Meta-analysis of Randomized Controlled Trials Comparing Standard versus Stump-preserving Techniques in Anterior Cruciate Ligament Reconstruction Using An Autologous Hamstring Graft
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Abstract
Background. Anterior cruciate ligament (ACL) injuries are prevalent among younger demographics due to sportsrelated incidents, contributing to knee joint instability. Current anterior cruciate ligament reconstruction (ACLR) involves either debriding the stump (standard) or preserving the stump (stump-preserving), which retains the vascular network and mechanoreceptors in the tibial stump, aiming to improve postoperative outcomes. The autologous hamstring tendon graft is the most used, providing a higher maximum load to failure than bonepatellar tendon-bone grafts.
Objective. This meta-analysis aimed to compare outcomes between the standard and stump-preserving ACLR techniques using an autologous hamstring tendon graft. The specific objectives were to evaluate primary outcomes (Lysholm Scores and the KT-1000 Arthrometer results), secondary outcomes (International Knee Documentation Committee (IKDC) Scores, results of the Lachman and pivot shift tests), and postoperative complications.
Methodology. The authors comprehensively searched PubMed, Embase, Cochrane Library, and grey literature, identifying randomized controlled trials meeting the inclusion criteria. Study characteristics and participant information were extracted, and potential bias was assessed using the Cochrane Collaboration methodology.
Result. Ten studies, encompassing 552 patients, met the inclusion criteria. Lysholm score and KT-1000 arthrometer results favored the stump-preserving group, achieving statistical significance. IKDC, pivot shift test and Lachman test favored the stumppreserving group, without statistical significance. Postoperative complications exhibited a higher incidence in the stump-preserving group, favoring the standard group, without statistical significance.
Conclusion. The meta-analysis suggested advantages in outcomes for stump-preserving ACLR, achieving statistical significance for the Lysholm scores and the KT-1000 arthrometer results. The stump-preserving group had better results in the IKDC scores, the pivot shift test results and the Lachman test results, while the standard group had fewer postoperative complications, but statistical significance was not achieved. In conclusion, while stump-preserving ACLR demonstrated promising trends in enhancing postoperative outcomes, further studies are necessary.
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References
Evans J, Mabrouk A, Nielson JL. Anterior cruciate ligament knee injury. In: StatPearls. Treasure Island (FL): StatPearls Publishing. November 17, 2023. https://pubmed.ncbi.nlm.nih.gov/29763023 https://www.ncbi.nlm.nih.gov/books/NBK499848
Sanders TL, Maradit Kremers H, Bryan AJ, et al. Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. Am J Sports Med. 2016;44(6):1502-7. https://pubmed.ncbi.nlm.nih.gov/26920430 https://doi.org/10.1177/0363546516629944 DOI: https://doi.org/10.1177/0363546516629944
Ellison TM, Flagstaff I, Johnson AE. Sexual dimorphisms in anterior cruciate ligament injury: a current concepts review. Orthop J Sports Med. 2021;9(12):23259671211025304. https://pubmed.ncbi.nlm.nih.gov/34993256 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8725014 https://doi.org/10.1177/23259671211025304 DOI: https://doi.org/10.1177/23259671211025304
Zbrojkiewicz D, Vertullo C, Grayson JE. Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000-2015. Med J Aust. 2018;208(8):354–8. https://pubmed.ncbi.nlm.nih.gov/ 29669497 https://doi.org/10.5694/mja17.00974 DOI: https://doi.org/10.5694/mja17.00974
Mlv SK, Mahmood A, Vatsya P, Garika SS, Mittal R, Nagar M. Demographic characteristics of patients who underwent anterior cruciate ligament reconstruction at a tertiary care hospital in India. World J Clin Cases. 2023;11(15):3464–70. https://pubmed.ncbi.nlm.nih.gov/37383898 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10294183 https://doi.org/10.12998/wjcc.v11.i15.3464 DOI: https://doi.org/10.12998/wjcc.v11.i15.3464
