-
Systematic Review
From FowOntario, Lon
The authofunding: D.BResearch, SmMusculoskeleResearch, Lin
Received FAddress
F.R.C.S.(Tr&Western UnN6A 3K7. E
� 2015 b0749-8063http://dx.d
Lateral Extra-articular Tenodesis Reduces RotationalLaxity When
Combined With Anterior Cruciate
Ligament Reconstruction: A Systematic Review of
theLiterature
Christopher E. Hewison, B.Sc.(Kin), Michael N. Tran, M.D.,
F.R.C.S.C.,Nicole Kaniki, A.T.C., M.Sc., Alliya Remtulla,
B.Sc.(Kin), M.Sc., Dianne Bryant, Ph.D.,
and Alan M. Getgood, M.Phil., M.D., F.R.C.S.(Tr&Orth),
Dip.S.E.M.
Purpose: To determine whether the addition of lateral
extra-articular tenodesis (LET) to anterior cruciate ligament
(ACL)reconstruction provided greater control of rotational laxity
and improved clinical outcomes compared with ACL recon-struction
alone. Methods: Two independent reviewers searched 9 databases for
randomized and nonrandomized clinicalstudies comparing ACL
reconstruction plus LET versus ACL reconstruction alone in a human
adult population. All yearsand 5 languages were included. Animal
and cadaveric studies, revision or repair surgical techniques, and
studies focusedon biomechanical outcomes were excluded. Quality
assessment of the included studies was performed with the
CochraneCollaboration tool. Outcomes of interest included the
pivot-shift test, KT-1000/-2000 measurements (MEDmetric, SanDiego,
CA), and International Knee Documentation Committee scores.
Results: The literature search yielded 3,612 ar-ticles. After
titles and abstracts were reviewed, 106 articles were selected for
full-text review, of which 29 studies met theinclusion criteria (8
randomized and 21 nonrandomized studies). Of the 8 randomized
studies, 3 concluded that the resultswere nonsignificant between
treatment groups, 4 were in favor of the extra-articular tenodesis,
and 1 was in favor of theACL reconstruction alone. The Cochrane
Collaboration tool showed an unclear to high risk of bias for most
articles. Ameta-analysis showed a statistically significant
difference for the pivot-shift test (P ¼ .002, I2 ¼ 34%) in favor
of ACLreconstruction with LET. No difference was found between the
groups for International Knee Documentation Committeescores (P¼
.75, I2 ¼ 19%) and KT-1000/-2000 measurements (P ¼ .84, I2 ¼ 34%).
Conclusions: Meta-analysis showed astatistically significant
reduction in pivot shift in favor of the combined procedure.
Studies lacked sufficientinternal validity, sample size,
methodologic consistency, and standardization of protocols and
outcomes. Level ofEvidence: Level III, systematic review of Level
I, II, and III studies.
ublished patient-reported outcomes after anterior
Pcruciate ligament (ACL) reconstruction have beenshown to be
favorable; however, biomechanical
ler Kennedy Sport Medicine Clinic and University of Westerndon,
Ontario, Canada.rs report the following potential conflict of
interest or source of. receives support from Empower, Canadian
Institutes of Healthith & Nephew, and Arthrex. A.M.G. receives
support from SBM,tal Transplant Foundation, Canadian Institutes of
Healthvatec, and Smith & Nephew.ebruary 4, 2015; accepted April
17, 2015.correspondence to Alan M. Getgood, M.Phil., M.D.,Orth),
Dip.S.E.M., Fowler Kennedy Sport Medicine Clinic,iversity - 3M
Centre, 1151 Richmond St, London, ON, Canada-mail:
[email protected] the Arthroscopy Association of North
America/15105/$36.00oi.org/10.1016/j.arthro.2015.04.089
Arthroscopy: The Journal of Arthroscopic and Related
assessment of conventional ACL reconstruction hasshown an
inability to restore normal tibial rotation.1-3 Ithas been
hypothesized that these abnormal kinematicsmay be to blame for the
development of osteoarthritisand the risk of reinjury.4
Recently published anatomic studies of the antero-lateral
capsule of the knee have renewed interest inthe anterolateral
ligament (ALL), hypothesizing itspotential role in helping the ACL
control anterolateralrotatory laxity.5-8 These studies have more
accuratelycharacterized the ALL’s anatomic description, as wellas
its histology and appearance, on magnetic reso-nance imaging;
however, the ALL as a concept is notnew. A number of surgeons,
including Segond9 backin 1879 and Hughston et al.10,11 in 1976,
havedescribed this structure. Pioneering surgeons such asStrickler,
Macintosh, and Lemaire used the concept of
Surgery, Vol -, No - (Month), 2015: pp 1-13 1
mailto:[email protected]://dx.doi.org/10.1016/j.arthro.2015.04.089
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Table 1. Inclusion and Exclusion Criteria
Inclusion criteriaHuman adult populationLevel I, II, and III
(comparative studies) evidenceComparison of ACL reconstruction with
LET v ACL reconstruction
aloneExclusion criteriaAnimal studiesCadaveric studiesLevel III
(other), IV, and V evidenceACL revision or repairStudies focused on
biomechanical outcomes, rehabilitation, and
imaging
ACL, anterior cruciate ligament; LET, lateral
extra-articulartenodesis.
2 C. E. HEWISON ET AL.
anterolateral capsule reconstruction to address theACL-deficient
knee by using lateral extra-articulartenodesis (LET).12 LET is
thought to be analogous tothe ALL in function, in terms of
controlling antero-lateral rotational laxity; however, the 2
differanatomically. The proximal fibers of the ALL are in-tegrated
with the origin and the fibular collateral lig-ament (FCL), run
superficial to the FCL, and insert onthe tibia between the Gerdy
tubercle and the insertionpoint of the FCL.8 Many LET techniques
incorporate aproximal fixation point close to the femoral
epicondyleand are fixed distally at or around the Gerdy
tubercle,often running deep to the FCL.12 Initially, ACL
defi-ciency was addressed by solely using LET withoutperforming an
ACL reconstruction, unlike the stan-dard treatment of today.12 The
benefits of the proce-dure were short-lived, however, because the
repairwould frequently stretch out and fail.13-16
Because of these concerns, as well as technologicdevelopments
and a greater understanding of theanatomic characteristics of the
ACL, combined intra-and extra-articular reconstructions were
developed,with good results reported.17 With the advent
ofarthroscopy, the intra-articular reconstruction tookcenter stage,
and it was believed that the extra-articularcomponent was surplus
to requirements and thus fellout of favor. Many surgeons still
believed in its benefit,however, particularly in Europe, where
surgeonscontinued to perform the procedure in combinationwith ACL
reconstruction.Recent clinical publications have shown that
current
ACL reconstructions do not restore the normal kine-matics of the
knee. Importantly, anterolateral rotatoryinstability, as
subjectively measured by the pivot-shifttest, is not controlled,
even with the advent ofdouble-bundle and, later, anatomic ACL
reconstructiontechniques.18 Although reported results are still
good interms of patient-reported outcomes, reduced rates ofreturn
to sport, a high prevalence of postoperativeosteoarthritis,19 and a
reinjury rate of greater than 20%in the age group younger than 20
years continue.18,20
It is hypothesized that a residual pivot shift may beassociated
with these issues and that obliteratinganterior laxity may not
significantly improve subjectiveand objective outcomes. This was
shown by studiesreporting that a residual pivot shift led to a
decrease inpatient satisfaction and an increase in
functionalinstability.21-23
The renewed interest in the ALL has led investigatorsto revisit
the question of whether the addition of ananterolateral capsular
restraint to help control the pivotshift would control rotatory
laxity more effectively. Thepurpose of our systematic review and
meta-analysiswas to determine whether the addition of LET to
ACLreconstruction would provide greater functional stabil-ity and
improved clinical outcomes compared with ACL
reconstruction alone. The hypothesis was that an
ACLreconstruction with LET would result in (1) increasedrotational
stability as measured by the pivot shift, (2)decreased anterior
laxity using the KT-1000/-2000arthrometer (MEDmetric, San Diego,
CA), and (3)improved clinical outcomes as measured by the
Inter-national Knee Documentation Committee (IKDC)objective
score.
MethodsThis study was conducted according to the methods of
the Cochrane Handbook for Systematic Reviews of
In-terventions.24 The findings are reported according to
thePreferred Reporting Items for Systematic Reviews
andMeta-Analyses (PRISMA) statement.25
Literature Search and Study SelectionA systematic literature
search of 9 databases was
conducted, which included PubMed, Medline Ovid,Embase, CINAHL
(Cumulative Index to Nursing andAllied Health Literature), Scopus,
SPORTSDiscus, Webof Science, Cochrane Library, and Proquest
Disserta-tions and Theses, from inception through March 13,2014.
Two independent authors (A.R., C.E.H.) sepa-rately completed the
search, which was directed withthe help of a librarian at our
institution. The base termused in each search was “anterior
cruciate ligament”; itwas used in combination with subject terms
from eachdatabase and the following keywords:
“extraarticular,”“extra articular,” “extra-articular,” “lateral
plasty,”“lateral-plasty,” “tenodesis,” “procedure,”
“augment,”“technique,” “reconstruction,” “Lemaire,”
“Losee,”“MacIntosh,” “Ellison,” “Andrews,” and “Hughston.”Five
languages were included (English, French, Span-ish, German, and
Italian).After the removal of duplicates, 2 independent au-
thors (N.K., C.E.H.) assessed titles and abstracts
foreligibility (Table 1). Any disagreement between authorsat this
stage resulted in the article being includedfor full-text review.
