Does Lateral Extra-Articular Procedures Combined With Primary ACL Reconstruction Elicit Superior Clinical And Functional Outcomes? A Systematic Review and Meta-analysis.

To conduct a systematic review and meta-analysis to determine whether the addition of a LEAP to an ACLR results in superior clinical and functional outcomes compared to an isolated ACLR.

Five databases were searched to identify randomised controlled trials comparing the clinical and functional outcomes following the addition of LEAPs to an isolated primary ACLR. Study selection was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of methodological quality for included studies was undertaken using the Cochrane risk-of-bias tool (RoB 2) for randomized control trials. Studies were eligible for meta-analysis if an outcome measure utilising similar time points were present across two or more of the studies and reported in mean differences (MD) or standard deviation (SD).

Meta-analysis of ten studies showed the addition of LEAPs to an ACLR can reduce rotatory instability (RR 1.45 [95%CI 1.17, 1.79]; p= 0.0006; I²= 0%) and graft rupture rates (RR 0.21 [95%CI 0.08, 0.55]; p = 0.00; I²= 0%). Short-term morbidity including increased pain, joint stiffness and muscle weakness compared to isolated ACLRs were resolved by 12-months post-surgery. No correlation between early knee OA and LEAPs were seen in this review. 

ACLR in combination with a LEAP results in superior clinical outcomes compared to an isolated ACLR. Despite early post-operative outcomes concerning pain and function favouring isolated ACLRs, any negative effects were not still observed six-months post-surgery. A conclusion around the correlation between LEAPs and accelerated knee OA could not be drawn due to the lack of long-term prospective studies available. 

This study adds further support for the positive influence that LEAPs have on clinical outcomes; reducing graft ruptures and pivot shift grades when combined with primary ACLR. It also investigates LEAPs impacts on functional outcomes and pain intensity, noting that further research in this area is required. Physiotherapists treating patients with LEAPs in addition to ACLR should consider including supplementary strategies to target increased pain, joint stiffness, and muscle weakness during the first 6-months of their rehabilitation.