Combined Anterior Cruciate Ligament Reconstruction (ACLR) and Lateral Extra-articular Tenodesis through the Modified Lemaire Technique versus Isolated ACLR: A Meta-analysis of Clinical Outcomes

Damayanthi, Essy Dwi; Kholinne, Erica; Singjie, Leonard Christianto; Sakti, Muhammad; Anesstesia, Ira Juliet

doi:10.1055/s-0044-1785492

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Sumário

Systematic Review and Meta-analysis • Rev bras ortop 59 (2) • 2024 • https://doi.org/10.1055/s-0044-1785492 copy

Combined Anterior Cruciate Ligament Reconstruction (ACLR) and Lateral Extra-articular Tenodesis through the Modified Lemaire Technique versus Isolated ACLR: A Meta-analysis of Clinical Outcomes

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

Lateral extra-articular tenodesis (LET) has been proposed to resolve rotatory instability following anterior cruciate ligament reconstruction (ACLR). The present meta-analysis aimed to compare the clinical outcomes of ACLR and ACLR with LET using the modified Lemaire technique.

Materials and Methods

We performed a meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) staement. The literature search was performed on the PubMed, EBSCOHost, Scopus, ScienceDirect, and WileyOnline databases. The data extracted from the studies included were the study characteristics, the failure rate (graft or clinical failure) as the primary outcome, and the functional score as the secondary outcome. Comparisons were made between the patients who underwent isolated ACLR (ACLR group) and those submitted to ACLR and LET through the modified Lemaire technique (ACLR + LET group).

Results

A total of 5 studies including 797 patients were evaluated. The ACLR + LET group presented a lower risk of failure and lower rate of rerupture than the ACLR group (risk ratio [RR] = 0.44; 95% confidence interval [95%CI]: 0.26 to 0.75; I² = 9%; p = 0.003). The ACLR + LET group presented higher scores on the Knee Injury and Osteoarthritis Outcome Score (KOOS) regarding the following outcomes: pain, activities of daily living (ADL), sports, and quality of life (QOL), with mean differences of 0.20 (95%CI: 0.10 to 0.30; I² = 0%; p < 0.0001), -0.20 (95%CI: -0.26 to -0.13; I² = 0%; p < 0.00001), 0.20 (95%CI: 0.02 to 0.38; I² = 0%; p = 0.03), and 0.50 (95%CI: 0.29 to 0.71; I² = 0%; p < 0.00001) respectively when compared with the ACLR group.

Conclusion

Adding LET through the modified Lemaire technique to ACLR may improve knee stability because of the lower rate of graft rerupture and the superiority in terms of clinical outcomes.

Level of Evidence

Keywords
anterior cruciate ligament reconstruction; joint instability; knee joint; tenodesis; treatment outcome

Study	Items on the Joanna -Briggs Institute’s tools for critical appraisal
Study	1	2	3	4	5	6	7	8	9	10	11	12	13
Castoldi et al.¹⁸18 Castoldi M, Magnussen RA, Gunst S, et al. A randomized controlled trial of bone-patellar tendon-bone anterior cruciate ligament reconstruction with and without lateral extra-articular tenodesis: 19-year clinical and radiological follow-up. Am J Sports Med 2020;48(07):1665-1672 (2020)	Y	Y	Y	NA	NA	Y	Y	Y	Y	Y	Y	Y	Y
Getgood et al.¹⁹19 Getgood AMJ, Bryant DM, Litchfield R, et al; STABILITY Study Group. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial. Am J Sports Med 2020;48(02):285-297 (2020)	Y	Y	Y	NA	NA	Y	Y	Y	Y	Y	Y	Y	Y
Eggeling et al.²¹21 Eggeling L, Drenck TC, Frings J, et al. Additional lateral extraarticular tenodesis in revision ACL reconstruction does not influence the outcome of patients with low-grade anterior knee laxity. Arch Orthop Trauma Surg 2022;142(02):291-299 (2022)	Y	Y	Y	NA	NA	Y	Y	Y	Y	Y	Y	Y	Y
Rowan et al.²²22 Rowan FE, Huq SS, Haddad FS. Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up. Arch Orthop Trauma Surg 2019;139(10):1425-1433 (2019)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Dejour et al.²⁰20 Dejour D, Vanconcelos W, Bonin N, Saggin PR. Comparative study between mono-bundle bone-patellar tendon-bone, double-bundle hamstring and mono-bundle bone-patellar tendon-bone combined with a modified Lemaire extra-articular procedure in anterior cruciate ligament reconstruction. Int Orthop 2013;37 (02):193-199 (2013)	Y	Y	Y	NA	NA	Y	Y	Y	Y	Y	Y

