Teknik satu insisi berbanding dua insisi untuk rekonstruksi ligamen anterior cruciate dengan bantuan artroskop dalam kalangan dewasa
Referencias
References to studies included in this review
References to studies excluded from this review
Additional references
References to other published versions of this review
Characteristics of studies
Characteristics of included studies [ordered by study ID]
Ir a:
| Methods | Study design: randomised controlled trial. Single‐centre study, secondary care setting. Place of study: Sahlgrenska University ‐ Hospital/Östra, Göteborg, Sweden. Randomisation method: allocation to 2 groups using closed envelopes. Assessor blinding: independent observer, not involved in the surgical procedure. No loss to follow‐up | |
| Participants | Inclusion criteria: 59 people with symptomatic ACL instability who had previously undergone supervised rehabilitation without success. Sex: 39 male (66%); 20 female. Median age: 27 years (range 15 to 45). Mean time since injury: not stated, range 3 to 92 months. | |
| Interventions |
| |
| Outcomes | Follow‐up: 3, 12, and 24 months after surgery. The IKDC score was registered at the final 2‐year follow‐up.
| |
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quotes: "patients were allocated randomly"; “Patients were allocated to the two treatment groups using closed envelopes” Comment: There is no description of method of sequence generation, but randomisation appears to be timed before patient consent. “In order to ensure that the surgical procedures were as uniform as possible, the patients were operated on in two consecutive series, starting with the 'outside‐in' technique (pre‐randomisation)” Comment: It thus appears that the 2 techniques were not performed concurrently. Quote: "All patients were informed about this randomisation procedure before surgery and only those who accepted the randomisation were included in the study" Comment: The number of postrandomisation exclusions is not stated. |
| Allocation concealment (selection bias) | High risk | Quote: “Patients were allocated to the two treatment groups using closed envelopes” Comments: Sequence generation was not appropriate, and the allocation concealment was performed with closed envelopes, but it is not clear whether the closed envelopes were opaque and numbered. Quote: "All patients were informed about this randomisation procedure before surgery and only those who accepted the randomisation were included in the study" Comment: Irrespective of whether allocation was concealed, this approach is likely to have led to post‐randomisation exclusions and thus make selection bias likely. |
| Blinding of participants and personnel (performance bias) | High risk | No available information about blinding of participants. Impossible to blind the surgeon. |
| Blinding of outcome assessment (detection bias) | Unclear risk | Quote: "all patients were followed up by an independent observer, who was not involved in the surgical procedure" Comments: It is not specified if the therapist was blind to the type of procedure. |
| Incomplete outcome data (attrition bias) | Unclear risk | No available information |
| Selective reporting (reporting bias) | Unclear risk | No trial registration or published protocol available. |
| Other bias | Unclear risk | Surgery was performed by 1 of 3 experienced knee surgeons, who were well acquainted with both methods. Due to overall poor reporting in the article, we are unable to judge whether there were other sources of bias (such as major differences in baseline characteristics and the influence of funding sources as a potential cause of bias). |
| Methods | Study design: randomised controlled trial. Single‐centre study, secondary care setting. Place of study: Homburg/Saar, Germany. Randomisation method: not cited. Assessor blinding: not cited. No loss to follow‐up | |
| Participants | Inclusion criteria: 20 people with isolated ACL deficiency of no greater than 6 months, side‐to‐side difference in thigh circumference of no more than 2 cm (measured 10 cm proximal to joint line), and the patient’s ability to participate in a standardised rehabilitation programme. Sex: 12 male (60%), 8 female. Mean age: 29.4 years (range 19 to 42). Mean time since injury: not stated. | |
| Interventions | Period of study: 12 months.
| |
| Outcomes | Follow‐up: 6 weeks, 3, 6, and 12 months postoperatively.
