Combined Anterolateral and Anterior Cruciate Ligament Reconstruction Improves Pivot Shift Compared With Isolated Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Purpose: To perform a systematic review and meta-analysis of the literature on anterolateral ligament (ALL) reconstruction as it relates to techniques, biomechanical properties, and clinical outcomes. Methods: PubMed, OVID/Medline, and Embase were queried in July 2020. Data pertaining to (1) techniques, (2) biomechanical properties, and (3) clinical outcomes of ALL reconstruction were recorded. DerSimonian-Laird random-effects meta-analyses were performed for included randomized controlled trials comparing combined ALL/anterior cruciate ligament (ACL) reconstruction and isolated ACL reconstruction. Data from lower levels of evidence were described qualitatively, and when possible, outcomes were reported as ranges to avoid inappropriate pooling of data. Results: A total of 46 articles were identified. Sixteen were biomechanical studies, 16 were clinical outcome studies, and 14 were technique studies. Of the 16 biomechanical studies, the majority demonstrated that anterior translation, internal rotation, and pivot shift was restored with combined ACL/ALL reconstruction and superior to ACL reconstruction alone. Ten biomechanical studies reported on constraint: 4 noted overconstraint when the femoral attachment site was proximal and posterior to the lateral femoral condyle, whereas 1 reported laxity. ACL failure rates after combined ACL/ALL reconstruction ranged between 2.7% and 11.1%. The mean postoperative Lysholm score ranged between 58.7 and 98.0; mean postoperative International Knee Documentation Committee score between 57.8 and 96.3; and mean postoperative Tegner score between 4 and 8. Six outcomes were explored through meta-analysis, of which the mean difference in Lysholm scores (2.26, P < .001) and restoration of pivot shift (relative risk 1.1, P = .046) was found to favor combined ACL/ALL reconstruction. Conclusions: Although indications for ALL reconstruction remain heterogeneous, contemporary evidence suggests that ALL reconstruction improves pivot shift and confers comparable clinical and functional outcomes with isolated ACLR.