band; LET, lateral extra-articular tenodesis; LOE, level of evidence; NA, not applicable; ROM, range of motion;VAS, visual analog scale.

LATERALEXTRA-ARTICULARTENODESIS

5

Table 4. Risk-of-Bias Assessment of Included Randomized Controlled Trials

Authors

RandomSequenceGenerator

AllocationConcealment

Blinding ofParticipants and

Personnel

Blinding ofOutcome

Assessment

IncompleteOutcome

DataSelectiveReporting

OtherBias

Acquitter et al.26 Low risk Low risk Unclear Unclear Low risk Low risk Low riskAnderson et al.27 Low risk Unclear Unclear Unclear Low risk Low risk Low riskGiraud et al.28 High risk Low risk Unclear High risk High risk Low risk Low riskKerschbaumer

et al.29Unclear Unclear Unclear Unclear Unclear Low risk Low risk

Trichine et al.30 Low risk Low risk Unclear Unclear Low risk Low risk Low riskVadalà et al.31 High risk Low risk Unclear Low risk Low risk Low risk Low riskZaffagnini

et al.32 (2006)High risk High risk Unclear Unclear Low risk Low risk Low risk

Zaffagniniet al.33 (2008)

Low risk Low risk Unclear Low risk Low risk Low risk Low risk


were resolved through third-party consensus (A.M.G.or A.R.). During analysis, the authors were blinded tothe authors of the study, title, and journal ofpublication.

Data AbstractionTwo authors (C.E.H., M.N.T.) independently extrac-

ted study demographic data. These included authors,date of publication, definition of the control group,definition of the experimental surgical technique,outcome measures, follow-up period, and conclusions(Tables 2-5). Two other authors (A.R., N.K.) indepen-dently extracted all outcome data involving pivot-shiftgrading, instrumented laxity measurements (KT-1000or KT-2000 arthrometer), and IKDC scores.

Table 5. Risk-of-Bias Assessment of Included Nonrandomized Tr

Authors

Evidence of SelectionBias/Prognostic

Imbalance

BlindingParticipants

Personne

Barber-Westin and Noyes34 Unclear UnclearBarrett and Richardson35 Low risk UnclearDejour et al.36 High risk UnclearFerkel et al.37 High risk UnclearGoertzen and Schulitz38 High risk UnclearHefti et al.39 Unclear UnclearHernández-Hermoso et al.40 Low risk UnclearKanisawa et al.41 High risk UnclearLaffargue et al.42 Low risk UnclearLerat et al.43 High risk UnclearMonaco et al.44 High risk UnclearNoyes and Barber45 Low risk UnclearO’Brien et al.46 High risk UnclearPaterson and Trickey47 High risk UnclearRiel et al.48 Low risk UnclearRoth et al.49 High risk UnclearSavalli et al.50 High risk UnclearSgaglione et al.51 High risk UnclearSonnery-Cottet et al.52 High risk UnclearStrum et al.53 Unclear Low riskVerdano et al.54 Unclear Unclear

Methodologic Quality AssessmentTwo groups of authors, group A (N.K. and A.R.)

and group B (C.E.H., M.N.T.), separately assessed thequality of each eligible study using the CochraneCollaboration tool for assessing risk of bias.55 Domainsevaluated included type of random sequence generator,allocation concealment, blinding of participants andpersonnel, blinding of outcome assessment, incompleteoutcome data, and selective outcome reporting. Fornonrandomized studies, we substituted our impressionof the risk of selection bias for the criteria of randomsequence generator and allocation concealment. Bothgroups independently recorded whether the studyshowed a low, high, or unclear risk of bias for eachcategory. Both groups compared their results, and any

ials

ofandl

Blinding ofOutcome

AssessmentIncomplete

Outcome DataSelectiveReporting

Unclear Low risk Low riskUnclear Low risk Low riskLow risk Low risk Low riskUnclear Low risk Low riskUnclear Low risk Low riskUnclear Unclear Low riskUnclear Low risk Low riskUnclear Low risk Low riskUnclear Low risk Low riskHigh risk High risk Low riskHigh risk Low risk Low riskUnclear High risk Low riskUnclear Low risk Low riskUnclear Unclear Low riskUnclear High risk Low riskUnclear Low risk Low riskUnclear High risk Low riskUnclear Low risk Low riskUnclear Low risk Low riskLow risk Low risk Low riskLow risk Unclear Unclear

LATERAL EXTRA-ARTICULAR TENODESIS 7

disagreements were resolved through consensus(Tables 2-5).