| |
| Notes | We extracted standard deviations for Lysholm scores from the graph of this outcome. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: “... who underwent unilateral anterior cruciate ligament reconstruction with bone‐patellar tendon‐bone autografts were randomly assigned to one of the two procedures” Comment: Insufficient information |
| Allocation concealment (selection bias) | Unclear risk | No available information |
| Blinding of participants and personnel (performance bias) | High risk | No available information about blinding of participants. Impossible to blind the surgeon. |
| Blinding of outcome assessment (detection bias) | Unclear risk | No available information |
| Incomplete outcome data (attrition bias) | Unclear risk | The power calculation revealed that the sample size was sufficient, however information was insufficient to determine if there was attrition. |
| Selective reporting (reporting bias) | Unclear risk | No trial registration or published protocol available. Potentially inadequate recording and reporting of adverse events |
| Other bias | Unclear risk | No information to assess whether baseline characteristics were comparable. “No author or related institution has received any financial benefit from research in this study” “Both operative procedures were standardized and performed by two experienced surgeons” |
| Methods | Study design: quasi‐randomised 3‐arm controlled trial. Single‐centre study, secondary care setting. Place of study: Nassau Bay, Texas, United States. Randomisation method: allocation according to birth month. Assessor blinding: all evaluations were done by the same independent physical therapist. Loss to final follow‐up: 3 participants. This trial, which included 3 groups, was published in 2 reports: O'Neill 1996, where 127 participants were recruited, of whom 125 where followed up for 2 to 5 years; and O'Neill 2001, where 1 of the original participants was excluded and an additional group of 101 participants was added, giving a total of 225 participants followed for a minimum of 6 years. In the following we provide separate summaries for participant characteristics, and the outcomes available in the 2 reports. 1 of the groups was not relevant to this review, thus the numbers are adjusted below to those included in this review. | |
| Participants | No mention of inclusion or exclusion criteria. 1996 report: 87 participants (2 lost to follow‐up). Mean age: 27 years (range 14 to 56). Mean time since injury: ? but 34 (40%) operated on within 3 weeks and 65 within 1 year. 2001 report: 150 participants. Sex: male:female ratio was 2:1 "in all groups", thus 100 male (67%), 50 female. Mean age: no information. Mean time since injury: not stated. | |
| Interventions |
| |
| Outcomes | 1996 report: Follow‐up: mean 43 months (range 24 to 60 months).
2001 report: Follow‐up: mean 102 months (range 6 to 11 years).
| |
| Notes | Data are not included in this review from the participants in the third group (40 participants in O'Neill 1996 and 75 in O'Neill 2001), which tested a two‐incision technique using a double‐stranded semitendinosus‐gracilis graft. Graft fixation was performed with 2 staples in the femur and 2 in the tibia. We did not include this group in the analyses due to relevant differences (different grafts and graft fixation devices) between this group and the one‐incision group that would confound the comparison of one‐ versus two‐incision technique. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | High risk | Quote: “The patients were randomly assigned to the type of operative procedure according to the month in which they had been born” Comments: Inadequate method of sequence generation |
| Allocation concealment (selection bias) | High risk | Comments: Inadequate method of allocation concealment |
| Blinding of participants and personnel (performance bias) | High risk | No available information about blinding of participants. Impossible to blind the surgeon. |
| Blinding of outcome assessment (detection bias) | Unclear risk | Quote: “All of the instrumented tests and scoring evaluations were done by the same independent physical therapist, to enhance reproducibility” Comments: It is not specified if the therapist was blind to the type of procedure. |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "125 patients were included in the previous two‐to‐five‐year follow‐up study. One of these patients died from a gunshot wound less than six years postoperatively and therefore was not eligible for the present study. In addition, 101 patients who had had insufficient follow‐up for inclusion in the original study were eligible for the present study. Thus, the final analysis included 225 patients" Comments: The reasons for exclusion of participants were given. |
| Selective reporting (reporting bias) | High risk | No trial registration or published protocol available. Introduction of participants not considered in the early report introduces substantial reporting bias. |
| Other bias | Unclear risk | “The author did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity" The author (O'Neill) performed all operative procedures. Due to overall poor reporting in the article, we are unable to judge whether there were other sources of bias (such as major differences in baseline characteristics). In the first cohort, more associated injuries were present in one‐incision group (35 (78%) versus 24 (60%)), and more meniscal injuries were operated on. However, O'Neill 2001 claimed there "were no significant differences with regard to the number of previous operations, associated injuries, or concomitant operations". |
| Methods | Study design: randomised controlled trial. Single‐centre study, secondary care setting. Place of study: Baylor Sports Medicine, Texas, United States. Randomisation method: not available. Assessor blinding: not available. Loss to follow‐up: 3 participants (at final follow‐up). | |
| Participants | Inclusion criteria: 30 people with chronic ACL instability. Exclusion criteria: medial collateral ligament instability > 1+, any posterior or lateral instability, previous surgery other than arthroscopic debridement or partial meniscectomy, flexion contracture, varus or valgus deformity, degenerative joint disease. Sex: 21 male (70%), 9 female. Mean age: 27 years (range 17 to 43 years). Mean time since injury: 29.5 months (range 3 to 264). | |