Two independent authors (N.K.,C.E.H.) reviewed full-text articles,
and disagreements
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Table 2. Randomized Controlled Trials Included in Systematic
Review
Study Year Country Control ExperimentalMean
Follow-up, yr Outcomes Conclusions LOE
Acquitter et al.26 2003 France Patellar tendon (n ¼ 50) Patellar
tendon plusquadriceps tendon LET(n ¼ 50)
4.8 IKDC, KT-1000 No statistically significantdifference
I
Anderson et al.27 2001 UnitedStates
Patellar tendon (n ¼ 35)and hamstring (n ¼ 33)
Hamstring plus Losee LET(n ¼ 34)
3 Physical examination, KT-1000,strength, radiographs, HSS
kneescore, IKDC
No statistically significantdifference
I
Giraud et al.28 2006 France Patellar tendon (n ¼ 34) Patellar
tendon plusquadriceps tendon LET(n ¼ 29)
7 IKDC, KT-1000, radiographs No statistically
significantdifference
II
Kerschbaumer et al.29 1987 Austria Patellar tendon (n ¼ 13)
Patellar tendon plus EllisonLET (n ¼ 37)
2.9 Physical examination, pivot shift,pain, return to sport,
ROM,effusion
Favors LET I
Trichine et al.30 2014 Algeria Patellar tendon (n ¼ 60) Patellar
tendon plus ITBLET (n ¼ 60)
2 IKDC, pivot shift, physicalexamination, radiographs
No statistically significantdifference
I
Vadalà et al.31 2013 Italy Hamstring (n ¼ 32) Hamstring plus
Cocker-Arnold LET (n ¼ 28)
3.7 Physical examination, pivot shift,KT-1000, Lysholm,
Tegner,VAS, IKDC
Favors LET I
Zaffagnini et al.32 2006 Italy Patellar tendon (n ¼ 25)and
hamstring (n ¼ 25)
Marcacci hamstring pluslateral sling (n ¼ 25)
5 IKDC, Tegner score, thighcircumference, pivot shift,Lachman,
KT-2000, ROM,return to sports
Favors LET I
Zaffagnini et al.33 2008 Italy Hamstring (n ¼ 37) Marcacci
hamstring pluslateral sling (n ¼ 35)
3 IKDC, Tegner score, KT-2000,Marx Activity Rating
Scale,psychovitality questionnaire,radiographs
Favors control II
HSS, Hospital for Special Surgery; IKDC, International Knee
Documentation Committee; ITB, iliotibial band; LET, lateral
extra-articular tenodesis; LOE, level of evidence; ROM, range
ofmotion; VAS, visual analog scale.
LATERALEXTRA-ARTICULARTENODESIS
3
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Table 3. Nonrandomized Trials Included in Systematic Review
Authors Year Country Control ExperimentalMean
Follow-up, yr Outcomes Conclusions LOE
Barber-Westinand Noyes34
1993 UnitedStates
Patellar tendon(n ¼ 52)
Patellar tendon plus Losee LET(n ¼ 32)
3.1 KT-1000, Sports Activity Scale Favors LET II
Barrett andRichardson35
1995 UnitedStates
Patellar tendon(n ¼ 38)
Patellar tendon plus ITB LET(n ¼ 32)
2.8 (control) and2.9(experimental)
Subjective VAS, thighcircumference, ROM, KT-1000,Lachman, pivot
shift
No statisticallysignificantdifference
III
Dejour et al.36 2013 France andBrazil
Hamstring (n ¼ 25)and patellartendon (n ¼ 25)
Patellar tendon plus Lemaire LET(n ¼ 25)
2.1 Radiographs, IKDC, pivot shift,pain, sensory
deficits,subsequent surgical procedures,return to sports, ability
to kneelor squat on affected knee
Favors LET II
Ferkel et al.37 1988 UnitedStates
Meniscus (n ¼ 71) Meniscus plus Ellison or modifiedEllison LET
(n ¼ 20), Ellisonwith popliteal advancement(n ¼ 1), or Ellison
withadvancement of ITB andpopliteus (n ¼ 8)
4.3 Standard questionnaire;instrumented
clinical-testingapparatus; Zarins and Rowesubjective, objective,
andfunctional rating
No statisticallysignificantdifference
II
Goertzen andSchulitz38
1993 Germany Hamstring (n ¼ 24) Hamstring plus Jäger-Wirth LET(n
¼ 32)
1 year Lysholm score, clinicalassessment, radiographs,Lachman,
pivot shift, KT-1000,isokinetic tests, Tegner
Favors LET II
Hefti et al.39 1982 Switzerland Quadriceps tendonplus
patellartendon (n ¼ 27)and patellartendon (n ¼ 25)
Carbon fiber combined with intra-and extra-articular
over-the-topreconstruction (n ¼ 23)
2 Clinical examination, pivot shift,Lachman, HSS knee score
Favors control II
Hernández-Hermosoet al.40
2002 Spain Patellar tendon(n ¼ 30)
Patellar tendon plus Lemaire LET(n ¼ 29)
7.5 (control) and7.8(experimental)
Level and frequency of athleticactivity, IKDC,
radiographicLachman, hop test
No statisticallysignificantdifference
III
Kanisawa et al.41 2003 Japan Hamstring (n ¼ 6) Hamstring plus
ITB LET (n ¼ 5) 1.6 Step up/down activity usinglateral fluoroscopy,
IKDC, KT-1000
No statisticallysignificantdifference
II
Laffargue et al.42 1997 France Patellar tendon(n ¼ 36)
Patellar tendon plus Lemaire LET(n ¼ 43)
2.5 ARPEGE CLAS, IKDC, pivot shift,radiographic
Lachman,radiographs
Favors control II
Lerat et al.43 1997 France Patellar tendon(n ¼ 50)
Patellar tendon plus quadricepstendon LET (n ¼ 60)
4 ARPEGE, dynamic radiographs,KT-1000
Favors LET II
Monaco et al.44 2007 Italy Hamstring (n ¼ 10) Hamstring plus
Cocker-ArnoldLET (n ¼ 10)
NA Manual maximum AP tibialtranslation, manual maximuminternal
rotation of tibia,manual maximum externalrotation at 30� of knee
flexion
Favors LET II
(continued)
4C.E.HEWISO
NETAL.
-
Table 3. Continued
Authors Year Country Control ExperimentalMean
Follow-up, yr Outcomes Conclusions LOE
Noyes andBarber45
1991 UnitedStates
Patellar tendonallograft (n ¼ 64)
Patellar tendon allograft plus ITBLET (n ¼ 40)
2.9 KT-1000, isokinetic testing, pivotshift, subjective
assessment(symptoms, functionallimitations during sportactivities
and activities of dailyliving, level of sports activity,changes in
level of activity)
Favors LET II
O’Brien et al.46 1991 UnitedStates
Patellar tendonallograft (n ¼ 32)
Patellar tendon allograft pluslateral sling of ITB (n ¼ 48)
4 Physical examination, KT-1000arthrometer, HSS ligamentrating
scale
Favors control III
Paterson andTrickey47
1986 England Patellar tendon(n ¼ 23)
Patellar tendon plus ITB LET(n ¼ 17)
2.9 Ireland and Trickey symptoms ofinstability, Lachman, jerk
test,patient views on operation
No statisticallysignificantdifference
III
Riel et al.48 1991 Germany Patellar tendon(n ¼ 31)
Modified Marshall-MacIntoshquadriceps and patellar tendonwith
polypropylene band(n ¼ 50)
3.8 KT-1000, return to sport,strength, Lysholm
Favors LET II
Roth et al.49 1987 Canada Quadriceps tendonplus patellartendon
withpolypropylenebraid (n ¼ 50)
Quadriceps tendon, patellartendon, and polypropylenebraid plus
biceps femoristendon advancement (n ¼ 43)
3.2 (control) and3.7(experimental)
Questionnaire, physicalexamination, objectivefunctional testing
(KT-1000,isotonic strength, horizontalhopping on 1 leg for
distance),radiographs
No statisticallysignificantdifference
III
Savalli et al.50 2008 France Hamstring(n ¼ 436)
Hamstring plus Lemaire LET(n ¼ 84)
1.2 Return to sport, IKDC No
statisticallysignificantdifference
II
Sgaglione et al.51 1990 UnitedStates
Repair plushamstring(n ¼ 21)
Repair plus hamstring plus ITBLET (n ¼ 51)
3.2 Questionnaire, physicalexamination, pivot shift,generalized
ligamentous laxity,KT-1000, HSS knee ligamentrating score,
radiographs
No statisticallysignificantdifference
III
Sonnery-Cottetet al.52
2011 France Patellar tendon,hamstring, orquadricepstendon(n ¼
1,769)
Patellar tendon, hamstring, orquadriceps tendon plus ITB LET(n ¼
188)
NA Septic arthritis Favors control III
Strum et al.53 1989 UnitedStates
Meniscus (n ¼ 75)or patellar tendon(n ¼ 9)
Meniscus (n ¼ 31), patellar tendon(n ¼ 3), or BPTB (n ¼ 9)
plusEllison LET (n ¼ 25), Galwayand MacIntosh LET (n ¼ 11),
orLemaire LET (n ¼ 7)
3.8 Questionnaire, physicalexamination, radiographs,instrumented
knee ligamenttesting
No statisticallysignificantdifference
II
Verdano et al.54 2012 Italy Hamstring (n ¼ 20) Hamstring
over-the-top techniquestapled at Gerdy tubercle(n ¼ 20)
4 Clinical evaluation, IKDC,Lysholm score, Tegner
activitylevel
No statisticallysignificantdifference
II
ARPEGE, Association de Recherche pour l’étude du Genou; AP,
anteroposterior; BPTB, boneepatellar tendonebone; CLAS,
compétition, loisir, actif, sédentaire; HSS, Hospital for
SpecialSurgery; IKDC, International Knee Documentation Committee;
ITB, iliotibial band; LET, lateral extra-articular tenodesis; LOE,
level of evidence; NA, not applicable; ROM, range of motion;VAS,
visual analog scale.