OutcomesThe studies used a variety of instruments and ques-

tionnaires to measure outcomes. Outcomes that werecommonamongmultiple studiesdand therefore could bepooled in a meta-analysisdincluded the pivot-shift test,KT-1000/-2000 arthrometry, and objective IKDC score.The pivot-shift test is routinely used in clinical ex-

aminations for the diagnosis of ACL deficiency.56 It hasbeen found to be an accurate diagnostic test, with highsensitivity and specificity, for ruptures of the ACL.57,58

The presence of a pivot shift has also been shown tocorrelate with functional outcomes.23,59 Therefore wedefined a positive pivot shift (grade 1, 2, or 3) as anevent for the meta-analysis.The KT-1000/-2000 arthrometer is used to quantita-

tively measure anterior tibial translation with respect tothe femur.60 It has been shown to be a valid instrumentin the diagnosis of ACL injury.61 Rangger et al.62 foundthat a difference in laxity of 3 mm or more comparedwith the contralateral knee was indicative of an ACLdeficiency in 99% of chronic cases and 95% of acuteinjuries. It was therefore determined that a KT-1000/-2000 measurement of 3 mm or more would be classi-fied as an event for the meta-analysis.The objective IKDC score was created by a group of

European and American knee surgeons to quantify kneeligament injuries and evaluate treatment results.63 It hasbeen found to have high criterion validity,64 and manyexperts have advocated its use.65 Patients are given anoverall grade of A (normal), B (nearly normal), C(abnormal), or D (severely abnormal). For the meta-analysis, a grade of C or D was considered an event.

Data AnalysisStatistical calculations and forest plots were created

using Review Manager (version 5.2).24 Each outcomewas dichotomized to represent the proportion of par-ticipants who had an event, as previously described.A Mantel-Haenszel analysis using a random-effects

model was used to generate a pooled estimate of theoverall odds ratio, 95% confidence intervals, andprobability value (P value). P < .05 was consideredstatistically significant. The Cochran Q and the I2 sta-tistic were also included to test for between-study het-erogeneity. The quantification of low, moderate, orhigh heterogeneity as defined by Higgins and Thomp-son66 was used. We hypothesized that heterogeneitymay be explained by separating studies in which thebetween-group choice of graft was the same (LET groupand non-LET group both reconstructed using patellartendon autograft) versus different (e.g., non-LET groupreconstructed using patellar tendon and LET groupreconstructed using hamstring graft) and by separating

studies in which the LET procedure was performed aspart of the reconstruction (e.g., lateral sling) versusthose in which it was not (e.g., Losee).

Results

Summary of EvidenceThe literature search yielded a total of 8,687 articles

across all databases, and after removal of duplicates,3,612 articles remained. One hundred six articlesremained after the review of titles and abstracts. Awritten request was made to obtain the full text for 1study that was not available online; this article wasexcluded because it was not possible to obtain the fulltext.67 After full-text review, 29 articles met the eligi-bility criteria, of which 8 were randomized controlledtrials and 21 were nonrandomized studies. There werea total of 642 patients in the randomized controlledtrials and 4,314 patients in the nonrandomized studies.The literature search is summarized in Figure 1.

Study QualityThe Cochrane Collaboration tool showed an unclear

to high risk of bias for most articles (Tables 4 and 5).

Variability of StudiesSurgical techniques varied across studies. ACL re-

constructions used a range of graft choices includingpatella/hamstring/quadriceps tendon autografts andallografts; single-bundle, double-bundle, nonanatomic,and anatomic tunnel placements were also described.The extra-articular tenodesis technique varied sub-stantially, with multiple described methods. Lemaire68

used an 18 � 1.5ecm strip of the iliotibial band (ITB)that was routed under the lateral collateral ligament(LCL) and into a lateral femoral condyle bone tunnel.This was then passed through a second tunnel andreattached to the Gerdy tubercle. The modified Lemairetechnique used an 8 � 1ecm strip of the posterioraspect of the ITB released proximally and left attachedto the Gerdy tubercle distally. This was then carriedunder the LCL and attached proximal and posterior tothe lateral femoral condyle with a staple or screw.69 TheMacintosh technique used a triple sling of fascia latathat remained attached to the Gerdy tubercle and wassutured proximally to the intermuscular septum. It wasthen fixed within the femur slightly proximal andposterior to the origin of the LCL.70 The Coker-Arnoldmodification of the Macintosh technique used an 8 �1ecm strip of ITB that was cut proximally and routedunder the LCL in an anterior-to-posterior direction. Itwas then looped back onto itself and sutured onto theGerdy tubercle,31 similar to that in the modified Lem-aire technique. Losee et al.71 described the ITB beingrouted from anterior to posterior through a femoraltunnel. It was then passed around the arcuate complex