| Interventions |
| |
| Outcomes | Follow‐up: mean 15 months (range 5 to 28 months), also 1, 3, and 6 weeks, and 3, 6, and 12 months postoperatively
| |
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: “They were randomized as they were scheduled for surgery” Comments: Insufficient information about the randomisation process |
| Allocation concealment (selection bias) | Unclear risk | No available information |
| Blinding of participants and personnel (performance bias) | High risk | No available information about blinding of participants. Impossible to blind the surgeon. |
| Blinding of outcome assessment (detection bias) | Unclear risk | No available information |
| Incomplete outcome data (attrition bias) | High risk | Three participants (20%) of the two‐incision group were lost to final follow‐up, but the reasons for this were not provided. Different losses at different follow‐up times are large due to the small numbers in the trial (e.g. pain at 6 weeks: 4 (27%) versus 2 (13%)) and are also likely to be a source of bias. |
| Selective reporting (reporting bias) | Unclear risk | No trial registration or published protocol available. |
| Other bias | Unclear risk | "Surgery was performed by orthopaedic residents under the direct supervision of the senior investigator (D.M.L)." Due to overall poor reporting in the article, we are unable to judge whether there were other sources of bias (performance bias due to disparity in the experience of the surgeons performing the procedures, and the influence of funding sources as a potential cause of bias). Although the groups were comparable in age, sex ratio, and incidence of associated pathology, the time between injury and surgery differed considerably in the 2 groups (one‐incision: mean 12 months (range 5 to 29 months); two‐incision: mean 47 months (range 3 to 264 months)). The implications of this are unclear. |
| Methods | Study design: randomised controlled trial. Single‐centre study, secondary care setting. Place of study: Clinic Orthopaedic University, Rome, Italy. Randomisation method: heads and tails method. Assessor blinding: 2 "blindly" randomised groups were analysed. No loss to follow‐up | |
| Participants | Inclusion criteria: 61 people with isolated chronic ACL instability. Exclusion criteria: acute injuries (< 2 months), multiple ligament injuries, extra‐articular reconstructions. Sex: 39 male (64%), 22 female. Mean age: 25.6 years (range 17 to 42). Mean time since injury: not stated. | |
| Interventions | Period of study: 24 months.
| |
| Outcomes | Follow‐up: 27.6 months (range 24 to 30 months).
| |
| Notes | ||
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Patients randomly assigned to one of the two treatment groups. Criteria of randomization was the heads and tails method" Comments: Coin‐tossing method seems to be appropriate for random sequence generation. |
| Allocation concealment (selection bias) | Unclear risk | Quote: "Patients randomly assigned to one of the two treatment groups. Criteria of randomization was the heads and tails method" Comments: No information regarding safeguards to ensure that the allocation was accepted (no concealment) |
| Blinding of participants and personnel (performance bias) | High risk | No available information about blinding of participants. Impossible to blind the surgeon. |
| Blinding of outcome assessment (detection bias) | Unclear risk | Quote: "We analysed two blindly randomized groups at 2 years' follow‐up" No details available of how this was achieved and it refers to analysis rather than data collection |
| Incomplete outcome data (attrition bias) | Low risk | No loss to follow‐up |
| Selective reporting (reporting bias) | Unclear risk | No trial registration or published protocol available. |
| Other bias | Unclear risk | The reported baseline characteristics appeared comparable and "no significant differences were observed between groups" was reported with regard to level of pre‐injury activity, type and frequency of sport. "All the ACL reconstructions were performed by the senior surgeon (PPM)." However, confirmation of equivalent experience or familiarity in both techniques by the experienced surgeon was not provided. |
ACL: anterior cruciate ligament
IKDC: International Knee Documentation Committee
Characteristics of excluded studies [ordered by study ID]
Ir a:
| Study | Reason for exclusion |
| Not a randomised trial: 2 parallel series | |
| Not a randomised trial: a prospective comparative cohort study that compared two‐incision versus one‐incision double‐bundle ACL reconstruction | |
| Not a randomised trial: a retrospective cohort study that compared one‐incision versus two‐incision ACL reconstruction techniques | |
| Interventions not in the scope of the review: this randomised controlled trial compared full‐length tibial tunnel technique with all‐inside techniques (tibial tunnel with partial length). | |
| Not a randomised trial: a prospective comparative cohort analysis of one‐incision versus two‐incision ACL reconstruction techniques | |
| Interventions not in the scope of the review: this randomised controlled trial compared one‐incision arthroscopic technique with two‐incision technique through mini‐open arthrotomy; the latter is an exclusion criterion of this review. | |
| Not a randomised trial: 2 parallel series | |
| Interventions not in the scope of the review: this randomised controlled trial compared anatomical double‐bundle, anatomic single‐bundle, and conventional (transtibial) single‐bundle ACL reconstruction techniques. | |
| Interventions not in the scope of the review: trial compared different fixation devices. | |
| Interventions not in the scope of the review: this randomised controlled trial compared different methods of the femoral placement of the graft, but the modified "over the top" intervention that involved no femoral tunnel used a different fixation device. | |
| Interventions not in the scope of the review: this randomised controlled trial compared transportal versus outside‐in technique double‐bundle ACL reconstruction. | |