LATERALEXTRA-ARTICULARTENODESIS
5
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Table 4. Risk-of-Bias Assessment of Included Randomized
Controlled Trials
Authors
RandomSequenceGenerator
AllocationConcealment
Blinding ofParticipants and
Personnel
Blinding ofOutcome
Assessment
IncompleteOutcome
DataSelectiveReporting
OtherBias
Acquitter et al.26 Low risk Low risk Unclear Unclear Low risk
Low risk Low riskAnderson et al.27 Low risk Unclear Unclear Unclear
Low risk Low risk Low riskGiraud et al.28 High risk Low risk
Unclear High risk High risk Low risk Low riskKerschbaumer
et al.29Unclear Unclear Unclear Unclear Unclear Low risk Low
risk
Trichine et al.30 Low risk Low risk Unclear Unclear Low risk Low
risk Low riskVadalà et al.31 High risk Low risk Unclear Low risk
Low risk Low risk Low riskZaffagnini
et al.32 (2006)High risk High risk Unclear Unclear Low risk Low
risk Low risk
Zaffagniniet al.33 (2008)
Low risk Low risk Unclear Low risk Low risk Low risk Low
risk
6 C. E. HEWISON ET AL.
were resolved through third-party consensus (A.M.G.or A.R.).
During analysis, the authors were blinded tothe authors of the
study, title, and journal ofpublication.
Data AbstractionTwo authors (C.E.H., M.N.T.) independently
extrac-
ted study demographic data. These included authors,date of
publication, definition of the control group,definition of the
experimental surgical technique,outcome measures, follow-up period,
and conclusions(Tables 2-5). Two other authors (A.R., N.K.)
indepen-dently extracted all outcome data involving
pivot-shiftgrading, instrumented laxity measurements (KT-1000or
KT-2000 arthrometer), and IKDC scores.
Table 5. Risk-of-Bias Assessment of Included Nonrandomized
Tr
Authors
Evidence of SelectionBias/Prognostic
Imbalance
BlindingParticipants
Personne
Barber-Westin and Noyes34 Unclear UnclearBarrett and
Richardson35 Low risk UnclearDejour et al.36 High risk
UnclearFerkel et al.37 High risk UnclearGoertzen and Schulitz38
High risk UnclearHefti et al.39 Unclear UnclearHernández-Hermoso et
al.40 Low risk UnclearKanisawa et al.41 High risk UnclearLaffargue
et al.42 Low risk UnclearLerat et al.43 High risk UnclearMonaco et
al.44 High risk UnclearNoyes and Barber45 Low risk UnclearO’Brien
et al.46 High risk UnclearPaterson and Trickey47 High risk
UnclearRiel et al.48 Low risk UnclearRoth et al.49 High risk
UnclearSavalli et al.50 High risk UnclearSgaglione et al.51 High
risk UnclearSonnery-Cottet et al.52 High risk UnclearStrum et al.53
Unclear Low riskVerdano et al.54 Unclear Unclear
Methodologic Quality AssessmentTwo groups of authors, group A
(N.K. and A.R.)
and group B (C.E.H., M.N.T.), separately assessed thequality of
each eligible study using the CochraneCollaboration tool for
assessing risk of bias.55 Domainsevaluated included type of random
sequence generator,allocation concealment, blinding of participants
andpersonnel, blinding of outcome assessment, incompleteoutcome
data, and selective outcome reporting. Fornonrandomized studies, we
substituted our impressionof the risk of selection bias for the
criteria of randomsequence generator and allocation concealment.
Bothgroups independently recorded whether the studyshowed a low,
high, or unclear risk of bias for eachcategory. Both groups
compared their results, and any
ials
ofandl
Blinding ofOutcome
AssessmentIncomplete
Outcome DataSelectiveReporting
Unclear Low risk Low riskUnclear Low risk Low riskLow risk Low
risk Low riskUnclear Low risk Low riskUnclear Low risk Low
riskUnclear Unclear Low riskUnclear Low risk Low riskUnclear Low
risk Low riskUnclear Low risk Low riskHigh risk High risk Low
riskHigh risk Low risk Low riskUnclear High risk Low riskUnclear
Low risk Low riskUnclear Unclear Low riskUnclear High risk Low
riskUnclear Low risk Low riskUnclear High risk Low riskUnclear Low
risk Low riskUnclear Low risk Low riskLow risk Low risk Low riskLow
risk Unclear Unclear
-
LATERAL EXTRA-ARTICULAR TENODESIS 7
disagreements were resolved through consensus(Tables 2-5).
OutcomesThe studies used a variety of instruments and ques-
tionnaires to measure outcomes. Outcomes that
werecommonamongmultiple studiesdand therefore could bepooled in a
meta-analysisdincluded the pivot-shift test,KT-1000/-2000
arthrometry, and objective IKDC score.The pivot-shift test is
routinely used in clinical ex-
aminations for the diagnosis of ACL deficiency.56 It hasbeen
found to be an accurate diagnostic test, with highsensitivity and
specificity, for ruptures of the ACL.57,58
The presence of a pivot shift has also been shown tocorrelate
with functional outcomes.23,59 Therefore wedefined a positive pivot
shift (grade 1, 2, or 3) as anevent for the meta-analysis.The
KT-1000/-2000 arthrometer is used to quantita-
tively measure anterior tibial translation with respect tothe
femur.60 It has been shown to be a valid instrumentin the diagnosis
of ACL injury.61 Rangger et al.62 foundthat a difference in laxity
of 3 mm or more comparedwith the contralateral knee was indicative
of an ACLdeficiency in 99% of chronic cases and 95% of
acuteinjuries. It was therefore determined that a KT-1000/-2000
measurement of 3 mm or more would be classi-fied as an event for
the meta-analysis.The objective IKDC score was created by a group
of
European and American knee surgeons to quantify kneeligament
injuries and evaluate treatment results.63 It hasbeen found to have
high criterion validity,64 and manyexperts have advocated its
use.65 Patients are given anoverall grade of A (normal), B (nearly
normal), C(abnormal), or D (severely abnormal). For the
meta-analysis, a grade of C or D was considered an event.
Data AnalysisStatistical calculations and forest plots were
created
using Review Manager (version 5.2).24 Each outcomewas
dichotomized to represent the proportion of par-ticipants who had
an event, as previously described.A Mantel-Haenszel analysis using
a random-effects
model was used to generate a pooled estimate of theoverall odds
ratio, 95% confidence intervals, andprobability value (P value). P
< .05 was consideredstatistically significant. The Cochran Q and
the I2 sta-tistic were also included to test for between-study
het-erogeneity. The quantification of low, moderate, orhigh
heterogeneity as defined by Higgins and Thomp-son66 was used. We
hypothesized that heterogeneitymay be explained by separating
studies in which thebetween-group choice of graft was the same (LET
groupand non-LET group both reconstructed using patellartendon
autograft) versus different (e.g., non-LET groupreconstructed using
patellar tendon and LET groupreconstructed using hamstring graft)
and by separating
studies in which the LET procedure was performed aspart of the
reconstruction (e.g., lateral sling) versusthose in which it was
not (e.g., Losee).
Results
Summary of EvidenceThe literature search yielded a total of
8,687 articles
across all databases, and after removal of duplicates,3,612
articles remained. One hundred six articlesremained after the
review of titles and abstracts. Awritten request was made to obtain
the full text for 1study that was not available online; this
article wasexcluded because it was not possible to obtain the
fulltext.67 After full-text review, 29 articles met the
eligi-bility criteria, of which 8 were randomized controlledtrials
and 21 were nonrandomized studies. There werea total of 642
patients in the randomized controlledtrials and 4,314 patients in
the nonrandomized studies.The literature search is summarized in
Figure 1.
Study QualityThe Cochrane Collaboration tool showed an
unclear
to high risk of bias for most articles (Tables 4 and 5).
Variability of StudiesSurgical techniques varied across studies.
ACL re-
constructions used a range of graft choices
includingpatella/hamstring/quadriceps tendon autografts
andallografts; single-bundle, double-bundle, nonanatomic,and
anatomic tunnel placements were also described.The extra-articular
tenodesis technique varied sub-stantially, with multiple described
methods. Lemaire68
used an 18 � 1.5ecm strip of the iliotibial band (ITB)that was
routed under the lateral collateral ligament(LCL) and into a
lateral femoral condyle bone tunnel.This was then passed through a
second tunnel andreattached to the Gerdy tubercle. The modified
Lemairetechnique used an 8 � 1ecm strip of the posterioraspect of
the ITB released proximally and left attachedto the Gerdy tubercle
distally. This was then carriedunder the LCL and attached proximal
and posterior tothe lateral femoral condyle with a staple or
screw.69 TheMacintosh technique used a triple sling of fascia
latathat remained attached to the Gerdy tubercle and wassutured
proximally to the intermuscular septum. It wasthen fixed within the
femur slightly proximal andposterior to the origin of the LCL.70
The Coker-Arnoldmodification of the Macintosh technique used an 8
�1ecm strip of ITB that was cut proximally and routedunder the LCL
in an anterior-to-posterior direction. Itwas then looped back onto
itself and sutured onto theGerdy tubercle,31 similar to that in the
modified Lem-aire technique. Losee et al.71 described the ITB
beingrouted from anterior to posterior through a femoraltunnel. It
was then passed around the arcuate complex
-
Fig 1. Flow diagram showing selection of studies for sys-tematic
review and meta-analysis. (ACL, anterior cruciateligament; LET,
lateral extra-articular tenodesis.)
