Does the Addition of a Lateral Extra-Articular Procedure to a Primary Anterior Cruciate Ligament Reconstruction Result in Superior Functional and Clinical Outcomes. A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background:
Current research focused on clinical outcomes suggests that lateral extra-articular procedures (LEAPs) can reduce rotational instability and graft failure rates in primary anterior cruciate ligament reconstructions (ACLRs). Limited studies have investigated the functional outcomes after LEAPs, including patient-reported outcome measures, sports participation, and physical performance.

Purpose:
To conduct a systematic literature review and meta-analysis to determine whether the addition of a LEAP to an ACLR results in superior functional and clinical outcomes as compared with an isolated ACLR.

Study Design:
Systematic review and meta-analysis; Level of evidence, 1.

Methods:
Five databases were searched to identify randomized controlled trials comparing clinical and functional outcomes after the addition of LEAPs to an isolated primary ACLR. Study selection was performed in accordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Assessment of methodological quality for included studies was undertaken using the Cochrane Risk of Bias 2 tool for randomized controlled trials. Studies were eligible for meta-analysis if an outcome measure utilizing similar time points was present across ≥2 studies and reported in mean difference or standard deviation.

Results:
Meta-analysis of 10 studies showed that the addition of LEAPs to an ACLR can reduce rates of rotatory instability (risk ratio, 1.45 [95% CI, 1.17-1.79]; P = .0006; I2 = 0%) and graft rupture (risk ratio, 0.21 [95% CI, 0.08-0.55]; P < .001; I2 = 0%). As supported by studies eligible for meta-analysis, this review showed that the addition of LEAPs to an ACLR can reduce rotatory instability. Short-term morbidity, including increased pain, joint stiffness, and muscle weakness, as compared with isolated ACLRs was resolved by 12 months after surgery.

Conclusion:
ACLR in combination with a LEAP results in superior clinical outcomes when compared with an isolated ACLR. Despite early postoperative outcomes concerning pain and function favoring isolated ACLRs, any negative effects were not still observed 6 months after surgery. A conclusion around the correlation between LEAPs and accelerated knee osteoarthritis could not be drawn, owing to the lack of long-term prospective studies available.