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Is augmentation the best solution in partial anterior cruciate ligament tears? A literature systematic review and meta-analysis
, Fortunato Giustraa, Michele Crivellaroa, Riccardo Giai Viaa, Alessandro Dario Laviab, Marcello Capellaa, Luigi Sabatinia, Salvatore Risitanoa, Giuseppe Roverec, Alessandro Massèa, Raju Vaishyad
∗Corresponding author: Francesco Bosco. francesco.bosco532@edu.unito.it
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
The appropriate management of partial anterior cruciate ligament (ACL) tears is still debated. There is a tendency in orthopedic clinical practice to prefer complete ACL reconstruction, while few surgeons perform ACL augmentation. The purpose of the present study is to evaluate the current evidence on the effectiveness of ACL augmentation compared with standard ACL reconstruction to assess whether ACL augmentation may be the treatment of choice in partial ACL injury.
According to PRISMA guidelines, literature research was performed in PubMed/Medline, Cochrane Library, Embase, Scopus, and Web of Science databases. A PICOS model was used, and a preliminary search resulted in 1101 articles. The methodological quality was assessed through ROBINS-I. A meta-analysis was conducted on postoperative Tegner, Lysholm scores and KT-1000 values between ACL augmentation and ACL reconstruction, and a p < 0.05 has been assumed as statistically significant. PROSPERO, ID: CRD42022343502.
Seven papers were included. A total of 472 knees underwent ACL reconstruction, and 311 underwent ACL augmentation. A statistically significant discrepancy was found in the postoperative Tegner score in favor of ACL augmentation compared with ACL reconstruction (p < 0.05). Regarding the postoperative Lysholm score and KT-1000 measurement, no statistically significant difference was shown between ACL reconstruction and ACL augmentation (p > 0.05).
ACL augmentation has proved to be an effective and safe procedure and should be preferred to ACL reconstruction in partial ACL tears for the tendency to achieve better functional outcomes.
Keywords
Partial ACL tear
ACL reconstruction
ACL augmentation
Arthroscopy
Knee
1 Introduction
The anteromedial (AM) and posterolateral (PL) bundles of an Anterior cruciate ligament (ACL) are characterized by different injury mechanisms due to their different course and biomechanical functions.1 Isolated AM or PL tears are quite common, with a frequency ranging from 10% to 35% of all ACL tears.2 These lesions may be symptomatic in 5%–10% of cases3 and evolve into complete tears in 38–50% of patients due to blood flow failure and intact bundle disruption.4–6
Historically, reconstruction of partial ACL injuries was characterized by remnant bundle sacrificing and new graft implantation to replace the entire ACL. More recently, in partial ACL injuries, many surgeons perform ACL augmentation (AUG), which consists of an isolated AM or PL reconstruction suturing the graft remnants. This procedure involves increased difficulty and precision in orienting the bone tunnels to avoid damaging the native bundle insertion site. However, in experienced hands, it results in only a modest lengthening of surgical time.7,8 The basic principle is that preserving native ACL fibers may contribute to healing and graft integration by creating an ideal environment for cell growth at the ligament insertion site and may improve proprioception.8–10 In recent decades, the issue of remnant preservation has been raised, and several papers have focused on treating partial ACL tears.11–13
This study evaluates the ACL AUG technique compared with standard ACL reconstruction (ACLR) to analyze the clinical outcomes, investigate its efficacy and safety, and assess whether ACL AUG could be considered the proper treatment for partial ACL injury in the daily clinical practice of orthopedic surgeons.
2 Materials and methods
2.1 Research question
Three authors (FB, MC, and FG) performed the search and reviewed the articles independently. A fourth author (RGV) was involved in resolving any doubts. The PRISMA guidelines were applied to perform this paper.14
The PICOS design was applied. Patient (P): Partial ACL tear; Intervention (I): ACLR; Comparison (C): ACL AUG; Outcome (O): Postoperative results of ACLR versus ACL AUG in a partial ACL tear; Study design (S): Retrospective studies.