8 C. E. HEWISON ET AL.
and under the LCL. Finally, it was tightened or “reefed”and
attached to the Gerdy tubercle with a barbed sta-ple.27,71 Marcacci
et al.72 used hamstring grafts toreconstruct both the
intra-articular and lateral tenodesisportions through an
“over-the-top” position. A groovewas made in the posterolateral
aspect of the lateralcondyle, where the graft was passed deep to
the ITBand then over the LCL. It was cycled and fixed with astaple
into the groove and then fixed below the Gerdy
tubercle with another staple. Colombet73 combined
theintra-articular and extra-articular portions as well, us-ing a
single-bundle hamstring graft through the tibialand femoral tunnels
and fixed onto the Gerdy tubercle.
Pooled ResultsOf the included studies, 14 reported pivot-shift
test
findings (1,141 patients), 5 reported KT-1000/-2000measurements
(314 patients), and 11 reported IKDCscores (759 patients). There
was a statistically signifi-cant difference in the odds ratio of a
resulting positivepivot-shift test (odds ratio, 0.50 [95%
confidenceinterval, 0.32 to 0.78], P ¼ .002, I2 ¼ 34%) (Fig 2)
thatfavored ACL reconstruction combined with LET. Therewere no
statistically significant differences betweenthe groups when we
compared KT-1000/-2000 mea-surements (P ¼ .84, I2 ¼ 34%) (Fig 3) or
IKDC scores(P ¼ .75, I2 ¼ 19%) (Fig 4).Because there was some
evidence of heterogeneity in
the analyses comparing pivot-shift results and KT-1000/-2000
measurements, the analyses wererepeated in accordance with the a
priori hypothesis, inwhich studies comparing the same graft, with
orwithout LET, were compared and studies usingdifferent grafts,
with or without LET, were removed.Although the conclusions of both
analyses remainedconsistent in their statistical findings, the
heterogeneitywas not reduced. Therefore the analysis with all
studiesincluded is presented.
Adverse EventsFew studies reported on adverse events. Among
the
randomized controlled trials, 1 study looked at osteo-arthritic
changes at 5 years postoperatively.32 It
Fig 2. Forest plot for pivotshift. (ACL, anterior cruci-ate
ligament; CI, confidenceinterval; LET, lateral extra-articular
tenodesis.)
-
Fig 3. Forest plot for KT-1000/-2000 measurement.(ACL, anterior
cruciate lig-ament; CI, confidenceinterval; LET, lateral
extra-articular tenodesis.)
LATERAL EXTRA-ARTICULAR TENODESIS 9
showed that 1 patient from the non-LET group haddegenerative
changes seen on radiographs. No removalof hardware, graft failures,
or other surgical compli-cations were seen in the 2008 study of
Zaffagniniet al.33 Anderson et al.27 reported that a number
ofpatients showed a degree of over-constraint, asmeasured by
KT-1000 testing, in the LET group ascompared with patients who
underwent only ACLreconstruction. Anderson et al. noted that the
LET wastensioned with the tibia externally rotated, which mayhave
had an impact on over-tightening the lateral sideof the knee.
Sonnery-Cottet et al.52 found the additionof the lateral tenodesis
to be a significant risk factor forthe development of septic
arthritis after ACL recon-struction (P ¼ .02). However, there were
otherpotentially confounding variables present that couldhave
played a role.
DiscussionThis systematic review of the literature shows that
the
addition of LET to ACL reconstruction results in a
sta-tistically significant reduction in rotational laxity, as
Fig 4. Forest plot for Inter-national Knee Documenta-tion
Committee score.(ACL, anterior cruciate lig-ament; CI,
confidenceinterval; LET, lateral extra-articular tenodesis.)
measured by the pivot-shift test. This finding supportsthe
hypothesis that an extra-articular augmentation ofACL
reconstruction, on the lateral side, with its longerlever arm, is
more effective at limiting anterolateralrotation than ACL
reconstruction alone. There was nodifference in KT-1000/-2000
measurements, showingthat anterior translation is controlled by the
intra-articular ACL reconstruction with or without a
lateraltenodesis. Thus a combined intra- and
extra-articularlyreconstructed knee would conceivably have
bothtranslational and rotational control; however, this didnot
translate into improved clinical outcomes, giventhat the pooled
IKDC scores showed no statistical dif-ference between groups.
Because of the large numberof different patient-reported outcome
measures usedfor the studies, a combined subjective rating was
notcalculated.The studies included in this systematic review
showed significant variability in terms of surgical pro-cedures
used and outcome measures reported. Aspreviously described, there
is variability among thedifferent techniques used for LET in the
studies. The
-
10 C. E. HEWISON ET AL.
techniques use different grafts that are placed in avariety of
anatomic locations, which may lead to anelement of performance
bias. Furthermore, althoughthese techniques are ultimately intended
to reduceanterolateral rotatory laxity, they are not anatomic
andshould not be thought of as anatomic ALL re-constructions. It is
also clear that patients were notstratified as to the degree of
preoperative laxity.Stratifying for these different grades of
preoperativelaxity may have shown a greater degree of
differenceacross more of the outcome measures of interest.However,
given the variability of the included studies,this was clearly not
possible.It is important to note that 3 studies defined pivot
shift as an event or non-event,29,38,39 rather thanassigning a
pivot-shift grade of 0 to 3, as was done inthe majority of other
studies. This discrepancy,depending on how one interprets an event,
can alterthe statistical analysis. Because of the subjectivity of
thepivot-shift test, an event was determined in this analysisif
there was an asymmetrical degree of anterolateralrotation, that is,
a pivot-shift grade of 1, 2, or 3. A non-event was a pivot-shift
grade of 0. By use of this anal-ysis, statistical significance was
reached (P ¼ .002) infavor of the combined procedure. However, in a
posthoc analysis, in which an event was determined as apivot-shift
grade of 2 or 3 and a non-event as a pivot-shift grade of 0 or 1, a
trend toward statistical signifi-cance was still found (P ¼ .06).
One of the objectives ofACL reconstruction is to reduce
anterolateral rotation,thereby reducing the pivot shift. It is
therefore justifiedto define an event as the presence of an
asymmetricalpivot shift because this systematic review is
investi-gating the absolute ability of an LET to control
antero-lateral rotational laxity. Given the fact that
ACLreconstruction techniques, such as double-bundlereconstruction
and anatomic reconstruction, haveevolved in an attempt to reduce
rotational laxity, it isimportant to investigate whether LET is an
efficaciousprocedure in performing this task. A concern of
someinvestigators is the potential for over-constraint of theknee
or the risk of osteoarthritis developing. Neither ofthese
complications was found to be significant in thisanalysis; however,
this finding could be a result of adegree of reporting bias and the
length of follow-up ofthe included studies.Engebretsen et al.74
showed that the addition of LET
to ACL reconstruction reduced the stress on the ACLgraft by 43%
in a cadaveric study. This load sharingmay therefore have a role in
reducing ACL graft stressand resultant strain, thereby helping
maintain the ki-nematic status of the knee, which is often found at
timezero after reconstruction. Unfortunately, given thevariability
of the articles included in this review, firmconclusions regarding
medium- to long-term patient-reported and functional outcomes could
not be
ascertained. It is clear that a well-controlled random-ized
clinical trial is required to determine the effect ofthe addition
of LET to ACL reconstruction on otheroutcome measures such as graft
failure and functionaloutcome.The strengths of this systematic
review include the
breadth of studies examined. By including all years, 5languages,
and broad search terms, the number of ar-ticles reviewed was
optimized. Extra-articular pro-cedures were performed as far back
as 1937,75 hencethe rationale to look at all years; however, this
will havehad an impact on the type of ACL reconstruction per-formed
and the subsequent rehabilitation, which isclearly different from
modern-day techniques. How-ever, it was believed to be an important
subset thatshould not be excluded. Inclusion of multiple
languagesalso allowed the capture of studies in countries whereLET
has remained a popular procedure. Exclusion ofthese studies would
have significantly biased the resultsof this review. Furthermore,
by use of broad searchterms, all articles with the term “anterior
cruciate liga-ment” were reviewed, resulting in a significant
reduc-tion in the chance of missing important studies usingesoteric
titles or terms.
LimitationsThe limitations of this study include the variability
of
surgical techniques that were used. However, evenwith the amount
of variability present, it appears thatan anterolateral
reconstruction of any kind will helpcontrol rotational laxity. This
can also be another di-rection for future research to determine
whether onetechnique is better at controlling rotational
instabilitythan another.
ConclusionsMeta-analysis showed a statistically significant
reduction in pivot shift in favor of the combined pro-cedure.
Studies lacked sufficient internal validity,sample size,
methodologic consistency, and standardi-zation of protocols and
outcomes.
References1. Ristanis S, Giakas G, Papageorgiou CD, Moraiti
T,
Stergiou N, Georgoulis AD. The effects of anterior
cruciateligament reconstruction on tibial rotation during
pivotingafter descending stairs. Knee Surg Sports Traumatol
Arthrosc2003;11:360-365.
2. Georgoulis AD, Ristanis S, Chouliaras V, Moraiti C,Stergiou
N. Tibial rotation is not restored after ACLreconstruction with a
hamstring graft. Clin Orthop Relat Res2007;454:89-94.
