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Background:
This meta-analysis was performed to compare the clinical outcomes of primary anterior cruciate ligament (ACL) reconstruction using the ACL remnant preservation technique versus the standard technique.
Methods:
PubMed, Embase, and the Cochrane Library were searched through December 24, 2017, to identify randomized controlled studies t...
Context in source publication
Citations
... In contrast, subsequent meta-analyses have shown a statistically significant difference in Lysholm scores favoring patients undergoing rACLR but no difference in IKDC scores. 16,[21][22][23] A recent prospective trial randomized patients undergoing single-bundle ACLR with hamstring autograft to either the remnant preservation group or remnant debridement group. 24 Of 49 randomized patients, 86% were available for telephone follow-up at 10 years. ...
Purpose
To compare a large cohort of patients who underwent remnant-sparing anterior cruciate ligament reconstruction (rACLR) with a matched group of patients who underwent anatomic single-bundle anterior cruciate ligament reconstruction (ACLR) with respect to clinical laxity, patient-reported outcomes, and functional testing.
Methods
Patients who underwent rACLR between January 2010 and December 2015 were matched according to age, sex, body mass index, and graft type to patients who underwent ACLR. The primary outcome measure was the ACL Quality of Life (ACL-QOL) score at final follow-up of 24 months. Secondary outcomes included functional tests and clinical laxity measurements at 6, 12, and 24 months postoperatively. Concurrent intra-articular pathology at the time of surgery and postoperative complications were also recorded. Statistical analyses included the dependent t test and the Wilcoxon signed rank test.
Results
A total of 210 rACLR patients were successfully matched to a corresponding cohort of 210 ACLR patients. There were no statistically significant differences in ACL Quality of Life (ACL-QOL) or functional testing results between the groups; however, scores in both groups showed a steady and statistically significant improvement over time. A statistically significant difference was noted with respect to the Lachman test findings, favoring the rACLR cohort (Z = –2.79, P = .005); no between-group difference was seen for the pivot-shift test (Z = –0.36, P = .72). The rACLR group had a significantly lower rate of concurrent meniscal and chondral injury. There was no difference in complications between the groups (Z = –0.49, P = .63).
Conclusions
There was no difference in patient-reported or functional testing outcomes in patients undergoing remnant-sparing compared with anatomic single-bundle ACLR. There was, however, a significantly lower rate of positive Lachman test findings after rACLR. Furthermore, the rate of concurrent meniscal and chondral pathology was lower in the rACLR group.
Level of Evidence
Level III, retrospective cohort study.
... 8,55,58 However, there is limited evidence, based on level of evidence 1 or 2 studies, of improved postoperative Lysholm scores and less anterior laxity measured with a KT-1000 or KT-2000 arthrometer in the remnant-preserving group when compared with standard techniques. 52,53 This systematic review and meta-analysis aimed to review current high-level evidence to compare outcomes of remnantpreserving ACLR versus standard ACLR in terms of clinical outcomes and measures of knee stability. We hypothesized that ACLR with remnant preservation would result in improved clinical outcomes and knee stability measures. ...
... There are a limited number of meta-analyses in the existing literature that have yielded findings consistent with our own. In 2018, Wang et al 53 conducted a meta-analysis based on 7 studies, all of which were categorized as level of evidence 1 or 2. In alignment with our study's outcomes, Wang et al 53 reported statistically significant improvements in Lysholm scores (MD, 2.2) and anterior laxity (MD, 20.71) associated with remnant-preserving techniques. Similarly, another meta-analysis, conducted in 2019, encompassed a data set consisting of 11 RCTs and cohort studies. ...
Background
Anterior cruciate ligament reconstruction (ACLR) is one of the most frequently performed procedures in sports medicine, and undesirable outcomes still may range from 3-18%. One technique that has been explored to improve outcomes is preservation of the ACL remnant tibial stump, as opposed to stump debridement, at the time of reconstruction.
Purpose
To review current high-level evidence and compare remnant-preserving anterior cruciate ligament reconstruction (ACLR) versus standard ACLR in terms of clinical outcomes and measures of knee stability.
Hypothesis
ACLR with remnant preservation would result in improved clinical outcomes and knee stability measures.