| Interventions not in the scope of the review: this randomised controlled trial compared transportal versus outside‐in technique double‐bundle ACL reconstruction. | |
| Interventions not in the scope of the review: this randomised controlled trial compared full‐length tibial tunnel technique with all‐inside techniques (tibial tunnel with partial length). | |
| Not a randomised trial: a retrospective study | |
| Interventions not in the scope of the review: trial compared different fixation devices. | |
| Not a randomised trial: a prospective comparative cohort analysis of one‐incision versus two‐incision ACL reconstruction techniques | |
| Interventions not in the scope of the review: trial compared two‐incision technique with transtibial technique with femoral fixation through a lateral approach, instead of avoiding the lateral incision. | |
| Interventions not in the scope of the review: this randomised controlled trial compared transportal versus outside‐in technique single‐bundle ACL reconstruction. |
ACL: anterior cruciate ligament
Data and analyses
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 1 Subjectively rated knee function: Lysholm scores (0 to 100: best function) Show forest plot | 2 | Mean Difference (IV, Fixed, 95% CI) | Subtotals only | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.1  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 1 Subjectively rated knee function: Lysholm scores (0 to 100: best function). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 1.1 At 3 months | 2 | 79 | Mean Difference (IV, Fixed, 95% CI) | 2.73 [‐2.70, 8.15] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 1.2 At 12 months | 2 | 79 | Mean Difference (IV, Fixed, 95% CI) | ‐3.68 [‐6.61, ‐0.75] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 1.3 At 24 months | 1 | 59 | Mean Difference (IV, Fixed, 95% CI) | ‐1.0 [‐7.34, 5.34] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 2 Subjectively rated knee function: Lysholm scores 90 or more Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.2  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 2 Subjectively rated knee function: Lysholm scores 90 or more. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 2.1 Long term: mean 43 months | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3 Adverse events Show forest plot | 4 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.3  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 3 Adverse events. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.1 Infection | 2 | 89 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.03 [0.07, 15.77] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.2 Nerve palsy | 1 | 59 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.34 [0.01, 8.13] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.3 Haemarthrosis requiring joint aspiration | 1 | 59 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.34 [0.04, 3.13] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.4 Deep vein thrombosis | 1 | 30 | Risk Ratio (M‐H, Fixed, 95% CI) | 3.0 [0.13, 68.26] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.5 Knee stiffness (loss of terminal extension) (2 to 5 years) | 2 | 144 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.77 [0.40, 7.79] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.6 Knee stiffness (loss of terminal flexion) (2 to 5 years) | 2 | 144 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.50 [0.14, 1.72] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.7 Recurrent instability (giving way) | 1 | 27 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.44 [0.11, 54.97] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.8 Knee swelling at final follow‐up | 1 | 27 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.12 [0.47, 2.65] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.9 Reoperations | 3 | 205 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.89 [0.37, 2.14] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3.10 Graft failure (6 to 11 years) | 1 | 150 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.25 [0.35, 4.47] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 4 Tegner activity score (0 to 10: top activity) at 24 months Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.4  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 4 Tegner activity score (0 to 10: top activity) at 24 months. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 5 Return to previous activity level (2 to 5 years) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.5  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 5 Return to previous activity level (2 to 5 years). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 6 IKDC objective assessment: normal or nearly normal Show forest plot | 5 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.6  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 6 IKDC objective assessment: normal or nearly normal. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 6.1 At 3 to 6 months | 2 | 43 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.59 [0.33, 1.03] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 6.2 At 12 to 28 months | 4 | 167 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.01 [0.85, 1.21] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 6.3 At 6 to 11 years | 1 | 150 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.99 [0.91, 1.07] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 7 Objective function tests: one‐leg hop quotient (% of other leg) (24 months) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.7  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 7 Objective function tests: one‐leg hop quotient (% of other leg) (24 months). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 8 Objective function tests: one‐leg hop > 90% contralateral (2 to 5 years) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.8  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 8 Objective function tests: one‐leg hop > 90% contralateral (2 to 5 years). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9 Static stability measures ‐ anterior translation, difference between sides (injured ‐ healthy knee) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.9  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 9 Static stability measures ‐ anterior translation, difference between sides (injured ‐ healthy knee). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9.1 Difference (mm) measured by KT‐1000 arthrometer at 89 N (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9.2 Difference (mm) measured by KT‐1000 arthrometer at 135 N (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9.3 Difference (mm) measured by KT‐1000 arthrometer at 89 N (24 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9.4 Difference (mm) measured by KT‐1000 arthrometer at 135 N (12 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 10 Static stability measures ‐ anterior translation side‐to‐side difference < 3 mm Show forest plot | 4 | 297 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.96 [0.85, 1.09] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.10  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 10 Static stability measures ‐ anterior translation side‐to‐side difference < 3 mm. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 10.1 Measured by KT‐1000 arthrometer (12 to 24 months) | 2 | 86 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.95 [0.78, 1.15] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 10.2 Measured by KT‐2000 arthrometer (2 to 5 years) | 2 | 211 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.97 [0.83, 1.14] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 11 Static stability measures ‐ various Show forest plot | 2 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.11  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 11 Static stability measures ‐ various. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 11.1 Pivot‐Shift (normal or nearly normal) (3 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 11.2 Lachman (normal or nearly normal) (3 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 11.3 Pivot‐Shift (normal or nearly normal) (12 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 11.4 Lachman (normal or nearly normal) (12 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 11.5 Lachman (normal or nearly normal) (2 to 5 years) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 12 Patellofemoral pain score (0 to 20: best outcome) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.12  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 12 Patellofemoral pain score (0 to 20: best outcome). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 12.1 Patellofemoral pain score (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 12.2 Patellofemoral pain score (12 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 12.3 Patellofemoral pain score (24 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 13 Pain (early and late postoperative pain) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.13  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 13 Pain (early and late postoperative pain). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 13.1 Pain (6 weeks) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 13.2 Late pain (mean 15 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 14 Knee range of motion (degrees) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.14  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 14 Knee range of motion (degrees). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 14.1 Flexion (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 14.2 Flexion (6 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 14.3 Flexion (12 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 14.4 Extension (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 14.5 Extension (6 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 14.6 Extension (12 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 15 Range of motion at mean 15 months follow‐up (range 5 to 28 months) Show forest plot | Other data | No numeric data | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.15
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 15 Range of motion at mean 15 months follow‐up (range 5 to 28 months). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 16 Peak torque forces (% contralateral side) at 3 and 6 months Show forest plot | Other data | No numeric data | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.16
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 16 Peak torque forces (% contralateral side) at 3 and 6 months. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 16.1 3 months | Other data | No numeric data | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 16.2 6 months | Other data | No numeric data | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17 Muscle strength (peak torque forces) at 12 months Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.17  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 17 Muscle strength (peak torque forces) at 12 months. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17.1 Extensors (60º) under concentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17.2 Extensors (180º) under concentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17.3 Extensors (60º) under eccentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17.4 Extensors (180º) under eccentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17.5 Flexors (60º) under concentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17.6 Flexors (180º) under concentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17.7 Flexors (60º) under eccentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17.8 Flexors (180º) under eccentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 18 Deficits in isokinetic muscle strength (6 to 11 years) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Analysis 1.18  Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 18 Deficits in isokinetic muscle strength (6 to 11 years). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 18.1 Quadriceps deficit > or = 10% | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 18.2 Hamstrings deficit > or = 10% | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Study flow diagram.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 1 Subjectively rated knee function: Lysholm scores (0 to 100: best function).