Sherman SL, Calcei J, Ray T, et al. ACL Study Group presents the global trends in ACL reconstruction: biennial survey of the ACL Study Group. J ISAKOS. 2021;6(6):322–8. https://pubmed.ncbi.nlm.nih.gov/34272329 https://doi.org/10.1136/jisakos-2020-000567 DOI: https://doi.org/10.1136/jisakos-2020-000567
Ma J, Smietana MJ, Kostrominova TY, et al. Three-dimensional engineered bone-ligament-bone constructs for anterior cruciate ligament replacement. Tissue Eng Part A. 2012;18(1-2):103–16. https://pubmed.ncbi.nlm.nih.gov/21902608 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246408 https://doi.org/10.1089/ten.TEA.2011.0231 DOI: https://doi.org/10.1089/ten.tea.2011.0231
Lee BI, Kwon SW, Kim JB, et al. Comparison of clinical results according to amount of preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft. Arthroscopy. 2008;24(5):560–8. https://pubmed.ncbi.nlm.nih.gov/18442689 https://doi.org/10.1016/j.arthro.2007.11.011 DOI: https://doi.org/10.1016/j.arthro.2007.11.011
Nwachukwu BU, Patel BH, Lu Y, Allen AA, Williams RJ 3rd. Anterior cruciate ligament repair outcomes: an updated systematic review of recent literature. Arthroscopy. 2019;35(7):2233–47. https://pubmed.ncbi.nlm.nih.gov/31272646 https://doi.org/10.1016/j.arthro.2019.04.005 DOI: https://doi.org/10.1016/j.arthro.2019.04.005
van der List JP, Vermeijden HD, Sierevelt IN, et al. Repair versus reconstruction for proximal anterior cruciate ligament tears: a study protocol for a prospective multicenter randomized controlled trial. BMC Musculoskelet Disord. 2021;22(1):399. https://pubmed.ncbi.nlm.nih.gov/33931067 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088019 https://doi.org/10.1186/s12891-021-04280-y DOI: https://doi.org/10.1186/s12891-021-04280-y
Buranapuntaruk T, Kongrukgreatiyos K, Itthipanichpong T. All-inside arthroscopic anterior cruciate ligament reconstruction and internal brace with recycling suture. Arthrosc Tech. 2021;10(11):e2429–34. https://pubmed.ncbi.nlm.nih.gov/34868844 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8626616 https://doi.org/10.1016/j.eats.2021.07.022 DOI: https://doi.org/10.1016/j.eats.2021.07.022
Ashraf Y, Senevirathna SR, Ashraf T. Conventional versus 'all-inside' anterior cruciate ligament reconstruction: a randomized controlled trial comparing hamstring strength and functional outcome. Bone Jt Open. 2020;1(11):706–8. https://pubmed.ncbi.nlm.nih.gov/33241220 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684417 https://doi.org/10.1302/2633-1462.111.BJO-2020-0012.R1 DOI: https://doi.org/10.1302/2633-1462.111.BJO-2020-0012.R1
Buerba RA, Boden SA, Lesniak B. Graft selection in contemporary anterior cruciate ligament reconstruction. J Am Acad Orthop Surg Glob Res Rev. 2021;5(10):e21.00230. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8547917 https://doi.org/10.5435/JAAOSGlobal-D-21-00230 DOI: https://doi.org/10.5435/JAAOSGlobal-D-21-00230
Murawski CD, Wolf MR, Araki D, et al. Anatomic anterior cruciate ligament reconstruction: current concepts and future perspective. Cartilage. 2013;4(3 Suppl):27S-37S. https://pubmed.ncbi.nlm.nih.gov/26069663 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4297063 https://doi.org/10.1177/1947603513486557 DOI: https://doi.org/10.1177/1947603513486557
Singh I, Singh A. Remnant-preserving anterior cruciate ligament reconstruction: remnant envelope technique. Arthrosc Tech. 2020;9(11):e1805–12. https://pubmed.ncbi.nlm.nih.gov/33294344 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695627 https://doi.org/10.1016/j.eats.2020.08.002 DOI: https://doi.org/10.1016/j.eats.2020.08.002
Takahashi T, Kondo E, Yasuda K, et al. Effects of remnant tissue preservation on the tendon graft in anterior cruciate ligament reconstruction: a biomechanical and histological study. Am J Sports Med. 2016;44(7):1708–16. https://pubmed.ncbi.nlm.nih.gov/27159314 https://doi.org/10.1177/0363546516643809 DOI: https://doi.org/10.1177/0363546516643809
Gohil S, Annear PO, Breidahl W. Anterior cruciate ligament reconstruction using autologous double hamstrings: a comparison of standard versus minimal debridement techniques using MRI to assess revascularisation. A randomised prospective study with a one-year follow-up. J Bone Joint Surg Br. 2007;89(9):1165–71. https://pubmed.ncbi.nlm.nih.gov/17905952 https://doi.org/10.1302/0301-620X.89B9.19339 DOI: https://doi.org/10.1302/0301-620X.89B9.19339