Study Design
Systematic review; Level of evidence, 2.
Methods
A systematic review of randomized controlled trials (RCTs) and cohort studies comparing remnant-preserving ACLR with standard ACLR with a minimum level of evidence of 2 was performed. Extracted data were summarized as general information, surgical characteristics, postoperative clinical outcomes, knee stability, graft evaluation, tunnel assessment, and postoperative complications. When feasible, a meta-analysis was performed.
Results
Seven RCTs and 5 cohort studies met the inclusion criteria. In total, 518 patients underwent remnant-preserving ACLR and 604 patients underwent standard ACLR. Ten studies performed the reconstruction with hamstring tendon (HT) autografts, 1 study with HT and bone–patellar tendon–bone autografts, and 1 study with HT and tibialis anterior allografts. On meta-analysis, remnant-preserving ACLR provided comparable outcomes with respect to International Knee Documentation Committee grades or Tegner scores. Even though there was a significant improvement in Lysholm scores (mean difference, −1.9; 95% CI, −2.89 to −0.91; P = .0002) with the remnant-preserving technique, this did not exceed previously reported minimal clinically important difference values. Remnant-preserving ACLR demonstrated superior knee stability in terms of patients achieving negative pivot shift when compared with the control group (88.89% vs 79.92%; P = .006). Although there was a significant improvement in the side-to-side difference in anterior tibial translation favoring remnant preservation ( P = .004), the mean difference was 0.51 mm.
Conclusion
Remnant-preserving ACLR, primarily with HT autografts, results in comparable clinical outcome scores and significantly improved knee stability relative to standard ACLR without remnant preservation without increasing the complication rate. Further studies will help clarify if remnant-preserving ACLR also has benefits in terms of enhancing graft integration and maturation, improving proprioception, limiting tunnel enlargement, and reducing complications.
... In this Current Concepts review, we summaries the present understanding of ACLR with remnant preservation, which includes selective bundle reconstruction of partial (one-bundle) ACL tears and single-and double-bundle ACLR with minimal to partial debridement of the torn ACL stump [8]. Reported benefits of remnant preservation include accelerated graft revascularization and remodeling, improved proprioception, decreased bone tunnel enlargement, individualized anatomic bone tunnel placement, improved objective knee stability and early mechanical support (with selective bundle reconstruction) to healing tissues [9]. However, clinical studies of ACLR with remnant preservation are heterogeneous in the description of remnant characteristics and surgical technique. ...
Anterior cruciate ligament (ACL) injuries are among the most prevalent knee injuries, often requiring surgical reconstruction to restore knee stability and function. Objectives: In this study we aimed to investigate the rate of re-rupture of the anterior cruciate ligament after tibial strut-preserving ACL reconstruction. Methodology of the study: This prospective cohort study was conducted at Sahiwal International hospital, from November 2022 to November 2023. The research included 98 patients who underwent anterior cruciate ligament (ACL) reconstruction surgery using the tibial strut-preserving technique. Data were collected including preoperative assessments, medical history, physical examinations, and imaging studies such as magnetic resonance imaging (MRI) or computed tomography (CT) scans. Postoperative evaluations were conducted at regular intervals to monitor patient outcomes, including functional outcomes, graft integrity, and the occurrence of re-ruptures. Results: Data were collected from 98 patients. Mean age of the patients was 32.7 ± 5.4 years. There were 55 (56.1%) male and 43 (43.9%) female patients, and out of 98 patients 70 (71.4%) belongs to middle class status. The International Knee Documentation Committee (IKDC) score exhibited a mean of 82.4 ± 7.6, indicating moderate to good knee function. The Lysholm score, measuring knee function and symptoms, yielded a mean of 89.2 ± 6.8, indicating a relatively high level of knee function and minimal symptoms. ACL reconstruction, resulting in a re-rupture rate of 10%. Conversely, in another group of 98 patients who underwent traditional ACL reconstruction, the re-rupture rate was observed to be slightly higher at 15%. Conclusion: It is concluded that Tibial Strut-Preserving ACL Reconstruction demonstrates a lower re-rupture rate compared to Traditional ACL Reconstruction. This suggests that preserving the tibial strut may contribute to improved stability and durability of the reconstructed ACL.