2.2 Protocol design
Inclusion criteria were articles published from January 1999 to October 2022, with full text available, written in English, showing a follow-up of at least one year, on human subjects with ACL partial tear undergoing ACLR or ACL AUG. Editorials, reviews, technical or case reports, and biomechanical studies were excluded.
2.3 Search strategy and study screening
PubMed/Medline, Cochrane Library, Embase, Scopus, and Web of Science databases were systematically reviewed using the following MeSH terms in association with the Boolean AND/OR operator: “anterior cruciate ligament reconstruction”, “ACL reconstruction”, “ACLR”, “ACL augmentation”, “anterior cruciate ligament augmentation”, “partial ACL tear”. With the above MeSH terms, the initial search yielded 1101 studies. After duplicate articles were excluded, the title and abstract were analyzed. Seven clinical studies were selected after assessing the eligibility of full-text articles and reviewing the bibliography of each article.15–21 The PRISMA flowchart is detailed in Fig. 1.
2.4 Methodological assessment
The reviewed articles were evaluated according to the level of evidence (LoE).22 The ROBINS-I was applied to measure the quality level of the included retrospective studies (Fig. 2).23,24 Three authors used this tool (FB, MC, and FG). A four-author (RGV) resolved any cases of disagreement. This study was registered on PROSPERO, ID: CRD42022343502.25–27
2.5 Data extraction
The following study characteristics have been included: authors and publication year, case number, age, sex, studies' follow-up, study design, LoE, Lysholm, Tegner score, and KT-1000 values.
2.6 Statistical analysis
A meta-analysis of clinical and subjective scores was performed before and after ACLR versus ACL AUG. Lysholm, Tegner score and KT-1000 evaluation allowed a valid statistical comparison. Statistical tests were conducted with R software (2022) by a professional statistician (ADL). Standardized mean difference (SMD) and standard deviation (SD) were estimated using random effects analysis and inverse weighting for pooling. Jackson's method calculated the mean effect size and 95% confidence interval. Cochran's Q and Higgins's I2 test statistics were performed to test for heterogeneity among studies. A p < 0.05 was considered a statistically significant value. Funnel plots and Egger's test were used to check for publication bias.28,29
3 Results
A total of 472 knees underwent ACLR, and 311 received AUG. The mean follow-up for ACLR was 27.97 (27.49–28.44) months. Table 1 shows the main demographic details, such as sample size, age, number of males, and follow-up of patients included in the studies. Lysholm, Tegner score and KT-1000 results before and after the surgical procedure are listed in Table 2.
| Included studies | Research Design | Level of Evidence | Sample size | Age | M | Follow-up | ||||||||||||||||||||
| N° | Average ± SD/(min-max); years old | N° | Average ± SD/(min-max); months | |||||||||||||||||||||||
| ACLR | ACL AUG | ACLR | ACL AUG | ACLR | ACL AUG | ACLR | ACL AUG | |||||||||||||||||||
| DB | SB | AM | PL | NS | DB | SB | AM | PL | NS | DB | SB | AM | PL | NS | DB | SB | AM | PL | NS | |||||||
