Lateral Extra-articular Procedures Decrease Rates of Graft Failure and Positive Pivot Shift in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

To synthesize the existing literature on clinical outcomes and patient-reported outcome measures following primary anterior cruciate ligament reconstruction (ACLR) and lateral extra-articular procedures (LEAP) in randomized controlled trials, whereas also determining ceiling effects for the patient-reported outcome measures utilized. A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. PubMed, MEDLINE, and Embase databases were used for an electronic search of Level I-II randomized controlled trials. Publications which followed skeletally mature patients randomized to undergo primary ACLR with or without the addition of LEAP were considered. Studies with <9-month follow-up were excluded to ensure clinical relevance. Twelve publications met eligibility criteria for this review, including a total of 1327 patients with outcomes available for data extraction. Anterolateral ligament reconstruction was performed in 7 studies, and lateral extra-articular tenodesis was performed in 5 studies. A significant reduction in graft failure was found in patients who underwent ACLR plus LEAP ([0.235, 0.580], P&#x2009;<&#x2009;.001). A significantly lower rate of positive postoperative pivot shift was also found in this group ([0.324, 0.703], P&#x2009;<&#x2009;.001). Regarding patient-reported outcome measures, Lysholm scores favored the addition of LEAP to ACLR ([0.779, 3.093], P&#x2009;=&#x2009;.001), whereas International Knee Documentation Committee scores ([-0.521, 3.757], P&#x2009;=&#x2009;.138) and Tegner scores ([-0.304, 0.222], P&#x2009;=&#x2009;.760) showed no significant difference between groups. Using a 15% threshold of study subjects, significant ceiling effects were found in 3 of 4 studies reporting International Knee Documentation Committee scores and all studies reporting Lysholm scores. Clinical outcomes, including graft failure and persistent positive pivot shift following ACLR with hamstring autograft, are improved by the addition of LEAP. Lysholm scores also improved, favoring the addition of LEAP to ACLR. The nonsignificant finding for International Knee Documentation Committee scores should be interpreted with caution, as there is a ceiling effect observed in a majority of included trials. Level II, meta-analysis of Level I and II studies.