Independent Versus Transtibial Drilling in Anterior Cruciate Ligament Reconstruction: A Meta-analysis With Meta-regression

Transtibial versus anteromedial transportal femoral tunnel in single-bundle anterior cruciate ligament reconstruction: a systematic review and meta-analysis of prospective randomized controlled trials

The purpose of this study was to systematically review and meta-analyze randomized controlled trials (RCTs) reporting the comparative clinical and functional outcomes, postoperative complications, and radiological outcomes of single-bundle anterior cruciate ligament reconstruction (ACLR) performed using the transtibial (TT) approach or anteromedial (AM) technique. A systematic review of the literature was performed according to Cochrane and PRISMA guidelines. RCTs comparing TT and AM techniques were considered only. The quality of the studies was defined using the GRADE system, and the risk of bias was assessed with the RoB 2 tool. The primary endpoint was to systematically review and meta-analyze the clinical outcomes, residual laxity and failure rate of both AM and TT techniques. In the current meta-analysis 13 RCTs involving 989 patients who underwent arthroscopic single-bundle ACLR (486 TT and 503 AM) were included. Patients undergoing AM technique resulted in higher objective-IKDC (p < 0.001) and Lysholm scores (p = 0.002), despite a lower incidence of pathological anterior tibial translation (p < 0.001) and positive pivot-shift test (p < 0.001). No differences were detected in IKDC subjective score (p = 0.26), Tegner activity scale (p = 0.18) and graft failure (p = 0.07). ACL reconstruction through AM portal technique provides better clinical outcomes and lower incidence of residual rotational and anteroposterior laxity in comparison with the TT technique. No statistically significant difference in subjective outcomes and graft failure was reported.

A Single-Surgeon 35-Year Experience With ACL Reconstruction Using Patellar Tendon Auto- and Allografts With the Transtibial Technique

Background

Long-term follow-up for anterior cruciate ligament reconstruction (ACLR) is limited due to heterogeneity in the number of techniques utilized, the number of surgeons included, and attrition bias.

Purpose

To analyze a single surgeon's 35-year experience with ACLR using the transtibial technique, with an emphasis on temporal trends in graft selection and subanalyses on rates of revision surgery, contralateral ACLR, and nonrevision reoperation among different demographic cohorts of patients.

Study Design

Case series; Level of evidence, 4.

Methods

All patients who underwent arthroscopically assisted single-bundle ACLR between 1986 and 2021 were identified from a prospectively maintained single-surgeon registry. Outcomes of interest included revision, reoperation, and contralateral rupture rates.

Results

A total of 2915 ACLRs were performed during the senior surgeon's career. The mean age for primary ACLR was 29.4 ± 14.8 years. During primary ACLR, 98.4% of patients received a central-third bone-patellar tendon-bone (BPTB) graft. Increasing patient age was associated with increasing allograft usage (P < .01), with a significant temporal increase in allograft usage over the senior surgeon's career (P < .01). There was a higher revision rate among younger patients (P < .01), female patients aged 21 to 25 years (P = .01), and patients who received an allograft during the primary procedure (P = .04). The contralateral rupture rate showed no difference between sexes (P = .34); however, patients who underwent ACLR with autograft had a greater rate of contralateral injury compared with those with allograft (P < .01). The contralateral rupture rate was greater than the revision rate (P < .01). The most common causes of nonrevision reoperation were failed meniscal repair, new meniscal tears, arthrofibrosis, and painful hardware removal.

Conclusion

The findings of this single-surgeon registry reveal temporal trends in ACLR over a 35-year career. There was a trend toward increasing BPTB allograft use in ACLR, especially in older patients and revision cases. A greater revision rate was observed among younger patients, female patients, and those receiving allografts during primary surgery. Contralateral ACLR was more common than revision surgery.

Anterior Cruciate Ligament Reconstruction in Young Athletes: A Comprehensive Review of Lateral Extra-Articular Tenodesis and Anterolateral Ligament Reconstruction Techniques

Anterior cruciate ligament (ACL) injuries are prevalent among young athletes and pose significant challenges due to their impact on immediate and long-term knee function. Traditional ACL reconstruction techniques, while effective, may not always meet the unique needs of this population, particularly given their high physical demands and the risk of future complications. This review evaluates two advanced surgical techniques - lateral extra-articular tenodesis (LEAT) and anterolateral ligament (ALL) reconstruction - as potential enhancements to conventional ACL reconstruction. LEAT involves augmenting knee stability by addressing lateral compartment issues, while ALL reconstruction focuses on reconstructing the ALL to improve overall knee function. The review compares these techniques regarding surgical procedures, clinical outcomes, biomechanical effectiveness, and complications. LEAT and ALL reconstruction are examined for their impact on recovery, return-to-sport rates, and long-term knee health, highlighting their advantages and limitations. Findings suggest that both techniques offer promising benefits, with the potential for improved outcomes compared to traditional methods. However, the effectiveness of each technique can vary based on individual factors and the specific demands of different sports. Further research is needed to fully understand the long-term implications and refine these approaches. This review aims to guide clinical decision-making and optimize treatment strategies for young athletes with ACL injuries, enhancing their prospects for a successful return to athletic activity.