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 2 Subjectively rated knee function: Lysholm scores 90 or more.
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 3 Adverse events.
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 4 Tegner activity score (0 to 10: top activity) at 24 months.
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 5 Return to previous activity level (2 to 5 years).
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 6 IKDC objective assessment: normal or nearly normal.
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 7 Objective function tests: one‐leg hop quotient (% of other leg) (24 months).
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 8 Objective function tests: one‐leg hop > 90% contralateral (2 to 5 years).
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 9 Static stability measures ‐ anterior translation, difference between sides (injured ‐ healthy knee).
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 10 Static stability measures ‐ anterior translation side‐to‐side difference < 3 mm.
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 11 Static stability measures ‐ various.
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 12 Patellofemoral pain score (0 to 20: best outcome).
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 13 Pain (early and late postoperative pain).
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 14 Knee range of motion (degrees).
| Study | Variable (degrees) | One‐incision n = 15 | Two‐incision n = 12 | Mean difference |
| Reat 1997 | Extension | ‐4° | ‐2° | ‐2° |
| Reat 1997 | Flexion | 135° | 134° | 1° |
| Reat 1997 | Range of motion | 139° | 136° | 3° |
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 15 Range of motion at mean 15 months follow‐up (range 5 to 28 months).
| Study | Muscle and conditions | One‐incision n = 10 | Two‐incision n = 10 | MD | Reported P |
| 3 months | |||||
| Hess 2002 | Extensor, 60 deg/sec, concentric | 65.8 | 52.3 | 13.5 | 0.05 |
| Hess 2002 | Extensor, 180 deg/sec, concentric | 80.3 | 57.7 | 22.6 | 0.01 |
| Hess 2002 | Extensor, 60 deg/sec, eccentric | 67.1 | 51 | 16.1 | > 0.05 |
| Hess 2002 | Extensor, 180 deg/sec, eccentric | 68.8 | 51.7 | 17.1 | > 0.05 |
| Hess 2002 | Flexor, 60 deg/sec, concentric | 110.4 | 82.7 | 27.7 | 0.02 |
| Hess 2002 | Flexor, 180 deg/sec, concentric | 118.3 | 91.5 | 26.8 | > 0.05 |
| Hess 2002 | Flexor, 60 deg/sec, eccentric | 82.3 | 67.7 | 14.6 | > 0.05 |
| Hess 2002 | Flexor, 180 deg/sec, eccentric | 92.2 | 75.7 | 16.5 | > 0.05 |
| 6 months | |||||
| Hess 2002 | Extensor, 60 deg/sec, concentric | 79.3 | 61.1 | 18.2 | 0.03 |
| Hess 2002 | Extensor, 180 deg/sec, concentric | 82.2 | 78.3 | 3.9 | > 0.05 |
| Hess 2002 | Extensor, 60 deg/sec, eccentric | 92.5 | 55 | 37.5 | 0.02 |
| Hess 2002 | Extensor, 180 deg/sec, eccentric | 77.9 | 65 | 12.9 | 0.05 |
| Hess 2002 | Flexor, 60 deg/sec, concentric | 108.1 | 91.5 | 16.6 | 0.03 |
| Hess 2002 | Flexor, 180 deg/sec, concentric | 100.6 | 99.9 | 0.7 | > 0.05 |
| Hess 2002 | Flexor, 60 deg/sec, eccentric | 94.5 | 79.8 | 14.7 | > 0.05 |
| Hess 2002 | Flexor, 180 deg/sec, eccentric | 107.8 | 87.9 | 19.9 | > 0.05 |
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 16 Peak torque forces (% contralateral side) at 3 and 6 months.