3. Tashman S, Collon D, Anderson K, Kolowich P,Anderst W.
Abnormal rotational knee motion duringrunning after anterior
cruciate ligament reconstruction.Am J Sports Med
2004;32:975-983.
http://refhub.elsevier.com/S0749-8063(15)00386-2/sref1http://refhub.elsevier.com/S0749-8063(15)00386-2/sref1http://refhub.elsevier.com/S0749-8063(15)00386-2/sref1http://refhub.elsevier.com/S0749-8063(15)00386-2/sref1http://refhub.elsevier.com/S0749-8063(15)00386-2/sref1http://refhub.elsevier.com/S0749-8063(15)00386-2/sref2http://refhub.elsevier.com/S0749-8063(15)00386-2/sref2http://refhub.elsevier.com/S0749-8063(15)00386-2/sref2http://refhub.elsevier.com/S0749-8063(15)00386-2/sref2http://refhub.elsevier.com/S0749-8063(15)00386-2/sref3http://refhub.elsevier.com/S0749-8063(15)00386-2/sref3http://refhub.elsevier.com/S0749-8063(15)00386-2/sref3http://refhub.elsevier.com/S0749-8063(15)00386-2/sref3
-
LATERAL EXTRA-ARTICULAR TENODESIS 11
4. Lohmander LS, Englund PM, Dahl LL, Roos EM. Thelong-term
consequence of anterior cruciate ligament andmeniscus injuries
osteoarthritis. Am J Sports Med 2007;35:1756-1769.
5. Claes S, Vereecke E, Maes M, Victor J, Verdonk P,Bellemans J.
Anatomy of the anterolateral ligament of theknee. J Anat
2013;223:321-328.
6. Vincent J-P, Magnussen R, Gezmez F, et al. The antero-lateral
ligament of the human knee: An anatomic andhistologic study. Knee
Surg Sports Traumatol Arthrosc2012;20:147-152.
7. Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA.The
anterolateral ligament: Anatomy, length changes andassociation with
the Segond fracture. Bone Joint J 2014;96:325-331.
8. Caterine S, Litchfield R, Johnson M, Chronik B, GetgoodA. A
cadaveric study of the anterolateral ligament: Re-introducing the
lateral capsular ligament. Knee SurgSports Traumatol Arthrosc in
press, available online 15 June,2014.
doi:10.1007/s00167-014-3117-z.
9. Segond P. Recherches cliniques et experimentales sur
lesepanchements sanguins du genou par entorse. Paris: AuxBureaux du
Progrès Médical, 1879.
10. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classifi-cation
of knee ligament instabilities. Part I. Medialcompartment and
cruciate ligaments. J Bone Joint Surg Am1976;58:159-172.
11. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classifi-cation
of knee ligament instabilities. Part II. The lateralcompartment. J
Bone Joint Surg Am 1976;58:173-179.
12. Schindler OS. Surgery for anterior cruciate
ligamentdeficiency: A historical perspective. Knee Surg
SportsTraumatol Arthrosc 2012;20:5-47.
13. Draganich LF, Reider B, Ling M, Samuelson M. Anin vitro
study of an intraarticular and extraarticularreconstruction in the
anterior cruciate ligament deficientknee. Am J Sports Med
1990;18:262-266.
14. Warren RF, Marshall JL. Injuries of the anterior cruciateand
medial collateral ligaments of the knee: A long-termfollow-up of 86
casesdPart II. Clin Orthop Relat Res1978;(136):198-211.
15. Kennedy JC, Stewart R, Walker DM. Anterolateral rota-tory
instability of the knee joint. J Bone Joint Surg
Am1978;60:1031-1039.
16. Marshall JL, Warren RF, Wickiewicz TL, Reider B. Theanterior
cruciate ligament: A technique of repair andreconstruction. Clin
Orthop Relat Res 1979;(143):97-106.
17. Getgood A, Spalding T. The evolution of anatomic ante-rior
cruciate ligament reconstruction. Open Orthop J2012;6:287-294.
18. Mohtadi NG, Chan DS, Dainty KN, Whelan DB. Patellartendon
versus hamstring tendon autograft for anteriorcruciate ligament
rupture in adults. Cochrane Database SystRev 2011;(9):CD005960.
19. Leiter JRS, Gourlay R, McRae S, de Korompay N,MacDonald PB.
Long-term follow-up of ACL reconstruc-tion with hamstring
autograft. Knee Surg Sports TraumatolArthrosc
2014;22:1061-1069.
20. Magnussen RA, Lawrence JTR, West RL, Toth AP,Taylor DC,
Garrett WE. Graft size and patient age arepredictors of early
revision after anterior cruciate ligament
reconstruction with hamstring autograft.
Arthroscopy2012;28:526-531.
21. Kocher MS, Steadman JR, Briggs KK, Sterett WI,Hawkins RJ.
Relationships between objective assessmentof ligament stability and
subjective assessment of symp-toms and function after anterior
cruciate ligamentreconstruction. Am J Sports Med
2004;32:629-634.
22. Lee MC, Seong SC, Lee S, et al. Vertical femoral
tunnelplacement results in rotational knee laxity after
anteriorcruciate ligament reconstruction. Arthroscopy
2007;23:771-778.
23. Ayeni OR, Chahal M, Tran MN, Sprague S. Pivot shift asan
outcome measure for ACL reconstruction: A systematicreview. Knee
Surg Sports Traumatol Arthrosc 2012;20:767-777.
24. Higgins JPT, Green S, eds. Cochrane handbook for
systematicreviews of interventions. Version 5.1.0. Oxford:
CochraneCollaboration, 2011.
25. Moher D, Liberati A, Tetzlaff J, Altman DG.
Preferredreporting items for systematic reviews and
meta-analyses:The PRISMA statement. Int J Surg 2010;8:336-341.
26. Acquitter Y, Hulet C, Locker B, Delbarre JC, Jambou
S,Vielpeau C. Patellar tendon-bone autograft reconstructionof the
anterior cruciate ligament for advanced-stagechronic anterior
laxity: Is an extra-articular plasty neces-sary? A prospective
randomized study of 100 patientswith five year follow-up. Rev Chir
Orthop Reparatrice ApparMot 2003;89:413-422 [in French].
27. Anderson AF, Snyder RB, Lipscomb AB. Anterior
cruciateligament reconstructiondA prospective randomizedstudy of
three surgical methods. Am J Sports Med 2001;29:272-279.
28. Giraud B, Besse JL, Cladiere F, Ecochard R, Moyen B,Lerat
JL. Intra-articular reconstruction of the anteriorcruciate ligament
with and without extra-articular sup-plementation by quadricipital
tendon plasty: Seven-yearfollow-up. Rev Chir Orthop Reparatrice
Appar Mot 2006;92:788-797 [in French].
29. Kerschbaumer F, Bauer R, Eichenauer M, Agreiter ZH.Personal
experiences in surgical treatment of chronicinstability of the
anterior knee joint. Orthopade 1987;16:140-148 [in German].
30. Trichine F, Alsaati M, Chouteau J, Moyen B,Bouzitouna M,
Maza R. Patellar tendon autograft recon-struction of the anterior
cruciate ligament with andwithout lateral plasty in advanced-stage
chronic laxity. Aclinical, prospective, randomized, single-blind
study usingpassive dynamic X-rays. Knee 2014;21:58-65.
31. Vadalà AP, Iorio R, De Carli A, et al. An
extra-articularprocedure improves the clinical outcome in anterior
cru-ciate ligament reconstruction with hamstrings in
femaleathletes. Int Orthop 2013;37:187-192.
32. Zaffagnini S, Marcacci M, Lo Presti M, Giordano G,Iacono F,
Neri M. Prospective and randomized evaluationof ACL reconstruction
with three techniques: A clinicaland radiographic evaluation at 5
years follow-up. KneeSurg Sports Traumatol Arthrosc
2006;14:1060-1069.
33. Zaffagnini S, Bruni D, Russo A, et al. ST/G ACL
recon-struction: Double strand plus extra-articular sling vsdouble
bundle, randomized study at 3-year follow-up.Scand J Med Sci Sports
2008;18:573-581.