Transphyseal arthroscopic anterior cruciate ligament reconstruction in children under 12 years

BACKGROUND

The incidence of anterior cruciate ligament (ACL) injuries in children is on the rise. Despite this trend, the optimal management of these injuries remains a matter of ongoing debate. In this light, our study seeks to assess the clinical, radiological, and functional outcomes of transphyseal ACL reconstruction in preadolescent patients in the medium-term.

METHODS

This prospective study included preadolescent patients aged up to 12 years who underwent ACL transphyseal reconstruction between 2010 and 2020 and had a minimum follow-up of 2 years. Clinical assessments encompassed joint stability and range of motion. Furthermore, leg length discrepancy (LLD) and femorotibial alignment were evaluated both clinically and radiologically using full-length lower limb standing radiographs. Pre- and postoperative functional outcomes were assessed using the International Knee Documentation Committee (IKDC) and Lysholm scales, and the return to normal sports activity was evaluated using the ACL-Return to Sport after Injury (ACL-RSI) scale. Complications and relevant follow-up data were also recorded. Statistical analyses were conducted to evaluate these outcomes.

RESULTS

A total of 35 preadolescent patients, consisting of 24 males and 11 females, with a mean age at surgery of 11.2 ± 0.7 years (8.7-12), were included in the study. The mean follow-up was 52.3 ± 20.7 months (24.1-95.9). No significant growth disturbances or clinically relevant LLD were evidenced. All patients demonstrated clinically stable knees with full range of motion at the 2-year follow-up. There were statistically significant improvements in pre- and postoperative IKDC (39.3 ± 13.5 vs. 99.7 ± 0.8, p < 0.005) and Lysholm scores (48.2 ± 15.1 vs. 99.6 ± 1.4, p < 0.005). All but two patients were able to return to their pre-injury level of sports activity, with a mean ACL-RSI score of 93.5 ± 1.3. The analysis revealed an 8.6% rerupture rate and an 11.4% rate of contralateral ACL injuries, with 5-year survival rates of 92.3% and 88.8%, respectively. Subgroup analyses based on age, gender, surgical delay, or associated meniscal lesions did not reveal any significant differences in functional outcomes. Additionally, there was no discernible relationship between age or timing of ACL reconstruction and the risk of meniscal injuries.

CONCLUSIONS

Our study reinforces the value of ACL reconstruction in skeletally immature preadolescent patients, with transphyseal technique proven to be a safe, effective, and technically simpler option, even for children under the age of 12. The findings indicate excellent functional outcomes, a high rate of successful return to sporting activities, and minimal to no incidence of growth-related complications in the medium-term.

LEVEL OF EVIDENCE

Level II, prospective comparative cohort study, before and after intervention.

Meta-analysis prediction intervals are under reported in sport and exercise medicine

AIM

Prediction intervals are a useful measure of uncertainty for meta-analyses that capture the likely effect size of a new (similar) study based on the included studies. In comparison, confidence intervals reflect the uncertainty around the point estimate but provide an incomplete summary of the underlying heterogeneity in the meta-analysis. This study aimed to estimate (i) the proportion of meta-analysis studies that report a prediction interval in sports medicine; and (ii) the proportion of studies with a discrepancy between the reported confidence interval and a calculated prediction interval.

METHODS

We screened, at random, 1500 meta-analysis studies published between 2012 and 2022 in highly ranked sports medicine and medical journals. Articles that used a random effect meta-analysis model were included in the study. We randomly selected one meta-analysis from each article to extract data from, which included the number of estimates, the pooled effect, and the confidence and prediction interval.

RESULTS

Of the 1500 articles screened, 866 (514 from sports medicine) used a random effect model. The probability of a prediction interval being reported in sports medicine was 1.7% (95% CI = 0.9%, 3.3%). In medicine the probability was 3.9% (95% CI = 2.4%, 6.6%). A prediction interval was able to be calculated for 220 sports medicine studies. For 60% of these studies, there was a discrepancy in study findings between the reported confidence interval and the calculated prediction interval. Prediction intervals were 3.4 times wider than confidence intervals.

CONCLUSION

Very few meta-analyses report prediction intervals and hence are prone to missing the impact of between-study heterogeneity on the overall conclusions. The widespread misinterpretation of random effect meta-analyses could mean that potentially harmful treatments, or those lacking a sufficient evidence base, are being used in practice. Authors, reviewers, and editors should be aware of the importance of prediction intervals.

