No Evidence of Superior Graft Remodeling and Maturation When Adding a Lateral Extra-articular Procedure to Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Studies

Background: The use of postoperative magnetic resonance imaging (MRI) to investigate the effect of concomitant lateral extra-articular procedures (LEAPs) is not well documented in the literature. Few studies have assessed the MRI signal intensity-measured by the signal-to-noise quotient (SNQ)-of the anterior cruciate ligament (ACL) graft between individuals who underwent ACL reconstruction (ACLR) with simultaneous LEAP and those who did not. These comparative studies have produced conflicting results, though, which makes the topic particularly relevant. Purpose: To systematically compare existing evidence on graft maturation by performing a meta-analysis of combined ACLR and LEAP versus isolated ACLR. Study design: Systematic review and meta-analysis; Level of evidence, 3. Methods: The methodology adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, Embase, and Cochrane Library databases were searched to identify potentially relevant comparative studies that analyzed postoperative graft maturation, at least 10 months after surgery, using MRI with SNQ after isolated ACL or ACL plus LEAP. The Methodological Index for Non-Randomized Studies was used for quality assessment. Results: A total of 542 patients were included, with 307 receiving isolated ACLR and 235 undergoing combined ACL plus LEAP. Meta-analysis revealed no statistical difference between the groups regarding SNQ (P = .574), with a mean difference of -0.58 (95% CI, -2.62 to 1.45). Neither the rank correlation test nor the linear regression test indicated any funnel plot asymmetry (P = .272 and P = .642 respectively). Conclusion: Adding a lateral extra articular procedure to ACLR does not improve graft remodeling and maturation. Furthermore, graft maturation is not influenced by the time from surgery, age, or sex. Despite the limited number of studies considered, these findings suggest that a lateral extra-articular procedure does not play a significant role in graft maturation and should be performed selectively.