... First, remnant-preserving ACL reconstruction has the potential to improve clinical outcomes and proprioception without any significant difference in complications compared to conventional ACL reconstruction. [17][18][19][20] In addition, injecting local anesthetic cocktails into the hamstrings harvest tract may effectively reduce postoperative pain and alleviate posterior thigh discomfort. [9][10][11][12][13][14] However, this technique does have some disadvantages, including the requirement for skilled surgeons to perform remnant-preserving ACL reconstruction, an increase in operative time, and the potential for some patients to experience allergies to the local anesthetic cocktail. ...
Arthroscopic anterior cruciate ligament reconstruction is a common procedure that requires effective postoperative pain management for successful rehabilitation. Opioids are traditionally used for pain relief, but their side effects decrease their widespread use. Local anesthesia techniques have gained interest as an alternative to opioids. This Technical Note discusses the use of an anesthetic cocktail for pain relief at the hamstring's donor site in anterior cruciate ligament reconstruction. This approach may enhance early rehabilitation and patient satisfaction.
... According to the above search strategy, 130 articles were initially retrieved, 32 duplicate articles were excluded by using the literature management software Endnote X9, 78 unrelated articles were excluded by reviewing the title and abstract, and 6 articles were excluded by reading the full text of the literature. Finally, 14 SRs were included [24][25][26][35][36][37][38][39][40][41][42][43][44][45]. The specific article retrieval and exclusion process is shown in Fig. 2. ...
... The 14 SRs included 5 to 15 original studies each. Four of the original research literatures included in SR were RCTs [26,[35][36][37]. All 14 SRs assessed the risk of bias in the original studies included in their analysis. ...
... All 14 SRs assessed the risk of bias in the original studies included in their analysis. One SR used PEDro [35], another used the JADAD scale [40], one used the modified Coleman methodology score (CMS) [24], one used the ROBINS-I [39], one used the Newcastle-Ottawa scale [38], and one used both the Newcastle-Ottawa scale (NOS) and the Cochrane bias risk assessment tool [25], Other SRs used the Cochrane Collaboration bias risk assessment tool [26,36,37,[42][43][44][45]. All 14 SRs included meta-analysis, and six of them performed sensitivity analysis [26,35,37,40,44,45]. ...
Background
Anterior cruciate ligament injury is a common knee joint injury. Anterior cruciate ligament reconstruction is a common surgical treatment to treat anterior cruciate ligament injury. It may have certain advantages to retain the ligament stump during the operation, but the results of systematic evaluation on whether to retain the ligament stump are different. The conclusion is still controversial, and the quality needs to be strictly evaluated.
Objective
To evaluate the methodological quality, risk of bias, reporting quality and evidence quality of the systematic review of remnant preservation in anterior cruciate ligament reconstruction, and to provide reference for clinical work.
Methods
We systematically searched the system evaluations in 8 electronic databases, the languages were limited to Chinese and English, and the time limit was from the establishment of the database to June 2023. Two reviewers independently screened literature and extracted data. The methodological quality, risk of bias, reporting quality and quality of evidence were evaluated by AMSTAR-2, ROBIS, PRISMA and GRADE tools.
Results
A total of 14 systematic reviews were included. The evaluation of results showed that the methodological quality of the included systematic reviews was relatively low, of which 5 were low quality and 9 were critically low quality. A small number of systematic reviews were low risk of bias. The system evaluation reports are relatively complete, but the lack of program registration is a common problem. A total of 111 pieces of clinical evidence were extracted from the included 14 systematic reviews. The quality of evidence was generally low, with only 7 pieces of high-quality evidence, 45 pieces of medium-quality evidence, and the rest were low and very low-quality evidence. Among the reasons for relegation, imprecision is the most common, followed by inconsistency and indirectness. The existing evidence shows that patients after anterior cruciate ligament reconstruction with remnant preservation have certain advantages in knee joint function, joint stability and proprioception recovery, which may be a more effective surgical method. However, it may also increase the incidence of postoperative complications and adverse reactions.