http://refhub.elsevier.com/S0749-8063(15)00386-2/sref4http://refhub.elsevier.com/S0749-8063(15)00386-2/sref4http://refhub.elsevier.com/S0749-8063(15)00386-2/sref4http://refhub.elsevier.com/S0749-8063(15)00386-2/sref4http://refhub.elsevier.com/S0749-8063(15)00386-2/sref5http://refhub.elsevier.com/S0749-8063(15)00386-2/sref5http://refhub.elsevier.com/S0749-8063(15)00386-2/sref5http://refhub.elsevier.com/S0749-8063(15)00386-2/sref6http://refhub.elsevier.com/S0749-8063(15)00386-2/sref6http://refhub.elsevier.com/S0749-8063(15)00386-2/sref6http://refhub.elsevier.com/S0749-8063(15)00386-2/sref6http://refhub.elsevier.com/S0749-8063(15)00386-2/sref7http://refhub.elsevier.com/S0749-8063(15)00386-2/sref7http://refhub.elsevier.com/S0749-8063(15)00386-2/sref7http://refhub.elsevier.com/S0749-8063(15)00386-2/sref7http://10.1007/s00167-014-3117-zhttp://refhub.elsevier.com/S0749-8063(15)00386-2/sref8http://refhub.elsevier.com/S0749-8063(15)00386-2/sref8http://refhub.elsevier.com/S0749-8063(15)00386-2/sref8http://refhub.elsevier.com/S0749-8063(15)00386-2/sref9http://refhub.elsevier.com/S0749-8063(15)00386-2/sref9http://refhub.elsevier.com/S0749-8063(15)00386-2/sref9http://refhub.elsevier.com/S0749-8063(15)00386-2/sref9http://refhub.elsevier.com/S0749-8063(15)00386-2/sref10http://refhub.elsevier.com/S0749-8063(15)00386-2/sref10http://refhub.elsevier.com/S0749-8063(15)00386-2/sref10http://refhub.elsevier.com/S0749-8063(15)00386-2/sref11http://refhub.elsevier.com/S0749-8063(15)00386-2/sref11http://refhub.elsevier.com/S0749-8063(15)00386-2/sref11http://refhub.elsevier.com/S0749-8063(15)00386-2/sref12http://refhub.elsevier.com/S0749-8063(15)00386-2/sref12http://refhub.elsevier.com/S0749-8063(15)00386-2/sref12http://refhub.elsevier.com/S0749-8063(15)00386-2/sref12http://refhub.elsevier.com/S0749-8063(15)00386-2/sref13http://refhub.elsevier.com/S0749-8063(15)00386-2/sref13http://refhub.elsevier.com/S0749-8063(15)00386-2/sref13http://refhub.elsevier.com/S0749-8063(15)00386-2/sref13http://refhub.elsevier.com/S0749-8063(15)00386-2/sref13http://refhub.elsevier.com/S0749-8063(15)00386-2/sref14http://refhub.elsevier.com/S0749-8063(15)00386-2/sref14http://refhub.elsevier.com/S0749-8063(15)00386-2/sref14http://refhub.elsevier.com/S0749-8063(15)00386-2/sref15http://refhub.elsevier.com/S0749-8063(15)00386-2/sref15http://refhub.elsevier.com/S0749-8063(15)00386-2/sref15http://refhub.elsevier.com/S0749-8063(15)00386-2/sref16http://refhub.elsevier.com/S0749-8063(15)00386-2/sref16http://refhub.elsevier.com/S0749-8063(15)00386-2/sref16http://refhub.elsevier.com/S0749-8063(15)00386-2/sref17http://refhub.elsevier.com/S0749-8063(15)00386-2/sref17http://refhub.elsevier.com/S0749-8063(15)00386-2/sref17http://refhub.elsevier.com/S0749-8063(15)00386-2/sref17http://refhub.elsevier.com/S0749-8063(15)00386-2/sref18http://refhub.elsevier.com/S0749-8063(15)00386-2/sref18http://refhub.elsevier.com/S0749-8063(15)00386-2/sref18http://refhub.elsevier.com/S0749-8063(15)00386-2/sref18http://refhub.elsevier.com/S0749-8063(15)00386-2/sref19http://refhub.elsevier.com/S0749-8063(15)00386-2/sref19http://refhub.elsevier.com/S0749-8063(15)00386-2/sref19http://refhub.elsevier.com/S0749-8063(15)00386-2/sref19http://refhub.elsevier.com/S0749-8063(15)00386-2/sref19http://refhub.elsevier.com/S0749-8063(15)00386-2/sref20http://refhub.elsevier.com/S0749-8063(15)00386-2/sref20http://refhub.elsevier.com/S0749-8063(15)00386-2/sref20http://refhub.elsevier.com/S0749-8063(15)00386-2/sref20http://refhub.elsevier.com/S0749-8063(15)00386-2/sref20http://refhub.elsevier.com/S0749-8063(15)00386-2/sref21http://refhub.elsevier.com/S0749-8063(15)00386-2/sref21http://refhub.elsevier.com/S0749-8063(15)00386-2/sref21http://refhub.elsevier.com/S0749-8063(15)00386-2/sref21http://refhub.elsevier.com/S0749-8063(15)00386-2/sref22http://refhub.elsevier.com/S0749-8063(15)00386-2/sref22http://refhub.elsevier.com/S0749-8063(15)00386-2/sref22http://refhub.elsevier.com/S0749-8063(15)00386-2/sref22http://refhub.elsevier.com/S0749-8063(15)00386-2/sref23http://refhub.elsevier.com/S0749-8063(15)00386-2/sref23http://refhub.elsevier.com/S0749-8063(15)00386-2/sref23http://refhub.elsevier.com/S0749-8063(15)00386-2/sref24http://refhub.elsevier.com/S0749-8063(15)00386-2/sref24http://refhub.elsevier.com/S0749-8063(15)00386-2/sref24http://refhub.elsevier.com/S0749-8063(15)00386-2/sref25http://refhub.elsevier.com/S0749-8063(15)00386-2/sref25http://refhub.elsevier.com/S0749-8063(15)00386-2/sref25http://refhub.elsevier.com/S0749-8063(15)00386-2/sref25http://refhub.elsevier.com/S0749-8063(15)00386-2/sref25http://refhub.elsevier.com/S0749-8063(15)00386-2/sref25http://refhub.elsevier.com/S0749-8063(15)00386-2/sref25http://refhub.elsevier.com/S0749-8063(15)00386-2/sref26http://refhub.elsevier.com/S0749-8063(15)00386-2/sref26http://refhub.elsevier.com/S0749-8063(15)00386-2/sref26http://refhub.elsevier.com/S0749-8063(15)00386-2/sref26http://refhub.elsevier.com/S0749-8063(15)00386-2/sref26http://refhub.elsevier.com/S0749-8063(15)00386-2/sref27http://refhub.elsevier.com/S0749-8063(15)00386-2/sref27http://refhub.elsevier.com/S0749-8063(15)00386-2/sref27http://refhub.elsevier.com/S0749-8063(15)00386-2/sref27http://refhub.elsevier.com/S0749-8063(15)00386-2/sref27http://refhub.elsevier.com/S0749-8063(15)00386-2/sref27http://refhub.elsevier.com/S0749-8063(15)00386-2/sref28http://refhub.elsevier.com/S0749-8063(15)00386-2/sref28http://refhub.elsevier.com/S0749-8063(15)00386-2/sref28http://refhub.elsevier.com/S0749-8063(15)00386-2/sref28http://refhub.elsevier.com/S0749-8063(15)00386-2/sref29http://refhub.elsevier.com/S0749-8063(15)00386-2/sref29http://refhub.elsevier.com/S0749-8063(15)00386-2/sref29http://refhub.elsevier.com/S0749-8063(15)00386-2/sref29http://refhub.elsevier.com/S0749-8063(15)00386-2/sref29http://refhub.elsevier.com/S0749-8063(15)00386-2/sref29http://refhub.elsevier.com/S0749-8063(15)00386-2/sref30http://refhub.elsevier.com/S0749-8063(15)00386-2/sref30http://refhub.elsevier.com/S0749-8063(15)00386-2/sref30http://refhub.elsevier.com/S0749-8063(15)00386-2/sref30http://refhub.elsevier.com/S0749-8063(15)00386-2/sref31http://refhub.elsevier.com/S0749-8063(15)00386-2/sref31http://refhub.elsevier.com/S0749-8063(15)00386-2/sref31http://refhub.elsevier.com/S0749-8063(15)00386-2/sref31http://refhub.elsevier.com/S0749-8063(15)00386-2/sref31http://refhub.elsevier.com/S0749-8063(15)00386-2/sref32http://refhub.elsevier.com/S0749-8063(15)00386-2/sref32http://refhub.elsevier.com/S0749-8063(15)00386-2/sref32http://refhub.elsevier.com/S0749-8063(15)00386-2/sref32
-
12 C. E. HEWISON ET AL.
34. Barber-Westin S, Noyes FR. The effect of rehabilitationand
return to activity on anterior-posterior knee dis-placements after
anterior cruciate ligament reconstruc-tion. Am J Sports Med
1993;21:264-270.
35. Barrett GR, Richardson KJ. The effect of added
extra-articular procedure on results of ACL reconstruction. AmJ
Sports Med 1995;8:1-6.
36. Dejour D, Vanconcelos W, Bonin N, Saggin PR.Comparative
study between mono-bundle bone-patellartendon-bone, double-bundle
hamstring and mono-bundle bone-patellar tendon-bone combined with
amodified Lemaire extra-articular procedure in anteriorcruciate
ligament reconstruction. Int Orthop 2013;37:193-199.
37. Ferkel RD, Fox JM, Del Pizzo W, et al. Reconstruction ofthe
anterior cruciate ligament using a torn meniscus.J Bone Joint Surg
Am 1988;70:715-723.
38. Goertzen M, Schulitz KP. Comparison of combined extra-and
intra-articular stabilization versus isolated arthro-scopic
semitendinosus repair after rupture of the anteriorcruciate
ligament. Sportverletz Sportschaden 1993;7:7-12 [inGerman].
39. Hefti F, Gachter A, Jenny H, Morscher E. Replacement ofthe
anterior cruciate ligament. A comparative study offour different
methods of reconstruction. Arch OrthopTrauma Surg
1982;100:83-94.
40. Hernández-Hermoso JA, Usandizaga Camats JM, MoralesCano J,
Jimeno Urban F. Intra-articular versus combinedintra and
extra-articular plasty in the treatment of chronicanterior knee
laxity. Rev Ortop Traumatol 2002;46:323-330[in Spanish].
41. Kanisawa I, Banks AZ, Banks SA, Moriya H, Tsuchiya
A.Weight-bearing knee kinematics in subjects with twotypes of
anterior cruciate ligament reconstructions. KneeSurg Sports
Traumatol Arthrosc 2003;11:16-22.
42. Laffargue P, Delalande JL, Decoulx J. Anterior
cruciateligament reconstruction with patellar tendon autograft:
Aseries of 79 cases with prognostic factors evaluation. RevChir
Orthop Reparatrice Appar Mot 1997;83:505-514 [inFrench].
43. Lerat JL, Mandrino A, Besse JL, Moyen B, Brunet-Guedj E.
Intra-articular reconstruction of the anteriorcruciate ligament
with and without extra-articular sup-plementation by quadricipital
tendon plasty: Four yearfellow-up results. Rev Chir Orthop
Reparatrice Appar Mot1997;83:591-601 [in French].