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 17 Muscle strength (peak torque forces) at 12 months.
Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 18 Deficits in isokinetic muscle strength (6 to 11 years).
| One‐incision compared to two‐incision techniques for arthroscopically assisted anterior cruciate ligament (ACL) reconstruction in adults | ||||||
| Patient or population: adults undergoing arthroscopically assisted ACL reconstruction1 Intervention: one‐incision technique | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No. of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Two‐incision technique (control) | One‐incision technique (intervention) | |||||
| Subjective function (short term)2: Lysholm knee score (0 to 100: higher scores = better function) | The mean Lysholm score in the two‐incision groups ranged from 84 to 90. | The mean Lysholm score in the one‐incision groups was 2.73 higher (2.70 lower to 8.15 higher). | ‐ | 79 | ⊕⊝⊝⊝ | The 95% CI are unlikely to include a clinically important difference.4 |
| Subjective function (intermediate term)2: Lysholm knee score (0 to 100: higher scores = better function) | The mean Lysholm score in the two‐incision groups ranged from 94 to 97. | The mean Lysholm score in the one‐incision groups was 3.68 lower (0.75 to 6.61 lower). | ‐ | 79 | ⊕⊝⊝⊝ | The 95% CI are unlikely to include a clinically important difference.4 A similar lack of differences was found in 2 studies at 24 months (very low‐quality evidence).5 |
| Subjective function (long term)2: Lysholm knee score (0 to 100: higher scores = better function) Follow‐up: mean 43 months; range 2 to 5 years | 900 per 10006 | 936 per 1000 | RR 1.04 | 85 | ⊕⊝⊝⊝ | ‐ |
| Quality of life(intermediate term)2 | See comment | See comment | ‐ | ‐ | See comment | No quality of life measures were reported. |
| Adverse events (overall) | See comment | See comment | ‐ | ‐ | See comment | 4 studies reported on specific complications but not overall numbers. There was very low‐quality evidence of little between‐group differences.8 |
| Activity level (intermediate term) Tegner activity score (0 to 10: highest sport activity) | The mean Tegner activity score in the two‐incision group was 5.7. | The mean Tegner activity score in the one‐incision group was 0.8 lower (1.9 lower to 0.3 higher) | ‐ | 59 | ⊕⊝⊝⊝ | ‐ |
| Objective functional knee assessments using IKDC10 (intermediate term)(normal or nearly normal assessment) | 698 per 100011 | 705 per 1000 | RR 1.01 (0.85 to 1.21) | 167 | ⊕⊝⊝⊝ | ‐ |
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1All grafts used in the five included trials were patellar tendons. The participants were mainly in their 20s. | ||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Subjectively rated knee function: Lysholm scores (0 to 100: best function) Show forest plot | 2 | Mean Difference (IV, Fixed, 95% CI) | Subtotals only | |
| 1.1 At 3 months | 2 | 79 | Mean Difference (IV, Fixed, 95% CI) | 2.73 [‐2.70, 8.15] |
| 1.2 At 12 months | 2 | 79 | Mean Difference (IV, Fixed, 95% CI) | ‐3.68 [‐6.61, ‐0.75] |
| 1.3 At 24 months | 1 | 59 | Mean Difference (IV, Fixed, 95% CI) | ‐1.0 [‐7.34, 5.34] |
| 2 Subjectively rated knee function: Lysholm scores 90 or more Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 2.1 Long term: mean 43 months | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 3 Adverse events Show forest plot | 4 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 3.1 Infection | 2 | 89 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.03 [0.07, 15.77] |
| 3.2 Nerve palsy | 1 | 59 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.34 [0.01, 8.13] |
| 3.3 Haemarthrosis requiring joint aspiration | 1 | 59 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.34 [0.04, 3.13] |
| 3.4 Deep vein thrombosis | 1 | 30 | Risk Ratio (M‐H, Fixed, 95% CI) | 3.0 [0.13, 68.26] |
| 3.5 Knee stiffness (loss of terminal extension) (2 to 5 years) | 2 | 144 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.77 [0.40, 7.79] |
| 3.6 Knee stiffness (loss of terminal flexion) (2 to 5 years) | 2 | 144 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.50 [0.14, 1.72] |
| 3.7 Recurrent instability (giving way) | 1 | 27 | Risk Ratio (M‐H, Fixed, 95% CI) | 2.44 [0.11, 54.97] |
| 3.8 Knee swelling at final follow‐up | 1 | 27 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.12 [0.47, 2.65] |
| 3.9 Reoperations | 3 | 205 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.89 [0.37, 2.14] |
| 3.10 Graft failure (6 to 11 years) | 1 | 150 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.25 [0.35, 4.47] |
| 4 Tegner activity score (0 to 10: top activity) at 24 months Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 5 Return to previous activity level (2 to 5 years) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 6 IKDC objective assessment: normal or nearly normal Show forest plot | 5 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 6.1 At 3 to 6 months | 2 | 43 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.59 [0.33, 1.03] |