Conclusion
Compared with Standard Technique, Remnant Preservation in Anterior Cruciate Ligament Reconstruction has more advantages in restoring joint function and stability and proprioception. But the potential risks should also be considered by surgeons. At present, the quality of evidence is generally low, and the reliability of the conclusion is insufficient. It still needs to be verified and further in-depth research is needed.
... According to the above search strategy, 130 related literatures were initially retrieved,32 duplicate literatures were excluded by using the literature management software Endnote X9, 78 unrelated literatures were excluded by reviewing the title and abstract, and 6 literatures were excluded by reading the full text of the literature. Finally, 14 literatures were included (19,21,(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40). The speci c literature retrieval and exclusion process is shown in Fig. 2. ...
... The number of original research literature included in SR ranged from 5 to 15. Four of the original research literatures included in SR were RCTs (21,(29)(30)(31). All 14 SRs assessed the risk of bias of the included original studies, and one SR used PEDro (29), 1 SR using JADAD scale (35), 1 SR using the modi ed Coleman methodology score(CMS) (19), 1 SR using the ROBINS-I(34), 1 SR using the Newcastle-Ottawa scale(33), 1 SR using the Newcastle-Ottawa scale NOS and Cochrane bias risk assessment tool (32), Other SRs used the Cochrane Collaboration bias risk assessment tool (21,30,31,(37)(38)(39)(40). ...
... Four of the original research literatures included in SR were RCTs (21,(29)(30)(31). All 14 SRs assessed the risk of bias of the included original studies, and one SR used PEDro (29), 1 SR using JADAD scale (35), 1 SR using the modi ed Coleman methodology score(CMS) (19), 1 SR using the ROBINS-I(34), 1 SR using the Newcastle-Ottawa scale(33), 1 SR using the Newcastle-Ottawa scale NOS and Cochrane bias risk assessment tool (32), Other SRs used the Cochrane Collaboration bias risk assessment tool (21,30,31,(37)(38)(39)(40). All 14 SRs included meta-analysis, and 6 SRs included sensitivity analysis (21,29,31,35,39,40), 7 SRs included subgroup analysis (19, 29, 31-33, 35, 39), Postoperative adverse reactions and complications were reported in 12 SRs (19, 21, 29-33, 35-38, 40), 6 SRs assessed publication bias (21,29,31,33,34,39), Sources of funding were reported in 7 SRs (29,32,(35)(36)(37)(38)40). ...
Background: Anterior cruciate ligament injury is a common knee joint injury. Anterior cruciate ligament reconstruction is the best way to treat anterior cruciate ligament injury. It may have certain advantages to retain the ligament stump during the operation, but the results of systematic evaluation on whether to retain the ligament stump are different. The conclusion is still controversial, and the quality needs to be strictly evaluated.
Objective: To evaluate the methodological quality, risk of bias, reporting quality and evidence quality of the systematic review of remnant preservation in anterior cruciate ligament reconstruction, and to provide reference for clinical work.
Methods: We systematically searched the system evaluations in 8 electronic databases, the languages were limited to Chinese and English, and the time limit was from the establishment of the database to June 2023. Two reviewers independently screened literature and extracted data. The methodological quality, risk of bias, reporting quality and quality of evidence were evaluated by AMSTAR-2, ROBIS, PRISMA and GRADE tools.
Results: A total of 14 systematic reviews were included. The evaluation results showed that the methodological quality of the included systematic reviews was relatively low, of which 5 were low quality and 9 were critically low quality. A small number of systematic reviews were low risk of bias. The system evaluation reports are relatively complete, but the lack of program registration is a common problem. A total of 111 clinical evidence were extracted from the included systematic reviews. The quality of evidence was generally low, with only 7 high-quality evidence, 45 medium-quality evidence, and the rest were low and very low-quality evidence. Among the reasons for relegation, imprecision is the most common, followed by inconsistency and indirectness.
Conclusion: The existing evidence shows that patients after anterior cruciate ligament reconstruction with remnant preservation have certain advantages in knee joint function, joint stability and proprioception recovery, which may be a more effective surgical method. At the same time, it may increase the incidence of postoperative complications and adverse reactions. The disadvantage should also be taken seriously. However, at present, the quality of evidence is generally low, and the reliability of the conclusion is insufficient. It still needs to be verified and further in-depth research is needed.