44. Monaco E, Labianca L, Conteduca F, De Carli A,Ferretti A.
Double bundle or single bundle plus extra-articular tenodesis in
ACL reconstruction? Knee Surg SportsTraumatol Arthrosc
2007;15:1168-1174.
45. Noyes FR, Barber SD. The effect of an
extra-articularprocedure on allograft reconstructions for chronic
rup-tures of the anterior cruciate ligament. J Bone Joint SurgAm
1991;73:882-892.
46. O’Brien SJ, Warren RF, Wickiewicz TL, et al. The
iliotibialband lateral sling procedure and its effect on the
results ofanterior cruciate ligament reconstruction. Am J Sports
Med1991;19:21-25.
47. Paterson FW, Trickey EL. Anterior cruciate
ligamentreconstruction using part of the patellar tendon as a
freegraft. J Bone Joint Surg Br 1986;68:453-457.
48. Riel KA, Ulm K, Bernett P. Value of synthetic (Kennedy-LAD)
augmentation in replacement of the anterior cru-ciate ligament.
Unfallchirurg 1991;94:351-354 [inGerman].
49. Roth JH, Kennedy JC, Lockstadt H, McCallum CL,Cunning LA.
Intra-articular reconstruction of the anteriorcruciate ligament
with and without extra-articular sup-plementation by transfer of
the biceps femoris tendon.J Bone Joint Surg Am 1987;69:275-278.
50. Savalli L, Hernandez MI, Laboute E, Trouve P, Puig PL.ACL
reconstruction in competition athletes: Short-termoutcome and
resumption of sports activities. J TraumatolSport
2008;25:192-198.
51. Sgaglione NA, Warren RF, Wickiewicz TL, Gold DA,Panariello
RA. Primary repair with semitendinosustendon augmentation of acute
anterior cruciate ligamentinjuries. Am J Sports Med
1990;18:64-73.
52. Sonnery-Cottet B, Archbold P, Zayni R, et al. Prevalenceof
septic arthritis after anterior cruciate ligament recon-struction
among professional athletes. Am J Sports Med2011;39:2371-2376.
53. Strum GM, Fox JM, Ferkel RD, et al. Intraarticular
versusintraarticular and extraarticular reconstruction for
chronicanterior cruciate ligament instability. Clin Orthop Relat
Res1989;(245):188-198.
54. Verdano MA, Pedrabissi B, Lunini E, Pellegrini A,Ceccarelli
F. Over the top or endobutton for ACL recon-struction? Acta Biomed
2012;83:127-137.
55. Higgins J, Altman DG, Gøtzsche PC, et al. The
CochraneCollaboration’s tool for assessing risk of bias in
rando-mised trials. BMJ 2011;343:d5928.
56. Jakob RP, Staubli HU, Deland JT. Grading the pivot
shift.Objective tests with implications for treatment. J BoneJoint
Surg Br 1987;69:294-299.
57. Kim S-J, Kim H-K. Reliability of the anterior drawer
test,the pivot shift test, and the Lachman test. Clin Orthop
RelatRes 1995;317:237-242.
58. Katz JW, Fingeroth RJ. The diagnostic accuracy of rup-tures
of the anterior cruciate ligament comparing theLachman test, the
anterior drawer sign, and the pivot shifttest in acute and chronic
knee injuries. Am J Sports Med1986;14:88-91.
59. Lane CG, Warren R, Pearle AD. The pivot shift. J Am
AcadOrthop Surg 2008;16:679-688.
60. Daniel DM, Stone ML, Sachs R, Malcom L.
Instrumentedmeasurement of anterior knee laxity in patients
withacute anterior cruciate ligament disruption. Am J SportsMed
1985;13:401-407.
61. Arneja S, Leith J. Review article: Validity of the
KT-1000knee ligament arthrometer. J Orthop Surg (Hong
Kong)2009;17:77-79.
62. Rangger C, Daniel DM, Stone ML, Kaufman K. Diagnosisof an
ACL disruption with KT-1000 arthrometer mea-surements. Knee Surg
Sports Traumatol Arthrosc 1993;1:60-66.
63. Hefti E, Müller W, Jakob RP, Stäubli HU. Evaluation ofknee
ligament injuries with the IKDC form. Knee SurgSports Traumatol
Arthrosc 1993;1:226-234.
64. Risberg MA, Holm I, Steen H, Beynnon BD. Sensitivityto
changes over time for the IKDC form, the Lysholmscore, and the
Cincinnati knee score A prospective
http://refhub.elsevier.com/S0749-8063(15)00386-2/sref33http://refhub.elsevier.com/S0749-8063(15)00386-2/sref33http://refhub.elsevier.com/S0749-8063(15)00386-2/sref33http://refhub.elsevier.com/S0749-8063(15)00386-2/sref33http://refhub.elsevier.com/S0749-8063(15)00386-2/sref34http://refhub.elsevier.com/S0749-8063(15)00386-2/sref34http://refhub.elsevier.com/S0749-8063(15)00386-2/sref34http://refhub.elsevier.com/S0749-8063(15)00386-2/sref35http://refhub.elsevier.com/S0749-8063(15)00386-2/sref35http://refhub.elsevier.com/S0749-8063(15)00386-2/sref35http://refhub.elsevier.com/S0749-8063(15)00386-2/sref35http://refhub.elsevier.com/S0749-8063(15)00386-2/sref35http://refhub.elsevier.com/S0749-8063(15)00386-2/sref35http://refhub.elsevier.com/S0749-8063(15)00386-2/sref35http://refhub.elsevier.com/S0749-8063(15)00386-2/sref36http://refhub.elsevier.com/S0749-8063(15)00386-2/sref36http://refhub.elsevier.com/S0749-8063(15)00386-2/sref36http://refhub.elsevier.com/S0749-8063(15)00386-2/sref37http://refhub.elsevier.com/S0749-8063(15)00386-2/sref37http://refhub.elsevier.com/S0749-8063(15)00386-2/sref37http://refhub.elsevier.com/S0749-8063(15)00386-2/sref37http://refhub.elsevier.com/S0749-8063(15)00386-2/sref37http://refhub.elsevier.com/S0749-8063(15)00386-2/sref38http://refhub.elsevier.com/S0749-8063(15)00386-2/sref38http://refhub.elsevier.com/S0749-8063(15)00386-2/sref38http://refhub.elsevier.com/S0749-8063(15)00386-2/sref38http://refhub.elsevier.com/S0749-8063(15)00386-2/sref39http://refhub.elsevier.com/S0749-8063(15)00386-2/sref39http://refhub.elsevier.com/S0749-8063(15)00386-2/sref39http://refhub.elsevier.com/S0749-8063(15)00386-2/sref39http://refhub.elsevier.com/S0749-8063(15)00386-2/sref39http://refhub.elsevier.com/S0749-8063(15)00386-2/sref40http://refhub.elsevier.com/S0749-8063(15)00386-2/sref40http://refhub.elsevier.com/S0749-8063(15)00386-2/sref40http://refhub.elsevier.com/S0749-8063(15)00386-2/sref40http://refhub.elsevier.com/S0749-8063(15)00386-2/sref41http://refhub.elsevier.com/S0749-8063(15)00386-2/sref41http://refhub.elsevier.com/S0749-8063(15)00386-2/sref41http://refhub.elsevier.com/S0749-8063(15)00386-2/sref41http://refhub.elsevier.com/S0749-8063(15)00386-2/sref41http://refhub.elsevier.com/S0749-8063(15)00386-2/sref42http://refhub.elsevier.com/S0749-8063(15)00386-2/sref42http://refhub.elsevier.com/S0749-8063(15)00386-2/sref42http://refhub.elsevier.com/S0749-8063(15)00386-2/sref42http://refhub.elsevier.com/S0749-8063(15)00386-2/sref42http://refhub.elsevier.com/S0749-8063(15)00386-2/sref42http://refhub.elsevier.com/S0749-8063(15)00386-2/sref43http://refhub.elsevier.com/S0749-8063(15)00386-2/sref43http://refhub.elsevier.com/S0749-8063(15)00386-2/sref43http://refhub.elsevier.com/S0749-8063(15)00386-2/sref43http://refhub.elsevier.com/S0749-8063(15)00386-2/sref44http://refhub.elsevier.com/S0749-8063(15)00386-2/sref44http://refhub.elsevier.com/S0749-8063(15)00386-2/sref44http://refhub.elsevier.com/S0749-8063(15)00386-2/sref44http://refhub.elsevier.com/S0749-8063(15)00386-2/sref45http://refhub.elsevier.com/S0749-8063(15)00386-2/sref45http://refhub.elsevier.com/S0749-8063(15)00386-2/sref45http://refhub.elsevier.com/S0749-8063(15)00386-2/sref45http://refhub.elsevier.com/S0749-8063(15)00386-2/sref46http://refhub.elsevier.com/S0749-8063(15)00386-2/sref46http://refhub.elsevier.com/S0749-8063(15)00386-2/sref46http://refhub.elsevier.com/S0749-8063(15)00386-2/sref47http://refhub.elsevier.com/S0749-8063(15)00386-2/sref47http://refhub.elsevier.com/S0749-8063(15)00386-2/sref47http://refhub.elsevier.com/S0749-8063(15)00386-2/sref47http://refhub.elsevier.com/S0749-8063(15)00386-2/sref48http://refhub.elsevier.com/S0749-8063(15)00386-2/sref48http://refhub.elsevier.com/S0749-8063(15)00386-2/sref48http://refhub.elsevier.com/S0749-8063(15)00386-2/sref48http://refhub.elsevier.com/S0749-8063(15)00386-2/sref48http://refhub.elsevier.com/S0749-8063(15)00386-2/sref49