Liu W, Wu Y, Wang X, et al. ACL stump and ACL femoral landmarks are equally reliable in ACL reconstruction for assisting ACL femoral tunnel positioning. Knee Surg Sports Traumatol Arthrosc. 2023;31(1):219–28. https://pubmed.ncbi.nlm.nih.gov/ 35947159 https://doi.org/10.1007/s00167-022-07084-2 DOI: https://doi.org/10.1007/s00167-022-07084-2
Jackson DW, Schaefer RK. Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction. Arthroscopy. 1990;6(3):171–8. https://pubmed.ncbi.nlm.nih.gov/2206179 https://doi.org/10.1016/0749-8063(90)90072-l DOI: https://doi.org/10.1016/0749-8063(90)90072-L
Ouanezar H, Blakeney WG, Fernandes LR, et al. Clinical outcomes of single anteromedial bundle biologic augmentation technique for anterior cruciate ligament reconstruction with consideration of tibial remnant size. Arthroscopy. 2018;34(3):714–22. https://pubmed.ncbi.nlm.nih.gov/29198590 https://doi.org/10.1016/j.arthro.2017.08.309 DOI: https://doi.org/10.1016/j.arthro.2017.08.309
Kambhampati SBS, Gollamudi S, Shanmugasundaram S, Josyula VVS. Cyclops lesions of the knee: a narrative review of the literature. Orthop J Sports Med. 2020 Aug 28;8(8):2325967120945671. https://pubmed.ncbi.nlm.nih.gov/32923503 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457408 https://doi.org/10.1177/2325967120945671 DOI: https://doi.org/10.1177/2325967120945671
Ettinger M, Etter F, Calliess T, et al. Long term results of bone-patella-tendon-bone ACL reconstruction. J Orthop. 2016;14(1):91–4. https://pubmed.ncbi.nlm.nih.gov/27829732 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5094599 https://doi.org/10.1016/j.jor.2016.10.027 DOI: https://doi.org/10.1016/j.jor.2016.10.027
Schoderbek RJ Jr, Treme GP, Miller MD. Bone-patella tendon-bone autograft anterior cruciate ligament reconstruction. Clin Sports Med. 2007;26(4):525–47. https://pubmed.ncbi.nlm.nih.gov/17920951 https://doi.org/10.1016/j.csm.2007.06.006 DOI: https://doi.org/10.1016/j.csm.2007.06.006
Aune AK, Holm I, Risberg MA, Jensen HK, Steen H. Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction. A randomized study with two-year follow-up. Am J Sports Med. 2001;29(6):722–8. https://pubmed.ncbi.nlm.nih.gov/11734484 https://doi.org/10.1177/03635465010290060901 DOI: https://doi.org/10.1177/03635465010290060901
Wilson TW, Zafuta MP, Zobitz M. A biomechanical analysis of matched bone-patellar tendon-bone and double-looped semitendinosus and gracilis tendon grafts. Am J Sports Med. 1999;27(2):202–7. https://pubmed.ncbi.nlm.nih.gov/10102102 https://doi.org/10.1177/03635465990270021501 DOI: https://doi.org/10.1177/03635465990270021501
Dheerendra SK, Khan WS, Singhal R, Shivarathre DG, Pydisetty R, Johnstone D. Anterior cruciate ligament graft choices: a review of current concepts. Open Orthop J. 2012;6:281–6. https://pubmed.ncbi.nlm.nih.gov/22888379 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3415142 https://doi.org/10.2174/1874325001206010281 DOI: https://doi.org/10.2174/1874325001206010281
Satora W, Królikowska A, Czamara A, Reichert P. Synthetic grafts in the treatment of ruptured anterior cruciate ligament of the knee joint. Polim Med. 2017;47(1):55–9. https://pubmed.ncbi.nlm.nih.gov/29160630 https://doi.org/10.17219/pim/76819 DOI: https://doi.org/10.17219/pim/76819
Wang H, Liu Z, Li Y, et al. Is remnant preservation in anterior cruciate ligament reconstruction superior to the standard technique? a systematic review and meta-analysis. Biomed Res Int. 2019;2019:1652901. https://pubmed.ncbi.nlm.nih.gov/31886174 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927015 https://doi.org/10.1155/2019/1652901 DOI: https://doi.org/10.1155/2019/1652901
Allende F, Allahabadi S, Sachdev D, et al. Comparing clinical outcomes and knee stability in remnant-preserving ACL reconstruction versus standard ACL reconstruction: a systematic review and meta-analysis. Am J Sports Med. 2024;52(14):3651–61. https://pubmed.ncbi.nlm.nih.gov/38551115 https://doi.org/10.1177/03635465231225984 DOI: https://doi.org/10.1177/03635465231225984