Study	Type	Level of evidence	No. of patients						Mean Age (years)		Mean/ minimum follow-up (years)	Mean Time from Injury to Surgery (months)		Graft		Tensioning method	LET fixation	ACL fixation
			LET			Non-LET			LET	Non-LET		LET	Non-LET	ACL	LET
			M	F	T	M	F	T	LET	Non-LET		LET	Non-LET	ACL	LET
Castoldi et al.¹⁸18 Castoldi M, Magnussen RA, Gunst S, et al. A randomized controlled trial of bone-patellar tendon-bone anterior cruciate ligament reconstruction with and without lateral extra-articular tenodesis: 19-year clinical and radiological follow-up. Am J Sports Med 2020;48(07):1665-1672 (2020)	RCT	2	47	13	60	43	18	61	26.2	25.9	19.4	NR	NR	BPTB	G	30 degrees of knee flexion	Suture fixation	Femoral/tibial side: absorbable interference screw
Getgood et al.¹⁹19 Getgood AMJ, Bryant DM, Litchfield R, et al; STABILITY Study Group. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial. Am J Sports Med 2020;48(02):285-297 (2020)	RCT	2	151	155	306	151	161	312	19.1	18.8	2	9.3	8.1	H	ITB	60–70 degrees of knee flexion	Barbed Richards fixation staple	Femoral side: femoral cortical suspensory fixation; tibial side: tibial interference screw
Eggeling et al.²¹21 Eggeling L, Drenck TC, Frings J, et al. Additional lateral extraarticular tenodesis in revision ACL reconstruction does not influence the outcome of patients with low-grade anterior knee laxity. Arch Orthop Trauma Surg 2022;142(02):291-299 (2022)	C	3	13	10	23	35	20	55	33.3	31.9	2.4	NR	NR	BPTB, H, Q	ITB	45 degrees of knee flexion	Suture fixation	Femoral/tibial sides: interference screw
Rowan et al.²²22 Rowan FE, Huq SS, Haddad FS. Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up. Arch Orthop Trauma Surg 2019;139(10):1425-1433 (2019)	C	3	34	21	55	120	98	218	26	33	2	NR	NR	ST + G	ITB	30 degrees of knee flexion	Fixation staple with spike	Femoral/tibial sides: absorbable interference screw
Dejour et al.²⁰20 Dejour D, Vanconcelos W, Bonin N, Saggin PR. Comparative study between mono-bundle bone-patellar tendon-bone, double-bundle hamstring and mono-bundle bone-patellar tendon-bone combined with a modified Lemaire extra-articular procedure in anterior cruciate ligament reconstruction. Int Orthop 2013;37 (02):193-199 (2012)	C	3	20	5	25	17	8	25	21.4	27.5	2	10.78	12.96	BPTB	G	Full extension	Suture fixation	Femoral/tibial sides: interference screw