http://refhub.elsevier.com/S0749-8063(15)00386-2/sref49http://refhub.elsevier.com/S0749-8063(15)00386-2/sref49http://refhub.elsevier.com/S0749-8063(15)00386-2/sref49http://refhub.elsevier.com/S0749-8063(15)00386-2/sref50http://refhub.elsevier.com/S0749-8063(15)00386-2/sref50http://refhub.elsevier.com/S0749-8063(15)00386-2/sref50http://refhub.elsevier.com/S0749-8063(15)00386-2/sref50http://refhub.elsevier.com/S0749-8063(15)00386-2/sref51http://refhub.elsevier.com/S0749-8063(15)00386-2/sref51http://refhub.elsevier.com/S0749-8063(15)00386-2/sref51http://refhub.elsevier.com/S0749-8063(15)00386-2/sref51http://refhub.elsevier.com/S0749-8063(15)00386-2/sref52http://refhub.elsevier.com/S0749-8063(15)00386-2/sref52http://refhub.elsevier.com/S0749-8063(15)00386-2/sref52http://refhub.elsevier.com/S0749-8063(15)00386-2/sref52http://refhub.elsevier.com/S0749-8063(15)00386-2/sref53http://refhub.elsevier.com/S0749-8063(15)00386-2/sref53http://refhub.elsevier.com/S0749-8063(15)00386-2/sref53http://refhub.elsevier.com/S0749-8063(15)00386-2/sref54http://refhub.elsevier.com/S0749-8063(15)00386-2/sref54http://refhub.elsevier.com/S0749-8063(15)00386-2/sref54http://refhub.elsevier.com/S0749-8063(15)00386-2/sref55http://refhub.elsevier.com/S0749-8063(15)00386-2/sref55http://refhub.elsevier.com/S0749-8063(15)00386-2/sref55http://refhub.elsevier.com/S0749-8063(15)00386-2/sref56http://refhub.elsevier.com/S0749-8063(15)00386-2/sref56http://refhub.elsevier.com/S0749-8063(15)00386-2/sref56http://refhub.elsevier.com/S0749-8063(15)00386-2/sref57http://refhub.elsevier.com/S0749-8063(15)00386-2/sref57http://refhub.elsevier.com/S0749-8063(15)00386-2/sref57http://refhub.elsevier.com/S0749-8063(15)00386-2/sref57http://refhub.elsevier.com/S0749-8063(15)00386-2/sref57http://refhub.elsevier.com/S0749-8063(15)00386-2/sref58http://refhub.elsevier.com/S0749-8063(15)00386-2/sref58http://refhub.elsevier.com/S0749-8063(15)00386-2/sref59http://refhub.elsevier.com/S0749-8063(15)00386-2/sref59http://refhub.elsevier.com/S0749-8063(15)00386-2/sref59http://refhub.elsevier.com/S0749-8063(15)00386-2/sref59http://refhub.elsevier.com/S0749-8063(15)00386-2/sref60http://refhub.elsevier.com/S0749-8063(15)00386-2/sref60http://refhub.elsevier.com/S0749-8063(15)00386-2/sref60http://refhub.elsevier.com/S0749-8063(15)00386-2/sref61http://refhub.elsevier.com/S0749-8063(15)00386-2/sref61http://refhub.elsevier.com/S0749-8063(15)00386-2/sref61http://refhub.elsevier.com/S0749-8063(15)00386-2/sref61http://refhub.elsevier.com/S0749-8063(15)00386-2/sref62http://refhub.elsevier.com/S0749-8063(15)00386-2/sref62http://refhub.elsevier.com/S0749-8063(15)00386-2/sref62http://refhub.elsevier.com/S0749-8063(15)00386-2/sref63http://refhub.elsevier.com/S0749-8063(15)00386-2/sref63http://refhub.elsevier.com/S0749-8063(15)00386-2/sref63
-
LATERAL EXTRA-ARTICULAR TENODESIS 13
study of 120 ACL reconstructed patients with a 2-yearfollow-up.
Knee Surg Sports Traumatol Arthrosc 1999;7:152-159.
65. Marx RG, Jones EC, Allen AA, et al. Reliability,
validity,and responsiveness of four knee outcome scales for
ath-letic patients. J Bone Joint Surg Am 2001;83:1459-1469.
66. Higgins J, Thompson SG. Quantifying heterogeneity in
ameta-analysis. Stat Med 2002;21:1539-1558.
67. Lerat JL, Chotel F, Besse JL, et al. The results after
10-16years of the treatment of chronic anterior laxity of theknee
using reconstruction of the anterior cruciate liga-ment with a
patellar tendon graft combined with anexternal extra-articular
reconstruction. Rev Chir OrthopReparatrice Appar Mot
1998;84:712-727 [in French].
68. Lemaire M. Instabilité chronique du genou: Technique
etrésultats des plasties ligamentaires en traumatologiesportive. J
Chir (Paris) 1975;110:281-294.
69. Christel P, Djian P. Anterio-lateral extra-articular
tenod-esis of the knee using a short strip of fascia lata. Rev
ChirOrthop Reparatrice Appar Mot 2002;88:508-513 [in French].
70. MacIntosh DL, Darby TA. Lateral substitution
recon-struction. J Bone Joint Surg Br 1976;58:142 (abstr).
71. Losee R, Johnson T, Southwick W. Anterior subluxationof the
lateral tibial plateau: A diagnostic test and operativerepair. J
Bone Joint Surg Am 1978;60:1015-1030.
72. Marcacci M, Zaffagnini S, Iacono F, Neri MP, Loreti
I,Petitto A. Arthroscopic intra-and extra-articular
anteriorcruciate ligament reconstruction with gracilis and
sem-itendinosus tendons. Knee Surg Sports Traumatol
Arthrosc1998;6:68-75.
73. Colombet PD. Navigated intra-articular ACL reconstruc-tion
with additional extra-articular tenodesis using thesame hamstring
graft. Knee Surg Sports Traumatol Arthrosc2011;19:384-389.
74. Engebretsen L, Lew WD, Lewis JL, Hunter RE. Kneemechanics
after repair of the anterior cruciate ligament Acadaver study of
ligament augmentation. Acta Orthop1989;60:703-709.
75. Strickler F. A satisfactory method of repairing
cruciateligaments. Ann Surg 1937;105:912-916.
http://refhub.elsevier.com/S0749-8063(15)00386-2/sref63http://refhub.elsevier.com/S0749-8063(15)00386-2/sref63http://refhub.elsevier.com/S0749-8063(15)00386-2/sref63http://refhub.elsevier.com/S0749-8063(15)00386-2/sref64http://refhub.elsevier.com/S0749-8063(15)00386-2/sref64http://refhub.elsevier.com/S0749-8063(15)00386-2/sref64http://refhub.elsevier.com/S0749-8063(15)00386-2/sref65http://refhub.elsevier.com/S0749-8063(15)00386-2/sref65http://refhub.elsevier.com/S0749-8063(15)00386-2/sref66http://refhub.elsevier.com/S0749-8063(15)00386-2/sref66http://refhub.elsevier.com/S0749-8063(15)00386-2/sref66http://refhub.elsevier.com/S0749-8063(15)00386-2/sref66http://refhub.elsevier.com/S0749-8063(15)00386-2/sref66http://refhub.elsevier.com/S0749-8063(15)00386-2/sref66http://refhub.elsevier.com/S0749-8063(15)00386-2/sref67http://refhub.elsevier.com/S0749-8063(15)00386-2/sref67http://refhub.elsevier.com/S0749-8063(15)00386-2/sref67http://refhub.elsevier.com/S0749-8063(15)00386-2/sref68http://refhub.elsevier.com/S0749-8063(15)00386-2/sref68http://refhub.elsevier.com/S0749-8063(15)00386-2/sref68http://refhub.elsevier.com/S0749-8063(15)00386-2/sref69http://refhub.elsevier.com/S0749-8063(15)00386-2/sref69http://refhub.elsevier.com/S0749-8063(15)00386-2/sref70http://refhub.elsevier.com/S0749-8063(15)00386-2/sref70http://refhub.elsevier.com/S0749-8063(15)00386-2/sref70http://refhub.elsevier.com/S0749-8063(15)00386-2/sref71http://refhub.elsevier.com/S0749-8063(15)00386-2/sref71http://refhub.elsevier.com/S0749-8063(15)00386-2/sref71http://refhub.elsevier.com/S0749-8063(15)00386-2/sref71http://refhub.elsevier.com/S0749-8063(15)00386-2/sref71http://refhub.elsevier.com/S0749-8063(15)00386-2/sref72http://refhub.elsevier.com/S0749-8063(15)00386-2/sref72http://refhub.elsevier.com/S0749-8063(15)00386-2/sref72http://refhub.elsevier.com/S0749-8063(15)00386-2/sref72http://refhub.elsevier.com/S0749-8063(15)00386-2/sref73http://refhub.elsevier.com/S0749-8063(15)00386-2/sref73http://refhub.elsevier.com/S0749-8063(15)00386-2/sref73http://refhub.elsevier.com/S0749-8063(15)00386-2/sref73http://refhub.elsevier.com/S0749-8063(15)00386-2/sref74http://refhub.elsevier.com/S0749-8063(15)00386-2/sref74
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Lateral Extra-articular Tenodesis Reduces Rotational Laxity When
Combined With Anterior Cruciate Ligament Reconstruction: A
...MethodsLiterature Search and Study SelectionData
AbstractionMethodologic Quality AssessmentOutcomesData Analysis
ResultsSummary of EvidenceStudy QualityVariability of
StudiesPooled ResultsAdverse Events
DiscussionLimitations
ConclusionsReferences
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