... 20,26,50 However, some meta- analyses have indicated that there is no difference in clinical outcomes between the 2 techniques. 29,52,54 Therefore, controversy remains regarding whether to preserve the remnant during ACLR. 16,20,26,29,43,50,52,54 No consensus has been reached as to whether the remnant-preserved procedure has advantages in bone-graft healing and clinical outcomes in clinical studies. ...
... 29,52,54 Therefore, controversy remains regarding whether to preserve the remnant during ACLR. 16,20,26,29,43,50,52,54 No consensus has been reached as to whether the remnant-preserved procedure has advantages in bone-graft healing and clinical outcomes in clinical studies. However, to date, most clinical research has focused on the preservation of the tibial attachment sites of the ACL remnant in ACLR without paying much attention to the femoral attachment site of the ACL remnant. ...
Background
The advantages of remnant tissue preservation in anterior cruciate ligament (ACL) reconstruction (ACLR) remain controversial.
Hypothesis
It was hypothesized that a large amount of remnant tissue, especially if anatomically positioned, would improve patient-reported outcomes and second-look graft appearance after preserved double-bundle ACLR (DB-ACLR).
Study Design
Cohort study; Level of evidence, 3.
Methods
This retrospective study included 89 consecutive patients who underwent unilateral remnant-preserving DB-ACLR using 2 hamstring tendon autografts. The authors categorized the arthroscopic findings into 3 groups according to the location and volume of the ACL remnant tissue in the femoral notch: (1) anatomical attachment (group AA; n = 34); (2) nonanatomical attachment (group NA; n = 33); and (3) no remnant (group NR; n = 22). Based on second-look arthroscopy, the reconstructed graft was graded as excellent, fair, or poor. Patient-reported outcomes were evaluated at 2 years after surgery using the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Japanese Anterior Cruciate Ligament Questionnaire–25 (JACL-25).
Results
The AA and NA groups had a significantly shorter time from injury to surgery compared with the NR group ( P = .0165). Considering the second-look arthroscopic findings, the authors found a significant difference in synovial coverage of the grafts between the 3 groups ( P = .0018). There were no significant differences in the overall KOOS and JACL-25 score among the 3 groups; however, the KOOS–Sport and Recreation and KOOS–Quality of Life subscale scores were significantly higher in the AA group compared with the NA and NR groups ( P = .0014 and .0039, respectively). The JACL-25 score for middle- to high-speed flexion and extension was significantly better in the AA group versus the NR group ( P = .0261).
Conclusion
This study showed that preserving anatomically positioned and adequate remnant tissue during DB-ACLR improved second-look graft appearance and KOOS–Sport and Recreation and KOOS–Quality of Life scores.
... During ACL reconstruction, whether to preserve the remnant is of controversy. Recent study indicated that ACL reconstruction with remnant preservation promotes similar graft synovial coverage and revascularization, and better sealing of the tibial tunnel, results in equivalent or superior postoperative knee stability and clinical scores, better proprioception restoration and similar total complication rate when compared with ACL reconstruction with remnant removal [2][3][4][5]. In our clinical practice, the remnant is always preserved when there is enough room for the graft and the remnant in the femoral notch. ...
Anterior cruciate ligament (ACL) rupture is a common clinical condition. Following ACL rupture, the remnant always disappears when the injury is chronic. However, there are still some patients having the remnant retained to some extent even in chronic stage. In acute stage of ACL rupture, the remnant is always preserved, which may be due to that the absorption process has not begun [1]. During ACL reconstruction, whether to preserve the remnant is of controversy. Recent study indicated that ACL reconstruction with remnant preservation promotes similar graft synovial coverage and revascularization, and better sealing of the tibial tunnel, results in equivalent or superior postoperative knee stability and clinical scores, better proprioception restoration and similar total complication rate when compared with ACL reconstruction with remnant removal [2–5]. In our clinical practice, the remnant is always preserved when there is enough room for the graft and the remnant in the femoral notch.