Study	Failure (%LET vs. %control)	Outcome
Study	Failure (%LET vs. %control)	KOOS pain score	KOOS symptom score	KOOS ADL score	KOOS sports score	KOOS QoL score	Tegner score	International Knee Documentation Committee score	Lysholm score	Marx score
Castoldi et al.¹⁸18 Castoldi M, Magnussen RA, Gunst S, et al. A randomized controlled trial of bone-patellar tendon-bone anterior cruciate ligament reconstruction with and without lateral extra-articular tenodesis: 19-year clinical and radiological follow-up. Am J Sports Med 2020;48(07):1665-1672 (2020)	Graft failure: 5/38 (13%) vs. 12/42 (29%)	−	−	−	−	−	−	82.4 ± 11.2 vs. 81.1 ± 14.38	−	−
Getgood et al.¹⁹19 Getgood AMJ, Bryant DM, Litchfield R, et al; STABILITY Study Group. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial. Am J Sports Med 2020;48(02):285-297 (2020)	Clinical failure: 72/291 (25%) vs. 120/298 (40%) (RR: 0.38; 95%CI: 0.21–0.52; p = 0.0001)	92.1 ± 0.6 vs. 91.9 ± 0.6	84.7 ± 0.8 vs. 84.6 ± 0.8	97 ± 0.4 vs. 97.2 ± 0.4	85.3 ± 1.1 vs. 85.1 ± 1.1	63.8 ± 18.9 vs. 58.4 ± 19.7	−	87.3 ± 0.8 vs. 86.8 ± 0.8	−	12.1 ± 5.5 vs. 12.7 ± 4.7
	Graft ailure: 11/291 (4%) vs. 34/298 (11%) (RR: 0.67; 95%CI, 0.36–0.83; p = 0.001)	92.1 ± 0.6 vs. 91.9 ± 0.6	84.7 ± 0.8 vs. 84.6 ± 0.8	97 ± 0.4 vs. 97.2 ± 0.4	85.3 ± 1.1 vs. 85.1 ± 1.1	63.8 ± 18.9 vs. 58.4 ± 19.7	−	−	−	−
Eggeling et al.²¹21 Eggeling L, Drenck TC, Frings J, et al. Additional lateral extraarticular tenodesis in revision ACL reconstruction does not influence the outcome of patients with low-grade anterior knee laxity. Arch Orthop Trauma Surg 2022;142(02):291-299 (2022)	Clinical failure: 3/23 (13%) vs. 6/55 (10.9%)	87.9 ± 14.6 vs. 87.9 ± 14.1	87.6 ± 15.4 vs. 87.3 ± 14.8	95.2 ± 8.2 vs. 93 ± 10	72.6 ± 25.9 vs. 76 ± 22.7	75.4 ± 1.3 vs. 74.9 ± 1.3	5.7 ± 1.3 vs. 5.9 ± 1.5	80.1 ± 14.9 vs. 77.5 ± 16.2	81.9 ± 14.2 vs. 83.8 ± 14.5	−
Rowan et al.²²22 Rowan FE, Huq SS, Haddad FS. Lateral extra-articular tenodesis with ACL reconstruction demonstrates better patient-reported outcomes compared to ACL reconstruction alone at 2 years minimum follow-up. Arch Orthop Trauma Surg 2019;139(10):1425-1433 (2019)	Clinical failure: 0/46 (0%) vs. 13/125 (10.4%)	−	−	−	−	−	8.04 ± 1.35 vs. 75.4 ± 1.35	−	98 ± 11.2 vs. 90 ± 16.2	−
Dejour et al.²⁰20 Dejour D, Vanconcelos W, Bonin N, Saggin PR. Comparative study between mono-bundle bone-patellar tendon-bone, double-bundle hamstring and mono-bundle bone-patellar tendon-bone combined with a modified Lemaire extra-articular procedure in anterior cruciate ligament reconstruction. Int Orthop 2013;37 (02):193-199 (2012)	Clinical failure: 0/25 (0%) vs. 2/25 (8%)	−	−	−	−	−	−	−	−	−

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[1] Address for correspondence Erica Kholinne, MD, PhD, Department of Orthopedic Surgery, St. Carolus Hospital, Faculty of Medicine, Trisakti University, Jakarta, Indonesia (e-mail: erica@trisakti.ac.id).