| Yoon et al. (2009)21 | RS | III | – | 82 | 40 | 42 | – | – | 28.9 (14–54) | 29.1 (17–61) | 27.8 (15–48) | – | – | 68 | 30 | 34 | – | – | 24.3 (12–38) | 24.1 (12–36) | 24 (12–42) | – | ||||
| Park et al. (2012)20 | RS | IV | 45 | – | – | – | 55 | 31.7 (16–57) | – | – | – | 30.4 (17–35) | 40 | – | – | – | 45 | 30.8 (24–37.3) | – | – | – | 34.1 (24–36.6) | ||||
| Nakamae et al. (2014)19 | RS | III | 82 | 61 | – | – | 73 | 24.8 ± 11 | 24.6 ± 11.9 | – | – | 26.6 ± 11.4 | 47 | 27 | – | – | 29 | 28.1 ± 6.7 | 29.4 ± 9.2 | – | – | 28.9 ± 9.1 | ||||
| Matsushita et al. (2015)18 | RS | IV | 37 | – | – | 16 | – | 26.9 ± 9.3 | – | – | 30.6 ± 13.2 | – | 16 | – | – | 12 | – | 30.1 ± 10.5 | – | – | 35.1 ± 16.4 | – | ||||
| Bodendorfer et al. (2019)16 | RS | III | – | 30 | – | – | 30 | – | 29.65 ± 5.65 | – | – | 29.34 ± 7.55 | – | 13 | – | – | 13 | – | 30.08 ± 5.89 | – | – | 29.0 ± 4.84 | ||||
| Ahn et al. (2020)15 | RS | III | – | 64 | – | – | 21 | – | 34.6 (18–58) | 32.4 (17–56) | – | – | – | 40 | 19 | – | – | – | 26.7 (19.2–36.5) | 28.3 (20.3–38.0) | – | – | ||||
| Iwaasa et al. (2021)17 | RS | III | 26 (Re) | 45 (Ab) | – | – | – | 34 | 27 ± 1.9 (Re) | 21.7 ± 8.8 (Ab) | – | – | – | 27.9 ± 11.4 | 9 (Re) | 18 (Ab) | – | – | – | 18 | 24 ± 0 (Re) | 24 ± 0 (Ab) | – | – | – | 24 ± 0 |
| Included studies | Tegner | Lysholm | KT 1000 arthrometer | |||||||||||||||||||||||||||||||
| Average ± SD | Average ± SD | Average ± SD | ||||||||||||||||||||||||||||||||
| ACLR | ACL AUG | ACLR | ACL AUG | ACLR | ACL AUG | |||||||||||||||||||||||||||||
| DB | SB | AM | NS | DB | SB | AM | PL | NS | DB | SB | AM | PL | NS | |||||||||||||||||||||
| Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | |||||||
| Yoon et al. (2009)21 | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | 5±2.3 | 1,9 ± 1.5 | 5±2.2 | 2,2±2.1 | 5,3±1.8 | 2.2±1.7 | – | – | ||||||
| Park et al. (2012)20 | 3.3 ± 1 | 6.9 ± 1.2 | – | – | – | – | 3.1 ± 1.2 | 7.3 ± 1.3 | 48.6 ± 8.7 | 86.4 ± 4.4 | – | – | – | – | – | – | 48.6 ± 9.7 | 88.3 ± 4.9 | 6.1 ± 3.1 | 1.7 ± 1.4 | – | – | – | – | – | – | 4.9 ± 2.7 | 1.5±1.5 | ||||||
| Nakamae et al. (2014)19 | – | – | – | – | – | – | – | – | 73.2 ± 4.4 | 97.0 ± 3.3 | 72.2 ± 4.4 | 98.1 ± 3 | – | – | – | – | 73.5 ± 3.8 | 97.8 ± 3 | – | – | – | – | – | – | – | – | – | – | ||||||
| Matsushita et al. (2015)18 | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | 91.7 ± 12.2 | – | – | 5.8 ± 3.1 | 0.9 ± 1.2 | – | – | – | – | 3.4 ± 1.7 | 0.8 ± 1.1 | – | – | ||||||
| Bodendorfer et al. (2019)16 | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | ||||||
| Ahn et al. (2020)15 | – | – | 3.1±1.2 | 7.2 ± 1.3 | 3.2±0.9 | 8.1±1.1 | – | – | – | – | 47.8 ± 9.8 | 78.3 ± 4.8 | 49.2 ± 8.3 | 89.1 ± 4.2 | – | – | – | – | – | – | – | – | – | – | – | – | – | – | ||||||
| Iwaasa et al. (2021)17 | 5.6±1.4 (Re) | 6±1.4 (Ab) | 4.9±1.3 (Re) | 4.9±1.6 (Ab) | – | – | – | – | 5,9±1.1 | 5,2±1.2 | 78.1 ± 12.6 (Re) | 77.4 ± 13.5 (Ab) | 96,7 ± 3,5 (Re) | 96.3 ± 5.8 (Ab) | – | – | – | – | – | – | 81.8 ± 10.4 | 94.9 ± 6.7 | 6.1 ± 2.9 (Re) | 7.0 ± 2.5 (Ab) | 1.6 ± 2.3 (Re) | 1.6 ± 1.7 (Ab) | – | – | – | – | – | – | 5.5 ± 2.7 | 0.3 ± 1.6 |
A meta-analysis demonstrated a statistically significant difference in the postoperative Tegner score15,17,20 in favor of ACL AUG compared with ACLR (Fig. 3).