Ochi M, Abouheif MM, Kongcharoensombat W, et al. Double bundle arthroscopic Anterior Cruciate Ligament reconstruction with remnant preserving technique using a hamstring autograft. Sports Med Arthrosc Rehabil Ther Technol. 2011;3:30. https://pubmed.ncbi.nlm.nih.gov/22141394 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3284875 https://doi.org/10.1186/1758-2555-3-30 DOI: https://doi.org/10.1186/1758-2555-3-30
Pandey V, Madi S, Thonse C, et al. Trends in primary anatomical single-bundle anterior cruciate ligament reconstruction practice in adult patients prevalent among arthroscopy surgeons of six southern states of india. Indian J Orthop. 2022;56(10):1703-16. https://pubmed.ncbi.nlm.nih.gov/28932303 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5591592 https://doi.org/10.3889/oamjms.2017.096 DOI: https://doi.org/10.1007/s43465-022-00719-z
Andonovski A, Topuzovska S, Samardziski M, et al. The influence of anterior cruciate ligament remnant on postoperative clinical results in patients with remnant preserving anterior cruciate ligament reconstruction. Open Access Maced J Med Sci. 2017;5(5):624–9. https://pubmed.ncbi.nlm.nih.gov/28932303 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5591592 https://doi.org/10.3889/oamjms.2017.096 DOI: https://doi.org/10.3889/oamjms.2017.096
Annear PT, Rohr EJ, Hille DM, et al. No clinical difference in 10-year outcomes between standard and minimal graft debridement techniques in patients undergoing anterior cruciate ligament reconstruction using autologous hamstrings: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2019;27(2):516–23. https://pubmed.ncbi.nlm.nih.gov/30238238 https://doi.org/10.1007/s00167-018-5146-5 DOI: https://doi.org/10.1007/s00167-018-5146-5
Demirağ B, Ermutlu C, Aydemir F, Durak K. A comparison of clinical outcome of augmentation and standard reconstruction techniques for partial anterior cruciate ligament tears. Eklem Hastalik Cerrahisi. 2012;23(3):140–4. https://pubmed.ncbi.nlm.nih.gov/23145756
El-Desouky MA, Ezzat M, Abdelrazek BH. Clinical outcomes in stump-preserving versus stump-sacrificing anterior cruciate ligament reconstruction; a randomized controlled study. BMC Musculoskelet Disord. 2022;23(1):703. https://pubmed.ncbi.nlm.nih.gov/35870924 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9308271 https://doi.org/10.1186/s12891-022-05665-3 DOI: https://doi.org/10.1186/s12891-022-05665-3
Lu W, Wang D, Zhu W, et al. Placement of double tunnels in acl reconstruction using bony landmarks versus existing footprint remnant: a prospective clinical study with 2-year follow-up. Am J Sports Med. 2015;43(5):1206–14. https://pubmed.ncbi.nlm.nih.gov/25748471 https://doi.org/10.1177/0363546515570850 DOI: https://doi.org/10.1177/0363546515570850
Matsumoto T, Kuroda R, Matsushita T, et al. Reduction of tunnel enlargement with use of autologous ruptured tissue in anterior cruciate ligament reconstruction: a pilot clinical trial. Arthroscopy. 2014;30(4):468–74. https://pubmed.ncbi.nlm.nih.gov/24582053 https://doi.org/10.1016/j.arthro.2013.12.014 DOI: https://doi.org/10.1016/j.arthro.2013.12.014
Shohat N, Lindner D, Tamir E, Beer Y, Agar G. Prospective comparison between remnant-preserving augmentation and double-bundle reconstruction in anterior cruciate ligament tears. Isr Med Assoc J. 2017;19(6):355–9. https://pubmed.ncbi.nlm.nih.gov/28647932
Wang Z, Tao HB, Wang Y, et al. Clinical application of modified Crain classification in the Design of anterior cruciate ligament reconstruction with remnant preservation. BMC Musculoskelet Disord. 2022;23(1):1066. https://pubmed.ncbi.nlm.nih.gov/36471273 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9721086 https://doi.org/10.1186/s12891-022-05912-7 DOI: https://doi.org/10.1186/s12891-022-05912-7
Zhang Q, Zhang S, Cao X, et al. The effect of remnant preservation on tibial tunnel enlargement in ACL reconstruction with hamstring autograft: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2014;22(1):166–73. https://pubmed.ncbi.nlm.nih.gov/23242378 https://doi.org/10.1007/s00167-012-2341-7 DOI: https://doi.org/10.1007/s00167-012-2341-7