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Technology-assisted anterior cruciate ligament reconstruction improves tunnel placement but leads to no change in clinical outcomes: a systematic review and meta-analysis

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To investigate the effect of technology-assisted Anterior Cruciate Ligament Reconstruction (ACLR) on post-operative clinical outcomes and tunnel placement compared to conventional arthroscopic ACLR.

Methods

CENTRAL, MEDLINE, and Embase were searched from January 2000 to November 17, 2022. Articles were included if there was intraoperative use of computer-assisted navigation, robotics, diagnostic imaging, computer simulations, or 3D printing (3DP). Two reviewers searched, screened, and evaluated the included studies for data quality. Data were abstracted using descriptive statistics and pooled using relative risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI), where appropriate.

Results

Eleven studies were included with total 775 patients and majority male participants (70.7%). Ages ranged from 14 to 54 years (391 patients) and follow-up ranged from 12 to 60 months (775 patients). Subjective International Knee Documentation Committee (IKDC) scores increased in the technology-assisted surgery group (473 patients; P = 0.02; MD 1.97, 95% CI 0.27 to 3.66). There was no difference in objective IKDC scores (447 patients; RR 1.02, 95% CI 0.98 to 1.06), Lysholm scores (199 patients; MD 1.14, 95% CI − 1.03 to 3.30) or negative pivot-shift tests (278 patients; RR 1.07, 95% CI 0.97 to 1.18) between the two groups. When using technology-assisted surgery, 6 (351 patients) of 8 (451 patients) studies reported more accurate femoral tunnel placement and 6 (321 patients) of 10 (561 patients) studies reported more accurate tibial tunnel placement in at least one measure. One study (209 patients) demonstrated a significant increase in cost associated with use of computer-assisted navigation (mean 1158€) versus conventional surgery (mean 704€). Of the two studies using 3DP templates, production costs ranging from $10 to $42 USD were cited. There was no difference in adverse events between the two groups.

Conclusion

Clinical outcomes do not differ between technology-assisted surgery and conventional surgery. Computer-assisted navigation is more expensive and time consuming while 3DP is inexpensive and does not lead to greater operating times. ACLR tunnels can be more accurately located in radiologically ideal places by using technology, but anatomic placement is still undetermined because of variability and inaccuracy of the evaluation systems utilized.

Level of evidence

Level III.

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Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

3D-CT:

3D-computed tomography

3DP:

3D printing

AARSC:

Anatomic ACL reconstruction scoring checklist

ACL:

Anterior cruciate ligament

ACLR:

Anterior cruciate ligament reconstruction

CI:

Confidence interval

CT:

Computed tomography

DB:

Double bundle

GRADE:

Grading of recommendations, assessment, development and evaluations

IKDC:

International knee documentation committee

MCID:

Minimal clinically important difference

MD:

Mean difference

MINORS:

Methodological index for non-randomized studies

MRI:

Magnetic resonance imaging

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

RCT:

Randomised controlled trial

RevMan:

Review manager

RoB 2:

Risk of bias 2

Robvis:

Risk of bias visualization

RR:

Risk ratio

SB:

Singe bundle

κ:

Kappa

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Acknowledgements

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The authors received no financial support for the research, authorship, and/or publication of this article.

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Authors and Affiliations

  1. Michael G. DeGroote School of Medicine, McMaster University, Waterloo Regional Campus, Kitchener, ON, N2G 1C5, Canada

    Ehsan Yavari & Sabreena Moosa

  2. Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada

    Dan Cohen

  3. Ortopedia y Traumatología, Hospital Ángeles Puebla, Puebla, Mexico

    David Cantu-Morales

  4. Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan

    Kanto Nagai & Yuichi Hoshino

  5. Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, MUMC 4E14, Hamilton, ON, L8S 4L8, Canada

    Darren de SA

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  1. Ehsan Yavari
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Contributions

EY conceived the study idea, developed its protocol, developed the search strategy, extracted the data, created final figures and tables, performed the statistical analysis, and drafted the manuscript. SM helped develop the search strategy, extracted the data, created final figures and tables, and contributed to the final manuscript. DC helped with development of search strategy, assisted in finetuning of statistical analysis, helped to resolve any conflicts, and contributed to the final manuscript. DCM, KN, YH, and DS contributed to the final manuscript. DS supervised the project. All authors read and approved the final manuscript.

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Correspondence to Ehsan Yavari.

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Ethical approval was not obtained for the following systematic review as data were extracted and analyzed from previously published studies where primary investigators already obtained appropriate informed consent.

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Informed consent was not obtained for the following systematic review as data were extracted and analyzed from previously published studies where primary investigators already obtained appropriate informed consent.

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Yavari, E., Moosa, S., Cohen, D. et al. Technology-assisted anterior cruciate ligament reconstruction improves tunnel placement but leads to no change in clinical outcomes: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 31, 4299–4311 (2023). https://doi.org/10.1007/s00167-023-07481-1

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