Fig 1. Flow diagram showing selection of studies for sys-tematic review and meta-analysis. (ACL, anterior cruciateligament; LET, lateral extra-articular tenodesis.)


and under the LCL. Finally, it was tightened or “reefed”and attached to the Gerdy tubercle with a barbed sta-ple.27,71 Marcacci et al.72 used hamstring grafts toreconstruct both the intra-articular and lateral tenodesisportions through an “over-the-top” position. A groovewas made in the posterolateral aspect of the lateralcondyle, where the graft was passed deep to the ITBand then over the LCL. It was cycled and fixed with astaple into the groove and then fixed below the Gerdy

tubercle with another staple. Colombet73 combined theintra-articular and extra-articular portions as well, us-ing a single-bundle hamstring graft through the tibialand femoral tunnels and fixed onto the Gerdy tubercle.

Pooled ResultsOf the included studies, 14 reported pivot-shift test

findings (1,141 patients), 5 reported KT-1000/-2000measurements (314 patients), and 11 reported IKDCscores (759 patients). There was a statistically signifi-cant difference in the odds ratio of a resulting positivepivot-shift test (odds ratio, 0.50 [95% confidenceinterval, 0.32 to 0.78], P ¼ .002, I2 ¼ 34%) (Fig 2) thatfavored ACL reconstruction combined with LET. Therewere no statistically significant differences betweenthe groups when we compared KT-1000/-2000 mea-surements (P ¼ .84, I2 ¼ 34%) (Fig 3) or IKDC scores(P ¼ .75, I2 ¼ 19%) (Fig 4).Because there was some evidence of heterogeneity in

the analyses comparing pivot-shift results and KT-1000/-2000 measurements, the analyses wererepeated in accordance with the a priori hypothesis, inwhich studies comparing the same graft, with orwithout LET, were compared and studies usingdifferent grafts, with or without LET, were removed.Although the conclusions of both analyses remainedconsistent in their statistical findings, the heterogeneitywas not reduced. Therefore the analysis with all studiesincluded is presented.

Adverse EventsFew studies reported on adverse events. Among the

randomized controlled trials, 1 study looked at osteo-arthritic changes at 5 years postoperatively.32 It

Fig 2. Forest plot for pivotshift. (ACL, anterior cruci-ate ligament; CI, confidenceinterval; LET, lateral extra-articular tenodesis.)

Fig 3. Forest plot for KT-1000/-2000 measurement.(ACL, anterior cruciate lig-ament; CI, confidenceinterval; LET, lateral extra-articular tenodesis.)


showed that 1 patient from the non-LET group haddegenerative changes seen on radiographs. No removalof hardware, graft failures, or other surgical compli-cations were seen in the 2008 study of Zaffagniniet al.33 Anderson et al.27 reported that a number ofpatients showed a degree of over-constraint, asmeasured by KT-1000 testing, in the LET group ascompared with patients who underwent only ACLreconstruction. Anderson et al. noted that the LET wastensioned with the tibia externally rotated, which mayhave had an impact on over-tightening the lateral sideof the knee. Sonnery-Cottet et al.52 found the additionof the lateral tenodesis to be a significant risk factor forthe development of septic arthritis after ACL recon-struction (P ¼ .02). However, there were otherpotentially confounding variables present that couldhave played a role.

DiscussionThis systematic review of the literature shows that the

addition of LET to ACL reconstruction results in a sta-tistically significant reduction in rotational laxity, as

Fig 4. Forest plot for Inter-national Knee Documenta-tion Committee score.(ACL, anterior cruciate lig-ament; CI, confidenceinterval; LET, lateral extra-articular tenodesis.)

measured by the pivot-shift test. This finding supportsthe hypothesis that an extra-articular augmentation ofACL reconstruction, on the lateral side, with its longerlever arm, is more effective at limiting anterolateralrotation than ACL reconstruction alone. There was nodifference in KT-1000/-2000 measurements, showingthat anterior translation is controlled by the intra-articular ACL reconstruction with or without a lateraltenodesis. Thus a combined intra- and extra-articularlyreconstructed knee would conceivably have bothtranslational and rotational control; however, this didnot translate into improved clinical outcomes, giventhat the pooled IKDC scores showed no statistical dif-ference between groups. Because of the large numberof different patient-reported outcome measures usedfor the studies, a combined subjective rating was notcalculated.The studies included in this systematic review