... A current meta-analysis has shown better Lysholm score and higher instrumented stability measurement (KT 1000) for remnant preserving ACL reconstruction compared to conventional techniques. 10 ...
Background
Recently, there has been an increase in interest in the quadriceps tendon (QT) as an alternative autologous graft option for primary anterior cruciate ligament (ACL) reconstruction.
Indication
Anterior cruciate ligament reconstruction in skeletally mature patients (high-risk patients for re-rupture and patients with medial instability).
Technique Description
The QT graft is harvested with a 4-cm skin incision over the superior pole of the patella. A double knife and an oscillating saw are used to obtain the QT graft with a bone block from the patella (65 mm x 10 mm graft and 15 mm bone block). Then an arthroscopy is carried out with assessment of the ACL tear and treatment of further intraarticular injuries. ACL reconstruction begins with debridement of the femoral insertion to expose the land marks. The medial portal is used for femoral tunnel drilling with the knee in more than 110° of flexion. A special portal aiming device is introduced via the anteromedial portal and a guide wire is placed in the area of the femoral anteromedial insertion. This guide wire is gradually overdrilled with various drills and dilators of increasing size. The final diameter should be 0.5 mm smaller than the diameter of the bone block of the graft to allow for press-fit fixation. Then, the tibial tunnel is drilled using a tibial drill guide leaving the tibial stump of the original ACL intact. The graft is pulled into the joint through the tibial tunnel until the bone block stops at the femoral tunnel entrance. The bone block is then pushed through the medial portal into the femoral tunnel (press-fit fixation). The tibial fixation is performed with an interference screw and optionally with an extracortical button.
Results
Prior studies with 2 years follow-up have shown that the clinical outcomes in primary and revision ACL reconstruction were not significantly different between the use of QT grafts with femoral press-fit fixation and the use of hamstring grafts with femoral suspension fixation.
Discussion/Conclusion
Quadriceps tendon bone autograft and femoral press-fit fixation provides an excellent alternative as a graft choice in ACL reconstruction. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
... Second look arthroscopies at one year postoperatively have shown that preservation of the ACL remnant with good synovial coverage had a positive effect on graft synovialization and graft integrity [15]. Current meta-analyses have shown that the remnant reconstruction technique leads to higher stability and better functional results [30]. The higher stability can probably be attributed to a larger diameter of the graft remnant construct as shown in a study by MRI [3]. ...
... The lower rate of graft rupture after remnant-preserving ACL reconstruction can also be attributed to improved proprioception. In the study by Ma et al., postoperative proprioception was significantly better after remnant-preserving ACL reconstruction than after conventional remnant-sacrificing ACL reconstruction [30]. It is speculated that preserving proprioceptive elements in the old stump leads to improved postoperative neuromuscular capabilities [18]. ...
Background
Remnant-preserving anterior cruciate ligament reconstruction (ACLR) should have advantages for postoperative remodeling and proprioception. However, it has been suggested that the larger diameter of the graft tends to lead to impingement phenomena with a higher rate of cyclops lesions. The aim of this work was to find out whether the remnant-preserving ACLR actually leads to an increased rate of range of motion restraints compared to the remnant-sacrificing technique.
Methods
Patients, who fulfilled the inclusion criteria, were followed up for one year after surgery. The primary endpoint was arthrolysis due to extension deficit or cyclops syndrome.
Secondary outcome measures were pain (NRS), knee function (KOOS), patient satisfaction and return to sports rate.
Results
One hundred and sixty-four patients were included in the study, 60 of whom received the “remnant augmentation” procedure (group 1). In the remnant augmentation group, one cyclops resection was performed, whereas in the non-remnant augmentation group three cyclops lesion resections had to be performed (odds ratio 0.6). There was no difference between the groups in pain (NRS) and knee function (KOOS) and patient satisfaction. The return to sports rate after one year was higher in the remnant augmentation group.
Conclusions
Patients who have undergone the sparing “remnant augmentation” ACLR have no increased risk of cyclops lesion formation or extension deficit in the first year after surgery. An improvement of the proprioceptive abilities by remnant augmentation ACLR should be investigated in further studies.
Level of evidence
III (prospective cohort study).