| 6.2 At 12 to 28 months | 4 | 167 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.01 [0.85, 1.21] |
| 6.3 At 6 to 11 years | 1 | 150 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.99 [0.91, 1.07] |
| 7 Objective function tests: one‐leg hop quotient (% of other leg) (24 months) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 8 Objective function tests: one‐leg hop > 90% contralateral (2 to 5 years) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 9 Static stability measures ‐ anterior translation, difference between sides (injured ‐ healthy knee) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 9.1 Difference (mm) measured by KT‐1000 arthrometer at 89 N (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.2 Difference (mm) measured by KT‐1000 arthrometer at 135 N (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.3 Difference (mm) measured by KT‐1000 arthrometer at 89 N (24 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 9.4 Difference (mm) measured by KT‐1000 arthrometer at 135 N (12 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 10 Static stability measures ‐ anterior translation side‐to‐side difference < 3 mm Show forest plot | 4 | 297 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.96 [0.85, 1.09] |
| 10.1 Measured by KT‐1000 arthrometer (12 to 24 months) | 2 | 86 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.95 [0.78, 1.15] |
| 10.2 Measured by KT‐2000 arthrometer (2 to 5 years) | 2 | 211 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.97 [0.83, 1.14] |
| 11 Static stability measures ‐ various Show forest plot | 2 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 11.1 Pivot‐Shift (normal or nearly normal) (3 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11.2 Lachman (normal or nearly normal) (3 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11.3 Pivot‐Shift (normal or nearly normal) (12 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11.4 Lachman (normal or nearly normal) (12 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 11.5 Lachman (normal or nearly normal) (2 to 5 years) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12 Patellofemoral pain score (0 to 20: best outcome) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 12.1 Patellofemoral pain score (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.2 Patellofemoral pain score (12 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 12.3 Patellofemoral pain score (24 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13 Pain (early and late postoperative pain) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 13.1 Pain (6 weeks) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 13.2 Late pain (mean 15 months) | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14 Knee range of motion (degrees) Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 14.1 Flexion (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.2 Flexion (6 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.3 Flexion (12 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.4 Extension (3 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.5 Extension (6 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 14.6 Extension (12 months) | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 15 Range of motion at mean 15 months follow‐up (range 5 to 28 months) Show forest plot | Other data | No numeric data | ||
| 16 Peak torque forces (% contralateral side) at 3 and 6 months Show forest plot | Other data | No numeric data | ||
| 16.1 3 months | Other data | No numeric data | ||
| 16.2 6 months | Other data | No numeric data | ||
| 17 Muscle strength (peak torque forces) at 12 months Show forest plot | 1 | Mean Difference (IV, Fixed, 95% CI) | Totals not selected | |
| 17.1 Extensors (60º) under concentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.2 Extensors (180º) under concentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.3 Extensors (60º) under eccentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.4 Extensors (180º) under eccentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.5 Flexors (60º) under concentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.6 Flexors (180º) under concentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.7 Flexors (60º) under eccentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 17.8 Flexors (180º) under eccentric isokinetic movement | 1 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18 Deficits in isokinetic muscle strength (6 to 11 years) Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Totals not selected | |
| 18.1 Quadriceps deficit > or = 10% | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
| 18.2 Hamstrings deficit > or = 10% | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] | |
