Comparison of Clinical Outcomes between Anteromedial and Transtibial Techniques of Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis

摘要

This study compared clinical outcomes obtained after single-bundle anterior cruciate ligament (ACL) reconstruction using the anteromedial (AM) and transtibial (TT) techniques, which comprise the conventional transtibial (cTT) and modified transtibial (mTT) techniques. This study included clinical randomized controlled trials and prospective and retrospective controlled trials with AM and TT techniques from the PubMed and Embase databases and the Cochrane Library. All databases were searched from January 2010 to July 2020. Two independent evaluators verified the quality of the included studies using the Cochrane Collaboration’s risk of bias tool and the Newcastle-Ottawa Scale (NOS). Outcome measures analysed included the Lachman test, pivot-shift test, side-to-side difference (SSD), Lysholm score, Tegner activity scale, International Knee Documentation Committee (IKDC) grade and score. Ten randomized controlled trials (RCTs) and 16 prospective and retrospective controlled trials were included with a total of 2202 patients. There were 1180 patients and 1022 patients in the AM and TT groups, respectively. Compared to the cTT group, superior postoperative results were observed in the AM group based on the negative rate of the Lachman test and the pivot-shift test, IKDC grade and score, Lysholm score, Tegner activity scale and SSD (p < 0.05). However, there was no significant difference between the AM and mTT groups (p > 0.05). Compared to the conventional TT technique, the AM technique exhibited superior clinical outcomes. Nevertheless, the modified TT and AM techniques had comparable results. With neither of the techniques (mTT or AM) producing significantly superior outcomes, surgeons can choose either of them depending on their preferences.Key points This meta-analysis was conducted based on the latest studies about the cTT, mTT and AM techniques.Compared to the cTT technique, the AM technique showed superior clinical outcomes.The mTT and AM techniques had comparable clinical outcomes.Surgeons can choose the one between the mTT and AM techniques, depending on their preferences. Key words: Anterior cruciate ligament reconstruction, anteromedial, transtibial, modified transtibial, meta-analysisIntroductionAnterior cruciate ligament (ACL) tears are among the most common knee injuries, and single-bundle ACL reconstruction has increasingly become the standard method for restoring knee stability and function (Kopf et al., 2010; Duquin et al., 2009). Technology in ACL reconstruction has made great progress over the past few decades (Csintalan et al., 2008). Initially, the conventional transtibial (cTT) technique for drilling the femoral tunnel played an important role in single-bundle ACL reconstruction (Mirzatolooei, 2012), owing to its simplicity in creating tunnels (Robin et al., 2015). However, several studies have shown that the conventional TT technique may lead to ACL reconstruction failure due to the increased obliquity of the femoral tunnel and placement of the graft in a non-anatomic site (Arnold et al., 2001; Heming et al., 2007; Loh et al., 2003; Paessler et al., 2004). Independent drilling techniques, such as the anteromedial (AM) and outside-in (OI) methods, have been advocated for single-bundle ACL reconstruction (Bottoni 2008; Duquin et al., 2009; Chechik et al., 2013; Seo et al., 2013). To restore anatomical insertion of the ACL, AM and OI techniques create an additional incision for a solitary femoral tunnel on the anteromedial and outside-in aspects, which is efficient but challenging. Recently, the modified transtibial (mTT) method has been introduced to the field. Furthermore, some studies have shown that the mTT technique may result in the femoral tunnel being in a similar anatomic position with comparable clinical outcomes to the AM technique (Hussin et al., 2018; Lee et al., 2014; Youm et al., 2014).Many studies have attempted to compare the cTT and AM techniques for single-bundle ACL reconstruction since 2010. Some of them reported that the AM technique yields superior outcomes. Based on the physical examination and functional outcome measures, two meta-analyses (Chen et al., 2017; Liu et al., 2017) agreed that the AM technique is superior to the cTT technique. However, several recent studies (Cury et al., 2017; Geng and Gai, 2018; ?zer et al., 2018) also claimed that the two techniques are not significantly different. However, it is unclear whether the mTT technique yields similar clinical outcomes to those of the AM technique with respect to anatomical reconstruction. Consequently, in this meta-analysis, we reviewed and analysed the latest studies on TT and AM techniques in single-bundle ACL reconstruction to compare postoperative clinical outcomes between the cTT and AM techniques, as well as for mTT and AM techniques.MethodsSearch strategyPubMed and Embase databases and the Cochrane Library were searched from January 2010 to July 2020. The following terms were searched in the title, ab