As for the postoperative Lysholm score,15,17,19,20 there is no statistically significant difference in the postoperative values of ACLR and ACL AUG (Fig. 4).
Regarding the postoperative KT-1000 arthrometer measurement,17,18,20,21 the forest plot shows no statistically significant differences between ACLR and ACL AUG (Fig. 5). For each outcome analyzed, no significant effect of publication bias was reported.
4 Discussion
This study reports a statistically significant better postoperative Tegner score in the ACL AUG group than in the ACLR one.15,17,20 This evidence is relevant because the Tegner score, comparing the sports activity level after the surgical procedure with that before the injury, demonstrated a better postoperative outcome and return to the sport in patients who underwent the ACL AUG procedure compared with ACLR.
A meta-analysis on the Lysholm score and KT-1000 arthrometer assessment was also conducted, and no statistically significant difference in postoperative values between ACL AUG and ACLR was reported.15,17–21 However, a trend toward improved postoperative Lysholm score15,20 and KT-1000 arthrometer measurements17,18,20 was described in patients with ACL AUG more than in those with ACLR.
Several other objective scores, such as an anterior drawer, Lachman, and pivot-shift test, were analyzed in the studies included in this paper. However, they were not considered for a meta-analysis because of the lower level of inter- and intra-observer accordance and liability compared with the assessment performed with the KT-1000 test.30 The pivot shift and Lachman tests for patients who underwent ACLR and ACL AUG were evaluated before and after surgery in four15,18,20,21 and five15,18–21 articles, respectively; no significant differences were detected. The anterior drawer test was analyzed in two studies.20,21 Park et al., in their paper, reported significantly fewer anterior drawer test-positive patients in the ACL AUG group20; conversely, Yoon et al. described no difference in the groups analyzed.21
Several other subjective tests were performed in the studies comprised in this paper. Bodendorfer et al.16 and Yoon et al.21 described a better International Knee Documentation Committee (IKDC) score in patients who underwent ACL AUG than ACLR. However, no significant differences were detected by Park et al.20 and Iwaasa et al.17 The Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score was evaluated in one study.16 Both surgical techniques, ACL AUG and ACLR, reported improvements in postoperative outcomes, although with higher results in the ACL AUG patients. The authors also analyzed the Knee Injury Osteoarthritis Outcome Score (KOOS) and its subscores. They did not find any statistical differences in the postoperative evaluation between ACL AUG and ACLR groups except for KOOS Sports and Recreation score and quality of life (QoL), which were significantly better in patients who underwent ACL AUG.16
Three studies analyzed the synovial coverage percentage during a second arthroscopic look, reporting significantly higher results in patients who underwent ACL AUG.15,18,19 Greater synovial coverage in the ACL AUG group is usually associated with better results. It may be due to increased proprioception due to graft tendon neovascularization which is favored by the preservation of ACL remnants at the tibial attachment during the surgery.19
Several complications were described in the studies included in this paper. The cyclops lesions were reported in three studies15,17,18; treated with radiofrequency ablation, they were more frequent in the ACL AUG group than in the ACLR one and may be explained by anterior remnant impingement on the femoral intercondylar notch.31 Ahn et al., in their paper, reported four cases of grafted tendon hypertrophy, all treated with radiofrequency, without knee flexion contracture or extension block.15 Graft re-rupture was described in two studies; Bodendorfer et al.16 reported two cases in both ACLR and ACL AUG groups, while Iwaasa et al.17 experienced two re-rupture cases exclusively in the ACLR group. However, the authors did not report the causes of graft failure, so it was not possible to estimate if the failure was due to the surgical technique used, ACL AUG or ALCR, or other reasons unrelated to the surgical procedure.32–34 ROM reduction was observed in two studies, one patient for the ACLR and ACL AUG groups, respectively; nevertheless, all patients underwent release in anesthesia four months postoperatively and experienced complete ROM recovery at the last follow-up.20,21