showed significant variability in terms of surgical pro-cedures used and outcome measures reported. Aspreviously described, there is variability among thedifferent techniques used for LET in the studies. The


techniques use different grafts that are placed in avariety of anatomic locations, which may lead to anelement of performance bias. Furthermore, althoughthese techniques are ultimately intended to reduceanterolateral rotatory laxity, they are not anatomic andshould not be thought of as anatomic ALL re-constructions. It is also clear that patients were notstratified as to the degree of preoperative laxity.Stratifying for these different grades of preoperativelaxity may have shown a greater degree of differenceacross more of the outcome measures of interest.However, given the variability of the included studies,this was clearly not possible.It is important to note that 3 studies defined pivot

shift as an event or non-event,29,38,39 rather thanassigning a pivot-shift grade of 0 to 3, as was done inthe majority of other studies. This discrepancy,depending on how one interprets an event, can alterthe statistical analysis. Because of the subjectivity of thepivot-shift test, an event was determined in this analysisif there was an asymmetrical degree of anterolateralrotation, that is, a pivot-shift grade of 1, 2, or 3. A non-event was a pivot-shift grade of 0. By use of this anal-ysis, statistical significance was reached (P ¼ .002) infavor of the combined procedure. However, in a posthoc analysis, in which an event was determined as apivot-shift grade of 2 or 3 and a non-event as a pivot-shift grade of 0 or 1, a trend toward statistical signifi-cance was still found (P ¼ .06). One of the objectives ofACL reconstruction is to reduce anterolateral rotation,thereby reducing the pivot shift. It is therefore justifiedto define an event as the presence of an asymmetricalpivot shift because this systematic review is investi-gating the absolute ability of an LET to control antero-lateral rotational laxity. Given the fact that ACLreconstruction techniques, such as double-bundlereconstruction and anatomic reconstruction, haveevolved in an attempt to reduce rotational laxity, it isimportant to investigate whether LET is an efficaciousprocedure in performing this task. A concern of someinvestigators is the potential for over-constraint of theknee or the risk of osteoarthritis developing. Neither ofthese complications was found to be significant in thisanalysis; however, this finding could be a result of adegree of reporting bias and the length of follow-up ofthe included studies.Engebretsen et al.74 showed that the addition of LET

to ACL reconstruction reduced the stress on the ACLgraft by 43% in a cadaveric study. This load sharingmay therefore have a role in reducing ACL graft stressand resultant strain, thereby helping maintain the ki-nematic status of the knee, which is often found at timezero after reconstruction. Unfortunately, given thevariability of the articles included in this review, firmconclusions regarding medium- to long-term patient-reported and functional outcomes could not be

ascertained. It is clear that a well-controlled random-ized clinical trial is required to determine the effect ofthe addition of LET to ACL reconstruction on otheroutcome measures such as graft failure and functionaloutcome.The strengths of this systematic review include the

breadth of studies examined. By including all years, 5languages, and broad search terms, the number of ar-ticles reviewed was optimized. Extra-articular pro-cedures were performed as far back as 1937,75 hencethe rationale to look at all years; however, this will havehad an impact on the type of ACL reconstruction per-formed and the subsequent rehabilitation, which isclearly different from modern-day techniques. How-ever, it was believed to be an important subset thatshould not be excluded. Inclusion of multiple languagesalso allowed the capture of studies in countries whereLET has remained a popular procedure. Exclusion ofthese studies would have significantly biased the resultsof this review. Furthermore, by use of broad searchterms, all articles with the term “anterior cruciate liga-ment” were reviewed, resulting in a significant reduc-tion in the chance of missing important studies usingesoteric titles or terms.

LimitationsThe limitations of this study include the variability of

surgical techniques that were used. However, evenwith the amount of variability present, it appears thatan anterolateral reconstruction of any kind will helpcontrol rotational laxity. This can also be another di-rection for future research to determine whether onetechnique is better at controlling rotational instabilitythan another.

ConclusionsMeta-analysis showed a statistically significant

reduction in pivot shift in favor of the combined pro-cedure. Studies lacked sufficient internal validity,sample size, methodologic consistency, and standardi-zation of protocols and outcomes.

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Lateral Extra-articular Tenodesis Reduces Rotational Laxity When Combined With Anterior Cruciate Ligament Reconstruction: A ...MethodsLiterature Search and Study SelectionData AbstractionMethodologic Quality AssessmentOutcomesData Analysis

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Lateral Extra-articular Tenodesis Reduces Rotational ...download.xuebalib.com/44taYqTAryJp.pdf · ACL-deﬁcient knee by using lateral extra-articular tenodesis (LET).12 LET is thought