One‐incision versus two‐incision techniques for arthroscopically assisted anterior cruciate ligament reconstruction in adults

Fernando C Rezende; Vinícius Y Moraes; Carlos ES Franciozi; Pedro Debieux; Marcus V Luzo; João Carlos Belloti

doi:10.1002/14651858.CD010875.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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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).

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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.

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Analysis 1.3

Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 3 Adverse events.

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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.

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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).

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Analysis 1.6

Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 6 IKDC objective assessment: normal or nearly normal.

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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).

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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).

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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).

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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.

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Analysis 1.11

Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 11 Static stability measures ‐ various.

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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).

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Analysis 1.13

Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 13 Pain (early and late postoperative pain).

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Analysis 1.14

Comparison 1 One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques, Outcome 14 Knee range of motion (degrees).

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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°

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).

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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

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.

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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.

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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).

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Summary of findings for the main comparison. One‐incision compared to two‐incision techniques for arthroscopically assisted anterior cruciate ligament reconstruction in adults

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 Setting: hospital operating theatre Intervention: one‐incision technique Comparison: two‐incision technique
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	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) Follow‐up: 3 months	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 (2 studies)	⊕⊝⊝⊝ VERY LOW³	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) Follow‐up: 12 months	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 (2 studies)	⊕⊝⊝⊝ VERY LOW³	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) Excellent score (90 or above) Follow‐up: mean 43 months; range 2 to 5 years	900 per 1000⁶	936 per 1000 (819 to 1000)	RR 1.04 (0.91 to 1.18)	85 (1 study)	⊕⊝⊝⊝ VERY LOW⁷	‐
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) Follow‐up: 24 months	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 (1 study)	⊕⊝⊝⊝ VERY LOW⁹	‐
Objective functional knee assessments using IKDC¹⁰ (intermediate term)(normal or nearly normal assessment) Follow‐up: 12 to 28 months	698 per 1000¹¹	705 per 1000 (594 to 845)	RR 1.01 (0.85 to 1.21)	167 (4 studies)	⊕⊝⊝⊝ VERY LOW ¹²	‐
*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). CI: confidence interval; IKDC: International Knee Documentation Committee; MD: mean difference; RR: risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹All grafts used in the five included trials were patellar tendons. The participants were mainly in their 20s. ²We defined short term as less than six months, intermediate term as six months to two years, and long term as two years or longer after ACL reconstruction. ³We downgraded the quality of the evidence two levels for very serious risk of bias (in particular high risk of selection and performance bias), and one level for imprecision, primarily reflecting the small sample size. ⁴The minimum detectable change (the minimum difference in an outcome score below which cannot be distinguished from random error in the measurement) for the Lysholm score has been estimated as 8.9. ⁵One study (59 participants) reported a 1‐point difference (MD ‐1.00 favouring one‐incision group, 95% CI ‐7.34 to 5.34), and the other study (61 participants) found a 2‐point difference (one‐incision group: 96.81 versus two‐incision group: 94.65; reported not statistically significant). ⁶The assumed control risk is that of the study reporting this outcome. ⁷We downgraded the quality of the evidence two levels for very serious risk of bias (in particular high risk of selection, performance, and selective reporting bias), and one level for serious imprecision, reflecting the small sample size and wide confidence interval. ⁸Reported adverse events were infection, nerve palsy, haemarthrosis requiring treatment, knee stiffness, recurrent knee instability, persistent knee swelling, reoperation (for meniscal and cartilage lesions, removal of deep hardware, etc.), and graft failure. ⁹We downgraded the quality of the evidence two levels for very serious risk of bias (in particular high risk of selection and performance bias), and one level for serious imprecision, reflecting the small sample size. ¹⁰Objective assessment included that of symptoms, range of motion, one‐leg hop test, and ligament examination categorised into four groups: A (normal), B (nearly normal), C (abnormal), and D (severely abnormal). ¹¹The assumed risk is the median control risk across studies. ¹²We downgraded the quality of the evidence two levels for very serious risk of bias (in particular high risk of selection and performance bias), and one level for imprecision, primarily reflecting the small sample size.

Summary of findings for the main comparison. One‐incision compared to two‐incision techniques for arthroscopically assisted anterior cruciate ligament reconstruction in adults

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Comparison 1. One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques

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]

Comparison 1. One‐incision versus two‐incision anterior cruciate ligament reconstruction techniques

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