Recent literature suggests that an ACL AUG should be preferred to ACLR whenever possible.11,20,35 There are several reasons for this choice. First, leaving the bundle and remnants intact allows innervation preservation, improving subjective outcome and return to preinjury sport level through better joint sensation. The ACL is extensively innervated, and Golgi tendon organ-like mechanoreceptors were described under the ACL synovial membrane.4,7,10,11 As assessed by joint position feeling and latency of reflex hamstring contraction, the proprioceptive function is worse in a knee without ACL than in a normal knee.36,37 In addition, the remnants may be able to feedback information to the central nervous system regarding the joint position in static and dynamic states of awareness, movement, and acceleration, enabling closed-loop nerve activity. This system provides joint motion control and prevents abnormal movement, which can lead to other ligament and menisci injuries.1,7,10,11,13,38,39 Another important reason is that if the intact bundle maintains its blood supply, the graft healing process could be improved, as demonstrated by several cadaveric and biopsy studies, in which the number of blood vessels in the connective tissue and within the ligament was more significant.2,4,9,11,13 The third reason is that if the entire bundle remains in situ, it gives more knee stability in the early postoperative phase, allowing quicker rehabilitation and return to sport.18 Finally, the remnant bundle could help surgeons identify the correct graft and bone tunnel positioning. However, no apparent clinical differences were found in the postoperative evaluation.11,13,40
The strength of this study is that all the included studies analyzed comparable groups of homogeneous patients, including the single injured bundles. Furthermore, the outcomes used to evaluate the clinical and functional effects using the two different procedures were similar to those used by other studies that have examined clinical and functional outcomes of ACL injuries.11,12,33
This paper presents several limitations that need highlighting. The included studies were retrospective, which may lead to a selection bias, and the follow-up is relatively short and heterogeneous, making it difficult to evaluate the reinjury rate. In addition, different objective and subjective scores were used. A potential bias may be related to slightly different surgical techniques and varying graft diameters. In some of the included studies, the group arms had some differences, making some assumptions necessary to compare them, which may bias the results. Lastly, different postoperative protocols were used for ACL rehabilitation, and a standard protocol absence could influence postoperative outcomes. Further high-quality studies may strengthen the results that emerged in this study.
Partial ACL tear treatment is still debated in orthopedic knee practice because specific guidelines still need to be provided. Decision-making considers the patient's medical history and physical characteristics, clinical evaluation, diagnostic imaging, factors predictive for progression, such as the number of damaged fibers, and intraoperative findings. This study demonstrates that ACL AUG was an effective and safe procedure, with comparable results to ACLR in the objective, subjective scores, and graft re-rupture rate. In addition, Tegner's score was statistically significantly superior in ACL AUG than in ACLR, suggesting that this procedure should be preferred over ACLR whenever possible, to ACLR, especially in young and athletic patients.
5 Conclusions
The ACL residual bundle preservation favors clinical and functional recovery related to the maintained proprioception and vascularity of the residual fibers, promoting successful graft healing. A better outcome in Tegner score after ACL augmentation than standard ACL reconstruction is reported in this paper. No statistically significant difference in the postoperative Lysholm score and KT-1000 arthrometer assessment was found, although there is a trend towards a better outcome after ACL augmentation rather than ACL reconstruction. ACL augmentation would appear to provide better results than ACL reconstruction and, therefore, should be preferred in partial ACL tear treatment.
Authors contribution
Francesco Bosco: Original draft preparation, Software, Data Curation, Methodology, Supervision. Fortunato Giustra: Original draft preparation, Conceptualization. Michele Crivellaro: Data curation, Original draft preparation. Riccardo Giai Via: Data curation. Alessandro Dario Lavia: Software, Investigation. Marcello Capella: Formal analysis, Investigation. Sabatini Luigi: Formal analysis, Investigation. Salvatore Risitano: Visualization, Supervision. Giuseppe Rovere: Supervision. Alessandro Masse’: Supervision. Raju Vaishya: Visualization, Supervision.
Funding/sponsorship
This research did not involve any specific grants from commercial, public, or non-profit sector funding agencies.
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