Modification of Outside-In Technique In Preparing Femoral Tunnel During Anterior Cruciate Ligament Reconstruction-"PL-Portal Outside-In Technique"

We propose modifying the outside-in technique by adopting a posterolateral (PL) portal as the working portal to introduce the anterior cruciate ligament reconstruction (ACLR) aiming guide while keeping the anteromedial portal as the viewing portal, the "PL-portal outside-in technique." This modification facilitates the preparation of an anatomical femoral tunnel, even when preserving a "big" ACL remnant or in small joint scenarios, such as pediatric ACLR. There is a minimal learning curve in adopting this technique because a standard 30° arthroscope is used, and the viewing portal is anterior.

ACL surgical trends evolve in the last five years for young European surgeons: results of the survey among the U45 ESSKA members

PURPOSE

Although the outcomes of ACL reconstruction are generally satisfying, there are several patients who do not regain their pre-injury sporting level and suffer persistent symptoms. Orthopaedic practice has evolved significantly over the last five years to address these drawbacks. The aim of the present survey was to analyze the changes in the approach to ACL reconstruction among a population of young ESSKA surgeons dedicated to ACL surgery.

METHODS

The survey was uploaded on the ESSKA website and was accessible to members under the age of 45. The ESSKA society has 1035 U45 members involved in multiple aspects of Orthopaedic practice. One hundred and forty questionnaires were returned. Several aspects of ACL surgery were investigated at baseline and 5 years prior. They included general details such as the volume of ACL reconstructions per surgeon per year, the graft choice in cases of low and high demanding patients, the technique for femoral tunnel drilling and the preferred device for femoral fixation. The approach to the management of damage to peripheral structures, as well as meniscal ramp and root tears were also investigated.

RESULTS

Hamstrings and quadrupled semitendinosus were the preferred graft choice in low-demanding patients (92.9%) while quadriceps tendon is gaining popularity in contact sport practitioners (from 4.3 to 10.7%). The percentage of surgeons using femoral screws had decreased from 37.9 to 29.3 while the percentage of those who used buttons increased from 52.9 to 69.3%. Extra-articular procedures (antero-lateral ligament (ALL) or lateral tenodesis have become popular. The percentage of surgeons who perform an additional peripheral reconstruction rose from 28.5 to 71.5%. Of those who perform the meniscal repair more than 50% of patients rose from 14.3 to 27.9%. Similarly, the percentage of surgeons who performed a medial meniscus ramp lesion repair rose from 29.4 to 54.7%. While the percentage of those who choose to perform a transtibial pull-out repair of lateral meniscus root tears significantly rose from 17.9 to 59.3%.

CONCLUSIONS

The present survey among under 45 years old ESSKA surgeons yields some notable findings. The new evidence on the impact of injuries on peripheral structures and menisci is stimulating surgeons towards a more anatomic approach if identified at the time of ACL reconstruction. This evidence will probably influence future research and decision-making.

LEVEL OF EVIDENCE

IV.

A systematic review of transphyseal ACL reconstruction in children and adolescents: comparing the transtibial and independent femoral tunnel drilling techniques

PURPOSE

Aim of this systematic review was to analyze the outcome after transphyseal ACL reconstruction in children and adolescents regarding the femoral drilling technique.

METHODS

A systematic literature search was carried out in various databases on studies on transphyseal ACL reconstruction in children and adolescents. The literature search was limited to the last 20 years. Primary outcome criterion was the failure rate. Secondary outcome criteria were growth disturbances such as leg length discrepancies or deformities and clinical scores. The present study was registered prospectively ( www.crd.york.ac.uk/PROSPERO ; CRD42022345964).

RESULTS

A total of 22 retrospective or prospective case series (level 4 evidence) were identified that reported on transphyseal ACL reconstruction in children and adolescents. The overall failure/rupture rate after transphyseal ACL reconstruction was 11.0%. The overall ACL rupture rate of the contralateral side was 9.7%. No statistical significant difference in the failure rates between independent and transtibial drilling techniques could be detected ((p = 0.76/p = 0.28)). Furthermore no statistical significant differences in the rate of reported growth disturbances between independent and transtibial drilling techniques were shown (p = 0.15). The reported clinical scores at follow-up (mean follow-up 5.05 years) revealed good to very good results.

CONCLUSION

This systematic review demonstrates that children and adolescents have a relatively high failure rate after transpyseal ACL reconstruction without any statistically significant differences between independent or transtibial drilling techniques regarding reruptur rates or the rate of growth disturbances. The results of this systematic review warrant a comparison of both techniques for femoral tunnel drilling in a controlled randomized trial.